1
 
ARMY MEDICAL  LIBRARY

         WASHINGTON
             Founded 1836
AM£X

Section.
Number -Z>.j£.-*£.£'_<1_
             Fokm 113c, W. D., S. G. O.
•»•  3—10543    (Revised June 13. 1936) 
 
 
TREATISE  ON  THE  DISEASES7
Ap
PHYSICAL  EDUCATION
OF
CHILDREN,
BY JOHN EBERLE, M.  D.
PROFESSOR OP THE THEORY AND PRACTICE OP MEDICINE IN THE MEDICAL COLLEGE
    OF OHIO; MEMBER OF THE AMEBICAN PHILOSOPHICAL SOCIETY; OF THE
        ACADEMY OF SCIENCES OF PHILADELPHIA; CORRESPONDING
            MEMBER OP THE MEDICO-CHIRCRGICAL SOCIETY
                OF BERLIN, IN PRUSSIA, &C. &C.
           THfRD EDITION
          <w]'/ixr' >■■■ '^ '■*


GEIGG & ELLIOT, 9 NORTH FOURTH STREET.
                1837.
/
f 
A
K
  \60
E  ifet
    ?3l
Entered according to act of Congress, in the year 1833, by
        JOHN EBERLE, M. D.,
    in the Clerk's Office of the District of Ohio.
       Printed by
  T. K. <te P. G. COLLINS,
No. 1 Lodge Alley, Philadelphia. 
                              TO




                 N .  R .  SMITH,  M .  D.,




PROFESSOR OF SURGERY IN THE UNIVERSITY OF MARYLAND, &c. &c.




                     THIS WORK IS RESPECTFULLY




                         INSCRIBED,




 AS AN HUMBLE ACKNOWLEDGMENT OF  THE HIGH REGARD ENTERTAINED





       FOR HIS PROFESSIONAL  TALENTS, AND PRIVATE WORTH,




              BY HIS  FRIEND  AND  FORMER COLLEAGUE,




                                THE AUTHOR. 
 
CONTENTS.
                 BOOK I.
OF THE PROPHYLACTIC, AND PHYSICAL MANAGE-
             MENT OF CHILDREN.
CHAP. L	Of the conduct of mothers during	PAGES.
	Pregnancy,	1
n.	Of the Management of new-born	
	Infants,	- 17
m.	Of the Nourishment of Infants,	25
IV.	Of Exercise,	- 43
v.	Air—Temperature—Exposure,	51
VI.	The Nursery,	- 58
VII.	Of Weaning,	61
vm.	Cleanliness. Washing. Bathing,	72
                 BOOK II.

       OF THE DISEASES OF CHILDREN.

CHAP.  I. Of Syncope, Asphyxia, and Imper-
              fect Respiration,        -        77
       IL Of the Meconium,     -      -     88
      HI. On the Tongue-Tie,        -        92
      IV. Of the Inflammation and Swelling
              of the Breasts of new-born Infants,   94
      5                            1* 
CONTENTS.               PAGES.
V.	Of Inflammation and Ulceration of	
	the Navel,	96
VI	Of the Jaundice of Infants,	99
VII.	Of the Retention and Suppression	
	of Urine, -	109
VIII.	Of Dysuria—or Painful and Diffi-	
	cult Micturition, -	115
IX.	Of Enuresis—or Incontinence of	
	Urine, -	120
X.	Of Dentition,	125
XI.	Of the Diabetes of Infants,	145
XII.	Of the Erysipelas of Infants,	150
XHI.	Induration of the Cellular Membrane	
	and Skin. Skinbound,	162
XIV.	Of the Coryza of Infants,	168
XV.	Of the Aphthae of Infants. Thrush,	171
XVI.	Ulceration of the Mouth,	183
xvn.	Of Colic,	187
XVIII.	Of Constipation,	201
XIX.	Of Vomiting, -	205
XX.	Of Diarrhoea,	211
XXI.	Of Intestinal Worms,	255
XXII.	Of Ophthalmia,	269
xxm.	Of Cholera Infantum,	283
XXIV.	Of the Remittent Fevers of Infants,	300
XXV.	Catarrh. Catarrhal Fever,	318
XXVI.	Acute Bronchitis,	327
xxvn.	Pleuritis, -	332
xxvm.	Parotitis. Mumps, -	336
XXIX;	Tonsillitis. Cynanche Tonsillaris.—	
	Quinsy, -	339
XXX.	Cynanche Trachealis. Tracheitis.	
6	Croup, -	344
 
	CONTENTS.	PAGES.
XXXI.	Cynanche Laryngea,	365
xxxn.	Arichnitis. Hydrocephalus. Dropsy	
	in the Brain,	370
xxxm.	Peritonitis. Ascites,	391
XXXIV.	Vaccina. Vaccine Disease,	396
XXXV.	Modified Small Pox,	411
K	Sect. 1. Varioloid Disease,	411
u	" 2. Varicella,	417
XXXVI.	Rubeola, Morbilli. Measles,	428
xxxvn.	Scarlatina. Scarlet Fever,	443
xxxvm.	Pertussis. Whooping Cough,	469
XXXIX.	Convulsive Affections of Infants,	489
XL.	Infantile Epilepsy,	508
xu.	Carpo-Pedal Spasms,	525
XLH.	Chronic Eruptive Affections,	533
xun.	Inflammation and Abscess within	
	the Ear, -	545
7 
 
BOOK  I.
OF THE PROPHYLACTIC AND PHYSICAL MANAGEMENT
                     OF CHILDREN.
                    CHAPTER I.

      OF THE CONDUCT OF MOTHERS DURING PREGNANCY.

  That the foetus may be variously and injuriously affected, by
causes acting through the medium of  the maternal system; and
that disease and constitutional infirmity are thus often produced
during the uterine stage of life does  not appear to admit  of a
doubt.  From the moment, therefore,  that conception  has taken
place, a new and most sacred duty devolves upon the female.   She
is bound by all the ties of maternal sentiment, of humanity and
of moral and religious obligations  to protect the nascent being in
her womb, against every circumstance under her control, which
may have an unfavourable  influence on its delicate and uninured
organization.
  Though not in itself a state of  disease, pregnancy is evidently
attended,  in the majority of instances, with a decidedly increased
aptitude to morbific  influences.  Augmented sensibility and irri-
tability of the nervous and sanguiferous systems, appears to be a
natural concomitant  of all great  efforts of physical development
in the animal organization.  We observe it  in dentition, and at
the age of puberty, and it is, in general, equally strongly marked
during the progress of those important developments which take
place in  the female system, from  the commencement-to the  com-
pletion of gestation.  When to  this  we  add  the  remarkable
tendency  to general plethora, and the rise of the various powerful
and pervading sympathies which occur during pregnancy, we
have a combination  of circumstances peculiarly calculated  to in-
crease the liability to  disease and injury, from the  influence of
exciting and irritating causes. 
2               OF THE CONDUCT OF MOTHERS

  Without doubt, many instances of pregnancy occur in which
good  health  is enjoyed  throughout  its whole  course, although
little or no particular care is taken to avoid the usual sources of
injury in such cases.  Very  frequently, however, the reverse ob-
tains- and  we daily witness  much suffering and danger,  both to
the mother and child, from  the influence of causes which, with
proper care, might be avoided or rendered inoffensive.
  The most serious, and perhaps, most common injurious conse-
quence resulting from errors in this respect is abortion.  Females
are not, in general, sufficiently impressed with the  great im-
portance of attending to the precautionary measures, which reason
and experience dictate, in relation to the prevention of this acci-
dent.   They are apt to look upon abortion, as a temporary evil—
an affair of a few hours, or at most of a (ew days suffering, and
generally of no other serious consideration than that which may
be due to the  premature destruction of the embryo.   This con-
sideration might, indeed, be deemed a sufficient motive  for the
exercise  of adequate care in this respect; but it may well be
doubted, whether it often receives the regard which a proper sense
of duty would dictate.   In  addition,  however,  to this  appeal  to
the moral sentiment of the mother, there are other circumstances
in relation to her own welfare, which when properly presented to
her mind, seldom fail to excite a suitable attention to this import-
ant subject.   Besides  the  very distressing  circumstance  that
abortion, is in general peculiarly liable to recur, after having once
taken place, we may mention the following as among the ordinary
evil consequences of this accident—namely leucorrhoea, menorr-
hagia,  dysmenorrhoea, prolapsus uteri; schirrus uteri,  various
nervous affections,  especially chronic hysteria, dyspepsia,  and
general debility and ill-health. It is indeed a very rare occurrence
to meet with  a healthy female who has aborted more than once.
Permanent injury to health is  much more apt  to result from
abortion than from regular parturition.  The benevolent author of
nature has endowed  every  being with  powers  adequate under
ordinary circumstances, to sustain the natural operations which it
is destined  to perform, without any particular evil consequences.
The premature separation and expulsion of the fetus, however,
is an occurrence  contrary to the design and regular course of
nature and can not  take place without more or less violence to
the system  and consequent disorder and infirmity.
  But  it is not simply with  the view of obviating this accident,
that the pregnant  female is so deeply concerned in  guarding
against the operation of injurious causes.   The  future health and
vigour of the  child may be materially affected by the conduct
of the mother in this  respect.   Organic  debility and  morbid
predispositions may  be thus produced, which,  in their ultimate 
DURING PREGNANCY.
3
consequences, may prove more afflicting than abortion itself.  It
has indeed been supposed, that as there exists no direct or con-
tinuous communication between the foetus and the mother, either
by the blood vessels or the nerves, the former, probably, never
participates to any serious extent, in  the general diseases of the
latter.  It is observed that infants, well nourished, and apparently
in good health, are occasionally born of mothers who had laboured
under severe and irremediable disease during the whole period of
gestasion.  This is doubtless the case inmany instances; but it should
be observed that  although the new-born infant may appear to
enjoy a good state of health, it frequently happens that the disease
or predisposition  contracted during  gestation, remains latent or
dormant for months or even years  after birth, before it is de-
veloped;  and thus, there may be the appearance of a sound and
healthful  state of the constitution, during infancy, although the
seeds of  disease may be deeply deposited in the system.  The
want of a continuous vascular or nervous communication between
the  foetus  and the mother, can not  be regarded as a sufficient
ground for denying the  possibility  of the  passage of  disease
from the  maternal to  the  fetal system.  The fact that  syphilis
and  small-pox, not to mention various other affections, have been
contracted by the foetus  in utero, furnishes  conclusive evidence
of the occasional  transmission of disease from the mother to the
foetus.  In the higher grades of miasmal fever, particularly in
yellow fever, miscarriage is by no means uncommon;  and in many
instances  of this  kind, the child is  born dead, and often with
evident marks of having died several days previous to its expulsion
from the womb.   It is nevertheless  probable that  the influence
of maternal disease, or of injurious causes acting through the
mother's  system  on the foetus, when  not sufficiently powerful to
excite abortion, is generally  confined  to the production, rather
of organic feebleness  and predisposition to  disease,  than to any
active state of morbid excitement or positive  malady.  Be this as
it may, the liability of the child to injurious  impresssions, during
its uterine existence, is abundantly verified  by observation; and
experience and reason justify the conclusion, that the welfare of
the foetus, in relation both to its physical and moral conditions, is
intimately connected with the health and regularity of the ma-
ternal system—and consequently, so far under the control of the
mother, as she may have it  in  her  power, to avoid  the sources
of disease and inordinate excitement.
   I.  Of  the dietetic regulations proper  during pregnancy.—The
peculiar tendency to febrile  irritation  and  general plethora, so
apt  to accompany  pregnancy, renders it  especially proper to
avoid the sources of undue  excitation and nourishment during
this period.   The sensibility of the  stomach, too, almost always 
4               OF THE CONDUCT OF MOTHERS
 undergoes peculiar modifications; and the remarkable activity of
 its sympathies, more especially with the uterine system, attending
 most instances of pregnancy, presents us with an additional reason
 for the. adoption of proper dietic regulations during  the  progress
 of gestation.
   It is not to be inferred, indeed, that the pregnant female unless
 labouring under some disease, is to be dieted like a valetudinarian;
 but admitting a substantial and adequate diet, we are nevertheless
 warned by experience, to enjoin that moderation and simplicity
 of food, which would always be best, but which  is  now especially
 proper; and to caution against the free use of heating or particu-
 larly stimulating ingesta.   As  the appetite is frequently  very
 oraving in pregnancy, an inordinate indulgence  in rich and high
 seasoned food is among the most common errors  of females during
 this period.  This error is the more apt to be committed,  from the
 erroneous idea which many entertain, that, as the  foetus  in utero
 draws its nourishment from the maternal system, a greater  quantity
 of aliment is required in pregnancy than is necessary in the un-
 impregnated state.  Dr. Dewees, in his work on the diseases of
 children, has placed the fallacy and injurious  tendency of this
opinion in a very strong light.  The eight or ten pounds of animal
substance which goes to the composition of the fully developed
foetus, being  gradually drawn  from the mother during a' period
of nine months, can not, surely, require any particular increase in
the nourishment taken by the mother—more especially, " as almost
every individual habitually  takes more food, than is required for
the regular support and health of the  system."
   The evils which are liable to  result to pregnant females  from er-
rors in diet, are various and often exceedingly distressing.  Where
a predisposition to abortion exists, the free use of very nourishing
and  stimulating articles of diet, may give rise  to this accident,
simply by favouring the usually prevailing tendency to  general
plethora and fever.  The occurrence of indigestion and gastric
irritation, also, is particularly calculated to produce serious conse-
quences in pregnancy.   I have known several instances where the
use of indigestible and irritating articles of food gave rise to the
most alarming irritation of the stomach and bowels, attended with
severe vomiting, and followed very speedily by abortion.   In  one
case, a young married  woman, in the fourth month of her first
pregnancy, was seized  with excruciating and obstinate dyspeptic
colic, soon after she had eat freely of some very indigestible food.
Notwithstanding the great risk and suffering which she had under-
gone from this attack,  which she could not but refer to  its  true
cause, and  while  her stomach was still weak and irritable,  the
strong  cravings of her  appetite led her, in about ten days after,
 to commit a similar, but still more glaring error.  The consequence 
                     DURING PREGNANCY.                    5

was, another violent attack of colic, followed immediately by in-
flammation of the bowels, which in the course of the second day
terminated in abortion, and on the following day in the  death of
the patient.
   The  exercise  of caution, in  the selection  of proper  food for
pregnant females, appears  to be particularly important  towards
the termination of gestation.  The occurrence of gastro-intestinal
irritation and dyspeptic colic, at this period, besides its tendency to
excite miscarriage,  seems to be particularly  favourable to the
supervention of peritonitis, after the delivery of the child.  There
is another circumstance in relation to this subject, which appears
to be well entitled to attention.   There is a chronic form of intes-
tinal irritation,  which  results  from  the  impression  of vitiated
secretions,  or unnatural  and  inordinately  accumulated faecal
matter,  and which,  though not often manifested  by any  very
conspicuous morbid effects  during  gestation,  often  exerts  an
alarming and fatal influence on the system, within a short period
after parturition has taken place.   A redundant, mixed, hetero-
 genous, and not  sufficiently digestible diet, is especially apt to lead
 to this condition of the bowels, where the  digestive functions are
 not very vigorous,  and the alvine evacuations insufficient.  The
 consequences which are liable to result from intestinal irritations
 of this kind, are: great prostration; puerperal convulsions; alarm-
 ing nervous affections; severe head-ache;  pain  in the lower part
 of the  abdomen; inability  to sleep;  and a peculiar and highly
 dangerous affection, resembling puerperal fever, characterized by
 a remarkable sinking of the vital energies.   That the liability to
 this very alarming form of puerperal disease, is greatly enhanced
 by errors in diet,—more especially by excess in the  quantity of
 food taken, during the later stage  of gestation admits of no doubt.
 I have  witnessed several instances in which the correctness of this
 observation  seemed to me very strikingly exemplified.  A lady
 who had enjoyed unusually good health previous to her pregnan-
 cy, but who could not be  restrained from indulging  her appetite
 to an improper  extent, became affected with severe and painful
 diarrhoea, about the middle of the last month  of gestation.  By
 the adoption of proper dietetic regulations,  and the employment
 of suitable medicines, the disease subsided in the course of seven
 or eight days.   A few days, however,  before the termination of
 the pregnancy, she indulged to excess  in eating plum-pie with a
  full proportion  of strong cheese, "to help the stomach  to digest"
  the farrago she had swallowed.  Diarrhoea was  re-excited;  and
  in a few days after she was delivered of a healthy child. On the
  second day after  parturition, she experienced  a slight  chill, fol-
  lowed  speedily by symptoms simulating puerperal fever, attended
  with irresistible prostration and sinking of the vital energies, which 
£               OF THE CONDUCT OF MOTHERS

terminated in death on the  fourth day.  These violent and  dan-
gerous effects of intestinal  irritation are, fortunately, not  very
common;  but there are many other affections of a discomforting,
and often distressing character, which are rarely entirely escaped,
by truw. who neglect a prudent attention to dietetic observances.
Flatulency, acid eructations,  pains in the stomach  and  bowels,
cephalalgia, hysteria, diarrhoea, a feverish and restless state of the
svstcm, depression of spirits, palpitations, not to mention various
other disturbing affections, are among the ordinary consequences
of a habitual disregard of proper  regulations, in relation to the
diet.   The pregnant female who observes a suitable  regimen, will
cceteris paribus, always  enjoy more tranquility both of  mind and
body, and incur much less risk of injury to herself and child,  than
she, who giving a free rein  to her appetite, indulges it to excess,
or in the use of improper articles of food.
  With regard to the particular dietetic regulations proper during
pregnancy, it may be observed  that moderation and  simplicity in
diet, are in general of more importance to the health and  comfort
of the female, than  any very cautious selection as to the  kind of
food.   This remark is more especially applicable to females en-
joying a good state  of health or who are free from any  particular
derangement of the digestive functions.   A healthy female may,
without risk of injury from this source, continue to take the same
kind of nourishment during gestation, to which she was  accustom-
ed,  and by which  her  health was  maintained previous to the
occurrence of pregnancy.   Where the digestive powers are  very
active and there exists a decided tendency to plethora and febrile
excitement, however, it will be proper to avoid  the  more stimu-
lating and  nutritious articles of food.  In such cases, a diet  con-
sisting principally  of the more digestible  kinds of  vegetable
aliment should be selected,  and all heating or  strong stimulating
drinks rigidly avoided.
  In cases attended with a weak and irritable state of the stomach,
a continued attention to the selection of suitable articles of nourish-
ment  is particularly important.   In  instances of this  kind, the
most distressing and alarming  consequences are apt to result  from
errors committed in this respect.   The necessity of enjoining un-
interrupted attention to the choice of proper articles of food, when
the digestive organs are in this condition, is the more urgent,  from
the circumstance that in cases of this  land, the appetite is fre-
quently very craving  and capricious,  requiring a degree of
resolution and forbearance which is seldom witnessed, until actual
suffering gives efficiency to the counsels of prudence and expe-
rience.  In general, such cases require the management proper in
dyspepsia.  Mild, unirritating, digestible and adequately nourish-
ing food, must be selected.   Ilice, barley, arrow-root, oat-meal 
                     DURING PREGNANCY.                    7

milk, the lean parts of mutton, lamb, venison, tender beef, soft-
boiled eggs, stewed apples and peaches, constitute appropriate
articles of nourishment  in  such  cases.  It should be observed,
moreover,  that moderation in eating, as well as  simplicity in the
variety of the articles of food, are indispensible to the comfort and
health of the patient under these circumstances.  It matters not how
suitable the diet may be as to its character; much, if not all the
advantage which might result from it, under a temperate use, will
be prevented, if it be taken  in larger portions than the stomach is
capable of digesting.   Coffee and  tea, when  not made  very
strong, seldom give rise to any obvious inconvenience or disorder,
and may in general, be  used with  perfect propriety during the
period of gestation, by females enjoying an ordinary state of health.
In subjects of a decidedly nervous temperament, however, or  in
such as are labouring  under a morbidly irritable state of the ner-
vous system, the use of strong coffee, and more especially of strong
green tea, should be interdicted as a habitual beverage at meals.
In  such cases, black tea or well  prepared chocolate,  may  in
general be taken with entire safety.  Milk, more or less  diluted
with  water, is also an  excellent drink  in habits of this kind.
With regard to vinous or alcoholic  drinks, it is  scarcely possible
to reprobate their  habitual use, in  terms  of censure sufliciently
strong. Excepting as mere medicinal agents, regularly prescribed,
they ought to be wholly and most rigidly avoided by pregnant fe-
males.  The  temptation, as Dr. Dewees very truly observes, to
taking small portions of cordial or brandy, in the early months of
gestation, is often very strong. The annoying sensations frequently
experienced in the stomach, and the general uncomfortable feel-
ing connected with them, are, usually, allayed or moderated for
a  time, by the use of  these potent  stimuli.   The  unpleasant
feelings, however, return,  and  recourse  is again had  to the
assuaging but insidious stimulus; and thus  it is taken again and
again, in  still increasing portions,  until the deplorable habit of
solitary dram-drinking is formed, and the health, happiness, and
character,  of, perhaps, an otherwise amiable and excellent being,
immolated to the  filthy and devastating  demon of inebriety.
The frequent or habitual use of spirituous  drinks, is particularly
apt to  favour the  occurrence of  abortion.  In the course of mv
practice I  have met with some very striking exemplifications of
this fact.   A lady,  who,  after the birth of her first child, became
deeply imbued with this lamentable vice, aborted four times  in
succession.  She then, by the earnest  and unremitting  exertions
of her friends, seconded by her own efforts, succeeded in throwing
off the  habit of intemperance, and in the course of the following
ten years gave birth to four children.  These children, however,
were remarkably feeble and sickly from their birth, and one only, 
8               OF THE CONDUCT OF MOTHERS

out of the four, is now living—about six years of age, and mani-
festly of a very delicate  and infirm constitution.  Examples ot the
very ruinous effects of habitual intoxication on the health and hie
of the fetus in utero, are unfortunately, but too common.   The
majority of children born of decidedly intemperate mothers, are
weak and  sickly, and but few of them arrive at the age of adoles-
cence.   Many females appear to think, that although  these and
other melancholy consequences, follow in the train of habitual in-
temperance, it is extremely improbable that any injury can result
to themselves or the foetus,  from the occasional use  of  small
portions of spirituous liquors.   Were it indeed absolutely certain,
that the use of such  potations, would always be restricted to oc-
casional small portions, the  indulgence  would  perhaps, rarely
occasion  any  serious consequences.  But as no  prudence  and
resolution can be safely regarded as an entire protection against
the gradual formation of the  habit of intemperance, where  >uch
drinks are occasionally taken during gestation, even though it be at
very considerable intervals and in very moderate quantities at first,
it is far the safest plan, to abstain wholly  from every  kind of
spirituous  liquors.  The propriety of total abstinence, is the more
obvious, from  the undeniable fact, that whatever temporary me-
lioration of the feelings  which may, at times, result from the use
of spirituous drinks, they very frequently contribute, ultimately,
to increase the infirmity or mischief for which they were taken.
   Before leaving this part of the present subject, it will be proper
to make a few remarks  upon that remarkable irregularity of the
appetite, or "  longing" as it is called, which many females expe-
rience during pregnancy.    The appetitive sensibilities of the
stomach  undergo so  much  derangement  in some instances, that
articles of food, which  previous to the occurrence of pregnancy
were very grateful and congenial, become highly disagreeable,
and an almost irresistible craving for unnatural and even disgust-
ing substances is experienced.  In general, this aberration of the
appetite, is more apt  to occur in weak and delicate females of a
nervous temperament, than in such as are of a robust and full habit
of body.   Different opinions have been expressed with regard to
the probable influence, which entirer resistance to these vehement
longings or disppointment  in satisfying them, may  have on the
mother and fetus.  It  is not unreasonable to presume, that the
strong mental affection  which may  be caused  by disappointment
in this respect, may exert an unfavourable influence on the health
of the mother and child, more especially  in very nervous and ex-
 citable females.   Disappointment,  and  its  consequent moral
affection, from this source, however,  has nothing  peculiar in its
 influence, and can be  no more  injurious in its reaction on the 
                     DURING  PREGNANCY.                    g
system than  an equally strong emotion  of the mind, from any
other source of disappointment or frustrated desire.
   If the substances longed for be  not evidently of an injurious
character, they should not be withheld.   The mind is always more
or less tranquilized by gratification, and, unless the indulgence be
carried to an immoderate extent, it will  very rarely occasion any-
particular disturbance.   It is very remarkable, indeed, that even
unwholesome articles, seldom give rise to any particular inconve-
nience or disturbance in the system, where there is a very urgent
and persisting desire experienced for them. Still it would not be
prudent to trust too much to this power of the stomach to  resist
the injurious impressions of the substances it calls for; and whenever
the appetite is thus directed upon articles of an offensive or hurt-
ful nature, means should be  used to divert it and determine it to
more suitable  alimentary  substances.  In some instances,  these
"longings"  must be regarded as  instinctive calls of the stomach,
favourable to the health of the individual.   If they are not grati-
fied, langour, inquietude and other symptoms of deranged health,
will be very apt to supervene.   Thus when a strong desire for
eating chalk, charcoal, clay, &c.is manifested, we are admonished
that the digestive powers, are feeble, and that  there exists a pre-
vailing tendency to acidity  in the stomach.   In such cases, the
appropriate means of relief are alkalines,mild laxatives, and tonic
vegetable bitters, with a suitable regimen.   Magnesia in combi-
nation with some vegetable bitter, or the bi-carbonate of potash
with small portions of aloes, or rhubarb, so as  to procure  one or
two free alvine evacuations daily, seldom fail to procure some ad-
vantage.  If the tongue is bitter and clammy, small doses of blue-
pill, with an occasional mild purgative, and moderate portions of
sulphuric or nitric acid, three or four times during the day, will
tend to bring the stomach back  from its aberrations,  to a  more
healthy tone of feeling.  It is not common, however, to find these
irregular determinations of the appetite so strong or so decidedly
injurious in their tendency, as  to require any  particular medical
attention; and  we rarely meet  with instances which may not be
moderately  indulged, without injury or inconvenience  to the
system.
  II.  Of the proper regulations in relation to dress and exercise.—This
is a most  important  subject  of attention to females during the
period of gestation.  Some of  the prevailing customs in relation
to dress, are so  obviously improper during pregnancy, that it
would  seem  very strange that  there should be  any difficulty in
procuring their temporary rejection  by females in this condition,
did we not know that the imperious commands of fashion are often .
more sedulously obeyed, than the dictates of humanity and of self
preservation.   The custom of wearing tightly laced corsets during 
 10              OF THE CONDUCT OF MOTHERS

 ge-tation, can not be too severely censured.  It must be evident
 to the plainest understanding, that serious injury to the health,
 both of the mother and child, must often result from a  continual
 and  forcible  compression of the abdomen, whilst nature is at
 work in gradually enlarging it, for the accommodation and devel-
 opment of the foetus.  By this unnatural practice the circulation
 of the blood throughout the abdomen is impeded—a circumstance,
 which together with the mechanical compression of the abdominal
 organs, is peculiarly calculated to give rise to functional  disorder
 of the stomach and liver, as well as to haemorrhoids, uterine haemor-
 rhage and abortion.   The regular nourishment of the fetus, also,
 is generally impeded in this way,—a  fact which  is frequently
 verified in the remarkably  delicate and emaciated  condition of
 infants, born of mothers who have practised this fashionable folly
 during gestation.  It may be observed, that since the custom of
 wearing tightly laced corsets has become general among females,
 certain forms of uterine disease are much more frequent than they
 were, previous to the re-introduction of this fashion.  My  expe-
 rience has satisfied me,  that leucorrhcea and prolapsus uteri, are
 vastly more common at the present day, among unmarried females,
 than they were sixteen or eighteen years ago.   It is indeed aston-
 ishing, that these disorders are not more frequent even than the}'
 appear to be;  for we can not conceive of any cause moredirectlv
 calculated to produce them, than the prevailingpractice of pressing
 the abdominal viscera down upon the womb, and thus forcing it
 cut of its natural position, into the lower part of the peh is, where
 the irritation it causes, gives rise to leucorrhaeal discharge.  Struve
 observes, in relation to the  injurious tendency of wearing corsets
 during gestation, " that the  parts which have suffered from  con-
 stant  pressure, become debilitated and incapable of co-operating
 in the important function of parturition; so that the passage of the
 child  is endangered, the labour rendered more  tedious and  pain-
 ful, and all the operations  of nature  retarded."   The  pressure
 of corsets, moreover, must tend to debilitate both the mother and
 infant, by impeding the  function of respiration, and preventing in
 some  degree, the  regular decarbonization of the  blood.  Struve
 cautions pregnant females against an error,  which is not likely to
be committed in the present mode of dressing—namely, " to avoid
wearing a number of heavy petticoats, by  which  the abdomen may
 be depressed, and a bad position of the fetus produced.   At  the
present day,  it is much more necessary to caution against  the
opposite impropriety, of using insufficient clothing to protect  the
body from the  injurious influence of cold and atmospheric vicissi-
tudes.  The abdomen and  feet especially, should  be  guarded
against injury from these causes.   In the winter or cold and damp
seasons, the use of a broad flannel or bandage or roller round  the 
DURING PREGNANCY.
11
abdomen, is very  useful in this  respect, and may be beneficial
moreover, by the uniform support which it affords to the abdomen
and its consequent tendency to obviate any unfavourable obliqui-
ties in the position  of the  womb, in the advanced periods of
gestation.
  The exercise which it may be  proper  to use during pregnancy,
must of course, vary according to the period of gestation, and the
particular condition of the female  in relation  to constitutional
vigour, predisposition  to abortion, and other affections, previous
habit, and temperament.   All  kinds of  "agitating exercise,such
as riding in carriages  with rapidity  over rough roads, dancing,
lifting, or carrying heavy loads, in short, all masculine and fatiguing
employments whatever," ought to be avoided by pregnant women.
The propriety of  avoiding agitating and fatiguing exercise, in-
creases  in  proportion as  gestation  approaches the  term of its
regular completion.   During the eighth  or ninth month of preg-
nancy, unusual corporeal exertion or fatigue, is particularly apt to
excite premature labour;  and where this accident has once taken
place the necessity of observing proper caution in this respect, in
subsequent pregnancies, is peculiarly. urgent:   In all  instances,
where a predisposition exists to abortion at any particular period,
it is scarcely possible to prevent its occurrence, unless the utmost
degree  of care is taken,  to avoid exciting or fatiguing exercise,
about the time when this accident is apt to take place.
  In weak, excitable, and nervous females, and in such as are of
an unusually plethoric and irritable habit of body, it is particularly
proper to observe  suitable precautions, in relation to exercise and
corporeal exertion.  It is to be observed, however, that if injury is
apt to result from too much exercise and agitation of the body, there
is reason also for  apprehending injurious consequences from  too
much indolence and inactivity.   Moderate and gentle exercise is
generally decidedly salutary during  gestation, and  should not be
neglected unless some particular reason exists for maintaining a
state of rest and bodily composure. Riding, in an easy carriage, on
even roads, or moderate walking, may be enjoyed with  great pro-
priety, and usually with obvious advantage during  gestation.
   III. Of moral influences.—Tranquility and cheerfulness  of mind
are always highly favourable to the health and  regular operations
of the animal economy.   In pregnancy,  the importance of a calm
and even temper  is especially great; for the re-action of mental
agitation or depression, is capable of producing very unfortunate
impressions,  both  upon the  mother  and fetus.   Violent  anger,
terror,'or jealousy seldom fail to produce unpleasant effects during
pregnancy; and the consequences are, sometimes, very  alarming,
and even fatal.  Convulsions, severe  paroxysms of hysteria, spasms,
syncope, insensibility, haemorrhage,  and abortion, may be pro- 
j2              OF THE CONDUCT OF MOTHERS
duced by moral influences of this kind.  Not more than ten months
ago, 1 witnessed the occurrence of hysteric convulsions iollowcd,
in the course of a few hours by abortion, in consequence of a  fit
of vehement rage from  jealousy.   But even when none of these
violent affections result  from  the  more agitating emotions, there
are various minor evils of a discomforting and distressing charac-
ter, which are apt to occur during pregnancy from moral influences
of this nature.  The functions of the stomach, the heart, the liver,
and of the brain itself, are strongly influenced by the mind.   The
depressing moral affections often exert a highly injurious influence
on  the  organization,  particularly  on the digestive  and biliary
organs.   Debility, indigestion, jaundice, emaciation, with various
other functional disorders,  and even  organic  affections, are fre-
quently  produced by  emotions of this kind;  more especially  by
intense and protracted grief, and mental distress.  Unfortunately
no effort of the will, or firmness, is always adequate to avoid these
distressing affections of the mind.   The accidents and  misfortunes
to which all  are liable,  sometimes bring grief, and sorrow, and
distress, with a force which cannot be sufficiently resisted.  There
are, however, other causes of mental disturbance, which are more
under the control of well constituted minds; and which are almost
as detrimental to the welfare of both the mother and  child,  as the
moral affections just referred to.   Fretfulness and moroseness of
temper; envious and jealous feelings, peevishness, hatred, discon-
tent, obstinacy and perverseness of disposition, are  under  the
subjection of reason and a sense  of propriety.   It is of great  im-
portance to the regular progress of gestation and to the well-being
of the mother and fetus, that every effort which good sense and
moral feeling dictate,  should be steadfastly made by pregnant  fe-
males, to keep down these injurious and degrading sentiments and
irregularities of temper.
   The maternal  imagination has been accused  of producing the
most extraordinary effects on the foetus in utero.  During the early
and middle ages, it was  almost universally believed, that malfor-
mations, moles, and  other unnatural appearances,  were very
generally produced by the influence of the imagination of mothers;
and  the opinion continued  to prevail with many reflecting and
well informed physicians, until within a comparatively late period.
A multitude of pretended examples of this kind, are on record—
many of which are of a character so strikingly preposterous and
impossible, that  they  can now be regarded only as extraordinary
and humiliating instances of human credulity.   We are told, that
black children have been born, of while parents, in consequence
of the maternal  imagination having  been excited by contempla-
ting the portrait of an  Ethiopan, and the same effect has been
produced, according to some statements, in consequence of preg- 
                     DURING PREGNANCY.                   13

nant females having contemplated with interest the portrait of an
Ethiopian, or having been frightened by a black man.   Damas-
cenes assures us, that he saw an infant born with the whole of its
body covered thickly with coarse black hair, caused,  as he states,
by the mother having  frequently looked at an image of St. John
dressed in a bear's skin.  A child  was born at Blois in France,
with the iris of one of its eyes accurately representing the dial-
plate of a watch, in consequence of the  mother having experi-
enced a very  strong desire to have a  watch, which from some
cause or other could not be gratified.
  Absurdities  of this gross and glaring character are now but little
entertained  even by the most superstitious and ignorant.  There
are still, however, some, who fancy that under strong excitement
the imagination is capable of producing indelible impressions on
the body of the foetus in utero.   It is not very uncommon, to hear
moles, marks, and various other blemishes and  malformations as-
cribed to mental influence.  Apprehensions of this kind, sometimes
seize on the minds of females, with irresistible force; and they often
occasion great anxiety and unhappiness during gestation.  With
weak, ignorant and superstitious females, every unexpected occur-
rence, that happens to  strike them with sudden alarm, or produces
any  particular excitement of the imagination, is apt to impress
them with alarming apprehensions, as to the effects it  may have on
the development and conformation of the child in the womb. These
distressing illusions are generally much increased by the  many
ridiculous stories of moles and malformations, occasioned in  this
way, which  seldom fail to reach the ears of those who are pre-
disposed to  listen to them; for nurses,  and gossiping old women,
are usually furnished with an ample stock of extraordinary exam-
ples of this kind.  The  evidences upon which such  tales  are
generally founded  are  never wanting.  If a child is born with
some blemish on its body, the mother  is forthwith closely ques-
tioned as to  the circumstances which may  have attracted her par-
ticular attention or excited her mind by sudden surprise or alarm.
If any thing of this kind is recollected which bears even a remote
similitude, in colour, shape, or otherwise,  to the mark  or defect
observed on the child,  it is immediately put  down as  its  indubita-
ble cause.  Sustained by  authorities of this kind, these absurd
apprehensions  often acquire an  ascendency over the minds of
pregnant females, which no expostulation or ridicule  can entirely
subdue, and which  sometimes give rise to the utmost degree  of
anxiety and distress of mind, and  occasionally even to physical
suffering and ill-health.
  I do not propose to  enter into a  formal refutation  of this erro-
neous and injurious notion.   It is now unreservedly rejected as the
fantastic offspring of ignorance and superstition, by  all sensible, 
 11              OF THE CONDUCT OF MOTHERS

 observant, and reflecting physicians; and it is much to be desired
 that it  should be  equally  repudiated, by those whom it  more
 especially concerns, and upon whose happiness and well-being, it
 tends to exercise so injurious an influence.
  But, although the idea that structural blemishes may be pro-
 duced by the influence  of the mother's imagination, is wholly
 without foundation, yet it can scarcely be doubted that injurious
 impressions may be made,  in an indirect manner, on the child in
 the womb, by affections of the maternal imagination.   If intense
 and  protracted  grief,  or violent bursts of passion  may exert a
 detrimental  influence on the fetus, we may presume that similar
 injurious effects may result from strong affections of the imagination.
 It is well known that disease and even death is sometimes produced
 by intense excitement  and  concentration of this mental faculty;
 and it is equally notorious that severe and long-standing maladies
 are often effectually removed by its powerful agency.  It is evi-
 dent, therefore, that the foetus in utero must be liable to injurious
 impressions from inordinate affections of the maternal imagination;
 for  without  presuming that the mental affections of the mother
 can exert  any direct and immediate impressions on the system of
 the fetus, the  diseases and  functional disturbances to which  the
 mother  is  liable  from influences of this kind, must tend, in some
degree, to  interfere with the regular nourishment and health of the
child.   Every kind of mental excitement, when excessive,  may
 prove detrimental to the health, both of the mother and the fetus;
 and it is probably as important, to guard  against the ascendency
of an excited  imagination,  as against the various agitating and
depressing emotions already mentioned.
  IV.  Of blood-letting during pregnancy.—Females very generally
 suppose that the condition  of pregnancy is, of itself, a sufficient
 reason for blood-letting; and that, although unaccompanied  by
 any circumstances, which might be justly deemed an indication,
 for this evacuation, it is necessary,both for the preservation of the
 mother's health, and  the safe  progress and termination of ges-
 tation.  This  is  a very  erroneous  opinion,  and  often  leads  to
 decidedly  prejudicial consequences.  Pregnancy is, indeed, gene-
 rally  attended with  a very peculiar tendency  to plethora and
 febrile  excitement; and, it may  be  admitted, that even in a
 state  of  apparent  good  health,  blood may often  be drawn
 during pregnancy  with a beneficial result.  In such cases how-
 ever,  the  pulse and  other manifestations of general plethora,
 indicate the propriety of  depletion; and unless  these  or  son:J
 other symptoms  calling for the abstraction of blood be present"
 it cannot  be practised without the risk of unfavourable  conse-
 quences.  When the symptoms  of vascular repletion are not very
 urgent, the plethora may, in general,  be much more beneficially 
DURING PREGNANCY.   ,                15
removed, by using a less  nutritious and stimulating diet,  than
by blood-letting.  By the former mode, we  not  only  diminish
the mass of  the  blood, but  we  generally  also  improve  the
condition  of the alimentary  canal, and  thereby contribute sen-
sibly  to the  comfort and  health of the  patient.  In weak,
nervous, and  relaxed  habits,  even where  the  manifestations
of vascular fulness  are conspicuous, the loss  of blood, some-
times, occasions  much debility, and  may even contribute to the
occurrence of  abortion.
  Pregnant females should not resort to blood-letting, unless mani-
fest indications  exist for its  employment;  and, as  they cannot
be competent  judges themselves, of the presence or absence of
such indications, the advice of a physician ought always be pro-
cured before recourse is had to this measure.   To bleed merely
because pregnancy exists, is a practice which is sanctioned neither
by reason nor  experience, and ought to be discarded as  a custom
calculated  to  do mischief in some cases at least, whilst  it cannot
do any  good,  unless called for by other  circumstances  than the
condition merely of pregnancy.
  A very severe and troublesome pain is often experienced in the
right hypochondrium during  the latter period  of pregnancy; and
this suffering is, almost always, sought to be mitigated or removed
by blood-letting.  When decided evidences of plethora  accompa-
ny this painful affection, bleeding will occasionally  procure con-
siderable temporary relief; but in the  majority of instances, no
mitigation  whatever is obtained from this measure.  The relief
which is sometimes procured by bleeding, is always of short dura-
tion, the pain  usually returning in the course of two or three days;
and if the bleeding  is thus frequently repeated, as  is sometimes
done, much mischief is apt to be produced, by the general debility
and languor which it tends to occasion.   When the symptoms of
vascular turgescence throughout the system  are conspicuous in
connection with  this  pain in the side, it will certainly be  proper to
diminish the mass of the circulating fluid by venesection; but where
no indications of this kind are present,  blood  ought not  to be
abstracted merely on account of this affection; for it  will  most
assuredly  fail  of procuring the desired relief; and may,  when not
particularly called for, operate unfavourably on the general health
of the patient.  Moderation in diet, together with a proper atten-
tion to the state of the bowels, and the use of gentle exercise by
walking, will, in general, do much more towards the removal of
this source of uneasiness and suffering, than will result from blood-
letting, where this evacuation  is not especially  indicated by the
fulness and  firmness of  the pulse, or by other manifestations of
general vascular plethora. 
 16              OF THE CONDUCT OF MOTHERS
   The breasts and nipples should be particularly attended to during
 the latter months of gestation, in order to prepare  them for the
 important function ofsuckling the infant.   To prevent the nipples
 from becoming excoriated and  inflamed, in consequence of  the
 irritation occasioned by the child's lips and tongue,  in  the act of
 sucking, means should  be used, some weeks before  the expected
 termination of gestation, to render them firm and to diminish their
 sensibility to irritating impressions.   For  this purpose the nipples
 should be daily washed with luke warm water, then dried by ex-
 posing them to the free air, and afterwards gently rubbed for five
 or six minutes with a soft piece of flannel or with the extremities
 of the  fingers.  Much  benefit may also be obtained, from the oc-
 casional application of a pup to the breasts during the last four or
 five weeks of gestation.  Washing the nipples with brandy  and
 water, and  with various  stimulating lotions is a very common
 practice; and where the skin of the nipples is very delicate  and
 sensible, considerable benefit  may, at times, be derived  from  such
 applications.   Dr. Dewees, however, is decidedly opposed to the
 use of astringent washes, for the  purpose of preparing the  nipples.
My own experience, does not lead me to apprehend any detriment
from certain  applications  of  this kind; on the contrary,  I have
been constantly in the habit of directing  the use of a wash, com-
posed of two drachms of the  tincture of myrhh diluted with two
ounces of water, with a drachm of laudanum; and in general the
effects have been manifestly  advantageous.   The nipples should
first be bathed in luke warm water, so as to soften and separate the
indurated cuticle, then dried,  and gently rubbed with soft flannel,
as has just been stated, and afterwards washed with  the lotion just
mentioned.  If this course is pursued daily, for  several  weeks
previous to the birth of the child, it  will, in general, obviate all
difficulties in this respect.  Compression of the breasts by corsets,
tight jackets, and stays, during pregnancy, is calculated to inter-
fere very materially with  the function of lactation.   The almost
constant pressure which is thus made on the nipples, forces them
inwards, and frequently buries them in the  yielding substance of
the breasts, so as to render suckling very difficult, and often wholly
impracticable.  The full and regular  development of the mamma-
ry glands too, is doubtless much  impeded by the pressure  which
they suffer in this way.  It is well known  that compression is a
 very powerful means  for promoting absorption; and surgeons
often avail themselves of this measure, for reducing glandular and
other enlargements on the external parts of the body.   We could
indeed scarcely adopt  more effectual means for  restraining  the
 natural growth and development of the breasts than tightly laced
 jackets, stays, and corsets;  and it  is, doubtless, to this circumstance
 that we must ascribe the flat and unfeminine breasts which are so 
         OF THE MANAGEMENT OF NEW-BORN INFANTS.       17

common  among the young females of the present day.   I have
been  frequently struck with the  fact, that in the country, and
among the lower classes of females, who  do not  compress their
chests, by corsets, &c. we generally find a much greater propor-
tion of full and well developed bosoms than in cities and among
fashionable ladies.
   When the nipples are very small or have been forced inwards
by the  pressure of corsets, &c, they should be  drawn out by
means of a suction pump, or with  a tobacco pipe, and all undue
compression of the breasts carefully avoided.  One of the white
earthen tobacco pipes, with a large bowl will in  general answer
this purpose very well.  The effort  of drawing the nipples out,
should be repeated several times daily, until they have acquired a
degree of prominency which will enable the child to lay  hold
of them without difficulty.
                    CHAPTER II.

         OF THE MANAGEMENT OF NEW-BORN INFANTS.

  The proper management and nursing of the infant during the
first few weeks after its birth, has a most important influence on
its future well-being.   Previous to its entrance into independent
life,  the  child enjoys a tranquil  state of vegetative  existence,
removed from the multifarious influences of external causes, with
but a narrow circle of organic actions to perform, and its sensorial
functions in a state  of total inactivity.  How  great the  change
which takes place  at birth!  In  a moment, a multitude of  new
and  highly important relations, are established between its tender
and  uninured organization, and the countless objects of external
nature.  Functions and operations which, up to this period, lay
passive and dormant, are. now suddenly called into action; and the
whole machinery of its system, starts forth  in  the performances
of the harmonious  series of vital  actions.  The air for the  first
time, comes in contact with its body—it rushes into the cells of
the lungs, and respiration is established; the current of the circu-
lation finds new channels,  and abandons those which were  pre-
viously the principal conduits of the vital fluid.  The senses are
awakened, light strikes the eyes, sound the ears, and its teste is
delighted  with  the simple nourishment, formed for it, in the
                   D           3 
18
OF THE MANAGEMENT
 maternal bosom; the sense of touch is acute, it feels the variations
 of temperature,and is keenly susceptible of pain from injurious im-
 pressions, and gratification from soothing and agreeable influences.
 The stomach begins to exercise  its instinctive calls  for nourish-
 ment; urine is secreted, the bowels begin to act, and to eliminate
 their fecal  contents,  and the various secretions subservient to
 digestion are established.  When we contemplate this remarkable
 transition of a most helpless and feeble  being,  from a state of
 repose and  almost total exemption from external  impressions, to a
 mode of existence which subjects its tender and uninured organi-
 zation to the ceaseless influence of a vast  multitude of varying
 agencies, it  would seem truly surprizing, that the new-born infant
 could prolong its existence, even for a lew hours, did we not know
 that the benovolent author of nature,  has endowed every  being,
 with powers adequate, under  ordinary circumstances, to sustain
 the changes and  modifications  which it is destined to undergo in
 the progress of its development from the nascent point, to the full
 state of adult  life.  It is  evident, however,  that this  power of
 accommodation  can  afford  no  protection  against the numberless
 accidental and unnatural impressions which the  new-born infant
 is liable to suffer;  on the contrary, there is  no period of life, in
 which there exists so great a susceptibility to injurious influences,
 as during the early stages  of infancy.  Apparently slight  errors
 during the first few weeks after birth, often  lay the foundation of
 permanent constitutional infirmity; and much suffering or early
 death, is but too common a consequence of improper management
 in relation particularly to the diet, dress, and exposure of the new-
 born infant.
  I. Of the  washing and dressing of the new-born infant.—When
 the infant is  born, and the function of breathing is well established
 it must be carefully  separated  from the mother and  secundines'
 wrapped up in a piece of soft  flannel and handed to the nurse.'
 If the child  breathes  feebly and  imperfectly, or exhibits other
 signs of great feebleness it should not be washed immediately, but
 suffered to remain as quiet and undisturbed  as possible, until the
 vital actions have assumed  some degree of activity.  When  on
 the contrary it  manifests an active state of the vital powers  the
 washing should be performed as soon as convenient after its sepa-
ration from the mother.  It is of importance  that this duty should
be carefully   and thoroughly executed.  The white caseous sub-
stance which is deposited on the surface of  the fetus, during  its
sojourn m the womb, adheres very closely to the skin; and as it
is wholly insoluble in water,  and  but very slightly acted on  bv
soap, it can  never be sufficiently removed, unless some other sub
stance is employed which has the property of rendering it soluble
 For this purpose, lard, or fresh butter, or the yolk of eggs may be 
                    OF NEW-BORN INFANTS.                  19

used.  Before any water is applied to the child's body, the skin
should be smeared and gently rubbed with one of these substances;
after which  the whole may be readily washed off with warm
water and soap.  Dr. Dewees advises that the finest soap should
be selected,  for the  stronger soaps, particularly " the brown and
stimulating soap, called resin soap," is apt to irritate and inflame
the tender skin of the infant, and to give rise to painful and pro-
tracted abrasions of the cuticle.  When the yolk of eggs is used
for  this  purpose, soap  is altogether  unnecessary,  simple warm
water being sufficient to cleanse the surface thoroughly.  It has
been much  disputed whether warm or cold water is most proper
for the first ablutions of the infant.   Under an impression that the
use of cold water  is calculated to invigorate the  infant, and  to
inure it early to vicissitudes of atmospheric temperature, and thus
to obviate, to a degree, the liability to disease from this source,
many physicians have strenuously  insisted on the  superiority  of
cold over warm water for this purpose.   Although there may ap-
pear to be some justice in these views,  yet general experience is
at present decidedly  in favour of the employment of warm water
for washing infants; and a correct view of the circumstances con-
nected with  this subject, gives it also, the decisive sanction  of
reason and common sense.   The infant having never experienced
but one uniform degree of temperature, during the whole period
of its uterine existence, cannot but receive a painful and often
injurious shock when suddenly subjected to the application of cold
water; and  it cannot be doubted, that the immediate exposure
of new-born  children to cold air or water is frequently produc-
tive  of serious maladies.  Were an adult confined for nine months
to an invariable temparature of 98°, and then  suddenly ushered
into  a medium of the temperature of 60°, is it not extremely pro-
bable that it would prove highly detrimental  to his health?  The
occurrence of disease from  much less remarkable vicissitudes than
the one just supposed, is a  matter  of almost daily experience.
How then can it be reasonably  contended  that the delicate,
feeble, and uninured  organization of the  new-born babe, should
be capable of bearing such a transition without experiencing any
injurious impressions.   Indeed, the struggles, the  pale and con
tracted skin, the shrieks, and the trembling which we often wit-
ness when the  infant is plunged or washed in cold water, afford
sufficient evidence that painful, and we may presume, injurious im
pressions are made on its system.  The propriety  of using warm
water is particularly urgent when the infant is feeble.  Doubtless,
with robust and vigorous infants, a salutary reaction often speedi-
ly takes place, under the depressing influence of cold  ablutions;
but where the vital energies are feeble, the reaction may fail, and
a degree of depression be produced, which may place the life  of 
 20                 OF THE MANAGEMENT
 the  infant in imminent danger.   Instead of abstracting heat, we
 find it much  more congenial to  the infanticile system  to impart
 a moderate degree of warmth from without; and  with very deli-
 cate and feeble infants the constant application of a comfortable
 degree of warmth is particularly important.   The water used for
 washing healthy and vigorous infants should be  luke-warm; but
 for such as are weak, water of  a higher  temperature will  be
 proper, and in cases of extreme feebleness, a small portion of wine
 may be  advantageously  added  to the  water.   To remove the
 unctuous  matter already mentioned, a fine  and  soft cotton or
 flannel rag should be used for washing.  This peculiar substance
 is in general, most abundant in the folds of the joints, particularly
 in the groins, and armpits;  and it is particularly important to the
 health and comfort of the child,  that every particle of it should
 be removed from these and other parts of its body.  It is some-
 times impracticable to remove the whole of this matter from the
 folds of the skin  and joints at the first washing, without causing
 too much  irritation by the  rubbing, which it  is necessary  to use
 to detach  it entirely from the skin.  When this is  the case, the
portion that remains may be removed at the second washing.
  Many  are  in the habit of bathing  the head  of the new-born
infant,  with brandy or some other spirituous liquor,  in order as is
imagined, to invigorate its system and fortify it against the inju-
rious effects of cold and other causes  of disease.   This practice
 can serve no useful purpose; and as it may do mischief by over-
 exciting the system as well as by causing pain and  inflammation
of the eyes, it ought to be abandoned.  When the infant is very
 feeble and  languid, a small portion  of some  stimulating  liquor
 may be added to the water in which it is washed; but unless such
 a special reason  for  stimulating applications  be  present,  plain
water is decidedly the most  proper. After the  child has been tho-
 roughly washed, it should be well  dried, and immediately dressed.
 Throughout the whole period of infancy  the utmost  attention
 should  be paid to keeping the child's  body in a state of perfect
 cleanliness.  The ablutions should be performed  every morning
 and evening, though in the  evening, the lower half of the  body
 only need be washed.  It is also  a matter  of very  great conse-
 quence to the cftmfort and health of the infant to keep every part
 of its body dry.   This is  particularly important with those parts
 which  are  subject to friction, from  being in  contact with  each
 other;  as  the nates, the  armpits, groin, folds of  the neck, &c.
 Excoriations and painful  inflammations are apt to occur in  these
 situations, when they are suffered to remain wet or moist.   The
 common  practice of  dusting fine starch or hair-powder over the
 body, with the  view of  keeping the skin dry  and soft, is im-
 proper, and ought not to  be adopted.   It interferes  with the 
OF NEW-BORN INFANTS.
21
regular transpiration of the skin,  and has a tendency to give rise
to a troublesome itching and harshness of the cuticle.  On the ap-
pearance, however, of slight excoriations, a little hair-powder, or
prepared tuttia  may be dusted on the parts with benefit;  but it
cannot be used with advantage as a preventive of such affections.
  II. Of the dress of the  child.—The first thing to be done in
dressing the infant, is to fix  the  remains of the navel string by
surrounding it with a piece of soft dry rag, and supporting it in a
proper position, by means of a roller or bandage, passed round the
child's body.  A simple strip of  flannel, about four inches wide,
is the best material for this purpose. Particular care must be
taken not to draw this bandage too tight round the abdomen.  It
should be sufficiently loose to admit'of the easy introduction of a
finger under it.   If it embraces the body too closely, it occasions
uneasiness, pain, and difficulty of breathing, by impeding the co-
operation of the abdominal muscles, and the free descent of the
diaphragm; at the same time that it tends, very strongly, to favour
the occurrence of umbilical, and particularly scrotal  hernia in
male infants, by its necessary effect of compressing the abdominal
cavity, which, with the forcible descent of the diaphragm in the
act of crying, coughing, and  straining, presses the viscera down,
and forces them through the  natural  openings into the abdominal
parietes.  I have repeatedly known inguinal rupture produced ki
this way.   The bandage should be worn four or five months be-
fore  it is laid aside; and where the parts about the navel appear
to be weak and ready  to yield to the pressure of the viscera, it
will  be proper to continue the use of  the bandage a much longer
period.  Previous to  the  separation  of the remaining  piece of
navel-string, care must be taken not to pull it; and the parts about
the navel should be kept as dry and clean as possible.   A neglect
in these particulars, is apt to  give rise to painful inflammation and
excoriation  of the umbilicus.   " Sometimes the vessels of the um-
bilical cord, which before were distended with blood, will collapse,
the bandage become loose, and the life of the babe be endangered
by excessive bleeding; the state  of  the bandage must therefore,
from time to time, be carefully examined."
  With regard to the clothing of  infants, it may be observed, in a
general way,  that  it should be  warm, light, and  loose.   It is
scarcely necessary, to say any thing, in reprobration of the old,
absurd, and injurious practice of swaddling infants.  This cruel
custom is now universally abandoned by every  civilized people;
and it is surprising that the common sense  and humanity of man-
kind, should have ever permitted its introduction.  To confine and
restrain every member and  almost  every  muscle  of  the  body
in this manner, during the  fragile state of infancy, must be as
detrimental to the health  and regular developement of the child,
as it is cruel and barbarous. 
22                    OF THE MANAGEMENT
  The clothing of infants should  be managed in such a way, as to
protect them against the effects of too high or low a temperature,
and  against sudden  alterations of the air and weather.  In  the
winter, or during cool seasons, flannel forms an essential part of
the clothing.  The  lightest and softest  kinds  of  flannel should
be selected.   In new-born infants of a feeble and languid habit,
the use of flannel next the skin, is particularly useful.   During
the first few months after birth, warmth is always peculiarly con-
genial to the infantile system; and where from  feebleness,  the
developement of the animal temperature is not very rapid,  it i3
particularly necessary to use flannel clothing, so as to favour the
accumulation of warmth in the child's body.  Besides the useful-
ness  of  flannel  as a means for obviating the depressing  and
injurious effects of cold and atmospheric vicissitudes, benefit may
also result from its gentle  stimulating impressions on the surface
of the body, by which the blood is solicited to the external capilla-
ries and unfavourable congestions obviated in  the internal organs.
During the warm  seasons, the flannel should be substituted by
muslin; but the moment that any sudden reduction of the atmos-
pheric temperature takes  place, the use of the  flannel should be
resumed.  Common  sense indeed, dictates the propriety of con-
stantly accommodating the clothing to the varying states of the
weather, and when  this  obvious duty is not  attended  to, much
disease and suffering is liable to  occur, which under a more pru-
dent management  in  this  respect, would be prevented.  In  the
summer season,  infants  are often exposed to unpleasant conse-
quences from being too thickly and warmly covered while sleep-
ing.   The infant with its usual quantity of clothing, is often laid
on a bed of feathers or down, into which its body sinks, and a thick
cover thrown over it; from which it is generally taken  up when
it awakes,  bathed in a copious  perspiration and of course  par-
ticularly  predisposed to receive  injury, should  it happen to be
immediately exposed to a current of fresh and  cool air.  There
can be no doubt that catarrhal  and bowel complaints are fre-
quently produced  in this way.   I  have known a  case  of fatal
cynanche trachealis speedily excited by carrying a child, taken
out of its cradle, in a state of free perspiration, into  a draught oi
cool air.  It is proper to observe, that the child should never be
suffered to  sleep in the flannel which has been worn during  the
day and in the morning it  must again be changed.
  During the first eight or nine months, the child's clothes should
be long enough, to extend considerably beyond  the feet, in order
that  the  lower parts of the body may be duly protected, against
the effects of cold and the variations of temperature.  After this
age, however, the  feet should be entirely unincumbered by the
clothing, so as to permit the free motion  of the inferior extremi- 
OF NEW-BORN INFANTS.                 23
ties.  During  cold weather,  fine woollen stockings,  sufficiently
wide to be easily put on and  to prevent every degree of compres-
sion, should be worn; but in  warm weather light and  soft flannel
socks will suffice.  The shoes should be made of light and pliable
materials, and sufficiently large to prevent all constraint of the
feet.   Some  writers  object  to putting shoes on infants.  It is
alleged that they tend to cramp the feet  and restrain their free
motion, and that consequently the child " does not learn to walk
so early, as when the feet are unincumbered by shoes." v These
objections, however, maybe obviated, "by having the shoes made
large and of the most pliant  materials;" and I fully accord  with
Dr. Dewees in the opinion, "that as  shoes afford protection from
cold, and security against accident when the child is placed upon
the floor,  especially on carpeted floors, where  pins, needles,
and other  sharp  substances,  are often concealed, they can not,
with perfect propriety, be dispensed  with."   The use of shoes is
decidedly proper when the child is. carried out of doors during
cold weather.   In very young infants, thin  woollen  socks will
protect the feet sufficiently during the warm seasons; but when
they are about  learning to  walk, it is best, for the reason just
quoted, to have  the feet invested in  shoes made of very soft and
light materials.
  It is highly important that the child should  be kept as dry as
possible.  Wet diapers or stockings,  when suffered  to remain on
the child for some time, are apt to give rise to bowel complaints
and  febrile affections,  more  especially during the cold seasons.
They tend moreover very strongly to favour the occurrence of ex-
coriations, and painful irritations of  the skin about the groin and
nates.   The  under-clothes  of  the  child should be  frequently
examined, and if any part is found to be wet, it should be imme-
diately removed and substituted by a dry and clean one.
   In  dressing children there ought to be as  few pins used as
may be practicable, for the proper, adjustment of the  clothes.
Children are frequently much injured by the points of pins being
accidentally directed inwards in handling them, or by their own
movements.  I have witnessed several instances of very unpleasant
consequences  from this source; and the instances  of slight but
painful punctures and scratches from pins  used in the dress of
infants are very  common.   Tapes and strings should therefore be
used instead of pins, whenever  they can be made to  answer the
purpose.   If pins are used at all, the larger kind should  always
be selected; for the  small pins now in general use, are much more
apt to slip through the clothes and  consequently to  wound the
skin than the larger kind (Dewees).
   Before leaving this subject it will be proper to say something
concerning the usual mode of dressing children, so as to leave the 
04                  OF THE MANAGEMENT

neck, upper part of the chest, and  forearms  perfectly  bare.
Whilst adults are careful to keep these  parts well covered and
protected against the influence of cold, children  are almost uni-
versally suffered to be without  such  protection; and the nudity
of the neck and arms is generally continued, until they are four or
five years old.  It has been  supposed that this custom is one  of
the principal reasons why inflammatory affections of the respira-
tory organs are so much more common during the period of child-
hood, than at a more advanced age; and there can be  no  doubt
that its influence, in this respect, is very  considerable.   Nothing
is more common than to see children out of doors, with  the arms
and  upper parts of the chest, completely exposed, even in  damp
and cold  weather; and it cannot be believed that such exposure is
unattended with  risk of injurious consequences.  Croup, inflam-
mation of the lungs, catarrh, and general fever are doubtless  fre-
quently the consequences of this irrational custom; and it  is not
improbable that the foundation of pulmonary consumption is often
thus laid, during the first few years of  life.   This custom,  there-
fore,  ought to be  abandoned,  as one of a  decidedly  injurious
tendency, more especially during the cold  and variable seasons.
During the warm months of summer, the arms, and neck may be
left bare,  without any particular liability to injurious consequences;
but every part of the chest should at all times be protected with
suitable clothing.  It  is generally supposed that  the usual  mode
of dressing children, is calculated to inure  them to the impressions
of cold,  and to obviate the liability to disease from  this cause.
Doubtless this may be the result with those who survive the ex-
periment; but before the system is thus inured, the child may be
carried off by some  inflammatory affection, produced by such ex-
posure.   It is certainly a most inconsistent practice to expose the
breast and arms during the  weak and tender age of childhood,
and yet to deem it necessary to keep these parts carefully covered
after the system has acquired firmness and its full powers of vital
resistance by a more mature age.
  The universal custom of covering the infant's head with a cap,
is of very doubtful propriety.  There is naturally a strong tendency
to a preternatural determination of blood to the  head during in-
fancy; and  the  predisposition  to  inflammatory  diseases of  the
head, is confessedly, much greater during this early age, than  at
any  other period of life.  If the rule  to " keep the head cool," is
ever applicable, it is particularly so during infancy.  In cold and
damp weather, a very  thin and  light  hat may be proper; but
during the warm seasons, it will be conducive to the child's com-
fort and  health to suffer the head to be  wholly  uncovered; and
even in winter, if the child's head is well  covered  with hair, and
it  be confined within doors, caps may  be very prudently dis-
pensed with. 
OF THE NOURISHMENT OF INFANTS.            25
                   CHAPTER  III.

              OF THE NOURISHMENT OF INFANTS.

  There is probably no single source of disease, during the first
few years of life, whose influence is so extensive and destructive,
as improper management in relation to the diet.   The foundation
of irremediable chronic diseases, and of constitutional infirmity,
throughout the subsequent period of life, is often laid within the
first  month, or even first few days after birth, by errors of  this
kind; and a great amount  of the suffering and mortality which
occurs during  infancy, must be  ascribed to the same prevailing
source of injury and disorder.   The almost universal custom of
feeding children with inappropriate articles of food, very soon after
birth, is extremely reprehensible.  No sooner is the infant washed
and  dressed, than the nurse is ready  with her spoon and cup of
gruel, pulverized crackers dissolved in water, or some such prepa-
ration, to fill  its  stomach to the utmost of its capacity; and this
process of stuffing is continued with a ruinous degree of diligence
and  perseverance.  The tender and uninured  digestive  organs
of the new-born babe are thus often seriously injured during the
first twenty-four hours.  Nature herself seems to point out the
impropriety of this practice.  She  withholds  the  nourishment
which she provides, until many hours after birth.  It seems highly
improbable, if it were necessary that the infant should receive
nourishment soon after birth, that  the  appropriate alimentary
fluid should be so tardily furnished.  We no where find such an
inconsistency  in nature.  It is true, indeed, that the secretion of
milk in  the maternal breasts  is often delayed a much longer pe-
riod, than it would be prudent to withhold nourishment from the
infant.  Still  we perceive, in this arrangement,  that aliment is
not  necessary to  the welfare of the child very soon after its birth.
It cannot be presumed that  the activity of the digestive organs,
and a demand by them  for nourishment is immediately awakened,
on  the child's entrance into the world.   We  no  where  see a
physical want established  without  the appropriate means  being
furnished for  satisfying it.   I do not indeed, mean  to inculcate,
that nourishment is to  be entirely withheld from the infant until
the milk is secreted; but I am persuaded,that with healthy infants,
                  E 
    2   26                  OF THE NOURISHMENT
    |   several hours, at least, should be suffered to pass immediately after
        birth  before any alimentary substances are  introduced  into its
   "sj   stomach; and I would most strenuously insist on the importance
    i   of exhibiting but small portions at a time, and at such intervals, as
    1   will obviate all risk of overloading or distending the stomach. This
    ¥   latter error is the most to be deprecated.   A few tea-spoonfuls of
    §   some very bland and weak fluid, could not be deemed detrimental,
   4^   though given immediately after birth; but the usual  practice of fil-
    «   ing the stomach to overflowing, and keeping it in this state of ful-
    J   ness and distention, is most ruinous to the health and comfort of the
    h   child.  At every period of life over-distention of the stomach, by
,**■  &  food or drink, is one of the most certain and  powerful causes of
        indigestion;  and we can scarcely conceive it possible, that  the
        tender and uninured  stomach of the new-born infant, can  escape
        serious debility and irritation, when early overcharged with food
        even of the mildest kind.  The digestive powers of the stomach being
        thus prostrated or enfeebled, all the harassing and painfal conse-
        quences of indigestion ensue.  Acidity, flatulency, colic, diarrhoea,
   £    vomiting, green and  griping stools,  emaciation, not  to mention
   »    other  distressing and dangerous symptoms inevitably  supervene.
  ^    In nine cases out often, perhaps, the griping, flatulency, diarrhoea,
   <4    and colic which so frequently harass infants, during the first half
   ?    year after birth, are the results of indigestion, brought on by errors
        in diet.   Not  unfrequently  the digestive  powers are effectively
        prostrated by the first feeding.  Conceiving that, as the child has
        been fasting during the long period of nine months, it  must needs
        come  into the  world  with an excellent appetite, and an imme-
        diate demand for nourishment, ignorant nurses—(and the ignorant
        are incomparably most numerous) deem it their duty,  to be most
        vigilant and industrious in charging the infant's stomach with some
        alimentary substance—often  extremely inappropriate.  To relieve
        the colic, griping, flatulency, diarrhoea, &c. which ensue, recourse
        is had to  cat-mint tea, anniseed tea, Godfrey's cordial, paragoric,
        or some other palliative or nostrum, and thus an additional source
        of gastric derangement or indigestion is brought into operation.
        The  screams and restlessness of the infant occasioned  by  the
        griping and colic, are frequently regarded as manifestations of
        hunger.   To appease this supposed craving, the stomach is almost
        constantly kept in a state  of distention with food;   and thus the
        helpless babe has no chance of escaping from the torments and
        ruinous consequences of its unfortunate condition.  Very vigorous
    & i and healthy infants often pass through the gastric irritation and dis-
    J^jt tress produced by improper nourishment soon after  birth, without
     \ sustaining any permanent  injury in health or constitutional infir-
   ^f^ mity.   After four or five months of flatulency, griping, &c, the
    <jN digestive organs gradually become inured to the impressions of the
r-
 i

,•4 
                         OF INFANTS.                       27
 food, and a considerable degree of health is obtained.  .In many
 cases, however, the irritation which is  thus kept up in the stom-
 ach and bowels, does not pass  off in so favourable a manner.—
 Jaundice, chronic and unmanageable diarrhoea, emaciation, slow
 fever, enlarged mesenteric  glands, dropsy in the brain, scrofula,
 chronic affections of the liver, epilepsy, and other dangerous ma-
 ladies, may, and not unfrequently do, result from this state of the
 alimentary  canal,  during  infancy.  Great distress and  suffering,
 are  sometimes witnessed during the early period of infancy, from
 indigestion, and consequent gastro-intestinal irritation, even where
 the  child is wholly nourished  by the breast.  For when, during
 the time which intervenes between the  secretion of milk, and the
 birth of the child, crude  articles of nourishment are superabun-
 dantly introduced into the infant's stomach, the digestive functions
 are  often, at once, so deranged  and  impaired, that  even the
 wholesome  and congenial fluid furnished by the maternal breasts,
 will not be  easily  digested;  and acidity, flatulency and  colic will
 continue to  harass the child, until the digestive powers  gradually
 acquire a greater  degree of vigour.
   That the jaundice of infants is generally produced by dispep-
 tic irritation, I have not the slightest doubt.   Mucous irritation
 of the  duodenum, is  now well known to be an active and fre-
 quent source  of this  malady; and this  affection  is very rarely
 found to occur in  new-born infants without being preceded by
 decided manifestations of irritation of the digestive organs.   Let
 the child's stomach be once or twice filled during the first twenty-
 four hours with gruel, or any of the ordinary preparations em-
 ployed by nurses for this purpose, and the chances will probably
 be as ten to one, that acidity, vomiting, colic, griping, and jaun-
 dice will supervene.  There is assuredly no period throughout
 the whole course of life, in which the  observance of caution, in
 relation to the ingesta is of greater moment  than in the compara-
 tively short  interval which passes between the birth of the infant,
 and  the secretion  of its  natural aliment.  If the powers of the
 stomach are not  prostrated during this short interval, which by
 the customary mode of management is seldom  avoided, and the
 child is  fortunate  enough to  be nourished  by its mother's milk,
 the  ordinary  gastric  disturbances of infancy will  rarely super-
 vene.  Alimentary ingesta, are not, however, the only sources
 of direct gastric irritation and indigestion at this early  period of
 life.  Much mischief is, doubtless, often done, by the means em-
 ployed for removing the meconium.  Active purgatives are some-
 times given  for this purpose; and there is much reason for belie-
 ving that the infant's digestive  functions are often injured in this
manner.  I have  hitherto dwelled especially on the importance
of withholding  nourishment from  the  child, immediately  after 
98
OF THE  NOURISHMENT
 birth, and before milk is furnished by the maternal breast.  I am
 induced to be the more urgent on this point, because many who
 would  not think of feeding the child, after the breasts supply a
 sufficient quantity of the appropriate nourishment, consider it ne-
 cessary to do so before the milk is secreted, lest it may suffer
 from want of nourishment.  I have already stated that there can
 be no objection to the exhibition of small portions of some very
 mild and simple fluid to the infant, previous to its  receiving nour-
 ishment from the breast; and when the secretion of milk is consi-
 derably delayed, this measure will even be  proper.   A mixture
 of two parts  of fresh  cow's-milk, and one part of warm water ap-
 proaches nearer to the nature of human milk than any thing else
 that can be conveniently procured.  Of this a few teaspoonfuls
 may be given from time to time, carefully avoiding overcharging
 the stomach, until the mother's breasts  are  ready to  yield their
 more congenial nutriment.  In order to excite the  early secretion
 of milk, it will be proper to let the  child draw the breasts, for a
 few minutes, soon  after the mother is comfortably fixed in bed,
 provided her health and strength will admit of it.  After the se-
 cretion of milk is once fully established, and furnished in sufficient
 quantity, the infant should be nourished exclusively by the breast.
 Not even the mild and  simple  fluid just mentioned should be al-
 lowed, unless some special reason exist for the use of additional
 nourishment.    It  seldom occurs  in healthy mothers,. that the
 quantity of milk supplied by the breast is not sufficient to afford
 adequate  nourishment  to the  child for  the first  two  or three
 months, and in general much longer, without the necessity of any
 additional  artificial food.  Should it be  otherwise, however, or
 should there be an inability of suckling the child, in consequence
 of the mother's ill-health, or disease of  the breasts, the mixture
 of milk and  water mentioned above, should constitute the sole
 aliment, until the primary teeth make their appearance; or what
 is  still more  suitable, a healthy and fresh wet-nurse should  be
procured.
   There is no  substance in nature, nor  can there be any thing
prepared by art, which forms so congenial and wholesome a nou-
rishment, during the early period of infancy, as the human milk.
When it is supplied  in sufficient quantity, no other alimentary
substance ought to be  given, during the first three or four months
after birth.   It seems, almost  superfluous to  remark that nature
manifestly intended this fluid, as the sole nutriment at this early
stage  of life.  Throughout the whole range of the higher orders
of animated  beings, the structure of the mouth, particularly in
relation to the absence or presence of teeth—their conformation
position and  situation,—furnishes unequivocal indications,  as  to
 the kind of food most appropriate and salutary.   The, same re- 
OF INFANTS.
29
lation between the  condition of the  mouth, in this respect, and
the kind of aliment best adapted to the welfare of the system,
occurs during infancy; and  an attention  to  this circumstance,
affords a good general index, as to the kind of diet best suited to
the new-born infant, and the changes which it will  be proper to
make according  as  it advances in age.  The infant  comes into
the world with soft and toothless gums,—full and prominent lips,
and an instinctive ability and readiness to  grasp the nipple with
its tongue and lips, and to perform  the actions of suction in the
most perfect manner.  For a considerable time it remains wholly
incapable of performing the mptions of mastication.   It is  evi-
dently the design of nature, that the infant shall obtain its nutri-
ment by suction; and as the maternal breasts with their grateful
and congenial lacteous fluid, correspond with this arrangement
and intention of nature, it is  manifest, that these  constitute the
only natural and truly appropriate source of nourishment during
early infancy,
   The  infant  should be nourished exclusively by the breast, until
the first teeth make their appearance.  No  other kind  of nou-
rishment whatever, should be allowed, anterior to  this period,
unless from deficiency of milk or some other cause, the use of ad-
ditional  aliment becomes  necessary.   After  the first teeth have
come out, small portions of barley-water, thinly prepared arrow-
root, or a mixture of equal parts of cow's-milk and water, may be
given two or  three times  daily, in  addition  to the nourishment
drawn from the  breasts.   I  do not  mean to say, that when the
child arrives  at this  stage, it becomes necessary, or even deci-
dedly proper, as a general rule, to exhibit any additional articles
of food.   In  general, however, the simple and mild liquids, just
mentioned, may  be given  at this period, with very little risk of
unpleasant consequences; for  the  digestive organs have, by this
time, acquired a degree of power and activity sufficient to obvi-
 ate the painful and disturbing effects which would arise from the
 use of such food during the  first four or five weeks after birth.
 I have very rarely known any  ill consequences to occur, from the
 moderate use of the  articles  of nourishment just mentioned, at
 this period of infancy; and I am satisfied, that when the breasts
 do not furnish a sufficiently copious supply of milk, they may, in
 general, be resorted to, with perfect propriety.  It is particularly
 important  however, when additional aliment  is used, to avoid
 overloading the stomach;  for  over-distention, seldom fails to im-
 pair the tone of the stomach, and to give rise to dyspeptic distur-
 bances.   It is also of much consequence that the food should be
 introduced into the stomach, as gradually as practicable.  In
 suckling the child receives its nourishment very gradually; and
 this should be imitated, when  artificial food is given by the hand.
                              4 
 30                  OF THE NOURISHMENT
 This can  be most conveniently done by causing the infant to
 suck the fluid aliment from a bottle, furnished with the usual
 silver tube,  the  mouth-piece of which  is pierced with a small
 orifice.  By this  contrivance, the child  will receive its food in
 the same gradual manner, as when nourished at the breast, and
 it will rarely take more than its appetite  calls for, an error which
 is frequently committed when fed  with  a spoon.  After the se-
 venth month, small portions  of the preparations of food just  men-
 tioned, should be given at regular periods, three or four times
 daily.  This  will prepare  the  infant,  for  the sudden  change,
 which it has to undergo in  the character of its  food, when it is
 weaned; and thereby tend  to lessen the liability to unpleasant
 consequences from the  change.   Infants who have been mode-
 rately fed  with suitable articles of food, sometime previous  to
 weaning, almost  always accommodate  themselves much more
 readily and with  much  less uneasiness to the change, than such
 as  have seldom or never received any  other aliment, than that
 which they draw  from the mother's or nurse's breasts.
   If the appointments of nature, and experience shew that human
 milk is the appropriate  aliment during infancy, it is manifest that
 the  mother's breasts  constitute the only genuine fountain  from
 which this delicious and congenial  nutriment is to be drawn bv
 the  infant.   Mothers ought never to delegate the suckling  of
 their infants  to others.  This sacred office should rest with the
 mother alone.  It is an irremissible duty, which can never be ne-
 glected or put off, without contravening the wise and benevolent
 arrangements of Providence.  The  mother who submits the suck-
 ling of her infant to another, while her own breasts are ready to
 furnish an ample supply of milk, can scarcely possess an amiable
 and  moral heart.  It is indeed a most extraordinary circumstance,
 that a duty which is so strongly enforced by the commands of
 nature, and which is connected with so many delightful and hal-
 lowed sentiments  of the maternal heart, should ever be volunta-
 rily relinquished.   Did  we  notice this unnatural and cruel prac-
 tice  only among the low and ignorant, we might ascribe it to that
 blunted sensibility and  obtuse moral  feeling which  is apt to be
 engendered by the privations and hardships of poverty.   But it
 is not so.   It is only  among educated, refined  and polished fe-
 males, that we witness the appointments  of  nature, and the
decencies of  maternal conduct thus outraged.  It would seem as
if  the higher refinements of civilization  tended rather to stifle
 than to cherish the pure and instinctive sentiments of the heart'
and to substitute the dictates of fashion for the original and uner-
ring impulses of nature.
  As it is manifestly the design of nature, that the infant should
 draw its food from the mother's breasts,  it is reasonable to  pre- 
OF INFANTS.                      31
sume that this design cannot be contravened, without  subjecting
both mother and infant, to an increased liability to injurious con-
sequences.  It can scarcely be doubted that the mother's milk, is,
in general, better adapted to the  constitutional temperament of
her  offspring, than that furnished by others.  Besides, when the
suckling of the  infant is submitted to a nurse, it is liable to vari-
ous sources of injury and disorder,  which are in a great degree, if
not entirely obviated, when this important  duty is performed  by
the mother. The nurse may not  be able to furnish a sufficient
supply of milk to afford adequate nourishment to the infant.   This
is by no means uncommon.  Nurses often practise great deception
in this respect.  In order to obtain employment, or retain their
situation, they will declare  that they have an abundance of milk,
when, in truth, the very reverse  is the case.  To supply this de-
ficiency of milk, the  wily  nurse will resort to clandestine feeding;
and as this is generally done in a very improper way, the child
usually fares much worse, than if it had been, from the beginning,
nursed exclusively by appropriate artificial food.  The food which
is thus secretly hurried into the stomach of the child, never fails
to give rise to griping, flatulency, colic, diarrhoea, and fretfulness.
To allay these sufferings, carminatives and anodynes are privately
resorted to; and thus, whilst the parents suppose that the infant
enjoys the advantage of proper nursing, its health,  and even life
are often sacrificed  to the  secret practices of a mercenary and
unprincipled nurse.
   The child, also,  runs much more risk of receiving bad and
unwholesome milk, when suckled  by a hired nurse, than when
this office is performed by the mother herself.   I have known
several  instances  of most  serious  injury inflicted on  the  child's
health and constitution in this way.  That syphilis may be, and
has been communicated through the milk of the nurse, I have not
the smallest doubt;  and  the communication of other loathsome
diseases, by nurses,  to their nurslings, such  as itch, tetter, &c, is
by no means uncommon.   But even where no specific disease of
this kind, is contracted, the general health and constitution are
often permanently injured  by the  unwholesome or uncongenial
 character of the  milk furnished  by the nurse.  When the milk
of the nurse is of a bad quality, it usually produces very obvious
disturbances in  the digestive organs of the  infant.   The stomach
 and bowels become weak and irritable.   The child vomits fre-
 quently, or is harassed by painful and watery diarrhoea.  It becomes
 restless, fretful, and peevish; its flesh wastes and becomes flabby;
its countenance assumes a  distressed, pale,  and sickly aspect; its
sleep is  disturbed by sudden starts;  it often cries out suddenly,
as if in violent  pain;  and, in most instances, fatal irritation, and 
32
OF THE NOURISHMENT
effusion in the brain,  finally ensue, and  terminate  the  infant's
sufferings.
  Besides the foregoing sources of injury to the health and com-
fort of the infant, there are many others, scarcely less detrimen-
tal in  their tendency,  incident to wet-nursing,  and which can
seldom be wholly avoided, when this mode of nursing is adopted.
To attend  properly to  an infant, by day and by night,  requires
sacrifices of ease and comfort, on the part of the nurse, which are
not often fully submitted to by hired nurses.   The mother  alone
can experience those  instinctive  and  anxious promptings, to ad-
minister to the wants  and comforts of her  offspring, which are
necessary  to  secure the faithful  performance of this important
duty.  Children often suffer much from the indolence and care-
lessness of nurses.  They are suffered,  frequently, to lie,  for
hours, in their  wet and soiled diapers, and  to  remain for days
without proper ablutions.  Much  neglect too, is sometimes prac-
tised in suckling  the infant.  Its stomach is now engorged with
milk, that  the  nurse may have time  to walk out, or attend  to
some of her own affairs, and then, all nourishment is withheld for
an unreasonable length of time.   At night particularly, the nurse
is too indolent or too sleepy to keep the child clean and dry, and
to apply it regularly to the breast; and in order that it may not
disturb  her rest, laudanum, paregoric, or some other anodyne, is
clandestinely given to the little victim.  The same culpable prac-
tice of stupifying the  infant with laudanum, is often resorted  to
during the day, in order that the nurse may attend to some affair
of pleasure, or business on  her own account.   These are not ima-
ginary charges.  I have repeatedly known them practised* where
such mismanagement was not suspected;  and too much vigilance
cannot be exercised in  observing and scrutinizing the conduct  of
nurses.  It is to be  observed  moreover that the child is liable  to
very serious injury from irregular habits on the part of the mo-
ther.   Intemperate  nurses are particularly to be reprobated.  I
have, in several instances, known infants to be very seriously in-
jured by nurses of this  description.  Women who hire themselves
out for wet-nurses, appear to  be more liable to  this vice, than
almost any other class of females.  Under an idea, that  while
suckling, they require some stimulus to support their strength
and to promote the  secretion of milk, they are apt to drink freely
of malt liquors, which  often leads them, in the end, to resort  to
the more ardent alcoholic  liquors.  Thus, the habit of intempe-
rance is sometimes formed; and although they may not drink  to
the extent of producing intoxication, yet the milk  will become
unwholesome and injurious to the infant nourished by it.
  From the foregoing remarks, founded on experience and obser
vation, the impropriety of excluding the child from the mother's 
                         OF INFANTS.                       33
breasts,  and submitting it to the nursing of a stranger, is very
manifest.  To be obliged to procure a wet-nurse is always  an
evil,  and cannot  but  be viewed  as  such, by every sensible, hu-
mane, and good mother.
   Unfortunately, however, mothers are not always in a condition
which enables them to suckle their own infants; and the employ-
ment of a wet-nurse, or recourse to artificial nursing, is unavoida-
ble.  The causes which may prevent the mother  from nursing
her child are:  1, A  decided deficiency, or total failure in the  se-
cretion of milk, in consequence of organic disease  or functional
torpor of the breasts.   2, A bad state of milk, rendering it deci-
dedly prejudicial to the health of the child.   3, The presence
of a morbid taint, or some communicable  chronic disease  in the
maternal system. . 4,  When suckling  gives rise  to painful  or
dangerous affections in  the  mother, as colic, cough, distressing
nervous affections, great weakness, epilepsy, &c.
  When causes of this kind render it improper or impracticable
for the mother to nurse her child, it  then becomes a question
whether a  wet-nurse  should  be  employed, or artificial nursing
resorted to.   If a healthy, fresh, and faithful  nurse can be pro-
cured, this mode of nourishing the infant, is certainly preferable
to artificial nursing.   It is not often, however, that a nurse can
be obtained who is, in all respects, well qualified  for this  office.
In general, a nurse who has no child  of her own to  take care  of,
is much to be preferred  to one who  has  this additional  charge;
more especially when  the infant intrusted to her care, is removed
from  the immediate observations of its parents.  The foster-child
is always more or less  neglected when the nurse has an infant of
her own to attend to.   If there is a  deficiency of milk for both,
the promptings of maternal feeling, will  be  very apt to favour
her own child; and, if the latter should become sick, and require  t
particular attention, the foster-babe  will seldom  receive proper
nursing.  When the wet-nurse is received into the parents' house,
the superintendence  of the mother, may, in general,  prevent such
misconduct on the part of the nurse; but when the child is nursed
out of the house, and removed from the presiding care of a watch-
ful  parent, the probability of its being neglected and maltreated
is always very considerable.  It would, in  general, be much bet-
ter to nurse the child artificially, under the eye of its mother,
than  to place it entirely at the mercy of the wet-nurse.   Nurses,
doubtless, are sometimes found, to whom  a child  may be  safely
intrusted;  but  experience  has but  too  often shewn that the
reverse is much more common.
  Attention must also  be-paid to the previous and  present health
of the nurse.   No woman, who has  led a debauched course  of
life, even though reformed, can be regarded as a perfectly safe
              F             4* 
 34                  OF THE NOURISHMENT.
 nurse, however careful  and attentive she might otherwise he*
 Females of this description are apt to have their systems contam-
 inated with some morbid taint, which may give an  unwholesome
 quality to the milk, and injure the child's constitution.   The ex-
 istence of scabby or scaly eruptions  on the skin, unless they are
 of transient character, and of chronic ulcers, particularly on the
 legs, should be regarded as  sufficient  objections to a nurse.  A
 manifest scrofulous habit, also, is decidedly objectionable.  The
 age of the milk is another point of considerable importance.
 Milk that  is six or seven  months old, seldom agrees well with
 infants  during  the first two or three months after birth.  In gen-
 eral the milk becomes much more  rich and nutricious after the
 fourth month, than  it is previous to this  period;  and hence milk
 of this  kind, from  its requiring stronger digestive powers than
 younger milk, often gives rise to much  disturbance  of the stom-
 ach and bowels in  new-born infants.  As a general rule, there-
 fore, the age of the milk, should not vary much from' that of the
 child, up to about  the  fourth  month*   After this period, such a
 relation between the ages of the milk  and child is  not  of much
 importance; for a child five or six months old  and upwards, may
 be well and safely nourished by a fresh breast.
   The occurrence of the menstrual evacuation, during lactation
 is  almost invariably attended with diminution  and  deterioration
 of the milk;  and constitutes a well-grounded objection to a wet-
 nurse.   This is more especially the case  during the first three or
 four months of  infancy.  When a child, at this  early period, is
 put to the breast  of a nurse who menstruates, it rarely fails to
 experience derangements of the stomach and bowels.  After the
 seventh or eighth month of age, there is much less inconvenience
 and disorder to be apprehended from this source; but even at
 this advanced period of infancy, the milk of a nurse, thus circum-
 stanced, may give rise  to disturbances in  the digestive organs,
 and should, if possible, be avoided.  Nature, here,  as elsewhere,
is a safe'guide.   We perceive that menstruation is almost univer-
 sally suspended during the period of suckling; and we may pre-
sume that this arrangement of nature is designed  for some useful
purpose—for the well-being, doubtless, of the infant.   Nature,
therefore, as  well as experience, indicates the propriety of with-
holding the  breast  from the  child, when from constitutional
peculiarity, or some accidental influence, the menses make their
appearance in the nurse.
  A nurse who  has but one good breast should never be selected.
A  child suckled by one  breast  only,  is  apt to contract the habit
of squinting, from having its eyes constantly directed to one side;
 and there is also some risk of its head and shoulders acquiring an
oblique  or  crooked form.  Even when both breasts are perfect 
OF INFANTS,
85
and exuberant, some nurses are disposed  to  suckle principally
with one only.   This should not be permitted.   The child should
be  nourished alternately  from both  breasts.  Some  attention
should also be paid to the nurse's nipples.   If they are very small,
the child will be apt to  fatigue itself in sucking, without being
able fully to satisfy its wants.   This defect can seldom  be  pro-
perly remedied.  The practice of drawing out the nipples by
suction, with a tobacco pipe, will be of advantage;  but when the
nipples are  very small, and deeply imbedded in the breast, it can
scarcely remedy the evil.  In  some instances the  nipples yield
the  milk so freely, that the  child is continually harassed  by a
sense of strangulation, while  suckling, from inability to swallow
as rapidly as the milk issues into its mouth.   This  may, in gene-
ral, be  remedied  by passing  a piece of fine tape pretty firmly
round the base of the nipple; or the nurse  may compress the
nipple moderately between the first and second  fingers, while the
child is suckling.      i
   Finally,  particular regard should be had  to the temper and
moral babits of the nurse.   An  irritable, passionate,  and  sour-
tempered female is but  illy suited for this important duty.   Not
only is the  child liable  to be maltreated by a nurse of this  char-
acter, during the fits of  ill-nature and passion; but the most seri-
ous and alarming effects may be produced on its tender organiza-
tion, by the milk  of such a nurse.  It is well known that violent
anger, and  habitual sourness of temper are peculiarly apt to give
a pernicious quality to  the milk.  Children have been thrown
into convulsions, by suckling soon after the nurse has been agita-
 ted by violent anger or rage; and alarming vomiting_and purging
 is particularly apt to occur from this cause.   Indeed every kind
 of inordinate excitement, or depression  of the mind is unfavoura-
 ble to  the  secretion  of healthy milk.  Protracted grief, sorrow,
 or mental distress and anxiety in  the nurse, seldom fail to exert a
 prejudicial influence on the health of the nursling.  This circum-
 stance ought not to be overlooked, in choosing a wet-nurse.  Wo-
 men, whose domestic relations expose them to moral affections
 of  this kind, cannot  be regarded as well adapted for this office.
 Tranquility of mind, and evenness of temper are  particularly
 desirable in a nurse; and no female ought to be admitted to this
 duty, who  is, either by temperament, or extraneous circumstances,
 placed in an opposite condition.
    Artificial Nursing.—Under judicious management, infants will,
 in general, experience no particular inconvenience from a course
 of artificial nursing; and, as  a general rule, this mode of nourish-
 ing children, when properly conducted, is upon the whole prefer-
 able perhaps, to the employment of a wet-nurse whose competency
 and fitness is equivocal.   This preference, however, is founded 
36                  OF THE NOURISHMENT

rather on the greater risk which the child incurs of being mal
treated and neglected, when submitted to the exclusive care of a
wet-nurse, than when nursed artificially, under the immediate su-
perintendence of a  parent; for there can be no doubt, that fresh
human milk, v.rhcn  uncontaminated, is always  the best possible
nourishment for infants.
  There are indeed  circumstances, in relation to the condition
of the child, which  render the employment of a wet-nurse, not-
withstanding all the  risks  that  have  been mentioned, decidedly
preferable to artificial nursing.   Very young, and peculiarly del-
icate and feeble  infants, seldom do well when raised by the hand.
Fresh and wholesome milk from  the breasts of the mother, or a
healthy nurse, is almost- indispensable  to the  well-being of an
infant  thus  circumstanced.   The  same  observations  apply  to
infants, whose stomach and bowels  are peculiarly weak and irri-
table, and  consequently particularly  liable to disorder, from
even slight sources of gastro-intestinal irritation.  Finally, if upon
trial, the slightest and most appropriate kinds of artificial aliment
are found to disorder the alimentary canal, the life of the infant
will very probably depend, on its being nursed by a fresh and
wholesome breast.
  In many instances, however, it is  wholly impracticable to  pro-
cure a suitable wet-nurse, and artificial nursing becomes unavoid-
able.   Sometimes the mother, though incapable of supplying a
sufficient quantity of nourishment by  the  breast, is still  able  to
furnish small portions of wholesome  milk, and when this is the
case she ought by all means, to continue suckling the child,  in
conjunction  with the use of artificial nourishment.   The kind
of aliment which should  be employed, and the  mode of  feeding
proper, in cases where there  is  a deficient  secretion of  milk in
the maternal breasts, have been pointed out.  A mixture of two
parts  of fresh cow's-milk, and one  part of warm water, with a
very small portion of sugar will, in general, answer the purpose
better than  any other article of food, that can be  contrived.
Thin barley-water,  or a  very liquid preparation of  arrow-root,
will sometimes be useful as a change of nourishment, where, from
accidental weakness, or  a prevailing  acidity in the stomach, the
milk curdles, and causes griping.  As has already been  men-
tioned, the sucking-bottle is decidedly the best mode of  feeding
the child.   Particular care should  be taken to keep the bottle
perfectly clean and  sweet.  It.. should be well  washed, both in-
side  and outside, with hot water, every  morning  and evening.
The same food should not be suffered to remain in the bottle more
than three or four  hours.  When kept too long it is apt to turn
sour, and to  become injurious  to the child's stomach and bowels.
After the child has satisfied its  appetite, no new supply of food 
OF INFANTS.
37
should be added to what may have been left.  The quantity of
nourishment put into the bottle, should not be much greater than
what may be deemed fully sufficient for one nursing; and  if any
remains, it should be emptied  and the bottle  well  rinsed with
fresh water.   By these precautions the food will always be sweet,
and  free from offensive or irritating qualities.  Dr.  Dewees  ad-
vises that " the extremity from which  the child is to suck  should
be covered with a heifer's teat, in preference to any thing else."
Teats of this kind, properly prepared, are not, however, always to
be procured;  nor do they appear to me preferable to a few folds
of fine and soft linen drawn over the mouth-piece, with a minute
orifice, corresponding with the opening of the tube.   The  teat is
often too bulky for the child's mouth, and it is very apt to become
hard and unyielding, unless removed and immersed in water after
each nursing; in which case it is, on the other  hand, liable to be-
come too flaccid and relaxed.   Two or three  folds of soft linen
are readily applied, and may be taken off and  washed, or  substi-
tuted by a fresh and clean piece, without any inconvenience.  A
common eight-ounce vial, or a half-pint decanter, furnished with
a silver tube having  a flat and oblong mouth-piece, will, in gen-
eral, answer this purpose very well.   When the child uses the
bottle,  it should be  taken up  and supported in an  easy semi-
recumbent position, on the lap or arms of the nurse.   The prac-
tice of dandling and jolting infants soon after they have taken
nourishment, is  decidedly improper.  The child  should be kept
quiet for at least thirty  or forty minutes after having received its
nourishment.  Rest is  particularly favorable to  digestion: more
especially during its  primary stage.  It would  seem as if the di-
gestive organs required a concentration of the vital energies upon
themselves, to enable them to perform this important function with
due rapidity and  ease.  Nature constantly verifies  the truth of
this observation.  All animals  manifest an inclination for  repose
and quietude  after a  full repast; and experience  has shown that,
the  process of digestion is particularly liable  to be impeded by
strong mental or corporeal exercise or agitation  immediately after
a full meal.
   Children, who are  entirely nursed by artificial  diet, should be
restricted to  the use of the milk-and-water mixture  mentioned
above, until several teeth have made their appearance.   They
will, in general, enjoy more perfect health and thrive better, when
nourished exclusively with  this simple aliment,  than  under the
use  of any other nourishment that can be made.  After the third
month, however, the proportion of milk should be somewhat in-
creased : namely, three parts of milk to one part of water.  After
the  first teeth are protruded, the food may be a little more  varied
and substantial.  Grated crackers  dissolved in  warm water; oat- 
gg                  OF THE NOURISHMENT
meal gruel; liquid  preparations of arrowroot, tapioca, or sago;
milk thickened with rice flour, and thin  pap,  may be allowed m
moderate quantities along with the ordinary milk-and-water mix-
ture.   When  these preparations do not  agree with the child s
stomach, they should  be mixed with  an equal portion of  weak
mutton, chicken, or beef broth, clear and well  freed from fat.  A
mixture of this kind  is,  in general, easily digested, and rarely
causes any unpleasant effects on the alimentary canal, when used
after  the first  teeth have made their appearance.   With some
children, no form in which cow's milk can be given will  agree
with the stomach.   In such cases, farinaceous decoctions, mixed
with a small portion of cream, are generally digested with perfect
ease.   Thin oat-meal gruel,  or rice flour boiled in water, with
the addition of a teaspoonful of cream to each gill  of the  liquid
preparation, will answer very well.
  After the first grinding teeth  are  protruded, weak broths,
slightly thickened with oat meal, rice flour, arrowroot, or grated
crackers, mixed with milk, constitute, in general, the most appro-
priate articles of nourishment.  A small  portion of stale  bread
may also be allowed, two  or three times  daily, at this stage of
infancy;  but all solid animal food should be withheld until the
canine teeth have made their appearance.  After these teeth are
protruded, small portions of animal food, in a solid state, may be
allowed with  perfect  propriety.  " The animal food  given to
young children should be plainly roasted or boiled.  Fried  and
broiled meats, and all food heated a second time, by hashing or
minciqg, being less  digestible, should be avoided. Many people,
from  a mistaken expectation of  strengthening weakly children,
give them more animal food, and sometimes twice or thrice a day;
but it will be found much more frequently to add to the debility
than to the increase of strength.   Those children, on the whole.
who eat the least animal food, are the most healthy.  Nothing if
more absurd than the notion that, in early life, children require 3
variety of food.   One food only is provided by nature for them
and it is too presumptuous to assume that the Creator of the worlt
acted in error, and that the ingenuity of man is able to correct it
or make any improvement in his works."
  The peculiarly excitable state of the system during dentition
and the consequent  tendency  to febrile irritation, render the fre\
use of animal food  decidedly objectionable during this  stage of
childhood.  Small portions of the more digestible meats may be
allowed to healthy children, once daily, with  little or no risk ol
injury; but they should never be permitted to  form  the principal
part of the food.   The lean parts of mutton,  lamb, tender beef,
game, and fowl, should be selected. Veal, pork, pig, goose, duck,
and all kinds of salted meats, being of much more difficult  diges- 
OF INFANTS.
39
tion, can  seldom be used without impeding digestion, and finally
injuring the tone of the stomach.  Veal is decidedly the most ob-
jectionable of  all the meats in common use.  Fresh fish, boiled,
and taken in moderate portions, seldom disagrees with  the sto-
machs of children, and may be  used, occasionally, with perfect
propriety.  Soft boiled eggs, too, form an appropriate article of
nourishment  for children  after  the  first teeth have come  out.
When  fried,  or  boiled hard,  they are altogether unsuitable.
Strongly seasoned meats, compound dishes, ragouts, hashes, meat
pies, and pastry are to be wholly rejected.  Simplicity and plain-
ness are all-important  requisites in the diet of  children.  Their
meals should be made on a few plain and simple articles of food.
Children who are indulged in the use of a variety of food, and in
compound dishes, very rarely escape debility and irritation of the
digestive organs.   They soon become pale,  dyspeptic, irritable,
and languid.
   The  introduction of fresh food into the stomach  before  that
which was previously taken is  entirely digested, seldom fails to
operate injuriously on the alimentary canal.  To obviate this
cause of mischief, an effort should be  made, as soon as the child is
weaned, to establish some regularity in the periods of taking
nourishment; and sufficient time should be allowed for each meal
to be completely digested before fresh food is taken.  If the meals
are not sufficiently remote from  each other,  the digestive organs
will almost inevitably become weakened, from the constant state
of action in which  they are kept by the continual supply of food.
As a general rule, from three to  four hours may be regarded as a
suitable interval between the meals.   If the child requires  nou-
rishment between the regular meals, small portions of liquid ali-
ment should  be  used.  When solid  animal  food forms a part of
the diet of children, it should be taken at noon, or  in the fore-
noon.   It should not be taken more than once daily, as a general
regulation.
   Pure water,  with or  without small portions of milk, constitutes
the best drink for children, as it does for adults.  The practice of
allowing them  a little wine, spirits, or  malt  liquors, is  decidedly
reprehensible.  Children require no stimulus of this kind to excite
and sustain their vital functions.   The use of such drinks is espe-
cially improper during the irritable period of dentition.  There
exists, naturally, a strong  tendency to a preternatural determin-
ation of blood to the head, in early childhood,—particularly while
the process of dentition is going  on.  Some of the most fatal dis-
eases of infancy are intimately connected with this condition of
the circulation; and it is obvious, that the use of alcoholic stimu-
lants  must have a  direct tendency to increase this irregular  flow 
40                  OF THE NOURISHMENT
of blood to the head, and consequently to increase the liability to
inflammatory diseases of the brain.
   Sivcetmeals.—Indulgence in the use of sweetmeats is a copious
source of disease and  mortality during childhood.   Dried  fruits
preserved with sugar, nuts, baked sugar, &c. are among the most
indigestible substances employed as food.  There are few individ-
uals, even in adult age, whose  digestive organs are sufficiently
vigorous to digest  such articles with facility;  and  their frequent
or abundant  use rarely fails to impair  the tone of  the stomach,
and to cause intestinal disturbances.  Fruits preserved with their
skins, as raisins, are particularly pernicious.   The cuticle, or skin,
of all fruits is of peculiarly difficult digestion.   The most  active
digestive powers are, in general, insufficient to digest this portion
of fruits.  Added to this the hard and  insoluble seeds which rai-
sins and  many other fruits in  common use contain,  render them
highly irritating and injurious to the alimentary canal.  In vain
are judicious dietetic regulations adopted for the nourishment of
children, if articles of this kind are allowed.  I have known two
or three raisins to produce the most serious and protracted disor-
der of the intestinal canal in  infants.   Three instances have oc-
curred to me, in which convulsions  and speedy death were, une-
quivocally, the consequence of  overcharging the  stomach with
this indigestible and irritating  fruit; and my friend, Dr.  Cobb,
has recently communicated  to me a case, which occurred in his
own  family, of the  most alarming character, produced by the
same  cause.  The infant appeared to be well when put to bed.
On attending to it about midnight, it was found cold, pulseless,
with a deathlike expression of the countenance, and apparently
dying.  In a short time spontaneous vomiting came on, by  which
a large quantity of  raisins was  thrown from  the stomach, after
which all the  alarming  symptoms speedily disappeared.   The
raisins had been given to the child by a servant of the family
without the knowledge of its  parents.
  The conduct of  parents, in  relation to this subject, is often ex-
tremely irrational  and pernicious  in  its  consequences.  They
would not themselves venture  on the frequent  and free use
of confectionaries of this kind; and yet will indulge their children
without scarcely any restraint, in the use of these pernicious luxu-
ries.    The sicklier and weaker the child is, the more apt, in gen-
eral, is it to be allowed  these  destructive gratifications.   The
pale, feeble, and sickly child, whose stomach is hardly able to di-
gest the  most simple and  appropriate aliment, is sought to be ap-
peased and delighted by the luscious and  scarcely digestible arti-
cles of the confectioner.   Indigestion, intestinal irritation, termin-
ating  often in ulceration and incurable diarrhoea, are the frequent
consequences of such conduct; and at best, such indulgences must 
                         OF INFANTS.                      41
inevitably, prolong the feeble and sickly condition of the child,
and not  unfrequently  eventuate  in permanent  constitutional
infirmity.
   With regard to the use of fresh fruits, writers, on this subject,
have expressed different opinions.  Apples, peaches, and apricots,
when perfectly ripe and mellow, may be occasionally allowed to
children, in moderate portions, with  entire safety, unless the sto-
mach and bowels be very weak and irritable.   In children of  a
costive habit, the temperate use  of these fruits may even have a
beneficial effect, by  their tendency to excite the action of the
bowels.   Nothing, however, of  this  kind  is  more prejudicial to
health  than unripe fruits.   Unripe apples, so frequently seen in
the hands of children, are particularly injurious;  both on account
of the difficulty with which  they are digested, and the peculiar
and  pernicious quality of  the  crude juice, or acid, which  they
contain.  Pears, even of the tenderest kinds, appear to be much
more indigestible than ripe apples or peaches,  and seldom fail,
when freely taken, to cause some uneasiness and  disturbance in
the alimentary canal.  Stewed or roasted fruits, particularly the
two  latter  kinds, are, in general, well adapted to the digestive
powers of young children, and maybe allowed, occasionally, with
perfect propriety, provided  they are not  very sour.   When the
acid prevails to such a degree as to require the  addition of sugar
to render them sufficiently palatable, stewed or  roasted fruits of
this kind rarely agree well with weak and delicate stomachs, and
cannot be allowed to young children without considerable risk of
unpleasant consequences.
    In general,  all  fruits having  a firm cuticle  or skin, such as
 grapes, whortleberries^  &c. are improper  articles  of food for
 children.   The latter berries, especially, are invested with so
firm a cuticle, that even .the  most energetic digestive powers are
insufficient to dissolve it;  and  it is, doubtless, in part, on this
 account, that of all fruits of the  kind they  are the most apt to ex-
 cite internal irritation and diarrhoea.   The pulp of grapes, freed
 from the seeds, rarely  causes disorder in the alimentary canal,
 when taken in moderation;  and  children may be safely indulged
 in the use of small portions of it.  When swallowed with the skin
 and  seeds, however,  grapes are decidedly hurtful; and, as chil-
' dren rarely attend properly to  the rejection of these parts, this
 fruit cannot be put into their hands, without considerable risk  of
 injury from this source.  Fruit, that contains small, hard and in-
 soluble  seeds—such  as  strawberries, blackberries, currants, &c.
 are particularly apt, when freely taken, to disorder the alimentary
 canal.   The seeds, resisting the digestive powers, irritate the mu-
 cous membrane of the bowels;  and when, from  previous causes,
 this  membrane has become enfeebled and irritable,  they may
                               G              5 
 42            OF THE NOURISHMENT OF INFANTS.
 readily excite  dangerous irritation.   Small insoluble  bodies of
 this kind, frequently remain lodged in the folds of the bowels for
 many days and even weeks, and give rise to severe and unmanage-
 able disorders of the alimentary canal.  I have known  a child to
 evacuate from  its bowels a great  many small seeds, three weeks
 after the fruit which contained them had been  eaten; and during
 all this time it had suffered painful and exhausting  diarrhoea.
 Cherries are among the most pernicious fruits in common use, and
 ought to be wholly excluded from the list of articles with which
 children may be occasionally indulged.   Even when eat without
 the stones, they are peculiarly apt to derange the bowels; and when
 swallowed with the stones, which, with children,  is not unfre-
 quently the case, they are capable of producing violent and even
 fatal impressions  on the alimentary tube.  No small number of
 instances have come under my notice, where the most alarming
 and, in  a few cases, fatal  consequences resulted  from the irrita-
 tion of cherry stones lodged in the bowels.  Convulsions, inflam-
 mation, unconquerable constipation, and exhausting and harrass-
ing diarrhoea, are among  the affections which are apt to arise
from this cause.  All fresh fruits have a tendency to excite, more
or less strongly, the peristaltic action of the bowels.  As a gene-
ral rule, therefore, every kind of  fresh fruit is  improper for chil-
dren whose digestive organs are weak and irritable, or who are
habitually liable to disorder of the bowels.  If the digestive pow-
ers are vigorous, and there  exists  no obvious tendency to bowel
complaints, small portions of the fruits in  common  use, the seeds
and skins  being rejected,  may be  allowed occasionally, with
little or no risk of mischief.  It is  of much importance, however,
that the quantity of such articles taken into the stomach at a time
be moderate; and  that  they should never, with children, be suf-
fered to form the whole, or even principal part, of  meals. 
OF EXERCISE.
43
                   CHAPTER  IV.

                        OF EXERCISE.

  The  importance of permitting the infant to have the unre-
strained  use of  its limbs, has already been dwelled on, when
speaking of Dress.  At first, its spontaneous motions are, indeed,
but very limited; for  the muscular power, and the command of
volition over it, are acquired in a very gradual manner.   Uncer-
tain and awkward motions of  the arms—stamping with  the legs,
and drawing them up, are the first feeble attempts which the in-
fant makes  in the use of its muscles.  But even these muscular
exertions appear to be indispensable to the preservation of its
health and the proper developement of its powers;  and  it should
be an especial object of care  to  allow entire freedom of motion,
several  hours daily, by avoiding  all modes of dress and  position
tending to  restrain the free use of the extremities.  With this
view, the infant  should*be taken from its bed and laid on its back
upon  a soft mattress, or any other level and slightly resisting sur-
face, and divested of  every thing calculated to restrain the mo-
tion of its limbs and body.  When thus indulged with freedom of
action, it will soon exercise its feeble limbs, by moving  them in
various directions; and manifest," by its repeated and apparently
earnest, efforts, how much it enjoys this exemption from restraint."
This should  be  repeated two  or three times daily;  and in warm
weather the air  should be  freely  admitted.  Voluntary exertions
of this kind are  much more efficient in developing the powers of
the muscular system,  and  bringing it early under the commands
of volition,  than any of the passive modes of exercise in common
use.  Children,  who  are  frequently permitted  to  exercise their
muscles in this way, will, coeteris paribus', learn to use their limbs
and walk earlier and more steadily than those who are seldom
allowed this freedom  of voluntary action.
   Carrying.—Besides the exercise  which  infants thus obtain by
their own muscular efforts, passive  exercise should  be  regularly
afforded them, by carrying in  the arms and riding in an  easy car-
riage.  This kind of  motion, when conducted in a proper way,
has a highly salutary influence on the developement and vigor of
the infantile organization.  The use of it should be commenced 
44
OF EXERCISE.
 as early as the second or third day after birth, provided the infant
 be not unusually feeble; and it should be  daily attendea to. as
 one of the regular and indispensable duties of nursing.  The man-
 ner, however,  in which very young children are  usually carried
 or exercised, is extremely reprehensible, as it is calculated to give
 rise to very unfortunate consequences  in  relation to the health
 and regular  conformation of the child's body.   I  allude, particu-
 larly, to the common practice of carrying infants with their bodies
 in an erect position, before  the spine and muscles have acquired
 a sufficient degree of firmness  and activity,  to support the trunk
 and head in this  posture.   The child  is  usually carried  by the
 nurse  pressing its thighs and  hips, with the  left forearm, against
 her body, whilst  its trunk is balanced  in an  upright posture, by
 resting lightly against her bosom.  Thus the  whole weight of the
 infant's trunk rests upon the feeble and yielding spine, while the
 unsupported  head  is,  in general, suffered to lean  constantly to
 one side, or to roll about in every direction.  It requires but little
 reflection to  perceive, that this mode of carrying infants must in-
 terfere, very  materially, with-the regular and symmetrical devel-
 opement of the body.  The feeble  spine, yielding  to the super-
 incumbent weight of the head and body, is always curved out-
 wards  while  ^he  infant is held or carried in the  erect position;
 and, when this is  daily repeated, for several hours, as is frequent-
 ly the  case, the back is liable to become permanently bent or
 distorted.  A habit, too, of  leaning the head to one side is some-
 times contracted  by the child; and, from  the violent manner in
 which the head is liable to fall from side to side, serious and even
 fatal injury may be inflicted on the spinal marrow of the neck—•
 a remarkable instance of which is related in  Hufeland's Journal.
 But even after the spine and its muscles have acquired a sufficient
 degree of firmness, to enable  the child, to  support its head  and
 body in the erect position, without difficulty, it incurs considera-
 ble risk of injury from the  usual practice of carrying  it, almost
 exclusively on one arm.  Nursery-maids are  very apt to fall into
 this error, unless particularly directed to change the arm on which
 the child is carried.   When this  precaution  is not used, and  the
 child  is carried almost wholly on one side,  it  is apt to acquire
 the habit of leaning to one side, which it is always very difficult
 to correct.  The  child, also, when carried in  this manner, usually
 throws one of its arms around  the neck of the nurse, in order to
 support itself more steadily in  the erect position;  and of course
always with the same arm, when the side on  which it is carried
is not changed by the nurse.  In consequence of this position  the
shoulder-blade  and side of the chest are liable to be forced' up-
wards  and  outwards, which  may ultimately result in permanent
 distortion of these parts.  The manner of carrying infants is in- 
OP EXERCISE,
45
deed, of far greater moment than seems to be generally supposed.
Many a parent has had occasion to lament the unfortunate con-
sequences which may result from the errors just mentioned; and
yet, it must be confessed, that mothers seldom  pay that attention
to this subject which  reflection and maternal  solicitude would
seem to suggest.
   The spine and  its muscles seldom acquire  sufficient  strength
and firmness, before the end of the third  month, to enable the
child to support its body in an upright position, without  inconve-
nience or risk of injury.  Until this power is manifestly acquired,
the infant should  not be carried, or suffered to sit, with its body
erect, without supporting it in  such a manner, as to lighten the
pressure made on the spine, and aid it in maintaining the upright
  osture of its head and trunk.  But even when thus supported
  y the nurse, it should  not be kept in an erect  position more than
one or two minutes at a time, and not until it is four or five weeks
old.  At first (a few days after birth) the infant should be taken
from its cradle or bed, two  or  three times daily, and  laid, on its
back,  upon a pillow,  and  carried  gently  about the  chamber.
Struve observes that,  the best mode of  carrying very young in-
fants is, to lay them into a small oblong  basket.  By this contri-
vance a gentle and agreeable swinging or undulating motion will
be communicated  to them; and the  sides of the basket being
three or four inches higher than the child's body, a cover may be
thrown over it, without restraining the free motion of its limbs.
After the third or fourth week, the child may  be carried in a re-
clining posture on  the  arm of  a careful  nurse, in such a  way as
to afford entire support to the body and head.  This may be done
by reclining the infant upon the forearm, the  hand  embracing
the upper and posterior part of the thighs, whilst its body and
head are supported by resting against the breast and arm of the
nurse.  When held in this  way,  it may be gently moved from
side to side, or up and down, while it is carefully carried through
a well ventillated  room.   When  it is found  that the child has
acquired a sufficient degree of muscular power to maintain itself
in a sitting posture—which  rarely occurs  before the completion
of the third month—it may be  carried about, in  this position, for
a short time, twice or  thrice daily, provided the spine and head
be supported by the nurse: an aid  which can seldom be pru-
dently dispensed with before the child is six or seven months old.
" During the first six months," says  Struve, " the head of the infant
should, in carrying, be supported  by the  nurse's hand; for the
muscles of the neck are, at  this tender age, too delicate  to pre-
serve the head in an erect  posture."  Mothers are fond of exhib-
iting the exploits of their babes, in raising and  supporting their
heads—" unconscious of the  mischief which may be  occasioned
                            5* 
46                      OF EXERCISE.

by this premature experiment." It is painful to see the violent and
generally abortive efforts, which  the infant makes to steady its
head, when raised into a sitting posture.  It will sometimes suc-
ceed in balancing its head for a moment, to the  great delight of
the fond mother; but the effort is almost invariably speedily fol-
lowed by a sudden and often violent rolling of the head from side
to side, which cannot but have an injurious tendency.
  All rapid, whirling,  and concussive motions are calculated to
injure the health and delicate organization of infants; and moth-
ers should be particularly vigilant in preventing nursery-maids
from subjecting  their charge to such violence. Running'or jump-
ing with an infant  in  the arms—rdescending rapidly a  flight of
stairs—whirling round, &c. ought  to be rigidly forbidden, as they
are attended with much risk of some serious accident, and may
interfere with  the regular distribution of the circulation, and the
healthy action of the  brain and other  important organs.  The
practice of supporting very young infants in a sitting posture on
the knee, and jolting them violently, cannot be too severely cen-
sured.   It is not uncommon to see  mothers and nurses jolt infants
in this  manner, with a violence that threatens  dislocation, and
manifestly occasions them much pain and distress. Tossing them
rudely  on  the arms, though less  concussive than jolting on the
knee, is equally reprehensible, as it is attended with  more risk of
injury from falls, blows, &c.   These violent agitations, "power-
fully affect the delicate organization of infants, and  may be pro-
ductive  of spasms, epilepsy, and  appoplectic fits."  Gentle  and
cautious tossing on the arms, affords an agreeable exercise of the
body, and  may be salutary by the moderate agitation which it
causes in the internal organs.
  Different opinions have been expressed with regard to the pro-
priety of  rocking infants  in  cradles.   To  gentle and  cautious
rocking, there  can be no just objection.  The swinging, or rolling
motion of the cradle, communicates an agreeable sensation to the
system,  and disposes  to calmness  and repose:  and when mode-
rately practised, and not very often  and long continued, it can
scarcely give rise to any evil  consequences.  It is otherwise,  how-
ever, with  violent, rude, and  almost constant  rocking.  Rapid
and long-continued rocking motion, instead of merely calming the
excitement of the brain and inducing a state of agreeable repose,
as is the case when gently and slowly performed, is apt to disor-
der the actions  of  this organ, in  a  very decided manner, and,
through it, to exert an injurious influence on the whole organiza-
tion.  With infants  predisposed  to diseases of the head, strong
rocking should be particularly avoided.
  Riding in a  Carriage.—This is an excellent mode  of affording
suitable exercise to  infants, and may, with great propriety, be 
OF EXERCISE.
47
employed as an  occasional substitute for carrying, in  the arms.
When cautiously managed, it affords a gentle, uniform, and very
agreeable motion, for which children, in general, soon contract a
great fondness.
  The body of the carriage should be long enough to permit the
infant to lie down at full length; and the sides ought to be suffi-
ciently high to prevent  it foiling or  rolling out.  The wheels
should be low, in  order to lessen the liability of oversetting; and
they must be  carefully  secured " against running off  when the
carriage is in motion."  Like  carrying in the arms, this mode of
exercising infants is liable to be conducted in a very improper
and hazardous manner. This duty is usually entrusted to children
or young girls, who being generally more disposed to consult their
own sportive inclinations  than  the comfort and safety of their
charge, are apt to draw the carriage  along with great rapidity,
paying little or no attention to the roughness or unevenness of the
ground  over which  they pass.  Such careless conduct ought  to
be  particularly forbidden  by parents; and  especial instructions
given, that the carriage be drawn along with  a moderate and
steady pace, and  over level grounds.  Very young infants should
be laid down in the carriage, on a pillow or a small and soft mat-
tress, with  the head slightly elevated, "and so confined  at the
sides as to prevent them from rolling when in motion." After the
child has acquired some degree of strength, it should be placed in
a semi-recumbent posture, with its head and back well supported
by pillows, &c;  and when it is capable of supporting its head, it
may be permitted • to sit upright in the carriage, being, properly
secured against being thrown from  side  to side by the rolling of
the carriage.
  Walking.—After the infant has acquired sufficient strength to
support itself in the  sitting posture, it should be placed on a soft
carpet, several times daily, and surrounded with its toys.   When
thus left to the free use of its  limbs, it will soon learn to crawl—
an exercise which should always be freely allowed, and even en-
couraged, as the  most natural preliminary muscular effort to the
more difficult one of walking.  The common practice of teaching
children to walk, by supporting  them, prematurely, on  their legs,
and leading them forward, without allowing them the advantage
of having their muscles previously strengthened and in some de-
gree  brought under the commands of the will, by the initial loco-
motive exercise of crawling, is objectionable on various accounts.
It seldom fails to  produce more or less unnatural curvature of the
legs; and in  infants of a scrofulous or  ricketty habit, it  may
readily give rise  to distortion of the spine 'and round shoulder.
Children, who are permitted to exercise their muscles by crawling,
generally acquire a  much firmer step, and enjoy more robust 
48
OF EXERCISE.
 health, than " those who  have been taught to walk without this
 useful intermediate muscular discipline."
   " Before  infants  attempt  to  walk,"  says Dr. Struve, " they
 should first  learn  to crawl.  With this intention, they should be
 placed on a  large  carpet, where they will soon busily employ
 themselves; move and extend their limbs, or roll about  to reach
 their playthings.  If the weather is serene, and the ground per-
 fectly dry, they may be carried out, and placed on  a grassplat,
 where they can range about in all directions; and if they happen
 to fall, they will not receive material injury on the soft ground,
 but  rather learn to be more cautious in future.   While in the
 nursery, they may be taught to rise from the floor by laying hold
 of chairs; and, if occasionally supported under the arms, they will
 easily learn to stand erect; but they should never be raised up
 by one arm only.  At an  early age they may be held under both
 arms; and when thus supported, the  hands of  the attendant  be
 occasionally withdrawn for a moment, they will soon acquire the
 power of standing alone.  Mild and  persuasive language ought
 to be used in these experiments; while the infant may be en-
 couraged by some toys placed" at a little distance, which will  in-
 duce it' to stretch out its little arms, and endeavor to advance  to-
 wards the place containing the desirable objects. By such means
 it may be allured to  visit different parts of the room.  The first
journey of this description ought to be attempted only from one
 chair to another; and afterwards, the little traveller may run  to-
 wards its mother, or nurse, who stoops  to receive it with extended
 arms.  As the child improves in its  efforts to walk alone,  the
 chairs may be placed at a greater distance from each other; and
 when it  sees its older companions  run and jump about, it can
 scarcely be restrained, so anxious is it to be placed on the floor,
 that  it may crawl or waddle after them.  At length, parents are
 gratified with one of the most delightful scenes:  they behold their
 child for the first time walking without any assistance.  If we are
 earnestly desirous of training up our children in such a manner,
 that  they may  acquire a  firm step, and well-formed limbs,  we
 shall gain our purpose much more certainly and safely, by pursu-
 ing this gradual and  cautious  mode of teaching them the use of
 their legs, than  by the more common practice of placing them
 prematurely, on their feet, without permitting them the previous
 exercise of crawling."
  Leading-strings and go-carts, formerly so much in use, are now,
 very properly, almost universally abandoned.   The former con-
 trivance is calculated to do very  serious injury, by the rude man-
 ner m which infants are  liable to be pulled about by inconside-
 rate  or illnatured  nurses;  for, when the child makes a false step
 or inclines too much forward or  to one side, and is in danger of 
OF EXERCISE.                      49
falling, it is usually raised by a sudden and violent pull at one or
both strings.   Dislocations and  other painful injuries have fre-
quently been occasioned in this way.  Leading-strings, moreover,
tend to  compress and distort the shoulders; and  children are apt
to acquire  an unsteady and awkward gait, when taught to walk
in this  manner.  Go-carts are still more  objectionable.  They
confine  and constrain the  body in a very uncomfortable manner;
and, as  in  pushing the machine along the floor,  the breast is usu-
ally firmly pressed against the circular top, injury may be done to
the regular developement and conformation of the upper part of
the chest.   The very  common practice of  teaching infants to
walk, by holding them  by one of  their hands, deserves the most
decided reprehension.  When led in this way, the  child's arm is
continually, and,often forcibly, extended upwards: if it  happen
to lose its balance, or trip, or if its legs are yet too  feeble to sup-
port itself long, in the erect posture, the whole weight of its  body
is often  suspended  by one arm.   Frequently, too,  it is entirely
raised from the ground by one arm, in order  to help it over  some
obstacle, or to hasten its progress  over a rough and  difficult piece
of ground.  It is easy to perceive that  this practice must, neces-
sarily, and in no inconsiderable degree, tend  to draw the shoulder
and side of the chest out of their natural position; and, when fre-
quently repeated,  to give permanent  deformity to these parts.
From the sudden and violent extension which the arm usually re-
ceives when  the  child  stumbles,  the shoulder and elbow joints
are liable  to be dislocated or sprained, or the  clavicle  may be
torn from its attachment with the scapula.   I have  met with sev-
eral instances of dislocation of the shoulder joint, which  were
occasioned in this manner; and the occurrence of painful sprains
—often of several  weeks continuance, from violence done in this
way, is by no means uncommon.  Parents should most earnestly
forbid this mode of leading infants, when entrusted  to the care of
servants out of doors.  Nursery-maids  seldom exercise sufficient
care  in this  respect.   Too indolent to carry the infant in  their
arms, as they are directed and  supposed  to  do, they are'apt, as
soon as they are no longer observed, to place the  child on the
ground, and  to hurry, or  rather, drag it along, in the most care-
less and unfeeling manner.   Of  a similar, but  still more repre-
hensible character, is  the practice of raising  infants  from the
ground by both arms and swinging them about in the air.  Frac-
tures, dislocations, sprains, and other dangerous  and painful inju-
ries, have  frequently resulted from this irrational  conduct.  No
prudent parent will  knowingly permit such an outrage; but, as
the ordinary attendants on children are often  thoughtless and rash,
they should always be especially cautioned on this  point.
   After children have acquired the entire  use of their legs, walk*
                            H 
50                       OF EXERCISE.

ing is decidedly the best exercise  they can  take.   When  the
weather is fine, they should be  taken  out  daily, and freely in-
dulged in running and walking about, under the superintendence
of a careful nurse.  These little excursions, if prudently conduct-
ed, have a highly salutary influence on the infantile system. Chil-
dren,  who  are  raised in the country, are in  general  much more
robust,  healthy  and active, than those who are brought up in
cities: and this difference is mainly to be ascribed to the greater
freedom which the former usually enjoy, of walking, running, and
tumbling about on grassplats—enjoyments often in a great mea-
sure denied to the latter. In taking this kind of exercise, children
should not  be accustomed to rely  too much  on the assistance of
others.   If the ground is favorable;  that is, if it is soft or covered
with grass, and free from stones, timber, &c, they should be per-
mitted to have their way.   A few falls will do them no injury;
but, on the contrary, make them less  timid, and teach them better
than  any other  instruction how  to  avoid a similar accident in
future.   Children, who are never suffered to surmount the little
difficulties which may occur in their sports,  by their own efforts,
and continually warned against trifling accidents, seldom fail to
become  unduly  timid, helpless and  irresolute in their actions.
Parents ought not to intimidate their children, by inspiring them
with a constant dread of falling or hurting themselves.  The cus-
tom of exaggerating the dangers  incident to their usual sports—
and  of plying   them continually with  admonitory  injunctions
against accidents, when they are engaged in their amusements, is
calculated  to favor the  occurrence of the very accidents  which
they are meant to obviate, by the  timidity which these perpetual
lessons of caution and fear almost inevitably inspire.  When the
ground is soft, it is much better to let the child take the chance
of two or three falls, and  give it full  scope for the exercise of its
limbs, by running and gamboling  about until it is satisfied. Noth-
ing  can be more invigorating to the whole organization than  this
kind of unrestrained exercise, in  suitable situations, and  under
the  superintendence of a prudent nurse. Struve, whose excellent
observations  on this subject I have already drawn on so  fre-
quently, observes  that, when children happen  to fall or hurt
themselves, they should not be soothed by expressions of extreme
pity and sorrow; for plaintive words  and expressions of great  sor-
row tend very effectually to render  them effeminate  and  timid.
Children, who are thus  accustomed  to excessive commisseration,
seldom  fail to acknowledge  this  tender sympathy, by straining
their  little lungs to the utmost by crying, on every slight  injury
they receive.
  After children have passed through the period of primary den-
tition, they should be encouraged  in the pursuit of active amuse- 
OF EXERCISE.
51
ment  out of doors, as an  essential and regular part of physical
discipline.  Nothing contributes more effectually to enfeeble the
body, and to lay the foundation of permanent constitutional infir-
mity,  than confinement within doors and want of active exercise
at this tender period of life. The developement of the moral and
physical energies of children can in no way be more effectually
promoted, than by permitting them to engage freely in the usual
sports of childhood,  in the fresh and open air.  The practice of
obliging children to remain within doors, and to con over their
lessons, between school- hours, is by no means commendable.
These intervals should  be devoted to innocent  amusement and
bodily exercise.  Trundling the  hoop—flying kites—playing at
ball,  shinny, or simply skipping and running about, with  other
juvenile sports unattended with danger, have a decided tendency
to improve the health  and vigor of  the system, and should be
freely permitted during  the hours not necessarily devoted to the
school.  Girls  may amuse themselves with  skipping the  rope,
dancing, walking, shuttlecock, a well constructed and safe swing,
riding in a carriage, &c.
                     CHAPTER   V.

  '              AIR,—TEMPERATURE,—EXPOSURE.

   That pure air is indispensable to the entire well-being of the
 human organization, is so well established by the common  sense
 and experience of mankind, that it seems unnecessary to enforce
r its truth by any especial illustrations.   The  importance, however,
 of attending particularly to this  point, in  the management of
 children, does  not, in many instances,  appear  to be sufficiently
 estimated.   At no period of life are the effects of confinement in
 stagnant and impure air,  more  obviously and lastingly detrimen-
 tal to the animal  economy than during  the feeble and susceptible
 age.of  childhood.  How deeply pernicious  a foul and  confined
 air  is, in its influence on the human  system, is most strikingly
 illustrated in the  pale, feeble, and  sickly aspect of those unfortu-
 nate children who are early placed in manufacturing establish-
 ments, where they are confined, nearly the whole day, in crowd-
 ed and ill-ventilated apartments.  Children brought up in the
 crowded and filthy parts of large cities, seldom exhibit a per-
 fectly healthy and vigorous  appearance.  Go  into the  country, 
52                       OF AIR, &c.
 and you will everywhere  meet with children  rioting in the exu-
 berance of  health—plump, ruddy, robust and active.  Exercise
 and simplicity of wholesome diet, doubtless contribute essentially
 to this healthful condition; but, no regulations of diet—no atten-
 tions to exercise, and no sanitary observances whatever, are ade-
 quate  to  produce  a similar fortunate result, when  counteracted
 by the continued depressing influence of a confined and contam-
 inated atmosphere.
   Infants ought to be early accustomed to the fresh and open air.
 The practice of confining  them, during the first five or six weeks,
 to the close and heated air of nurseries, has a direct tendency to
 impair the energies of the system, and to impede its healthful de-
 velopement.  The  daily enjoyment of fresh air, for an  hour or
 two, contributes very essentially to the health and sprightliness
 of infants; and  constitutes one of the most efficient  preservatives
 against that delicate and  sickly condition, which is so frequently
 witnessed in those who are almost constantly confined  and pam-
 pered  in  nurseries.  " Pale  countenances, weak eyes,  general
 relaxation of the body, an accumulation of all the inconveniences
 and sufferings of childhood—at  length  consumption and  early
 dissolution of life:  all  these are the natural and frequent conse-
 quences of such confinement.  On  the contrary, there is no me-
 thod, by which children may be more effectually preserved against
 such unfortunate events,  than by permitting  them  to inhale a
 fresh and  uncontaminated air.  Pure air is, indeed, most grateful
 to the feelings of children. After having been carried out, but a
 few times, they evince, even at a very early age, a strong desire
 to return  to the open air.  While yet on the arms  of the nurse,
 they anxiously point to the door, and make efforts  to  approach
 and open it.  When they can scarcely crawl, they instinctively
 advance towards that part of the room from which they have a
prospect of escaping.   Hence, in the bosom of nature they expe-
rience  the greatest comfort;  and their tears can frequently be
stopped in no other way, than by taking them out of doors into
the free air."   (Struve.)
  When the weather is clear and of a mild temperature, infants
should be  carried into the open air, once or twice daily, as soon
as they are two weeks old.  During cold and humid  weather,
they should  be  occasionally conveyed out of the nursery into an
adjoining  well-aired room: avoiding,however,strong currents of
air, and sitting with them near  an open window.  Important as
the enjoyment of fresh air  is to the health and comfort of  infants,
care should be taken to accustom them gradually to the impres-
sions of the external air—more especially when the atmosphere
is cold and damp.   The practice of exposing children, soon after
birth, at once to the open  and cold  air, with the view of "hard-
• 
OF AIR, &c.
53
ening them," as it is called, is attended with considerable risk of
injury, and should  not be permitted by parents, except when the
weather is clear and very mild.  Catarrhal and other inflamma-
tory affections are frequently contracted in this way; and in fee-
ble children, low temperature, when  thus  suddenly applied,  is
apt to occasion  serious depression of the vital energies, and to
predispose very  strongly to the occurrence of febrile and other
dangerous maladies from the subsequent influence of the ordinary
exciting causes of disease.  Instead, therefore, of exposing any
young infants, at once,  to the  direct impressions of the external
air, when  the state of the atmosphere  is unfavorable, they ought
to be gradually inured to such a transition, by carrying them fre-
quently out  of the nursery into the cooler and less confined air of
well-aired and unoccupied rooms.   In this way, they will soon
become, in some degree, habituated to sudden  transitions of tem-
perature,  and  to the  more direct impressions of the open air.
Even in summer, the infant should  not, as a general rule, be car-
ried, at once, into the external  air, without having been previ-
ously accustomed to the air of  a well-ventilated chamber.  After
the child  is  three or four days old, it ought to be conveyed, sev-
eral times daily, out of  its nursery, into  a room having, at first,
only the windows open, and in four or five days afterwards, the
doors also, so as to admit of a free circulation of the air through
every part of the room.  This having been practised for ten or
twelve days, the child may then be carried out of doors, and per-
mitted to  enjoy the pure and open air.  At first, it should not be
allowed to remain out of doors more than ten or  twelve minutes
at a time; but the duration of  this indulgence must be gradually
extended, so as to keep  it in correspondence with  the progressive
developement of the child's organization and energies.   After a
child has  acquired the power of walking, it should be suffered to
spend a great portion  of its time in the open air, and  in the pur-
suit of its ordinary amusements, provided the weather  is suffi-
ciently temperate and dry. Nothing affords more  real enjoyment
to children,  and at the  same time  tends  more  decidedly to give
them a sound and  active tone of mind  and body, than  a liberal
indulgence in exercise and their innocent sports out of doors.   A
country residence possesses  many important advantages in this
respect, which cannot be had  in  large cities.   There, they con-
stantly breathe a delightful and  perfectly pure air, and  may be
safely permitted to run, skip, and tumble about under the shade
of trees, and on the soft and green surface of a lawn or grassplat,
almost without restraint and risk of receiving any serious hurt or
injury.  In cities, on the contrary, the atmosphere is always more
or less contaminated with impure and noxious exhalations; and
children cannot be prudently permitted to enjoy the same freedom
                                            6 
54
OF AIR, &c.
of exercise and active amusement out of doors, as in the country,
from the constant risk of receiving some injury when  suffered to
be on the side-walk, and the confined and narrow space of ground
usually allotted to the houses.  But, although 'the atmosphere of
cities  is always far from being perfectly pure, still, the daily enjoy-
ment  of the open air, impure as it may be, is decidedly beneficial,
and should never be withheld, under an idea, that by free ventila-
tion and cleanliness the air breathed within  may be rendered as
pure as it is out of doors.  In cities of small extent, children " may
be taken to a garden or field near the town;" and the larger cities
generally afford public squares, or parks, devoted to the exercise
and recreation of the citizens, to which children may be, conve-
niently,  taken, where they may enjoy a free and  fresh air, and
amuse themselves by playing  and  running about on the grass."
(Struve.)   These little excursions have a very salutary tendency;
for, besides the excellent effects of the exercise which they afford,
there  is  something peculiarly enlivening and grateful in the influ-
ence of  the open air, which children seldom fail to manifest by
their expressions and actions.  When they have the advantage of
a lawn or grassplat, children should  be allowed  to amuse them-
selves freely in their own way.  "Boys may be permitted to  run
about, without  their hats, though exposed to the wind and sun.
If they do not, spontaneously, complain of heat or cold, it may be
considered as a proof that they are in good health; for diseased
and debilitated children will speedily return to the nursery.   If
they cry, and  cannot bear the blast of a moderate  wind, or a
slight degree of cold, it is then proper to return with them to the
house, as they are probably indisposed; but  if, on the contrary,
we find  them  lively and cheerful, they may be allowed  to  con-
tinue  in the air as long as  they are comfortable and easy.   Chil-
dren should not be forced  against their  inclination to go out of
doors, during a fall of snow or the intense heat of summer.  If
they are once  inured to a  rough atmosphere, no  compulsion will
be necessary." During the first two or three years of infancy, no
difference need be observed in relation to this subject  between
boys and girls.   Parents are, in general, averse to allowing girls
the same freedom of exercise and amusement in the open air that
is usually granted to boys, on account of the tendency which free
exposure to the atmosphere and the direct rays of the sun has to
render the skin dark and  harsh.  A white and smooth skin, and
a delicate organization are, by many, regarded  as  marks of a
genteel  education; and these vain distinctions are often  sought
and obtained at the expense of health and a firm constitution, by
too much seclusion from the external air and light of the  sun.
Girls, like boys, ought to be freely and frequently exposed to the
open  air and weather.  The complexion  may not become so del- 
OF AIR,&c.                        55
 icate and fair, when this freedom of exposure is permitted;  but
 the more pleasing appearance of florid and robust health, accom-
 panied with  a delightful feeling of buoyancy and vigor, will  be
 obtained in its stead:  a result  infinitely more valuable than fair-
 ness and smoothness of skin and delicacy of structure,—and which
 will extend  its salutary influence throughout  the whole subse-
 quent period of life.  " Not a day," says Willich, " should be suf-
 fered to pass without affording children—both  boys and girls—
 the benefit of exercise in the open air.  In this instance, custom
 ought to become second nature; they must be inured to external
 impressions;  and the daily enjoyment of this balm of life should
 constitute an essential  part of their regimen."
   Although children should be permitted  to indulge freely in ex-
 ercise and active amusement, during their daily excursions in the
 open air, constant care ought to be had, that they do not lie down
 or sit on the cool and damp ground, or in  a strong current of air
 in the shade, when they are in  a  state of  perspiration from exer-
 cise; nor should they, on any account, be permitted to drink cold
 water, except in very  small portions, and at considerable inter-
 vals, when in this heated condition.   A neglect of these precau-
 tions is apt to give rise to the most serious consequences. Inflam-
 mation of the brain, lungs, stomach, bowels, liver—catarrhal affec-
 tions,  terminating  ultimately in  disorganization of the  lungs,
 croup, and violent inflammatory rheumatism, are often suddenly
 excited by cold and dampness when  applied while the  body is
 thus especially predisposed to their morbific  influence.  Nurses
 and servants should always be especially instructed on this point;
 and as soon as children are old enough to comprehend the lessons
 of caution, they should be earnestly impressed with the evil con-
 sequences of these practices, and of the necessity of avoiding them
 as an irremissible condition of their being  permitted to run about
 and play out of doors.
  It is not enough, however, that  children be taken into the open
 air, for an hour or two daily, in order to secure them the full amount
 of benefit which maybe derived  from this source; for unless proper
 attention be  constantly paid to the  preservation of a compara-
 tively pure and fresh air, in the rooms  in which they sleep and
 spend the greater part  of their time, the temporary enjoyment of
 the external air cannot effect a  great deal  towafds the permanent
 invigoration and health of their systems.
  Particular care should, therefore, be taken to prevent the air
 of nurseries from becoming impure and stagnant, by proper at-
 tentions to cleanliness and ventilation, and  the avoidance of every
 thing  which may tend  to  give  rise to  unwholesome  effluvia.
 When the atmosphere is mild, the external air ought to be freely
admitted into the room, by  keeping a window  open during the 
5G                       OF AIR, &c.
day;  and at night the chamber door may be left open, or a sash
raised, whilst the  current of  air is  intercepted  by the  closed
shutters.  In cold and humid  weather, the upper sash of  a win-
dow should be occasionally drawn down a few inches during the
day.  At night, a window in the adjoining  apartment ought to
be left open, the fresh air being suffered to  enter the nursery, by
the door of communication.  Chimney boards,  as they impede
the free circulation of the air  in rooms, are decidedly inadmissi-
ble in well-regulated nurseries.  The same objection  exists to
"double doors,  linings, listings and sand-bags"—all of which, by
preventing some degree of ventilation, contribute to an unwhole-
some condition of the air.  Indeed the maintenance  of a proper
circulation of air in the apartments appropriated to children, can-
not be too strongly urged  on the attention of  parents.  Even
where the general atmosphere is impure, as is always the case in
large cities, free ventilation should never be neglected: for, how-
ever contaminated the  external air may be, it soon becomes still
more impure and insalubrious,  by being breathed in a confined or
stagnant state.   The practice  of using the nursery as a common
sitting room, by the female portion of the family is extremely im-
proper,—more especially when from the inclemency of the weath-
er, the doors and windows cannot be  kept sufficiently open, to se-
cure a proper renewal and circulation of the air.   Each individual
exhausts the  vivifying  principle of nearly a gallon of air every
minute: and the contaminating and putrescent exhalations  which
are continually issuing from the  human body, constitute a source of
rapid atmospheric deterioration.
  The observance of strict  cleanliness, also, is indispensable to
the preservation of a pure air in  nurseries.   The floor should be
kept clean and dry; wet and soiled articles of clothing must not
be suffered to remain in the room;  and the child's excretions
ought always  to be speedily removed.   " No food should be cook-
ed in nurseries, if it can possibly be avoided; nor should linen be
washed, dried or  ironed there, as these processes tend to render
the air offensive and impure.   Hanging up the linen  of children
or drying their diapers in the  place where  they respire, produ-
ces exhalations highly   detrimental to their eyes, as well as inju-
rious to the general health."   No flowers ought to be cultivated
in nurseries,  since  they  not only tend to deteriorate the atmos-
phere during the night,  but often give out effluvia that are highly
injurious to the animal economy.  It  need scarcely be  observed
that the burning of charcoal,  out of the full draught of a good
chimney, is always attended with the utmost risk of  alarming or
fatal consequences.
   There is no part of the management of nurseries more impor-
tant in its consequences,  than a proper regulation of  the temper- 
                        OF AlR,&c.  •                       57
ature.   The  apartments of children are, in  general, kept much
warmer than  is consistent either with comfort or health.  Nothing
tends more directly to enfeeble and relax the«human body, and to
predispose it  to the injurious influence of cold and atmospheric vi-
cissitudes, than habitual confinement in heated rooms.   The cuta-
neous  and pulmonary exhalents, being kept, almost  continually,
in a state of inordinate excitement by the stimulus  of the heat,
acquire so great a susceptibility to  the depressing influence of
low temperature, that the slightest exposure to the open air, is
apt to arrest their action, and to give rise to the various distress-
ing and dangerous consequences of a suddenly checked perspira-
tion.   " Warm rooms," says Struve, " in my opinion, principally
contribute to the extraordinary  mortality  of children,  who are
carried off by convulsions, in the first months of their lives.  As
they daily become weaker from the constant action of heat, every
draught of air occasioned by opening the  windows  or  doors is
dangerous to their organs.  It is an established  fact, that in the
proportion as we  habituate ourselves to warm  dress and heated
apartments,  so do we render the body more liable to  be injured
by exposing'it to the influence  of fresh or cold  air."  Children
who are accustomed to immoderately warm rooms are seldom en-
tirely  free from  coughs and colds during cold and humid weather;
for as  they cannot be always confined to their apartments they are
unavoidably  at times  exposed to the impressions  of cold air.  As
the continued influence of atmospheric heat has a very decided
tendency to increase  the irritability of the system—rendering it
morbidly susceptible of the impressions of irritating causes, the
practice of keeping the air of nurseries very warm is particularly
detrimental to children during  the period  of dentition.   Under
the most judicious sanitary regulations, the systems of children
are apt to acquire a morbidly irritable condition during this pro-
cess.  It is manifest,  therefore, that when this natural tendency to
an irritable habit, is  promoted by the cause  under consideration,
the liability to disease must be peculiarly great.   When we take
into view the tendency which exists during dentition  to a preter-
natural determination of blood to the head, in  connection with
the general irritable and  inflammatory condition just  referred to,
it is obvious  that children who spent the  greater part of their
time in heated rooms, must be  especially liable  to inflammatory
affections of  the brain, from the occasional impressions of cold to
which they are necessarily more or less exposed.
   The temperature of nurseries should never be suffered to ex-
ceed 70° of Fahrenheit.   In general  a temperature of about 65°
or 66°, is sufficiently comfortable; and experience  has  shown?
that it is best  adapted to  secure the health and  vigor of the
human system.  This moderate degree  of heat does not favor
                               I             6* 
58                      THE NURSERY.

the generation of noxious effluvia from  decompositions; nor does
it impair the natural powers of vital  resistance, to the injurious
impressions of cold,, or sudden transitions of temperature.  Chil-
dren who are  accustomed to this temperate  degree of warmth,
may be  taken into the open and cold air, without any peculiar
risk of injury, from its sudden depressing influence.
                    CHAPTER VI-

                       THE NURSERY.

  From what  has already been  said, in the preceding chapter,
in relation to the great importance ol  preserving a pure and fresh
air in the apartments of children, it is obvious that a good nursery
ought to be  spacious, perfectly dry, airy, and elevated above the
ground floor.  In general these important requisites to the proper
adaptation  of nurseries for the purposes  of comfort  and health
are too  much neglected.   Instead of  selecting  a larga  and airy
apartment, the narrowest, most indifferent and cooped up room  in
the house is  often appropriated to  this purpose. It is very diffi-
cult to preserve a proper degree  of  purity and circulation in the
air of a small room, without subjecting its inmates to much incon-
venience and risk of taking cold.   From the smallness of the
space, the air of such a room,  soon becomes  contaminated  by
breathing, perspiration and other unavoidable sources of impure
effluvia.  To preserve a  sufficient degree of purity and freshness
in the air, recourse must be had to frequent ventilation, by open-
ing a window or door.   A  constant fluctuation of temperature is
thus kept up in the apartment; and those who remain in it, are
much exposed to  the injurious influence of repeated currents  of
damp and cold air.  These unfavorable circumstances are, in a
great degree,  obviated by  a  large and  airy room.   Ventilation
need not be so  frequently repeated, and may be performed with-
out injurious vicissitudes of temperature, or  direct exposure  to
strong and sudden draughts of cold air.  Independent of the greater
facility of keeping up a suitable  degree of temperature, purity,
and circulation  in the air of spacious  apartments,  nurseries  of
ample dimensions are particularly desirable  also on account  of
the opportunity which they afford to children of taking  exercise,
by running and jumping about on the carpet, " when the weather
will not permit them to enjoy the advantages of the open  air." 
THE NURSERY.                    50
A nursery consisting of two chambers opening into  each other
possesses many very important  advantages  over a single room.
With such an arrangement the  children may sleep in  one room,
and  remain  in the other while  awake.  They may thus enjoy
the advantage of going to sleep in pure air;  and of passing,  in
the morning, out of their bed-chambers, at once into the renewed
and purified air of the other apartment.  They  may also avoid
inconvenience and  risk of injury, from the dust, currents of air,
&c. which attend the sweeping, dusting, washing and ventilation
of the nursery; for while these operations  are  going on in one
room, they may retire into the other.
  With regard to the best means for warming nurseries, there
exists some difference of  opinion.   Dr. Dewees objects to the use
of stoves, because: " 1st,  there is greater danger that the  children
may get  severely  burnt; 2d, they are almost always too much
heated;  3d,  they render the air too dry;  4th, the air is almost
constantly injured by substances thrown upon the stove, as grease,
meat, &c; 5thi, there is always a temptation to do some kind of
cooking upon or in the stove, to the annoyance of the comfort, or
the injury of the  health of the inmates, besides the  serious risk
of scalding by heating  water upon it."  Carelessness  and  im-
proper conduct may, indeed, convert any contrivance for warm-
ing apartments into a nuisance.   Most of these  objections apply
with equal, if not greater propriety to  open fires.  The  risk of
injury from  burns, is  certainly  quite as great from an open fire,
as from a stove.   How  often  do we hear of children receiving
the most serious, and even fatal burns, from their clothes taking
fire by coming in  contact with open fires?   The use  of a good
fender, will, doubtless, obviate  the liability to this accident;  but
the risk of receiving burns from a stove may be quite as effectu-
ally prevented by surrounding it with a proper railing—and this
should always be done in apartments appropriated to children.  The
tendency of stoves to produce  too great a dryness in the air may
be readily counteracted by keeping a small basin of water slowly
evaporating  on or near the stove.   The objection that stoves are
apt to be kept too warm, is founded rather on the abuse than  on
any positive  unfitness of this mode of heating rooms, and may be
effectually obviated by proper care and management.   The same
observation applies to the other objections—namely that stoves
are apt to be  used for cooking; and that  grease,  meat and other
substances calculated to give  rise to offensive effluvia are often
thrown upon  them, and the air thereby rendered impure.  Open
fires, are, in  truth, much more frequently used for  cooking in
nurseries, than stoves; and. although much  of  the  steam and
effluvia may  be carried up by the draught of the chimney, enough
of them is in  general diffused  throughout the room, to give an 
  60                      THE NURSERY.

  unpleasant and  unwholesome character to the air.   Whether
  'stoves or open fires be used, cooking ought never to be permitted
  in well-conducted  nurseries.   If  rooms warmed  by stoves are
  more liable to be heated to excess, open fires, on the other hand,
  are more apt to keep up an  injurious variation of temperature.
  The preservation of a steadfast and uniform  degree of warmth,
  throughout every part of the room is particularly desirable in
  nurseries.  This is easily effected  by means of  a stove, however
  spacious  the chamber may be.  With an open fire, on the con-
  trary, it is always extremely difficult to procure a uniform temper-
  ature in  large  apartments;  for while the /iir near  the fire is
  uncomfortably warm, that of the  remoter parts of the room is
  often  disagreeably cold.   Nevertheless, in small  and  confined
  nurseries, an open  fire is upon the whole, preferable to a stove;
  for as the air of  a small chamber is soon rendered impure by the
  breathing, perspiration, &c. of its  inmates, a more regular influx
  and circulation of air is required,  than in  large rooms,  to keep
  up a proper degree of atmospheric purity—and this is much more
  certainly obtained by the draught  of an open chimney than by an
  ordinary close stove.
    The windows  of nurseries  should be provided with bars fixed
  across the lower  half of them, in order to prevent children from
  falling out—an accident which is by no means uncommon, when
  this precautionary measure is neglected.  They should  also be
  supplied  with shutters, particularly  when they face the south,
  "that the room may be darkened,  when the  exclusion of light
  becomes  necessary or proper."
    The floor of nurseries should be covered with a soft woollen
  carpet.   This is  especially proper, during early infancy; before
  children have acquired the full use of their legs, and while they
  are  as yet subject to frequent  falls and blows, in their feeble and
  uncertain efforts to move about the room.   Children  rarely
  receive  any material injury  from falling on a  soft carpet: and
  when we advert  to the very serious consequences  which are apt
  to result  from severe blows  on the head during  childhood, the
  want of carpeting must be  regarded as a very considerable defect
  in a nursery. All superfluous furniture,  should  be excluded
  from  the apartments appropriated to children.   They  should,
. however, be supplied with well-adapted contrivances for infantile
  amusement and  exercise.   A well-constructed rocking  horse,
  usually affords children much delight  combined with excellent
  exercise. 
OF WEANING.                     61
                   CHAPTER VII.

                        OF WEANING.

  The period to which suckling may be extended without affect-
ing the health either of the mother or" infant is so entirely under
the control of a variety of circumstances of an accidental charac-
ter, that no particular term, of general applicability, can be assigned
at which infants should be finally separated from the breast.  In
general, this important function is continued much longer, than a
proper attention to these circumstances  would justify; and the
consequences of this error, are often of a very serious character.
The only thing that is usually regarded by mothers, in fixing on
the time for weaning, is the age of the infant.  The  child is suck-
led until it attains a certain age, without any regard to the devel-
opement of its digestive  powers, or the  state of  its health and"
constitutional  vigor.   By this course, children may be kept at the
breast, long after  the vigor of the digestive functions, and the
demands of the system require a more substantial  and nutritive
diet; and on  the  other  hand, they may be separated from the
breast, before  the stomach has acquired sufficient energy to digest
with due facility a stronger  and less congenial aliment.   The
progressive  developement of the  digestive powers,  and the
demands of the organization in relation to nutrition, are very vari-
ous among different infants.  It is particularly important that the
condition of infants, with regard  to these circumstances, should be
consulted  in  regulating the period of lactation.   The  obvious
correspondence which exists between the  successive appearance
of the teeth,  and the developement of  the  digestive powers,
affords us a safe  guide in  relation to this subject.  The  child
comes into the world with teethless gums, and instinctive powers,
adapted in the most perfect manner, for drawing its nourishment
from the maternal breast.  It is  not furnished with teeth, because
neither  the mode in which its appropriate nourishment must be
taken, nor the character  of the  nourishment itself requires such
organs,  nor are the  powers of the stomach  as  yet sufficiently
active, to digest, in a proper manner and without injury, the kind
of food which would require the  aid of teeth.   After the lapse of
some time, varying in different cases from about two  to four or
five months, the first two inferior cutting teeth protrude through 
 62                       OF WEANING.
 the gums.   In the course of from four to six weeks afterwards,
 the two corresponding teeth of the upper jaw make their appear-
 ance.  These, in three or four weeks, are succeeded by the lateral
 cutting teeth of  the lower jaw; and in  a few weeks subsequently,
 those of the upper jaw also make their appearance.
   Now, as in relation to their use, the teeth have a direct refer-
 ence to a more substantial aliment, than that which the stomach
 of the new-born  infant is capable of digesting, we may reasonably
 infer, that the successive appearance of these accessary instruments
 of digestion, corresponds with the progressive developement of the
 important function which they are intended to subserve.   Thus
 an infant that is furnished with four  or more teeth, at the age of
 six months, may be presumed to possess more  active  digestive
 powers, and  to require a more varied  and nourishing food, thaa
 one, who, at the same age, is as yet destitute of these little instru-
 ments.  When speaking of the nourishment of infants, it was
 remarked, that immediately after the first teeth have made  their
 appearance, it will, in general, be proper to allow the child  small
 portions of some of the  blandest kinds of artificial food; and that
 both the quantity and nutritious quality of the aliment  should be
 gradually  increased, in proportion  as  the teeth are successively
 protruded  through the gums.  By the  time that all the  cutting
 teeth have  made their appearance,  the child's  digestive organs
will have acquired sufficient tone and activity to enable them,to
digest, without difficulty, a simple and appropriate artificial  diet;
and the system,  in  general, will  have attained a state of devel-
opement which renders such a nourishment more suitable to the
exigences of the  organization,  than the less  substantial aliment
derived from the maternal breast.
  This period then—namely soon after  all  the incisor teeth have
made their appearance—ought to be  regarded as the proper time
for weaning,  provided no  adverse circumstances,  either on the
part of the infant or the mother, render it necessary to terminate
lactation sooner, or to prolong it to a more advanced age.  It is
evident, that according to this rule, the proper period of  weaning,
must vary considerably in different cases. It will seldom, however,
be delayed  beyond  the  eleventh  month, and in the majority of
instances will occur between the ninth  and tenth month.  I am
 entirely persuaded,  both by  experience, and  by  what appear
 to be the obvious intentions  of nature, that, if the duration of
 suckling were always regulated by this rule, no inconsiderable
 amount of sickness  and  constitutional infirmity, both in relation
 to the  mother and the infant, would be  avoided.
  Unless urgent  reasons exist for an immediate separation of the
 infant from the breast, weaning ought always to be accomplished
 in a gradual  manner.  A sudden transition from the mild  and 
OF WEANING.
63
 simple nourishment obtained at the breast, to the exclusive use of
 a more  substantial  artificial  food,  could rarely fail to produce
 disorder of the digestive organs and  bowels,  even  in the most
 robust and healthy children.   If the mode of management which
 has already been indicated, in relation to the nourishment of the
 child be  adopted:—that is,'if small portions of the most simple
 and bland  kinds of artificial  food be allowed after the first teeth
 have made their appearance, and its quantity and nutritious quality
 be gradually increased,  in  proportion as the other incisor teeth
 come out, the stomach  will  be sufficiently prepared when the
 proper period of weaning arrives, to admit  of an immediate
 passage  from the nourishment of the breast to an exclusive arti-
 ficial aliment, with but very little or no risk of unpleasant conse-
 quences.   When  the period  of weaning is  approaching small
 portions of bread, bread and  milk, milk thickened with rice, or
 flour, rice, chicken,  mutton or beef tea, &c, should be allowed
 the child, two or three times daily;  whilst, at the same time, the
 intervals  of suckling should be more and more prolonged.  By
 this course of management the infant's stomach will be gradually
 accustomed to a  more substantial nourishment, and  its  attach-
 ment to the breast insensibly diminished.  When the child mani-
 fests great reluctance to a total separation  from  the breast, we
 may sometimes facilitate the weaning by applying some offensive
 substance to the  nipples, such as aloes, infusion  of colomba, or
 gentian,  assafoetida, or a  weak  solution of  sal ammoniac, &c.
 Some advantage may also be  obtained by accustoming the child,
 to drink out of a tea-cup, saucer,  or glass, and thus teaching it
 early, to receive its nourishment from vessels of this kind.
   After the  child has been  weaned  its principal  nourishment
 ought still to consist of liquid or  semi-fluid substances.  Milk,
 milk boiled with  bread, or slightly  thickened with rice or wheat
 flour, rice, preparations of  arrow root, tapioca or sago, oatmeal
 gruel,  pulverised crackers dissolved in warm water with a little
 milk and sweetened, should constitute the principal nourishment
 until the eye teeth or fangs have made their appearance.  Along'
 with these fluid alimentary substances, small portions of bread,
 bread and butter, and weak  and simple broths may be allowed'
 occasionally, with perfect propriety.  It is particularly important
 to guard against too  full and nourishing a diet immediately after
 the weaning has been accomplished.   Though gradually brought
in the  way just stated, to bear the simpler kinds of solid nourish-
ment when  taken at distant intervals, the  stomach is readily
oppressed and disordered,  at  this  period, if the  transition  to a
substantial diet is abrupt.   It will  digest  small portions of such
food, without difficulty, when  taken at considerable intervals;
whilst a frequent and free use of the  same  articles, would soon 
64                       OF WEANING.

overwhelm and exhaust  the digestive powers, and give rise to a
train of distressing dyspeptic affections.   The quantity of solid
food should, therefore", not be  materially increased immediately
after weaning:  nor should there be any particular increase in
the general quantity  of nourishment  whether  solid or liquid,
until the stomach has been fully accustomed to the change.  After
the eye  teeth have made their appearance,  however,  the solid
and  more nourishing kinds of food should be gradually increased,
until the process of primary dentition  has been  completed—by
which time, the powers of the stomach are, in general, sufficiently
developed, to admit of a full and substantial aliment.

   Circumstances requiring a deviation from the above general rule*
for determining the duration of lactation.   The progress  of  denti-
tion is, doubtless, our safest guide, in regulating the nourishment
of infants, and  in deciding on  the period,  at  which they may
with propriety be put on the exclusive  use of artificial food. Not
unfrequently, however, circumstances of an  irregular  or morbid
character, render it expedient, or even indispensable,  to  wean
the child, before it has attained the age and organic developement,
which, under ordinary circumstances would be deemed requisite
to justify  its final separation from the breast.
   1.  The mother may be affected with some constitutional malady,
which may so contaminate her milk, as to render it highly injuri-
ous to the child's health, if she continues to nourish it at the breast.
I have known several instances of extremely distressing affections
in infants, obviously produced by the tainted  milk obtained from
nurses laboring under syphilis.  Mothers, affected with scrofula
in an active state, or with ulcerated cancer, should, on no account,
suckle their infants.
   The mother may also be so exhausted and debilitated  by an
attack of some acute disease, and the depletory measures requisite
to subdue it,  that she cannot continue  to suckle her infant, with-
out  increasing  her prostration  and  superinducing a  train of
alarming and highly distressing affections.  The  same  difficulty
is apt to occur, in mothers of a feeble, delicate and nervous habit
of body, particularly when the digestive powers are weak, or so
disordered that  nourishing and substantial  aliment cannot be
taken.  Under these circumstances, suckling can seldom be con-
tinued without producing the worst effects.   The constant drain
of the nutrient elements of the blood, through the breasts, causes
 X rapid increase of the debility, and gives rise ultimately, to a train
 of very distressing nervous  affections, which cannot be removed
 or even materially mitigated so long as the infant is nourished at
 the  breast.   If the suckling be continued, the appetite and  diges-
 tive powers fail;  severe pains  in the  head ensue, the  nervous 
                       OF WEANING.                      65
system becomes greatly disturbed; transient pains, alternating
with spasmodic twitches or numbness, occur in various  parts of
the body; the debility  and emaciation  advance rapidly; a mul-
titude  of anomalous  nervous  affections constantly harass the
patient;  a  most distressing sense of sinking and emptiness,  is
at times  felt in the region  of the  stomach; the mind  becomes
disturbed and tormented often with an intense dread of  dying,or
a constant apprehension of  some  dreadful  accident.   At  last
delirium and even mania sometimes supervene.
   I have recently met with a striking example of this kind.   The
lady—always of an extremely delicate and feeble habit of body—
was suckling a robust  infant, about four months old, when I first
saw her.  Her digestive powers were very weak, and her general
strength was so much  impaired that she was obliged to remain,
almost constantly, in bed.  At times she experienced violent pains
in different  parts of the body—most frequently, however, in the
hack part of the head, and  in  one  of the temples.  Her whole
nervous system was extremely excitable, and she suffered without
intermission, a variety of exceedingly harassing nervous affections,
Sometimes she felt a distressing sinking  and emptiness in the
pit of the stomach; at others, a general numbness extended itself
throughout her extremities;  often, she experienced alarming pal-
pitation, and almost constantly complained of a benumbed feeling
in the tongue, accompanied, occasionally,  with  an inability to
swallow, and rapid spasmodic  twitchings of the muscles  of the
face and extremities.   These symptoms were attended with great
mental disturbance—manifested by  a constant and intense dread
of dying, and great apprehensions of some overwhelming misfor-
tune.  Not  the  slightest  advantage was obtained from medical
treatment, although a great  varfety  of means, apparently adapted
to  the  case, were employed, with anxious diligence,  for more
than two months.  She  had  repeatedly been urged to wean the
infant which she  continued to suckle,  but always  obstinately
refused to comply with the request.  At  length, however, she was
prevailed on to wean  the cnild.  In the course of three or  four
days, the symptoms under which she had so long suffered,  evidently
began  to abate; and  at the  end  of the third week, she was
entirely freed of her harassing  complaint.   I have, indeed, often
met with cases of a similar  character, and the instances of  very
serious suffering and prostration among young and delicate moth-
ers, from suckling,  are probably of much more frequent occurrence
than seems to be generally supposed.  " Many young ladies," says
a late writer, " on becoming mothers, are incapable of supporting
the constant drain  to  which the wants of their  infants subject
them.   They lose  their good looks, become gradually weaker and
paler, and as their  strength declines, they become more and more
                             R              7 
66                       OF WEANING.
afflicted with a  variety of harassing nervous affections."   Medi-
cinal means  are of no permanent advantage.  They may procure
more or less  temporary mitigation of the symptoms, but they are
whollv inadequate to  the removal of the malady.   Nothing but
weaning will  suffice—and  the entire separation of the child from
the breast, is generally soon followed by a progressive subsidence
^of the sufferings of the patient.  But it is not simply on account
of the mother,  that weaning becomes  indispensable, in cases of
this kind; the welfare of the infant, also, is intimately concerned.
In nearly all  instances  where  lactation produces the  pernicious
effects  just  stated,  before  the regular period of weaning, the
secretion of milk is much diminished  in  quantity,  as well as
deteriorated  in quality; so that it is not only wholly insufficient to
supply the wants of the infant, but moreover often decidedly in-
jurious, in its effects on the infant's digestive organs and general
state of health.
   The foregoing observations refer  more  particularly   to the
necessity of  weaning at  a comparatively early period after the
child's birth, when from the mother's feeble and delicate condition,
suckling gives rise to symptoms of exhaustion, and nervous disor-
der.   " Many mothers," says Dr. Hall," are incapable of suckling
longer than three or four  months, without producing symptoms of
undue lactation, or exhaustion.  Delicate females who  are enfee-
bled by haemorrhage during parturition, or who have been freely
depleted, and confined  to a very simple and innutritious diet, in
consequence of some  inflammatory affection  soon after confine-
ment, frequently suffer  much exhaustion from suckling."   If, in
the  early period of  lactation, the mother becomes progressively
weaker, with loss of appetite, and increasing symptoms of nervous
irritation without any obvious cause, we mjay suspect exhaustion
,from suckling as the immediate source of the  illness;  and should
this be the  case, nothing but  an  entire separation  of the child
 from the breast will be adequate to restore her health.
   It has already been observed above, that suckling is in general
 continued much longer than is consistent with  the welfare either
 of the mother or the child.  On the part of the mother,  the effects
 of unduly protracted lactation are sometimes extremely pernicious.
 We not unfrequently see women pale, debilitated, and constantly
 tormented with dyspeptic and  nervous affections, suckling their
 infants  for  eighteen or  twenty months, and  occasionally much
 longer, without suspecting that their sufferings and ill-health, is
 the result of exhaustion, from the constant drain of the nutritious
 elements of the blood which is kept up by the suckling.  To
 relieve this  exhausted  and  disordered condition of the system,
 medical aid is usually resorted to, and tonics,  antispasmodics,
 alteratives, and nourishing diet freely and perseveringly employed 
OF WEANING.
67
—but always in vain, and often  even, with manifest injury.   At
length, after  the mother  has been reduced  to a  state of great
feebleness and general disorder of the vital functions, the child is
weaned; and now, what might have been effected in a few weeks,
by a timely separation of the  child from the  breast, can hardly
be accomplished in many months, by the most judicious and care-
ful  remedial management.   Thus  irremediable  constitutional
infirmity and nervousness  are  sometimes produced at  an early
period of life, which, under a  more rational and prudent  course
of management, in relation  to the duration  of suckling, might
have been entirely avoided.
  Many  mothers are able to  suckle their children until they
arrive at the proper period of weaning, without the least incon-
venience, who, nevertheless, will suffer very serious derangements
of health, when the nursing is extended considerably beyond the
time, which nature points out as the proper period for terminating
this important function.   When lactation is prolonged, as it often
is, until it becomes a source of morbid exhaustion, the first mani-
festations of its injurious influence consist in an obvious increase
of debility, attended with disagreeable sensations in the region of
the stomach and head.  The digestive powers soon become much
enfeebled, and various distressing dyspeptic symptoms ensue; the
countenance  becomes peculiarly  pale and  languid; severe pains
occur in the head, often confined to the posterior part, or to one side,   N
and a tormenting pain also is usually felt, "just below the cartilages
of the false ribs on the left side, or directly below the left breast."
Connected with these symptoms, a state of chronic hysteria, or
extreme  and harassing  nervousness almost  invariably occurs,
Palpitation  of  the heart  and alarming paroxysms of  nervous
agitation come  on,  at  uncertain intervals;  more or less cough
generally occurs; the mind becomes despondent, irritable, and in
aggravated cases, sometimes, decidedly deranged.   Added to
these symptoms, there  is always more or less emaciation; and
ultimately night sweats with slight febrile irritation ensues.  The
bowels are usually torpid.  In consequence of the enfeebled state
of the digestive  powers, nothing but  the simplest and mildest
articles of food can be  tolerated by the stomach.   Articles  that
are not easily digested,  or such as are of an irritating character,
seldom fail to produce severe pains and  disturbance in  the head,
and various distressing sensations in the stomach and chest.  "In
this state of things," says Dr. Hall, " the patient  is apt to try to
support her strength by a generous diet and wine.  This, however,
is a vain effort.   For the tone of the stomach is already enfeebled,
and  this organ  is therefore altogether  incapable of bearing the
increased burthen thus put upon it; and wine only induces fever-
ishness, or at least a false and temporary appearance of strength." 
68                       OF WEANING.
I have thus been particular in describing the evil consequences
which are apt to result in females of weak digestive  powers and
nervous temperaments, from unduly protracted suckling, because
I am persuaded, that this subject is too much neglected, and that
the instances of serious indisposition and suffering from this source
of exhaustion, are much more common, than is generally supposed.
The proper course of remedial management in such cases, consists
in the immediate  weaning of the child, in conjunction with the
use of a mild, simple, and nutritious diet, and remedies calculated
to restore the tone of the digestive organs and improve the alvine
secretions.
  On the part of the m/an/, also, suckling when continued much be-
yond the proper period, is apt to exert a highly injurious influence.
It is well known, that after the eleventh or twelfth month, the milk
almost invariably becomes diminished in quantity, as well as more
or less deteriorated in quality: and in proportion as the lactation
is protracted, so  will it  lose more and more  its  nutritious and
wholesome character.  In many instances  indeed the milk begins
to deteriorate as early as the ninth or tenth month, corresponding
in this respect, with the proper period of weaning as it is usually
indicated  by the  progress of dentition.  That the child must be
liable to sustain injury in  its health, when nourished by milk thus
depraved is very obvious; and the  liability to disease from this
source, must of course increase in  proportion as the suckling is
protracted.  Children who are suckled an undue length  of time,
generally gradually lose their fresh and healthy appearance.  The
countenance becomes very pale and  acquires  a languid, fretful
and  sickly expression.  The digestive  powers are enfeebled—
giving rise  to  acidity, flatulency, colic, vomiting  and diarrhoea.
In some instances, the abdomen becomes tumid,  firm to the touch
and  tender, whilst the  extremities  are progressively  emaciating.
Strumous swellings are apt to appear  on  the neck or under  the
ears; and scabby  erruptions on the head and  face.   It would
seem too, that a very decided predisposition to  convulsive'affec-
tions  is often  created by unduly continued lactation,  and Dr.
Morton has adduced  a number  of cases to show that-it  not only
produces a strong  predisposition to  meningites, but frequently
operates as  a direct exciting cause of this dangerous malady.  He
states it as his  conviction, founded on  experience, "  that if chil-
dren be suckled for an undue length of time, that is, any period
beyond nine or ten months, they will be peculiarly  liable to  be
affected  with  meningites.  Or that,  should  they  not  become
affected with this disease, during or soon after the  time that they
are  thus  improperly suckled,  they will,  nevertheless,  acquire
therefrom, a predisposition  to cephalic disease, at some future
period of their lives; and finally, that the same injurious effects, 
OF WEANING.                       69
 will take  place in infants, if suckled by women who have been
 delivered  an undue length of time, although the infants them-
 selves, may not have been at the breast for too long a time."
   In some instances, the milk loses its wholesome properties at an
 early  period of lactation, without any very serious or obvious de-
 rangement of health in the maternal system.  When this occurs,
 the infant, often, throws  up the milk  again, soon after nursing,
 and becomes harassed with colic, griping,  acidity and diarrhoea,
 attended with paleness, debility, emaciation, and  frequently with
 scabby eruptions about the face and head.  If the child becomes
 affected in this manner, when nourished exclusively at the breast,
 we may presume, that the milk has become depraved and injuri-
 ous to its' digestive organs.   If any doubt exist as to the agency
 of the milk in the  production of the disorder, the breast should
 be withheld  from the child as long as  can  be done without any
 particular  inconvenience to the mother, and artificial nourish-
 ment, or the milk of a nurse  substituted.   If the mother's milk
 has been the cause of the child's illness, an obvious abatement of
 the symptoms will  soon  take place;  and should  this occur,  the
 child ought to be gradually entirely separated from the maternal
 breast.

   Mental inquietude, deep grief or  sorrow, and other violent affec-
tions of ihe mind, have a  strong tendency to deprave the milk.
Women of a very nervous habit and an irritable temper, are  pe-
culiarly liable to  those mental perturbations which are apt to  de-
teriorate this nutrient secretion.   " Those  mothers," says  Dr.
Struve, " who are so unfortunately situated  that they cannot avoid
provocation,  grief, or sorrow,  as well as others who possess  an
irrascible and bilious temperament, or  are subject to great ner-
vous debility, accompanied by great susceptibility of every stimu-
lus, will confer no benefits on their children by presenting them
with a corrupted  milk, which  cannot fail to injure their health,
and lay the foundation of fatal maladies."

   The recurrence of the menses, during Jactation, exerts, in  many
cases, a decidedly prejudicial  influence  on  the properties of the
milk, and often renders weaning necessary, long before the usual
period of separating the child from the breast.  I have, in several
instances, where menstruation had returned as early as  the sixth
month, known the child to become extremely ill, evidently caused
by the deteriorated character  of the milk, in consequence of the
renovated menstrual function, as was demonstrated by the speedy
return  of health, after weaning was  accomplished.  The  reap-
pearance of the menstrual evacuation, moreover, renders the lac-
tescent female more liable to the recurrence of pregnancy—a con- 
 70                       OF WEANING.
 dition which invariably lessens the quantity of the milk, and in
 some instances deteriorates its quality.   Neither the appearance
 of the menses, nor the occurrence of pregnancy during lactation,
 however, can be taken as a positive and constant indication of the
 propriety or necessity of weaning.  Occasionally, infants are kept
 at the  breast, while the catamenia are regularly recurring, and
 during  the early period of pregnancy,  without receiving the
 slightest apparent injury.   The reverse nevertheless frequently
 takes place, and  weaning  becomes indispensable to the welfare
 of the infant.  When therefore the mother finds the child becom-
 ing sickly,  feeble, and annoyed with disorder of the stomach and
 bowels, after menstruation has returned, or after she finds herself
 in a state of pregnancy, and relief is not obtained, in due  time,
 from the use of appropriate remedial means, the child  ought to
 be gradually weaned.  " Should  a woman,"  says  Dr.  Morton,
 " with an infant at the breast, again become pregnant, one of two
 things will  usually take place; either she will miscarry, or her
 milk will become  impoverished in quality and diminished in quan-
 tity. It was not intended by nature that the processes  of pregnancy
 and lactation should go on simultaneously; but, on  the contrary,
 that the one should commence when the other had terminated;
 and experience sufficiently proves, that they will not proceed well
 together: the reason of which, as it appears to  me, may be easily
 given.  During pregnancy, and particularly during  the latter pe-
 riods, the vessels of the  womb gradually enlarge,  and  a much
 greater quantity of blood than usual is determined to that organ
 for the increase and perfection of the embryo, and its appendages;
 which after delivery becomes transferred to the breasts to supply
 the material for the secretion of the milk: but if during pregnancy,
 lactation be also  persevered in, the  blood becomes directed,  at
 tjie same time, to  two different parts of  the body, somewhat re-
mote from each other; and hence, neither is likely to receive its
 due proportion of this vital fluid, and  consequently  the functions
 of one or the other, or of both, are liable to become impeded  or
suspended.   If the breasts continue to receive a sufficient quantity
 of blood, the secretion of milk  goes on properly, but the  womb is
 deprived of its  necessary supply;  the  embryo, in consequence,
 languishes and dies, and, becoming an extraneous body, is thrown
 off, producing abortion:  while, on the  other  hand, should the
 womb  still  obtain its due proportion  of blood, the breasts are
 robbed of it, and the secretion  of milk, if not altogether suppress-
ed, is  rendered either deficient  in quantity or  deteriorated  in
 quality."
   If from causes of this kind, it occasionally becomes necessary to
 separate the child from the breast sooner than would otherwise be
 deemed proper, circumstances  may also occur,  which will render 
OF WEANING.
71
it expedient to protract the duration of suckling, beyond the pe-
riod that might be indicated by the progress of  dentition, or the
mere  age of the infant.  The child may be laboring under some
disease, or it may be in a very debilitated condition  from previ-
ous disease—or its digestive organs may be weak  and irritable,
at the regular period of weaning.  Under such circumstances, it
would undoubtedly be improper to wean  the child, unless good
reasons existed for believing that the milk had become decidedly
unwholesome.   The bland and  congenial  nourishment obtained
at the breast, could hardly be  substituted by the mildest artificial
food,  without retarding the progress of the  child's convalescence;
and in a  very debilitated condition of  its  digestive  powers,
such  a transition  could hardly  fail to  give rise to very serious
affections. Children should never be weaned when they are sick,
unless the indisposition is found  to have been produced or to be
supported by an unwholesome state of the milk (Dewees).
   Some  attention should also be paid to the season of the year,
in fixing on the period of weaning.   In general, weaning may be
accomplished with less inconvenience and risk of unpleasant con-
sequences to the  child, during the mild months of April,  May,
September, October, and the early part of November, than whilst
the weather is  inclement.   Exercise  in the open  air, is always
highly beneficial to the child,  at the time of weaning.  It tends,
in no  inconsiderable degree, to fortify the system of the child, and
to enable its digestive organs to  bear without inconvenience, the
change of nourishment. In consequence of the peculiar tendency
of warm weather to excite cholera infantum, particularly in cities
or large towns, it is in general inexpedient to separate children
from the breast, during the months of June, July and August; for
it  has been abundantly ascertained that the transition from the
maternal milk to an exclusive artificial nourishment, during this
season, has  a decided  tendency to favor the occurrence of this
dangerous malady.  Nevertheless, should the child be manifestly
suffering from a deteriorated state of the milk, it ought to he sepa-
rated  from  the  breast, without any regard  to season; f©r a bad
condition of the milk, would doubtless, be  more injurious in this
respect than a suitable artificial  nourishment. 
72            CLEANLINESS.  WASHING. BATHING.
               .   CHAPTER VIII.

              CLEANLINESS.  WASHING.  BATHING.

   The skin is one of the most extensive and important emuncto-
ries of the human system.   Through its countless pores, a  large
portion of the secrementitious elements of  the  body are continu-
ally  passing.   Whatever interferes with  the  regular action of
these emunctories, or impedes the free elimination of the perspir-
able materials of the blood, becomes a source of more or less seri-
ous disease; and  on the other hand, every tiling  that  tends to
maintain a healthy activity of this function, contributes, very large-
ly to the preservation of a healthful condition of the system.
   Cleanliness is a most important requisite for keeping up a healthy
state of the skin.   When ablution  is neglected or inadequately
attended to, particles  of perspirable matter, together with  the
dust  which  settles  on  the  cuticle, insinuate themselves  into  the
pores, and  spread  a film of impurities over the whole surface.
This, not only interferes with  the regular progress  of the cutane-
ous transpiration, but tends, moreover, in no slight  degree, to dis-
order the healthy  structure of the cuticle  and cutis, and,  ulti-
mately, to give rise to protracted and dangerous  constitutional
maladies.   Children who are neglected in  this respect, are much
more apt to suffer severely from  the contagious  eruptive fevers,
incident to  childhood, than those whose skin  is  kept clean  and
pure.  The tendency of a foul state of the skin, to give rise to
various chronic cutaneous disorders, of a loathsome  and harassing
character, is well known. Itch, scabby eruptions on various parts
Of the body, tetrous affections, painful and  offensive excoriations
and herpetic disorders, are often  the result of uncleanliness of the
body.  The general, health, too, is liable to be impaired,  by an
habitually  unclean state of the  surface; and  it unquestionably
predisposes the system to the occurrence of indigestion, and other
forms of gastric and intestinal disease.  The agreeable feelings
which entire cleanliness is calculated to produce, as well as  the
excellent moral influence which it is capable of exerting on the
mind, are,  in  themselves, of sufficient moment to claim for it the
most solicitous attention.   Children, who  are  early accustomed
to the comfortable and healthful impressions  of  washing  and
bathing, will rarely, in after life, neglect the observance of  per-
sonal cleanliness; and  those, on the contrary, who are neglected, 
              CLEANLINESS.  WASHING.  BATHING.            73

 in this respect, during childhood, will seldom  manifest  a proper
 regard for this  physical virtue, in the subsequent stages of their
 lives.
    Infants ought to be thoroughly washed over the whole surface
 of the body once every day  until  they  are  weaned.    After
 this period it will in general  be sufficient  to make the ablutions
 once every other day.  The  water  ought to be warm during the
 first three or four months.   It should then be reduced to luke-
 warm, and continued at this temperature until the progress of pri-
 mary dentition  is completed,  when it ought to be still further re-
 duced until it excites a decided sensation of  coolness when first
 applied to the  body.   The washing should be performed with a
 soft sponge or a piece of soft linen; and particular care taken to
 remove the impurities which  are apt to remain in the folds of the
 skin and joints.  In addition  to this indispensable means of pre-
 serving a pure  and healthful condition of the skin, bathing must
 not be neglected.  The bath ought, to be  used every other day,
 during lactation, and afterwards at least twice every  week.  The
 regular use of the bath  seldom  fails to exert a highly salutary in-
 fluence on the/system, and  ought never to be regarded as super-
 fluous even as a means of cleanliness, however carefully the gen-
 eral ablutions be attended to.   Until the end of the third year at
 least, the bath ought to be tepid; and for feeble  and sickly chil-
 dren it will be proper to continue the use of tepid water for this
 purpose to a more advanced age. When the child is healthy and
 vigorous,  however, the tepid, should be gradually substituted by
 the cool bath after  the  third year; though injury is, probably,
 much more frequently done, by  too early a transition  to the cool,
 than by too long-continued  a use of the tepid bath. In using the
 bath, the  child's body ought to be'immersed up to the shoulders
 or neck.   The practice  of immersing  only the lower half of the
 body in the bath, is decidedly objectionable.  The upper part of
 the chest  being wet, and exposed to the cooler temperature of the
 air, generally feels chilly or uncomfortably cold,  while thus par-
 tially immersed  in  the tepid  water—a  situation which is  well
 calculated to give rise to catarrhal and other inflammatory affec-
 tions of the respiratory organs.
  The time during which it may be proper to remain  in the bath
 must be varied  according to the age of the child.  For the first
 four or five weeks, the infant  should not  be kept beyond two or
 three minutes in the bath—and the duration must, afterwards, be
 gradually  prolonged, as the child advances in age, until it extends
 to twelve  or fifteen minutes—a  period which a child may, with
propriety, be allowed to spend in the bath after  it has attained
the age of four years.
  It is to be particularly observed, that children should never be
                             L 
74            CLEANLINESS.  WASHING. BATHING.

permitted to enter the bath while they are in a state of  free per-
spiration from exercise—a precaution  which is especially impor-
tant when the water is below the tepid temperature.
  The best time for bathing children  is about two hours after
breakfast or dinner.  Infants should not be put in the bath imme-
diately after having been freely nourished at the  breast.  To ob-
viate the risk of taking cold, the  bathing ought  to be conducted
in a room heated to a comfortable degree of temperature; and on
removing the child from  the bath, it  should, without  delay, be
wiped  perfectly dry, and immediately  invested in warm and dry
linen.  " Infants may then be  placed in bed, which  in winter
should be previously warmed; and they will generally fall into  a
refreshing sleep, attended with a gentle and  beneficial  perspira-
tion.   Children, further advanced in age, who have  already been
accustomed to the cool bath, need not be put to bed, but rather
induced  to take  exercise  after it in  the open air,  though much
depends  here  on the  circumstance,  whether they have been
bathed in warm, cool, or cold water.   If warm  water  has been
used, the child should  be  immediately put to bed;  for  nothing  is
more apt to ^predispose to  the injurious effects of cold than warm
bathing."  In  that  general  tendency to increased perspiration
which  is produced by the  tepid bath, every draught of air, and
especially the sudden removal to a cold atmosphere, is peculiarly
apt to give rise to catarrhal and  other febrile affections.   After
cool-bathing,  on the contrary, no apprehensions of injurious con-
sequences need be entertained from  exposure to the open air;
and active exercise, after  coming  out of such a bath, exerts, in
general,  a very salutary influence  on the health  and feelings of
the individual (Struve).  " In rough weather, however, it is more
advisable to keep the young party, after bathing, for half an hour
in the nursery, where they may run about according to  their own
pleasure, and then enjoy the fresh air,  but with strict injunctions
not to sit down on the grass."*
  Some writers advocate  the use of cool and even cold water,
both for washing  and bathing infants;  and many mothers pursue
this practice  under the fallacious idea  that it tends  to invigorate
the infantile system and fortify it early  against the injurious influ-
ence of cold  and sudden changes of temperature.   Reference is
usually made to the custom, in some  countries, of plunging new-
born infants into cold water, as an evidence of the propriety and
usefulness of this practice;  and it cannot be doubted,  that of those,
whose  strong constitutional energies enable them to pass safely
through this severe process of hardening, many may ultimately
be benefited by, its inuring tendency.  It is well known, however,
* On the Domestic Education of Children. By C. A. Struve, M. D. 
CLEANLINESS.  WASHING.  BATHING.
75
that many infants perish, at an early period, in consequence of
this  cruel  and unnatural exposure; and that,  in  general, those
only who are endowed with vigorous powers of life, are able to
sustain  its depressing influence, without injurious  consequences.
Warmth is peculiarly congenial to the physical habits and sensi-
bilities of the infantile system. Until birth, the infant is surround-
ed by a medium of the temperature of its own body;  and there
can be no doubt, that its sensibility to cold, for some time after
birth, must be such as to render its impressions very distressing
and painful.   Cold is a sedative or debilitating agent, in its direct
and essential  operation on  the  animal  system.  The increased
activity which sometimes follows the application of cold, is caused
by the  reaction of the vital powers, after their temporary de-
pression;  but when the system is feeble, the depression*caused by
the cold, is often so great, that the powers of life are incapable of
developing a healthy degree of reaction, and more or less perma-
nent prostration  and disorder of the system, is  the inevitable re-
sult.  Feeble and sickly children ought to be as little exposed to
low temperature as possible, until, by a judicious course of man-
agement, their systems are gradually inured to its chilling  and
depressing influence.  The use of  cold or even cool water, for
washing and  bathing very young infants of weak constitutional
powers, is frequently  attended  with the  most unhappy conse-
quences, and' always, with a great deal of suffering.  Even robust
and vigorous infants often  manifest, by their screams, and their
protracted paleness, shrunken appearance, and tremor of their
bodies, the painful and  depressing effects produced by being wash-
ed  in cold water.   Instead of being invigorated, they are  fre-
quently enfeebled by this practice; and before they become in-
ured to the impressions of the cold or cool water, serious catarrhal,
febrile,  or  bowel  affections  may be caused by its  tendency to
check the perspiration, destroy  the regular balance of the circu-
lation, and depress the vital powers.  By the use of tepid water,
on the contrary, the cutaneous exhalents are gently excited, with-
out the  risk of suspending their action, or of causing a sudden and
dangerous revulsion of blood from the surface  to  the internal
organs; at the same time, that the  congenial temperature of the
bath, produces an agreeable and salutary excitement throughout
the whole system.  In urging the propriety of using tepid, in pre-
ference to cool water,  however, it is proper to observe that  the
employment of decidedly warnl water for bathing children, is  not,
in  general, advisable, except during the first  few weeks after
birth, or as a remedial agent, in certain states of  feebleness and
disease.  Warm bathing, by its tendency  to over excite  the ex-
halents  of the skin, is apt to produce a state of general relaxation
and languor, unfavorable to the regular performance of the vital 
76
CLEANLINESS.  WASHING.  BATHING.
 functions, and to predispose the system, very strongly, to the inju-
 rious influence of cold.  Children, who are often bathed in warm
 water, are apt to acquire a susceptibility to the impressions of low
 temperature, which  renders them much more liable to catarrhal
 and other affections, from exposure to the  open and cold air, than
 those who are habitually bathed in tepid or lukewarm water.  As
 a general rule, the temperature of the bath ought to be about 98°
 of Fahrenheit during, the first ten or twelve days.   It should then
 be progressively reduced, about one degree every month, until the
 end of the first year, and continued at this degree of warmth until
 the completion of the second year.  After this period the  tempe-
 rature must be further lowered, though in a very gradual manner,
 until about the end of the third year  the bath creates a sensation
 of decided coolness.  In relation to this subject, however,  regard
 must be had to the particular condition of  the child with  regard
 to its constitutional vigor, predispositions, and health.  Weak and
 sickly children, generally require  a  greater degree of warmth,
 and  a more cautious transition to cool bathing than such as are
 robust and healthy;  and this observation is especially applicable
to those who  are strongly predisposed to bowel complaints, or to
cutaneous eruptions. 
BOOK  II.
OF THE DISEASES OF CHILDREN.
                     CHAPTER  I.

     OF SYNCOPE, ASPHYXIA, AND IMPERFECT RESPIRATION.

   In the majority of instances, the child begins to breathe and
cry, and the various  functions of independent life commence their
circle of action, as soon as it is ushered  into the world.   This,
however, is  not  always the  case.  Many children manifest no
signs of animation when born, in whom, nevertheless, the  spark
of life still lingers, and may, occasionally, be re-excited by prompt
and judicious management.  This state of apparent death, may
depend either on an apoplectic condition, or on syncope, or on
great feebleness  and exhaustion of the vital  powers.   When it
depends on an apoplectic state of the brain, the infant's counte-
nance exhibits a livid or deep red and bloated appearance—the
prolabia are purple or almost black, the eyes prominent, and the
surface of the body  warm, reddish and somewhat tense.  This
condition generally arises from a tedious and difficult passage of
the infant's head through the  pelvis, and particularly from the
umbilical cord being wound tightly round the child's neck,  impe-
ding the return of the blood from  the head, and thereby causing
inordinate sanguineous congestion  in the brain.  This apoplectic
condition is produced, also, by the unceasing and vehement ute-
rine contraction, which is often excited  by ergot; for infants who
are still-born, or in a  state of asphyxia, after the efficient adminis-
tration of this substance, generally  exhibit very strong marks of
                            8              77 
78                      OF SYNCOPE, &c.
excessive vascular turgescence in the head.   Indeed, it is difficult
to conceive, how a  long-continued and powerful  action of the
uterus could fail  to produce dangerous or fatal sanguineous con-
gestion in the brain.  The water, by which the foetus is surround-
ed, being wholly incompressible, the entire force of pressure ex-
erted by the womb, must necessarily act directly upon the child,
and cause so great a compression of the more yielding parts of the
body, as  nearly to arrest the circulation in them—the  inevitable
consequence of which must be, an excessive  accumulation in the
brain, heart and  lungs, parts that are protected against external
pressure, by the bony walls which enclose them.   This is proba-
bly the ordinary manner in which  ergot, when exhibited  under
circumstances unfavorable  to the  speedy completion of labor,
proves injurious or fatal to infants.
  In  some instances of this kind, the child is born without any
manifestations of life whatever.   Its face is swollen and livid, the
body  flaccid, and  the navel string has ceased to pulsate. Although
but very little hope can be entertained of recovering an infant in
this condition, it ought not to be immediately abandoned  without
making suitable  efforts for the resuscitation  of its vital  powers.
As almost every thing, in such cases, depends on the speedy re-
moval of the congested condition of the  brain, the uihbilical cord
should be immediately cut, and an effort made to strip some blood
from it with the fingers.  It is but very  rarely, however, that any
blood can be obtained in this way, and never after the heart has
ceased to pulsate. I think it probable, that a sufficient  quantity
of blood  might be abstracted, by dividing the cord within  about
an inch of the umbilicus, and applying a wide-mouthed cupping-
glass, furnished with an exhausting pump, over the  navel and its
short portion of  cord.  By exhausting the cup, the blood would,
doubtless, flow from the extremity of the  cord, even perhaps, after
the heart had ceased to act; and it appears  to me not unlikely,
that a considerable influence might, thus, be  exerted in re-exci-
ting the circulation.  The child's head should be supported in an
elevated  position, and the inferior parts  of its body wrapped in
dry and warm flannel.  In conjunction with  these measures, an
effort should be made to excite the respiratory function, by arti- 
                        OF SYNCOPE, &c.                     79
ficial inflation of the lungs, and compression of the thorax with
the hands, so as to imitate  the alternate acts of inspiration  and
expiration.  In inflating the lungs,  the accoucheur  must apply his
mouth to that of the infant, at the same time closing its nostrils,
and endeavor, by a moderate but  uniform force of insufflation, to
fill its lungs with air.  During this effort, the child's chest should
be a little  raised, and its  head  slightly thrown  backwards, to
facilitate the entrance of the air into the larynx.  Dr. Dewees
says, that the attempt to expand the lungs must be by a "forcible"
insufflation—an advice which may readily lead to very unfortu-
nate  consequences.  It appears,  from  a series of experiments,
made a few years ago in  France,  on animals, and from observa-
tions relative to the human subject, that no very great force of
insufflation is  necessary, to  rupture the delicate air cells,  and
cause a fatal emphysema of the pulmonary structure.   In sheep,
and in the dead human  subject, the air cells were ruptured by a
force of insufflation, not greater than that which may be made by
a person of ordinary respiratory vigor, without any very violent
effort.
   It  is not improbable, I think, that " forcible" efforts  to inflate
the lungs of infants born in a state of asphyxia, has often resulted
in fatal rupture of the pulmonary air cells.   To obviate this very
unfortunate accident, the air ought to be thrown into  the respira-
tory passages, through  a silk handkerchief folded double, or a fine
napkin, laid over the mouth of the  infant.  This, I am persuaded,'
is a very useful precaution, and should never be neglected, when
artificial inflation of the lungs is attempted.   Of the tendency of
forcible insufflation to  rupture  the air cells of the lungs, I had a
very striking illustration, a few years ago.   I attended a lady in
a tedious and rather difficult labor.   The child was still-born; but
I nevertheless made  some efforts to effect a resuscitation.   I in-
flated the lungs in the usual way.   The child, however, did not
recover.   A  singular tumor situated just above the middle of the
left clavicle, induced me to ask permission to  examine it with the
scalpel.  The tumor extended a short distance into the thorax, in
following which, I opened the chest.  On raising the sternum, I
found the superior portion of the left lung in a complete state of 
80
OF SYNCOPE, &c.
 emphysema, and a good deal of air diffused under  the  anterior
 and lateral surface of the pulmonary pleura.  With the exception
 of the inferior portions, both lungs were  crepitous, and appeared
 to have been well inflated.  That the emphysema was the result
 of rupture of the air cells, caused by the  forcible inflation, and
 not of putrefactive decomposition, I could not doubt; for up to
 within about two hours of the termination of the labor, the child's
 motions were distinctly felt both by the mother and myself.
   When the umbilical cord continues  to pulsate, in infants, born
 in this apoplectic or oppressed  condition, relief may, in  general,
 be speedily obtained, by promptly dividing the cord, and suffering
 more or less blood to flow from  it.   When  the  cord beats vigor-
 ously,  nothing more is, generally, required for setting the vital
 functions  in  play, than the prompt abstraction of blood in  this
 way.  As the blood  flows, the lividity and  turgid  state of the
 countenance, usually, disappear, and in  a  short  time the infant
 begins to breathe.  The efficacy of this measure may, in  general,
 be enhanced, by supporting the infant's head in an elevated posi-
 tion, applying cool water to the scalp,  and immersing the inferior
 extremities and hips in the warm-bath.
   When the pulsation of the cord is slow and feeble, inflation of
 the lungs  is frequently requisite, in addition to the abstraction of
blood in the way just mentioned, in order  to excite  the respiratory
organs into action.  Artificial respiration, however, is very rarely
capable of procuring any decided advantage in cases of this kind
unless  aided  by  the loss of blood.   Whenever the face is turgid
and livid,  accompanied, as is usually the  case, with signs of gen-
eral  sanguineous  repletion, bleeding from the divided cord,  is a
measure of paramount importance.   It is proper to observe, how-
ever, that in  cases unattended with these manifestations of cepha-
lic congestion and general fulness—that is, when the face and
body present a  pale  and shrunken  appearance, blood cannot be
abstracted without incurring much risk of injury.
  Some infants, who are ushered into the world with great rapid-
ity, by a  quick  succession of vehement  parturient contractions,
remain for a  minute or two without any, or but a few, imperfect
respiratory efforts, although they will  open their eyes and move 
                        OF SYNCOPE, &c.                     81
 their extremities with sufficient activity. A few drops of cold wa-
 ter sprinkled on the chest and abdomen, will instantly cause them
 to breathe and to cry out lustily.   The  main point of caution, in
 cases of this kind, is to avoid tying the cord until its pulsation has
 ceased, or has - become  quite feeble.   The  pulsation, in  these
 cases, is always very strong, and generally continues longer than
 in ordinary instances.  I have known the respiration  to become
 immediately much embarrassed  and the face to  assume a livid
 aspect, on the application of a ligature  to the cord, while pulsa-
 ting actively,  although the child had previously breathed and
 cried very strongly.
   In all instances where respiration does not ensue, or is embar-
 rassed, immediately after birth, prompt attention should be paid
 to the speedy removal of the viscid mucus which is usually lodged
 in the mouth, fauces, and larynx, of new-born infants.  In many
 cases, breathing is much impeded by this cause; and in some in-
 stances, the quantity and viscidity of the mucus is so great, as  en-
 tirely  to obstruct the entrance of the air into the  lungs.   To
 dislodge this  mucus from the fauces, a finger surrounded with a
 piece of soft linen, should he carefully introduced, and the tena-
 cious slime brought away from the posterior part of the mouth.
 The child  should  then be turned with its  face downwards, and
 the body raised higher than the head.  In this position, the child's
 back (between  the shoulders) should  he patted with  the  hand,
 and its body gently shaken, " so as to disengage any mucus that
 may be lodged  in  the trachea, and permitting it to flow  out of
 the mouth, by making this the depending part" (Dewees).
   Infants are sometimes born in a state of asphyxia, without any
 signs of cerebral congestion  or vascular fulness; the surface  of
 the body being pale, and the face free from the puffiness which
 occurs in the apoplectic or congestive cases.   If, in instances  of
 this kind, the cord continues to pulsate, it must, on no account,  be
 divided, until the pulsation has ceased.  The viscid mucus should
 be immediately removed from the  fauces and larynx, in the man-
 ner just  mentioned; and a  little  cold brandy, spirits, or even
 water, dashed on the pit of the stomach.  This, almost always,
immediately excites the respiratory actions;  and nothing further
is necessary, until the  pulsation of the  cord  has ceased, when  it
                           M              8* 
82                     OF SYNCOPE, &c.
must be divided, and the child suffered to remain quiet, until ita
strength is in some degree recruited.  Should these measures fail
to excite the respiration, which however rarely happens, so long
as the cord beats actively, advantage may sometimes be obtained
from the application of some volatile stimulant to .the nostrils and
lips—such as brandy, hartshorn, spirits of camphor, or ether.  It
will, also, be proper to rub the body and extremities, gently, with
dry warm flannels.  If, notwithstanding the employment of these
means, respiration do not  commence, while  the pulsation of the
cord becomes more and  more feeble, or. wholly arrested,  the
chance of ultimate success must be  regarded  as exceedingly slen-
der.   When the pulsation of the umbilical cord has ceased, and
the child is flaccid, every effort must be made to keep up the na-
tural temperature of  the  body, by the  external  application of
warmth, and to excite the respiratory function by artificial infla-
tion.  The cord must be divided, and  the infant wrapped  in dry
and heated flannel.  I agree, perfectly, with Dr. Dewees,  in giv-
ing a preference to dry warmth, by heated cloths, over the  warm-
bath.  Experience has convinced me, that the  former is a much
more efficient means, for imparting warmth and exciting the fee-
ble remains of vitality than the latter.   It seems probable that,
water may, in  some degree, counteract  the  exciting effects of
warmth, by its strong tendency to abstract the electric fluid from
the body.  Flannel, being  a very imperfect  conductor both of
electricity and  heat, is,  doubtless, the  best medium, in  cases of
this kind, for applying warmth to the body.   The heated cloths
ought to be frequently renewed, so  as to keep up a uniform  tem-
perature, and their application continued as long as there may be
any hope of ultimate success.   At the same  time that warmth is
thus  diligently imparted to the infant's body, the efforts to excite
respiration by alternately inflating the lungs and compressing the
chest, in  the way mentioned above,  should be regularly  and cau-
tiously persisted in  until the child   begins to breathe, or there is
reason to think that all  further exertions must necessarily prove
fruitless.   Infants, in this condition, should  not  be hastily aban-
doned.  I have in several instances  known more than thirty min-
utes  to pass under the employment  of these resuscitating means.
before the  child began  to respire;  and cases have occurred in 
                        OF SYNCOPE, &c.                     83
 which resuscitation was effected after a much longer period of
 exertion.
   Dr. Underwood thinks that the electric influence might be ad-
 vantageously employed in cases of this kind: and, from the extra-
 ordinary tendency of galvanism to excite muscular action, even after
 the animal functions are entirely abolished, it can scarcely be doubt-
 ed that much benefit might sometimes be derived from this active
 and  pervading agent. This, however, is one of those means, which
 though capable perhaps, of doing much good, can very  rarely be
 brought into use, on account of the delay which must necessarily
 always occur in procuring the apparatus and putting it in action.
   Respiration generally commences by a short and deep spasmodic
 inspiration or sob, which, at first, recurs at considerable  intervals,
 becoming, gradually, more and more frequent and complete, until
 the  respiratory function is  established.  Occasionally,  however,
 instead of a progressive improvement in the action of the lungs,
 the respiratory efforts become more and more imperfect, after the
 first  two or three forcible sobs, until the vital actions are entirely
 arrested, notwithstanding the continued exertions to excite and
 support them.   Sometimes  the  respiration, when established, is
 for several hours so feeble, that the slightest fatigue or  agitation
 is apt to arrest it, and exhaust the languid powers of life.  In all
 instances, where a resuscitation has been effected from a state of
 asphyxia, it is of the utmost consequence  to suffer the infant to
 lie perfectly at  rest,  for several hours, before it  is subjected  to
the agitation and  fatigue of washing and  dressing.   When the
 respiration is very feeble, a strict attention  to this precaution is
 indispensable to ultimate success.   There can be no doubt, that
 many infants have died  in consequence of the fatigue and pros-
 tration  caused by washing  and  dressing, during  the very feeble
 and exhausted condition which often succeeds recovery from a
state of apparent death immediately after birth.   An instance  of
this  kind occurred to me about six years ago.  The  infant was
born in a state of asphyxia.  Its face  was neither livid nor bloat-
ed, and the cord pulsated feebly.   By the employment of the
usual resuscitating means, it soon began to breathe, but in a very
weak and  sobbing manner.  I had it wrapped in warm flannel
and laid on a bed.  By the time I left the room, its breathing had 
 W                     OF SYNCOPE, kc.
 become regular, and it made some feeble attempts to cry. I earn-
 estly enjoined that it should be left perfectly at rest, until I called
 again.   I had not left the house more than an hour, before I was
 hastily summoned to visit the infant, with a message that  it was
 dying.   The child was dead before I arrived.  1 learned that as
 soon as I had left the house, the grandmother of the infant insist-
 ed that agitation and motion would " stir up life," and proceeded
 forthwith to wash and dress the infant in no very gentle manner.
 The immediate result  was fatal  exhaustion.   It is of great impor-
 tance, also, to continue the external  application of warmth until
 the  respiration is fully  established, and the child  is able to cry out
 strongly.   In applying the heated  cloths,  however, care should
 be taken to agitate the child's body  as little  as possible.  Some
 advantage may be obtained from applying a few drops of warm
 wine and water to the infant's lips and nostrils; and  I have known
 manifest benefit derived from gently washing the face with a very
 weak mixture of warm spirits and water.
   The preceding  observations relative  to the prostration which
 often succeeds recovery from a state of apparent death, are equally
 applicable to infants born in a  very feeble condition, and to the
 majority of those who are born prematurely.  Rest and warmth,
 in such  cases, are all-important  requisites for the gradual devel-
 opment of the vital functions.  Infants born between the seventh
 and  eighth month, generally remain in a somnolent  state, for sev-
 eral  weeks, and ought to be as little disturbed by washing, dress-
 ing,  feeding, or  in any other way,  as possible.  When they are
very feeble, it will be  most prudent  to leave them perfectly at
 rest, for several days before  they are subjected  to the fatigue of
 washing  and dressing.   Dr. Dewees mentions two children born
a little after the sixth month, who were neither washed nor dress-
 ed " for many days," and both recovered.
   Occasionally,  feeble  infants—particularly such as  are much
exhausted in consequence of a partial separation of the placenta
or compression of the cord  during labor, suddenly sink into  a
state of apparent death or syncope after respiration has  been fully
 established and every thing seems to go on in a favorable  man-
 ner.  Without any obvious cause the infant becomes pale, cold,
 flaccid, the  breathing very feeble and  interrupted, and finally 
                       OF SYNCOPE, &c.                     85
wholly arrested; the countenance shrunk, the eyes fixed and half
open, the hands livid, and the pulse extinct (Dewees). This death-
like condition usually continues a few minutes, and then  gradu-
ally passes off, leaving  the child in a languid and fretful state
for  many  hours.  These attacks are apt  to recur at uncertain
intervals, " unless  the disease be arrested by suitable remedies,
or death closes the scene."   The few instances of  this affection
that  have  come under  my notice, were  attended with manifest
disturbance in the alimentary canal;  and Dr. Dewees observes
that " a small quantity of very green fluid is  almost  always dis-
charged  from the bowels during the fit."  In one of the  cases I
witnessed,  several  copious discharges of a thin dark-green matter
occurred, immediately after the attack had subsided.   The affec-
tion is doubtless the result of intestinal irritation, in conjunction
with a feeble and irritable condition of the system; and we accor-
dingly find, that the employment of remedies calculated to correct
the functions of the liver and intestinal canal, rarely fails to prevent
a recurrence of the attack.   During the paroxysm, efforts  must
be made to re-excite the vital  powers, by a prompt recourse to
external  stimulating applications.  The  child's body should be
wrapped in a piece of thick flannel wrung out of hot whiskey or
brandy;  a  little warm water and wine may be thrown into the
rectum;  and a drop of ether, spirits of camphor, or sharp vinegar,
should be applied to its nostrils and lips, and weak sinapisms laid
on the soles of the feet.  Under the influence of these exciting
applications, the suspended functions of life usually return, in  a
gradual manner, until the action  of the heart and lungs are fully
re-established.  To prevent the recurrence of the affection, re-
course must be had to remedies  calculated to correct the func-
tions of the liver and alimentary canal.   A few minute doses of
calomel—that is, from one sixth to a fourth of a grain, given in
the evening, and followed on  the  succeeding morning, by  four or
five  grains of rhubarb, or a teaspoonful  of  castor oil, generally
produces an excellent effect in such  cases.  Great care must also
be taken to prevent the infant from over-distending its stomach
with nourishment.
  With regard to  the proper time for tying the  umbilical cord,
writers have expressed different opinions.   Baudaloque, Denman, 
86                      OF SYNCOPE, Sic.
White and Dewees, maintain that " we can  never safely depart
from the rule, that1 the cord is not to be tied until the pulsations of the
umbilical arteries have ceased."  Mr. Burns, on the other hand, ob-
serves, that " when the child is vigorous and cries lustily, there
is no occasion of delay in tying of the  cord until it has ceased to
pulsate."   That very serious injury may result to infants from
tying the  cord, whilst it pulsates  actively, even when the respira-
tion is fully established, does not admit of a doubt;  and, although
the cord may, in general, be tied without the slightest unpleasant
consequences in vigorous infants breathing freely, after its pulsa-
tion has become decidedly feeble,—yet,  as a general rule, it is un-
questionably safest to delay the tying, until the cord has entirely
ceased to  pulsate.   When  the  cord  is tied whilst  pulsating
strongly, the  breathing, sometimes, instantly becomes irregular,
catching and feeble, and the countenance turgid and livid. Some
years ago, I witnessed a striking instance of the evil effects which
may be produced by the premature ligature of the cord.  The
infant  breathed freely and  cried out lustily,  as soon as it was
born.  I waited three or four  minutes, until the  cord pulsated
feebly, and then tied it.  As soon as the ligature was drawn, the
breathing became  catching, irregular, and  in a  few moments
almost wholly suspended, and the  lips  acquired a deep livid hue.
I immediately divided the cord below  the ligature, but obtained
only a few drops of blood  from it; and  it was with  the utmost
difficulty, and only in a  very gradual  manner that the action of
the lungs and  heart were fully re-established.
  Injury may also result to the child, from  too long a delay in
putting a ligature on the cord, or separating it from the placenta.
When the uterus contracts very powerfully soon after the birth
of the child, the blood contained in the placenta, may be pressed
out of it, as from a sponge, and engorge the vessels of the infant
to a degree which may prove highly injurious and even fatal.   1
am  convinced  that I have seen several instances of alarming con-
sequences from this cause, after the employment of ergot for hast-
ening the labor. When ergot is given in the latter stage of labor,
the womb is apt to contract with great energy upon the placenta,
immediately after the expulsion of the infant; and it  cannot  be
doubted that,  when this takes place, the blood contained in the 
                    OF ASPHYXIA, &c                      87
placenta must be more or less powerfully forced into, the vascular
system of the infant.  I have known an infant to breathe and cry
strongly for a short time, and then, suddenly, on the occurrence
of a strong uterine  pain or contraction, to fall into an oppressed
condition, with a turgid and livid countenance, and feeble, inter-
rupted and suffocative respiration, and a state of apparent insen-
sibility.  When, after respiration has been established, and the
cord  remains united, phenomena of this kind supervene, the cord
ought to be immediately divided, and the blood suffered  to flow
until tne symptoms of oppression are removed. 
88                   OF THE MECONIUM.
                    CHAPTER II.

                      OF THE MECONIUM.

  The foecal matter formed in the bowels of infants, before birth,
is called  meconium, and  consists of a  dark green, yellowish, or
party-colored residual substance of a viscid and semi-fluid consist-
ence. When this recrementitious  matter is retained in the bowels
of the new-born infant, it seldom fails to give  rise to  intestinal
irritation, and more or less general disorder of the system.   Ex-
hausting  and painful diarrhoea, colic, mucous inflammation of the
intestines, obstinate jaundice, convulsions, trismus, induration and
enlargement of the mesenteric glands and consequent wasting of
the body, disease of the  liver, erysipelas with induration of the
subcutaneous cellular tissue, not to mention other forms of dis-
tressing and dangerous disease, may, it is believed, arise from the
irritation occasioned by meconial  matter in the alimentary canal.
The timely  removal of this substance from the bowels, is there-
fore an object of no small degree of importance.  Nature, in gen-
eral, furnishes the appropriate  purgative  for this purpose, in the
first milk or colostrum, secreted in the maternal breasts; and, in
many cases, nothing more is necessary for  the  expulsion of the
meconium, than the early application of the infant to its mother's
breast.   The small  portion of  fluid which the child, usually, ob-
tains at the breast, during the first nine or ten hours, possesses a
decidedly purgative character, and  generally causes the entire
evacuation of the meconial matter.  As the colostrum  is formed
before the proper milk begins to be secreted, the child ought to
be early  put to the breast, in order to obtain this purgative  fluid,
before it becomes diluted  and weakened by the milk.  When the
first suckling is delayed until the breasts are filled with the lacte-
ous secretion, the bowels frequently remain unmoved, and recourse
must be had to other means for removing the meconium.  There 
                      OF THE MECONIUM.                   89
can  be no doubt, that, in general, the colostrum is fully sufficient
for effecting the expulsion of this substance from the bowels;  and,
as it was evidently intended for this purpose by the author of na-
ture, it must be  regarded  as  decidedly the most  appropriate
means for freeing the infant from this source of intestinal irrita-
tion and disease.  The practice of at once resorting to purgative
remedies  for the removal of the meconium is  highly reprehensi-
ble.  Instead of putting the child early to the breast, and waiting
for the operation of the congenial laxative prepared for it by na-
ture, the almost universal custom is, to introduce some purgative
substance into its  stomach, such as  castor oil, syrup of rhubarb,
senna tea, magnesia, sweet oil, manna, or molasses, as soon as the
infant is washed and dressed.  When we reflect, that the stomach
of the new-born infant  has as yet never experienced  any foreign
impressions, and must necessarily be extremely delicate and sus-
ceptible,  the  impropriety of introducing  such irritating articles
into it, immediately after birth, and  before  the digestive powers
have been brought into action, appears very obvious.  The stom-
ach is thus often thrown into a state of severe irritation and func-
tional derangement, which if it does not lead to speedy death,
never fails to  give rise to a train of extremely harassing conse-
quences.   Long experience has fully convinced me, that the dis-
tressing dyspeptic affections—the colic, acidity—painful diarrhoea,
and  general sickly condition, so frequently met with  during the
first  five or six months of infancy, very often have their origin in
the gastro-intestinal irritation, caused by the purgatives employed
for evacuating the meconium.  The purge, given for this purpose,
acting on  the  delicate and highly sensitive stomach, weakens, at
once, its digestive  energies; the  very first  nourishment that is
taken, is,  therefore, but imperfectly digested; more  or less fer-
mentation, consequently, occurs in the primae viae, by which  acid
and other irritatory matters are  generated, and additional sources
of gastric irritation furnished. Unless judicious dietetic and other
remedial  measures be  immediately adopted, a train  of painful
dyspeptic   and general  irritative affections will ensue, and soon
acquire an ascendency, which  can seldom be wholly  subdued
during the period of infancy.
  Although the undue retention of meconial matter in the bowels,
                               N               9 
 90                  OF THE MECONIUM.
 is certainly very apt to prove detrimental to the health of the in-
 fant, yet it is by no means necessary to resort at once, to the use
 of purgative remedies for its removal.   It was undoubtedly the
 design of the Creator, that this office should be performed by the
 colostrum;  and there need be no harm apprehended, from the de-
 lay, which  a dependence on this purgative secretion may require.
 Instead of giving to the infant an artificial laxative, let it be early
 applied to  its mother's breast before the proper milk is secreted,
 and in nine cases out of ten, adequate purgation will be produced,
 without  the slightest ri^k of injurious irritation of the stomach
 and  intestinal  canal.  When the colostrum or first milk fails to
 produce  the  desired  effect,  recourse should, unquestionably, be
 had to artificial means for expelling the meconium from the bow-
 els; and for this purpose a teaspoonful of molasses  diluted with a
 small portion  of warm water,  or  a solution of manna, or a  tea-
 spoonful of cold-pressed castor oil, should be given and repeated
 until the requisite evacuations have been procured.  Rapid  and
 free  purging, however, is improper.  A moderate action of the
 bowels, procured by gentle means, is fully adequate, in a great ma-
jority of cases, to dislodge and remove the meconial matter in due
 time.  It is of  importance, however, to keep up a moderate de-
 gree of purgation until the meconium is completely removed; for
 the retention of even small portions of this substance, may ulti-
 mately give rise to very unpleasant consequences.
   Sometimes, though very rarely, cases occur in which very great
 difficulty is experienced in exciting an efficient action of the bow-
 els.  In  such cases purgative enemata ought to be employed, in
 conjunction with laxatives administered in full and repeated doses,
 until the requisite effect is produced.   Dr.  Dewees, relates a re-
 markable instance of intestinal torpor of this kind, in which, after
 frequent doses of castor oil and magnesia with injections of various
 kinds and the warm bath had been  used without any advantage,
 relief was ultimately obtained from a grain of carbonate of soda
 administered  every fifteen minutes until ten grains were  taken.
 In a few very obstinate cases of this kind, I have succeeded well
 with a mixture of Ipecacuannha and rhubarb assisted by purga-
 tive enemata.   Two grains of ipecac, with five grains of powdered
 rhubarb, may be  given  every  hour until  free  evacuations are 
                     OF THE MECONIUM.                    91
produced.  The warm bath will, in general, promote  the opera-
tion of the purge, and exert a favorable influence on the general
system, by its tendency to keep up a regular action of the cutane-
ous exhalents.  The extraordinary torpor of the intestinal canal,
which sometimes occurs immediately after birth, depends, proba-
bly, in most instances,on cerebral congestion; for I have frequently
noticed that  those  infants who are born with a turgid and livid
appearance of the face, and other manifestations of preternatural
fullness of the vessels of the head, are much more apt to resist the
purgative powers of the colostrum, and to require artificial purga-
tions for the  removal of the meconial  matter, than such as are
free from symptoms of cerebral congestion.   Immersing the legs
and lower portions  of the abdomen in a bath, raised to as high a
temperature as the  infant can bear, without pain, at the same time
that a piece of flannel wet with cold water is applied to the top of
the head, frequently has an obvious effect in facilitating the ope-
ration of the purgatives that may be given in such cases.  An in-
stance which quite  recently came under my notice has convinced
me, that much advantage may sometimes  be derived from this
mode of management, where there is difficulty encountered from
intestinal torpor in procuring the evacuations of the meconium.
The infant had taken three teaspoonfuls of castor  oil with ten
grains of rhubarb in conjunction with the repeated use of injec-
tions without the desired effect.   Thirty hours after birth no  al-
vine evacuation had taken place.  The little patient lay in a state
of partial stupor; its abdomen was  distended and evidently very
sore to pressure.  In  this state  the  lower parts of its  body were
placed in warm water, while cold applications were made to the
head.  In less than five minutes after these measures were resorted
to the bowels began to act, and  four or five  copious evacuations
ensued in the course of three or four hours. 
92
ON THE TONGUE-TIE.
                  CHAPTER  III.

                    ON THE TONGUE-TIE.

  It frequently happens that the tongue of infants is so tied down,
and restrained in its actions by a preternatural conformation of its
fraenum,  that  sucking is rendered extremely difficult, and, if it
be not remedied, the power of  articulating words, at a more ad-
vanced age greatly embarrassed.
 „ In the majority of instances, the part which ties down the tongue
consists of a thin transparent membrane, extending from the fleshy
part of the fraenum Jo near  the extremity of the tongue.   Dr.
Dewees considers this transparent, membranous production as an
adventitious formation, wholly distinct from the proper substance
of the fraenum.  It appears to me, however, to be a mere mem-
branous prolongation of, and perfectly  continuous with the struc-
ture of the fraenum.  In some instances, instead of this membra-
nous prolongation, the thick and fleshy fraenum itself is extended
forwards in the same way, so as  to confine the tongue and embar-
rass its actions.  When the tongue is in this condition, the infant
is incapable of elevating  it, or protruding it  beyond the  lips;
sucking is  performed with great  difficulty, and  attended with a
peculiar  "clucking" noise in the fauces.   When the  infant at-
tempts to suck, the nipple is  constantly  slipping from its  lips,
from an inability to grasp it firmly with the tongue. It alternately
seizes  the  nipple, and after a  few imperfect efforts,  lets it slip
again, until it becomes fatigued and irritated with its  fruitless ex-
ertions, and begins to fret and cry.
  When the portion of the fraenum which restrains the actions of
the tongue in this  manner, is membranous, it ought, of course, to be
immediately divided.  According to my own experience, a pair
of small blunt-pointed scissors is the most  convenient and  safe in-
strument for  dividing  this membrane.  Dr. Dewees, however,
prefers a gum lancet for this purpose.   The child must be taken 
                     ON THE TONGUE-TIE.                   93
 into a good light, and laid across the nurse's lap with its face up-
 wards.  In this position the operator should insinuate the extremi-
 ty of the forefinger of the left hand, between  the  side of the
 tongue and the corresponding portion of gums, and push the tongue
 upwards, whilst with the thumb of the same hand the lower jaw
 is depressed.   The  fraenum may thus, in general be exposed to
 view, and the stretched  membrane  divided by one stroke of the
 scissors or gum  lancet. Crying often facilitates the operation con-
 siderably, by exposing the membrane freely and putting it on the
 stretch. There is seldom more than a few drops of blood discharged
 from the divided membrane. By carelessness and with improper in-
 struments, however, very serious mischief has been done, even in
 cases of this kind.  About twenty  years ago I witnessed an in-
 stance, where a young physician, in endeavoring to divide the
 membranous portion of the fraenum, with a pair of sharp-pointed
 scissors, pierced a blood vessel under the tongue, which occasioned
 an extremely alarming haemorrage.  Just as he was  about  clip-
 ping the membrane, the infant suddenly threw its head upwards,
 and plunged the points of the scissors in, under the tongue. Sharp-
 pointed instruments ought never to be used for this purpose.   No
 one  can be entirely secure against accidents of this kind, in the
 sudden and active  struggles which infants are apt to make during
 the operation.
   When the tongue is tied down,  by the proper, fleshy fraenum
 extending too near its extremity, nothing can, with propriety, be
 done towards remedying the evil.   Dr. Dewees, has "never ven-
 tured to do any thing in cases of this kind."  This variety of the
 tongue-tie is indeed very rarely so  great, as to  give rise to any
 serious difficulty  of sucking; and the  advantages to be gained from
 a division of the  fraenum, are by no  means adequate to justify an
 operation attended with so much risk of alarming consequences.
 Very alarming and even fatal haemorrage  has been the result of
this operation, and authors mention  convulsions and "swallowing
of the  tongue,"  as occasional consequences.
9* 
54      INFLAMMATION AND SWELLING OF THE BREASTS.
                    CHAPTER  IV.

   OF THE INFLAMMATION AND SWELLING OF THE BREASTS OF
                     NEW-BORN INFANTS.

  New-born infants are liable to a singular inflammation and en-
largement of the breasts, which though very rarely attended with
any serious consequences when properly managed, has often been
converted into a very painful and dangerous affection by the ig-
norant and rude officiousness of nurses and others.  The common
opinion among mothers and nurses,  is that these swellings arise
from the accumulation of milk in the  infant's breast, and, "that it
must be squeezed or milked out, that  they may be cured." Every
effort is accordingly made, by squeezing,  sucking, pressing, &c. to
extract the supposed fluid, and as no milk can be obtained, the in-
flammation which often  follows-this rude treatment, is usually as-
cribed  to the retention of the milk in the breast, and considered
as a direct proof of the  correctness of this opinion.   I have met
with several instances, in which this preposterous and highly inju-
rious practice, brought on violent inflammation, which soon termi-
nated in extensive  suppuration of the breast, and  in one case—a
female infant,  both breasts were entirely destroyed.
  These swellings  come on immediately after birth; and it has
been supposed, though I think erroneously, that they are generally
formed before  the infant is  born.   They are  somewhat tense,
elastic, and firm, and appear to consist of a moderate degree of
inflammation of the cellular membrane with serous infiltration into
this tissue. When the inflammation is aggravated, it extends itself
to the  mammae, and the skin becomes purplish over  the central
parts of the tumor.  Occasionally, though, indeed, very rarely,
the inflammation, even under a proper course of management, be-
comes  severe and continues for five or six days before it begins to
subside.   I  have, however, never known a case of this kind  to 
       INFLAMMATION AND SWELLING OF THE BREASTS.       9§
terminate in suppuration and abscess, except where the inflamma-
tion was aggravated by rough handling in the commencement.
  In  moderate cases  Dr. Dewees applies  nothing more than "a
piece of linen moistened  with a little sweet oil;" and where the
swelling and inflammation are considerable, he recommends the ap-
plication  of a bread-and-milk poultice, renewed every  three or
four hours.  These are doubtless appropriate and useful remedies;
but it has appeared to me, that in the ordinary cases of this affec-
tion, a weak solution of the muriate of ammonia in vinegar and wa-
ter—in the proportion of a drachm of the ammonia, to four'ounces
of water with the same quantity of common vinegar, acts much
more promptly and certainly in reducing the swelling and inflam-
mation, than either sweet  oil or emolient poultices.  The solution
ought to be applied  warm, by moistening pieces of linen with it,
and laying them over the affected parts. I have seldom used any
other application than this one, even where  there was a considera-
ble degree of inflammation. When the swelling and inflammation
become severe, a few leeches, applied to the parts, succeeded by
warm emolient poultices, will in general prevent the occurrence of
suppuration. 
96      INFLAMMATION AND ULCERATION OF THE NAVEL.
CHAPTER  V.
       OF INFLAMMATION AND ULCERATION OF THE NAVEL,

  Inflammation and consequent ulceration about the navel is a
frequent occurrence during the  first nine or ten days after birth.
This may arise from irritation  occasioned by rude  management
in washing and  dressing  the navel, before the cord has  been
thrown off; or it may be the result of a slow and imperfect sepa-
ration of the cord, in consequence of which it remains attached
by a thin and firm filament and  prevents the healing of the navel.
Frequently, too,  it arises from  deficient attention to cleanliness,
in the first  washing of the  infant;  for if the white caseous matter,
which is found deposited on its skin, be not carefully washed off
from about the umbilicus,  it soon  acquires a very irritating  char-
acter, and gives rise to inflammation and excoriation of the navel.
This, I am  well satisfied is by far the most common source of this
disagreeable affection of the navel.  Children who are  not pro-
perly freed of this peculiar caseous deposition, where it occurs in
abundance, almost invariably suffer  more or  less irritation and
inflammation about the navel.   Of the tendency of this white
matter, to  inflame and excoriate, the skin, when  not properly
removed, we often have abundant  evidence on  various parts of the
body—particularly in the folds of the skin about the neck, joints,
nates and groins.
  When the navel becomes irritated and inflamed, it soon acquires
a deep red, excoriated  and fungoid condition, discharging a thin,
offensive and purulent  matter, and evidently  causes much suffer-
ing and uneasiness to  the infant.  In some instances, the  navel
presents an elevated ulcerous surface, with an inflamed condition
of the surrounding skin, and a copious discharge of thin irritating
matter; in  other  cases, the central part of the navel shoots up a 
         INFLAMMATION AND ULCERATION OF THE NAVEL.      97
  kind of fungous excrescence, of a dark-red and excoriated appear-
  ance, with  but little surrounding  inflammation or actual  ulcera-
  tion.   This fungoid  tumor sometimes assumes a button-like form,
  with a narrow base, and a round expanded head like a cherry;
  in other  cases, the tumor is broad  at the base, tapering towards
  the top,  or exhibiting nearly a cylindric form.
    When the navel becomes excoriated or ulcerous and discharges
  matter, while the cord remains attached by a filament, the simple
  division of this slight connexion will often suffice to arrest the pro-
  gress of the ulceration, and dispose the navel to cicatrize.  When-
  ever the  cord is so far separated as to retain  only a  simple fila-
  mentous  connection with the umbilicus, the separation  ought to be
  completed  by clipping  the filament with a pair of  scissors, whe-
  ther there be inflammation and ulceration or not; for if this  partial
  connection is suffered to continue after the usual period of separa-
  tion, it, of course, prevents the healing, and almost invariably
 causes severe inflammation and ulceration of the navel.
   When  the fungoid little  tumor in  the bottom of  the umbilical
 cavity has a narrow base, it may, in general, be speedily removed
 by passing a ligature round the pedicle, and drawing it  sufficiently
 tight to arrest the circulation,  without cutting  into its substance.
 A strong  silk thread will answer very well for this purpose.  In
 the course of a few days, the tumor, usually, drops off, after which
 the part should be dressed with saturnine ointment, spread upon
 lint.  Should  the fungus, however, shoot up again, it must  be
 repressed  by astringent applications, or destroyed with one of the
 milder escarotic remedies.  I have found  the root of the sanguin-
 aria canadensis very  finely  powdered, an excellent escarotic in
 cases of this kind.   A small portion of the powder should be put
 on the fungus,  once or twice daily,  and covered with lint spread
 over with a little lead ointment.  When the surface and margin
 of the umbilical cavity are excoriated, and the discharge of mat-
 ter is copious, advantage may be obtained from the  occasional
 application of  a solution of sugar  of  lead, or what is better, a
 weak decoction of oak bark.
  In cases where the tumor is broad  at the base, and  where, of
course, ligatures are inapplicable, recourse must be had to  suita-
ble  astringents and  escarotics.  Dr. Dewees  recommends  «a
                               O 
98     INFLAMMATION AND ULCERATION OF THE NAVEL.
pretty strong solution of the nitrate of silver," applied by means
of a camel hair pencil, " and repeated until the part heals."  The
nitrate of silver is an excellent escarotic where the surface of the
tumor is ulcerated or raw and  spongy.   In some instances, how-
ever, these excrescences are of rather a firm texture, and covered
with a fine membrane—and in such cases, this escarotic is  always
extremely slow in  destroying the tumor.   I have occasionally
used a strong solution of the sulphate of copper, with a satisfac-
tory result in instances of this kind.   One drachm of the sulphate
should be dissolved  in an ounce of water, and applied  twice daily
by means of a camel-hair  pencil or a dossil of lint.   We  may
frequently reduce these tumors without any escarotic applications,
by means of strong astringents constantly applied, as is often done
with haemorrhoidal  excrescences.  Very finely pulverized  oak
bark, or  Aleppo galls, sprinkled on  the  tumors, will   sometimes
cause them to shrink, at the same time that it tends to subdue the
surrounding inflammation and  to arrest  the purulent discharge
from the umbilical cavity.  In the last case of this kind which
occurred to me, I directed  the nurse to drop a pinch of oak-bark
powder, upon the excrescence thrice daily, and to wash the parts
carefully with lukwarm water, every morning and evening;  and
the result was perfectly satisfactory.
  When the  navel presents an  elevated, ulcerous surface, we
may often do much good by touching the ulcerated   part  very
lightly with  lunar caustic,  and applying saturnine ointment,
spread on lint, over it. If there is much inflammation of the navel
and  adjacent parts, a soft  poultice made with lead-water  and
crumbs of bread, forms  an excellent application.  A  solution of
the sulphate of copper, in the proportion of ten grains to an ounce
of water, may be applied with much advantage, when there is
superficial ulceration, without much inflammation.   It should be
applied once  or twice daily, and the part afterwards covered  with
lead ointment.  Sprinkling the  ulcerated  surface with white
lead, or with powdered oak bark or galls, will, in slight cases,
frequently restore the parts to a healthy condition, without  any
other applications.  I have  seen prompt and very decided  benefit
derived, in a  very aggravated case of ulcerated  navel,  from wash-
ing the  part, twice daily, with  a decoction of the wild  indigo 
        INFLAMMATION AND ULCERATION OF THE NAVEL.      Q9
root, (baptisia tinctoria).  The best mode of applying this article,
however, is in the form of a liniment, made by slowly simmering
the coarsely powdered root in cream, and afterwards squeezing
it through  a thick piece of linen or flannel.  This should be ap-
plied with  a soft pencil or feather, three or four times daily; or a
piece of lint may be moistened with it, and laid over the ulcerated
surface.  I have repeatedly applied this liniment, to  excoriated
and ulcerated nipples, and generally with great advantage.
  Cleanliness is an important observance in cases of this kind.
Whatever  applications may be  made, the parts should be care-
fully washed with lukewarm water, at least twice daily, and where
the discharge is particularly offensive, or copious, the parts imme-
diately surrounding the umbilical cavity  should be  washed or
carefully wiped clean,  with a soft piece of linen wrung  out of
warm water, repeatedly during the day.
                    CHAPTER VI


                 OF THE JAUNDICE OF INFANTS.

   Newly-born infants are liable  to an icteric state of the skin
 which though generally of a very slight and transient character,
 requiring little or no  attention, sometimes  assumes a degree of
 violence and  obstinacy which  calls for prompt and  active reme-
 dial measures.
   In a great majority of infants, this yellowness of the skin comes
 on within three or four days after birth, unattended  by any mani-
 festations of indisposition;  and after having remained stationary,
 for a few days, gradually disappears, without any unpleasant con-
 sequences.  This peculiar discoloration of the skin  is, generally,
 regarded  as wholly distinct from jaundice, and altogether inde-
pendent of hepatic derangement, or deposition of bilious matter
under  the cuticle.  " It is difficult,"  observes  Dr.  Dewees, " to 
100                 JAUNDICE OF INFANTS.
say, to what this yellow tinge may be owing;  certain it is, it can-
not be attributed to the presence of bile, since neither the urine
nor the white of the eyes assume the  yellow hue."  It  may be
doubted, however, whether either of these facts can with propri-
ety be regarded, as " certain" ev idence, that the yellowness~in
question, is independent of bilious matter, since a temporary secre-
tion of the carbonaceous matter which during fcetal life is secre-
ted by the liver, may it is presumed, take  place into the rete-mu-
cosum without  showing itself either in  the urine or in the eyes.
Nor  does the assertion, that the urine is always free of bilious
matter accord with my own observations;  for since my attention
has been particularly directed to this subject, I have not met with
one instance, where the urine did not acquire a slight bilious hue,
about the time  the yellowness of the skin  was going off, although
previously of a  perfectly natural color.  The liver appears to be
the principal depurating organ, during the uterine stage of  life.
As soon as the infant is born, however, a large  share of this office
is transferred to the lungs and the skin.   The skin at the same
time,  suddenly becomes highly engorged with blood, as is mani-
fested by the redness and fulness which  usually occurs a  short time
after birth.—It becomes the principal seat of sensibility and  sen-
sation, and its transpiratory function, is for the first few days, per-
formed in a feeble and  imperfect  manner.  It seems probable,
therefore, that whilst these changes  in the  excretory functions are
going on, the blood may become slightly charged with  recremen-
titious matter of a bilious or  carbonaceous character, and that
in the irritable  and congested condition of the  skin to  which we
have just referred, a portion of this matter may  be  deposited
on the rete-mucosum or cutis, without any actual morbid derange-
ments either of the liver, or of the general system.
  When the infant does not become restless and fretful and takes
its nourishment freely, and the  alvine discharges are manifestly
colored with bile, this yellowness of the skin requires no particular
attention, as it will pass off spontaneously, in the course, generally,
of three or four days, without any unfavorable  effects, either imme-
diate or remote. But when the white of the eyes becomes yellow,
the urine charged with bilious matter, the bowels costive, and the
stools whitish or clay-colored, accompanied with an inclination to 
                    JAUNDICE OF INFANTS.                 10]
vomit, or with actual vomiting, and an anxious and distressed ex-
pression of the  countenance, the disease  is evidently connected
with more or less serious disorder of the biliary organs, and should
be promptly opposed by a suitable  course of remedial measures.
When along with these symptoms, there is fever, and a  swollen
and tender state of the right hypochondriac and epigastric regions,
the worst consequences are to be apprehended;  for cases of this
kind, frequently resist every curative effort that can be made, and
proceed with increasing violence to a speedy termination in death,
or assume a chronic character, with progressive emaciation of the
extremities, and tumefaction and hardness of the abdomen, until
the vital powers are consumed.   Fortunately, however, these dan-
gerous  cases are not common.   In by far the greater number of
instances, the disease  is not attended with  any violent and dis-
organizing form of hepatic  disorder, and, though  manifestly de-
pendent on  biliary derangement, is of a comparatively mild and
manageable character.
  The  exciting causes of infantile jaundice are, doubtless, very
various, Mr.  Baumes thinks  that meconial matter  unduely re-
tained in the bowels, is frequently concerned in the production of
the disease;  and Mr. Gardien expresses the same  opinion.  Dr.
Underwood does not believe  that  the meconium  can have any
part in producing jaundice, except, perhaps, by obstructing the
orifice of the biliary duct, for which it seems to  be well adapted
by its peculiarly viscid  and adhesive consistence.  I am inclined
to think, however, that  this writer has not attached sufficient im-
portance to this recrementitious substance as a source of jaundice
in newly-born infants.   To whatever circumstance it may be as-
cribed, I am  persuaded that  this disease occurs more frequently
where there is delay and difficulty experienced in purging offthe
meconium, than  where this substance is easily and entirely evacu-'
ated during the first twenty-four hours.  It is, indeed, not probable
that the yellow color of the skin is, in any degree, derived from
absorbed meconial matter; and it may well be questioned whether
any portion of this recrement is ever absorbed into the circulation.
The way, perhaps, in which retained meconial matter contributes
to the production of infantile jaundice is, by exciting irritation in
the  intestines, and, in conjunction with other causes, particularly
                                             10 
 102                JAUNDICE OF INFANTS.
 the purgatives that may be employed for the removal of this sub-
 stance, giving rise to mucous inflammation of the duodenum and
 consequent functional derangement of the liver, or obstruction to
 the flow of bile into  the  bow.els.  That a morbidly irritable or
 inflamed condition of the  mucous membrane of the duodenum, is
 apt to give rise to jaundice is well known.  "A curious patholo-
 gical fact," says Dr. Johnson, "has lately been fairly established—
 namely, that  irritation or inflammation of  the mucous membrane
 of the duodenum, will sometimes produce jaundice, where no ob-
 struction can be detected  in the biliary ducts."   Cases of this
 kind are always attended  with excruciating paroxysms of pain in
 the region of the  duodenum, an hour or two after taking nourish-
 ment, resembling  the pain produced  by the passage of a biliary
 concretion  through the common bile duct.   I have met with
 several cases  of this variety of the disease, in adults, which, after
 all the usual  remedies  for jaundice had been  ineffectually tried,
 were speedily cured, and without a single recurrence of the pains
 by an  exclusive liquid mucilaginous  diet, and  the application of
 a blister to the  epigastrium.  It is highly probable, that the jaun-
 diced appearance which occurs in yellow fever, depends, mainly,
on the gastro-duodenal inflammation so universally connected with
that disease.  In relation to  infantile jaundice, my own observations
have satisfied me, that, in  some instances at least, this disease is
the immediate result of mucous inflammation of the upper portion
 of the intestinal canal.  In a dissection which  I made about two
years ago, of an infant that had died  in a state of deep jaundice,
 apparently in consequence of inflammation of the liver,  I  found
the mucous membrane of the duodenum in a highly diseased con-
dition.  Some parts of it were of a uniform scarlet color,—others
were softened to the consistence of jelly, and of a gray or ashy hue,
and in several places it  was entirely destroyed and removed,
leaving the muscular tunic bare.  The orifice of the bile duct
was slightly  tumified, but  the duct  was pervious throughout.
 The liver was much engorged with blood, but exhibited no other
 obvious marks of structural lesion.   Improper artificial  nourish-
 ment during the first two or three days after birth,  and the exhi-
 bition of irritating purgatives for the removal  of the meconium,
 •»re doubtless frequently concerned in the production of this dis- 
                    JAUNDICE OF INFANTS.                 103
ease.   The gastro-duodenal irritation which is apt to be excited
in this way, can seldom fail to  produce more or less functional de-
rangement of the liver;  and  when the duodenal irritation pas-
ses  into  a state  of actual inflammation, jaundice  may  result,
either from spasmodic closure  of  the mouth of the  common bile
duct, in  consequence of the extremely irritable  condition of the
duodenum, or from sympathetic irritation with excessive sanguin-
eous engorgement of the liver, and consequent functional torpor.
In cases  attended with a highly irritated or sub-inflamed condition
of the duodenum, there  is usually much sickness  and  frequent
vomiting of a glairy fluid; the epigastrium is tender to pressure,
and  the  little patient is affected with occasional  paroxysms  of
violent screaming and agitation, particularly some time after tak-
ing nourishment.
  In some instances the disease is unequivocally attended with in-
flammation of the liver.   The right hypochondrium becomes tu-
mid, tense, and tender to the touch.  The fever is strong, the
respiration short and oppressed, and almost every attempt to move
or lift the infant, immediately increases its sufferings and causes it
to scream out with anguish.
  Very  frequently,  however, the  hepatic  derangement upon
which the jaundice depends is entirely unconnected with inflam-
mation.  The liver may be in  a state of inactivity from excessive
sanguineous engorgement; or its torpor may depend on induration
with or without enlargement, or on some other form of structional
disorder.  In cases of this kind  there is, in  general, but little  or
no febrile irritation.  The infant is apt to fall into  a drowsy and
languid  condition,  with  weakness of the digestive  functions,
acidity, vomiting, and flatulent colic pains.   The disease usually
assumes a chronic character, attended with progressive emaciation,
and derangement of the  alimentary canal.   Instances depending
on excessive sanguineous congestion of the  liver, are usually at-
tended with manifest indications of a general plethoric condition
of the system.  It has appeared  to me that jaundice, from this
cause, is  most apt to occur in  those infants, who  are born with a
turgid and livid appearance of the face and body, and an oppressed
state  of  the brain—more especially where the vessels  are not
promptly relieved by abstracting blood from the  divided  cord. 
 104                JAUNDICE OF INFANTS.
   Without doubt, too, infantile jaundice, may in some instances
 depend on obstruction to the regular flow-of the bile, from spas-
 modic constriction of the biliary canals, wholly independent of any
 local or general  inflammatory excitement.  Mr.  Gardien, ob-
 serves that spasmodic constriction of the biliary pores may be oc-
 casioned by, the sudden exposure of the newly-born infant to cold
 air or water—the constringing impressions of which, may be sym-
 pathetically  conveyed  from the skin to the hepatic system.  When
 we advert to the intimate relation which subsists between these two
 organs, and the extremely sensible and excitable state of the skin,
 immediately after birth, we can  scarcely doubt that the disease
 may, be prod ced in this way.

   Treatment.—It has  already been stated  that in the ordinary
 cases of yellowness of the skin—when the infant docs not manifest
 any obvious indications of indisposition, and the alvine discharges
 continue to be colored with bile, no active treatment is required.
 The customary warm bathing for preserving a pure and healthful
 condition of  the skin,  and a proper attention to the state  of the
 infant's bowels—promoting their action, when they are torpid, and
 restraining it when there is a tendency to griping and diarrhoea,
 is in general  all that  is  required in cases of this simple character.
  When the disease is not attended with an inflamed condition of
 the liver, though obviously connected with  derangement  of the
 biliary organs—that is, when the skin  and eyes are  yellow\ the
 urine bilious, and the stools whitish or clay-colored, without any
 soreness or tenderness to pressure in the right hypochondriac and
 epigastric regions, much benefit may sometimes be derived from
 emetics.  In cases of mere congestion and inactivity of the liver,
or in hepatic torpor from any cause, the concussive operation of an
emetic frequently proves highly beneficial by accelerating the cir-
culation in  the portal system, exciting the action of  the liver, and
relieving its congested condition, by determining  the  blood from
the internal  to  the external parts of  the body.  A few  grains
of ipecacuanna should be given every fifteen or twenty minutes
until vomiting is  produced; and when the  disease is obstinate,
the emetic may be advantageously repeated, every other day, until
 the alvine evacuations acquire a  bilious appearance.   In  all in- 
                   JAUNDICE OF INFANTS.                 105
stances, however, of a manifestly inflammatory character, attended
with fulness, tension and unequivocal soreness of the region of the
liver and stomach, emetics cannot be employed without consider-
able risk  of injurious consequences.   The bowels ought to be
freely evacuated in the commencement of the treatment;  and for
this purpose calomel and castor oil appear to be the most suitable
means.   A fourth of a grain of calomel should be given every
two hours, until two or  three  grains have been taken.  If free
purging does not ensue, the operation of the calomel must be pro-
moted by castor oil, given in teaspoonful doses every hour, until
the desired effect is obtained.   After the bowels have been once
freely evacuated, they must be kept in a loose state, by adminis-
tering a fourth of  a grain of calomel" every morning noon and
evening, with an occasional teaspoonful of castor  oil, should the
torpor of  the intestines  render an additional purgative necessary.
Calomel is a valuable medicine in every modification of infantile
jaundice, on account, both of its aperient effects on the  bowels,
and its specific operation on the biliary organs, and general capil-
lary system.   In conjunction with these  remedies, the daily use
of the warm bath, is often decidedly beneficial; and when the in-
fant can bear it without manifest suffering, gentle  frictions with
the bare hand, over the  region of the liver and stomach, repeated
several  times daily, frequently  produces  an obviously salutary
effect in cases of this kind.   It need  scarcely be  observed, that
frictions of the abdomen would hardly fail to prove injurious in
cases  attended with hepatic inflammation or abdominal tender-
ness.  It is only when the  region of the liver and stomach may
be pressed without causing the infant to cry or manifest increased
distress  and sufferings that frictions can be used with propriety—
and when  this is  the  case, they almost always prove decidedly
beneficial.
   When infantile jaundice  is attended with a febrile  condition,
and symptoms indicative of hepatic inflammation—such as fulness,
and tenderness in the region of the liver—a very scanty secretion
of high-colored urine, absence of the respiratory motions of the
abdominal muscles, frequent nausea and vomiting, and an expres-
sion of  pain  and suffering in the countenance, a treatment more
decidedly antiphlogistic  is required.  Four or five leeches, if they
                             P                10* 
106                JAUNDICE OF INFANTS.
can be procured, ought to be applied to the right hypochondrium.
The local abstraction of blood, by leeches, in cases of this kind,
is of the utmost importance, and ought never to be omitted, where
it is practicable.  In violent cases, the application of a small blis-
ter to the region of the liver, will often  procure very considerable
relief.   No  injurious consequences  need  be apprehended from
a  vesicatory,  at this  early  stage  of life,  if  managed  with
proper care.  I have  in several  instances, where the  liver ap-
peared to be in a state of inflammation, resorted to the applica-
tion of a blister, with unequivocal advantage.   The plaster should
not be suffered to remain on the skin longer than about two hours.
The skin generally becomes  slightly inflamed by this time; and
if the plaster be now removed, and a soft warm poultice laid over
the part, a fine  blister will be raised, without harassing  the  in-
fant.   The bowels must be freely  evacuated with calomel, aided
by castor oil.  A half a  grain of calomel  should be given every
two hours, until  two or three grains are taken, and followed by a
teaspoonful of castor oil, every two hours until active purging is
produced.  When the stomach is very  irritable, however, and
there is  reason to apprehend the existence of a  highly irri-
tated or subinflammatory condition of  the  mucous membrane  of
the stomach and superior portions of the intestinal tube—that is,
where there is frequent vomiting of a glairy fluid, with occasional
fits of agitated screaming and manifest distress  soon after taking
nourishment into the stomach, together with tenderness and ten-
sion  of the epigastrium, it  will be better to employ minute doses
of calomel  and ipecacuanna without  the castor oil,  and pro-
mote their action on the bowels by laxative clysters.  I have in
a few cases employed these two articles, according to the formula
given below,* with a very  satisfactory  result.   A dose should be
given every two hours, in conjunction with the administration of
laxative enemata, until adequate evacuations have been procured.
The same powders,  or minute portions  of calomel without the
ipecacuanna, must afterwards be regularly given every morning,
noon, and evening, until the alvine discharges become  conspicu-

  * R. Submuriat. Hydrarg.  gr. iii:   Pulv. Ipecac, gr.  ii;  Sacher. Alb. gr.  xii.
Mix and divide the whole into 12 equal parts. 
                   jaundice of infants.                 107
ously bilious.  No ill effects need be feared from ipecacuanna in
this irritable and irritated state of the primae vise.  When exhib-
ited  in very small doses, so far from exciting or irritating the
stomach, it  generally exerts a decidedly calming and anti-emetic
influence, and almost always promotes, to an evident degree, the
aperient operation of the calomel.  In cases of this inflammatory
character, some advantage may be  derived from the application
of a large warm emolient poultice over the  upper part of the ab-
domen, and frequently renewed  so as  to keep it warm.  In some
instances the calomel fails to  excite the action of the liver, and
causes injurious irritation of the mucous membrane of the bowels,
giving rise  to frequent small  turbid watery discharges, attended
with severe griping and increased abdominal tenderness.  When this
occurs, we may sometimes obtain the desired mercurial influence
on the liver, by applying a mercurial plaster over the region of this
organ, or by the  internal use of a quarter of a grain of Dover's
powder in union with half  a grain of finely powdered dry and
hard  mercurial mass, exhibited every morning, noon and evening.
A fourth  of a grain  of Dover's powder, in conjunction with a
grain of the bi-carbonate of soda, given every three or four hours,
is an  excellent remedy for allaying the  intestinal irritation and
exhausting  diarrhoea which, some times occurs in  the  advanced
stages of the disease.
  In  general calomel and purgatives are the means upon which
our main reliance should be  placed in treatment of  this malady.
The bowels are usually very torpid, and  considerable difficulty is
often  experienced in procuring the  necessary evacuations.   It is
seldom, however, that any more active purgatives are required
than the articles already mentioned, in conjunction with laxative
enemata.   Should this necessity occur, we may safely, and with
almost certain success add from eight to ten drops  of spirits  of
turpentine to the dose of castor oil.   I have resorted to this mix-
ture, in cases of this kind, with the happiest effect.
  The vegetable  alkalies have a very beneficial tendency in cer-
tain modifications of this disease.  The bi-carbonate of soda, is
especially useful in cases of a chronic character, unattended by
symptoms of active abdominal inflammation.  A grain of this al-
kali, dissolved in a teaspoonful of carbonated water, or a teaspoon- 
  108                JAUNDICE OF INFANTS.
  ful of the common  soda mineral water, (of the strength of sixty
  grains of soda to ten ounces of carbonated water,) given at inter'
  Vals of two or three hours, is well adapted to do good, where there
  is a deficiency of bile in the bowels, by its direct tendency to  pre-
  vent fermentation and  the consequent generation of acid  and
  other irritating substances in the primae viae, and by promoting the
  regular  peristaltic action of the bowels.   After the alvine  dis-
  charges have become  bilious, the  regular exhibition of both the
' /soda and calomel should be discontinued, and  the bowels kept in
  a loose state by  small doses of castor oil, or the occasional admin-
  istration of an injection.   In  chronic cases of infantile jaundice,
  considerable advantage may, sometimes, be gained, from the use
  of the extract of dandelion, in union with bi-carbonate of soda.
  Ten grains of  the  extract, dissolved in about a teaspoonful of
  Warm water, together with two grains of the soda, may be given
  three times daily.  It generally keeps up  a regular action of the
  bowels—excites the urinary secretion, and appeaVs to produce a
  salutary effect upon the biliary organs, and general capillary sys-
  tem, as  may be inferred, from the  gradual subsidence of the ab-
  dominal fulness and tension, and the disappearance of the yellow-
  ness of the skin, under its use. In a case which I attended a few
  months ago, the disease  gradually increased in violence under the
  use of small doses of calomel, and ipecacuanna.   The abdomen
  became distended and hard, and the skin  of a deep yellow color.
  The calomel was finally omitted, and ten  grains of the dandelion
  with two grains of soda administered three times daily.  In a few
  days after the  use of this remedy was commenced, the disease
  began to abate, and gradually disappeared altogether.
     [n cases attended with severe flatulent and spasmodic pains of
  the stomach and bowels, three or four grains  of assafoetida, dis-
  solved in a few tablespoonsful of warm water, and injected into
  the rectum, will generally  afford much relief.   We may also ad-
  minister two or three drops of sulphuric asther in a teaspoonful of
  hop tea, with decided benefit in such cases.  The infusion of hops
  is, indeed, a most excellent palliative in  the jaundice of infants.
  It does  not  interfere with the action of the necessary laxatives,
  and along with its  anodyne effects, generally exerts a decidedly
  favorable influence  on the digestive functions.  When the disease 
        OF THE RETENTION AND SUPPRESSION OF URINE.     109
depends on engorgement and torpor of the liver, without structural
lesion, Gardien recommends  the  use of the black oxide of iron,
with the yolk of an  egg.   Two or three grains of the former,
beat up with  a  yolk  of an egg, given three  times daily, is said
to produce excellent effects, in some instances of this kind.
CHAPTER VII.
        OF THE RETENTION AND SUPPRESSION OF URINE.

   Some urine  is probably, in most instances, secreted, and de-
 posited in the bladder, before the infant leaves the womb; for, in
 the  majority of cases, a discharge of urine occurs, within a very
 short time after birth.  Sometimes, however, the kidneys appear
 to remain inactive, and little or no urine is evacuated for many
 hours after the birth of the infant.   I have met  with several in-
 stances where a period of upwards of twenty hours elapsed before
 a  sufficient  quantity of urine was secreted and  collected in the
 bladder  to excite an evacuation.  It is of great consequence, in
 cases of this kind, to acertain whether the non-occurrence of the
 urinary discharges, depends on a suppression of the secretion from
 torpor or inactivity of the  kidneys, or whether the urine though
 adequately secreted, is retained in the bladder in consequence of
 some obstruction to its discharge, or  deficient  contractile  power
 of the bladder.  When there  is but little or no urine secreted
 during  the first fifteen or twenty hours after birth, the infant
 seldom  manifests any uneasiness that can be  referred  to  this
 cause; but when the renal  inactivity is protracted much beyond
 this period, the consequences  may be very serious and even fatal.
Cases of this  kind are, indeed, extremely uncommon.  I  have
 seen but one instance of very protracted ischuria renalis,m a newly-
 born infant.   The child was born about 10 o'clock in the evening.
 On the following morning I was informed that it had as yet voided 
110     OF" THE RETENTION AND SUPPRESSION OF URINE.
no urine. It appeared to be quite healthy, and free from uneasiness.
I  ordered  a  teaspoonful of weak  parsly-tca, with  two drops
of sweet spirits of nitre every twenty  minutes.  In the evening, I
found the child in a drowsy state, and restless.  I assured myself
that the bladder was empty,  by the introduction of  a  very small
catheter.   The warm bath was  ordered, and  frictions  over the
abdomen and loins, with a mixture of juniper-oil, and tincture of
squills.  Internally three drops of sweet spirits of nitre, together
with four drops of the vinegar of squills were given,  every half
hour in a teaspoonful of wild carrot-seed tea.   Next morning the
little patient was in a  state of complete stupor—the respiration
slow, weak and irregular, and the eyes insensible to light.  On
the following night it died.   I was not permitted to make a post-
mortem examination.   In general, the action of  the  kidneys  is
readily excited, where the urinary secretion is slow, or suppressed,
during  the  first nine or  ten hours after birth.  A few teaspoon-
fuls of  parsly or wild  carrot-seed tea, with two  or three drops
of sweet spirits of nitre, given every half hour, and the warm hip
bath, (after the bowels have been freely evacuated,) are generally
sufficient to excite the  secretory action  of the kidneys.   Should
these means fail to produce the desired effect, recourse may be
had to friction  over the loins and hypogastric  region, with warm
vinegar of  squills, or a mixture of about a drachm of juniper oil
with an ounce of sweet oil, or with the expressed  juice of onions
diluted  with water;  and  internally, to  the exhibition of a  few
drops of the vinegar of squills, a drop of spirits of turpentine in a
teaspoonful of  milk or four or five drops of the expressed juice of
roasted onions, every thirty or forty minutes; in conjunction with
warm bathing,  laxatives, and if necessary laxative enemata.
  When there  is retention of the urine—that is when the urine  is
regularly secreted, and conveyed into the bladder, but cannot be
discharged in consequence of a spasmodic constriction or mechani-
cal obstruction of the urethra, or perhaps, deficient contractile
power of the muscular coat of the bladder, the  phenomena, con-
sequences and appropriate mode of management are very different
from those which belong to  suppression of the urinary secretion.
Instances of more or less complete retention of the urine, immedi-
ately after birth are by no  means uncommon.   Obstruction of 
        OF THE RETENTION AND SUPPRESSION OF URINE.     HI
                         t
the urethra or of the neck of the bladder by viscid and inspissated
mucus,  is probably the  most frequent cause of retention of the
urine in newly-born infants.   When by the gradual accumulation
of the urine, the bladder becomes considerably distended, the in-
fant  begins to  manifest pain  and distress, which is obviously in-
creased by pressure  made with the hand upon the hypogastric
region.   The distended bladder maybe more or less distinctly
felt above the pubis; the infant is restless,its countenance has an
expression of suffering  and  distress, and its  legs are constantly
drawn up, to relieve the pressure of the abdominal  muscles.  If
the obstruction be not removed, the abdomen gradually becomes
more and more enlarged by the distended bladder, and  acquires,
at last, a tense and shining appearance, with the superficial veins,
very much enlarged and turgid  with blood.   If relief be not
obtained, rupture of the bladder finally takes place, and death is
the  inevitable  consequence.  The  bladder sometimes becomes
enormously distended before ulceration or rupture takes  place.
Dr. Dewees  gives an account of a very remarkable instance of
this kind, in which Dr. Parrish drew at one time eighteen ounces
of urine from the bladder.  The child did not recover.  A few
years ago I was called to consult  in a case of this kind.  The
attending physician was a very young man, and tampered with
inefficient means until it was too late.  Before I arrived the blad
der had yielded to the distending force, and  the urine was extra
vasated into the cavity of the peritoneum.   Of this I satisfied my-
self by a post-mortem examination.
   In some cases, after the bladder has become much distended,
small portions of urine are, from time to time evacuated, although
the quantity retained, is progressively increased; and this  occur-
rence almost always misleads the nurse, and often even the medi-
cal attendant, and removes  every suspicion of urinary difficulty.
The urine is thus gradually accumulated, and the manifest dis-
tress and  suffering is ascribed  to other causes, until the bladder,
at last, gives way, and the infant dies in great agony from  peri-
toneal inflammation.  I am persuaded that infants sometimes die
in this way, who might easily be saved if the real cause of its suf-
ferings  did  not thus escape  the  attention of the  practitioner.
" We have strong reasons to  believe," says Dr. Dewees,  " that 
112     OF THE RETENTION AND SUPPRESSION OF URINE.
many have died of suppression (retention) of urine, though we were
assured they had  passed water—the same was insisted on, for
awhile in the case (referred to above) just mentioned, and perhaps
there may have been a small discharge, as always happens  when
the bladder becomes excessively distended."  When the infant
becomes restless  and fretful, and  persists  in  keeping its legs
drawn  up, and particularly when we are informed that  its  abdo-
men is  swollen and hard, the region of the bladder should be
carefully examined, and no reliance placed  on the nurse's decla-
ration, that the urine is regularly evacuated, if there is the slight-
est reason on examination, to suspect an accumulation of urine
in the bladder.
   The external urinary passage ought always to be carefully ex-
amined in newly-born infants.   I was once called into the coun-
try, to  visit an infant, which, I was told, had not discharged any
urine since its birth. I  saw it about forty hours after birth, and
found it evidently in a state of very great suffering. The bladder
was very  much distended, and  could  be easily felt beneath the
abdominal muscles.   On examining the urethra, for the purpose
of introducing a small flexible  bougie,  I found its orifice closed,
by a thin semi-transparent membrane, about the tenth of an inch
below the surface, or extremity of the passage.   I divided it with
a sharp-pointed history, and the  urine instantly gushed out with
much force.  Sometimes the prepuce is entirely closed.  I have
seen two cases of  this  kind.   In one there was a very  small
opening,  scarcely admitting a pin's head, and altogether in-
sufficient to admit of the discharge of the urine;  in the other case,
the cloSure was complete.   In'both, the difficulty was speedily
removed by circumcision.
   The common practice  of exhibiting diuretics, or remedies cal-
culated to increase the secretory action of the kidneys, in cases of
retention of the urine, is  always highly improper, as it cannot, in
any way, aid in removing the  obstruction, but must necessarily
tend to aggravate the distress and danger, by rapidly increasing
the fluid in the bladder.
   When  the inability to discharge urine, depends on retention of
the secretion in the bladder, and the vesical distention and sufferings
of the  little patient are, as yet, not so great as to require prompt 
        OF THE RETENTION AND SUPPRESSION OF URINE.     113
 relief, a trial may be made with the warm bath, purgatives, emo-
 lient enemata, and gentle frictions with camphorated oil, or tinc-
 ture of hyosyamus, over the pubic region.  Where the obstruction
 is slight, these measures will sometimes, remove the difficulty and
 bring  on  the  urinary discharge.  They should not, however, be
 long persisted in, if they do not procure some advantage before
 the  symptoms become more urgent.  The  bougie and catheter
 are the proper means for giving relief; and the obstruction is but
 very rarely of such a character as to render the judicious employ-
 ment of them necessarily abortive.   The introduction of a small
 bougie will, sometimes, remove  the obstruction  and procure re-
 lief. But when the retention arises from a spasmodic constriction
 of the urethra, or sphincters of the bladder, or when the bladder
 has lost its power of contraction from over distention, the bougie
 can do little or no  good, and recourse must be had to a proper
 sized flexible catheter.  Great care and delicacy must be prac-
 tised in the attempt to introduce such an instrument into  the
 bladder of an  infant. A very slight force will lacerate the urethra,
 and form an artificial passage  into the cellular tissue of the per-
 ineum.  I once knew a young surgeon, in attempting to introduce
 the catheter into the bladder of an infant, (male) push it through
 the membraneous portion of the urethra  two  or three inches be-
 fore he discovered that the instrument was  not in the  natural
 passage.  The child died.  When the bladder has been greatly
 distended, and relieved by the catheter, its contractile power is
 apt to become temporarily impaired, so as to suffer the urine to
 re-accumulate to an extent sufficient to keep the infant in  a state
 of constant uneasiness or distress, although a regular and  appar-
 ently sufficiently copious discharge from the bladder takes place.
 Hence in instances of retention, where there  has been great dis-
 tention of the bladder, it often becomes necessary to use the
 catheter repeatedly, until the bladder regains sufficient power to
 evacuate itself, without artificial assistance.   Sprinkling a little
 cold water on the lower part of the abdomen will sometimes
 excite  the bladder into action in cases of this kind.   The  appli-
 cation  of camphorated oil, by gentle friction  over the pubic re
 gion, may also aid in restoring  a proper tone to the muscular coat
of the bladder.
                               Q             11 
 114     OF THE RETENTION AND SUPPRESSION OF URINE.
   When there is  reason to believe that the retention depends on
 spasmodic constriction of the urethra, a drop of the  muriated
 tincture of iron, given every twenty or thirty minutes, may be
 beneficial.   In spasmodic retention of urine in adults, this article,
 sometimes affords speedy relief;  and it would doubtless exert  a
 similar beneficial  effect in retention of the same character in in-
fants.  In all cases  particular attention ought to be paid to the
state of the bowels.   The meconial matter should be completely
evacuated, if the urinary difficulty occurs during  the  first  few
days after birth—and in all instances  the bowels  ought to be
freely evacuated. 
OF DYSURIA.                       US
CHAPTER VIII.
    OF DYSURIA—OR PAINFUL AND DIFFICULT MICTURITION.

  Pain and difficulty in voiding urine is  a frequent complaint
among infants.  It  is particularly apt to occur during dentition,
and sometimes acquires a very  distressing  degree of violence.
The child may, in other respects  appear perfectly well and play-
ful, but the moment it begins to  discharge urine, it becomes agi-
tated with excruciating pains, and  shrieks uninterruptedly  and
violently until the evacuation is completed, when it instantly be-
comes quiet and as well as usual.  Not unfrequently this painful
urinary affection goes on for  many days, before its true character
is  detected—the vehement fits  of screaming being  usually as-
cribed to griping or transient colic pains.  When an infant is ob-
served to have  occasional fits of violent shrieking and agitation,
without any obvious cause, painful micturition may be suspected:
and on proper enquiry it will, probably, be found that these spells
of suffering, occur only when the infant is voiding urine—a coin-
cidence which will, at once render the nature of the evil manifest.
In many instances, however, the pain is much less severe.  Instead
of the occasional fits of excruciating suffering, the child manifests
a very frequent desire to pass urine, which is voided in very small
quantities and always with obvious distress and uneasiness.  This
difficulty sometimes continues for many months—particularly if the
child be cutting teeth, and may ultimately lead to very distressing
consequences.
   These affections  are almost always attended with an unnatural
condition of the urinary secretion.   In the majority of cases the
urine contains a large portion of lithic acid; and occasionally it
is highly charged with phosphatic  sedimentous matter.   These
substances impart  a peculiarly irritating  quality  to  the  urine; 
116                      OF DYSURIA.
and when they  are copious, and  the system  is in an irritable
condition, as it usually is during dentition, they may readily pro-
duce a considerable degree of irritation about the neck of the blad-
der, and give rise to pain and difficulty in passing urine.  Children
who  are much affected with acidity in  the  primae  viae, are most
apt to experience urinary difficulties of this kind.   The tendency
of acid in the alimentary canal to increase the secretion of lithic
acid  by the kidneys is well known;  and it is equally well ascer-
tained that an excess of lithic matter in the  urine, seldom fails to
manifest itself by some  irritation about the neck of the bladder,
and more or less painful micturition.
  Dentition, and a disordered  state of the digestive functions con-
stitute the principal remote causes of this  form of urinary disease.
The  former  by the general irritative  condition  of the  system
which it  causes, strongly favors the development of the lithic
acid  diathesis; and, as has  already been stated, the generation
of acid in the alimentary canal, in  consequence of feeble digestive
powers, or the use of improper articles of food, appears to furnish
the elementary  materials, for the  formation of lithic deposits In
the urine.  Intestinal  irritation from worms, appears in some in-
stances to give rise to painful and difficult micturition—though
in cases of this kind the urinary deposits  are usually of the alka-
line  variety.   Ascarides frequently occasion  considerable  irri-
tation about  the neck of the  bladder, and become the source of
urinary difficulties.

  Treatment. When a child becomes affected  with pain and  dif-
ficulty in passing urine, this  secretion ought to be carefully exam-
ined, both in a recent state, and after it has stood for some time.
If the sedimentous  matter of the urine  be of a red, or  reddish
color, remedies  calculated  to  counteract the  secretion of lithic
acid by the kidneys will be indicated and will probably procure
speedy relief.   The proper treatment in such cases, consists in
the employment of means suited to  correct  the digestive and in-
testinal functions, and to keep up a regular  action of the  cutane-
ous emunctories.  The bowels should be freely  evacuated with
magnesia and rhubarb, and afterwards kept in a moderately loose
state by the daily use  of small doses of  calomel and ipecacuanna. 
                         OF DYSURIA,                      117
A grain of the former, with a fourth of a grain of the latter, con-
stitutes a proper dose for a child under five years of age. Where
there is a prevailing tendency to acidity in the primae viae, much
benefit may be obtained from the use of the sub-carbonate of pot-
ash, in union with a weak infusion  of colomba.  From  two to
three grains of the potash dissolved in a teaspoonful of weak in-
fusion of colomba, diluted with a small portion of barley water,
flaxseed  tea, or some other mucilaginous  fluid,  may  be given
once, twice, or thrice daily, according to the urgency of the uri-
nary affection.   The diuretic and antilithic properties of the sub-
carbonate of potash, renders it  a  peculiarly  suitable  medicine in
cases of this kind. Small doses of magnesia, lime-water and  milk,
and the bi-carbonate of soda, also, frequently procure relief. When
the general system is in  a slightly febrile condition, as it often is
during dentition, considerable advantage may be derived from te-
pid bathing, in conjunction with mild diaphoretic  remedies such
as  the spirit, minderiri,  with the addition of a small portion of
sweet spirits of  nitre, and syrup of squills.  Particular attention
should be paid to the  diet.  When  the tendency to  the forma-
tion of acid in the primae viae is very great, beef or chicken tea
should be in part substituted for  the  usual  farinaceous  nourish-
ment, and all saccharine and acescent articles should be avoided.
  When painful and difficult micturition is attended with a copi-
ous secretion of the phosphate of magnesia and ammonia—an oc-
currence by no means uncommon, a very different treatment  is
required.   In cases of this kind, the urine is usually pale, rather
abundant, depositing a whitish or yellowish white sediment, and
peculiarly prone to become putrid when suffered to remain at
rest.  It is almost always attended with an irritable condition of
the general system, and with obvious derangement of the  diges-
tive organs  and  irregularity in  the action of the bowels.   Aperi-
ents, mild tonics, opiates, and the vegetable  acids, constitute the
appropriate remedies  in  such  cases.  The bowels, in the  first
place, should be freely evacuated with  rhubarb or caster oil.__
Very small doses of Dover's powders, given two or  three times
daily, generally produce an excellent effect.   A half a grain  of
this article,  with a grain of powdered valerian, may be given ev-
ery six hours, to a child between two and five  years of age.  The
                                             11* 
HQ                     OF DYSURIA.
occasional use of lemonade, or of water sweetened  with lemofl
syrup, will sometimes assist very materially in correcting the uri-
nary secretion.  The diet should be of the mildest and most nu-
tritious kind:  considerable benefit may  also be derived from the
employment of muriated tincture of iron, in cases of this kind.   I
have known two drops of this  tincture,  given three  times daily,
to afford great relief in such a case. The diet should be mild and
nutritious, and taken in  very moderate quantities.  Children who
have passed through the period of primary dentition, may be al-
lowed small portions of the tender and lean parts of beef, mut-
ton, lamb, and chicken;  but at an earlier age, the  usual farina-
cious preparations, mixed with a little of beef or chicken tea, are
undoubtedly the most proper.   Magnesia and other articles of an
alkaline character, are decidedly improper.
   When pain and difficulty in voiding urine is not attended  with
a morbid condition of the urine either acid or alkaline,  mucilagi-
nous and slightly diuretic diluents, in conjunction with laxatives,
and the occasional use of the warm bath, may be resorted to with
a  prospect  of advantage.  A weak  infusion of the wild-carrot
seed, or of parsley  mixed with an equal portion of flax-seed or
water-melon seed tea, will usually do  well for this purpose.
   In some instances, extremely painful micturition depends on an
irritable or slightly inflamed state of the  extremity  or orifice of
the urethra.   This difficulty is almost wholly confined to female
children.  I have quite lately witnessed a case of this kind.  The
child (about two years  old) suffered  severe  pain every time  it
passed urine.   The affection had continued seven or eight  days
before the source of the urinary difficulty was discovered.  The
orifice of the  urethra was slightly swollen, red, and so extremely
sensible, that  it could not be even lightly touched, without caus-
ing the child  to shriek with pain. In cases of this kind, the pain
and uneasiness usually  continue for  several minutes  after the
urine has ceased to pass off. The case just mentioned was speed-
ily relieved by  washing the inflamed  and tender  part with  a
strong solution  of borax.  The application of citrin  ointment,
weakened by mixing it with an equal portion of lard, seldom fails
to reduce  the inflammation in such cases.  I have  also used an
infusion of galls, together with a watery solution of opium, with 
                          OF DYSURIA.                     119
an excellect effect in this variety of painful micturition.  It should
be applied  with  a dossil of lint.   Merely covering  the  inflamed
part with lard, or some mild ointment, will  generally protect it
from the painful  impressions of the urine, and enable it to heal.
   During dentition  the urine sometimes becomes  more or less
deeply tinged  with  blood,  without  any difficulty or pain in void-
ing it.  The appearance of blood in  the urine, always excites con-
siderable alarm; but where it is not attended with symptoms  of
irritation or inflammation in the urinary organs, it generally passes
off without any  unpleasant  consequences.  Small  doses of the
muriated tincture of iron, mild laxatives, and warm bathing, and
mucilaginous  drinks, seldom fail to remove it speedily.
   It is of great  consequence to attend to  the urinary affections
of infants, even though they may  not appear to be of a  serious
character in their immediate  effects.  This is  particularly true
in relation to those instances of urinary difficulty that are attend-
ed with  lithic acid,  or phosphatic  sediments.  Dr. Prout ob-
serves,  that " children in general,  and especially the children
of dyspeptic and gouty individuals,  or who inherit a tendency to
urinary diseases,  are exceedingly liable to  lithic  acid  deposits
in the  urine.   If the urine be examined, it will always  be found
to be very unnatural, and frequently loaded with lithic acid; and
should this  prove to be the fact, the case requires immediate at-
tention, as there  is much  greater risk, at this period of life,  than
at any other, of the  formation of stone in the bladder." *  In an-
other place, this highly respectable  writer states: every thing in
our power  ought to  be done, "for  preventing*the effects of (li-
thic acid deposits in the urine) and  eradicating the disease in
early life; and perhaps, it may not be deemed superfluous, here,
to insist upon the absolute necessity there is for attending to the
subject, when children are concerned."  In such cases, it should
be constantly borne  in mind, that by proper care, the formation
of stone in  the bladder, may  almost certainly be prevented; but
by inattention, this dreadful occurrence  is as certainly likely to
take place.

  * Prout—Inquiry into the Nature and Treatment of Affections of the Urinary Organs.
Chap. vi. s. ii. 
120
OF ENURESIS.
                  CHAPTER  IX.


           OF ENURESIS, OR INCONTINENCE OF URINE.

  Incontinence of urine—or rather a habit of discharging urine
at night, while sleeping in bed, is a very common affection during
childhood.   Although very rarely attended with any particular
uneasiness, or painful urinary irritation, it is always an extremely
disagreeable occurrence, and the habit  is apt  to become so  con-
firmed, that unless early counteracted  by suitable  measures, it
often continues to the age of puberty, and occasionally, even  to
adult age.  .It is generally  supposed that the  discharge takes
place involuntarily,  without the least  consciousness of its occur-
rence; and this is doubtless frequently the case.  In the majority
of instances, however, the discharge is a voluntary act—the result
of an active effort of volition, under the fallacious conceptions of
a dream.   In children,  this disagreeable affection is very often
associated with an unnatural condition  of the urinary secretion
itself. In those cases, especially, where the discharge takes place
in consequence of a voluntary effort  excited  by a lively dream,
the urine, almost always contains an excess of sedimentous matter,
particularly lithic acid, and its compounds, imparting to it an
acrid and irritatyag character. " Hence," says Dr. Prout, "I have
been led to infer, that in this species of urinary incontinence, the
acrid properties of the urine are chiefly in fault;  and that these,
favored, perhaps, by the position of the body, and probably, also,
by the morbid sensibility of the bladder, excite so vivid  an im-
pression on the imagination, as actually to lead to  a voluntary
effort to discharge the urine."
  The urine is seldom discharged during  sleep, except  when the
individual  is lying on his back.  Mr. Charles Bell affirms,  that
" incontinence of urine never takes  place but while  the boy  is
asleep upon his back."  In this position  the urine gravitates back-
wards, and presses immediately on the " sensible spot—the master- 
                        OF ENURESIS.                     121
spring of the muscles of the bladder, situated a little behind  and
below its orifice."
  When children neglect to pass off the urine just before going
to bed, the bladder is apt to become distended  in the course of
the night.   The impressions thus made on the bladder,  pass to
the brain, and awaken a dream occupied with a desire to mictu
rite, and the sphincter yields to  the  voluntary effort  prompted
by the desire.
  That incontinence of urine is very frequently, perhaps always
in the first instance, excited by an  acrid condition  of the uri-
nary  secretion, or by distention of the bladder,  in  the way just
mentioned, admits of no doubt; yet in the majority of protracted
cases, the recurrence of  the discharge  depends mainly on  the
influence of habit; and in many instances, this  is doubtless  the
sole cause of its repetition.
  Dr. Prout thinks that  " some peculiar morbid condition of the
urinary organs" constitutes the most frequent cause of those cases
of nocturnal incontinence of urine, in which the discharge  takes
place involuntarily, and without any  consciousness  of its occur-
rence.  Cases of this kind are almost always  very obstinate in
their course. They often continue  for  many  years,  and some-
times "even till late in life."   It is by no means improbable, that
this variety  of incontinence  sometimes depends on some obscure
morbid state of the bladder; but it can scarcely be doubted, that
in the majority of such cases, the recurrence of the involuntary
urinary discharges, depends  chiefly or entirely on  the potent in-
fluence of habit.  That the recurrence of the discharge in pro-
tracted  cases, frequently depends solely upon habit, seems  to be
demonstrated by the character of the  means, most commonly suc-
cessful in arresting its continuance.  We may often remove this
evil by exciting a slight degree of irritation about the neck of
the bladder; so that the moment the urine begins to flow,painful
strangury occurs, by which the  person is  awakened, and  the
evacuation is prevented.   By  repeating this for some time,  the
habit is  broken  up,  and the involuntary  discharge  ceases x->
recur.
  I am entirely satisfied  that this unpleasant complaint very gen-
erally commences in consequence of an unnatural condition of the
                           R 
122                     OF ENURESIS.
urine itself.  When the urine becomes unusually irritating, its
impressions on the bladder during sleep, when it  becomes accu-
mulated, are sufficiently strong to affect the  sensorium  commune
in such a way as to excite a desire, and a consequent volition to
micturate.  It is not improbable that even  in cases that are deemed
strictly involuntary, and unperceived  by the mind, the  discharge
takes place under an act of volition, which, however, is not remem-
bered on waking.  Persons who walk  about while  asleep, unques-
tionably  exercise  conscious volition, though  wholly unable to
recollect any thing about  it when  awake.   Many  things have
been done during sleep, manifestly under the control of the will,
and probaflly even under the guidance of the senses,  of which
not the slightest trace is left on the mind, in the waking state.

   Treatment.—From what has been said above, it need scarcely be
observed, that in prescribing for a case of this kind, particularly
when of a recent  character, the urine ought to be carefully in-
spected, as a preliminary step in the adoption of a suitable plan
of management.  Should the urine be found to contain much se-
dimentous matter,  remedies ought to  be employed for correcting
the urinary secretion.  If the lithic acid deposits predominate,
small doses of magnesia, lime water,  the sub-carbonate  of potash,
or of the bi-carbonate of soda, should be resorted to, in conjunc-
tion with laxatives and other means  for improving the  digestive
andhepatic functions.   In cases attended with phosphatic urina-
ry deposits, remedies calculated to invigorate the digestive organs,
together with opiates, vegetable acids, and acescent articles of
nourishment  will  be proper.  By such a course of management,
recent cases may sometimes be completely arrested.  But should
the  attempt to remove the evil, in this way, fail, it  is  always of
much consequence to correct the urinary  secretion, when  it is
found to be in an unnatural condition. "When the incontinence
of urine in children is associated  with gravel, or  an  excess of se-
dimentous  matter, it is of the utmost consequence that this cir-
cumstance be  attended  to, and  that remedies  appropriate for
counteracting the  formation of these urinary deposits  should be
employed, before any other means are used to restrain the uri
nary incontinence;" for without this,  all other remedies will be 
                         OF ENURESIS.                     123
 useless (Prout).  When the urine has been brought to a healthy
 or natural state,  and the incontinence continues  to recur; or  in
 cases  that seem to continue under the influence of an established
 habit, recourse must be had to remedies calculated to  alter the
 sensibility of the urinary organs—more especially of the neck of
 the bladder.  There is no article that has been so generally pre-
 scribed  for  this purpose, as the tincture of cantharides;  and it is
 doubtless better  adapted to produce this effect  than any other
 remedy  we possess.  Its mode of operation in the case of this af-
 fection has already been explained above.  By producing a slight
 degree of strangury, the person is awakened by the first  efforts to
 urinate; and by thus repeatedly interrupting the discharge, the
 habit will finally be destroyed.   From ten to fifteen drops, accord-
 ing to the age of the patient, should be given three times, in the
 course of twenty-four hours, and the dose daily increased by two
 or three drops, and continued until a burning  pain is experienced
 at the neck of the bladder on passing urine.   When this effect is
 produced,, its use must be omitted, or continued in occasional doses,
 so as to keep up a slight degree of the urinary irritation.  Should
 the strangury become too violent, suitable doses of laudanum must
 be given, at proper intervals, with emolient clysters—and the free
 use of mucilaginous diluents, such as flax-seed, or mellon-seed tea,
 barley-water, or a solution of gum-arabic, and the warm hip-bath.
 Blisters applied over the sacrum, are sometimes equally beneficial.
   Incontinence of urine in children sometimes depends on a mor-
 bidly irritable state  of the bladder.  The patient is during the
 day more or less  harassed with a frequent desire  to urinate, and
 the discharge is always accompanied with considerable uneasiness,
 and  sometimes with much pain.   These cases are usually associ-
 ated with a morbid condition  of the urine—sometimes  with an
 excess of lithic acid,  and  occasionally with phosphatic  deposits.
 Instances of this kind must be managed in the way stated above.
 The use  of cantharides, or of other remedies calculated to irritate
 the neck of the bladder, would be highly improper in such cases.
 An irritable state of the bladder may, however, occur, without any
 morbid appearances in the urine, and give rise to urinary inconti-
nence.  Here,  the  remedies, proper for counteracting the secre-
tion of the lithic acid, or phosphatic sediments would, probably, 
124                     0F ENURESIS.
prove injurious.  In such cases recourse must be had to the warm
oath—cooling laxatives, opiates, particularly Dover's powder, the
application of a stimulating plaster over the  sacrum, and a mild
and digestible diet.
  When incontinence  of urine is attended with irritation of the
rectum by ascarides, means should be used to remove these an-
noying little worms out of the bowels.  I once attended a little
girl who was for several months much troubled with  uneasiness
on passing water, and scarcely a night passed, without a discharge
of urine during sleep.   I  at length  learned that she was also
greatly annoyed by ascarides.   By the use of aloetic injections a
large mass of them were brought away from the reqtum, and the
urinary difficulty and incontinence disappeared, for eight  or nine
months, when they returned, and were again removed by the same
means.
  Whatever means may be  employed for the cure of nocturnal
incontinence of urine, care should always be taken to accustom
the patient to sleep upon his side or the belly.   In this position
the urine gravitates towards the fundus of the bladder, and does
not rest upon the sensible spot, referred to above; and the patient
is therefore not so apt "to be excited to dream of making urine,
and to exert a voluntary effort, to urinate,  as  when he lies on
his back."   Children should always be required to empty the blad-
der just  before going to  bed,  and when they  awaken at  night
they  ought to be taught to riae and  pass off the urine.  By a
careful attention to these things, the occurrence of the disordei
may generally be prevented. 
OF DENTITION.
125
CHAPTER X.
                       OF DENTITION.

  The  development and progress of the teeth through the gums,
takes place in a very gradual manner.  The germs of the teeth
present themselves  in  the  form of small  follicles, containing a
pulpy substance, attached to, or continuous with the fascicle of
vessels and nerves which penetrate the cells or alveoli in which
they are placed.  The period at which these  germs first  make
their appearance in the foetal jaws has not been satisfactorily de-
termined.  It is  sufficiently ascertained, however, that  the first
traces of ossification, very  rarely occur previous to the fourth
month;  and it is equally uncommon to find the commencement
of this process delayed beyond the middle of the fifth month. At
birth, the development of the primary teeth is  already consid-
erably advanced.   The whole crown is formed,  but the root is
still imperfect, consisting of a short and thick tubular projection,
with very thin sides.
  The  number of  these primary teeth is twenty—namely, four
incisors or  cutting teeth, two cuspid or eye  teeth, and four  grind-
ing teeth in each jaw.  Between the appearance of the first and
the lastofthe primary or milk teeth, several years usually intervene.
The first seldom protrude through the  gums before  the  fourth
month, and the last  generally  make their appearance about the
end of  the second year.  The  two middle cutting teeth of the
lower jaw, are usually the first that make their appearance.   In
the course of three  or four weeks afterwards, the corresponding
incisors of the upper jaw protrude through  the gums.  These in
a few weeks more,  are succeeded by  the lateral cutting teeth of
the lower jaw; and in a short  time afterwards, the lateral inci-
eors of the upper jaw  also pierce  the gums.  In the course of
                                              12 
126                    OF DENTITION.
from about two to four months after the eight cutting teeth have
made their appearance,  the  anterior grinders of the lower jaw
"elevate their white surfaces above the gums," leaving vacant
spaces between them and the two lateral incisors, for the cuspids
or eye teeth.   Soon afterwards,  the   corresponding grinders of
the upper jaw also make their appearance.  The cuspids or eye
teeth next come out, those of the lower jaw preceding the upper
ones.   Finally, the second grinders pass through the  gums, and
terminate the process of primary dentition.
   Although the general progress and order of dentition is  such
as has just been stated, yet great diversity occurs in different in-
dividuals, both in relation to the time at  which the teeth pro-
trude through the  gums, and the order  or succession of their
appearance. In some instances, the first incisors appear as early
as the second month, and in others, they do not make their appear-
ance  until  the seventh or eighth month.   The usual period of
their appearance, however,  is about  the fifth  or sixth month.—
The  irregularities, in this  respect,  are  sometimes very great.
Infants have been born with one or more  well-formed teeth pro-
truded.  Van Swieten mentions cases of this kind, on the authority
of Pliny, Marcellus Donatus, Colombo,  &c; and Haller and
Voigtel  refer  to  a great number  of similar instances.  I  have
myself seen an infant furnished with two well-shaped incisors, as
early as the fourth week after birth.  The instances of very tardy
dentition are sometimes equally remarkable.  I have a child now
under my care, which has, as yet, not a single tooth, although up-
wards of eleven months old.  Van Swieten mentions an instance, in
which the first teeth did not make their appearance until the child
was upwards of nineteen months old; and many cases of much
greater delay in the appearance of the teeth, are recorded by
Haller, Voigtel,  and other writers.
   With  regard  to the order in which the teeth are protruded,
deviations from the ordinary  course, as stated  above, are by  no
means uncommon.   In some instances, the two  lateral cutting  '
teeth of the lower jaw,  make their  appearance before the mid-
dle ones.  Sometimes the incisors of the upper jaw precede those
of the  lower; and occasionally the  eye teeth  come out before
 the lateral cutting teeth.  It is rare, however, to find the eyr. 
                        OF DENTITION.                     127
 teeth advanced through the gums before the first grinders, although,
 occasionally,  this takes place.  Instances  are sometimes met
 with  in  which  all the incisors  pierce  the  gums almost simul-
 taneously.
   Although a process  of physical  development, and, therefore,
 strictly in accordance with the regular progress of nature, denti-
 tion is, nevertheless, almost invariably attended with more or less
 obvious deviation from a healthy condition of the system.  The
 progress of the teeth through the gums  is usually accompanied
 with a  manifest increase of the general irritability of the  system.
 The mouth is generally very hot, and the saliva secreted in great
 abundance.  In many instances diarrhoea occurs;  and in  female
 infants, a slight mucous or leucorrhceal discharge from the vulva,
 is not uncommon.   The infant evidently experiences  an  unplea-
 sant tickling sensation in the gums,  as may be inferred from the
 eagerness with which it bites upon  hard  substances, and the  evi-
 dent gratification it derives from having its gums  firmly pressed
 and rubbed with  the point of a finger.  The sharp margin of the
 gums gradually expands and  becomes  flatter, and, in difficult
 cases,   inflamed  and swollen, as the teeth  approach the  sur*
 faCe.  The infant  manifests an irritable and fretful  temper; slight
 exciting causes are apt to  give rise to febrile irritation, and one
 or both cheeks are often flushed, more especially towards evening
 and after a full meal.   When asleep, the child frequently starts
 as from sudden fright, and the expression of the countenance un-
 dergoes repeated changes.
   The  general and local disturbances accompanying dentition,
 are, however, often of so slight a character, as to require no atten-
 tion, or to escape notice altogether.   This is most apt to  be the
 case in  children whose constitutional  habit is healthy, and who
 have  been nourished  with mild and appropriate food,  and in
 whom  the advance of the teeth through the gums  is attended
 with a free secretion of saliva, and moderate loosness or diarrhoea.
 These evacuations are, in general, decidedly salutary. The free
discharge of saliva has a direct tendency  to relieve the irritable
and congested capillaries  of the gums and mouth, and to derive
the blood  from the brain, and moderate its  irritative condition.
 The diarrhoea  may prove beneficial, by "determining the circu- 
•
128                     OF DENTITION.
lation from the head  to  the intestines, and  particularly by  its
effects in lessening the quantity of blood in the system, and dimin-
ishing the strong action of the heart and arteries."
  Even the most favorable instances, however, are attended with
an increased susceptibility to the injurious influence  of  irritating
or exciting causes; and hence all diseases, whatever maybe their
cause or origin, are  apt to assume a more violent character du-
ring dentition than at other periods.  There can be  no  doubt
that many complaints, which at other periods would have  termi-
nated favorably, often acquire a fatal violence from that irritable
and irritative condition of the system, which  attends difficult den-
tition.   From this circumstance, as well as from  the direct ten-
dency of dentition to originate violent affections, the period during
which this process is going on, is  justly regarded  as one  of the
most perilous stages of life.  It has been computed  that one tenth,
at least, of all the  deaths which occur during childhood, may be
fairly ascribed to dentition; and it does not  appear to me that
this is an exaggerated estimate.
  When the gums become inflamed, swollen, and painful, and the
secretion of saliva  scanty, with torpor of the  bowels, the  whole
organization, generally, sympathizes strongly with the local affec-
tion, and the nervous system especially is liable to great and dan-
gerous  irritation.   Indeed, when from the influence of previous
morbific causes, the system has become  feeble,  and unnaturally
irritable, the most alarming consequences sometimes result from
the irritation of the advancing teeth, before any signs of irritation
and inflammation  are discoverable in the gums.
   Among the various circumstances which are apt to render den-
tition difficult and dangerous in its  consequences,  a  deranged or
dyspeptic state  of the digestive  organs, from errors in diet, is
probably the most common and pernicious in its tendency.  Chil-
dren who are nursed  exclusively at  the breast,  are, in general,
much less apt to suffer inconvenience or disease,  from  dentition,
than those who are either  wholly, or in part, nourished  with,arti-
ficial food. When the digestive organs are habitually disordered,
from the use of inappropriate articles of food, the risk  of serious
consequences from dentition is always very  considerable.  The
general system, usually, becomes enfeebled  and morbidly irritable, 
                         OF DENTITION,                    129
 by a continued course of improper nourishment;  and in this con-
 dition the local irritation of the advancing teeth is not only pecu-
 liarly apt to give rise to general irritative affections,  but by its
 reaction on the stomach and bowels, adds also greatly to the dis-
 ordered state of these organs, and  ultimately, often procVaces vio-
 lent and highly dangerous affections.   In robust and healthy
 children, the use of stimulating articles of nourishment and drink
 is  calculated to do much injury, in this respect, independent of
 its tendency to derange the digestive  organs,  by increasing the
 phlogistic condition of the system,  and promoting the occurrence
 of febrile and inflammatory affections, from the local irritation in
 the gums. A close and contaminated atmosphere, more especially
 when aided  by high temperature, has  a decided tendency to
 increase the  difficulty and morbid  consequences of  dentition.—
 Children who reside in populous cities, or who are much confined
 to close  and ill-ventilated  apartments, are much  more liable to
 unpleasant consequences from teething, than those who enjoy the
 pure and salubrious  air of the eountry.   The tendency of  inac-
 tivity, impure air, and high atmospheric temperature, to increase
 the irritability of the system, and predispose  it  to the  injurious
 -nfluence of irritating causes, is well known.   Dentition can sel-
 dom go on without giving rise to considerable disturbances in the
 system,  where  these causes are in full and  continued operation
 during the process.  The practice of keeping the heads of infants
 very warm, by  flannel  caps, or "sleeping on very soft pillows,
 which nearly envelop their heads," may do injury  during denti-
 tion, by favoring the determination of blood to the  head,  and
 thereby increasing the liability to inflammatory irritation of the
 brain, &c.
   The morbid, sympathetic effects  of difficult dentition  are  very
 various.  In robust, full, and otherwise healthy infants, the general
 disturbances, usually, consist in slight febrile irritation,particularly
 towards night, attended with a frequent,  quick and sharp pulse;
 a very warm and somewhat dry skin, more  or less costiveness^
 increased thirst, flushed cheeks, dull and heavy eyes, and a fretful
 and irritable temper.  Cases of this  kind are seldom accompanied
with a copious secretion of saliva; on  the contrary, the free  dis-
charge of this secretion, or the supervention of moderate diarrhoea,
                              S                12* 
130                   OF DENTITION.
almost invariably mitigates the general irritative condition,  to  A
very obvious degree.   In some instances, the brain sympathizes
so strongly with the local affection,  as  to give  rise to the usual
phenomena of incipient arachnitis or acute  dropsy of the head.
In cases attended with this state of cerebral  erethism, the child
generally  sleeps with  its eyes half open, a  circumscribed  flush
frequently appears on one or both cheeks, the  eyes  become
slightly injected, and  unusually sensible to  light; the eye-brows
are often contracted into a peculiar frown, accompanied with a
discontented and anxious expression of the countenance; and the
child is extremely fretful and irascible; when  asleep,  it often
starts suddenly and screams out violently, or moans as if in pain;
it is frequently observed to raise its hands and press them against
the forehead; vomiting is apt to occur  on rising  suddenly from a
recumbent to a sitting or  erect posture, or after  taking stimu-
lating articles of nourishment; and the bowels are almost invaria-
bly in  a disordered condition,  being either torpid,  or disturbed
with griping, colic-pains and diarrhoea.  The pulse is frequent,
quick,  and contracted—the temperature of the skin variable, the
hands  and feet being, at times, remarkably cool,  whilst the head
and  body  are preternaturally warm.   Cases  of this kind are
always attended with  considerable danger.   When neglected or
mismanaged, particularly in  relation to the diet, they are apt to
terminate in fatal oppression of the brain,  from effusion into its
cavities and upon its surface, or disorganization of its structure.
   In some instances of difficult dentition, attended with an irrita-
ted condition  of the brain, a  remarkable swelling  occurs on the
hands and feet, which as the case advances, generally becomes
associated with symptoms of alarming  and frequently fatal ner-
vous irritation.  This swelling  " has  a  considerable degree  of
roundness and elevation, and looks like that  sort  of tumor which
might rise, on the same parts, from a blow or contusion.  It seems
to arise suddenly, as it has, generally, this roundness and eleva-
tion, from the time of its  first attracting observation."   When
first observed it  has somewhat  of a mottled,  lived,  and purplish
color, resembling the chilled hand of a full and healthy child after
exposure to a cold and frosty atmosphere.  It feels  cold, at  least
it has no  inflammatory heat and does not appear to be morbidly 
                        OF DENTITION.                     131
sensible, or to give any pain to the child when handled.  It does
not pit on pressure, but rather gives the sensation of firmness and
resistance.  The  swellings are confined to the anconal aspect of
the metacarpus of the hands, and the rotular aspect of the meta-
tarsus of the feet, terminating abruptly at the carpus and tarsus.
The  duration of  these   tumors   is  very  various in different
cases.  Sometimes they disappear in three or four days—at others
they  continue for many weeks without either increase or diminu-
tion;  and occasionally they disappear and return again, at short
intervals for a number of weeks.  In some cases these  swellings
pass off without any unpleasant or alarming consequences.  More
frequently, however, symptoms of a much more formidable nature
ensue—consisting  of a peculiar spasmodic affection commencing
in the flexors of the hands and feet, and gradually extending itself
until  it terminates in general convulsions or tetanic spasms of the
whole body.  The reader is referred to the chapter "On Convul-
sions," in this  work, where this very singular affection is fully de-
scribed under  the  name of Pedo-carpal Convulsions of Infants.*
   The occurrence of convulsions from difficult  dentition is very
common.  When they come on suddenly, and are attended with
a full and flushed countenance, they are in general, much less dan-
gerous, than when they are preceded, for some time, with symp-
toms of active cerebral irritation, and accompanied, with a pale
and contracted aspect of  the countenance.  Cases of the former
kind generally depend  on simple  irritation and vascular tumes-
cence of the brain;  whereas the latter are often connected with
slow meningeal inflammation, effusion, or disorganization of some
portion of the  brain.   When  the  child  remains in a  state of
stupor or partial insensibility, with its eyes half  open and turned
up under the upper lids, for a considerable time after the parox-
ysm has subsided—and particularly when along with these symp-
toms, the respiration is very irregular with an  occasional deep
moaning  sigh, and a very slow  or extremely rapid and  small
pulse, the chances of a favorable termination are always extremely
slender.  When on  the other hand the infant, soon after emer-

  * Notes on the Swelling of the Tops of the Hands and Feet, &c. By Geo. Kellie, M. D.
Edinburg Medical and Surgical Jour. vol. 12. p. 449. 
132                    OF DENTITION,
ging from a fit, takes notice of surrounding objects, and  breathes
freely and regularly, without any particular manifestations of sen-
sorial torpor and  drowsiness, the probability of a favorable re-
sult, will be very considerable.  Nothing tends more strongly to
favor the occurrence of convulsions during dentition, than gastric
or intestinal irritation, from the use of improper articles  of nour-
ishment, or from overloading the stomach.   Children  who are
under the influence of difficult dentition, seldom enjoy a  perfectly
healthy state of the digestive organs, even under the  most careful
and  judicious dietetic  management.   The stomach  during  this
process, is  often morbidly irritable, and  hence errors in diet are
much more apt to produce injurious consequences  during this,
than at any other period of life.   So far  as my own  observations
enable  me to form an opinion, I am inclined to think  that, the
majority of instances of convulsions, usually ascribed to the sole ir-
ritation of dentition, are in fact excited by improper or immoderate
alimentary ingesta. When the diarrhoea which frequently accom-
panies dentition is suddenly arrested by astringents, opiates &c.
the liability to convulsions is  always much increased, more espe-
cially in robust and plethoric infants.   The  same thing occurs,
when from cold, or some other cause, the salivary secretion is
suddenly checked or suspended,  and the bowels remain costive.
In general, convulsions are much more  apt  to occur during the
eruption of the first grinders and  eye-teeth, than while  the inci-
sors are making their  way through  the  gums.   This may arise,
in part at least, from the circumstance that during the cutting of
the incisors, children are as yet usually nourished exclusively at the
breast;  whilst during the latter stage of dentition, when the grin-
ders and eye-teeth are advancing  through the  gums,  they are
generally weaned, and therefore  much more  exposed to gastro-
intestinal irritation from improper articles of food.
  Various eruptions on the  skin are among the most  common
morbid consequences of difficult dentition.  Of these, the crusta
lactea is by far the most disagreeable and unmanageable.  That
this  affection  is intimately associated with dentition, is  manifest
from the fact, that it very rarely makes its appearance previous to
the  commencement of dentition, and never, I believe, after the
process has been  completed.  Excoriations behind the  ears, and 
                       OF DENTITION.                     133
the various species of strophulus—particularly the strophulus con-
fertus or tooth rash, are, also, very common during this period of
infancy.  The Strophuli are almost invariably accompanied with
derangement of the digestive organs, and diarrhoea; but the two
former  affections, namely crusta lactea and excoriations  about
the ears are generally attended with a strong appetite and consi-
derable torpor of the bowels.
   Infants  are also liable to a  peculiar croupy affection during
dentition, which is evidently of a spasmodic character, and de-
pendent on cerebral irritation.  In some instances, the singular
swelling of the hands and feet mentioned above, becomes  associ-
ated with  occasional attacks of this  croupy affection, about the
time that the disease is assuming a distinctly spasmodic character.
This form of croup, which has been aptly called "cerebral croup,"
is most apt to come on at night or early in the morning.   It is
attended with extremely difficult respiration and the hoarse and
sonorous cough of ordinary croup.   The attack  is always very
sudden, and generally of short duration, seldom continuing beyond
fifteen or  twenty minutes, and often not above  a minute or two.
I attended  a child about three years ago, which, during the erup-
tion  of the eye teeth, was  seized with an  attack of spasmodic
croup, almost every night, for six or seven weeks.  As soon as the
eruption of the eye-teeth was completed, the croupy  affection
ceased to recur.  Under the head of croup, this singular malady
is more circumstantially described.  Slow and  difficult  dentition
is sometimes attended  with a  very  troublesome spasmodic  or
" nervous"  cough, which comes  on in sudden and violent  parox-
ysms, at irregular and sometimes remote intervals.  The breath-
ing during the fit, is oppressed and  suffocative; and the cough
usually continues until the contents of the stomach are thrown off.
At night the  child  is generally very restless, and the breathing
peculiarly  irregular, being now, extremely hurried and short, and
then, slow, interrupted, sighing and moaning.  In several remark-
able cases  of this kind—one of them in  my own family,—the uri-
nary secretion was unusually small, and frequently voided with evi-
dent pain.  The cough generally continues to  recur, until the teeth
are all cut.  I have never known it to continue after this process
was completed.  In many cases of spasmodic cough during diffi- 
 134                    OF DENTITION.
 cult dentition, the principal irritation is evidently located  in the
 stomach.   In these  instances, the  epigastrium is distended, the
stomach and  bowels  disordered  and the  alvine  evacuations
glairy and bilious.   The fits of coughing are most apt to occur a
short time after  taking nourishment,  and they usually continue
until the greater  part of what was received into the stomach, is
thrown  off by vomiting.  There is seldom much saliva secreted
in cases of this kind, and the tongue, generally, presents a bright
red color along the edges and  point, with a coat of thin white fur
along its middle.
   In some instances, of painful dentition, the urinary organs sym-
pathize  strongly  with the  local irritation  in the gums.  This is
most apt  to  be the  case, when the digestive  powers are weak,
and the primae viae  habitually charged with acidity.   The con-
nection  between  habitual acidity in the stomach and bowels, and
urinary  difficulties, has already been pointed out in  the chapter
on uDysuria."  The urine, in such  cases is often loaded with an
excess of  lithic acid, or its compounds, and, on this account fre-
quently  so  irritating, as to give rise to severe burning pain in the
neck of the bladder and urethra on being voided.  Occasionally,
however, an opposite condition of the urine obtains.  The urinary
deposits are  alkaline or earthy,  and the  urine is secreted in
great abundance, assuming the character of diabetes  insipidus.
This latter condition of the  urine, is  seldom attended  with any
manifestations of febrile irritation; the  hands and feet are usually
cool,  the system relaxed and languid, and the  countenance pale
and expressive of distress or suffering.
  Fever, as has already been stated, is perhaps the most common
sympathetic  affection of difficult dentition.  It seldom, however,
assumes a vehement  character, unless there are other sources of
febrile irritation present.   It is generally slow, irregular, change-
able, intermitting or  remitting—presenting the usual phenomena
of chronic irritative fever, from slight local affections.   The ma-
jority of instances of fever  that occur during dentition, are exci-
ted, or at least greatly promoted by other causes.  In that irrita-
ble state of the system, which  usually attends the progress of the
teeth through the gums, a  slight accession of  other sources  of
febrific irritation, will give  rise to fever. 
                         OF DENTITION.                    135
  Management.—Throughout the whole course of dentition partic-
ular care should be taken to avoid every source of undue excite-
ment or irritation.  Even the most  regular  and mild cases are
usually attended with an increased susceptibility to the influence
of exciting or irritating causes.  The stomach and bowels, especi-
ally, are apt to acquire an increased predisposition to the injurious
operation of causes of this kind.   Slight errors in diet are apt to
disorder the  digestive organs, during  this  period;  and the occur-
rence of gastro-intestinal irritation is  always peculiarly unfavora-
ble to  the easy progress of dentition.   In all instances, therefore,
the diet ought to be as simple and unirritating as possible.  If the
nurse furnishes a sufficient quantity of wholesome milk, nothing but
this congenial nourishment  ought to  be allowed  during the first
period of dentition—that is until all the incisors at least, are pro-
truded.  Weaning should never be effected during the active pro-
gress  of dentition.  In  general  the  most favorable  period for
weaning, is soon after  all the incisors have  made their appear-
ance.  Should it become necessary to resort  to the use of artifi-
cial nourishment, in addition to that  obtained  at  the  breast, no-
thing can be more appropriate than  the simple mixture of milk
and water mentioned in the chapter " On the Nourishment of In-
fants."   All  solid  articles of food ought to be rigidly avoided—
more especially during the primary stage of dentition.  After all
the incisors have made their appearance, the child may occasion-
ally take small portions of oatmeal  gruel, crackers  grated  and
dissolved in warm milk and water, barley water, and  liquid  pre-
parations of  arrow root, tapioca, or  sago, provided the general
and local irritation be not considerable.   Moderation  as to quan-
tity also, is an important requisite to the proper dietetic manage-
ment of infants during  dentition.   A full  diet may do harm by
increasing the general plethora and febrile tendency  of the sys-
tem, or by oppressing the digestive organs and giving rise  to a
disordered state of the stomach and bowels.  The great objects
to be  kept in view,  while  dentition is  going on, is to  guard
against every thing which may have a tendency to render the
child feeble  and morbidly irritable, or increase the fulness  and
inflammatory diathesis of the system.
  Regular exercise by gestation in the open air, has an excellent 
136                    OF DENTITION.
prophylactic  tendency during dentition.   When the  weather is
sufficiently mild  and dry, the  infant, if free from fever, ought to
be daily exercised  in  the fresh and open  air, by carrying, or
riding it in a  carriage.  Inactivity and confinement to an impure
and  stagnant atmosphere are decidedly  unfavorable to the easy
and undisturbed  progress of dentition.  Children who enjoy suita-
ble exercise, in the salubrious air of the  country, almost always,
pass  through  this period, with less inconvenience and danger than
those who are confined to the  contaminated  atmosphere of popu-
lous  cities.  It is  to  be observed, however, that exercise  is not
recommended in cases attended with distinct fever, or with a de-
cided tendency to  secondary inflammations.   It is to be regarded
as a  preventive measure—as a means for  avoiding the  occurrence
of morbid  irritability, and irritation, rather than for removing
them when once developed.  With this view, much benefit may
unquestionably be derived from it.  When aided by the influence
of a  salubrious air, it  tends, in no small degree, to fortify the ge-
neral powers of the system, and to prevent that feeble and irri-
table condition,  which is so  apt to occur during difficult denti-
tion, and so favorable to the  occurrence of alarming  irritative
affections.
   Care should also be taken to avoid, as much as possible, every
thing that may cause a preternatural determination of blood to the
brain.   The head  ought to be kept cool.  During warm weather,
no caps should be worn;  and  at night, or when sleeping, the head
should be suffered  to remain  uncovered.   A very soft and large
pillow of feathers, so as to cause it to lap round the infant's head,
is particularly improper.   The head must  also be carefully se-
cured from the direct rays of  the sun when  the child  is carried
out into the open air.   A light  straw hat, is decidedly the best
covering  for infants  during  the  warm seasons.  During cold
weather  caps, made of very thin materials  may be worn within
doors; and when the child is taken out,its head should be further
protected against the  cold, by a thin cloth cap, while the feet are
kept as warm as possible by thick flannel stockings and shoes.
   Costiveness must be obviated by enemata, and the occasional
administration of a mild purgative.  Much care is required, how-
ever, lest, in  the anxiety to remedy this state  of the bowels, a 
                        OF DENTITION.                     137
more serious one be not substituted, by harsh and repeated pur-
gations.   I  am certain that I have seen much harm done in this
way.  At no period of life, perhaps, are strong purges, so apt to
give rise to intestinal irritation, as during the active progress of
dentition. Habitual costiveness during dentition, is very generally
attended with a deficient secretion of bile.   The stools frequently
present a whitish or clay-colored appearance and the urine is usu-
ally loaded  with bilious matter.  In cases of this  kind, a small
portion of calomel should be ^ given every third or fourth evening
and a moderate dose of castor oil  or magnesia on  the  following
morning.   From  one  to two  grains of calomel, will in general.
suffice for this purpose. During the intermediate periods purga-
tive enemata ought to be administered, so as to procure at least
two free evacuations every twenty-four hours.   Small doses of
cpsom salts dissolved in some bland  and slightly  mucilaginous
fluid forms  an excellent laxative  in cases  attended with febrile
irritation.   In the employment of calomel during dentition great
care should be taken, that it be not carried to the extent of in-
flaming the gums, or producing a general mercurial  action on the
system.  I have witnessed several highly distressing instances of
extensive ulceration and sloughing of the gums  and cheeks, in
consequence of the incautious employment of calomel, while the
system was under the  influence of dentition.
  If moderate diarrhoea occurs, it ought not  to be checked or ar-
rested, unless the child be in a very feeble condition  from previous
sickness. But even in this case, it should always be subdued in a
gradual and gentle manner.  Its  tendency,  as has  already been
stated, is in  general, decidedly favorable, both by moderating the
general febrile disposition of the system, and by counteracting the
preternatural flow of blood to the head.  When suddenly arrested
by opiates or astringents, the local  and general disturbances sel-
dom fail to acquire a  more severe and dangerous character.  Con-
vulsions, fever, and inflammatory  affections  of the  brain,  are
among the evil consequences which  are  apt to result from  the
injudicious interference with  the diarrhoeal  affection.  In many
instances, however, the diarrhoea assumes so violent a character,
-- to exhaust and disorder the system to a very dangerous extent.
In cases of this kind, remedial  assistance is indispensable.  When-
                              T             13 
 138                    OF DENTITION.
 ever the system is obviously debilitated and relaxed by this affec-
 tion, measures should be adopted to moderate its violence.  Unless
 the necessity of  prompt and energetic measures be decidedly in-
 dicated, the excessive action of the bowels ought  to be moderated
 in a gradual manner; and when the complaint can be reduced to
 a mild state, no attempt should be made to arrest its course wholly.
 Small doses of ipecacuanna, in combination with  prepared chalk
 and minute portions  of calomel, have, in general, succeeded bet-
 ter, in my hands,  in cases of this kind, than any other remedy.  A
 powder composed of a fourth of a  grain of ipecacuanna, one sixth
 of a grain of calomel, and  four or  five  grains of  prepared chark,
 should  be  given  every three or four hours until the diarrhoea is
 sufficiently moderated.   By  continuing  the exhibition of two or
 three doses daily,vthe complaint may generally be kept in a suffi-
 ciently moderate  state, until the advancing teeth are protruded.
 I have rarely known a violent case of diarrhoea wholly arrested
 during the active progress of dentition, without an obvious increase
 of the general and local irritation.  In  cases of decidedly  difficult
 dentition, attended with an irritated state of the nervous and vas-
 cular  systems, it  is  generally extremely difficult to manage the
 diarrhoea without either suffering mischief from the exhausting
 effects of the bowel complaint, or aggravating the  general and lo-
 cal irritative affections by giving it too  great and  sudden a check.
 A striking example of the correctness of this observation occurred
 to me not more than ten days ago.  The infant  was cutting the
first molares, with  considerable difficulty,  though nothing of a
dangerous character  occurred except a diarrhoea, which in a short
time became extremely violent and prostrating.   I  prescribed the
 above powders of ipecac, chalk and calomel, which had the effect
of moderating the  complaint considerably, though not to a sufficient
 extent.   As this remedy did not seem  to do any further good, I
advised a decoction  of the  root of  geranium maculatum in milk.
 This was given, and the bowel complaint was soon entirely arrest-
 ed.  In about ten hours after the complaint was thus stopped, a
violent  paroxysm  of  convulsions occurred, which terminated in a
 torpid or comatose condition; and although an active purgative and
 repeated enemata were  administered,  a second fit of convulsions
 ensued and terminated the life of the little sufferer. 
                       OF DENTITION.                    139
   The  child's mouth ought to be washed out with fresh water
every morning.  This is always very grateful, and tends to mod-
erate the uncomfortable heat and irritation of the mouth.  The
practice of putting some hard substance into the child's hands, to
press and rub its gums with, is proper, and  should never be neg-
lected.   A piece of smooth coral, ivory, orris root, or firm-grained
wood may be used for this purpose.   The  substance ought to be
smooth  or polished, and of such a size and shape as to enable the
child to hold it firmly with the hand, and prevent its slipping back
into the fauces or throat.   An  ivory ring,  about an inch  and a
quarter in diameter, is an excellent contrivance for this purpose.
The ring may be suspended round the child's neck, so as to be al-
ways within its reach.  This practice has been  condemned by
some writers, on account of its  supposed tendency to harden the
gums, just as the soles of the feet and palms of the hands are indu-
rated by much walking and manual labor.  This apprehension is,
however, entirely unfounded.   The tendency of compression and
friction  is rather to promote the absorption of the gums, than  to
consolidate and render them more resisting to the advancing teeth.
Indeed  the instinctive  and  apparently  irresistible  propensity
which all children manifest  to press and  rub their gums  firmly,
upon every thing they lay hold of; and the very obvious relief and
gratification which they derive from it, may be regarded as  a suffi-
cient warranty that the practice is not only  harmless, but decided-
ly Jbeneficial  and  desirable.   Friction  and pressure  manifestly
moderate the painful sensations of the gums;  and  they may do
good, also, by promoting the free secretion  of saliva, and thereby
diminishing the heat and irritation of the mouth.
   From time to time, the  gums should, in  all cases, be carefully
inspected; and when found  to be in an inflamed and swollen con-
dition, they ought to be promptly and freely divided with  a lan-
cet, even though no unpleasant consequences be produced by the
local irritation.  When the gums are in this condition, a slight,
additional exciting cause,  will  be apt to give rise to dangerous
affections.   An error in diet, an accidental derangement  of the
digestive organs, or a slight cold, may bring on an attack of con-
vulsions, of fever, or of profuse and exhausting vomiting and purg-
ing. By a timely division of the inflamed and swollen portion of the 
140                    OF DENTITION.
gums,  the  liability to consequences of this kind, will be much
diminished.   During the actual presence of these and other affec-
tions depending on difficult dentition, a division of the gums should,
on no account, be neglected, if they are  manifestly distended, or in
a state of inflammatory irritation.   The diseases of dentition ap-
pear to depend, mainly, on the distention of the membrane inves-
ting the crown  of the teeth, and pressure upon the pulp, nerves
and vessels at the bottom of the socket, in consequence of the re-
sistance which  the advancing teeth experience, from  the tension
and firmness of superincumbent gums.   By dividing the gums, this
pressure  and distension is moderated, and if no other exciting
cause be present, speedy and important relief will  frequently en-
sue.   Little or  no advantage, however, can be expected from this
operation, so long as the  edge of the  gums is  sharp  and  wholly
free from inflammation.   It is not  necessary, indeed, that there
should be distinct swelling and inflammation present, to render
this measure proper  or useful.  If  the part over  the advancing
teeth is expanded, or thickened and  tense, relief may be expected
from the operation, although no decided marks of inflammation be
present—in other words, if the teeth have approached near the
surface, and unpleasant or alarming sympathetic affections occur,
it will be proper to divide the gums freely.  "Under every cir-
cumstance, of indisposition arising  from dentition,  the lancing of
the gums ought never to be omitted.  As soon as the gum is lanced,
and the membrane is divided, the tooth  obtains an increased room,
the pressure  is  immediately  taken off from the socket, and the
cause of the irritation is removed" (Fox).
  In reply  to the objections  that  have been urged  against the
propriety and usefulness of this  operation, I offer the following
remarks from the writer just quoted.   "It is very surprising, that
notwithstanding the manifest advantage, which attends  the lancing
of the gums,  in cases  of painful dentition, there are persons who
entertain strange prejudices against  this safe and important source
of relief.  But the uniform experience  of its good effects, and no
instance of its doing harm ever having occurred, should produce
an unanimous consent for adopting it.   Some persons object to the
operation, on account of  the  pain  which it will occasion to the
child, not considering that the inflammation produced by  the re- 
                        OF DENTITION.                    141
 sistance of the gum to the tooth, is far more acute, than dividing
 the gum with a sharp instrument.  Others suppose that the form-
 ation of the teeth is injured, and that they are more liable to de-
 cay; but neither of these circumstances can occur; for at the time
 the tooth  is about to pass through,  the enamel is completely form-
 ed, and no injury can be done to the formation of the fang, which
 is always  continued for some time after the appearance of the
 crown."
   " When it is necessary to lance the gums sometime before the
 teeth are quite ready  to appear; they unite, and in this case the
 cicatrix has been said  to impede the progress of the tooth, present-
 ing a greater resistance than the gums, in their natural state; but
 it is now certainly known that a newly formed part, or cicatrix,
 always gives way sooner to the process of absorption than the sur-
 rounding parts,  and hence the passage of the tooth is facilitated.
 The hemorrhage which is occasioned by the operation, is scarcely
 ever considerable, but is always beneficial:  the vessels become un-
 loaded, and the inflammation is always soon diminished."
   Under an idea that the cicatrix  may impede the protrusion of
 the tooth, some advise that the division of the gums should be made
 at the side near the edge, rather than directly over the crown of
 the advancing teeth.   This, however, is not only unnecessary, but
 unfavorable to success.  The incision should be made in the direc-
 tion of the gums, and immediately over the crown of the teeth.
 A single incision will be sufficient for the incisors; but when the
 molares are near protruding, and the gum is swollen and tense, a
 crucial  incision  may be advantageous.  Mere scarification can
 afford  but  little  advantage.  The gums must be freely divided,
 down to the teeth.  The  principal difficulty arises from the dis-
 tension of the firm membrane stretched over the teeth; and unless
 this be divided along with the gums, the operation will fail to pro-
 cure the full benefit which it is capable of affording.
   When convulsions occur during dentition, the  gums should be
 immediately divided if they  exhibit  any signs of inflammation
 or distension from the advancing teeth.  Some writers recommend
 this operation in all  instances of  convulsions, while the process
 of teething is going on,  whether  marks of irritation or distension
of the gum be present or not.   "The advantages of this operation 
 142                    OF DENTITION.
are so great," says Underwood, "that whenever convulsions take
place about the usual period of dentition, recourse ought always
to be had to it, though by an examination of the gums there be no
certain  evidence of the convulsions being owing to such a cause.
At any rate the operation can  do no harm,  even  at any  period;
and should the  shooting of teeth be only an  aggravation of the
true cause of the disease, lancing the gums  must be attended
with  advantage."  I am, however, convinced  from experience,
that cutting down through the gums, at so early a period, is always
entirely  useless;  and I have known  very troublesome and even
alarming  hemorrhage to occur from  a deep  incision, while the
teeth were yet far from  protruding, and the  gum wholly free from
the enlargement or distention  which  accompanies the advanced
stage of dentition.  It is not necessary, however, that there should
be obvious inflammation and swelling present, to render this  ope-
ration proper, or  likely to afford benefit.  Whenever, from the
fulness of the gum, it appears that the tooth is near the surface, a
free incision should undoubtedly be made, if convulsions or other
alarming  affections supervene.  For a full  account of the mode
of managing convulsions from  dentition, the reader is  referred to
the chapter "On Convulsions."
  Should  the child become affected with cutaneous diseases, while
under the influence of dentition, the utmost caution ought to be
observed, in the employment of external remedial applications.
This is particularly important,  in relation to discharging sores be-
hind the ears, and scabby eruptions about the head.   The appli-
cation of  astringent, drying, or repelling substances, may lead to
the most violent and dangerous consequences.   Indeed these affec-
tions, like the copious secretion of saliva, may have a favorable
effect, by  deriving the irritation and preternatural flow of blood,
from the brain and other internal organs.  If the external affection
be suppressed, the sympathetic irritation will not be subdued, but
only transferred to some other  part of the system.  If it falls on
the brain, as it often does, convulsions, or meningitis (dropsy of the
brain) may be the result; if on the lungs,  severe  pneumonic or
cynancheal affections  maybe the consequence; and, if the stom-
ach and bowels receive the introverted  irritation, rapid and un-
manageable diarrhoea or cholera, will probably ensue.  This is no 
                         OF DENTITION*                     143
 imaginary view of the evil consequences that may result from an
 improper meddling with eruptive affections of a scabby  or humid
 character,  about  the head,  during dentition.   I  have witnessed
 some very striking examples of this kind, in the course of my prac-
 tice.  An instance occurred  to me about eight months ago.  Dur-
 ing the active progress of dentition, a scabby and discharging
 eruption occurred on the cheeks, forehead, and behind the ears.
 I directed simple means, merely with the view of moderating the
 irritation and keeping the parts clean, and urged  the impropriety
 of applying any thing calculated to dry up  or remove the disease.
 The mother nevertheless, could not content herself with-seeing
 the infant's face in so disagreeable a state, and, of her own accord,
 used astringent washes and other means, to remove  the  affection.
 In about a week after these applications were used, I was again
 called to prescribe for the child.   The eruption  was now almost
 entirely removed;  the  little patient was feverish and extremely
 restless and  fretful.  Suitable remedies were resorted to, but in
 apposition to all my efforts, the disease rapidly increased, and ter-
 minated in fatal coma, paralysis, and convulsions.   See  the chap-
 ters on "Crustea Lactea" and on "Sore Ears," for further directions
 on this subject,
   The application  of blisters behind the  ears, or on the back of
 the neck, is often of essential service in the  diseases that arise
 from difficult dentition.  When symptoms  of cerebral  irritation
 supervene—such as  great  fretfulness, flushing of the cheeks,  a
 warm and  dry skin, starting  and restlessness during sleep, and un-
 usual sensibility of the eyes to the light, the timely application of
 blisters behind the ears, or on  the back of the neck, may prevent
 the development of inflammation in the brain  or its meninges, or
 obviate an attack of dangerous diarrhoea, convulsions, &c. &c. In
 violent and obstinate diarrhoea, from dentition, I have  often de-
 rived unequivocal advantage from this practice. Whatever is cal-
 culated to diminish cerebral irritation, or to  lessen the determina-
 tion of blood to the brain, may be usefully applied, in the sympa-
 thetic diseases of dentition; for, with the exception of eruptive af-
 fections, they are almost always dependent on, or at least connect-
ed with and  aggravated by,  cerebral irritation.  In the sudden
convulsive affections,  which  are so apt to occur during dentition, 
144                     OF DENTITION.
immersing the feet and legs in warm water,  and applying a cloth
soaked with cold water to the head, is, in general, more certain
and prompt in procuring relief than any other remedy we possess.
The simultaneous application of cold to the  head and warmth to
the feet, has a powerful tendency to diminish sanguineous conges-
tion  and inordinate excitement in the brain.   These two  applica-
tions should always go together when the brain is in an irritated
and congested condition.  The  propriety of keeping the bowels
in a  loose  state during dentition, has  already been mentioned.
When violent affections supervene, or when  there are indications
of the approach of  serious sympathetic disorders from dentition,
and  diarrhoea does not attend,  great benefit may frequently be
obtained, from active purgatives.  By  stimulating the bowels in
this way, and directing the circulation and excitement upon them?
the brain will be relieved, and  the diseases depending on its irri-
tated condition either prevented or mitigated.
   When the gums become ulcerated, before  the teeth are protru-
ded, they should be  lanced, and touched occasionally with a solu-
tion of sulphate of copper, or of the nitrate of silver.  Four grains
of either of these articles, dissolved in an ounce of water, and ap-
plied with a dossil of lint, forms an excellent application in cases
of this kind.   A decoction of the root of coptis trifoliata, (golden
thread), has frequently done much good in my hands, in ulcerated
gums. 
DIABETES OF INFANTS.                 145
                   CHAPTER XI.

                OF THE DIABETES OF INFANTS.

  Diabetes is, probably, a much  more frequent disease during
infancy than is generally supposed.  Since it was first noticed by
More ton, in his Phthisiologia, it has received but little attention,
from writers on the diseases of children.  Mr. Venables, however,
in his recent work on diabetes,  has contributed some interesting
and^yaluable information on the diabetic affections of children; and
it is from this source, principally, that the following observations
are drawn.
  Infantile diabetes seldom  occurs after the second year of age.
Dr. Dewees states that "all the children he has seen affected with
it, were under  fifteen months old."  It does not, however, seem
apt to come on  during lactation; for, according to the observations
of Mr. Venables, its appearance  previous to weaning is extremely
uncommon.
  In the commencement of the disease,  the child loses its usual
playful and active disposition, and, although no obvious malady
be discernible,  it soon becomes dull, languid and fretful, with an
uneasy and anxious expression of the countenance.   In a short
time, its flesh begins to waste; and as the  emaciation gradually in-
creases, the skin becomes dry, harsh, and so flabby, that "it seems,
at length to hang loosely about the body/' During the early stage
of the disease, "the bowels are  regular, and little or no deviation
from the natural and healthy appearance of the alvine discharges
is to be noticed." The tongue, too, exhibits a natural appearance,
in the beginning,  but  in the advanced  stage  of  the  disease, it
always becomes more or less conspicuously covered with a coat of
white  fur,  or  thick  transparent  mucus.  After the disease has
made  considerable progress, the bowels  begin to act irregularly,
and the alvine discharges acquire an unnatural, and,  generally,
bilious appearance.   The skin  becomes uniformly dry and very 
146                 DIABETES OF INFANTS.
warm;  and emaciation  goes on with increasing rapidity.  The
pulse is at first  somewhat accelerated,  becoming  small,  quick,
hard and wiry, as the disease advances in its course.   The abdo-
men, gradually becomes  more and more distended,  and tense,—a
symptom which in connection with the progressive  emaciation,
"frequently leads to the supposition of mesenteric disease."  In the
advanced stage of  the  complaint, the brain generally becomes
more or less affected.  "Headach, vertigo,  and temporary delir-
ium occasionally attend, and when a fatal termination takes place,
the patient usually dies comatose and sometimes apoplectic."'   A
considerable degree of fever,  generally prevails during the latter
periods of the disease; and in cases of long continuance, anasarca,
and  even general dropsy have been known to occur.  "The most
remarkable occurrence,  however, although  it frequently escapes
observation, is the inordinate discharge of urine. This discharge
increases.in quantity so  gradually, that it is  not usually noticed.
By the time it has become more remarkable, great thirst prevails,
and hence it is neglected  or unnoticed, because parents and friends
conceive an excessive discharge of urine and an  excessive con-
sumption of fluid as naturally associated."  The qualities of the
urine vary in different cases.  In some instances the urine is per-
fectly  limpid, without any sedimentous  matter, or  deposit;  in
others "it is milky, or like a mixture of chalk and water." Occa-
sionally the urine is transparent, and  "of a pale straw color;" and
Mr.  Venables saw a case in which it was of a green  color.   It
appears, frequently, to contain a considerable portion of coagula-
ble serum; and when the proportion  of  the coagulable matter is
great, and the urinary discharge  very copious, "the emaciation
is always rapid and extensive."*  Mr. Venables does not mention
the occurrence of a saccharine condition of the urine, in infantile
diabetes.   In the case related by Moreton, the urine was very per-
ceptibly sweet: I have  myself witnessed three very distinctly
formed cases of infantile  diabetes, in all  of which, the urine,
though extremely copious, was perfectly insipid.
   There is reason to believe, as is observed by Mr. Venables, that

  * A Practical Treatise on Diabetes; with Observations on the tabes diurctica,or Urinary
Consumption, especially as it occurs in Children, &c. By R. Venables, M. B. &c. p. 5-16 
                    DIABETES OF INFANTS.                 147
many cases that have been regarded as instances of dropsy in the
head, marasmus, and mesenteric disease, were in reality cases of
diabetes.   I am the more persuaded of the correctness of this ob-
servation from the error which I committed myself, in this respect,
in the first case  of this kind I witnessed.   The child appeared to
me to be laboring under mesenteric  disease, and after having
treated the case as such, for three or four weeks, the mother casu-
ally observed, that the little patient passed a great deal of urine.
I now directed my attention to this circumstance, and soon satisfied
myself that the quantity of urine discharged was truly excessive.
In the course of twenty-four hours, three pints of urine were col-
lected, and much  was discharged at night, as well as during the
day, that could  not be collected.   The urine was clear, and of a
pale straw color, but I neglected to ascertain whether it contained
any coagulable  matter.  The infant was but fifteen months old.
Infantile diabetes is, indeed, very rarely recognized, in its incipi-
ent, or early stage; "and when it has made considerable progress,
it simulates so many other diseases, that the real character of the
complaint is not developed till its history is either wholly  lost, or
so confounded with symptomatic or secondary affections,  that it
can no longer be unravelled."   Too little attention is, in general,
paid to the urinary secretion, in the diseases of children.  In mal-
adies of a protracted character, attended with emaciation, and a
general irritative condition, the urine ought always to be carefully
inspected.   There can be no doubt that serious derangements  of
this secretion often occur in children, without being suspected.  I
was quite recently called into consultation, in the case of  a child
about eighteen months old.  It appeared languid, and was much
emaciated; its bowels were irregular, the stools  slimy and mixed
with green bile, and it was evidently harassed with constant thirst.
In this case the urinary secretion, on proper inquiry, was found to
be preternaturally copious.  It could not indeed be regarded as an
instance of diabetes; but the quantity of the discharge was such,
that it could not fail  to contribute materially to the exhaustion
and emaciation of the little patient, and manifestly required par-
ticular attention in the remedial management of the  case.  The
urine in this patient contained a considerable portion of sedimen-
tous matter of the phosphatic variety.  From what I have obser- 
148                 DIABETES OF INFANTS.
ved in relation to the urinary affections of children, I am induced
to think, that infantile diabetes is frequently attended with an ex-
cess of the earthy phosphates in the urine.  This state of the uri-
nary secretion,  says Prout, "frequently occurs in  sickly children,
in whom the functions of the digestive organs are deranged;" and
it is well known, that where this condition of  the urine prevails,
"symptoms very analogous to those of diabetes are apt to super-
vene."  From the connection which is known to exist between an
excess of urea in the urine,  and the symptoms usually denominated
diabetes  insipidus, in adults, there can be no doubt that a similar
state of the urine is sometimes present in the diabetic affections of
infants.   This disease may, moreover, be associated with an albu-
minous  or coagulable condition of the urine, since this state of the
secretion is sometimes  attended with profuse diuresis, at a more
advanced age.   These circumstances are worthy of notice;  and
when properly  estimated, may aid considerably  in  instituting a
proper  course  of treatment; for it cannot be doubted that these
different conditions of the urine require corresponding modifica-
tions of remedial management.

   Treatment. In the treatment of this  affection, much  will  of
course  depend, on the character of the urinary secretion.  In
cases attended  with a saccharine state of the urine, recourse must
be had to those means which experience has ascertained to be
most beneficial in diabetis mellitus,   Instead of the usual farina-
ceous or milk diet, the nourishment should consist principally of
the lighter and more digestible kinds of animal food.  If febrile
symptoms attend, it may be  beneficial to apply  six or seven
leeches to the lumbar  regions.  Mild aperients, and the occasional
use of  the warm bath, will be proper.   Opiates are  often deci-
dedly beneficial in this affection—more especially in the form of
Dover's powder.  To a child between one and two years old, a
grain of this anodyne mixture,  with, or without three  or four
 grains  of powdered uva ursi  may  be given two or three times
daily.  In the diabetes of adults, Mr. Latham used opium and the
 carbonate of iron with decided advantage; Mr.  Venable speaks
very favorably of the  effects of phosphate of iron,  in this com-
 plaint.   Magnesia, given in small and repeated doses, has proved 
                     DIABETES OF INFANTS.                 149
 serviceable; and Richter mentions a case of diabetes, in a child,
 which yielded to a course of emetics.
   It  is but very rarely, however, that the urine is sweet in the
 diabetic affections  of infants.  In the  ordinary forms of the dis-
 ease, mild laxatives, in  alternation with Dover's powders and uva
 ursi,  will often procure relief.  Small doses of the bi-carbonate
 of soda, in union with  two or three grains of the carbonate of
 iron,  may be resorted to with a  prospect  of advantage.  When
 the urine deposits a whitish sediment, hyoscyamus, or  lauda-
 num, with uva ursi will sometimes  prove beneficial.   In one of
 the cases referred to above, I prescribed a solution of the extract
 of hyoscyamus, in the proportion  of  one scruple to  an ounce of
 water, in conjunction with infusion of uva  ursi, with manifest ad-
 vantage.   Five drops of the narcotic solution, with a teaspoonful
 of  the uva ursi tea, were given three times daily.   Dr. Dewees
 cured several cases by "keeping the  bowels freely open, and put-
 ting a quantity of the spirits of turpentine upon the clothes of the
 chidren, so  as  to keep  them in a terebinthinate atmosphere.  I
 have seen much good done in a case of this disease, by a turpen-
 tine plaster laid over the region of the  kidneys.  When the dis-
 ease has advanced so far as to be attended with much intestinal
 disorder, and a tumid and  tense  state  of the abdomen, consider-
 able benefit would probably be derived from the internal use of
 small  doses of balsam copaiva, or spirits  of turpentine, with an
 occasional  mercurial  laxative.   In this aggravated state of the
 disease the diet should consist of the  simplest and blandest farina-
 ceous preparations.  Where the digestive powers are good, and there
 are no manifestations of intestinal  irritation, beaf tea or weak
 chicken broth, mixed  with the usual farinaceous nourishment, or
 a portion of milk, will generally prove most beneficial. The gums
 should always be attended  to, and if they are swollen and the
 teeth  are near protruding, they ought to be divided or scarified
 with a lancet.  When the child is fretful, and evidently harassed
 by painful sensations about the head  and gums, small blisters laid
behind the ears will sometimes procure  much relief, and aid ma-
terially in removing the diabetic affection.  In every variety of
this disease, it is of much consequence  to  promote  the action of
the cutaneous emunctories.  The warm bath, and frictions  with
                                          14 
150           OF THE ERYSIPELAS OF INFANTS.
dry flannel, repeated at proper  intervals, are very suitable reme-
dies for this purpose.
CHAPTER XII.
               OF THE ERYSIPELAS OF INFANTS.

  Infants are liable to a peculiar erysipelatous inflammation, of
a very obstinate and dangerous character.  It usually comes on
within a few days after birth, and occurs but very rarely after the
fourth  or  fifth week.  Dr. Dewees mentions  two  cases, which
came on at a much later period—one after the third and the
other after the  sixth month.  I have witnessed but one instance
of its occurrence after the eighth week, and not more than three
after the third week.  Richter states  that children have  been
born with  blotches of erysipelatous inflammation so far advanced
as to exhibit vesications  and spots of gangrene.  I saw a fatal
case, about ten years ago, which had come on within five or six
hours after birth.
  The inflammation generally commences, on the lower parts of
the body, particularly about the nates, groins,  and  umbilicus, in
the form of a small red blotch, and gradually spreads, irregularly,
over the abdomen and along the back and inside of the thighs.
The inflamed part is firm and extremely painful to the  touch,
presenting  a  swollen, dark-red or purplish surface  of irregular
shape.  Generally, towards  the end  of the first day, large but
thinly scattered vesicles appear, having inflamed livid bases, tend-
ing sometimes rapidly to sphacelus.   In some instances vesication
does not occur  until the  disease has continued for several days;
in others, the vesicles make their  appearance, soon after the in-
flammation is  established.  Occasionally no  vesication occurs
throughout the whole course of the inflammation. When the in-
flamed part vesicates  early, the disease  generally  spreads very 
                OF THE ERYSIPELAS  OF INFANTS.           151
 rapidly and soon acquires  an extremely  dangerous condition.
 The tendency to gangrene in infantile erysipelas is, indeed always
 very considerable, except, perhaps, in those mild cases, which re-
 main free from blistering—a- form of the disease, however, which
 is unfortunately, not often met with.  The disposition to sphacelus
 is particularly great, when the  inflammation is seated on the ab-
 domen; when it affects the extremities, it is more apt to termin-
 ate in ulcerative suppuration of the  subcutaneous cellular  struc-
 ture, but this occurs also,  frequently, on  the body, particularly
 about the  nates and loins.  The pus  formed is generally very
 thin, of a greyish color, and frequently somewhat acrid and sani-
 ous.  It travels along through  the  meshes of the cellular mem-
 brane, under the skin and between  the muscles, until this tissue
 (the cellular) is  almost entirely destroyed in the affected part.
 Small portions of the skin, finally slough off, and give exit to the
 confined matter, which is, usually, mixed with flocculi and shreds
 of sphacellated  cellular  membrane.  Symptoms of  intestinal
 and hepatic disorder,  are seldom  wholly  absent  in  infantile
 erysipelas.
   The discharges from the  bowels are usually frequent, griping
 and of a grass-greep color.   In some cases, however, there is con-
stipation, with colicky affections, and  frequent ejections of acid
 fluid  from  the  stomach.   The whole  surface of the body, often
 presents a slightly jaundiced appearance, and the urine  is usually
manifestly imbued with bilious matter.
   Great diversity occurs, in relation  to the violence and duration
of this malady. In some instances, the inflammation passes off, in
two  or three daj's, without any very unfavorable  consequences.
Cases of this mild character are however very rare. Sometimes, al-
 though the inflammation is not  extensive,  it successively invades
almost every part of the body.   In  its erratic passage over the
surface of the body, it sometimes travels on by a continuous exten-
sion in one direction while the parts  previously affected are freed
from  the  inflammation.  Occasionally, however, it leaps  as it
were, from  one  place to another, disappearing from the part it
occupies, and  reappearing speedily  in  some other and  perhaps
remote part of the body.   In some instances the skin  surrounding
the inflammation, to the distance of nearly an inch from its mar- 
 152            OF THE ERYSIPELAS OF INFANTS.
 gin, is peculiarly firm to the touch, and cannot be pinched up or
 moved over the subjacent parts, as maybe done in a health v slate
 of the body.
   Meckel, in examining the body of an infant that  had died of
 this disease, found the umbilical vein, together with  a considera-
 ble extent of the surrounding peritoneum strongly inflamed; and
 this fact, led him to believe, that inflammation of this vein, occa-
 sioned by rude management, in cutting and  tying the umbilical
 cord, constituted the primary cause of this malady.   Osiander
 gives  an account of a fatal case, which commenced in the geni-
,tals of a male infant soon after birth.   The inflammation spread
 itself rapidly over the whole  abdomen.  On dissection, he found
 the umbilical vein full of thick yellow pus, from the navel to the
 vena-porta, with other traces of inflammation  in the adjacent
 parts.  Inflammation  of  the umbilical  vein, might, perhaps, ac-
 count for the occurrence of erysipelas in the parts surrounding the
 navel; but even where the  umbilical vein is found to be inflamed
 on  post  mortem examination, the correctness of this pathology
 must be very doubtful, since it is  impossible to say, whether, the
 inflammation of the vein was primary, or the result simply of an
 extension of the erysipelas, from the  external surface along the
 vein.  Nevertheless, the fact, that in a very large majority of in-
 stances,  the  disease cQmes  on either before or soon after the ex-
 tremity of the cord is cast  from the navel, leaving this part in a
 tender and  irritable condition, together with the circumstance
 that the erysipelas almost always makes its first appearance on the
 lower parts of the body, seems to favor the idea, that this danger-
 ous affection is frequently in  some way or other connected with
 umbilical irritation.  In some peculiar states of the system, the
 slightest  injury of the skin  is apt to give rise to erysipelatous in-
 flammation in adults;  and it is not improbable, that a similar pre-
 disposition, in co-operation with  irritation about the umbilicus
 may be  a common source of infantile erysipelas.   It may be said
 that as this disease sometimes occurs long after all irritation about
 the umbilicus has passed off, this mode of accounting for its occur-
 rence cannot be correct.   It certainly cannot be presumed, that
 all, or perhaps even a majority of the cases are produced in this
 way;  yet it is by no means  improbable, that in some instances, at 
               OF THE ERYSIPELAS OF INFANTS.            153
least, irritation about the navel, in conjunction with a peculiarly
depraved or irritable condition of the system, constitutes  the ex-
citing cause of the disease.   It is worthy of notice, that in those
cases which occur at an advanced period, after the navel has ac-
quired a perfectly firm and  healthy condition, the inflammation
almost always occurs on  the extremities or  about the head and
shoulders.   Irritation and functional disorder  of the liver and ali-
mentary canal has also been  referred to as the primary source of
infantile erysipelas.  There  can be no doubt, that derangement
of the biliary and  digestive  functions frequently co-operate with
other causes in the production of this malady. Symptoms  of func-
tional  disorder of the  liver, and  digestive  organs,  are  seldom
wholly absent in this affection, and require especial attention in
prescribing for its cure.  We can, however, hardly ascribe much
influence to  hepatic  and intestinal  derangements  as exciting
causes of this  affection, since functional disorders of the digestive
and biliary organs are very common throughout the whole period of
infancy,  whilst infantile erysipelas occurs but seldom, and is, in a
great  measure, confined  to  the first  three or  four weeks after
birth.   This  latter  circumstance justifies  the presumption, that
there is something peculiar to this early stage of infancy, to which
the principal agency in the causation of this malady must belong.
The disordered state of the biliary and intestinal functions, is per-
haps, in  many instances, an effect rather than  a cause of the mor-
bid condition  upon which the erysipelatous affection depends.  Its
unfavorable influence on the disease, however, cannot be doubted,
and a principal part of the remedial treatment consists in restor-
ing the healthy action of the liver and alimentary canal.  Breath-
ing an impure atmosphere, has a very decided tendency  to favor
the occurrence of this disease.   It is on this account, that the dis-
ease is so much more apt to occur in lying-in, and foundling hos-
pitals, than in private  habitations.   Dr. Underwood says, that  he
rarely met with  infantile erysipelas  in  private  practice, but re-
peatedly in lying-in Institutions.  It has, indeed, often prevailed
endemically, in crowded and ill-ventilated  hospitals.
   It does not  appear that infantile erysipelas  differs in any essen-
tial  point from the erysipelas  of adults.  It occurs under all the
modifications,  as  to its phenomena  and progress, that it is known
                             X             14* 
154            OF THE ERYSIPELAS OF INFANTS.
to assume at  a more advanced age.  In  some instances, though
very rarely, it continues for fourteen or fifteen days, with but little
vesication, and no cellular suppuration.  In general, however, vesi-
cles appear very early; and in such cases, the tendency to suppu-
ration and gangrene, is usually very great.  In the majority of in-
stances, the cellular tissue about the inflamed part becomes much
infiltrated with serum.   When deep incisions ^re made into the
affected parts after death, a large portion of thin fluid issues, and
the skin exhibits a firmer and thicker structure than in the natural
state.  In the commencement,  the febrile reaction is sometimes
of a high inflammatory grade; but when vesication begins, it often
speedily assumes a low and typhoid character, and in many cases,
the tendency to sinking is manifest as soon as  the inflammation is
established.   The approach  of suppuration  is always  attended
with an obvious failure of the vital energies; and the instances of
recovery after this has taken place are extremely uncommon.

   Treatment.—Though, in  the  commencement, often associated
with an  active grade  of febrile excitement,  infantile erysipelas
rarely admits of very decisive antiphlogistic  measures.  An ob-
vious tendency to prostration  often occurs almost as soon as the
inflammation makes its appearance, the  fever being of a typhoid
character from the onset  of the malady.  Occasionally, however,
the fever  is of a high or synochal grade, and in cases of this kind
direct depletion may be resorted to with  much propriety.  I have
met with  but one instance in which it appeared to me, decidedly
proper to abstract blood.   The infant was unusually robust; and
the pulse and general appearance of the little patient, indicated
a high degree of febrile reaction.  The inflammation occupied
the upper part of the right thigh, groin and illiac region, and had
not vesicated at the end of the third day.  After the use of some
purgatives, I  directed four leeches to be applied  around the in-
flamed part,  and the  result was  unquivocally  beneficial.  If
leeches can be procured, they ought always to be used, in  pref-
erence to venesection, at this  early stage  of  infancy.   It  is
proper to observe, that, when leeching is resorted  to in this affec-
tion, the  leeches should always  be applied  to the  sound  skin,
surrounding  the inflammation.   Leeching is most apt to prove 
               OF THE ERYSIPELAS OF INFANTS.            155
beneficial, where the erysipelatous inflammation is of an erythe-
matous character-—that is, superficial, with but little swelling and
infiltration of the subjacent cellular tissue. "A trifling abstraction
of blood, will be  sufficient to effect every useful purpose, where
this measure is  indicated."  It will very seldom be proper, to ap-
ply more than four leeches of the ordinary size; and, in the ma-
jority of such instances, two or three leeches will be quite suffi-
cient.   When  the inflammation spreads rapidly, and is attended
with  vesication, the leeches should  be applied to some remote
part,  as a general depletory measure, if  the condition of the sys-
tem indicates the propriety of bleeding.  I am not  disposed, how-
ever,  to urge the employment of bleeding, whether general  or
topical, in infantile  erysipelas, for although it  may doubtless  do
good  in some cases, yet I am entirely satisfied, that an active an-
tiphlogistic treatment is  attended with much risk of irremediable
injury, even in  cases that seem to warrant its adoption.
  The  milder  antiphlogistic means--more  especially laxatives,
and  diaphoretics are  almost always decidedly indicated  in the
early stage of the disease.   From the constant and intimate sym
pathy which subsists between the skin, and the mucous membrane
of the alimentary canal, there can be no doubt, that intestinal ir-
ritation from acrid foeculent matter  and  morbid secretions must
tend to  support and aggravate the external  erysipelatous inflam-
mation.  One of the first remedial measures, therefore, should  be
to evacuate  the bowels freely.  For  this  purpose, a grain of calo-
mel, followed some hours  after, by  a teaspoonful  of castor oil,
generally answers very  well.  If difficulty occurs in procuring
free  evacuations, laxative enemata should be  resorted to in con-
junction with the use  of internal purgatives.   After the bowels
have  in the  first place  been well evacuated,  they should  be
kept in  a loose  state, by  small doses  of calomel in combination
with rhubarb, or with  ipecacuanna.   A mixture of calomel, ipe-
cacuanna, and bi-carbonate of soda forms a most excellent  aperi-
ent in this disease.  A powder consisting of a fourth of a grain  of
calomel, the same quantity of ipecacuanna and one grain of the bi-
carbonate of soda, rubbed up with a few grains of white sugar,
should be given every  three or four hours, or at longer  intervals,
so as to procure three  or four alvine discharges in the course  of 
156            OF THE ERYSIPELAS OF INFANTS.
about twenty-four hours.  The ipecacuanna promotes the laxa»
tive operation of the calomel, and tends to keep up the action of
the cutaneous exhalents, whilst the soda counteracts the forma-
tion of acid in the primae viae.  Mr. Lawrence, recommends the
use of a mixture of James's powder and calomel, and there can
be no doubt of its being very well adapted for this purpose. One
sixth of a grain of the former with a fourth of a grain of the latter
may be given three or four times daily.   Calomel can seldom be
omitted with  propriety in the treatment of the early stage of in-
fantile erysipelas.  The  liver is, probably, always more or less
disordered in this  disease; and calomel is doubtless often benefi-
cial, by its operation on  the  biliary organs, independent of its
aperient effects on the bowels.  The stools,  generally, present
a grass-green appearance; and I have seen an instance in which
they were black and viscid, like meconial matter, for several days.
It is  necessary, however, to proceed with caution in the use of
calomel at this early period of infancy.  When given very freely,
it is apt, at this tender age, to give rise to dangerous irritation of
the stomach and intestinal canal.   Throughout the whole course
of infantile erysipelas our principal aim  should be to restore the
regular action of  the liver, alimentary  canal  and of the skin.
Should the small doses of calomel and ipecacuanna fail  to keep
up the requisite action of the bowels, an occasional dose of castor
oil, or of magnesia, should be used;  and to promote the regular
action of the  cutaneous exhalents, warm or tepid bathing may be
resorted to with a prospect of advantage.  In the erysipelas of
adults, attended with symptoms of biliary derangement, Desault,
strongly recommends  the use  of emetics, and  from a case which
came under my notice, about eight years ago, in an infant nearly
four weeks old, I am inclined to think, that the occasional use of
emetic doses of ipecacuanna, would often prove serviceable in the
early stage of infantile erysipelas. In the child referred to, pretty
active vomiting was unintentionally excited by a dose of calomel
and ipecacuanna on the third day of the disease; and the erysipe-
latous  affection almost immediately assumed  a more favorable
appearance.  When the skin is very dry  and warm, some benefit
may be derived from the use of mild diaphoretics.  From fifteen 
               OF THE ERYSIPELAS OF INFANTS.            157
to thirty drops of the  following mixture* will usually answer
very well for this purpose.
  Where the tendency  to visication  and gangrene, is  obvious, or
where the attending fever is of a  low and typhoid character,
tonics  must  be  employed  at the  same time that the bowels are
kept in a  loose state by the aperients already  mentioned.   The
necessity of  resorting to the use of tonics, is  especially urgent,
when  the  inflammation is about terminating, or has already ter-
minated in suppuration  or gangrene. Experience has shown that
the sulphate of quinine is decidedly the most valuable tonic we pos-
sess in cases of this  kind.   To  an infant within the first month
the sixth of  a  grain of this article, may be given every two or
three  hours.   It may be  advantageously united with a suitable
portion of the extract of hyoscyamus—a combination which I have
found  peculiarly  beneficial  in the  typhoid erysipelas of adults.
The tenth of a grain of this extract may be given to an infant, two
or three times daily.  Should  diarrhoea  occur  after suppuration
has taken place, it must be immediately checked. For this purpose
minute doses of Dover's powder, in union with prepared chalk,
is probably the most suitable remedy.   The fourth of a grain of
Dover's powder, with two or  three grains of chalk, mixed with
mucilage of gum arabic, should be given every three or four hours
until the bowels are  quiescent.   One "or two drops of laudanum,
also, given at proper intervals, will often suffice for this purpose.
To support the system, where there is a tendency to prostration,
some writers speak very favorably of the employment of the car-
bonate of ammonia.   I have used it in conjunction with quinine,
with manifest advantage in a case of infantile erysipelas. Ammo-
nia may in  general be given earlier, without risk of increasing the
inflammation, in cases attended with considerable fever, than qui-
nine.  When the circumstances are such as to render it doubtful
whether stimuli and tonics should be employed or not, the carbon-
ate of ammonia ought  to be selected, if it be concluded to resort
to such remedies. The diaphoretic tendency of this article, renders
it more eligible in diseases of a typhoid character, attended with
local inflammation, than, perhaps,  any other article of  the kind

  * R. Spirit Minderiri gi. Vin. Antimonii, gtt. xxv.  Syrup  Lemonis 3"ii.  M. ft. 
158            OF THE ERYSIPELAS OF INFANTS.
we possess—more especially where  the propriety of such reme-
dies may be doubtful.   One of my medical  friends has informed
that, he had in  two instances of infantile er)sipelas derived un-
questionable benefit from the internal use of spirits of  turpentine.
He gave  three  drops  of it, every four hours, to an  infant about
six weeks old.   In the erysipelas of adults I have in several in-
stances, prescribed the turpentine, and, as it appeared  to  me,
with a very good effect.
   Various opinions have been expressed with regard to the propri-
ety or usefulness of attempting to subdue or restrain the erysipela-
tous inflammation by local applications. Bateman asserts, that ex-
ternal applications, "are in general  unnecessary if not prejudicial,"
in the  early stages of the disease; and the same remark is made
by some other writers of respectability.   The weight of good tes-
timony, however, is decidedly in favor of external applications to
the affected part;  and  my own experience has convinced me, that
very important advantages may often be obtained from a judicious
management of this class of remedies.  Cooling applications, such
as cold water—lead-water and other soothing means, were  for-
merly much resorted to in the  treatment of erysipelas. Experience
however, has not sustained the character of such applications as in
general suitable remedies in this variety of inflammation.  There
evidently exists a  close analogy between erysipelatous inflamma-
tion, and the inflammation caused by a scald or burn.   In both,
the inflamed capillaries appear to  be in a debilitated and pas-
sively distended condition, requiring applications of an  exciting
character.  In  the erysipelas of adults, blisters often  produce
highly beneficial effects, and by proper management  they  may
doubtless be used with equal advantage in the erysipelas of in-
fants.   Dr.  Dewees, seems to place considerable reliance  on them
in the  treatment of this affection.   I have not resorted to blister-
ing in  more than one case, and in this instance it had a very good
effect.   The blister should be large enough to extend beyond the
inflamed part, so as to vesicate a portion of the surrounding sound
skin.   After the plaster is removed, the blisters should be opened,
and the vesicated surface dressed  in the usual way, or what I
should prefer, with weak mercurial ointment.   When the erysip-
elas is seated on one of the extremities, a blister round the limb, 
               OF THE ERYSIPELAS OF INFANTS.            159
on the sound skin, will frequently arrest its progress in that direc-
tion.  Blistering is most apt to prove useful, when the febrile ex-
citement is moderate, the  tongue  moist, and the skin somewhat
hot and tense.
  Of late  years, the mercurial ointment has been a good  deal
employed in erysipelatous inflammation; and Dr. Dewees speaks
favorably of its use in the present variety of  the  disease.   In
one instance under my care, its effects were obviously beneficial;
but in the last case I witnessed, it did no good whatever.  It should
be applied,  by spreading it on pieces  of linen,  and laying them
over  the  whole of the inflamed part.  Dr. Dewees directs, it
should be applied only to the inflamed margin,  and  a portion of
the surrounding sound skin, after the vesicles  have  opened,  and
the part has become covered with a crust of concrete serum.  A
weak solution of corrosive sublimate,  also, has been frequently
employed in this country, as a local application  in erysipelas, and
I have,  in some instances, known it to produce  very  excellent
effects.   Three grains  of the  sublimate  to an ounce of water,
forms a solution of proper strength  for this purpose.  Pieces of
linen moistened with it, should be laid over  the inflamed  part,
and renewed from time to  time, as they become dry,  until the
inflammation  assumes  a  pale  color.  The external use of the
nitrate of silver, also, will  occasionally procure decided benefit in
this disease.   I have more frequently succeeded in subduing ery-
sipelatous inflammation with this application, than with any other
remedy I have employed.  The solution, in the  proportion of five
or six grains to an ounce of water, should be  applied over the
whole inflamed surface, by strips of linen, in  the way just men-
tioned.  In employing this remedy, the persons  about the patient
should be informed,  that  it will  give a black color to the skin;
for without  such premonition, the discoloration of the skin will be
apt to be mistaken for mortification, and excite great apprehen-
sion and anxiety of mind.
  A lotion composed of sugar of lead and sub-carbonate of ammo-
nia—one drachm of each, and a pint of water,  is highly recom-
mended by Dr. Peart, as  a local application in this disease.—
Some of the English surgeons speak very favorably of  an  oint- 
1G0            OF THE ERYSIPELAS OF INFANTS.
ment formed of equal parts of ceratum calaminae, ceratum sapo-
nis, and unguentum plumbi acetatis.
   The practice of making  free incisions through the  inflamed
skin, and subjacent cellular and adipose structures,  has recently
been greatly extolled as  a  means for  arresting the progress of
phlegmonous  erysipelas.  Mr. Lawrence declares,  that " these
incisions are followed, very quickly, and sometimes almost instan-
taneously,  by relief, and a cessation of the pain and tension; and
a corresponding subsidence  of the  inflammation almost always
ensues.  In  twenty-four  hours, the redness has usually disap-
peared, and the skin itself is found wrinkled from the diminution
of the general inflammatory tension.  The immediate relief, al-
though very desirable  to the patient, is, however, of less conse-
quence than the decided  influence of the  practice in preventing
the further progress  of the disorder; and this important result has
never failed to occur within my experience, when  the  case has
been a proper one for the practice, and the state  of the patient
has admitted of its being  fairly tried."  The incisions ought to be
made in the early stages of the complaint, with a view rather of
preventing the  ultimate  consequences of the  inflammation, by
giving exit to the blood and extravasated serum, than of evacua-
ting  the puss and  sloughed  cellular membrane.  " It  is  when
the action  is beginning, has commenced, or is  at its acme; when
the heat is burning, the thirst  ardent, the tension great, the pulse
active, the pain acute, and the texture engorged with blood, that
incisions are most apt to  prove beneficial."  Mr. Lawrence re-
commends  one long incision, extending from one boundary to the
other of the inflamed part.   Mr. Hutchinson, on the contrary,
thinks it  better to make a number of smaller incisions—about an
inch  or an inch and a half  in length,  through the skin and
subjacent  cellular structure.  Mr. Lawrence  and  others have
restricted this practice to  phlegmonous erysipelas; but it appears
from the experience of Dr. Dill, that it may be extended with
advantage  to other modifications of this disease.
  I am not aware  that this practice has ever  been tried in the
erysipelas of infants.  It is not improbable, that it might be re-
sorted to in many cases of this kind, with  much advantage.  In-
fantile erysipelas often presents a well-marked phlegmonoug char- 
               OF THE ERYSIPELAS OF INFANTS.            16l
acter; and in such cases,  if the situation of the inflammation
were  favorable, I should be much disposed to try the effects of
the practice.
  When suppuration has taken place, an opening should be made
into the most depending part of the cavity, so as to give free exit
to the purulent fluid and sloughed cellular structure. If the mat-
ter is suffered to remain confined, it will make  its way between
the muscles and tendons, destroying the cellular tissue as it pro-
ceeds, until the patient  sinks  under  the general irritation and
exhaustion which it produces.  When a portion of the inflamed
part becomes gangrenous, and offensive ulcers occur, the char-
coal poultice is perhaps the best application.   A poultice  made
of crumbs of bread, and  a strong decoction  of oak-bark, with a
small portion of yest, forms a valuable application,  where the
ulcers assume a phagedenic character.
Y
15 
162
SKINBOUND.
CHAPTER  XIII.
INDURATION OF THE CELLULAR MEMBRANE AND SKIN. SKINBOUND.

  In private practice, this remarkable and very dangerous mal-
ady is but seldom  met with; but in lying-in and foundling hos-
pitals, it is of very frequent occurrence.  In the Hospice des Enfans
Trouves, at Paris, 645 cases took place from 1808 to 1811;* and
in 1826, there were 240 instances  of it in the same institution.!
On an average, one out of every twenty-five infants admitted into
this hospital, become affected with this disease; and of those who
are affected, not above twelve out  of a hundred usually  recover.
In a vast majority of instances, the disease comes on within the
first nine or ten days after birth. Mr. Billard states, that "nearly
all the cases that occurred in 1826, in  the  abovenamed  institu-
tion, were in children of from one  to eight days  old,  and some
were affected  from birth."  Cases, nevertheless, sometimes occur
at a much more advanced period of infancy.  Mr. Andrews has
recorded a remarkable instance, which occurred in a child eigh-
teen months old; and I have seen a case in a child between the
sixth and seventh  month of age.
  In some respects, the disease is evidently closely allied to infan-
tile erysipelas; and in others, it often manifests an obvious affinity to
the convulsive  affections.  It usually  commences on  the lower
parts of the  body, particularly about the pubic region, and on the
inner aspect of the  thighs, and gradually spreads, becoming more
or less conspicuous  in different parts,  until, in violent  cases, the
whole surface  of the body  becomes affected.  The affected part
is firm  and  incompressible to the touch, resembling the hardness
and tension  which  occurs in phlegmasia dolens. The skin adheres
so firmly to the indurated cellular tissue, that it cannot be pinched

  * Casper. Characteristick der Franzoesischen Medicine, p. 505.  + Billard, Archives
Generates de Medicine,  Fev. 1827. 
                         SKINBOUND.                     163
up or moved even where it is  usually most loose.  In  some in-
stances, it presents a yellowish or  wax-like appearance, and  in
others, it is of a pale red or purple color.  Those parts that are
reddish or purple, are  generally considerably swollen; yet the
swelling does not pit, although firmly pressed on with the finger.
When the skin has a  pale  yellowish appearance, the  tumefac-
tion is,  in general, very slight; but the  firmness and tenseness of
the part is even greater than where there is lividness. The affected
parts of the skin, whether pale or purple, are  remarkably cold it
the  touch, and  the surface generally  is dry and harsh.   The
countenance is pale and contracted, and the little patient almost
constantly " makes a peculiar kind of moaning noise," and appears
to be unable to  make a full inspiration  and to cry out, from the
restrained action of the thorax.  Deglutition is  generally very
difficult, and sometimes wholly impossible.  In some cases, tetanic
spasms supervene, in the latter stage  of the disease;  the jaws
become locked,  and the head  and  trunk are sometimes rigidly
bent backwards. The pulse is usually small, irregular and rapid;
and  the  bowels  are almost always disordered—the discharges
being sometimes of a bright green, and others  of a whitish or clay-
colored appearance.  The  urine is generally freely  secreted,
although, in some instances, the reverse takes place.
  Mr. Billard asserts, that there are two distinct varieties  of this
disease.   He considers  one variety as depending  wholly  on the
infiltration of coagulable serum into the cellular structure. Cases
of this kind are  characterized by considerable tumefaction of the
affected parts, with a deep red or purplish color of the skin. The
other variety, attended with a wax-like appearance of the skin,
and  but very little  swelling, depends  upon  a hardening  of the
subcutaneous adipose substance without, and with but little  serous
infiltration into  the  cellular  structure.  The parts where the adi-
pose hardening,  and consequent tightness of the skin, are usually
most conspicuous, are the cheeks, the thighs,  the calves of the
legs, and the back.  On  dissection, in cases of this kind,  the
adipose substance  is found  as firm and condensed as suet, and
the skin contracted and firmly adherent to it.
  The variety of the disease which  arises  from serous infiltration,
is,according to Mr. Billard's observations, "nothing else than true 
164                      SKINBOUND.
oedema, altogether of the same nature with that which occurs in
adults, affected with disease of the heart, or great  blood-vessels."
The hardness of the  skin, he thinks, " is entirely owing to  iU
being much less loose in  early infancy than at  a maturer age,
and consequently yielding less readily to the pressure of the extras
vasated fluid."  In making incisions into the indurated part,  an
abundance of serous fluid flows from the cellular  structure; and
Mr.  Billard affirms, that when this  is done at an  early stage of
the disease, the skin soon loses all its hardness.
  Very little of a satisfactory  character has been brought to light
with regard to the exciting or remote cause of this formidable
complaint.  It has been  ascribed  to  the influence of cold, soon
after birth; but its endemic occurrence in certain hospitals, does
not  favor this opinion.  It is  evident from this fact, that foul or
deteriorated air must have a considerable  agency in the  produc-
tion of the  disease.  In private  practice, it is most  commonly
met  with among the poor, who live in crowded and filthy habita-
tions.  Children who are nourished with artificial food, appear to
be much more liable to the disease, than those who are nourished
at the breast.  In the Foundling Hospital in Paris, there are
always a number of fresh nurses; and it has been  observed, that
whenever there is a deficiency of wet nurses in the institution, and
the  children are chiefly or entirely confined  to  artificial nour-
ishment, the disease  is most  common.  These facts,  in  connec-
tion  with the circumstance, that  the  bowels are often much dis-
ordered, before the occurrence of the external affection, would
seem to  indicate that intestinal  irritation, in  co-operation with
that depraved and irritable state  of the system, which is apt to
arise from breathing a contaminated air, constitutes a principal
source of this malady.   The causes of this disease differ, proba-
bly,  very little from those which  give rise to infantile  erysipelas.
This affection is often attended with a condition of the skin very
analogous to erysipelas; and  we  frequently find erysipelatous
inflammation associated with  considerable  induration  of the sub-
cutaneous cellular  tissue, for  some  distance beyond the inflamed
margin.   It occurs sometimes in  the progress of other diseases—
particularly in protracted affections of the bowels, accompanied
with biliary disorder.  The  case  related by Mr. Andrew was 
                          SKINBOUND.                     165
 preceded by a feverish and restless state, accompanied with diarr-
 hoea.  The last case but  one which I witnessed, was preceded
 for upwards of two weeks with loose and griping stools, a  gen-
 eral irritated state of the system,  and an obstinately dry skin.
 Hardening of the cellular structure and skin is frequently accom-
 panied by  a jaundice.d appearance of the surface.   M. Billard
 states, that in the Parisian foundling institutions, " the most com-
 mon accompanying disease, is jaundice."
   On  post mortem examination, the cellular tissue  is generally
 found  thickened,  condensed, engorged  with serum,  and often
 of  a dense,  reddish,  and  granular appearance, " not unlike  a
 portion of hepatized lung." In many cases, the adipose substance
 is peculiarly consolidated,  with more or less infiltration into the
 cellular membrane.  The lymphatic glands are  frequently found
 indurated, and enlarged, more especially  those of the mesentery.
 Out of ninety cases examined by Mr. Billard, there were  twenty
 that presented a decidedly  morbid condition of the  liver; and
 fifty, in which there was inflammation of the alimentary canal.
 In all  the cases, there  was " a very remarkable general conges-
 tion.   The venous blood especially predominated in  the different
 tissues."  Mr. B. thinks that this congestion does not  depend on
 mechanical obstruction in any point of the circulation, but is due
 to " a  general superabundance of blood  in the system, or a kind
 of congenital plethora."   From  the remarkable and unconquer-
 able dryness of the skin, there  is evidently " some derangement
 of the  capillary circulation;" and this morbid  inactivity of the
 cutaneous exhalents, in conjunction with a general plethoric and
 irritative condition of the system, constitutes, perhaps,  the imme-
 diate cause  of cellular infiltration and tension of the skin.

  Treatment.—Although an  extremely dangerous affection, this
 singular malady is not so entirely  beyond the  control of reme-
 dial treatment as was formerly supposed.  Out of 645 cases which
 occurred in the Hospice des Enfans trouv&s, from 1808 to  1811,
 there were 78 cured; and the proportion of recoveries has of late
years been considerably greater.   Mr. Billard thinks that the
opinion respecting its fatality, has arisen, in a great degree, from
                                             15* 
166                      SKINBOUND.
the circumstance of its being very frequently associated with other
diseases of a dangerous character.
  The aqueous vapor  bath is decidedly the most valuable remedy
that has hitherto been recommended for the cure of this affection.
As  soon  as  the disease  makes its  appearance, the infant ought
to be subjected to  the  vapor bath; and this should be repeated
every three or four hours, until the skin becomes moist and soft,
and  the  tightness and hardness has disappeared.   The  heat of
the  vapor should not exceed 105c ; the most comfortable  and
salutary temperature  being from 98 to 100 °.   When the child
is taken out of the bath, it should be wrapped up in warm and dry
flannel, and laid in its bed. The simple application of warm flannel
immediately to the skin, and  frequently renewed, will sometimes
bring on a gentle perspiration, and reduce the local oedema.* If no
suitable apparatus for applying the vapor be at hand, the infant
should be laid in its bed, and hot bricks wrapped up in wet pieces
of flannel, placed a short distance from its body under the covers,
supported by hoops or some other contrivance,  so  as to  leave  a
free space for the accumulation  of the  vapor.  Richter speaks
very favorably of the effects of blisters in this complaint. When
early applied to the affected parts, they may remove  the sanguine-
ous engorgement of the sub-cutaneous structures, and arrest  the
progress of the induration. The only instance of recovery which
has  occurred  in  my  practice, was effected by the  vapor bath,
and  blistering.  The  induration commenced on the  anterior  sur-
face of the left thigh and groin.   An epispastic was applied over
the whole surface of the affected part, and suffered to lie  about
three hours, when it was substituted by a large emolient poultice.
The tumor and hardness of the part were obviously diminished
by  the blistering, and  they  did not extend beyond  the limits
which they occupied when the blister was applied.  As the liver
and  bowels  are  generally more or less disordered, minute doses
of calomel, in union with ipecacuanna, as recommended in infan-
tile erysipelas, may be  employed with occasional advantage.—
Some writers, indeed, look upon calomel as a remedy of indis-

  * In the foundling hospital at Florence, this disease is treated by the application of
external heat, made by keeping the infant wrapped up in warm flannel, in conjunction
with stimulating frictions.
                                                   / 
                         SKINBOUND.                     167
pensable importance; and there can be no doubt, that when the
disease  is attended with prominent disorder of the liver, its influ-
ence will often be highly salutary.  In those cases that are accom-
panied  by a jaundiced appearance of the skin, mercurials are
especially indicated, and can never with propriety be wholly ne-
glected.  It appears to me - not improbable, that free incisions
through the skin and subjacent; cellular tissue would prove bene-
ficial.   The  engorgement of the  subcutaneous capillary vessels
ought,  perhaps, be removed in this way, and  exit  given to a
portion of the infiltrated serum—effects which could hardly fail
doing good, in certain cases of this complaint.  The tepid or warm
bath, which has been much  recommended by some German wri-
ters, appears to be much less beneficial than dry warmth,  or the
vapor bath;  and it is  even  asserted, that warm bathing has fre-
quently proved injurious. 
168
OF CORYZA.
CHAPTER  XIV.
                OF THE CORYZA OF INFANTS.

  This disease was first described by Underwood, under  the
name of coryza maligna—an affection, which, he says,  " is  not
only far more severe, but  of a very different character," from the
complaint which passes under the name of the " snuffles."  Dr.
Denman, who, afterwards, published a more ample and circum-
stantial account of this malady, speaks of it as " a new and very
peculiar affection."  It appears to occur but very seldom; and it
is doubtful whether it  has ever been observed in this country.  I
have  met with one case, which appeared, in  many respects, to
accord with the descriptions  given of  this complaint  by Under-
wood and Denman; but it was, probably, nothing more than an
aggravated case of the common coryza from cold.  It was at first
supposed, that it never occurred in infants over a month old; but
Underwood  states, that he has seen  instances of it at  a  much
more  advanced age.
  The disease is characterised by a purulent discharge from  the
nose,  acquiring  in  some instances, a sanious character, attended
with  complete  stoppage  of the nostrils, and great difficulty of
breathing, especially during sleep.  The infant appears pale and
languid, and a singular purple streak encircles the margin of the
eyelids, which Mr. Denman was disposed to regard as  pathogno-
mic.  There  is usually " a general fulness  about the throat and
neck externally," which  comes  on soon after  the purulent dis-
charge from the nose commences.   After these symptoms have
continued for some days,  the tonsils and fauces present a tumified
and dark-red appearance, " with ash-colored specks upon them,"
terminating, in some cases, in extensive ulcerations.   As the dis-
ease advances, the infant declines rapidly in  strength; and the
breathing, often, becomes so difficult,  that an attendant "is  rr 
                         OF CORYZA.                      169
quired to watch the little patient, in order to open its mouth as
often as it may be requisite to prevent suffocation."  The disease
usually continues two or three weeks, and when it does not ter-
minate in death, is very apt to leave a state of chronic indisposi-
tion, attended with much disorder of the alimentary canal.
  This appears to be a very dangerous affection. Denman states
that of eight cases which he witnessed in the course  of about a
year, two,  only, recovered.   Dr. Underwood, however, observes
that the cause of its frequent fatality, when it was first noticed,
arose, rather from the true nature of the disease having been im-
perfectly understood, than from any positive difficulty in control-
ling its progress by remedial management.   The disease appears
to consist  in  a  peculiar inflammatory affection of the  mucous
membrane  of the nasal cavities, extending backwards to the fau-
ces and, in some instances, descending into the stomach and bowels,
giving rise to painful  and exhausting diarrhoea.  The  alvine
evacuations are frequently of a peculiar bluish or green color, par-
ticularly after the employment of repeated purges.  Mr. Hunter
and Mr.  Home examined  the  body of an infant that had died of
this malady; but the  only morbid appearance they discovered
was a dark-red and highly injected state of the lining membrane
of the nose.

  Treatment.—According to the experience of Dr. Denman, the
employment of laxatives so  as to keep the bowels freely open,
and remove from them the acrid matter which descends into the
stomach  from  the  nose, constitutes " the grand means of cure."
If this be not constantly attended to, painful and rapidly wasting
diarrhoea almost invariably arises from the irritating fluid that is
continually passing into the  stomach.  The free use of mucil-
aginous  drinks,  also, will be  beneficial in this respect.   Harsh
purgatives, however, are highly improper, as they could scarcely
fail to produce almost as much irritation as the irritating cause
which they are intended to remove.  " One or more teaspoonfuls
of castor oil should be given, every day, so as to procure three or
four motions daily.   It is remarkable, that even weak infants en-
dure purging better under this complaint than under any other,
unless it  be the fever  caused  by painful dentition" (Underwood). 
170                      OF CORYZA.
The employment of mild clysters also will be proper,—more espe-
cially, when the lower part of the rectum becomes considerably
irritated. Dr. Denman states, that he often derived much benefit
from small doses of opium, or the syrup of white poppies.  There
can be no doubt of the  great propriety of using narcotics in this
affection, for it is  evidently attended  with an irritative state of
the general system, without  a very active inflammatory condi-
tion, or a tendency to  high febrile excitement.  Dover's powders,
given in small doses, would,  probably,  have a very beneficial
effect, by allaying  the morbid irritability and disposing to general
diaphoresis.  When the disease continues for several weeks, and
" the infant  becomes pallid and very feeble, a recourse to the de-
coction  of 6ak bark has  at once removed  the snuffling, and given
vigor to the infant  in the course of a few days." The sulphate of
quinine would, doubtless, be  a useful remedy in  cases attended
with much debility and exhaustion.   The disease sometimes as-
sumes a chronic character, and continues four or five weeks, and
occasionally for several months. Such cases are apt to be attended
with occasional attacks  of spasmodic respiration," as if the infant
were dying."  This  symptom, " as well  as  the snuffling  often
recurs some time  after the child seemed  to be cured:"  and even
the purulent discharge  from the nose, may recur from time to
time, after the disease appears to have been wholly subdued.  In
cases of this kind, Underwood, besides purging, recommends fo-
menting applications  to the bridge of the nose; and "afterwards
to  apply some aromatic liniment."   The application of a few
leeches to the root of the  nose would, perhaps, be  beneficial in
the early as well as in this advanced stage of the disease. There
appears to be  some risk  in using vesicatories in this affection;
for Underwood observes, that " the  parts  on which blisters had
been laid in the beginning, and which had been apparently heal-
ed, often sphacelated  towards the conclusion." 
APHTHAE OF INFANTS.
171
                  CHAPTER XV.


            OF THE APHTHAE OF INFANTS.  THRUSH.

  This is one of  the  most common  diseases of infancy.  It i9
characterised by a peculiar eruption of minute pustules, giving
rise to a whitish incrustation of the tongue, and lining membrane
of the mouth and  fauces.  The aphthae sometimes  make their
appearance  without any previous symptoms of general indisposi-
tion, or disorder of the alimentary canal.  Much more frequently,
however, symptoms of disorder of the stomach and bowels, associ-
ated with manifest  languor and drowsiness, precede the occurrence
of the aphthous, affection.  The aphthae usually appear, first, on
the inner surface of the angle of the lips, and about the tip of the
tongue, in the form of white specks, resembling small flakes of co-
agulated milk.  From these parts, the eruption spreads, more or
less rapidly, until,  in some instances, a continuous aphthous crust
is formed, over the whole surface of the tongue, mouth and fauces.
In many cases, however, the eruption is much less extensively dif-
fused, the aphthae occurring only on the tongue, and central parts
of the cheeks; and we occasionally  find them scattered in small
patches with intervening spaces, over the lining membrane of the
mouth and surface of the tongue.  In these mild cases the infant
seldom experiences any particular uneasiness or disturbance from
the local aphthous affection; but when  the eruption is extensive,
it rarely fails to, give rise to more or  less suffering and disorder in
the system.   In cases of this kind, there is, generally, much thirst,
restlessness, languor, acid and  flatulent eructations, loose, green,
and griping stools, drowsiness, pain, and difficulty of sucking,  and
a copious  flow of saliva and mucus from the mouth.   The skin is
usually dry and  harsh; and, in the severer instances of the disease,
a slight degree of  febrile irritation often occurs.   The stomach
and bowels  axe almost always prominently disordered in such 
    172                 aphthj: of infants.
    cases.  The infant is apt to vomit after taking any thing into its
    stomach, and the milk is generally thrown up, in the form of firm
    coagula.  Profuse watery diarrhoea frequently ensues, and the lit-
    tle patient is greatly harassed by  sour and  offensive eructations,
    griping and colic pains, and tenesmus from the extremely sensible
.•    and excoriated condition of the margin of the anus.  Under these
    symptoms emaciation and loss of strength go on rapidly; the
    child's countenance becomes pale, sunken, and expressive of much
    suffering and uneasiness.   The difficulty of swallowing increases,
    and at last  sometimes becomes altogether impossible.   The abdo-
    men is always sore to the touch, in cases of this violent character,
    and frequently much distended and tympanitic.  If the disease is
    not arrested, the infant, at length, dies in convulsions, or in a state
    of stupor and insensibility, resembling the last stage of hydroce-
    phalus, or from exhaustion.
       In mild forms of the disease, the aphthous eruption continues
    of a white  or yellowish  color throughout;  but in severe cases it
    soon acquires a dark brownish color, and instead of being soft and
    humid, as in the ordinary instances, it often becomes dry and harsh,
    as the disease advances.  It is generally believed, that the aphthae
    frequently extend from the mouth, throughout the whole tract of
    the alimentary canal.  Dr. Dewees is disposed to doubt whether
    such an extension of the eruption does ever occur.  He is inclined
    to believe that it never passes lower down than to the cardiac ex-
    tremity of the oesophagus.  In  examining the body of an infant
    that had died from aphthae, he found " the whole tract of the oeso-
    phagus  literally  blocked up with an aphthous incrustation to the
    valve of the cardia,  where it suddenly stopped.  Not a trace of
    aphthae was discovered below this place."  I have  myself had an
    opportunity of examining the body of an infant, that had died of
    this disease.  In this case, the aphthae were very distinct through
    out the whole course of the oesophagus.  The stomach and bow-
    els presented nothing that bore any resemblance to this eruption;
    but there were decided marks of inflammation in the mucous mem-
    brane of the small intestines, with a vast number of minute super-
    ficial  ulcerations,  and larger patches of  softening of  this  tissue,
    throughout the colon, and lower part of the rectum.   The mucous
    membrane  of the alimentary canal, doubtless,  always becomes 
                     APHTHJS OF INFANTS.                 173
more or less diseased  in the severer  forms of this malady.  It is
probable, however, that the minute pustules, which give rise to
the aphthous incrustation on the more dense mucous membrane
of the mouth and oesophagus, terminate speedily in superficial
abrasion, or ulceration, in the delicate mucous tissue of the stom-
ach and bowels.  In the case which I examined, these minute ul-
cerative points were very obvious in several portions of the large
intestines.   The  excoriation of the anus, which is generally re-
garded  as an  evidence  that  the aphthous affection has passed
throughout the whole extent of the alimentary canal, arises, per-
haps, solely from the  irritation produced by the acrid discharges
from the bowels.   Tenderness and excoriation  of the anus is by
no means an uncommon consequence of acrid diarrhoeal discharges.
  The duration of this affection is very various.  In slight cases,
the aphthae disappear in  a few days, without  any unpleasant con-
sequences.  In some  instances, the  aphthous eruption continues
for several weeks, without becoming very severe, or causing any
material deviations from  health.   Sometimes, the aphthous crust
falls off, and is soon succeeded by another one;  and these separa-
tions and renewals of the eruption, may occur three or four times,
in the course of the malady.  " The oftenerthe crust is renewed,
the worse  it becomes,  for each new eruption is usually thicker and
less white, than the preceding one."   When the  crust falls off, it
exposes a smooth, red and slightly excoriated surface.  The cav-
ity of the  mouth is always unnaturally hot, and  the affected parts
are,  in  general,  very sensible and painful when pressed on  or
touched.
  Infantile aphthae very  rarely occurs a second time in the same
infant—at least as an  idiopathic affection.  It may, indeed, recur
frequently, at every stage of life, as a symptomatic effect  of other
diseases—particularly in the advanced stages of protracted mala-
dies attended with irritation of the alimentary canal.   But it is ex-
tremely doubtful, whether these secondary or symptomatic affec-
tions are  identical in their character,  with  the usual aphthoe of
infancy.'
  Some writers affirm that trie-disease is very rarely, if ever, at-
tended with fever; whilst others declare that the occurrence of
febrile irritation in this complaint, is very common.   Hecker di-
                                           16 
174                 APHTHiE OF INFANTS.
vides the aphthae of infants into three varieties.   His second vari-
ety, which  he affirms is very common in Germany, is always at-
tended with decided febrile symptoms; and he thinks that the dis-
ease is closely allied in its nature,  to the  exanthematous  fevers.
It commences with manifestations of lassitude, restlessness, drow-
siness,  and  much thirst.  The child seizes the nipple eagerly, but
immediately  leaves it again, and cries, as if the effort of sucking
gave it much pain.   The cavity of the mouth is hot, dry, red, and
very sensible.  The child is apt to vomit; frequent  watery, green,
and painful alvine discharges occur, and the urine becomes scanty,
the pulse is accelerated, and the skin preternaturally warm and
dry; the voice becomes rough and slightly hoarse; and finally,
after these  symptoms have  run on for three or four days, the aph-
thous eruption  makes its appearance.  Dr. Hecker  asserts, that
when the disease occurs epidemically, it  almost always  assumes
this febrile character, assuming, in some  degree, the regular pro-
gress of an exanthematous  fever.   According to my own observa-
tions, the ordinary simple cases of the disease are invariably with-
out the slightest manifestations of fever.   When the eruption is
extensive, however, and there is much disorder of  the alimentary
canal, slight febrile symptoms are certainly often developed. I am
at present  attending an infant severely  affected  with this com-
plaint.  The aphthous  crust extends over the whole surface of the
tongue, mouth, and  fauces, and from the manifest  pain on swal-
lowing, probably passes down to a considerable distance  into the
oesophagus. This child is in a decidedly febrile condition; although
before the  aphthous eruption appeared, its general  health seemed
to be good.  The febrile symptoms that  occasionally attend the
ordinary forms of the  disease, depend,  probably,  chiefly on the
inflammatory irritation which is apt to  occur in  the alimentary
canal,  and  are wholly accidental.
  In hospitals, this disease  sometimes assumes a highly dangerous
character.   In the French  foundling institutions, it  is said to carry
off a great  many infants.   In these malignant cases, the aphthous
crust soon becomes thick and  of a dark  brown color.  When it
falls off, it leaves a number of yellowish-brown ulcers, of a corrod-
ing character.   The diarrhoeal discharges are green, and extreme-
ly acrid, and the#vital powers sink very rapidly.   Is the aphthae 
                     APHTHiE OF INFANTS.                  175
01  thrush  of infants  a  symptomatic  or  an  idiopathic affection?
The general opinion appears to be, that it is altogether symptom-
atic—occurring as an accidental consequence of gastro-intestinal
disorder.   Dr.  Dewees, expresses himself in a very ambiguous, or
rather contradictory manner, on this point.   In the beginning of
his chapter on this disease, he says, " that this affection is one of a
symptomatic kind—rarely, perhaps never,  idiopathic;"  yet in a
subsequent paragraph, he observes,  " the  opinion  so commonly
credited, of its being a  symptomatic  affection,  is very questiona-
ble;" and  then goes onto  give  a number  of " facts,"  which he
says have " lately" led  him  " to  question the sympathetic  origin
of aphthae."  Nevertheless,  the  very next paragraph commences
in these  words:  "This symptomatic  affection  is not confined to
early infancy."   The fact is, the arguments which led the Doctor
to doubt the correctness of his opinion, that the disease is purely
symptomatic, would have convinced him of its entire erroneous-
ness, if he had not viewed them through the  medium of a contrary
sentiment long  and thoroughly entertained.  It takes a powerful
battery of " facts " to knock down  an opinion that has become firm
by age.  For my own part, I am well satisfied that the disease,
as it occurs in early infancy, is of a peculiar and strictly idiopathic
character; although an aphthous affection of the mouth  may, and
often does, occur at every stage of life, as a symptomatic or sec-
ondary phenomenon of  other forms of disease, or morbid  condi-
tions of the digestive organs.  We see this often, in the  last stage
of phthisis  pulmonalis,  and  in nearly all protracted diseases of a
febrile and exhausting character, as they  approach a fatal termin-
ation.   It is, also, frequently observed in children, as an attendant
on other maladies; particularly such as are attended with disorder
and inflammatory irritation of the alimentary canal.
   If the  aphthae of infants were  a purely sympathetic  affection,
depending on disorder  or irritation of the alimentary canal, it
could of course never take place without the previous occurrence
of gastro-intestinal disorder.  Cases, however, do occur, in which
no obvious signs  of derangement of  the digestive  or  intestinal
functions  can be noticed.  Dr.  Dewees states that he has seen
two instances,  in which the alimentary canal  "was in  the most
perfect order; and I have, certainly, witnessed several cases which 
 176                 APHTHAE OF INFANTS.
 were entirely free from any manifestations of disorder of the stom-
 ach and bowels.   It may be presumed, too,  that were the disease
 symptomatic in its origin, derangement of  the  alimentary canal
 would be much more frequently associated  with aphtha^, than it
 is known to be.   At every period of life, from early infancy to ad-
 vanced age, disorder and irritation of the stomach and bowels oc-
 cur very  frequently,  and pass  through every grade of  violence,
 without giving rise to aphthae.  Mere  disorder or irritation of the
 alimentary canal, is very rarely productive  of aphthous  eruptions
 in the mouth, unless it be connected with a chronic form of febrile
 irritation, and general exhaustion.   In infantile aphthae, however,
 the child often appears to enjoy good health, up  to the time when
 the aphthae make  their appearance; and in mild instances, there
 is frequently no material indisposition  during  the continuance of
 the aphthous eruption.   This, I believe, never occurs in the aph-
 thous affections which take place at  a more advanced age. These
 cases are always, unequivocally, connected  with serious general
 maladies, and seldom occur, until  the  diseases of which  they are
 symptomatic phenomena, have acquired a highly dangerous, if not
 a necessarily fatal degree of violence.  The circumstance, how-
 ever, which seems most clearly to shew that infantile aphthae is a
 peculiar  idiopathic affection, is the fact,  that infants who have
 passed through the disease, very seldom become affected with it a
 second time, although the stomach and bowels may become re-
 peatedly disordered, and remain so, during the subsequent period
 of infancy and childhood.  We often see  infants affected with
 aphthae, previous to the third month, with very little disturbance
 in the alimentary canal; yet they will not become affected with
 it again,  although they  may afterwards be repeatedly and long
harassed  by disorder of the stomach and bowels.   The circum-
stance, too, that this affection is almost wholly  confined to the age
of infancy, would appear to indicate that there is an  essential pe-
culiarity in its character and mode of origin.  If it were  an acci-
dental sympathetic phenomena of gastro-intestinal irritation, with-
out any specific peculiarity in its nature, we should expect to meet
 with it at every period of life,  instead  of seeing its occurrence
 almost entirely restricted to  a particular stage  of childhood. The
 occasional  appearance  of this  infantile malady in  an epidemic 
                    AFHTH^ OF INFANTS.                  177
manner, is also manifestly opposed to the idea of its being a purely
symptomatic affection.  In some foundling hospitals in Europe, it
has frequently prevailed endemically for a season; an occurrence
which could not, with the slightest plausibility, be ascribed to
any  disorder of a symptomatic character.  In  mild cases,  the
aphthous  affection  may often be speedily removed, by local  ap-
plications to the mouth, alone;  and occasionally, even severe in-
stances will yield to remedies of this kind,  without the  employ-
ment of any thing for improving the general health, or correcting
the  morbid condition of the alimentary  canal (Dewees.)  From
a view of the foregoing considerations, the idiopathic character
of infantile aphthae can, I think, hardly be doubted.  It is very
manifest, however, that disorder of the stomach  and bowels, con-
tributes very materially to the  production of this disease, either
by creating a predisposition to it, or by exciting the latent ten-
dency in the infantile system to its occurrence.
   Feeble and sickly children scarcely ever escape this disease;
and  they  are much more apt to become  severely affected with it
than those who are of a robust and healthy habit of body. What-
ever is capable of disordering the stomach and  bowels, may be
regarded  as an exciting cause of the disease.  Unwholesome and
indigestible  nourishment,  and  over-distention  of the  stomach,
during the early stage of infancy, almost inevitably lead to the
occurrence of aphthae.  Bad and old milk, and  thick farinacious
preparations sweetened with brown sugar or molasses, are espe-
cially apt to give rise to the disease.  Inattention to keeping the
infant's mouth clean by occasionally washing out the sordes with
a  soft piece of  linen and fresh water, and particularly the nau-
seous  practice of permitting the child  to suck portions of food
tied up in a piece of cloth in  the form  of a nipple, contributes
greatly to the production of the aphthous  eruption.  Breathing
an impure and deteriorated air,  also, appears to have a decided
tendency to favor the occurrence of this malady.  Children who
are  kept  in  crowded and ill-ventilated  apartments, or who are
suffered to sleep much under  the  bed-clothes, are especially lia-
ble  to become affected with it.   The occasional great prevalency
and  fatality of the  disease in  foundling institutions, doubtless
arises, in part, fiom this cause.  When imoroper nourishment co-
                            2  A        *     16* 
178                 APHTHE OF INFANTS.
operates with foul air, the disease is apt to acquire a highly dan-
gerous character.  It has been supposed that the apthae of infanta
is often  propagated  by a specific contagious virus.   Dr.  Good is
of this opinion, and  refers, as some of the German  writers do, to
the excoriations, which  frequently occur on the nurse's  nipples,
when the nursling is affected with aphthae.  There is evidently
i very acrid and irritating fluid discharged from the minute pus-
tular eruption, which occasions the aphthous crust; and when the
nipples  are tender, they can scarcely fail to become more or less
inflamed and excoriated, by the impressions of this acrimonious
gecretion.  In hospitals, where several  infants  often suckle the
same nurse in succession, it is not improbable that the occurrence
of the disease may sometimes be favored in this way.  The natu-
ral predisposition to the disease, appears to be much  stronger
in some families than in others.   In my own, consisting of eight
children, this affection  has never occurred, although all of them
suffered from the usual stomach and bowel complaints of infancy.

  Treatment.—As the alimentary canal is almost invariably more
or less  deranged in the aphthae of infants, a principal object'in
the treatment must,  of course, be to remedy the disordered con-
dition of the stomach and bowels.  In general, the  ejections from
the stomach are sour, and the alvine evacuations of a grass-green
color.   When this is the case, magnesia, with  small portions of
rhubarb and powdered valerian, will generally prove very bene-
ficial.   I have  more frequently derived decided advantage from
this mixture, than from  any other mode of administering  magne-
sia.   From three to four grains of magnesia, with  two grains of
rhubarb, and  one  grain of powdered valerian, should be  given
every two or three  hours, Until the bowels are  freely evacuated.
Ifthereismuch  general irritability and restlessness, the tepid bath,
followed by a drop or two  of laudanum, should be employed after
the magnesia has operated on the bowels.  The  mucous  mem-
brane of the intestines is apt to become highly irritated in severe
cases, after the aphthous eruption has  continued  for some days.
The alvme evacuations, in such instances, become very frequent,
small, watery, with occasional streaks  of blood, and painful; and
the margin of the anus  red and extremely sensible.   In  cases of 
                    APHTH.E OF  INFANTS.                 179
this kind, a large emolient  poultice over the abdomen, in con-
junction with the internal use of minute portions of Dover's pow-
der, with a solution of gum  arabic  as drink, has frequently proved
highly  beneficial in  my practice.  Dr. Dewees speaks  very fa-
vorably of the oil of butter, when the bowels are much irritated.
" The oil of  butter is  prepared by putting a lump of perfectly
sweet butter into a cup, and pouring on it a quantity of boiling
water, and agitating it  well with a teaspoon,  that it may  be de*^
prived of its salt—the oil is then  skimmed off, as it is  wanted.
A teaspoonful may be given three or four times daily."   I have
used this oil in a few instances, but it did not appear to answer
quite so well  as a pretty thick solution of  gum arabic,  given in
teaspoonful doses at short intervals.  Magnesia, and olher  purga-
tive remedies, seldom fail to do harm in cases attended with much
intestinal irritation.  In a few instances of extremely obstinate
aphthae, accompanied with frequent irritating stools, and an exco-
riated state of the anus, I have procured marked  benefit from a
very  weak solution of the nitrate  of silver.   Incompatible  as the
article may seem to be with a highly irritated state of the mucous
membrane  of the bowels,  it nevertheless often  exerts a  very
soothing effect on this tissue, when under peculiar forms of irrita-
tion.   I have given about half a  teaspoonful of a solution  of a
grain of this article to  two ounces of water, every four hours, to
infants between  two and six months old, with unequivocal  advan-
tage, and without the slightest aggravation of the sufferings of the
patient.  In  cases  attended  with much acid in  the  stomach,
without a great deal of intestinal irritation, or  diarrhoea, lime-
water, with a weak infusion  of peruvian bark, usually  produces
an excellent effect.  When the acidity of the primae viae is accom-
panied with free diarrhoea, without any symptoms of inflammatory
irritation of the bowels, prepared chalk, in  union  with minute
portions of Dover's powder, generally proves decidedly  useful.
From four to six grains of the chalk, with the fourth of a grain
of Dover's powder should be given every two or three hours,  until
the diarrhoea is checked, and  the  discharges assume a more natu-
ral color.  I have  given powdered  borax internally in  aggrava-
ted cases of infantile aphthae, with  very decided advantage.  There
is nothing in this article that  forbids its  internal  employment. 
1§0                 APHTH.E OF INFANTS.
The Germans use it frequently in this way; and I have,  myself,
often resorted* to it, in  bowel complaints, with evident benefit.
In the present disease, I am persuaded that it may be given inter-
nally, with peculiar advantage, in the severer forms  of the com-
plaint accompanied with frequent irritating diarrhceal discharges.
I have  been in the habit of applying large fomenting poultices
over the abdomen, in cases of an aggravated character; and I am
satisfied  that this application  is capable  of doing much good.
When the disease runs on for a long time, and the  little patient
becomes  much  exhausted, mild tonics and  stimulants  should  be
employed  to support  the  system.   Weak  wine whey—infusion
of cinchona, or a weak solution of quinine,  in moderate portions,
 may be resorted to for this purpose.
   If  the infant  is not weaned, it should receive no other nour-
 ishment than its  mother's milk.  If it is  nursed with artificial
 nourishment, nothing  but the most bland alimentary prepara-
 tions ought to  be used.   A solution of gum arabic,  cowVmilk
 and water,  barley-water and weak chicken or beef tea, form
 proper articles of food for this purpose.   If  the child is nourished
 at  the breast, an attention to dietetic regulations on the part of
 the mother,  is believed to be  of considerable importance.  She
 ought to avoid  the  ordinary articles of vegetable food, as they
 favor  the generation  of acid  in the primae viae.   All kinds of
 spirituous and  fermented drinks, too, have an unfavorable ten-
 dency, and ought to be particularly avoided.   The more digesti-
 ble meats, soft-boiled eggs, rice, stale bread or crackers, fresh
 butter,  with weak tea or coffee, constitute  appropriate articles of
 nourishment in cases  of this kind.
    Local  applications  are generally highly serviceable,  and in
 slight cases, are,  by themselves, often   sufficient  to remove the
 disease in a few  days.  Borax is a  familiar remedy with nurses
 and mothers, as well  as  with the profession, for  this purpose;
 and it is doubtless the most  valuable article we possess, as a local
 remedy in this  affection.  It may be used  in the form of powder
 or solution.   If the former is employed, two or three grains of it,
 mixed  with a  small  portion  of pulverized  loaf-sugar, must be
 thrown into the mouth every two or three  hours.  If the solution
 be used, a drachm of the borax should be dissolved in two ounces 
                    APHTTLE OF INFANTS.                 181
of water.  This may be applied to the mouth, with  a soft linen
rag, tied to the extremity of a pliable piece of whalebone or wood,
or with a  soft feather.  The powder, however, is the most con-
venient mode of applying this remedy.   In making local applicat
tions, care  should be taken that the aphthous crust be not rudely
rubbed off.   This always causes much  pain to  the infant; and
is calculated to increase the  inflammation and  keep  up the  dis-
ease.   The practice of forcibly rubbing off the aphthous erup-
tion with a piece of linen,  on the point of a finger—so common
with ignorant  nurses, is extremely reprehensible.   Nothing  can
be gained by this rude and painful treatment, and much mischief
may readily result from it to the  little patient.  When  rubbed
off  in  this way, the crust is,  almost always,  soon, renewed in
an aggravated form, and the irritation in the mouth is  generally
much  increased.   So long as the aphthous  incrustration remains
white, the borax may be deemed the most efficient local remedy.
When the eruption assumes  a yellow or brown  color, however,
it frequently fails to do any decided good.  In  such cases,  Dr.
Dewees generally employs " the  armenian bole, in  fine powder,
with loaf sugar,"  small  portions of which mixture, are, from time
to time, thrown into the mouth, as directed  above for the borax.
"Should this fail," he says, "to give pretty speedy  relief,  and
particularly if the mouth be very red, livid  or ulcerated, we then
have  recourse to  a weak decoction of bark."   A half ounce of
powdered bark, boiled  about thirty  minutes,  in half  a  pint of
water, forms a proper decoction  for this purpose.  "About the
third of a teaspoonful  of this is put into the child's mouth, every
hour or two."  I  do not doubt that these  remedies are capable
of  procuring much relief in cases of this kind.   Instead  of the
armenian bole, however, I  prefer using a weak solution of the
nitrate of silver,  in the proportion of a grain to an  ounce  of
water, and applying it with a soft piece of linen  fixed to the end of
a thin  piece of whalebone. Nothing need be apprehended from the
introduction of a  small portion  of this fluid  into the stomach.
On the contrary,  its effects  on the morbid  condition of the mu-
cous  membrane  of the alimentary canal, are  often  decidedly
salutary in cases  of this kind.   A  decoction of oak-bark, par- 
 182                 APHPH.E OF INFANTS.
 ticularly where there  is much diarrhoea, will sometimes produce
 a very good effect as a local remedy.
  As the acrid alvine discharges are very apt  to  inflame and
 excoriate the parts about the anus, constant attention should  be
paid to keeping these parts as clean as possible.  The  nates should
be frequently washed with tepid milk and water, or with flax-seed
tea; and after they are  carefully dried, fresh lard should be applied
over the irritated  parts, to  afford them  some degree of protec-
tion  against the impressions of the  acrid evacuations.   When
the inflammation and sensibility  of these parts become very se-
vere, they should be occasionally, washed with a weak solution
of sugar of lead, mixed with proper  portions of a watery solu-
tion of opium. 
ULCERATION OF THE MOUTH.              183
CHAPTER  XVI.
                 ULCERATION OF THE MOUTH.

  Children are liable to an ulcerative affection of the mouth,
which is evidently, entirely distinct  in its origin and character,
from the ordinary aphthous eruption.  It consists, in a number of
small ash-colored and excavated ulcerations, with elevated edges,
situated about the frcenum, and  along the inferior margin of  the
tongue, the gums, and on  the cheeks.  The ulcers usually begin
in the  form of small, red, slightly  elevated and painful points.
At  first  they are superficial, and  occasionally even somewhat
raised above the surrounding skin; but in the course of a day
or two, the edges rise up,  and the ulcerated  surface becomes con
siderably excavated.  When the ulcers appear on the upper sur
face of the tongue, which, however, occurs  but seldom, they  are
generally quite superficial, appearing more like excoriations than
actual ulcerations.
  The disease commences with slight symptoms of febrile irrita-
tion.  The child manifests some degree of lassitude and restless-
ness.   The skin becomes warmer  and dryer  than  natural,  the
pulse somewhat  accelerated and sharp, the bowels  usually cos-
tive;  there is generally much thirst; the tongue is coated with a
thin white  fur, over wrhich, a thick  layer of transparent slime is
 pread, and there is a constant profuse discharge of saliva and mu-
cus from the  mouth.  The mind and body  are peculiarly irrita-
ble.  The child h generally exceedingly fretful and uneasy, "espe-
cially when it is about to take the nipple, which it frequently seizes,
and then lets go, with a whining cry as if in pain."   The febrile
symptoms usually continue for two or three days, and often much
longer, before the ulceration commences.  After the ulcers  are
formed, however, and the slavering is profuse, the fever generally
subsides.  In  some instances  the ulceration of the  gums  and 
 184              ULCERATION OF THE MOUTH.
 cheeks becomes very extensive.  In cases of this kind, a slow, ex-
 hausting fever  is apt to occur, which generally renders the man-
 agement of the complaint very difficult.   I  have met with two
 cases of this disease, in  which the gums were almost entirely  de-
 stroyed.   In one of them, the whole inferior maxilary bone was
 at length  deadened  and separated, and  was  removed  by Dr.
 McLellan. These aggravated instances of the complaint, are fortu-
 nately not common, and the disease is, in general, easily managed
 when early attended to.
   This  affection  is almost always associated with weak or disor
 dered digestive functions, and a bloated and  torpid state  of  the
 bowels.  Children whose  breath is offensive, with a variable  ap-
 petite, and a tumid and hard state of the abdomen, are most  lia-
 ble to this complaint.   The irritation of dentition, doubtless, con-
 tributes, in some degree, to  the production  of  the disease;  but
 the primary source of the complaint, appears to be located in  the
 alimentary canal.

   Treatment.—Purgatives are highly useful remedies in this com-
 plaint.  The bowels should be freely evacuated, though not with
harsh or very active purges.  A small dose of calomel, followed,
in the course of four or five hours, by a suitable dose of castor oil,
will answer this purpose very well.   The oil without the calomel,
or a  proper dose of magnesia, should be repeated daily, until  the
febrile symptoms  are  subdued.   Even where no fever is present,
mild laxatives are highly useful, more especially, if the abdomen
be full  and somewhat tense.  I have  known much benefit  de-
rived, from the use of a  few mild emetics in cases of this kind.
When the  breath is offensive, and there is a tendency to  nausea
and vomiting, the exhibition of  an ipecacuanna  vomit, will fre-
quently do much good.   In a case of a severe character, which  I
saw, about a year ago, I ordered five grains of ipecacuanna, with
two grains  of calomel.   Active vomiting was induced, and three
or four alvine evacuations followed.   On the following  morning,
the child's mouth was evidently better; and  it continued to im-
prove rapidly.  The tepid bath, and  gestation in the open air, if
the weather be  mild, will  often aid considerably in arresting the
 local ulcerative affection.   After the operation of a  purgative, 
                 ULCERATION OF THE MOUTH.              185
the general irritability of the system should be allayed, by a few
drops of laudanum, or one or two grains of Dover's powder.  In
using calomel in this affection, great care ought to be taken, lest
it affect the gums—an occurrence, which could hardly fail to im-
part a dangerous character to the ulcerations.
  When the febrile irritation is subdued, much advantage maybe
procured from local applications.   A solution of the sulphate of
copper, mixed with a portion of honey,  will generally  soon im-
prove the appearance of the ulcers, and hasten their healing.. Ten
grains of the  sulphate should be dissolved in about three teaspoon-
fuls of water, to wrhich four teaspoonfuls of honey must be added.
This solution must be applied to the ulcers, once or twice  daily,
by means of  a strong camel's hair pencil.   Dr. Dewees advises
the addition  of two drachms of powdered bark, and a drachm of
powdered gum arabic to this solution; but  I have not found it to
answer better, than the simple solution I have mentioned. Touch-
ing the ulcers,  with a solution of the nitrate of silver, also, is an
excellent local  remedy.   In several very severe cases, I obtained
more decided benefit from this application than from the sulphate
of copper.  In slight  instances  of the disease, a strong decoction
of oak bark, with a small portion of alum dissolved in it will gen-
erally suffice  to arrest the progress of the ulcers, and dispose them
to healing.   I have derived evident benefit, in cases of this kind,
from  the internal use  of small portions of powdered charcoal.
  The diet should be particularly attended  to.   If the child is
still nourished at the  breast, its mother's milk is doubtless the best
nourishment.  If it has been weaned, however, nothing but the
simplest and  mildest articles of food should be allowed.   If, how-
ever, the child has been previously, almost exclusively nourished
by farinaceous aliment, it will in general be useful to change it, in
part, for beef or chicken tea, or  very light  and simple broths.
Solid food  must on no account be allowed; more especially salted
meats or fish.
  Dr. Underwood has described  a variety of ulceration of the
mouth, under the name of Aphtha gangrenosa, which appears to dif-
fer materially from the preceding affection.  It seldom oocurs in
children under  two years old, and has been but rarely noticed
after the ninth year of age.  It usually commences with a swollen
                            2 B             17 
186             ULCERATION OF THE MOUTH.
spongy and  dark-colored condition of the gums,  attended  by
"great tenderness of the inside of the cheeks and mouth."  In
the course of  a day or two, small dark-colored ulcers appear on
"the gums, the inside of the lips and upon the tongue;"  and  oc-
casionally, ulcers of the same appearance occur on the tonsils and
uvula.   "Asthe disease proceeds, the cheeks become slightly  tu-
mefied, and are very tender when touched; and there is often an
unusual redness upon that portion of the  skin  which covers  the
lower jaw."  The tongue is  covered with a thick yellowish brown
fur, becoming  darker  as the disease advances, and the teeth  are
apt to become covered with a  black  sordes.   The breath  be-
comes  extremely offensive after the  ulceration has made some
progress.  There is usually a very copious flow of saliva from  the
mouth.   There is from the  commencement of the complaint con-
siderable  febrile irritation.   The child becomes languid  and  fee-
ble, the pulse small and quick, and the skin very warm  and dry;
the appetite is impaired, but the little  patient often sleeps well,
and at times appears  cheerful and disposed to amuse itself with
play.  The disease may continue  for a period of from two to  five
or six weeks.
   Dr. Dewees says that this variety of ulceration of the mouth,
occurs only, when children  are cutting teeth, particularly when a
number of back teeth, are about making their  appearance at the
same time; and this accords entirely, with my own observations.
It is a disease of the gums, arising from cutting  the last of the  first
set of teeth—it therefore never attacks after this process Cprimary
dentition) is completed; or at least not  until_the teeth of  the
second dentition are about to appear.    The  gums at first swell
and  become dark red and  very tender.   In the course of two or
three days, "the parts of the  gums  immediately over the teeth
about to be protruded give way by ulceration to a greater or less
extent"   (Dewees.)
   This  disease, though of  an alarming appearance, is by no
means a dangerous affection.  In children of  a sickly and scor-
butic habit of body, however, it sometimes becomes very trouble-
some, and resists, for a long time, the usual remedial application
in diseases of this kind.  The swollen parts of the gums ought to
be divided down to the advancing teeth; and the child's mouth 
                          OF COLIC.                      187
frequently washed with a strong decoction of peruvian bark.   I
have used a solution of the chlorite of lime, with a most excellent
effect in several severe instances of this affection.   I  dissolved a
drachm of the chlorite in six ounces of water, and applied it with
a soft piece of linen tied to the end of a probe.  A decoction  of
oak bark  too, with or without a small portion of alum forms  an
excellent application.
                  CHAPTER XVII.


                          OF COLIC.

  There are very few infants who do not suffer more or less from
colic pains.  In many instances, indeed, they are so slight and
transient, that they require  no particular remedial  attention.
Very frequently, however, they become extremely harassing, re-
curring often, and with great severity, during the first five or six
months of infancy.  In some cases, these painful attacks occur
several times daily, at uncertain intervals; and in others, they
come  on at regular periods, assuming  a distinctly  periodical
progress.
  In slight cases of colic pains, the infant suddenly becomes very
fretful, draws up its legs  towards the abdomen,  and  whines or
cries for a few moments and then resumes its usual quiet condi-
tion.  After a very short  interval of rest, another attack, of the
same  kind occurs, and  again soon subsides; and thus, it will go
on, with alternate spells of crying and quietude, until a volume of
wind  breaks  from the stomach or bowels, or a thin foecal dis-
charge takes place, when entire relief ensues.   In  many cases,
however, these manifestations of suffering are much more vehe-
ment and distressing.  There is excessive, long-continued and un-
appeasable screaming, forcible drawing up of the legs, or violent
kicking, flushing of the face, and various  writhings of the body 
188                       OF COLIC.
with a distended, tense and tympanitic state of the abdomen.  In
the majority of instances, these attacks are associated with habit-
ual symptoms of indigestion and disorder of the bowels—such as
acid eructations, flatulency and diarrhoea.  The stools are fre-
quently of a  grass-green color, or slimy, and  occasionally mixed
with portions of imperfectly digested  food.   In some cases, how-
ever, the alvine discharges are neither too frequent nor of an un-
natural appearance, although the infant almost daily experiences
severe paroxysms of colic.   The  breath  often  has a peculiarly
acid smell, and when vomiting occurs, which,  however, is  not
often  the case, the milk, if the child is nourished at the breast, is
thrown off in dense  coagulated masses.  When the  colic pains
come on frequently, and are attended with prominent symptoms
of indigestion and diarrhoea, the general health of the infant al-
most always suffers  obvious derangement.  The child  becomes
pale, feeble, and  fretful, and does not thrive.  Sometimes, how-
ever, the  appetite remains  good, and although the child suffers
frequent and very severe attacks during a period of two or three
months,yet no inroads appear to be made on its general health, and
it goes on thriving, as if it were in every respect perfectly healthy.
This is most apt to occur in those instances, where the paroxysms
of  colic recur at regular  intervals, or in  a periodical  manner.
This form of the complaint, is seldom connected with any decided
manifestations of indigestion; and instead of being attended with
loose and  griping stools, it is very generally accompanied by con-
stipation or slowness in the action of the bowels.  Dr. Dewees
states, that the paroxysms, usually, occur  between  four and six
o'clock in the afternoon; but in this  respect, I have not noticed
any particular uniformity in the cases that have come under my
own observation.  I have  known the attack  to occur, regularly
at a particular period in the forenoon; and I  have recently pre-
scribed for a case in which the paroxysms,  uniformly came on
between one and two o'clock every night.
   There evidently exists a very material difference between these
periodical cases, and the ordinary irregular form of the complaint.
The latter appear to depend on a dyspeptic condition of the ali-
mentary canal, and are manifestly greatly under the influence of
diet and other causes capable of producing weakness or irritation 
                          OF COLIC.                      189
tof the digestive organs.   The immediate cause of the colic pains,
in the  majority of cases,  appears to consist in violent flatulent
distention and irritation  of some portion of the bowels.   That
this is the case seems very obvious from the drum-like  distention
of the abdomen which usually occurs  during the paroxysm, and
from the relief which almost always follows the free  discharge of
wind from the bowels.  The foundation for this painful affection is
frequently laid during the first two or three days after birth.   The
extremely reprehensible practice of filling  the infant's stomach
with artificial food immediately afterbirth, before nature furnishes
the appropriate  nourishment, is, I  am persuaded,  a  very com*
mon source of this distressing complaint.  The child's  stomach is
thus often, in the very beginning of life,  thrown into  a state of
irritation  and feebleness-^-so that even the congenial  nutriment
afforded by the maternal  breasts, will pass into the bowels  in an
imperfectly digested state, and give rise to acid and flatulent disten-
tion of the intestines.  The exhibition of active purgatives, for the
removal of the meconium, also, is well calculated to originate this
complaint.  After the digestive  organs have once been brought
into a  state of irritation or functional derangement, the mildest
and most appropriate nourishment, will not be properly digested;
and this state of things must almost necessarily continue until the
digestive energies have acquired a considerable degree of devel-
opment; for the  acid and flatus  which are  generated  in conse-
quence of the weakened condition of the stomach tend continual-
ly to keep up the deranged state of the digestive functions.   Thus
when the delicate stomach of  the newborn infant is overloaded
with any of the.usual alimentary preparations, it can scarcely es-
cape being, in some degree,  weakened and irritated.  The very
first nourishment  which the child afterwards draws from its mother'?
breast, will, probably,  not be  duly digested.  Acid and  wind
will, therefore, be generated.   These  morbid products become
additional causes  of irritation and disorder of the digestive organs;
and thus the complaint, generating  as it were its own cause, may
go on,  for many months, however mild and fitting the nourishment
may be.  I know from repeated experience, that infants who  re-
ceive no aliment,  or only small portions of suitable nutrient fluids,
until the  appropriate nourishment is supplied by the rnaternal
                                           17* 
190                       OF COLIC.
breasts, will, in general, be much  less liable to colic and griping
pains,  during the first two or three months of infancy, than such
as are gorged with food, in the usual way. soon after birth.  When
the digestive  organs  are thus  early disordered, the colic pains
usually commence within  three or four  days  after  birth.  The
stools become frequent, green, watery, or curdled, and very pain-
ful, and in most cases, aphthae  supervene,  before the  end of the
second week.   In general, errors in diet,  constitute the ordinary
source of the colic, and griping in infants.  Overdistention of the sto-
mach, especially with artificial food; or administering nourishment
at such short  intervals that  the stomach is constantly kept in a
state of repletion and exercise, is particularly apt to give rise to these
harassing complaints.  Even the most appropriate articles of food,
will not  prevent the occurrence of colic and griping, if  they are
very frequently and superabundantly administered, so as to deprive
the digestive organs of the requisite and regular intervals of rest.
Not  unfrequently, very painful  disturbance  of  the  alimentary
canal, arises from a bad state of  the mother's or  nurse's  milk.
Mental disturbance in the  nurse sometimes exerts the most extra-
ordinary influence in this respect,  by the changes which it causes
in her milk.   A few years ago, I met with a very striking instance
of this kind.   I wras  called to  an infant about five months old,
extremely  harassed  with  colic pains.   Most violent  and  pro-
tracted paroxysms of screaming and agitation occurred, three or
four times daily.   Its bowels were disordered, and  frequent ejec-
tions of acid, fluid mixed with coagula of milk, took place from the
stomach.   The  child was nourished exclusively at its  mother's
breast.  I  was told that these attacks  first came on,  about two
weeks before I saw the little patient, and soon after the mother
had  unexpectedly heard of the sudden death  of  her husband at
sea.   Previous to this distressing occurrence, the infant appeared
to be perfectly healthy.  I advised immediate  weaning, and the
use of two parts of cow's milk with one part of warm water, for its
nourishment.  In less than twenty-four hours after  the child was
put on the  exclusive use of this food, it was almost entirely freed
from  its painful  attacks;  and  in  a few  days more,  appeared
to be  as well as  it  was,  previous to the first accession of the
complaint.    The  children of nervous,  fretful, and ill-tempered 
                          OF COLIC.                       191
women are much more liable to colic and other forms of gastro
intestinal disorder, than those of placid and equanimous mothers.
Protracted grief, sorrow, or despondency in the nurse, often gives
rise to very severe and continued colic pains in the suckling, which
nothing but  weaning or  a change of the nurse  is capable of
preventing.
  Even physical pain in the nurse, when long-continued and ha-
rassing—such as tooth-ach and neuralgia, may occasion very ob-
stinate and severe disorder of the alimentary canal in the nursling.
Dr. Dewees relates a very curious instance of this kind.   In the
second week  after birth, the child  began  to experience moderate
attacks of colic; which gradually increased, in violence and fre-
quency, until they became extremely severe and protracted.  No
relief could be obtained, except from laudanum, given "in large
and constantly increasing doses."   The fluid thrown from the sto-
mach was sour; and  the alvine evacuations were   griping, thin,
and often green.  There was much emaciation.   "In this situation
did things continue, until the child was five months  old, by which
time it was (without  a figure)  nothing but  skin and bone."  In
one of his  visits the Doctor noticed the mother applying her hand
very suddenly to her  face and pressing it firmly.  On  being ask
ed the cause  of her doing so,  she  stated  that she had been for a
long time much tormented with tooth-ach. The Doctor advised her
to have the tooth immediately extracted.   "This was accordingly
done; and from that day the child began to recover, and in a short
time was perfectly restored to health."
  Inattention to proper dietetic regulations, and consequent disor-
der of the digestive functions, on the part of the mother or nurse,
may also give rise to such alterations in the milk, as will occasion
colic  pains and griping in the infant.  Under the head of wean-
ing, several other circumstances, in relation to the mother have al-
ready been mentioned, as sources of more or less serious disturb-
ance in the stomach and bowels of infants.   Of these a deficiency
in the quantity of milk furnished by the breasts js a very common
indirect cause of this painful affection in infants.  To supply
this deficiency, artificial nourishment must, of course, be resorted
to:  and in doing  so, the child's stomach  is apt to be overloaded
with inappropriate articles of food. 
tr)$                       OF COLIC,
  Colic pains and griping may also proceed from the influence of
cold__particularly from  inattention  to proper changes of  the
child's wet and cold linen,  and  from insufficient  clothing and
warmth about the abdomen and inferior extremities.
  It has already been observed  above, that the  periodical form
of this complaint, appears to differ very materially  both inits char-
acter and mode of origin, from the ordinary cases of irregular flat-
ulent colic.  It is seldom associated with a dyspeptic condition of
the digestive organs; and the beneficial influence of dietetic regu-
lations, is certainly much less obvious in cases of this kind, than in
the usual  instances of the complaint; nor are those remedies which
are  generally relied  on  for preventing the generation of acid
and wind in the primae viae, or for removing them, capable of  pro-
curing any decided advantage in these periodical cases.  These
attacks continue to recur regularly,  for several months; their re-
currence  usually ceasing  spontaneously, "as soon  as  the child
reaches the age of three months." Dr. Dewees thinks  that cases
of  this kind,  depend, probably,  "upon some constitutional pecu*
liarity, over which we have but a temporary control."   It appears
to me likely that they do not differ  from the gastralgia of adults
—a form of neuralgic affection., which frequently assumes a peri-
odical character, and which, like the  present complaint, can sel-
dom he materially influenced by the ordinary remedies for colic
and griping pains.   The attack in cases of this kind, generally
comes on  suddenly, and after having  continued  with occasional
transient remissions  for an indefinite  period, varying from a few
minutes to one or even two hours, it ceases as abruptly as it came
 on. From a close attention to several instances of this form of the
complaint, I  have been led to suspect that the pain, in such ca-
ses, is generally seated exclusively in the stomach.   The pain is
not aggravated  by taking food or drink into the  stomach; and in
one instance,  which came under my notice, the sufferings were
almost always  obviously mitigated,   by  administering a  few
teaspoonfuls of thin arrow root, barley water, or of a mixture of
 milk and water.   During the attack there is usually a  good  deal
 of flatulent noise in the abdomen, attended with epigastric disten-
 tion, and eructations of air, which, however, possess neither acidi-
 ty nor fetor.  The digestion is nearly always good, and sometimes 
                          OF COLIC.                      193
even more rapid than in a perfectly healthy condition of the sto-
mach and bowels.
  The colic of infants, as has already been observed, is by no means
a dangerous, though  always an extremely distressing affection.
Nevertheless when the flatulent distention becomes very great, it
may so weaken the muscular coat of a portion of the intestines,
as to give rise, ultimately, to habitual costiveness of a very trouble-
some  and unmanageable character.  In some cases a highly irri-
tated or sub-inflammatory condition of the mucous membrane of
the bowels is excited in the progress of the disease, giving rise to
painful and  exhausting diarrhoea, a hard and tumid state of the
abdomen, derangement of the digestive functions, and  a general
irritable and irritated condition of the sanguiferous  and nervous
systems.  These  consequences, however, rarely ensue,  except
where errors in diet are habitually committed, or where harsh and
irritating purgatives and other medicines are frequently employed.

   Treatment.—In the ordinary cases of infantile colic, associated
with derangement of the digestive functions, or with habitual acid-
ity and flatulency of the primae viae, judicious dietetic regulations
are all-important  remedial  measures,—without  which  the  most
appropriate remedies will, at most, procure but temporary pallia-
tion.   When there is reason  for believing that the mother's milk
is unwholesome, an effort should be made to ascertain the cause
of its faulty condition, which may, perhaps consist in habitual im-
proprieties in diet, or  in some accidental and removeable disorder
on the part of the  mother.  Should  the first be the case, proper
dietetic measures should be  immediately  adopted by the mother
or nurse, and every thing that tends to promote the generation of
acid in the alimentary canal carefully avoided. If, notwithstanding
a judicious regulation of the mother's diet, the infant continues to be
harassed with frequent attacks of colic, some advantage may oc-
casionally be obtained by applying it to the breast at long  inter-
vals, and substituting  small portions of suitable artificial nourish-
ment—such as  very thin arrow-root, barley  water, or a mixture
of equal parts of cow's milk and water.   When the child has been
partly nourished by artificial food, in consequence of a deficient
secretion of milk, we  may sometimes derive much benefit from a
                             2 C 
194                       OF COLIC.
change of the artificial  portion  of  nourishment.   A striking in-
stance of the advantage that may occasionally be obtained in this
way came under my observation a few weeks ago.  The infant
about two months old was almost constantly in a state of alarming
torment. The mother did not furnish sufficient milk for its sustenance,
and it was regularly fed  with a  mixture of equal parts Of  cow's
milk and water.  Arrow-root, barley-water, tapioca, and sago, in
suitable preparations were successively tried, but without the least
benefit.  A mixture of weak chicken-tea  and a  very thin pre-
paration of arrow-root, in the proportion of one part of the former
to two parts of the latter, was finally resorted to.  By  the use of
this nourishment, the complaint was soon very obviously mitiga-
ted; and under the additional influence of small  doses  of magne-
sia and powdered valerian, yielded almost entirely in the course of
nine or ten days.   As the error  often consists more in  the  excess,
than in the quality of the food, particular attention ought always
to be paid to this point.
   Infants who are partly nourished  by artificial  food, are par-
ticularly liable to  be  injured by over-feeding.   I have repeat-
edly  known  great benefit  derived from  a mere reduction  of
the quantity of nourishment habitually taken by the infant—and
particularly by lengthening the intervals between the meals so as
to avoid the  injurious practice of taking fresh food into the sto-
mach before that which was previously taken has been  fully di-
gested and passed into the intestines.   There are but few cases of
flatulent colic that may not, in some degree be benefited  by a ju-
dicious management of the diet.  Frequently, however, the re-
lief obtained from measures of this kind is but small, and recourse
must be had to other means for  correcting the disordered condi-
tion of the stomach and  bowels, and especially to temporary pal-
liatives for mitigating the violence of the attacks.
   Magnesia  by its antacid  and  purgative effects, is one of the
most useful remedies we possess for the management of this com-
plaint.  When there is a prevailing tendency to generate acid in
the  primae  viae, small  doses of this  article, given two or three
times daily, almost always produce an obvious abatement  in the
frequency and violence of the attacks.   I have generally given it
in union with small portions of powdered valerian root, and when 
                          OF COLIC.                       195
the bowels are torpid, with the addition of a few grains of rhu-
barb.   Three grains of magnesia, with two grains of powdered
valerian, may be  given twice or thrice daily, until the acidity in
the stomach is removed.   If this do not keep up a sufficient ac-
tion of the bowels, the proportion of magnesia should be occasion-
ally, increased, or a few grains of rhubarb added to the powders.
Valerian is an  excellent auxiliary  to the magnesia, in cases at-
tended  with weakness of the digestive powers.  I  have used a
solution of the bi-carbonate of soda in an infusion of valerian root,
with  very obvious benefit, in  cases  attended with  much  acidity.
Twenty grains of the bi-carbonate  of soda may be  dissolved in
two ounces of valerian infusion,* to which  two or three drachms
of  ginger  syrup may be  added.  A teaspoonful of this  solution
may be given  several times daily, to an infant of from one to three
months old.   With the view of invigorating the digestive organs,
and thereby impeding the formation of acid and flatus in the ali-
mentary canal, small doses of a very weak infusion of colomba or
of quassia may be resorted to with a prospect of considerable ad-
vantage, in cases associated with general feebleness and relaxa-
tion and a dyspeptic condition of the stomach.   When the com-
plaint is accompanied by thin,  green and acid diarrhoeal dis-
charges, some advantage  may be gained from the occasional ad-
ministration of very small doses of calomel, either by itself or  in
union with minute portions of ipecacuanna.  A frequent employ-
ment of this article, however,—particularly when given  in full
doses, is by no means advisable.  Some years ago, 1 administered,
in several cases  of this complaint attended with  constant acidity,
flatulency, and diarrhoea, a  mixture composed  of five grains of
prepared chalk, three grains  of the poAvdered root of simplo-
carpus foetida (skunk cabbage) and  two of rhubarb, every morning
and evening for  five  or six days  in  succession, with unequivocal
benefit.  The difficulty of procuring the powdered skunk cabbage
in our shops, has since that time, prevented me from giving it
again; though I am inclined to believe,that it possesses very ex-
cellent powers, both as a palliative, and as a means for invigorating

  *  The infusion should be made by macerating ene ounce of the valerian root in a pint
of warm water, for about twenty-four hour*. 
196       -                °F COLIC.
the depressed digestive energies of the stomach.   When costive-
ness prevails, this article may be given in  union  with magnesia,
in the way mentioned above, or with valerian.
   In cases attended with frequent watery, green, or curdled and
sour stools, accompanied with violent griping, antimonial emetics
are strongly recommended by Armstrong.   When the abdomen
is  not tender to pressure, and the little patient is free from febrile
irritation, an occasional emetic dose of antimonial wine, followed
by suitable doses of Dover's powder, will sometimes do much good
in such cases.   An instance of the usefulness  of this practice,
came under my notice about six months ago.  The infant, about
five months  old, was extremely harassed with frequent small di-
arrhoeal discharges  of a watery and grass-green  character; and
each evacuation was preceded by excessively severe and protrac-
ted griping, as was  evident from the child's vehement and unap-
peasable screaming. An antimonial vomit  was given in the morn-
ing, followed after its operation by a grain and a half of Dover's
powder.   The  disease was  manifestly mitigated  by these reme-
dies;  and by repeating them three times in the course of about a
week, and employing, afterwards, small doses of  prepared chalk
and Dover's powder, in conjunction with the occasional applica-
tion of rubefacient embrocations to the abdomen, the bowels were
brought to a pretty healthy condition, and the little patient freed
of his sufferings.  In general, however, emetics are not appropri
ate remedies in infantile colic, except in  cases where the morbid
excitement is concentrated on the large intestines, and the stom-
ach is in  a languid  or inactive condition.   As a mere palliative,
an emetic dose of ipecacuanna, will sometimes procure considera-
ble relief when administered during, or at the commencement of
the paroxysm, by expelling the wind  and thus removing the dis
tressing distentions of the stomach and duodenum.  A repetition
of emetics, however, could hardly fail,  in the ordinary cases of the
complaint, to disorder the digestive functions, and to favor the oc-
currence of inflammatory irritation in the stomach and bowels. The
application of a large warm  poultice over the abdomen, having
previously rubbed the skin with hartshorn liniment, or, with the
common camphorated mixture, will often assist materially in sub-
duing the complaint, when it is accompanied with much intestinal 
                          OF COLIC.                       197
irritation, manifested by frequent small, thin  and acrid or very
foetid evacuations.
  As a temporary palliative for lessening the violence and dura-
tion of the  attacks, Dr. Dewees, relies chiefly on  the following
mixture,*—which, he asserts " rarely fails to  give  instant relief,
and sometimes even effects an entire cure."  Twenty drops of this
mixture should be given when the child is in  pain, "and if not
relieved in half an hour, ten drops more are to be administered."
I have  found  this remedy, to  procure prompt  relief in some in-
stances, but it has not been so uniformly  beneficial, in my hands
as the  following preparation.  Dissolve one drachm of camphor
in an ounce of sulphuric aether.   Take thirty drops of the solu-
tion, twenty grains of  magnesia, six drops of laudanum, and mix
them together with an ounce of fennel-seed tea.  Of this mixture
a teaspoonful  may be  given, to an  infant from two to six weeks
old; and if sufficient relief be not obtained in  half an hour, about
half a teaspoonful more  should be  administered.   I have fre-
quently procured prompt relief by  administering two or three
drops of the simple ethereal solution of camphor, in a teaspoonful
of sweetened water, and I  am satisfied  that we have not a more
efficient palliative, for relieving  the  distressing  pains  attending
this complaint.   When remedies of this kind must  be frequently
employed, camphor is, in some  respects preferable to opium, un-
less diarrhoea and much intestinal irritation be present, in which
case opiates  in some  shape or other can hardly be entirely dis-
pensed with.  In cases associated with diarrhoea  and griping, the
camphor may be advantageously given in union with  laudanum.
Two drops of the solution  of camphor with half a drop of lauda-
num may be given three  or four times in  the course of a day,
when  the pains are violent  and of protracted duration.
   Gentle frictions with dry flannel or with the  bare hand over the
epigastric and umbilical regions, sometimes aids considerably in
procuring the expulsion of the confined flatus.   The introduction
into the  rectum, of a soap suppository during the colic attack,
frequently produces copious discharges of wind and  faeces, with
great relief to the little sufferer.  When costiveness prevails, lax-
  * R.  Magnes. calcinat. 9i. Tinct. assafoetidae gtt. lx. Tinct. opii. gtt. xx. Aq.
fontan. g'- M.
                                             18 
198                       OF COLIC.
ative  enemata, with the addition of twenty  or  thirty drops of
tincture of assafoetida,  are appropriate  and often  very efficient
means of temporary relief.
  In the periodical form of the disease, dietetic regulations rarely
afford any decided advantage.  The diet should nevertheless be
carefully attended to; for there can be no question as to the injuri-
ous tendency of  errors  in this respect.  The abovenamed pallia-
tives  may be resorted to with temporary benefit;  but the reliei
obtained by remedies of this kind, is seldom so prompt and con-
siderable in the present as in the common irregular form of the
complaint.  When employed at all, they ought to be given, "the
instant the paroxysm is about to commence;" for when the colic
is once fully developed, it very  rarely yields  in  any obvious de-
gree, to remedies of this character.  The only article that I have
found, capable of  occasionally  producing a decidedly favorable
effect, is a few drops of the spirits of turpentine in a teaspoonful
of good sweet oil, or milk.  In some instances I  have known this
remedy to effect a speedy subsidence of the pains in this variety
of the disease.   From  three to  six drops of the  turpentine may
be given to a child of from one  to three months old, and the dose
may be repeated in the course  of an hour without the least risk
of injury.  Viewing it as a strictly periodical complaint, Dr.
Dewees has administered a decoction of the bark during the in-
tervals of the  attacks, and, as he informs us, "with the happiest
effect in several instances."  Formerly I employed the prussiate
of iron in several cases of this kind; and in one instance, the e£
fects of this remedy were surprisingly' beneficial.   To an infant
between one and three months old, a half a grain of  this article
may  be given  every three or four hours during the intervals of
the paroxysms.  In the successful case just referred to, this pre-
paration of iron was  given in union  with powdered valerian.
The infant was about two months old.  A violent attack of colic
occurred about  six o'clock, every evening, and  generally con-
tinued for nearly an hour.  The child had been affected with the
complaint for upwards  of three  weeks before I saw it.   After the
bowels were freely evacuated by a dose of a few  drops of syrup
of rhubarb, I prescribed half a grain  of the  prussiate of iron with
three grains of powdered  valerian root to be taken every three 
                           OF COLIC.                       199
hours during the  intermission.  The first paroxysm after these
powders were  taken, was perhaps, as severe as any of the pre-
ceding ones.  The medicine was, however, continued, during the
next intermission;  and now, the attacks gradually subsided in vio-
lence and duration, until, at the  end of eight or  ten days, the
child was almost entirely, freed of the complaint.  I have, since
this  case, employed  the  same  combination in another  instance;
but  the effects, though  not without obvious advantage, were by
no means so promptly and decidedly beneficial as in the former
instance.  As the  bowels are generally torpid in these cases, mild
laxatives, must be used  from time to time, to keep up the requi-
site  alvine  evacuations.   Active purging, however, is not only
useless, but often  decidedly injurious—a fact which I  have, in
several instances,  seen strikingly verified.  It would, I think, in
general be  better to procure the necessary evacuations by laxa-
tive enemata, than by aperients taken into the stomach.   If  the
latter be preferred, fresh cold-pressed castor oil, and syrup of rhu-
barb, are the most appropriate.
  The practice, so common with mothers and nurses, of admin-
istering various irritating substances of an anodyne or carmina-
tive  character, is  often  carried to a highly injurious extent, and
cannot be too severely censured. The habitual use of opiates in in-
fantile  colic, almost always leads  to very unfavorable, and often
to very distressing and dangerous consequences.  In order to ob-
tain the requisite  degree of anodyne effect, the dose must be pro-
gressively increased; and  thus a  habit  is soon formed,  which
renders the  discontinuance of the anodyne a source of inexpressi-
ble distress  and inquietude, whilst its continuance,  in increasing
doses never, fails to operate perniciously on the whole organization.
   Under the habitual use of these treacherous palliatives, consti-
pation soon  ensues; the  appetite and digestive powers fail:  the
body emaciates and the skin becomes sallow, dingy, and shrivelled;
the countenance acquires an expression of languor and suffering,
and  a general state of apathy, inactivity and feebleness ensues,
which, ultimately, often leads to convulsions, dropsy  of the head,
glandular indurations, incurable jaundice, or fatal exhaustion of
the vital energies.  The more immediate effects of opiates, also, are
frequently extremely unpleasant, particularly in very young infants. 
200                       0F COLIC.
The pain may indeed be lulled by the anodyne, but though qui-
eted, the infant is evidently under the influence of highly disa-
greeable sensations, as is manifested by the sudden startings, un-
natural  whining cry, and the exceedingly irregular respiration,
being now very hurried for a moment, and then slow and moaning
with  occasional intermissions, of so protracted  a  duration, that
"one would  think  the breathing had ceased  altogether."  All
the usual soothing mixtures, such as Godfrey's cordial and Dalby's
carminative, so much employed  for allaying the colic pains, and
griping of infants, contain more or less opium;  and innumerable
infants  have been  irretrievably injured by the habitual use of
these popular nostrums.
   Heating and irritating articles, such as diluted spirits, infusion
of spicy and aromatic substances, soot, and repeated  active pur-
gatives may do much injury, by irritating  the  delicate mucous
membrane of the stomach and  bowels,  impairing the  digestive
powers, and finally exciting a  state  of chronic inflammation in
this structure, which it is  always very difficult, and often impos
sible to remove by any subsequent care  and management.  The
observations are  addressed rather to mothers and nurses than to
physicians;  for it cannot be questioned  that all these remedies,
more especially opiates, may, by judicious management be bene-
ficially employed  in certain instances and conditions  of the
complaint. 
OF CONSTIPATION.
201
CHAPTER  XVIII.
                      OF CONSTIPATION.

  Torpor of the bowels, and consequent costiveness, of more or
less protracted duration, is of frequent occurrence among infants.
In some instances, the bowels are habitually so very inactive,
that scarcely any alvine evacuations take place, except when excit-
ed by artificial means.  This state of the bowels is the result either
of a constitutional habit, or of accidental  causes.  The former va-
riety of  costiveness is very rarely attended with unpleasant con-
sequences, "and indeed children of such  a habit of body are fre-
quently the  most thriving" (Underwood).  Dr. Dewees observes,
that a period of from two to ten days may intervene between the
stools,  in constitutional costiveness,  "without the child  receiv-
ing the least injury from this torpor of the bowels."   I have re-
peatedly met with instances, where not more than  two or three
evacuations took place in the course of a week, without the slight-
est  inconvenience to the infant; and Dr. Dewees mentions a case,
where the stools occurred  "but once in  eight or ten days," for a
long period, although  the infant throve well and appeared to be
"in excellent health."   Mothers, generally, express much solici-
tude, in cases of this kind; and under the  apprehension of evil con-
sequences from this condition, frequently urge the  administration
of aperients to a very injurious extent.   When the infant mani-
fests no symptoms of ill-health, and continues to thrive well, con-
stitutional costiveness very seldom requires any remedial interfe-
rence, "though it will be prudent carefully to  watch it." Where
there is a tendency to convulsive affections—a tendency which is
sometimes  manifested in children  of a perfectly healthy and ro-
bust appearance, it will undoubtedly be advisable to obviate pro-
tracted  costiveness by the occasional  administration of suitable
aperients; for, "fine lusty infants are sometimes seized  with  vio-
                            2 D              18* 
202                   OF CONSTIPATION.
lent convulsive fits, without any other apparent cause, than a nat-
urally costive state of the bowels, and as uniformly recovered from
the fits, merely by procuring stools and breaking off the wind"
(Underwood).   During dentition, also, it will, in general, be expe-
dient to increase the frequency of the  alvine evacuations, by arti-
ficial  means, where there  is much intestinal  inactivity.  The
most suitable aperients, in cases of  this kind,  are castor oil, man-
na, and magnesia.  I have for many years past, been in the habit
of prescribing the  following mixture for  this  purpose.   It is cer-
tain, and peculiarly mild in its operation, and of so pleasant a taste
that children generally take it with little or no reluctance.
                R. 01. Ricini   -   -   3 i
                   Magnesiae calcinat.      3 u
                   Sacchar. Albi, -   -   3 u'
                   01. Anise,   -   -  gtt. ii
          Mix them intimately, by rubbing them together in a mortar.
   One or two teaspoonfuls of this mixture may be given at a dose.
During the first two or three months of infancy, we may, in gen-
eral, keep the  bowels sufficiently soluble by the use of manna—
an article which is, perhaps, less apt to disagree with the stomach
or to cause unpleasant effects in the alimentary canal of infants,
than any other aperient we possess.  It should be  dissolved with
warm water, to the consistence  of a thick syrup, and given in tea-
spoonful doses.
   Costiveness from accidental causes  is a very common affection
during infancy.  Instances of this kind are, properly, morbid con-
ditions, and can seldom be entirely neglected without incurring some
risk of injurious consequences.   A torpid state of the bowels may
occur as a symptom of some obscure deviation from health.  If it
be not removed it  may become  an  additional source of irritation
in the  system, and aggravate the  latent  disorder  upon which it
depends.   Thus a preternatural determination of blood to  the
brain, may give rise to inactivity of the bowels, without any other
obvious signs of ill-health, or disordered function. The costiveness,
if it be suffered to continue, will hardly fail to increase the already
preternatural determination of blood to the head, and thus a very
serious affection may  ultimately be developed  in the brain or the
alimentary canal, which might have been obviated by  a judicious
course of aperient remedies.  The  occurrence of costiveness dur- 
                       OF CONSTIPATION.                   203
ing dentition, may always be regarded as an unfavorable  event.
Children almost always  suffer much more general irritation, and
incur much more risk of convulsions and other dangerous affec-
tions  from dentition, when the bowels become torpid and  consti-
pated, than when they are moderately loose during this process.
   The  very reprehensible,  and frequently clandestine practice,
among  nurses of giving opiates  to infants, to make them  sleep,
that they may not require much attention during the night, is a
frequent  source  of  obstinate  and injurious costiveness.*   I met
with a remarkable instance of this kind a few years ago.  The
infant, when about two  months old became very costive.   Aperi-
ents were from  time to  time,  resorted to,  but  the torpor of the
bowels  continued,  and  gradually increased, until no evacuations
could be procured except by large doses of the most active pur-
gatives.   The child became sickly, and much harassed with acid-
ity and flatulent pains in the stomach.  After I had for nearly a
month endeavored to bring the bowels into a more regular condi-
tion,  without the slightest advantage, it  was accidentally ascer-
tained that the nurse had been in the habit of giving the infant a
dose of laudanum every evening to the extent of at last ten or twelve
drops at once.  The laudanum was now gradually withheld, and in
about two weeks the child's  bowels were restored  to their former
regular state, although  its general  health continued to be very
infirm for several months afterwards.
   Costiveness may also  occur, as a consequence of particular arti-
cles of nourishment.  Children who  are chiefly nourished by
pap, or  by  preparations of  rice,  are apt to become  more or
less constipated;  and  in general, all the  usual  farinaceous  ar-
ticles  of  nourishment   have a greater  tendency to  produce
costiveness,  than milk  and  the  nutrient animal  fluids.   In
some instances,  though  rarely, the mother's or  nurse's  milk,
has a constipating effect on  the child's bowels:  but this,  prob-
ably, depends more frequently on a peculiar constitutional  habit
  * "Nurses," says Dr. Dewees, "are now so familiar with this drug (laudanum) that it
is as regularly carried about them as their scissors or thimble, and is much more indispen-
sable to their comfort than either of those emblems of industry.  If the child does not go
to sleep, or if it is even feared it will not, at the exact moment which will suit the arrange-
ments of the nurse; or if it cry from any cause, so as to give any additional trouble, laud-
anum is given to make 'assurance doubly sure.' " 
204                   OF CONSTIPATION.
on the  part of the child, than on the particular qualities of the
milk.  This was certainly  the case in one instance which came
under my notice some years ago.   The mother, with an abundance
of milk, suckled her twin infants, and treated them in every  res-
pect precisely alike.  One of them was constantly costive, except
when nourished  principally with cow's  milk;  whilst the other
child was uniformly regular in its bowels.   When children are ob-
served to become costive, and to continue so under the use of any
particular kind of  nourishment, an  immediate change of  food
should be made;  for a nourishment  which is capable of produc-
ing this effect, will,in conjunction with the costiveness it has caused,
be likely to occasion more serious disturbances in the system if its
use be persisted in.
   Accidental costiveness is usually attended with flatulency and
occasional attacks of colic pains.  If it be suffered to continue, it
may ultimately give rise to inflammatory irritation of the mucous
membrane of the bowels, which may manifest itself either by obsti-
nate and painful diarrhoea, or swelling, tension and soreness of the
abdomen, or finally, by various sympathetic affections of the head,
chest or the general system.
   The aperients already mentioned, will in general procure all
advantages that can be derived from remedies of this kind.  Cold-
pressed castor oil, is an excellent laxative in the ordinary cases of
costiveness. When the alvine discharges manifest a deficiency of
bile—that is, when they are whitish or clay-colored, much bene-
fit may be obtained, from the occasional administration of a small
dose of calomel in  the evening,  followed next morning,  by one or
two teaspoonfuls of castor oil.  Magnesia is the appropriate laxative
when  the intestinal torpor  is accompanied with acidity  in the
primae viae. In moderate cases of constipation, relief may frequent-
ly be obtained from the daily introduction of a soap suppository into
the  anus.   Laxative enemata also,  may be advantageously em-
ployed in cases of this kind.   They are especially useful, as occa-
sional  substitutes for the internal aperients,  where the necessity
of resorting to artifical means for moving the bowels continues  a
long time; for a long-continued and frequent employment of even
the mildest laxatives, is apt to injure the digestive functions, and
 to give rise  to some degree of  intestinal  irritation.  When the 
                        OF VOMITING.                     205
abdomen is free from tenderness or soreness to pressure, frictions
and  gentle kneading of the abdomen with the hand, sometimes
produces an excellent effect, both in constitutional and accidental
colic.
                CHAPTER  XIX.


                        OF VOMITING.

   Vomiting occurs more frequently, and, in general, with much
less unpleasant consequences during early infancy,  than at any
other period of life.  We often see perfectly healthy infants, who
are in the  habit of throwing off a portion of the contents of the
stomach, several times  daily, without sustaining the least disagree-
able consequences from it, whatever.   The vomiting in these ca-
ses arises solely from an overloaded condition of the stomach, and
is  not attended either by nausea, or by any strong and disagreeable
vomitive efforts. It seems to be almost entirely effected by a sudden
momentary contraction of the stomach, with little or no aid  from
the abdominal muscles and  diaphragm.  This harmless kind of
vomiting is particularly apt to occur,  in robust infants who are
nourished  at  exuberant breasts; and it  seldom  happens  except
immediately after the infant has  sucked.  The milk is generally
thrown off, in  an unchanged condition; and the infant is so  little
annoyt,.4 by the vomiting that it will often preserve its  usual placid
and cheerful countenance, whilst  the milk is regurgitating  from
its stomach.   This variety of vomiting may therefore be regard-
ed, rather as a salutary than a morbid occurrence; for the super*
abundant nourishment  with which the digestive organs are habit-
ually overloaded, would, doubtless, soon give rise to indigestion
and its various disagreeable consequences, if the stomach did not
regularly relieve itself  by throwing off a portion of its oppressive
load.  So long as  the  infant  remains healthy, and the ejections 
206                     OF VOMITING.
are, manifestly, mere efforts of the stomach to relieve itself of its
over-distended condition, nothing ought to be done, in the way of
remedial applications,  to  prevent the vomiting.  Nevertheless,
these  efforts of the stomach to relieve itself, though obviously salu-
tary, show, that the infant is habitually going beyond the proper lim-
its of moderation in its nourishment; and as a frequent repetition
of this error, however transient in its  influence,  may  ultimately
weaken the tone of the digestive organs or establish a habit of
immoderate indulgence in eating, it will always be proper, to en-
deavor to obviate the cause of the vomiting—namely the over-reple-
tion of the stomach, by preventing the infant from taking too much
nourishment at a time.  With this view," the child should be taken
from the breast, the moment it begins to dally with it, or as soon as
it ceases to draw as if it were really gratifying a necessary and pro-
per appetite."   When the infant has satisfied its appetite, it ought
not to be immediately jolted  and dandled, but suffered to remain
perfectly at rest, for at  least thirty minutes, after it has been taken
from  the breast.   The common practice of tossing and  jolting
infants immediately after they have  taken nourishment is  highly
improper.  In cases of the kind now under consideration—where
the stomach is usually charged to the utmost of its capacity at each
nursing, this practice is particularly objectionable, as it  rarely fails to
excite vomiting and interfere with the regular progress of digestion.
If the child is kept in a state of quietude after its removal from
the breast, and  the quantity  of  its nourishment somewhat dimin-
ished, in the way just mentioned, the habit of vomiting soon after
the reception of its food, may almost always  be effectually over-
come.  The mere cessation  of this inconvenience, however, is
not the only advantage which may be  expected from these mea-
sures.  Infants  who are in the habit of vomiting after sucking,
from  mere over-distention of the stomach, are peculiarly apt,  at a
subsequent period, to become affected  with habitual torpor of the
bowels or costiveness.   I have repeatedly noticed this connection
between vomiting from repletion during the early period of infan-
cy, and habitual costiveness at a more  advanced  age.  It  would
seem  as if the excitability of the alimentary canal  became, in a
manner  concentrated in the  stomach.   This consequence might,
doubtless, be, in a great measure, obviated, by constant attention 
                        OF VOMITING.                    207
to a suitable moderation in the infant's nourishment.  This is the
only mode by which we may prudently attempt to prevent the re-
currence of this kind of vomiting.  All efforts to obviate the vom-
iting by medicinal agents, must not only prove abortive, so long
as the infant is permitted  to fill its stomach to excess, but often
decidedly injurious, and should never be attempted incases of this
kind.

   Morbid Vomiting may be excited by injurious or offensive  sub-
stances lodged in the stomach, or occur as a symptom of some lo-
cal or general affection of the body.   Underwood says, that trou-
blesome vomiting sometimes occurs in consequence of a "suppres-
sion of the discharge behind the ears; and from the sudden dis-
appearance of  some eruption  on the skin."   Dr. Dewees, how-
ever, doubts whether vomiting ever occurs as a direct consequence
of these causes. " We have never witnessed it," he says "from ei-
ther of these  causes."  That such  cases do occur, I have had un-
equivocal evidence.  I attended a child within the present year,
affected with frequent vomiting, which was manifestly connected
with an excoriation and occasional serous discharge behind both
its ears.   It was  observed, that whenever there was a  discharge
from these sores, the child was free from vomiting and appeared
well; but as  soon as the serous  discharge ceased, which it occa-
sionally did without any obvious cause, the little patient became
pale, sickly, and  vomited five or six times  daily.  The infant was
about eighteen months old.  When I first saw it, there had been
no discharge  for  five or six days.  The parts were  perfectly dry
and scurfy.  The child was  pale, and threw up  almost every
thing it took  into its stomach.   I applied blisters behind the ears
and on the following day no vomiting occurred.   By the occa-
sional application of blisters, and the use of equal parts of lac sul-
phuris and magnesia,  the  child finally regained a good  state of
health.  This is the only case of this kind, I have met with.
  Dentition is sometimes attended with a very irritable state of
the stomach giving rise to frequent vomiting.  This probably de-
pends on an extension of  the irritation from  the  mouth  to the
brain, causing a kind of erithism of this organ—a condition which
is almost invariably associated with an irritable  stomach  and a 
208                     0F VOMITING.
strong disposition to vomit.   The best means for checking this spe-
cies of vomiting are, blisters applied behind the ears, or  on the
back of the neck; dividing the gums down to the advancing teeth;
warm pediluvium;  purgatives,  or purgative enemata; and small
doses of laudanum.
  Vomiting is sometimes excited by a bad condition in the  nurse's
milk.  When it arises from this cause, the child generally throws
up the milk almost as soon as it is done sucking.   We may read-
ily satisfy ourselves, whether it depends upon this cause, by put-
ting  the infant upon the use of some other suitable nourishment,
or suffering it to suckle another nurse.  If no vomiting occurs af-
ter such a change of its nourishment, the source of the evil is man-
ifest, and a permanent change  must be adopted, unless the vomit-
ing be but trifling.
  One of the most frequent sources of vomiting, however, is a dys-
peptic state of the stomach,  occasioned by improper  articles of
nourishment, or immoderate feeding.  These cases are generally
attended with a prevailing acidity in the primae viae.   The  milk
is thrown up in dense coagula, and has an acid smell; the child
is troubled with flatulency, acid eructations, and the stools  are,
usually green, more or less griping, and sometimes diarrhceal.  In
some instances however, the bowels are torpid, and the child expe-
riences occasional attacks of slight  colic pains. In these cases the
milk or food is seldom thrown up, until it  has lain some time in
the stomach.  Dr. Dewees, observes that when the vomiting de-
pends on an excess of acid, " the milk is thrown up in a few min-
utes  after it has been received  into the stomach."  This does not
accord with my own observations.  I have seldom known vomiting
to ensue in cases of this kind,  until the milk had lain, at least, a
quarter of an hour in the stomach,  and, in many cases, the inter-
val between receiving it and throwing it off again, is much longer.
In such  cases,  the diet ought to be  carefully regulated,  and
above all, moderation in the quantity of food taken,  rigidly en-
joined.   If the child has  been weaned, much benefit may some-
times be obtained by mixing its usual farinaceous nourishment or
milk, with beef or chicken tea, or weak  mutton broth.   Equal
parts of barley-water  and chicken tea forms an excellent nour-
ishment, where there is a strong tendency to acidity in the stom- 
                         OF VOMITING.                    209
 ach.   To  arrest the vomiting, lime-water,  and milk,  given  in
 repeated doses, often produces an  excellent effect, where the
 cause of the evil consists in a redundancy of acid in the primae
 viae.   If costiveness or  slowness of the bowels attend, small and
 frequent doses of calcined magnesia, are  preferable; and I have
 occasionally administered the bi-carbonate of soda, dissolved in a
 very weak infusion of  colomba with prompt and complete  ad-
 vantage in instances of this kind.
   Acid is not, however, always present in cases of vomiting, de-
 pending on  a deranged condition of the digestive organs.   In
 some instances, there is a total deficiency  of acid;  the milk, com-
 ing up in a perfectly unchanged state, and wholly free from any acid
 smell.  The vomiting in such cases, seldom takes place, until the
 nourishment has lain a considerable time in the stomach, and it is
 generally preceded by very obvious signs of nausea.  The child's
 countenance  becomes pale and expressive of great anxiety and
 distress, and in a moment the  contents of the  stomach are thrown
 with  great  force.  In cases of this kind, a  teaspoonful of good
 lisbon or maderia wine, given at proper intervals sometimes pro-
 duces a very happy effect.   A drop or two of nitric acid, in a lit-
 tle sweetened water, also  forms an  excellent  remedy in such
 cases.  Dr. Dewees, says that he has rarely  failed procuring
 relief, in this condition  of  the stomach, "by the occasional exhi-
 bition of small quantities of lemonade." I  have used a mixture  of
 the spiritus mendiriri and lemon syrup, in  several instances, with
 prompt and complete success.   Three ounces of the former, with
 an ounce of the latter, forms a good mixture for this purpose.   A
 teaspoonful of this may  be given every half hour, or at remoter
 intervals according  to the urgency  of the case.
   When the  vomiting  is excited  by the  presence of improper
 articles of  nourishment  in the stomach, the exhibition of a mild
 emetic will often proves decidedly beneficial.  Four or five grains
 of ipecacuanna, may be given without the least risk of injury,
and generally with  much advantage.  I have always preferred
this article, to antimonial wine, in the gastric  affections of infants
when a remedy of this kind was deemed proper.   It is much less
apt to irritate  the mucous membrane of the alimentary canal and
to debilitate the system than antimony;  and its secondary effects
                           2E             19 
210                     OF VOMITING.
are, in general, much more salutary, in cases attended with an
irritable condition of the stomach, than those of the latter article.
We may, however, frequently procure the entire evacuation of
the offensive substances lodged in the stomach,  in cases of this
kind, simply by the exhibition of warm water, by which the vom-
iting is, at first, promoted,  and  the stomach freed of its offensive
contents.  If, after this has been effected, the vomiting does not
cease, a few drops of laudanum or of camphorated spirit, given in
a little milk, will generally prevent its recurrence.
  We, however, often  meet with cases of vomiting  in infants,
which are neither excited by an excess of acid, nor by improper
articles of food  nor  by any other offensive  substances lodged in
the stomach, and for which, in fact, we can assign no other cause
than that the stomach has, from some circumstance or other, be-
come  extremely irritable.  In cases  of this kind—that is, when
the stomach is morbidly irritable and the matter  thrown up, con-
tains little or no  acid, we may sometimes do much good by the
administration of minute doses of calomel and ipecacuanna.   I
have repeatedly succeeded in arresting vomiting, from inordinate
gastric irritability in infants, by exhibiting the eighth of a grain
of calomel with the one sixth of a  grain of ipecacuanna every
hour or two, in conjunction with the application of a stimulating
poultice or plaster over the epigastrium.   The  application of a
poultice of this kind, is  calculated to operate beneficially, what-
ever may be the cause of the vomiting.  A teaspoonful of pulver-
ized cloves, with the same quantity of black-pepper, formed into
a poultice with  crumbs of bread and water, will, in general,
answer this purpose  very well.   A handful of dried mint, rubbed
up and made into a poultice with meal or bread, forms, also, an
excellent stimulating application in this condition of the stomach.
With the  exception of small doses of laudanum, internal stimula-
ting remedies seldom procure more than very transient relief, and
may readily occasion a great deal  of mischief, where there is
much irritability of the stomach.  The occasional use of laxative
enemata, will sometimes assist materially in such cases.   When
opiates are deemed proper, no preparation, I am inclined to think,
is more suitable, in  this state of the stomach, than the common
paragoric  tincture of the shops.   All the purposes however, that 
                        OF DIARRHCEA.                    211
opium is capable of fulfilling  may be fully obtained by applying
it  externally.   One or two grains of morphia  sprinkled on the
surface of a small plaster of common cerate, and laid over the
pit of the stomach, will procure a sufficient degree of narcotic in-
fluence.  When the skin is broken, this article will operate  as
promptly, and  with nearly the  same degree of energy as  if it
had been received into the stomach.
CHAPTER  XX.
OF DIARRHOEA.
   Although by no means peculiar to infancy, diarrhoea is, un-
 questionably, by far more common during this early age, than at
 any other period of life.  From  the peculiarly susceptible and
 uninured state of the  alimentary  canal, and the general organic
 feebleness of  infancy,  it is, also, in general, much more apt to as-
 sume an unmanageable and dangerous character, at this period,
 than at a more  advanced stage of childhood or adult age.  In
 some instances, the diarrhoeal discharge sare faeculent, and easily
 managed.   In others, the stools consist principally of viscid mu-
 cus, streaked, occasionally, with a little blood.  Sometimes the
 evacuations are conspicuously bilious.  In other cases, the dis-
 charges present a white or milky appearance, accompanied with
 rapid emaciation  and  prostration; and in some instances they
 consist of a mixture of faeculent matter, mucus and imperfectly
 digested articles of food.  Although irritation of the mucous
 membrane of the bowels, constitutes the immediate cause of the
 increased peristaltic action and consequent inordinate discharges,
yet each of these modifications in the character and appearance
of the evacuations, is essentially connected with peculiar patho-
logical conditions, which it is  of great practical importance to
discriminate.  It should be observed, however, that the simplest
or feculent variety of the disease,  may, under improper manage- 
212                      OF DIARRHEA.
ment or the continued operation of irritating causes pass into any
of the  other  modifications—there being no  essential  difference
between them, except what arises from the degree  of inflammato-
ry irritation—the portion of the  bowels principally affected, and
the extent to which  the digestive powers, as well as the neigh-
boring  structures and organs become implicated in  the disease.
Thus, if there is simple irritation of the alimentary canal without
much impairment of  the  digestive  functions, the  stools will be
faeculent.  If the inflammatory irritation is seated principally in
the small intestines, and extends itself to the mesenteric glands,
the discharges will probably be  chylous.   Should the  irritation
be  severe, and chiefly located in the large intestines, the stools
will be mucous:  If the liver becomes unusually excited, bile will
manifest itself in the evacuations;  and when the stomach  be-
comes very irritable and the digestive  functions depressed por-
tions  of imperfectly digested food will pass off with the stools.
  The  exciting causes of diarrhoea are extremely various.  Some
of them act directly on the mucous membrane  of the intestinal
canal, whilst  others affect the bowels, sympathetically, through
the  medium  of  the   general nervous  system.   Of the former
variety are all irritating substances received into, or generated
in the alimentary canal; and of these, by far  the  most common
are:  irritating,  crude,  or inappropriate  articles of  food and
drink;  acrid  and vitiated secretions from the liver and intestinal
exhalents; worms, acid, fresh fruit,—particularly such as are very
sweet &c.   The foundation of diarrhoea, in infants, is often laid
during  the first  twenty-four  hours  after  birth.   The habit of
gorging the infant's stomach with alimentary fluids, previous to
the secretion  of its natural and  congenial nourishment by the
maternal breasts, often at  once, produces a degree of gastric irri
tation and feebleness,  which predisposes to the occurrence of di-
arrhoea, colic &c. from the slightest causes.   Children who are
entirely nourished at the breast, are much less apt to become af-
fected with this complaint, than  such as are partly nourished by
artificial food.  There exists, however, great diversity in relation
to the effects of the same article of nourishment, in different indi-
viduals.  Some infants are  invariably purged,  when fed with
cow's milk,—even when considerably diluted with  water.  In 
                         OF DIARRHIEA.                    213
 some children the ordinary preparations of arrow-root  produce
 costiveness, whilst we occasionally find this article to give rise to
 much disturbance in the alimentary canal, and  purging.   This,
 however, is but seldom the case, its usual effects being rather  of
 a constipating character.   But it  is not  from the  usual  farina-
 ceous and mucilagenous  articles, that any particular mischief is
 to be apprehended in this  respect.  On the contrary, they are
 generally the most appropriate dietitic means for preventing and
 counteracting diarrhceal affections.  It is only, when given to ex-
 cess—when the stomach is habitually overloaded with them, that
 they are apt  to give rise to disorder of  the bowels.  However
 mild and congenial the nourishment maybe, it will be apt to give
 rise to weakness of  the  digestive powers,  and purging, when
 taken in  excessive  quantities.  Over  distention   of the sto-
 mach, by  the immoderate reception  of food, seldom, however,
 produces any immediate  bad effects  in  this  way.   It is  in
 general  only,  by degrees,  that  the  tone  of the stomach is
 thus  impaired;  and that it gives rise  to intestinal irritation and
 purging.  Infants who are fed with solid articles of food, seldom
 escape suffering more  or less from diarrhoea.   The practice of
 allowing potatoes, meat, pastry, dried fruit, and  other articles of
 this kind, to infants, is peculiarly calculated to give rise to  intesti-
 nal irritation, and all  its disagreeable and alarming consequences.
 This injurious practice is seldqm  confined to the production  of
 simple diarrhoea.   It is apt, ultimately, to produce a slow form of
 inflammation in the mucous membrane of the  bowels, terminating
 often in  ulceration or incurable disorganization of this delicate
 structure.  Chronic cases of diarrhoea, attended with general irri-
 tation and emaciation, are almost always  connected with  inflam-
 mation and  structural lesion of the intestinal  mucous membrane;
 and the  majority of such  instances are the result  of errors in
 diet—particularly of crude and irritating articles of solid food.
   In  some  instances,  the mother's or nurse's milk, disagrees with
 the infant's stomach, and gives rise to troublesome vomiting, colic
 and purging.  This does  not always  depend on any obvious ill-
 health,on the  part of the mother or nurse.  I have recently seen
 an instance of protracted diarrhoea, in an infant about six months
old, which was nourished exclusively at the breast, and the mother
                                             19* 
214                     OF DIARRHOEA.
appeared, in every respect, perfectly healthy.  The breast wa»
withheld, and a mixture of cow's milk and water substituted for
its nourishment, which had the effect of  immediately putting  a
stop to the diarrhoeal affection.   The milk, in cases of this kind,
is,doubtless,in mostinstances faulty; but it is probable that idiosyn-
cracy, on the part of the infant, is sometimes  the principal if not
the exclusive source of the mischief, independent of any positive
bad quality in the milk.   When the  milk disagrees with the in-
fant's stomach, the usual  consequences,  in the first place, are
vomiting, and acidity.   The digestive functions soon become de-
ranged, and the milk passing into the bowels, in an imperfectly
digested state, together with the abundant acid usually generated,
causes intestinal irritation  and diarrhoea—the discharges exhibit-
ing a curdled, stringy, yellow or green appearance.  Cases of this
kind, are generally attended with occasional paroxysms of severe
colic pains; and the eructations and  ejections from the stomach
have a very acid smell.  Irascible and passionate nurses, and such
as are under the  influence of some depressing mental  emotion,
are peculiarly apt to furnish milk of a bad and irritating quality,
tending to produce diarrhoea, and other forms of intestinal disorder.
The nourishment, too, which is taken  by  the  nurse has a decided
influence on  the  qualities of the milk, and consequently on the
digestive organs of the nursling.   The free use of salted meats by'
the nurse, has  a tendency to render the milk  acrid or offensive to
the delicate digestive organs of the  infant;  and I have  known
very rapid diarrhoea to occur in consequence  of a free indulgence
in  eating fresh fruit, particularly cherries, on the part  of the
nurse.
   The influence  of  dentition on the alimentary  canal  is well
known.   Many infants are almost constantly  affected with  loose-
ness of the bowels during this important process;  and when  the
diarrhoeal discharge is moderate, it may be regarded as decidedly
salutary  in its  tendency,  and ought  not to be checked.   It has
been supposed that the immediate cause  of the  diarrhoea  which
 often attends dentition, consists in an acrid condition of the saliva
 —in consequence of the irritation in the gums, extending to the
 salivary  glands, and perverting their action.  Some degree  of
 gastric irritation  may occasionally arise from this cause; but the 
                        OF DIARRH(EA.                    215
principal source of the complaint, appears to consist  in a pecu-
liarly irritable state of the alimentary canal, caused, by the  den-
tal irritation.   The whole  nervous system often becomes highly
irritable during the process of dentition.  The brain  becomes
remarkably excitable, manifesting in many instances, a decided
state of erethism, and the whole organization acquires a preterna-
tural susceptibility to the impressions of exciting causes.  In this
irritable condition of the intestinal canal, therefore, even the or-
dinary and appropriate kinds of nourishment, may give rise to ir-
ritation of the bowels and consequent diarrhoeal discharges.   The
digestive functions may, moreover, suffer derangement from den-
tition, and favor the  production of acid and other causes of intes-
tinal irritation.
  Cold,  by suddenly  checking the perspiration  and determin-
ing the blood  to the internal organs, frequently gives rise to
bowel complaints in  infants.  Cold-bathing, or washing; suffering
wet  diapers, stockings, &c. to remain  too  long  on  the infant;
setting or lying down on damp grass-plats, floors, steps, &c, pass-
ing suddenly from a  close and warm room into the cold external
air; and exposure to cold and humid weather without  sufficient
clothing—particularly about the abdomen—these are the ordinary
ways in which diarrhoea, from the influence of cold, is produced in
infants. Cases arising from this cause, are generally attended with
slight catarrhal symptoms, more especially with cough; and some
degree of febrile irritation almost invariably occurs.  There is in
general, a greater tendency to inflammation of  the mucous mem-
brane of the bowels, in cases of this kind, than in those produced
by the other causes of the disease mentioned above.   The skin is
usually dry and harsh,  and the discharges are commonly very li-
quid or watery, containing flocculi of mucus,  with little or  no
bilious matter or acid.

  Atmospheric Heat, also, is frequently concerned in the produc-
tion  of this complaint.  Its tendency to excite  and derange  the
functions of the liver is well  known.  The  occurrence of bowel
complaints among children, is incomparably more frequent during
the hot months  of summer, than in the colder seasons of the year.
It is probable that the agency of  solar heat in the production of 
216                    OF DIARRHOEA.
bowel complaints, depends as much on the miasmatic exhalations
which it generates, as on its own direct operation on the animal
system.  It is certain that complaints of this kind, are vastly more
common in situations favorable for the development of miasmata,
than in localities not abounding in materials fitted for its genera-
tion.   There  can be no doubt, however, that high atmospheric
temperature, by its direct influence on the system, is capable of
giving rise to diarrhoeal affections.  There appears to subsist a
direct relation between the liver and the skin;  so that when the
cutaneous exhalents are kept in a state of unusual action by the
influence of atmospheric heat, the liver, acquires a corresponding
degree of activity, giving rise to a  copious secretion of bile.
Hence bilious diarrhoea is most frequently met with during warm
weather.  In many cases of diarrhoea from this cause, however,
there is but very little or no bile perceptibl  in the evacuations.
The liver, in such cases, is torpid and engorged  with blood.  This
may arise from the alternate influence of high and low tempera-
ture.   When the skin and liver are in a state  of activity from at-
mospheric heat, the system is extremely susceptible to the impres-
sions of  low temperature.   If an individual in this situation  is ex-
posed  to the influence  of cold or even cool air—as the cool  night
air after a warm day, the cutaneous exhalents and liver are sud-
denly  rendered torpid.  The blood, passes from the external to
the internal organs, and the liver becomes at once greatly con-
gested and torpid—a  condition which is always attended with
great  irritability  of  the stomach and  bowels.   Cases resulting
from these influences, seldom assume the character of simple diar-  '
rhoea. They generally occur in the forms of cholera or dysentery.

   Fozculent Diarrhoza.—This  is the simplest  and in general the
most  manageable variety of  diarrhoea.   The  evacuations are
faeculent, resembling those which are produced  by the operation
of  an  active cathartic.  The pathological condition of the bow-
els, in  this modification of the complaint appears to consist in sim-
ple irritation, depending either  on the  presence of acrid and
offensive substances lodged in the  alimentary canal, or on in-
creased  irritability, in  consequence of which the ordinary con-
tents of the bowels excites excessive peristaltic action and con 
                         OF DIARRHOEA.                    217
sequent diarrhoea. When the diarrhoea, depends on the presence
of acrid or offensive substances in the intestines, it  frequently
cures itself; for as soon as the irritating materials are  evacuated,
the inordinate  action of the bowels, usually ceases, and the dis-
charges  assume  their natural and  healthy character.  Perhaps
the majority of instances of diarrhoea, are, in the first place, ex-
cited in this way:—that is,  by irritating substances either intro-
duced into the stomach from without, or generated in the intesti-
nal canal,  by fermentation,  decomposition, and morbid secretions.
Very frequently, however, cases, that commence in  this way—
the  diarrhoea  being  at first similar  to the purging excited by
cathartics,—are soon associated with  a morbidly irritable  condi-
tion of the bowels; and when this occurs, a spontaneous cure can
no longer  be expected, since the  mildest  substances will cause
irritation and inordinate peristaltic action.   When the diarrhoeal
discharges continue for three or four days,—more especially after
the operation of an  efficient laxative, we may presume that the
complaint no longer depends, mainly  on the presence of acrid or
irritating  substances, but on a morbid change in the sensibility
and irritabiltiy of the bowels.  Cases of this kind, sometimes as-
sume a very severe and intractable character, in consequence of
the supervention of inflammatory irritation or of sub-acute inflam-
mation  in the  intestinal mucous membrane.  These cases are,
however,  rarely attended  with faeculent discharges  properly so
called, and must be ranked with one  of the subsequent varieties
of the complaint.
   The most common source of simple faeculent diarrhoea consists
probably,  in dietetic  errors.  When  the stomach is overloaded
with nourishment, or when the articles of food are crude, insolu-
ble and of difficult digestion, more  or less disorder of the alimen-
tary canal is inevitable.  If, after an  error of this kind, the food
is not soon rejected  by the stomach,  portions of it will pass into
the bowels in  an imperfectly digested state, and give rise  either
to severe  colic, or to rapid and painful diarrhoea.  If the error
be not repeated, and a moderate and  appropriate diet used, cases
of this kind sometimes cease as soon as the offensive materials are
evacuated.  In  general, however,  the digestive powers, suffer
more or less impairment from the irritating impressions and resist-
                              2F 
218                    OF DIARRHOEA.
ance of the improper food; so that even  the  mildest  and most
congenial articles of nourishment may afterwards fail to be pro-
perly digested.   When this happens,  gastric  disturbances and
diarrhoea, of a protracted  and obstinate  character often  occur,
which can seldom be  entirely removed without especial attention
to the digestive organs.  The diarrhoea which results from a bad
or unwholesome condition of the mother's -or nurse's milk, is al-
ways in the beginning faeculent, and generally remains so through-
out its course—that is the  digestive functions are  impaired and
the bowels in a state  of simple irritation.
   In some instances of faeculent diarrhoea, the exciting cause con-
sists in a superabundance, or in a depraved condition of the bilia-
ry secretion.  In cases of this kind, the evacuations are conspi-
cuously  mixed with  bilious matter, sometimes of a  dark, but
more frequetly of  a  light  green  color.   The appetite is often
strong, but the digestive powers are almost always  impaired.
   Sickness of the  stomach, and vomiting, occur much  more fre-
quently in this variety  of diarrhoea, than in any other modifica-
tions of the complaint.  This is more particularly the case, when
the diarrhoea is excited by bad milk,  or irritating  and inappro-
priate articles of food.   Nausea usually supervenes a short time
after taking nourishment.   This is soon followed by pain in the
bowels, and  more  or less  rapid purging.  When the nausea is
frequent  and considerable, or when  vomiting  occurs  often, we
may presume, that the morbid state of  the  stomach  manifested by
these symptoms, constitutes the main pathological condition of the
disease, and that it requires very especial attention in its remedi-
al management.   This disordered  state of the stomach, appears
to consist of simple irritation and weakness of its digestive ener-
gies, without any fixed inflammatory irritation or phlogosis.
   Diarrhoea from the application of cold to the body is not often
of  the simple faeculent  variety.  If, in the  beginning of the
complaint, the discharges are faeculent, which may frequently be
the case, they seldom continae to exhibit this character through-
out,  more especially when its course is  protracted, and  other
sources of gastric  derangement  are present.   The tendency to
high  inflammatory  irritation in the  mucous membrane of the sto-
mach and bowels in cases excited by cold, is in general very con- 
                        OF DIARRHCEA.                    219
siderable, and  many instances of this kind, accordingly,  early
assume a much more violent character—the discharges becoming
watery with  floculi of mucus—or mucous with streaks of blood,
attended with  febrile  symptoms, and a  constant tenderness  or
soreness of the abdomen.
  The occurrence of simple feculent diarrhoea from  dentition is
very common.  . When the complaint arises from this cause the
discharges are  sometimes mixed with an abundance of green bile,
more commonly however there is but very little or no hile, in a
separate state perceptible in the evacuations.  The stomach also
usually considerably disordered, and the child generally manifests
a fretful  and irritable temper.   In  some cases the diarrhoeal dis-
charges alternate with short periods of costiveness, and these in-
tervals of intestinal torpor  are almost invariably attended with
increased symptoms of general irritation.

   Treatment.—It has already been stated that feculent diarrhoea
from crude or irritating substances taken  into the stomach some-
times terminates  spontaneously as soon as the offensive materials
are evacuated by the purging which they excite.  It would  not,
however, be prudent to rely long on a spontaneous cessation;  for
the  irritating cause may be retained many  days, notwithstand-
ing the occurrence  of frequent copious and forcible diarrhoeal dis-
charges, and ultimately give rise to inflammatory irritation in the
mucous membrane of  the bowels.  It is, therefore,  always the
safest plan, in cases of this kind, to secure an early and entire ex-
pulsion of the'irritating contents of the bowels, by suitable purga-
tives. Magnesia is the most appropriate article for this purpose where
there are indications of acidity in the primae viae. In cases unattend-
ed with acid in the stomach, castor oil, rhubarb with or without small
portions of calomel, and in very young infants, syrup of rhubarb,
are, perhaps, the most  suitable purgatives.  After the purge has
operated, the excitement of the bowels ought to be allayed by an
opiate. The last time, in general, for exhibiting the opiate is in the
evening.  From one to three grains of Dover's powder, according
to the age of the child,  or a few drops of laudanum, should  be
used for this purpose.   A suitable dose of Dover's powder in union
with a small portion of calomel, forms a peculiarly useful anodyne 
220                     0F DIARRHOEA.
in cases of this kind.   If the last discharges brought away by the
purge  exhibit an unnatural appearance, or if there is reason to
think that the  bowels have not been entirely freed of their irri-
tating contents, the purgative ought to be repeated, and again fol-
lowed by an opiate.  The nourishment  should be simple and
bland, and< taken in moderate  quantities.  Arrow root, barley
water, oat meal gruel, sago, boiled milk, rice, &c. constitute the
most appropriate articles of diet.   Particular care should be ta-
ken that the stomach be not overloaded with  food.  The bland-
est nourishment will be apt to keep up  the complaint, if more of
it be taken at a time, than can be easily digested.   The portion
that remains imperfectly digested, becomes a source of  irritation
to the bowels,  and keeps up the disease.
   When in recent cases arising from  errors in diet or  irritating
ingesta, considerable nausea or ineffectual efforts to throw off the
contents of the stomach occur, much benefit may sometimes be de-
rived from the operation of an emetic.   Dr. Dewees recommends
full doses of calomel, as "the best possible" means for relieving the
stomach in cases of this kind.   It  rarely fails to produce pretty
active vomiting,  and operates also as a purge.   I have  generally
preferred the use of ipecacuanna, where an emetic was indicated,
both on account of its  mild operation, and its tendency, in minute
doses, to allay intestinal irritation.  After the stomach  has  been
well evacuated by the ipecacuanna, a small dose of calomel, fol-
lowed in the course of three or four hours by a suitable portion of
castor oil, should be given to remove the irritating contents of the
bowels.
   Recent cases  of feculent diarrhoea, excited by improper in-
gesta or errors in diet, generally yield readily as soon as  the offen-
sive materials are evacuated and the bowels tranquillized by an
opiate.  Sometimes, however,  the cause that has excited the dis-
ease, produces, at once, a considerable degree of irritation in the
mucous membrane of the bowels,  in consequence of which the
diarrhoeal  discharges  continue  after the  original cause of the
complaint has  been removed.   When this happens, and the dis-
ease continues, purgatives are no longer adequate to arrest the
progress of the bowel affection.  Indeed, it is of great importance
to bear in mind, that harsh and  frequent purging may do a great 
                         OF DIARRHOEA.                    221
 deal of injury by increasing the mucous irritation, and converting
 it into actual inflammation.  Simple diarrhoea, is frequently con-
 verted into an aggravated form of the disease, by the injudicious
 practice of exhibiting active purgative remedies, after the bowels
 have been once or twice freely evacuated in the beginning of the
 complaint.  It is seldom necessary or proper to employ more than
 two or three active  purges in cases of feculent diarrhoea, from
 transient or temporary exciting causes.   To obviate the retention
 and injurious impressions of vitiated secretions, in cases of this kind
 minute portions of calomel and ipecacuanna in union, followed by
 a moderate dose of castor oil generally answers very well.  A half
 a grain of calomel with the same quantity of ipecacuanna, for a
 child of from  one  to two years old,  seldom fails to produce a
 sufficient  laxative  effect.  Should it fail, however, its operation
 may be promoted by the administration of a moderate dose of cas-
 tor oil.  When feculent diarrhoea assumes a protracted and ob-
 stinate character,  without any decided  indications of inflamma-
 tory irritation  in the  mucous membrane of the bowels, the  regu-
 lar employment of small doses of Dover's powder,  in union with
 prepared chalk, and minute portions of calomel,  together with a
 strict attention to the diet, often produces an excellent effect.  A
 powder composed,  a grain of Dover's powder, one sixth of a grain
 of calomel, and five grains of prepared chalk may be given two,
 three, gr four times daily, according to the age of the patient and
 violence of the complaint.  Vegetable astringents, also, often do
 much good in protracted cases  of  simple diarrhoea, provided the
 mucous membrane  of  the bowels be free from inflammatory irri-
 tation and the irritating contents of the alimentary canal  have
 been properly evacuated by purgatives.   They are by no means
 suitable, however, in cases associated with an inflammatory state
 of the bowels,  or with  an irritable and febrile condition of the
 general system. When the diarrhoeal discharges are feculent and
 very liquid, and unaccompanied by griping and tenderness of the
 abdomen, remedies  of  this kind often operate very beneficially.
 A decoction of blackberry root, or the root of geranium macula-
 turn, in milk has more  frequently succeeded  in my hands, than
any other article of this kind.   The geranium root especially, is
an agreeable and efficient astringent, and may be freely employ-
                                            20 
222                     0F DIARRHOEA.
ed  with but very little  or no risk of unpleasant irritation.   An
ounce of the dry root should be boiled in a pint of fresh milk, un-
til one half is evaporated.  From a teaspoonful to a tablespoonful
of this decoction should be given four or five times daily according
to the age of the patient.  I consider this astringent decidedly pre-
ferable  to the gum kino, so frequently employed for this purpose.
Kino is  more apt to derange the digestive organs and to occasion
irritation  in the mucous membrane of the bowels than the gera-
nium.   The effects of the latter, too, in  arresting the inordinate
action of the bowrels, are much more mild, gradual and permanent
than those of the latter, which though sometimes very prompt, are
often transient, the  complaint recurring after a temporary  sus-
pension.  It may be again observed, however, that astringents as
a general rule, are  decidedly improper, in diarrhoea, connected
with high irritation, inflammation, or  structural lesion of the in-
testinal mucous membrane.
  Cretaceous preparations were formerly almost indiscriminately
used in the bowel complaints of children. When the complaint
arises from acidity in the primae viae, and when there are no indi-
cations  of inflammatory irritation of the bowels present, cretaceous
remedies sometimes produce very excellent effects.   They are not
proper, however, in cases of an opposite character—that  is where
the discharges are mixed with masses or flocculi of mucus, and ac-
companied with much tormina and soreness of the abdomen.  In the
ordinary bowel complaints of infants, during the summer months,
there is usually a very  considerable tendency  to inflammation or
high vascular irritation of the mucous membrane of the intestinal
canal, and hence cretraceous remedies often lead to very  unfavor-
able consequences in these cases.
  When faeculent diarrhoea arises from cold, it is almost  invaria-
bly accompanied with more or less conspicuous symptoms of febrile
irritation.  The skin is  usually dry and hot, and the patient fret-
ful  and  irritable.  In some instances of this kind, the evacuations
are watery, and copious, and passed off with little or no  griping.
More frequently, however, there is a considerable portion of  mu-
cus mixed with the faeces, and the patient experiences severe tor-
mina.   In such cases it will be useful  to  promote the expulsion
of the acrid secretions from the bowels, by one or two mild laxa- 
                        OF DIARRHOEA.                    223
tives; but repeated and active purging, is calculated to do much
mischief, by increasing the centripetal determination of the circu-
lation, and favoring the occurrence of inflammation in the mucous
membrane of the bowels.   After the contents of the bowels have
been freely evacuated by a dose of castor oil, small doses of Do-
ver's powder  and calomel  generally  prove  highly beneficial  in
these cases.  One grain of the former with  half A grain of the
latter may be given, twice, thrice, or four  times daily, according
to the age of the patient and the urgency of the complaint.  The
abdomen should be  enveloped with  flannel,  and the feet  kept
warm and  dry.   The warm-bath  may also be used with consid-
erable advantage in such cases,—particularly when the skin is
dry  and  harsh.  Astringents and absorbents are entirely  inappro-
priate in cases of this kind.
   In diarrhoea, depending on dentition, it is necessary to  proceed
with much caution in the employment of remedies calculated to
arrest its progress.   Moderate diarrhoea, often exerts a very salu-
tary effect during dentition.  It tends to  counteract the preter-
natural determination of blood to the head, and to diminish the
cerebral  irritation which is apt to  occur in difficult dentition.
Children who are affected with diarrhoea while cutting teeth, are
much less apt to become affected with convulsions and tliseases of
the brain, than those whose bowels are habitually torpid during
this  important process.  If the complaint is moderate, no attempts
ought to be made to arrest its course by internal remedies.  It
will  tend, in-some degree, to protect the brain from injurious irri-
tation, and to keep down the general  irritable and febrile condi-
tion  of the  system.   If the gums are swollen, they ought to be
divided with a lancet down to the advancing teeth, and particular
care should be taken that the nourishment be simple, and unirri-
tating.   It is,  indeed, of the utmost consequence in cases of this
kind, to avoid every thing, in the way of diet, that is calculated to
increase  the intestinal irritation.   If the  patient is permitted to
use crude or inappropriate articles of food, it will scarcely be pos-
sible to prevent the complaint  from  assuming a very aggravated
and unmanageable character.   Diarrhoea from dentition, depends,
mainly on  a morbidly irritable condition of the  bowels.   If the
ingesta are bland and adapted to the digestive  powers of the 
224                     OF DIARRHOEA.
child, the complaint may go on moderately, and with a salutary
tendency, until the teeth are protruded.   A single error in diet,
however, may give rise to a state of inflammatory irritation in the
bowels, which it will  be extremely difficult to remove, so long as
the system is under the influence of dentition.   When diarrhoea
from teething acquires a violent character, advantage may be de-
rived from am occasional dose of castor oil, opiates, ipecacuanna
and warm-bathing.  There is no variety of diarrhoea in which
opiates operate more favorably than  in cases arising from  denti-
tion.   The Dover powrder, from its decided diaphoretic tendency,
is, in general, the best form for using  opiates in complaints of this
kind.   I have hitherto, generally, depended chiefly on the use of
this article, for moderating severe cases of diarrhoea,, during diffi-
cult dentition.  It should be given  in very small doses, at  suffi-
cient intervals to prevent nausea or vomiting. Ipecacuanna, also,
is an  excellent remedy in cases of this kind.  When administered
in doses of a sixth or a fourth of a grain, it often exerts a very
tranquillizing  influence  on  the bowels.   The dose  should  be
repeated every two or three hours.   When the evacuations  man-
ifest  a deficiency  of bile, small portions of  calomel should  be
united with the Dover's powders.   Care must, however, be taken
not to carry the use of calomel to the  extent of affecting the gums,
or producing a general  mercurial excitement.  Astringents are
wholly inadmissible in these cases.

   Bilious Diarrhoea.—This variety of the complaint is attended
with inordinate  functional activity of the biliary organs.  The
secretion of bile is excessive  in quantity, and doubtless, also, fre-
quently vitiated  in its composition.   The evacuations  are very
fluid, copious, and mixed with a great abundance of green or yel-
low bilious matter.  The urine is generally conspicuously imbued
with  bile, and when the complaint goes on for two or three days,
the skin and white of the eyes, usually acquire a yellowish or
slightly jaundiced hue.   Cases of this kind seldom occur during
the cold seasons of  the year.   High atmospheric temperature
appears to be the ordinary remote cause of this modification of
 diarrhoea.  It is not improbable, however, that what  is usually
 ascribed to the direct influence of solar heat on the animal system, 
                        OF DIARRHOEA.                    225
in the production of this and other forms of bilious disease, may de-
pend, mainly on the influence of the miasmata which  are always
more or less abundantly diffused throughout the atmosphere during
hot seasons, and which are well known to exert a direct and powerful
influence on the biliary organs.  Bilious diarrhoea is  much more
Common in situations abounding in materials adapted  for the gen-
eration of malaria, than in localities  of an opposite character.  In
populous cities and in marshy districts, this complaint  is very com-
mon during the hot months of the  year; whereas in dry, open
and elevated situations, it is but very rarely met with.
   In some instances, the bile, though extremely copious, exhibits a
perfectly natural or healthy character;  in other cases, it presents
an unnatural  appearance, and is  so acrid, as to  cause a severe
burning  sensation in the extremity of the rectum, and sometimes
very painful irritation about the anus.  Cases of the former kind
are usually easily managed; but the latter, are apt to  assume a
violent and obstinate character, in  consequence of the early su-
pervention of inflammatory irritation in the mucous membrane of
the intestinal canal.   Cases sometimes occur in which the evacua-
tions are at first highly bilious.  After having continued for some
days, the appearance of bile, in  file discharges ceases, and the
evacuations become  watery, without  the slightest trace of bilious
matter.  When this change takes place, the stomach, usually, be-
comes irritable, and the disease assumes the character of chronic
cholera.  The liver in cases of this kind, appears to be torpid,
from great sanguineous engorgement.
   Diarrhoea of a highly bilious character, is sometimes  produced
by improper nourishment, or by bad  milk.  These cases are most
apt to occur during the first two or three months of infancy, and
are  generally  associated with  much acidity in  the primae viae.
When the disease is excited in this way, the discharges are gene-
rally of a bright-green  color, and attended with severe griping.

   Treatment.—In the treatment of this modification of diarrhoea,
the  indications, are, to remove the acrid  secretions out of the
bowels, to subdue the morbid irritability of the  intestinal canal,
and  to correct the functional derangement of the biliary organs.
The bowels should, in the first place, be thoroughly evacuated
                              2 G          20* 
226                     OF DIARRHOEA.
by a suitable dose of castor oil.  After this has been effected, mi-
nute portions of  calomel and ipecacuanna must be given, in
repeated doses during the day, and an opiate in the evening.  The
fourth  of a grain of calomel with the same  quantity of ipecacu-
anna may be given every two or three  hours, to a child under
three years  old, and continued until the  character of the evacua-
tions is improved.  Minute portions of calomel  are, in general,
more beneficial in diarrhoeal affections, associated with an excess
of bile, than large and purging doses.  When large doses are fre-
quently repeated—more especially in  infants—they sometimes
give rise to much irritation in the mucous membrane .of the  ali-
mentary canal; and they are, moreover,  less  apt to allay the mor-
bid irritability of the  bowels than very small doses.
   To prevent the retention and accumulation of vitiated or irri-
tating  secretions  in the bowels, it will be proper to exhibit an oc-
casional  dose of castor oil; or an additional portion  of calomel
may be given, once daily, or  every other day, according to the
effects of the ordinary doses and the character of the evacuations.
Opiates, are in general, much less useful in this variety of diar-
rhoea than in the preceding one.  If the patient is free from fever,
advantage may be  obtained from a few  drops of laudanum, or a
moderate dose of Dover's powder  administered in the  evening,
particularly after the operation of a purgative; but opiates ought
not to  be employed for the purpose of arresting the  diarrhoeal dis-
charges so long as the evacuations are characterized by a super-
abundance of bilious matter.  Astringents  and absorbents  are
still  more  objectionable.  The principal  object to be  kept in
view, in the treatment of this variety of the  complaint, is to  cor-
rect the functional disorder of the biliary organs;  so  long as this is
not accomplished all attempts to restrain the  inordinate action of
the bowels, by opiates or astringents, must not only be abortive,
but often highly  injurious.  Should the evacuations assume a na-
tural appearance, and  the diarrhoea, notwithstanding continue, it
will then be proper, to administer small doses of Dover's powder
in union with the calomel, in order to subdue the morbid irrita-
bility of the bowels.
  In cases attended with febrile irritation, recourse should be had
to antimonials.   A few drops  of antimonial wine, or a teaspoon- 
                       OF DIARRHOEA.                     227
ful of a solution of tart, emetic, of the strength of a grain to two
ounces of water, should be  given every hour  or  two.  James'
powder is an excellent antiphlogistic  in cases of  this kind.   It
may be very advantageously given in union with calomel.  I have
often used the following mixture with very decided benefit in such
cases.  A teaspoonful of it, should be  given every two or three
hours.
                      Spirit Menderiri .  .  gii.
                      Spirit Nit. Dulc. .  .  3ii.
                      Vir. Antimonii  .  .  3'-
                      Tinct. Opii.   .  .  . gtt.

  Some  advantage  may also be  obtained  from warm bathing,
and from the free use of mucilaginous diluents, such as barley
water, slightly acidulated with lemon juice.   When the abdomen
becomes tender or sore to pressure, the application of a large emo-
lient poultice over the abdomen, and renewed from time to time,
is calculated to do much good.  When the abdominal tenderness
is attended with very thin  discharges—resembling  a solution of
verdigris in turbid water, containing flakes of intestinal mucous,
purgatives must be very cautiously  employed.  Frequent purg-
ing, under such circumstances, could scarcely fail  to  aggravate
the intestinal irritation.  The small  doses of calomel and ipecac-
uanna mentioned above, in conjunction with an occasional pur-
gative enema, will, in general, suffice to prevent the undue  re-
tention and accumulation of acrid substances in  the bowels.
Should a purgative be deemed  necessary,  however,  castor oil,
with a few  drops of  laudanum, is decidedly the  best  article.
After the purge has  operated, the bowels  ought to be tranquil-
lized by an efficient dose of laudanum or Dover's powder.
  Mucilaginous diluents may be freely allowed; and in the present
variety of the complaint, slightly acidulated drinks, are often pecu-
liarly grateful, and I have never known any ill effects to result
from their use.  The diet ought  to be of the simplest  and bland-
est farinacious substances.  Thin preparations of arrow-root, ta-
pioca, sago,  rice, barley, and boiled  milk,  constitute the  most
suitable nourishment in cases of this kind.   Animal fluids—such
as beef or chicken tea, are  apt to irritate the bowels  and to ag-
gravate the diarrhoeal affection.   After the disease has been sub- 
22S                     OF DIARRHOEA.
dued, a mixture of equal parts of a thin preparation of arrow- root,
and beef or chicken tea, forms a very proper nourishment; bu
durin^ the continuance of the bowel complaint the patient ought
to be restricted to the exclusive use of the mucilaginous articles
just mentioned.  The body should be carefully protected against
the injurious influence of cold.  Cool and damp night air, after a
warm day, is particularly apt to excite or aggravate bilious diar-
rhoea.  Children affected with diarrhoea  ought not to be Avashed
with cold water.   This precaution is particularly proper in very
young infants.

   Mucous diarrhaa.—In this variety of diarrhoea, the  mucous
membrane of the  bowels is in a much  more  irritated condition
than  in the two preceding modifications of the complaint.  In
faeculent  and bilious  diarrhoea, the irritation is chiefly located in
the small intestines;  but in the  present form, its principal seat is
in the colon and rectum.  In some instances the evacuations con-
sist almost entirely of intestinal mucus; but in the majority of
cases a considerable portion of  feculent matter of an unnatural
appearance passes off with  the mucus.   The mucus is generally
the last  portion evacuated, and  in many instances a small quan-
tity of unmixed mucus precedes  the  faeculent  portion of the dis-
charge.   The evacuations are seldom very frequent or copious.
They are sometimes streaked with blood, and a slight degree of
tenesmus and straining occurs  in many cases.  The discharges
are usually preceded by severe tormina, and in protracted cases,
the  abdomen  becomes  decidedly  tender  or sore to  pressure.
Mucous diarrhoea, in fact, differs  only in degree from dysentery.
When neglected  or  mismanaged it sometimes  assumes all the
characteristic phenomena of the latter form of intestinal disease.
It may be regarded as a catarrhal affection of the bowels, and is
produced, generally, as  other catarrhal  affections are, by cold—
causing  a sudden  torpor of the  cutaneous  exhalents.  In mild
cases, the mucus,  usually, presents its ordinary natural appear-
ance; but when the disease continues for sometime, and assumes
a  more  severe  character, it, generally becomes  opake and whit-
ish resembling  cream or pus.   The appearance of  the whitish
or puruloid matter in the evacuations, indicates the existence of 
                        OF DIARRHOEA.                    229
inflammation in some portion  of the  mucous membrane of the
bowels, and is always to be regarded as  a highly unfavorable
symptom.  Cases of this kind, are generally attended with slight
febrile irritation, and the skin is almost invariably dry and harsh.

   Treatment.—r-Dr. Dewees recommends the daily exhibition of a
moderate dose of castor oil, and  an  opiate in the evening until
the bowels are relieved.  This mode of treatment, will frequently
put a  speedy stop to  the  disease; but the daily exhibition, of
even  so  mild a  purge as castor  oil, may do  serious injury,
by aggravating the mucous irritation  of the bowels.  I am  quite
certain that I have seen mild cases pass into severe or purulent
ones, under the daily employment of purgatives; and I am equally
satisfied that daily purging is, in general, altogether unnecessary
to the safe and successful treatment of the complaint.   The dis-
ease, as  has already been  stated, is generally  brought on by a
sudden suppression of the perspiration.   An  important object,
therefore, in its remedial  management, is  to restore the regular
action of the cutaneous exhalents.  In the commencement of the
treatment, the  bowels ought to  be freely  evacuated, by an effi-
cient dose of castor oil, to which a few drops of laudanum should
be added. After the oil has operated, small doses  of ipecacuanna
and calomel should be given at regular intervals, and a full dose
of Dover's powder in the evening.  To an infant of between one
and two years old, a fourth of a grain of the former with the sixth
of a grain of the latter, may be given every two hours.
   When the evacuations are attended with severe tormina, and the
patient is free from fever, small doses of Dover's powder should
be occasionally substituted for the ipecacuanna.   To prevent the
retention of irritating substances in the bowels,  a mild laxative
clyster should be  administered, once or  twice daily.  A few
drachms of manna dissolved in a gill of warm water,—barley wa-
ter with a teaspoonful of  common salt, or molasses-water, form
proper mixtures for this purpose.  When the stools are  frequent
and small, and the patient is observed to remain a long time  on
the vessel  and to strain, mucilaginous injections with  a suitable
portion of laudanum, generally afford very considerable relief.
Should the disease continue for three or four days, a second dose 
230                    OF DIARRHOEA.
of castor oil and laudanum may be given, if the ipecacuanna and
calomel, together with  the  laxative enemata do not appear to
free the bowels sufficiently of their vitiated  contents.   To  pro-
mote the action of the cutaneous exhalents, warm bathing,  will
be  useful;  and a broad flannel  roller should be worn  next the
skin, round the abdomen.  The drink and diet should be mucila-
ginous.  All  solid food  is  decidedly objectionable.  When the
disease assumes a chronic character, with a puruloid appearance
of the  mucous discharges, considerable benefit may sometimes be
derived  from small  doses of balsam capaiva, in the form of an
emulsion.  From five to ten  drops of the balsam may be given
two or three times daily, together with a few drops of laudanum.
I have frequently employed  this article  in conjunction with mi-
nute portions of Dover's powder with the happiest effect in cases
of this kind.

   Chylous diarrhaa.—In this variety of diarrhoea, the evacuations
are of a whitish or milky color with a manifest deficiency of
bilious matter.  The principal irritation, in cases of this kind, is
evidently seated in the upper portion  of the small intestines.
The mucous membrane of this section of the bowels, appears  to
be in a sub-inflamed condition; in consequence of which, the sen-
sibility of the mouths of the lacteals is so  changed or perverted as
to  prevent them from  taking up  the chyle.   The tormina  or
griping is always felt in the upper part of the abdomen; and the
epigastrium  is almost invariably somewhat distended, and tender
to  pressure.   The hands and feet are apt to be cold; and the skin
usually acquires a peculiarly sallow appearance, more  especially
in  cases of protracted duration.   The patient is soon much weak- «*
ened,  and  emaciation generally goes  on very rapidly.   Chylous
diarrhoea, is  seldom  attended with distinct febrile  symptoms, but
the nervous system often becomes morbidly irritable.
   This variety of diarrhoea occurs under very different degrees
of violence  and  duration.  Recent cases, excited, suddenly, by
irritating or  improper articles of nourishment or cold, are usually
mild and of easy management; but when the complaint comes on
slowly, in consequence  of long-continued derangement of the di-
gestive organs, or habitual disturbance of the  bowels, it frequently 
                         OF DIARRHOEA.                    231
assumes a chronic and very obstinate character, so as sometimes
to resist remedial effort.
   Dr. Dewees, thinks that the absence of bile in the duodenum,
constitutes the principal cause of the chylous evacuations.   The
want of bile, he  conceives,  will prevent the healthy elaboration
of the chyme, in  consequence of which it will "act upon the sus-
ceptible bowels," as an irritant, and "urge them to an increased
peristaltic  motion."
   It may be observed, however, that the absence of bile in the
duodenum  generally produces a very different effect, from that
which is ascribed to it in this explanation.  Torpor of the bowels
and constipation are the usual consequences of deficient biliary
secretion, and it appears moreover from, the experiments of Tied-
eman  and Gruelin that the presence of bile is not necessary for
healthy elaboration of the chyme.   It seems more probable that
chylous diarrhoea depends on a highly irritable and irritated con-
dition of the mucous membrane of the  small intestines, more es-
pecially of  the duodenum, in connection  with an impaired and
imperfect performance of the digestive  functions.   The absence
of bile in the evacuations is, perhaps, occasioned  by a spasmodic
constriction of the orifice  of the bile duct; and the lacteals may
fail to take up the chyle from a similar condition of their mouths.

   Treatment.—The principal  indications are, to allay the irrita-
bility and irritation of the duodenum, and to restore the healthy
functions of the digestive organs.   Purgatives are wholly inad-
missible in  the treatment of  this variety of  diarrhoea.   Minute
doses of calomel and Dover's powder, in conjunction with emo-
lient or stimulating applications to the  epigastrium, warm bath-
ing, and  proper dietetic regulations,  constitute  the  principal
means for combating this affection.  The sixth of a grain of~cal-
omel, with a fourth of a grain of Dover's powder, should be  given
every  two or three hours, until the  evacuations become bilious.
A stimulating plaster or a large emolient poultice should be laid
over the upper part of the abdomen.  A plaster  composed of a
tablespoonful of powdered cloves, the same quantity of black pep-
per, a few  teaspoonfuls of cayenne, and  two tablespoonfuls of
flour, mixed up into the consistence of paste with strong vinegar, 
232                     0F DIARRHOEA.
forms an excellent  stimulating application for this purpose.  A
simple emolient poultice, will, in general, do much good, in cases
of this kind.  In severe and obstinate cases, recourse should be had
to the application of a.blister over the epigastrium.   The plaster
should not be left on the skin more than three or four hours.  If it
is removed, as soon as the skin is slightly inflamed, and an emolient
poultice laid over  the part, a fine blister  will be raised in the
course of a few hours, and procure all the advantage that can be
obtained from  vesication,  without subjecting the child to the se-
vere pain which commonly attends the usual mode of blistering.
   In a few instances of this modification of diarrhoea, I have ob-
tained much benefit from small doses  of the muriated tincture of
iron and laudanum.   Two drops of the former with a drop of the
latter, may be  given three or  four times daily.  A mixture com-
posed of three  or four grains qf powdered chamomile flowers, a
grain of Dover's powder, and a fourth of a grain of calomel, taken
three times daily, will,  also, sometimes  operate very beneficially.
Whatever remedies may be employed,  a strict attention  to pro-
per dietetic regulations is.indispensable to  success, in treatment
of this affection.  All solid food must be rigidly forbidden.  Noth-
ing but the simplest mucilaginous fluids should be allowed—such
as barley water, very thin  arrow root,  prepared without  milk,
gum arabic water, a liquid preparation  of  sago, tapioca, rice wa-
ter, or a mixture of equal parts of  cow's milk  and water.  It is
particularly necessary to avoid taking much food at a time; and
the intervals between the meals should  be sufficiently long to  en-
sure the  entire  digestion of the food last taken, before fresh nour-
ishment is received into the stomach.

   Lienteric Diarrhoea.—In this variety of diarrhoea, the evacu-
ations, along with more or less vitiated feculent matter, mucus, oc-
casionally bile, contain articles of food in an imperfectly digested or
wholly unchanged condition.   At first the discharges do not occur
until several hours after eating:  but if the disease is suffered to
continue, the intervals between the reception of food and its evac-
uation by the bowels, becomes shorter and shorter, until at last al-
most every thing that is taken into the stomach is speedily thrown
off again by the intestines.  Soon after eating, the patient, usual- 
                         OF DIARRHOEA.                    233
 ly, -experiences a good deal of uneasiness in the epigastric  and
 umbilical regions.   This is in a short time followed by severe tor-
 mina, which in a few moments terminates in a rapid diarrhoeal evac-
 uation.  In many cases, however, the  discharges occur with but
 very little or no griping whatever.  The appetite is always much
'deranged.  In some instances it is weak  and capricious, loathing
 almost every thing, but a few particular, and  generally  strong,
 articles  of food.  In  other  cases the desire for food is voracious;
 and the most crude, irritating and high-seasoned articles are those
 which are often the most desired.  In cases of this kind the abdomen
 is freqently very tumid and hard, and the extremities  and body ema-
 ciated.  Moderate pressure on the abdomen seldom occasions any
 decided manifestation of tenderness or pain; but a sudden concus-
 sive agitation of the body, such as coughing or sneezing, or jump-
 ing from a chair, &c. almost always  gives rise to a  feeling of sore-
 ness and pain in the epigastric and umbilical regions.  In the ma-
 jority of instances, there is but very little or no  bile observable in
 the evacuations.  Occasionally,  however, the  stools are mixed
 with a considerable quantity of dark  green bilious matter of  a
 glairy consistence, or of a bright green fluid, resembling a solution
 of verdigris in water.
   This  form of diarrhoea very seldom, if ever, arises from  the
 operation  of a temporary exciting cause.  It generally comes on
 gradually, as a consequence of mismanaged  feculent or  bilious
 diarrhoea, or from the habitual use of irritating  articles of food, in
 conjunction, perhaps,  with other causes capable of deranging the
 digestive organs.
   Lienteric diarrhoea may be regarded as a  violent form  of indi-
 gestion accompanied with excessive irritability  and subinflamma-
 tory irritation of the stomach  and small intestines.   In  chylous
 diarrhoea, the morbid irritability and irritation  is  principally lo-
 cated in  the small intestines, more  especially  in the duodenum,
 without much  impairment of the digestive powers; whereas, in
 the present variety of the complaint, the stomach is manifestly
 the principal seat of the disease.  The mucous membrane of the
 stomach is probably always  in a subinflamed condition in  violent
 cases of lienteric diarrhoea.  In some instances,  the morbid condi-
 tion  of the mucous membrane, extends throughout nearly the
                              2H                21 
234                     OF DIARRHOEA.
whole tract of the intestinal canal.  In cases of this kind, the ap-
petite is often quite voracious, the abdomen is tumid and  tense,
and  the  evacuations are generally mixed with an abundance of
mucus.   These  cases are to be regarded  as instances of chronic
diarrhoea, attended with a morbidly irritable and  enfeebled con-
dition of the digestive  organs, and  are always  connected with
chronic inflammation, and frequently ulceration  of  the mucous
membrane of the colon.  In general, when chronic diarrhoea is
the consequence of irritating substances taken into  the stomach,
and the  digestive powers are much disordered, the evacuations,
are apt to assume more  or less of  a lienteric character.

   Treatment.—It is obvious, from what has been  said in relation
to the pathology of  this variety of  diarrhoea, that the  principal
objects to be kept in view in its remedial management, are, to sub-
due the morbid irritability and inflammatory irritation of the sto-
mach and bowels,  and to restore the healthy performance of the
digestive functions.   One of the most important and indispensable
means for the fulfilment of these indications, is a perfectly bland,
simple, and  moderate  nourishment.  All  solid  articles of food
must be rigidly avoided.  If the child is still nursed at the breast,
no change of course, is necessary, unless  there are good grounds
for believing that the milk  is depraved.    Thin  preparations of
arrow-root, tapioca,  sago, rice,  or  barley, a mixture of cow's
milk and water, a solution  of gum arabic in water, &c. constitute
the best articles of nourishment in such cases. The  drink too ought
to be perfectly bland, and cool.   Even these bland alimentary
substances ought to be used in moderate portions.  The  patient
can derive no support from the reception of more food than the
stomach can digest. A small portion only will be digested;  the re-
mainder passes in an undigested state into the duodenum, and keeps
up the exhausting diarrhoeal discharges.   Among  the internal
remedies suitable in cases of this kind, opium, hyoseyamus, muri-
ated tincture of iron, and very finely powdered charcoal, are deci-
dedly the most valuable.  In the commencement, two or three
drops of the muriated tincture of iron with one or  two drops of
laudanum may be given once, twice, or three times daily, accord-
ing to the age of the patient.  I have, in several instances of this 
                        OF DIARRHOEA.                    235
 kind, resorted  to  the  external  application of morphia with  the
 happiest effect. The tenth of a grain of this narcotic preparation
 applied to a part from which the cuticle has been  removed by
 blistering, will procure all  the soothing effects of opium, without
 incurring the risk  of nauseating the stomach.  Calomel is not, in
 general, a proper remedy in this form of diarrhoea.   When the
 liver is manifestly  torpid, however, minute portions may be given
 once or  twice  daily, in union with opium; but I have generally
 preferred' applying a mercurial plaster over the right  hypochon-
 drium.   Hyoscyamus,  in conjunction with small doses of the mu-
 riated tincture of iron  or of chalybeate wine, sometimes operates
 very beneficially.   Thirty  grains of good  extract of hyoscyamus
 may be dissolved in two ounces of water.   Of this solution, three
 or four drops in union with  the same quantity of chalybeate wine,
 or a drop of the muriated  tincture, may be given two or three
 times daily, to  a child between one and three years old.   After
 the irritability  of the stomach has been, to a considerable degree
 allayed, small doses of finely prepared charcoal with minute por-
 tions of opium, frequently produce  very excellent effects  in this
 modification of diarrhoea.  In some instances, however, I have
 found this article to increase the gastric irritation;  yet in  the ma-
jority of cases, in which I have employed it, its effects  were une-
 quivocally beneficial.  Five grains  of the charcoal,  with the
 twentieth of a grain of opium, may be given two or three times
 daily.   In addition to the foregoing means, rubefacient or vesica-
 tory applications, can never be neglected without losing very im-
 portant remedial resources  in cases of this kind.
  The abdomen should be  rubbed with dry flannel, or  with some
 stimulating liniment, until the skin become red, several times daily.
 I have known much benefit to result from the application  of the
 spice plaster to the abdomen, already mentioned under the head
 of chylous diarrhoea.  In  severe cases, postulation  with tartar
 emetic ointment, or what appears to me better, the application 01
a blister to the epigastrium, may be resorted to with much pro-
priety.  Indeed, I have more frequently made  a decided and
prompt curative impression on the disease by blistering, than by any
other remedy.  The plaster need not  be  sufficient to remain on
the skin until the vesication has taken place.   When taken off as 
236                     OF DIARRHOEA.
soon as the skin is uniformly red or inflamed, which usually occurs
in three or four hours, and  a soft  emolient  poultice applied over
the part, a fine blister will  be raised, without subjecting the child
to much irritation or pain. The blistered surface will afford an excel-
lent opportunity for the external application of opiates. Gentle ex-
ercise, by gestation in the open air, will be a useful auxiliary to  the
means already mentioned.  I have known children, who had been
a long time harassed with this form of diarrhoea in the city to re-
cover,  speedily on being removed into the  country.   In  general
cases of this kind pass off very slowly.  When the disease is con-
nected with chronic inflammation of  the colon, and the abdomen
is tumid, tense and sore to pressure, it often resists  every effort to
subdue it.  I have in one instance of this character, succeeded in
curing  the disease, by use of the conferva helminthocordon.  I em-
ployed a decoction, made by boiling two drachms of it in a pint of
water, down to half a pint.   This was administered in teaspoonful
doses every four hours, in union with three drops of laudanum.
The child was between four and five years old.*
   After the lienteric  discharges have ceased, and the evacuations
present a natural feculent character, benefit may be derived from
small doses of colomba, or powdered chamomile.  Nothing of this
kind, however, must be used until the  discharges  are decidedly
and wholly faeculent.   Great  care  should be taken that noth-
ing but the simplest and  most appropriate diet be allowed for sev-
eral months, after the patient has recovered from  the complaint.
Slight errors in diet may re-excite the disease.

  Chronic Diarrhcga.  Atrophia Ablactatorum.—Children  are
liable to two distinct varieties of chronic diarrhoea.  The most
common  modification  of  chronic diarrhoea,  generally   occurs
at  an  early period  of  childhood, and  is  manifestly attended
with  prominent  derangement of  the  liver stomach, and small
intestines.   The other variety  generally occurs  at a more ad-
vanced  age, and  corresponds  entirely  with  the  chronic diar-

  *  I was induced to employ this remedy,  by having noticed several obstinate cases of
chronic diarrhoea, entirely removed by Swaim's Vermifuge—a nostrum, which I have
sufficient grounds for believing, consists principally, of a decoction of the conferva Aei-
minthocordon. 
                         OF DIARRHOEA.                     237
 rhoea of adults, depending mainly on chronic inflammation, of the
 mucous  membrane of the colon.  The first of these varieties
 of the complaint, has been well described by Dr. Cheyne, under
 the  name of "atrophia  ablactatorum,"  as  a new  and very pe-
 culiar form  of diarrhoeal  disease.   It differs, certainly very con-
 siderably, in its  phenomena  and pathological character,  from
 the chronic diarrhoea of adults; but this difference depends rather
 on the portion of the alimentary canal principally diseased, than
 on any essential diversity in  their  natures, both  being  nothing
 more than different modifications of confirmed or chronic states
 of common diarrhoea.  When recent cases of bilious or feculent
 diarrhoea  are  neglected, or mismanaged, or when  the  exciting
 cause continues  to act,  they are apt to assume an aggravated
 and obstinate character, presenting  all the appearances that are
 described as characterizing the " weaning  brash," or atrophia
 ablactatorum.  Dr. Cheyne is of opinion  that "this form of chro-
 nic  diarrhoea  is  imputable to an increased secretion of  acrid
 bile."  The biliary  secretion is certainly often very  abundant
 and  perhaps depraved in cases  of this  kind;  but this  morbid
 condition  of the  bile is  probably a  consequence, rather  than
 the  cause of the  gastro-intestinal  irritation, upon which the
 diarrhoeal affection depends.   It seems, to me very  clear that
 the  exciting causes of this complaint do not  differ from  those
 which give  rise  to the usual feculent and bilious varieties of
 diarrhoea.  Gastric irritation   from  inappropriate  articles  of
 nourishment, or  other errors  in diet,  appears to be  the or-
 dinary  source  of this complaint.  It may be observed, that
 inasmuch  as this disease is incomparably  more common imme-
 diately after weaning  than at  any other period of infancy,
 there must be something, peculiar  in its mode of origin and
 character.  It  might be  expected,  however, that  a  complaint
 which arises from gastric  irritation, produced by inappropriate
 alimentary ingesta, should  be  much  more common at   the  time
 when  the child suddenly  passes from  the bland and  congenial
 nourishment  provided for  it  by nature,  to an  exclusive and
 frequently illy  adapted   artificial  diet.   Few  individuals  can
sustain a  sudden and  total change  of food, without  experien-
cing  more  or  less disorder of  the  stomach  and bowels.  A
                                                21* 
238                    OF DIARRHOEA.
person  who  has  been  a long  time confined to  animal food,
will  probably  become  affected  with diarrhoea,  if he  passes
suddenly to  an exclusive  vegetable diet.   The  tendency  of
weaning, to give rise to bowel complaints, is,  doubtless,  much
increased  by  the  influence of  dentition  on  the  alimentary
canal.   This process, is frequently accompanied with so much
irritability of the stomach  and bowels, that the mildest articles
of nourishment  are apt to operate as irritants and to excite diar-
rhoeal discharges.   It is  easily to be conceived, therefore, that
diarrhoea must  not only be  much more frequent, but also more
violent  and protracted when weaning and dentition co-operate
in deranging the alimentary canal than at any other period. Dr.
Cheyne says, that, " the disease is most frequent in  children who
are weaned before the eighth or ninth month;" and this  corres-
ponds entirely with my  own observations.  At this  early  period,
teething is usually going on actively, and the powers of the sto-
mach are in general not yet sufficiently developed, to digest with
due facility, the artificial nourishment substituted for the mother's
milk.  The liability to gastric derangement and diarrhoea from
these causes, is much greater when the weaning is  abrupt,  than
when it is accomplished, as it always  should be when practicable,
in a slow and gradual  manner.   When the change is  suddenly
effected, and especially, when the  nourishment is  unsuitable  to
the delicate and excitable state of the infant's stomach, it can
hardly fail  to occasion some degree of gastric derangement.   In
many instances the stomach gradually accommodates itself to the
new kind of nourishment, and all  inconveniences which may have
resulted from it at  first,  disappear.   When, however,  the diges-
tive organs and liver are particularly predisposed to morbid excite-
ment, as they often are during dentition, or when the  diet is
decidedly improper, weaning is  apt to be  followed by  a high
degree of gastrio-intestinal irritation, or violent and obstinate diar-
rhoea.   Thus, the artificial nourishment, at first, deranges the diges-
tive  powers; the food remains a long time in the stomach before
the process of digestion is completed; acid and other  irritating
fluids are generated.  These together with the imperfectly diges-
ted food, irritate  the stomach and bowels still more, and excite
purging.  The irritation is extended  to the liver, and a redun- 
                         OF DIARRHOEA.                     239
 dant or vitiated secretion of bile takes place.  The irritating cau-
 ses being thus progressively increased, and the original exciting
 cause, namely the inappropriate  nourishment continued, a high
 state of irritation  is established in the mucous membrane of the
 alimentary canal,  with great perversion of the hepatic and intes-
 tinal secretions; which, in the majority of instances, finally passes
 into actual inflammation.
   Dr. Cheyne,  in the  account  he has  given of  the  post-
 mortem  appearances, states  that throughout  the  whole  tract
 of the intestinal   canal  a number  of " singular  contractions
 with one  or more  intus-susceptions,"  were  noticed  in every
 instance.  " The  liver was larger  than  natural,  exceedingly
 firm, and  of a bright red colour."  The mesenteric glands were
 inflamed and swollen in some instances; in others they were near-
 ly natural.  The intus-susceptions were without inflammation or
 adhesions.   The  contractions  were " of a   spasmodic kind,"
 and could  be "permanently dilated again, by pushing the finger
 into them."   " These appearances, he says, lead me to imagine
 that the weaning  brash in its  confirmed state is ascribable to  an
 increased secretion of acid bile, or rather to  the morbid  state of
 the liver which  occasions this."* Dr. Dewees, observes, that the
 post-mortem appearances detailed by  Dr.  Cheyne correspond
 with those made in France by Andral and Cruveilhier. With re-
 gard to the dissections of Andral this is not correct.  He distinct-
 ly mentions softening of the mucous membrane of the small intes-
 tines, and other marks of inflammation, as frequently connected
 with fatal  cases of this kind.   Since I have  directed  my atten-
 tion particularly  to the diseases of  children,  I have had an op-
 portunity of dissecting but one  single subject of this kind. In this
 case the mucous  membrane of the pyloric extremity of the sto-
 mach  and duodenum was in a  highly injected condition; in the
 lower  part of the  ilium,  there  were a number of livid patches
 of irregular shape, in this  tissue, and  the whole length of the co-
 lon was contracted to a size that scarcely admitted my little fin-
 ger. It can hardly be supposed, indeed, that the acrid and irrita-
ting substances which are continually in contact  with this deli-
cate structure in cases of this kind, could fail to excite some de-
             * Cheyne, On Atrophia Ablactatorum &c. p. 18. 
340                     OF DIARRHOEA.
gree of inflammation in it.  During the early stage of the disease
the mucous membrane of the small intestines is probably only in
a highly irritable and irritated condition.   As the disease advan-
ces the biliary and intestinal secretions become  more and more
depraved, and the alimentary canal more irritable. The constant
operation of  these   irritating  causes, ultimately gives  rise to
more or less of inflammation, the irritation is extended to the liver
and mesenteric  glands, and these undergo morbid changes, and
increase the severity and obstinacy of the disease.   This complaint
occurs  most  frequently,  during  the summer  and  autumnal
months.   Dr. Cheyne says, that  he " has  seldom, comparatively
speaking, seen it commence before the solstice, nor after the end
of the year."   The  tendency  of warm and humid weather to fa-
vor the occurrence of bowel complaints in children, is well known.
Solar heat  renders the  organism irritable, and, both through
the  agency of the miasmata which it engenders, and by its own
direct influence on the human body, has a very decided tendency
to excite  and derange the  biliary  secretion.  Children who are
weaned during summer, while dentition is going  on, are peculiar-
ly liable  to diarrhoea of a severe and obstinate character.   This
complaint generally commences, in the form of simple bilious, diar-
rhoea. The stools at first are faeculent liquid and mixed with an abun-
dance of bilious  matter of a light green color.  In the  course of
four or five days, if it is  not counteracted by  suitable  remedies,
sickness of the stomach, and occasionally  bilious vomiting occur;
and the  purging becomes more  frequent and  often extremely
painful.  The patient now begins to lose his appetite; more or
less  febrile  irritation ensues,  attended  with  great fretfulness,
restlessness, a warm and obstinately dry skin,  and urgent thirst.
The  diarrhoeal discharges  gradually  become  more watery, gri-
ping  and  frequent; and the  bilious matter, in general, less copious
than  at first.  The body wastes, the flesh becomes soft and flabby,
and the debility  increases rapidly.  In the course of three or four
weeks, the fever assumes  a regular form,— that is,  slight exa-
cerbations occur regularly once or twice  daily,  attended  with a
" hectic blush on one cheek,"  and a very frequent  quick and
 corded pulse.  " But the most characteristic symptom of this dis-
 ease  is a constant peevishness,  the effect of  unceasing griping 
                        OF DIARRHOEA.                    241
pain—expressed by  the whine of the child,  but especially by
the settled discontent of the features."
  The evacuations  are  by no means uniform  in  appearance
throughout the course of the disease.  At first the stools usually
consist of a yellowish feculent matter mixed with green bile of a
glairy or uniform consistence.  As the disease advances, and the
intestinal irritation increases,  the bile generally ,becomes more
abundant and  unnatural, presenting a curdled  and dark-green
appearance mixed with foetid watery discharges.  Sometimes the
evacuations are dark brown, very fluid, and extremely foetid, con-
taining flocculi of mucus, and little masses of dark bile.   Not un-
frequently the discharges are, for a short time, ochrey or claycolor-
ed, and then  change again to dark and bilious.  At an advanced
period of the disease, the stools are sometimes  mixed with a con-
siderable quantity of a  yellowish white, or puruloid matter; and
occasionally they assume a lienteric character,—small portions of
imperfectly digested food appearing in the evacuations.   When
the discharges acquire a watery flocculent  and very foetid  cha-
racter; or when they become lienteric, or mixed with puruloid
matter, we may conclude that the mucous membrane of some por-
tion of the intestines is  in an  inflamed condition, and that the
disease  will probably resist every effort to remove it.
  This form of diarrhoea, generally runs a very protracted course.
It seldom terminates fatally " before  the sixth  or  seventh week,"
and in many instances it continues three or four months before
death takes  place.  During the first two or  three weeks, its
course may often be speedily arrested  by judicious management;
but when the complaint is mismanaged and suffered to run on for
four or  five weeks,  it frequently  resists every  remedial effort.
When the disease  proves fatal at an early period, it  is generally
from its assuming the form of cholera, or from the supervention of
convulsions.                                            _,
  Dr. Cheyne seems to think that dentition has but very little if
any agency in the production of this complaint.  " The weaning
brash," he says," I have the strongest reason  to  believe, has no
connection with teething farther than they sometimes meet in the
same  child.   I  have known this disease, in many instances, where
the gums were neither  swelled, nor indurated, nor inflamed, and 
242                    OF DIARRHOEA.
where there was no salivation nor any appearance in the mouth.
I have seen it where children were cutting  their teeth easily;
and where many of them came without difficulty before weaning,
still the disease has supervened.  But perhaps the strongest argu-
ment that can be used would arise from the observation which I
have  frequently made, that  this disease occurs  in  children of
three months; and  I have often  known it several months  before
teething came on."  There can  be no doubt, indeed, that the dis-
ease may, and often does, occur wholly independent of dentition;
yet that the occurrence of  the complaint is much favored  by the
irritation of dentition appears to me equally unquestionable. Dif-
ficult dentition is, in general, attended with obvious derangement
of the digestive functions, and its tendency to increase  the  irrita-
bility of the stomach and bowels,  cannot, I think, be questioned.
It is, at all events, quite certain, that the instances of this disease,
in which irritation from teething is manifestly present, are incom-
parably more frequent, than  those in which no signs of dentition
are observable.  I have known  bowel complaints in  children be-
fore they were weaned, speedily brought to a favorable termina-
tion,  simply by dividing  the inflamed and  swollen gums; and
when the gums are in this condition from teething, in the present
form  of diarrhoea, unequivocal benefit is frequently derived from
this operation.  The observation made by  Cheyne, that this com-
plaint sometimes  occurs before dentition  commences, does not
disprove its agency in the production of the  complaint, where it
does occur; but only shows that the disease  may come on with-
out this source of irritation.   No one can deny the great share
which abrupt weaning has in bringing on this disease;  and yet it
occasionally occurs before the child is weaned, or many months
after the weaning took place.  The truth is?  this disease does not
differ materially, in relation  to its exciting causes, from other va-
rieties.of diarrhoea.  The reason why it  is more apt  to assume a
violent  and chronic character, must be sought, as has been already
stated above, in the  permanency  of its  exciting causes,  rather
than in any thing peculiar in their character.
   There is another form of chronic diarrhoea which is common to
infants  and adults,  and which differs very  considerably from the
preceding variety, both in its phenomenaand pathological character. 
                        OF DIARRHOEA.                    243
The evacuations in this form of the disease are characterized by
an abundance of mucus, which, as the disease advances becomes
mixed with a whitish or cream-like  matter, sometimes slightly
streaked with blood,  and occasionally mixed with small portions
of imperfectly digested food.   Except,  in the early stage of the
complaint bile rarely forms a conspicuous part of the discharges.
In some instances the evacuations are liquid, of a dirty brown
color, containing an abundance of mucus in the form of flakes and
small masses of purulent matter.   Occasionally the feculent mat-
ter mixed with the stools is of a whitish color and of a pap-like
consistence.   The appetite is generally very variable, and capri-
cious.  It is sometimes wholly depressed, though more frequently
sufficiently active, and sometimes quite voracious.  After the dis-
ease  is completely developed, slight  febrile irritation generally
occurs—particularly towards  evening and a few  hours after eat-
ing.  The pulse is generally frequent, small, quick, and sharp,
and the skin almost uniformly dry and harsh.   The abdomen , in
some cases,  becomes  tumid and hard, while the  body emaciates
more or less rapidly.  The face acquires a pale,  contracted and
morose expression, and the temper becomes irritable and fretful.
The  patient usually  experiences very severe colic pains a few
hours after eating, more  especially when the food consists of solid
articles; and, in general, even the mildest nourishment is followed
in an hour or two after receiving it into the stomach, by severe
tormina, flatulency, and rapid diarrhoeal discharges.  The  abdo-
men is almost always tender or sore to pressure, and the feet, and
sometimes the face,  ultimately become  somewhat oedematous.
The liver is generally inactive, and the small portion of bile that
is occasionally discharged, is usually curdled and of a dark green
or black color.
   This variety of chronic diarrhoea, is seldom met with in chil-
dren under two years old.  It is generally the result of neglected
or mismanaged feculent or bilious diarrhoea. Indeed, any of the
modifications of diarrhoea that have been mentioned, in this chap-
ter, may degenerate into the present form of the complaint.   It is
usually of very  protracted duration.  It seldom destroys life in
children before the third or fourth month; though the  chance ot
a favorable termination, even under the  most judicious treatment 
244                     OF DIARRHOEA.
after the disease has  continued to this period, is  generally very
slender.  So long, however, as the evacuations are free from pur-
ulent matter, and the  febrile irritation has not assumed a hectic
character, there is still considerable probability of success from a
judicious and persevering course of remedial management. 1 have
seen several  cases of recovery after the disease had run  on, be-
yond the sixth month.
   In the former variety of chronic diarrhoea, as has already been stat-
ed the principal disease is seated in the stomach, small intestines, and
liver, and consists more frequently of a high degree of  irritability
and irritation of these parts, than in actual inflammation;  though
this latter form of disease is often ultimately superadded.  In the
present variety of the disease the principal affection  is seated in
the colon,  and consists of chronic inflammation, with  or without
disorganization or ulceration in the mucous membrane of this por-
tion of the intestinal canal.
   On postmortem examination, the mucous membrane of the colon,
and ilium present distinct traces of inflammation.  We sometimes
discover a number of  irregular patches of a fungoid appearance
and of a dark or livid color, slightly elevated above the surround-
ing parts.   In other instances, small well defined ulcers with ele-
vated  margins,  or extensive irregular ulcerations with  ragged
edges  are  met with.  The coats  of  the intestines, particularly
those of the colon, are sometimes  thickened at the parts where
these ulcers  are situated; and in some instances,  this  thickening
is so  great as to diminish the area of the intestinal  tube very
considerably.  Instead of ulcers the mucous membrane, occasion-
ally exhibits a great number of small tuberculous elevation.  The
appearances just mentioned are in general most conspicuous about
the lower portion of the colon.   The  mucous  membrane of the
small  intestines, is usually very much injected, presenting here
and there  extensive patches of a bright  red appearance.  The
stomach seldom presents any decided traces of disease.

   Treatment.—When  diarrhoea has  once acquired a chronic cha-
racter, it is  always of peculiarly difficult management.   In the
treatment of this form of diarrhoea, the attention must be directed,
not so much to the mere diminution and suspension of the diarrhoeal 
                         OF DIARRHOEA.                     245
 discharges, as to the removal of that fixed morbid condition of the
 stomach  and bowels, upon which the excessive  evacuations de-
 pend.  The excessive irritability, the inflammation,' and the func-
 tional disorder of the liver and intestinal  exhalents are the objects
 against which our remedial measures must be principally directed.
 One of the most  important requisites, to the successful treatment
 of chronic diarrhoea, is a total  avoidance of every kind of stim-
 ulating  or solid  aliment.  In the " weaning brash," this  precau-
 tion is, perhaps, not so uniformly indispensable as in the ordinary
 chronic diarrhoea, attended with mucous inflammation and ulcer-
 ation of  the colon.   In this  latter form of the complaint nothing
 can be effected without the strictest attention to this point.  The
 nourishment  must consist  exclusively of  thin mucilaginous fluids,
 such as gum-arabic water, barley water, very thin preparations of
 arrow-root, tapioca, sago, oatmeal gruel, and rice water.   Not a
 particle of solid  food, of  any kind, should  be allowed; and the
 patient should guard particularly against overloading his stomach
 even with the mildest kinds of nourishment.  I have often known
 the  best  directed course of remedial  treatment, frustrated by a
 neglect of this important point of practice  in  such  cases.   Milk
 seldom answers well in this disease.   It is apt to coagulate, and
 to pass through the bowels in an undigested condition, appearing
 in the evacuations in the  form of small  white flakes.  This, of
 course, always increases the intestinal  irritation,  and aggravates
 the tormina and frequency of the discharges.  Beef or chicken
 tea and  thin  broths are, in  general, still more objectionable, as
 they rarely fail to increase the  intestinal irritation  and rapidity
 and  painfulness of the evacuations.   So  far as my own observa-
 tion  enables  me to  form an opinion, I am  inclined to think that
 a very liquid preparation of tapioca, with infusion of slippery-elm
 bark for drink, forms the most appropriate  artificial nourishment
 in cases of this  kind.   When the disease  arises from weaning,
 however,  nothing  can  be more  appropriate and  beneficial, than
 the milk of a fresh and healthy nurse.   Speedy restoration of the
 child  to the breast, will often, of itself put  a stop to " weaning
 brash."  Should diarrhoea of an obstinate character occur, while
 the child  is still nourished at the breast, and there  is  reason to
suspect some unwholesome condition of the milk, a  fresh nurse
                                                22 
246                     OF DIARRHOEA.
should, if practicable, be immediately procured.  Even artificial
nourishment, such as gum-arabic water, or very thin preparations
of tapioca or arrow-root, would under these circumstances be pref-
erable to the continued use of the unwholesome milk, by which
the disease was excited.   It is well, however, not to be very pre-
cipitate in separating the child from the breast in such cases; for,
although it may be proper, and perfectly safe, to change the nurse
when the quality of the milk is suspected, yet we ought to be well
assured that this  is actually the case, before the breast is entirely
withheld, and the  patient put on the exclusive use  of artificial
nourishment.  Within the present  year I  was requested  to con-
sult in the case of an infant about nine months old, and not yet
weaned.  The child  had been affected with diarrhoea, for more
than four months.  A variety of suitable remedies had been per-
severingly used, but all  to no  purpose.   We concluded to urge
the immediate  separation of the  child from  the  breast, and to
nourish  it, exclusively with  gum-arabic water, and thin tapioca.
This was done, and under the use of this nourishment and minute
doses of calomel and opium, the little patient was, in the course of
about two weeks, freed from its dangerous malady.  The treat-
ment of  chronic diarrhoea in children is often rendered extremely
difficult  and  irksome, by the ignorance and perverse conduct of
mothers  and nurses.   In despite of the most earnest injunctions to
withhold every kind of nourishment but the simple mucilaginous
fluids just mentioned, the little patient is often clandestinely sup-
plied  with what are deemed innocent delicacies, though in reality
highly inappropriate  and. injurious.  They cannot conceive that
a " little soft cake," or a " bit of tender chicken," or some  such
article,  could possibly do any harm.   I have often been foiled in
my efforts to cure cases of this kind, by this unwarrantable and
pernicious departure from the directions that were given on  this
point; and the young practitioner  ought  to bear in mind, that
unless this part of his curative plan is rigidly fulfilled, he can ex-
pect nothing but disappointment and defeat  in his  attempts to
arrest the progress of the  malady.
  During the early stage of weaning brash, the liver and alimen-
tary canal appears to be  in the same condition as  in common
bilious diarrhoea.  The stools are of a green, somewhat slimy and 
                        OF DIARRHOEA.                    247
 curdled  appearance, accompanied with frequent nausea  and oc-
 casional vomiting.   The principal objects to be kept in view in
 prescribing for the  complaint  at this period, are to correct the
 functional derangement of the  liver and to allay the morbid irri-
 tability and irritation of the stomach and  bowels.  In the com-
 mencement of the treatment  the intestinal  canal should be freely
 evacuated by a moderate dose of  calomel followed, in three or
 four hours, by a full dose of castor oil.  After the purge has ope-
 rated, the alimentary canal ought to be tranquillized by a suitable
 dose  of laudanum or  Dover's  powder.  To correct the morbid
 condition of the liver, and moderate  the excessive irritability of
 the bowels, recourse must next  be had to the regular exhibition of
 minute portions of calomel and opium.  The fourth of a grain of
 the former with the twentieth of a  grain of the latter, may be
 given three or four  times daily, according  to  the age of the pa-
 tient and  the urgency of the  symptoms.  After these  powders
 have been used for two or three days, another dose of castor oil
 with a few drops of laudanum  should be administered.  The oc-
 casional  exhibition of a mild laxative is proper and beneficial; but
 a frequent repetition of active purgatives is  calculated to do much
 injury in cases of  this kind; and after the disease has acquired a
 strictly chronic character,  even the mildest purgative remedies
 must be employed with great caution.   The calomel may be con-
 tinued until the bile becomes  less abundant in the evacuations,
 and assumes a more natural appearance.   It is  to be observed,
 however, that in the employment of calomel, particular care is
 necessary lest it be carried to the extent of producing a decided
 mercurial action in the system—a result which is apt to give rise
 to very unpleasant consequences in children  while dentition is
 going on.  I have witnessed several very distressing instances of
 6laughing of the gums and general mercurial erethism, from the
 protracted use of  calomel  in chronic  bowel complaints of chil-
 dren.  When there are symptoms  of acidity  in the alimentary
 canal, alkaline and  cretaceous remedies should  be employed,
 along with the calomel and opium.  From five to ten grains of
 prepared  chalk, in union  with  half a grain of Dover's powder
and a fourth of a grain of calomel, forms an excellent remedy in 
248                     0F DIARRHOEA.
such cases.  The chalk  may also be conveniently given in  the
form of a fluid mixture, thus:
B Cret. ppt.
3"-

gss.
gtt. xx.
3ii-
                      Sacch. Albi.
                      Mucilag. G. Arab.
                      Tinct. Opii.
                      Syrup Rhcei.   . v
                      Aq. fontanae
                      M. f.  Of this a teaspoonful should be given every two or
three hours.
  I have employed a solution of bicarbonate of soda, inla weak in-
fusion of hops, with the happiest effect in this form of diarrhoea,
when accompanied with  acidity in the primae viae.  At the same
time that these  remedies are  employed, a stimulating  plaster
ought to be laid over the  epigastrium, or frictions  made with  ru-
befacient liniments.   A plaster made by melting equal parts of
burgundy pitch and common diachylon plaster, spread on a piece
of sheep  skin, forms an  excellent application for this purpose.
The spice plaster, mentioned under the head of chylous diarrhoea,
may also  be used with advantage.   Under  the employment of
these means, in conjunction with the most rigid adherence to a
bland mucilaginous diet, this form of diarrhoea may often be sub-
dued without  much  difficulty,  when encountered  at an early  pe-
riod, or before inflammation or structural lesion has taken place
in the affected parts.
   When the disease has acquired a strictly chronic character, and
is accompanied with symptoms indicative of inflammation  of the
mucous membrane of the  bowels, the treatment must be, in some
degree, varied from that which has just been mentioned as  appro-
priate, while the local affection consists, as yet, of simple irrita-
tion and functional derangement. The symptoms  which indicate
this aggravated state of the disease  are;  a frequent,  quick, and
sharp pulse, more especially towards evening, and an hour or two
after eating; tenderness of the  abdomen to pressure; small evac-
uations consisting chiefly of mucus, streaked  occasionally with
blood, and  containing, at times,  small masses of a cream-like or
purulent matter, or very watery discharges, of a reddish color, with
a large quantity of flocculent mucus, resembling the washings of
flesh;  a red, raw, rough or glassy  appearance of the tongue;  urgent 
                         OF DIARRHOEA.                     249
 thirst;  extreme moroseness and fretfulness of temper; rapid ema-
 ciation; and occasional circumscribed flush on one cheek; draw-
 ing up the legs towards  the  abdomen when lying down; and a
 peculiarly contracted and anxious expression of the countenance.
 When these symptoms are present, there can be no doubt of the
 existence of chrpnic inflammation in some  portion of the mucous
 membrane of the bowels; and when the  evacuations are very fre-
 quent, watery and whitish, and the emaciation is extremely rapid,
 we may presume that the mesenteric glands, also, are in a state
 of disease.
   In this aggravated state of the disease, local depletion by leech-
 ing, and counter irritating applications are among the most useful
 remedies we possess.  If leeches  can be procured, two or three
 should  be occasionally applied to the epigastrium, and a large
 emolient poultice laid over the abdomen  after the leeches have
 been separated.  Whether  leeching be practised or not, active
 counter irritation ought  never to be  neglected  in such cases.
 Very little, will be effected  by internal remedies,  without  the
 concurrent aid of active irritating applications  to the region of
 the affected organs.  Blistering appears  to me decidedly the best
 means of fulfilling this purpose.  Pustulation with tartar emetic
 ointment, is apt to give  rise  to corroding and extremely painful
 ulcerations in infants.  When the epispastic is properly managed
 it seldom occasions  much suffering;  and the derivative tendency
 of blistering is, probably, greater than that of any other  applica-
 tion of  this Trind.   The vesicatory should be removed as soon as
 the skin is reddened or slightly inflamed, which usually occurs, in
 about three hours, and a soft emollient poultice laid over the part.
 In the course of a few hours a fine blister will be raised, which is
 then to be opened and dressed in the usual manner.  I have been
 in the habit of dressing blisters, in cases  of this kind, with weak
 mercurial ointment, omitting at the same  time the internal use of
calomel, and, as  it appeared to me, often  with obvious advantage.
Calomel, even in minute doses, if  long continued, sometimes pro-
duces very unpleasant irritation, when the  mucous membrane of the
bowels is in a  state  of chronic inflammation.   As the liver, how-
ever, is always in a very disordered condition, mercurials  are ob-
viously indicated; and  hence, the  use of mercurial ointment in
                              2 K           22* 
250                     0F DIARRHOEA.
the way just mentioned, doubtless has a very beneficial tendency in
this affection.   I have known the continued application of large
emolient poultices over the abdomen, without  blistering, or any
other mode of counter-irritation, to  produce excellent effects in
cases of this kind.  The poultice should  be renewed three  times
daily;  and before a fresh one  is  applied, the  skin  ought  to be
washed with warm water, and  afterwards  rubbed with flannel
until it is dry and somewhat reddened.   I  am  persuaded, from
what I have witnessed, that a diligent course of management, in
this way, is calculated to do a great deal of good—as much, pro-
bably, as is usually derived from the more painful counter-irrita-
ting  applications.
   Among the  internal remedies, opium, calomel, the sulphate of
iron, and the nitrate of silver, appear to me the  most valuable in
this aggravated state of weaning brash.   After  the bowels have
been gently evacuated by a dose of castor oil with a few drops of
laudanum, small doses of calomel and opium  should  be  given
three or four times daily, until  there  is reason to think that the
action of the liver  has been improved.   Much  more  caution is
necessary in the use of calomel  in this  stage of the disease, than
at an early period, before inflammation of the mucous membrane
has taken place.  When this tissue is in a state of chronic inflam-
mation, calomel not only sometimes increases the local  irritation,
but is apt, when frequently  used, to  produce a  general  erethism
of the system, which is always  extremely unfavorable in its ten-
dency.  Calomel,  indeed, can  rarely have any direct  beneficial
operation upon the intestinal canal, when  its mucous coat is in a
state of chronic inflammation.  Its usefulness under these circum-
stances depends on its  well-known tendency to correct the morbid
condition of the liver, and consequently to improve  the vitiated
or acrid biliary secretion.   Opium may be very beneficially em-
ployed, throughout the whole course  of the disease.  I have more
frequently succeeded in arresting the disease, in this stage, by the
internal use of small  doses of opium and  sulphate of iron, in con-
junction with  the  external means mentioned above, than by any
other remedy.   After the morbid condition of the liver  has been,
in some degree, corrected by small doses of calomel  and opium,
the sulphate of iron may be very advantageously substituted for 
                        OF DIARRHOEA.                    251
the calomel.   A powder composed of the  twentieth of a grain
of opium, the eighth of a grain of sulphate of iron, etod five or
six grains of powdered gum arabic, should be given three or four
times daily according to the age of the child.  Harsh and inappro-
priate as  the nitrate of silver may appear to be, in cases of this
kind, I have, nevertheless, in a few instances, found its internal
administration  to produce  the  happiest effect.  In an extremely
severe case of chronic diarrhoea, which commenced in- the usual
way of weaning brash, and which  was evidently  attended with
chronic inflammation, and,  as it seemed to  me, ulceration of the
mucous membrane of the colon, I administered this article in union
with laudanum, with prompt and decided benefit.  One grain of
the nitrate was dissolved in an  ounce and a half  of gum-arabic
water, to which twenty drops of laudanum were added.  A tea-
spoonful of this solution was given three times daily.   The dis-
charges  soon  became less  frequent and of a better appearance;
and under the continued use of this remedy, together with blisters
dressed with weak  mercurial  ointment, and  the mildest possible
nourishment, the  disease gradually  yielded, until it was finally
entirely subdued.   The patient was about eighteen months old.
In several other  instances  of  a similar character, this  treatment
was attended with  unequivocal advantages;  and  I  have  never
known  the  slightest  inconvenience  to result from  the use of
this article in chronic  mucous inflammation of the bowels, when
administered in a mucilaginous  solution and  in very small doses.
In  cases of this kind, the  nourishment should consist exclusively
of barley-water, a solution of gum arabic, infusion of slippery elm,
the mucilage of iceland moss, and  a very liquid  preparation of
arrow-root.   The smallest  portion of solid food, will  generally do
more harm, in a  few hours, than  can be  remedied in several
weeks.   In this advanced stage of  the disease, purgatives  ought
to be employed with the utmost degree of caution.   Dr. Dewees
advises that " small but repeated doses of  castor  oil should be
given."  I cannot but regard this advice as decidedly injudicious,
and calculated, if followed  up, to do much mischief.  In ordinary
cases of diarrhoea, depending on simple irritation  from offensive
substances lodged in the bowels, repeated purging is often indis-
pensable.   In  such cases, the principal objects  are—to remove 
252                     OF DIARRHOEA.
the irritating  substances out of the bowels by laxatives, and to
allay thei/inordinate irritability by opiates.  In the present form
of diarrhoea a very different state of things obtains.   The mucous
membrane of the bowels is inflamed, and perhaps ulcerated. The
diarrhoeal discharges depend on this diseased  condition of the
intestines, rather than on the acrid secretions which are poured
into them.  It could hardly be expected therefore, that any ad-
vantage would result, from frequently irritating the inflamed mu-
cous membrane and urging the  already too greatly excited peri-
staltic action of the  bowels, by  purgatives.  In the chronic diar-
rhoea of  adults, accompanied with  mucous inflammation of the
colon, no  prudent and experienced  physician, certainly, would
resort to " repeated  doses of castor oil."   I have repeatedly wit-
nessed the pernicious consequences of this practice in cases of this
kind.  I do not mean to object  to the occasional administration of
a moderate  dose of castor oil with a few drops of laudanum.  If
the dose be repeated once every three or four days, and laxative
enemata employed, during  the  intermediate periods, the bowels
will be kept in sufficient motion to prevent the undue retention
and accumulation of acrid secretions in them.
   It may be objected to the preceding observations, that if arti-
cles so corrosive and active as lunar  caustic, and the sulphate of
iron, may be given with advantage  in  this complaint, no  harm
can be reasonably apprehended, from the mild  impressions of
castor oil, or other gentle purgatives.  This argument, however,
is  not supported by experience.   There  is something very pecu-
liar in the  impressions made by these articles.  The nitrate of
silver, especially,  though a highly active irritant, often  exerts a
peculiarly soothing and alterative effect on inflamed surfaces.  In
certain varieties of ophthalmia,  this article is  pre-eminently use-
ful; yet were castor oil or rhubarb applied to the eye, the inflam-
mation would, undoubtedly, be greatly increased.   It  is not the
strength but the character of the irritant  that renders it  either
salutary or hurtful in certain affections.  Purgatives excite the
intestinal nerves and increase the peristaltic action; lunar caustic
and the sulphate of iron, not only excite, but change the sensibil-
ity and irritability of  the  inflamed  mucous  membrane of the 
                        OF DIARRHOEA.                    253
bowels, and thus contribute essentially to the reduction of the
inflammation.
  In the chronic diarrhoea of adults, the sulphate of copper, has,
within the last four or five years, been employed in Europe with
entire success.  When the inflammation and ulceration is chiefly,
if not wholly, confined  to the colon, this article sometimes pro-
duces a very good effect.  I have  used it  in  a few instances, of
this  kind, in adults, with unequivocal advantage.   It is not im-
probable  that it might be used with equal  benefit in the chronic
diarrhoea  of children—more  especially in the second variety men-
tioned  in  the former part  of this section, and which does not dif
fer, in  its  pathological character, from the ordinary chronic diar^
rhoea of adults.  This modification of the complaint, as has already
been observed, is generally the result of neglected or mismanaged
acute  diarrhoea, and is seldom met in very young infants.  The
stools are slimy, usually streaked with blood, often attended, with
a slight feeling of tenesmus, or with  considerable straining, and
almost  invariably  conspicuously  mixed with purulent matter.
In such  cases, besides  the  remedies already mentioned as  ap-
plicable  in chronic  diarrhoea,  the sulphate of copper, may be
tried.  It should always be given with opium.   The  one tenth of
a grain, with the fifteenth of a grain of opium, may be given every
morning,  noon, and evening; and the proportion of the sulphate
ought  to  be  gradually increased, until it is found  to produce
nausea or vomiting.  The balsam copaiva, too, may sometimes
be  used with decided benefit in  such cases.  I have used  this
article repeatedly in the chronic  bowel  complaints of children,
and  occasionally with considerable advantage. It should be given
in the form of emulsion and in union with small doses of lauda-
num.  Five or six drops of the balsam, with a drop or two of
laudanum should be given three or four times daily.   In cases of
this  kind  I have seen much  good  done by a decoction of the con-
ferva helminthocordon.   I am satisfied that  this  is  a valuable
remedy in  certain varieties of  protracted  diarrhoea.  Where
there  is  reason  to suspect the  presence  of  verminous irri-
tation,  this article is,  probably,  the most  useful  remedy  we
possess.   It has, pretty active vermifuge powers, and by the small
portion of iodine which it contains, may operate very beneficially 
 254                    OF DIARRHOEA.
 on the liver and mesenteric glands.  Be this as it  may, I  have
 witnessed its good effects in several very long-standing cases, after
 various other remedies had  been  used without  any manifest ad-
 vantage. Two drachms of the conferva should be boiled in half a
 pint of water, down  to four ounces.  The  dose of  this  is a tea-
 spoonful three or four times daily, and I have usually added about
 a tenth of a grain of the sulphate of iron  to each dose.  Diarrhoea,
 of a very obstinate character, alternating, however, with occasional
 short periods of costiveness, sometimes arises from the presence of
 worms in the bowels. These cases are, almost without exception,
 attended with a tumid and hard state of  the abdomen, slimy eva-
 cuations, a peculiarly offensive breath, a pale countenance, vora-
 cious appetite, and frequently with tumefaction of the upper lip.
 As instances of this kind  are not necessarily, or even  generally,
 connected with mucous inflammation of the  bowels, recourse may
 b. e had to pink-root tea, or to small and repeated doses of calomel
 followed by an active purgative.   My own  experience, however,
 has led me to prefer a decoction of the helminthocordon, in cases
 depending, or connected with verminous irritation,  to any other
 remedy I have tried.
  Astringent and  cretaceous remedies are not, in general, calcu-
 lated  to do good in chronic diarrhoea.  When there is mucous in-
 flammation or ulceration present, they seldom fail to do manifest
 harm.  After the local affection has  been subdued, and the fecu-
 lent and copious diarrhoeal discharges result from weakness and
 relaxation  of the  bowels, vegetable  astringents will sometimes
 operate very favorably.  So long, however, as the evacuations are
 small, slimy, streaked with blood, or mixed with  purulent matter,
 remedies of this kind  are wholly inadmissible.  During conval-
escence, they may sometimes be proper;  but very rarely, if ever,
during the active stages of the disease.   The blackberry root, or
the root of geranium maculatum, are among the best, if not the
very best astringents we have, for purposes of this kind. 
OK WORMS.
255
                   CHAPTER XXI.


                   OF INTESTINAL WORMS.

   Concerning the origin  of intestinal worms, much  has been
conjectured, but little ascertained.   It is a subject, by  no means
unworthy of particular research; for beside  the interest  it pos-
sesses in the eye of the  naturalist, it has peculiar claims on the
attention  of the physician.  An exact and complete knowledge
of the sources and generation of these animals, might furnish ma-
terials for a certain prophylactick mode of treatment.  As the in-
quiry, however, does not come properly within the design of this
work, we will not enter into an  extensive examination of the va-
rious notions,  that have been started with respect to the forma-
tion of worms, but briefly  notice the two hypotheses, which are
supported by the greatest number of probabilities.
  The first of these is framed in accordance with the  ancient
dogma, omnia ex ovo, and derives its  principal evidence from the
analogy of nature, and the inadequacy of any other mode for ex-
plaining the origin of intestinal worms.  According to this notion,
these animals are evolved  from  ovula, received into the stomach
and bowels from  without, along with the food and drink.   It
may be remarked, that the theory necessarily involves the suppo-
sition of the  existence without the body  of worms, by which
these ova  are generated, and  which are similar to  intestinal
worms.  But the most accurate  observation is in contradiction  to
this supposition.   The few earth-worms,  resembling toenia and
ascarides, are of very rare  occurrence and only to be  met with
in certain localities; whereas these species of vermin are common
both to man and the inferior animals, in all countries and every
variety of situation.   Linnaeus, Gmelin and a few  others report,
indeed, that they have discovered similar worms in stagnant wa-
ters and marshes;  but the ablest helminthologists of the  present 
256                      OF WORMS
day, assert, that they are quite dissimilar, in structure and habits.
to those generated in the intestines of animals.   Moreover, intes-
tinal  worms, when expelled from the body, and  exposed to the
air or placed in water, almost  immediately die—a circumstance
hardly to be  looked for, if originally derived from without.  Fi-
nally, it is ascertained, that earth-worms and such as live in water,
do not change their forms or characters, when accidentally received
into the alimentary  canal.   Instances  have been mentioned, of
various aquatic animals  being taken into the stomach, where
they have  thriven so wonderfully as hardly to be recognized as
individuals of  the different  species to which they naturally be-
longed.  In  all these cases, however, the change was in their
magnitude, not in their structure and essential  nature.  These
facts  go to prove that intestinal worms constitute  an entirely dis-
tinct  species from all others, and  it therefore, becomes rather a
perplexing task, for the advocates of the ovular theory, to point
out the sources whence the verminous ova are derived.
   But there are other difficulties in the way of this hypothesis.
Cases, on the best authority, are recorded of worms found in the
intestines of foetuses, and of infants newly born.  Kerkringius dis-
covered lumbrici  in  the  stomach of a seventh month foetus: in
another instance, he found a great number of small worms in the
bowels of a child, just after birth.   A tape worm, as Pallas states,
was found, by Brendel, in  the  intestines of a newly-born infant;
and according  to the testimony of Block, Hains met with a simi-
lar instance.  Taenia have  been discovered in the bowels of a
pup, immediately after birth, as in the case stated by Rudolphi
to have occurred under the notice of the  celebrated Blumenbach.
It is also on  record, that  a  fasciola hepafica  was detected in a
lamb still  in utero.   The fact, too, that hydatids  and other ani-
mals are not  unfrequently met with in parts of the body, that can
have  no communication outwardly, discountenances the ovular
hypothesis.
   A view of these difficulties has contributed to turn the atten-
tion of many ingenious men to the doctrine of  the spontaneous
generation of worms within  the body.   This  doctrine is chiefly
sustained  by the facts we  have just  mentioned, as  militating
against the notion of verminous  generation from extrinsic Ova. 
                         OF WORMS.                     257
That the  ovula of worms should be transmitted through the
medium of the ingesta, Dr. Bremser thinks altogether improbable.
An experiment, performed by Schreiber, is also adduced by him
in support of the hypothesis of spontaneous formation.  A pole-
cat was fed for six weeks upon milk, containing  the eggs and
various species of intestinal worms.   The animal being killed at
the  end  of that period, to the  astonishment  of all, not  a single
worm could be detected in his body.
   The advocates of the ovular theory, in attempting to obviate
the  difficulties that beset their  opinions, and  to combat  the
adverse hypothesis, contend, that  there is no improbability in
supposing, there may be  a transmission  of eggs through the
medium of air, food and drink. . As to Schreiber's experiment,
they deem  it  quite inconclusive.   Other circumstances, beside
the mere presence of the  ova, are necessary to the formation  of
worms.  The intestines must be so debilitated or disordered, that
they  shall be  unable to  destroy  and cast  off these parasitic
animals.   Now in the experiment  related, the stomach of the
pole-cat was in its usual healthy condition—at least there is no
reason to  believe otherwise.  It is further remarked, there are
positive experiments to prove that worms  may be propagated in
the human  body.  Pallas, by  a small incision, introduced into
the cavity of a dog's abdomen, the ova of taenia, from the bowels
of another  dog.  At  the end  of a  month  young taenia were
thriving in the cavity.  In this case, they wrere not checked in
their developement, by the active powers of the alimentary canal,
nor liable  to be thrown off by its healthful motions.  The case of
hydatids  and other animals,  found  in  the  close cavities of the
body, is acknowledged to present considerable difficulties—not so
many, however, it is said,  as surround the hypothesis of a sponta-
neous formation.  Besides, it is  quite  possible, they remark, thaf
the eggs from which these  verminous animals are generated, aftei
being received  into  the system,  may, from  their extreme minute
ness, have been taken up and carried away by the absorbents, to
the different parts of the  body, where they  are found  in their
developement.  The same remark  is applicable to instances  of
worms discovered in foetuses.  Owing to the intimate communica-
tion established between the mother and the child, in  utero, the
                           H              23 
 258                     OF WORMS.
 diseases of the parent not unfrequently become the diseases of her
 offspring—and peculiarities of physical and moral constitution are
 also transmitted.  Why then, it is asked, may not  the  ovula of
 worms, received into  the system of the mother, be taken up by
 the  absorbent vessels, and after passing into  the  circulation, be
 ultimately deposited in the bowels of the foetus?  The  difficulty,
 growing out of the distinct specific  nature of intestinal worms, they
 attempt  to lessen, by supposing, that  a change  in  situation  and
 mode of living may so far alter  the external appearance of these
 worms, as to conceal  their real character.
   Such are the principal grounds, upon which the two hypotheses
 stand.  I will leave the student to make up  his own opinion on
 the subject, with a single remark in particular reference  to the no-
 tion of a spontaneous formation.   It appears to  me  that an erro-
 neous sentiment of religion and the force of long-received opinions,
 —in other words, that partial views of the economy of  nature, as
 also an undue deference to authority,—have exerted too much in-
 fluence over the enquiries of men, touching  this  subject.  The
 ancient dogma, omnia ex ovo, unquestionably true in the general,
 is deemed by some universally so;  although it is manifest it should
 not be extended beyond the experience upon  which it  is based.
 If then, certain remarkable phenomena should  be observed, by no
 means in accordance with the general theory,  analogy should not
 be a sufficient reason to make us doubt the evidence of our senses,
 and believe in opposition to facts, that such exceptions are  not
 real, but apparent.

   Species of Intestinal Worms.—There are five distinct spe-
 cies of intestinal worms.
   1.  The tricocephalus dispar—(Trichuris—tricocephalus hominis,—
ascaris trichuria).—This worm, called  by  the  English the long
threadworm, is from an  inch and a half to about two inches in length.
About two thirds of  its length is as thin as  a horse  hair,  the
remaining and posterior part being considerably thicker, termin-
ating in  a rounded or blunt extremity.  The thin part is trans-
versely striated; and the alimentary canal may be seen,  by means
 of a lens,  running  from its  thinner extremity in a direct line
 through  the centre, into the  thick  posterior portion, where it 
                          OF WORMS.                      259
 assumes a flat  and spiral form.   These worms  are  seldom nu-
 merous, and are principally found in the coecum.  They have been
 discovered in the rectum, and some say they have met with them
 in the jejunum.
   2. Ascaris vermicularis.—(Oxyuris  vermicularis—-fusaria  vermi-
 cularis—mane or thread worm).—This is a very small white worm
 —the male being not  above two lines in length, with a rounded
 or blunt extremity anteriorly,  tapering  to  a point  posteriorly.
 The female  is considerably larger, being from four to five lines
 in length, terminating in an extremely fine extremity posteriorly,
 resembling the point of the finest needle.  These worms are found
 only in the large intestines, and principally in the lower part of
 the rectum, where they are often congregated in almost countless
 numbers.  The reports, that have been made, of their existence
 at times in the ventricles of the brain may be justly discredited.
   3. Ascaris lumbricoides.—(Fusaria lumbricoides—lumbricusteres).
 These worms are from two or three to ten or twelve inches in
 length, round, of a yellowish  white  or brownish-red color, of
 nearly a uniform thickness, except at the extremities; which taper
 to a blunt point. They are from two to three lines in thickness.
 The head may be distinguished by a circular depression within  a
 line of one of the extremities, terminating  in three small tuberos-
 ities or valves, which the worm has the power of opening or clos-
 ing.  When they are opened, a very minute patulous projection
 may be seen, which constitutes the mouth  of  the worm.  A very
 small groove  passes longitudinally from one extremity to the  other,
 on both sides.   The alimentary canal terminates in a transverse
 depression on the under surface, near  the  posterior extremity,
 The male is smaller than the female, and may be distinguished by
 its shortly curved caudal extremity. In some instances the organs
 of generation are conspicuous—consisting of two small cylindrical
 projections in the curved part of the tail.   These worms inhabit
 the  small intestines, and occasionally ascend  into the stomach.
 It is said, too, that they have been discovered  in the gall bladder
 and common  bile duct.
  4. Tcenia lata.—(Bothriscephalus latus—tania membranacea—t.
vulgaris).—This  worm often acquires a very great length,—from
thirty to forty feet  and more.   It  is from four to ten lines in 
 260                      0F WORMS.
 breadth, flat, white, and composed of a series of concatenated
 joints, resembling a piece of white tape.  The head is armed with
 two processes, by which the worm attaches itself to the intestines.  It
 inhabits the upper portion of the bowels and the stomach. Three or
 four of these worms sometimes exist in the same person.  Where
 they prevail, the taenia solium is seldom met with.

   5.  Taznia solium.—(Tcenia cucurbitini—t. osculis margin-albius.)
 This worm is rarely, if ever, voided whole.   It  is passed off in
 pieces of a greater  or less number of joints,  or in single joints,
 bearing considerable resemblance to the seeds of gourd.  Pieces,
 however, upwards of twenty feet in length, have been discharged,
 although generally not more than three or four joints, pass off to-
 gether.  The  anterior part tapers off into a very fine, thread
 like extremity, the head being extremely small, and furnished at
 its sides with four small apertures (oscula).  This is the most com-
 mon species of  tape-worm,  and like the taenia lata, inhabits the
 stomach and small intestines.  The name would indicate that one
 worm alone inhabited the bowels of the same individual; but this
 is not  so, two  or  three frequently  being voided  by  the same
 person.

   Circumstances, favoring the generation of intestinal worms.—Al-
 though unenlightened with regard to the origin of these parasitic
 animals, observation has revealed to us many of the circumstan-
 ces, that favor  their production and increase.  The principal of
 these are, a general debility of the  system, and a feeble or de-
 ranged condition of the alimentary canal.  Whatever, therefore,
 disposes to  these  states, constitutes  a remote cause of worms,—
such as, too rapid  growth;  scrofula;  a sedentary and an inactive
mode of life; habitual  exposure to  a  damp atmosphere; indul-
gence in crude,  unripe fruits; the abundant use'of fat, and  farina-
ceous articles of diet, and of fresh milk; the ingestion of more
food than the stomach will readily digest, or than is necessary to
the wholesome sustenance of the system.  Dr. Bremser asserts,
that all esculent articles, containing an abundant proportion  of
 nutritive matter, will when taken in quantities more  than suffi-
 cient to minister to the necessities of life; greatly favor the form- 
                         OF WORMS.                      261
ation of worms.  Sugar by some has been thought to aid largely
in the development of these animals; but this has been denied by
others  who have  enjoyed equal opportunities of correct obser-
vation.
   That verminous  diseases have ever prevailed as epidemics, is,
by some, denied and not unfrequently ridiculed.  Why the state-
ment should have excited ridicule, we are at a loss to discover;
since there certainly can be no absurdity in the notion, that pecu-
liar atmospheric conditions may at times prevail throughout large
districts of country, affecting the intestinal canal in such a man-
ner, as  shall particularly dispose it  to  favor the generation of
worms.   Besides, if the concurrent testimony of many very  emi-
nent authorities is to be believed, we shall be obliged to admit the
actual occurrence of such epidemics.  A very remarkable instance
of this kind is related by Marie, which occurred at Ravenna and
the surrounding district.   Block has also given  an account of an
epidemic worm-fever.
   In some  countries, verminous affections prevail far, more  than
in others.   In Savoy and Chambray intestinal worms  are said  to
be remarkably common in all classes of society, (Daquin,  Brem-
ser,) and the same  observation has been repeatedly made of  Hol-
land and Switzerland.   The prevalence of verminous disease,, in
the latter country  is ascribed by Bremser to the abundant use of
milk and cheese.  Nevertheless we may be  said  to be  ignorant
of the various circumstances that occasion the spread of these dis-
eases in particular districts.  Holland, in climate and situation,
differs entirely from Switzerland, being low, flat,moist and marshy;
and moreover, fish enters largely into the diet of the inhabitants.
Still we find the Swiss  peasant, living amidst  rugged Alps, and
"breathing the difficult air of the iced mountain's top," equally lia-
ble with the Hollander to verminous  complaints.   It is thought
by some that worms  are more prevalent in cities than in the
country; and  Pallas believes that carnivorous animals are  more
subject to them than those of the graminivorous sort.  Bremser
states on the other hand, that it is no unfrequent circumstance to
find large  numbers of worms in the intestines of those  animals,
that subsist principally on vegetables.   The  greater prevalence
of verminous affections in cities, is attributed, by him, to the larger 
262                      OF WORMS.
proportions of causes, tending to enfeeble or deprave the general
system, and derange the digestive functions—such as  impure air,
deficient exercise, luxurious  living and irregular habits.  It has
already been femarked that an over nutritious diet tends to pro-
duce worms,  but a deficiency of nutriment would not seem to
occasion the same result.
  Different  districts of country are  liable to the prevalence of
different species of worms.   The occurrence of the tape-worm is
particularly common both in Switzerland and Holland; and it is
worthy of remark, that, in the former country, the bothriocepha-
lus  latus is by far the most  frequently met with.  In Germany,
the greater  part of France, in  Italy and even in the Tyrol, the
taenia solium is almost the only species of tape-worm to be found.
In Sweden, according to Rhudolphi, the broad tape-worm occurs
but rarely, but the taenia solium is of frequent occurrence.  This
latter  species prevails  also  most frequently in  Great  Britain,
although the former sort is not seldom met w'ith.  (Rhind.)   The
Guinea worm, infesting the sub-cutaneous cellular tissue, is con-
fined to tropical countries: although brought into the temperate
regions, by persons afflicted with it, it has never there become a
prevailing affection.
  Childhood is the period  of life, especially subject to  vermin-
ous disease.   The  tape-worm, however, is generally the pest of
riper years.   As a general rule,  those children, who are confined
altogether to their mother's milk, suffer least from worms.   Dr.
Dewees declares, that he has never seen worms in children under
ten months of age, and only in two instances of that age,  both of
whom were weaned at four months.

  Symptoms.—The symptoms, arising  from verminous irritation,
are  as numerous and  diverse, as  the sympathies  that subsist
between the  alimentary canal and the different parts of the  body.
It is on account of the variety  and  complexity of these  sympa-
thies, and because we have no  certain means of indicating the
specific marks of verminous irritation, that the symptomatology
of worms is so imperfect.   The  only sure  indication of  their
existence, is their appearance in the evacuations.   Nevertheless,
there are many symptoms that will lead the judicious practitioner 
                         OF WORMS.                     263
to suspect their presence and prescribe accordingly.  The coun-
tenance is pale and leaden-colored, with occasional flushes, or a
circumscribed spot of red in one or both cheeks; the eyes become
dull; the pupils dilate; an azure semicircle runs along the lower
eye-lid; the nose is irritated, swells and sometimes bleeds; there
is tumefaction of the upper lip; occasional head-ache, with hum-
ming or throbbing  in the ears;  an unusual secretion of saliva;
slimy  or  furred tongue; breath  very foul, particularly in the
morning;  appetite variable,—sometimes voracious, with a gnaw-
ing sensation of the stomach; at others, entirely gone;  fleeting
pains in the stomach; occasional nausea and vomiting, the matter
thrown up, being limpid like water: violent  tormina through-
out the abdomen, particularly about  the umbilical region; bow-
els irregular—at times costive,  and  then disposed  to frequent
dejections; stools slimy, not unfrequently tinged with blood; belly
swrollen and hard, attended with emaciation of other parts of the
body;  urine turbid, yellowish or—after  depositing a sediment,
has  the  appearance  of  milk and water, (Rhind); respiration,
occasionally difficult and  accompanied by hiccough; sometimes
cough, dry and convulsive, stertorous or suffocating; uneasy and
disturbed sleep, with grinding of  the teeth; temper variable, but
generally irritable.   Of  all these, the most infallible  symptoms
are  by some supposed to be, unusual enlargement of the pupil;
voracious appetite; inordinate secretion  of saliva;  emaciation;
pricking sensation of the stomach; swelling and hardness of the
abdomen, and loathing of food.  Nevertheless, all these symptoms
may arise from other affections.  According  to Rosenstein, the
surest indication of their presence, is the uncomfortable sensation
experienced  by the patient after a draught  of cold  water, and
voiding some worms  or  fragments of worms.  There can, of
course, be no doubt as to- the infallibility of the latter symptom.
   It has been fancied by some persons, that worms perform very
wholesome offices in  the  animal economy, consuming the super-
abundant nutriment,destroying morbid secretions, and stimulating
the intestines to the expulsion of ungenial  substances.   But daily
experience  and correct  observation  teach, that  these  are  but
imaginary benefits, whilst the evils they inflict are exceedingly
mischievous and  almost  inevitable.   Undoubtedly it may have 
264                      0F WORMS.
happened, that many  disorders have, without any foundation,
been  ascribed to verminous irritation; for the etiology of disease
is by no means a certain science.   Besides, the same condition of
the intestinal canal, that favors the generation of worms, may be
the principal source of  many of the complaints, co-existent with
the presence of these  animals.  That verminous irritation, how-
ever,  is  sometimes the direct  and exclusive exciting cause of
severe and dangerous disorders, we may not disbelieve.  Chorea,
epilepsy, hydrocephalus, emaciation, convulsions, paralysis, fevers,
dropsy, mania, and a  vast variety of anomalous affections,  are
at  times the immediate  consequences of verminous irritation,
and frequently  disappear after  the expulsion  of the  worms.
Esquirol knew eleven  persons cured of mania by  the expulsion
of a large number of lumbrici.   Brera states, that a lumbricoi-
des in the urinary bladder, produced nephritis and fatal disease
of  the bladder.   The same  author  narrates, a case in which
pains in the joints, similar to those of arthritic rheumatism, were
occasioned by worms in the intestinal canal.  The pains immedi-
ately ceased upon the expulsion of nine large  lumbricoides.  The
presence  of worms sometimes induces  singular idiosyncrasies.
An instance is recorded  of a patient, afflicted with taenia  and
ascarides, to whom the sound of music, instrumental or vocal,
was quite intolerable.   Another  case is selated, where a person,
in a  convulsive fit from verminous  irritation, heard by accident
some musical sounds, and was immediately cured.

   Treatment.—In prescribing  for intestinal worms, we  should
have  strict regard to  the regimen, confining  the  patient to  a
spare  and liquid diet, and  exhibiting two or three mild  purga-
tives, a few days previous to the  administration  of anthelmintic
remedies.   These preparatory  measures are calculated to secure
success more frequently, from the employment of the ordinary
vermifuges.

   Lumbricoid.—My own plan of management for the expulsion of
the long round worm, is to put the  patient on  a liquid diet, and to
order him a small dose of epsom salts every morning for three or
four days.  On the fourth  morning, I direct a decoction  of  the 
                          OF WORMS.                       265
root of spigelia,  in  the  proportion of  an ounce of the root to a
pint of water, boiled  down to a half pint.  This, being sweet-
ened, is to be drunk  in  the  course of three or four hours, by a
child  of from five to ten years old, commencing in the  morning
after having taken a little milk and water into the stomach.  As
soon  as  the whole of the  decoction is taken, an active dose of
calomel  and jalap  is to be administered, or a dose of castor oil
and turpentine, in the proportion of half an ounce of the former
to two drachms of the latter, given in doses  corresponding to the
age of the patient.  I have rarely failed by this plan, to procure
the discharge of  worms, where they existed in the bowels.  The
remedies and modes of treatment, recommended for the expulsion
of this species of worms, are almost innumerable.   A  few of them
deserve our attention.  According to Bremser, the electuary append-
ed below* is^highly efficacious as a vermifuge.   It is to be given
to a child in doses of a teaspoonful, every morning and evening for
six or seven  days. I have used  this electuary in four or five cases,
with  complete success.    Exhibited to such  an extent as  to pro-
duce  frequent and watery evacuations, it does far less good, than
when managed  so  as to procure  three or four consistent stools
daily. The empyreumatic oil of Chabertt has obtained great cele-
brity in Europe for  its  anthelmintic  properties, especially  in
respect to taenia, and is indeed  universally used on that continent.
Bremser and Brera  speak very highly of its virtues, and  Rudolphi
asserts, that it is decidedly the most efficacious vermifuge we pos-
sess.  Fifteen or twenty  drops may be taken three or four times
daily, by  children from  two to seven  years old.  Small doses of
           * Sen. Santonic.    ........•  .  gss.
             Pulv. root valerian..........3ii.
               "   "  Jalapae   .........3ss— gii.
             Snlphat. Potassae..........3iss—3ii.
             Oxymel. Scillit...........q. s.
             utfiat electuar.  M.

  t This oil is made by mixing one part of the fetid spirits of hartshorn with three parts
of the spirits of turpentine, and suffering them to digest for four days. The mixture is
then to be put in a glass retort, and distilled in a sand bath, until three fourths of the
whole have passed over into the receiver.  This is to be kept for use in small and well
closed phials.
                             2M 
266                      0F WORMS.
calomel, with the  powdered roots of spigelia and valerian, may
be employed with advantage.  Calomel, however, given in this
way, is  apt to  produce ptyalism, especially as it is necessary to
continue its use for several days, to insure its anthelmintic action.
The chenopodium anthelminticum is well known in this country,
as a vermifuge. By means  of syrup, an electuary is sometimes
made of the powdered seeds, and given, in doses of a tablespoon-
ful, to a child of from two to five years old, twice a day—care be-
ing taken  to abstain from  food several hours.   It is generally
necessary to repeat the dose four or five days.   Beside these arti-
cles, the most efficacious medicines, for the destruction and expul-
sion of  the round worm, are—sem.  santonic;  garlic;  conferva
helminthocordon;  spirits of turpentine;  geoffrea  surinamensis;
camphor; the green rind of unripe walnuts, and tin filings.
   The  expulsion of lumbrici is not, in general, a ^ery difficult
task.   But  to  accomplish this desirable  object  completely, we
should persist  for a considerable time  in the use of anthelmintic
remedies, so as not only to destroy the already existing worms,
but  the eggs  containing the germs of others.  Their expulsion
being effected, strict  regard should now be paid to preventing a
reproduction of them.  In view of this object, the patient should
attend particularly to his diet, living abstemiously on  plain food.
A free  indulgence in saccharine matter, in milk, cheese, or but-
ter, must be forbidden.  Animal food ougTit to enter largely into
the diet.   Whatever tends  to invigorate the general system, and
bestow a wholesome  energy on the stomach, should be  carefully
enjoined.    Recourse  must be had  to tonics, particularly chalybe-
ates, in conjunction with minute doses  of aloes.  A strong decoc-
tion of  the  helminthocordon has appeared to me, not only valua-
ble as  a  vermifuge,  but particularly so, as a corrective of that
deranged  and debilitated condition cf the alimentary canal,  favor-
ing the production of worms.  An ounce of this marine vegetable,
with a drachm of  valerian,  should  be  boiled in a pint  of  water
down to  one gill.  Of this a teaspoonful  may be given  every
morning, noon  and evening, with peculiar advantage.  I have
known several  instances, in which children, apparently suffering
from verminous irritation, were restored to perfect health by the
use of this remedy, without any appearance of worms in  their ex- 
                         OF'WORMS.                      267
cretions.   It is particularly beneficial in cases attended with the
usual  symptoms of ^orms, connected with want of appetite  and
mucous diarrhoea, which arise from mere debility of the digestive
organs and a vitiation of the secretion of the bowels.
  Ascarides.—These worms, in  general, are extremely annoying.
From their being involved  in  the  folds at  the lower part of
the rectum, they frequently give rise to inflammation of the anus,
tenesmus  or  haemorrhoids.  During the 'day, they are seldom a
source of  much uneasiness; but  towards evening, and especially
after lying down, they occasion  a tormenting, an almost insup-
portable irritation and titillation about the anus.   So distressing
indeed is the irritation, that nervous children are not unfrequently
thrown  into  convulsions thereby.   In females,  they sometimes
pass into  the vagina, giving rise to extreme uneasiness.  Doctor
Bremser states, that he knew a case of nymphomania, occasioned
by their presence in that passage.   They have also been known
to enter the bladder  and urinary passages.   They are  generally
more  troublesome in damp than in dry weather.
   The complete  removal of these worms is a work of great  diffi-
culty.  They  are  so wonderfully  reproductive, that no matter
though thousands be brought away, we may soon have to recom-
mence our task.  The ordinary vermifuges, too, are of little avail in
the destruction of ascarides.  Their action is more particularly ex-
erted upon the upper portions of the intestinal tube, and  at all
events lose their virtues before they arrive at the location of these
animals.   Even the most active cathartics are insufficient to expel
them.  Aloes, however, from the peculiar influence it exerts over
the lower portion of the bowels, frequently causes their expulsion
in large quantities, especially if assisted by the action of proper
enemata.   My usual mode of proceeding for the removal of these
troublesome worms, is to prescribe three or four aloetic purga-
tives every second day, together with two or three enemata, com-
posed of  a mixture of lime-water and milk, in equal proportions,
daily. Injections of a solution of aloes, or of infusions of any of the
abovenamed vegetable  anthelmintics, will generally succeed in
bringing away great  numbers of these little  animals.  In a few
instances, I have procured their expulsion in large quantities, by
injections, composed of spirits of turpentine, mixed with milk, in 
268   ,                   OF WORMS.
the proportion of a teaspoonful of the former to a gill of the lattr .
Injections of  any of the common  oils will ©ftentimes soothe the
extreme  irritation, and also  destroy the worms.   According to
Nil Rozen, a  drachm of refined sugar, dissolved  in warm milk,
has been  injected writh great success.  Another  remedy, highly
spoken of, is  a bougie, smeared over with mercurial ointment,
and introduced into the rectum. Dr.  Vanvert asserts, that flowers
of sulphur, taken in the morning on an empty stomach, is one of
the most efficacious remedies for the  destruction and expulsion of
ascaridies. In obstinate cases, the fumes of tobacco, or an infusion
of the male fern, has been recommended by Dr. Bremser. When
these worms  have crept into  the vagina,  the same author states,
that injections of cold water, with a small portion of vinegar, is
the best remedy we possess.
   As taenia occur chiefly in  the adult, their  treatment does not
come properly under notice in this work. 
OF OPHTHALMIA.
269
CHAPTER XXII.
                      OF OPHTHALMIA.

  Purulent Ophthalmia.—-The  purulent ophthalmia  of  infants,
generally commences  between  the  fourth and  eighth day aftei
birth, though instances of  its  coming  on at a more advanced
period are occasionally met with.   At  first the eye-lids  are ob-
served to be glued together, in the morning attended with slight
swelling and external  redness.  If the lid is raised, so as to expose
its  conjunctional surface,  it is found  of a uniformly red and
slightly thickened appearance.  As the disease proceeds, the swel-
ling of the eye-lids  increases; a thick purulent matter begins to
issue  from the eyes;  the child  becomes fretful and uneasy,  and
manifests much  intolerance of  light, keeping its eyes constantly
and firmly closed.  In the course of three or four days  the con-
junctiva  becomes  highly inflamed and  oedematous—rising up
around  the cornea, so as almost to conceal it, or causing it to
appear as if it were sunk deep  into the eye.   The  secretion of
pus is now extremely copious, and being confined under the swol-
len and firmly closed  lids, it bursts forth, from  time to time, and
runs down the cheeks in large drops.  If the disease be not arrest-
ed, the lids become distended  to the utmost degree,  giving rise,
sometimes, to eversion and  consequent bulging out, or protrusion
of the inflamed and highly infiltrated conjunctiva. The cornea, also,
has by  this time become implicated,  and is more  or  less opake.
Should the disease continue, corneal ulceration and sloughing takes
place, the aqueous  humor escapes,  and a total  destruction of the
organ ensues.  Mr. Guthrie states that  there are two varieties of
infantile, purulent ophthalmia.  In one, the inflammation is seated
almost exclusively,  in the conjunctiva of the lids;  whilst in the
other variety, the conjunctiva of the eye-ball is  equally implicated
in the disease.   I have repeatedly  noticed these diversities in the 
270                   OF OPHTHALMIA.
suppurative ophthalmia of infants.  When the  inflammation is
confined to the lids, the disease seldom leads to any very serious
injury to the eye; but it is, in genera], quite as obstinate, and diffi-
cult to be subdued as the latter variety of the complaint.
  The  exciting  cause of the suppurative ophthalmia of infants
appears to consist of some acrid or morbid secretion in the vagina
of the mother, applied to the infant's eyes during its passage from
the womb into external life.   I have never met with an instance
of this  disease, where  upon enquiry I  did not learn that the
mother was affected with leucorrhoea or some other morbid vag-
inal secretion.   The  tendency  of gonorrhceal  matter,  when
applied to the eyes, to excite purulent ophthalmia is well known:
and I have witnessed some striking examples of the same  effect,
from the  application of leucorrhoeal to the eyes, in adults.   The
fact, too, that the matter  discharged from  the  eyes in  cases of
this kind, is capable of producing the same disease when applied
to the  eyes of others, furnishes strong testimony in favor of this
etiology of the disease.   Mr. Ryall, whose opportunities for obser-
vation  on this subject have  been very extensive,  states, that  he
has frequently known purulent ophthalmia excited in nurses, "by
the accidental application of the matter from the infant's eyes to
their own."   The time of its occurrence,  also,  affords  some evi-
dence of its dependence  on a cause, connected in some way or
other with the birth of the infant.  If the disease were excited by
intestinal irritation from bile and sordes in the  alimentary  canal,
as  some have supposed, it would,  doubtless occur at every stage
of infancy; whereas, its occurrence is almost universally confined
to the two first weeks after birth,  and in a vast majority of cases,
comes on as early as the fourth day.   This disease has also been
ascribed to the "too early and unguarded admission of light and
heat to the eyes of the new-born infant."*  The great and sudden
transition from the darkness  of the womb to the  external  light,
from the  contact of the bland and congenial liquor amnii, to that
of the atmospheric air, may,  perhaps, at times operate injuriously
on the tender eyes of the infant.   It may be observed, however,
that the good and all-wise author  of nature, has endowed  every
* Edin. Med. and Surg. Journal, vol. 4. p. 247. 
                       OF OPHTHALMIA.                   271  *
creature with a capacity to accommodate itself to the inevitable
changes and transitions,  which it is destined to undergo, in the
regular progress of its development, and it seems inconsistent with
<he perfect adaptation of the appointments of Providence that the
new-born infant should be liable to serious inconvenience or injury
from this cause.   It cannot be doubted, indeed that unnecessary
exposure of the infant's eyes,  to a bright and heated light, may
do much mischief.  The practice of taking the infant, as soon as
it is born, before a blazing fire, with perhaps a candle at no great
distance, and keeping it "in this situation, not only during the time
necessary for dressing, but often, long after this task is performed,
lying on its side, on the nurse's knees, and with the face turned to
the fire," is unquestionably very improper, and may be the source
of much injury to the eyes.

   Treatment.—Whenever there is reason to suspect the existence of
some morbid vaginal secretion, more especially gonorrhoeal, on the
part of the mother, the infant's eyes ought to be immediately wash-
ed, in the most careful manner with  tepid water.  The  wrater
should be frequently changed  and freely applied, so as to ensure
the entire removal of the irritating matter that may adhere to the
eyes.  In all instances, care should, also, be taken, that the in-
fant's  eyes be not immediately exposed to a very strong  light;
for,  although this  may not, of itself, be capable of exciting this
disease, there can be no  doubt of its tendency to irritate the
eyes, and  to favor the  occurrence of inflammation from other
causes.  By these precautionary measures, the disease may often
be prevented, even where the most active virus has been applied
to the eyes during the birth of the infant.
   As the  inflammation,  in  this affection is always very violent
and rapid, the treatment during the early stage must be strictly
and actively antiphlogistic.  If leeches can be procured, two or
three should be applied to the external angle or on the under lid
of each eye; and the bleeding from the leech-bites should, after-
wards, be promoted by warm  fomentations or  by the application
of a soft emolient poultice  over the eyes.   The child should be
kept in a dark room, and when the  blood has ceased to ooze from
the leech-wounds, the poultice and bandages must be  removed, 
272                    0F OPHTHALMIA.
and  a thin and  soft piece of linen, constantly kept moist with
a weak solution of the sugar of lead,  laid over the eyes.   The
eye-lids must be  prevented from  adhering to each  other, by
washing the tarsi  frequently with  tepid water, or with thin mu-
cilage of quince seed or of  the pith of sassafras.   If this be not
attended to, and the pus be suffered to remain confined under the
closed and  adhering lids, the risk of blindness,  from corneal
opacity, or a total destruction of the eye will be greatly increased.
Bland and tepid fluids  should, from time to time, be cautiously
injected under the lids, to wash away the purulent secretion; and
for this purpose, a weak decoction of poppy heads, or the  muci-
laginous fluids just mentioned, or tepid milk  and water are most
suitable.  The bowels  should be freely moved by small doses of
calomel, in union with ipecacuanna, or pulvis antirnonialis,  with
an occasional dose of  castor oil.   A  powder  composed of one
fourth of a grain of  calomel and one grain of the  pulvis antirno-
nialis or a half a grain  of ipecacuanna may be  given four  times
daily.  If these do not keep the bowels sufficiently loose, a tea-
spoonful of castor oil should be given, once daily, so as to procure
four or five evacuations every twenty-four hours.  The addition of
antimonial powder to the calomel, has appeared to me peculiarly
beneficial in such cases.  The nausea  and vomiting which is apt
to follow the use of this mixture appears, frequently to  do  much
good.   Indeed the occasional administration of a gentle emetic in
the early stage of the complaint, sometimes proves  decidedly ben-
eficial.  I have, in several instances known immediate and  very
obvious benefit to  result from the operation of an emetic dose of
antimonial wine.
  If in  the course of about  thirty-six hours  the violence of the
inflammation be not moderated, the leeching ought to be repeat
ed.  During the active period of the  inflammation  emolient fo
mentations, such as warm water, or  infusion of white poppy head*,
will assist in mitigating the pain,  and local  irritation: but,  with
the exception of a  very  weak solution of sugar of lead, all astrin-
gent and stimulating applications are in general highly injurious.
As soon as the inflammation has been in some degree moderated,
blisters  should be laid on the temples, or immediately  over the
closed eye-lids, and kept discharging by some irritating ointment. 
                       OF OPHTHALMIA.                 •   273
When applied directly over the eyes, they generally produce a
more speedy and decided reduction of the inflammation than when
laid on the temples.   Under the prompt and active employment
oT these antiphlogistic measures, the pain, irritation, and swelling,
usually begin to subside about the third or fourth day,  and the
discharge becomes gleety, at the same time that  the conjunctiva
assumes, a paler and flabby appearance.   When  the inflamma-
tion has thus,  in part, subsided, recourse must be had to astringent
and stimulating collyria.   It is of great consequence, however,
that remedies  of this kind be not applied, until, the inflammation
is considerably reduced.  The most serious injury may result from
exciting applications to the eye, during the active stage of the dis-
ease.   After the discharge has acquired a gleety character, and
the swelling and redness of the lids and conjunctiva are obviously
moderated, great  benefit may be  derived from remedies of this
character.  A solution of the chloruret of lime, in the proportion
of about ten grains to  an ounce of distilled water, has been  found
peculiarly useful in the purulent ophthalmia of infants.  I have
myself employed it, in several cases,  with unequivocal benefit.
The nitrate of silver also,  in the proportion of two grains to the
ounce of water, forms an excellent local astringent  in this affec-
tion.   A few drops of this solution should be introduced into the
eye, two or three times in  the course of twenty-four hours.   The
best way of doing this is to lay the infant on its back, and pour a
small portion of the solution into the inner angle of the eye.  By
slightly separating the lids  the fluid insinuates itself between them
and comes in contact with  the inflamed conjunctiva.   I  have fre-
quently  injected this  solution  under  the eye-lids with  a  small
svringe, and generally with  manifest advantage. When used in this
way it must be diluted with an equal quantity of warm water. Dr.
Dewees prefers a solution of the sulphate of zinc in rose water (in
the proportion of a grain of the former to an ounce of the latter)
to all other astringents. I  have occasionally employed this article
and generally with evident benefit.  Its good effects, however, are
commonly much less prompt and decided, than those of the nitrate
of silver or the chloruret of lime;  and in several  instances where
its use was not attended with any obvious benefit, I have known
the nitrate of silver injected in the way just mentioned, to produce
                             2 N           24* 
274                    OF OPHTHALMIA.
very excellent  effects.  This  writer appears to me to  entertain
greater apprehensions of injurious consequences from the use of
astringent collyria in this affection than is, I think, warranted  by
experience.  During the active and unmitigated progress of the
inflammation, all such applications to the diseased conjunctiva arc
unquestionably decidedly improper;  but after the  violence of the
inflammation has been moderated, and the purulent  secretion be-
comes profuse, thin and greenish, applications of this kind are not
only harmless, but in general indispensable to the entire removal of
the disease. I have never known any obvious injury to result from
the use of nitrate of silver at an advanced stage of the complaint;
and I have, in some cases, employed a solution of the strength of
four grains  to  the ounce of water.  Travers  and several other
writers, recommend a  solution of alum, of the strength of  two
grains to an ounce of water.
   Should the inflammation, unfortunately, gQ on to ulceration and
sloughing of the cornea, the infant's system ought to  be supported
by tonics and anodynes.   A teaspoonful of a weak infusion of the
cinchona bark should be given three or four times  daily, with the
addition of a drop of laudanum every evening.

   Scrophulous,  or  Exanthematous  Ophthalmia.—This variety of
ophthalmia  generally occurs during childhood, and  is frequently
the first manifestation of the scrophulous diathesis. It is not, how-
ever, always attended with a scrophulous habit; and it  may even
be doubted whether its connection with the strumous diathesis is
sufficiently common, to justify the term " scrophulous," by which it
is  usually designated. From its frequent association with eruptive
affections about the head, thfi term exanthematous, has been given
to it by Mr. Wardrop;* and Mr. Christian of Liverpool, has de-
scribed the same affection under the name of porriginous ophthal-
mia, from its  being in  many instances preceded  by porriginous
pustules on the face and scalp.t   Mr. Wardrop, however, affirms,
that scrophulous inflammation of the eyes," is a disease  quite dis-
tinct from exanthematous ophthalmia."   I cannot undertake to
decide upon this point; but I am very sure, that all  the cases of

  * Transact. Med. Chir. Society of Edinburg, vol. ii.   -f Glasgow Med. Jour. No. I. 
                       OF OPHTHALMIA.                   275
ophthalmia  which I have hitherto met with in children,  and
regarded as instances of scrophulous inflammation of the eyes, were
characterized by the same phenomena that  are  ascribed  to the
exanthematous variety of the disease.
  This form of ophthalmia is frequently attended with discharging
sores behind the ears, and pustular eruptions on the scalp and face.
The disease is characterized, by excessive intolerance of light, an
enormous secretion of tears, and a muco-purulent secretion from
the glands of the tarse, which, during sleep, is apt to agglutinate
the eyelids.  The pain, except in  the commencement, is seldom
great, and is attended with the peculiarity, that firm pressure upon
the eye, always affords very considerable relief.   Nor is the red-
ness of the conjunctiva generally very conspicuous;  but in recent
and acute cases, an effusion of serum sometimes occurs around the
cornea, giving rise to an elevated,  oedematous circle, about a line
or more  in thickness, occupying the  margin of  the cornea, and
presenting a peculiar reddish brown appearance (Jeffreys). Chil-
dren, who are afflicted with this disease, are so painfully affected
by the light, that they are constantly resorting to every mode in
their power, for excluding it, as much as possible, from their eyes.
The little patient keeps his eyes continually closed, holding the
head down, and pressing his hands or  a handkerchief^firmly upon
the eyes; or he rests his head against a chair in some obscure part of
the room, or lies with the face buried in a pillow, or in the attendant's
lap. "The intolerance of light is always most severe in the morning;
and in the afternoon, it sometimes remits so much, as to allow the
patient to open his eyes." The tears are not only extremely profuse,
but so hot and acrid that they irritate and frequently excoriate the
cheeks, alae of the nose and upper lip.   The parts  immediately
under the eyes, are almost constantly  inflamed, and  covered with
a minute pustular eruption.  In the majority of cases, the eyelids
become somewhat swollen with turgid veins  ramifying on their
surface.   " On trying to open the lids, a torrent of tears  gushes
out;" and the  patient keeps them so firmly closed, particularly
when an effort is made to open them,  that it  is always extremely
difficult to obtain  a view of the eye.   Neither the kindest lan-
guage, " nor the severest punishment," will induce the little
patient to open his eyes; and such, indeed, is the suffering which 
276                    C»F OPHTHALMIA.
is occasioned by the light, that the utmost effort of the will seems
incapable of overcoming the involuntary contraction of the orbic-
ularis of the eyes.   In many instances,  minute vesicles  appear
scattered over the cornea and conjunctiva.  These vesicles break
in violent cases, and form superficial ulcers.  If the inflammation
be not checked, these  ulcerations sometimes gradually penetrate
deeper into the substance of the cornea, until they form an open-
ing into  the anterior chamber and  give  exit to the aqueous hu-
mor.   This unfortunate termination, however, occurs but very
seldom, and only in cases of  a very acute and violent character.
More or less opacity of the cornea, is a very common occurrence;
and when the disease  becomes chronic, this event  is inevitable.
In cases-of  long continuance, tinea ciliaris  and  lippitudo occur;
minute pustular ulcerations  appear along  the roots of the eye-
lashes, exuding a muco-purulent fluid, by which the edges of the
eyelids are glued together; or the margin  of the lids acquire a red
and excoriated condition.
  In general the pustular eruption  about  the head, and  the  dis-
charging sores behind  the ears, which precede the occurrence of
this variety  of ophthalmia, disappear soon after the inflammation
of the eyes is fully developed.  If  these  eruptions  recur during
the progress of the disease, then  the inflammation of the eyes
generally subsides, and the cornea  can be examined.  Wardrop
asserts, that in exanthematous ophthalmia, no  morbid secretion
from the meibomian glands ever takes place.  This statement is,
however, contradicted by other writers; and I am confident, that
I have seen several cases, unequivocally of this  kind, in which
there was manifest disease in the edges of the lids, attended with
a glutinous secretion from these  minute glands.
  Along with these local  symptoms, there are always  distinct
manifestations of constitutional disturbance. The child  is gene-
rally fretful  and irritable;  the pulse frequent, quick and sharp;
the skin often preternaturally warm and dry; the  tongue  covered
with a thin white fur, and the stomach and bowels in a disordered
condition.   In many cases  the abdomen  is tumid and hard, the
breath very  offensive, and the alvine evacuations irregular and
of an  unnatural  appearance.  In  cases  of long standing,  the 
                       OF OPHTHALMIA.                    277
flesh wastes,—particularly on  the  extremities, and  the system
becomes feeble and very irritable.
   This form of  ophthalmia is most frequently met with among
the poor, of relaxed  and irritable habits, " who  have.a white
pasty complexion, with a tense and swollen state of the abdomen,
and not unfrequently, enlarged lymphatic glands."   It frequently
succeeds measles, scarlet fever and other exanthematous diseases;
more especially when  soon after the subsidence of these affections,
the individual has been subjected to the morbific  influence of a
cold and damp atmosphere.  Children who have suffered eruptive
affections about the  head from difficult dentition, and  who are
much  pampered with improper articles of food,  often  become
affected  with this variety of ophthalmia—more  especially when
the eruptions or discharging sores, have been prematurely dried
up, by astringent and stimulating applications.   It is probable,
that this irritable form of ophthalmia is often excited by the
ordinary causes of conjunctival inflammation, such as cold, dust
or  other  common sources of irritation, and that it assumes the
aggravated and obstinate character peculiar to this complaint, in
consequence  of  a highly irritable and depraved habit of  the
system, from  the influence of previous diseases or morbific causes.

   Treatment.—In the commencement of the treatment of this
variety of inflammation of the eyes, the principal  attention, is to
be directed to the general state of  the system.   All  local appli-
cations of a  stimulating or  astringent character  are not  only
wholly useless, but  decidedly improper, until the  morbid condi-
tion of the system has  been improved, by a judicious course of
general treatment.
   General bloodletting does not  appear  to exert any  obvious
influence  in subduing  scrophulous or exanthematous ophthalmia.
In recent and very acute cases, however, some advantage may
occasionally be derived, from the application of leeches to the
temples and external angles of the eyes; but in instances of chro-
nic character or of long continuance, leeching is not only wholly
useless, but often decidedly injurious in its consequences.  In the
beginning of the treatment, the bowels ought to be thoroughly
evacuated, and  afterwards kept in a loose state by the  regular 
278                    0F OPHTHALMIA.
administration of suitable laxatives.   Free and repeated purging
is particularly important, when the abdomen is tumid and  hard,
and  the alvine discharges  of an unnatural character.  " Even
when  this ophthalmia appears  in a feeble and emaciated child,
it will, usually be found, that, by the exhibition of purgatives,
feculent matter, both  unnatural  in quantity and in quality, will
be  evacuated;  and until its evacuation has been completely
effected,  other remedies will avail  but little."   Calomel com-
bined with rhubarb, or jalap, should  be given every two or three
days, in doses sufficiently active,  to produce pretty copious  purg-
ing;  or a few  grains of colomel  may be  administered late in the
evening, and  followed, next morning by a dose of castor oil, or
senna infusion.  In cases that have assumed a strictly chronic char-
acter, repeated active  purging  is   not, in general, beneficial.
After the bowels have in the  first place, been well evacuated, it
will be  sufficient, in instances of this kind, to keep them  mode-
rately loose, by small  doses  of  calomel and castor oil.  In  all
instances indeed, particular attention should be paid to the alvine
discharges, and in proportion as  they are observed to acquire a
more natural appearance, the purgatives must be given at longer
intervals and  in  less  efficient doses; "for though the greatest
benefit will  be obtained, by evacuating the  bowels, long con-
tinued and violent purging will be found equally prejudicial."
   In some cases the digestive organs are prominently deranged—
 the appetite  being variable  and  capricious,  sometimes  much
 depressed, and at others quite voracious.  When this is the case,
 emetics  are  capable of procuring very  considerable advantage.
 An aqueous  solution  of tartar  emetic, appears to be the  best
 article for this purpose.  The  emetic  may be repeated every
 third or fourth day during the  active stage of the inflammation.
 In protracted or chronic cases they rarely prove beneficial.
   To promote the regular performance of the various excretory
 functions, minute portions  of calomel  and  pulvis  antimonialis
 should be given, several times  daily; and when the system is
 very irritable, and the child does not  rest well at night, a few
 grains of Dover's powder may be very advantageously added.*
   * ft. Calomel grs.ii.  Pulv. Antimonialis----Doveri----aa vi. Divide into equal
 parts.  Give one every six hours. 
                      OF OPHTHALMIA.                    279
After the disordered condition of the alimentary canal has been
improved, by the means just mentioned, much benefit may some-
times be derived, "from the carbonates of soda and potass, either
singly or combined with rhubarb and the bitter infusions."* The
sulphate of quinine, also is a highly valuable remedy  in this
variety  of ophthalmia, after  the  bowels  have been properly
evacuated.  Dr. Mackenzie of Glasgow, asserts, that he has used
it in a great many cases, and that, in the majority of instances
its beneficial effects, " were very remarkable."  In most of the
little patients to whom the quinine was administered,  "it acted
like  a charm."   Sir A. Cooper, too, speaks in the most favorable
terms, of the employment of this article in scrophulous inflamma-
tion  of  the  eyes.  I have myself,  used it in nine or ten cases of
this  obstinate complaint, and in every instance with unequivocal
benefit.  In  three of these cases, it effected a speedy and com-
plete removal of the  inflammation and morbid sensibility of the
eyes.  It is  proper to observe, however,  that its good effects can
seldom  be obtained at a very early period  of the disease, and
before the disordered  condition of the bowels has been improved
by mercurial purgatives, and a  mild and digestable diet.  The
dose for a child of from three to seven years old, should  be from
a quarter to half a grain three times daily.
  Various other internal remedies have been recommended for
the cure of this malady—amongst which the muriate of barytes,
and  the iodine, appear to be the most important.   Hufeland, in a
small work on the employment of  the  former of these articles in
scrophula, gives  an account of five  or six instances of scrophulous
inflammation of  the eyes, which yielded to the influence of this
remedy.  I  have prescribed it, in several cases of this complaint,
with considerable  advantage, and  it appears to  me, worthy of
more attention, in this respect, than it has, of late years received.
The best mode  of exhibiting this  article is in solution.  A half
a drachm of the muriate of barytes,  should be dissolved in an
ounce of distilled water; of  this  solution, from  ten  to  twenty
drops may be given, to a child between two and seven years of
age.  The best  vehicle for administering it, is sarsaparella syrup,
* Wardrop.  loc. citat. 
280                   OF OPHTHALMIA.
or the compound decoction of this root, as directed in the Dis-
pensatories.  The iodine has, of late, been strongly recommended
as a remedy in this form of  ophthalmia;  but my own experience
has not furnished me with any evidence of its usefulness in this
respect.   I have prescribed  it in four cases of this kind, and al-
though its use was continued for several months, not the slightest
benefit resulted from it, in any instance.   Nevertheless, no incon-
siderable number of cases have been reported, in which this arti-
cle is said, to have  proved decidedly beneficial, and from its well
known influence over strumous affections it is, doubtless entitled
to attention as a remedy in the present disease.
   Astringent and  stimulating applications to the eyes seldom
afford any permanent relief; and when used at an early period, be-
fore the  general health has been improved, they may do mischief.
As palliatives,  however, slightly astringent  collyria, such as a
weak  solution of the sulphate of copper,  or  of nitrate of silver,
may sometimes be used with advantage.   When the  inflamma-
tion and pain are considerable, much relief is usually procured by
fomenting the eyes, four or five times daily, with a decoction of
white poppy heads, with a small portion of the extract  of conium
dissolved in it.  I have repeatedly employed the nitrate of silver
for this  purpose, and occasionally with evident advantage.  A
few drops of a solution, of the strength of  two grains to an ounce
of water are to be instilled  into the eye, once or twice daily.
Mr. Mackenzie speaks favorably of a collyrium, composed of one
grain of the muriate of mercury to eight ounces of water.  After
the intolerance of  light and excessive secretion of tears has been
so far subdued, as to enable the patient  to  open his  eyes in a
moderate light, considerable benefit will often result  from.the in-
troduction of a small piece of red precipitate ointment (15 grains to
an ounce of lard) within the eye-lids.   At this stage of the disease
important relief may often be obtained from slightly scarifying the
conjunctiva of the lids.   "If," says Mr. Wardrop, "a  superficial
incision,  or rather  a very slight scratch be  made, with a sharp-
edged instrument, or a common wedge-shaped scarificator, across
the enlarged and  distended vessels of the palpebral conjunctiva,
the under eye-lid being previously completely everted and pressed
 on the edge of the  orbit,  an astonishing quantity of  blood will 
                       OF. OPHTHALMIA.                   281
sometimes flow, and the relief obtained from this simple operation
is  often very remarkable.  If this operation is followed by con-
siderable alleviation, it may  be a few times repeated, until the in-
creased fulness of the vessels and thickening of the eye-lids are
removed, and one or two days allowed  between each operation.
Sometimes, however, the mere  abstraction of blood is not suffi-
cient to produce such a beneficial result, and then  a small piece
of the common ointment of the red oxide of mercury, may be put
within the eyelids, immediately after the blood has  been drawn."
   When the  tarsi are much affected,  benefit may  be  obtained
from  the  application  of the red-precipitate  ointment,  of the
strength mentioned above, to the edges of the lids.  The citrin
ointment, will also be found of great use, in such cases.  When the
disease is so far  subdued as to admit  of an examination of the
cornea, " one or  more specks, will  generally be discovered, and
in many instances distinct ulceration."   If small pustules  be ob-
served on the cornea, they should  not be opened by art, as they
are then apt  to degenerate into corroding ulcers, an occurrence
which always greatly increases the obstinacy of the  disease as
well as the risk of ultimate loss of sight, from destruction  or per-
manent opacity of the cornea.
   Blisters do not  often procure any  obvious benefit in scrophulous
ophthalmia.  In cases manifestly attended with a scrophulous habit
they may even do harm, by the pustular inflammation which is apt
to occur around the blistered part,  and  the consequent additional
source of general and local irritation which is thus produced. When
however, the disease  succeeds the healing or drying up of discharg-
ing sores behind the ears, or scabby  eruptions about  the head, con-
siderable benefit may be obtained from a succession of small blis-
ters behind the  ears.   In general, however,  the insertion of a
seton in the back of the neck, is much more  efficacious  than vesi-
cation in this variety of ophthalmia.  After the acute character
of the disease has subsided, the establishment of such a drain will
almost always produce favorable effects.  To prevent a relapse__
and the tendency to a return of the disease  is usually very great
—the seton or pea issue is peculiarly valuable.
  During the whole  course of the  treatment particular attention
must be paid to the diet and habits of life.  In recent and  acute
                            2 0              25 
282                   OF OPHTHALMIA.
cases of the nourishment should be simple and unirritating, such
as liquid  and farinaceous  preparations or thin animal broths;  but
in instances  of a  strictly chronic character,  particularly  when
attended with feebleness and relaxation a more nourishing though
plain and digestable diet must be allowed, in order to support the
vigor of the system.  All  stimulating  drinks,  such as wine, and
malt liquors  must  be carefully avoided.  " The body should  not
be loaded with cloths, and the head particularly ought to  be but
slightly covered: protecting the eyes with only a single and nar-
row fold of black silk, hanging loosely over them, and not wearing
a large bonnet.  The hair ought to be  cut very short, and  the
greatest advantage will be found from sponging the head and neck
with fresh  water every morning—using it at first of an agreeable
temperature, and making it colder by degrees, particular care be-
ing taken to dry the head well afterwards" (Wardrop).  During
the declension of the disease, and after it has been subdued, regular
exercise in the fresh  and  salubrious air of the  country, sea-bath-
ing, and the  tepid shower bath, will contribute  very materially to
the entire and permanent  removal of the complaint. 
OF CHOLERA INFANTUM.
283
CHAPTER  XXIII.
                    OF CHOLERA INFANTUM.

   The cholera of infants differs in several material points, from the
 ordinary cholera of adults.  It is almost invariably attended with
 distinct febrile irritation—frequently comes on in a gradual man-
 ner,—and is peculiarly liable to become protracted in its  dura-
 tion  or to assume  a chronic character. In  many instances the
 disease commences with diarrhoea, which after having continued
 for a few days becomes associated with more or less violent vom-
 iting.  In the majority of cases  however, the vomiting and pur-
 ging  come on  nearly at  the  same  time, without any  other
 premonitory  symptoms, than, perhaps, diminished or  unusually
 craving  appetite,  flatulency and  acidity  of the  primae viae,
 langour, and an uneasy  and  fretful  temper.   From  the  com-
 mencement of the  disease, whether its accession be  sudden or
 gradual, the pulse is usually frequent, quick, small and somewhat
 tense.  The  tongue is  generally, at first, covered  with a thin
 white fur; but in the progress of  the  disease,—particularly
 when  it tends to  a  chronic form, its surface often  acquires a
 dry, red, smooth or polished appearance.  At first the  discharges
 from  the bowels  usually consist  of a turbid frothy fluid, mixed
 with small portions of green bile, or of a nearly colorless water
 containing small  flocculi of mucus.   After  the disease is fully
 developed, the  evacuations very rarely exhibit any  traces of
 bilious matter, the biliary secretion being evidently entirely sus-
 pended.  In some instances the disease commences and proceeds
 with  such violence, as to  exhaust the vital  powers  and termi-
nate in death  in the course  of  a single day.  More commonly
however, the vomiting and purging are not so rapid as to pros-
 trate  the system immediately, and the  disease continues for five 
284                 OF CHOLERA INFANTUM.
or  six  days,  before  convalesence begins  or  fatal  exhaustion
ensues.   In many instances the  vomiting, in the  course of four
or five hours,  becomes less and less frequent, and finally ceases
altogether, or, recurs.only two  or  three times daily, while the
diarrhoea goes  on, until, at last it assumes a strictly chronic cha-
racter.   In the early stages  of the disease,  the  little patient is
evidently harassed with painful and distressing  sensations in the
stomach and bowels; and when the discharges  are  violent and
very frequent, the  muscles of the abdomen, and even those of the
extremities are apt to become  affected with spasmodic contrac-
tions.   If the disease does not  terminate fatally,  during the first
few days,  rapid emaciation  ensues; the hands and feet  become
cold and pale, while the head and body are always preternaturally
warm; the skin is usually  dry and harsh  and acquires  a peculiar
wilted appearance, particularly  on the inner part of the thighs,
and over  the  abdomen.  The  countenance becomes pale and
contracted, the eyes,  inanimate,  and sunk, the nose sharp, and
the lips thin, dry, and shrivelled. The thirst is always very great,
more especially after the disease has continued for some days, and,
no drink is palatable but cold water, which is generally  thrown
up soon after it  is  swallowed.   Food of every kind  is  usually
loathed and refused. If the disease be not subdued or  moderated,
by proper remedial  means,   the  little  patient, by degrees
becomes somnolent,he sleeps writh the eyes half open, rolls his head
about, when awake, and at last, sinks into a state of insensibility
and coma,  and dies in a paroxysm of convulsions, or under symp-
toms  resembling those of the last stage of acute  hydrocephalus.
When  the disease is of protracted duration, or assumes a chro-
nic form, the  alvine discharges generally acquire a  dark, very
offensive, and  acrid  character.  The digestive powers become
so enfeebled, that  almost  " every thing  taken into the stomach
passes through the  bowels,  in  an imperfectly digested state."
Aphthae finally appear  on the tongue and inside  of the cheeks;
the face acquires a bloated or oedematous appearance, the abdo-
men becomes  tumid and  tympanitic; the parts  about the anus
are excoriated by the acrid discharges, and towards the fatal con-
clusion, spots of effused blood  under the cuticle, sometimes appear
on various parts of the body—more especially  on  those  upon 
                  OF CHOLERA INFANTUM*                 285
which the patient lies.  The little patient at last lies in a coma-
tose and insensible state, with the eye lids half open, and the globe
of the eye turned up so as completely to hide the cornea.  Dr.
Dewees states that  in  many  instances as death approaches," a
crystalline  eruption" appears on  the chest, consisting  of an
immensity of watery vesicles  of a  very  minute size, which he
says,  " as far as he has observed," are always indicative of a fatal
termination.  "This symptom, he says,  may readily escape ob-
servation if not looked for; it requires that the surface on which it
has spread itself, should be placed between the eye and the light,
and viewed nearly horizontally."  I have, myself, never witnessed
this eruption, but I do not doubt the correctness of the Doctor's
observations on  this point.  There is another symptom mentioned
by this respectable  writer, which I have sometimes noticed in
the last stage of this complaint,  and which I have also occasion-
ally observed in other forms of chronic disease of the alimentary
canal; it is" the thrusting the  fingers, nay almost the wrhole hand
into the backpart of the mouth, as if desirous of removing some-
thing from  the  throat."  This symptom is  no  less unfavorable
than  the preceding one.
   The duration  of  cholera infantum  is exceedingly various.  It
sometimes runs on to a fatal  termination in the course of five or
six hours.   In other cases, the disease continues for many weeks,
until  the body is reduced  to a state  of extreme exhaustion and
emaciation, and, nevertheless  terminates favorably.  Death some-  .
times takes place "  most unexpectedly;" and recoveries, now and
then  occur "in  a state of things apparently hopeless."  When
bilious matter begins to make its  appearance in the evacuations
and becomes more and  more  copious, a  favorable  result may be
expected;  but when  the discharges become watery and  nearly
colorless, and continue in this state, a fatal termination is inevi-
table.  I  have  never  yet  witnessed  an  instance of  recovery
from  this malady, without the appearance of more or less  bile  in
the alvine  evacuations.   So long as the liver remains  torpid, the
morbid irritability and  inordinate action of the bowels  will con-
tinue.  A uniform moisture accompanied  by a natural tempera-
ture of the skin, is a highly favorable symptom;  for such is the
sympathetic  connection  subsisting  between the liver  and  the
                                            25* 
286                OF  CHOLERA INFANTUM.
skin, that the latter scarcely ever resumes its regular functions
without a simultaneous recurrence of the biliary secretion.  When
the  pulse becomes  feeble and thready, the discharges from the
bowels  watery  and colorless—or  reddish like  the washings of
flesh, or turbid foetid and mixed with flocculi of mucus, accompa-
nied with great uneasiness, and jactitation, or stupor and  partial
insensibility; and  when in addition to these  symptoms  the skin
becomes cold and  clammy, and the countenance pale and cadave-
rous the worst consequences are to be apprehended.
   When death takes place early in violent  and rapid cases, the
vessels  of the liver, stomach, and intestines, are found,  on dis-
section, engorged with blood.  The mucous membrane  of  the
bowels, generally exhibits traces  of inflammation; and when  the
disease  has continued for a  considerable length of time,  ulcera-
tion and abrasion of this structure, are occasionally met with.  In
some instances, considerable portions of the intestinal  tube are so
much contracted as scarcely to admit a small sized quill.    The
liver, besides  the engorged  state of its  bloodvessels, is often
 greatly enlarged, particularly in cases of long continuance, and
 this enlargement is usually attended with a manifest increase of
 the firmness and denseness of its structure.   In the majority of
cases the gall bladder contains a pale or almost colorless fluid;
but in  some instances  it is filled  with a dark green and viscid
bile.  The brain in nearly  all cases, is in  a highly  congested
 condition; and in protracted  cases, serous effusions into the ven-
 tricles  and upon  the surface, of  this organ are frequently met
 with.
   The etiology of the cholera of infants, differs in some important
 circumstances, from that of-the ordinary form of the disease in adults.
Both these varieties of cholera, are  almost  exclusively confined
to the  hot  months of  the  year;  but cholera infantum is  vastly
more prevalent in large  and crowded cities than in the coun-
try—a circumstance wrhich does  not obtain, in  relation  to the
cholera morbus of adults.  During a practice of  twelve years in
the  country, I met with but two or three cases of this disease in
infants.  Again, the cholera of infants very rarely occurs pre-
vious to the  third  month, or after the twenty fourth month  of
age?—its occurrence being  almost  exclusively  confined  to  the 
                    OF CHOLERA INFANTUM.                287
period during which the process of primary dentition is  going
on.  There are therefore three causes whose  concomitant influ-
ence is intimately concerned in the production  of this variety of
cholera; namely, high atmospheric temperature, the  contami-
nated  air  of crowded  cities,  and  the irritation produced  by
dentition.   From the  great prevalence  of this disease during
the hot months  of summer, in  the  more  filthy parts of crowded
cities,  it has been supposed, that it is a malarious malady,  and
" a mere Variety of  the bilious fever of our climate, the force of
which is turned inwards upon  the intestines"*.  In  support of
this opinion, it is alleged by the respectable physician just quoted,
that though seldom met with in salubrious districts of the country,
"a majority of the children fall victims to cholera infantum, in the
neighborhood of marshes, or in low, wet and otherwise unhealthy
situations."   This however is, by no means, confirmed by the ob-
servations  of those  who practice in  paludal districts,  where
miasmata are most abundant.  Unquestionably, cholera is more
common, both in infants and in adults, in miasmatic  localities,
than in the  high and dry districts of the country; and there can
be no doubt, that miasmata  have a tendency to favor the  occur-
rence of this disease in infants as well as adults.  That malaria,
however, is  not the principal morbific agent  concerned in  the
production  of  cholera  infantum, is  evident  from the circum-
stance, that the disease is almost exclusively confined to the  first
two years of infancy.   If this were the chief  exciting cause of
the malady, it could  not be  thus  limited in the period of its oc-
currence.   It is, moreover,  to be observed that this disease  usu-
ally commences as early as  the  latter end of May and  acquires
its most extensive sway  in July,  some  time before the ordinary
miasmatic diseases  are  wont to make their appearance in  our
climate,  except here and there perhaps a few instances.   In the
eastern cities of this country, particularly in  Philadelphia cholera
infantum often  prevails extensively during the months of June
and  July, when scarcely any of  the  diseases justly  ascribed to
the influence of miasmata are met with.

 * Dr. Condie. See his  valuable Essay on "Cholera Infantum."—in the Phil'a
'our. of Med. and Phys. Sciences. May. 1825—p. 13. 
288                OF CHOLERA INFANTUM.
  High atmospheric  temperature is manifestly, intimately con-
cerned  in  the production of this dangerous complaint.  It  com-
mences with the hot weather, "increases and becomes more fatal
with the rise of the thermometer, and declines with the cool wea-
ther in autumn.   During its continuance, it may be observed to
vary with every permanent change of temperature.   A few very
hot days in succession in the month of June, are sufficient to call
it into action;  and during the height of its prevalence, a spell of
cold weather will diminish, if not suppress it."*   But as high and
continued  heat seldom  gives rise to  cholera, in  infants enjoying
the pure  air of the country, there  must  be some  other  circum-
stance peculiar to cities which especially favors its  tendency to
develop the disease.  This accessary  cause consists, doubtless,
in  the confined and impure air of cities; and hence we always
find this complaint most  prevalent in the more crowded and filthy
districts, and in the narrow and confined alleys, courts and avenues.
" Let  any one," says Dr. Parrish, " take a  walk in a  summer
morning, through the thickly built lanes and alleys of Philadel-
phia, he will be  struck wtth the appearance of the children,
reclining their heads, as if exhausted, upon  the breast of their
mothers, with a pale and languid countenance, a cool and clammy
skin, a shrunk neck, and other signs of debility, arising from their
 confinement, during the night, to close and hot apartments."
   Dentition, also, manifestly contributes, in  no  small degree, -to
the occurrence of cholera infantum.  Children,  who have passed
 the period of primary dentition, though equally exposed to the
 heated and impure atmosphere, very rarely become affected with
 this complaint.  It is evident, therefore, that the exciting causes
 of the disease must be materially influenced by some circumstance
 peculiar to infancy.  It seems  to  me  highly probable, that, in
 that irritable and enfeebled habit of body, which arises from the
 continued  influence of  a heated and impure air, the irritation of
 dentition is frequently intimately concerned in the production of
 this malady.   In many  instances the brain is in an irritated con-
 dition, even before the  disorder of the stomach and bowels com-

   * Dr. I. Parrish.  Remarks on the Prophylactic Treatment of Cholera Infantum, &c.
 North American Med. Jour. vol. ii. p. 68. 
                    OF CHOLERA INFANTUM.                289
 mences.  Throughout the whole course of the disease, the head
 is always  preternaturally warm, and in most  cases, the infant is
 unusually restless, and fretful, for several days previous  to the
 accession of the disease.   The tendency of cerebral irritation to
 give  rise to inordinate irritability of the stomach  and bowels is
 well  known.  Diarrhoea is a very common, and when moderate,
 a salutary occurrence during the process of painful dentition.  In
 the commencement of hydrocephalus, much gastric irritability and
 vomiting are seldom absent.   In concussion of the brain vomiting
 is often  a very troublesome symptom; and  sea-sickness, which is
 often so violent as to resemble cholera, appears to depend entirely
■ on a  peculiar  cerebral excitement  occasioned  by the swinging
 and  rocking motion of a vessel at sea.  The great tendency of
 cholera  infantum, in its chronic form, to terminate in a state of
 cerebral oppression and  coma, seems also to show,  that the brain
 is especially predisposed to disease.
   We may, therefore, presume, that in the irritable condition of
 the system, produced  by the influence of  a very warm and con-
 taminated atmosphere, dentition causes more or less cerebral irri-
 tation, which being reflected on the stomach and bowels, renders
 them preternaturally irritable.   If in this state of the alimentary
 canal, the cutaneous exhalents are over excited  and debilitated
 by high atmospheric temperature, the slightest  reduction  of
 temperature, a current of fresh air, or damp night air, will readily
 cause a sudden  torpor of these emunctories.  The  blood will
 retreat from the surface  to the internal organs, and give  rise to
 engorgement of the vessels of the liver and mucous membrane of
 the bowels, in consequence of which the irritability of the alimen-
 tary canal will be still further increased, and the  characteristic
 symptoms of the disease  excited.
   There is still another circumstance which  must be taken into
 view, in an  account of the exciting causes of cholera infantum—
 namely, improper nourishment or errors in diet.  Irritating, and
 inappropriate articles  of food, are  at  all times  apt to produce
 disorders of the stomach and  bowels,  and when the  system is
 predisposed to affections of this kind, by the causes mentioned
 above, slight errors, in  this respect, may give rise to an attack  of
 cholera.   A sudden transition  from the  bland  and  congenial
                              2P                      * 
 290                OF CHOLERA INFANTUM.
 nourishment obtained  at the mother's breast,  to  an exclusive
 artificial  diet during hot weather, is  often  speedily followed by
 an attack of this dangerous malady.

   Treatment.—From what is stated above, in relation to the pa-
 thology of this  affection, it would appear, that torpor  of the
 hepatic and cutaneous  functions,  in  connexion with  cerebral
 irritation from dentition, exert a powerful influence, in develop-
 ing and  sustaining that  irritable  condition of  the alimentary
 canal, upon which the characteristic  phenomena of the disease
 depend.  No means calculated to allay the excessive  action of
 the stomach and  bowels, can be of any permanent  avail, if  they
 do not, at the same time, tend to correct the morbid condition of
 the liver and skin; and hence,  opiates and astringents are, not
 only useless, but almost  invariably detrimental, unless  accompa-
 nied by remedies capable of exciting  these functions, and obviat-
 ing cerebral irritation.   In prescribing for this disease, our prin-
 cipal objects, therefore, must be, to restore the regular action of
 the liver and skin, to obviate irritation and sanguineous congestion
 in the brain, and to determine the circulation from the engorged
 vessels  of the liver and mucous membrane of  the alimentary
 canal, to  the external  parts  of the body.   To answer these  pur-
 poses, I generally commence the treatment,  with the application
 of leeches to the temples or small blisters behind the ears, the
 exhibition of small doses of calomel  and ipecacuanna, and  a
 large stimulating  poultice over the abdomen.  I am persuaded,
 by what I have repeatedly witnessed  in my practice, that great
 benefit will in general  result from local depletion, or from the
 application of blisters behind the ears,  or on the back of the neck,
 in this affection.   During the last seven years, I have treated but
 very few cases in  which I did not, at once, apply blisters behind
 the  ears;   and  1 may confidently affirm,  that  since  I have
 adopted this practice, I have been much  more successful in the
 management of this disease,  than previously.  Dr. Parrish  was,
I believe, the  first who  pointed out  the  usefulness of blisters
about the head in the cholera of, infants.  " In severe cases," he
says "much good maybe expected from the application of blisters
behind  the  ears.  I was  led  to this practice, by  observing that 
                   OF CHOLERA INFANTUM.                291
the eruption, which, during dentition, is apt to make its appear-
ance  behind the ears, often proves a most  salutary effort  of
nature; and that while it continues, the  infant generally enjoys
an  exemption  from those  dangerous disorders  incident to this
critical period of life.   To imitate nature as closely as possible,
the discharge from  the blistered surface should be maintained for
some time, by stimulating dressings.  I have witnessed the  most
beneficial effects from this practice and can strongly recommend it
to the attention of the profession."*  The gums should always
be carefully examined in cases of this complaint. . If they are in
a swollen or inflamed  and painful state, they  should be freely
divided, down to the advancing teeth.  For the purpose of mode-
rating the gastro-intestinal  irritability and  of  stimulating the
action of the liver, minute portions of calomel and ipecacuanna
constitute, I think,  the most efficient internal remedy we possess.
From one sixth to a quarter of a grain of calomel in union with
a quarter of  a grain of ipecacuanna should be given every half
hour, or hour, until the evacuations become  mixed with bilious
matter.  The appearance of bile in the evacuations, is always to
be hailed, as  a very favorable sign; and the sooner the liver can
be brought to resume its secretory action, the greater,  in general
will be the probability of ultimate success in  our attempts  to
subdue the disease.  Indeed so long as the liver remains inactive
and  the alvine discharges free  from bile, the disease  may  be
regarded as still possessing all its violence and dangerous ten-
dency, whatever temporary abatement may occur in the severity
of the vomiting and purging.   Ipecacuanna, in minute doses is a
most  excellent auxiliary to the  calomel, in  affections attended
with  morbid  irritability and* excessive  peristaltic action of the
alimentary canal.   Its tendency to counteract inordinate action
of the bowels, when given in very small portions is very consider-
able,  and its tendency, moreover, to excite diaphoresis, renders
it still more  applicable  in  this and other intestinal affections of
this kind.  When  the vomiting and purging  are extremely fre-
quent, other means calculated to calm the irritability of the sto-
mach and bowels may he  advantageously used  along with the
* loco citat. 
292                OF CHOLERA INFANTUM.
calomel and ipecacuanna.  The spirits of turpentine is an excel-
lent  remedy for  this purpose.  Dr. Condie,  states that in his
practice, the administration  of  from ten to thirty drops of this
remedy, three or four times daily,  "has not in a single instance
failed in speedily checking the disordered action of the stomach."
I have used this article in a considerable number of cases, and in
most instances, with decided benefit.   I prefer, however, giving
it in much smaller and more frequent doses—namely, from four to
six drops every hour until  the violence  of the vomiting has  been
moderated.  I have also, occasionally, used a solution of camphor
in sulphuric ether, (a drachm of the former to an ounce of the
latter) with very  obvious  advantage.  Five or  six drops of this
solution given every half hour or hour, seldom fails to moderate the
excessive vomiting in this complaint.  A large stimulating poul-
tice, applied over the abdomen,  is, generally,  of material service
in allaying  the inordinate action  of the stomach and  intestines.
Two  or three  tablespoonfuls of powdered black pepper, with a
few teaspoonsful  of cayenne, mixed up  with a common emolient
poultice will answer very well for this purpose.  The application
of a piece  of flannel moistened with a mixture of equal parts of
spirits of camphor  and tincture of capsicum, often produces  a
very good  effect.  Blistering, however, is, I think  decidedly
the most  efficient  counter-irritating application.    Before  the
blister is applied to the epigastrium, the part should be slightly
bathed  with spirits  of turpentine, in order, to  procure  vesication
as speedily as possible.   The vesicatory should not be  suffered to
remain on the skin more than four  hours.  As  soon as the surface
is uniformly inflamed, which  in  children usually occurs in about
four hours, and sometimes  much sooner, the plaster ought to be
removed, and a thick, and soft  emolient poultice  laid over the
whole  abdomen, including of course the inflamed surface.   The
poultice will, in a short time, excite the inflamed vessels to  pour
out a copious quantity of serum,  under the cuticle, and raise a
large  blister, which should  then  be opened, and dressed  with
mercurial ointment prepared without turpentine or other irrita-
ting substances.
  When from the tumid and  tense state of the abdomen, there is
reason to presume that the bowels  are loaded  with faecal matter, 
                    OF CHOLERA INFANTUM.                 293
 the first few doses of calomel should be sufficiently large to pro-
 cure its purgative operation.  A grain or two may be given every
 two or  three hours, until its evacuant effects are decidedly pro-
 cured.   After the faeculent contents of the bowels have been well
 evacuated, in this  way, it will, I think, in  general, be best to
 return to the minute and frequent doses of this article mentioned
 above. Except under the circumstances just mentioned—namely,
 a loaded state of  the bowels, purgatives are not, in  general, ad-
 visable in the commencement of the disease.   When the disease
 continues, however, until  the liver, under the  exciting influence
 of the calomel, pours out an abundance of bile, mild laxatives are
 undoubtedly very useful.   In cases that  come on  gradually and
 proceed  slowly, it may perhaps  be  better to commence at once
 with  purgative doses of calomel, than with the minute portions
 mentioned above.  In instances of this  kind, the  bowels are  fre-
 quently much  loaded with fcecal matter and vitiated secretions,
 which  it is of much consequence  to evacuate, as  speedily and
 completely as can be done, without resorting  to very  active or
 irritating purgatives.  When there is reason to suspect the exist-
 ence of  acid in the stomach and intestines, much benefit may be
 derived from the administration of five or six grains of prepared
 chalk, with  each dose  of calomel and  ipecacuanna; or what is,
 perhaps, preferable, from the use of small portions of magnesia in
 combination with ammonia, as recommended by Dr. Kuhn.*  I
 have  in  some instances of this kind, administered  six  or eight
 grains of calcined magnesia, in union with five or six drops of the
 abovementioned etherial  solution of camphor, with  the happiest
 effect.   Indeed, this combination is  not only peculiarly effectual
 in  cases  attended with  acidity in the primae viae, but  is  also  a
 highly valuable remedy, for allaying gastric irritability, or exces-
 sive vomiting, even where there  is a  total freedom from acid.
   When the abdomen is tumid, tense  and tender to the touch,
 whilst the pulse is frequent, contracted and quick, blood  ought to

  * " The prescription made use of by Dr. Kuhn," says Dr. Condie, "was the following:
 R Magnes. calcinat. 9iv;  pul. g. arab.. Qi: sacch. alb. 3ii; aq. menth. pep.gss; aq.
fontanae 3>'ss> M.: add aq. ammonia pura, gtt.  xlviii to clxiv, according to the age of
the patient.  The dose of this mixture is a teaspoonful every two hours.  Vide Dr. Con-
die's Essay. Loct. Citat.
                                              26 
294                OF CHOLERA INFANTUM.
be abstracted either with the lancet, or by  the application of
leeches to the epigastrium.  If blood be not promptly and effi-
ciently abstracted, in cases attended with these symptoms, it will
be " in vain to depend upon the effects of any remedy; for inflam-
mation and  its consequences will  have  ensued,  long  before wc
can hope  to make any impressions on the affected viscera,  even
by the use of calomel."  After blood has been abstracted, in cases
of this kind, a blister ought to be  applied over the upper portion
of the abdomen.  In all instances  indeed, whether attended with
symptoms of abdominal inflammation or not, blistering  the region
of the stomach, is a most useful mode of making counter irritation.
   The warm  bath, also, is an excellent auxiliary in the treatment
of this disease.  It  is especially indicated, Avhen  the skin is very
dry and harsh, and the pulse quick and irritated.   While the pa-
tient is immersed in  the warm water up to the neck, a napkin wet
with cold water,  should be applied to the head, in order to lessen
the determination of blood to the  brain.
   In the early stage of cholera infantum, the use of opium  is, in
general, highly improper.   The great tendency to congestion and
irritation of the brain, in  this affection, renders all medicines of
this  kind decidedly prejudicial when given at an  early period of
the disease, or where, in its advanced stage, symptoms of cerebral
oppression are manifestly present.  Nevertheless, when  in the
chronic form of the  disease, the patient is very restless  and wake-
ful, with a  dry and  withered state of the skin, and there are no
particular indications of cerebral  congestion, small doses of  Do-
ver's powder, in union with minute portions of calomel, will some-
times produce very  excellent effects.  Great caution,  however,
ought to be used, in the  administration of opium, even in cases
of a  strictly chronic  character.   I  have witnessed  some instances
of this kind, in which the employment of this  narcotic was spee-
dily  followed by stupor or cerebral compression without any ob-
vious beneficial effect on the intestinal disorder.
-   Astringent  and absorbent remedies are in general  decidedly
improper, in the  early stage of  the complaint.   Much mischief
has  been done by the early administration of cretaciqus juleps,
astringent mixtures, aromatic draughts and opiates in this malady.
After the  faeculent contents of the  bowels have been well evacu- 
                    OF CHOLERA INFANTUM.                295
 ated, and the secretory action of the liver has been  excited  by
 calomel, and in cases that have assumed a chronic character, the
 milder or less stimulating astringents, will, under judicious  man-
 agement, often procure very considerable benefit.  I have, in
 some instances, derived very obvious advantage from  a decoction
 of the root of the geranium maculatum in milk, in the advanced
 stages of the complaint.   The acetate of lead has been very favor-
 bly mentioned, as a remedy in this affection.  As  early as 1805
 Dr. Mann of Massachusetts, recommended this article,  as capa-
 ble of procuring "considerable benefit in this disease."* Dr. Irwin
 of Charleston, South Carolina, also speaks strongly in favor of the
 employment of this remedy in the cholera of infants; and we have
 moreover, the authority of Dr. Chapman, in behalf of its useful-
 ness in this dangerous affection.  I have employed  this article in
 four or five instances, with a result sufficiently favorable, to induce
 me to believe, that considerable benefit may be derived from its
 use, provided the action of the liver has been  excited by the pre-
 vious employment of mercurials.  So long, however, as the evac-
 uations indicate the existence of functional torpor of the biliary
 organs^  and there  is reason to believe that the  intestines are
 charged with  faeculent matter, it will, I am persuaded, be most
 prudent to abstain from this, and all other astringent substances.
 After the  bowels have  been thoroughly evacuated by calomel,
 and the alvine discharges assume a bilious appearance, and in ca-
 cases  of a chronic character, small doses of the acetate of lead,
 may be used with a favorable prospect of advantage.  The  fourth
 of a grain of this article with an equal quantity of Dover's powder
 should be given every two or three hours, and  continued until the
 inordinate diarrhoeal action of the bowels is checked.   In the ad-
 vanced  periods of the disease, I have occasionally procured con-
 siderable benefit, from a solution of the tartrate of iron.   Forty
 grains of this preparation, may be dissolved in two ounces of water,
 to which half an ounce of ginger syrup should  be added.  Of this
 from twenty to forty drops maybe given to an infant four or five times
daily.  Dr. Robert Jackson  speaks very favorably  of the use of
finely powdered charcoal, in diseases of the intestinal canal at-
  * A Dissertation upon Cholera Infantum, &c. By James Mann, M. D.  Vide a Re-
view in New-York Med. Repository, vol. ii. p. 309—for 1805. 
296                 OF CHOLERA INFANTUM.
tended with morbid secretions; and Dr. Condie, states, that he has
used this article with much advantage, "in the latter stage of the
disease, when it had become, in some degree, chronic, and thesis-
charges, from the bowels were acrid, dark colored and offensive."'
From my own experience, 1 can say nothing of this remedy, but 1
do not doubt  its occasional usefulness, under the circumstances just
mentioned. From five to ten grains of the pulverized coal, in union
with four or five grains of rhubarb and a grain of ipecacuanna may
be given every three or four hours.
  When from the violence and rapidity of the disease, or from its
long continuance, the  exhaustion becomes  very great, the extre-
mities cold, and the pulse very small and feeble, internal as well
as external stimulants become  necessary.   Stimulating frictions,
wrapping the body in flannel wrung out of hot brandy and water,
together with the use of wine-whey, milk punch, or a weak solu-
tion of carbonate of ammonia, with an equal portion of the com-
pound tincture of cinchona, are indispensable to support the sink-
ing  energies of the system.  I have  known,  much  benefit to
result from the use  of  the tincture of cinnamon.  From fifteen to
twenty drops should be administered in some mucilaginous fluid
every four hours.
  In the advanced periods of the complaint, severe colic pains,
from  flatulent distention of the  stomach and bowels frequently
greatly harass the  little patient.  To  relieve these  pains, Dr.
Condie strongly recommends a few drops of the spirits of  tur-
pentine; and my own  experience enables me to speak favorably
of this remedy.  The juniper oil, also, is an excellent palliative,
for this purpose. When given with sulphuric ether and laudanum,
it seldom fails to procure, very considerable relief.  From ten to
fifteen  drops of the following  solution,  may be given three or
four times  daily.*
  After the  disease has been, in a considerable degree subdued,
and  the alvine  discbarges, have  assumed a natural appearance,
recourse should next be had, to remedies calculated to invigorate
the stomach  and intestines.  A decoction of blackberry root in
milk, in the proportion of half an ounce of the root to a pint of

  * R. 01 juniper, 3ii.   Sulph..Ether, gss.  Tinct. Opii. gtt. be. M. ft. 
                   OF CHOLERA INFANTUM.                297
milk, often  proves  very useful at this advanced and  declining
stage of the disease.  The common cretacious mixture, with the
addition of a small  portion of the tincture of kino, forms also, a
veay useful  remedy for  this purpose.  But the remedy  I  have
found most beneficial, in restoring > the  tone of the alimentary
canal, is a mixture of equal parts of lime water, and infusion of
peruvian bark, with four or five  drops of the tincture of kino,
with each dose.  The dose for an infant, is a dessert spoonful four
or five times daily, mixed  with a  little barley water or solution
of gum arabic.
   Throughout the whole course of the disease, particular  atten
tion must be paid to the proper  regulation of the diet.   If the
child is nourished  at the  breast, and the  mother or nurse fur-
nishes a sufficient supply of wholesome milk, no other  nourish-
ment whatever, should be allowed.  If it has been weaned, great
care must be taken that the food be of the simplest and blandest
kinds possible.   Boiled  milk;  liquid preparations of arrow-root,
tapioca, sago, rice;  thin  oat meal  gruel, barley water, or a solu-
tion of gum arabic, are  decidedly the  most suitable articles of
nourishment in every stage Of cholera.   In the chronic form of
the disease, however, beef  tea, or  weak chicken broth, either by
itself or mixed with  some of the preceding articles,  sometimes
produces a  favorable change in  the state  of the stomach and
bowels.  In cases of this kind, the little patient sometimes mani-
fests  a  most urgent  craving, for certain  strong  and stimulating
articles of food, such as salted and smoked herring or shad, old
and rancid  bacon,  salted beef, &c. whilst  the stomach appears
to loathe all the  light and unirritating  articles of nourishment,
enumerated  above.  When this  occurs, it will be proper too,
cautiously  to  gratify the  newly-awakened appetite,  however,
opposed to the ordinary dietetic rules the indulgence may appear
to  be.  "I have seen  many children recover," says  Dr. Rush,
" from being gratified in an inclination to eat salted fish, and the
different kinds of salted meat.  In some instances, they evince an
appetite for butter, and  the richest gravies of roasted meat, and
eat them with obvious relief  to all  their symptoms."  Without
these strong  instinctive calls of  nature, however, it  would  be
highly improper to allow such coarse articles of food—yet  where
                              2Q             26* 
298                OF CHOLERA INFANTUM.
the inclination for  them, is distinctly manifested, it ought to be
gratified, though always  in a cautious manner.
  Nothing contributes more to the removal of this disease—more
especially when it tends  to a chronic form, than the enjoyment
of the pure and salubrious air of the country.   Whenever  it is
practicable' the little patient ought to be removed into the coun-
try;  for this change is often sufficient to subdue the disease  in a
short time, without the aid of any other remedial means.  If the
circumstances do not admit of a removal from home to a suitable
situation in the country, some advantage may be gained by carry-
ing the patient about in the open and fresh air; and still more
by frequent rides into the country in a carriage.
  As a preventive measure, residence, or at least daily gestation,
in the pure air of the country has a most salutary influence.  If
this advantage cannot be procured, every other practicable means
should be adopted, to protect the infant against the relaxing  and
enervating effects of a heated and confined air.  The practice of
keeping the windows and doors closed, at night, and placing the
infant upon a soft feather  bed, with  an abundance of covering,
during the warm months of summer, has a  most pernicious effect.
"Examine," says Dr. Parrish, "in the morning, a child who  has
passed the night thus  confined.  You will find him limber as a
rag, exhausted  by perspiration,  wholly destitute  of animation,
without appetite, and on the very verge of cholera."  To avoid
these injurious effects, the doors of the infant's sleeping apartment
should be open, and, if the room is  large enough to prevent the
current of night air, from passing immediately over the child,
the windows, also,  should be kept open, with the shutters  closed.
The child should sleep on  a mattress, "or on blankets folded and laid
upon the floor; and the covering ought to be light but comfortable."
The use of the tepid bath, or frequent ablutions with cool water will
assist materially in fortifying the infant's system, and lessening the
liability to an  attack of this disease.  The respectable physician,
whom I have just quoted,  strongly recommends, allowing infants
the free use of cool and  fresh water, as a  beverage  during  the
heat of summer, as  a prophylactic against  this and  other mala-
dies;  and I have not the slightest doubt of the entire propriety
of this advice.  The child should be daily carried  out, into  the 
                   OF CHOLERA INFANTUM.                299
open air, and, if practicable, beyond the bounds of the city.  All
strong, flatulent, and indigestible articles of nourishment, should
be carefully avoided.  During the first year no nourishment is so
congenial and appropriate as the  mother's milk.  Nourishment
at the breast is particularly important during the active progress
of dentition. If the child has been weaned, milk, preparations
of arrow-root, tapioca, and sago-—oat meal gruel, weak chicken
broth,  and beef-tea,  constitute suitable articles of nourishment.
Experience  has shewn, that " the sucking of small pieces of salt
meat—as ham, or dried beef," is often productive of manifest
advantage.  If the gums become inflamed and swollen they should
be freely divided,  down to the advancing teeth.  Dr.  Parrish
speaks very favorably of the  habitual use of aromatics, during
the summer, as a means of guarding against the occurrence of
this malady.  He does not, however, advise,  that they should
be given, "  indiscriminately to all children, during the summer."
They are proper only in those cases, "in  which a predisposition
to cholera infantum exists."  The daily use of moderate portions
of ginger tea, or of a weak infusion of cinnamon, or of nutmeg,
produces  an excellent effect, in giving  tone to the  alimentary
canal, and fortifying it against the influence of the usual exciting
causes  of this .malady.   I can say nothing from my own experi-
ence of the effects of this practice;  but it seems very probable
that, where there  is general languor, with a weak  and inactive
state of the  digestive organs, considerable  benefit may be derived
from the judicious employment of the*milder and more agreeable
articles of this class of stimulants,  The use of  small  portions of
porter  and water, has appeared to  me very beneficial in feeble
and relaxed infants, during the warm seasons, as preventive of
bowel complaints. It is to be observed, however, that when the sys-
tem is  under the influence of painful dentition, where the pulse is
contracted and irritated, and the head very hot, particularly when
attended with great irritability and fretfulness of temper, all arti-
cles of this kind are decidedly objectionable.   It  is only in cases
of weakness and languor, accompanied with a feeble and relaxed
state of the  alimentary canal, and a sluggish state of the circula-
tion, that they can be employed with propriety and advantage. 
300
REMITTENTS OF INFANTS.
                CHAPTER  XXIV.


            OF THE REMITTENT FEVERS OF INFANTS.

   Children  are  subject  to various  modifications of remitting
fever, which, in their phenomena, progress and causes, differ very
materially from the ordinary remittent fever of adults.  Authors
have described this fever, under the titles of worm  fever, the hec-
tic of dentition, hectic of infants, and  marasmus.   Underwood
gives a short description of four " kinds" of fever, peculiar to in-
fancy and childhood, all of which are treated of by Butler, Pem-
perton,  Colley and others, under  the general head of infantile
remittent.   Burns divides the remittents of children into two vari-
eties—namely, that which occurs "in early infancy," and that
which takes place after  the process of primary dentition  is com-
pleted.   This division is judicious and useful; for  the cases that
occur during dentition are  usually characterized by some peculiar
phenomena, and require corresponding modifications in the reme-
dial  treatment.
   I.  Of the remittent fever of infants during dentition.—This mod-
ification of infantile remittent, generally bears a close j/esemblance
to the  forming or  initial stage of acute  hydrocephalus, and
indeed, there is not much difference between them;  " for in both
we have much cerebral irritation, and the difference is more in
the  result than in the early condition."
   The first  manifestations of indisposition, generally, occur during
the night.   The infant is, unusually restless, and starts frequently
in its sleep,  as if from sudden fright, or it remains awake and ex-
tremely fretful during  the  greater part of the night.  Its'skin is
hot and dry, until towards  morning, when a slight moisture breaks
out about the head and chest.  In the early part of the forenoon,
the countenance is pale with an expression of suffering and dis-
content, and the little  patient ceases to  evince its usual playful- 
                   REMITTENTS OF INFANTS.                301
 ness and interest in its toys.   The pulse is always very frequent,
 and generally contracted and firm.  In  the afternoon the irrita-
 bility and  fretfulness of temper increase, a circumscribed  blush
 commonly  occurs on one or both cheeks, the child  is inclined to
 vomit, the  frequency and tension of  the  pulse increase, the skin
 becomes hot, the urine is  scanty and high colored, and in some
 instances  so acrid, as to  cause the  infant to  cry out with  pain
 during micturition. A slight cough,  with augmented secretion of
 bronchial mucus, generally supervenes after the disease has  con-
 tinued for  some days, and the bowels are irregular, mostly costive,
 while  the  alvine  evacuations are extremely offensive,  and of a
 muddy-brown or  bright-green and  curdled appearance.  If the
 disease be not counteracted by suitable  remedies, the  febrile
 symptoms  gradually increase.  The exacerbations  become more
 violent and protracted—during which the infant generally lies in
 a somnolent or drowsy state, with the  eyes half open and turned
 upwards so as to conceal  the cornea.   If the disease continues,
 the remissions become shorter and Jess distinct, and  the symptoms
 of cerebral irritation more  and  more  conspicuous—the  eyes
 acquiring a dull, heavy and slightly injected appearance, and the
 countenance an expression of surprise or stupor.   By degrees
 symptoms of cerebral oppression or  effusion ensue, arid the child
 dies in a state  of  coma or a paroxysm of convulsions.   In  some
 instances, however, instead of these hydrocephalic symptoms, the
 little patient is gradually exhausted, " by the continuance of the
 fever, or, more quickly, by the accession of rapid and  obstinate
 diarrhoea.
   If the disease is suffered to run on for six or seven days, it sel-
 dom terminates favorably before the  end of the second week •  and
 in some instances, after the violence  of the disease has been sub-
 dued, a slow irritative fever  continues for  many  weeks, or until
 the  advancing teeth  are   completely protruded.   In these pro-
 tracted cases, the  infant is pale,  languid,  extremely fretful and
restless, with irregular bowels, and  a frequent and very  small
pulse.  The head  is, usually, very .warm, while the hands and
feet are often cold; and in some instances, the face acquires a
bloated or  tumid  appearance. Not unfrequently, however,  the
disease begins to subside as early as the fourth or fifth day.  The 
302               REMITTENTS OF INFANTS.
exacerbations become shorter and less severe;  the  child  rests
better at night, and  the skin becomes cooler and more uniformly
moist and soft.  The declension of the disease is often attended
with moderate diarrhoea, or  a profuse secretion of saliva, and
" we sometimes find that, at this time, one or more  teeth  have
made their appearance."
  This modification of infantile remittent fever, appears to be an
irritative  fever depending  on difficult dentition, modified  and
aggravated  by gastro-intestinal irritation or a disordered condi-
tion of the  chylopoictic organs.   Throughout the whole course
of the disease, distinct  manifestations  of cerebral irritation are
present, and in many instances, the brain is obviously in  a  state
of erethism  for many days, before the disease assumes  a decidedly
febrile  character.   The  disease very rarely,  if ever,  occurs,
when the  advance  of  the  teeth through the gums is attended
with a profuse secretion of  saliva or a moderate diarrhoea.  Cos-
tiveness and a dry and  unusually warm condition of the  mouth,
are among the most constant  symptoms of the early stage of this
disease;  and in most instances there are very obvious indications
of irritation in the gums.

   Treatment.—The  mouth  should always be carefully inspected,
and if the gums  are in the  slightest degree swollen or  inflamed,
they should be freely divided.  The irritated and irritating con-
tents of the bowels must be evacuated, and remedies prescribed
for correcting the  biliary  and  intestinal secretions.  For this
purpose, one or two grains of calomel  should be administered, so
as to procure free purging.   If the calomel is slow in operating,
or inefficient, it should be  followed, in three or four hours  by one
or two  teaspoonfuls of castor oil or  of the  syrup  of  rhubarb.
After the intestines have been, thus, well evacuated, they  must
be kept  in  a loose  state  by the  regular administration of very
small doses of calomel  in union with ipecacuanna.   The fourth
of a grain of  the former with half a grain of the latter, may be
given four times daily, and if these do  not keep the bowels  suffi-
ciently open, their aperient operation  ought to be promoted, by
a suitable portion of magnesia, castor oil, or rhubarb, once every
twenty-four  hours.   If the  child  is robust and plethoric much 
                   REMITTENTS OF INFANTS.                303
advantage may be derived from the abstraction of an  ounce or
two of  blood, either  with the lancet,  or by leeching about the
head;  and when the pulse continues to be active and tense, and
there are decided indications of cerebral irritation, the  bleeding
ought  to  be repeated until an evident impression is made on the
action of the heart and arteries.   After the violence of the reac-
tion has been, in some degree, moderated, by evacuants, a blister
should be applied to  the  back of the  neck.   When the head is
very hot  and a  tendency to  stupor  occurs, cold  applications  to
the head  are very useful;  and, if at the same time the hands and
feet are cold, sinapisms or vesicatories may be advantageously
applied, to the wrists and  soles of the feet, or above the ankles.
Some  benefit may also be obtained from the use  of diaphoretic
remedies.  The  following mixtures are well adapted for  this
purpose.*  When the stomach is not too irritable, tart, emetic, in
minute doses, is  calculated to operate  very beneficially in  cases
of  this kind.   When there is much cerebral irritation with an
active  and firm  pulse, this article may, in  general  be  given  in
pretty  active doses,  without  exciting much  vomiting.  I  have
often given the  eighth of a grain, every two or  three  hours, to
infants laboring under this complaint, with but little or no vomit-
ing, and  generally, with  a  decided sedative impression on the
action  of the heart and  arteries.   The effects of opium in this
complaint are  very  uncertain.  In some instances, it operates
very injuriously,—increasing  the  determination of blood to the
brain, and hastening the  supervention of cerebral inflammation
and oppression.  In other cases, its effects are highly beneficial.
It moderates  the general irritative  condition  of the patient,
lessens  the frequency and tension  of the pulse, and removes all
the alarming symptoms of approaching inflammation and effusion
within  the head.  It is,  indeed,  often extremely  difficult, to
determine satisfactorily, merely from the symptoms, whether  this
narcotic be proper or not.  When the symptoms indicate a strong
tendency to, or the actual presence of inflammation of the brain,—
  *  R. Pulv. Extract Glycyrrh. 3ii;  Pulv. Nitrat Potass Qi; Aq. fontana gii; Vin.
Antimon. gtt. xl; M.  Dose, a teaspoonful every two or three hours.
  *  R. Spirit Minderiri, gii; Syrup Limonis gi; Vin. Antimonii gtt. 40:  Spirit Nitri.
Dulc. 3iss. M. ft.  Dose, a teaspoonful every three hours. 
304               REMITTENTS OF INFANTS.
that is, when  the child rolls its head about on the pillow, keeps
its  hands pressed on  the forehead, shuns  the light, starts and
screams out suddenly, has a discontented and frowning expression
of  the countenance and  is withal  of  a robust and plethoric
habit, the use of opium, will probably result in serious injury to
the  patient.   When, on  the other hand, the general  habit  is
feeble, or free evacuations have been  premised, and the little
patient is restless, irritable and  fretful,  with a pale and languid
countenance,  we may, writh but little risk of injury resort to this
remedy y and  its  effects in cases of this kind, are often highly
favorable.   Even  in cases,  however, where  there  was  much
reason to apprehend the existence or near  approach of  cerebral
inflammation, I have known the most decided benefit to result
from the regular exhibition of  small doses of Dover's powders in
union with calomel.  Free purging, should  always be premised;
and when the pulse is active  and  tense, as it almost always is,
blood ought  to  be  efficiently  abstracted,  before  opiates  are
resorted to.
   The best form, perhaps for administering  opium in this disease,
is in combination with calomel  and pulvis  antimonialis.   The
twentieth of a grain of this narcotic, with a fourth of a grain of
calomel  and half a  grain of antimonial  powder,  may be  given
every three or four hours.  Burns  recommends the use of a few
drops of the tincture of hyoscyamus, with a saline julep, to mo-
derate the general irritation.   I have used the tincture of bella-
donna for this  purpose with evident benefit.   Three or four drops
given, twice  or  thrice  daily, frequently produces  an  obvious
abatement of  the irritability and restlessness of the little patient.
The daily employment of the tepid bath,  is calculated to do con-
siderable good, in moderate cases of the complaint  by relaxing
the skin, and allaying  irritation.  It should be used during the
febrile exacerbation, and  the  child must not be suffered to re-
main in the bath longer than about  ten minutes.   This remedy
is  particularly useful in cases, depending, mainly,  on  difficult
dentition.  It  seldom fails to tranquillize the system, when  used
in instances of this kind.
  If after the acute  spmptoms have gone off, the disease continues
in a chronic form, the child being pale, languid, emaciated, fretful, 
                    REMITTENTS OF INFANTS.               305
 and  restless during the night, with a small and thready pulse,
 and a disordered state of the bowels, gestation in the open air of
 the country, often  proves highly beneficial.  In this stage of the
 disease, I have  derived very considerable  advantage, from the
 use of Dr. W. Fordyce's pidvis antihecticus infantum—consisting of
 from ten to twenty grains of the sulphate of potash, in union with from
 five to eight grains of powdered rhubarb, according to the age of the
 child.  Such a portion should  be given every morning,  until the
 alvine  evacuations assume  a  more  natural appearance,  and the
 action of the  bowels become regular.   A few  grains of Dover
 powder, with  the fourth of a grain of calomel  should  be given
 every evening.   In cases of this kind,  the tincture of hyoscyamus
 and belladonna  are, in  general  peculiarly beneficial.    Three
 drops, in  a teaspoonful of spirit Minderiri sweetened with lemon
 or ginger syrup,  should be given three or four times daily.
   The infant's diet must be carefully regulated throughout the
 whole course of the disease.  Animal  food of every kind is deci-
 dedly objectionable.   If  the child is still nourished at the breast,
 and the mother or nurse furnish a  sufficient supply of good milk,
 no other nourishment is necessary.   If there is a deficiency of milk,
 or if the child  has been weaned, it should be confined to the use
 of thin preparations of arrow-root, sago, and oat-meal, and a mix-
 ture of three parts of cow's milk and one of water.  During conva-
 lescence, or in  a  low and  chronic state of the disease, weak beef
 or chicken tea  may be allowed, along with the farinacious prepa-
 rations  just  mentioned.  Equal parts  of thin  arrow-root  and
 chicken tea  forms  a good  nourishment in  this condition of the
 patient.

   II. Of the remittent fever of children  after dentition.—This mod-
 ification of remitting fever, very  rarely occurs previous to  the
 second year, and  is  evidently intimately associated with derange-
 ment of the chylopoictic system, or gastro-intestinal irritation. In
 some  instances the disease comes on suddenly, in consequence of
 overloading the stomach, or  of the use  of irritating and indigesti-
ble articles of nourishment.   The attack generally occurs at
night.   The child becomes pale and cold or  is seized with  chil-
liness, which, in most cases, is soon followed by nausea and vomit-
                          2R            27 
306                REMITTENTS OF INFANTS.
ing.   Febrile reaction speedily  ensues;  the  skin  becomes  ex-
tremely warm and dry, the pulse very frequent and strong, and the
little  patient is very restless,  thirsty, and usually complains of
headache, and  severe  transient pains in  the stomach.   Towards
morning, a slight perspiration breaks out about the  head and
chest, and the febrile symptoms remit, leaving the child pale and
languid, without  the least appetite  for food.  In the  course of
the morning  generally about ten or eleven  o'clock, the child's
countenance becomes contracted and very pale, its hands and feet
are cold, nausea, and generally vomiting occur, and a second febrile
exacerbation ensues, which usually continues  until  the following
morning, when a remission takes place, which, if the disease is not
arrested, is again  succeeded  by a  paroxysm of fever.  During
the first ten  or twelve hours, the tongue  is generally  clean;
but  in  the course of the second day, it becomes covered with a
white fur, which soon acquires a brown appearance, and in pro-
tracted cases, at  last  becomes  almost black.  The bowels are
generally extremely torpid, the pulse though frequent, full  and
quick, is seldom  firm  or  tense; the thirst is always very  great,
and  the child complains of almost constant headache.  During
the first two or three days, nausea and vomiting occur repeatedly,
and the child, usually, feels somewhat  relieved, particularly of
the headache, after each spell of vomiting.   After the disease
has continued for some days, the little patient is apt to remain in
a drowsy state  during the febrile exacerbations, and is  apt to
pick  the lips and  nose with his fingers, until they become quite
sore.
   Cases of this  kind, if not  subdued, at an early  period, often
continue for several weeks.   The  abdomen, at last, becomes
tumid and  distended  with  wind, or tympanitic; a  black  sordes
collects about the lips and teeth; if a purgative is given,a reddish,
or muddy water passes off, mixed with small  masses  of solid fecu-
lent  matter  and  small flakes »of mucus, or  the discharges are
black and glairy, or green and curdled.
   Much more frequently, however, this variety of fever comes on
in a  gradual manner.  The  child begins to droop;  its counte-
nance is pale, with an expression of languor and uneasiness, the
pulse frequent and small, the hands and  feet cool and the head 
                   REMITTENTS OF INFANTS.               307
and body generally unusually warm.  In  the afternoon—slight
febrile symptoms occur, and in many instances, several attacks of
feverishness take place in the course of the day, during which,
the  child, generally lies down, and falls into a heavy and dis-
turbed  sleep.  In the intervals of these slight febrile exacerba-
tions, the little  patient appears to be " tolerably well,  but  is
easily put out of temper,"  and seems  to feel a  general soreness
of the flesh, causing him to fret and  cry out as if in pain when
touched or lifted. The tongue is covered with a thin white fur, the
thirst is moderate, and  the appetite,  in  general, depressed and
capricious.  The bowels  are  usually  torpid,  though in some
cases,  the stools are frequent, liquid  and very offensive.   The
evacuations are  seldom very bilious, and in many instances, there
is a manifest deficiency of  bile.   These  symptoms,  generally,
continue for eight or ten days, when  all at once, a severe parox-
ysm of fever, occurs, preceded by chilliness or shivering attended
commonly with nausea and  vomiting.  The pulse becomes very
frequent, full, and somewhat tense, the countenance flushed, and
the  drowsiness  is much increased.   The  patient  seldom com-
plains of pain in any part, except occasionally, of transient and
sometimes very severe pains in the abdomen.  If,  however, pain
does  occur in the  head, which is  by no  means  common, it is
usually "both violent and permanent"  One of  the  most con-
stant symptoms  attending  the fully developed state of this fever,
is, an incessant picking of the lips, nose, and angles of the eyes.
When  the  disease  has advanced to this  stage, there  is an
entire  loathing of every kind of food;  digestion  appears to be
wholly suspended, and the  tongue becomes covered with a thick
fur, which soon acquires a dark brown color.  The intestines are,
almost invariably, exceedingly torpid, and the alvine evacuations
are " without  the smallest resemblance either in appearance or
smell, to those faeces, where the  power of digestion  has been
exerted."  They are dark or black  and  glairy,  or  thin  and
foamy, resembling yeast, or curdled and dark green, with a very
peculiar offensive smell; and in some instances, they are whitish
or clay-colored,  " indicating a deficiency of bile." (Burns.)   As
the disease advances, delirium occurs during the exacerbations
and  in  the  last  stage, it sometimes continues for two or three 
308               REMITTENTS OF INFANTS.
days, with but slight and temporary abatements in the morning
In general, however, the  patient may be roused from the deli-
rium for a minute or two, so as to answer  questions distinctly.
At first the febrile  exacerbations occur only  in the afternoon;
but by degrees, they become  prolonged, so as to leave but very
short and  imperfect  remissions between them.   During the
delirium, the  child picks at the  bed-clothes, is very  restless,
starts up suddenly, and moans and sighs almost constantly; and
in severe cases it has fits of violent screaming and agitation.
Towards the fatal termination of the disease, convulsions, paraly-
sis of one side, strabismus, or deep coma sometimes occurs.   The
abdomen, generally, becomes tumid  and tense or tympanitic, in
the advanced  stages of the disease, and, in some instances a total
retention of the urine takes place.
   After this fever is  once fully developed, it  seldom terminates
before the seventh or eighth day, and, most frequently, continues
for  several weeks.   When paralysis, strabismus, or convulsions
occur, there can be but very slight hopes of a favorable termina-
tion.  These  symptoms are, however,  not always indicative of a
fatal result, for patients sometimes recover, after all the  usual
signs of cerebral effusion  have supervened.   Nevertheless, when
symptoms of  this kind are attended with a bloated and  tense
state of the abdomen, and watery discharges from the bowels,
all hopes of a fortunate termination are in vain.
   In some  cases, this fever never  becomes  very  violent,  but
creeps on in a slow or chronic form for three or four weeks.   In
instances of this  kind, there is always a considerable remission
in the morning, even in the advanced stages  of the complaint,
and the exacerbations are scarcely ever attended with delirium
or very great  drowsiness.  At first the appetite is depressed, but
in the course  of four or five days, it generally improves, and the
child will eat, pretty freely, during the  remissions.  The alvine
evacuations, however, exhibit a very unnatural appearance, and
are  extremely  offensive.  The intestines  become greatly dis-
tended with wind so as to  give a tumid  and  drum-like elasticity
to the abdomen.   Evacuation goes on  rapidly, and the counte-
nance acquires a very pale and haggard  appearance. The brain,
 at last, sorhetimes becomes affected; the child becomes more and 
                   REMITTENTS OF INFANTS.                309
 more fretful during the  remissions and drowsy in the exacerba-
 tions.   It starts and screams out in its sleep, grinds its teeth, turns
 the eyes up so as to hide the cornea, and finally sinks into a state
 of constant somnolency,  coma, attended, perhaps, with paralysis
 and convulsions.
   Dr. Underwood mentions a modification of this fever, the most
 remarkable symptom of which, he says, is the occurrence of "in-
 flamed and sometimes painful tumours," seated chiefly on the in-
 ferior extremities, more especially along the  spine of the tibiae.
 They acquire  the size of a nutmeg, in the  course of the second
 day, and  soon  become soft,  resembling small abscesses.   They do
 not, however, suppurate, or contain matter, and  generally disap-
 pear again, in four or five days.   I have met with a few instances
 of this kind, and have not  found them to be  attended with  any
 peculiar difficulty or obstinacy.
   It i6 often extremely difficult to distinguish  infantile remittent
 fever from acute hydrocephalus, and in some cases, indeed, there
 exists no  essential difference between them—the causes and pro-
 minent  pathological  conditions being in every important respect
 of the same nature.   In many instances, however,  infantile  re-
 mittent fever, though similar in  appearance, with hydrocephalus,
 is nevertheless, sufficiently distinct from it, to render a correct di-
 agnosis between them of considerable consequence, both  in a
 prognostic and remedial point of view.  The following  circum-
 stances, will in general enable us  to distinguish the two com-
 plaints from each other.   In hydrocephalus, the face is frequently
 flushed, and the child tosses its hands above the head, or presses
 them on the forehead.  In  infantile remittent, the countenance,
 though  occasionally flushed  is generally pale and leaden or of a
 dingy pallid appearance; and the little patient is constantly pick-
 ing the lips and nose  with   the fingers.  In hydrocephalus head-
 ache is  an almost constant  symptom, and is  often so  acute as to
 cause the  child to cry out  "oh my head."   It is, also, usually
 connected with much intolerance of light.   In infantile remit-
 tent, headache  rarely  occurs, and when it does come on it is usu-
 ally transient and  connected with nausea or vomiting.   In  the
early stage of hydrocephalus there is generally frequent vomiting
particularly when the  child is raised into a  sitting or erect pos-
                                          27* 
310                REMITTENTS OF INFANTS.
ture.   In remittent fever, this is much less common, nor is apt to
occur when the patient's head is suddenly raised.  In the former
affection, the abdomen almost always  becomes flattened; whereas
in infantile remittent fever, the abdomen becomes tumid, tense
and elastic or  hard.  Goelis insists  particularly on  the impor-
tance of this circumstance, as a diagnostic sign in these affections.
In idiopathic hydrocephalus, diarrhoea or looseness of the  bowels
scarcely  ever occurs, in the early stage of the disease.  In remit-
tent fever, diarrhoea is no uncommon symptom, in the commence-
ment  of the complaint.   In the former affection, the nostrils and
mouth are dry, in the latter, they are generally moist with mucus,
and the secretion of saliva is increased.   The delirium of hydro-
cephalus, is  generally more constant, and, after it has continued
for some time, the patient cannot be roused from it, as in the re-
mitting fever.  The pulse also, is much more irregular and tense,
and in the advanced stage, when  stupor or coma is present, it,
usually,  becomes slow and  intermittent.  There is  strabismus,
deep  sighing, sudden  and violent screaming, and in most cases,
constant  rolling of  the head, and frequent grinding of the teeth.
In the infantile remittent the breath  is often offensive, which is
rarely the case  in  idiopathic  hydrocephalus.  In  the advanced
stages of the former complaint, there  is almost invariably a great
aversion  to every kind of food; but in the latter disease, the pa-
tient  frequently takes without reluctance, whatever is  offered,
"apparently  making  no distinction between what is palatable
and what is  nauseous."   The  alvine evacuation, will, also, aid
us in  forming a satisfactory diagnosis.  In the fever under consid-
eration the stools are always "remarkably changed from their natu-
ral appearance."  They are sometimes perfectly black and glairy,
resembling tar, with a smell that has been compared to putrid mud;
at other times they  consist of a dark green fluid mixed with shreds
and flocculi of mucus.   In hydrocephalus, the  stools are, at first
often light colored, and after the disease has continued for four or
five days or  longer, they frequently  exhibit a  foamy and  light
green  appearance,  of  the consistence of thick syrup or pap, re-
sembling chopped spinage.  If after an attack of convulsions, the
mental faculties are restored  "and the history of the  disease ac-
cord with the symptoms above  described, we may securely pro- 
                    REMITTENTS OF INFANTS.               311
 nounce that the head is not the source of the convulsions, but that it
 is merely a symptom of intestinal irritation" (Pemperton).  It may
 be observed, that when  the symptoms are so ambiguous as to
 render it doubtful whether they depend  on  meningeal inflamma-
 tion and effusion, or on mere sympathetic irritation and vascular
 tergescence of the brain, the exact diagnosis cannot  be of mate-
 rial service in the treatment, since the same means are indicated,
 and would be used whether the cerebral affection be  primary and
 independent, or secondary and symptomatic of gastro-intestinal
 irritation.
   The usual exciting causes of the present variety of  infantile
 remittent fever, are, improper food, a torpid state of the bowels,
 worms, vitiated or  acrid secretions from the  liver, cold and moist-
 ure, dentition, and  perhaps deficient attention to cleanliness, pure
 air, and exercise.  All who have written on this disease agree, in
 referring it to a primary irritation  located  in the stomach and
 bowels, with disordered functions  of the  biliary organs.   Mr.
 Colley thinks, that  the primary disorder consists in torpor or de-
 fective action of "some part, or of the whole of the chylopoictic
 system, and generally of the liver stomach and intestines."  It is,
 indeed, sufficiently evident  that both the  stomach  and bowels
 are extremely inactive, in this malady; digestion is soon  entirely
 suspended; and, in the early periods of the complaint, the alvine
 evacuations often, indicate a deficient secretion of bile.  In con-
 sequence of this torpid state of chylopoictic organs, the  contents
 of the  intestines, probably, undergo such chemical changes "as to
 become the source of extreme irritation" to the mucous membrane
 of the  alimentary canal.  The vitiated secretions from the  liver
 and intestinal glands, also, contribute to the same injurious result;
 and it  is not improbable that the blood itself, may undergo some
 morbid change,  in consequence of the absorption of chyle imper-
 fectly  elaborated, and vitiated by the depraved fluids generated
 in the  alimentary canal.  The tendency of gastro-intestinal irrita-
 tion to excite disease in other organs, particularly in the brain, is
well known.  Dr. Burns observes, that "we are not yet enabled
to say, what particular mode of irritation-  gives rise to  the dif-
ferent modifications of phenomena; or why, in one case the same
apparent exciting cause should produce spasmodic, and in another 
312               REMITTENTS OF INFANTS.
febrile affections." Broussais has thrown some light on this inter-
estino- subject.   It would appear, that when the local irritation is
purely nervous, the sympathetic consequences will be confined to
the nervous system;  but when the local  irritation involves, also,
the capillary blood-vessels, that  is, when there  is inflammatory
irritation, the secondary effects will be febrile and inflammatory.
Thus if  some very indigestible substance be  taken into the  sto-
mach, the  immediate  impression on  the gastric nerves will  be
communicated to the brain, and convulsions  or some other spas-
modic or purely nervous affection  will  probably occur.  If  the
substance  remain long enough to excite local vascular irritation
in the stomach or bowels, the sympathetic consequences will be
febrile.

   Treatment.—From the symptoms, causes and pathological cha-
racter of this disease, it is obvious, that  the principal objects to
be kept in view in the treatment, are, to clear the bowels of their
 vitiated and irritating contents;  to correct the biliary and intesti-
 nal secretions;  to obviate cerebral irritation; and finally, to mod-
 erate the excessive action of the heart and arteries. In cases that
 come on suddenly after eating some improper substances, or over-
 loading the stomach, the immediate exhibition of an emetic, fol-
 lowed, after it has  ceased to operate, by an active purge, will in
 general suffice to put a speedy termination to the disease.   The
 irritating  causes are thus removed  out  of the alimentary canal,
 before they have excited a fixed inflammatory irritation, and the
 disease consequently speedily subsides.  If, however, the offensive
 substances received into the stomach  are peculiarly  irritating,
 and  a predisposition exists  to inflammatory irritation in the  mu-
 cous membrane of the alimentary canal, or in some  other organ;
 or if proper evacuants be neglected  soon  after the  accession of
 the fever, the disease will be apt to continue for many days, how-
 ever diligently the stomach and bowels be evacuated by emetics
 and  purgatives.   It  is  generally very  difficult to procure  free
 evacuations from the intestines in cases  of this kind, particularly
 when the disease has been excited by hard and very indigestible
 substances, such as  cherrystones, orange  peel, raisins, almonds,
 &c   In some instances, portions of the irritating substances are 
                  REMITTENTS OF INFANTS.               313
retained, and discharged in  an imperfectly digested condition,
four or five days after they were taken into the stomach, although
the bowels are daily evacuated by active purgatives.  If the in-
testines resist  the free operation of purgatives, active clysters
ought to be administered to procure the desired effect.   When
the pulse is full  and active, and particularly when the face is flush-
ed and the head very hot,  much  benefit may be derived from
bloodletting.   It would seem that the  intestinal  torpor,  in this
complaint, frequently depends,  in a considerable degree, on vas-
cular fulness in the  brain;  and hence an  efficient abstraction of
blood,  almost always increases  the susceptibility of the bowels to
the operation of aperients.   It is not, however, merely on this
account, that bleeding  is proper, during the  exacerbations of this
fever.   When the pulse is full  and strong, the  momentum of the
circulation should be speedily moderated, with the view of obvi-
ating local inflammation and dangerous congestion.
   In the second modification of the disease—that is, in those cases
that  come on gradually, emetics are much less  important reme-
dies, than  in the preceding variety,—brought on suddenly,  in con-
sequence of the  reception of  irritating substances into the sto-
mach.  Nevertheless, if in the commencement of the disease there
is  reason  to suspect the „ existence of offensive materials  in  the
primae viae, more  especially when  the  patient  is affected with
nausea or  retching, the exhibition of a gentle emetic, generally
produces a very beneficial effect.  The bowels should, in the first
place,  be  thoroughly evacuated, and aftewards  kept in  a loose
state by the regular  employment of suitable aperients.  It is often
as difficult to procure free evacuations from  the bowels in this as
in the  preceding modification of the disease.   In general, how-
ever, sufficient  purging may be excited by the administration of
from six to eight grains of calomel, followed, in four or five hours,
by a full dose of castor oil,  or of infusion of senna and manna. In
some instances  of extreme torpor of the bowels in  this affection,
I have obtained very copious purging, by the employment  of cas-
tor oil  in union with  the spirits of turpentine, some hours after the
exhibition of a dose of calomel.   A dessert spoonful of the oil
with twenty or  thirty drops of the turpentine may be given every
hour, until active purging is produced.  Calomel, however, both
                                2S 
314               REMITTENTS OF INFANTS.
as a purgative and an alterative, is, undoubtedly, the most impor-
tant remedy we possess in  the treatment of this malady.  After
the alimentary canal has been well evacuated, this article ought
to be regularly employed with a view to its constitutional or alter-
ative influence, as well as  to its  aperient operation.   Whether
the liver  be  torpid or otherwise, it is quite certain that its func-
tions are much disordered; and, until the morbid condition of this
important organ is improved, no favorable change can  take place
in  the  general state of the disease.  With  this view, calomel
should be exhibited, in small doses, three or four times daily, and
its laxative effects promoted by the occasional administration of a
dose of castor oil, or of epsom salts.   It may  be very advantage-
ously given in union with small portions of ipecacuanna or of the
pulvis antimonialis.  I have generally prescribed a grain of calo-
mel with  half a grain of the antimonial powder, three times daily;
and, on the following morning one or two drachms of epsom salts,
or a few teaspoonfuls of castor oil.   This course should be pur-
sued until the alvine evacuations begin to exhibit a more natural
appearance,  after which the  calomel  must  be given at more
remote intervals, or wholly laid aside.  In general more benefit
may be derived from  small  and repeated doses of calomel than
from large ones less frequently administered.  Although purga-
tives are  always  decidedly indicated in the treatment of this
affection, yet  very active purging, after the  bowels have been
freely evacuated, is, as a general rule, by no means advisable. The
daily employment of drastic, or very active purgative remedies, is
apt to give rise to inflammatory  irritation of the mucous mem-
brane of  the  bowels,  attended with  muddy  or  reddish  watery
stools, and a tender, swollen and tympanitic state of the abdonlen.
Two or three  alvine evacuations, in  the  course of twenty four
hours, are sufficient  to prevent any injurious accumulation of
acrid or vitiated secretions.  After the disease has continued for
two or three days, and the faeculent contents of the  intestines
have been well evacuated, the milder purgatives, only, ought to
be employed, in the way mentioned above.  If these do not pro-
cure sufficient discharges, their operation on the bowels ought to
be assisted by active clysters.
   If in the commencement of the fever, the  pulse is full, active 
                   REMITTENTS OF INFANTS.               315
and firm, more especially, when the child is of a robust and pleth-
oric  habit, or when there are decided indications of  strong  san-
guineous  congestion, and irritation in the brain, blood ought to
be abstracted, either with the lancet  or by leeching.   Even  in
the advanced stages of the disease, blood-letting may sometimes
be resorted to with  much advantage, when the head is much
affected and the pulse is still active and tense.  If, after the dis-
ease has continued for five or six days,  the pulse continues to be
full and pretty active during  the exacerbations, the abstraction of
three or  four ounces of blood, seldom fails  to make a favorable
impression on the disease.   When strong delirium or a state of
stupor supervene, and the momentum .of the  general circulation
has  been moderated, much  benefit may occasionally be derived
from leeching behind the ears or on the temples.  In general,
however, more  advantage may be obtained, under these circum-
stances, from cold applications to  the head, than from local de-
pletion.   I have frequently known, the symptoms of cerebral irri-
tation and congestion  in cases of this  kind, speedily  and  very
greatly moderated by the continued application of cold water or
ice to the top and forepart  of  the head.  If the feet  are  cool,
which, in the latter  period of the  disease is sometimes  the  case,
they ought to be excited by stimulating frictions or by warm ap-
plications, at the same time that cold is  applied to the head.
   Besides the remedies already mentioned, diaphoretics also, are
very useful means for reducing the febrile reaction.  The skin is
generally obstinately dry and very hot; and a free  action of the
cutaneous exhalents is almost invariably attended with obvious
abatement of the general febrile irritation.  A simple solution of
tartar emetic in  water,  or the antimonial wine, given in small
but repeated doses so as jto keep up a slight degree of nausea, will
frequently do considerable  good.  I have  often employed the
following mixtures with unequivocal benefit.*   To a child of from
three to six years old a dessert spoonful should be given every two
hours during the exacerbations of the fever.  A mixture of spirit.

  * H Nitrat potassae gii; pulv. extract, glycyrrh. 3"!tart- antimonii, gr. i; spirit, nit.
dulc. 3'i» acl' fontanae giv. M. ft.
  R  Muriat. ammon. 3'i or pulv. extract, glycyrrh. 3iii> vin. antimon. 3"» acl- i°nta-
nas giv. M. ft. 
316               REMITTENTS OF  INFANTS.
menderiri, and the sweet spirits of nitre, in the proportion of <i.i
ounce of the former to a drachm of the latter, and sweetened with
lemon syrup, forms also an excellent diaphoretic, in this complaint.
One  or two teaspoonfuls should  be given, every two or three
hours, according to the age  of the patient.  If, after the violence
of the febrile  reaction has been moderated, the brain continues to
be in an irritated  or congested  condition, that is, if much delirium
or stupor be  present, blisters  applied to the back of the neck, at
 the same time, that cold applications are made to  the head, will
sometimes procure very considerable relief.
   It  is often very difficult to determine whether the manifestations
of cerebral disturbance arise from incipient inflammation, or from
mere sympathetic irritation of the brain.   If the former be the
case, opiates, are  of course wholly inadmissible; but, in  instances
of the latter condition, they often produce a highly salutary effect.
In general, when at an advanced period of the disease, the deli-
rium and cerebral disturbance  is associated with a small, frequent
and feeble pulse, a pale and sunken countenance, great jacthalion
and cool hands and feet, and especially when with these symptoms
the patient can be roused from his stupor or delirium, opium may-
be employed with  a prospect of much advantage.  The best mode
of using this narcotic is in the  form of  Dover's powder, in union
with  small portions of calomel. I have in some instances derived
very  great benefit from the administration of this remedy, in grain
doses repeated every three or four hours.   When the cerebral dis-
turbance is entirely irritative and symptomatic of  gastro-intestinal
irritation, the pulse becomes softer and slower, the skin moist and
of a natural temperature, and the patient falls  into an easy and
sound sleep, as soon as  the system is under the influence  of the
opium.  When he awakens his  mind is usually much tranquillized,
and the whole aspect of the disease  is sometimes changed for the
better.  In the latter period of the disease, when the fever is about
subsiding, the  patient, though not distinctly delirious, is occasion-
ally extremely restless, and unable to obtain any sleep during the
night. In instances of this kind,  two or three grains of Dover's
powder, given in the evening, generally produces  a very soothing
effect.  It must be particularly observed however, that, although
often  highly beneficial  in the  advanced periods of the  disease, 
                  REMITTENTS OF INFANTS.               317
opium can  very rarely be employed at an early stage, or before
the febrile reaction has been considerably moderated by evacuants
without incurring much risk of serious injury,  hi feeble and sick-
ly children, I have occasionally administered a few grains of this
anodyne, after the  free operation of a purge, with evident advan-
tage, at an early period of  the complaint.  In these  cases, how-
ever, the face was  not flushed and the patient was very restless
instead  of drowsy, as is usually the case, during the exacerbations.
   When the abdomen becomes tumid and tender to pressure, the
application of a few leeches to the epigastrium generally produces
a very good effect.  A large emolient poultice laid over the whole
abdomen, may also be resorted  to, with much advantage in cases
of this  kind.   The  abdominal tumor in such cases,  arises from
flatulent distention of the bowels; and hence the  expulsion of {Jie
confined flatus,  frequently affords immediate relief.   For this pur-
pose injections of a watery solution of assafcetida, may sometimes
be used with considerable benefit; but the remedy which has most
frequently  succeeded, in my hands, in reducing the abdominal
distention, is the spirits of turpentine, administered internally, in
doses of from eight to twelve  drops three or four  times daily.
In very  protracted cases, when the system is much prostrated and
the bowels  are  in an irritated and  tympanitic condition this
article is indeed a very excellent remedy.   It not only excites the
bowels to contract, and to expel the confined wind,  but it  often
exerts an evident beneficial influence on the intestinal secretions,
and, it would seem, on the irritation of the  mucous membrane of
the stomach and bowels.
  After the disease has been  in a great measure subdued and the
alvine evacuations  have acquired a natural appearance, mild tonics
may sometimes be used with  considerable benefit, during conval-
escence.  Awreak infusion of bark, or of Colombo,  will answer
well for this purpose.  I have in several instances used finely pow-
dered charcoal, in  union with powdered ginger, with very obvious
benefit.   From ten to fifteen grains  of the former, to  six or eight
grains of the latter article, may be  given  three or four times
daily.
  The diet ought to be of the lightest and most unirritating kind
possible.  During  the active  stages of the  disease,  toast water,
                                           28 
318                 OF CATARRH.  FEVER.
thin barley water,  or rice water, will be sufficient.  Every kind
of solid food must be rigidly prohibited.   For drink,  the patient
may use weak lemonade,  toast water, and  occasionally a table
spoonful or two, of fresh water.  During convalescence, chicken,
lamb, or  mutton  broth, boiled  rice,  arrow root &c.  will be
proper.
                  CHAPTER XXV.


                CATARRH.  CATARRHAL FEVER.

   Catarrhal affections  under various forms and grades of vio-
lence, are  among the  most common  diseases of infancy  and
childhood.  These complaints  are particularly apt  to  occur
during raw, variable, and humid weather, and hence  they are
most frequently met with in the spring and winter, more especi-
ally when the  latter season  is moist and open.  It is also, apt to
occur during summer, when after a long spell of damp  and  clear
weather, the  atmosphere suddenly becomes dry and  very hot.
Catarrhal fever sometimes prevails  epidemically, and the disease
has been known to confine itself, in a great measure, to children.
An epidemic of this kind occurred  throughout the eastern states
in  1824,  in which by  far  the greater number of  cases  were
among children.
   This malady is characterized by fever, cough, slight hoarseness,
some difficulty of breathing, running at the nose, sneezing, and
that peculiar watery appearance of the eyes which occurs in the
commencement of measles.  The disease  begins  with a slight
feeling of chilliness, and occasionally  with a distinctly formed
chill.   The hands and feet become cold, the whole surface of the
body pale and  contracted, and the patient  appears  languid  and
drowsy.  This state of  depression  frequently  continues for a
whole day before  the febrile  reaction  is  fully  developed.  In 
                    OF CATARRH.  FEVER.                 319
many instances, however, the fever supervenes in a very  short
time after the first feelings of indisposition.   The patient  com-
plains of aching pains in the extremities and back, the pulse be-
comes  frequent, somewhat  tense  and generally full, the cheeks
flushed, the eyes suffused with tears, and a thin transparent fluid
usually issues from the nose attended in the commencement with
frequent sneezing.  The skin is  dry and  husky, though seldom
much above  the natural temperature.  The bowels are torpid,
and the urine  scanty and  high-colored; and, in  many instances
the alvine evacuations, during the first few days,  manifest a defi-
cient secretion, and sometimes  an entire absence of bile.  In
some cases, cough with slight hoarseness, is  one  of  the  earliest
symptoms; more  frequently, however, the cough  does not  come
on until the fever is fully developed, and often not until  the dis-
ease has continued for two or three days.   The breathing  is not
often much oppressed in the early periods of the  disease, though
frequently attended with considerable rattling in the trachea. In
severe cases, however, respiration is  frequently  difficult and
wrheezing, almost as soon as the fever is developed, owing to the
abundant secretion of mucus into  the air cells.  This is most apt
to be the  case in infants, who, from not making any efforts to
relieve the lungs by expectoration, suffer the bronchial  secretions
to accumulate, in the  air passages.   Hence the operation  of an
emetic, or spontaneous vomiting, by expelling the mucus  from
the bronchia, is always followed by an immediate, though but
temporary cessation of the pectoral oppression and dyspnoea.  In
general, the more violent the cough  is in the early stage of the
disease, the less mucus  is secreted and discharged  from the lungs-
and when the bronchial irritation is about passing into  inflamma-
tion, the cough, usually, becomes  perfectly dry.  In the ordinary
form and course  of the disease, the expectoration becomes very
abundant, after the fever has continued for three or four  days;
and as the copious secretion of mucus keeps up  a constant irri-
tation of the bronchia,  the cough, usually  becomes very frequent
as the disease advances.
  The liver, often, is  much affected in this variety of fever.  In
infants,  the epigastrium and right hypochondrium, sometimes,
become tumid, tense  and sore to pressure—a condition, which 
320                  OF CATARRH. FEVER.
has led to the vulgar notion that the child is " liver grown," as it
is called.  The liver, in  cases of this kind, is evidently greatly
engorged with blood, attended with more or less functional tor-
por.  During the first two or three days, the discharges from the
bowels are frequently whitish  or clay-colored;  but as the dis-
ease advances, an abundance of light-green or dark bile appears
in the evacuations.  In violent cases, delirium sometimes occurs,
particularly in the afternoon and at night.  There is generally a
distinct remission of the febrile symptoms, in the morning, though
usually of very short duration.
   The occurrence of bile in the evacuations, if accompanied with
a soft and moist skin, and a more copious  secretion of urine, is
almost always followed by a speedy declension  of the disease.
When, on the  contrary, the alvine  discharges  become watery
and muddy, or reddish, with shreds and  flocculi of mucus, resem-
bling the washings of flesh, attended, as  these discharges almost
invariably are, by a bloated or tympanitic state of the abdomen,
and a very dry and harsh condition of the  skin, the worst conse-
quences are  to be apprehended.   When death takes place, at an
early period, it is generally from engorgement of  the  lungs and
sudden effusion into the air cells, or from  the supervention  of
bronchial or  pneumonic  inflammation.   The occurrence of con-
vulsions, in this complaint, is always a highly unfavorable circum-
stance.  Great somnolency  or  drowsiness, when attended with
difficult breathing, is  also very  unfavorable, as  they indicate
strong cerebral and  pulmonary congestions.
   During the declension of the disease, a very copious  discharge
of thick mucus generally occurs from the nose, and trachea; and
this, with the cough, often continues  for several weeks after the
fever has .completely subsided;
   Treatment.—In  prescribing for this disease, we  must endeavor
to restore the regular action of the skin and  liver; to moderate
the  febrile excitement  of  the  heart  and arteries; to allay the
irritation of the mucous membrane of the  respiratory passages, and
to obviate local congestions or inflammations. The bowels should,
in the first place, be freely evacuated, by a full dose of calomel,
followed, in three  or four hours, by a dose of castor oil, magnesia,
or infusion of senna and manna. 
                     OF CATARRH.  FEVER                 321
   If the pulse is full and active, or when symptoms of severe pulmo-
 nary congestion or inflammation  occur, blood ought to be drawn,
 so as to  make an obvious impression on the circulation, either
 with the lancet or by leeching.   When the child complains of
 pain in the chest, or when the  breathing is laborious, this mea-
 sure is of great importance, and should never be neglected.  In
 many cases, however, the pectoral symptoms are slight and the
 pulse is not sufficiently active to require or warrant the abstraction
 of blood.  As  soon as the bowels have been well evacuated, re-
 course should be had to antimonials,  and to small doses of  calo-
 mel in union with ipecacuanna, with a view of exciting the  cuta-
 neous and hepatic secretions and keeping up a moderate action
 of the bowels.  JFrom a quarter to a half a grain of calomel, with
 a half a grain or a grain of ipecacuanna, according to the age of
 the patient, may be given three or four times daily, until the stools
 have become distinctly bilious.  When this  occurs, a dose of cas-
 tor-oil, or of magnesia  should be administered, so as to procure
 pretty free purging.  At  the same time that  this remedy is em-
 ployed, small doses of tartar emetic may be very beneficially ad-
 ministered. The best way, perhaps, of employing antimony in this
 disease, is to give it in combination with some mild expectorant mix-
 ture.  I have found the  following, very excellent mixtures for this
 purpose.*  A teaspoonful maybe given to an infant every two or three
 hours.  After the febrile reaction has been  moderated, or wrhere
 it is feeble in the early stage of the complaint,  much benefit will
 often result from the use  of small doses of Dover's powder. Where
 however, the lungs are much oppressed,  by  too copious a secre-
 tion of bronchial mucus, and the patient  appears drowsy, opiates
 are  decidedly improper in infants; for, if the bronchial irritation
 is lulled by the use of  opium, the cough will be suspended, and
 suffer the mucus to accumulate to a dangerous extent in the air cells
 and bronchia.   When the breathing is oppressed from this cause
 in infants, nothing affords more certain and speedy relief than the

  * R-  Muriate of ammonia,  gii; Extract. Glycyrrh. 3iii; Aq. fontanffi, giii; Tart.
 Antimonii, grs. ii; Syrup. Scillas, 3"i.  M.
                              or
  R. Spirit. Minderiri, gii; Syrup. Scillae, gss; Vin. Antimonii, 3ii; Spirit.  Nitri
Dulc. 3iii; Sacch. AJbi gss.  M.
                             2 T           28* 
 322                  OF CATARRH.  FEVER.
 operation of an emetic.   The concussive action of vomiting, rare*
 ly  fails  to  free the  lungs  from the viscid  mucus,  that may  be
 lodged in the bronchia and air cells.  When the pectoral oppres-
 sion is severe, a large emolient poultice laid over the breast, will,
 frequently, procure considerable relief; but when the cough is
 violent  and painful, and the breathing laborious, a blister applied
 to the chest will be  the most effectual means of relief and ought
 not to be  neglected.  To  promote the action of the cutaneous
 exhalents, the warm  bath is sometimes very beneficial, particularly
 after the acute symptoms have, in some degree, subsided.  During
 the declension of the disease, expectorants and small doses of opi-
 ate remedies, are usually of essential service.   A mixture of equal
 parts of tinct. opii. camphoratae, syrup of squills, and sweet  spirits
 of  nitre, forms an  excellent remedy  for this purpose.   From
 twenty to sixty drops, according to the age of the patient, should
 be  given three or  four times daily.  The hive syrup, and  brown
 mixture,* are also very useful expectorants, in the latter stage of
 the disease.

   Congestive Catarrhal Fever.—Infants  are liable to a catarrhal
 affection, in which the prominent symptoms  are those of violent
 pulmonary  congestion, with but little or no development of febrile
 excitement.  So far as I know, Dr. Parrish, of Philadelphia, is
 the first, who has given a particular account of this dangerous ma-
 lady 4 This modification of the disease commences with cough, and
 the breathing  soon becomes laborious and wheezing;  the face is
 very pale,  and the whole  surface cold, though generally soft or
 moist.   The pulse is considerably accelerated, but is free from
 tension, quickness, or firmness.   The countenance acquires a
 peculiar expression of distress and anxiety, and in severe cases, the
 cheeks become very  cold even when the other parts of the sur-
face, are of a natural temperature.   The stomach and bowels are
generally inactive, and the urine is small in quantity,  but  so far

  * R. Extract, glycyrrh.  3»; Aq. fontanae giv; Vin. Antimonii  3ii; Tinct. Opii.
Camph. 3ii.  M.   Dose from one to two teaspoonfuls every three or four hours, accord-
ing to the age of the child.
  t Observations on a peculiar Catarrhal Complaint in children.  By Joseph  Parrish,
M. D. Sec—See, North American Medical and Surgical Journal, vol. i. p. 24. 
                     OF CATARRH.  FEVER.                 323
as I have observed, nearly of a natural or healthy color.   After
the disease has continued for some.time, a cold perspiration some-
times breaks out on the face and neck. The cough is at first dry,
attended with a wheezing sound in the chest;  but towards the
termination of  the  complaint, it  frequently  becomes  humid
or rattling.  The  pulse, in violent cases, becomes very small and
rapid, and the tendency to sinking, is in all instances, very  obvi-
ous.   There  is constantly much  difficulty of breathing, but at    *
times, the oppression  becomes  so great as to resemble a violent
attack  of asthma.  Occasionally considerable  remissions  occur,
for a short period, during which the pulse  will become somewhat
fuller and slower, and the countenance brighter and more calm.
When  the disease is tending to a fatal termination, the patient
becomes drowsy, insensible and comatose,  and death  takes place,
by suffocation, or in a paroxysm of convulsions.
   This disease seldom continues  longer than two or three days,
and  in very young infants, death sometimes takes place, in the
course of the first  day.  It is most frequently met with in infants
under a year old, and I have witnessed several cases during the first
month.   After dentition is completed, catarrhal affections appear
to be less apt to assume this congestive character; although vio-
lent pulmonary congestion and fatal  effusion into the air passages,
occur at every period of  life as  consequences  of pneumonia or
bronchial inflammation.
   Dr. Parrish thinks  that the dyspnoea, whi«h  forms the promi-
nent symptom of the disease,  " is  undoubtedly of a spasmodic
character," depending probably on  " a constitutional debility of
the respiratory organs."   My own observations have led me to a
very different  conclusion.   From carefully attending to the phe-
nomena and progress of several cases of this kind, I am entirely
convinced, that the oppressed respiration and other characteristic
symptoms of this disease, depend mainly if not wholly on  great
sanguineous engorgement of the  pulmonary blood-vessels.  The
disease  is manifestly  catarrhal; but  the  lungs  are, at  once, so
entirely oppressed by excessive  sanguineous congestion, that the
vital energies are too much depressed to admit of the develop-
ment of distinct  febrile reaction,  and local  inflammation.  It
seems to me  to bear the  same relation  to acute bronchitis or 
324                 OF CATARRH.  FEVER.
peripneumony, that apoplexy or coma does to phrenitis.   It is a
kind of apoplexy of the lungs.  Extremely oppressed respiration,
paleness of countenance, cough, and coolness of the surface, are
precisely the phenomena we should expect to occur, from exces-
sive  sanguineous  engorgement  of the  lungs.  Dr.  Parrish  uses
antispasmodics, particularly assafoetida and the  oil of amber  in
the  treatment of this malady; and  he  seems to regard their
apparent  usefulness,  as an evidence  of the  correctness  of hia
opinion on this subject—namely, that the "dyspnoea is undoubt-
edly of a spasmodic character."  It must be observed, however,
that he employs, also, emetics, purgatives, blisters to the  breast,
and  the warm bath; and although he  regards them only as "use-
ful auxiliaries" to the assafoetida and oil of amber, they are just
such remedies, as one would place most reliance on for the removal
of pulmonary  congestion; and I cannot doubt that they were in
reality  the  means which  effected  the beneficial  results  in the
cases he has reported.

   Treatment.—The  principal object  in  the  treatment of this
complaint, is to relieve the congested condition of the lungs, and
to prevent the development of inflammation.   The  child  should
be immediately placed in a warm bath, and an antimonial  emetic
administered.   Vomiting  seldom fails to procure some benefit:
but the relief obtained from it, is generally temporary, and in the
beginning of the disease, sometimes but very slight.   The most
effectual means for relieving the lungs, is the  application  of a
large epispastic over the breast, and this should neVer be omitted
when the pectoral oppression is severe.  The bowels, also  should
be freely evacuated;  and for this purpose, a full dose of calomel
is, perhaps, the most beneficial.  Frequent and very active purg-
ing,  however, has appeared to me injurious  in this complaint.
After the intestines have, in the first place, been well evacuated,
it will, I think, be best to keep them in a loose state, by the exhi-
bition of  a moderate dose of calomel in the evening, assisted
.f necessary, next morning, by a small portion of castor oil.  To
determine the circulation to the inferior parts  of the  body, some
advantage may also be derived from the application of sinapisms
to the feet.  Dr. Parrish speaks very favorably of the  use of assa- 
                     OF CATARRH. FEVER.                 325
 foetida  and the oil of amber.   He mentions an extreme and an
 apparently hopeless  case, the unexpected recovery of which he
 ascribes chiefly to the agency of the former of these antispasmo-
 dics. " I should," he says," have despaired of the case, had I not
 known under  what apparently  hopeless circumstances  infants
 sometimes recover.   I ordered the warm  bath, sinapisms to the
 feet, a  large blister over the breast, and laxative injections con-
 taining assafoetida.  But the remedy  on which 1 chiefly relied,
 was assafoetida rubbed up with mint water, given frequently and
 in large doses.   To the astonishment of every one who witnessed
 the case, my little patient perfectly recovered." The assafoetida,
 doubtless, had  its share in the production of this fortunate result;
 but  this case certainly cannot be regarded as a fair example of
 its efficacy, since the other means employed along with it, are
 by themselves, generally, sufficient to  remove the  disease.  I
 have never yet employed any antispasmodics in the treatment of
 this  affection—having always relied, principally, on the remedies
 already mentioned,  particularly  blistering, the warm bath, and
 emetics.  When the pulse is very feeble, wine-whey, or a weak
 solution of the carbonate of ammonia may  be used with much
 advantage.  I  would not, however, say any thing against the free
 employment  of assafoetida; on the contrary, the authority of Dr.
 Parrish, is sufficient  to  convince  me, that it is a remedy of excel-
 lent powers  in this  complaint.   I doubt,  however, whether its
 good effects can be justly ascribed to its antispasmodic operation.
 It is rather by a general stimulant and expectorant influence, I
 conceive, that  it contributes to  the reduction of this formidable
 malady.  Dr. P. directs, that one drachm of this gum, be rubbed
 up with an ounce of mint-water, and given'in teaspoonful doses,
 repeated every two hours.  "If  this shall be found  too strong, it
 should be diluted, till of such a strength as the child can bear."
  I  have  as yet said nothing of blood-letting.  When there is
 considerable  fulness  and activity in the pulse, the abstraction of
 a small quantity of blood, with the lancet, is  often highly benefi-
cial.  I  have,  in  some  instances,  procured  prompt  and  very
decided relief  by bleeding.  When the pulse is very frequent,
small, and feeble, as  it sometimes is, blood cannot be  drawn
without considerable risk of increasing the prostration to a fatal 
326                  OF CATARRH.  FEVER.
extent.   Before bleeding is resorted to, where the state of the
pulse does not distinctly indicate the propriety of the measure, it
will, in general, be best to premise the use of the warm bath, and
the application of sinapisms to the feet.  If these do not, in some
degree, increase the  fulness and force of the  pulse, it will be
most prudent to abstain from drawing blood.
   In moderate cases,  I have  known very obvious benefit  to
result from the application of a large emolient poultice, renewed
every two or three hours, so as to keep it sufficiently warm and
moist.
   When the bronchial exhalents begin to relieve themselves, by
secreting an abundance of mucus; or when the respiration and
cough are attended with a rattling sound in the chest, the hive
syrup, or a decoction of the seneca root, repeated at short inter-
vals, until vomiting  is  produced, will sometimes procure very
considerable relief.  Opiates are, in general, decidedly improper
in this affection, particularly in very young infants, and when the
secretion of  bronchial  mucus is copious.   Dr.  Parrish, says that
the fumes of  rosin "are often highly beneficial."  I  have my-
self, in one instance, resorted  to the inhalation of these  fumes,
with an evidently beneficial effect on the breathing. 
OF ACUTE BRONCHITIS.
327
                 CHAPTER  XXVI.


                      ACUTE BRONCHITIS.

   This disease, as it occurs in infants, often bears a close resem-
blance, in its  early stage, to the congestive complaint described
in the  preceding section.  They are, indeed, produced by the
same cause; but in the  present disease along with the sanguine-
ous  engorgement of the lungs, more  or  less  inflammation, is
developed in the mucous membrane of the bronchia.
   The  disease usually begins, with chilliness, or a cold and con-
tracted state  of  the  surface, a  languid  and  pale appearance
of  the  countenance,   slight  cough,  and some  difficulty of
breathing.   After some time, the pulse becomes frequent, quick
somewhat full  and resisting.  The  cough increases, is  slightly
hoarse, and has  a stifled sound.  The breathing also, rapidly
becomes more and more oppressed and  laborious.  When the
child is  old enough to give an account of its sensations, it com-
plains of a feeling of weight and tightness in the breast, but
seldom  of any pain.   Nevertheless, when  the cough is  violent,
infants sometimes cry out, as if  from pain; and the inspirations
are  occasionally  catching and attended with  an expression of
pain in the countenance.  At first the breathing and cough are
dry, but in the course  of the first twelve hours, and often soon
after the commencement of the febrile reaction, a copious  secre-
tion of transparent, viscid mucus takes place, into the bronchia.
In most instances, vomiting occurs during the first twenty-four
hours; and  the epigastrium  frequently becomes distended and
elastic.   As the  disease advances, the mucous secretion into the
air cells and bronchia, increases progressively;  the child becomes
drowsy, the  lips livid, and the  countenance expressive of  great
distress, the  muscular debility is always very great.   When the 
S28                OF ACUTE BRONCHITIS.
disease is once fully developed, the child often  manifests much
uneasiness  by being  placed in the  recumbent  position.  The
countenance is very rarely, evgn  slightly, flushed; on  the con-
trary,  throughout the  whole disease,  it  is  almost invariably
extremely pale and anxious.   Towards the fatal termination,  the
cheeks  and  lips  sometimes acquire  a slightly  livid hue.  The
temperature of this  surface,  is generally somewhat above  the
natural standard, on the trunk,—but  the hands and feet, are  fre-
quently cool or about the regular temperature.  The difficulty
of respiration, is not uniform.   Occasionally it is pretty easy, for
a short period, and then  suddenly, becomes, extremely oppressed.
The cough too, after the disease has continued, until the secre-
tion of bronchial  mucus is very copious, becomes, in a manner,
paroxysmal—violent spells coming on at irregular, and generally
short periods,  with comparative  exemption from it, during  the
intervals.
   The progress  of the  disease, is generally rapid.   In some in-
stances  it terminates fatally as early as  the  third  day;  more
frequently, however, its course is protracted to the sixth day.
Great drowsiness or coma, almost invariably precedes the fatal
termination.  But even  after the lungs appear  to be completely
clogged with the effused  mucus, and the child  has  sunk into  a
comatose state, " gleams of hope sometimes burst upon us.  For
a short time the  difficulty of respiration may seem to subside, and
the child to be better. * But these hopes  are very rarely realized;
 for even the next exacerbation of dyspnoea may terminate in
 suffocation."
    On dissection the lungs do  not  collapse when the thorax  is
 opened.   The whole structure of  the  lungs,  usually appears,
infiltrated, or  engorged  with a thin viscid fluid.  The mucous
membrane of the  bronchia, is generally of  a bright red  color,
from minute injection  of its  capillary vessels.  The smaller
branches of the bronchia, are commonly filled with tough mucus,
bloody serum, or purulent matter.   In  those cases  that succeed
 pustular exanthematous  affections, the mucous membrane of the
 large bronchial tubes, sometimes presents a number of very small
 ulcerations, and  slight fungoid elevations.  In severe cases, it  is
 not uncommon to meet with a  red hepatized  condition, of  a 
                     OF ACUTE BRONCHITIS.                 329
 portion  of the lungs;   and occasionally there is an  approach
 towards the formation of tubercles.
   The great  muscular prostration and somnolent condition which
 occur in this  disease, doubtless, arise from  deficient  decarboni-
 r.ation of  the blood; for death generally occurs  from asphyxia,
 or suffocation, in consequence of the entire obstruction of the air
 cells, and  smaller bronchial branches, by the viscid mucus so co-
 piously  secreted in this affection.   It seems  probable, however
 that death sometimes occurs, also in consequence  of the inflamed
 mucous membrane preventing the atmospheric air from producing
 the  necessary change in the veinous blood.   Cases of fatal dysp-
 noea are related by M. Andral, jr. in which no effusion or redundant
 secretion of mucus had taken place, nor any  lesion of  the proper
 substance  of the lungs, discovered on dissection.  It seems highly
 probable, that, whether the oxygen enter into the blood-vessels, or
 the  carbon be thrown out through the mucous membrane, the regu-
 lar influence of the air, on the  veinous blood, will  be impeded or
 perverted  when this delicate  structure  is  in a state  of intense
 inflammation.    The difficulty of respiration which occurs  in the
 early stage of this complaint, is, perhaps, chiefly  attributable to
 this  cause, and not to the clogging of the bronchial cells, by vis-
 cid secretions, as is generally supposed.

   Treatment.—Blood-letting is in general a highly  valuable means
 of relief, in the early stage of this affection.   In robust  and  ple-
 thoric infants, particularly when the pulse is active, prompt  and
 efficient, bleeding, either with the lancet or by leeching, may  be
 deemed  indispensable.   The period, however, during which  this
 measure may  be resorted to with a prospect of advantage is not
 very long.   The blood ought to be abstracted at an early period
 —as soon after the inflammation is developed, as possible.  If it
 be delayed, until effusion or a copious secretion of bronchial mucus
 has  taken  place, the chance of benefit from it, will be but very
 small, and  injury, probably, will be  the  result.  If the cough is
 dry,  and the respiration not  attended with a rattling sound in  the
 trachea,  blood may be drawn, with a fair prospect of advantage;
and a sufficient quantity ought to be taken away,at  the first bleed-
ing, to make an obvious impression on the action of the  heart and
                            2U              29 
330                 OF ACUTE BRONCHITIS.
arteries.  Much benefit may be derived from the application of
leeches to the chest;  more especially, after blood  has  been ab-
stracted  with the  lancet.  No  remedy,  however,  contributes
more powerfully to the reduction of the bronchial inflammation
than blistering.   As soon as blood has been efficiently abstracted
or at once in  the very commencement of the disease if  the pulse
be small and feeble, a  large epispastic ought to  be laid over the
breast and suffered to remain until the skin is uniformly inflamed.
It must then be removed and a large emolient poultice laid over
the part.
   The bowels should be freely evacuated, by a full dose of calomel
and rhubarb; and afterwards  kept in a loose state by  purgative
enemata, and small doses of some of the milder  laxatives.   Half
a grain of calomel with the same quantity of ipecacuanna may be
advantageously used for this purpose.  Emetics also are very use-
ful remedies, in this affection.   They generally procure immediate
relief of the oppression in the chest, by expelling the viscid mucus
which  clogs  the bronchial cells, and diminishing the pulmonary
congestion.   A  mixture of antimonial wine and syrup of squills,
in the proportion of orte part of the former to three parts of the
latter,  forms an  excellent  emetic, for this purpose.   A teaspoon-
ful of this mixture should be given every  twenty  minutes, until
active vomiting is excited.  Expectorants may also be used with
advantage in  this affection.  In the early period of the disease,
the more stimulating articles of this kind must be avoided.  I have
frequently employed the following mixture, for this purpose, with
evident benefit.*  After the febrile reaction has been moderated
and there is much secretion into the bronchia,  the more stimula-
ting expectorants, will be proper.   The following combination,
frequently, produces a very good effect, in the  advanced  periods
of the  disease.!   When there is much prostration, or  when the
pulse is small and feeble, in the latter stage of  the disease, stim-
ulants should  be used, along with  expectorants.   The carbonate-
of ammonia is an excellent remedy in this state of the disease. It

  * R. Tart, antimonii. gr. ii; sal. tart. 3'ii; aq. fontanae giiss mel. opt.  giss. M.
Dose, a tea spoonful every hour or two.
  f R. G. ammonias Qii; infusio polygala senegas giv; syrup scilte gss.  Dose, a tea-
spoonful, every two hours. 
                    OF ACUTE BRONCHITIS.                 331
may be given according to this formula.*   Hoffman declares, that
he has known a combination of the  flowers of benzoin and cam-
phor, to procure complete  relief, in cases, apparently hopeless.
To an infant, of from one to three years  old, a quarter of a grain
of the former article with half a grain of the  latter, rubbed  up
with a small portion of sugar, may be given every two hours.
  Opium is seldom beneficial in this  disease; and may readily do
a great deal of harm, by suspending, for a time, the efforts to ex-
pectorate, and thus giving rise to a dangerous accumulation of
mucus in  the bronchial  tubes.  When  the cough  remains dry,
(which however, is rarely the case) and 'the momentum of the cir-
culation has been diminished by depletion,  considerable benefit
may be derived from the judicious employment of  this narcotic.
In such cases, small doses of Dover's powder,in union with calomel,
generally moderate the violence of the cough, and assist  expecto-
ration.   To allay general irritation,  and  restlessness, during the
declension of the disease, the tincture of  hyoscyamus or of bella-
donna is often very useful.  Exhibited in doses of  from two  to
four drops every four hours, it seldom fails to tranquillize the ner-
vous system, and to moderate the cough.   When the skin is slow
in resuming its regular perspiratory action, these narcotic tinctures
may be very beneficially given  in union with antimonial wine.

  * R. Carbon, ammon. 9 ii; ext. glycyrrh. 3ii"> aq. fontanas, giv, acid. sciUse  3»-
M. Dose, a tea spoonful every hour or two. 
332
OF PLEURITIS.
                CHAPTER XXVII.


                         PLEURITIS.

  Inflammation of the pleura is a much more common affection,
during infapcy than many suppose.*  It commences  as other in-
flammatory affections do, with a feeling of chilliness  and a pale
and  contracted state of the surface.   This is soon succeeded by
high febrile reaction.   The skin becomes very dry and warm, the
face flushed, and the pulse frequent, full and strong.   The breath-
ing is hurried, short and somewhat oppressed, particularly when
the patient is lying down.  The cough is at first  dry and short,
and the infant evidently endeavours to stifle it as much as possible,
to avoid the pain which it always occasions.   When the  child is
laid down, it generally begins to cough and cry, and  the muscles
of its countenance are  contracted into an expression of pain and
suffering.   There is also much more  cough and uneasiness, when
the patient lies on one side than on the other.   In  some instances,
the patient rests easiest when lying on his back, with the  head
and shoulders  raised, both sides being equally affected.  Some-
times each inspiration is attended with a whine or moan, and the
countenance is always  expressive of pain.  If the disease is not
early moderated, or checked in its  course, the breathing becomes
more and more difficult and painful;  and if any of the viscid bron-
chial mucus is thrown out, it is  frequently found streaked with
blood.  "The  cough is attended  with  a rattling sound in the
trachea;   the  extremities become cold; the  countenance  often
slightly livid, and the patient finally  sinks into a state of drowsi-
ness or stupor.  The pulse, at last, becomes irregular, and often
intermittent, the extremities swell, the breathing  becomes short,
and a frothy fluid  oozes  from the mouth."  During the whole
course of  the disease the respiration is performed, chiefly by the
* Dr. Bums. 
                        OF PLEURITIS.                     333
action of the abdominal muscles, and diaphragm—the motion of
the chest being instinctively restrained by the patient, on account
of the increase of pain which the dilatation of the thorax or eleva-
tion of the ribs always occasion in the inflamed pleura.
   On post mortem examination, the pleura is generally found uni-
formly red, or punctuated with  an infinitude  of red  specks of
irregular shape, and  very  close together.   In  many cases a con-
siderable quantity of serum is effused into the cavity of the pleura;
and adhesions, more or less extensive, between the costal and pul-
monary pleura occur in the majority of instances.  Occasionally,
some portions of the  lungs are found hepatized; and  a  general
infiltration of serum into the pulmonary  structure is not  un-
common.
   The occurrence of diarrhoea in this  disease, is always  an ex-
tremely unfavorable circumstance; convulsions and coma, too, are
no less ominous of a fatal tendency.  Great  distress and agitation,
when placed in recumbent position, particularly when the breath-
ing is attended with a wheezing  sound in the trachea, and the
pulse is  small  and irregular  are extremely  unfavorable  signs.
   When the skin becomes uniformly moist, the pulse  less frequent
and soft, the cough attended with a free discharge or  raising of
bronchial mucus, and the  patient is able to  rest on either side, a
favorable termination may be confidently expected.
            *
   Treatment.—Prompt and veTy efficient blood-letting is indispen-
sable in the treatment of this form of pectoral inflammation.
Blood should be freely drawn  with the lancet, until a decided im-
pression  is made on the pulse.  The early application  of leeches
to the chest is also a highly important measure.  As soon  as the
momentum of the circulation has been moderated, a  blister ought
to be laid over the breast, and managed in the  way mentioned in
the preceding chapter.  The  bowels must  in  the first place be
freely evacuated, by an efficient dose of calomel and rhubarb, and
kept in a loose state throughout the whole course of the disease,
by small doses of calomel and ipecacuanna, or suitable portions of
epsom salts.
   The cooling diaphoretics are very  useful  auxiliary remedies in
this affection.  The nitrate of potash with minute portions of an-
                                             29* 
334                      OF PLEURITIS.
timony generally contributes materially to the reduction of the fe-
brile  irritation.  The  following  is an excellent mixture for this
purpose.*   Small doses of the pulvis antimonialis, in union with
calomel, may also be employed, with much advantage, when the
skin is very dry and warm.   With the view both of diminishing
the action of the heart and arteries, and  of promoting expectora-
tion,  a  simple solution of tartar emetic, given in very small but
frequent doses, often proves decidedly beneficial.   Dr. Burns says,
that antimonials ought never to be given, in this complaint,  to the
extent  of producing  "decided sickness."   I have  witnessed no
evil consequences from nauseating doses of tart, emetic, in the
present disease, but, on  the contrary,  often unequivocal  bene-
fit.   I  have generally made it a point to administer this arti-
cle so as to produce  slight manifestations of nausea; and  I  am
persuaded, that in the early stage of the disease, while the pulse
is active and  the skin hot and  dry, much  advantage will  in
general, result, from this  mode of employing antimony.  As a dia-
phoretic expectorant, the  kermes mineral,  given  according  to
the formula below,t sometimes produce  a very good effect, parti-
cularly when the  cough is dry and harsh.  If after the disease has
been in a great degree subdued,  the cough continues to be very
severe, and the patient is restless,  considerable benefit may some-
times be obtained from the use of small  doses of Dover's powder.
A few  grains  administered, once or  twice daily, usually has the
effect,  of improving the expectoration, allaying the pain and rest-
lessness,  and  exciting the  regular action of the cutaneous ex-
halents.  This article is  particularly useful, during convalescence
from 'this and other  forms of pectoral inflammation, more espe-
cially  when the  pulse is small,  and  irritated and the skin dry.
In the  advanced  stages of the disease, when (although the local
inflammation and  fever, appear to be almost entirely subdued,) the
child is incapable of resting in a recumbent posture, the employ-
ment of  diuretic remedies is sometimes attended  with marked

  * Nitrat. potassae, gii; extract, glycyrrh. 3ii; tart,  antimonii gr.  ii; sacch. albi.
gss; aq.  fontanae giii.   M.  Dose, one or two teaspoonfuls, every hour or two, according
to the age of the patient.
  t Kermes mineralis gr. xv; extract'glycyrrh. 3U; aq. fontanaB giii.;  syrup Scilla
 3ii.  M. Dose, a teaspoonful every two or three hours. 
                        OF PLEURITIS.                    335
benefit.  In cases of this kind there is  often a considerable quan-
tity of serum effused into the cavity of  the pleura, so that the mo-
ment the child is laid  down, with its head low, it becomes agitated
and begins to cough,  pant, and cry.   To promote the absorption
of the effused fluid,  small doses of squill and calomel, ought to be
given three or four times daily, until the child is able to sleep in
a horizontal position.   The fourth of a grain of dried squills with
the same quantity of calomel forms a full dose for a child, of from
one to three years old.  A mixture of the tincture of digitalis and
vinegar of squills, in equal quantities,  may also  be used for this
purpose; and I have known much benefit to result in this respect,
from a mixture of equal portions of the syrup of squills and  the
sweet spirits of nitre, given in doses of from twenty to thirty drops,
three or four times  in the course of a day.   When after the pleu-
ritic symptoms have  been removed, the  child  continues to  be
affected with cough, and a short and uneasy respiration, no reme-
dy has appeared to me so valuable  as the tincture of sanguinaria
Canadensis.  I have rarely known it to fail in removing the pul-
monary irritation in such cases.   From two to four drops may be
given three times daily to a child under three years old. 
336
OF PAROTITIS. MUMPS.
                CHAPTER  XXVIII.

                       AROTITIS.  MUMPS.

  Parotitis  is  a specific inflammatory affection, particularly
liable to be  transferred to the  testes in males and mammae in
females; propagated by a peculiar  contagion,  and occurring
sometimes spasmodically.
  Symptoms.—Slight febrile symptoms generally usher in the
disease, which is first manifested by a feeling of stiffness about
jaws, and a little tumor and pain in one or both parotid glands.
The swelling in the beginning is moveable, but it soon  becomes
widely  diffused, frequently involving the  maxillary glands.   It
gradually increases until the fourth day, when the affected gland
is very firm,  tender and elastic to the  touch.  The skin  over the
tumor retains for the most  part its natural hue, although in some
instances  it is changed to a pale red, and occasionally  a bright
red  color.  The maxillary glands, are sometimes more largely
affected than the parotid.  Mastication and deglutition are in -all
cases attended with considerable pain.  The fever is in general
mild, though the patient is frequently troubled with considerable
restlessness and  nervous irritability.   The inflammation begins  to   ,
decline about the fourth  day, and very rarely tends to  suppura-
tion.  The other inflammatory  symptoms now likewise  subside,
and about the  seventh day from  the  beginning  of  the disease,
detumescence is complete.  Diaphoresis, more  or less  general,
and a red urinary deposition, usually accompany the subsidence
of the affection.
  Metastasis of the disease sometimes occurs upon the decline  of
the  inflammatory symptoms. In females,  the  breasts, and  in
males, the testicles are  apt to become hard, swollen and more  or
less painful  to  the  touch.  This symptom, according  to some
respectable writers, is rather favorable than otherwise;  for some-
times where  it  has  been absent, an exacerbation of the sympto- 
                          OF MUMPS.                      337
 matic fever has taken place, violent cerebral disturbance ensued,
 and  death been the result.  Dr. Hamilton relates several instan-
 ces,  in which, after  considerable  enlargement of the testicles,
 occurring  upon the decline  of  the disease, this organ  wasted
 entirely away, so that the tunica vaginialis became an empty sack.
 Improper exposure to cold, will sometimes cause a sudden transi-
 tion  of the affection to these parts, in which case, if the treat-
 ment be not judicious,  suppuration  may ensue—a very  painful
 event and one that may terminate  fatally.   The same cause
 sometimes occasions a metastasis  of the inflammation to the brain.
 Coma, or furious delirium now  generally  supervenes,  and death
 usually follows in the' course of a  few  hours.   A  case  of this
 kind  came under my notice, where in  less  than  an hour, the
 patient expired in a paroxysm of  convulsions.  We  must not
 forget that a  metastasis of the disease to  the mammas or testes
 is no absolute security against a secondary translation of it to
 the brain.*
   Children and young  persons are  most liable to the  attacks of
 this complaint, its appearance in maturer life being  very uncom-
 mon.   It rarely affects the same individual more than once, resem-
 bling  thus the other acute contagious diseases.   Parotitis, occurring
 in advanced life, shows an aptitude at times to take on a chronic
 form, accompanied by  very serious  symptoms.   This aptitude is
 most  apt  to  occur in  females in whom the menses  are  about
 ceasing, and whose general systems are in some measure deranged.
 Although suppuration is an  uncommon termination in  this com-
 plaint, it may yet under circumstances favoring it, take place.
   With the exception just noted, Parotitis  may be said to be nei-
 ther  a severe  nor dangerous affection—particularly where the
patient avoids exposure to low or variable temperature, and keeps
the affected parts moderately and uniformly warm.

   Treatment.—In  mild  cases, beside attending to  the precau-
tions just mentioned, little more is  necessary than keeping the
bowels open and using gentle diaphoretics.   Sometimes the in-
flammatory  symptoms run  high,  and we should then resort to
 * See history of an Endemic Parotitis, &c.  Edinburgh Med. and Surg. Journ. Vol. 4, 
338                      0F MUMPS.
active antiphlogistic measures.  When the swelling disappears in
the neck and shows itself in the testicles, blisters should be applied
to the parotids, and every effort made to excite a general diapho-
resis.  A mild, cooling regimen is to be enjoined, and where the
pain is extreme and the symptomatic fever severe, we must have
recourse to full purging and sometimes to venesection.  Emetics
have occasionally been productive of much benefit in such cases.
To discuss the hard tumefaction not unfrequently remaining after
the disappearance of the inflammatory symptoms, frictions with
mercurial ointment, spirits of camphor or rubefacient liniments
should be used. 
QUINSY.
339
CHAPTER  XXIX.
        TONSILLITIS.  CYNANCHE TONSILLARIS.  QUINSY.


  Inflammation of the tonsils and fauces, is a frequent complaint,
among  children.    It generally  commences with a  feeling  of
chilliness, accompanied with a huskiness of voice, an uneasy sen-
sation in the fauces, and  a stinging or cutting pain, in this part,
on swallowing.  More or less febrile  reaction  ensues;  and in a
few hours a fixed pain is  experienced in the  region of the tonsils,
and the swallowing becomes  more and more painful, until at last
the action is productive  of extreme anguish.  On examination,
one or  both tonsils are  found  swollen, and  the  whole surface
of the fauces present a tumid and florid aspect.   In some instan-
ces, the  uvula and soft palate,  exhibit a highly oedematous and
dark red appearance.  The  tongue is covered  with  a white fur,
through which the florid  and  enlarged  papillae project;  and over
the whole, a  thick layer of tough transparent slime is spread.
In severe cases, the face becomes flushed and tumid; the carotids
beat strongly; respiration is laborious, hearing obtuse, the pulse
frequent, full,  and  hard,  and  the voice  indistinct or whispering.
In general, the patient swallows soft  or  pultaceous  substances
with more ease and less  suffering,  than liquids.   Severe pains,
usually dart from  the fauces into the ears,—particularly when
the patient attempts to speak or to swallow; and the  mouth  is
opened with great  difficulty and pain.   The breathing is much
obstructed by  the  extremely viscid mucus, which  is so copiously
secreted in the fauces; but in  violent  cases, the principal and
most alarming source  of  difficult respiration  is  the enlargement
of the  tonsils; for when  both are  inflamed, they  sometimes 
     340                        QUINSY.
     become so much  swollen, as to come in contact w tth  each other,
     confining  the uvula behind them, or pressing  it forward into the
     mouth.
       In  some  instances  flakes of coagulable lymph  of a  whitish
     color adhere  to the  inflamed  tonsils,  resembling  superficial
     sloughs.   In cases of this  kind, the inflammation  is  always of a
     vivid red color, and its tendency is either to resolution or suppura-
     tion.  Occasionally, however, the inflammation assumes more of an
     erysipelatous character, the affected parts exhibiting a dark livid,
     and oedematous appearance, with small aphthous ulcers of white
     or grey color on the tonsils and uvula.  Instances  of this kind,
     very  rarely  terminate in  suppuration.
    1   Inflammation in this disease terminates in resolution or  suppur-
     ation,—gangrene hardly ever occurring, although at times a few
     sloughy spots are visible in the fauces.   In no structure is abscess
     more frequently the result of inflammatory action, than  in the
     tonsils.  Internal suppuration will often take place in a few days,
     despite of the most  active local  and general  antiphlogistic mea-
     sures.  The quantity of  matter formed in  a suppurated tonsil is
     seldom abundant: it is not often  very perceptible in the sputa, a
     portion of it undoubtedly  being  commonly swallowed with  the
     saliva.  Occasionally the  abscess has pointed and broken out-
     wardly, under the angle of the jaw.  Dodonasus relates a case, in
     which the patient appeared near death, where prompt relief was
     procured  by an  external incision in the abscess, and the conse-
     quent discharge of a large  quantity of pus.
       This disease is never contagious, and though for  the most part
     violent in its character, it is of short duration.  In some instances,
     the inflammation passes down into the  larynx,  an occurrence that
     always' increases the risk from the affection.  Where  this  disease
     occurs in  the same individual more than once, a predisposition to
     it is apt to be established.  Frequent attacks tend also to occasion
'     permanent enlargement  and induration  of the tonsils.  In cold
     and variable climates, it is  a complaint of frequent  occurrence;
     and although by no means  so dangerous as anginose affections of
     the respiratory passages, it is much more painful, in violent cases
     always alarming, and sometimes fatal.  The young and the san-
     guine are said to be particularly liable to its attacks. 
                           QUINSY.                       341
   Some  individuals are peculiarly predisposed to  this disease.
This, as  before observed, is especially  the  case  with persons,
who have  suffered once or twice  from its invasion.  But other
causes such as the constitutional influence of mercury, salivation
and a  strumous habit of body, appear  to create or constitute a
predisposition to the complaint.
   Cold and damp  air, or cold applied in any manner, so as to give
a sudden check to  the perspiration, is the ordinary exciting cause;
and hence the frequency of its occurrence in spring and autumn,
when vicissitudes and variable temperatures are most common.
Standing or sitting long on cold and damp ground is  particularly
apt to give rise to^the  complaint, in  those who are predispo-
sed to it.
   Treatment.—The treatment of  this affection must, of course,
be strictly antiphlogistic; and, it is of much importance that effi-
cient means be employed as soon as the disease is noticed; for,
even where the onset of the disease is mild, we have no security
that its course will not be marked with extreme violent e.  When
the pulse is full and active, blood ought to be promptly and effi-
ciently drawn.  In children, however, the febrile reaction  is not
often so  vehement in the commencement of the disease,  as  to
require a copious  abstraction of blood;  and  in mild cases the
inflammation  may often be speedily subdued, with counter-irrita-
ting applications, purgatives, warm pediluvium, &c, without the
aid of direct depletion.  Nevertheless, blood-letting, when regu-
lated  according to the state of the  pulse, is  always  a safe and
useful measure, and should never be omitted  when the symptoms
do not readily yield to  other  appropriate means.
   Purgatives are highly beneficial remedies in this affection. An
active purge   should be administered in the commencement  of
the treatment, and, repeated daily, until  the inflammation is sub-
dued, or has terminated in suppuration. For this  purpose we
may use five or six grains of calomel, followed in an hour or two
by a suitable  dose of epsom salts.  I have  known prompt and
decided  relief obtained from  the  use  of the  following emeto-
cathartic  mixture, given  in doses  of from a dessert to a  table
spoonful  every hour, according to the age of the patient,  until
30 
342                        QUINSY.
vomiting and  purging was produced.*  Diaphoretics, also, are
useful  auxiliaries, in the treatment of this affection.   Nitre,  in
union with antimony, forms an excellent remedy for this purpose.
Some  advantage may be gained by causing the patient to  place
the nitre  on his tongue, and swallow  it as it is  gradually dis-
solved in the mouth.  Much benefit may in general  be  derived
from nauseating doses of tartar  emetic.  Of two ounces of water,
holding a grain of tart,  antim. in solution, a teaspoonful  is to  be
taken every  thirty minutes,  so as to keep up  a considerable
degree of nausea for several  hours.  I  have frequently prescri-
bed the  medicine in this way with the happiest results.   The
muriate  of ammonia, dissolved in water,  with  the extract  of
liquorice, has been  particularly recommended, t
   Emetics were once a  good deal employed in tonsillitis, but their
 effects are much less beneficial in this, than in any of the other
 anginose affections.   In infants, however,  they are often highly
 beneficial, by removing the  extremely viscid mucus  which  ad-
 heres to the  palate, tonsils and fauces,  and obstructs respiration.
   Topical bleeding, by scarifying the tonsils, generally produces
 excellent effects.  Kopp  thinks, that blood drawn in this way
 from the tonsils, is the most certain, prompt and efficacious reme-
 dial measure we possess.  The early  application  of leeches to
 the throat or under the ear, although of less value, perhaps, than
 scarification, should by no means  be neglected.   Cupping on  the
 back  of the  neck  and  under  the ears, may, also, be resorted to
 with advantage.
   So soon as the momentum of the circulation has been reduced
 by  venesection, a blister should be applied to the throat, or on
 the back of the neck.  In slight cases of the disease, rubefacients,
 particularly the spirits  of turpentine, or a  liniment composed of
 two parts of aq.  ammoniae to one of sweet oil, will in general
 suffice.   Emollient poultices are also very useful  applications in
 mild cases.  Employed  in the commencement  of the disease,
 together with warm pediluvium and a purgative, the further pro-
 gress of the inflammation, will  sometimes be speedily and effectu-
                    * R Sulph. magnesiaB,......gss.
                        Aq. fontanse,..........gviii.
                        Tart, antimonii,........gr. i.
   I Leoffler.  Beitacgen Zur Arzn.  Wissensch. 1. Th. Leips. 1791, p. 142. 
                           QUINSY.                       343
 ally arrested.  Three  or  four folds of thick flannel  round the
 neck, in such instances, with the auxiliaries just  mentioned, are
 often sufficient to prevent the developement of the malady.   But
 in  every case where  inflammation  is considerable, immediate
 recourse  must be had  to vesication.
   The early use of astringent and acid gargles has been  much
 recommended.  Cullen advises a decoction of oak  bark, with
 alum  dissolved  in  it,  as  a useful  prescription for this purpose.
 For myself, I generally prefer simple  warm* water, acidulated
 with vinegar.   The principal advantage of gargles in this com-
 plaint would  seem  to be that of dissolving and removing  the
 viscid mucus, adherent to the tonsils and palate;  and this is best
 accomplished by warm water, either alone, or  with a portion of
 some vegetable acid, and perhaps honey.  Pringle says, that he
 never derived any benefit from  astringent gargles, and accord-
 ing to Storch,  they have at times been evidently injurious, by
 checking the exhalation and  secretion from the  mucous surface
 of the inflamed  parts.
   The inhalation of certain vapors  by any simple machine, is one
 of the  oldest remedies in this affection.  The vapor of vinegar
 and water was used by Hippocrates.
   If it is  obvious that suppuration  cannot be  prevented,  every
 proper measure should be taken to facilitate this termination.
 The steam of warm water, or of water  impregnated with rose-
 mary  or  chamomile leaves,  should be inhaled,  and astringent
 gargles should at once be discontinued.  When the fluctuation
 and other symptoms indicate the formation of a tonsillar abscess,
 it should  by all  means  be immediately pierced  with a lancet; as
 the discharge of the matter will always give instant relief from
 the pain and difficulty  of  respiration.  After the  operation, the
 patient should continue for a little while, the use of some mild
 and slightly  acidulated or astringent gargle.
  Occasionally, from the  extent and violence of the inflamma-
 tion in tonsillitis, there has been so much danger of suffocation,
 that it has been found necessary to make an opening into the
 trachea; which  has been done sometimes as high as the larynx,
and  sometimes  considerably  lower; and under both kinds of
operation the patient  has recovered.  (Good.) 
344
CROUPv
                  CHAPTER XXX.


         CYNANCHE TRACHEALIS.  TRACHEITIS. CROUP.

   Cynanche trachealis may be defined:  an inflammation in the
glottis, larynx and upper part of  the  trachea, attended with  a
hoarse and ringing cough, sonorous respiration, and a sense of
impending suffocation.
   This form of cynanche does not appear to have been generally
known as a distinct disease, until Home described it in a work
published at Edinburg in 1765.  It is not at all likely, however?
that the disease is one of modern date, since  its ordinary causes
have always existed, and  it cannot be presumed, that at any
period of the world, their influence could  have been  materially
different from what it  is at the present day.   The disease was
confounded, no doubt, with other anginose affections, to  some of
which it bears, indeed,  a very close resemblance  in many of its
prominent  phenomena.
   In the long list of human diseases, there  is none which presents
a  more painful scene of anguish and  distress, or which excites
more poignant feelings of sympathy in the  heart of the physician,
than the one now under consideration.   I have witnessed the ap-
proach of death under a multftude of appalling forms; but in all
the death-bed scenes which it has been my misfortune  to witness,
I have never had  my  feelings so deeply afflicted as when looking
on a blooming  child  struggling under the ruthless grasp of this
terrible  disease.  In  some instances this disease  comes on sud-
denly, and in a very short time acquires the utmost degree of vio-
lence.  More frequently, however, it is gradually developed—a
dry and hoarse cough, attended with slight  difficulty of breathing,
roughness of voice, and some degree of languor  or lassitude, being
the first intimations of its approach.  These symptoms  sometimes
continue /or several days, before the disease is fully developed. 
                            CROUP*                        345
 Sooner or  later, however, the breathing becomes more difficult,
 the febrile irritation  more obvious, the voice more indistinct and
 whispering, and  the cough more hoarse and sonorous.  There is
 something so peculiar in this  hoarsness—such a rough, ringing,
 and dry sound in the cough, as  can  never be mistaken by those
 who have once  heard it—and whoever has once heard it in con-
 nection with the distressing symptoms which characterize the dis-
 ease in its state of  full development, can  never  hear this croupy
 cough, without  the  most  anxious apprehensions.   The  disease
 now advances rapidly, and  in  a short time, acquires the most
 alarming and distressing degree of violence. The  countenance
 is flushed; the eyes prominent, injected and heavy; the pulse fre-
 quent, tense, and quick; the skin dry and hot; and  the respira-
 tion extremely laborious and anxious.   In the commencement of
 the disease  the cough is often quite dry; but in the  majority of
 cases, a very  viscid and thick  mucus  is secreted by  the mucous
 membrane of the fauces and  larynx  from its very  on-set,  and
 which from its spissidity contributes greatly to increase the diffi-
 culty of breathing.   The  sound attending  the respiration, espe-
 cially the act of inspiration, is at first ringing and  rather  clear;
 but in the advanced  period of the disease, it is characterized  by
 a peculiar wheezing, as if the air were forcibly driven through a
 Very narrow aperture. The act of inspiration is always performed
 with much more difficulty, and occupies a much  longer time than
 the expiration of the air.   This latter  act  is, comparatively,
 quick  and always unaccompanied with  the shrill and  wheezing
 sound which attends inspiration.   In the advanced periods of the
 disease, the cough  is in all instances attended  with a rattling
 sound, and the expulsion of  extremely tenacious mucus from the
 trachea.
   If the progress of the disease be not checked, the difficulty of
 breathing increases progressively, until, at last, the oppression be-
 comes inexpressibly distressing.  The countenance  and motions
 of the little patient indicate the utmost degree of anguish and suf-
 fering.  The  head is thrown backwards, and the mouth kept
 open to facilitate respiration; the face is of  a pale livid hue, the
eyes are prominent and  half closed; the lips purple, the muscles
of the face agitated with the respiratory effort; large drops of sweat
                             2  Y              30* 
346                        CROUP.
hangon the temples and upper lip; the extremities become cold and
clammy; partial insensibility ensues; the breathing becomes fee-
ble and interrupted, and the patient finally sinks into a state of
total insensibility, which soon puts a termination to the agonizing
struggle.
   Such are the ordinary course and symptoms of this dangerous
affection.   Much  diversity,  however, Occurs, in relation  to the
degree of violence and  rapidity of these phenomena.   In some
instances, the disease  proceeds very slowly, the child being trou-
bled during the day with some difficulty of breathing and a hoarse
and dry cough, while at night an  alarming paroxysm of croup will
occur, and  continue until towards morning.  In  this way, the
disease will sometimes go on for five or six days;  the patient being
so free from any difficulty of breathing during the day, as to induce
a belief that the disease has been subdued.   At night, however,
another attack will, perhaps, occur, and continue, with unceasing
violence, and in opposition, often, to all our remedial efforts, until
it terminates  in death.   Occasionally the disease  is very gradu-
ally developed, and continued for nine or ten days, without at any
time acquiring a very alarming degree of violence.  In cases of
this kind the patient is  harassed with a very hoarse cough, and
considerable difficulty of breathing,  with occasional  severe  ex-
acerbations of the croupy symptoms, both during the  day and at
night.  There is generally a pretty copious secretion of  mucus in
the trachea  in such cases, and  the  respiration  is usually  con-
stantly attended with a rattling sound in the chest.  These pro-
tracted and remitting cases of croup are most apt to occur during
difficult dentition.
   It would seem,  that in  some instances, the predisposition to
this disease is  congenital; for it is well known, that the children
of some families  are  peculiarly predisposed to  this complaint,
 whilst in  other families,  it never makes its appearance.  It is
manifest, also, that there is something peculiar  to infancy and
childhood, which  increases  the  liability to this affection; for its
occurrence is  vastly more  c'ommon between the  first  and fifth
year of age, than  in  the whole  subsequent period of life.  This
aptitude to the disease during early childhood, has been ascribed
to the  peculiar condition of the  glottis and  larynx, at this age; 
                           CROUP.                        347
fof the existence of some peculiarity in this portion of  the respi-
ratory passages during infancy and childhood, unconnected, pro-
bably, with mere size of aperture, may be inferred from the cha-
racteristic voice at this early period, and  its  remarkable change
at the age  of  puberty.   There  is another  circumstance, how-
ever, which may have a share  in creating  the  aptitude in ques-
tion, and which ha3 reference to the exciting cause of the disease.
The  almost univeral mode of clothing infants—with their necks
and  upper  part of the breast  bare, cannot fail to render them
more subject to the influence  of cold, and the consequences  of
this  cause, in the parts thus exposed.   It is a fact, which has
been  forcibly pressed on  my  attention, that in the  country—
especially among  J;he  Germans, who are  in the habit of cloth-
ing their children in such a manner as to leave no part of the
breast and  lower portion  of  the neck  exposed,  cynanche  tra-
chealis  is an exceedingly  rare disease.   Whereas, in cities, or
among  people  who adopt  the  modes of dress  common in cities,
this  frightful disease is, in proportion  to  the  population, vastly
more frequent.   During a practice of six  years among this class
of people, I recollect of having met  with but  a  single case of
this  affection,  and this  case  occurred  in  a  family, who had
adopted the present universal  mode of suffering the  necks and
superior portions of  the breasts to remain uncovered.  Certain
exanthematous affections, also,  sometimes give rise to an increased
aptitude for this  disease.   This is especially the case  with scar-
latina, measles,  and miliary fever.  Children of robust  and full
habits, appear to be much  more liable to  the disease than those
who are feeble, relaxed, and sickly.
   Cold  and sudden vicissitudes of  atmospheric temperature,
constitute  the  principal  exciting  causes  of this  disease; and
hence its  more frequent occurrence  during the variable  damp
and cold months of autumn and spring, than in the more tempe-
rate  and uniform season of summer. Sitting  or lying down on a
damp grass plat, or in a current of air after the body has been
over-heated by  exercise in the sun, is particularly apt to bring on
an attack of this complaint.  It has been  observed  also, that in
situations naturally abounding in moisture,  cynanche trachealis is
a much  more common disease, than in localities of an opposite 
348                         CROUP.
character.   Under the head of occasional causes may be noticed
also,  the  habit to  which I have  already adverted;  namely,
that  of  suffering the  necks  and  upper  part  of the  breasts
of children to  remain freely exposed to the air.   I  have more
than  once  known  this disease produced, by  children throwing off
the bed coverings at night, "when asleep and in a state of free per-
spiration from the warmth of the bed.  In  general this disease is
most apt to occur soon after,  or  during the  prevalence of epi-
demic, catarrh, measles or scarlatina.  During convalescence
from the two latter of these affections, there exists, often, an es-
pecial aptitude to cynanche from the influence of cold.   It would
seem, also, that the predisposition to this disease is much increased
by having suffered an attack of it; I have  known  the same indi-
vidual, suffer five or six attacks of this disease during the period
 of childhood.
   Cynanche  trachealis, is a phlegmasial affection,  consisting es-
 sentially, of inflammation of the mucous membrane of the supe-
 rior  portion  of the respiratory tube.  The correctness of this
 pathology is confirmed, not only by the known character of its
 most common exciting cause, but especially, also, by the more di-
 rect evidence  of the symptoms of the disease,  and the appear-
 ances on  post-mortem examination.  Unequivocal  signs of pre-
 vious inflammation are invariably discovered in the larynx and
 trachea on dissection.  It  is indeed surprising, that this disease
 should still be viewed by some of the German and French patho-
 logists, as essentially spasmodic in  its nature, and wholly indepen-
 dent either of a general or local inflammatory condition.  "Several
 of the late continental  writers on this disease, regard the fever
 and  inflammation, which they acknowledge sometimes to exist, as
 wholly accidental,  and as  in no manner essential  to  the perfect
 constitution of the malady.   Professor Nasse  regards impaired or
 disordered functions of the  pneumo-gastric nerves, as  the proxi-
 mate cause of this disease.  The  characteristic symptoms of the
 disease, he asserts, bear  a strong resemblance to those which re-
 sult from the division of the eighth pair of nerves.  The inflam-
 mation which occurs in the mucous  membrane of the trachea, is,
 according to  his view, secondary, and a consequence of the dis-
 ordered function  ol the pneumo-gastric nerves. 
                            CROUP.                        349
   There are  two varieties  of inflammatory croup.  In one the
 inflammation  commences in the  fauces, and afterwards descends
 into the larynx and trachea.  In cases of this kind, the breathing
 is, at first, but little affected, but the cough has a peculiarly rough
 and hoarse sound.  On inspecting the  fauces, the tonsils, uvula
 and palate present a swollen and dark red appearance; and the
 child  always complains of considerable difficulty  and pain in
 swallowing.   In the other, and most common variety of the com-
 plaint, the inflammation commences in the larynx or trachea, the
 fauces remaining entirely free from redness and swelling.  The pa-
 tient experiences no pain in swallowing, and the respiration is much
 oppressed from the  commencement of the disease.   The former
 variety is, generally, much slower in its progress than the latter,—
 the hoarse cough and occasional  spells of difficult breathing, con-
 tinuing sometimes for four or five days, before the symptoms ac-
 quire a very alarming degree of violence.
   The inflammation which occasions the characteristic phenomena
 of the disease, does not always remain confined to the larynx and
 trachea.  In some instances  it extends downwards into the bron-
 chia, and sometimes even into the smallest  ramifications.   This
 extension of the inflammation is  always attended with the utmost
 degree  of  danger;  and when it passes  down into  the extreme
 bronchial tubes, the  result, indeed, must almost  inevitably  be
 fatal.  In cases  of this kind death usually takes  place from effu-
 sion into the air cells.
  In many instances the viscid albumenoid  fluid, which is so co-
 piously secreted  by the inflamed lining membrane of the larynx
 and trachea, concretes, over the internal surface of these passages
 into a sort of membrane; and to this membraneous substance many
 of the  latter  and fatal phenomena  of the  disease are usually
 ascribed.   It must not be supposed, however, that such a pseudo-
 membrane  is formed in all fatal cases;  nay, it  is quite certain,
 that it does not occur, even in the majority of cases.
  In other instances, the inflammation instead of giving rise to a
 concrete membraneous substance, terminates in the secretion of a
 muco-purulent fluid,  of an  opake and  yellowish  appearance.
There  are  other cases again, and these are probably, the  most
common, in which the inflammation produces neither false mem- 
350                        CROUP.
brane nor a puruloid matter,  but an extremely copious secretion
of a very viscid, transparent and frothy mucus.   Blaud thinks that
these different modes of termination, constitute good grounds for
dividing the disease into three principle varieties, indicating three
different grades of inflammation.  It is  not  improbable  indeed,
that the inflammation is at its highest grade of violence in those
cases which are attended with the formation of a false membrane.
It would appear to be less intense, when, instead of this coagula-
ble exsudation, there is only a muco-purulent secretion formed;
and where the secretion consists, simply of tough, transparent and
frothy mucus, the inflammation is  doubtless at its lowest grade.
In the first and  most  aggravated  variety  of the disease, the
cough and respiration are dry or free from that  peculiar  rattling
sound in the respiratory passages, which occurs when  these  con-
tain viscid secretions.   In cases of this kind, the patient generally
experiences considerable pain in the larynx, and the fever is usual-
ly  very strong.   The period at which the false membrane  is
formed, after the commencement of the  inflammation, appears to
vary considerably.   M. Blaud states that he has found the larynx
and trachea lined  with pseudo-membraneous  matter, in cases
whose whole  course did not occupy more  than twenty  hours;
whilst in other instances several days appeared to elapse before it
was formed.   Occasionally only a part of the internal surface of
larynx is found lined with this concretion; but in some cases  it
extends down into the bronchia, and even into the smaller ramifi-
cations.  Sometimes instead of  a  membraneous expansion,  the
upper part of the trachea is found almost entirely blocked up with
a thick mass of concreted albumenoid secretion;  and this  is gen-
erally located just within the glottis.  I  have seen an instance of
this kind, in which the opening left through this concreted mass
would hardly admit a crow's quill.
   When the cough and respiration become  humid or rattling,
as soon as  the inflammation  is developed,  we  may  infer that
there will be no  membraneous concretion formed.  Mr. Blaud
thinks, that  the viscid  mucus which is   so copiously secreted in
these milder cases, is  entirely different in its properties, from the
secretion which occurs in  the former  variety—and  that it is
incapable of being so inspissated as to  give rise to a  membra- 
                           CROUP.                        351
neons concrete.   In the^e cases,  the  mucus in the larynx  and
trachea is  often  so  abundant,  as to  threaten  suffocation by
obstructing the glottis.
  Whatever may be thought of M. Blaud's  division of this dis-
ease,  or of his sentiments in  relation to the radical distinction
between the inflammation and secretion which give rise to mem-
braneous structures, and that inflammation and  its consequent
mucous secretion which  occurs  in cases  unattended with  the
formation of false membrane, it must be admitted that there ex-
ists at least a two fold  diversity in  relation to the immediate
local  consequences of the laryngotracheal inflammation—name-
ly,  one variety  in which false membrane is formed,  and  in
which the cough and respiration  are  at  first dry, or do not indi-
cate  the  existence of much mucus in the respiratory passages;
and another variety in which the cough and respiration are hu-
mid, in the  early period  as well  as throughout the disease,  and
in which a very  copious secretion of  transparent and  extremely
viscid mucus occurs.   The  former are  exceedingly  dangerous,
nay,  almost hopeless,  unless subdued by the most prompt and
powerful  antiphlogistic  measures  in their very onset.  The lat-
ter are much less dangerous, and may  generally be  cured by
more  moderate  antiphlogistic  measures, and  the expulsion  from
time to time of the tenacious mucus from the larynx and trachea.
In nearly all cases  the  mucous membrane  of the larynx  and
trachea is found very conspicuously injected on dissection; and in
those who die under  the conjoined symptoms of bronchitis  and
tracheitis, traces of inflammation present  themselves, throughout
the whole extent of the bronchial ramifications, and in some in-
stances, the substance of the lungs is infiltrated with serum,  and
the air cells  are  choked up with viscid mucus.  In the majority
of cases,  the glottis is  narrowed by a  kind of thickening or
tumefaction of its lips.
   Considerable  diversity  of  opinion  has  been  expressed as to
the immediate cause of  the distressing difficulty  of breathing
and of death in this disease.   In relation to the latter, it is mani-
fest, that  an impediment to the  intromission  of atmospheric air
into the lungs, is the immediate  cause of death, and that, there-
fore, death  occurs in  this disease, from asphyxia.  The circum- 
852                        croup.
stances which  cause the exclusion  of the air from the  lung9,
consist either in a  spasmodic closure of the glottis, or  in an
occlusion  of this aperture by tumefaction of its sides, or  by the
formation of false membrane  or a mass of concreted lymph, or
finally by an excessive quantity  of a very ropy and viscid mucus
closing up the passage.  Death  is also sometimes the immediate
consequence of an effusion into, and consequent choking up of the
bronchial cells,  a  mode of  termination  which almost   always
occurs  when the  inflammation  descends into the bronchial ram-
ifications.
   Spasmodic contractions of  the glottis may be excited  by the
irritation of the  concreted  membraneous  lymph,  immediately
within this  aperture.  It is a remarkable  circumstance that the
difficulty of drawing the air into  the lungs  is  always much
greater, and attended with much more  sound  than  that which
accompanies expiration or the act of  throwing the air out from
the lungs.   This cannot be explained, as some  have attempted,
by supposing that the portion of the false membrane nearest the
glottis  becomes  separated from the  sides  of the trachea,  and
that, consequently, more difficulty and noise is produced   during
inspiration,  on account of a portion of the inspired  current of
air  being forced in  between the detached membrane and the
surface of the larynx, whereby the ingress of the external  air
is impeded; whilst  in the  act  of expiring the air, the detached
extremity of the membrane  would be pressed outwards  against
the  sides of the  treachea, and offer, therefore  no particular
impediment to the outward current of air.
   That such consequences  might follow the  separation  of the
superior  portion  of  the  membrane, immediately   within the
glottis, cannot be doubted; but when it is observed that the same
relative  increased difficulty of the  inspiration is present, in all
instances, from the very  commencement of the disease, and before
any  membraneous concretions can  be formed, we are forced to
admit that,  the circumstance  in question, depends on some other
morbid condition of  the parts, implicated in  the disease.
   The solution of this problem  must I think be sought for in the
altered sensibility of the glottis and  trachea, in consequence of
which the contact of the atmospheric air, produces an irritation 
                           CROUP.                        353   *
which excites  spasmodic contraction  in the glottis.   It is  well
known how greatly the vital properties are altered by inflamma-
tion.   In drawing the external air  into  the trachea, it irritates
the mucous  membrane, and excites the glottis,to contraction, by
which the  ingress of the air is retarded,  and  the  difficulty  in
question produced.   This is entirely analogous  to  what occurs
in other organs when in a state of inflammation, from the impres
sion of their appropriate stimuli.   Thus light  to a  healthy eye,
is any  thing but disagreeable; yet when this organ is inflamed,
even a moderate degree of light, gives rise  to pain,  and  an
involuntary contraction,  or closing of the eye-lids.   When the
urethra or the neck of the bladder is inflamed, the contact of the
urine often excites so much spasm of this canal, as to prevent the
discharge of this secretion altogether.  In a similar  manner
therefore, we may conceive, is  the increased  difficulty of inspira-
tion produced in this affection.  1 wish to be understood, however
as referring here  only to the  comparative difference of  the acts
of inspiration and  expiration, for the dyspnoea taken  as a general
symptom, is undoubtedly mainly dependent on the circumstances
already mentioned—namely, tumefaction—viscid mucus adhering
to the  glottis,  and  in  the  advanced  stages  concreted pseudo-
membraneous substances diminishing the calibre of the  respira-
tory tubes; and finally effused lymph or  mucus into the bronchial
cells.   During expiration, the  air ceases to irritate the glottis in
consequence of its more elevated temperature, which is  now on
a level  with that of  the inflamed  organ; and probably also, in a
degree, in consequence of the carbonic acid which it  contains
and which is well known to be  a very considerable sedative to
irritable parts.

   Prognosis.—Cynanche trachealis is  always to be regarded as a
very dangerous  affection.  Formerly the majority of  cases ter-
minated fatally; but under the present improved pathology and
mode of treatment the mortality  from this disease is greatly di-
minished.  When early attended to, this complaint is,  indeed, as
much  under the control of vigorous antiphlogistic measures, as
any of the more serious phlegmasial affections.    In  general, the
obstinacy and dangerousness of the disease,  is proportionate to
                             2 Z             31 
354                        CROUP.
the intensity of the inflammation,  and the  extent to which  it
passes downwards into the lungs.  When  the fever and croupy
symptoms come on suddenly, the danger is, usually, much greater,
than where the disease is slowly developed.   A sudden attack with-
out fever, however,is not,in general, attended with peculiardangcr;
for  in  this case, the  affection  is, probably, purely spasmodic—a
form  of croup much  more manageable  than inflammatory or
febrile cynanche.   The shriller and more sonorous the cough is,
the more reason is  there to apprehend danger.  The prognosis
in this affection is, often, extremely uncertain.   Sometimes, when
the symptoms appear to be in a great degree subdued, and every
thing promises a speedy recovery, a violent exacerbation will sud-
denly supervene, and destroy the patient.   On the other hand,
death may appear to  be impending, when, on the sudden expul-
sion of a membrane, or even without such  an occurrence, a rapid
change for the better will ensue, and lead on to full convalescence.

  Diagnosis.—There is a  disease which, in most of its prominent
symptoms, bears  so close  a resemblance to tracheitis, that  many
have been induced to regard it as the  same affection,  or at most
as only a modification of the disease now under consideration.  I
allude to the acute asthma of Miller, or the  disease  which by some
pathologists is denominated, and with perfect propriety, spasmodic
croup.   Although attended with the same extreme difficulty of
breathing  and sense of impending suffocation which belong to
inflammatory croup, spasmodic  croup is essentially distinct in its
pathological  character from the former disease,  and of course
requires a mode of  treatment correspondingly  modified.   An
attention to  the following circumstances will  enable us to distin-
guish these two forms of croup from each other.
  1. The approach of cynanche trachealis is generally gradual, and
preceded by  the usual train of precursory symptoms, which usher
in catarrhal affections.  Spasmodic croup, on the contrary, almost
always comes on suddenly, and is rarely preceded by the ordinary
premonitory  symptoms of catarrh.  It  is  true, indeed, that in
some instances, cynanche  trachealis also,  supervenes  quite sud-
denly; but when this is the case, it  is always so manifestly of an
inflammatory character, and is attended with so much fever, that 
                           croup.                        355
 there can be no difficulty in distinguishing it from the spasmodic.
 variety of the disease.
   2. Cynanche trachealis is essentially a febrile disease—the phe-
 nomena of fever being never absent.   Spasmodic croup, on the
 contrary, is entirely free from fever, except it be present, as an
 accidental occurrence.  In the former, the urine is almost, inva-
 riably, high-colored and scanty: whereas, in the  latter  affection,
 it is usually pale, watery and often copious.
   3. Cynanche  trachealis  is  often  attended  with  considerable
 remissions; but  these  are  generally of very short  duration and
 incomplete.   Entire intermissions, except immediately after vom-
 iting, or on the approach of syncope from bleeding, never occur.
 In spasmodic croup, the intermissions are often complete and pro-
 tracted; and this circumstance,  perhaps more than any other,
 characterizes this form of croup.
   4. Cynanche  is  always attended with a peculiar hoarse and
 sonorous cough, and frequently with a copious secretion of viscid
 mucus in the trachea. Spasmodic croup is rarely associated with
 much cough, often none at all, and it is always dry.
   5. The peculiar ringing sound of the cough and inspiration, so
 characteristic of cynanche trachealis, does not occur in the spas-
 modic form of the disease.
   6. In cynanche trachealis the pulse is generally frequent, full,
 quick and tense, and the skin is hot, except towards the fatal termi-
 nation of the disease, when from the imperfect performance  of the
 respiratory function, animal heat ceases to be generated with due
 rapidity, in consequence of which the extremities and surface gen-
 erally, became cool or cold.  In  spasmodic croup, on the other,
 hand, the pulse is small, very frequent  and feeble, and  the skin
 not above the natural temperature.
   Dr.  Rush  has given an account of a post-mortem  examination
 of a child, that had died of spasmodic croup.  In this subject, no
 membrane, nor even any unusual quantity of mucus, was found in
 the respiratory passages; and the  trachea as well as the  lungs ex-
hibited a perfectly healthy  appearance.  It is, indeed, sufficiently
ascertained,  that cases of a purely  spasmodic character occur,
which in the extreme difficulty of breathing and other phenomena,
bear a  strong resemblance to cynanche trachealis.  This form of 
356                         CROUP.
the disease is evidently of the nature of spasmodic  asthma, and
appears to depend on cerebral or dental irritation, by which the
functions of the respiratory nerves are thrown into disorder.

   Treatment.—The  principal objects to be kept in  view,  in the
treatment of this affection, arc: to  subdue the local and general
inflammatory irritation;  and to  promote  the discharge of the
viscid and concrescible secretions, which are lodged within the su-
perior portions of the respiratory tube.  Fortunately the remedies
which are found  most efficient, in the accomplishment of the lat-
ter object, are also  among  the most useful auxiliaries for the re-
duction of the febrile excitement and local inflammation.  With-
out doubt, however, the remedy upon which our principal reliance
should be placed, for the removal of the tracheal inflammation is
blood-letting.  In the whole catalogue of inflammatory affections,
there is no disease, in which bleeding when promptly and efficient-
ly practised, is more likely to prove beneficial, than in the one now
 under consideration.  He who, in  violent cases, neglects this im-
 portant measure, and places his hopes on one or more of the em-
 pirical remedies, that  have, by different practitioners, been ex-
 tolled for their supposed specific tendency to counteract the trache-
al affection, will, we may be assured have but  little reason  to
flatter himself for his success in the management of this malady.
 Here, however, as in most of the other phlegmasial diseases, the
 beneficial effects of bleeding, are limited to the early period of
 the  complaint.  If bleeding be  neglected, or inefficiently em-
 ployed in the first  stage of the malady, its progress will  be ex-
 tremely  perilous,  whatever other remedial  measures  may be
 adopted.  When called to a patient labouring under a severe at-
 tack of this  disease, a  vein should  be  immediately  opened, and
the blood suffered to flow until a very decided impression is made
on the pulse, or until an  approach  to syncope is induced.   When
blood is thus efficiently drawn, all the distressing symptoms usually
 subside for a time;  and in some instances this first blow at the dis-
 ease, subdues its strength so far, as to prevent it from  afterwards
 recovering any alarming degree of violence.  More frequently,
 however, the fever  and difficulty of breathing, rise again  in the
 course of an hour or two, and when this happens, and the pulse 
                           CROUP.                       357
 >e not soft and weak, more  blood should be drawn, and again to
the extent of producing a very obvious impression on the circula-
tion and general system.  I have been obliged to open a vein three
or four times in the course of the first twelve hours, before a per-
manent and decisive impression was made on the febrile and in-
flammatory symptoms.  My  usual mode of bleeding in this disease,
is to have the patient supported in a sitting posture, with his feet
immersed in warm water, whilst a vein is opened in the arm.   In
this way syncope will be induced much more readily, than when
the patient remains in a recumbent posture during the operation.
Nothing tends so powerfully and promptly to arrest  the progress
of inflammation as  partial syncope  induced by  blood-letting.
During this state the momentum of the circulation is greatly dimin-
ished, and a general relaxation of the cutaneous exhalents ensues;
effects which have a direct  and  powerful influence, in reducing
the inflammatory condition of the system.
  Such copious depletion is, however, demanded  only in cases
where the local and general  inflammatory action  is strong;  where
the pulse is active, firm, quick or tense, attended with a dry and
sonorous cough and respiration.  Cases of this kind, are apt  to
terminate in the formation of pseudo-membraneous concretions in
the larynx, and our efforts ought to be prompt and vigorous to re-
duce the inflammation below the grade  necessary for the forma-
tion of  false  membrane.   After  the effusion  which gives  rise to
these concretions has taken place, bleeding will afford but very little
or no advantage.   Where the febrile symptoms are moderate,
and the pulse is free from tension and  hardness, and  especially
where in connection with moderate febrile irritation, the cough and
respiration are accompanied with a copious transparent, and viscid mu-
cus, blood-letting need very  rarely be  carried to the extent that
has just been mentioned; and may even, in mild instances, be
wholly dispensed with.
  Next in importance to  prompt and decisive blood-letting are
emetics.  They are, indeed,  altogether indispensable in managing
this formidable malady, and, when assisted by warm pediluvium,
rubefacients to the throat, and mercurial purgatives, they will of-
ten subdue mild attacks of the disease, without the  aid of direct
depletion.   When the febrile excitement is strong, however, and
                                              31*   , 
358                        CROUP.
the breathing is very difficult,with a turgid and flushed appearance
of the face, it would be  highly imprudent to rely on emetics and
their usual auxiliary remedies, without prompt and decisive vene-
section.   Nevertheless, even where bleeding may be regarded a9
our main stay, emetics are highly useful, and ought always to be
employed concomitantly with venesection.   They are especially
beneficial wrhen the disease is early attended with a copious secre-
tion of viscid mucus  in the larynx and trachea.   Much of the
difficulty of breathing in cases of this kind,  depends on this vis-
cid  secretion, obstructing the  entrance  of  the air into the lungs.
The occasional expulsion of this glutinous fluid  from the trachea,
by the operation of an  emetic, not only greatly relieves the dis-
tressing difficulty of  breathing and sense of suffocation, but con-
 tributes also  to obviate  the formation of false membrane, by pre-
 venting the accumulation and removal of the coagulable secretion
 in the trachea.  They tend moreover, to equalize the circulation
 and to promote the cutaneous exhalation,  as well as to  diminish
 the general arterial excitement by the nausea which precedes and
 accompanies their operation.   When the cough and  respiration
 are dry, as they commonly are, during the first stage of highly in-
 flammatory cases, we seldom derive  decided  advantage  from the
 operation of  an emetic, so long as this dryness  of the larynx ana
 trachea continues.  In such cases the proper period for adminis-
 tering emetics, commences with the appearance  of the viscid secre-
 tions in the respiratory passages.   Without doubt, from the general
 antiphlogistic tendency of nausea and emesis,  some benefit may
 result from the employment of emetics, before  any  morbid secre-
 tions occur in the trachea;  but the peculiar usefulness of this class
 of remedies, is always most conspicuously displayed when the up-
 per portion of the wind pipe is clogged with viscid  mucus.
    In the commencement of the disease, there  seldom exists any
 difficulty in  procuring free vomiting;  but after the disease has
 continued for some time, or even in the beginning when the re-
 spiration is extremely oppressed, there exists,  often, so much in-
 sensibility of the stomach, in consequence of the imperfect decar-
  bonization of the blood, and the sanguineous congestion in the
  brain, that great difficulty is experienced in  procuring the opera- 
                             CROUP.                       359
 ion of emetics.  To remove this gastric torpor and procure vomit-
 ..ng, we must endeavour to  diminish the congestion  in the brain;
 and this may, in general, be readily accomplished, by putting the
 patient's feet in warm water, and applying a napkin wet with cold
 water, to  the head.  The  abstraction  of blood, also, while the
 patient  is  supported in a sitting or erect posture, rarely fails to
 restore  the sensibility of the stomach  and  to ensure the prompt
 operation of emetics.
   The articles I prefer, as an emetic in  this disease, are  calomel
 in union with tartar emetic.  I commonly administer  from five
 to six  grains of the  former article  with one fourth of a grain of
 the  latter,  to a child  of two to five  years old.  This may be
 repeated every fifteen minutes until vomiting is excited.  I have
 frequently given  from   eight to ten grains of calomel alone, and
 have generally found it to excite active  vomiting in a very short
 time.   The peculiar advantages,  which appear  to me to attend
 this practice, are the protracted nausea, which the  calomel pro-
 duces, an effect  which  has  a powerful  antiphlogistic tendency:
 and the alvine evacuations which  almost always  speedily ensue.
 Besides these effects,  benefit may  also  be expected  from the
 early constitutional influence  of the calomel—an influence which
 in the  present disease especially is very generally acknowledged
 to be  highly salutary.   Tartar emetic, ipecacuanna, sulphate of
 zinc, squills, and  the sulphate of copper, have  all been used and
 recommended in this affection; and where the object is merely to
 procure the expulsion of the tracheal  mucus,  or perhaps pseudo-
 membraneous matter, any of these articles may answer our pur-
 pose.  1 have in some cases administered the lobelia inflata with
 a view to its emetic operation with the happiest effect.   From its
 well known  powerful  influence  on the respiratory  functions in
 asthma, independent of its emetic effects, there is reason for pre-
 suming that, in  relation to  the  present  disease, it may  possess
 peculiar  virtues, and my limited experience with it, inclines me
 to this  opinion.   When the stomach is very torpid,  and there is
 urgent necessity for  procuring  the immediate  expulsion  of the
viscid secretions from the trachea, the sulphate  of zinc,  will fn
general answer better than any other article of this  kind.  The
following mixture is strongly  recommended by M. Jadelot as an 
360                         CROUP.
emetic, in this affection.*   In mild cases, a  mixture of two parts
of the syrup of squills, and one part of antimonial wine, <{iven in
tea spoonful doses every fifteen minutes, until vomiting is produc-
ed, frequently procures speedy relief.   The common hive syrup
of the shops, is also an excellent preparation  for this  purpose.
In some instances when the accumulation of the viscid secretions
is very rapid, it becomes necessary to repeat the emetic three,
four or five times in the course of twenty four hours.
   Purgatives are useful  auxiliary  remedies in the treatment  of
the disease.  In the commencement of the treatment the bowels
should be  freely evacuated,  by an  active purgative.  After this
has  been effected, it will be  best to employ the  gentlest articles
of this class of remedies, so as  to procure  two or three  evacua-
tions daily,  until the inflammation is subdued.  Very  active
purging throughout the course of  the disease, tends to exhaust the
powers of  the  system, without  affording  any  peculiar benefit,
over milder aperients.  After the  first cathartic, it will in general
be sufficient to  keep  the bowels  in  a loose state  by laxative
enemata.

   Calomel, given with a view to its constitutional  influence, has
"been  generally regarded as  a  highly valuable remedy in this
affection.   The late Dr. Rush placed  great reliance on its pow-
ers in croup.  When given in large doses in  the commencement
of the disease and continued  afterwards  in small  doses, " the
Peruvian Bark," he affirms, " is hardly  a more  certain remedy
in intermittents than calomel in  croup."  Dr. Hosack, also speaks
very favorably of the employment of this article in  conjunction
with James' powder, given at short intervals, during the second
stage  of the complaint;  and the  late Dr.  Bard  placed much
reliance  on  its powers.   That the constitutional influence  of
mercury is calculated to do good  in cynanche trachealis, I am
well persuaded from my own experience.  It tends to reduce the

            * K. Infus. polygate Seneg. giv.
                 Syrup. Ipecac.  . •  • 3'-
                 Oxymil. Scillse  .  .   3iii.
                 Antimon. Tart. .  .  gr. ss.
      M. Take a table spoonful every 15 minutes until vomiting fa excited. 
                           CROUP.                       361
local laryngo-tracheal inflammation, and to counteract, as it would
appear, the formation of the pseudo-membraneous  concretion.
In the  more acute and rapid cases, however, many of which run
to a fatal termination in less than twenty four hours, the constitu-
tional operation of this remedy is much  too slow to afford any
particular  advantages.   Where  on  the contrary the disease  is
protracted in its course, or assumes somewhat of a chronic  char-
acter,  great benefit  may  unquestionably be derived from this
potent remedy.  My usual mode of giving calomel, after the first
or second emetic, is  to exhibit one grain every hour or two, with
about one fourth of a grain of ipecacuanna.
   Among the  remedies that may be usefully employed  for the
reduction of the tracheal  inflammation,  the warm bath  deserves
to  be particularly mentioned.   Used along  with the remedies
already  mentioned, its benefits  are often  considerable,  more
especially when the skin is  very dry  and  harsh.  It  is to  be
observed, however, that its  usefulness  is. in a.great measure,
confined to the early period  of the disease;  for in the advanced
stages of violent or unsubdued cases,  the pulse is not only weak
and very frequent,  but the surface  is generally bathed  with a
profuse and  cold perspiration.  Under these circumstances,  no
advantage but rather injury, would result from the relaxing  in-
fluence of the warm bath.
   Rubefacients and blisters are important remedies in the treat-
ment of this affection.   As soon as blood has been drawn, some
irritating liniment, or a blister, ought to be applied to the  throat
of the patient. In general, the spirits of turpentine answer better
for .this purpose than any other rubefacient we possess. Its action
on the skin is very  prompt and  powerful; and if the derivative
powers of such applications be proportionate to  the degree  of
irritation and pain they produce, few articles  can equal  the pre-
 sent one in this respect.   A piece of flannel may be imbued with
the turpentine and applied round the neck. Children seldom hear
this application more than twenty or thirty minutes at a time.  It
should therefore be removed  and reapplied, from  time to time,
according to the violence and permanency of its effects upon the
ekin.  The oil of  the monarda punctata, with an equal proportion
                           '  3A 
362                        CR0UP-
of camphorated liniment, forms, also, an  excellent rubefacient in
this affection.
   Judging from my own experience, I am induced  to prefer the
employment of rubefacients to that of epispastics.   The former
have always appeared to me to do as  much  good as  the  latter,
and they possess the great advantage of acting with great promp-
titude—a circumstance of  no small consideration  in  a disease
which often runs its fatal course in a few hours. A blister requires
 four or five hours before its effects  on  the skin can be of any par-
 ticular avail;  whereas  the impressions of some of  the essential
 oils  are  almost  instantaneous.  Nevertheless, where the disease
 proceeds  slowly, blistering will be highly beneficial, and should
 not be neglected.
    Local bleeding, by leeching,  does not appear to  make obvious
 impression on the tracheal inflammation;  and it is now seldom if
 ever resorted  to, except where the disease is attended with inflam-
 mation and swelling with the tonsils and palate.   In one instance,
 in a child about six years old, I have  known cupping on the back
 of the neck to procure manifest relief;  but this  case,  was asso-
 ciated with conspicuous inflammation in the fauces.
    Formerly, the root of the polygala senega was held in high esti-
 mation as a remedy in this disease; and it is unquestionably a very
 useful medicine in certain states of the disease, although, most as-
 suredly, far from possessing the powers which were at first ascrib-
  ed  to it by Archer and others.  In  the  commencement  of the
  complaint—more  especially in violent cases, this article is objec-
  tionable on  account  of its stimulating properties; but after the
  general and local inflammatory irritation has been to a considera-
  ble degree subdued, or the disease has lost its acute character,  or
  assumed a chronic form, it is often  highly beneficial.  When a
  dry and hoarse cough, with slight difficulty of breathing remains,
  after  the inflammation has been subdued,  the  polygala  will  in
  general prove more useful than any other remedy we possess.   In
  all  chronic croupy affections, and in  the catarrhal  sequela of this
  and other accute affections  of the respiratory organs, it is a rem-
  edy of very excellent powers.  It should be  given in  decoction.
  An ounce of the root to a pint of boiling water, simmered down
  to about three, gills and sweetened with  honey forms  a  suitable 
                           CROUP.                        363
preparation.   From one to two or three  tea spoonfuls of this de-
coction should be given every hour or two, according to the age
of the patient and the urgency of the symptoms.
   The hepar sulphuris (deuto-sulfure of potassium) was introduced
to the nojtice of the profession, as a remedy in this disease, about
twenty years ago, in a prize  essay on cynanche trachealis, pre-
sented to the French Ecole de Medicine.*  Its  introduction was
founded on the erroneous doctrine that croup consists essentially in
a morbid coagulability of the  tracheal mucus, and  which, it was
asserted the sulphuret of  potash  had the power of  preventing or
correcting.   It need, scarcely, be observed, however, that a rem-
edy, which might possess such a power, without, at the same time
exerting any influence in  subduing the inflammation, could afford
but  little advantage in this affection; and the result of later  ex-
perience goes to show that this,  at  first highly  lauded  remedy,
exerts no obvious  influence over  the  tracheal inflammation—and
it is accordingly, now, very properly, universally abandoned.
   When called to a patient labouring under this disease the fauces
should be carefully inspected.   It is now well ascertained that  the
albumenoid exudation  which forms the false membrane,  often
commences  on the surface of the  inflamed tonsils,  and thence
spreads along the  arches of the palate,  and at last  descends into
larynx  and  trachea.   In such cases the fauces will be found
tumefied and of a dark red colour, and whether there be any  ap-
pearance of  false  membrane or not, immediate attention should
be paid to this inflammation.  Dr. Mackensie, states that the  ap-
plication of a solution of the nitrate of silver, to the tonsils and soft
palate, will, in such cases, often remove the membraneous crust
completely, and procure  speedy  and great relief, and ultimately
an entire removal of all the dangerous symptoms.  " The solution
which I employ," says Dr. Mackensie, "is a scruple of the nitrate
of silver in an ounce of distilled  water.  By means  of a large
camel hair pencil, this solution is to be  freely applied,  once,  or
twice a day according to the severity of the symptoms, to the
whole lining  membranes of the fauces.   The surface of the ton-
sils, or wherever else the fibrinous crust is actually in view will of
  * Rapport sur les ouvrages envoyees. au  'concurs, sur le croup, par la commission
chargee de l'examen et du jugement de ces ouvrages.  Paris, 1812. 
364                        croup.
course be particularly attended to; but I do not hesitate to push
the pencil to the lower part of the pharynx.   This remedy so far
frcm being productive of any irritation beyond the mere mechani-
cal and temporary one attending its employment, uniformly alle-
viates the symptoms  of the croup, such as the difficult respira-
tion,  the barking cough, and  the  peculiar anxiety of the little
patient."
   In  one instance which came under my notice, this application
was decidedly beneficial.  Laennec has published an account of
some cases from which it appears that insufflation  of very finely
powdered  alum, generally affords speedy relief, not  only  in this
variety of the disease, but also in cynanche  laryngea and tonsil-
laris.  I have recently prescribed  in a case  of this  kind, in
which I derived unequivocal advantage from this remedy.   Four
or five grains of finely powdered alum should be introduced into
the end of a small tube, (the  barrel of a quill will answer,) and
forcibly blown into the fauces.  This practice appears to me of
the utmost importance in cases of this kind, and ought never to
be neglected, where the fauces on inspection, present an irritated
and inflamed condition. Success in the treatment, must depend
materially on the prompt reduction of this primary extra  laryn-
geal  inflammation.
   With a view of expelling  the  false membrane, emetics have
been  recommended in the  advanced period of the disease, and
 the  records  of medicine are not wanting  in instances in which
 this  object was effected by such a measure.   It offers, however,
 but and exceedingly slender foundation to build  any hopes upon.
 The  same object has  in one or  two instances  been obtained by
 exciting violent  sneezing  by blowing snuff  into  the nostrils
 through a small tube.  As to the proposed operation of tracheo-
tomy in order to detach and remove the membrane, all experience
has so far decided against it. 
CYNANCHE LARYNGEA.
365
                  CHAPTER XXXI.

                    CYNANCHE LARYNGEA.

   This disease generally  commences with a slight  sensation of
chilliness, alternating with flushes  of heat, attended with a feel-
ing of soreness in the fauces, more or less tenderness to pressure
about the top of the thyroid  cartilage, and  some pain and diffi-
culty of swallowing.   The  voice  soon  becomes changed into a
thick,  hoarse whisper, and on strong inspiration the  air seems to
enter into  the trachea with difficulty, or as  if it  were forced
through a very narrow aperture, and is attended with a dull rough
sound.  On inspecting the fauces, the tonsils, soft palate, and uvula,
present a bright red, and oedematous appearance.   There is sel-
dom much expectoration, but the saliva is usually abundant and
of a very viscid character.  The febrile  symptoms are not vehe-
ment, the face being for  the most part pale,  and the pulse fre-
quent, small and tense.  The tongue  is covered with a thin white
fur, over which a thick layer of transparent mucus is spread.  As
the disease advances, deglutition becomes more and more painful,
and is apt to excite alarming and distressing paroxysms of suffo-
cative  breathing.   The  temperature  of the surface  .is very
unequal, some parts  being  very warm, whilst others are preter-
naturally cool.  Dr. Armstrong observes, that the most peculiar
and characteristic symptom of this  affection, is  the total  inability
to cough out, as is done in pneumonic and catarrhal complaints;
the  attempt to  do  so, resulting  in a  kind  of  suppressed or
suffocative effort,  terminating " in a low,  grumbling and almost
grunting sort of noise in the throat."   The difficulty of breathing
increases progressively as the disease advances, with  frequent dis-
tressing paroxysms of dyspnoea, until, in unsubdued cases, death
at last occurs by actual suffocation.
  The  disease sometimes approaches  in  a very gradual  and
insidious manner,  the symptoms  for a day or two, resembling
                                            32 
36G                 CYNANCHE LARYNGEA.
those of  ordinary  catarrh, with slight  hoarseness   In  some
instances, it comes on suddenly and in a very short time acquires
a fatal degree of violence.  Mr. Porter relates  two  instance*,
where the individuals went to bed at night, without complaining
of any illness, '• and were found  dead from this  affection, the
next morning."   A case is also reported by M. Leville, which was
so  marked by  erysipelas of  the face, as to escape  observation
until within a few hours of its fatal termination.*
   Cynanche laryngea  may be  distinguished from croup, by the
following circumstances.  In this affection there is  always pain
experienced in the larynx, generally referred to the  top of the
thyroid  cartilage.   Deglutition, too,  is  invariably painful and
difficult,  and after the disease  is fully developed, often wholly
impossible.   On inspecting the fauces they are found  somewhat
swollen and  inflamed; and every attempt to swallow brings on
a paroxysm of suffocative breathing.   None  of these symptoms
occur in cynanche  trachealis, except occasionally swelling and
 inflammation of the tonsils and palate.
   " The seat of this affection  is more in the cellular tissue con-
 necting the mucous membrane with the adjacent parts than in the
membrane itself, although this latter structure is very frequently
in an inflamed condition."!  The tonsils, soft palate, larynx, and
epiglottis are always tumefied, red, and in some instances vesicated.
The rima-glottidis, also, is in general, so much swollen as nearly
 to close the  aperture.  The swelling of these  parts appears  to
be oedematous, depending, mainly, on the effusion of serum  into
 the submucous  cellular tissue.  Sometimes the inflammation is
 confined to the larynx, but  in  some cases, it extends down into
the trachea  and even into  the bronchia.  (Armstrong.)   The
principal  seat of the inflammation, however,  is in the epiglottis,
which is usually " red, erect, oedematous, and during life resembles
a piece of raw meat."   (Porter.)  Cases have occurred in which
the inflammation terminated in the formation of one  or more
abscesses in the cellular tissue surrounding the larynx.
                      * Gazette de Sante 1827.
  t Observations on the Surgical Pathology of the Larynx and Trachea, &c.  By Wm.
 Henry Porter,  p. 98. 
                    CYNANCHE LARYNGEA.                 367
   Treatment.  Laryngitis is a most rapid and dangerous affection.
It often terminates fatally in less  than twenty four hours, under
the most  energetic  and judicious course of treatment.   Blood-
letting does not appear to exert the same degree of influence in
arresting the progress in this  affection  as it  generally does in
other varieties of tracheal inflammation.  Dr. Armstrong declares,
that he has known "one hundred and sixty ounces of blood drawn,
within the space of  six hours" in adult patients, without making
the slightest impression on the progress of the malady.   In only
one out of six cases, he says, did blood-letting  appear to  afford
any obvious advantage.  From the occasional vesication  of the
affected parts, and the serous  infiltration into  the  cellular tissue,
it would seem, that the inflammation partakes more of the erysi-
pelatous than of the  phlegmonous character; and this is probably,
the reason why bleeding though prompt  and copious, exerts so
feeble an influence over its progress.
   But although blood-letting does not often procure any  promi-
nent benefit in this affection, it is unquestionably decidedly indi-
cated, and ought always to be promptly and efficiently practised.
Dr. Beck  of New York thinks, that the  apparent inefficacy of
bleeding in this complaint, is  to  be ascribed  to the inadequate
manner in which it has been usually employed.   When carried to
the extent of producing syncope, he says, it is as likely to do good
in this as in other severe inflammatory affections of  the respira-
tory organs.  My own experience, does not,  however,  entirely
accord with this observation.   Nevertheless bleeding to the extent
of producing fainting,  ought to be regarded  as an indispensable
measure in the treatment of this affection.  After blood has been
efficiently drawn with  the lancet,  leeches should be  largely ap-
plied to the throat.  Martinet has reported a case, which termin-
ated favorably under the employment of general and local bleed-
ing and blistering.   Dr. Arnold, has, also, related a case, in which
the use of the lancet and leeching was decidedly beneficial.*  A
blister ought to be early applied to the throat, or to the back of
the neck.  In a case which I attended about two years ago, very
obvious benefit was derived from  blistering the back of the neck,
while leeches were applied to the throat.  It is  not necessary or
                 ♦Med. Chir. Transact, vol 9, p. 31. 
368                 CYNANCHE LARYNGEA.
even advisable to delay the application of the epispastic until the
momentum of the circulation  has been moderated by depletion.
The earlier the  blistering  is resorted to,  the greater the chance
of deriving advantage from it.  Armstrong places more reliance
on the repeated  employment of antimonial emetics in this com-
plaint than on any other remedy.  After he had repeatedly failed
in subduing the disease by blood-letting  and counter-irritating
applications, he resolved  to  try the effects of repeated emetics.
He accordingly, resorted to the use of antimonial emetics in five
cases, to which he was subsequently called; and, he declares, that
"no circumstance in his professional life ever gratified him more
than the  great  and sudden  relief which vomiting afforded  in
these cases.  It removed all  the urgent  symptoms  at the time,
and, being re-excited as soon as ever the slightest signs of stricture
in the larynx returned, it at last completed the  recovery."'  In a
well marked case, which I attended a few years ago,  in a child
about four years old,  blood-letting to the extent of producing
syncope,  followed by a blister to  the throat,  and three active
emetics in the course of about fifteen hours, effected a cure.  Pur-
gatives, are very useful auxiliaries in the management of this com-
plaint.   The bowels should,.in the first place, be freely evacuated
by a full dose of calomel in  union with rhubarb or julap; and after-
wards kept in a loose state, by enemata, and repeated  doses of
calomel, both with a  view  to its aperient and constitutional opera-
tion.  In the case reported by Dr. Arnold, the symptoms,  though
checked by blood-letting, did not entirely yield, until  the gums be-
came sore from the free use of calomel.  From what I have witness-
ed in a case which occurred to me a few months ago, I am inclined
to believe, that great benefit would, in general, be derived from
blowing  finely  powdered  alum through a small  tube  into  the
fauces.   In cynanche trachealis  attended  with inflammation  of
the tonsils and palate, this  application has within the  last three or
four  years, been much employed with the happiest effect, both  in
Europe and in this country; and it seems  highly  probable that
an early  recourse to it in the present affection, would often  do
much good.
  Tracheotomy has in several instances, been performed with en-
tire success in this disease;  and Dr. Porter strongly recommends 
                    CYNANCHE LARYNGEA.                 369
the operation whenever the remedies already mentioned do not
make an early and decided impression  on the laryngeal affec-
tion.  " There are many reasons," he says, " why the practitioner
should decide, at once, on the performance of tracheotomy, if the
appropriate antiphlogistic  measures do  not  afford early relief.
Thus it allows the organ in  which the inflammation is seated, to
remain in a state of perfect repose.  Considered as a wound, it
adds nothing to the patient's danger;  and as  the relief it affords
is, at least for a time, complete, it imparts confidence to the sur-
geon, and  allows  him leisure to examine the symptoms and the
remedies accordingly.  If however,  the operation be not early per-
formed, it had much better  be let alone altogether."  Dr. Cramp-
ton has reported a most interesting instance of the successful per-
formance of this operation in acute laryngitis.  Professor Regnoli,
has given an account of two successful instances of tracheotomy
in chronic  laryngitis.  Acute laryngitis,  he observes,  sometimes
terminates in chronic inflammation  and  oedema of the  epiglottis
and mucous membrane of  the larynx, which ultimately renders
respiration extremely difficult, and may even cause death by suf-
focation   In cases of this kind tracheotomy is the only means of
relief »s our power.*

           * Nuvo mercurio, delle scienze  mediche.  Maza 1829.
3B
32* 
370                 DROPSY IN THE BRAIN.
                 CHAPTER  XXXII


     ARACHNITIS.  HYDROCEPHALUS.  DROPSY IN THE BRAIN.

  Arachnitis often makes its approaches in a very gradual man-
ner.  In many instances manifestations of an unusually irritable
condition of the brain occur, and continue for several weeks be-
fore the disease is fully developed.  During this irritative stage of
the  disease, the patient  manifests a  very  irritable  and  fretful
temper;  he is wakeful, and  when sleeping  he  grinds  his teeth,
and often  starts or awakes suddenly with violent screaming and
a peculiar expression of alarm  in the countenance.  Infants cry
frequently  without  any  apparent  cause,  and  often  start  at
the  slightest  noise  and shrink  suddenly as if pricked with  a
pin.  The bowels  are generally irregular,  and  the evacuations
of an unnatural appearance.   This irritative condition sometimes
continues for a considerable time, without passing into actual  in-
flammation, the child gradually  regaining  its ordinary state of
health.  If, however, some additional exciting causes supervene,
such as difficult dentition, cold, or gastro-intestinal irritation from
improper food or other offensive matters lodged in the alimentary
canal, this irritative condition of the brain,  is more or less rapid-
ly aggravated, until it finally passes into actual inflammation.  A
new train of symptoms now ensues, which characterizes the  in-
flammatory stage of the disease.
  The patient  now begins to experience transient  pains  in the
head, and in most cases in the abdomen.  These abdominal pains
are occasionally very violent, but always very  transient.  The
restlessness, and irritability of temper increase and the counte-
nance is expressive of discontent and  suffering.   The face is
usually pale with an occasional  flush  on one cheek.   The eye-
brows are, at times,  contracted  into a peculiar  frown; and the
eyelids  generally kept  in a  half-closed state on account of the
sensibility of the retina.  The  appetite is variable, in some  in- 
                     DROPSY IN THE BRAIN.                 371
 stances voracious, but more frequently impaired.  The state of the
 bowels also is variable, being sometimes—indeed most general-
 ly—torpid, and at others relaxed, the stools presenting an unnatu-
 ral appearance.  As the complaint  progresses the pains in  the
 head become more and more severe.  They are however seldom
 continuous; becoming occasionally much lighter, and at times for
 a few minutes entirely absent.  The  headache is chiefly seated
 in the forehead, shooting  backwards  and  towards the temples.
 Children manifest their sufferings from this pain by almost con-
 stantly putting their hands to the  forehead, and I have seen in-
 stances in which the little patient kept one of the hands contin-
 ually applied to the head,  and would not suffer it to be removed
 for an instant.  At  this period of the  disease, the  stomach  is apt
 to become very irritable-—the retching and vomiting being some-
 times  very troublesome, particularly on  sitting up or taking any
 thing into the stomach.  Children, affected with this disease, sel-
 dom bear the erect  position  without  much uneasiness.  I have
 met with many instances, in which the patient manifested no dis-
 position to vomit while  in a recumbent posture, but the  moment
 his head was raised from the pillow,  sickness  and vomiting en-
 sued.  In the early part of the disease, however, the patient does
 not, generally, sleep easy with his  head low.  He is very restless,
 turning and tossing  from one side of  the bed to the  other, and
 frequently groans, or whines, as if under the influence of pain.
 In some  instances,  the  pain in the head, and the sickness and
 retching alternate with each other, the former ceasing as soon as
 nausea  and vomiting come on.   Frequent and  deep sighing, is
 one of the most constant and characteristic symptoms of this mal-
 ady.  It is  seldom very conspicuous, however,  until  the disease
 has made considerable progress, and is generally most remarka-
 ble, about the time when the inflammation is  terminating in effu-
 sion, and  some degree of cerebral torpor and somnolency are pre-
 sent.   Delirium usually, occurs, during the latter part of the in-
 flammatory  stage: but it is never  violent  or furious, and very
 rarely so great, that the patient may not be roused  from it,  so as
 to give correct answers.   Martinet  observes  that  when the
arachnoid membrane of the convexity of the brain  is the princi-
pal seat of the inflammation, the delirium is much more constant 
372                 DROPSY IN THE BRAIN.
and conspicuous,  than when the base of this organ  is the part
chiefly affected.  The skin,  during  this stage is  generally dry
and above  the natural temperature; and the pulse  is frequent,
quick, and tense or sharp, but seldom full.   The tongue, usually,
remains clean, or covered only with a thin white fur, with pale
red edges; but incases depending on intestinal irritation, it gene-
rally  becomes loaded with  a thick brown  fur,  which towards
the  termination  of the disease  becomes  dark,  dry and rough.
After these  symptoms have continued for an indefinite period,
a new series of phenomena ensues, characterizing  the third,  or
somnolent stage of the disease.  The delirium now returns more
frequently and continues longer; the countenance exhibits a pecu-
liar expression of surprise and stupor, which it is  impossible to
describe, but which when once seen cannot be easily mistaken or
forgotten.   The  conjunctiva, presents a suffused and reddish ap-
pearance; the pupils  are dilated or  much  contracted, and the
retina, in some cases, is extremely sensible to light.   During sleep,
the eyes are  generally turned up, so  as completely  to hide the
cornea under the upper lids.  The patient now manifests a con-
stant disposition to sleep; he becomes  inattentive to surrounding
objects, and  when roused from his stupor he soon relapses into the
same somnolent state.   There is, in nearly all cases, great torpor
of the intellectual faculties, or an impossibility, it would seem, of
directing them to any object, or bringing them into action, so that
the patient can seldom be induced to  utter more than monosylla-
bles.  This  mental apathy and torpor does not, however,  occur,
until disorganization or effusion is about taking place in the brain;
for in the  earlier periods of the disease, there is often  great  ac-
tivity of the mental faculties.  The drowsiness and mental torpor
increase more and more, until a complete state of coma ensues.
This morbid somnolency is the most constant of all the phenomena
of the advanced period of the disease.   In no instance where the
complaint  is not early arrested, does this symptom remain absent.
In some  cases, after the febrile and inflammatory symptoms have
continued  for some time, the coma comes on suddenly, in conjunc-
tion with paralysis of  one side or of one extremity; but, it much
 more commonly supervenes in the gradual manner just mentioned.
 Indeed instances occur, in which the febrile irritation is so slight 
                     DROPSY IN THE BRAIN.                373
 as to escape attention, the first obvious manifestations of the dis-
 ease, being an unusual  drowsiness and mental torpor.  In cases
 of this kind arachnoid inflammation, is no doubt going on without
 manifesting itself by the  usual local and general symptoms of in-
 flammation.   It is  a fact, well ascertained,  that  inflammation
 sometimes goes on  in the brain, even to the extent of producing
 fatal disorganization, without manifesting its existence either by
 pain or  any other  symptom indicative  of inflammation.  Soon
 after the somnolent stage supervenes,  paralysis  generally occurs
 on one side, or in one extremity.   In  infants  we  generally,  at
 first, notice a tremulous motion of one arm with the hand firmly
 bent inwards.  By degrees the power of using the arm and leg of
 one side, becomes  much weakened, which, in a short time, ter-
 minates  in complete paralysis.  At  the same time,  one  or both
 the  upper eye-lids,  usually, become paralyzed, so that the patient,
 in endeavouring to  look at any thing, is unable to raise the lids by
 their proper muscles, and is therefore obliged to draw them up
 with the integuments of the forehead by  the contraction of the
 occipito-frontalis  muscle.   Strabismus, almost always occurs, pre-
 vious to  the supervention of paralysis, or deep coma.  When the
 symptoms, last mentioned, namely strabismus, paralysis and coma
 occur, we may presume that disorganization or effusion has taken
 place in the brain.   Soon after the  inflammation has  terminated
 in effusion, a sudden amendment, usually, takes place in all the
 alarming symptoms.  The patient seems to have suddenly passed
 into a  state tending to convalescence;  and parents and friends,
 nay  even physicians are apt to  flatter themselves, that a speedy,
 though unexpected, recovery is at hand.   This flattering calm is,
 however, almost universally fallacious,  and  of short  continuance;
 for sooner or later,  a paroxysm of convulsions suddenly super-
 venes, or the patient relapses into a state of fatal coma and stupor,
 which, at once and  forever, puts an  end to all  hopes of a favora-
 ble termination.  Convulsions rarely, if ever, remain wholly ab-
 sent towards the  fatal termination  of  this disease.   The pulse
 which  in the first and second stages of the complaint, is quick,
 frequent, and tense, becomes slow, full  and generally irregular or
intermitting, during the somnolent  stage;  but when  paralysis,
and especially convulsions supervene, it again becomes very fre- 
374                 DROPSY IN THE BRAIN.
quent, small, and corded.   In the latter  stage of the disease,
vision, and occasionally hearing are wholly destroyed, yet general
sensibility, or  the sense of touch, usually remains  to the last
moment.   Infants will sometimes readily lay  hold of the nipple,
and suck freely, although in a state of continued stupor and wholly
deprived of the sense of seeing.  The paralysis which  occurs in
the latter stage of the disease, is almost universally of the hemiple-
giac kind.  Infants are apt to keep the unaffected  arm in con-
tinued motion.
   The disease does not however always come on in  the gradual
manner or proceed with the train of symptoms just described.  In
many cases the attack commences and proceeds in a manner very
similar to what occurs in the disease described by authors under
 the name of infantile remittent.  In instances of this  kind, the
 patient, after  a few days'  languor  and drooping  is seized with
 considerable fever attended with head-ache, flushing of the coun-
 tenance and tenderness of  the abdomen.  The fever differs from
 that  which occurs in the ordinary form of the disease by  being
 subject to frequent  and   irregularly  recurring  intermissions.
 During the exacerbations there is generally considerable stupor;
 the patient often screams and starts up, in a state of great alarm
 and agitation.   The stomach is always  exceedingly irritable—
vomiting being often excited merely  by  changing the position;
 and the bowels are in a state  of obstinate constipation.   The
 countenance is usually expressive of terror and pain or of dejeo
 tion and intellectual torpor.
   In some cases the disease is ushered in  by convulsions without
 any previous manifestations of febrile excitement.   In instances
 which make their invasion in  this manner,  however, there is
 always some evidence of ill-health previous to the occurrence of
 the convulsions—such as a peevish and fretful temper, variable
 appetite, irregularity of the bowels, tumid abdomen,  foul breath,
swelled upper  lip, starting and grinding of  the teeth during
6leep—in short, all that train of phenomena  which results  from
 gastric irritation in  consequence of worms, or  other irritating sub-
 stances lodged in the alimentary canal.   I have known the first
 intimation of the presence  of this almost hopeless disease,  to be 
                    DROPSY IN THE BRAIN.                 375
coma, attended  with deep sighing, cold hands  and feet,  pale
countenance, and paralysis.
  Occasionally the disease  commences and  proceeds to the last
stage with  scarcely any other  symptoms  than slight  febrile
irritation, with little or no pain in the  head, but a very frequent
desire to pass urine, which is voided in very small quantities and
with much difficulty.   I  attended a  case a few years  ago, in
which  not above a gill of urine  was discharged in twenty  four
hours, accompanied with no other manifestations  of indisposition,
than a slightly feverish, and drowsy condition during the first five
or six days.  Dr. Monro, observes, that " there are cases in which
the  little patient has a desire, every hour, to pass urine."
  The liver almost always suffers considerable functional derange-
ment in arachnitis.  During the forming stage of the complaint,
there is generally a manifest deficiency of bile in  the evacuations,
but in advanced periods, this secretion generally is not only  copi-
ous, but decidedly vitiated in its quality.  This is particularly
observed in the latter  period of  the second stage, or in the com-
mencement of the third  stage,  when the symptoms of cerebral
oppression are  about  supervening: at  this period, the stools,
frequently, consist  almost  wholly of  dark  bile and   intestinal
mucus,  presenting  a very dark  green and  glairy  appearance,
resembling, as  Dr. Cheyne  observes, " chopped spinage," or, in
some instances, tar.

  Diagnosis.  The characteristic symptoms of the first stage are:
great irritability of temper;  irregularity of the bowels; variable
appetite;  an irritated and quick pulse; wakefulness; and a pecu-
liar  frowning expression  of the  countenance.   In  the  second
stage:  more or less continued  pain  in the head; torpor of the
bowels;  nausea and vomiting particularly on  rising  from the
recumbent posture; irregular febrile exacerbations; a peculiar
distressed  expression of the countenance; sudden waking  from
sleep;   transient and  severe pains  in  the abdomen, alterna-
ting frequently with  acute pain in the  head; a circumscribed
flush on one  cheek; intolerance  of  light and  sound;  a hot and
dry  skin, with  a frequent, tense,  and  generally active pulse.
When  the disease has advanced to the third stage it is easily 
376                 DROPSY IN THE BRAIN.
recognized, by great drowsiness, strabimus, hemiphlegia, paralysis
of the upper eye-lids, and finally  coma  and convulsions.  The
disease with which arachnitis is most  apt to be  compounded is
infantile remittent  fever.  In this latter' affection, however, the
remissions  are  regular and  generally   complete;  whereas in
arachnitis, there is the utmost irregularity in the recurrence  of
the exacerbations  and remissions,  nor are they so perfect as in
infantile remittent.  Dr. Cheyne  observes that  the appearance
of the stools,  also, affords us  a good diagnostic  sign  between
these two affections.  In infantile   remittent the alvine  evacua-
 tions  are very  fetid,  and of a dark brown or mud-like color;
 whilst in arachnitis, they are usually of  a dark  green  or glairy
 appearance, resembling the fresh ordure  of  cows.   In idiopathic
 arachnitis,  the  abdomen,  almost  always becomes collapsed  or
 flattened, without an increase of the alvine evacuations;  whereas
 in infantile remittent,  the belly  is generally tumid, tense, and
 elastic.  This  circumstance  is much  insisted on by Goelis, as a
 diagnostic  sign between these complaints.  There is seldom much
 secretion of saliva, in arachnitis, both  the mouth and nose being
 usually dry.   In infantile remittent, on the other hand, the saliva
 and  mucus of the nose  are generally  abundant.   In the former
 affection, the tip and margin  of the tongue are commonly clean
 and  red; whilst in the latter, the whole surface of the tongue  is
 covered with a thick, white fur, which becomes darker, and dry as
 the  disease advances.   There is  almost invariably  severe  and
 continuous pain in the  head,  in  arachnitis; whilst in  infantile
 remittent, or worm fever, headache is  a very uncommon occur-
 rence.   In the latter disease, the little patient is almost constantly
 picking his lips and nose with his  fingers; while in the former
 complaint  he is apt to direct his hands to the forehead.   In infan-
 tile  remittent, moreover, the patient  is often  observed to have
 a movement  of the  deglutition during  sleep,  and when awake,
 he sometimes thrusts his fingers back into the fauces, as if desirous
 of removing something.  These symptoms rarely, if ever occur in
 idiopathic  arachnitis.   In the former, the face is usually pale and
 leaden in the advanced  periods of  the  disease; whereas in the
 latter, a conspicuous circumscribed flush often appears, on one or
 both cheeks.   In  arachnitis  the  head  is  generally the hottest 
                    DROPSY IN THE BRAIN.                377
part of the body; in infantile remittent, the abd6men  is usually
the warmest part.  " Vomiting is one of the most invariable symp-
toms in  the  first stage of arachnitis, and is attended with this
peculiar  characteristic—namely, it  comes on unexpectedly and
suddenly, without  being preceded by much nausea, and is more
frequent when the  patient is supported in a sitting  position, than
in a recumbent  posture.  If a child  vomits frequently, at con-
siderable intervals, if it be costive or the alvine evacuations are
irregular and unnatural  in appearance, if the abdomen is collaps-
ed or flat and painful to pressure, if the urine be slimy and high
colored, if there is  much headache,  and if the whole state of the
disease manifest an obstinate or  unmanageable  course,  then  we
have great reason  for believing that the complaint  is principally
located  in the head,  and that, if not  subdued, it must result  in
cerebral oppression."
   Although these circumstances will frequently enable us to form
a  satisfactory diagnosis, in  relation to these two  affections;  it
must be confessed,  that in the commencement, arachnitis, is seldom
cognizable;  and that there is no symptom, which can be depend-
ed on as characteristic of the disease, during its early periods.
   Dr. Alexander Monro has described a variety of hydrocepha-
lus,  which he  calls  the "hyper-acute form" of the disease, a
form of very rare occurrence, and simulating in some of its most
striking  symptoms,  inflammatory croup.  "This  rare  form  of
the disease is very sudden in  its attack.  There  is no previous
headache, drowsiness, stupor, nausea, vomiting, paralytic state
of any part  of the body, or any other symptom denoting  a  de-
rangement of the functions of the nervous system.  It begins like
croup.  The child awakens in the  night  in a  state of extreme
agitation, and much flushed, and with a quick pulse; he is hoarse,
and the sound of the voice when he inspires is similar to that of
croup.  The patient, at the onset of the disease, seems in a state
of nervous irritation; often starts  in his sleep, and in a short time,
the disease assumes the  appearance rather of a spasmodic  affec-
tion of the larynx, than  of the  inflammatory croup.  The matter
thrown up by vomiting, consists generally of indigested food.  The
longer the disease continues, the shriller  and hoarser the  voice
becomes."
                             3C               33 
378                 DROPSY IN THE BRAIN.
  In the dissections which were made of children who died of
'•this form  of disease, Dr. Monro  found in one instance,  the
vessels of the pia mater at the corpora quadrigemma and tractus
obtici, and at the origin of the eighth pair of nerves, much  dis-
tended with blood.   No  morbid  appearance was discovered in
the larynx  and trachea."  In another  case, "the upper  part of
the brain,  particularly the superior part of the posterior lobes,
was covered with transparent gelatinous  effusion;" and about an
ounce of colored serum was found in the ventricles.  "The vessels
of the spinal marrow were turgid, those  of  the  cervical  portion
of a vermillion-red  color,  and those of the  lumbar portion of a
dark-red hue.   The eighth pair of nerves  was of a deep  uniform
red color along  its  whole tract,  as far  as its branches, going to
the lungs."
   Dr. Burns attributes this form of hydrocephalus, "to an affec-
tion of the origin of the eighth pair of nerves, induced by the state
of  the  extremity of the  fifth  pair, in  dentition, acting on its
origin,  which is near the eighth."*

   Prognosis.   The  prognosis in this disease must be always  ex-
tremely unfavorable.  The  instances of recovery from it  are
indeed  exceedingly  few.   In the course of twenty years' practice
I have known but two fully developed cases, which terminated in
health, and it has fallen to my lot to have seen, and prescribed for
 a very considerable number of patients ill with  this appalling dis-
 ease.  I have already adverted to the flattering but illusive truce
 which sometimes occurs in the latter period of the disease.—Often,
 in the early period of my professional  career have I been  induced
 to  think, by this ominous calm, that I had conquered the  disease;
 and to announce to the anxious friends my good hopes of a speedy
return to health. These  hopes, however, were  always  blasted;
and though taught by previous experience I have again and again
 thus hoped and thus encouraged, and always with the same painful
 conviction of the fallaciousness of this delusive  interval.   It is
 indeed extremely difficult to see so perfect a freedom from all the
 previous alarming  symptoms,  and not  to  flatter  oneself,  that

         * The Morbid Anatomy of the Brain. By A. Monro, M. D. 1827. 
                    DROPSY IN THE BRAIN.                379
recovery may ensue.  When we see the little  patient,  emerge
from a state of intense suffering and danger, and assume the smile
and playfulness  of convalescence—when from a state of stupor
and unconsciousness, he awakens, as it were,  to the feelings and
actions of returning health, it is not easy to persuade oneself that
all this hope-inspiring change  is but the illusive prelude to  the
last, painful struggle,  which inevitably leads to the grave.

  Post-mortem appearance.—The appearances  discovered in  the
brain,  on dissection,  are very  various.   In some  instances  the
arachnoid membrane  is minutely injected, presenting  a very red
appearance, throughout its whole intent; in others this membrane
is found  considerably thickened and  opake.  A purulent, sero-
purulent, or sero-gelatinous matter,  is in many cases found be-
tween the arachnoid and pia mater; and in the greater number
who die of this conplaint, from  one  to four or six ounces of serous
fluid is  effused into the lateral  ventricles of the brain.—In some
cases, however, very little or no serous  fluid is entravasated into
the ventricles or between the membranes of the brain.   Martinet
and Duchatelet, in their interesting work on this disease, state
that in eight cases out of twenty-six, there was scarcely a trace of
serous effusion discovered within the cranium.  In cases of this
kind, the substance of the brain, is generally found  conspicuously
altered, both in  consistence  and color.  Considerable portions of
the brain are sometimes completely disorganised and reduced to
a pap-like consistence; and  instances have occurred,  in which a
portion  of the cerebral  substances was found much  indurated.
Occasionally cases are met with, where no other manifestations of
cerebral disease, are detected, than signs of strong sanguineous con-
gestion in the brain, with but little serous effusion and no marks of
meningeal inflammation or structural lesion.   Not unfrequently,
unequivocal marks of previous disease in the abdomen, are detect-
ed,—sometimes the colon presents an enlarged and distended  ap-
pearance; at others, considerable portions of it, are so much con-
tracted  as  hardly to admit of  the  introduction of a large sized
bougie.   Frequently we  find more  or less extensive portions of
the mucous  membrane of the  bowels, minutely injected; and I
have seen it extremely red,  throughout the whole extent of the 
380                 DROPSY IN THE BRAIN.
small intestines.   In one case, the lower part of the ileum was of
a dark livid color resembling incipient gangrene.   Dr. 1. C. Smith
has given an account of a  case of hydrocephalus,  in  which on
post-mortem examination, the stomach was much contracted, and
"on laying it open, an ulcer was found near the cardia, and the
mucous and muscular coates, at this place were entirely destroyed,
nothing remaining but a greenish mucus."

   Causes.—A strong predisposition to this disease, is manifestly
hereditary, or constitutional, in some instances.  The peculiar/ap-
titude to this affection,  in some families, is sometimes strikingly
exemplified.  I know several families  who have  lost nearly all
their children by this indomitable malady.  It  is  difficult, it not
impossible, to say in what  this  predisposition consists.   It  may
be presumed, indeed, that  children of an irritable habit of body,
with a strong tendency  to a preternatural determination of blood
to the brain, are  more liable to the  disease than such as are of
an opposite temperament.   It has been supposed that children
who have very large heads, are peculiarly  predisposed  to the
arachnitis; but  the correctness of this opinion is decidedly con-
tradicted by experience and observation.   It has been affirmed,
moreover, that the scrophulous habit is often attended with a par-
ticular predisposition to this complaint—an observation  which
appears, indeed, to be well founded.   In a large proportion of
instances, Dr. Mills found, on post mortem examination, unequiv-
ocal appearances of scrophula; and out of twenty-two cases which
came under the observation of Dr. Percival, eleven "were deci-
dedly scrophulous."
   Among the most common exciting causes of this  disease in chil-
dren, are injuries, inflicted on the head  by blows or  falls.  It has
been observed, however, that injuries of this kind,  rarely  give
rise to  arachnitis, unless they are  sufficiently  violent to cause
some degree of concussion of the brain, and my experience leads
mc to think, that there is truth in the observation.   Suppressed
discharges,  and repelled cutaneous  eruptions,  particularly the
sudden drying up of serous discharges  behind  the  ears,  is apt
to give rise to this affection, more especially, when  aided  by the
irritation  of dentition,  and   intestinal disorder.  A  sudden  and 
                    DROPSY IN THE BRAIN.                381
total suppression  of the diarrhoea, which frequently accompanies
dentition, sometimes excites arachnoid inflammation, and conse-
quent dropsical effusions in the  brain.  Dentition is often  inti-
mately concerned in the production of this complaint.  This pro-
cess, when  difficult, is always  attended  with an irritable and
irritated condition of the system, and a preternatural determina-
tion of  blood  to  the head.  This, in itself, may be sufficient to
excite  the disease, in subjects who are predisposed to it, by con-
stitutional  habit, or from previous ill-health.  It  is probable,
however, that dentition is seldom the sole  cause  of the disease;
but that it most commonly acts in conjunction with other causes,
especially with irritation in the alimentary canal.   If, while den-
tition is going on, the digestive functions become disordered from
improper diet, or some other circumstance, or if irritation  be
established in the bowels, there will be a concomitance of causes,
peculiarly calculated  to  develope this fatal malady.   The ten-
dency of intestinal irritation to occasion an undue determination
of blood to  the brain, is well known.  In infancy, this determi-
nation to the head, when  long continued, is  apt  to  give  rise  to
inflammation of the brain, or the disease now under consideration.
In middle age it frequently terminates  in  mental derangement;
and in the decline of life, it is apt to  result in apoplexy or palsy.
It is believed by  many, that arachnoid inflammation, or hydroce-
phalus,  during childhood, is very generally  the consequence of
intestinal irritation; and there  are, in fact, many circumstances,
which go to confirm this opinion.  In very many cases, I think it
may be  safely asserted, that in a large majority of instances, there
are unequivocal  signs of  intestinal irritation, both previous and
during the existence of the disease.   The variable appetite—the
irregular action  of the bowels, with the unnatural appearances
of  the  alvine  discharges—the tumid and tender abdomen—the
picking of the nose, and the pale and sickly  aspect of the coun-
tenance,  which so commonly precede the developement of the
disease, all point  to the alimentary canal as  the original source
of the irritation.   Where this irritation exists, there  is, doubtless,
always  a strong predisposition to the disease; and if to this  he
added some other exciting circumstance, such as a blow  on the
head, or the  supervention of painful dentition, or general fever
                                              33* 
382                  DROPSY IN THE BRAIN.
from cold—or, in short, any occurrence which  gives  rise cither
to general  arterial excitement, or local  irritation of the brain,
the  liability to the disease will be greatly  enhanced.  Worms,
acrid secretions, and an accumulation of fecal matter in the bow-
els,  are  the most common remote causes  of this disease, when it
depends on intestinal irritation.  The strong tendency of intestinal
irritation to  give rise to arachnitis and consequent serous etfiVion
into the brain is often  strikingly illustrated  in cholera infantum.
When it runs into a chronic or subacute form, this  disease fre-
quently  terminates  fatally, under all the characteristic symptoms
of the last stage of hydrocephalus.  In two instances of this kind,
in which I  had an opportunity  of a  post mortem  examination,
I found the traces of arachnoid  inflammation unequivocal, with
copious serous effusion  into  the ventricles, and between the cir-
cumvolutions of the brain.*
  Hooping cough, when  it  occurs in  subjects naturally predis-
posed to the disease, more especially, when it  is associated with
a strumous diathesis, or a loaded and irritated state of the intes-
tines, is  no uncommon exciting cause of arachnitis.  The violent
and frequently recurring spells of coughing,  forces the  blood
powerfully into the vessels of the brain, and where the superven-
tion of the disease is favored  by previous predisposition, or some
other concomitant circumstance, may thus  readily give rise  to
arachnitis.   During the period  of convalescence  from measles
and scarlatina,  children seem  to be much predisposed to this
disease.
  While we give all the importance  to intestinal irritation, as a
cause   of arachnoid inflammation,   which   it   unquestionably
demands, we must bear in mind, that this same cause sometimes
gives rise to  a form of cerebral oppression,  strongly resembling
the  last stage  of arachnitis, but  which is, nevertheless, wholly
unconnected  with  cephalic  inflammation.   The determination
to the head, in  such cases, results merely in a state of strng
venous congestion of the brain,  giving rise  to a somnoler   did

  *  An interesting and striking  case, in which hydrocephalic symptoms were r  meed
by organic disease of the intestinal canal, is related in the Med. ana Cbir. Re  July,
1826. p. 102. 
                     DROPSY IN THE BRAIN.                 383
oppressed  state of the  system, which  may be readily mistaken
for hydrocephalus.  (Cheyne.)*

   Treatment.—There are three principal  indications  to be kept
in view  in  the treatment of arachnoid inflammation—viz. 1. to
moderate the general febrile excitement;  2. to obviate sanguine-
ous congestion and inflammatory  irritation in  the  brain;  3. to
remove  those causes of  irritation, which tend to produce  and
sustain a preternatural determination of blood to the brain.
   The disease is  not  often detected  in  its incipient stage, on
account  of the gradual  and insidious manner, in which it usually
makes its approaches.    When  it  does  become an  object of
medical  attention at this early period of its course,  every effort
should be made to remove the sources of irritation, and especially
to obviate  all undue  determination of the blood, to  the head.
With  this view, it is of the utmost importance to attend to the
state  of  the  alimentary  canal;  for it is in  the stomach  and
bowels, especially that the primary irritation and exciting cause
of the cerebral congestion most commonly exists.
   Purgatives  are, accordingly,  the most valuable means  we  pos-
sess, for preventing  the full developement of the cephalic inflam-
mation at this early period  of  the disease.  The bowels  should,
in the first  place, be freely evacuated, by  an efficient mercurial
cathartic,  and afterwards kept in a loose state by the daily ad-
ministration of small doses of calomel, succeeded by a moderate
portion of some mild purgative.   From three to four grains of
blue pills, or  a few  grains of calomel  should  be  given in the
evening, and   followed  next morning by a weak dose of epsom
salts, rhubarb, or of castor oil,  and continued until the  alvine dis-
charges  assume a natural appearance.   At first, it may be neces-
sary to repeat these aperients daily, for four or five days in  suc-
cession,  after which it will, in general,  be sufficient to  administer
them  every second, third, or even fourth  day,  according to the

  * Some writers contend, that hydrocephalus is almost invariably a sympathetic affection.
Dr. Yates in particular, thinks that this disease has almost invariably its origin in the
irritation of some organ remote from the brain.  Spurzheim admits, that the primary
irritation is frequently  located in the abdomen; " yet anatomical dissections have con-
vinced me," he says, '* that, in the greater number of cases, the morbid appearances of
the abdomen are secondary of the cerebral disease." 
384                 DROPSY IN THE BRAIN.
urgency  of the symptoms.  Mercurials are particularly useful in
the incipient stage of this complaint, not only  as aperients,  but
as means for correcting the functional torpor of the liver, which
almost invariably attends the early stages of the disease.' In ad-
dition to these  means,  especial  attention must  be paid to the
proper regulation of the patient's diet.   The  appetite is  some-
times very craving, during the incipient  stage  of the  complaint,
and it requires much care and vigilance to prevent children from
taking improper food, or overloading their stomachs.   It is of the
utmost importance,  to guard against these errors, as they never
fail to accelerate the progress of the disease, and  to  render the
most judicious remediate treatment abortive.   The  most simple,
unirritating and digestible articles of nourishment alone  must be
allowed: such  as boiled milk, barley-water,  arrow-root, boiled
rice,  oat-meal gruel, weak beef or chicken  tea, &c.   All stimu-
lating drinks must be carefully avoided.  If dentition is going on,
and the  gums  are  swollen or inflamed, they should  be  freely
divided  down to the advancing teeth.  Much  benefit  may some-
times be derived during the initial stage of the  disease,  from
the application  of blisters behind the ears, or on the back of the
neck; and  in  cases preceded by the drying  up  of discharging
sores behind the  ears, or on the head,  blistering, in this  way,
should never be neglected.
   When the disease is once fully developed, prompt and decisive
antiphlogistic measures, in conjunction with revulsive and deriva-
tive applications are indispensable.   Blood-letting ranks, of course,
among our  most efficient remediate means at this  period of the
disease, more especially, when the encephalic  inflammation has
been caused by some injury inflicted on  the head, or  when it  is
the consequence of some general cause, such as cold.  In instan-
ces of this kind, the pulse is almost invariably tense, quick, resist-
ing and active; and nothing but  prompt and very efficient blood-
letting  will make  any  decided impressions  on  the  disease.
Whenever the pulse is  firm, and active, a sufficient quantity of
blood should be taken away at once, to check, conspicuously, the
 momentum of the circulation.  I am inclined to believe, that if
 bleeding were carried to the extent of producing an approach to
 syncope in  the  commencement of  the  inflammatory  stage, our 
                    DROPSY IN THE BRAIN.                 385
efforts would be more frequently crowned with success than they
unfortunately are.   " The temporal artery, or a vein in the arm,
should be opened, and the blood allowed to flow, until a very obvi-
ous impression is made on the system, or until the morbid actions
of the vascular system of the brain are modified or totally changed.
That such  an effect has taken place, may be known  by  a pale-
ness of the countenance, a shrinking  of the features, and a ten-
dency  to deliquium; or  by  a diminution of, or removal of the
heat, pain,  wreight,  or uneasiness of the head."  (Mills.)  The
blood-letting ought to be repeated, as soon as the febrile reaction
and local inflammatory symptoms rise again.  In cases depending
on intestinal irritation, the  arterial  excitement is seldom  very
active.  Here, blood-letting, though ai vays indicated in the early
periods of the inflammatory  stage, must be employed with more
caution; for copious bleeding, by weakening the energies of the
system, is peculiarly apt to increase the morbid sympathetic affec-
tions of intestinal irritation.
  With  regard to  the utility of local bleeding in  this and othei
forms of encephalic inflammation, different opinions are expressed
by practitioners.   Nearly all the French writers on this  disease
are decidedly in favor of the local abstraction  of blood.   It ap-
pears,  indeed^ very reasonable  to expect  peculiar advantages
from a mode of depletion which abstracts the blood  more imme-
diately from the affected parts;  and  yet, in relation  to  the pre-
sent disease, a contrary opinion has_ been expressed by  several
eminent practitioners.   Mr. North, in his work on the convulsive
affections of infants, observes, " that he never found well marked
symptoms of determination  to  the  head, ■ removed  by  leeches,
however  freely they  were  applied."  In cases  in  which  the
cephalic determination depends on intestinal irritation, this obser-
vation is, perhaps, well founded; for the blood which  may  be
thus removed from the vessels of  the head, will  be immedi-
diately replaced by the  continued  preternatural afflux of this
fluid.   It must be observed, moreover, that so long as the  momen-
tum of the general,circulation is considerable, local bleeding can
scarcely produce any other advantages than such as would result
from abstracting the same  quantity of blood  by  means of the
lancet.  General  bleeding is, therefore, an essential preliminary
                             3 D 
386                 DROPSY IN THE BRAIN.
to the  beneficial  employment of leeches or  cupping.  After the
impetus of the circulation has been moderated by the use of the
lancet, leeching the temples, and along  the posterior parts of the
ears, is a valuable auxiliary in the treatment  of arachnitis.  It
sometimes happens that blood cannot be obtained from a vein in
the arm, and  occasionally,  not even from the temporal  artery.
In this case, the application of leeches is indispensable.   They
should be applied in large numbers, to the temples,  occiput,  and
behind the  ears, and the flow of blood encouraged,  until  a very
obvious  impression is made on the pulse, or a manifest tendency
to syncope ensues.  Dr. Mills, in his interesting paper on  this
disease, strongly recommends  leeching, immediately after vene-
section, "in order to postpone the  period of the  exacerbation, or
break the chain of diseased action.   I have observed  that these
two modes of drawing blood, when successively employed, make
a. greater impression on the disease than  either of them is capa-
ble of effecting when singly had recourse to."
   Purgatives are among our most useful means for subduing  this
disease.   When  the bowels are  loaded with irritating substan-
ces, and  the cerebral affection is symptomatic  of intestinal irrita-
tion, laxatives are, in truth, the  main stay of  our hopes.   They
are, indeed, almost equally useful in idiopathic arachnitis; for
besides their effect  in evacuating irritating  causes, they tend,
very particularly,  to diminish the afflux of blood to the brain, and
to moderate the general momentum of the circulation.   "Should
we ascertain," says Dr. Cheyne, " that  the alimentary canal is
torpid,  and  imperfectly performing its  functions, admitting an
accumulation of feculent matter; or that the secretions flowing
into it are  vitiated or diminished  in quantity—circumstances
which we ascertain  by the peculiarity in  the appearances, or the
pungent fetor of the stools, we must, by steadily pursuing the
purgative plan,  endeavor to effect  a change; for  while  this is
produced in the appearance of the stools,  we are effecting a most
important change  in the hepatic system,  alimentary canal,  and
all the parts including every organ essential tq life, which is con-
nected with them."  In symptomatic cases, depending on  pri-
mary irritation of the  alimentary canal, the  milder purgatives
after the first thorough evaraation of the be vvels, will, in general, 
                    DROPSY IN THE BRAIN.                387
be more beneficial, than the repeated use of very active purges.
Frequent purging, by the more  active and irritating cathartics,
though at first apparently useful, tend, ultimately, to increase the
inflammatory irritation of the bowels, and consequently, the cere-
bral affection.   It must be recollected that intestinal irritation is
not always dependent solely on the presence of acrid or irritating
substances in the bowels.  The  mucous membrane of the alimen-
tary canal may be in a state of sub-acute inflammation, or of high
vascular irritation.  In cases  of this kind, the milder laxatives
are manifestly more appropriate than the more irritating articles
of this class,  since they are sufficient to evacuate the contents of
the bowels without causing injurious irritation.  Undoubtedly, the
first purgative should be sufficiently active, to evacuate the intes-
tines freely.  From five  to six grains of calomel, followed  in  a
few  hours, by infusion of senna  and manna, or a suitable portion
of epsom salts, will answer well for this purpose.   The bowels
must afterwards be regularly evacuated, so as to procure three
or four discharges daily, by the use of small doses of calomel,
promoted by castor oil, and laxative enemata.
  In idiopathic arachnitis, however, the  intestines are  generally
very torpid, and can seldom be 8ufficiently moved by the milder
purgatives.   In  cases of this kind,  it is  often necessary to resort
to large  doses of the most active cathartics, in order to procure
adequate evacuations  from the bowels.   The  same  difficulty
sometimes occurs, in cases  attended  with a great  accumulation
of fecal  matter  in the intestines.   Calomel should always  enter
largely into the  purgatives employed in  this disease.  Independ-
ent of its aperient effects, its constitutional or specific influence,
if early  obtained, is sometimes attended with great benefit.
From one to three grains may be given every three or four hours,
according  to the age of the patient, with  an occasional dose of
of castor oil, infusion of  senna, or  epsom salts.   Where there is
reason to suspect the presence of worms in the intestines, anthel-
mintics  should  be employed,  in  conjunction with  purgatives.
An infusion of spigelia with a small  portion of senna,  may be used
with a  prospect  of much  advantage in such cases.  In some
instances the stomach is  so irritable in this disease,  that no arti-
cles will  be retained a  sufficient time to operate on the bowels. 
388                 DROPSY IN" THE BRAIN".
Where this state exists, we must endeavor in the first plat v. to
allay the gastric irritability, and this may in general  be efl'ected
by minute  doses of calomel and ipecacuanna:  the one sixth  of
a grain of the former, in  union with one-fourth or one-third of
a grain of  the latter,  has  repeatedly  succeeded in my hands to
restrain the tendency to vomiting in this disease.
  Mercury, as has been  already observed, is undoubtedly a rem-
edy of valuable powers in the treatment of this affection. Doctors
Percival, Dobson, Rush,  Cheyne, Mills, not  to mention many
other names  of great  celebrity, have related  instances  which
yielded to  the influence of this potent remedy.  Employed with
a view to its constitutional operation, mercury  often contributes
very powerfully to the reduction of visceral inflammation; and
experience has shown, that in the present affection, it deserves to
be  regarded  as  one  of our most valuable remedies.  It is, in
general extremely difficult to procure the constitutional influence
of  mercury, to an obvious extent, in very young children; and
hence, to  obtain this  desirable object sufficiently early to  derive
decided advantage from it, many have  advised the use of mer-
curial frictions at the same time that calomel is administered in-
ternally.   Dr. Mills  of Dublin, strongly recommends the use of
calomel in union with opium, " as soon as a check has been given
to the disorder of the head," by venesection, leeching and purga-
tives.   " The good effects," he says, " of a combination of these
remedies,  seem to depend on their power of equalizing the circula-
tion, increasing the  secretions, and  exciting  the action  of the
cutaneous vessels."  I cannot bring  to  my recollection a single
instance,.  in  which this remedy, when  judiciously administered,
after depletion, was followed by disagreeable consequences; and
in cases  unaccompanied by great  irritability of the stomach, its
powers are occasionally increased by the addition of small quan-
tities  of ipecacuanna, or antimonial  powder."*   The " watery
extract," he thinks, is decidedly  the best preparation of opium
for this purpose.  " It procures rest, diminishes  pain and irrita-
tion, and  diffuses throughout the frame an  agreeable sensation,
at the same time  that it is devoid of any narcotic or nauseating

    * Transact, of the  King and Queen's College of Physicians in Ireland.  Vol. ▼. 
                     DROPSY IN THE BRAIN.                 3S9
quality, and does  not cause vertigo, pain, or a sense of fulness
in the head."   My own experience enables me to bear testimony
in favor of this  preparation;  for I have seldom  known  it  to
produce the disagreeable effects  that are so apt to follow the use
of laudanum or opium, in its ordinary state.
   Dover's powder, also,  has found advocates as a  remedy in this
disease.   Drs. Brooke,  Percival, Cheyne,  and  Crampton,* all
speak favorably  of  its   employment  in  hydrocephalus.   After
adequate  depletion  and  purgation, in  cases  connected  with
intestinal irritation, small doses of this  composition often  prove
highly serviceable, by allaying general irritability and inducing
a gentle diaphoresis., It should  be  observed, however, that  in
the idiopathic form of the disease,  opiates of every description,
must  be carefully avoided, as  their  tendency  to increase the
flow of blood to  the  brain,  could hardly fail to prove very injuri-
ous.  When  preternatural determination to the head depends
on a  remote focus  of irritation—as in the mucous membrane  of
the bowels—opiates,  by  diminishing nervous excitability as well
as local irritation, will frequently reduce, also, the irregular de-
terminations which depend  on such irritations.    It is in cases  of
this kind only, that we may venture on the exhibition of Dover's
powder, and not  in these instances until the impetus of the cir-
culation has  been moderated, and  the alimentary  canal well
evacuated.
   Dr. Stocker, of  Dublin,! speaks very favorably of the  use  of
James'' powder in  hydrocephalic affections.   According  to his
observations, it tends, very considerably, to lessen the determina-
tion of blood to  the brain.  It should be  given  in small but
frequent doses, and may  be very properly  administered in  union
with calomel.  Dr. Monro states that he has  cured several cases
of this disease by a plaster composed  of  tartar emetic and wax
ointment, applied  to the head,  in conjunction with  the internal
use of calomel combined with  James' powder.   He states, that
he has found  this combination  peculiarly useful,  in restoring the
healthy action of the bowels.    Tartar emetic, also, has been used

  * Transactions of the  Associat. of Fellows and  Licentiates of the Queen's College
of Physic in Ireland.  Vol. vii.
  t Dublin Medical Essays, 1806. 
390                 DROPSY IN THE BRAIN.
with great  advantage in  this disease.  Laennec, has reported
some cases  of acute  hydrocephalus, in  which  he administered
twelve grains  and more of this article during the day,  with  com-
plete success.
  Mr.  Newnham asserts, that green tea has a strong tendency to
lessen  morbid vascular excitement in  the brain.  " In the acute
irritation  of the membranes of the brain in children,"  he says,
" the  efficacy  of green  tea has  been  strongly marked in my
practice.   Exhibited  during  the  early  symptoms, as soon as a
sufficient quantity of  blood has  been  taken,  and  before effusion
occurs, it  has  proved  a  more  powerful means than any other we
possess, of controlling the  morbid action, which, if  suffered to
proceed to  its second stage, is scarcely  to be overtaken by  any
treatment."*
  Nothing is more common in the treatment of  this disease, than
the application of blisters to  the  shaven scalp;  but this practice
is, I conceive, of very doubtful propriety.  I have always pre-
ferred  placing them on the back of the neck or behind the ears,
while  ice or cold water is applied to the top of the  head, and
warm or rubefacient applications made  to the feet.  Dr. North,
whose  interesting work  I have  already  mentioned, observes,
" that blisters to the head are  decidedly prejudicial in the convul-
sive diseases of infants;"  and  the same observation is applicable,
I think, to the disease under  consideration.  The application of
ice or  iced water, in the manner  mentioned in the last chapter,
may be accounted  a  very  useful auxiliary  in  the treatment of
arachnitis, and to favor its revulsive influence, warm or stimu-
lating applications to the  feet  may be usefully  employed.  Dr.
Regnault  recommends in very strong  terms, the application of
moxa  in  this  complaint;t and its known efficacy in subduing
deep-seated articular inflammation, justifies the expectation of
considerable advantage from its use in  arachnoid inflammation.
Neither this application nor blisters, however, should be resorted
to, until the activity of the circulation is reduced by general and
local blood-letting.   The  tartar-emetic ointment  also may be
very beneficially applied.  (Monro.)
              * Med. Chir. Rev. July, 1827.
              t Medical and Physical Journal, Vol. xi. p. 16. 
PERITONITIS.  ASCITES.                 391
                CHAPTER  XXXIII.


                    PERITONITIS.  ASCITES.*

  Subacute or  chronic inflammation of the  peritoneum, and
consequent effusion of serum into the cavity of the  abdomen, is
not a  very uncommon  disease  among  children.   Its  progress
through  the first or inflammatory stage, is often so obscure as to
escape particular attention, until effusion has taken place, and the
abdomen has become tumid and tense.   In many instances slight
pains  are  occasionally  experienced in some part of the  abdo-
men, which are usually  ascribed to flatulency or disorder of the
bowels.  The patient manifests a sullen  and fretful  temper, and
is  disinclined to engage in the usual amusements and  sports  of
children.  When pressure is made on the abdomen,  a sensation
of soreness is felt, in certain parts, generally about the umbilical
region; and the same effect  sometimes  results from coughing,
sneezing, or any sudden concussive motion of the body.  At night
the patient is.restless, and  his sleep is  broken and  " of shorter
duration than  formerly."  The face and whole surface of the
body are pale, and the countenance expressive of discontent, suf-
fering  and languor.   The appetite is variable; the  tongue cov-
ered with a white fur along the middle, with nearly clean and
pale-red edges; the bowels are irregular, being sometimes costive,
and at others affected with diarrhoea.  In cases of this kind, the
pulse  is seldom perceptibly affected in the  forepart  of the day;
but  in the afternoon, and particularly towards evening, it gen-
erally  becomes  somewhat accelerated,  contracted, quick and
sharp.   The surface  is seldom  above the  natural temperature,
  * Dr.  H. Wolff, of Bonn, is I believe, the first who  has described this disease, as it
occurs in infants. He describes it as " a peculiar form cf ascites in children," in a paper
published in Hufeland's  and Osann's " Journal des practischen Heilkunde" for May,
1829. I have not seen Dr. Wolff's memoir on this subject; and avail myself of an in-
teresting review of it, published in the 7th vol. of the North American Medical and Sur-
gical Journal. 
392                 PERITONITIS.  ASCITES.
except during the slight evening exacerbations, when it becomes
preternaturally warm and dry.
  The disease does not, however, always commence and proceed
in this obscure manner.  In some cases, " the pain  in the abdo-
men is constant,  severe, and much  increased  by external pres-
sure,  and is  attended with  vomiting, a  hot  skin, a quick,  firm
and contracted pulse,"  and great muscular  debility.
  After these symptoms have continued for an indefinite period,
varying  from five to fifteen or twenty  days, effusion begins  to
take place into the cavity of the peritoneum,  and the  abdomen
gradually becomes enlarged.  The  nature of the abdominal dis-
tention is rendered manifest by the fluctuation produced by  per-
cussion.   If  the progress of the disease be not interrupted, " the
abdomen gradually increases in size;  the inferior extremities
become emaciated; the skin at the upper and  inner  part  of the
thighs, hangs infolds;  the fluctuation of the abdomen becomes
less perceptible as  the disease advances, while the  tumefaction
continues unabated.  Every part of  the body, with the  exception
of the face,  becomes emaciated; the little patient loses rapidly
its strength;  the lower extremities are no longer able to bear the
weight of the body: in the midst of these symptoms, the appetite
may,  however, continue,  or  even be increased.   The  bowels
are in general variable, being at one  time affected with diarrhoea,
at another constipated, or at least seldom opened.  A febrile ex-
citement now occurs, and the child, in a state of extreme maras-
mus,  sinks gradually into its grave." (Wolff.)  The writer just
quoted, mentions  a peculiar appearance of the countenance occur-
ring in the second or hydropic stage, which he regards as one of
the most certain  diagnostic signs of  the disease.  " The appear-
ance referred to,  consists  of a tumefaction of the skin.at the  root
of the nose,  immediately between the eyes."  "The parents of
my patients," he says, "frequently noticed a change in the expres-
sion of the countenance, without being able to say  in what  it
consisted; but as soon as I  directed their attention to  the tume-
faction of the skin at the spot mentioned, they agreed  with me,
that the change in  the  appearance  of the child's countenance
arose  from it,  and were  surprised,  they had not discovered  it
themselves." 
                    PERITONITIS.  ASCITES.                393
  Causes.—This disease appears to be frequently the consequence
of gastro-intestinal irritation; or rather of  mucous inflammation
of the alimentary canal—the inflammation passing from the mu-
cous membrane, to the  peritoneal covering of the bowels.  Crude,
irritating  and indigestible articles of nourishment, are probably
the most  common exciting  causes of this  affection in children.
I have witnessed two  cases within  the  present  year, both of
which were preceded by prominent symptoms of intestinal irri-
tation, for many weeks before the  peritoneal affection became
obvious.   In adults, I have met with several very striking instan-
ces of subacute  peritonitis,  and consequent serous effusion into
the abdomen, brought  on by acute mucous inflammation of the
bowels, in consequence of irritating  ingesta.  There are, doubt-
less, various other causes which may give rise to this affection
in children.  It may be the result of acute or  chronic  inflamma-
tion of the solid abdominal viscera—particularly of the spleen and
liver.   Blows   and  other  injuries  inflicted  on  the  abdomen;
repelled cutaneous eruptions; cold, and perhaps  protracted con-
stipation,  may  give rise to the disease.
  When properly treated during the first stage, this disease may,
in general, be readily subdued.   " Even in the first  period of
the stage  of effusion, it is by no means incapable of being arrested;
but when neglected, mismanaged, or submitted to medical treat-
ment only in the advanced period of the  second stage, as is but
too commonly the case, death is the ordinary result."  The great
difficulty,  indeed, arises from  the gradual and obscure manner
in which  the disease frequently advances through  its inflamma-
tory stage, so that very few cases are recognized or properly un-
derstood, until effusion has taken place. During the first'or inflam-
matory stage, the symptoms are usually ascribed by the  parents,
to  worms.  Anthelmintics  are accordingly resorted  to, which
seldom fail to aggravate the disease, and  to  hasten its progress
to an incurable state.  Dr. Wolff asserts, that "most of the severe
cases which had fallen  under his notice,  were those in which
anthelmintics  had been administered, either by  the parents, or
occasionally by a physician, on the first appearance of the symp-
toms,  from a supposition that they owed their origin to the exis-
tence of worms in the intestines."  This  practice, he  says, is
                             3 E              34* 
394                 PERITONITIS.  ASCITES.
extremely pernicious.  "For although, in a few instances, worms
may be  discharged, yet  so  far from the patient's disease being
removed, every symptom becomes aggravated; the pain of  the
abdomen increases in  intensity, and is  rendered more constant;
vomiting is excited, the appetite is entirely destroyed, the  thirst
augments, the febrile symptoms are rendered more marked; and
the patient is  apt to  suffer severe  attacks of colic, soon after
eating."

   Treatment.—During the  inflammatory stage, local depletion,
and counter-irritating applications to the abdomen constitute our
principal remedies. After blood has been  abstracted by leech-
ing, to an extent corresponding with the age of the patient,  and
violence of the local symptoms, a large blister should be applied
to the abdomen, and kept discharging by dressing it with mercu-
rial ointment.   I  have never  in  children derived any  decided
benefit from pustulation with tartar emetic ointment.  The warm
bath, and fomentations  to the abdomen, may also be used  with
advantage.  Internally, small  doses of calomel and ipecacuanna,
should be regularly administered.   A fourth of a grain of each
may be given  three or four times daily; but if no mercurial oint-
ment is used externally, the quantity of calomel should be increased
to a half a grain.   Should the calomel not keep the bowels suffi-
ciently loose, a small dose of castor oil must  be occasionally ad-
ministered.  To allay general irritation, a few grains of Dover's
powder  may  be  given  in  the evening with much  advantage.
Throughout the whole course of the disease, the patient should
be restricted to  the  blandest and  simplest articles  of  nourish-
ment.   Without  strict  attention  to this  important injunction,
there  can be but little hope of a cure in this  affection.  Arrow-
root, tapioca, sago, rice, boiled milk and crackers, barley water,
weak  chicken  tea, &c,  constitute  appropriate articles  of diet.
In the second stage, that is, after  effusion  has taken place  into
the  abdomen,  leeching may still be useful if the abdomen be
tender to pressure.  At this period of the disease, much benefit
may sometimes be derived from frictions on the abdomen,  with
 mercurial ointment.  Laennec and  Velpeau  speak  in the most
 favorable terms of this practice;  and my own  experience  has 
                    PERITONITIS. ASCITES.                 395
furnished me with unequivocal evidence of its  usefulness.   Dr.
Wolff strongly recommends calomel, with  very  minute portions
of digitalis; and at a still more advanced period, "digitalis  with
cream of tartar in the form of powders."   He asserts, that under
the use of these remedies, most of the patients he treated became
convalescent,  at the end of two,  three, or at most four weeks.
Whether mercury be used externally, as recommended by Laen-
nec, or internally,  digitalis,  is doubtless a most important auxil-
iary,  and should never be  omitted after effusion has taken place.
Irritating diuretics, and  drastic purgatives, are extremely impro-
per.  They never fail  to  aggravate the  disease. 
396
VACCINA.  VACCINE DISEASE.
CHAPTER  XXXIV.
                 VACCINA.  VACCINE DISEASE.

  Much uncertainty still hangs  over  the origin  of the  vaccine
disease.  The  opinion  that  it is derived from the  complaint in
horses, denominated grease, is sustained by very imposing, though
not conclusive, evidence.  We have  excellent authority for be-
lieving, that inoculation with the  virus  of  grease, occasions an
eruption in the human subject and cow, precisely similar to that
arising  from vaccina.  Loy, Sacco,*  Decarro  of  Vienna, and
Frise, director of vaccine inoculation in Silesia, have all perform-
ed  this experiment, according to their several  statements, with
perfect  success; and so well  assured were the two latter gentle-
men, of the  identity of the two infections, that it is said  they
used  indiscriminately the matter  of  grease and of vaccina for
inoculation.  Cazenane met with  two cases in  the hospital of
St. Louis, of true vaccine disease on the hands of grooms, having
the  care of horses affected with grease.  By the application of
the recent blackish matter of this  complaint, to the raw surface
of a sore on the teat of a cow, Ring succeeded without difficulty
in producing genuine vaccina.  The same gentleman publishes a
letter from Mr. Rankin, wherein is related a case of pustular dis-
ease, closely resembling the vaccine affection, produced on the hands
and face of a  farmer by the virus of the equine disorder.   Be-
sides, it would seem probable, that persons  infected with a pus-
tular disease from this source, enjoy an immunity from the  con-
tagion of small pox.  Dr.  Jenner has  recorded a case of this

  * Neue Entdeckungen uber die Kuhpocken, die Mauke u. Schaafpocken.  Translated
from the Italian by W. Sprengel.  1813. 
                VACCINA.  VACCINE DISEASE.               397
kind.   There  can  be no doubt, however, that further and more
careful observations  are  requisite to the formation of a correct
judgment on this point.  Dr. Jenner supposes, that the infection
of grease  is transmitted through the intervention of  the male
domestics,  who, after  dressing  the  heel  of  the horse, proceed
without cleansing themselves to aid  in milking the cow.  But, in
several  countries where  vaccina is  prevalent, it  is well known
that the grooms have nothing to do with the offices of the dairy,
and  in  America,  where horses  and cows are attended to by
different persons, the latter  are  sometimes affected with the dis-
ease, though running in pastures from which the horse is exclu-
ded.  These facts, though they do not disprove the similarity of
the two viruses, throw many difficulties in the way of accounting
for one as the  consequence of  the other.
   It is  now well  known that sheep are subject to  an eruptive
disease  about  the  mouth and head, the matter of which being
inoculated, will produce effects very similar to those of grease.
It is also affirmed,  that persons, to whom this infection has been
communicated, are rendered  insusceptible  to  the contagion of
variola.   We  find  this fact  stated in a  letter, addressed by Mr.
W. Bruce,  consul at Bushire,  to  Erskine of Bombay.  After
very extensive and cautious enquiry, he  felt justified in yielding
full  credence  to the report of  several  tribes of the  natives,
that those of  them who attended to the flocks, were  not unfre-
qently affected with  an eruptive malady, caught from the sheep
amongst whom it widely prevailed,  and  were thereby completely
secured  against the attack of small-pox.  Sacco and Richter
likewise bear  testimony, that  inoculation  with  this  infection
confers  on the human subject an exemption from the contagious
influence of variola.
   The curious circumstances we have  mentioned in relation to
the marked affinity subsisting  between  the various eruptive dis-
orders furnish  no slight grounds  for the  opinion, that they are all
essentially identical  in their nature, and derived from  the  same
ultimate source.  The hypothesis with regard to variola is, that
it was originally nothing more than  the cow-pock, or the grease
of horses  in Arabia, transferred  casually or otherwise to the hu-
man system, and that by such transference and  by its  continuous 
398              VACCINA. VACCINE DISEASE.
propagation through the human species, it gradually deteriorated,
until  it had  acquired all  the virulence and  activity of what  is
now termed small-pox.*  This hypothesis is by no means extrava-
gant.  It would  seem from experiment, that  the milder sort of
small pox under proper management, may be  made to assume
by successive inoculations  so  meliorated a form as hardly to be
distinguished from vaccina.  Dr.  Adams inoculated a  certain
number of children, with lymph taken from the pustules of a mild
variety of variola, denominated by him the pearl sort.   With the
matter of the mildest of the resulting  cases,  he inoculated a sec-
ond number, and so  on, till he produced a  small  pox so  melio-
rated as to resemble  the vaccine disease.  If small pox can thus
be made  to  take on  the gentle nature of the vaccine disease, the
inference is, that vaccina under certain  circumstances may have
acquired  all the virulence of the variolous contagion.  Another
argument in favor of the identity of the two affections, grows out
of the commonly received fact, that two diseases, arising from es-
sentially  distinct  contagions,  cannot exist simultaneously  in the
 same individual.  If a subject for example, be inoculated  at the
 same time with the  virus  of small pox and that of measles, the
 influence of the one will  be entirely suspended, until the other
 has commenced and finished its course, when it too will develope
 itself and run its usual  career uninterruptedly.   Now  if the
 matter of vaccina, and that of variola be inserted at once  in sep-
 arate parts of the same body, the eruptive  distemper resulting,
 will pursue  a  simultaneous course,  exhibiting precisely the same
 character, as if  their respective viruses had  been  inoculated  at
 different periods.  This  is probable  evidence  of  their original
 identity,  how dissimilar soever they may have been rendered by
 accidental circumstances.   But positive evidence  is not wanting
 to sustain this  point.   Cases are recorded  where variolous matter
 inserted in the udders of cows, produced in them a  pustular affec-
 tion, not to  be distinguished from cow-pox.   This  observation is
 made by Richter on the  authority of Garsner.t  We  may also
 remark here, on  the authority of Da Lisa, that sheep, inoculated
 with the virus of variola, are protected entirely from what is
   * Dictionnaire des Sciences Medicales.
   f Specie!! Therapie. 
                   VACCINA.  VACCINE DISEASE.            399
called sheep-pox.  Inoculation in them is said to produce but one
pustule at the point of insertion.*  If we may rely on the correct-
ness and  veracity of Dr. Ozaman, of Lyons, and  more recently,
of Dr. Sunderland, of Barman, the original identity of vaccina
and variola, is established beyond doubt.  The former in a paper
read in the French Academy of Medicine, in July, 1830, asserts,
that the inoculation of variolus matter, mixed  with fresh  cow's
milk, will develope an eruption similar in  all respects to that
occasioned by the vaccine virus, and will fully answer for the in-
ductions  of the usual vaccine disease.t   Dr.  Sunderland's experi-
ments! would seem  still more conclusive.  The following experi-
ment performed by  him is so interesting, we will give it in detail.
A woollen bed cover is permitted to lay on the bed of a patient
who has  died of small-pox in the suppurative stage, or who, placed
in a narrow and badly ventilated apartment, is suffering from the
disease in a considerable degree,  until it is well  saturated  with
the contagion.   It is then rolled up, wrapped in linen, and spread
for twenty-four hours on the back of a cow, in such a  way that
the animal cannot throw it off.   In the same  manner,  it  is ex-
tended on the  back of each of three other cows,  for the same
length of  time; after which it is so suspended in their stall, that
they may constantly inhale the contagious effluvia as they arise.
In the course of a few days the animals become  sick and  fever-
ish; and on  the fourth  or fifth day, a pustular eruption  breaks
forth  upon the  udders and other parts,  covered  with hard skin
and displaying the usual  appearance of the vaccine disease, soon
becomes  filled with lymph.  Inoculation with this  lymph, which
precisely resembles the matter of genuine cow-pock, will produce
perfect vaccina.

  Symptoms and Progkess of Vaccina.—There are two varie-
ties of vaccina, the casual  and inoculated.  The casual cow-pock
is apt to  affect the joints  and tips of the fingers of domestics, hav-
ing the care of cattle laboring under the vaccine disease.   It  is
always more severe than the inoculated variety, on account of the

  * Mediz. Chirur. Zeit. 1809. No. xliii.  Salsbury.
  t Rev. Encyclop. Aout. 1830.
  J Journal der Praktischen Heilskunde, Jannar. 1831. 
 400              VACCINA.  VACCINE DISEASE.
 number of vesicles produced, and  the  membranous, rigid struc-
 ture of the parts involved  in  the eruption.   Inoculated vaccine
 is, in general, indicated by one pock alone, and its whole course
 may be divided into two periods.
   1st. The first period commences towards the close of the second
 day after the insertion of the virus, at which time may be discern-
 ed  a minute point of inflammation at the spot where the puncture
 was made.  This point is more distinct on the third day, and on
 the fourth,  it has the form of a very small pimple, surrounded by
 a faint and  narrow inflamed areola.  There is a gradual enlarge-
 ment of the pimple, and  on the fifth day, it  begins to display a
 perfectly regular and circumscribed outline with a flattened  sur-
 face, and a  small depression at the centre, somewhat darker than
 the rest of  the surface,—an appearance it  retains  throughout its
 whole subsequent course.  The pimple about this time becomes
 a vesicle, containing a limpid fluid, and presents  a  dull whitish
 aspect.  From  the fifth to the ninth day, the circumference of
 the pock continues to enlarge, without its elevation being percep-
 tibly increased, so that its flattened appearance becomes still
 more remarkable.
  2. The second period begins at the full maturity of the pustule,
 which  takes place on the ninth, when constitutional derangement,
 if any occurs, is apt to supervene.  In some  instances,  the axil-
 lary glands  at this period  become irritated and swollen, and  the
 patient complains of drowsy languor and  faint  creeping  chills,
 alternating  with flushes of heat.   Constitutional  symptoms  arc
 not unfrequently  altogether absent.  By the tenth  or  eleventh
 day, the belt of inflammation around the pustule, that began on
 the eighth day to widen, has become a broad, beautiful and viv-
idly red areola  encircling  the  pock.   The areola is now perfect,
and  attended  with some degree of tumefaction  and hardness.
The central indentation of the pustule  begins, on the  eleventh
day, to assume a darker hue, and this darkness gradually spreads
towards the circumference: so  that by the fourteenth  day,  the
surface of the pock is transformed into a brown scab, which grows
darker and darker, acquiring a deep brown or mahogany color.
In a few days more, the circumference of the  scab  becomes loos-
ened, but  the centre still retains its attachment, till between the 
                  VACCINA.  VACCINE DISEASE.              401
third and fourth week from the time of vaccination: the whole
then falls off, leaving a slight, regularly defined depression in the
skin, and a scar which is indelible.

   Deviations.—Such  is the ordinary course of the disease, for it
is occasionally  subject to deviation.  The  period,  for  example,
intervening between the insertion of the virus and appearance of
the pustule, is  sometimes  prolonged  to the tenth, fifteenth or
even twentieth day.  In some cases, the whole course of the disease
is completed in eight or nine days, well-formed lymph being pro-
duced by the fourth  day.   When the umbilicated indentation in
the centre of the pustule is  wanting,  there may  be  two pus-
tules, partially blending with each other.   It is seldom that inoc-
ulation  produces more than one pock, but occasionally one or
more smaller pustules manifest  themselves in the vicinity of the
primary one.  Instances indeed have  occurred,  where they ap-
peared  in  considerable numbers on different parts  of the body.
In the report of the central vaccine committee of France in 1818,
19, it is stated that a spontaneous eruption of  many  pustules had
occurred in several cases after vaccination; and moreover, that the
matter of this eruption had the  power of inducing  as perfect  a
disease as that excited by  the virus of the  primary pock.
  Considerable  inflammation  sometimes supervenes on the day
succeeding  the vaccination, and an  elevation  of  the  cuticle
takes place at the point where  the puncture was made.  In this
case, the failure of the operation may be considered certain. The
inflammation,  after  continuing  a day or  two, speedily subsides,
without leaving  any  local  affection.
  Instead of a vesicle, a true  pustule is occasionally formed, the
inflammatory action  arising on the  day after the vaccination, or,
at the furthest, on the succeeding one.  A well-defined areola en-
circles the pustule,  in which instead of a  depression, there is a
conspicuous elevation of the centre above the ridges. Its increase
is rapid, and about the fifth day, it  is converted into a yellowish
brown scab, which soon disappears without leaving any scar.   In
this case, also, the operation is abortive and  should be repeated.

  Spurious Pock.—According to Willan, there are three varieties
of spurious pock.  In the first, though the vesicle is perfect, there
                             3F               35 
402              VACCINA.  VACCINE DISEASE.
is no areola around it on  the ninth or tenth day.   In the second,
the vesicle is much smaller than the genuine vesicle, and is pearl-
colored, flattened, without a rounded or prominent margin, with
a hard, inflamed  and slightly elevated base, and an  areola of a
dark-red color.   The  vesicle in the third variety, is  small  and
pointed, with a very extensive, pale-red areola. The areola in the
two latter varieties, are observable on the seventh or eighth  day,
and disappear about the tenth. A very small scab is then formed,
which is not so regular in  its shape as that of the true vesicle.
The spurious disease may arise from the following causes;  1st.
The existence of some cutaneous distemper, capable of counter-
acting or perverting the action of the genuine vaccine virus.  2d.
Certain idiosyncrasies, or a  depraved condition of the system,
vitiating or  impeding in some way the  regular operation of the
virus.  3d. Vaccination  with spurious  matter, or with genuine
matter whose virtues have  been  impaired  by long keeping; or
with matter taken from a true vesicle at too late a period. Beside
these, friction with the clothes, or by other means, so as to cause
a rupture of the vesicle, and the frequent abstraction of its lymph
by punctures, may be  considered as depriving  the disease of its
genuine character.
   The spurious  and true cow-pox sometimes pursue their course
simultaneously in the same  individual, in which case it does  not
seem that the protective power of the genuine virus is in any de-
gree diminished.

   Diagnosis.—In  attempting to distinguish true vaccine from
false, we should carefully observe the following particulars:
   1st. In  the genuine disease, inflammation, saving  that  which
occasionally arises from the irritation of the puncture, is scarcely
observable until the  third day, and sometimes  considerably later.
On the other hand, the spurious affection is marked by an  ele-
vation of the cuticle and no slight degree of inflammatory action,
so early as the second day.
  2d.  The small inflamed  point, in  true vaccina, appearing in
two or more days after the  insertion of the virus,  has a gradual
increase until the seventh day after  its  first manifestation, when
it is in a state of perfection.   The spurious pustule becomes ma- 
                 Vaccina,  vaccine  disease.              403
tured, and finishes its course in, a much shorter time; the scab-
bing commences on the third or fifth day after the development
of inflammation.
  3d. A beautiful, circular, and well-defined areola almost always
surrounds the pustule of genuine vaccina, and  is seldom perfect
until  the seventh or eighth day.  In the false  disease, the pus-
tule is begirt with an  irregular, superficial  inflammation, super-
vening on the first or second day after the appearance of the pus-
tule;  and the pustule itself is more like a common festering sore
occasioned by a  thorn, than a pustule excited by the vaccine
virus.
  4th. The  genuine pustule is  perfectly and regularly defined,
with a flattened surface, and a slight central indentation, and con-
tains a colorless,  limpid fluid.  The spurious pock is more  eleva-
ted, not depressed in the centre, is irregularly circumscribed, and
contains  an opaque purulent matter.

  Remediate  Treatment.—General remediate treatment is  rarely
required in the inoculated form of vaccina.  Febrile excitement
occasionally exists, and  even a slight exanthema may appear, in
which case we should direct a low diet, diluent drinks, and  a gen-
tle  aperient,  together with spiritus mindereri or sweet spirits of
nitre.  The  vesicle should  be especially shielded from  friction,
whereby it is apt to be greatly irritated, particularly about the
time when the areola is making its appearance.  From friction
or other  cause, the inflammation and swelling around the pustule
sometimes become so severe as to demand immediate relief.  Cold
water, a weak solution of sugar of lead, or poultices made of lead-
water, should be  applied to  the part, to allay pain and inflamma-
tion,  at  the  same time that laxatives, with some of the milder
refrigerant diaphoretics are given internally to subdue febrile
irritation.

  The relation  op  Vaccina with other diseases.—I have
thought  it proper to defer  until now,  the  consideration of the
relation of the vaccine disease with other affections, that I  might
present in a connected form  all I have to say on this  part of our
subject.  It was early noticed, that the infection of vaccina  had a 
404              VACCINA.  VACCINE DISEASE.
tendency to correct a general  depravation of the system and to
remove various  chronic complaints, especially those of the lym-
phatic  and cutaneous systems.  There are  well authenticated
cases, in which crustea lactea, scrophulous ophthalmia and tumors,
and certain varieties of scaly  tetter have been entirely cured by
the constitutional influence of the vaccine virus.   Herpetic erup-
tions,  after vaccination,  not unfrequently assume an  appearance
resembling that of vaccine pustule, and fade away with the de-
siccation and falling off of the scab.   Violent whooping cough has v
been  arrested at the moment of the appearance of the eruption,
and  permanently  cured.  Of  the  power of vaccina  to  mode-
rate and abridge the course of pertussis, I have myself witnessed
many  examples.  In  this respect,  it differs greatly from both
casual  and inoculated small pox, which have been known  to ex-
cite the active developement of disorders, to which there existed
previously a latent disposition.   In accounting for these peculiai
effects of the vaccine  disease, we can hardly suppose that its in-
fluence over other disorders  is specific in its nature, otherwise it
would be more constantly and uniformly exerted. It may be consid
ered rather the result of an irritation, universally diffused through-
out the system, penetrating the minutest portion of living fibre; for
it is well known that the creation of a comparatively slight gen-
eral irritation is sufficient, at times, to relieve a graver disorder
already existing.  We may observe, that the meliorating influ-
ence of vaccina over other complaints, is generally  more mani-
fest, when a  considerable  degree  of irritation  is  produced.
Hence, when  such  an influence is  desirable, it may be proper
to insert  the  virus  by several  punctures.
  The diminution  in the prevalence of small pox,  occasioned
by the general introduction of vaccination, is, if we may be-
lieve  Dr. Watt, very curiously associated with  the  increase of
measles.   His  observations, which  are restricted to Glasgow, go
to prove,  that  the  increase of  measles  in that city,  since the
adoption of vaccination, has borne  a nearly equal proportion to
the decrease of small pox.   If such be the fact, it should perhaps
be ascribed to peculiar local causes, especially as further obser-
vations have afforded no countenance to his opinions. 
                 VACCINA.  VACCINE DISEASE.             405
  As a prophylactick against that terrible scourge the small pox,
the virtues of the vaccine disease are now happily and extensively
known.

  Origin of Vaccination.—Dr. Jenner has the inestimable honor
of introducing  this  operation to the notice of the world; but
long before his  time, it had been known by agriculturists in some
parts of England,  that an infection in the  hands and  about the
joints of the fingers  received from a cow laboring under what is
now called vaccina,  would confer an immunity against the  small
pox.  Benjamin Jesty, a farmer of  Dovnbay, in  the isle of Pur-
beek, so early as the year 1774, inoculated himself, wife, and two
sons, with virus taken  from the pustules on a cow's  udders, suf-
fering with the vaccine disease.  He did this, to protect  himself
and  family from the  attack of small pox, at that  time prevalent
in the vicinity.  The operation  was perfectly successful.*  But
the prophylactick power of the vaccine disease had not only been
previously known  in the dairy  counties of England, but also in
different parts of Europe, and, if we may rely upon the testimony
of Humboldt, even in several districts of South America.   It has
been  attempted, unsuccessfully  as  we think,  to prove that the
first suggestion of the expediency  of  inoculation with vaccine
virus, was made by  a native of France to an  English physician,
and  by him communicated  to Dr.  Jenner.   But from whatever
source this gentleman may have derived the notion of vaccina-
tion,  to him  alone must be awarded the honor of its first intro-
duction to general  notice.  Successful experiments were per-
formed  by him with vaccine matter,  so early as  the  year  1796,
but the result of his  enquiries was not,  until  two  years after, an-
nounced to the public.  From that period on, the knowledge of
the virtues of vaccination spread rapidly throughout Europe and
this  country, and  there is now no civilized people  on earth,
amongst whom  its blessings have not been realized and gratefully
acknowledged.

  Prophylactick power.—For a  while  the  prophylactick  pow-
er of vaccination  was  generally thought  to be  complete  and
                 * Edinburgh Journal, vol. 1st, p. 513.
                                               35* 
406            VACCINA. VACCINE DISEASE,
universal, and whoever presumed to hint doubts of its cfticacy in
any case, was  sure  to meet with  the indignation or contempt  of
the profession.  Since  then the general sentiment  has undergone
a considerable change.   From some cause or other, as yet unre-
vealed, so many well-attested cases of failure  in  the preventive
power of vaccination have taken place, and so remarkable of late
years has been the progressive increase of such  cases, that the
vaccine disease is no  longer considered by practitioners a suffi
cient safeguard in every case from the variolous contagion.  "This
circumstance," says Dr. Gregory, " cannot be met  by a reference
to the fact, that small-pox once gone through does not always pro-
tect the  subject from a  second attack."  Cases of variola  after
vaccination are far  more frequent than second attacks of that dis-
ease.  Dr. Gregory has given a table of the total  number of ad-
missions into the small-pox hospital, in ten different years.   From
this statement it appears, that in  the year 1810, the proportion of
cases of small-pox  after vaccination to the whole  number of ad-
missions, was as 1 to 30, while in 1815, it was as 1 to 17; in 1821
as 1 to 4; and during the year 1823, as  1 to Si. We may remark,
however, that as  this is  the register of  a single hospital, certain
local circumstances  may have occasioned the augmenting ratio of
cases: no general  conclusion can therefore be legitimately drawn
from the facts set forth.  The statement, moreover, may be inex-
act, seeing there  could  be  no infallible method of determining
whether the vaccination  had  been genuine and produced its con-
stitutional effects.
   Notwithstanding  these facts, vaccination must still be regarded
as an invaluable means for lessening the amount of mortality, and
as deserving all confidence  as a protecting  power against small-
pox.   For although it may not, in many cases, render the system
wholly insusceptible to the variolous infection, yet the number of
instances in which it affords perfect immunity from  small-pox, is
beyond all comparison  greater than that in which it fails to afford
complete protection; and even where it does not entirely subdue
the susceptibility to the small-pox, it almost invariably lessens it to
such a degree, as  to render this latter disease so mild and simple,
as in most instances scarcely  to require  any remediate attention.
   By many it is believed, that the constitutional influence of the 
                  VACCINA.  VACCINE DISEASE.              407
 Vaccine virus  gradually wears out, until  the  system  regains  its
 original  susceptibility to the contagion of small-pox.   In opposi-
 tion to this hypothesis it  is remarked, that variolous cases occur
 with nearly equal frequency at all periods after vaccination,—as
 many indeed being met with at one year, as at five, ten or fifteen
 years subsequently to that operation.  The results of experience
 however, are favorable to the hypothesis. Some have limited the
 vaccine  impression to ten years.   Dr. Brown  has inferred from
 his observations,  that immediately after vaccination, the antiva-
 riolous influence of the virus is nearly perfect;  that in about three
 years afterward, the created ^insusceptibility is so  much diminish-
 ed, as  readily to allow the operation of  the variolous contagion;
 although  the disease then occurring will appear in a mitigated
 form; that at the period of five or six years, hardly any security
 from  small-pox  is enjoyed, and so diminished  is the influence of
 the vaccine virus, fhat if variola do occur, it will very nearly ap-
 proach  in severity to the natural  disease; lastly, that the consti-
 tutional influence of vaccina cannot be depended upon any longer
 than  six  years  from the  period  of  vaccination.   Dr. Leo
 Woolff, in an  interesting memoir on this subject, has  adduced
facts and  reasonings to show, that the vaccine influence is effaced
by the constitutional changes that take place at the period of pu-
 berty.   That the prophylactic power of vaccination progressively
 diminishes, until  it is perhaps entirely worn  out, I  am myself
 much inclined to believe, from  facts that have come under my
 own observation.  But the attempt to determine its gradual sub-
sidence by any accurate,  fixed periods, must  necessarily be  an
 almost impracticable task; since it  may well be supposed, that
 idiosyncrasies, modes of living, accidental as well as  innate pre-
 dispositions, and perhaps habitual extraneous agencies, may occa-
 sion many variations in this respect.  The general fact or possi-
 bility of the gradual effacement of the constitutional influence of
 vaccina, should admonish  us of the propriety of re-vaccinating, in
 order to renew the prophylactic impression. This practice is certain-
 ly rational, and cannot be detrimental, as a precautionary measure.
   The manner of Vaccinating.—Vaccination has been perform-
ed in three ways—by blistering,  incision, and  puncture.  The 
408             VACCINA. VACCINE DISEASE.
first, being apt to create an irritation detrimental to the vaccina-
tion, and the second, endangering the washing away of the virus
by the great flow of blood, are now generally superseded by the
method of puncture.  The spot usually selected for the operation
is  at the lower  insertion of the deltoid  muscle.   The posterior
part of the  arm of the person to be vaccinated, is to be firmly
grasped with one hand, while with the other, the lancet, at whose
point is a tangible drop of the virus, is to be inserted a few lines,
from above, downwards.  It should be continued a few moments
in the puncture, and its  point pressed against the lower surface
of the wound. It is expedient to  mjike several punctures, merely
that the chances of a successful operation may be increased.

    The  character  of genuine  Virus.—The vaccine  lymph,  up
to the time when it begins to desiccate, is a limpid, viscous liquid,
colorless, inodorous, and of a salt,  acrid  taste.   Exposed  on a
smooth, flat surface, it dries rapidly, but without  losing its tran-
sparency.  Chemical observation  has taught us, that it is decom-
posed and rendered inert  by the action of light and  heat; and
that even at the ordinary temperature, the continued influence of
the atmosphere greatly  impairs its virtues.  To obtain the virus,
the edges of the pustule must be punctured in  several points.
The lymph will  then ooze out, and may be collected and preser-
ved between glass plates.  Jenner recommends that it should be
taken  just before the appearance of the areola.   He  thinks its
virtues diminished after  the  manifestation of the efflorescence,
and  always, if possible, avoided collecting  it beyond the eighth
day.   Of late years, and especially in this country, vaccination is
most  commonly performed from  the scab.  The virus may  be
preserved  longer  uninjured, in  the form of scab, than in any
other mode.  Matter of six or even ten months old, if kept in this
way, will readily  communicate  the infection.  No scab, except
from a perfect pustule, should  be taken.   It ought to be smooth,
of a dark-brown,  or  mahogany  color,  and rather brittle  than
tenacious in its texture.  When  used, the margin, which is of a
lighter hue than the rest, should  be removed with a knife,  and a
portion of the remaining dark,  hard, internal part reduced  to
powder on a glass, and moistened or dissolved in a little cold water. 
                  VACCINA.  VACCINE DISEASE.              409
  In whatever way the virus be procured, we  ought carefully to
examine whether  the  person, from  whom it  is taken, be in a
healthy state; whether he may not be the subject of some cutane-
ous affection, or a vicious  constitutional taint.   Carelessness on
this point may result in incalculable injury.  I have several times
known  obstinate  and  alarming  cutaneous distempers communi-
cated to children by vaccination with virus from  an  unhealthy
person.   Unprofessional people  have a notion, that various trou-
blesome eruptions are  occasioned by the vaccine disease; and it
is somewhat sanctioned by enlightened observation.   Accidents
of this kind, however, may for the most part be charged upon that
carelessness, of which we have just spoken.

  The condition of the person to be vaccinated.—Age generally
would seem to have little  or no influence on the success of this
operation.   Certain  idiosyncrasies are occasionally met with in
persons of every age, counteracting completely the action of the
virus; and sometimes  cases  occur,  in which  several  successive
operations are requisite,  before success is obtained.  Vaccination
is commonly performed in childhood; but,  as a general rule, it
should not  be attempted in children under six weeks old.   The
constitutional disturbance, occasioned by the agency of the virus,
is more considerable in  mature  years, than  early life.  The ex-
istence of disease does not generally contra-indicate the propriety
of the operation, if we except herpetic eruptions and some other
cutaneous disorders.   Nor does dentition nor pregnancy consti-
tute any valid objection to its performance, provided there be no
severe derangement of the nervous system.
  As to the season for vaccination, it  appears to be equally suc-
cessful throughout the year.   It would seem,  however, that the
course of vaccina is  retarded  by  cold  and hastened by  hot
weather.
  The  fact, that important varieties and modifications of the vac-
cine disease are occasioned by the existence of certain cutaneous
affections,  is well established,  and  merits  particular attention.
Dr. James, in a paper published in the sixty-sixth  number of the
London Medical  and Surgical Journal, states that a single serous
blotch  on the skin, during  the progress of the vaccine vesicle,
                           3G 
410              VACCINA.  VACCINE DISEASE.
may cause such irregularity, and deviation from the natural course
and character of the disease, that it cannot be depended on as a
prophylactic against the variolous infection. In a letter addressed
by him to  the medical  profession  generally, in April, 1821,  he
observes—" I have observed abrasion of the cuticle produce the
same effect,—such, for example, as we find in the nurseries of the
opulent, as well as in the cottages of the  poor, behind the ears and
on many other parts, where  the cuticle is  tender.   We find irre-
gularity in  the vaccine vesicle, if the skin is beset with herpetic
blotches, or even simple serous oozings from  an abraded cuticle.
A speck behind the ear, that might  be covered with a split pea,
is capable of disordering the progress of the vaccine vesicle."

   Test of vaccination.—The increasing number of failures in the
protective power of vaccination, has by many been attributed, in
great part, to an insufficient inoculation.  It is, therefore highly
important,  to ascertain, in  some way, whether the constitutional
impression  of the virus  has been  procured.   Bryce's method of
 determining was, to re-vaccinate with matter from the pustule of
the first vaccination, at  the end of the fifth or beginning of the
sixth day after the  operation, between  thirty six and forty eight
hours before the appearance of the areola. If the disease be per-
fect, a pustule will  arise at the point of the second insertion, but
it will become accelerated in its course, so that about the second
 or third day from its coming forth, it will be surrounded with an
 areola, increasing and fading away, pari passu, with that of the
 first  pustule. If, on the contrary, the first disease be not sufficient,
 the irruption from  the  second  insertion will  pursue its  regular
 course as in other cases.   This is now to be regarded as the pri-
 mary disease, and  the  same method of re-vaccination  is to be
 practised, with matter from its pustule,—and so on, until a perfect
 affection shall be induced.  Others have proposed to re-vaccinate
 about twelve days after the operation.  If this has  been sufficient,
 the second vaccination will either  not succeed at all, or give rise
 only to a  spurious or an irregular pock.  But the most certain
 test  is inoculation with small-pox matter,—a test, from which we
 derive at  once  our reliance on the general  protective power of
 the disease, and on its efficacy in the particular case. 
                     VARIOLOID DISEASE.                  411
  A distinct, circular, radiated, punctulated, and not very large
cicatrix is a pretty certain  indication, that the vaccine  affection
was perfect.   When the scar " is large, and bears the marks of
having been formed by high  local inflammation, and wants the
distinctive  character just mentioned,"  there is much reason  to
apprehend, that the system has not been secured against second-
ary variolous disease.
                CHAPTER XXXV.


                    MODIFIED SMALL POX.

                 Sect. 1.   Varioloid Disease.

  The  term,  varioloid,  is applied to certain  forms of eruptive
disease, resembling  small pox in their general character, and
supposed  to  originate from the variolous contagion.  We find
irregular forms of variola, described in  the earlier writers, under
the names of vesicular,  pustular, spurious small pox; swine pox,
sheep-pox, stone-pox, horn-pox, &c.   They were developed both
in persons who had been affected  with  the genuine disease, and
in those who had never suffered from it, and  were all referred to
some irregular action of the small pox virus.
  The  introduction  of inoculation first, and after it of vaccina-
tion, seems to have  influenced these anomalous affections in  no
other way, than by increasing the  frequency of their occurrence.
Soon after the epoch of vaccination, spurious eruptions  of this
sort were  more particularly observed.   A few believed them to
possess a  specific character, and to  arise from a peculiar conta-
gion; a majority regarded them as chicken pox; whilst  a third 
412                   MODIFIED SMALL POX.
class  deemed them nothing more,  than  the result of variolous
contagion, acting upon systems partially protected by the vaccine
disease.   During the last fifteen years, varioloid distempers have
been on the increase.  In various countries, they have frequently
within this period, prevailed  in extensive epidemics,—affording,
by the way, a strong presumptive proof of the gradual obliteration
of the vaccine impression from the system.
  As mentioned above, three opinions have been held with regard
to the nature and origin  of  this disease, some identifying it with
varicella, a  few contending for its  specific nature and  peculiar
origin, and others  asserting it to be  an imperfect result of the
variolous  influence.  The last opinion is the one now generally
adopted by the profession, and its correctness is sufficiently evin-
ced  by the  two following  proofs:  1. The  varioloid disease  is
known to have arisen directly and exclusively from the contagion
of variola; and inoculation with small poxvirus has produced it in
its full character,  in persons who had  been perfectly vaccinated.
I, myself, have produced a well-marked varioloid eruption, by in-
oculating with variolous  matter, an individual who had  been sat-
isfactorily vaccinated  about ten  years before: 2. The varioloid
does sometimes  produce genuine small pox in the unprotected.
Two striking examples of this sort I have  myself witnessed,  and
the testimony on this point is abundant and unequivocal. That
the disease when acting upon the constitution of persons, who have
never undergone the vaccine or variolous infection, does generally
reproduce itself in its characteristic form, and not occasion true
variola, detracts nothing from the weight of the argument  just
offered: for it can hardly be doubted, that in a majority of vario-
loid cases, the small pox contagion is so modified or meliorated,  as
to be incapable of giving rise to the genuine affection, except
where the susceptibility  to its influence is extremely acute.
  The works of several  recent writers abound in observations,
illustrative of the variolous origin of  this disease.  Dr.  Thomp-
son, particularly has adduced conclusive  evidence on this point;
and to his work, as also  to my own chapter on varicella,  1 would
refer the reader, who may wish to satisfy himself more fully upon
the subject.
  It is evident from what has been said, that small pox, both ca- 
                      VARIOLOID DISEASE.                  413
sual and inoculated, and the vaccine disease,  are the principal
agents that modify the action of variolous contagion, in such a man-
ner as to give rise to varioloid.  Independent, however, of these
causes, we must not forget, that certain  idiosyncrasies or peculiar
atmospheric conditions may exert  a similar modifying influence.
As  the degree and manner, in which these different  causes ope-
rate,  are  extremely various, it is  obvious that the  irregular  or
varioloid  affections, resulting from  their action combined with
that of small  pox virus,  must be  correspondingly diverse.  We
accordingly find the diversity so  great,  that no description can
be given of them, that can have more than a general application.
1 confine myself at present to that form of varioloid  disease,  re-
sulting from small pox virus, modified by previous vaccination.
  In many instances,  as has been  already stated, the vaccine  af-
fection  entirely  destroys the  susceptibility to variolous  conta-
gion.    The  system,  in  other cases, is  but partially protected
by  its influence; or if the  susceptibility  be  temporarily  taken
away, in the lapse of years, it is again gradually acquired  by
the constitution.   The disease that  results from the action  of
small pox virus upon a  system, thus partially deprived of its vari-
olous suceptibility, and which of late years has become so com-
mon,  deviates  more or less conspicuously from regular variola;
and is in a great measure  divested of the dangerous character
of the latter affection.
  Small pox occurring a second time does not so often assume the
varioloid  character,  as  when it  supervenes  after vaccination.
But it must be confessed, that its  occurrence after vaccination is
more common than after casual variola.  This may in  part  be
ascribed  to  some imperfection or  disturbance of the  vaccine
affection,  by which  its   prophlactick powers   are impaired  or
destroyed.  Dr. Jenner believed,  that in every case where small-
pox happens after vaccination, it is owing to an imperfection  of
the vaccine vesicle, occasioned  by one or more of the following
circumstances: 1. pre-occupation  of the skin by some chronic  cu-
taneous affection; 2. the use of spurious vaccine matter; 3.  incau-
tiously  depriving the  vaccine vesicle of its lymph, or otherwise
iniuring it by external violence,  so as to give rise to common
phlegmonous inflammation.   Nevertheless, there can be no doubt
                                               36 
414                 MODIFIED SMALL POX.
that modified small pox or a second variolous infection, resulting
in a spurious form of the disease, may and often does occur after
the most complete and satisfactory vaccination.  It would seem
from the observation of Dr. Gregory, that the aptitude to vario-
lous infection after vaccination,  prevails in an especial  degree
in some families.   The same writer infers from facts which have
come under his notice, that modified small pox after the vaccine
disease is most apt to occur in persons between the ages of fifteen
and twenty-one.  My own observation though limited, fully sus-
tains this inference: by far the greater number of varioloid cases
I have yet  seen, were in young persons of the age just mentioned.
This  accords with the opinion before noticed,—that the vaccine
impression is gradually weakened or partially obliterated, during
the constitutional changes that take place about puberty
   The precursory symptoms of this affection are not generally
severe.  In a large majority  of cases the eruptive fever is so mild
and inconspicuous, as scarcely to attract attention.  Sometimes
however,  its invasion is marked  by as much intensity of febrile
excitement,  as happens in the  severe  forms of small pox.  The
succeeding eruption in these cases is not, as might be looked for,
necessarily violent or extensive: but a small crop of little pustules,
varying in number from one  to twenty, may ensue, and dry  up
in the  course of four or five days.   The  duration of this stage is
no less irregular,  terminating sometimes as early as the  second
day, and  at others, not until  the  fifth day from its commence-
ment.   In all cases, whether of a mild or severe character, the
eruptive fever  completely subsides, so soon as the  pustules ap-
pear;  so that the patient no longer finds it necessary to keep
his bed.
   A transient uniform efflorescence precedes in many cases the
eruption:  a rash, resembling measles,  is also not an unfrequent
precursor.   Sometimes  the varioloid  exantheme  commences on
the limbs; frequently it  is developed  at the same time on differ-
ent parts of the body; but generally it makes its first appearance
on the face.  In the beginning, it almost invariably exhibits the
form of small, firm elevated, red papulae.  These pursue different
courses,—many of them  drying off without undergoing any fur-
ther change, while the remainder gradually assume the vesicular 
                      VARIOLOID DISEASE.                 415
or pustular form.  The vesicular transformation is completed  in
the course of the first  day;  occasionally, not  until  the  second;
The vesicles are small, acuminated, filled with a limpid, watery
fluid, and in many instances encircled by a faint red areola,  so
as to resemble  in a certain degree  the vaccine pock.   They
usually  burst about the third or fourth day, or wither  away—
without assuming a pustular character, the  fluid  in them becom-
ing whey-like in appearance.  "This variety," says Dr. Thom-
son, "in the mildness of the eruptive  fever; the strictly vesicular
character, short  duration and mode of disappearance of the erup-
tion, corresponded (in the epidemic he described) so  exactly with
the descriptions usually given of the mildest varieties of chicken
pox, as not to have been distinguishable from that disease."
  In many cases, the vesicles become filled  with a puruloid fluid,
present  a slight central indentation,  and,  by the  third or  fourth
day, are converted into thin dark scabs.   These separate and fall
off usually about the sixth or  seventh day after  the appearance of
the eruption, but sometimes not until the tenth or even twelfth day.
Occasionally the vesicles remain distended with a colorless lymph
for four or five days, and then become pustular containing a pus-like
fluid.  They usually continue in this state  longer,  before desic-
cation and scabbing commences.  In some cases the scales being
detached, are replaced, particularly on the  face, by  elevations in
the form of warts, which disappear but slowly and by successive
desquamations.   (Cazenene.^
  The quantity  of eruption varies in  different  instances,  from a
single one  to so  great a number, as  to cover  the whole surface'
of the body.  From  the description  just given of the course of
the  disease, it is evident, that papulae,  vesicles, pustules, and
scabs, are frequently to be seen intermingled upon the same indi-
vidual.   Where  the eruption is successive  during several days,
as sometimes happens,  this appearance is still  more  conspic-
uous.
   The  complaint not  unfrequently assumes so  nearly the aspect
and  character of distinct small pox, that  it is  difficult to decide
for the  first five  or six  days, whether it should be regarded as a
modified or regular variolous affection.  In cases too, where the
varioloid eruption is extremely abundant, it is  quite possible to 
416                 MODIFIED SMALL POX.
mistake  it sometimes  for the confluent form of variola.  Vei
generally however, the smallness of the pustules, the whey-likc
appearance of their contents, and the early period at  which de-
siccation and scabbing commence, will distinguish such cases from
genuine  small pox.  Dr. Thompson observes,  that the areola and
its pustule sometimes  exhibit a remarkable resemblance to the
vesicle and  areola of cow pox,—a resemblance that betrays the
mixed variolous and vaccine character of the  disease.
   The duration of this complaint is from six to twelve days, and
its termination almost  always favorable.  Varioloid pustules very
rarely leave any  marks on  the  skin.  When the scabs remain
a long time they occasionally leave  slight pits,  but much more
commonly, warts or fungoid elevations.
   From  the foregoing account,  we  perceive how extremely di-
verse are both the local and general phenomena of this affection.
In one case it presents the characteristics of varicella, in anoth-
er, it can hardly be distinguished from small pox, and in a third it
bears a striking  resemblance to the vaccine pustule.  It differs
chiefly from genuine small pox, in its general  mildness, its strong
tendency to a favorable termination, and in the briefness and ir-
regularity of its course.

   Diagnosis.—The following circumstances may  be stated, as its
common and characteristic features:
   1. The eruption comes forth in successive clusters, at uncertain
periods between the second and fifth day.
•   2. The eruption rarely, if ever, enters into  complete suppura-
tion, as happens in small pox.
   3. The eruption is  unaccompanied by fever, except  in very
violent cases.
   4. Desiccation  or scabbing invariably occurs much earlier than
in regular variola.  It commences generally on the fifth or  sixth
day, and the  scabs usually separate  by the  eighth or ninth
day, leaving red  disks or tuberculous elevations instead of de-
pression.

   Treatment.—In the milder cases  of varioloid affections,  little
or no remedial treatment is necessary.  In all instances, however, 
                         VARICELLA.                       417
it will be proper to exhibit a mild  purgative  in  the  commence-
ment of  the disease, and throughout the febrile stage, the  diet
and drink ought to be simple, unirritating  and cooling.   When
the irruptive fever is very high, the abstraction of a few ounces
of blood  will  be beneficial.  In general, however,  the  febrile
reaction  may  be sufficiently restrained, by free ventilation, cool
drinks, refrigerant diaphoretics, laxatives and rest.  Where, in
short, the disease is so severe as to demand any medical attention,
the treatment  is to be conducted on the same  plan that is proper
in simple small-pox.
               Sec. 2.   Varicella.   Chicken-pox.

   There is, perhaps, no  subject in medicine, that has given rise
to greater diversities of opinion, than the disease termed Varicella.
From -the first notice of its  existence to  the present time,  there
seems to have been  no fixed, general sentiment, with  regard to
its origin or pathognomic symptoms.   The earliest records of va-
riola inform us of the occurrence of various exanthematous  affec-
tions, coincident with the prevalence of small-pox, and analagous
to it in character.  These affections were at first generally  be-
lieved  to be mere  varieties of spurious small-pox, and  to derive
their origin  from variolous  contagion.   Rhazes, who wrote  in
the beginning of the tenth century,  and  has  given  us  the first
history of variola, speaks of certain spurious eruptions, of a vario-
loid  character, whose occurrence in  individuals  afforded  them
no protection against epidemic small-pox.   In the same uncertain
style, we find several succeeding authors, describing such  erup-
tions under the various names of improper, bastard, lymphatic, crys-
talline pox, &c.  Viden Vidius, in the sixteenth century, thought
himself justified in  distinguishing them from  small-pox, and  he
described them under the  name of chrystalli.  Subsequently,
Sennertus noticed  certain varieties of variola, eruptions of wrhich
instead of being pustular, were vesicular in character, and  dried
off in the course of a few days.   Sheep-pox, horn-pox, and wind-
pox, were also enumerated by him, and the two latter terms, he
conjectured, designated the  same  affections  as the  crystalli of
                           3 H             36* 
418                  MODIFIED SMALL-POX.
earlier writers.  Riverius  speaks of these varioloid  affections as
common in his time, and introduces a description by Ingnassius,
of the variety denominated crystalli.   The eruption was similar
in size and figure to that of variola, but consisted of limpid vesi-
cles  filled with a  watery fluid, and desiccating on  the third day
without danger.   Sydenham, in  his description of an epidemic
small-pox,  alludes to a spurious  variety, unconnected with the
genuine disease, and inefficient  in securing the constitution from
variolous contagion.  In  the latter part of the seventeenth cen-
tury, the term chicken-pox, a name in general use out of the pro-
fession, was first introduced into medicine  by Morton.   It was
used by him to designate what he regarded as the most benignant
form of variola; for it was his opinion, as well as that of the pro-
fession  generally  who  had preceded him, that varicella was  a
mere variety of small-pox.  Some, however, even at this period,
believed it to  be a disease sui generis—but  all concurred  in the
opinion, that  its occurrence never conferred an immunity from
small-pox.  In 1767, Dr. Heberden published his memoir* upon
chicken-pox,  in which he asserted the specific  character of
varicella, its identity with swine-pox, and its origin from a pecu-
liar  contagion, altogether distinct from that of small-pox.  Very
soon after  this we have from Dr. Sims, an  account of a certain
eruptive disorder, which he termed  chicken-pox.   The  descrip-
tion of the eruption as witnessed by him, differs somewhat from
the  characteristics of the disease as laid down by Dr.  Heberden;
but  they both agree in regarding variola and varicella  as  radi-
cally distinct  affections. This soon became the general sentiment
of the  profession,  and  so continued till within the last eighteen
years, during which its validity has been strongly disputed by sev-
eral ingenious writers.   MM. Berard and de Lowit,t from obser-
vations on  a small-pox epidemic during its prevalence at Montpe-
lier,  came to the  conclusion, that variola and varicella, though
differing in their  outward  manifestations,  could  ultimately be
traced to the same contagious principle.  Dr. Thomson^ particu-
larly, an  able investigator  of this subject,  has  in our opinion

  * Transactions of the College of Pbgucians, vol. iv.
  t Essai sur les  Anomalies de la Variole et de la Varicella.
  J An Account of the Varioloid Epidemic, &c. By John Thomson, M. D. 
                          VARICELLA.                      419
adduced abundant and  conclusive evidence to prove, that the
various forms of chicken-pox, corresponding to the  diverse de-
scriptions of the older and more recent writers, may be correctly
referred, for their  source, to variolous contagion.
  This view of the subject throws some light  upon those multi-
form and perplexing exanthematous distempers, that usually pre-
cede or accompany epidemic  small-pox.  We  see the same mor-
bific principle, modified in its action by different susceptibilities
and peculiar circumstances, giving rise to a vast variety of ano-
malous eruptions, diverse  indeed in  many particulars,  but of
sufficient  similitude, on  the  whole, to point out  their  family
alliance and origin.
  The plan of this work renders it  inexpedient  to  enter  into a
full review  of  the merits of this  question: a  brief  notice  may
suffice.
  In favor of the common origin of the two diseases, it is asserted,
1st. That variolous  and varicellous  epidemics never exist sepa-
rately  and independently; 2dly. that the two affections mutually
give rise to each other; 3dly, that varicella  seldom  occurs  in
individuals,  who have undergone neither  the  vaccine nor vario-
lous complaint.  In objection  to these observations the principal
arguments are the following:
  1. Epidemic small-pox, it is asserted, often rages, without being
attended by varicella, and varicella occasionally prevails without
the concomitance of small-pox.   This, I am inclined to believe,
is an unfounded assertion.  So far as my enquiries extend, every
variolous  epidemic,  described with  any particularity, has been
preceded, accompanied, or immediately followed,  by variola  or
varioloid  affections, exhibiting the characteristic marks of vari-
cella.   Dr.  Mohl,* it is true, asserts, that from  the year 1809 to
1823,  small-pox was entirely absent  from Copenhagen, whilst
cases of chicken-pox were met with every year.  But the same
author does not deny, that subsequently to this during the preva-
lence of a small-pox epidemic in that city, varicellous  affections
were  constantly present.  After  all, allowing the objection to
be true, it does not therefore follow that those  affections are rad-
* De varioloidibus et varkellis. Scripsit Nic Christianus Mohl, &c. 
420                 MODIFIED SMALL-POX.
ically distinct.  It is well known that, at different periods, small-
pox  assumes very dissimilar  appearances.   Some epidemics are
mild  some severe, and others malignant to a great degree: some-
times the pustules become filled with a bloody  matter,  and at
others they are  crystalline.   These  differences, exhibited by
variola  at  different  periods,  are scarcely less remarkable  than
those subsisting between it  and varicella.   These result, it is
probable, from accidental peculiarities in the  action of the vari-
olous poison, or in the susceptibility of the  human system, occa-
sioned  by unknown causes.   It is not, therefore,  an irrational
supposition, that certain atmospheric conditions, or other circum-
stances as yet undiscovered, may so modify the human suscepti-
bility, or  variolous contagion, over  large  districts of country,
that  a  spurious  or varicellous affection may be the  prevailing
epidemic.
   2.  During the prevalence  of a small-pox epidemic, it is exceed-
ingly difficult to ascertain, whether it be true  that varicella may
give rise to variola, and this to varicella.   Dr. Thompson,  how-
ever, who had abundant  opportunities  for  observation,  in the
varioloid  epidemic that occurred in  Edinburg, asserts, that the
varicelloid cases, with the exception of one  whose origin was not
traced, all occurred in situations, where they could be referred to
the agency of variolous contagion alone; and  that where varicel-
loid cases occurred, small-pox afterwards appeared precisely at
the  period it ought to appear, on the supposition that varicella
may give  rise to small-pox.  It is stated  by Dr. Mohl,  indeed,
that he never saw chicken-pox occurring in families, where vari-
ola prevailed;  but at the same time he adds, that in  such circum-
stances, he observed twice or thrice  the occurrence of an  erup-
tion  resembling  varicella.   We all  know the difficulty of draw-
ing an  accurate diagnosis in such cases, and we  may reasonably
conclude that the eruption was really variolous.  In confirmation
of Dr. Thompson's observation, Dr. Luders amrms, that variolous
contagion  does  sometimes  give  rise to chicken-pox.   One of
the  cases  he  mentions seems quite  conclusive.   The  circum-
stances were of such a nature, that  it was quite impossible to
suppose the operation of any other contagion  than  that of small
 pox, and  yet varicella was produced. 
                         VARICELLA.                     421
  Unvaccinated persons, who have never had the small pox, are
liable to attacks of varicella, a proof it is affirmed that this affec-
tion is not a mere form of modified small pox.  In answer to this
we  may observe, that  it is generally conceded that chicken pox
is of far more frequent occurrence after variola or vaccina, than
where neither of these has been undergone. Drs. Bryce and Aber-
crombie saw but three cases in which the vaccine  disease or va-
ricella took place in persons, who had  not experienced  either
vaccine disease or variola.  But admitting such an occurrence to
be more frequent than correct observation warrants us to believe,
it could have little influence upon the argument.   The question is,
not whether varicella be a form of small pox, modified by previous
vaccination  or variolation, but whether it be an imperfect result of
variolous contagion.  The vaccine disease and variola seem indeed
to be more powerful agents in modifying the subsequent develop-
ment of  the variolous  principle, than any  other agents with
which we are  acquainted.  But there can be no doubt, for rea-
sons  above mentioned, that other circumstances may in  a manner
we cannot now understand, exert the same kind  of modifying in-
fluence upon the human system.
  4. Again  it  is asserted that varicella is at present more preva-
lent  than before the introduction of  vaccination, although  small
pox  was then of far  more frequent occurrence.   This only  proves
that there are now more systems insusceptible  to  the full action
of the variolous contagion than formerly, and rather sustains the
hypothesis of their identity.
  5.  The occurrence of small pox does not prevent or modify
varicella.   Of course  it is not meant in this  objection  to  af-
firm, that chicken  pox happening now and then after  small
pox, would militate against the identity of the two diseases;
else upon the same ground,  the distinct character of  secondary
and primary variola might be estabjished.  The objection must
mean, that  the occurrence of small-pox does not generally prevent
or modify the varicellous disease.   Dr. Thompson, however, as-
serts, that out of one hundred and fifty-five persons, whom he saw
pass through the small pox, not one  was afterwards affected with
the  vesicular  disease."   This  is  the  more conclusive, because
" upon the  supposition of a varicellous  and variolous  epidemic, 
422                  MODIFIED SMALL POX.
most, if not all of this number have been exposed to the influence
of both contagions."  By the way we  may remark,  that if this
mode of augmentation be advisable, we  must  conclude that vac-
cina and variola are identical in nature, seeing they  usually pre-
vent and modify each other.
   6. The vaccine disease may be  communicated to a  patient soon
after his recovery from varicella,  and it will  pursue its  regular
course; which  never  occurs  after variola.   Few  experiments
have been made upon this point;  and we  are as yet  not justified
in asserting, that the result of vaccination  after the vesicular dis-
ease will  be uniformly of the  same character, as that stated  in
the objection.   It is, besides, well known that small-pox in fre-
quent instances fails to  take away the constitutional susceptibility
to  the infection of cow pox.   Many cases are recorded  on
the best authority, where the insertion of  the vaccine virus, sub-
sequent to an  attack of small pox,  has produced all the  pheno-
mena  of perfect vaccina. But even admitting the objection  were
sustained by general observation,  it could  be  met on  the  supposi-
 tion, that the vesicular disease being an imperfect result of vario-
 lous contagion, was  incapable of  conferring upon the system the
 same insusceptibility to the vaccine disease, as the fully developed
small pox.
   7. Varicella, it is maintained, is not communicable by inocula-
 tion.  This would seem to be erroneous.  Mr. Bryce, it is true,  al-
 leges that he found it impossible to communicate chicken  pox  by
 inoculation, but Heim  asserts that it is more communicable than
 small pox.   Dr. Thompson also gives conclusive evidence  on this
 point, and we have the authority of Dr. Heberden, for believing it
 can be inoculated.   For confirmation of the  identity of the two
 diseases, we may introduce here the statement of Reil,* that vari-
 ola, occurring after varicella,  is much milder than where this dis-
 ease has not been experienced, more especially if the varicellous
 affection  has been severe.   So that the occurrence  of varicella,
 would seem to shield the constitution in  a partial degree from the
 virulence of variolous contagion.
   8. Small pox  and chicken pox are essentially different in  their
* Erkentnntniss und cur der Ficher. bd. 5. 8. 386, 
                         VARICELLA.                     423
characters and eruptions.  This fact will have very little weight
when it is considered, how difficult it is to indicate the precise
nature of exanthematous affections by the character of their erup-
tions, and what confusion has existed in particular, with regard to
the specific appearance of varicella, and its  diagnosis from small
pox  or varioloid, even amongst those who  believe in its distinct
nature.   In  view  of these  circumstances, and of the  abun-
dant  evidence derivable from other sources,  favoring the  iden-
tity of these diseases, a mere difference in  their external charac-
ters can hardly be considered a valid objection, especially as we
find no less striking dissimilarities  in certain varieties of genuine
small pox.
  Upon  the hypothesis advocated, there would seem to be little
difficulty in explaining satisfactorily, the occurrence of  modified
small pox with all its numerous diversities,  whether of a varioloid
or varicelloid character.  Vaccination  or  variolation, we are
aware, does by no means in all cases obliterate the constitutional
predisposition to be affected by the variolous contagion.   Even
after  the system has passed through the  most perfect  form  of
small pox, a second attack will in some instances  ensue; and we
cannot  for a moment doubt that the same  event may take place
after  vaccination, since  it is  unreasonable to believe, that the
vaccine disease can be a  more certain prophylactick against vari-
olous contagion, than small pox itself.  But  facts, illustrative  of
both  these positions are too abundant and conclusive to permit
any longer a  doubt concerning their truth.   Now between that
state of the system, induced by vaccine or  small pox, which con-
fers  entire immunity from variolous  contagion, and that state  in
which the susceptibility to its influence, is totally undiminished,
numerous degrees of susceptibility undoubtedly take place accor-
ding to the individual idiosyncracy,  temperament and  accidental
concomitant influence: and perhaps also the variolous poison may
differ in the degree of its virulence and exert its agency  under
diverse modifications.  If, then, after vaccina or variola, the pre-
disposition to  the latter disease is not entirely,  but only partially
destroyed,  ought we not to look for an  imperfectly developed
form of the disease, should a second infection take place—espe-
cially too,  as  in  this instance the variolous  contagion may have 
424                  MODIFIED SMALL-POX.
been meliorated in its character?   It is in this way, we believe,
that varioloid affections occur in persons who have undergone the
vaccine or variolous disease.
  As  to  the  occurrence  of such affection  in those who have
never  had  either of these  diseases,  it may be  observed, that
the degrees of natural  susceptibility in different individuals  are
correspondingly diverse.  We see in the same family, into which
this contagion is introduced, one individual affected so slightly as
scarcely to require  attention;  another perhaps indisposed with
only variolous fever, without any eruption; a third seized with a
pretty severe attack of distinct small pox; and a fourth sinking
under the most aggravated form of confluent variola.  The pre-
sumption therefore is, that where small pox contagion acts upon a
system naturally or accidentally insusceptible to the full influence
of its powers, it will produce  either an extremely mild variolous
eruption, or an irregular  modified one;—in other words, a vario-
loid or varicellous affection.
   On a review of the whole argument, I am induced in common
with many others, to regard varicella, together with varioloid, as
spurious  or modified small  pox,  or at least, as being referable
for its ultimate source to genuine variolous contagion.

    The initial  stage of Varicella.—Varicella  is generally ushered
 in  by restlessness, thirst, loss of appetite, occasional pain  in the
 epigastrium, increased heat of the surface and acceleration of the
 pulse.   These  symptoms may oocur in various grades of intensity;
 but, for the most part, they are  by no means severe.   In many
 cases the febrile excitement is scarcely observable; still it is occa-
 sionally almost as violent  as in the severe varieties of small-pox,
 being attended with the same pain in the back, head and extrem-
 ities as this latter affection.  A severe cough and soreness of the
 throat are sometimes  accompaniments of the initial  fever, and
 during its continuance infants  not unfrequently suffer from  con-
 vulsions.   This fever  continues  from one  to three  days,  ter-
 minating  generally on  the  appearance  of the  eruption,  al-
 though in some instances prolonged two  or three  days after
 this  period.
    The  eruption,  which   is  vesicular  in varicella, is  often 
                         VARICELLA.                      425
preceded,  for  a few  hours,  by a general erethematous  rash,
as in small-pox, and is  generally accompanied  by a vexatious
tingling or itching in the skin.  It appears first on the breast and
back, next on the face and scalp, and lastly on  the extremities.
An incidental eruption of pustules is sometimes observable among
the vesicles.   The varicellous vesicles generally come out in sue
cession during three  or four days, so that at the same time, some
will  be just appearing, some perfectly matured, others shrivelling,
and a fourth set converted into scabs. They are sometimes closely
approximated, though seldom confluent.

   Varieties of the eruption.—The dissimilar forms assumed by the
vesicles, in different cases, has given rise to a  division of the dis-
ease into three varieties.
   1st.  Lenticular.—The  eruption  in this variety  appears  very
early.  It is characterized by small, red  elevations, rather oblong
in shape, and having a flat shining surface, in the  centre of which
is  a minute transparent vesicle.  The vesicle at the end of the
second day, is somewhat enlarged, being now l-10th of an  inch
in diameter, and is filled with a whitish lymph. The fluid assumes
a pale  yellowish or straw color on the third day.   On the fourth,
the vesicle is shrivelled, desiccation commences, and in two  days
more it is transformed into  a thin brown crust.   The scab  falls
off about the ninth or tenth day, leaving a red spot but no depres-
sion  on the skin.  Owing to  the successive  appearance of the
vesicles, this variety  is prolonged for two or three days.
   2d.  Conoidal.—In this form  the vesicles come forth suddenly,
surrounded by a slightly inflamed border.   On the first day, they
are acuminated and filled  with a bright limpid serum.  They
are  more  distended on the second day, containing a very pale
yellowish fluid, and  the surrounding inflammation is more exten-
sive.   On the third day, many are shrivelled, but others remain
entire, attended with considerable inflammation,  and containing
a  purulent matter.   These  vesicles generally leave permanent
cicatrices.   Scabbing commences on the fourth day, some of the
scabs assuming a dark brown,  others a rounded, yellowish and
transparent aspect.   " A fresh  eruption  of vesicles usually takes
place on the second and  third days; and as each set has a similar
r                            3  I               37 
426                  MODIFIED SMALL POX.
course, the whole duration of the eruptive stage in this species of
varicella, is six days: the last-formed  scabs,  therefore, are not
separated till the eleventh day.*"

   Globate,  or  Swine-pox.—Swine-pox is characterized  by large,
globose vesicles, with irregular circular bases, and surrounded by
an inflammatory areola.  At first  they contain  a  transparent
fluid, which on the second day of the eruption becomes turbid, or
assumes  a whey-like appearance.   On the  succeeding day, they
subside,  or begin to shrivel, acquiring a yellowish hue, and some
of them containing purulent matter.  Small, thin, dark-colored
scabs appear on the fourth day, and in the  course of four or five
days fall off, leaving small red marks, which soon disappear.
   Diagnosis.—Believing, as we do, that  varicella and varioloid
originate from the same source, and in some instances approxi-
mate so  nearly in character, as hardly to be distinguished apart,
we can give but little credence to the assertion of some authors,
that a diagnosis may be drawn, which shall  be universally infalli-
ble.  It may be well, however, to attend to  the following diag-
nostic marks, which  in  the general  will enable  us  to  recognize
varicella.   1. The eruptive fever is  generally more severe in vari-
oloid than in varicella:  2. In chicken-pox, the eruption is for the
most part vesicular from the  beginning;  while in varioloid, it is
always pustular, except in  the vesicular form, where it is pustular
for a day or more: 3. Tuberculous bases are not observable in
varicellous vesicles, but in the varioloid eruption they are distin-
guishable from its commencement.
   The varicellous pocks are, by some, believed  never to present
that central indentation, which frequently occurs  in  varioloid;
but this is discredited  by many accurate  observers.  Dr. Heimt
has described  a form of varicella,  one of the characteristics of
which is a slight depression in the centre of the pock.  Berad de
Hauit and other authors have mentioned the same appearance.
If we may believe Dr. Luders, there is a difference in the seats of
varicellous and varioloid eruptions—the former affecting the cel-

   * Bateman: Practical Synopsis of Cutaneous Diseases.
   t Die specielle Therapie nach den  hinterlassenen Papieren des verstorbenen A. G.
 Richter: B. 2. p. 342.—1817. 
                         VARICELLA.                       427
lular tissue between the skin and cuticle, and the latter  being
situate in the true skin.
   Varicella prevails more  frequently in the beginning of the
year, or vernal months.   Like small-pox, it seldom occurs more
than once in  the  same  individual.   Secondary  fever  is  of
rare  occurrence.   The  scabs,  on falling  off, not unfrequently
leave  depressions  in  the  skin;  but the  cicatrices differ con-
siderably from those occasioned by variola.  Heim, who regarded
these affections as essentially distinct, has adduced  this circum-
stance among others in favor of his views.   The pits of varicella,
he  says, are whiter than  the rest of the skin, and quite smooth
or e^en; whilst  those, left by variolous pustules, have the color
of the surrounding  skin, and are uneven, like the surface of an
orange. The margin of the varicellous pit is smooth and rounded;
that of the variolous pit, generally somewhat indented and angu-
lated.   Hairs  never grow in the disks of the former, in  those of
the latter they do.

  Remediate Treatment.—Varicella rarely requires any medicinal
application.  General aperients,  tepid drinks, and an antiphlo-
gistic diet, are the principal remedies necessary. 
428
MEASLES.
               CHAPTER  XXXVI.

                  RUBEOLA, MORBILLI,—MEASLES.

  The term rubeola and morbilli are used as mere synonymia by
the American, English and French  practitioners;  but the Ger-
man  writers universally employ them  to  designate two  distinct
diseases,—appropriating  the latter term to the  present affection,
and the former to a different, though somewhat similar complaint
(roethlen) described by Willan, under the name of roseola.
  The contagiousness of  measles  has by some  been  denied.
Among other circumstances, it is stated that the disease can never
be  traced from house to house, or  from street to street, as may
frequently be  done  in  small  pox  and  scarlatina; and that its
first appearance is generally simultaneous in several individuals,—
both of which  facts are opposed to  the notion of its  being pro-
pagated  by contagion.   But  this,  together  with  every other
argument of the kind is fully met by the  well established truth,
that  the  malady may be  communicated  by inoculation.  Dr.
Home  succeeded in verifying this fact in a number of instances;
and more recent experience has fully demonstrated the practica-
bility of  morbillious inoculation.*
  The contagion of  measles does not seem  to  be so  active  or
powerful as that of small pox.    During the greatest prevalence
  *Vogel, Percival, Brown, Manro, and Tissot, recommended inoculation for measles;
and Home and Horst practised it with success.   Professor Sparanza, more lately, in an
Epidemic that prevailed in  the territory  of Mantua, employed inoculation for measles
with decided benefit.  Six boys in the House of Industry, and afterwards he himself,
were inoculated.  A mild and regular morbillious affection was the result in all.  Him-
self  and  others  subsequently  repeated the experiment with equal success.  " A slight
cut was made into one of the most vivid of the large blotches, with a lancet, the point
of which was covered with the blood effused. With this, small incised punctures were
made in the arm, and a proper bandage applied."—Edinburgh Med. and Surg.  Journal,
1826.  See  also, Bibliotheca Italiana.  Agosto, 1825. 
                           MEASLES.                        429
of the disease, many individuals entirely escape infection, although
exposed to its full influence; and it is no infrequent thing to find
in the same family, a few affected  and  the rest  totally unaffected
by the malady.  It  is difficult  to say at what  period of its pro-
gress, measles  become infectious.   Many believe it incapable of
communicating itself, until the appearance of  the  eruption; but
it would seem, from a  few well attested cases on record,*  that
the disease may acquire  an infectious power  in  a day or two
before this event.
  Measles, like small-pox,rarely affect the same individual twice;
and  indeed a second attack of the former would seem  to be less
frequent than  of the latter complaint.!  After a careful obser-
vation of more than twenty years, Willan declares that he never
met with a secondary attack of febrile rubeola, and I have myself
witnessed  but one  unequivocal example  of the  kind.  Home
mentions a singular instance, in which  enlargement of some of
the lymphatic glands followed an attack of measles.  About  six
months having elapsed,  the glandular swelling  subsided, and the
patient became a second time  affected  with measles.J
  Measles  rarely  occur sporadically;  but when they appear, as
before mentioned, many individuals usually become affected with
them at the same time.  As in all other epidemic diseases, the
general course and phenomena of this  complaint are often  strik-
ingly modified;  and systematic writers have  therefore, divided
it into several varieties, according to the regularity or irregularity
of its symptoms, the  nature  of the  attending  fever, and the
character and  violence of the local affections with which it may
be complicated.
  According to the observations of some, morbillious fever may
occur without  any exanthematous affection.||  It certainly is not
uncommon during the  prevalence of epidemic  measles, to  meet

  *■ Edinburgh Med. and Sur. Journal, 1828.
  t See Dr.  Baillie's  paper, in the transactions of a society  for the improvement of
Medical and  Chirurgical Knowledge. Vol. iii.
  J Medical Facts and Experiments.  Richter, Specielle Therapie.
  II Morton mentions a morbillious fever unattended by any exantheme; and De Haen
asserts that cases of this  kind frequently occur during  the prevalence of  epidemic
measles.
                                               27* 
430                       MEASLE8.
with  fevers, attended  with the usual  catarrhal symptoms of tho
malady,  but  unmarked  by  its   peculiar  eruptions.   Uichtet
observes that  persons  affected by  these  fevers, are generally
exempt from  the  disease during the subsequent progress of the
epidemic.
  Sometimes  the  measly  exantheme takes place without any
fever.   The German writers* describe this modification of  the
disease under the  name of false  measles,  corresponding to  the
rubeola sine catarrho of Willan, ar.d  the rubeola sine febre, of
others. It is characterized by a regular measly rash, without fever,
catarrh,  or ophthalmia.  It does not take  away the suscepti-
bility of the system  to a subsequent invasion of febrile rubeola.
" An  interval  of many months, even two  years,  has been observed
between this   variety  and  the  subsequent  febrile  rubeola;
but the  latter more frequently takes  place  about three or four
days after the non-febrile eruption."—(Bateman.)
  Peculiar atmospheric constitution evidently exerts considerable
influence over this disease; for at one period,  its symptoms will
be so light as  scarcely to require medical attention;  at another,
it will assume  a highly aggravated form;  in a third period, it may
take place under every grade of violence, from the lightest to the
most malignant; and in a fourth, it " will  hold a middle course,
between the mildest and most dangerous forms of the malady."
(Armstrong.)   On  the whole, however, the  regular and moderate
cases  are infinitely more frequent than  the violent  and  malig-
nant ones.
  Measles  appear likewise to be decidedly influenced in  their
character by constitutional habit  or  idiosyncrasy.  Hence it is
that we sometimes meet with the disease under all its grades of
intensity, in children of the same  family—several very remarka-
ble examples  of which have  come under  my  own observation.
In general, measles are apt to be  more regular and mild during
the warm and equable, than the cold and variable seasons.
  The time/intervening between the  first impression of the rube-
olous  contagion and the actual commencement of the resulting
disease, varies from a few days to two .and even three weeks; but

  •  Vogel, Standback, Bd. 3 p. 203, Metyger, wermischto  Schriftcn, Bd. 2, p. 167. 
                          MEASLES.                       431
 the  period of incubation, generally, is from five to seven days.
 In nearly all the cases inoculated by Home, the eruptive fever
 commenced  about  the seventh day from  the insertion of the
 virus.

   Symptoms of the Eruptive Fever.—The initial symptoms of this
 complaint do not differ from those, which usually mark the inva-
 sion of catarrhal fever.   Transient flushes of heat, alternating
 with faint creeping chills; slight redness and  tenderness of the
 eyes, with an increased secretion of tears;  cough  and sneezing,
 with a watery discharge from  the  nostrils,  are generally among
 the first symptoms of the  morbillious fever.  Sometimes  two or
 three days of febrile excitement elapse, before the  supervention
 of catarrhal  symptoms; but in all cases, these symptoms occur
 sooner or later, in  a very manifest  form,  and may  be placed
 among the specific phenomena of the disease.  The cough in the
 beginning is dry and harsh, attended with  oppressive breathing,
 and  some degree of soreness in the fauces.   Not  unfrequently,
 some of the lymphatic glands about the neck, and along the mar-
 gins  of the eyelids, become tumefied and tender.  The stomach is
 apt to become quite irritable about the third day, and sometimes
 earlier, occasioning considerable nausea and  vomiting;  and where
 the febrile symptoms are  highly aggravated, slight delirium may
 ensue in the evening of the same day.   The fever is in general a
 marked synocha, as indicated  by the hot  and dry skin, and the
 quick, frequent and hard pulse.

  The  exantheme,  generally,  makes  its  appearance between
 the  third  and  fifth  days.  This  event, in cases of a  violent
 character,  is sometimes  preceded  for  a  few hours  by more
 or less coma; and in small children, convulsions are by no means
 uncommon  at this period.  The eruption comes out first on the
 forehead, chin, nose  and cheeks, and then  on  the  neck,  breast,
body and extremities successively.   It consists of small, red spots,
apparently papular, and resembling flea-bites.  They soon  en-
large, and, as their number increases, run into each other, forming
 larger  patches of an irregular  or semi-lunar shape;*  whilst the
                         * Bate man. 
432                      MEASLES.
skin in the intermediate spaces  retains  its  natural color.  Some
of the measles on the  first day exhibit a small  vesicle  in  the
centre (Cazenane.)
  The eruption on the face, during the second day after its  ap-
pearance, becomes  completely developed, and,  on the following
day begins to fade away; whilst on the rest of  the body it  con-
tinues vividly red.   The exantheme, on the  face, may be  felt
slightly elevated above the surface of the skin; but on other parts
this elevation is not perceptible.  Severe cases are attended with
tumefaction  of the face, in  some instances so  great as almost to
close the  eyelids.  The  eruption is  not confined to  the surface
of the body: red patches appear  on the  gums, spread over the
mucous membrane of the mouth, extend to the  tonsils and uvula,
and, acccording  to  Frank,  are  visible  on the tongue.  Leutaud
saw the measly exantheme in the  oesophagus and upon the  mu-
cous  membrane of the  trachea, and  even on the surface of the
abdominal and thoracic viscera.*   The eruption fades away over
the  body in the same progressive manner in  which it came out;
so that by the eighth day from the commencement of the fever,
it begins to disappear from the back of  the hands, where it is
wont to remain longest.  On the succeeding day, the  exantheme
acquires a faint yellowish hue.  Desquamation now  commences
on  the face, and is completed over the whole body by the  tenth
or eleventh  day.
   The appearance of the eruption occasions no remission of the
fever; but,  on the contrary, is commonly attended with a mani-
fest aggravation of both the febrile and  catarrhal symptoms. The
subsidence of the eruption is, generally, marked  by  an  amend-
ment of all  the symptoms; and for  the  most part, the fever disap-
pears entirely by the  time the rash has desquamated. Occasionally,
however, both the fever and cough continue, and even become
worse after the  complete  disappearance of the measly exan-
theme.  It  is observed by Dr. Heberden, that  in violent cases
there  is sometimes a recurrence of the coma, after the rash  has
gone off.
   During the  subsidence of the eruption, the  supervention of
more or less diarrhoea is by no means infrequent;  and when  not
                    * Precis de Medee. p. 604. 
                            MEASLES.                        433
 violent, it  almost always meliorates the  general and local symp-
 toms.  Occasionally a copious diarrhoea comes on just before the
 appearance  of the  rash.   As  it  tends to interfere with the
 regular course of the exantheme, and to occasion a retrocession, it
 should be considered as an unfavorable occurrence.
   The period, at which the eruption takes place, is various.  It
 is generally stated to be the fourth day;  and for  the  most  part
 this is correct.  Nevertheless, it is important not to lose sight of
 the fact, that  even when the  disease is perfectly regular in its
 character  and  course,  the exantheme sometimes  comes  out
 much earlier, and  occasionally, later than the period just named.
 It is observed by Dr. Armstrong, that the rash does not uniformly
 or generally appear,  on  the fourth  day from  the first develop-
 ment of the reaction.  " I  have seen," he  says, " the eruption
 come out at all times, between the  first  and the seventh days;
 though perhaps,  the most common period is between the third
 and fourth  days after the reaction.
   The aspect, under which this disease has just been described is
 that which  it generally assumes.   It appears, however, occasion-
 ally, under various striking modifications, requiring corresponding
 modifications in the treatment.   Sometimes it pursues its career,
 unmarked by any  serious complications;  in a majority of instan-
 ces, It manifests a considerable  tendency to inflammation, partic-
 ularly  of the  eyes and  respiratory organs; and occasionally,
 reaction  is   sluggish  and  difficult.   Hence, according  to  Dr.
 Armstrong, we have  three  varieties  or modifications  of  the
 disease,—the simple, the inflammatory, and the congestive.  To these
 we may add the typhous and gastric modifications,—the first being
 characterized by  a typhous state of  the  system, and the last by
 prominent symptoms of gastro-intestinal  irritation.
  Synochal  fever  of a high  grade is  the characteristic of in-
flammatory*  measles.   The  pulse is hard, vigorous and accele-
 rated;  the skin dry and very hot;  cephalalgia is severe, attended
 frequently with considerable delirium through  the night;  the
 eyes are very red; the cough is harsh, violent and distressing, with

  ♦Strictly speaking, every case of measles is inflammatory; but the general and  local
 phlogistic  phenomena often  preponderate  to such a degree,  that such cases may with
 propriety V) distinguished by the terra  inflammatory.
                             3 K 
 434                       MEASLES.
 little or no  expectoration, and  the  respiration  oppressed and
 frequently painful.   The exantheme for the most part appears
 early, and is usually of a  vivid red.   The diseases that  are par-
 ticularly apt to supervene in this variety, are cynanche trachealis,
 pleuritis, peripneumania with bloody expectoration, bronchitis,
 cerebral inflammation, and gastro-enteritis.
   The  malady in the congcstic form is indicated by the ordinary
 symptoms of internal congestion.  Reaction is tardy and  imper-
 fect,  sometimes  wholly  deficient.  The  vital  energies of the
 system  are generally much  depressed; there  is  pallor of the
 countenance;  torpidity of the bowels; the pulse  labors and  is
 weak;  the breathing slow  and oppressed;  the  extremities are
 cold, and the  features sunk  and anxious.   The eruption does not
 appear  at all, or it comes out slowly on some parts of the body.
 If reaction be not induced, coma or  stupor, and in some instan-
 ces, convulsions ensue.  Young children and persons of a relaxed,
 delicate habit of body, are peculiarly liable to this  form of the
 complaint.  Two  cases of this kind were seen by Dr. Armstrong,
 in which  the  patients died comatose  and convulsed.   Autopic
 examination revealed in both cases great engorgement of the lungs.
   The pecular symptoms  of typhus fever,  constitute  the typhus,
 or as  some have termed  it, the malignant  sort of measles.  The
 pulse is generally weak and frequent, sometimes nearly natural;
 the skin possesses the true calor mordax, communicating a burning
 or acrid sensation  to the  hand, and on parts of it not occupied by
 the measly eruption, petechias appear.  Colliguative hemorrhages,
 diarrhoea, and profuse sweats often occur, and the energies of the
 whole system seem to be  sinking.  It  is a happy circumstance,
 that this variety of measles occurs so rarely, as it is always terribly
 malignant and fatal.  Nevertheless it  has  occasionally prevailed
 as an epidemic.   Sir William Watson has given us the  history
of a putrid morbillious epidemic;  but it may be doubted whether
the affection  he describes,  was really measles or  scarlatina,  as
 these diseases were  believed  by him  to be essentially the same.
Nevertheless,  the portrait he gives of the  complaint,  answers
more  fully the peculiarities of rubeola than of scarlatina.*
*Watson.—Medical Observations and Inquiries.  Vol. iv. p. 132 
                           MEASLES.                       435
   4. Gastro-intestinal irritation  exerts  a marked  influence in
some cases,  giving rise to the gastric  modification of measles.
The attendant  febrile  symptoms are not very conspicuous, the
pulse  being small and feeble,  though inordinately  frequent.
There is  severe pain in the forehead;  the tongue  is brown;  a
sense of tension and fulness is often experienced in the epigas-
trium, or short cutting pains distress the bowels.   Violent  vom-
iting  and purging sometimes occur before and  immediately after
the appearance of the  rash, which is pale and often indistinct.
The cough is short, tormenting, and almost incessant.  In  some
instances, great difficulty of breathing and a sense of oppression
in the chest will suddenly ensue, especially in  young and  irrit-
able children.   There  is occasionally extreme  restlessness, with
much jactitation, dyspnoea and  an anxious expression of counte-
nance, particularly on  assuming an  erect attitude.  (Dr. Arm-
strong.)

   Sequela.—The tendency  to irregular  local determinations, ob-
servable throughout the whole course of measles, is more  espe-
cially manifest during the periods of desquamation and convale-
scence.  It is therefore a common  remark that less is to be ap-
prehended from the disease itself  than  from its  sequelae,—and
the assertion is generally true, when made in reference  to the
ordinary or simple form of the complaint.  Few, if any, diseases
leave  the system with so great a susceptibility  to the hurtful in-
influence of  cold or atmospheric vicissitudes; and hence  chiefly
the frequent  supervention of inflammatory and  other after affec-
tions during convalescence.
   The  most common sequelae of measles are,  pneumonia, bron-
chitis, croup, otitis, arachnitis, chronic ophthalmia, and rheuma-
tism.    The development of tubercular  action is not  an infre-
quent result of the disease in phthisical habits; and it is especially
apt to  bring forth latent disorders of the lymphatic system, and
occasion local  manifestations of scrofula,  where there  is a  stru-
mous diathesis.  Hence  an attack of it is often followed by scro-
phulous ophthalmia and tumors about the neck, with other distem-
pers of like character.   Porriginous eruptions on the head, and
serous ulcerations behind the ears, also frequently occur; and in 
436                        MEASLES.
some  instances, induration of the mesenteric  glands and maras-
mus.   Among the occasional consequences,  are herpes,  boils on
different parts of the body, discharges from the ears, and anasar-
cous swellings.

  Diagnosis.—The  diagnosis between rubeola  and scarlatina is
at times  attended with much difficulty.  Indeed  until  the time
of Withering, in 1793, they were very generally undistinguished.*
Nevertheless, the careful observer will always be able to draw a cor-
rect diagnosis between the two diseases, from the catarrhal symptoms
accompanying measles, and the peculiarities of its eruption.  The
small vividly red spots, like fleabites; their  union  into irregular
semilunar patches;  and  the natural  color  of  the  intermediate
skin,  distinguishes  the rubeolous  exantheme  from  the large,
irregular,  more uniform  and  raspberry colored  efflorescence
of scarlatina.  In measles the rash is characterized by small red
spots blending with each  other, and  displaying  central points
more vivid than the coalescing margin so as to give a maculated
appearance to  the skin.  In the other affection the blush is more
diffuse  and  uniform,  and  the eruption  consists of innumerable
minute  red points united together, resembling  much the redness
of a boiled lobster.   The difference in the general course  and pro-
gress of the two  affections is another diagnostic mark.   The
fourth day from the  eruption of the fever, is  the  usual  period
of the  manifestation  of the measly rash.    In  scarlatina,  the
eruption  generally  comes  out on  the  second, and not  unfre-
quently  on  the  first day.  Lastly  the catarrhal  symptoms,
so rarely  absent  in measles, can hardly  fail to  confirm  the
diagnosis.

  Prognosis.—Measles, when uninterrupted in its regular progress
and uncomplicated with internal inflammation, is not to be consider-
ed a dangerous  malady.  However violent in its simple  charac-
ter,  provided it proceed  regularly in  its  course, the  hazard
is  generally but  little.   Percival calculated, that about  one
  * Bateman says, thai the publication of Dr. Witbering's  Essay on Scarlet  Fever—or
rather the second edition of that work, in 1793—may be considered  perhaps as the date
of the correct diagnosis of this disease.  Synopsis, p. 66. 
                           MEASLES.                        437
out of fifty cases of rubeola terminated fatally; and of this propor-
tion one half took place in subjects under two years eld.  Rube-
olous  epidemics, of terrible fatality have indeed been  recorded.*
Obstinate  internal congestion,  preventing febrile  reaction, are
greatly to be apprehended.  The sudden retrocession of the rash,
either spontaneously or from violent purging, the application of
cold  or any other cause,  is hazardous.  It is an alarming inci-
dent, when internal inflammation, particularly of the lungs, brain
or trachea, supervenes.  Laborious respiration, with  a  wheezing
sound in the trachea, indicates much danger in infants.  Amongst
the most fearful symptoms, are petechias, great muscular prostra-
tion and colliguative hemorrhages.   The disease is attended with
imminent  risk,  when it attacks  females in  the latter  period of
pregnancy, or in the puerperal state.   In general,  nervous, de-
bilitated,  and delicate subjects  have more reason to fear danger
than persons of robust and healthy constitutions.

   Treatment.—In  relation to the treatment  of this disease, Dr.
Armstrong makes the following very important observation: "From
an  impartial  consideration  of the facts which have  come be-
fore me, I am convinced that  our plan of treating measles,  (in
its regular form) is too uniformly active when the eruptive fever
is developed; and that we should be more fortunate in  the main,
if we  interfered less with the operations of nature,  in cases of a
mild and regular character."  The attention of the practitioner
is particularlyly called to this remark.   That it is true  and high-
ly  important, I  am thoroughly persuaded, both from my own ex-
perience, and my observation of the practice of others.    An active
and antiphlogistic treatment, where no internal local inflammations
are present,  is generally  not only uncalled for, but decidedly in-
jurious—even   though considerable  febrile  excitement  should
mark the  eruptive fever.   The eruption in this, as in  every other
exanthematous  affection,  must be  regarded  as an  effort of the
system  to relieve itself from the noxious influence of  some inter-
nal irritation, by a critical or metastastic deposition on the sur-

 * From the great fatality of these epidemics, the disease acquired its name morbillvt
or little plague.  Were  these epidemics measles?  Both small pox and scarlatina were
formerly confounded with measles.
                                                38 
438                        MEASLES.
face.   Whatever  materially  interferes with the  regular course
of the precursory fever, tends to disturb  the regular appearance
and character of the eruption: but the development of this is es-
sential to the  safe and complete resolution of  the disease: there-
fore, when the eruptive fever is regular, not very violent, and un-
complicated  by internal  inflammation or congestion, we should
abstain  from  severe  measures,  and employ a gentle remediate
treatment.  All that  is usually  requisite  in such cases is to keep
the bowels in a soluble condition by the employment of mild lax-
atives;  to direct the patient to make a free use of tepid diluent
drinks; and in instances  attended by a very moderate degree of
febrile  excitement, to prescribe some of the  gently stimulating
diaphoretic ptisans—such as, infusions of sage, elder blossoms,
marjoram, balm, or eupatorium.   A high  grade of fever undoubt-
edly indicates the  propriety of moderate venesection; and in
this case the refrigerand diaphoretics should by no means be neg-
lected,  as  they often  suffice, without bleeding, to procure a pro-
per reduction of  the  general excitement.  Small  doses  of anti-
monial  wine,  with sweet spirits  of nitre,  the  saline effervescent
draught, and the ordinary nitrous powder may be employed  for
this purpose.   The subjoined formula*  is particularly  suitable,
but I have generally preferred the following mixture.t
   When visceral inflammation, oppressive internal congestions
or other irregular and alarming symptoms are  associated with
the disease,  our  remediate  measures must be  far  more  ener-
getic.
   After the initial stage of oppression, if no reaction should ensue
and  the face  remain pale and sunken, the pulse  feeble, and  the

                * R- Spirit mindereri,  -  - Jv'
                     Spirit, nitri. dulc. -  -  gnss
                     Vir. antimonii - -  -  3iss
                     Syrup lemonis -  -  -  3U
               S. dose,—a teaspoonful or two every two hours.

                t  R. Muriatis ammoniae   -  3'"
                     Pulv.Extract.Glycyrrhii Jss
                     Tart. Antimonii  -  -  gr.i
                     Aq. fontanae  - -  -  3V'"    M.
Dose—a dessert spoonful every two hours for a child between two and five years of age. 
                          MEASLES.                       439
breathing heavy, with great muscular prostration and  torpidity
of the sensorial powers, we must endeavor promptly and decisive-
ly to obviate the internal congestion, and arouse the action of the
heart and  arteries.  If this be  not  effected,  the  eruption will
not come out, and fatal  stupor or coma will  ensue.  Dr. Arm-
strong, a strenuous advocate of venesection in the congestive form
of fevers, recommends  the moderate and  exceedingly  cautious
abstraction of blood in congestive measles.   Internal congestion
however,  appears to result from  a previous loss of energy in the
vital powers,  and especially of the  extreme vessels.   It  would
therefore seem to be a more efficient and prudent method to impart
warmth and vigor to the system, and  to recall  the  circulation to
the extreme vessels of the surface.   Stimulating frictions to the
skin with tincture of capsicum  or flannels wrung  out of hot bran-
dy; sinapisms to the epigastrium; and bottles filled with hot wa-
ter applied to different parts of the body and extremities, are the
means best calculated to procure these  ends.   Measures of this
kind expose  the  peculiar  advantage of  exciting the energies of
the system without  diminishing its resources, at the  same time
that they most efficiently tend  to equalize the  circulation and re-
move the congestion.  In addition to  the above means, we should
not  neglect  the  use of warm and  gently stimulating drinks.
In several instances of congestive measles I have employed cam-
phor, suspended in a  mucilaginous  fluid with  obvious  benefit.
The carbonate of ammonia, in my hands, has  proved a very use-
ful remedy in a few cases  of this kind.*
   The disease is not so much  benefited,  by the  exhibition of ei-
ther of these stimulants, where the congestive state precedes the
exantheme, as when the rash,  after appearing, suddenly recedes.
In cases of this kind, oppressed respiration, a  short, dry cough, a
feeble and quick pulse,  with an irregular distribution of the ani-
mal temperature—'some parts being cool or cold, while others

                * R- Carbonatis ammon.  -  3"
                     Pulv. g.  arab.  -   - -  giii
                     Sacch. albi. -  -   - -  gss
                     Aq. fontanae - -  - -  gviii
                     Tinct. opii. - -  -  -  gtt. xl
             M.  Ft. S.  A teaspoonful or two every hour or two. 
 440                        MEASLES.
 are preternaturally warm—and a death-like paleness of counte-
 nance,'indicate extreme danger; and unless prompt relief be obtain-
 ed, " the patient sinks rapidly under an apparent load of phlegm in
 the bronchia." (Armstrong.)  Camphor here is an exceedingly valu-
 ble remedy.   Armstrong recommends in strong terms, a large
 dose of calomel, combined with camphor, antimonial powder, and
 a few drops of laudanum.  A combination of opium and camphor
 is the appropriate remedy in cases of retrocession, occasioned by
 inordinate purging  or vomiting;  and in conjunction  with this
 remedy, the  use of sinapisms, stimulating  friction, blisters, the
 warm bath, or dry warmth to the surface, may be deemed indis-
 pensable.  We should remember, however, that except in very
 feeble subjects, moderate diarrhoea is rather beneficial than inju-
 rious; and we should  by all  means refrain from interfering with
 it,  particularly in robust  and  plethoric individuals,—unless indeed
 there be evident symptoms of its hurtful  influence upon the reg-
 ular appearance and course of the rash.  (Armstrong.)

   Inflammatory  measles  require energetic antiphlogistic and de-
 pletory  measures.    Whatever difference  of sentiment there
 may  be touching the employment of the lancet in  the sim-
 ple form of rubeola, no one disputes its efficacy, when the mala-
 dy  becomes  complicated with  visceral  inflammation.   Prompt
 and decisive venesection, both generally and locally; epispastics
 over the region of the  affected part;  gentle laxatives and nausea-
 ting doses of the antimonials,  are the principal measures on which
 we should  rely.  Antimonial emetics, especially  in young chil-
 dren, have frequently an excellent  effect, where  bronchitis or
peripneumonia have  supervened.   Whatever  organ,  in  short,
may become the focus of  irritation, our measures should be adap-
ted to the existing inflammation, without any other reference to
the morbillious affection,  than to the grade and character of the
attendant fever.
  Certain varieties of inflammatory measles have  occasionally
occurred in which venesection is reported not only to have effect-
ed no good,  but to have  been absolutely detrimental.   Thus the
very fatal rubeolous epidemic,  that prevailed at Paris in 1828,
although nearly always complicated with  inflammation of impor- 
                           MEASLES.                       441
 tant organs, particularly of the lungs, was mitigated in no degree
 by sanguineous evacuations.*   Opium and calomel might be use-
 ful in cases of  this sort.  I speak doubtfully, as 1 have never had
 an opportunity of witnessing such violent examples of the disease.
 Nevertheless  I am induced  unhesitatingly to recommend the
 combination in this variety of measles, from the experience I have
 had of its excellent effect in pneumonia typhoides.   Blisters, cup-
 ping and  the warm bath  may  be regarded as indispensable in
 such cases.
   In the remediate management of measles, vicissitudes of tempe-
 rature must be especially guarded against.  An equable temper-
 ature, and one  neither productive of chilliness, nor much warmth,
 should be preserved.   When the eruptive fever is very moderate,
 and  the patient is of a feeble and  irritable habit, the air of the
 sick chamber ought to be so regulated, as to communicate a sen-
sation of warmth; and this is particularly requisite in  congestive
cases.
   I have already adverted to the many disagreeable and danger-
ous sequelae of measles and their frequent dependence on injudi-
cious exposure to cold during convalescence.   Common  sense,
therefore, dictates that the patient should during this  period re-
main within doors, and avoid in  every  way the noxious influence
 of a cold and damp atmosphere. "Even in summer, convalescents
should not be  suffered to go out of doors except in the middle
of fine days, and  not without additional apparel."   (Armstrong.)
   Stimulating drinks of whatever kind should be positively inhib-
ited, during the subsidence of the disease and the period of con-
valescence, and the diet must be light and unirritating.
   There is occasionally dryness of the skin and a slightly febrile
pulse after the appearance of the rash.  Gentle  diaphoretic feb-
rifuges are the suitable remedies in these cases, and it will  often
be expedient to continue their exhibition during convalescence.
An excellent diaphoretic of this kind is the spirits mindereri, in
union with a small portion of sweet spirits of nitre and  of  anti-
monial wine.   When pectoral symptoms continue troublesome at
this stage of the complaint, the muriate of ammonia with vinegar

        * See Biett's Report, in the Journal Hebdomadaire, No. XLII.
                             3 L                38* 
442                        MEASLES.
of squills  and antimony, is one of our most efficient remedies.*
   Tonics are almost invariably injurious in  convalescence from
measles.  If the system is left in an  exhausted but unirritated
condition, a weak infusion of serpentaria may be given;  and this
with mild and  nourishing  diet, will soon  restore health and vigor
to the debilitated frame.
   The following observation,  by  Dr. Armstrong,  shall conclude
what I have to say on this subject: "It is a remarkable fact, that
when  any cutaneous affections arise after  measles, the internal
organs generally remain  free from  disease;  and  even  where
some internal disorder has existed, I have not  unfrequently seen
it disappear, on the occnrrence of some  spontaneous eruption of
the skin.   Indeed there are many cases of this nature on record.
At all times, we should, therefore, be most wary in meddling with
vesicles, pustules, boils and the like,  when they come out after
the measles; for although they may be  temporary blemishes on
the surface, they are often the occasion of saving the vital works
within.

                * R. Muriat ammoni. -  -  3"'
                     P. extract, glycyrrh. -  gss
                     Aq. fontanae - -  - gvii
                     Acid. Scillae - -  . gss
                     Vin. Antimon. - -  -  3'    M.
            S. Dose—A tablespoonful every four hours for an adult. 
SCARLATINA.
443
                CHAPTER XXXVII.


                 SCARLATINA. SCARLET FEVER.

  Scarlatina is characterized by fever, a peculiar exantheme, and
inflammation in  the fauces—rapidly  terminating, in some cases,
in ulceration and sloughing.

  General Observations.—Scarlet fever arises from a specific conta-
gious miasma; but certain circumstances, it is possible, may con-
cur in such a  way as to generate the affection  independently of
contagion.  " There is abundant  evidence that fever attended
with  scarlet eruption, and possessing all  the other characters of
this disease, does occasionally arise from exposure to cold."(Greg-
ory.)   The period of the greatest activity of the contagious virus,
is said to  be the stage of desquamation. (Cazenane.)   From three
to five or  six days usually intervene between its first  impression,
and the manifest development of the resulting disease.
  As in small-pox  and measles, one attack of  scarlatina secures
the system against  a subsequent invasion.   On this point there
has been some diversity of opinion.  Withering and Willan never
witnessed a second  attack of the disease, and they deny the pos-
sibility of its occurrence:  Bateman, too, observes, "that this fact
is now fully ascertained." On the other hand, Bicker,* Neuman,|
Burns, and other authorities equally respectable, deny that the
susceptibility  of the system is  invariably  taken  away by  one
attack; and   they  adduce  some  examples in confirmation  of
their  opinion.   It  is also observed by Richter, that  cases of a
second, nay even a third attack of scarlatina have been noticed.J
  * Beschreibung eines Scharlachfiebers.—Rotterdam, in 1778, and 1779, p. 162.
  t Aufsatze and  Beobachtungen fur Aerzte, p. 284, as quoted by Reid. Soc. cit. t. v.
  136.
  \ Specielle Therapie, b. d. ii. p. 440. 
444                     SCARLATINA.
  The activity of the contagious principle may be influenced by
various circumstances; such as constitutional idiosyncrasies, age,
sex, climate, accidental predisposition, and peculiar atmospheric
temperament.  Certain  individuals  are entirely insusceptible to
the contagion, never becoming affected with the disease, though
fully exposed  to  its  cause.  Females, it is said, (Reid,  Richter,
Steiglitz,) are more  susceptible than males; and it is the  voice of
general experience,  that nurslings and old persons are much les9
liable  to the disease than individuals of  the  intermediate  ages.
Some  epidemics  expend nearly  all  their violence  on  children;
adults and  adolescents are principally visited by others.   Reid
witnessed a malignant epidemic scarlatina, that was almost en-
tirely  confined to persons between the ages of fifteen and twenty
five.   The  disease prevails at all seasons;  but warm, humid wea-
ther, and the air of low marshy districts, would seem to promote
its dissemination, and aggravate  its violence.   Certain peculiari-
ties of atmospheric  constitution,  hitherto unrevealed, appear  to
exert  considerable influence over the intensity of the contagion;
 as is  manifest from the occasional  prevalence of  the disease  in
epidemics,  and the different grades of severity and many varieties
of character these  have assumed.   Great irregularity  at  times
marks the  progress of the epidemic.  After  raging extensively
with much  violence, it may suddenly abate so as almost to disap-
pear,  and then resume its power, and prevail with more malignity
than ever.  The contagion seems occasionally  to linger for several
 years in a  certain district, affecting  from time to time only a few
 individuals.
   Scarlatina may appear in so simple and gentle a character, as
 to require nothing but the mildest remediate  management; or in
 a form so severe and  malignant, that the promptest and most en-
 ergetic measures will  scarce mitigate  its violence.   Between
 these  two  extremes it  occurs under every  grade of  severity.
 According  to the differences of intensity and character, in relation
 to the fever, exantheme,  and inflammation  in  the fauces, the
 disease has been divided  into three  varieties,—s. simplex, s. san-
 guina, s, maligna.

    Symptoms of S. Simplex.—A period, varying from one  to three 
                         SCARLATINA.                     445
 or four days, usually intervenes between the manifestations of the
 ordinary premonitory symptoms of febrile diseases, and the com-
 mencement of the eruptive fever. At the end of this time, slight chills
 come on, alternating with transient flushes of heat.   The patient
 complains of depression, nausea, pain in the loins, lower extremi-
 ties and head;  has a hot and dry skin, and a frequent quick pulse.
 Forty eight hours usually elapse from the commencement of the
 fever  before the appearance of the  eruption.   This comes out,
 first on the face, then successively on the neck, trunk and extrem-
 ities,  and finally spreads over the surface of the mouth, fauces and
 nostrils: in some  instances it is visible even on the albuginea.  It
 consists  of innumerable red points, which coalescing with  each
 other, give a continuous and diffuse blush to the skin, not unlike
 the shell of a boiled lobster. (Armstrong.)  In some cases, there
 is a uniform diffusion of the scarlet efflorescence over the whole
 body; in others, large irregular patches appear, leaving the inter-
 vening skin of the natural hue.  There is commonly some enlarge-
 ment  of the miliary glands and papillae  of the skin, whereby the
 surface, particularly of the breast and extremities, acquires a slight
 roughness to the touch.   On pressure with the point of a finger,
 the redness vanishes for a moment,  leaving a  transient spot  of
 white.
   Coincident with the irruption of the fever, or  soon  after, the
 voice  becomes thick and less sonorous, and  the patient experiences
 some  difficulty in swallowing, together with slight soreness of the
 fauces.   The edges  and extremities of the tongue are usually
 red, while a thick white  fur covers the rest of the surface, through
 which the  scarlet points of the  enlarged papillae are visible.
 In most instances the face becomes somewhat swollen; the skin
is hot, and  the  pulse  frequent,  quick,  sometimes  tense  and
vigorous.   The  thirst  is not  commonly  troublesome,  but the
appetite is always  impaired.  The  evening exacerbations are
attended with considerable  restlessness and occasionally  slight
delirium, both of which generally disappear on the  approach
of morning.
   On the fourth day,  the  full developement of the fever and
eruption is gradually accomplished, and  their stage of declination
commences on  the day following.   They continue to  decline, 
446                       SCARLATINA.
pari passu, till almost the  end of the  seventh day, when there is
an entire  disappearance  of both.   When the eruption is  about
subsiding, the tenderness of the  fauces abates; cutaneous trans-
piration is  re-established; there  is a copious  reddish sediment
in  the urine,  and  diarrhoea often takes place.   Desquamation
commences  on the  eighth  day.  It  is  generally attended with
considerable  itching, and is followed by an unusual sensibility
of*the skin over the whole  body.  The  appearance of the erup-
tion is occasionally attended with a considerable abatement of the
febrile symptoms.  Sometimes the fever throughout  the  disease
is so  slight, as hardly to  attract attention; at others so grave as
to  demand  vigorous and  decisive measures.   It should be  borne
in mind, that, though the  affection mav  commence  and continue
for a  day with great  mildness, it  may  suddenly  assume all the
violent characteristics of  the anginose variety.*

   S.  anginosa.—A  higher  grade  of fever and  a more  severe
anginose affection characterize  this  form of  scarlatina.   The
forming stage is  almost  invariably  attended with considerable
headache,  praecordial oppression, general muscular  prostration,
nausea and sometimes vomiting.   A  feeling of stiffness and dull
pain in the muscles of the neck and  under the ears  and angles
of the jaw, accompanies  the fever from its  commencement, and
not infrequently precedes it.  A red and slightly tumid appear-
ance  is presented by the   fauces,  palate, tonsils   and  uvula.
The  voice soon becomes  hoarse, an unpleasant  sense  of constric-
tion in the throat is  felt in  respiration, and deglutition is painful
and difficult.   There  is  a  rapid development  of febrile action,
the pulse acquiring  great quickness  and  frequency, but  rarely
  * In  reference to cases of this nature Dr. Armstrong has the following observations:
" Simple excitement may readily produce inflammation, and in fact is the most frequent
cause of it; for if  there be a latent weakness in any organ, the simple excitement, if not
timely moderated, is sure to give rise to inflammation there.  It is on this account that
many diseases merely marked by simple excitement at the beginning, are complicated
with inflammation in their progress; and hence it is, that apparently benign seizures of
■carlitina may eventually become the cause and concomitants of serious affections of some
of the viscera. It is, indeed, only in subjects of the soundest constitution, that we ever see
isimple  excitement uncombinedly  exist throughout the disease: and the  only reason it
so frequently occasions inflammation is, that some tissue or other had been secretly in
fault before its occurrence—On Measlesy Scarlatinay Sic. p. 157. 
                         SCARLATINA.                     447
possessing the  vigor, tension  and fulness, by which it is marked
in the simple variety of the disease.  The skin is more intensely
hot than  in any other febrile  affection, and  there generally is
very great  thirst.  According- to Currie  and Willan,  the heat
of the surface has risen to 108 and even 112 degrees of Fahren-
heit's thermometer.  The tongue becomes dry, its edges are very
florid,  and on its  surface  are  seen the projecting  points of the
inflamed papillae.   Considerable uneasiness or pain is felt in the
head, and  the whole  course  of the disease is  marked by much
languor, restlessness and prostration.
   In this variety, the eruption is not manifested so early as in sim-
ple scarlatina,—the third day of the fever being the common date
of its appearance.  It  is scattered on different parts of the body,
particularly about the elbows, in irregular, not very large patches,
but is seldom diffused  over the whole surface.  Sometimes the
rash disappears  the  day after  it has come  out, and " reappears
partially at uncertain times,  but  without any  corresponding
changes in  the general disorder; and the whole duration of  the
complaint is thus  lengthened, and  the desquamation  is less
regular."  (Bateman.)
   If the declension of the febrile symptoms takes place as early as
the fourth or fifth  day, the swelling  and inflammation  of  the
fauces generally pass off by resolution with the eruption and fever,
without  terminating  in  ulceration.   But   when,  during  the
first three or four days the excitement is violent,  or when it is
protracted  beyond the  period just mentioned, small ulcers  are
formed about the tonsils and palate,  which are rapidly converted
into ash-colored, superficial sloughs, a considerable quantity  of
tenacious mucous is always secreted in the fauces, and concretes
very frequently  into white flakes, presenting the  appearance  of
ulcers, where in reality there is none.  The parts should therefore
be carefully examined, before an opinion is expressed as to the
existence of ulcers. (Armstrong.)  With the subsidence of the
fever, the sloughs in the throat  separate, leaving  red ulcerated
surfaces, that usually cicatrize without difficulty.   Occasionally,
instead of separating about the eighth day,  they enlarge, assume
a brown color, and discharge an acrid sanious fluid.   The glands
about the neck, in such cases are hard, swollen and painful; and 
448                      SCARLATINA.
harassing diarrhoea and tenesmus supervene.   The  inflammation
may extend into the  trachea, and death ensue under symptoms of
acute bronchitis.
  This form of the disease  is not seldom complicated with vis-
ceral  inflammation.  During  the eruptive stage, the brain  is
often deeply involved, and symptoms of severe and fatal coma are
exhibited.   Abdominal  inflammation may likewise  take place.
" At first there are only  slight pain and soreness in some part of
the  abdomen, with a quickened  pulse and hurried respiration;
but  the pain and soreness gradually increase, and at length are
attended with vomiting, eructation, fulness of  the belly, and gen-
eral restlessness.  In  six, seven,  or  eight  days, the  abdominal
soreness and pain abate or disappear, while the pulse grows rapid
and feeble, the  breathing more anxious, and  the vomiting more
urgent. Cold, clammy sweats and a universal collapse now spee-
dily supervene, and are the immediate  precursors of death."
(Armstrong.)

   S. Maligna.—In the beginning, this variety of the disease may
wear the aspect of scarlatina anginosa, but it speedily  betrays its
violent and  dangerous character.  The eruption  comes  out  at
uncertain periods between the second and fourth days. It is usually
pale at first, but in  the  progress of the  affection, it acquires gen-
erally a dark or livid hue.  Great irregularity marks its duration;
and it will often vanish soon after its first appearance,  and at the
end of two or three  days reappear on different parts of the body.
The pulse, active in the commencement, becomes small and fee-
ble  in the course of the second day.  The heat of the  skin is
variable, but in general  not very intense.  At  an early period,
delirium  usually  comes  on;  and, with occasional intermissions
and exacerbations,  often  continues  throughout  the subsequent
course of  the disease.  In nearly all cases, there is considerable
disturbance of the sensorial functions; and  in aggravated exam-
ples, the eyes become dull  and inflamed, and a  livid  flush over-
spreads the cheeks.  A brown and dark fur covers the  dry tongue
and the breath is fetid.  In the fauces, on  the soft  palate and
tonsils, may be  seen grey-cobred sloughs, which  soon acquire a
brown and finally a dark color.   Sometimes, before the  ulcera- 
                         SCARLATINA.                     449
tion  becomes severe  or extreme, death will take  place  under
symptoms of cerebral oppression.  " In general," says Dr. Arm-
strong, "it is only when the fever is protracted beyond the fourth
day, that  the ulcers are converted into ill-conditioned, black and
fetid sloughs."  A large quantity of very viscid mucus  is gene-
rally secreted into the  fauces, occasioning difficult respiration and
a rattling noise in the throat.   When  the  sloughs  are extensive
and foul, a thin, acrid fluid issues from the  nostrils and gives rise
to painful irritation  and  excoriation of the  parts over  which it
flows.
  Where the disease has assumed a particularly violent character
collapse  supervenes  towards the  middle or end of the  second
week.  Great prostration of all the vital energies now ensues; the
pulse becomes very frequent and feeble; the heat of the  surface
sinks;  the tongue is dark, brown, or black; exhausting diarrhoea
often takes place;  and, in  some cases, hemorrhages from  various
parts and petechiae occur towards the fatal termination of the
complaint.  The  fever and affection of the fauces may frequently
exist without an eruption at any period of the disorder.  As early
as the  second or third day, death sometimes closes the scene;  and
it is observed by  Bateman, that occasionally the symptoms  con-
tinue to be moderate till an advanced period, when they suddenly
assume a malignant and rapidly fatal character.
  Three modifications of malignant scarlatina have been descri-
bed by Dr.  Armstrong,—the inflammatory, congestive, and mixed:
the latter being characterized  at once by much internal  conges-
tion and a moderate reaction of the heart and arteries.
  The inflammatory modification  corresponds with the putrid
variety of Richter.*   Its commencement  is  marked by  a  high
grade  of inflammatory excitement, as indicated  by  the full, hard,
and vigorous pulse, the intensely hot  skin,  and early delirium.
For a  day or two, it differs little in appearance from scarlatina
anginosa, but the early supervention of collapse or a typhous state,
and of the  gangrenous condition of the throat mentioned above,
soon reveal its true character.  The  eruption comes out early;
at  first  vividly red, but  as the disease advances,  it acquires a

                  * SpecielleTherapie, bd. ii. p. 466.
                     3 M                     39 
450                     SCARLATINA.
darker or purple hue.   The animal powers speedily sink; a burn-
ing, acrid  sensation is felt on touching  the skin; the pulse be-
comes weak,  small and hurried;  the exantheme purplish,  and
petechiae or a miliary eruption, coliquative  diarrhoea and  hae-
morrhages ensue.   The extreme violence of the anginose affec-
tion,  and its decided  early tendency to  terminate  in  extensive
gangrenous ulceration, are the principal  characteristic phenom-
ena of this modification.  Inflammatory scarlatina  maligna was
formerly described under the name of putrid sore throat.
   The want of reaction distinguishes the congestive variety.  The
patient is pale, faint, oppressed, and complains of universal pros-
tration, giddiness, deep-seated pain, and a sense of weight in the
head, nausea, much anxiety and oppression in  the praecordia.—
" There  is often a mixture of lividity and paleness in the face, and
the eyes are  usually dull, acquiring  a fatuous or inebriated ex-
pression  in the course of the disease.   The mind at first alarmed
and confused or dejected, soon becomes disordered with delirium;
an indifference to surrounding objects and a stupor succeed, under
which patients frequently expire."   Respiration may be  quick
and short, or slow and impeded; and the  pulse is weak, sluggish,
and irregular.   The tongue, at first covered with a white  fur,
becomes rough and brown in the course of the disease.  There is
torpor of the bowels in the beginning, but in the latter period of
fatal  cases, diarrhoea nearly always supervenes, attended, not un-
frequently, with petechiae, gangrenous spots, and wasting haemorr-
hages from the nose, mouth and bowels.  The rash, from its first
appearance, is  pale or copper-colored, acquiring at last a purple
hue.   This modification of the  disease is seldom protracted in its
course, but very often  terminates as early as the second, third or
fourth day. The anginose affection  is seldom extreme, and is sup-
posed by Dr. Armstrong  to have little to do in  bringing about a
fatal termination.  The mortal tendency of the disease he ascribes
chiefly to the " venous congestions of the brain, liver, spleen, lungs,
and of the vessels of the heart, giving rise to universal collapse
and visceral  disorganization," and  perhaps to a change in the
constitution of the blood itself.

   Diagnosis.   Measles and miliary  fever are the only two  disea- 
                          SCARLATINA.                     451
 ses with which this  affection  is liable to  be confounded; and it
 must be confessed, that a correct diagnosis between them and the
 simple and anginose  varieties of scarlatina is at times  attended
 with very considerable difficulty.  No single symptom can be re-
 garded as peculiar to scarlatina.  The eruption is at times wholly
 or nearly absent, diffused in blotches, and occasionally papular.
 Irregularity also marks  the anginose affection, which may vary
 from a  slight redness to much tumefaction, and occur with or
 without ulceration and  sloughing.    Nevertheless, an  accurate
 diagnosis may nearly  always  be framed, by a contemplation of
 the following circumstances.  In scarlatina, the usual time for the
 appearance of the eruption is  during the  first forty eight  hours
 of the fever: the rash, in  measles rarely comes out until the third
 day, and  most commonly not until the fourth.  The  exantheme,
 in the former affection, consists of innumerable points,  intermixed
 with small papulae, dispersed over the cuticle,—resembling  a dif-
 fuse erethematous blush.  The rubeolous rash on the contrary,
 is made up of small circular dots, like flea-bites, of a  more vivid
 red  in the centre than circumference, so  that their coalescence
 presents a  less uniform  blush  than  is  displayed  in  scarlatina.
 These red and slightly elevated dots are  generally congregated
 in clusters and patches, so as to  exhibit an irregular crescent shape.
 "The crescent-like form of the patches of  measles, and the more
 diffuse, and irregular shape of those of scarlatina, will  be a mate-
 rial  diagnostic guide." (Bateman.)   In scarlatina, the  eruption
 resembles in color the boiled lobster  shell, and is generally of a
 lighter red than that of measles, which also is somewhat inclined
 to a brownish hue.   The most striking diagnostic mark, however,
 is furnished by the catarrhal symptoms, so very conspicuous in
 nearly every case of measles,  but eilher  entirely absent, or ex-
 tremely  slight and  partial in  scarlatina.  The  inflamed  eyes,
 copious weeping, red and tumefied edges of the eyelid, intolerance
of light, coryza,  sneezing, strong,  harsh,  and hoarse  cough, so
 seldom  absent in measles, and  so rarely present in scarlet fever,
 will, in  general obviate  all danger  of mistake.   Finally, the
 ulceration and sloughing of the fauces in  s.  maligna and anginosa,
 are quite sufficient to distinguish this  affection from rubeola.
  Simple scarlatina, approaches very nearly, at times,  to the cha- 
452                      SCARLATINA.
racter of miliary fever, so that a superficial observer, might very
easily be  led into error.  They  may be distinguished,  by the
miliary  eruption being almost universally attended with consider-
able perspiration, which is not the case in the appearance of the
scarlatina efflorescence.  The little points composing the exan-
theme of the latter affection, rise out of a uniformly erethematous
blush of the skin,  whilst those of miliary fever appear to be seat-
ed on a skin preserving its natural color.   Great praecordial anx-
iety generally attends the coming of the miliary eruption: and
about the period of its subsidence, a second eruption similar to
the first may appear, in  some instances followed  by a third crop
of papulae.

   Prognosis.—As  the disease  may take place under diverse mod-
ifications  and every grade of severity, from the mildest to the
most malign, the prognosis  must, of course be extremely va-
rious.   It should  in all cases be formed with a proper degree of
caution, even  where  the disorder  at first assumes the  least
alarming  aspect;  for  the  symptoms maybe those  of the simple
and  regular form  alone during a few days, and then suddenly
give place to others of the  most violent and dangerous  char-
acter: this is more especially apt  to be the case when considera-
ble severity characterizes the prevailing epidemic.  Bearing this
in mind, we may remark, that simple scarlatina is rarely attended
with any hazard to the patient, unless dangerous secondary affec-
tions supervene during the subsidence of the disorder, or the period
of convalescence,  from cold or accidental causes.  Peculiar dan-
ger is always connected with the anginose  variety of the disease;
and, in  the malignant  form, it is to be ranked  among the most
fatal  of maladies.  Generally, and perhaps justly, the  hazard
from scarlatina is  estimated by the character and violence of the
anginose affection.    Dr.  Armstrong seems  to  hold  a con-
trary sentiment: at least, the affection of the throat by itself, he
regards  as  but  rarely  the  cause of death—a  termination,  he
thinks, attributable rather  to violent  internal venous  congestion
and visceral disorganization, so common in the more violent grades
of this disease.  When the eruption is brightly red, and uniformly
diffused over the whole or a greater part of the body, the progno- 
                           SCARLATINA.                  453
 sis is better than when it is pale or purple or brownish, and ap-
 pears only here and there in large patches.   (Armstrong, Reil.)
 Irregularity of the eruption is an  unfavorable symptom,—as, for
 example, where  it displays by turns a  red,  pale or brownish
 aspect;  now  appears  chiefly  on one  part, then on another;
 vanishes for a time and  again  reappears; or at an early  period
 suddenly vanishes altogether.   It is  remarked that a white
 streak, passing down along each side of the nose and encircling it
 below, is a fatal sign.   (Reil.)   A  vivid redness and considerable
 tumefaction  of the fauces, attended with pain or swelling, are
 better indications than a livid or dark red aspect of the inflamed
 part, without swelling and painful deglutition.   White sloughs in
 the  fauces  are also more favorable than cineritious or brown
 ones.  If on a sudden a strong inclination is felt to urinate, and a
 copious quantity of crude watery urine  is voided, the danger may
 be considered great.   (Richter.)  The  occurrence of gangrenous
 ulceration in the throat is of course always alarming.
   The grade and character of the attendant fever, as might be
 expected, has an  important  bearing on the  prognosis. A mod-
erate degree of reaction is favorable;  a typhus grade is  the
 reverse; and extreme  violence of fever in the  commencement,
 with much angina, is a sufficient  reason for apprehending  early
and  hazardous collapse.  Where  febrile reaction is  prevented
or much impeded by great internal  nervous  congestion, there is
 every thing to fear; and a no  less alarming  event  is the  super-
vention of visceral inflammation.  Collapse  soon comes  on  in
these cases;  and if death does not speedily ensue, great pros-
 tration  takes  place,  with the  fatal symptoms  of coma,  con-
stant delirium, and cold  extremities:   if  to these  be  added
petechia?, wasting hemorrhages and involuntary discharges from
the bowels,  a hasty dissolution may with certaijity be predicted.
   Children  except when suffering from  painful dentition, are
apt to be  afflicted  more lightly  than  adults with the disease.
It is said to  be most dangerous when  it assails persons between
the ages of fifteen and  twenty-five.*  Peculiar hazard likewise
attends it, when it makes its appearance during pregnancy, and
particularly in  the puerperal   state.   In general,  robust  and
                       * Reil. loc. cit. vol. V. p. 138.
                                            39* 
454                      SCARLATINA.
healthy individuals suffer less from scarlatina, than subjects of a
feeble, lymphatic and nervous temperament.
  A  regular  abatement of the  heat  and efflorescence of the
skin, associated  with diminished frequency in the pulse, and a
lateritious  deposit  in  the urine;  a subsidence of the  swelling,
with  separation of the sloughs, and  healthy granulation  of the
ulcers;  and lastly desquamation of the  cuticle, are all indicative
of a favorable termination to the disease.

   Sequela.—Many  troublesome and often  dangerous  disorders
ensue on an attack of the scarlet fever.   Of these anasarca is by
far the  most common, there being no other acute  disease, that is
so liable to be followed by dropsical effusions.   This emphatically
is true in reference  to the  anginose  variety.  Nine  or ten days
almost  always elapse after the disappearance of the  eruption,
before the anasarca is perceived; and  it continues commonly for
the  space of  two or three weeks.   It is observed by Bateman,
that  " when  anasarca becomes pretty  general, a  sudden effusion
occasionally takes place into the cavity of the chest, or into the
ventricles of the  brain, occasioning the death of the patient in a
few  hours."  But, in  general we have no reason to  apprehend
dangerous consequences from the dropsical effusion.
  At times the disease has given rise to various nervous affections,
such as hysteria, spasmodic asthma,  chorea,  epilepsy,* and  neu-
ralgic pains in the extremities; and occasionally  it has been fol-
lowed by strumous disorders, chronic cutaneous eruptions, herpes,
gutta serena,  and rheumatic pains.  The malignant and anginose
varieties are moreover sometimes succeeded by tonsillar abscesses,
enlargement of the parotids, inflammation of the testicles, ophthal-
mia, deafness, otitis, inflammation of  the mucous membrane of
the  bowels, excoriations  about  the nates, suppuration  of the
glands  of the neck, chronic  cough, bronchitis,  or  other slow
suppurative inflammations, with hectic fever and its train of evils
Dr. Armstrong and  others have observed, that the  hair is very
apt to come out on the abatement of scarlatina,  in  which case
it will never look or grow well  again.
  * Kreysig. Abhandlung uber des schailackfieber, &c. p. 59.   See also Cappel. abhand
von Scharlachsauschlage, p. 90. Reil. Fieberlebre. Bd. 5. p. 122. 
                         SCARLATINA.                     455
   The  more  complete and  conspicuous the desquamation, the
less liability is there to secondary disease during convalescence.

   Treatment.—It is evident from  the description we have given
of scarlatina, that our treatment must be greatly varied, to adapt
it properly to the many varieties and modifications the  affection
is  wont to assume.
   Simple scarlatina  requires nothing but  the mildest  antiphlo-
gistic management.   One or  two gentle  aperients or oenemata
should be administered;  cool or tepid drink prescribed,  such  as
barley water, lemonade or toast water acidulated with lemon juice
or muriatic acid;  and the patient be restricted to mild unirrita-
ting liquid diet.   He should  also be  confined  in a room, the
temperature  of  which  must be kept  at  a moderate  and  an
equable  degree.  In  addition to  these measures, nothing more
in general is necessary, than  the use of slightly  astringent and
emollient gargles, such as sage tea, with a small portion  of  alum,
and sweetened with honey; or an infusion of green tea.
   Occasionally  the forms of the  disease  will assume  a severe
aspect, and present symptoms of very considerable febrile irrita-
tion.  More vigorous  measures  are  now  required, as it may be
converted by a continuance of the high vascular excitement into
scarlatina anginosa.   Although the disease be manifestly simple
in its form, if the febrile  action be aggravated, it is prudent that
we should endeavor promptly to restrain the phlogistic tendency,
without  interfering  too  much with the  regular, and  we may
presume, necessary excitement of the heart  and arteries.  The
" nimia diligentia medici" has doubtless been sometimes productive
of much harm in simple  scarlatina; but to the judicious  prac-
titioner, the grade of  the existing symptoms will be a safe guide,
in the employment of antiphlogistic measures.
  It should moreover, be borne in mind, that from the aspect of
the disease in its onset, we  cannot always  correctly predict  its
subsequent character—whether it shall be  simple or complicated
mild or dangerous.   However benign therefore, the prevailing
epidemic, whenever we are  called to a case in the former stage
marked by considerable lassitude and oppression, paleness of the
face and skin, some  headache and nausea, it is expedient to  com 
456                      SCARLATINA.
mence the treatment, as if the complaint were about to assume
an  aggravated  character.   An emetic, promptly administered,
will do much good by removing  internal  venous  congestions and
encouraging wholesome reaction.  After its operation, it will be
proper to exhibit a brisk  mercurial purge.  Where  much  affec-
tion of the head exists in the forming stage, Dr. Armstrong advi-
ses the use  of  the warm bath strongly impregnated with salt.
"This practice," he remarks, "assisted by a brisk purgative, will
in  general give immediate relief,  and  contribute  powerfully to
moderate the subsequent  reaction."   When the  succeeding feb-
rile excitement is of a high grade, it should be reduced by purga-
tives,  tepid  effusions, cooling drinks, rest, ventilation, and some
of the more  gentle diaphoretics—such asspiritus mindereri, sweet
spirits of nitre, or small doses of antimony and nitre.*
   Far more  vigorous measures are required in the anginose vari-
ety of  the disease.  Emetics in the beginning of this, as indeed
in  every  other  form  of scarlatina,   are  justly  regarded by
the profession as among our  most valuable curative means.   The
earlier their employment, the more beneficial  in  general will be
their effects: in the forming stage particularly,  or  at  the very
onset of the  malady, they are most decidedly efficacious.!  Given
thus early, they often  meliorate the whole subsequent course of
the disease;  and, in some instances, interrupt, almost completely,
the train of morbid action. Some have indeed recommended them
at every period of the complaint; (Withering,) but almost all
practitioners are agreed, that the forming stage is the only proper
period for  their exhibition.   The good  effects of an emetic, in
the  beginning of the disease, depends,  probably, chiefly on  the
centrifugal direction which active vomiting  communicates to the
circulation, tending, thereby, to obviate internal  congestions and
secondary  visceral inflammation; and, perhaps,  also, in part on

  * Armstrong,  Treatise on Scarlatina, Ancerles, &c.
  t Numerous authorities of great weight might be quoted in evidence of the good effects
of emetics in this disease.  They are recommended by Tissot, (Anis au-peuple,) Stoll;
(Ratio medend. torn. ii. p. 248;) Withering; (account of scarlet fever and sore throat, as
it appeared at Birmingham in 1773, and London in 1779j p. 300;) Steiglitz; (Versuch
enier pruifung und verbersserung der yezt gewcehnlichen behandlimgs art de» scharlachfie-
Ders, p.  231; Richter; (Specielle Therapie, Bd. ii., p. 480;)  Reil;  (Feberlehre, torn.
v. p. 166;) Armstrong; (on scarlet fever, &c.;) Rush; (Medical Inquiries.) 
                           SCARLATINA.                       457
 the impairment  or  disturbance of the  morbid  sympathies, con-
 nected with the disease.
   Formerly, there existed  much  prejudice against the employ-
 ment of purgatives in this  disease,  but  of late  years  they have
 been   strongly   recommended.     Dr.   Hamilton* particularly
 insists upon their efficacy in scarlatina, and the testimony  of all
 modern writers is in accordance  v. ith his opinion.  My own expe-
 rience, though limited in this form of the affection, has led  me to
 think very highly of the utility of moderate purgation.   With the
 exception of an antimonial emetic in the beginning, I have, in a
 majority of cases, confided almost exclusively in the employment
 of aperients, with cooling  applications to the surface, or an anti-
 phlogistic regimen and the  local  applications,  to be  hereafter
 mentioned.   No  measure is better calculated to prevent the haz-
 ardous  occurrence of coliquative  diarrhoea  in  the latter period
 of the disease, than  the proper administration of laxatives in the
 earlier  stages.   But as a general rule,  strong purgation is by no
 means necessary  or expedient.   From three to four evacuations
 in the  course  of twerjty-four hours are sufficient to procure all
 the advantages  derivable from purgatives,! unless cerebral con-
 gestion  exists, when active catharsis is obviously indicated.J
   The efficacy of antimonials, and the  usual  refrigerant diapho-
 retics, does not appear to be very decided in  this affection.   "In
 truth,"  says Dr. Bateman, " the temperature is too high  to admit
 of a diaphoresis;  and the only safe and effectual method of pro-
 ducing this effect, consists  in reducing the heat  of the surface by
 the application  of external cold."  Nevertheless,  we  have  the
 authority of Richter in favor of the internal use  of muriate of
 ammonia, when the fever is strong after the sufficient evacuation

  * Treatise on Purgatives.
  t Bateman, Gregory, Richter, Reil, Willan.  By Dr. Armstrong, active purges are
 preferred to  mild ones in anginose scarlatina.
  f Rhubarb and calomel;  rhubarb and soda, in equal parts; calomel with small por-
 tions of antimonial powder;  (Willan;) calomel, followed by a small dose of magnesia;
 small portions of the sulphate of soda or magnesia; an occasional dose of two or three
grains of calomel, with the daily use of castor oil, or the administration of laxative ene-
 mata, may be used for this purpose.
                                3N 
458                      SCARLATINA.
of the bowels.*   It should be given in union with emetic  tartar,
according to the following formula:
                  R. Muriat. ajnraoniae,.... gss.
                     Pulv. extract, glycyrrh. gi.
                     Tart, antimonii.......gr. i.
                     Aq. fontanae,.........gviii. M. ft. s.
                           A teaspoonful to be given every three or four hours.
   Notwithstanding the use of the  foregoing remedies, the inflam-
matory condition will sometimes increase, and the patient become
anxious and very restless.  Diluted sulphuric acid, in these cases,
has been given  by Steightz in large and frequent doses, with ex-
cellent effect.  (Abhandl. feur Pract. Arzte, B. xxii. p. 307.)
   The application of cold water to  the surface cannot  be too
highly estimated in  the  higher grades of  this affection.   " We
are possessed of no physical agent," says Bateman, " as far as my
experience  has  taught me, (not excepting even  the use of blood-
letting in acute inflammation) by  which, the functions of  the ani-
mal  economy are controlled with so.  much certainty, safety and
promptitude, as by the  application of cold  water to the  skin,
under the augmented heat of scarlatina and of some other fevers.
This  expedient  combines in itself all the medicinal  properties
which are indicated in this state of disease, and which we should
scarcely, a priori, expect  it to possess; for it  is not only the most
effectual febrifuge (the' febrifugium magnum,' as a reverend au-
thor, Dr. Hancoke, long ago called it,) but it is  in fact the only
sudorific or anodyne which will not disappoint the expectation of
the practitioner under these circumstances.  I have had the sat-
isfaction, in numerous instances, of witnessing the immediate im-
provement of the symptoms, and  the  rapid change in the counte-
nance of the patient, produced by washing  the skin.   Invariably,
in the course of a few minutes, the pulse has been diminished in
frequency, the thirst abated, the tongue has become moist, a gen-
eral free perspiration has broken  forth, the skin  has become soft
and cool, and the eyes, have brightened;  and these indications of
relief  have  been speedily followed  by  a  calm  and  refreshing
sleep." The only precaution requisite in the application of cold
water in this, as in every other febrile affection, is  to ascertain
that no sense of chilliness is present, and that the skin  is dry and
                   * Specielle Therapie, B. ii.  p. 490. 
                        SCARLATINA.                     459
above  the  natural  temperature.   Pouring or affusion over the
body is the best method of applying  the water, where  there  is
excessive vascular  action with intense heat of the surface; but
where  either of these modes is impracticable, or opposed to the
wishes of  the patient and his friends, we must resort  to washing
or sponging the skin, every hour or two, until the temperature
and circulation  be moderated.   Cold water  simply, or vinegar
and water may be used  for this purpose. As the disease advances,
Dr. Armstrong  recommends that tepid affusions be substituted for
cold;  and, as a general rule, he  thinks it prudent to commence
with them after the third day of the stage of excitement.  It is
best, however, to be  governed in this matter by the  degree of
cutaneous heat  and arterial excitement present;  for at any period
of the disease,  provided there be a hot and dry skin, cold water
may be safely and beneficially employed.* (Dr.  Stranger.)  Pur-
gatives and cold affusions maybe employed conjointly.   Accord-
ing to  Armstrong, they are more  efficacious in this way, particu-
larly during the first three days of the stage of  excitement, than
when employed separately; and  my own observation is in favor
of this opinion.  Within the period just named, blistering may
also be beneficial.  Where tonsillar inflammation and tumefaction
exist to such a degree as to occasion painful deglutition, a blister
to the  throat will often afford considerable  relief.  Willan, He-
berden, and Rush  speak very highly of this practice.
   The complication of the complaint with visceral inflammation,
renders the employment of  cold or tepid affusion almost, if not
entirely useless; and it is  observed by Armstrong,  that where
these means in  conjunction with purgatives  are unavailing, tho
practitioner may be sure of the existence of some latent inflam-
mation.  In a case of this nature, provided there be no signs of
approaching collapse, recourse must be had to sinapisms, blisters,
and small general  or topical abstractions of blood.  When much
vascular irritation exists, or  incipient phrenitis comse on—as indi-
cated by the flushed and turgid countenance, intolerance of light,
severe pulsating pain in the head, more  or less delirium, and  a
disposition to somnolency—the patient must be laid in a cool sit-
uation with his  head elevated, and blood drawn  according to the
           * Willan on Cutaneous Diseases. Note at p. 360. 
 460                      SCARLATINA.
 state of the pulse.*   In addition to this, an active purgative should
 be given, warm fomentations or sinapisms applied to the feet, cold
 water to the head, and cups to the temples, or blisters to the back
 of the neck.  But in all our measures we should never lose sight of
 the  imminent risk of collapse,—as this condition  nearly always
 speedily ensues in this affection, upon the supervention of internal
 visceral inflammation, and when present, utterly forbids  the  use
 of sanguineous or  other  evacuations.  Dr. Armstrong remarks,
 that " in such examples, the question is  simply this—whether is
 greater danger to be apprehended from the inflammation or from
 the depletion?"   Visceral  inflammation, in  his  opinion, almost
 invariably terminates  fatally, but depletion  only  occasions  de-
 bility, and  rarely is debility the cause of death.   He believes it
 therefore right, even in the stage of collapse, to arrest, if possible,
 the inflammation, by depletion, wherever it  may  be seated.    It
 is true,  that debility  may rarely be  "the cause of death";  but
 that it favors the occurrence of this event can hardly be doubted.
 Why is visceral inflammation so fatal in  these cases?  The most
 rational answer is, because it  is associated with universal  debility.
 It is  evident, therefore, that whatever augments this debility or
prostration,  must  hasten  a  fatal termination.  Depleting does
indeed appear to us to be a desperate practice; and before adopt-
ing it, we would do well  to  recollect, that internal  inflammation
cannot be materially mitigated by a small bleeding, and that from
a large  one death  must inevitably result.  Herein  is the reason
why cases of this nature are so exceedingly perplexing; the most
efficacious remedies for inflammation  being  sure to increase  the
prostration.   When the inflammation is seated in  the  brain, we
may apply fomentation to  the feet, and dry cups to the temples or
shaven scalp, at the same time that we exhibit active purgatives
in conjunction with carbonate of ammonia or  camphor.   In other
visceral phlegmasiae attended with collapse, I should be disposed
to resort to calomel  and  opium, with dry  cupping  and  large

  •♦Armstrong; Marcus, (Specielle  Therapie, torn. in. p.  272); Lorry, (Hist, de la
Soc. Roy.  de Med. t. ii.); P. Frank,  (de Curand.  Homin. Morbus) ; Rush; Burserius,
(Institut. Med. Pract. vol. ii. p. 72) ; Heim, (Horn's Archiv. fur Medic. Erfahr. vol. iv.
b. 1. p. 150.) ; Richter;  and many other eminent authorities may be adduced in favor
of prompt bloodletting in such cases. 
                         SCARLATINA.                     461
fomenting cataplasms over the region of the affected part.  Blis-
ters in these cases are almost as hazardous as bleeding: they give
rise to much general irritation, and gangrene  often  takes place
in the blistered part.

   Malignant scarlatina exchanges so speedily its highly phlogistic
symptoms for those of a low and typhus state, that physicians were
once  in  the habit of resorting immediately to the use of bark,
wine  and other stimulating  and tonic remedies. " These reme-
dies," says Dr. Armstrong, " so forcibly, so  indiscriminately, and
so fatally recommended by  numerous authors, were once  the
means upon which,  unfortunately, I relied  for the  cure of this
modification of scarlet  fever;  and from repeated trials of them, I
can truly affirm that they are the most pernicious in the first stage,
and most destructive  in  the second."  However  quickly this
variety of the disease may put on a malignant form, its irruption
is often marked by highly inflammatory symptoms.   The vehe-
mence of the attack and  the intensity of the excitement rapidly
exhaust the vital energies; so that  in proportion  to  the violence
of this tumultuous, transient stage, will  be  the tendency of  the
complaint to assume a  putrid  character.  Energetic measures  are
therefore imperiously required promptly to allay the initial febrile
commotion.   The remark I have already made in  reference to
the exhibition of emetics, followed by brisk purgation, in the com-
mencement of the other forms of scarlatina, are equally applica-
ble to this variety.  If called  sufficiently  early, these  should
always be our first remedies. When, after their operation,  the
stage  of excitement  begins with violent symptoms—such as  in-
tense  heat of the skin, a frequent, quick, and tense  pulse, severe
headach and delirium—prompt  and efficient venesection should
be practised. (Burserius, Lorry, Armstrong.) As the time allowed
us for the prosecution of these vigorous  measures is  but short, it
is highly important to draw blood at  once,  to the extent of pro-
ducing a very decided impression on the system; or, according to
Armstrong, until syncope  approaches.  One such  bleeding, with
the brisk operation of a purgative, will often so allay the violence
of the disease, that  its subsequent  course shall be divested in a
considerable degree of its  dangerousness.  But it should be borne
                                              40 
4Q2                        SCARLATINA.
in mind, that  these active  depletory remedies must be entirely
restricted  to the early period of the stage of excitement; for the
approach  of  collapse renders  bleeding utterly  inadmissible.—
(Armstrong.)
   In every form of scarlatina,  during  the  stage of excitement,
purgatives  may be  employed with  propriety.   Calomel has been
particularly recommended, both in the mild and  malignant  vari-
eties;* and by Dr. Rush was administered throughout the whole
course of the  malady.  A combination of  calomel, precipitated
sulphuret  of antimony, and emetic tartar, according to the annex-
ed formula,! is recommended in high terms by Seelig:  it is said to
be a gentle laxative, and an  antiphlogistic  alterative in the dis-
ease under  consideration.   In conjunction  with purgatives, the
 warm-bath may be advantageously employed, particularly in cases
attended with internal inflammation.
   The  collapsed   stage of  the  inflammatory  modification of
scarlatina, is  not apt to be extreme, where a prompt and vigorous
 antiphlogistic  treatment has been pursued in the commencement
of the  disease.  When  it takes place after  such  a treatment,
we  may in general sufficiently sustain the system  by the admin-
istration of wine whey, weak solutions of  ammonia, infusion of
serpentaria  and by  directing a milk diet, quietness  and proper
ventilation.   (Armstrong.)  But when from inefficient or improper
measures  in the beginning, or a peculiar malignancy of the disease,
 great and universal  collapse ensues, (and  such is the result but
too frequently, both  in the inflammatory and congestive modifica-
 tions of malignant scarlet fever,) recourse  must  be  had to more
 decisive  stimulating and tonic treatment.   The  carbonate of
 ammonia  in frequent and active doses;  wine; camphor and opium
where the brain is not particularly affected;  infusions of serpen-

   * " It is somewhat remarkable," says Armstrong, " that calomel, though given in large
and frequent doses,, will hardly ever produce ptyalism in  scarlatina."  He states, that
 he has frequently given from six to eight grains of this article to  children, twice, thrice,
 and even four times daily, without having, in a single instance, known it to produce sali-
vation. It is considered by him the best purgative in every modification of this disease.
      t R  Calomel,  ...........9ss.
           Sulphuret. antimon. prsecipit.  gr. i.
           Part, antimon.........gr. ss.  M. Divide into twenty equal parts.
   Dose-one part  to be  taken by a child six years old, every third or fourth hour. 
                         SCARLATINA.                    463
taria, with  large doses of elixir vitriol;  quinine and capsicum
are the remedies  on which we must rely.  Peculiarly excellent
effects appear  to be  derived  from  the use of capsicum as  an
excitant in this form of the affection.  It  was first employed with
this view by Dr. Stephens, in a very fatal epidemic of scarlatina
maligna, that  prevailed at St.  Christophers, (West Indies,) in
1787.   Since then, many eminent practitioners have borne full
testimony  to its  efficacy.   The following  is the  manner  in
which it  is prepared for use: Take a tablespoonful of small red
pepper, a teaspoonful of common Cayenne pepper, and one tea-
spoonful of salt: beat them into a paste, and pour upon them half
a pint of boiling water.  This is to be  strained, and about  a gill
of good vinegar  added  to it.   Of this liquor, when cold, a tea-
spoonful is to be taken every half hour, and the throat should be
frequently gargled with it.  It is stated by Dr. Stephens that he
employed this remedy in about four  hundred cases, and with sur-
prising success: the slough in the fauces was soon thrown off, and
the ulcers began to heal; an agreeable  sensation of warmth spread
throughout  the general system, and a more vigorous condition of
the vital powers was superinduced.
   The flowers of arnica are favorably mentioned by Malfatte,* and
by Steiglitz they were employed with much advantage in this
stage of the complaint.  Reil speaks in high terms of large doses
of musk, especially where the patient is much harassed by restless-
ness and nervous irritation.  We may also derive advantage from
stimulating frictions with brandy, camphorated spirits, or tincture
of capsicum.   (Reil, Steiglitz.)  The  cooling drinks,  acidulated
with  lemon juice, the sulphuric  or muriatic acids, which should
•be freely  allowed in  the  stage of  excitement  are well sub-
stituted during the subsequent stages  by  infusions of sage, balm
or catnep, with sulphuric acid.
   The treatment proper in the  congestive  modification of scarla-
tina maligna, does not require  in this place an extended notice.
As the  curative  principles in  all congestive states of febrile
diseases are alike, what has already been  said in relation to the
treatment  of congestive measles,  is  applicable to the  present
malady  when appearing  under this  modification.   Our first
                   * Hufeland's Journal,  Bd. 12 at 120.
• 
464                     SCARLATINA.
efforts, if symptoms of oppressive internal venous congestion should
mark the rise and progress of the complaint, must be to rouse the
action of the sanguiferous system and recall the blood to the surface,
thus relieving the overburthened internal organs.   To accomplish
this object, we should  make an  assiduous  use of frictions and
warm and stimulating applications to the skin; stimulating ene-
mata; warm and gently stimulating ptisms; large doses of calomel,
(5-10-15 grains), and small  doses of camphor  where there  is
much irritability of stomach.   If these measures succeed in bring-
ing about  a  moderate febrile reaction,  we may  properly com-
mence at once with the use of the milder stimulating remedies—
such as infusions of serpentaria or calamus,  wine whey or carbo-
nate of ammonia in small doses.  But as the disease  advances
and collapse approaches,  we  must resort to the more active  ex-
citements already noticed, with a vigor correspondent to the degree
of prostration present.

   Local Treatment.—To diminish the  tendency in  the  fauces to
ulcerate, to arrest the progress of ulceration, to promote the sepa-
ration of the sloughs, and dispose the ulcers to heal, are the ob-
jects to  be effected by our local applications.   Of  these a great
variety  has been recommended.  Fumigation  with  nitrous gas is
highly spoken  of  by Willan; others advise the application of  a
weak solution  of nitrate of silver;  and  some, of the sulphate of
copper, to the sores.  They are doubtless all beneficial at times.
Various gargles have also been employed, and of these, the infu-
sion of Cayenne, mentioned  above, is  perhaps  the  best.  Dr.
Jackson, of Northumberland, Pa. states that he has recently made
use of ice and iced water with surprising success.  He permits the
patient  to drink the coldest ice-water, and, enclosing a piece of
ice in a  gauze bag, he puts it far back into the mouth that it may
be dissolved and swallowed.   I have seen much good done by a
strong infusion  of the root of baptisia tinctoria (indigo plant); and
the black  wash  (calomel, gr. xx. lime-water, gviii.) I have  also
found a  very valuable article in several cases of putrid sore throat.
An excellent gargle to wash away the acrid matter from the in-
flamed and ulcerated fauces,  is barley-water, acidulated  with sul-
phuric or muriatic acid.   The same  good  effect  may  often be 
r

                                 SCARLATINA.                     465
         derived from a gentle emetic, provided neither Collapse in the an-
         ginose variety, nor visceral inflammation be present. "Emetics,"
         says Armstrong, " are the best gargles, where the throat is much
         obstructed from an  accumulation of tenacious mucus; their ope-
         ration effectually dislodges that morbid secretion for a time; often
         greatly relieves the respiration;  improves the appearance of the
         ulcers; and they may be repeated where no abdominal  inflam-
         mation exists, at  any time, during the continuance of  the fever,
         whenever the respiration and deglutition become much impeded
         by an accumulation of phlegm."

           Convalescence.-—Convalescence from scarlatina is generally very
        tedious.  During its continuance, light and nourishing diet should
        be directed, and the patient carefully guarded against cold and
        vicissitudes.  Where much weakness  and relaxation are  com-
        plained of, it will be proper to prescribe the usual tonic and cordial
        remedies—-such as weak infusion of serpentaria, colomba, gentian,
        or calamus  aramaticus, with some of the  mineral acids, particu-
        larly the sulphuric. These remedies are wholly inadmissible, where
        more or less irritation remains, which is sometimes the case during
        the early part of this period—as indicated  by the quick and fre-
        quent pulse, pale and dry skin, anorexia, disturbed sleep, and
        inactive bowels.  Here, we must  resort to gentle aperients, dia-
        phoretics and  warm-bathing; and direct a  simple, unirritating
        diet.   Small doses of calomel in union with  ipecacuanna, three
        or four times daily; the muriate of ammonia; digitalis with nitrate
        of potass; spiritus mindereri with minute portions of emetic tar-
        tar; infusion of eupatorium or elder blossoms;  acidulated diluents,
        &c. will generally answer well in cases of this kind.   As the sus-
        ceptibility to the harmful influence of vicissitudes is always pe-
        culiarly great immediately after an attack of  this  disease, the
        patient should be extremely careful to avoid taking cold, remain-
        ing within doors during the whole period of convalescence, unless
        the weather be warm or mild.
          The frequent occurrence of dropsy after every modification of
        scarlatina has been, generally, ascribed to injudicious treatment
        In the febrile stage of the disease, or to errors in diet, or impru-
        dent exposure to cold during the period of desquamation and con-
                                     3 O             40* 
406                      SCARLATINA.
valescence.  -This may be true, in part; but, from the occasional
supervention of this sequela, after the most judicious management
in all these  respects,  it would seem that a tendency to hydropic
effusion is created by the orignal disease itself, by reason,perhaps
of some irregularity  in the development of its train of morbid
actions,-—in  which case the  dropsy or some other disorder may
accrue  as a complemental affection.*  These dropical  effusions
are seldom   attended with danger,  and in general are  easily
removed.  We may expect, in most examples of the sort, to find a
manifestly phlogistic state of the  system,—the pulse being quick,
sharp, tense, frequent, and sometimes full; the skin dry, harsh, and
above the natural temperature;  urine small in quantity, high-
colored and  charged with coagulableserum; and the bowels usually
torpid.   Every thing indicates the propriety of an antiphlogistic
treatment.    Venesection  is strenuously recommended by Richter
and other eminent authors, some of whom  are quite recent.  In
the epidemic scarlatina,  described by Burserius, that  prevailed
at Florence in 1717, the affection  readily yielded to the measures
advised by Sydenham. About the twentieth day of convalescence,
many became affected with cough, a sense of weight in the chest,
and  oedema of the face  and forepart of the neck.  Fever soon
ensued;  the dropsy  became  general;  the breast was sore; the
abdomen distended and painful; the urine very small in quantity,
and in some instances entirely suppressed.  All who took diuret-
ics died.  Dissection soon revealed  inflammation of the  lungs,
intestines and kidneys.!  Bloodletting was  now freely practised,
and with uniform success.  Gregory does not appear to be deci-
ded as to the propriety of venesection.   " I have met," says he,
" with several cases  which appeared to indicate bleeding  and
purging, but which resisted both, and ultimately yielded to bark
and aromatic confection." Where there is an evidently phlogistic
diathesis, my own experience is in favor of the measure, not in-
deed as a principal curative  means, but as  an important prepa-
ratory step to the use of diuretics, purgatives and diaphoretics.
   Digitalis,  alone or  in combination with small portions of calo-
mel and nitrate  of potass, is  the best diuretic in cases of  this

  * Reil, loc. cit. vol. ▼• p. 186.    f Burserius, Institutiones Med. Pract. vol. ii. p. 81. 
                           SCARLATINA.                        467
nature.   In this, as well as  every other variety of inflammatory
dropsy, I have found the following a very useful prescription.* It
possesses at once purgative and diuretic properties.  Advantages
may also be derived from small doses of tart, antimon. dissolved
in  a large quantity of some mucilaginous  diluent.  'Calomel in
large doses is recommended by Richter, who prescribes from five
to ten grains daily to children.   Throughout the treatment, quie-
tude should be enjoined, and the patient restricted to the mildest
farinaceous diet, with cooling acidulated  drinks; and the  occa-
sional use of (he tepid bath will often prove  beneficial.
   But febrile irritation is not always associated with these hydro-
pic effusions.  They may be connected with a relaxed,  torpid,
and leucophlegmatic state of the system—constituting  the hydrops
frigidus of the German writers. (Reil.)  "The principal remedy,"
according to  Richter, " in cases of this kind, is calomel in  doses
sufficiently large to evacuate the bowels freely.  Decided  advan-
tage may often be derived from the use of the cinchona bark, and
the various medicinal preparations of iron—particularly the black
sulphuret.   As diuretics in this variety of dropsy, squill, spirits of
turpentine,!-and the tincture of cantharidies,  have been  highly
recommended, (Hufeland, Buchholz.)  The following  mixture  is
said to have done much good in such cases.§

                        *K Crem. tart. 3 i.
                           P. sulphat. potassse, 3"*-
                           P. scillae, 3ii.
                           Tart, antimon. gr. iss. M. s.
  Give From four to six grains three or four times daily, to a child of five years old.
  Kreisig is equally favorable to the use of calomel in this and other  morbid conse-
quences of scarlatina.  " Against the sequela of scarlatina," he remarks, " the powers
of calomel are great and cannot be too highly praised." Abhandl. euber das Scharlach-
Jieber, Sic. p. 107.
  \ R  Spirit terebinth, gi., tinct. opii, gtt. 1. M. s. From  ten to twenty drops to be
given thrice daily to children from five to ten years old.
                 (RP. cinchon. gss.
                    Aq. fement. gxii. coque andremand. gvi. dein adde.
                    Rad. polygal. seneg. 3'i-
                    Fol. digitalis, Qi. cola. dein. adde
                    Spirit, nitri dulc. 3'i-
                    Syrup cort. aurant. gss. M. s.
Take from a tea to a tablespoonful every two hours, according to the age of the patient. 
468                      SCARLATINA.
  Prophylactic Measures.—Bella-donna, regularly taken by persons
exposed to the contagion of scarlatina, is supposed to protect the
system effectually against the  disease.   Hahnemann, the author
of the homaepathic doctrines, was the first who introduced to the
profession the prophylactic powers of this narcotic, and since then
many statements have been published in Germany and France in
confirmation of the fact.* In conformity to his peculiar notion, it
was prescribed by him in  infintesimal doses.   He gives but forty
drops, in seventy two hours, of a solution, of which one drop con-
tains no more than the twenty millionth part of a grain of the ex-
tract!  We may well be sceptical as to the efficacy of these doses;
but that small doses of the article do really possess prophylactic
virtues, is strongly  testified  by  many respectable authorities.
Berndt states, that he gave it with unequivocal advantage in this
respect.  It was found by Dr. Koreff of Berlin, to protect persons
completely against the disease, when taken for eight or  ten days
before they were exposed  to its contagion.   Three grains of  the
extract are to be dissolved in an  ounce of  cinnamon water, two
or three drops of which may be given to children under one year
old, and one drop more for every year above this age.
   It has been found that,  seclusion of the sick,  free ventilation,
frequent changes of linen, and other similar precautions, will pre-
vent the spread of the disease  even in  the same  family.   Unlike
other contagions, the contagious miasm of scarlatina appears to be
incapable of  attaching itself to clothes:  but  an intensely infec-
tious power is said to reside in the breath of patients laboring un-
der the  malignant  form of the  disease,—as  also in the matter
discharged from the fauces.
                 * Ed. Med. and Surg. Journ. Jan. 1825.. 
WHOOPING COUGH.                   469
                CHAPTER  XXXVIII.

                PERTUSSIS—WHOOPING COUGH.

  According to  certain writers, whooping  cough was brought
into Europe from Africa, in  the thirteenth century.   It would
seem, however, that the ancients were by no means unacquainted
with this remarkable disease.   Hippocrates, in the 6th book on
epidemics, and also in the 6th  section of his aphorisms, speaks of
a cough, which, from the short description  he gives of it, may be
regarded, I believe,  as the same affection that is now known
under the name of whooping cough.   The first distinct and com-
prehensive  account we have  of the disease, was furnished by
Maezray, in the year 1414, in his chronological history of France.
Since that  period, numerous circumstantial records of its occur-
rence in epidemics  have been published; and  its nature  and
treatment have  been discoursed upon, in  not  a few  elaborate
monographs.
  Symptoms and progress of the  disease.—The symptoms of com-
mon catarrh usually precede the invasion of whooping cough.
In the beginning, lassitude, head-ache and  sneezing, with hoarse-
ness and occasional oppression of breathing, are experienced
in a greater or  less  degree.   Dreams and sudden starts disturb
the  sleep;  there  is impairment of  the appetite;  the bowels
become  sluggish; and  a slightly febrile  excitement is evident
towards  evening.  During  the  first two  or three  weeks, the
cough  is almost  invariably dry  and ringing; and the paroxysms
short and unattended by that peculiar convulsive clangor, termed
whooping.
  About the end of this period, the disease begins to manifest
a more convulsive or spasmodic character,  so far at least  as the
mere cough is concerned.   The frequency and duration of the
fits of coughing  are increased, and  when the malady is at its
height, their violence is sometimes terrific.  A sense of tickling 
470                   WHOOPING COUGH.
in the larynx  and  prascordia,  and a feeling of tightness  in the
breast are the usual precursors  of a  paroxysm.  During its con-
tinuance, the  inspirations  are extremely  difficult, slow  and
stridulous,  attended with  a sense of obstruction  or spasmodic
stricture of the glottis, rendering the cough distressingly suffoca-
ting, and in a manner  convulsive.  The face become's turgid and
purple from suffusion;  the  eye-balls are protruded and  swollen;
and the whole system  violently agitated.   So severe, in some
instances, is  the fit of coughing, that it induces a state of partial
insensibility, and  a dreadful  feeling of impending  suffocation.
Occasionally, sanguineous determination to the head  is  so great,
that blood bursts  from the nostrils and mouth; and  it is nothing
uncommon  for  children to be attacked  with convulsions, in con-
sequence of  cerebral  compression,  resulting from  this  cause.
The discharge of  a large quantity of viscid mucus, in this  period
of the disease, is  the  ordinary termination of a paroxysm; and
the patient now frequently complains of some pain in the breast.
In many cases, the  cough  continues until the  accession of free
vomiting,  when it is immediately  arrested, the patient greatly
relieved, and a craving for fresh food experienced.  The duration
of the fits  of coughing is very  various: in some instances, being
less than half a minute, in others, five or six minutes, and occa-
sionally longer.
   This stage of the complaint  commonly lasts from four to six
weeks, about which time it begins to abate.  The declension is
always very gradual, and  from two to four weeks longer elapse,
before the complete termination of the  affection.

   General  Observations.—Fever is not essentially connected with
whooping  cough,  although in  many   instances an accidental
concomitant.
   Children chiefly are liable to this disease, but adults  are not
always exempt.  Two cases of it have I seen in subjects beyond
the fiftieth  year of age, and several in individuals, but a  few
years younger than this.  The contagiousness of whooping cough
has been denied by Stoll  and a few others, but the profession
concur generally in regarding it as highly  contagious; and the
fact is certainly unquestionable, although  the range of its con- 
                      WHOOPING COUGH.                  471
tagion may not be extensive.  It is almost always epidemic in
its appearance.  I have never yet witnessed a sporadic case of
this affection, but such instances may undoubtedly occur.  The
susceptibility of the system to its infection is taken away by one
attack, so that it rarely, if ever, affects the same individual twice.
As in the case of all other epidemical diseases, various grades of
violence mark  the  different  epidemics  of  this malady.  Some-
times, it is so gentle, that numbers of those  who are still sus-
ceptible to its influence, entirely  escape, and its  treatment can
be conducted without difficulty; at others, it  assumes a violent
and  dangerous character,  is  exceedingly  intractable,  and  lays
hold  of almost every individual, whether old or young, who has
not yet had the disease.  It would seem as if some sort of a latent
connexion  subsisted between this malady and measles; for whoop-
ing cough frequently prevails most extensively, either immedi-
ately before the occurrence of epidemic measles, or in alternation
with them, or directly  after  their  disappearance.*  Spring and
autumn are most favorable to the  prevalence of  pertussis; and
its invasions  during the wet and  changeable periods of these
seasons, are attended with  far more danger,  by reason' of the
pneumonic predispositions  and affections  occasioned  by atmo-
spheric vicissitudes.

  Prognosis.—When whooping cough assumes a  periodic form,
which, however, is an exceedingly rare occurrence, it  will most
likely be very intractable.  A singular case of this  kind is related
by Dr. Percival, in which the paroxysm  came on daily, at a cer-
tain hour, attended with tremor of  the whole body, and termina-
ting by a shriek rather than a whoop.   The  complaint was ob-
stinate for several  months, and returned  at the same season for
two years. It yielded to no medicine, and was supposed to depend
on some morbid condition of the liver. (Good.)
  A fatal termination of the  disease is  not to he apprehended,
unless by the supervention of bronchitis, pneumonia,  cynanche
trachealis, hydrocephalus, apoplexy, or marasmus.   These secon-
dary  affections are by  no  means uncommon, particularly in
* Richter's Soecielle Therapie. 
472                   WHOOPING COUGH.
variable and  humid  seasons; the disease,  therefore,  upon the
whole, should be regarded as one of considerable danger.
   In northern or cold climates, far more violence marks the affec-
tion, than in the milder and more equable regions  of the middle
and southern latitudes.   Rosenstein  states, that in Sweden there
were 43,393 deaths from  this disease, between  the years  1749
and 1764—and of these, 5,832 deaths occurred in the year 1755
alone.   (Richter.)
   In general, the danger is inversely as the age of the subject.
In other words, the younger the patient, the more hazard of a
fatal termination.   It is observed  by  Cullen,  that by  far the
greater number of those who die of this disease, are  children
under three years  of age.  Much is to be apprehended, when  it
attacks weak and delicate  infants, within the first few  months
after birth; but even at this early age, robust and healthy infants
generally pass through the disease without much difficulty or
danger.   The  supervention of pneumonitis,  during its continu-
ance, is more common in adults than in  children.
   Its occurrence during pregnancy  is to  be feared, as not tlnfre-
quently*it has occasioned abortion.   Frequent haemorrhage is an
unfavorable symptom, protracting in almost every  case the dis-
ease, and where it proceeds from the lungs, often occasioning the
development of phthisis.
   Whooping cough is exceedingly apt to excite the local mani-
festations of scrophula in children of a strumous diathesis.   Thus,
its attacks are often  succeeded by scrophulous ophthalmia and
glandular tumors in the neck.  I know  of no complaint whose
occurrence is more to be dreaded, in subjects of an hereditary
consumptive habit  than whooping cough.  It rarely fails to develop
phthisis pulmonalis, in persons predisposed to the  formation  of
tubercles, or in whom these exist in an incipient and dormant state.
  Chronic bronchitis is not an unfrequent termination of the dis-
ease.   This is particularly apt to occur, when the  patient takes
cold from exposure to a damp and variable atmosphere—a  cir-
cumstance that always greatly  aggravates the  violence and
danger  of the  affection.  I have  seen but few deaths  from
whooping cough, that were not attended with bronchitis, puru-
lent  expectoration and hectic symptoms, occasioned by  having 
                      WHOOPING COUGH.                  473
taken cold.  In these cases,  the matter expectorated,  usually
resembles, more than  any  thing  else  I  know, a  mixture of
cream and mucus.
   The  cough,  in some  instances,  after nearly disappearing,  is
renewed and protracted for several months by an accidental cold.
Cases of this sort often continue for six or seven months.   When
the disease, either from  cold or some other casual circumstance,
thus assumes a  chronic form, fatal hydrocephalus sometimes ter-
minates its career—especially in  patients, habitually subject  to
disordered bowels, or laboring under the irritation  of  difficult
dentition.
   Cynanche  trachealis  will  often  supervene  during whooping
cough.   Children of robust and full habits, in the early stages of
the affection, are more particularly liable to this accident.   It is
almost always  the consequence of cold,  and attended with the
most imminent danger.
   According to Richter,  a profuse watery diarrhoea,  supervening
suddenly  in this  disease, in  connexion with pneumonic irri-
tation, is  always to  be regarded as one of the most dangerous
occurrences.    Death, he says,  often  follows such  a discharge
very speedily.   The appearance of apthae in the mouth  and fau-
ces, in  the latter period  of the  disease, is inauspicious.   (Edem-
atous swellings of  the  feet  and face, supervening  in the com-
mencement of  the complaint, portend much danger, more espe-
cially when accompanied  by a  turbid,  milky  urine; but their
occurrence towards its conclusion,  which is by no  means rare,
needs seldom excite any apprehensions. (Richter.) A sudden ces-
sation of the cough,  it has been remarked, is an  unfavorable
event, and is frequently followed by pulmonary  inflammation.  In
general, the more fever there is in this affection, the more violent
and dangerous  may it be considered.
   Free  vomiting, soluble bowels, plenteous expectoration, warm
extremities and an open skin  are  regarded as favorable symp-
toms.  According to  Hufeland, the occurrence of some degree
of strangury in  the advanced stage of the complaint, is in general
soon succeeded by a manifest mitigation of the symptoms.
   It is  said by certain writers,  (Hufeland, 1. c. p. 420: Lentin,
Memorabilia, p. 36:  Jahn Kinderkankn. p. 399,) that*children
                            3P               41 
474                   WHOOPING COUGH.
laboring under some chronic cutaneous affection,  as tinea, itch,
&.C., very  rarely  take this  disease;  and if they  do become
affected  with  it, they  almost invariably pass through it in the
lightest  manner.  This  is  contradicted  by  others, particularly
by Hoffman and Haase.
  The  following are  the principal  affections that are properly
£alled sequela of this  complaint:  strumous swellings, dropsy,
epilepsy, opthalmia, rickets, general  cachexy, aneurism, deafness,
dementia,  paralysis, and phthisis pulmonalis, ruptures and in-
curvations of the spine.  A majority of these  diseases I have
known to ensue as consequences of whooping  cough; and amongst
them, epilepsy,  struma, phthisis  pulmonalis and  ophthalmia
appear of most frequent occurrence.  When perfectly free from
any adventitious complications, pertussis cannot  be considered  a
disease of much danger, except in very young and feeble subjects.
Still, in connexion with the grave sequela  above mentioned, and
many other consequences by no means uncommon, it assumes  a
very serious aspect, and is attended with no little hazard.

   Cause.—The exclusive cause  of whooping  cough, so far as our
knowledge extends, is a peculiar  contagion, generated by the
disease itself.  That this, as well as every other  contagious dis-
temper  must at one  time or  another have  had a cause, inde-
pendent of contagion, cannot, it is evident, be denied.  But the
nature of  this cause,  together  with the period  of its origin and
the circumstances requisite to its generation, is  involved in utter
 darkness.   Nothing, in truth, is more incomprehensible, than the
origin of maladies, now engendered and propagated  by specific
 agents alone, which are elaborated by  the living body, actually
 laboring under their  influence. The  only notion we can offer,
 (and it is indeed vague as the ancient  dogma of fortuitous atoms,)
is that, in the infinite combinations of which the material ele-
 ments  of the universe  are capable, agents  may  have  been
 evolved by a peculiar concurrence  of circumstances, which had
 the  power of creating  these  affections in  the human system.
 This is the only plausible  explanation that  can be given, of the
 occasional  rise of new  diseases, which,  when  once originated,
 propagate themselves by elaborating their own specific causes;— 
                      WHOOPING COUGH.                   475
unless, indeed, we choose to refer them directly to the will of the
Creator, as their immediate cause.  But whatever may be  our
speculations in relation to this subject, whooping cough now is in
all cases  the product of a specific contagion.  It is observed by
Richter, that beside this principal cause, cold in conjunction with
humidity  may  give birth to the affection.   The  grounds for  this
opinion are rather insufficient; and  it  seems to  me just as im-
probable, as  that small pox  or measles should arise from acci-
dental circumstances.
   Linnaeus, who at one time  advocated  the animalcular origin of
almost all diseases, maintained that whooping cough was pro-
duced by inhaling, with the air of respiration, the  minute eggs
of a peculiar species of insect.   Riverius,  Dessault, Rosenstein
and more recently Clesius concur in this opinion;  but  it  seems
to  have met  with but  little  countenance  from  the  profession
generally.
   Whooping  cough does  not  appear  to  possess  a contagious
character, until it has made  considerable progress (Richter;) or
until  the  second or convulsive  stage has supervened.   Its con-
tagion, although very active, extends to  no great distance beyond
the body  of the affected person.  Accordingly separation of the
healthy, from the infected portion of the community, will almost
always prevent its influence.

   Autopsic phenomena.—Various, and often contradictory, are the
appearances  discovered  on  post-mortem  examination.  This
might naturally be expected, when  it is considered, how diverse
are the affections adventitious to this complaint, and at what differ-
ent periods of the disease death takes place.  We cannot, for
example, anticipate the same post-mortem appearances in a case
terminating fatally in  consequence  of  pneumonia, as  in one,
where death results from apoplexy; nor is it reasonable to pre-
sume there should be  much uniformity, where  the immediate
cause of death is so various, or dependent on so great a diversity
of accidental disorders.
   The respiratory  organs  being the  parts most obviously impli-
cated in whooping cough, pathologists  have of course  sought an
explanation of the nature  ©f the  disease,  especially in  the 
476                   WHOOPING COUGH.
autopsic phenomena  they exhibit.   Traces of  inflammation in
the mucous membrane of the bronchia and larynx, have  been
frequently  discovered   and  particularly   described.   Strong,
Cullen, Astrue, Lettson  and  Dany, mention these appearances
as being by far  the  most common; and  more  recently striking
examples of the  same sort have been adduced by Whatt  and
Marcus.  The former  lost three of his  own  children by this
disease, and in each,  the marks  of previous inflammation in the
mucous  membrane  of  the  bronchia were very  conspicuous
throughout  its whole  extent.  Marcus gives but two dissections
in which bronchial  inflammation was revealed.   In one of these,
a considerable quantity of pus was discovered in  the air passages,
the  smaller branches of which were in a state of most intense
inflammation,  approaching in some parts to gangrene.
   In some  instances, no traces whatsoever of bronchitis  have
been discoverable; but the  lungs have been found exceedingly
congested, and the air-cells choked  up with an  extremely viscid
mucus.   Loboustein  Loebel relates a case, in which a consider-
able portion of the diaphragm was  covered with  a number of
small pustules containing a  purulent fluid.*   Various  other
appearances have at  different  times  been  observed,  such  as
adhesions between the pleura  pulmonalis and costalis, tubercles
in diverse stages  of development, enlargement  and scrophulus
degeneration of the bronchial  glands, &c.
   Sometimes  the respiratory  organs may  be entirely unaffected
in their  structure, exhibiting  not the minutest traces  of any
disease  whatever;  whilst the  brain presents  various  striking
marks of the previous existence of severe cerebral derangement.
In a case related by Dr. Webster  of London, the  following
appearances were observed on  post-mortem examination;  both
hemispheres were extremely vascular, and  the convolutions were
so pressed  together as almost  to disappear. A good   deal  of
serous effusion was visible under the piamater, particularly at the
anterior  and upper part of the brain, where  a  few  spots  of
coagulable lymph were  seen;  and the  membrane itself was
injected  with  blood.   The hemispheres slightly cohered ante-
* Richter's Specielle Therapie. 
                      WHOOPING COUGH.                  477
 frorry4,  the  ventricles contained about  two  ounces  of serum,
 and in the sheath of the medulla oblongata, nearly half an ounce
 of fluid was discovered*
   After all, it is incontestible, that  in  many cases of death from
 whooping  cough, no morbid appearances whatever  have been
 detected on dissection; and there are many reasons for believing
 that  the  inflammation  and  other  phenomena, so  frequently
 observable  on  post-mortem   examination,  have  no  essential
 connexion with the  disease, but are  altogether adventitious or
 secondary.

   Proximate cause.—-Concerning the  nature  or proximate  cause
 of this disease, there has been  much diversity of  sentiment.  By
 Hoffman it  was thought to depend upon an acrid serum in the
 lungs.  Sydenham ascribed it to the influence of irritating effluvia,
 cast off from the blood into the  lungs, in consequence of the
 insensible transpiration through the skin, being checked  by cold
 and  damp air.   It  was referred by  Huxham to some morbid
 condition of the intestinal canal;  to  derangement of the liver
 by Butler, whilst others have considered it the  result of gastric
 irritation, or with  Stoll,  of crude and  bilious  matters in  the
 stomach.
   The  opinion, seemingly  most prevalent at the present day,
 is  that the  disease essentially consists in bronchial inflammation.
 This  inflammation  is  assumed  to  be specific in its nature, and
capable of  giving rise to the peculiar  convulsive  cough  of
 pertussis;  for it is  well  known  that  the train of  symptoms
 characteristic  of this disease  are  not  induced  by  bronchitis.
 The doctrine  would  seem to receive support from the presence
 of febrile  excitement in  most instances  of the affection, and
 from the appearances revealed  by autopsic examinations of the
 mucous membrane  of the bronchia and trachea.  On a super-
 ficial view of the subject, the notion does certainly appears plaus-
ible;  but objections insurmountable in my opinion, may be urged
against its validity.   In the first place, although fever is a frequent
attendant on pertussis, many cases occur, in which not the slight-
est febrile  movements are perceptible in  its  early stages; and
not a few happen, where, during the whole  course  of the disease,
                                             41* 
478                   WHOOPING COUGH.
febrile excitement  is  entirely absent.   Again, that  traces  of
inflammation are sometimes  manifested  on postmortem exam-
ination, is  not  denied; but these appearances are by no means
visible in all cases,  which  ought to be the  fact, if the doctrine
in question were true.   Besides, it is no difficult matter to explain
the frequent occurrence of inflammation, without having recourse
to this hypothesis.  Is it not natural  to look for the supervention
of bronchitis or  other inflammatory  affection of the respiratory
organs, in  a disease that so violently  and frequently agitates the
thoracic viscera, as does whooping cough?   There can be no doubt
too, that in many instances, where this  cause fails in developing
pulmonary  inflammation,  it  may strongly predispose  the lungs
to the injurious  influence of atmospheric  vicissitudes, whereby
pulmonary  catarrh  or bronchial irritation  are  at  last  super-
induced.   We therefore have good grounds for concluding, that
the signs  of phlogosis so  frequently  detected,  on dissection,  in
the mucous membrane  of the  respiratory passages, are  always
adventitious, and by no means essential to the disease.  It may
be further observed, that  bronchial  inflammation is probably far
from  being so common, as   autopsic appearances would lead
one to think.   Death, it must be recollected, takes place princi-
pally  where unequivocal symptoms of inflammation are present;
we may  reasonably   expect  therefore, to find in these  cases
phlogistic  appearances,  although in  milder  instances no such
inflammatory condition may exist.  To conclude this part of the
argument,—if  bronchial inflammation be  the proximate cause
of the disease, it must, of necessity, be present in all  cases;  no
less in the mild than the violent; a circumstance that is  decidedly
contradicted by almost universal  observation.  The only dissec-
tion I ever witnessed  of a victim to this  malady, presented  no
evidence   of the existence   of  previous  inflammation  in the
bronchia.  The patient died suddenly  of convulsions during a
violent paroxysm of coughing.
   That bronchitis is not the proximate cause of whooping cough,
or essential thereto, is further evident from the fact, that the two
diseases totally differ in their symptoms.   Bronchial inflammation
is rarely, if ever, attended with  a violent cough, much less the
peculiar cough, distinguishing pertussis. *  Moreover, rapidity of 
                      WHOOPING COUGH.                  479
 course, strong fever, and  a  continued  sense of  tightness and
 oppression in the breast, characterize bronchitis in its acute form.
 In the chronic form, the expectoration is invariably purulent, and
 entirely distinct in its character from the ropy and transparent
 mucus discharged in whooping cough.  Almost invariably, too,
 the  usual  symptoms  of  hectic  fever  are  present.   Cough,
 dependent  on  acute inflammation of the respiratory passages,
 almost always  begins to decline so soon as the secretion of the
 bronchial  mucus  becomes  copious.   In whooping cough,  the
 reverse generally obtains.   During  the first few  weeks  of  its
 course, there  is seldom much mucus secreted in  the  bronchia,
 but so  soon as the secretion becomes  more  abundant, which
 happens after the second or third week, the  cough also acquires
 more violence,  and assumes that  convulsive character, which
 distinguishes it from other varieties of cough.
  Very commonly, moreover, the slight  symptoms of fever that
 accompany the development and first few weeks of the  disease,
 vanish entirely  in  the  second stage when  the cough  becomes
 more  spasmodic and violent in its paroxysms.  (Richter.) This
circumstance most assuredly does not favor  the idea, that  the
disease is of an inflammatory character; for if this were the case,
 we should expect the cough to decline with the fever, instead of
 which, it is always found to  acquire much more violence.
  It appears  to me that whooping cough is  essentially a spas-
 modic or nervous affection, the proximate cause of which consists
 probably in a peculiar irritation of  the eighth pair of nerves—or
 pneumo-gastric.
  Close attention  to the  phenomena, that immediately precede
 and accompany a  paroxysm  of the disease, has sufficiently con-
 vinced me of its nervous character.   The sense of stricture in the
 breast and of the glottis, felt  just before the fit of coughing—the
 suddenness  and convulsive  nature  of the  cough—the peculiar
 constrictive feeling in the praecordia—the stridulous respiration—
 all clearly indicate  a spasmodic  condition  of  the  respiratory
 organs.  That the irritation which  calls  forth the convulsive
 action of the diaphragm and the other  parts immediately con-
cerned in  the act of coughing, is seated in the eighth pair of
 nerves, may, I believe, be inferred from the known agency these 
480                   WHOOPING COUGH.
have, in the production of the various phenomena manifested by
the  pulmonary  apparatus.  Experiment, too,  furnishes  quite
satisfactory evidence on this point.  Professor  Naase, in a series
of experiments, instituted  for  the  purpose  of elucidating the
pathology of cough, found  that, on bruising or  strongly pinching
the par vagum so as to break down its structure, a violent con-
vulsive cough was invariably excited.   The same kind of injury
inflicted  on the diaphragmatic  nerve, occasioned no such effect.
This  experiment proved, that the act of coughing is performed
almost wholly by  the  sudden  spasmodic  contractions  of the
diaphragm.  By opening the abdomen  of various animals, and
exposing the  lower surface of this  muscle, he saw distinctly its
violent convulsive motions during the cough, which was excited
by bruising with  a pair of forceps the pneumo-gastric nerves.
The peculiar  tone of the cough  and sense of constriction of the
glottis, may  arise  from  the extension  of the irritation  to the
recurrent branches  of the par vagus nerve. That this irritation is
peculiar  or specific in its  character, may be inferred  from the
nature of its exciting eause.       «

   Treatment.—It is generally believed  that  medicine   can only
alleviate  the symptoms of whooping cough, without materially
controlling its progress or shortening its regular course.  This,
I believe, to be an unfounded notion,  the belief of which has
largely contributed to render the  treatment of the disease uncer-
tain and inefficient.  Sydenham,  Werhoff, Hufeland, and several
of the more recent German, Italian and French writers admit
that  its course  may  be arrested;  but  this, it is asserted, can
never be done before the fourth week  after  its commencement.
However this may be, my  own  experience has  fully convinced
me, of the possibility of abbreviating its progress; and, to sustain
this  opinion, not a few well-authenticated instances  might be
adduced from  late publications.
  The propriety of venesection in whooping cough  has been
frequently questioned.  Where inflammation or general fever is
present, all concur  in  advising  its adoption;  but in  every other
case  it is by some deemed inadmissible, as the severity of spas-
modic affection is frequently aggravated by the  use of the lancet. 
                      WHOOPING COUGH.                   481
Now an unusual or preternatural momentum of the circulation may
in many instances exist, without  giving rise to strictly febrile
symptoms; but it should not therefore be regarded as a harmless
circumstance, even in diseases purely spasmodic.  Let the essen-
tial nature of a complaint be what it may, if activity and fulness
characterize  the pulse, blood-letting  cannot be improper, and its
employment may be  productive of much benefit.  The abstrac-
tion of blood in the present disease, may be marked  by no direct
influence  on  its peculiar symptoms; but it will greatly tend  to
diminish the liability  to the supervention of inflammation, and
the danger attendant  upon the violent cephalic congestion, in-
duced  during the paroxysm  of coughing.   Where  bronchial or
pneumonic inflammation is present,  the lancet is of  course indis-
pensable.  Bleeding in such cases should be prompt and decisive,
both in a  general and local way.   Leeching  here is particularly
valuable.   Tampering with the ordinary remedies  now,  would
be to risk the life of the patient.  It is the accidental inflamma-
tion, not the  original  disease, that must claim our attention; for
great must be the danger and obstinacy of pulmonitis in an
affection, which so frequently and  violently agitates  and irritates
the respiratory  organs.
  The bowels in  this, as in every other disorder, should be care-
fully  attended to.-  The  extensive and intimate  sympathetic
relations of the intestinal  canal with  the  various organs  of the
body, cause it  to participate more or less in whatever derange-
ments  may affect the  human system.  No  matter what may be
the nature of the malady or of its location, sooner  or later the
alimentary canal suffers functional  derangement,  giving rise
either  to   a  remora of  its recrementitious  contents, or  of its
vitiated secretions.   These evils  in  their turn become  sources
of  intestinal irritation,  and  it  is  needless  to point out the
strong  tendency  of such  irritation to  aggravate  and continue
diseases, whatever may be  their primitive origin and  character.
There  is almost invariably a morbid  condition of the  primae viae
in whooping cough; the stools being sometimes bilious, at others,
almost entirely mucous, and in  many instances, dark  and exceed-
ingly offensive.  These conditions should be rectified by  appro-
priate  purgatives, and a soluble  state of the bowels preserved 
482                   WHOOPING COUGH.
throughout  the  whole course  of the  complaint.   Very active
purgation, as it aggravates  intestinal irritation, especially  when
frequently repeated, must by all  means  be avoided.  A grain or
two of calomel in the evening, followed  by a small quantity of
rhubarb, or other unirritating laxative in  the morning, will gene-
rally answer our purpose.   Small doses  of sulphate  of soda or
magnesia  are preferable,  where much  febrile  excitement  is
present.
   The utility of emetics in the  treatment of pulmonary diseases,
is fully acknowledged,—especially in affection of the respiratory
organs  marked  by an abundant  secretion of bronchial  mucus.
Much of the suffocative  distress occasioned by whooping cough,
arises from  the  lodgment of a large quantity of viscid mucus  in
the trachea and bronchia; and the  removal of this obstacle  to
respiration is the principal object to  be gained by the exhibition
of emetics.  A part of their beneficial influence may perhaps
be attributed to  the impression they make on the pneumo-gas-
tric nerves in the stomach.   They moreover induce a determina-
tion to the cutaneous surface, thus exerting a beneficial, derivative
influence on the  lungs; and also manifest a tendency to  disturb
the  recurrence  of the paroxysms.   In the whooping cough of
infants, they are  especially calied for; their strength is  insuffi-
cient to expel the viscid mucus, which  sometimes accumulates to
such a degree as completely to clog the respiratory passages, when
death takes place from suffocation.  If, therefore, the cough in
very young children is violent, and attended with symptoms of im-
pending suffocation, an emetic should be quickly administered, or
the fauces irritated with a  feather, so as to bring on speedy vom-
iting.   Sulphate of zinc, by the  promptness of its operation, is
especially suited  to  these cases; but I have in general preferred
ipecacuanna to any  other  article of the  kind.   Dr. Fothergil
speaks very highly of the following combination as an emetic in
this affection:
                   R. Pulv.  chel. cancror.      3SS"
                      Tart, antimon.         gr. ii.
                      Misce.
   According  to the  age of the patient, 1, 14 or 2 grains of this
 may be  given for a dose.   The  union of an absorbent with the 
                      WHOOPING COUGH.                   483
emetic has been thought peculiarly  beneficial in this complaint.
Syrup  of squills  is  another excellent  emetic.   I  have  often
prescribed it  advantageously, united with a  small portion  of
antimonial wine.   The  antimonial wine, combined  with an
emulsion  of assafoetida, may be used with considerable benefit
as a  palliative.  Let  it, however, never be forgotten,  for the
sake  of the future health  of our  patient, that  weakness and
irritation of the stomach are frequent consequences  of too long
a  persistance   in the  use  of emetics, particularly  those of the
antimonial kind.
  Some of our most  valuable  remedies for  the treatment  of
whooping  cough  are  found among narcotics.   The belladonna,
particularly, has been highly celebrated, and  is without  doubt
by far, the best article of the kind we possess.   Professor Borda
was the first, 1 believe, who used it as a remedy in this affection,
and his belief  in its efficacy is almost unlimited.  According to
his declaration, in numerous instances every symptom  of whooping
cough was  removed  in ten or twelve days  by  its exhibition;
and where it failed to  eradicate entirely the complaint, it almost
always  mitigated in a marked degree its  severity.  Cases came
under his  notice, that appeared to  be beyond the power of med-
icine,  and yet  were  relieved by this remedy.   Hufeland,and
Alibert are almost equally  decided in their praise of the virtues
of this article;  and the testimony of many other writers, together
with a large mass of evidence adducible from the current medical
publications,  might be added to  establish still  more  firmly the
fact  of the efficacy  of  belladonna in  this  singular malady.
My own experience leads me to testify confidently on this  point.
I have prescribed it within the last six years, in  perhaps twenty
cases, and in  the majority of them with  evident  advantage*
Since  the  publication of my work on the materia  medica, my
good  opinion of its powers has been increased.   In two  cases,
both of an exceedingly violent character, it arrested the disease
almost entirely in the  course of eight days.  The principal cir-
cumstances that  render its  exhibition  useless  or improper, are
fever and bronchial inflammation.   In these instances, our chief
dependance must of course be placed in  bleeding  general and
local, and blisters or frictions with tartar emetic ointment on the 
484                   WHOOPING COUGH.
chest.   But  in  the purely  spasmodic form  of pertussis, when
inflammatory action is absent, it is often singularly efficacious.
  Dr. Butler speaks highly of the virtues of conium in this com-
plaint, and it once possessed perhaps more celebrity than any
other narcotic.   It is said to delay the  recurrence of the  par-
oxysms  and  mitigate their violence, and was prescribed by Dr.
Butler in every period of the disease, whether complicated or not
with  other  affections.  This gentleman  states,   that  he has
frequently  used the following mixture with marked benefit:
                   R Extract, coni.  gr. iii.
                      Magnes. Sulphat. Q i.
                      Aq. carui.  .  . 3V-
                      Syrup rhad.  .  3*-
                   M. take 30 drops 3 times daily.
  This article has, however, so frequently failed  in  general
practice, that its virtues are not at present very highly estimated
by the profession.
  Lactuca virosa, hyoscyamus and opium have also been employ-
ed as palliatives in whooping cough.  Opium has the recommen-
dation of many eminent practitioners, but the general sentiment
of the profession is opposed to its employment  in this  affection.
It is objectionable both on account of its constipating effect and
its tendency to determine the blood to the  brain.
  Ledum  palustre, or  marsh cistus,  according to  Linnaeus, is
extensively  and  successfully employed  in  Westrogotha,  as  a
sedative in whooping cough.   This praise of its virtues is  sup-
ported by  Wahlin and other European  writers, but I am unable
to say any  thing concerning it from my own experience.
  Antispasmodics  are  often used in  this affection, and  at times
with temporary advantage.  Musk  has been  frequently adminis-
tered in every mode and in all proportions, but so uncertain and
even contradictory  are its effects, that little  confidence is  now
reposed  in  its   efficacy.   Assafoetida will  occasionally prove
quite a valuable palliative, in cases unattended by fever or strong
pulmonary irritation.  It   answers  the  two-fold purpose of an
expectorant  and  antispasmodic.   In a  few instances,  I have
witnessed  excellent effects from a  mixture of the vinegar of
squills and an emulsion of assafoetida.
  The  violence  of the  symptoms  may  sometimes be assuaged 
                      WHOOPING COUGH.                   485
by the  use of expectorants.  The appended  mixture,  strongly
recommended by Dr. Pearson, I have known to give considera-
ble tempoiary relief.
   Tonics have, in many instances, been found useful.  Dr. Cullen
strongly recommended the Peruvian  bark as a  very  efficient
remedy: " I consider," he says, " the use of this medicine as the
most certain means of curing the  disease in  its second stage; and
when there has been little fever  present,  and a sufficient quan-
tity of the  bark has  been given, it  has seldom  failed of  soon
putting an  end to  the disease.  The  same  remedy is in  high
repute  almost  universally  among the German physicians, and
there can be no doubt that it is  frequently very efficacious; but
it  should not be forgotten, that its  good  effects  are  confined
chiefly to the latter stages of  the disease.   In some instances the
cough assumes a chronic  character,  continuing long after the
usual period of its termination.   These cases are frequently com-
plicated with chronic bronchitis, and must be relieved by  the most
efficient measures; otherwise the constitution will be undermined,
the system  worn down, and  the patient will die  in a  state of
marasmus or  under  symptoms  of phthisis pulmonalis.   Strong
doses of cinchona or quinine here, are often peculiarly serviceable.
This  tonic  may  also  be  very beneficial   in cases of a purely
spasmodic character, when the disease  becomes protracted, and
is kept up by habit.
  Various other  remedies have been employed in  this affection,
such as lobelia inflata, tincture of cantharides, rhus vernix, lead,
arsenic, &c.
  Of the lobelia I can speak from experience, and to its excellent
powers  in  whooping  cough  I can testify  most fully.   I  have
prescribed   it within  the  last five or six years in  a very consid-
erable  number  of cases,  generally  with  some  advantage, and
in several instances, with the most decided success.   It not  only

              *  R Aq.  fontana  .  . .  gi.
                  Syrup.....3'"*
                  Sub-carbonat.  Soda   gr. xxv.
                  Vin. ipecac.  . .  .  3'-
                  Tinct. opii.    .  .  gr. vi.
  M. The sixth part every four or five hours is the proper dose for a child between one
and two years oJd.
                                              42 
486                   WHOOPING COUGH.
mitigates  the violence of the cough, but  abbreviates, I believe
in many  cases, the course  of the  disease.  I have generally
administered the saturated tincture in union with the syrup of
squills in doses of ten drops of each, four or five times daily  to
a child two  years old.  I have given  indeed as much as twenty
drops  of  the  tincture of lobelia,  to  several children about this
age, and have always found it strongly palliative, when it excited
sickness or slight vomiting.
  Tincture  of cantharides is well  spoken of by certain writers,*
when given to the extent of producing stranguary.  Dr. Sutclill
asserts that  it will sometimes, in a great measure remove the dis-
ease in four  or five days.  The same practice has the authority of
Hufeland and Lettson  in its favor.  Sutcliff combined it with bark
and the camphorated tincture of opium as in the subjoined formula.t
  The rhus vernix stands upon  the  authority of  many eminent
foreign practitioners, and is stated to be  a  very useful  remedy
in whooping cough.   Dr. Fresnoi asserts, that  he  has employed
the extract of the leaves with decided  success.  He gave half
a grain  in   half  an  ounce of  syrup,  to a  child  every three
hours.  According to  his statement,  the cough generally abated
and  in most instances, ceased altogether by the time  eight  or
ten  doses had been  taken.   Forty-two  children, he adds, were
cured at Vallenciennes in 1786, by this practice.
  Lead was perhaps first introduced to notice as  a  remedy  in
whooping cough,  by  Dr.  Forbes of Edinburgh, who used the
liquor subacetatis, or Goulard's extract, and  who speaks highly of
its success. (Good.)  It has obtained  little credit in this respect
with the profession.
  Of the  mineral tonics, arsenic has been most commended for its
powers in this affection.   Dr. Ferriar placed much dependence
on this remedy in cases unattended with fever.   His own experi-
ence  induces him  to state, that " arsenic  is  the only remedy

  *  Armstrong, Chambers, Millar, Bucholtz, Lode, and  others, speak much in favor
of this remedy  in whooping cough.
                 t R  Tinct. peruvian spirit gi.
                      Tinct. opii. camph.  . gii.
                      Tinct. cantharid.   . gii.
            Two drachms of this mixture to be taken thrice daily. 
                      WHOOPING COUGH.                  487
which promises to shorten the disorder effectually."  " I have,"
says he, " employed  this article in several cases of infirmary pa
tients with tolerable success; and I have occasionally given it in
private practice with so  much  advantage, that I think it deser-
ving of further trial." I formerly employed this remedy frequently;
and in some instances its good effects were obvious.  The proper
dose for  a child, between one and two years old, is two drops of
Fowler's solution, twice or thrice daily.  I have commonly given
it in union with small doses of the extract of belladonna or coni-
um.  It  should be remembered  that, in all cases attended with
febrile excitement or bronchial inflammation, its use is wholly
inadmissible.
   Calomel, in minute quantities,  would seem to possess some effi-
cacy  in whooping cough. Dr. Gregory states, that he has derived
great advantage from small doses of this article, (a grain  twice a
day)  with a few grains of scammony, in the latter stages of  the
affection, attended with symptoms of marasmus.
   When the disease, at an advanced period, becomes complicated
with  chronic bronchitis, balsam  copaiva may be employed with
good effect.  I  have  prescribed it, in a few examples of this kind,
with  the most evident advantage; and I am fully persuaded, that
no other remedy promises so much as this one, in such cases.
   The application of local  revellents to the chest  or along the
course of the spine,  has been in~vogue a long time, and is justly
regarded as  an excellent  remediate  means  in the treatment of
whooping cough.  It is particularly valuable in cases complicated
with bronchial inflammation or hazardous sanguineous congestion
in the head.   Dr. Gregory advises  the  following embrocation to
 be used on the chest and along the whole  chain of the spine.*
Frictions with tartar emetic over the praecordial region, will, in
many instances, be greatly serviceable.  This practice originated
with Autenrierth, and has been  extensively adopted by the Ger-
 man physicians.   Dr. Meyer, of Minden, speaks highly of sprink-

                    * R Antim. tart.....gii.
                        Tinct cantharid. . gi.
                         Aq. rosar......gii. M.
   The tartar emetic is to be dissolved in the rose water, and the tincture of cantharides
 then added to it. 
 488                   WHOOPING COUGH.
 ling a small portion of morphia on the  raw surface of a blister
 raised over the praecordia.   He  directs  a small blister to be ap-
 plied to this region, and the cuticle being detached, half a grain
 of morphia, rubbed up with starch, to be sprinkled on the exposed
 surface.   The morphia is to be repeated every evening; and, if
 necessary, the blister may be applied  every third  day.   Five
 cases, according to his  statement, were so  far relieved by this
 treatment in the course  of eight days, as to require  no further
 attention.  When  pneumonic  affections complicate the disease,
 blisters and  rubefacients, in conjunction with venesection  and
 especially leeching on the breast,  are indispensable.
    Inhalations of various kinds have been used with  considerable
 success in this disease.   The fumes of tar are  said to  be produc-
 tive of excellent effects, in cases unattended by inflammatory symp-
 toms, and where a  great accumulation of mucus in the bronchia
 exists, giving  rise to extreme difficulty of breathing.   Immediate
 and copious expectoration and relieved respiration are sometimes
 the  direct effects.  The nitrous acid vapour has also been parti-
 cularly recommended, and I have  myself employed  it in  a few
 cases with some benefit.
    Change of air and exercise by  gestation have generally an ex-
t cellent influence in tedious  and obstinate  cases,  attended with
 much exhaustion.  In instances of this kind, a change of air, says
 Dr.  Gregory,  " is often the only thing that gives  the patient  a
 chance of life."  I have seen one very remarkable recovery effect-
 ed by removal to the country and the free use of milk diet.  This
 measure is inadmissible in cases attended with bronchial inflam-
 mation, as it rarely fails to aggravate the symptoms immediately.
 Cold bathing, according to  the  experience  of some, is a very
 certain and prompt remedial agent; especially where, from never
 having been used before, it introduces a new action into the sys-
 tem.  A  limestone  soil  would seem to exert a very beneficial
 influence  in the cure of whooping cough.  Dr. Ferriar says, that
 he has had " an  opportunity of verifying this  fact in some very
 striking instances."
    The diet should be light and digestible;  and it is particularly
 important  to  guard the  patient  against the influence of a cold,
 variable and damp atmosphere. 
CONVULSIONS.                     489
CHAPTER  XXXIX.
             CONVULSIVE AFFECTIONS OF INFANTS.

  At no period of life are convulsions so apt to occur as during
the  age of infancy.  With a  nervous system  peculiarly ex-
citable, infants  are  subject  to  so many sources of permanent
and  transient irritation, that  a very large  portion of them suffer
more or less from convulsive  affections; and these constitute an
alarming proportion  in the catalogue of fatal infantile  maladies.
According to the statement by the late  Dr. Clark  of Dublin,
it appears that of 17,650 children born in the Dublin lying-in
hospital, one sixth part died during the first year; and of those
who died, nineteen out of twenty perished by convulsions.  This
proportion of mortality from convulsions, however, very  greatly
exceeds that  which a similar  estimate  drawn  from  private
practice would yield.  Still the frequency and  fatality of this
affection, under its various forms, is by no  means inconsiderable
in every rank of society, and under every variety of climate, and
external circumstances.   Both the anatomical and physiological
peculiarities  of the  infantile  system,  are  indeed  such as to
account for the especial aptitude to convulsive maladies during
this  tender period of life.  The mind and body of an infant,
not  yet inured to  the  impressions of internal  and external
causes, possess the   most lively susceptibility  to  the  various
perturbating and  exciting influences to which it is unceasingly
subjected.
  All children, however,  are not equally disposed to convulsions.
Mr. North observes that " the children  of parents who marry
at too early or too  advanced  an age, are  more susceptible of
convulsions than the progeny of those persons who marry in the
prime of life."   I  have met with several, very striking instances
of aptitude to  convulsions in families which accord entirely with
     r                       3 R             42* 
400                     CONVULSIONS.
this observation.  That the predisposition to convulsive  affec-
tions  is sometimes hereditary,  appears to be highly probable.
Boerhaave and Lorry, mention instances which strikingly illus-
trate  this  fact.  We  often meet with  families, in which the
occurrence of convulsions, is almost a matter of course in all the
children as they successfully pass through the process of primary
dentition;  and on the other hand, in very many families, blessed
with a numerous offspring such affections never occur, although
the ordinary exciting causes, may be  conspicuously present.  It -<
would appear also, that convulsions are much more common in
cities, and  particularly in the higher and more luxurious  classes
of society, than among those who "are regular in their mode of
living and who enjoy the calm tranquillity of a country  life." _
The fresh and pure air of the country, has an especial tendency
to invigorate the infantile system, and to diminish nervous irrita-
bility, and  thus to render the ordinary causes of convulsions less
apt to excite such affections.   It is, probably, mainly, from the
want of pure and wholesome air in hospitals, that convulsive
diseases  are so  much more common in these institutions than
elsewhere.  The children of mothers, endowed with a very sus-
ceptible, physical and moral  constitution—with a quick and
lively imagination, great sensitiveness, and mobility of temper, are
in general peculiarly apt to suffer convulsive affections, during
the period of dentition.  Mauricean, Leuret, and others, assert,
that children who have very large  heads are more liable to
convulsions, than those who are less  liberally furnished in this
way.   This observation,  however, appears to be  wholly with-
out any foundation, with regard to  children who are healthy.
" In ricketty children the  size  of the head is disproportionally
large; and from the general symptoms of rachitis, it is evident
that the head and spinal marrow are  considerably affected; the
brain  increases  rapidly  in size, the senses  are usually  very
acute, and convulsions  are very frequent attendants of this dis-
tressing  malady.  It not  unfrequently happens,  when  some
children of the same parents are affected with rachitis, that
others who are exempted from the disease are at a very early
age destroyed by convulsions.*  (North.)
             * Diet, des Sciences Medicales, tome xlvi. p. 602. 
                         CONVULSIONS,                    491
   Whatever may be the source and nature of that condition "of
 the organization which predisposes to convulsive affections, the
 following circumstances  may be  regarded as characteristic of
 "that state of increased irritability, from which their occurrence
 is to be anticipated.  The child is more  restless than usual and
 is apt to start at the most trifling noise.  During sleep, he often
 starts up  and cries out  suddenly; or he remains  restless and
 almost entirely without sleep throughout the greater part of the
 night.   His  natural temper undergoes a  change.  He  becomes
 peevish, fretful, and discontented; "quarrels with his  compan-
 ions, and derives either no  pleasure at all, or but a ^momentary
 amusement from  his most favorite  playthings,  which  he  will
 suddenly thrust  away,  after they  have for a moment occupied
 his attention."  The pupils are very variable—being often ex-
.tremely contracted  for a moment, and then suddenly dilated to
 an unusual degree. "I  have frequently," says Mr. North, "held
 a candle close to  the  eyes of a child when I have anticipated
 convulsions,  in order to remark  the effect produced.  In  some
 instances,  where the pupils had been much contracted at the
 moment the light was  applied, it  has suddenly dilated, and as
 suddenly again contracted, although the light was steadily held
 close to the  eye.   The effect of  light upon  both pupils is not
 always similar.  One may remain  fully dilated, while the other
 contracts.  I  am inclined to believe  from frequent observation,
 that when a light  is applied close to the  eyes, and the same
 effect is not produced  upon both pupils, that  we  have much
 reason to fear some serious  affection  of  the  head." Children
 who are strongly disposed to convulsions,  are apt when asleep,
 to lie " with  their limbs almost  rigidly extended, the great toes
 and  thumbs  being turned inwards."  (Good.)  The color and
 expression of the  countenance, varies frequently.  At one mo-
 ment it  is pale  languid or anxious, and at another flushed and
 animated.  Respiration is irregular, and frequently interrupted
 by long and deep inspirations, succeeded by " a short and catchy
 breathing."  This disordered respiration, in connection with the
 preceding train of phenomena has  been considered as peculiarly
 indicative  of approaching  convulsions.   "If we observe  the
 fingers  of  a  child, highly disposed to convulsive diseases, we 
492                    CONVULSIONS.
shall see them either in frequent  and sudden motion, or firmly
pressed towards the palm of the hand.  The thumb is  more
frequently contracted upon  the  palm, the fingers  at  the  same
time being extended and separated from each other."
  Every part possessing  muscular fibres, is  liable to  become
affected with spasmodic or convulsive contractions.  The  parts,
however, which are most frequently the seat of convulsions, are
the face, the  superior and inferior extremities and the respira-
tory muscles.   The countenance is always more or  less distorted;
and in some instances the convulsive attack is almost entirely con-
fined to tht muscles of the face.   In some instances, the different
parts of the body are separately and successively affected; in other
cases, the whole system of voluntary muscles, are simultaneously
thrown into convulsive agitation.  "The most  common form of
convulsion" (says Dr. Clark) " is that in which there is a universal
spasmodic contraction of all the voluntary, and many of the in-
voluntary  muscles, of the body, accompanied by foaming at the
mouth, protrusion of the tongue, staring of the eyes, distortion of
the eye-balls, laborious and  obstructed respiration,  sometimes ac
companied with a violent redness of the face and scalp in the
beginning of the paroxysm, followed  by a purple color of the
whole body at the end  of  it.  This latter symptom sometimes
continues until the child dies."
   The redness of the face and  scalp, and  the foaming at the
mouth mentioned by Dr. Clark, are, however, not very common
in  cases of simple convulsions.   These symptoms  are more par-
ticularly  connected  with epilepsy  and convulsions  depending
 on organic  affections of the brain.  It is a  remarkable fact,
 that simple convulsions seldom occur at  night, while the child is
 sleeping; and in  this respect, they  differ very materially, from
 epilepsy, which  in  a great many instances comes  on only  al
 night.

    Causes.—It is asserted, by many writers,  and doubtless  very
 correctly, that the occurrence of  convulsions  among  children is
 much more common at the present  day,  than at  any  former
 period.   This has been  ascribed to the increase  of  luxury and
 refinement, of late years, and particularly to the  vicious  system 
                        CONVULSIONS.                    493
of educating infants  so prevalent  in  modern  times.  Unques-
tionably nervous  and convulsive  diseases " have increased  in
proportion as polished education has  removed  children from
bodily freedom, and carelessness of mind, which to a certain
extent are so essentially necessary to  the preservation of their
health."  Among the Indian tribes of this country, it is said that
convulsions are scarcely known; and among the industrious and
frugal inhabitants  of the  country, where children enjoy  an
abundance of healthful exercise, and  a  plain  but  wholesome
diet,  convulsive  affections  are very uncommon.  The practice
so much favored at the present time, of urging the tender minds
of infants, to premature efforts in the  acquisition of knowledge,
is liable to very serious objections.   That  it must tend to weaken
the general organization,  and predispose to  bodily infirmities,
can hardly be doubted.  " It may be a source of consolation to
those parents, who are  too apt to lament any  apparent  loss of
time  in the very  early periods of life, to remember, that early
acquirements, are  not  to  be gained, without much risk of im-
pairing health; and that the future progress and mental powers
of the individual depend  upon the  foundation which is laid in
infancy, by judiciously  adapting  the studies of the child to its
age  and  constitution.  By  premature efforts to improve  the
mind, the brain  and nervous system becomes  over  excited,  ex-
hausted  and  finally enfeebled.  The practitioner, therefore,
cannot too forcibly reprobate precocious studies.  The injurious
effects arising from the vanity of parents, who are ambitious of
holding forth their  children  as specimens  of extraordinary
talents, arc constantly presenting themselves  to  our view, in a
train of nervous symptoms, and of susceptibility  to ordinary im-
pressions, which frequently lead  to  decided paroxysms of con-
vulsions." (North.)
   The exciting causes of convulsions are extremely various.   In
general, whatever is capable of causing strong sanguineous de-
terminations to the brain, or of producing  nervous irritation of
the organ may give rise to an attack of convulsions.  The vas-
cular turgescence within the head, which in adults causes coma,
or  apoplexy, is apt, during infancy,  to  produce  convulsions.
Even a moderate degree  of sanguineous engorgement of thex 
494                     CONVULSIONS.
brain is often sufficient to produce convulsions, in children, who
are predisposed, by constitutional habit, or previous enervating
causes, to the  affection.   This is often illustrated by the occur-
rence of strong convulsions in fevers of strong vascular reaction,
and  particularly in the cold  and sometimes in the hot stage of
intermittents.   In infants  the paroxysms  of an ague  are  very
often ushered  in  by convulsions.  I  have met with  cases in
which the  convulsions came on  regularly, at  the same hour,
for four  or five days, before  the  nature of the malady was
understood."
   In some  instances, however, convulsions are  the  immediate
consequence of cerebral  or nervous irrritation without any ex-
traordinary sanguineous determination to the head; and these
are, in general, the most serious and unmanageable cases.   This
cerebral irritation is usually purely sympathetic, depending on a
primary local irritation seated either in the alimentary canal, or
in some other part, more especially in the gums from dentition.
It must be observed, nevertheless, that both intestinal  irritation
and  dentition are  very frequently attended with  an increased
determination of blood to the brain;  and the latter, especially,
is very rarely unaccompanied by this  additional source of cere-
bral disturbance.
  When an attack of convulsions is preceded  and attended with
a flushed and  turgid  countenance,  dilated pupils,  a full and
active, or a contracted, frequent and tense pulse, with strong
beating of the arteries of the neck and temples, and a warm and
dry skin, we have  conclusive evidence that the cerebral irrita-
tion  which causes the convulsions is mainly, if not wholly, pro-
duced by vascular turgescence in the  brain.  In such cases, the
child generally remains  in  a lethargic  state,  for a longer or
shorter time after the subsidence of the convulsions.  When, on
the contrary, the countenance is pale and the  pupils contracted,
the skin cool  or of the natural temperature,  the pulse small,
frequent, quick and irregular or feeble, we may infer that  the
attack is not dependent on  sanguineous irritation  of the brain,
but the result of nervous  irritationy transferred to the common
sensorium, most probably from a  primary nervous irritation
located  in the intestinal  canal.  There  is no  cause to which 
                        CONVULSIONS.                     495
infantile convulsions, are  more apt to be ascribed, than worms.
That verminous  irritation is  capable of exciting convulsions,
admits, indeed, of no doubt; but, I  am  persuaded, that the in-
stances which  depend  upon this cause are, of comparatively
rare occurrence;  and this accords  with the observations  of
many of the most experienced writers on this subject.   "In com-
mon" says Mr. North, " with every other practitioner who has
had opportunities of seeing much of the  diseases of children,
many worm cases have fallen  under my notice; and I do not
remember a single  instance where  convulsions appeared to de-
pend upon the presence  of worms  in  the  intestines, or to be
relieved by their being  discharged."  My  own  practice has
furnished me with but  few instances of convulsions, that could
be fairly ascribed to verminous irritations.
  Errors  in diet, with regard, both  to quantity and  quality,
are  unquestionably by far the  most  common sources of convul-
sive affections, in infants;  "So  long as nurses and mothers
believe that children thrive in proportion to the quantity they
eat, so long will  convulsive diseases be frequent and severe."
Over  distention  of the  stomach, with inappropriate  articles
of food is peculiarly apt to give rise to convulsions.  I have
known several fatal attacks of  this affection, brought on by
eating  raisins, during convalescence from  slight febrile com-
plaints.  Children whose digestive powers are feeble, or who are
affected with a  disordered state  of  the bowels,  are peculiarly
liable  to  convulsions,  from the reception of substances of this
kind into the stomach.   During dentition, especially, the utmost
care should be taken to  prevent errors of this kind; for  I am
entirely convinced,  that  many  of  the  cases that are usually
ascribed to dental irritation, are the result rather of gastro-intes-
tinal irritation from errors in diet  or  improper  ingesta.   An
instance which I recently saw, brought the  truth of this obser-
vation  forcibly to my mind.   The child had for several weeks
been a good deal disturbed by painful dentition.  While amus-
ing  itself  with its  play  things it was  suddenly seized with  a
violent paroxysm of convulsions.  In a few minutes, it threw
from its stomach a  large quantity of fluid, containing a mixture
of almonds, raisins and sponge cake.  I administered an emetic, 
496                     CONVULSIONS.
and  brought  away  no  inconsiderable  quantity  of  the same
destructive mixture;  after  which the  convulsions  gradually
subsided.
  Repelled cutaneous eruptions and suddenly suppressed discharges
from ulcers or sores, particularly about the  head, or behind the
ears, may give rise to convulsive affections.  Mr. North doubts,
" whether convulsions were  ever produced either by the natural
or artificial disappearance of cutaneous discharges or eruptions,
provided, that a slight action was kept up, for some  time  upon
the bowels, by the assistance of purgatives, and their effect was
not allowed suddenly to subside."  Undoubtedly, by such precau-
tionary measures, the ill  effects of drying up discharges or  re-
pelling eruptions, may generally  be obviated;  but my experi-
ence warrants me to  say, that  even this course  of management
will not always suffice to prevent the occurrence of convulsions.
It must be observed, however,  that children  who  are not under
the influence of difficult dentition,  seldom suffer any particular
disturbance,  from the desiccation of cutaneous discharges;  but
during the active progress of teething, attended with a general
irritative condition of the system, it  would most assuredly be
extremely  hazardous, to  dry up  serous discharges behind  the
ears, even though the bowels be regularly acted on by aperients.
It does not appear, however, that the sudden drying up of scabby
or  suppurative  eruptions, has  any  obvious  tendency to excite
convulsive affections.  It is to  sores  discharging  a serous fluid
that these observations more especially apply.   General plethora,
with a predisposition to irregular  sanguineous determinations to
the brain, may, doubtless, contribute very materially to the oc-
currence of  convulsions.   It is, however, to be regarded, rather
as a strongly predisposing or accessary, than an exciting cause of
such affections; for  it may be doubted whether mere  plethora,
ever produces simple convulsions, without  the  concurrence of
some  other  cause capable of  producing a  preternatural deter-
mination of blood to the head, or causing cerebral irritation.
Dentition, is incomparably the most frequent source of convulsive
affections  during infancy.  In many  instances, it is manifestly
the sole  cause  of the convulsive paroxysm;  but it frequently
operates only as a strongly predisposing cause, in consequence of 
                        CONVULSIONS.                    497
which, slight additional sources of irritation may bring on an attack
of convulsions.  Convulsions not unfrequently occur in the acute
exanthematous affections, either just before the eruption is about
making its appearance, or in consequence  of the sudden reper-
cussion  of the exantheme, before the  period of its regular de-
clension.   Convulsions may also  be  excited by a direct  or me-
chanical injury of the brain.  I  have known several instances
where a fall on the head so as to  cause  considerable concussion
of the brain,  almost immediately gave rise to general convul-
sions, without  any permanent or fatal lesion of the brain.   Even
severe local injuries, of parts  situated remote from the ence-
phalon  will sometimes  excite an attack of convulsions.  "In-
fants,"  says Mr.  North,  "are  liable  to  convulsions,  almost
immediately after birth; and it  cannot be doubted, that they
occasionally arise from excessive and long-continued pressure of
the head, during protracted labor."  Convulsions depending on
this cause, seldom continue longer than  a minute or two.
  In some cases, a slow and insidious inflammatory irritation will
go on in  the  brain, or  its meninges, with  scarcely any decided
symptoms of disease, until either an effusion of serum upon the
surface, or into the ventricles of  the brain or some other cere-
bral lesion is  effected.  In cases of this  kind, a paroxysm of
convulsions is sometimes  the first unequivocal intimation  of the
child's indisposition; and what was previously considered as mere
fretfulness and  general irritability of temper, of no serious im-
port, now suddenly assumes the character of an almost hopeless
form of cerebral  disease.  Cases of this  kind, however, are
almost  invariably connected with more or less paralysis, and
frequently with strabismus,  and  must  be regarded rather as
insidious instances of hydrocephalus or of cerebral inflammation,
than as convulsions of the ordinary form, of which I am now
speaking.
   Convulsions, may, moreover, be  the result of moral  causes.
The emotion  of fear or violent alarm, when suddenly excited,
is capable of  producing the most violent effects upon the irrita-
ble and sensitive frames of children.  Mr. North, states  that an
instance occurred to him, in which a child of four years of age,
" who had never previously been affected  with convulsions, was
                            3 S             43 
498                    CONVULSIONS.
suddenly attacked with a violent paroxysm which destroyed him,
in consequence  of the  nurse  having improperly threatened to
throw  him from a window, if he did not cease crying."  An
instance  occurred  to me about ten years ago, in which a child
about six years  old, was thrown  into an extremely violent and
protracted paroxysm of  convulsions, by her sisters  suddenly
appearing before her, in a frightful mask.
  It is a remarkable fact, that violent mental emotions or exces-
sive  bodily fatigue on the  part of the nurse, sometimes produces
the  most alarming effects  on the system of the suckling infant.
A striking case, in point, is related in one of the early  numbers
of Hufeland's Journal.  A woman, immediately after a vehe-
ment burst of rage, put her infant to her  breast.  In less than
twenty minutes  the child  was seized with  a violent paroxysm
of convulsions, although it had previously been wholly free from
any  manifestations of ill  health.  Mr. Gillibert, mentions the
case of a child who died of convulsions, " after having sucked a
nurse who had been exposed to hard labor under a burning sun;"
and  Boerhaave, has given  an account of two instances of epi-
lepsy,  which were in the  first place excited, by being suckled
immediately after  the nurses had  been under the influence  of
violent fits of passion.  Baumes, also, states, that  one  of his
professional brethren had lost an infant suddenly  by  convul-
sions, in  consequence of having been suckled by a woman soon
after she had been violently exasperated. Many more instances, of
a similar character might be collected from authors; and although
an infant may be affected with convulsions, under circumstances
of this kind, from  causes wholly independent of the nurse, there
can  be no doubt, that  the most serious consequences may some-
times result to the  infant,  by  being suckled  by a woman of an
impetuous and ungovernable temper.
  The Prognosis of infantile convulsive affections -fnust depend
mainly on the nature of the exciting cause, and the violence and
duration of the  attack.  Cases arising from a primary irritation
located in the alimentary canal, or from the irritation  of denti-
tion, are, cceteris paribus, always  less dangerous than instances
depending on a primary irritation or  lesion of the  brain, or its
spinal  prolongation.  Even purely sympathetic irritative con- 
                        CONVULSIONS.                     499
vulsions, arising from intestinal or dental irritation, may terminate
fatally, by the  shock and structural lesion which the brain may
receive  from the violent determination of  blood which in some
instances  takes place to the vessels of the encephalon.  This  is
more particularly apt to be the case in children of a  corpulent
and very plethoric habit, and where the convulsive attacks are of
a protracted duration.  In  ordinary habits, there is but little  to
be apprehended  from convulsions  during  infancy, when the at-
tacks are  slight  and of short  duration;   and this  observation
applies especially to those instances which, instead  of leaving the
infant in a dull and lethargic condition, are almost  " immediately
succeeded  by the. natural  cheerfulness of the child." (North.)
When death occurs suddenly during a  paroxysm of convulsions,
we almost  always perceive  manifest  signs of strong sanguineous
congestion in the vessels of the head,—such as a darkish and
turgid aspect of the face, fulness of  the veins of the neck and
head, heavy and  almost stertorous breathing;  and  in such in-
stances, the  little patient  dies  " in a state  nearly allied to apo-
plexy in the adult."  The  reviewer of North's excellent treatise
on this  affection, asserts that he has made  more than  thirty dis-
sections of children who had died of  convulsions, and that be in-
variably found the vessels of the encephalon strongly engorged
with blood, attended  with more  or less serum in the ventricles  of
the brain;  and, in several cases, " considerable extravasation  of
blood from a ruptured vessel"  was  detected.  When paralysis
and  squinting  occur, the most serious cerebral lesion may be in-
ferred, and the prognosis  is, of course, of the most unfavorable
kind.  Convulsions  that come on  suddenly, without any premo-
nitory symptoms, are, in general, much  more  apt to  terminate
favorably, than those cases which supervene after a considerable
period of  slight  indisposition—such  as great fretfulness, starting
from sleep, grinding the teeth, occasional flushes on one or both
cheeks, a variable appetite, deranged state  of the bowels, &c.

   Treatment.—It  has been  doubted  whether  any  course  of
treatment during the convulsive paroxysms, is capable  of short-
ening  its  course, although it might mitigate  its violence and,
perhaps, obviate  a fatal termination.  In general this  is unques- 
500                     CONVULSIONS.
tionably  the case; yet I am inclined  to think, that  in  some
instances, the paroxysm may be  shortened, as well as moderated
in its violence, by appropriate remedial applications.
   The chief indications to be attended to in  the treatment of
convulsive affections  are: to  obviate, as far as  may be in our
power, the influence  of the  remote or exciting  cause; to allay
cerebral  and  general  nervous  irritation;   and  especially,  to
counteract  the  preternatural determination of   blood  to the
brain.
   When  called  to a  child  affected  with convulsions, its gums
should be  immediately  examined.  If  they present a  swollen
and inflamed or irritated appearance from teething, they should
be at once freely  divided down  to the advancing teeth.  This
measure  can never be  omitted, where  the  gums are distended
and irritated without  the most  culpable  neglect.  Care  should
be taken  that the incision be  sufficiently  deep to divide, com-
pletely,  the firm  membranous  expansion  which   covers  the
crown of the approaching tooth; for a mere superficial division
of the gums, can afford but very little or no benefit.
   Should  there be reason  to believe, that the convulsions  are
the  consequence  of   an oppressed state  of the  stomach from
crude or indigestible  ingesta or acrid secretions, immediate steps
should be taken to remove the offending cause.   If any unusual
food, or  substances of difficult digestion have been received into
the  stomach  a short time  previous  to the occurrence  of the
convulsions, it will  be proper to  administer  a full dose  of
ipecacuanna, in order to evacuate the  contents of the stomach
as speedily as  possible.  To remove the irritating matters that
may be  lodged in  the intestines, purgative enemata, should  be
freely administered.  In all  instances, indeed,  stimulating  injec-
tions are decidedly proper, and whatever other remedies may be
employed   these,  if the necessary means are at hand,  should
never be neglected.
   Blood-letting,  though not always  applicable, is  in some  in-
stances a  very important auxiliary in the management of these
affections.  A principal object in the treatment of convulsions  is
 to protect the brain from fatal  oppression:  and  for this purpose
 bleeding is one of our most efficient means.  Where  the signs of 
                        CONVULSIONS,                    501
Itrong determination to the head are manifest—and especially in
robust and plethoric children, blood should be promptly abstract-
ed.  On the contrary, however, it will  be prudent to abstain from
this evacuation in patients of a weak and relaxed habit, and, where
the ordinary evidences of vascular engorgement are absent.  With
regard to local bleeding, by  leeches to  the head,  my own  expe-
rience accords  entirely with the following  observations of Dr.
North.   " I have never seen well marked symptoms of determi-
nation to the head in children removed by leeches, however freely
they were applied.   Their application  never fails to annoy the
little patient considerably, and  their effect is not to be relied on."
If it be deemed necessary to draw blood directly from the vessels
of the head, this writer  recommends bleeding from the jugular
vein,  or  by cupping  upon the  temples or behind  the ears.   In
eases  where  the little patient sinks  into a state of coma, with
flushed countenance, throbbing  of the carotids, &c. after an  attack
of convulsion, local depletion, in  any of these  latter muscles, is
sometimes indispensable to the  safety of the patient's life.
   Revulsive applications are among  the most  useful   remedies
we possess for  moderating or  arresting  convulsions.   Warm
pediluvium, the  water being as warm as can  be borne without
injuring the  skin, is  one  of the  most  beneficial of this class of
remedies.  This measure  is particularly apt  to afford   relief in
convulsions excited by the  irritation of difficult dentition.  The
good  effects of warmth applied  to the feet, are  always much
enhanced by cold applications  to the  head.  While the feet and
legs are immersed in warm water, a piece of flannel, wet with
cold  water,  should constantly be applied over the  head  and
temples.   These  measures are  especially  important  in cases
attended with symptoms of sanguineous  congestion in the head,
and cannot be omitted  without losing one of our most efficacious
remedies in such affections*  Not unfrequently, these applications,
moderate the violence of the convulsions at once, and bring them
to a speedy and favorable termination.   " In many instances," says
Mr. North," I believe I have rescued children from a state of great
danger, by the incessant application of cold to the head."   While
these applications are being  made, " the countenance and pulse
should be attentively watched.  When paleness and collapse of the
                                           43* 
 502                    CONVULSIONS.
 face supervene, and the pulse  declines or intermits, the cold
 applications  should be suspended,  and  the  head  and trunk
 covered  with a dry cloth;  but as soon as signs of reaction return,
 the process is  to be resumed  even to the  third or fourth time,
 till its good effects  shall be  decisive and  manifest in  the sup-
 pression  of all convulsive motions."  The French  and  German
 physicians, frequently  employ the  warm  bath, immersing the
 whole body; while  ice is applied to the top of the head.  I am
 inclined  to believe however, that more benefit may in  general be
 derived from merely placing the inferior extremities in the bath;
 for the  tendency of general  immersion in the warm  bath, to
 increase  the flow of blood to the head, is always very considerable;
 whilst the application  of  warmth to the  inferior  parts  of the
 body, often exerts a powerfully derivative effect upon the turgid
 vessels of the head.   Dr. Currie, in his valuable work  on the use
 of cold water, asserts from much  experience, that  cold  effusions
 are highly efficacious in removing the  convulsions of children,
 from  whatever cause  they may arise.  I have witnessed  one
 instance  in which  this  remedy  was tried, and the  result was
 highly gratifying.  When the countenance is flushed  and turgid,
 the surface warm, and the  pulse full  and active, there  can be no
 doubt, I  think, of the  usefulness of cold effusions.   The child's
head should be raised and the water poured on it, out of a pitcher.
In cases  of an opposite  character, however, that is,  where the
face is pale, the extremities cool, and the pulse small, the practice
 would, probably, be  attended  with very serious mischief.
   Counter-irritating  applications,  also,  are decidedly  indicated.
Blisters are in general too slow in their effects to derive any par-
ticular advantage  from them during the paroxysm.   Neverthe-
less, where there is  reason to apprehend a repetition  of the at-
tacks, small blisters laid behind  the ears or on the back of the
neck, may afford considerable benefit.  Vesication  on this part
is particularly calculated to afford advantage in those cases which
supervene, on the drying up of superficial and discharging ulcer-
ations  behind  the ears.  Some  benefit may be also expected
from  the application of blisters to the inferior extremities.  Or.
Clark strongly advises the application of vesicatories to the calves
 of the legs; and Dr. North asserts that in many cases attended 
                        CONVULSIONS,                      503
witl strong determination of blood to the head "without any gen-
eral vascular excitement" he has obtained the best  effects from
this Practice.   The common practice of applying blisters to the
seal/,  in diseases of this kind,  is by no means advisable.  They
not only almost invariably fail of doing good, when applied in
this way,  in any of the inflammatory or congestive affections of
the brain, but often prove decidedly prejudicial.  In hydrocepha-
lus, for instance, I have never known even the slightest temporary
advantage  to result from vesicating the scalp.   Sinapisms, are in
general more beneficial, as counter-irritating applications,  than
blisters.   Their operation  is prompt  and  energetic,  and when
applied to the  inferior extremities, or along the tract of the spine,
they often  contribute, very materially  to  the reduction  of the
vascular excitement of the  brain.  "In  my  opinion," says  Dr.
Clark, " we have too little confidence in the powers of sinapisms
applied to  the feet, where there is a great degree of cerebral ex-
citement to be  contended with.   In many cases, both of children
and adults, I have found them  to be very powerful  auxiliaries."
  Much benefit may also be derived from  rubefacient frictions,—
particularly along the course of the spine.  I think I  have seen
much  advantage obtained  from frictions over the spinal regions
with a mixture of equal parts of the oil  of amber, laudanum, and
spirits  of camphor.  I seldom  omit this application in the  con-
vulsions of very young infants, and I feel confident it has frequent-
ly been of much service.   When the convulsions assume a tetanic
character—the body remaining for some time, rigidly bent back-
ward, leeching, and sinapisms,  over the spinal  region, would seem
to be especially indicated.   Indeed, in all instances, counter-irri-
tating  applications along the tract of the  spine, are appropriate,
and calculated  to do good.
  Purgatives, if they can be introduced into the stomach, ought,
in no instance to be omitted.   In cases depending upon intestinal
irritation from acrid secretions, or other offensive matters lodged
in the alimentary canal, free purgation may be deemed indispen-
sable.   Calomel in combination with jalap,  or where there is
reason to suspect verminous irritation, a strong  infusion of senna
and spigelia, are very  suitable remedies for this  purpose.
  Some practitioners  are  in the habit of giving large doses of 
504                     CONVULSIONS.
calomel, in the convulsions of infants, under an idea flat there ll
something peculiarly beneficial in the operation of this article in
affections of this kind, and I am inclined to think that this opinion
iswell founded. Dr North, however, objects strongly to this practice,
as tending in no small degree to injure the constitutionsof children.
That calomel  is too heedlessly and indiscriminately  given in the
affections of children, particularly in the United States, I have not
the smallest doubt.  I am quite certain, that  I have seen  instan-
ces where this practice was the cause of great and irreparable
constitutional injury.   Nevertheless,  it has appeared to me, that
one or two active doses of this article, so as  to cause free alvine
evacuations, is capable of procuring more  advantage,  in  gen-
eral,  in  the convulsions  of  infants, than  any  of the  other
usual means for evacuating the alimentary canal.  Indeed, it has
seemed to me, that even where the calomel  fails to excite purg-
ing, or before this effect is produced, considerable benefit  some-
times results from its immediate impressions on the nerves of the
stomach.   Dr.  Brachet,* who  appears to have had very exten-
sive experience in affections of this  kind, strongly recommends
the use of calomel in combination with the extract of henbane in
infantile convulsions.  To a child of two years old,  he gave two
grains of calomel every two hours, and one grain and a half  of
the extract of black henbane  every half  hour, with the happiest
effect.  I have myself, in a few instances of obstinate convulsions,
used this combination, and in one case at  least, with unequivocal
benefit.
  Formerly, physicians were much in the habit of exhibiting an-
tispasmodics in  infantile  convulsions—such  as assafoetida, cam-
phor, valerian, musk, and ol. succine.  In children of  very nervous
or irritable habits, some benefit may occasionally be  derived, dur-
ing the fit, from assafoetida, musk, or the oil of amber,  provided
no  signs of determination  to the  head be present.  Upon  the
whole,  however, these are, under the most favorable circumstan-
ces of very equivocal propriety; and they are decidedly improper,
where the arterial reaction is considerable, and the vessels  of the
head engorged.
* Memoire sur les Convulsions des Enfans.  Paris, 1834. 
                         CONVULSIONS.                    505
   Opium is a remedy that may, either do very serious  mischief
 or no small degree  of good, according to the particular state of
 the  system, and the character of the attending circumstances  of
 the  cases.  In instances attended with febrile irritation,  and a
 strong determination of blood to  the brain,  nothing perhaps
 would be more likely to do harm than  opium,  more especially in
 robust and plethoric subjects.  In general, wherever local or general
 depletion is indicated, opiates may be regarded as improper.  On
 the  contrary, however, where convulsions arise symphathetically,
 in consequence of some remote and fixed irritation—as in the ali-
 mentary canal, and  the habit of the patient is irritable, relaxed,
 and feeble, opium,  judiciously administered, may afford decided
 benefit.   It is indeed, anceps remedium, but the practitioner, who
 has  learned to discriminate between the circumstances that indi-
 cate or contra-indicate the propriety of its use, will often find it
 a most valuable auxiliary.   In general, it is altogether inadmissi-
 ble in convulsions arising from the irritation of dentition; and in
 cases depending on causes  seated within the head, it is, if possible,
 still more inappropriate.   When the primary irritation is located
 in the alimentary canal, we  may, under the other favorable circum-
 stances just mentioned, employ small doses of Dover's powder, re-
 peated accordingto the exigencies of the case, with manifest advan-
 tage.  Opiate embrocations over the chest and spinal region, will
 also, in such cases, afford benefit.   These are particularly useful,
 where from great nervous  irritability there is a strong tendency
 to convulsive attacks,  unaccompanied with general, vascular irri-
 tation.   In  that irritative  condition'of  the system  to which  Dr.
 Nicholl  has applied the term "cerebral erethism," and which,  if
 not subdued,  almost invariably terminates in some form of con-
 vulsions, opiates in alternation with laxatives, are in general de-
cidedly beneficial.   When the child is sleepless at night, and un-
usually peevish and  fretful  during the day, with a small and rapid
 pulse,  a pale and anxious  expression of the countenance,  slight
 twitchings of  different muscles and tendons, the carotids, beating
violently for a moment and  then suddenly subsiding into languid
action, sudden starting, agitation or tremor, from slight causes;—
in this condition, depletion is generally injurious, and nothing  af-
fords so much relief as narcotics.  Brachet  recommends the  em-
                             3 T 
506                     CONVULSIONS.
ployment of henbane, but I doubt whether we possess any article
of this kind more appropriate and beneficial than Dover's powder,
given in small but repeated doses in union with  small portions of
calomel, and with  an occasional  laxative  enema.   Mr. North
states, that in cases of this kind, he has frequently given  the ex-
tract of hemlock or of henbane in conjunction with alkalies, with
great advantage.
   The German physicians are much in the habit of administering
the oil of valerian, in convulsive affections, unconnected with  fe-
brile irritation, or independent of  local disease.  I have known
very considerable advantage derived from this  remedy, in cases
attended with great irritability of the nervous system, and a pale
and contracted appearance of  the countenance.  In convulsive
affections arising from verminous  irritation, with a languid and
relaxed state of the system, I am inclined to regard this  remedy
as entitled to much attention.
  In cases attended with prominent gastric derangement and acidity
of the primae viae—instances of which are frequently met  with in
very young  infants, alkine  remedies  are especially indicated.
Three or four grains of the bi-carbonate of soda dissolved in a tea-
spoonful of the syrup of rhubarb, with a drop of the oil of vale-
rian, forms an excellent remedy in such cases.  The  oxyde of zinc
also, has .been  much  employed in the  convulsive  affections of
children.   Mr.  North states that  he  has frequently prescribed
this  remedy, "and in many instances with much advantage."   In
cases wholly independent of organic disease or unconnected with
febrile  irritation, this article will  occasionally do  much good.
Dr.  Brachet considers it among our  most  useful remedies, in cases
recurring from the force of habit and from inordinate nervous ir-
ritability.  He recommends it to be given in union with cicuta
or henbane.   He relates several cases, in which  the protraeted
use of this combination, entirely prevented the repetition of the
convulsive paroxysm, and "to which the children had been subject
for a very considerable time."
  To mitigate the violence of  the convulsive  paroxysm, some
writers  recommend pressure upon the epigastrium, as almost in-
variably beneficial.   Dr. Brown,*  asserts, that a gradually in-
              * Journal Gen. de Medecine, tome  xxxi. p. 437. 
                        CONVULSIONS.                     507
creased pressure upon the region of the stomach with the hands,
usually relieves the struggles in a  remarkable manner.  If the
pressure is suspended for a moment, "the convulsions will return
with increased violence," but on renewing the pressure, the strug-
gles are again speedily moderated.
  Mr. North, states, that in several cases attended with "every
symptom  of  approaching convulsions," the experiment of com-
pressing , the  carotid arteries, as recommended by Dr. Parry  in
the treatment of adults, has appeared to him to have had a most
excellent  effect.  "It is certainly to be regretted," he says, "that
the plan is not  more frequently adopted in the cerebral derange-
ments of children which threaten  to  produce convulsions, but
which do  not either  demand or justify  the abstraction of blood."
Dr. Blaud has published an interesting paper, from which it ap-
pears  that he has employed compression of the carotids, in chil-
dren " with the most gratifying result."  There can  be no doubt
indeed  that in cases  attended with undue determination of blood
to the brain, much benefit must result from this  practice.  It is
extremely difficult, however, in most children to apply sufficient
compression to  the carotids, to produce any obvious effect upon
the cerebral circulation. Where it is practicable it may be resort-
ed to with great propriety, and probably with much advantage to
the patient. 
508
INFANTILE EPILEPSY.
                    CHAPTER  XL.


                     INFANTILE EPILEPSY.

  Epilepsy is a disease of frequent occurrence in  children.  It
is liable to be confounded with  simple convulsions, but the fol-
lowing  circumstances will,  generally, enable us  to  distinguish
them without  much difficulty or risk of mistake. In the epileptic
paroxysm there is a total  abolition of  the senses, from the  com-
mencement to the termination of the attack.  In simple convul-
sions, on the contrary, "the senses are only abolished during the
violence of the fit, and some degree of consciousness is  manifest-
ed when the paroxysm is mitigated, and, often long before the
convulsions  have entirely subsided."  Epileptic convulsions al-
most  invariably terminate in  a  deep stupor, from which the pa-
tient  awakes in a state of confused and stupid surprise, or with a
dull, heavy, and fatuous expression of the countenance.  In simple
convulsions this rarely happens, except in cases of extreme vio-
lence, attended with sanguineous congestion in the brain.
  The  predisposition  to  epilepsy  is sometimes hereditary;  and
when this is the case,  almost any thing which is capable of dis-
turbing the natural actions of the system, may excite the disease.
Boerhaave, mentions an instance, in which all the children of an
epileptic father died of this disease, and Stahl has  related a  sim-
ilar occurrence.  Tissot, also, mentions a remarkable instance of
this kind.  An epileptic man had eight sons and three grandsons,
all of whom, he says, became affected with this  disease.   The
exciting causes of epilepsy do not differ from those which produce
simple convulsions, and as these  have already been described in
the preceding  chapter, it is unnecessary to repeat them in this
place. Many of the epileptic affections of children, commence, in
the form of simple convulsions, which by repeated recurrence and
mismanagement ultimately acquire  a strictly epileptic form.   "It
is  to  be remembered,  that however trifling may be the  original 
                     INFANTILE EPILEPSY.                  509
convulsive affection, if it is frequently repeated,  and the patient
is of a highly susceptible disposition, it may gradually increase in
severity, until it, at length, degenerates into pure epilepsy.
   In children, perhaps the most fertile source of epilepsy may be
traced to derangement of the stomach  and bowels, from which,
at first slight attacks of simple convulsions may  succeed, which
ultimately acquire the character of epilepsy; or an epileptic par-
oxysm at once occurs, without any convulsive malady of a milder
nature."
   On the subject of the proximate cause of epilepsy, very discre-
pant opinions have been expressed by pathologists.  Without en-
tering into a detail of these opinions, all of which are hypothetical
and many of them absurd, I shall content myself with a statement
of those circumstances, which experience and observation appear
to sanction, in relation to the pathology of this affection.
   1. The immediate  cause of the epileptic paroxysm,  whatever
its essential character may be, is always seated in the brain.
   2. In the majority of fatal cases, organic and other obvious af-
fections of the  brain—particularly of the  cerebellum,  or of the
meninges, are found on dissection, and which we  may infer, con-
tributed to the excitation of the epileptic paroxysm.
   3. The cerebral affection is in some instances, primary, and the
result of causes that act directly upon the brain.   In others, pro-
bably in the  majority of cases,  it is secondary, depending on pri-
mary irritations  located remotely from the  braiu.
   4. Immediately, before the accession of the epileptic  attack, it
would seem,  that vascular turgescence takes place, in the enceph-
alon; and the pressure thus created, in co-operation with the gen-
eral predisposition to the  disease, and the organic cerebral affec-
tion, where such disorder exists, is probably the immediate excit-
ing cause  of the  paroxysm.
   The epileptic attack sometimes comes on suddenly without any
intimation of its approach.   In  general however,  certain symp-
toms precede the occurrence of the paroxysm, and of  these the
following  are the most common:  a dull heavy pain, or a confused
and distressing feeling in the head,  giddiness, sparks, or the ap-
pearance  of light fluttering before the eyes; distention of the
veins of the  head and neck, a buzzing in the ears,  palpitation of
                                             44 
510                 INFANTILE EPILEPSY.
the heart,  tremors and an  agitated  and alarmed appearance,
starting during sleep, temporary confusion of mind, great drowsi-
ness, spasmodic twitches of particular muscles, especially in those
of the face, sudden pains in the stomach succeeded by nausea and
perhaps vomiting, a  sudden change of temper manifesting unusu-
al perverseness,  fretfulness  or passion, a creeping  sensation  in
various parts of the body, and rapid changes in the color and ex-
pression of the countenance.
   In many instances the  epileptic attack, invariably comes on at
night while the child is sleeping.  When  the  paroxysm occurs
while the patient is  sitting or on his feet, he suddenly falls down
in a state of  insensibility and immediately becomes  more or less
violently convulsed.   In some cases the convulsive actions of the
muscles, particularly those of the face are frightfully violent; the
whole frame is violently  agitated; the eye-lids are in constant
motion;  the eyes appear to project  unnaturally  and are fixed,
or turned upwards  so  as to hide the cornea; the  face is occa-
sionally pale, but much more commonly, red or livid, "and some-
times  almost black," and  the veins  of the head and neck  are
excessively turgid.   The tongue is  often  spasmodically thrust
from the mouth,  and is sometimes severely injured by the teeth,
from the  forcible and rapid  convulsive contraction of the jaws.
Sometimes the  teeth  are  firmly fixed, and at others, the jaws
are widely and  fixedly  distended;  the thumbs are,  generally,
firmly pressed in  upon the palms of the hands;  the head is thrown
about in  various directions, and  sometimes  becomes suddenly
fixed in  one position, from which no force can move it.  The
spasms are generally of the clonic kind, but  in some instances,
the muscles remain  for a time rigidly contracted, the body being
bent, either backwards or on one side, or forwards, as in tetanus.
Occasionally  the abdominal muscles  are violently  retracted
towards the spine.  The respiration is irregular, oppressed and
sometimes extremely laborious and  even  stertorous, in  violent
cases.   The convulsions sometimes subside for a moment, to be
again renewed, with undiminished or increased violence.  " The
same remission   of the convulsive movements,  occurs also,  fre-
quently  during  the paroxysms of simple  convulsions.  During
this cessation, however, the  expression  of the countenance, and 
                     INFANTILE EPILEPSY.                 511
the  gestures of even a very young child, lead to the conviction
that it is  sensible of its state of  suffering.  Not  so in the
abatement of the true  epileptic  paroxysm.  The  child  either
lies motionless  and totally insensible, or rolls its eyes about with
a  wandering and unfixed gaze, without  the appearance of any
degree of consciousness."  In general, the convulsive actions are
more conspicuous on one side of the body than on the other.
Towards the termination of the paroxysm, a considerably quantity
of a  frothy  saliva usually flows from the  mouth, and in very
violent cases, the  feces  and urine often pass off involuntarily.
Sooner or later the convulsions abate—generally gradually, but
occasionally quite abruptly.  The breathing becomes  freer; the
pulse  which during the fit  is irregular, small, and frequent,
becomes fuller  and more regular; the countenance assumes  a
more composed  appearance, and the patient  finally falls into a
state of stupor, or deep and heavy sleep,  out of which he awakes
with  a feeling of languor,  and  confusion or  torpor of mind,
which generally continues for ten or twelve hours—the counte-
nance  exhibiting a vacant and stupid  expression, with a dull,
staring and  wandering appearance  of  the  eyes.   In violent
attacks, the mind  is apt to remain obtuse  and fatuous, and the
temper irritable and morose, for several  days after the paroxysm.
During the heavy sleep in which the paroxysm usually termi-
nates, the patient  generally perspires  freely,  particularly about
the head, neck  and breast, and the  perspiration has in many
instances a very peculiar, offensive smell.
  Epilepsy does not however  always exhibit  the violence and
course of  phenomena just described.   Sometimes  the  patient
remains fixed in  the position "in which he happened to  be at
the moment of the attack, while the head is moved  from side  to
side  with  great rapidity, all  consciousness  being  destroyed."
Occasionally instead of actual  convulsions, there is  a  trembling
of  the whole  body, with twitching of the tendons, which is
succeeded by a tetanic  rigidity of the  whole frame  and  total
unconsciousness.   In  some  instances  the  attack  supervenes
suddenly without  any sensations  or  appearances indicating its
approach,  and  after a few moments  of partial convulsions  of
the muscles of the face  and neck, quickly subsides,  and restores 
512                 INFANTILE EPILEPSY.
the patient  to  consciousness.   In  general  the  disease  is  much
milder in infants  before they  are weaned, than in children  of
more advanced age.  The symptoms during  infancy, are com-
monly confined "to irregular  and rapid motions  of the eyes,
convulsed contractions of the  muscles of the face,  blueness  of
the countenance and contraction of the lower jaw, with abolition
of the senses," and their  duration is seldom prolonged beyond
ten minutes.
   With  regard  to the  duration of the  epileptic  paroxysm,
great diversity occurs.  The convulsive stage generally continues
from five to ten minutes, sometimes for half an hour  and occa-
sionally  much longer.   In infants at the breast, as  has just been
observed, it is seldom  protracted beyond  eight or  ten minutes;
but after the  usual period of weaning, particularly when the
child is  under  the influence of painful  dentition, the paroxysm
is apt to continue a much longer time.  In some  instances one
fit only occurs at a time; in other cases,  several paroxysms occur
in quick succession, the patient remaining in  a state of stupor,
during the intermissions.   In  general the first  attacks are much
shorter  than those  which  occur after  the disease has become
confirmed   in  the  system.  The contrary, however, generally
happens, when the first  attack is excited by  some  sudden  and
violent  mental  impression, as terror.   Much  diversity, also,
occurs in relation to the interval between the  epileptic seizures.
It is asserted by some writers, that epilepsy never occurs oftener
than once a day."  This, however,  assuredly is not correct.  I
have seen one case, at  least,  in  which two distinct paroxysms
at times, occurred in the course of twenty-four hours; and Mr.
North assures  us that he has " certainly  witnessed several epilep-
tic paroxysms,"  in the same  child, in the course  of a day.   It
must be confessed,  indeed, that  instances  of  this  kind are very
uncommon,  though the ^occurrence  of a paroxysm daily, is not
unfrequent.   In  general, however,  the intervals  between  the
attacks are much longer varying  from a few days  to  several
months.  In some instances  the paroxysms  observe a more or
less perfect periodicity in their occurrence; but the majority of
 cases are quite irregular in this respect.
   One of the most distressing circumstances connected with this 
                     INFANTILE EPILEPSY.                 513
disease, is its tendency to impair the understanding,—to produce
hebetude, and finally even total abolition of the mental faculties—
a  condition infinitely more lamentable than death itself.  Much
diversity, however, occurs, in relation to the effects of epilepsy
in this respect, in different  individuals.  Some children will bear
repeated  and even violent attacks,  without appearing to suffer
any permanent injury either in body or mind; whilst in other in-
stances the patient is soon destroyed during the paroxysm, "or is
reduced to a state of idiotism."  In all instances, however, where
the disease continues for a  long time, the mind is more or less en-
feebled, however mild the  paroxysm may be.
   Epilepsy seldom proves fatal, except through the intervention
of apoplexy.   Although,  the  immediate danger of an  epileptic
paroxysm, is not in general very great, yet in relation to the san-
ability of the disease, the prognosis is always highly unfavorable.
Even where a cure or suspension of the disease has been effected
the liability  to a relapse is  always very considerable.  I have
seen instances where the disease returned  after a suspension of
its  attacks  for several years.   When   epilepsy depends  on
some  organic affection within the head all attempts to effect a
cure, must, almost necessarily end in  disappointment.   In what
are called symptomatic  cases—that is, where the  disease  is  un-
connected with structural disorder, depending solely on morbid
predisposition and irritation in the nervous system, a  cure may
sometimes be effected by an appropriate course of management.
After the mental faculties have become obviously impaired,  by the
repeated attacks of the disease, all hopes of a cure may be aban-
doned.  Experience,  too,  has shewn that those epilepsies which
commence soon after birth, or during early infancy, very rarely yield
to remediate treatment.  Richter observes that a long continu-
ance of the sleep and  subsequent  stupor and confusion of mind,
after the subsidence of the paroxysm, is a very unfavorable sign.
Epilepsy from moral causes, such as terror, is generally extremely
obstinate in its course (Lahn); and it is said, also, that those cases
which come on at night during sleep, are, in general, much more
intractable than such as occur during  the day, and  are  preceded
by premonitory symptoms (Richter).   It has been  affirmed by
men of great experience that epilepsy occasionally ceases sponta-
                             3 U             44* 
514                  INFANTILE EPILEPSY.
neously on a change of climate, or at the age of puberty where the
disease has not been of protracted duration, (Lentin).  Heredita-
ry epilepsy, is perhaps always incurable.   The morbid appearan-
ces on dissection, are often similar to those which occur in apoplexy
and palsy. In many instances the cerebellum, exhibits stronger tra-
ces of  structural disorder than the cerebrum, though this, as in-
deed the whole encephalon is usually found, highly engorged with
blood.   Wensel,  whose  dissections were very numerous, states,
that in the majority of instances, he found the pineal gland,  and
parts immediately surrounding it, more frequently in a state of dis-
ease than any other part  of the cerebrum. The cerebellum was in
many cases, conspicuously diseased.   It was sometimes preternatu-
rally soft and of a  dusky red color; but much more commonly,
this  portion of the  brain  was of a hard and compact consistence,
with a peculiar yellowish friable matter lodged between the lobes.
These  dissections, however, refer to adult subjects, and it may be
doubted, whether  similar appearances would present themselves
in children.  Roederer, dissected many children who had died of
this  disease, and he affirms,  that structural  disorder  of the cere-
brum was a frequent occurrence. Esquirol, states that in his dissec-
tions at the Salp6triere, he found in nine  cases out of ten, the  spi-
nal marrow or its  membranes in a distinctly diseased  condition.
The spinal marrowr was  generally much  softer than natural, in
different parts of its length;  and the meninges almost  uniformly
presented unequivocal traces of previous inflammation.  It must
be confessed, however, that  in some instances, the brain and  its
coverings, as well  as the  spinal marrow do not exhibit the  slight-
est evidence of structural disease, though much engorgement of the
blood-vessels occurs in nearly all cases.

  Treatment.—The causes  of epilepsy  are  so various, and  in
general so wholly beyond our cognizance, that  we can seldom
lay down any general and rational  therapeutic principles for the
guidance of our curative  efforts.  Medical treatment in this  dis-
ease, is therefore often necessarily purely empirical.   If we wish
to make any  effort against the progress of this distressing malady,
we  have, frequently,  no  other course left open to us, than to re-
sort to  those remedies which, according to the reports of eminent 
                    INFANTILE EPILEPSY.                  515
physicians, or our own experience, have occasionally succeeded
in removing  the disease, without our being able, to  give  any
other satisfactory reason  for doing so.  This, however,  is not
always the case.  In some instances  we have  sufficient light in
the symptoms and causes  of the disease, to enable us to  form a
consistent and  rational plan of treatment.  When called to a
case of epilepsy, therefore, the first  object of the  practitioner
should be to inquire into  the  nature  of the exciting  cause, its
duration, the time and manner of its attack,  the constitutional
habit of the patient, his age, previous or  concomitant diseases,
his habitual temper and disposition of mind, his manner of living,
his probable hereditary predispositions, in short, into every thing
which can throw light on the particular character of the disease.
By well directed inquiries of this  kind, we may sometimes find
a clue, which will serve to guide us in the treatment to a fortu-
nate result.
   In  cases preceded by obvious premonitory symptoms, we  may
sometimes prevent the accession of the paroxysm by the timely
administration  of some remedy capable of producing a  sudden
change in the excitement of the nervous system.  When in chil-
dren of robust and plethoric habits any feelings occur which may
appear to indicate the approach of an epileptic paroxysm—more
especially, when the child  complains of giddiness, with the veins
of  the head turgid,  and the carotids beating  strongly, prompt
and efficient bleeding will  probably keep off the impending epi-
leptic attack.   When the premonitory stage is protracted, and
connected with manifest signs of derangement of the bowels, pur-
gatives are indicated and may occasionally postpone the approach-
ing paroxysm.   Emetics are, particularly recommended by Rich-
ter, for this purpose.   They are most  apt to prove serviceable, in
keep.ng off the attack, he says, in those cases  which continue to
recur from  the  influence of  habit, after the original exciting
cause has  been removed.   He asserts that he succeeded in ef-
fecting an entire cure, in a case of this kind, by repeatedly sus-
pending the paroxysm, by the administration of an active  emetic
a  short time  before the expected occurrence of the  epileptic
attack.   Many  eminent  authorities,  however, might be  cited,
against the use of emetics in this affection; and as a general rule 
516                  INFANTILE EPILEPSY.
they are certainly to be regarded, as of very  doubtful propriety.
In cases attended with strong congestion in the  vessels  of the
head, the  operation  of an emetic, would doubtless be  attended
with very considerable risk of injury.  When the epileptic par-
oxysm is  preceded, by the premonitory sensation termed aura in
one of the extremities—that is, by a peculiar feeling  of heat, as
if a current of warm air were directed on the part, passing more
or less rapidly from one of the inferior extremities to the head,
the  paroxysm  may,  sometimes  be  effectually  prevented,  by
compressing  the  limb firmly, with a  tourniquet or bandage, ap-
plied above the part, at which the aura may  have reached.  Dr.
Cullen observes, that " a ligature upon the limb, above the part,
from which the  aura arises  should always, in those cases be ap-
plied, both because the prevention of a fit breaks the habit of the
disease, and because the frequent compression renders the nerves
less fit  to propagate  the  aura."   An  instance is  related in  the
London Medical and  Physical Journal, in which pressure in this
way, prevented the occurrence of the paroxysm. (Cook.)  Brech-
tedt and Michaelis, also, mention instances, of the successful em-
ployment  of compression in cases preceded by the aura.  It must
be confessed, however, that cases attended with this remarkable
premonitory symptom are extremely uncommon.  In the course of
my practice I have met with but two instances of this kind; and
in both, the passage of the  aura from the leg to the head was so
rapid, and came on so unexpectedly, that there was not sufficient
time given to resort to this means  for preventing the accession
of the fit.
   The  immediate danger, attending an epileptic  paroxysm, de-
pends  almost entirely on  the vascular turgescence in the brain;
for when death takes place  during the attack, it is almost inva-
riably,  in  consequence of cerebral oppression, from excessive
engorgement of the  cephalic circulation—terminating in apo-
plexy.  During  the  paroxysm,  therefore, our principal  object
should be  to diminish  the preternatural congestion of the cere-
bral vessels, in order to protect the brain against fatal oppression
or lesion.  The importance of  attending to this  indication, is
particularly great, in children of robust and plethoric  habits, and
where the signs of inordinate sanguineous congestion in the head, 
                     INFANTILE EPILEPSY.                 517
are conspicuous.   In instances of this kind, blood ought  to be
promptly and freely abstracted, sinapisms applied to the feet, and
cold applications made to the  head, while every thing which
might compress the veins of the neck and impede the free return
of blood from the brain to the  heart,  should be removed.  Al-
though no treatment during the paroxysms, can, I think materi-
ally mitigate its  violence or  shorten its duration,  yet by these
remedies we may at least  protect the brain, and obviate a fatal
termination.
  It is during the intervals of the attacks, however, that our prin-
cipal efforts must be made for preventing the recurrence of the par-
oxysms or effecting a permanent removal of the disease.  I have al-
ready adverted to the importance of attending to the nature of the
exciting cause, in instituting  a course of treatment, for its radical
cure.  If our inquiries, in this respect  are successful, it will aid
us very materially, in the adoption of an appropriate plan of treat-
ment.   Thus, if on a careful examination, it be found  that the
bowels  are in a loaded and  irritated state, and particularly,  if
manifestations of intestinal disorder  existed previous to the oc-
currence of the disease, it will, undoubtedly be very proper to at-
tend to the state of the alimentary canal, as an important prepara-
tory measure in the treatment.  In children, epilepsy is frequent-
ly originated by gastro-intestinal irritation; and in many cases
arising from other causes, the disease is aggravated and sustained
by a deranged state of the alimentary canal.  In cases of this kind
emetics,  according to the experience of many eminent physicians,
have occasionally produced the happiest effects.  Richter declares,
that in some instances of this disease attended with nausea, flatu-
lency, acidity, colic pains, and other manifestations of indigestion
and gastro-intestinal irritation, he has resorted to a course of
emetics  with entire  success.  In a child about five years old,
which had been affected with epileptic paroxysms, twice and some-
times three times a month,  for upwards of a year and a half,  I
succeeded in arresting  the progress of the disease entirely by a
course of emetics.   An efficient  dose of  ipecacuanna in  union
with a few grains of  calomel, was administered every third day,
and continued for nearly six weeks.   This case came on, after a
severe attack of  ague,  which was speedily cured with Fowler's 
518                  INFANTILE EPILEPSY.
arsenical solution.   When the disease is attended with a prevail-
ing disposition to generate acid in the primae viae, as is frequently
the case  in infants, alkaline remedies, in conjunction with mild
tonics, and an occasional laxative, are sometimes decidedly bene-
ficial.  The famous powder of Margrave, which was formerly so
much  employed,  by  the Germans,  in  infantile epilepsy owes,
whatever power it possesses to its antacid, tonic  and  aperient
"irtues.   It is composed of one ounce of  powdered mistletoe, the
same quantity of white sugar, and half an ounce of the carbonate
of magnesia. The dose is a teaspoonful, two or three  times a day,
for a child  under five years old.  When vomiting occurs at the
end of the paroxysm, we may presume,  says Richter, that, the
primary cause of the disease is located in  the stomach; he men-
tions,  also, a peculiar tremulous motion of the under lip, as a sign
of gastric irritation,  from vitiated secretions or other offensive
matters.  Van Swieten, states, that in  a  case of epilepsy, in a
child, in which the paroxysms were invariably preceded by this
tremulous motion of the  under lip, he employed emetics and pur-
gatives with entire success.  It need scarcely  be observed, that
in  cases attended  with worms  in the bowels anthelmintic reme-
dies should be employed.  More than twenty years  ago, I saw a
child, which for upwards of six months, had one, and  sometimes
two, well marked epileptic paroxysms every week, attended with
paralysis of the left arm, and which was, finally entirely relieved
of the convulsive affection, by the  expulsion of an enormous mass
of lumbrici, in consequence of the use of  a strong decoction  of
spigelia. In general  small  doses  of  calomel,  with an occa-
sional active dose  of castor  oil and   turpentine,  will answer
better in such cases  than any other remedies we  possess.  The
German physicians  are  much  in  favor of  the   employment
of full  doses of  powdered  valerian  root,  in epilepsies  de-
pending on verminous  irritation.  I have  known  the paroxysm
to be suspended for many months  by the use of this article  in
 union with the oxyde of zinc; and from  cases published in late
 European medical journals it would appear that valerian in con-
 junction with the elutriated  oxyde  of  tin, has been  used with
 complete success.  From ten to twenty grains of the former, with 
                     INFANTILE EPILEPSY.                  519
from three to six grains of the latter article,  may be given three
times daily, to children of from two to seven  years old.
  In cases that come on soon after the sudden drying up of some
long standing eruption about the head, or discharging sores behind
the ears,  the manifest indication is to restore the local affection,
or to substitute in their stead  others,  artificially.  Issues, setons,
blisters, and frictions with tartar emetic ointment, may be advan-
tageously resorted to for this purpose.  Diaphoretics, purgatives,
warm-bathing and stimulating frictions, are also appropriate reme-
dies in such cases.  Prichard recommends mercury to the extent
of producing ptyalism in cases arising from this cause; and Rich-
ter states, that he has found musk and camphor, peculiarly benefi-
cial in this variety of this disease.
  Epilepsy from local injuries of the head,  has been cured by
surgical operation.   Successful  instances of  trepanning in cases
of this kind are  related by Boerhaave, Thenier, Stalpart, Van
der Weil, and Tissot.  Dr.  Massie,* has given  an account of a
case of epilepsy which was produced by a blow on the head, and
consequent depression of a portion of the cranial bones.  After
the disease had continued  for nearly four years the  patient was
trepanned,  and a spicula of the depressed  bone removed after
which  the paroxysm did  not return.   Dr.  Dudley  of Lexing-
ton, also succeeded in curing a  case of Epilepsy,  by removing a
spicula of bone, which had penetrated the substance of the brain;
and Dr. Rogers of  New-York  succeeded  in a similar  case by
such an operation.   Dr.  Guild, of Alabama, has given an  ex-
tremely interesting account of a case of epilepsy,  which deserves
to be consulted as a remarkable instance of  successful trephining
in this disease.t
   In very many cases, however, the  most careful inquiries lead
us to no satisfactory information, as to  the  primary  or exciting
cause of the disease; and in the majority of  cases, the causes are
of  such a character  as to be wholly beyond our control; or the
original cause may have disappeared, and the disease be contin-
ued by the influence of habit, in co-operation with an acquired
or  hereditary  predisposition.  Under  such circumstances,  we
           * Philadel. Med. and Physical Journal. 1829.  No. 35.
           t American Journal of Medical Science. October, 1829. 
520                  INFANTILE EPILEPSY.
have no resourses  left us, but those which  are founded on bare
experience—and we are obliged if we  wish to make any reme-
dial effort, to resort to some one,  or many by turns, of that long
list of remedies, which, according  to  the testimony of eminent
practitioners or our own observations, have been known occasionally
to effect a cure. These remedies are, generally, much decried in
the books, as  empirical.   It is, nevertheless, certain,  that many
of them, have, at times, cured, even inveterate cases, and when
all lights to a more rational course of  treatment fail,  it can nei-
ther be wise nor proper  to  reject these  "empirical" resources.
The truth is, that in cases that are unconnected with organic dis-
ease and continued merely by the  force of an established predis-
position and  habit, any thing which is capable of producing a
permanent change in  the excitability and excitement of the brain
and  nerves,  may  under  favorable  circumstances, suspend,  or
wholly arrest the recurrence  of the paroxysms.  The following
are the most celebrated of these anti-epileptic remedies:
   Valerian was formerly much employed in this disease.   Quarin
asserts, that he has  more frequently found it beneficial in the
epilepsies of infants than any other medicine.   It is said to be
most useful in cases depending on verminous irritation.   It should
be given in large doses.  Biett, who speaks in the most favorable
terms of its powers in this disease, recommends the oil.  From
five to ten drops of the oil of valerian may be given to a child of
from two  to seven years old, three  or  four  times daily.  I have
in several instances postponed the paroxysms for two and three
months by the use  of this remedy.  The animal oil of Dipple,
has also  been  much  commended  as a remedy in this disease.
Hoffman,  Cullen, Bang, Kortrum, Quarin, Werlhof and Richter,
mention cases that yielded to its powers.  The latter writer found
it most useful in epilepsies arising from repelled cutaneous erup-
tions.  The dose for  a child between  two and ten years  old
is from  five to ten  drops.  Of late  years, the spirits of turpentine,
has been strongly recommended in certain varieties of epilepsy in
adults.  Biett has  employed it in infantile epilepsy with complete
success.   It is particularly adapted to  cases depending on intes-
tinal irritation.  The oxyde of zinc, is  generally regarded as one
of our most valuable remedies in epilepsy: and from the testimony 
                      INFANTILE EPILEPSY.                  521
 extant  in relation  to its powers, as well as from facts that have
 come under my own notice, I am inclined to regard it as a medi-
 cine of considerable powers in this  affection.  I  used this arti-
 cle in the case of a child, about four years ago, with unquestion-
 able  advantage.  The fit which recurred twice and sometimes
 three times a month, was suspended by the use of this medicine
 for upwards of four months, and it never after returned more than
 once a  month.  This medicine ought to be given in as large do-
 ses as the stomach  will bear.   A child two years old may begin
 with a  quarter of a grain, and gradually increased to a half or
 even a  whole grain, and the dose should be repeated thrice daily.
 The sulphate of zinc also, has been successfully employed in this af-
 fection.  Weikert mentions several cases in children, which yield-
 ed to this remedy.   Lettoom, Cullen, Ideler and others, speak in
 favorable terms of its powers.   This, and the preceding article, ap-
 pear to be most apt to  do good, in cases, recurring from habit, and
 where the original  exciting cause is no longer present.  The cu-
 prum ammoniacum, was a favorite  remedy with Cullen, in the
 treatment of this affection.   I have used it very frequently, in the
epilepsies of children;  but generally with but little or no obvious
advantage, excepting one instance  in which it effected an  entire
cure.   It should never be  given in cases attended with a mor-
bidly irritable, or irritated state of the alimentary canal. Richter
asserts,  that  it is only calculated to  do good in torpid, inirritable
and phlegmatic habits, connected with a healthy condition  of the
digestive functions.   According to  the  experience of Haase an
eminent German writer, this article is much better  adapted to
the cure of epilepsy in adults, than in children; and  he accords
with  Richter in  regarding  inirritable  and phlegmatic sub-
jects, as most apt  to  derive benefit from its use.   The dose to
a child between two and ten years, is from the 20th  to 8th of a
grain three times daily, and  gradually  increased until it creates
nausea.   No remedy has of late years been more frequently em-
ployed, in epileptic affections, than the nitrate of silver; and from
the varioifs and highly respectable testimonies we have in relation
to its powers, it is without  doubt,  entitled to considerable  atten-
tion as a remedy in this disease.  To derive  any decided advan-
tage from its  use, it ought to be given in as  large doses as  the
                            3X              45 
522                  INFANTILE EPILEPSY.
stomach  will bear.  Small  or inefficient doses  very rarely,  if
ever,  make any  obvious impressions   on the disease.  When
given in the form  of pills, it may  in general be administered  in
much larger doses without unpleasant effects on the alimentary
canal,  than when  exhibited  in  solution.  It  may  be  advan-
tageously given in  union  with the extract of cicuta, or of hyos-
cyamus.   Richter states that  this article  seldom  does any good
unless the digestive organs are in  a healthy and active condition;
and Dr. Harrison considers  it  as particularly adapted  to  those
cases  which are connected  with a morbid irritability  of the
nervous  system.  Out  of a  considerable  number  of cases,  in
which. I have employed this remedy, one only was  permanently
relieved  under  its use.   This  case  was in a  child,  about seven
years old, and was occasioned  by sudden and violent terror.
When  recourse  is had to  this  remedy, its use ought  to  be
continued, without interruption, for  several months; for  it  will
sometimes manifest no beneficial effects for many  months, yet
finally arrest the  progress of the disease.  It is a common prac-
tice  to  discontinue the use of this and other similar remedies,
if no obvious advantage  is derived  from it, in the course of five
or six weeks.   This I am persuaded, is sometimes  the cause of
failure in our attempts to subdue this malady.   I once succeeded
in curing a case  of seven years standing by persisting with the
use of the same remedy for nine months.
   Tin, also, has been strongly recommended as a remedy in this
affection.  Dr.  Shearman asserts, that the elutriated oxyde of tin
has more  frequently succeeded  in  his hands, than any other
remedy he has ever  employed.  To children, it may be given
in doses of from  three  to ten  grains,  three or four times daily,
It is said to be  particularly useful in cases connected with ver-
minous irritation.   I have employed this  article in combination
with powdered  valerian root,  in one instance with  the  effect  of
postponing the  paroxysm for five  or  six weeks  beyond the usual
time of its recurrence.  In adults I have known the sugar of lead
to be used  with  entire success;  and many authorities of  great
respectability might be  cited, in favor of its employment in this
affection.  Dr.  Rush cured two cases with this remedy, and Drs.
Spence and Agnew, declare  that they have used it with  great 
                     INFANTILE EPILEPSY.                  523
 advantage in  some cases.   A  great  variety  of other remedies
 have been employed with occasional  benefit, and are recommen-
 ded by different writers, as worthy of attention in this intractable
 malady.  Some  of the  narcotics, particularly opium, camphor,
 belladonna and stramonium, have occasionally done some good.
 Very generally, however, no advantage whatever, can be obtained
 from remedies  of this kind; and  they  are often decidedly inju-
 rious, by increasing the  flow of blood  to the head.   The root
 of thepaony was formerly much esteemed for its sanative powers
 in this  complaint.   Hufeland,  speaks  of it  in very  favorable
 terms.  He asserts that in the epileptic affections of children, it is
 one of our most  valuable  remedies.   From  three to ten  grains
 of the dried root, according to the age of the child, may be
 given three times  daily; or an infusion of an ounce of the root
 to a pint of  water, may be  given in  doses of one or two tea-
 spoonfuls, every three or four hours.  Upwards of twenty years
 ago, I was acquainted  with an  empiric, who used this article
 in epilepsy, and I know that  he effected an entire cure in several
 cases, one  of which had previously been under  my own care.
 The following mixture  has  been used with complete success in
 some instances of this disease, and frequently with the effect of
 postponing the paroxysm for many months.  Dr. Otto  of Phila-
 delphia, assured  me that  he has, repeatedly employed it with
 very decided advantage.*
  Mercury,  carried to  the  extent of producing salivation, has
 been  known  to cure this disease.  It  is said  to be most  apt to
 prove  serviceable  in cases depending on  suppressed discharges
 or repelled chronic  cutaneous eruptions.  Bang, Willes,  I. Frank,
 Tissot,  and  others mention cases  in  which  this remedy was
successfully used.
  Various  external means have also been employed, and  occasion-
ally with decided  benefit, in  the treatment  of this complaint.
 Galvanism, has been  employed, and  in  a few instances with
great  advantage.  According to the  experience  of Mansford,

                 * B Pulv. Zingiberis.
                     Pulv. fol. Solivfe.
                     Pulv. sem. sinapi aa gss.
        Dose a tea spoonful, three times daily, for a child five years old. 
524                 INFANTILE EPILEPSY.
little or no benefit is to be derived from galvanism in this disease
unless  it be  applied steadily and uninteruptedly,  and only with
a weak force.   The negative  pole, he  says, should be applied
as near the brain as possible, and the positive one on some distant
part of the  body.  Setons, and  issues may be useful in certain
cases, connected with a  prevailing  tendency to  inordinate deter-
minations of blood to the head, or arising from suppressed dis-
charges or  repelled eruptions.  Pustulation with tartar emetic
ointment, was  used  by  Mr.  Crighton, in six  cases  with very
obvious benefit, though not with entire success.  The  ointment
was  rubbed in along the whole  tract   of the  spine.  More
recently Dr. Carter has employed this remedy in  five cases of
epilepsy,  with  unequivocal advantage.  Besides the  foregoing
remedies, a  great many others have been  employed and recom-
mended in this  affection: such as artemisia vulgaris (Burdock;)
veraeium album, (Stark Greding,) mistletoe (Boerhaave, De Haen,
Hufeland;)  the  root  of  white lilly (Hufeland;) philandrium
aquaticum;  radix mea (jahn) sedum acre (Zachorn;) fol aurantio-
rum (Van Sweiten,  De Haen,  Stoerk; the  carbonate of potash in
large doses.   (Hufeland's Journal.) 
CARPO-PEDAL SPASMS.
525
                   CHAPTER XLI.


                    CARPO-PEDAL SPASMS.

  This affection  was,  I believe,  first  distinctly noticed  by
Dr. John  Clark  of  Dublin, in his  Commentaries.   About
sixteen years  ago, an interesting  paper  was  published  by
Dr. Kellie on  this  subject;* and at a subsequent period, Dr.
James Johnson published some  observations on the disease,
of a  very interesting  character.f   The  most satisfactory  ac-
count  of  this  remarkable   form of  convulsive  disease, that
has as yet been  given to the  public, is to  be found in  the
treatise of Dr. North.  Dr.  James Johnson  denominated this
affection  carpo-pedal spasm;  others have  designated it as a
form  of cerebral  spasmodic croup; and Dr.  North  has treated
 of  it under  the  head:—A  spasmodic affection of the chest  and
larynx in young children,  accompanied by general or partial con-
vulsions.   The  following  are  the  phenomena  and  general
course  of  this  affection, as detailed  by  Dr.   North,   and
in  the interesting  paper  on this subject  published  by  Dr.
Kellie.
   The disease generally  occurs between  the  third  and  sev-
enth  month of  age.  It usually makes its approaches in  a
very  gradual manner.   At  first, the  symptoms  are  often so
 slight  as scarcely  to  attract   the  attention  of  the persons
 about the infant.   Among  the earliest symptoms of  the  ap-
 proach  of the  disease is a very  peculiar  hurried breathing,
 accompanied " by that kind of noise which an  increased se-
 cretion of mucus in  the  air passages would produce," occur-
 ring  at the moment the child wakes  from sleep.   Frequently
 the  child awakens,  as  in   a fright,  and  is  immediately af-
             * Edinburgh Med. Journal, Vol. 12.
             fMed. Chir. Journal, Vol. 3, 1817.
                                             45* 
526                 CARPO-PEDAL SPASMS.
fected with this  agitated  respiration, and  rattling  in  the tra-
chea.  "If the little patient has previously enjoyed  a  good
state  of health, the characteristic rotundity of feature observ-
able in infants, quickly undergoes  a remarkable change; the
countenance becomes anxious, the sides of the  nose are drawn
in,  the face is  pallid  and emaciated, the  child   frowns  al-
most  constantly,  and when put to the  breast, it  sucks  greedily
for a  moment,  but  suddenly  ceases  to  do so, (hrowing back  the
head  with violence."  The bowels  always become  constipated
in the  progress  of the disease.   These symptoms  may recur,
with  more  or less frequency,  for  a very  considerable  time,
before  any remarkable change takes  place, indicative  of a
further development  of the affection.  "A convulsive  motion
of the  hand is usually the  next morbid  sign  which  excites
attention.   The  child's thumbs will be found  constantly and
firmly pressed  upon the  palm of  the hand; the  wrists and
ankle-joints are bent rigidly  inwards;  the head  is often  thrown
backwards, by which  the anterior muscles of  the neck are
kept  painfully  upon the  stretch.   The inconvenience  at the
moment of waking is not now a mere acceleration  of breath-
ing.   This symptom still  continues in an aggravated degree—
but  the noise accompanying  the   respiration  has gradually
assumed a very  different character  from  that  which  at first
marked  it.   Each  inspiration  is  now attended  by  a  loud
crouping noise,  which  may be heard  in  an adjoining apart-
ment; the chest  and larynx appear to be painfully constricted;
the heart palpitates violently; the  child sobs, but never  cries
in its  natural  manner,  during these paroxysms of suffering.
So  great  is the  difficulty  of breathing, that it  sometimes ap-
pears to be almost totally suspended  for a few seconds.  The
countenance  is then  pale, as in syncope.  Sometimes, though
rarely,  the face  is dark, and the  vessels of the  head and
neck  turgid, as  in apoplexy.   As  the disease  advances, the
little  patient  experiences  more  or  less  frequent  attacks  of
general convulsions, during which the features  are  much dis-
torted;  and the  whole  body is occasionally implicated  in the
convulsive  movements.   In a child,  in  whom the  convulsions
were  very frequent and severe, the  state  of opisthotonos was 
                    CARPO-PEDAL SPASMS.                 527
SO complete,  that  for  many  days  the head and  heels  were
the only parts which  touched the  bed; and if, with difficulty,
this  apparently painful  position was  altered by the mother,
it  was quickly resumed.  In  the  majority of cases, no sus-
tained febrile action is  to  be  detected,  nor is there  usually
any  indication of  particular  determination  of  blood  to the
head."*  Sometimes, the locked state  of the  thumbs,  rigidly
bent  position  of  the hand  and foot, and stridulous or croupy
respiration,  will  continue  several  weeks with  scarcely any
intermission, though irregular  intervals of  remission and  ex-
acerbation  are  always   more  or  less  conspicuously noticed.
"The child sometimes appears lively for a  short  period, and
the  countenance  may be animated by  a  momentary  gleam
of cheerfulness;  but it  almost  invariably   awakens from its
slumbers, however tranquil  they may sometimes appear,  with
a  convulsive  paroxysm  similar  to  that  described  above."
After the termination  of a paroxysm, the child appears  to be
greatly exhausted,  and  with  scarcely the power of voluntary
motion  for some  time.  Dr. Kellie's description of this  affec-
tion  is  somewhat   different  from  the one just given from
Dr.  North's work;   but in  the main and  characteristic  phe-
nomena, they coincide sufficiently to enable any one to refer
it  to  one and the  same form  of infantile  disease.  "On  the
anconal  aspect  of the  metacarpus  of the  hand," says Dr.
Kellie, " and  on the  rotular aspect of the metatarsus of the
foot,  a  remarkable  tumor  occurs,   having  a  considerable
degree  of  roundness  and elevation, resembling  that  sort of
swelling which might  arise on the same parts from  a blow
or contusion.   It  seems to  arise  suddenly,  and  when first
observed, it  has somewhat of  a  mottled,  livid and purplish
color, resembling  the chilled  hand  of  a  full  and  healthy
child after  exposure  to  a  cold and  frosty atmosphere.   It
has  no inflammatory  heat, and does not appear  to be mor-
bidly sensible, or to  give any pain  to the  child when  han-
dled;  nor  does  it pit  on  pressure,  but  rather gives  the
sensation of  firmness  and  resistance.   When  an  attempt is
*North. loc. chat.  p. 259. 
628                 CARPO-PEDAL SPASMS.
made  to  move it sideways, under the  skin, it  conveys  the
notion of a disease  peculiai to infants,  known   by the  name
of  skin-bound.    These  tumors   terminate  abruptly  at  the
carpus and  tarsus, so that in  lusty children  it seems in these
places,  as if confined by a cord  or  bandage.   They  some-
times continue for two  or three  weeks;  occasionally,  they
disappear in a few  days;  and in other  instances, they  disap-
pear  and re-appear  at  short intervals.   The  tumor sometimes
becomes  leucophlegmatic,  loose,  with   considerable oedema
spreading upwards on the legs.   This  however never occurs
unless  the  swelling  continues   for  several  weeks  without
abatement; but  its  more sudden  disappearance without un-
dergoing  these  changes, or without passing into a state of
leucophlegmasia, is  by far more  common.  This swelling on
the  tops  of  the  hands  and feet is  connected in  a great
proportion of cases with a spastic contraction of the flexor muscles
of  the  thumbs in the  upper, and the  toes in   the lower ex-
tremities.   The  thumb   becomes  rigidly  contracted,  and
permanently bent downwards and laid flat upon the  palm
of  the  hand; and in like  manner, the  toes are bent  down
to  the  plantar  aspect  of the foot.  Along with the  thumb,
the  carpus  is also in  some cases drawn inwards by a spastic
contraction of its flexors."*
   In Dr. James Johnson's case,t the child, (nineteen  months
old) was  seized  three or four times  in  the  hour, "with spas-
modic  affections  of the  respiratory muscles,  consisting of
repeated  attempts to fill  the  chest, during which, she threw
herself back, as in  opisthotonos, and appeared  as though she
would  be suffocated.  These  fits would  last ten  or  twelve
minutes,  after  which  the child  was somewhat  easier,  but
always fretful  and  peevish.   The  backs of  the hands  and
insteps were swollen and hard; the thumbs rigidly contracted,
and  locked  across  the  palms   of  the  hands;  the   toes
were bent  down towards the soles  of  the feet; and  both
wrists and ankles were  firmly bent by  the contraction  of the
flexor muscles.   The bowels  were torpid; the stools clayed or
             •Dr. Kellie. loc. citat
             tMed. Chir. Jour. May 1817. pp.  448,  449. 
                    CARPO-PEDAL SPASMS.                 529
slimy, and offensive; and the child was extremely irritable,
both by  day and  by night."  During the  preceding  summer,
I met  with  an instance of  this affection,  in a child about
nine months old,  in  other  respects of a remarkably  vigorous
and  robust state of health.  The symptoms of this case coin-
cided so closely with those  mentioned in Dr. Johnson's case,
that his  description applies  in  every point to its phenomena
and  course.
  It does not  appear that  this  singular affection is  attended
with much  danger, wdien  timely aid is afforded  with proper
remedial  means.   Dr. North had seen  but  one fatal instance
of  this  malady;  and  Dr.  Johnson  states, that in  his  own
practice  no instance of death has occurred from it.  The case
which  came under my own observation, terminated favorably,
after the  process  of primary  dentition  was  completed.   It
should  nevertheless be  regarded  as a  disease of an unfavor-
able tendency; for if cannot be doubted  that  the  cerebral
irritation  which  gives rise  to  its characteristic  phenomena,
may, under certain states of predisposition, and in co-opera-
tion  with other causes, tending  to  encephalic disease,  readily
pass into  a state of vascular  irritation, or sub-inflammatory
action  in the brain or its meninges;  and thus ultimately give
rise  to fatal  effusion, or  lesion  in  the brain,  or  its  spinal
prolongation.
  In the only  dissection  which is reported  by Dr. North, the
traces  of cerebral disorder  were  sufficiently conspicuous.  The
vessels  of the  brain were  very turgid; a small portion  of
blood was effused under the dura  mater in  several parts;  a
small quantity  of serum was found in the ventricles;  and the
whole  mass  of the cerebrum was unusually  firm, while  the
cerebellum was softer  than common.   The  thorax  was  not
examined.   Dr.  North ascribes the  inordinate determination
to the  head, and the  evidences of encephalic  disorder, pre-
sented  on  dissection,  in  this   case,  to an  accidental and
overwhelming  "rush of blood to the head, caused by a very
passionate fit  of  crying," just before the  occurrence  of the
last  and  fatal  paroxysm.   He  thinks  the  characteristic  phe-
nomena  of the disease  are entirely  independent  of  cerebral 
 530                 CARPO-PEDAL SPASMS.
 derangement,  and  that  "in  the  majority of  cases, there  is
 no  evidence  of affection  of  the brain," and  that we  have
 no  right  to  assume  that  certain  individual  symptoms__such
 as the  crouping noise  or bent  thumb,  must  necessarily  be
 followed by affections of  the brain.
   From a general  view of  the  phenomena  of the malady,
 it  appears to  me,  nevertheless,  highly  probable, that the
 disease  is ab  initio  and  essentially  connected  with nervous
 irritation of the sensorium, propagated at last  in very violent
 cases  to the  spinal  cord.  The frowning  aspect of the  coun-
 tenance—the  starting  from  sleep—the   peevish  and  fretful
 temper—the occasional flushing of one  cheek mentioned  by
 Kellie,  the costiveness and hepatic torpor, &c., all seem to
 indicate a state of nervous irritation or erethism of  the brain;
 and the opisthotonic  spasms,  which are  wont to supervene in
 aggravated cases, point very directly to irritation of the  spinal
 cord.
    Whatever   may  be thought, as  to  the proximate   cause
 of this  affection, all writers on this subject agree in ascribing
 its origin to dental  irritation.  It seems to be much more apt
 to occur  in  children  of  a robust  and  full  habit   of  body,
 than in  such as are  of an opposite  constitution.  So far as I
 have been  able to  ascertain,  the disease has  never  been
 observed to  occur  except   during the   actual  progress  of
 primary detention;  and  where  it does  not  terminate fatally,
 at an earlier period,  it always subsides  soon  after  the  com-
 pletion  of this  process.

   Treatment.  This  affection,  as  has already been   observed,
 is  almost always intimately connected  with difficult  and  pow-
 erful dentition.   In all instances the  gums should be promptly
 examined,  and if they exhibit a swollen or expanded appear-
 ance, they should  be, at  once, freely divided  down to the
 advancing  tooth.   "I  have  known"  says Mr. North,   "the
 croaking respiration  and spasms of the  hand and feet' instantly
 subside upon freely lancing the  gums."  Care should  be  taken,
in  performing this operation, that  the gum be perfectly divided
down  to  the  tooth,  for  unless the  firm  membrane  which  is 
                     CARPO-PEDAL SPASMS.                  531
spread  over the  crown of  the  advancing  tooth, be  com-
pletely  divided,  little  or  no   benefit can result  from the
operation.   A  simple  incision  will be  sufficient for  the  in-
cisors and canines,   but  "we should  always make  a  crucial
incision,  when  it is our  object  to  liberate  the  molares."
  Purgatives  are,  in  general, indispensable  in  this affection.
In  nearly all   instances, the  bowels  are  either constipated,
or  disordered  in  such   a  way,  as  to require  the   use  of
purgatives.  The  milder articles of this  kind are "rarely if
ever to  be depended on."   It is necessary  to  procure active
purgation; and for this purpose, calomel and jalap, or  calomel
succeeded  by infusion of senna and manna, are in general to
be  preferred.   In many instances the alvine  evacuations  are
of a  whitish or clay color,  manifesting  a  deficiency  of the
biliary secretion.  In  such cases small doses of calomel  in union
with ipecacuanha will be very  useful.   They should  be  given
three or four times daily, with an  occasional dose of castor oil,
or senna infusion, until the stools  become conspicuously mixed
with  bile.  In robust and plethoric infants, it  will,  often, be
highly useful to abstract  blood,  either from a vein with  the lan-
cet, or by leeching from the  head.  Where the determination
of blood to the brain is very strong, North  advises  opening  a
jugular vein, or  cupping upon the temples.  I  have, in a few
instances, derived great  benefit from the application of blisters
behind the ears, or   on  the back  of the neck.  They  cannot,
however, be used, with propriety,  where the pulse is active, or
where depletion is indicated.  In cases attended with a small and
frequent pulse, and great irritability of the system, small doses of
Dover's powder, or of the extract of hyoscyamus, will generally
procure  very  considerable   relief.  Great  care, however, is
necessary in the  employment  of  narcotics in this  affection.
Where the face is often flushed, and the  pulse tense or  corded,
or where the habit is  manifestly febrile, they can  seldom  be used
without considerable  risk of  injury.  It is only after the gums
have  been lanced—the  bowels freely purged, and the  patient
is free from febrile irritation, with more of nervous than vascular
irritation, that  remedies of this kind can be used  with a pros-
pect of benefit;  and under circumstances of this kind they often 
532                 CARPO-PF.DAL SPASMS.
operate "beneficially.   Mr. North  states,  that  in  some  cases
" where the convulsive breathing and violent action of the dia-
phragm  were  very  great, frictions  upon the  chest  with a
liniment composed of laudanum, spirits of camphor,  and soap
liniment, three or four times a  day has afforded much relief.'1
I have  used frictions  along the spine,  with  a mixture of two
parts qf laudanum and one of the  essential oil of amber, with
great  benefit,  in  this  complaint.   The frictions should be
repeated three or four times daily.  Rubefacient applications,
also, along the spinal region, may afford some relief;  and it
is not impropable  that  cupping  over the  spine would prove
advantageous.  In the  early stages of the disease,  the  warm
pediluvium, repeated two or three times  daily, is capable of
affording very considerable benefit.  In a  case I attended some
time ago, the  child was  invariably much relieved by placing its
inferior extremities in warm water.   The bath was  repeated
every three or  four hours, under the employment of which, in
conjunction  with the use of purgatives,  blisters  behind  the
ears,  and lancing the  gums, the disease gradually subsided,
and the infant is now perfectly  healthy.
   Cold applications to the head, while the feet are placed in
warm  water, seldom fail, promptly to  mitigate  the  paroxysms
of spasmodic respiration.  No advantage can be  derived during
these paroxysms, from stimulating anti-spasmodics, such as asa-
foetida, ether, camphor, &c.  Indeed,  articles of this  kind, at
any period of the disease, are generally decidedly injurious.
   If the  child has been weaned, nothing but the blandest  and
simplest nourishment must be allowed.   All stimulating articles of
diet and drink must be carefully avoided.   If the weather is fine,
exercise, by gestation in the  open  air, will contribute to mod-
erate themorbid  irritability of the system. 
CHRONIC ERUPTIVE AFFECTIONS.   _         533
                  CHAPTER  XLII.


               CHRONIC ERUPTIVE AFFECTIONS.
               ,Zr\:i :<^7.v'. ...    •.
   This very disagreeable  eruptive disease,  is, I believe, alto-
gether confined to infancy, and is evidently intimately associa-
ted with1 dentition, since it very rarely occurs either before the
commencement of this process, or after it is entirely completed.
The appearance of this eruption varies considerably, according
to the degree of inflammation, and the greater or less thickness
of the scabs.  In some,instances a number of  small pustules are
scattered over the scalp, forehead, temples, and cheeks, which in
a few days break  and form  thin and  moist  crusts.  This  mild
form of the disease  is almost entirely confined  to very young
infants.  In the majority of cases, the  eruption  commences  on
the cheeks or near the centre of the  forehead, in the form  of
small whitish pustules, grouped in clusters on an irritated and
bright  red surface.  These soon break, and  a viscous, yellow
fluid is effused, which concretes into thin, soft crusts of a yellow-
ish green colour.   These crusts gradually increase  in thickness
and  extent, and a thin viscid fluid oozes from  beneath them
of an offensive and acrid character.  Very frequently the whole
face, with the exception of the nose  and eye-lids,  are  covered
with an almost continuous crust, the child appearing as if it had
a mask  en its  face.  When the first scabs fall off, the surface
which they expose appears highly inflamed,  with a vast number
of minute excoriations, from  which a sero purulent fluid issues,
which soon concretes into a fresh crust.   Sometimes  large pus-
tules come out  behind the ears, around the  mouth, and on the
chin, which speedily give rise to a thick greenish yellow crust
on  those parts.  " Under some circumstances, the mouth is sur-
rounded with large, thick, yellow  incrustations, which are  of a
deep  brown in certain spots, where  a little blood has mixed
with the dried  fluid;  in these movements  the  lips are  much
                                            46 
 534            CHRONIC ERUPTIVE AFFECTIONS.
 impeded: at other times these thick incrustations occur behind
 the ears." (Cazenave.)  This eruption occurs not only on the
 scalp, forehead, and face, but occasionally extends also  to the
l)ody and limbs.  Dr. Dewees states that he has seen it " cover
 nearly every part  of the cuticular system;*1 and I have met with
 several instances,  where  the eruption  extended itself  to  the
 body antl extremities.   In some cases the  disease is confined to
 the cheeks—in  others  the forehead and temples are the only
 parts affected; and  occasionally it is seated exclusively on  the
 hairy scalp.
   There is always much itching in the  parts affected; and in
 some instances the itching and pain are so severe and constant,
 as  to wear down the  infant, and  bring  on a slow irritative
 fever, attended with much exhaustion and emaciation.
   When the disease is about disappearing,  the discharge from
 the  sores diminishes;  "the crusts  are formed more  clearly  and
become thinner and whiter,  the  surface upon which they  rest
becomes less  and less red; they are  soon replaced by a slight
desquamation, which also speedily disappears,  and  there only
remains a light rosy tint on the  spots that were the seat of  the
disease, and this also gradually fades away."  This eruption never
leaves any  permanent marks or  cicatrices—the skin of  the
affected parts acquiring its natural  smoothness  and color, in the
course of five or six weeks after the eruption has disappeared.
   The duration of this disease, is  extremely variable. In some
instances it disappears spontaneously in the course of four or  five
weeks; more frequently, however, it continues for three or four
months, and often much longer.  I have known several instances
to continue for upwards of a  year.
   Crustea Lactea is not a contagious affection. Children of robust
and full habits, appear  to be more liable to it, than  those who
are in a feeble and sickly condition.  Nothing, satisfactory  has
been  ascertained, in relation to the  causes of the disease.  It is
evident, however, that the irritation of dentition is in some way
or other, intimately connected with the eruption.  The constant
preternatural determination of blood to the head, which is apt to
take place during dentition, is propably  a principal cause of  the
disease. 
               CHRONIC ERUPTIVE AFFECTIONS.            535
  In the majority of instances, the general health remains good,
during the continuance of the eruption.  Occasionally the irrita-
tion and itching are so great and incessant, that the child sinks at
last into a slow and wasting  irritative fever.   Sometimes  a  con-
siderable de_gree of gastro-intestinal irritation supervenes, causing
diarrhoea, emaciation, and exhaustion.   The disease, however, is
probably never fatal except when it becomes complicated  with
disease of some important viscera or  with rapid  and profuse di-
arrhoea.   Dr. Dewees, has seen two  instances  of death, from this
disease.   In these cases, the eruption "covered nearly the whole
of the  body," and the children "were destroyed by the pertina-
city of the fever  and the profuseness of the diarrhoea."   In gen-
eral, however,^the prognosis in  this  affection is  quite favorable.
Indeed, many infants appear to be healthier  during this complaint
than they were previous to its occurrence; and it  seems, often,
to counteract  the  supervention of  other  diseases—particularly
cholera infantum, hydrocephalus and convulsions.
  Contrary opinions have been  expressed with regard to the pro-
priety of remedial applications in this diagreeable  affection.  It
is contended by some, that the eruption is the result of a salutary
effort of nature, and that it can seldom be removed by  artificial
means, without much risk of bringing on  other and vastly  more
dangerous affections.  Others say, we  may with perfect safety, in
all instances, remove the disease; and that it should never be suf-
fered to continue if we  possess means capable  of arresting its pro-
gress.   That great and irremediable injury may result from the
sudden removal of this eruption, by artificial means I have not the
slightest doubt.  I am confident that I have seen indomitable diar-
rhoea, hydrocephalus, and general emaciation and febrile irritation,
brought on, by a rash  and successful interference with this dis-
ease.  Within the  present year I witnessed two instances of the
pernicious  consequences of  suddenly  drying up  the  eruption.
Both  infants were  remarkably healthy, although  the forehead
and cheeks were covered with a thick  porriginous crust.  The
mothers were unwilling to  permit their infants  to remain in this
unpleasant condition; and  although  earnestly cautioned  against
the use of the remedies they proposed,  they  pursued  their own
views  and in a short  time effected a complete removal of the 
536            CHRONIC ERUPTIVE AFFECTIONS.
eruption.  In six weeks afterwards, one of these children died of
hydrocephalus, and  the other was extremely wasted  by diar-
rhoea and  finally died from intestinal irritation and exhaustion.
It cannot be questioned, indeed,  that* in many instances the dis-
ease may be removed by remedial applications, without the slight-
est  ill consequences; and when the  cure is effected  in  a gradual
manner, in conjunction  with  proper precautionary measures, it
will very rarely lead to  any unfavorable results.  It is against the
external application of active remedies—remedies capable of caus-
ing a rapid desiccation  and  disappearance of the eruption, with-
out  suitable  preparatory measures,  that I  would  particularly
object.

   Treatment.—I have generally commenced the treatment with
the use of small doses of calomel, in union with the golden sul-
phur of antimony, with an occasional laxative dose of sulphur
and magnesia.  A quarter of a grain of calomel, with  the same
quantity of golden sulphur of antimony, given three or four times
daily.  If this does not keep the bowels in a sufficiently loose
condition, a  moderate  dose of  lac sulphuris and magnesia (terf
grains of each,) should be given, from time to time, so as to pro-
cure, at least three loose evacuations every twenty-four hours.
The affected parts should be frequently fomented with tepid milk
and water, or with a decoction of bran.   By the employment  of
these remedies we  may in general, moderate the irritation and
itching of the affected  parts very considerably, in the  course of
ten or twelve days.  When an obvious impression is made on the
disease in this way, the calomel should be less frequently  admin-
istered, and the mixture of sulphur  and magnesia employed daily,
or every other day, so as to keep up a loose state of the bowels.
Having employed these remedies for two or three weeks, we may
next resort to local applications; and for this  purpose, fresh citrin
ointment, weakened by the addition of an equal portion of lard,
has  more  frequently answered my intentions than any other rem-
edy of this kind I have tried.  Dr. Dewees recommends the use
of calomel ointment, prepared according  to the following  formu-
la.*  The tar ointment also,  has been much employed for this
        R. Calom. ppt. 3ii; Cerat. Simp. Ji; Ess.  lemon gtt. xx.  M. 
               CHRONIC ERUPTIVE AFFECTIONS.            537
purpose; and I have frequently used  it with much advantage.
Whatever  application of  this kind be resorted to, it  ought not
at once, to be applied to the whole or even an extensive portion
of the porrigenous surface.   A small portion, only, of the diseased
partshould, in the first place, be touched with the ointment. " When
this  becomes relieved, a second  spot must  be selected for its
application, and so  on  until the whole  of the diseased surface
has been passed over and relieved."
   The French physicians, are much in  the  habit of employing
sulphurs, alicaline lotions, in this affection, and they are undoubt-
edly often  very effectual.   A wash made by dissolving a drachm
of sulphuret of potash, and two drachms  of the sub-carbonate of
soda in a pint of  warm water, is recommended  for this  purpose
by Cazenene.   I have used  this lotion  in a few instances with en-
tire satisfaction.  When the  disease appears on the body and
limbs, this writer advises the use of "sulphurous, alternated with
tepid emollient baths."
   Where there is much inflammation, and the child is of a robust
and  plethoric habit, considerable  benefit  may be  derived from
blood-letting, or from the application of  leeches behind the ears.
When the  disease attacks the  scalp, the hair should be cut very
short, and emollient cataplasms applied  over the affected  parts,
until the crust separates.   The tar or reduced citrin  ointment
should then be applied, not over the whole surface at once, but in
the successive manner that has just been mentioned.
   When the irritation and itching are very great I have frequent-
ly known great relief obtained from the application of fresh cream
to the affected parts.  It will also tend  much to the comfort of
the child, if the acrid  secretions are frequently washed off,  with
tepid milk and water, or a weak solution of fine soap.
   Formerly  the viola tricolar  (hearts  ease)  was  much  em-
ployed as  an  internal remedy in this  affection.  About  eigh-
teen  years  ago, I  employed this  article  in  a very severe
and  obstinate case,  and as it appeared to me with considerable
advantage.  The expressed juice of the fresh plant  is given in
doses varying from  one to two drachms; or a decoction of the
dried levaes in milk, in the proportion of an ounce of the leaves
                              3  Z                46* 
538            CHRONIC  ERUPTIVE AFFECTIONS.
to a half pint  of milk may be used.  This quantity must be
taken during the  day.
  The diet of the  child  mu9t  be  carefully  attended  to.  If
the infant  is still nourished at  the  breast, much benefit  may
sometimes  be obtained by changing  the  milk.  Where this  is
impracticable, it  should not be  permitted  to suck more than two
or three times in the  course  of twenty-four  hours, whilst the
deficiency  of  nourishment from the breast,  is  made up by
feeding it on thin water gruel,  cows' milk and  water, thin arrow
root,  or barely water.  The nurse too,  ought to avoid eating
salted meats,  and in  severe cases,  should be confined  almost
entirely to a milk and vegetable diet.  All spiritous  drinks, such
as  wine, brandy  and  water, ale, beer,  &c.  should rigidly be
avoided, on the part of the nurse.   Children  who are weaned,
should be  nourished on milk  and water,  arrow root, sago, oat-
meal gruel, &c.   Every kind of stimulating food and drink must
be forbidden.  Exercise in the  open air, by  gestation, will be
useful; and the head must  be kept wholly uncoverevl.

           2.  Sore Ears.  Excoriations behind the ears.
   This  is a very common affection with  robust and  plethoric
infants during dentition.  It begins in the form of small pustules,
 which soon  ulcerate;  or  instead of pustules,  the skin becomes
 inflamed, and in  a short time,  terminates in superficial ulceration
 or  excoriation,   from which   an  offensive serous fluid  issues.
 When these sores are neglected or mismanaged, they are apt
 to degenerate  into very painful and severe  ulcers, which are,
 in general,  extremely difficult to  bring to a mild and healing
 condition.  In this aggravated state, there is almost always a very
 copious discharge of offensive, purulent matter,  which in many
 instances  becomes so  acrid as to inflame and excoriate the parts
 over which it flows.   The whole external ear, sometimes becomes
 much inflamed  and   swollen,  and  a  deep  ulcerous  fissure  is
 formed in the  groove behind the ear.
    Dr. Dewees asserts that the apprehension of dangerous conse-
 quences  from drying up these sores, " is a popular prejudice,
 perpetuating an evil which should never have been permitted  to
 have existed."   I am  not  of this  opinion.   I conceive,  and I 
                CHRONIC ERUPTIVE AFFECTIONS.            530
think on  very good grounds, that irreparable injury may result
from the sudden drying up or healing of these sores, particularly
during  the active  progress of dentition.   The Doctor has been
more fortunate  than I have been, if he has never known any
serious  evils to result from this  cause.   I  doubt  whether any
prudent physician would advise the application of drying reme-
dies to excoriations of this  kind, while the infant was  under the
lufluence  of painful dentition.   That these sores may be improved
and gradually  healed by  a  cautious and  judicious course  of
management,  without any unpleasant  consequences, I freely
admit.  I have never suffered this affection  to continue without
making efforts  to moderate its severity and to bring it by  degrees,
to a healing condition.  The positive declaration, however, that
the notion that such sores are  not to  be hastily dried up, is a
vulgar or "popular prejudice," is certainly not  warranted by the
experience of  many of the most  eminent practitioners that have
expressed their opinions on this subject.
   In the  majority of instances, more or less  torpor of  the bowels
is Connected with the appearance of these sores.   Whether this
be the case or  not,  however, purgatives are always indispensable
in  the  management of the complaint, not only with the view of
 moderating the inflammation and  promoting the cure of the
 sores, but as means calculated to obviate the unfavorable effects
 that might arise from the drying up or  healing of the disease.
 Very active purging, however, is neither necessary nor proper,
 at least  not after the bowels have  in the first place,  been freely
 evacuated.  It will be sufficient  to procure three or four free
 evacuations in  the course of a day.  For this purpose, I  have
 generally administered a  grain of calomel  in the evening, with
 a  small  dose  of magnesia and sulphur, or of  castor  oil on  the
 following morning.   If the gums are inflamed or swollen, from
 dentition, they should be divided  by a free  incision down to  the
 advancing teeth.  The use of warm pediluvium,  may also be
 beneficial  by its tendency to counteract the preternatural deter-
 mination  of blood  to  the head,  which  usually attends  such
 cases.  The sores should be kept as clean as possible, by washing
 them repeatedly with tepid milk and water, or warm  water with
 a  small portion of fine  soap dissolved  in it.   This  is  of much 
540            CHRONIC ERUPTIVE AFFECTIONS.
importance; for if the acrid  and offensive discharge is suffered
to remain, and spread itself  over the surrounding parts, it never
fails to increase  the  pain and  inflammation,  and  enlarge  the
extent of the ulcer or excoriation.  It is  indeed always extremely
difficult, if not impossible, to improve the  condition of the# sore,
whatever means may be employed, unless  the strictest attention
be paid to keeping the affected  parts clean.  In  cases attended
with  severe ulceration  and  inflammation, much relief may be
obtained from the application of soft emolient poultices, renewed
every four  or five hours, until  the pain  and  inflammation are
moderated.    Fomentations  with  a decoction of  white  poppy
heads, generally afford great  relief where there is much irritation
and itching in the parts.  I have also employed a weak solution
of the sulphate of morphia,  in  the  proportion of a grain to two
ounces of water, for this purpose, with the happiest effect.  After
having continued this course  of management for nine or ten days,
or until the  inflammation and itching  are moderated, we may
have recourse to applications  of  a more active character.  I have
been in  the habit of using  the  unguent, zinci.  oxidi, for this
purpose, and  in  general with  entire satisfaction.   It should be
spread on a slip of fine  linen, and laid over the affected part,
having previously washed away  the offensive  secretions.  This
ointment  is particularly useful in mere excorialions behind
the ears.   The citrin  ointment reduced by adding an  equal
portion of  fresh  lard, is also an  excellent application in this
affection.  It  should be spread thinly on a soft piece of linen and
laid  on the sores during the night.  In the morning,  the parts
should be carefully washed with wrarm  wrater and fine soap, and
then dressed with the ungt. zinci. oxidi.  Dr. Dewees strongly
recommends the use of calomel ointment, " to be smeared upon
the  external  margins of the sores, as well  as upon the sound
skin itself,  twice daily, taking care that the parts  be carefully
washed before each application of the ointment,  and gradually
encroaching upon the  sores every day, by a more  extensive
application  of the ointment." I have used an ointment, prepared
by triturating twenty grains of very finely pulverised red precip-
itate, with  half an  ounce of lard, in  the way recommended by
Dr. Dewees, for the calomel ointment, with  peculiar advantage. 
                CHRONIC ERUPTIVE AFFECTIONS.            541
 The infant's diet should be carefully regulated.  If it is weaned,
 no animal food of any kind should be allowed.  It must  be con-
 fined to a milk  and vegetable nourishment, such as arrow root,
 sago, barley,  oat-meal  gruel,  and rice.  If  the  child  is still
 nourished at the breast, it should be less frequently suckled, and
 small portions of a mixture of cows milk and water, barley water,
 or very thin dat-meal gruel allowed.

   3 Strophulus Confertus.  Tooth Rash.—This  affection  is pecu-
 liar to infants at the breast,  and is manifestly intimately associa-
 ted with dentition.  It consists in an eruption  of papulae, "seated
 chiefly on the cheeks  and forehead,'when they occur about the
 fourth or fifth month, and are smaller,  more crowded together,
 and less vivid in their color than in the affection called red gum"
 to which in other  respects it bears a close resemblance.   When
 they occur in children at a more advanced age—that is,  about
 the seventh or eighth month, which is by no  means uncommon,
 they appear in large irregular patches on the outside of the hands,
 arms, and shoulders, and are  hard  and close set, so as to give
 to the whole surface a high red color."   These papulae, never as-
 sume a chronic character. They usually continue about twelve
 or fourteen days,  when they begin to fade and desiccate, and
 gradually disappear.    In some  instances,  though  rarely, this
 variety of strophulus appears  on the  the legs, extending in  a
 short time to the loins and naval, imparting a uniform redness to
 the cuticle,  "which cracks and separates, in  large pieces, occa-
 sioning much distress to the child."  This affection is but very sel-
 dom attended with constitutional disturbance, unless it  assumes
 the severe form, that has just been mentioned.   Not unfrequently
 it is attended with very troublesome itching, by which the infant
 is  sometimes  much disturbed during night.  In the majority of
instances, however, no particular inconvenience attends the erup-
tion; and children often appear perfectly healthy during its con-
tinuance.
   If the  gums  are swollen  and inflamed,  from dentition, they
should be freely lanced.   The bowels should be kept in  a  loose
condition by magnesia or castor oil, with an occasional small dose
of calomel in  the evening.  .The affected parts should be kept 
542            CHRONIC ERUPTIVE AFFECTIONS.
clean by repeated  ablutions with tepid  milk and water;  and af-
ter each washing,  a little flour  or  fine hair powder should be
dusted upon them.   Every thing  capable of irritating the skin,
such as flannel or muslin should  be  removed from the diseased
parts.

   4 Strophulus Intertinctus.   Red Gum.—This variety of strophu-
lus seldom occurs after the sixth week of infancy, and consists in
papulae of a vivid  red color, appearing "most commonly on  the
cheeks, fore arms, and back of the  hands."  In many instances,
howrever,the eruption is universally diffused over the whole surface
giving it a uniform  bright red color, not unlike the rash of measles.
The papulae are generally distinctly separated from each other, and
"are intermixed  with minute red dots or stigmata, and often with
large red patches, which have no elevation."
   This eruption appears to  be intimately connected with a de-
ranged state of the alimentary canal; for in most instances, sick-
ness of the stomach, with griping and diarrhoea,  precede the ap-
pearance of the rash.  A debilitated state of the digestive organs
from errors in diet, giving rise to acid, and other irritating causes
in the stomach and bowels, appears to be the ordinary source of
this affection.   Its  occurrence  is doubtless much  favored, by
keeping the infant too  warm,—an  error which is  but  too fre-
quently committed by nurses and mothers.   In  its ordinary and
mild form, this  eruption is rarely attended with any manifesta-
tions of general indisposition.  The bowels, indeed, are frequent-
ly more or less disordered, but this does not often create  any ob-
vious illness or general disturbance.
   This disease does not often require  any  active medical treat-
ment.  Ablutions with warm water, and the occasional use of the
tepid or warm bath, so  as to keep the skin free from sordes, and
promote  the regular  action of the cutaneous exhalents, may be
resorted to with advantage.
   Mild aperients, also, are useful.  Small doses of magnesia and
rhubarb, should  be given to keep up a moderate looseness  of the
bowels.   The following combination  has appeared to me pecu-
 liarly useful for this purpose.*   If the child is affected with colic
   * R. Magnes. Calc.  gr.iv; P. Rhcei gr.ii; Pulv. rad. valer. gr.ii.   M.  To be given
 at once. 
                CHRONIC ERUPTIVE AFFECTIONS.            543
pains or griping a drop of laudanum or four or five drops of tinct.opii
camphorata should be given after the operation of the laxative.
" The cold bath or even exposure to a stream of cold air should
be  avoided" during the  continuance of the eruption; for if in
consequence of want of caution in  this  respect, the ra§h is
repelled, very alarming  effects will be  apt  to ensue.  Oppressed
breathing, drowsiness and stupor, severe  colic pains, rapid and
exhausting diarrhoea, and convulsive  affections,  may arise, in
consequence of the sudden retrocession of  the eruption.  When
this occurs  the infant should be immediately put into a  warm
bath, and some wine whey, or a few  drops of the  compound
spirit of ammonia administered.  It should be kept in the bath
until the skin has acquired warmth; and when removed, it  must
be well dried, and wrapped  up in warm flannel.   Sage,  marjo-
ram, or catnip tea, may be given with advantage in this condition;
and where the symptoms  are severe and obstinate, a blister laid
between the shoulders, may afford great benefit.

  5. Strophulus  Volaticus.—This is by no  means a common
complaint.   It  consists  in  small circular patches of papulae,
appearing and disappearing  successively on different parts of the
body.  There are seldom more  than  ten  or twelve papula? in
one cluster;  and "both the  papulae and the  interstices between
them are of a  vivid red color."  The eruption  is  generally
attended with considerable  heat and itching, and in most cases,"
a slight degree  of febrile irritation occurs.  About the  fourth
day these patches begin  to turn brown, and soon exfoliate; so
that " the whole series  terminates in three  or four weeks.  In
some instances, not more than three or four clusters of papulae
make their appearance, and  these are usually situated on the fore
arms and cheeks.   Inmany cases, however,  as one patch declines,
another makes it appearance "at a small distance from it, and in
this manner the complaint gradually spreads over the face, body,
and limbs."
  The pulse is generally accelerated, the tongue  covered with a
white fur, the skin very warm and not disposed to perspire, while
the  little patient  is sometimes unusually  restless and uneasy.
This eruption seldom  occurs during the  first  nine months after 
544            CHRONIC ERUPTIVE AFFECTIONS.
birth.  Dr. Dewees  observes, that  "it has always, according to
his observations, appeared later than is  usually described, or  not
until  the child was about cutting the  first jaw teeth."  This
accords entirely with my own experience.   I have  never wit-
nessed this eruption before  the  ninth  or tenth  month, and most
commonly about the period  mentioned by Dr. D.  This affection
would seem to be  intimately connected  with a disordered state
of the stomach and bowels; for  in  most instances, the evacua-
tions are either very unnatural, or  the child is manifestly  troub-
led with acidity, flatulency, and griping stools.
   The diet should be of the simplest and most unirritating kind,
more  especially,  when the eruption is attended with febrile
irritation., Milk, arrow root, sago, grated crackers dissolved in
warm water, oat-meal gruel, and rice, form appropriate articles
of nourishment in this affection.  Gentle purgatives will be  use-
ful throughout  the whole course of the complaint.  Very small
doses of calomel in the evening, with a  moderate  dose of mag-
nesia or castor oil on the  following  morning, will answer very
well for this  purpose.   The affected parts  should be  frequently
washed with warm milk and water; and  when the eruption is
severe and obstinate, the application of reduced citrin ointment,
or calomel ointment,  as directed for  crusted lactea, should be
resorted to.  When the bowels become much affected with griping
and diarrhoea, minute portions of calomel in union  with ipecacu-
anna, should be administered three or four times during the day,
with an occasional dose  of castor oil, and a few drops  of lauda-
num in the evening.  The warm bath also, is very useful in such
cases.   When  the eruption is about drying up, and the bowels
have been properly evacuated, mild chalybeate preparations may
be employed with  considerable  benefit.  Bateman recommends
a watery solution of the tartrite of iron for this purpose,  "as
particularly adapted from  its  tasteless quality to the  palates of
children and possessed of more efficacy than vinum ferri." 
INFLAMMATION AND ABSCESS WITHIN THE EAR.     545
CHAPTER XLIII.
        INFLAMMATION AND ABSCESS WITHIN THE EAR.

  Infants are sometimes affected with inflammation, terminating
often in abscess within the ear, which as they can give no distinct
account of their sensations, is apt to be mistaken  for some other
painful  affection, and is consequently often either entirely neg-
lected or mismanaged.  Children affected  in  this way are, at
times, extremely restless, leaning the head to one side, or moving
it from side  to side, with frequent spells of vehement and unap-
peasable crying, and a countenance expressive of great suffering.
At night the child is apt to awake and cry  violently for some
time, after  which it sinks into a  sound and quiet sleep,  "from
which it will, probably, be roused  by renewed torture."   There
is seldom any distinct febrile  irritation connected with this pain-
ful  affection;  and  it is on this  account,  probably, that these
distressing  pains, were formerly generally regarded  as of  a
spasmodic character.  This affection may be  distinguished from
colic, for which  it is frequently mistaken, by the paroxysms of
suffering being free from the agitation and retraction of the infe-
rior extremities, so constantly observed in severe abdominal pains.
The hands and feet too are warm, which is seldom the case in colic.
Dr. Dewees observes,  "that we have always reason to  suspect
this pain to arise from an abscess  forming  in the ear, when the
child throws its head backwards and forward, and indeed in all
directions during the paroxysm of pain." One of the  most  certain
indications, however of this affection, is obtained by pressing with
the point of a finger, "against the lower portion of  the external
meatus."  If the child shrinks and cries  when  pressure is thus
made and the symptoms already mentioned are present, there can
be little if any doubt, that an abscess is forming in the ear. Chil-
 dren affected in  this way, seldom rest easy, when lying on the af-
                             4 A              ^ • 
546     INFLAMMATION AND ABSCESS WITHIN THE EAR.
fected side.   In some instances, after the abscess  has made con-
siderable progress, it may be seen by looking into the ear.
  There can be no doubt however, that extremely violent pains
within the ears, often occur, without either inflammation or ab-
scess.  We  frequently meet with  cases, which come on sud-
denly, and after having continued  for some time, with occasional
intermissions, as suddenly disappear, without any further inconve-
nience.   The pain in cases of  this kind is usually extremely in-
tense, and may in  general be speedily relieved by dropping some
laudanum into the ear, or taking a full dose internally, and plac-
ing the feet in warm water.  When the pain depends on inflam-
mation or abscess, laudanum procures  but slight  and temporary
relief.
   When the formation of the abscess is not prevented by prompt
and appropriate remedies,  it continues to torture the little pa-
tient, until it bursts and the mattter issues  from the ear.   When
this occurs,  all the pains suddenly subside, and the child becomes
perfectly  easy.  Occasionally, however, when the first abscess
has discharged its contents, a second one commences and passes
through the  same painful course,  and thus a third  and even a
fourth abscess may occur and protract the sufferings of the child,
with  occasional intermissions,  for several months.  In  some in-
stances  serious and irremediable injury is  done to the organ of
hearing.  "The small bones of the ear become detached by sup-
puration, and are discharged with the pus which constantly flows
from  the external  orifice of the organ."  The pus in these cases
generally acquires an acrid, thin, and  extremely offensive char-
acter, inflaming and excoriating the  external parts with which it
comes in contact.  Fortunately, however,  these severe and dis-
tressing  cases are by no means common.  In  a great majority
of instances the abscess heals without much difficulty, and leaves
the ear in a perfectly healthy condition.  Not unfrequently the
posterior part of the meatus becomes excoriated, or affected with
chronic superficial ulceration, without any serious injury to the or-
gan of hearing; and these  cases are attended  with  a thin sero-
purulent discharge from the ear, which often continues for seveal
years.  These chronic discharges from the ear, are almost always 
         INFLAMMATION AND ABSCESS WITHIN THE EAR.     547
attended  with dullness  of hearing, and in some  instances this
organ never regains its original acuteness.
  When there is reason to believe that the sufferings of the child
arise  from inflammation and the formation of an abscess in the
ear, five or six leeches, if practicable, should be applied behind
the ears or on the mastoid  region.  A few  drops of laudanum
should be instilled into the ear, and an active purgative of calo-
mel and rhubarb administered.  The  application  of a  blister
under or behind the ear, is however, in general more effectual in
arresting the progress of the complaint than any other means we
possess.  By the prompt employment of these remedies, when
applied before suppuration  has commenced, we may in general,
remove the complaint  without much  difficulty;  "but unfortu-
nately the  time for useful exertion is almost always lost, by a trial
of  temporizing applications,  and  we have but too often  the
mortification to witness only the discharge from the ear."
  When the disease has advanced to this stage, we must endeavor
to  promote  the healing of  the  abscess, and  to   prevent it
from  degenerating  into a chronic  discharging   ulcer.  For
this purpose, it is of great importance  to keep the  affected parts
as  clean as  possible, by repeatedly throwing warm milk and
water  into the ear  with a small syringe.   If, after these mild
injections  have been  used  for several days, the discharge from
the ear continues,  a weak infusion of peruvian bark, or warm
water mixed with tincture of myrrh, (in the proportion of twenty
drops of the latter, to half an ounce  of the former) should  be
thrown into the canal three  or  four times daily, immediately after
the secretions have been washed away with the milk  and  water
injections.   Dr. Dewees recommends, for this purpose, a mixture
of lime water and milk, with a small  portion of the tincture  of
myrrh.*   " This mixture should be prepared only as it is wanted,
and thrown into the ear four or five times a day."   In cases of  an
obstinate character,  where there is   a  constant discharge  o
offensive matter  from the ear, without any  particular pain  or
uneasiness from the affection,  a weak solution of the nitrate of

  * Lime water and milk, of each two tea spoonfuls; tincture of myrrh, twenty drops.
Mix. 
548     INFLAMMATION AND ABSCESS WITHIN THE EAR.
silver,  as  recommended by Curtis, is  frequently very beneficial
In four or five instances of this kind I have employed this solution
with complete success.  Four grains to an ounce of water forms
a  solution of proper strength  for  this  purpose.  In  obstinate
chronic purulent discharges from the ears, Buchanan asserts that
he has used a weak mixture of pyroligneous acid, as an injection,
"and found it to surpass his most sanguine expectations, in dimin-
ishing  the discharge, and  almost immediately restoring the hear-
ing." He states that he has made repeated trials of this injection,
and  almost uniformly with entire success.   "I may  venture to
say," he continues, " that a more valuable medicine than pyrolig-
neous acid, has not been  introduced into'acoustic surgery either
in this  or the last century."  It may be used in children according
to the  following formula:
                    R acid, pyrolign. 3'«
                      Aq. distillat.  gvi.
                       Ft. injectio.
The mode of using it, is first to wash out the meatus, with tepid
water, and then  to inject the mixture " so as to be  directly
applied-to the abraed or ulcerated surface."
  The insertion of an  issue in the arm, or on the back of the
neck, has been known  to arrest the progress  of  this affection;
and  Dr. Dewees " thinks  he has seen  some advantage derived
from the little patient  wearing a burgundy pitch plaster under
the affected ear."
  The child should be  made to lie on the affected side, when in
bed, in order to prevent an accumulation of the offensive matter
in the bottom of the meatus. 
                     A  TABLE
EXHIBITING THE  DOSES  OF  MEDICINES,
              ACCORDING TO DIFFERENT AGES.
Aloes, soccotrine.........
Antimonial Wine........
Antimonial powder.......
Ammonia  Carbonate, )
  salt of hartshorn   $
Aqua Ammonia, spirit )
  of hartshorn       $
Assafcetida gum.........
Calomel................
Camphor...............
Charcoal powder.........
Cream of tartar..........
Carbonate of Magnesia  ...
Carbonate of potass......
Carolina pink-root, )
  powdered  root   3
Carolina pink-root, infusion
  3ss to one pint of water
Castor oil.................
Chalk, prepared...........
Croton oil................
Dandelion Extract.........
Colomba root,  powder.......
Colocynth, compound >.....
  extract of        3
Corrosive Sublimate, >____
  as an alterative    3
Dewberry root, decoction, )
  3j to one  pint of water  $
Dovers powder...........
Elixir of Vitriol..........•
Emetic tartar, repeated doses
Epsom salts..............
Essence of peppermint......
Ether sulphuric............
              549
Adult Age.
10   to
3ij   to
 6gr.-
 6gr.-
  From
4 to 7 years.
 15
3s
 8
 12
 5   to   3
3j   to   3i
 2gr-   4
 4gr.-   2
10 dr. -    20
10gr.-
10 gr.-
 6gr.-
Bj   to
20
20
10
3j
3j   to  3ss
3j   to   3ij
10gr.-30gr.
3j   -    3ij

3iv  to 3viii
3j   to  3jss
Bj   to   Bij
 1 g<t- to  2 g«
3j   -   3ij
10gr.-30gr
10gr.-20

 igr.-rV

3ij   -   3iv

 8 gr. -   12
10g«-30g«
 2gr.-  3gr.
3j    to  3jss
20 g"--30 g«
20g«.-30g«
5 dr.-   10
  From
3 to 1 years.
 2   to   J
20 dr.-   40
 igr.-   1


 1 dr.-   2
 5gr.-
 5gr-
 2gr-
10 gr.-
Bj   to  3ss
Bj   to   S|i
 5gr-   10

9j   -   Bij

fl
3ss  -   3j
10 gr.-   20
  lg«._   1
9j   to   3j
  5gr-   10
  6gr.-   10
 3gr.-   1
 4gr.-   2
 lgr-   i
10 gr-   4
9 j  to 10 gr.
9j  tolOgr
 5gr.-   2
20 gr-   10

3ij   -  3ss
3ij   -   3j
 6gr.-   3
 ig«-   A
9j   to   Bss
 3gr.-   1
 5gr.-   2
grains.

grains.
grains.

drops.
grains.
grains.
grains.
grains.
3J   ~  3jj
 4gr.-  6
 6g"-15g«
 igr.- lgr.
3ij   -  3ss
 5 gu.-  10
 5g«-  10
3j   to  3ij

 3gr.-   j
 5gtt- 3 g«
 *gr.-  *
3j   -   Bj
 3g»- lg"
 4 g"-  2

47*
grains.


fl.
fl.
gr.
drop.

gr.
gr-

gr-

fl.

gr-
drops.
grain.

drops.
drops. 
A TABLE OF  DOSES OF MEDICINES.
\
•N
Extract of butternut, laxative
------of Belladonna......
------Hyoscyamus, henbane
------of Gentian.........
Adult Age.
20 gr.
 £
 2
 6
 1
 1
-30gr.
to jgr.
tolOgr.
tolOgr.
to 4gr.
to 4gr.
  3jss
12 gr.
Foxglove, digitalis, powder ..
Gamboge—cathartic........
Geranium  root,  Cranesbill \
  root, decoction, 3j  to one y 3ij   -   3iv
  pint of milk or water
Glauber Salts.............3j
Hartshorn Salt............  6 gr.
Hive Syrup, as an emetic
Hoffman's Anodyne........30
Huxham's tincture of bark .. 3j
Iron filings, tonic..........10
Iron, Muriated tincture of... 10 g"'
Iron, Phosphate  of..........20
Iron, Prussiate of..........10
Iron, Tartrate of...........3ss
Iron sulphate..............  ^
Iodine, tincture of— )       i0g«'
  3j to 3j of alcohol  S       I
Ipecacuanha powder........9j
Jalap powder..............9j
                            10
                             2
                            20 gtt.
                            3j
                            3j
                            3j
                            3j
                            3ij
                             igr-
Kino, gum powdered......
Lactucarium—lettuce opium
Laudanum,  tincture  of opium
Lime water.............
Magnesia, calcined.......
--------, carbonate......
Manna.................
Milk of sulphur.........
Morphia................
■-------, sulphate of—the
  same  dose as morphia.
Nitre—Salt-petre.......
Oil of Peppermint.......
Oil of Juniper............
Oil of Turpentine.........
Oil of Wormseed.........
Opium..................
Oxyd of Zinc............
  .  2     550
-40dr
-   3ij
-20gr.
-   20
-   40
-   15
-    3j
-  2gr
-   15

-   3ss
-   3ss
-20gr
-  4gr.
-   40
-   3iv
-   3ij
-   3ij
-   3i
-   3iij
10 gr.
10 g"
10 g«
20 g«.

 lgr.
 2
-    30
-    20
-    20
-   100

-    3
-  6gr.
  From
4 to 7 years.
 6 gr-   15
 8  to   \
 h  " 1 gr-
 lgr.-   5
 J  to   i


3j   -   3ij

3ij   -   3ss
 4   -2gr
10   -15 dr
3ss  -   3j
 5   -10 gr.
     -10 g"
     -   10
20
 5
 5
 4   -
10 gr.-
 i   _   i
 3   -5g-
8 gr.-   12
8gr.-   12
4gr.-   6
\   - lgr-
    -10 g«
    -   3ij
    -   3j
    -   3j
    -  3
    -   3ij
4   - 6gr,
3 g«-   6
3-6
6   -   IS
6 gtt-   1C
i   _   i
ff       IT
i   -   *
  From
3 to 1 years
5gr.-   2
i
2gr,
i
i
5
3ss  -  3ij

3j   -  3ss
grains.
grains.
grain.
gr.
gr.
gr.

fl.
30 g«-
 8   ■
15 dr.-
 3   ■
 4   ■
 3
 3   ■
 6gr.-
J
10
3
5
1
2
2
1
2
2   -   *
 5
 6gr.
 2
 i
 5g"
3j
9j
9j
3j
3ss
3
2
2
5
5g«
 i
TIF
1
S
    3
    2
    1
    i
    2
 ■  3ss
-10 gr.
-10 gr.
"   Bj
"   Bj
gr.
drops.
drops.
fl.
grains.
drops.
grains.
gr-
grains.

drop.

gr.
gr-
grains.
grains.
drops.
fl.
 2
 1
 1
 3
 2
 i
 1
Tfl
gr.
grains.
drops.
drops.
drops.
drops.
grains. 
A TABLE  OF DOSES OF MEDICINES.
Paragoric Elixir.........
Peruvian Bark..........
Pink-root powder........
Quinine................
Rhubarb, powder.........
Snake-root,  Senega, deco-
  tion, 3j to 1 pint of water
Soda, Carbonate of )
Soda bi-carbonate  j
Spirit of Camphor........
Sulphur, Flowers  of......
Sweet Spirit of Nitre.....
Syrup of Squills.........
Syrup of Rhubarb........
Tinct. of Assafoetida.....
----- of Blood-root, >
Adult Age.
  From
4 to 7 years.
  From
3 to 1 years.
 sanguinaria        3
---- of Foxglove.....
---- of Belladonna ...
---- of Lobolia inflata
---- of Peruvian bark
Uva Ursi,—decoction, 3j )
  to one pint of water   j
Wormseed...............
White Vitriol, as  an emetic
3ij
3j
3j
gr.j
3ss

3j

10 gr.
20 gtt
3j
3j
3j
3j
20 g«-
20 g«.

20 g«-
20 g«- -
3j    ■
3j    •
3ij   ■
3ij   -
gr.10-
3iij 3ss  -    3j'3ss  -
 3ijl5gr-  3ss'15gr.-
 3ij9j    -  9ij9j   -
-   5
igr-
          lgr.
 3jl2gr.-   Bj
3ij 3jss  -  3ss
-    9j
-    30
-   3ss
-   3iij
-   3ij
-   3iv
-    40
-    30

-    30
-    30
-   3
-    3ij
-   3i
6gr.-   12
 6g...
9j
9j
9j
3j
10 g«-
 8g»-
 1   _
10 gr.-
3jss  -
9j
10
3j
-   12
-   3j
-   3j
-   3j
-  3ss
-   20
-   15
 6g«-
 5 g«-
Bj   "
BJ   ~
3ss  -
9ij   -
gr.4 -
 6gr.-   3
 5 gtt-   2
Bj   -   10
9j   -   10
Bj   -12 g«t
3j   "   ~
10 g«-   5
 6 g"-   3

 5g«-   2
 4 g«.-   2
9j   -   10
9j   -   12

3ij   ~
         3j
9ij   -   Bj
gr.3-   2
fl.
gr-
grains.
gr-
grains.
fl.

gr-
drops.
grains.
fl.  dps.

fl.
drops.
drops.

drops.
drops.
drops.
drops.
fl.
                          EXPLANATIONS.
  The mark 3 signifies ounce.
             3 ------drachm, or £ of an ounce.
             9j ------scruple, or £ of a drachm.
  The letters ss. signify half;  thus, 3ss, stands for half an ounce; 3ss,
for half a drachm; g<«-  stands  for drops; so  also do the letters, dr.;
fl, signifies fluid;—thus, 3j fl, means one fluid drachm: gr., stands for
grains.
          551 
\ 
INDEX.
Pages.
    35
Artificial Nursing,
Air—the enjoyment  of fresh air by
  infants,     -
Asphyxia of newborn infants,
       how to be treated,
Aphthae,  -      -       -       -
       Treatment,
Aphthae gangrenosa,
Atrophia ablactatorum,
       Treatment,
Ascarides,     -
Acute Bronchitis, -
Arachnitis,    -
       Diagnosis, -
       Prognosis,
       Causes,   -
       Treatment,
Ascites,   -
       Treatment,

                   B
Blood-letting in pregnancy,
Bathing the infant,
Breasts of infants, swelling and inflam-
   mation of,   -
Bilious diarrhoea,  -
Bronchitis Acute,
        Treatment,
Clothing of infants,
Cleanliness, with regard to the infant,
Colastrum, best for purging oflf the me-
  conium,
Coryza of infants,
       Treatment,
Colic,         -
       Causes,   -
       Treatment,
Constipation,     -
Cylous diarrhoea,
Chronic diarrhoea,
Cholera infantum,
       Causes,
       Treatment,
Catarrh,  -      -       "
Catarrhal fever,
       Treatment,
       Congestive,
Cynanche tonsillaris,
       Trachealis,
 51
 78
 79
171
178
185
236
244
267
317
370
375
378
380
383
391
394
 14
 73

 94
224
327
329
Pages.
   344
   353
   354
   356
   365
   367
   417
   489
   492
   498
   499
   525
   Croup,    -
          Prognosis,
          Diagnosis, -
          Treatment,
   Cynanche Laryngea,
          Treatment,
   Chicken pox.
   Convulsions,  -
          Causes,
          Prognosis,
          Treatment,
   Carpo-pedal spasms,   -
          Treatment,        -      -    530
   Chronic Eruptive affections,   -       533
   Crustea Lactea,   -                  534
          Treatment,     -      -       636
          Sore ears.  Excoriations behind
             the ears,     -      -       538
           Strophulus Confertus.   Tooth
             Rash,       -      -       541
           Strophulus Intertinctus.   Red
             Gum,       -      -       542
           Strophulus Volaticus,      -   543

                       D
    Diet proper during pregnancy, -         3
    Dress during pregnancy,   -       -     9
    Dressing the new-born infant,  -        18
    Dress of the infant,        -       -    21
    Dysuria,       ...       115
 21        Treatment,        -       -   116
 72 Dentition,     -       -      -       125
           Causes rendering it difficult,    128
           Morbid sympathetic effects,    129
168        Causes,  sometimes swelling in
169          the hands and feet,  -       130
187        Convulsions from,  -       -   131
189        Cutaneous eruptions,  -       132
193        A remarkable croupy affection, 133
201        Dysuria caused by dentition,    134
230        Management of dentition,     135
236  Diabetes,     -       -      -       145
283        Treatment,        -      -   148
286  Diarrhoea,    -       -      -       211
290        Exciting causes.   -       -   212
318        Faeculent diarrhoea,   -       216
 to.               Treatment,        -   219
320        Bilious diarrhoea,      -       224
322               Treatment,        -   225
339        Mucous diarrhoea,     -       226
344        Cylous diarrhoea,   -      -   230
                              553 
554
INDEX.
D		Pagfs.
Lienteric diarrhoea,	-	232
Treatment, -		- 234
Chronic diarrhoea,	-	236
Treatment, -		- 244
Dropsy in the brain,	-	370
Treatment,		383
E Exercise during pregnancy,	.	9
Exercise of the infant,		43
by carrying,	-	to.
walking,		- 47-55
Enuresis,	-	120
Erysipelas,		- 150
Treatment,	-	152
Incisions through the	affected	
part,	-	160
Exanthematous ophthalmia,		- 274
Epilepsy, Infantile,	-	508
Excoriations behind the ears,		- 538
I
Intestinal Worms,
Infantile epilepsy,
       Treatment,
Inflammation  and abscess  within the
  ear*   -
Pages.
   255
   508
   514
545
Foetus—influence of the mothers ima-
  gination on it,   -
Food, improper, ill effects on the in-
  fant,   -
Food proper for the infant when nursed
  by hand,        -
Faeculent diarrhoea,
Fever, remittent,  -
Fever, catarrhal,
       Treatment,
Fever, congestive catarrhal
Gums, mode of lancing them,
Hydrocephalus,
       Treatment,
 12

 26

 29
216
300
318
320
322
140
370
383
Longing, during pregnancy,
Leading-strings and go-carts,
Lactation, protracted injurious effects
       on the mother,
       injurious effects on the infant,
Lienteric Diairhoea,
Lumbrici,     -
Laryngitis,        ...

                   M
Mothers' conduct during pregnancy,
Moral Influences during pregnancy,
Management of new-born infants,  -
Menses, an objection to nursing,
Mental inquietude, effects on the qual-
        ity  of the milk,        —
Milk, deteriorated by various causes,
 <iy

 65
 68
232
255
365
 1
11
17
34

69
ib.
I
Imagination, mother's influence on the
  faetus,  -      -       -       -
Infants, management immediately af-
  ter birth,
       washing imediately after birth,
       dressing,
Infant's dress, -
       nourishment,
Inflation, artificial, of the infant's lungs, 79
Inflammation of the new-born infant's
  breasts,      -
       and ulceration of the navel,
Jaundice of Infants,   -
       its exciting causes, -
       Treatment,
Incontinence of urine,
        Treatment,
Induration of the cellular membrane,
        Treatment,     t-       -
       by the recurrence of the menses, ib.
       by pregnancy,      -      -    70
Meconium,           -               88
       how to be evacuated,      -    89
Micturition, painful and difficult,       115
Mouth, ulcerations of,     -      -    173
Mumps,       ...       336
Modified Small Pox,      -      -    411
Morbilli.  Measles,   -       -       428
       Symptoms,        -      -    431
       Sequelae,       -      -       435
       Diagnosis, -             -    436
       Prognosis,      -      -        ib.
       Treatment,        -      -    437
                    N
 Nipples, proper attention to them during
       pregnancy,     -      -        16
 New-born infant, washing and dressing, 18
 Nourishment of infants,       -        25
 Nursing.  Causes preventing the  moth-
       er from nursing,
 Nourishment improper, ill effects of, on
       the infant,
 Nurse, character of a good one,
 Nursing, artificial,
 Nurseries, cleanliness of,   -
       regulation  of temperature,
 94
 96
 99
100
104
120
122
162
162
                                      33

                                      26
                                      34
                                      35
                                      56
                                      ib.
Nursery, what is required for a good one, 58
       means of warming nursery,       59

                   O
Ophthalmia,       -       -       -    269
       Treatment,     -      -       271
       Scrophulous,       -       -    274
                   P
Pregnancy, mothers' conduct in,          1
       Blood letting in,   -            14 
INDEX.                                555
       proper dress and exercise in,
       proper diet in,
Pernicious effects of confining  infants
       to close and warm rooms,   -
Purgatives active, improper for evacua-
       ting the meconium,
Pleurisy,
Pages.
     9
52
 89
332
233
336
391
393
394
46:)
471
474
475
477
460
       Treatment,
Parotitis,      ...
Peritonitis,
       Causes,
       Treatment,
Pertussis.   Whooping Cough,  -
       Prognosis, .-
       Cause, -
       Antopsic phenomena,
       Proximate cause,
       Treatment,
                   Q
Quinsy,       -       -       -       339
                   R
Respiration, imperfect,of new-born infant, 80
Retention of  urine in infants,  -       109
Remittent Fever during dentition,  -    300
       Treatment,     -       -       302
Remittent Fever, after dentition,   -    305
       Treatment,     -       -       312
Rubeola,  -       -       -       -    42d
Red Gum,                           542
Sweetmeats, injurious effects of, on in-
    fants,     -
Suckling, protracted injurious effects on
       the mother,
       injurious effects on the infant,
Syncope, of new-born infant,  -
Suppression of urine in  infants,
Swelling in the hands and feet from
       dentition,   -
Skin-bound,    .       -       -
       Treatment,
Scrophulous Ophthalmia,
Swine Pox,
Scarlatina.  Scarlet Fever,
       Anginosa,  -
       Maligna,
              Diagnosis,  -
              Prognosis,
              Sequela,
              Treatment,
              Local Treatment,   -
              Convalescence,  -
Sore Ears,
Strophulus Confertus,  -
Strophulus Intertinctus,
Strophulus Volaticus,  -
   Teething,     -
          Causes rendering it difficult,
          Morbid sympathetic effects,
   Thrush,   -
   Torpor of the bowels,  -
   Tonsillitis,       -
   Tracheitis,    -
   Tooth Rash,     -
                      U
   Ulceration and inflammation of the na-
      vel,    -      -       -      -
          how to be treated,
   Urine, retention of,  in children,
          pain and difficulty in  voiding
             it,
          incontinence of,
    Ulceration of the mouth,
                       V
    Vomiting,       -
    Vaccina, vaccine disease,
          Symptoms and progress,
          Spurious Pock, -
          Diagnosis,
          Remediate treatment,
          Relation with other diseases,
          Origin of vaccination,
          Prophylactic power,
          Manner of vaccinating,
          Character of genuine virus,
          Condition of the  person to be
             vaccinated,
          Test of vaccination,
 40 Varioloid Disease,
          Diagnosis,
 65       Treatment,
 68 Varicella,
 77       Initial stage,
109       Varieties of the eruption,
                  Lenticular,
130               Conoidal,
162     «        Globate, or Swine Pox,
160       Diagnosis,
274       Remediate treatment,
426                   W
443 Washing the new-born infant,
446 Weaning,    -
448       Proper period for,
450       How to be effected,
452       Causes   requiring  premature
454          weaning,
455 Washing and keeping the infant clean,
564       How to be performed,
465 Worms,       ...
538       Species,   -       -      -
541       Causes favoring  their genera-
542          tion,
543
Pages.
   125
   128
   129
   171
   201
   339
   344
   541
Tongue-tie,
92
       Symptoms,
       Treatment,
Whooping Cough,
       Treatment,
 96
 97
109

115
120
183

205
396
399
401
402
403
 ib.
405
 ib.
407
408

409
410
411
416
 ib.
417
424
425
 ib.
 ib.
426
 ib.
427

  18
  61
  62
  63

  64
 72
 73
255
258

206
262
264
469
480 
T.
v