? 4 A • ¦ PRACTICAL TREATISE . ¦ ji ON THB ¦» DISEASES OE CHILDREN: INCLUDING* AN INTRODUCTORY CHAPTER, ON THE MANAGEMENT OF INFANTS IN HEALTH. BY JAMESJTEWART, M.D., A.M., /FT,LOW OF TUB COLLEGE Or PHYSICIANS AND 8VBOEONS, ONE OF THE CONSULTING PHYSICIANS OF THE NORTHEAN DI8FENSABY OF THE CITY OF NEW YORK, LATK PHYSICIAN TO THE OAF HAN ASYLUM, XTC, ETC. Kx toto non sic pueri, ut viri, curftfi debent Celsus, De MedidnA, lib. iii. jfourtb aBUftfon, carefulls SUbfstt. NEW YORK: HARPER & BROTHERS; PUBLISHERS, 1854. Entered, according to Act of Congress, in the year 1843, by James Stewart, In the Clerk's Office of the Southern District of New York. PREFACE TO THE FOURTH EDITION. A demand for a new edition of a work is at once the most gratifying and the most unequivocal evidence that an author can desire of the favorable reception of his production. In complying with it, two important duties devolve upon him, if his work treat of any branch of science. The first is, that it keep pace with the progress and results of scientific investigations which may have occurred from the, time of his previous publication ; the second, that he avail himself of the remarks and suggestions of and by duly considering them in a careful revision of the subject, ascertain whether in his judgment any essential improvement can be made in his treatise. The author of the present work has not been unmindful of these obligations, on presenting another edition to the profession. With respect to the first-mentioned, it has been his endeavor to record every important improvement in both theory and practice; and with reference to the second, the kindness of reviewers has left him but little to accomplish in the way of material alteration. The addition of about sixty pages of new matter, more particularly adapted to- general use, will be a sufficient evidence that he has not been remiss in availing himself of every circumstance which in his estimation could enhance the value of the work. 3 Abingdon Square, January, 1848, PREFACE. The rapid advancement of physical science, in the continually new application of its principles to the necessities of mankind, demands, from time to time, a review of the various subjects which it embraces, and a digest of the most prominent theories, and their practical deductions, which have been elicited by the laborious and enlightened investigations which characterize the present day. In the department of medicine especially, the numerous treatises in its different branches bear evidence of the vast amount of interest felt in the investigations of the numerous facts existing throughout professional records, and in the occasional examination of prevailing doctrines. That branch of medicine which embraces the consideration of children's diseases, has received a full share of the attention of the cultivators of medical sciences, both in Europe and America; and several works, abounding in practical experience on this subject, have issued from the press. It can not, however, be denied, that a treatise, in which the whole subject of disease at the important period of childhood, is presented in a concise form, is now needed ; especially as the actual condition of disordered parts, the result of morbid> action, has of late received more than ordinary attention from the cultivators of pathological anatomy; a new era, it may be said, having commenced in the investigation of the diseases of man during the important period of growth. But it is unfortunate' that many of the industrious cultivators of morbid anatomy have rarely applied their investigations to strictly practical purposes, which should be the object of all medical inquiry. To attempt, therefore, the condensation of existing knowledge from facts, both from his own sources and from the recorded ex- VI PREFACE. perience of others, and thus present, without the detail of cases, a treatise on the affections of children, in which the subject may be considered with a direct practical bearing, is the object of the author in the present essay. In the required investigation, a great many works have been consulted, which it is unnecessary here to enumerate, as references have been made to them throughout these pages. That of Professor Schill on Pathological Semeiology, translated by Spillan, has afforded material assistance on the evidences of existing disease, but from the nature of the subject no reference has been made to this work. For access to many of these works, the author is indebted to Dr. John W. Francis, whose extensive and valuable library, rich in some of the rarest treatises in professional literature and the kindred sciences, was freely placed at his disposal; and it affords him no little gratification to avail himself of the opportunity now presented, to express his sincere acknowledgments for this and many similar acts of friendship. New-York, April, 1841. CONTENTS. Erysipelas, 357 Porrigo Larvalis, %. 355 Impetigo, W. 353 Prurigo, 352 Strophulus, 350 Intertrigo, 349 Vesication, 349 Pernio, 348 Encausis, 344 Alopecia, 343 Crinones, 342 Verrucae, 342 Noevi Materni, 340 Cutaneous Diseases, 331 Diabetes, 325 Retention of Urine, 323 Dysuria, 320 Incontinence of Urine, 317 Rickets, 312 Tabes Mesenterica, 299 Scrofula, 279 Diseases of the Excernent System, 279 Signs of Disease from the Excernent System, 275 System, 268 Excernent System, 267 Peculiarities of the Excernent Hernise, 265 Pe itonitis, 262 Dysentery, 258 Enteritis, 250 Gastritis, : 248 Worms, 232 Constipation, 227 Hepatic Affections, 225 Cholera Infantum, 211 Mixed and Chronic Diarrhoea, 204 Bilious Diarrhoea, 201 Serous Diarrhoea, 199 Feculent Diarrhoea, 194 Diarrhoea, 194 Indigestion, 178 Diseases of the Intestines,.. 177 Digestive System — ?A0K. Diseases of the Stomach and Intestines, 177 Oesophagitis, 175 Parotitis, 174 Cynanche Maligna, ¦ 167 Tonsillitis,... 164' Cynanche Maligna 167 Morbid Dentition, 157 Tongue-Tie, 156 Gangrene of the Mouth.... 154 Stomatitis, 144 Diseases of the Digestive System, 144 Signs of Disease from the Digestive System, 140 System, 132 Digestive System, 132 Peculiarities of the Digestive Natural Functions, 132 Infantile Remittent Fever,. 121 Cyanosis, 118 Diseases of the Circulatory System. 118 Signs of Disease from the Circulatory System, 117 System 112 Circulatory System, 112 Peculiarities of the Circulatory Pertussis 97 Spasmodic Croup, 89 Inflammatory Croup, 68 Croup, 65 Coryza, .' 63 Pleurisy, 60 Pneumonia, 49 Bronchitis 40 Asphyxia, 31 Diseases of the Respiratory System, . % 26 Signs of Disease from the Respiratory System, 26 ry System, 20 Respiratory System, 20 Peculiarities of the Respirato- Vital Functions 20 Preliminary Observations, 1 PAGK. Management ok Children In Health ix VIII CONTENTS PAGE. PACE. Excernent System — Nervous System, 475 Peculiarities of the Nervous Jaundice, 361 Urticaria, 367 System, 475 Lichen, 369 Signs of Diseases from the Nervous System, 479 Roseola, 370 Eczema, 370 Diseases of the Nervous System, 482 Herpes, 372 Convulsions, 482 Purpura, 373 Chorea, 494 Furunculus. 375 Hydrocephalus, 500 Psoriasis, 376 Acute Hydrocephalus, 500 Chronic Hydrocephalus, 523 Porrigo Favosa, 377 Tinea, 378 Hydrencephaloid Disease,... 527 Ecthyma 383 Diseases affecting the appendages of the Nervous System, 529 Pemphigus, 384 Rupia, 384 Ophthalmia, 52° Otitis, 532 Scarlatina, 3S5 Rubeola—Measles, 424 Motor System, 534 Peculiarities of the Motor Sys- Variola—Small-Pox, 427 Varioloid, 439 tem, , 534 Varicella—Chicken-Pox,.... 443 Signs of Disease from the Motor System, 536 Vaccinia—Cow-Pt>x, 445 Vaccination, 451 Diseases of the Motor System,.. 537 Syphilis, 468 Abfcess of the Hip Joint,.... 537 Scabies, 473 Club-Foot, 539 Animal Functions, 475 Note to Vaccination, 541 ON THE SOURCES OF DISEASE II CHILDREN, AND THE MANAGEMENT OF INFANTS IN HEALTH. A knowledge of the origin of the disorders of the system at every period of life, is often the first step in the efforts toward a cure ; while the prevention of disease has been so generally acknowledged as one of the most important modes of managing the physical ills of life, that it has passed into a universally-received proverb. There are peculiarities in children which render this knowledge of great importance with reference to them that do not exist in the adult state. These peculiarities exist in connection with a state of growth: the period of the increase of the body rendering it more liable to derangements than when it has acquired its full development. To this, as the principal cause, must be attributed the greater number of diseases in children ; and a knowledge of the requirements of the child, while in a state of health, is absolutely necessary for the gradual development of all the parts, and the promotion of their healthy action. All the parts of the body are in a comparatively delicate state, and on this account demand a more than usual amount of care in their nurture. The derangements occurring at an early life from the arrest in the development of a part, or the imperfect nourishment occurring in a part during the period of growth, is not unfrequently the cause of ill health in after life. A foundation is here laid for innumerable ills that make life a burden. Who has not seen, as the child advances- in age, the dire effects of an inordinate and premature use of the mental faculties, from the misdirected anxiety of a fond parent to develop the intellect by close application, at the expense of the other parts of the system 1 The muscular system is thereby deprived of its proper exercise and due supply of nervous power for its proper nourishment and development. The consideration of these subjects will be left for their appropriate place; they are merely mentioned as illustrations of the principles here advanced. A more extended discussion of X INFANTS IN HEALTH. this topic will be found in the Preliminary Remarks on the Diseases of Children. For our present purpose, it is sufficient to bear in mind that the great predisposing cause of the numerous diseases of the stake of infancy and childhood is the process of the development of the body, while those which bring them into existence, known as the exciting causes, are a neglect of those laws which the Creator has imposed for the protection of our bodies. A brief view of the requisitions of the system during health will be necessary to a proper understanding of these laws, and a requisite preliminary to the consideration of the diseases themselves; this will be considered under the heads of the duties demanded of the parent before the birth of the child, its clothing, diet, sleep, exercise, &c. DUTIES BEFORE BIRTH. An important period of growth, and which is also a period of the origin of disease, is before birth. Children have been born with the traces of disease upon them which have undei - gone.a spontaneous cure; others, still affected with it in its progress, and others with the permanent effects of previous diseased action, either in the form of imperfect or unequal development during the growth of a part, as hare-lip, or from the permanent contraction of a muscle during a spasm, as clubfoot. It is also during the foetal state that a foundation is laid for the formation of those affections called hereditary. These are often, it is true, beyond our power to prevent; but, in some instances, a careful deportment on the part of the mother will exercise a salutary influence on the offspring. A very important duty, therefore, devolves upon the mother during the period of pregnancy, to protect the young being by every means in her power against all influences which may act unfavorably on it during this stage of imperfect organization. Pregnancy is never a state of disease, but it is evident to every observer that it is so nearly bordering upon it that it might almost be denominated such. There usually exists a state of plethora, greatly disposing the female to disordered action, while a high amount of nervous irritability adds to this morbid condition of the system. One peculiarity of pregnancy is a large amount'of sympathetic influence, or deranged action arising in remote parts from the irritation produced upon the nervous system. The influence of mental emotion of the mother upon the foetus in the womb, although much exaggerated by many ludicrous and absurd stories, does unquestionably exist. Moriceau, a distinguished French writer on obstetrics, relates the case of a lady who, in the eighth month of her pregnancy, was suddenly informed that her husband had been BEFORE BIRTH. XI killed. Premature labor followed, and the child that was born retained during its whole life a trembling precisely like that experienced by the mother when she received the intelligence. Baron Perg, a French military surgeon, mentions a very extraordinary occurrence which happened at the siege of Landau in the year 1763. The arsenal blew up with a terrible explosion, and of ninety-two children born in the district within a few months, sixteen died at the moment of birth, thirtythree died in eight months, eight became idiotic, and died before the age of five years, and two were born with fractures of the bones produced by the convulsive starts of the mothers. There can be no question of the accui-acy of this statement, as it is related by a man of eminence, and of the most undoubted veracity. In all these instances the effect produced is upon the general constitution of the child, without any strange and curious impressions of marks of various warlike instruments, such as the credulity of people would lead us to expect to see. It has been long believed that vivid mental impressions would produce a corresponding effect upon the foetus; and formerly, all deformities with which children were born were referred to the imagination of mothers. It has been asserted that black children have been born of white parents, and white children of black parents, from the effects of the imagination. Some early writer assures us that he saw an infant born entirely covered with hair, caused by the mother having been frightened during her pregnancy by the image of St. John covered with the skin of a wild beast. Now children have been born with hair over the body, but it is simply the continuance of the hair with which a young foetus is often covered, but which, for the most part, gradually drops off some time before birth. Another instance is related of a child being born with the iris of one eye exactly resembling the dial of a watch ; and another, the eye marked withlhe initial letters of Napoleon Bonaparte. Such absurdities are too great for the belief even of the most ignorant. But there are many who believe in the idea of the capability of the imagination to produce marks of various kinds, and the fear of having blemishes of this nature upon their offspring is a source of the greatest distress to many an anxious mother. Every occurrence of an unexpected nature produces in timid and superstitious females a great excitement of the imagination, and apprehensions of the most deplorable consequences often follow the witnessing of such an event. Now, although these particular consequences, corresponding so accurately with the event witnessed, however trifling, can not be allowed to exist, and all fear of 6uch should be dismissed from the mind, yet it is of tha XII INFANTS IN HEALTH. greatest importance to the well-being of the child that the mother's mind be kept quiet and free from all undue agitation. The condition of the mother, both mentally and physically, exerts a powerful influence upon the child, and it becomes her duty to exercise cheerfulness of disposition, and not yield to every foolish whim, which always increases in proportion as it is indulged. As we have seen, the mental alarm of the female here produced very serious consequences upon the offspring; and as every grade of mental emotion, from whatever" source, might reasonably be supposed to produce its amount of effect, it is obvious that every gloomy or painful impression ought to be carefully guarded against, and good humor and equanimity of temper cultivated by all with whom she associates. Grief, or violent fits of passion, have been known to produce very serious effects upon the foetus; and as disease and death have been produced from these causes, as well as from protracted mental despondency, it is evident that the foetus must suffer, depending as it does for its growth upon the mother, whose condition ought at least to be one of unimpaired health, to furnish it with the necessary supply of nourishment. She should occupy her leisure moments not only by healthy and invigorating exercise, but also by intellectual and moral engagements, as the best mode of counteracting any tendency to despondency and anxiety about her situation. It is by no means necessary that the usual cares incident to managing a family should be neglected, aa is too often deemed advisable; it should only be the case where experience has proved it to be detrimental to the health. Such occupations, while they engage the mind, furnish a degree of physical exercise of the most congenial kind. The necessity of breathing pure air is of the greatest importance during pregnancy, and hence the necessity of taking out-door exercise of a moderate kind, but to such an extent as may be warranted by the previous habits and constitution of the individual. All species of violent and agitating exercise, such as produce jolting, should be avoided; and the lifting of heavy weights, and efforts to reach upward in arranging curtains and other furniture, are particularly injurious, and should never form any part of the duties of a pregnant female. As the pregnancy advances, the necessity of carefulness, with reference to undue or excessive exercise, increases, and especially during the latter weeks; premature labor is often excited by undue exertions, and then an infant is born imperfect in its development, and consequently unsound in its constitution. Not only is this the case in one labor, but the habit thus induced will expose the female to abortions afterward, even though the original exciting cause is not present. At all periods of gestation, mod- BEFORE BIRTH. XIII *erate exercise, as walking, or riding in an easy carriage, is particularly useful and advantageous. The diet of the mother is a subject also of great importance, for feeble and badly-developed children are frequently born of mothers who can not furnish them with the adeqir&te nourishment. This does •aot always arise from poverty and an insufficient quantity of food, as is die case among the impoverished class in Europe, but it also arises •from an imperfect digestion, from over-feeding on a variety of articles, whereby the powers of the stomach are perfectly prostrated, and the food being imperfectly digested, furnishes a deficient supply to the mother. The infant suffers the same as if there had been an inadequate quantity of food. There is also another source of danger in the fact that there is a constant tendency to febrile irritation and plethora during a state of pregnancy. When, therefore, the powers of digestion are good, all exciteist-ent from undue irritation from the quality and quantity of food should be carefully avoided. The idea is too prevalent that the condition of a woman having the support of the infant added to her own, requires more than ordinary supply of nourishment. In no instance is there any need of an additional supply of food, unless the general health is much impaired, and an increased appetite and the vigor of the digestive process show that nature demands an additional supply of nourishment. Let not this, however, be a reason for indulging a voracious appetite, and the indulgence in all description of food. It is evident, from the frequent nausea to which women are subject when pregnant, that nature interferes to prevent the reception of an undue quantity of nutriment, proving incontestably that the system, far from needing an additional supply of food at this period, really demands a lessened quantity. That it is beneficial, "is evident from the well-established fact that women troubled with nausea rarely miscarry, while those of plethoric habits are the most liable to such an accident. There exists in many women, while pregnant, a waywardness of appetite, familiarly known by the name of longing. This state of appetite is an evidence of delicate health, and is more likely to arise in those who have indulged the appetite too freely under ordinary occasions, and especially among such as have indulged too freely in indolent habits. Longing invariably increases with its excessive indulgence, and is more an affection of the brain than of the stomach; consequently, it requires for its removal continual occupation of the mind and body, while plain and simple food, such as the stomach can digest, is used for nourishment. In some cases, however, an excessive desire C XIV INFANTS IN HEALTH. for unusual food may be temporarily indulged in a cautious way, while the simple means of cure above mentioned are persisted in. The desire for stimulating cordials is often very great in the early period of pregnancy, arising from the sinking sensation which is experienced in the stomach, affrl which is readily relieved by some stimulant. The relief experienced is, however, but transitory, while the desire for additional stimulation increases with its use. Besides the bad consequences to the individual from this habit, the offspring invariably suffers. Children born of mothers who have indulged even to a moderate extent in the use of alcoholic stimulants, are always more or less feeble and sickly from birth ; and, in general, those of intemperate mothers are short-lived. If there is any condition of life in which " total abstinence" is needed, it is during the period of gestation ; for whatever temporary relief the woman experiences from the use of small quantities of these stimulants, the permanent effects both on the mother and her offspring are fraught with irremediable mischief. With reference to the use of coffee and tea, except in decidedly nervous constitutions, they can scarcely do any injury unless made strong. Green tea, when strong, is particularly injurious to a morbidly-irritable constitution. Black tea should in all cases be substituted. Cocoa or chocolate, deprived of its oily ingredients, forms a very excellent beverage for the evening and morning meal; so, also, does milk and water, especially for those who are excessively susceptible to impressions upon the nervous system. The dress of a female during pregnancy, such as tight lacing, may become also a source of disease to the offspring. It scarcely needs any reference to this subject to satisfy any one of the obvious impropriety and injury that this must occasion both to the* mother and child. The compression of the abdomen is directly contrary to the order of nature at this period. Besides the disturbance occasioned the mother by producing disorders of the lower stomach and bowels, piles, &c, the foetus is thus deprived of its proper nourishment by the arrest of the circulation, and children who have been thus subjected to this unnatural pressure are remarkably delicate and imperfectly developed. And our experience has shown that the pressure from dress has produced such a debility of the parts engaged in parturition, that the labor is always rendered more or less tedious. It is a subject of congratulation that there is not at this time so much cause for cautioning females on this point as formerly; the repeated reference to the evil effects of this species of dressing by physicians has had a highly salutary effect, and there is some hope that ere long the unnatural and preposterous habit of tight lacing will only exist, like that of the swaddling clothes of infants, as a matter curious in the history of the past. FOOD. XV FOOD. The use of proper nourishment in the infant is of the greatest importance ; and to the neglect of confining it to that which nature has provided maybe attributed not only most of the disoi'ders which affect infancy, but also many of the chronic diseases which render life a burden throughout its whole existence. The period of infancy presents to our attention circumstances in connection with diet which have no parallel at any other time of life. The desire for food is frequent; all the actions of the system proceed with great vigor at this period devoted to growth; wherein it differs from the adult state, as in the latter the action of vitality is comprised in preserving and restoring the body, while in the former is added that of developing the body. Growth is much greater during the first year, and the constant desire for food during that period is a circumstance of common observation. In young infants the whole time is occupied with receiving nourishment and in repose. It is remarkable that the food of all animals, in their earliest period of existence, is derived from animal substances, even in those which afterward subsist upon vegetable grains; the chick, even after being hatched, uses part of the egg for nourishment. Man, after infancy, obtains his nourishment from both animal and vegetable substances; and the great variety of articles of food makes a curious exhibition of his omnivorous nature, the effect of custom, climate, religion, &c. The carrfivorous propensities of the people at the extreme north, with their feasts of whale blubber, and the Indian Brahmin, with his meal of rice; the cannibal of the South Pacific Ocean ; and the luxurious tables prepared by the most scientific French cuisinier for the civilized convivialist; the oak-bark bread of one nation; the flesh feast furnished by dogs, rats, and mice of another; or snakes, lizardsrcaterpillars, locusts, worms, and other reptiles of the African negro; and even the meal of clay used by the Otomacs, certainly present a wide variety in the articles used for sustenance, without considering the minutiae of our daily food, to prove that man is omnivorous. But under all circumstances of climate, whether in the frozen regions of the north or under the burning sun of the tropics ; of superstitious customs or savage barbarity ; whatever be the circumstances influencing the character of man's diet, there is for infancy but one kind of food, and that of an animal nature. Milk is his sole article of sustenance until the time when a change in his system takes place; when a new arrangement of his or ganization requires him to seek his food among more varied substances. It must be, therefore, a highly reprehensible practice to feed infants- XVI INFANTS IN HEALTH. with articles to which their digestive organs are in nowise adapted; and nothing can be more absurd than to feed the infant immediately after birth either with thin gruel, or milk and water in which pulverized crackers have been diffused, under the erroneous idea that it needs instant nourishment. That this idea is erroneous, is evident from the fact that the stomach and bowels of the infant are filled with an abundance of a dark-colored mucus, which must first be removed before any digestion can take place. It is also remarkable that the first milk is always purgative; and there can exist no reason for the early administration of any medicine, as is also too often a course of practice. The use of farinaceous articles of food in the young infant is the principal source of the various affections attendant upon indigestion, and which will be more fully considered under the head of Indigestion of Infants, Jaundice, and other affections of the digestive organs. The simple rule for nourishing an infant is to confine it to the breast until the* teeth appear; until this period no other kind of nourishment should be allowed, as the teeth indicate that an alteration has occurred in the system requiring some change in diet. At this period a little change may be made by adding some thinly-prepared arrow-root, or a small quantity of barley-water, or a mixture composed of equal quantities of cow's milk and water, and thus by degrees accustom the child to a little additional and varied food. It being evident that the mother's milk is the only nourishment needed by the infant, it is of some importance that its use should be suitably regulated. It is not an infallible sign that when a child cries it is hungry, and that it must always be put to the breast. An infant will cry from anj cause that will produce pain or uneasiness; yet in a young infant, as the principal want is hunger, uneasiness is more frequently expressed from this want; it is thus that it is so generally regarded as indicating the necessity of food. The principle to be adopted in supplying nourishment to the young child i« according to its actual need. During the first few days of existence, it should be nursed immediately upon awakening from sleep; and, as it grows older, a little time should be allowed after sleep, and the interval gradually increased ; never allowing it to be less than two hours and a half. There is, however, some difference in the requirements of children, and no great error can arise if the infant seeks the breast with an eagerness which shows an instinctive appetite for nourishment, and not a restlessness arising from mere wantonness. The cravings of appetite, as a general rule, may be safely followed; while, at FOOD. XVII the same time, great care is needed to distinguish a morbid and capricious appetite arising from too great indulgence. As an infant needs much more frequent feeding than a child, it is necessary to furnish nourishment at night as well as by day, but not so often. A little care in the management, in the regulation of the time of feeding the infant, will prevent a great deal of trouble. In the early period of an infant's life, it may be put to the breast three times during the night; afterward, late at night and early in the morning will be sufficient. Under all circumstances, and from the earliest infancy, it should be the endeavor of the nurse to observe, as far as practicable, regular intervals in the giving of nourishment; a habit which can as well be established as the opposite one of irregularity and uncertainty. On the subject of selecting a nurse, weaning, &c, full "directions will be given when treating of the subject of Infantile Indigestion. We have seen that the use of appropriate food is of great consequence, in a state of health, to the tender infant, for whom a bland and unirritating substance is so abundantly provided. If it is of importance to confine the infant to a simple article of nourishment in health, of how much greater consequence is it to preserve a similar simplicity in diet when the body is contending with the derangements of disease, when the disorder of the system materially interferes with the proper discharge of the functions of life. The greater or less change in the appetite for food, or its entire absence, which occur in every disease, at once points out that an important change has occurred in the functions of the organs destined to supply the daily waste of the body. The natural instinct of man leads him to make some alteration in his diet when sick, and the experience of all ages proves the benefits of such a measure, when judiciously adopted. The establishment of a well-regulated diet is the chief resort of designing impostors in the management of chronic diseases, and which it is st5 difficult to enforce. The physician can not, perhaps, say that certain enumerated articles of diet are incompatible with the medicine he is giving, for that may not be the truth; he commonly directs his patient to follow a certain course of diet in connection with the medicine as necessary for his cure, and which the patient will follow just so long as he is inclined to do, and no longer; but if he can be made to believe that, while he is taking certain kinds of medicine, a list of articles with which he is furnished is little less than poison, it is easily conceived with what care he will unwittingly carry out the views of his medical attendant. Few persons are aware of the great variety of food that is taken in the course of a day; let any one enumerate all that is usually consumed, and he will be at once convinced that a very important change must be ef« XVIII INFANTS IN HEALTH. fected in some chronic diseases by a reduction in the number of articles. In diseases of an acute character there is but little danger of a transgression of the rules imposed; for the appetite for food, especially for that of a solid kind, is altogether absent. Of much more importance is the subject of diet under those circumstances where the period of life and disease unite to impart a peculiarity requiring a closer attention to diet. Nature having provided but one kind of food for the infant, a sudden change to substances essentially different in their nature must be injurious, to a greater or less extent; this is a natural and direct inference from the facts already stated. In adults, where every species of food is used, an entire change, and a restriction to one coui'se of diet, are always productive of important effects upon the general system ; and where a scarcity of food has compelled large numbers of men to alter their food, and suddenly to adopt entirely different substances from what they were accustomed to eat —as was the case in some parts of France in the year 1817, when a failure of the crops obliged the inhabitants to submit to great transition, and to feed upon whatever vegetables could be found—extensive disease and serious permanent effects are the results. The influence of an entire alteration of food, from its powerful effects upon the system, causes it to be regarded as a measure of great value in the treatment of many diseases, and the change to vegetable food is not unfrequently an important remedial measure. In the adult such a change is but the restriction of him to a class of substances that is natural to him, and which he can easily assimilate, and therefore does no violence to his physical nature. In the infant, on the contrary, the adoption of a vegetable diet is actually contrary to the arrangement of his digestive organs, and to the provision which is naturally made for his daily sustenance ; and, in the diseases of the stomach and bowels, must, from the extra demand made upon them to assimilate substances foreign to their nature, add to the existing derangement. Acidity, flatulency, griping, diarrhea, and other symptoms of indigestion, are of very common occurrence in young infants; and indigestion is the most ordinary affection at that early period, showing how easily their digestion can be impaired. A very obstinate disease will sometimes arise in infants about the time of weaning, and particularly if the change from the bland food furnished by the mother be sudden; hence the care usually taken to accustom the infant to a different species of food, by commencing feeding it some time before this period, and thus gradually accustom it to the necessary alteration of diet. If this precaution is necessary to prevent injury where nature indicates that a different FOOD. XIX kind of food is required, how much more is it needed where greater injury is likely to arise on a sudden change at a period when there is no such natural indication, and which it is so common a practice to disregard upon the invasion of any affection of the bowels ? Immediately upon the appearance of these, arrow-root, tapioca, or sago, formed into jelly, rice, or barley-water, is given, from the supposed bland and soothing qualities of these various articles, which it is supposed render them peculiarly applicable to the inflamed surfaces of the part affected. Such is, undoubtedly, the case in the majority of instances in childhood and in adult age; but in infancy this course is followed by no other than an injurious effect. I have watched carefully the influence of these substances for some years past, and am satisfied that the additional labor the digestive organs have to perform in their attempts to assimilate an unnatural food greatly aggravates the disorder of the bowels; and if they should fail in digesting the entire quantity, the remainder must be a foreign substance to the bowels, and thereby become an additional source of irritation. Vegetable food requires for its digestion more time and more energy of the digestive organs than animal food; flatulency and acidity are more frequent upon its use. Under ordinary circumstances, starchy nourishment, such as arrow-root, passes more quickly through the intestines than animal food. It very often swells and undergoes some change without being digested, giving rise to the existence of gas, either in the bowels or stomach, and, even when perfectly digested, hunger returns very quickly whenever the person is kept exclusively upon it. Some kinds of food are much more difficult to digest than others; and although there are a variety of circumstances in the individual which influence the alteration of sustenance taken into the stomach, yet the digestibility of food is very often affected by circumstances relating to the food itself. Thus oils and fats are slow of digestion, as is well known to most invalids ; s©, also, vegetable substances exhibit this indigestibility, in a greater or less degree, when in a crude or raw state, or when in any artificial condition. If these effects are produced in the adult, for the reasons already mentioned, it is much more the case in the infant; and many instances of the obstinate perseverance of disease of these parts may be referred to the injudicious system of feeding during its prevalence. It is a rare event to have the secrets of the digestive process revealed, and subjected to the test of actual experiment during life or after death. The former, however, has been exhibited to us in the case of an adult, by Dr. Beaumont, and the latter, in the case of children, by M. Natalis Gluillot, of Paris. It is the custom at the Parisian hospitals and similar institutions, whenever an infant is sick, to withdraw it from XX INFANTS IN HEALTH. the breast, and to substitute for the milk some farinaceous substance* made fluid by boiling; arrow-root, gummed rice-water, or a thickened preparation of rice, called cream of rice, and other preparations of a similar nature forming the diet of the sick infant. In the reported cases of the Foundling Hospital, and those for the reception of sick children, prescriptions of this nature form a very important part of the treatment. The mortality in the French hospitals is very great, and opportunities are thus constantly afforded for examination, in such numbers as to establish to a certainty almost any fact which requires the. proof of anatomical demonstration. The attention of M. Guillot being directed to the changes which the food given to children underwent, and to the excessive mortality among them, he instituted a series of investigations in a number of cases of death, with special reference to the state of the contents of the bowels. He was struck with the uniform similarity, a jelly-like substance being present in the bowels, and, in some instances, lining all the bowels. This was subjected to proper chemical tests, and proved to be pure starch. Here we have a direct proof of the deficiency of the digesting power ; the articles given for food had passed through the length of the intestines, and had undergone very little change, and could only act as foreign and irritating substances. The almost entire suspension of the digestive process might, indeed, have occurred upon the use of any description of food; but when it is considered that a sudden change is usually attended with injury, even in the adult; that vegetable substances are, under ordinary circumstances, more difficult to digest than, animal; that the natural food of an infant is entirely dissimilar in its nature to what was at once substituted in the instances above mentioned, we might very reasonably expect to find a suspension of the digestive powers a very serious aggravation of disease, and the results already stated. From all these facts, it is evidently most rational to preserve as much uniformity in the diet as the nature of the case and attending circumstances will admit. If in health, when the digestion is unimpaired, as we have seen, food of an animal nature is the proper kind for an infant,, in disease there can scarcely be any alteration to food of an entirely different kind without incurring some risk. It is not my intention to assert that no alteration whatever is to be adopted, and because one kind of food is provided for the infant, that it would be hazardous to depart from it under any circumstances; such a course would be to discard all sound theory, to abandon all attempts at controlling disease, and, if fully carried out, would reach even to the administration of medicine itself. While we avail ourselves of the plain suggestions of science, and the- FOOD. XXI accumulated experience of ages, let us so adapt them to the peculiar condition of a class of individuals as not to do a positive injury by their injudicious and indiscriminate application. The aged, the robust, the toil-worn laborer, the inhabitant of the city or of the country, the delicate female and the tender infant, all demand some modification in the application of the same universally admitted principles of medicine. In the case of infants, we can, without removing them entirely from the breast, avail ourselves of the mild and un irritative effects of substances of the same nature as that upon which the infant feeds. One principal reason given for the adoption of vegetable mucilage, such as infusion of flax-seed, arrow-root, etc., is, that it is a soft and soothing application to the tender and inflamed mucous surface. Now if the same object can be attained by any substance that possesses the same bland qualities, and is also of the same nature as the infant's food, there will be no necessity for resorting to substances possessing such highly undigestiblequalities as those of a vegetable nature. It is not that we may alter the diet from milk; but to select from some simple elementary substances, which it is deemed advisable to employ as medicinal agents, that which, from its essential composition, will be found more nearly allied to the nourishment which nature so abundantly supplies, and thus do no violence to the physical constitution. Such a substance is found in what is called gelatin, an article soluble in water, and forms with it a jelly. There are different species of gelatin obtained from different parts of the animal, differing somewhat from each other, but agreeing in their general character. The gelatinous solution which constitutes a considerable portion of soups,, hashes, and stews is by no means easy of digestion, having been altered in its character by a high degree of heat, and being combined with other articles, which make it very difficult of digestion. But this is not the case with the purest gelatinous food, such_as calf's-foot jelly r or jelly made from isinglass. These articles rarely disagree with the stomach of the most fastidious dyspeptics, if they are good and freshprepared ; and where there is any inflammation of the mucous membrane of the stomach, when arrow-root and other vegetable jellies produce pain" and flatulency, I have found this animal jelly to remain and to be easily digested. The object in giving gelatinous food to infants is not to supply an amount of nourishing matter, but to present to the surface of the stomach something which is in accordance with the demands of nature, and which, instead of exciting that organ to expel it as an unsuitable substance, will promote a healthy action in it by being speedily digested. The most convenient way to obtain animal jelly is by using isin- XXII INFANTS IN HEALTH. glass, which contains seventy-five to ninety per cent, of gelatin, and its use will be the best method of attaining the desired object in the treatment of the diseases of the bowels of infants. Another article or appropriate food for young infants is albumen, of which the white of the egg consists; this, whipped up into a froth and sweetened with white sugar, is an excellent article of diet for the sick infant. For some years past, it has been my practice to recommend a thin mucilage, or jelly made from isinglass, in the treatment of the affections referred to, when a soothing and unirritating food is indicated, in preference to the use of arrow-root, and with so much uniform advantage, that I have been fully satisfied of its peculiar advantage to infants. To give instances, would be to detail almost every case I have been called to attend. It rarely happens that acidity, and other evidences of imperfect digestion, arise to any great extent when this is used ; and from the use of animal jelly, in cases of inflamed stomach and intestines, I have been so satisfied of the advantages therein arising, that nothing could induce me to substitute any other species of food. It has been long the practice to administer to young infants, when laboring under the distressing scourge of cholera infantum, or summer complaint—when prostrated by debility, and attenuated by protracted suffering—various stimulating articles, such as the juice of clams and oysters, chicken water, or a piece of boiled ham, from repeatedly witnessing their beneficial effects. It is surprising with what avidity the little sufferer will seize and relish a piece of fat pork, when every other species of food is rejected. This instinct, experience teaches us, may be gratified not only with safety, but with actual benefit to the child. CLOTHING. In nothing has the adaptation of the necessities of the child to the physical laws of the system been made more evident than the improvements in clothing. Formerly it was universally the custom, and it still is in some parts of continental Europe, to swaddle the infant in a succession of bandages, or rollers, to such an extent as entirely to prevent the use of its limbs. This custom is happily now abandoned among most civilized people. There needs not, therefore, any elaborate direction for the clothing of infants, other than that the dress ought to be so arranged as not only to permit of the free motion of the limbs, but also those of the chest and abdomen. The latter, especially, requires the most attention, from the fact that many nurses apply the flannel bandage required by the infant at its birth with too much tightness, apprehending the protrusion of the intestine through the opening at the navel. A flannel roller in winter, and one of soft muslin or linen during the heat CLOTHING. XXIII of summer, is needed both for a suitable support to the navel, and also for warmth. Great care, however, should be taken not to apply it with such a degree of force as to impede respiration, which it will do when applied to the bowels, by preventing the descent of the diaphragm. Undue pressure, also, becomes a source of indigestion, by mechanically preventing the natural movements of the intestines. In health there is constantly a gentle, undulatory movement of the bowels from above downward, whereby their contents are urged forward toward the natural passage; an arrest of this movement by tight bandaging, it is obvious, must very essentially interfere with the proper action of the bowels. In the adult, it is very common to find dyspeptics with the muscles of the abdomen drawn tight, and thus mechanically binding the intestine down, a.3 it were, and preventing their natural move - ments. The same will occur in infants whenever pressure is made ar tificially by a roller, which is applied with such force as to destroy the natural rotundity of the abdomen. In all feeble infants the material next to the skin should in every instance be of the softest flannel; and in all children this should be used during the winter season. As the supply of animal heat is very small in infancy, it becomes necessary to adapt the clothing to the needs of the child, and in every case to watch carefully any changes of temperature, that the requisite change in the dress may be made; this is especially necessary when infants are taken out for the benefit of the air. It too frequently happens that the body is but partially covered with clothing, the neck, part of the breast, and arms being frequently uncovered. This practice is highly injurious to the young child. Bronchial affections may, for the most part, be referrible to such a practice, as it has been remarked that among those whose custom it is particularly to guard the neck and throat, as among the Germans, croup, and other affections of the airpassages, are comparatively rare. In our country, where there exist great extremes of heat and cold, it also becomes necessary to guard against the effects of excessively hot weather, which are often more injurious than the cold ; these, however, are more liable to occur, by allowing the infant to be too closely covered with bed-clothes during the enervating heat of a summer's night. The child's bed ought to be composed of soft, elastic materials, but never of feathers in such quantities as to allow of its yielding to the pressure of the body, and rising up on each side ; a most debilitating sweat is produced by being thus buried in the bedding. Older children manifest the need they have of the invigorating effects of cool air, while in bed, by their restlessness, and by throwing off the clothes, XXIV INFANTS IN HEALTH. and thereby exposing themselves to changes of temperature which sometimes occur during the night. To obviate this difficulty, it is well to provide them with a night garment, with sleeves and legs, and thus prevent them from being altogether without covering. A very great improvement in the dressing of infants has been in abandoning the use of caps. We scarcely know of a change so decidedly beneficial as this. Many serious affections of infancy have • been caused by habitually keeping the head heated by covering it night and day, and thus causing a continual flow of blood to a part already supplied abundantly, arising from the demands of the brain, which is in a state of more active development during infancy than any other part of the system. THE NURSERY. The great proportion of deaths in the infant population of cities, amounting, according to accurate statistics carefully collected, to three times the number occurring in the country districts, shows the great influence exercised by the qualities of air that is breathed. Impure air affects the young with a power far more injurious than the adult experiences, both in its suddenness and its duration. Convulsions, so common in infants, are often owing to the deteriorated atmosphere they breathe; and, even when they arise from some other evident cause, the state of the atmosphere will be, in truth, the principal acting agent to produce them. The scourge of our summers—cholera infantu —may be given as a familiar illustration of the effects of the malaria of cities on young children. The imperfect carbonization of the blood by the lungs causes a demand upon another part of the syste —the liver—to supply the wants of the system; irregular and deranged actions thus ensue, while the infant is, at the same time, contending with the distresses incident to teething. The importance, therefore, of pure air proves the necessity of selecting, where it can be done, an apartment so situated that it may be easily ventilated, and where it is not exposed to permanent humidity. The nursery ought to be situated in the upper part of the house, and with doors communicating with an adjoining room, that it may be freely ventilated in fine weather by opening the windows and allowing the external air to pass through. It ought, also, to be large, and the ceiling high, otherwise it would be difficult to preserve the air sufficiently pure when the state of the weather will not allow of a free admission of air from without. Care should be taken not to allow too many children, with their attendants, to occupy the same room at night; the air becomes extremely impure where many sleep in the same room. NURSERY. XXV If it were possible, the sleeping apartment should be separate from that occupied by children during the day; if such an arrangement can not be made, the room may be constantly ventilated by removing a pane of glass from the upper part of a sash, and substituting a piece of gauze wire. Another important thing in sleeping apartments to be observed is, never to allow curtains to surround the bed, or any arrangement whereby a constant supply of free air may be kept from the bed. For similar reasons, a low bedstead should never be used which it is customary, during the day, to place beneath another; the accumulations of the contaminated air of the night are thus kept among the bed-clothes, and all the evils of a badly-ventilated apartment experienced even in an otherwise well-regulated nursery. A great amount of injury is inflicted upon cjiildren by occupying the basement story of a house, either as a nurseiy or for an ordinary sitting and eating apartment, in which the children of the family are kept for the most part of the time. In addition to the impossibility of procuring a free current of air in such an apartment, there always efxists a degree of dampness which is more or less injurious to any individual who is constantly exposed to its influence. During the winter it is for the most part kept closed, and is rarely ventilated ; while in the summer a constant humidity exists, made evident by the comparative coolness of the place. The temperature of a nursery is also an important point to be considered. The infant, at birth, has suddenly passed from a temperature of 98°, and possesses but feeble powers of generating heat; it therefore becomes necessary so to regulate the temperature of the room as to furnish for it the requisite amount of heat. For the first few days the temperature ought to about 70°, after which it should be kept at about 65°. . m The mode of warming a nursery is of some importance; and that which secures a good ventilation is decidedly to be preferred. An open grate will do this most effectually; at the same time, there is much danger arising from partial currents of air flowing toward the fire-place. This, however, can be guarded against by covering the crevices in the lower parts of the room, as under the doors, by the use of sand-bags, or listing them. No harm from this cause is likely to occur from these openings in the more elevated parts of the room; and it is much better to permit them to remain unclosed, so as to secure the necessary entrance of fresh air. It is well, in the coldest of weather, to have a large screen placed near the door, to diffuse the large current of air that is admitted whenever the door is opened. XXVI INFANTS IN' HEALTH. To prevent the dreadful accident of the clothes taking fire in older children, a suitable fender of large size ought always to be kept before the fire; and young infants should always be so guarded that they are not exposed to the strong glare of light and the heat from the fire. Inflammation of the eyes, and even blindness, have been produced by a neglect of this precaution. Exercise is essential to health at all periods of life; but in the early infant state it is confined to the movements of the involuntary muscles. The organs of voluntary motion are in an imperfect state of development, and the muscles and bones in a very feeble condition ; hence any premature or unnatural exercise of the limbs will interfere with their proper symmetrical development, and which the feeble action of the muscles is incapable of preventing. In early infancy no attempt should be made to force the action of the voluntary muscles in efforts to make the child support itself by sitting or standing. Exercise at this period should be purely of a passive kind, such as carrying in the arms in a reclining posture,, with a* frequent change of position upon any manifestation of uneasiness. Although exercise in the open air is necessary to health, yet some caution is requisite in exposing the child to the action of the external atmosphere and to the glare of the sunlight; very serious injury having resulted from a want of proper caution upon these points. With respect to exposure to the air, the infant, if born in the spring or summer, may be taken out for a few minutes at the end of a fortnight; a considerable time longer should elapse before it is thus exposed in the winter, and only during mild and pleasant weather. The* exercise of the child should be adapted to the actual development of its strength. During the early perioa of its existence passive exercise is all that is required ; as soon, however, as it manifests a desire to use its limbs, every facility should be afforded for assisting it in the exercise of independent motion; but this should be confined to limiting its movements to its own instincts. The first attempt at locomotion in a child is creeping, and to use the superior extremities a long time before the inferior. By allowing the child thus to follow its. own inclination, we yield to the order of the development of the parts. A child uses the arms much earlier than the legs, because they are much earlier developed for action, and their use in crawling very essentially assists in developing the chest. The pelvis, which is the principal part of support to the body in standing or sitting, remains for a comparatively long time small and contracted; and being at the same time composed of several parts united by cartilage, while the bones THE NURSERY. XXVII themselves are still soft, furnishes a very imperfect support for the weight of the body. From the soft condition of the bones, which causes them to yield easily to a slight pressure, it must be evident that all mechanical contrivances to support the body in assisting it to effect any desired motion are positively injurious. It matters not in which part or by what means the pressure is made, whether by pulling or by the simple weight of the child's body, if it be an habitual, or frequently-recurring local pressure, it will inevitably be followed by a greater or less degree of distortion. A young infant is never carried for any length of time in one position ; its restlessness demands that this be frequently changed, while the change itself becomes a species of exercise for every part of the body, and, indeed, the only one affecting the voluntary muscles of which the infant is capable. Most persons who hive had the care of young children must have noticed the truth of this remark, when, from some infirmity of the attendant, the child has been kept in the arms in such a position as allows of but little liberty in the movements of the limbs. The same result will follow at all periods when the actual development of the parts is disregarded in bringing them into use, and the natural freedom of self-regulating movement is controlled by artificial means. Hence leading strings will compress the ribs or distort the shoulders; supports that maintain the child upon its legs before the bones have strength to keep the body upright, will cause curvatures of these parts; and seats on which the infant is to be frequently suspended, must, for the same reason, distort the pelvis, which, until the eighth or tenth month, is less perfectly formed than any other of the bones; and if this distortion, even to a small extent, continue to adult age, it will be fraught with great evil to the female. On the subject of the sitting posture, generally, it is necessary to remark, that a child should never be compelled to assume it, and that an infant should not be so carried for the first four or five months; for, in addition to the reasons already mentioned, there will be caused in the young infant a great impediment to its respiration by the falling of the head toward one side, and death has even resulted from this sudden accident* After.the fifth month, the power over the muscles of the neck is so great as to enable the child to maintain this posture for a short time without any evil effects. Even after the expiration of this period, for the reasons already mentioned, the child ought not to be allowed to keep the sitting posture only for a few minutes. When the child exhibits a desire to use the limbs, in place of efforts to excite premature attempts at walking or standing, it should be placed upon the floor and allowed to exercise the muscles according to its own XXVIII INFANTS IN HEALTH. inclination. Thus unrestrained, the use of the different muscles will be acquired in proportion to the development of the organization. The sleep of the infant demands a few words. During the first few weeks the infant sleeps nearly the whole time, and little interference is needed except to regulate the conditions under which it should be indulged. The first of these is to provide suitable warmth; this is of great importance, as the infant is incapable of supplying its own heat. It ought, therefore, to be kept for the first month by the side of the mother or nurse, while proper care is taken to prevent the accumulation of bed-clothes over the head of the child; otherwise the access of the external air may be prevented, and the child either suffocated or compelled to breathe a noxious atmosphere. After this period the child may be removed to a separate bed, as it will then be able to*maintain its own heat, and will be more abundantly supplied with pure air; besides, the temptation of frequent nursing will be, in a great measure, removed. The best contrivance for a separate bed for infants is the crib, of the height of the nurse's bed, and placed by its side with a railing moving on hinges. This should be furnished with a mattress of elastic materials sufficiently soft to insure warmth and prevent any undue pressure upon any part; a soft feather-bed is decidedly objectionable, from the constant and debilitating perspiration it induces in infants. TREATISE ON THK DISEASES OF CHILDREN PRELIMINARY OBSERVATIONS. In considering the diseases of children, that view of the subject which is the most natural, and consequently most in accordance with sound philosophy, is that which is in closest connexion with the successive development of the various functions ; for upon the unimpaired discharge of the functions of every organ, the healthy condition of the system, especially in a growing state, absolutely depends. Besides this general consideration of the influence of growth in the successive operation of the assimilating process, and of the gradual development of the animal frame toward that state of perfection necessary for its ultimate adaptation to the sphere in which it was designed by its Creator to move, a more particular attention to the alteration occurring in the minute capillary circulation is necessary, at a period of life when growth forms the most prominent phenomenon. In the organized frame during the period of increase, where the successive formation of parts is so signally controlled by the previous condition of the separate tissue, as well as of the entire body, this investigation into the molecular changes, constituting interstitial growth, becomes necessary, for the proper study both of the healthy and diseased state. This mutual dependance of the various functions of the human frame, and the chain of causes and effects as occurring at all periods of life, have long been the subjects of study: those arising solely from the development of parts during the period of infancy and childhood—the time allotted to the increase of the body—and the effects arising from their arrest or derangement, have received less attention from medical philosophers. That some cause must exist in addition to those to which adults are exposed, to predispose children to disease, and to produce th* great mortality among them, is a self-evident truth. And this cause doubtless has its origin in the process of development, or in the necessarj dependance of successive developments; as the occurrence of a suspension of the growth of a part must, without any other cause, be productive of disordered action, and thus be a source of disease. The excess of vitality, and the consequent redundancy of excitability, is a peculiar condition of the state of infancy and childhood, in close connexion with the development of the whole body, and a fruitful source of disease. 1 2 DISEASES OF CHILDREN. When the effects of growth are better understood—when the labors of the human and comparative physiologist —which have already opened to our view some of the hitherto deeply-hidden mysteries of our physical nature—shall be extended to the investigation of the principles which more immediately direct the development of unformed parts, may we not confidently anticipate the time when the nature of morbid affections in children will become better understood, and more under the control of the physician ? The consideration of these subjects suggests an extensive field for cultivation, the magnitude of which increases with the contemplation of it in all its relations, and the difficulty of its proper study: it is a task for which the author is conscious that his abilities are totally inadequate ; indeed it is one which, in the present state of science, it can scarcely be expected can be presented to the consideration of the physician, as a subject on which to found exclusive principles of practice for the treatment of disease. Although deeply impressed with the importance of this view of the additional causes of children's diseases, he will not, in the following pages, attempt to apply them to the various affections to which children are subject; but will be contented with suggesting, in the systematic arrangement, the broad principle of the successive development of the functions, as the boundaries and landmarks of theii morbid affections, and the process of increased capillary circulation attendant on growth, as the chief predisposing cause of the frequency of disease among them. The division of the subject adopted in this work, is that founded on the functions of the human frame, as the most natural; and the one which is most practically applicable is that proposed by Galen, and which, until the time of Bichat, was the division generally adopted. Bichat arranged the functions into those which relate to the preservation of the individual, and those which relate to the preservation of the species. The former were again subdivided into several minor divisions. Such an arrangement of the functions is inapplicable to the subject here undertaken ; but that proposed in former days is here adopted—a division which is in fact the foundation of the various suggestions of physiologists made in later times. The diseases of children have therefore been arranged under the three divisions of the functions of the human body, which are the most natural in the order of their development, and which, on this account, may become the sources of disease. L The vital functions, or those which are essential to life, and without which animals can not exist; as the circulation and respiration. 2. The natural functions, those which are instrumental in repairing the several losses which the body sustains; as digestion, chylification, and secretion, which may be suspended for a time without destruction of life. 3. The animal 3 PRELIMINARY OBSERVATIONS. functions ; those by the agency of which we hold communication with the surrounding world ; as the motor and nervous systems. Such is the arrangement proposed ; and with this system the whole subject can be properly brought under consideration, in the order presented to us by the successive appearainces and development of the great functions of the human body; commencing with the first in the natural order, that of the simple organic function of circulation, and terminating with the last in the succession, which gives the young being his place in the scale of animals and created intelligences. In considering the various subjects treated of in this work, those phenomena which depend on the derangement of vitality, so liable to occur when this abounds —on the manifestation of disease during life—the disorder of function, and the mutual dependance of the different organs, will be regarded as of importance in considering the pathology and treatment of disease ; and as in many cases preceding ihe sanguineous congestion or disorganization of the solid portions of the body revealed on dissection. How important soever the ultimate effects of deranged action, the destruction of a part exhibited on autopsical examination may be—and none can be more sensible of its importance than the author— it is evident that too much reliance has in some instances been placed on these revelations as the only guide for us in practice, without duly considering that they ought rather to be.regarded.as the effect of previous diseased action. Disorganization of structure is the evidence of the loss of vitality in the affected part; it is the consequence, not the essence of the disease : we should not therefore regard this condition as in every instance giving all the information we need, and as our sole guide in the treatment, but only as a mark of what has pre-existed, and which alone we are to consider as the disease. Anatomical investigations are of great value in detecting the changes which occur from diseased actions in the various tissues—to determine the nature of these alterations and their relations to the symptoms —but are of little use in ascertaining the nature of disease producing these alterations. An exclusive attention to the solids, when investigating disease, and the almost entire predominance given to organic changes, by some cultivators of pathological anatomy, have caused the alterations which occur in the fluids—constituting five sixths of the body of an adult, and inchildren a predominance beyond estimation, while in the early embryo almost its whole substance—to be left altogether out of view ; and although the pathology of the humors may have been in former times carried to an absurd extent, yet it is equally absurd in the present day to pass to the other extreme, and to deny the existence of changes in this portion of the materials of the body, when it is considered that the solids , 4 DISEASES OF CHILDREN. themselves are dependant on the proper proportion of the constituents of the blood for their healthy condition. It might easily be supposed that the complicated nature of this fluid would readily expose it to alterations, and that morbid changes would occur in a rare as in a dense part of the structure ; for the simple consistency of the part can have but little influence on its liability to alteration, except that the harder and more permanent parts of the body would be the least exposed to these alterations. It may not be out of place to refer briefly to a few well-known changes, as the facts they prove have some bearing on the subject under discussion. The blood may be deficient in some of its component parts, or may possess an excess of one or more of its elements ; as the fibrine, albumen, haematosine, or the saline ingredients. The spontaneous separation of the cruror and serum shows at times a difference in its process; the former being firmly coagulated and cupped, and the latter in appearance excessive in quantity. Again, the opposite condition exists, the coagulum less dense, while the serous part is apparently small in quantity. In other instances it exhibits the albumen on the surface of the coagulated mass, which, in connexion with the fibrine, forms the buffy coat. Various other changes may occur, as has been proved by experiments on the lower animals by Gendrin, Dupuytren, Noger, Dupuy, Cruveilhier, Magendie, Andral, and others. Its dissolved condition was long since observed by Sydenham and Huxham,* and more recently by Dr. Stevens.f With regard to the important influence of its coagulability, the experiments of Magendie, contained in his recently published lectures on the blood, give very striking illustrations ;J having demonstrated that this property is an indispensable condition to the free and regular continuance of its movements in the capillary system. Of what inconceivable importance, then, must it be to the growing child, and what a source of disease ? where all depends on the proper proportion of its ingredients! Chemical tests will also detect the occasional alterations of the blood; that drawn from a variolous patient is acid, as is shown by placing a piece of litmus paper in the serum, according to the experiments of Magendie, in the work just mentioned :|| other chymical changes are also given by him. Many diseases which have been considered as new tissues, as medullary sarcoma, melanosis, etc., ought to be regarded, according to the views of Andral, as * On Epidemics, vol. II., p. 68, et seq. f Observations on the Blood, read at the College of Physicians and Surgeons, May 3d, 1830. X Lectures on the blood and its Changes.—Philadelphia edit., p. 12. I Page 20. PRELIMINARY OBSERVATIONS. 5 the effect of altered secretion; for every degeneration of a part, on considering the process of its formation, is but an alteration of the circulatory and secretory process. It is evident, then, that both solids and fluids are affected in diseased action, and the cause must be sought in that peculiar property of organized structures denominated vitality, existing in all parts, on which the growth and maintenance of the body depend. If the healthy increase, and the property of resisting the tendency of all such bodies to decomposition, either in whole or in part, are to be referred to this power, any disturbance of it must be attended with a derangement of the functions of the part, and if continued, with an alteration of structure. So long as the vital property is in normal exercise, so long will the system continue in the healthy discharge of the functions of digestion, nutrition, circulation, etc., the relative actions of deposition and absorption will be maintained, and the health of the individual effectually preserved. As this property is in exercise in all the body, and in every separate portion of it, both solid and fluid, in a manner which may be regarded as in a degree independent, so any particular abnormal alteration of its action must be attended with a corresponding change in the part experiencing these alterations. This will appear more evident when the ordinary manifestations of vitality are considered, and which it is necessary to examine, that the views here suggested as to the commencement and progress of diseased actions, and the important agency of the development of the body in their production, may be the better understood. The idea of life most in accordance with the present advanced state of physiology, the result of continued investigation, and the illustrations which have been afforded by comparative physiology, is not that of an imaginary principle presiding over the whole system, directing and controlling its operations—an idea which was formerly adopted to explain what had eluded the closest researches, by referring the phenomena exhibited by a living body to a separate agent or power—but as one of the essential properties of organization manifested in an assemblage of phenomena, which distinguish the two great classes of the organic kingdom, vegetables and animals, to which alone these phenomena appertain. All organized matter possesses, in its very constitution, certain properties so peculiar in their nature, that upon the application of certain stimuli, those phenomena are produced which are known as vital actions, the effect of properties not superadded after the formation of the organized mass, as formerly understood—an elementary substance controlling the body— but, as is most natural to believe, and the most agreeable to the uniform simplicity observed in works of the Creator, imparted on the original formation of the classes as a part of their constitution : each class mani- 6 DISEASES OF CHILDREN. festing its own peculiar series of phenomena, by which it is distinguished from the other, and both thereby widely separated from the inorganic kingdom; while the analogous action of each tissue in both classes is sufficient to prove the identity of this principle or property of organization. It has been supposed to be a peculiar principle of action, an aura or gas, an abstract power presiding over the body, and known by the names of vital principle, anima, archams, etc., by Aristotle, Van Helmont, Stahl, and others, even of quite recent times, among whom is the physiologist Miiller.* From this it would appear that a controlling anima was supposed to exist in vegetables as well as in animals ; but whatever be the precise nature of the cause, all observation would lead us to the conclusion, that it is not thus that the phenomena of vitality seen in plants are to be explained, but that they arise from an inherent property, common to the whole organic kingdom, distinct from the addition of the nervous system in animals, and from that principle superadded in men, which, ¦while it adds perfection to his organic system, by placing him in the highest part of the scale of animated nature, is, at the same time, the connecting link between him and the incorporeal intelligences of the spiritual world, the perfection of that remarkable gradation which the observing naturalist has traced as pervading the two divisions of the vital kingdom. Of the precise nature of the cause of the phenomena of life, it is impossible for us at any time to have any clear comprehension ; but some knowledge of its general manifestation, and consequently, the nature of its connexion with an organized structure, will be obtained by considering the analogy observable throughout the vegetable and animal world. Under different modifications, vitality exhibits its phenomena in every organ in the vegetable and animal structure; in both, the great agent of nutrition, and in the latter, that also of the functions of relation, by which this class is adapted to the surrounding world in a manner different from the other class, and thus from the assemblage of its manifestations in some sense independent, presents to us at once the general principles from which we may infer that it is the inherent property of the organization. In the propagation of plants and animals, there is an analogy in the process of generation. In both, the first manifestation of vital action is in the germe —a fluid possessing the power of spontaneous life—and the action is that of simple development. As the different parts are successively formed, vitality exhibits itself by phenomena peculiar to the dif- * Elements of Physiology, by J. Miiller, M. D. Translated by Baly, Lond. 1837, p. 28. PRELIMINARY OBSERVATIONS. 7 ferenl parts formed. Circulation, deposition, absorption, contractility, follow each other in both classes, both growing by nourishment absorbed from analogous parts —the plant from the albumen of the cotyledon of the seed; the foetal chick from the vitellus or albumen of the egg. The growth of the foetus bears a close resemblance to the entire vegetable life, from its attachment and dependance on a source exterior to its own body for its entire support, and may in one sense be termed a zoophyte. The young animal, unlike his after mode of existence, obtains his nourishment by absorption, or transmission of the appropriate stimuli for development and support. Plants may be produced by offsets or cut* tings ; in the lower animals, zoophytes and polypes, propagation is effected in the same manner. Growth and nourishment are here produced by the inherent vitality of the separated slip or portion of the plant or animal, entirely distinct from any supposed centre of vitality which exists in the germe or matured structure; the principle of development being excited into activity by the influence of heat, moisture, and perhaps other causes, of which, in our present state of knowledge, we have but a very imperfect idea. r — • Plants, like animals, possess a circulating system; arteries and veins, sap vessels or lacteals, and lymphatics. The arteries arise from the root, and convey nourishment upward; next to these are the veins, which return the elaborated sap from the leaves to the new layer of the liber.* The sap vessels, corresponding to the lacteals in animals, convey the nourishment to the body of the plant as the chylous vessels do from* the intestines of the animal. The lymphatics of the plant are found immediately beneath the cuticle, and from the direction of the valves appear to be intended to pass the fluid in the same direction as the veins. Plants, then, have a double circulation; the arteries and lacteals to convey the sap upward, the veins and lymphatics to pass it in the opposite direction.! Plants also possess, equally with animals, vessels for cutaneous transpirations. Some of them, as the sunflower, Helianthus annuus, give out an enormous quantity of perspirable fluid compared with their bulk. A compound fluid exists in vegetables, corresponding to the blood in animals ; and as the secretion of substances possessing various qualities, from that of a simple article of nourishment to one highly destructive to animal life, occurs in the same plant, so does the blood separate in animals, as in some of the reptile tribe, secretions for nourishment, and a poisonous juice, destructive to the life of animals, for defence. Respiration is a process which is continually taking place in plants as well as in animals : and, in the fungi, almost as actively as in animals. * Smith's Introduction to Botany, p. 56, et seq. t Wildenow's Introduction, p. 236. 8 DISEASES OF CHILDREN. Contractility, on the application of stimuli, is another analogous function existing between vegetables and animals, in neither continuing longer than the existence of vitality. The examples of this contractile irritability in vegetables, corresponding to the irritability of the muscular fibre, are very numerous, and in some instances so allied to sensibility and consciousness, and consequently to the appearance of voluntary power, as to have given rise to the fanciful idea of the existence of a brain and the corresponding passions. Vegetables, in some instances, like some of the insect and reptile tribe, • annually exfoliate their cuticle, and thus give another instance of the analogy of vital action, which, in both classes, thus entirely leaves a portion of the body destitute of this sustaining property of organization. Both plants and animals sustain themselves uninjured under great changes of temperature; and both classes, from the existence of innate warmth, have been known to affect the thermometer. Deciduous plants resist the severity of the winter's cold, and bear removal without being injured. So also, eels, newts, and leeches, have been frozen in ice, torpid, and to appearance dead, and upon thawing the ice were restored. The first-mentioned animals have been conveyed thousands of miles in Russia, and been completely revived after carefully thawing them. Plants have also been found to resist extremes of heat. Flowers flourish in the neighborhood of volcanoes, where the thermometer stands at 210°; and conferva? grow in springs, at a temperature of 212°. Fishes, also, have been seen swimming in water at 158°, while men have often been exposed uninjured to a heat of 264°, and for short periods even higher than 300°. Both animals and vegetables afford instances of their amphibious nature ; the tortoise, eel, etc., among the former, the rush, rice plant, and algae, among the latter. Animation may be suspended in both, often for a surprising length of time, while the animating property continues to preserve the organic frame. This is seen not only in seeds and eggs, but also in the matured structure. The torpidity or hybernation in most vegetables and some animals, shows this suspension from the same cause, and its restoration in both with the return of spring. Mosses and animalculee have been deprived of all appearance of life, on being dried, and kept apparently dead as specimens in cabinets of natural history for years, and then moistened into life and activity. It would be extending these remarks to an unreasonable length, were we to enter into a detail of all the analogies existing in these two classes ; the classical work of Good on the Study of Nature, and the more PRELIMINARY OBSERVATIONS. 9 elaborate and scientific production of Carpenter, may be consulted for further information on this subject.* What are the natural inferences from the analogy thus found to exist throughout the two classes of organized matter ?—An analogy in some instances so close, as to amount to identity of action, rendering it difficult to know whether to consider some genera of plants as animals, partaking, as they do, so much the nature of both, as to have received a name indicating their mutual identity. It is clear that the property which causes the phenomena of life is the same in both, and an inherent part of the organization for developing the structure, and sustaining it against its natural tendency to decomposition —a distinguishing mark of one of the great kingdoms of nature; and that a derangement of this essential property, either directly or indirectly induced, must produce disease. As it appears that vitality is no special controlling agent, a distinct power or essence apart from organization, but a law of its nature, or that plan for its continued action which the Creator has originally given to it, and which is essential to its existence, so it might be expected that vitality would be found as an inherent property in every tissue, organ, and fluid, constituting the organized structure. That vitality is inherent in the tissues, or in a set of organs, appears from various experiments that have been made on animals, and particularly on the muscular fibre, proving it to be independent of the peculiar action of any other part; and it is also proved by the analogous action in vegetables. In animals, until the time of Haller, the nervous system was believed to regulate all the functions of the body, including, of course, the contractile power of the muscles, the actions of which were divided into voluntary and involuntary, a distinction long since made by Willis, Boerhave, and others ; the first-mentioned class taking their power from the cerebellum, while the latter were referred to the cerebellum. The experiments of Haller led him to the belief that there existed in the muscles a property independent of the nervous power, the vis insita or contractility, by which it yielded to the influence of appropriate stimuli : the involuntary muscles to the stimuli of the blood, alimentary substances, etc., and the voluntary muscles to the stimulus of the nervous power, the exciting or suspending of which was the source of action or rest in these muscles. The existence of a power independent of the cerebro-spinal system has been repeatedly proved by the experiments of dividing the nerves going to the muscles, and then stimulating them to contraction ; this contraction has also taken place after the limb has been removed from the body. •Principles of General and Comparative Physiology, by William B. Carpenter, London, 1839. 2 10 DISEASES OF CHILDREN. In recent experiments, Dr. Philip* has proved that the muscular action of the heart, and vessels which carry on the circulation, even in the remotest parts, arise from an inherent power independent of the nervous system, and that the circulation in the capillaries is itself independent. In the muscles of voluntary power, the nervous influence, so far from bestowing excitability, exhausts it, like other stimulants. The muscular power of the stomach and intestines, also, like that of the heart and bloodvessels, resides in themselves ; and they consequently act from their own power, when deprived of the nervous influence. The vessels of secretion, also, have no necessary dependance on the nervous system ; and although the nervous power occasionally influences them, yet these, as well as those of circulation, possess an intrinsic vitality, manifested by their own peculiar phenomena. These facts have a very remarkable analogy exhibited in the contractility of the fibrous tissue in vegetables; a texture which Vauquelin has proved does not exist exclusively in animals, having been also discovered in plants, where no organs for the transmission of nervous power have ever been found. .This contractile power is very great in several plants, the Venus fly-trap, Dioncea rnuscipula, the sensitive plant, Mimosa sensi tiva, and other highly irritable vegetables, furnish remarkable instances, independent of anything like nervous power; for galvanism has been applied in vain to excite contraction of the vegetable fibre in these plants The brain and nervous system in animals are manifestly organs of rela>ion, connecting them more perfectly with the surrounding world, and in .he body being a medium of union between the various parts of the system, by which the mutual dependance of parts is made more subservient to the perfection of organization : they are not therefore to be regarded as the source of vitality, but simply as possessing a vitality of their own, with their own mode of its manifestation. If vitality be a property of organization, it must exist in every part of the organized body, in the fluids as well as the solids ; and experiments prove its existence also in the fluids. The celebrated physiologist, John Hunter, has proved in a number of instances the life of the blood ; making it analogous to the muscles, in possessing the property of contractility on the application of stimuli; this contractility or coagulability is greatly increased where vital action is much exalted, as in fever and inflammatory diseases. It retains also an equality of temperature in every degree of atmospheric cold, while circulating in the body; and even in the state of the germe or ovum, as is seen in the young chick, it resists for a long time a great degree of cold and heat, and the process of decomposition. * An Experimental Inquiry into the Laws of the Vital Functions, by A. P. W Philip, M. D.; London, 1839, pp. 43, 99, 103. 11 PRELIMINARY OBSERVATIONS. The blood, in limbs that have become paralytic, has the power of preserving life when the vital energy has departed from every part. It can, also, by its own inherent power, produce new vessels of every description from its own substance. The blood, also, like the muscular fibre, may by a stroke of lightning be in an instant deprived of its vital properties, and, like the effect of the same agent on muscle, it may be left uncoagulated and uncontracted. Vital actions have been regarded by some, who have repudiated the idea of a controlling power or principle, as nothing more than certain movements of either particles or masses of matter, closely analogous to those in unorganized matter, denominated chymical or mechanical, and which are justly ascribed to the powers resident in these matters causing the phenomena of attraction and repulsion ; similar powers and properties in organized structures being competent, while they are in mutual cooperation, to effect those actions in which life consists, and which of course terminate on the cessation of this co-operation, as the ingredients of a chymical compound cease to be agitated when their affinities are satisfied.* Sucb>a view of it goes further than the present state of science will warrant; and all we at present know of it is, that this remarkable property, so essential to organization, can only be known by its effects. We have seen that its manifestations and results are exhibited with close analogy in vegetables and animals; that upon its normal exercise depend growth, nourishment, and preservation ; and that the organization itself extends and multiplies vitality, so that both life and organization are mu tually dependant, the one of necessity existing with the other. A more perfect knowledge of its nature, in all probability, we will never possess ; and indeed, in the present state of science, there is nothing more known of physical phenomena than their effects, which, from the similarity of their manifestations, their freedom from complication, the definite ideas we form of them from the simplicity of one physical property in many cases, make us contented with observing them in their results, and being satisfied with this amount of our knowledge in reference to them : those which are the product of vital action, being much more multiplied, from the great variety of the organs which exhibit them, so complicated from their connexion with other paris, especially in animals, and, on these accounts, affording us less definite notions, as the results of one power, we naturally feel less satisfied with the knowledge we have of them. As the proper exercise of vitality is necessary to health, so any de- * Rudiments of Physiology, by John Fletcher, M. D. j Edinburgh, 1837. Part V* p. 26. 12 DISEASES OF CHILDREN. rangement of it must be productive of disease ; therefore it is not to be expected that structural alteration must in all cases precede disordered function, as has been asserted by some ; a condition disproved by daily experience, all the phenomena of disease being often, except in the case of physical injury, nothing more, at the commencement, than the evidences of deranged action. That vitality may at once be affected independently of any previous disorder of the organization, appears from a stroke of lightning, or from the effects of prussic acid. It is also well known that an attack of congestive scarlet fever will cause a great loss of vital energy, depriving the heart and blood-vessels of their power to carry on the circulation, tho patient steadily and rapidly parting with vitality, and quickly dying, without the slightest evidence of reaction. These are extreme cases, but are on that account remarkably illustrative of the derangement of vitality being a cause of disease and death. The spontaneous gangrene of a limb, which is its total death, is an instance of the effect of the loss of vital energy in a distinct and separate portion of the body, showing, that as the vitality of the part is in the part itself, so, from a cause for which we can not assign a reason, the cessation of this action will necessarily arrest the process of absorption and secretion, and terminate the sustenance of the part, abandoning it to the operation of those chymical changes to which all animal substances naturally tend, when not under the control of vitality. It is not from this cause alone that diseases may arise ; they may be produced by derangement of structure, as the primary movement affecting the life of the part, as is natural to suppose would be the case when the sustaining power is a property of organization. Contusions, wounds, or fractures, are the most prominent instances of derangement of function from molecular disturbance: the vitality of the part being thus affected, becomes in its turn a cause of irregular action, thus materially affecting the natural progress of nutrition, and the organization experiencing, and, when sufficiently continued, exhibiting, the effects of this morbid influence. Vitality and organization being therefore dependant on each other, whatever deranges the one must necessarily affect the other; each in its turn becoming successively the cause of disease, manifested by various phenomena exhibited according to the different organs or tissues affected, and the stage of the disease. Inflammatory action, structural alterations all disordered action of whatever nature, must be referred in the com mencement to the altered action of the inherent property referred to produced either by a cause affecting it directly or indirectly through the structure. PRELIMINARY OBSERVATIONS. 13 It it be impossible for us to explain in what manner it exists, or what is the nature of its departure from the normal action in the production of disease, or to direct appropriate remedies for the prompt removal of the deranged action, we have no greater amount of ignorance in relation tc this subject, than of the nature of magnetism, and of the variation of the magnetic meridian, or of the means of correcting the deviation; and in the remedies for both aberrations, the analogy still exists, our efforts being rather to counteract by suitable means the effect of these changes, than to attempt to alter their real cause. This law applies to every department of natural science. The tissues or anatomical elements of the organs may be individually diseased, possessing as they do the property of vitality in themselves. The dermoid, osseous, exhalent, absorbent, cellular, and mucous tissues, are those apparently more often diseased than others. The skin, from its complicated structure, and from the facility of observing its changes, affords a familiar illustration of the independent affections to which a tissue is subject. In erythematic inflammation of slight character, the reticulated vascular tigsue is the morbidly affected part, and the only symptoms is a slight itching, and as an ultimate effect, the separation of the cuticle in small scales. The sub-cutaneous cellular tissue may also become the seat of inflammation, producing tumefaction, exhalation of serum, or. secretion of pus. The various forms of eruptive or exanthematous affections have their seat either in layers of the skin, or in the sebaceous and mucous follicles. Whatever be the forms of the disease, they are the effects of a deranged, and generally an exaltation of the organic action of the part, and may occur independently of the action of any other tissue. From the intimate association of one organ and its functions with others, and from the harmony existing throughout the whole frame, a part of the animal system, however small it may be, can rarely be disordered, without producing a deranged action in other parts; no modification can occur without involving in its changes other organs and disordering their functions. These effects may arise from simple mechanical obstruction or contiguous sympathy, from the necessary dependance of the whole system on the proper exercise of the functions of the organs, and from the general sympathy exercised by the organs on each other through the medium of the nervous system. This connexion is more perfect in proportion to the high grade occupied by the animal; in man, therefore, it exists in the highest state of perfection, and arises from the necessity of the actions of the functions to preserve life ; and when all the organs throughout the system act in harmony, a healthy activity is the result. 14 DISEASES OF CHILDREN. It is obvious, therefore, from this mutual dependance, that when a disordered action occurs in one part, others will participate to a greater or less degree in the derangement, whether it be of function or organization ; and when either are affected, the other will participate in the derangement. Respiration gives an instance of the influence of a function on the organization ; for if it be from any cause interrupted or suspended, and the venous blood be no longer changed by the oxygen of the air, every part instantly feels the effect, and of necessity dies; the brain, spinal marrow, and heart, all have their functions arrested, and circulation and consequently nutrition cease, from the defect of the supply of oxygenated blood to the tissues. Upon the integrity also of the digestive function depends the healthy formation of the sanguineous fluid, and consequently the process of the interstitial nutrition, and the proper action of the organization: disease must therefore ensue where so important a function is deranged. When the organization is affected, also, as in the case of injury to the respiratory muscles, or to the portion of nervous system supplying them with the, nervous influence, respiration is necessarily affected. t The connexion of parts from sympathy may be illustrated in irritation of the mucous membrane of the stomach and bowels ; from undigested or acid ingesta, exciting a similar action, or even one of greater severity, in the brain ; convulsions in children not unfrequently arising from this cause, without the existence of any morbid state of the structure ; all the symptoms being speedily removed upon the evacuation of the irritating cause. It is also worthy of remark, that sympathy exists in a greater degree where vitality is in the greatest exercise ; children consequently manifest it in a very marked manner, and in acute diseases, it is also more perfectly developed than in health. From this sketch, vitality is evidently a property peculiar to the organized structure, and as such, its actions are traceable through all living things, from the lowest cryptogamic plant to the highest part of the scale of animal life, as - an independent property of the anatomical elements, possessing throughout an identity which proves it to belong to the remote part of organization where nutrition occurs, and on which the growth and preservation of the body depend. Its manifestations by different phenomena in the different organs and fluids, from which the solids are formed, are presumptive evidences of its inherent, independent nature in each tissue, corroborated by the analogy of the lower animals and vegetables, where separate portions possess the power of separate existence as distinct individuals. The healthy action of each part and 6f all parts, therefore, depends altogether on the integrity of this property ; for without its agency all parts must suffer, and disease and disorgan- 15 PRELIMINARY OBSERVATIONS. ization be the result; being essential to health, wherever it is in any degree affected, disease of greater or less severity must follow. In the adult, the whole operations of vitality may be comprised in the preserving and recuperative processes ; to them are added, in the infant and child, the more active process of development, with all the train of consequences upon its disturbance in any one part or tissue. In the child everything predominates that is connected with organic growth, and of necessity with a redundance of vitality; and on which alone the growth of the body depends. The desire for food is frequent, the digestion rapid, the blood and all the fluids are in great excess ; capillary action, secretion, deposition, and interstitial increase, proceed with great vigor, while the nervous sensibility is in the highest activity. In all parts of the body, therefore, when growing, vitality is in the most powerful exercise ; and, from all the phenomena attendant on growth, the latter differs from inflammatory action only in degree, a condition which may speedily be induced upon any disturbance of the developing process. In the various ways in which vital action may be deranged, whether it be by being suddenly attacked independently of the organization to which it belongs, or secondarily through a disturbance of the minute tissue of the structure, how important does it appear to the growing child, and how fraught with danger to its existence, where this property of the structure is interrupted in its energetic action. ¦ It has been remarked that infants grow more during the first year, the increase becoming less rapid as the child approaches the fourth or fifth year ; and it is well known that during the first-mentioned period, violent disease and sudden mortality more frequently occur than at any other time of life. Here, then, is a direct relation subsisting between the rapid increase of the body, and its tendency to severe, sudden, and fatal disease : the naturally exalted action of the capillaries in developing a part being easily made to pass the boundaries of the healthy process of growth, and become the active agents of inflammation. The obstruction also of one part, and the continued development of another, may give a preponderance to an organ or set of organs, which, although not so violent and fatal as the instance just cited, may yet impart a peculiarity to the body materially affecting the health through after days. The symptoms accompanying the procesf of dentition are a familiar illustration of the influence of the development of a part in producing diseased action. Although a natural and healthy process, yet it is almost always accompanied with an increased* flow of blood to the gums and salivary glands, the former becomes swelled, and the latter are excited to increased activity. In the greatest number of instances, stomatitis to a greater or less degree occurs, and the mouth appears hot and dry, and 16 DISEASES OF CHILDREN. febrile disturbance not unfrequently attends this process; and these derangements are remarkable in proportion to the number of teeth growing at once. Another instance of the effect of development of parts is the disproportion between the rapidity of the eruption of the teeth and the growth of the jaw : the tardy development of the latter uniformly occasioning inflammation. The connexion between teething and disease is one of great importance in the treatment of children during that period; for whatever morbid phenomena may arise, this process invariably adds to the existing excitement, from the great susceptibility of the system at this time. Acute diseases, or simple nervous disturbance, may often be speedily alleviated by removing the irritation of the gums; and a knowledge of the fact of the great derangement produced by the irritation of the protruding teeth, has long enabled the physician to bring a most powerful remedial means to the relief of children suffering from disease during the development of the teeth. The influence of growth has also been remarked in the effect of the pits left in early life after small-pox, whereby the excretory ducts of the skin, of which there are many millions, are obliterated. At the early period of life a serious change occurs in some of the most important functions of the animal economy; for the integrity of the circulation on the surface of the body, which is a very essential process in early life, is materially affected. To this have been referred the diseases of the glands, eyes, eyelids, bones, and other organs, which have been observed to follow small-pox, and to continue, with remarkable obstinacy, until age has in some respect restored the circulation to its proper balance.* Another illustration of the effect of the development of parts in the production of disease, is that afforded by the muciparous follicles of the intestines. Before the period of dentition they are scarcely to be discerned, even on the closest inspection. When in the order of the natural unfolding of the various parts of the infant's frame, those parts which are about to be fitted to the reception of a new kind of food are undergoing the necessary changes, these follicles for the first time show themselves in a state of activity, pouring forth an abundance of their peculiar secretion. Thus far their action is a natural one, and one of health. Should it become excessive, a serous diarrhoea is the consequence, demanding the interference of ftie physician for its removal. This same condition of development of the follicles, when complicated with other derangements of the system, and kept in a state of morbid activity by the continual operation of certain exciting causes, terminates by pro ducing one of the most fatal diseases of our climate, the cholera of infants. •T. Chevalier, London Medical and Physical Journal, August, 1828. PRELIMINARY OBSERVATIONS. 17 The development of the brain also gives another instance of the deranged vital action, at a time when this action is in the greatest excess, causing disease. It is*well known that this organ, although large in size, is very imperfect at the time of birth, consisting merely of a mass almost fluid. It is not complete in its parts until a year or more has elapsed, during which period the vital energy of the part is in great activity, carrying on the process of development. Is it therefore a matter of surprise that infants are so often attacked with convulsions, on the application of any cause which will in any way disorder the all-important action of building up the great source of supply of the stimulus to the muscles ?— irregular and involuntary contraction taking the place of the ordinary effect of a healthy condition of the brain, and the regular transmission of nervous power. Besides these particular evidences of the effects of development, there are others in which an excess of action in one set of organs gives a preponderance of one system over another, and imparts to the child a peculiarity which predisposes it to a certain class of diseases. Thus, where the circulating system is active and vigorous, everything shows great strength, the body receiving a full supply of blood ; nutrition proceeds with great activity, and a strong tendency to inflammatory diseases exists, where this development, or sanguine temperament, occurs. Other children are seen with a sluggish circulation, little activity of the muscular system, and presenting the appearance of greater development and preponderance of the lymphatic system ; and congestions of these organs, and obstructions of the mesenteric glands, are the affections to which such are subject. * It can therefore scarcely be questioned, that parts undergoing development, from the necessity of active nutrition during that process, are exposed to greater danger than those which have attained their proper maturity; and as we have seen that the predisposition to disease is evident in particular organs, which give unequivocal proof of their liability to derangement during growth, so we may naturally conclude that all parts, when growing, are more exposed to the action of the great variety of exciting causes of disease. Where the active agent of development is in full exercise, any interruption in one part, by disturbing the equilibrium of the process, will produce an inflammation or congestion, either in the part itself, or in the contiguous structure from which it receives its supply of fluids. The derangement will be in proportion to the healthy organic action oC the part, if the principle in physiology be correct, that an organ is disordered in proportion to its previous activity. Vigorous circulation in the organs, and an abundant supply of blood-vessels in the tissues, render children extremely liable to sudden inflammatory affections, rapid in their 3 18 DISEASES OF CHILDREN. progress, and too often fatal in their termination ; effusion quickly following an acute attack of disease, of serum in serous membranes, as the arachnoid, or of lymph in the mucous membranes, as in the trachea. The extreme excitability of the nervous system, from the excess of vitality, also will cause a sympathetic irritation in other organs, which themselves become proportionably disordered, from their own naturally exalted action at this period of life. This strong disposition to sympathetic disorder is a peculiar source of danger; for, however slight or unimportant the original or primary affection may have been, the complication induced in an organ, on whose normal action the well-being of the child depends, becomes the cause of serious and fatal symptoms ; the degree of danger often depending on the importance of the parts complicated in the disease. Thus it appears that the excess of vitality dependant on development is the source to which the great frequency of diseases in children is to be traced, and from the same cause, rendered far more dangerous by the sympathetic participation of other organs. Their diseases are for the most part sudden, and the participation of other parts, especially the brain and its membranes, no less sudden and severe: the disordered affection soon passing through its course, and, if its acute action continue, terminating in effusion and death. The practical deductions from the suggestions and facts here set forth are, first, to meet the diseases of children in their invasion with promptness and decision, whatever be the remedial means resolved on ; and secondly, never, under the most discouraging circumstances, to consider any case as hopeless. Much valuable time may be lost by a temporising method; such a course, if even ever admissible, can be so only when the acute symptoms have disappeared. Perhaps the physician is called too late to take the case under his care with energetic and active treatment; indeed, the symptoms even of severe affections may be obscure, and the oppression of the circulation impart a languor and feebleness to the frame when important organs are affected, not only giving the parents no suspicion of danger, and thus causing delay in the employment of proper remedial moans, but also not unfrequently being a source of embarrassment to the physician in his diagnosis. But when the disease is seen in its commencement, and especially if it be strongly marked with inflammatory or congestive symptoms, decided measures should at once be adopted, and the disease, if possible, be at once cut off; for upon measures promptly and judiciously used at the commencement, the life of the child may altogether depend. These may often be followed with singular benefit by such remedies as will tranquillize the morbid excitement of the nervous system, administered according to the prevailing symptoms, and the. 19 PRELIMINARY OBSERVATIONS. nature of the affection, and thus prevent the lighting up of disordered affections in other organs. It is not intended here to specify either diseases or their remedies, but simply to suggest the general principles on which the diseases of children are best managed, depending, as they do for their production, on the important agency of a superabundance of vitality; views which are fully borne out in practice, the only true test of the correctness of any theory. In the second place, from the powerful activity of all parts engaged in supplying, developing, and repairing the structure, when once the violence of the disease is removed, the physician should never abandon the child, however hopeless the case may appear to be. "Where vitality is in so great activity, the powers of the system are adequate to almost any reparation, and are often exhibited to an extent, and under circumstances of depression, which will leave him without excuse who would regard any case as beyond the reach of remedies. It is true these instances do not make their appeal to us so much by their numbers, as by the evidence they give of the strong inherent power of the body to resist destruction at the commencement of life, and thereby afford a powerful inducement for increased endeavors to add to the numbers already increased five fold in the space of three centuries. Since the natural tendency of the body at this early period is—not to die—but to live, to increase, to unfold itself, and by successive developments to become, by degrees, fitted to the high station in animal and intellectual life for which it was destined, how does it behoove those who have assumed the important charge of its preservation, to use all the efforts which enlightened science affords, to assist the natural inherent powers of the system in resisting any tendency to dissolution, at a period of existence when dissolution is in reality an unnatural process of the structure. With the knowledge of these facts before us, and of the progress already made in the nature and seat of disordered affections—with the still greater insight into the mysteries of other departments of physical science which has been attained, and the control which this knowledge has enabled us to exercise over some of the most powerful agents in nature, is it too much to hope that the bright beams of science, still dispelling the clouds which obscure the operations of the organic kingdom, may exhibit to our view the nature of the secret actions which give to living bodies the powers they possess, and thereby enable us, also, promptly to control their actions and to arrest their aberrations ? And thus restore to their wonted energy the deranged and disordered functions, on which the integrity of the structure and the life of the individual depend. VITAL FUNCTIONS. RESPIRATORY SYSTEM. PECULIARITIES OF THE RESPIRATORY SYSTEM. Tub respiratory organs consist of the nasal fossae, larynx, trachea, lungs and its membrane, together with the thorax, on the movements of which the act of respiration depends. The air passage through the nose varies in children in its form but little from that of the adult, and its comparative size is about the same. It differs in this respect from the passage to the lungs formed by the larynx and trachea, which is much smaller in proportion to the body. The larynx especially develops itself much more slowly than other parts, and consequently does not acquire its full form for some years. Another remarkable feature in the development of the larynx is, that it is irregular in different children, not undergoing the same changes in all, so that it is smaller in some subjects than in others who are even younger.* At the time of birth, the cartilages, bones and muscles of these parts are very small and flexible, and all the cartilaginous rings are distinct, as in the trachea of an adult. At this period it is not unusual to find the larynx and trachea filled with mucous secretion, apparently without the existence of disease, to so great an extent as to interrupt, and even prevent entirely the function of respiration, producing in the new-born child complete asphyxia. The larynx, but more especially the glottis, remains of a very small size for a very long time, differing but little in a child of three years and one of twelve. This smallness of the size of the glottis, is the reason that affections of those parts that are attended with any tenacious secretion, or tumefaction of the lining membrane, are so highly dangerous in children, for a complete closure • Manual of Gen. Descrip. and Pathol. Anat., by J. F. Meckel; translated by A*. Sidney Doane, M. 1). Vol. III., p. 338. 22 DISEASES OF CHILDREN. of the opening may ensue even from slight causes. This condition occurs from the plastic exudation of croup, and in the cedematous state of the epiglottis, diseases remarkably fatal in young children. The different capacity of the opening, in some instances, may also be one of the causes of the frequent attacks of suffocating diseases in some infants, while others are for years quite exempt from affections of this nature. At the age of puberty, however, the difference is so great, that the glottis doubles in length and breadth in the course of a year; hence the remarkable difference observed in diseases affecting these organs at an early time of life, and after the period of puberty, when there is an almost entire exemption from those symptoms which characterize these affections in young children. The bronchia?, also, during the period of childhood, are quite small, but enlarge at the same time that the larynx undergoes a change. The size of the thorax is proportionally smaller than any of the other cavities of the body during infancy; but on account of the greater length of the cartilages of the ribs, in proportion to the osseous part, it possesses much more elasticity, and thus in a measure compensates for its deficiency in size. The lungs in the foetus are only a dense mass of substance, of a brownish color, entirely different in appearance and texture from the lungs of a child after respiration has been established. These organs are of a bright rose color, inclining to red in young infants; in youth they are of a darker color, but do not assume their permanent hue until about the age of twenty years, when they appear of the well-known marbled color of adult age. The functions of the lungs present the most remarkable changes of any occurring in the infant frame; for when in a normal condition, they almost instantaneously perform their appropriate function on the application of their natural stimulant, thus changing at once the condition of the child from a parasitic to an independent state of existence. Respiration is carried on with great activity in an infant, amounting to thirty-five or forty inspirations in a minute, those of the ad.ult being about eighteen or twenty in the same period. Although this is stated to be about the number of inspirations, yet it is extremely difficult to ascertain the fact with much precision, for when the thorax is uncovered in order to observe its movements, the exposure causes an immediate acceleration in the action of the respiratory muscles. Nothing, therefore, can be ascertained with any degree of satisfaction, when desirous to obtain information from this source, as to its indicating the violence of diseased action. When they are noisy, from any obstruction in the nasal passages, the respirations may be counted. 23 RESPIRATORY SYSTEM. A remarkable circumstance in the manner in which respiration is performed by an infant is, that the ribs alone are the chief agents, the diaphragm acting but little, the size of the abdominal viscera not permitting it easily to descend. Infants, when sucking, breathe allogether through the nose; when this is obstructed by tenacious mucus, great difficulty is experienced both in breathing and sucking. The nose is, therefore, at this period, an important appendage to the respiratory apparatus. Children at all ages, but especially during infancy, require a free supply of pure air, as is evident from the fact of the great number of deaths in large cities, and more especially in the crowded alleys, densely-populated houses, and hospitals for young infants, or under any circumstances where there is an evident insalubrity of atmosphere. All animals, especially when young, harve been known to suffer from this cause. In Paris twenty-five per cent, of the deaths are children under the age of two years, in London twenty-eight per cent., and in Philadelphia about thirty-three, and in New York a trifle less. On percussion, the chest of a child is very sonorous, owing both to the small development of the muscles covering the part, and to the free and active condition of the ultimate termination of the bronchia?; and it is probably owing to the same cause that the respiration in children is much louder than that of adults ; and when a portion of the lungs is required to perform more than its ordinary amount of functional power, from disease existing in its vicinity, a similar sound is heard by auscultation, and has for this reason been called puerile respiration. . This remarkable condition of a child's lungs exists until about the twelfth year, when respiration assumes the characters peculiar to it in the adult. On the establishment of respiration, the child cries, caused doubtless by the painful impression made by the cold air, for the first time applied to the surface of the body and lungs; this feeling of excitement, or perhaps some degree of distress, appears from the rapid movements of its arms and legs. Physiologists have long attempted to account for the agency by which the first inspiration is effected. It was the opinion of Whytt, that the foetus received blood already prepared for. it by the mother, and that when this supply ceased, an instinctive feeling, analogous to hunger, took place in the chest, by which the child naturally sought for air to supply the existing want. The brain excites the motion of the chest, thus preventing the fatal effects that would follow a quiescent state of the lungs. This appetite for air commences at birth, from the excited circulation arising from the struggles of the child; a quantity of 24 DISEASES OF CHILDREN. blood is thus sent through the lungs, and becomes the direct cause of the desire.* Haller ascribed it to the habit of opening the mouth while in the uterus, in swallowing the liquor amnii. When this motion is repeated, on the child's being ushered into the world, the air finds its way in, and passes directly into the lungs; blood is distributed through them on their expansion, and a continual supply of air is required to prevent the blood from stopping in its progress from the right to the left side of the heart.t Darwin adopts a like view of the subject in reference to the habit of moving the mouth in the uterus; but this can not, he thinks, be the sole cause of the first inspiration, for breathings and deglutition are different acts. The foetus, at birth, experiences an uneasy sensation from the want of air, for the relief of which, all the muscles of the body are thrown into action, and those of the thorax, together with others, by which the uneasiness is relieved.} The French physiologist, Adelon, supposes that the successive development of the lungs and their appendages predisposes them to the act of respiration. As the lungs increase in size, and the pulmonary vessels enlarge, the ductus arteriosus becomes less, whereby the lungs are prepared, on their being properly excited, to discharge their proper functions. The contractions of the uterus, also, prepare the foetus for the new change, by pressing the blood out of the placenta, and thus deranging the circulation. By this derangement in the distribution of the blood, an additional quantity of blood is sent to the lungs. A new impression is then made on the child by the action of the external air; its coldness and weight make a painful sensation on the skin and other parts of the body. These impressions are conveyed to the brain, and reflected to the different parts of the muscular system, through the nerves; the muscles of inspiration, as well as the others, receive this impression, transmitted by the nerves, whereby they are excited into contraction.§ The views of Dr. Philip are, that the muscles of inspiration are altogether under the control of the will, and are brought into action by the uneasy feeling which the foetus experiences on being separated from the mother, analogous to the first act of deglutition ; both acts arising from the will, and producing the contraction of certain muscles for the relief of unpleasant sensations.|| J)r. Bostock's opinion is, that it is entirely of a mechanical nature, arising from the elasticity of the parts, from the removal of the pressure to which the body was subjected while in the womb • Whytt on Vital Motions, sec. 9, p. 111. f Elements of Physiology, viii. 5, 2. } Zoonomia, vi., sec. 16. § Physiologie de 1'Homme, p. 20. j} Wilson Philip, M. D., in the Quarterly Journal; vol. xiv., p. 100. 25 RESPIRATORY SYSTEM. the expansio of the trunk depending merely on the removal of this pressure.* Dr. Marshall Hall, in his valuable work on the nervous system, explains the establishment of inspiration by the action of the excitomotor system of nerves, whereby the cold impression on the trifacial nerves, and also on the spinal nerves, distributed extensively over the cutaneous and mucous surfaces, is transmitted to the medulla oblongata, and thus stimulates the nervous centre which reflects the necessary stimulus to the pneumogastric nerve. This is experienced every day in a very marked manner on the birth of a child. The foetus in the womb, surrounded by the warm liquor amnii, is but little exposed to the action of any stimulus on the cutaneous surface : but no sooner is it subjected to the sudden change of temperature, arising from the exposure of the body to the cold air, than an immediate excitement takes place at the minute origin of the incident nerves, which is transmitted at once to the centre, to be reflected in the manner just mentioned. Il is a very common practice, when the infant does not breathe, to expose it more freely to the influence of the air, to blow, or to sprinkle a little cold water on the face, when a sudden catching or sobbing ensues. The cry of an infant demands some attention, as it not unfrequently affords some indications of disease; it should therefore be the duty of the physician to become acquainted with the natural cry of an infant. The division of the cry made by Billard, is one which is considered by all of great practical use, founded, as it is, in the philosophy of nature. His division of the cry is into the cry proper, and the interval, or reprise. The former is produced by expiration, while the latter is die sound formed by inspiration, and appears to be caused by the sound of the air passing through the glottis in order to reach the lungs. The reprise is heard but little in a young infant, and increases in intensity as the child advances in age ; it is the predominating sound heard after a child has been exhausted by crying, and known by the name of sobbing. The crying of a young infant is unconnected with the shedding of tears. The secretion of tears is remarkably dependant on the mental emotion arising from sorrow ; it would appear, therefore, that as the brain of a young child can not combine ideas, its distress is altogether of a physical nature. Crying is not always an expression of severe pain, but often of some uneasiness and instinctive want, arising from the position of the body, uncomfortable arrangement of clothes, or hunger and •Elementary System of Physiology, by John Bostock, M. D., vol. ii., p. 31. 4 26 DISEASES OF CHILDREN. thirst. This may be known by the cries occurring at intervals, and also by being easily calmed. The peculiarity of voice in childhood appears to be connected with the cartilaginous condition of the larnyx, and the cry or natural language is caused by that tube alone, without the assistance of the organs of articulation. Although there are changes occurring in the larynx during childhood, yet there is nothing very appreciable until the period of puberty : at this time a change occurs in every part; the opening of the glottis becomes larger, and the cartilages and muscles of speech increase in size. These changes are observed to occur in the male, in whom an alteration of voice takes place ; in the female but little change occurs, and the voice continues without much alteration. The thymus gland is an organ composed of distinct lobes, situated at the upper anterior part of the thorax of the foetus ; it lessens in size after birth, and entirely disappears about the twelfth year. From a continued enlargement of this body after birth, it has been supposed to become a cause of some distressing and fatal affections in infancy, arising from the obstruction to the breathing which it produces. SIGNS OF DISEASE- FROM THE RESPIRATORY SYSTEM. Crying being the first and most common expression of distress in a child, the peculiarities arising during this act naturally attract our first notice; and by a close and watchful attention, the cry of a child may enable us to make some kind of a diagnosis of its diseases. When crying is remarkable, for its strength and obstinacy, and especially if accompanied by- an expression of distress in the face, with pallidness, it is a sign of the existence of severe pain, arising from protracted disease. It is sometimes sudden, and accompanied by an accelerated movement of the respiratory organs; it is then an evidence of a violent and sharp pang, as that arising from the pricking of a pin, or a sudden paroxysm of pain : this occurs in peritonitis and spasmodic affections of the bowels. This sudden crying, or screaming, sometimes becomes protracted, when it indicates the presence of local inflammation, or continued pain from the pressure of the teeth on the gums. It is broken up into short paroxysms when the respiratory organs are the seat of the inflammation, from the severe pain which is produced by the act itself. In prolonged disease the cry will not be continued throughout, but will falter, and have a dying sound at its r lose. This kind of cry is found in diseases of a very seriou? lature, as gelatinous RESPIRATORY SYSTEM. 27 softening of the stomach, chronic pneumonia, inflammation of the brain and pericardium. In severe pain there is an acuteness in the cry, both in inspiration and expiration. From its occurring in the active stage of hydrocephalus, M. Manuoir, of Geneva, has denominated such a cry, hydrencephaliquc, and regards it as peculiar to that disease: it will, however, mark the existence of any severe pain. The cry may sometimes be interrupted or intermittent, characterizing affections of the larynx, and is caused by spasmodic affections of the muscles of the voice. This sound is peculiar to croup. The sound on inspiration is that which is distinctly heard, while the other is lost. The alteration in the tone, which is something between a cry and a cough, imparts to it a crowing sound, and is produced by a sudden intermittent movement of the larynx. This acuteness of tone produced by inspiration, occurs also in inflammation of the mouth, propagated to the tonsils and larynx, and may be regarded as a distinctive sign of inflammation in the trachea or larynx. When the sound of the voice is husky, it is a sign of catarrhal affections, and arises from the thick mucus obstructing the bronchia?, and preventing the air from circulating freely through the tubes in its passage to the glottis. The imperfect cry gives a moaning sound-at times, and in newborn infants is a sign of extreme debility ; the child using no muscular effort. Under such circumstances, and when following much inflammation, it is almost a certain precursor of-death. Moaning is also an unfavorable indication, when it occurs with sudden stupor, after violent excitement, accompanied by screaming; these, together with sighing, and a drawling and nasal sound, indicate cerebral affection, bordering on effusion. When it is simply an indication of pain in the bowels, and accompanied with a drawing up of the lower limbs, so common in spasmodic affections of ihe stomach and bowels, it is not to be regarded as indicating anything serious. Fretfulness is in general a sign of simple uneasiness, and if long continued, denotes, the invasion of some disease, and should, on this account, never be overlooked, as the successful treatment of infantile disease often depends on the early stage at which the proper remedies are used. It becomes important, therefore, when accompanied by other indications of disease. The voice in older children gives the same indications of disease as in adults, being shrill in spasmodic affections of the larynx, as in Millar's asthma. Hoarseness occurs in catarrhs, inflammations, and thickening of the mucous membrane of the larynx, and often re* mains for life, after an attack of croup or measles. 28 DISEASES OF CHILDREN. Hiccup is produced by a sudden expansion of the thorax, and narrowing of the glottis, from a spasm of all the muscles of inspiration. In children the cause usually lies in the intestinal canal ; it may also arise from an affection of the nervous system, and especially in cerebral diseases. It often exists, without being a dangerous symptom, in irritations of the stomach or intestines, from any cause ; but should there have been any inflammation of the intestinal canal or peritoneum, the prognosis is unfavorable. Sneezing is a sign of an inordinate stimulation of the mucous membrane of the nasal cavities, and in children is usually an evidence of a local inflammation in these parts ; it may occur in irritations of the intestinal canal, from worms and other causes. Cough indicates a general disease of the respiratory organs, either idiopathic, from disease of the larynx, frachea, bronchia?, lungs, or muscles of respiration ; or it maybe sympathetic of irritation in the bowels, either from saburra or worms —a very common cause of coughs in children. Sometimes great anxiety precedes the cough, as in hooping-cough, when the nervus vagus is affected. A single short cough denotes pleuritis ; on the contrary, a paroxysm of coughing comes on in catarrh with profuse secretion, and in hooping-cough. In intermittent cough there is great nervous irritation, with or without organic changes of the organs; it is chiefly observed in croup and hooping-cough. A constant cough is a sign of inflammation of the larynx, bronchia?, or lungs. A harsh tone in the cough is a sign of catarrh ; a barking tone, of croup. A whizzing tone, without harshness, is an evidence of catarrh of the bronchial mucous membrane, before the secretion, which characterizes this affection, has appeared. The sound of the cough in hooping-cough is distinguished by its loud shrieking character. A dry cough appears at the commencement of catarrhs and inflammations of the respiratory organs, and is of short duration when the inflammation is seated in the mucous membrane, and continues longer in pneumonia, and other serious affections of the lungs. In judging of the frequency of respiration, the age of the patient should be taken into account, as the frequency is much greater in young than in older children. The varieties resulting from sex, or mental emotion, are not, as in adults, of any account in young children. When the last-mentioned cause influences the respiratory organs in children, crying is produced, which takes the place of the rapid breathing observed in adults. Frequency of respiration occurs when a portion of the lungs is unable to perform its office, or when a more than ordinary quantity 29 RESPIRATORY SYSTEM. of blood passes through these organs in a given time, In the former case the frequency arises from disease of the lungs, or an affection of their walls; in the latter, from the increased quantity of blood passing through them, as in a paroxysm of fever. The prognosis may in general be favorable, when the frequency diminishes with the disappearance of fever, as it may be regarded as arising from the increased circulation attendant on a febrile state. A quick respiration is denoted by the rapid motions of the thorax ; in protracted disease it is of a very unfavorable import. Strong respiration marks a great exertion of the respiratory muscles, and denotes more especially disease of the air passages, particularly of the larynx, and a narrowing of the bronchia?. It also occurs when the lungs are loaded with blood, during a violent paroxysm of fever. Sometimes this kind of respiration becomes difficult, constituting dyspnoea of authors; it occurs where portions of the lungs are impervious to the air. , When respiration is rare, the cause exists in the debility of the muscles of respiration, as is frequently seen in infants that are premature, or that are born feeble. If it is at the same time quick, it is an evidence of pleuritis, or of great debility occurring after violent exertion in coughing, in pneumonia, chronic bronchial catarrh, or effusion into the cavity of the pleura. The species of respiration which is performed by the upper part of the chest, indicates very serious disorders of the thoracic viscera, as it is in proportion to the difficulty of ordinary respiration. That kind which has been called cervical, is performed by the exertions of the muscles of the head and neck, and is an evidence of the highest grade of difficult respiration in diseases of the lungs. Cephalic respiration is of common occurrence in pulmonary diseases of children, and is known by the mouth and nose moving violently in expiration and inspiration. It is produced by a mechanical obstruction of the lungs, as their engorgement in pneumonia, effusions in the air cells, closure of the glottis in croup ; and is an instinctive movement to increase the volume of air, and gives a very unfavorable prognosis. Inspiration is very difficult in diseases of the larynx, oedema of the glottis, or in any affections of this part, constituting what has been called Millar's asthma, and in most cases of croup, and causes the peculiar sound of these diseases. Expiration, on the contrary, is the most difficult part in diseases of the bronchia?. In chronic diseases of the lungs, a form which not unfrequently occurs in children in that peculiarity denominated lobular inflammation, there is a gradually increasing dyspnoea, which is an unfavorable sign. Regular respiration is a favorable phenomenon, while irregular respiration is connected with a state of extreme debility 30 DISEASES OF CHILDREN. from cerebral affections. If this amount to cessation in breathing, it is then intermitting, and is very unfavorable in cerebral affections and pneumonia. In healthy respiration, inspiration is of longer duration than expiration ; but in cases where inspiration causes great pain, as in pleuritis and peritonitis, it is cut short, and the relation is inverted. Inspiration is performed with great difficulty in diseases of the larynx, oedema of the glottis, inflammation of the epiglottis, and in most cases of croup. Expiration is the most difficult part of respiration in affections of the bronchia?. When a deep inspiration and free expiration occur without pain, and the ordinary respiration is frequent and difficult, it is an evidence that the disease is not seated in the respiratory organs, but is a sympathetic action arising from disease in another part. The knowledge of this fact is of some importance in children's diseases, but can not be made available in the case of infants. In healthy respiration, no sound is perceptible by the ear removed from the chest. It becomes sibilous in laryngitis, oedema of the glottis, and in croup. When it produces a sighing sound, the cause is generally in a congested state of the lungs, or debility of the respiratory muscles ; when it occurs in diseases of the brain, and acute hydrocephalus, it is an unfavorable sign. When it is necessary to obtain still more correct results by means of auscultation, the method practised in adults will "be applicable to children, taking into account the age, sex, and temperament, of the patient. The respiratory sound is very remarkable in every part of the chest in children, forming the puerile respiration, and therefore does not become a sign of diseased action, as in adults. A slow respiration takes place in very debilitated infants, and marks a diminution of the action of the heart; yielding an unfavorable prognosis. Diminished intensity of the respiratory murmur shows that there exists inflammation of the small bronchial ramifications, or obstructions in them from mucus ; its entire absence, with bronchial respiration, shows the existence of pulmonary induration or pleuritis. Auscultatory sounds, in general, do not vary from those described as existing in adults, and therefore need no further notice than a reference to them in the monographs devoted to their consideration. The stethoscope is not so easily used as in the adult, on account of the continual motion of the child ; it is much easier to apply the ear to the chest. Percussion may be employed by elevating the child in the air with one hand, while the sound is obtained by the other. When the pleximiter is used, it will be advisable to employ two at the same time, that the sound at the diseased part may be compared with that. 31 RESPIRATORY SYSTEM. of the unaffected portion. The sonorous nature of the chest in young children greatly favors the employment of percussion ; and in simple pneumonia there is either a complete dulness, or so evident an obscurity in some parts, as to contrast very strongly with the clearness of sound in another. Those most experienced in ihe examination "of children by this method, prefer the direct application of the fingers to the intervention of a pleximiter. DISEASES OF THE RESPIRATORY SYSTEM. ASPHYXIA. The literal meaning of the word asphyxia, is a deprivation of pulse, oa deep, sudden Catch, followed by a prolonged expiration or sigh, with a considerable interval between the respirations at first: the intervals gradually becoming less, respiration at length assumes its regular action, the cry of the child first giving the evidence of its complete establishment, and is one of the best proofs we can have of the vigor of the infant. According, therefore to the strength of the cry should we estimate the vigor of the child; and if this be powerful, strong, perfect in both its parts, and well sustained, we may, without fear as to the result, direct the child to be washed and dressed, which, without these evidences of the strength of the child, have produced a fatal exhaustion. Upon the subject of tying the cord, there have been different opinions as to* the proper time. Some have maintained that the pulsations in the funis should cease entirely before the application of the ligature ; while others have contended that it is only necessary for the child to breathe and cry vigorously, to admit of the tying and separating the cord. The former practice is undoubtedly the safest, although abundant experience proves that but little hazard can arise where the respiration is fully established, although the pulsation may not have entirely ceased. For a long time after breathing has commenced, pulsation will continue near the body of the child, while it will be found that it has entirely stopped near the placenta. An unnecessary delay may be avoided, by first ascertaining the effect of compression on the cord between the fingers ; when the pulsation is found to be quite feeble, and easily arrested by the compression, without the appearance of any disorder in the circulation, the ligature may then be applied, and the cord divided with the most perfect safety. Where any malformation exists, it is obvious that but little can be effected by artificial means ; those already detailed will be those most applicable, according to the prominent symptom, if the conformation of parts allows of any hope of success in the use of them. Under all circumstances, particular attention should be paid to the temperature, for, from a disregard to this, numbers of infants doubtless have perished: for next to respiration, the maintenance • A Treatise on the Diseases and Physical Education of Children, by John Eberle, M. D.; Philad. 1837, p. 79. RESPIRATORY SYSTEM. 39 of a proper warmth is of absolute necessity to the preservation of the life of the young child. Between the temperature of the womb and that of the body, there exists a difference, never less than 30° ; the sudden effect of this change, like that from heat to cold, acts as a powerful stimulus to the circulation; but wnen this effect is accomplished, no benefit can possible arise from a continued or an occasional exposure to cold, but on the contrary, decided injury must arise from the continual abstraction of heat, where the power of its production is but feeble, and where the degree is less than in adults. Inattention to keeping a sufficient supply of warmth, independently of any unnecessary exposure, has sometimes proved fatal in a few days, resisting all endeavors to remedy the condition of coldness and depression when this state has been discovered. A continual moaning and sighing, together with a shrunk and bluish appearance of the face, and a leaden color of the hands, will point out, with unerring certainty, the condition of the child, demanding as close attention to preserve life as an imperfect condition of the respiratory function. Among the other auxiliary means, is the employment of a warm enema composed of gruel or warm water, its temperature being about 100°. Warm barley-water, or warm milk and water may also be given to the child with a teaspoon by the mouth, and the effort of the child to suck when the spoon is placed within the lips is an indication of the freedom from danger. After the restoration of the child, it is not uncommon for a complete relapse of all the symptoms of asphyxia to take place, and for want of proper care death will ensue. The child should therefore be carefully watched, and a repetition of the remedies, more particularly of those which will excite the respiratory act by the stimulation of the nervous excitors, ought to be perseveringly employed. In those cases of labor where the body of the child is delivered some time before the head, there is great danger of the child's being lost, from the continual compression of the cord, before there is an opportunity for the mouth to be exposed to the atmosphere. Dr. Bigelow* has shown that the life of the child, under such circumstances can be saved, even if the size of the head and the resistance of the pelvis and soft parts render the delivery of the head by traction either difficult or hazardous, by forming a communication between the mouth and the atmosphere, before the delivery of the head. The fingers should be introduced, so as to reach the mouth of the child; when this is accomplished, the hand is to be raised from the throat of the child, making the ends of the fingers a fulcrum, and pushing the perinceum backward, by which the air will be admitted as far as the chin. The middle fingers are then to be separated, and a free passage will thus be made to the mouth. If • American Journal of the Medical Sciences, August, 1829. 40 DISEASES OF CHILDREN. the mouth be situated too high to be reached with the fingers, or if, from great compression, it is found difficult to pass the fingers, Dr. Bigelow recommends the use of a flat tube, made of gum-elastic, or spiral wire covered with leather, about half an inch at its largest diameter, to sustain life during the retention of the head. He even thinks it practicable to inflate the lungs under these circumstances. BRONCHITIS. Bronchitis, or inflammation of the lining membrane of the bronchia?, is of frequent occurrence in children at every age, varying from a slight degree of irritation with mucous secretion, to a severe phlegmasia of the mucous membrane. When slight, or attended with but little inflammation, but exhibiting a copious secretion of mucus, it is that form of bronchial disease known under the name of catarrh. As the term catarrh implies simply the existence of inordinate secretion, and relates to the secretion only, without reference to the pathological condition of the part, it will not here be considered as a distinct disease, but included in the description of bronchitis, of which it forms but a symptom. Any peculiarities, therefore, which bronchial catarrh assumes, on account of which it has been described as a distinct affection, will be considered under the present head. Etiology.—This disease is most apt to occur in cold, wet, and variable weather, during the spring and winter. Not only may the exposure to the atmospheric vicissitudes become a cause of bronchial inflammation, but cold applied to the surface of the body in any way, as damp clothing, accumulation of urine for a long time without changing, etc. Smoke, or irritating gases, may also excite an inflammatory action in the mucous membrane of the respiratory passages. Bronchitis also arises from the constitutional irritation attendant on teething, as other inflammatory diseases are ex cited by the same cause, according to the peculiar predisposition of the child ; an important practical fact, to be kept in view in the treatment of all affections of children. It may also occur on the disappearance of an eruptive disease, when it often becomes protracted and obstinate, resisting, for a long time, the measures adopted for its removal. Semeiology.—On the first appearance of the disease there is a chilliness of the surface of the body, which is soon followed by a quick pulse and hot skin. Cough is usually present from the commencement, at first slight, increasing gradually in hoarseness, and' as the disease advances, accompanied with pain, which in young children may be known by a violent cry. The cough, at the commencement, is unattended with any secretion of mucus; but short- 41 RESPIRATORY SYSTEM. ly after the invasion of the disease a free secretion of mucosity takes place, which increases in quantity until the complete transmission of air to the air-vesicles is prevented, and all the distressing symptoms of suffocation present themselves; the countenance becomes anxious, and the prolabia livid ; all of which are aggravated on placing the child in a recumbent position. The coughing is often attended with strangrtoig, and paroxysms of threatening suffocation, until relief is obtained by vomiting. These symptoms are, toward the termination of the disease, sometimes attended with convulsions or stupor. The disorder of the respiration accompanies the other symptoms in their march, and as the latter increase in intensity, becomes more oppressed and difficult. Percussion yields a clear sound in every part of the chest at first, but different portions become dull toward the termination of the disease. Auscultatory examination discovers the existence of the mucous ronchus, and it may even be heard without applying the ear to the chest, or without the intervention of the stethescope. The use of this instrument in severe cases can scarcely be dispensed with, if we are desirous of making a prognosis of the disease ; and if we discover its peculiar characteristic, the mucous ronchus pervading the whole of the chest, and the inflammation occupying the bronchia? of both lobes, great danger may be feared if much constitutional derangement also exist. If, on the other hand, it is discovered to be partial, our prognosis may, in general, with ordinary constitutional vigor on the part of the child, be favorable, although the paroxysms of coughing and difficulty of respiration may be severe and exhausting. In very young children bronchial catarrh may often arise without any evident cause, and will scarcely exhibit any other symptom than the mucous ronchus, or a short, noisy respiration, without any distinct sound, which may be so denominated. When it attacks young children, it will at times continue during the whole period of lactation ; on other occasions it will increase in intensity in a very insidious manner, attended at first with no evidence of pain or distress. As the affection in this form advances, the breathing attracts attention from its peculiar wheezing character, almost imperceptibly changing to dyspnoea, and attended with drowsiness. This laborious respiration occurs for the most part in paroxysms, leaving the child during the intervals free from any urgent symptom, if the quiet drowsiness which generally attends it is not regarded as such. This, however, is one of the most fatal signs, and this form of bronchitis, when once it has made strides thus far onward, is scarcely to be arrested by remedial means. One peculiarity is, that cough, so distinctive in ordinary bronchitis, is not always present 6 42 DISEASES OF CHILDREN. in this form, and therefore is'no mark of the disease. The pulse is extremely quick, while the- skin is cool and moist. A variety of bronchitis known by the names of catarrh and catarrhal fever, has at times prevailed epidemically, and been exceedingly fatal to children. The symptoms are much the same as those of ordinary bronchitis, but with much greater depression at the commencement; the coolness and langigar, and contracted condition of the surface, often lasting a whole day before the febrile reaction is fully developed. It appears to be a secondary affection, connected with a great derangement of the secretions of the chylopcetic viscera ; the liver being in a torpid condition, and the alvine evacuations either deficient in bile, or giving evidence of its absence altogether. Convulsions and drowsiness also occur toward the close of the symptoms, and are always to be regarded as indicating an unfavorable termination, arising as they do from congestion in the brain and medulla oblongata, produced by the increasing obstruction in the pulmonary circulation, which thus crowds these organs. Among other varieties of this disease is that described by the late Dr. Parrish, of Philadelphia, as the congestive catarrhal fever.* It commences in the usual manner observed in bronchial inflammations, but without the febrile symptoms noticed in the ordinary bronchitis. The symptoms are those usually observed in all congestive fevers. The pulse is frequent, but gives no evidence of fulness and activity in the circulation. The skin is cold and pale, and free from any dryness. The prima? via? partake also of the general torpor of the system, and the bowels are inactive ; but the discharges do not give evidence, as in the last-mentioned variety, of any derangements in the hepatic system. The cough, like that of the ordinary form of bronchial affections, is at first dry, but becomes moist during the progress of the disease. The most marked symptom, however, is the dyspnoea of a violent and distressing character, which induced Dr. Parrish to regard it as a spasmodic affection, and to treat it as such. It is exceedingly fatal to young infants, seldom lasting more than two or three days, and is almost beyond the control of remedies; the excessive local congestion, and the loss of vital power, of which this is an evidence, make the use of ordinary remedies of little avail. Morbid Anatomy and Pathology.—Autopsical examinations show the bronchial mucous membrane in a state of increased vascularity, as appears from the injection of the capillary vessels with blood ; it is often thickened, but seldom softened. On account ol * Observations on a Peculiar Complaint in Children. N. A. Med. and Surg. Jour. Vol. I., p. 24. 43 RESPIRATORY SYSTEM. the obstructions in the bronchia?, the lungs do not collapse on opening the thorax. A thin but tenacious fluid fills the entire substance of the lungs. Mucus, more or less thick, is usually found in the ramifications of the bronchia?, sometimes mixed with purulent matter, similar to what is occasionally discharged from the mouth in very severe cases of the disease, that have been quickly fatal. In other instances some degree of hepatization has been found in the lungs, particularly at its lower posterior portion : apparently the first progress of the disease toward pneumonia. Tubercles have at times been found at the root of the bronchia?, and in the lungs. Treatment.—The treatment of acute bronchitis must be strictly antiphlogistic, and adapted to the urgency of the symptoms. When called early, the disease may be removed by the administration of a little syrup of ipecacuanha, every ten or fifteen minutes, until vomiting is induced, followed by pediluvium. The abundant secretion of mucus in the air-cells will often produce a difficulty of breathing almbst at the commencement of the disease in infants, from their inability to expectorate ; the early exhibition of an emetic, therefore, becomes an important remedy for the relief of the distressing dyspnoea arising from this cause. This condition may in general be known by the cough being less at the commencement. When there is much inflammation, the cough is more urgent, and there is a destitution of secretion to a greater or less degree. If there exist but little febrile action, and the disease is of a slight character, the chest may be rubbed with some stimulating application, and a warm emollient poultice afterward applied. In using embrocations in inflammatory affections of the chest, ammonia, which is so commonly employed, made into a liniment, should be avoided, as the fumes arising from it will tend greatly to aggravate the existing inflammation. If the disease be not alleviated at once by these measures, no time should be lost in availing ourselves of the principal remedy in the management of active inflammation, especially if there is pain in the chest, when blood should be taken from the arm of the child, until an effect is. decidedly manifested in the pulse. In robust children, bleeding by the lancet is indispensable when there exists much heat of skin and febrile action, or much difficulty in respiration. To be decidedly beneficial, it ought to be employed early. If the evidences of bronchial inflammation continue, leeches may be applied to the upper part of the chest, immediately under the clavicles. After bleeding, if but little febrile action follow, a blister should be applied over the chest, a means which ought not to be neglected in the treatment of bronchitis. It ought not to be left on 44 DISEASES OF CHILDREN. until complete vesication has taken place, for in children the ulcerated surface left after a severe blister is often very difficult to heal, and extensive sloughing has followed its use. If, however, the violence of the circulation has not been relieved, it would be well to attempt to allay the fever and dyspnoea by such remedies as relax the system. Nauseating substances, as ipecacuanha or tartar emetic, are used for this purpose ; and, given in small and repeated doses, so as to act, also, as an emetic, will be found of great benefit in the treatment of this affection. Tartar emetic can not be used without some hazard in young children, and I know of two deaths that occurred from poisoning with this substance, in small doses given medicinally. Professor Hamilton, of Edinburgh, also mentions the occurrence of fatal ef fects from its use, but refers it to the child having taken the medicine on an empty stomach ; he therefore advises that the child be allowed to suck or drink before taking it. With this precaution, from one eighth to one sixteenth of a grain of tartar emetic may be given to a robust child at the age of three years, every ten minutes, until vomiting ensue ; in children under the age of two years its use should be avoided. Vomiting is peculiarly serviceable in every stage of this disease; and where there is much accumulation of mucus in the bronchia?, should be employed so as to act promptly, and thus relieve the tendency to congestion of the lungs, by removing the mucus which clogs the extreme branches of the air-passages. A very excellent combination is that so often used, composed of antimonial wine and syrup of squills ;* it is more useful where free secretion has taken place in the bronchia;. Antimony, by itself, is more applicable to the. first stage of the complaint, while the mucous membrane is in a state of inflammation. To quite young or new-born children, syrup of ipecacuanha is preferable, as the dose may be exceeded without any unfavorable effects following. A teaspoonful may be given to a child three or four months old, every ten minutes, until vomiting be excited, and half that quantity to one within the month. From the commencement of the disease, the bowels should be kept in a soluble state by the use of mild laxatives, but no advantage can arise from free purging. In robust children, a few grains of calomel, combined with rhubarb and ipecacuanha, may be given • fi Vin. Antim., 3jj. (1) Syrup. Scillae, |iss. M. A teaspoonful every ten or fifteen minutes, until vomiting ensue. ft Pulv. Ipecac, 3j. (2) Antim. Potass. Tart., gr. j. Oxymel. Scillaj, Syrup. Simp., Aquaj Font., aa. M. For children three or four years old, from one to two teaspoonfuls. 45 RESPIRATORY SYSTEM. at first, and the bowels kept in an open state by the use of the annexed laxative prescriptions.* Where the secretion is slow in taking place in the inflamed membrane, and the violence of the disease, and the constitutional disturbance attendant on it, are in a measure allayed, expectorants will be indicated. Any of the nauseating articles may be used for this purpose. The efficacy of tartar emetic is greatjy increased by its union with some alkali, probably from its facilitating the absorption of the medicine.t But when there is a decided relief of the febrile symptoms, those of a more stimulating nature may be used, as the syrup of squills, in doses of ten or fifteen drops every two or three hours, to a child of two years. As its operation is by stimulating the capillaries, and thus exciting secretion in the diseased membrane, it is counter-indicated in the active form of the disease. It may be judiciously combined with other articles which act also as expectorants, and thus obtain the combined influence of different remedies of the same nature, but acting in different modes.} In the last stages of the disease, when it has assumed a chronic character, more stimulating expectorants will be needed, and the senega snake-root (polygala senega), so useful in croup, will be found of great efficacy. Some mucilage ought to be combined with it when it is given in decoction, in order to allay, in some measure, its acrid properties. || In very advanced stages of this disease, and in its chronic form, when attended with much debility, it may become necessary to add some stimulant, to prevent the prostrating effects which sometimes follow from its free action on the • ft Hydrarg. Subm., gr. x. (3) Pulv. Rhei, 3j. Pulv. Ipecac, g. j. Syrup. Simpl.,|ss. M. One third is a dose for an infant. ft Manna?, (4) Emulsio. G. Arab., Syrup. Viola?, 3ij. Bene Admisce, et aade, Aquae, From 3j> to 3»j. every three hours, until an effect be produced, for an infant. ft 01. Ricini, %ss. (5) Syrup. Rosas, Vitel. Ovi, un. Tinct. Senna?, 3iss. M. One to two teaspoonfuls, for an infant, every hour. f ft Antim. Potass. Tart., gr. j. (6) Sub. Carb. Potass., 3j. Syrup. Simpl., M. A teaspoonful every two hours. t ft Vin. Antim., 3ss. (7) Oxymel. Scillas, ?ss. Potass. Tart., Ext. Glycyrrh., aa 3j- Aquae, |j. M. One or two teaspoonfuls, for an infant of twelve to eighteen months. ft Oxymel. Scillas, (8) Syrup. Ipecac, aa. 3-ss. Succ. Glycyrrh., 3j. Mucil. G. Acaciae, M. A teaspoonful once in two hours, to a child of a year old. || ft Infus. Senega?, (9) Syrup. Scilla?, Mucilag. G. Acacia?, M. A teaspoonful once in two hours, to a child three years old. 46 DISEASES OF CHILDREN. bowels. Ammonia has been added for this purpose $• this, together with an anodyne, will sometimes be needed to meet bad cases of prostration.* Although, as a general rule, narcotics are to be avoided where it is necessary to keep up the secretions from the affected part, which is the indication throughout the whole period of bronchial inflammation, yet it may at times become advisable to allay the violence of the cough, which is often so great in protracted cases as greatly to distress the child, and deprive it of rest. A combination of Dover's powder with calomel and squills will be found highly useful when an anodyne is needed,t or either of the following mixtures, as the case appears to require ;} and often the most salutary alterations will occur from the use of anodynes in long-continued cases, by allaying the morbid irritability to which children are so greatly subject, and allowing the powers of the system to rally from the wearing out of the nervous energy. When the skin becomes moist, they may be used with safety, care being taken to prevent the bowels from becoming constipated. The sanguinaria canadensis has been extensively used in pulmonary affections ; being an active stimulant, it is only useful in protracted cases, where the stimulation of the bronchial membrane becomes necessary to excite its secretion. In addition to these measures, the condition of the gums should be examined ; and if the teeth appear pressing on the gums, a free incision ought to be made ; and indeed it should be our duty, in the first place, to examine whether the irritation of teething be not the exciting cause ; for, as was before remarked, where children are naturally predisposed to bronchial affections, the constitutional disturbance arising at the period of dentition may be its sole cause. A great deal of useless treatment may be prevented by attention to this subject. After a child has for some time had a free discharge of saliva, under the irritation produced by the pressure of the teeth * ft Decoct. Polygalse, (10) Carbonatis Ammonite, gr. iij. Tiact. Cinnam., Syrupi Tolutani, aa. 3u» Syrupi Papav., 3u- M. 3i. every second hour. t ft Pulv. Doveri, gr. x. (11) Hydr. Subm., gr. iij. Pulv. Scillee, gr. i., Sacchar. Alb., 3ij« Div. in pulv. No. vi. M. One to be given once in four or six hours, to a child of two years. J ft Tinct. Camph. Opiat., §ss. (12) Vin. Antimonii, Succ. Glycyrrh., Pulv. G. Acaciae, aa. 3u« Aquae Fervent., M. A teaspoonful every two hours, to a child of six months. ft Vini Antimonii, 3j. (13) Ext. Hyoscyam., g. iij. Syrup. Simpl., |ij. M. A teaspoonful every two hours, to an infant from six to twelve months. ft Ext. Belladome, g. j. (14) Syrup. Ipecac, M. From five to ten drops, to a child of « year old, in troublesome cough. RESPIRATORY SYSTEM. 47 on the gums, the affections of the bronchia; are very liable to make their appearance when it is arrested. If, therefore, the mouth be found dry, and the gums swollen, the gums over the protruding teeth ought to be freely divided. In those cases which occur in connexion with the derangement of other organs, and which are dependant on them, the treatment must of course be directed to the removal of the primary cause of the disease. Affections of the liver, which, under some epidemic influence, have preceded the bronchial disease, and on which it appears to depend, must receive our first attention. The object ot the physician must be to restore the healthy action to the liver, by removing its congested state. A full dose of calomel will be required for this purpose, followed in a few hours by some laxative mixture. A free discharge of bilious matter will be tbe best evidence of the relief of the congested liver. In cases exhibiting severe congestion, or inflammation of the pulmonary system, bleeding will be a necessary part of the treatment; and in other respects the treatment need not differ from that adopted in cases of ordinary bronchitis. In the congestive catarrh, described by Dr. Parrish, a similar course of treatment will be needed, as the engorgement of the blood-vessels of the lungs constitutes the disease; but as congestion is accompanied with great loss of vital energy of the system, and, indeed, as it is an evidence of this want of vital power, we should be cautious about abstracting blood, until some degree of reaction is produced by external stimulants. A large sinapism ought to be placed over the chest, and the feet and legs immersed in a stimulating bath. If these means fail in producing reaction, the child ought to be immersed in a warm bath, rendered stimulating by the addition of salt; blisters may then be applied to the legs, and on the appearance of a restoration of the circulation to its ordinary vigor, blood must be drawn as freely as the condition of the child will admit. The most important agent in the prevention of bronchial affections in young children, is the preservation of a uniform temperature ; for the changes in atmospheric heat is one of the most common causes of the complaint. A great deal has been formerly written on the advantages of early exposure to the changes of the air; and even the practice has been urged, of daily immersing a young infant in cold water, for the purpose of hardening it, and enabling it to resist the deleterious influences produced by alterations of temperature; those individuals who, from necessity have been much exposed to atmospheric vicissitudes, having the power generally of resisting the effects of cold. But such practices are extremely reprehensible toward young children, and those who re- 48 DISEASES OF CHILDREN. sist them prove thereby the robust vigor of their constitution. The power of producing animal heat, and, consequently of resisting the effects of external cold, is different in all animals at different periods of life. When young, the natural instinct of all, teaches them to seek the genial warmth afforded by the mother, and her first desire is to impart it to her offspring. Mr. Hunter has proved that the young animal has less heat than the adult, and its power of evolving it much less ;* they must, therefore, be more liable to the baneful effects of cold. From experiments made by Edwards, in the Hospital des Enfants, at Paris, it is evident that the temperature of infants at the time of birth is at its minimum, and that it increases with the advance of age; it is obvious, therefore, that they would be unable to bear the abstraction of heat with the same safety as adults at this early period. This important principle is borne out by some recent French statistics, which show a great mortality, during the cold winter months, among infants, who are taken out at a very early age, at all seasons, for the purpose of being baptized and registered. How important, therefore, does it appear to attend to these matters, as a preventive of the pulmonary affections of children, especially in a climate so variable as ours! I am far from being an advocate of the opposite extreme of complete seclusion and undue tenderness, thereby destroying the stamina, and developing a morbid susceptibility to external cold; but would, on physiological principles, urge a strict attention to the subject, and the adoption of rational views in the prevention of disease in children. In proof of the beneficial effects of constantly maintaining an equable temperature in preventing bronchial inflammations, or, as they are usually termed, common colds, I would mention, that in those families where a temperature of a moderate degree is uniformly preserved throughout the winter, by means of hall stoves, I have had but few instances of these diseases to witness, compared with those where such means of warming the house have not been in use. A remarkable and very unfounded prejudice exists in the minds of some on the subject of warming houses in this manner, not considering that it is far preferable to the warmth of a single apartment which is constantly exposed to the changes produced by the opening of the door, and that in a room warmed by means of an open fireplace, continued streams of cold air are always passing from the crevices toward the fire, and children are thus exposed to the effects of cold. A fire, placed in a stove in the lower part of a house, will preserve a uniform temperature throughout every part; and if all the doors in apartments are kept open, a vast mass * Observations on certaim parts of the Animal Economy, etc., by John Hunter, F. R. S.; London, 1837, p. 134. 49 RESPIRATORY SYSTEM. of air will be thus warmed, which will not be liable to be changed in its temperature by the admission of air from without, as is the ease in a small apartment; while a free circulation is maintained throughout the house by the rarefication produced by the stove in the lower part. pneumonia. This disease is unnoticed by any other than modern writers as an affection of children. The ancients speak only of hoopingcough as a distinct affection, and confound all other pulmonary disorders under the general name of cough; and even among many of our modern systematic writers it has not attracted the attention which its importance demands. Underwood passes it by almost unnoticed, simply mentioning it as connected with pleurisy and pulmonary catarrh. Mr. Burns and Dr. Hamilton scarcely allude to this frequent and distressing disease of childhood, except incidentally, when treating of catarrh and bronchitis. The more recent work of Evanson and Maunsell contains scarcely a page on the subject; that of Dr. Eberle has but little in relation to pneumonia, but some valuable remarks on its kindred affections, acute bronchitis and congestive catarrhal fever, while Dr. Dewees does not mention it at all. Although all these diseases have been considered as distinct, yet there was no attempt, until the essay of M. Duges,* to make any proper distinction between them. The articles of M. Guersent in the Diet, de Med., and the theses of MM. Legert and Denis,j: together with that of M. Brunet|| and Dr. and the extended remarks of Mr. Valleix, furnish the most valuable assistances in the proper diagnosis of the pulmonary affections of children. The paper of Dr. is exceedingly valuable on account of its judicious character, and the highly practical nature of his remarks on the treatment of this affection. The more recent work by MM. Rilliet and Barthez,** has supplied some important distinctions overlooked by other writers, in relation to the precise pathology of the disease, and in showing, also, the existence of the acute form of lobular disease, which had been unnoticed by others. From the investigations of the above-mentioned pathologists, it * Recherchea sur les Mai. les Plus Import, et les moins Conn, des Enf. Nouveau nes; Paris, 1821. t Essai sur la Pneumonie, des Enf.; Paris, 1823. t Recherches Anat. et Physiolog. surquelques Mai. des Enf.; Comercy., 1816. || Mern. sur la Pneum. Lobulaire., Journ. Hebdom., 1833. § American Journal of Med. Science, vols, xiii., xiv. IT Transactions of the Assoc. of Fellows and Licentiates of the King and Queen'* College of Physicians, Ireland, vol. v., p. 28. •* Mai. des Enfans. Affections de Poitrine, Prem. Part. Pneumonie; Paris, 1838. 7 50 DISEASES OF CHILDREN. is evident that pneumonia, in children of tender age, presents char acters which differ greatly from the disease as it occurs in adults. These peculiarities will be noticed hereafter more particularly; it is sufficient here to remark, that its characters are derived from the inflammation affecting the lobules. The period at which it assumes characters corresponding with a similar affection in adults, is fixed, by Dr. Gerhard and MM. Rilliet and Barthez, about the age of six years, seldom exhibiting the same anatomical peculiarities at an earlier period of life. The disease may attack children when in perfect health, or, what is of more frequent occurrence, makes its invasion in those that labor under some other affection, during the progress of which, an insidious form of pneumonia, with very obscure symptoms, often appears. Such cases have been denominated latent, and would often remain undiscovered without the aid of auscultation. The disease, therefore, naturally presents itself under the forms of acute and chronic, or idiopathic and symptomatic pneumonia. Etiology.—Among the predisposing causes is age, which, from the little attention bestowed on the subject until within a few years, would scarcely be supposed to be, as it in truth is, the most frequent. Children between the ages of two and five years, on postmortem examinations, show a greater number of lesions of the pulmonary tissue than is to be found at any other age. In sixty cases of this disease, mentioned by MM. Rilliet and Barthez, forty were between the ages above-mentioned, and twenty from six to fifteen. M. Hache, quoted by these authors, mentions that in one hundred and eight autopsies, he met pneumonic inflammation in seventy-one between the ages of two and five, and but thirty-seven from the latter age to fifteen.* An hereditary tendency, also, is one of the usual predisposing causes, and ranks next to the early period of growth and development. I have had frequent opportunities of noticing the great tendency to pulmonic inflammation in the children of some families. This disease, in its acute form, is more prevalent in the spring and winter; in its chronic and complicated form, it is found to prevail more in the summer season. In many instances it can not be traced to any well-ascertained cause; but variations of temperature, even where they can not positively be ascertained, are doubtless the most common agents in the development of this disease, especially when combined with moisture. The acute variety may arise during the existence of some acute disease, as measles and other eruptive disorders. As to the chronic form, it makes its invasion in the youngest children in a very insidious manner, after an attack of some kind * Op. Cit., p. 77. RESPIRATORY SYSTEM. 51 of eruptive fever; but generally after a chronic inflammation of the bowels. Almost any protracted affection, and the general derangement of the health from this continued irritation, as well as the excitement of the system during the process of dentition, may become a cause of chronic inflammation of the lungs. M. Billard regards the pneumonia occurring in young infants as caused by the state of th* blood in their lungs: the blood under these circumstances becoming a foreign body, and producing its effects by mechanical engorgement ; and adduces, as one reason, the frequency of its occurrence on the right side, from the custom of the nurses in the Hospice desEnfantsTrouves placing the children on that side when laying them down ;* but the frequent occurrence of inflammation of the lungs in the right lobe, in adults as well as in children, will not admit of this explanation being sustained. Semeiology.—The attack of acute pneumonia is for the most part preceded by symptoms of a slight catarrhal affection of indefinite duration, and other evidences of inflammation of the mucous membrane of the bronchia;, which, extending to the substance of the lungs, is soon followed by all the signs of a decided inflammation of the pulmonary tissue. When the disease is fully formed, there is no disease of infancy which presents a higher degree of fever than the one under consideration. The skin becomes hot and dry, the pulse exceedingly active and full, beating from 120 to 160 times in a minute. The pulse, which at the commencement of the disease is generally hard and full, during its progress becomes very feeble, and toward the close almost imperceptible, and is one of the best means whereby a prognosis of the disease may oe made. The cough is dry and painful, and performed with great effort, md is usually either preceded by a cry, or accompanied by some other evidence of pain. The frequency and fulness of the cough «re good signs of the violence of the disease. When the former exists, with marked efforts to resist it, the disease is in proportion serious; when, on the contrary, the cough is infrequent and full, and performed without pain, there exists, comparatively, but slight affection of the lungs. In children, until the age of three to five years, cough usually precedes the other evidences of inflammation; while in those that are older, this symptom shows itself simultaneously with others. The cough is sometimes entirely suspended toward the close of the disease; a return of the cough, after it has for a time entirely ceased, is to be considered a symptom of convalescence. In some cases, the cough indicates the extension of the inflammation to the trachea and larynx, and is known by the hoarse, ringing sound, peculiar to croup. Expectoration, it is well * Op. Cit., p. 406. 52 DISEASES OF CHILDREN. known, never occurs in infants at the breast; or rather, the expectorated matter, which is of a white color, tough and stringy, is never ejected from the mouth except by vomiting. M. Valleix has noticed the discharge of a viscid froth from the mouth, slightly bloody, evidently from the bronchia?, for a similar product was found in these tubes on post-mortem examination. In older children, however, it takes place as in adults ; and a free discharge of mucus is a favorable symptom. The breathing, in acute pneumonia, is very much quickened above its natural standard, and may often be counted from sixty to eighty in a minute. Dr. Cuming even mentions, that in one case of a child of six months there were no fewer than one hundred and eighteen in a minute. The respirations may be intermittent, returning to the natural slowness for four or five respirations, and again becoming frequent, for about the same period. The respiration, as the disease advances, becomes laborious, as is evident from the heaving of the chest, the anxious expression of the face, and the alternate contractions and dilation of the ala? nasi. In some instances the lungs appear to be so loaded with blood, as materially to obstruct the circulation of blood through them ; and if this congested state of the lungs be the most prominent symptom, and is not quickly removed, the jugulars swell, and the face assumes a livid hue, most remarkable in the lips and cheeks, while symptoms of cerebral oppression show themselves. Under these circumstances the disease proceeds with great rapidity, the respiration be comes irregular, the child sighs and gapes, the circulation loses its force, the pulse becomes small and frequent, and the skin cold. Death ensues from the third to the tenth day after the attack. The favorable symptoms are, a diminution of all these symptoms of inflammation and congestion, and of the violent constitutional disturbance, such as restlessness and wakefulness, connected with them ; while the bronchial mucous membranes secrete freely, and the healthy action is restored to the skin, and the secretions generally show an abatement of the diseased action, and a return to the due performance of the functions of the system. The chronic form which appears in children where the constitution is impaired by other diseases, is very insidious in its attack, and not unfrequently has proceeded to a fatal termination, with scarcely a suspicion existing of its nature. At other times it shows itself by a short cough, at first dry, afterward with the usual signs of a secretion in the bronchia?, and frequent respiration, varying from thirty-five to seventy in a minute; the face is partially flushed, and in severe cases, livid. In the generality of chronic cases, however, the skin is cool, face pale, and great emaciation exists, while the extremities are cedematous. RESPIRATORY SYSTEM. 53 In nearly all chronic cases there exists more or less derangement of the digestive system, and diarrhoea is a very common attendant on this affection. Diarrhoea usually continues throughout the whole period of the'disease, and consists of green liquid matters. The tongue is moist, and covered with a yellow fur in the most chronic cases; such as approach more nearly to the acute form, the coating is whitish. Vomiting is of rare occurrence, except when induced by severe fits of coughing. The appetite generally is not impaired, but becomes so in proportion as the disease loses its chronic character, and where the dyspnoea is extreme, is almost gone. The physical signs of pneumonia are important in the diagnosis of the disease. In the peculiar form of the disease in young children, that in which the lobules are the seat, percussion, according to Mr. Valleix, is of little avail in detecting its existence ;* Dr. Gerhard, on the other hand, asserts that percussion is frequently of more utility than auscultation, as a means of diagnosis in lobular pneumonia.t This discrepancy appears to arise from not sufficiently discriminating the different periods of the affection, for it is unquestionably true, that in the early periods of the disease, in its chronic state, when there is but little development of the disease, and the inflammation is scattered over a large surface, with intervals of healthy lobules, but little or no alteration will be found in the sound of the chest on percussion. It is probably only useful when the lung has become indurated or hepatized to some extent, and it is to such cases that the remark of Dr. Gerhard applies, as would appear from the anatomical details of his cases. When the disease has arrived at the stage in which the change is appreciable by percussion, a dull sound will be heard, in proportion to the extent of the induration ; and when the induration occupies the greater part of the lung, the sound is decidedly flat. Nothing, therefore, can be expected to be derived from this method of examination until a considerable change has taken place in the lungs. It is not so with common lobar pneumonia, or simple pneumonia, as it is called by Valleix; here obscurity of sound, varying to complete dulness, is perceptible in every part of the affected portion of the chest, strongly in contrast with the clearness of the healthy portion. This indication of disease often extends with surprising rapidity, and in a few hours, an acute pneumonia, will change its boundaries to a great extent. None but such as have made the experiment can fully appreciate the important information which this fact conveys ; and the rapid progress of the disease thus proved, shows how valuable are the few hours at the commencement —op- for treatment never to be regained when once neglected. The peculiar form which infantile pneumonia assumes, will also •Op. Cit., p. 135. f Amer. Jour., vol. xv., p. 101. 54 DISEASES OF CHILDREN. often prevent the discovery of auscultatory phenomena early in the disease, when the affected lobules are widely scattered. But although, when there scarcely exists any rational symptom, the stethescope detects the presence of mucous or subcrepitSnt ronchus, at times mingled with dry ronchus : the subcrepitant ronchus often exists throughout the whole of the disease. Bronchial respiration is usually not developed until toward the termination, when the induration has extended to a considerable portion of the parenchyma. This remark, of course, applies to the slow insidious form of pneumonia ; for in the active form, as well as in lobar inflammation, bronchial respiration is always found ; in the last mentioned, being heard over the entire lung, while in the former, when the case is examined sufficiently early, in a portion of it, but rapidly extending. In those cases, indeed, where from sudden and excessive congestion of the lungs, and the closure of the bronchia;, the respiration ceases entirely in these tubes, bronchial respiration of course will not be heard. Although, therefore, percussion and auscultation are, together, the means of ascertaining the existence of pneumonia, yet where the latter fails to procure the pathognomonic sign of the disease, other symptoms connected with the rapidity of its development will come in to perfect the diagnosis. Pneumonia may be distinguished from pleurisy by the following physical signs : The same dulness is observed on percussion ; and although in both, extending widely with great rapidity, yet in the latter disease it is unattended with the excessive disturbance of the system noticed in the rapid extension of pulmonary inflammation. While in both the dulness exists, in pleurisy there is nothing of the subcrepitant or mucous ronchus. The distinction between pneumo nia and bronchitis is not difficult, if the symptoms already detailed are borne in mind. W T hen the mucous or subcrepitant ronchus is heard in the latter disease, it is uniformly on both sides. This is the only auscultatory sign that may cause these diseases to be confounded. When it is heard at the lower portion of one lung, it is to be regarded as the commencement of pneumonia. Morbid Anatomy and Pathology.—One of the most remarkable distinctions between the inflammation of the lungs in adults and children, and which has already been alluded to, when speaking of the symptoms, is the affection of separate lobules, instead of a continuous inflammation of the entire pulmonary tissue, which characterizes the disease in the former. This is the form which the insidious invasion of the disease assumes, and which renders its detection«often difficult, and without the aid of auscultation, in many cases impossible ; for on dissection, small, distinct indurated portions will be found in the midst of lobules free from disease, or very slightly inflamed, while the patient during life, presented but few RESPIRATORY SYSTEM. 55 -distinctly marked symptoms of pulmonary affection. This inflammation of the lobules is what characterizes the diseases of the lungs in infancy and early childhood, as it is never found after the age of five or six years. Young children, however,f*jiay also be affected with an inflammation of the lobes of the lungs in the same manner as adults are affected, but never, after the age above mentioned, has it been found to partake of the lobular form. While, therefore, autopsical examinations show that the partial, lobular, latent pneumonia ought to be regarded as a peculiarity of the disease in young children, they still have, at times, the true pneumonia of adult age, inflammation affecting the entire lobe ; the former being, in a great number of cases, a chronic affection, and such as we might expect to meet with in debilitated subjects, and among those that are treated in public hospitals; the latter occurring in those that are of a robust habit of body, attacked either during health, or while laboring under the influence of some acute disease. The first stage of lobular pneumonia or induration, exhibits the cut surface of the lung of a marbled appearance of a grayish rose or red color. These red spots are circumscribed to a greater or less degree, and are easily torn; they float in water, and crepitate when pressed. The second stage is that which is usually met with on dissection. The exterior of the lung is generally found quite soft, and of a gray color, inclining to a rosy teint; prominent circumscribed spots have %lso been seen, of a firm consistency, and of a violet color. These spots are usually circular, but occasionally vary from that form, and present an oval appearance from above downward; they are observed mostly in the posterior part of the lung, but have occasionally been found in other parts of the organ. The incised surface appears mottled with spots of a grayish rose color, to a deep violet. The dark spots noticed on the external surface of the lungs penetrate the substance, and are, unquestionably, the result of inflammatory action ; and all the alterations of structure observed in different parts of the lungs, are from the same cause; differing in no respect from similar disordered action affecting the same tissue in adults. The third stage is that of suppuration. This condition, according to MM. Rilliet and Barthez, may easily be overlooked, as the color of the lungs has returned to their natural state; but some of the lobules will be found more prominent than the others, and on being cut and pressed, pus will be found to ooze from the surface. Abscesses have also been discovered in this form of pneumonia; and cavities exist, from the size of a hemp seed to that of a pea, .and in some instances communicating with the bronchia;. These lobular inflammations may increase to a great number, un- 56 DISEASES OF CHILDREN. til the entire lung is affected, producing a complete alteration in the appearance of the lung, and which has been denominated by the authors just mentioned, lobular pneumonia generalized. Other alterations Jfave been found in the lungs of young children, presenting, when cut, a number of granulations of the size of a millet seed, of a yellowish color, containing a fluid of a purulent nature, which can be squeezed out when cut. Again it has been found shrunken, of a violet color, with white lines marking the divisions of the lobules. The cut surfaces of the lungs appear smooth and red, resembling muscle in their structure, and without crepitus on pressure. The violet color shows that it differs from the hepatization of adults, while it bears a resemblance to the condition described by M. Louis, under the name of carnification, and has been so denominated by those who have investigaled the pathology of children. All writers agree as to the frequency of double pneumonia in children, a circumstance of very rare occurrence in adults ; but like the disease in the latter, when it is confined to one lung, it is most usually the right lobe that is affected. The complication of pleurisy with pneumonia is very frequent in adults, but pleuro-pneumonia is very rare in young children. In one hundred and twenty-three cases which came under the notice of M. Valleix, pleurisy occurred only in twenty instances; a fact whieh was before noticed by Dr. Gerhard in the paper already referred to. In young children, all their affections are more or less complicated, with evident derangements of the chylopoetic viscera; and in the disease before us, lesions of the intestinal canal exist, principally of a chronic inflammatory nature, as appears from the condition of the mucous membrane. Such is the amount of our knowledge on the subject of the pathology of pneumonia of young children; important, inasmuch as the frequently insidious progress of the disease—so slow and imperceptible as to have received the name of latent—might often put us off our guard until the affection has made a fatal progression. When the invasion is sudden and well-marked, it will matter but little whether the disease be strictly lobular or lobar; but as it is proved that the former affection is a peculiarity of young children, and that pathological anatomy has demonstrated the existence of a serious and fatal lesion formerly unsuspected, it will be our duty to ascertain, by the means which modern science has placed in our hands, the existence or non-existence of such a form of disease in protracted cases of infantile affections, and by the timely discovery, to apply the appropriate remedies for its removal. As to ihe pathology of lobar inflammation, it differs in no respect 57 RESPIRATORY SYSTEM. from that of adult age. This, as was before remarked, may occur in children at every age, although some have been of opinion that it never appears until after the age of six years; and M. Berton asserts, that it is not until the age of fifteen years that pneumonia assumes all the pathological characters peculiar to the disease ir adults.* Among the effects of inflammatory action in the lungs, is the infiltration of in their tissue, forming a real oedema of the lungs. This condition is generally attended with very laborious respiration ; but in some cases, extensive oedematous effusions have been found, without this condition having been manifested during life. Mr. Gardien mentions that it will be found without the presence of any antecedent lesion, and after symptoms which threaten immediate suffocation. But this generally is not the case, for it is usually complicated with bronchitis, pleurisy, and pneumonia, and is evidently the result of extensive inflammation in the various tissues and membranes of the lungs. Treatment.—In severe acute pneumonia, the success of the treatment mainly depends on the early period at which the treatment is commenced, and the promptness with which the proper remedies are applied; and, although one of the most violent and serious affections which a physician has to encounter, yet there is none more completely under his control than idiopathic pneumonia. A delay of twenty-four or forty-eight hours may place the patient entirely beyond the relief of remedies. The disease, as was before remarked, when considering its symptomatology, is astonishingly rapid in its progress, involving successive portions of the lungs in its influence, with a quickness, as revealed by percussion, which soon places it beyond the control of art. It is therefore his duty to attack it at once, and extinguish it at its commencement. The first indication clearly is, to arrest the inflammation by the appropriate remedy of blood-letting, proportioned to the age and constitution of the child, and the violence of the inflammatory symptoms of the disease. On the subject of general blood-letting in children, a difference of opinion has existed among physicians. Dr. Cuming,t Clutterbuck,} and others, are strong advocates for its use. Sydenham, also, observes that it may as safely be performed in children as in grown persons, and adds, that " it is so necessary in the peripneumonic fever above mentioned, and in some other disorders to which children are subject, that there is no curing them without it." || On the other hand, Professor of Edin- * Traite des Malad. des Enfants, etc., par A. Berton ; Paris, 1837, p. 478. t Op. Cit., p. 48. } Lecture on Blood-letting, republished in Bell's Select Medical Library. H Account of the Measles of the year 1670. $ Hints for the Treatment of the Principal Diseases of Infancy and Childhood, p. 84. 3 58 DISEASES OF CHILDREN. burgh, Billard,* and some others, principally French and Germa* physicians, disapprove of its use, and recommend leeches as a substitute. Dr. Hamilton objects, it would seem, to the loss of blood in any form in children. There exists in the minds of some a great dislike to the use of this remedy in children; but believing that the fears so often entertained are'in many instances groundless, I can not too strongly urge its employment where the attack is recent, and the child in the possession of ordinary vigor, Hiving so repeatedly seen the immediate benefits of this course. It is an error to believe that children do not bear the loss of blood with advantage in inflammatory diseases. They indeed, when the remedy is judiciously and early employed, appear to be more decidedly and promptly relieved than adults, arising doubtless from the simple and uncomplicated nature of diseases in the former. It also arises from their peculiar condition as growing creatures, where the interstitial action is in a state of activity bordering on inflammation, causing their inflammatory affections to assume a violence of character which causes a rapid occurrence of fatal symptoms. Young children do not bear the repetition of venesection well, and when the further abstraction of blood is necessary, leeches must be applied to the axilla of the affected side. Immediately alter the employment of blood-letting, a purgative will be found serviceable, both as a revulsive to the intestines, and for its agency in promoting the secretions from the liver and intestinal mucous membrane. There is no class of remedies, however, which appears to exercise so little influence on pneumonia as purgatives ; they should therefore be regarded only as assistants to the general treatment, and used principally to remove the foecal accumulations which are so apt to occur in febrile affections generally. The action of the purgative should be prompt and efficient; for this purpose, calomel, combined with jalap and ipecacuanha, is what I have been in the habit of using. Jalap is an excellent adjunct to other purgatives in children, for its operation is not confined to any particular portion of the intestinal tube ; a copious secretion usually follows its use, and when combined with ipecacuanha, as in the subjoined prescription, makes an excellent purgative powder for inflammation of the chest. To keep the bowels free, one or two grains of the same powder may be given every hour to a child of a year old.t After the operation of the cathartic, if the lungs are still much * Op. Cit., p. 269. (15) t ft Subm. Hydr., gr. v. Pulv. Jalap., 3ss. Pulv. Ipecac, gr. v. Sacchar. Albi., gr. x. M. From 2 to 5 grains every third hour. 59 RESPIRATORY SYSTEM. oppressed, it will be proper to administer an emetic ; and antimoniaV. emetics are, in general, used for that purpose, as their operation is beneficial, not only in relieving the loaded bronchia; of its secretion, but also in restoring the equilibrium of the circulation. Where antimony is deemed hazardous, from the tender age of the child, syrup of ipecacuanha may be substituted, as recommended in the preceding article. The effect, however, of emetics, is not so beneficial in this disease as in simple bronchial inflammation, attended with a free secretion of mucus. Revulsives should by no means be neglected, but the feet and legs ought to be early immersed in a stimulating bath, especially when the violence of the inflammatory symptoms is in some degree abated. During the continuance of the inflammation, diaphoretics should be constantly used, and any emetic substance acts in this manner when given in small doses ; these, and the expectorants recommended under the article on bronchitis, are applicable to the disease before us. When the inflammatoty symptoms are in some respects removed, and the heat of the skin and fever is abated, while evidences of pulmonary congestion or irritation continue, blisters will often be found of great service, applied over the affected part. When secretion becomes free in the bronchia;, the treatment must be directed to the relief of the symptoms arising from excessive secretion in these ttlies, by the use of emetics, which may be varied according to the* circumstances of the case ; the treatment differing but little from bronchitis, to which subject the reader is referred for the use of the different expectorants and emetics. The treatment of chronic pneumonia is based upon the same principles which should direct us in the management of the acute form of the disease; all our efforts being directed to diminishing the quantity of blood passing through the lungs. In general, bloodletting should be by leeches, or scarification and cups ; which latter method many practitioners prefer, on account of the facility of ascertaining the quantity of blood thus taken. After the abstraction of blood, if this is deemed necessary, as in some debilitated cases it might be deemed hazardous to have recourse even to the smallest quantity of bleeding, revulsives are the remedies principally to be relied on: stimulating baths to the lower extremities, sinapisms to the chest and back. Dr. Gerhard mentions that no bath is superior to the sulphur bath in chronic cases of pneumonia, taking care that the child's face be not exposed to the vapors arising from it, and that he be removed before symptoms of exhaustion arise. The bowels should be kept open with mild laxatives ; and when the disease is connected with an inflammatory affection of the mucous membrane of the bowels, and protracted diarrhoea, the remedies 60 DISEASES OF CHILDREN. recommended under that head must be associated with the treatment. When not counter-indicated by the presence of other symptoms, the use of the more stimulating expectorants will be found necessary. Coxe's hive-syrup, the compound syrup of squills, in doses of five to ten drops every three or four hours, to a child of two or three years, may be found useful for this purpose; or where more stimulation is needed, the subjoined prescription.* PLEURISY. Pleurisy is a disease of greater frequency in young children than is generally supposed, although occurring less often than either bronchitis or pneumonia ; owing probably to the fact that this membrane is less exposed to the immediate influence of the action of the atmosphere. MM. Rilliet and Barthez, on the contrary, say they have very rarely met with simple pleurisy unconnected with other pulmonary inflammation, between the ages of two and five years. Although comparatively rare in young infants, it is found to occur as frequently in children from the age of three years and upward as in adults, and with the same violence. In younger children its appearance is usually insidious, its progress slow, and its character either sub-acute or chronic ; but violent acute pleurisy may occur at any age, as I have repeatedly seen, if anything like diagnosis can be depended on. Etiology.—The causes of this affection are those in general which produce inflammatory diseases, of which cold, applied to the surface of the body, is the principal. As this has been already considered, and the inferences arising from it as to the prevention of disease, have already been alluded to under the article on bronchitis, it is unnecessary here to repeat them. Semeiology.—When acute, pleurisy commences with the usual symptoms of inflammation : chills, succeeded by febrile excitement. There is great restlessness, and evidently severe pain, as the constant crying of the child indicates. When the pain allows the cry to be free, it is heard clear and distinct, without any other alteration, except such as arises from pain and exhaustion. In addition to restlessness, there exists great difficulty in the attempt to fill the chest: and the dilatation of the thorax is made with great pain, and accompanied with marked contractions of the abdomina * ft Rad. Seneg., 3ss. (16) Infus. in s. q. Aq. Ferv., per | hor. colatur, ?iv. Adde, Ammonia? Hydrochl., 3ss. Syrup, althaea.', A teaspoonful every hour, to an infant of six months. 61 RESPIRATORY SYSTEM. muscles. This distress is increased when the child lies on one side. Although at times disposed to cough, yet it is often arrested, from the pain attending the effort. As the disease advances, the difficulty of breathing increases ; the pulse loses its force ; the eyes appear sunken and livid; the extremities cold and cedematous, and a comatose state ensues before death takes place. The disease, however, is sometimes destitute of these stronglymarked symptoms, and will make its advances with signs so obscure, as to render it difficult to detect its presence. The child, in the incipient stage, is for a time languishing and feeble, daily losing its flesh, and crying, as if suffering from some continued distress, which increases on lying down. It will therefore be necessary, from the obscurity of the rational symptoms, to ascertain, from the physical signs, the existence of this or of some other pneumonic disease. It is extremely difficult, it has been asserted by Billard, Rilliet, and Barthez, to ascertain precisely the presence of pleuritic inflammation, as both percussion and auscultation give very uncertain signs of the disease. Unless there also exists some degree of effusion, the physical signs are obscure ; they, however, consist of dulness on percussion, and the presence of bronchial respiration. The dulness affects the entire part of the side affected with the disease, while there is less violence in the symptoms than attends a similar extent of pneumonia. As the inflammation decreases in convalesence, the subcrepitant ronchus is not heard, as in pneumonia. Morbid Anatomy and Pathology.—In acute pleurisy adhesions are found, which, in cases of short duration, are easily separated; a condition entirely different from that which arises in protracted or chronic disease. Besides these, plastic exudations between the pulmonary and costal pleurae, effusions of lymph, purulent matter, or sero-purulent fluid, are found in the pleural sac. The membrane itself is usually spotted with a number of red points. In chronic cases there exist more extensive adhesions of a firmer character, with appearances of granulations, and evidently of a longer standing. Treatment.—On the first appearance of acute pleurisy, blood must be freely taken from the arm, and permitted to flow until a slight effect is evidently made on the circulation, known by the increasing softness of the pulse, and the paleness of the face. If the child be old enough to describe his feelings, the same rule should be observed as in treating the same disease in adults ; the pain should be evidently lessened. On the return of fever, pain, and the usual accompaniments of inflammation, leeches ought to be applied to the affected side. When the constitutional symptoms are relieved, a blister may be advantageously applied, with the precautions already suggested on that subject. The bowels ought also to 62 DISEASES OF CHILDREN. be opened, and kept in a soluble condition, by means of neutral salts, or the formulas mentioned in p. 45. Nitrate of potass has been recommended as a. suitable refrigerant and antiphlogistic, in pleurisy of children, as it so sensibly relieves the heat of the body, and diminishes the frequency of the pulse. But, although generally useful in adults, in delicate subjects it has been found to disorder the functions of digestion and assimilation; it is, therefore, inadmissible in the case of young children, uncombined with some article to prevent its too irritating action on the mucous membrane of the stomach; although Henke prescribes it in childhood, in all those diseases for which it is given in adults. Dover's powder is the best for modifying its influence, besides the advantage which may be derived from its controlling the circulation, and relieving the general irritability of the system. The subjoined formula is a form of combination,* which will be found very suitable for children, as there seldom exists a disease in them, without the presence of gastric derangement, or its supervention, during the progress of their diseases. In very robust children, where there is much difficulty in restoring the secretions generally, a combination of calomel, antimony, and nitre, will be sometimes found advantageous.t Where there exist symptoms of effusion, diuretics will be required, and acetate of potash is one peculiarly suitable for children, especially in chronic cases, as it possesses deobstruent qualities, and may thus assist in relieving visceral obstructions, which not unfrequently complicate their chronic affections. In cases of much irritability, digitalis is a powerful medicine for controlling the frequency of the pulse, influencing the capillary circulation, and increasing the urinary discharge. Its use is therefore indicated in inflammatory affections, attended with serous effusions. It may be given to children under a year, in the dose of one eighth to one fourth of a grain twice a day, or it may be administered in infusion, which is probably the best method of using it.} • The medicine produces a feeling of nausea and languor when the system is under its effects, and when excessive, blindness and vertigo succeed; its operation, therefore, should be carefully watched, and its use suspended for a while, until these untoward symptoms have disappeared. The best antidotes to an over-dose * ft Potassae Nit., gr. ij. (17) Pulv. Ipecac., gr. Pulv. Doveri, gr.j. Carb. Sodae, excic, gr. j. M. To be given every two hours, in a .itlle barley water. tft Potassae Nitr., gr. xx. (18) Hydr. Subm., gr. j. Antim. Tart., gr. J. Of this, two or three grains may be given every second or third hour. } Fol. Digital.,gr. viij. (19) Aquae Ferv., ?iij. A teaspoonful may be given to a chil from two to four years, every three hours. RESPIRATORY SYSTEM. 63 of digitalis are stimulants, a little weak brandy and water, or an infusion of serpentaria, while a blister is applied to the pit of the stomach. For the purpose of more fully directing its effects to the kidneys, a few drops of the syrup of squills may be added to each dose, and ten or fifteen drops of the spirits of nitre may be given in the child's drink every three or four hours. The remarks generally on the subject of pneumonia and bronchitis are applicable to the disease now under consideration, except that but little advantage is to be derived from the employment of expectorants, as might be supposed from the seat of the affection. CORYZA. The flow of mucus from the nares, which is known by the names of coryza, gravedo, or snuffles, arises from an inflammation of the mucous membrane lining the nasal fossa?. It is, when protracted, a distressing disease in young infants, as it prevents their sucking; respiration being in a great measure arrested, the child is compelled frequently to stop sucking in order to breathe. It appears under two forms, the simple, which may be either acute or chronic, and the malignant, as described by Drs. Denman and Underwood, agreeing with the pellicular, as it is termed by Billard. ETiOLOGY. —The ordinary cause of inflammation in the pituitary membrane, is that common to all inflammations of the respiratory organs, the application of cold to the surface of the body, either by improper exposure, or from negligence in not changing their clothes when wetted with urine. Another cause is the direct influence of the solar rays and light, when children are first taken out early in the spring for an airing, when unaccustomed to the effects of the sun ; hence the popular idea of the unhealthiness of the sun in the month of May, as young children are observed to sneeze often when thus exposed. first symptom of this affection is sneezing, which is soon followed by a secretion of mucus from the nostrils, at first clear. The child being unable to breathe through the nose, as usual, lies with the mouth open when asleep. As the disease advances, the secretion increases in quantity and consistence, and the difficulty of respiration increases in proportion. The discharge, at times, completely closes the nostrils, and prevents sucking, from the impossibility of breathing; he frequently leaves the nipple, manifests fretfulness and distress, while the face becomes purple from obstructed respiration. There is sometimes danger of immediate suffocation when the nostrils are stopped with the secretion, on account of the mouth being also filled with the nipple and milk; under these circumstances, also, the child is in danger of suffering 64 DISEASES OF CHILDREN. from inanition. This, however, is an extreme case ; and in general it is a disease of little danger, although exceedingly annoying to the child. The malignant variety described by Dr. Denman, is, on the contrary a very serious and fatal disease. It appears to prevail mostly among children of bad habit of body, and is therefore found among those that suffer from defect of nourishment, and who, from breathing an atmosphere filled with impurities, are exposed to all the consequences resulting from these combined causes of deterioration in the fluids. Cerebral affections are the most ordinary complications of coryza, from the proximity of the inflammation to the brain, and the arrest of the circulation from the obstruction of the respiration; drowsiness often occurs during its progress, and when fatal, frequently terminating in convulsions. Morbid Anatomy.—A great degree of tumefaction exists in the nasal mucous membrane, with evidences of severe inflammation, being very red and soft, and the passage filled with thick mucosity. The malignant or pellicular variety exhibits the formation of a pseudo-membranous lining, covering the whole nasal fossae, and in some instances it is said to have extended back to the fauces, oesophagus and stomach. Treatment.—The treatment must consist of such measures as will allay inflammation: this, however, is often so slight, that it scarcely requires those active agents which are usually employed. The principal source of distress, is the abundant secretion, the existence of which shows that nature is taking the proper course for the relief of the phlogosed membrane. Laxative drinks, made of infusion of prunes, or manna dissolved in milk, by boiling, may be given to a young infant; and in cases with evident febrile excitement, some saline cathartic, or a little calomel may be needed. Where sucking is materially interfered with, from the closure of the nostrils, the child will have to be removed from the breast, and fed with a spoon, until able again to swallow the milk drawn from the nipple. In severe cases it may be requisite to apply a leech at the side of the nose, and a small blister behind each ear. In the malignant form, the same principles of treatment must be pursued. Dr. Underwood recommends castor oil particularly as a laxative in this disease, observing that debilitated children endure purging under this complaint better than in almost any other; he recommends one or more teaspoonfuls, so as to procure three or four motions daily. As the bowels show great derangement, an attention to them is necessary to a successful treatment of the disease; and much greater benefit is to be derived frpm removing the acrid secretions and'accumulations, than by attempts to neutralize and re- RESPIRATORY SYSTEM. 66 move their acrid qualities by absorbents. Antispasmodic enemata should also be given on the appearance of convulsions. Opiates, also, are useful; and the syrup of poppies is an excellent means of calming the nervous irritability, and should be given every night, after the operation of the laxative. Under this plan of treatment the disease will yield in the course of two or three weeks ; but it will be necessary to use some purging medicine after the discharge has stopped. The snuffling will often recur some time after the disease is to appearance cured; it will then be useful to foment the nose with infusion of camomile or elder flowers, and afterward apply some aromatic liniment.* The removal of'the tenacious and acrid secretion from the nose, appears to be a necessary means of cure. After the inflammatory symptoms have subsided, it is recommended, by Billard, to have recourse to some extraordinary measures for its removal, as blowing gently a little fine calomel, or a mixture of sugar and alum finely powdered, into the nostrils ; *before this, it will be sufficient to rejj§ move it gently by means of a soft rag. CROUP. This distressing and often fatal disease of childhood, has, within fifty years, received much attention from physicians; a great number of essays, remarkable for the patient and learned investigation they display, having appeared, to illustrate its pathology and nature. From this circumstance, also, various appellations have been given to it, according to the views of the different authors who have directed their attention to the subject. It has, accordingly, been described under the names of asthma infantum, angina suffocativa, suffocatio stridula, morbus strangulatorius, angina membranacea, sive polyposa, tracheitis infantum, laryngo-tracheitis, diphtherite tracheale, etc.; all which names express some of the most prominent symptoms of the disease. The name croup, probably, is the best that can be employed, from its long use, and its adoption in other languages; thereby sufficiently indicating the disease, without being identified with the peculiar speculative opinions of any author, or without taking any one remarkable symptom, occurring in one stage only of the affection, as a type of its nature throughout its entire progress. Croup is a disease which was formerly singularly fatal ; the majority of those attacked with it dying. As its pathology is now bet ter understood, an improvement in its treatment has very sensibly lessened its mortality. Vieusseux states, as the result of his experience, that of twenty cases occurring under his notice in the early •Treatise on the Diseases of Children, etc., by Michael Underwood, M. D., p. 11 9 66 DISEASES OF CHILDREN. part of his practice, (1775), ten died ; while at a much later period, the relative mortality was very small, and nearly all were cured ;* and from the observations of J urine, made from the closest calculations, the proportion, at the time he wrote, (1812) is stated to» have been one in ten. Other statements, made at different places, go to confirm the fact of the improvement in practice, in its adaptation to the nature of the symptoms, and the violence and rapidity of its progress. Michaelist and Bard} state the mortality as in the proportion of two out of three. It must, however, be acknowledged, that there are a variety of circumstances controlling it, which render an exact computation of the proportionate mortality at different periods, a difficult task. Yet there can be no question as to the increased amount of cases that are cured ; the majority being now on the side of those who live, the reverse of the result of the cases occurring half a century ago. It has been a question with some, whether this disease was known •to Hippocrates, Celsus, Galen, and other ancient authors, from the difficulty arising from the infrequency of post-mortem examinations, in enabling us to ascertain whether it was a disease described by them. That it has existed at all periods, and among all people, as the causes have always existed, can not admit of a question. It has been found among the aborigines of our country, prevailing with great severity and fatality.|| Dr. Coxe, in a learned essay,§ says, that from the first moment that medicine was cultivated as a sci- ence, croup has been the subject of observation ; and although not described as a distinct disease, yet records of an affection identical with this disease, are found in the writings of Hippocrates, Rhazes, and Avicenna, and in later times, in those of Platerus, Fabricius, Etmuller, Sylvius, Vigo, Ramazzini, Willis, and others. Martini Ghisi, of Cremona, gave a clear description of it, as it prevailed very extensively in that place in the early part of the last century. *[[ It was, however, reserved for Dr. Francis Home, in 1765, to give a full practical account of this disease, and to designate more clearly than had before been done, its distinctive characters. The next in order, and the first American writer, is Dr. Rush, who addressed a letter to Dr. Millar, in London, and giving as his opinion, that croup is always spasmodic. In a subsequent work,** he, however, admits his error in regarding croup, in every instance, as a purely spasmodic affection, and that experience had satisfied him of the * Memoire sur le Croup, p. 1. t De Angina Polyposa, etc.: Gaetting. 1778. } Inquiries into the Nature, etc., of Ang. Suffoc. by Samuel Bard, M. D., 1771. H J. D. Hunter, N. Y. Medical and Surgical Journal, vol. i., p. 311. § American Journal Medical Science, vol. iii. •ffLetterae Medichia?, 1784. ** Medical Inquiries and Observations, 1794. 67 RESPIRATORY SYSTEM. existence of another form, which, from the presence of mucus in the trachea, he denominated cynanche trachealis humida, and distinct from cynanche trachealis spasmodica. Dr. Samuel Bard, Professor of Medicine in King's College, New York, published an essay, in 1771, on angina suffocativa, which is clearly the secondary form of croup, occurring after severe inflammatory affections of the fauces and tonsils, and which has, within a few years, been particularly described by Bretonneau and others, under the name of diphtheritis. A few years after, Dr. Chalmers, of South Carolina, directed his attention to the inflammatory affections of the larnyx and trachea in children, and described with great minuteness, the disease now under consideration.* In the year 1780, Dr. Middleton, Professor in King's College, in a letter to Dr. Richard Bayley,t made a distinction between genuine croup, and that form which had been known under the name of the sore throat distemper.} About the same time, Vieusseux, of Geneva, received the prize of the Royal Society of Paris for the best essay on this subject. From this period there is no disease which has attracted so much the notice of physicians, and on which there has been so much written ; receiving from every one a name, designating his peculiar views of its nature. In Great Britain, Germany, France, Russia, and the United States, a great number of monographs have been published ; and, as might be supposed, from observations made under the varieties of circumstances arising from difference of climate, mode of living, etc., much diversity of opinion would exist as to its nature and treatment. Most of the cases, also, especially in continental Europe, have been described from those that have terminated fatally. It would, therefore, be difficult to recognise the mild forms or stages of the disease from descriptions taken exclusively from these cases ; and thus another cause will be found for the differences of opinion in reference to its nature and treatment. In addition to the ordinary interest felt by physicians in investigating disease*, an additional inducement was offered by the Emperor Napoleon, on the occasion of the death of a son of Louis Bonaparte, king of Holland, in 1807. The prize offered for the best essay, was adjudged to two of seventy-nine that were presented ; one to Jurine, of Geneva, and the other to Albers, of Bremen. There are, therefore, abundant sources of information on the * An Account of the Weather and Diseases of South Carolina, by Lionel Chalmers, M. D.; London, 1776. fNew York Medical Repository, vol. xiv., p. 347. | For a full account of the early American writers of Croup, see Dr. J: B. Beck's paper in the New York Medical and Physical Journal, vol. i. 68 DISEASES OF CHILDREN. subject of croup, from men of acute observation, rich experience, and philosophic minds. Indeed, on no subject has there been more talent and investigation bestowed ; none, perhaps, where they have been followed by more practical results; for the very differences of opinion have arisen, in part, from causes which go more clearly to illustrate the nature of the disease, and the advantages of its practical division into different stages. These remarks apply more particularly to croup, when caused by an inflammation in the mucous membrane of the trachea, or the inflammatory variety ; the other, or spasmodic croup, will receive a distinct consideration. Although several able writers, among whom are Bard, Hosack, and Blaud, have expressed an opinion, that there exists no- other form of the disease than that arising from inflammation, yet there is unquestionably a variety which arises from a spasmodic affection of the epiglottis; for in some fatal cases no traces of inflammation whatever have been found.* It is not necessary for disordered action or derangement of function to occur, that a state of inflammation should in every case exist; the excitement of the nerves, and the spasmodic contraction of the muscles, independent of inflammation, are evident in galvanic experiments; and simple mechanical pressure will at times produce a derangement of muscular action. While some have maintained the existence of inflammatory croup as the only form to be met with, others Schenk, Des Essartz, and Lobstein, contend that it never is an inflammatory affection. It is evident, however, that the exclusive views of both are erroneous; yet those who maintain the former opinion are much nearer the truth, for inflammation constitutes the disease in the greatest number of instances. INFLAMMATORY CROUP. Etiology.—The peculiar condition of the system in infancy and childhood, is the most prominent predisposing'cause of this affection, for it is rarely found in after life; the instances in which it occurs in adults, are so exceedingly few in number as to be regarded as curious instances of departure from the almost uniform law which appears to control its formation. This predisposition is doubtless in some degree connected with the condition of the larynx, and is probably dependant on the imperfect development of the part, but in what manner it is impossible for us to explain. Dr. Cheyne regards it as arising from this cause, and • See cases by Mr. Pretty, Lond. Med. and Phys. Journ., vol. iv. Also a case by Mr. Davis, Lond. Med. Rep., vol. rviii. RESPIRATORY SYSTEM. 69 remarks, that there is scarcely any difference in the size of the opening* of the glottis of a child, at the age of three years and at twelve ; after the latter period the aperture is suddenly enlarged, and in the male an alteration of voice ensues. The most accurate observers have noticed that it rarely occurs during the first few months after birth, but prevails more among children from the age of two years to five ; after the age of twelve it is rarely seen~ Boys are more subject to it than girls, according to the experience of Jurine, Albers, and Bla^id.* Children of robust habit and body, and who abound in blood,, are, from this circumstance more predisposed to croup, as they areto all inflammatory diseases. Peculiar districts of country, where there is great variety in the temperature, predispose children much more to this disease than sections where either much cold or dampness prevails, as has been remarked by writers who have noticed closely the effects of different conditions of the atmosphere. Vieusseux says, that the town of Geneva, although not so damp as the borders of the rivers or the bottoms of valleys, is yet more subject to the prevalence of croup, from the sudden changes of the atmosphere, from heat to cold, and from cold to heat.t These remarks are confirmed by observations made in this country by Drs. Rush, Currie, Stearns, and Archer, in their publications on this subject; although Dr. Home and others have stated, that it is particularly confined to maritime situations. I have also remarked the effects of sudden atmospheric vicissitudes, in forming this disease. Another predisposing cause is to be found in the manner of clothing children with the neck and breast bare. It has been observed, that croup is a very rare disease in Germany, where the custom prevails of clothing the children very carefully, and completely covering the throat with their dress. Dr. Eberle also remarks, that he saw but one case of croup in a number of years, among a large population of Germans, whose manner of clothing leaves no part of the breast or lower part of the neck exposed.} This affection, although found at all seasons, more frequently prevails in autumn, winter, and the early part of spring, when a peculiar constitution of atmosphere appears to exist, predisposing to catarrhal diseases ; for it is more rife during the existence of epidemic catarrh and hooping cough. • Certain other diseases, principally of an exanthematous nature, as miliary eruption, scarlet fever,|| measles, small pox,<§> and thrush. •Essai sur le Croup, par G. Fourquet, p. 11. t Rapp. sur le Croup, p. 77. t Op. Cit., 347. j| Lec. on the Prac. of Physic, by David Hosack, M. D., p. 514. § Cheyne, Op. Cit., p. 39. 70 DISEASES OF CHILDREN. appear to impart a predisposition to this disease, as it not unfrequently attacks children laboring under them. Drs. Bard, Rush, and Francis, have observed it as a sequel of malignant sore throat ;* and Dr. Ferriar also relates iwo cases which occurred from the same disease.t The most common exciting cause is a sudden exposure to draught of cold air—a current of air blowing on the child, when resting, perhaps, after great fatigue ; or by any exposure, whereby the cutaneous transpiration is suppressed, and the aerial passages are excited to undue action, the first stage of inflammation. To these may be added the throwing off of the bed-clothes, so common in young children, and the change of the temperature of a bedroom, toward morning in which fire is usually kept: a sudden check of perspiration necessarily ensuing from these causes. Semeiology.—Croup is usually preceded by the symptoms of catarrh. The child appears weary, fretful, and at times feverish, especially at night; this condition alternating with cold. A teazing cough and coryza attend the formation of the disease. These symptoms may last for some days without exciting any suspicion. At other times the formation of the disease gives scarcely any premonition. Whatever be the manner of the invasion, the incipient stage is one of the greatest importance in reference to the successful treatment; and, accordingly, practical writers have been led to recognise the disease as having three stages, and that it is on the prompt treatment of the disease in its incipient stage that success mainly depends. Guersent,} Blaud,|| and Hosack,§ regard the forming stage, the catarrhal symptoms, as one of the most important for the treatment of the disease, and always preceding decided inflammatory symptoms, which are in their turn followed by the exudation, which is the characteristic of the disease. To this view every practical physician will bear his testimony. The symptoms presented by croup may therefore be divided into three stages, as the most convenient for clearly detailing the succession of symptoms, and as a guide for the proper treatment of the disease. The first stage is characterized by the affection being purely local, the irritation not extending to the whole system. In some instances the child will be even seen lively and playful. The attack usually comjes on at night, and will be easily recognised by the loud breathing, in which the inspiration alone is heard, giving a sound at times * Bard, Loc. Cit. Francis, Med. and Phys. Journ., vol. iii., p. 56. Med. Inq. and Obs., by B. Rush, M. D., vol. ii., p. 376. t Med. Hist., vol. iii., p. 205. j Diet, de Med. et de Chirurg. || Nouvelle Recherche sur la Laryngo-Tracheite, par P. Blaud; Paris, 1824. § Hosack, Op. Cit., p. 515. RESPIRATORY SYSTEM. 71 resembling the clucking of a fowl, and at other times like the crowing of a young cock. The cough is frequent; of a hoarse, dry, ringing sound. If the child is asleep at the time of the attack, he suddenly awakens, and appears at times to be in great distress, often passing his hand to the throat. There are frequently intervals of relief, in which the child does not breathe with any more difficulty than when in health. In the second stage, the feeling of suffocation increases, the face becomes swollen and red, the surface of the body hot, and the pulse strong and frequent. The tongue is white, and all the symptoms show the existence of increased local inflammation, and general febrile action. The lungs and bronchiae being loaded with blood, the difficulty of respiration has no interval of relief, while the arrest of the circulation through the lungs produces an apoplectic condition of the brain in plethoric children. The fauces, if examined, do not exhibit any alteration ; sometimes, however, the tonsils and velum are a little reddened and tumefied. French writers have recourse to such examination to ascertain the existence of a pellicular deposite over the surface of the fauces, making a diagnosis of the disease ; if there appear a grayish pellicular exudation in plates, the symptoms then do not arise from the existence of primary croup.* The symptoms are more intense, after renewed attacks of the disease, to which a child is very liable when once affected with it, as it often returns for several successive nights; and if not met by appropriate remedies, the violence of the disease increases, and as it approaches the third stage, or stage of effusion, the cough sometimes excites a retching, when a glairy mucus will be discharged by the efforts to vomit. A momentary relief is then experienced, but the pulse still shows the continuance of febrile action, while the voice remains hoarse. The application of the stethoscope may be useful in ascertaining the progress of the disease; and during the interval in the stridulous breathing produced by vomiting, the loud mucous ronchus may be distinctly heard. The sibilant ronchus will also be distinguished as the disease advances, while percussion gives a dull sound in every part of the chest. The third stage is characterized by effusion into the trachea, bronchiae, and on the surface of the lungs; which in the trachea assumes a membranous appearance. When these symptoms arise, the intensity of the cough and labor of respiration increase to a distressing degree, and its whistling sound may be heard at a great distance. The face is high colored and much swelled, the eyes • Fourquet, Op. Cit., p. 4. 72 DISEASES OF CHILDREN. are prominent and suffused, and the carotids beat with great force. The tongue is white, and the mouth dry; the child drinking with great eagerness. The disease continuing its progress, the sense of immediate suffocation is so intense, that every position is instinctively sought for relief; but the head is for the most part thrown backward, whereby the trachea is extended, and its capacity increased ; the child struggles violently to free itself from restraint, and if old enough, will attempt to get upon its feet. The matter vomited, either spontaneously or by means of art, consists of thick mucus, or portions of a white membranous substance, which forms the false membrane lining the trachea. There is occasional relief from the most violent symptoms, but of very short duration. The distress and labor of respiration increase; the cough becomes more hoarse; the voice is almost a whisper. The child struggles more violently than ever for breath; the pulse intermits, a cold sweat covers the body, the limbs are cold and swollen, and the circulation is evidently fast failing. As death approaches the cough ceases, but the suffocation increases; and coma or convulsions close a scene of the most appalling distress that the physician is ever called to witness. • Such is the usual progress of the disease when fatal. There are, however, other circumstances attending it, which deserve the attention of the physician. These are the remissions which are noticed during its progress, varying from some hours to several days, which has led some authors to regard the existence of an intermittent croup. This opinion, however, can not be any farther than that the disease will remit, at very uncertain intervals. . The relief is often very great, especially after free vomiting, and the child falls into a quiet sleep, without giving the least evidence of the existence of the disease, suddenly, however, awaking with an attack more severe than the former. It not unfrequently happens that children, after a severe attack of croup, will recover their strength and appetite, and are to appearance restored to health, leaving the parents free from any apprehension of danger; but a relapse will sometimes very suddenly take place after an interval of greater or less duration, much more violent than the former one, and is often quickly fatal. The physician should therefore be guarded in his Prognosis, and not pronounce a child to be restored, until the evidences of an entire relief from all the symptoms are placed, if possible, beyond a doubt. M. Desruelles* is of opinion, that it is not until after seven days have passed that the patient ought to be pronounced free from the danger of the return of paroxysms of croup. • Traite sur le Croup, etc.; Paris, 1822. RESPIRATORY SYSTEM. 73 Without being so particular as to designate the exact time, the prognosis may be made with tolerable correctness, by noticing clearly the usual appearances which denote a return of health. If expectoration be free, discharges from the bowels copious, urine abundant and depositing a sediment, while the skin is soft and moist, and the child free from any morbid exhilaration, the remission may be pronounced to be a favorable one. It is not difficult, when these three stages of the disease are taken into consideration, to estimate the danger to which the child is exposed. In the first stage, when the disease is purely local, and only accompanied by cough, without laborious respiration,, there is little danger to be apprehended; but when the respiration becomes laborious, and gives the peculiar sound of croup, a sound as if the air was passing through a narrow tube, with the cluck or crowing so remarkable in this disease, it is evident that the larynx is severely inflamed and tumefied, and if not promptly relieved, will rapidly pass to the third stage, or stage of effusion, which is so almost certainly fatal, as to have been denominated the fatal stage of croup. Morbid Anatomy and Pathology.—Dissections exhibit all the signs of active inflammation in the trachea and bronchia?; the mucous membrane is found red, and covered with an exudation, which is of a tubular form and solid in the trachea, and fluio and albuminous in the bronchia?; the last-mentioned secretion differing from the former only in its consistency. Besides inflammation in these parts, it also appears, at times, over the whole mucous membrane of the lungs, and fluid is even found filling the cavities of these organs. In severe and protracted cases, serum has been seen effused in the cavity of the pleura. In cases of long standing, the lungs have been found hepatized. The morbid products of the inflammation are in proportion to the progress of the disease, and are very abundant if the child has for a long time resisted the invasion of death. The pseudo membrane is generally detached from the mucous surface, from which it is separated by a recently exuded viscous matter; it also preserves the form of the air-tubes, forming a species of cord.* In those cases which are suddenly fatal, after a disappearance of the violent symptoms, a closure of the trachea takes place, from a partial detachment of the membrane forming a sort of valve, which closes the passage to the lungs, as remarked by Dr. Cheyne. In some instances extensive inflammation has been found in the airpassages, on a post-mortem examination, without any appearance of an adventitious membrane.t In such instances, the peculiar * Fourquet, Case ii., p. 20. fDr. Francis's Essay in N. Y. Med. and Physical Jour., vol. iii., p. 56, and Dr. Jackson's Cases, N. E. Jour., vol. i., p. 385. 10 74 DISEASES OF CHILDREN. symptoms of croup are doubtless produced by the tumefaction of the glottis and adjacent parts; for the passage to the larynx is so exceedingly small in a child, that a slight swelling of the mucous membrane of this part will nearly close the passage, and produce the characteristic inspirations of croup. A remarkable illustration of the instantaneous effect of the altered state of the mucous membrane of the glottis, occurred in my practice a few years since, in the case of a child that swallowed, or attempted to swallow, some sulphuric acid that was standing in a cup, which a servant was using to clean brass, the child mistaking it for water. The respiration had the peculiar sound of the breathing in croup, and could be heard a considerable distance. With regard to the chemical composition of the false membrane of croup, it is composed, according to the experiments of Schwilgue, Desruelles, Bretonneau, and others, principally of albumen, and is nearly the same as mucus, the buff of the blood, or the epidermis. According to the opinion of Lelut, it appears to arise from the mucus secreted by the inflamed part rendered more rich in fibrin by the inflammatory condition, from the chemical analysis of all these substances having so great a resemblance. Dr. Hosack is of opinion that the membrane arises merely from the rapid passage of air through the trachea. From the symptoms and post-mortem appearances of the disease, there can be no question as to its inflammatory character; and the nature of its pathology may be suspected from the causes, even before the symptoms have arrived at that stage which gives unerring evidences of its character. The symptoms are, from the beginning, those of violent inflammation: the local pain attended with febrile excitement, and the augmentation of the secretions in the air passages, clearly point out the exalted action of the sanguineous system. These are confirmed by post-mortem examination. The parts affected may be either the larynx alone, or the trachea, bronchiae, and substance of the lungs themselves; for it is evident that it is not confined exclusively to the larynx, as was maintained by Desruelles. When the causes of croup are considered, it is evident that it admits of a division into two forms, the one arising from an original or primary affection of the air-passages, and the other as a consecutive effect of disease in adjacent parts. The division, therefore, made by Dr. Stokes,* of primary and secondary croup, is a very judicious and highly practical distinction. Primary croup is a disease of an active inflammatory nature, sporadic and endemic. In this form the exudation first commences • Treatise on the Diag. and Treat, of the Diseases of the Chest, by William Stokes, M. D., M. R. I. A.; Dublin, 1837. RESPIRATORY SYSTEM. 75 within the trachea, a'nd spreads upward, and is, in most cases preceded by symptoms of catarrh. The secondary croup is the diphtherite of Bretonneau,* and, as we have already seen in the symptoms above described, is connected with an affection of the pharynx, as in scarlet fever, malignant sore throat, etc.; the exudation proceeding from above downward, while the ability to swallow is almost always lost. The last-mentioned writer asserts, that inflammation of the pharynx always precedes croup. It is an epidemic disease, and exists without being preceded by catarrh. By keeping this distinction in mind, important practical benefits will arise in the treatment, and the conflicting statements of different writers will in some degree be reconciled. This secondary affection has also been observed by Mr. Pretty, as following scarlet fever and malignant sore throat ;t and there can be no question as to the great practical utility of the division just stated. From the pathological condition of the larynx and trachea, in different instances, M. Blaud} makes three modifications of the disease, depending on the violence of the inflammation, and manifested by the nature of the secretion from the inflamed mucous surface. In the worst cases, laryngo-tracheitis exhibits itself with the most violent symptoms, succeeding each other with great rapidity, and almost always fatal. In this variety the secretion consists of a false membrane of different degrees of thickness, covering either the whole or a portion of the surface of the affected part. Another form, less severe in its progress, is often favorable in its termination; in this, the secretion is opaque and puriform. In the mildest variety there is little inflammation; it quickly disappears without the interference of art, while the mucous secretion is thin, limpid, and frothy. This would appear to be a very unnecessary division of the subject, as there is every shade of inflammation insensibly passing into each other, and. the prognosis and treatment will depend entirely on the extent and violence of this inflammation. .When this is light, it will yield to but little treatment, and will easily be recognised by the secretion not assuming the membraniform appearance. It often gives evidence of no other disease than the existence of a catarrhal affection, of greater or less extent; and in proportion to the violence of inflammatory action, will it need the active interference of the physician for its removal. The cough, or the peculiar sound so remarkable in expiration in croup, is observed to exhibit two kinds of sound. The first, acute, from the active spasmodic contraction of the muscles of the larynx • Des Inflam. Speciales du Tissu Muqueux, etc., par P. Bretonneau. t Lond. Med. and Phys. Journal, January, 1825. t Op. Cit., p. 18, etseq. 76 DISEASES OF CHILDREN. excited at first by the column of expired air*; the grave, which succeeds it, from the forced enlargement of the glottis, by the shock of the same column of air overcoming the contraction of the muscles. A prognosis may therefore be made from this fact; for in proportion to the acuteness of the sound is the violence of the disease: when, on the contrary, the more grave the sound, the easier the muscles yield to the force of the expired air, affording an evidence of the lightness of the affection, which is in proportion to the graveness of the sound.* The difficulty of respiration, also, must arise in part from the same cause impeding the passage of air to the lungs, and in part from the thickening of the mucous membrane covering the opening of the glottis, and the presence of the secretion, both in the larynx, trachea, and bronchia?; and it is evident that death must ensue from ihe obstruction of the air-passages, and the clogging of the air-cells, by which atmospheric air is excluded from the lungs. Treatment.—The first, or forming stage of the disease, is the period when the strongest impression can be made, and the progress of the affection at once arrested. The practical advantage of recognising different stages in the inflammation, although the line of demarcation may be indistinct, is obvious, when the importance of decisive measures is considered, and that the successful treatment of croup altogether depends on the adaptation of remedies to the existing state of the inflammation, on which the train of frightful symptoms in croup depends. It is on this account that the arbitrary division becomes important; and although it is not in our power to mark precisely the transition from one condition to the other with exactness, yet it can be easily seen by the observant physician, when the period of purely local excitement—the period requiring only the use of such remedies as will restore to the affected membrane its normal function of secretion—-is passed, and when the necessity for speedily adopting measures,to relieve the intense inflammation, and the febrile disturbance accompanying it, exists. To prevent the establishment of decided and active inflammation, and to remove it, when it is established, by the most prompt and energetic treatment, is the only effectual way of preventing its proceeding to the last stage, or that in which the disease is so often fatal. The attempts, therefore, to cure this most terrible of all diseases, should, if possible, be made when it is in its incipiency; and when this opportunity is afforded, we never need fear the result. To restore a healthy action and secretion to the affected part, an emetic will be found the most efficient, and, indeed, the only means for * Op. Cit., p. 352. RESPIRATORY SYSTEM. 77 effecting it at once : the disease having frequently been promptly arrested in its progress by this remedy. Tartar emetic, as a general rule, is to be preferred to any other article for accomplishing this object, but the employment of any emetic substances ought to have reference to the particular case; and if the child be very young, or of a debilitated constitution, the use of tartar emetic may be attended with some risk, from the prostration of the vital powers which it produces. It had better be combined with ipecacuanha, and administered in a dose sufficiently large to produce full, free vomiting, in the proportion of a grain of the former to ten or fifteen of the latter, to a robust child two or three years old. The advantage of a judicious combination of other emetic substances, which also appear to excite an action in the mucous membrane of the air-passages, different from the diseased action, is apparent in the use of squills in connexion with it, or of the compound syrup of squills, where, from the tender age of the child, or from a feeble constitution, the use of tartar emetic is to be feared. These are matters not to be disregarded. Having known of utter and irremediable prostration, and death quickly ensuing, from the use of tartar emetic in young children, I have, since these unfortunate cases, been particularly guarded in its use. If the child has arrived at the age of two years, and possesses an ordinary amount of vigor, and, especially, if the disease appear to be rapidly advancing to that stage in which the whole sanguineous system participates in the abnormal changes above mentioned, a combination of tartar emetic and ipecacuanha may safely be used, and is powerfully efficacious in averting the development of febrile action, from its effects in augmenting the secretions from the liver, pancreas, kidneys, skin, and intestines. It should be repeated every ten or fifteen minutes, until free vomiting is produced. A large quantity of tenacious mucus will be discharged ; and from the altered sound of the cough, it will be seen that the natural secretion has been restored to the part; and if the functions of the skin are also restored, the patient may be considered for a time free from danger. Where there is reason to apprehend excessive * prostration from the use of tartar emetic, either alone or combined with ipecacuanha, it may be administered in conjunction with oxymel of squills ;* or ipecacuanha, either in a powder or syrup, may with safety be given to the youngest infant; and there is but little hazard in an excessive dose of this medicine. It may be given to the youngest infant, in doses of half a grain to a grain, with sugar, every fifteen minutes, or •ft Oxymel. Scilla!, 3j. (20) Vini Antimonii, M. A teaspoonful every fifteen minutes, until vomiting is produced. 78 DISEASES OF CHILDREN. half a teaspoonful of the syrup. After a year old it may be doubled, and given with greater frequency. However efficient the operation of these emetics may be, and how much soever the patient may be relieved, it still behooves the medical attendant to be prepared for a return of the disease ; for it will often recur at intermediate intervals, and, upon the slightest reappearance of the symptoms, should be promptly met by the same means. The bowels ought, at the same time, to be moved by a full dose of calomel, aided in its operation by castor oil or enemata. From five to ten grains may be given for this purpose, if the effects of the emetic substances have not extended to the bowels. The main dependance, it must be recollected, is upon the free and full operation of emetics; and such are the powerful effects of this class of remedies in arresting the progress of the diseasej that practical men in every country regard them as the principal resource in the forming stage of croup. If febrile symptoms show themselves, or if, on the first arrival of the physician, there appear to exist undoubted evidences of inflammation, no time should be lost, but blood must be drawn freely, in proportion to the age and vigor of the child : from two to four ounces for a child under two years, arid from four to six ounces for one five or six years of age. As in the incipient stage of the complaint the prompt administration of an emetic is our best resource, so on the formation of the disease, and the establishment of inflammation, our principal reliance must be on decisive and efficient blood-letting. No time should be lost in attempts to relieve the child by emetics, or any other means, to the neglect of bleeding. The relief procured by the loss of blood is often immediate, and if followed by other appropriate measures, is not unfrequently permanent. It more often happens that the urgent symptoms return, on the return of reaction, again demanding the operation of bleeding, which is almost with certainty followed by a mitigation of the disease. The extent to which bleeding is to be carried, must depend upon the sound judgment of the physician on the case under treatment ; yet it is not to be questioned that it has been carried to too great an extent; and in no instance ought the child be bled to syncope, as recommended by Bayley,* Ferriar,t Dick,} Chapman,|| and others. Dr. Eberle urges bleeding, as far as it can with safety be practised, when he recommends the patient to be bled in a sitting posture, with his feet immersed in warm water, until partial syncope be produced. He limits such copious bleeding to cases of the most * Letter to W. Hunter. t Med. Hist., vol. iii., p, 207. j Supplement to Dr. Barton's Med. and Phys. Journal, May, 1809, p. 242. H Phil. Journal Med. and Phys. Science, vol. i., p. 303. RESPIRATORY SYSTEM. 79 violent inflammatory action, indicated by an active, firm, tense pulse, and a general fever.* Dr. Hosack, although an advocate for large bleedings in croup, does not approve of their being carried to such an extent as to produce fainting, having observed in several instances very serious and permanent evils arise from the excessive loss of blood. This opinion is sustained by my experience ; and although prompt, decisive, and repeated bleeding is neces§ary, yet the constitution will often suffer from the loss of blood, carried to the extent insisted on by many writers, where the nervous system feels the effects of this remedy, as at this early age ; its conseqences continuing for a long time after. There is nothing more difficult in medicine than the practical application of general principles ; and the judicious practitioner will always proportion the remedy to the circumstances of the case before him, and especially in the abstraction of blood, keep in view, in addition to the object to be attained, its effects on the system generally, and its ultimate consequences; and while the urgency of the symptoms and the fatal tendency of the disease are considered, the age and constitution of the patient, and the period of the disease, must also be weighed ; for, in addition to the vigor of the patient, there is a period in which bleeding would be decidedly hazardous, although the most prominent symptoms of the disease continue unsubdued ; that period when nothing more than the effect of inflammation, the exudation of lymph, exists —a period characterized by the loss of vital force, contra-indicating the use of blood-letting in any form. This leads me to consider the custom of local bleeding in croup, during the period of active inflammation, so common in continental Europe; some practitioners depending altogether on this method of treating the disease- There are others, however, in France,t who recommend general blood-letting, as decidedly preferable to local depletion by leeches, but advise their use, should it be neces-; sary to have recourse to the loss of blood a second time. Practitioners in this country rely but little on the effect of leeches to the throat. Dr. Dewees, indeed, is opposed to their use altogether, under any circumstances, never having seen them productive of any benefit; but on the contrary, from the length of time necessary to' obtain the requisite quantity of blood, the exposure of the throat during their application, and the coldness of the leeches, the symptoms of croup have increased during their application.t Another objection has been made to their use, arising from the difficulty of stopping the flow of blood from the part covering the larynx. It is, indeed, a serious one, and one which ought always • Op. Cit., p. 357. f Fourquet, Op. Cit.. p. 42. t Treatise on the Physical and Medical Treatment of Children, by William P. Dewees, M. D.; Philad., 1826, p. 441. 80 DISEASES OF CHILDREN. to be considered when applying leeches to the throat, especially in children. To obviate any difficulty from this cause, it has been proposed to apply them immediately above the upper extremity of the sternum; and, as it may doubtless at times occur that blood should be drawn from near the inflamed part, they may be with advantage applied in this situation. Dr. Dewees recommends cups, where it is to use local depletion, applied between the shoulders, but never around the throat. It is, indeed, seldom necessary to have recourse to local bleeding ; for after a strong impression has been made on the circulatory system, the circulation can often be sufficiently controlled by other remedies, and by efforts made to excite the action of the secretory system, thereby preserving an equilibrium, a means, when properly used, as powerful in the relief of inflammation, as the abstraction of blood. Dr. Cheyne and other writers advise drawing blood from the jugular vein ; but from the impossibility of ascertaining the quantity thus taken, arising from the constant restlessness and coughing of the child, and the difficulty of closing the vein for the same reason, it should seldom if ever be attempted; a sufficient quantity of blood being always to be obtained from the arm of the youngest child, with a little practice in the efforts to bring the vein near the integuments, by pressing the cellular substance with the finger from around it after the bandage has been applied. I have rarely been foiled in bleeding a child, if sufficient time has been taken to press the part immediately over the spot where the vein lies with the moistened finger. A vein on the back of the hand, or on the foot, may also often be found, after having immersed the limb in warm water. Immediately after bleeding an emetic ought to be administered, if the symptoms are not decidedly improved ; and that no time be lost, a decided advantage will be obtained by combining it with a cathartic, that the whole secretory functions of the stomach and abdominal viscera may be excited into action.* If the physician has seen the case from the commencement, and administered such remedies as will act on the intestines, it may perhaps be unnecessary to repeat the cathartic immediately, if the progress of the disease has been rapid. But, as is most frequently the case, he for the first time sees the case during the period of active inflammation, when, in addition to the local affection, the entire circulatory * R Hydr. Subm., gr. XX. (21) Antim. Tart., 3 j. Divid. in Pulv., No. iv. M. For a child three or four years old, one powder to be given every fifteen minutes, until vomiting ensue. 81 RESPIRATORY SYSTEM. system participates, it becomes his duty promptly to use all the means in his power for the arrest of this truly frightful disease. The action of an emetico-cathartic is a powerful adjunct to bleeding, when the symptoms are not relieved by this operation ; the taausea, together with the vomiting, and the discharge of biliary andlhtestinal fluids, have a powerful influence on inflammatory action. These active measures, however, are not admissible in every case ; the violence of the inflammation, and the ability of the child to bear the evacuations, must be in all cases taken into consideration. The great efficacy of calomel in croup has induced some practitioners to rely almost exclusively on its use in the treatment of the disease ; and it is to American physicians that the profession is indebted for the mercurial treatment of croup. Dr. Rush considered it as the main resource in managing a case of croup, and as certain a remedy as the Peruvian bark in intermittent fever.* Dr. Kuhn was in the habit of giving five or six grains of calomel, three or four times a day, to a child of two years. Dr. Redmond prescribed it in doses of three grains every three hours, until fifteen grains were taken, to the youngest and most delicate infants. Dr. Hosack also gave it in doses of' five to ten grains every two hours, until a decidedly cathartic effect was produced; and if the bleeding, emetics, and cathartic, failed to subdue the febrile symptoms, and divert the irritation from the trachea and lungs, he combined it with James's powder, from two to five grains each, every two hours, to a child under four years, until a sufficient evacuation from the bowels was produced. Dr. Hamilton, of Edinburgh, considered calomel as one of the most powerful remedies in croup, and has succeeded in curing it under the most unpromising circumstances; but remarks, that no relief whatever can be obtained from it, unless given in very large doses. He gave it to the extent of one hundred and thirty-three grains in sixty hours,t to a child of seven years. This certainly is an enormous quantity, but not equal to that taken by a child of two years, to whom, under desperate circumstances, he gave one hundred grains in twenty-four hours.} •To an extent like this no prudent practitioner can bring himself to prescribe calomel in croup, where the intestinal mucous surface is fully exposed to its action; unlike the condition in some other diseases, where a coating of thick mucus prevents the immediate contact of the remedial agent, as is sometimes found to be the case in scarlet fever. Dr. Stearns, of New York, relies principally on the use of calo- • Rush's Inquiries, vol. ii., p. 378. t Use and Abuse of Mercury, by John Hamilton, M. D..; Edin. 1809. t Chapman on Croup, Phil. Jour. Med. Scien., vol. i., p. 308. 11 82 DISEASES OF CHILDREN. mel, combined with the cerated glass of antimony, in the treatment of the disease, to the entire exclusion of blood-letting; regarding the disease as arising from a torpor in the absorbents of the trachea, and not as an inflammatory disease. He gives twenty grains of calomel, combined with eight grains of cerated glass of antimony, to a child one year old, when the symptoms have assumed a v*rolent character, with a proportionate increase for older children, repeated every eight hours. One dose, he observes, is generally sufficient, and he has never had occasion to administer more than four. In connexion with this he gives a decoction of polygala senega, as an expectorant.* No doubt can exist as to the salutary influence of calomel in this disease, from its agency in exciting the secretory functions generally. It is unquestionably an active expectorant, especially when combined with other remedies which exercise an action on the bronchial mucous surface. The warm bath, from 92° to 9S°, is an exceedingly useful adjunct to other measures in the treatment of this disease, particularly in the early periods. It has a peculiarly exciting effect on the capillaries of the skin, producing an action in its exhalent function; the internal tissues are thereby relieved from their superabundant supply of fluids, and the local internal congestion and inflammation are met by a most powerful remedy. Blisters are important remedies in this disease; and if the symptoms are not materially relieved by the means already suggested, and the state of the pulse evidently affected, one should immediately be placed over the throat covering the larynx and trachea. Some recommend the blister to - be applied to the neck, between the shoulders ; others on the arms, or on the upper portion of the chest. In a disease of so rapid a progress as the croup, but little advantage can be derived from the application of a blister in a part remote from the seat of the disease; and if an impression has been made on. the circulation by the course already pursued, the blister should be applied directly over the affected part, which is first to be well irritated by warm turpentine; it will very copiously deplete from the capillaries of the part, and aid in fulfilling the general indication. Rubefacients, however, where the disease is evidently arrested in its progress, will often be all the external revulsive required. They may consist of a sinapism, or an embrocatio/i of equal parts of tincture of capsicum and tincture of Spanish flies, or warm spirits of turpentine. The last-mentioned articles may be applied by friction over the throat, and a flannel moistened with them then put around the neck. In all affections where the respiratory organs •Coxe's Med. Museum, vol. v., p. 195. RESPIRATORY SYSTEM. 83 are concerned, liniments made of ammonia ought carefully to be avoided, from the stimulating effects' of the volatile part of the liniment on the diseased mucous membrane. It very often happens, especially if the remedies above mentioned have been promptly and diligently employed, lhat the disease is relieved without manifesting the invasion of the third or membranous stage. Yet, from the deceitful nature of the intervals of respite, it is the duty of the physician to be carefully guarded in his prognosis, and to employ such remedies as experience has instructed, as will best preserve the secretory functions of the tracheal mucous membrane in its normal condition, while other means are used to maintain the circulation in its equalized state. For effecting the first mentioned object then, the expectorants already mentioned, page 45, may be used; or perhaps there is nothing better than a combination of syrup of squills and antimony, or a few drops of the compound syrup of squills, every two or three hours. These expectorants have been found exceedingly valuable after the active inflammatory symptoms have subsided ; and when combined with antimony, their stimulating effects, so much dreaded by some physicians, are very materially controlled, while their expectorating qualities are sensibly increased. The physician should carefully watch the progress of the affection, and there will be but little danger of erring, by prescribing a stimulating expectorant. It even happens that a temporary debility will exist after active inflammation in a part, bordering on paralysis, and where a slight stimulating medicine will be needed to prevent a relapse of the disease in such a case, squills or senega may be advantageously used, and,, as above suggested, may in some cases be united with antimony.* Dr. Archer, of Maryland, was the first who introduced thepolygala senega into practice as a remedy for croup ; and where the violence of the inflammation has been subdued, it is unquestionably the best that can be employed where the croupy cough continues, as it often does for a number of days : or where it has assumed a chronic form, no other remedy possesses so great a control as this over these protracted symptoms. Where the addition of antimony is not necessary, as it forms an ingredient in the compound syrup made of senega, it may be given in decoction, made by boiling an ounce of the root in a pint of water, down to three gills, and with the addi- tion of two ounces of honey, fuls every hour or two, to a c f t in the do child three dose of two or three teaspoonee or four years of age. • ft Syrup, Scillse, (22) Syrup. Tolu., Vin. Antimonii, aa M. Eight to ten drops once in two hours, to a child of a year old. * ft Decoct. Senega?, ?ij. (23) Oxymel. Scillas, 3ij. Syrup. Ipecac, 3j. Antim. Tart., gr. ss. M. A teaspoonful every two or three hours,,, for a child two years old. 84 DISEASES OF CHILDREN. To fulfil the second indication, great care should be taken to preserve a suitable warmth to the surface, by proper clothing of flannel, frequent bathing of the feet in warm water, and by carefully guarding the child from any sudden exposure to a draught of cold air. Rubefacient applications, also, ought frequently to be applied to the chest. The third stage of croup is characterized by the formation of a membrane in the trachea, or of a quantity of purulent lymph, extending even to the minute ramifications of the bronchia;, as far as the anatomist can trace it. In this stage the breathing still continues laborious, with an increasing cough, and which gives not the slightest relief by expectoration, while suffocation appears every moment about to close a scene of indescribable suffering. Here the treatment must be to remove the membranous exudation and lymph which obstruct the air passages, and, if possible, to restore and maintain a healthy secretion in the inflamed part. As in the former stages emetics were among the most important remedies, so in this, also, they have been found the most valuable resource, indeed, almost the only one on which we can depend, being restricted also in the class from which they are taken. Those of a stimulating character are here indicated, as the mucous membrane of the trachea and bronchia; have passed beyond the period of preternatural excitement. Among these the polygala senega stands foremost, and may be given according to the directions of Dr. Archer. He prescribes it in decoction, made by infusing half an ounce of the bruised root in half a pint of boiling water, which is simmered down to four ounces ; of this a teaspoonful is to be given every half hour or hour, according to the violence of the symptoms, with a few drops given at intervals, to keep up an action on the fauces, until it can produce an emetic and cathartic effect; after which, a small quantity is to be frequently given, to preserve a continued stimulating effect on the mouth and fauces. The powder, also, has been used with equal advantage, in doses of four or five grains, mixed with a little water.* By means of the polygala the twofold advantage will be obtained, of procuring an evacuation of the morbid secretion, and exciting the mucous surface to a new and altered action. Where it appears to affect the bowels alone, a few drops of laudanum may be combined with it, and will suffi ciently restrain any tendency to pass off in this manner. Among the remedies which have been successfully used for the expulsion of the membranous formation, under circumstances which afford but little reasonable hope for recovery, are vitriolic emetics. The sulphate of zinc and sulphate of copper have been resorted to, «vhen scarcely any expectation of relief could be indulged. The •Treatise on Croup, by G. Archer; Philad., 1798,. y. 33. 85 RESPIRATORY SYSTEM. former has been used by Dr. J. W. Francis, of New York, in three cases, with complete success, where all hopes of recovery had been previously abandoned.* A strong solution, consisting of two drachms of sulphate of zinc to an ounce of water, was made, of which a large teaspoonful was administered every twenty minutes to a child of two years, for about two hours, without effect. A solution of sulphate of copper, of the same strength, was prepared, and after twice giving it, a portion of the membrane was detached; the white vitriol was then again resorted to, with the effect of dislodging a large quantity of similar membranous substance. Dr. Francis, to whom the profession is indebted for the introduction of this remedy, remarks, that vitriolic emetics may be given with more safety than is generally supposed, in those cases where inflammatory action has been subdued. Sulphate of copper alone, and combined with calomel, has recently been introduced into practice in Germany, in epidemic or secondary croup, which will be considered below. The membrane has sometimes been expelled spontaneously in violent fits of coughing, and at other times been removed by the introduction of some chemical or mechanical irritant to the upper part of the oesophagus, and even within the opening of the glottis itself. Desault and Depuytrent had recourse to these means ; and with the assistance of a piece of fine sponge, moistened and fixed on the end of a small slip of whalebone, introduced irritating substances into the opening of the glottis. These are, however, hazardous experiments, and have scarcely ever been attended with success. M. Billard mentions the almost instantaneous death of a child on the application of powdered alum to the glottis.} Although the membrane has been removed, yet recovery has not in every instance followed. This should be always kept- in mind, for recovery is generally expected where this result has followed the powerful means used for its expulsion. Several writers, Michaelis, Dewees, Cheyne, and others, record instances in which the membrane has been completely discharged, and death ensued. This, however, should not deter the physician from using all the means in his po\ver for its prompt and effectual removal. This naturally leads to the consideration of the operation of tracheotomy, which has been proposed both for the purpose of expelling the membrane, and affording a longer time for the performance of respiration ; a brief notice of which it may be proper to give, that the whole subject of the treatment of croup may be duly considered. When all measures of a strictly medical nature have failed to * New York Medical and Physical Journal, vol. iii., p. 54. t Guersent, Diet, de Med. t Op. Cit., p. 388. 86 DISEASES OF CHILDREN. produce a relief of the urgent symptoms in the last stage of croup, it was proposed, a long time since, by Home and Michaelis, to have recourse to surgical means, as the only thing left to be done, and where death appears to be'the certain termination of the disease. It is indeed a desperate resource, and one which has not received the sanction of many eminent men, either in Europe or in this country, having produced the wished-for result in but few instances. It has been tried in Spain, Denmark, several parts of Germany, in Geneva, Brest, Lyons, and Paris.* In our own country it was also attempted by Dr. Physict in two instances, both of which were unsuccessful. The principal objections to the operation are, that it is not certain to remove all the causes of the obstruction to the respiration, for the tenacious mucus often exists below the opening: neither will it prevent the disposition of the part from forming new depositions of membranous matter. Within a few years past the attention of physicians has been directed again to the subject; and that it may in some desperate cases be successful, appears from the result of the dissections of M. Bretonneau, in primary and secondary croup. In fifty-five cases, examined by him at different ages, there were six or seven where the membraniform matter reached to the ultimate ramifications of the bronchia?. In one third of the whole number, it extended as far as the bifurcation ; and in the remaining number, thirty or thirty-one, it terminated at different parts of the trachea. It may, therefore, be successful in those cases where it is confined to the upper part of the trachea and larynx, by maintaining respiration until the process of the deposition of lymph has ceased ; in the other instances it must be evidently of no manner of utility as a means of cure. To decide as to the precise seat of the affection during life, and thereby be guided in our opinion as to the necessity of the operation, must be admitted by all to be a matter of the greatest difficulty, if not of utter impossibility, notwithstanding the opinions of some to the contrary. M. Fourquet,} who strongly advocates the use of tracheotomy, records the successful operations of M. Bretonneau, in five cases out of seventeen, and of M. Trosseau, in six out of twenty-one; five of which occurred in the last eleven, on whom tracheotomy was performed. Since the publication of M. Fourquet's essay, in 1834, the results of one hundred and forty cases operated on, have been reported to the Royal Academy of Medicine at Paris, which probably include those just mentioned; twenty-eight of which were cured, and the remaining one hundred and twelve died.|| They were doubtless cases partaking more of the character of laryngitis than croup. * Royer-Collard, Diet, des Sc. Med., torn, viii., p. 417. t Dewees, Op. Cit., p. 447. t Op. Cit., p. 57, et seq. ;j Journ. des Connais. de Med., June, 1837. RESPIRATORY SYSTEM. 87 When a child has once had an attack of croup, it will be very liable, on the slightest exposure to cold, to have a return ; every proper means ought, therefore, to be had recourse to by the parents, on the appearance of a slight cough, to prevent, at an early period, the full formation of the disease. When the child becomes hoarse, all stimulants must be withdrawn, and the patient confined to an apartment of agreeable warmth, and immersed in a tepid bath, and a drachm of the subjoined mixture given every hour; or every two hours, if it produce vomiting.* At the same time the child should be gradually accustomed to the vicissitudes of the atmosphere, while the body is well clothed, and especially the neck and throat well covered. These remarks apply more particularly to the primary form ot croup. It remains now to consider that variety of the disease which arises as an effect or a consequence of inflammation existing primarily in the fauces and tonsils, and spreading thence to the airpassages ; a distinction which some writers appear not to have noticed with sufficient care, but which will not be regarded as useless, as a modification of treatment will necessarily arise, from the difference in its nature. When speaking of the causes of croup, it was remarked that the pre-existence of other affections, known generally under the name of anginose diseases, was occasionally productive of the symptoms of croup, not unfrequently terminating in that disease in its most aggravated form ; and it is unquestionably this secondary form which the late Dr. Samuel Bard described under the name of angina suffocativa, occurring after cynanche maligna. Dr. M'Kenzie, professor of anatomy at Glasgow, has also described this form of croup as frequently commencing on the surface of the tonsils, and spreading thence along the arch of the palate, coating the superior surface of the velum palati, and at last descending to the internal surface of the larynx and trachea.t M. Bretonneau has more particularly described it under the name of angina pellicularis ; and from the identity of diphtheritis and the malignant sore throat, it is doubtless the same affection which was a number of years before described by Dr. Bard.. It was also remarked that several eminent men have recorded the fact of its appearance as an effect of scarlet fever, small-pox, measles, etc. We may therefore be prepared to find it prevailing as an e'pidernic disease, and observing the same laws as k o its development and extension as the diseases just mentioned. It existed in this manner in the year 1827, in France, and was char- • R Vin. Ipecac, (24) Syrup. Tolu., Mucilag* G. Acacia?, aa §j. M. f Ed. Med. and Surg. Journal, April, 1825. Med. Chirurg. Review, June, 1827. 88 DISEASES OF CHILDREN. acterized by coryza and inflammation of the tonsils, followed by an* exudation, which spread to the respiratory passages. Post-mortem examinations discovered a false membrane covering the membrane lining the nostrils, tonsils, oesophagus, glottis, larynx, and trachea, from two or three lines in thickness.* In the treatment of the secondary form of croup, regard must be had to the nature of the primary affection. Nothing can warrant the employment of active depletion in any case for the relief of the urgent symptoms of croup, as these always arise in the latter stage of the affection ; the depletory measures must be resorted to early in the disease, before the characteristic signs of croup have appeared. Topical applications, of a stimulating and escharotic nature, have been the measures principally used in its treatment, applied to the fauces and tonsils. The method of treating anginose affections with topical applications is by no means modern, for Areteus appears to have used them, although it is somewhat doubtful whether he was acquainted with croup. He applied alum in gangrenous affections of the throat, probably under precisely the same circumstances as it has of late been used by those who have so particularly described the disease in all its forms, and as connected with the affection now under consideration. MM. Bretonneau and Trousseau relied chiefly on the use of astringent and stimulating topical measures ; mild caustic substances were applied by them in all cases of diphtheritic inflammation with great success. Nitrate of silver dissolved in distilled water, in the proportion of one scruple to an ounce, is the best application in such cases. Various other stimulants, as diluted sulphuric or nitric acid, or chlorine, may also be used for the same purpose. The reader is referred to the article on malignant sore throat, on which this form of croup depends, for further details of treatment. In Germany, the sulphate of copper has been recently introduced into practice for the treatment of epidemic croup. Dr. Leolerwas successful in several cases of this disease, giving it to a child of eighteen months, in the dose of three grains, mixed with a little sugar, and then a quarter of a grain every two hours, until vomiting followed. A teaspoonful of the following mixture was given to a child aged three years, which produced vomiting after each dose.f • M. Borgeois, Journ. Gen. de Med., June, 1828. t R Cupri. Sulphat., gr. v. (25) Decoc. Had., Althaeae, |iss. Syrup. Althaeae, ?ss. M. Hu/eland's Journal, Bd. 78, 1834. RESPIRATORY SYSTEM. 89 SPASMODIC CROUP. It does not appear that this disease was accurately described until the year 1761, when Dr. Simpson published an inaugural dissertation, in which this remarkable spasmodic affection is considered under the name of spasmodic asthma of infants. A few years after, Dr. John Millar pnblished his work on the same subject,* when it received the name of Millar's asthma. Far from rendering the subject more clear, it appears to have added confusion to the description, and rendered its identity uncertain, both from the account of it being connected with that of another disease, and from its having been described in later times under the different names of spasm of the glottis, cerebral croup, laryngismus stridulus, etc Dr. Rush published an account of the same affection in Philadelphia, shortly after the appearance of Millar's book. In the various treatises on the diseases of children, published within a few years, the affection has found a distinct notice. Wharburton, in his work on female complaints and on children, published in 1809, describes it; and in Clark's Commentaries, published in 1815, a full description of spasmodic croup, which he refers to cerebral irritation, may be found. Of late, spasmodic croup has attracted much attention, and cases have been recorded in the different journals ; those particularly of Mr. Pretty and Dr. Davies have already been referred to. Cases have also been recorded by Mr. Hood,t Dr. Marsh,} and* Dr. Joy ;|| the last-mentioned writer giving a clear and detailed account of the disease. In Germany, also, it has been described by Dr. Kopp and Dr. Hirsch, and known by the name of thymic asthma, from its supposed dependance, in every instance, on an enlarged thymus gland. Dr. Ley has recently published a voluminous work on this subject, characterized by extensive research and great practical experience; a treatise in every respect perfect, if we except his referring it to the condition of the bronchial, or deep lymphatic glands, which, when enlarged, cause a pressure on the recurrent nerves, and thus paralyze the muscles they supply. It is often too quickly relieved, to have this organic affection for its cause in every instance. Etiology.—Among the predisposing causes, that which exists in inflammatory croup, the peculiar condition of the larynx in children, is the most evident; for like the other form of croup, it is a disease peculiar to infancy and childhood. Although instances have occurred of its existence at the ages of five and seven years * Observations on Asthma and Hooping Cough, 1769. t Edinburgh Journ. Med. Scien., July, 1827. j Dublin Hospital Reports, vol. v. || Cyclop. Pract. Med. 12 90 DISEASES OF CHILDREN. yet the greatest number of cases occur in children during the process of teething. There is, besides age, a constitutional tendency in some children, several members of a family being the subjects of it, as was remarked by Mr. Pretty and Dr. Davies, in the papers already referred to. OtherPractitioners have noted the same fact, and that three in succession have been attacked when exposed to the same exciting cause. This is evident also from the fact that there is so great a susceptibility in some families to the disease, that infants even within the month have had an attack. Dr. Ley remarks, that the affection often owes its origin to the climate and season. In warm climates, it is but little known, and in dry, elevated situations, it is rarely to be found. It prevails mostly in damp, cold regions, and during the colder seasons of the year; for this reason it appears to be unknown in those parts of a country which possess a warm, dry air, while in other portions that are damp and cold it is found to be very prevalent. Dr. Ley* attributes to the change of climate in America, arising from the inhabited parts being cleared of the forests, and in consequence of this change, its great immunity from diseases which arise from damps and fogs, that our earlier writers speak of its prevalence, while at this time they doubt its existence; and refers to this cause the change of opinion which Dr. Rush adopted, in the interval between the publication of his letter to Millar, in 1770, and his Inquiries, in 1794 and 1805.* Among other occasional predisposing causes, are found errors in diet, and a consequent disordered state of the digestive organs, with green discharges from the alimentary canal, and that state of the stomach of infants known as the weaning brash. There is also an increased tendency to constriction of the glottis in scrofulous children, where there exist glandular enlargements. All diseases of the respiratory organs predispose the system to this affection. Dentition is the most common exciting cause of this affection, both on account of the high susceptibility of the nervous system at that period, and ready transmission of excitement from the inflamed and swollen gums tQ the nervous centre, and thence to the motor nerves and their appropriate muscles, often manifesting itself in a slight muscular twitching, and which, if affecting the vocal muscles, constricting the glottis, and thus producing the peculiar sound known by the name of child-crowing—as well as from the swelling of the absorbents and glands about the neck, when the gums are inflamed, causing a pressure on the nerves leading to the part affected. An inflamed and ulcerated scalp, which is usually attended with enlargement of the glands of the neck, is also stated by him to be another cause of this affection of the epiglottis. * An Essay on Laryngismus Stridulus, by Hugh Ley, M. D.; Lond., 1836, p. 56. RESPIRATORY SYSTEM. 91 Semeiology.—The symptoms of this disease are well marked and can not easily be confounded with any other disease. They usually occur suddenly, on awaking from sleep in a sort of alarm; a violent and ineffectual effort to breathe takes place, which at last terminates in a long, deep-sounding inspiration, of a crowing sound. The paroxysm again occurs in a short time, while the child is awake. The face, during the paroxysms, shows all the evidences of obstructed respiration, sometimes sallow and livid. The eyes are fixed and staring, and the whole countenance expresses great distress. The head is thrown backward, while the spine is bent in the form known as opisthotonos. After a violent and frightful struggle, the child obtains relief by a forcible and full inspiration, which is immediately followed by a fit of crying, when he falls asleep from exhaustion. The paroxysm rarely continues over a minute or two, but has at times continued as long as ten or fifteen minutes. Several have occurred when once the disease has been excited; and an infant rarely passes a night in which it is attacked, without having three or four repetitions of the fit of stridulous breathing. Any alarm, inordinate exercise, or sudden excitement from any cause, will bring on the disease during the day when it has made its attack. The spasm not unfrequently extends to the other muscles, and the thumb is frequently drawn to the palm of the hand, while the fingers and toes are sometimes widely spread, bearing a great resemblance to the affection known and described as the corpo-pedal spasm. Indeed, being for the most part a purely spasmodic disease, when severe and long continued, it would be likely to affect the other muscles, and assume the appearance and characters of other affections of the same nature. If the disease be not relieved, the general condition of the system soon participates; the digestion generally becomes more disordered, the bowels are consequently deranged, and the alvine discharges are green and slimy, while the complexion of the child becomes pale, with a general appearance of sinking health. The duration is very uncertain, death having sometimes occurred suddenly on its first invasion, and at other times the disease has continued for weeks, or even months. Although the paroxysm comes on in the order mentioned in by far the greatest number of instances, yet it has happened that the symptoms are renewed and the spasmodic action of the fingers and toes precedes for a considerable time the crowing inspiration, and has continued for weeks after the peculiar affection of the larynx has disappeared. The spasmodic affection of the epiglottis may be known from inflammatory croup by the following signs: Its pathognomonic symptom is a crowing inspiration, with purple complexion, not fol- 92 DISEASES OF CHILDREN. lowed by cough. In tracheitis there is a ringing sound in the cough and inspiration. It does not make its appearance like inflammatory croup, with the ordinary symptoms of catarrh, but usually in a very sudden manner, without the premonitions observable in that disease. It is entirely free from fever, unless the presence of febrile symptoms should be present as an accidental circumstance. In inflammation of the trachea, fever is an essential part of the disease, when the inflammation is established, with the ordinary signs of hot skin, high-colored urine, diminished in quantity. In spasmodic croup the pulse is small, frequent and feeble ; in the inflammatory variety it is for the most part full and strong during the inflammatory or active stage, diminishing in strength as the disease approaches a fatal termination. Spasmodic croup is always to be regarded as a dangerous disease. If the child, however, be of a vigorous frame, and possess no particular disposition to diseases of the respiratory organs, and especially if the spasms be not very frequent, and no general convulsions ensue, it must not be regarded as hopeless. Morbid Anatomy and Pathology.—The pathology of this disease was until recently involved in obscurity. The dissections of Hirsch and Kopp show the trachea healthy, the thyroid anc thymus glands tumefied,* and sanguineous extravasation covering the trachea at the junction of these two glands. The tongue w.is large, and thick at the root. The body generally showed the appearance of death from suffocation, the skin being blue, anr* congestions of blood being found in the brain and lungs, f.jveral other occasional departures from the normal condition exiued, but the thymus gland was always found considerably enlarged, chiefly in length and breadth, but more often in thickness; die texture was not altered, although it was rather firmer, but wit! jut any trace of tuberculation, suppuration, or induration, being rither in a state of hypertrophy ; from which condition a pressure vas made on the heart, lungs, and large vessels. Hence it receiver; the name of thymic asthma. The idea has been supported by Jaspari,* Pagenstecker,t and Cornmaul.f Dr. Rosch|| of Sch Wenninger, on the contrary, entertained opinions in opposition to these views; and still more recent dissections made in Germany uy Fricke and Oppenheim,§ the plexus choroides was found full of blood, effusion * Uber das Asth. Thym.; von Franz Anton, Caspari, stadt phisicus en chcminitz Heidleberger Kliniske Annalen, VII Bands, 2 Heft. Heidleberg, 1831. f Beitrage zur naheren Erforschung des dsthma Thymicum. j Inaugural Abhandlung uber das Asthma Thymicum, von F. Cornmaul., Zweibruchen, 1834. U Asthma Thymicum, von Dr. Rosch, Unteramtsarzte zu Schwenningen von Ko aigreich Wcrtemberg, Journ. Pract. Heilkunde von Hufeland and Osann lxxxii. fl Zeitschrift fur die gesammte Medicin; Hamburg, Bd. 13, Heft. 1, Jan., 1840. RESPIRATORY SYSTEM. 93 in the chest, the larynx normal; the glottis was erect, and the rima glottidis open ; there were no swellings in the neck, and no displacement of the par vagum or recurrent; the nerves were in their site, and the structure perfectly normal. The thymus gland did not correspond with the condition described by Kopp and Hirsch, but it was heavier than in the normal state. Dr. W. C. Roberts has recorded the post-mortem examination of five cases of enlargement of the thymus gland, where the symptoms were those of acute pneumonia. The editor of the New York Journal has also given the dissection of two cases with similar symptoms, and the same condition of the thymus gland.* Dr. Ley, in the work already referred to, devotes a large portion of his treatise to the consideration of the pathology of the disease. He carefully examined the peculiar constitution in which it occurs, and finding the strumous diathesis to be that in which it most frequently occurs, endeavored, by close investigation, to discover the connecting link between this state of the system and the peculiar symptoms of the disease. This connecting link he found to be an enlargement of the thoracic and cervical absorbent glands pressing on the recurrent nerves, and thereby causing a paralysis of the muscles to which they are distributed.t There can be no question, that although dissections show that mechanical pressure may, perhaps, in most cases be the cause of this affection, other instances have arisen from a simple affection of the muscles of the glottis; for it has occurred, according to Dr. Marsh, upon the exposure of a child to the effluvia emanating from new paint, returning whenever the patient was thus exposed-! It has been referred to the brain by Dr. Cheyne and Dr. Clarke, the former of whom gives the result of three cases in which an incipient disease of the brain was discovered, but of different characters; one, where there was induration of the substance; in another, serous congestion; and in a third, scrofulous tubercles. The existence of scrofulous enlargements of the glands in delicate children, sufficiently explains this complication in those who are the most liable to the affection ; and the facility with which it is often removed, yielding not unfrequently to the removal of irritations existing in the gums or stomach and intestines, sufficiently proves its formation, independent of any mechanical pressure on the affected parts.|| It is evidently therefore connected with a disordered state of the nerves supplying the • Amer. Journ. Med. Sciences, for August, 1837, and Nov., 1838. N. Y. Journ. •f Med. and Surg., January, 1840. N. Y. Med. Gaz., No. 2, vol. i. The opposite opinion is maintained by Dr. Chas. A. Lee, in an extended monograph in the Amer. Jour. Med. Sciences, for Jan., 1842. f Op. Cit., p. 113. t Evanson and Maunscll, p. 207. j) Dublin Med. Journ., vol. 9, p. 520. 94 DISEASES OF CHILDREN. muscles of the glottis, whether arising from pressure on the nerves th'emselves, or from some more remote cause connected with convulsive action, often inappreciable on dissection. That a simple derangement of nervous power is capable of producing a constricted condition of the glottis, and the peculiar sound of child-crowing, appears from the fact that this sound may be produced in children who inherit a delicacy of nervous power, by tossing them up, as is common with nurses; an immediate and intense excitement is often produced, of a nature allied to the derangement of the nervous system, where laughing and crying are remarkably blended. Fright, passion, and, as we have seen, certain odors, will produce the same effect. The effluvium from anthracite coal has also caused similar symptoms. The existence of a state of system on which convulsions for the most part depend—teething and derangement of the digestive organs —is the source to which we must look for their origin; effected by an action of a reflex kind produced on the motor nerves which control the movements of the constrictor and other muscles of the larynx. The important experiments of Dr. Marshall Hall have satisfactorily proved that the cause of all convulsive diseases not arising from the centre of the motor system itself, exists in the excitor nerves, which transmit the irritation they receive through the trifacial nerves in teething, the pneumogastric, in over-fed infants, and the spinal, in constipation and other affections of the bowels. From the spinal centre this irritation is reflected, either partially or generally, as above mentioned, by the true motor nerves to the muscular system. A remarkable attendant on this affection, already mentioned, and which was noticed by those who first directed their attention to the subject, is the contraction of the fingers and toes. In connexion with this well-marked spasmodic affection, it may be remarked that strabismus, and spasm of the muscles moving the corners of the mouth, not unusually accompany the disease. These local spasms, the effect of dentition and disordered bowels, are the ordinary precursors of convulsions. Such morbid actions of different muscles, under similar conditions of the body, most clearly point out a common cause of the convulsive affections of infants, to which class the one under consideration belongs; convulsions being sometimes altogether local, at other times extending to the muscles of the body generally, forming at one time a local spasm, and at another a general convulsion. The disease may also arise from a direct affection of the centre of the spinal system itself, as is shown by the remarkable instance of crowing inspiration given by Dr. Hall, in a case of spina bifida, where the crowing was produced whenever the tumor was pressed; and in another instance, convulsions were caused by pressing on the RESPIRATORY SYSTEM. 95 medulla oblongata of an anencephalous infant. From the extremely small opening of the glottis in infants, it is very rational to suppose that a spasmodic action of a most trifling extent affecting the muscles which close it, would cause phenomena, such as mark the disease in question, to arise. It is a disease, therefore, which although exhibiting an affection of the respiratory organs, may more properly be classed with those which pertain to the nervous system. Treatment.—From its occurrence so frequently during dentition, the first obvious step in the treatment is to examine the gums, and where they are found swollen, to make a free incision through them to the tooth: spasms of infants, wherever they occur, either in the larynx, glottis, or throughout the whole system, often depend upon some slight irritation, or painful pressure on the nerves, even in a part remote from the immediate seat of the affection. The condition of its food, also, and the state of its stomach or bowels, should be examined, and the proper measures taken to cause a healthy supply of nourishment, suitable to the age of the child, if improper food, particularly of an artificial kind, has been used. More particular directions for the proper food of infants will be found under the head of indigestion. Daily evacuations from the bowels should be effected by mild aperients, composed particularly of such as will neutralize any acid in the stomach, if costiveness should exist. If the' bowels give evidence of unhealthy secretions in the prima? viae, alteratives may be used to promote a proper change in the secretions. The preservation of a suitable warmth by means of good clothing, especially around the neck and over the chest, is of great importance in the proper management of this disease. This should also be connected with free exposure to the open air, in fine weather, as one of the best means of giving vigor to the constitution, with suitable food, as above mentioned. This exposure ought to be free, and not partial, for there is nothing of an atmospheric nature which so soon produces a deleterious effect as a current of cool air upon any one portion of the body. For the same reason, also, cold winds should be avoided. Among other means of invigorating the system, is that of sponging the body daily with salt and water; commencing with it warm, and using it cold when the child is able to bear it, and appears to thrive under its use : this may be known by a glow appearing on the surface after the sponging. The warm bath is also an important auxiliary in the management of this affection, from its tranquillizing effects on the nervous system. When it is evidently connected with cerebral congestion, or when it occurs in a robust child, bleeding should not be neglected, for it may depend on a morbid condition of the brain, which must be discovered before a proper mode of treatment can be adopted. 96 DISEASES OF CHILDREN. Rubefacient applications to the throat and upper part of the chest, and, in severe cases, frequent blistering, will become necessary. When it depends on a local cause, with an inflammatory diathesis, local bleeding by leeches will be the proper treatment. As this local affection may be at times a cause of this disease, an examination as to the enlarged condition of the glands about the neck and throat is indispensable to its proper management. This must receive the particular attention of the physician, if the firstmentioned course of treatment fail to give relief. After the application of leeches, if the glands continue enlarged, with the usual evidences of a scrofulous habit, iodine will be the proper remedy, with such other measures as are used for the treatment of that affection. The reader is referred to that section for details of its history and treatment. In those cases unconnected with much sanguineous fulness, antispasmodics will be useful. Assafcetida was early prescribed by Millar, who administered it in excessively large doses : an ounce in the course of two days to a child of eighteen months. It is a highly useful medicine in spasmodic affections of these parts, from its quick and effectual operation. The proper dose will be five to ten grains to a child from four to six years, and one or two grains for one of two years of age. Musk, also, has been much used in spasmodic diseases of the air-passages, in doses of two to six grains every six hours to a child of three years ; its efficacy is so great as to cause it to be regarded by some as a specific. It is more useful in proportion to the absence of febrile symptoms.* There is nothing, however, that can take the place of such remedies as strike at once at the root of the disease ; and while anti-spasmodics may be found useful as auxiliary remedies, the cutting of the gums freely, promptly, and repeatedly —that they may bleed, and the distension of the gums be thus removed, and the nervous twigs be released from the pressure, while the crowding of the parts by the advancing tooth is. also removed—should under no circumstances be neglected. A full enema, containing a small quantity of common salt, to cause its more prompt action, ought also to be given whenever there is any suspicion of the approach of the disease. The application, also, of tobacco, is an admirable and prompt remedy in an attack of this disease ; and it is owing to its quick influence in the spasmodic form alone, that it has obtained its great reputation for the treatment of croup. It is best applied by means of a poultice sprinkled with Scotch snuff. No circumstance, how- • ft Moschi, gr. vi. (26) Sacchar. Albi., 3»j. Aqua; Foenic, Juj. Mist. Acacia:, 3>j. M. A tablespoonful for a child two or three years old, every two hours. RESPIRATORY SYSTEM. 97 ever, can warrant the risk of an enema of an infusion of tobacco, as has been recommended and practised by some ; the prostration is excessive under any condition of the system, and may in a young child be suddenly fatal. During the paroxysm the child ought to be freely exposed to the cool air, while water is dashed in the face ; the spine should also he rubbed with some-stimulating embrocation, and the child placed ia a warm bath as soon as it can be prepared. PERTUSSIS. HOOPING COUGH Hooping-cough was described, by the Greek and Roman writers, by terms significant of the violence and distress of its symptoms. Its nature, as might be supposed, was very imperfectly understood, and no clear account of the disease was made until the essay of Willis.* The treatise, also, of Millar,t Butter,f and the works of several German authors, abound in practical matter. The most perfect account of the disease is given by Dr. Watt,|| of Glasgow. Much, however, remains to be known as to its nature ; and at the present day, with all the assistance of numerous post-mortem investigations, the precise pathology" of the disease is but imperfectly known. Etiology.—The causes of hooping-cough are often difficult to ascertain. From its close resemblance to ordinary bronchitis, in its early and forming stage, it would appear to depend on the ordinary causes of bronchial and pneumonic diseases, and exposure to cold appears often to be connected with its development. The age of the child evidently has an influence upon the formation of the disease, for it rarely appears in the first two months of infancy ; yet it will occasionally attack a child within the month. Among other causes to which the production of hooping-cough has been assigned, that of the irritation of the bronchial tubes by the inhaling of the larva? of insects, was a favorite one of the celebrated naturalist, A similar view was also adopted by Rosen, with some modifications as to the djrect influence of the exciting cause, regarding it as the effect of a derangement of the nervous system, by the presence of animalculi in the respired air.^f It is, indeed, difficult to trace the precise agent of the disease " De Morb. Convulsiv., etc., cap. xii.; Oxf. 1667. f Observations on Asthma and Hooping-cough, by John Miliar, M. D.; London, 1769. J A Treatise on Kink-Cough, etc., by William Butter, M. D.; London, 1773. || Treatise on the History, Nature and Treatment of Chin-Cough, etc., by Robert Watt, M. D.; Glasgow, 1813. § Diss. Exanth. Viva. Vide Amaen. Acad., vol. v., p. 82. u Treatise on the Diseases of Children, by Nicholas Rosen, M. D.; translated from the Swedish; London, 1776. 13 98 DISEASES OF CHILDREN. with anything like satisfaction. There can, however, be no question of its propagation, like scarlet-fever, by a specific contagion; it has often prevailed as an epidemic, and few children escape when exposed to its influence, and, like other diseases of similar nature, it rarely occurs more than once in the course of life. Although, as was before remarked, it seldom attacks adults, yet this has occurred where there has been an exemption from it in early life, and when the individual has afterward been exposed to its influence. I have recently seen a remarkable instance of this, in the case of an elderly female who had the sole charge of a child about two years old, who was laboring under a severe attack of the disease. She had it in a very severe form, with violent paroxysms of hooping, which lasted, with gradually lessening severity, for three or four months. The occurrence was during the summer, and everything appeared to support the belief of its infectious nature. Semeiology.—The first symptoms of hooping-cough are those which usually accompany simple bronchitis, such as cough, and a slight mucous secretion. Thirst and fever, for the most part accompany it; both, however, at the commencement, very slight. In the incipient stage, which may last from ten days to a fortnight, it is often impossible to distinguish it from a simple cold, except that the cough is usually drier than in ordinary catarrhal affections, and attacks in paroxysms. These symptoms constitute the first stage. It is not long, however, before the cough assumes a decidedly convulsive and paroxysmal character. During the paroxysms of coughing a number of violent and rapidly succeeding inspirations are made, threatening the child with immediate suffocation. These fits of coughing occur at intervals of from half an hour to four hours or more, and when the disease is fully formed, the peculiar hooping sound is heard in one or two violent inspirations ; after a momentary rest, another fit of coughing, with its peculiar hoop, is heard ; these' successive coughs and rests are at last followed by a discharge of mucus from the bronchiae, and almost always attended with vomiting. This free secretion of mucus usually attends the disease when at its height, when the slight febtile action disappears, and the pulse shows no evidence of excitement during the intervals. During the attacks of coughing, the face and neck are swollen and red, with every appearance of suffocation : the eyes project, and the tears start, the little patient struggles violently for breath, and suffers great distress from this cause, instinctively seizing any object within reach that can afford support; and after the paroxysm, he appears much exhausted, and sometimes becomes quite faint. In some violent fits of coughing, blood starts from the nose and lungs, and it is said even from the eyes and ears. After a paroxysm of severe coughing, in which the child appears RESPIRATORY SYSTEM 99 to be dying from suffocation, or on the point of falling into a general convulsion, all the distress and all the remembrance of suffering are at an end, for he returns to his sports with as much eagerness as ever. As the disease differs in severity, so the number of paroxysms differs during the day, and they are less violent in proportion to the freeness of the expectoration. The second stage will continue at its height about three weeks, and then the violence of the symptoms gradually lessens, while the expectoration increases, and the skin becomes moist. By almost insensible degrees the cough loses its peculiar sound, but retains its paroxysmal character, often for a long time; but in the simple form of the disease, it usually disappears at the end of the fourth week. It frequently happens that after an entire subsidence of the affection, it will return with the distinctive spasmodic hoop, on an exposure to sudden cold, or under any circumstances favorable to the production of pneumonic disease. It has in some instances observed an intermittent or periodic nature. A case of this kind, of a peculiarly intractable character, which occurred daily at a certain hour, is mentioned by Dr. Good.* It was obstinate for several months, and returned at the same season for two years. The stethoscope discovers the ordinary signs of bronchial catarrh. There is no uniform sound in every part of the chest; the respiratory murmur being distinct in some parts, while the peurile respiration is discovered in others, with the mucous and sibilous ronchi. There is for some moments before and after the paroxysm an absence of the bronchial murmur and pulmonary respiration. These are the usual symptoms, in its uncomplicated form, except so far as a simple form of bronchitis may be considered a complication ; which is indeed so common, that few, if any, are found without it, so that the inflammation has been regarded by some as the disease itself. As to the diagnosis, it is not difficult; the convulsive character of the cough and the long sonorous inspirations followlhg it being very readily recognised, and not easily confounded with any other species of cough. Its usual attendants, the discharge of a quantity of glairy mucus, and the ready evacuation of the stomach after a paroxysm, will also aid in the diagnosis, when, as is sometimes the. case in the early period of the disease, the well-known hoop is absent. The prognosis is in general favorable. In cold and wet seasons it is more dangerous than in warm ; and as the disease, however mild at first, may be complicated with other and more formidable • Study of Med., vol. ii., p. 393. 100 DISEASES OK CHILDREN. affections, such liability ought always to be considered in forming a prognosis. In very young children, and in those undergoing the irritation of teething, or during the existence of other circumstances which tend to derange the system generally, as the change of diet at the period of weaning, these complications are more likely to occur. As the connexion of hooping-cough, therefore, with other affections, from which it, for the most part, receives its fatal character, is of so common occurrence, the consideration of these complications, existing either originally, or as they arise during the progress of the disease, will be necessary to a proper understanding of it in all its forms. When hooping-cough is complicated with pneumonic inflammation, it is not difficult to detect the existence of this complication, from the symptoms already mentioned as distinctive marks of this affection, whether they give evidence of active inflammation of the bronchia?, or of the parenchyma of the lungs. In the invasion of an extended inflammation of the lungs, which it is necessary to ascertain early in the disease, for its proper treatment, a change will first be observed in the pulse ; which, from being- but occasionally quickened during the paroxysms, becomes permanently quick and hard. So, also, the breathing is found to be hurried during the intervals, which, in simple hooping-cough, presents no departure from the healthy standard. It is unnecessary to detail all the symptoms attending pulmonic inflammation, as they dp not differ from those already described; the rational signs are but added to the peculiar hoop of the disease, while the stethoscope gives the same physical signs. The fatal termination is always accompanied by all the evidences of violent congestion of the lungs, or of a complete closure of the air-passages, from the accumulation of the mucous secretion following severe bronchial inflammation. Instead of pulmonic inflammation, there are often evidences of great gastric and intestinal disease ; the furred tongue, loss of appetite, and the altered alvine discharges, show considerable derangement of chylopoetic viscera. These symptoms, together with the existence of fever, present the disease as complicated with infantile remittent fever. When thus combined, it usually exists from the commencement, and in many cases appears to precede it, when it is essentially connected with its development. The ¦ approach of the fever is very gradual, and its commencement difficult to ascertain ; but the evidences of great derangement in the secretions of the abdominal viscera always exist before the fever has made its appearance. During the fever the respiration is hurried, and the coughing severe, but the stethoscope will detect the absence of inflammatory disease in the chest. When hooping-cough is connected with cerebral disturbance or RESPIRATORY SYSTEM. 101 turgesence, partial convulsions soon appear in the hands during the paroxysms of coughing; these are almost invariably followed by general convulsions. They are often caused simply by the interruption to the circulation in the jugular veins, by which the cerebral vessels are crowded with blood, while the face becomes livid in the midst of a fit of coughing, without the presence of a distinct hoop. These turns are extremely dangerous, especially in very young infants, for they almost invariably, if of frequent recurrence, terminate in effusion and death. The permanent dilatation of the pupil marks the invasion of cerebral disease. This complication of hydrocephalus is generally preceded by convulsions; but sometimes it makes its invasion very gradually, the child giving the first intimation of it by coma, and paralysis of one side of the body, while the arm of the opposite side is moving in the sawing manner, so often observed in cases of cerebral effusion in children. Wherever, therefore, there exist convulsions, or paralysis on one side, we may very reasonably infer the existence *of effusion in the brain. When the convulsion is general, before coming to the same conclusion we should ascertain the precise history of the case, the hereditary tendency in the family, and other circumstances connected with the predisposition to this disease, pointed out in the article on that subject. It may be looked for when there is great drowsiness, and at times screaming and starting during sleep, followed by fever and vomiting; while the alvine evacuations give no evidence of a disordered state of the secretions of the abdominal viscera. The breathing in the hydrocephalic complications is not quick but often deep and sighing ; a remarkable difference from what takes place in inflammatory diseases of the chest. Morbid Anatomy and Pathology.—Dissection, in the simplest form of hooping-cough, has revealed but little as to its peculiar pathology, besides the inflammation of the bronchial tubes. The simple disease, uncomplicated with other affections, is seldom fatal; on this account it is that autopsical investigations have shown, in the greatest number of instances, the presence of inflammation, and its effects in other organs distant from the immediate seat of the disease, as the most marked symptoms would indicate. It would be an unsatisfactory and almost an endless task, to record the results of post-mortem examinations which have been made to ascertain the seat of this peculiar disease, as complications, in some form or other, have for the most part been its attendants. Tfee following appears to be the summary of the results of these examinations, and the theories resulting from them. Where opportunities have occurred, in which the disease has had but little or no complication, bronchial inflammation in various 102 DISEASES OF CHILDREN. stages of its progress has been found, as appears from the red color of the mucous membrane,.and the presence of a greater or less quantity of mucus at the same time in the tubes, together with the existence of purulent matter at their extremities.* A dilatation of.the bronchia? has also been frequently seen in connexion with this inflammatory state, but principally confined to the extreme branches, as pointed out by Laennec. In connexion with other lesions, traces of inflammation of the lymphatic ganglia, near the bronchia?, have existed in a number of instances. Again, the lungs have been found in a state of induration, showing,' in severe cases, the existence of inflammation in the parenchyma of these organs, as well as in the mucous membrane lining the air-passages. In other instances, tubercles have been discovered, in a state of suppuration, at the root of the lungs. The lesions which are found in complicated cases are as various as the diseases which attend a protracted case of hooping-cough. In addition, therefore, to those above mentioned, it is not unusual to find chronic enteritis, worms, and other affections of the viscera of the abdomen. The great sympathetic and splanchnic nerves have exhibited a firmer consistence than is natural, and the ca?liac plexus is considerably firmer and more elevated. So, also, the trunks of the phrenic nerve and the vagi have been found enlarged and looser in their texture. In other instances, the only lesion that has been found was in the brain, where effusion of serum existed; from which it would appear to be solely dependant on the condition of the brain. When, however, effusion is found in the brain, it is connected with bronchial affection; so frequent is this occurrence, that it has been denominated by some French authors, broncho-cephalite. It is unnecessary to record the various appearances found in this complication, as they will be fully detailed when the subject of hydrocephalus is under consideration. On these appearances, when considered in connexion with the symptoms which the disease exhibits, the different views as to its nature have been founded. And it is not a matter of surprise that so many different ideas of the pathology of the disease have existed, when the post-mortem appearances have been so various, and the disease often so obstinate and uncontrollable; thereby apparently disproving the preceding theory, which in its turn, also, has been supplanted by other hypotheses. The theory of its purely inflammatory nature has been adopted by Watt, Guersent, Laennec, Billard, Dawson, and others. Dr. Watt especially, who wrote largely on this affection, regarded it as always inflammatory, and affecting the larynx, bronchia? and air- * Ballard, Op. Cit., p. 427. RESPIRATORY SYSTEM. 103 cells alone, when mild ; and when serious or fatal, it is either transmitted to other parts, or affects the original seat of the disease, with the usual consequences of severe inflammation. The reasons for regarding it as purely and always inflammatory, are, that the ordinary bronchial inflammation, occurring in winter, not unfrequently shows a tendency to spasmodic action ; and that the results of autopsical examinations in hooping-cough prove the existence of inflammation in the bronchial tubes, as in bronchitis. As to the precise location of the inflammation, Dr. Dawson is of opinion that it is exclusively in the larynx or glottis, while others think its seat to extend throughout the whole of the air-passages. By others it is regarded as a spasmodic disease, arising from the condition of the brain, or of some other portion of the nervous system: Cullen, Lobenstein, Le Roy, Hufeland, Jahn, Breschet, and Webster, adopt this opinion; the last-mentioned writer placing it in the brain, and considering that the affection of the respiratory organs is altogether secondary, from an effort of nature to relieve the congested brain by an expansion of the chest.* Hufeland, Jahn, and Breschet,, were disposed to regard the phrenic and pneumo-gastric nerves as the original seat of the affection, and that the lesion constituting the disease continued there; while Lobenstein believed that the disordered action originally existed in the diaphragm, and was subsequently communicated to these nerves.t Dr. Copland's opinion is that it is a disease of nervous irritation alone, having its commencement in the respiratory organs and transferred principally through the medulla oblongata, and again transferred to the lungs and also to the stomach; and that other concomitant causes, or a predisposition, may convert it into an inflammatory affection. In addition to these views, M. Desruelles, in the work already referred to, regards the disease as bronchitis complicated with cephalitis, the one invariably preceding the other; the primary affection causing a simple cough, while the subsequent irritation of the brain produces a spasmodic action of the respiratory muscles. Without adopting any of these conflicting views, it is enough for all practical purposes to keep in mind, that at the commencement of the disease it is inflammatory : increased vascular action for the most part-existing, in some instances perhaps in a very slight degree ; but that it is essentially the nature of the disease in its first stage, is evident from the fact of the presence of symptoms which point out this condition of parts, if the local affection be increased even but a little. Expectoration accompanies the cough at the be ginning, like ordinary catarrh or bronchitis, while a slight febrile action is a very common attendant, rendering the diagnosis at this • Med. and Phys. Jour., De'c. 1822. t J. Wendt, Der Kinderkrankheiten systematisch dargestellt; Wien., 1835. 104 DISEASES OF CHILDREN. early period often doubtful. The stethoscopic signs also give evi dence of a similar condition of the parts affected. While it is in the first stage an inflammatory disease, or perhaps a complication of inflammation with some inexplicable action of the nervous system, which modifies the simple bronchitis, it is unquestionably in the last, one in which spasmodic action prevails, as is abundantly evident from the success in adopting such remedies in its treatment which are known to exercise a controlling influence over the morbid sensibility and actions of the nervous system. Severe pulmonic inflammation, however, will arise during its progress at any stage. The cough, which is an act of expulsion from the lungs of the air for the removal of a foreign body, as in the present instance, of a quantity of mucus, is so violent as to exhaust the lungs almost entirely, and hence the loudly-sounding hoop on a sudden inspiration to supply the vacuum ; hence, also, the congested state of the blood-vessels about the head and neck, and the asphyxiated appearance of the face in protracted paroxysms. The different complications of this disease must be regarded as secondary affections, arising from the excessive congestion produced in the fits of coughing, of which hydrocephalus is the most common when the disease is fatal. Treatment.—From these views the treatment of ordinary hooping-cough may be easily deduced ; it must be antiphlogistic in the first stage, and when this is relieved, anti-spasmodics and sedatives will, in general, be indicated. Although our remedies should be at first of such a nature as to allay the inflammatory action of the part, yet it is evidently unnecessary to adopt any active measures of this sort in all cases, for in many instances in simple hooping-cough there is but little interference needech During the existence of symptoms of catarrh, the diet should be light, consisting of milk and vegetables, while the child is kept within-doors, and clad warmly ; this course, together with the constant use of warm diluents, the breathing of warm air, and pediluvium, will tend to preserve the skin in a soft and active condition. At the same time the bowels should be kept open by mild cathartics ; a few grains of rhubarb, combined with ipecacuanha, may be used for this purpose.* If these do not also operate as an emetic, those of a more effective character may be given. Ipecacuanha, in the form of syrup, or the compound syrup of squills, may be ujed, according to the age of the child, • ft Pulv. Rhei., gr. xij. (27) Pulv. Ipecac, gr. ij. Sacchar. Alb., q. s. M. Ft. Pulv. No. iv. One to be given every night to an in- fant j two for a child of two or three years. ft Pulv. Rhei., gr. x. (28) Hydr. Subm., gr. iij. M. Divid. in Pulv., No. ij. One for an infant of six months, to be repeated in six hours, RESPIRATORY SYSTEM. 105 and the urgency of the symptoms. Proper formulae for emetics will be found at page 45. Emetics are particularly useful in this disease, and should be repeatedly employed—unless counter-indicated by a phlogosed state of the gastric mucous membrane—until expectoration is freely established. It has sometimes been found difficult to induce vomiting: when such a difficulty exists, it is usually an indication of a severe form of disease ; apparently, too, depending at times on the existence of an inflammatory state ; at others, on the congested condition of the nerves on which the act of vomiting depends. An antimonial emetic may be needed in some cases, and all measures used to prevent the occurrence of active inflammation of the bronchial mucous membrane or parenchyma of the lungs, on the prevention of which the welfare of the patient often altogether depends. The progress of the symptoms must be carefully watched, and if there exist any signs of increasing inflammation in the lungs, early and efficient bleeding must be resorted to, to prevent at once, if possible, the establishment of a serious and perhaps uncontrollable inflammation of the lungs. While the means for controlling the inflammation are in active operation, such as will promote a free expectoration must be used ; and those that are applicable to bronchial and pulmonary inflammations may also be had recourse to, when indicated. It has been the custom to be rather cautious in the use of the lancet, where there are evidences of much spasmodic action present ; but where the inflammatory condition is evidently on the increase, a free bleeding is absolutely necessary, and can by no means be dispensed with, to arrest that state of the diseased part which gives to hooping-cough its dangerous character, and which is always found after death to exist, unless the morbid action has been entirely transferred to other and distant parts. Leeches are highly useful, when the violence of the constitutional symptoms have been in some degree arrested, or when, from some peculiar debility of the patient, general blood-letting is counter-indicated. Like all other pulmonary affections, hooping-cough receives but little benefit, in its simple form, from the use of active purgative remedies ; indeed, the unfavorable symptoms have at times appeared to be increased by their use, the operation of a cathartic scarcely ever being unattended with some degree of spasmodic action of the bowels, as appears from the griping effect usually attendant on its operation. In general, it will be necessary to preserve a proper secretory action in the intestines, by the use of mild laxative medicine ; and such as have already been mentioned may be used for that purpose. On some occasions, however, the use of these may be hazardous, when there exist a morbid irritability of the stomach and intestines, and other evidences of gastro-intestinal inflammation. Under these cir- 14 106 DISEASES OF CHILDREN. cumstances, neither emetics, in general so useful in hooping-cough, nor laxatives, should be used, but the treatment ought to be conducted by the warm bath, blistering, and small doses of nitre ; while the bowels are kept open by enemata. It is in the second stage, or period of spasmodic action, often unattended with inflammation, that the host of specific remedies has been successful; and although their use has been denounced by some as empirical, yet experience has fully proved the highly practical advantages resulting from the employment of anti-spasmodic and sedative remedies, and that success has often followed a judicious use of these means. The extract of conium maculatum has been highly praised foiMts efficacy in allaying pulmonary irritation, and especially that form which constitutes the disease in question. To obviate the objection urged against its use by some, that it arrests the expectoration, it has been given in combination with tartar emetic, by some German physicians.* When used alone, it may be administered in the dose of half a grain to an infant, and one grain to one between the ages of two and four years. Having had no experience in the use of this remedy, I can only speak from the experience of others. For the same purpose, opium has been extensively used. Henke, Millar, Kirkland, and others, extol it highly in the spasmodic coughs of children. Opium should always be combined with some nauseating remedy, whereby its controlling effect on the secretions may be counteracted. Dover's powder offers a good form for this purpose ; or the combination recommended by Dr. Pearson, consisting of a draught composed of a drop of tincture of opium, five drops of wine of ipecacuanha, and two grains of carbonate of soda, for a child of two years, to be repeated every fourth hour for several days. Hyoscyamus, also, is another of the narcotics that has been used in the treatment of hooping-cough. Its properties are analogous to those of opium ; but it does not interrupt the secretions like opium, and is on this account to be preferred. I have found a most decided benefit to follow its use in protracted cases, giving it in the extract with water, or in case of the presence of any slight degree of febrile action, combined with antimony, as recommended* by Hufeland.t •ft Ex. Conii, gr. ij. (29) Antim. Potass, tart., gr. j. Aquae, Syrup. Croci., Zss. To be taken in the course of two days, by an infant. Schlcsinger. t ft Extr. Hyoscyami, gr. x. (30) Vini Antimon., 3u- M. Eight drops four times a day, to an in- fant a year old. il Villi Antim., 3j. (31) Extr. Hyoscyami, gr. iij. Syrup. Simpl., M. A teaspoonful eve"ry two hours, to an infant from six months to one year. W7- RESPIRATORY SYSTEM. Assafcetida is another medicine that has been used with sticcess for the relief of the spasmodic disease. Millar was the first who prescribed it, giving it in enormous doses. The Germans, also, have used this remedy in the latter stage of hooping-cough, with a relief of the paroxysms, and a general improvement to the secretions generally.* Musk is another medicine extensively used in this disease, in the dose of two or three grains to infants of a year old, every Jiour. Belladonna, a powerful sedative and narcotic, and possessing, also, the qualities of promoting the excretions, has likewise been much employed for the purpose of diminishiug the irritability of the nerves supplying the laryngeal muscles. To a child two years old a quarter of a grain may be given three times a day, and half a grain to one of four years. It was used by Dr. Kahleiss, with great success, in one hundred cases of pertussis, in conjunction with ipecacuanha and sulphur, and the alternate use of hydrocyanic acid. This method has also been used by Dr. Valk, of Providence, R. I., with similar success.f The subjoined formulae are those which he used for a child of seven months ; four times the quantity was used by Dr. K., for children of the age of two years.} Other practitioners speak highly of its good effects, when the disease is purely spasmodic. Hydrocyanic acid has also been greatly extolled by Dr. Muhrbeck, of Demmin,|| and Dr. Hamilton Roe the latter especially observes, that it is so uniformly successful, that when he finds a child that has not been relieved by it, the first impression is, that the medicine could not have been good. Dr. Atlee, of Pffiladelphia, has used it in a great number of cases, and completed a cure in from four to fourteen days. His method of administering it was, to give a teaspoonful of a mixture, containing one drop of the acid in an ounce of syrup, twice a day'to a child six months old, increasing it to three teaspoonfuls, if no bad symptom followed its, use. He adds two drops to an ounce of syrup, for a child between the ages of one and two years, and an additional drop for each year The subjoined is a prescription of Dr. Roe.^[ • ft Assafcetidae, 3ij. (32) Mist. AGaciai, Syrup althacae, &&. jj. M A teaspoonful every two hours, to a child three or four years old. fAmer. Journal Med. Science, vol. vii., p. 417. J ft Pulv. Rad. Bellad., gr. j. (33) " Doveri, gr. ijss. Sulph. Precip., 3j Sacchar. Alb., 3ij. M. Divid. in Chart. No. xx. One powder every three hours, and between each dose, twelve drops of the following mixture: Yl Aquae Camomile., Zss. (34) Syrupi Simpl., 3u- Acid, Prussic, gt. vi. M. || Rust's Mag., January, 1836. § Treatise on the Nat. and Treat, of Hooping-Cough, etc.; London, 1838. IT Acidi Hydrocyan., (Scheele's), m. xij. (35) Liquor. Antimon., Tart., 3j- Tinct. Opii. Camph,, 3ijss. Mustura? Camph., M. A tablespoonful every four hours, to a delicate boy of four years old, to be given in some warm drink. DISEASES OF CHILDREN In * protracted cases, attended with great debility, tonics have been resorted to, and found highly efficacious. In many instances cinchona has been used alone, and combined with cantharides, for the restoration of the lost strength, and to break the habit of a periodical return of the paroxysms. However useful it may have been found to be, cantharides ought never to be given to very young children, from the extremely irritable state of their nervous system. The following is the formula reeommended by the Beatty, of Dublin.* Cinchona is more useful where the disease assumes a periodic character; while the preparations of iron, as the sesquicarbonate, are more applicable lo such cases as are attended with a decided debility of the system. This last-mentioned preparation has been given in very large doses ; even to the amount of twentyfour to thirty grains in the course of a day, to very young children. The bowels should be kept free whenever tonics are used, and their employment ought to be suspended whenever symptoms of congestion or inflammation appear. Arsenic was used by Dr. Ferriar, for the same purpose, in doses of a drop daily of the solution of Dr. Fowler; and Guersent advises, under the same circumstances, the oxide of zinc, a grain every hour. According to the experience of some, arsenic has effected a complete cure in the course of a fortnight; it is, however, too hazardous a remedy to be generally adopted. The acetate of lead also has been used with benefit where tonics are indicated : it is liable to the same objections as arsenic, and ought rarely to be given to young children. Nitrate of silver lias been employed where tonics are indicated. When, however, there exists a necessity for the use of tonic remedies, the sulphate of quinine, probably, is the best.t During the application of th'ese remedies, stimulating embrocations may be useful to establish a revulsion on the skin; and the " Pommade d'Autenreith" has been much used for tfiis purpose: it differs but little from the tartar emetic ointment in common use in this country. This ointment is prepared by adding one drachm of tartar emetic with seven of lard ; a drachm of which should be rubbed on the chest and epigastric region, night and morning, until a crop of inflamed tumors appears. An old and valuable external application is that made of the oil of amber, oleum succini, combined with common oil, with the addition of the oil of cloves ; two ounces of the oil of olives, with half an ounce of each of the others, for an embrocation., • R. Tinct. Cinchon. C, ?V. (30) « Canth., " Opii Camph., aa M. 3ss.—3j- three times a day. tft Quina? Sulph., gr. x. (37) Acid. Sulph. Dilut., gtt. xv. Aq. Cinnam., |ij. M. A teaspoonful three or four times a day, to a child of two years. 109 RESPIRATORY SYSTEM. An endermic method of treating hooping-cough, although to accomplish a different object from that usually intended by external applications, has within a few years been recommended by Dr. Brendt.* He employed the acetate of morphine, by applying a grain of the salt to the blistered surface whence the skin had been removed. Four grains of powdered gum arabic were mixed with it, and applied by sprinkling it over the spot. In several instances it was attended with decided benefit, but not until the full effects of its narcotic power had been experienced. On this account it can not be unattended with hazard, as we have the remedy so little under our control: the power of absorption differing greatly in different individuals. Fumigation with the vapor of benzoin, was accidentally discovered, a few years since, to allay with remarkable quickness the paroxysms of hooping-cough, which had continued for nearly three months, during which time several remedies, including belladonna, had been used in vain.f The vapor of tar has been used by Dr. Watt with success ; and the fumes arising from warmed spirits of turpentine, it is also said, have been followed by decidedly good effects. In all cases of obstinate hooping-cough resisting the succession of remedies, which in all probability will be tried, a change of air will be often of inestimable benefit to the patient, and should by no means be neglected, when it is in the power of the patient to obtain the advantage of so powerful a tonic. It is in summer almost invariably followed by an improvement in the symptoms, and may at that season be used in all the stages of the disease, unless, indeed, a violent inflammation of the lungs should render such an exposure hazardous. Such are the means to be used in the treatment of hoopingcough, as it for the most part occurs. Inflammation of some portions of the pneumonic system, in a degree at least, even if slight, so invariably attends it in the first stage, that it can scarcely be regarded as a complication of the disease. The affections of the bowels, however, and of the chylopoetic viscera generally, must be regarded as a very serious complication, as this state of the system so often precedes hydrocephalus in young children. It therefore demands the closest attention of the physician; and the peculiar symptoms already pointed out must by no means be disregarded, as upon the restoration of the healthy action of these important viscera, the success of the treatment in a great measure depends. • Klinische Mittheilungen, von Dr. F. A. G. Brendt, KOnigl. Geheimen Medi«inal—Rathe, Greifswold, 1833-34. f PfafPs Mittheilungen, lste Jahgr., 1 und 2 Heft. 110 DISEASES OF CHILDREN. When, therefore, the tongue indicates the disordered action in the prima? via? and their appendages, and a constipated condition of the bowels exists, it will be necessary to administer a cathartic, which should be repeated occasionally, until the secretions of these parts have given evidence of a recent secretion, by an entire improvement in their appearance. A regular action of the bowels should then be kept up by the use of milder measures. To fulfil the first indication, calomel, in full doses, will be found the most effectual for the removal of the morbid turgescence of the abdominal viscera, and the speedy restoration of their functional activity. Calomel and rhubarb, or a few grains of calomel, followed by infusion of senna, will be the best to fulfil this object. After the bowels have been freely moved, a mixture of blue pill and rhubarb will suffice to preserve their action.* It is not unfrequently found that the secretions exhibit much alteration in their character, while the alvine evacuations are natural, as regards their habitual recurrence ; it will not be necessary, under these circumstances, to use the more active purgative medicines, but simply the mild combination already mentioned. Although cathartics have been but little employed in the management of this disease, yet they have been found necessary where the alvine secretions exhibit departure from their ordinary healthy character. Sometimes they are deficient in bile, as in jaundice. It will then be necessary to employ the more active cathartics, as calomel, jalap, and colocynth, to excite a more natural sensibility in the intestinal canal and its appendages. It is probably the deranged state of the secretions, with the predominance of acid in the imperfectly digested contents of the stomach, and the relief which has followed the use of alkalies and absorbent preparations, combined with those that exert an influence on the secretory function of the bronchial mucous membrane, that has brought these remedies so much in repute as to have rendered them popular. The disease has been regarded by some as in every instance necessarily connected with an acid state of the stomach. Such a condition is not peculiar to this disease alone, children suffering from any acute disorder have more or less derangement of the stomach and bowels. It is therefore always safe practice to keep this in mind, and whenever there is any evident derangement in the prima? via?, to combine an antacid with the prescriptions used. It is of more importance than it is often conceived to be. The effects of acidity of the stomach are often exceedingly annoying, as * ft Pul. Rhei., gr. x. (38) Hydrarg. Oxid.. gr. iij. M. Fit. Pulv., No. iij. One every night, to a child a year old. RESPIRATORY SYSTEM. 111 we are all aware, producing a dull heavy pain in the head, a feeling of stricture about the brain, a languor and unfitness for active mental exertion, but quickly relieved by neutralizing the acid. If such be the effects in the adult, how much more dangerous in the irritable condition of the infant state. It therefore should have our constant attention when prescribing for infantile diseases. It is this state of the stomach which probably renders the operation of an emetic, combined with cretaceous powder, as was used by Dr. Fothergill, so beneficial in the treatment of hooping-cough. When the secretions continue unaltered, and there is evidence of the constant presence of acid in the stomach, the hydrargyrum cum creta., combined with the rhubarb, will be a good combination for correcting this state of the stomach, and improving the secretions; it is peculiarly suited to the bowels of young children, being an extremely mild and unirritating preparation.* It occasionally happens that the bowels are in an extremely irritable condition, forbidding the use of laxatives in any form, while the secretions are in an unhealthy state. Here the object will be, while we attempt to improve the secretory functions of the liver and intestinal mucous membrane, to allay the morbid irritability of the prima? via?. This is blst done by combining the above-mentioned preparation of mercury with Dover's powder,t while anodyne enemata are used in cases of violent tenesmus and irritation in the rectum. This powder ought to be followed by a little castor oil, when the morbid irritability is removed. By close attention to the secretions of the bowels, and their appendages, we may prevent the occurrence of convulsions and effusion in the brain. When convulsions make their appearance, all the usual sources of irritation in infants must be examined, and if the gums be found swelled and inflamed, they must be freely divided. Convulsions will sometimes continue for a long time, without being in any degree relieved by the usual means employed for their removal. When this is the case, an entire change of diet will be necessary ; this subject will be more particularly noticed under the article on indigestion, and that of convulsions. •ft Pulv. Rhei, 3j. (39) Hydr. c. Creta, gr. x. Pulv. Sacch. Alb. gr. x. M. From three to five grains every third hour. tftHydr. c. Creta, 3j. (40) Pulv. Ipecac. Co., Sacchar. Alb., 3ss. M. Four to six grains for an infant of six months, to be repeated p. r. n. DISEASES OF CHILDREN.* 112 CIRCULATORY SYSTEM. PECULIARITIES OF THE CIRCULATORY SYSTEM. At the period of birth, on the establishment of respiration, a remarkable change takes place in the circulation of the blood. The heart, from being in the foetus a single organ, like that of the Crustacea and pisces, intended but to send the blood through the vascular system, for nourishment and growth, becomes double in its action, and in fact double in the arrangement of its parts. Upon the full development of respiration, a new set of vessels is brought into action; and in addition to the circulation of the sanguineous fluid through the nutritive capillaries, another direction is given to it, and another circulation is superadded—that through the lungs, for the restoration of its nutritive properties, a .process hitherto dependant on the mother—while olher vessels peculiar to the foetus are obliterated. The heart, then, for the first time undergoes a change in its internal form, by which there, are two distinct organs, although united in one; that on the right side transmitting the blood through the lungs, forming the pulmonic circulation ; the other,#on the left, denominated the systemic circulation, for the-nourishment of the body. Although at once entering into the full discharge of its functions, the heart is still peculiar, and in some respects differs from the adult heart. But before these are noticed, it is proper to refer to the changes which occur on the establishment of the independent circulation, and the period at which it occurs. A number of new-born infants were examined by M. Billard, with reference to the precise period at which the foetal openings were completely closed, and found to vary from the age of one day to that of eight days; a detailed account of them may be seen by referring to his work.* The. result of all these investigations is, that the foetal openings are not always closed immediately after birth; but the period is extremely variable, occurring, however, usually on the eighth or ninth day after birth. The circulation ceases first in the umbilical arteries, next in the vein; the ductus arteriosus is next obliterated, and lastly the foramen ovale. These openings may therefore continue, without producing any symptom of disease. The mode of the obliteration is detailed at length by the author above-mentioned ; and the result of his observations is, that the blood in the arteries is forced through by a succession of modifications occurring in their parietes, by which their calibre is gradually • Op. Cit., p. 436, et. seq. CIRCULATORY SYSTEM. 113 reduced in size, while in both of the foetal veins the arrest of the circulation occurs as the result, and not the cause, of the retropulsion of the blood. * The blood of an infant, therefore, can not, during the first days •of life, undergo so perfect an oxygenation as afterward, as it does not all pass through the lungs. M. Billard is of opinion, that it is not necessary that the blood of an infant just born should be charged with too much stimulating properties, and that this state of transition is better adapted to the imperfect condition of the infant frame, whose organs might be too powerfully excited by a sudden supply of perfectly oxygenated blood. The lungs, on the first establishment of independent life, might be suddenly congested ; the patulous state, therefore, of the ductus arteriosus affords a relief to this condition, and allows the blood to flow through it, as the congested state of the respiratory organs will not permit the air to arrive freely in the cells. In infancy the heart, like other muscles, is much softer than at later periods of life, and its color is paler; it is also much thinner. At the time of birth there is no difference in the thickness of the parietes; but after the closure of the foetal openings, those of the left ventricle, from the increased demand made on them as the entire source of transmission of blood through the systemic circulation, rapidly increase in thickness, until they become four times as thick as those of the right. At this time, although the parietes of the heart are the same in thickness, the cavities differ in their capacity, the left ventricle being much the largest. Gradually, however, after birth, the capacities of these cavities are reversed, that of the right side becoming the largest, from the causes already stated, which produce an alteration in their parietes. The color of the right cavities is usually of a deep violet. In this respect they also differ from the left, which are of the usual red. The larger vessels of this side also present the same color, which does not appear to depend on venous turgescence. As the organs of circulation are in an active state even during the foetal life, the nerves of the ganglionic system, which supply the heart and involuntary muscles, are much more developed than those of the cerebro-spinal system. The heart of an infant is of large size, but possessing less powers than the heart of an adult; it is, therefore, more fitted for the transmission of a large quantity of blood, but not to so great a distance. Its great irritability, or, as it has been termed, organic force, renders its contraction much more active than in after life; a remarkable provision, by which the demand of the system for nutrition, during the period of growth, is quickly supplied, for a large 15 114 DISEASES OF CHILDREN. quantity of materials is constantly needed, at a time of life which is characterized as one of transition from an imperfect state to a state in which all the organs are adapted to the full performance of their functions. Jacquemier, in his treatise on auscultation, has endeavored tc* establish the medium pulsation of the heart of an infant; and after a great number of experiments, has found the minimum pulsation in a new-born child to be 97, the maximum, 156, and the medium, 126.50.* M. Lediberder, in a memoir on the changes occurring in the circulation of an infant at the moment of birth, states, that the result of auscultating the heart, even before the umbilical cord was cut, gave eighty-three double pulsations in the first minute; but they quickly increased in number, for after the third minute the medium pulsation in sixteen cases, was 160.t The pulsation of the radial artery, which is not always isochronous with that of the heart, has been variously stated by different authors; Floyer fixed it at 134, Haller, 140, Soemmering, 170. Billard states, that the pulse in new-born children often does not exceed that of an adult, but that it increases in frequency in proportion as the child advances in age; and in the generality of cases, the pulse of children is more frequent, he observes, than in adults. In a great number of experiments conducted by M. Valleix, the average pulsation, at the age of 2 to 21 days, amounted to 87; at at 64.7 months, to 108.31 : at 23.6 months, 121.68; at 11 months, 129.9 ; at 14 months, 125.66 ; and at 20 months, 117.754 The pulse, at the age of seven months, is much more frequent than at a few days after birth; it afterward diminishes until the age of six years ; after this period, there has been nothing ascertained as to the effect of age on the pulse. M. Trousseau has found that the average pulsation of infants from eight days to six months old is 131 for boys, and 134 for girls ; from six to twenty-one months the average for boys was 113, and for girls 126 ; he also found the extremes to vary frequently far above and below the average. The state of sleeping and waking also exerts an effect on the pulse, as was ascertained by Trousseau, the average pulsation in the former state in infants from fifteen days to six months was 121, and in the latter 140; and iii infants from six to twenty-one months was 112 during siee"p, and 128 while awake ; there is also a remarkable difference where the child is alarmed. The result of all these examinations is, that the pulse of children * De I'Auscultation applique" au Systeme Vascula'ire du Foetus, etc.; Paris, 1827. t Valleix, Op. Cit., p. 26. t Op. Cit., p. 25. 115 CIRCULATORY SYSTEM. at the hreast varies from 100 to 150; after the first two months it is a iiltle more frequent in females than in males ; and it is about twenty pulsations higher in a state of waking than it is during sleep.* The healthy pulse of infants is very soft, and easily compressed; the artery, instead of striking the finger, appears to glide under it, requiring some care in pressing on the vessel. The crying of the child has a very marked effect on the pulse, even before it has commenced; for when a child is about to cry, there is often so great an increase in the pulsations, that it is difficult to count them. With respect to the ordinary characters of the pulse, as indicating disease, they do not differ from that of an adult; but this subject will be considered in the next section. Among the many differences existing between the child and the adult, arising from the demand for the materials for growth, there is none more remarkable than the proportion which the blood-vessels bear to the other organs. The arteries abound in every part of the infant frame; and during this period of active interstitial deposits, the sanguineous appearances are very remarkable in every part of the structure, even of the most solid, when subjected to anatomical examination. These gradually disappear after the period of youth, and are scarcely to be found on separating the periosteum from the bones in old persons. This contraction and disappearance of the arteries take place in the extreme branches; and, as was observed by Bichat, the younger the subject the more easily could injections used for making anatomical preparations be made to pass to the minute portions of the arteries; while in the old, such is the resistance which the contraction of the smaller vessels oppose, that it is with difficulty that even the largest trunks can be filled. At an early age, also, the coats of the arteries show very plainly the existence of the vessels which belong to them, but which gradually disappear in after life. The changes thus occurring in the arteries depend on their containing much more cellular substance than the veins, and the increasing condensation ol'this substance produces a thickening of the vessel. Changes to such an extent, however, do not occur till late in life ; and this .is the reason why the young are more subject to arterial hemorrhage than the old ; for, in the former, the quantity of blood in the arterial system is always most abundant, and the power of contractility of the arteries much greater: all this tends to distend the extreme parts of the arteries, and also to add to the bulk of the body. In the old, the veins have gradually dilated, while, the arteries have contracted their calibre; the arteries, therefore, yield more readily to the force of the circulation in early life, and • Journ. de Med. et de Chirurg. Prat., Aug., 1841. 116 DISEASES OF CHILDREN. the plethora of young people is that of the arteries, while in age it is in the veins. • As the capillaries are the principal agents in the nutrition of the body, and necessarily form the most intimate part of the texture, they must therefore abound at the early period of life, when the increase of parts is the most characteristic phenomenon. On this account, also, it is that diseases in early life are so sudden and so violent, and require more prompt and energetic treatment than those of adults : all the morbid phenomena having their seat in the capillary system, which is at this period of life in so active and vigorous action in building up the body. The quantity of blood in the body of an adult is estimated by Haller at about one fifth of the weight of the body; but as all the fluids abound in infancy and youth, the proportion is much greater in early life, when the continued addition of new materials is more needed than at an after period of life. The consequences of this activity of the circulation, and redundancy of fluids, may be traced in all the organs. The blood is not only sent in abundance to every organ, but is better prepared, by the air acting on a much .larger portion of it in a given time, for the purposes of nutrition and secretion. The round and plump form of the infant, and the softness of all its parts, show this redundancy, while the bright red color of the skin gives evidence of the constant circulation of aereated blood through its tissues. There is also a difference in the composition of the blood in infancy and early life. At this period the proportion of azote is less than in advanced life; the watery exhalations also are greater, and the fibrine less. In the foetus there is no fibrine at all, but the blood contains in its place a gelatinous substance, which does not become reddened by contact with the air; neither are there any phosphoric salts found in this fluid.* Phosphate of lime and fibrine increase with the growth of body, and the former, in adult age, sometimes becomes excessive. In proportion to the increase of these elements, the quantity of gelatine diminishes, and also changes in quality, as is well known to glue-manufacturers, for the glue obtained from the young differs materially from that yielded by adult animals. The condition of the secreted fluids naturally falls under another division of the subject, and will be considered when the lymphatic apparatus comes under our notice. • Fourcroy, Anal, de Cliimie, t. vii., p. 162. CIRCULATORY SYSTEM. 117 SIGNS OF DISEASE FROM THE CIRCULATORY SYSTEM. Affections of the heart, during the first periods of life, generally arise from congenital lesions, in which they differ from the abnormal state in the adult or advanced age, where they arise from ossifications, or from diseases of the bronchia? or lungs. Contractions in infancy arise from fibrous or cartilaginous degeneration, while they are of ah osseous nature in old persons. Palpitations often arise in young girls, which do not occur from any organic lesion ; they usually disappear on the establishment of the catamenial discharge. It is unnecessary to detail at length the various signs of diseases which may be drawn from the pulse and appearances of the blood; these do not differ from those in similar diseases in adults, the difference in frequency being taken into consideration. The following signs, however, are peculiar to many diseases of children :— A frequent pulse may occur in inflammations, especially of the mucous, synovial, and serous membranes ; but a frequent pulse seldom occurs in inflammation of the brain : it is, on the contrary, strong, hard, and full. The pulse is also frequent in extreme debility, when it will at the same time be found small and weak ; it then yields an unfavorable prognosis after the continuance of acute disease, as it indicates the first degree of effusion in hydrocephalus, etc. The rare pulse is an evidence of very severe cerebral disease, especially where there exists great pressure on the organ, as in hydrocephalus, or tumors of the brain. This kind of pulse also exists in cardiac diseases, when arising from any obstruction in the circulation ; hence it is found in cyanosis of children. An intermittent pulse will occur when there is a congenital malformation of the valves of the heart, and. in all diseases of the lungs and pleura, where a part of the lungs has become impervious, or the entrance of the air has been prevented. In inflammations and effusions in the brain, and in spasmodic affections, the pulse will become intermittent; and where this peculiarity arises in gastric disorders and worms, it is explained by reference to the derangement of the nervous system. An irregular pulse is a higher degree of the intermitting. It points out the existence of higher grades of the diseases above mentioned. An unequal pulse is an unfavorable sign at all ages. It is not very common in young children, but it often occurs in diseases of the brain; and it is also an evidence of obstruction of the circulation, from effusion in the pericardium, or of congenital diseases of the heart. 118 DISEASES OF CHILDREN. A strong pulse is an evidence of inflammation and congestion in different organs. A weak pulse is a sign of debility; it also occurs in gangrene, softening, or purulent infiltration. A full pulse is a sign of plethora ; and it is often the precursor of hemorrhages, evacuations, and exanthematous eruptions. A hard pulse indicates inflammation or spasm. The hard pulse of spasmodic'disease is distinguished by its smallness and irregularity, whereas in inflammation it is strong and regular. The attempts to discover organic affections by the pulse have not been successful.* It is of more value to discover the character of the disease in general, and for making a .prognosis, than for discovering the seat of the disease. , DISEASES OF THE CIRCULATORY SYSTEM. CYANOSIS. Cyanosis is characterized, as its name imports, by a blue appearance of the skin ; whence the names of blue disease, puer ceruleus, cyanopathia, as it has been at different times called. It is the blue jaundice of the ancients. Infants at birth are often cyanosed, from an impervious state of the lungs, or from an inefficient action of the respiratory muscles ; it also arises from pressure on the brain, after severe labor. This condition has been already considered in the article on asphyxia of new-born children. The disease now to be considered, is that which persists after the establishment of respiration for an uncertain length of time, even to full adult age. For the most part, children thus affected, if they survive the period of infancy, die soon after they have attained the age at which they commence the use of the most powerful muscles of the body in walking. Etiology. The causes of this affection necessarily include the morbid anatomy and pathology, for it arises from a congenital malformation, or pcrsistance of the natural foetal openings of the heart, or of some dilated or thickened state of the right cavities. It is not the blue appearance of the skin, which arises from a peculiar condition of the capillaries, and a stasis of venous blood in the surface, such as is found toward the close of pulmonary diseases, fevers, and the Asiatic cholera. There have been several dissections, by Corvisart and others, of persons who have been affected with this blue color of the skin, in whom no continuance of the foetal openings, and a persistance of the partial foetal circulation, was found to exist—the usual cause of CIRCULATORY SYSTEM. 119 these symptoms. On the other hand, Fourquet, Breschet,* and Crampton,t have recorded cases, in which a large communication has existed between the two ventricles, without the presence of a cerulean hue of the skin, or the existence of the distressing symptoms usually accompanying an imperfect condition of the heart. In one instance the foramen ovale has been found open even to old age, without much interference to the functions of the body4 The latter are curious exceptions to the general rule, for it can scarcely be conceived that a large quantity of venous blood can be (transmitted into the arteries, without interfering in some degree with the functions of the body. • Whenever a cyanosed state of the system exists, unconnected with protracted disease, it results in every instance from a malformation of the heart, by which a portion of the venous blood is mixed with the arterial, or from some condition of the lungs, whereby blood sent to them is not properly changed by the vital and chemical actions, which in a normal condition of the lungs occur in them. In those instances where cyanosis does not take place, and the foetal circulation in part remains, it is doubtless because the blood passes through the lungs in sufficient quantity to become oxygenated to such a degree, as so render the venous blood, with which it is mixed, sufficiently altered, for the purposes of nutrition and growth. Anatomical examination, however, has established the fact, that the right cavities of the heart are always found altered in size, whether there exists an opening between the two sides of the organ or not; and the livid color of the lips is an invariable sign of lesions in the right side of the heart. The disease, therefore, does not always depend on an imperfect closure of the foramen ovale, but in the greatest number of instances, especially when accompanied by the symptoms which will be described in the. next section, this imperfection doubtless exists. As has already been stated, the persistance of the interauricular opening and arterial duct does not, in the first days of life, produce any very remarkable symptom, nor does it afterward, if the blood is in reality sufficiently oxydized. In general, however, especially if there exists much plethora, and the respiration be imperfectly established at first, from the constant interference of a partial foetal circulation, the disease known by the name of cyanosis, or peur ceruleus, results from this condition of the heart; for if any alteration from the normal action occurs, by which the heart performs its part * Diet, des Scien. Med. f Med. Trans, of the Coll. of Phys. in Dublin, vol. i., New Series. J Geschichte einer Chir., Privatgesellschaft in Kopenhagen. Bertholin. Anal., Lib. li. 120 DISEASES OF CHILDREN. in the circulation of the independent being but imperfectly, and fails in transmitting the blood to the lungs, the unchanged venous blood must be sent into the general circulation. That this does occur, appears from the singular case described by Dr. Sandfort. This was a boy, who had been affected with asthma from the second year until his death, which took place in his thirteenth. He was of a leaden color, and known as the blue boy. On making an autopsical examination, the aorta was found to arise from both ventricles, while the pulmonary artery was of so small dimensions as scarcely to admit a probe.* There are several other instances recorded, where the disease was connected directly with openings between the ventricles; the patients living to the sixteenth and twentieth year with great distress.f Dr. Baillie gives the case of a child who lived two months, where the aorta arose from the right ventricle, and the pulmonic artery from the left $ in this case, and other similar ones, the color was uniformly blue.|| A remarkable case of an accidental occurrence of the formation of a passage between the two ventricles, from some injury, as was supposed, is recorded by Corvisart. It occurred in a boy who died at the age of twelve years, and who had not manifested any symptoms of irregular respiration until within five months of the time of his death, when the whole train of distressing symptoms for the first time made their appearance. With these remarkable facts, and the similarity of the condition of the heart of a young infant, the distressing symptoms which characterize the disease in question, may, in most cases be attributed to the continuance, in some degree, of the foetal circulation ; and in all, whether it has existed with a malformed heart or not, it indicates an imperfect oxygenation of the blood ; for a partial- cyanosis may exist in severe congestion of the lungs, when the lips and ala? nasi will become of a livid color. Semeiology.—When a young infant is affected with this disease, the respiration is at intervals very laborious and distressing, sometimes accompanied with loud screams. Immediately after each fit, the face, which before was of a bluish color, returns to its natural hue, and the pulse becomes regular. In a few minutes the respiration is entirely suspended; the eyes are vacant, the hue of the face changes; it is more particularly of a deep blue on the upper lip, while the pulse is extremely irregular. In the course of ten minutes the blueness extends over the whole face ; afterward the extremities become blue and cold, and the pulse scarcely percep- * Observationes Anatomico-Pathologicce; Lugd. Bat. 1777, quoted by Dr. Good t Morgan, de Sed. et Caus. Morb., Ep. xvi., t Morbid Anatomy, Plate vi., p. 21. H Transact. Medico-Chirurg. Soc, Edinb., vol. i., Art. vi., by Dr. Holmes. 121 CIRCULATORY SYSTEM. tible. While in this condition the child suddenly screams, is convulsed,* and with two or three sudden inspirations the circulation is again restored, the leaden color disappears, and the. skin recovers its natural hue. • Such are the symptoms attending violent paroxysms of the disease in y%ung infants. In others it is not so severe, although in all there is great distress in breathing, on the occurrence of any circumstances which will excite an increased action of the heart. The child will continue for three or four years with the skin completely blue, and without the occurrence of any untoward symptom of a sudden or alarming nature. But when he has arrived at the age at which he commences the use of his limbs in walking, the increase of circulation from this cause embarrasses the heart in its action, and repeated fainting fits are the result. The child thus affected scarcely survives this period of life ; but, as has already been stated, cases have occurred where a wretched existence is prolonged, even to puberty and adult age. Treatment.—In the violent paroxysm above stated, occurring in young infants, and threatening almost immediate death; the object should be to sustain the vital energy of the sinking frame, until the heart has in some degree recovered its tone, from the congestion both in its cavities and in the pulmonary system. For this purpose there is nothing so effectual as a stimulating bath, aided, in severe cases, by a blister to the chest. Dr. Hosack, in the appendix to the American edition of Thomas's Practice, gives the successful result of two cases treated by these means. The children were placed in a bath raised to a temperature a little above the natural temperature of the body, composed of an infusion of Peruvian bark and brandy, with the addition, from time to time, of a little aqua ammonias. The violent paroxysms were quickly relieved, and the children recovered. In the other form, but little can be done besides keeping the child as much at rest as is possible, confining him to a light diet, and preserving the bowels in a soluble condition. There have been instances where the blue skin has gradually disappeared, arising from the natural removal of the organic causes of the disease. INFANTILE REMITTENT FEVER. Febrile disorders, of a remitting nature, are of very common occurrence in children, and rank next in frequency to croup, pneumonia, and diarrhoea. The first clear and distinct account we have received of the remittent fever of infants, was written by Dr. Butter, in 1782 ;* although there exist allusions to a similar affection * Treatise on Infantile Remittent Fever, by William Butter, M. D.; Lond., 1782. Hi 122 DISEASES OF CHILDREN. in children in the work3 of Sydenham, Sauvages, and Hoffman, under the names of hectica infantilis, and febris lenta infantum. Etiology.—The predisposition to a remitting form of fever in children arises'from the peculiarly irritable condition of the nervous system, by which the circulation is easily excited to undue action, and as quickly exhausted of its accumulated excitement. This condition is more remarkable where an irritative action is present in some portion of the intestinal canal. The irritation of teething, also, often gives rise to similar symptoms. The variations of atmospheric temperature, cold or damp, may occasionally excite the disease. It has at times prevailed as an epidemic, and by some has even been supposed to have been contagious. The sudden suppression of an eruptive disease has not unfrequently been a cause of remitting fever. The excitement, however, of the intestinal mucous membrane is the great source of remittent fever of children ; but the immediate exciting cause will appear more at length when the symptoms and pathology are considered: it will on this account be necessarily left to be considered under the section on the pathology of the disease. Semeiology.—The remittent fever of infants is very slow in its progress, and its first symptom is irregularity of the bowels; sometimes costive, and at other times relaxed. There are several accessions of fever during the day, accompanied with great drowsiness. Dr. Butter makes three different forms of the disease; these he denominates, from the most prominent symptoms, the acute, the slow, and the low infantile remittent fever. The distinction can scarcely be applied to practice, although the varieties unquestionably exist. Without going into the detail of the symptoms of each, it is sufficient to re,mark, that the difference is found principally in the mode of invasion. ' Thus, the acute is violent in its attack, and generally preserves more of the inflammatory character during the progress ; the slow, although with much the same detail of symptoms, is yet more imperceptible in its invasion ; while the low variety is distinguished by the determination to the brain, and the occasional presence of delirium, succeeded by a low, quiet state: the child being indifferent, and at times insensible to surrounding objects. All the occasional forms of this disease may be comprised in the following symptoms, variously altered, according to the violence of the fever, or the attending complications. The strength is observed to decline gradually, the abdomen is tumefied, and the breath offensive. One of the most remarkable symptoms is the itchjng of the nose, which induces the child to be constantly picking or scratching it. The sleep is much disturbed, and he is observed to grit the teeth, and occasionally to start in his sleep. These symptoms are fpllowed by a chill, which is succeed- 123 CIRCULATORY SYSTEM. ed by fever ; first making its attack during the night. Before the fever is fairly established, there are several exacerbations in the twentyfour hours; and during the remissions the child appears almost well. These accessions are at first slight, soon, however, they become more severe, and the intervals short. The exacerbations are then generally about three in number, during the day; the last, occurring in the evening, sometimes continues through the whole night until morning, and is very distinct when the disease is fully formed. From the commencement there is a total loss of appetite, with foul tongue, and constant thirst. Every symptom shows the digestion to be entirely suspended; and after the disease has continued for a few days, the nausea, which always attends the taking of food, increases, until the child vomits everything it swallows. The intestines, also, lose their power, for the food passes off without any other change than that produced by putrefaction. During the fever, when the disease is fairly established, the pulse is from one hundred and forty to one hundred and sixty. The skin is dry, the surface of the body hot; but the heat varies in different parts, the abdomen and palms of the hands being warmer than other parts. The thirst is very great, and increases with the increase of the fever; the cnild drinking cold water with remarkable eagerness. The urine during this time undergoes a change, and is of a clear orange color. While asleep, the child tosses about in a very restless manner. In other instances the head appears to be the most affected part; drowsiness, stupor, and occasionally delirium appear, as the complication of the disease. At other times the complication appears to be in the pulmonary system, as manifested by increased and painful respiration and coughing. The paroxysms of fever go off with partial sweating, and the symptoms usually abate during the remissions, but do not wholly disappear; and when the fever is severe, the remissions are often almost entirely imperceptible. Although a partial moisture appears, the skin for the most part continues dry, even if cool. In proportion to the distinctness of the remissipns, is the relief the child experiences from the peculiar symptoms of the disease, the sleep becomes refreshing, and the child more lively. The exacerbations are milder and shorter, while the appetite returns; and the secretions generally manifest an improved state of the system, the urine becoming turbid, and depositing a sediment of a reddish color, while the stools exhibit a return of the healthy action of the liver; a general moisture,'also, takes place over the skin. The pulse loses its extreme frequency, but continues, through convalescence, somewhat above the natural standard. These are the usual symptoms of the disease, and include the three varieties described by Dr. Butter. Often, however, they are 124 DISEASES OF CHILDREN. not so strongly marked, and assume a less tangible form; the fever being so slight as scarcely to attract attention, while the debility and protracted indisposition show the progress of a very serious affection, gradually wearing out the vital energies of the system. The symptoms do not differ much from those above described, except that those of the abdominal viscera predominate, and the circulatory excitement is less active. The tongue is more furred, the abdomen irjore prominent and hard, and the alvine evacuations show a greater derangement of the secretions, being very offensive and irregular in their appearance. There is an obstinate costiveness at first, wnich is not of long duration, for a severe diarrhoea will occur at times, with every evidence of a great derangement of the secretory functions, the discharges being of a dark brown color in most cases, but in some green, and in others red. In protracted cases the abdomen becomes tender, and streaks of blood are mixed with the faeces, while a severe tenesmus will often attend each evacuation. In this slow and indistinct variety, the urine preserves the white color peculiar to it at the commencement of the disease, and it is supposed to indicate the presence of the earthy phosphates, and is an evidence of a broken-down constitution. This appearance of the urine is described as very common by all the European writers. It is not of so invariable an occurrence in this country, for it would seem that the affection generally is of a more active nature here; and this symptom, with others, indicating a preternaturally bad condition, giving a peculiar type to the fever, is not here of so frequent occurrence as it is described to be in Europe. In general the disease is easily managed, and the prognosis is favorable, unless a complication takes place of congestion of the cerebral organs. When the remissions evidently become longer, and the appetite returns, the child may then be considered as convalescent. A lessening of the intervals, together with an increased swelling of the abdomen, may be regarded as affording an unfavorable prognosis. The most unfavorable symptom of infantile remittent fever is the cerebral affection, which almost invariably terminates in hydrocephalus. The diagnosis of this disease from the first stage of hydrocephalus is one of great difficulty ; and so closely do the diseases resemble each other, that they almost appear identical. One of the most remarkable signs of the cerebral affection is the screaming and starting in the sleep, and the throwing of the hands over the head, and the constant attempt at bending the head backward. There is also a great intolerance of light, and an evident affection of the intellect, together with strabismus. The child also swallows food without apparently discriminating its nature. In the disease now under consideration these signs of cerebral derangement do not ex- CIRCULATORY SYSTEM. 125 ist; there is no intolerance of light, no particular pain in the head, nor strabismus; but, on the contrary, abdominal symptoms prevail, and the appetite is so entirely lost, that there is no disposition left to take any kind of food. The alvine evacuations are very dark colored and offensive; not having the odor of faeces, but of putrefaction. Sometimes convulsions arise, which may bear some resemblance to idiopathic cerebral disease; but when they cease, the intellect of the child is perfectly restored. The state of the circulation, also, is different in these two diseases : the remittent fever having no distinct stages, the pulse is more uniform throughout, and never falling below the natural standard. Dr. Golis is very minute in the diagnosis of this disease, or wormfever, as it is denominated by him.* The disease, according to this distinguished writer, attacks children of a phlegmatic temperament, with large bellies, and exhibits well-marked remissions : the face is swollen, and there is a general appearance of stupidity and sluggishness. In hydrocephalus all the distress is referred to the head, or rather alternates with the abdomen and pain in the limbs. He is unnecessarily minute in some of his descriptions, and the number of points of distinction rather tends to confuse than assist the diagnosis. The accurate designation is not of so much consequence as it .would appear to be by the pains bestowed on it. The termination of remittent fever by effusion in the brain, being the probable termination of the disease when fatal, it should be the duty of the physician in every instance to keep in mind this tendency of all diseases, and especially the one in question in children, and be ready to meet the symptoms of turgescence or inflammation of the brain when they arise. When this is constantly borne in mind, the necessity of an accurate diagnosis is rendered of little moment; and indeed these minutiae are often of very little consequence, and tend too much to absorb the mind, and to draw it off from the consideration of the main object of medical practice. It is sufficient for us, when there is great difficulty in accurately forming a diagnosis, to keep in view the strong and probable tendency of the disease ; to be on the watch for the appearance of such symptoms as give the disease its fatal character, and either anticipate them by the timely administration of remedies, or remove them, when they arise, by the energetic application of such means as the nature of the case demands. Morbid Anatomy and Pathology.—Dissections have furnished but little light on the morbid condition of the system in remittent fever ; for on a fatal termination, the transmission to the brain is the ordinary course of the disease ; and effusion of serum in the • A Treatise on acute Hydrocephalus, etc., by Leopold Anthony Golis; translated ly Robert Gooch, M. D.: London, 1821, p. 46, et seq. 126 DISEASES OF CHILDREN. ventricles will be all that will be found remaining of the disease, which at its commencement indicated but little more than derangement of the primae via?. Pemberton discovered, in one case, the intestines very greatly distended, and the mesenteric glands much enlarged, without any signs of inflammatory action having existed in any part of the bowels, or in any of the abdominal viscera, or without effusion in the abdominal cavity.* The occasional appearance of worms in the alvine evacuations of children affected with remittent fever, has led to the belief that it was owing to their presence in the intestines that the peculiar symptoms oL remittent fever occurred ; and even where their presence was not discovered in the faeces, the morbid secretions were regarded as dead and broken worms ; a notion which is still extensively popular. The idea of the presence of worms in the bowels as a cause of fever, was very prevalent during the last ceniury, and was adopted by. Baglivi to explain most of the diseases of children. Sauvages and Hoffman also entertained the like notions with respect to the causes of these febrile affections, such diseases being known by the name of febres verminosae. The contrary opinion has been maintained by several distinguished practitioners, and the errors which have so long prevailed, in •considering the disease as dependant on the presence of parasitical animals, have been pointed out. Dr. Musgrove showed that these affections did not arise from worms, but from irritating matters, or saburra in the intestines.t Dr. Clark, also, particularly refers to the fact that the remittent fever of children is rarely, if ever, cured by anthelmintics.^ From the deep research and the philosophical acumen it displays, Dr. Butter's treatise is the standard to which all reference is made at the present day. It is unquestionably the most complete essay on the subject, and the most in conformity with experience, both as to the ordinary appearance of the disease, and from the success of the treatment pursued by him, and which is the foundation of that adopted now. He does not regard worms as in any way essential to the disease, but refers all the symptoms which mark the disease, in almost every instance, to a debilitated state of the digestive organs, and to the accumulation of unhealthy secretion in the bowels, connected with the peculiarly sensitive condition of the infant state. Dr. Marsh|| adopts a similar opinion, regarding the disease as arising * A Practical Treatise on the Diseases of the Abdominal Viscera, by Christopher Robert Pemberton, M. D., F. R. S.; London, 1806. f An Essay on the Nature and Cure of the (so called) Worm-Fever ; London, 1776. j Observations on Fever, etc., by John Clark, M. D.; London, 1778. || Dublin Hosp. Reports, vol. iii., p. 316. CIRCULATORY SYSTEM. 127 from a deranged state of the gastric organ, and from a morbid action seated in the mucous membrane of parts. This appears to be a very correct view of the disease, when the group of symptoms is taken into consideration ; when the morbid action is regarded at times as extending to the appendages of the intestinal tube. The affection of the mucous membrane may exist in different degrees in various cases, which difference is not always to be ascertained. It can not be regarded as being, in every instance, a state of inflammation of this membrane, as is usual to consider it in France, although such a condition will unquestionably arise during the progress of the disease. At first the affection of the mucous membrane is one of simple irritation, as I have frequently seen occurring suddenly from the ingestion of some irritating and insoluble substance ; the fever disappearing when it was removed. In one instance, where an infant suffered for some days without my being able satisfactorily to ascertain the cause, free and copious vomiting came to its relief, when a large mass of caseous matter was discharged, to the entire abatement of all the symptoms. This, and ot.ljer instances, afford a satisfactory proof of the relation subsisting between infantile remittent fever and a simple irritation of the gastrointestinal surface, without any inflammatory action being in every instance established. Besides irritation of the mucous membrane, the symptoms, in most instances, point out a depraved state of the secretions, which does not necessarily depend on the phlogosed state of the mucous membrane ; and the success of such measures, which will slightly alter or modify the secretory action of the gastric and intestinal mucous membrane, is much greater when there exists equivocal evidence of the inflamed state of the part, than the constant and sole employment of antiphlogistic and demulcent remedies. Dr. Joy considers it as a variety of gastric fever, modified by the irritable constitution of infancy, and closely allied to the febris pituitosa of Frank.* From an examination of the opinions of the various authors, compared with some amount of experience in the disease, remittent fever appears in general to be a symptomatic disorder, from derangement of the stomach and intestines, or of the appending viscera; or from an irritative action, at first excited in the mucous membrane of these parts. It has been observed that almost all fevers connected with gastric derangement assume a remittent character. This disposition, added to the irritable constitution of young children, gives their febrile affections this peculiar type. When there exists any severe local inflammation, the fever is less likely to assume this * Cyclopaedia of Pract. Med., Art. Fever. 128 DISEASES OF CHILDREN. character, from which it is evident that it is one more of irritation than inflammation. • Treatment. —The treatment must, of course, be regulated according to the existence of the symptoms, from which we are to judge of the immediate cause of the fever. It is evident that in some cases it is a disease arising from simple irritation of the mucous surface of the stomach, from the presence of indigestible food, which ought to be promptly removed by some mild emetic. There is a difficulty often in ascertaining whether there exists this irritating cause alone, and independently of disordered action in the viscera. It may, however, be suspected, when it has arisen suddenly in children who have passed the period of lactation. In those at the breast, it is almost always a matter of difficulty to ascertain the existence of indigestible matters irritating the tender mucous membrane. This irritating cause is often a long time gradually accumulating, and for the most part consists of the alteration of the milk, and the formation of a mass of cheesy matter, and until the removal of which, the symptoms of fever will obstinately continue. Where there is reason to believe the presence of irritating matter of this nature, a gentle emetic will be needed to remove it; a measure which can not be attended with hazard, where there exists no tenderness of tlte stomach on pressure, and when the other signs of gastric inflammation are wanting. Should a doubt exist on this point, the treatment may be commenced with a dose of castor oil, and the administration of enemata, with warm stupes to the abdomen. In this disease, as there usually is much disordered action of the liver, and an entire alteration of the secretory functions of the bowels generally, it will be necessary to give at first some more powerfully active remedies, which will produce an altered state of the secretions, especially of the liver. It is usual to prescribe calomel, in combination with jalap or rhubarb, or calomel alone, and promote its operation with an infusion of senna. Where the irritation is confined exclusively to the abdomen, and the foul breath and furred tongue give proof of the congested state of the liver, and general derangement of the secretions, this course is unquestionably the most proper; the operation of calomel with other purgatives being the most effectual, and the most prompt in the removal of the derangement on which the febrile action depends. Where, however, there is much fever, and especially a determination to the head, as hydrocephalus is almost an invariable termination of the disease, it is thought by Dr. Hosack to be inadmissible, from the increased arterial excitement caused by the use of mercury.* His remarks appear to be more applicable to the disease, when caused • Op. Cit., p. 332. 129 CIRCULATORY SYSTEM. oy teething, or when it is complicated with this process. The existence of hydrocephalus is much more prevalent, according to the opinion of Blackall, Pemberton, and Willis, since the indiscriminate use of mercury in the affections of children. If the abdominal viscera are those most deranged, the use of mercury as a prompt cathartic can scarcely be dispensed with, for there is no article of the materia medica which exerts so general an action on the digestive organs, and which is so often followed by an improvement of their secretory functions. The employment of so active an agent is clearly indicated at the commencement, when the premonitory symptoms —those of irregularity of the bowels, or total failure of the appetite, and a foetid state of the breath—show an altered and morbid condition of the secretions. Experience abundantly confirms the opinion here advanced, that it is on purgatives that we must rely at first, where this morbid condition of the alvine discharges and urine, and swelling of the abdomen, are the most prominent symptoms; for the gradual disappearance of the fever will almost invariably follow the use of mercurial purgatives under these circumstances. Dr. Hosack advises, in the place of calomel, an infusion of senna, combined with super-tartrate of potash and manna, where symptoms of hydrocephalus show themselves, as a purgative, which he has used with the most decided advantage.* To prevent this termination, he advises an open state of the bowels, and a free use of antimony, to unlock the surface of the body, together with warm bath and blisters, to create a new and relatively safe seat of irritation. The combination of calomel and antimony is highly useful in relieving the bowels, and controlling the febrile action when the latter runs high ; and may in some degree remove the objections above made to the use of mercury at all in this disease. James's powder may therefore be advantageously given in this disease, combined with calomel, in the dose of one to five grains, or with the hydrargyrum c. creta, when there is a tendency to inordinate action of the bowels. This was a favorite course with Dr. Cheyne, in infantile remittent fever, especially when the sensorial functions were affected, and hydrocephalus apprehended. His practice was to prescribe a pill of calomel and antimonial powder three times a day, interposing between every two pills a moderate dose of a common purgative mixture. To persevere in the use of purgatives is not unattended with danger, for the action of these articles themselves becomes a source of irritation; our object being simply • ft Fol. Sennoe, (41) Potassae Sup. tart., Mannas, aa. ?ss. Infuse in half a pint of boiling water. A wineglass every two hours, according to the age of the child. 17 130 DISEASES OF CHILDREN. to remove the excessive accumulation of undigested matters and morbid secretions, and by stimulating the mucous membrane, excite it to a healthy action. Carried beyond this point, purgatives are decidedly injurious. Upon the appearance of severe local congestion, with high febrile excitement, blood-letting, either local or general, will form a necessary part of the treatment; and often a small quantity of blood abstracted, on the appearance of the symptoms, will allay the fever and arrest the local disease. It will be necessary, however, to preserve the bowels open, by the use of mild aperients, so that there may be two or three evacuations in the course of twenty-four hours. Dr. Butter was in the habit of using sulphate of potash for this purpose, or some of the other neutral salts, from their acting on the kidneys as well as on the bowels ; while the febrile action is at the same time allayed, as he supposed, by their operation on the nervous system, especially by the sulphate of potash. Be this as it may, it is unquestionably an admirable medicine for children, as a deobstruent and cathartic. It appears to exercise a stimulating effect upon the liver and pancreas. Dr. Fordyce used it as a favorite alterative cathartic in visceral obstruction in children, where there existed a swollen abdomen and defective digestion. It is usually used in combination with rhubarb,* or it may be used in a solution, uncombined with any other cathartic, as used by Dr. Butter, in the proportion of a drachm to four ounces of sweetened water, of which a teaspoonful was given every hour, to a child of five years. When it had operated sufficiently on the bowels, he was in the habit of substituting the nitrate of potash; and if a diarrhoea existed, five grains of the extract of conium were dissolved in four ounces of water, and taken in the course of twenty-four hours. The rule for giving the conium, was a grain daily for every year of the child's age. The advantage of this medicine is the combined effect it had, both of relieving the fever and controlling the diarrhoea. Sydenham's practice was, to give rhubarb in infusion, so as to act as a mild aperient, depending chiefly on this course for the management of the affection. When the disease is protracted, a continued use of hydrargyrum c. creta may be necessary to restore the secretory function of the liver, either combined with rhubarb, or used alternately with it, where it is deemed necessary, al the same time to procure an evacuation from the bowels every day. Where the contrary condition exists, the hydrargyrum c. creta may be used alone. In case evidences of inflammatory action of the mucous mem * ft Potassae Sulph., gr. x. (42) Pulv. Rhei., gr. v. Pulv. Sacchar. Alb., gr. x. M. Twice or thrice a day, for children above the age of six years. CIRCULATORY SYSTEM. 131 brane appear, and the abdomen becomes tender on pressure, and the stools contain streaks of blood, mucilages in some form will be necessary, while the bowels are kept open by mucilaginous enemata, occasionally containing a few drops of laudanum, if the tenesmus be severe. In every case it will be necessary to examine the condition of the gums, and if they are swollen, to cut them freely down to the tooth ; this, together with some mild aperient, when the fever depends on this irritation, will remove all the symptoms. Where there is great debility and the disease is long continued, it may become necessary to administer some tonic medicine; and sulphate of quinine will be found the best for this purpose. But the early use of such remedies as has been advised by some practitioners, can scarcely ever be found of any advantage ; on the contrary, the symptoms will unquestionably be increased from the use of tonics and stimulants, if given shortly after the commencement of the disease, even if evacuations are used as preliminary steps in the treatment. NATURAL FUNCTIONS. DIGESTIVE SYSTEM. PECULIARITIES OF THE DIGESTIVE SYSTEM. The digestive organs of man, in a state of infancy, are of great simplicity, when compared with their condition at any other period of life. They possess fewer parts than those of adults, as their office is of the simplest kind. The food of the infant not requiring mastication, there exist no teeth; its simplicity rendering its mixture with the salivary fluid unnecessary. The glands supplying this fluid are, in early infancy, found to be of very minute size, and exercise no functional activity. When the teeth first appear, and during the period of dentition, these glands are in a state of great activity; hence the quantity of saliva so often seen to flow in children that are teething, which, while it shows the simultaneous development of the salivary glands and the appearance of teeth, affords also an outlet for the accumulation of blood, when there exist great irritation and congestion from increase of functional power. Man, at the earliest stage of his life, differs from his condition in after life, in not being omnivorous. Nature has provided for him but one kind of food, and the slightest departure from the use of nature's nourishment would be to hazard the health and life of the young being. Should it become necessary to substitute any food for the mother's milk, that which has the greatest resemblance to it, both in consistence and quality, is the only one that can with safety be used. Milk is the sole food provided for his sustenance until the time when a change in his system takes place, when a new arrangement of his organization enables him to receive nourishment from other substances. The appearance of the first teeth indicates the time when a change may be made in the nature and consistency of his diet, as they point out the ability of the child to use his efforts to separate the coherent particles of his food. Farinaceous articles may be 133 DIGESTIVE SYSTEM. made to form an addition to his aliment; and in proportion to the appearance of the remainder of the teeth, its variety and solidity'* may be increased. The rudiments of the teeth are seen in the foetus of the second and third month, and are at first in the form of a double sac. A pulp of vascular and nervous matter is formed at the bottom of this sac, surrounded by a transparent fluid, which disappears as the pulp enlarges. Ossification first appears on the upper part of this pulpy substance about the end of the third month. The en amel is not secreted until some time afterward. The alveoli are formed by the groove which runs along the edge of the jaw, and by its intersection, from the growth of osseous matter which extends from side to side. The crowns of the molars and incisors are generally completely formed and ossified at the time of birth. The ossification of the roots does not occur until afterward, by which process, and by the alteration of the form of the alveoli, the tooth is crowded upward, and absorption of the gum follows the pressure. The tooth at length makes its appearance above the gum. The teeth sometimes appear as early as the fourth month, while in some children that are of a delicate and feeble constitution, they do not show themselves until the end of a year; and it has happened in some cases that the first tooth has not appeared until the fourteenth month. The process of teething is generally completed before the second year, but it has occasionally been protracted beyond that period, apparently depending on the vigor of the child. As a general rule, however, the teeth first protrude, about the sixth month, and appear in the following order, except in a few anomalous cases : The two middle incisors of the lower jaw, the two corresponding ones in the upper; next the two lateral incisors of the lower jaw, which are followed by the two corresponding ones in the upper jaw; the two cuspidati of the lower jaw then show themselves, succeeded by the two corresponding ones in the upper jaw ; and, lastly, the two molars in the same order as the preceding; and about the fourth to the sixth year appear four other molars, which remain permanent, making in all twenty. Although the teeth are generally developed in the order above stated, yet there have been many exceptions. Sometimes the upper middle incisors, or lower lateral incisors, appear first; the cuspidati, and very rarely the molars, have been known to protrude first, and in some cases, have been known to appear all at once. Pliny, Colombo, Marcellus Donatus, Van Swieten, and others, have given us instances of these anomalies. Louis XIV. was born with six teeth, and the celebrated orator, Mirabeau, had at birth two molars. On the other hand, there have been instances where they 134 DISEASES OF CHILDREN. never appeared, and what is remarkable, instances of this have ! sometimes been hereditary. The jaw of a child grows but little after the first set of teeth are completed, and the peculiar plump form of the face of infancy continues until the first permanent molars have appeared: and at the end of seven or eight years, the jaw begins to lose its circular appearance, and the face consequently assumes an elongated ap- pearance. In children of a healthy constitution, dentition proceeds without much disturbance of the system; it is strictly a process of development, and therefore may, in the greatest number of cases, be left to the resources of nature. Heat and tumefaction are first perceived in the gums, when the teeth are about to appear. The first teeth, however, which are the incisors, very often show themselves without any previous manifestation of their approach. There is an instinctive desire for the child to press and bite the nipple, fingers, and almost everything presented to its reach, probably from the itching attendant on the sanguineous turgescence of the part. Saliva .flows abundantly in most cases, and greatly relieves the congestion of the parts surrounding the teeth. The second set of teeth gives less disturbance to the system than the first, and the effects, from the protrusion of the teeth, are purely local. Children usually shed their teeth at about six or seven years of age; and the permanent set make their appearance in the following order, occupying about five years in its completion : The middle incisors of the lower jaw, then those of the upper; next, the lateral incisors and anterior molars; the lateral incisors of the upper jaw then show themselves; the anterior bicuspides protrude about the ninth year, and the posterior, about a year afterward. The cause of the shedding of the temporary teeth, is the disappearance of the branches of the artery supplying them with nutrition ; the roots and the sockets arc then removed by absorption. The whole of this is probably effected by the growth* of the jaw, which at this period assumes a new shape, thus crowding and obliterating the artery and nerve, and thereby obstructing the flow of blood to them, causing them to perish for want of nutrition. The salivary glands are quite small until the period of dentition, when they assume a considerable size, and secrete an abundance of fluid. They have a magnitude proportionate to the co'mplexity of the digestion ; hence they are always smaller in carnivorous animals than in those living on vegetables; and during the infant state, when the food is remarkable for its simplicity, they are scarcely to be seen. During the period of youth these glands are fully developed, and, indeed, possess more than their ordinary sup- DIGESTIVE SYSTEM. 135 ply of blood; and for that reason are, at this period of life, more predisposed to disease. The mucous glands of the stomach and intestines are also very small before the eruption of the first teeth, agreeing in this respect with the salivary glands; a general development of every part concerned in digestion taking place at this period, either to furnish fluids for the assimilation of a new species of food, or to supply a lubricating fluid for the protection of the tender mucous surface from its irritation. At this time of life the mucous membrane of the entire intestinal canal, including the fauces, pharynx and stomach, is covered with villi, and is highly vascular and sensitive. Hence the importance of confining the child to the mild and unirritating food provided for it by nature. The small intestines are much longer in proportion than* in the adult, and are about a third more in length, when compared with the entire length of the whole canal: the large intestines are longer in proportion to the small. The valvula? conniventes are scarcely apparent, the vermiform process is very long, and the ccecum is very largely developed. The ccecum and colon do not present their depressions and prominences in so distinct a manner as in adults. The digestive passages are filled with a quantity of mucous during the first year, varying in color and consistency in different parts of the intestinal canal. In the duodenum and jejunum it is thick, white, and very adherent. Sometimes it is colored yellow by the bile. The large intestines are always at birth filled with thick, pitchy, deep green meconium. There remains in the intestines, after all the liquid matters have been removed, a layer of condensed mucus, adhering closely, like a plastering, to the mucous membrane, capable of being raised like a continuous membrane; this will separate of itself, and is seen in the faeces in the form of small white floculi. The liver of an infant at birth fills almost a third of the abdominal cavity, descending even to the crest of the ilium. On the change of its circulation and obliteration of the umbilical vessels and ductus venosus, the left lobe diminishes, the vena porta? is developed, and the secretion of bile occurs in abundance. The color of the liver changes to a darker hue as life advances; and its size diminishes, when compared with the size of the individual ; but there have been instances where the size of the organ remained through life in the same proportions as in the foetus. The liver is nearly in the middle of the abdomen, with its anterior border near to the parietes. It ascends about the fifteenth year, so as to be entirely within the ribs when the child is recumbent. 136 DISEASES OF CHILDREN. The gall bladder is quite small at birth ; it soon grows, and contains green, bitter bile, which, however, is less viscid than at a more advanced age. There has been nothing worthy of remark observed in the spleen. No alterations in its form have been noticed, except such as may arise from disease. The anatomical characters of the abdominal viscera differ also with respect to their relative position, arising from the relations which the boundaries of the cavity have to each other. Thus, the distance from the sternum to the pelvis, in a new-born child, is nearly the third part of the length of the body, while, in the adult it is about one fifth. The middle part of the abdomen, also, is more developed at the period when the distance is the greatest. The spine, also, being less curved at this period, it is deeper from the anterior to the posterior part. The pelvis being much smaller in children, and the sacrum being considerably curved forward, the capacity of the pelvis is comparatively smaller than at a later period of life; consequently the abdominal viscera are confined to the middle of the belly, until the growth of the pelvis and the enlargement of the ribs superiorly, which take place in the process of general development, increase the space for the lodgement of these viscera. The stomach reaches nearly to the navel, and lies almost perpendicularly, with its great curvature obliquely toward the left side, and the smaller toward the right. The omentum, therefore, is situated more toward the left; a fact of some practical importance, for it might be mistaken for an obstruction in the colon. The duodenum is almost entirely behind the stomach ; and the whole volume of the intestines is situated much higher than in the adult. The spleen, which in the adult is on the left side of the hypochondrium, can be distinctly felt under the short ribs, toward the middle of the abdomen.* After the first year, the organs of digestion do not differ greatly from their condition in the adult state ; and the presence of teeth, and the activity of the salivary glands, show that the stomach may receive with advantage different kinds of food, which at an earlier period would have been productive of great disorder of the digestive organs. Although a variety of food may he used in early childhood, it is evident, from the condition of the organs for mastication, that food of the softest kind should still be used, that is to say, until after the completion of the eighth year; for until that period the power of mastication is but feeble. Digestion is a process of great activity in all children at every* * Analekten uber Kinderkrankheiten, vol. I., p. 51; Stuttgard. DIGESTIVE SYSTEM. 137 IS age—the constant growth of every part of the body'demanding a continual supply of nourishment. This process, however, ceases to be so active in proportion as the child advances in age ; and the food becomes more stimulating, when the* secretions more closely resemble those of the adult, and the faecal matters require to be less frequently voided, and are no longer passed independently of the will. The first process in digestion in the stomach of an infant is, the coagulation of the milk, as is seen to be the case when an infant throws up the milk shortly after sucking. The next is its solution, by the peculiar secretions of the stomach, liver, pancreas, and intestines ; but of the process we have a very imperfect knowledge, and are still unacquainted with the immediate part performed by the various glands. When considering the peculiarities of the physiology of children, and especially those which are connected with that part which performs so important an agency in their economy as digestion, we are struck with that peculiarity, which, at first sight, would appear to be a serious interruption to the process of digestion and nutrition — the vomiting which so frequently occurs in infants. •We might be apt to consider it as a disease of the most serious character, connected as it is with the first step in the progress of the all-important function of assimilation — a function so intimately connected with the growth of the child. But when we watch more closely, we constantly see infants discharge the contents of their stomach without any inconvenience resulting from it, even though the vomiting may be repeated several times a day ; and far from exhibiting any evil which might be supposed to result from thus frequently vomiting their milk, they actually appear to thrive, and the most robust children appear to be those most commonly affected with this species of vomiting. It is doubtless connected in some degree with great irritability of the stomach, arising from the congested state of the mucous membrane of the whole intestinal canal, by which it is predisposed to act in relieving itself of the superabundance of aliment; but from the absence of nausea, it would appear to depend on some other cause than either a condition of the mucous membrane of the stomach, or on an extrinsic exciting cause, the ordinary sources of vomiting, both in older children and adults. Professor Schultz,* in an ingenious essay, refers it to the different form of the infant and adult stomach ; the former bearing a greater resemblance to that of carnivorous animals that vomit with great ease. Before stating in what this difference consists, it should be observed that his views, and which appear to be the most in accord- * Hufeland's Journ., Mora, 1835. 138 DISEASES OF CHILDREN. ance with the ordinary facts which occur in our every day experience, are adverse to the opinions of Boyle, Van Swieten, and to the deductions of Magendie, in later times, that the stomach is passive in vomitirfg, and that its evacuation is effected by the contraction of the abdominal muscles and diaphragm. If, as maintained by them, the action of these muscles was the only Gause of vomiting, it ought to be purely voluntary, which it is well known is not so, except in very rare cases ; and which, on that account, are regarded as curious instances of departure from the ordinajjy physiological condition of man. Vomiting, therefore, cannot be the act of these muscles alone. The movements of the stomach, like those of the intestines, are of. a very gentle character, and are in strong contrast with the convulsive action of the powerful muscles, which are in full force during vomiting, especially during the experiments which are made to ascertain the action of the different parts. On this account, probably, the French experimenters concluded that it was perfectly at rest, and free from movement of any kind, there existing no convulsive motion in the stomach, its action being of the ordinary and almost imperceptible movement natural to it. These muscles, therefore, not being the cause of vomiting, the doctrine of the older physicians of the antiperistaltic -motion of the digestive organs, comes in to explain it. The existence of both these motions at one and the same time, is evident from the occasional effect of cathartic medicines, which, when about to produce the alvine evacuation will also cause vomiting. Foecal vomiting is also an evidence of the existence of an influence other than abdominal pressure, and proves the operation of the antiperistaltic motion from the large intestines, to the cardiac orifice of the stomach. The form of the infant's stomach explains the cause of the frequent and easy vomiting, it being much more conical than that of the adult, and resembles more the shape of the stomach of carnfvorous animals. Professor Schultz remarks, that the oesophagus is inserted into the fundus at the left extremity, and at a distance from the pylorus. In the adult stomach the oesophagus is not inserted into the left extremity, but in the middle, between it and the pylorus, which is drawn toward the cardia, bringing both parts very near each other. The small curvature, therefore, in the adult, is very short, while in the infant it is comparatively long, and the large curvature is but little developed: this latter part in the adult is of great size, forming four fifths of the entire circumference. In the infant the fundus loses itself gradually in the pyloric portion; in the adult they are separated by a sort of contraction, more or less marked. From this arrangement of parts it will be seen how easy vomit 139 DIGESTIVE SYSTEM. ing is effected in young children, as the food is equally propelled by the motion of the stomach to both extremities, and the situation of the oesophagus at one of them causes it readily to receive the food. On the contrary,'from the great size of the large curvature in the adult stomach, the contents of this viscus are not in like manner equally propelled to both extremities, but are principally confined to that extended cavity, and are moved rather in a rotary manner; the contraction above mentioned arresting them in one direction, and the situation of the oesophagus preventing their passing in the other. Hence the difference in the vpmiting of the adult and infant — in the latter easily effected, often without much general commotion ; in the former, not produced without the powerful aid of the diaphragm and abdominal muscles. This illustration receives confirmation from comparative anatomy; dogs and cats, where the stomach is of a conical form, and bears a close resemblance to that of an infant, vomit with great ease, and even throw up pieces of food, or a bone, if swallowed in an inconvenient manner. In the horse, rabbit, or hare, where the stomach is of the kind more resembling the stomach of an adult, with a large circular development of the fundus, vomiting can not be excited even with the strongest emetics. The cause of the difference in the form of the infant and the adult stomach, is doubtless the nature and quality of the food at these different periods of life. The cylindrical form continues only while the child is fed on milk, a purely animal food ; and as it uses vegetable food the fundus greatly enlarges. Professor Schultz has shown, in illustration of this, in another work,* that the stomach of carnivorous animals, dogs and cats, will assume a circular form, after they have been fed on potatoes, bread, and other similar vegetable articles; but that it will retain its conical form if they are fed on animal food alone. The round stomach of domesticated carnivorous animals is never seen in wild animals of the same class. The reason of the greater development of the fundus by the use of vegetable food, is owing to the greater difficulty of its digestion, and its long retention in the stomach before it is propelled into the intestines. The food is moved in the stomach in a rotary manner, and the digested portion is gradually separated, while the undigested mass still requires the motion and agitation necessary to its perfect digestion. In carnivorous animals, the food, soon digested, passes directly toward the pylorus, and being in a smaller mass, and not requiring much agitation for the separation of its nutrient part, but ittle development of the fundus takes place. Nutrition is performed with great activity in all children, espe- * De Alimentorum Concoctione. 140 DISEASES OF CHILDREN. cially in infancy; for however defective may be the organs of relation, those which are essential to his nutrition and growth are in a state of perfection, at least so far as are adapted to the food provided by nature, even at the earliest period of his life. The growth, through infancy and childhood, is evident both in the organs in particular, and in the body at large. These changes exhibit themselves more to our senses in the organs of animal or relative life, than in those of the organic functions. These will be more particularly considered, when we come to consider the development and growth of the cerebro-spinal system. A male infant, at birth, weighs about one pound and a half more than the female, and is about an inch longer; the growth of the female is less than that of the male, but she is more rapid in the development of her organs. During the first year, the increase in stature is about eight inches; it becomes less rapid toward the fourth year, but increases with great regularity after that period. The growth of children is a great source of disease, from the derangement of the balance of the various functions, so likely to ensue on the application of any cause which will arrest the development of any part of the body, as is seen in almost every child. An unusual growth of the brain will cause great liveliness of character and intelligence, while the cause of this precocity will predispose the child to convulsions, on the application of any cause which may derange the circulation in that organ. In others, the sanguineous and muscular systems preponderate. Here the face will be found florid, and the general frame vigorous; the child will be strong and active, and much disposed to inflammatory diseases or hemorrhages, arising from similar derangements in the capillary circulation. In others, again, where the lymphatic temperament prevails, obstructions in the growth and development of these organs, will produce glandular swellings and ulcerations of the glands. As the child advances in life, the organic gradually cease to be the predominating organs, being replaced by those which constitute him an individual in the great family of intelligent creatures. SIGNS OF DISEASE FROM THE DIGESTIVE ORGANS. A white coating, of a curdy consistence, on the tongue of infants, denotes acidity of the primae viae; indeed, all the phenomena exhibited by the secretions on this organ are sympathetic, and, in general, indicate diseases of the intestinal canal and lungs, from the membrane covering the tongue being a continuation of the mucous DIGESTIVE SYSTEM. 141 membrane of these organs. White points and aphthae are sometimes idiopathic, but in most cases show a deranged state of the stomach and intestines. An enlarged tongue may be occasioned by hypertrophy, inflammation, or congestion. Swelling of the tongue in croup, measles, variola, or pulmonary inflammations, is an unfavorable symptom. A soft, moist, tongue, of the natural size, affords a favorable prognosis. A pale color of this organ is a sign of great debility and sinking. A red tongue indicates a violent inflammation of.the intestinal tube, and is mostly present in exanthematous diseases, especially in scarlatina. A tremulous motion of the tongue is an evidence of great nervous disturbance; but if it occur in chorea, it ought not to be regarded as a dangerous sign. Grinding of the teeth often occurs in children without any disease; but if it occur in children who never evinced any such symptoms before—if it occur with starting from the sleep —if it be accompanied by great brightness of the eyes and flushing of the cheeks, there is reason to apprehend convulsions. It occurs in worms in the intestinal canal, and in cerebral affections. Increased secretion of saliva takes place in irritation near the parotid gland, or in the cavity of the mouth, in stomatitis, dentition, or tonsillitis. Diminution of saliva, with violent insatiable thirst after the continuation of acute diseases, is an unfavorable symptom. Redness of the throat is a sign of inflammation, both idiopathic and symptomatic, as in scarlatina, measles, and in chronic inflammation of the digestive or respiratory organs. Difficulty of swallowing arises from inflammation or swelling of the pharynx, oesophagus, tonsils, tongue, or parotid gland, ulcerations in these parts, or polypi in the pharynx and oesophagus. Coughing, after swallowing, indicates an inflammation of the larynx; but this coughing should not be confounded with the strangulation and coughing arising in infants who receive their milk with more rapidity than they can swallow. When a young child drinks often, and with eagerness, and if the mouth be hot and dry, it is very evident that a febrile condition of the system is present. Sometimes children drink with so great avidity that there is scarcely time given to breathe; they are soon obliged to stop, respiring with a loud noise. Where there is an affection of the larynx, as before observed, a cough ensues; and where the affection is severe, or extends to the lungs, the child cries; and in those who have arrived at an age at which they can exercise their intellectual faculties, upon experiencing the distress produced by drinking, will obstinately refuse all drink. Insatiable thirst, in long-continued affections, is a very unfavorable sign: the agonizing eagerness with which a young child will seize and swallow any kind of drink in protracted affections, almost always precedes dissolution. 142 DISEASES OF CHILDREN. The continuance of a healthy appetite in chronic affections is a favorable symptom. When it is morbidly increased, it arises from some irritation in the stomach, but more especially from the presence of worms in the intestinal passages. An inordinate appetite, at the beginning of acute diseases, is an unfavorable sign ; so is it after the subsidence of the active symptoms, if the strength of the child does not return. Loss of appetite, in acute diseases, is no unfavorable sign. If it occur in chronic affections, it is an evidence of.great debility, and affords an unfavorable prognosis in children, where nourishment and growth are the most prominent and active functions of the system. Loss of appetite is a constant symptom, where disease of the digestive passages exists in the stomach, but less constant when the affection is in the lower intestines. Loathing of food, when arising from the condition of the mucous membrane of the stomach, is one of the usual phenomena of acute diseases, and is therefore not unfavorable. It is generally an attendant on a phlogosed state of the mucous membrane of the intestines, and affections of the pancreas, spleen, liver and mesenteric glands. There is occasionally loathing of food when there are worms in the intestinal tube, or inflammation, ulcerations and indurations of these organs. In chronic diseases, protracted loathing is indicative of organic changes in the digestive organs. Vomiting, in nursing infants, often arises from the stomach receiving more than it can contain, and which, if not thus rejected, would'be a cause of indigestion and colic. Vomiting may also be a sign of affections situated in remote organs, as the head, kidneys, and neck of the bladder. It may also arise from acidity in the stomach, or from the presence of some acrid or other deleterious substance, and when painful, is an evidence of inflammation of the oesophagus or stomach. In new-born infants it occurs in obliterations or obstructions in some parts of the oesophagus or intestinal canal. Vomiting is favorable if it follow simple repletion, and if the child, when old enough, expresses relief from the loathing and nausea, and if the fur on the tongue becomes loose, the skin moist, and pulse soft. Vomiting is unfavorable if there is no relief from the previous oppression ; and if the epigastrium becomes painful, it is an evidence of the existence of inflammation. If protracted, of some organic change, or is symptomatic of hydrocephalus, or some remote affections. Young children not unfrequentiy vomit a caseous substance, apparently formed from their milk, when the previous symptoms of distress, colic, fever, etc., disappear. Green substances vomited, 143 DIGESTIVE SYSTEM. not bile, are evidencesof a gelatinous softening of the stomach, and is decidedly a bad symptom. The discharge of gas from the intestines occurs where the digestion is weakened ; when not discharged, it produces the phenomena of flatulence, enlargement of the abdomen, and borborygmus. Children at the breast evacuate the bowels, several times a day without the presence of disease ; but any irritation may increase the normal secretion, and give rise to purging, which is not always a sign of disease, as in the excitation of the functions of the muciparous follicles during the period of teething. On the other hand, it should be regarded as a serious affection when occurring after the continuance of scarlatina, measles, or small-pox, or when, under any circumstances, it produces debility and emaciation. Tenesmus is a sign of disease in the rectum or colon; haemorrhoids, or worms, in the large intestines. Constipation may arise from defect in the biliary or intestinal secretion, or from inflammation of the intestines or of the brain, or from mechanical obstructions in the bowels, as scybala, conglomerations of worms, and intussusceptions. The alvine evacuations vary in a healthy state according to the food used. New-born children evacuate the dark substance known by the name of meconium. Sucking children pass a quantity of faeces, of the consistence of pap, and of a yellowish color. The prevailing color of the faeces in children, at all ages, is yellow. The substances discharged may be food, serum, mucus, bile, pus, blood, false membranes, and worms. If digestible substances pass partly or not at all digested, it is a sign of inflammation in the intestinal tube, or of weak digestion. The discharges may be acid, frothy and highly offensive, as in cholera infantum, and are evidences of the deficiency of the biliary secretion. Thin fluid mucus is a sign of intestinal catarrh. It occurs in childreu affected with remittent fever. If it be viscid, the prognosis is worse than when it is thin. Excess of bile occurs during the heat of summer, and is an evidence of great irritation of the liver or duodenum. The evacuation of blood is a sign of hyperoemia, irritation, and inflammation, wounding or ulc eration of the intestinal canal; it is less unfavorable in little children than in adults. The passing of worms is an important diagnostic and prognostic sign : for if the symptoms of disease abate after their discharge, it is an evidence that they were caused by the worms, and the prognosis is favorable. The fulness of the abdomen is an important means of distinguishing diseases of the intestinal canal from those of the brain in children; and in them the fulness undei the epigastrium, by the enlargement of the transverse colon, is very common, especially in those of a scrofulous habit. A very inconsiderable disturbance in 144 DISEASES OF CHILDREN. the functions of the intestines produces it in them, because theii pelvis is small, and the liver large. If abdominal pain arise from peritoneal inflammation, slight pressure or mere contact produces a great aggravation ; but if paroxysms of pain arise from flatulence, they abate on pressure. When there is severe pain on pressure of the abdomen, nothing will divert the attention of a young child. The best method of ascertaining the actual existence of pain, is to raise the child from its bed, expose it to a strong light, and press with force on the abdomen ; and although the child may have cried violently before, its cries will cease, and its attentions be fixed steadfastly on the light, if there exist no abdominal pain. If this sudden exposure to light fail in calming the child, we may then be satisfied of its acute and continued suffering. DISEASES OF THE DIGESTIVE ORGANS. STOMATITIS INFLAMMATION OF THE MOUTH. The mucous membrane of the mouth is very liable lo become inflamed in young children. It may be simply an erythematic form, without being followed by any result; or may terminate in exudation of concrete mucus, ulceration, or gangrene. The first-mentioned termination of stomatitis is an altered secretion of the part, having the appearance, most commonly, and always at the commencement, of white spots, resembling a small white flower, known in France by the name of muguet. Ulceration may occur in any part of the buccal mucous membrane. When it appears on the mucous follicles, it is the second stage of aphthae. Gangrene may be the termination of all the others, or may be a distinct variety, commencing usually with an oedema of the part, and sanguineous congestion of the cellular tissue. Etiology.—This disease often arises from a state of congestion in the mucous membrane, at the earliest age, a condition peculiar to the young infant at birth. The youngest children may therefore be affected with the simple variety, and that which is attended with a concrete exudation or altered secretion, or muguet; a term which has also been recently adopted in the English language. It may also be brought on by cold, any irritation in the mouth, as hot or stimulating food, too frequent use of the sucking bottle, but more especially from teething. Scarcely an infant passes through the period of teething, without suffering more or less from this affection. A deranged condition of the alimentary canal, ac- I DIGESTIVE SYSTEM. 145 conipanied by acidity, is almost always the cause of tne aphthous and ulcerous variety of stomatitis; and, indeed, the disease, in all its forms, appears connected with an irritated or phlogosed state of the other portions of the prima? via?. The different forms of stomatitis have of late years attracted a great deal of attention in France, and a diversity of opinions prevails as to the nature and cause of these varieties. These will be considered below, under the head of pathology. It appears to prevail extensively, where many children are crowded together, and suffer from the necessary deterioration of the air; it has on this account been thought contagious. Children, however, who have not been affected with it, have not taken it even after drinking from the cup used by those who have labored under the disease. When it extends to the cellular tissue of the cheek, and terminates in a total destruction of the tissue, forming the affection known by the names of gangrenous erosion of the cheek, or cancrum oris, it becomes a very serious and fatal affection. The connexion of the inflammation with an cedematous condition of the affected part, appears to cause a retention or stoppage of the blood in the capillary vessels, by which an indolent engorgement takes the place of inflammatory action. That this pressure is the cause of the gangrene, appears from the fact, that the most usual place of its appearance is where the parietes of the mouth are most exposed to pressure, opposite the horizontal part of the jaw and dental arch. There exists in infants a predisposition to serous infiltrations, which renders them liable to this termination of stomatitis. It would appear to be more common ha foreign hospitals than in this country, and is there exceedingly fatal, as indeed are all the inflammatory and ulcerous disorders of the mouth. This cedematous condition of the cellular tissue of young infants is peculiar to continental Europe, and the infiltration proceeds to such an extent, as to produce an induration of the body. Where this gangrenous affection occurs in older children, there is also a manifest tumefaction, with other symptoms, either local or general, of dropsical effusions. Semeiology.—In the simple or erythematic form of stomatisis, the mouth appears very red and hot; sucking, mastication or deglutition are difficult, and often very painful; and the pain arising from sucking, will often prevent the child from taking the breast. When it appears in teething children, an exceedingly profuse flow of saliva occurs. The inflammation spreading to the borders of the lips, forms ulcers, which, exciccating, produce a species of herpes. If the disease be very severe and protracted, small ulcers appear on different parts of the mucous lining of the mouth, on the fra?num of the tongue, at its base, internal surface of the cheek, and on the 19 146 DISEASES OF CHILDREN. palatine arch, which have a yellowish white appearance, and around their edges the inflammation is very intense. A considerable degree of fever and restlessness, together with a derangement of the digestive organs, attend the local inflammation ; and when the disease is extensive, it is attended with more or less diarrhoea. The cry of the child indicates pain, without, however, any alteration in the tone. When the disease produces an exudation on the surface of the diseased membrane, it is known by the names of millet, white thrush, muguet, and is the form of disease designated by nosological writers by the title of aphtha lactantium. In this form the inflammation is very extensive, descending throughout the whole intestinal canal, when the disease is severe. This secretion varies much in appearance in different parts of the mouth ; sometimes appearing in small white spots on the tongue, and again occupying other parts of the buccal mucous membrane, in the form of irregular patches. Sometimes, also, it will be spread over the entire surface of the back part of the mouth, in the form of a membrane. This affection of the mucous membrane, pouring out an altered, concrete secretion, must not be confounded with aphthous ulcerations. It is only of late years that the distinction has been made, and the difference clearly ascertained. It may be known from apthae by the curd-like appearance of the concretion, as if the affected part were dotted, or lined with cream or curd. When the disease increases, the concretion spreads, and unites in the form of a pellicle, constituting the confluent form. Vomiting and diarrhoea not unfrequently attend this disease, when it has continued for a length of time, and are evidences of the progress of the inflammation to the other portions of the digestive passages. When the inflammation more especially affects the muciparous follicles of the mouth, which may occur in those in whom they are prematurely developed at an early period, or at the time of dentition, when they first assume their peculiar functions, which is indeed the period of the affection of the follicles, a peculiar form of the inflammation, and subsequent degeneration, arise. This is what is usually known as aphtha?. The disease shows itself under the form of small white points, with the appearance of a slightly prominent spot, of a darker color in the centre. They may appear distinct, and few in number, or spread over every part of the mouth; and usually show themselves first near the lips and angle of the mouth. Sometimes the inflammation stops in the first stage, without proceeding to ulceration ; but if it persevere, a while purulent looking fluid is seen to issue from the centre, diffusing itself over the surrounding parts. When the ulceration proceeds, the aphthae assume a new appear- DIGESTIVE SYSTEM. 147 ance ; the borders are prominent, the ulcer slightly cupped, and this ulceration secretes a pultaceous matter, which adheres for a while, and then becomes detached in the form of a small scab. When the aphthae are numerous, the ulcerations unite, run into each other, forming a confluent state of the disease. At the commencement of the ulceration, a bloody oozing not unfrequently takes place, which drying, forms a brown scab. Such are the local symptoms of aphtha?; and when the affection is mild, the child will experience but little, if any, disturbance of the general system. When, however, the eruption is extensive, there is often a great degree of drowsiness, sometimes with a slight fever, thirst, and pain. A great restlessness usually accompanies the disease, while the acid eructations, and loose green stools, attest the extensive nature of the affection. There is no moisture of the skin, which is generally harsh and dry. The prima? via?, however, are more often affected than any other part, as the frequent vomiting, and thin, offensive alvine evacuations show. These discharges are often so acrid as to excoriate the anus and nates. As the disease advances, the looseness of the bowels increases, and the child becomes much emaciated, and suffers greatly from severe languor and sinking. When aphtha? becomes gangrenous, the surface is of a brownish hue, covered either with a hard or pultaceous eschar, while the parts surrounding them are of a dark modena hue, and much swollen. The edges.of the ulcer appear as if burned, and emit a very offensive odor. The sufferings of the child prevent him from closing the mouth, and the saliva, mixed with fragments of the eschars, freely flows out; the face becomes pale, and the pulse extremely feeble ; the child at last sinks in a complete state of exhaustion, from the combined effects of the profuse discharges from the bowels, and the state of inanition into which it falls, from the impossibility of swallowing food. From this account of the symptoms attending stomatitis, the various forms of the affection may be readily distinguished. The only difficulty on this point may arise between a severe exudatory stomatitis and the aphthous affection ; the latter, however, may be known from the manner of its commencing, always appearing in spots, by its uniformly preserving its circular form, and by being always surrounded by a red circle. The aphtha?, before they become inflamed, may generally be seen, and always felt, asM. Billard asserts. Morbid Anatomy.—The anatomical nature of the simple form of stomatitis is evident from the symptoms detailed above. It consists of a sanguineous congestion of the mucous membrane, and is often attended with a similar condition of the stomach and intestina* canal. 148 DISEASES OF CHILDREN. The ulcers that form from the erythematic inflammation of the mucous membrane, appear to be a softening of the mucous membrane. A sort of pulpy degeneration of its texture, according to AL Denis, takes place in the palate about the median line. If this pulp be raised, the bottom of the ulcer is found to be the healthy bone. The exudation following the inflammation of the mouth has received, within a few years, a great deal of attention on the part of the French pathologists ; and it is only of late years that its true pathology has been ascertained, and the line of distinction drawn between this form of disease and the aphthous affection of the mouth. The works of Breschet, Guersent, Lelut, and Billard, contain a -clear account of the nature of this pseudo-membranous formation. Guersent* considers muguet as a local affection, capable of affecting almost any part of the intestinal tube. M. Denist also considers it in the same light. Valleix} entertains the same view of it, and that its seat is throughout the entire digestive passages, the affection of the mouth being merely a part of the general disease. M. Billard regards it as stomatitis, with altered secretion. There is reason for believing, that, like all other affections of the mucous covering of the mouth, the disease may be transmitted by continuity of membrane; and this is precisely what takes place: for it not unfrequently appears around the gums, edges of the tongue, etc., extending ultimately to the pharynx and oesophagus. A sanguineous congestion always attends the disease in question ; points or shreds of a white concrete mucus are spread" over every part of the interior of the mouth, and always on the surface of the epithelium. The varieties of form have reference to the seat; that which appears in points is at the extremity of the tongue. The cheeks are covered with lamina?; and that which assumes the membranous appearance occurs at the velum and base of the tongue : the villosities of the mucous membrane being longer and less fine at these parts, the mucus is secreted in the form of a membrane. M. Lelut, after a number of experiments on the nature of the membrane, arrives at the opinion that it bears a great resemblance to the buff of the blood and false membrane of the croup ; hence it would appear that the inflammation had rendered the mucous secretion more rich in fibrin. When the inflammation has extended to the pharynx, tonsils, and parts adjacent, an exudation of a very dangerous nature occurs, known by the name of diphtheritis ; its danger arises from the nar- * Diet, de Med., in 21 volumes, Art. Muguet. t Recherches d'Anat. et de Physiolog. Path, sur plusieurs Mai. des Enf., 1836, p. 106. t Clinique des Mai. des Enf.; Paris, 1838, p. 203. DIGESTIVE SYSTEM. 149 rowness of these passages in children. This exudation is of the nature of lymph, and may be at times removed from the part over which il is spread, without leaving any destruction of parts beneath, even though the pellicle itself be in a state of decomposition. In many instances, however, where the disease is rapid, the parts beneath have been found in a state of gangrene and disorganization. The precise nature of aphtha? has been the subject of much investigation ; and from the time of Bcerhaave to that of Bichat, much genius has been displayed in the endeavor to ascertain their precise seat and nature. Callisen has described them as small tumors, arising from the affection of the mucous glands. Gardien regards them as vesicles ; and Billard considers them as a morbid development of the muciparous follicles of the mouth, sometimes in a state of simple tumefaction, at other times in a state of ulceration. In fatal cases of aphtha?, the inflammation not unfrequently prevails through the whole intestinal canal, while the aphthous affection in some cases extends only through the oesophagus. Small superficial ulcerations have been found in various parts of the intestinal passages. Excoriations exist about the anus, caused by the acrid nature of the discharges. The pathology of the ordinary affections of the mouth which terminate in gangrene, is detailed in the symptoms of these affections ; for the actual anatomical disorganization is through life the subject of every day's inspections, and therefore needs not to be repeated here. A few words, however, are necessary, with respect to the nature of the gangrenous erosion of the cheek, and the pathological condition connected with it. •The subjects of this disease are generally in an enfeebled condition, often from the effects of previous disease, as intermittent or remittent fever, and, as is not unfrequently the case, as a sequela of these diseases, the patients are in a dropsical condition. The local affection scarcely appears to be of an inflammatory nature, while a swelling and apparent congestion exist in the forming stage, and the part actually appears paler than natural, and no increase of heat is perceptible. An oedema of the part is doubtless one of the causes of the rapid disorganization and sloughing. In children advanced beyond the period of teething, gangrenous affections of the mouth appear to depend on diseases of the teeth, their fangs, or the periosteum, covering their roots or sockets. Where great debility of the system prevails, and the still growing teeth press on the periosteum, a membrane possessing but little vitality, it is unable to bear the additional extension it undergoes across the unyielding bone. The blood consequently ceases to circulate in it, and it dies. Ulceration of the adjacent parts fol- 150 DISEASES OF CHILDREN. lows : and the periosteum having scarcely any sensibility, the sympathies of the other parts of the system are but little interested, until an extensive portion of the mucous membrane of the mouth or mass of cellular substance becomes afTected. This explains the rapid and extensive penetration of the ulcer along the roots of the teeth, and the destruction of the bone.* Treatment.—The treatment of stomatitis, in its various forms, may be divided into local and general. Local Treatment. —The milder form of this disease, in its different varieties, will often require no other treatment than such remedies as may be applied directly to the seat of the affection. In the simple erythematic inflammation, mild mucilaginous applications are the most rational and the most efficacious ; and nothing can be more injurious than the use of irritating and stimulating agents, which not unfrequently are resorted to at the very commencement of the disease. Various mucilages have been used, such as a mixture of cream and the white of an egg. A piece of the bark of slippery elm (ulmus fulva), saturated with simple syrup, may be given to the child to chew, or it -may be held in the mouth by the nurse ; or a decoction of flaxseed, or powdered gum-arabic, may be used for the same purpose.t The latter substance, in fine powder, introduced in small quantities into the mouth, I have found to be the remedy the easiest of application, and the most efficacious for the disease, the adhesive nature of the gum causing it to be retained in the mouth much longer than any other substance. It may sometimes happen that the violence of the inflammation may require leeches to be applied ; when these are necessary, the angle of the jaw, or about the part near the inferior portion of the ear, will be the best place for their application. When an enlargement of the submaxillary glands accompanies these affections of the mouth, they should be applied in the vicinity of these glands. Some caution, however, should be used in applying leeches in those cases where there is much constitutional debility, or where the affection has arisen after other protracted diseases. Should ulcers appear, or the exudation of altered mucus show itself, some stimulating applications will be necessary to alter the action of the capillaries of the affected part. In the former case these applications may be made- directly on the appearance of the ulcer; in the latter, not until the inflammation has been in some measure allayed. Borax has for a long time been a highly popular remedy. * V. Dr. Coates, in N. A. Med. and Phys. Journal, 1826. t ft Mist. Acacia?, (43) Albuminis ovi., Syrupi, aa. partes cequales. M. Linctus for local inflammation about the mouth. DIGESTIVE SYSTEftJ. 151 combined, in a fine powder, with an equal quantity of white sugar, which may be put into the mouth dry; or a wash made of a drachm of honey of borax and an ounce of water, applied by means of a soft piece of rag, or a camel's hair pencil. Alum has also been used for the same purpose, and is certainly a very useful remedy, and has appeared more successful than the more popular one just mentioned.* The cutting of the gums should never be neglected, if there are indications of the protrusion of the teeth; and scarifying the gums is necessary in that form which accompanies the process of dentition, known by the tumefaction and sponginess of the gums and decaying of the teeth. The mouth, in this affection, should also be freely washed with a decoction of cinchona or oak bark. These astringent washes, also, are often all that is required to treat the slight ulcerations of the mouth; a small piece of alum should be dissolved in the infusion, to increase the efficiency of these means; and, in severe cases, chloride of soda, in the proportion of half a drachm to three ounces of water, will be found useful. In the ulcerated mouth, and in aphtha?, properly so called—the second stage of the morbid development of the follicular apparatus of the mouth—much the same treatment will be necessary ; and in obstinate cases, a change in the remedies applied will often be found necessary. Dr. Devvees speaks of the benefit derived from Armenian bole, mixed with powdered loaf sugar, and sprinkled in the mouth. Sulphate of copper, however, is the most powerful and useful stimulant and should be applied in the proportion of ten grains to an ounce of water, with a fine camel's hair pencil. According to the strength of the solution, it is either a powerful stimulant or an escharotic, and therefore is applicable to every form and variety of. ulceration. Nitrate of silver is also a very efficacious means of arresting the extension of the ulcers; and in the case of confluent ulcerations, may be applied in solution over every part of the diseased surface. In distinct aphtha? the solid form is the best, being used to touch the ulcers, which will quickly yield to this remedy. Chloride of soda has been recommended by M. Guersent; it is more particularly applicable when sloughing has ensued, and the decomposition of parts has commenced, which may be known by the foetid odor of the breath. In these instances of sloughing, the most powerful escharotics will be found necessary for the arresting of the disease, by the destruction of the part; and the muriate of antimony is that which has been found the most efficacious. Muriatic acid has also been used in severe cases, even in an undiluted state ; but it is not so safe as other escharotics, from the difficulty of controlling its ac- •ftMellis Rosas, (44) Aluminis, 3j« Tinct. Myrrhas, 3ss. To be applied to the ulcers of tne mouth. ft Aluminis, 3j.—-3ij. (45) Aquae Rosse, zij. Solve. M. 152 DISEASES OF CHILDREN. tion. In the use of all these stimulating and escharotic applications, their effects should be carefully watched, that an increase of inflammation may not be caused by a too persevering use of them. They may from time to time be suspended, and mucilages substituted, when much irritation or inflammation is present. They may be applied with more safety by means of a small glass capillary tube, immersing one end in the acid, and drawing up one or two drops, and then depositing them on the surface of the affected part. On the separation of the eschar thus formed, it would not be proper to repeat the same application, as the part would be left in a state of extreme irritability. A pencil of nitrate of silver will be found the best escharotic for subsequent use, as it can be repeatedly used without causing an increase of the inflammation. General Treatment. —In every form of stomatitis, a greater or less derangement of the prima? viae exists; it will, therefore, be necessary to pay some attention to the condition of the stomach and bowels. It ought, in the first place, to be the care of the physician to ascertain whether there exists any inflammatory action in the mucous membrane of these parts, before the administration of active purgatives or emetics. Often, however, the existence of a high state of irritability, or slight inflammation, has its cause in the presence of acrid or acid indigestible matters, which ought to be removed by appropriate means ; and it not unfrequently happens that the disease has been entirely arrested by the administration of some mild purgative. Castor oil or magnesia, according to the prevailing indication, is the medicine most applicable to the condition of the stomach and bowels, when it is deemed necessary to administer aperients; the occasional use, also, of mild purgative remedies, when not contra-indicated, will also be necessary throughout the disease, to preserve the secretory apparatus of the intestines in a state of functional activity.* A full dose of calomel, when the bowels are obstinately constipated and tumefied, may be required. When the-breath is offensive, with nausea, a mild emetic, such as ipecacuanha, will often remove the irritating cause of the affection. In case of tenderness of the abdomen, indicating inflammatory action in the bowels, or when the stools are streaked with blood, warm baths and fomentations to the abdomen will be necessary, while active purgatives should be avoided; mucilages ought, under these circumstances, to be freely used. The warm bath will also be serviceable when there exists much general heat of the body; •ft Pulv. Rhei., 3j. (46) Magnesice, 3ij. Pulv. Acacias, gr. x. M. Dose from three to four grains every third hour, to a child of six months old. Six to ten grains, for one a year old. ft Infus. Rhei., §8S. (47) Sulph. Potassae, 3ij. Tinct. Cinnamon, Syrupi Sennas, 3> v « M. One to two drachms every three houi s. DIGESTIVE SYSTEM. 153 and if accompanied by restlessness, anodynes,* judiciously administered, are of singular efficacy in calming the nervous commotion of young children, and greatly add to the diaphoretic effect of other remedies, and materially aid in the restoration of the lost balance of circulation. One of the best forms in which an anodyne can be given, is Dover's powder. Should there exist much acidity, and especially if accompanied with diarrhoea, and absence of abdominal pain on pressure, prepared chalk, combined with the pulv. ipecac, c, before mentioned, should be given every two or three hours, to arrest the alvine discharges. Dr. Eberlet says, that in obstinate cases of aphthae, he has found great benefit to arise from the use of a solution of nitrate of silver, internally administered, in the proportion of a grain to two ounces of water, a teaspoonful to he administered to infants between two and six months old, every four hours. Powdered borax has also been given in similar cases with advantage. It is extensively employed in Germany in the treatment of infantile diseases, in cases of acidity and aphthae. It is given in the form of a*linctus, made with the honey of roses; half a drachm to one drachm of the former to two ounces of the latter; a teaspoonful four times a day. Richter advises it, combined with magnesia. Mercury has been used, it is said, with good effect in these affections ; and it has been recommended on the ground that the constitutional change resulting from its use will not be counteracted by the affections of the salivary glands or gums. It must, however, be a hazardous remedy, and one which we should not be disposed to try in any form of stomatitis, especially after the period when the salivary glands have begun to act. On the appearance of sloughing, great prostration of strength ensues, and it will be necessary to resort to stimulants to sustain the strength, as wine whey, or ammonia. Tonics, also, become necessary, and at the head of this class of remedies stands tjuinine.f The tartrate of quinine, especially, has been recommended in cases of gangrene. Chlorine, in the form of chloride of soda, has also been used as a stimulant, in sinking cases fections of the mouth. Dr. Evanson of aphthae and gangrenous afmentions that the use of iodine •ft Aquae Destil, £j. (48) Mist. Acaciae, Syrupi. Simp., |ss. Tinct. Opii. Guttam. M. Dose, a teaspoonful repeated every half hour, till rest be procured. Double that quantity after a month. ft Aq. Fceniculi., (49) Tinct. Opii, gt. vi.—viij. Syrup. Aurantii, 3vj. M. A teaspoonful every hour, to a child of two years, f Op. Cit., p. 179. J ft Quince Sulph., gr. ij. (50) Acid. Sulph. Aromatic, gtts. xvi. Syrup. Caryophill., Aquae Destill., M. S. Dose, 1 to 2 drachms i hrice a day. L>0 154 DISEASES OF CHILDREN. lias been attended with success; the manner of its exhibition and dose he does not mention. The subjoined formula, however, maybe used.* Where it is necessary to remove the irritating and putrid matters swallowed, and to keep the bowels free in the sloughing stage of these affections, spiced or aromatic syrup of rhubarb will be found peculiarly appropriate, carefully watching against a hypcrcatharsis. In the state of debility and manifest loss of vital powers, after the gangiene has commenced, it may sometimes be necessary to have recourse to stimulants, to rally the receding powers, and to restore energy to the action of the heart.t Tlie child should be kept exclusively to the breast, if it be not weaned. The mildest and least irritating food must be the only kind allowed to those artificially fed, or who have passed the period of nursing. Arrow-root, soft boiled rice, sago, or tapioca, are the most proper vegetable aliments; and soft boiled eggs, calves' feet jelly, chicken broth, may be required, when a state of debility and sinking demand articles more abounding in nutrient qualities. GANGRENE OF THE MOUTH. That form of ulceration which is known by the name of gangrenous ulceration, or gangrenous erosion of the cheek, and which consists of a tumefaction of the affected part, and its subsequent alteration, softening and destruction, demands an especial notice; for it can hardly be classed with any of the preceding forms of stomatitis, inasmuch as it appears to depend for its peculiarity more on an oedema of the part, and the congestion of the capillaries, than an active inflammation. MM. Baron and Guersent have written largely on this subject. The former, especially, has examined closely into its nature, and caused the treatment in the different stages of the disease to be more strictly founded on pathological principles. Etiology.—This affection is peculiar to children between the ages of two and five years ; and makes its appearance in such as are of a debilitated habit, arising from imperfect diet; while impure air and a low, damp situation increase the predisposition. Some- * R Iodinii, gr. v. 031) Potass. Hydriod., 3ss. Aq. Destil. M. To children under seven years 2 drops twice a day, gradually increased to 5 drops ; to children above seven, the dose may be progressively advanced to 16 drops, tn a little water. f ft Aqua? Mentha?, |iss. (52) Sp. Ammon. Arom., 3ss. Sp. iEiheris Nitrici., gt. xij. Sp. Lavand. C, 3j- Syrup Caryoph., |ss. M. Dose, a teaspoonful every two hours, ft Ammonia? Sesquicarb., 3ss. (53) Aq. Menth. Pip., Syrup. Aurant., M. A tablespooful occasionally. DIGESTIVE SYSTEM. 155 times it follows long-continued fever, evidently depending on the debility thereby induced. It has often been a severe scourge in alms-houses and asylums for children. A few years ago it prevailed in the New York alms-house to a great extent, the impurity of the air from the crowded condition of the house being evidently the chief predisposing cause. Semieology.—The first appearance of this disease is a tumefaction in the cheek without inflammatory action. There is no pain, nor any tenderness on touching it: indeed so little of disease appears in the part, and as there is no complaint, it for sometime escapes notice, and it is only the enlargement that attracts attention. The skin over the tumor is shining and white, of a remarkably peculiar aspect. The interior of the mouth exhibits in the part corresponding with the externaf*-tumor an ash-colored eschar, also destitute of the usual marks of inflammation. The general system is affected in no other way than by an unusual lassitude and debility, with a trifling fever. In the second stage of the disease, the slough spreads over the cheek and lip, and the saliva escapes in large quantities, becoming as the disease increases of an offensive sanious nature. The outside of the cheek at this period also exhibits the commencement of disorganization, at first in the form of a pale ash-colored spot, which quickly becomes livid. The discharge is of an acrid an irritating nature, excoriating the parts over which it passes, and it even appears to possess the quality of inducing a similar disorganization, for other parts of the lips and lower portions of the face put on the appearance of commencing mortification. The disease even extends to the alveolar process and osseous parts of the jaws, producing a loosening of the teeth, and at times an excessive destruction of the maxillary and nasal hones. The pulse is in most cases feeble, small and frequent even from the commencement of the disease. The bowels are constipated at the commencement of the disease, but become excessively relaxed toward the close. Treatment. —In the forming stage, that of infiltration, the application of stimulating frictions to excite the absorbent vessels will be found necessary. Liniment of hartshorn may be used for this purpose, or a solution of muriate of ammonia, applied to the cheek by means of pledgets saturated with the solution. Upon the appearance of the least ulceration, or should a violet spot show itself on the cheek, more active measures will be necessary; and muriate of soda, muriatic acid and honey, caustic potash, and muriate of antimony, have been employed by various practitioners with success, according to the representations of the French physicians. The actual cautery, also, in the hands of MM. Jadelot, Guersent and 156 DISEASES OF CHILDREN. Baron, it is said, has been of eminent service in the gangrenous stage of this affection ; but we may judge of the success of these means, and especially of the latter, by the candid acknowledgment of M. Marjolin :* "Almost all children," says he, "affected with this disease in the Parisian hospitals, die." He also uses the bistoury and scissors to remove the thick sloughs. Dr. Burns used chloride of lime, nitrate of silver, carrot or yest poultice. Nitric acid, also, has been employed with advantage in severe cases of gangrene. Sulphate of copper, however, is the remedy which has succeeded beyond all others in changing the character of the ulcers, and causing a rapid healing of the part. It has the advantage over actual cautery, from the facility with which it may be applied to every portion of the disease; and part ought to be brought under the influence of the application. The solution should be made strong, in the proportion of two drachms to a four ounce mixture, t The general constitution should receive particular attention, and every means used to impart tone and vigor to the system. Sulphate of quinine and similar tonics, especially iron, will be the most appropriate remedies for fulfilling this indication where there is no febrile excitement; and the diluted sulphuric acid where fever is present. Alcoholic stimulants also will often be found necessary when there is much debility, and the means suggested for the treatment of stomatitis will be found the most suitable for the disease now under consideration. TONGUE-TIE. The fraenum of the tongue sometimes extends quite to the extremity, or is so short as to interfere with the proper movements of that member. When this is found to be the case, and the child sucks with difficulty, the division of the membrane must be made; an operation of great simplicity, although not free from danger, as serious hermorrhages have occurred from a wounding of the bloodvessels beneath the tongue, and from the tongue passing back on being loosened, so as to close the glottis. The best method of performing this operation, is to place the fore and middle fingers of the left hand beneath the tongue, on each side of the fraenum,- and with a single stroke, with a sharp gum lancet or probe pointed scissors, in a downward direction, divide jhe fraenum. It is very common for nurses and mothers to request the attention of the physician to this subject when no interference is necessary, which may be known by the child being able to suck. * Art. Gang, de la Bouche, Diet, de Med. t Vide Dr. Coates, in N. A. Med. and Surg. Jour., 1826. DIGESTIVE SYSTEM. 157 MORBID DENTITION. Some philosophical writers on medicine do not allow dentition to enter into the number of diseases; but it is evident to all practical men, that irritation, inflammation, fever, and other affections, both local and general, not unfrequently attend this process. Although the operations of nature are conducted in so complete a manner as to make it unnecessary and unwise to interfere in the natural development of parts, yet the inflammation, fever, and other morbid phenomena, dependant on the eruption of the teeth, fraught as they are with great evil in the tender and susceptible system of infants, demand for them a distinct notice. Dentition is not itself a disease ; yet the injudicious feeding of infants, impure air, and other circumstances attending an artificial mode of life, will render the process one of difficulty and danger.* Etiology.—The morbid phenomena attending, teething have their origin in the pressure of the growing teeth on the periosteum and gums; depending in a'great degree on the peculiar temperament of the infant. Some are affected with inflammatory, and others simply with a nervous excitement. This pressure is not in the same degree through the whole course of teething. At first, before the teeth have pressed much on the gums, and while they are passing from the pulpy to the bony consistency, the pressure is principally by the root shooting inward ; this occurs about the third or fourth month of infancy. At a little later period, about the sixth month, the pressure is exerted on the gum, and the peculiar symptoms of dentition present themselves. The pressure is also made by the rising tooth on the membranous expansion over the tooth. From these irritations, distant organs are also sympathetically affected. On this account, the period of teething is the most critical of childhood, and the diseases with which children are attacked at this time, are rendered more dangerous from the constitutional irritation produced by teething. This extensive sympathy arises from the extremely irritable state of the system in infancy ; for at a later period, when larger teeth are cut, but comparatively little constitutional disturbance ensues. * The following fact, related by M. Roberts, in his Traite des Principaux Objets de Medicine, is an instructive illustration of the effect! of morbid dentition. A child, after having suffered greatly from teething, died, as it was supposed, and was duly laid out in its burial clothes. M. Lemonnier, having some business at the house of the nurse where the child had been during its last sickness, learned the facts above stated, and being curious to ascertain the condition of the alveoli in an instance where the teeth had not protruded, requested and obtained permission to make an autopsical examination. He commenced by an extensive and deep incision into the gum; and while he was preparing to extend his investigations, he observed the child open its eyes, and give other signs of life. He immediately applied such remedies as the nature of the case required; stripped off its shroud, applied other and warmer covering, and with care and good nursing the teeth soon appeared, and the child ultimately recovered its health. 158 DISEASES OF CHILDREN. One of the causes of painful and morbid dentition, is the unequal and disproportionate development of the teeth and jaw ; their sudden and simultaneous appearance also becomes a source of disease, from the united pressure of many teeth, and the great afflux of blood it occasions. The conditions of the system predisposing to constitutional disturbance from teething, are those which are connected with an irritable state of the nervous system, from whatever cause it may arise. The younger, therefore, the child is, the more will it be likely to be affected with serious disturbance during the process of teething ; and all feeble and delicate children are more affected in this process than those who possess more stamina. Such infants often suffer from protracted diarrhoea, and die, wasted with marasmus. This class of patients is found among those who suffer from bad food, who labor under the effects of indigestion, and who are exposed to the debilitating'influences of impure air. In children of an opposite condition,.also, the consequences of difficult teething often show themselves with great severity; in those, whose condition is that of plethora, the effects of teething are often sudden and violent, and accompanied by much febrile disturbance and inflammatory action. In them, also, the cerebral disturbance is often very great, from the supply of blood required in the state of active development of the brain. There can be no question that the greater number of diseases, at the time of teething, have their origin in plethora, induced by over feeding, or any other cause which will produce an irritated state of some of the organs; thus predisposing the child to be influenced by the excitement of teething. Accumulation of heat, therefore, about the head, by having it too warmly covered, may excite a flow of blood to the cerebral organs. So, also, warm clothing generally will produce a febrile action, which, when the system is under the additional excitement of dentition, will be developed into some inflammatory or congestive disease. Semeiology.—There is always a considerable swelling, heat, redness and pain in the gums. Their tenderness is at first extreme, allowing scarcely any pressure. Afterward, as the tooth advances toward the surface, a change occurs in the appearance and sensibility of the gum ; it is no longer so fiery red, and pressure rather-gives ease than pain. The salivary glands enlarge, and an abundance of saliva flows from the mouth. With this afflux of blood to the mouth, stomatitis, in some of its various forms, arises. The blood being determined to the head, a turgescence of the face and eyes will appear. Thirst, heat, restlessness, and the usual symptoms of fever, also show themselves: the sleep is disturbed, short, and unrefreshing, arising from the disturbance of the brain DIGESTIVE SYSTEM. 159 and nervous system. This irritation of the nervous system may increase, until some convulsive movement is observed, together with a rolling of the eyes during sleep. Other spasmodic movements may arise, and when affecting the glottis, produce a difficult and distressing respiration. This affection has been known by the names of spasmodic or chronic croup. M. Gilersent has described it by the name of Pseudo-croup nervcux ; M. Gardien, by that of Spasmc du thorax ct de la glotte. It has also received the attention of Cheyne, Munroe, Hamilton, and others. This disease is more particularly described under the article of spasmodic croup, to which the reader is referred. The late Dr. Parrish has described a peculiar spasmodic affection of the intestines, arising, as he supposes, from the irritation caused by teething. The abdomen swells, while a spasmodic contraction of the muscles of the face and limbs takes place, and the ordinary action of the bowels is arrested from the same cause. On the escape of air from the bowels, a complete relief to the symptoms occurs. During the period of teething, there is always a greater or less disturbance of the digestive organs, manifested by a morbid irritability of the stomach, and an acid odor of the breath and matters vomited. The diarrhoea, so common in teething children, is, when moderate, always to be regarded as a salutary evacuation, as it relieves the tendency in plethoric children to local congestions. This diarrhoea, however, should only be regarded as the effect of the simultaneous development of the muciparous follicles of the intestines, which occur with other parts of the system concerned in digestion : that is, the teeth and salivary glands. The tongue, with this diarrhoea, continues natural, the appetite is unimpaired, and the child continues to thrive. Both the diarrhoea and vomiting which sometimes occur, may continue until they become very serious and fatal affections. The vomiting and purging, so common in teething children, not unfrequently pass into a very serious disease. It has received particular notice from MM. Cruveilhier and Guersent; the former of whom describes it under the name of Maladic gastro-intest'aiale des cnj'anls acec desorganisation gelatinijbrmc. The name sufficiently indicates the nature of the disease, when it has passed from a simple disturbance of function, to a disorganization of tissue ; dissection showing that the mucous membrane of the stomach and intestines has been reduced to a pulp, but without any appearance of inflammation. Among the diseases to which children at this period are affected, one mentioned by Underwood as an occasional accompaniment of painful dentition, is a peculiar swelling of the hands and feet. He 160 DISEASES OF CHILDREN. regarded it, like diarrhoea, as decidedly beneficial, or of but little importance.* It has, however, been described more at large by Dr. Kellie ; and although in some instances slight, yet at other times it has constituted a very serious affection. It arises suddenly, is of a purplish mottled appearance, without heat, or any sign of inflammation. The swelling first appears on the dorsum of the hand or foot, and is firm, and does not pit on pressure. It sometimes continues for a month, and usually disappears suddenly. At other times it assumes a leucophlegmalic appearance, and extends to the whole limb. This condition is generally connected with a spasmodic contraction of the fingers and toes. The thumb is strongly bent inward, and pressed into the palm of the hand, as the toes are bent in a similar manner on the sole of the foot. The carpus is at times drawn in such a manner as to increase the sphericity of the metacarpal bones. There appears to be but little pain in the affected part.t Diseases of the skin often occur during dentition, and from their disappearance on the protrusion of the teeth, are evidently caused by the irritation in the system at this period of life; and like diarrhoea, appear to be salutary, and therefore, when connected with teething, ought not to be removed. Among these cutaneous affections are strophulus confertus, strophulus candidus, and the species of porrigo on the forehead and cheeks, known by the names of crusta lactea % together with the erythematic efflorescence and ulceration behind the ears. Dysuria, also, is an affection with which teething children are sometimes attacked. It occurs mostly in those that are debilitated, and whose digestion is feeble ; and acidity of the stomach is its invariable attendant. As all these disorders are considered in other parts of this work, it is unnecessary to treat of them here in detail. Morbid Anatomy.—In those children who have died from the effects of teething, manifested especially by great tumefaction of the gums, the post-mortem examination reveals a violet colored swelling, with fluctuation. On opening the tumor, dark colored fluid blood is found in the alveoli. The teeth are generally discovered loose and floating in the midst of the effused blood, which formed the tumor, and fall out with the blood that flows. These effusions in the alveoli become less frequent in proportion as the child advances in age, and as the tooth by its size fills the aveolar cavity. Other pathological appearances occur in other organs, according to the nature and seat of the complication. * Treatise on the Diseases of Children, by Michael Underwood, M. D., p. 140. t Notes on the Swelling of the Tops of the Hands, etc., by Geo. Kellie, M. D., Ed. Med. and Surg. Jour., vol. xii., p. 449. 161 DIGESTIVE SYSTEM. Treatment. —There were formerly a number of strange and superstitious practices recommended for the treatment of difficult teething 5 ; and the universal idea prevalent at every age, that something must be done, is an evidence of the distress that accompanies teething. The most barbarous, as well as the most refined, have thought it necessary to resort to some method of assisting the efforts of nature. The aborigines of our country gave smooth stones to their infants, with which to press their gums. The ancients, among those remedies that were rational, not unfrequently had recourse to such as had their origin in superstition or ignorance. Amulets and charms were formerly in common use: and such remedies as the a sucking pig, milk of a bitch, and the blood of a cock's comb, rubbed over the gums, were freely used, by being applied to the part with the finger. The latter, especially, "is truly praiseworthy; for this," says Harttman, "being only once or twice, at most, anointed on the gums with the finger, causes a production of the teeth without difficulty, and free from accident."* However absurd these may appear, they still are evidences of the universal prevalence of morbid phenomena in teething children, and that the distress experienced by them requires the interference of art for its relief. The local treatment of teething, when there exist heat, swelling and redness of the mouth and gums, or, in other words, when simple stomatitis is present, should consist of soothing emollients and mucilages. Cold water is exceedingly grateful to the hot and irritated mouth, and therefore the mouth should be frequently washed with it, and the child allowed freely to drink it; indeed, water ought frequently be given to a young child, especially in summer. A violent fit of crying will often be arrested by a draught of cold water. The instinct of the child for biting on hard substances, may be indulged with safety and advantage; therefore, a smooth piece of coral, ivory, or .gum elastic, may be given to the child for this purpose. The practice of furnishing children with a piece of coral is of great antiquity, and appears to have been connected with some superstition among the Romans, as we learn from the writings of Pliny; it was a charm against witchcraft, and was a common amulet of the Roman children. The use of this doubtless had its origin in the benefit children derived from it, and the superstition connected with it, from the mystical attributes which were supposed to belong to the substance.t The use of hard substances has been objected to by some physicians, but without much reason; for it is evident that the absorption of the gum is greatly promoted * Henlock's Practical Treatise on Teething, 1742. f Vide C. Plinii Secundi, Hist. Mundi, Lib. xxxii., Cap. ii. 21 162 DISEASES OF CHILDREN. by the use of these substances, and the child is obviously much relieved by the use of them. Dr. Good supposes ptyalism is promoted by the use of a ring of gold, as the experiments of Dr. Chrestien show that powdered gold, applied to the gums by friction, produced ptyalisni; but it is probable that no particular advantage can arise from a gold ring over one of ivory or bone. A piece of liquorice root, or slippery elm bark, or a crust of bread, will also be found highly useful in promoting the flow of the salivary fluid. When the gum becomes expanded over the tooth, and thereexists much local inflammation or general disturbance, it should befreely divided, until the tooth is felt. •Such a free division of the: gum will often prevent the occurrence of serious consequences,, which sometimes attend on teething, and which a slight exposure to cold or error in diet may induce. The effect on the general system of a young infant, by the pressure of a growing tooth, may be understood better when it is considered that the membrane which covers the crown is put on the stretch, whereby the nerves at the root are crowded, and great pain and irritation caused by the pressure. In every disease, whatever be its nature, the gums should be examined during dentition, and if there are evidences of the advance of any of the teeth, the gum should be promptly divided; for if the disease be not caused by the teeth, for the reasons just mentioned, the most serious irritations will be produced by the confined tooth, and thus add to the existing disturbance of the system. The relief afforded to some children by the operation must be great, for they have sometimes, by pointing to the gum with the finger, signified a wish to have the operation repeated. Objections have been made to cutting the gum, and its propriety questioned ; but experience most abundantly proves the usefulness of the practice. ItJias been asserted, that the cicatrix which forms over the tooth, should the latter not appear immediately, will impede its advancement. This, however, is not true; for it is now well ascertained, that newly-cicatrized parts are the first to be removed by the absorbents, upon their excitement from any cause Newly-healed wounds, on the derangement of the system by whicl these vessels are brought into morbid action, soonest yield to their influence. The cicatrix would, therefore, rather favor the passage of the tooth, by its giving way easier to the process of absorption. It has been also said that the instrument might injure the teeth; but this can not occur, for the enamel is fully formed, and will sufficiently protect the teeth against any injury. The p»in of the operation, also, has been urged as an objection to its use. The pain, If any, is instantaneous, and not to be compared with the DIGESTIVE SYSTEM. 163 constant suffering of the child during the pressure of the teeth, and the relief always experienced on removing this pressure. It should be performed by laying the child horizontally on the nurse's lap, who must, also, firmly secure the hands of the child; the gum-lancet is then introduced by the operator, who, with one hand secures the immobility of the jaw, and an incision is made deeply through the tumefied gum to the tooth. It may sometimes be necessary to repeat the operation, in consequence of the return of pain, irritation and tumefaction; for the tooth does not always appear, although the capsule in which it is enclosed be freely divided. As to the general treatment, it of course depends on the complications, which have nothing in them peculiar, except so far as they depend on the local irritation, or are aggravated by it. These diseases will be considered in their proper places, and our remarks be limited to the general management of children during the period of teething. As even the mildest cases are attended with great susceptibility of the system, every measure to keep the child calm and cool should be adopted. The head ought to be lightly covered, to prevent an undue accumulation of blood ; and it has even been advised, by experienced practitioners, to wash the head every day with cold water. But the propriety of a measure like this may well be doubted, where the child has not been previously accustomed to such ablutions. It will be sufficient to use such measures as will naturally suggest themselves to every one, to prevent an increased determination to the brain, such as the avoiding the use of soft, warm pillows, the exposure of the head to the heat of a fire, or the rays of the sun. The tendency to indigestion in teething children will require the greatest care with respect to their food. If the child is at the breast, it should by no means be weaned, if there is a sufficient supply of food, until nature herself has pointed out, by the appearance of the first teeth, at least, that the child is in a condition to receive a different species of nourishment; when an alteration may be made by commencing with some weak animal broth. When the child is artificially nourished, the lightest and least irritating food should be used; milk and water, tapioca, sago, arrowroot, or a mixture of rice water and milk. If the child appear to have a craving appetite, so as to require frequent feeding, by which a plethoric habit might be induced, it will be necessary lo lessen the quantity of the nutritious portion, by diluting the food with water. One of the least irritating articles of food for a young infant, is the crumb of stale bread, well-boiled with water, and strained when it is first used, and mixed with a third of cow's milk ; the consistence may be gradually increased or diminished, according to 164 DISEASES OF CHILDREN. the necessity of the case. An error in diet, either in quantity or quality, may cause a great derangement in the prima? via?, and diarrhoea, accompanied with colic and other distressing sympt'oms, ensue. A moderate diarrhoea is both natural and salutary, and requires no interference. If, however, the discharges become green, attended with pain or much prostration, it will then be necessary to interfere for the relief of these untoward symptoms. The subject will be more fully considered when we are treating of diarrhoea, keeping in mind that a sudden stopping of the discharges from the bowels of teething infants, is always attended with danger of producing convulsions. The subjoined prescription will be found useful in controlling these evacuations, when they become excessive and prostrating.* Costiveness is best treated by enemata of warm water. Active purgatives should, if possible, be avoided, for there is a strong tendency in the inflammation which exists in the mouth, to extend to other portions of the mucous membrane lining the digestive passages. A small piece of manna, dissolved in the milk and water with which the child is fed, affords a good laxative for this condition of the bowels. The ffhild should be regularly accustomed to use such kind of exercise as it is capable, and if not rendered hazardous by existing diseases, taken in the open air when the weather is good ; for there is scarcely anything that tends sooner to excite feb/ile irritation, and a disordered condition of the bowels, than close confinement within doors, particularly in cities, during the summer. Cutaneous affections in teething children demand an especial attention. But it ought here to be remarked, that great care should be observed in the application of remedies for their removal, as fatal consequences have not unfrequently ensued from the drying up of eruptions behind the ears and on the head ; they had much better be left without any other applications than such as are necessary to preserve cleanliness. TONSILLITIS INFLAMMATION OF THE TONSILS. Among the parts of the digestive system which are very liable to inflammation in children, particularly after the fourth or fifth year, are those masses of mucous follicles known by the names of tonsils or amygdala?. As their oftice appears to be to lubricate the upper-part of the pharynx, and one of the most common inconve- * R Pulv. Ipecac, gr. j. (54) Hydr. Subin., gr. ij. Cretse, p. p., gr. xx. M. Divid. in pulv. No. iv. One may be given every three or four hours, until the discharge becomes lessened. DIGESTIVE SYSTEM. 165 niences arising from their inflammation being pain in deglutition, it appears proper to class them at least as appendages to the digestive organs. This disease has been known by the various names of amygdalitis, cynanche tonsillaris, angina, squinancy or squinsy, of the old medical writers. Hippocrates speaks of it; and it is also clearly described by Celsus, Aetius and others, among the Romans. n Etiology.—The most common cause is cold applied to the surface of the body; and it is consequently found most prevalent in damp situations, and in cold, variable climates, and at the season of the year when most atmospherical vicissitudes prevail, as the autumn and spring, especially the latter. Those children who are of a sanguineous habit of body are greatly liable to attacks of this disease; and a great predisposition to renewed attacks exists in those who have once been affected. Semeiology.—This disease is easily recognised by the redness and tumefaction of the fauces. Where the inflammation is severe, the tonsils become exceedingly swelled, so as to impede deglutition ; the uvula and soft palate appear also swelled and cedematous. When attempts are made to swallow, great pain is produced by the effort; and in severe cases of this disease, fluids are sometimes returned by the nose. The tongue is white, the papilla? being seen in red dots through it at the commencement; afterward a thick tenacious mucous covers the whole surface of this organ. As the disease advances, the clogging of the fauces by the thickened secretion, together with the enlargement of the affected part, cause a difficulty in respiration, and a total inability to swallow. For the most part there is a great deal of fever accompanying this affection, and usually ushered in by a universal chilliness; the pulse is full and strong; the carotids beat with great force, and the face is flushed and swollen. The eyes, in violent cases, are red and prominent; and when the fever is great, the general tumescence of the brain causes a compression of the cerebral mass, and delirium ensues. The external parts of the throat and neck are greatly swelled, and give the strongest evidences of sanguineous congestion. After the inflammation has continued for a short time, resolution, one of its most frequent terminations, takes place, and the patient recovers his strength in a few days; occasionally, however, great debility follows, and convalescence is protracted. It also frequently terminates in suppuration of one or both tonsils, which will occur even after the most prompt and decided treatment. The flisc-harge of the pus thus accumulated, either spontaneously or by artificial means, affords immediate relief to all the urgent symptoms. In some instances the inflammation is stationary, neither a disap- 166 DISEASES OF CHILDREN. pearance of the tumors nor suppuration occurs, but a permanen enlargement of the tonsils remains. This, it is said, is most likely to occur in children of a scrofulous habit, and those who are pre disposed to phthisis. Pathology.—Redness, tumefaction, suppuration, and ulceration, are the anatomical characters of tonsillitis ; such as have been described under the semeiology of the disease. Treatment. —The antiphlogistic treatment is that which is especially demanded in this affection. In mild cases, saline purgatives,* warm pediluvium, rubefacient liniment to the throat, and diluents, will be all that will be required. Indeed, purgatives are highly useful in tonsillilis; and where it is necessary to administer such as will make a more decided impression on the system than those just mentioned, a few grains of calomel, followed by either of thesf 1 saline cathartics. A mixture of Epsom salts and tartar emetic, so as to operate both by the bowels, and restore the healthy action to the part by its emetic effect, would in most cases be advisable. The restoration of the cutaneous secretion is also indicated ; and one of the'best articles for lessening febrile action in children is nitrate of potass,t and when combined with ipecacuanha, forms an admirable diaphoretic in mild cases.} Tartar emetic, one grain in two or three ounces of water, a teaspoonful every two hours, may also be given for the same purpose. In young children, especially where there is much viscid secretion around the fauces, an emetic is highly useful, and in some cases decidedly necessary, to relieve the entrance to the respiratory passages. In severe cases of this disease, with great febrile action and full pulse, it will be necessary to bleed from the arm. In all cases, when the disease does not yield to the remedies first mentioned, it will be proper to apply leeches to the swelling, or to scarify the inflamed tonsils. When leeches are applied, it will be. necessary in young infants to draw all the blood required by a single application, for the prostration is often excessive and alarming when the bleeding is promoted by warm applications, and suffered to continue. After the bleeding has ceased, a warm poultice ought to be put * ft Infus. Ros. Co., (55) Magnes. Sulph., 3vi. Syrup. Lemon., Zss. M. One or two teaspoonfuls every three hours. R Magnes. Sulph., 3ij. (5C) Mannse., fSolve in Emuls. Amygd., ?iv. M. A dessert-spoonful every two hours, for a child two years old. f R Mucilag., (57) Potass. Nit., 3j. Oxymellis, Sit linctus. A teaspoonful to be slowly dissolved. t R Pulv. Ipecac, gr.'iij. (58) " Potassae Nit., gr. xii. M. Ft. Pulv. No. vi. Dose, one every three hours. DIGESTIVE SYSTEM. 167 around the throat; indeed, an emollient poultice is one of the best applications in ordinary cases, under all circumstances. Acidulated astringent gargles have been recommended by various practitioners, but in the ordinary inflammation there can be hardly any advantage from them; and Pringle says that he never saw any good resulting from their use. Eberle, also, disapproves of their use, and recommends in their place simple warm water, acidulated with vinegar, for the purpose of removing the viscid mucus about the tonsils and palate. These astringent gargles, however, may be used with advantage, after the tonsils have suppurated, and have been opened, or have discharged spontaneously.* When suppuration is about to take place, every means in our power should be used to effect it. Poultices should be continued externally, and the vapor of warm water frequently inhaled. As soon as the matter appears to be formed, the tumor must be opened with a lancet, rather than let the patient run the hazard of his life, by allowing the tumefaction to continue, for the suffering from the excessive swelling is sometimes very great, and the danger of perishing from suffocation imminent. In a few instances, the abscess has pointed and broken externally. In some cases, the tumefaction has been so great as to render it necessary to make an opening into the trachea; an operation which has been performed at different parts of that tube. CYNANCHE MALIGNA. MALIGNANT SORE THROAT. This disease has, at times, made frightful ravages among children in different parts of Europe ; and from the number of records of its history which we have received, there is no want of information relative to its symptoms, progress, and the supposed nature of the morbid changes occurring in this variety of inflammation of the tonsils and fauces. From the earliest ages in which there exists any account of medical writings, it appears to have been described in some form or other. Aretaeus speaks of it; and the ulceration of the tonsils is clearly recorded by him, corresponding remarkably with the modern account of the affection.t Since the commencement of the seventeenth century, its prevalence in the southern countries of Europe, and islands of the Mediterranean, has enabled numerous authors to describe the symptoms, course, and ravages of the epidemic. During the following century, its extensive prev- • ft Querci, 3ij. (59) Aluminis, I s3 - Aqua? Fervent, oj. F. Gargarisma. .ft Tinct. Myrrhae, 3ij. (60) Acid. Sulph. Dilut., 3j. Alumninis, gr. x. Decoc. Hordei, oj. Ft Garg. tAretaeus, de Caus. et Sig. Acut. Morb., Lib. ii. 168 DISEASES OF CHILDREN. alence throughout Europe has caused a number of accounts to be published, and many excellent essays now exist on this subject. Although not so severe, it has appeared as an epidemic in this country, and the first mention of it is in the early part of the last century. The peculiar product of the inflammation, the pseudo-membranous formation which is poured out on the surface of the inflamed mucous membrane, has of late received much attention in France; and the description of it, principally by Bretonneau, has probably been taken from the milder form of the affection; for the term he applies to it, diphtheritis ( Atydtoa, membrana), signifies an inflammation, attended with an exudation of a membranous substance, which is represented as its only peculiarity, but which, in strictness, can not always be so regarded. In some instances the pellicle may be peeled off, leaving the mucous membrane beneath, red, and free from any ulceration; but in the greatest number of instances it is found covered with an ash-colored slough,' or studded with patches of gangrene,* corresponding with the malignant sore throat of earlier writers. This affection, known also by the names of angine coenneuse,t angina pseudo-membranacea, etc., ought to be considered identical with cynanche maligna.f Etiology.—Cynanche maligna, or ulcerated sore throat, is most prevalent in spring and autumn ; and it has been thought that a damp atmosphere, or a low marshy situation, is necessary to its production ; but such has not always been found to be the case ; for in an epidemic in France it prevailed during a remarkably dry season, and the marshy districts were even more free from the disease than more elevated situations. It usually prevails as an epidemic. Sporadic cases of it also occur, but-are in general of much less violence than when raging among a community in a town or village. It is said that it appears simultaneously among several individuals exposed to the same influence, while other members, similarly exposed, have escaped entirely, and other persons having intercourse with them have' not been affected, whence it has beeninferred that it is not contagious. On the other hand, those who have been careful observers of the disease, and who have had abundant opportunities of remarking its nature and progress, strongly maintain its contagious character. M. Trousseau asserts, that one individual affected with it may introduce it into a community, and cause its spread through several individuals in every variety of its forms. Several instances of its * Evanson and Maunsell, p. 130. t Guersent., Diet, de Med. t V. An excellent Monograph, by Professor Geddings, of Charleston, South Carolina, on Pseudo-Membranous Inflammation of the Throat. Amer. Journ. Med. Sciences, May, 1839. DIGESTIVE SYSTEM. 169 contagious character are given by this writer,* as well as by Guersent,t Bretonneau, and others. Like most diseases of like nature, it may become communicable under peculiar circumstances, as in a state of atmosphere resulting from crowded habitations, want of cleanliness, insufficient ventilation, and other causes which may render it vitiated. These circumstances may reconcile the conflicting opinions on this subject. Those most liable to an attack of this affection are children ; and when they are crowded in close habitations, and especially when suffering from poverty afro filth, are very violently and fatally affected. Yet it not unfrequently happens that numbers are attacked with it who enjoy every comfort and luxury of life. # Semeiology.—This disease is very insidious in its A little chilliness, languor, stiffness of the throat, are all the symptoms which precede an attack. In some instances, indeed, the child manifests no distress nor uneasiness, and, when old enough to describe his feelings, expresses no inconvenience, except a slight burning in the throat. If the fauces be examined, even at the earliest period of the disease, they will be found of a deep red, covered either partially or generally with transparent mucus. This mucus gradually increases in quantity and consistency until it has the appearance of a concrete covering, or plastering, of a grayish color, inclining to yellow. This may often be peeled off, leaving minute bloody points on the mucous membrane, which, in the milder form of the disease, is not much swollen. The pellicle at first, in detached portions, soon becomes confluent, and the whole of the fauces and mouth become lined with this thick exudation. The color of this pseudo-membrane is at first grayish, it then becomes brown, and afterward black. The mucous membrane beneath, when it is exposed to inspection, is now found to be of a dark red, soft, and is easily made to bleed. At this stage of the affection, the cellular membrane participates in the disease, or in the irritation arising from it, and the neck and adjacent parts become swelled. Sometimes the inflammation and its effects spread to the larynx, giving rise to the secondary form of croup. As the disease advances, or in those cases which, from the commencement, are more than usually severe, the tonsils and fauces become more swelled, and the exudation assumes a dark ash or brown color, which being thrown off in shreds, leaves the parts beneath in a sloughing condition. The sloughs rapidly extend into* the substance of the tonsils and. surrounding parts, while a darkcolored sanies is discharged from the nose ; and vesicles, which become gangrenous, appear on the inner surface of the cheeks and * Diet, de Med., Art. Diphtherite. t Ibid., Art. Angine Membr. 22 170 DISEASES OF CHILDREN. tongue. The mouth is dry, dark-colored, and finally black ; the gums become soft, and partake of the general disposition to slough. The tongue at first is red at its edges, and white on the surface; afterward it becomes brown or black, and dry, while small ulcerations appear on its sides. Nausea and tenderness in the epigastrium indicate the existence of gastritis in severe cases, and diarrhoea not unfrequently occurs under such circumstances. W At the commencement of the disease, the febrile symptoms are oflfen considerable, but they abate in intensity as the disease advances. The pulse becomes irregular and frequent, and a general prostration of the powers of life ensues, and the patient perishes from hemorrhage, induced by the extensive separation of the eschars, or from the exhaustion caused by the diarrhoea, which so often attends a violent attack of the disease. It has been confounded by many writers with scarlatina. Fothergill, Cullen, Withering, Morton, Bard, and others, regard the eruption of scarlatina as a pathognomonic symptom of the disease, considering the two as identical. The scarlet eruption, however, is not necessary to the characters of malignant sore throat, as the latter often occurs without the other, and is truly an idiopathic affection : an inflammation which derives a peculiar character from some local or epidemic cause. I have very recently seen a rapidly fatal case of sporadic malignant sore throat, without any of the usual marks which characterize scarlatina, and without being able to discover any case of the latter disease in the vicinity. The prognosis is generally unfavorable when there appears much tendency to sloughing, accompanied with great prostration of strength, or any local congestion of an important organ. If the disease has continued mild for the first week, a favorable termination may be expected. If there should arise any laryngeal or gastric inflammation, the complication gives an unfavorable prognosis. Pathology.—Bretonneau regards the membrane, formed in the disease he denominates diphtheritis, as the result of specific inflammation ; but in what it consists, he finds it difficult to say. There is doubtless an influence produced, by the operation of the epidemic causes affecting the nervous energy, by which a peculiar character is imparted to the inflammation. Naumann was of opinion that a change was wrought in the properties of the blood, by which its albumen could not be retained in solution, and it exuded on the inflamed surface.* It is a curious coincidence, also, that in this disease, according to the experiments of Donne, the secretions are highly acid ; and Raspail's views are, that fibrine is only coagulated albumen from the effect of acid. The loss of the power of interstitial growth, and the derangement of the secretory function of the * Handbuck der Med. Klinik, bande iv., p. 81. DIGESTIVE SYSTEM. 171 diseased part, and the changes wrought in the secreted matters, which give evidence of the great tendency to gangrene, show the effect of the epidemic influence on the ganglionic nerves, by which their energy is impaired, and their controlling power over the secretion of a diseased part in a measure lost. Treatment. —A great difference of opinion has existed as to the treatment of this disease, attributable to the different appearances the disease has assumed in the various epidemics; accordingly, where the epidemic has been marked with the predominance of inflammatory action at the commencement, bleeding has been resorted to from necessity, and the remedy considered as one of the greatest importance in the management of the disease. In individuals, too, of robust frame, in whom the invasion was attended with a vigorous action of the sanguineous system,, and the usual attendants, heat and tenseness of the pulse, such cases of abstraction of blood would be the remedy most naturally suggested. Even, therefore, in the same epidemic, a difference of treatment might have been found necessary; and the opposite views of Gendron,* recommending bleeding, and those of Bretonneau, disapproving of it, may thus be reconciled. In the early stage of the disease, especially in vigorous children of sanguineous temperament, bleeding should be practised with the lancet, together with leeches to the throat; in attacks characterized with less disturbance of the general system, and less violence of the local inflammation, blood-letting may be limited to the application of leeches to the throat. Where there exists, however, much depression of vitality, with a cool skin and feeble pulse, even at the commencement, blood-letting, in every form, should be avoided, for even the leech-bites will slough under circumstances like these. One of the most important remedies, where there is no gastroenteritis, is an emetic, not only for the purpose of removing the membranous formation and sloughs from the throat, but also from its general revulsive effect. Sulphate of zinc is one of the best that can be used. It may either be given alone, in doses of two or three grains in two ounces of water, by spoonfuls every ten minutes, or in combination with ipecacuanha.t Mild aperients will be all that will be required throughout the whole of the disease, where the condition of the bowels demands the interference of art to keep them in a soluble condition. All * Note sur l'Angine couen., etc., Jour. Complimen. des Soc, Med., t. xxx., p. 269; Paris, 1828. f R Sulphat. Zinci., gr. v. (61) Pulv., Ipecac, gr. xxv. M. Divid. in pulv. No. v. One every fifteen minutes. 172 DISEASES OF CHILDREN. other kinds of cathartic medicines should be avoided, on account of the great tendency to diarrhoea.* Calomel, as a cathartic, has been strongly recommended by Dr. Jacob Ogden, formerly of Jamaica, L. I.,t Dr. Bayley,} and others. Bretonneau has also used it with advantage; he says it net only cleansed the throat, but produced a general subsistence of all the unfavorable symptoms. On the other hand, respectable and experienced practitioners|| have not found any advantage in the use of it. It is not only admissible in the earliest stage of the disease, and in plethoric and vigorous individuals, and where the disease has at the commencement extended to the larynx, producing symptoms which indicate the existence of croup, but throughout the entire disease. External stimulating applications are undoubtedly useful to produce a revulsion to the surface. Any of the ordinary rubefacient liniments may be used for this purpose ;§ but blisters should, under ordinary circumstances of gangrenous sore throat, never be used to the part, from the great tendency of all sores to slough ; they are only admissible when there is much swelling of the throat, and after the violence of the inflammatory action has in a measure been subdued. Those who have had experience in the epidemics that have prevailed in Europe, recommend them, under the circumstances just mentioned, to be applied to the nape of the neck. A tepid bath, at the commencement of the disease, will greatly tend to restore the equilibrium to the circulation ; and the constant sponging of the body with tepid vinegar and water, while a febrile heat continues, will be found both refreshing to the patient, and tend much to the diversion of the disease, by constantly exciting the action of the cutaneous follicles. Warm sinapised pediluvia may also be repeatedly used with advantage. To allay the febrile action, the effervescing mixture of supercarbonate of soda, or potass, may be employed ;*"J the latter is peculiarly soothing to an irritated stomach, and may with safety be used, when there exists much gastric irritation. Where there is gastric inflammation, cold, * ft 01. Olivae, 3ss. (62) Pulv. Acacias, q, s. ut fiat, cum Aq. Foeniculi, emulsio, cui adde, Mannae, Syrupi, ?ss. M. A dessert spoonful every hour, t V. Dr. Ogden's Letters to Mr. Hugh Gaine, " On the Malignant Sore Throat Distemper," dated 1769-1774. Republished in Med. Repos., vol. v. } N. Y. Med. Repos., 2 Hex., vol. i., p. 331. —3 Hex., vol. ii., p. 345. || V. Roche, Art. Angine couenneu.se, Diet, de Med. § ft Aquae Ammoniac, (63) 01. Olivar., aa. Tinct. Camphorae, ?ss. 01. Terebinth., 3ij. M. ft. Linim. ft Potassas Bicarb., 3j. (64) Aquae, M. A dessert spoonful every two hours, mixed with Succ. Limon., 3j. DIGESTIVE SYSTEM. 173 iced drinks are much craved by the patient, and will be found highly serviceable. This method of treatment is, of course, applicable only to those cases which possess more or less of an inflammatory action. When, however, the skin becomes cool, the pulse feeble, the inflammation of the fauces disappearing, and the part assumes a dark, gangrenous appearance, it will be necessary to resort to such measures as will restore energy to the system;* as ammonia, camphor, wine whey, snake-root in infusion,f mineral acids, f etc. This course of treatment must only be adopted when there is a decided sinking of the system, and the disease has assumed , the gangrenous form. And when it is necessary to adopt a more tonic course, sulphate of quinine, enemata of infusion of bark and camphor,|| may be required ; the latter especially, where there still exists much gastric irritation. When it is thought advisable to §\ve it by the mouth, in severe forms of the disease, with great loss of vitality, it may be administered according to the annexed formula. As a powerful and efficient stimulant, a mixture of capsicum and salt has been used with great benefit.^ To cleanse the throat, and stimulate the ulcerated surface to a new action, stimulating and detergent gargles have been long in use «"[ When, however, sloughing has actually taken # place, cauterizing the affected part becomes indispensable; and the best method of effecting this is by means of a pencil of lunar caustic, or the powder applied to the part with a pledget of lint, covered with some glutinous substance, to which the nitrate of silver will adhere; or a pledget on the extremity of a probe may be saturated with a solution, composed of twenty grains of nitrate of silver to an ounce of water, with which the part should be touched two or three times a day. Muriatic acid has also been used for the same purpose.** • ft Ammonia; Carb., gr. viij. (65) Mist. Acacia;, Syrup. Simpl., ua. 3 SS - Aquae, 3iv- M. A teaspoonful every two hours. f ft Rad. Serpent., 3iss.—3iij. (66) Inf. in s. q. Aq. per \ hr. Colatur., ?iv. refrig. Adde, Syrup. Aurant., M. A tablespoonful every hour. } ft Acid. Sulph. dil., 3ss.—3j. (67) Aquas, iv. Syrupi, 3j. M. A tablespoonful three or four times a day. || ft Cort. Cinch, 3ij. (68) Aquee, 3»j» Aq. Camphor, 3ss. M. ft. enema. § ft Capsici, 3iij- (69) SodaeMur., 3ij. , Aquas Fervent., deinde Adde, Aceti, M. A teaspoonful every hour. ff ft Herbiae Salvia?, (70) Inf. Aqua; Fervid, q. s. Colatur, Acid. Hydrochloric!, 3> ss - Syrup, M. m •• Guimier. Mem. sur un Epidem. d'Angine Malig., &c, Journ. Gen. de Med.; Paris, 1828.—Guersent, art. Ang. Gang., Diet, de Med. 174 DISEASES OF CHILDREN. Nitrate of silver is decidedly the best for general use, as but little irritation is left after the formation of the eschar by its use. Alum, chloride of soda, sulphate of copper, sulphate of zinc,* have each in their turn been found of great efficacy as escharotics or stimulants, according to the strength in which they are employed. Guersent and Bretonneau speak very highly of alum; and Guersent has used chloride of soda, or the borate of soda, with decided advantage. Dr. Geddings suggests the use of creosote, properly diluted, as an escharotic. He also mentions that tincture of cantharides, either pure or diluted with one half or two thirds of water, has been used by him, injected into the throat by means of a syringe, when the patient is unable to swallow. PAROTITIS. MUMPS. As an appendage to the digestive system, the inflammation affecting the parotid gland in children next comes under consideration. The mumps is a disease which few children escape, and having once been affected with it, rarely, if ever, have a second attack. It is for the most part a trifling affection, scarcely ever demanding much interference. Etiology.—Inflammation of the parotid gland may be produced by the causes which usually develop inflammatory affections; such as exposure to cold, wet feet, or damp bed-clothes, in those who are predisposed by a sanguineous temperament to inflammatory diseases. Besides arising sporadically, it may also prevail as an epidemic, when it is manifestly contagious, spreading through a family when once introduced, few if any of those who have not before been affected escaping its influence. Semeiology.—The disease first appears as a swelling, either on one or both sides, in the vicinity of the ear. When it first shows itself it is evidently confined to the parotid gland, as it is moveable. The cellular tissue is then involved, and a large swelling occupies the region around the angle of the jaw and cheek. When severe, it extends sometimes to the maxillary glands, causing a good deal of uneasiness, but scarcely ever producing severe pain. It usually passes through its stage of increase in four days; after that period it gradually declines. In the greatest number of instances it is a very mild disease, attended with but few marks of inflammation of the part, other than tumefaction, with no attendant fever. At other times, especially * ft Zinci. Sulph., 3j. (71) Infus. Salvia?., 3ij- Mellis Rosa?, |j. M. ft. Linctus. DIGESTIVE SYSTEM. 175 when the neighboring glands are involved, its symptoms are more violent, inflammation is more severe, the fever is high, with a great determination to the brain, as appears from delirium and other cerebral affections, which, it is said by Dr. Cullen, have proved fatal. This latter symptom, it has been remarked, is more likely to occur, where the disease passes through its course without exhibiting the peculiar sympathetic affection of a transfer of inflammation to the testes, or mammas; a symptom very commonly occurring when it is first on its wane. Although, in the greatest number of instances, the local inflammation is but light, yet it has at times been so severe as to terminate in suppuration of the parotid, tonsils, and neighboring parts, or even in scirrhus; the latter, however, is rare in young subjects, as is also the occasional termination in chronic and malignant diseases of the part, which have been observed in old persons. Treatment.—It is in most cases so slight as scarcely to require any other treatment than a gentle cathartic, pediluyium, and the application of some stimulating liniment to the skin of the affected part. This, with abstinence, will usually abate the inflammation, and facilitate the natural tendency of the disease to resolution. When the local inflammation is severe, and the accompanying fever violent, with a determination to the brain, venesection must be resorted to, with active cathartics and diaphoretics ; and when the violence of the constitutional symptoms has been in some degree subdued, a blister should be applied behind the ear. The local abstraction of blood, by means of leeches, should never be omitted when the symptoms of inflammation are violent; and even when there exists no febrile action, they ought to be used, if the violence of the local inflammation threatens the formation of an abscess. After these, a fomentation of hops will be found useful in allaying the local nervous excitement, which often greatly influences inflammatory action. Where the termination of the inflammation is evidently tending to an abscess, notwithstanding the measures adopted for subduing it, the secretion of pus must be promoted, by the application of soft poultices of bread and milk, or slippery elm. On the disappearance of the disease, the bowels should be kept free, to prevent the translation of the disease to other organs ; this, however, need not be feared, where proper measures are employed in the course of the affection. OESOPHAGITIS. INFLAMMATION OF THE OESOPHAGUS. CEsophagitis is a disease of much greater frequency in young infants than is generally supposed. It occurs more frequently in them than in adults, and is probably often the cause of vomiting. In- 176 DISEASES OF CHILDREN. deed, it isin r the latter of rare occurrence, and is caused by the in troduction of some irritating or corroding poison; but in the infant it is a disease peculiar to the period of life, arising from the natural congenital predisposition of the part to inflammatory action. It is an affection often overlooked or confounded with some other disease. Etiology.—The congenital congestion of the oesophageal canal in newborn infants, as appears from modern dissections, is one of the predisposing causes of this affection, and is on this account, as was before observed, of much greater frequency than in adults. The exciting causes are principally the high temperature of drinks or food which the child takes. It not unfrequently arises from heated milk, panada, or other food, which is given to an infant artificially nourished; and it is easily conceived how this organ, predisposed by sanguineous congestion, may become by these means seriously inflamed. Semeiology.—One of the most prominent symptoms of oesophagitis in infants, is the vomiting of the milk immediately on swallowing. From the pain arising on swallowing the child refuses the breast, and becomes rapidly emaciated for want of nourishment. Not unfrequently other matters which come from the stomach are vomited, beside the milk which the child takes : when this is the case, there is probably an extension of the inflammation toward the stomach. The cause of the incessant vomiting in oesophagitis is doubtless owing to the contractions arising from the stimulation of the part by food. It is not an easy matter to distinguish this affection from diseases of the stomach, for the symptoms are few in number, and are generally similar to those which characterize inflammations of the gastric organ, such as refusal of the breast, vomiting after deglutition, and emaciation. Yet it may be suspected, if the vomiting occur immediately after an attempt at deglutition, and that the substances vomited exhibit no alteration; the milk given, shows no change in its character, such as is usual to find after it has been submitted to the action of the gastric secretion. Another method of detecting the existence of this disease, is the pain produced upon pressing along the track of the oesophagus, by which the cries of the child may be excited; this is indeed the only way we have of ascertaining the existence of pain, for children at the age at which they are usually the subjects of this affection, are unable to indicate its presence in any other way. In the case of stomatitis extending toward the fauces, we may have every reason for believing that the progress of the inflammation on the continuous membrane may not be arrested before it reach the oesophagus; and in the different varieties of this affection, the oesophagus may also become affected, and its existence DIGESTIVE SYSTEM. 177 should be suspected when vomiting supervenes on the other symptoms. Morbid Anatomy.—The anatomical characters of this disease do not differ materially from those of stomatitis. The habitual congestion of the oesophagus in newborn children, might sometimes lead to an error in supposing this canal to be inflamed, when it is really not in that pathological condition. When oesophagitis exists, there is almost always present some lesion by which the disease will be sufficiently identified, such as a destruction of the epithelium, ulcerations, and a peculiar carmine hue of the whole tract. The surface of the mucous membrane is sometimes found covered with the concrete exudation found in stomatitis. The pharynx is usually much injected; the glottis infiltrated and red. Besides the separation of the epithelium, often in large shreds, several red, and sometimes black striae exist, where the epithelium is not destroyed. Extensive ulcerations, also, have been found after a violent case of oesophagitis, characterized during life by the lancet, and to administer a purgative. These means, joined to the use of a light diet, consisting principally of well-boiled farinaceous substances and milk, will often restore the secretion, and impart to it the proper consistency. Where, on the contrary - , there exists a general debility of the system, without any organic affection, a stimulating diet may be necessary. This, however, is seldom the case ; a too great eagerness for over feeding is the usual fault with nurses, and there is scarcely a necessity on the part of the medical attendant for prescribing this course. In the treatment of indigestion from weaning, Dr. Cheyne relied * Cheyne, Op. Cit., p. 22, et. seq. 24 186 DISEASES OF CHILDREN. mainly on small doses of calomel, half a grain night and morning, preventing its too powerful operation on the bowels by enemata of laudanum. One of the most common attendants on indigestion is vomiting, accompanied in most cases by acidity of the stomach, flatulency, pain, and sometimes diarrhoea. When obstinate vomiting arises from the bad quality of the milk, occurring immediately on the child's sucking, nothing but an improvement of the milk, or some permanent change, either by the employment of another nurse, or the adoption of another kind of food, will be necessary. As was before remarked, the protracted lactation and the disorder of the system, from the action of the uterus, arising either from the return of the menses or pregnancy, will produce an alteration in the quality of the milk. It has been remarked that nurses who are subject to nervous affections, secrete milk having the appearance of the white of an egg. Although acid is generally present in the matter vomited by young infants, yet there are instances in which this appears to be unconnected with the vomiting; but an irritated state of the stomach is the only cause to which it can be assigned. In such cases, ipecacuanha and rhubarb will be found a valuable prescription.* Dr. Eberle recommends small doses of calomel and ipecacuanha to allay gastric in conjunction with a stimulating poultice or plaster to the epigastrium. This may be made with mustard in flour, mixed with rye meal or wheat flour, and is one of the most efficient counter-irritants. The effect of the application of mustard should be carefully watched, for very severe cutaneous inflammation may be the result of allowing the mustard to remain on too long ; blistering and sphacelation have also sometimes followed a careless application of sinapisms. From fifteen to twenty minutes is the proper time for the mustard poultice to remain on; and, in children of great irritability, a piece of fine gauze ought to be interposed. Where it is not deemed necessary to produce a speedy impression by the use of these stimulating poultices, an ordinary poultice may be mixed with a small quantity of the powdered mustard, in the proportion of about four ounces of the former to a drachm or two of the latter; or flannels may be dipped in a weak infusion of mustard, and applied over the stomach. Should there be much inflammation or pain following the application of mustard, a little fresh cream or mucilage of slippery elm may be applied to allay their violence. One of the best means of treating this affection, in addi • R Pulv. Ipecac, gr. j. (72) Pulv. Rhei., gr. xij. M. Divid. in Pulv. No. iv. One three times a day. t R Hydr. Subm., gr. iss. (73) Pulv. Ipecac, gr. j. M. Divid. in Pulv. No. vi. One every hour or two. CIRCULATORY SYSTEM. 187 tion to the means already mentioned, is by producing a revulsion on the lower portion of the intestines, by means of stimulating enemata ; half a teaspoonful of salt, in a gill of warm water, is an excellent one for this purpose. Dr. Eberle speaks highly of the use of morphia, applied externally, by means of simple cerate ; one or two grains of the former, mixed with a plaster of the latter, wfll often have a sufficient narcotic influence to allay this morbid vomiting, arising from an inordinate irritability in the mucous membrane of the stomach. Vomiting may also occur when there exists a deficiency of acid in the stomach. It is well known that there is always present, during healthy digestion, a quantity of free acid, which, according to the experiments of Beaumont and Lauret, is the hydro-chloric. From the uniformity of its existence, and from the suspension of the process of digestion, by the neutralization of this acid, it would appear to be necessary to healthy digestion. When there exists a deficiency of acid, it may be known by the milk remaining a long time in the stomach before it is vomited ; the child in the mean time exhibiting every sign of nausea, and discharging the milk in an unchanged condition. A few drops of hydro-chloric acid, in a little water, will be found a very efficient remedy, as it supplies the deficiency of the natural acid; and in cases where the experiment has been tried in adults, the restoration of the process of digestion, which has been arrested by neutralizing the acid, was quickly affected by administering it. Lemonade is also an excellent prescription in such cases. Madeira wine, either diluted, or in the form of whey, will also be found to be highly beneficial, especially where there is any debility or depression of the system. Often the matters ejected will possess a decided acid odor, and the child will not be relieved by the vomiting, but continue pale and distressed. When these symptoms are present, there is probably some caseous matter still remaining in the stomach, and a gentle emetic of ipecacuanha will be necessary to remove it. Very distressing symptoms often arise from this cheesy matter remaining undigested. The emetic should be followed by a small dose of calomel, when there is evidence of a derangement of the biliary secretion or the hydrargyrum cum creta, which may, in cases of great irritability of the bowels, and tendency to diarrhoea, be combined with Dover's powder. Vomiting, occurring in those children who have been either overfed, or who have been fed with improper food, is generally attended with a quantity of acid. Under these circumstances it will be necessary to change the food, and where the child is weaned, to mix some prepared arrow-root or barley with almost any kind of weak broth. Barley water, in which gum arabic is dissolved, or milk 188 DISEASES OF CHILDREN. diluted with rice water, and combined with a small quantity ol chicken water, or other weak solution of animal substances, will arrest the tendency to acidity arising in those children who are fed principally on milk or farinaceous substances. Lime water, mixed with an equal quantity of milk, a teaspoonful of wmch to be given every half hour, I have found to be the best to allay inordinate vomiting, arising from the existence of acidity in the stomach. Where there exists costiveness, magnesia is the most proper antacid that can be administered, and especially when combined with super-carbonate of soda.* After the contents of the bowels have been removed, the irritability of the stomach may be calmed by a little tincture of opium or tincture of cainphor.t In the indigestion of children there not unfrequently exists a severe purging, which it will be necessary to arrest; and this should be done by astringent and anodyne remedies, if the composing mixture just mentioned for an irritable stomach should fail in effecting it.} An anodyne enema may first be tried, made with two or four drops of the tincture of opium in two ounces of prepared starch, or infusion of flaxseed. External stimulation of the abdomen is a very valuable auxiliary to the treatment, effected either by simple friction with the hand, or by means of heated flannel or warm spirits; if the latter be used, care should be taken, by sufficiently covering the part, to prevent evaporation, otherwise the object would be defeated, and cold applied instead of heat. For the relief of a paroxysm of colic, in addition to the general principles detailed for the treatment of indigestion, on which it depends, it will be necessary more especially to resort to the use of those remedies which will remove the more immediate cause of the affection; such as small and repeated doses of magnesia, should acidity be evidently, as it in most cases is, connected with it. And where it appears to be dependant on debility in the organs of digestion, a mild stimulant will often be found the best remedy for its relief, as an infusion of catnip, fennel, or aniseseed. These may advantageously be combined with an antacid. Dr. Eberle advises twenty grains of bi-carbonate of soda, dissolved in • R Magn. Calc.,gr. x. (74) Sup. C. Sodae, gr. v. Sacchar. Albi, q. s. M. ft. Pulv. No. iv. One to be given every three or four bours. tft Camphone, gr. ss. (75) Mucil. g. Acaciae, |ij. Vini Opii, gt. i.—ij. M. A teaspoonful every hour or two. t ft Aq. Cinnam., ?j. (76) Mist Creta?, ~ss. Tinct. Kino, 3ij. " Opii, gtts. viij. m Syrup. Simpl., Z l J- M» One or two teaspoonfuIs every hours, until the purging be checked. DIGESTIVE SYSTEM. 189 an infusion of valerian root, in the proportion of one ounce to a pint, with a drachm or two of ginger syrup ; a teaspoonful of which may be given several times a day, to an infant from one to three months old; or the annexed formulae may be used.* In violent and sudden attacks of pain, it will be necessary to resort to remedies which will afford more prompt relief; that recommended by Dr. Devvees is one of the most effectual.t An enema of an infusion of catnip or camomile flowers will often give immediate relief to a paroxysm of colic, or a laxative one with tincture of assafaetida. Fomentation of warm water applied to the abdomen, or immersing the feet in warm water, will also be found useful adjuncts to the general treatment. It has been made a serious question with some physicians, whether in case of the inability of the mother to nurse her infant, an artificial course of feeding is not preferable to the employment of a wet nurse. Baldini, in Italy, Betzski, in Russia, Raulin, Desessarts, in France, citing the custom of the Scythians among the ancients, and that of the Russians and Danes among the moderns, have decided in favor of the artificial method.} Armstrong, also, after having for a number of years filled the office of physician to an institution where many infants were received, in London, recommended the nourishing the infant by the spoon. On the other hand, Thouret, Auvity, and others, have maintained that the natural feeding possesses incalculable advantages over the artificial, from a number of experiments made in public hospitals. There can scarcely exist a doubt as to the advantage of a proper wet nurse over the other method, as the nourishment she can afford possesses the closest resemblance to that which should constitute the nourishment of an infant. When it becomes necessary to remove the infant from the mother's breast, care should be taken in the selection of a healthy young woman to take the situation of nurse. The best nurses are those who possess all the evidences of good health. The tongue clean, teeth and gums sound, indicating healthy digestion. The breath free from any unpleasant odor. The surface of her body free from eruptions, and the insensible perspiration inoffen- • ft Magnesia*, gr. iij. (77) Sem. Anisi. Cont., Sem, Fcenic. Cont., aa gr. ij. Croci, gr. j. Sacchar. Alb., gr. vij. One half to be given at once, and the remainder in half an hour. ft Magnes., gr. xv. (78) Pulv. Rhei., 3j. Aquas Fceniculi, Syrup. Rhei., A teaspoonful three or four times a day. f ft Magn. Calcin., 3j. (79) Tinct. Assafcetid., gt. lx. Tinct. Opii., gt. xx. Aquae Font., |j. Dose, twenty drops for a child from two weeks to a month old; ten drops more to be given in half an hour. t Carrault, Guide des Meres, p. 78; Paris, 1828. 190 DISEASES OF CHILDREN. sive. Her breasts smooth, firm, and prominent; the nipples well developed, rosy colored, and easily swelling when excited. The milk should flow easily, be thin, bland, of a bluish teint, and of a sweet taste; and when allowed to remain undisturbed, be covered with considerable cream. It is said that women of a brown complexion generally have an abundance of milk, and of an unusually rich quality ; and that those of a fair complexion have less substantial nourishment, and that it tends much to keep the bowels relaxed, probably from abounding in a greater proportion of salts. Females, when giving suck, should use moderate and regular exercise in the open air, and subsist on light, but generous diet, composed of a proper mixture of animal and vegetable substances, regard being had to their usual manner of living. It may, and often is necessary to excite the flow of milk, by the use of additional fluid nourishment, which may sometimes require to be made slightly stimulating. Dr. Struve recommends the drinking of a glass of cold water every morning. He also gives the following prescription, when a little stimulating drink is necessary in women who have been much exhausted by suckling: Two parts of milk should be made to boil over a slow fire, to which is added one part of well-fermented beer, previously boiled. Sugar may also be added, and the beverage should be taken cold. From the impossibility of obtaining a good nurse for the infant, it will sometimes be necessary to resort to artificial feeding; when such food, the constituents of which bear the greatest resemblance to the maternal milk, must be provided. Milk of all animals is a white, bland fluid, of greater specific gravity than water, consisting of serosity, curd, or caseous matter, and cream —or, to speak more philosophically, of water holding sugar, soluble salts, and some traces of azotic matter in solution — caseum, and fatty matter; the solid parts being about fourteen per cent.- There are, however, different proportions of these elements in different classes of mamiferous animals ; and each kind yields milk, which can be distinguished by its peculiar taste, as well as by the proportion of its constituent parts, on a chemical examination. The milk of the human female contains more whey, or serosity with soluble salts, than that of the cow, goat, or sheep, arid more sugar than that of any other animal. It contains less caseum than the milk of the goat, sheep, cow, and ass; and also less butter than that of the sheep, cow, or goat, but more than the milk of the ass. Human milk is whiter than cow's, and appears to be acid, on the application of the proper tests. Its composition, however, varies remarkably in different individuals. In some, where there 191 DIGESTIVE SYSTEM. is an irregular portion of whey, and but little or no caseum, it yields more or less cream, but never can form butter, even with considerable agitation; in this case, it will not coagulate on the addition of acid. In other cases, substantial cream is formed, and after moderate agitation, yellow butter, of a firm consistence, may be obtained ; this milk is coagulable by acids, and a white solid curd separates from it. The principal constituents of the milk of the five different animals, with that of the human female, which have been submitted to examination, viz , the sheep, goat, cow, ass, and the mare, it appears, generally exhibit very uniform proportions. In the first three, all ruminating animals, the caseous matter and butter predominate, as has been already remarked. The other two, which are herbivorous animals, have their milk very much resembling that of the human female, in the abundance of whey and sugar. Therefore, if it were possible to procure a regular supply of the milk of these animals, it would be decidedly the best substitute we could obtain for the mother's milk; but as this is almost an impossibility, it will be necessary to prepare an artificial substitute from cow's milk, which is always at hand, and so dilute it and combine it, as will make it more closely resemble the natural nourishment of the infant. It should be prepared, by adding at first an equal quantity of rice water, and a little of the purest crystallized sugar. The infant will require no other nourishment than this, which may be altered gradually, so that at the end of the first month to consist of two parts of milk to one of rice water. An infant will scarcely ever require any other nourishment, until about the fifth or sixth month, when thin pap, made by pouring boiling water on stale bread, and combining it with fresh cow's milk, may be given. While the child is still fed with diluted milk alone, especially in the early part of its life, the use of the sucking bottle is decidedly preferable to feeding with the spoon, as the exertion of sucking evidently promotes the salivary secretion ; a very necessary process at all ages. Care should be taken that the vessels be well cleansed by washing them with boiling water, that nothing be allowed to remain which will cause acidity; this should always be done immediately after the child is fed. Although, as a general rule, the young infant will not require anything more than milk diluted until about the time of the appearance of the first teeth, yet there may be, and often there are, circumstances which demand a more nourishing course of diet; and in case the infant does not appear to thrive, or is affected with diarrhoea, or any other symptom dependant on indigestion, it would be well to vary the food, and gradually accustom it to the use of different and more substantial nourishment. The milk may 192 DISEASES OF CHILDREN. be thickened with arrow-root, potato-starch, sago, etc., and its effects carefully watched. With all these substances sugar should be plentifully mixed ; it is the condiment which best agrees with the digestive organs of infants: indeed, it affords a vast degree of nourishment to all animals, at every age, as is evident, during the season for gathering the cane, when both the negroes, oxen, and mules, show the evidences of its nutritious effects on their sysems. As the infant advances in age, it is evident that an alteration in .he consistence of its food is necessary, preparatory to a final discontinuance of nursing ; and the substances just mentioned ought to form a prominent article of food about the time of the appearance of the first teeth. It may also be varied, by giving some light animal infusion, either of beef or chicken, with the fat removed. The different articles of food must be used, and that generally adopted which is found the least disposed to become acid. This is the proper place to speak of the subject of weaning, as one of the means necessary for the treatment of indigestion in infants, where it arises from the impaired quality of the milk, from whatever cause. The age of the milk will also make it necessary to wean the child, even though there should not be decided symp toms of sickness; for it has been remarked by some physicians, that a general debility of the system may arise from the continuancfc of suckling too long, and also that those children whose nursing is protracted are likely to suffer from hydrocephalus. The period for weaning the child depends in some measure on the constitution of the mother, and that of the child. The condition of the milk, as has already been observed, may render it necessary even before the appearance of the teeth, or their tardy appearance may render a protracted suckling necessary; but as a general rule, the child ought not to be kept at the breast beyond a year; it may also, in the majority of instances, be weaned about the ninth or tenth month. A French writer, Baillon, recommends that infants be suckled at least for two years and a half; another, Madame Lerebours, goes still farther, and advises suckling to be continued until the fifth year.* If the child has been gradually accustomed to a change of diet, weaning will not be found to be a process of much difficulty ; and if, after weaning, the food still consist principally of milk, thickened with arrow-root, ground rice, etc., there will be little to fear from indigestion. Cow's milk, therefore, should invariably constitute * V. Carault, Guide des Meres ; Paris, 1828. On this subject the author remarks, " C'est bien donner prise a la plaisanterie, mais l'auteur est d'un caractere trop respectable pour qu'on so le permette." DIGESTIVE SYSTEM. 193 the chief ingredient in the food of children for some months after their removal from the breast, occasionally giving some simple animal broth. More solid nourishment will be needed when the molar and canine teeth have made their appearance; and food of a greater variety, and containing more nourishment, must be given when the digestive organs have acquired an increase of vigor, and are in a condition to allow of its reception. When a sufficient number of teeth have appeared to enable the child to chew, a moderate quantity of animal food may be used at dinner, with the usual vegetables. The breakfast of children ought generally to consist of milk in some form; and for young children, should be added to a little bread pap. About the fourth year, bread and undiluted milk may be given, and the child's inclination in some degree consulted. For supper, which ought to be taken about an hour before the child is put to bed, the same as is used in the morning. There is often great anxiety on the part of mothers on the subject of insufficient nourishment, which their children obtain from light diet, so often recommended by physicians. There is, however, little danger of children suffering from this cause; indeed, I never saw an instance. On the contrary, numbers have been brought to the grave by too frequent feeding, and the large quantity of food given. The works of Sydenham, Boerhaave and his commentator, Van Swieten, contain several instances of persons who, from necessity adopted a milk diet, and retained their ordinary vigor. " Sufficient nourishment" was afforded to a rheumatic patient of the first named-writer, by a " little bread and a gallon of whey," taken during the day.* Van Swieten quotes Aretaeus' remark, that milk is more suitable to children than any other food ; and that if any one will drink milk enough, he will need no other food. The illustrious Boerhaave himself, it is said, for a long time took scarcely any other nourishment than whey. It is by no means intended, by these remarks, to recommend any one course of food to the exclusion of all others; man is omnivorous, and experience should be the only guide. It is also impossible for the experience of one individual to be the rule by which another is to be directed in his diet. This subject is one on which it is hardly possible to form any theory; for the facts which are familiar to us in relation to it, being liable to be controlled and influenced by a great variety of conditions, everything that may thus influence it should be taken into the consideration in each case that comes under our notice. • Epist. to Dr. Brady, p. 328. 25 194 DISEASES OF CHILDREN. DIARRHOEA. This disease, in some form or other, is extremely frequent among children, both as a functional disorder of the intestinal tube or its appendages, and as a symptom of organic affections. The former class is what we shall at present notice. Several varieties of diarrhoea are considered by authors; but as some of them are clearly symptoms of indigestion—as that form in which the food is passed unchanged, known by the name of lienteric diarrhoea, and that attendant on weaning—those only, which, from the nature of the evacuated matters, evidently arise from the deranged functions of the intestines, or parts connected with them, and not from gastric indigestion, will be considered as belonging to this class of diseases. The nature of the evacuations in diarrhoea are very varying, even in individual instances, both at the same period and during the course of the disease; yet the prevailing character which they exhibit, has caused a classification to be made by practical writers— an arrangement well-founded, and of great use as points of general reference, even in the most complicated cases. There appear to be three varieties of diarrhoea: feculent, serous, and bilious, as the predominating nature of the alvine evacuations indicates. All these may, however, pass into each other, and what at first would appear to possess the distinctive characters of one form', may, by a transfer of irritation, ultimately become of another character; and in all the forms there is more or less mixture of bilious matter, rendering close examination of the alvine discharges necessary to detect the nature of the affection. This inspection of the fecal matter was the subject of much attention in former times ; and Hippocrates appears to have been greatly in the habit of close attention to this subject ;* and physicians of the present day would do well to imitate this practice of the father of medicine. These varieties are placed in the order of their simplicity ; and the first, or the simple form, very naturally first attracts our notice. FECULENT DIARRHCEA. This variety consists altogether of the ordinary feculent contents of the bowels, from an increase of their peristaltic motion. It precedes every other form of diarrhoea ; for the ordinary contents of the bowels must first be evacuated, before the morbid changes in the secretion occur, which are the distinguishing marks of other forms. * Aph. xiv., et scq. DIGESTIVE SYSTEM. 195 Etiology.—One of the most common causes of this disease is the presence of acrid matters of the food, still imperfectly digested, or from irritating substances introduced into the intestines. In one serise it may be considered as the effect of indigestion, and therefore might be regarded as a symptom of that disease ; but the food may in reality be digested, although there may be acid or other irritating matters contained in the mass of the contents of the bowels, from a deficiency in its entire alteration, by which some chemical changes have occurred, rendering them a cause of excitement to the mucous membrane. Cold or wet applied to the surface of the body, constringing the skin, and thus directing the course of the blood to the internal surfaces, already predisposed to excessive action, from their constant natural action in the process of nutrition, will also produce a common diarrhoea in children ; but an inflammatory affection is most commonly the result of this cause, and the disease is more likely to become of a mucous form. The retrocession of eruptive affections is also a frequent cause of diarrhoea, and is often a critical change of the disease with which a child is affected. Indeed, any cause which will produce an increase of the ordinary peristaltic motion of the intestines, will be followed by a diarrhoea, consisting of the ordinary fecal matters. Children, to the age of three years, are frequently attacked with simple diarrhoea. Semeiology.—It is almost always attended with a little nausea and abdominal pain, which disappear immediately on the passage of the feces, to return after a short interval. The evacuations areof the usual fecal appearance, although much more liquid than natural, and therefore it is easily distinguished from other forms of the disease, scarcely containing any of the morbid secretions which characterize them. Pathology.—In this mild form of the disease there exists merely a morbid degree of irritability or sensibility in the mucous membrane of the intestines, by which the fluid secretions are more abundantly formed and mixed with the contents of the bowels. The mucous membrane can not be considered as in a state of disease ; and as this variety itself is never fatal, no opportunity has been afforded to examine the pathological condition of the intestines. Protracted cases of feculent diarrhoea can not exist, without the nature of the affection changing its character, exhibiting either signs of other forms of diarrhoea or of dysentery: and the pathological state arising from the change of the disease, will be indicated by the alteration of the stools—by their color, consistence, and other physical signs. These, together with the results of autopsical investigations, will come under our consideration when the other varieties of diarrhoea are discussed. 196 DISEASES OP CHILDREN. Treatment.—This disease is often removed by the spontaneous evacuation of the offending matter, on which its existence depends ; the morbid action ceasing on the complete discharge of the contents of the bowels. Should the occurrence, however, of diarrhoea be frequent and continued, it will be an evidence that the whole of the irritating substances have not been removed, and the interference of art will be necessary to prevent the occurrence of an inflammatory state of the mucous membrane, by the effectual removal of all the irritating causes of the disease. This should, in every instance, be effected by the most gentle and unirritating means, and such as will neutralize the acid, which in almost every case exists, and which is the principal source of irritation. Calcined magnesia neutralizes the acid of the stomach, without any extrication of gas, and a mild purgative salt is formed by the union ; this may be combined with rhubarb, a medicine peculiarly applicable to this disease, from its tonic influence. As a medicine for children affected with simple diarrhoea, rhubarb is of great value, from its astringent effect after evacuating the bowels. To disguise the taste, cinnamon is the best aromatic that can be selected, and may be used where there is no inflammation in the stomach.* When there are no evidences of acidity in the prima? via?, castor oil,or rhubarb either alone, or combined with a small quantity of calomel, in the proportion of ten grains of the former to one of the latter, for a child of a year old, will be the most proper to remove the contents of the intestines. The officinal preparation of the syrup of rhubarb is also an excellent mode of administering that medicine. The common dose of castor oil for an infant, is from half a drachm to two drachms, combined with a little sugar; a tablespoonful may be given to a child three or four years old. If the stomach should be unusually delicate, the medicine may be made into an emulsion, with some aromatic infusion, by the intervention of mucilage, or the yolk of an egg.t After these have produced their effects, the irritability of the bowels should be calmed with an anodyne, either the tincture of opium or Dover's powder. The latter preparation, otherwise known by the name of the compound powder of ipecacuanha, is a very mild and safe opiate for children, and may be given in doses of a quarter to half a grain during the first three months, and from one to three grains after a • R Magnes., 3ss. (80) Tinct. Rhei, 3j. Aquae Cinam., 3vi. Syrup. Simpl., jj. M. A teaspoonful every hour, to a child of fix months, until the bowels are freely evacuated. tft 01. Ricini, (81) Syrup. Rosae, Vitel. Ovi, un. Aquae Anisi, Dose, two or three teaspoonfuls, to an Infant of six months. DIGESTIVE SYSTEM. 197 year, and from three to six grains at the ages of four to seven. Tincture of opium may be given in the following doses: half a drop for a child under ten days ; a drop for one from that period to the end of the month; a drop and a half or two drops for one from that period to three months; three drops from this time to nine months ; four drops from nine months to eighteen ; five or six drops from that time to three years ; then for every succeeding year a drop or two may be added.* It will seldom be necessary to repeat the laxative medicines after the bowels have been freely moved, for it may then be reasonably supposed that the offending cause has been removed. If, however, the purging should continue, it wiU be an evidence of a considerably excited state of the mucous membrane ; and in addition to the necessary attention to the diet, by the use of mucilages combined with the customary food of the child, and its mixture with an alkali, as mentioned under the article indigestion, it will become the duty of the physician to endeavor to arrest the discharges from the bowels. Indeed, it has been made a question whether any attempt should be made to remove the feculent matters by an aperient, for fear of irritating the mucous membrane. Evanson and Maunsell, also, are of opinion, that when the inftint is very young and the evacuations profuse, we should in all cases try to moderate the discharge from the bowels from the first, and only use aperients when the diarrhoea is recent, and occurs directly in connexion with an overloaded state of the bowels.t This practice is doubtless the best, when we are satisfied that this simple diarrhoea depends on other causes than irritation from acid or acrid contents of the bowels, fitis, however, is rarely the case. Where it does arise from this internal irritation, the experience of the most eminent practitioners, both of former days} and of the present, go in support of the views here advanced ; and that where there is an irritating cause acting on the mucous membrane, the attempt should first be made to remove it, and thus endeavor to allay the irritation of the mucous membrane. If these fail in effecting this object, opiates and other measures must be used to calm the commotion of the bowels. Before having recourse to direct astringents, it will be the better practice to endeavor still to remove the irritating acid matters, by neutralizing them with some fixed alkali, as potass or soda, which also exerts a direct sedative influence on the gastro-intestinal mucous membrane. • Dewees, Op. Cit., p. 363. fOp. Cit., Amer. edit., p. 154. t The following is Harris's opinion, which was the result of much experience:— " Diarrhoea infantum ab orgasmo humorum in intestina delabentium, vel a turgescentia illic bilis cum acido proedominium habente semper profluens, nequae astringentibus proprie dictis, nequte norcoticis est cohibenda." Harris, Op. Cit., p. 30. 198 DISEASES OF CHILDREN. thereby equalizing the inordinate peristaltic motion of the bowels.* Super-carbonate of soda is a very useful adjunct to magnesia, where much acidity prevails, and when large doses of the latter would act too powerfully on the bowels. An excellent form, also, for the administration of super-carbonate of soda to children, is that of lozenges, made with sugar and gum arabic, containing one twentieth of their weight of the alkali. In those cases arising from the application of cold or wet to the surface of the body, the indications are clearly to restore the lost action of the skin, which is generally found harsh and dry. Dover's powder, or small doses of ipecacuanha, are the proper medicines for effecting this object. The subjoined formula will be found peculiarly applicable lo such cases,t especially if assisted with warm bathing and fomentations. If the disease resists the measures already recommended, and there still continues evident acidity of the stomach and bowels, it will then be necessary to have recourse to more powerful measures to arrest the discharges. Chalk, or the friable carbonate of lime, is a powerful antacid, and is a very efficacious medicine in diarrhoea, after the irritating matters have been removed by aperients.} A small quantity of opium may be added where the ca*e is obstinate, and the discharges profuse. Pure argil has of late been much used in diarrhoea, accompanied with acidity, as it forms with the acids an astringent salt. The substance is prepared from the sulphate of ammonia and alumina, by exposing it to a strong, red heat, in a crucible. Argil, in the form of a white pow6$r, remains, possessing great astringent powers. It has been very freely used by the German physicians. Riecke recommends the formulae which are subjoined.|| * ft Soda? Sup. Carb., gr. x. (82) Syrupi Aurantii, Z'lj. Tinct. Opii, gtts. vj. Aqua?, One drachm every two hours, to an infant of twelve months, until relief be obtained. t ft Sodee. Carb. Excic, gr. vi. (83) Pulv. Ipecac, gr. j. " Ipecac. Com., gr. vi. " Sacchar. Alb., 3u- Nitratis polassae, gr. x. M. Divid. in pulv. vi. One every two or three hours. t R Pulv. Acaciae, 3j. (84) Solve in Aq. Fceniculi, ?j. Adde, 9 Cretse, 3ss. Syrup. A teaspoonful every two hours. || R Emuls. Sem. Papav., Ziijss. (85) Argilloe Purse, Syrup. Althajae, M. A teaspoonful to a child two years old, affected with diarrhoea. ft Argil. Pur., 3ss. (86) Gum-Arab., 3j- Sacch. Alb., 3ij. Aq. Foenicul., M. A teaspoonful to a child a year old. DIGESTIVE SYSTEM. 199 A strict attention to the diet of the child is of Sacchar. Com., ~ss. Macerate for four Hours, and strain. Two tablespoonfuls for a child of three years. • ft Inf. Senna;, -ij. (100) Pulp. Prunoe, ziv. " Tamarind., Syrup. Simpl., lbj. 01. Carui., gt. xx. ft. elect. • A teaspoonful for a child three or four years, at bedtime. f ft Fol. Senna?, 3iij. (l()l) Soda? Sulph., 3»j- Manna?, zj. Aqua?, ziv. M. Steep the senna for four hours in boiling water, then add the salts and manna. A tablespoonful of this mixture to be given repeatedly, until an evacuation is produced. 233 DIGESTIVE SY^fTEM. In addition to those of the class of intestinal worms, which is the subject of the present chapter, a vast number of the insect and reptile tribe has been described as existing in various parts of the body, as well as within the intestinal tube. The writings of Schenkius, Marcellus Donatus, Borelli, and others, contain, also, descriptions of various kinds of animals, besides insects, that have been discharged from the body, such as frogs, lizards, serpents, etc. ; while every organ of the body, even the blood-vessels themselves, have been found, by the microscopic philosophers, to be the abode *of numbers of animalculi.* Some of these accounts, written during the sixteenth, and at the commencement of the seventeenth century, are great exaggerations of some simple occurrence, similar to what is seen at the present day; for occasionally there have been voided both larva? and perfect insects, of forms entirely different from intestinal worms, so commonly discharged from the bowels of children, and to which a fruitful imagination has given the appearances above mentioned. Such instances have sometimes been met with ; and Dr. Bateman mentions the discharge, from the anus of a young woman, of several larva? of the Tenebrio molkor, L., or meal worm; and in another instance, of the larva? of the Musca domcstica, or common fly. He also refers to Forestus, as describing a species of caterpillar by vomiting, and of the dejection of several scarabei. Accompanying the paper of Dr. Bateman, are figures of grubs, seen by Dr. Cheyne, which were discharged from the bowels.t It is unnecessary, and entirely foreign to the object of these remarks, to enter into an account of the supposed insect origin Qf various diseases. Measles, small-pox, hydrophobia, syphilis, petechia?, elephantiasis, and numbers of others, have been referred to the presence of insects in the different tissues, as their cause. The morbid effects of marsh malaria have, by some ancient authors, been attributed to myriads of animalculi suspended in the air, and entering the body in the act of inspiration. Such ideas, however, are but the speculations of the imagination; having no foundation in fact, for they are destitute of the least proof adduced for their support. It is only to that class of entozoa, which so commonly infests the intestines, and becomes either the cause of much disease and suffering, or the evidence of a great loss of energy in the digestive system, and thereby needing the interference of art for their removal, that the present remarks are necessarily limited. It is certainly a strangle idea, which was advanced some years * Hist. Naturalis e t Med. Latorum Lumbricorum intra Hominem ct Animalia Nascentium, Auct. D. Le Clerc, 1718. t Account of Larva?, etc., discharged from the Human Bowels, by T. Bateman, M. D.; Ed. Med. and Surg. Journ., vol. vii. 30 234 OF CHILDREN. since by Roederer, and Wagler, in his treatise on the mucous disease, that they are useful for the consumption of superfluous nourishment, and thereby prevent plethora. Dr. Butter, also adopted the same views, and considers them of very little importance in the production of disease in children. He thinks that although .they may exist in disease, they are neither the cause nor a symptom of disordered affection. He regards them as positively useful, by their movements, in promoting the peristaltic motion of the bowels, and thus assisting in the evacuation of the morbid secretions. Dr. Rush, also, from the frequency of their occurrence in all animals, without apparently being accompanied by disease, is disposed to adopt the opinion, that they are in some respects useful, in consuming the superfluous nourishment which all young animals so freely take, and even suggests the idea, that perhaps some children may be disordered for want of them, as they are found, he says, more frequently in stout and vigorous children, than in others. He is of opinion, also, that there exists no such disease as the idiopathic fever, which has by some been attributed to worms; and adopts the views which have been held by the aborigines, that the discharge of worms is to be referred to the fever, and not the existence of fever to the worms. In some cases, however, he admits that they cause anomalous symptoms, which call for the use of anthelmintic remedies in combination with others.* A number of monographs have been written on the subject of intestinal worms, but the best which has appeared on the subject, probably, is the classical production of Rudolphi.t It is unnecessary to consider the five different families, and their various species, which are treated of at large by this author, and by Frank,} as some of them are not intestinal worms, the only species which naturally forms the subject of the present essay. A compendium of the natural history of all these entozoa, will be found in Dunglison's Commentaries on the Diseases of the Stomach and Bowels of Children. The worms that chiefly infest the intestinal canal of children are the following : the Ascaris lumbricoides, Tricocephalus dispar, Oxyuris vcrmicularis, Strongylus gigas, Distoma hepaticum, Taenia solium, Taenia lata. The ascaris lumbricoides, or long round worm, resembles very much the common earth worm, (Lumbricus tercstris, L.) It is found in every part of the intestinal tube, and has even been found in the pancreatic and hepatic ducts, and occasionally in the gall bladder. Sometimes it has been vomited from the stomach, and is * Enquiries, vol. i., p. 203. t Entozoor. sive Vermium. Intest. Histor. Nat. Auctore Carlo Rudolphi; Amster. 1811. $ De Curand. Horn. Morb. Epit., Lib. vi. DIGESTIVE SYSTEM. 235 even seen in the oesophagus and pharynx. Andral mentions the case of a child who was suddenly seized with convulsions while apparently in good health, and died with symptoms of suffocation. On post-mortem examination, one of these worms was found to have ascended from the stomach, and attempted to crawl into the glottis, which caused the spasmodic closure of the orifice and the death of the child. At other times they have been seen entirely in the air-passages, having probably ascended the oesophagus, and found their way into the trachea, and even the bronchia?, before they produce death, A case of this kind is recorded by Haller, of a girl aged ten years, who died from suffocation, caused by two of these animals in the trachea.* M. Blandin also mentions the case of a child that was suffocated by a large Ascaris lumbricoides, which had found its way into the trachea and right bronchia?.? A still more remarkable case is recorded in the Archives Gen. de Med., for January, 1S36, where thirty-seven of these animals were discovered in the trachea and bronchia? of the right side. The patient was suddenly seized on the third day before her death with dyspnoea and general distress, which increased until she died from convulsions. Besides those seen in the air passages, there were thirty-six in the intestines. They have at times existed in immense numbers, and passed off, rolled together in the form of a ball. The color of this worm is generally a pale red, but it occasionally varies from this, according to the color of the fluid in which it happens to have been lodged Its length is usually three or four inches, and it has been found even as long as fifteen inches. The Tricocephalus dispar, or long thread worm, is about an inch and a half to two inches long ; the head is acute ; the body striated on the fore part; the tail about twice the length of the other portion, and terminates in a hair-like point. The color of this animal resembles the preceding, and like it, is also found in the horse, ox, ass, and hog. It usually inhabits the coecum of sickly children, and is rarely in any other part. The Oxyuris vcrmicularis, maw-worm, or thread-worm, has the appearance of the ends of thread. The name maw-worm is not derived from the occasional migration of this worm to the stomach, but from the sympathetic irritation it creates there. It is usually found about the rectum, and is the kind known by the name of ascarides. These are often also seen in masses, rolled up in the form of a ball, completely covered with mucus. They are more prevalent in the spring than at any other season of the year. They do not remain exclusively in the rectum, but occasionally find their way into the external parts of generation of females, and cause a great * Opuscul. Patholog. Lausanne, 1768., p. 26. t Traite d'Anat. Topographic, p. 199. 236 DISEASES OF CHILDREN. itching and leucorrhal discharge. This kind often exists in the intestines of the foetus and newborn children. The Strongylus gigas is a worm of a deep red color, and measures in length from four inches to three feet, and in breadth from two lines to half an inch. It is chiefly found alive in the kidneys, and sometimes, although rarely, in the intestines. The Distoma kepaticum, or fluke, is a flat obovate worm, with a large abdomen. The size of this species is about an inch in length, and from four to six lines in the breadth. Its color is a yellow, greenish, or brown. It is found in the gall-bladder, and occasionally in the intestinal canal. It is very common in all kinds of quadrupeds, fishes, and reptiles. Although discovered in all parts of the intestinal canal, it is more common to meet with it in the liver; and when abundant in that of the sheep, is the fatal disease among them known as the rot. It is not satisfactorily ascertained whether these parasites are the cause or effect of this disease. These worms have been seen in the gall-bladder, vena portarum, ductus choledicus, and parenchyma of the liver, and occasionally in the intestines of children that have been from time to time dissected. The Taenia solium has a broad, depressed, articulated body ; the joints obtuse, anterior short; the next obtuse, and the remaining oblong. The size of this worm is usually a few feet, but occasionally of great length. Robinus found, on dissecting a man that had died, after having discharged fragments of tape-worm, the worm extending through the intestines, from the pylorus to within a few inches of the anus, and measuring about thirty feet. Bremser mentions a case, in which one hundred and fifty feet of tape worm were discharged by stool. Frank speaks of one forty-seven cubits in length. It has even been stated, that they have been discharged six hundred feet long. This, although enormous, is exceeded by that stated in the Copenhagen Transactions,* where a case is given of a tape worm measuring eight hundred ells, or upward of seventeen hundred feet! Such an extreme length is scarcely credible, and must have arisen from some error arising, perhaps, in the measurement, taken probably at different times, when different portions were discharged. The taenia inhabits principally the small intestines, where it is often curled up in a roll, and is felt by the patient as he moves about in bed. At other times it is lengthened out to the whole extent of the intestinal tube. It is occasionally exceedingly distressing, from the continual motion, which has been described as a species of con- • Referred to by Dr. Stokes, Lond. Med. and Surg. Journ., May, 1834. DIGESTIVE SYSTEM. 237 vulsions of the animal. Other worms may exist at the same time with the taenia; and both the Oxyures vermiculares, and Ascarides lumbricoidcs, have been discharged, with a portion of taenia, on the operation of an active vermifuge. The Taenia lata, or broad tape-worm, is characterized by the head and marginal depressions being oblong, without any neck; anterior articulation rugous; the other broader, and almost square; the last one somewhat elongated. It is nearly flat and measures from ten to twenty feet in length; it is of a white color. This species is of very rare occurrence in the human body. Etiology.—The most remarkable predisposing cause of worms is climate; at least so it would appear from the writings of Hasselquist, Linnaeus, Rudolphi, and Roscoe, with reference to the taeniae; the taenia solium being more common in Egypt, Italy, Holland, and England. In Switzerland and Russia, the taenia lata is of more ordinary occurrence than the other species. Neither of these are very often met with in the United States; and tape-worm may be regarded as rather a rare disease in this country. Childhood is the time of life that greatly predisposes the system to worms; accordingly we find them at every r period of childhood. Cloquet mentions, that at the Salpetriere, where none but aged persons are received, there were scarcely any of these parasitic animals found on opening the bodies of the deceased; but at the children's hospital nothing was more common than to find them, and sometimes in great numbers. The Oxyures vermiculares, and Ascarides lumbricoidcs, are those most frequently found in children. The taenia? are rare in children, but occasionally exist in youth. Other predisposing causes are debility of the digestive organs, whether induced by an hereditary condition, or whether acquired by imperfect or insufficient food, or by a damp, cold, or insalubrious residence. They have been compared by Frank to parasitic plants, which thrive best in poor and uncultivated soil, while the vigorous and fertile fields present but few of these dependants on other living plants and shrubs. The origin of worms in animals is as unsettled now as it was in the time of Aristotle; and there is no of medical science, either physiological or pathological, of so much interest, as the presence of worms in the intestinal canal, and the various cavities and tissues of the system. The cause—the origin of their existence—still remains one of the most inscrutable things in nature, and is a subject which has occupied the attention of natural philoso phers in every age. The opinions of those who have made it the subject of investiga-, tion may be classed under two heads; those who believe in sponta- 238 DISEASES OF CHILDREN. neous generation, and those who are of opinion that the ova of these* animals have been introduced into the body. Almost all the writers of the opinion of equivocal generation, and are supported among the moderns by Buffon, Needham, Patrinus, Rudolphi, Bremser, Stokes, and others. It is explained by being a formation analogous to the organization of a portion of lymph thrown out on a serous membrane, which afterward becomes organized, and acquires all the properties of life. When it is separated it becomes an independent animal; the difference being, that in one case the organized mass remains adherent, and in the other is separate, forming a new creature. According to some, intestinal worms are formed from partially assimilated nutriment m the digestive tube; the portion not taken up becoming a living animal. Those who maintain the idea that they spring from without, and' are the product of ordinary generation, are Harvey, Linnaeus, Gadd, Unzer, Tissot, Leeuwenhoeck, Muller, Good, and most of the physiologists of the present day. They have endeavored to show that all these creatures have been found in some situation out of the body, as the Distoma hepaticum in fresh water; the Taenia lata in muddy water, in rivers, and in wells; the Ascarides vermiculares in marshes, and about the roots of trees, etc. Wherever a great difference in their appearance is manifest, it is attributed to the effect of a different situation, and a modified development from this cause. One of the principal difficulties of this theory, is the existence of parasitic animals in the foetus of different animals, which have at times been discovered. The ovum in such cases must be exceedingly small, to have been received by the mother and transmitted through her blood-vessels and placenta to the foetus, and there- developed into the perfect animal. Rudolphi and Blumenbach have given instances in which taeniae have been found in the intestines of newborn lambs and puppies; and Forman has discovered the Distoma hepaticum in the liver of the foetal sheep. Entozoa have also been seen in the intestines of the chick which has just broken the shell. Brendel has seen the taeniae in the human foetus in utero. Hoking describes a foetus in which the intestines contained a number of small worms, and another in which a large Ascaris lumbricoid.es was found in the stomach. To account -for all these different occurrences is certainly a dif ficult subject; but for its explanation we need not resort to the doctrine of equivocal generation. It is not necessary, either, that all the parasites found in animals come from without, and that they exist in ponds or other places, and are first taken into the mouth, either as food or drink ; for some appear to be so uniformly founds in a particular part of the body, that it would seem to be both their 239 DIGESTIVE SYSTEM. proper nidus and habitation, like other parasitic animals, as the larvae of certain insects, which find their food and habitation only on one kind of plant. Cuvier observes, that "the entozoa are remarkable, because a greater number inhabit the interior of other animals, and there can only propagate. There is scarcely a single animal that is not the domicil of several kinds, and those which are observed in one species, are rarely found in many others." These parasites have no trachea, nor any other organ of respiration ; they therefore do not receive oxygen, except through the medium of the animal in which they live; another strong presumptive proof that their proper habitation is in the animal they inhabit. it can be no objection to this theory, that the ova have to travel through the entire system, and be deposited in some tissue or cavity, in which the animal is found, even in the foetus; for the probability is, that the ova are so extremely small, that they may be easily carried through the circulation, and then deposited in some of the cavities. That such may be the case, would appear to be not improbable from analogy. We know that the atmosphere is loaded with myriads of the eggs of the insect tribe, unknown to us until some circumstance occurs which arrests them in their flight, and furnishes them with a proper nidus for their development. Whatever difficulties there may appear to be in the manner in which these parasitical animals are brought to inhabit the different parts of the animal frame, it is certainly a great assumption to suppose them to exist there by spontaneous generation. Although the multiplication of some of the lower animals by sections, proves that there are other ways of reproduction than by eggs, yet there is nothing in this to prove that any animal can be produced by a spontaneous formative movement; while the existence of different sexes for reproduction, shows their mode of propagation to be like that of other animals. And it is clearly unphilosophical to suppose them to be the result of a spontaneous organization, either of lymph, or of an excess of nutriment in the bowels; which organization, at the same time, also provides them with the organs for a continuance of their respective kinds. Morbid Anatomy and Pathology.—This is a subject of great importance in the treatment, or rather in the prevention, of worms; for if the positive condition of the mucous membrane of the intestinal tube, on which the existence of these animals depends, could be ascertained, there would be little difficulty in the treatment. Unfortunately, however, it is but little understood in the present state of science, for worms have been discovered in every condition in which the intestinal tube has been found, and even when in a state of health. It is the opinion of Broussais, that they are the effect of a gas- 240 DISEASES OF CHILDREN. tro-enteritis; while Andral states that they have been found in every condition of the intestine, and usually lying in a quantity of mucus, and the little redness which has been noticed around them is rather the effect than the cause of worms. They have been seen in animals of great variety that have presented the appearance of perfect health, and, therefore, it would seem that their existence is independent of any pathological condition other than a modification of vital energy, and therefore not traceable by ordinary dissection. As for the opinion of Broussais, and the practical consequences which result from it, all experience proves its incorrectness : for the most powerful means of relief of some of the serious symptoms of worms, are of a nature which would necessarily aggravate all the gastro-intestinal inflammation. Indeed, he deprecates the use of anthelmintics in the treatment of worms, on account of their stimulating effects on the mucous membrane of the intestinal tube. Semeiology.—It is extremely difficult to ascertain, by any symptoms, the positive existence of worms. Irritation in the stomach and intestines produces so many symptoms in remote parts, from the extensive sympathy of all parts of the body, that it is sometimes even difficult to trace the connexion to the intestinal or gastric mucous membrane ; and when it is evidently seated in the mucous membrane of the intestinal tube, it is no less difficult to ascertain with certainty its cause, all irritations in this part producing symptoms analogous to those of worms. The face is usually tumid and pale; the inferior eyelids of a livid hue; the nostrils itch, with.occasional bleeding from the nose. The breath is very offensive, or of an acid odor, and the gums are covered with sordes. The upper lip is usually much swelled; sometimes there is a difficulty in the speech, and even a loss of voice. The eyes are fixed and staring, and at times affected with strabismus; the pupils are often dilated. At times there is pain in the head, and severe convulsions, vertigo, or delirium, sometimes follow a turgid state of the brain. To these symptoms there is added a stubbornness of disposition, or a listlessness, with occasional fits of terror. When asleep, the child appears to be affected with terrific dreams, and awakes in great alarm. The respiratory organs are also sympathetically affected, for the breathing is hurried, and at times difficult. There is also a dry, tickling cough, and sometimes of a convulsive character; pains also affect the chest, bearing a great resemblance to pleurisy. Stethoscopic examination will detect the sympathetic character of the pulmonary affection, and thereby enable us to form a diagnosis of the disease. All these symptoms may be regarded as symptomatic. The semeiology of the abdominal organs is of more importance, in a diagnosis of the disease, than any of those above mentioned 241 DIGESTIVE SYSTEM. 31 which, although occurring in some form or other, are, it must be admitted, often fallacious. The appetite is variable, the hunger sometimes insatiable; but notwithstanding a large quantity of food is devoured, emaciation rapidly increases. There are also nausea and vomiting, pains in the stomach and abdomen, and often a sudden enlargement of this part, which becomes tympanitic. Often there appears to exist an indescribable sensation of distress and gnawing in the stomach and bowels. There are also at times severe tenesmus, bloody stools, mixed with mucus, and other symptoms of inflammation in the large intestines. None of these are conclusive ; and the appearance of worms in the alvine evacuations is the only positive testimony of their being the cause of these symptoms. Such are the general symptoms of the presence of worms in the intestinal canal. There are others, which attend the existence of worms of a particular species, which appear to demand some attention. Thus the Ascarides lumbricoides, or common round worms, which are usually found in the ileon, although often existing without producing any symptoms of distress, when causing any uneasiness or pain, will excite it in the region of the umbilicus, either of an itching or spasmodic kind, resembling colic. The Oxyures vermiculares, or small thread worms, cause an intolerable itching about.the anus, and a similar irritation of the nose and mouth, inducing a constant picking of the nostrils and mouth. When, also, there exists a feeling of great nausea and sinking at the stomach, the existence of these worms may be suspected, particularly if accompanied by irritation of the rectum. The taenia? cause much greater distress than either of the others. The same voracious appetite occurs, as in the lumbricoid variety; but there is a sensation of much greater weight and movement in the abdomen, with a pricking and gnawing of the stomach. Worms are by no means so dangerous as was formerly believed; the danger arises altogether from the violence of the sympathetic affections; and convulsions, and inflammation of the brain, are the affections most to be apprehended from the irritation of these animals. At other times they exist without even causing any symptoms of their presence, which has induced the belief in the minds of some, that they are actually beneficial, by consuming the excess of nutriment, and thus prevent plethora. There can be no question, that the condition of the system which predisposes to worms is also productive of other diseases; and the derangements, and even fatal consequences, which have at times followed the presence of worms, may be referred to the general disorder of the chylopoetic viscera, which gradually undermines the constitution, and which has too often been attributed to the presence of these animals : one of the symptoms of the effects of this deranged condition 242 DISEASES OF CHILDREN. of the organs, so essential to the healthy performance of the functions of the system. This we see to be the case in persons sick with disorders affecting the digestion; and in those of a delicate frame of body, which has been inherited from parents, in such as are affected with a scrofulous disposition, etc.; all suffer more or less from derangements of the assimilating function, and are those most commonly affected with worms. In fevers, especially in viriola, scarlatina, and measles, worms often abound in great numbers, and would therefore appear to arise from the condition of the system in these diseases; for it will not be supposed that the diseases are caused by the worms. In violent fevers, worms have been observed to creep out of the mouth and anus. This is regarded as an unfavorable symptom. The contrary opinion is entertained by Hippocrates, and ancient authors generally, probably from considering worms as more frequently the cause of diseases than they are, and that their removal, either spontaneously or otherwise, is necessary for the cure of the disease. They have often been noticed to make their appearance, on the approach of death, on the outside of the body, a strong presumptive proof of their occupying the intestines as their natural habitation, and that their instinct leads them to forsake the animal which will no longer afford them support. None of the worms which infest the human intestines can be regarded as dangerous in themselves, excepting, perhaps, the taenia?. These often create a great and continued distress and irritation in the system; and the extreme difficulty of their expulsion, and the powerful remedies often required for this purpose, will at times endanger the life of the patient. Even after they have been removed, such is the violence of their irritation, that the distressing symptoms will continue for some days, from the habit which the intestines have acquired of putting on a morbid action. All the symptoms above enumerated more frequently attend this kind of the entozoa than the others, and are sometimes greatly aggravated by the powerful measures taken to rid the patient of their cause. Convalescents, it has been observed, recover very slowly after fever, when affected with ta?nia?.* It has been asserted by some that worms have at times penetrated the intestines, and found their way into the cavity of the abdomen and other parts, and even exterior to the body. Hunerwolf gives an account of a case of enteritis where the worms had produced perforations; Heister and Coith, also, relate instances of perforated intestines and worms in the cavity of the abdomen.t There are other instances on record of worms being found both within and outside of the body; but they have been in every instance • Frank, p. 268. f Dunglison, Op. Cit., p. 42. DIGESTIVE SYSTEM. 243 connected either, with an abscess or an ulcerative process. It is scarcely probable that it should occur in any other manner, for it appears so contrary to the nature of parasitic animals to migrate in this manner. Treatment. —As the predisposing causes of worms arc such as affect the powers of the digestive organs, it will be necessary to adopt such general measures, during the continuance of the disease, as will restore these organs to their healthy vigor. Whatever, therefore, appears, from the peculiar condition of the child, to be the principal cause of this want of tone in the system, must receive our chief attention, otherwise the attempts to cure the disease by the ordinary remedies for destroying and expelling the worms, will be of little avail; and, in some instances, will even be injurious, by their powerful effects on the mucous membrane, rendering the powers of digestion more feeble than before. It is unnecessary to enter minutely into the details if this course; it will suffice that a good substantial diet be adopted, when insufficient nourishment has been the cause; or a change of air, where the circumstances in which the child has been placed, have rendered it probable that a want of free air may have produced a debilitated state of the system. At other times, tonics will be indicated to restore the digestive function to its proper tone. The remedies which are used to expel worms from the intestinal canal, are prodigious in number. Besides that of an indirect nature, such as are mentioned above, for the purpose of restoring energy to the lost digestive powers, there are many which act in a direct way, and destroy the worms, either by expelling or by killing them by such means as are poisonous or by such as act mechanically. Anthelmintics may therefore he divided into these three classes. A vast number of experiments have been made, to ascertain the effects of various agents on these animals, after they have been discharged alive from the body, for the purpose of ascertaining the medicinal substance which would destroy them the soonest. They have been placed in cold and hot water, in infusion of aloes, in solutions of muriate of soda, oxymuriate of mercury, and other salts. They have also been immersed in brandy, wine, and alcohol. They have also been placed in various essential oils, which it is unnecessary here to enumerate; also in expressed oils, under the supposition that, like other vermicular animals, the spiraculae would thereby be obstructed, and the animals killed. We have seen, however, that there exist no respiratory organs in the parasitic worms infesting the bowels, and, as might be expected, they lived as long in these oils as in any other fluid. From all these experiments, very little if any satisfactory results have been obtained ; for the accounts are exceedingly contradic- 244 DISEASES OF CHILDREN. tory, and in some instances quite unexpected, as was the case in one instance related by Rosen Von Rosenstein, where a worm that was discharged from a child was kept alive a whole day in alcohol.* The most practical manner of treating the subject, is unquestionably that wherein each species of intestinal worms is separately brought into consideration; for although almost all the ordinary anthelmintics, are applicable to every kind of worm, yet each requires some modification of treatment, arising both from the nature of the worm, and the particular part of the intestinal cafial it inhabits. The worm most commonly met with is the Ascaris lumbricoides, and it naturally demands our attention first. The first step in the treatment of these worms, is to administer a purgative of an active nature, as a combination of calomel and jalap, when the condition of the alimentary canal does not forbid the employment of so active an agent. If there exist any appearance of inflammation in the intestinal tube, such a course must be avoided, and one of a milder nature substituted, as castor oil. The brisk action of a cathartic will often remove a quantity of slimy matter which adheres to the worms, and in which they live, and prepare them to be acted on by such direct means as it may be necessary to use for their destruction. Formerly, calomel was very much in use as a vermifuge, but it is doubtful whether it possesses any power, other than its active effect as a cathartic; but in this mode, calomel, as well as other active purgatives, often al once removes many of the lumbricoides. The operation of calomel, or of any other purgative, should be thorough and effectual at once; it will then remove a large quantity of mucus, in which the worms are lodged. Where there is much mucus present, it is often difficult to procure a good cathartic effect from calomel, even when combined with jalap or rhubarb to quicken its operation. Scammony has been found useful when this state of the bowels exists, in combination with calomel and sulphate of potash, which modifies the griping qualities of scammony, and forms an admirable cathartic in worms.t After the operation of the cathartic, which should not be often repeated, on account of the debilitating effects on the intestinal * On the Diseases of Children. Translation by Sparraann, p. 230. t ft Hydr. Subm., gr. v. (102) Pulv. Scammon., Potasses Sulphat., aa. gr. x. Sacchar. Alb. Pulv., gr. v. 01. Cinnam., gt. j. M. ft. Pulv. No. vi. One every four hours, to a chad three years old, till an effect is produced. 245 DIGESTIVE SYSTEM. tubes, it will be necessary to resort to anthelmintics, if the cathartics fail in expelling the worms. Of these there is a great variety, almost too numerous to record at length, and many of them, probably, are wholly inefficacious. The oil extracted from the seeds of the Chenopodium anthelminticum is an anthelmintic in common use, and is certainly very efficacious; but from its strongly stimulating properties is rather hazardous, by exciting inflammation of the mucous membrane. The same remarks apply also to tansy, Tanacetum vulgare. The subjoined formula is the celebrated anthelmintic electuary of Bremser.* At the same time an enema of similar ingredients should also be used 1" It has also been applied externally, in the form of a poultice, made with camomile flowers boiled in milk. Common salt is a tonic in small doses, and acts as a cathartic in larger; it has been used as an anthelmintic, in the dose of a spoonful every morning. It seems particularly to annoy every species of worms, and its use is well known to every farmer, as the best cure and preventive of worms in all kinds of animals. Its ordinary daily use is of great benefit where there are children predisposed to worms, as the best prophylactic that can be employed. The Indian pink, Spigelia Marylandica, is a very powerful anthelmintic, long in use in the United States. Its effects are decidedly narcotic, and in an overdose producing dimness of sight, dilated pupils, and vertigo; even terminating, it is said, in convulsions. These are not apt to occur, however, if the medicine be cautiously used. I have never known but one instance where a patient appeared to suffer from the effects of this remedy, and the unfavorable symptoms soon disappeared on stopping the medicine. It may be regarded as one of the most useful anthelmintics. Spigelia may be given, either in powder or decoction. Of the former, a child four years old may take fifteen or twenty grains every morning, followed by an active cathartic, after three or four doses have been taken. The decoction i$ the most eligible form for its administration ; and it may be given either mixed with coffee for breakfast, or sweetened and prepared like the usual beverage taken at that meal. It is made by boiling an ounce of the plant in a pint of water down to half a pint; a half an ounce of which may be taken morning and evening, by a child five or six • R Flor. Tanaceti, Zss. (103) Pulv. Itad. Valerian., 3»j. Pulv. Jalapae, 3j. Potassae Sulph., 3»J- M. Oxymel. Scillae, q. s. ut. • ft. electuarium. A teaspoonful twice a day. f R Artemesiae Absynth., (104) Rad. Valerianae, aa. ?j. Cort. Aurantii, Flor. Tanacet., aa. 3SS. M. c. m. f. Spec. Two tablespoonfuls being infused for a night, and strained; the strained liquor mixed with a spoonful of fresh ox gall, to serve for the enemata. 246 DISEASES OF CHILDREN". years of age, until the whole is taken ; when a purgative of an active kind ought to be given. This is almost invariably followed by an expulsion of the worms. Spigelia has also been given in the form of a syrup, made by boiling five parts of the plant for an hour, in ten parts of water. When the decoction has stood for twelve hours, it should be strained and sweetened, and evaporated to the consistence of syrup. This syrup is to be taken three or four evenings in succession, in a quantity proportionate to the age of the child, followed by a dose of castor oil.* Spigelia is often advantageously combined with purgatives ; and a very popular prescription is a mixture of senna and pink-root. The following prescription is from the Materia Medica of Drs. Wood and Bache.t Another excellent one is the combination of pink-root and savine, as in the subjoined prescription.} It is unnecessary to mention any more of the narcotic class of anthelmintics; those already mentioned will be found in general sufficient for the removal of the Ascaris lumhricoidcs. If these means, however, should fail, and the condition of the mucous membrane will allow of its use, spirits of turpentine will oe very efficient against this kind of worms, as well as all others. It may be given, it is said, with perfect safety, even to the youngest children, as it does not produce so much irritation in the mucous membrane, as we might suppose, from its powerfully irritating effect on the skin. The dose is from half a drachm to two or three drachms, to children three years of age, mixed with milk, or beat up with the yolk of an egg, or, what is better, by combining it with castor oil. The bristles or pubes of the Dolichos prurieris is the best of the mechanical anthelmintics. It produces on the skin a most distressing itching; but no sensation of this nature follows its use when given internally, and the mucous membrane of the intestinal tube does not appear to be in the least affected. It is, at the same time, one of the safest and most effectual remedies for the lumbricoides, * Journ. de Connaiss. de Med., January, 1835. t ft Spigelian, 39s. (105) Senna?, 3 ij- Manna?, •Fceniculi, 3U- Aqua? Bull., M. Mascera per horam in vase leviter clauso et cola. A wineglassful to be given to a child from two to four years old. t ft Rad. Spigel. Maryland., 3vi. (106) Fol. Senna?, 3u« Fol. Sabina?, 3ss. Aqua? Bull., M. Preparation and dose as the preceding. DIGESTIVE SYSTEM. 247 which generally appear after a few doses have been administered. The proper dose is from five to ten grains in syrup, followed by a dose of castor oil. Grained tin was formerly supposed to owe its efficacy to the presence of arsenic in a metallic state; but it has been satisfactorily ascertained that pure tin itself possesses all the anthelmintic properties. It has also been supposed to act by the hydrogen it generates in the bowels, and that its efficacy is increased by its mixture with sulphur, by which sulphurated hydrogen is formed. By others, its action is considered as purely mechanical, both annoying the worms, and exciting the peristaltic action of the intestines. It is usually given in doses of one to two drachms, mixed with syrup, three or four days in succession, in the morning, followed by a cathartic. The principles on which the treatment of worms is founded, are the same in all; but there are some differences in the different varieties which demand an alteration, which will make the remedies more particularly applicable to one class. Thus, owing to the situation in which the oxyures are found, in the rectum or lower portions of the intestines, the remedies may be often given by enema; that already mentioned will be found highly useful in the removal of these worms when they are situated at the lower extremity of the intestinal tube. Enemata of sulphate of iron, consisting of three or four grains dissolved in four or six ounces of water, or of equal parts of milk and lime water, or salt and water, or camphorated oil, are all very useful in removing these worms from the rectum. Infusions of valerian and garlic have also been used, for the same purpose. At the same time it will be advisable to administer an aloetic purgative by the mouth ; and the aloetic mixture of Evanson and Maunsell is probably the best for administration to children, as the liquorice tends to conceal the taste.* The anthelmintic properties of this mixture are greatly increased by the addition of half a drachm to two drachms of muriated tincture of iron. The operation of aloes is principally on the lower intestines, as it is believed to pass unchanged through the small intestines, probably from the difficulty of its solution; it is, therefore, particularly useful in promoting an action in the rectum, where these worms are principally confined, while its action from above will also tend to prevent these worms from moving from their usual habitation, and occupying, as they sometimes do, higher parts of the intestinal tube. Any of these enemata should be daily used, and a purgative once or twice a week will, for the most part, be sufficient •Decocti Aloes Comp., (107) Extr. Glycyr. 3ij. Vini Aloet., 3ij. M. One or two drachms twice or thrice a day. 248 DISEASES OF CHILDREN. to remove them; while a generous course of diet, and the habitual use of tonic medicines, where the state of the digestive organs seems to demand their use, will be necessary to secure the system against a return of them. The muriated tincture of iron is an excellent tonic for strengthening the mucous coats of the intestines and stomach and preventing the reproductions of the oxyures. It may be given in the dose of two to ten drops, largely diluted with water, or in the following prescription.* The taenia? are rare in children; they require much the same course of treatment as the Ascaris lumbricoid.es, except that the difficulty of their removal demands often a constant recourse to the different anthelmintics. The prescription of Bremser, already men tioned, is one which, when followed by an active cathartive, and the immediate use of the empyreumatic oil of Chabert, is remarkably successful, according to this celebrated German practitioner, as well as by Frank.t The empyreumatic oil differs but little from the oil of turpentine in its effects, and consists of one part of the empyreumatic oil of hartshorn and three of the oil of turpentine; the dose for an adult is two dessert-spoonfuls morning and evening. The celebrated remedy which was revived by Mad. Nouffleur, the male fern, Polypodium filix mas., was in use in the days of Galen and Dioscorides, as a remedy for tape-worm. From the testimony of numbers of physicians in every country, it has been successful when every other remedy has failed. An instance of this kind occurred in the case of the late Dr. Jones, of this city ; all the varieties of anthelmintics had been used without effect, until recourse was had to a decoction of fern, when a worm measuring forty-five feet came away. GASTRITIS. Inflammation of the stomaeli is described, by the French writers, as a disease by no means unfrequent among children. It is to MM. Saillant and Billard that we are indebted for the information we possess in relation to this disease, as it occurs in young children. The last-mentioned author particularly records all that is known as ta the pathology of the disease. Dr. Burns,} also, has a few practical remarks on this disease, which he observes is not common in infancy, nor is it discovered without much attention. Etiology.—This disease is at times of congenital origin, the researches of Billard furnishing us with instances in which the foetus * R Tinct. Ferri. Muriat., gt. x. (108) Aquae Cinnam., 3jss. Syrup. Simpl., |j. M Two teaspoonfuls every hour. t Op. Cit., p. 290. t Principles of Medicine, including the- Diseases of Women and Children, by John Burns, M. D., American edition, p. 727. DIGESTIVE SYSTEM. 249 was evidently affected with it. It is unnecessary here to give the cases in detail; the reader is referred to the work of M. Billard for the accounts of these interesting cases. When it arises in infants after birth, its causes do not differ from those occurring in adults. The irritation of irritating ingesta, or of poisonous articles taken into the stomach, sometimes occurring accidentally, from the solution of a metallic oxide from the vessel in which the food has been prepared. Cold or wet applied to the surface of the body, also, will produce it, as in adults. Morbid Anatomy.—The stomach is found inflamed in different parts of its structure, from which the disease has been arranged in different forms: that affecting the capillary vessels of the stomach, causing a ramiform capillary injection, or appearing in patches or striae in the mucous membrane, or in the papillae and villosities, has been distinguished by the name of erythematic gastritis. Another form is that in which the secretion of the stomach is principally affected, corresponding with the altered secretion of the mucous membrane of the mouth, and known, when it occurs in that part, as the thrush, or muguet of French authors. When these symptoms occur after the mouth has been affected with aphthae, there can be no question that the inflammation has extended to the stomach. The third form of gastritis is that affecting the follicular apparatus of the stomach, sometimes appearing under the form of small, white, round, slightly projecting granulations, with a black point at their summit; at other times inflaming and ulcerating. The fourth variety is that denominated gangrene of the stomach, and consists of a true disorganization of its tissue. This last is rare in infants, but it has been found where the mucous membrane had become of a deep brown, and partially in a state of putrefaction, and diffusing an offensive odor. The shreds of the separated membrane were diffused in a dark colored fluid. Another variety of gastric inflammation is the gelatinous softening, as is described by M. Cruveilhier. The mucous membrane in this variety is found pale and colorless, and almost transparent, as if macerated in water and reduced to a pulp, while the mucous follicles are in their natural state. This alteration of the tissue of the stomach is most evident at the greater curvature. These are the different results of inflammation of the stomach, condensed from the accounts furnished by MM. Cruveilhier and Billard, and they all arise from inflammation, varying in violence and seat, and modified by the constitutional vigor of the patient. All these varieties, although described as distinct, may yet occur together, and Billard has given a case in which such an assemblage of morbid phenomena was formed; proving them to be the result of inflammation, varying from the causes above mentioned. 250 DISEASES OF CHILDREN. Semeiology.—The characteristic signs of gastritis are pain on pressure over the stomach, evident from the child shrieking or crying. The bowels are usually loose. If the child be old enough, he will describe the pain as of a burning character. In addition to these symptoms there is constant vomiting. There are often a continual coughing and difficulty of respiration, but the disease may be distinguished from pulmonary inflammation by the absence of vomiting in the latter. The expression of countenance is remarkably altered in gastritis. There is but little or no difference in the symptoms of the different forms of the disease, except that in the follicular variety there is often bloody vomiting. In that, also, which is known as the gelatinous softening, the symptoms are remarkable for their severity. The skin is cold, the pulse irregular; the face is much wrinkled, and expresses great pain, while at the same time there is great prostration and insensibility, occasionally alternating with severe pain. Treatment.—The first indication in the treatment of gastritis, is to allay the violence of the inflammation, by the abstraction of blood, if the strength of the patient can bear the evacuation. It will rarely, however, be necessary to adopt general blood-letting in young children, in whom the prostration is often very great. In those that are older, where there is much tension of the pulse, the lancet is our main dependance. Leeches may in general, however, be safely applied on the epigastrium, followed by warm stupes. These, or cataplasms throughout the disease, are admirable means of lessening the inflammation, and should be constantly used. When the action of the blood-vessels is subdued, a blister may be applied over the affected part. Purgatives should be carefully avoided; and if it become necessary to relieve the bowels, it should be done by means of laxative enemata; even the mildest and least irritating laxative ought to be withheld from the stomach, much more those nauseating remedies, so useful in inflammations in general. Mucilages may be freely used, and the thirst satisfied with iced drinks. In chronic cases it has been recommended to use frictions with tartar emetic ointment; but this can not be employed without hazard, from the effect that antimony almost invariably exerts on the stomach, especially in debilitated or young subjects. Revulsion may, however, be made by stimulating baths, and the application of sinapisms or blisters to the lower extremities. ENTERITIS. Inflammation of the intestines is of common occurrence in infancy, and in some instances assumes so great a difference in its DIGESTIVE SYSTEM. 251 symptoms, as to be one of the most difficult diseases at times to recognise. This arises from its occurring in every degree of intensity, and affecting so many different portions of the intestinal tube, whereby its sympathetic irritations vary in almost every instance. But these will be more particularly noted under the semeiology of the disease, and especially the remarkable difference between this disease in adults and youth, and as it occurs during the period of infancy. For the remarkable facts connected with this affection, we are in debted to Dr. Abercrombie,* and to those indefatigable French physicians, MM. Billardt and Valleix,} who have so ably investigated this interesting subject in the hospitals in Paris. Etiology.—This disease, like the preceding, has been found in children so shortly after birth, as to leave no doubt of its congenital origin, it having existed both in an acute imd chronic state; and the extreme feebleness of some infants, no doubt, arises from inflammation of the first passages which has existed before birth ; for in some, in which there existed no other symptoms than excessive feebleness, extensive inflammation of the intestines has been found, and was the only abnormal condition existing. The high state of excitability in the mucous membrane of sucking infants, together with the activity of the digestive function, renders it extremely liable to inflammation. Irregularities of diet, also, an error so frequently committed, is one of the most common causes of inflammation of the bowels. The pernicious practice of administering purgative medicines on the slightest disorder of the child, is another very evident cause of inflammation in these parts. It is, therefore, of the greatest importance that this habit be not early acquired; many a child has been sacrificed to the pernicious custom of using a cathartic immediately after birth, which not only is itself productive of direct injury, but by rendering the bowels disposed to inaction without the repetition of this stimulant, increases the necessity of cathartic medicines. Semeiology.—The symptoms of enteritis in young infants differ greatly from those occurring in adults. In the latter, the abdominal region is the part mostly affected the symptoms varying with the portion of the tube which is diseased. The progress of the disease is also much more rapid in the adult; there are fewer complications, and the prognosis is much more favorable. In the newborn child there is but little febrile action; the progress of the disease is slow, and death almost certain, and the secondary symptoms often very numerous and variable; although in some few there exists a want of these symptoms of complication, which occurs more especially where the disease is of congenital origin. In children, however, • Op. Cit., p. 46. t Op. Cit., p. 296, et. seq. t Op. Cit., p. 462, et seq. 252 DISEASES OF CHILDREN. where there is much febrile excitement manifest, other and distant parts often are the only parts which manifest any disturbance; and, while in the adult the local tenderness is the most marked symptom, in infants there exist many marks of irritation in the pulmonary and cerebral systems ; so that there have existed severe signs of pulmonary inflammation, as would appear from the rapid and laborious breathing, while the physical signs gave satisfactory indications of the nonexistence of disease in the thorax. Such cases must have been seen by almost every practitioner of any observation, and where the remedies applied for the relief of pulmonary disease have been unattended with any satisfactory result. Again, symptoms of cerebral irritation are very common in children affected with enteritis. After the severest symptoms of inflammation of the brain, dissection has at times exhibited no remains of disease in the head, while severe inflammation has been found in the abdominal viscera. Such, however, is the intimate sympathetic relation between the mucous membrane of the digestive passages and the brain, that in the treatment of the diseases of children this relation should constantly be borne in mind ; for serious diseases of the brain are often the result of inflammatory action in the digestive organs; a fact well known to the ancients, but more particularly pointed out by modern writers. The pathological sympathies are so great, that, according to some investigators, the meninges of the brain participate in an equal degree with the affection of the mucous membrane of the bowels, having at one time a chronic action, and at another an acute character, according to the amount and degree of the primitive disease. Laborious and varied researches have been made on living animals, on animals that have been suddenly killed, and on men that have met with a violent death, for the purpose of ascertaining the natural condition, if possible, of the meninges of the brain, before coming to this conclusion.* With every allowance for the enthusiasm of those devotees of science, in regarding the cerebral meninges as affected with precisely' the same shades of diseases as are found to exist in the mucous coat of the intestinal canal, no doubt can remain of the intimate relations between them, and of the danger arising to the brain from the existence of abdominal disease; for the part at first only sympathetically irritated, may at last absorb the whole of the disease ; or, what is of more common occurrence, exist in connexion with the original visceral affection. The most common symptoms of this disease are vomiting, diarrhoea, tympanitis, and abdominal pain, which is increased on pres- • See a paper by M. Scoutettin, in the twenty-eighth volume of the Jour, des Sciences Mcdicales. Also, Researches d'Anatom. et Patholog., etc. etc., sur le Cerveau. par J. Sabrioles, passim. -, Paris, 1826. DIGESTIVE SYSTEM. 253 sure. Fever is often absent, but there is great heat on the abdomen ; this is so constant a symptom, that the physician should always examine the abdomen and the surrounding parts, to ascertain the existence of morbid heat in the part. The heat, for the most part, is greater in proportion to the violence of the inflammation, although it exhibits exacerbations and remissions. As a general rule, the inflammation is at its height when the heat is the greatest, while at the same time there is violent thirst, dry skin, and cold extremities. The thirst*is greatest in proportion to the extension of the inflammation toward the duodenum, according to the opinion of M. Broussais. In the early stages of the disease, it is difficult to distinguish it from ordinary bowel complaints. As it advances, the tongue becomes furred and dry ; there is great restlessness and wakefulness. In the first appearance of the inflammation, the bowels are loose, but toward its close the evacuations are but seldom made ; and when alvine discharges occur, they are often attended with great pain and force. The color of the evacuations has been usually described by French physicians as green. But their color varies ; sometimes it is brown, reddish, or clay-colored ; influenced considerably by the color of the food that is taken, which also imparts its consistency to it. No digestion taking place, the feces retain the appearance of the food when first taken into the stomach. From its resemblance to ordinary diarrhoea, at its first appearance it often excites little or no alarm, until sympathetic disturbance, or general constitutional symptoms arise. As the disease advances, the skin becomes cold and wrinkled; the face, particularly, shows the effect of the suffering the child experiences, and has a wrinkled and corrugated appearance, like that of an old person. The debility at this period is extreme, sometimes coming on with remarkable suddenness ; at other times the disease terminates in a profound stupor. No better summary of the symptoms, for the purpose of diagnosis, can be made, than that furnished by an analysis of eighty cases of enteritis, seen during life, and anatomically examined, by M. Billard. From these it appears that tympanitis, vomiting, and diarrhoea, are the most prominent signs of inflammation of the mucous membrane of the small intestines. Inflammation of the large intestines, which he denominates colitis, is for the most part without vomiting or swelling of the bowels, but always attended with diarrhoea. This is what is usually termed dysentery ; and as it requires some considerable modification of treatment, will be the subject of separate remarks. The absence also of febrile excitement is very common in this disease, in young infants, and on this account we should not wait for the manifestation of any inordinate excitement of the blood-vessels, before we are led to suspect the existence of 254 DISEASES OF CHILDREN. severe inflammation of the bowels ; for a fatal inflammation mayoccur without any manifestation of it by the pulse. It is also of some importance to be able to distinguish inflammation from simple functional derangement; in this there are often severe vomiting and purging, which may be arrested without hazard to the child. This condition may generally be ascertained by the absence of pain on pressure, and the tenseness of the abdomen, which occur more or less in every case of enteritis. The absence of heat will also distinguish the existence of functional derangement. Another diagnostic sign is in lineaments of the face ; first pointed out by M. Jadelot, and contained in M. de Salle's edition of Underwood.* These are described by him as occurring more particularly in children advanced beyond the period of infancy. One of the most certain marks of abdominal affections, according to M. Jadelot, is first the genal lineament, which extends from the commissure of the lips to the lower part of the face, where it loses itself; the second, the nasal lineament, extending from the inside of the ala? of the nose, and surrounds the whole of the orbicularis oris muscle. These, as was before remarked, are not always to be seen in very young infants, yet some trait of them may be observed, as a fold in the commissure of the lips, or outside of the orbicular muscle, corresponding with the nasal lineament. When the child suffers violent pain, there is a corrugation of the skin of the forehead ; and, indeed, the sudden appearance of wrinkles in any part of the face almost always indicates the presence of abdominal pain, and demands the attention of the physician, for they are invariably marks of distress not to be overlooked. A pinched expression of face, without the presence of any particular lineament, in very young infants, is always a sign of gastro-intestinal inflammation. All these inflammatory affections of the bowels may become chronic; the thirst then is very great, the tongue much furred, and the appetite is much impaired, or is entirely lost; the abdomen remains distended, while the rest of the body is much emaciated. The surface of the body is remarkably dry, and becomes of a dirty ash color. The fever is remittent, and not violent in its character. Morbid Anatomy.—Dissections have shown, in some instances, simple capilliform injections throughout the intestinal canal; in others there existed patches of redness, of greater or less extent, with tumefaction of the digestive tube, and friability of the mucous membrane. Blood has also been found effused in different portions of the intestines where there existed violent inflammation ; when this is the case, it is usual for it to appear in the stools during life. In more advanced stages, there are found patches or stria? of a brown • Traite des Mai. des Enfants de M. Underwood, etc., p. 36- DIGESTIVE SYSTEM. 255 or slate color, in the mucous membrane, indicating a chronic phlegmasia of the membrane. There has also been seen the altered condition of the secretion known as muguet, the disease which, when situated in the buccal mucous membrane, is called milk thrush. It has been described as a peculiar form of intestinal inflammation by some, while others maintain that muguet is in every instance essential to the disease. The muciparous follicles, the glands occupying the upper portion of the small intestines generally, and isolated in the ccecum and colon, sometimes become the seat of various alterations from inflammation. Sometimes they are red and tumefied, at other times disorganized and ulcerated, giving to the ulcers in the intestines a peculiar appearance. The mucous membrane has also been seen in a state of disorganization and softening, a condition entirely different from the white softening occurring in the same membrane during simple indigestion. This inflammatory softening arises where the mucous membrane has been long the*seat of inflammation ; it at last becomes so altered in its structure as to retain few, if any, of its membranous characters, but is, on the contrary, a soft red mass. Some circumscribed spots of the mucous membrane have been found sphacelated, more particularly about the ileo-coecal region. Eschars and adhesions, also, are very common in different portions of the intestines: these generally arise after very violent inflammation. Such is the analysis of the various facts obtained from different sources. From these the French pathologists make four varieties of enteritis, designating them as erythematic, follicular, with altered secretion, and with disorganization of tissue. Inasmuch, however, as there is great difficulty, if not impossibility, in distinguishing them during life by any marked symptom, the distinction can not be of much practical value in treating the disease. The violence of the symptoms may lead us to expect the termination of inflammation in the worst form, or disorganization of tissue, and to proportion the activity of the treatment accordingly, or lo make a prognosis of the case ; which, under these circumstances, must be unfavorable. All these varieties may occur simultaneously, and it appears to be a useless distinction to describe them as separate forms. In all an altered state of the secretion occurs, so that the form of muguet may be found more or less in every case. Indeed, so common is this state of the mucous membrane, that M. Valleix* is of opinion, that inflammation very rarely exists without the presence * Op. Cit., p. 487. 256 DISEASES OF CHILDREN. of muguet; for of forty-six cases there were but three which appeared to present enteritis without muguet, on the simple uncomplicated erythematic enteritis. Treatment.—As in the disease just considered, it requires some judgment as to the abstraction of blood—a course by no means called for in every case of inflammation of the stomach or bowels. Indeed, the prostration is at times so great as to render the application of even a few leeches extremely hazardous ; and, in these affections, to cause their interdiction almost entirely in the Foundling Hospital at Paris. The cases found there are those of great debility, and are by no means guides for us, as I have repeatedly experienced. Still there is, perhaps, no inflammatory disease of infancy in which there exists so much prostration as in those affecting the stomach and bowels. In children, however, somewhat advanced, when there is every evidence of acute inflammation, the use of leeches can by no means be dispensed with. But even in these cases the flow of blood should be carefully watched, as excessive prostration may ensue from the loss even of a moderate quantity of blood. In two instances I have met with a very serious prostration, and nearly fatal from this cause; so that whenever there is a necessity of applying leeches to the epigastrium in children, I am particularly cautious not to allow the blood to flow until exhaustion is produced. Drs. Evanson and Maunsell advise a repetition of leeching, as preferable to allowing any continued loss of blood, which may greatly reduce the strength of the child without arresting the disease, and very judiciously advise the physician himself to superintend the flow of blood, that it may be arrested when necessary. Fomentations, warm baths, and blisters, are powerful means of combating enteritis. Counter irritation in some form should never be omitted. Fomentation ought to be substituted for the warm bath where the debility is great. So, also, in general, sinapisms may. with safety be used in extreme debility ; they, as well as blisters, ought to be applied to the extremities. Sinapisms ought not to be kept long applied; as soon as a little redness and smarting are produced, they ought to be removed and re-applied, if necessary. Opium, in the form of Dover's powder, is a highly useful medicine in the treatment of enteritis, and should be used where the irritability of the stomach does not forbid its use. When this condition of the stomach exists, opium, as heretofore directed at page 196, will be found of great efficacy in allaying the extreme irritability of the bowels, and producing an action on the skin. Opium is of admirable benefit in inflammatory complaints of children, especially after bleeding, and was much in use by the older DIGESTIVE SYSTEM. 257 American practitioners. A reference to this subject has already been made in the article on pneumonia. It is not safe to have recourse to much internal remedies of any kind in this disease, except the opiates above mentioned, with gum syrup, or some other mild mucilaginous substance, taken cold. The child, if at the breast, should not, as is the custom in some foreign hospitals, be taken from the breast; but if the milk be thought too irritating, it may be pressed from the breast and mixed with water before it is given to the child. M. Valleix, from the complete inefficiency of the means employed in the treatment of some cases reported by him, which consisted chiefly of mucilages and feculent nourishment, is of opinion that a greater change of measures than is usually pursued, is clearly necessary for the successful treatment of enteritis ; and refers to the measures adopted in the treatment of the affection in adults, as an evidence of the more successful method of managing the disease, observing that opiates are freely used in the latter, while a much greater change is made in their regimen. In children, on the contrary, but little change is made, and feculent substances are given in very large quantities, so that they are in fact kept suffering the whole time from indigestion. It appears to have been a very common practice in the Foundling Hospital at Paris, to give gummed rice, or a thickened preparation of the same article, known by the name of "creme de riz," or salep, and other thick, feculent matter, for food to children, without making much if any change in these diseases. M. Guillot has made it appear, by some very simple experiments, that young infants digest with great difficulty these feculent articles of food. In twelve children that died of different diseases, the feces found in the small and great intestines were subjected to the influence of the tincture of iodine, and a very intense blue color was the result; from which there tould exist no doubt that a great portion of the fecula had passed through the whole of the intestinal canal without undergoing any change.* These are important facts, and in some respects account for the great mortality in the Hopital des Enfants Trouves, for they must constantly suffer from indigestion, and when affected with gastritis or enteritis, be exposed to the continued irritation of unassimilable food. The bowels may be kept open by the means of enemata, composed simply of warm water, or castor oil mixed with an infusion of flax-seed. As costiveness is a very distressing and irritating condition of the bowels, it should be removed, and, if possible, by means of enemata. Tepid milk has been used as an enema in costiveness, and is a very efficient laxative. In no case should active purgatives be given ; but the most decided advantage will at times • Valleix, Op. Cit.. 489. 33 258 DISEASES OF CHILDREN. arise, in protracted cases, from the use of a few grains of calomel and Dover's powder, followed by a little castor oil. Castor oil has been objected to as a cathartic in irritations and inflammations of the bowels, from its being too irritating. These are contrary to my experience, and it has always appeared to me a mild cathartic, operating promptly and with little or no griping, the alvine secretions being but little affected, while the contents of the bowels are freely evacuated. It is therefore particularly applicable to inflammatory diseases of the bowp|«, when it becomes necessary to procure evacuations from the bowels, which can not be effected by means of enemata. A very good combination is an emulsion containing mucilage.* For further details of the treatment, when diarrhoea is the most common symptom, the reader is referred to the article on that subject. When the disease becomes decidedly chronic, the mesenteric glands are likely to be affected and become indurated. Here it will be necessary to use more freely the hydrargyrum cum creta, and to rub the bowels with the ointment of iodine or hydriodate of potash. The article on the mesenteric disease contains the details of the treatment which it will be necessary to pursue when these glands become enlarged. In protracted and chronic cases, it will sometimes be necessary to allay the irritable condition of the bowels, at other times to arrest the too copious discharges, and in some cases to support the strength of the patient, by the use of tonics and bitters. All these varieties of treatment must depend on the judgment of the physician. The circumstances under which they are applicable, are considered more at length under the article on diarrhoea, to which the reader is referred. DYSENTERY. Although this variety of intestinal inflammation offers but little if any dissimilarity in its appearance from that which it exhibits in the adult, and therefore scarcely to be regarded as a disease of childhood, yet, inasmuch as it is a very common affection of children in summer, and the symptoms exhibit some peculiarities distinct from inflammation in other parts of the intestinal tube, and as some difference of treatment is required, arising principally from the seat of the affection, it will be briefly considered with reference to its peculiarities. From the seat of the inflammation in the large intestines, it has •ft 01. Ricini. 3>ij-—vi. (109) Pulv. Acacioe, q. s. Syrup. Simpl., 3yss. M. ft. Kmulsio. A dessert-spoonful every hour, until it operates. DIGESTIVE SYSTEM. 259 of late been denominated colitis, as distinct from the inflammation seated in other parts of the intestines, which has received the name of ileitis. Both these diseases may exist together, and severe gastritis may be also connected with them ; but nothing is more common than to see pure and uncomplicated dysentery existing in childhood and infancy, entirely unconnected with inflammation in other parts of the intestinal tube. Etiology.—As this form of enteritis is more prevalent during the latter part of the summer and autumn, the sudden changes from extreme heat to the cold and damp of the night are unquestionably its most frequent causes. All the causes, also, which are the active agents in the production of other forms of inflammation in the mucous membrane of the intestinal tube, such as irritating and indigestible food, will be productive of this. Malaria, also, is unquestionably a very efficient agent in the development of dysentery; it is accordingly found to prevail as an epidemic in situations favorable to the existence of intermittent and remittent fevers, and it often exists simultaneously with them, or is observed to follow such affections. The remarkable connexion of these diseases was long since observed by Sydenham; and it is without question attributable to the influence of this agent on the liver and portal circulation, which are considered more at length in other parts of this work. Semeiology.—Dysentery usually commences with diarrhoea; the discharges at first being feculent and afterward watery, with slight admixture of blood. They gradually change to mucus, in which there is more or less blood. There is but little fixed pain, but at times, immediately before a stool, a violent and very distressing tenesmus occurs. This is the ordinary character of the evacuations throughout the disease, with the occasional appearance of true feculent matter in the stools. When the disease is uncomplicated with inflammation in other parts of the mucous membrane, the regular and periodical evacuation of healthy feces will often take place, while the mucous and bloody discharges are continued during the intermediate periods. Fever, for the most part, attends this disease, although it is often but slight, and the pulse is a little quickened, although not much, if in any degree, increased in force. In very severe cases the fever is high and the tongue furred, while the local symptoms, tenesmus and mucous stools, are very frequent; the bowels continue costive, the alvine evacuations being occasionally mixed with scybala. As the disease advances the anus becomes excessively painful and hot, and if relief he not afforded,, great prostration of strength ensues, the pulse is feeble and the skin is cold ; distress and pain are experienced throughout the intestines^ 260 DISEASES OF CHILDREN. nausea and vomiting supervene, and aphtha? appear in the mouth. As in most abdominal diseases of children, coma and cerebral effusion are the most ordinary symptoms at the close. Dysentery is one of the most obstinate of all the diseases we have to encounter, and the favorable symptoms are often extremely fallacious, a chronic affection of the mucous membrane frequently following a protracted disease. From chronic dysentery recovery is very rare. Morbid Anatomy and Pathology.—Marks of inflammation are found in the mucous membrane of the colon and rectum —occa- in the small intestines. These parts are also covered with shreds of inspissated mucus, or coagulable lymph, the thinner portions having been discharged by stool. Ulcerations also exist in violent cases, while sphacelus is not uncommon under similar circumstances, especially if the case be protracted. In chronic cases there is some difference in the appearance of the mucous membrane, which is often mamillated, looking as if cicatrization were in progress. Dysentery, therefore, in its early stage, is an inflammation of the mucous coat of the large intestines. This inflammation, spreading to the other coats, causes ulceration, and disorganization of their tissues. At other times, the inflammation is chronic in its nature, more slow in its progress, and less destructive to the parts affected. The division, therefore, of chronic and acute dysentery is well founded, and is of daily occurrence. Treatment.—The remarks as to the necessity of early bloodletting already given, when treating of gastritis and enteritis, are applicable to the disease now under consideration, with this exception, that it may, in general, be more freely used than in inflammations of other portions of the digestive tube ; the prostration accompanying the disease not being so great as in either of the other affections. Leeches may he applied, in ileitis, to the anus ; but with far greater advantage in this disease. The free abstraction of blood in this manner is of decided advantage; and in those cases where the blood flows freely in a spontaneous manner, I have noticed much less tormina than in those cases where the evacuations consist principally of mucus. When leeches are applied to the anus, the bleeding ought especially to be watched, as the hemorrhage may sometimes be excessive, from the extreme vascularity of the part; and great loss of blood, especially from capillary bleeding, has at times been fatal lo young children. In dysentery, children bear the operation of mild purgatives far better than in other forms of enteritis. These, therefore, may occasionally be given, and castor oil, combined with a few drops of tincture of opium, will be the most suitable, from the mildness and DIGESTIVE SYSTEM. 261 efficiency of its operation. As the appending viscera are also simultaneously affected in many instances, and more especially the liver, calomel, in small doses, when combined with Dover's powder, will be the proper means of exciting the biliary secretion, and relieving the congested state of the organ, and thus restore a freedom to the circulation of the abdominal viscera. Anodyne enemata are extremely useful in all degrees of tenesmus accompanying dysentery, but great caution should be observed in the quantity of laudanum used in the enema. The rule in the adult is to give treble the quantity which would be administered by the mouth. In very young children, it is not uncommon to see complete stupor produced by the same quantity given by the anus which it is usual to administer by the mouth. It should therefore be cautiously given. Children appear to be peculiarly susceptible to the action of opium ; and although a most decided advantage often follows the use of it in the peculiarly irritable condition of the system at this period of life, yet from the great rapidity of absorp-' tion, the smallest quantity can not be given without some hazard. Four drops of laudanum has killed a child a month old; and in another, three drops given to a child of fourteen months, was followed by coma, convulsions, and death, in six hours. Diaphoretics may be more freely given in this than in the other forms of intestinal inflammation ; and in robust children, advanced beyond the period of infancy, antimony will be admissible when the febrile action is high. But Dover's powder, from the peculiar action of its different ingredients, is admirably adapted to the treatment of dysentery. The disease often becomes exceedingly protracted, bearing some resemblance to severe diarrhoeal affections, with great prostration and exhaustion from the excessive mucous and bloody discharges. Astringents have been used in this condition with decided advantage. Various means of this kind have from time to time been employed, and among them the acetate of lead in the dysentery of adults. This has also been used in cholera infantum, and the kindred diseases of children. For further observation on the use of astringents, the reader is referred to the articles on cholera infantum and diarrhoea. The subjoined vegetable astringents have been more especially used in the protracted form of dysentery of children, and the annexed formula is highly recommended by Dr. Zollickoffer, of Maryland, in the third volume of the New York Medical and Physical Journal.* Dr. Cogswell, of Washington * M Euphorbia? Hyper. Fol. Excit., ?ss. (110) Aqua? Bullient., oj. ft. Inf. A large spoonful every hour, until the morbid symptoms cease. 262 DISEASES OF CHILDREN. county, New York, when the disease prevailed very extensively among children, relied principally on vegetable astringents for the treatment of the disease in this form. These were composed of the white oak, Quercus alba, blackberry root, Rubus villosus, and the yarrow, Achillea millefolium, combined. They were boiled together in milk, or milk and water, which, when sweetened, was readily taken by children. No particular rule was observed as to the proportion of the ingredients, except that the oak and blackberry predominated. This course is represented to have been very successful in the epidemic dysentery, which prevailed some years ago in Washington county, in this state.t With respect to the diet and regimen of children laboring under dysentery, the same rules already laid down for them in other diseases of the bowels are applicable to this disease ; and the general principles of the treatment need not differ from that adopted in adults. A more particular detail, therefore, of what relates to the %iature and management, is on this account deemed unnecessary in this work. PERITONITIS. The peritoneum is more commonly inflamed in young infants than is supposed, and many of the cases of abdominal inflammation which have been referred to the intestines, have doubtless been of their investing membrane; at least such would appear to be the case from the anatomical investigations of MM. Duges and Billard. Etiology.—Children have been born with every symptom of acute peritonitis, and its existence verified after death by the usual examinations. In other instances infants have been born feeble and emaciated, without exhibiting much evidence of disease, and after death, which usually with this affection takes place within a few hours, old and firm adhesions have been found between different convolutions of the intestines, and in the peritoneal cavity, which have doubtless been formed during intra-uterine existence. M. Duges gives a very interesting account of a case of acute peritonitis, which occurred at the Maternite, in a child prematurely born, measuring about sixteen inches in length, and weighing between three and four pounds. It died in three hours after birth. On a post-mortem examination, all the usual appearances present in inflammation of this membrane were found.t In other instances infants have been born quite vigorous, and died a short time af- *N. Y. Med. Repos., vol. ii., p. 127. tRecherches surlesMalad. les plus import, et les moins connues des Enf. Nou veau nes ; Paris, 1821. DIGESTIVE SYSTEM. 263 ter birth, and the existence of peritonitis for the first time revealed on a post-mortem examination.* It is difficult to account for the origin of these cases of intra-uterine disease, which, from the firm and old adhesions existing, appears to have been of long standing, and to have passed through the various stages while the child was in utero. The mothers appear not to have had any disease of this nature, and, in general, were in perfect health. Peritonitis, like other inflammations, has its origin also in the usual causes of pyrexial diseases, and may attack children at all ages, as they are subject to the numerous exciting causes with which we are surrounded ; and irritation and inflammation of their organs are, from the greater susceptibility of their systems, much more liable to inflammatory action. Infants at the breast are not unfrequently attacked with this disease; but some anatomists have observed, that it appears to have arisen from a constipated condition of the bowels, or from some strangulation or obliteration of a portion of the intestinal tube. It has also been remarked that mothers, suffering from puerperal peritonitis, do not impart it to their offspring. The disease also may arise as a sequel of others. I once knew a severe and fatal case of peritonitis, which suddenly supervened on the dropsy following scarlet fever, where the general symptoms were of so trifling a nature as scarcely to demand any attention. Semeiology.—In acute peritonitis the disease may be known without difficulty. The symptoms are severe pain in the abdomen, which is increased on the slightest pressure. The extreme tenderness of the inflamed part makes the pressure of the ordinary cloths and bandages, and even the weight of the bed-clothes, insupportable ; while the abdomen is greatly distended and tympanitic. The pain and tension are particularly severe around the umbilicus. With these symptoms there is also great restlessness, with crying, and a peculiarly pinched and painful expression of the face. There are also eructations and vomiting, as the disease advances, and a constipated state of the bowels, continuing from the commencement. The pulse is small and frequent, and, indeed, even at the beginning, can scarcely at times be felt. If there should be any difficulty still in making a diagnosis of the disease from pleurisy with these symptoms, percussion of the thorax will be sufficient to establish it; a dull sound of the thorax being always present in inflammation of the pleura. This may be the more necessary, as dyspnoea is not a pathognomonic symptom of thoracic disease. Chronic peritonitis is much more difficult to ascertain; the symptoms are slight, and easily confounded with those of enteritis, or chronic pleurisy. • Billard, Op, Cit. p. 353, 264 DISEASES OF CHILDREN. Peritonitis is one of the most fatal diseases of infancy, and its prognosis is decidedly unfavorable. Morbid Anatomy.—The usual signs of severe inflammation exist in every portion of the peritoneal cavity, as in the adult. Not only have these been found in that membrane, but all the abdominal viscera have been covered with concrete albuminous matter, by which the convolutions of the intestines were adherent. The surfaces of the liver, bladder, and of all the abdominal and pelvic viscera, have also been coated with albuminous exudation ; while seromembranous layers exist on the mesentery, and sero-purulent fluid is occasionally discovered in the cavity of the abdomen. Treatment.—The general principles of treatment of inflammation are applicable to this form of phlegmasia. The application of leeches to the integuments of the abdomen should be one of the first measures to be adopted, while the bleeding from the bites should be encouraged in the usual mode. The extreme feebleness of the circulation almost renders general blood-letting impossible in infants. In older children it must by no means be neglected ; and although the pulse is often so exceedingly small, and the surface of the body so cold as almost to forbid the use of the lancet, yet, as under similar circumstances in adults, the pulse will in general show the effect of the increased circulation from the affected part toward the surface of the body, by an increase of its fulness. The warm bath is of undoubted efficacy, from the powerful revulsion it creates to the surface ; but what particular advantage can be derived from the marshmallow bath, as used in France, is difficult to understand. The application of flaxseed o* marshmallows to the abdomen, is of use, from the length of time with which they may be applied, and thus preserving a continued flow of fluids to the capillaries of the integuments. M. Chaussier, as quoted by Duges, recommends covering the surface of the abdomen with oil of camomile and oil of almonds. It is difficult to comprehend for what purpose such a measure is recommended. Stimulating baths to the lower extremities ought to form a part of the treatment of this affection, and every method employed to preserve an action on the surface of the body, especially in the extremities. Cathartics may safely be given in peritonitis, although, like most other remedies, often with very little effect on the disease in young infants. Calomel and ipecacuanha, from their effects in exciting copious secretion from the liver and intestinal mucous surface, and thus making a powerful revulsion, are an excellent combination when followed by other active cathartic mixtures, as infusion of senna, castor oil, etc. Antimony, James's powder, and other diaphoretic articles, may with more safety be administered in this disease than in those affect- DIGESTIVE SYSTEM. 265 ing the intestinal mucous surface ; with the precaution necessary in the use of all such remedies, in cases of young infants, who are very easily, and not unfrequently fatally prostrated by the use of antimonial preparations. In convalescence, the usual precautions which are necessary in all abdominal inflammations, must be carefully employed in this disease, such as the application of flannel to the surface of the body, and the careful protection of the legs and arms from the cold; for a return of the affection is very likely to ensue on any neglect of these measures. HERNIjE. Children are liable to hernia; from any of the natural openings of the body. Those occurring in the abdomen may arise not only from the natural openings, but also from some imperfection of the abdominal parietes. The latter are very rare, but the former are not unfrequent, and often arise from a natural predisposition, for it is not unusual to see two children of a family thus affected. The most common of these is omphalocele, or umbilical hernia. Umbilical hernia will therefore form the principal subject of these remarks. Etiology and Morbid Anatomy.—The cause of this affection must be sought in the natural conformation of the part, and the relative condition of the intestines, of the foetus and the umbilcal opening. In the early period of foetal existence, almost the whole of the intestines are contained in a sort of pouch at the base of the cord. As the foetus is developed, and the different parts assume their proper size and relative position, the convolutions of the intestines gradually recede within the abdominal cavity, while the opening which admits the cord closes, until at birth it is just sufficient to admit the umbilical vessels. The base of the cord however, will at times continue still large enough to retain a portion of the intestine, and a species of pouch is thus found to exist, formed by the skin and cellular tissue, and the peritoneum. A portion of the intestines, therefore, instead of returning within the cavity of the body, occupies the natural lodgment thus afforded ; and the constant pressure on the mass of the abdominal viscera by the abdominal muscles, assists in continuing them in this situation The hernial sac for the most part contains a small part of intestine, but there have been found instances in which the liver, spleen, and a great portion of the small and great intestines have been found, as is the case in an instance mentioned by Scarpa.* When these large tumors exist, they appear to be connected with some other • Traite Practique des Hernies. Translated from the Italian by Cayol, p. 323. 34 266 DISEASES OF CHILDREN. malformations about the abdomen, or with an enlargement of the protruded viscera. But besides this, a difficult labor may cause this condition to exist, or at least, increase it; for, according to Scarpa's experience, the cases of enormous hernia occur in children that are born after difficult labors. Semeiology.—It is easily known by a tumor at the umbilicus, soft and yielding, and always increased on crying or coughing. The tumor can, in most instances, be temporarily removed by gentle pressure. When the intestines is thus removed, a vacant place, well defined, is distinctly felt by the finger. When this hernia exists, it is generally evident from birth ; but in many cases it does not show itself until some days afterward, as the intestines do not protrude until they have been distended with food. Treatment.—Compression is the proper means of treating this affection ; that by ligature, formerly adopted, is generally disapproved of by modern surgeons: the rapidity with which the navel is closed, greatly facilitates the cure. These protrusions will continually occur for some weeks or even months after birth ; but with a very gentle compression, aided by a bandage, a complete cure is soon effected, if nothing more than the intestine be protruded ; and even if it be for some time, even for years, neglected, the application of a proper truss, or even of a bandage, will almost certainly effect a cure. The object being to preserve the intestine within the abdomen, the means of effecting it may be that which is best adapted to this end, without putting the child to any pain or inconvenience. For the most part a simple roller applied around the body, having in its centre, corresponding with the umbilicus, a graduated compress, is the best. This should be carefully applied, and will answer the purpose far better than any truss which can be procured; for in general a truss is exceedingly difficult to keep properly applied to the abdomen of a young infant. Congenital inguinal hernia may also exist in young infants. It differs from all others, in the circumstance that the tunica vaginalis forms the hernial sac ; the portion of intestine forming the rupture being in immediate contact with it, arising from the non-adherence of the peritoneal canal, by which the testes have descended with the intestine ; in consequence of which, the protruded bowel and the testes lie together in the tunica vaginalis. In some cases the testicle has not descended, which should be first ascertained before any bandages are applied. It is to the genius of Haller,* Hunter,f and Pott,} that we are • Program. Herniarum. Observat., etc.; Gotting., 1749. t Medical Commentaries; London, 1762. j Account of a Particular kind of Rupture, frequently attendant on Newborn Children, etc.; 1757. 267 EXCERNENT SYSTEM. indebted for our knowledge of the causes and morbid anatomy of this species of congenital hernia. For a further detail of its nature, these works, and those especially devoted to surgery, may be consulted. In some instances, this kind of hernia has taken place for the first time at tli3 age of twelve or fifteen years. It has been supposed that in these cases the testes have remained until that period within the abdomen, and that the bowels accompanied them in their descent. Semeiology.—To distinguish inguinal hernia is sometimes a matter of difficulty, as hydrocele is apt to be taken for it. In hydrocele, however, the scrotum is translucent; and, with a little care, the absence of the intestine may be detected. One of the principal sources of uncertainty is the increase of both tumors on coughing and crying; and that the fluid, like the protruded bowel, may be returned to the abdomen. Treatment.—After the hernia is reduced, the same principle adopted in the management of all species of hernia? is applicable to the present form. A temporary bandage, however, is more suitable than a truss for young infants ; the latter, however, may be used for older children, as in adults. The bandage and compresses should be frequently changed, as it is impossible to prevent the urine from soiling them, and causing inflammation and severe excoriations of the skin. This will almost certainly effect a cure, if the child be kept still, as the natural tendency during growth is to obliterate the opening through which the intestine has protruded EXCERNENT SYSTEM. The term excernent is used as applicable to the two functions which are discharged by the secreting and absorbing vessels. It is a term used by Dr. Good, as best to express these two functions, which bear the same relation to each other as those of the arteries and veins. As the consideration of some of the various diseases of the different systems of necessity includes the excess or diminution of glandular secretion, the present system will be limited to such as affect the lymphatics, and those organs whose office is the separation of*excrementitious secretion, comprising the kidneys and the skin 268 DISEASES OF CHILDREN. PECULIARITIES OF THE EXCERNENT SYSTEM. Lymphatic System.—The lymphatic system is a part of great importance, but it was not until comparatively in recent times that its use was properly understood, although some parts of it were known to Galen and Eustachius. The organs which form the system of absorption are of two kinds, the lymphatic vessels and the lymphatic glands. The former, as is well known, perform the office of transmitting into the sanguineous system the fluids which are absorbed from the various surfaces of the body. They exist in two sets — the one superficial, the other deep seated; but both anastomose very freely by plexuses. The form and arrangements of the commencement of the absorbent vessels, from their extremely minute size, are altogether unknown. Although detailed descriptions and drawings have been made of them as they appear on the internal surface of the intestines, and traced by the microscope to originate in the villi, or small projections that are attached to this part, yet the lymphatic absorbents have baffled the skill of microscopic philosophers to detect their origin. The lymphatic glands occupy a large portion of the absorbent system, connected with the lacteals and lymphatics. They are small bodies, of different forms and sizes, and situated singly or in groups in the course of the absorbent vessels; always more abundant about the joints, arm-pits, neck, and mesentery. These glands are very numerous in the mammalia. They are rare in birds, and still more rare in fishes. Although apparently essential to the proper transmission of the fluids, judging from their number, yet their use is unknown ; but whatever be their use, they are evidently more important in the young, where nutrition is a process of great activity; they are consequently found much larger, and contain a larger quantity of fluid, than in advanced life. During infancy and childhood the activity of the absorbent system is surprisingly great, while the secretory function, and consequently the process of nutrition, are also in a state of high functional vigor; these changes of interstitial removal and deposite being necessary during this period of growth. The action of this system declines as age approaches, and is very feeble in advanced age. The formation of fat is very abundant in young children, and in the foetus it appears in masses, unconnected with other portions. Thus, it is found between the muscles forming the cheeks, in the form of globular bodies, and gives to the cheeks of newborn infants the peculiar prominence which distinguishes the form of the face The color of the fat is much lighter in children thgn adults. EXCERNENT SYSTEM. 269 The extreme activity of this system during childhood renders it liable to diseases; and affections of the lymphatic organs are strikingly peculiar to this period of life. Affections of this system at this time, illustrate, in a very remarkable manner, the principle of the predisposition to disease being often dependant on growth. The lymphatic glands differ in no respect from those of adults, except that their texture is softer and their size larger, and that in young children the lymphatic ganglia of the neck are more liable to be diseased than those of the mesentery; although to this rule there are some exceptions, as I have seen. These glands are diseased in proportion to their development; and those of the mesentery being but slightly developed before the age of a year, are but little liable to be affected by disease before that period. They are very remarkably under the influence of the atmosphere. When the climate or season is constantly cold and damp, and, especially, if added to this there is also great impurity from want of a sufficient ventilation, and if there exists also a deprivation of light, a complete assimilation of food can not take place, and the development of the body is imperfect. Like other fluids, that circulating through the lymphatics may be either in excess or deficiency, and thus affect this part of the body with all the consequences of a plethoric condition of the lymphatic system, or with the general want of vigor and tone arising from a defect of the important substances it conveys for nourishment and growth ; the former causing those peculiar inflammations which some individuals manifest, so different from the violent sanguineous action, turgescence, and suppuration, with which those abounding in blood usually present. The character of lymphatic turgescence, or inflammation, partakes more of the nature of simple irritation in its general symptoms. So obscure are they, that they do not appear to be attended with any increased action; but the deposition of albuminous matter, and the enlargement of the lymphatic glands, show the existence of this species of plethora. The opposite state of this system will manifest itself particularly in a great loss of energy, and a defect in the general process of nutrition throughout the body. The lymphatic plethora will also impart to the blood a peculiar quality, known by the deficiency of red globules and fibrine, whereby the body is less capable of resisting the effects of cold, so that not only the glands themselves, as above stated, but the whole body, will be more susceptible to a lessened temperature. Thus, the lymphatic temperament, with its peculiar manifestation in the ganglia, will be formed, and which, like other ultimate molecular conditions of the system, may be transmitted to posterity. The inflammation of the glands of the lymphatics is often exci- 270 DISEASES OF CHILDREN. ted by the irritation transmitted along their course. Besides this state of the mucous membrane in producing the mesenteric disease, the effect of insalubrious nourishment is also evident in the irritation excited in these glands by improper chyle formed from it. These, however, will be again brought to notice under the proper head. The effect of suitable nourishment in the production of lymphatic diseases is evident, not only in children who have arrived at the age when a variety of food is required, but it is also seen in sucking infants, who become scrofulous if nursed, when first born, by a woman who has been several months delivered. From the inspiration of impure air and the use of insufficient or improper food, the nourishment of the body is very materially influenced. If, therefore, a due supply of nourishment does not take place, the whole system must suffer, from the digestive to the nutritive functions. In some diseases,the digestion, even of proper nourishment, is imperfectly performed. In although perfectly digested, yet when introduced into the absorbent system, from some sluggish action in these vessels, arising from the causes already mentioned, and also from an hereditary transmission, the affections of these glands take place. In other instances, again, the influence of the deranged action is only evident in the process of deposition and nutrition, when the disease will be seated in the ultimate assimilating powers. One of the most striking evidences of a morbid state, and often in children without other marks of disease, is the arrest of the deposition of animal oil, and the consequent loss of plumpness of the body. In this instance, the action of the secernents appears to sympathize with the diseased action in other parts and tissues of the body. In other instances the secernents themselves are in a state of morbid action, and, as in the case of rickets, there is a deficient supply of earthy matter, or of phosphoric acid, which are necessary, for the formation of bone. In the growing condition of childhood, a full supply is needed, to effect a proper expansion of the body, and to continue and to maintain it in strength and firmness. This supply, when continued in a sufficient manner, preserves this part of the frame in its integrity ; but when in any degree defective, causes that condition of the system which so seriously affects the bones ; producing one of the most serious and lamentable diseases of childhood. The diseased action of the secernents is also apparent in dropsical affections, diabetes, and the numerous diseases of the skin. Cutaneous System.—The excretories of the skin form a very important outlet to the system; and in endeavoring to trace the lymphatics, il is evident that a great number of them have their or- 271 EXCERNENT SYSTEM. igin near the cutis, absorption very readily taking place under circumstances favorable to this process. Works on general physiology contain numerous instances and experiments in proof of this power of the cutaneous vessels. The skin of the foetus, when first apparent, consists of a viscid coating, through which the immediate subjacent parts may be seen. It gradually increases in density until birth. The skin exhibits in infancy and childhood no wrinkles, in con sequence of the quantity of fat beneath it; when this is absorbed, the skin appears more in the form of folds than wrinkles. The exhalent vessels of the cutaneous system are peculiarly delicate ; and when from any cause the cuticle is abraded by mechanical violence, or by heat, or other chemical action, they are immediately exposed to the action of the air, and are violently excited, and, in children, rarely escape inflammation ; resulting in the formation of purulent matter, or in the excessive action of the vessels themselves, pouring out a quantity of serous fluid. These excretory vessels are also remarkably controlled by the changes affecting the atmosphere, without any removal of their natural covering, being often chilled and rendered torpid by a sudden depression of atmospheric heat. They are also easily excited by irritations in the stomach and bowels, whether they are induced by inflammation, or simply by the presence of irritating food, exciting the mucous membrane. Urticaria is a familiar instance of the general sympathizing influence on the skin. Eruptive fevers, also, appear to direct their principal force on the excretories of the skin ; at least such is the opinion of some eminent physiologists and physicians; but in one or two of these diseases, the whole capillary system would appear to be their seat, both within and outside of the body. The absorbents of the skin often become torpid in their action, by which only a portion of the fluid deposited is carried off; hence the deposition of more than can be removed, causing accumulations in the cutaneous follicles, whereby various pustular, and other eruptions are produced. The cutaneous secretions consist of what is denominated sebaceous matter, from the small glands above mentioned, which are situated in the tissue of the skin. These glands appear to have beeu in a very active state during foetal life, from the quantity of sebaceous matter which covers the child at birth. The circulation of the skin is very active in children, and especially in young infants. The consequence of this excess of blood is the high vermilion hue so well known in children. This color, however, does not exist before birth. As it receives, during intra-uterine life, only black blood, the skin undergoes a 272 DISEASES OF CHILDREN. very remarkable change in its color at the period of birth, from the red blood, which for the first time circulates through the body on the establishment of respiration. This is an important fact, as the color indicates the condition of the respiratory system. This intense red color rarely continues beyond the eighth day after birth ; from that time it gradually diminishes, and disappears at an indefinite period. It is one of the strongest evidences of the health of the child. This abundance of fluids gives to the skin its plump, soft and elastic qualities, so different from the harsh and dry sensation which it imparts in old age. This softness continues for some time after birth, and the integuments can very easily be melted into jelly by ebullition. They arrive at their greatest density about the age of puberty. The skin, therefore, for the greatest period of growth, possesses these marked peculiarities, and from abounding in all the requisites of development, becomes thereby greatly predisposed to numerous diseases in its different tissues : a constitutional irritability peculiar to infants and children. The various strophuli, and other inflammations of the skin, have their origin in the sanguineous turgescence and state of high excitability of the skin in children. During intra-uterine life, the animal sensibility of the skin, it is supposed, does not exist; but after birth, it is, on the contrary, very great. Its high vital properties render it extremely susceptible to the impressions of surrounding objects. The water used in washing the child, the clothes, and even the stimulating effect of the atmosphere, communicate a great degree of excitation. All infants present at the time of birth much the same color of the integuments ; but about the third month the peculiar hue of the child becomes evident, and the dark complexioned can then be distinguished from the pale and ruddy. The peculiar complexion of children is greatly under the influence of external causes: temperature and exposure, as well as the peculiarities of constitution, cause great variations in whole tribes of people. The reticulated tissue is that on which the natural color of the skin depends, and these alterations are caused by some unexplained change in the blood, which circulates in it in great abundance. Its mucous or fatty consistence has caused a doubt as to the propriety of terming it a distinct coat or texture; but whatever be its nature, it is the proper coloring portion of the skin ; it therefore differs greatly in different races of men, and often differs in the same individual in different parts of the body, causing the various spots or moles observed on the skin of children and adults. In some it is absent, or rather from a defective secretion of the rete muscosum, or from an imper- EXCERNENT SYSTEM. 273 feet elaboration of it when secreted, it imparts a peculiar dead white hue to the skin, forming the disease called albinism. Haller mentions the existence of spotted infants, and also of instances of black children being born of white parents, and white children whose parents were black. The mottled appearance of the arms, a violet, mingled with white and red, although it would appear to arise from an impediment in the local circulation, is generally regarded as an evidence of health; those that are plump, and whose limbs are large and full, are such as exhibit this hue when their limbs are exposed to the influence of a slight depression of temperature. Sometimes the skin has exhibited at birth various kinds of excrescences in different parts of the body; they are generally those of a prolongation of the integuments, or the marks known by the name of noevi materni, which appear to be the first stage of these cutaneous excrescences advancing toward inflammation. Other colored spots are the simple alteration of the cutaneous pigment. Some authors have described the birth of children whose face, body, and limbs, were covered with hair, and which have been mistaken for wild beasts, and were on this account deprived in anciem times of their legal rights as children.* This condition is simply the continuance of hair, which covers the foetus in the early part of inira-uterine life. Perhaps it was the persistence of these hairs on the faces of infants, which has been described as a beard.t Among the most common phenomena in infants, is the healthy separation of the epidermis, described by Orfila, Thierrey, and Billard. It occurs after birth, and only in mature children. This separation of the cuticle commences at uncertain periods; out generally not before the second or third day after birth; it is usually at its height on the third or fifth day. The duration of this process, also, is very variable; it having continued even as long as two months. The cause of this process has been explained to be from the transition the child experiences from immersion in the waters of the amnios, by which the skin is kept moist. On exposure to the air it becomes dried, and the cutis then cracks and dies ; separating in scales, plates, lines, or powder, according to the part of the body from which it exfoliates. From the extreme activity of the absorbent system in children, and the like exaltation of the functions of secretion and deposition which have been noticed, it is evident that the process of nutrition and composition, of repairing and building up, is very great during the time of life allotted to growth. At this period, arterial action, so necessary to the proper performance of the secretory function, • Haller, Opera Minora., Lib. i. t Eph. Nat. Cur. Dec. Uv, Case 163. 35 274 DISEASES OF CHILDREN. predominates over the venous; this arterial predominance is evident lo the eye throughout the entire cutaneous surface; and anatomical investigations show the same throughout every part of the infant frame. The nerves, also, of organic life, are in a state of high activity; for on a harmony of action of the sanguineous vessels which supply the requisite nourishment, and of the nerves which control the nutritive process, depend the proper and healthy deposition of materials for the growth of the body. In this process the absorbent system largely enters, and on the undisturbed harmony of these, the preservation of the body, in its healthy condition, depends; while, during the process of development, the nutritious or depositing function must be in excess. At the time, therefore, when those changes occur, which are necessary to the increase of the body, and where there already naturally exists a difference in the various powers, a great disturbance of this mutual action must ensue, when any circumstance arises to interfere with the harmony of action. Congestion or inflammation, both sudden and violent, usually follows an interruption of the harmony of action attending the process of nutrition. * From the activity of the nervous system, also, at this time, by which a healthy vigor and a uniform deposition of materials of growth is preserved, by the universal sympathy of the body with the action of its different parts, arise also those sudden derangements in distant parts, and especially in those where this nervous influence is in high activity, for the growth more particularly of a part, as the brain in children. This sympathetic action is observed in man at all ages, but far more sudden in its invasion, active in its progress, and fatal in its results, in the infant. The actions connected with nutrition and growth, occur in the parenchyma of the different organs in the internal and external tissues of the body, and in vessels themselves, on which growth depends in every tissue. During the development of the foetal body, the effect of deranged action in the formative process is evident in the various malformations of the child. After the completion of the body, and on the establishment of independent life, malformations rarely occur, but the body is subject to the various laws which are observed to control it in the adult, and similar diseases are excited into action by causes which produce them during the different periods of life. But how much more frequent and violent they are during childhood, is familiar to every observer; arising from a predisposition acting also during the progress of disease. The natural and necessary harmony of action is thus completely deranged ; and the diseases of childhood, when once excited, are remarkable for their violence, and demand a correspond ing promptness in their treatment. EXCERNENT SYSTEM. 275 SIGNS OF DISEASE FROM THE EXCERNENT SYSTEM. The lymphatic organs exhibit few appearances indicative of disease when considered by themselves, independently of their effects in controlling the development of the body generally, or of some particular portions. These are, therefore, more properly considered under other diseases, as the effects of a deranged action are often more manifested in other parts than in the lymphatic system itself. The peculiar state where the lymphatic temperament predominates, is manifested by the leucopalhic condition of the whole body. The process of secretion appears to be very active in some parts, while the absorption of the fluids is not in the same state of activity; hence the fulness of the cellular tissue takes place, particularly in the abdomen, and children with this predominance exhibit an unusual protuberance of this part of the body. The skin in this temperament is pale, the muscles are soft, and the circulation is slow—the pulse being soft and weak. The vital force is but languid, and any disturbance of its action, is attended with but little inflammatory action of an acute kind. The enlargement of the lymphatic glands about the neck not unfrequently arises from tinea capitis, and appears to be the effect both of a transmitted inflammation along the course of the absorbent vessels, and of the absorption of the imperfect secretion in the scalp. The swelling of these glands also arises in the hereditary disease denominated scrofula, and is an evidence of the tendency of the system to chronic inflammation in the different absorbent ganglia throughout the system. When these tumors persist for a long time, and become of a livid or purple red, they are unquestionably of a scrofulous nature. These latter tumors rarely appear before the second year, and seldom continue after the seventh. In other instances, however, the disease does not make its appearance till after the seventh, and for the most part disappears about the fourteenth year. The cutaneous system furnishes many indications of disease arising from its size, consistence, contractility, color, sensibility, and from the existence of inflammatory eruptions. The size or volume of the integuments depends on the condition of the sub-cutaneous tissue, being much increased in hyperemia of the part, which is very common in eruptive fevers, especially in scarlet fever. It also arises from the presence of fat or serum, and invariably attends local inflammation in a greater or less degree. The volume of the integuments of the face is not increased in 276 DISEASES OF CHILDREN. acute abdominal diseases, except when they are complicated with congestions about the brain; it therefore yields a good diagnostic sign in diseases of children, where this complication so often occurs in the progress of their diseases. A swelling behind the ear, which terminates in suppuration, gives favorable prognosis in diseases during the period of dentition, but is more particularly favorable in exanthematous affections. In acute exanthematous disease, there is always a congestion about the head; and a swollen condition of the integuments of the face always accompanies this state of the head. The presence of fat may easily be recognised by the uniform volume of the body, and the elasticity of the skin. (Edematous swelling may be known by the pitting of the integuments on pressure, and the shining appearance of the whole surface. These swellings occur after scarlatina, measles, and erysipelas, but more frequently succeed the first-mentioned disease. Infiltration of the cellular tissue, occurring as a sequel of these diseases, is not of so serious a nature as the same swellings arising from other causes ; the former being simply an effect of local inflammation, the latter more often the result of derangements or malformations in the centre of the circulation. A diminution of the size of the integuments in chronic diseases, especially in affections of the mesenteric glands, is an unfavorable sign ; when occurring in acute diseases, the prognosis is not so unfavorable. An increase of the consistence of the skin takes place with an increase of its volume. The skin of the face, and especially of the forehead, is tense and shining in hydrocephalus. This tenseness will arise from the serous infiltration of the cellular tissue, and is the disease known in Europe as the skin-bound, or induration of the cellular tissue. The temperature of the skin is very great in all fevers and inflammations, and is particularly marked in scarlet fever. In inflammations of the bowels the heat of the abdominal integuments is also great; and, in general, the heat of any particular portion of the integuments indicates an inflammation in the parts beneath. The color of the skin depends on the state of the vascular system in young children. In those that are older, emotions of the mind, as in adults, produce changes in its color, showing the influence of the nervous system on the remote circulation. A leucopathic state of the skin depends on the excess of serum in the blood, and indicates the preponderance of the lymphatic temperament. The change of the skin in eruptive fevers to white, is a very unfavorable symptom; so is also this color in the congested variety of scarlet fever, when often no eruption appears until after death. 277 EXCERNENT SYSTEM. A general redness of the skin is its natural color in infants—a local redness is a sign of cutaneous inflammation, and also of inflammation in the subjacent organs ; as in the case of such an affection of the brain, the skin of the face exhibits an excess of blood. Alternate paleness and redness of the face denote the inflammatory condition of the meninges, which terminates in hydrocephalus. The blue color of the skin arises from some disturbance in the circulatory and respiratory apparatus. A preternatural fulness of the small veins of the skin appears to be its immeediate cause. All causes which prevent the oxygenation of the blood, as such diseases of the heart as interfere with the proper transmission of venous blood to the lungs, will cause a blueness of the integuments. It is therefore usually an indication of the persistence of the foramen ovale, although this has been at times found to exist on a post-mortem examination, while the alteration in the color of the integuments has not existed. The prognosis is decidedly bad if it be connected with an impediment in the respiration, which can not be remedied. An ashy or earthy color of the skin occurs in protracted diseases of the bowels, and especially in cholera infantum, and in all diseases connected with a chronic disturbance of the chylopoetic viscera and defect of nutrition. The yellow color of the integuments arises from absorption of the bile, from congestion of the liver, and obstructions in the bile ducts, arising from various causes, but in children more particularly from worms. The jaundice in children is a much more favorable disease than that occurring in adults, as in the latter it for the most occurs in organic changes of the liver. The orange color of the skin in newborn infants may arise either from bile received into the bloodvessels, or from a peculiar yellowness of the serum. The former may be known by the adnata of the eyes partaking of the general tinge of the body; when it arises from a simple yellow coloring of the serum, the eyes remain unaffected. A yellow color of the skin in young infants, connected with a disease of the stomach and brain, is much more unfavorable than when not thus complicated. The skin is usually more dry in the first stage of all acute diseases, but more especially in inflammation of the bowels; and if this dry state continue long, the prognosis is rather unfavorable, but not so much so as in adults; and, in general, the excretion of the skin does not, in young children, yield so satisfactory a prognosis as in those that are older. Local sweats, especially when occurring about the head, are unfavorable during acute disease. 278 DISEASES OF CHILDREN. Copious sweat often occurs after the disappearance of a convulsive paroxysm in children ; it is not then to be regarded as critical, for a recurrence of the convulsions often takes place after a free sweat. The natural odor of the sweat is acid, but not so marked in children as in adults ; in the miliary eruption it is more evident. In affections of the skin the sweat assumes a peculiar odor. In porrigo it has the smell of cats' urine: in scabies an empyreumatic odor prevails ; in protracted pityriasis it has a mouldy smell, and smallpox gives an odor resembling fish-brine. The diagnosis of cutaneous eruptions will more properly be considered under the heads of the respective cutaneous diseases. Eruptions generally, which occur after the continuance of acute or chronic diseases, give a favorable prognosis. Herpetic eruptions are usually connected with diseases of the stomach and liver. Herpes labialis is a critical eruption in all inflammatory and febrile diseases. Pemphigus is generally an indication of gastric affection ; and the species denominated gangrenosa infantilis is a sign of great debility, and gives an unfavorable prognosis. The regular course of the eruption in scarlatina and rubeola is to be regarded as giving a favorable prognosis, when not accompanied with severe complications of some internal organs. Its disappearance is to be regarded in an unfavorable light. Erythematous eruptions, when not caused by any direct application to the skin, are signs of acute or chronic disease of the intestinal tube. Ecthyma occurs as a critical eruption in acute intestinal diseases. Porrigo fovosa is a sign of a scrofulous habit. The sensibility of the skin is either exalted or diminished in diseases. The alterations in the ordinary sensations of the skin, such as tickling, itching, and prickling, occur in the affections of the skin, at the orifices of the mucous membranes, and are usually the signs of irritation in the gastro-intestinal mucous membrane, either from inflammation or the presence of worms ; if at the rectum, of the existence of the oxyures. These sensations, when existing on the surface of the body, and when accompanying an acute excitement of the blood-vessels, indicate the occurrence of an exanthematous eruption. 279 EXCERNENT SYSTEM. DISEASES OF THE EXCERNENT SYSTEM. SCROFULA. Scrofula has, from the remotest periods of which we have any records, received a particular attention from physicians, and appears to have been a disease of more universal prevalence than almost any other. Among the moderns, it has been the subject of a number of essays in Europe, where it is much more prevalent than in'the United States. Morgagni, Wiseman, Carmichael, Fothergill, and others, have all directed their attention to this highly interesting subject. It would be vain to enumerate all the writers on scrofula which have appeared within the last half century; a few of the most prominent will suffice. The work of Hamilton, on scrofulous affections, contains many valuable practical suggestions.* One of the best, probably, that has appeared, is by Hufeland; first published in 1795. This work has been translated into English, and is a valuable addition to our stock of professional literature.t Baumes and Baudelocque, in France, and Lloyd, in England, have also published excellent monographs of the disease.} Struma or scrofula appears under two forms ; one, where the disease is confined to the lymphatic glands alone, and is purely a local affection. In this variety it appears as tumors, generally ending in ulceration ; situated chiefly about the neck, and is the affection known as the king's evil.|| The other form is, where the disease has become a constitutional affection, and shows itself in dif- * Observations on Scrofulous Affections, etc., bv Robert Hamilton, M. D.; London, 1791. t A Treatise on the Scrofulous Disease, by C. G. Hufeland, Physician to the King of Prussia, etc. Translated by Charles D. Meisrs, M. D.; Philad., 1829. t Mem. sur le Traitement de la Malad. Scroful., etc. Sur le Virus Scrophuleux, Paris, 1805, par F. Baumes. Treatise on the Nature and Treatment of Scrof., etc., by Eusebius Arthur Lloyd ; Lond., 1821. || The name king's evil is derived from the supposed virtue in the royal touch, for the cure of this disease. Edward the Confessor was the first who touched invalids suffering with it, and it is said he received this special privilege from heaven ; and the same power was attributed to all his lineal descendants. Ancient authors consider the virtue possessed by the king, as referable to his sanctity and not to his royalty. It would appear, therefore, that there exists a very good reason for the absence of this power in some of his posterity. During the reign of Charles the Second, the practice of resorting to the royal touch was at its height; and multitudes flocked to receive the benefit of the royal remedy. The number of persons touched by him in twenty-four years, was 92,107. The newspapers of that period announced the event, and the ceremonies attending it, and detail the particulars on one occasion, where 600 persons were touched. Cromwell afterward tried, in vain, to exercise this royal prerogative. The practice continued even to the time of Queen Ann ; and Dr. Johnson, when a child, was taken to be touched for the scrofula, by the advice of the celebrated Sir John Floyer. The third volume of the Edin. Med. and Surg. Journ. contains a very interesting aecount of the practice of « touching for the evil." 280 DISEASES OF CHILDREN. ferent parts of the system, in the well-known diseases of phthisis, rickets, and the various affections arising from a scrofulous diathesis, and appearing in almost every tissue and organ of the body. The first-mentioned form, as a disease particularly of the lymphatic system, is that which is the subject of the present remarks. In former days the term scrofula was applied to the tumors existing in the parts already mentioned, and characterized by the peculiar marks of the disease. The description given of them by the Roman disciples of Hippocrates, corresponds exactly with the disease as it appears at the present time.* From the accounts vye have, neither the Greek nor Roman writers appear to have regarded the disease as a constitutional affection, although phthisis, and other diseases depending on a scrofulous diathesis, unquestionably existed. Etiology.—Scrofula was long supposed, and the idea continued even to a very recent period, to be contagious; but every attempt to propagate it by inoculation, and by exposing those in health to its influence, by placing them in the same bed with scrofulous patients, has failed. It is, therefore, satisfactorily proved, that it does not arise from a specific virus. The predisposition to scrofula without doubt exists in some individuals by inheritance from their parents. This hereditary transmission consists rather of such a natural arrangement in the ultimate molecules constituting the structure of the body, as to dispose it to a peculiar set of actions, whereby one class of functions naturally tends to certain modifications in their performance, than in the transmission of any peculiar taint in the body, as is the case in syphilis or small-pox. A constitutional peculiarity and predisposition to the disease, therefore, descends from the parent to the child. It does not, however, follow from this that all the children of a scrofulous parent are necessarily affected with scrofula, or manifest that peculiarity which is denominated a scrofulous diathesis; for they may pass through an entire life without any appearance of the disease, from the absence of an exciting cause, and may even transmit the predisposition to their offspring, without being affected with the disease in any other than a latent form. The hereditary predisposition may he illustrated by the configuration of the external parts of the body, by which children so often bear a striking resemblance to their parents. If this be so in the visible parts of the frame, it may likewise exist in other parts which * Struma quoque est tumor, in quo subter concreta quaedam ex pure et sanguine quasi glandular oriuntur; qua? vel prscipue fatigare medicos solent, quoniam et febres movent, nec unquam facile maturescunt; et sive fcrro, sine medicamentis curantur, plerumque iterum juxta cicatrices ipsas resurgunt; multoque post medicamenta srepms; quibus id quoque accedit, quod longo spatio detinent. Nascuntur maxime in cervice; sed etiam in alis, et inguinibus, et in lateribus. CeJsus, Lib. v., xxviii.—7. EXCERNENT SYSTEM. 281 are concealed from direct observation. The molecular conformation of the body in its several parts, being, therefore transmissible to the offspring, the action of these parts will undergo certain modifications dependant on the organization, and from this cause children will be subject to the diseases with which their parents are affected. In children, where the disease is hereditary, the constitution exhibits externally a peculiar appearance, and this diathesis may be known where there exist a softness and flaccidity of the flesh, light hair and blue eyes, florid cheeks and a smooth skin. Children with this scrofulus tendency often have a large and tumid upper lip. Although at every period of life the disease may be developed, yet unquestionably childhood is the time when the predisposition to the local disease is the greatest; in addition to this, scrofulous affections of the eyes and bones are most likely to occur also at this period. After puberty the lungs become more often the seat of this peculiar affection than before that period; and there is nothing that so clearly exhibits the influence of growth in developing certain diseases, as the change in the liability to disease manifested in the absorbent and lymphatic system. This predisposition is not hereditary in every instance, for numerous causes may arise to produce a morbid change in the action of the lymphatic system, and thus give rise to the disease; this, it is evident, must have at some time been the case, even in hereditary diseases. It may therefore be acquired by the action of the same causes which develop it in those subjects who are predisposed to the disease. This important fact illustrates, in a remarkable manner, the pathology of the disease, which will be considered hereafter. Among the most common exciting causes, is the influence of a cold and humid climate. The effects of climate are of familiar observation ; and the change from a cold, wet country, to a warm and dry region, upon those who suffer from the various forms of a scrofulous habit, is well known, producing alterations which no medicine can effect, while the change from a warm climate to a cold; damp country, will cause the development of scrofulous affections, as has been observed to occur in the youthful inhabitants of the East and West Indies on their removal to a colder region. The variable weather so often occurring in the winters of temperate climates, is a fruitful source of the disease, especially when, as is always the case, this variation is accompanied with great humidity of the air; and it is more common to find it in these climates, or in those elevated situations of hot climates which expose them to sudden atmospheric changes, than in those countries where a uniform cold is maintained from the commencement of winter until its close. 36 282 DISEASES OF CHILDREN. The cold is subject to but little vicissitudes in the winter in the northern sections of the state of New York, the New England States, and Canada, and the disease consequently is less prevalent than in other portions more subjected to alterations in temperature. The effect of this cold and humid atmosphere is not only in the obvious influence it produces on the disturbance of the capillary circulation of the surface, but also by its constant action on the extensive respiratory surface, by which an irritation is maintained in the lungs, whereby an imperfect change is effected in the blood— a change interfering with the nutritive process; for the proper performance of which a full alteration in the blood should be produced. Such would, indeed, be expected to be the case, where the disease exists primarily in that part of the system which forms so important an office in the composition of the body as the lymphatic. But in addition to this cause, there exists another, having a close analogy to the former; and this is the deterioration of the atmosphere, from the crowding together of a number of inhabitants in large towns and manufactories. It is well known how much more prevalent this disease is, in all its forms, in towns and cities, than in the pure air of the country; and every one is familiar with the distressing consequences manifested in the different scrofulous affections in the town of Manchester, in England, a number of years since, as recorded by Dr. Percival.* The whole number of deaths from scrofulous cases, as mentioned by him, was about one third of the entire number of deaths among the children of that place. In the hospital for sick children, at Paris, one half of the bodies that were opened exhibited marks of scrofula in some part of the body. Dr. Alison has conclusively established this fact, by carefully comparing the relative mortality from this cause, among children in the pure air of a country parish in Scotland, and that of the manufacturing town above mentioned.f The bad effects of impure air on the tender and susceptible frame of children, I have frequently had occasion to observe, and have often noticed that it is far more injurious of itself than improper diet in older children; the latter, although unquestionably a great cause of diseases, may yet be rendered digestible by habit; and an entire change of food, at first difficult of digestion, may become suitable for the child, and be easily digested. These remarks apply more especially to the formation of the constitutional predisposition. This agent is so evidently a cause of scrofula, that Baude- Jocque has given as his opinion, that it is perhaps the only cause of the disease; and Sir James Clark considers il as a more powerful agent in the destruction of human life among children living in * Percival's Works, vol. iii., p. 107. t On Path, of Scrof. Dis., Trans. Medico-Chirurg. Soc, Edin., vol. i., p. 383. EXCERNENT SYSTEM. 283 workhouses, where we have seen that scrofula prevails, than impoverished diet.* In accordance with this are the facts mentioned by Mr. Carmichael, of Dublin, in his account of the scrofulous disease which prevailed in the House of Industry in that city, where one hundred and fourteen children were lodged in one ward, the air of which became insupportable in the morning, while hundreds were confined in the school-room during the day; the disease prevailed under these circumstances in all its fatal violence. The effects of impure air, even on the foetus, in interfering with the nutritive process, is evident in the remarkable fact mentioned in the London Medical Gazette, of the year 1S32, that monstrous births are not unfrequenl in the gloomy dungeons of Lille. The influence of light on TOe development of ova, has been shown by Edwards in experiments on those of tadpoles, the regular process of which is materially affected by a deprivation of this agent.t It is here proper lo remark, that scrofula is by no means so prevalent in this country as in Europe. The same cause developing a different morbid condition of the system, and affecting chiefly the chylopoetic viscera. From the influence of climate a diarrhoea is often the result of confinement to an impure atmosphere; as was recently the case among the pauper children of this city, where a severe and fatal affection of the bowels prevailed, arising from the badly-ventilated condition of the building on Long Island, in which they were lodged. To this cause may also be added that of bad food, which, when united to those already mentioned, will invariably produce a diathesis favorable to the formation of some form of scrofulous affections. Imperfectly-elaborated milk will also dispose the sucking infant to scrofula ; and Wiseman mentions that a child nursing from a scrofulous nurse, will have the disease developed. Whatever differences of opinion there may be as to its precise pathology, it unquestionably, when first developed, owes its origin to those causes which produce an alteration in the nutrition of the system; and therefore we find that the combined influence of a cold, wet atmosphere, a confined and ill-ventilated residence, and an insufficient diet, are the principal incidental causes of the disease; and when a union of these circumstances is found, strumous diseases prevail more extensively than where any two of them alone are present. These have been more especially pointed out in an excellent monograph by Baudelocque, published in 1833. Local injuries have also, in children predisposed to it, excited it into activity; so also has small-pox, measles, or hooping-cough, * Clark on Consump. and Scrofula, p. 233. f Influence des Agens Physiques sur le vie, p. 398. 284 DISEASES OF CHILDREN. and any protracted disease which acts on the general system, as the other causes above stated, by impairing the energies of the body, and thus affecting the process of nutrition. Semeiology.—The disease shows itself in the lymphatic glands, principally of the neck, in children, about the third year, or from this period until puberty; after this it seldom appears in this form. Tumors appear not only on the side of the neck and behind the ears, but under the chin and in the arm-pits. They are at first moveable, and of an oval or globular form, and a little elastic to the touch. They are at first without pain and discoloration of the skin ; in this state they may continue for a long time, and will even acquire a large size, without any suppuration or but will be removed by absorption. This, however, the usual course of these scrofulous tumors. The skin, for the most part, assumes a reddish or purplish hue, when their consistence undergoes a change ; from being slightly elastic they are now soft, with a feeling of fluctuation in some parts of the enlarged gland; for this softness, and the ulceration which follows, are by no means uniform throughout the diseased part. The skin over the softened portion becomes thin and pale, and at length small openings form, giving passage to a kind of purulent matter, at first of a yellowish color, and curdy consistence. These openings unite, and the discharge changes to a fluid resembling whey. These ulcerated tumors gradually subside, but others arise near them, passing through the same stages of tumefaction, softening, and ulceration. At other times the ulceration proceeds, and a sore, very tedious and unmanageable in its nature, is the result, discharging a sanious fluid, mixed with curdy flakes. This ulceration sometimes heals partially, while the discharge continues in another portion, and fresh tumors, which also degenerate into ulcers, form in their vicinity. This irregularity in the ulcerative process, partial healing, and the formation of new tumors and ulcers, give to the affected part, when healed, a very unsightly, and even, at times, deformed appearance, from the irregularity of the cicatrices, and the deep scars, crossed by bands and wrinkles, and the puckered form of the skin. Morbid Anatomy and Pathology.—The different stages of the enlarged glands of scrofula exhibit different appearances in the texture of the morbid part. Thus, Dr. Abercrombie states that they exhibit, in the first stage, when cut, a uniform fleshy texture, of a pale flesh color, and soft consistence. This color becomes paler and the texture softer. The glands then undergo a change in these particulars in different portions, for some parts lose their flesh color, and appear somewhat transparent, while the texture has EXCERNENT SYSTEM. 285 the appearance and consistence of cartilage. Alterations are, also, at the same time observed, from the natural color to the peculiar white, which is the last stage of morbid alterations, and in every respect analogous to the white tubercle in the lungs. The irregular progress of the disease is manifested in the existence, at times, of all these changes at once, observable in different parts, of large masses of the disease. In the most advanced stage, the white, opaque, ash-colored, tubercular matter abounds the most, and is afterward softened into the well-known cheesy and ill-conditioned suppuration.* The pathology of scrofula has been the source of much discussion, but the opinions appear to have settled down to the inflammatory nature of the disease, in all its forms, whether of glandular enlargement or the formations of tubercle. With respect to the glandular or local affection, which is the form of the disease now under consideration, it would seem, in some instances, to be a simple congestion o' the gland at first, by the lymph flowing through the vessels, and which afterward excites, by its mechanical distension, the inflammatory action with which the glands are affected. At other times the inflammation appears to be coeval with the existence of the tumors, and from the commencement identified with the disease; under both circumstances it is evidently a modified inflammation, as we see it here, although in some forms it appears to be destitute of all other characters of inflammation than that of tumefaction. The opinions of several writers are, that it is always a disease of debility, and dependant on debilitating causes.t Dr. Good appears inclined to this opinion, and quotes Gam and Richter.} By far the greatest number, however, adopt the opposite view. Broussais,|| in France, Alison,§ in Great Britain, Gross*!!", Paine,** and others, in the United States, all identifying tubercle with the disease before us, and regarding it as dependant on one and the same cause. It was formerly supposed that an acidity of the humors was present in scrofula; and that an altered state of the lymphatic fluid, in some respects, existed, has been the opinion in almost every country. Hufeland's views are,*that the disease consists of debility, with a specific irritation of the lymphatic system, and a peculiar alteration of the lymph. This scrofulous acrimony, as he terms it, he considers as the alterations produced in the lymph, by the altered action of the lymphatic glands, whereby the assimilation is not proper- * Abercrombie on the Nature and Origin of Tubercular Diseases. Trans, of the Medico-Chirurg. Soc, Edinburgh, vol. i., p. 685. t Armstrong on Acute and Chronic Diseases, vol. ii., p. 101. j Study of Medicine, vol. iii., p. 221. || A treatise on Physiology, p. 470. § Trans, of the Med. Chirurg. Soc, Edin., 1824. H Path. Anatomy, vol. i., 1834. ** Med. Comment, vol. ii., p. 608. 286 DISEASES OF CHILDREN. ly effected, and an imperfect fluid is the result, which becomes a source of irritation to the glands.* A change in the fluid is not incompatible with the opinion of the congestive or inflammatory nature of the disease. The difference of opinion which has prevailed as to the nature of scrofula, may admit of some explanation when the various causes which are known to modify the same disease are considered. Among them may be mentioned climate, and an imperfect development of the diathesis, which it is well known determines the tendency of inflammation in the formation of scrofulous diseases. The difference in the type is what is observed in all diseases, in different countries, and probably therje is no disease which presents the same uniform character in all; as climate influences the development of diseases, so it will also exert a modifying effect on the disease when formed. The differences thus arising, are the only way to account for the discrepancies of existing opinion as to the nature of the same disease. This is remarkably illustrated in measles and scarlet fever, which in some countries and in certain seasons appear scarcely to require any remedy; while under other circumstances they may be violently inflammatory, or be attended with great prostration. We need but refer to past records to be satisfied of this fact, and of the great benefits arising from the use of remedies at one time, which at others have been discarded, from having been found decidedly hurtful. In the scrofulous diseases of children the same condition may, and doubtless does exists; and the continual exposure to the causes already mentioned, but more particularly to the effects of impure air in closely confined and crowded habitations and manufactories, may control the actions of the system, so as to prevent the development of a true inflammatory action ; while it is easily conceived that in those cases where a predisposition exists in subjects removing from a warm to a cold climate, and the disease for the first time excited by the action of the latter cause, sciofula may exist in a state of active inflammation. An imperfect development of diathesis, which determines the character of the inflammation in scrofulous habits, or, perhaps, as it may be better expressed, the proportion of normal action still maintained in the system, will impart to the diseased action a character more or less allied to diseases in organs which have undergone but little alteration from their normal state. This leads to the consideration of the predisposing cause of scrofula, which must he sought for in the nutritive process, whether the alterations in the composition of the body during the time of growth have been hereditary or acquired ; for we must go back to the ultimate state of interstitial action, in order to obtain some idea of the * Op. Cit., p. 63. EXCERNENT SYSTEM. 287 pathology of scrofula, as it appears in the different organs, depending, as it clearly does, on the imperfect action of the nutritive process. This view of the departure from the liealthy state of the organs will present the subject, if not in a form perfectly satisfactory, yet in some degree approximating to the truth, as it will exhibit the disease in question as depending on that important part of the nutritious function, the lymphatic system, so actively engaged during the period of growth. That which strikes the observer, when considering scrofula as manifested in the remote tissues, is the peculiar phenomena which arise on the application of the ordinary exciting causes of inflammation. A chronic inflammatory action ensues in some of the tissues, with characteristic symptoms, producing a disease remarkable for its obstinacy; while in others tubercles form, giving rise, when in the lungs, to phthisis. The phenomena are so different from those of inflammation occurring in an individual not possessing the scrofulous diathesis, as at once to arrest the attention of the inquirer, and direct it to some change in the original composition of the affected part, by which a very marked alteration is produced ; if it were otherwise, the phenomena would be such as are usually observed in properly elaborated tissues. It must, therefore, be dependant on the nutritive process —on the deposition of ultimate molecules during the growth of the body, in some degree destitute of the proper proportions which are necessary to form the part in its normal state. This, as we have already seen, may be hereditary or acquired ; in both instances depending on the supply of healthy materials in the blood, which is the agent employed in the nutrition of the body. The blood being composed of the constituents of the chyle and lymph, must necessarily be affected with any changes which may occur in them, and thus affect the condition of the various parts of the animal frame. The absence of this disposition may usually be known by the existence of the sanguine temperament. The blood abounds in fibrine, the complexion is dark or ruddy, the muscles firm and well marked ; those, on the contrary, that possess the diathesis, which leads to the formation of tubercles, exhibit a softness of the muscles, possess a light or delicate red complexion ; the red particles of the blood and the fibrine being deficient, while lymph and albuminous matter abound. All this impoverished state of the fluids arises from the causes already mentioned as productive of scrofula ; and the preponderance of the lymphatic system will naturally create a lymphatic plethora. It appears, therefore, to be connected with the active state of the lymphatic vessels, as there is in scrofula a manifest excess of 288 DISEASES OF CHILDREN. albumen, chemical analysis having detected a large proportion in lymph. Although there is still needed a much more extended set of experiments on the subject of lymph than has yet been made, to render our knowledge in its change, either in quality or quantity, more satisfactory, yet abundant evidence exists that it is in greater quantity in time of youth. Haller has shown that the lymphatic glands contain a larger proportion of fluid in the young than in the adult.* Mascagni also states that these glands are more turgid with lymph at this period of life.t A larger quantity also exists after a long fast. If an abundance of lymph exists, the blood must be surcharged with albuminous materials, and a deficiency of fibrine prevails ; from this cause an imperfect composition of the body must ensue, which is thereby predisposed to take on a peculiar diseased action, on the application of an exciting cause of disease. This is seen to exist constitutionally in phthisis and rickets. The last-mentioned disease exhibits, in a very evident manner, the effects of imperfect nutrition ; for during the process of growth a remarkable change occurs in a healthy subject in the consistence of bones, while in those individuals suffering under the peculiarities of constitution caused by scrofula, the bones are often defectively nourished, and their development does not correspond with the development of the body generally. The tubercular disease, on the contrary, does not exhibit similar marked effects from growth with imperfect nutrition, for the soft parts undergo but little change from growth, but are formed with much the same elements as they afterward possess. The consideration, however, of constitutional struma, is foreign to the object of the present chapter; but the diseases of a general character, which more especially affect children, and which are modified by a scrofulous constitution, will be treated of under their respective heads. The subject has been merely alluded to as in connexion with the action of the absorbent system, the important agent in moulding the body during growth. There can be no question, as is remarked by J. Hunter, that the nutrition of the body is supplied principally by the chyle, and that the office of the absorbent system is to preserve the symmetry of the body, while nutrition from this source is but a secondary function. If, from any cause, the latter function is more than ordinarily and permanently excited, either by the hereditary constitutional peculiarity, or by the continual use of insufficient and improper food, which acts not only in supplying the blood with imperfect chyle, and thus directly affecting the process of nutrition, but likewise by exciting the action of the absorbent system to supply the defective •El. of Physiology, vol. ii., p. 325. t Vas. Lymph, pt. 1, sect. 5, p. 33. EXCERNENT SYSTEM. 289 nourishment, whereby an undue quantity of albumen is conveyed to the blood, an alteration of nutrition would ensue. The most severe and violent forms of constitutional strumous affections are connected with impure air. The blood thus deprived of the salutary change it undergoes when exposed to the influence of oxygen, interstitial nutrition is directly effected. When, however, inappropriate food is used by children, the effect appears to be more direct on the lymphatic system ; but in all its forms an undue supply of albumen to the blood exists, showing an increased supply of materials through the lymphatic vessels. The local effects of a deranged action of this system, in the production of the chronic irritation, and enlargement of the glands of the neck, axilla, etc., and known as scrofula, or the king's evil, i3 the disease more especially considered. This affection is not to be confounded with that occurring in the glands, arising from the transmission of the inflammation along the course of the lymphatics, and traceable by a red line or streak, which, for the most part, is painful to the touch. This not unfrequently occurs in inflammation of the skin, tinea capitis, etc. When the glands are inflamed from this cause, they are rapid in their swelling, hard and painful to the touch, and terminate by the formation of a true pus. Such inflammations are likely to occur in those of a sanguine temperament. In such as possess the scrofulous diathesis or lymphatic temperament, an entirely different condition of the gland occurs; the symptoms of which have already been described. In this form a true suppuration never takes place, but the termination shows a condition differing from a sanguineous inflammation. This form of disease is described by M. Broussais as a sub-inflammation. If by this is meant an inflammation produced by the white blood or lymph, and corresponding in this respect with what is usually known as inflammation, produced by the agency of the red, fibrinous blood, the designation is correct. But it is evident that the term is very liable to be misunderstood; for there is not at first, essentially, a real inflammation in the irritated and enlarged glands, although it usually occurs in the course of the disease, and may at times appear so early, as to be almost simultaneous with the tumefaction of the gland ; for it may inflame, and also be congested, with albuminous fluid contained in them; if it occur afterward, it is produced by the mechanical pressure of the part. The fluid conveyed through the lymphatics, in a healthy state of the part, is arrested in the glands, and there undergoes some change, as appears from experiments made by Mascagni; for the lymph en tering into them differs from that which passes out.* They there- * Mascagni, Loc. Cit. 37 290 DISEASES OF CHILDREN. . fore appear to form some important part in nutrition ; but in what this consists it is impossible to ascertain ; that it is important, is evident from the large size of these glands in children and youth, when nutrition proceeds rapidly, and the action of the lymphatic vessels is great, from the necessity of the continued changes in the dimensions of all the parts of the body. This is a very striking illustration of the principle, that growth is a great predisposing cause of disease. Here, then, we have, at an early period of life, a greater action of these glands; and from the laws of physiology, the more an organ is exercised, the more is it predisposed to disordered action, and from their necessary incessant performance of their function is found their liability to disease. What is the irritation which first causes a stasis of the lymphatic fluid in the gland is impossible to say ; very little, if anything, is known with respect to the normal action of these parts, and much less of the departure from it. That a congestion of lymph occurs is evident from the fact, that, sometimes when these glands yield a fluctuating feeling on pressure, and, from the supposition that pus exists, an opening is made, nothing will flow hut a little blood and lymph, and in a short time lymph alone will ooze from the wound- It may be supposed that some irritating qualities exist in the lymph itself, as it owes its origin to all the varying parts of the body ; for although in appearance the same, yet close examination has detected a difference in lymph flowing from different parts ; and it is also an important fact to remember, that, while the lacteals possess an elective property, and only convey chyle, the lymphatics will take up anything that is presented to them, both such as are extraneous to the body, and such as form the varied parts of the body itself, both solid and fluid. Besides those different actions of these two sets of vessels, another property they possess might also tend to produce an alteration in the fluids of the one and not in the other. It is the difference in their respective functions: the one simply conveys the nutritious fluid already prepared, the other elaborates what it removes ; hence an altered and morbid condition may exist from the imperfect action of the vessels themselves. In the first stage, therefore, the disease is always caused by a simple lymphatic congestion of the part, and is variously modified with regard to the accompanying inflammation, by the peculiar constitution of the patient and the influence of climate. While in some places it has been regarded as a disease altogether of debility, in others it has, in every instance, been considered, as one of inflammation, more or less acute. It can easily be conceived, that among children suffering from the combined effects of bad air and impoverished diet, insufficient also in quantity, a degree of debility EXCERNENT SYSTEM. 291 must ensue, which would altogether forbid the employment of depleting measures; while such as have not been thus exposed will retain a different amount of vigor, materially controlling the disease when formed. The disease in some is one of a purely lymphatic congestive character, for a long time exhibiting no pain on pressure, and exhibiting neither heat nor discoloration of the skin even in such as do not possess a marked deficiency of stamina ; the inflammatory stage, however, is always sure to make its appearance before suppuration ensues. In others this inflammation will quickly appear on the enlargement of the gland ; this occurs when the lymphatic temperament is but slightly developed, where any irritation will readily excite inflammatory action. This accumulation of lymph imparts to the suppurated gland its imperfect character, as regards the pus secreted, which possesses but little resemblance tc* properly-formed pus being a thin fluid, mingled with curdy matter. Treatment. —The principles of the treatment have varied at different times, according to the existing ideas of the nature of the disease. The supposed presence of acids in the fluids has led to the employment of alkalies. Narcotics and sedatives have also been much used, doubtless also from the irritation caused, as was believed, by the acrimonious nature of the lymph, while the actual benefit arising from their use may be referred to allaying the irritability of the system generally, and thereby, in some instances, affording nature an opportunity of returning to the normal exercise of her functions. The doctrines which have more recently prevailed, have induced some physicians to consider it exclusively, and under all circumstances, as inflammatory, and they have consequently been induced to use local antiphlogistic measures, and lo rely solely on the local abstraction >f blood for the treatment of scrofulous tumors. The judicious physician will not adopt either mode to the exclusion of others, but will suit the remedy to the condition of the existing case. According to the views of ihe nature of the disease above stated, the treatment naturally divides itself into, 1st, hygeinic ; 2dly, general ; 3dly, local. As the disease depends on the abnormal action of the absorbent system, a function of the greatest importance during the period of childhood, a lime of active nutrition and growth, we may reasonably look for a natural tendency of the system to the normal exercise of its functions, as the period of demand gradually ceases. This may often be effectually anticipated by a judicious application of the rides of hygeine. The food ought to be nutritious, and in every respect suited to the condition of the patient. It seldom happens that we see the 292 DISEASES OF CHILDREN". disease in such a form as to require a decidedly tonic and highly nutritious diet, but a proper supply of nourishment is absolutely necessary to the healthy action of the nutritive process. Wine and malt liquors, so much recommended formerly, are rarely, if ever, required, for this disease in the United States. In connexion with appropriate diet, there is nothing so beneficial as free exercise in the open air ; nothing indeed can compensate for the want of this. Where it is used, children seldom suffer from scrofula; and the natural exercises of running, leaping, etc., so incessant among children, keep their absorbent and capillary system in full activity, and distribute the tone and vigor thus induced over the whole frame. The effects of active bodily exercise in imparting the signs of the proper supply of red fibrous blood, is evident in all persons whose employments lead them much in the open air; and among such of the ancients whose education was founded in a great degree on gymnastics, scrofula was but little known. For the same reason, those children who are disposed to scrofulous diseases ought to be guarded in the too early use of their intellecual faculties, especially in learning long lessons at school. Their tasks ought to be short, and followed by some amusing occupation. They should not be subjected to severe punishments, but every method ought to be taken to invigorate the system, by rendering their necessary studies as much a pleasure as possible. It will also be necessary to pay particular attention to the sleeping apartments of children, a subject often receiving less attention than almost any other hygeinic regulations of children. They, for the most part, pass the greater part of their time in them ; and a close attention to ventilation, and a proper choice of their situation, where the latter can be made, is of vast importance; not only in the management of the disease before us, but also in all affections of children. Mattresses form the best bed for them; the accumulation of heat, and of the miasms which are disengaged from the body during the night, do not so easily take place on a hard surface as in a mass of feathers, where their escape is almost impossible: the relaxation from these causes, as well as from the excessive perspiration, will produce a debility greatly affecting the functions of the absorbent system. If it be possible, the bedroom of children ought to be in an upper story, with windows so arranged as to allow of a free ventilation. The habitation, also, should, if it be in a low and humid situation, be removed to a dry and warm place. All these details it may be said, are impossible to have properly attended to; but much may be done in the prevention of diseases in children, by procuring a free circulation of air. While these precautions are used, the body ought to be kept EXCERNENT SYSTEM. 293 well protected with suitable clothing. The variations of temperature produce the most serious consequences ; and the use of woollen garments in winter, and suitable protection from sudden changes at every season, should form a part of the hygeinic measures. In connexion with these measures, frictions are very important agents in the management of weakly children; they have a direct effect on the sanguinary capillaries, and also excite the radicals of the absorbents, whereby circulation through the lymphatics is promoted. These may be performed by means of a soft flesh brush, or a piece of flannel or dry sponge, three or four times a day. An entire removal may, in severe cases, become necessary; and a residence near the sea, in the summer months, will be an efficacious means of invigorating the system, where the exhausting summers destroy the energies of the system. In short, every rational means of improving the general health will be needed in the prevention and cure of scrofula. The application of pharmaceutical agents may be either general or local; and the general principles of science will be our guide in their use generally, even in such as appear to partake in some degree of the nature of specifics. When commencing the treatment of this disease, the condition of the prima? via; should be examined, and if evidences of derangement be found to exist, the treatment should be commenced by restoring the secretory functions of the chylopoetic viscera. For this purpose purgatives must be employed. The use of resinous cathartics, Hufeland remarks, is more important than is generally supposed; and where there is a want of tone in the stomach and bowels, with a tendency to constipation, jalap he has found the most useful of purgatives; besides its influence in relieving the bowels of their load of mucous secretion, an impression appears to be exerted on the lymphatic system. Mild purgatives have but little effect on the indolent engorgements of children. He gives it in doses of from four to six grains, to children two or three months old, combined with a little magnesia. It appears to be much more safe to give it in smaller doses, in the proportion of six to fifteen grains, for children from three to six years. When an addition to its purgative qualities is needed, any of the neutral salts, or the bi-tartrate of potash, may be combined with it, or it may be combined with calomel. The addition of oil of lemon will correct its nauseous taste, and it may be rubbed up with a little sugar.* • R Pulv. Rad. Jalapa;, gr. xv. (Ill) Hydr. Subm.., gr. iij. Oleo. Sacch. Citr., 3j. M. For a child eight years of age. 294 DISEASES OF CHILDREN. The resin of jalap is a good purgative, and may be given in an emulsion, rubbed up with sugar or with almonds. Aloes is another of this kind of purgative medicine, which will be found very efficacious in the treatment of this disease, when attended with much derangement of the abdominal viscera,'as it combines a tonic property with its cathartic qualities. Wherever, therefore, there exist a loss of appetite and a general debility, aloes will be a useful article for the correction of the disordered action of the bowels, and to impart, at the same time, tone to the stomach. Aloes, combined with rhubarb, has been long a favorite purgative with German physicians; and where the object is to procure a free evacuation without the loss of strength, which often attends a copious action of the bowels, these substances are of great value.* While speaking of the necessity of attending to the state of the prima? via;, it will be the proper place to allude to alkalies and antacids in general, which have been so much in use in the treatment of this disorder, and the benefit of which has been so abundantly demonstrated by experience. Lloyd is very partial to antacids, particularly soda; and without reference to any acid condition of the lymph, it is a sufficient indication of their necessity when there exist evidences of acidity in the stomach ; for the digestive process is, under such circumstances, very materially deranged, and the nutritive functions also more or less disturbed. They have been for a long time in use, and were supposed not only to destroy the acid of the stomach, and thus remove one of the exciting causes of scrofula, by improving the functions of the digestive organs, but also by exerting an action on the lymph in correcting the acid which it contains. Any of the alkalies or absorbent earths may be employed for fulfilling the above indication, according to the condition of the bowels; if they need to be moved, .soda or potash may be combined with the cathartic medicine already mentioned.f If a simple correction of acidity is all that is needed, they may be given alone} or combined with some mucilage,|j or if there exist no evidence of gastric inflammation, * ft Pulv. Rhei., gr. iij. (112) Potass. Bitart., gr. vi. Oleo. Sacchar. Macid., 3ss. M. ft. Pulv. dent. tal. dosi., No. vi. One to be given thrice a day. t R, Rad. Rhei, 3j.—3ij. " (H3) Digere per hor. c. Aq. Fervid., "j. in colat. solve, Potass. Bi-carb., COj. Syrup. Aurantii, ? ( ss. M. Sit. Mistura. A tablespoonful three or four times a day, to a child three or four years of age. t ft Potass. Bi carb., 3ss. (114) Aqua; Destill., Ziss. Solve. A teaspoonful three or four times a day. II ft Potass. Bi-carb., gr. x. (115) Mist. Acacia;, 3j- Vitell. Ovi, No. ij. Aquae Font., giij. Syrup. Simpl., 3j. M. ft. Emulsio. Dose, a dessert-spoonful three or four times a day. EXCERNENT SYSTEM. 295 and a mild stimulant appears to be needed, combined with some aromatic infusion.* The bi-carbonate of potash has been particularly recommended in scrofulous affections by Richter and others. Where there is a decidedly debilitated condition of the system generally, needing tonics and bitter infusion, the Colombo root will be found the best, as it is an excellent stomachic, with but little stimulating qualities, and does not astringe the bowels; it may be given in the dose of a tablespoonful of the infusion of the pharmacopoeias, either alone or combined with some alkali and aromatic confection. Dr. Hamilton advises small portions of mercury or antimony, or both combined, in very small doses ; or of neutral salts dissolved in water. The former of these he recommends for infants and the latter for children, especially toward the age of puberty. He decidedly prefers the " neglected remedy of the polycrest salt." His practice was to administer an aloetic pill at night, and the sulphate of potash in the morning, continuing this practice for several weeks. After the bowels had been freely acted on, he then commenced with chalybeate preparations, but without discontinuing the use of the neutral salt. The general remedies for scrofula, which have been considered almost as specifics, are all of a tonic and stimulating nature, and are therefore only applicable to the stage of simple engorgement without inflammation. Whenever, therefore, there is pain on pressing the tumors, or a slight febrile action, these should not be used, but the treatment must be conducted on the general principles of combating inflammation and fever, but particularly by attention to the condition of the stomach and bowels. Mercury has long been an efficacious remedy in the treatment of scrofula, and, under the circumstances just mentioned, may very advantageously take the place of other remedies of a general nature. It is evidently a very powerful exciter of the lymphatic system, while it augments the whole secretory functions. It is, therefore, useful in cases where there exists febrile reaction, and when the fever is great should be combined with antimony; and it is to this stage alone that its use should be confined. In those cases where there is great irritability, it should be carefully avoided, and in protracted cases, where there is much constitutional affection, it is inadmissible. It has been used in scrofula, combined with hemlock and antimony. The subjoined prescription is from * R Aquae Foeniculi, (116) Potassae Bi-carb., 3iL Syrupi, M. A dessert-spoonful occasionally. 296 DISEASES OF CHILDREN. Frankel.* Mercury should never be given to salivation in thisdisease. Among the remedies of a tonic nature which have been considered almost as specific, is the chloride of barium (muriate of baryta),, used by Hufeland in Germany, and Crawford in St. Thomas' Hospital, in London. It has been highly extolled by many German, English, and French physicians. Hufeland recommends it in such cases as are attended with increased irritability and inflammation. It ought to be given with great caution, as violent griping may be caused by an overdose, together with hypercatharsis and inflammation of the throat and stomach. Pinel and Hebrerard have seen these effects even from a single grain of the medicine given every other day. I have never used it; but if such are the violent effects occasionally arising from its use, prudence would dictate its abandonment altogether, notwithstanding the high encomiums bestowed on it by the distinguished physicians above mentioned, particularly as we are in possession of a much safer remedy, which has within a few years been introduced into practice, and which has almost taken the place of other measures of treating the chronic engorgement or indurated glands in scrofulous affections. • Iodine was first introduced into practice by M. Coindet, of Geneva, f Its operation is decidedly tonic, as the augmentation of appetite, and the increased strength of those who use it judiciously,, and in small doses, prove. Lugolf asserts that he never observed emaciation to occur from its use, when properly employed, but on the contrary, an increase of vigor was the result. Its action on the nervous system increases that of the heart and arteries, and restores the functions of the sanguiferous and organic systems, as remarked by Brera. These observations have been confirmed by Sir G. Clark, Baudelocque, and others. The symptoms usually observed from its internal use, are an increased flow of urine and improved appetite, the alvine evacuations are rendered more frequent, and at times the action of the salivary glands is increased. Although these are the ordinary symptoms produced by the use of iodine, yet, in some instances, these salutary results have not followed ; it will therefore be necessary carefully to watch the effects of the medicine, and to suspend its use if an opposite effect is produced, to he renewed at the interval of a * ft Hydr. Subm. (117) Aiitimon. Oxysulph., »u. gr. j. Extr. Conii, gr. j. Sacch. Alb., 3j. M. ft. Pulv. dent. tal. dos. No. xij. To children under two years, half a powder morning and evftung. To older chil» iren a whole one. f Bibliotheque Universale, July, 1820. } Mem. sur 1'Emploi de l'lode, etc., Paris, 1829. EXCERNENT SYSTEM. 297 week. Sometimes it is excessive in its action on the bowels, and accompanied with severe colic ; it must, under these circumstances, be suspended for a time, as it is evident that a morbid excitability of the mucous membrane exists, forbidding the employment of this remedy. From its stimulating effects, its administration ought to be limited to those cases in which there is no inflammation in the tumors, and where indurated tumors remain after the disease has passed through its stages- M. Lugol recommends the use of mercury to precede the employment of iodine, as the unloading the intestines, and the establishment of the intestinal secretions, greatly favor the operation of the latter on the system. All practical writers refer to the necessity of commencing the treatment of scrofula by cathartics, as recommended above. In very irritable conditions of the system its use should be avoided, until some energy is restored to the organs by hygeinic measures. A removal to the country, or to the seaside in hot weather, together with the use of mild bitter infusions, will very naturally precede the employment of iodine, under the circumstances just mentioned. It is usual to prescribe iodine in conjunction with the hydriodate of potash, the solubility of the former being augmented by this combination. The subjoined prescription is that employed by M. Lugol, and is preferred by him to the tincture of iodine, as a precipitate usually forms after it has remained for a short time, and water always causing a precipitate in the simple alcoholic tincture.* The formula of Lcmasson, is also given below.t Some will bear with advantage much stronger doses of iodine than that of M. Lugol. but it ought to be commenced in the minimum dose, and gradually increased. M. Baudelocque, commencing with the proportions similar to those above mentioned, increased it by degrees to six grains of the hydriodate of potash, and three grains of iodine daily. In the use of this medicine the greatest precaution should be observed, and the dose should never be increased without carefully watching its effects ; and upon the slightest appearance of nervous irritability, or derangement of the functions of the stomach, its use must be suspended. Among the unpleasant consequences • R Iodini, gr. v. (118) Potass. Hydriod., 3ss. Aq. Destill., Two drops twice a~day to children under seven years, gradually increased to five drops. Sixteen drops will be the maximum dose for children above seven. To be given in sweetened water. t R Iodini, 5)j. (119) Potass. Hydriod., 3ij. Aquae Destill., Contere Iod. et Potass, hydriod. in mortario, vitreo, sensim. Aquae Destill., et adde. Four drops thrice a day, in a little sweetened water. 138 298 DISEASES OF CHILDREN. occasionally resulting from the employment of iodine, are distressing pains in the chest and bowels, and in some, very severe convulsions. The permanent effects are palpitations, cough, debility, emaciation, wakefulness, trembling, headache, and tumefaction of the legs. When any untoward symptoms arise from iodine, mucilages of starch and anodynes, with emollient and anodyne enemata, will counteract them. The experience of physicians, generally, as to the proper time for giving iodine, is shortly after a meal; it is less apt to produce nausea at that time than when taken fasting. About an hour or two, therefore, after eating, appears to be the best time for giving it, and some have even recommended animal food as an adjuvant. M. Lugol has strongly recommended ioduretted baths; but, from the rapid evaporation of the iodine, it is doubtful whether much benefit can arise from their use. The proportions used by him for children between the ages of four and seven years, is from thirty to thirty-six grains of iodine, and sixty to seventy grains of hydriodate of potash, to nine gallons and a half of water. There have been a vast number of other articles used at different times in the general treatment of scrofula, from their real or supposed effects on the lymphatics, such as calamus, balsam of sulphur, iron, mezeron, sarsaparilla, etc.; and various narcotics have also been employed and lauded as specifics, as hyoscyamus,digitalis, solanum, asclepias, and some others ; they, however, possess no other effects than as assistants to other and more rational means, for the purpose of allaying a morbid irritability. With respect to the local measures to be used, these must, like others, be directed altogether by the condition of the part; if the tumors appear red, and possess much tenderness on touching them, leeches should be applied, and the inflammation subdued by the usual means. On no account must stimulant applications be made, in such a condition of the parts. In general, however, there appears to be at the commencement a simple congestion of the gland by the lymph, and demands a local treatment corresponding with general measures. The peculiarly stimulating effects of iodine will, therefore, render it necessary to adopt it in connexion with the internal use of the same article. When externally applied, it causes a yellowish stain on the skin. There is but little hazard in the use of it when externally employed, for as the part heals it becomes less sensible to its influence; and the evident disappearance of the tumor is a sufficient indication of the proper effects of iodine, in time to prevent any possible injury arising from its excessive employment.* Dr. Hildreth, in the American •ftlodinii, gr.xij. (120) Potassae Hydriod., 3j. Adipis, M. ftlodid. Plumb., 3j- (121) Adipis, M. EXCERNENT SYSTEM. 299 Journal of the Medical Sciences, for August, 1840, extols highly the iodo-hydrargyrate of potassium in glandular enlargements.* Where the tumors break, they should for a short time be covered with a soft poultice ; and when the discharge is somewhat abated, the application of stimulant lotions is in general indicated, as solutions of alum,t sulphate of zinc,} or nitrate of silver.|| In very indolent conditions of the ulcers, great benefit is derived from a saturated solution of sulphate of zinc. A highly irritable stale of the parts sometimes exists, which requires soothing applications and a poultice of hemlock, or a lotion made with the extract of conium will be peculiarly beneficial to allay this morbid irritability. If fungous excrc-cences arise, they should be removed with burnt alum or nitrate of silver; the latter, also, when applied to the edges of the indolent ulcer, greatly favors the establishment of a new action in the part, and is the best application of an escharotic nature that can be used, as it leaves but little irritation and inflammation. When any escharotics produce an increase of local excitement, it should be allayed by the application of poultices, and cataplasms of some mild narcotic. The indolent and permanently-enlarged glands have been successfully treated by compression, care being taken not to apply it until the inflammation is removed. Scrofulous ulcerations, also, have been treated upon a similar plan, and the method of Mr. Baynton in treating ulcers on the legs, successfully used. After the ulcers are covered with simple dressings; a soft compress should be applied, and the whole bound closely by means of adhesive straps, where the situation of the ulcers will admit of it; about the neck, pressure should be avoided, over the pomum Adami, lest respiration should be affected. ' TABES MESENTERICA. This disease, known also by the names mesenteric scrofula, atrophia mesenterica, chronic mesenteritis, is more frequent in children about the period of weaning than in after life; if we except the time intervening between this period and the age of seven years. It some been confounded with remittent fever, which occurs in children, but the latter may exist without any affection of these glands; and the only resemblance between them is, that a deranged state of the chylopoetic organs exists, and that fever will in some • ft Deutiodid. Hydrarg., gr. viij. (122) Hydr. Potass., 3ij. Axung., 1'}. M. To be applied to the tumors, two or three times a day. f ft Alumen., gr. v. (1-3) Solve in Aqua? Ros., ?j. M. t ft Zinci. Sulpha't., gr. iij. (124) Aqua?, M. il ft Argenti Nitratis, gr. iij. (125) Aqua? Destill., 3j. 300 DISEASES OF CHILDREN. stages of the disease attend it, and thus render it liable to be confounded with remittent fever. The affection known as the disease of the mesenteric glands, and which consists in an enlargement of these bodies, accompanied with great emaciation and hectic fever, a peculiar form of chronic disease attendant on a strumous diathesis, is what is proposed to be considered under the present title. Some degree of inflammation attends it, chiefly during the progress or toward.the termination of the affections; and although the acute inflammation and true suppuration of the part must be regarded as a distinct affection, yet in many instances the disease known as the tabes mesenterica may be greatly modified, and approach more closely to the ordinary action of inflammation, according as a less degree of the strumous diathesis is in the system, the complications in both being an inflammation of the mucous lining of the intestinal tube. The diagnosis is, under such circumstances, a secondary consideration, for the treatment will be similar in both, as the disease then assumes one of the forms of enteritis. When, from an accurate investigation of the case, we are satisfied that its slow progress, and the absence of fever at the commencement, give evidence of the non-inflammatory nature of the disease, it may then be referred to the development of a strumous affection, analogous to that already described. In this form of the disease the wasting away of the frame is an invariable occurrence, and hence the name tabes, which, although describing but a mere symptom, is yet an important and very striking designation of the disease. Etiology.—Children of a strumous habit of body are those who are predisposed to enlargements and softening of the mesenteric glands, and indeed they are the glands where the scrofulous disease shows itself the soonest. Sir Astley Cooper remarks that they are, next to the cervical glands, the most liable to be affected with this disease ; but according to the results of the investigations of the distinguished anatomist, Meckel, and of Andral* the latter undergo the changes which impart the peculiarities of scrofula sooner than any other part of the system. It is unnecessary here to repeat the usual marks by which this predisposition may be suspected, as they have already been mentioned in the preceding section. That this condition of system exists in tabes mesenterica, has been the opinion of several writers, whose opportunities of examination have enabled them to discover, after death, the simultaneous existence of this disease and phthisis. Portal* and Guersentt have both found tubercles in the lungs of those that died with tabes mesenterica. •Sur La Phlhisie de Naiss., Mem. de l'Acad. des Sciences, 1781. t Diet, de Med., art. Carreau. EXCERNENT SYSTEM. 301 It has been supposed that a prominent abdomen is an evidence of the predisposition to mesenteric affection ; this, however, is not always to be regarded as a. sign of the existence of the disease, even when it is developed, much less can it be regarded as a certain evidence of a predisposition to it. A full and prominent abdomen, when connected with other signs of a lymphatic temperament, point out the strumous diathesis, and may rationally lead to the suspicion of an enlargement of the mesenteric glands, when symptoms appear which are pathognomonic of the disease. As a sign of the predisposition to the disease, as remarked by Evanson and Maunsell, it has been greatly overrated, if, indeed, it posge'sses any : the mesenteric glands adding nothing to the size of the abdomen until the disease has advanced to some extent. This remark I have had some opportunities of verifying: and at the present time have a little patient who exhibits unequivocal symptoms of the existence of disease of the mesenteric glands from a scrofulous predisposition, without any inordinate size of the abdomen. Guersent* also positively asserts that extensive mesenteric disease has been found in instances which came under his notice, where, during life, no greater enlargement of the abdomen existed than is usual in children of the same age in health ; and maintains that a large abdomen is no sign of the liability of the subject to this affection. Besides the strumous predisposition, the active development of these glands, which is a gradual process from birth to the period of teething, renders them liable to take on diseased action. Accordingly, at the time when the entire digestive syslem undergoes a change, and all the glandular apparatus immediately connected with the process of digestion is excited to an increase of its natural functions from the requisitions of the system for a different species of food, these glands, with others, exercise a great increase of their natural actions. The most accurate observers have noticed that the disease, for the most part, makes its appearance about the eighth month, to a year.f The development, therefore, of the mesenteric glands, like that of other parts of the system, gives a very strong predisposition to disease, easily excited on the application of the usual causes. The exciting causes are those which have already been enumerated, as producing a congestion and enlargement of the lymphatic glands ; such as insalubrious air, deficient exercise, but more particularly improper food, and the change occurring in the diet at the time of weaning. This latter is a very common cause, where, from the inability of the mother to nurse her offspring, it is necessarily weaned before the proper period, while artificial food is substituted for the breast milk. •Diet, de Med. art., Carreau. t Andral, Path. Anat., vol. ii., p. 448 302 DISEASES OF CHILDREN. As was remarked when treating of scrofula, diet itself is not so invariably a cause of mesenteric disease as it would generally be supposed ; but when to impoverished diet are added the baneful effects of bad air and crowded habitations, this disease is most apt to make its appearance. The most common cause in dietetics is not so much, perhaps, a poor or vegetable diet, as food that is altogether inappropriate, such as the too early or too frequent use of animal food, broths, &c. The inflammation of the intestinal mucous membrane is considered as the principal, if not the sole cause of enlarged and diseased mesenteric glaRds, by many pathologists of the present day. Dr. Cheyne, in his valuable work on the abdominal diseases of children, observed that this was a frequent cause of the diseased glands—an important fact to recollect in the treatment of the affection, the nature of the exciting cause having a direct bearing on the treatment. The disease, when produced in this manner, is usually marked by symptoms which indicate the presence of an inflammation more or less severe from the commencement, and will therefore come under the notice of the physician as a disease at first differing from that now under consideration, and leading to it as a result or consequence. Besides, therefore, the non-inflammatory development of tabes, any of the causes which will produce enteritis, or cause an irritation in the mucous membrane of the intestines, may become a source of enteritis. The retrocession of cutaneous eruptions may consequently produce this disease, as this frequently excites inflammation of the mucous lining of the bowels. Semeiology.—It is extremely difficult, by any precise signs, to detect at first the existence of enlarged mesenteric glands ; all the varying symptoms of gastric and intestinal indigestion and inflammation being more or less evident, and are the necessary attendants on the disease of these glands when they exhibit any symptoms of disorder; for there have occurred cases where they have been found in a state of suppuration, without any suspicion of such disease existing. The commencement of the disease is exceedingly obscure ; and the only cause of suspicion is found in the existence of a strumous diathesis, and the appearance of scrofulous enlargements about the neck, while the obstinacy of the symptoms of disordered digestion and their repeated occurrence, will almost confirm the suspicion that the mesenteric glands are likewise the seat of the chronic engorgements, to which they, in common, with the lymphatic glands, are liable. The affection has been divided into three distinct stages : the first, as has just been observed, being very difficult to distinguish. EXCERNENT SYSTEM. 303 This division is generally adopted by practical writers, although, like all other arbitrary divisions of disease, it is at times very difficult accurately to distinguish. The following are the symptoms which have been assigned to each of these stages by Capuron, Gardien, and other writers, and which in the last two stages may easily be recognised.* At first the child loses its ordinary vivacity, becomes sad, pale, and feeble. The digestion is deranged, the appetite nearly lost, the abdomen appears flatulent, swelled, and tense, more especially toward night. The alvine evacuations are occasionally liquid, with intervals of costiveness. The lungs exhale an acid odor ; respiration is irregular, and the pulse intermittent. The urine appears white and milky. Cramps sometimes occur in the limbs, which become very feeble. The face is thin and wrinkled, and the skirt is dry and harsh. All these symptoms, it is very evident, are common to the ordinary gastric and intestinal derangements. The second stage, in which the peculiarities of the disease are more evident, may be known by the variable appetite ; usually, however, it is exceedingly voracious, without any improvement in the appearance of the child, who continues to become greatly "emaciated. The food taken appears to cause distress ; producing horborygmus, and other symptoms, caused by an inordinate mass of undigested matter in the bowels. The abdomen is largely distended, and it is at this stage of the disease that the indurated glands may be felt, solid, knotty, and isolated : the only symptom on which M. Guersent relies, as an unequivocal evidence of the existence of tabes mesenterica. When an examination of the abdomen is made for the purpose of ascertaining the existence of these diseased glands, it should be done while the bowels are empty, when the glands may be felt, and giving pain on pressure. The pain is only felt when the glands themselves are pressed. This is a diagnostic sign of some importance, for there is evidently but little or no inflammation of the intestines when no pain is produced on pressing the abdomen in the usual manner. It has been observed that the pain of simple strumous mesenteric glands is not increased by pressure on the abdomen ; they can not therefore be always complicated with a phlogosed state of the intestines. When the child is old enough to give an account of the pain attending the disease, it is described as sharp and deep-sealed, not continued, but recurring at intervals like the griping pain of colic, but situated more toward the loins. In this stage the urine flows in small quantities. The stools * Traits des Mai. des Enf., par J. Capuron, p. 416. Diet, des Scien. Med., art. Mai. des Enf. 304 DISEASES OF CHILDREN. are very irregular, and occasionally altogether suspended ; sometimes they are soft, and present a very natural appearance ; at other times, and much more frequently, they are of a white or cha'ky appearance, which has been regarded as peculiar to this disease. Worms are often found in the alvine discharges. The body becomes exceedingly emaciated, the face pale, and the features sharp, while the abdomen gradually changes. In this stage a fever of a very irregular type makes its appearance. It is at first obscure and intermittent, but if the disease is attended with inflammation of the mucous coat of the intestines, it becomes more distinct and acute, but for the most part assumes the remittent form. When it is simply the effect of irritation caused by the preternaturally enlarged glands, its exacerbation occurs toward evening, accompanied with great restlessness and a rapid pulse, beating from 120 to 130 in a minute. This fever is preceded by severe chills, and ends in profuse sweating, with colliquative diarrhoea ; it is a true hectic fever, the paroxsyms terminate toward morning, to he renewed at the close of the day. There is but little disturbance of the intellectual faculties; and listlessness and indifference *to surrounding objects, and avoidance of all exertion, are the principal manifestations of any change in the sensorial powers. In this stage, also, it is not unusual for anasarca to take place, if the tumors are large, from their pressure on the veins. From the same cause, also, a change occurs in the functions of contiguous parts, and the actions of the stomach, liver, and kidneys, are very materially impaired. During the entire progress of the disease, but more especially at the period designated as its second stage, a variation of the symptoms will be observed in different cases, according to the complication of the mesenteric affection, with phlogosis of the intestines. When the disease of these glands exists independently of any such complication, or when the latter is very light, the accompanying fever bears little or no resemblance to the remittent fever of infants, which is its character when the inflammation of the mucous membrane of the intestines is severe. A close attention to the symptoms, principally by examining the condition of the abdomen on pressure, will sufficiently enable the physician to detect the evidences of inflammation of the bowels. When this exists, the disease is usually rapid in its progress, and differs in no respect, in its manifestations and results, from enteritis. In the last stage, this inflammation almost invariably exists, even if it should have been absent at the other periods of the disease. The glands have passed from their indurated condition, and become softened or suppurated. The fever is decidedly hectic, and 305 EXCEKNENT SYSTEM. great prostration of strength ensues, with extreme emaciation. Excessive discharges by stool take place, and pus, mixed with streaks of blood, appear in the alvine evacuations. The abdomen becomes more tumid and tender to the touch, serous effusions in the cellular tissue and peritoneal cavity increase, and the child dies in a state of complete marasmus. It is a subject of acknowledged difficulty, accurately to distinguish this disease from others which affect the abdominal organs of children. One of the most unequivocal signs of the presence of enlarged mesenteric glands, is the existence at the same time of scrofulous tumors in other parts of the body, while the symptoms above mentioned show the disordered state of the prima; viae. Where these signs also are absent, the tubercular affection of the mesenteric glands may be suspected, when the child exhibits the usual appearance of a scrofulous habit; while fever, which usually attends gastro-intestinal inflammation, is absent. The nature of the alvine discharges, in connexion with other symptoms, will throw some light on the nature of the disease. If there exist a diarrhoea, the food taken appears for the most part to excite it; and the crude nature of the evacuations will show that "it has been rapidly urged through the bowels, from an exalted action, produced by the increased susceptibility to impressions, which follow an inflammatory excitement. The stools, also, have a mucous or slimy appearance, showing an alteration in the secretions of the mucous surface. The pain will, for the most part, be increased immediately on taking food, when there is any gastro-intestinal inflammation ; and where there is inflammation, especially of the small intestines, pain will immediately be increased on pressure. The discharges, on the contrary, in the scrofulous affection, commencing in its ordinary manner, although there may appear in them illdigested food, are yet destitute of the morbid secretions which attend inflammation of the mucous membrane. All the symptoms of an abdominal nature are equivocal ; but when they present a deranged condition, and the child has the usual symptoms of a scrofulous diathesis, and with them continues to grow emaciated, while the appetite is good, or perhaps voracious, the strong presumption is, that the mesenteric disease is the cause of all the untoward symptoms. Morbid Anatomy and Pathology.—On a post-mortem examination, the exterior of the body presents a rough and ashy appearance, the skin is dry, and from the great emaciation of the body, seems almost in some parts closely adherent to the bones. On opening the body the mesentery is found often infiltrated with pus, and studded with engorged and tuberculated tumors, in various states of disorganization; some partially suppurated, and others to- 39 306 DISEASES OF CHILDREN. tally destroyed. Those which are in the earliest stage are red, and somewhat increased in size. These glands and tumors are of various sizes, from that of a pea to that of a hen's egg. They are often agglomerated into masses of great size; and those which are advanced to the second stage of disorganization, are of a dull, white color, and firm consistence. The glandular structure of the mesenteric glands is at times found entirely altered, and tubercular matter deposited in its place. This tuhercular deposite also appears on the surface of the glands, which gives them the appearance of being much enlarged ; but, according to Andral, it is not so, but it is the effect of the additional deposite of tuhercular matter, commencing either in the centre, or in several points of their bodies. It has been supposed to occur in the cellular tissue; for injections show that the permeability of the lymphatic vessels, through the glands, remains the same as if there were no disease, for injections readily pass through them. These tumors, when softened, exhibit precisely the same characters as tubercular matter in other parts, the caseous appearance being in every respect like that observed in tubercular matter of the lungs in phthisis. Besides these lesions in the part which is the immediate seat of the disease, various others are occasionally found. The peritoneum is sometimes inflamed, with adhesions and effusions in its cavity. Appearances of inflammation also have been found in various parts of the intestines, with ulcerations of the mucous surface. These, it has been remarked by some observers, are not uniformly the case in enlargements of the mesenteric glands, and their existence is as frequent without a diseased condition of the glands, and they have no dependance on each other, as cause and effect, notwithstanding that this theory has had such strong advocates.* The analogy offered by the enlargement of the cervical lymphatic ganglia by a primary affection, without being traceable to an abnormal condition of the adjacent parts, with-which it is connected, shows conclusively that an independent disease can exist in them. It is very rare that there are not found tubercles in other parts; the liver generally contains* some, and they are also found on the peritoneum. The greatest number exists in the lungs, as we learn from the dissections made by Guersent, in the Children's Hospital at Paris.t The disease is then of a scrofulous nature, depending for the peculiarities of its manifestations on the development of the strumous changes in the mesenteric glands and the adjacent parts, and analogous in every respect to similar alterations in other glands and • Dr. Joy, Cyclop. Prac. Med., art. Tabes Mesenterica. t Loc. Cit. 307 EXCERNENT SYSTEM. tissues. Like most diseases, it scarcely ever exists without its complications. It is from this cause that much diversity of opinion has prevailed as to its precise nature; for diseases affecting the prima? via? of children are much more liable to the admixture of other derangements, as one part can hardly ever be affected without other portions being likewise disturbed in their functions, or suffering perhaps from organic changes. Inflammation not only occurs in the mucous membrane of the bowels, but traces of it are found in the peritoneum, and tubercles are discovered both tri this serous membrane and in the liver. The complications are important in a practical point of view; and the early appearance of inflammation appears to demand a course of treatment which the judicious physician would hesitate to adopt, under circumstances which exhibit at once a tendency to the fatal debility and marasmus which characterize the disease in question. It has been common, since the doctrines of Broussais have been introduced, to regard the disease in every instance, as produced by an inflammation of the mucous membrane of the intestines. Tubercular matter is now regarded as a distinct morbid product, and the mesenteric glands may become tuberculated like other glands ; and this change is accompanied with inflammation at some period of the disease, but is not necessarily preceded by it. That these glands become inflamed and suppurate, from the cause just mentioned, no one can deny ; for there is no reason why we should question the analogy between them and other glands, as those of the groin, which it is well known become inflamed, and suppurate from transmitted continuous inflammation. But such is evidently not the disease in question, for it is one purely of a tubercular nature : it has been regarded as such by Bichat,* Sir A. Cooper,t Andral,} Carswell,|| and others. It may be generated in the part itself, without being transmitted from another. Whatever be the theory of the actual development, it would appear, from its nature, to be capable of being excited into action, in a manner different from that of ordinary inflammation and suppuration, and not necessarily dependant first on an inflammation of the mucous membrane. Such inflammation as we see in other glands, results, for the most part, in real genuine suppuration. There exists in these, as in other glands, a real inflammatory enlargement, which follows inflammation of the bowels, and which may be an attendant of the remittent febrile affection of children. This distinct disease has been described by Pemberton ; and although an enlarged condition of the glands was found, yet it was destitute of the peculiar cheesy • Anat. Patholog. d'apres un manuscrit autographe, etc., P. A. Beclard. t Lancet, vol. iv., p. 102. t Morbid Anat., p. 209. || Path. Anat., fasic. iv.; Lond., 1834. 308 DISEASES OF CHILDREN. matter existing in tuberculated glands. It is, he says, an enlargement from the irritated and inflamed membrane with which they are surrounded.* As was before remarked, the disease is rarely found uncomplicated with irritation, inflammation, and at times even ulceration of the mucous lining of the intestines. This inflammation in those of a scrofulous habit is liable to run into tabes, and the disease thus produced is very easily confounded with the simple ordinary inflammation, excited in the same manner. Inflammation, both in the glands and in other parts, is also influenced by the amount of the strumous diathesis developed in the system, and like other forms of scrofula, will be modified in its appearance and progress by this condition of the system. Treatment.—The treatment must be, as to the general principles, similar to that pointed out for the management of scrofula. It will, therefore, be necessary to adopt similar hygeinic rules, and to give the patient, if possible, the benefit of good free air in a healthy district of country, and by good nourishing food and plenty of exercise, suited to the age and vigor of the child, give the constitution an opportunity of attaining a state of healthy development. It is unnecessary here to repeat what has been already said on this subject. The remarks under the head of scrofula are applicable to the present disease ; bearing in mind that the seat of the affection, and the great liability to complication by inflammation of the mucous surface of the bowels, render great circumspection necessary in the use of stimulating or nutritious food. It will be of the greatest importance in the treatment of this disease, throughout all its stages, to recollect the frequent liability to an inflammatory action in the mucous membrane; and to examine closely at the first appearance of disease, attended with derangement in the actions of the chylopoetic viscera, whether there do not exist some degree of inflammation in these parts, or their de pendant membranes, and other organs with which they are connect ed. When these are found to exist, the treatment should be commenced with the abstraction of blood, by means of leeches applied to the surface of the abdomen, and the use of warm fomentations, warm bath, and frictions over the surface of the body. Such measures will form a powerful counter-irritation to the disease, even if there should not be inflammation decidedly manifested by tenderness on pressure, but only symptoms of evident derangement of the abdominal organs, which would lead us to suspect the presence of diseased glands, and if much febrile action attends the other symptoms. This course will he more beneficial at the commencement * A Practical Treatise on the Various Diseases of the Abdom. Viscera, by C. R. Pembeiton, M. D.; Lond., p. 17. EXCERNENT SYSTEM. 309 of the disease, before debility or emaciation has ensued. Indeed, it is scarcely applicable at any other period, for the child can rarely ever bear the repetition of the abstraction of blood, without serious debility being the result, when the glands are the seat of the scrofulous affection. The local inflammation and irritation most commonly exist, to a greater or less degree, in all these affections at first; and it is not incompatible to resort to these measures for its removal, while efforts are at the same time made to invigorate the general system, principally by the measures already mentioned. To tell the precise point when measures of a local depletory nature ought to be suspended, is sometimes a question of great difficulty, especially in the disease before us. That it can not be pursued, and the treatment mainly conducted on the supposition that it is essentially inflammatory, all experience fully justifies. It is also a safe practice, and one which is borne out by experience, to use mild aperients where the bowels are sluggish in their action; that of calomel and rhubarb will be decidedly the best: the former, from its well-known action on the secretions generally, and the latter, from its property of controlling excessive discharges. Purgatives were formerly very much in use in the treatment of this disease; of late they have been almost* entirely discarded, and nothing allowed to pass to the internal surface of the bowels but the blandest substances. Although, when injudiciously used, they unquestionably greatly aggravate irritation in the mucous surface of the bowels, yet daily observation proves, also, that by their effects on the secretions they also'relieve inflammation in the very parts where they exert their irritating properties. Besides, in this disease, and in all affecting the chylopoetic viscera, we are not certain that the mucous membrane always continues inflamed throughout its whole process, even if it were so at the commencement. An altered condition of the secretions of the liver and intestines, known by a foul tongue, and dark-colored discharges, highly offensive in their character, will, for the most part, indicate the necessity of aperient medicines. The relief afforded to the vessels by the free secretions, produced by medicines of this nature, will not only tend to relieve the local affection" but will likewise impart an increased vigor to the constitution. The indiscriminate and persevering use of cathartics has brought remedies of this nature too much in disuse, especially where the viscera of the abdomen are implicated in the disease ; but under the circumstances just named, those of a mild character, and which exert their principal effects on the liver, will be such as will be needed. When these are indicated, calomel should have the decided preference, and, as before remarked, will be best combined with rhubarb; or a small dose of calomel at night, followed by a combination of rhu- 310 DISEASES OF CHILDREN. barb and sulphate of potash on the following morning. This course should be adopted for a week or two, intermitting every third day, until a decided improvement is seen in the alvine discharges. It has been the custom in Europe to administer at the same time some mild, bitter infusion, combined with a narcotic, for the purpose of procuring a tonic effect, and allaying constitutional irritation. These means may advantageously be adopted where there is no fever present, or any mark of inflammation. Such cases will sometimes occur, and be decidedly benefited by this course. A combination of these means is recommended by Underwood, who, after using small doses of calomel two or three times a week, advises the sub-carbonate of soda on the succeeding day, or an infusion of senna and burnt sponge, with which he was almost certain of effecting a cure —regarding the purgative system as the most essential to the cure of this dangerous disease, and even to be used when there is a loose state of the bowels. After the bowels had been thus freely acted on, he then combined small doses of calomel with ipecacuanha, eicuta, and Colombo. All practitioners agree as to the beneficial effects of mercury in some form, given only to Influence the secretions, but not to produce salivations. Lloyd, for this purpose, recommends blue pill, or Plummer's pill, followed by a decoction of sarsaparilla. Abernethy uses mercury, combined with rhubarb and ginger, for the purpose of restoring the secretions and imparting tone to the stomach, and thus improving the digestive organs. All these various combinations may be found fiseful, and the union of a tonic with an aperient, even immediately after local depletion, may in reality be found useful practice ; for a local affection, like that now under consideration, will not be found to he aggravated by the increased vigor imparted to the constitution by a mild tonic and improved digestion. The form of mercury, which is generally the most useful in the deranged secretions in children, and especially if accompanied with any degree of looseness, is the hydrargyrum cum creta, combined with rhubarb. Formula:, which are applicable to the present disease, have already been given. Whatever be the form in which this medicine is given, it should never be carried so far as to affect the constitution. Frictions, therefore, of mercurial ointment, which for a time were much in use, are inadmissible in this disease, for they produce no action on the system until absorbed, when the constitutional effects will produce very serious consequences in a strumous habit. It can only be given with safety in such quantities as will procure an increased secretion from the liver and intestinal surface. Where there exist good reasons for not using calomel, rhubarb 9 311 EXCERNENT SYSTEM. combined with sub-carbonate of potash, or sulphate of potash, will be found useful, from its mildness, and may be employed daily, for some weeks, where purging is deemed necessary. A most important means should not be overlooked in the management of this disease, that is, the employment of frictions and external stimulants throughout the whole course of the disease. This method of treating chronic affections is too much neglected ; but it is among the most useful which can be adopted, for it not only produces a counter-irritation, but, by the active influence on the capillary system of the surface, powerfully excites it into action, and thus produces a constitutional effect on the capillary system generally, from the extensive sympathy which exists with the vessels and nerves of the dermoid surface. The body and limbs may be frequently rubbed with some stimulating liniment, while the ointment of iodine, which exerts so powerful an influence over the glandular system, may be rubbed over the abdomen twice a day. The ointment of the hydriodate of lead is considered as preferable, on account of its not causing so great an irritation on the surface to which it is applied as other forms of iodine. Formula; for applications of this nature have already been given under the head of scrofula. It was before observed that tonics are at times called for in the treatment of this disease. They were much more freely used in* former times than at the present day; but while they were formerly too indiscriminately resorted to in the early stages of the disease, and greatly relied on for its cure, they have been too much disre-" garded in the present day. Whenever tonics, whose action is di-« rect on the digestive functions, are used, they ought always to be combined with some aperient medicine, whereby the secretions are excited, while a vigor is imparted to the digestive organs. When such are deemed necessary, which can only be the case when there is an entire absence of all febrile action, the sub-carbonate of iron, combined with rhubarb and Colombo, is one of the principal means employed by Sir Astley Cooper in the treatment of scrofulous diseases generally. With respect to the employment of iron, it is only useful in cases of extreme debility and a leucopathic state of the system, where the serous fluids predominate. In such cases, after the employment of a proper alterative course, and when there is evidently a great want of tone, iron may be useful in overcoming the glandular obstructions, by the energy and vigor it imparts to the circulation. Notwithstanding its recommendation from high authority, it should be given to children with great circumspection, as it is a powerful excitant, and only under the circumstances just mentioned can it be considered as useful. Chalybeate mineral waters have also been found greatly to benefit those suffering from this, as well as other forms of scrofulous diseases, but they are not to be 312 DISEASES OF CHILDREN. used when there is any inflammation of the glands, or of the intcs tinal or gastric mucous membrane. They should never be resorted to when there is any indication of such irritation with febrile action. As a tonic and deobstruent the muriate of barytes has for a long time been held in high repute in Europe. Its value has probably been highly overrated, as it is now very generally abandoned. Dr. Ferriar, some years since, made several experiments with this medicine without finding the benefits he anticipated from its use, as it failed in the greatest number of instances. Although in more recent times it has been advocated by some French practitioners, yet the hazards attending its use far overbalance the advantages. Very alarming effects sometimes follow its employment, such as colic, hypercatharsis, vertigo, inflammation of the mucous lining of the throat, stomach, and intestines; and even death has ensued, where its proper dose has been a little exceeded. Since the powerful effects of iodine have been known, it is the principal, if not the sole tonic on which reliance has been placed, in the treatment of this and other scrofulous affections, although in the mesenteric disease experience has not so fully proved its efficacy as in other forms of the scrofula. The objections to its use have been, that it so easily excites the mucous membrane of the intestines to inflammation, and aggravates it when such a condition exists. The form in which it has been found most beneficial is that of the tincture of the hydriodate of potash, in doses of from five toten drops, to young children, as already mentioned, when speaking pf scrofula. Guersent, on the contrary, says it is totally inefficient in the affections of the mesenteric glands; with the remark, that it is to be more cautiously used, from the fact that an active inflammatory state of the bowels may be more easily induced in this than in other forms of scrofula. The observations already made on this subject in the preceding article, will be applicable to the present disease. RICKETS. The name rickets is derived, it is said, from the Greek word p*X'f, the spine, from the curvature of this part of the body. Dr. Good, however, doubts this etymology, believing that, as the disease was first observed in England, it received its name from the Saxon rick or ricg, signifying a hump. This idea is the most probable, as the Greek term is not to be found in any of the Greek or Roman medical works. It has been supposed that this, in common with other diseases, must have existed among the ancients, but there does not appear any description corresponding with this affection in any of the wri- # EXCERNENT SYSTEM. 313 tings of the early period of medicine. Hippocrates contains no account of it as a distinct affection. It was probably confounded with some other disease, since we can scarcely doubt its existence. Homer describes the deformed and hunch-backed Grecian, Thersites, in his account of the siege of Troy. And the no less celebrated Tyrtaeus, the poet, of whom Horace speaks, was sent in derision to the Lacedemonians, when the oracle promised success to the arms of the latter on their obtaining a celebrated general from Athens. Other allusions exist in various ancient authors in relation to deformed persons, which prove a disorder of the osseous system, corresponding with that now known as the rickets. The earliest description of the disease was given by Glisson, in 1650. He states that it first appeared in England, in 1620, whence it spread over Europe.* Etiology.—This disease may be developed at all ages, but children are most predisposed to it. Some have asserted that it is never formed until after birth, and others have stated'thal it does not make its appearance until the age of two or three years; but Pine! has dissected a foetus, and preserved the skeleton, in which the disease was fully developed.t Children, at all ages, are far more subject to Ihe disease than adults ; and from its being also found in the foetus, is one of the evidences of the influence of the development of the body in the formation of disease. The subject will again be referred to, under the head of the pathology of rickets. It has been supposed to be contagious, but there exists no proof of its propagation in this manner; the idea has probably arisen from its being one of the complications of scurvy, scrofula, and syphilis. Although not contagious, it appears to be hereditary, like other diseases affecting the nourishment of the body. With respect to the exciting causes, some have denied their existence altogether, and assert that it arises spontaneously from a simple natural impulse. But most practitioners are of a different opinion, and refer the formation of the disease to the action of various causes acting on the hereditary predisposition. These are chiefly such as tend to produce a debilitating effect on the general system, as impure and confined air, that is rarely exposed to the influence of the sun, and is consequently loaded with moisture. It is peculiar, also, to some climates, and prevails more in the valleys of the Pyrennean mountains, than it does, from all the accounts we receive at the* present time, in Great Britain. It has also been found in Chinese Tartary. Although occasionally seen in the United States, it may be considered as of rare occurrence. With • De Rachiti de sive Morbo Puerili Tractus; Lond. 1650. t Capuron, Malad. des Enf., p. 421. 314 DISEASES OF CHILDREN. # these may also be classed the want of nutritious food and regular exercise, and the absence of cleanliness, so common among the poor. In some instances, however, there appears to exist no actual cause for its appearance, other than the natural process of development, with an imperfect supply of the proper materials for the growth of the osseous system. It has occurred in families where everything necessary to comfort and health existed ; one child, perhaps, out of several, exhibiting the morbid development of the bones. In those of a scrofulous diathesis, an injury done to the bone by changing the vital action of the part, has produced the disease. An example of this is given by Chaussier, in the case of a man thirty years of age, who received a violent blow on one of the parietal bones; and also of the alteration in the bones of the carpus, from a severe fall on the part. Other causes have been charged with the production of the disease; as the presence of worms, acidity of the stomach, dentition, etc.; but these are probably only accompanying affections, aggravating the existing disorder. Semeiology.—The progress of the disease is very gradual, and almost imperceptible at its commencement. The skin is soft and flaccid, and the complexion fair and delicate, while a general appearance of debility occurs. The child is indifferent to occupation of any kind, and languid; and being indisposed to exert his limbs, lies for the most part in bed. The digestion is evidently deranged, as appears from the acid odor of the breath, and the irregularity of the stools. The head is the first which exhibits the effects of the diseased condition of the osseous system ; not only in its enlarged size, but also in the separate state of the sutures. The neck at the same time becomes slender and flexible, while the jugulars appear more prominent. If the disease be not arrested at this period, the epiphysis of the bones appear more enlarged than in a healthy state, while the limbs themselves, from the emaciation, are much smaller. The sternum becomes softened and convex, and the ribs flattened, while their articulating extremities are increased in size. All the bones are softened, the limbs are unable to support the body, and the spine becomes distorted. If the disease continue, the rJelvis, also, is softened and crooked, materially impeding the action of the bowels. The progress of the disease is not confined to the bones solely, for in very severe cases the liver, spleen,.and mesenteric glands, become tuberculated; hydrocephalus, hydrothorax, and acites, take place, and the child, at same time being greatly emaciated, presents EXCERNENT SYSTEM. 315 a hideous spectacle of deformity. A colliquitive diarrhoea ensues, which soon terminates in death. These extreme symptoms are rare among the native inhabitants of the United States, but may at times be seen in some of the wretchedly indigent immigrants arriving on our shores. Pathology.—A marked deficiency of earthy matter in the bones, which is diminished about one half, characterizes the disease. It is usually connected with other evidences of scrofula, and, consequently, the two diseases are essentially the same, but manifested in different parts of the system. They both depend on the supply of imperfectly-elaborated materials for the proper and healthy growth of the body. The different ages at which the various forms of scrofulous diseases appear, afford a remarkable illustration of the predisposition, to disease from development. The tubercular disease of the lungs rarely appears before the age of puberty, for these parts undergo but little change from their state as it exists immediately after birth. Their condition appears to vary but little at any age, and therefore they are not liable to those alterations with which they are so often affected, until the period of puberty, when changes occur in the vocal organs, or the repeated exposure to Other exciting causes develop the latent disease. Again, scrofulous disease, properly so called, which is manifested in the enlargement and alteration of the lymphatic glands, appears at an earlier period of life, while the demand for nutrition keeps the lymphatic system in a state of preponderance. At early period, also, the scrofulous diathesis will be exhibited in the ultimate tissue, the seat of interstitial growth, in those parts which undergo great changes in their structure during their growth. The bones, therefore, will soon manifest this, inasmuch as they are, at first, nearly cartilaginous, and requiring a continual deposite of earthy material in increased proportions; a defect in the supply, or in the proper elaboration of the materials supplied, is soon manifested in an imperfect development of the bones, constituting the disease in question. The growth of the bones, therefore, requiring, as they do, a supply of different materials, and the defect of the proper nutrition from constitutional causes, exhibit the predisposition to disease during the changes attendant on growth. Treatment.—There is but little to add on this subject to what has already been said when speaking of scrofula. As debility and languor characterize the disease, every attention should be bestowed on invigorating the system, principally by means of exercise, pure air, and a good and substantial diet. In order to relieve the head from the supposed engorgement, it was formerly the practice, from the recommendation of Glisson, whose work is remarkable for its accuracy in the account of the 316 DISEASES OF CHILDREN. disease, to cauterize the part between, the second and third cervical vertebrae. But this remedy appears to be not only useless, but injurious, in a disease independent of any internal congestion, and where continual and increasing debility is one of the essential symptoms. Among the remedies which have been long in use, and which was so indiscriminately employed in children, both in sickness and health, in former times, is the cold bath ; a remedy strenuously urged by Floyer, but whose partiality for it has led to its too general employment in young children, where the abstraction of heat is often attended with great danger to their lives. In rickets, which is characterized by a general debility, the good effects of cold bathing are evident in the increased energies of the nervous and circulatory system. Sea-bathing has the advantage of the tonic effects of the salts in solution,on the cutaneous vessels, and the stimulating effects of the cold water. Whenever a child is to be submitted to the influence of cold bathing, it should be done by gradually accustoming it to an increase of temperature, commencing with tepid water. After being immersed in the bath, the surface of the body should be wiped dry, and the child wrapped in flannel, and, as soon as dressed, should be allowed to take freely such exercise as it is capable of using. The child may also in the same manner be accustomed to cold effusions, which may be employed with perfect safety, if caution is at first used to have tepid water, and gradually lessening its temperature. Factions are of great service after removal from the bath, and should in every instance be employed. A vast number of remedies have been used at different times ; it is unnecessary to mention them, for the principles of the treatment will be found in the preceding article on scrofula. The different 'preparations of iron are useful in these derangements of the digestive organs which require tonics. The attempt to supply the deficiency of phosphate of lime, by administering this substance, has never been followed by the anticipated success. The treatment, therefore, must be based upon the necessity of invigorating the system ; and when it becomes necessary to use tonics internally, those must be selected which produce the least irritability. Iron, as recommended by Boyle and Cullen, is the best for this purpose. In rickets, therefore, after a preliminary aperient course, and the adoption of the obvious hygienic measures, if the disease still persists with evident debility and a leucophlegmatic state of the system, iron, by imparting energy to the system, will exert a salutary agency. Iron filings may be given where chalybeates are indicated, in the dose of half a grain to two grains three times a day to children under two years, and from two to five grains to children between the EXCERNENT SYSTEM. 317 ages of two and four.* Iodide of iron is one of the most valuable preparations, and is peculiarly applicable to this disease. Unless the affection is local, no advantage can arise from the application of any mechanical contrivance for the support of any part of the body, as pressure must be made on some other part, all the bones being in a pliant and flexible condition ; and while one part may be benefited, another will be rendered more deformed by the pressure ; besides the impossibility then existing of the child's using any exercise, so important in restoring the energies of the system. The greatest danger, during the progress of the disease, is the deformity of the thorax, which becomes convex anteriorly and flattened on the sides. By gently compressing the sternum as recommended by Dupuytren, this deformity may be removed during convalescence. It should be done daily with the hand ; and the serious interruption which would otherwise occur to the proper motions and expansions of the lungs in after life" will thus be obviated. The bed on which the child lies should be moderately incompressible. A hair mattress is the best; and if unable to walk, he should be carried or ridden on one, to obtain the necessary exposure to the air, as the ordinary method of carrying can scarcely, if ever, be adopted in a bad case of this disease, where all the bones participate in the morbid changes. Where the child is old enough, all reasonable measures should be adopted to encourage gymnastic exercises, as a means not only of invigorating the general system, but also of preserving the symmetry of the limbs. INCONTINENCE OF URINE. This is an affection of very frequent occurrence in children at all ages, even until the period of puberty. It affects children of both* sexes, but it is said that girls are more subject to it than boys. It is one of great annoyance, and when very frequent and continued, is a symptom of general derangement of the system, and is accompanied with other evidences of debility and disorder of the body, such as indigestion, emaciation, etc. Etiology.—A most common cause is the natural irritability of the bladder, which appears to exist in infants, and the want of voluntary power over the sphincter. The habit, also, which the child * R Ferri. Rament., gr. iij. (126) Cretae, p. p. Oleo. Sacchar. Citr., aa. 3ss. M. . ft. Pnlvis. divid. in vi. partes cequales. One powder twice a day. R Ferri. Rament., (127) Pulv. Rhei., K Cinnamon, aft. gr. ij. Magn. Carb., gr. ij. Sacchar. Albi., 3ss. M. ft. Pulv. dent. tal. Dos. No. vi. A powder night and morning. 318 DISEASES OF CHILDREN. acquires, of exercising no control over this evacuation, is also a cause of its continuance for some years. This habit is promoted by the natural indolence of some children, who will not rise at night to relieve themselves when urged by the promptings of nature. Among the other causes producing an involuntary flow of urine, is the profound sleep of children, which prevents the stimulus of the urine on the mucous coat of the bladder from being felt. This disease exists in different degrees, for while some experience it only at night, others are affected during the day as well as at night. Those who are affected with eneuresis generally have frequent calls to evacuate the bladder at all times. The urine is more copious; and this increased secretion is the cause of the demand being so frequently made for its discharge. The origin, therefore, of the disorder, appears to be in the secretory function, and arises from a derangement in the action of the kidneys. Semeiology.—When the affection is long continued, and the discharge very frequent, the general health of the child is apt to suffer. He becomes emaciated, and loses his strength; but as age advances, the natural strength improves, the untoward symptoms gradually disappear, and the voluntary control over the sphincter of the bladder is acquired. At the period of puberty the incontinence of urine generally disappears without the interference of art. When it appears to depend on an hereditary condition of the nervous system, which is often manifested by a great irritability, it has occasionally lasted beyond puberty—the child, on being frightened, losing his control over the bladder. When at other times it In- In-been relieved, it has again made its appearance on the development of the organs of generation, both of the male and female, when the latter takes place widi more than ordinary vigor. This renewal of the disease renders it one of great obstinacy, and very •difficult of management. Treatment.—The causes of this affection must be the guide for the treatment, which ought, accordingly to vary in different cases. In those arising from continuance of a bad habit contracted at an early period of life, the chief means must be directed to correcting it, by accustoming the child to arise once or twice during the night, while all late suppers are to be avoided. A great variety of means has been used at different times for the relief of the nocturnal eneuresis of children, each of which, although considered as infallible at the time, has been obliged to give place to others of no greater efficacy. It is of importance to find some remedy for this distressing complaint; for although of itself it may not he one of hazard to the future health or life of the child, yet, from the shame nttacTied to it, and the means often resorted to, by unreflecting persons, to break the habit by severe chastisement or ridicule, a serious 319 EXCERNENT SYSTEM. effect may often be made on the temper and morals of the sufferer. It has been attempted to be cured by the position in bed, and Sir Charles Bell has asserted, that the urine is only voided by children when lying on the back; and that a cure may be effected by altering the position of the child in bed, and causing him to lie on the side or face. This, however, does not appear to be the case ; besides the great difficulty of preserving children in this position, which must almost preclude the possibility of relying on this method of cure. As the disease evidently depends on the increased secretions of urine, such remedies as experience has discovered, to control this increased action of the function of the kidneys, must be resorted to for its relief. These* are medicines possessing a sedative nature, combined with a tonic. An infusion of Colombo root, jvith a drop or two of tincture of opium added to each dose, according to the age of the child, will be a useful means of controlling the increased action of the kidneys. There is always more or less want of vigor in the digestive organs requiring some mild tonic or bitter infusion, to restore the lost tone of the stomach. The muriated tincture of iron has also been used for the same purpose; it may be given in doses of from two to ten drops, largely diluted with water, two or three times a day. The leaves of the arbutus uva ursa, given in the dose of five to ten grains, to children of five or six years, are a useful means of controlling the action of the kidneys ; this medicine possesses both tonic and astringent properties. Of late, the extract of nux vomica has been highly recommended by the German physicians, in incontinence of urine.* It is said to be more applicable to children for irritability, from whatever cause it may arise, as its action is confined particularly to the spinal marrow, and does not disturb the sensorium, like preparations of opium. This is a remedy which I never have tried in the affections of children, and therefore am unable to give any result from experience. It is too hazardous a remedy for so trifling a complaint. It has been given in Germany, in the proportion of a grain mixed with four ounces of mucilage. A teaspoonful of this mixture, every two or three hours, is the dose for a child from one to three years; while the tincture of the seeds is applied by friction to the loins. A blister to the loins has been occasionally found serviceable, as well as the more permanent effects from the use of stimulating plasters, such as Burgundy pitch. The latter may be made a little more efficacious, by the addition of some stimulating substance, such as camphor. With respect to instrumental means for relieving this disease, they ought, as much as possible, to be avoided ; but in obstinate • Schwartz, Heidelbergcr Mcdicineische Annalen., Bd. :., H. 1, 1835. 320 DISEASES OF CHILDREN. cases, which resist all other means, the introduction of a bougie or sound into the bladder will sometimes be found useful, by stimulating the neck of the bladder, and exciting a new action in the part. Instruments, however, which have sometimes been applied to the penis, for the purpose of compressing the urethra, are decidedly injurious in various ways to young children, and ought never to be employed. Although they may arrest the flow of the urine for the time, they never cure it; and the injury done to the part, and the premature excitement they cause to the genital organs, are far greater than the temporary advantages resulting from use. DYSURIA. Dysuria"attacks children at all ages, and is one of the most distressing diseases of infancy, and often, like other affections of the urinary organs, will continue for some time without any suspicion of its existence. Etiology.—It may arise from different causes ; inflammation in the bladder, urethra, or kidneys, or the presence of oxyures vermiculares in the rectum, will give rise to difficulty and pain in urinating. The excitement of the system during teething, and the derangements of the digestive organs at this time, attended with an acid state of the imperfectly-digested food, will also excite dysuria. This condition of the digestive organs tends always to the formation of lithic acid, and urinary calculi is the result. Quite young children are often affected with calculous diseases, the concretions existing in the kidneys, ureters, bladder, or urethra; and they have been found lodged beneath the prepuce. It is well known that they consist essentially of lithic acid; and where the mass of calculus is composed of phosphatic salts, the nucleus is lithic acid. There is a variety of dysuria which is occasionally met with, and which Dr. Willis, in his late work, speaks of having seen a few cases. It is a symptomatic form of disease, and is the same as described by Professor Schoenbein, and the name of urodialysis neonatorum.* The symptoms of this affection are described by him as follows: A very small quantity of urine is voided, and often only a few drops at a time ; it is high-colored, and stains the linen yellow. It is evidently attended with great pain, for the little patients cry violently, and draw up their limbs as if suffering great distress. It is dependent on the condition of the digestive organs, as is evinced by the acid odor of the breath, and the knotty and indurated state • Op. Cit., p. 28. EXCERNENT SYSTEM. 321 of the alvine evacuations : it is uniformly attended, also, with a highly irritable state of the skin. Semeiolgy.—Distress on urinating may be suspected by the cries of the child, caused by the pain and tenesmus it experiences when passing urine. This fluid flows only in drops, with great effort. In general it is high colored, and when the difficulty is caused by calculous concretions, is sometimes mixed with blood. When there is sand or gravel, it may be known by the deposite of lithic acid, on permitting the urine to stand undisturbed for a short time ; the immediate causes of this deposition are the chemical changes spontaneously occurring in the urine, but which it is unnecessary here to particularize. The precipitate is a brown sediment, either in the form of powder or small crystals. At times it is of a purple or pink color, from the combination of purpuric with lithic acid. As is the case in adults, these evidences of a morbid state of the urine are occasionally absent, while the child is suffering from larger accumulations of calculous deposites. The only method of ascertaining the existence of calculi is with the sound, or perhaps they may be discovered by the finger introduced into the rectum. But when a calculus is arrested in the ureter, great suffering may exist without our being able satisfactorily to ascertain the cause. Children affected with calculi are very liable to convulsions, in the state of high sensibility at the tender age of infancy. When inflammation exists in the urethra, or neck of the bladder, or in the mucous coat of the bladder itself, a quantity of mucus is discharged with the urine; this symptom attends the urodialysis neonatorum above mentioned. In this affection there is much febrile action; the skin is hot and irritable, and often becomes the seat of eruptions of different kinds, either prurigo or urticaria. At other times, the cutaneous disorder appears under the form of psydraceous pustules scattered over different parts of the body, causing troublesome sores, especially in the folds of the skin. The symptoms of dysuria may be easily detected by a little attention ; for the child cries most violently when about to make water, and which is only voided in drops. During these paroxysms he will often carry the hand to the genital organs. Treatment.—The treatment should, in every instance, be commenced with mucilaginous drinks, emollient applications to the pubes, enemata of infusions of linseed or catnep ; the latter is an excellent anodyne in painful affections of children, affecting either the lower intestines or urinary organs. The hip bath, also, forms an essential part of the treatment of all disorders affecting the urinary organs. The excitement of the system" during teething, and the disorders of the digestive organs arising at this time, demand the 41 322 DISEASES OF CHILDREN. special attention of the physician. As the stomach abounds in acid, the usual measures for destroying its excess must be employed, while close attention is paid to the improvement of the digestion. Among the alkalies, soda seems to possess the most powerful influence on the bladder in controlling its irritability. As the connexion between the acid state of the stomach and bowels, and the urinary organs, where calculous concretions are formed, is evident in all that are affected with the latter disease, the use of soda becomes a very prominent means in the treatment of those cases of dysuria which are dependant on the formation of lithic acid. It not only corrects the acid in the stomach, but also the secretion of lithic acid in the kidneys. Where there is any hereditary disposition to calculous diseases, they may almost with certainty be prevented by the timely and constant use of alkaline remedies. The annexed formula may be given where there is much indigestion existing, and where a mild tonic is indicated ; it may be administered in some barley water, gruel, or other mucilaginous drink, three or four times a day.** Under other circumstances it will be necessary only to give the soda uncombined with any other remedial agent, either in the form of lozenges or solution, from three to twenty grains in the course of the day. The perseverance in this plan will effectually prevent the formation of lithic acid deposites in the kidneys and bladder. During the employment of these means, additional measures may be needed to influence the digestive organs, by exciting the secretory functions of the liver and intestines. Calomel and rhubarb may therefore be given, to which ipecacuanha should be combined, if there is any fever.t It is only in the prevention of the formation of lithic acid, that we chiefly can expect any success by the use of these means. The correction of the deranged digestion, and the neutralization of the excess of acid, will therefore form the principal object in our treatment; the latter especially, when the red crystalline deposite exhibits the predominance of lithic acid in the system. On the principle that diet, destitute of azote, is as applicable to the disease in question, as an opposite course is found in diabetes mellitis, M. Magendie has recommended a vegetable diet generally in this affection, where azote is in too great excess. A white deposite, indicating the presence of phosphatic salts, requires a different course of remedial agents. In such cases Sir William Prout recommends mineral acids, uva ursi and cinchona. • ft Rad. Colomb., gr. x. (128) Sodae Sesquicarb., gr. xl. Aqua; Ferv., M. A teaspoonful three or four times a day. f ft Pulv. Rhei.,gr. vi. (129) Hytlr. Subm., gr. iv. Pulv. Ipecac, gr. j. M. Divid. in pulv. No. iv. One twice a day to a child four years old. 323 EXCERNENT SYSTEM. Muriatic acid is particularly recommended by him. A child from two to six years of age may take a tablespoonful of a mixture, composed of a scruple of acid and six ounces of water, three times a day. The muriated tincture of iron is also useful, as it combines the tonic effects of the iron with the specific effects of the acid, which is always in excess. It may be given diluted with water, fifteen drops to two ounces—a teaspoonful, three or four times a day, to a child of the same age. Anodynes, in such cases, are also indispensable, and may he united with tonics. As in other diseases of children, attended with great irritability, Dover's powder is one of the most useful forms in which opium can be administered. Where it is necessary to keep the bowels open, the neutral salts should be substituted for magnesia and other alkaline purgatives; this may be rendered somewhat more efficient by the free use of diluents. RETENTION AND SUPPRESSION OF URINE Retention of urine is an affection which Dr. Dewees remarks is more frequent than is supposed, and that some infants have perished from this cause without its having been suspected. Immediately upon the birth of the child, the effects of the impression of the air upon the surface of the body are apparent, as well as on the mucous membranes exposed to its influence. The nares and bronchial passages both give evidences of the excitements they experience from the stimulating influence of the cold air; and the bladder, from its sympathy with the skin, is one of the first organs to contract and repel its contents. Although one of the first excretions, yet it sometimes happens that the urine does not flow for some days after birth. Etiology.—The obstruction to the passage of water may arise from spasm at the neck of the bladder, or congenital inflammation of this part, or of the rectum ; or from the clogging of the urethra by inspissated mucus. Besides these causes, in the first days of infancy, the irritating qualities 6f the mother's milk may become a cause of this affection ; or, during the process of teething, when the • teeth protrude with difficulty, a retention of urine may arise. Semeiology.—From whatever cause it arises, the child evinces great distress on attempting to urinate, and cries violently at such times, while it appears continually to suffer from some pain. In older children there will not be so much difficulty in ascertaining the nature of the suffering, but in young infants it is often a matter requiring close attention to ascertain the cause of the distress. As it is a disease of great danger, the Condition of the diapers should be r.arefully examined, whenever a young infant suffers great pain and 324 DISEASES OF CHILDREN. cries much. No reliance should be placed on the representation of nurses that the urine is regularly discharged, unless they positively state that it is found regularly wetted. When the disease is suspected to exist, the abdomen and pubic region should be examined ; they will generally be found tender, very painful, and much swelled. Where retention has existed for some time, fever arises, the skin becomes hot, a determination of blood takes place to the brain, and convulsions and death ensue, even when its cause has not been suspected. Treatment. —Where it arises immediately after birth, its cause is frequently the existence of a little mucous clogging up the urethra, and which may be removed with a small probe. Fomentations with hops, or a flannel dipped in warm water, may be applied to the pubic region ; or frictions may be used over the affected part with camphorated oil, which will often relieve the spasm of the neck of the bladder. If these are ineffectual, the whole system must be relaxed by immersing the child in a warm bath ; an enema of warm water alone is also a useful adjunct to the other measures. If these means fail to procure a flow of urine, no time should be lost in resorting to the use of the catheter, the only effectual method of relieving retention of urine. A small-sized flexible catheter should therefore be introduced into the bladder, which, in a young infant, it is scarcely ever necessary again to use. If the fever continue, and cerebral oppression arise, a couple of leeches applied behind each ear may be necessary lo relieve the congestion, and prevent the occurrence of convulsions. With respect to retention of urine arising in children that are teething and sucking, the evident exciting cause will sufficiently point out the remedies which are applicable to such cases. The mother should use diluent drinks, and avoid all stimulating aliments which impart an irritating quality to her milk. If, on examining the hypogastric region, the bladder be found empty, which may be suspected when there appears to be no swelling or pain in the part, there is then doubtless a suppression of urine. This disease, anuria, arises from a defective action of the kidneys, • and it occasionally happens that this function is not exercised for twenty-four or even forty-eight hours after birth ; not having been established. It appears to arise from a congenital paralysis of the kidneys. Retention of urine may also arise from congenital deformity of the male in the urethra. This passage is sometimes entirely absent, and is usually accompanied with other deformities in the anterior portion of the bladder and parietes of the abdomen. Congenital hypospadias, where the urethra passes a short distance along the penis, and- opens on its lower surface, may exist. The orifice of the urethra is also sometimes simply closed ; an incision EXCERNENT SYSTEM. 325 may m this case be made, and the part kept from uniting by means of a tent, or a small piece of gum-elastic catheter. The means to be resorted to in the treatment of suppressed urine, are such as will excite the secretory action of the kidneys by a direct influence on these • organs : such as an infusion of parsley-root, apium pretrosclinum, with a few drops of sweet spirits of nitre. In ordinary cases this will generally succeed in relieving it, while enemata and the warm bath are at the same time used. The latter is especially beneficial in all the forms under which the disease appears. In this affection mild diluents should take the place of any excitant to the kidneys, whenever fever is present; and in any form of the disease when there is evidence of inflammatory action in the affected part, leeches should he applied to the lumbar region. DIABETES. Diabetes is usually divided into two species : diabetes insipidus, and diabetes mellitus. The former, which corresponds with the hydruria of Dr. Willis, in his recent work on the subject of the diseases of the kidneys,* is characterized by the simple, increased quantity of urine, independently of any increased action of these organs, from imbibing largely of some watery fluid. The other species, or melaturia, as it has been recently called, is distinguished by a quantity of saccharine matter in the urine, which is also very greatly increased in quantity. Both these forms affect children ; the first-mentioned is that which is most frequent. There is another variety which may be classed with the insipid form of diabetes; this is where the copious discharge is attended with a deficiency of urea, and described by Dr. Willis, by the name of anazoturia, from the absence of the azotic principle of the urine. This is the form of the disease which he observes has been so often reported as cured, and is the kind most frequently occurring among the children of the poor, who suffer greatly from privation of both food and air. In treating of this disease, the name so long used to designate an excessive secretion, will be retained ; and although it is more phi-* losophically correct to disunite that form in which the urine, although in excess, still retains the proper proportion of its solid ingredients, from that in which it is destitute of one of them, yet the distinction is one which it is sometimes difficult to make; while the term diabetes is applicable to inordinate secretion, and frequent evacuation of urine, attended with great emaciation and debility, whether the urine is deficient in its component parts, or whether it is, on the other hand, characterized by the remarkable additional * Urinary Diseases, and their treatment, by Robert Willis, M. D.; London, 1838. 326 DISEASES OF CHILDREN. qualities it acquires in the saccharine form. Besides, it will be more suitable to the nature of the present treatise to treat the subject in a more general sense ; as it can scarcely be considered the peculiar object of this work to enter into a discussion of the nature of such diseases as are common to all ages. A concise view of the subject, with reference to its occurrence in children, and any remarkable aspect it may assume, or treatment it may require on this account, is all that can be expected in a work devoted exclusively to the diseases of children. For more particular information, therefore, as to the pathology of diabetes, and the distinctions which modern science has made in the various renal affections, other and more elaborate works may be consulted. As occurring in children, diabetes was first noticed by Morton, in 1694,* and described much more recently by Venables,t whose observations are exceedingly valuable with reference to the disease in children. The last-mentioned of these writers has noticed the two kinds; but all agree that the insipid diabetes is the most common in early life. Etiology.—As to the predisposition to the disease, it is in some instances hereditary, as several members of a family, and their descendants, have been known to be affected with it; and it frequently occurs in those of a scrofulous habit, although not confined to them. It has been remarked that phthisis has not unfrequently both preceded and accompanied diabetes ; and that there is scarcely an instance of this disease existing among adults that is not attended with some pulmonic affection. It has been noticed to alternate with it, and the symptoms of phthisis have for a time been suspended ; and on the temporary relief of the diabetic symptoms, the tubercles have become fully developed, and have passed through their various stages, and terminated in the death of the patient. It therefore appears in some measure connected with the imperfect assimilation in the ultimate tissues, occurring in the scrofulous habit. The ordinary exciting causes appear to be exposure to sudden vicissitudes of the weather, and the use of improper and badly prepared food. Experiments on the lower animals prove the influence of a certain species of diet on the urinary secretions. Dogs and rabbits fed on rye-meal, or exclusively on wheat-flour, become greatly emaciated, while diabetes insipidus is produced. It is also known to arise with the changes in the system occurring during the period of dentition, produced probably by the changes which occur at this time in the functions of the digestive system. Teething adds to the general irritation in this as well as in other diseases. • Phthisiologia, sive Exercitationcs de Phthisi., by Richard Morton, M. D.; Lond. 1694. t A Practical Treatise on Diabetes, etc., by R. Venables, M. D.; London, 1825. EXCERNENT SYSTEM. 327 Semeiology.—Children are rarely if ever affected with it after the fifteenth month. It is most liable to occur about the period of weaning, as would be supposed would be the case, when it is considered how intimately it is connected with diet. This remark is applicable, of course, to infants, for the disease occurs at all ages; and pure diabetes mellitus has been noticed from the age of three years to twelve, including also the period of infancy. For the most part it is very insidious in its approach, and emaciation and languor exist for some time before the cause is suspected. If the increased discharge of urine be at all remarked at first, it is scarcely regarded as a disease, and much time is necessarily lost before proper treatment is instituted. The languor and emaciation, which are prominent symptoms of the disease, steadily increase from the great loss of the solid matter of the body; for experiments show that although the thirst is very great, yet the quantity of urine passed far exceeds the fluids taken by the mouth. As the disease advances, the skin becomes dry and flabby, the little patient is feverish and fretful, and excessively prostrated. At first, the alvine evacuations are not much altered from their natural con- dition, but with the progress of the other symptoms, they also become greatly deranged, showing a great alteration in the secretions of the liver and intestinal surface; the former exhibit an increase in the bilious discharge, while the latter show a slimy and inspissated state of the mucus, furnished by the muciparous follicles. Among the abdominal symptoms, are the increasing enlargement and tenseness, while the steady emaciation presents a strong contrast, resembling, in this respect, the progress of the mesenteric disease. The circulation, which at first is but little affected, becomes more excited; the pulse is quickened, and is afterward weak and small, while a considerable degree of fever exists as the disease advances. As in the adult, these symptoms are attended with an excessive discharge of urine, and the desire for passing it is incessant. Dr. Francis informs me, that in a case which occurred to him in a child aged twenty months, six pints were discharged in the course of .twenty-four hours, for several days. Dr. Mott* recorded the case of a boy aged nine years, who voided from nine to ten pints daily, of a clear limpid urine, very sweet to the taste. The light limpid color is characteristic of the urine destitute of its urea, the azoturia of Dr. Willis. The non-existence of urea may be ascertained by evaporating a portion of urine, when it will scarcely leave a residuum. In urine still retaining this essential property, it will evaporate to the consistence of a thick syrup, which, on cooling, concretes into a crystalline mass. This will be sufficient to ascertain the fact, should any doubt exist, without proceeding further * Amer. Med. and Philosoph. Register, vol. i., p. 347. 328 DISEASES OF CHILDREN. with the analysis. The thirst is generally proportioned to the quantity of urine discharged, but the quantity of fluid usually exceeds the quantity taken. It is a very distressing symptom, and one which, in a young child, might easily be disregarded, as thirst is of very common occurrence. Although, for the most part, the urine is clear and limpid, yet its color and consistency are different in different cases; for in some it deposites white sediment, in others it is of a straw color, while in some instances it is green. One remarkable symptom exists in this disease in children; it is the strong tendency to cerebral effusion, preceded by all the usual symptoms, such as pain in the head, throbbing of the temples, and other evidences of cerebral congestion. When it has long continued, its termination is in effusion in the brain; and the disease,, from inattention to the original affection, is regarded as primarily hydrocephalus. Morbid Anatomy and Pathology.—The most careful anatomical investigations have thrown but little light on the nature of diabetes. Almost every morbid condition has been discovered in those who have died from this affection of the kidneys. The stomach has been found enlarged, and its vessels greatly dilated. The lymphatic system of the abdomen, also, more than usually developed. Tubercles have been found in the lungs, and various other morbid changes, which appear to have arisen from the long continuance of a violent constitutional affection, and were, to appearance, more the consequence than the cause, such as deposites of coagulable lymph, and serous effusions in the cellular tissue. The kidneys are the parts more frequently found in a morbid state than any other of the abdominal viscera. They are, in general, enlarged, and the blood-vessels leading to them turgid; the renal capsules firmer and harder than usual, while the substance of the kidney itself has undergone some organic changes. They have presented the granular or mottled state described by Dr. Bright, as occurring in cases of albuminous urine. Although these alterations have been found, there are other cases in which no change was discovered in the size or structure of the kidneys, for both were of the same size and form, and differing in* no respect from the state of the kidney in health. In all cases, however, the blood-vessels leading to them are large and turgid with blood. No alterations have been found in the nerves going tome kidneys. The ureters, in some instances, are enlarged, as well as the bladder, and in others contracted. In some cases, no departure from the normal condition has been discovered. It appears that all the alterations discovered in the kidneys are referable to a long continuance of morbid action in them. The liver is usually found congested. 329 EXCERNENT SYSTEM. The nature of the disease has not been satisfactorily explained by any pathologist, and it still remains one of the most obscure ; for anatomical investigation has not, as yet, presented it in a form whereby we can direct our practice. The only approximation to the truth is to be found in the disorder of the digestive organs, and that the disease primarily exists in the deranged functions of the stomach. •• The experiments recently made by Dr. Bouchardt,* go very strongly to prove the origin of the disease to be in the impaired digestive function. One of the most prominent symptoms is excessive thirst, and is always in direct proportion lo the quantity of farinaceous or saccharine aliment taken; these being diminished, the quantity of sugar decreases. Farinaceous food forms fecula or starch, in the deranged condition of the digestive organs just mentioned. Sugar is formed from fecula precisely as it is in the laboratory of the chemist, and during the transformation requires to be dissolved, when seven times its weight of water is necessary for the solution. Hence the great demand for water in this disease. The other form of diabetes, in which the urine is insipid, but destitute of urea, appears to arise from a similar derangement of the digestive organs, whereby a full elaboration of the nourishment is not effected. Urea having been found to exist in the blood, must be formed during the process of digestion. Treatment.—From the few facts which have come to our knowledge, as to the pathology of diabetes, the treatment is founded. The precise changes in the kidneys are unknown, but that a disorder of the digestive functions exists, is a well-established fact. As in both forms it is dependant on the condition of the digestive organs, these must receive our first attention. It has been seen that both diabetes insipidus and the mellitic variety are produced by farinaceous food; the first step in the treatment, therefore, is to withhold such food as experience has proved to be one of the main causes. For the first suggestion of this fact in the treatment of diabetes, the profession is indebted to Dr. Rollo; and his views have been fully confirmed by repeated experiments on the lower animals, and by the investigations of chemical philosophy, as well as by the favorable result of the practice. The most appropriate kind of animal food for children is milk, which should be liberally used, and alternated with light broths. The latter, however, may be dispensed with when there exists much heat of the surface. Jelly made with isinglass also forms an excellent article of diet. The bowels should be kept open by mild aperients, and rhubarb and aloes, from their tonic effects, are the best that can be employed. The rhubarb may be given in infusion, * Revue Medicate, Jain, 1839. 42 330 DISEASES OF CHILDREN. as the taste may be concealed more easily in this form than in any other.* After the operation of this, some anodyne should be administered : opium, however, with great caution, owing to the strong tendency to cerebral congestion in children affected with this disease, flyoscyamus, from its salutary action in not accelerating the pulse, is better for those cases in which there exists fever, than opium, besides the advantage gained from its not increasing the tendency to fulness of the blood-vessels of the brain. The proper dose of hyoscyamus is a quarter of a grain, for children within the year; older children may take a half to one grain, three or four times a day. The only form in which opium is admissible in this disease, is Dover's powder; a grain of which may be given two or three times a day to a child two years old. During the use of these means the skin should be kept excited by the warm bath, or by the use of a flesh brush ; a very important measure in all diseases of the kidneys, and every case of diabetes is accompanied with an affection of the skin. Among the remedies which have been used for the relief of diabetes in children, and in the hands of M. Venables with success, is the phosphate of iron ; it is both astringent and tonic in its operation, and therefore useful in this disease, where its employment is not counter-indicated by the febrile action of the system. It may be given in doses of from two to three grains to children aged between one and three years, and from five to ten grains to children from four to seven. On the appearance of any inflammation in the kidneys, leeches should be applied to the loins, and the ordinary measures adopted for the purpose of combating infl animation. In the simple form of diabetes, known as the disease termed azoturia, bitter infusions, with alkalies, have been found the most beneficial, by Venables, Prout, and Willis. An infusion of gentian or Colombo, with the sesquicarbonate of soda, will be found useful, while mild anodynes, as already mentioned, are used. Dr. Dewees advises spirits of turpentine applied to the clothes in. such a manner as to create an atmosphere of trebinthinate vapor around the child ; in this manner he has cured several cases. From the successful results which have followed the internal use of iodine, made after the formula; of Lugol, and also the administration of the hydriodate of potash, in three obstinate cases of the mellitic variety which occurred in adults in the practice of Dr. Francis, the * R.Infus. Rhei., (130) Tinct. Cinnamon., 3ss, Syrup. Simpl., 3jss. Tinct. Aloes Comp., 3j. M. One or two teaspoonfuls every three hours. 331 EXCERNENT SYSTEM. employment of this new remedy promises advantages which will probably lead to its more general use in this disorder. During the period of teething it will be necessary to examine the gums, and cut them, if the teeth appear to be pressing upon them, and thus take off one source of irritation on the system. CUTANEOUS DISEASES. The great multiplicity of cutaneous diseases, their different causes, and the almost endless variety of their appearances, render a proper classification of them necessary, that they may be advantageously studied and properly treated ; for without some distinctions, founded either on their pathology or cause, or on both combined, it is in vain to expect to possess any correct principles for their management. The first attempt at classification appears to have been made in 1585, by Mercurialis,* who separated those diseases which affect the scalp from such as exist on other parts of the body. Turnerf adopted a similar division, from remarking an essential difference in the treatment necessary in those affections occurring in parts covered with hair, and in other parts of the tegumentary surface; he also refered to the causes as a good basis for their classification. Lorry,} in 1777, in his work on the same subject, maintains the same views, with some modification. Plenck afterward arranged cutaneous affections according to their appearances, without taking into consideration their etiology, or rather rejecting it altogether.]! Willan and Bateman's classification is based on the same views,§ which are also adopted by Alibert and Rayer, who have greatly multiplied the number of affections incident to the skin.*[[ Plumbe, in his able work on this subject, has considered more the cause of these affections, and in his classification has referred to the influence of the constitutional condition in giving origin to them, or modifying their character and progress; unquestionably the only safe course to proceed with reference to these diseases, which are more frequently symptoms of the existence of other morbid affections ; and he justly remarks, that there can be no correct arrangement for practical purposes, in which the constitutional •De Morbis Cutaneis. Venet., 1572. f A Treatise on the Diseases Incident to the Skin, by Daniel Turner, M. D.; London, 1714. J Tractatus de Morbis Cutaneis ; Paris, 1777. H Doctrina de Morbis Cutaneis, J. J. Plenck; Vien. 1783. § Description and Treatment of Cutaneous Diseases, by R. Willan, M. D.; Lond. 1805. A Practical Synopsis of Cutaneous Diseases, by Thomas Bateman, M. D.; Lond. 1814. IT Description des Maladies de la Peau, par J. L. Alibert; Paris, 1814. Traite Theorique et Pratique de la Malad. de la Peau, par M. Rayer ; Paris, 1826. 332 DISEASES OF CHILDREN. causes do not form some portion.* The same view has been adopted by Dendy, and applied by him to a much larger number of these diseases than is embraced in Plumbe's treatise.f All the existing arrangements of these diseases are still evidently imperfect; and one based on scientific principles, which may be made practically applicable, is still a desideratum. The difficulty, however, of this part of the subject is acknowledged by all to be very great. A want of accuracy and precision exists in all the systems, founded either on the pathological conditions of the part, or on the external appearances of these affections. If, on the one hand, the pathological alterations of the parts be taken as the basis of the classification, the difficulty at once meets us in the fact, that it rarely happens that one tissue alone is affected through the course of the disease; others become involved, offering a complication of the original affection, in the pathological alterations of other portions of the cutaneous system. Again, if the phenomena they present be taken as the groundwork, a similar difficulty will be found to exist, for the reasons just mentioned. Although great skill and singular accuracy have been exhibited in the pictorial delineations, yet as the appearances change, not only from the natural course of the disease in one tissue, but likewise from its involving other portions of the cutaneous system, whereby a disease, with the wellmarked appearance of one genus, may present that of another in the course of its progress, it is evidently not safe to rely on an arrangement so arbitrary and artificial. Difficulty also attends the more recently revised system of arranging them according to their etiology ; the same disease being at times produced by different causes. A system founded, both on the anatomy of the skin, with the seat of the morbid changes occurring in it, and the influence of external and internal causes in the production of these morbid changes, appears to be the correct and only one for practical purposes which could be adopted. The subject is one almost, if not altogether, impracticable in the present state of science. An increased attention, however, to the anatomy of the skin, has been manifested within a few years; a subject which affords a better opportunity for the successful culture of the knowledge of morbid conditions now under consideration, than can be derived from the simple inspection of the diseased part, unconnected with its state in health. The recent works of Breschet, Vauzeme, and Guilt, on the anatomy of the skin, may be regarded as highly important in directing the investigation of the diseases of •A practical Treatise on the Diseases of the Skin, etc., by Samuel Plumbe; London, 1824. f Practical Remarks on the Diseases of the Skin, etc., by Walter C. Dendy, Surgeon, ete.j Load., 1837. EXCERNENT SYSTEM. 333 the skin, to the state of the various parts of this complicated structur —the seat of several important functions—in its normal condition. Without pretending to be able to simplify a subject which has baffled the genius of many distinguished men, I shall confine myself principally to the consideration of the causes of cutaneous affections of children, inasmuch as it appears to be more usefully applicable in their treatment, than an arrangement founded on their external appearance. It is to their causes, therefore, that the arrangement here proposed will be chiefly directed. The pathology of these affections will also be considered in a general manner, in connexion with the etiology, as a guide for the arrangement; which will be such a modification of the existing systems, as experience justifies in considering the best applicable to their management. General Etiology.—The first of the predisposing causes is the hereditary conformation of the skin. Besides the actual alterations in its condition, exhibited in the existence of noevi materni, congenital spots, and malformations, these parts, as well as others, participate in the molecular changes arising from the transmission of peculiarities in the process of nutrition. Hence we find the obstinate diseases which occur in those who inherit a scrofulous diathesis, and also the eruptions on the surface, arising from the transmission of syphilitic affections. But independently of this, there are those who are born with an extremely irritable state of the skin, although no such morbid condition could be found to exist in their parents. The latter are remarkable for their robust health, and transmit to their posterity that abundance of vitality, which greatly disposes those parts that are exposed to the immediate action of exciting causes, to pass into a morbid condition. Very severe inflammations have occurred under such circumstances, showing the predisposition to disease abounding in a part in a high state of vitality and development. The abundance of blood in the tegumentary tissues of an infant, imparts a strong predisposition to inflammatory affections, easily excited ; hence the early appearance of an eruption, on the application of a very slight degree of their ordinary exciting causes. M. Valleix describes a species of pustule, occurring in newborn children, which appears to depend on the ordinary state of vascular excitement or congestion natural to children at this age. These pustules are usually mistaken for a congenital syphilitic affection, from their early occurrence ; this opinion he conceives to be erroneous, from the frequent mildness of the disease, and other circumstances connected with its rapid disappearance without the interference of art. 334 DISEASES OF CHILDREN. From the same cause many children are affected from birth with an inflammation of the sebaceous follicles, producing a disease of the most remarkable obstinacy. Although diseases of the skin generally may occur in any class of persons, and under a variety of circumstances of constitutional and local derangement, yet they are most likely to take place where there is an enfeebled state of the capillaries of the skin, exhibited in the irregular and imperfect action of the functions of this part, especially in children advanced beyond the period of infancy, where the normal action assumes more the characters which are peculiar to the state of the adult. Whenever there exists a want of uniformity in the proper action of the part, as appears from the irregular action of the sudatory glands, the cutaneous secretion being easily excited or suppressed, there is a much greater liability to cutaneous disease. An excited state of the blood-vessels, in this condition of the capillaries, is much more liable to terminate in disease, than when the entire assemblage of the functions of the skin is in a normal state. In some degree allied to this last-mentioned condition of the capillaries, is the congenital or acquired debility of the cutaneous vessels. Such a state produces those affections characterized by a deficiency of vigor in the capillary vessels of the skin, causing alopecca, elephantiasis, ptyriasis, ichthyosis, etc. The exciting causes of all cutaneous diseases may be referred to such as act directly on the skin; to the sympathy which the skin experiences with the derangements, either functional or organic, with other organs, and to the peculiar effects of a specific contagion on the dermoid surface, which this part experiences in common with other tissues. Among the external irritants of most frequent occurrence is caloric. The atmosphere acts directly on the external surface of the body, and when a high atmospheric temperature exists, an active and.an extremely irritative action characterizes the diseases of the skin. The increased action of the vessels on the surface, from an increase of atmospheric heat, is familiar to every one, and scarcely needs an illustration. Eruptions are much more severe in hot climates than in temperate regions, and, as would be supposed would be the case, are in general more frequent. In tropical climates the lichen tropicus, or prickly heat, is much more severe than in the tropical summers of some temperate climate. The eruptions common to young infants, from the highly vascular condition of the skin, are greatly increased, if not altogether produced, by the direct application of heat to the surface. Strophulus is much more extensive in summer than in winter, or where, from the over tenderness of parents and nurses, the skin is maintained in a state of EXCERNENT SYSTEM. 335 excessive heat from artificial warmth of the apartment, or from a too great quantity of clothing, especially if it be of an irritative nature. Roseola, also, is a cutaneous affection, depending on the direct action of heat for its production. It occurs more frequently in summer and autumn than at any other season of the year ; and although occasionally complicated, as indeed are all other diseases, with a disturbance of the digestive organs, yet it depends for its existence on the immediate action of heat. Most cutaneous diseases are very seriously aggravated on the approach of summer, although there are some, such as lepra and inpetigo, which exhibit an opposite effect, being relieved in summer, and becoming more aggravated in winter. Exposure to the rays of the sun, to the heat of a strong fire, and, on the same principle, to extreme cold, will cause cutaneous inflammation ; for a direct injury is thus produced on the skin, terminating in various kinds of inflammatory affections. The same effects follow the application of a blister, the bites and stings of insects, punctures, and any corrosive or irritating substances. Uncleanly habits are the great sources of cutaneous diseases, as is evident from the effects of ablution in most of these diseases among the poor. Where this is neglected, and a derangement in the secretory functions of the skin is allowed to take place, irritation and itching are the consequences ; and the scratching used for its relief aggravates the existing irritation, until ulcers, and a complication of cutaneous affections, which often defy all attempts at classification, are the result. In connexion with this part of the etiology of cutaneous disease, is the burrowing of the small insect acarus scabiei, giving rise to the well-known cutaneous affection, which derives its name from the incessant itching—the itch. Another class of causes is to be found in the disordered action of the internal mucous surface, and principally of that of the alimentary canal. This is a frequent cause of cutaneous disease, and numerous facts go to show the physiological and pathological connexion between these parts- The healthy action of the one is very clearly connected with that of the other, and more especially with the mucous lining of the gastro-intestinal surface. This part is so evidently connected with the pathological condition of the skin, as rarely to be affected without some change being produced in the action of the cutaneous system. Scarcely can any derangement arise in the circulation and secretion of the mucous membrane of this part, without the cutaneous surface participating in some degree in the change, and suffering likewise in its circulation and secretion. Cutaneous affections may arise from a simple derangement of the functions of the part. A temporary indigestion will cause urticaria* 336 DISEASES OF CHILDREN. a variety of purpura combined with the peculiar irritative action of urticaria,.and other affections of a similar character. Many acute cutaneous diseases have their origin in inflammation of the same membrane ; and those arising from the attack of an eruptive fever have been referred to this as a cause. But this is not the cause of the cutaneous eruption ; it is a part of the disease which simultaneously affects both the skin and mucous membrane ; and in some of these affections the cellular tissue and meninges of the brain, or peritoneal coat, also participate in the disease. Another class of diseases, differing from all others principally in the periodical changes they undergo, in their incipiency, maturation, and decline, arise from a specific contagion, Besides this, they are also characterized by the presence of febrile action, from which circumstance they have been denominated eruptive fevers. The presence of inflammation in the skin, although characteristic of these affections, does not always necessarily exist; in some severe forms it has been absent altogether, and the disease has spent its force, generally having a fatal termination, on the brain or other internal organ. The disease of the skin is therefore but one of the strongly-marked symptoms of this class of diseases, but so generally uniform in its appearance, that its absence is regarded as an irregular course ; its presence is, in every instance, essential to their proper development. Among the contagious cutanei are the syphilida, differing from the others in the absence of the changes occurring in the eruption at regular periods, and the formation of the disease, without the necessary fever existing in the former. General Patholocy.—The congenital marks or spots, known by the name of noevi materni, whatever be their form or color, are in some respects allied to malformations. Some, indeed, may be regarded as such, while others possess an active circulation, making them closely allied to inflammation, Some of these spots appear to be simply a change in the natural pigment; others, are the excessive development of the papillae and vascular net-work of the skin, with more or less vascular action. Although seated generally in the parts just mentioned, other textures of the tegumentary system may become likewise affected with this congenital hypertrophy. The most common affections of the skin are inflammatory in their nature, varying in their appearance according to their seat in the different textures, and according to the violence of the affection ; these different forms may also arise from some peculiar action of the exciting cause, producing in the same texture a circumscribed, instead of a diffuse inflammation. Infla mmation of the simplest kind is found in the external or cuticular surface of the skin. When this part is affected with a dif- EXCERNENT SYSTEM. 337 fuse inflammation, it constitutes erythema, erysipelas, etc. In these affections there is but little swelling; when these superficial inflammations are diffused, and are accompanied with elevated patches, they are denominated wheals, and constitute the disease termed nettle rash. The general termination of these rashes is by resolution, but not without the secretory function of the cutis being materially impaired ; a separation of the cuticle is the consequence of this derangement of the secretory Ibtion. Dr. Cragie explains this process by referring to the apparent fact, that the cuticle is secreted in successive layers, first fluid, then becoming From the derangement of the secretory functions of the part, this process is imperfectly performed, and the connexion between the secreting surface and the recently secreted portion becomes dissolved ; therefore, during the progress of the disease no new cuticle is formed. The morbid action gradually subsides, and as the cutis recovers its healthy tone, a new and delicate cuticle is formed.* Sometimes, however, a long-Continued inflammatory action of this outer surface of the cutis results in the effusion of a watery fluid beneath the cuticle, forming blisters or blebs; this is the most severe form of inflammation of this part. The cause of this species of inflammation also modifies its appearance. The inflammation of the skin in measles and scarlet fever is always peculiar, both in color and form, although the cutaneous part of the disease does not extend any deeper than the outer surface of the chorion. Papillary diseases, as strophulus, lichen, and prurigo, are seated in the small eminences of the cutis, called papillae. These affections are slight, and usually terminate in resolution. The inflammation affecting the substance of the skin, when occurring in a circumscribed form, gives rise to pustules. This kind of inflammation may either arise on the outer surface of the skin, and successively proceeding inward, and affecting the other portions, or may commence originally in the substance of the skin itself. This circumscribed form produces pustulous inflammations. From the progress of the vesicle inward, it is evident that a distinction between the vesicle and pustule is very difficult to make, as the disease, at first affecting the outer surface of the skin alone, and ex oibiting only the characters belonging to a vesicular eruption, may, from subsequently involving other portions, become a real pustular disease. Such is the psydracium ; a small, circumscribed elevation of the cuticle first appears : the parts beneath are then involved, and several of them uniting, discharge a small quantity of puriform matter ; the affection is so superficial as never to leave a scar or de- * Elements of the Practice of Physic, etc., by David Cragie, M. D., F. R. S., ete. j Edinburgh, 1836. 43 338 DISEASES OF CHILDREN. pression. This disease is the closest allied to the vesicular of all the pustular forms. The next disease, and more approximating to the real pustule, is the achor; this, like the former, although discharging purulent matter, leaves no s£ar. The favus exhibits a deeper affection of the cutis, the pustules being surrounded with a marginal ring, indicating a higher grade of inflammation and a more extended disease. On the disappearance of this pustule a scab forms, which, on becoming detached", leaves a slight scar. The phlyetidium is the pustule produced by the small pox, or by the application of tartar emetic ointment. It is characterized by a circular inflammation of the skin, surrounded by an inflamed circle, which is the outer part of the skin much injected and elevated. Suppuration occurs within the inflamed border, and never extends beyond it. The most perfect form of a pustule is the phlyzacium. It commences in the substance of the integuments, and is a large pustule on a hard circular base, of a red color, slow in its progress, and its suppuration always attended with a considerable loss of substance, and a deep scar. These pustules form the disease known by the general name of ecthyma ; one form of which, from its occurring in infants, has been made a distinct species. Inflammation attacking the sebaceous follicles, the corial follicles or sudatory pores, the sacs at the root of the hairs, all produce pustulous diseases, having the phlyzacium for their character. It is very rare that the internal surface of the skin becomes originally the seat of the disease, without involving likewise the adjacent cellular tissue. When this occurs, the highly inflamed tumor known as the furunculus, or boil, is the result. The hordeolum, or sty, is also one of the forms of this inflammation. It appears to be an inflammation of the conical prolongations of the subcutaneous cellular tissue, which penetrates the chorion in every part; therefore the affection can rarely occur without extending to the parts beyond the skin. Its progress is alwaystto the surface, with severe inflammation, imperfect suppuration, and sloughing in the internal parts. This slough, or cone, is formed of the cellular membrane, infiltrated with pus. Although these are the more marked and prominent characters of cutaneous inflammation, yet when more than one part is simultaneously affected, it is evident that it may be difficult accurately to distinguish them for classification. This difficulty more commonly occurs in chronic inflammations of the skin, where the entire mass of the various parts of the chorion may become more or less involved in the morbid action. The consideration, therefore, of their causes—whether of local or general origin; whether from constitutional derangement, from disordered functional or organic action of the gastro-intestinal mucous membrane, or from the action EXCERNENT SYSTEM. 339 of a peculiar infection on the system —becomes practically of more importance than the simple appearance of the disease. The classification of cutaneous affections, as papular, pustular, vesicular, etc., however correct it may be, can yet go but little to direct us in their treatment. As they are for the most part symptoms of some other disordered action, the disease itself, of which they are but the symptoms, should, if possible, in the first place be ascertained ; while the actual character of the cutaneous affection shows the violence of the constitutional derangement, or marks the degree of predisposition in the affected part, to become inflamed on the development of the exciting cause. When no such constitutional disorder exists, and it is ascertained that the disease is purely local, the treatment is necessarily simplified to local applications alone. The following arrangement is proposed, with reference to those diseases of the skin which are found to affect children; all others are omitted. It is a modification of that proposed by Dendy, and is merely intended to simplify the matter, and to place it in the condensed form necessary in a treatise devoted to general subjects. For more extended information, the various treatises on cutaneous diseases must be consulted. MORBID CONDITIONS OF THE SKIN, INDEPENDENT OF CONSTITUTIONAL CAUSES. i. From Local Peculiarities, or ( Noevi materni, Verrucae, Crinones, Conformations of the Skin. ( Alopecia. ii. From Fxternal Irritation J Encausis, Pernio, Vesication, Injc ruin didXitf fiui xn uuiiu/t. s • I tertngo. MORBID CONDITION OF THE SKIN FROM CONSTITUTIONAL CAUSES. I. • From Gastric or Intestinal Dis- ( Strophulus, Prurigo, Impetigo, . turbance during Lactation or < Crusta lactea, Erysipelas, Jaun- Dentition. ( dice. IT. f Urticaria, Lichen, Roseola, Her- From Gastro-Enlcric Irritation J pes, Purpura, Furunculus, Ecat all periods. j zema, Psoriasis, Porrigo favosa, • Tinea. III. From Constitutional Debility. Ecthyma, Rupia, Pemphigus. 340 DISEASES OF CHILDREN. From Specific Contagion. IV, ( Scarlatina, Rubeola, Variola, < Varicella, Vaccinia, Syphilida, { Scabies. FROM LOCAL PECULIARITIES, OR CONFORMATIONS OF THE SKIN. NGEVI MATERNI. There are two varieties of noevi; flat blotches or apparent stains, and elevated tumors, characterized by a preternatural development of some part of the vascular net-work on the sub-cutaneous cellular tissue. The first kind are the stains known as port wine marks, or stains resembling those produced- by a raspberry. They have also been seen of a yellow, brown, blue, and black color. ' They are the effect of a diseased action in the corpus mucosum, where the capillary vessels deposite the pigment, or they may exist in the vessels themselves; and a distinction, not however of much practical utility, has been made between pigmentary and vascular noevi. This alteration in the normal action of the skin, from the intimate relation subsisting between all the parts, extends sometimes to every portion of the tegumentary layers and their respective functions ; it has therefore happened that these spots have, from the altered action of the papilla? of the skin, been the seat of hairs of different colors. These colored spots always become paler on pressure, and are increased in intenseness under the influence of atmospheric heat, or anything that will increase the vascular circulation. The congenital elevated tumors are of two kinds : erectile tumors, and varicose tumors. The former are of various colors and shapes, and from this circumstance have been compared to cherries, raspberries, strawberries, etc. Sometimes they have a broad, and at other times a pediculated base. They are found usually on the lips, eyeli'ds, cheeks, inside of the thighs, arms, etc. At first they are often very small in size, but their increase is uniform but slow. Congenital tumors are sometimes more deeply-seated, and of a less regular shape ; and, from the mass of sanguineous vessels of which they are evidently formed, are more properly varicose tumors than tumors from a preternatural development of the capillaries, or the abnormal process of nourishment. These have been known also by the names of varicose wens, sanguineous fungi, etc. These affections are in general not to be regarded as serious, they are of a large size, or grow rapidly; when such is the case, they may form ulcerations, ending in a fatal hemorrhage. EXCERNENT SYSTEM. 341 Treatment.—The various methods of treating noevi are compression, refrigerant applications, styptics, cauterization, artificial inflammation, ligatures to the tumor, or to the blood-vessels supplying it, or excision with the knife. Compression is only applicable to small tumors situated over hard parts. Mr. Abernethy advises, in addition to compression, the simultaneous use of cold and styptic applications. Where styptic remedies are used, a strong solution of alum is probably about the best; although these remedies will be found of little avail. The method of exciting inflammation in them by introducing the vaccine virus, has been advised. The application of tartar emetic ointment for the same object has also been successfully used by Dr. Young.* Cauterizing has been long in use for treating ncevi. It is only necessary in small tumors to touch the superficial parts in succession, and they will in general shrivel up and disappear. • For this purpose, quicklime, nitrate of silver, and caustic potash, have been used; the last-mentioned article more easily assimilates with animal substances, and is therefore to be preferred to the others. Nitrate of silver usually leaves an indelible scar, and is on this account an unsuitable application. Caustic applications have been freely used by Mr. Wardrop,f in large and bloody ncevi, without any hemorrhages following; and their use has been uniformly successful. Having excised small tumors with a knife, I can unhesitatingly give the preference to caustic applications. On the same principle, nitric acid is also useful, and I have completely destroyed small noevi by its use. Where these tumors are pediculated, the ligature has been used ; it was first recommended by M. A. Petit4 Messrs. Bell and White have recommended, where the base of the tumor is large, to pass a needle through it armed with a double ligature, and, by tying it on both sides of the tumor, thus enclose it on all parts. Ligatures have also been applied to the principal artery going to the tumor; these are used when the noevus is of so great a size as to forbid its removal by any other means, or when it involves important or inaccessible parts. It is also used as a preparatory step when the tumor is to be excised, for the purpose of preventing excessive hemorrhage. Among other methods of treating ncevi, it has been proposed to pass a seton through them ;|| this, of course, is applicable to erectile, and not vascular tumors. Dr. Hall has recommended the intro- • Glasgow Med. Journ., vol. i., p. 93. f London Lancet, 1827. t Obs. Chirurg., Paris, 1700. |j Lawrence, in the London.Lancet, 1831. 342 DISEASES OF CHILDREN. duction q/ the cataract needle into the tumors, and, without withdrawing the instrument, to pass it in several directions in the body of the tumor.* It is very important for the welfare of the child that the removal of these tumors be not attempted while the child is quite young. When, however, they are evidently on the increase, the operation should not be delayed, for their great size may render this not only difficult, but dangerous. VE RRUC^E. WARTS. Warts are small elevations, of a hard and rough character, produced by hypertrophy of the papilla?, or of the different layers of the skin. They are insensible on their surface, but at times have some inflammation and increased nervous sensibility surrounding them. Although occurring at all ages, yet childhood is the time of life at which they are most common. After a few years they disappear spontaneously, without returning. In youth, however, they not unfrequently are reproduced after having disappeared. They appear singly and in clusters on different parts of the body, but more esper cially on the hands. Treatment. —They may be removed by excising them in thin successive layers; and when the blood begins to flow, the surface should be cauterized with nitrate of silver. They may also be removed by tying a fine silk or horse-hair around them, if the narrowness of the base will admit of a ligature. Any escharotic substance will remove them. The acrid juices of several vegetables are used for this purpose, such as the chilidonium majus, juniperus sabina, ficus indica, etc. Among the mineral escharotics are the muriate of ammonia, which may be rubbed on the warts; first dissolving a portion of it by moistening it, and the nitric acid carefully applied only to the excrescence. The last application is decidedly preferable to any other means that has been recommended; they will almost certainly be removed after a few applications. CRINONES. These are the minute black spots which, on being pressed out, assume the appearance of worms. They appear on the face of yrd. From this fact we see tffe cause of the frequent occurrence of convulsions among children, where the ingesta are generally greater than the requirements of the body. From the extreme irritability, also, of the nerves, any irritating cause existing in the bowels, whether it be the meconium, worms, or hard, undigestible substances, will become a cause of this affection. I once had a case of a child about four years of age, who obtained no relief from the most severe convulsions, until a copious discharge was obtained from the bowels, when a large number of cherry-pits were evacuated. Constipation, also, has terminated in convulsions, and ultimately in death.* That it is not necessarily connected with the brain is evident from the fact, that some children, when suffering from severe convulsions, will remain in possession of all their perceptive faculties. Instances of this I have occasionally seen, and they generally occur when the convulsive movements are partial. In one instance, however, which lately came under my observation, in a child of ten years, the affection of the muscular system appeared to be universal, and lasted for six hours with great severity; the eyes were fixed obliquely. On his recovery he spoke of the perfect possession of his mental powers, and described the measures which had been adopted for his relief, although unable to articulate during the paroxysm. The two varieties of convulsive diseases have already been referred to, when treating of the causes of these affections. Their division into idiopathic, or such as arise from a disorder primarily seated in the spinal cord or brain, and such as originate in a remote organ, and conveyed to the spinal centre, and thence transmitted by a reflex action to the muscle.?, are, on account of their direct practical utility, facts of great value. There can exist no doubt, since the clear and satisfactory experiments of Muller, and Dr. Marshall Hall, and especially of the lat ter, that muscular action depends' On nervous power from a distinct system, the centre of which is the medulla spinalis, separate from the voluntary and sentient system, which has its seat in the cerebrum. A spinal" or motor system acts in two directions, incident and reflex—the one proceeding from the nervous centre, and the other toward it. There is still some connexion between * Morgagni, Epist. 31. 490 DISEASES OF CHILDREN. the nerves of the excito-motor system, since they are compound nerves, and have a cerebral as well as a spinal origin. Idiopathic convulsions, whatever be the precise anatomical changes discovered on dissection, arise from the direct irritation of the spinal cord itself, or of the cranial portion which is exposed to the irritation or stimulus produced by their affections. Cerebral congestion, effusion, or compression, from whatever cause, will, also, by acting in the same manner on the upper portion of the centre of the motor system, produce spasmodic or convulsive action. The action of this cause appears in the last stage of hydrocephalus, convulsions invariably, to a greater or less extent, arising after the effusion has for some time taken place, while at the commencement of the disease no such affections exist, but with the increasing inflammation, congestion of the brain, stupor, loss of consciousness and voluntary power, are the most strongly-marked symptoms. The most common variety of convulsions in children, is that produced by the irritation of the expanded filaments of the incident nerves distributed to certain organs, and conveying the stimulus they receive to the spinal cord, and its reflexion by the motor nerves to the muscles they supply—an eccentric cause —a term adopted by Dr. Hall in opposition to centric, in which the seat is originally in the nervous centre, producing the first-mentioned form of convulsions. The excitor nerves, distributed over the gums, are, during the period of dentition, in a state of irritation from the swelling and inflammation existing there ; so likewise the nerves of the mucous surface of the stomach and intestines in an overloaded state of the former, or costiveness in the latter, will convey the stimulating impression they receive to the spinal column, and thence to the extremities of the reflex nerves, producing every grade and variety of convulsion and spasm : the faint smile so frequently observed in the sleeping infant, the slight strabismus, rolling of the eyes, grinding of the teeth, twitching, startings, changes of the secretions, and finally, general convulsions. Treatment.—For the proper management of convulsions, it is obvious that the cause should at first be ascertained and removed. It is therefore of the greatest iirfportance that correct information be obtained, if possible, as to the general condition of the child, and the circumstances connected with the invasion. Sometimes it will occur immediately after eating, and depends on the food irritating the stomach, which ought to be immediately removed by. an emetic, if it be possible to administer one. In the majority of instances the child is unable to swallow; and any attempt to give medicine by the mouth only aggravates the disease, by the obstruc- NERVOUS SYSTEM. 491 fion it produces in the respiration, and the strangulation it causes. Where it is evident that indigestible food has been recently eaten, and an intermission occurs sufficient to give the medicine, a gentle emetic of ipecacuanha ought to be given as the least irritating, the object being simply the evacuation of the stomach. The syrup of ipecacuanha for young infants, or tartar emetic combined with powdered ipecacuanha for older children, will be sufficient to accom"plish this object. During the paroxysm it is often impossible to give an emetic ; under such circumstances, and whenever there is any reason for believing the existence of irritating matter in the bowels, a common enema should be given. An enema not only evacuates the bowels of accumulated feces, but has a quieting effect in cases of convulsions, probably from its revulsive effects. In infants it may consist of a small quantity of olive or castor oil, with warm water. In older children, especially when the convulsions are attended with turgescence of the head, it may be made more stimulating, either by using a solution of common salt, or an infusion of senna. In very young infants it is often caused by the extrication of gas in the bowels; this may be suspected when the child has cried much, and given the usual evidences of colic pain. In addition to an enema, the abdomen may be gently rubbed with a little warm brandy or liniment on the hand, and as soon as the state of the child will admit, a cathartic must be given. When the child can swallow, the most efficient medicine to act as a cathartic, is a full dose of calomel, which, if there be much febrile action, maybe combined with ipecacuanha; the union of the latter with calomel, and given in small doses, so as not to act as an emetic, exerts an excellent effect in controlling and equalizing the circulation, while the operation of both on the glandular system generally, tends greatly to restore the functions of the various parts of the system. It is usually the custom to immerse the child in a warm bath; where, however, there is much plethora, or a loaded state of the brain, the universal application of warmth seems t« aggravate the symptoms. A partial warm bath, by immersing the legs in warm water, appears to afford more relief by the revulsion it occasions, especially if the head and spine be at the same time covered with cloths dipped in cold water. The feet and legs should always be immersed in a hot stimulating bath, prepared with cayenne pepper or mustard ; a powerful revulsion will thus be made on a part distant from the seat of the affection. Under all circumstances the gums should be examined, and if evidences exist of the pressure of the teeth on the gums, they ought to be liberated by making a free incision. 492 DISEASES OF CHILDREN. In children of a full, robust habit, if the paroxysms be not quickly relieved by the measures, above-mentioned, it will be necessary to draw blood from a vein in the arm. In such habits it often happens that other measures will have but a very"imperfect effect until a little blood is drawn ; a cathartic or an emetic having scarcely any operation until the pressure on the nervous centre is removed. This may often be accomplished in infants by the application of a few leeches behind the ears. In idiopathic convulsions, such as arise from cerebral or spinal inflammation, and especially if it is clearly the result of injuries from blows or falls, bleeding is of the utmost importance, and should be regarded as the principal remedy on the establishment of reactions. Sometimes the convulsions will continue unabated, or return after short intervals of rest, with as much violence as ever, even after all the remedies which were indicated by the peculiar .condition of the child, at the time of the attack, had been used. The gums may have been freely cut; other remedies may have been fully applied, emetics and cathartics, or enemata, have actively operated with hut little abatement of the symptoms. Under such circumstances, where a child has been bled, I have not hesitated applying a blister to the neck, of an oblong shape, so as to extend a short distance down the spine. As there is hut little time for the use of remedies, and as everything must be done with promptness, the blister ought to he drawn with strong aqua ammoniac, by means of a flannel soaked with it and applied to the part, and there held with the hand. But a few minutes will be required to produce a perfect vesication, upon the establishment of which I have seen all the untoward symptoms permanently disappear. It was remarked that convulsions may arise from two opposite conditions of system; it would therefore be obviously' improper to resort to bleeding in every case, even when they are protracted for a long time after the apparent cause is removed. When doubt exists as to the state of the system, the condition of the fontanels will point out the state of the brain. When the former is convex, there can be no question as to the plethoric or congestive condition of the brain. The depressed or hollow state of this opening, on the contrary, indicates a deficiency of fluids, and requires an opposite course of treatment, or rather the avoidance of a direct sanguinary depletion. This state is connected with other evidences of debility, and want of the proper and healthy quantity of fluids, as appears from the pale and wasted condition of the body, first pointed out, I believe, by Dr. Locock. Whatever be the temporary condition of the face, having the marks of vascular turgescence during the immediate paroxysm, if a permanent con- NERVOUS SYSTEM. 493 cavity exists in the fontanelle, bleeding* must not be resorted to for the removal of the convulsions. In this condition of system, and also, after the necessary depletion in that arising from increased vascular action or turgescence, when the convulsions are kept up by a morbid irritability engendered in the system, it will he necessary to resort to such measures as will calm the disturbance of the nervous system. Antispasmodics, however, ought never to be used until the supposed causes on which the convulsions depend are removed. After the*bowels have been relieved, and such other means adopted as the case re-, quires, to remove every probable cause of the disease, antispasmodics and composing medicines may be very properly adopted. Among the best articles of this class, is assafcetida, which may very properly be given in an enema, especially in such cases as depend on intestinal irritation as the primary cause. From six to eight grains may be blended with an infusion of flaxseed for a young infant, or a scruple to half a drachm for a child two or three years old, to be repeated according to the necessity of the case. Musk is another very powerful agent in controlling the morbid irritability of the nervous system, when it is connected with debility ; it appears also to be particularly beneficial when convulsions depend on the sympathetic irritation. Its benefits are obvious, in proportion to the absence of sanguineous fulness. It may be given in the dose of half a grain to two grains every hour to young infants, or when there is much prostration, in the subjoined forms.* Those medicines, also, which act from their narcotic powers, are also useful in allaying the excessive nervous irritability. Opium, however, is objectionable, from its effects in arresting the secretions. Hyoscyam us possesses properties analogous to opium, and from its tendency to promote the intestinal secretions, and to allay morbid irritation after its immediate narcotic influence has ceased, is well adapted for children. It may be given in the dose of a quarter of a grain to sucking children, aud from two to five grains to children from four to seven years of age. When there exists any febrile heat, it may be given with ipecacuanha or James's powder. If, on the contrary, the most prominent symptoms be those of debility, hyoscyamus may be used with some stimulant, as valerian.t It • R. Moschi, qr. vi. (169) Amnion. Sub. Carl)., gr. iv. Sacchar. Albi, 3i«j- Aquae, M. A teaspoonful every hour, to an infant. R Moschi, gr. iij. (170) Tere cum Aquae Anisi., 3vi. Adde Spts. Amnion. Foetid., 3j. Syrup. Simpl. M. A teaspoonful every hour, to an infant of six months. f R Ext. Hyoscyam., gr. v. (171) Tinct. Valeriana?, C. gtt. xx.. Syrup. Simplicis, |ss. Aquae Cinnamon., M. A teaspoonful may be given every hour, to a child from six months to a veer 494 DISEASES OP CHILDREN. has also been used in infantile convulsions, combined with calomel, in obstinate cases, where it evidently depends on the primary irritation of the gastric mucous membrane. It has been employed in France, in the dose of a grain and a half every half hour, with two grains of calomel every two hours, to a child two years of age. In cases of frequently recurring convulsions, attended with great debility and emaciation, it will become necessary to have recourse to some direct tonic, as the carbonate of iron, iu the dose of five grains to a scruple, to a child five or six years of age. The phosphate .is also a useful preparation, and may he given in similar doses. Stimulating applications to the spine are often of great efficacy in protracted cases of convulsions. Benefit is often derived, also, from the employment of such as possess some direct antispasmodic properties, as the oil of amber, applied with a piece of flannel to the whole course of the spine. Convulsions in children being so often connected with a deranged state of the prima? via?, a close attention to the state of the stomach and bowels is necessary, where the child is predisposed to these affections; in preventing a costive condition, by the occasional use of laxative medicine and enemata; in regulating the secretions by the judicious use of blue pill and ipecacuanha, where the whiteness of the stools indicates a deficiency in the biliary secretion ; but more especially in the supply of suitable nourishment, according to the age of the child. A change of diet, about the age of two years, will often effect more than medicine, where the child has been too exclusively fed on pap. Chicken broth, and animal food generally, should be adopted, where convulsions.persist under such circumstances ; a marked alteration will appear in the health of the child. chorea. Chorea is a disease characterized by the irregular action of the muscles arising from the incomplete control exercised by the will over them ; hence voluntary action becomes imperfect, and the muscular motions are rendered irregular and uncertain. An affection exhibiting every symptom of chorea was described by the ancients with great accuracy, at least so far as the lower extremities were concerned; from the irregular motions of which it took its name. In later times it has received the name now usually adopted, which is derived from the Greek, and signifies a company of dancers. It was in Germany that the appellation of St. Vitus's dance was first applied to this affection, from the tradition that this saint was a sufferer from the disease. A chapel was dedicated at Ulm, in Souabia, where such as were afflicted with this disorder repaired, and offered their vows and prayers for relief. The name of St NERVOUS SYSTEM. 495 Vitus has therefore been added to the other appellation, and it has by some nosologists been distinguished by the title of Chorea Sancti Viti. Etiology.—The predisposition is found in the age of the patient, and it chiefly occurs between the ages of eight and fourteen, especially in those who are debilitated from sedentary habits; although it rarely appears after puberty, yet it has occurred at every age in those in whom the constitution is feeble and the general health impaired. Whatever produces a morbid irritability of the nervous system, predisposes to this disease, such as impure air, imperfect diet, excitement of the nervous system from the inordinate and premature exercise of the intellectual faculties. Climate appears to have some influence on the predisposition; for it is rare in southern regions, and in some parts of the West Indies it has never been seen. The greater susceptibility of the nervous system in females renders them much more liable to this affection than males. Of an aggregate of one hundred and seventy-four cases, reported in various medical journals, one hundred and twenty-two were girls, and fifty-two boys. Dr. Elliotson slates, as the result of his experience, that the proportion is as three to one. Among the occasional causes is found terror or fright; several cases are reported as arising from these causes. -Imitation, also, has produced chorea. Wounds and injuries on the head have likewise been followed by this affection. The various disorders of children have at times preceded chorea; among these are teething and suppressed eruption. The retarded appearance of the catamenia is also a very common cause. The most common, however, is gastric or intestinal irritation from worms, or disordered secretion or constipation; all which are of very common occurrence before puberty. There can be but little difficulty in distinguishing this disease from paralysis or convulsions. As lo paralysis, the only form which may be mistaken for chorea, is paralysis agitans; but this affection occurs in advanced life, and is more partial in its extent, while the peculiarly ludicrous character of chorea is absent. The muscular movements of convulsions are much more violent, and are in every respect involuntary. It is rare that this disease terminates unfavorably, unless some other affection, as epilepsy, paralysis, or effusion in the cavities of the brain occurs; therefore the prognosis may in general be favorable. It has been remarked that when the muscles of one arm or of the head are affected, the disease is likely to be much more protracted, than wlren the disorder is more general. Semeiology.—The first symptom shows itself in the inability to control the motions of the arms or legs; usually the limbs of 496 DISEASES OF CHILDREN. one side exhibit the convulsive movements which mark the disease. The child is observed to halt or stumble in walking, or to twist the foot of the affected limb awkwardly on attempting to place it to the ground. When it appears in the hand or arm, the same awkward motions are noticed, together with a tetal inability to retain the member in the situation in which it is placed. These are particularly observed to occur when the child's motions are watched, when they often become quite ludicrous. The hand is more than usually unsteady, whenever the child wishes to preserve its proper motions; as in carrying a glass of water to the mouth. All these involuntary motions increase until, in the most aggravated forms, all the actions are performed by jerks; the walking by a species of jumps or starts, while those of the arms are equally unsteady. At times the limbs have the appearance of being paralyzed, especially the lower extremities. When the disease is much aggravated, it affects many of the muscles about the face, producing grimaces; the lower jaw, tongue, and muscles used in deglutition, become implicated; the latter at times to such an extent as to interfere with swallowing. The irregular movements of these muscles give often a very ludicrous expression to the face. During the progress of the affection those muscles which were originally deranged in their functions, continue so during the whole of the disease. The symptoms which characterize chorea are in general suspended during sleep ; in very severe cases, however, they continue during the. period of sleep, as well as during the hours of wakefulness. Great irritability of mind follows long-continued chorea, succeeded by hysterical capriciousness of temper and fatuity. Epilepsy and hemiplegia not unfrequently follow severe and protracted cases. These latter symptoms are most likely to occur about the period of puberty; so are also the complications of rheumatic affections of the muscles, especially those of the spine. In very severe cases it appears to affect all the voluntary muscles; and the distortion of the face and protrusion of the tongue impart a ludicrous and sometimes a distressing appearance to the countenance. ' , Morbid Anatomy and Pathology.—Effusion has been found in the ventricles of the brain, with the appearance of turgescence or chronic inflammation ;* in other instances tumors have been seen in the cerebrum. Dr. Hawkins discovered no lesion in the brain in a fatal case examined by him, but the source of irritation appeared in some of the abdominal and thoracic viscera.t it has been supposed by Dr. Olutterbuck and others, that inflammation ex- * Dr. Coxe's Med. and Phys. Jour., vols. xiii. and xviii. f Lond. Med. and Phys. Journal, vol. xvii. NERVOUS SYSTEM. 497 G3 isted in the brain. Chorea has also been referred to a hypertrophied state of that organ and of the spinal marrow, and likewise to a hardened condition of the anterior portion of the latter. In some cases of dissection, ecchymosis of the inverting membranes, a pulpy degeneration of the medulla spinalis, and the formation of bony plates, have been found. Various other pathological states have been discovered, such as morbid conditions of the uterus, mesentery, liver, etc., while nothing indicating disease of the brain of medulla spinalis existed. M. Serres also mentions cases where no morbid condition could be found in the brain, while in others there was sanguineous effusion in the corpora quadrigemina, in another, a tumor pressing on that part, and in two cases, an inflammation of that part.* Dr. Coxe is of opinion that it arises from hydrocephalus, or the inflammation which precedes this disease. It appears to be often connected with it either as a cause or effect; but it is difficult to ascertain from dissection which is the primary affection. It is not necessary that lesions should always at first exist in any part of the cerebro-spinal system to produce this affection; for, like other diseases of a similar nature, it may have its cause in some remote organ, and, when once excited, it may often be kept up by habit, even after the cause is removed. A morbid susceptibility, it is obvious, often exists in the nervous system, whereby an emotion of the mind will be productive of irregular muscular action ; it can hardly be supposed that under such circumstances there can exist any appreciable vascular turgescence. Treatment.—-As the disease is so varied in its cause, the treatment must consequently have strict reference to its origin, if this can be discovered. In order to commence the treatment of chorea, the peculiar condition of the system must be studied, for upon an early discovery of the most prominent derangements and their successful management, often rest the whole result of the case. This is peculiarly applicable to the disease in question, which has its origin in conditions of the body so variable as to render the practice in too many instances almost empirical, judging from the vast variety and opposite nature of the remedies used. It is this different state of the system that has given rise to the employment of a great variety of remedies of the dissimilar character, found in every day's experience. The points to ascertain in the first place are, whether there are present any irritation, inflammation, or congestion of the spine as an idiopathic affection, and in the second, if there be any disorder in the prima? via?, which* it is so well known, causes by a reflex action, an irregular motion of the spinal nerves. At an early period of this disease in some cases, there may be * M. Serres, London Lancet, vol. xiii. 498 DISEASES OF CHILDREN. found various evidences of inflammation or congestion of the brain and spinal column, manifested by pain in the head, with heat and throbbing of the carotid and temporal arteries, or a tenderness of the neck and spine upon pressure. Very frequently an unusual irritability or excitement of the mind is present, pointing out cerebral action of an inordinate degree. In such cases, especially where there is a tension of the pulse, a small quantity of blood may be abstracted by means of leeches : such a measure, however, requires great caution, and the physician should be satisfied from the inpompressibility of the pulse, that it is. absolutely required before it is adopted ; otherwise great and irremediable injury may be the result. "Where there is any doubt, it is the safest course to avoid the use of blood-letting in any form. Rest, quietude, and freedom from all mental excitement and study, must be strictly enforced. The diet should be free from any stimulating quality, and the use of tea, coffee, and exciting condiments, ought to be altogether prohibited. In by far the greatest number of instances, there is at the commencement a great disorder of the prima? via?, and the judicious use of purgative remedies will be found of vast importance, either to remove the original cause of this affection, or to prepare the system for the administration of another description of remedies. The use of purgatives formed the principal method of treatment with Sydenham, and was revived by Dr. Hamilton, and is the principal measure used by Cheyne, Guersent, and Chapman. Aloes, senna, calomel, and scamony, are the purgatives which have been the most employed in the treatment of chorea ; all these are applicable to different states of the chylopoetic organs. Purgatives may often be advantageously combined with antispasmodics, such as valerian, assafoetida, etc. For ordinary cases, a dose of calomel, followed by castor oil, which may be repeated every few days, will be needed. To judge of the necessity of the repetition of calomel, the evacuations ought to be carefully inspected, and so long as they continue unusually offensive, and are accompanied by scybala, the calomel should be repeated. In the use of further purgatives, reference must be had to their effects on the muscular system, and to the costive habit of the patient. Milder purgatives ought then to be employed, and if there is much debility and loss of appetite, may be advantageously combined with a tonic, as gentian and senna in infusion. The safest plan, after the first impression is produced by calomel, is to combine, as before stated, purgatives with antispasmodics. Spirits of turpentine, combined with olive oil, will be a good pur gative when there are worms present in the intestines. It is by no means necessary to persevere with powerful and active purging, even where the furred tongue, offensive breath, and other symptoms, point out the primary irritation to be in the intestines; mild aperi- NERVOUS SYSTEM. 499 ents will often be all that is needed to remove the cause of the disease in delicate patients, the operation of active purgatives often adding to the existing distress. When connected with a disordered condition of the secretions of the abdominal viscera, it is always found in pale, debilitated and irritable subjects. It will, therefore, often become necessary to have recourse to tonics to invigorate the body, and thereby diminish the nervous susceptibility, where the condition of the mucous membrane does not counter-indicate their use. The metallic tonics especially have been the most extensively employed, and found more successful than those from the vegetable kingdom. Among the remedies, of this nature, the sub-carbonate of iron has been the most successful, in doses of from five to twenty grains. It is usual to prescribe it with some aromatic* Other preparations of iron have also been used in chorea; the sulphate, in doses of three or four grains, to children eight or ten years old. Zinc, also, in the form of oxyde and sulphate, has been prescribed with great advantage in this disease ; the former, from two to five grains, and the latter, from one to three grains, to children between four and eight years. Dr. Francis has been eminently successful with the hydro-ferro-cyanuret of zinc in the dose of one to two grains, in the form of pills, two or three times a day. This may be occasionally blended with the twelfth of a grain of strychnine. The nitrate of silver has been used with benefit in obstinate cases of chorea, connected with a disordered condition of the digestive organs. Arsenic has also been found efficacious in adults, where tonics are indicated; but. from the powerful impression it makes, and the rapid absorption in children, I am inclined to think it a hazardous remedy. Iodine has lately been used with great success by Dr. Peltzt and others; the dose and manner of its exhibition will be found under the head of scrofulous diseases. Narcotics and antispasmodics have also, at times, been attended With good effect, when the disease has been kept up by habit, connected with a morbid sensibility of the nervous system, independent of any local cause. Belladonna, opium, camphor, valerian, musk, and other medicines of this class, have been used for this purpose. A combination of the extract of henbane and camphor has been employed with success by Dr. Bright. In long-continued cases I have used electricity, but with no advantage ; it has, however, in the hands of others, been successful. * ft Ferri Sub-carb., gr. x. (172) Pulv. Valeriana?, gr. xx. Syrup. Zingiber., q. s. M. ft. bolus. For a child of ten or twelve years, t N. A. Med. and Phys. Journal, vol. ii. 500 DISEASES OF CHILDREN. De Haen employed this agent with success, and found one of its effects to be an eruption resembling urticaria. Galvanism has also been used in protracted cases of chorea. The shower-bath and cold bathing have been recommended, but in the high susceptibility of the nervous system in chorea, it must be regarded as rather too hazardous a measure for general use. Various external irritants have been used to the spine, such as spirits of turpentine, tartar emetic ointment, blisters, setons, and issues, with no uniform effects. 1 Regular exercise in the open air, cold bathing, constant occupation, together with the tonic course above mentioned, and a residence in a dry and cool section of country, will, with ordinary precautions in removing the exciting cause of the disease, almost certainly effect a cure. HYDROCEPHALUS. This disease receives its name from the effusion of serous fluid in the ventricles and other cavities of the brain, occurring either suddenly or in a very gradual manner, and preceded either by a very marked acute inflammation, or by a chronic state of irritation in the arachnoid membrane. In the latter case it is often congenital, and may continue for a number of years ; the skull separated at its sutures, being widely distended, and exhibiting an enormous increase in its size. It is therefore properly divided into acute and chronic. ACUTE HYDROCEPHALUS. This form of the disease has received the various synonyms of hydrocephalus internus, hydrencephalus, febris hydrocephalica, apop.lexia hydrocephalica, eclampsia ah hydrocephalo, arachnitis, meningitis, dropsy of the brain, etc. The term at the head of this article appears to be the best, as it includes in its signification all the possible varieties, and is not adverse to the doctrine of previouslyexisting inflammation ; while other terms, as arachnitis, or meningitis, can not be always applicable to the affection now under consideration, for the affections may not always terminate in effusion, which is the disease here considered. It appears not to have been noticed as a distinct disease by Hippocrates and other ancient writers, although the father of medicine alludes to the existence of water in the brain—in a manner, however, that leaves a doubt whether he referred to an external or an internal accumulation of water. But both Hippocrates and Celsus, as well as other ancient authors, doubtless saw the disease, and there is no reason for believing that in their account of it, under 501 NERVOUS SYSTEM. precisely the same title as it is now described, they ever meant any other affection, although a question has been raised on the subject.* In the year 1733, Mr. John Paisley published a clear account of this affection, occurring in a boy aged about six years, who was attacked with the usual symptoms of inflammation of the brain. The case terminated fatally, and, on examining the brain, a tumor presented itself, formed of the dura mater, enclosing a small quantity of serum. In the ventricles, also, there existed a large quantity of yellowish serum.t The first complete essay, however, was published by Dr. Whytt, professor of medicine in the University of Edinburgh, in 1768,f in which a very accurate and philosophical accountof the disease is given. This essay is replete with excellent practical remarks on the different appearances of the disease at different periods. The symptoms are accurately described, and its division into the very obvious distinction of different stages, shows the accuracy of the distinguished author's observations. The pathology of the disease is necessarily imperfect, and the treatment consequently not so energetic as that adopted at the present day. The subject has received the attention of Fothergill, in England, Odier, in Switzerland, and our distinguished countryman, Dr Rush. Of late years, Bricheteau, Cheyne, Yeats, and Coindet, have published excellent remarks on this subject. One of the most complete essays that has ever appeared, is that of Dr. Golis, of Vienna, a translation of which has been made into English by Dr. Gooch. Dr. Golis considers it as it was regarded by Dr. Quin, Dr. Rush, and others, as an inflammatory affection, and the effusion as the effect of this cephalitis ; but, like them, does not extend his views to its frequent origin in the chylopoetic viscera. Etiology.—Authors, generally, have remarked, that those children who have large heads are more predisposed to hydrocephalus than others, and that it occurs more frequently in children of great precocity of intellect. This, in itself, can scarcely be regarded as a necessary condition of the disease, although it not unfrequently has been found to co-exist with it. Those children who possess a quick sensibility, and who also give evidence of great excitability in the nervous system by irregular spasmodic movements, are evidently more predisposed to it than others. One of the most common predisposing causes of this affection, which is one almost exclusively of infancy and childhood, is the growing condition of the brain, and the extreme of the * Hippoc, De Morb., Lib. ii., sec. v. Celsus, De Med., Lib. iv., Cap. ii. f Med. Essays ; Edinburgh, vol. iii., p. 333. J Obs. on Dropsy of the Brain, etc.; Edinburgh, 1768. 502 DISEASES OF CHILDREN. blood-vessels from that cause. The brain, during the first periods of life, undergoes great organic modifications, and the exercise of its peculiar functions has also been remarkably developed; for it gradually acquires a control over the other organs, and becomes fitted to receive the impressions from them. It is on this account, as M. Billard .observes, that during the early months of the child's existence there is but little excitement in the brain, it then undergoing nothing more than organic change; but as it becomes fitted to receive impressions, fever and inflammation ensue, often from very slight sympathetic irritation, as derangement from indigestible substances, dentition, so common in children; for acute hydrocephalus is not a disease of early infancy. The predisposition to cerebral disease is also hereditary, and it is not an unusual circumstance to see several individuals in the same family affected with it, as has been remarked by Cheyne, Coindet, Brachet, etc. Armstrong mentions the occurrence of hydrocephalus in four brothers, and Underwood, the death of six, at the age of two years. I have known of four deaths occurring in one family from this cause, successively arising as the children arrived at the age of two or three years. Dr. Percival has, by recording a number of cases, determined the age with considerable accuracy at which children are most disposed to hydrocephalus; and from his observations it appears that it most commonly occurs between the ages of two and seven years. M. Coindet, of Geneva, has, also, by means of tables of deaths kept for twenty years, ascertained the same facts. A similar result is also found in the tables of Dr. Emerson, of the deaths occurring in Philadelphia for twenty years, recorded in the first volume of the American Journal of the Medical Sciences; for, out of 1,602 cases of fatal hydrocephalus, 1,395 occurred before the fifth year, and between the ages of five and ten. These facts go to illustrate, in a remarkable manner, the influence of the increasing activity and sensibility of the brain in predisposing children to this affection in its acute form. Dr. Green states, that it is between the ages of five and seven that the greatest number of cases occur.* It is said to prevail more in sOme countries than others. In England, France, and the United States, it is a frequent and fatal disease, while it is rarely to be seen in Holland, and Switzerland, according to the statements of Camper and Tissot. The exciting causes are very numerous; indeed, there is scarcely any affection to which, children are subject that may not become its occasional cause, while blows, or any injury or compression of the head, are also the agents of its production. The causes then divide themselves into direct and indirect, idiopathic and sympto- * Contribut. on the Path, of Children; Lancet, vol. ii., 1835. NERVOUS SYSTEM. 503 matic. Blows and falls on the head are frequent exciting causes, as young children are much exposed to them from want of strength in supporting themselves while learning to walk; they often, however, thus experience injury, without any serious or lasting consequences resulting. The blows, therefore, ought to be sufficiently powerful to produce an inflammation of the meninges of the brain, from the violence of the concussion. Extreme heat is also another exciting cause, especially from the rays of the sun, whereby an inordinate flow of blood to the head is produced, terminating in inflammation of the arachnoid membrane. The indirect causes may arise from various abnormal conditions of the system, and among these is that of suppressed eruptions, or of habitual discharges, such as that so common to children, the serous and puriform oozings from excoriations behind the ears. Among this class o,f causes are scarlet fever, measles, and other eruptive diseases; the former most frequently, when fatal, terminating in hydrocephalus. It has in these cases been supposed by many authors to arise from an interruption in the regular course of the disease, which has its proper periods of incubation, progress, and maturity; this irregularity being produced by the impression of the external air, as Bricheteau supposes. Whatever be the cause of the metastasis, nothing is more common than to see it follow cutaneous affections, and those sometimes of a very slight character, as the miliary eruption. Intestinal irritation, or irritation of any of the digestive viscera, is also a very frequent cause of the disease in question; and authors ascribe it, in a great number of instances, to the sympathy existing between the various abdominal viscera and the encephalon. This strong tendency to cerebral inflammation, in diarrhoea, cholera infantum, and other diseases of the chylopoetic viscera, in infancy and childhood, is familiar to the most casual observer; and, indeed, -is so frequent a termination of these affections, as to cause all diseases of the head to be referred by some physicians to the digestive canal as their sole origin. Among these more particularly are MM. Sabrioles* and Senn ;t the former of whom has devoted an octavo volume of three hundred pages to the consideration of this subject; both regarding gastro-enteritis as the principal, and, indeed, the sole cause of these affections of the head. There can be no question of the strong tendency to diseases of the head in children, where there exists much disturbance of the bowels, and especially where there is any inflammatory action; both these affections often appear simultaneously, as is evident from the symptoms, which will be noted when that portion of the subject comes * Recherches d\A.natomie et de Phys. Pathol., etc., par G. Sabrioles; Paris, 1826. t Rccherches Anatomico-Pathologiques sur la meningitis; Paris, 1825. 504 DISEASES OF CHILDREN. under consideration. These evidences of gastric and -intestinal disturbance are important diagnostic signs of the nature of the exciting cause,-and on which a successful treatment of the ordinary hydrocephalus very essentially depends; for the removal of any irritation from the bowels, whether it be worms, or acrid secretion, often is important in removing the first link in the chain. These views are not peculiar to the French physicians, but were long since entertained by Harris, and more recently more closely inves tigated and practically applied to the disease before us, by Drs. Cheyne and Yeats. In addition to the deranged condition of the alimentary canal, they considered the congested, sub-inflamed, or sluggish state of the liver, as the principal exciting cause of the common cerebral affections in children—views more in accordance with general experience and the practical benefits derived from them. This extended consideration of the sybject, in leading the practitioner to anticipate the disease, when the symptoms of deranged action in this viscus are apparent, gives a high value to these treatises, and makes them important, as marking a new era in practice as relates to this disease. The irritable state of the system during dentition is also a subject of common observation; and the excitement attendant on this state is an active agent in the production of hydrocephalus, both from the general febrile condition, as well as the inordinate determination of blood to the head, from the sympathy arising from contiguity of parts. Violent paroxysms of coughing, crying, and even of anger, become exciting causes of inflammation of the membranes of the brain, terminating in effusion, by causing an excessive flow of blood to the cerebrum. In like manner, an inordinate use of the cradle has been found hazardous, from its producing similar effects, convulsions having, in some instances, been brought on by violent rocking. A moderate motion often has a soothing effect, and cannot be regarded as hazardous; but the practice of continued and violent motion of the cradle, can not be too highly reprobated. As was just remarked, violent coughing is a prominent cause; to this, therefore, may be referred the effusions in the brain, so commonly following hooping-cough. But in addition to this cause, there is doubtless existing in all children a predisposition to cerebral disease; the simple excitement attendant on protracted hooping-cough is sufficient, in some instances, to cause the development of arachnitis. All these facts unquestionably prove the predisposition to exist in the brain of children, from some peculiarity at this period of life, which exposes it to be excited by derangements existing in other parts of the system, by which it participates in common with NERVOUS SYSTEM. 505 64 others. But from excessive circulation in the brain, evident in the great size of the head of children in proportion to other organs, and its excitable condition, as appears from the extreme mobility of the nervous system, there can scarcely remain a doubt that this condition of development is what predisposes it to be so easily affected by derangements in the system generally, which excite preternatural action in the blood-vessels. Physiologists generally, from Stahl to Bichat, have noted particularly the condition of the cerebral organ, and have considered it as the predominant organ of the period of childhood; by which is probably meant the organ which, from its imperfect development, needs a large supply of blood to carry on the process which nature requires, and, therefore, circulation predominates in this viscus; for it can scarcely be regarded as a predominating organ, when its essential function of thought is but in imperfect action. Semeiology.—The invasion of hydrocephalus is often like that of an ordinary fever arising from derangements of the abdominal viscera, and is* marked by similar symptoms, such as colic pains, nausea, vomiting, and sometimes, as the disease advances, is accompanied by a diarrhoea of green discharges, showing an excess of biliary secretion. The sleep is disturbed, the child also waking as if alarmed. These symptoms may continue for several days, or even weeks, as was long since noticed by Dr. Whytt. At other times the invasion is sudden, but generally the progress of the disease is marked by a distinct set of symptoms; and authors, since the essay of Dr. Whytt, have generally admitted the existence of three stages.of hydrocephalus. These divisions, although founded in nature, and highly useful in practice, will often be very irregular in their progress, and thus, at times, will render it difficult to assign with precision the symptoms which arise to their proper stage. A close watching of the symptoms may, notwithstanding, enable us to obtain a sufficiently accurate knowledge of the existing state of the disease. Dr. Cheyne and others have proposed modifications of the divisions of Dr. Whytt, founded, as it was intended, more on physiological principles ; that of Cheyne is divided into the stages of*excitement, torpor, and. of convulsion, while Itard* makes two, the first of irritation, the second of compression. The division of three stages, when considered as founded on the pathology of the disease, is the most practical, as having different causes for the production of their peculiar symptoms, and consequently requiring treatment appropriate to the removal of these causes. The first is the stage of simple irritation, and may be known by the usual indications of an irritable state of the brain, as extreme * Diet, des Sciences Med., Ar!. Hydrocephale Aigue. 506 DISEASES OF CHILDREN. wakefulness, starting and grinding the teeth when asleep, and suddenly awaking with a loud scream and the appearance of fright. There appears to be a sudden feeling of distress at times in the head, producing a violent cry, where both parts of the cry are acute and shrill, and described by M. Maunoir, and Coindet of Geneva, as peculiar to this disease, and designated by the name of " hydrencephalique." This condition often continues for four or five weeks, and even longer, and may often disappear without passing into the other stage. The excitement, however, attendant on indigestion, or irritation of any kind in the stomach and bowels, the invasion of any pulmonary disease, suppression of cutaneous eruption, habitual discharges, the sudden application of cold to the surface, or the continued irritation of teething, may increase the irritative action of the brain, until an inflammatory action has commenced in the meninges. Among other symptoms at this period, is the functional derangement of the stomach and bowels, such as indigestion, irregularity of appetite ; with other instances of a deranged actiqp in the digestive viscera, of a character the most opposite, such as constipation, and at times diarrhoea. Most commonly, however, the former exists. The liver gives evidence of derangement in its secretory function. At first, a great deficiency, of bile exists ; but as the disease advances, and the symptoms of inflammatory action become decided, an increase of secretion occurs, and free discharges of green bile take the place »f the constipation. Vomiting is a remarkable symptom, and whenever a sudden discharge of the contents of the stomach takes place, and continues after the administration of the usual remedies for the relief of such symptoms, mischief in the brain may be suspected. A remarkable characteristic of this vomiting is, chat it appears to be unattended with nausea, or the usual appearances on the tongue, indicating an idiopathic affection of the stomach. Another characteristic of vomiting from this cause is, that it more frequently occurs when the patient is raised, rarely while recumbent. The obstinacy vomiting, and existence of headache in infants, may be suspected by their sharp cries ; and, in older children, their ctmplaints will sufficiently,,point out its nature. These symptoms of incipient hydrocephalus ought to be carefully ascertained ; for upon a prompt discovery of the early stages of the disease, the successful treatment almost entirely depends. The second, or inflammatory stage, is indicated by the increase of the symptoms above mentioned, and in very young infants may, by the careless observer, be like those of the first stage, rather ambiguous, if we except that of vomiting, and other derangements of the prima? via?. 507 NERVOUS SYSTEM. The tongue is generally white if the inflammation runs high, and is an idiopathic affection ; if, however, it arises from sympathetic irritation, from a disordered or inflamed condition of the stomach and bowels, it becomes dry, and covered with a dark brown fur. There exist great restlessness, irritability, and.an increased sensibility to the light, the eyelids being partially closed, and the brows contracted. The pain in the head is intense, and is more severe when the inflammation has been caused by a fall or a and is a tolerably accurate indication of the degree of inflammation. The mechanical movement of the hands to the head will point out the seat of the pain, which is sometimes at the back part, sometimes at the front, or in the temples ; and children will often keep their hands on the part, and not suffer them to be removed even for a moment The pain and distress cause great restlessness, tossings, and continued wakefulness. These symptoms, however, are not always constant, but intermit, and are alternated with vomiting, and abdominal pains of a violent but transient character. The face for the most part is pale, but occasionally with a redness of one cheek. It is in the period of inflammation that the cry above alluded to, as characteristic of the disease, becomes most peculiar and constant. M. Mathey* describes its peculiarity to consist in a piercing, prolonged sound, but without indicating violent pain. It is only found in acute hydrocephalus, and not in any other disease ; and when taken in connexion with the altered state of the physiognomy, points out the condition of the brain connected with.hydrocephalus, and is more expressive of a morbid distress or terror than of acute pain. Although children cry in every disease of an acute and painful nature, yet this fact does not diminish the importance of this diagnostic sign, as these cries are rather of an impatient or fretful character, and with a little attention may be distinguished from the peculiar sharp expression of suffering in hydrocephalus. Delirium is not very frequent at the commencement of this stage, but almost always exists toward the latter part. It is not of a ferocious character, and the child, if old enough to understand and converse, is easily aroused. The circulation in this stage is somewhat quickened, and the pulse is frequent and tense ; the skin continues but little altered in temperaturefwhich is something above the healthy standard, and destitute of moisture. The condition of the pulse, at different periods of the disease, has been very accurately noted by Dr. Whytt; but the extent to which he has carried his views renders them of little avail in practice. Sighing is a constant and very remarkable symptom of the dis- * Mern. sur l'Hydrocephale, qui a remporte le Prix au Jugement de l'Academie de Dijon, le 4 Juiliet, 1818, p. 46. 508 DISEASES OF CHILDREN. ease toward the termination of the inflammatory stage, and may be regarded as a very unfavorable one, as it commences immediately before the appearance of symptoms indicating the third, or stage of effusion. • The last, or stage of effusion, is that from which the disease has received its name, and at this advanced period may almost be regarded as incurable; hence the opinion of those who formerly wrote on it, Whytt, Fothergill, and others, that it is an incurable disease, from having only apparently recognised it in the last stage, without any knowledge of the inflammatory condition which preceded it, and upon the treatment of which the success almost entirely depends. In this stage the* most prominent symptom is drowsiness, or a greater or less degree of stupor; indeed, it is an invariable attendant on the state of effusion. Its duration is various, and has even continued for the space of two weeks. When this is the case, it alternates with spasmodic affections and lucid in* tervals. At other times the attack of effusion is sudden, and has been well described by Dr. Golis under the significant name of wassersehlag, or water-stroke, from its sudden violence. Cases of this nature have been noticed by every practitioner of any experience. When this stage comes on in its most usual manner, after a period of active and well-marked inflammation, confusion of mind show? itself at first, rather than violent delirium, accompanied with a peculiar expression of countenance, indicating a great derangement 01 the perceptive powers. The child is in a state of stupidity when aroused, which gradually becomes more difficult to effect, until he is at last completely comatose, and can not be made to manifest any consciousness. A perfect torpor ensues in the latter part of the disease in every organ of sense; the sight is entirely lost, and deafness becoming more and more profound, marks the progress of the compression on the origin of the nerves. The sense of feeling is the last which is lost, and, as might be supposed, where the effusion is in the brain alone, the lower extremities retain longest their power of motion. In the early periods of the stage of effusion, the eyes give some very important signs .of the progress of the disease. The conjunctiva is suffused with blood, and while the child sleeps,*the eyes are turned upward. The state of the pupils is that which has most attracted the attention of physicians, for it is a clear indication of the progress of the effusion. They maybe enlarged even in the early stages of hydrocephalus; but this condition is not permanent, and it is easy to discover whether it arises from a certain species of irritation alone, by placing a light before the eyes; the'pupils will contract and a immediately enlarge on the removal of the light. 509 NERVOUS SYSTEM. Then, again, by leaving the light some time before the eyes, the pupils will alternately contract and dilate, from what appears to be a'convulsive the iris. When, however, there exists effusion in the ventricles of the brain, the enlargement of the pupil is permanent, and the eye remains insensible to the light. This symptom is a fair indication of the existing condition of the brain ; for it is more completely marked toward the close of the disease, when compression has destroyed the remains of sensibility. Strabismus is almost always a symptom of the disease; more commonly occurring, however, at the commencement of the effusion, and usually precedes* paralysis or convulsions. When a paralyzed condition" of the muscles occurs, it is sometimes confined to one arm or one leg of the same side, or to the muscles that move the eye or elevate the palpebra. Before a permanent paralysis occurs, a throwing of the arm of one side, irregular movements of the muscles of the face of that side, and the apparent want of entire control over the motions, already show the existence of a partial paralysis. The paralysis comes on gradually, first showing itself as an apparent debility, until the power of moving the limb or limbs is entirely lost. Convulsions almost invariably occur, to a greater or less extent, in hydrocephalus. Sometimes they are confined to one arm or leg, even when they have already suffered paralysis ; or a simple^spasmodic twitching of the muscles of the face, or an irregular rolling of the eyeballs may alone exist. At other times they are general, and exist toward the termination of the disease, and the child not unfrequently dies in a convulsive paroxysm. In this stage the pulse is variable, according to the extent of pressure on the brain. If there is much drowsiness and stupor, it is slow and full; these symptoms not usually prevailing to a great degree at the commencement of the effusion. A remarkable quickness is observed in the pulse, which continues, if convulsions or partial paralysis take the place of the stupor, gradually becoming weaker, until its beatings are imperceptible. Dr. Whytt has considered slowness of the pulse as a pathognomonic sign of effusion in the brain ; but this is not always so, for it is found to differ in many patients, although dissection has revealed the exisience of serum in the ventricles. The condition of the pulse will in general be found dependant on the extent of the pressure on the brain. Besides,, in young children, the circulation appears to be so susceptible of changes and irregularities from very slight causes, that, as Harris has long since remarked, the condition of the pulse is not so perfectly to be relied on in them as in older children or adults. 510 DISEASES OF CHILDREN. The skin, at the commencement of this stage, is usually hot and burning ; as it advances, a dripping moisture covers the whole surface of the body, and almost every olhev symptom of complete prostration exists, the child either dying in this state, or a violent paroxysm of convulsions closes the scene. A peculiar condition of the system exists a short time before death, which all authors have mentioned, and which must have been noticed by every practitioner; it is that which produces an almost complete remission of the symptoms of oppression ; and, in some instances, so complete is the relief, that the child will, from being insensible to all surrounding objects, become restored to the use of his sight, hearing, speech, etc. The relief is at times so great as to give the most flattering hopes "of a favorable termination, that even the experienced physician can scarcely bring his mind to the belief that it is a deceitful brightening, preceding a more profound state of coma, invariably terminating in death. This is the ordinary course of the invasion, progress, and termination of hydrocephalus ; but it is not always that the disease observes such regularity in its progress; and when the effusion occurs suddenly, the precursory symptoms are very transient, or are absent altogether. Although there will always exist some evidences of ill health, the digestive organs being those which are observed to be the most deranged, and often in that variable condition so common in irritation of the gastro-intestinal mucous membrane, and with the itching of the nostrils, grinding of the teeth, that frequently attend this state of the stomach, yet there are cases where there scarcely appears to be any marks of disease whatever, either in the abdominal viscera or brain. Dr. Rush has recorded cases where there was not even pain in the head, and where the usual symptoms of nausea, dilated pupil, and strabismus, were absent.* There are others having no other precursory symptom than a catarrh. In such cases the urine appears to be passed with difficulty, in a very small quantity, and is described by M. Coindet as being farinaceous, or chalky. A drowsiness, with very slight febrile exacerbations, are the only symptoms of the disease under these circumstances. As might be supposed, there are different degrees of severity in these symptoms, and a great variety in the appearances of the disease, arising from the different temperaments in the individuals affected. Thus, we may expect to find in one where the sanguineous temperament predominates, violent inflammatory symptoms; quick, hard pulse, violent headache, with occasional delirium; in one of a lymphatic temperament, a greater degree of stupor will exist from the commencement, accompanied with a slow pulse and with but little febrile action. * Med. Inq., vol. ii., p. 210. 511 NERVOUS SYSTEM. The diagnosis of this disease is in some cases difficult; for almost all disorders of the bowels, as well as the irritation of. teething, will produce symptoms, bearing a close resemblance to those of hydrocephalus, such as coma, strabismus, spasms, startings in sleep, etc. These, however, are confined to the last stage ; an4 when they are found without the usual premonition, an immediate attention to the condition of the bowels may relieve all the untoward symptoms, and enable us to make a correct diagnosis of the disease ; for it not unfrequently happens that a free alvine evacuation, or a simple incision of the gums, will remove every symptom of cerebral disorder. Dr. Cheyne* considers the appearance of the alvine evacuations as affording a good diagnosis of the disease, when it is liable to be confounded with intermittent fever of young children. In the inflammation of the arachnoid membrane which precedes the condition constituting hydrocephalus, they are of a dark green color and slimy consistence. In the last-mentioned disease, also, as observed by Dr. G61is,t the abdomen is always in a collapsed or flattened state, while in the febrile affection just referred to, it is tense and swollen. In arachnitis the head is the hottest part; in the remittent febrile affection of children the abdomen is hot, while the head is comparatively cool. In this disease, also, or worm fever, as it is generally known and described by authors, the inner surface of the nose is moist, the smell is acute, and there is a great itching of the part; in acute hydrocephalus the discharge from the nose is stopped, and the patient gradually loses the sense of smell. In this disease, also, the eye is very sensible to the light during the inflammatory period, and perfectly insensible to it after the effusion has taken place. In the intermittent fever from gastric irritation, the patient never complains of a strong light, nor is there a state of insensibility to the light at the termination of the disease, nor does there exist any paralytic affection at the approach of death, as in the state of effusion in hydrocephalus. . The work of Dr. Golis, a very excellent and practical monograph on the subject, is needlessly minute on the subject of the diagnosis of the in making distinctions between the various affections of a febrile nature with which children are so often attacked, when, in reality, the symptoms are evidences of a similar condition of the cerebral meninges, generally ending in effusion. The detail of the shades of differences occurring in the diseases with which it is liable to be confounded, rather tends to perplex than assist the practitioner—a variety of symptoms depending on various occasional causes not unfrequently occurring in every disease, which, if always taken into account, to raise a doubt as to its •Op. Cit. f Op. Cit.,p. 53. 512 DISEASES OF CHILDREN. identity, would indeed make the diagnosis in some instances a matter of complete uncertainty. Other writers, Itard, Bricheteau, etc., have also extended their investigations to a in giving the symptoms of other inflammatory affections of the brain, which can scarcely ever be applied to any practical use. Without, therefore, going further into a detail, it is sufficient for all practical purposes to know, that when children are old enough to describe their feelings, there are good grounds for suspecting the disease to be present when they complain of severe pain in the head, accompanied with frequent pulse and frequent vomiting, es pecially on being raised in bed. Even then, it is not always easy to decide whether the symptoms are those occurring in the first stage of the disease in question, or that with which it may be so easily confounded —the remittent fever of infants. In a practical point of view it is but of little moment ; for if the symptoms of cerebral derangements in the last-mentioned disease are so violent as to create a doubt as to its precise nature, no injury can possibly result from an error in regarding them as directly tending to the effusion of scrum, and adopting a vigorous course for the prevention of this almost certainly fatal termination of the disease ; indeed, it is under these circumstances, nothing more than secondary or sympathetic hydrocephalus. In younger children, the physician may also have reason to suspect the existence of the forming stage of the disease, when they are observed to cry incessantly, pass a long time without sleep, and the usual symptoms of violent pain in the bowels, such as writhing and drawing up of the legs, are absent; when they have irregular alvine evacuations, vomiting, and a diminished quatitity of urine. Hydrocephalus is always to be regarded as a disease of the greatest danger, and, when arrived at the stage of effusion, is almost necessarily fatal. Thompson says he never saw a patient recover from it. Cheyne, Golis, and other writers, also bear testimony to the great mortality of the disease. Dr. Eberle states, that in the course of twenty years' practice, he never knew but two fully developed cases which terminated in health. In a great number of cases coming under my observation in the course of several years, 1 know of but one recovery where effusion had actually occurred, and this was a case where every hope of recovery had been abandoned, and where a sudden and very copious discharge of urine came to the entire relief of the patient. The prognosis is more favorable, other things being equal, in proportion to the early period of the appearance of the disease, at which it is subjected to medical treatment; and the earlier prompt and judicious remedies are applied, the more hope is there of recovery. Morbid Anatomy and Pathology.—Authors have been very NERVOUS SYSTEM. 513 particular in recording every appearance of disease in the brain, on post-mortem examinations. On this account it is that the appearances have been described as very various; and while the effusion of serum has been regarded as its peculiarity, tubercles, cysts, suppurations, sanguineous effusions, adhesions, and other changes, have been carefully noted whenever they have occurred. M. Bricheteau considers this minuteness as an unnecessary accumulation of isolated facts, and that the record of the occasional departure of the disease from its strict nosological place, gives evidence of but little discernment in the various affections of the brain, in regarding them as essential to the disease in question, which in strictness is an accumulation of serum in the cavities. But it is clear, that in a practical point of view these facts are of the greatest importance; and in so far as pathology can clear up the mystery of disease, go much toward affording a correct knowledge of the nature of hydrocephalus, as they give unequivocal evidence of the existence of an inflammatory period, which, from dissection, could not be proved from simple effusion of serum. The most common appearance, on dissection, is a quantity of serum in the lateral ventricles of the brain, varying in quantity from two to eight ounces; occasionally, however, the quantity has been found to be much greater, even to the extent of twenty-four ounces, according to M. Brachet, in the other ventricles and base of the brain. On other occasions but little or no serum is found in the ventricles, but between the membranes. It is a limpid fluid, resembling whey, and is not coagulable by heat like the effused serum of other cavities. Although usually clear and colorless, yet it is sometimes turbid and yellow, and occasionally mixed with albuminous flakes ; at other times it is of a gelatinous consistence between the convolutions of the brain. The substance of the brain, according to the dissections of Laennec, Golis, Jadelot, and Bricheteau, is often of a firm consistence, and in some degree, as it were, hypertrophied; where this is the case, there is but little effusion in the cavities. In other instances there exist great disorganization and softening; this is more particularly the case where there has been a large quantity of effusion, by which the brain has been exposed to compression. In some, on the contrary, a part will be found completely indurated. Pus has also been found on the surface of the brain, of which Abercrombie has given two cases,* that followed the usual symptoms of hydrocephalus. Besides effusion in the ventricles, and alterations in the consistency and organization of the brain, the pia mater and tunica arachnoidea, as well as the adjacent cellular tissue, are for the most part • Patholog. and Pract. Researches on Dis. of the Brain; Edinb., 1828. 65 514 DISEASES OF CHILDREN. the seat of the usual marks of inflammation, such as sanguineous injections, or exudations of albuminous matter on their surface. The plexus choroides is always dark red, and in some instances enveloped in a thick coating of albumen. The veins and sinuses of the brain also partake of the diseased alterations, for they are always found engorged and distended with blood. In addition to these appearances of disease Jn the brain, the abdominal viscera show the - existence of which has, by sympathetic irritation, caused the cerebral affection. Brachet, Sabrioles, Senn, Cheyne, and Yeats, note particularly the inflammatory appearances of the intestines. The two latter, especially, have remarked the congested state of the liver. Some have strangely attributed these appearances in every instance to the excessive use of purgative medicines, when all the symptoms on the original invasion of the disease are sufficient proofs of the deranged state of .these organs. It is frequently found that the mucous membrane of the intestines is in a state of inflammation ; and, from the alterations in the calibre of some of the intestines, there exist the most undoubted proofs of a previous state of inflammation. Among other conditions of the brain in this disease, which the investigations of modern pathologists have brought to light, is the presence of tubercles. These depositions of tuberculous matter, until within a few years, were scarcely suspected, although, in fact, according to the results of the dissections of Dr. Green, they occur in one fourth of the number of children dying of cerebral diseases.* It has indeed been long noticed, that children dying of hydrocephalus were mostly of a scrofulous temperament, and this condition has been shown to exist by the dissection of a number of cases by Dr. Mills ;f but the positive proof of this affection being present in any of its forms, was unnoticed, until the subject was elucidated by the essays of MM. Mitivie, Giraud, Tornelle, Levielle and Defour, in France, referred to by Dr. Green, in the essay above mentioned : it has also received much attention from Dr. Gerhard, of Philadelphia, in the American Journal of Medical Sciences.:}: The latter has drawn his cases, also, mostly from the Parisian hospitals, which are filled with patients who have suffered much from insufficient and bad nourishment, and also from impure air, a class of subjects where we might expect to find the effects of a degenerated condition of the fluids ; and the inference which he appears to draw as to the nature of the disease called hydrocephalus acutus and meningitis, in regarding it as a tuberculous disease, is scarcely ap- • London Lancet, Loc. Cit. f Trans. King and Queen's College, vol. v., p. 350. X Vols. xiii. and xiv. 515 NERVOUS SYSTEM. plicable to other cases of the disease. These tubercular deposites have often been found in children who have not manifested any cerebral disturbance during life, and have even attained a considerable size without producing any symptoms of inflammation ; in other instances small tubercles have been discovered, evidently the cause of very great irritation and inflammation, effusion and death, proving them to be a cause of inflammation, and thus one of sources of serous effusion. In eighty cases collected by Dr. Green in the paper above mentioned, the maximum number of tubercular formations occurred between the ages of two and four years. It is evident from the detail of the symptoms, and the appearances on dissection, that the effusion constituting the disease is a secondary affection from previous inflammation of the membranes of the brain, which itself is consecutive on affections of the abdominal viscera, except in those cases arising from some direct cause. The varying appearances on dissection prove this beyond a doubt, especially when considered in relation to the pathognomonic symptoms, which are clearly those of cephalitis, when observed before the final stage of effusion. These views were the opinions of our distinguished countryman, Rush, and of Henke, Stark, Sprengel, Golis, and others. From numerous dissections made by Golis, and still more recently by Billard, this inflammation, or meningitis, as it is termed by the last-mentioned author, appears under two forms, that of a simple inflammation, with nothing more than a vascular injection or spotted redness, with or without the formation of a pellicular concretion or false membrane. Under these circumstances, convulsions and violent cries are the symptoms that are the most common. The other form is that which marks the disease we are now considering, and known by the presence of serum or seropurulent fluid in the cavities of the brain. This state of the brain is known by the symptoms already described, and in the primary stages are those which are peculiar to simple inflammation of the meninges. These symptoms, it is true, are often very various as respects their duration, intensity, and exacerbations ; but whatever be their varieties of form, their fundamental character always exists; and it will not be a difficult thing for the practitioner to detect the disease from the characteristic phenomena which inflammation of these membranes exhibits. In those cases in which effusion appears to be very sudden, causing the immediate death of the patient, it has been thought by some that the suddenness of the effusion is only apparent. This variety has been known by the names of apoplexia hydrocephalica, hydrocephalus hyper-acutus, and described by Dr. Golis under the term of water-stroke, from the suddenness with which the symptoms ao- 516 DISEASES OF CHILDREN. pear. Dr. Golis describes it as passing through the stages of turgescence and inflammation, without giving the usual evidences of their existence, and that the stages of transudation and palsy, four stages being his division of the subject, are also confounded together, and can not accurately be distinguished. He has, notwithstanding this apparent absence of the periods of excitement, discovered upon dissection traces of turgescence and inflammation. The effused fluid was always found turbid, with much less coagulable lymph than in ordinary hydrocephalus; a circumstance which led him to the opinion that lymph was partly mixed with serum, and that the whole mass was the product of a morbid action of the vessels. The effusion, therefore, may have occurred slowly, and not have produced its peculiar effects until it had become abundant t such is the opinion of Billard, and appears to be supported by daily experience and by natural analogy. Treatment.—In the treatment of this disease it is of the greatest importance to take into consideration the circumstances which have preceded and which accompany the attack, for the successful management of it depends not only on the early application of suitable remedies for present symptoms, but also on the nature of the exciting cause, for a prompt removal of this is our main dependance for the cure. As the disease is naturally divided into idiopathic and symptomatic, an early inquiry into the immediate cause of the cerebral disorder in children, will enable us to apply the appropriate remedies, and at once use such means as are the best calculated to extinguish the disease before it has got its fatal hold. When its cause is one which has acted directly on the brain, such as exposure to excessive heat, falls, or blows on the head, or when the inflammation has been produced by obstructed perspiration, the indications are, 1st, to relieve the excited state of the blood-vessels of the brain ; 2dly, to allay any general febrile excitement, by which the circulation in the brain is maintained in an excessive state of action ; and 3dly, to produce such revultions as will create a permanent flux of blood from the affected part. Nothing is so effectual for fulfilling the first indication as the prompt abstraction of blood from the arm, and the quantity taken should be sufficient to produce a decided effect on the general system. The pulse, in the state of active inflammation, is usually hard and frequent, and an impression on the force of the circulation by the drawing of blood is essential to the management of the case; indeed, there is nothing that can take the place of general bleeding, in a disease of so great danger as inflammation of the brain, and one which will not allow of the slightest waste of time tn the use of other and comparatively trifling remedies. If it be NERVOUS SYSTEM. 517 not vanquished at the commencement, and the inflammatory action at once extinguished, there exists but little hope of carrying the disease to a successful termination; the march of inflammation in children is so rapid, the termination in effusion, where the inflammation is seated in the arachnoid membrane, so certain, that our only hope is to arrest the inflammation by the only efficient means above mentioned. To be the most effectual it ought to be performed at the commencement of the inflammatory symptoms, and carried to a sufficient extent to produce a disposition to syncope at first. When it is necessary to repeat the operation, some care will then be required in regulating the quantity to be taken, for serious and even fatal convulsions may ensue from incautiously carrying the loss of blood to the extent of producing a continued tendency to fainting in young children. On the recurrence, therefore, of reaction, the vein may be again opened, and it will generally be found that, compared with the first bleeding, a small quantity will affect the momentum of the circulation. Dr. Mills* recommends the drawing of blood by leeches immediately after venesection, as decidedly more efhcacions than venesection alone; or the local abstraction of blood by leeches alone, which has been so strongly recommended in continental Europe, and almost generally adopted there. In the use of so important a measure as blood-letting, reference ought in all cases to be had to the constitutional vigor of the patient, and, whether performed by venesection or leeches, should never be persevered in until exhaustion is produced. There will be but little hazard of serious effects resulting from blood-letting, if it be performed promptly upon the first appearance of sanguineous turgescence, before the general circulation has largely participated in the disordered action, and before the heat from over-excitement has become predisposed to yield to a serious collapse from the loss of blood; nothing, therefore, can compensate for the loss of the first few hours where this remedy is withheld. The next means for the fulfilment of this indication is the use of purgative remedies, and which, from their powerful influence on the whole secretory apparatus of the alimentary organs, strongly tend, at the same time, to fulfil the second indication, and are almost indispensable measures whenever the circulation requires to be controlled. Whenever the usual evidences of inflammatory irritation in the mucous membrane of the bowels are absent, as is the case in the disease in its purely idiopathic form, an active cathartic may be given without hazard, ana to insure its good effect it ought to operate promptly. For this purpose, a solution of some neutral salt or infusion of senna, or calomel, combined with jalap * Trans, of the King and Queen's College of Physicians, in Ireland; vol. v., p. 457. 518 DISEASES OF CHILDREN. or rhubarb, will be found the most suitable purgative. Whatever be the precise article selected, or the particular mode of its administration, it will, if active in its operation, exercise a powerful effect in addition to bleeding, in arresting the development of inflammation in the meninges of the brain at the early period of the disease. In connexion with these means, which have a direct effect in* fulfilling the first two indications of cure, antimonials have also been used with much success by Laennec, in France, and Dr. Stoker, of Dublin. The former gave tartar emetic, and the latter, James's powder, to control the activity of the circulation, and thereby lessen the proportionate action in the brain. The application of cold directly to the scalp, is a very useful means of arresting the excessive action of the blood-vessels in the brain. It has been supposed by some, that the effect of this agent would rather be the reverse of controlling the activity of the bloodvessels within the cranium, by constricting the capillaries, and thus increasing the inflammation from the crowding of the larger vessels, and those not immediately under the influence of this therapeutic agent. But experience proves these objections to be without foundation, and that it is one of our most powerful measures for the treatment of the disease, as it lessens the action of all the blood-vessels in these parts, by its action on the carotids, from continuous sympathy. In addition to these measures, that of revulsion on the lower extremities ought by no means to be neglected. A stimulating pediluvium is one of the best; but the use of this and other revulsive remedies will be considered more at large when we come to the subject which is of more frequent occurrence in children, that of the ordinary form of hydrocephalus, arising from a deranged state of the digestive and chylopoetic viscera; the inflammation occurring in the meninges under these circumstances, and preceding the effusion of serum, requiring nearly the same treatment as an idiopathic inflammation of the part. It is of the greatest practical importance that the origin of ordinary cerebral affections in children should be constantly kept in view, that the disease in its incipient stage may be promptly met by appropriate measures ; for upon this very materially depends the success of the treatment. If inflammation has commenced, it is indeed difficult, and in too many instances impossible, to control its course, and to prevent its running into the stage of effusion. The strong tendency, therefore,* to cerebral disorders, when there exists a continued derangement of the digestive viscera, ought to be the subject of the physician's fears, that by timely remedies, of a nature which experience has proved to be of undoubted efficacy, the fatal prog- 519 NERVOUS SYSTEM. ress of the.disease may be prevented. In this disease, more than in any other, the anticipating method must take the place of that baneful mode of practice known as the expectant method. The early, or forming symptoms of the disease, are often entirely overlooked and neglected; and it is not until the languor, and general paleness of the whole surface, together with the evidences of gastric and intestinal derangement have, after a continuance of some time at least, ended in heat and turgescence of the head, that the disease is for the first time suspected, and much valuable time is lost by the delay. It is to attack the disease at this period, on which Dr. Yeats so much insists, and on which the safety of the patients often rests. He judiciously remarks, that if we proceed upon the principle that the disease is only in the head, we shall be constantly exposed to disappointment, and to unavailing regret fo/ the commission of errors. Regarding the disease, therefore, in its ordinary form, as consisting of three stages, the indications are, in the first stage, or period of abdominal irritation, to restore the healthy action to the chylopoetic viscera; in the second, to allay the violence of the inflammatory action, to control the febrile condition of the system, and to divert the current of fluids from the brain. In the third stage, that of effusion, our efforts may be almost regarded as hopeless ; yet as recovery has sometimes taken place under the most unpromising circumstances, we may still attempt the removal of fluid by establishing discharges from the capillaries by blisters, or by the vicarious evacuation of urine. We are indebted to the enlarged views of Dr. Cheyne for the first clearly suggested opinion that our treatment must, in the forming stage of hydrocephalus, be directed to the abdominal viscera, and especially the liver; the deranged secretions of which, manifested in the morbid appearances of the stools, give a certain indication that here is to be found the true origin of the disease. In' many cases there is a tenderness in the right hypochondrium; this, together with the dark, green, and unhealthy appearance of the bile, demands the use of mercurial cathartics for the purpose of eliciting a free discharge of the biliary secretion. The fostid condition of the breath, and the yellow, or dark appearance of the tongue, more particularly indicate the cases in which calomel may be freely used. If, however, there should be much soreness manifested on pressing on the region of the liver, leeches should be applied, or if there be much general excitement, blood should be taken from the arm. Calomel has been found, by all practical men, remarkably efficacious in the treatment of hydrocephalus, and it is, doubtless, from its influence over the secretory function of the liver, that its good effects are derived. It should, therefore, form 520 DISEASES OF CHILDREN. the basis of the cathartic plan, which for the most part? is indicated in the treatment of this disease, whether or not it be deemed necessary to associate blood-letting in the treatment of this stage. Golis directed a quarter of a grain to a child from one to four months ; from one to two grains to a child of six months to a year. Clarke gave one grain every six, four, or three hours, unless a diarrhoea should ensue. The administration, however, of repeated doses of medicine, especially of a cathartic nature, ought, if possible, lo be avoided in young children, as its tendency is to keep up an irritative action in the mucous surface of the intestines, which children can not well bear even for a short time. On this account it ought to be • given in a full dose, and followed in a few hours by a small quantity of castor oil, or neutral salts. As to the dose of calomel, it does not so much depend on the age in a disease of so great danger as acute hydrocephalus, as upon the urgency of the symptoms, and the effect on the intestinal canal. Five to ten grains to a child from four to eight years of age, and from two to four grains for one between one and four years, will produce a full purging effect. In the use of cathartics, the appearance of the tongue and nature of the breath ought carefully to be examined ; and if the former be found free from fur, clean, or red, and the latter destitute of odor, we ought to avoid the use of any medicine of a purgative nature, which would aggravate the irritation, or perhaps the inflammation of the gastric mucous membrane. When the tongue is red, and there is a tenderness about the epigastrium, cathartics must be avoided, and leeches applied over the affected part. In every instance where there exist much febrile excitement and tenderness of the hypochondrium, this excitement must first be allayed by the application of leeches to the part, or by venesection, before any advantage can be expected from the use of calomel. It occasionally occurs that the deficiency of constitutional vigor of the child forbids the use of blood-letting, and it may be necessary to substitute other measures to allay the increased action of the vascular system ; for this purpose James's powder, or antimony in some form, has been recommended by different practitioners. Dr. Cheyne used antimony in combination with calomel, in cases of infantile remittent, which is very liable to terminate in hydrocephalus. In cases which forbid the use of blood-lettiag, it would not be unattended with hazard to young children, especially in infants, to make use of antimony ; and in place of it, ipecacuanha may be substituted in combination with calomel: a small quantity of ipecacuanha given with a few grains of calomel, and repeated every three or four hours, until a free evacuation from the bowels ensues, would fulfil the most prominent indication at this period of the disease. This method ought, according to the judicious views of Dr. Cheyne, be 521 NERVOUS SYSTEM. G6 persevered in until an alteration is visible in the stools. Where these measures fail in producing an alteration in the secretions, Dr. Cheyne, Percival, and Brooks, all advise the use of opiates in some form, they appear to be more applicable where the abdominal disease is connected with irritation in the intestines, and known more especially by the presence of abdominal pain relieved by pressure. It is not safe to give children, and especially those quite young, repeated doses of any simple opiate. Dover's powder, therefore, especially when combined with calomel, will be found eminently beneficial, both in allaying the irritation, and determining the flow of fluids to the surface. The allaying of the morbid irritability of the nerves in children by opiates, is often of signal benefit when judiciously resorted to ; and decidedly the best form for its administration is the compound powder of ipecacuanha above mentioned. By the use, therefore, of cathartics and alteratives, with the occasional administration of a mild opiate, we may often allay the irregular excitement arising from abdominal derangement, which so frequently leads to inflammation in the brain, terminating in effusion ; and a seasonable interference of art may entirely arrest this formidable disease in its commencement, at a period when there appears but little if any danger. In the next stage the symptoms assume a formidable and wellknown appearance, and demand the abstraction of blood both generally and locally. Our distinguished countryman, Dr. Rush, was early led to regard the origin of the disease as an inflammatory affection, and relied principally on copious venesection for its cure ; he has recorded several cases of the success of this practice.* Blood-letting must therefore be our principal reliance, where turgescence, inflammation, and pain in the head, constitute the most marked symptoms of the disease. Drs. Mills, Eberle, and other practical writers, bear testimony to the great efficacy of bloodletting, to be repeated upon the appearance of any return of inflammatory action. The remarks already made on the extent to which bleeding is to be carried, are applicable to every form of inflammation of the brain, for the preternatural activity of the blood-vessels must be arrested, if we wish to prevent a fatal effusion *» and the principal difference in the treatment of idiopathic affectidhs of the brain, and those arising from a disordered state of the chylopoetic viscera, is in the order with which the remedies are used ; commencing in the latter with such as will directly affect the secretions of the viscera connected with digestion, and in the use of such as are known to exercise a more special influence upon the hepatic system. The abstraction of blood, also, from the right hypochondrium, will also be found at times a necessary preliminary measure * Med. Enq. and Observ., vol. ii., p. i>3. 522 DISEASES OP CHILDREN. in the treatment of the ordinary form of hydrocephalus. When, however, the disease has seated itself on the brain, and the symptoms of inflammation have made their appearance, there can be no difference in the treatment of the affection ; for in both, bleeding must be our main dependance. Cold, also, must be applied to the scalp, by means of cloths wetted with iced water 1 . When cold is employed, its effects should be carefully watched, for it may otherwise be carried to a dangerous excess. On the subject of revulsive remedies, there exists but one opinion as to their efficacy; but a difference on the subject of those of an epispastic nature. They should never be used until after the activity of the circulation has been subdued by proper evacuations, and even then the extreme irritation they produce in children makes them a dangerous means. Stimulating baths to the lower extremities may be used with decided benefit in connexion with other measures. It is upon a steady perseverance in ihese remedies, and a judicious application of them to the existing symptoms, that the disease is to be overcome ; for if the next stage, the treatment of which we are now to consider, succeeds, but little hope can exist for the patient. In the last stage the indication is to remove, if possible, the serous effusion. This may be attempted if there still appears to be much vascular excitement, by the continuance of local depletion, and by the use of mercurial cathartics, where there are symptoms of derangement in the abdominal viscera. The next method of effecting this is by the application of blisters, which, however, should never be used where much vascular action is present. When they are used they ought to be applied behind the ears or upon the back of the neck, and a free discharge maintained by means of stimulating applications. Great benefit has also been derived from dressing the blistered surfaces with strong mercurial ointment. Hydragogue cathartics have also been resorted to with success under the most unpromising circumstances; a recovery has taken place when the symptoms of effusion had appeared, after giving half a drop of croton oil, given every two hours. In another instance, a» spontaneous discharge of urine occurred in a child aged about six%nonths, where all hopes of recovery had been abandoned ; immediate relief of all the symptoms of cerebral oppression took place, and the child ultimately recovered. A perseverance, therefore, in the employment of those remedies which will excite a copious flow of the urinary or intestinal secretions, would appear to be the duty of the physician, even when the case appears to be hopeless. The sudden effusion, to which Dr. Golis has given the significant name of water-stroke, I believe is always fatal; whether it is 523 NERVOUS SYSTEM. preceded by the slight evidences of cerebral excitement, manifested simply by exhilaration of spirits, which is its only premonition, or whether it arises as a complication of some cutaneous eruption, as measles, scarlet fever, etc. In both, the most close observations are unable to detect the inflammatory affection of the brain, on the treatment of which success almost altogether depends. The course to be adopted should be that used for the removal of the effused fluids mentioned above. CHRONIC HYDROCEPHALUS. Etiology.—This form of the disease appears to be connected with some irregularity in the progress of the formation of the brain ; for it is frequently of congenital origin, or shows itself for the first time at a very early period of infant life. It is difficult, such is the insidious manner of its approach, to tell when the disease commences, unconnected as it is with the usual causes of hydrocephalic affections, or with any evident inflammation in the meninges. M. Billard* is of opinion that those cases which are congenital, in all probability arise from an inflammation of the meninges during intra-uterine life, or of some malformation difficult to ascertain, resembling in some respects the nutritive hypertroplry of the brain. The latter idea receives some support from the development of the brain and cranium in the foetus affected with hydrocephalus. The bones acquire a breadth and thickness, evidently showing an increase of nutrition; and it has also been observed that those infants in whom the brain and cranium are very much developed, are very much exposed to hydrocephalus. The vital activity therefore, or the power of nutrition, ought to be regarded as one of the causes of the form of disease now under consideration. The activity in the nutritive process must almost of necessity increase the secretion from the membranes of the encephalon, and fill the ventricles, and even the surface of the organ beneath the cranium with serous fluids. f * Semeiology.—Chronic hydrocephalus is very insidious in its approach, and passes through its different stages in a very slow and gradual manner. When it appears to have made its invasion after the birth of the child, it shows itself by fits of languor and drowsiness, with but little, and often no febrile excitement whatever. Although usually attacking young children, it may occasionally affect those of more advanced age in a very insidious degree, and terminate in the enlargement of the head, which is known as the form called chronic. In the majority of those instances, however, which make their invasion after the period of infancy, there exist more or less • Op. Cit., p. 467. 524 DISEASES OF CHILDREN. symptoms of the inflammatory stage, such as hot skin and headache ; and it can not, although gradual in its approach, and perhaps protracted and permanent in its effects, be regarded as the chronic form of the disease. As the effusion increases, the head enlarges sometimes to an enormous size, while the sutures separate, and the scalp covering the fontanelles is projecting and fluctuating with fluid when pressure is made on the head. At an indefinite period from the first appearances of effusion, symptoms of oppression on the brain make their appearance. These nrst show themselves in the eyes ; strabismus, and dilatation of the pupils successively occur ; the intellectual faculties become much impaired, and in proportion as the disease advances are entirely blunted. The locomotive power is gradually lost, the limbs at length become paralytic, or convulsed. The loss of nervous energy is evident in other parts of the system, for the bladder refuses to perform its functions unassisted, and the catheter is sometimes required to draw off the retained urine. All these symptoms may extend to a number of years, and the patient live to an advanced age in a state of idiotism. There are, however, cases on record where the intellectual faculties have remained but little impaired, notwithstanding an excessive accumulation of fluid and a corresponding enlargement of the head. A case of this kind is mentioned by Dr. Monro ;* it was that of a child who was brought to St. George's Hospital, at the age of eighteen months, with a head very much enlarged. The size of the head steadily increased, until at the age of eight years it measured two feet four inches in circumference, and the forehead alone was half the entire length of the face. The head was exceedingly heavy, so that the child could scarcely preserve her balance in walking. Her memory was strong and retentive, and she was as lively as children usually are at her age. Michaslisjt also, mentions the case of a patient of the age of twenty-nine years, whose intellectual faculties were not in the least impaired, and whoJiad been affected with the disease from his birth. Very often all the symptoms of chronic effusion appear at the time of birth, and the head has at times been so greatly enlarged as materially to interfere with parturition, and as much as four pounds of fluid have been evacuated from the head of a foetus after birth. Children born with this accumulation of water within the cranium, will usually live but a few months: the head acquires a large size, the sutures are widely separated, and with other symptoms of oppression of the brain the child becomes paralytic, or dies convulsed. There are several cases on record in which an erormous quantity of water has-been found after death, or which nas • Med. Trans., vol. ii., p. 359. t Medical Communications, vol. i., art. xxv. NERVOUS SYSTEM. 525 been evacuated by the operation of tapping. Dr. Ireland, in the fourth volume of the Medical Repository, gives an account of a boy aged five years, from whose brain fifty-six ounces of water were removed after death, in the same volume there is also detailed by Dr. Baxter, the case of a child in Philadelphia, who died at the age of eighteen months, whose head measured in circumference twenty-seven inches and a half, and in whose brain was found serum to the amount of nine pints, or one hundred ounces. Another case is given in the same journal, in which an attempt was made to cure the disease by removing the water, and during the space of three months, nine pints and three quarters were removed at differ ent times, from a child seven months old. Pathology.—Chronic hydrocephalus consists in a great abun dance of serum infused in the ventricles of the brain and arachnoid cavity. It is this which has made the distinction between hydrocephalus internus and hydrocephalus externus, although the latter has indeed been applied to the accumulation of water between the integuments and the bone; but this is clearly nothing more than dropsy of the cellular membrane, and not hydrocephalus ; but in some cases the fluid has accumulated within the cranium, and through some channel has passed into the cellular membrane, and distended the integuments. The quantity of fluid is sometimes very great; fifteen and even twenty-five pints of serum have been evacuated after death, where the disease has gone on steadily increasing.* In some instances there has been found an external tumor, where the bones of the cranium have been widely separated in hydrocephalus, through which the brain has protruded, forming a real hernia cerebri. This is clearly the result of the compression which the brain undergoes from the effusion of the serous fluid. The hernia may be satisfactorily ascertained by noting the situation of the tumor, as it always occupies a part corresponding to one of the fontanelles.t A remarkable case of this nature is recorded in the fourth volume of the American Journal of the Medical Sciences, by Dr. Horner, where the fluid had forced out the posterior lobes of the cerebrum through the posterior fontanelle. As was before remarked, chronic hydrocephalus, which appears very early in life, is connected with some degree of malformation of the brain ; and dissection reveals in such cases the existence of some imperfection, or defect in the organization, which is a remote cause of the disease. The brain, also, has been found in a spongy and fungous state,f and sometimes disorganized so completely, as * Bonnet, Sepulcho., Lib. i., sec. xvi. t Billard, Op. Cit., p. 471. j Conrad, Diss, de Hydroceph., Argent. 1778. 526 DISEASES OF CHILDREN. to present the appearance which has been of late described under the name of ramollissement, affecting at times both parts of the brain. The brain has been found partially absorbed, the part which it occupied being nothing more than a sort of pouch; from the absorption of a portion of the brain, the effused fluid finds its way from the ventricles to the dura mater, in contact with the upper part of the cranium.* In general, the whole head increases in size. In some cases, however, there has been found an elastic tumor formed by the yielding of the dura mater, which gradually increases in size, until it becomes equal to the head. The bones of the cranium have in many cases become very thin,, and being deprived of the calcareous part, have appeared to consist of scarcely anything more than cartilage. There can exist no doubt that effusion of fluids may occur from a relaxed condition of the secernents, as well as from the excited action of those vessels ; but in the disease before us it appears to be evidently connected with the active state of the secernent vessels, dependant on the growth of the brain, and perhaps connected with a torpor of the absorbents. The frequent connexion of the disease under consideration with a malformed state of the brain—a state of nutritive hypertrophy—sufficiently proves these views. When this form of disease, however, comes under our notice, it can scarcely be regarded as one of activity; we see it only in its consequences, and may compare it to the third stage of acute hydrocephalus ; but from its identity with the development of the brain, the accommodating powers of nature have enabled the parts to yield to this diseased state of things, and afford one of those numerous instances of the resistance of the system to dissolution at the early period of life. Treatment.—The treatment must be directed to the removal of the effused fluid, either by endeavoring to promote absorption, or by evacuating it. Diuretics have been used, and Dr. Withering recommends particularly digitalis, a medicine which can not be employed with safety in young children, from its depressing power on the circulation. Active purging can not be advantageously used in this disease, and at the early period of life at which it usually makes its appearance. Calomel, as a tonic and alterative has been used, it is said, with advantage; but of this I can not speak from any experience. Blisters and issues have in some instances been followed by good effects—rarely, however, when the disease is deep-seated and extensive. A permanent drain established on the vertex is recommended by Dr. Mills. The first who operated on the head for the purpose of curing * Baillie, Morb, Anat. Fasic. x., p. 213. NERVOUS SYSTEM. 527 chronic hydrocephalus, by drawing off the water, was Dr. Vose, formerly of New York. This was in the year 1806. The cure has been effected by Dr. Conquest by tapping the head ; in some instances, under the most unpromising and deplorable circumstances, where there was a total loss of sight, convulsions, etc. Of nineteen cases operated on by him, ten were cured: the quantity of fluid discharged varied from six to forty-eight ounces. Dr. Charles A. Lee has given the results of this operation, where the child was so far restored as to perform the ordinary movements of the head, and suck freely on the twelfth day. For eight days was it doing well, when symptoms of accumulation appeared, and the op eration was again performed. The child died on the twentieth day after the second operation, of cholera infantum.* There is a case recorded by Dr. Hbfling,t of a boy, aged five years, cured of chronic hydrocephalus by accidental paracentesis. He received a kick from a cow which fractured the frontal bone, already extremely thin; a quantity of serum flowed from the wound for eight days. Two years after this accident the boy enjoyed good health, and the head bore but a proper proportion to the size of the body. From the belief that chronic hydrocephalus might at times result from a want of due resistance in the bony parietes of the head, compression has been resorted to by means of bandages and adhesive straps; the former method was used by Sir Gilbert Blane, and the latter by Mr. Barnard. Recently this method of treating the disease has been successfully practised by Dr. Engleman, a German physician. In all the cases in which it was.used, ten in number, the method was followed by the absorption of the fluid and recovery of the patient. His method consists of the application of bandages and adhesive straps, which are to be renewed as the head diminishes in volume. The cases are detailed in the Archives de Medicine, for June, 1838. HYDRENCEPHALOID DISEASE. There is a remarkable affection of the brain which demands an especial attention, on the part of the practitioner, from its close resemblance to hydrocephalus arising from an over-excited action of the vessels of the brain, but which has its origin in an entire different condition of that organ. We have seen that certain symptoms such as stupor, coma, and similar affections of the cerebral organ, are traceable to an increase of blood in the part affected, and a subsequent effusion of fluid as a direct consequence *N. Y. Med. and Phys. Journal, vol. vi., p. 490. t Wochenscrift fur die gesammt Heilkunde, No. 41. 528 DISEASES OF CHILDREN. of such over-excitement. We have now to consider much the same manifestation of disease, but arising from an opposite condition. In the former there were pain, throbbing, heat, wakefulness in the commencement, and sleep and stupor at the termination of the malady; in that now under consideration there are much the same excitement and exhaustion ; but a deficiency of blood throughout the system, and a state of general exhaustion and languor, with paleness of the surface, show a condition materially differing from the former. This peculiar form of cerebral disease was first noticed by Abercrombie, and afterward by Gooch and Hall. Etiology.—Spurious hydrocephalus appears to be connected with a deficiency of blood in the general system, and although excitement may cause an increase of circulation in the organ which is the seat of the disease in question, yet from the impoverished quality of the blood, it fails to stimulate it to inflammatory action. It is, therefore, mostly found to prevail among those who are delicate and small, or those who have been reduced by excessive evacuations from the bowels, produced by improper feeding, weaning, dentition, etc. The injudicious use of purgatives, or excessive and unnecessary bleeding, will not unfrequently be followed by symptoms closely resembling active meningitis, a state really arising ¦from a condition of a totally opposite nature. Convulsions, blindness, and coma, will quickly follow the loss of blood, which has at first produced a quickened pulse, with throbbing of the temples and exalted sensibility. This train of symptoms has been seen in animals that have been bled to death. Exhaustion from want of food has also been succeeded by similar symptoms. Pathology.—This is easily understood from the account just given of the causes of this affection. Autopsical examinations show occasionally serous effusion in the cerebral cavities, sometimes accompanied by venous congestion: the latter may exist without any effusion. Semeiology.—Children thus affected have a frequent pulse, heated skin, an excessive sensitiveness and irritability, crying and exhibiting great fretfulness on the most trifling occasions : a slight touch on the skin will produce a starting if asleep and a fretful impatience when awake. There is much sighing with moaning when asleep. These symptoms are not uniformly present, —they are but the premonitions, the manifestations of a state of system which is unfavorable to evacuations of any kind. When the hydrencephaloid condition is actually present, the child lies quietly as if partially asleep, occasionally opening and closing the eyes. No interest is manifested by the patient in any surrounding objects, not even for a light, even if it be brought near to the nuoils. There is a 529 NERVOUS SYSTEM. paleness of the entire surface, and a coldness of the cheeks. The respiration becomes slow and feeble, with the sound of mucus in the trachea, and at times a dry husky cough. These symptoms in crease until there is a perfect coma. Treatment. —When these symptoms arise from hemorrhage, stimulants ought to be promptly given, such as wine whey, arrowroot and wine or brandy, and five or ten drops of aqua ammonia? in an ounce or two of water, of which the child may take as much as it can conveniently swallow. If an infant, it ought to be fed with the breast milk with a spoon, if unable to suck. Common chalk mixture, with the addition of a few drops of the camphorated tincture of opium, may be given, if diarrhoea be present, and has produced these symptoms of exhaustion. Warm flannels, and frictions gently applied, should also be used, and the patient exposed to an elevated temperature, while the skin continues cool. A recumbent posture must be continued ; a disregard to this might be suddenly fatal. A blister to the neck, and similar external irritants to the other parts of the body will be found highly useful in restoring action to the system. A good diet during convalescence is of the greatest importance in this affection DISEASES AFFECTING THE APPENDAGES OF THE NERVOUS SYSTEM. The ordinary affections of the organs of intellectual sensation, comprising those of sight and hearing, will necessarily form part of the diseases of the present system ; those connected with the corporeal or nutritive senses having already been considered. Such diseases of these organs only as are peculiar to children, will be the subjects of the present remarks : for those that are common to all ages, the reader is referred to works ex prqfesso on these subjects. OPHTHALMIA. Etiology.—This would appear at times a real congenital affection, for infants are seen born with the marks of inflammation that had evidently existed in the foetal state. For the most part, it appears within a week after birth, and arises either from the contact of the part with a vitiated secretion from the vagina of the mother, or from the stimulating influence of cold or too great heat, or from the effects of light or smoke. It is a very common occurrence to find it following leucorrhoea ; indeed, when a woman has been thus disordered during gestation, the child will almost certainly be affected with some degree of oph- 67 530 DISEASES OF CHILDREN. thalmia. So, also, gonorrhoea will be invariably followed by this affection in the infant. At other times it appears to arise from the stimulating effects of light, smoke, or other external causes, acting directly on the eyes. When it is produced by these agents, it is later in its invasion than when it occurs from causes connected with parturition ; scarcely, however, appearing after the fifth day. Neglect of cleanliness in not carefully washing the child, may become a cause of this affection, especially when any redness appears in them from an atmosphere filled with smoke. Badly-ventilated apartments, it is well known, will cause a development of ophthalmia, and is one of the chief causes of its prevalence in foundling hospitals. Semeiology.—The disease sometimes appears immediately on the birth of the child, but in most instances does not show itself until the second or third day after birth, rarely after the fifth. It appears in two stages, the first of inflammation, the second of suppuration. The first appearance it exhibits is a slight inflammation, attended with a considerable degree of tumefaction, with a slight oozing from the eyelids, which causes them to adhere on its becoming slightly hardened. At this period, when the palpebrae are opened, a drop of white fluid escapes, and the inner surface is of a deep red. This is attended with a great aversion to light, the child keeping the eyelids closely shut in a lighted apartment, but opening them on the light being removed. When the inflammation is severe, it is evidently attended with pain, as indicated by the crying; and the intolerance of light is so great, that it is difficult to obtain a sight of the eyeball. After a short but indeterminate period the purulent stage commences, which is known by the increased swelling of the eyelids, and a discharge of pus taking place from between them. When they are separated a great discharge ensues, and if the conjunctiva can be seen, it appears to be excessively inflamed. A great sensibility still continues in the affected part, and the patient keeps the head continually turned from the light. The drying of the pus causes the eyelids to adhere, when the accumulation beneath them is often very great, and the tumefaction is excessive. At other times small granulations are formed on the conjunctiva, and the swelling of the folds of this membrane forces the tarsi outward, and produces a complete inversion of the eyelids. The purulent discharge is thick, and usually of a yellow color, sometimes mixed with blood. This discharge may be of a greenish hue in children of an unhealthy constitution. After continuing about a week, the symptoms in favorably cases, and in such as have been met by suitable treatment, gradually subside. If the inflammation should continue longer, a 531 NERVOUS SYSTEM. purulent infiltration of the cornea takes place, and ulceration of this part occurs, usually in a circumscribed spot, but, in very severe cases, throughout its whole extent. When the eye is examined after a spot of ulceration has proceeded until it has penetrated the cornea, the iris will be seen protruding. In still more severe cases, where the cornea is ulcerated to a considerable extent, the whole of the humors of the eye will be found to have escaped. Opacity of the cornea is, however, the most common result, existing either in a small, circumscribed spot, or covering the whole extent. This condition may be in every degree, from a slight hazy appearance to a perfect thickening, entirely destroying its transparency. Sometimes adhesions of the iris to the cornea take place ; at other times there is an opaque spot, of the size of a pinhead, in the outer hemisphere of the capsule of the lens. In general, although the symptoms may be very severe, and the distention from the quantity of pus very great, the termination of infantile ophthalmia is favorable ; but cases of extensive sloughing or opacity of the cornea have occurred, where the affection has been much neglected, as is sometimes the case among the poor. Treatment. —The first stage of ophthalmia should be treated on strictly antiphlogistic principles ; by which, however, it is not meant that in every instance the abstraction of blood is needed ; this being only necessary in severe cases of inflammation. It will be often sufficient to keep the eyes well washed with tepid milk and water, or the mucilage of linseed or slippery elm; the latter, especially, has a remarkably soothing effect on the inflammation of these tender parts. This course, when adopted immediately on the appearance of inflammation, with an open state of the bowels, and great care being taken to keep the child from the light and smoke, will in many instances readily remove the disease. When, however, there is a redness of the eye itself, or if this can not be seen, but the lids are swollen and red, blood must be taken from the part by means of a leech, or the conjunctiva may be scarified. If the former method be adopted, one leech will suffice, for, from the great vascular turgescence of the part, the blood will flow with great readiness. The subjoined formula may then be advantageously used, as an application to the inflamed eyes ; but all astringents and stimulants should in this stage be avoided.* An aqueous solution of opium may be employed with very good effects where there exist much pain and intolerance of light. A solution of some of the salts of morphine, in the mucilages already mentioned, I have also used un- * R Plumbi. Acetat., gr. iv. (173) Aquae Destill., Mucilag. G. Acaciae, M. 532 DISEASES OF CHILDREN. der these circumstances with benefit. At the same time more active effects should be produced on the bowels than above mentioned, by means of a small dose of calomel, to which may be added a quarter of a grain of ipecacuanha, if much febrile excitement be present. This course, followed by a small portion of castor oil from time to time, will keep the bowels free. A small blister ought also to be applied to the temples, or behind the ears. In the second, or purulent stage, astringent or stimulating collyria will be needed; great care, should, however, be observed, in not resorting to remedies of this nature at too early a period of the disease : the proper time for their use will be known by the disappearance of the excessive redness. A solution of the sulphate of zinc, in the proportion of a grain to an ounce of water, or two grains of alum to an ounce, may be used, and will in general effect a cure. A solution of the bi-chloride of mercury, one grain to an ounce of water, forms a good collyrium, where a stimulant is needed; or a solution of alum, from four to ten grains in an ounce of solution. In obstinate cases, the nitrate of silver will be found useful, in the proportion of two grains to the ounce, gradually increased to six grains. Any of these solutions may be injected between the eyelids three or four times in the course of twenty-four hours. Where there is great prostration with a destruction and sloughing of the eye, tonics are indicated, and among these, quinine is one of the best. OTITIS. Inflammation of the ear occurs frequently in children, from the great sensibility of the part, and for the same reason is a very painful affection. It is either acute or chronic. Etiology.—The predisposing causes are plethora, a scrofulous habit, excitement of dentition, etc. The most common exciting cause of the acute form is cold, and especially the washing of the head and neck with cold water, and the exposure of these parts to a stream of cold air. Children not unfrequently have an attack of ear-ache after having the hair cut, and being exposed to the causes already mentioned, especially while in a state of perspiration. Any foreign body introduced into the ear-passages will also produce an inflammation of these parts. It is also produced by other diseases, as inflammations about the throat; and consequently it often follows an attack of scarlet fever, malignant sore throat, and ordinary tonsillar inflammation. A chronic inflammation is most frequently the result of these last-mentioned causes, and known by the name of otorrhcea, from the discharge which takes place from these parts. Semeiology.—It is known by the pain in the ear, which is very 533 NERVOUS SYSTEM. severe and distressing, both from the great sensibility of the part, as from the tense and unyielding nature of the membrane forming the tympanum. This for the most partis confined to the ear itself, but not always ; as the side of the head, and even the brain, have become involved in the inflammation. When this occurs there is a great increase of the circulation, with heat, fever, thirst, delirium, and stupor. The inflammation will sometimes terminate in suppuration, and the discharge gradually changes its character to thin, offensive sanies, from the deep-seated ulcers formed in the ear. The chronic form of otitis, when there is a continual discharge from the part is frequently a termination of the acute disease. It is a very common affection after scarlet fever, and is characterized by a discharge, which varies in quantity and color, but is for the most part uniformly of an offensive odor. When it is continued for a long time, the inflammation and disorganization extend through the tympanum, and the small bones of the ear are discharged. Deafness, for the most part, is a prominent symptom throughout this affection, increasing in proportion to the extent of the disease. Treatment.—For the ordinary form of otitis or otalgia, by which name it has been called from the violence of the pain, such remedies only are required as will remove the local irritation, and restore a secretion to the inflamed surface, such as the application of warmth and moisture to the part, by means of a poultice of hops; the latter, especially, will have a very soothing effect, and if accompanied by purgatives and warm pediluviurn, will often arrest it at once. An ordinary poultice, with laudanum, will also be a useful remedy ; and when the pain is very severe, a few drops of laudanum and sweet oil on a small piece of cotton will afford great relief. A small lump of camphor enclosed in a piece of cotton will often relieve a severe attack of ear-ache. The wax in the ear at times becomes hardened, and should be softened and removed. This may be done by means of warm water injected into the external passage by means of a syringe with a large orifice whereby the part may be thoroughly washed. If these measures are not followed by an abatement of the symptoms, either local or general bleeding will be necessary ; this should be followed by a continuance of the soothing local applications above mentioned. The necessity of a strictly antiphlogistic course may be known by the increase of heat, pain, and some degree of tumefaction, which may be discovered on. inspection. Leeching, general bleeding, with purgatives and antimonials, will in some cases be demanded, according to the extent and violence of the inflammation. If suppuration occur, and the inflammatory symptoms have subsided, stimulating and astringent injections will be indicated, as the sulphate of zinc, in the proportion of two or three grains to an 534 DISEASES OF CHILDREN. ounce of water. The chloride of soda, also, will be highly useful, especially when the discharge from the ear is offensive. In the chronic discharge from the ear, a general tonic course is required, while the part is kept well cleansed by injections of soap and water, and gently stimulated with the injections above mentioned. A permanent issue, also, will greatly assist in disposing the part to heal; it should be placed on the back of the neck or on the arm. The cure of chronic otitis is a subject of acknowledged difficulty, and is in proportion to the extent of the injury and the length of time it has continued. It is of great importance to ascertain the state of the general health of the patient, and to adopt a course of treatment for the restoration of this. If a scrofulous habit prevail, a full course of iodine will be needed, combined with mercury or iron, according to the indication in each particular case. At other times a tonic course, simply, will be all that is required. The applications at first should consist of tepid water injected by means of an ear syringe ; this course ought to be persevered in for a a long time. After which injections of a weak solution of the sulphate of zinc, acetate of lead, or nitrate of silver, may be used, which may be gradually increased in strength according to the requirements of the disease; bearing in mind that the discharge must by no means be suddenly arrested especially in young children. Should this occur it might be followed by a severe cerebral affection. On any sudden disappearance of the usual discharge, warm fomentations or a soft poultice ought to be applied without delay and continued until the evacuation is restored, while the astringent injections are withheld. When the discharge has become much lessened in a gradual manner, it would be well still to guard against any serious effects of its entire stoppage, by applying a blister behind the ear, and to keep up a permanent drain from the blistered surface. MOTOR SYSTEM. PECULIARITIES OF THE MOTOR SYSTEM. The bones connected with the limbs are, like the rest of tne skeleton, in a very imperfect state of ossification at the period of birth; the chemical constitution also differs at this period, and dur ing childhood, from the bones of an adult. The different processes of the scapula are not perfectly united to the body of the bone until about the fourteenth year. The clavicle is one of the first bones formed, and during the foetal state is com 535 MOTOR SYSTEM. paratively of a large size, and is of a full proportionate size in infancy. The humerus at birth is only one nucleus of bone in the small head. The condyles are formed some time after birth, and are perfectly united with the body of the bone a considerable period before the full growth of the child. The same may be remarked with respect to the bones forming the fore-arm, the shafts being comparatively perfect, and the different processes not completely united to the body, until about the age of ten or twelve years. The bones forming the pelvis are much less developed in an infant, than the scapula and clavicle forming the bones of the upper extremities. All the bones composing the pelvis are separate ; and the three portions forming the ilium of a new-born child are not united until the seventh year. The femur observes the same laws in its development as the humerus, but the union of the processes is much later than that of the firstrmentioned bone. The tibia and fibula are also rather later in the full disappearance of their cartilaginous portions. From the difference, therefore, in the development of the upper and lower extremities, we see the cause of the greater ability of the child to use its arms and hands almost from the period of birth. The imperfect formation of the bones of the pelvis and lower limbs prevents the child from using them at all; and the narrowness of the pelvis deprives it of the ability to sit, even if there existed muscular power sufficient to support the body in an erect position. During these alterations in the bones, the muscles undergo changes in their appearance, as they increase in cohesion and solidity. They are at birth much lighter colored and softer than at other periods of childhood. Gelatin abounds in infancy ; as age advances the proportion of fibrine increases. When the growth of the body is complete, their red color is then strongly marked, and their power increases. As the bones and muscles change with the growth of the body, the child exerts his powers of movement, and all his muscles are in a continued state of activity. This restlessness is a peculiarity of childhood, and appears to be connected with the process of development, as the muscular efforts are rather those of simple action than of power. Muscular exercise is essential to the proper growth of the body, and therefore the infant and child should be allowed to use such exercise as nature demands. Simple carrying is all that a young infant needs, and will often allay the accumulated excitability arising from the want of exercise. Premature attempts at making the child sit or stand are always injurious, by causing an undue pressure on the viscera of the abdomen and thorax. Active exercise in older chil 536 DISEASES OF CHILDREN. dren should be freely allowed, as nothing tends more to the full action of the nutritive process, and the proper development of the body. SIGNS OF DISEASE FROM THE MOTOR SYSTEM. The excessive increase in the length of the bones is a frequent occurrence after exanthematous fevers; and rachitis is not an unusual consequence of this derangement of nutrition. In protracted disease it is a sign of debility, and yields an unfavorable prognosis. When the bones are suddenly developed in youth, without any apparent disease, it has been supposed to indicate a premature development of the sexual instinct. The bones of the foot are often changed in their form from the powerful action of one set of muscles, producing club-foot; so, also, curvatures of the spine may occur from a preponderance of action in some of the muscles. • Enlargement of the ends of the bones is an evidence of the existence of scrofula and rickets; it is very common also after severe cases of scarlet fever or measles. The muscles usually diminish in size after the continuance of any febrile disease; but this of itself is not to be regarded as unfavorable. If this wasting continue after the disappearance of fever, or when it attends chronic disease, it is decidedly unfavorable, as it indicates the existence of disorganization. The wasting of the spinal muscles marks the existence of tabes dorsalis. The sudden increase of muscular activity in a young child, especially if accompanied with great exhilaration of spirits, denotes an increased circulation of the brain, and often precedes sudden attacks of hydrocephalus. Lassitude and weariness are very common in children before acute diseases, especially those of a contagious nature: muscular debility being always produced by the influence of contagion, and is a good diagnosis of the disease during the prevalence of epidemics. A prognosis may also be made from the extent of debility during the continuance of acute diseases, as it always marks the extent of the disease, and denotes the affection of some important organ. The sudden loss of muscular power gives a very unfavorable prognosis; and the total want of ability in a child to stand, denotes a serious affection of the brain, and is usually the precursor of the sudden effusion denominated water-stroke. The alternation from great debility to increase of strength in chronic diseases is also an indication of cerebral disease, and is a much more unfavorable sign than the continuance of debility. > Great restlessness, and involuntary movements of the muscles in 537 MOTOR SYSTEM. long-continued disease, are unfavorable signs, and usually denote cerebral disease. Convulsions and spasms usually proceed from irritation, inflammation, or other affections of the brain and spinal cord. In other instances they appear to depend solely on the irritation of the ganglionic nerves, from worms or other irritation in the stomach and bowels; when this is the case, there is but little or no cerebral disturbance, and the child, if old enough, will perhaps recollect and describe the occurrences which took place during the paroxysm, although unable at that period to articulate. Spasms affect either the whole body or a certain set of muscles; and in chorea, the spasmodic action occurs in different muscles in succession. When spasms affect the muscles of the face alone, it is a more unfavorable sign than when any other set of muscles are affected. Spasms in children are much less dangerous than in adults; but when they occur in chronic diseases, they give in all a bad prognosis. When proceeding from gastric irritation, worms, or dentition, they are not in general to be regarded as dangerous. Other affections of the muscles are considered under the signs of disease, from the influence of the nervous system. DISEASES OF THE MOTOR SYSTEM. ABSCESS OF THE HIP JOINT. Abscess of the hip joint, or morbus coxarius, is a disease very insidious in its approach, and often makes rapid progress toward the destruction of the bones forming the joint, and consequently producing irremediable lameness before it is discovered. A close watchfulness, therefore, becomes necessary, that the disease may be detected, and the remedies applied in its incipient stage. Etiology.—A scrofulous habit of body appears, in some instances, to predispose the joint of the hip to inflame, suppurate,, and become carious, for it is difficult to trace the disease to any other source than the spontaneous occurrence of inflammation, which is apt to arise in such conditions of system. It has been supposed at other times to arise from the injuries children receive in their sports. Semeiology.—The first sign of the existence of the hip disease, is the inability to move both limbs equally: one of them appears to drag while the other is properly moved. A child, also, that has this affection, in its forming stage, will be often seen to fall, as if tripped by the carpet. This arises from the toes of the af- 68 538 DISEASES OF CHILDREN. fected limb being a little inclined downward when.the foot is raised; no complaint being made, the existence of disease is not even suspected from this circumstance, but the child is supposed to have met with an ordinary fall, to which it is so liable in its sports. The affected limb, when compared with the other, is discovered to be a little shorter; and when the presence of disease is evident, its nature is still mistaken, for the child refers his uneasiness to the knee and lower part of the thigh. As it advances, the rotundity of the affected hip disappears, and a more marked shortness of the limb is noticed, while the child evidently limps in walking. By a careful examination, the seat of the disease will easily be discovered, principally by flexing the limb with the hand; the knee, where most pain is felt, bejng easily moved. After the affection has continued for some time, suppuration will take place, and the bones of the joint will be involved in the disorganization, and become carious. An abscess forms and discharges an unhealthy pus; great prostration ensues, and the patient dies in great exhaustion. Treatment.—The treatment in the first stage must consist of A the usual means of allaying inflammation, while the limb is kept at perfect rest. When there is much heat of the surface and activity of the pulse, the child should be bled from the arm, and the bowels freely opened by active purgatives. These should be repeated if there is a continuance of the pain and fever. The hip, also, ought to be leeched or cupped, if the pain and other evidences of inflammation continue unabated; local sanguineous depletion should always be used when bleeding from the arm is counter-indicated by the debility of the child. A constant open state of the bowels must be preserved by means of daily purgatives, suited to the age and strength of the patient; the pulvis purgans and calomel may form the first purgative mixture, followed by an infusion of senna every day or two in a robust child, until a sensible reduction of the pulse takes place. The child should be kept, if it be possible, constantly lying on a hard mattress, and no opportunity whatever of exercising the limb afforded until an entire cure is effected. Where this can not be accomplished in a young child, the use of a splint adapted to the part may prevent the movements of the limb. With this course, adopted in the stage of inflammation, a cure will in most cases certainly follow; but where the disease is left until suppuration, or disorganization has occurred, very little can be done to prevent a permanent lameness. In this stage it is often very much protracted, and attended with great suffering, prostration, and emaciation. In the early part of the suppurating stage, if the child retain sufficient strength, a permanent issue should be made near the affected joint, and the usual hygeinic measures of a MOTOR SYSTEM. 539 change of air, or a residence near the sea in hot weather, cold bathing, and a nourishing course of diet adopted, to impart energy and vigor to the constitution, so necessary to enable the child to resist the effects of continued irritation, and the exhaustion from the excessive drain. CLUB-FOOT. Distortions of the feet, from the time of Hippocrates until the close of the last century, attracted but little attention from surgeons; and the only method of cure attempted was the application of bandages and other mechanical contrivances, for the gradual adjustment of the distorted and displaced bones. At this period, important improvements were suggested by Lorenz, a surgeon in Frankfort, at the suggestion of Thilenius, a physician of that city. In the year 1838, Dr. Louis Strorneyer, of Hanover, published an essay on the subject of orthopcedia, with practical observations on the division of contracted muscles and tendons. The next work of note appeared in London, in the year 1839, by Dr. W. fj. Little, in which the nature and treatment of club-foot are considered at length. This important subject has received the attention of surgeons in the United States, and additional suggestions have been made by Dr. Thomas D. Mutter, of Philadelphia, and Dr. W. Detmold, of New York.* A few practical suggestions occur in the various medical periodicals, but the above comprise the monographs that have been published on the subject. Etiology and Semeiology.—Congenital club-foot was formerly attributed to a malformation of the astragulus and other tarsal bones, and on this account the replacement was considered a very difficult operation, if, indeed, it could be performed at all. Subsequent observations, however, have shown that it is in most instances referable to the contractions of the muscles, arising from a primary affection of the nervous centre, causing convulsions which the foetus suffers. These distortions have been found in foe- tuses of from three to five months old, where there were deficiencies and malformations in the cerebrum and medulla spinalis; and anencephalus and hemicephalus embryos have exhibited both hands and feet distorted in that manner. The affection has been known to be hereditary, arising from the transmission of the irritability of the nervous system, producing convulsions and spasmodic contraction of the muscles. It may also arise after birth from a similar cause, producing paralysis of the muscles; when, on a partial recovery, the flexor muscles act more powerfully than the extensors, and thus cause the • A Lecture on Loxarthus, or Club-foot, by Thomas D. Mutter, M. D.; Philadelphia, 1839. An Essay on Club-foot, etc., by W. Detmold, M. D.; New York, 1840, 640 DISEASES OP CHILDREN. distortions of those parts more easily affected by the powerful action of the muscles, and which also, from the arrangement of their bones, more easily yield to this unequal action. Club-foot has been divided into four species by Dr. Little, with the generic appellation of Talipes; these being of practical use, are now generally adopted to describe the various distortions of the foot. The first, Talipes varus, *is where the heel is drawn up and the foot turned inward ; the toes are also turned inward, and the patient walks on the outer ankle. It is produced by the contraction of the gastrocnemii and the abductors of the foot. The second species, Talipes valgus, is where the foot is turned outward, and where the patient walks on the inner ankle. The gastrocnemii and the abductors of the foot are \\ere contracted. The third, Talipes cquinus, where the gastrocnemii muscles are contracted without any affection of the others. In this species the patient walks upon the toes. The fourth, Talipes calcaneus, is caused by the contraction of the muscles in front of the leg; when the patient walks on the heel. Treatment.—The improvement in the treatment of club-foot is one of the greatest triumphs in modern surgery, whether it is regarded as the results of the accurate knowledge of the morbid condition of the part, or the benefits which result from the means used to remedy this deformity. The indications of cure are to remedy the contractions of the muscles producing the deformity, and to afford an opportunity to those which act in opposition, to recover their power of action. These are accomplished by means of apparatus adapted to the extension of the contracted muscles, the extension to be gradually but steadily increased until the permanent contraction is overcome; or by a resort to the section of the contracted muscle or the tendon connected with it. The division of the tendo Achillis was first resorted to for the cure of club-foot, in the year 1784, by Lorenz, of Frankfort. With some variations in the details, the same operation was performed by Michaelis and Sartorius; and about the year 1816, by Delpech, in France ; but owing to its failure, a number of years elapsed before recourse was again had to the knife. In 1831, Dr. Stromeyer, of Hanover, undertook the operation with complete success. Since this period it has been the usual recourse for the removal of deformities of the limbs, by a number of surgeons in Europe and America. It was first performed in the United States by Dr. James H. Dickson, of North Carolina, in 1835, and by Dr. N. R. Smith, of Baltimore, in 1836, and in the following year by Dr. Detmold, of New York. 541 MOTOR SYSTEM. It is not within the limits prescribed to this work, to describe at length the operation of tenotomy, which has of late years been so successful in the removal of the deformities of the feet and limbs ; the works already mentioned contain a great amount of practical matter on this subject, and are in the hands of every surgeon. However important and successful the division of tendons may have been, it is not to be resorted to on all occasions, and an unnecessary number cut. On this subject Dr. Detmold makes the following judicious remark: "We are far from sanctioning an indiscriminate use of the knife, and if a little more patience and attention on the part of the surgeon will render the division of the muscle unnecessary, we consider it the urgent duty of every surgeon not to yield to a fondness for operating, but be guided solely by the result of a conscientious examination in deciding that the knife is absolutely necessary or at least preferable." NOTE TO "VACCINATION." At the request of the author, Dr. Morrell, physician at the Long Island Farms, a department of the New York Alms-House where children are received, kindly furnished him with the statistics of the cases of varioloid which occurred at that establishment from the first of November, 1834, to the first of May, 1843, comprising a period of eight years and a half. From this, it appears that of 5,856 children who were received during that period, there were but eight deaths from varioloid, among those in whom it was ascertained that vaccination had been practised. This result, added to that already stated at page 467, exhibits an aggregate of nearly 16,000 children vaccinated, and but eight deaths among them from the effects of small-pox contagion. APPENDIX. TRANSLATION OF THE PRESCRIPTIONS. Page 44. 1. Antimonial Wine, 2 drachms. Syrup of Squills, 1 i ounce. Mix. 2. Powdered Ipecacuanha, 1 scruple. Tartar Kinetic, 1 grain. Oxymel of Squills, Simple Syrup, Water, each £ ounce. Mix. Page 45. . 3. Calomel, 10 grains. Powdered Rhubarb, 1 scruple. Powdered Ipecacuanha, 1 grain. Simple Syrup, £ ounce. Mix. 4. Manna, £ ounce. Emulsion of Gum Arabic, A ounce. Syrup of Violets, 2 drachma. Mix well, and add, Water, 1 ounce. 5. Castor Oil, £ ounce. Syrup of Roses, .\ ounce. Yolk of 1 Egg. Tincture of Senna, U drachms. 6. Tartar Emetic, 1 grain. Subcarbonate of Potass, 1 drachm. Simple Syrup, 2 ounces. Mix. 7. Antimonial Wine, £ drachm. Oxymel of Squills, h ounce. Tartrate of Potass, Extract of Liquorice, each 1 drachm. Water, 1 ounce. 8. Oxymel of Squills, Syrup of Ipecacuanha, each £ ounce. Liquorice, 1 drachm. Mucilage of Gum Arabic, 2 ounces. Mix. 9. Infusion of Senega Snake-root, 2 ounces. Syrup of Squills, £ ounce. Mucilage of Gum Arabic, 2 ounces. Page 46. 10. Decoction of Polygala Senega, 1£ ounce. Carbonate of Ammonia, 3 grains. Tincture of Cinnamon, Syrup of Tolu, Syrup of Poppies, each 2 drachms. 11. Dover's Powder, 10 grains. Calomel. 3 grains. Powdered Squillp 1 grain. White Sugar, 2 drachms. Mix well, and divide into six powders. 12. Paregoric, £ ounce Antimonial Wine, Liquorice, Powde/ed Gum Arabic, each 2 drachms. Boiling Water, 4 ounces. Mix. 13. Antimonial Wine, 1 drachm. Extract of Hyoscyamus, 3 grains. Simple Syrup, 2 ounces. Mix. 14. Extract of Belladonna, 1 grain. Syrup of Ipecacuanha, 1 ounce. Mix. Page 58. 15. Calomel, 5 grains. Powdered Jalap, £ drachm. Powdered Ipecacuanha, 5 grains. White Sugar in powder, 10 grains. Mix. Page 60. 16. Senega Snake-root, J drachm. Infuse it in 4 ounces of boiling water for a quarter of an hour, and add, Hydrochlorate of Ammonia, £ drachm. Syrup of Althea, 1 ounce. Mix. Page 62. 17. Nitre, 2 grains. Powdered Ipecacuanha, \ grain. Dover's Powder, 1 grain. Dried Carbonate ot Soda, 1 grain. Mix. 18. Nitre, 20 grains. Calomel. 1 grain. Tartar Emetic, \ grain. Mix. 19. Digitalis Leaves, 8 grains. Boiling Water, 3 ounces. Mix. Page 77. 20. Oxymel of Squills, 1 drachm. Antimonial Wine, £ ounce. Mix. Page 80. 21. Calomel, 20 grains. Tartar Emetic, 1 grain. Mix, and divide into four powders. Page 83. 22. Syrup of Squills, 1 ounce. Syrup of Tolu, Antimonial Wine, each £ ounce. Mix. 23. Decoction of Senega, 2 ounces. Oxymel of Squills, 2 drachms. Syrup of Ipecacuanha) 1 drachm. Tartar Emetic, £ grain. Mix. 544 APPENDIX Page 87. 24. Wine of Ipecacuanha, £ ounce. Syrup of Tolu, Mucilage of Gum Arabic, each 1 ounce. Mix. Page 88. 25. Sulphate of Copper, 5 grains. Decoction of Althea Root, 1£ ounce. Syrup of Althea, £ ounce. Mix. Page 96. 26. Musk, 6 grains. White Sugar, 3 drachms. Fennel Water, 3 ounces. Gum Arabic Mixture, 2 drachms. Mix. Page 104. 27. Powdered Rhubarb, 12 grains. Powdered Ipecacuanha, 2 grains. White Sugar in powder, a sufficient quantity. Make into four powders. , H8. Powdered Rhubarb, 10 grains. Calomel, 3 grains. .Mix, and divide into six powders Page 106. 29 Extract of Conium, 2 grains. Tartar Emetic, 1 grain. Distilled Water, 2 ounces. Syrup of Saffron, £ ounce. 30. Extract of Hyoscyamus, 10 grains. Antimonial Wine, 2 drachms. Mix. 31. Antimonial Wine, 1 drachm. Extract of Hyoscyamus, 3 grains. Simple Syrup, 2 ounces. Mix. Page 107. 32. Assafoetida, 2 drachms. Mixture of Gum Arabic, Syrup of Althea, each 1 ounce. Mix. 33. Powdered Belladonna Root, 1 grain. Dover's Powder, 2£ grains. Precipitate of Sulphur, 1 scruple. White Sugar, 2 scruples. Mix, and divide in twenty parts. 34. Chamomile Water, £ ounce. Simple Syrup, 2 drachms. Prussic Acid, 6 drops. Mix. 35. Prussic Acid, 12 minims. Liquor of Tartar Emetic, 1 drachm. Paregoric, 2£ drachms. Camphor Mixture, 7£ ounces. Mix. Page 108. :tC Compound Tinct of Cinchona Bark, 5 ounces Tincture of Cantharides, Paregoric, each £ ounce. Mix. 37. Sulphate of Quinine, 10 grains. Diluted Sulphuric Acid, 15 drops. Cinnamon Water, 2 ounces. Page 110. 88. Powdered Rhubarb, 1 grain. Oxyde of Mercury, 3 grains. Hake into three powders. Page 111. 39. Powdered Rhubarb, 1 scruple. Mercury with Chalk, 10 grains. Powdered White Sugar, 10 grains. Mix. 40. Mercury with Chalk, 1 drachm. Dover's Powder, 2 scruples. White Sugar, £ drachm. Mix. Page 129. 41. Senna Leaves, Cream of Tartar, Manna, each £ ounce. Page 130. 42. Sulphate of Potass, 10 grains. Powdered Rhubarb, 5 grains. Powdered White Sugar, 10 grains. Mix Page 150. 43. Gum Arabic Mixture, White of Egg, Syrup, each equal parts. Mix. Page 151. 44. Honey of Roses, 2 drachms. Alum, 1 drachm. Tincture of Myrrh, £ drachm. 45. Alum, 1 to 2 scruples. Rose Water, 2 ounces. Dissolv Page 152. 46. Powdered Rhubarb, 1 scruple. Magnesia, 2 scruples. Powdered Gum Arabic, 10 grain* 47. Infusion of Rhubarb, A ounce. Sulphate of Potass, 2 drachms. Tincture of Cinnamon, A oum e. Syrup of Senna, 4 drachms. Mir Page 153. 48. Distilled Water, 1 ounce. Gum Arabic Mixturo, £ ounce. Simple Syrup, A ounce. Tincture of Opium, 1 drop. Mix. 49. Fennel Water, 1 ounce. Tincture of Opium, 6 drops. Syrup of Oranges, 6 drachms. ML* J.. Sulphate of Quinine, 2 grains. Aromatic Elixir of Vitriol, 16 drops. Syrup of Cloves, £ ounce. Distilled Water, 1£ ounce. Mix. Page 154. 51. Iodine, 5 grains. Hydriodate of Potass, J scruple. Distilled Water, 2 ounces. Mix. 52. Mint Water, 1A ounce. Aromatic Spirits of Ammonia, J drachm. Spirits of Nitric Ether, 12 drops. Compound Spirits of Lavender, 1 drachm. Syrup of Cloves, £ ounce. Mix. 53. Carbonate of Ammonia, £ drachm. Peppermint Water, 7 ounces Syrup of Oranges, J ounce. Mix 545 APPENDIX 69. Capsicum, 3 drachms. Muriate of Soda, 2 drachms. Boiling Water, 8 ounces. Add, Vinegar, 8 ounces. Mix. 70. Sage, £ ounce. Infuse in hot water a sufficient quantity. Strain 8 ounces. Muriatic Acid, 1£ drachm. Syrup, 2 ounces. Mix. Page 174. 71. Sulphate of Zinc, 1 drachm. Infusion of Sage, 2 drachms. Honey of Roses, 1 ounce. Mix. Page 186. 72. Powdered Ipecacuanha, 1 grain. Powdered Rhubarb, 12 grains. Divide into four powders. 73. Calomel, 1£ grain. Powdered Ipecacuanha, 1 grain. Divide in four powders. Page 188. 74. Calcined Magnesia, 10 grains. Supercarbonate of Soda, 5 grains. White Sugar, a sufficient quantity. Make four powders. 75. Camphor, A grain. Mucilage of Gum Arabic, 2 ounces. Wine of Opium, 1 to 2 drops. Mix. 76. Cinnamon, 1 ounce. Chalk, £ ounce. Tincture of Kino, 2 drachms. Tincture of Opium, 8 drops. Pimple Syrup, 2 drachms. Mix. Page 189. 77. Magnesia, 3 grains. Aniseed, bruised, Fennel Seed, bruised, each 2 grains. White Sugar, 7 grains. Mix. 78. Magnesia, 15 grains. Powdered Rhubarb, 1 scruple, Fennel Water, 1A ounce. Syrup of Rhubarb, £ ounce. Mix. %. Magnesia, 1 scruple. Tincture of Assafoetida, 60 drops. Tincture of Opium, 20 drops. Water, 1 ounce. Mix. . Page 196. 80. Magnesia, A drachm. Tincture of Rhubarb, 1 drachm. Cinnamon Water, 6 drachms. Simple Syrup, 1 ounce. Mix. 81. Castor Oil, £ ounce. Syrup of Roses, £ ounce. White of 1 Egg. Aniseed Water, 1 ounce. Mix. Page 198. 82. Supercarbonate of Soda, 10 grains. Syrup of Oranges, 2 drachms. Tincture of Opium, 6 drops. Water, 1A ounce. Page 164. 64. Powdered Ipecacuanha, 1 grain. Calomel, 2 grains. Prepared Chalk, 20 grains. Mix. Divide into four powders. Page 166. "jo. Compound Infusion of Roses, 5£ ounce*. Sulphate of Magnesia, 6 drachms. Lemon Syrup, A ounce. Mix. 56. Sulphute of Magnesia, 2 drachms. Manna, I ounce. Dissolve in Almond Emulsion, 4 ounces. Mix. 57. Mucilage, 2 ounces. Nitrate of Potass, 1 drachm. Oxymel, 1£ ounce. 58. Powdered Ipecacuanha, 3 grains. Powdered Nitre, 12 grains. Make six powders. Page 167. 50. White-oak Bark, 2 ounces. Alum, £ drachm. Boiling Water, 1 pint. Make a gargle. 60. Tincture of Myrrh, 2 drachms. Diluted Sulphuric Acid, 1 drachm. Alum, 10 grains. Decoction of Barley, 1 pint. Make a gargle. Page 171. 61. Sulphate of Zinc, 5 grains. Powdered Ipecacuanha, 25 grains. Mix. Divide into five powders. Page 172. 62. Olive Oil, £ drachm. Powdered Gum Arabic, a sufficient quantity to make an emulsion with 3 ounces of Fennel Water ; then add, Manna, 1 ounce. Syrup, £ ounce. Mix. 63. Water of Ammonia, Olive Oil, each 1 ounce. Tincture of Camphor, £ ounce. Oil of Turpentine, 2 drachms. Mix. 64. Supercarbonute of Potass, 1 drachm. Water,' 2 ounces. Mix. Page 173. 05. Carbonate of. Ammonia, 8 grains. Gum Arabic ,Mixture, Simple Syrup, each £ drachm. Water, 4 drachms. Mix. 6(i. Snake-root, 1£ to 3 drachms. Infuse in watt-r half an hour. Strain 4 ounces; when cold, Add, .Syrup of Oranges, 1 ounce. Mix. 67. Diluted Sulphuric Acid, £ to 1 drachm. Water, 4 ounces. Syrup, l drachm. 68. Cinchona Bark, 2 drachms. Water, 3 drachms. Camphor Water, 4 ounce. Mix Make an injection. 69 546 APPENDIX 63. Dried Supercarbonate of Soda, 6 grains. Powdered Ipecacuanha, 1 grain. Dover's Powder, 6 grains. White Sugar, 2 drachms. Nitre, 10 grains. Mix. Divide into six powders. 84. Powdered Gum Arabic, 1 drachm. Dissolve in 1 ounce of Fennel Water. Add, Chalk, A drachm. Simple Syrup, 1 ounce. Mix. 80. Emulsion of Poppy Seeds, 3A drachms. Pure Argil, 2 scruples. Syrup of Althea, A ounce. 86. Pure Arsil, A drachm. Gum Arabic, 1 drachm. \\ hite Sugar, 2 drachms. Fennel Water, 3 ounces. Mix. Page 200. 87. Powdered Gum Arabic, 2 drachms. Powdered Ipecacuanha, 1A grain. Water, 1 ounce. Sugar, a sufficient quantity. Mix. Pago 203. 88. Calomel, 2 grains. Powdered Ipecacuanha, 1 grain. White Sugar, a sufficiency. Divide into lour powders. Page 204. 89. Liquor of Acetate of Ammonia, A ounce. Antimonial Wine, .'. drachm. Distilled Water, 3 drachms. Simple .Syrup, A ounce. Page 209. 90. Calomel, 3 grains. Powdered Opium, J grain. Divide into four powders. 91 Mercury with Chalk, 1 drachm. Dover's Powder, 2 scruples. Carbonate of Magnesia, A drachm. Mix. Puge 210. 92. Infusion of Simnrouba, 1\ ounce. Nitric Acid, 4 to 6 drops. • Syrup of Cloves, 4 drachms. Tincture of Opium, 6 drops. Mix. Page 211. 93. Balsam of Copaiba, A drachm. Tincture of Opium, 6 drops. Mucilage of Gum Arabic, 1 ounce. Mix. Page 223. 94. Magnesia, IS grains. Aromatic Syrup of Rhubarb, 1A drachms. Sweet Spirits of Nitre, 1 drachm. White Suiiar, 1 drachm. Powdered Gum Arabic, 3 drachms. Water, 2 ounces. Mix. Page 224. 95. Sugar of Lead, 4 grains. Dover's Powder, 1 grain. Mix. Make 12 powders. Page 225. 96. Sal Martis, 2 grains. Sulphuric Acid, 20 drops. . White Sugar, I drachm. Spring Water, 1 ounce. Mix. Page 231. 97. Phosphate of Soda, A ounce. Boiling Water, a sufficiency. Arrow root, A ounce. Sugar, a sufficiency. 98. Supertartrate of Potass, 2 drachms. Manna, A ounce. Boiling Water, 4 ounces. Syrup of Oranges. 3 drachms. Mix. Page 232. 99. Senna, 2 drachms. Tamarinds, 1 ounce. Bruised Coriander Seeds, I drachm. Sugar, A, ounce. Mix. 100. Infusion of Senna, 2 ounces. Prunes, 4 ounces. Tamarinds, A ounce. Simple Syrup, 1 pound. Oil of Caraway, 20 drops. Make an electuary. 101. Senna, 3 drachms. Sulphate of .Soda, 2 drachms. Manna, 1 ounce. Water, 4 ounces. Mix. Pago 244. 102. Calomel. 5 grains. Powdered Scammony, • Sulphate of Potass, each 10 grains. Powdered White .Sugar, 5 grains. Oil of Cinnamon, 1 drop. Mix. Make 6ix powders. Page 245. 103. Tansy, A ounce. Powdered Valerian, 2 drachms. Powdered Jalap, 1 scruple. Sulphate of Potass, 2 drachms. Oxymel of Squills, a sufficiency to form as electuary. 104. Artemesia, Valerian Root, each 1 ounce. Orange Peel, Tansy, each A ounce. Mix. Pago 246. » 105. Pink Root, A ounce. Senna, 2 drachms. Manna, 1 ounce. Fennel Seed, 2 drachms. » Boiling Water, 1 ounce. Mrx. 106. Pink Root, 6 drachms. Senna, 2 drachms. Savine, A drachm. Boiling Water, 4 ounces. Mix. Page 247. 107. Compound Decoct'on of AIocb, IJ ounce. Liquorice, 2 drachms. Wine of Aloes, 2 drachms. Mix. 547 APPENDIX Page 248. 108 Tincture of Muriate of Iron, 10 drops. Cinnamon Water, A drachm. Simple Syrup, 1 ounce. Mix. Pago 258. 109. Castor Oil, 3 to 6 drachms. Powdered Gum Arabic, a sufficiency. Simple Syrup, 2), drachms. Mix. Make an emulsion. Page 261. 110. Dried Leaves of Euphorbia, A ounce. Roiling Water, 1 pint. Mix. Make an infusion. Page 293. 111. Powdered Jalap, 15 grains. Calomel, 3 grains. Sugar, 1 scruple. Mix. Page 294. 112. Powdered Rhubarb, 3 grains. Supercarbonate of Potass, 6 grains. Sugar, A. scruple. Mix. 113. Powdered Rhubarb, 1 to 2 drachms. Digest for an hour with 1 ounce of boiling water. Strain, and dissolve in it Supercarbonate of Potass, 1 scruple. Syrup of Orange Peel, A ounce. Mix. 114. Supercarbonate of Potass, J drachm. Distilled Water, 1A. ounce.* Dissolve. 115. Supercarbonate of Potass, 10 grains. Gum Arabic Mixture, 1 drachm. White cite Eggs. Water, 3 ounces. Simple Syrup, 1 drachm. Mix. Page 295. 116. Fennel Water, 6 ounces. Supercarbonate of Potass, 2 scruples. •Syrup, 1 ounce. Mix. Page 290. 117. Calomel, Oxysulphnte of Antimony, each 1 grain. Extract of Hemlock, 1 grain. White Sugar, 1 scruple. Mix. Page 297. 118. Iodine, 5 grains, liydriodate of Potass, £ scruple. Distilled Water, 2 drachms. Mix. 119. Iodine, 1 scruple, liydriodate of Potass, 2 scruples. Distilled Water, 1 ounce. Rub them together in a mortar with the water. Page 298. 130. Iodine, 12 grains. liydriodate of Potass, 1 drachm. Lard, 1 ounce. Mix. 121. Iodide of Lead, 1 drachm. Lard, 1 ounce. Mix. Page 299. 122. lodo-hydrargyrate of Potassium, 8 grains, liydriodate of Potass, 2 scruples. Lard, 1 ounce. 123. Alum, 5 grains. Dissolve in Rose Water, 1 ounce. Mix. 124. Sulphate of Zinc, 3 grains. Water, IJ ounce. Mix. 125. Nitrate of Silver, 3 grains. Distilled Water, 1 ounce. Mix. Page 317. 126. Iron Filings, 3 grains. Prepared Chalk, Sugar, each A drachm. Make a powder" and divide into six equal parte, 127. Iron Filings, Powdered Rhubarb, Powdered Cinnamon, each 2 grains. Magnesia, 2 grains. White Sugar in powder, A scruple. Mix. Page 322. 128. Colomba Root, 10 grains. Supercarbonate of Soda, 40 grains. Hot Water, 2 ounces. Mix. 129. Powdered Rhubarb, 6 grains. Calomel, 4 grains. Powdered Ipecacuanha, 1 grain. Mix. Divide into four powders. Page 330. 130. Infusion of Rhubarb, A ounce. Tincture of Cinnamon, A, drachm. Simple Syrup, £ ounce. Compound Tincture of Aloes, 1 drachm. Mix. Page 347. 131. Sulphate of Zinc, 2 grains. Liquor of Acetate of Lead, diluted, 1 ounce. Mix. 132. Chloride of Lime, £ ounce. Water, 1 pound. Mucilage of Gum Arabic, 2 drachms. Mix. Page 348. 133. Tincture of Cantharides, 3 ounces. Compound Soap Liniment, 2 ounces. Mix. 134. Litharge Water, 1 drachm. Distilled Water, 1 pound. Crumbs of Bread, a sufficiency. Mix. Page 349. 135. Chloride of Lime, 3 drachms. Dissolve in Distilled Water, 1 pound. Add, Wine of Opium, 1 drachm. Mix. 136. Chloride of Lime, Borax, each 1 drachm. Lard, 1 ounce. Mix. 137. Creasote, 30 drops. Oil of Sweet Almonds, Cerate, each 1 ounce. Mix. Page 357. 138. Sulphur, 10 to 20 grains. Mixture of Gum Arabic, 2 drachma. White Sugar, A ounce. Rose Water, 1 "drachm. Mix. 548 APPENDIX 139. Sulphur, A drachm. Carbonate of Magnesia, 1 scruple. White Sugar, 2 drachms. Mix, and make a powder. 140. Sulphuret of Potass, 2 drachms. Subcarbonate of Soda, 2 drachm?. Hot Water, 1 pound. Mix. Page 360. 141. Calomel, Powdered Rhubarb, each 6 grains. Supercarbonate of Potass, 12 grains. White Sugar, 1 drachm. Mix. Page 361. 142. Prepared Chalk, 2 drachms. Tincture of Opium, 20 drops. Simple Syrup, £ ounce. Aniseed Water, 1 ounce. Mix. Page 365. 143. Calomel, 2 grains. Powdered Ipecacuanha, 1 grain. White Sugar, 10 grains. Mix. Divide into six powders. Page 366. 144. Assafcetida, 6 grains. Infusion of Chamomile, 1 ounce. Gum Arabic in solution, a sufficiency to form an injection. Page 367. 145. Extract of Dandelion, 20 grains. Confection of Senna, Supercarbonate of Soda, each 5 grains. Water, 1 ounce. Mix. Page 375. 146. Powdered Rhubarb, 15 grains. Mercury with Chalk, 6 grains. Aromatic Powder, 4 grains. Mix. 147. Oil of Turpentine, £ drachm. Castor Oil. 3 drachms. Powdered Gum Arabic, 3 drachms. Water, a sufficiency to form a draught. Page 380. 148. Nitrate of Silver, 15 grains. Distilled Water, 1 ounce. Mix. 149. Sulphate of Copper, 5 grains. Dissolve in Distilled Water, 5 ounces. Mix. Page 382. 150. Carbonate of Lead, 1 ounce. Powdered Litharge, 2 drachms. Corrosive Sublimate, 1£ drachms. Lard, 4 ounces. Venice Turpentine, 1 ounce. Mix. 151. Chloride of Lime, A drachm. Rose Water, 1 ounce. Oil of Sweet Almonds, 1 ounce. Mix, 152. Solution of Chlorine, 1 drachm. Olive Oil, 1 ounce. Mix. Page 406. 153. Powdered Ipecacuanha. 1 scruple. Antimonial Wine, 1 drachm. Distilled Water, £ drachm. Syrup, £ ounce. Mix Page 407. 154. Powdered Ipecacuanha, 1 scruple. Tartar Emetic, 1 grain. Oxymel of Squill!, Simple Syrup, each £ drachm. Water, 1 ounce. Mix. 155. Powdered Rhubarb, Supercarbonate of Soda, each 15 grains. Powdered Ipecacuanha, 1 grain. Divide into six powders. Page 409. 156. Camphor, 4 grains. Gum Arabic Mixture, Syrup, each A ounce. Mix, and add Orange Flower Water, 1 ounce. 157. Carbonate of Ammonia, 8 grains. Gum Arabic Mixture, Syrup, each £ drachm. Aniseed Water, 3 drachms. Mix. Page 411. 158. Snake-root, 6 drachms. Hot Water, 8 ounces. Infuse for four hours, and, when cold, add Spirits of Sulphuric Ether, 1 drachm. Page 422. 159. Syrup of Ipecacuanha, £ ounce. Syrup of Tolu. £ ounce. Liquorice Water, 2 ounces. Mix. 160. Solution of Acetate of Ammonia, 5 ounces. Sweet Spirits of Nitre, 2 drachms. Antimonial Wine, 1A drachins. Simple Syrup, 2 ounces. Mra. Page 424. 161. Syrup of Squills, 2 drachm?. Water. 6 drachms. Acetate of Morphine, A, grain. Mix Page 438. 162. Powdered Ipecacuanha, Calomel, each 15 grains. White Sugar, 2 scruples. Divide into twelve powders. Page 439. 163. Acetate of Lead, 5 grains. Water, 4 ounces. Mix. Page 472. 164. Proto-ioduret of Mercury, 6 grains. Extract of Opium, 4 grains. Juice of Lettuce, 24 grains. Extract of Guaiacum, 48 grains. Mix. Page 474. 165. Sublimated Sulphur, 2 ounces. Lard, 4 ounces. Mix. 166. Bublimated Sulphur, 2 drachms. Subcarbonate of Potass, 2 drachma. Lard, 1 ounce. Mix. 167. Sulphuret of Potass, Prussic Acid, each 1 ounce. Water, 3 pounds. Mix. 549 APPENDIX^ 168. Sulphuret of Potass, 6 ounces. Castile Soap, 2 pounds. Olive Oil, 2 pounds. Oil of Thyme, 2 drachms. Mix. Page 493. 169. Musk, 6 grains. Subcarbonate of Ammonia, 4 grants, White Sugar, 3 drachms. Water, 1 £ ounce. Mix. 170. Musk, 3 grains. Rub with Aniseed Water, 6 drachms. Add, Foetid Spirits of Ammonia, 1 scruple. Simple Syrup, 1 ounce. Mix. 171. Extract of Hyoscyamus, 5 grains. Compound Tincture of Valerian, 20 drops*. Simple Syrup, £ ounce. Cinnamon Water, A ounce. Mix. Page 499. 172. Subcarbonate of Iron, 10 grains. Powdered Valerian, 20 grains. Ginger Syrup, a sufficiency to make a botaav Page 531. 173. Acetate of Lead, 4 grains. Distilled Water, 4 ounces. Mucilage of Gum Arabic, £ ounce.. Mix. GLOSSARY OF TERMS. Abdomen, the belly. Abdominal viscera, the contents of the abdomen. Abortion, miscarriage. Abscess, a collection of matter. Anthelmintics, medicines which destroy worms. Antiphlogistic, remedies against inflammation. Aphtha, sore mouth. Artery, a tube or vessel carrying blood from the heart. Auscultation, listening to the action of the heart or lungs. Axillary, relating to the arm pit. Cardia, the left orifice of the stomach. Cerebral, relating to the brain. Chyle, a white fluid produced by digestion. Chyme, the first product of digestion. Clavicle, the collar bone. Coagulum, a clot. Collyrium, a wash for the eyes. Combustion, burning. Congenital, formed at birth. Congestion, the crowding of a part with blood. Connate, born with. Cranium, the skull bone. Diaphragm, the part which separates the chest from the abdomen. Dorsal, relating to the back. Duodenum, the intestine first below the stomach. Dyspepsia, indigestion Enema, an injection. Enemata, injections. Etiology, causes. Excitement, an action produced by a stimulant. Exfoliate, the separation of pieces of bone. Farinaceous, mealy. Faces, the excrement. Fatal, belonging to the foetus. Falus, the animal before birth. Follicles, small glands, from which issue a fluid. Foramen ovale, the opening in the division of the heart in the foetus. Gangrene, mortification. Glottis, the opening of the windpipe. Hepatic, relating to the liver. Hernia, a rupture or burst. Idiopathic, an original affection of a part. Integuments, the skin. Larynx, the upper part of the windpipe. Meconium, the first faeces of the infant. Miasm, effluvium capable of producing disease. Miasmata, the plural of Miasm. Nasal fossa, the hollow of the nose. Nausea, sickness of the stomach. Nitrogen, one of the component parts of the air. Nephritic, relating to the kidneys. (Esophagus, the tube leading from the mouth to the stomach. Ophthalmia, inflammation of the eye. Ovum, an egg. Oxygen, the vital portion of the atmosphere Papula, small elevations on the skin. Fancies, the walls or boundaries of a cavity. Pathology, the doctrines of diseased actions. Pectoral, relatiug to the breast. Percussion, sounding the chest. Physical, relating to the natural system, to opposition to moral or intellectual. Physiology, the doctrines of living actions. Plethora, a state of fullness of blood. Pus, matter formed after inflammation. Pustule, an elevation of the skin containing matter. Rickets, a disease of the bones. Rupture, a protrusion of any of the bowels through the abdomen. Salivary, relating to the secretion of the mouth or spittle. Sanguineous, bloody. Scirrhus, a tumor of the glands. Scrotum, the sac containing the testicles. Secretion, the separation of the various fluids from the blood. Semeiology, description of signs or symp torus. Serum, the thinner parts of the blood. Stomatitis, inflammation of the mouth. Symptomatic, arising from an affection of some other part. Syncope, fainting. Tabes, wasting. Tendons, the sinews. Tenesmus, aconstant disposition to go to stool. Thorax, the chest. Trachea, the windpipe. Tubercle, a small, hard tumor, which under* goes an imperfect suppuration. Umbilical cord, the navel cord which attaches the infant to the mother. Umbilicus, the navel. Uterus, the womb. Vesication, blistering. Vesicle, a small elevation of the cuticle, con-' taining a fluid, as* the vaccine vesicle INDEX PAGE. Air, pure, necessary for children . . 23 Asphyxia 31 Etiology of 31 Semeiology of .... 34 Pathology of 35 Treatment of .... 35 Apoplexy, Congenital 34 Auscultation in Bronchitis ... 42 Pneumonia ... 53 Pleurisy .... 61 Aphthae 144 Amulet. Coral, in teething . • . .161 Absorbent System, Activity of, in children 268 Alopecia . . .... 347 Artificial Feeding 190 Animal Functions 475 Bronchitis 40 Etiology of 40 Semeiology of . . .40 Morbid Anatomy of . . .42 Treatment of . . .42 Blood, quantity of, in the child . . . 116 Baldness . 342 Burns 344 Treatment of 352 Cry of an Infant 24 Crying, the various kinds of . .24 Cough, different kinds of . . . .30 Cord, different conditions of, cause of Asphyxia 33 Period for tying 39 Catarrh 40 Catarrhal Congestive Fever . . .41 Treatment of 47 Coryza 63 Etiology of 63 Semeiology of 63 Morbid Anatomy of . . . .64 Treatment of 64 Croup. History of 65 Inflammatory 68 Etioloay of 68 Semeiology of 70 Treatment of 76 Spasmodic, History of . .84 Etiology of . . .84 Semeiology of .91 Treatment of 95 Complications of Hooping-Cough . . 100 Convulsions, 482 Semeiology of 485 Morbid Anatomy and Pathology of 488 Treatment of . . . '490 Circulatory System 112 Signs from . .117 Diseases of . . .118 Cyanosis 118 Etiology of 118 Semeiology of 130 Pi.O«. Cyanosis, Treatment of . . .121 Corpo Pedal Spasm 159 Cynanche Maligna 167 Etiology of . . . .168 Semeiology of ... 169 Pathology of . . .170 Treatment of . . - .171 Catamenial Discharge affects the milk . 180 Cholera Infantum, History and Etiology of 211 Semeiology of . 212 Morbid Anatomy and Pathology of . . 216 Treatment of . . 217 Constipation, Etiology of . . . . 227 Semeiology of 227 Treatment of 229 Cutaneous System, peculiarities of ., . 274 Cutaneous Diseases 331 Etiology of . . 333 Pathology of . . 336 Arrangement of . 339 Crinones 342 Chilblains .348 Crusta Lactea 355 Colic 183 Contractions of Tendons after Scarlet Fever .* 403 Chorea 494 Etiology of 495 Semeiology of .... 495 Morbid Anatomy and Pathology of 496 Treatment of 497 Club-Foot ... • 539 Etiology and Semeiology of . 539 Treatment of . . .540 Divisions of the Diseases of Children . 3 Disorder of Function important to consider in all diseases .... 3 Development of the Body a great source of disease 17 Ductus Arteriosus, obliteration of # .113 Digestive System 130 Signs from . . . 140 Diseases of 145 Dentition, Morbid 157 Etiology of . . . .157 Semeiology of . . . . 158 Morbid Anatomy of . . . 160 Treatment of . . . .160 Diet in Teething Children . . . .163 Diarrhoea, Feculent 194 Etiology of . . .19* Pathology and Treatment of . . 195 Serous, Etiology, Semeiology, and Pathology of . 199 Treatment of 200 Bilious, Etiology of . 201 Semeiology of . 303 Treatment of .203 70 554 INDEX PAGE. Diarrhoea, Mixed and Chronic . • .204 Etiology and Semeiology of . • -206 Morbid Anatomy of . 207 Treatment of . . 208 Dysentery, Etiology of . • • • 258 Semeiology and Pathology of 259 Treatment of . . • • 260 Dysuria, Etiology and Semeiology of . 320 Treatment of . • .321 Diabetes 32-) Etiology of 326 Semeiology of . . . • 327 Pathology of 328 Treatment of • 329 Dropsy after Scarlet Fever . of Emetics, Vitriolic, in Croup ... 85 Emetic, Tartar, its danger . . . M Enteritis, Etiology and Semeiology of . 2j0 Morbid Anatomy of . . • 251 Treatment of . . .256 Excernent System 267 . Signs from . . . 2<5 Diseases of . . 279 Kn-ausis 241 Erysipelas, Etiology of • 357 Semeiology of ... 3S9 Treatment of . . • • 367 Eczema . . . . • • • 370 Ecthyma 383 Fluids, importance of changes in . 4 Constitute a large portion of the body of a child . . . .11 Foramen Ovale, obliteration of . . . 112 Food, improper, a cause of indigestion . 181 Fruits, use of. for children . . .181 Feeding,- Artificial 190 Furunculus 375 Growth, importance of, in considering the Diseases of Children .... 1 Glottis, size of the 23 Gangrenous Erosion of the Cheek . . 146 Gastritis, Etiology of 248 Morbid Anatomy of . . , 249 Semeiology and Treatment of . 250 Hooping-Cough, HPtory of . , . .97 Etiology of ... 9/ Semeiology of. . .98 Morbid Anatomy and Pathology of . . . 101 Treatment of . . . 104 Heart of the Foetus and Child . . .112 Pulsations of . . .114 Hepatic AfTections 225 Hernias, Etiology and Semeiology of . 265 Treatment of • 269 Herpes 372 Hydrocephalus Acute > 500 Etiology of .501 Semeiology of . 505 | Morbid Anatomy of 512 Treatment of . . 516 Chronic, Etiology of . . 623 Semeiology of . 523 Pathology of . . 525 Treatment of . 626 Hydrencephaloid Disease .... 527 Hip Joint, Abscess of 537 Etiology and Semeiology of . 640 Treatment of . . .541 Independent Life, Changes in Circulation 111 Indigestion, Infantile, Etiology of . . 178 Semeiology of . 182 Morbid Anatomy of 184 Treatment of . 185 Integuments, color of, in Infants . . 273 Incontinence of Urine, Etiology and Semeiology of 317 Treatment cf . 318 Intertrigo 349 PAGE. Impetigo .... ... 353 Jaundice 361 Joints, AfTections of, after Scarlet Fever . 402 Life, views of its nature .... 6 Larynx of Children, size of . .23 Lungs of Cliildren ... .24 Lobular Pneumonia ... .54 Lobar Pneumonia ... .66 Leeches, directions for applying . . 166 Lymphatic System, peculiarities of . . 271 Lichen 369 Moaning*, its indication 29 Malformation of the Thorax, a cause of Asphyxia 34 Millar's Asthma 89 Mouth. Ulcerated . . . . .144 Milk, by what affected . 0. . . 180 Properties of good . . . .190 Meconium, retention of . . . . 228 Motor System, Peculiarities of , . . 531 Signs of Disease from . 536 Morbus Coxarius 537 Neevi Materni 340 Nettle Rash • . 367 Nervous System, Peculiarities of . . 475 Signs of Disease from . 479 Diseases of 482 Oesophagitis, Etiology and Semeiology of 176 Morbid Anatomy and Treatment of ... 177 Ophthalmia, Etiology of . . . .524 Semeiology of 530 Treatment of. . . .531 Otitis, Etiology and Semeiology of . . 532 Treatment of 333 Preliminary Observations .... 1 Percussion, Peculiarities from ... 26 How employed in Children . 30 Parents, extremo youth of, a cause of Asphyxia 32 Placenta, detachment of, a cause of Asphyxia 32 Pneumonia . . . • • .49 Etiology of .... 50 Semeiology of . . . .51 Morbid Anatomy and Pathology of . 54 Treatment of . 57 Pleurisy, Etiology of 60 Morbid Anatomy of . .61 Treatment of 61 Percussion in Bronchitis .... 42 Pneumonia .... 53 Pleurisy . . . ¦ . 60 Pertussis 97 Pulse of Children 114 Signs from . . .117 Parotitis, Etiology and Pathology of . 174 Treatment of .... 174 Passions affect the milk . . . .180 Peritonitis, Etiology of . . . .262 Semeiology, Morbid Anatomy, and Treatment of . . 263 Pernio 348 Prurigo 352 Porrigo Larvalis 362 Purpura 3^3 Psoriasis 376 Porrigo Favosa 377 Pomphigus 384 Respiratory System ..... 20 Peculiarities of . .20 Signs of Diseases from 26 Respiration, Peculiarities of . .23 How first effected ... 23 Remittent Fever 121 Ftiolosyof . . .122 Semeiology of . . . 123 Morbid Anatomy and Pathology of .135 INDEX 555 PAGE. Remittent Fever, Treatment of . . 128 Rickets, Etiology of 312 Semeiology of ... 313 Pathology of 314 Treatment of . . . .315 Retention and Suppression of Urine . 323 Etiology and Semeiology of . 324 Treatment of ... 324 Running Tetter 360 Roseola 370 Rupia 384 Rheumatic Affections of Joints after Scarlet Fever . . . . . .408 Rubeola—Measles 415 Etiology of 416 Semeiology of . . . .417 Morbid Anatomy and Pathology of 421 Treatment of 422 Solids, the great attention to ... 4 Stomach of an Infant .... 13 Stomatitis 144 Etiology of 144 Semeiology of . . 145 Morbid Anatomy of . . . 150 Treatment of . . .150 Swelling of the Hands and Feet . . 159 Stomach and Intestines, diseases of .' 178 Suckling, Protracted, in its effects . . 180 Scrofula, History of 279* Etiology of 280 Semeiology of . . . 284 Pathology of . . . .284 Treatment of .... 291 Strophulus 350 Scarlatina, 385 Etiology of . . . • . .386 Semeiology of ... . 389 Sequelae of 389 Suppurations of Glands after . 402 Morbid Anatomy of . . . 404 Treatment of ... 412 Syphilis 468 Treatment of 471 Scabies 473 Treatment of . . . .474 Trachea, peculiarities of . . . .23 Thorax, size of . • . . . .24 Temperature, uniform, the necessity of . 48 PAOK. Teething, process of 132 Tongue-Tie 156 Ton si Utis . .' 164 Etiology of It54 Pathology and Treatment of . 166 Tabes Mesenterica . . • . . 209 Etiology of .... 300 Semeiology of ... 302 Pathology of . . . .311 Treatment of . 313 Tinea 378 Tendons, Contractions of, after Scarlet Fever 408 Urine, Incontinence of . . . . 323 Retention and Suppression of . 329 Urticaria 367 Vitality, its nature considered ... 6 Its action in Adults ... 17 Children ... 17 Vital Functions 20 Voice of Childhood 27 Vomiting, Physiology of ... 136 Verrucas 348 Vesication 349 Varioloid 439 Varicella—Chicken-Pox .... 447 Etiology of . . 447 Vaccinia—Cow-Pox 445 Experiments on . 446 Vaccination 451 Statistical Results of . 467, 541 Variola—Small-Pox 427 Etiology of . . .428 Semeiology of . . 430 Morbid Anatomy and Pathology of . . 433 Treatment of . 435 Worms, History of 232 Etiology of 237 Pathology and Semeiology of . 239 Treatment of .... 243 Supposed to be a cause of Remittent Fever . . . 136 Weaning Brash 180 Time for 192 Warts . * 342 Wet Nurse, preferable to artificial food 189 Yellow Gum 361 THE END.