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ON
THE DISEASES OF CHILDREN.
f 
 
PRACTICAL TREATISE
DISEASES OF  CHILDREN
        ■I
      D. FRANCIS CONDIE, M.D.,

SECRETARY OF THE COLLEGE OF PHYSICIANS ; MEMBER OF THE AMERICAN MEDICAL
   ASSOCIATION J MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY ;
        HONORARY MEMBER OF THE PHILADELPHIA
           MEDICAL SOCIETY, ETC.
THIRD EDITION, REVISED AND AUGMENTED.
   LlBKAliY
SU«3!ON6CN£BAi:snrF(C£ j
   MC-5--19U1
    PHILADELPHIA:
LEA AND BLANCHARD.
         1850. 
7
A
1
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mo
      Entered, according to Act of Congress, in the year 1847,
                  By Lea & Blanchard,
In the office of the clerk of the District Court, for the Eastern District of
                      Pennsylvania.
     PHILADELPHIA:

C SHERMAN, PRINTER.
*; 
PEEFACE.
  In the preparation of a third  edition of the present treatise, every
portion of it has been subjected to a careful revision.  A new chapter
has been added on Epidemic Meningitis, a disease which, although not
confined to children, occurs far more frequently in them, than in adults.
In the other  chapters of the work, all the more important facts that
have been developed since the appearance of the last edition, in  re-
ference  to the nature, diagnosis, and treatment of the several diseases
of which they treat, have been incorporated.   The great object of the
author has been to present, in each succeeding edition, as full and
connected a view as possible of the actual state of the pathology and
therapeutics  of  those affections which most  usually occur  between
birth and puberty.
  To the present edition there is appended a list of  the several works
and essays quoted  or  referred  to in the  body of the work, or which
have been consulted in its preparation and revision.

  That  the condition  of the organization  during  infancy  and the
early period of childhood produces a very considerable modification
in the character, progress,  and termination  of the morbid actions
that take place in the several  tissues, and in the phenomena to which
they give rise, as well as in the operation of remedial  agents  gene-
rally,  was perceived by many of  the older physicians, by  whom
several  elaborate treatises  were devoted especially to  the diseases
incident  to infancy  and childhood.
  Who  indeed does not perceive, remarks Faust, that  the  maladies
of infants  and  children form a class,  in some  measure apart from
those  of the  adult; that they have their peculiar language; run often
a very different course; and require  for their cure  a particular  mode
of treatment?  Nor will this be wondered  at, if attention be given to
the condition of the body and its functions, in these early periods of
existence, when nearly all  the organs are but  imperfectly formed,
some of  them being still inactive, while others, so to speak, are yet to
be organized.  From the first stages of infancy, there exists truly much 
Xxii                       PREFACE.

activity of life,  employed  in the building up and perfecting of every
portion  of the system;  but this very excess of vitality, inviteth the
occurrence of disease, and giveth to it, when it  does occur, a pecu-
liar character and direction.
  To the investigation of the diseases of the earlier stages of exist-
ence, much  attention has been recently given; and the numerous
facts  that have been  adduced,   within a  short period,  in relation to
their  character,  the organs and tissues  in which  they are ordinarily
seated,  their diagnostic phenomena, and usual course and termina-
tion, have thrown not  a little light  upon much  that was heretofore
obscure in regard to their pathology,  while  they  have tended  to ren-
der the treatment of them, generally speaking, more  simple, certain,
and successful.
  While the author of  the present treatise has  appropriated  to his
use every important  fact that he has found recorded in the works of
others, having a direct bearing upon either  of the subjects of which
he treats, and the numerous valuable observations—pathological as
well  as practical—dispersed  throughout the pages  of the medical
journals of Europe  and America,—which are, in some measure  lost
to the student and busy  practitioner, for the want of being arranged
and carefully collated with each other,—he has, nevertheless,  relied
chiefly upon the results of  his own observations  and  experience, ac-
quired during  a long and  somewhat extensive practice, and  under
circumstances peculiarly well adapted  for  the clinical  study  of the
diseases of early life.
  He has made use of the  labours and adopted the opinions of others,
only when he has found them to correspond  with, or to be confirma-
tory of, the results of his own observations and inquiries.
  In  the few instances in  which, from the high professional standing
and authoritative character of the individuals from whom they ema-
nate,  he has considered it proper  to  notice  pathological  views or
plans of treatment, the accuracy of  which he has had no opportunity
of testing, or which are in discordance  with  his own  observations
and  experience, the fact is  invariably stated, so that the credit or
responsibility may  rest  with their  respective authors.   And, in all
cases, in which an opposition  of opinion, upon  any important point,
exists between  medical  authorities  of equal weight, he has  always
adopted those views which comport the  nearest with his own  obser-
vations ; presenting,  at  the same time, when  it  is demanded  by the
importance of  the subject under consideration,  a  fair exposition  of
the views of others in relation to it. 
PREFACE.
XX111
  Every species of hypothetical reasoning has, as much  as  possible,
been avoided.  The author has endeavoured throughout the work  to
confine himself to a simple statement of pathological facts, and plain
therapeutical directions—his chief object  being to render it, what  its
title imports it to  be, A Practical  Treatise  on  the Diseases  of
Children.
  In the description of the several maladies, he  has endeavoured  to
delineate with  clearness and precision, the  character, and  the most
usual order  of  succession   of their  respective phenomena, and the
modifications and changes  these undergo, in the different grades and
stages of the same disease.  Indicating, as far as  was  practicable,
those which are essential and diagnostic, and such as are merely ac-
cidental, and often entirely absent.
  It has been objected to  writers  on the diseases of children, of  no
very  remote date, that they often confound  morbid affections of  a
very  dissimilar character—as well in regard  to their  location as to
their leading symptoms; while phenomena dependent upon  the same
form of disordered action, and seated in the same organs and tissues,
are erected  by them into  separate and independent diseases.  That
the objection is,  to a certain extent, well founded,  there can be  no
doubt.  How far the author of  the present treatise  has been led into
a similar error, must  be left for others  to determine;  he trusts, that
his endeavour to avoid it has been attended with success.   It is pos-
sible, however, that future  and more extended investigations may
show that  some of the diseases which are now considered as inde-
pendent  of each  other, are the result, merely, of different grades  or
stages of the same morbid action, and  that phenomena, referred  to
the same lesion, depend, in fact, upon those of a very dissimilar cha-
racter and location.
  In  describing  the pathological anatomy of  the different affections
incident  to the early stages of existence, the author  has endeavoured
to be as full and  accurate as  the  materials in his  possession would
permit.  For the elucidation of this important subject,  we are mainly
indebted to  the labours of  contemporary physicians.  Of these  the
author has  freely availed  himself; without,  however,  neglecting  the
results of his own investigations.
  In regard  to the directions for the treatment of the several diseases,
he  has almost  exclusively depended  upon  the  results of his personal
experience.  To  notice every remedy that has been proposed, at dif-
ferent  periods, and by different practitioners—the recommendation of
which is founded, perhaps,  upon the result  of its exhibition in two, 
  xxw                      PREFACE.

  three,  or,  at  the  furthest, half a dozen  cases, would have been  a
  means, certainly, of filling up his pages,  and might  have gained for
  him the credit of extensive research—but would have contributed but
  little towards the instruction of his  readers.  He has preferred  to
  present only those remedies and plans of treatment which he has
  found,  from actual observation  made at  the bedside of the patient,
  to be best adapted to relieve or to remove  the several  forms of disease
  of which  he treats; and which he  is convinced will  be the least
  likely to disappoint the  expectations of the  practitioner, when promptly
  and judiciously administered.  He has not failed, however, to notice
 every remedy and  plan  of  treatment which comes  to us with the
 recommendation of practitioners  of  unquestionable  authority, even
 although he may not have had an opportunity of testing its efficacy.
   In his selection of remedial agents, he  has always studied simpli-
 city—being convinced  that, in  the  treatment of  the diseases  of
 children especially, a few simple  but  efficient remedies  are, in every
 point of view, preferable  to a multiplicity—all calculated, perhaps,  to
 produce similar effects—even when  the efficacy of each  may have
 been fully tested.   But, as it  occasionally happens,  that  in  certain
 cases a change of means, even without any change in our  immediate
 indication,  will be  productive  of beneficial results,  those remedies
 have been pointed out,  that may, under particular circumstances, be
 advantageously substituted for each other.
   Great attention  has  been paid  to  describe  the proper hygienic
 management of the several affections treated of.  This is a  subject
 which,  in the generality  of the treatises on the diseases of children,
 has  been  too much overlooked.   In  reference  to all diseases, it is of
 very great importance,  but in none is it more so than  in those occur-
 ring during infancy and  the earlier periods of childhood.   In  these,
 hygienic management is often sufficient alone to effect a cure, while
 it constitutes, invariably, an  essential adjuvant  to the therapeutic
 measures  employed, and  by  which the successful  operation of these
 is invariably, and often  very greatly, promoted.
   The leading endeavour of the author has been  to  render  the pre-
 sent treatise  throughout, a useful guide to  the student in the acquisi-
 tion of a knowledge of the character, seat, causes, prevention, and
 treatment  of the several diseases of infancy  and  childhood; and he
 feels persuaded, that should   his  fellow-practitioners  be inclined  to
 consult  its pages,  they may derive from   them  some  few  facts and
practical hints, not altogether unworthy of  their  notice.
Philadelphia, December, 1849, 
CONTENTS.
PART   FIRST.
CHAPTER  I.
                  THE HYGIENIC MANAGEMENT OF CHILDREN.

1.  Air.  Temperature, -
2.  Cleanliness.  Bathing,
3.  Clothing,
4.  Food,
5.  Sleep,
6.  Exercise,
7.  Moral Treatment,
CHAPTER  II.
ON THE  PECULIARITIES OF ORGANIZATION AND FUNCTION, DURING  INFANCY
                              AND CHILDHOOD.

                                                                            79
                                                                            79
                                                                            86
                                                                            9-2
                                                                            92
                                                                            93
CHAPTER  III.
PATHOLOGY OF INFANCY AND CHILDHOOD.
CHAPTER  IV.
SEMEIOLOGY OF THE DISEASES OF INFANCY AND CHILDHOOD.
1.  Of the Countenance, -       -       -      -      •      -      -       -       126
2.  Of the Gestures,        --------   128
i>0
37
41
43
57
62
69
1. Infancy, -
    Organization,
    Functions,
2. Childhood,   -
    Organization,
    Functions,  - 
XXVI
CONTENTS.
 3. The Phenomena During Sleep, -
 ■1. The Cry,   -       -
 5. Respiration,
 6. The Tongue and Mouth,    -
 7. Of the Surface, -
 8. The Breath,
 9. Discharges by Vomiting and Stool,
10. The Urinary Discharge,  '  -
11. The Bones,
PART  SECOND.
SECTION  I.
DISEASES OF THE DIGESTIVE ORGANS.
CHAPTER I.
DISEASES  OF THE MOUTH.
1.  Erythematic Stomatitis.  Inflammation of the Mouth,   .
2.  Erythematic Stomatitis, with curd-like Exudation,  -
3.  Follicular Stomatitis.  Aphthae, ....
•1.  Ulcerative Stomatitis,       ....
5.  Gengivitis.   Inflammation of the Gums, -
6.  Gangrene of the Mouth,     ....
7.  Difficult Dentition,     .....
CHAPTER II.
                          DISEASES OF THE THROAT.

1. Tonsillitis,  ......
2. Pseudo-membranous Inflammation of the Throat,
3. Gangrene of the Throat,    ....
4. Parotitis.  Inflammation of the Parotids.  Mumps,
5. Angina Externa,    .....
CHAPTER III.
OESOPHAGITIS.
CHAPTER  IV.
                          DISEASES OF THE STOMACH.

1.  Indigestion, ......
2.  Gastritis.   Inflammation of the Stomach,      .      i 
CONTENTS.
XX VII
CHAPTER  V.
                        DISEASES OF THE INTESTINES.

1. Enteralgia.  Colic,  .......
2. Diarrhoea,      -      -      .      .      - .     -
3. Cholera Infantum,  ......
4. Prolapsus Ani,  ......
5. Polypus of the Rectum,     -
6. Invagination of the Intestines,  ....
7. Intestinal Worms,   ......
8. Enteritis. Inflammation of the Small Intestines.  Ileitis,
9. Colitis.   Inflammation of the Large Intestines.  Dysentery,
206
211
229
238
240
244
245
256
261
                             CHAPTER  VI.


Peritonitis.  Inflammation of the Peritoneum, -
264
                            CHAPTER  VII.


The Remittent or Gastric Fever of Infancy,
268
SECTION II.
DISEASES OF THE RESPIRATORY ORGANS.
1. Asphyxia, -	.	277
2. Coryza, -	.	. 282
3. Bronchitis, -	.	285
4. Pneumonia,	.	- 294
Atelectasis Pulmonum,	.	309
5. Pleuritis,	.	- 310
6. Tracheitis. Croup, -	.	316
7. Spasmodic Croup,	.	. 334
8. Spasm of the Glottis,	.	339
9. Pertussis. Hooping-cough,	.	. 347
10. Foreign Bodies in the Larynx	and Trachea,	364
SECTION III.
DISEASES OF THE NERVOUS SYSTEM.
1. Hypertrophy of the Brain,	.	• 366
2. Cerebral Hyperaemia and Haemorrhage,	-	372
3. Convulsions, -	.	- 382
4. Acute Meningitis, -	-	397
Meningitis Encephalica,	.	- 407
5. Epidemic Meningitis,	-	408
6. Subacute Meningitis, - -	.	- 419
Chronic Hydrocephalus, -	.	434
7. Chorea, -	.	- 436
 
XXV111
CONTENTS.
SECTION  IV.
DISEASES OF THE SKIN.
CHAPTER  I.
ERUPTIVE  FEVERS
EXANTHEMATA.
1. Measles, ....	.	.	447
2. Scarlet Fever. Scarlatina,	-		- 457
Inflammatory Scarlatina, -	-	-	458
Scarlatina Anginosa, -	.		- 459
Congestive Scarlatina,	-	-	470
3. Roseola. Scarlet Rash, -	.		- 480
4. Variola. Small-pox,	.	-	481
5. Vaccination,	.		. 501
Phenomena of Vaccination,	.	-	505
Period for Vaccination,	.		- 507
Mode of Vaccination,	.	.	508
6. Modified Small-pox. Varioloid, -	.		. 510
7. Varicella. Chicken-pox,	-	-	513
CHAPTER  II.
CUTANEOUS ERUPTIONS.
Eruptions occurring previous to Weaning, and during Dentition
      1. Strophulus,       .....
      2. Prurigo,     .....
      3. Crusta Lactea,    .....
      4. Impetigo,    .....
Eruptions chiefly connected with Gastro-enteric Disease.
      5. Erythema,       .....
      6.  Eczema,     .....
      7. Urticaria.  Nettle Rash,  ....
      8. Erysipelas,   .....
      9. Phlegmonous Tumours,  -
     10. Herpes,      .....
     ,11. Psoriasis, ----..
     12. Follicular Wart,     ....
     13. Porrigo,  ......
Eruptions connected with Languid Cutaneous Action.
     14. Pityriasis,    .....
     15. Ichthyosis,       .....
     16.  Ecthyma.  Rupia,    -
     17.  Pemphigus,-     -       -       .              .
     18.  Purpura,     .....
From Infection, independent of Visceral Disease.
     19.  Psora.  Scabies.  Itch,  -       .
     20.  Syphilitic Eruptions,  ....
517
518
519
521

523
524
525
528
534
539
541
543
544

549
550
552
555
557

561
564 
CONTENTS.
XXIX
SECTION V.
DISEASES OF THE NUTRITIVE FUNCTION.
Scrofula, .....	.		. 568
Scrofulous Inflammation of the Lymphatic Glands,		.	574
Ophthalmia, Otitis,	-		. 575 578
Discharges from the Vagina, Disease of the Mesenteric Glands.	Tabes Mesenterica,		. 579 580
Disease of the Bones,	.		. 581
Rickets,	.	.	581
White Swelling, Hip Disease,	-		- 582 584
Disease of the Spine, -Tubercular Depositions,	.		- 585 587
Tuberculization of the Bronchial Glands,	.		- 590
Lungs, -Tubercles of the Brain,	■	-	592 - 592
Treatment of Scrofula, -	.	.	594
Scrofulous enlargement of the Lymphatic Glands, Ophthalmia, ..... Otitis, ......		-	- 600 602 - 605
Discharges from the Vagina, Tabes Mesenterica, -	■	-	606 . 606
Disease of the Bones. Rickets,	.	.	607
White Swelling, Hip Disease,	.		- 609 610
Disease of the Spine,	.		. 611
Tubercular Depositions, -	.	-	613
SECTION VI.
DISEASES OF THE URINARY ORGANS.
1. Dysuria.
2. Anuria.
3. Ischuria.
4. Enuresis.
5. Diabetes,
 Painful and Difficult Micturition,
Suppression of Urine, -
 Retention of Urine,
 Incontinency of Urine,
613
619
620
623
628
                      SECTION VII.


CONGENITAL AFFECTIONS, AND ACCIDENTS OCCURRING, MOST
             GENERALLY, WITHIN THE MONTH.
1. Fractures,      -
2. Congenital Malformation of the Intestines,
3. Tongue-tie,    ....
4. Haemorrhage from the Navel,
5. Cyanosis.  Morbus Cceruleanus, -
6. Spina Bifida. Hydro-Rachis,
7. Inflammation and Ulceration of the Navel,
632
632
635
636
637
644
648 
XXX
CONTENT S.
 8. Intumescence and Inflammation of the Breasts,
 9. Ruptures.  Hernias,
     Arrest of the Testicle,
10. Vaginal Hasmorrhage,  -
11. (Edema of the Prepuce,
12. Cohesion of the Labia and Nymphs,
13. Hare Lip,   -
14. Club-Foot.  Talipes,   -
15. Induration of the Cellular Tissue,  -
16. Naevus, .      -      -       -
17. Jaundice.  Icterus Infantilis,
18. Purulent Ophthalmia,  -
19. Hydrocele,  -
20. Paronychia,
21. Burns and Scalds,  - 
ON
THE DISEASES OE CHILDREN.





         PART I. 
 
ON
THE  DISEASES OF  CHILDREN.
                        CHAPTER I.


          THE HYGIENIC MANAGEMENT OF CHILDREN.

  " When we reflect upon the many painful and dangerous maladies
to the attacks  of which children,  from the earliest period of their
existence, are liable, and by which  so large a proportion of them are
annually destroyed, and when we consider, also, that in many, perhaps
in the majority of cases, these attacks might easily be avoided by a
proper attention to those external agents, to the influence of which the
infant is subjected from the moment of its birth, and which, while they
are essential to  its existence, become, when counteracted or mis-
managed, the cause of nearly all its infirmities and diseases; the phy-
sician can scarcely be considered as fulfilling all his duties, when he
neglects to point out  and urge the administration  of the means by
which the occurrence of disease may be prevented, as well as those,
which, when disease is already present, are adapted to remove it."
(Faust.)
  These remarks, made upwards of a century  since, by one whose
writings have been consigned to unmerited oblivion, are still substan-
stially true.  A vast amount of the  disease and suffering that occur in
early life, is unquestionably produced by errors committed  in  regard
to diet, clothing, and exercise,—by impure air, unwholesome dwellings,
imprudent exposure, and a general neglect of physical and moral edu-
cation.   Even  now the proper management of infancy and  childhood
is but imperfectly understood,  and many erroneous opinions in relation
to it, giving birth to practices the most pernicious, are entertained,
even by physicians.  A general view of the more important particulars
connected with the subject would seem, therefore, to be a proper  and
necessary introduction to the consideration of the pathology and treat-
ment of the maladies incident to the early periods of life.


                   1.—Air.  Temperatnre.

  The first want  of the new-born infant is a free supply of air—and
this want continues to recur during every moment of its future exist-
                              3 
34
DISEASES  OF CHILDREN.
ence.  But it is not only necessary that the infant should be supplied
with a sufficient amount of air to carry on the function of respiration;
it is equally necessary that the air it breathes be perfectly pure;  an
impure and stagnant atmosphere being  even more  deleterious  during
infancy and childhood, than in more advanced life.  From this cause
alone, according to the statement of Dr. Clarke, in the year 1782, out
of 7650 infants, born in the  lying-in-hospital of Dublin, 2944 were
destroyed  within the first two weeks  after their  birth.   They nearly
all died in convulsions—many of them foamed  at  the  mouth—their
thumbs were drawn into the  palms of  their hands—their jaws were
locked—and their faces swollen and  of a  bluish  tint, as though they
had  been  strangled.  So soon as proper measures were  taken, at  the
suggestion of Dr.  Clarke, to insure  a free  circulation of  pure  air
throughout the wards of the  hospital, the dreadful  mortality that had
previously occurred  among  the infants inhabiting them, was  almost
immediately suspended.
  Even when not immediately productive of any violent or fatal train
of symptoms, by gradually impairing  the powers  of life, a vitiated and
stagnant atmosphere produces a general unhealthy condition  of  the
organs—prevents their due development, and lays the foundation  for
maladies, that are always difficult, and often impossible to remove.
  Children that have been, from any cause, confined in small, unclean,
badly ventilated or overcrowded apartments, almost invariably exhibit
the deleterious influence of an impure and  stagnant  air, in their pallid
countenances, flaccid muscles, and emaciated limbs;  their impaired
digestion—their panting respiration upon any trifling exertion—their
stunted growth, and sickly appearance generally, as well as their pre-
disposition to some of the most  dangerous  affections of the lungs,
stomach, brain, and other organs.  There is no doubt,  that in these
cases, the injurious effects of a  vitiated  atmosphere, are,  in some
degree, augmented by the want of proper and sufficient exercise; it
would be  in vain, however,  to attempt to counteract them by any
amount  of exercise,  so  long  as the little sufferers are debarred from
enjoying the pure fresh air.
  The importance, therefore,  of selecting as a nursery  the largest and
the most lofty room in the house, and of taking  every precaution to
insure, at all times, the purity  of its air, by free but cautious ventilation
—by the strictest cleanliness of the apartment and its furniture, and by
removing  from it every possible source of vitiation, should be frequently
and forcibly urged upon  parents—and  every neglect of the  means
adapted to preserve the infant from the influence  of an impure and
vitiated atmosphere, should receive a  prompt rebuke on the part of the
physician  in attendance.
  Among the most usual  causes, independent of  a neglect of cleanli-
ness  and ventilation, by which the purity of the air in rooms occupied
by young  children, is liable to be impaired are, the smoke of  lamps,
and  of wood fires—the gases produced by the combustion of stone
or charcoal—the washing, drying,  and ironing of the infant's gar-
ments—the cooking of various articles of food—the smoke of tobacco,
and all domestic processes that have a tendency to rob the atmosphere 
MANAGEMENT OF CHILDREN.               35
of its oxygen, or to load it with effluvia of any kind; all of these should
therefore be carefully guarded against.   The impropriety of exposing
infants to the infected air of small, crowded, and confined  apartments
need scarcely be pointed out.
   As soon as a child is sufficiently old, it should be carried daily, for
a few hours, into the open air, whenever the state of the weather, and
the temperature of the season will permit.  By no other  means can
we so effectually secure to it the full enjoyment of a pure, fresh air—
and contribute so essentially to insure its health and  promote its
sprightliness.  " The open air," Struve with great justness remarks,
" is particularly grateful  to  the feelings of infants.  When they have
been accustoicrtM 40 it for & fo$v-TftfcfeS, irrfey■ e?tncl,*e^en at a very
early age, a strong desire to return to it. .When .unable to walk, they
point anxiously to  the door, and make efforts to approach and open it.
When  they can scarcely  crawl, they instinctively advance  towards
that part of the room from which they have a prospect of escaping.
Often their cries can be  arrested  in  no other  way than by carrying
them into the free  open air."
   Not  unfrequently, even when there is nothing  to  object to in the
condition of the atmosphere which  the child respires within  doors,
and notwithstanding the precaution is taken to carry it abroad, at
short intervals, into the open air without, it is deprived of the full bene-
fit of a pure atmosphere by various practices originating in ignorance,
prejudice, or misconception.  Thus, during the many  hours passed by
infants in sleep, by covering their faces carefully with  the bed-clothes;
by enclosing the cradle or cot with a closely-drawn curtain;  or when
jhey are taken  abroad enveloping the entire head in a hood or with a
shawl;  or carrying them completely enclosed beneath the shawl or
cloak of its mother  or nurse, they are made to breathe  a  confined
atmosphere, which  their own  respiration  and the exhalations  from
their bodies tend constantly to render impure, and in the highest degree
noxious.  We have, in several instances, seen convulsions and symp-
toms of decided asphyxia produced by these absurd and  indefensible
practices.
   A healthy and robust infant may be carried  daily into the open air,
in dry  weather, and  when the temperature of the season is sufficiently
mild, as soon as it is two or three weeks old.   Even during the winter
season, days will  frequently occur when  a robust infant, of a more
advanced age,  may  be exposed, for a short time, to the open  air, pro-
vided its body be protected  with  a sufficient amount of clothing, not
only without danger, but with positive advantage to its health.
   From the period when a child becomes able to walk alone, it should
be allowed to pass  many  hours,  every day, in the open air.   The
robust, fully developed and active limbs, and the ruddy and sprightly
complexion exhibited  by children who pass much of  their time in the
open air, form a striking  contrast with  the pallid countenances, the
general listlessness, the fragile frames, and the  inactive disposition of
those who are confined nearly the  whole day within doors.
   The temperature of the air to which infants and young children are
exposed, is equally important with its purity.  It has been shown by 
36
DISEASES  OF CHILDREN.
   Dr. W. F. Edwards, that in the young of the human  species, as well
   as of the warm-blooded  animals" generally, the power of generating
   heat is but  imperfectly developed, and that, consequently, not only is
   the temperature of their bodies less, but their capability of resisting the
   depressing influence of cold is far below what it is in after life.  We
   can readily perceive, therefore, that exposure to air of too low a tem-
   perature must be peculiarly prejudicial to young infants;—and although
   the power of producing heat goes on  increasing until adult age, still,
   young children, and especially  those  of a feeble  constitution, will
   suffer discomfort, and have their health impaired by a degree of cold
   that would  be tolerated  with impunity bv  those who are older and
   more  robust, ^vftaal^ • fv<ffe>«Ul? ^Z5L~Z* <-+? &h*
     According to Drs. Milne Edwards, and Villerme, of Paris, and Dr.
/  Trevisano,  of Ca'stel  Frarfeo, in Italy—and the accuracy of these
-gentlemen's statements is fully confirmed by Drs. Lombard, of Geneva,
   and Quetelet, of Brussels, and  by subsequent  observers—the greatest
   mortality among children,  from  birth to  the age  of three months,
   occurs during the season of greatest cold, and consequently, we find
   that the  mortality  among children is greater in northern than  in
   southern  climates; and in the northern climates, during winter than
   during the other seasons of the  year.   Allowance, however, must  be
   made for particular local circumstances, or the occasional visitation
   of epidemic diseases :—thus, in most of our  larger cities,  in the middle
   and southern states, the excessive heat of the summer, when conjoined
   with  causes  which prevent free  ventilation,  and  tend  otherwise  to
   diminish  the purity of the air, produces annually  a very great  mor-
   tality among children under two years of age; rendering, with us, the
   season of greatest warmth far more fatal to infants than even that of
   the greatest cold.
     From  the foregoing facts it must be evident,  that to maintain a
   sufficient degree of warmth in the air of  the apartments occupied  by
   children, is indispensable, not only to their comfort, but for the preser-
   vation of their health and lives.  It  will not do, however, for parents
   or nurses to judge of the temperature required for the well-being of an
   infant by their own sensations—for what may be sufficiently comforta-
  ' ble to them may be destructive to the latter—nor should they suppose
   that because no alarming symptoms supervene  immediately after the
   exposure of children to cold, their constitution does not suffer—uneasi-
   ness,  at first slight, is by a  repetition of the cause, almost invariably
   converted into serious disease.  Thus, inflammation of the throat,  air
   passages, or lungs, more or less severe, or a predisposition to incurable
   affections of these and other parts, is, in infants and young children,
   often  the result of exposure to a degree of  cold, from  which danger-
   ous consequences are least suspected to ensue.
      Infants, and children of a feeble constitution, or in whom, from any
   cause, the powers of life have been  depressed, should especially be
   guarded from exposure to the external air during cold or damp weather.
   Important as the enjoyment of the fresh  air is to the health and comfort
   of infants, the practice of carrying them abroad in cold weather, under
   the idea of confirming their strength or rendering  them hardy, is not 
MANAGEMENT OF CHILDREN.
37
less cruel than absurd.  A child of sufficient age and vigour to enable
its  system to react  promptly under  the depressing influence of cold,
and, by an increased evolution of heat, to maintain its  temperature,
may, it is true, sustain with impunity, or even derive advantage from
exposure for a short period to a moderate degree of cold,—but,  in all
others, so far from an increase of strength and vigour, or the ability
to endure without injury sudden  vicissitudes  of temperature,  being
acquired by their exposure to cold, either in or out of doors, the very
opposite effect will  ensue—if an  attack of severe disease be not im-
mediately produced.
  While urging the  importance of a due  degree of external heat, to
the comfort and health of infants, and the necessity of carefully pro-
tecting them from exposure to even  slight degrees of cold, we would
not wish to be understood as recommending that the air of the rooms
they occupy should  be kept at a high degree of  temperature.  To
subject children of any age constantly to an over-heated atmosphere,
is highly improper.   From  the  excessive stimulation thus produced,
and the profuse perspiration in which their bodies are almost con-
stantly bathed—especially during sleep—they  soon become relaxed
and enfeebled,—their nervous  system, at the same time, acquires  an
undue degree of irritability; every trifling vicissitude of temperature  .
causes them to suffer, and they become  liable to  attacks of severe
disease from the slightest causes.
  A temperature of from §8° tc^70° of Fahrenheit, is that best adapted /
to the nursery—a less degree of "heat would  not  be prudent for very
young children, and  even those more advanced in  age will scarcely
tolerate, with perfect impunity, a much lower temperature.  It is  to be
recollected,  that notwithstanding a  robust and healthy child, when a
few years old, will suffer  no injury from a dry and  cold atmosphere,
whilst engaged in active exercise—even out of doors—yet, when at
rest, within doors, its health and comfort will be best promoted by the
air of the room  being sufficiently warm to prevent the least sense of
chilliness.
  The injurious consequences  we have pointed out as resulting from
constant exposure to too high a degree of artificial heat, will indicate
the propriety of  protecting children,  as much as possible, from the in-
tense heat which usually  prevails during the summer  months,  espe-
cially in the cities of our southern  and middle states—by a free venti-
lation of the  apartments they occupy, and by frequent exposure to the
fresh  air, in  open and shady situations.  The deleterious effects of the
heated and  confined air of a large  city upon the health of children,
may, in a great measure, be  counteracted by these  means, as well as
by daily rides into the surrounding country, or by excursions upon the
water; the means for which, in most of our larger cities, is placed
within the reach  of  all by the  numerous  steamboats that depart for
short  trips, at almost every hour.

                 2.—Cleanliness.  Bathing.
  The important functions of the skin, and the intimate relations which
exist  between it and every other  part of the body,  point  out the 
38
DISEASES OF CHILDREN.
 necessity of guarding it from whatever is calculated to impede its free
 and healthful action.   More especially should the utmost attention be
 paid to preserve it, by frequent ablutions, from the influence of foreign
 impurities, as well as from an accumulation  of its own  excretions.
 Whenever  this is neglected, disgusting, painful, and  obstinate cuta-
 neous eruptions are liable to be produced, or the foundation is laid for
 derangement  of  function or serious disease of one or other of the
 internal organs.  At no period of life is  injury more liable to be pro-
 duced by a neglect of cleanliness, than during infancy—at no period,
 therefore, are repeated ablutions of more importance.
   Immediately after birth, the body of the infant requires  to be care-
 fully washed, and the  same  operation must afterwards be performed
 daily to insure its comfort, and to preserve it from disease.
   The skin of the new-born infant  is  more or less covered  with a
 white unctuous matter, the  vernix caseosa; whatever office  this may
 perform in  foetal  life, it is unnecessary, and even injurious, to allow it
 to remain for any length of time after birth.  It may be very readily
 removed by washing the  skin with warm water  and a soft cloth or
 sponge.  Dewees and others recommend, in order to facilitate the
 removal of the vernix caseosa, to "smear every part of the child with
 fine hog's lard," and then to wash with  soap and  water.   Dr.  Eberle
 recommends  smearing the body with the  yolk  of  eggs, when, he
 remarks, "  simple warm  water will be  sufficient to cleanse the sur-
 face thoroughly."  Notwithstanding  the high  authorities by which
1 these practices are recommended, we doubt their necessity, and are
 far  from  being  convinced of their propriety.  When  a  sufficient
 amount of  water, of a proper temperature, is employed, and  sufficient
 care is taken in  the process of washing, we have  seldom seen any
 difficulty experienced in clearing the skin of its caseous coating.
   In washing a new-born infant, no degree of friction should be used,
 for fear of irritating or abrading the tender skin ; and notwithstanding
 it is important to remove, as soon as possible, the caseous matter from
 the folds of the joints, where it is generally most abundant, yet if this
 cannot be readily done at the first  washing, what remains should be
 left, and at the second washing, with ordinary care, the skin may be
 freed from  every portion  of it.
   The washing being completed with  as little delay as possible, the
 surface, particularly the folds of the  joints, the neck, the  groin, &c,
 should be thoroughly dried  with a soft  napkin, and the child dressed
 as quickly  as possible.
   We have directed the infant to be washed in warm water.   This is
 not a matter of indifference; to plunge the body of a new-born child
 in cold water, and keep it  there until the process of washing is com-
 pleted, is to subject it to unnecessary suffering—if not to endanger its
 life; when the same process is pursued, day after day, although the
 robust and vigorous  may  survive  it,  and  even acquire additional
 strength and vigour from the dangerous ordeal through which they
 have been  made to pass, the generality  of infants will suffer  from it
 serious discomfort, if not permanent injury; while  the feeble and de-
 bilitated will inevitably perish under it. 
MANAGEMENT OF  CHILDREN.
39
   The absurd notion so generally entertained, that the cold  bath is
 adapted, in all cases, to augment the strength and invigorate the powers
 of life, and which  has induced so many to view it as an important
 agent in  the physical education  of infancy and  childhood, has been
 fully exposed by the experiments of Dr. Edwards  and others.   By
 these  it has been  shown that the direct effect of cold water, when
 applied to the surface, is invariably to depress the strength and vigour
 of the system; and that  this depressing effect  is always in a direct
 ratio with the feebleness or exhaustion of the individual subjected to
 its influence.  When we add to this, that by the same experiments it
 has been  proved, that the power of generating heat, and consequently,
 the ability to support a diminution of temperature, is at its minimum
 at birth, and goes on gradually augmenting as the child  approaches
 maturity, we can readily understand the  folly and danger of applying
 cold .water to the skin of a  young infant, as well as the necessity of
 the water in which it  is washed being always sufficiently warm to
 prevent the production of the least degree of chilliness.
   As the infant increases in age, the temperature of the  water may be
 gradually reduced—watching, however, its effects the  more closely,
 the nearer it is reduced to a state of coldness.  If its application to the
 surface be followed by a glow all over the body, and a sense of com-
 fort in the child, it  is not too cold; but should  it occasion chilliness,
 pallor of  the face, or evident languor  and depression, it must be im-
 mediately exchanged for water of a higher temperature.  As a general
 rule, however, during no period of childhood should the washing be
 performed in perfectly cold water.  Tepid water is  better adapted to
 remove impurities from the surface, and to preserve the skin in a healthy
 condition, while injury to health is less liable to result from its use.
   As it is important that the entire surface of the body should be sub-
 jected to daily ablution—for without this, personal cleanliness cannot
 be maintained—we are  in  favour, even from the period of birth, of
 applying the water in which the child is washed in the form of a bath.
 It is much better to  immerse the body of the new-born babe  into a
 large basin of warm water,  its head and  shoulders being supported by
 the hand and arm of the nurse, than to subject its tender body to the
 handling and exposure  which are necessary when it is washed upon
 the lap.  By immersing it in a sufficient  quantity of  warm water, the
 washing, also, can  be more promptly and effectually performed than
 by the too common practice of sopping  portion after portion of the
 surface with a wet  rag or sponge—while at the same time, the infant
 is spared the danger of becoming chilled, which can scarcely be done
 by any other plan.  Nothing should be added to the water—with pro-
 per attention an infant may be kept perfectly clean without the  use of
 soap.  When, however, from any cause soap is required, the finest
white kind should be employed.
   The practice so generally pursued of bathing the head of infants, at
the first and subsequent dressings, with some spirituous  liquor, should
be discountenanced; it does  no possible good, but  by  irritating  the
scalp, cannot fail to  cause considerable smarting, or even more serious
mischief. 
40
DISEASES OF CHILDREN
             During the entire period of infancy, the whole surface of the body
           should be washed in warm or tepid water every morning—and during
           the day,  such portions of it as may become soiled by the natural eva-
           cuations, or from any other cause.  Nor should the maintenance of
           personal  cleanliness, by similar means, be neglected after the child has
           passed beyond the term of infancy.  The daily use of the bath, and
           more frequent ablutions  of the face, hands, and feet, should  still  be
           enjoined, and any neglect in regard  to  them prevented by a  careful
           surveillance on the part of the parents or guardians.  Frequent bath-
           ing in tepid water, independently of its removing  from the surface
           every source of impurity, benefits the health of the child by promoting
           the functions of the skin, and encouraging the free and regular circu-
           lation  of the blood through its numerous  vessels, securing thus the
           regular growth and full development of  every portion of the body.
t*'<d4*A»t,  "I consider bathing," remarks Struve, " as the  grand argajiiun of
           'supporting  health, on which account, during infancy  it ought to  be
           regarded as one of those sacred maternal duties, the  performance of
           which should on no account be neglected for a single day."
             The time during which the child should remain in the bath will vary
           according to its age.  For the first month after birth the immersion
           should not continue longer than three or four minutes—the time being
           gradually prolonged as the child advances in age—continuance in the
           bath  beyond ten or fifteen minutes is, however,   unnecessary, and
           scarcely  prudent at any period of childhood.  Children  should not be
           permitted to enter the  bath  when  in a  state of profuse perspiration,
           nor for some hours after a meal.
             Intimately connected with the subject of cleanliness is a proper at-
           tention to the hair.  In early infancy, all that is  necessary is to  subject
           the head, in common with every other part of the surface of the body,
           to daily ablutions in warm water;  as the  child increases in age, and
           the hair  begins to grow, a little soap may be added  to the water with
           which the head is washed, and the hair should be repeatedly but gently
           cleansed with  a soft brush.   This will prevent the greasy matter which
           exudes from the scalp accumulating and forming a  dry black crust—
           disgusting in its appearance, and liable  to occasion  ulcerations of the
           skin beneath it of a most obstinate and  painful  character.
              Many parents are opposed to frequently washing the head of an in-
           fant, from a supposition that it will  render it liable to take cold, and be
           otherwise prejudicial to health; no such  fears, however, need be enter-
           tained—the child's health will be much more endangered by neglecting
           to keep its head scrupulously clean than by the too frequent application
           to it of water of  a proper  temperature.  A soft brush should alwavs
           be  used instead of a comb, for cleansing and  smoothing the hair "of
           young children, there being less  danger of the brush scratching or
           unduly irritating  the skin.
              During the entire period  of infancy and childhood  the  hair should
           be  kept short.   Nothing is more common than to see a luxuriant head
           of  hair accompanied in children with  paleness of complexion, weak-
           ness of the eyes, and frequent complaints of headache;  independently
           of  this, eruptions and ulcerations of the scalp are  more apt to occur, 
MANAGEMENT OF CHILDREN.
41
than when the hair is kept short and thin.  The degree of heat, also,
which a profuse  growth of hair  produces in  the head, invites to the
brain an  undue amount of blood, and augments its liability to those
diseases to which at this period of life it is always more or less pre-
disposed.
  " The trouble, also, of keeping  long hair sufficiently clean, and the
length of  time necessary for  that purpose, are often a cause of much
ill humour, and many cross words between children and their atten-
dants, which would  be better avoided.   Mothers, whose  vanity may
be alarmed, lest  constantly cutting the  hair, until the eighth or ninth
year, should make that of their daughters coarse, may be assured that
they have no cause for this apprehension, if the hair  be kept constantly
brushed.  I have never seen softer, better hair, than  on girls who have
had  it kept short,  like that  of schoolboys, until they were in their
tenth year."

                          S.~ Clothing.
  " The essentials in the clothing of children," remarks a sensible
writer of the last  century, " are lightness, simplicity, and looseness.
By its being as light as is consistent  with due warmth, it will neither
encumber the child, nor cause any waste of its  powers; in consequence
of its  simplicity, it will be readily and easily  put on, so as to prevent
many  cries and tears; while by its looseness it will leave full room for
the growth and due and regular expansion of the entire frame; a mat-
ter  of infinite importance for the securing of health and  comfort in
after life."  (Willis.)
  The texture and amount of clothing, during infancy and childhood,
should be such  as to preserve every portion of the body of a sufficient
and  equable warmth—neither allowing  it, on the one hand, to experi-
ence the  slightest sensation of chilliness, nor on the other, unnecessa-
rily  augmenting its heat.   The younger  the infant the warmer should
it be clothed, and the more care should be taken to protect every part
of its  surface by an appropriate covering.  Older children, especially
in the variable climate peculiar to our northern, middle, and western
states, require their clothing to be adapted in its  material and amount
to the average state of the weather.   It  should be neither too  flimsy
and  light in summer,  nor  too warm and oppressive in  winter;  a
medium covering being that ordinarily worn throughout  the year,
with appropriate additions, adapted to changes in the weather, to the
prevailing temperature of the season, or to particular circumstances of
exposure.
  For the under garments of children flannel is indispensable during
the autumnal, winter, and  spring  months.  Worn in contact with the
skin  flannel preserves, better than any other material, a moderate and
equable warmth of the body, and  more effectually protects it from the
influence of sudden alterations in the temperature of the atmosphere.
During the  summer season, however, the flannel may be changed for
muslin or  cotton; the softer species of which,  that which is neither of
a very fine texture  nor highly dressed, should be selected.  Even in
winter, when from any unusual sensibility of the surface, the contact of 
42
DISEASES OF CHILDREN.
the flannel excites an irritation of the skin, or produces profuse perspi-
ration, thick muslin may be substituted, or a soft muslin dress may be
worn next to the body, and over this a flannel garment.
  The fashion of a child's clothing is a matter of  perfect indifference
if the material of which it is composed be sufficiently warm, and it be
made perfectly loose, and to protect effectually every part of the body.
To leave the neck, shoulders, and arms of a child nearly or quite bare,
however warmly the rest of the body may be clad, is a sure means of
endangering its comfort and health;  violent attacks of croup or bron-
chitis, or even inflammation of the lungs, are often induced by this irra-
tional custom; and it is not improbable that the foundation of pulmo-
nary consumption  is often thus  laid during  childhood.   It is an
important precaution, therefore, to have the dress worn by children so
constructed as to protect  the neck, breast, and shoulders, and with
sleeves long enough to reach to the wrists.
  By having its garments of sufficient length, the lower extremities of
an infant may be kept  perfectly warm, especially if in cool  weather,
the feet are covered with soft woollen socks; but when it becomes old
enough to be carried abroad, or  commences to walk, its legs and  feet
should be defended by soft woollen stockings  which reach above the
knees, but  without  garters, and  by easy comfortable  shoes, of some
soft  material, with  leather soles; the latter are indispensable when-
ever the child is  placed  upon the  floor, to protect its feet from being
injured by any  sharp  substance with  which  they may accidentally
come in contact.
   The head, even from  birth, may be fully protected,  under  every
degree of exposure to which it is proper to subject  an infant, without
the necessity of enveloping it day and night with a cap.  When on the
lap of the mother or nurse, if  the room be of a proper temperature, a
soft  woollen shawl, thrown loosely around the infant's neck and shoul-
ders, and brought up over its head so as to form  a kind of hood, will
be sufficient to guard it from any accidental draft of cool air.  When
carried abroad, in  cool weather, a  similar covering will render  any
other than a thin, light, and soft cap, unnecessary.
   Caps  when worn within doors, are objectionable  by keeping the
child's head too warm, and thus inviting to the  brain an additional
amount of blood, at a period when, from its soft texture and great  vas-
cularity, it is prone to hypersemia  and  to inflammation from slight
causes.  The material of which the cap is composed, being generally
lace or worked muslin, by the roughness or harshness of its  surface is
calculated also to fret and irritate the delicate skin with which it  is in
contact, and if not productive of eruptions, cannot fail to occasion  con-
siderable uneasiness to the child. By covering and confining the ears,
 and compressing them against the sides of the head, the cap, even if
 it occasion no other injury, is  apt to  produce pain and inflammation of
 these organs, or a disgusting,  sometimes dangerous, soreness and run-
 ning behind them.
   It is  all-important that every part of a child's clothing  should  be
 sufficiently loose to give perfect freedom to all its  movements, and to
 prevent compression of any portion of the  chest, loins, or extremities; 
MANAGEMENT OF CHILDREN.
48
 without this the muscles will fail to acquire their proper development
 and strength, the chest  its full expansion, or the figure that upright-
 ness and perfectness of form, upon which beauty and  health so inti-
 mately depend.
   As a general rule, the clothes worn at night should be both lighter
 and looser  than the  day clothes.   The additional warmth  produced
 by the bed and its coverings renders unnecessary the same amount of
 garments as is required during the day, and would be liable, were no
 change  in the clothing made, to overheat the body, or to exhaust it
 by causing  profuse perspiration ; while the least restraint or compres-
 sion of  the limbs, chest or abdomen renders the sleep disturbed—and
 by impeding the free action of the heart and lungs, is liable to produce
 various uneasy sensations or even partial  or general spasms.
   Every article of dress worn during the day should be  changed on
 retiring  to rest: this is demanded for the promotion of the comfort as
 well as the health of children; it allows  the different portions of the
 clothing to  be aired  at  short intervals, and prevents any injury that
 might result from the gaseous and  vaporous exhalations given off by
 the skin, and imbibed, to a greater or less extent, by the clothes being
 retained too long in contact with the body.
   For infants, a simple long gown of flannel in cold, and of muslin in
 warm weather, made with wide sleeves covering the  whole of the
 arms, is  the most appropriate night-dress.  For older children, of both
 sexes, who  are  very apt in their sleep to thrust their arms and legs
 from beneath the bed-clothes, it is better to make the night-dress in the
 form of  a jacket and long trousers, with feet; the whole being,  how-
 ever,  in one piece, and secured, where it is left open behind, to enable
 it to be put  off and on, with tapes.
   Every article of clothing worn during infancy and childhood should
 be kept scrupulously clean, to which  end it should  be frequently
 changed.  It is all-important likewise that it  be preserved as  dry as
 possible.  During the early period of infancy especially, the under
 garments should be examined at short intervals, and if any one of  them
 has become wet, it should be immediately removed and replaced by
 a dry and clean one.  If this be neglected, the child is liable to become
 chilled, and its  health to be endangered.  We have known  severe
 inflammation of the skin about the upper portion of the thighs and
 nates to be induced when a wet diaper has been allowed to remain on
 for too long a period.
   For fastening  and adjusting the clothes of young children, tapes
 should be substituted as much as possible,  for pins; painful punctures
 and scratches, from the points of the latter being brought in contact
 with the skin in handling infants or even by their own movements, are
 of daily  occurrence, and we have  numerous  instances  on record of
 more  serious consequences  resulting  from the  pins, accidentally de-
tached, becoming embedded in the infant's flesh.

                            4. —Food.
  The milk  of the mother is the natural and  only proper  food for an
infant.   " Nature does not afford, nor can art supply any substitute." 
44                 DISEASES OF CHILDREN.
To it, therefore, should the child  be entirely confined, whenever it is
possible, until the process of dentition has made some progress.
  The difficulty of rearing an infant, when from any cause it is deprived
of the maternal  breast, or  that of a healthy nurse, is pointed out by
almost every writer that has treated on the subject of infantile hygiene.
In the asylums for foundlings and young infants, where feeding by the
hand, has been substituted for the natural nourishment, the mortality
has been, invariably, the most appalling.   Forty, fifty, sixty, and even
as high as eighty and ninety per cent, of the infants being destroyed.
—(Annates  d'Hygiene,  t. xix.)   It is true,  as Auvity very properly
remarks, that, in the domestic nursery, and where the utmost care and
attention are bestowed at every moment, upon a single infant, feeding
by the hand is far less destructive to life.  Under such circumstances
robust and healthy children have certainly been reared entirely with-
out the breast.  Still the task is a difficult one, and against the few
instances in which it succeeds, we must place the very many in which
it entirely fails.   " I am convinced," says Dr.  Merriman, " that the
attempt to  bring up children by hand  proves fatal, in  London, to at
least  seven out of eight of these miserable sufferers; and this happens,
whether the child has  never  taken the breast, or having been suckled
for three or four weeks only, is then weaned.    In the country, the mor-
tality among dry-nursed children is not quite  so great as in London, but
it is abundantly greater than is generally imagined."  When, therefore,
from  any cause, and the case is one of very rare occurrence, a mother
is unable  to suckle her infant, the  breast of  a proper nurse should be
substituted.
   The danger which attends every attempt  to  rear an infant by the
hand, as it is termed,  is indeed now  very  generally recognised by
mothers; the importance, however, of confining it entirely to the breast
during the  first months  subsequent  to  birth, is still far  from being
understood.   It is too often the case that an infant is forced to partake
daityof substances, to the digestion of which the powers  of its stomach
are totally inadequate, or which are altogether unadapted to afford  to
it wholesome nutriment, under the absurd notion that some other food,
in addition  to the  mother's milk, is necessary to support its  strength,
and promote  its growth.   The beneficial effects of the natural  food
are, in this manner, in a great measure counteracted, while the infant
is subjected to many of the  dangers resulting from dry nursing; the
functions of its digestive organs become almost invariably deranged;
it suffers more or less  from flatulence, griping pains, and  irregularity
of the bowels, and becomes weak and emaciated, even if distressing
spasms of the glottis, general convulsions, or still more serious disease
be not induced.
   As a general  rule,  subject to few exceptions, the mother's milk
alone will afford, during the first eight, ten, or twelve months of exis-
tence, adequate nourishment, while it is that  best adapted to promote
the proper and regular growth of the infant's body, and to  maintain its
stomach and all the other organs in a state of health.   Circumstances
may, however, occur  under  which it will be necessary and prudent,
notwithstanding the infant continues at the breast, to supply it with ad- 
MANAGEMENT OF  CHILDREN.
45
ditional nourishment; thus, when the milk furnished by the mother is
too small in  quantity, although perfectly good in quality, in addition
to the food it receives from the breast, the infant may be supplied, at
proper intervals, with a mixture of cow's milk and water, sweetened
with loaf sugar.
   The milk should be taken fresh from a healthy cow, and if possible,
always, from the same animal; because, as Dewees judiciously remarks,
different cows, feeding upon the  same materials, often give different
qualities of milk, and the stomach, very generally, becomes reconciled
more readily to any one certain quality, than to a mixture.   The
quantity of milk required for use should be diluted with nearly an equal
quantity of warm water, and well sweetened with the best loaf sugar.
Neither stale nor skimmed  milk, nor that which has the slightest ten-
dency to acidity should, on any consideration, be  employed;  nor
should any greater quantity of  the  mixture be made  than will be re-
quired within a short period, lest it turn sour by  standing.  With this
mixture the infant should always be fed by means of  a  sucking-bottle
—such as is  now supplied by all our apothecaries.  The advantages
of the bottle are, that the infant draws from it its nourishment by pre-
cisely the same process as it does its natural food from the breast of
its mother.  In this  manner the food becomes mixed with the  saliva
previously to being swallowed, and  the stomach  is less apt to become
over-distended  by too much being  taken at one time, as is the case
when the infant is fed by means of a spoon.
   The utmost care  should be taken  to preserve the sucking-bottle and
its tube perfectly clean and free from sourness.  After each time it is
used, any portion of the contents that remain should be poured  out,
and the bottle with its tube immediately well washed in hot water, and
always rinsed out with warm water before it is again used.
   We have recommended diluted cow's milk sweetened with loaf sugar
as being, under ordinary circumstances, the most appropriate aliment
for an infant that may require nourishment in addition to what it obtains
from its mother's breast.  We believe it to be the best, also, during, at
least, the first four or five months, when, from  any cause, the child has
to be brought up entirely by hand.   It affords sufficient  nutriment, in
general agrees well with the stomach, and in most situations is readily
obtained  pure  and  fresh.  The milk of the ass  and mare, which in
their composition  certainly approach nearer  to that of the  human
female than the milk of the cow or  goat, is strongly recommended by
many of the continental writers for the  nourishment  of infants, while
a late writer, Carault, (Guide des Meres,) gives the preference to ren-
net whey and a decoction of malted barley.
   The nearer the aliment that  is given to an  infant, in addition to, or
as a substitute  for its mother's milk, approaches  in its qualities  to the
latter, the better.   Scarcely anything, in the  form of food, could be
devised  that  is so little adapted for nourishment, during the first months
of existence, or more  liable to produce derangement of  the  stomach
and bowels, and injury to the  infant's health  generally, than the vile
compounds of flour and milk, bread and  water, or oatmeal and  water,
large quantities of which, under the names of pap, panada, and  water- 
46
DISEASES OF CHILDREN.
gruel, were, until a very late  period, forced down an infant's throat,
under the absurd supposition, that  this was necessary in order to pro-
mote its strength and vigour, and to save the mother from the too great
exhaustion which, it was imagined, would ensue if the infant was per-
mitted to depend  upon the breast for its entire nourishment.  But as
the powers of the infant's stomach are altogether inadequate to digest
properly or entirely the articles of food  thus  forced  upon it, gastric
irritation, griping pains, disturbed sleep, fits of violent screaming, fre-
quent watery discharges from the bowels, discoloration of the skin,
and rapid  emaciation are the  usual consequences of their use; to re-
lieve these, the  little sufferers too often, are  made to partake of an
additional quantity of the same kind  of food, or it is liberally supplied
with carminatives and  cordials, and thus  the mischief is  constantly
increased, until some severe or incurable disease is induced.
  " That the jaundice of infants is  generally produced by dyspeptic
irritation, I have not," says Eberle, " the slightest doubt; mucous irri-
tation of the duodenum is well known to be an active and frequent
source of this malady, and this affection is very rarely found to occur,
in new-born infants, without being preceded by decided manifestations
of irritation of the digestive organs.  Let the infant's stomach be once
or twice filled during  the twenty-four hours with gruel, or any of the
ordinary preparations employed by  nurses for this purpose, and the
chances will  probably be  as ten to one, that acidity,  vomiting, colic,
griping, and jaundice will supervene."
  Very vigorous and healthy infants, it is  true, often pass through the
gastric irritation and distress, produced by improper nourishment soon
after birth, without sustaining  any permanent injury in health, or con-
stitutional infirmity.  After four or five months of flatulence, griping,
and disordered bowels, the digestive  powers gradually become inured
to the  impressions of the food, and  a considerable degree  of health
and vigour is obtained.  In many cases, however, the irritation which
is thus kept  up  in the  stomach and bowels, does not pass off in so
favourable a manner.  Jaundice, chronic and unmanageable diarrhoea,
emaciation, slow fever, enlarged  mesenteric  glands,  dropsy in the
brain, scrofula, chronic affections of the liver, epilepsy, and other dan-
gerous maladies, may, and not unfrequently do, result from  this state
of the alimentary canal, during infancy.
  After dentition has made some progress, a portion of gum, barley,
or rice water may, with propriety, be added to the sweetened milk ; or
we may give, in addition to it, a little plain beef or mutton broth, or
the juice of the same meats when not over-roasted, deprived, as much
as possible, of fat.  But as a variety of food  is more apt to disagree with
the stomach, than one simple article  when properly selected, in every
instance in which the infant appears to be well nourished, there should
be no hurry in changing or adding to its diet, which, until  several of
its teeth  have been cut, should consist, pretty  much, of the articles
above enumerated.
  Whatever  may be the food with which the infant is  nourished,
whether  it be solely the breast-milk of the mother, or a  mixture of
cow's milk, water, and  sugar, care should be taken that it be allowed 
MANAGEMENT OF CHILDREN.
47
to partake of it only in such quantities, and  at  such intervals, as are
absolutely necessary to its proper nourishment.   The stomach should
never be  overloaded;  nor should  the  process of digestion, which,
though extremely rapid  in  the  earlier periods of life, nevertheless re-
quires a certain period for its perfect  accomplishment, be interfered
with by the too frequent introduction of food.
  In the early period of infancy, the rapidity with which the digestion
is effected, requires the stomach to be supplied with food at very short
intervals;  but as the infant increases in age, these intervals are gra-
dually to be lengthened; so that, while at first it takes the breast almost
every few  hours, or even oftener, it subsequently requires it only three
or four  times in the course of the day and night.
   The rule to be observed in nursing or feeding an infant is, never to
withhold from it the breast or bottle when it indicates a desire to par-
take of it, but, at the same time, not by any means to provoke it to partake
of either when it exhibits no such desire.  It  is surprising, how very
early, by  a neglect of this rule, a morbid appetite may be created.  It
is too often the custom with mothers and nurses to take it for granted,
that because an infant cries, it must be hungry, and to force it, then, to
take the breast; or when fretful from any cause to  attempt to appease
it by administering food.
   No fixed rule can be laid down as to the number of times, or pro-
per  periods, at  which an  infant  should partake of nourishment; the
natural wants of its system  ought alone  to be consulted; and these
are made known, even in the youngest infant, by signs which the most
superficial observer can scarcely mistake.
   By a little care, instead of having the child, when awake, constantly
hanging at the breast, it may be soon taught  to require it only at re-
gular periods; and the danger of over-distending its stomach with milk
will then be, in  a great measure, avoided.  It is not uncommon for an
 infant to be accustomed to lie all night at the breast; a practice from
which injury may  result, not only by inducing the child to overload its
stomach, but  by interrupting its  sleep,  and causing it to breathe for
many hours a confined, heated, and impure atmosphere.
   Infants, who  are confined entirely to the breast-milk of a healthy
mother or nurse, or, at least, with no other  addition to it  than  cow's
milk diluted with water and sweetened  with loaf sugar,  until after the
first dentition is accomplished, have always  appeared to  us to thrive
well, and to be seldom troubled with  affections of the stomach and
bowels.   Nevertheless,  after  dentition has  made  some  progress, we
may, with great propriety, allow them, once or twice in the  course of
the day, in place of the milk  and water, to partake of rice  flour, ar-
row-root, or tapioca, prepared with milk, and well sweetened—milk in
which  grated cracker or  stale bread has been well  stirred—animal
broths with bread or cracker mixed in  them—or roasted potatoes re-
duced to a fine thin pulp with cream.   These articles should,  however,
be given in moderation, and be invariably prepared  fresh each time
they are used.
   Until after the first dentition is completed, solid  animal food,  in our
opinion, should form no portion of an infant's diet; it is apt to increase 
48
DISEASES OF  CHILDREN.
the febrile excitement to which the system is already predisposed, and
to augment the irritability of the digestive organs, which is an almost
invariable attendant, to a greater or  less extent, upon the process of
teething.  Subsequent, however, to the completion of the first set of
teeth, a small portion of the more nutritive  and digestible  meats may
be allowed, to children in perfect health, once a day; but these should
never constitute their principal food:  which should consist of prepa-
rations of milk with various farinaceous substances, plain custard, soft
boiled eggs, bread and milk, and plain rice pudding.  " Many people,
from a  mistaken expectation  of strengthening weakly children, give
them much  animal food, sometimes twice or thrice a day; but it will
be found much more frequently to add  to their  debility than to in-
crease their strength.   Those  children, on the whole, who eat the  least
animal food, are the most healthy."   (Clarke.)
  Infants  experience, from even a very early age, the sensation  of
thirst, and are highly gratified and refreshed by a few  mouthfuls  of
cool water,  which, particularly during the period of teething,  they
earnestly, and repeatedly solicit, and swallow  with  avidity when  pre-
sented.  The gratification of this craving  should not,  therefore, be
neglected, but the infant should  be offered  occasionally a portion of
pure water, cool, but  not decidedly  cold.  From the inattention of
mothers and nurses, young infants suffering  from thirst, are not unfre-
quently refused the only effectual means of gratifying it;  and under
the supposition that they are  hungry, are made to take the breast, or
food is forced into their stomachs, of which they stand in no need, and
which rather enhances than diminishes the uneasy sensation  they ex-
perience ;  while a few spoonfuls  of water would immediately  satisfy
their wants and quiet their restlessness or  crying.
  As a general rule, it  is  undoubtedly a duty incumbent upon every
mother to nourish her own infant; occasionally, however, when from
disease, some constitutional infirmity, or a defect in the nutritive pro-
perties of her milk, the  mother is incapacitated from performing this
delightful task, it becomes necessary,  as well for her own good as for
that of her offspring, to transfer the care and nourishment of the latter
to a proper nurse.   The  choice of a proper  nurse is, however, a  mat-
ter of no little importance.
  It is essential, in the first place, that the female  at whose breast an
infant is to be nourished, should be in the prime of life; between twenty
and thirty years is the  most desirable age, though a few years below
or beyond this period will be of little importance, provided she  is of a
sound constitution, and enjoys perfect health.  This latter is an all-essen-
tial requisite, upon which the due support of the infant and its  future
health, in a  very great  degree depend.   No female, therefore, should
be selected  as  a child's nurse, who  is  labouring under any  bodily
infirmity; or who is even  strongly predisposed to consumption, scro-
fula, or convulsive diseases.  Her breast should be full, firm, and  well
formed, the nipples  sufficiently salient, and yielding the milk upon the
slightest pressure.  Her  catamenial discharge should be entirely sus-
pended.  Her milk, also, should be as  nearly adapted to the age of the
infant as possible; a slight difference, is,  however, no objection;  and 
MANAGEMENT OF  CHILDREN.
49
the fact of her milk being adapted to a somewhat younger infant than
the one she is about to suckle, is of  less importance than if it be milk
adapted to one many months older.
  But  it is not merely necessary that the foster-mother should enjoy
the physical advantages just enumerated ;  she should possess, likewise,
great mildness of disposition, considerable cheerfulness of temper, and
an inexhaustible stock of patience.
  There are a number of moral defects which render a female totally
unfit to give nourishment to an infant, or to assume the charge of it
in any manner.  Thus, an irritability of disposition, giving rise to fre-
quent gusts of violent passion, has been known to produce so deleteri-
ous an effect upon the milk, as to render  the infant liable to convul-
sions, that partakes of it, during, or  immediately after such exhibitions
of  ungovernable  temper.   Grief, envy,  hatred,  fear, jealousy,  and
peevishness, likewise, independently of their abstracting the mind from
the duties necessary to be fulfilled  towards the infant, by their influ-
ence upon her health, tend to alter the qualities of the nurse's milk, so
that the stomach of the infant  becomes quickly disordered by it; while
at the  same time it is altogether unfitted for its proper nourishment.
  We take too little into  consideration the pernicious and long-con-
tinued, if not permanent, injury, which  the character of  a nurse may
have upon the temper, the intellectual  powers, and the disposition of
an infant, by producing, through the nourishment she imparts to it, as
well as by her  treatment, permanent  derangement  of the  digestive
function, with consequent imperfect nutrition of the several organs,
and disturbance  of the nervous system.
   The ancients  evince, by their writings, a far greater acquaintance
with this important truth than exists at the present day, if we  may
judge from the advice of Plutarch to mothers who refuse to nurse their
own offspring.   "  They should," he observes, " be cautious at least, to
choose carefully the  nurses and attendants of their children ; not taking
the first that offers, but rather selecting the best that can be obtained.
These should, in the first, place, be Greeks in morals; for not more
attention does the  body of man require from the period of his birth, to
insure  the growth  of his limbs in strength and symmetry, than does
his mind, in order that, to  his moral qualities may be imparted  the
same firmness and perfection as to his physical.  During the period of
infancy the tender and plastic  mind  receives readily whatever impres-
sions, and assumes whatever form we may desire to  give it."
   Much, it is true, of the physical as well  as moral evil resulting from
the misconduct of a nurse may be obviated, if the mother entrust not
entirely the offspring to her care, nor consider, because she is obliged
to delegate to another the task of giving nourishment to her infant, she
is thereby exonerated from the duty of attending constantly to the pro-
motion of its welfare.
  The diet of a nurse—whether that nurse be the mother or a stranger
—should  be a subject of strict attention;  the quality of the food she
takes exerting a  powerful influence upon the character of the nourish-
ment she imparts to  the infant at her  breast, and consequently upon
the health of the latter.  Her  diet should  consist of such wholesome
                                4 
50
DISEASES OF CHILDREN.
aliment as is in ordinary use, simply cooked, and eaten in moderation.
Soups properly prepared, fresh  beef or mutton  plainly roasted or
boiled, with a proper amount of vegetables, are to be preferred to made
dishes, rich gravies and highly seasoned viands, as well as to salted
and smoked  meats.  As to vegetables, the  different leguminous and
farinaceous seeds or roots, variously prepared—the saccharine fruits
of the season, either cooked or perfectly ripe—and the various dishes
consisting of milk and vegetables, in common use, are all well adapted
as food for a nurse; and, with bread, should compose a considerable
portion of it.  Acid and unripe fruits,  pickles, and similar articles,
will very generally  prove injurious  to her milk, and of course  to the
infant she suckles.
  " I have known," remarks Marley,  " a plentiful secretion of milk to
be diminished in quantity, from the  over anxiety of the mother; who,
thinking it necessary her nurse should live well, allowed her to eat a
greater proportion  of  animal food than her  stomach  could digest.
Others, who  are fond of indulging  an excessive  and gross appetite,
take advantage of their situation as  wet nurses to satisfy their propen-
sity for eating,  under the plea of having two to support; others object
to certain meats,  as being injurious  to their little charge.  In fact, it is
well known that upon taking the situation of wet nurses, those women,
who, a short time previous would have been thankful for a plentiful
meal  however  homely, are suddenly transformed into fastidious  and
dainty beings,  considering their  wants  and wishes of  the greatest
importance.  I have always observed, that if a woman who is nursing,
eat heartily, but not immoderately, of plain food, avoiding that which
is stimulating, she will, generally speaking, preserve her health, the
result of which will be a plentiful secretion of milk.  I consider meat
once a day as quite sufficient."
  The only  drink  of a nurse should be water—simply water.  All
fermented and distilled liquors, as well as strong tea and coffee, she
should strictly abstain from.  Never was there a more absurd or per-
nicious notion, than that wine, ale, or  porter, is necessary to a female
whilst giving suck, in order to keep  up her strength, or to increase the
quantity, and improve the nutritive properties of her milk.  So far from
producing  these effects, such drinks, when  taken  in any  quantity,
invariably disturb, more or less, the health of the  stomach, and tend
to impair the quality, and diminish the  quantity of the  nourishment
furnished by her to the infant.
  They " excite," to use the words of a recent writer, " a feverish
state of the body, and create an artificial thirst,—a thirst which is not
expressive of any real  want of the  constitution, but  a certain proof
that the want does not exist.  The greater the craving for them, under
these circumstances, the more  certain we may be  that  they are not
needed, and that they will cause positive mischief to both mother and
infant.  The constitutions of both are stimulated by them beyond what
nature ever intended that they should be.   The laws which govern the
animal  economy are positively infringed,  and it is impossible that
either mother or infant  can escape  the  penalty of that infringement.
Both will suffer to a certainty in some shape or other, if not immedi- 
MANAGEMENT OF CHILDREN.
51
ately, at a future period."  " Thousands of infants are annually cut off
by convulsions, &c, from the effects  of  these beverages acting  upon
them through the mother."  (Courtenay.—London Lancet, Feb'y, 1840.)
  Moderate daily exercise in the open air, which, while it is sufficient
to counteract the effects of her sedentary occupation, is not carried to
the  extent  of producing fatigue, a nurse should never be induced to
neglect.
  The place in which the nurse resides, if the infant be committed to
her charge in her own habitation, is far from being a matter of  indif-
ference.  It should be either in the driest and most healthy part of the
city,  or, what  is preferable, in a  healthy situation in the country—
always freely ventilated and kept scrupulously clean.   A country resi-
dence for a nurse  has  one important advantage,—it indemnifies, in
some degree, the infant  for its removal from the maternal breast, par-
ticularly when the  mother inhabits the confined and  illy  ventilated
streets of a crowded city, the air of which is always more or less pre-
judicial in early life.  Infants  have been  found  invariably to suffer, to
a certain extent, in health, when, after being accustomed to respire  the
pure atmosphere of the country, they are removed to the city, and  made
to breathe the confined and impure air which prevails in too many of
its streets and dwellings.
  The proper  period for the infant to be taken from the  breast, or
weaned, and nourished  altogether  independent  of the  mother's  milk,
may be stated,  as a general rule, to be at the termination of a  year;
within which period, however, the occasional use of other food may
with propriety  be allowed, according  to the directions  already given.
  At the termination of the twelfth month, the cutting of the first  set of
teeth is, in  general, considerably advanced, and the digestive organs of
the child are in a condition to effect  promptly the solution  of almost
every species  of plain and wholesome food; hence the propriety of
depriving it entirely of the breast at this period.   But when,  as is
occasionally the case, the process  of dentition  is more rapid, and  the
infant is at the same time healthy and vigorous, it may be weaned at
any period after the tenth month; while on the  other hand, when den-
tition is  more  tardy, or the infant is weak and sickly, it may be pru-
dent, if the  mother have a sufficient supply of milk, to continue it at
the breast  somewhat longer than  a year. We are to recollect that,
while the health of an  infant is  very generally impaired by its being
too early weaned, on the other hand,  by  confining it  too  long to  the
breast, it may likewise be seriously injured, as well from a diminution
in the nutritive properties of the  mother's milk, as by this  being no
longer adapted  to the condition of the digestive organs of the infant—
the functions of which have become more developed—nor to the per-
fect nutrition of the several organs of the body.
  In deciding upon the  proper period for weaning, the season of  the
year should be  taken into consideration.   In many parts of the United
States, especially in the  larger cities, this is indispensable to the safety
of the infant.   When deprived of the breast at the commencement of
or during the summer months, its liability to a disordered state of  the
bowels, or to a severe attack of cholera infantum, is invariably much 
52
DISEASES OF CHILDREN.
increased.   Hence the spring or autumn should, if possible, be invaria-
bly made choice of for the period  of wTeaning; and only under circum-
stances of the  most imperious necessity, should it ever be attempted
during the season of greatest heat, unless the stomach of the infant has
already become fully  accustomed to other species of food, and the
functions of the digestive organs are performed w ith perfect ease and
regularity.   In  almost every instance, therefore, when upon the ap-
proach of summer, a mother ascertains that, from any cause, she will
be unable to suckle  her infant  until cool weather again returns, it will
be more judicious to wean it somewhat earlier than, under other cir-
cumstances, would  be desirable; so that  its  stomach may become
accustomed to the new kind of food which is to take the  place of the
mother's milk, before the  intense and continued heat of the weather
shall have  augmented  the  irritability of the entire  alimentary canal,
and rendered this liable to disease  upon a change of diet.  When, how-
ever, nothing occurs to prohibit it, the infant's safety from disease will
more certainly be secured, if the period of weaning be postponed until
after the heat of summer is over.
  When the diet of the infant has been properly attended to, previously
to weaning, and it has, for some  months, been accustomed to other
food than the milk of its  mother, it  may be deprived at once of the
breast, without the least fear of inconvenience resulting. It will, never-
theless,  not  be  proper to allow  the  infant, immediately after  it is
weaned, any amount of solid  or stimulating food; neither  should its
diet be composed of too great a variety of articles.   It should still be
kept, for some time, upon a simple, bland, semi-fluid aliment, taken in
moderate quantities, and at proper intervals; otherwise we run great
risk of over stimulating the system, or of oppressing the stomach, im-
peding or disordering the digestive process, and thus impairing or dis-
turbing the regular nutrition of the different parts of the body.
  At first, the principal food should be bread with milk—milk boiled
with rice—soft boiled  eggs—roasted potatoes  with  milk—oat  meal
gruel—plain rice pudding—the different  preparations of arrow-root,
tapioca and sago, and simple meat broths, mixed with the crumb of
bread or grated crackers, or  in which rice or barley has  been well
boiled.  After a time the child may be gradually accustomed  to a more
solid and nourishing diet.
  Until the age of puberty, preparations  of milk and the farinaceous
vegetables should, in fact, constitute the principal nourishment.   Dur-
ing youth, a large amount of animal food  is not necessary, as many
imagine, to promote the growth and vigour of  the body, nor to pre-
serve it from the inroads  of disease; these important ends are much
more certainly  attained by a more simple and less stimulating diet.
   Whatever may be the  kind of food allowed during childhood, it
should  never be taken in excess; wre are to  recollect,  at  the same
time, that children have usually very keen  appetites, and that a  suffi-
cient supply of nourishing food is absolutely necessary to  renew the
waste of their systems, and to supply materials for their daily growth.
Three, or perhaps four, light  meals a day, will, in general, be all that
is necessary. At one of these, the dinner or mid-day meal, animal food 
MANAGEMENT OF  CHILDREN.
53
—beef, mutton, or fowl, plainly boiled or roasted—may be allowed in
moderation; for the others, bread, or potatoes, and milk, various pre-
parations  of rice, or  rice and  milk, plain rice or bread pudding, or
custard, will form a proper and wholesome diet.   All salted and high-
seasoned dishes, all fat gravies, every kind of overdone  and richly
cooked food, should be forbidden.
  Some have objected  to butter for children; experience, however,
would appear to show, that a very moderate  allowance of butter, when
eaten upon bread, is by no means unwholesome.   Of vegetables, pota-
toes, carrots, turnips, beets, and cauliflowers, will  be  found the most
wholesome; they should all be of good quality, and, with the excep-
tion of the potatoes, should be  well boiled.   In general, the potato is
most easy of digestion, and agrees best with the stomach, when roasted;
it, as  well as the turnip, should  be eaten without  being reduced to a
fine pulp, or mixed with butter or fat gravy.   Children should never be
indulged in cakes or pastry of  any kind ;  they may occasionally take
a little of  the cooked fruit of a pie, but even this should be only in
moderation.
  The drink of children should  be simply water; or, occasionally, they
may be allowed milk, milk  and water, whey, or  very weak tea, with
milk  and  sugar.   Pure water,  however, is  the only beverage calcu-
lated  effectually to quench  thirst, and promote a free  and healthy dis-
charge from  the various excretory surfaces and  glands; and when
children are accustomed solely to its  use, they crave no other drink,
but prefer it on all occasions to every other.   Stimulating liquors,
whether  distilled or fermented, are not merely  unnecessary, during
childhood, but positively injurious: by the undue excitement they pro-
duce, they endanger the occurrence of fever, indigestion, inflammation,
or convulsions, to say nothing of the  danger of a taste for  " these
pleasing poisons" being induced, leading, in after life, to habits of con-
firmed and beastly intemperance.
   The period of a child's meals should be so regulated, that the inter-
vals between them may not  be so  great as to permit a sensation of
hunger being experienced for any length of time; but  at the same time
a sufficient period should be allowed to elapse between the meals, to
prevent a  disturbance of the  digestive  process by the introduction of
new food  into  the stomach, before  it  has properly  disposed of that
already taken.
  Children should get their first meal or breakfast, as  soon as  possible
after  they have risen, and have been properly washed and combed;
their stomachs are then empty,  and the  appetite is, in general, keen. If
food be too long withheld under such  circumstances, the  cravings of
the stomach  become either  too  importunate, and too much food is
taken, or the appetite entirely fails.  Supper, or the last  meal, should
invariably be composed of the plainest and  lightest  articles  of food,
and be taken an hour or two  before bed-time. l
  As little variety of food as possible  should be  set before children,
since  every additional article  becomes a new incentive to appetite, and
consequently to excess.  They should never be indulged with a second
course.  If they sit down with  an appetite they will  always satisfy it 
54
DISEASES OF CHILDREN.
by eating freely of the  first article presented to them, hence all  the
rest is superfluous, and therefore injurious. If the appetite be but slight,
the less they eat at the time the better,—as by taking but little, the  ap-
petite will more certainly return  at the next  meal.   But should this
instinct of nature for an  observance of moderation be  neglected, or be
attempted to be overcome by variety, repletion, with all its evils, will
certainly ensue.   Instead of a renewed and healthy appetite following,
as would have been the  case had the instinct been obeyed, the appetite
will be found diminished, and even headache, fever, oppression, nausea,
or vomiting may occur.
  Children should not be allowed to eat frequently of bread, bread and
butter, bread and molasses, sweetmeats, cakes or fruit, between meals,
for this will either destroy the regular appetite, or  induce  them to eat
too much.  In the first case, the stomach will be interrupted in its regu-
lar routine of  function,  consequently the appetite will be either irre-
gular or capricious; in the second case, all the evils attendant upon an
over distension of the stomach must  follow.   They should, therefore,
not be suffered to carry  food in their pockets, to eat between meals, or
during school-hours,—as this produces the injurious habit of requiring
food  at improper times,  by which the  digestion of the previous meal is
interfered with—a fresh  quantity of food being forced upon the stomach
before it  has properly digested that previously received.  We are  far
from advocating the  plan  which  debars  a  child  from "an adequate
quantity of wholesome  food at any period throughout the day, when
the cravings of a natural appetite actually demand it;"  but we never-
theless believe it far better that the child should be accustomed to par-
take  of food only at regular periods; and this is  very soon  effected,
when those periods  are made to correspond pretty  closely with  the
periods of stomachic digestion.
   Children who have no regular times for their meals, in general eat
too much, and when refused  food, however often  they may crave it,
become fretful and discontented.   " They eat all day long—and soon
impair their digestive powers,  and become sick and debilitated."
   Children should be early taught to eat slowly and deliberately, so
that each portion of whatever solid food they take  may be fully mas-
ticated.  To hurry children at their meals, by requiring them to finish
as soon  as their parents, though  they may be helped  last, and have
usually  much  greater  appetites than adults, is  injurious, by obliging
them either to leave off before  they have  had enough, or to swallow
their food without its being properly comminuted by chewing.
   Children are to be restrained from  any  violent exercise immediately
after eating.   They need not be kept  perfectly at rest, but merely pre-
vented from engaging in any pastime or occupation that requires con-
siderable bodily exertion; and, as they should be early  accustomed to
eat slowly, and chew their food well, on this account alone  the habit
of resting after a meal is of importance, as it prevents  them from
swallowing their food  hastily, in order that  they may return more
quickly to  their play.
   In regulating the diet of children, care  should be taken not to force
any  particular article upon them, after it is found,  by  fair  trial, not to 
MANAGEMENT OF  CHILDREN.
55
agree with their stomachs.  The contrary practice is  both cruel and
injudicious: cruel, because the poor child is forced to swallow what is
disagreeable to it; and injudicious, because it is liable to perpetuate a
disgust which, most probably, would have subsided, had no forcible
attempt been made to overcome it.  At the same time, however, great
care must be taken that permanent, capricious dislikes  are not formed
at this period of life against certain wholesome articles of food.  This,
however, is often a matter  of very great  difficulty—a good deal of
close observation and  discernment being required in  order to  distin-
guish  between  a  wayward prejudice and an  actual disgust.  The
former, if indulged in too long, may be converted into the latter—
while the latter may often, by judicious and well-adapted means, be
entirely removed.
   Children  should never be allowed to eat alone, unless the proper
amount of food be  meted out to them; otherwise they will, almost
always, eat too much.  Whenever a child demands more than is judged
proper for it, its importunities should always be resisted with firmness,
or it will too certainly acquire habits of gluttony.
   Children would  seem to have a natural taste for sugar, and all arti-
cles in which saccharine  matter abounds;  and they, in fact, are able
to partake of a greater  quantity, and for a greater length of time, of
these articles, without their appetite becoming cloyed, than is the case
with adults.  Whether or not children should be indulged in the use of
sugar  and other saccharine substances, has, however, been made a
grave  question of dispute by physicians.  " He," says old Slare, " that
undertaketh to  argue against sweets in general, taketh upon himself a
very difficult task; for nature seems to have recommended  this taste
to man and all sorts of creatures." Nevertheless, there are writers, and
of no mean eminence, who condemn, in the strongest terms, the use
of sugar and other sweet substances, as injurious to the stomach, de-
structive to the  teeth, and  otherwise prejudicial to the health  of the
system.  How such an opinion  could  have originated it is certainly
very difficult to imagine; so far from any bad effects being produced
by the free use of sugar, at least under ordinary circumstances of
health, it is shown, by the  most conclusive evidence,  to be  a  highly
nutritious and useful article of diet.
  It is, in fact, to the saccharine matter they contain, that a long list of
fruits and other vegetable  productions, which constitute so large a
portion of the food of man, and of the inferior animals, owe their nu-
tritive properties ;  and experience has fully  shown  that sugar forms a
very proper addition to the food of children as well as of adults. " It
is the only condiment," says Leroy, " proper during the period  of  in-
fancy."  Whether, however, pure sugar  can be eaten by itself, with
perfect safety, is somewhat doubtful.  To insure its  ready digestion,
and in that manner prevent  its turning sour  in the stomach,  it  would
appear to be necessary that it should be combined with other alimen-
tary substances.  It is  in combination with  mucilage and other vege-
table matters, that it  is met with in the juice of the cane, and in those
fruits which the experience of mankind  has shown  to be the most
nutritious.  Hence, as a  general rule, sugar should be given to chil- 
56
DISEASES OF CHILDREN.
dren rather as an addition to less palatable articles of diet, than as the
principal food.
  Much difference of opinion, also, exists as to the propriety of allow-
ing children to partake of fresh fruits: by many they are entirely in-
terdicted,  while by others  their  allowance is qualified  by numerous
restrictions not very  easy, under ordinary circumstances, to be ob-
served.  By a  healthy child, nearly all  the  saccharine fruits, when
perfectly ripe and  mellow, may be  eaten in  moderation with perfect
safety;  they furnish a very grateful and proper addition to their ordi-
nary food. It must be recollected,  however, that  the wholesomeness
of fruit is  always in proportion to its pulpiness, and to  its saccharine
and mucilaginous qualities.   Unripe  fruit, of every species, is decidedly
injurious—as well on  account of its being almost  entirely indigestible,
as from the  injury inflicted upon  the stomach  by  the  crude acid
juices it contains.   All fruits that are  invested with a firm cuticle or
skin, are also improper for children: but the  ripe pulp of those fruits,
as in the case of grapes, where it can  be entirely freed  from the skin
and seeds, is in general sufficiently wholesome and nutritive.  Fruit
containing an abundance of small, hard, and insoluble seeds, as straw-
berries, blackberries,  huckleberries, currants, and the like, should be
eaten by children only in very moderate quantities, as  the seeds are
liable to be retained in the alimentary canal,  and  may excite conside-
rable irritation of its lining membrane.
  Cherries are among the  most  pernicious fruits  in common use, and
ought to be wholly  excluded from the list of articles with which chil-
dren may be occasionally indulged.  Even  when  eaten without the
stones, they are peculiarly apt to derange the bowels; and when swal-
lowed  with the stones,  which, with children, is not unfrequently the
case, they are capable of producing violent, and even fatal impressions
on the alimentary tube.   No small  number  of instances have come
under my notice, Dr.  Eberle remarks, where the most alarming, and,
in a few cases, fatal consequences, resulted from the irritation of cherry-
stones lodged in the bowels.  Convulsions, inflammation, unconquera-
ble constipation, and  exhausting and harassing diarrhoea, are among
the affections which are apt to arise from this cause.
   Fruits  stewed or roasted, with the addition of sugar, are always
very acceptable to children, and  when tolerably ripe, and not  too sour,
in general agree well with their  digestive organs.  The same remark
will apply to fruits preserved in sugar: when eaten in moderation,
with milk or bread,  they form  an innocent, and in  the  case of the
habitually costive, an  advantageous  addition to their meals.   They are
improper only when the bowels are peculiarly irritable and liable to be
disordered from slight causes—when taken  in immoderate quantities,
or upon a loaded stomach.  Dried fruits, when deprived of their skins,
and stewed with the  addition of sugar, seldom produce any injury to
the stomach of a child; but when uncooked, and eaten with their skins,
they are difficult of digestion, and disorder, often to a very considera-
ble extent, the  digestive organs.  We have, in repeated instances, seen
attacks of violent vomiting and purging—distressing  colic—and even
convulsions of a very dangerous character,  produced from the use of 
MANAGEMENT OF  CHILDREN.
57
this kind of fruit—notwithstanding the amount taken has not  been in
the least degree immoderate.

                           5. — Sleep.
   During the first period of its existence, an infant passes the greater
part of its time in  sleep; it awakes merely to satisfy the instinctive
calls for food, and, when these are appeased, falls again into a state of
repose. This tendency to sleep is a wise provision of nature—abstract-
ing the infant, for a time, from the influence of those agents, the con-
tinued action of which would  cause  too great an  excitement  of its
nervous system, and interfere with the regular and perfect performance
of the functions  of its various  organs.  Almost constant sleep is, in
fact, equally important to a new-born infant as sufficient and proper
nourishment, in promoting  the growth  and due  development of  its
system.
   We may rest assured, that whenever an infant is wakeful and  rest-
less for many hours, during the day or night, it suffers from too much
or improper food, tight clothing, or from some  uneasy sensation pro-
duced by other causes.  After the lapse of a few weeks, however, the
senses become cognizant of external objects, and the sleep of the infant
is less continued, occurring only  when the organs, fatigued by the
exercise to which they have been subjected, require to have their ener-
gies renewed by repose.  The infant sleeps now  less during the day,
while at night its repose is seldom broken.   When  six months old, it
may be accustomed, by proper management, to require sleep only at
regular periods, and soon  after, during  the night alone.   As soon as
this can with propriety be  effected, it is of advantage to both child and
mother.
   The sleep of an infant,  to whatever period it is  confined, should  be
the result, always, of the natural tendency to repose, prompted by pro-
per nursing, and never, either by day or night, should  it be procured
by the administration of opiates.   The  mother or nurse, who to gain
time for other occupations, or  to  prevent her own repose from  being
disturbed by the wakefulness of the child during the night, causes it to
sleep by the administration of stupifying drugs, runs  the risk  of pro-
moting her own ease and comfort at the expense of the health and life
of the infant.  " Many an infant," says Combe, " the true cause of whose
death was not  always suspected, even by the guilty person, has thus
passed prematurely to its grave."
   A young infant requires  a  soft, warm  couch for its repose, with
sufficient covering to protect it from the slightest impression of cold.
The covering should, however, be  at the same time, sufficiently  light
to prevent undue pressure upon any portion of the  infant's body, and
so accommodated to the state of the weather, as  to preserve a suffi-
cient degree of  warmth, without overheating the child  or endangering
profuse perspiration. It is too much the custom to lay an infant, when
asleep, with its  body warmly clad, in  a feather-bed, and to  cover it
carefully with a thick blanket  or two.  The  consequence is, that in
mild weather, or in a warm room, a copious perspiration is  quickly
produced, which, besides weakening the child, exposes it to catarrhal 
58
DISEASES  OF CHILDREN.
or even  more dangerous affections, when,  upon its  awaking, it is
exposed to the air of the room, or perchance  to the draft from an open
door or window.
  During the  first few weeks after birth, it is perhaps best that  the
infant should sleep at night in the same bed with its mother, especially
if the weather  be cold; subsequently, however, it may be accustomed
by night, as  well as by day, to sleep in  a cradle or cot.
  By a few physicians it is advised to  have  the cradle  invariably
without rockers—the motion communicated to the child in rocking
being considered decidedly injurious.  There are few infants, however,
to which this motion does not appear to communicate a pleasing sen-
sation, predisposing to quietude and sleep; and we are convinced that
when gentle, and not resorted to to induce a state of repose at impro-
per periods,  it can be productive of no possible inconvenience or injury.
We  admit that violent, long-continued rocking,  by the  sudden  and
repeated jolts it communicates to the tender organs of the  infants, may
be productive of  injury, and  should, therefore, never  be allowed.
There is one disadvantage, however, resulting from the use of a cradle,
which is, that infants often become so habituated to its  motion as to be
with difficulty made to sleep without it: they require,  in consequence,
an almost constant attendance, awaking the moment the motion of the
cradle is suspended, and continuing to cry until rocked to  sleep again;
whereas,  infants who have been  accustomed to  sleep in a cot,  will
remain comfortable and quiet for hours even after they awake.  The
cot has unquestionably some advantages over the cradle; nevertheless,
with proper  precautions, either may be  adopted, according to the taste
or convenience of parents.
  It  is, unfortunately, too often the  case, that in infants the  natural
instincts in regard to sleep and wakefulness are but  little  attended to.
An infant is often aroused improperly from its repose, because it may
be convenient for  the  mother  or nurse at that particular moment to
wash and dress it, or  from a  supposition that it has been too  long
without the breast; while, on the other hand, every means, and often
very improper ones, are frequently made  use of to force an  infant  into
a state of repose when not inclined to sleep, or to prolong its repose
when it is about to awake.  The effect  of this improper interference is
to render the infant restless, peevish, and far more troublesome than it
would have  been had it been allowed to indulge freely its natural dis-
position  to  repose or to wakefulness.  When  an infant is  in  perfect
health, properly  clad, and judiciously  nursed, it  seldom  gives much
trouble;  it  awakes when it requires  nourishment, and  falls  readily
asleep when its system demands repose; and  every attempt to interfere
with this natural state of things is attended with more  or less injury to
the health of the little being.
   When a healthy infant does not fall speedily asleep  on being placed
in its cradle, but lies awake, fretful and restless, we may in  general be
certain, either that  it does not feel  the want of repose, or  that some-
thing incommodes it or causes  it pain; that  some portion of its dress
is too tight; or the point of a pin is in contact with its body; that  it is
in want of  food, or has been over-fed or with improper aliment; or 
MANAGEMENT OF  CHILDREN.
39
that is  suffering from cold or  heat, or from a too confined or impure
atmosphere.   It will be readily perceived, therefore, that the only pro-
per means to lull it to sleep is to remedy at once the cause upon which
its wakefulness depends.
  It is important that the sleeping couch of an infant be placed in such
a position that the eyes of the occupant shall be screened from a daz-
zling or unequal light, and the latter prevented from falling upon them
sideways or very obliquely.  When the light which enters the apart-
ment is moderate, and of a mellow character, the face of the infant
should  be  directly in front of it;  but  when intense or dazzling, it is
better to place the infant in such a direction as to allow it to fall upon
the back part of the head, or on the back of the cradle or cot.  When,
in the evening, a lamp or candle, or an open fire is burning in the room,
the same precaution should be observed.   As an infant, the moment it
wakes, directs its eyes almost instinctively, towards the light, there is
danger, unless this be uniformly diffused throughout the apartment, or
placed  in a direct line with  the eyes, that the child will acquire a per-
manent obliquity of vision, from  the  habit of viewing it sideways.
This deformity is more particularly liable to take place, and to a much
greater extent, when, from the head being sunk  in the pillow, or en-
veloped in a  cap with  a projecting border, the  light  can be viewed
only with the eye which is the  farthest from it.
  The  position in which an infant when  asleep is laid  upon its couch,
is a matter of much greater importance than, at first view,  it would
appear  to be.  If it be placed upon  its back,  the fluids which  are
abundantly secreted  by the  glands of  the mouth  and throat, are in
danger of flowing into the windpipe, and thus impeding respiration, or
causing a  violent—almost spasmodic—paroxysm of coughing, which
may be avoided by the infant being laid upon its side.   Care should be
taken, however, not  to lay it always upon the  same side of the body,
lest permanent deformity be occasioned,  in consequence of the circu-
lation of the blood, in the limbs upon which the infant  constantly rests,
being partially impeded, and their proper growth  in this manner pre-
vented.
  The  face of an infant should never be entirely covered, nor so em-
bedded  in the  pillow as to obstruct in the least degree, the freedom of
respiration.  Occasionally it happens, that  when  a  young  infant is
placed  in a soft feather bed with a thick, soft pillow,  its own weight
causes it to slip, so that its head is brought entirely beneath the exter-
nal coverings, and, in common  with its body, becomes so completely
buried  in the  feathers as to endanger suffocation. This accident is
best guarded  against by dispensing with the  pillow entirely.
  In cold climates, and during the winter season, a feather bed is cer-
tainly a very effectual means of securing to a new-born infant  a neces-
sary degree of warmth; but after a few months, especially in summer,
or when the temperature of the  air is mild, a wrelI-constructed  hair
mattrass, with a proper amount of light, soft bed-clothes, is to be pre-
ferred.  Independently of the undue degree of heat  which is generated
by a feather or down bed and pillow, and the exhaustion which thence
ensues, the attitude into which the infant's body falls during sleep, may 
60
DISEASES  OF CHILDREN.
induce, when it is resumed  every night, a  permanent distortion.   A
feather pillow, also, by keeping  the head  too warm, not unfrequently
becomes  the remote or exciting cause of catarrhal affections, inflam-
mations of the ear, eruptions, pain of the head, or even more serious
disease.  For the  same reason, children  should be accustomed, from
an early  age, to sleep with the  head bare—the covering with which
nature has, in general, so plentifully supplied this portion of the body,
being amply sufficient to protect it from cold.
  The cots occupied by infants should  always be without  curtains,
which do injury, by preventing the proper circulation of the air; they
become also receptacles for fine particles of dust, which are liable to
be inhaled during sleep, whenever disturbed by the motion of the cur-
tains  or  of the cot: this  alone, according  to Willich, is a  cause to
which may be referred the  origin of many a consumptive  attack in
early life.
  Children should never be allowed to sleep on beds placed upon or
too near  the floor.   It is well known, that in  all apartments  occupied
by living beings, the inferior portions of the atmosphere are always the
most impure.  The most wholesome  situation for a bed is in the mid-
dle of the room, and raised  some feet from the floor.  From the vi-
tiated state of the atmosphere immediately above the latter, and  the
great importance of a free ventilation, the practice of placing the chil-
dren's bed or cot beneath another  bedstead,  during the day, cannot be
too severely reprobated.
  The chamber occupied by children, during their hours of repose,
should be kept scrupulously clean, and free from dampness;  and at all
seasons, when the weather is not rainy or otherwise very  humid, it
should be freely ventilated during the day.   It should be divested of
all  unnecessary  furniture; and, unless of  considerable  size,  should
never contain more than one bed.   There cannot  be a  more perni-
cious custom, than that pursued in many families, of  causing children
to sleep in small confined apartments, in which two or three  beds  are
crowded together.
  Plants, flowers, and  strong perfumes of every kind should be care-
fully excluded from  the sleeping  apartments of children.   The  first
have  a tendency to render the  air of the apartment  impure, and  the
latter have been found  to produce a very deleterious  impression upon
the nervous  system of young  children.  An instance is related by
Kopp, of a child, two weeks old, destroyed by the scent of savine oil,
which became diffused through the room in which  it was  sleeping,
while the father was applying it to his thigh as a rubefacient  for the
removal  of a rheumatic affection.  The child until then had  been  per-
fectly healthy, and no other apparent cause of death could be discovered.
   Children should not be allowed to sleep with persons  advanced in
age, nor with those of a  broken  down or  debilitated constitution, or
who are labouring under any chronic disease.  The  idea that  any in-
jury to health can result from passing the night in the same bed with
the aged, or those who are labouring under any other than contagious
or  infectious maladies, has been ridiculed by some physicians—while
by others it is considered as fully established  by numerous facts. We are 
MANAGEMENT OF CHILDREN.
61
among the number who believe the apprehension of injury from this
cause to be well grounded.  Although  we are not prepared to assert,
with Carault, that in " young infants, accustomed to sleep with their
grandfathers  or grandmothers, or with an  aged nurse, that part of
their bodies, which, during sleep, approaches the nearest to their bed-
fellows, will  become enfeebled, pale, and emaciated," yet we have
seen, in more than one instance, the general health of children sensibly
impaired  by  sleeping with  old  and diseased  persons—and  quickly
restored when the practice was discontinued.
  By many of the continental writers, to prevent the too frequent and
close contact of young children with adults generally, of whose entire
health we are not well assured, is considered, and we think very pro-
perly, to be an important precaution. It is unquestionably a filthy and
pernicious custom, remarks  Struve, to  suffer infants to be indiscrimi-
nately embraced, fondled, and  kissed  by strangers or  servants; be-
cause in this manner there is danger of their becoming  infected with
many virulent diseases.   But even though no particular malady should
be imparted by their close contact with strangers, it is to be feared
that the humours of the child may be contaminated by  absorbing the
poisonous saliva of a diseased individual.
   A young child should not be awoke from its sleep  suddenly—nor by
any rude  motion or loud noise.   The shock which is thus inflicted on
its delicate brain and nervous system may occasion  a severe attack of
convulsions, spasmodic closure of the glottis, and other equally severe
and dangerous  effects.   " Being of opinion," remarks  a quaint old
writer (Marquis of Halifax), " that it  did  trouble and disturb  the
brains of children, suddenly to awake them  in the morning, or snatch
them violently and  over-hastily from their slumbers, wherein they are
 much more profoundly envolved  than  we, my father caused me only
 to be  waked by the soft strains of some musical instrument."
   To prevent infants from starting from their repose in affright at every
 slight noise which occurs in  their vicinity, no  particular pains should
 be taken  to maintain perfect silence when they are about to fall asleep,
 nor during their repose;   If accustomed to the ordinary sounds of the
 nursery, they will fall readily asleep amidst them,  and much of the
 danger of their being suddenly awoke or unnecessarily disturbed, is
 removed.  With Combe, we agree that, when asleep, an infant should
 be excluded from " light  and noise."   " Even when they  do  not pre-
 vent sleep, these tend to render  it troubled and unrefreshing;"  and
 they commit a great and pernicious mistake, who " act in direct oppo-
 sition to this rule, and think  it of no consequence what talking or noise
 goes on in the  nursery, provided the  infant be not roused  np broad
 awake."  It is to the opposite error, of attempting to exclude from the
 vicinity of a  sleeping child every kind and degree of sound, that we ob-
ject.   We have known children  who have been so accustomed to a
dead  silence when  falling into sleep, and during its continuance, that
the occurrence of the most  trifling sound would immediately awake
them, and, if a  little louder, would cause an alarming excitement, of
long  continuance, and difficult to subdue.
   Children should  be accustomed, from a very early age, to retire to 
62
DISEASES OF CHILDREN.
bed early in the evening, and to rise the moment they awake after day-
light.  Habits are thus formed, of the utmost importance to their health
and comfort throughout life.

                          6.—Exercise.
   For the first few weeks of its existence, the infant requires but little
exercise of any kind ;  and it is not until some months have elapsed that
its organization has acquired a sufficient degree of firmness to permit
of its enjoying any other than such  as is of the most gentle, passive
kind.   From an early period, however, gentle friction with the hand
over the whole surface of the body, carrying it  about in a horizontal
or slightly reclined position on  the nurse's arms, either within doors,
or when the weather will permit, in  the  open  air, will not only  com-
municate  a pleasurable  sensation to the infant, but, by promoting a
free  and  equal circulation  of  the  blood, contribute  to  the  full and
regular development of every part of its body.  But while this  amount
of exercise  is decidedly beneficial, and should  not  be  neglected,  we
are to recollect, that every species of dandling and tossing—every kind
of motion, in fact, excepting of the  gentlest kind, is liable to produce
present discomfort, if  not permanent injury.
   For the first month  or two the  infant should be handled  as  little as
possible, and never placed in an erect or sitting posture.  To sit it
upon the lap while its  bones are soft  and pliable, its joints slight, and
imperfectly developed, and  its muscles small  and feeble, and to jolt it
thus by the hour—its poor little head  moving about as if palsied, and
its tender  back bending and  twisting from side to side—is the very
worst plan that can be adopted to minister to its comfort, or to pro-
mote its regular and symmetrical growth.
   Many nurses would appear to think  that the greater the  amount of
motion to  which an infant is subjected the better: they toss  and roll
it about as if it were a bundle of rags, and pull and twist its limbs,  till
the joints crack.  Under such treatment, it is  not to  be wondered at
that the poor child  moans, cries, or screams, during  the whole  time
occupied in dressing it, or that  it should suffer from  deformities and
other injuries.
   Another barbarous practice is that of tossing an infant up and down
in the arms, held at full length from the body.   The motion thus com-
municated is of too violent  a  kind  to be borne with impunity by the
tender  frame of a young infant, to say nothing of the serious accidents
which  may result from the  practice, even when  the utmost care is
observed.
   Until an infant is able to sit alone it may be allowed to amuse  itself
upon its cot, or on  a soft cushion spread upon the floor; here it will
lie for hours, until it acquires strength to roll about, and is much more
contented, and thrives far better than when continually nursed in the
arms or upon  the lap; the  danger of deformity is likewise avoided,
and the child acquires, at a more early period, the  power to raise
itself, and  sit upright, without assistance; and at nine  or ten months
will, in genera], be able to get upon its feet and walk.
   When sufficiently old to  be attracted  by surrounding  objects, car- 
MANAGEMENT OF CHILDREN.
63
rying it frequently into the open air, especially into the country, during
the mildest seasons of the year, has a highly beneficial tendency.  The
freshness, beauty, and  variety of  the  scenes of nature, are highly at-
tractive, even at a very early period of life; and,  independently of the
healthful influence of a pure and  unconfined  atmosphere, the impres-
sions thus resulting are always of a decidedly salutary kind.
   In carrying an infant, some important precautions  are necessary.
The spine, being soft and yielding, is incapable of supporting the weight
of the head, and other parts of the body which rest upon it in the erect
posture.  To prevent deformity, therefore, an infant should not be held
seated upon the arm of its nurse or attendant; it  ought always to be
carried in an inclined position, so that the head, and every part which
bears  upon the  spine, may receive an  equal and adequate support.
Neither should the child be  carried for too long  a time in the nurse's
arms without  changing the  position  in  which it is held—otherwise
there is a danger of its becoming  permanently deformed, from its body
being  twisted to  one or the  other side.  To obviate this, the child
should be carried, alternately, on both arms.  Even in  suckling an in-
fant, it is important that it be not confined exclusively to one breast,
but nourished, alternately, from both—as well to prevent  its  contract-
ing a crookedness of form, as to guard against its acquiring  a habit of
squinting, from one of its eyes, while nursing, being constantly direct-
ed towards one point.
   Infants, in general, derive much pleasure from  riding in a  little car-
riage  drawn  by the  hand—and as it affords a  convenient  means of
conveying them, frequently, when the weather is  mild  and otherwise
favourable, to one of the public squares or parks which  exist in most
of our larger cities, or even to a garden or field without the town,
where they may enjoy a free  and fresh  air—this species of exercise
may be occasionally substituted for carrying in the arms—to which,
for out-door excursions, it is, for very young infants, in  many points
of view preferable.
   The body of the carriage should be long enough to permit the in-
fant to lie down  at  full length;  and  the sides ought to be sufficiently
high to prevent it falling  or rolling out.   The  wheels should  be low,
in order to lessen the liability  of oversetting; and  they should be care-
fully secured against running off when the carriage is in motion.  Very
young infants should be laid down in the carriage on a pillow or soft
mattrass, with the head slightly elevated, and so confined at  the sides
as to prevent them from rolling when in motion.   After  the child has
acquired some degree of strength, it should be placed in a semi-recum-
bent posture, with its head and back  well  supported by pillows, &c.;
and when it is capable of supporting its head, it may be  permitted to
sit upright, and properly secured  against being  thrown from  side to
side, by the rolling of the carriage.
   The carriage  should be drawn by  none but  a prudent and trusty
person, with a moderate and steady motion, and  never over rough or
uneven ground:  when the motion is too rapid, or uneven and  jolting,
much injury may be inflicted on the infant.
   Children, when placed in the carriage, should never  be kept stand- 
64
DISEASES OF CHILDREN.
ing in the sun, if it be warm ; nor should they be kept motionless, when
the weather is cool.   In cold weather, they should be amply covered,
since from the passiveness of their situation, they will require additional
clothing.  Nor should  the ride ever exceed  half an  hour at a time,
especially if the  child  is  observed to  become sleepy—it being  ha-
zardous to allow children to sleep in the open air; and after a few trials,
the exercise almost invariably will predispose them to sleep, and thus
destroy the benefit  of the exercise,  as well as interfere with their
regular habits of repose. (Deicees.)
   It is only towards the end of the ninth or tenth  month, and, when
the child is feeble, even  much later, that it is proper to teach it the  use
of its feet.   It is perhaps always better that, before an infant  attempts
to walk, it should first learn to crawl.   With this intention, it should be
placed upon a soft carpet, where it soon busily employs itself, moves and
extends its limbs, or rolls about to reach its playthings.   The instinc-
tive desire for  locomotion, and the various things  that  attract it in
different parts of the room, will soon induce it to crawl upon its hands
and feet.  This it should be allowed, and even encouraged to do; as
children  who are  permitted this " useful intermediate muscular dis-
cipline," are sure to acquire a much firmer step, and enjoy more robust
health, than those who have been taught to walk without it.
   In  no instance  should any  particular attempt be made to induce
children to use their  feet at an early period, nor until  the  bones have
acquired a sufficient degree of solidity to sustain the body, without the
danger of their  becoming bent by its weight.
   In teaching a child to walk, it should  be left pretty much to its own
efforts; all artificial support is injurious.  As generally applied, such sup-
port has a tendency to produce an unnatural elevation of the shoulders,
while the infant, depending upon it, almost alone, for maintaining the up-
right  position of its body, is accustomed to bend too much forward,
or to  one side.  By this may be laid the foundation of a permanent de-
formity, or at least of an ungraceful gait, which it is impossible in after
life to" correct.
   While in the nursery, infants may be taught to rise from the floor
by laying hold  of chairs;  and, if occasionally supported  under the
arms, they will  easily learn to stand erect; but they should never be
raised up by one arm only.  At an early age they may be held under
both arms; and when thus supported, if  the hands of the attendant be
occasionally withdrawn for a  moment,  they will  soon   acquire the
power of standing alone.  Mild and persuasive language  ou«-ht to be
used in these experiments;  while the  infant  may be  encouraged  by
some toys, placed at a  little distance, which will induce  it to stretch
out its little arms, and endeavour to advance  towards the place con-
taining the desired objects.  By such means, it may  be allured to visit
different parts of the room.   The first  journey of this kind  ought to be
attempted only from one neighbouring chair to another ; afterwards the
little  traveller may run  towards its mother, or nurse, who, with ex-
tended arms, stoops to receive it.  As  the infant improves in its efforts
to walk alone,  the chairs  may be placed at  a greater distance  from
each  other, until, finally, it walks  firmly  in  every direction, without
assistance of any kind.  (Struve.) 
MANAGEMENT OF CHILDREN.
65
  The practice of assisting a young child to walk, by holding him by
one of his hands, is extremely reprehensible; the child's arm  being
thus continually, and, more or less forcibly, extended upwards, should
the little pedestrian  lose his balance, or trip, or if, from the feebleness
of his limbs, he be unable for any length of time  to maintain the erect
posture, the whole weight of his body  becomes suddenly suspended
by one arm.  It is easy to perceive, that this practice must necessarily,
and in no inconsiderable degree, tend to draw the shoulder and side of
the chest out of their natural position, and, when frequently repeated,
to cause permanent  deformity of these parts. From the sudden and
violent extension which the arm  usually receives  when the child stum-
bles, the shoulder and  elbow joints, also, are liable to be dislocated or
sprained, or the clavicle may be torn  from  its  attachment with the
scapula.  Dr. Eberle remarks, that he has met with several instances
of dislocation of the shoulder joint, which were occasioned  in this
manner; and the occurrence of painful sprains—often of several weeks'
continuance—from violence done in this way, is  by no means uncom-
mon.   Similar injuries are also inflicted by raising the child from the
ground by one arm, in order to help it over some-obstacle, or to hasten
its  progress over a  rough and  difficult piece of ground.  We  have
seen a  heavy child  carried thus, by one arm, for a considerable dis-
tance.  The practice cannot be too strongly condemned.  Some of the
most  violent and troublesome affections of the elbow and shoulder
joints that we have met with, in children, were thus induced.
   As soon as a child has acquired sufficient strength to walk alone, he
should be  allowed  the  most perfect freedom of exercise; upon this,
with the free use of pure air, will depend,  in a great measure, his
health, vigour, and  cheerfulness, during the period of youth, while it
will contribute essentially to the permanence of the same blessings
until the close of life.
   Throughout the whole animal  kingdom, the young are prompted  by
an instinctive impulse, to almost constant  exercise.   Conformable to
this intimation of nature, a large portion of the  youth of man should
be passed in those harmless sports, which exercise the limbs, dilate the
chest, and  communicate motion and vigour to every part of the body
susceptible of it,  without,  at the same  time, requiring any minute di-
rection from the head.
  Experience has shown, that when attempts are  made, in early youth,
to interfere with  the natural movements and exercise  of  the body;
when, from a false idea of improving the shape, or giving grace to the
carriage, children are debarred  the free and unrestrained exercise of
their limbs, and are confined to any particular position, for too long a
period, they become restless and uneasy, and their  muscles acquire
tricks of involuntary motion.  Twitching  of the features, gesticula-
tions of the limbs, even dangerous and  permanent deformity, or some
severe nervous affection may be  the result of such unnatural restraint.
Error in this respect, it is true, is but of occasional occurrence in the
physical  education of boys.  But  how often has an over  anxiety for
delicacy of complexion in a  daughter, or the apprehension that her
limbs may become coarse  and ungraceful, and her habits vulgar, been
                                5 
66
DISEASES  OF CHILDREN.
 the means of debarring her from the enjoyment of either air or exercise,
 to an extent sufficient to insure the due development, health, and vigour,
 of her body.  The consequence is, that in too many instances, females
 acquire in infancy, a feeble, sickly, and languid habit, which renders
 them capricious and helpless, if not the subjects of some troublesome
 or painful disease, which may continue throughout  the  whole course
 of their after lives.
   The bodily exercises of the two  sexes ought, in fact, to be the same.
 As it is important to secure to both, all the physical advantages which
 nature has formed them to enjoy, both should be permitted, without
 control, to partake of the same rational means of insuring that vigour
 of body,  and cheerfulness of mind, which  will enable their various
 organs to perform, regularly and perfectly, their respective functions;
 and by which alone their health and comfort can be  confirmed.  Girls
 should not,  therefore, be confined  to a sedentary life within the  pre-
 cincts of the nursery, or, at most, permitted a short  walk, veiled and
 defended from every gleam of sunshine, and from every breath of air.
 The unconstrained enjoyment of their limbs and muscles, in the open
 air, without a ligature to restrain the freedom of their motions, or an
 ever-watchful eye, to curb  the lively joy of their  unclouded  spirits, is
 equally important to their health and well-being, as it  is to that of their
 brothers.
  To hope to communicate graceful form  and motion to the limbs of
 a child, health and vigour  to its constitution, and cheerfulness  to its
 spirits, by confinement, belts, ligatures, and splints, superadded to the
 lessons of the posture-master, is about as rational as would be the
 attempt to improve the beauty and  vigour of our forest trees, by trans-
 ferring them to the greenhouse, and extending their branches along an
 artificial framework.
  Equally absurd and irrational is  it, to fetter the active motions of a
 child, almost as  soon as he has acquired the free use of his limbs,
 under  the pretence of improving his mind.   To confine a lad within
 doors, and especially in the heated and impure air of a crowded school-
 room, for the greater part of the day; to chain him to a desk, and re-
 quire him  to fix his attention, hour after hour, upon tasks, always with-
 out interest, and often beyond his comprehension, may  be a certain way
 to train up enervated puppets, or to produce, perchance, a short-lived
 prodigy of learning; but it is illy calculated to form  healthy, well-in-
formed, and accomplished men.
  Every feeling heart  must have  looked  with pity, upon the sickly
 countenance, and melancholy aspect, of the  poor little puny creatures
 of eight, ten, or twelve years, sometimes exhibited by parents as pro-
 ficients in learning, or for their early acquirements  in languages,
elocution,  music, or drawing.   Debarred from the healthful  and joy-
 ous pastimes adapted to their age, and  from  inhaling " the pure fresh
breath of heaven," their mind has been  forced, through constant, pain-
 ful application, to a premature, but  imperfect and unequal exertion of
 its faculties, the effect of which is to exhaust its powers, and impede its
full development; while, at the same time, the natural cheeerfulness of
youth is destroyed, the  health and vigour of the body materially im- 
MANAGEMENT OF CHILDREN.
67
paired, the duration of life shortened, and  the  remaining  period  of
existence rendered too often a burden rather than a blessing.
  We are far from objecting to an early attention to the proper culti-
vation of the  intellect.   All  we  insist upon is, that it should  not, in
early youth, be taxed beyond its powers;  but  that the greater part of
every day should be devoted to active exercise in the open air.
  There is not, perhaps, remarks a sensible  German writer, a greater
and more reprehensible mistake  in  education, than the very common
practice of compelling children to extraordinary mental exertions, and
exacting from them an early and rapid  progress  in intellectual pur-
suits ; this  is, too often, the grave both of their health  and of their
talents.  The age of infancy is designed for bodily exercise,  which
strengthens and perfects the frame,  and not for study, which enfeebles
it and checks its  growth.
  Let the  beginning of life, the first  six years, perhaps, be devoted
entirely to forming the  body and the organs of sense, by exercise in
the open air.  It  is not necessary that the child should be permitted to
grow up like a wild animal; for, with proper care, his mind may be
made to receive  considerable and  valuable instruction, through  the
medium of the senses, and the conversation  of those around him.  In
these two ways  he  may, indeed, acquire more  useful  knowledge by
the end of his sixth year, than a child who had learned to read  in his
fourth. In his seventh year, he may spend an hour or two daily at his
book; in his eighth, three hours; and so on until his fifteenth, when
he may have six  or seven hours  allotted for  study.
  Children are frequently confined to the school-room for many  hours
daily, when not occupied in any useful pursuit;—which time, without
detracting from that necessary for the cultivation of the mind,  might,
writh great propriety, be devoted to  those bodily exercises and recrea-
tions, which tend to develope the strength, and promote the regular
and energetic action of every organ of the frame—the brain and ner-
vous system included.
  The first occupations of the day should be abroad, for the benefit of
inhaling the early morning air.   There is always a striking difference
in the  health and  freshness of complexion, and  cheerfulness of features
exhibited by the child who has spent some time in out-door exercise
before his morning task, and the one who passes immediately from his
couch to study, or other in-door occupations.   Children  are always
fond of early rising, when their natural activity of disposition, and dis-
inclination to remain long in a state of quiet, have not  been counter-
acted by habits of indulgence.
  We are to recollect, that it is not amusement alone that is sufficient
to confirm the health, and promote  the growth  and regular develop-
ment of the frame, in  childhood.   Hence, as Struve  well  remarks,
sedentary games  are improper for children,  whose principal occupa-
tion  should be to exercise their limbs.
  To walk, to run, to skip, to jump, to put things together,  and sepa-
rate them ;  to erect and destroy houses built of blocks and other simi-
lar materials; to  trundle a hoop, fly a kite, or  arrange, construct, and
manage little vehicles in their own way ;  all these  are diversions tha 
68
DISEASES OF CHILDREN.
ought to be sedulously encouraged, and the necessary articles for their
pursuit supplied.  The latter, however, should  be simple, and ot little
intrinsic value, as this is soon enhanced in the possession of the young.
For boys, a ball, a top, a hobby-horse, a little chaise, a wheelbarrow,
which children can  manage without any extraneous assistance, are
preferable to more expensive toys, which  afford amusement without
exciting  to  bodily exercise.   A  somewhat similar  remark  may be
made in relation to the playthings proper for female children :—it  is a
material error in physical education, to make that  ill-founded distinc-
tion  between the sexes,  which condemns female  children,  from  the
cradle, to a sedentary life, by permitting them scarcely any other play-
things than dolls and  tinsel-work, or toys, while their sprightly brothers
are amusing  themselves  in  the open air, by beating  their hoop, or by
other active diversions.   Such premature  confinement is dearly  pur-
chased at the expense of health and of a cheerful mind.
   All amusements, even the most  active, are  most beneficial when
pursued in the open air.  Were it  possible to keep children of both
sexes continually in the fields and  gardens, there would  be  no neces-
sity for supplying them with playthings;—the natural objects around
them would present  a sufficient  variety for their  amusement, and in
these they would find an inexhaustible store of materials for construct-
ing toys, which being works of their own creation, would please them
far more than the most expensive artificial contrivances.
   Society increases  the charms of exercise, and augments  its benefi-
cial effects.  It is, therefore, desirable  and proper  to allow a number
of children to assemble in their sports and amusements.  It will, how-
ever, be prudent to watch their conduct; but without rigour, or unne-
cessary interference on  the part of the overseer.   Children are the
most happy, and  most actively engaged in exercise when left to them-
selves in its choice and pursuit.
   Even  at an early age children should not  be taught to depend too
much on  the assistance and direction of their nurses or superintendents.
If the ground be favourable, that is, if it be soft or  covered with grass,
 and free from  stones, timber, &c, they should be permitted to  have
 pretty much their own way.  A few falls will do them no injury; but,
 on the contrary, will make them  less timid, and teach them better
 than any other instruction, how to avoid similar  accidents in future.
 Children who are  never suffered to surmount the little  difficulties
 which may occur in their  sports, by their own efforts, and are conti-
 nually warned against trifling accidents, seldom fail to become unduly
 timid, helpless,  and irresolute  in their actions.   Exaggerating the
 dangers incident to the usual sports of children, and plying them con-
 tinually with admonitory injunctions against accidents when they are
 enwaaed in play, is calculated  to favour the occurrence of the  very
 accidents which these  means are  meant to  obviate, by the timidity
 they almost inevitably inspire.—(Eberle.)
    The leading precautions to be observed in regard to the exercise of
  children, is to prevent it from being carried on in the open  air in very
  damp or wet weather; and, during warm weather, to  guard against
  exposure to the direct rays of the sun.   Exercise, also,  of  a  very 
MANAGEMENT OF CHILDREN.
69
active  character, should not be engaged in by children, immediately
after  meals;—nor, when by exercise the body becomes heated, or
perspiration is  induced, should children be permitted to throw off a
portion of their clothing, or to sit upon the ground, or in a draught of
air, in order to cool themselves.   It would be better, particularly
during the milder seasons of the year, if, whilst actively engaged in
exercise, a lighter dress than usual were worn, some additional  cloth-
ing being immediately resumed when  the exercise is suspended.
  While a large amount of  active exercise is essential  to health,  and
to promote the full and  regular development of the body, in children
generally, there is no class of them who stand more in  need of it, or
who derive from it  a greater amount of benefit, than those who, in
consequence of their delicate and slender  organization, are  too often
confined within doors,  and debarred entirely from engaging  in the
boisterous pastimes of their more robust companions.  They may  not,
it is true, be able to endure, at first, the same amount and degree of
exercise as the  latter; but when allowed to follow their  own inclina-
tions, they  will be led by the  example of others, to pass the greater
part of their time in childish sports, in the  open  air, by which their
limbs  will speedily  acquire development  and  strength, and  every
function of their system  that full  activity, which can  alone  guard
them in after life from suffering and disease.
   The absurd notion, that the health of weakly or delicate children is
to be promoted by confinement and inactivity, has  not unfrequently in-
duced parents to commit a very serious error in determining upon the
future occupation of their sons; selecting  for those of a slender  and
delicate frame, a profession, or some sedentary employment; while, to
the robust and  vigorous, is often assigned a more active and laborious
occupation, demanding considerable bodily exertion, and repeated ex-
posure to the open air.   As a general rule, the  very opposite of this
course should be pursued: the robust being best able to bear up against
the pernicious effects of that confinement and inactivity,  to which the
enfeebled constitution will very speedily fall a prey ; while  the latter
will be materially benefited by the  very  exertion and exposure to
which it is supposed to be unadapted.

                      7.—Moral  Treatment.
   At no period of life does the cultivation of a cheerful  disposition
tend more  powerfully to the promotion of health, than during infancy
and youth.   It is a common observation, founded  upon experience,
that fretful and peevish children seldom thrive well; and it is amazing
how soon, by mismanagement or neglect, their  naturally cheerful and
joyous dispositions may become impaired, or exchanged  for a state of
almost constant fretfulness and discontent.
   A due attention to the moral education of children is  seldom com-
menced sufficiently early.  Although  it is true, that many of the  pas-
sions  have no existence during infancy, while others may be said  to
be  still in  the bud, nevertheless, even in the cradle, the exhibition of
fear, anger, resentment, jealousy,  and their kindred emotions, is by no
means unfrequent—and if not counteracted by firm, prompt,  and judi- 
7()                  DISEASES OF CHILDREN.

cious  management, on the  part of parents and nurses, these passions
become often  prematurely  developed  to a fearful extent,—impairing
the present health and comfort of the child, and sowing the seeds of
discomfort and suffering, to destroy the  happiness  of  the  whole re-
maining period of its existence.
  It is too commonly  the case, that the entire system of nursery dis-
cipline has a direct tendency to call into  action, at  an  early age, the
passions of the child—rather than to still them, or to direct them into
their appropriate channels.   At one time he is dandled and  coaxed, in
order to quiet  him;  at another he is scolded and beaten for the  very
same purpose.  We either do what he desires,  or oblige him to do
what we  like: we comply with  his  whims, or make  him submit to
ours.   Thus no medium is observed ; and he is doomed to be always
either giving orders or receiving them.  The first ideas  he  forms are
those of dominion and slavery; before he can speak, he commands—
before he acts, he obeys; and sometimes he is corrected, before  he  is
conscious of faults ; or even before he is capable of committing  any.
Thus we seize the earliest opportunity of implanting in his tender  mind
those passions, which are  afterwards unjustly attributed to nature—
and having taken  pains to render  him depraved, we complain when
we find him so.  (Rousseau.)
   A peevish and fretful disposition  in infancy, if not, as is generally
the case, the result of errors in nursing, or too close confinement in a
stagnant and impure atmosphere—by  which the energies of the system
are impaired—digestion  materially impeded, and  the sentient organs
subjected to impressions, if not positively painful, at least uncomfort-
able—is often induced by unkindness, impatience, or want  of temper
on  the part of the mother or nurse.   An infant  whose natural inclina-
tions are  continually thwarted—who is placed  in the cradle  and  at-
tempted to be  forced to sleep, when it would be awake  and playful—
and whose disinclination to repose,  and the cries by which  this is ex-
pressed, expose  it  to  angry chidings—a passionate slap, or  a rough
shaking from  its attendant—or whose calls for its natural food, or de-
sire to be nursed  and diverted,  are  repelled  by equally  injudicious
means, will seldom  fail  to become peevish, restless, and  fretful.  It
may be proper, on many occasions, to soothe an infant to  repose, by
gentle fondling, and the soft lulling notes of some nursery  air; but if
these do not quickly succeed in producing the desired effect, it is better
to desist at once, than to resort to any others.
   By endeavouring, as soon as the first period  of infancy is passed, to
accustom the  child, as much as possible, to regular  periods for eating,
sleeping, and  all other natural operations, much of the trouble atten-
dant upon the duties of the nursery may be avoided, and its quiet less
often disturbed.  If the infant is encouraged to start up at any moment
of the day or  night, and demand  the breast, or if the latter is constant-
ly offered to it as a means  of soothing its cries, whether it be hungry
or not, perpetual restlessness and  discontent must  be the result; and
these once established as a habit, the  mother's  peace and  enjoyment,
and the child's health and  welfare,  are sure to be sacrificed.  The in- 
MANAGEMENT OF CHILDREN.
71
fant may be quieted for the moment in this way, but it will be at the
expense of tenfold trouble and disappointment at a future time.
  An infant  should, on  no occasion, be subjected  to any degree of
harshness, either of voice or of manner; it should  be invariably ad-
dressed in a  soft and soothing tone—be surrounded  by none but smil-
ing and  affectionate countenances, and ever receive at  the hands of
its attendants the tenderest treatment.   Struve objects, very properly,
to the constant playful teasing of young children, practised by many
persons, as well as to the attempts often made to excite  them to acti-
vity when they feel inclined to lie quiet, as  so many means of render-
ing them peevish  and uncomfortable.   Even when the fretfulness of
the infant is the result of some accidental irritation, the  smiling coun-
tenance and  tender cares of the mother, and the simple and cheerful
songs  of the nursery,  are  the means best  adapted to quell it.   Care
must be taken,  however, not to mistake an  improper indulgence of the
whims and caprices of an irritable child, for a proper degree of gentle
care and  tenderness.   These should  invariably be  opposed, and by a
little gentle firmness may  very quickly be subdued, whereas, if indi-
rectly  given  way  to, the foundation may  be laid  for permanent and
very serious  defects of disposition.
   All  attempts to prevent or soothe the fretfulness of an infant by
cakes, sweetmeats, and confectionary, should be absolutely prohibited.
The child soon acquires a morbid appetite for such things, which is
ruinous to its health; and it is often surprising how quickly it learns to
cry and fret  in order to obtain them.  Neither should children, when
they happen  to fall or receive a slight hurt, or experience  disappoint-
ment of any kind, be soothed  by expressions of extreme  pity or sor-
row, and be  allowed, in order to  still  their cries, some foolish indul-
gence.  Nothing  tends more certainly to  encourage a fretful,  com-
plaining, and exacting disposition, or to induce violent and long-con-
tinued paroxysms of crying for the most trivial causes.
   A prudent mother, who is herself of an amiable and cheerful dispo-
sition,  must perform but illy her duties as a  nurse, or she  would seldom
have cause to  complain that her  time is wholly occupied during the
day, and her rest disturbed at night by the  cries of a fretful infant.
   The most  perfect mildness, gentleness,  and  kindness in the treat-
ment of infants, are all-important; not  only to prevent their becoming
peevish and fretful, and to cherish the germs of those affections, which,
" growing with their growth, and  strengthening with  their strength,"
shall  shed over every scene of after life their happy influence; but,
also, to preserve them from the immediate  attacks of disease.
   The excitability of the nervous  system, which is  always greater in
infants than in adults, is often so excessive, that an unusual sound—an
angry look—a  loud  tone of voice—a  repellent countenance—a rude
shake—even being suddenly awoke from sleep, is sufficient to produce
an impression that may immediately bring  on a violent  attack of con-
vulsions—or of spasm of the glottis; and,  if frequently repeated, may
eventuate in  positive disease of some portion of the brain.
  Young children are readily excited  by trifling causes;  and though
it is not exactly the emotion of fear that  is produced—yet the deep 
72
DISEASES  OF CHILDREN.
alarm expressed by every feature, the agitation in which every limb is
thrown, and the fearful  screams, or rather shrieks, that are uttered—
prove that it is one of too intense a character for the delicate organism
of an infant to sustain with impunity.  No one who has witnessed the
apparent agony and piercing cries of an infant, that has been  alarmed
at some loud  and unusual sound striking upon its ear—at some unex-
pected and perhaps  uncouth  object suddenly presenting itself before
its eyes—or even at the motion made by a strange person of repulsive
mien, to take  it from the arms  of its mother or nurse,  will be surprised
that from the same cause, should, occasionally, result convulsions, and
other forms of violent disease.
  Fear of the most intense kind—causing immediate injury to health,
and capable of producing a lamentable  degree of feebleness of cha-
racter in after life, is not unfrequently excited and cherished in chil-
dren, by the reprehensible conduct of parents and nurses in attempting
either to render them quiet, or to enforce their obedience to the com-
mands given them, by threatening them  with a visit from some object
of terror.  In not a  few instances the intense fear thus engendered in
the mind of the child, has been productive of effects almost immediately
fatal.   We recollect  the case of a female child, repeatedly threatened
by her parents to be  given to a sweep, that he might carry her away
in his bag, who, on accidentally encountering  a   sweep, that  had
entered the house in pursuit of his avocation, fell down immediately
in a violent fit of convulsions, which terminated fatally in a few hours.
  When, by these injudicious practices,  the sensation of fear has been
deeply engraven on  the mind  during infancy, it is  seldom  entirely
eradicated in after life.  The sensation palsies, to a certain extent, the
powers of  reason, and produces, under particular circumstances, a
deplorable state of mental  imbecility; which not only detracts from
the comfort of the individual, but lays him open to the  inroads of dis-
ease.   We are liable to be ruled often by the influence of incidents
and impressions that we have forgotten; or, in other  words, sensations
are subject to revival by association, when the causes which first pro-
duced  them are  remembered  no longer.    How studious, therefore,
ought those who have the care of children to be, that  no impressions
be made on  their minds, which, as Darwin has observed, may  bias
their affections, mislead  their judgments, or render nugatory their best
resolves, to the end of their lives.
  Parents are often heard to complain of the obstinacy of their infants,
and  the  necessity of severe measures to  reduce them to obedience.
In a large number of instances the obstinacy of the child is either ima-
ginary, or  the result of the parent's  own mismanagement; and the
severe means used to conquer  it, in many cases, tend to confirm it,
while they act prejudicially upon the health of the little sufferer.  The
young infant is often reputed obstinate,  because it cannot conform its
wants to the convenience or the caprice of its parents; because it will
not close its eyes in  sleep at their desire—refrain from  crying for  food
when it  is hungry, and the mother is not ready to attend to its wants;
or, when it begins to prattle, articulate sounds, at her command, to the
pronunciation of  which its organs of  speech are  not  yet  adapted. 
MANAGEMENT OF CHILDREN.
73
When the child is somewhat  older, he is, perhaps, commanded to
remain within doors, and sit still and study his lesson, while perhaps
the gladsome sounds of his companions' sports  strike on his ear, and
stimulate his desire to partake of them,  or he beholds, from his cham-
ber, their gambols  in  the  neighbouring fields;  under such circum-
stances, he can neither fix his mind upon  his book, nor remain quiescent
for any length of time, however repeatedly he may be commanded to
do so.  The child in this instance evinces neither obstinacy nor diso-
bedience;  he is merely  following the natural instinct of his age  for
bodily action; and if an attempt be made to restrain this by  punish-
ment, the mind  and the temper, as  well as  the health of the body,
equally suffer injury.
   The reluctance to stop, when a child is once in motion, is often mis-
taken for obstinacy : when he is running, singing, laughing, or talking,
if he  be suddenly commanded to desist,  he is  unable instantly to obey.
The inability to  desist suddenly from any occupation, is often so pain-
ful to children, that to avoid that pain,  they become obstinate.  It is,
therefore, better to stop them by presenting new objects to their atten-
tion, than by the stimulus of a  peremptory voice, or  the  still more
objectionable means of corporeal punishment.
  "Be careful," observes Locke, "before punishing a child for obsti-
nacy, that  his fault really arises from wilfulness, and not from child-
ishness, or inability to do what  you bid him.  Inadvertency, forgetful-
ness,  unsteadiness, and wandering of thought, are the natural faults of
childhood,  and, therefore, where they are not observed to be wilful,
are to be mentioned softly, and  gained upon by time."
  Children, if properly trained  from their  birth, are far  more docile
than the generality of parents are inclined to believe.  If, unfortunately,
they have been suffered to contract a disposition to obstinacy, this may
be readily  corrected by great kindness, and a little patience  and good
temper, on the part of parents and instructers; whereas, to attempt to
command  obedience by severe measures, will  often confirm  and
strengthen the very fault for the correction  of which these  are  re-
sorted to.
  " Children, at  a very early age, can  distinguish between what is
reasonable, or unjust, in our behaviour towards them.  They should,
therefore, be treated as rational creatures, and be made sensible, by the
mildness of our  carriage, and by the composure even in our  correc-
tion of them, that what is done is  reasonable in us, and useful  and
necessary for them ; and  that it  is not out of caprice, passion, or fancy,
that they are commanded, or forbid anything.  This, they  are capa-
ble of understanding; and there is no virtue they should be exacted to
perform, nor fault they should be kept from, which I do not think they
may be convinced of; but it must be by such  reasons as  their  age
and understanding  are capable of, and  those proposed in a very few
and plain words."   (Locke.)
  Among the emotions most readily excited into action in childhood—
and often displayed to a  most fearful extent, even before  the  tongue
can lisp a syllable—is that of anger.  Nothing is more common than
to witness an infant break forth in violent paroxysms of rage, when in 
74
DISEASES OF CHILDREN.
the slightest degree controlled  in its  actions, or subjected to the least
disappointment.   Independently of the direful consequences, which, in
after life, may result from this disposition in the infant to passionate
excitement, it is, in its immediate effects, in the highest  degree preju-
dicial to health, by determining to the head an undue amount of blood.
Unfortunately, it is, in too many cases, produced solely by gross mis-
management on the part of parents and nurses.   An  infant, who is
made frequently to witness the exhibition of violent passion in those
who surround it, or is taught to express its dissatisfaction by menacing
gestures—or whose puny fits of displeasure with its attendants or play-
things are encouraged or even excited, can scarcely fail to become
angry and resentful at whatever opposes its desires, or gives it  mo-
mentary uneasiness; and  the emotions, thus brought into play, acquire,
in a short time, a  force, which the best-directed efforts seldom suc-
ceed in effectually counteracting.
   Crying, screaming, and various gesticulations of the limbs and body,
are the means by which  the passion of anger, and  other violent emo-
tions, are generally expressed in infancy.  Children, it is true, frequently
cry from  pain or  uneasiness;  while, not unfrequently, particularly at
a very early age, their cries would appear  to be excited by a kind of
instinctive impulse, there being no other cause to which, apparently,
they can be referred.
   Many  authors  have  conceived it to be improper to prevent, in any
case, the crying of an infant, unless  it proceed from  absolute pain or
sickness;  they believe that, during early infancy, frequent fits of crying
are useful, by expanding the chest, developing  the lungs, and calling
into exercise the  muscles of respiration. That, to a certain extent,
these effects are produced by the crying of infants, cannot be doubted.
But, it is not true, that crying is very common in infants during health,
and when they are properly nursed; nor that allowing them frequently
to indulge in it, has any  salutary effects; on the contrary, when from
any cause, whether improper  food or  clothing, a confined or impure
atmosphere, neglect of cleanliness, pain or passion, an infant is thrown
into frequent paroxysms  of crying, particularly when  these paroxysms
are of long continuance, as is generally the case when they are excited
by fear or  anger, their effects are often  very serious.  The undue
amount of blood they cause to be determined to the brain, not unfre-
quently produces  an injury of that  organ, laying  the foundation for
dropsy of the  head, or  giving rise  to convulsions of various kinds.
" Violent mental emotions, by throwing the heart into inordinate action,
and thus  pouring extraordinary currents of blood on  the delicately
organized brain, conduce to the development of hydrocephalus in  the
predisposed. The neglect or maltreatment of children among the poor,
where they are left crying  almost to convulsions,  for hours together,
must lead, in many instances,  to effusion in the brain."  (Johnston.)
   Hence the importance of  guarding an infant from every cause that
is capable of exciting these violent paroxysms of crying, by a judicious
course of nursing; or, when, unfortunately, they have been excited, of
endeavouring quickly to calm them, by walking the infant about; by 
MANAGEMENT OF CHILDREN.
75
 attracting  its attention to some object  calculated to  amuse  it; by
 soothing caresses, and the nurse's lullaby.
   Two means, however, that are frequently resorted to, to arrest the
 cries of infants, are strongly to be reprobated.  The  first is, applying
 it immediately to the breast, or forcing into its stomach, with the spoon,
 a quantity of food.  " It  is a great  mistake," observes Combe, " to
 treat crying as an  infallible sign of an  empty stomach.  No  doubt
 silence is sometimes  obtained by the apoplectic  oppression of a sto-
 mach thus distended, but no sane being will seriously contend that such
 quiet is really beneficial."   The  functions of the stomach thus over-
 loaded, quickly become deranged, and  severe colic, or even  more
 serious mischief is induced.
   The other means to which we have alluded, is the use of laudanum,
 and other  narcotics.   Independently of the well-established fact, that
 very young children are often peculiarly sensible to the poisonous ac-
 tion of opium, so that it is scarcely possible to give them the most insig-
 nificant dose with safety, when the use of opiates is once commenced
 with, there is a strong inducement again and again to resort to them,
 until the necessity for their almost constant employment, and for the
 gradual augmentation of the dose in which they are given, is fully es-
 tablished.   The frequent  administration  of opiates to  infants,  never
 fails, very speedily, to destroy the powers of the stomach, to retard
 the  growth and  development of the  body, and to induce a  general
 condition of the system altogether adverse to the healthful discharge
 of its functions.
   It is not our intention to enter at length into a  consideration of the
 powerful influence which the moral and intellectual education of chil-
 dren may exert upon the health and well-being of both mind and  body,
 according as it is well or ill-conducted.   Interesting as the entire sub-
 ject is in a hygienic point of view, an examination of  all its important
 bearings does not come within the scope of the present treatise.
   We have already pointed  out, when speaking of the importance of
 daily exercise, during the period  of youth, the injury resulting from too
 early an attempt to bring into action the purely intellectual powers.
 Devoting the mind  in  early youth to close and intense study, is pro-
 nounced by Struve, to be " a positive  crime against nature."   The in-
 tellectual powers can be developed prematurely,  only at the expense
 of health, and of that cheerfulness of disposition, that happy buoyancy
 of temper, which, when extinguished by any cause in youth, is but
 rarely regained subsequently.   Even the  mind itself,  when  taxed
 beyond its powers, by too early and  ill-directed  efforts to educate it,
 is deprived of much of that capacity for  depth and vigour of reflec-
 tion, to which it might have attained under a more rational system of
 training.
  Even such children as early display a peculiar aptitude for learning,
—a  propensity to  inquire,  and  to reflect upon subjects of inquiry—
should not, from a proper  regard for their health and well-being, be
devoted to study at a much earlier age than others, even though they
may delight in it, find no difficulty in  their tasks,  and rapidly acquire
knowledge.   Struve, with  much good sense, recommends, that  in re- 
76
DISEASES OF CHILDREN.
gard to these children in particular, the very opposite plan should  be
pursued; for, he  remarks, the  early maturity of mind they exhibit,
certainly borders on disease.   Hence  it would be prudent  even to
check, judiciously, so forward  a pupil, to  abridge  his school hours,
and to employ him more with bodily than with mental exercise.
  Perhaps the most advisable course, in all cases, would  be, to make
no positive attempts at  cultivating the intellectual powers of  children
previous to the fourth year.  Let them rejoice, till then, in their exist-
ence,  without confining their limbs, damping their spirits, or burdening
their memories with things, which are seldom more than loosely con-
nected and arranged in the recesses of their minds.
  There is,  however,  an important branch of education, which, ac-
cording as it is wisely or unwisely directed  and  controlled, exerts a
most powerful influence over the character, happiness, welfare, useful-
ness, and, to a certain  extent, over the health of every human being,
and which commences the moment the child is able to form even the
simplest ideas; it is the education of circumstances—of examples;  in-
sensible education, as a  popular writer  correctly terms it; the results
of which, like those of the insensible operations going on in the physi-
cal world, are often more  striking and more permanent, than of such
as are open and apparent.  To this education everything contributes
by which the child is surrounded,—the example, the conversation, the
manners, the opinions,  the prejudices of his parents, and  of  those in
whose society he  is brought, or accidentally falls,—the sentiments  he
hears] expressed while playing unnoticed in the corner of a room, the
conduct of his parents and seniors towards himself as well as  towards
others.  From these influences, it is not  in the power of parents, even
were  it advisable, to withdraw their children ; but it is in their power
to surround them  with such influences, only, as are calculated to give
to the  mind  in early life that  proper moral bias, which no light temp-
tation, in their future  intercourse with  the world, will be able to de-
stroy.
  " Although," remarks Madame de Genlis, " many of the most hor-
rid vices might be witnessed by a child, without the least danger, from
his inability  to understand them, yet, trifles, such as almost escape our
observation, will often pervert his unformed judgment,  and deprave his
heart.   Circumstances, which we considered the least important, may,
in the mind of a child two or three years old, sow the seeds of cruelty,
injustice, and other vices."
  On the other hand, nothing is more easy, by presenting always be-
fore them, in the conduct and conversation  of their parents, and  those
with whom  they constantly or occasionally associate, none  but  good
examples—and by taking advantage of every little incident and casual
occurrence,  to connect the practice of the virtues with the vivacity of
pleasurable  sensation,—to render truth, fidelity, benevolence, genero-
sity, firmness, and strict integrity, dispositions essential to the mind__
principles interwoven with its constitution, and habits it spontaneously
indulges.
  What idea  can we have of  a father, who being himself guilty of
swearing, punishes his  son for that vice; or who preaching up tempe 
MANAGEMENT OF CHILDREN.
77
ranee, is himself intemperate.  This holds in all actions, however in-
considerable, as we  know that children  ape and mimic those with
whom they converse.  It is in vain to tell them, such things are al-
lowable in grown persons, but unbecoming in children ; as vice will
only thus be placed in a more engaging point of view, and the  great
opinion  they form of grown-up persons, make them wish  to  be soon
able to resemble them.  But, can  it be imagined, that there are any
parents  who take delight in the vices of their children,  and train  them
up in them'? and yet without their  desiring to do it, nothing is  more
certain.  A child scarcely begins to lisp, than he repeats the abusive
language he hears  from his parents or others, which, too frequently, is
not only approved  but encouraged, from the supposition that there can
be no harm in a child repeating words, the import of which he cannot
understand ; and then it is so comical and diverting in him !  But the
child perceives, full well, the nature of the feeling which gives birth to
the words, and soon learns to employ them to express his own rage or
displeasure; and the language he lisped in infancy, he will, in future
years, habitually utter.
  The same thing  is true in innumerable other particulars.   A  child,
for instance, begins to cry; to pacify him a stick is offered him to beat
the naughty stool or stone that  made him stumble ; with this, perhaps,
the child is quieted;  but  thence he  instinctively  acquires the disposi-
tion to revenge himself on whatever gives him uneasiness or inconve-
nience,  whether things or persons;  and thus  the desire for revenge is
so deeply implanted in his mind, as scarcely ever after to be entirely
eradicated.  This is equally true of other vices, as idleness, negligence,
prodigality,  cruelty, &c, when practised or countenanced by parents
in the presence of their children; who  thus,  in fact, while truly  wish-
ing them to do well, by their own example, implant in their offspring
the seeds of every  vice.
   The  perceptive, are the first  of the intellectual faculties that become
active,  and they are, in many cases, exercised at a surprisingly early
period.   The infant, in the nursery, is often a very quick, if not always
a very accurate observer.  By  taking advantage of this observing and
inquisitive disposition of children, and carefully directing it to familiar
natural  objects and phenomena, with a short and  simple  explanation
of their leading qualities or causes, they may  be made to acquire,
almost imperceptibly, a vast amount of useful knowledge, at an age
when any direct application of the mind to study would be prejudicial.
   In this manner, the powers of the intellect become gradually  deve-
loped, and the child soon acquires the capability of comparing and as-
sorting  his ideas; of referring effects to causes, and distinguishing truth
from error;  and, by rendering him familiar with  the beauty, order,
and harmony of nature,  and the wisdom and beneficence exhibited in
all  its operations, his moral faculties, equally with his  intellectual, are
cultivated and improved.  This kind of mental culture  is effected with-
out confinement, or in any degree detracting from the exercise of the
body ; it allures the pupil forth  into the open air, " amid the  garden's
cultured walks : o'er grassy fields ;  along  the river's brink ;  amid  the
silence  of the  forest's  shade;  upon the hillside, or  by  old  ocean's 
78
DISEASES OF CHILDREN.
shore," where every object elicits attention; and while it amuses, it
excites the mind to reflection, and the better prepares it for future in-
tellectual attainments.
   It is, indeed, to be regretted, that so small a portion of the educa-
tion of youth is devoted to  the acquisition of knowledge from personal
observation.  The perceptive faculties are thus in a great measure ne-
glected, and the erudition of books, even in the acquisition of the natu-
ral sciences, is made to supplant the more exact, vivid, and permanent
impressions derived through their medium.  On every subject of know-
ledge,  the mind receives a foreign impression,—it is made to learn by
the observations of others, rather  than by  original reflection, and  to
receive upon the authority of books, what it should admit only in con-
sequence of previous self-conviction,—its  own  original powers of ac-
quisition being sacrificed at the shrine of authority.
                        CHAPTER  II.

    OF THE PECULIARITIES OF ORGANIZATION AND FUNCTION
                DURING INFANCY AND CHILDHOOD.

   An acquaintance with the physiological  condition of the different
portions of the body, and the successive and rapid changes which they
undergo, in organization and function, from the period  of birth  until
that of puberty, is essential  to a correct understanding of the  pathology
and therapeutics of infancy and childhood.  It is to the physiological
condition of the  several tissues and organs—their successive develop-
ment and relative activity—that the predisposition to  particular forms
of morbid action, as well as the various modifications which the phe-
nomena, march, and  terminations  of disease exhibit, in the earlier
stages of existence, are to be attributed, and to  which also  reference
is to be had, to a certain extent at least, in the choice of the therapeu-
tical agents which are  then employed.
  At the moment  when the  human  being emerges from the womb,
and  enters upon the enjoyment of a separate state  of  existence, it
presents physiological  as well  as  physical  characters, which it pre-
serves  during a  certain period, altogether distinct  from  those which
are proper  to  it  in the  subsequent periods of life.  All of the organs
are imperfectly  developed, while many of them are, as  yet, merely
rudimental,  and  the whole of the functions of life are confined, almost
exclusively, to those of nutrition.   By degrees, however, the different
parts of the system become  more perfectly organized ; the  body in-
creases  in size, and exhibits  an  augmentation of strength and vigour;
organ after organ  becomes successively developed,  and  enjoys for a
time a predominance of activity ; the  number  and extent  of the vital 
PECULIARITIES OF  ORGANIZATION.
79
phenomena  are thus increased, until, finally, the  entire organism  is
adapted to the active and regular performance of all its functions.
  During the whole period of infancy, the activity of the digestive
and nutritive functions, the great and rapid change of material which
the different organs experience, and the consequent demand for a con-
stant  supply of appropriate nourishment  render, under the influence
of various disturbing circumstances, the occurrence of errors of nu-
trition, or of disease dependent upon  deficient or improper food,  of
frequent occurrence.  The great  size and vascularity of the brain,
also, the extreme delicacy and excitability of the skin and mucous
membranes, and the great development of the whole lymphatic system,
causes these parts,  more frequently than others, to be  the  seat of se-
rious and extensive disease.  Their susceptibility to  morbid  impressions
being still more increased somewhat later by the process of dentition.
The rapid development of the  brain, and  the  activity  of many of  its
functions, as well as the simultaneous changes going on in the intesti-
nal mucous  membrane, as  the teeth make their  appearance, render
both, at  this particular period, especially prone to disease  from slight
causes.
   The excessive nervous excitability of the infant  gives to  its diseases
a peculiar character of mobility—that is to  say, morbid irritations
occurring in one organ are quickly reflected upon others; and from
the  great  vascularity  of every   part, especially the abundance  of
arterial capillaries with which all  are supplied, during  the  progress  of
rapid growth, sympathetic irritations become very soon converted into
organic disease.
   While  the physiological condition  of  the  several  organs, in the
stages of infancy and youth, renders them thus prone to take on par-
ticular grades of morbid action, it, to  a certain extent, also modifies
the action upon them of the various remedial agents; nearly all  of
these acting with increased energy at this period of life, and requiring
to be administered in diminished doses, graduated by the particular
age of the  patient.   Some remedies  have, likewise, a peculiarity of
action different from that  produced in the adult, while the action  of
others is more  or less prejudicial.  But it  is unnecessary, in this place,
to extend further  our  remarks on  this  subject;  we  shall have fre-
quently to recur to it in subsequent portions of the treatise.

                           1.—Infancy.
   The  age of infancy extends, agreeably to  the division we shall
adopt, and which corresponds with that of Miiller, from the period  of
birth to the commencement of  the second dentition, or, generally
speaking, until the  end  of the sixth year.  According to M. Halle,
this period of hfe includes three  distinct  physiological epochs:  The
first, extendingffrom birth to the commencement of the first year/ the<^f$r lv<+i
second, comprehending  the period occupied in the process of ^lenti-  x^- 9 /
tion; and the  third, extending to the appearance of the permanent      ' ,
teeth.
   Organization.—At birth, as already remarked, the  entire organisth
is but imperfectly developed.   The  body measures from seventeen  to 
80
DISEASES  OF CHILDREN.
 twenty-one inches  in  length, and in weight, varies, agreeably to the
 repeated observations of Professor Chaussier, from six to nine pounds.
 The skin is of an extreme delicacy, and of a more or  less deep  red
 colour.  It is, also, more vascular,  and  more freely  supplied with
 nerves than in after life.   At the end of a few weeks, it loses its deep
 red tint, changing, by degrees, to a dirty yellow, and finally assuming
 a degree of whiteness which it seldom retains in after life.   According
 to Billard,  it is not  until towards the end of the  third  month, that the
 distinct colour of the skin becomes established, and we can distinguish
 dark-complexioned children from those that are  fair.  At a much ear-
 lier period, the hair has  assumed its proper hue, but it is  only at the
 third month that the skin on the  body becomes dark or light-coloured,
 the face either pale or ruddy, and the traits peculiar to each constitu-
 tion are delineated.
  A few days after birth the epidermis  commences to  exfoliate, and
 by the fortieth day is usually separated from the whole surface in  the
 form of scales or fine powder.   During  the entire period of infancy,
 the skin exhibits  great irritability, and  is very liberally supplied with
 blood.   The articulations retain, for a short time after  birth, a semi-
 flexed  condition, and the whole trunk a forward  curvature.
  The limbs of the infant are round, smooth, and plump, as well as
 all the prominent parts on the  exterior of the body.  This arises from
 the large amount of fat, and of soft  cellular  tissue filled with serum,
 which  are interposed between  the skin and  muscles.  As infancy  ad-
 vances the fat diminishes, and the cellular tissue  becomes more dense,
 while the exudation into its areola is lessened ; the outlines of the mus-
 cles are in  consequence rendered more apparent, and the form of  the
 limbs and trunk, especially in males, is somewhat changed.
  The head and abdomen of the young infant are of a bulk dispropor-
 tionately large, compared with  that  of the  rest of the body.  The
 pelvis  is small and contracted,  and the inferior limbs  have a much
 less degree of development than  the superior;  the median point of the
 body is at the umbilicus,  or a  line or two below it.  Several months
 elapse  before the lower limbs acquire  a  size proportionate  to that of
 the other parts.  The thorax is small, flattened at its sides, but some-
 what prominent anteriorly.  All  the tissues abound in lymph, and  the
 lymphatic  vessels  and glands have a development and activity  far
 superior to  what they possess in  after life.
  In the early period of infancy, the bones  are  small, red, and  defi-
 cient in earthy matter, being still, in a  great  measure, cartilaginous.
 The central cavity of the long bones can scarcely be said to exist, and
 the sinuses  in those of the head are not at all, or but imperfectly deve-
 loped.   The bones of the skull and the ribs are, however, much more
 advanced in ossification than  those destined for  muscular attachment
 or locomotion.                                    "
  The muscles are at first soft, pale, and gelatinous;  they contain  • • " ,
 but  a small amount  of fibrine,  and, in common with all the soft parts,
are destitute of firmness.   They  are slender in shape, their fibres are
loosely united, the fasciculi not being embraced  by fasciae or aponeu-
roses. 
PECULIARITIES OF ORGANIZATION.
81
  The digestive organs, though less perfectly organized in the early
period of infancy than they subsequently become, are, nevertheless, in
a condition adapted to produce rapid changes in the aliment introduced
into them, and thus to  afford  a constant supply of materials  for the
nutrition of the system.
  The mouth, with the  exception of the teeth, is fully formed, and, by
the disposition of the lips and palate, and the obliquity of the posterior
nares, is especially adapted for the performance of its proper office of
suction.         •
  The mucous  membrane, throughout the whole tract of the alimen-
tary canal, is thick, soft, and  villous—more plentifully covered  with
mucus, as well as more sensitive  and vascular, than in after life.  In
the stomach, duodenum, and jejunum, it is of a bright  rosy tint, but
somewhat paler in the ileum and remaining intestines; it often exhibits
on  different parts of its  surface, large patches of a yellow hue, owing
probably to the action of the bile.
  When all the liquid parts of the  intestinal tube, in early infancy, are
removed, there  will still  remain  a  layer of thick mucus,  adhering
closely to the internal surface  of  the  canal, forming  on it a  kind of
plastering.  It may be raised by the nail,  under the form of a pellicle,
resembling, to a superficial observer, portions of the  mucous membrane
itself.  This layer never remains but for a short time; detaching  itself
by  a kind of natural exfoliation.   This exfoliation occurs in very thin
laminae, which, being rolled together, form the small, white flocculi, so
frequently met with in the stools of young infants.  When the surface
of the duodenum or jejunum is coloured with bile,  the removal of this
layer of  mucus removes also the yellow stain.  (Billard.)
  In  the infant, the stomach  is much more conical than  that of the
adult; the entrance of the oesophagus is situated at the left extremity,
some distance from the  pylorus; the short curvature is also compara-
tively long, and the large  curvature but little developed.  It is,  proba-
bly, in consequence of this  form of the stomach, that vomiting is  so
frequent  and easy in the infant.  The stomach is placed in an  almost
perpendicular direction, extending from the epigastrium to  the umbili-
cus, in place of  transversely, as in the adult.   The omentum is pecu-
liarly delicate, and almost entirely devoid  of fat.
  The small  intestines in  the infant, are nearly one-third  longer, in
proportion to the length of  the whole tract, than in the adult, and the
large intestines are longer in proportion to the  small, but their calibre
is relatively less.  The  valvulse conniventes are  scarcely  apparent;
some separate mucous follicles, about the  size of a pin's head,  and of
a white colour, often exist in the jejunum, and in the ileum, follicular
plexes, white and  projecting, and  often with a slight  black  point on
the top,  as  in the adult.  The ccecum is  largely developed, and the
vermiform process very long.   The ileo-coecal valve slightly projects,
while the opening it surrounds  is so extremely small, that, in most in-
fants, it would be  difficult  to pass through it even a crow-quill.   At
this age it prevents the regurgitation of substances, and even gas, from
the  large into the small intestines, but allows a free passage  for the
contents  of the small intestines into the large. (Billard.)  The depres-
                                6 
82
DISEASES OF CHILDREN.
sions and prominences of the coecum and colon are less marked in the
infant  than  in  after life.  The lacteal vessels, and mesenteric glands,
are largely developed.
  In the infant the liver has a bulk greatly disproportionate to the re-
sidue of the abdominal organs; at birth, it fills nearly one-third of the
abdominal cavity, descending even to the crest of the ilium; but  with
the change in its circulation, caused by the obliteration of the ductus
venosus, and the development of the  portal vein, its bulk diminishes,
bv a reduction, especially, in the size of the left lobe^
 ' The gall-bladder is small at birth, but soon enlarges; it contains
bile of a green colour, but less  viscid, and containing less of its pecu-
liar principles, than at a more advanced age.
  The spleen is  small in size, but  presenting no apparent  difference
from its usual structure in the adult; it can be distinctly felt in the in-
fant, under the short ribs, towards the centre of the abdomen.
  The pancreas  and kidneys are large; the lobular structure of the
latter quickly disappears, and the supra-renal  capsules, which are at
first of considerable size, rapidly diminish.
  The urinary bladder is small, having a more elongated shape  than
in the  adult, and is  placed  rather above than within the pelvis.   The
pouch, or fundus of the bladder, is but imperfectly developed, and the
cervix  is much more dependent than in the adult, which may be one
cause of the frequent discharges of urine, and the difficulty of retaining
it during infancy.
  The respiratory organs are well developed in the infant.  At the pe-
riod of birth, the cartilages and bones, as well  as the muscles of the
larynx,  are  perfectly formed,  though very  small and flexible.   The
cartilages of the trachea  are perfectly distinct from each other, but
soft, and filled with  blood.   The mucous membrane of these parts is
soft, thick, very vascular, and abundantly supplied with mucus.   The
dimensions of the larynx and glottis  are  very small at birth, and re-
main so during the greater part of childhood, differing but little in size
in a child of three or four and one of twelve years.   It is this which,
in young children, renders all diseases of these parts that are attended
with exudation upon, or tumefaction of their mucous membrane, so
eminently dangerous, from the complete closure of the glottis that  then
takes place.  The bronchi are perfectly formed, but small, in the in-
fant ; they, however, quickly acquire a greater development.
  The dimensions of the thorax are proportionably less than those of
the other cavities, at birth, and  for some time afterwards.
  The lungs, which in the fcetus were small, dense, and of a brownish
colour, expand immediately after birth  to  double their former bulk,
and become soft, crepitant, and of a rosy hue.  Though of less specific
gravity than  in the foetal  state, in consequence of the air which per-
vades their cells, yet their absolute weight, from the greater amount of
blood transmitted to them, is doubled.
  The chest of the  infant upon percussion is  very sonorous; chiefly
from the thinness of the parietes, and the freedom with which the air
permeates  the  bronchi and  the air-cells of the lungs.   The thymus
gland, which exists at birth, continues to grow after birth, and remains 
PECULIARITIES OF ORGANIZATION.
83
of considerable size during the first year, after which it usually gradu-
ally diminishes, and, in many instances—but by no means so uniformly
as has been  generally  supposed—it disappears about  the  period of
puberty.
  The organs  of circulation are fully developed  at birth, but during
the early period of infancy present several remarkable peculiarities.
  The volume of the heart is proportionably large; its muscular struc-
ture  is soft, and of a paler colour than in after life, and of nearly equal
thickness  throughout.   The  capacity of the  left ventricle, and of the
principal arterial trunks, is greater than that  of the right ventricle and
of the large  venous trunks.   The  colour of the  cavities, on the two
sides of the  heart, as well as of their respective vessels, likewise dif-
fers—those of the right being usually of a deep violet, while those of
the left are red.  After the closure of the foramen ovale, and the obli-
teration of the ductus arteriosus, the parietes of the left ventricle, which
then becomes charged with the propulsion of the  blood throughout the
body, rapidly increase in thickness, while, at the  same time, the right
ventricle acquires a capacity which exceeds considerably that of the
left.
  Every portion  of the  body, during infancy, is  more plentifully sup-
plied with arteries than in after life—the capillary system is much
more expanded, and every organ and tissue is more fully permeated
with red blood;  nor is it  until  the stage of active growth is passed,
that  this extreme vascularity  ceases, and  the  venous radicles and veins
begin to assume their preponderance.
   The blood of the infant contains a much less amount of  fibrine and
phosphate of lime, than that of the adult, and  a much larger proportion
of albuminous matter and water.
   During infancy, the brain  is large in size, and  nearly resembles, in
its general form, that of the  adult.  It is of  a soft, paste-like consist-
ence, and soon softens when  in contact with the air.  It  is of a whitish
colour, the medullary and  cineritious portions being scarcely distin-
guishable—the situation of the latter being merely indicated by a line,
more coloured than the central substance, winding over  the superficies
of the cerebrum, throughout its  convolutions.   In the cerebellum,
though the two portions are  less marked than in the adult, they are,
nevertheless,  more so than in the cerebrum.   The  medullary substance
of the brain  is generally of  a reddish colour in  the infant, having a
number of blood-vessels ramifying  through it. The convolutions are
less prominent, and apparently less numerous than in after life.  The
cerebellum, as well as the medulla oblongata,  are much more advanced
in organization than the other portions of the brain.
  The dura mater is thinner, and  its adhesions are less firm, than in
the adult,  and, in common with the pia mater,  it is more vascular.
The  latter, where it envelopes the  medulla oblongata, is more dense
and cellular than  upon the brain.  The connexion of the tunica arach-
noidea with the brain, is less intimate than is  the case in after life.   A
larger amount of fluid also exists between the membranes, and in the
ventricles.
  As the infant advances in age, the organization of the various por- 
84
DISEASES  OF CHILDREN.
tions  of  the  brain becomes more perfect.   Between  the  ninth and
twelfth months, the cineritious portion becomes more fully developed,
and assumes, after passing through various gradations of colour, the
reddish-gray  by which it is distinguished in the adult;  the  medullary
portion  assumes  a  firmer  consistence; the  convolutions  are more
defined  and  prominent;  the peripheral  surface of the brain  is more
extensive, and, at the same time, the cerebrum augments in  size, caus-
ing a  very marked change  in  the form  of the head, by the increased
development  of the anterior regions of the skull.
  To accommodate the rapid  growth of the  brain, during the early
period of infancy, the bones of which the skull are composed, are im-
perfectly organized, and  but loosely connected to each  other ;  the an-
gles of those especially which compose  the vault of the cranium, are
entirely wanting,  the deficiency being supplied by a dense membrane,
forming  the openings or  spaces denominated  fontanelles.  These gra-
dually close,  as the ossification of the  bones  becomes perfected, and,
generally, between the fourth and sixth years the sutures are all firmly
united.
  In the infant, the  medulla spinalis is white, its cineritious centre
being  well defined, but of a brighter colour and softer consistence than
in the adult.   The two lateral  cords of which it is composed, may be
unrolled with great ease.   Behind the dura mater, there exists a thick
layer  of cellular  tissue, which, in young infants, is infiltrated with a
yellow serosity, the consistence of which  is  sometimes gelatinous.—
(Billard.)  The  network of  spinal veins, is, in  the  infant, almost
always engorged  with blood.
  The annular portions of the vertebra?, which form the canal for the
spinal marrow, are fully ossified  at  birth, while the  solid  portion of
these  bones, upon which  the weight  of  the body is sustained in after
life, is but slightly expanded, and cartilaginous,  and the processes for
muscular attachment have little prominence or solidity.
  The nerves of organic  life are those most perfectly developed in the
infant.  The  ganglionic, or great sympathetic, presents, indeed, nearly
the  same proportions and perfection of organization as  in the adult.
The nerves of sensation and of motion, as well as the special nerves of
sense, appear fully formed at birth; but in the  early period of infancy,
they exhibit but imperfectly their appropriate functions; less, however,
we  suspect, from  their incapacity  to convey the impressions made
upon them, than from the imperfect condition  of those portions of the
nervous centres with which these nerves are immediately connected.
  The organs of the external  senses are all present at birth, and the
nerves distributed to them are  large.  The eye presents  no appreciable
difference in  structure from that of the adult.   The tympanum of the
ear is small, its membrane oblique,  and the internal  structure of the
organ is but  imperfectly  developed.   The nose is small, and the nasal
fossa? are either  wanting, or imperfectly  developed.   The larynx  is
very small, both in depth and diameter,  and presents  no protuberance
at the anterior part of the neck.
  The genital organs  of both sexes are fully  formed in the infant,
though  small in size.  The clitoris  and nymphae  of the female are 
PECULIARITIES OF ORGANIZATION.
85
often, however, disproportionately large, in comparison with the other
parts.
  Until the termination of the first  period of infancy, the general or-
ganization  and appearance  of the  body  undergo  but  little change.
The infant, however, gradually increases in size and weight.  The
head, though still  voluminous, diminishes  in  the relative size it bears
to the rest of the body; while the pelvis expands, and the inferior ex-
tremities become  longer, and more fully developed.   The softness of
the tissues diminishes gradually, and they acquire a  greater degree of
density.  The fat  and serosity become reduced in quantity, and al-
though the temperament  is still decidedly lymphatic, the predominance
of the white fluids  over the blood diminishes, as the termination of in-
fancy approaches.
   The bones lose by degrees  their cartilaginous form, by the con-
stant progress of  ossification.  The central canal of the long bones,
and the sinuses, and other cavities in those of the  face  and head, be-
come more fully developed.   The  articulations acquire greater firm-
ness, and those of  the extremities augment in bulk.   The muscles lose,
by  degrees, their  gelatinous character, become more fibrinous, aug-
ment in bulk and density, and acquire more and more of the deep red
colour which distinguishes them in after life; while the aponeurotic
sheaths, and tendinous appendages, become more and more fully de-
veloped.
  During the entire period of infancy,  the digestive and  nutritive or-
gans maintain their predominance.  From  the  first month, the jaws
gradually expand; and  between the  sixth and  seventh months, the
first teeth make their appearance, and by the end of the  second year,
when the first dentition is completed, each jaw contains ten.  These
teeth, which have received  the popular denomination of milk  teeth,
are retained until  about  the  seventh year, when the second dentition
commences ; and the permanent teeth successively make their appear-
ance to the number of  twenty-eight.   When dentition commences, the
salivary glands, which were previously but  slightly developed, aug-
ment considerably in bulk, and  furnish  an abundant  secretion.
  During the progress of dentition,  the mucous follicles and glands of
the stomach become developed, and  by the termination of the first
year, the several  portions of the digestive apparatus have  acquired,
very nearly, their complete  organization, and differ but little from
those of the adult.  The  disproportion in  the size of the liver, espe-
cially of its middle lobe, decreases gradually ;  it recedes  more towards
the ribs, and its parenchyma becomes  of a darker colour.  The gall-
bladder augments in capacity, and the urinary bladder assumes more
of an ovoid form, and sinks  lower  into the pelvis.   The lungs gradu-
ally  develope themselves, but still  preserve  their great vascularity,
their redness of colour, the  smallness of their cells, and a degree of
density, greater than they present in after life.
  The heart becomes, in  the progress  of  infancy, gradually changed
in its form and volume,  and in  the relative capacity of the cavities
and thickness of the parietes of its two sides, until,  finally, it assumes
all the characteristics  of the adult heart.   The  foramen ovale and 
86
DISEASES  OF CHILDREN.
ductus arteriosus, usually become  obliterated  on or before the  tenth
day after birth—the first remaining longer patulous than the last.
  During the entire period  of infancy, the predominance of the  arte-
ries over the veins, and  the extent of the  capillary system is but little
changed.  The blood, however, towards the close of this period, pre-
sents an augmented amount of fibrine, and approximates  more nearly
in its composition to that of the adult.
  The disproportionate  size of the brain diminishes—it  increases  in
consistence, its convolutions become more apparent, and its colourless
red; the proportion of its medullary matter  is increased, its cortical
portion is more distinctly marked, the bulk of the whole  of the  cere-
brum  is increased, and by the termination  of infancy, it is found  to
have acquired, very nearly, that form and organization  which  it re-
tains during the remainder  of life.
  With the  growth of  the body in height, there is a corresponding
elongation of the spinal marrow, which at the same time increases in
bulk, and acquires, gradually, a more perfect organization; but from
the early period at which it exhibits a perfectness of development be-
yond that of the brain, the changes  which take place in it are less ex-
tensive and striking.
  During infancy, but little apparent change takes place in  the organs
of hearing, of sight, and of taste;  the cavities of the nose,  as well  as
of the mouth, however, become more developed,  and  the  sense  of
smelling, and probably that of taste, more acute and discriminating.
  The organs of  generation  undergo  but  little,  if any, important
change, until towards the age of puberty.
  The growth of  the body and its increase  in  height,  weight, and
strength, are  modified in some degree by sex, while its ratio of in-
crease differs at the different stages of life.  According to M. Quetelet,
who has investigated this  subject  with great care, the weight of the
male infant at birth, is about half a pound greater than that of the fe-
male, and the length about  an inch.  The annual growth  of the first, is
greater than that of the  last, while  the progress of development is re-
versed.  Immediately subsequent to birth, the  weight of the infant di-
minishes,  and does not begin  sensibly  to  augment until the second
week.   The increase  in stature is more  rapid during the first twelve
months, being nearly eight  inches;  it is  less  rapid  as the  infant ap-
proaches its fourth or fifth year,  diminishing, apparently, in direct
ratio to the age,  up to that period.  The growth  in  the second year
being half that of the first; in the third only one-third ; but subsequent-
ly it goes on in a tolerably  regular progression.
  Functions.—Immediately after birth, the function of respiration com-
mences.  The lungs and chest  dilate, and the external air rushes into
and distends the  pulmonary cells, while the closure of the communica-
tion, which in the foetus exists between the two  auricles of the heart,
the obliteration of the umbilical vessels, and of the arterial and venous
canals, a few days subsequently, cause the whole of the blood received
by the right side of the heart, to pass through the lungs, in order to
become there arterialized  by its contact with the atmospheric air. 
PECULIARITIES OF  ORGANIZATION.
87
From this period, the arterial and venous blood circulate, each in its
distinct  set of vessels.
   Respiration  once  established, continues without interruption as in
the adult;  it is, however, more frequent; being, during the first year,
from 35 to 40  in the  minute, or nearly double that of the adult; it is
accomplished almost entirely by the intercostal muscles.   Examined
by the stethoscope, it is found to be  louder,  also, than  in after life, as
though  the bronchial  ramifications experienced  a greater degree of
dilatation, and received a proportionately greater amount of air.  This
peculiarity  continues until about  the twelfth year,  when  respiration
assumes the same characters  as  in  the adult.  Notwithstanding the
activity of the process of respiration, it would appear, however, that a
less amount of oxygen is consumed by the  infant than in after  life.
With  the  advance of infancy, respiration becomes gradually slower
and the amount of oxygen consumed greater.
   Infants,  during  the act of sucking,  respire  entirely by the nose,
which is then to be considered as an important part of the respiratory
system.
   The circulation, which in the infant is accomplished in the same
manner as in the adult, is much quicker and  more  rapid.   The pulse
of the infant is, in  consequence, more quick and frequent, beating  one
hundred strokes, or Upwards, in  a minute.   It gradually decreases,
however, with the approach of youth.*
   Soon  after birth, digestion  commences, and during the entire period
of infancy is peculiarly active, demanding an almost  constant supply
of the  food furnished by nature in the  breast-milk  of the  mother.

   * The following statement of the number of pulsations  during infancy and childhood, is
given by Miiller.
                  At birth,.........140 to 130.
                  During the first year,.....130 to 115.
                  During the second year, .  .  •  .  115 to 100.
                  During the third year,.....100 to 90.
                  About the seventh year,  . .  .  .  90 to 85.
                  About the fourteenth year,  .  .  .  85 to 80.
   M. Valleix, as the  result of his examinations, states, the pulse from the 2d to the 21st
day after birth, amounts to 87; at 11  months, 129; at 14  months, 125; and at 20 months,
117.  Del'Auscultation.  Paris, 1827.
   Dr. Hohl states, from his observations, that at birth the pulse varies from 100 to 156;
24 hours after birth, from 100 to 150; 36 hours after birth, from  110 to 154; 48 hours after
birth, 108  to 146; 72 hours, 108 to 140; 5 days, 108 to 170. Die Geburtshiilflicfie explo-
ration.  Halle, 1833.
   Dr. Gorham gives  130 as the mean number of pulsations from the fifth month, to the
second year, and 107 from the second to the fourth  year;  from which time until the tenth
year, he observed but little variation to occur.—Med. Gazette, 1837.
   M. Billard states, that from his observations, " it appears that the pulse of a very young
infant is often not much more frequent than that of an adult, but it increases in frequency in
proportion as the child advances in age ; whence it follows, that it is wrong to assert, in a
manner so exclusive  and general as  is usually done, that the pulse  in children is more
frequent than in adults."  It appears  to him to be clearly  demonstrated, that this rule has
many exceptions.—Diseases of Infants.
  According to the observations of M. Trousseau, during the first two weeks after birth
the pulse  may vary from 78 to 150;  during the second two weeks, from 120 to 164; one
to  two months, from 96 to 132; two to six months, 100 to 162;  six to twelve months, 100
to  160; twelve to twenty-one months, 96 to 140.
   The foregoing statements show how little reliance is to be placed upon the pulse, as a
sign of disease in infants. 
88
DISEASES OF CHILDREN.
This food, which is the only kind adapted to the peculiar condition of
the digestive organs in the earlier months of existence, increasing in
consistence, as  the  energies of the stomach become more developed,
is fully adequate for the  support of the system, until  the commence-
ment of the first dentition, when  a more substantial aliment  would
seem to be required.  The appearance  of the  teeth, the augmented
size  and greater activity of the salivary glands, and  the increased
bulk of  the muscles subservient to mastication, enable the infant, after
the first year, to partake of solid  food, which the stomach then digests
with facility.
  The whole of the functions concerned in the nutrition of the system,
are equally active  with  those of digestion.  The process of assimila-
tion  predominates  considerably over that  of decomposition, as  is
evinced  by  the constant growth of the body, and the rapid develop-
ment of the  majority of the more important organs.
  The  discharges  from the  bowels  are  frequent  and passed almost
involuntarily.   In the earlier  period of infancy, they differ from those
in after life, by their lighter  colour, their curdy appearance, and by
the absence of  any decided fcetor.  After the first year, they become
less  frequent, darker coloured, and exhale a stronger odour.  They
are then, also, more under the command  of the  will.
  The urinary  secretion is in full activity at birth; but the urine is at
first pale and watery, and scarcely contains any of those  peculiar
principles which distinguish it in after life.  The benzoic acid exists
in a larger  amount, generally, in the urine of infants, than  in that of
adults.
  The  exhalant function of the  skin is extremely active during this
age, and from this circumstance,  and the great excitability  of the
dermoid texture, it is readily augmented by a  slight  stimulation, and
as readily checked  by a trifling diminution of temperature.
  Calorification is  at first feeble, the heat of the body  in young infants
being, according  to  the investigation  of Edwards, and later ob-
servers, several degrees less than in the subsequent periods  of life.
For several months after birth  the  infant suffers severely from the
influence of a  cold atmosphere, and  the proper temperature of its
surface  can  be maintained only by sufficient clothing, and other arti-
ficial means.   By degrees,  however, the  process  of calorification
acquires a greater  degree of  energy, and the body becomes less sensi-
ble to the influence of atmospherical vicissitudes.
   The functions of relation commence at birth, and are rapidly deve-
loped during infancy, but do  not attain their utmost perfection  until a
subsequent  age.  The moment  the infant emerges from the womb, it
commences to cry, and  to  move  its body and its limbs  in  different
directions.   It  will  grasp at any  objects in its immediate vicinity, and
sometimes   seizing  them mechanically,  will even carry them to its
mouth.   If the breast be now presented to it, it will  grasp  the nipple
with  its lips, and instinctively perform the complicated movements of
the mouth and  tongue required in the act of sucking.
   It is difficult to decide upon the actual cause which  prompts the first
cries of the infant, and the agitation into which its limbs are thrown. 
               PECULIARITIES OF ORGANIZATION.            89

 They would appear, however, to be, in  some  measure at least, occa-
 sioned by the uneasy sensations to which the sudden entrance upon a
 new state of existence gives rise.  The muscular movements observed
 in the new-born infant are evidently purely automatic in their character.
   In proportion as  the infant advances in age, it exercises the arms
 and hands by reaching towards the objects which are within its grasp;
 and it is soon  found to  avoid such as are not agreeable,  and to be
 attracted by those which afford  pleasure.  We often see very young
 infants seize with eagerness a finger or coral presented to their notice.
 Almost all will place the hand in that of the nurse; or, introducing one
 or more fipgers into the  mouth, occupy themselves with sucking.
   During the few first weeks of life, the external senses are but slightly
 developed; the infant is,  nevertheless, sensible to the impression of
 cold, and  experiences pain when the skin is  irritated or  wounded :
 very soon, however, the existence of the sense of touch is manifested.
 The sense of taste  is, also, exercised very early; that of smell, how-
 ever, is but imperfectly developed until a later  period, in  consequence
 of the  incomplete state of the nasal  cavities, and the limited extent of
 the Schneiderian membrane.
   It is not until about the third or fourth week that any  indication is
 presented of the exercise of sight or hearing; but subsequently to this
 period  these senses  speedily acquire their full development.  Vividly
 illuminated objects, it is certain, very soon attract the  infant, but it  is
 evident that the  eyes are merely directed to them, at first, passively.
 Light would appear  to  be at all times pleasing to the infant, which
 seems naturally to dislike  darkness; but a very bright light is  annoy-
 ing as well as injurious to  the eye at this period.
   Hunger and thirst, and the instinctive desire for the constant admis-
 sion of fresh air into the lungs, are among the internal sensations which
 are first experienced; they have, during infancy, the same general
 characters which they exhibit in  after life.
   Those sensations which  prompt to the exercise of the voluntary mus-
 cles, and probably those connected with the evacuation of the  bowels
 and bladder,  are experienced at a  very early period.   As  infancy
 advances, the first of these sensations is more intense, perhaps, than
 in the after ages of existence.  So  soon as the muscles become suffi-
 ciently developed, and the  locomotive organs generally have acquired
 adequate strength and vigour, the infant, during its waking hours, is in
 almost constant motion ;—indeed, while in health, a state of inaction,
 for a single instant, would appear to be to it one of actual suffering.
   The  motions of the arms are  those first brought into exercise; to
 these succeed those of the head, which, at first tottering, now becomes
 fixed upon  the neck.   In proportion  as the  faculty of vision is deve-
 loped, the movements of the head become of a more decided character.
 At the end of the first month the  infant will turn  his head, on the lap
 or pillow, to either side upon which a brilliant object is presented.  At
 the age of six weeks, and sometimes earlier, he voluntarily fixes his
 attention upon  surrounding objects, and is attracted particularly by a
 strong  light; hence the necessity  of preventing the rays of  light from
falling  obliquely upon the face of  an infant in the cradle, lest the axis 
90
DISEASES  OF CHILDREN.
of vision should, in consequence, be  made  to deviate from the right
direction.
  At  birth, and for several months subsequently, the imperfect  ossifi-
cation of the bones, the disproportionate size of  the  head,  and the
smallness and obliquity of the pelvis, the laxity of the articulations, and
the imperfect development of the  muscles, render the erect posture
and progression impossible.  By degrees,  however, the inferior ex-
tremities acquire an augmented size, the bones become  more solid, the
articulations firmer, and the spinal column, by the increased  ossifica-
tion of the  bodies of the vertebrae, and of the processes for muscular
attachment, is better adapted to sustain the weight of  the body.  At
the same time, the muscles become  more  fibrinous, and augment in
bulk and strength.
  Until the sixth or eighth week, the infant has scarcely acquired
the power to support its head, but is constantly seen moving it about
in an  irregular  manner, it appearing too heavy for the  muscles of the
neck to sustain and to direct properly its movements.   By the end of
the second month, however, the infant in general  becomes able to hold
the head erect; and in  a  few  weeks later, to support its  body with
tolerable firmness in the sitting posture.  The  widening of  the hips
increasing, the  sitting  position is constantly becoming more firm and
easy;  and by the seventh or eighth  month the infant is able to place
himself in it, and to move the body from right to left, or forwards and
backwards, with perfect facility. It is about this period it commences
to creep.  The firmness and muscular power of the lower extremities
are next developed; and it  is not until about the ninth or tenth month,
and often much later, that the infant is able to raise itself upon its feet
and to walk; after which period, the motions  of the body become
daily  more firm, prompt and active;  the power to  assume the several
attitudes, and to exercise the various  movements of which the human
body  is capable, is quickly  acquired; and, from the very great supple-
ness of the entire frame, the child  pursues  with  ease and delight  all
those  muscular exercises which require facility and quickness of motion,
rather than strength or skill.
   From this view of the gradual and  successive  development of the
different portions of the osseous and muscular systems, will be per-
ceived the importance of the precautions, given in a preceding chap-
ter, to keep the infant in a horizontal position until the muscles have
acquired sufficient strength to maintain the  head erect; and even after
that, to support carefully the  trunk of  the body, whenever the infant
is placed in a sitting posture, until the  firmness of the  spinal column,
and the power  of the muscles inserted into it, are adequate  to its sus-
tentation ; and, finally, to desist from all premature attempts  to  place
the child upon its feet,  and  from every effort to  induce it to walk at
too early a period.  A neglect of these precautions is often productive
of serious inconvenience, and even permanent deformity.
   During the few first weeks of existence, the moral and intellectual
faculties are  entirely wanting.  The whole external world appears, in
a certain sense, to be, as it were, shut out from  the infant.  Uncon-
scious of existence, it awakes merely to satisfy the instinctive calls for 
PECULIARITIES OF ORGANIZATION.
91
 food, and when these are appeased, falls  again  into a state of repose.
 A state of sleep would seem, indeed, to be that which is the most na-
 tural to it at this period.  The little being is only wakeful and restless
 when suffering from  pain, hunger, thirst, or other uneasy sensations.
   It is the ganglionic system of nerves which  seems to constitute the
 entire nervous apparatus of the infant at birth, and for some time sub-
 sequently.   During a considerable portion of infancy these  nerves, in-
 deed, preserve a very decided predominance of action; the organic
 functions being then  in greater activity than at any subsequent stage
 of life.  By degrees, as the  brain becomes more perfectly  organized,
 and  sensibility is rendered more acute and discriminating, the infant
 gradually emerges from its  merely vegetable  existence, and exhibits
 the indications of commencing intelligence ; its eye takes cognizance
 of the objects by which it is  surrounded, and by degrees, learns to
 distinguish  them from each other; its ear, also, becomes sensible to
 sounds, and discriminates between such  as  are harsh and repulsive,
 and those which are soft and  pleasing.   It soon commences, now, to
 know its parents or its nurse, and  to distinguish them from the other
 individuals  of the family, and these latter from strangers.  It manifests
 desires and will;  it  experiences affection, aversion, anger, joy, and
 grief; it becomes capable of laughter and of genuine tears.   Infants
 rarely smile before they are three  weeks old—but usually it is not,
 according to Billard, until about the age  of one month that an infant
 really begins to laugh.
   About the end of  the first year—sometimes  sooner—attempts  are
 made at the  pronunciation  of words, and very soon afterwards the
 infant is possessed of speech. For some time previously to this period
 the infant makes known  its wants by various expressive gestures of the
 face and hands, and  by  inarticulate sounds, the meaning of which  its
 attendants soon learn to  understand.
   The  articulation of the  infant is, at first, very defective, and from
 the imperfect state of many of the organs of speech, the tones of the
 infantile voice  are weak, shrill, and deficient in modulation; nor do
 they attain to their full perfection until some  time after puberty.
   At the end of the  first  year, the infant passes  less time in sleep.
 Nevertheless,  the constant exercise to which  the  waking  hours  are
 devoted, renders still  a larger amount of sleep necessary than in  the
 adult; the repose is, also, much more perfect and profound.  At this
 period, the intervals of sleep  are very irregular; whenever  the senses
 or the muscles become fatigued, slumber immediately ensues;  but, as
 the age of infancy advances, the  period of wakefulness is  prolonged,
 and sleep occurs only at regular periods,—most generally, on the ap-
 proach  of  night, and  ceases with the return of light on the ensuing
 day.
  During the entire period of infancy, the  nervous susceptibility is par-
ticularly acute—all impressions are vividly felt, though  usually tran-
sient in  their effects.   Sympathetic  affections from reflex action are
readily induced, and often give rise to irregular or morbid action from
trifling irritations.
  From the end of the first year to the termination  of infancy, the de- 
92
DISEASES OF CHILDREN.
velopment of the intellectual faculties proceeds  regularly,  and often
with great rapidity.  The senses soon acquire their utmost degree of
activityrand the perceptions become prompt and rapid. The memory
has at this period a very great activity and extent—enabling the infant
not only to treasure  up the ideas excited by the physical  and other
properties of the thousand objects which surround him, but the words,
also, or the names which have  been affixed to them, as well as those
by which the various  sensations and wants, which he himself  experi-
ences, are expressed.  A knowledge of the prominent qualities of ex-
ternal objects, and of language, is, in fact, acquired, almost exclusively,
during infancy and childhood.
  While the faculties of  perception and of language are thus  active,
those of comparison,  reflection, judgment,—the reasoning powers,—
are in a  great measure absent.  It is by instinct, or from present sen-
sations only, that the infant appears  to judge and to reason: hence the
numerous errors into which he constantly  falls, and the  necessity of
giving, by a proper education,  a correct and useful  direction to his
ideas.  From  the  want of reflection, judgment, and  experience, the
infant is  credulous, docile, and ingenuous:—he is pleased with trifles,
and lives, as it were, for the present moment only.
  All the affective faculties, if we except those connected with the re-
productive instinct, manifest themselves  in a striking manner, during
the latter stages of infancy, and give rise to their appropriate  expres-
sions and gestures.   Thus the  young  being exhibits, from an early
period, the feelings of attachment  and aversion, of anger, vanity, jeal-
ousy, pride, and shame;  and the frequent and unrestrained indulgence
of one or the other of these passions, unless a judicious moral culture
is early commenced, causes it to  obtain a predominance, which will
materially affect the character and happiness of the  individual  in after
life.
  The higher sentiments, as the sense of justice and of religion, are
among the latest to  come into operation,  requiring some assistance
from the understanding for their direction and support.

                         S. — Childhood.
   The age of  childhood commences with the second dentition, and
extends to puberty;  including,  under ordinary circumstances, in this
climate, the period of life between the seventh and  fourteenth years.
It is the  second infancy, according to the division of ages, adopted by
M. Halle.
   Organization.—At  the commencement of childhood, the twenty teeth
produced by the first  dentition, during infancy, become separated from
each other, in  consequence of  the  more perfect development of the
maxillary bones, and  the increased expansion  of the dental  arches;
and, with the exception of the third  molaris in each jaw, become loose
and fall  out, their  place being supplied by  the appearance, during the
progress of childhood and youth, of twenty-six permanent teeth.
   By the enlarged size of the maxillary  bones, the face  assumes a
greater  depth and breadth, and the general character of the counte-
nance becomes materially changed.  Towards the  period of puberty, 
PECULIARITIES OF ORGANIZATION.            93
this change is still further increased, in males, by the appearance upon
the upper lip  and chin, of a fine downy hair, which subsequently in-
creases in thickness and coarseness, constituting the beard of the adult.
  While the second set  of teeth  are making their appearance, all the
other parts of the body acquire a more perfect development.  The
lower extremities assume a size and  bulk  still more in proportion to
those of the upper limbs; and the pelvis, especially in females, becomes
deeper and more expanded.   The bones become still more completely
ossified, and those portions of them which, in the infant, were united
by  cartilage only, are, during this  age, consolidated with the body of
the bone.  The  frontal  and  maxillary sinuses acquire their full deve-
lopment; the joints  their permanent  forms, and increased firmness;
the permanent cartilages assume a greater degree of density, as well
as the various aponeuroses and ligamentous bands.
   The muscles are still small, but fuller, denser, and of greater  strength
and activity, than in  infancy; in the male, they have also a greater
degree of prominence, in consequence of the continued absorption of
the subcutaneous fat,  and the increased  density of the  cellular mem-
brane.  This absorption and  condensation does  not take place to the
same extent in the female, in whom, throughout the greater part of life,
the limbs, as well as the other external parts  of the  body continue, in
consequence, fuller, rounder,  and more plump than in the male.
   The thorax acquires,  during  childhood, a greater degree of expan-
sion, and the  air-cells of the lungs augment in size.  The dimensions of
the larynx are likewise  increased; and towards the period of puberty
it presents, in the male, a considerable prominence, at  the  anterior
part of the neck; which, however, is more marked in  some subjects
than in  others.   The rima glottidis  is  also  enlarged, and the thyro-
arytenoid muscles are elongated.
   The organization and development  of the brain—particularly of the
anterior and superior portions  of the cerebrum—are gradually per-
fected during childhood.  About the period of puberty, the cerebellum
acquires a very rapid development, being then  nearly twice  as large,
in  proportion to the other  portions  of the  brain, as it was at birth.
The remaining  portions of the  nervous  system become perfected in
organization, and all the organs of sense attain, during childhood, their
complete development.
   Towards the  close of childhood, the  organs  of generation, in both
sexes, are  fully  evolved, and become covered,  externally, with hair.
In  the female, at this period, the mammae  begin to appear  upon the
upper part of the chest.
   All the parts of the body preserve, during the earlier stages of child-
hood, much of the softness of infancy; the predominance of the white
fluids, however, gradually diminishes ; but the various  tissues are still
liberally supplied with arterial blood,  and the capillary system is still
more extensively expanded than in after life.
   Functions.—The whole of the vital functions proceed rapidly during
childhood towards their complete development.
   Digestion  is still  extremely active; almost every species of whole-
some aliment is rapidly converted  into chyme by the stomach; the ap- 
94
DISEASES OF CHILDREN.
petite is acute, and a frequent and plentiful supply of food is demanded.
The sense of hunger is more imperious, and less easily borne at this
age, than at any subsequent period  of life.  Thirst, or a desire  for
aqueous diluents, is more frequently experienced than during child-
hood, as well in consequence of the more solid and stimulating charac-
ter of the food that is eaten, as from  the greater waste of  the watery
portion of the blood, by the active  muscular exercise  to  which  the
child is prompted by an instinctive impulse.
  Nutrition  is  equally active with digestion,—assimilation  still pre-
dominating  over decomposition; and hence the body  continues  to
increase in size.  The cessation  of growth  seldom  takes  place until
the twentieth or twenty-first year ; and Quetelet has found, from nume-
rous comparative observations, that in the male, the height frequently
increases after the above period, even as late as the twenty-fifth year;
and we have reason to believe, that a  regular physiological  increase
in other organs, especially in different portions of the brain, may occur
even beyond this period.
  Respiration, although not so frequent as  in infancy, is fuller  and
deeper, in consequence of the greater  expansion of the chest; and a
larger amount of oxygen is consumed in the process.  The action of
the heart, though still frequent, is less so than in  infancy, and more
energetic.  The process of calorification has an increased degree of
activity, consequently the temperature of the body is higher, and more
uniformly maintained, the influence of moderate degrees of cold being
borne with greater impunity.
  The functions of all the external senses are peculiarly acute, and  the
intellectual and moral faculties augment daily in extent, as well as in
activity.  The powers of observing, comparing, judging, of reasoning
generally, though still imperfect, have  acquired a much greater extent
and accuracy.   The memory is still quick and tenacious.   Hence this
period of life is, with great propriety,  the  one usually devoted  to
mental education.
  Not only is the intellect  in childhood  more fully expanded, but  the
higher moral faculties have likewise come into action.  The child is
capable of distinguishing  between right and wrong, virtue and vice,
and of understanding, to a certain extent, at least, his several duties,
whether of a natural, civil, or religious character.   He acts less from
instinct and  feeling, and more from deliberation and judgment, than
the infant; nevertheless, he is still, in a great measure, the  slave of
impulse and  of passion.
  The expressions and gestures of childhood are  strongly marked, and
very mutable, betraying the great activity of the  mind, and the varied
sensations that are experienced in rapid succession.   This period of
life is noted for great inquisitiveness and extreme loquacity.
  Towards the latter  period of childhood, articulation has attained a
considerable degree of perfection; the voice does not, however, acquire
its full depth and compass until subsequent to the period of  puberty.
  The same desire for constant  bodily exertion exists, to  a  greater
extent even than in infancy.  Confinement of all kinds is endured with
difficulty, and, if too long continued, is productive of serious injury to 
PECULIARITIES OF  ORGANIZATION.
95
health.  Sleep is still profound, and  a much greater amount is de-
manded than in the subsequent periods of life.
  As puberty approaches, the genital functions, and the desires con-
nected with them, begin to be developed.   The menstrual discharge in
females usually commences  towards this period.
  In the foregoing brief sketch, we have presented the condition of the
organization, and of the functions of the  human body, at the  several
stages of development, from infancy  to puberty, as it occurs in the
generality  of cases.  Exceptions, however, frequently occur, not only
in regard to the period and order of succession in which the march of
organization in individual organs takes place, and the activity  of their
respective  functions is displayed, but in the period of growth,  and full
development of the entire organism.
   The number of years that have elapsed since birth, does not afford
always a  positive indication  of the  physiological condition  of the
human body, nor of any one of its organs.  Climate, moral and phy-
sical education, diet, regimen, and  various other circumstances, pro-
duce so powerful an influence  either  in retarding or accelerating the
development of the whole, or certain parts of  the organism, that the
same physiological condition of individual organs, or of the entire sys-
tem, will occur in one individual several weeks, months, or even years,
sooner or later than in another.   Thus, the age of puberty, especially
in females, is attained, in tropical  climates, at an  age  at which, in
colder regions, the individual is still  scarcely emerged from infancy. In
fact,  all those circumstances which exert  a stimulating influence upon
the nervous system, or which tend  to call early into exercise  particu-
lar organs, are calculated to produce  a rapid and premature develop-
ment of function,  and^ at the same time, by hurrying the  organism
through the  various stages of organization, impair its energies, and
abridge the period of its existence.   While, on the other hand, every-
thing calculated to abstract  the organs of the  body from  the full
influence of the natural  stimuli—to  retard their exercise or impair
their nutrition, will protract the period of their development,  or even
prevent  their complete organization.  Thus,  in warm climates, the
stage of infancy is extremely short,  that of puberty is early attained,—
the period  of maturity arrives and passes with  equal rapidity,  and the
decrepitude of old age is experienced, often, when, in colder climates,
the body is still in the enjoyment of all its vigour.  A soft and luxuri-
ous life, heating aliments and drinks, deprivation of muscular exercise,
premature  exercise of the intellectual organs,  or early excitement of
the passions, exert a somewhat similar influence.  On the other hand,
in cold climates, and by deficient or unnutritious food, the want of pro-
per  moral  and intellectual  culture, and other  depressing causes, the
development of the  body is retarded, and its complete organization,
with  the full and vigorous exercise of its functions, if attained  at all, is
attained only by slow degrees, and  at a late period.
   From a  variety of causes, to which  the child  is subjected from birth,
or during the period of infancy or childhood, a single organ, or system
of organs,  acquires a degree of development, beyond that of the rest,
and  causes the functions performed by it to  assume a  very  evident 
96                 DISEASES OF CHILDREN.
predominance.   Thus, in some children, the head is large, and great
activity and  intelligence are early displayed; in such,  the cerebro-
spinal system has acquired a predominance of development and func-
tion, constituting the nervous temperament.   In other children, great
muscular power is early displayed ; the chest is capacious; the various
parts of the body well nourished, and the complexion florid; the cir-
culatory system, and the organs engaged in hsematosis and nutrition,
predominate;—there is  considerable  strength and  activity of body,
with, in general, moderate intellectual activity or power.  This con-
stitutes the sanguineous temperament.
  A prominent abdomen, with a languid circulation, and paleness of
the skin, a craving appetite, and  but  little activity either of mind or
body, indicate the predominance of the abdominal  organs and  lym*
phatic  system,  and  constitute the marks of  the  lymphatic tempera-
ment.
  " The expression  of the countenance, or form of the features, is
also," remarks Evanson, "some indication of the prevailing tempera-
ment.  Thus, the development of the forehead, indicates the propor-
tion of the encephalon;  the part between the forehead and mouth is,
in general, in harmony with the development  of the thorax; while the
lower part of the face is in relation to the size  of the abdomen; so
that  in each we have an index of the temperament, whether cranial
(nervous), thoracic (sanguineous), or  abdominal (lymphatic)."
  Other varieties of temperament occur, and some individuals pre-
sent no strongly marked temperament—the development  of the seve-
ral organs being nearly  equal; or, on the other hand, more than  one
of the  above temperaments  may occur in the same individual.   In
infancy and childhood, the lymphatic  temperament has a tendency to
prevail.  The nervous becomes more  particularly manifest  at or after
the age of seven, when, as we have seen, the brain attains a more full
development,  while the sanguineous Wongs, more properly, to  a later
period, when  the thoracic organs acquire their proper  organization
and fulness of function.
  The particular temperament of the individual may be  born  with
him, and, in many cases, is hereditary; or it may be developed  during
infancy and childhood, by the influence of the external agents to which
the child  is subjected, or by errors in his physical  and  moral treat-
ment.  The leading principle upon which  the treatment of children
should  be  invariably conducted, is  to allow to every organ its equal
and appropriate nutriment; and while no one is forced into activity
prematurely, to give  to each its equal and appropriate share of exercise
—promoting  the development, at the proper season, of  those  which
are deficient  in activity, and removing  every unnecessary stimulant
from such as exhibit a tendency to a disproportionate development and
activity of function. 
PATHOLOGY OF  INFANCY AND CHILDHOOD.         97
                           CHAPTER  III.


               PATHOLOGY OF INFANCY AND CHILDHOOD.

      During infancy and childhood there exists a very strong predispo-
    sition to disease.   This predisposition  is the greatest within the first
    year subsequent to birth, and it gradually decreases with the increase
    in the age of the child.  During the first few weeks of existence, the
    imperfect organization of every part of the body, and  the  deficiency
'   in vigour of most of its functions, render  it peculiarly liable  to the
    action of various agents, the impression of which, while it is sustained
    with comparative impunity at  a later period, produces in the delicate
    organs of the infant, the most  serious disturbance, resulting,  in the
    greater number of cases, in  a  rapid extinction of life.   At birth, and
    for a short time subsequently, the vital  powers  are, in fact, so  feeble,
    that they present but little resistance to the agents by which they are
    assailed,  but sink rapidly  under  their  influence.1   Even  when  the
    infant has become endued  with greater tenacity of life, the predomi-
    nant activity of the ganglionic system, and  of the  nutritive function,
    and the extent of the capillaries throughout every organ and  tissue,
    give to each  a degree of susceptibility, and a tendency to take on
    morbid action, far beyond what it possesses at. any future period of
    life;  and this tendency is still further increased as the more important
    organs become more or less rapidly developed, and  assume,  for a
    season, a predominance of action.
      The large amount of arterial blood with  which, during infancy, all
    parts of the organism are supplied for the purposes of nutrition, causes
    a state of hyperaemia, in one or other of the tissues, to be readily pro-
    duced ; while the  exalted activity of the capillary system during the
    progress  of development, and  especially in those  organs  in  which
    nutrition  for the  time  predominates, is  quickly  transformed, by any
    accidental irritation, into inflammatory action.b
      The skin, and the mucous membrane of the digestive canal, and of
    the respiratory organs, are, in  the  infant, the principal surfaces upon
    which  morbid  impressions  are  received, and consequently they are
    those also in which disease usually commences.   It seldom, however,

     * During the ten years preceding 1845, 1145 children under one year of age died in
    Philadelphia from debility alone.  ,
     b During the ten years preceding  1845, the entire number of deaths in  Philadelphia,
    excluding the still-born, those from old age, congenital malformations, and casualties, was
    48,694 ; of which 26,510, or 54-4 per cent., were of children under 15 years of age;  namely,
    Under 1 year of age, 12,467 or 25-61 per cent, of the entire no., and 47- of those under 15.
    Between 1 and 2 years 5,570 or 11-43      "           "      27-
           2 and 5   "   5,470 or 11-        "           "      27-     "
           5 and 10  "   2,308 or 4-74      "           "      8-7    "
      »   10 and 15  "    695 or  142      "           "      2-7    "
                                    7 
98
DISEASES OF CHILDREN.
remains for  any length  of time  confined to these tissues, but, in the
greater number of cases, from the extreme susceptibility of every por-
tion of the system, is sooner  or  later reflected upon other,  and  often
distant organs; in this manner increasing the  extent of morbid action
—or ceasing at the part where it originally commenced, as it  augments
in intensity in the organ secondarily affected, changes thus its  loca-
tion.  It is in this manner that affections of the skin, alimentary canal,
and respiratory organs reciprocally produce each other, and that the
brain becomes in early  life, so  generally involved in the  course of
nearly every disease that occurs, when it is of a severe or protracted
character.
  The diseases of children  are, in  fact, very  rarely simple.   If they "
attack those who were previously in a state of  health, it is seldom that
they pass through their different  stages, without some other occurring,
and thus diminishing the chance of  a speedy and favourable termina-  *
tion.   As  Barthez and Rilliet very correctly remark, this  first  com-
plication very often creates  a second, and  these successive maladies
constitute  a continued series  of morbid  conditions, which frequently
cease only with  the life of the patient.
  In other cases the secondary affection, instead of succeeding, makes
its appearance before the  termination of the primary disease, pro-
ducing a  combination of symptoms at  first view altogether  inexpli-
cable.
  MM. Barthez and  Rilliet  have endeavoured  to  discover whether
between the primary and secondary diseases of children  there exists
any relation in regard to their character  and location.  The result of
their observations has proved, that in the great majority of instances
one disease predisposes to the occurrence of another,  which is either
identical with or analogous to it in its nature, or which  is seated in the
same tissue or organ—the primary  affection acting  as  a kind of local
stimulus or irritation which solicits  the development of the second.
  The closer  that diseases  resemble each other in their nature, the
more they have a tendency to  succeed to, or  produce each other.
Thus, Barthez and Rilliet remark, that if the first disease is an inflam-
mation, we soon find one or more phlegmasia  to develope themselves,
as secondary or tertiary affections.   If a dropsy exist in  one  portion
of the body, other organs are liable soon to become the seat of a serous
effusion or infiltration.  If tubercles form in one of the tissues, they
speedily become generally diffused.   In a word, there exists particular
diatheses, that is to say, general conditions of the organism, which pre-
dispose it  to the occurrence of one  particular  form of disease rather
than another, and which  disease will often occur simultaneously or
successively in  several organs, as the result of  the  same exciting
cause, or even where no such cause is apparent.   These diatheses are
sometimes primitive, preceding the  local  affection ; in  other cases, on
the contrary, they are secondary, or the result  of  some local disease.
  During infancy, morbid action always exhibits a greater tendency
to spread  over the tissues in which  it occurs, than in the adult.  This
is especially the case in inflammations of the mucous membrane; these, 
          PATHOLOGY OF INFANCY AND CHILDHOOD.       99

unless quickly arrested by appropriate remedies, almost invariably ex*
tend themselves, in a greater or less degree, along the course of the
membrane;  increasing thus the extent of the disease, and at the same
time diminishing  the  chances of its favourable termination.  It is
seldom that inflammation of the fauces  and pharynx in infants, are
not found to extend to some distance, into the oesophagus, or into the
larynx.   The diphtheritic or pseudo-membranous angina of childhood,
is  confined, in  but a very few cases, to  the mouth  and fauces,  but
extends  into the  nose, along the Eustachian tubes into  the  ears,< as
well as  into the  larynx, and down the pharynx into the oesophagus;
producing, when  it invades  the larynx, all the symptoms of  genuine
croup.  In croup, we have  this tendency of inflammation  to spread
along the course of mucous surfaces, strikingly exemplified.  Confined
in the early stages of the disease to the  larynx and upper portions of
the trachea, the  inflammation descends from thence, more or less
rapidly, into the bronchi and air-cells of the lungs.  The same  thing
takes place in  inflammations of the digestive canal; their tendency
being to  spread downwards  along the course of the intestinal mucous
membrane.
   Effusion,  whether of  serum or of lymph, is  peculiarly liable to
occur, and often  at a very  early period, in  the, inflammations of the
serous and  mucous  tissues, during  infancy.  A very slight irritation
of the arachnoid  membrane will early give rise to effusions of se,rum
in the brain; while towards the commencement of dentition, when the
muciparous follicles of the intestines become developed, any accidental
cause, exciting these to an increased activity of function, will  produce
the most profuse watery discharges  from the bowels.  Upon  both the
serous and  mucous membranes, inflammation during  infancy has a
tendency to produce exudations of lymph :—the production of diphthe-
ritic exudations upon the mucous surfaces, would appear to be, in some
measure, a  result of inflammatory  action peculiar  to infancy.   Not
only do these occur upon the throat and respiratory tubes, but upon the
apertures of the genito-urinary organs; the contour of the  anus; Xhe
external  meatus of the ears; the folds of the groin, and other similar
parts, when these are in a state of excoriation or ulceration.—(Trous-
seau.)
   The delicacy of the  skin during the earlier stages of infancy, its
extreme irritability, and very great vascularity, render its several tis-
sues peculiarly liable to disease of various  grades, from the  simplest
rash, to the most violent inflammation, terminating rapidly in extensive
disorganization; and from the action  of causes, which in the  adult
would scarcely produce any morbid effect.  Infancy is, in fact, the
age when eruptive  complaints most  commonly prevail,  especially
those of an acute character.  A large number of the cutaneous  diseases
occurring at this  period, are evidently dependent upon a morbid con-
dition of the digestive organs; others  are  produced by a neglect of
cleanliness, and a few, without  including the febrile exanthemata, are
the result of irritations directly applied to' the surface.
   Many of  the febrile exanthemata are almost  exclusively confined 
100
DISEASES OF CHILDREN.
to the period of infancy; this is particularly true of measles and scarlet
fever—diseases that are but seldom met with in the adult.*
  The respiratory mucous membrane is liable, in the infant, to various
grades of inflammation; in general, however, of a  very acute charac-
ter.  Bronchitis and croup being among the most common, and fatal,
diseases of infancy.   Laryngitis is also of frequent occurrence.   The
same is true of pneumonic  inflammation  and pleuritis.   These  affec-
tions of the  respiratory organs are, in general, produced by  the influ-
ence of cold, and often from the improper exposure of the  upper por-
tion of the  chest, in consequence of the  dictates of fashion, rather
than those  of prudence, being  consulted in  relation to the  dress of
infants.  Among the German population  in the interior of  Pennsyl-
vania, who are in the habit of clothing their children in such a manner
as to leave no part of  the  breast  and lower  portion of the neck ex-
posed,  Dr. Eberle met  with but one case of croup, during a practice
of six years, and this case occurred in a family who had adopted the
fashionable mode of dress, in which the neck and upper portion of the
chest is left uncovered.
  There is some difference of opinion as to the form  of pneumonia
most generally met with  in  infants,—it  being maintained by  many
recent  writers on the disease, that in children under five years of age,
lobular pneumonia is the most frequent form, while  lobar pneumonia is
more common in children beyond this age.
  According to  Cerhard, Rufz, Billard, Valleix, Rilliet, Barthez, and
others, the pneumonia of very young infants is not an idiopathic  affec-
tion, resulting  from  an irritation developed in  the pulmonary  tissue
under the influence of atmospherical causes, but is  evidently the  result
of a stagnation  of blood  in  their lungs.  It  is maintained that the
disease occurs almost invariably in infants that have been exhausted
by previous  disease, or who are placed under unfavourable  hygienic
influences.   From these causes, it is supposed that  a change occurs in
the composition of  the  blood, in consequence of which it gravitates
towards  the inferior lobules of the lungs, where, acting in  some mea-
sure as  a foreign  body, it produces  congestion  and  inflammation,
terminating in an induration of the substance of the individual lobules,
similar to hepatization.   It  is believed by some that, in the majority of
the cases to which these observations refer, the apparent change  in the
texture of the  lungs, instead of being produced by inflammation, con-
sists in the continuance of the foetal state of the  lung, subsequent to

  a In Philadelphia, during  the  ten years preceding 1845, 2154 deaths occurred from
scarlatina, in individuals under 15 years of age, viz.: 122 in infants under one year; 400
in those between one and two years; 1083 in those between 2 and 5; 493  in children
between 5 and 10; and 56 in those between 10 and 15; and but 66 in individuals  beyond
this age.
  During the same period, 574 deaths occurred from measles, in individuals under 15
years of age, viz.: 93 in those under 1 year; 158 in those between I and 2; 253 in those
between 2 and 5 ; 59  in those between 5 and 10; and 6 in those  between 10 and 15; and
but 8 in individuals beyond this age.  The deaths from these two diseases, comprised ra-
ther more than one-ninth of the whole number of deaths, within the same period, in indi-
viduals under 15 years of age.
  So far as we can judge from the number of deaths that  occur, small-pox is less exclu-
sively a disease of early life; for within the above period, 844 deaths took place from this
disease, of which 257 were of individuals over 15 years of age. 
          PATHOLOGY OF  INFANCY AND CHILDHOOD.       J01

birth—from a restricted functional development, independent of any
original defect of formation in the respiratory organs—or from an  oc-
clusion  of certain of the  pulmonary vesicles,  occurring after birth,
from mere contractility of tissue or from  congestion  of  the vascular
network exterior to the vesicles.  Atelectasis pulmonum, as Jorg  de-
nominates the peculiar condition here referred to, may be  distinguished
from patches of true hepatization,  the result  of lobular inflammation,
by insufflation,  which  reproduces,  more or less  completely,  the natural
condition  of the lobules.  Lobular pneumonia  is certainly very com-
mon in  infants under five years  of age; such, at least, is  the result of
our  own  experience.   But  young infants are by  no means  exempt
from  ordinary lobar pneumonia, nor is lobular pneumonia  exclusively
confined to them.  Both forms of the disease occur during infancy as
well as subsequently, and from precisely the  same causes which give
rise to pulmonary inflammation in older patients.
   Of one hundred  and eighteen  cases of idiopathic pneumonia,  oc-
curring in patients under ten years of age, which came under  the
notice of Dr. Charles  West,  at the London Infirmary for children, in
the years  1841  and 1842, thirty-three were in infants under one year;
seventy-seven in those between one and five; and fifteen in those over
five years of age.
   According to the observations of Dr.  West, the period of infancy
at which  pneumonia  is most prevalent,  coincides exactly with that
during  which the  process  of dentition is going on  most actively—
namely, from the sixth to the eighteenth month.
   Dr. West presents, in a tabular form,  the general results of thirty-
seven post-mortem examinations of children who died of pneumonia.
The morbid appearances are arranged under the heads of lobar, lobular,
or vesicular pneumonia, according as one or other form of the disease
predominated.
   Of these 47 cases, 22 were lobar, 11 lobular, and 4 vesicular.
   Of the  22 cases of  lobar pneumonia, 2  were in infants under 1
year of age, 9 in infants between  1  and 2 years old, 8 in infants  be-
tween 2 and 5 years,  and 3 in children over  5  years of age.
   Of the 11 cases of lobular pneumonia, one  was in an infant under 1
year of age, 4  in infants between  1 and 2, 4  in infants between 2 and
5, and 2 in children over 5 years  of age.
   Of the 4 cases of vesicular pneumonia, one  was in an infant between
1 and 2 years of age, 2 in infants between 2  and  5, and 1 in a child
over 5 years of age.
   Of the 22 cases of lobar pneumonia, 18 were idiopathic.
   Of the  11  cases of lobular pneumonia, 5 were idiopathic, and 3 of
the 4 cases of vesicular pneumonia.
   It will  be evident from the  foregoing data, that lobar  pneumonia
attacks children much more  frequently, in  comparison with the other
forms of the disease, than has  been  supposed  by many  of the conti-
nental pathologists; that differences  of age  do not occasion such a
liability to one  form of the  disease, and  such  an immunity from  the
other forms  as would be inferred from  their  statements, and that,
finally, lobular pneumonia, at whatever age it occurs, is,  in the  majo- 
102
DISEASES OF CHILDREN.
rity of cases, the result  of the  same  morbific causes  as lobar pneu-
monia.
  It has been asserted that pneumonia in young  children is invariably
preceded bv bronchitis;  that such  is  often the case is unquestionably
true.   In a"large number of cases, inflammation occupying the smaller
ramifications of the bronchi will be found to coexist with lobular pneu-
monia.   But not unfrequently, even when  this coexistence is supposed
to be present,  the observations of Bailly  and Legendre  have shown
that what is taken for lobular hepatization, is, in fact, only a portion of
the lung in the  foetal state.
  Among  the   affections of  the  respiratory organs peculiar  to the
period  of  infancy and  childhood,  are to be ranked  hooping-cough
and  laryngismus stridulus;  the first  rarely occuring after puberty,
and  the last being confined almost exclusively to the period which
intervenes  between  birth  and the  termination of the first  dentition.
Both these  affections  are of a spasmodic character;  for although in
hooping-cough, especially in its  earlier stages, there  always  exists
bronchial inflammation, to a greater or less extent, yet the peculiar
characteristics  of the disease  depend  evidently upon  a disordered
action of the respiratory  muscles, resulting from nervous irritation.
  Laryngismus stridulus  would appear to be altogether dependent upon
an irritation of the laryngeal nerves, produced by disease of the brain,
by a cold, ponfined, and impure atmosphere, or by the reflex action of
irritations  seated in the digestive organs.   The  enlarged state of the
thymus gland,  or of the  lymphatic glands of the neck, so often met
with in infants affected with this  disease, and by which  many patho-
logists suppose it to be produced, is to be viewed, we suspect, in nearly
every instance, merely as an  accidental occurrence.*
   It is the gastro-intestinal mucous membrane that is the chief seat of
disease in infancy.  A slight excess of food, or that which is too stimu-
lating, or food  unadapted to the condition of the digestive organs at
this period of life;  a trifling reduction of  the temperature of the skin,
personal impurities, or any degree of impurity in the atmosphere, will,
in general, give rise to colic, vomiting and  purging,  aphthae, tympa-
nitic distensions of the abdomen, and the  other phenomena of irrita-
tion, and of acute or chronic inflammation of the stomach and bowels.
  * In Philadelphia, during the period referred lo in the preceding note, of the 26,510 deaths
among children under 15 years of age, there were—
	Under one	Between 1 and	2 and 5	5 and 10	10 and 15
	year.	2 years.	years.	years.	years.
i Bronchitis,	1172 643	276	201	47	5
Croup,	1149 319	238	474	112	6
Pneumonia,	1592 693	414	345	115	25
Hooping-cough,	781 371	208	171	30	1
r diseases of the	[283 123	56	57	35	12
piratory Organs,					
	3977 2149	1192	1248	339	49
  Being nearly one-seventh of all the deaths in individuals under 15 years.
  It is probable that under the head of pneumonia are included many cases of bronchitis.
  Of deaths from laryngismus  stridulus, no  mention is made in the  bills of  mortality;
these are probably included under the head of croup. 
          PATHOLOGY OF INFANCY AND  CHILDHOOD.       103

Softening and perforation of the stomach, constituting the disease to
which the denomination Gastro-malacia has been applied by the Ger-
man writers, most frequently occurs during infancy.
  The inflammation, in many instances, extends from the alimentary
canal to the mesenteric glands, producing their enlargement and dis-
organization, attended,  in a few extreme cases, with enormous disten-
sion of the abdomen,  and extreme emaciation  of  the body.  It is
seldom, however, that  the existence of enlarged mesenteric glands
can be detected during the lifetime of the patient.   There is, as Dr.
West remarks, no symptom pathognomonic of tubercle of the mesen-
teric glands, except  their being perceptible  through the abdominal
parietes.  This, however, they  never  are during the early stage of
the affection.
  Inflammation frequently extends from  the  digestive mucous mem-
brane to the peritoneum.   It  here often assumes a very chronic form,
and, sooner or  later, causes  an effusion of serum into  the  cavity of
the abdomen.
  Intestinal invagination is of very frequent occurrence during  the
earlier stages of infancy.   In  many cases, its existence is not  indicated
by  any other symptom  than habitual costiveness.  It often,  however,
gives rise to acute pain, considerable  distension of  the abdomen, ex-
cessive vomiting, and death; and  is always to be ranked among the
most dangerous affections to which the infant is liable.*
  Drs.  Friedleben and  Flesch, of Frankfort, in a paper on the patho-
logical  anatomy of the intestinal mucous membrane in the  infant at
the breast, remark, that hitherto, softening of the mucous membrane
of the stomach,  and enlargement of  the mesenteric glands, have been
usually regarded as the only causes of  the acute or chronic  diarrhoea,
with atrophy, to which so great a mortality is due within the first year
of life.   This view they think they can disprove by exact post-mortem
investigations.   Softening of the mucous membrane of the stomach
they regard as exceedingly rare, having met  with it only in two  in-

  '  In Philadelphia, within the period already mentioned, there occurred 6180 deaths from
various diseases of the digestive organs, in children under 15 years of age, as follows:—
                                                   5 and 10    10 and 15
                                                    years.    years.
                                                      8       5
                                                     85      24

                                                     85      35

                                                     22       2

                                                      8       1

                                                     19       7
                  6068 3590       1568       609      227       74
  If to these be added the deaths from teething, the majority of which are from disease of
the alimentary canal, viz., under 1 year, 50; between 1 and 2,51; between 2 and 5,9;
between 10 and 15, 2—total, 112—the total of deaths from these diseases will be 6180.
Being about one-fourth of all the deaths in individuals under 15 years.
	Under one	Between ] and	2 and 5
	year.	2 years.	years.
From Diarrhoea,	832 535	205	79
" Dysentery,	546 151	169	117
" Infantile Cholera,	2583 1706	752	125
" Inflammation of.	I		
the Stomach!	> 825 411	163	131
and Intestines,'	>		
" Marasmus,	930 596	210	100
" Aphtha?,	43 33	9	1
" Worms,	47 5	12	21
" Colic,	21 19	1	1
Other affections of Sto- ( mach and Intestines, (	'■ 241 134	47	34
 
104               DISEASES OF CHILDREN.

stances, in one of which it  proved fatal within twenty-four hours;
while  in  the  other, there existed a fatal complication of intestinal
disease.  Diminished consistence at the  fundus of the  stomach was
more frequently observed, but its origin was at  all times  secondary.
They  found  enlargement  of the mesenteric glands also  to  be uni-
formly secondary, of limited extent, and  rarely of distinct character,
except in the glands on the root of the mesentery.  The enlargement
of these glands could not have been felt through  the abdominal walls,
and hence it seems certain that  hardened feculent masses have been
mistaken  by many for  enlarged  glands.  These gentlemen indeed
affirm, that even in  the dissecting-room, after opening the abdominal
cavity, the mesenteric glands cannot be felt  enlarged  until the intes-
tines have been removed.
  Before entering on the pathological appearances, they give a sketch
of the normal  appearances of the parts concerned, in  infants at  the
breast.  The colour of the mucous layer, as well as of the subjacent
mucous membrane itself, is either grayish-white, or yellow, from  the
colouring principle of the bile, or more or less of a darkish livid colour,
from imbibition of blood.  It is  to be remarked, however, that in this
last case  the  mucous  membrane  is free from any arborization  or
punctation.  The mucous membrane adheres very closely to  the sub-
jacent tissue, so that, after being cut through, it can be detached only
to a small extent.   The  mucous membrane of the colon, however, is
less firmly adherent, owing, probably, to the  greater amount  of sub-
jacent cellular tissue; its consistence is always great enough  to pre-
vent it from being rubbed off by the finger or with the back of a knife.
Where the adhesion appears lessened, without simultaneous diminution
of its consistence, large pieces of the mucous membrane may  be sepa-
rated  from the subjacent cellular tissue.   The solitary glands, neither
of the small intestines nor of the colon, are visible to the naked eye.
As  to those of the colon, however, we discover, occasionally,  delicate
roundish spots, presenting a contrast to the rest of the  membrane  by
their opaque colour, but  without any elevation.   The villous layer, and
the glands of Lieberkuhn, are also invisible.   The  Peyerian  patches,
on the contrary, may be discovered at the earliest period of life, when
the intestine is held  up to the light, owing to their  greater opacitv as
compared with the rest of the  membrane.   Whenever these patches
are recognised at first sight, a  pathological  state may be suspected.
The largest of the patches are seated near the ileo-coecal valve, where
they may be distinguished by their marked limits.  The number of the
patches varies as much as from sixteen to thirty-six.   The  cases  in
which they are found to be only from one to six, are regarded by the
authors as referable to atrophy  of the mucous  membrane.
  After presenting  a minute  description  of the  several pathological
conditions of the intestinal mucous  membrane, the authors  sum  up
their observations by the following general conclusions :—
  1. Morbid alterations of the intestinal mucous membrane are a very
frequent, probably the most frequent, post mortem appearance  in  the
infant at the breast.  2.  When  of  a chronic character, these altera-
tions lay the foundation of atrophy; when acute, their most prominent
effect is exhausting diarrhoea, which, from the cerebral symptoms often 
          PATHOLOGY OF INFANCY AND CHILDHOOD.       ]05

attendant on it, had been mistaken by many observers for softening of
the stomach (gastromalacia).   3. The frequency  of the  alterations
above described, is as remarkable as the rarity of those which  were
once  believed to be  of common occurrence,—for example, enlarge-
ment  of the mesenteric glands, aphthous formations, gastromalacia, &c.
4. It  is also to be remarked, that the diseases of the intestinal  tract
are in general  far  more frequent than those of the stomach, which,
with the  exception of softening of the  fundus, are  proportionally rare
at this period of life.  5. The ulcerations  of the  mucous membrane,
unless when  secondary, are in most cases isolated.   6. The most fre-
quent of the alterations under examination is chronic inflammation  of
the Peyerian patches, and this is the only anatomical cause of atrophy.
7. Next  to this, but far more rarely, the red and white softenings are
essential causes of atrophy.  8.  Red and white softenings are but dif-
ferent stages of the same morbid process;  the simple and gelatinous
softenings give but a difference of form.  9. In atrophy of  infants  at
the breast, chronic ulceration of the solitary glands of the small  intes-
tines  is among the rare occurrences.   10. The acute inflammation of
the Peyerian patches, though hitherto little attended to, is among  the
most  fatal of morbid alterations.  11.  This is a true inflammation,  as
is attested by the attendant affections; for example, croup, lobular  pneu-
monia, &c.   12. It  is an affection not generally known, and the few
who  are acquainted with it commonly refer it  to  dothinenteritis—a
disease which does not occur in the infant at the breast.   13. Secon-
dary  acute inflammation of Peyer's glands, as well as inflammation of
the solitary glands, belongs to tuberculization ; in all such cases, tuber-
cles of the spleen are met with  simultaneously, but never in the  intes-
tinal  tract.   14. The colonitis of the French observers was  often met
with, but uniformly of small  extent, and  of subordinate importance
compared with the simultaneous, but far more serious, alterations  of
the mucous  membrane  of the  small intestines.   15. The mesenteric
glands, with the exception  of  slight  redness and  elevation  in a few
cases, were, for the  most part, normal; the alteration  of these was
never either  considerable or prominent; in  general  tuberculization, it
is true,  they were infiltrated with tuberculous matter, but even then
their  enlargement could not be felt through  the abdominal walls.   16.
The peculiarity and frequency of the above-described  morbid altera-
tions, and the absence of others known to occur  in  the  next year  of
life,  as   typhoid fever and abdominal tubercles, present features  of
great interest in the pathology of the alimentary canal during the first
year of life.
   During infancy, the large size of the brain, the delicacy of its struc-
ture,  its  extreme vascularity,  and the activity with which the nutritive
process is there carried on during the period of its rapid development,
render it extremely  liable to disease, from  morbid  impressions  made
directly  upon it, or by irritations transmitted to it  from other parts.
Hence, spasms, convulsions, deep comatose  sleep from congestion  of
its blood-vessels, and inflammation of the substance  of the organ
or of  its membranes, terminating in serous effusion within its ven-
tricles, or a  softening, more or less extensive, are  among the  most
frequent diseases of infancy.   Few cases of extensive, intense, or  long- 
106
DISEASES OF  CHILDREN.
continued irritation  of the  alimentary canal, occur at this  period  of
life, without producing more or less disease of the brain.   Nothing, in
fact, is more common, than for symptoms, indicative of cerebral dis-
ease, to occur, in the course or towards  the termination of  nearly all
the affections of infancy.
   Few  of the nervous affections,  properly  so  called, occur during
infancy,  notwithstanding the extreme susceptibility  of their nervous
system, and  its liability to disturbance from direct as well as remote
irritations.   This disturbance, in the infant, most commonly exhibits
itself in  the  production  of  spasms  or convulsions.   Convulsions, and
convulsive diseases,  are, indeed, of  more frequent  occurrence during
infancy,  than at  any  subsequent  period of life.   Arising not unfre-
quently, from diseases of the brain or spinal marrow, they are, never-
theless, produced, in  perhaps the majority of instances, from  irritations
transmitted  to these  parts from the digestive organs; and it is often
surprising, from how slight a cause they will result, and how promptly
they cease upon  its  removal.  Epilepsy and chorea generally occur
during the  latter  period  of infancy, and the early stages of child-
hood.1
   The extreme development and activity of the whole lymphatic sys-
tem during  infancy,  causes  it to become, readily, the centre of irrita-
tion, giving rise to enlargement, inflammation, and suppuration of the
lymphatic glands, to a tuberculous condition of  the  lungs, brain, and
other organs, to serous infiltration of the  cellular tissue, and to various
other symptoms of scrofulous disease.
   Tumefaction, inflammation, and suppuration of the lymphatic glands,
particularly of the neck, axilla, groin, &c, frequently occur during in-
fancy and childhood, independently of any scrofulous affection.  En-
gorgement, often running into inflammation, of the parotid gland, would
appear to be, in some respects, peculiar to the period of  infancy.  It
often prevails as  an  epidemic, and is attended with several  peculiari-
ties, which give it somewhat of a  specific character.  It seldom occurs
more than once  in  the  same  individual; and has  always  a  strong
tendency to cease suddenly and be immediately followed by an inflam-
mation of the  testicle in the male, and of the mammas in the female,
generally of the same side as that on which the disease in the neck is
seated.
   (Edematous swellings of various parts of the  body, are very com-

  * From diseases of the  brain, the number of deaths during the ten years referred to
were
                Under one  Between 1  Between 2   Between 5  Between JO
                  year.  and 2 years,  and 5 years, and 10 years, and 15 years  Tota1'
From Convulsions,    1932     428       352       100       12     2824
  "   Dropsy,         748     554       438       148       18     1906
  "   Inflammation,    293     223       200       126       42      884
  "   Apoplexy,         7       3        4         4        2       20
Other Diseases of the)  on«     ,or       ln,i         r,.
  Brain,         \  20°     135       124         71       22      552

                  3180     1343      1118       ~449      "96     6786
  Being rather more than one-fourth of all the deaths in individuals under fifteen years of
age. 
          PATHOLOGY OF INFANCY AND CHILDHOOD.        107

mon during infancy, either in the course  of protracted irritations of
the alimentary canal, or towards the  close of certain febrile affections.
  Serous effusions into the  several cavities, or infiltrations into the
tissues of the  organs, constituting the various forms of dropsy, are in
fact among the  most frequent affections of childhood.  They may be
either active or  passive, primitive or secondary.  The primitive  form
is confessedly very rare.  Barthez and Rilliet have, however, collected
some incontrovertible cases of it.  It  is usually a mild disease, attended
with a  distinct, though slight febrile  movement, and seldom or ever
proves fatal.  The acute secondary  form presents a somewhat similar
character, excepting that in its consequences it is far more serious. It
occurs either  as a very acute disease, causing death  in a few days or
even hours, or as a less acute affection readily cured, or it may become
chronic, and then sometimes terminate fatally.
   The cachectic dropsies, as they have been termed  by Barthez and
Rilliet, or  those  resulting from  a general  diseased condition of the
organism, are frequent,—being sometimes of short duration, and pro-
duced almost instantaneously.   They  resemble the  chronic form in
being unattended by febrile  symptoms, in  giving rise to few general
symptoms, and causing great enlargement of the cavities of parts into
which the serum is effused.   The acute and active forms of dropsical
effusions  are  most frequently met with  in  robust children, especially
males, over six years of age, while  the  chronic and cachectic forms
are  most usual in girls and feeble children, generally under six years
of age.  (Tome i. p. 750.)a
   A very peculiar condition  of the cellular tissue occasionally occurs
in young infants, from an  extensive effusion of serum, giving to the
parts affected a feeling of hardness, as if an induration of the subcu-
taneous  tissue had  really taken  place.  The  actual cause  by which
this effusion is produced, it is somewhat difficult to  determine.   Ac-
cording to Billard, who appears  to  have examined the subject with a
good deal of  care, the predisposing  causes are, the natural feebleness
of the infant;  a  state of general plethora; a superabundance of venous
blood in the tissues; and a dry state of the skin previous to the exfolia-
tion of  the epidermis ; while the  immediate causes are, an obstruction
of the circulation of the  blood, from over-distension of the vessels;
its engorgement in the cellular tissue ; and lastly, the action of external
agents on the  skin, by  which  the  cutaneous transpiration is  suspended,
and consequently, the  accumulation  of serosity in the cellular tissue is
promoted.
   In the infant there exists a very strong predisposition to  the forma-
tion of tubercles in  almost every part of the body.  Even at  birth,
their existence, in various stages of  advancement, to complete soften-
ing, has been  detected.
   During the  latter part of infancy,  tubercles occur very frequently in
the  lungs;  pulmonary consumption  being, at  this  period, a common
  a During the ten years already referred to, 289 children are reported to have died in
Philadelphia from dropsy, viz.: under 1 year, 32 ;  between 1 and 2 years, 42 ; 2 and 5
years, 106; 5 and 10 years, 79 ; 10 and 15 years, 30. 
108
DISEASES  OF CHILDREN.
and destructive  disease.*  The disease often  assumes a  very acute
form,  and rapidly destroys the  patient, while in other cases it is ex-
tremely chronic, and unless pneumonia supervenes, it may continue for
a great length of time before the child sinks under it.
  The occurrence of severe  pneumonia in the course of phthisis, ap-
pears  to be much more frequent in children than  in  adults.  In the
acute  form it sometimes co-exists  with the  earliest symptoms of the
deposition of tubercles, but more generally it does not set in until after
the indications of pulmonary tubercles have existed for some time.
  It is a curious fact, that haemoptysis is of rare occurrence in any of
the forms of pulmonary phthisis occurring  during infancy or child-
hood.    Sir James Clark, in his work on consumption, states, that he
does not recollect to have met with any case in which it  was present.
Though a less frequent accompaniment of phthisis in  children than in
the adult, it is by no means invariably absent.   We have observed its
occurrence in numerous cases; and in 118 cases of pulmonary tuber-
cle in children, observed consecutively, and  within  the same year by
Dr. Hennis Green,  with  the  view  of forming  a groundwork for the
history of phthisis in children, he  met with five examples of haemo-
ptysis, and in a  few other cases the  parents or patients  alleged that
spitting of  blood had occurred  at  some period previous to the child's
admission into the hospital.   In 70 other cases, observed, not consecu-
tively,  but at different  periods, haemoptysis did  not  occur once, at
least while the patients were under observation.
   Dr.  Green remarks, that the absence'of  haemoptysis may, in part,
be accounted for by the circumstance, that children—especially those
of tender years—do not expectorate, but swallow everything which
may be brought up  into the mouth from the pulmonary mucous  mem-
brane.  And he cites a striking example of this fact from  the  thesis
of Mr. Murdock.   A child,  two years old, died  suddenly, from the
rupture of  a blood-vessel  which traversed a tubercular cavity  in the
right  lung. A very  small quantity of blood had been discharged by the
mouth, the child  having swallowed the greater part of it. The stomach
and upper portions  of the small intestines were found, upon examina-
tion after death, to  be filled with enormous clots of blood, which were
moulded over their internal surface.  Two cases somewhat similar to
this have fallen  under our own notice.
   A form of pulmonary haemorrhage is noticed by Dr. Green, which
is peculiar to  children, and  invariably and  instantly fatal.  It occurs
in cases of bronchial phthisis, and results from a  perforation of the
pulmonary artery;  of this he has seen one example. In a second case
there was no haemorrhage, but the  artery was so completely flattened
between two masses of diseased bronchial glands, that the passage of
the blood was interrupted, and death  took place as from disease of the
 heart.
  1 During the period already referred to, the deaths from consumption, in individuals
under 15 years of age, were as follows: under 1 year, 225 ; between 1 and 2, 206; 2 and
5, 256; 5 and 10, 140 ; 10 and 15, 136.—Total 963.
  Being 37 per cent, of the whole number of deaths that occurred  under fifteen years of
age. 
          PATHOLOGY OF INFANCY AND CHILDHOOD.       109

  The main character by which tuberculation of the lungs in children
is distinguished from that of adults, is the much  larger surface of the
lung it occupies, its more rapid secretion, and its more frequent com-
plication w7ith tubercular disease of other organs.  Hence,  children
often sink under phthisis before the complaint has arrived at  its third
stage, while, on the other hand, the modifications produced by an ex-
tensive diffusion of tubercular matter, often render the diagnosis obscure
and  difficult.  We have, in  addition, the peculiarities occasionally-in-
duced  by extensive tuberculization of the bronchial glands, a form  of
disease altogether confined  to the child.
  The physical signs are rarely as well marked as in the adult, and
the young child frequently dies before the practitioner is able to decide
whether the lung is actually the seat of cavern or not.  The  cause of
which is, that in children, the tubercular matter is widely diffused, and
has  implicated many important viscera; in the  brain it  may excite
hydrocephalus or meningitis; beneath  the serous membrane of the
chest, pleurisy ; in the abdomen, peritonitis; in the intestines, ulceration.
These complications rarely  fail  to undermine the resisting power of
the little patient; diarrhoea sets in, and  death ensues  long before the
period at which a fatal termination takes place  in the adult.
  The symptoms which constitute hectic fever in the adult, are seldom
present in any marked degree.
  To show that the general diffusion  of  tubercular  matter  forms a
striking characteristic of phthisis in children, Dr.  Green compares some
of M. Louis's results with those deducible from  a table of 180 cases
which fell under Dr. G.'s own observation.  Thus,  in  358  cases  of
phthisis in adults, M. Louis  notices the existence  of  tubercular mat-
ter in the brain or its membranes only once.   In the bronchial glands,
tubercles were found in about one-fifth of the cases; in the mesenteric
glands, in one-fifth; in  the liver, only twice; in the kidneys, five times
in 170 cases; on the other hand, ulceration of the larynx existed  in
one-fourth; ulceration of the bowels, in five-sixths of the cases.
  The history of phthisis in children, presents us  with  very  different
results.  The brain was affected in one-ninth of the cases; the bron-
chial glands, in 100 out of 112; the mesenteric glands in  one-half;
the liver,  in one-ninth ; the kidneys, in one-eighteenth ;  but ulceration of
the larynx occurred only once; and ulceration of the bowels, sixteen
times in 112 cases.
  The bronchial glands, as  stated, were more or less affected in 100
out of 112 cases.   In a few  of these cases only,  were the glands suf-
ficiently enlarged to produce symptoms through their mechanical ef-
fects, or by communication between caverns in  the lungs  and  the
bronchi, and to such cases the term bronchial phthisis should be  con-
fined.  Understood  thus, this form of phthisis is  peculiar  to children,
and  attended with very characteristic symptoms ; but it is not as some
writers assert, of frequent occurrence.
  M. Cless, of Stuttgard, has also published the  results obtained from
the examination of upwards of 180 bodies affected  with tubercular
disease.   In 152 autopsies of adults affected with tubercles,  M. Cless
found the  lungs free from tubercles  6 times.  In  21 autopsies of chil- 
110
DISEASES  OF CHILDREN.
dren, he only found the lungs free from tubercles once.   This was in
a boy 11  years of age, who, besides a considerable serous effusion into
the ventricles of the brain, had two large masses of tubercle  in  the
cerebellum, many small ones  on the surface of the liver, and caries of
the vertebrae.
  In 146 adults affected with tubercles in the lungs, there were  only
35 in whom the disease was  confined exclusively  to the lungs.   In
children, M. Cless found only three cases out of twenty  in  which all
other organs were free.   In 146 adults, in whom the lungs  were dis-
eased, vomicae were found 105 times.  In children there were only nine
cases out of twenty, in which  they were found.  Usually, the younger
the child the less frequent is the occurrence of vomicae.  The  very
young  ones most commonly sink,  according to  the observations  of
M. Cless, under an acute tuberculization, which  causes  death  before
passing on to suppuration;  moreover, young children are frequently
carried off by other diseases superadded to the tubercular deposit, such
as acute hydrocephalus, &c.
  M. Cless never found the bronchial glands in children affected with
tubercular deposit without the existence of tubercles  in  the  lungs
also.
  In 13 adults and one child  there were tubercles in the pleura.  In
61 adults, and four children, the tubercles were limited  to  the peri-
toneum eight times.   The four children were between six months and
ten years of age.
  In 152 adults affected with  tubercles, the small intestines were af-
fected 83 times, and the large intestines 37 times,—and in 21 children
the small intestines were affected 7 times,  the  large ones only once.
Among 152  adults, 32 had tubercles in the mesenteric  glands, while
they occurred in these glands in 7 out of 21 children.  In all the cases
tubercles were found in other organs.
  Tubercles in the liver occurred once in an adult, twice in children,
while other organs were affected.   In 4 adults and 12  children,  the
spleen was affected with tubercles,  these at the same time existing  in
other parts of the body.   In children, M. Cless remarks, the  paren-
chyma of the spleen is often completely invaded by  tubercles.  In the
kidneys, tubercles were met with four times in adults, and three times
in children.
  Of five children, aged from 8 months to 11  years,  in  whom  the
membranes of the brain presented  tubercles,  4  died of acute hydro-
cephalus.  In all there were tubercles in the  lungs  and  other organs
also.  The tubercular granulations  had always their seat on the ex-
ternal surface of the arachnoid, between this membrane  and the pia-
mater,  never within the cavity of the arachnoid.  In 27  children who
died from tubercles, four had  tubercles in the brain, as  also in other
organs ; M. Cless never found any in the brain of adults.   Besides,
in the mesenteric and bronchial glands,  M.  Cless found tubercles in
the glands of the neck \nfive adults and one  child.   (Gaz. Med.  Jan.
1845.)
  Diseases of the heart are not of  very common occurrence during
infancy and childhood.  Of pericarditis twenty-four cases have been 
          PATHOLOGY OF INFANCY AND CHILDHOOD.       m

collected by Rilliet and Barthez.  They describe it as almost exclu-
sively met with in children over six years of age, as a complication in
the course of some other  disease, especially rheumatism and  scarla-
tina ; it may be distinguished by an obscurity in the beating of the heart,
dulness on percussion, prominence of the precordial region, a rubbing
sound or a bellows murmur, during the first sound of the heart.  It is
not considered a  very grave affection, especially when partial and oc-
curring with rheumatism;  it is more  so when general.
   The occurrence of pericarditis, as  a  complication of scarlatina, is
noticed by Drs.  Joy,  Burrows, Bird, Von Ammon, and  others, and
attention  has been  recently directed to the  fact in a  paper by Dr.
Alison; we doubt, however, the frequency of the complication.  Of
endocarditis, Rilliet and Barthez  have collected and analyzed  three
cases; in these, evidences of inflammation of the internal membrane
of the heart, similar to those observed in adults, but at a less advanced
stage, were detected.  They relate also one case of chronic valvular
disease, in which acute endocarditis supervened and destroyed the
patient.
   Dr. West describes six cases  of what he considers to have been ex-
amples  of endocarditis—in three of these, which terminated  fatally,
other lesions were detected equally as important as those peculiar to
endocarditis.
   Of dilatation and hypertrophy of the heart, thirteen cases are given
by Rilliet and Barthez.   By these the two affections would appear to
be of very nearly equal frequence.  Those gentlemen, however, are of
opinion that children are much more  disposed to dilatation than to hy-
pertrophy of the heart—which they consider not at all astonishing when
it is recollected that the feebleness and atony of the  organ are the ori-
gin or consequence of a great number of the diseases of children.1
   To the existence of tubercles in the  brain, and the connexion be-
tween tuberculous depositions in that organ and hydrocephalus, atten-
tion  has  but  recently been  directed.  According to Dr. Carswell,
tubercle of the brain is more frequent in young  infants than at a later
age; while Dr. Hennis Green found, that the age  at which it most
generally occurs, is from three to seven years, inclusively.
   In  numerous instances, tubercles of the brain give rise to no par-
ticular symptom by  which their existence can be detected;  in other
cases, the phenomena produced by them are, in their chronic stage,
severe pain  of the head, partial or general  convulsions, paralysis,
weakness  or  contraction  of  certain  muscles, change  of  temper,
amaurosis or  strabismus, and coma; in their acute stage, the  symp-
toms produced are those of acute hydrocephalus, or of softening of
the brain.
   Many infants present  at birth, a particular organization, indicated
either by a fair,  transparent complexion,  with  light eyes and  hair;
or, by a dark, muddy complexion, with hazel eyes, and black hair.  In

  * In Philadelphia, during the ten  years preceding 1845, 130 children are reported as
having died of diseases of the heart, other than congenital malformation, viz.: under one
year, 42; between 1 and 2 years, 9 ; between 2 and 5 years, 21; between 5 and 10 years,
29 ; and between  10 and 15 years, 29. 
112
DISEASES  OF CHILDREN.
 the progress of infancy, the forehead, in general, becomes projecting,
 the upper lip tumid, the thorax remains  narrow, or  flattened, the
 abdomen protuberant, and the lymphatic glands  of the exterior un-
 usually large and prominent; children thus  constituted, grow rapidly,
 and often present great quickness  and precocity of intellect.  The
 impression of any of the usual morbific agents is liable  to produce in
 them, a diseased condition of the glands of  the neck, or  of the mesen-
 tery ;  and the slightest irritation, affecting either the lungs or bowels,
 very generally gives  rise to the formation of tubercles, particularly in
 the pulmonary tissue.
   The peculiar condition of the organism  above  described  is often
 produced, after birth, from a variety of morbific causes,  by which the
 healthy condition  of the blood, and the regular and perfect  nutrition
 of the several organs, are impaired; but especially, from deficient or
 improper food, from  exposure to an atmosphere  rendered unwhole-
 some, whether by want of ventilation, by humidity, or by impurities;
 from long-continued  exposure to a degree of cold, insufficient to pro-
 duce inflammation; from neglect of personal cleanliness, and from
 deficient exercise.
   In such cases, the limbs remain small, the muscles soft, flaccid, and
 deficient in energy; the  skin  assumes a pale, or a dirty yellow com-
 plexion ;  the  articulations become enlarged, and the bones soft, so as
 to be readily bent and distorted,  by the  action of  the  muscles, or by
 the weight of the body.   The lymphatic glands are liable to  chronic
 enlargement, or to inflammation  and suppuration,  giving place to a
 thin, serous  discharge, containing flakes—often large masses—of a
 curdy appearance. The ulcers which result are long in  healing, and,
 very generally, leave  large, permanent cicatrices,  of a very peculiar,
 and unseemly appearance.
   Most of the inflammatory affections occurring in such  children are
 subacute,  and of long duration;  and  are, frequently, the  cause of the
 development  of tubercular disease of the lungs  and other  organs.
 Diseases  of the skin, of a very obstinate and intractable character, are
 also of common occurrence.    The same is true of inflammation of the
 edges of  the  eyelids, with more or  less injection of the  conjunctiva;
 and of inflammation of the external meatus or deep-seated portions of
 the ear, giving rise to long-continued and highly offensive discharges
 from that organ, and often to a  complete destruction of its  internal
 structure.
   Inflammation of the kidneys is not unfrequent  during childhood.
 The most accurate account we have of the disease  during this period
 of life  is  that contained in the work of Rilliet and  Bdrthez.   Agree-
 ably to the observations of these  gentlemen a very remarkable differ-
 ence exists between the albuminous  nephritis of adults, and the same
 affection in children, and which renders  difficult the anatomical dis-
 tinction at this age between   simple and albuminous  nephritis,—the
disease in children rarely producing the granulations  of Bright, and
 in the generality of cases passing  only to the third stage.  Of eleven
children,  who presented, during life, the symptoms of albuminous ne-
phritis, viz., more or less  extensive  anasarca, with  albuminous urine 
         PATHOLOGY  OF INFANCY  AND  CHILDHOOD.     H3

during a longer or shorter period, four only presented the third stage,
two the second, and four the first, while  in one case, the kidneys were
putrescent.   In a twelfth case, the existence of granulations was de-
tected upon dissection,—but  the  urine had not been examined during
life, and furnished no albumen  after death.  On the other hand, in the
few  cases of simple nephritis  they have seen, they never  met with
suppuration, either  diffused, in scattered  points, or collected in ab-
scesses.
   According to Rayer, the two forms of nephritis are with difficulty
distinguished at their commencement, the only difference he points out,
is the consistence of the kidney being increased in the one,  and  dimi-
nished in the other.  In simple nephritis the increase of consistence has
appeared to Rilliet and Barthez to be more marked in children than in
adults; while in the first three degrees of albuminous nephritis, they have
noted a marked diminution of consistence in  the cortical  substance.
Thus, in respect to their anatomical relations these two forms of nephri-
tis closely resemble each other.  And when we add that, during life the
difference is not always more marked, it must  be admitted that during
infancy the two affections are but slightly separated from each other.
   Anasarca, which is the prominent, as  well as the first symptom no-
ticed, for in no case was the urine examined  by Rilliet  and Barthez
before this appeared, is liable to vary in extent, and even to disappear,
leading to the hope that a cure has been effected.  The cessation  of
albuminuria is, however, alone, a positive symptom of the restoration
of health.
   It  is from the complications of the disease that the greatest danger
arises.  The most important of  these is inflammation of the organs,
which are subject to dropsical effusions; this occurs most  frequently
in the serous membranes and in  the lungs, and is attended with  more
or less copious serous effusion.   The only cases of  simple albuminous
nephritis which Rilliet and Barthez met with were in children;  all  of
which terminated favourably.
   Secondary albuminous  nephritis  is chiefly  met with after eruptive
and intermittent fevers.   After scarlatina it  occurs generally during
the period of desquamation—from the twelfth to the  nineteenth day
from  the commencement,—and is  caused generally by exposure  to
cold, or a change of temperature.   It is, according to  the observation
of the gentlemen just quoted, as frequently met with, relatively to the
frequency of the two affections, after intermittents as after  scarlatina.
In one of every six cases collected  by them,  it  followed the former.
It was in these cases chronic, and contributed, with  the other compli-
cations, to produce  a fatal termination.*
   Dysuria  is  often met with in  young  children.  It may result from
irritation, seated at  the neck of the bladder, or reflected upon it from
disease of the  digestive organs.  It also occurs frequently during den-
tition, and occasionally  in the course of certain febrile affections.  An
  * But six cases of death from disease of the kidneys are reported to have occurred in
children, in Philadelphia, during the ten years referred to, viz., in those under 1 year, 4,
between 1 and 2, 1, and between 2 and 5, 1.
                                8 
114
DISEASES OF  CHILDREN.
increased flow of urine is very common, in infancy, during dentition,
and in certain disordered conditions of the digestive functions.  Genu-
ine diabetes is said to occur  in infants, accompanied with  a copious
diarrhoea, intense thirst, and rapid emaciation.  Cases  are  mentioned
by Isenflamm,a Morton,b McGregor,0 Willis,d Venables,8 Mott,f and
others; we have never met with them.  During the twenty years, pre-
ceding 1845, but one death is reported to have occurred in Philadelphia
from diabetes, in  an infant  under five years, and one  in  a child  be-
tween ten and fifteen years.
  The urine, particularly in irritations of the digestive organs, is often
of a whitish  appearance, or lets fall a whitish deposit, as it cools or is
evaporated.  Very deep-coloured urine, is often  passed in the  febrile
affections of children.
  Gravel often forms, in children, from derangement of the digestive
function, either from improper food, confinement in a close and  im-
pure atmosphere, or, from  exposure  to cold and dampness. It may
occur in the form of a red  deposit, consisting of uncrystallized lithic
acid,, when its passage is  attended with  little or no irritation of the
urinary organs ; or, it may consist  of the  acid, in a crystalline form,
causing in its passage  more  or  less irritation.  Urinary calculi  are
occasionally  met  with in  children; they ordinarily  consist of  the
lithate of ammonia, and are small in size, and of a clay colour.
  Incontinence, or an involuntary flow of urine, is of frequent  occur-
rence, during infancy and childhood.  We have already  noticed, in
what  manner the anatomical  condition  of the  bladder  renders it
difficult for the  urine  to be retained, after it has accumulated to a
certain extent.
  Incontinence of urine is often, in children, the result of  habit, or it
occurs during deep sleep, at a particular hour, and may often  be re-
medied, by accustoming the child to regular  periods of urinating, or
by awaking him from sleep, for the purpose of evacuating the bladder,
previous to the  hour when, the involuntary  discharge usually takes
place; in a  short time, the bladder becomes accustomed  to endure
the presence of its contents, until they are evacuated  by a voluntary
effort.
   Incontinence of urine, in children, is attributed, by Willis, to  a de-
rangement of the secretory function of the kidneys, by which a copious
separation of watery fluid from the blood takes place, in which there
is a deficiency of  the characteristic ingredients of the urine.  This is
certainly not true  in all cases; we  have seen  it result, as it appeared
to us, from the  irritation of the  rectum, by oxyures.  It would often
seem to  arise also, from a want of proper control over the  sphincters
of the bladder; or, to so great an irritability of the bladder itself, as to
cause it to expel the urine, almost as soon as it reaches its cavity.   We
have seen many instances, in  which incontinence of urine was a con-
genital affection—the urine dropping constantly  from the urethra; in
a Uber die Eingeweide, 1784.       b Phthisiologis, Lib. I. cap. viii. 1697.
c Lond. Med. Gaz. vol. xx.         d On Urinary Diseases.
• On Diabetes, 1825.             f Amer. Med. and Philos. Register, t. i. p. 387. 
        PATHOLOGY OF INFANCY AND CHILDHOOD.     U5

a majority of these  cases, the  patient died early, from disease of the
brain.
  Most of the acute diseases of infancy and childhood  are  attended
with more or less febrile  reaction, which usually assumes the remit-
tent  type, with exacerbations towards evening, or during the night.
Gastro-intestinal irritation  or inflammation, which, being  one of the
most common of the affections  of early life, is that which most usually
gives rise to the remittent fever, described by writers as a  disease pe-
culiar  to  children; and  attributed, by many of them, to the  presence
of worms.
  To nearly all the fevers, infants and children  are liable; but not to
the same extent as adults—if we except the  exanthematous, many of
which are of rare occurrence after the age of puberty.  In those dis-
tricts in which intermittent  fever is endemic,  children even at the
breast, will become  affected with it.   The same is true of the bilious
and  yellow fevers.  It is  more than probable that typhoid fever will be
found to be a much  more frequent disease among children  than has
heretofore been supposed.  The memoirs of Rilliet and Taupin afford
sufficient evidence that many of the cases of what was formerly con-
sidered as enteritis in children,  as  well as of that form of fever which
has  been vaguely denominated worm  or gastric fever, are in fact
cases of genuine  typhoid fever.   In severe epidemics of typhus and
typhoid fever, large  numbers of infants  have been known to be at-
tacked, and fall victims to the disease.1
  The general observations, made  in reference to the diseases incident
to infancy, will equally apply to  those of the earlier period  of child-
hood.  Though  cutaneous  affections  are  still frequent, yet the skin is
less  liable to disease, than during the  preceding stage of existence.
Furunculi, or circumscribed  phlegmonous  inflammations of  the skin,
are common at this age.   The  respiratory mucous membrane, as well
as that of the alimentary canal, become readily irritated and inflamed.
The brain, also, from the great activity of its  functions, is  now pe-
culiarly exposed  to  disease;  hence,  violent pains of the  head, and
  * In Philadelphia, during the ten years preceding 1845, the deaths of children from fever
are as fellows:—
Under 1 year.	Between 1 and 2 years.	Between 2 and 5 years.	Between 5 and 10 year3.	Between 10 and 15 years.	Totals.
Intermittent, 4	2	6	3	1	16
Remittent, 20	14	37	43	14	128
Bilious, 3	6	11	8	8	36
Typhus, 4 Typhoid, 4 Congestive, 9	2 5 3	18 12 5	22 22 3	23 14 1	69 57 21
Inflammatory, 3 Brain, 3	0 1	0 2	3 1	0 0	6 7
Mesenteric, 0	0	1	0	0	1
Miliary, 0 Hectic, 1	1 1	1 2	0 1	0 1	2 5
Fever, without any dis- i -R tinctive appellation, \	25	42	16	5	146
109	59	137	122	67	494
 
116
DISEASES OF CHILDREN.
 cerebral inflammation, are of frequent occurrence; convulsions are,
 however, less frequent, than during the period of infancy.
   From the great development of the capillary system, which con-
 tinues during youth, and the tendency to hyperaemia, and to irritation of
 the respiratory mucous membrane, haemorrhages  from the lungs are
 very liable to occur towards the close of childhood; about this period,
 also, profuse epistaxis is not unfrequent.   Tubercular disease of the
 pulmonary organs is  often developed during  childhood;  and scrofu-
 lous swellings and ulcerations of the superficial lymphatic glands are
 of common occurrence.
   From the amount of exercise to which the body is subjected during
 youth, inflammations of the joints are liable to be produced;  rheuma-
 tism is, also, more frequent at this age than  previously.   The  heart
 readily sympathizes with the various irritations that occur in the other
 organs; hence, most of the diseases which then take place, are accom-
 panied with febrile symptoms, of  a more intense character than  in in-
 fancy.
  The causes of disease are nearly the same during infancy and child-
 hood, as in the subsequent periods of life—from  but few are  they en-
 tirely exempt—while nearly all the ordinary morbific agents act upon
 the infant with much greater severity than in after life.
  Many of the  affections that occur in early  life,  may exist at birth;
 thus children  are occasionally born affected with syphilis, small-pox,
 a tuberculous condition of various organs, softening of portions of the
 stomach and bowels, inflammation of the different of organs; hydroce-
 phalus, and various malformations.  Or, there may exist from birth,
 a peculiar condition of the organism, predisposing it, subsequently,
 from the action of slight causes, to a particular form, or class, of dis-
 eases.   This condition of organism may exist in  all  the children of
 certain families,  and would appear, in many cases, to be hereditary—
 the same diseases prevailing, for many generations, in the same family.
  Mental impressions—deep  anxiety—and the various  intense affec-
 tions of the mind, whether of a depressing or exciting character, which
 constitute so fruitful a source of disease in the  adult, are scarcely ope-
 rative in the infant; and  are  seldom the cause of serious disturbance
 in the child.
  Violent excitement of the nervous system, however, from loud and
 unexpected  sounds; arousing the  infant  suddenly  from its sleep;  or
 exciting  in it intense  alarm or fright; have been known, in many in-
 stances, to produce, even at an early period of infancy, the most seri-
 ous effects, resulting in a fatal attack  of convulsions, or, at a  later
 period, in confirmed idiocy:—violent paroxysms of anger, by what-
ever cause excited, are equally injurious, during infancy and  child-
 hood.
  Notwithstanding the lively and  cheerful disposition, so common in
childhood, its quick forgelfulness of past suffering, its little anxietv for
 the future, and its perfect contentment with the enjoyment of the pre-
sent moment, yet, by improper treatment, or a neglect of  moral edu-
cation, the passions, even at this early period, may be made the source
of much disease and suffering.  By parental unkindness—a mistaken, 
         PATHOLOGY OF  INFANCY AND CHILDHOOD.     117

 and over-rigid discipline—confinement from  childish amusements and
 exercises—indiscreet ridicule of faults or imperfections, and the with-
 holding every species of encouragement; the spirits, even of the child,
 may be depressed, and discontent, hatred, jealousy, may be engender-
 ed, and become the remote or exciting causes of serious disease, either
 mental or bodily.
   Too much, or  deficient, and improper food, are among  the most
 common of the  causes of disease, from birth until puberty.  By the
 disorder of the digestive function induced by errors in diet,  the blood
 becomes vitiated, or imperfectly elaborated, and the nutrition of every
 part of the body  deranged, or defective; while, at the  same time, irri-
 tation of the alimentary canal is produced, running on  to inflammation
 and rapid disorganization, or irritation becomes, sooner or later, trans-
 mitted to the brain, or reflected upon other  organs, disturbing their
 functions, or producing serious disease of their substance.
   In infants  disease is often produced by the impure or innutritive
 state of the mother's milk, even  in cases when no such  deterioration of
 the milk is suspected, the health of the female being apparently unim-
 paired.  A very  interesting  paper  on this subject, by M.  Girard, has
 recently appeared in the Archives Generates de Medecine; in which  is
 pointed out the  importance  of testing the character of the milk by a
 microscopic examination in  all cases in which the infant, when nou-
 rished  solely  by the breast, becomes affected with symptoms of indi-
 gestion.
   Every physiologist is aware of the change  produced in the proper-
 ties of  the mother's  milk, by  the nature, as well as by the quantity, of
 the food habitually taken.  Too much, or too little food; a too  stimu-
 lating  diet; the  use of vinous or  distilled liquors, more  especially  if
 taken in excess,  and articles of food of difficult digestion, cannot fail
 to  affect the secretion of milk,  and render the latter  unfitted for the
 nutriment  of the infant who partakes of it; milk thus deteriorated, will
 very generally produce irritation of the infant's stomach, and  all the
 symptoms of  indigestion.
   If an infant, in consequence of the inability of the mother to suckle
 it, is  nursed  at the  breast of a female whose own child is several
 months  older than it,  indigestion will  very generally ensue, in  conse-
 quence of  the milk containing an amount of  caseum, to the digestion
 of which the stomach of the younger child is  inadequate; the propor-
 tion of  caseum in the  milk of the human female always  augmenting
 with the age of the infant.
   The occurrence of the menstrual discharge  is generally enumerated
 as a cause of  deterioration in the milk, calculated  to occasion serious
 injury to the infant who partakes of it.   When the catamenia are sus-
 pended  during the first  eight or nine months subsequent  to parturition,
 and then reappear, there will, very  commonly, be found to take  place
 a diminution  in the supply, and a decided change  in the properties of
the milk; and the child  will very generally suffer if it be continued at
the breast.  But we are by no means convinced that every occurrence
of the menses, during lactation, is calculated to produce similar effects
upon  the milk.    We  have  known  several  females  who menstru- 
118
DISEASES OF CHILDREN.
ated regularly during the  entire period of suckling, and their infants
throve equally well with those of mothers  in whom  the catamenial
discharge is suspended.  From a series of observations recently pub-
lished, by Raciborski, it has been ascertained that the health of chil-
dren nursed by  menstruating females suffers no kind of injury.  If,
however, upon the appearance at any time of the menses, the milk is
found  to  disagree with the  child at the breast, it will  be prudent to
cease suckling it so long, at least, as the discharge continues.
  Pregnancy is  also set down as producing an alteration in the milk,
unfitting  it for the nourishment of the infant:  During the first  three
months of pregnancy, we have certainly seldom noticed any particular
change to occur in the milk;  at a later period, however, it is probable
that the safety of the mother, as well as the  health of  the infant at the
breast, will require it to be weaned, or, if too young for this, that the
milk of a healthy nurse be substituted  for that  of the  mother.   It is
true, that infants'have been suckled to a late period of pregnancy, or
even to its termination, without apparent injury; while in  other cases,
according to Dewees, so great a deterioration of the milk has occurred,
as to require that the child should be taken from the  breast at a very
early period.
  Another cause which  is  generally supposed to render the milk of the
mother injurious to an infant, is, continuing the latter for too long a
period at the  breast.  This is unquestionably true.   If, after the  ap-
pearance of the  molar teeth,  the  child be confined exclusively to  the
breast, symptoms of indigestion will  very generally occur; and even
with a supply  of other food, continuing it at the breast after the ninth
or tenth month,  will often  be found  productive of injury.  There are,
however, striking exceptions  to this rule; some  of the finest children
we have  seen  were among those who  were suckled—taking, however,
at  the same time, a portion of other food—until they were  fifteen
months old.   We may remark that,  in all these cases, the menstrual
discharge was suspended during the whole period of lactation.
  Intense grief,  mental  anxiety, paroxysms  of violent passion, or any
long-continued or violent emotions of the  mind are, unquestionably,
causes of very considerable deterioration in the  milk.   Severe  vomit-
ing, and  even  general convulsions, have been known to result from the
child being applied to the breast immediately after the nurse has expe-
rienced any intense mental excitement—whether of an exhilarating or
depressing character; and it is a general remark, that the  children
nursed by females who are labouring under intense  grief, or mental
anxiety of any kind, seldom thrive.  We have met with several cases
of  this kind, in which the safety of the child required it to be  taken
from the mother's breast, and  where every symptom of disease ceased
soon after it was furnished with the breast-milk of a healthy nurse.
   Another fruitful source of disease, in infancy and childhood, is im-
pure or  confined air.  This acts  upon the blood  through  the medium
of  the lungs, and, probably, of the  cutaneous surface also.  Indepen-
dently of preventing, in this manner, the due oxygenation of the blood,
impurity and  want  of ventilation in the atmosphere would appear to
produce a deleterious effect upon the infant organism, by acting imme- 
        PATHOLOGY OF  INFANCY AND  CHILDHOOD.     \\g

diately upon the nervous system.  The convulsions which occur within
the first two or three months—trismus nascentium, spasm of the glottis,
in young infants, and other spasmodic diseases, seem evidently to result
from the action of impure air upon the nerves.
   In children exposed, for any length of time, to the * influence of a
corrupted or confined atmosphere, the powers of life become depressed;
digestion  and sanguification are imperfectly performed; and  nutrition
is impeded, or disturbed.  The skin assumes a pale and sickly aspect;
the muscles a soft and flabby feel; and disease of the alimentary canal,
lungs, brain,  or lymphatic glands, sooner or later ensues.   Children
who are confined to badly ventilated and imperfectly lighted apartments,
even where no cause exists capable of imparting  foreign impurities to
the air respired, present, invariably, a pale and unhealthy appearance,
and are prone to disease.   It is probable that to the purity and freshness
of the air, and  the greater amount of exposure to its influence,  as well
as to that of the light,  are to be chiefly attributed the deeper colour of
the skin, and the  larger amount of health and robustness, possessed by
children who inhabit elevated country situations, compared with those
who are brought  up entirely within the confines of a large and crowd-
ed city.   Alison  and Baudelocque  ascribe more  influence in the pro-
duction of scrofulous affections, to impure and confined air, than to an
impoverished diet, or improper food.
   Cold, either alone or combined with dampness, so fruitful  a  source
of disease during every stage of existence, is peculiarly so in infancy
and early  childhood—in consequence  of the defective  power which
then exists of generating heat,  and, consequently, of resisting  the in-
fluence  of even a slight impression of cold.   Exposure  to too low  a
degree of atmospheric temperature; to drafts of cool air, when the
body is in a state of perspiration; too  slight  clothing, or that which
protects only partially, the surface; occupying damp  rooms or beds,
and allowing portions of the dress that have  become wet  from any
cause, to  remain  unchanged ; or exposure to rapid and  sudden alter-
nations  of temperature, are the  usual means by which, in children, the
heat of the surface is reduced, and the organism subjected to the dele-
terious  influence  of cold, by which  inflammations of the alimentary
canal and respiratory organs are induced.
   The morbid effects of cold are invariably increased by  its being
combined with  dampness ? hence,  children are often seriously affected
by a degree of what is termed  rawness of the air, not amounting to
positive cold.  Cold, combined with dampness, is the fruitful source of
bronchitis, croup, and of certain forms of diarrhoea and dysentery in
children.   It  is this which renders low, damp situations, and deep,
secluded valleys, so  especially prejudicial to health, in the early stages
of life.
   During sleep, children are even  more subject  to  the  morbid influ-
ence of sudden alternations of temperature, than during  their waking
moments.   An  attack  of  bronchitis, croup, or abdominal inflamma-
tion, is frequently caused  by their being put to  sleep at night, in a
colder apartment  than  that they occupied  during  the day;  by their
throwing off the clothes, during sleep, when heated or  in a state of 
120
DISEASES  OF CHILDREN.
 perspiration, or by the cradle  or bed,  in which they repose, being
 placed in a draft or current of air.
   The injurious effects of cold and dampness are not always exhibited
 in the immediate production of acute disease.  Continued exposure to
 a  cold and  damp  atmosphere,  in  early life, by depressing the vital
tpowers of the organism, may gradually  undermine  the health of  the
 system, or give rise to chronic affections, the existence of which  are
 first rendered apparent towards the period of dentition or of puberty,
 or upon  the  occurrence of some acute  affection, resulting from  the
 action of any of the causes of disease to  which children are liable, and
 invariably render it more unmanageable.
   Intense heat, which is always more or less injurious to infants,  be-
 comes, under  certain  circumstances, a fruitful source of  disease in
 early life.  Thus, when succeeded by a  sudden reduction of tempera-
 ture, or when the body  is accidentally exposed to any cause by which
 its temperature is suddenly diminished, serious disease is very gene-
 rally produced. But it is principally in  the narrow  lanes, courts, and
 alleys of the larger cities  of the middle and southern  states, that,
 during the summer months, excessive heat, in conjunction with a con-
 fined and impure air, displays its baneful influence  upon the infant—
 subjecting them, upon the occurrence of the  slightest irritation of  the
 alimentary canal, to  an attack of infantile cholera, which  can seldom
 be arrested,  excepting  by a prompt removal from the  heated and
 infected  air  by which it was generated.
   From what has  been said, it must be evident that the seasons of the
 year exert a considerable influence upon the  health of infants, and to
 a certain extent, also, upon the form and character of their diseases;
 thus bronchitis, croup,  and  pulmonary  inflammation prevail to  the
 greatest extent, among children, during the  more changeable and
 colder months ; while bowel complaints,  and especially cholera, pre-
 vail during  the season  of greatest heat, and  dysentery  and certain
 forms of diarrhoea during the autumnal months.   The spring or autumn
 is the season during which epidemics of scarlatina, measles, and hoop-
 ing cough, usually prevail; while small-pox  is  more common during
 the  winter.
   In the city of Philadelphia, the mortality among  children varies
 greatly with the season.  Thus, under five years, the  largest number
 of deaths, for the years  1837 to '44 inclusive,  occurred in the months of
 June, July, August, and September, namely, 8781—this being the season
 of greatest heat, the mean range of the thermometer averaging from 70°
 to 79°.   The next highest amount of mortality, occurred during  the
 months of December, January, February, and March, namely, 5641—
 this being the season of greatest cold, the mean range of the thermo-
 meter averaging from 32° to 35°.  The  smallest amount  of mortality
 occurred in  the  months of  April, May,  October,  and November,
 namely, 4815 ; the mean of the thermometer ranging from 45° to 65°.
 The relative mortality of children, under five years, compared with the
 whole number of deaths, at the respective periods, is as follows: from
 June to September,  inclusive, 56-91 per cent.; from December to 
PATHOLOGY OF INFANCY AND  CHILDHOOD.
121
March, inclusive,  45*32 per cent., and during  the  remaining four
months, 41-39 per cent.
  The following table exhibits  the  entire mortality during the years
referred to, and the  mortality of the several  periods  of infancy; the
months being arranged  according to their greater or less mortality at
each of the periods respectively :
Mean Temperature and Total number of Deaths at all ages. No.	Total deaths in children under fif-teen y'rs	In childr'n under 1 year.	Between land 2.	Between 2 and 5.	Between 5 and 10.	Between 10 and 15.
July, 77° 4631 August, 750 4C04 January, 32o . 3(j27 March, 400 3379 June, 700 3372 April, 500 3179 February, 32© 3171 May, 60o 3063 September, 65o 2904 October, 55o 2854 November, 45o 2537 December, 350 2489	July 3297 Aug. 2709 June 2080 Jan. 1967 Mar. 1869 Apr. 1692 Sep. 1638 Feb. 1534 May 1495 Oct. 1350 Dec. 1214 Nov. 1143	July 1889 Aug. 1310 June 1052 Jan. 861 Mar. 762 Apr. 674 Sept. 642 Feb. 606 May 557 Oct. 480 Dec. 457 Nov. 429	Aug. 733 July 715 Sep. 430 Mar. 354 June 351 Jan. 344 Apr. 330 Feb. 318 Oct. 288 Sept. 283 Dec. 217 Nov. 201	Jan. 469 Mar. 438 July 402 Apr. 381 June 378 May 366 Aug. 357 Feb. 323 Oct. 317 Sept. 312 Dec. 2«2 Nov. 291	Mar. 194 Apr. 191 Aug. 186 Jan. 170 June 166 Feb. 161 July 159 May 155 Oct. 144 Dec. 130 Sept. 129 Nov. 113	May 64 June 63 July 62 Feb. 56 Sept. 55 Aug. 53 Jan. 53 Oct. 51 Mar. 51 Dec. 48 Apr. 46 Nov. 39
  Annexed, we present  the proportionate ratio, in the first column, of
the mortality in  children under  fifteen years of age, compared with
the entire mortality;  in the second column, the ratio of the mortality,
in infants under  one year, to the whole  mortality; and  in the third
column, the ratio of mortality in  infants under two years,  to the entire
mortality:—the  months being ranged as above, according to their re-
spective mortality:
Ratio of children to whole	Ratio in infants under	Ratio in infants under
mortality.	one year.	two year3.
June, 61-7 per cent.	July, 40-7 per cent.	July, 56* per cent.
July, 61-	June, 31-37	Aug-. 44-37 "
Aug-. 58-8	Aug. 28-4 "	June, 41-6
Sept. 56-5	Jan. 23-46 "	Sept. 36-
Mar. 55-3	Mar. 22-55	Jan. 33- "
April, 53- "	Sept. 22- "	Apr. 31-58 "
May, 48-8 "	Apr. 21- "	Mar. 30- "
Jan. 48-7 "	Feb. 19- "	Feb. 29- "
Dec. 48-77 "	Dec. 18-3 "	May, 27-42 "
Feb. 48-37	May 18- "	Dec. 27- "
Oct. 47-3	Nov. 16-9 "	Oct. 26-9 "
Nov. 45* "	Oct. 16-8 "	Nov. 20-89 "
   Worms in the bowels are generally ranked among the most usual
causes of the complaints of infancy.   That their  presence may give
rise  to a morbid degree  of irritation  in the gastro-enteric mucous
membrane, and secondarily, in the mesenteric glands, the brain or the
lungs, there can  be little doubt; nevertheless, they are less often  a
cause of disease, than they are popularly supposed  to be, or even than
they were formerly esteemed to  be by physicians.   The symptoms that
are commonly ascribed to the presence of worms, are produced, in the
majority  of cases, by a diseased condition of the alimentary canal, en- 
122
DISEASES  OF CHILDREN.
tirely independent of the presence of these animals, and may continue,
notwithstanding the destruction or removal of the latter.
  The first  dentition is frequently  accused  of being the immediate
cause of the diseases which occur during the second period of infancy.
Dentition, however, cannot, of itself, be considered a disease, during
either infancy or childhood; but when  a predisposition to morbid
action exists, the process of dentition may, then, become the exciting
cause of the most alarming symptoms.  The irritation produced in the
gums, during the progress of the teeth to the surface, almost invariably
gives rise  to increased heat and redness of these parts, and sometimes
to positive inflammation; and as the irritation of the gums extends to
the gastro-intestinal mucous membrane, which, at this period, from the
development and activity of its muciparous follicles, is readily excited
to an increased secretion of mucus, some degree of diarrhoea  very
commonly attends  the process of teething.   If,  from any cause, the
stomach or bowels have been brought previously into a state of mor-
bid irritability, excessive vomiting and purging, fever, and other symp-
toms of more severe disease may, be induced.
  In other cases, when the process  of  dentition is  accomplished with
great difficulty, violent  inflammation or even sloughing of the gums
may occur; and in children in whom the powers of life have been re-
duced, and the nutrition of their bodies  impaired,  by constant exposure
to a cold,  damp, and confined atmosphere, or by deficient or improper
food, the irritation, developed during the process  of teething, may in-
duce the  peculiar  gangrene of the  mouth of children, to which the
terms cancrum oris, water kanker, &c, have been applied.   In Phi-
ladelphia,  and other large and crowded cities, the irritation of teething
is a very common  exciting cause, during the summer months, of the
cholera infantum.
  In many instances, not only does the  process of dentition excite irri-
tation of the stomach and bowels, but in consequence of the increased
amount of blood which it attracts to the vessels of the head and face,
the  tendency to disease in these parts is increased; hence, convul-
sions, ophthalmia, inflammation of the  glands of  the neck, ulcerations
behind the ears, eruptions of the face  and scalp, meningitis, and hy-
drocephalus, very frequently occur at this period of infancy.
  Deformity and disease are often occasioned during infancy by falls,
by improper postures of the body long continued,  by improper forms
of" clothing calculated to impede the motion of the limbs, or to prevent
the development of certain  parts of the body, and by  too  early  at-
tempts to  induce the child to assume the erect posture, or to walk.
  Some discrepancy of opinion exists,  among pathological writers, as
to the susceptibility of infants to contagion, some  ascribing to them an
entire immunity from its influence,  while nearly  all consider them to
be less subject to it than adults.  In  very young infants, it is true, we
seldom  meet with  any of the febrile  affections,  the propagation of
which is generally ascribed to contagion; but after two years of age,
contagious diseases, if we include under this term small-pox, varicella,
scarlatina, measles, and hooping cough, are  of far more frequent oc-
currence, than after the period  of puberty. 
SEMEIOLOGY  OF INFANCY  AND CHILDHOOD.    123
                       CHAPTER  IV.

  SEMEIOLOGY OF THE DISEASES OF INFANCY AND CHILDHOOD.

   The detection and diagnosis of disease in the infant, is based, the
 same  as  in the adult, upon a careful  examination and analysis of its
 various  phenomena; but in the infant, the  occurrence and extent of
 these  phenomena must be derived, altogether, from the attentive ob-
 servation of the physician,  compared with those of the parents or
 nurse.  From  the  little patient we can derive no other information
 than such as  is expressed by the countenance, the positions of the
 body,  the motions of the head, trunk, and limbs, the nature of the cries
 emitted, and the condition of the respective organs, as indicated  by
 the regularity of their functions, or  the extent and manner in which
 these are disturbed.
   In the infant, the condition of the skin, the state of the various secre-
 tions and excretions, the appearance of the eye, the manner in which
 respiration is performed, have the same  amount of value, as indica-
 tions of the seat, nature, and extent of morbid action, and are as readily
 detected as in the adult.   But, in  the infant, the physician can derive
 no assistance in forming his diagnosis, from the character and  location
 of any pain, or other uneasy sensation the  patient may experience—
 constituting, in many cases of disease, an important pathological fea-
 ture—excepting from the external physiognomy peculiar to the various
 grades of suffering  that occur in the different organs.
   It is this physiognomy of  suffering, as  derived from  the expression
 of the  face, the cries, and the movements, which constitutes,  in a great
 measure, the special semeiology of infantile diseases.  M. Jadelot has
 attempted to present a correct exposition of the indications of disease,
 as derived from the expressions of the  countenance, from the period of
 the first  dentition until  puberty:-—his  remarks, as furnished us by M.
 De Salle, in his edition of Underwood, are certainly interesting, but,
 in many respects, they are purely  hypothetical.
  The general  phenomena of disease in infancy, notwithstanding they
 experience certain modifications, dependent  upon the peculiar state of
 the organization, differ, nevertheless, but little from those observed in
 the adult.  There  are,  however, a few morbid phenomena that  are
 peculiar  to the  infant; and others, which in the correct diagnosis of
 disease, have an  importance far beyond  what they possess  in after
 life.
  As a preliminary to the study of the semeiology of  the diseases of
infancy, it is essential that the physician should make himself fully ac-
quainted  with the external appearance usually presented by  an infant,
during health:  the expression of his  countenance, the attitudes of his
body, as  well as with the physiological condition  generally, at the dif-
ferent stages of development, of his  several  organs, and of their re- 
124
DISEASES OF CHILDREN.
spective functions.  It is only from the nature and extent of the devia-
tions from the normal standard, that, in many cases, he will be enabled
to appreciate the value of the morbid  phenomena that exist, either in-
dividually or collectively.
   It is but within a very short period, that the physiology of infancy,
and the manner in which its organism is  developed, have been accu-
rately investigated ; and it is curious, that not a few of the phenomena
which  writers on  the diseases  of the early stage of existence, of no
very remote date, described as important  indications, or as results of
morbid action, are found to be invariably present  in the infant, during
health.
   We  have already presented  a  brief sketch  of  the condition of the
different  organs, during  infancy,  and  the  manner in which their re-
spective  functions are successively brought into action.   We  need
here only remark, that, in the  healthy infant, the  limbs  are uniformly
covered with flesh, rounded and  plump, and to the touch, present a
certain feeling of  firmness and elasticity.  The skin  is soft, flexible,
and of a rosy hue; the  complexion lively and fresh.   The eye, when
attracted by any object,  has a peculiar quickness and  suddenness in
its movements; the pupil is usually large when the  infant is awake,
but often minutely contracted  during  sleep; and  always more or less
turned upwards, beneath the upper eyelid.  The  countenance, when
in repose, exhibits, in the earlier stages of infancy, but little or no ex-
pression, except that of perfect calmness ; but at a later age, it becomes
quickly lighted  up, smiling  and animated, upon  the approach of its
parents or nurse, or when attracted by any pleasing object.  The sur-
face of the infant is cool; the abdomen full and soft—gentle  pressure
upon it seeming rather to please, than  to cause the slightest uneasiness.
The tongue is generally slightly covered  with a  whitish mucus; the
mouth is always  moist, and the lips fresh-coloured, and often  pro-
truding.
   The sleep of the healthy infant is  quiet and profound : it awakes
from  it cheerful  and smiling,  and soon  demands food.  During its
waking hours, after, at least, the first month or two, it is inclined to as
much activity as its limbs will permit,  and  exhibits a surprising springi-
ness and rapidity in all its movements.  It delights to be played with
and carried about, and, when old enough, to roll and crawl about upon
the carpet.
   In health, infants seldom  cry, excepting to  express their wants, or
in consequence of experiencing some accidental  uneasiness  or  pain,
and  are  immediately quieted  upon their  wants  being gratified,  the
cause of their uneasiness removed, or  their pain appeased.   Crying is
not, however, always the indication of either ungratified wants, pain,
or disease:—some infants cry repeatedly, being with difficulty appeased,
without our being able to detect any apparent cause of  suffering, and
without any interruption to the full nutrition, and regular development
of their bodies.
   Every deviation from what we have just given, as the picture of a
healthy child, is not, however, to be considered, of itself, an indication
of disease.   The limbs  of an  infant  may exhibit a certain degree of 
        SEMEIOLOGY OF INFANCY AND CHILDHOOD.     125

meagreness—its complexion may be somewhat pallid—its sleep short,
or occasionally restless—or many of its waking hours  may be passed
in crying, without the existence of any positive disease.   All changes,
however, occurring in an infant, either  suddenly or gradually, whether
in the ordinary expression of its countenance—in  the condition of its
body—its habits or disposition—should be looked upon with a suspicious
eye, and be the signal for a careful  examination into the condition of
its several organs;  in one  or other of  which, some commencing dis-
turbance will, in general, be detected.
   Whenever there is observed  in an infant, any marked alteration in
the  countenance,  or  in  the external  appearance of the body—an
unwonted dulness of the eye—an indisposition to  playfulness—a loss
of its  accustomed  gaiety—unusual listlessness—disturbed  sleep—un-
common  wakefulness—sudden starting in slumber or awaking with
apparent affright—an unusual degree of somnolency—the occurrence
of sudden paleness  of the face, or paleness alternating with a suffusion
of red, more or less deep—increased heat of the hands and feet, or of
the entire surface—unusual coldness of the extremities—unaccustomed
fretfulness—frequently repeated  or prolonged  fits  of crying,  or  a
marked change in the character of the cry—frequent or constant cor-
rugation of the brow—twitching  of the muscles of the face—rejection
of the breast, or of food—unusual  movements of the head and  limbs
—and crying or  moaning when the  body is moved or handled, are
invariably to be considered as the indications of nascent or confirmed
disease.
   No  disturbance or irregularity  of function, occurring  in an infant,
however slight, should be considered as unimportant. The suddenness
with which some of the  most violent  affections of this period of life
are  developed, and the rapid occurrence of effusion or of disorganiza-
tion, in the tissues and organs in  which morbid action is seated, give
to every indication by which the  inception of disease can be detected,
even a greater degree of importance than in after life.   In their com-
mencement many of the maladies of infancy may be promptly arrested
by simple remedies, that  if allowed to become fully developed, are
scarcely  within the  control of the most judicious  and  active  plan
of treatment.
   A slight irritation of the gastro-intestinal  mucous membrane of the
infant, will often, by being  suddenly transmitted to the brain, give rise
to a violent convulsive attack, or  produce some  other and equally
serious train of  symptoms, which might  have been prevented by the
early detection and removal of the  primary irritation.
   Not a few, also,  of the  maladies that  occur  during infancy, give
rise, during their first  stages, to so few  prominent symptoms, that their
existence is often unsuspected, until disorganization of some important
organ  has taken place, or a sympathetic affection of the brain occurs,
and  their character and extent are thus  revealed, at a  period when
their cure is impossible.  Even in these insidious forms of disease, by
a  close attention  to  the countenance, manners, and gestures of the
little patient, the physician  will seldom fail to detect the presence of
morbid action, and make out, with sufficient accuracy,  its diagnosis, 
126
DISEASES OF CHILDREN.
      at a period when it is still within the control of appropriate remedial
      agents.
        The principal sources of diagnosis  in the diseases of infancy, are
      the expressions of the countenance—the gestures—the phenomena of
      sleep—the mode in which respiration is effected—the cry—the condi-
      tion of the tongue and mouth—the condition of the surface—the state
      of the breath—the evacuations.

                        1.—Of the Countenance,
        The infant's countenance offers to us the most interesting and the
      most intelligible page in nature's book. In its calm, we read the health
      and ease of all  the  organs,—of all the functions.  In  its smiles we
      read the happiness of body and of mind.  In  its  expressions  of un-
      easiness  or pain we first discover the invasion of disorder or disease.
      Our attention will probably be first attracted by some undefined change,
      which it will require a stricter observation to decipher, and associate
      with its peculiar cause.  (Hall.)
        Although  we cannot go  as far as does M. De  Jadelot, and assert
      that, from the movements of the infant's face, we may determine the
      location  of its diseases,  in one or other of the great splanchnic cavities
     —the disturbed expression of the upper part of the face, the forehead,
     eyes,  and brows, indicating disease of the brain, or of the nervous
     system ; the altered features of the middle portion of the face, particu-
     larly of the nose, being indicative of affections of the thoracic organs;
     while the expression  of the lower part of the face, the mouth and lips,
     point  to the abdominal region  as the seat of morbid  action; yet  we
     are convinced that from the condition of the countenance alone—often
     from some indescribable expression of suffering—the observing physi-
     cian will be able to detect, at  once, the  existence of disease, and  not
     unfrequently to determine its location.
       In most of the diseases of the alimentary canal, the face of the in-
     fant is pallid, and exhibits a very peculiar expression of fretfulness or
     peevishness—excepting when these diseases give rise to febrile reaction,
     during the exacerbations of which, the face  is more or less flushed.
     In many  of  the chronic affections of the digestive organs, especially
     when  attended with disease or functional derangement of the liver, the
     face and  surface generally acquire a dirty  brown, or  a  deep yellow
     hue.
       Great paleness of the face, if accompanied with diminished tempe-
     rature, or alternating suddenly with flushing  and  heat, is often  the
     indication of exhaustion; as  from profuse  diarrhoea: it is likewise
     frequently observed previously to the occurrence of convulsive attacks,
'   '  or of acute meningitis.
       In extreme cases of exhaustion, particularly from profuse evacua-
     tions from the bowels, as in protracted cases of cholera infantum, the
     cheeks are cold and pallid, and of a waxy appearance; the eyelids are
     half closed ; the pupil contracted; the eyeball  sunk in the socket, and
     rolled upwards, so as partially to conceal the  pupil beneath the upper
     eyelid ; the conjunctiva  is injected with dark-coloured blood;  the cor- 
        SEMEIOLOGY  OF INFANCY  AND CHILDHOOD.     127

nea covered with a thin film of mucus; and the orbitar circle is of a
livid or dark-brown colour.
  In the acute affections of the head, the face is usually flushed, some-
what turgid, and hot.
  In  affections  of the respiratory organs, the  face is generally of a
dusky red, and swollen; and in extensive hyperaemia of the lungs, the
lips and cheeks  are often of a deep livid hue.
  In hydrocephalus, the skin  of the face, and  especially of the fore-
head, is tense and shining.  The smooth and shining appearance of the
skin upon  the forehead, is also very generally  observed in protracted
cases of cholera infantum.
  Deep blueness of the countenance, in young children, is  indicative
of morbus coeruleanus, arising from an impediment to the free circula-
tion of the venous blood.  It usually exists from birth, and is increased
in intensity by any exertion of the body.
   A  sudden contraction of the countenance, especially if accompanied
by a sudden motion of the body, and a sharp scream, is generally the
indication of some sudden attack  of pain, usually of a  spasmodic
character.   If, at the same time, retraction of  the abdominal muscles,
drawing  up of the knees, or  a  sudden extension of the body takes
place, the pain is seated in some part of the alimentary canal.  In this
case there is also a whitish circle often observed about the mouth.
   When  the painful sensation comes on more gradually, and  is more
prolonged in its duration, the brows are corrugated, the upper lip is
stretched and elevated, and the nostrils become sharp and contracted.
 The contraction of the brows is  usually most marked in pain of the
 head ;  sharpness of the nostrils, in painful affections of the chest;  and
 drawing  up of the  upper lip, in abdominal pain.
   Upon the approach of convulsions, the upper lip  is often stretched
 firmly over  the  gums, and of a whitish or livid hue; there occurs  a
 slight divergence in the axes  of the eyes; there is an unusual upturn-
 ing of the eyeballs, or a singular rotation of the latter, upon their own
 axes; or a fixed staring condition of the eye, with a rapid contraction
 and  dilatation of the pupils;  there is often slight  twitchings of the
 muscles, on one or other side of the face, and a quick alternation of
flushing and pallor of the countenance.  All these appearances are not
observed to precede every convulsive attack; the occurrence, how-
 ever, of one or more of them  is sufficient to call attention to the gums,
 alimentary canal, or nervous  system, in order to detect  the source of
 irritation, that, by its removal, the threatened attack may be prevented.
   Whenever there exists any great impediment to the freedom of re-
 spiration, the nostrils are widely dilated during inspiration, and strongly
 contracted during expiration, the  mouth is held open, and the lips are
 often puckered, and always of a livid hue.
   In the more severe forms of gastro-intestinal inflammation, the mouth
is extended, the lips—often pale, dry, and cracked—are applied closely
to the teeth, and the chin has the  appearance of unusual projection.
   In chronic irritations of the bowels, the nose and upper lip are often
tumefied.  A peculiar puckering of the corners of the lips, is frequently 
128
DISEASES OF CHILDREN.
            observed to precede the occurrence of gangrene of the mouth in
            children.
              The countenance of infants that  have been subjected to an almost
            habitual use of opiates, has a peculiar  and striking appearance; the
            skin is of a sallow or dirty brown hue, and thrown into wrinkles, from
            the emaciation of all the soft parts beneath it;  the eyelids are red and
            tumid; the eyes dull and watery; the lips dry and pallid, and drawn,
            so as to  leave the mouth partially open, and the chin projecting.  The
            whole countenance presents, indeed, a faithful  miniature likeness of a
            sickly aged person.
              The eyes are usually prominent and suffused, their superficial blood-
            vessels being often  minutely injected with blood, in violent paroxysms
            of crying, and of cough, and in all affections of the respiratory organs,
            attended with  much difficulty of respiration,  as in croup, the more
            violent forms of bronchitis, hooping cough, &c.
              The pupil of the eye, in infancy, is usually dilated, during health,
            and it is often closely contracted during sleep, and rapidly dilates  upon
            the  child's  awaking.   The state of the pupil, however, varies fre-
            quently,  and it is only from its fixed or permanent dilatation, or con-
            traction, that the indications of disease are to be derived.
              In the course of  most diseases, the occurrence of a fixed dilatation
            or contraction of the pupil,  indicates the extension of irritation to the
            brain.
              In the early stage of  encephalic inflammation, the pupil  is,  in gene-
            ral, contracted, and, in the last stage, dilated, and  insensible to light.
              Occasionally the  form of the pupil is irregular; this has been ob-
            served by M. De Jadelot, in cases of intestinal irritation from worms.
              The sudden  occurrence  of strabismus, in  the course of disease, is
            usually an indication of the occurrence of some cerebral affection, and
            is then  always an  unfavourable  symptom.   Slight  irritation of the
            bowels, as from worms, indigestible food, &c, often gives rise, how-
            ever, to temporary  strabismus.

                                  %.—Of the Gestures.
              In infants, old enough to be attracted by surrounding objects  or to
            be played with and amused, the approach of disease is often marked
            by a total disregard of everything that  had previously pleased  them,
            and  an indisposition to motion of any kind; instead of being active
            and  playful when awake, they lie still and listless upon the nurse's lap,
         .   and  no efforts to attract their attention, or to excite a smile upon their
jtf^-C^^-fcountenance,  are successful.  The  cooing,  chgruping sound,  with
A&~^ /f"g  which they expressed their feeling of satisfaction or delight, gives place
£JliM<*A,  to perfect silence, or to a short querulous plaint when moved,  or when
            teased by the importunities  of those  around them.
              If  the  infant had already commenced to hold  up its head,  to sit
            alone, or to stand,  on the  approach of disease, there often occurs a
            degree of muscular debility, which prevents these attitudes from being
            continued, and the  position  assumed by the body and limbs is expres-
            sive of extreme languor.
              When in suffering, particularly in cases of intense abdominal  pain 
        SEMEIOLOGY OF  INFANCY AND CHILDHOOD.     129

the infant will often draw up its knees, and bend forward its body, or
throw about  its limbs  in  a wildly agitated manner; or, as we have
often observed, forcibly extend its  whole body, and  then suddenly
relax it.  When one Hmb is kept motionless, or moved with sudden
jerks, particularly if its motion excites the cries of the child, that limb
is generally the seat of pain.
   If, after an infant has commenced to walk, it is found to apply only
the  toes of one of the feet to the ground, and to exhibit a gradually
increasing limp in his gait, particularly if he complain of pain  in one
of the  knees, and exhibit uneasiness when  that limb is handled,  we
should  suspect the presence of articular inflammation of the hip.
   When a child is observed frequently to trip and stumble, in  walking,
or when as he moves hastily or unguardedly, his legs cross each other;
 when  he stands upright, his knees  totter and bend  under him, and
when seated, his legs  are crossed and drawn up under the seat;  par-
 ticularly if he exhibit, at the same time, great languor and listlessness,
 and complain of frequent pains and  twitchings in his thighs, we may
 suspect some disease of the  lower portion of the spine, probably ca-
 ries of the vertebrae.
   A frequent application of the  hands to the head, is, generally, an
 indication of suffering  in this part  of the body, the seat of which is
 to be detected by other symptoms.  A pulling at one of the ears,  and
 violent, often frequently repeated  scratching of the parts in its imme-
 diate vicinity, with frequent  moans,  or short acute  cries is, generally,
 indicative of otitis.  Rolling the head constantly from side to side, as
 it lies upon the pillow, or bending it forcibly backwards upon the spine,
 is usually an indication of cerebral  disease.
   Picking at, or frequently rubbing  the nose, is, usually, a symptom of
 irritation of the alimentary  canal;  it is a very common indication of
 the presence of worms.
    Convulsive movements of one or  other of the limbs, of the muscles
 of the  face, of one side of the body,  or of the  voluntary  muscles
 generally, may result from  irritation  or inflammation of the brain, or
 spinal  marrow; or they maybe  produced by an irritation seated in
 other organs, and transmitted to  the nervous centres. Convulsions are
 often the precursors of eruptive diseases.
    Contraction  of the fingers and toes, in consequence of which the
 first are forcibly flexed upon the palms of the hands, and, the latter,
 towards the soles of  the feet, whilst the  back part of the hands, and
 the upper surface of the feet, present a soft, puffy swelling, is an indi-
 cation of convulsions.  An opposite  condition, or when the fingers and
 toes are forcibly extended,  while  the first  are semiflexed  upon the
 metacarpus, and this, at times, upon the carpus, and in  the same man-
 ner, the toes, upon the metatarsus, is a common attendant upon laryn-
 gismus stridulus.
    As early as the  fifth or sixth day  subsequent to birth, infants are oc-
 casionally attacked by spasms of the muscles of the face, lower jaw,
 or neck, and, in severe cases, there is often a complete fixation of the
 jaw.   This  condition  has  been  attributed to retention of the meco-
 nium, or to inflammation of the vessels of the  cord :—it is more ge-
                                 9 
130                DISEASES OF CHILDREN.
 nerally, we suspect, produced by a confined and impure air, or certain
 conditions of the atmosphere, endemic to particular localities.
   During dentition, and from trifling irritations of the digestive canal,
 infants are frequently affected with slight  convulsive movements  of
 the muscles of the face, which give to the countenance an appearance
 of smiling.  This symptom is frequently the precursor of severe gene-
 ral convulsions.
   A rigid extension of the limbs with a turning inwards of the thumbs
 and great toes, is often  the precursor of a convulsive  attack.
   When, upon the  child being put to the breast, it sucks eagerly for a
 moment or two, and then suddenly ceases, throwing back the head
 with an expression  of anxiety in its countenance, it will, in general, be
 found that  it is labouring under some disease of the respiratory organs,
 as severe  bronchitis  or pneumonia. The  same  phenomena, with a
 rolling of the  head from  side to side, are often the precursors of an
 attack of convulsions.
   Sudden rejection of the breast after sucking for a few moments, the
 infant  at the  same time  exhibiting pain or uneasiness by its  cries
 and the movements of its body, is common in cases of coryza and  of
 inflammation of the throat,—it is often observed, also, in severe cases
 of stomatitis.
   Weakness or contraction of certain muscles, or partial paralysis,
 often marks the formation of tubercles in the brain.
   Partial paralysis, as  of one leg, is not, however, an  uncommon
 symptom, during  dentition and gastric  irritation.   Although  this, in
 some cases, is a serious symptom, yet, very generally, the paralysed
 limb, sooner or later, regains  its power.
   An uplifted step, or staggering gait, and a rocking of the legs, or a
 total inability to stand erect,  are indicative of serious disease of the
 brain or spinal marrow.   These symptoms are often the precursors of
 sudden serous effusions upon the brain.
   A sudden increase of  muscular activity in young children, with un-
 wonted exhilaration of  spirits, and liveliness  of manner,  denotes in-
 creased excitement  of the brain, and often precedes acute attacks of
 meningeal inflammation.
   Great restlessness,  and frequent  involuntary  movements  of the
 limbs, are, in general, when they occur  in  the course  of protracted
 maladies, unfavourable symptoms,  and depend  upon disease of some
portion of the brain.

             I—The  Phenomena during  Sleep.
   In a  healthy infant, sleep  is calm and  profound;  the  position is,
generally, upon the  side, with the limbs perfectly relaxed; the respira-
tion is full,  slow, regular, and quiet.  The eyelids  are never forcibly
closed,  and not unfrequently, are  slightly separated; the cornea  is
partially concealed  beneath the  upper lid, the ball of the  eye being
turned  upwards;  the pupil is often  greatly contracted.   The skin is
soft and cool.
   It is  not uncommon in the sleep of infants for imperfect respiration
to occur for a time, followed by  a deeper inspiration, or sigh,  to 
        SEMEIOLOGY  OF INFANCY  AND CHILDHOOD.     131

supply the  previous  deficiency in the function.  This  has  sometimes
been mistaken for an indication of disease; it is, however, a perfectly
healthy phenomenon, and results from the reduction of innervation that
occurs during sleep.  Cutaneous  transpiration  is  always increased
during the  period of sleep:—if the room in which the infant reposes,
is warm, or he is too warmly clad, or covered with  too  many bed-
clothes, profuse perspiration is liable to occur, particularly about the
head and neck.
  On awaking from  sleep, the healthy infant is lively and cheerful, and
quickly seeks the breast or calls for food.
  The younger the infant, the greater is the time passed in sleep; after
the first month or two, the intervals of waking  and  repose become
more regular, and  the  infant will,  very generally, fall  asleep  and
awake, very nearly  at stated hours.
  During sleep, the  countenance of the  infant will, by its expression,
often give  intimation of  the existence of uneasiness or pain, of which
no  indication is presented during  the period of wakefulness,—the
infant's attention being  then  diverted from slight  degrees of  bodily
suffering, by the various objects, and  sounds, that occupy its external
senses.
  The commencement of irritation in the bowels, or brain, may often
be  detected  by slight twitchings of the mouth and eyelids, or  by the
grinding of the teeth, that occur during sleep, when no symptom  is
manifested while the child is awake.
  In  the same manner, the approach  of disease  will be indicated by
frequent movements  of the body and limbs, and by sudden starts that
take place  during sleep.
  Sleeplessness, when  not the result of suffering, is usually caused by
a morbid excitability of the brain; it is often present during convales-
cence from acute affections.
  Sudden  starting  from sleep, with a wild,  alarmed  expression of
countenance, or without the child appearing,  for some time, to recol-
lect himself, or to recognise surrounding objects, is often  caused by
irritation of the alimentary canal, and may,  in many cases, be the
precursor of convulsions, or of acute  meningeal inflammation.
  Children often awake from sleep  in affright, and quickly burst into
tears; at other times, their sleep appears troubled, and, without  awak-
ing, the child sobs,  or utters  words  or indistinct sentences;  this is,
generally, produced by the occurrence of dreams, excited by intestinal
irritation, or  by the  presence  of too  much or improper food  in the
stomach.
  An unusual degree of  somnolency,  in general indicates  hyperaemia
of the brain; it is sometimes  observed during teething, or when the
stomach is  overloaded with food.
  Deep soporose  sleep, or coma, always indicates serious  disease of
the  brain;  and, when it occurs in the  course of acute diseases, or sud-
denly supervenes after protracted  illness, is to be viewed as an un-
favourable  symptom.
  Short, disturbed sleep, the infant, on awaking, being fretful, peevish 
 132                DISEASES OF  CHILDREN.

 or morose, is, very generally, an indication of disease of the  alimen-
 tary canal.

                          L — The  Cry.
  Crying is the natural language by which the infant  expresses its
 wants and sufferings.   During health, an infant, properly nursed, cries
 but seldom, and never exhibits violent and repeated  paroxysms of cry-
 ing, or the continued plaintive cry of distress.
  In  new-born infants,  loud  and vigorous crying  is  always an  un-
 equivocal sign of  health and  vigour;  and is, doubtless,  produced by
 the impression upon the body,  of the  various novel stimuli to which it
 has become suddenly subjected.   After the sentient  surfaces have  be-
 come accustomed  to  these, the infant's cries proceed  from  some
 want, from  uneasy sensations or pain, accidentally induced, or from
 disease.
  Violent paroxysms of crying are usually the result of intense pain;
 occasionally, however, they are the expression merely of passion ; and,
 when this is the case, the child will often suspend its breath for  some
 time,  and the face will  become livid  from the interruption of the  cir-
 culation through the lungs.
  Violent and prolonged fits of crying, from whatever cause they re-
 sult, are  always injurious, and in some  instances,  have been imme-
 diately succeeded by an attack of convulsions.
  A fretfulness of disposition and frequent crying,  may  be produced
 from the child being continually vexed and teased by its nurse, without
 the actual presence of pain or disease.
  Violent and frequently repeated  crying, or  shrill and  piercing
 screams, are the  indications of acute pain; and are, hence, observed
 to occur in most of the inflammatory affections  to  which infants  are
 liable, especially in their early and  acute stages.  In inflammation of
 the gums, the cry will be more or less protracted; while  in inflamma-
 tion of the chest and abdomen, the increase of suffering to which they
 give rise, will induce the  child,  as  much as  possible, to  control its
 cries, the cry becomes  then sudden, short, and at intervals.   In severe
 pain of the head, as in the acute stage of meningeal inflammation, the
 cry is often a short, piercing scream, occurring at intervals. The same
 is the case also in  spasmodic pains of the alimentary canal.
  To the seat of the pain, we will be directed by the local  symptoms.
 Intolerance of light, contraction of the brows, and tossing of the head,
 with,  often, increased heat  of the latter, will point to  the brain as its
 seat.  A quick, panting, or difficult respiration, rapid contraction  and
 dilatation  of the nostrils, and cough, to the lungs;  constipation, .diar-
 rhoea, or vomiting,—tenderness on pressure, and increased heat of the
 abdomen, to the alimentary canal; and loud, crowing, and difficult re-
 spiration, to the larynx.
  When the cry  is hoarse or husky, it is an  indication of effusion
 within the bronchi, preventing the free passage of the air to the glottis,
 or of inflammation and thickening of the  mucous  membrane of  the
fauces, larynx, or trachea.
  When the cry has a nasal sound, there is inflammation or  enlarge- 
        SEMEIOLOGY OF  INFANCY AND CHILDHOOD.     133

ment of the tonsils, inflammation and thickening of the Schneiderian
membrane, or a polypous tumour at the posterior nares.
   A  peculiar ringing  sound of the  cry is often  the first  indication of
an impending attack of croup, or of laryngismus stridulus.
   When the  cry is scarcely audible, and accompanied  with  a low,
sibilant prolongation, there in general exists some disease of the glottis.
   Fretfulness, or peevishness, when  habitual, or  occurring in children
who  had  previously exhibited a lively and  cheerful disposition, may
either be the indication of uneasy sensations, resulting from the action
of a variety of irritating causes, and the consequent impairment of the
general health of  the system; of some chronic irritation, seated, most
commonly, in the  alimentary canal, or of the invasion of acute disease.
Habitual fretfulness, or its sudden occurrence, should, therefore, never
be overlooked.
   A  low, moaning cry is, in the infant, invariably an important and
alarming  symptom of disease.   In acute affections, the moaning is
continued at each expiration.   During painful dentition, the  infant is
often  heard to moan, and grind its teeth at  intervals.  Moaning is
particularly characteristic of painful diseases of  the alimentary canal.
When it  occurs  after violent  excitement,  accompanied with acute
screams, and is attended with stupor, it is an unfavourable symptom,
indicating, in  general, the early occurrence  of effusion from  cerebral
disease.

                        5. —Respiration.
   In  the healthy  infant, respiration is full,  regular, and quiet;  more
frequent  than in  the  adult, and performed almost exclusively  by the
movement of the ribs.
   Difficult and loud  respiration is present in all the diseases  of  the
pulmonary apparatus.   In affections of the  larynx, glottis, and upper
portion of the  trachea, inspiration is performed  with difficulty; while
in diseases of the  bronchi, the difficulty is experienced in  expiration.
   When the  difficulty  of  respiration gradually augments in intensity,
it  is an unfavourable indication  in all  affections  of the lungs.  Respi-
ration often becomes  irregular,  and occasionally intermittent, in  the
course of pneumonia,  and in affections of the brain this is always an
unfavourable symptom.
   In pleurisy and  peritonitis, inspiration is rendered short and difficult
from  the increase  of pain to  which it gives rise.
   Difficult  respiration, attended with heaving of the upper portion of
the chest, elevation of  the shoulders, violent  exertion of the muscles of
the neck, or rapid  motions of the mouth and  nostrils, is attendant upon
serious disease of the thoracic viscera, and is usually the  indication of
an unfavourable result.
   In the healthy respiration of the infant, no sound is heard unless  the
ear is applied to the chest; it is hoarse in bronchial inflammations; it
is  sibilant in affections of  the larynx, glottis,  and  upper portion  of  the
trachea;  and presents  a sighing sound in hyperaemia of the lungs, and
in  cases  of exhaustion, or debility of the respiratory muscles.  The 
134
DISEASES  OF CHILDREN.
sighing sound is an unfavourable indication in acute affections of the
brain.
  The respiration is very quick and panting in most febrile affections,
during the exacerbation;  when rare, there in general exists debility of
the  muscles of respiration;  a quick and rare respiration exists in pleu-
ritis, or it may occur  from exhaustion, from violent  exertion of the
respiratory muscles;  it is also  present in pneumonia, chronic bronchi-
tis,  or pleuritic  effusions.
  The indications derived from auscultation and percussion are nearly
the  same in children as in  adults, and need not, therefore, be noticed
here.   The respiratory murmur—puerile  respiration—being remarka-
bly  loud over every part of the chest in infancy, is not, as in the adult,
so important an indication of disease.  It is diminished in intensity in
inflammation of the bronchial  ramifications, and entirely absent in in-
duration of the lungs, and in pleuritis.
  Cough may result  from disease of some portion of the  respiratory
apparatus, or it may be caused by irritation transmitted to  the respira-
tory organs  from the alimentary canal, or from disease of the brain.
In the first case, it is generally attended with mucous expectoration;
in the  second, it is usually dry and irritative;  and in the last, spas-
modic.
  A short, hacking cough, with little expectoration, is present in pleu-
risy, and  in the  incipient  stage of tubercular phthisis.   Continued
cough accompanies inflammations of the larynx, trachea, bronchi,  and
lungs.  Intermittent cough  is  a symptom of croup, laryngismus stri-
dulus, and hooping cough.
  In the commencement of inflammation of the respiratory  organs
the  cough is dry, but is soon  accompanied with  expectoration when
the  disease is seated  in the mucous membrane; but in pneumonic in-
flammation it continues longer dry, and  the expectoration is seldom
copious.
  In catarrhal affections, the cough is hoarse; in croup, it  has a pecu-
liar barking, or crowing sound; in hooping  cough, a loud shrieking
sound; and  in the early stage of bronchial inflammation, previous to
the  occurrence of effusion within thei>ronchi, it has a whizzing sound,
without hoarseness.
  Sneezing may arise from any accidental irritation of the Schneide-
rian membrane, or from irritation transmitted  to  this part from the
alimentary canal.  It is one of the prominent symptoms of coryza in
children, arising then from  the increased  irritability of  the nasal mu-
cous membrane, consequent upon inflammation.
  Hiccup is a frequent symptom in children of slight irritations of the
alimentary canal;  it  may arise also from  cerebral irritation, and be
then a precursor of convulsions.  When occurring in  the course of
inflammatory affections of  the bowels, peritoneum, or brain,  it is in
general an unfavourable symptom.

                  6.—The Tongue  and Mouth.
  In the infant, during health, the tongue is moist, smooth, and gene-
rally covered, in  its middle and towards  its root, with a thin coating 
         SEMEIOLOGY OF INFANCY AND CHILDHOOD.     135

 of whitish mucus.  The mouth is always moist and of a palish hue,
 and the gums of a bright red.
   When the tongue is loaded with a white curdy matter, disturbance
 of the digestive process, or slight  irritation of the alimentary canal, is
 generally present.
   Increased redness, heat, and dryness of the tongue and parietes of
 the  mouth, indicate the first stage of stomatitis, and often accompany
 inflammations of the alimentary canal.
   Small white points, or patches,  dispersed over the tongue, and pari-
 etes of the mouth, are the result of inflammation of the epithelium of
 these parts, and are usually symptomatic of disease of the stomach or
 bowels.  As  a local affection,  this condition  of the tongue may  be
 produced by confined and impure air, want of cleanliness, &c.
   Aphthse of the tongue and mouth, are the result of follicular inflam-
 mation ; they may depend upon improper food and vitiated or con-
 fined air; or they may be developed by dentition, or be  symptomatic
 of disease of the alimentary canal.
   A pale, flabby tongue, is  the indication of great debility  or exhaus-
 tion.  Redness of the tongue is  symptomatic  of acute  inflammations
 of the gastro-intestinal mucous membrane.
   In scarlatina, the papillae of the  tongue become enlarged and pro-
 minent, presenting numerous red points—the  tongue itself is also red,
 and the throat covered with efflorescence.
   Swelling of the tongue occurs in scarlatina, measles,  croup, laryn-
 gitis, and small-pox, and is usually an unfavourable indication.
   In febrile diseases, and in most of the affections  of the alimentary
 canal, the tongue is covered with a whitish coat.  In protracted irri-
 tations of the bowels, the coating of the tongue generally assumes a
 dirty yellow or brownish colour.
   Increased secretion of saliva occurs  immediately preceding, and
 during the process of dentition, and in the course of stomatitis, it is also
 a common precursor of the  gangrenous affection of the mouth in chil-
 dren.
   A diminished secretion of saliva takes place  in most  of the acute
 and febrile affections that occur during childhood.   Great dryness of
 the mouth, with constant thirst, occurring in the course  of acute dis-
 eases, is generally unfavourable.
   Increased heat and redness, with swelling of the gums, occurs  at
 the period of dentition.  A dark, red, and tumid state of the gums,
 generally precedes the occurrence  of gangrene of these parts.
   Increased redness of the  throat occurs in scarlatina,  measles, and
 small-pox, in inflammations of the tonsils and  larynx, as  well  as  in
 chronic inflammations of the digestive and respiratory organs.

                     7. —Of the Surface.
   In infancy, the skin, during health, is soft, moist, and cool, and uni-
formly distended, from the large amount  of soft, cellular  tissue, and
subcutaneous adipose matter.
   Whenever it becomes harsh, dry, and hot, or flabby and wrinkled, 
136
DISEASES OF CHILDREN.
it is an indication of the existence of more or less extensive disease, in
one or other of the organs.
  A hot, and dry skin, is common in all  the febrile and  acute  affec-
tions of infancy; the heat is not, however,  always diffused  over  the
entire surface, but is often greater in one region than in the others;
thus, in inflammatory affections of the brain, the heat of the head is
increased, while the rest of the body may be of its normal  tempera-
ture, or the  lower extremities  even  cold; in  inflammations of  the
abdominal organs, the  increased  heat will often  be  confined to  the
epigastric, umbilical, or hypogastric regions, or to  the surface of the
abdomen generally.   A dry, burning feel  of the  palms of the hands, is
often attendant upon disturbance of  the digestive function, irritations
of the alimentary canal, or  irritation  of the  lungs  connected with
tubercles.
  A uniform redness,  or rosy hue of the surface, is the indication of
health  in infancy;  when, however, the lymphatic temperament is
strongly marked, the skin, particularly of the face, may be pallid and
puffy, without the existence of positive disease.  Such a condition  of
the  skin, should, however, be always a warning  for additional precau-
tions in  the hygienic management of the child, lest a scrofulous condi-
tion of the lymphatic glands,  or tubercular depositions occur.  This
state of the skin is common in children who are  too much  confined
within doors, or who  are  exposed to a  damp, stagnant, or impure
atmosphere, or fed upon food deficient in nutrition, or of a bad quality:
it occasionally presents itself when, after scarlatina, and some other
diseases, effusion, more or less extensive, takes place in  the cellular
tissue.
  Increased redness of the surface, is either an  indication of inflam-
matory  or eruptive diseases of the skin, or it may result  from febrile
excitement,  or acute  inflammations of  internal organs.   Thus,  in
inflammation of the  brain,  the face  becomes flushed; and in certain
diseases of the lungs and digestive organs, a circumscribed redness of
the  cheeks is not unfrequently observed.
  Intense redness of the skin in  children,  we have  known to be pro-
duced, in many instances,  by  certain articles of diet, and  to cease  the
moment these were  discharged from the stomach by spontaneous  vo-
miting, or by the operation of an emetic.
  An alternate paleness and flushing of the face,  is common in me-
ningeal  inflammation.
  Intense blueness of the skin is observed in certain cases of malfor-
mation of the heart; or it may arise  from  any cause  which  prevents
the  oxygenation of the blood in the function of respiration.
  Yellowness of the skin is usually connected with irritations of the
alimentary canal, or with some  affection of the  liver, in  consequence
of which the serum  of the blood becomes  surcharged with the colour-
ing matter of the bile; in this case, the adnata of the eye  exhibits  the
same yellow hue as the surface  of the body.
  In very young infants, however, yellowness of skin is  occasionally
produced by an unusual yellow  colour of the serum, and in such cases
is seldom a symptom of much importance. 
        SEMEIOLOGY  OF INFANCY  AND CHILDHOOD.     137

   In protracted diseases of the alimentary canal—chronic diarrhoea,
cholera infantum, &c.—the skin assumes a sallow, dirty yellow, or
brownish hue.
   The fulness and tension of the surface  is increased from hyperaemia
of the cutis  and subcutaneous tissues, in eruptive fevers, and in local
cuticular inflammations.  In hyperaemia and inflammation of the brain,
the integuments  of the face are very generally increased in fulness
and tension.   Tension of the integuments of one cheek, accompanied,
at first, with increased redness, and subsequently with a shining white-
ness, is an indication of one of the most common varieties of gangrene
of the mouth.
   Tension of the abdominal integuments, when accompanied by ten-
derness, is an indication of inflammation of the  abdominal viscera,
particularly of the alimentary canal; when unaccompanied by tender-
ness, it may  be produced by the formation of gas within the intestines,
or by effusion within the peritoneum.
   General or  local  tension of the surface of the body, may be  pro-
duced by the effusion  of serum within the  cellular  membrane gene-
rally, as in anasarca, or in some particular portion of it, as in oedema;
it is then distinguished by the diminished temperature of  the surface,
wherever the effusion occurs; by the pitting upon  pressure, and by
the paleness of the skin.
   A reduction of the fulness and tension of the skin, may be produced
by the action of  cold, or by deficient food, or it may result from ema-
ciation, resulting from protracted disease.  In serous  diarrhoea, and
the cholera of infants, it often occurs with great rapidity.
   Perspiration is readily excited in children;—during, or immediately
succeeding a violent attack of coughing, of convulsive paroxysms, and
of intense pain of the bowels, it is a common occurrence for a copious
perspiration  to break out about the head and face.  A general mois-
ture of the surface, occurring in acute diseases, with an abatement of
their respective symptoms, is, in general, a favourable indication; but
when the perspiration is local, being confined to the head and face, or
to the extremities, it is, in general, an unfavourable symptom.  A cold,
profuse perspiration, with sunken  eyes, a  livid hue of the countenance,
and  short, slow, imperfect respiration, is a sign of great  prostration,
and is always an unfavourable occurrence.
   The natural odour of the sweat in young  children is acid; in the
miliary eruption,  the acidity is very decided.  In  particular forms of
cutaneous eruption, the sweat presents  a  very peculiar  and character-
istic odour.
   Many of the cutaneous eruptions  are  indicative of disease of the
alimentary canal, and other organs,  or  they may depend on simple
derangement of the digestive  process.   Thus the several species of
strophulus, prurigo, urticaria, and erythema, result,  in  general,  from
improper, or too much food, an unwholesome condition of the mother's
or nurse's milk,  acid food or drinks; from  certain articles of food
eaten  at improper seasons,  as  fish;  from food of too stimulating  a
character; and, in certain constitutions, or in particular conditions of
the stomach, from articles of food not generally esteemed  unwhole- 
138
DISEASES  OF CHILDREN.
some, as  strawberries,  honey, &c.   Many of these eruptions  are
attendant upon the process of dentition.
  Herpetic and erythematous eruptions, and pemphigus, are very ge-
nerally connected with disease, either acute or chronic, of the diges-
tive organs.  The occurrence of ecthyma is often favourable in the
acute affections of the intestinal canal; and herpes labialis in all febrile
and acute diseases.  Minute vesicular eruptions occur in chronic diar-
rhoea, and in protracted cases of cholera  infantum.  Petechiae  are
common in many of the intestinal diseases of children; they are usually
an unfavourable  symptom.
  Roseola may  arise  from irritation of the digestive tube, or it may
occur in the course of catarrhal and other complaints.
  Itching  and prickling of the skin are produced by gastric derange-
ments or intestinal irritation.  Itching of the nose is a common symp-
tom of intestinal  worms, and itching of the orifice of the rectum of the
presence of oxyures.  An itching and tingling of the skin often precede
the occurrence of exanthematous diseases.

                        8.—The  Breath.
  The breath of a young infant has often the smell of the breast-milk;
occasionally its smell  is slightly sour;  it is generally, however, during
the entire  period of infancy and childhood, destitute of any  peculiar or
very decided odour.
  Every marked change in the odour of the breath is the indication
of disease  of the  mouth, nostrils, or digestive apparatus ; or of disturb-
ance of the digestive function.
  When the breath of an infant is decidedly acid, it is usually in con-
sequence of imperfect  digestion of the food, and hence the  occurrence
of an acid breath is generally accompanied, sooner or later, with diar-
rhoea or colic.
  In the diseases of the alimentary canal, and in the febrile affections
of children generally, the breath has a peculiar smell, difficult to de-
scribe, but when once observed, always readily recognised.
  A foetid state of the  breath may arise from indigestion, from disease
of the alimentary canal,  from ulcerations of the  nose,  mouth and
throat, and from gangrene of the gums or cheek.  It is present, also,
in small-pox, and the latter stages of the more violent forms of scarla-
tina anginosa.
  A rancid smell of the breath is, ordinarily, the result of  indigestion,
from overloading the stomach with animal food.

           9.—Discharges  by Vomiting and  Stool.
  Infants  at the breast often vomit from mere repletion of the stomach
with milk; a greater  amount being  sucked than the stomach can di-
gest.  The vomiting,  in this case, is beneficial, and is favoured by the
peculiar position and structure of the stomach, during the first months
of existence.  The milk  thrown up is unchanged, or partially coagu-
lated.
  Vomiting,  however, may be induced  by some disturbance of the
digestive  process; the milk discharged, in this case, being decidedly 
        SEMEIOLOGY  OF INFANCY  AND CHILDHOOD.     139

acid.  Repeated vomiting is, in general, however, an indication of dis-
ease of the alimentary canal, and is often accompanied with purging.
   In  certain cases the caseous portion of the milk is  retained in the
stomach, undigested, in the form of a hard, tenacious coagulum;  and
gives rise  often, to gastrodynia, colic, and even  convulsions; when
discharged by vomiting, an  almost immediate relief of  all  the  unplea-
sant symptoms induced by its presence in the stomach is experienced.
   Almost  incessant vomiting,  increased  upon anything being taken
into the stomach, the discharges being decidedly acid,  and often of a
green colour, is a symptom  of gastro-malacia, or that form of stoma-
chic  disease  of children, terminating in a gelatiniform softening of the
coats of the stomach.
   Vomiting occasionally attends the process of dentition ; it very gene-
rally ushers in an attack of scarlatina,  and not unfrequently terminates
the violent paroxysms of spasmodic cough, in severe cases  of pertussis.
   Vomiting, attended with increased bilious discharges from the bow-
els, is common  in  infants during the heat of summer, particularly at
the period of weaning, or during dentition:—when violent and pro-
tracted, and accompanied by  repeated—almost constant discharges
of a  yellowish or  colourless fluid, from the bowels, it constitutes the
cholera infantum.
   Frequent vomiting, attended with gradual, sometimes rapid, emacia-
tion,  is  common in  infants who are deprived at an  early period, of the
breast,  and attempted to be  reared upon other food.
   Vomiting  is  occasionally symptomatic of diseases of the brain,  and
is often one of the indications of incipient hydrocephalus.
   In  early infancy, repeated evacuations from the bowels occur in the
course of the day; and during the whole period of infancy and child-
hood, the  evacuations  from the bowels are much more frequent than
in after life.   Increased evacuations, are then also, in general, much
more readily produced from trifling errors in diet, and slight degrees
of irritation of the intestinal  mucous membrane.  The period of teeth-
ing is very generally  accompanied by increased discharges  of thin
mucus from the bowels.
   Diarrhoea in  children may arise from improper, or too  much food,
the irritation of teething, irritation or inflammation of the intestinal
canal, the  action of cold, and  from increased acid secretions in  the
stomach, the effect of functional derangement or disease of that organ.
When profuse or long continued, it often proves fatal by the great ex-
haustion produced.
   Immediately  after birth, the discharges from the bowels are of a
very dark  green or black colour—the m-e^ornum.  During the early/H'V^^
period of infancy, the discharges are of a soft, curdy consistence ana^C^^-cc
appearance, occasionally tinged with bile  and without foetor;  during,^-w^v/t
the remainder of infancy and  childhood, they are  more or less soft,
and of a yellow or light brownish hue.
   Frothy, acid discharges from the bowels, of a light yellow, or slightly
green colour, indicate  a  disturbance of the digestive function; gene-
rally from over-feeding or improper food.
   Discharges of slimy mucus occur in irritations of the bowels, from 
  140                DISEASES OF CHILDREN.

  worms or teething;  or in  consequence of an increase of the mucous
  exhalation from the  follicles of the intestines, caused by the impression
  of cold upon the surface.
    Repeated  discharges of viscid  mucus, occasionally streaked  with
  blood ; or of a greenish fluid, mixed with small masses resembling the
  curd of milk, are frequent in  most of the inflammatory affections of
  the bowels.
    Profuse and frequent discharges of thin  or frothy fluid, nearly co-
  lourless, and devoid of foetor, mark the occurrence of cholera infantum.
    A deep green colour of the stools, the discharges resembling chopped
  grass  or spinage, is generally a  symptom of serious disease of the
  stomach or  intestines, and is  a striking feature in gastro-malacia, and
  the  more acute grades of gastro-intestinal inflammation.
    In chronic diarrhoea the stools are thin, dark brown, and often in-
  tolerably foetid.
    In cases of worms, and in certain cases of intestinal irritation  from
  other causes, the discharges from the bowels consist occasionally of a
  slimy  fluid of a whitish colour, resembling milk.
    Light brown or clay-coloured stools, are, in general, the indication
  of hepatic disease, attended with a diminished secretion of bile.
    Worms are occasionally passed with the stools, during  the latter
  period of infancy, and in childhood,  without any  symptoms  having
  been present to indicate their existence.
    A diminution in the number of stools, when diarrhoea  occurs as a
  symptom of the  diseases of children, with  a return  to the ordinary
  healthy condition in the colour and consistence of the discharges, is a
  favourable symptom.
    The appearance of natural faeces in cases of dysentery, and of bile
  in the discharges in infantine cholera, is a favourable indication.
    Blood  is occasionally observed  in  the discharges of  children, in
  hyperaemia,  irritation and  inflammation  of the mucous membrane;  it
  is generally mixed with mucus or faecal matter, and  never occurs in
  any great quantity.
    The passage from the  bowels of the  substances taken as food, en-
  tirely  unchanged, or  but  little altered,  is an indication  of excessive
  irritability of the alimentary canal; it occurs occasionally in inflam-
  mations of the stomach and  bowels, but more frequently in protracted
  cases  of cholera infantum, and chronic diarrhoea.
    Constipation is not unfrequent in the early stages of infancy, and  in
  many cases  appears to be constitutional, and in others to depend upon
  the quality of the mother's milk. We have frequently known in a young
'•infant  several days to pass, and no  evacuation, by  stool, to occur,
  without,  apparently, any  inconvenience resulting,  but when, finally,
 , the desire to discharge the contents of the bowels occurred, the violent
  straining, and the  pain attendant upon the passage of dry, hardened
  masses of  fasces, were particularly  distressing to the little  patient.
  Constipation should, therefore, never be overlooked, as  it may be the
  means of inducing  violent colic, invagination, or inflammation of the
  intestines.
    Constipation often  exists  in the early period of  many of the  acute 
        SEMEIOLOGY OF INFANCY  AND CHILDHOOD.     J4J

affections of infancy, particularly of the head and chest;  it may arise,
in some  cases, from functional derangement or disease  of the liver,
preventing the  free secretion of  bile.   Constipation is,  not  unfre-
quently, induced  in infants  and young children, by the imprudent use
of opiates.
   In very young infants, the retention of the meconium occasionally
gives rise  to a deep comatose condition, terminating, if not speedily
relieved, in asphyxia and death, while in other cases partial or general
convulsions have been  known to arise from this cause.

                   10. — The  Urinary Discharge.
   The condition of the  urine, during infancy and childhood,  affords
but little  important aid in  the diagnosis  of the seat or  character of
morbid action.  In most of the  acute febrile affections the urine is
high-coloured and  scanty, and its  passage  often  attended with some
degree of pain.   It is often  white in intestinal  irritation from the pre-
sence of worms, and in hydrocephalus.
   In irritation of the gastro-intestinal mucous membrane, it is frequently
of a bright yellow or deep orange hue.
   Incontinence of urine is frequent in children  at all ages.   It  may
simply depend upon the extreme  irritability which the mucous mem-
brane of the bladder possesses during infancy; from an  augmented
secretion of  serous urine,  in consequence  of a  derangement  of the
renal function, or from neglect on  the part  of the child  of the sensa-
tions incident to the natural call  to urinate, in consequence of which,
the command of the will over  the  action of the bladder and its sphinc-
ter is lost.  It occasionally results from irritations  seated in the lower
portion of the intestinal canal; and in some  cases, from disease of the
brain or spinal marrow.
   An excessive amount of limpid, watery urine  is  often voided by
infants and children, and is  indicative  of  a disordered state  of the
digestive function from improper  food; it often occurs at the period of
weaning, and is occasionally attendant upon dentition. The increased
flow of urine in children is  said to  be, occasionally, diabetic.
   When pain and difficulty  are experienced in urinating, it is  indica-
tive of inflammation of the kidneys,  neck of the bladder, or urethra;
or of calculous concretions in the ureters, bladder, or urethra.   It  may
originate, however, from irritations  seated  in  the rectum, or of the
digestive organs generally.
   In young children, scanty and painful urination occurs from disease
of the kidneys, connected, most generally, with long-continued intes-
tinal disease, or with some affection of the brain.  In these cases, the
urine is  passed only in small quantities, and is usually high-coloured,
and stains the linen yellow.
   Retention  of urine is occasionally present during difficult dentition.
In very young infants it is sometimes produced by some peculiarity of
the mother's milk.  We have known it, also,  to be a symptom of
worms in the rectum.
   Scanty urine occurring towards  the decline of scarlatina, and other 
142                 DISEASES OF CHILDREN.

acute exanthemata, is in general connected with dropsical effusion
within the abdomen or in the cellular  tissue.

                         11.—The Bones.
  A premature, or very rapid development, in the longitudinal dimen-
sion, of the  long bones, particularly, if, at the same time, there is not
a correspondent but rather a deficient development  in the dimensions
of the chest, very generally indicates a predisposition to tubercular
disease of the lungs.
  A rapid increase of the osseous structure in length, is a very fre-
quent occurrence, towards  the decline or immediately after fevers,
especially the febrile exanthemata. With this direction of the nutri-
tive  process, the development of rachitis  and tubercles, so generally
consequent upon rapid growth, would  seem to be connected.  (Schill.)
  Curvatures of the long bones of the lower extremities, are often the
result of too early attempts to induce  the child to walk;  of a bending
or imperfect fracture of the bones from  violence;  this occasionally
occurs in the upper extremities, from  imprudently lifting an infant by
the arms.   Curvature of the bones, is  also one  of  the symptoms of
rickets.
  Curvatures of the spinal column in young infants, are sometimes the
result of placing them too early in the sitting posture; in children  they
may arise from debility of the spinal muscles, or disturbed equilibrium
in their action,  the  result of improper positions of the body, too  long
continued, and defective  exercise.  Curvature of the spine is,  also, the
effect of rickets, and of caries of the vertebrae.
  Lengthening of one of the lower extremities, exists as a symptom of
the second stage, and a shortening of  the extremity, of the third stage
of hip disease.
  Enlargement of the articular extremities of the long bones is com-
mon in scrofula and rickets.  Enlargements of the larger joints occur
sometimes after the acute exanthemata, or upon  the sudden repulsion
of chronic eruptions.
  Excessive development of the  skull, is  a symptom of hypertrophy
of the brain; it also takes place in  chronic hydrocephalus, and in
rickets.  In idiocy there is commonly a very decided diminution in the
development of the  skull.
  A diminished development in the capacity of the chest, or a flatten-
ing of the ribs  at  the sides, with undue projection of the sternum, is
common in  children predisposed to tubercular disease of the lungs. 
THE DISEASES OF CHILDREN.





         PART II. 
 
A  PRACTICAL  TREATISE
THE  DISEASES  OF  CHILDREN.
               SECTION  I.

DISEASES  OF  THE  DIGESTIVE ORGANS.
     CHAPTER I.

DISEASES OF THE MOUTH.
         STOMATITIS.—INFLAMMATION OF THE MOUTH.
        A*
           fe4/sf 1.  Erythematic Stomatitis.

    rythematic i nnam m ationof me mucous  membrane of the mouth
is a common disease during infancy.  The inflammation may be con-
fined to the tongue, or to a portion of the parietes of the  mouth; or
it may be universally diffused  over the entire cavity.   It varies in in-
tensity in different cases—in  some, being so slight as scarcely to at-
tract the attention of the child's attendants, and disappearing promptly
—while  in others it  assumes  a considerable  degree of severity, and
causes severe  suffering  to the little patient for many days or weeks,
and by extending to the  oesophagus and  stomach, or  into the larynx
and trachea, it may prove finally fatal.
  Simple erythematic inflammation of the mouth is characterized by
increased heat and redness of a part or of the whole of the  parietes
of the  mouth and surface of the tongue, accompanied with  more or
less dryness of the parts affected.   The sensibility of the  inflamed
membrane  is increased,  and pa^l^is experienced by the infant, when
any part of the mouth is touched, and in the motions of the tongue
and lips in the  act of sucking.
  The first indications of the  disease are, in general, the fretfulness
and restlessness manifested by  the infant;  its suddenly quitting the nip-
ple after sucking for a  few moments—or,  when fed by the hand, refu-
sing its food, and crying  when  this  is attempted to be forced upon it.
  When the inflammation extends over the whole surface of the mouth,
it often spreads, also, to the lips, which tumefy, excoriate, and cjack,
and not unfrequently become affected with herpes.  f^> ##/,. /^/c/fy^ ***•/{.
                              10 
146
DISEASES OF CHILDREN.
  In very young infants, the  disease is  seldom attended with  febrile
reaction;  but when it occurs  about the period of dentition, it  is fre-
quently accompanied by some degree of fever, and when of any dura-
tion, it is then often attended also by profuse ptyalism.
  Simple erythematic stomatitis may occur as an  idiopathic affection,
or it may be symptomatic of  a diseased  condition of the  alimentary
canal.  In  the first case it may be produced by exposure  to cold, by
too  hot or stimulating food, by the violent exertions of the  tongue and
muscles of the mouth, in attempting to  derive nourishment from an
over-distended breast, or from a too small or badly formed nipple, or,
finally, it may result from the  irritation of the mouth consequent upon
dentition.
  In its simplest form, erythematic stomatitis is seldom a very violent
or obstinate disease, and is very promptly relieved by simple emollient
washes, as a solution of the pith of sassafras or of the  inner bark of
the  slippery elm, in cold water.  When  marked by a greater degree
of severity, it may be necessary to apply a leech or two at the angle
of the jaws.  In aggravated cases of the disease, we have derived ad-
vantage from washing the parts affected with a weak solution of  ace-
tate of lead in water.  (Three grains of the  acetate of lead to one
fluid ounce of water.)
  When  the inflammation of the mouth is symptomatic of irritation
or inflammation of the  alimentary canal, it will, in general, yield to
the operation of the remedies adapted for the removal of tk&^atter.*

    %.—Erythematic  Stomatitis with ^iird-lii^m™Bift!jl\
  A common result of erythematic stomatitis isthe secretion" or a white
matter, which appears, usually, in the form of small points  or patches,
resembling minute portions of curd, adhering to the surface of the in-
flamed membrane; this is particularly the case in infants at the breast.
It constitutes the muguet of the French writers, the thrush or children's
sore mouth, of nurses; and the aphtha lactumina and aphthae infantiles
of the older physicians.
  This form of erythematic  stomatitis is among the most  common of
the affections incident to the early stage  of infancy, and many nurses
are under the impression, that if it does not occur within  the  month,
the infant is rendered liable at a later period to some  other form of
disease, which it  might have escaped, had it gone through " the sore
mouth," at the proper age.
  By most pathologists, the  affection under consideration has  been
confounded with aphthae;—from thtifatter it differs,however,in many
important particulars.
  Its occurrence is most commonly confined to the period of suckling.
In many cases, it is preceded by no very striking  symptoms.  The in-
fant is, however, generally peevish and  fretful, and exhibits more or
less pain and difficulty in sucking, and often  abruptly quits its hold of
the nipple, or cries when attempted to be  applied to it, or to be fed with
artificial food.  Occasionally there is considerable languor, or  even
drowsiness, and. not unfrequently,  more or less disturbance of the sto-
mTrch ahd, bowel*.  If the  mouth be now examined, the whole of its 
            DISEASES OF THE  DIGESTIVE ORGANS         147

cavity will be found red, hot, and  preternaturally dry.  After a day or
two, sometimes within  a few hours, small white points make their ap-
pearance  at  the  extremity, or  on the  sides of the tongue, or  at the
angles  and on  the inner surface  of the lips.  These points have the
appearance of minute  fragments of curd, adhering to  the  parts men-
tioned, which latter are of a dark-red colour, hot and dry.
  In mild cases, the inflammation, in  a short  time, disappears; the
particles of white curdy matter become detached, and fall off, leaving
the membrane beneath of a smooth and healthy appearance.
  If the inflammation  continues unabated, the points of curdy  matter
increase in number, and often  extend  over  the whole surface of the
tongue and mouth, or a number of the  points unite together upon the
tongue or inner surface of the lips and  cheeks, in the form of patches,
often of considerable thickness; these patches, sooner or later, become
detached and  fall off, and their  place is quickly supplied by a new
exudation ; and this separation  and renewal  of the patches is repeated
so long as the inflammation  continues.   In other instances, however,
the patches formed upon the tongue, and upon the inside of the lips
and cheeks, coalesce, and the whole of these  parts become covered
with a whitish  granulated crust, which  often extends  into the  fauces,
pharynx, and in some  cases into the  larynx.
   The general symptoms connected with this form of stomatitis vary
with the degree of intensity in the local disease.  When the latter is
mild, and of short duration, the child is fretful, or dull and peevish;
he exhibits pain from the motions of the mouth in sucking, or in taking
food, especially when this is warm or  in  the slightest degree stimu-
lating.   In general, the surface of the  body is hot  and dry, and the
thirst is increased.
   In the more aggravated forms of the disease, there is often great
restlessness, alternating with drowsiness: disturbance  of the stomach
and bowels, and other symptoms, dependent upon the affection of the
alimentary canal, with which the inflammation of the mouth is very
generally associated.
   The duration of the disease is various;  in slight cases it terminates
in a few days; in other cases, it  may continue much longer, without
producing any very severe or alarming symptoms.   Excepting when
complicated with inflammation  of the alimentary canal, it is usually a
troublesome, rather than a dangerous affection.
  'In those cases  in which  large  patches of exudation form upon the
inside of the lips or cheeks, or  upon the velum of the palate, the dis-
ease, particularly in situations where a number of children are crowded
together in ill-ventilated apartments—occasionally assumes a malig-
nant character, and  is  then attended  with very considerable danger.
The patches of exudation acquire a dark colour—the breath becomes
foetid—the submaxillary glands enlarge and  become painful—and the
face swollen, and of a dusky red.  The lips and gums become tumid
and bleed upon the slightest touch—while a  fcetid sanious saliva flows
constantly from  the  mouth—diarrhoea, also, often attends, the dis-
charges being dark-coloured  and  highly offensive—the surface of the
body becomes dry and hot, and  the child sleepless and restless; finally, 
148
DISEASES OF CHILDREN.
the patient sinks; death being occasionally preceded by a deep coma-
tose condition.
   The usual causes of this  form of stomatitis, are bad or  improper
food, a neglect of cleanliness, and confined and impure air.  It is often
produced by the bad  quality of the  mother's milk, or by feeding the
child with food unadapted  to the condition of its digestive organs;
children  prematurely weaned seldom escape an attack of it.  It is very
prevalent, also, in public institutions, where many infants are crowded
together; especially in small, illy-ventilated rooms.
   By some writers it has been supposed to be communicated by con-
tagion ; we know of no facts, however, in support of such  an opinion.
Baron and Billard positively  deny its contagiousness ; while Girelli
states, that he has  known  healthy infants to  become attacked by
sucking  from  the same breast as  those affected  with the disease;
and a similar statement is made by  Marley.  This fact may,  however,
be very readily explained by the deteriorated condition of the nurse's
milk, without  the necessity  of admitting the communication of the
disease by a contagious matter, derived from an infected  infant, and
communicated by the  nipple it has sucked.
   The true character of the affection under consideration appears not,
very generally, to be understood.  By the majority of medical writers,
it has been confounded, as we have  already remarked, with aphthae, in
connexion with which it  occasionally occurs.   Breschet, Guersent,
Veron, Lelut, and Billard, have studied both diseases with  great care,
and  it is evident, from the result  of their observations^ that, while
aphthae are the result  of follicular inflammation, the curd-like exuda-
tion, which takes place in the erythematic inflammation of the mouths
of children, is the result of an altered  secretion  from the  inflamed
mucous  surface, in the form either of small curd-like particles or
flocculi, or, as in other diphtheritic inflammations, of large patches of
a soft pseudo-membranous matter, which Lelut has attempted to show
is  analogous to, or identical with the false membrane of croup, while
Billard terms it coagulated  mucus, and Guyot, mucus  rich in fibrine.
Upon the  separation  of  these morbid exudations,  the  membrane
beneath  is  found to be smooth, and without solution  of continuity;
this fact  we have tested  in numerous examinations.   According  to
Guersent, the  morbid  curd-like exudation is  deposited beneath the
epithelium, and its separation is  consequent  upon the rupture of the
latter:—Plumbe is of a similar opinion.   Guyot and Billard,  however,
never saw it in any case, excepting upon the surface of the epithelium,
and this accords with  our own observations.
   There is some dispute  among medical writers as to how far this
morbid exudation extends beyond the mouth and fauces.   It is  gene-
rally admitted that, in  severe cases, it has been found in the oesophagus
as far down as its cardiac orifice; but  while  some, including Billard,
have asserted  that it has been observed throughout the whole tract of
the alimentary canal: others, with Veron, maintain that it has, in no
instance, been known  to occur  beyond the  oesophagus—the  curd-like
crusts occasionally found in  the stomach being, in their opinion, con-
veyed thither from the mouth, by deglutition.  Guyot,  however, gives 
DISEASES OF THE DIGESTIVE  ORGANS.         149
   a  case in which  the disease  was  detected, after death, throughout
   nearly the whole  tract of the intestines.   We have  not had  many
   opportunities ourselves of examining, after death, the condition of the
   alimentary  canal  in infants affected  with stomatitis with  curd-like
   exudation;  but in the few we have  examined, we were never able to
   trace the disease beyond the oesophagus:—a similar statement is made
   by both Dewees and Eberle.  M. Valleix maintains that the disease is
   almost invariably attended with softening of the gastric mucous  mem-
   brane,  often  accompanied  by redness  and thickening.  There  can
   be little doubt that in the majority of the fatal  cases, various morbid
   alterations  of the mucous membrane of  the  alimentary canal are
   present, but these  alterations have  evidently no necessary connexion
   with the  disease of the mouth.
     The treatment of erythematic stomatitis with curd-like exudation,
   will depend very much upon the extent of the local affection in each
   case, and of the morbid condition of the alimentary canal, with  which
   it is accompanied.  In the milder cases, the  frequent application to
   the parts affected, of some  emollient wash, as directed  in simple ery-
   thematic inflammation, with proper attention to the food of the child,
   the daily use of the warm bath, and exposure to a dry and pure atmo-
   sphere of a proper temperature, will be sufficient to effect a cure.
     In the  more severe and obstinate cases, Guersent  advises a  fourth
  .part of chloride of soda to  be added to the mucilaginous wash, and
^ iS^lard a small  quantity of alum ; while  Dr.  Darling  speaks  in the
  ^ highasih l£rmsv>f ^he ^pliilion ofchlotale of §oda^,a^one of the best
  'rrrearrs ofsu*DdWng^manDn! of the lmfhg mSmDnfnexjfnie mouth and
   fauces.   The application which we have found the simplest and most
   successful, is the borate of soda and  white sugar—equal parts—rubbed
   together; a small portion of which, being occasionally sprinkled  on the
   infant's tongue, soon becomes  dissolved by the saliva, and applied to
   every part  of the mouth;  or the  borate of soda  may be mixed with
   honey, in the proportion of one part of the former to six or eight of the
   latter; by some practitioners a solution of borate of soda in water, with
   the addition of a fourth part of alcohol, sweetened with honey or  sugar,
   is  preferred.  In  many cases, we  have found  the most decided good
   effects result  from the weak solution of acetate of lead, noticed when
   speaking of simple erythematic stomatitis.  Whatever washes are
   used, great  care should be taken in their application, to avoid all harsh
   rubbing,  or, indeed, any degree of friction of the inflamed surface.
     When  large patches of curdy exudation occur, these may be touched
   with a mixture of hydrochloric acid and honey, (one drachm  of the
   acid to one ounce of honey,) and when  the exudation assumes a gan-
   grenous aspect, a  wash of chloride  of lime,* or of a  strong  decoction
   of Peruvian bark with chloride of  soda ;b a mixture of creasote and
   mucilage,0 or of vinegar and alcohol,dor a solution of nitrate of silver,
      * R.—Mucilag. acaciae, 3j.                   c Creasot. gtt. iv.
        Calcis chlorin. gr. xv. ad xxx.                 Mucilag. G. acacim, 3ss.
        Syrup, cort. aurant. gss.—M. (Angeloi.)         Aq. Camphorae, 3viij.—M.
      b Decoct, cinchonse, 3iij.                     d Aceti, 3j.
        Syrup, cort. aurant. 3j.                      Alcohol, Jiij.
        Sodse chlorin. 3j.—M  (Guersent.)              Syrup, simpl. gj.
                                              Aquce, 3iij.—M. 
150
DISEASES OF  CHILDREN.
(from two to four grains to the ounce of water,) may be employed, and
repeated at shorter or longer intervals, according to circumstances.
  In even the mildest forms of the disease, acidity of the alimentary
canal, and some degree of diarrhoea,  are often present; in such cases
occasional small  doses of magnesia and rhubarb with ipecacuanha,3
will be found advantageous.  In all the more severe cases, alterative
doses of calomel, combined with  magnesia  or prepared chalk and
ipecacuanha, will be demanded ;b and in those in which the exudation
in the mouth assumes a gangrenous aspect, quinia  should be adminis-
tered.0
     * Magnes. calcinat. gj.               b Calomel, gr. ij. ad iij.
      Rhei pulv. 9j.                     Magnes. calc. vel Cretae ppt. gr. xxxvj.
      Ipecacuanhas !pulv. gr. j.                   ad ^ij.
M. f. ch. No. iv.  One to be given daily or      Ipecacuanhas,  gr. iij.—M. f. ch. No.
  oftener.                                xij.  One to be given every two or
                                       three hours.
                     c Aq. purse, giij.
                      Sutph. quinios, gr. viij. ad xij.
                      Sulph. acid, dilut. gr. xv. ad xx.
                      Syrup, simpl. 3j.—M.
                   A teaspoonful, every two or three hours.
  When combined with disease of the alimentary canal, the latter is
to be treated by its  appropriate remedies.

                  S. — Follicular  Stomatitis.                /*-


  Follicular inflammation of the mouth is also  a frequent disease of
infancy and childhood,  and constitutes the affection  ordinarily de-
scribed  as aphthae, by medical writers. It is more commonly observed
about the period  of dentition, than at an earlier age; and it is espe-
cially liable to occur in children in whom the lymphatic temperament
predominates, or in whom haematosis  is  rendered imperfect, by im-
proper or unnutritious food, a damp and cold, or an impure  and stag-
nant atmosphere, exclusion  from the  light, and neglect of cleanliness.
It is likewise a common occurrence in the course of most of the chronic
affections of the intestinal canal.
  The disease usually commences by the  occurrence of a few small
white specks on the inner surface of the lips and cheeks, and upon the
sides and inferior surface of the tongue, and often over the greater part
of the soft  palate.   These specks are slightly elevated, and  usually
surrounded by a red circle, more or less decided.  They may be few
in number, and irregularly dispersed over the angles and inner  surface
of the lips and cheeks;  or they may occur in groups  upon the lips,
cheeks, and sides of the tongue; or they may cover every portion of
the  cavity of the mouth; extending, in some cases, into the oesophagus,
and even throughout the alimentary canal; and in others, penetrating
into  the pharynx, and, according to some writers, into  the trachea
also.
  The inflammation of the follicles will often continue, for some time,
without making any further progress; or, as often happens, the  disease 
             DISEASES OF THE DIGESTIVE ORGANS.         151

 may be arrested in its  first stage, and the  mucous  membrane of the
 mouth return to its natural condition.
   If, however, the inflammation proceeds, the specks enlarge, a whitish
 matter exudes from their centre, and ulceration takes place;  a super-
 ficial ulcer then occurs, with  slightly elevated  edges, and  surrounded
 by a circle of inflammation.  From these ulcers, there is often  secreted
 a white curdy  matter, adherent, at first, to their surfaces; but subse-
 quently, becoming detached, it is either swallowed, or ejected with the
 saliva of the infant.
   When the aphthous ulcerations are numerous, and in close contact,
 the curdy  exudation spreads from one to the other,  forming  a layer,
 often of considerable thickness and extent.
   Occasionally, instead of a curdy excretion,  there exudes  from the
 ulcers« a small  po*rti«n If blood, which forms  upon  them  a dark-co-
 loured crust, that has not unfrequently been mistaken for a gangrenous
 slough.
   Upon the  disappearance of the inflammation, the ulcerated follicles
 readily cicatrize,  without leaving any permanent scar.
   When the aphthous crusts,  formed by the ulcerated follicles, become
 detached and fall off, they are often  succeeded by  others, which, in
 their turn, become detached ;  and thus, in protracted cases, the crusts
 are detached and renewed,  for several  successive times; or only  a
 portion of the crusts are detached, while the general layer of curdy
 matter continues adherent for weeks.
   Follicular stomatitis  is occasionally attended with  scarcely  any
 other than the local symptoms.   The little patient is generally, how-
 ever, fretful and  peevish; his skin is dry,  and its temperature is
 increased ; there is an augmentation of thirst; often some degree of
 diarrhoea; and an evident indication of pain  and tenderness of the
 mouth, by the child when sucking suddenly leaving off and crying.
 Even when the disease of the mouth is more extensive, fever is seldom
 present, excepting towards its close, or when it occurs  subsequent  to
 the period of infancy; but even then, fever is absent  in many cases.
   When the  follicular inflammation involves nearly the entire extent of
 the lining membrane of the mouth, the general  symptoms are usually
 much more  violent.  There is  then great restlessness; considerable
 pain is experienced in the act  of sucking; the infant  seizes the nipple
 eagerly, but  instantly relinquishes it,  and expresses its suffering by
 its cries.   The mouth is dry and hot, but in the course of the disease kr-*~
 there generally occurs a profuse ptyalism, with painful inUim^scence of m&1t
 the salivary glands; the nippleof the nurse quickly experiences a sense 4^*4*
 of heat and irritation, and becomes excoriated and excessively tender.
 The child  is  troubled with  frequent  acid  eructations,  and  repeated
 watery discharges from the bowels, of a green colour,  and  attended
with severe griping.  Vomiting is apt to occur from an  early period
of the disease, particularly upon anything being  taken into the stomach.
The surface of the body becomes pale ;  the countenance exhibits con-
siderable peevishness  or distress;  emaciation  quickly ensues, and is
often extreme ; the child is wakeful; and occasionally great restlessness 
152
DISEASES OF CHILDREN.
        is alternated with dulness, or some degree of stupor.  In some cases the
        attack is ushered in by great drowsiness.
          As the disease advances, the discharges from the bowels increase in
        frequency, though  diminished in quantity; the verge  of  the anus
        becomes excoriated and inflamed; and in some instances  we have
        known  extensive erysipelatous inflammation of the  nates to ensue.
        The abdomen is generally swollen, and occasionally tympanitic; and
        there is more or less tenderness of the epigastrium.  Gangrene of the
        mouth occurs in some  cases;  but in  general, the patient  dies from
        exhaustion, or from inanition, in consequence of the entire suspension
        of the digestive functions of the stomach and  bowels.
          When the disease extends to the oesophagus, there is usually  great
        difficulty of swallowing ; and when propagated to the larynx, the cry
        of the infant becomes harsh and sibilant. **U*X<>.# ✓£? -/Wjk?*
          Occasionally, the aphthous ulcerations become gangrenous.  This
        form of the disease  is well described  by Billard.  The edges of the
        ulcers shrink, and assume a ragged, flabby appearance;  a  brownish-
        coloured slough forms in the centre, which,  on separating, leaves a
        granulated surface, of a vermilion hue; or, in place of a slough,  the
        ulcers become  covered with a brown, creamy  fluid, that  exhales a
        very decided gangrenous odour.  The parts surrounding  the ulcers
        become tumid, soft, and of a violet colour.  From the half-open mouth
        of the child, is discharged a ropy—often foetid—saliva.  The counte-
        nance becomes pale and  puffy;  the pulse is feeble;  and  the  entire
        surface  of the  body,  pallid,  and deficient in  sensibility.   Frequent
        vomiting, profuse diarrhoea, and a tympanitic condition of the abdo-
        men, generally  occur ; and  occasionally hiccup, and frequent eructa-
        tions ; and the child finally dies  without  febrile  reaction, or cerebral
        excitement.  The termination of this form of the disease is very gene-
        rally fatal.
          Follicular stomatitis most commonly occurs in infants of a relaxed
        habit, with predominance of the  lymphatic system.   It may be pro-
        duced in infants at the breast, whose  nutrition is  impaired from the
        want of an adequate supply of milk on the part of the nurse, or from
        the  milk of the mother or nurse being deficient in its nutritious proper-
        ties, or otherwise of a bad quality.  It more  frequently occurs, how-
        ever, in infants who are attempted to be nourished upon  other food
        than the milk of a healthy nurse; or who have  been prematurely de-
        iprived of the breast.  Improper or deteriorated food, is, indeed, among
        its most common exciting causes.  In infants  at  the breast, aphthas
V»Vyi& may result from their  being at  the  same time imprudently fed,  on
        thick, farinaceous substances—pap;  paste composed  of flour  boiled
        with  milk;  crackers  soaked in  milk—especially if these  are over-
        sweetened with brown sugar or molasses.
          Children born before the full period, or of weakly women,  are said
        by Dewees to be more liable to aphthous  inflammation of the mouth,
        than chidren born at the regular  period, or of robust, healthy mothers.
        The infants of delicate  females  sometimes  suffer considerably from
        this affection, by the mothers persisting in suckling them, even when
        assisted by what is  supposed to be an  adequate quantity  of  spoon 
            DISEASES OF THE  DIGESTIVE ORGANS.        15g

victuals; while as soon as all  attempts at suckling are abandoned, and
the infant is confined  entirely  to  other  appropriate and wholesome
food, the disease disappears, and the general health rapidly  improves.
  The tendency to the disease is increased by everything that impairs
the general health of the infant, and impedes haematosis; as a neglect of
personal cleanliness, and to remove, daily, with a piece of soft linen
and fresh water, the sordes which collect in the mouth ; an impure and
confined, or a cold, damp atmosphere ;  exclusion  from  the  light; ne-
glect  of exercise ; and, according to Underwood, by allowing the in-
fant to sleep constantly with its face covered, and thus to breathe an
air contaminated by its own respiration,  and  often by the emanations
from its parent's or nurse's body.   Follicular stomatitis is also a com-
mon occurrence  in the course of nearly all the prolonged affections
of the  alimentary canal, that occur during infancy and childhood.  The
severer forms of the disease are more liable to prevail in low, damp
situations.   Van Sweiten, and  subsequent writers, describe it as pre-
vailing to  a considerable extent  in various  parts of  Holland ;  and
Hecher notices a severe form of aphthae  as very common in a part of
Germany.    The disease likewise prevails,  in its  more aggravated
forms, in many of the public institutions  of Europe for the reception
of infants.
   It is said, occasionally, to occur as an  epidemic; and by many wri-
ters, is supposed to be communicated by contagion.  Frank declares
this to be  the case, when the  matter  is applied  immediately to the
mucous membrane of the mouth;  and Girelli states, that in the found- ^
ling hospital of Brescia, he has known the disease to be  communicated **%£
to healthy infants, who had been suckled at the same breast with one bty'fiia.
labouring under aphthae. Moss mentions the same fact, and Burns re-
marks, that it would appear to be produced by sucking  an excoriated
nipple; this latter we have known to occur in numerous instances.
   There has existed not a little difference of opinion,  as to the true
character of aphthae.  Many of the older writers describe them as a
vesicular eruption.  Among these  are Van Sweiten, Arnemann, Calli-
sen,  Plenck, Etmuller, and Pinel.   Among the more  recent writers
who regard  them as vesicular, are Rayer, Bateman, Dendy, Girelli,
and Evanson.  Andral  divides them into three species, the papular,
vesicular, and pustular; Gardien describes them as tubercles;  and
Guersent, Billard, Guyot, Marley, and  others,  as  an inflammation of
the follicles of the  mucous membrane of the mouth, presenting two
stages; the  first, consisting  of small, white, miliary  tumours ;  the •*»      {f
second, of superficial ulcers.  This latter view of the disease, we are
led, from our own observations, to believe to be the correct one.
   There can be little doubt, that the aphthous inflammation frequently
extends into the pharynx, oesophagus, and even in  severe  and  pro-
tracted cases, through the entire extent of the alimentary canal.  Nu-
merous accurate observations attest this fact.   The excoriation of the
anus, which is usually adduced, to prove  the  extension of the disease
to the lower  portion of the intestinal tube, affords, however, no evi-
dence of such being the case:  in the majority of the instances in which
the excoriation occurs, it is evidently produced by the  acid  and  irri- 
154                DISEASES OF CHILDREN
      tating nature of the  discharges ;  it is  a  frequent occurrence, also, in
      cases where no aphthae are present.
        Many writers speak of this  disease as never occurring again, after
      a first attack.   This  is unquestionably a mistake; and one which, in
      all probability, has originated from confounding it with stomatitis with
      curd-like exudation,  which is a disease seldom, if ever, met with, ex-
      cepting in  young  infants:—follicular stomatitis we have known, in
      repeated instances, to recur more than  once in the same individual.
        The treatment of the early stage, and milder forms, of follicular sto-
      matitis, differs  in  nothing from that  already recommended in simple
      erythematic inflammation  of the  mouth ; namely, mild mucilaginous
      washes, frequently repeated.  At the  same time, it is all-important
      that the child should  be placed in a pure, fresh, and  dry atmosphere,
      of a proper temperature.   If at the breast, and any suspicion is enter-
      tained of the insufficiency or bad  qualities of the nutriment thence de-
      rived, the breast of a healthy nurse should  be substituted for that of
      the mother; and  if  the infant  be  weaned, its food should consist,
      almost exclusively, of barley or rice water, sweetened with loaf sugar.
      Care should be taken to  preserve perfect cleanliness of the surface,
      and to promote the functions of the skin,  by the daily use of the warm
      bath, followed by gentle friction.   The thirst which  generally attends
      the disease, should be allayed, by  presenting to the child, frequently, in
      the course  of the day, a few spoonfuls of cold water, in which a small
      portion  of gum acacia has been dissolved.  This is peculiarly grateful
   ^  and refreshing  to  the little  patient;  and by some, it has been  consi-
 \t0* dered, in conjunction with the daily washing of the_mouth with cool,
4 f ^ fresh water, as a very powerful means of preventing the occurrence of
      the disease.  An occasional dose of magnesia, or  of magnesia and
      rhubarb, will, in general, be required, and will  tend to remove, in part,
      the acid which generally abounds in  the stomach and bowels.
        When the disease  extends over a considerable portion of the mouth
      and is attended with  great  pain,  as  indicated  by the uneasiness and
      cries of the child in the act of sucking, a  few leeches  should be applied
      to the angles of the jaw.   Billard advises, in such cases, the  addition
      of syrup of poppies  to the  mucilaginous washes, in  the proportion of
      one or two drachms  of the former, to two ounces of the mucilage;—
      we have derived much advantage  from a weak  solution in water, [three
      or  four grains  to the ounce,] of acetate  of lead.  Acetate of lead  is
      recommended by Stoll, as  a local application, in cases of aphthae, on
      the authority of " certain English physicians," and by Latham, in what
      he terms, Cachexia Aphthosa. Of the perfect safety with which it may
      be employed, in this  manner, and of its  good effects, in allaying the
      pain and inflammation, our  own  experience has fully satisfied us.  In
      cases attended  with considerable  stupor,  according to Girelli, a blister
      to the back of  the neck, has been found beneficial.   After ulceration
      has occurred,  a good,—probably the best—local application, is the
      borate of soda and sugar, applied in  the form of powder, as  directed
      for stomatitis with curd-like exudation.
         When the aphthae  remain stationary, or become confluent, the addi-
      tion of  a few drops of sulphuric or hydrochloric acid to the  mucilagi- 
DISEASES OF  THE DIGESTIVE  ORGANS.         155
 nous wash, will be often beneficial, or the mouth may be washed with
 the chloride of soda.  Eberle  recommends, as a wash, a  solution of
 nitrate of silver, one grain to an ounce of water; and Billard  advises
 the ulcers  to  be touched with a piece of alum.  We have seen  the
 most decided good effects in obstinate cases, from the use  of  a weak
 solution of the sulphate of copper, as a wash.
   When the aphthous ulcerations assume a gangrenous character, we
 should endeavour to arrest  the progress of  the  gangrene,  by  the  ap-
 plication of the chloride of  soda, or of creasote,  by the internal use of
 quinia, and by a generous diet.  Billard directs  the application of a
 drop or two of sulphuric or hydrochloric  acid, by means of a capil-
 lary tube,  to the gangrenous ulcerations; and afterwards to touch  the
 remaining gangrenous parts, with a pencil of nitrate of silver, sharp-
 ened to a point.
   When the disease is attended with frequent watery discharges, and
 griping  pains of the abdomen, it has been recommended  by some of
 the  German writers, to  administer, internally, a  solution of borate of
 soda.   Pitshaft (HufelanoVs  Journal) declares, that in severe cases of
 aphthae, one of our most effectual remedies  is the borate of  soda, (two
 to four grains) combined with  the carbonate of  magnesia,  (five to six
 grains,)  repeated two or three times in the twenty-four hours.  We  are
 in the habit of employing, in these cases, a combination of acetate of
 lead, calomel, ipecacuanha, and extract of  hyoscyamus.a   Under  the
 use of this combination, the irritation of the bowels is very often  quickly
 diminished, the griping stools are suspended, and the general symptoms
 of the case improved.
                     * Acetat. plumbi, gr. vj. ad xij.
                       Calomel/gr. iij.
                       Ipecactjuinhas pulv. gr. ij.
                       Ext. Hyoscyami, gr. iv. ad vj. M. f.
                       Chart. No. xij.
       One to be given every three or four hours according to circumstances.

   In cases attended with inflammation of the  bowels, leeches to  the
 epigastrium, warm, emollient fomentations  to  the abdomen, and  the
 other remedies applicable to such inflammation, are to be resorted  to,
 in conjunction with the local treatment already recommended.
  Care should be taken throughout the disease to keep the parts about
 the anus perfectly clean.  The  diaper should be removed immediately
 after  every stool,  and  the  nates, and  orifice  of the anus carefully
 washed with ah infusion of  the bark of slippery elm ;  and after being
 well dried, the parts which appear red and  irritated, may be smeared
 with a little perfectly fresh lard.  When  the irritation is considerable,
 the occasional use of a  wash of a  weak solution of  acetate of lead,
 will be found advantageous.
  In  cases  of aphthae  attended with evident prostration of strength,
without any acute disease of the alimentary canal, some light tonic, as
the cold  infusion of cinchona, or the sulphate of quinia, may be admi-
nistered.
  In prolonged cases of aphthous  ulceration, the use  of iodine, and
other alteratives, with change of air, and a well-regulated diet, will, in 
156
DISEASES  OF CHILDREN.
many instances, by restoring the nutrition  of the system to a healthy
condition, effect a cure.

                4. — Ulcerative  Stomatitis.
  Independently of the aphthous ulcerations just described, the mouths
of children are liable to be the seat of ulcers, resulting from acute phleg-
monous inflammation.  These may occur  upon any part of the  lining
membrane of the  mouth, but  are usually  situated on the sides of the
fraenum, along the inferior margin and edges of  the  tongue, on the
gums, the inner surface  of  the cheeks, and the palatine arch.   They
seldom occur upon the upper surface of the tongue.
  The disease usually commences  with some degree of febrile excite-
ment, indicated by increased  heat and dryness of the surface, aug-
mented thirst, lassitude, and restlessness.    The infant becomes un-
usually fretful—lets go the nipple when it has commenced sucking, and
indicates the painful state of its mouth, by its cries.   On examining the
mouth, one  or more small, inflamed, and  slightly elevated points are
perceived; the apex, or central portion of these, in the course of a
day or two—often within a much  shorter period—becomes softened,
and of a yellowish hue, and, finally, a small ulcer is formed, at first su-
perficial, but gradually  becoming  more deeply excavated, and  often
exhibiting an inflamed and  elevated margin.  The ulcerated surface is
generally covered with an ash-coloured or yellowish matter, but it is
occasionally bare, and readily bleeds.  When the  ulcers  occur upon
the upper surface of  the tongue, they are in most cases superficial,
having the appearance, rather, of slight excoriations.
  After ulceration has taken place, there occurs, in general, a profuse
ptyalism, with a subsidence of the febrile excitement.   The bowels are
ordinarily, costive at first, but become loose, and often purged  in the
course of the disease.
  In  some cases, but one or two ulcerations, of no  great extent, are
present, which, after a short time, fill up with granulations, and  rapid-
ly cicatrize; in other cases, however, the ulcers are more numerous;
sometimes thickly studding the inside of the cheeks, the gums, the arch
of the palate, and both sides of the  base of the tongue.  In other cases,
again, one or two ulcers will  occur, which slowly extend in size and
depth, and exhibit no disposition to heal; the little patient, at the same
time, wasting away with a species of hectic fever, with exacerbations
night and morning.
   Denis describes a species of ulceration, caused by a softening of the
mucous membrane of the  palate,  and which invariably  occupies  its
centre, either on the median line, or on the outside of this line.   The
 mucous membrane is changed into a kind of pulp, of  a red, inclining
to  a fawn colour.  If the pulpy matter be removed, the edges  of the
 ulceration are found  to be  perpendicular, with the bare  bone  at the
 bottom of the ulcer, apparently in a healthy  condition.   This affection
 we have never observed.
   Ulcerative stomatitis frequently occurs during  dentition, and is a
 common disease in children labouring under a disordered state  of the
 digestive organs, with a costive or irregular state of the bowels,  vari- 
DISEASES OF  THE DIGESTIVE ORGANS.         157
able appetite, offensive breath, inertness of disposition, a  pale puffy
complexion, and hard, tumid abdomen.
  The treatment differs but little from that directed for aphthous ulce-
ration.  When unattended with serious derangement  of the digestive
organs, simple mucilaginous washes for the  mouth,  and,  when  the
bowels are confined or irregular, a small dose of calomel, followed, in
the course of a few hours, by a dose of castor oil, with the tepid bath
daily, and a plain, unirritating diet will, in general, promptly effect a
cure.   If, however, the ulcers are tardy in  healing, they may be
washed with a solution of borax in water (15 grains  to the ounce);
or with the chloride of lime, or a weak solution  of  nitrate of silver
(one grain  to the ounce); or  of sulphate of copper  (5 grains to the
ounce).   According  to  Dr. Dewees,  the following wash has never
failed to quickly arrest the ulceration.*
                       1 R.—Sulph. Cupri, gr. x.
                            Pulv. Cinchonas, 3ij.
                             "  G. Acacia?, 3j.
                            Mellis, 3ij.
                            Aq. purse, 3iij.—M.
          With this wash the ulcers are to be touched twice a day, with
                     the point of a camel's hair pencil.

   When  accompanied with extensive derangement of the  alimentary
canal, the proper remedies adapted to the removal of the latter will be
demanded.   In many cases, indeed, the ulcerations of the  mouth will
be found to  resist every local application, until the digestive organs are
restored to  a healthy  condition, and  the nutrition of the system gene-
rally is improved.

        5. — Gengivitis. — Inflammation of  the Gums.

   The  gums, from the period when dentition  commences, until the
completion  of the first set of teeth, are liable to become inflamed, inde-
pendently of the residue of the buccal cavity.   In some cases, the m-^-v^tAi^(^
flammation  is but slight, and of short duration; but in others, particu-gsfic/Jt*
larly when  it occurs  in  children whose general  health has become
impaired, in consequence of a  deranged state of the digestive organs,
the inflammation  is often severe, and productive  of extensive ulcera-
tion, by which the alveola and teeth are frequently entirely destroyed.
This disease has very commonly been confounded with scurvy of the
gums.
   The  gums become of a deep red or livid colour, swelled and painful;
the tender state of the gums rendering  mastication difficult, and often
causing even spoon victuals to be refused.   The child is, in general,
very languid, with a  hot and  dry skin, a small and  quick pulse, im-
paired appetite, and considerable thirst.  The tongue is usually covered
with a thick yellowish fur.   The patient's sleep is seldom much dis-
turbed, and in some cases there is increased  somnolency.
   When  the inflammation takes place, as it frequently does, previously
to  the  protrusion of  the  molar teeth,  a small ulcer is liable to occur
upon the  surface of the gum, immediately over the teeth about  to pro-
trude, and,  quickly extending, often lays bare  the alveola, and causes 
158
DISEASES OF  CHILDREN.
the destruction of the  teeth.   In other cases, the ulceration occurs at
the edge of the gum, and extends rapidly downwards.  In every case
in which the ulceration is allowed to go on, the teeth  become loose,
black, and  carious, and are often reduced to a soft, pulpy state.
   When ulceration takes place, there is always  a copious flow of
foetid saliva, the  breath  becomes extremely offensive, and the counte-
nance of the child assumes a  pale, sallow hue;  a bloody fluid oozes
from  the gums upon the least pressure, and often a very profuse diar-
rhoea ensues.
   This disease is very often produced by too much, or improper food,
particularly that which is of too stimulating a nature;  and it is, very
generally, attended with more or less—often with very extensive—de-
rangement of the digestive organs.
   In  the early stage of the complaint, the proper remedies are, mild
emollient washes to the gums, with, twice or thrice a day, a wash of
a solution of acetate of lead, (five grains to an ounce of water,) applied
by means of a soft sponge, or dossil of lint.  If the inflammation is not
promptly reduced by these means, a few leeches should  be applied to
the angles of the jaw, or to the gums themselves.   Some writers ad-
vise the gums to be freely scarified, and, in many instances, when well
timed, we have seen advantage to result from this procedure.
   The bowels should be freely  opened by the  administration of a few
grains of calomel, combined with magnesia, and followed, after a few
hours, by a  dose  of castor oil, or  sulphas  magnesiae; the tepid  bath,
should be administered  daily, and the child put upon a  diet composed
entirely of milk and farinaceous substances.                         r
   When ulceration has taken place, and the inflammation of the gums
is  diminished, some light astringent wash will  be  beneficial; an infu-
sion of oak bark, with alum,11 we have found peculiarly advantageous;
the chloride of lime will, also, in many cases,  speedily arrest the ulce-
ration ; or,  we may employ, as  a wash, diluted  hydrochloric  acid.b
We have often found a solution of the sulphate of copper to succeed,
however, when other topical applications have failed.

* R.—Corticis Querci. gj.               b R.—Acid. Hydrochlor. 3ss. ad 3j.
     Aquae, Oss.                         Mellis,
     Boil to a pound and strain, then add—      Aqua? Rosae, aa. gj.—M.
     Sulph. Alumin. 9j.                 To be applied three or four times a day.
To be applied to the ulcerated parts by means
  of a soft sponge, or dossil of lint, several
  times a day.

   The child should be exposed to  a fresh, pure air, and be supplied
with a nourishing, easily digested, and perfectly unirritating diet.
   When the ulceration of the gums is very extensive, and the strength
of the child  is evidently impaired, the cold infusion of bark, or the sul-
phate of quinia may be  administered; and will often very materially
accelerate the healing of the ulceration of the gums.
   It is important that the teeth  which have  become destroyed  by the
disease be early removed.
   The disordered state of the alimentary canal will demand, of course,
its appropriate remedies. 
DISEASES OF THE  DIGESTIVE ORGANS.         159
                 6. —Gangrene of  the Mouth.

(cANCRUM ORIS--GA.NGRJ2NOPSIS—-^ANKER OF THE MOUTH--WATER ^CANKER.)

  Gangrene of the mouth is not a disease of so common occurrence in
this  country, as it would appear to be in many parts of Europe;  it,
nevertheless, does  frequently occur, and  has, in more than one of our
public institutions for the reception of infants,  prevailed  endemically.
  Gangrene  may ensue in either of the forms of stomatitis  already
noticed; and, occasionally, in the follicular form, it becomes one of the
most unmanageable and fatal of its terminations.
  It is, however, in cases of inflamed gums, occurring in children of
lax  and debilitated habits, of a strongly marked lymphatic tempera-
ment, or the energies of whose organic functions have been impaired
by previous disease, that gangrene of the mouth most frequently takes
place.
  The  patient is, in general, affected with great languor and listless-
ness. He is indisposed to engage in play, or even to move about;  but
is peevish and discontented, and unable  to sleep; he has no  appetite
for food, but usually his thirst is increased. The countenance becomes
pale and dejected, and a peculiar puckering of the cheeks, about  the
corners of the mouth, is often observed.   There is, in many cases,
considerable emaciation, with nocturnal  sweats.
  In the course of one or two weeks, the patient begins to complain of
jdijirp.'pains in his mouth and gums;  his breath becomes more or less
fo3tid,Tind there is an increased discharge of saliva.  A sense of itching
or pricking, and heat is experienced in the gums, which become of a
dark red  or leaden hue, swollen, and  spongy, and bleed upon' the
slightest touch.  The discharge of saliva becomes more profuse, ac-
companied often with a slight discharge of dark-coloured blood, and
a tumid and painful condition of the  salivary glands.  The odour of
the breath, and the appearance of the gums, at  this stage of  the dis-
ease, bear so  strong a resemblance to those  of a case of mercurial
pytalism, that we have known it to be  mistaken for such by physicians
of skill  and experience.
  The disease being allowed  to proceed, the edges of the gums, most
generally  those of the inferior jaw, separate from  the necks of the
teeth, and present  a ragged, flabby, and livid aspect.   The teeth be-
come loose, and often fall out of their sockets; or, if they remain, be-
come covered with a thick coating of a  dirty white or ash colour.
  Fever now generally occurs; at first towards evening, and attended
often by an increase of the  nocturnal sweats.  The bowels are  also
often affected with diarrhoea.
  MM. Rilliet and Barthez state that  in the cases observed by them
the skin was always rather dry than humid ; a similar remark  is made
by MM. Baron and Destrees.
  The disease may continue in the state just described for many weeks,
or even months.
  Usually, however, in the course of a few days, a number  of  ash- 
160
DISEASES OF CHILDREN.
   coloured vesicles appear upon the gums, which rapidly enlarge in size,
   coalesce, and  finally rupture; the denuded gum presenting a black
   and  gangrenous appearance.  When the dead  portions of the gum
>  separate, the ulcer which ensues assumes immediately a gangrenous
   appearance, and very rapidly the  entire gum becomes destroyed, and
*   the whole of the alveola, and sometimes  the greater part of the infe-
   rior maxillary bone are laid bare;—the alveola are, generally, carious;
   portions of which, with the teeth, are separated and thrown off.
     From the gums, the  gangrene, sooner or later, extends to the lips
   and cheeks, which become more and more swollen, as the disease in-
   creases in extent.
     At this stage, and sometimes much earlier, a difficulty is  experi-
   enced in moving the lower jaw, in consequence of which, the  mouth
   becomes  occasionally firmly closed.  This, Reimann has erroneously
   considered  to result from  an actual tetanic affection; it is, evidently,
   the mere effect of the  intumescence of the  soft parts, and the pain
   which is consequent upon any effort to move the jaw.
     In the course of a few days, should the little patient not sink at an
   earlier period, which is generally the case, the whole of the  soft parts
   surrounding the mouth, will become involved in the disease,  assuming
   a dark livid colour, and  discharging a putrid sanies, of a most offensive
   odour.
     The fever, which now often augments in intensity, presents a nervous
   or hectic character, and the child dies upon the eighth, or, at furthest,
   on the fourteenth day from the commencement of the  gangrene, his
   body presenting all the  indications of a general colliquation. Xt$A*%4
     The disease just  described, is evidently a gangrene  of the  gums,
   extending thence to the surrounding soft parts, and induced by acute
   inflammation, occurring in children in whom  the organic energy has
   been reduced, either by bad or deficient food, long-continued exposure
   to an impure and stagnant, or to a damp and chilly atmosphere, or by
   previously existing disease, particularly of the digestive organs.
     It is this form, which, according to Richter, prevails endemically in
   the asylums and hospitals  for children, and in low, damp situations,
   bordering upon the sea.
     There is, however, another form of gangrene of the mouth, of much
   less frequent occurrence than the former, and differing from it in many
   important particulars.
     There is no preceding inflammation of the gums;  but the disease,
   which commences in the soft parts surrounding the  mouth, often at
   one of the  angles of the lips, generally makes its appearance,  as  it
   were, abruptly; without, at least, any previous symptom, indicative of
   its occurrence.  A hard indolent tumour, about the size of an almond,
   is commonly first observed in some part of the lips or cheeks; the
   tumour is deeply seated, and accompanied by a slight degree of red-
   ness  of the skin by which it is covered.  Upon examining the  mouth,
   nothing unusual is discoverable. For a few days, the tumour gradually
   augments  in size, and the skin becomes of a deeper red; the internal
   surface of the cheek, over  the tumour, assumes a gangrenous appear-
   ance, and an extremely offensive  odour  is exhaled from the  mouth. 
DISEASES OF THE  DIGESTIVE ORGANS.         161
Exacerbations of fever generally occur towards evening; the appetite
and disposition of the child are seldom, however, much affected.
  If the disease be allowed to proceed, the external circumscribed red-
ness of the lip or cheek soon becomes paler, livid, then of a grayish
hue, and surrounded  by a  red  areola, which extends as the disease
progresses.  In  a few hours, frequently, the gray  sphacelated portion
becomes completely black.
  If the mouth be now examined, it will be found, that in the imme-
diate  neighbourhood of that  portion of the lip or cheek at which the
disease commenced, the gums are in  a  state of gangrene; the teeth
here become  loose, covered with an ash-coloured mucus, and, finally,
drop out.
  The affection  of the gums, is, in this form of gangrene of the mouth,
secondary to that of the cheek or lip, and does not occur until this has
made considerable progress.
  Necrosis of the maxillary bone is seldom observed in the variety of
gangrene just described; death usually taking place from a general
sinking of the powers of life,  previously to any very extensive destruc-
tion of the soft parts.
  A much milder form  of the  disease is described by Richter, many
cases of which have  fallen under our notice.   In this, circumscribed
spots of gangrene, of a dark-brown colour, surrounded  by a  red
margin, and  of  various  sizes, occur suddenly upon  the  lips, near to
their  angles,  and upon  the cheeks ; the general system of the patient
remaining apparently unaffected.   In some cases,  the gangrenous
spots are preceded, for  one  or two days, by a slight  redness of the
skin where they occur.  The gangrene is always superficial, involving
little more than the skin, and there is but little loss of substance when
the sloughs separate; a suppuration of a healthy character quickly
ensues, followed by  granulations and  cicatrization.  Occasionally,
when the gangrene occurs at the commissure of the lips, it affects the
entire thickness of the latter; the slight loss of substance which ensues,
is, however, speedily  filled  up by granulations,  and little or no defor-
mity ensues.
  These mild cases usually occur subsequently to attacks of some of
the acute exanthemata; indeed, the disease in this form, according to
Richter, Baron,  Romberg, and  others, succeeds to acute  affections of
the skin, as small-pox, measles, scarlatina, &c,  where these have run
an  irregular  course, or have, by any  means, been suddenly arrested
during their evolution.  We have seen it more frequently, however, in
children who have laboured for some time under symptoms of irregu-
lar  remittent fever, connected with chronic gastro-intestinal disease.
  A third form of gangrene of the mouth, and the one which, next to
that consequent upon acute  gengivitis, we have the most  frequently
met with in  private  practice,  is that in which  the  gangrene com-
mences upon the centre of the internal surface of one of the cheeks.
  Its occurrence is, in general, like the last-described variety, sudden.
The patient becomes, all at once, unusually restless  and peevish, and
affected with slight accessions of fever.  If closely observed, some in-
tumescence of one side of the face will be detected.   The disease is
                               11 
162
DISEASES OF CHILDREN.
occasionally, however, ushered in by nausea, vomiting, or  diarrhoea.
Ooe of the cheeks  becomes  quickly  swollen, hard, dark red, and
shining.   As the external swelling augments in size, and the skin be-
comes greatly distended, the centre of the tumour often assumes a per-
fectly  white  and shining appearance; the eyelids at the same  time
become ^edematous,  an  increased flow of saliva takes place, and the
breath acquires a very peculiar foetid odour.
   If the mouth  be now examined,  one or more grayish vesicles will
be perceived, upon the internal surface of the affected  cheek, which
after some days, rupture, and form an ulcer of a dirty gray colour, of
a rounded form, with red, distinctly circumscribed edges; and at the
same time, a slight excoriation or fracture of the skin often occurs at
the angle of the  mouth on the affected side.
   This form of gangrenous ulceration of the  mouth  is not always
immedialely detected,  and is  occasionally entirely overlooked, by
those unacquainted with the disease; the  whole of the attention being
directed upon the external swelling.   There is, in fact, some difficulty
in making an accurate examination  of the inner surface of the cheek,
from the difficulty the little patient  experiences in opening his  mouth
to a sufficient extent, after the external swelling has acquired any size.
   As the  gangrenous ulceration  within  becomes  deeper and  more
extended, a livid spot, surrounded by a red areola, makes its appear-
ance on the external  surface, at the  spot where the tumefaction is the
greatest; this soon acquires a  darker  hue, and augmenting  in  size,
involves, in the course of from four to eight weeks, nearly the whole
of the  soft parts  on that side of the  face.   Portions of it are soft and
of a gray or greenish hue, and  present all the characteristics of humid
gangrene, while  other portions are  completely mummified, hard, and
of a deep black colour.
   If the gums be now  examined, they will be found to be in a gan-
grenous condition, immediately opposite to where the gangrene com-
menced on the cheek, while in every other part they are apparently
sound :—the gangrene of the gums being in this, as in the last variety,
a consequence of the preceding mortification of the cheek; whereas,
in the first variety, the gums are the part  in which the gangrene com-
mences, the jaw being frequently destroyed previously  to the cheek
becoming affected.
   In the progress of the disease, the functions of the alimentary canal
become deranged, the appetite of the patient is destroyed; his thirst
augments;  nausea and vomiting often occur;  the diarrhoea becomes
more copious, the discharges being thin, dark-coloured, and offensive;
the skin of the body is  dry and hot, while that of the extremities is
colder  than natural; the abdomen  becomes tympanitic; the patient
falls finally into a soporose condition, and death speedily ensues.
   In our own practice, this variety of gangrene  of the mouth has most
usually occured in children who had for some time been affected with
disease of  the gastro-intestinal mucous membrane,  attended with fe-
brile symptoms  of a remittent character.  In  no  one of the cases,
however, which have fallen under our care, did  the gangrene involve
the whole  thickness of the cheek.   In every instance, we were ena- 
DISEASES OF THE  DIGESTIVE  ORGANS.         163
bled to arrest its progress, before it had extended beyond the mucous
membrane lining the cheek in which it had commenced, and a small
extent  of  the  gums in the immediate  neighbourhood.  It  may be,
however, that the  cases  we  have seen, were, even  in their earlier
stages, of a much milder character than those described by the Euro-
pean writers.
  Gangrene of the  mouth is an affection almost exclusively confined
to the period of infancy.  It may  occur at any time between the
second and tenth years, but is most commonly observed between the
second and fourth.   By Rilliet and Barthez it was observed most fre-
quently in children between the age of three  and five  years.  Few, if
any, cases have been met with in infants during the period of lacta-
tion.
  The children in whom  gangrene of the mouth most usually occurs,
are those of delicate habits,  of a lymphatic temperament, with soft      %
and flaccid  muscles and pale skin, and in whom the functions of assi- fclglt^l**t
milation and nutrition have been depressed from a variety of morbific wJtt/tfitfi
influences.   In no  instance has the  disease  been known to occur '" /w>n fj^itwm
children of a robust and healthy constitution.   It is hence seldom met
with excepting among the children of the  poor, who  are imperfectly
fed, or upon food of an improper quality; those who are exposed to
the influence of a  damp  and chilly, or impure and  confined atmo-
sphere; in whom  personal cleanliness is neglected, or who have be-
come reduced by some  severe acute  affection, particularly of the skin,
or have suffered from chronic disease of the stomach  and bowels.
  It is a disease of  frequent occurrence in public institutions, where a    ¥ vHiD%
number of children are crowded together in small, low, or ilb/venti- <Jr
lated apartments.   Hence, in the  asylums and hospitals destined for
the reception of children, the disease frequently occurs as an endemic.
In the Children's Asylum of Philadelphia there was, at one  period,
among the  two hundred  and forty inmates of the institution, seventy
affected with gangrene  of the mouth.—(B. H. Coates.)
  As the children of the poorer classes in Europe, who live upon the
borders of the sea,  are exposed at one and the same  time to most of
the predisposing causes of gangrene of the mouth, it is, in consequence,
an affection  extremely prevalent in Holland,  Sweden,  Denmark, Nor-
way, and in  many parts of England, Ireland,  and Scotland.
  The influence of  long-continued exposure  to a damp climate, and
the constant  use of unwholesome food, in the production of the disease,
are sufficiently established by the report of  the physicians attached to
the  French  army which  occupied Spain, they having to treat, fre-
quently, a gangrenous  inflammation of the  mouth which occurred
among the soldiers, and which received from the Spaniards the name
of fegar, or  fegarite.—(Richter.)
  The disease is mentioned  by more than one writer as having pre-
vailed epidemically in the Netherlands, as a consequence  of gastric
fevers.
  Gangrene  of the  mouth is, no doubt, in the  majority of instances,
intimately connected with gastro-intestinal disease.  The causes which
have been enumerated evidently predispose to the disease, by disturb- 
164
DISEASES OF CHILDREN.
      ing the healthy condition of the stomach and the other organs appro-
      priated to digestion and assimilation, and to nutrition generally.
        In all of Poupail's cases, seventy-two, the disease followed an attack
      of intermittent or remittent fever;  in nine of the cases reported by Dr.
      Jackson, formerly of Northumberland, it occurred in the course of, or
      subsequent to, an  attack  of  remittent  or bilious fever.  Dr. Marshall
      Hall  states that, in all the cases he has seen, the disease succeeded to
      disorders of  the digestive organs,  typhus fever, or some inflammatory
      affection.  In  the observations of Rilliet and Barthez, it was in the
      lungs and intestines that  disease was  most frequently detected.  The
      affections of the intestines were entero-colitis, either acute or chronic,
      or softening.   In all the cases which have fallen under our notice, the
      affection of the mouth had been preceded by more or less decided in-
      dications of gastro-intestinal  disease; in the majority, the children had
      suffered for  some time from the  infantile remittent and intermittent
i>W>fevers-
,;^  '   Another fruitful cause  of  the disease would  seem to be the'acute
      exanthemata; an imperfect crisis, or sudden repulsion of the cutaneous
      eruption, appearing to favour, in an  especial manner, the development
      of gangrene of the mouth.
        Dr. Willan  notices its  occurrence in scarlatina, and Dr. Marshall
      Hall, after variola, rubeola, and scarlatina.  Dr. Cuming states  that,
      in two cases which fell under his observation, the  disease occurred as
      a  sequela of  measles; in another, in the advanced stage of dysentery;
      in a fourth, upon the termination of infantile remittent fever; and adds,
      that  it is more generally  observed at  the close of the exanthemata,
  \  , than  at that of any other  of the acute affections to which children are
      liable.  Rilliet and Barthez  state, that the disease, in the  course of
      which they have more frequently  observed gangrene of the mouth to
      occur, is measles.   They have occasionally observed it in scarlatina,
      small-pox, and pneumonia.   They have also known it to follow intes-
      tinal  affections, hooping cough, scrofula, &c.  In Dr. Duncan's cases,
      the disease appears to have  most generally occurred in  children la-
      bouring under some affection of the intestinal canal; although in seve-
      ral of the cases the gangrene  occurred  after  measles.  Of the six
      cases observed by Dr. West, of  London, two succeeded  to  typhus
      fever, two to measles, one occurred  in a child whose health had been
      completely broken down by ague, and one supervened in a tuberculous
      child, who had been  affected for many weeks with ulcerative stoma-
      titis in a severe form.
        By a few of the writers on gangrene of the mouth, its propagation
      by contagion is asserted; but of this no well-authenticated instances
      have been recorded.  In every case, however, as a prudent  precau-
      tion,  it will be proper to separate as much as possible the individuals
      affected from those in health, as well as from each other.  A number
      of patients labouring  under gangrene of the mouth  being confined in
      the same room cannot fail, even with every precaution in regard to
      cleanliness and ventilation, to render the disease, to a certain  extent,
      more unmanageable than when the patients are placed in separate and
      distant apartments. 
DISEASES OF  THE DIGESTIVE ORGANS.         165
   Few examinations of the lesions presented by the internal organs,
 in the children who  have died of gangrene of the mouth, are upon
 record; and of the few that are reported, the majority appear to have
 been performed with very little accuracy, so  that of the pathological
 anatomy of the disease we know but little.
   In the examinations we have made, which, however, have been very
 limited—for we have had the good fortune to  lose but few of our pa-
 tients—the principal organs  in which  morbid appearances were  pre-
 sent were the stomach, intestines, and liver.  In all the cases, the two
 former presented  the indications  of inflammation, of  a more or less
 chronic character; the latter appeared to be affected with  hyperaemia,
 rather than with any structural change.  In the majority of cases the
 mesenteric glands were greatly enlarged.
   In none of the cases observed by Rilliet and Barthez was the gan-
 grene of the mouth  the  only lesion  detected.  The internal organs
 were invariably found to be affected with indications of disease, which
 had existed anterior to that of the mouth, or was concomitant with or
 consecutive" to*it.« •'Fhe:-nrfost frequent weje  acute affections of the
 lungs—entero-colitis, acute or chronic, and softening of the intestines;
 more rarely tubercles, which, however, were  very abundant in one
 case.   In  a  very few cases, gangrene of the pharynx  and lungs was
 present, and  in a  still fewer  number, pleurisy,  pneumo-thorax, perito-
 nitis, pharyngitis, and nephritis.
   In the  examinations made at the Children's  Asylum, between June
 1st,  1827, and January 1st, 1830, the morbid  appearances exhibited
 were enlargement and hardening of the mesenteric  glands; a scrofu-
 lous condition of the glands of the neck; and, in every  instance, tuber-
 cles of  the  lungs.  In general, the whole substance of the lungs was
 thickly  studded with tubercles, in various stages of development.  The
 condition of the gastro-intestinal mucous membrane is  not recorded.
   Richter remarks, that every physician who has had an  opportunity
 of treating the gangrene of the mouth in children, agrees, that if it be
 not  entirely  beyond  the control of medical treatment, speedily  pro-
 duces, in at least the majority of cases, the death of the patient; while
 Rilliet and Barthez declare that death is the ordinary termination of  q f
 the disease.  It  is certainly true, that when the disease occurs in il),y*  0^
 constructed and crowded  asylums for children, or in any situation in
 which the patients remain constantly exposed to a confined  and impure
 or to a damp  and  chilly atmosphere, or when  it  occurs  in  children
 greatly exhausted by previous  illness, the disease is one very generally
 fatal.  When, too,  its real character  is misunderstood ;  when it is
 overlooked in its first stages, or treated by inert or improper remedies,
 death can very seldom be prevented.
  We have not found the disease, in any case in which we have been
enabled to  treat it in its early stages, so difficult to cure, however, as
most of the European writers describe it to  be.   We have, indeed,
seldom failed in arresting, very speedily, the progress of the gangrene.
This is also the experience of  Dr. B. H. Coates, who had  the  charge
of the Children's Asylum of Philadelphia, previously to  the year 1828,
and of his successor in that  institution; where, although  the disease 
166
DISEASES OF CHILDREN.
    had frequently prevailed epidemically, it has been productive of a very
    small mortality.   With a judicious treatment, early commenced, the
    disease would appear to be even more manageable than many of the
    other severe affections of childhood.
      The  period  when the treatment is commenced, is, however, all-
    important to insure its success.  This, perhaps, more than almost any
    other circumstance, will determine, in the majority of cases, the greater
    or less  mortality of the disease. When the physician has been enabled
    to detect it  at the period of its development, he will, very generally, be
    able to arrest its further progress, and  to save the life of his patient.
      It is  remarked by many writers, that when the gangrene commences
    by a tumour or livid spot upon the cheek, it is very generally under
    the  control of medicine.  We have not,  however, found the other
    forms of the disease to be less so.
      According to Richter, when the gangrene of the  mouth occurs
    subsequently to affections of the alimentary canal, it is of a less malig-
    nant character  than  when  it succeeds  to diseases of  the skin, or to
    fever, in children of a scoj^utic habit. 4j&W"*&9# &qa*JW-*i*
      Upon the true pathological character of gangrene  of the mouth,
    much difference of opinion exists  among the writers who treat upon
    it. That the first variety we have described is the result of inflamma-
    tion of the gums, no one can doubt, who  has examined the disease
    with care; and, according  to Richter, the two  other  varieties, also,
    result from  an inflammation of the parts in  which they first occur—an
    opinion which we believe to be well founded.
      Gangrene of the  mouth has been ascribed to inflammation of the
    lymphatics, by Bidloe; to a softening of the affected  tissue, similar
    to what takes place in the  stomach, uterus, brain, and other organs,
    by Klaatsch, Hesse, Weigand, and Boer; to a scrofulous affection,
    cheilocace,  by Lentin;  to  a scorbutic  affection,  by Van  Sweiten,
    Seibert, and most of the older writers, and finally, to an induration of
    the cellular tissue from infiltration, similar to what occurs in new-born
    infants, by Fischer and Billard.
      In the majority of cases, the  treatment  of gangrene of the mouth
    consists simply in the application  of remedies  adapted  to arrest the
\   further progress of the local  disease.  When, however, we are called
    in previous to the occurrence of gangrene, in many cases  much  may
    be done to  prevent its occurrence, by directing our remedies to the
    removal of the existing predisposition.
      Whenever it can  be accomplished, the patient should be subjected
    to the influence of a dry and pure atmosphere: the  strictest cleanli-
    ness, of both person and clothing,  should be enjoined, together with  a
    diet perfectly unirritating, and easy of digestion, and  adapted, in re-
    spect to the substances of which  it is  composed, to the actual con-
    dition of the digestive organs in each case.  If the gums are in a  state
    of inflammation, the remedies directed in the section on that disease
    should be resorted to.
      In the great majority of cases, more or less disease of the stomach
    and alimentary canal generally, will be found  to  exist: this is to be
    treated by its appropriate remedies; recollecting, however, that altera- 
DISEASES OF THE  DIGESTIVE  ORGANS.         167
tive doses of calomel, even when indicated by the symptoms present,
are to be employed with the utmost caution, in every instance in which
we have reason to apprehend the occurrence of gangrene of the mouth
—for there can be no doubt that the disease has, in many cases, been
developed by the incautious use of mercury.   When judiciously pre-
scribed, and their effects are carefully watched, small doses of calomel
will, nevertheless, often be productive of beneficial results.
  In a few instances, we have found the administration of the sulphate
of quinia, and washing the gums repeatedly with a strong decoction
of oak bark, to be beneficial in  preventing  gangrene of the mouth, in
cases in which we had every reason  to anticipate its speedy occur-
rence.  In every case in which decided symptoms of local inflamma-
tion exist, leeches to the part will be  proper.  When tumefaction of
the cheek occurs, blisters over the tumour have been, also, found bene-
ficial by  Dr. Jackson,  formerly of Northumberland, now of Phila-
delphia.
  The remedies that have been applied locally, with a view of arrest-
ing the  progress  of the gangrene, are very numerous.   All  of them
are reported to have succeeded in the hands of some physicians, while
in those of others they have entirely failed.
  The wash or lotion which  we have found by far the most success-
ful, is a  strong solution of sulphate of copper (thirty grains to the ounce
of water), applied very carefully twice  a day, or oftener, to the full
extent of the gangrenous ulceration.  A solution  of the  sulphate of
zinc (one drachm  to an ounce of water), either alone or with the ad-
dition of tincture  of myrrh,* will also be found, in many cases, an
                      a R.—Sulph. Zinci. 3j.
                           Aquae, 3ij. M. et sol v.
                           Dien adde Mollis,
                           Tinct. Myrrh, aa 3ij.—M.
admirable  remedy.  Nitrate  of silver was the  only  local  remedy
employed in the cases of gangrene of the mouth, that occurred in the
Children's Asylum of Philadelphia, from June  1st, 1827, to January
1st, 1830, the  greater portion of which  terminated favourably.  As
soon as  the disease of the mouth was detected, the nitrate of silver,
either in pencil or solution, was applied freely to the parts affected.
  Creasote, Dr. Dunglison informs us, was found to be an admirable
local application in the gangrene of the mouth, which occurred, as an
epidemic,  in the Philadelphia  Almshouse, in 1838, incisions being first
made through the gangrenous sloughs.  His prescription  is  creasote
and alcohol, equal parts, to  be applied by means of a pencil.
  In the Children's Hospital at Paris, cauterization of the gangrenous
spots  with hydrochloric  acid,  and afterwards  covering them  with
powdered chloride of lime, with the use of tonics—generally the syrup
of cinchona, given per anum,—is said, by Baudelocque, to have proved
a very successful mode of treating the disease.
  The hydrochloric, sulphuric, and acetic acids, have all been highly
recommended, as  local  applications.    Van Sweiten  employed  the
hydrochloric acid, twenty drops to half an ounce of honey, or when
the case was of an aggravated character, the acid alone, and invariably 
168
DISEASES OF CHILDREN.
found the extension of the gangrene to be arrested, and the dead parts
to separate in a short time; it was equally successful in the hands of
Seibert, and is spoken of in terms of commendation by  Bernstein,
Richter, Jadelot, Boyer, Baron,  and others.   Heuter considers one of
the best local applications  to  be, a mixture of hydrochloric and acetic
acids.
   The application of  sulphuric acid  has succeeded in effectually ar-
resting the disease, in the hands of Bruineman and Courcells; and the
acetic acid, in  the hands of Klaatsch  and  Reimann.  To obtain from
the acids any  beneficial effects, their application should be repeated
every half hour, or, at furthest, every  hour.   They may be applied
either by  a  pencil, or  by covering the affected parts with lint moist-
ened with them ; their application  being continued  until the gangrene
ceases to spread, and granulations are formed.   When thick firm
sloughs occur,  these should be freely scarified previously to the appli-
cation of whatever wash is used.
   The actual cautery  is recommended by Baron, the chloride of lime
or soda, by others, and the tincture of iodine by Davies.  Cases illus-
trative of the  good effects of the actual cautery, have  recently been
published by Henry  Obree, Esq.
   When sloughs have formed upon the cheeks, some advantage may
be derived from poultices, containing the chlorides of lime or soda, or
the pyroligneous acid.  The early extraction of the loosened teeth is
of importance, and should never be neglected.
   The administration  of internal remedies would  appear to interfere
but little with the progress of the disease.
   The diet of the patient should be light and nutritious; it may consist
of beef tea, plain beef  or mutton broth with rice ; milk with  rice; tapi-
oca, sago, and the like farinaceous articles.  Wine whey may be occa-
sionally given with advantage; and we can conceive of cases, in which
a moderate use of sound wine  may be  necessary, in order to sustain
the sinking powers of the little patient.  Such cases, however, have
never fallen under our notice.
   From the administration of the.sulphate of quinia in solution, or of
the cold infusion of cinchona, we have,  in many instances, seen much
good to result.1
  1 R.—Quiniae sulphat. gr. x.          Or R.—Quinise sulphat. gr. viij.
       Acid, sulph. dil. f*X *•                Aq. chlorin. 3j. vel,
       Sacch. alb. 3iv.                     Acid, sulph. dil. 0% v.
       Aq. cinnamon, giv.—M.              Syrup, limon. §iv.—M. (Dunglison.)
Dose, a teaspoonful, every three hours.
   The chlorine water and the chloride of lime, or the chloride of soda,
are said to prove advantageous internally administered.*
                      a R.—Calcis chlorin. gr. x. vel,
                          Liq. sodae chlorin. <\\ "v^iij.
                           Syrup. 3ij.
                           Aquas, 3iv.—M. (Dunglison.)
        Dose, a dessert-spoonful every three hours, for a child, six years old.
   The free, internal use of the chlorate of potassa—one to three scru-
ples, in twelve hours,  according to the age of the child, is strongly re-
commended by Hunt. 
DISEASES OF  THE DIGESTIVE  ORGANS.         169
   The iodide of iron has also been suggested by Dr. Dunglison as a
 means of improving the  condition of the nutritive function, which, in
 this disease, is evidently impaired.*
                    * R.—Vini Hispan. (sherry) giv.
                         Ferri iodid. 3j.—M.
                      Dose, a teaspoonful, four times a day.
   When a  profuse diarrhoea occurs  in the course  of the disease, we
 have found it often to be very quickly arrested, by adding to the solu-
 tion  of sulphate of  quinia, two or  three drachms  of the tincture of
 kino.   In some cases, we have given, with good effect, three or four
 grains of powdered  galls, repeated every three or four hours ;  should
 these  remedies fail, we may give the  acetate of lead, in the following
 prescription.*
                    • R.—Acetat. plumbi,  gr. xvj.
                         Cretan ppt. 9ijss.
                         Ipecacuanha?, gr. iv.
                         Opii pulv. gr. ij.—M.
                  One to be given every three or four hours.

                    7. — Difficult Dentition.

   Dentition  is a purely physiological process, and in  the healthy in-
 fant, with  an  organism in  no part of which there  exists any  strong
 predisposition  to morbid  action, it is  attended in genera],  with little
 suffering or danger.  It may, nevertheless, give rise  to much suffering,
 or even be the  exciting cause of some violent and quickly fatal malady,
 whenever the  irritability of the infant's system  has become unduly
 augmented—when its energies have been impaired,  and a tendency to
 disease  in the  alimentary canal, in the brain,  or in the respiratory
 organs, has been developed by bad nursing—or by an impure, heated,
 or confined air.
   It is usually  between the fifth and seventh  month, that dentition, in
 the ordinary acceptation  of the term, commences.  In different cases,
 however, the period when the teeth  begin to protrude from  the gums,
 will be found  to vary—in some, the  teeth appearing earlier, and, in
 others, not until some weeks, or even months, later.
   As soon as dentition commences, there is very generally an increased
 redness, attended with considerable heat and tenderness of  the  gums,
 and  an increased secretion of saliva.  Occasionally, there is a slight
 febrile reaction—redness of the cheeks, watering of the eyes, and aug-
 mented thirst.  The child is often fretful, and disturbed  in  its sleep.
 The discharges from the bowels are more frequent and  fluid than
 usual,  and occasionally of a greenish hue;  and  the stomach is mor-
 bidly irritable,  the matters discharged from  it having often a strong
 acid smell.  Occasionally, eruptions appear upon the skin, particularly
 upon the forehead and cheeks—in some  cases an  erythematic inflam-
 mation, and ulceration behind the  ears, and, not unfrequently, a slight
tumefaction of the salivary glands. As the advancing tooth approaches
 the surface of the gum, the fingers of  the child are  frequently held in
his mouth; and he presses firmly between his gums the nipple in suck-
 ing,  or any object  which he can  readily  seize  and convey to his 
170
DISEASES.OF CHILDREN.
mouth; this appears to ease some uneasy sensation experienced by the
child, as does also pressing, or rubbing the gum with a finger.
  The foregoing symptoms are not invariably present during dentition.
In some children, the process is attended with such slight  inconveni-
ence, that the first two incisors  are  frequently cut without attracting
the slightest attention, until their points are seen protruding beyond the
gum.
  It  is principally, when there is a disproportion between the develop-
ment of the teeth and jaw, as when dentition commences very early,
or when a number of teeth are cut at the same time, that much pain
or difficulty occurs.   The molar teeth are, also, cut with  more diffi-
culty than the incisors.
  Even when the symptoms we  have described above, do occur, all
that  is necessary is, to confine  the child  to the breast of a healthy
nurse,  and  to  supply him, occasionally, with moderate  portions of
fresh water, in  which a small quantity of gum acaciae has been dis-
solved ; or if he has been weaned, to  restrict him to a diet composed
chiefly of milk  and farinaceous substances, and for his drink, to toast,
barley, or rice  water; animal food, all stimulating drinks, and every
kind of spice being withheld.  The child should be kept in a  pure, fresh
air, and not overheated either by too much clothing, or by too great a
temperature of the room he occupies.  His head, in particular,  should
be kept cool, as well during the night, as in the day.  The daily use of
the tepid or warm bath will  be advantageous; and if the weather per-
mit,  daily exercise in the open air should not be neglected.
   Little attention need be  paid to  the diarrhoea that  is usually atten-
dant upon dentition—it is  seldom very profuse.  If accompanied with
considerable griping,  an injection  of  thin starch, or of a decoction of
flaxseed, with the addition of a little sweet oil, will, in general, be suf-
ficient; but if the griping  still continue, a few grains of calomel may
be given  by the mouth, followed, in  the course of four or five hours,
by a dessert-spoonful of castor oil.   If, as occasionally happens,  the
bowels, in place of being more free than usual, are constipated, a dose
of magnesia, or of castor oil may be given. The eruptions, which often
appear about the face, and  the  inflammation  and  ulceration which
occur behind the ears, demand no particular attention; the latter may
be washed, night and morning, with  some mild mucilaginous fluid, as
water in which the pith of sassafras or the inner bark of the slippery
elm  has been  infused.  The eruptions and ulceration very commonly
disappear when the teeth  have protruded beyond the gums.
   As infants appear to derive relief  from a slight degree of pressure
upon the gums during dentition, something should be allowed them for
that purpose.   A substance that will yield to the pressure of the gums
is to be preferred; an oblong piece of gum caoutchouc, two or three
inches in length, and half  an inch in breadth, will probably be the best;
it should be suspended round the neck by a ribbon or tape.  All hard,
rough, or unyielding substances are positively injurious.
   A variety of washes for the mouth have been recommended, by dif-
ferent writers,  to "soften, soothe, and refresh the gums, during denti-
tion." When  composed of any  simple mucilage, these washes  will do 
DISEASES OF THE DIGESTIVE ORGANS.         171
no harm; they are unnecessary, however, if the child be supplied with
cold mucilaginous drinks:—the good effects that have been attributed
to them, in allaying the irritation of the gums, is  referable, we suspect,
entirely to the gentle friction produced by the  nurse's fingers, in their
application.
   It is not always, however, that the process of dentition is accom-
plished with so little inconvenience.   In children of very irritable ha-
bits, in those who are gross and plethoric, or in  whom there exists a
strong tendency to disease in one or other of the  organs, dentition may
become the exciting cause of some  of the most serious and fatal mala-
dies incident to the period of childhood.   In such cases inflammation
of the mouth or gums, terminating in ulceration or gangrene—long-
continued and extensive disease of  the bowels, accompanied with fre-
quent and vitiated discharges—spasmodic closure of the glottis—con-
vulsions, often of a violent character—and hyperaemia,  inflammation,
or dropsy of the brain, are among the most common results of difficult
dentition.   In the children of the poor especially, who are exposed to
the overheated, stagnant, and impure atmosphere  of the confined streets,
courts, and alleys, of our larger cities in the Middle and  Southern
States, dentition  becomes, during the summer  season, one of the most
common exciting causes of the cholera of infants.
   Much  may be done even in such cases, by  a judicious course  of
treatment, towards preventing the mischief which the process of den-
tition has a tendency to develope.   The child should, as  far as possi-
ble, be  removed  from the influence of whatever morbific causes he
may be surrounded with.   He  should be placed  in a pure, fresh atmo-
sphere.  His diet should be mild, nourishing, and easy of digestion.  If
of a plethoric habit, every species of animal food should be withheld;
while, if he be labouring under great exhaustion or debility, it may be
necessary to allow him beef, mutton, or chicken  broths, or even a por-
tion of the meat of which these are prepared, plainly cooked, and  in
moderate quantities.  The strictest  cleanliness of person and clothing
should be observed: the daily use of the warm bath, and  frequent ex-
posure to the open air, in suitable weather, with an amount of exercise
adapted  to his age and state of health, should be strictly enjoined.
   The condition of the gum should be daily and carefully examined;
and  the  moment it appears hard and swollen, and  the teeth are evi-
dently distending it, a free incision should be made with a lancet, at
the points where they are about to protrude, so as completely to divide
the tough membrane by which the tooth is enveloped, the distension  of
which by the  advancing  tooth, being the cause  of much of the pain
and  irritation  consequent upon  difficult dentition.  The lancet should,
in every instance, be carried  down until it reaches the tooth, and if it
be one of the molar teeth  that  is about to protrude, a crucial incision
will be necessary.  This operation gives  but little pain, and  is rarely,
when judiciously performed,  attended with danger  or inconvenience,
while, in many cases, it is followed by immediate relief,  and may be
the means of preventing the occurrence of fever, convulsions, or fatal 
172
DISEASES OF CHILDREN.
disease of the brain.*  Even subsequent to the occurrence of convul-
sions,  of spasmodic closure of  the glottis,  or of deep  stupor from
hyperaemia of the brain, a free division of the gum over the advancing
teeth has been  known, in repeated instances, to be followed by an
almost immediate cessation of every alarming symptom.
  A curious case is related by M. Robert, in  his Treatise on the Prin-
cipal Objects of Medicine, illustrative, as well of one of the effects of
difficult dentition, as of the division of the gum.  We give it  upon the
authority of M. Carault, not having seen the  work of M.  Robert.
  A child, after having suffered greatly from difficult dentition, appa-
rently  died, and was laid out for interment.   M. Lemonnier, having
some business at the house of the nurse, with whom the child resided,
after fulfilling the object of his visit, was desirous of ascertaining the
condition of the alveola.  He accordingly made a free incision through
the gums; but, on  preparing to pursue further his  examination, he
perceived the child  to open its eyes, and give other indications of life.
He immediately called for assistance; the shroud was  removed from
the body, and by careful  and persevering attention, the  child's life was
saved; the  teeth  in due time made their  appearance,  and its health
was fully restored.
  When considerable redness and tenderness of the gums occur about
the period when  the process of dentition is  expected  to  commence,
without, however, either of the teeth having advanced sufficiently near
to the surface of the gum, to render an incision of the latter necessary,
emollient washes should  be frequently  applied to the gum, and a leech
or two to the angles of  the jaw.   If  the bowels are costive,  a purga-
tive of calomel,  followed by castor oil,  may be administered.  Should a
considerable degree of febrile excitement be present—particularly, if it
be attended by heat and  tenderness of the abdomen—a few leeches to
the gums, and over the epigastrium, the tepid bath, and small doses of
calomel and ipecacuanha,' will be generally found advantageous.
                    a R.—Calomel, gr. ij. ad iij.
                         Magnes. calc. gr. xxiv.
                         Ipecacuanha?, pulv. gr. ij. ad iij.—M. f. ch. No. xij.
                    One to be given every three hours.
  When  dentition is  attended with frequent and copious discharges
from the bowels, of a thin watery consistence, and accompanied with
more  or less griping—bland mucilaginous drinks, and  the tepid bath,
will, in general, afford relief; if,  however, the diarrhoea continues un-
  * We have said that the division of the gum over the protruding teeth, when performed
at a proper time, and in a proper manner, is " rarely attended with danger or inconve-
nience."  It should be performed only when the gum is evidently raised by the advancing
tooth, and the surrounding parts are red and painful.  We have never seen the aphthous or
gangrenous ulceration which Billard apprehends may be produced by the incision.  Were
it to happen, in the majority of cases it would be a less troublesome  and unmanageable
occurrence, than that to prevent which the incision is made.  In two instances, however,
which fell  under our notice, both occurring in children of a scrofulous habit, and who had
suffered from long-continued chronic disease of the bowels, a  constant oozing of blood
took place from the incision, and which could not be arrested by any means  that were
resorted to, including the actual cautery. 
DISEASES  OF THE DIGESTIVE ORGANS.          173
abated or increases, we have found the best means of arresting it to be
a solution of acetate of lead given by the mouth.*
                    a R.—Acetat. plumbi, gr. viij.
                         Acid. acet. impur. m/ viij.
                         Sacch. alb. 3j.
                         Aq. purse, 3j-—M.
  An ordinary sized teaspoonful of which may be given as a dose; and repeated, three or
four times a day, until the frequency of the discharges is abated.

   When there exist increased heat  and redness, with turgescence of
the vessels about the head—particularly if, at the same time, the child
is unusually drowsy, or  starts frequently from its sleep, with a wild,
affrighted aspect—a few leeches should be applied behind the ears, and
the head sponged frequently with cold water alone, or cold water, withj ,#|  f(
the addition of one-fourth of proof-spirit; while the bowels should also.    V
be freely opened by calomel, followed by castor oil  or epsom salts.  '*  '
Where  the tendency to disease of the brain is very decided, after the »   '» t
application of leeches, blisters behind the ears, repeated as they heal •'
up, will often prove serviceable. The slightest indication of an approach-
ing attack of convulsions or  spasm,  should be  carefully watched, and
treated by its appropriate remedies.
   The dysuria, so common in cases of  difficult dentition, is best  as-
suaged,  by the free exhibition of some mild, demulcent  drink.  If the
pain be  considerable, and there is nothing present to forbid its use, an
opiate may be administered.*
  * R.—Sulph. magnes. 3»j.  ad 3iij. Solve in  Or, R.—Hydrochlor. ammonias, 3j.
       Aquae puree, 3j. dein adde                 Pulv. ipecacuanha), gr. iv.
       Spir. aether, nitrici, 3ij.                  Pulv. opii, gr. ij. M. f. ch. No. xv.
       Tine, opii, m/ vij. ad. xv.              One to be given once or twice in the
  Dose—a teaspoonful, to be repeated accord-       course of the day, according to cir-
    ing to circumstances.                      cumstances.
                         CHAPTER  II.

                    DISEASES OF THE THROAT-J"^ £,/^^fc*e.

                          1. —Tonsillitis.

   Inflammation of the tonsils and veil of the palate, is a frequent dis-
ease, in  the  latter stage of infancy, and during the entire  period of
childhood.   It seldom, however, assumes the decidedly acute charac-
ter, so common  in  the  tonsillitis of adults.  From a very early age,
the tonsils are liable  to  a subacute form of inflammation, producing,
in many cases, a  very considerable  enlargement of these parts, which
often continues for a long period,  changing the tone of the patient's
voice, and impeding his breathing,  deglutition, and hearing.
   Tonsillitis usually commences with a sense of pain or uneasiness in 
174
DISEASES OF CHILDREN.
            the throat, a huskiness of the voice, and a sense of chilliness and lan-
            guor, quickly followed by more or less  febrile reaction.  The pain in
            the throat increasing, deglutition becomes more difficult, and a sense
            of heat or  burning is often complained of in the pharynx.  There is
            often considerable nausea, and  in children at the  breast, regurgitation
            of the milk, shortly after it is swallowed; in children a few years old,
            there is a frequent hawking and rejection of tough mucus.
              The throat being examined, the velum palati and pharynx are found
            to be increased in redness, and tumid;  both the redness and  intumes-
   P        cence being, often, more  considerable on one side than on the other;
            while  one or both tonsils are found to be  swollen, and generally covered
            with a coat of thick, tough mucus, often of a dirty white colour.   In
  fi IfJWJjMtkomQ cases, the soft palate  and uvula present a dark red and cedetna-
^ .'^^/u^^ttous appearance.  The throat  is tumid, and painful to the touch, ex-
 Cltff *'j. f*ernally.  The tongue is covered with a white fur, through which the
 fj/^/ <TjC€» P^'l86' enlarged and of a bright red  hue, project—a thick pellicle of
            transparent mucus being spread over  the whole; when,  as  is  occa-
            sionally the case, the inflammation of  the throat is complicated with
            gastric disease, the tongue is generally covered with a yellowish fur,
            and a sense of pain or heaviness is  experienced over the eyes.
              The swelling of the tonsils is often very considerable, impeding re-
            spiration, often entirely preventing deglutition, rendering  the voice in-
            distinct and whispering, and the hearing obtuse.
              The disease, when properly  treated,  commonly terminates by reso-
            lution.  We never recollect to have seen an instance of extensive sup-
            puration in a child.  A substance, somewhat resembling pus, is, how-
            ever, occasionally seen, adhering to the surface of both tonsils; and,
            in some cases, a slight, circumscribed,  diphtheritic exudation.   Very
            frequently, the  redness and tumefaction  of the velum and pharynx sub-
            side, while the  enlargement of the tonsils continues.
              More  frequently the symptoms,  from  the commencement of  the
            attack, are  of a  much less marked character.   The child, if  at  the
            breast, exhibits a difficulty and pain in  swallowing, and throws up its
            milk  soon after it is swallowed; the throat, externally, is somewhat
            swollen, and tender to the touch; and there is a peculiar huskiness of
            the cry.   If the child is old enough, it complains of pain in the throat,
            increased at every.aUempt to swallow;  and the swelling of the throat
            externally, is'offen very considerable; there is a difficulty of breathing,
            and a  frequent  hawking up of a thick, tenacious mucus.  On examin-
            ing the throat, a slightly increased  redness of the palate is observed,
<            with considerable and irregular enlargement of the tonsils, which pre-
            sent a kind of lobulated appearance, their surface being covered with
            a thick coating of tough  mucus.  This  form of the disease is very
Si;           generally complicated with disease of  the  alimentary canal; and is
            more common  in children of a  lymphatic, than in those of a sanguine-
            ous temperament, and plethoric habit.
*              The causes of tonsillitis are, in general, exposure to cold  and damp-
            ness—sudden vicissitudes of atmospherical temperature—cold drinks,
            when the  body is in a state of perspiration—and  cold to the feet.   It
            frequently exists  simultaneously with the  acute  exanthemata.   It is 
DISEASES OF THE DIGESTIVE ORGANS.         175
more prevalent in  spring  and the latter part of autumn, than  in  the
middle of either summer or winter.
  The treatment of inflammation of the tonsils is very simple,  and, if   -
early commenced,  a very prompt resolution of the inflammation may
in general be effected.  In slight cases, some rubefacient to the  throat,
externally,* followed by an emollient  poultice;  a purgative of a few
grains of calomel,  with a moderate dose of the sulphate of magnesia
a few hours subsequently, and a warm pediluvium  at bed-time, will
frequently be sufficient  to arrest the inflammation.                     ^x j ^#
1 R.—01. olivae, 3j.
     Aq. ammonias, 3ij.
     Sp. terebinth. 3j.—M.
V
  When, however, the  inflammation of the throat is  more  consider-
able, a few leeches should  be applied to the neck, or behind the ears;      ~
and, internally, minute doses of tartar emetic, either  simplv dissolvedt%Ct 4 f
in water,* or in a solution of sulpTiate of magnesia.b     Jj[ flgT+X^ifiC'*?
       * Aquae purro, gij. ad iv.              b Sulph. magnes. 3iv. solve in
        Tart, antimon. gr. j.—M.             Aq. purae, 3iv, dien adde
     Dose, a teaspoonful every two or           Tart, antimon. gr. j.—M.
       three hours.                             Dose, the same.
  We have derived very great advantage, in cases of tonsillitis, from
the use of a combination of the hydrochloride of ammonia, ipecacu-
anha, and calomel.*
                 * Ammonias hydrochlor. gr. xxxyj. ad 3j.
                   Ipecacuanha? pulv. gr. ij.—iv.
                   Calomel, gr. iij.—vj.—M. f. chart. No. xij.
                 One of which is to be given every three hours.
  The hydrochloride of ammonia, in  inflammations of the  throat  in
children, is a favourite prescription with  many of  the continental phy-
sicians.  Loeffler  recommends  it  in tonsillitis, to be given internally,
dissolved in water, with the addition of the extract of liquorice.
   Blisters to the throat, are directed by most writers, when the inflam-
mation of the tonsils is severe, and  is not quickly arrested by the other
remedies employed.  We have seldom seen much  good  result from
the application  of blisters to  the throat in young children; nor  any
instance in which they were required, in the disease under considera-
tion.  If resorted to, they should be kept on only so long  as  to redden
the skin; and, on their removal, the part to which they were applied
should be covered with an emollient poultice.
   If the child be at the breast, it is  better not to allow it to suck, until
the inflammation of the throat is subdued—it sucks in general with so
much avidity, that a large quantity of milk is carried to the  throat  at
one time, which is almost immediately afterwards discharged, by re-
gurgitation or vomiting.  Its thirst  may be assuaged by a few spoon-
fuls of water, rendered somewhat mucilaginous by an infusion of slip-
pery elm bark or pith of sassafras,  or  by a mixture of milk and water,
given occasionally.  Older children should be debarred from all food,
and allowed toast-water, or some simple mucilaginous fluid as a drink.
  Patients affected with tonsillitis, should be kept  in a dry apartment,
the air of which is of a moderate and  equable temperature. 
176
DISEASES OF CHILDREN.
               When accompanied by disease of the alimentary canal,  the latter
             should be treated by its appropriate remedies.
          »     The treatment of  the subacute form of tonsillitis, which, according
             to our experience, is the one  most frequently met with  in children,
             differs in nothing from that of  the acute form.  Leeches to the throat
             will be occasionally required.  The mixture of hydrochloride of am-
             monia, ipecacuanha, and calomel, will be found particularly advanta-
             geous.
               When an  indolent enlargement of the tonsils remains, after the
 A&G/nffyremoval of the inflammation, the application of solid nitrate of silver
  **         over the surface of the enlargement, will occasionally  be found  ser-
             viceable.   We  have seldom,  however, seen much injury, or very
             serious inconvenience, to result from enlarged  tonsils in  children;
             they  have usually gradually dispersed, and have seldom continued
    I     •# beyond the period of puberty.

. **r^tfh)tirAf$* '■V-Psgjiflo-membranons, or Diphtheritic Inflammation
',/V£sU<                           of tne Throat.
 ^             This is one of the most common forms of inflammation of the throat
             in children, and  is that which most generally accompanies scarlatina,
             when the latter prevails as an  epidemic.  Its most conspicuous cha-
             racter, is the early excretion of a thin, pseudo-membranous pellicle,
             either continuous or in patches, and closely adherent to  the surface of
             the inflamed mucous membrane, upon which it is produced.
               Pseudo-membranous inflammation  of the throat commences often
             with symptoms of so mild a character, as  to attract scarcely any at-
             tention, until the local disease  has made considerable progress.  The
            deglutition is but little—or not at all—impeded ; only a trifling soreness,
            or rather a sense of roughness in the fauces  is experienced,  while no
            febrile excitement is present.  The child often continues to indulge in
            its ordinary sports, with, perhaps, a little more fretfulness and dejection
            than usual, and becoming, apparently, more quickly tired.
              In other cases, there is, from the commencement of  the  attack,  a
            sense of languor and  general discomfort;  a  feeling  of chilliness,
            alternating with  flushes of heat; increased thirst; pain of the head;  a
            sense of heat or  burning in the  throat; while the act of swallowing,
            and the slightest motion of the  neck,  cause more or less  pain.  The
            skin is hot and dry ; the eyes are often red and watery ;  and the coun-
         -   tenance flushed.  Frequently, however, the countenance is  tumid, pale,
            and expressive of sadness or dejection. When there exists any decided
            febrile excitement, an exacerbation generally occurs night and morn-
            ing.   There is, in many cases,  considerable nausea, and  tenderness of
            the epigastrium.  At first, there is usually a  constipated state of the
            bowels:—diarrhoea, however, occasionally supervenes,  in  the  course
            of the disease, and in severe and protracted cases is often  copious.
   '           From the very commencement of the attack, the mucous membrane
            of  the fauces and   tonsils  is  of a  deep red  colour, and becomes
          •  speedily covered with a layer of tenacious transparent mucus.  The
            mucous membrane,  particularly  of the pharynx  and soft palate, is
            in  some cases infiltrated with blood, in the form of small disseminated 
DISEASES  OF THE  DIGESTIVE  ORGANS.         177
points, having a linear arrangement; or of small, oblong ecchymoses,
of a dark red colour.  Occasionally, the  mucous membrane presents a
few dry, oblong, grayish spots, as though it had been, at these points,
cauterized with an acid.
  As the  disease advances, the exudation becomes  more abundant,
and forms a firm pellicle, of a dirty yellow or grayish  colour.  It  is
usually disposed, at first, in patches, more or less circumscribed, often
slightly  elevated in the centre, but thin and  flocculent at the circum-
ference.   These patches increase in  extent, more or less  rapidly;—
sometimes, in the course  of a  few hours the whole  of the posterior
fauces becomes covered with them. They are at first  thin, but become
increased in thickness, by successive depositions, and acquire, often,
so much firmness, as to permit them  to  be  detached  entire from the
mucous membrane, to which they adhere  by numerous minute fila-
ments, that appear to  penetrate  the  orifices of the  mucous follicles.
Their detachment is  generally followed by  more or less oozing of   i
blood from the denuded membrane, which exhibits but  little  intumes-
cence, and is of a dark red colour, often variegated with  points or
striae, of a deeper hue.
  Between the pseudo-membranous  patches, the submucous cellular
tissue assumes, occasionally, an cedematous appearance; in  conse-
quence of which, the corresponding portion  of the membrane  is ele-
vated, and causes the portions that are occupied by the  pseudo-mem-
brane to assume somewhat the  appearance of ulcers, covered with a
tenacious  exudation.  The patches, very generally, become soon con-
fluent ; so that,  in  many  cases,  the whole of the  soft palate, the
pharynx, and the inner surface of the cheeks, are lined by a continuous
pseudo-membranous exudation, often of considerable consistence, which
is rapidly renewed,  as often as it  is detached.
  In the commencement of the  disease, the tongue is pointed, red at
the edges, and covered on its surface with a thin layer of white mucus,
through which the enlarged and florid papillae protrude.  There is an
increased  secretion of saliva, which soon becomes dark-coloured, from
the admixture of blood  discharged from  the mucous  membrane as
portions of the pseudo-membranous deposit  are detached,  and of an
offensive odour, from  the vitiated state of the secretions of the throat
and mouth.
  In the course of the disease, the colour of the pseudo-membranous
excretion  changes to an ash, brown, and, finally, black colour; the
mucous membrane beneath becoming of a dusky red hue. The tongue
and mouth  are  often dry, and  dark-coloured, and the teeth more or
less thickly covered with a dirty white, or blackish incrustation.
  If the affection of the throat  is of any extent, and the inflammation
is not early  arrested, the  submaxillary glands become enlarged and
painful, and  the  surrounding cellular tissue infiltrated with serum,
causing often a considerable intumescence of the neck.   More or less!> ■
tumefaction of the tonsils and  soft palate, and occasionally  of the. -\
tongue,  takes place, frequently to such an extent as to interfere with  •;»
the freedom of respiration ; ulcers form along the edges of the tonguej**»v
the palate, and upon the inner  surface of the cheeks; and there is a
                               12 
178
DISEASES  OF CHILDREN.
              constant  oozing of blood from the mucous membrane  of the mouth
              and fauces, which is increased upon the slightest irritation.
                The febrile excitement sometimes continues with but little abatement,
              until towards the close of the disease.   The heat of the surface, how-
              ever, in general abates—the  skin assuming a dusky appearance, and
              doughy feel; profuse diarrhoea often occurs; the secretions, generally,
              become vitiated, and  either  increased or diminished  in quantity; the
              prostration of strength augments; and a state of torpor, or even decided
              coma, is  not unfrequent.
                When  the inflammation and pseudo-membranous deposit extend into
              the pharynx and commencement of the oesophagus, there is a sense of
:              soreness and of heat in these parts, accompanied with increased diffi-
              culty of swallowing—every  attempt at  which is productive of severe
              pain.  When the disease extends, through the posterior nares, to the
              mucous membrane of the nose, the patient is unable to respire through
          ,    the  nostrils;  from  these there takes place a discharge of a  serous,
              yellowish and flocculent or bloody sanies, often of a very foetid odour,
              and which produces more or less inflammation and excoriation of the
              external openings.  When the disease extends to the Eustachian  tube,
              pain  is experienced in the ear, with more or less defect of hearing,
              often complete deafness, which, in consequence of the obliteration of
              the tube, is, occasionally, permanent.
                The pseudo-membranous inflammation is particularly liable to extend
              into the larynx, trachea, and  bronchi.  This extension of the disease,
              in some cases, takes place almost immediately upon the first appear-
              ance of the patches in the fauces; in other instances the respiratory
              organs are not  affected until about the second or third day, or  even
              later.  At whatever period the respiratory tube becomes affected, the
              symptoms of  croup—hoarseness,  shrill  cough, great  difficulty of
              respiration, and  more or less  aphonia, are  immediately developed, and,
              in the greater number  of cases, the patient is rapidly destroyed.  It is
              supposed  by many  pathologists, that croup is, in every  instance, pro-
              duced by  an extension of the pseudo-membranous  inflammation  from
              the throat to the larynx and  trachea; although we cannot admit that
              such  is invariably the case, we have reason to believe, that croup is
              more frequently preceded by  pseudo-membranous inflammation of the
              throat, than is generally supposed.
                Besides the extension of pseudo-membranous inflammation to the
              larynx and trachea, giving rise to the phenomena of  croup, it is said
              by Guersent to  be  productive, also, in certain cases, of a species of
              pneumonia, extremely  insidious in its commencement,  and marked, in
              part, by the symptoms which are referable to the disease of the throat.
              The  cough, in this affection, is different  from that of  croup, and is
              unattended with aphonia; the mucous expectoration is often streaked
   -           with  blood, while auscultation and percussion give all the indications
 «fr£*AA*» j, 4C*of a more or  less extensive catarrhal engorgement of  the lungs.
J^/fopJZK*- There is not only a  tendency in the pseudo-membranous inflamma-
yc*.0Jt$t>*C  tion to extend along  the mucous membrane of the  throat, into the
„ .J Cm JMiC""t;— of the nose, even to the frontal sinuses, into the Eustachian
              tube, the  pharynx,  oesophagus, larynx,  trachea, and  bronchi, but it, 
            DISEASES  OF THE DIGESTIVE  ORGANS.         179

likewise, often seizes upon remote parts of the body, particularly in
situations covered by a mucous membrane, or from which the cuticle
has been accidentally removed by a blister, or by ulceration, (Trous-
seau.)  Thus, it is often observed upon the lips, the alae nasi, the concha,
the external meatus, and the parts behind the ear, upon the nipples, in
the folds of the groin, around the contour of the anus, within the vulva,
upon the surface of blisters, leech-bites, &c.
   In favourable cases  of pseudo-membranous  inflammation of the
throat,  as  the membranous exudation becomes detached  from the
mucous membrane, its place is quickly supplied  by a new formation,
and, after each separation, it becomes in general,* whiter, and much
thinner.  In other cases, the exudation, instead of being separated in
fragments, becomes, in  part, softened  to  a  pulpy consistence, and is
discharged from the mouth, mixed  with bloody mucus.   This separa-
tion and renewal of the  pseudo-membranous deposit, continue, in most
cases, for the  space of  eight  or ten days;  when, finally, it ceases to
appear, leaving,  most generally, the mucous tissue to which it  had
been attached, perfectly sound  throughout its whole extent, of a light
red, uniform colour, and covered, usually, with a thick yellow mucus,
more or less resembling pus.
   As the disease in the throat disappears, the glands of the neck, pro-
vided they are not in a state of suppuration, which very rarely occurs,
diminish in volume, and are no longer painful or tender to the touch.
The difficulty in deglutition disappears; the tongue loses its pointed
appearance, and becomes clean and moist, the skin soft, moist, and of
a more natural appearance, the countenance more animated and cheer-
ful ; while the  stomach  and bowels gradually resume the regular per-
formance of their  functions, and the general strength and  vigour of
the patient become slowly reinstated.
   In severe and unfavourable cases, the disease is  often  more pro-
longed;  the whole of the  symptoms become aggravated; the mouth,
tongue, and throat become dry, and of a deep black colour;  the diar-
rhoea becomes profuse, and the strength of the patient more and more
exhausted; general colliquation  ensues,  and death  takes place, fre-
quently  preceded  by deep coma, or, in children  somewhat  advanced
in age, by violent delirium.
   When the disease  is confined  to the soft  palate, isthmus  of the
fauces, and  pharynx, it  is  seldom attended with much danger, and
generally yields readily  to an appropriate treatment;  or, when the in-
flammation is of little extent, it may even disappear spontaneously in a
few days. When, however, the disease extends to the larynx, it is very
frequently fatal, by the  occurrence of tracheitis, bronchitis, or pneu-
monia.
   The causes, nature, and treatment of pseudo-membranous inflam-
mation will be noticed after we  have  described  the  gangrene of the
throat.

                  I—Gangrene  of the Throat.
   Actual gangrene of the throat is of far less frequent occurrence than
it was generally supposed to be by the older writers, or is still believed 
180
DISEASES  OF CHILDREN.
    to be by many physicians of the present day.  That form of anginose
    disease  to which the term putrid, malignant, or gangrenous, has been
    most commonly applied is, strictly speaking, unattended with either
    gangrene or sloughing of the throat; it is, in fact, a highly aggravated
    or malignant form  of pseudo-membranous inflammation.  Sloughing
    of the throat, or a species of gangrenous ulceration of this part may,
    however, occur in  certain cases of epidemic  pseudo-membranous an-
    gina, and particularly in the angina accompanying epidemics of scar-
    latina of a very malignant character.
^£&  Malignant angina, in its commencement, differs but little from ordi-
11  nary pseudo-memb*ranous inflammation of the throat.  The fauces pre-
    sent the same membraniform exudation: it is more generally confined,
    however, to the mucous membrane anterior to the larynx, over which
    it is more uniformly spread; it also more early assumes a dull ash
    colour, quickly changing to dark brown or black.  The disease seldom,
    if ever, extends to the trachea or bronchi.  The pain and tumefaction
    of the submaxillary glands, are much more  considerable than in the
    preceding form of the disease; and they are, also, more liable to run
    into suppuration.   The mucous membrane of the fauces is almost uni-
    formly injected with blood of a violet colour, and more or less swollen,
    but without the ecchymosed appearance noticed in the preceding va-
    riety; the tonsils, also, are  more swollen, softer, and infiltrated with
    mucus and pus. The face exhibits a bloated, bronzed aspect; the eyes
    are heavy, dull, and watery.
      There is often extreme difficulty of deglutition;  the voice is entirely
    guttural, and the power of articulation is occasionally suspended.  In
    some instances, the respiration  is rendered difficult from the excessive
    tumefaction of the tonsils and soft palate.
      In the commencement of the attack there is generally intense  febrile
    excitement, with a dry, hot, burning skin, parched mouth, urgent thirst,
    and often considerable delirium.  The fever is attended with an exa-
    cerbation towards evening.  Nausea, vomiting, with tenderness and
    oppression at the epigastrium, and  diarrhoea, accompanied with thin,
    acrid, and intolerably offensive discharges, are often present from the
    commencement of the attack, or occur at an early period.
      A foetid, sanious  discharge from the nostrils occurs often from the
    very commencement, and the  patient  discharges  from the throat at
    first, a thin, bloody mucus, which becomes, subsequently, puriform, and
    mixed with shreds  of a membranous appearance.   In some cases, the
    discharge is dark coloured, almost putrid, and highly offensive.
      In the milder cases of the  disease, upon the separation of the pseudo-
    membranous exudation, the  mucous surface beneath presents a  moist,
    red appearance, without ulceration or loss of substance; the discharges
    from the mouth become of  a less offensive character, and are dimi-
    nished in quantity; the tumefaction of the throat subsides; the  tongue
    becomes cleaner  and more moist; the febrile  symptoms gradually
    abate, or entirely disappear; the dejections from the bowels diminish
    in frequency, and become more natural in appearance; a general ame-
    lioration of all the  other symptoms ensues, and  the patient by slow
    degrees  acquires his accustomed strength and vigour. 
            DISEASES  OF THE  DIGESTIVE ORGANS.         181

  In cases of greater malignancy, the symptoms rapidly increase  in
intensity; the pseudo-membranous deposit in the throat assumes a dark
colour, and separates in flocculi, or  shreds,  of an intolerable foetid
odour.   The  mucous membrane at first presents a dark red, and raw
appearance, while from its surface there oozes a dark-coloured blood;
but it speedily assumes a sloughy condition; the tongue  becomes dry
and parched, and coated with a dark  brown or black crust; the teeth
and gums are covered with dark-coloured sordes; and the gangrenous
condition extends from the mucous  membrane to the tonsils and soft
palate.  The accompanying fever assumes a low, typhoid character,
and  petechia? of the external surface are often observed.  Dark-co-
loured vesicles  occasionally occur about the corners of the  mouth,
and on the inner surface of the lips and cheeks,  and occasionally upon
the tongue,  and, becoming ruptured, form  gangrenous ulcers that
quickly extend, and cause extensive  destruction of the surrounding
soft parts.  The diarrhoea increases in frequency; the discharges  be-
coming more thin, acrid, and offensive; the strength of the patient be-
comes more and  more prostrated; and stupor and insensibility ensue,
which are quickly succeeded by death.
   The progress of gangrenous angina is ordinarily very  rapid,  the
disease often  running through all its periods in the space of a week or
twelve days.  It generally attains its height  in  seven or eight days,
after which period the febrile symptoms abate or disappear.   It may
destroy life in a very short period, but occasionally runs a  protracted
course of several weeks.  When it terminates fatally, death usually
takes place within the first week, either from extreme exhaustion of
the vital powers, or in consequence  of the occurrence of extensive
lesions of the digestive or other organs.
   When the disease occurs epidemically, it is  often  productive of a
very great  mortality;  under  all  circumstances, it  is  a  dangerous
malady, and  one but little  within the control of  medicine.
  No little difference of opinion prevails, as to the pathological  cha-
racter of pseudo-membranous  angina.   Bretonneau, Guersent, and
many other of the continental writers, denominate it a specific inflam-
mation ;  which, in fact, amounts to little more than a confession of
their  ignorance of its true character.  Broussais maintains, that the
disease is, in fact, a gastro-enteritis; the affection of the throat being
secondary to the inflammation of the digestive  organs.  Emmangard,
also, adopts this opinion.  There can  be no doubt, that, in numerous
instances, the affection of the throat is preceded or accompanied by
symptoms  of more  or less severe  gastro-enteric disease; but it  has
been  known to occur as frequently, perhaps, without any such symp-
toms being present—at least in its early stages.
  Jolly refers  the disease to  a  haemorrhagic inflammation, in which
the  colourless fibrin is exuded upon the surface  of the mucous mem-
brane ; and Naumann, with a few other German  pathologists, suppose
it to result  from a separation and exudation of the albuminous portion
of the blood, in consequence of a change in the condition of the latter, 
182
DISEASES  OF CHILDREN.
produced by an epidemic influence.  Collineau regards the disease as
one dependent upon a general, and not upon a merely local affection;
while according to the views of Andral, the disease consists in  an
acute hyperaemia of the mucous membrane of the fauces, with exuda-
tion of coagulable lymph.
  That pseudo-membranous angina consists in an intense erythema of
the mucous membrane, giving rise to an albuminous exudation, there
can, we conceive, be little  doubt.  This exudation is a common oc-
currence in the inflammations of the mucous tissue in children ; and in
them  appears to be  connected  with a  peculiar organization  of  this
tissue, and  a certain condition of the blood, difficult to be  understood.
Its gangrenous form is doubtless the result of defective organic power,
and consequent impairment of the nutritive function.
  The causes of the disease have not been well made out.  It is  met
with at all  seasons, and in every variety of climate and  locality.  It
may occur either  sporadically, or as  an epidemic.  It is,  however,
most prevalent during cold, wet, and damp seasons, and in low, damp,
and marshy situations, especially during the spring and autumn.  It is
of most common occurrence, also, among the children of those classes
by whom personal and domestic cleanliness is neglected, and who,
from poverty or other causes, are deprived of a sufficient amount of
wholesome nutriment.  The disease is liable to occur endemically, in
situations where a  number of children are crowded together, and due
attention is not  paid to preserve the air pure, and freely ventilated.
It is, also, a common accompaniment of epidemic scarlatina.
  By nearly all  the earlier writers, as well  as  by some of the more
recent, the  disease, especially its gangrenous form, is considered to
be due to a specific contagion; or to be capable of being  propagated
by a contagious  miasm, generated in situations where many  persons
are crowded together, without a proper attention  being paid to clean-
liness and free ventilation.
  In looking over the arguments by which this opinion is attempted
to  be  established, we find  them, however, altogether inconclusive.
They are derived  entirely from  certain endemic or epidemic occur-
rences of the disease, and instead of proving its propagation from one
or more foci  of contagion, they  merely show, that a number of indi-
viduals had been exposed to the same local or general morbific cause;
and that, while many were affected by it simultaneously, in some it
produced the  disease at an earlier, in others at a later period. That
the disease  has occurred sporadically, affecting only one member  of a
family, or a  single individual of a community, is admitted by nearly
all writers; but that it has ever been communicated directly from the
sick to the well, we have not the slightest evidence.
  The treatment of pseudo-membranous  inflammation of the throat,
will, in a great measure, depend upon the  character of each case.   In
mild, sporadic cases, the disease will generally yield to a very simple
treatment;  while, in its more aggravated forms, and especially when
it  prevails  as an endemic  or epidemic, the most  energetic remedies
will be demanded,  from its  very onset.
  In  every instance, in which there is no disease of the gastro-intes- 
DISEASES OF  THE DIGESTIVE ORGANS.         1Q3
tinal mucous membrane to counter-indicate its use, an emetic of ipe-
cacuanha, administered in the commencement of the attack, will, in
general, be found  beneficial; and even at a later period  mild emetics
will very frequently do good, by expelling the tenacious excretions ac-
cumulated  upon the fauces, and thus rendering the respiration freer,
and deglutition more easy.
   Although the detraction of blood, either from the arm, or locally, by
means of leeches, from the neighbourhood  of the throat, is not so im-
peratively demanded  in pseudo-membranous inflammation, as in  the
other acute inflammatory affections of the throat in children; cases of
the  disease do, nevertheless,  frequently occur, in which  it is unques-
tionably called for, and will be productive  of the  best effects.    In
robust children, particularly in those of  a sanguineous temperament
and plethoric habit, in  whom the swelling and  inflammation of the
throat are considerable, and attended with symptoms of intense febrile
excitement, general, as well as local  bleeding, should be resorted to.
Even when general bleeding may not be considered admissible, leeches
to the throat, behind the ears, or to the angles of  the jaws, will, in
many  cases, be found advantageous.   Broussais, Emmangard, and
others, recommend, in all  cases, leeches to the epigastrium ; and when-
ever there exists tenderness, with increased heat at this part, their ap-
plication should not be neglected.
   In cases  attended with evident depression of the vital energies, with
little febrile  action, a cool skin, the  fauces  being of a  dark colour,
with considerable  foetor of the breath, bleeding from the arm would be
inadmissible, and even the application of  leeches might be, under such
circumstances, attended with danger.
   There can be no doubt of the beneficial effects  of calomel, in many
cases of the disease.  In the earlier stages it forms our best purgative,
and in those cases in which the larynx and trachea  are implicated, it
constitutes  one of our most important remedies ; it should be adminis-
tered in large and repeated doses, either  alone or combined with ipe-
cacuanha.*   Even in the ordinary forms of the disease, occurring in
patients possessed of some degree of vigour of constitution, calomel
has been found advantageous,—relieving  the throat of the membranous
exudation, and other vitiated excretions, and producing a marked  ame-
lioration of the symptoms generally.
               * R.—Calomel, gr. xxxvj. ad xlviij.
                    Ipecacuanha?, pulv. gr. iij. ad iv.
                    Magnes. calc. 3ss. M. f. ch. No. xij.
               One to be repeated every three hours.
   The employment of calomel, at first with emetics, and subsequently,
by itself, in  small  repeated doses, was a favourite practice with Dr.
Rush, in malignant angina.
   In all cases the patient should be liberally supplied with diluent drinks.
In the same class of cases in  which active depletion has been recom-
mended, the drinks should  consist of iced water, iced lemonade, or cold
water slightly acidulated with vinegar; even portions of powdered  ice
may be placed in the patient's mouth, and allowed  gradually to dis-
solve.  In other cases, cool drinks may be allowed; but where the 
184
DISEASES  OF CHILDREN.
powers  of  the  patient are depressed,  and the skin  cool, the drinks
should be  given  of  a tepid, or even  warm temperature.   In cases
attended with decided febrile reaction, the neutral or effervescing mix-
ture may be advantageously administered.
  In the commencement of the attack, the tepid bath, with friction of
the skin, will invariably be found productive of good effects; and when
the heat of the surface is considerable,  generally diffused, and steadily
maintained, the surface should be  sponged with cold water, or cold
vinegar and water.  In cases where the inflammation and swelling of
the throat are considerable, warm pediluvia, with the addition of salt
or mustard, will  act  beneficially as a revulsant.  Where the  powers
of life are depressed, the pulse feeble, and the skin cool, the warm bath
should be substituted for the sponging with cold fluids, as recommended
above.
   Much difference of opinion exists as to the propriety of blisters to
the throat,  in this disease.  We confess  that we are averse to blistering
the throat  in young  children; and  in the few instances in which we
have applied them in pseudo-membranous angina, we have had reason
to regret their use.  In the early stage of the disease, the rubefacients
recommended under the head of tonsillitis, followed by warm, emol-
lient cataplasms,  will occasionally be found useful.  In cases of great
violence, blisters  may be applied to the back of the neck, with some
active rubefacient to the throat.
   The diet should be regulated according to the leading symptoms of
each case.   Where the attack is  one which calls for active depletion,
little else should  be  allowed than  barley water, rice water, or water
gruel.   Rennet whey and buttermilk we have, occasionally, found to
be useful and refreshing articles of  diet in this disease.  When the in-
flammation occurs in children of debilitated habits, or is attended with
symptoms  of exhaustion,  beef tea,  or  plain mutton  or beef broth, in
moderate quantities,  may be allowed.
   In the gangrenous form of the disease, with diminished heat of the
skin, a feeble pulse, and other symptoms indicative of a depression of
the vital energies, a discreet use of tonics and stimulants, will frequently
arrest the progress of the gangrene, and produce a favourable change
in its leading symptoms.  The cold infusion of cinchona, the sulphate
of quinia, the mineral  acids,  an infusion of serpentaria, or the acetate
or carbonate of  ammonia, or wine whey, may be  administered, ac-
cording to  the  circumstances of  the case.  The acetate of  ammonia,
either alone, or combined with  camphor; an infusion of serpentaria,
or the cold infusion of cinchona, with some light aromatic, will be
found among the most efficacious excitants and tonics in this disease.
We have often combined with each dose of the bark, a portion of the
hydrochloric or sulphuric acid, with decided advantage.   The use of
these remedies should, however, be invariably resorted  to with the
greatest caution, and their effects upon  the symptoms of the case care-
fully watched; if they produce dryness of the tongue, increased heat
of the surface, inclination  to stupor, or other unfavourable effects, their
use should  be discontinued.  When  we are unable to administer tonics
by the mouth, a decoction of bark,  or  of serpentaria may be given, in 
DISEASES OF THE  DIGESTIVE ORGANS.         1Q5
 the form of enemata, and in many cases will, in this manner, produce
 a very beneficial result.
   When extensive tumefaction and tenderness of the  glands  of the
 neck occur, leeches may be applied  upon the  tumours, or they may
 be kept constantly covered with  cloths, wet  with cold water, or cold
 vinegar and  water.  The effects of which are often peculiarly striking.
   Various local  applications to the fauces, in the form of washes or
 gargles, have been proposed in the treatment of pseudo-membranous
 inflammation of the throat, and, by  many, are considered to constitute
 the most efficient remedies for the disease.  In the early stage, a wash
 or gargle of equal parts of good vinegar and  water, is, perhaps,  one of
 the best we can employ; diluted hydrochloric acid, or solutions of the
 chloride of soda or of lime, or a saturated  solution of the  borate of
 soda, also, in many cases, form an excellent  wash for the throat.  A
 solution of the acetate of lead, may be employed for this  purpose; it
 will be found, in general, in the  commencement of the disease, very
 beneficial.   A strong infusion  of cinchona, or of oak bark, with the
 addition of alum, creasote diffused in  water, or a saturated solution of
 the sulphate  of copper, will also  be found  to constitute  useful washes
 for the throat, particularly when the occurrence of a gangrenous con-
 dition  is apprehended.
   The application to the  fauces, two or three times a day, of hydro-
 chloric acid, either pure, or combined with three parts of honey, has
 been highly extolled by many of the French and German physicians.
   Among the local applications,  in favour of the beneficial effects of
 which we have the  greatest amount of evidence, is that of the nitrate of
 silver, either in strong solution, from  fifteen to twenty grains in an  ounce
 of water, or in its solid form.  It  will  not only cause the separation of
 the pseudo-membranous deposit, but also produce a more healthy ac-
 tion in the inflamed  mucous membrane of the throat.  It may be applied
 in the  liquid  form, by imbuing a portion of soft sponge, firmly attached
 to a whalebone, with the  solution;  great care  being used to prevent
 any portion of it from entering  the pharynx.
   Alum, reduced to a very fine  powder,  and blown  into the throat
 through a  tube,  the end introduced  into  the patient's mouth  being
 defended by a piece of fine gauze, is strongly recommended in this dis-
 ease, by Bretonneau, Guersent, Bourgeois, and  other  practitioners.
 The sulphate of copper has been employed in  the  same  manner by
 Gmelin.  We have never administered these  remedies in the manner
 here described, from the  apprehension that a portion of the  powder
 should pass into  the larynx, and excite violent  coughing.  A  much
 better mode of applying them is, in solution, as a wash, or by forming
 them into a stiff paste, by the addition  of honey and water, which may
 be smeared upon the diseased surface by means  of a sponge, brush, or
 small spatula.
  When  the patient is unable to gargle,  or when, from  the extensive
 swelling of the throat, or the extreme restlessness of the  child, it is
found to be  impossible to apply, effectually, any of  the washes to the
throat, by means of a sponge or swab, they may be injected  into the
mouth  through  a small syringe, the nostrils being closed, to prevent 
186
DISEASES  OF CHILDREN.
their immediate escape.  Any of the local applications noticed above,
may be applied in this manner, with the  exception  of the nitrate of
silver or the mineral acids.
  When the disease is attended with a profuse and  exhausting  diar-
rhoea, we may employ the cretaceous mixture, with the addition of the
tincture of kino,a or—what we have found  particularly  beneficial in
such cases—a combination of powdered galls, camphor, and ipecacu-
anha,1" or the acetate of lead, in solution.
» R.—Mucil. G. Acaciae, 3iij.             b R.—Pulv. Gallae,  3j.
     Cretae ppt. 3j-                          "  Camphor, gr. iv. ad. vij.
     Tinct. Kino, ^ij.—M.                    "  Ipecacuanhae, gr. iij.  ad. iv.
 A teaspoonful every two or three hours.                M. f. chart. No. xij.
                                     One to be given every three hours.
  We need scarcely refer to  the  importance of keeping the  apart-
ments  occupied by patients labouring under pseudo-membranous in-
flammation, perfectly clean, and of  a moderate, equable temperature,
and freely ventilated.

  4.—Parotitis,—Inflammation of the Parotids.—Mumps.
  Inflammation of the parotids generally occurs epidemically, and sel-
dom attacks the same individual more than once. In the majority of
cases it is a very trifling affection,  subsiding spontaneously in  a few
days;  while  in a few, it  is attended with very considerable swelling
and pain, and febrile symptoms of some intensity.
  It is usually preceded by more or less  chilliness, succeeded by
increased  heat of the skin, and a sense of pain,  or uneasiness, in the
region of  one or both parotids.  A stiffness of the jaws, producing a
difficulty in mastication, is very commonly present.  Sooner or later,
a tumefaction is observed, behind the angle of one or both jaws, with,
frequently, augmented heat and redness, and more or less severe pain,
which is increased  by the motions of the jaw, and by pressure.   The
swelling,  in  general, goes on increasing, producing  a  large,  hard,
movable tumour, sometimes  on both sides  of the neck.   The skin
covering the tumour is often  unchanged in colour; and, occasionally,
when  the  tumefaction is rather oedematous than inflammatory, the
colour of  the skin by which  it is covered, is even paler  than natural.
In severe  cases, the swelling  assumes a  bright  or  deep red  colour.
The inflammation frequently extends from the parotids to the submax-
illary glands, and is attended with  symptoms of considerable  febrile
excitement, increased thirst, and constipated  bowels.
   The tumefaction usually attains its height by the fourth or fifth day,
when  it begins  gradually to  diminish, and soon entirely disappears;
the febrile and other symptoms declining  and disappearing, with the
diminution and resolution of the swelling in the neck.  It is extremely
 rare for the disease to terminate in suppuration, though a few instances
 of this are on record.
   A  curious  circumstance  in connexion with   this disease,  is,  the
 liability of the inflammation suddenly to disappear from the neck, and
 to be immediately followed by a painful swelling of the testicles,  in the
 male,  and of the mammae in  the female.  The latter affection,  under 
            DISEASES OF THE DIGESTIVE  ORGANS.         187

an  appropriate  treatment,  in general terminates very promptly  by
resolution; in  males, it has been known, however, to produce an entire
absorption of the testicle.  In some instances, the inflammation sud-
denly ceases in the testicles or mammae, and the pain and tumefaction
of the parotids reappear.
  Instances occasionally occur, in which the sudden  subsidence  of
the  inflammation of the  parotids,  has  been  succeeded  by intense
febrile symptoms, and more or less cerebral disease, indicated by deep
coma, convulsions, or delirium.   This occurrence has taken place
even in cases in which the inflammation has ceased in  the neck and
been followed by inflammation of one of the mammae or testes.
   Parotitis generally occurs in children over five years of age; and,
as we have already remarked, the  occurrence of one  attack usually
produces such a change in the parts affected, or in the organism gene-
rally, as to prevent a recurrence of the disease in future.   Males are
said to be more frequently attacked than females ;—our own experi-
ence does not confirm the truth of this observation;  we  have cer-
tainly met with the disease as often in females as in males.
   Parotitis is evidently produced by some epidemico-endemic influence,
it being, most generally,  confined exclusively to certain localities;
though  it is probable, that with the  predisposition produced by the
prevailing atmospherical influence, exposure to cold, or  sudden transi-
tions of temperature, may tend to bring on an  attack.
   The disease prevails at all seasons, and in  almost every variety of
climate, but it is said to be much milder, and the so called  metastasis
less  frequently to occur, when  it prevails  in warm and dry, than  in
cold and damp weather.  We  have found the disease, however,  to
be but little influenced  by the state of the atmosphere.
   Parotitis is seldom either  a severe or dangerous affection, and, in
the majority of instances, spontaneously disappears, when  the patient
is kept within  doors, and  upon  a  mild, unirritating diet.   It will be
proper, in most cases,  to  administer a  saline purgative;  to keep the
neck moderately warm, and to immerse the lower extremities in warm
water, the child being, at the same time, kept at rest, and upon a plain
farinaceous diet.
  Should the tumefaction of the neck be very  extensive, and attended
with considerable pain, heat, and fever, it will be prudent to apply
leeches to the seat of the disease, in numbers  proportioned to the ex-
tent  of the local symptoms; and, after the bowels are fully  evacuated,
by a mixture of sulphate of soda and magnesia, the following may be
administered internally.1

                 a R.—Sulph. magnesia?, 3iv. Solve in
                      Aq. purae, 3iv. et adde
                      Tart. ant. gr. j.
                      Spir. aether, nitrici, 3iij.
                      Sacch. alb. 3vj.—M.
                 Dose, a teaspoonful every three hours.

  Warm  pediluvia will be found beneficial, and, in many cases, the
tepid bath.
  When  the testicles  or mammae become affected, leeches  may be
applied to these parts, followed by emollient fomentations; purgatives, 
188
DISEASES  OF CHILDREN.
and antimonials, will likewise be proper, according to  the nature and
extent of the symptoms present.  It has been generally recommended,
to attempt by stimulating applications to the neck, "to bring back the
inflammation to the parotids."   We do  not, however, believe that any
good can result from this practice; according to our experience, it is
not calculated to effect  the desired result; and, if it were so, no ad-
vantage will be gained;  the inflammation of the testicles or mammae
being as readily controlled, by its appropriate remedies, as  when the
disease is seated in the parotids.
  When symptoms  of  cerebral disease manifest themselves,  these
should be promptly attacked by leeches to the temples, or behind the
ears, active purgatives, warm sinapised pediluvia, cold applications  to
the scalp, and antimonials.

                     5.— Angina Externa.
  Under the name of phtegmone parotidea, Dr. Good describes a very
common affection  in children, consisting in an  inflammatory tumour,
occurring in  the  neighbourhood  of  the  parotids, and proceeding
slowly on to  suppuration, forming, often, an  extensive abscess.  The
same disease  is described by James,  in  his " Observations  on the
general  Principles, and  on the particular  Nature  and Treatment
of various species of Inflammation," as angina, externa.   Both names
are founded  upon an erroneous pathology.  The affection consists
simply in an inflammation of  the cellular  tissue surrounding the
parotid  or other glands  of the  throat, which  is generally circum-
scribed, but occasionally diffused.
  The disease usually  commences in  the same manner as parotitis.
The swelling is, however, more  extensive, red,  and painful; in many
cases preventing deglutition, and rendering the respiration so difficult,
that the patient can scarcely sleep, from the sense of impending  suffo-
cation.  There is, ordinarily, considerable febrile excitement.   When
the swelling  is very great, extensive oedema of the face not unfre-
quently occurs.
  Suppuration usually takes place ; sometimes very early, but, in the
majority of instances, very slowly.   The swelling becomes more pro-
minent at some part of its surface—the  skin  here becomes paler—a
fluctuation is soon after detected, and, sooner or later, the skin gives
way, and a discharge of healthy pus  takes place.  The tumour now
gradually diminishes in size, cicatrization takes place,  and  all the
symptoms of inflammation finally disappear.   Often, however, some
degree of hardness of the parts occupied by the inflammation, remains
for a considerable time,  and only diminishes by  very slow degrees.
  It occasionally happens that  the inflammation  and swelling are situ-
ated immediately below the chin, and  we  have  seen cases where the
tumour occupied the whole of  the front of the throat from ear to ear.
  Instead of a circumscribed  inflammation  and suppuration, the in-
flammation  is, occasionally,  deep-seated  and  diffused, and  the pus,
when it forms, is then liable to extend, under the  angle of the jaw,  to
the pharynx, or downwards, into the upper  part of the  thorax, pro-
ducing extensive destruction of the cellular membrane about the  neck,
and great distress to the patient.  In  this form of the disease, the ex- 
             DISEASES OF THE  DIGESTIVE ORGANS.         189

 ternal swelling is less prominent and circumscribed, and there is less
 redness  of the  skin.   When  suppuration  takes  place, the swelling
 acquires a doughy feel, and an indistinct fluctuation may be observed
 at one or more points.   The matter is slow in arriving at the surface,
 and in discharging itself externally.  In some instances, distinct, deep-
 seated collections of matter form, and the pus, mixing with the dead
 cellular membrane, pecomes putrid, and the evolution of gas thus pro-
 duced, causes a kind of ephysematous condition  of the  parts.  The
 febrile symptoms  now  assume a low  typhoid character, the strength
 of the patient is  rapidly exhausted, and  death very generally ensues;
 or if recovery takes place, in  these extreme cases, an extensive and
 unsightly cicatrix deforms the  patient for life.
   Inflammation of the cellular tissue of  the neck  generally occurs in
 children  of gross  plethoric  habits, particularly in those who are fed
 upon a diet consisting principally  of rich animal  food, in which they
 are allowed to indulge to excess.  It  is, very frequently, connected
 with more or less disease of the alimentary canal. We have seen the
 disease in children of almost every age; it is more common, however,
 subsequent to the period of dentition, than in infants at the breast.
   In perhaps the majority of cases, the  inflammation is perfectly cir-
 cumscribed ;  and, if  suppuration  ensues,  a  simple  circumscribed
 abscess results, the disease being rather troublesome and painful than
 dangerous; but, when in children  of  an unhealthy habit, the inflam-
 mation is diffused, unless a free exit is given to the pus by early inci-
 sions, the  affection  is  one attended with severe  suffering,  and very
 generally terminates fatally.
   In cases  of simple phlegmonous inflammation, the  treatment con-
 sists in the application of leeches to the neck, in numbers proportioned
 to the extent of the inflammation, and their repetition, after a short in-
 terval, if the local symptoms are not  sufficiently reduced by the first
 application.  After the leech-bites have ceased bleeding, the tumour
 should be covered with pledgets of linen, kept constantly wet with cold
 water, or with a solution of the acetate  of  lead.   A dose of calomel
 should early be administered, followed by a sufficient dose of sulphate
 of magnesia, to insure  its  speedy operation.  The patient should be
 restricted to  a  mild unirritating diet,—in severe cases, no other food
 being allowed than  barley water or water gruel.   In  cases  attended
 with considerable febrile excitement, the solution  of sulphate of mag-
 nesia, with tartarized antimony, as directed in parotitis, will  be benefi-
 cial.  So soon as a disposition  to suppuration is observed, the tumour
 should be covered with emollient poultices, frequently renewed; and,
 when a  distinct fluctuation is observed, the  abscess should be opened
 with the lancet, and a free exit  given to  the  pus;—the application of
 the poultices being continued until  cicatrization commences, when a
 dressing of simple cerate spread upon lint, may be substituted.
  When the inflammation is diffused, a similar treatment will be de-
 manded  in  the early stage; but as soon as the swelling of the neck
acquires  a doughy feel, especially if there is great difficulty of  swal-
lowing, impeded respiration, or a  constant  dry  cough, free  incisions
should be made, followed by the application  of emollient poultices.  If 
190
DISEASES  OF CHILDREN.
the patient's strength becomes depressed, a plain nourishing diet should
be allowed; and, if necessary, moderate doses of the cold infusion of
bark, or of a solution of the sulphate of quinia.  The treatment of each
case, must, however, be governed by the particular symptoms present;
the safety of the patient not unfrequently depending entirely upon the
promptitude and judgment of the practitioner.
                       CHAPTER  III.

       OESOPHAGITIS—INFLAMMATION OF THE OESOPHAGUS.

  It is to Billard, that we are indebted for our knowledge of the oeso-
phagitis of infants;—he first pointed out its  frequent occurrence in the
first period of infancy, and described its diagnosis.   From him, there-
fore, we shall be under the necessity of borrowing  our account of the
disease, it being one  mentioned  by no other writer, and  in relation to
which our own observations have not furnished us with any additional
facts.  We have repeatedly recognised in  infants, the symptoms re-
ferred by  Billard to inflammation of the oesophagus, but have not had
an opportunity, as  yet, of testing, by an examination after death, the
accuracy  of his diagnosis.
  The principal symptom of oesophagitis in infants, is frequent vomit-
ing, occurring almost  immediately after  the  deglutition of drinks  or
aliments;  which are discharged  almost in the same  state in which they
were  taken.  The child refuses the  breast, and fluids generally—but
often swallows, without much difficulty, half solid aliments.  The undi-
gested food and drinks vomited by the patients, are, occasionally, mixed
with matters secreted by the stomach, particularly if  the  latter  be
affected, at the same time, with inflammation.  More or less  pain is
no  doubt  experienced  along the whole track of the oesophagus, but
at the age at which the disease  occurs, we cannot  determine its pre-
sence by any exterior sign; it is  probable, however, that pressure upon
the  throat, in the direction of the oesophagus, may excite the cries of
the  child.  Nutrition is interrupted, and emaciation rapidly  ensues.
Oesophagitis  is seldom accompanied by any degree of febrile excite-
ment.
  The disease may consist  in  a simple erythematic inflammation of
the  mucous membrane of the oesophagus, in inflammation, with altered
secretion,  or  in gangrenous inflammation.
  As oesophagitis is almost invariably preceded by stomatitis, it is pro-
bable, that according as  the mouth is affected with inflammation at-
tended with  curd-like  exudation, or with follicular inflammation, the
inflammation of the oesophagus will also be attended with altered se-
cretion, or with aphthous ulceration.  It is, however, difficult  to distin- 
           DISEASES OF  THE DIGESTIVE  ORGANS.        \Q\

guish the existence of ulcers or gangrene of the  oesophagus, unless the
matters vomited contain shreds, derived from the disorganization of
the oesophageal mucous  membrane.   More extended observations,
Billard  remarks, will  probably enable us to form  a more accurate
diagnosis of the several forms of the disease.
   The pathological changes detected after death, in cases of oesopha-
gitis, are, vivid redness, with destruction of the epithelium of some por-
tion of the mucous membrane of the oesophagus, especially at its upper
part; aphthous ulceration ; curd-like exudation, more or less extensively
diffused ; separation of the epithelium, often in large shreds; numerous
red  or  dark-coloured  striae, where the epithelium is not destroyed;
large, irregular eschars of a  black colour, with intervals of deep, bright
red excoriations, and gelatinous softening of nearly the entire thickness
of the oesophagus.  The pharynx, in general, exhibits considerable in-
jection ; the glottis is infiltrated and reddened.   The  stomach is often
perfectly free from  disease, but, occasionally, presents the various
lesions incident to gastric inflammation.
   The hyperaemia of the mucous membrane of the oesophagus, which
always exists  in the early stage of infancy, is the chief cause of the
frequency of oesophagitis at this period;  its occasional causes are the
same as those of stomatitis.   It may be produced by too hot or stimu-
lating food.  When infants  are fed with the spoon, if wine or spiced
victuals, or if broth, milk, or panada of too high a temperature be given
them, we can  readily conceive that a very serious  irritation may be
excited  in an organ, already predisposed to disease, in consequence of
its habitual state of hyperaemia.
   The treatment of oesophagitis is  very simple.  The child should be
debarred from all stimulating and hot drinks; it should be supplied, at
short intervals, with  small portions of some plain, mucilaginous fluid,
as  gum water, or an infusion of the pith of  sassafras, or of the inner
bark of the slippery elm; the throat, externally, should be covered with
an emollient poultice, especially when the oesophagitis succeeds to sto-    *
matitis, and a few grains of calomel  may be administered, followed
by injections of milk with the addition  of  sugar.   If necessary, the
strength of the patient may be supported by injections  of milk and
broth, or of milk with rice flour, tapioca, or arrow-root.
   We have derived advantage in cases presenting  the symptoms of
oesophagitis, from leeches along the sides of the neck, and internally a
solution of acetate of lead.
                       R.—Acetat. plumbi, gr. iv.
                          Acid. acet. impur. HJ" iv.
                          Aq. puree, 3j.—M.
                  Dose, a teaspoonful every three hours. 
192
DISEASES OF CHILDREN.
                      CHAPTER  IV.


                   DISEASES OF THE STOMACH.

                         1.—Indigestion.

   We employ the term indigestion, to indicate an affection of the sto-
 mach, very common  in children, in which the  function of that organ
 is suspended or disturbed, and the food, either unchanged or imper-
 fectly digested, is  discharged by vomiting or by stool, while no symp-
 toms exist, indicative of gastric inflammation,  or  of disease of other
 organs.
   Indigestion is invariably dependent upon too much, or improper arti-
 cles of food, or upon some accidental circumstance interfering with
 the process of digestion.   There can  be no doubt that more  or  less
 disease of  the mucous membrane of the stomach, is present in every
 case, and that if the cause of the functional disturbance be continued,
 or repeated, inflammation of an acute or chronic character, may be
 excited.
   Nausea and vomiting, are the most common symptoms of indiges-
 tion, during infancy.  Infants at the breast will repeatedly discharge
 from the stomach, immediately  after sucking, by a species of regurgi-
 tation or by actual vomiting, a portion of the milk taken, without
 appearing  to suffer any inconvenience.  The vomiting in these cases,
 arises, generally, from an overloaded state of the stomach, and is un-
 attended  by either  nausea  or straining.   The milk is  usually returned
 unaltered;  occasionally, however, it  is coagulated in masses of greater
 or less size.
   This species of vomiting generally occurs in very young infants, of
 a robust habit, particularly when suckled by a nurse, in whom the sup-
 ply of milk is  profuse, and flows  with  great freedom.  It  is  rather
 salutary than injurious; preventing the effects  of over-distension  of the
 stomach; hence the common saying among nurses, that those infants
 who throw  up their milk thrive the best.   But as the cause is an habi-
 tual repletion of the stomach—more milk being taken than can be rea-
 dily digested—it must be evident, that in every instance, there is dan-
 ger of a  disturbance of the  digestive  function, or even more serious
 injury being, sooner or later, induced.  The cause of the  vomiting
 should therefore be removed, by preventing  the infant  from sucking
too much at a time, or too frequently in the course of the  day.   It
should, as Dewees  directs, be removed from the  breast,  the moment it
 begins to dally with it, or as soon as it ceases  to suck with avidity, as
if it were gratifying a necessary and proper appetite.
  A common cause of vomiting from repletion of  the stomach  in  in- 
            DISEASES OF THE DIGESTIVE  ORG.US.         193

fants, is applying them to the breast whenever they are fretful, or with
the view of lulling them to sleep, or allowing them to lie at the breast
all night.   There is in some infants, also, a disposition to eject the
milk taken into the stomach, that is  induced by dandling them in the
arms or jolting them upon the knee, or walking them about soon after
they  have sucked, even  when  no  undue quantity  has been  taken.
As a general rule, therefore, but especially when vomiting is  readily
excited, the infant  should be allowed to  remain perfectly quiet for a
short time after its  removal from the breast.
   A common error committed by nurses,  is that of giving the breast
to infants, immediately after  they  have  ejected  the  contents of the
stomach.   This should be avoided in every instance, it being calcu-
lated to increase the irritability of the stomach and render the vomit-
ing more frequent.
   The more or less coagulated state of the  milk discharged from the
stomach, most generally arises from  its having remained in that organ
a short time  before its ejection; the milk invariably undergoing coa-
gulation in the  infant's stomach, previously to its  digestion.  In  some
cases, however, the coagulation of  the  milk, as well as the vomiting,
appears to be due to the secretion in the stomach of an undue  amount
of acid.  The breath of the infant, and the coagulated milk thrown up,
have then a sour smell, and very often sour, curdy evacuations take
place from the  bowels, preceded by more  or less griping.   The cause
of this acidity it is very difficult to determine;  whether it results from
an irritation of the stomach, causing an excessive secretion of acid, or
from the occurrence of acetous fermentation in the milk, we have been
unable to satisfy ourselves.
   It  is not uncommon for dense coagula of milk to form in  the sto-
mach of an infant; in some cases causing severe colicy pains, and in
others, violent convulsions, which cease upon the  rejection of the coa-
gula.  The retention of these coagula in the stomach, appears  to arise
from the  disturbance of the digestive process, independent of  gastric
inflammation;  though some degree  of this is liable to be induced, if
the irritation of the dense coagula does not cause  their speedy ejection
by vomiting.
  Not unfrequently, repeated vomiting occurs in children, attended
with paleness, and other indications of considerable nausea; preceded,
generally, by severe griping pains of the  bowels, and followed by more
or less diarrhoea.  The matters vomited, whether milk or  other arti-
cles of food, are, usually,  partially digested, and exhale  an  acid or
rancid odour.  Preceding the vomiting, the  child exhibits, ordinarily,
a considerable degree of uneasiness, and continues fretful and languid
for some  time  after the spontaneous evacuation of the  stomach  and
bowels.  In such cases there exists a disturbance of the digestive func-
tion, attended with considerable irritation  of the mucous membrane of
the whole of the  alimentary canal, but seldom  any symptom of posi-
tive  inflammation.  The mischief is almost invariably owing to im-
proper, or too much food.
  When the disease occurs in infants at the breast, its cause is, gene-
rally, to be sought for  in some condition of the mother's or  nurse's
                               13 
194
DISEASES OF CHILDREN.
milk, by which it is rendered either indigestible, too irritating to the
stomach, or unadapted to  the  functional  powers of thelatier; or to
the child being occasionally fed with improper kinds of artificial food.
  When the milk of the mother or nurse is perfectly healthy, adapted
in all respects to the condition of the infant's digestive organs, and suf-
ficient in quantity, indigestion may still be produced by the practice too
commonly pursued, of giving to the  child, occasionally, a portion of
artificial food, often of the most indigestible quality.  Previously to the
appearance of the first molar teeth, under  ordinary circumstances, no
other nourishment is required than the breast-milk of the mother; and
every kind of food  which  differs materially in  its qualities from the
latter, will produce serious disturbance of the digestive organs.   We
have seldom known an infant, to whom there  was given, in addition to
its mother's milk, any of the various compounds of bread  and water,
bread and milk, flour and milk, and the like " vile nursery compounds,"
who has not  suffered from indigestion, and often from severe  irrita-
tion, or even  inflammation  of the stomach and intestines.  Disease of
the alimentary canal being more certainly produced, in the generality
of these cases, by the carminatives, antacids, and opiates, administered
to relieve the vomiting, expel the wind, and allay the  griping caused
by the improper diet.
  Slight symptoms of indigestion are frequently attendant upon the
process of dentition, in consequence of the  irritation  of the gums being
extended to the digestive organs; they seldom, however,  occur to any
extent, unless when  too much food, or food of too stimulating a quality
is allowed at this period.
  Children too early weaned, are especially liable to be troubled with
indigestion, as  well  as  those who,  weaned at a proper period, are
placed immediately  upon a too  rich and stimulating, or otherwise un-
fitting diet. Vomiting and diarrhoea—more or less griping pain of the
bowels—and rapid emaciation,  are the prominent symptoms induced.
The matters vomited consist usually of the partially digested aliment,
often of a  decidedly sour or rancid smell:—the dejections from the
bowels are similar  in  character.  In some cases,  however, the food
taken into the stomach passes  through the alimentary canal, and is
discharged entirely unchanged, while little or no vomiting is present.
The appetite often continues unabated, or is even increased; but, from
the disturbance or suspension of the digestive process, the nutrition of
the system ceases, and the child dies from inanition ; in many cases,
however, the  irritation of the alimentary  canal  is  reflected upon the
brain, and violent convulsions supervene; or a chronic inflammation
of the mucous membrane of the stomach and bowels may occur.
  In children brought up by the hand, or improperly fed  subsequently
to weaning, indigestion occasionally occurs, attended by  symptoms of
considerable severity. There is  generally loss of appetite, peevishness,
restlessness, and want of sleep; the  tongue is covered with a layer of
white or yellowish mucus ; the breath is often sour, and, in some cases,
aphthae appear upon the parietes of the mouth.  There is constant diar-
rhoea, intense thirst, and great emaciation  and exhaustion.  The diar-
rhoea, after a time, frequently diminishes, or ceases  entirely, but  soon 
DISEASES OF  THE DIGESTIVE ORGANS.         195
 returns with increased violence—the discharges being a thin, serous
 fluid of a yellowish or greenish  colour, and exhaling a  strong, acid
 smell.  The face and extremities become cold; the pulse small and
 irregular;  the respiration quick and short.  The countenance becomes
 shrunken and pale.  The child utters continually a low piteous moan,
 or lies upon his  back, with the eyes fixed, glassy, and half closed.  No
 pain or  tenderness is indicated upon gentle pressure of the abdomen;
 the latter, however, is often greatly swollen and tympanitic.  The child
 becomes more  and more exhausted, and finally, expires  quietly, and
 without convulsions.
   This appears  to  constitute that form of disease which  is described
 by Camerer, Pommer, Hergt, Romberg, Droste, and others, as gastro-
 malacia ; the stomach and intestines generally, presenting, after death,
 a gelatinous softening of their parietes, to a  greater or less extent, but
 without any indications  of inflammation; the  softening appearing to
 depend  upon a diminished cohesion of the tissues—the result of dis-
 ordered or suspended nutrition.
   In older  children, indigestion  is usually the  result of loo much or
 improper food.   Over-feeding is among the  most  common  of its
 causes, and is often induced  by  parents  supposing  that the strength
 and growth of  the  body are best promoted by a  large amount  of
 animal food. Acid and unripe fruits, and the cakes and confectionary,
 with which children are  so apt to overload their stomachs, very  gene-
 rally produce an attack of indigestion, attended  with excessive nausea,
 a sense of weight and oppression about the praecordia, severe griping
 pains of the bowels, followed, sooner or  later, by repeated vomiting,
 and a  copious diarrhoea; the  attack being succeeded, in some  cases,
 by long-continued loathing of food; and  in others, by an augmented
 appetite: this difference depending, probably, upon the greater or less
 degree of irritation produced in the stomach.
  The  affection of  the  stomach  and  bowels we have described  as
 indigestion, is unattended with febrile  excitement; it is essentially a
 disturbance or suspension of  the  functions of the digestive organs, in
 consequence of the food taken  being too great in quantity, or unadapted
 in quality to undergo the changes necessary to its proper assimilation.
 We must, however, recollect,  that in all cases, more or less disease of
 the mucous  membrane of the  alimentary canal is produced, and that if
 the causes of the disease are continued, inflammation  of that tissue will
 be very liable to ensue;  or,  if this  be  not  the case, from  defective
 nutrition alone, softening  of the stomach and bowels, or a disorganiza-
 tion of other organs may result.
  It is hardly necessary to enumerate the symptoms  of indigestion, as
 it occurs during infancy and childhood, these  having been already
 pointed out.  They are, chiefly, uneasiness after eating, fretfulness and
 peevishness, nausea, griping or colicy pains, and frequent acid eructa-
 tions, followed by vomiting, and generally by diarrhoea. The matters
discharged  by vomiting and stool, being  the food taken,  partially or
not at all altered, and exhaling  a sour or rancid odour, and occasionally
 mixed  with yellow or greenish bile;  the absence of febrile symptoms
and of tenderness of the  epigastrium;  more or less emaciation;  with 
196
DISEASES OF CHILDREN.
paleness of the  surface, and occasionally, flatulent  distension  of the
bowels.  The appetite is often  unimpaired, or even increased.  Not
unfrequently the irritation is reflected from the bowels, upon the brain,
producing convulsions;  or upon the nerves of the larynx, producing
spasmodic  constriction of the glottis;  or inflammation of the stomach
and bowels may take place.  In other cases the vomiting  or purging
continuing  unabated, extreme emaciation  ensues, and the child dies
from inanition.
   When indigestion is properly treated in its early stages, it is generally
a very manageable disease, and  even at a later period it may often be
remedied;  but protracted cases, especially when we  find it  difficult to
remove its  cause, and when excessive marasmus has occurred, very
generally terminate fatally.
   The dissections in cases of simple indigestion have been  very rare;
death  seldom taking place excepting in protracted cases,  or until
structural changes have occurred in the alimentary canal, or some
other organ.  Traces of inflammation  are  occasionally observed in
the mucous membrane of the stomach, or intestines;  more commonly,
however, there is a pale,  anaemic  condition of the  membrane, with
softening, sometimes  in  circumscribed  patches, and in  other  cases
involving a considerable portion of the mucous  coat of the stomach,
or small intestines.  This softening  is evidently the effect of imperfect
or suspended  nutrition, and is also often met with in  the  brain, and
other organs.  Portions of the intestinal tube are generally distended
with gas, and  have a transparent appearance, from the small amount
of blood in the vessels, and the paleness of all the coats.  A quantity
of white frothy mucus is frequently found in the stomach and intestines.
Invagination of the intestines is also a very common  occurrence.
   The treatment of infantile indigestion  consists almost entirely in the
removal of the cause by which  the disturbance of the functions of the
stomach has been produced.
   In young infants, when mere  repletion of the stomach produces  a
regurgitation or vomiting of the milk, we have already pointed out
the proper  remedy;  namely, preventing  the  infant from sucking too
much at a time, and being careful not to place it too often at the breast;
and when the irritability of the stomach is such as to cause the ejection
of its contents upon the slightest motion communicated to the infant,
being careful to allow it to remain at perfect rest for some time after
it  has  been at the breast. A  young infant is  naturally inclined  to
perfect  quietness, and generally to sleep,  after sucking, and the inter-
fering with  this inclination is seldom  unattended with  injury.,  Rude
dandling, jogging upon the knee or in the cradle, jolting  in the arms,
or even carrying a young infant rapidly up and down the room, is at
all times improper, but particularly so, immediately after taking it from
the breast.
   When, from any cause, the milk of the mother is found to disagree
with the infant's stomach, if the cause of this be under the control of
diet and regimen, it should be at once removed.
   When young infants are troubled with indigestion, and  the  cause
cannot be traced to the condition of the mother's milk, it will, in gene- 
DISEASES OF THE DIGESTIVE  ORGANS.         197
 ral, be found  to result from the injudicious overloading of the infant's
 stomach with some kind of pap or panada,—articles which  are inva-
 riably injurious,  even when, from a deficient supply of milk  on the
 part of the mother, additional aliment is required.
   In addition to the proper regulation of  the infant's diet, in cases of
 indigestion, the functions of the  skin should be promoted by the daily
 use of the warm bath, followed by gentle friction of the surface; and
 when the weather will permit, the child should be carried into the open
 air daily.   Riding short distances in an open carriage, or  sailing in
 a boat, when  practicable, will invariably be found advantageous.  The
 body should be preserved  of a proper and equable temperature, by
 appropriate clothing, and by rooms sufficiently heated in winter, and
 well ventilated in summer.
   Medicine of any kind will seldom be required in a  case  of simple
 indigestion.  When considerable  nausea  and retching occur  without
 free vomiting, it may, however, be proper  to unload the  stomach by
 a gentle emetic of ipecacuanha.  If considerable  acidity of the sto-
 mach exists, a dose of calcined magnesia  may be  given; or, if the
 bowels are constipated, a dose of equal parts of magnesia and rhubarb;
 if diarrhoea be present,  the  simple cretaceous mixture, or  what  we
 prefer, the prepared chalk in powder, combined with  small doses of
 ipecacuanha,* will be proper.
                    ■ R.—Cretae ppt. 3j.
                         Ipecacuanhas/pulv. gr. ij. ad iij.—M.
                         f.  ch. No.  xij;
                     One to  be repeated every three hours.

   Dr. Kuhn preferred, in all cases of acidity affecting the  alimentary
 canal of children, and unattended with  inflammation, the aqua  ammo-
 nia, to either  the magnesia or carbonate  of lime.  He prescribed it
 in the following formula.*
                    * R.—Aq. pure,  3iij.
                        Gum. acacias, pulv. 9ij.
                        Sacch. alb. purae, 3ij.
                        Aq. cinnamon, eimpl. vel,
                        Aq. anisi. gss.—M. et adde
                        Aquas ammonia?, TTXxIviij.—lxxx.
  A teaspoonful to be given every one, two, or three hours, according to circumstances.
   When the infant is troubled  with  severe griping, pains, the  warm
 bath, friction with some anodyne liniment,  followed by  warm  fomen-
 tations to the abdomen, and the use of the aqua ammonia,  as directed
 by Dr. Kuhn,  will be found  in many cases  to afford prompt relief.
   The remedy from which  we have seen the best effects  to  result in
 the colic of children, from indigestion, is a combination of magnesia,
extract of hyoscyamus,  calomel,  and ipecacuanha.*  In some  cases,
a few drops of aq. camphorata, or of the etherial solution of camphor,
will promptly  allay the  colicy  pain.b  Three to five drops  of spirits
of turpentine,  mixed with  a little  sweetened  water,  and  repeated
in the course of an hour, will, also, often produce a decidedly favour-
able effect. 
198
DISEASES OF  CHILDREN.
  * R.—Magnesias calc. Bijss. ad 3j.       b R-—Camphors?, 3j. solve in
       Ext. Hyosciami, gr. viij. ad xij.         iEther. Sulphuric. 3j.
       Pulv. Ipecac, gr. iij.              Add thirty drops of this solution to one
       Calomel, gr. iij.—M. f. chart. No.     ounce of simple aniseed  water,  with
        xij.                          two drachms of refined sugar.  The dose
  One to be given every two or three hours.    is one or two teaspoonfuls, according to
                                     the age of the child.
  When,  however, the  pain  is very intense,  and  is not promptly
allayed by the remedies  already enumerated,  a dose of tincture of
opium, adapted to the age of the child, may be given, in a little sweet-
ened aniseed water, or it may be administered in  the form  of enema
combined with thin starch.   Great caution  should, however, be ob-
served in  the employment of opiate  enemata in  the affections  of in-
fants,—neither to  resort to them unnecessarily, nor to repeat them too
often.  The opiate should be, also, in small doses, and its effects care-
fully watched, as very minute doses of the tincture of opium have, even
when injected into the rectum, not unfrequently proved fatal to infants.
   In cases of indigestion attended with frequent and copious discharges
from thel)owels, it will, occasionally, be prudent  to  administer some
slight astringent.    The tincture of kino will, in general, very promptly
suspend the diarrhoea; it may be given in combination with  the  cre-
taceous mixture.*
                      * R.—Mucilag. G. acacia?, 3ij.
                        Sacch. alb. purrf, 3ij.
                        Aq. cinnamon. 3j.
                        Cretae, ppt. 9ij.
                        Tine. Kino. 3j. ad 3ij.—M.
                      A teaspoonful three times a day.
   In cases of indigestion from too  early weaning, when practicable,
the infant should  be  reapplied  to  the breast,  or,  if this  cannot be
effected, it should be confined entirely to milk  and water, sweetened
with loaf  sugar as directed in our section  on  the diet of infants.
   The indigestion occurring at the period of weaning is usually very
readily managed by a proper attention to  diet, the warm  bath, daily
exercise in the open air, when the weather will permit, and the  remo-
val of any symptom of unusual severity that  may occur by the  reme-
dies already detailed.
   In older children, it will be proper, in most cases  of indigestion, to
administer an emetic of ipecacuanha,  followed, if the bowels are
much disturbed, by a moderate dose of magnesia  and rhubarb ; after
which, a proper regulation of the diet, as well in regard to  quality as
to quanity, will,  in general, very  speedily remove every unpleasant
symptom, and restore the regularity and activity of the digestive func-
tion.  Confining  the patient, for a  short  time,  to  a milk and farina-
ceous diet alone, or with the occasional use of plain meat broths, with
the addition of rice or  crackers,  will  be proper.   Every  species  of
pastry and confectionary,  crude and  ascescent fruits,  and  flatulent
vegetables, should be strictly proscribed.
   Every case of indigestion occurring in children should be carefully
scrutinized and cautiously watched, and if any symptom indicative  of
the occurrence of even a slight degree of inflammation in any part  of
the gastro-intestinal mucous membrane, be detected; if the  skin be- 
DISEASES OF THE DIGESTIVE ORGANS.          199
comes dry and parched, the tongue red at its edges and extremity, and
coated on its upper surface with a whitish mucus; or if increased heat
of the epigastrium, with tenderness or pain upon pressure are found to
exist, leeches and fomentations  to the abdomen,  with  cool  mucilagi-
nous  drinks internally, will  be demanded.
   In  protracted cases of indigestion in children, with entire suspension
of the function of the stomach—the food  and drinks passing through
the bowels without change  almost as soon as they are taken—but little
can in general be done to prevent a fatal result.   In some cases much
benefit, however, has resulted from the use of a cold infusion of bark,
with  the addition of a few drops of hydrochloric acid;  or of the tinc-
ture of the sesquichloride of iron, or chalybeate wine in small doses—
one or two drops of the first, and from three to six of the  latter, in a
teaspoonful of water.  We  have occasionally seen good effects result
from  the carbonate of iron, combined with hyoscyamus and  acetate
of lead.*
                * R.—Ext. Hvosciami, gr. vj. ad viij.
                    Carb. Ferri, gr. xxiv. ad xxxvj.
                    Acetat. plumbi, gr. xij.—M. f. chart. No. xij.
                         One to be given every three hours.
   Friction along  the spine with the weak liniment of ammonia, re-
peated daily, and frequent  exposure to  the open  air,  by riding in a
carriage, will, in general, be found useful.   The  diet  should consist
exclusively  of beef-tea or  milk, with the  addition  of rice flour,  or
arrowroot.  What would be the effect of tannin,  or  of the  pure sul-
phate of alumina in these cases, we are not prepared to say—never
having had an  opportunity of making a trial of them.
   In  that form of infantile indigestion in which softening of the sto-
mach is most likely to occur, trial may be made of the hydrochloride
of iron, which appears to have  frequently succeeded in restoring the
healthy functions  of the  stomach, in the hands  of Pommer, Hergt,
Camerer, Droste, and others.*
                ' R.—Ferri hydrochlorid. gr. x. ad xv.
                    Mucil. G. Acacite, giij.
                    Sacch. alb. pur. 3ij.—M.
              A dessert-spoonful to be given every hour.
           Or,
                   R.—Tinct. Ferri. sesquichlorid.,
                      Extract, cinchonas, aa 9ss.
                      Aq. flor. aurant. gij.
                      Syrup, cort. aurant. 3j.—M.
                  A teaspoonful to be given every hour.

         8. — Gastritis.  Inflammation  of the  Stomach.

  Inflammation of the mucous coat of the stomach is of more frequent
occurrence during infancy and childhood than is  generally  supposed.
It varies in degree, in different cases, from a slight erythematic inflam-
mation, confined to a small  portion of the gastric  mucous  membrane,
and attended  by symptoms so obscure as to cause its existence, in its
earlier stages, to be entirely overlooked ; to an intense inflammation of
the greater part of the stomach and bowels, accompanied by symptoms 
200
DISEASES OF CHILDREN.
of a very decided and violent character, and rapidly producing disor-
ganization of the tissues in which it is seated.  It is seldom that the
stomach  is  alone  affected;  in  the great majority of instances, the
inflammation extends to the duodenum, and the other small intestines.
  The leading symptoms of gastritis in the infant are retching or vo-
miting; increased heat and tension of the epigastrium ;  shrinking, and
painful cries when this part is compressed; an expression of counte-
nance indicative of distress; a dry, parched skin; redness of the point
and edges of the tongue :  a  coating of white mucus over its surface,
through which the enlarged and  florid papillae  protrude; great rest-
lessness ; a small and contracted  pulse, often greatly increased  in fre-
quency ; augmented thirst, and,  generally, aversion from food.   These
symptoms vary in  intensity, in different cases, and  are  often compli-
cated with others,  arising from  disease of adjoining or remote organs,
by which the gastritis has been  preceded, or which  become developed
simultaneously with, or subsequently to, its occurrence.
  The most constant symptoms are, frequent  vomiting, heat, tension,
and pain upon pressure of the epigastrium, and an expression of coun-
tenance indicative of suffering.
  The vomiting  is most liable to occur upon any drink or food being
taken into the stomach, which  is almost immediately rejected.  The
vomiting is occasionally attended with considerable retching, and is
evidently, in severe cases, a cause  of much suffering  to the patient.
The matters vomited are the  food and drinks taken  ; a thick, ropy, or
frothy mucus, often mixed with yellow or greenish bilious matter;—
brownish, or dark  brown, and even bloody discharges  are  occasion-
ally observed.  The matters vomited are not unfrequently  decidedly
acid.
  Some degree  of heat and tension  of the  epigastrium  is  seldom
absent.  These symptoms are at first generally slight;  but  when the
inflammation of the stomach is  fully established,  and of any degree of
intensity, the heat  and tension of  the abdomen are usually very consi-
derable ; the heat of this part, in many cases, being the  more marked,
from the temperature of the surface generally, not being augmented ;
while that of the lower extremities is perhaps  reduced.   The  tender-
ness of the epigastrium may be detected only upon  pressure;  by the
patient starting and moaning, or  crying  out, with the peculiar acute
tone belonging to the cry from  pain; or  it may be to  such  an extent
as to render the  slightest touch  a source of suffering, and to  cause the
patient to lie upon his back, with  his knees drawn up.  In these cases,
the countenance, as well as the restlessness and constant cries of the
infant, indicate the severity of its suffering.  When the child  is  old
enough to express his feelings, he, in general, complains of a burning
pain in the stomach.  When the gastric pain  is severe, respiration is
short and quick, and performed, almost exclusively, by the ribs.
  Diarrhoea is common in cases of gastritis;  the matters discharged
from the bowels being at first faecal, but, subsequently, similar to those
ejected by vomiting. Gastritis is occasionally, however, attended with
constipation.
  The disease  is  often, especially in young  infants, unattended, 
DISEASES OF THE DIGESTIVE ORGANS.          2Q1
throughout, with any degree of febrile excitement; occasionally, how-
ever, there is considerable  fever, with a hot and burning skin, quick
and frequent pulse, and delirium, or a tendency to coma.  In general,
the febrile symptoms are remittent, with  exacerbations, toward even-
ing, or even later.
   Gastritis may terminate in resolution, ulceration, or gangrene, or in
softening of the gastric mucous membrane, or of the whole of the coats
of the stomach, causing a perforation of the organ.
   In violent cases, great prostration of strength, attended with profuse
perspiration about  the head and face, subsequently extending over the
greater part of  the  body, hiccup, cold  extremities, a sinking  of  the
pulse, and  often convulsions, early occurs, and is, generally, speedily
followed by death.
   Gastritis may become chronic, and continue for a length of lime,
with occasional vomiting—some degree of tenderness and tension of
the epigastrium—irregular appetite—occasional diarrhoea, alternating
with costiveness—a  dry and  harsh  condition of  the surface—febrile
symptoms  of a remittent  character—and  progressive  emaciation.
White softening of the stomach, with perforation, may occur in these
cases; or,  the brain  may become affected, and effusion in that organ
take place;  or, tubercles becoming developed in the lungs, the patient
may die with all the symptoms of tubercular phthisis.
   The causes of gastritis in children are, either  irritating substances
—improper or deteriorated articles of food, or some acrid or poisonous
matter—introduced  into the stomach, cold and  moisture applied to
some portion of the surface, sudden alternations  of temperature,  the
sudden  suppression of cutaneous eruptions, or of the discharge from
ulcerations behind the ears.   In many cases, particularly in young in-
fants, the  inflammation of the stomach is  preceded by an attack of
stomatitis; in others, the stomatitis occurs subsequently to the gastritis.
   The disease would appear to prevail, occasionally, as an epidemic.
Inflammation of the  stomach, however, rarely occurs in children as a
primary affection;  in the great majority of cases, it becomes developed
in the course of other diseases.
   The appearances observed after death, in cases of gastritis, are  in-
jection and redness, with thickening, or a softened  condition  of  the
mucous membrane of the stomach. The redness may consist in simple
injection of the blood-vessels, and present an arborescent arrangement:
—this occurs chiefly in the slighter cases of the  disease:—when  the
inflammation is more intense, the  redness is more  or less diffuse; or it
occurs in patches  of a greater or less extent—or in irregular striae,
which follow, generally, the course of the corrugations of the stomach,
or in numerous, closely approximated red points.  (Billard.)  The sto-
mach often contains  a quantity of thick, tenacious  mucus.  The  pa-
pillae, or villosities  of the  mucous membrane, appear occasionally to
be  somewhat enlarged.  In a few cases, large patches of curd-like
exudation adhere to the mucous membrane;—in others, the follicles of
the stomach  are morbidly developed,  forming a number of  small,
rounded granulations, of a white colour, terminating in a black point; 
202
DISEASES  OF CHILDREN.
or the mucous membrane may be the seat of aphthous ulcerations, or
of ulceration extending through the inner and middle coats.
  When the inflammation  of the stomach terminates in gangrene,
which is of exceedingly rare occurrence, (we have never met with a
single case,)  sloughs of various  extent, implicating the whole  of the
coats of the stomach, occur, which, on becoming detached, give rise
to perforations; or the mucous membrane alone may be reduced to a
gangrenous condition.
  In cases of gelatinous softening of the stomach, the mucous mem-
brane alone may be found reduced  to a jelly-like consistence;  or the
softening may extend  to all the tissues of the stomach, rendering them
liable to be perforated by the slightest force; or a complete perforation
of the coats of the stomach may have occurred.  All of these condi-
tions may exist in the  same stomach at different points.  These  soften-
ings, or perforations, occur especially at the great curvature, seldom
extending beyond the most depending parts.   Some observers, how-
ever, describe the softening as involving,  occasionally, the greater part
of the mucous  membrane.  Distinct traces of inflammation are fre-
quently  observed surrounding  the softened  parts; and the parietes of
the stomach often present a serous infiltration.
   Rilliet and Barthez describe the softening as being, in some cases,
to such  an extent that by the slightest scraping the mucous membrane
is reduced to a soft amorphous mass, leaving bare the submucous tis-
sue.  This degree of  softening occurs only in  very severe cases, and
coincides almost always with a decided uniform redness of the stomach.
In the ordinary run of cases, the mucous membrane, which still pre-
serves a certain degree of consistence, gives  way upon  the slightest
scratching, and is thus easily removed.  (Maladies des Enfans, Tome
lr, 444.)
   Many pathologists  have  denied the connexion, in any instance, of
softening of the stomach with  inflammation, and maintain that, in  the
majority of cases,  it  is a cadaveric phenomenon, resulting from the
action of the gastric juice upon  the tissues  of  the organ; others, with
Jaeger, Zeller, and Camerer, refer it to a paralysis of the nerves of the
stomach, with increased acidity  of the gastric  fluid, by which the sto-
mach is dissolved during the lifetime of the  patient.   A  somewhat
similar  opinion is entertained by Laisnd, Chaussier, Desbarreaux, Ber-
nard, and others.
   Without denying that the stomach may be dissolved after death, in
consequence of the generation in its cavity of  an excess of acid, and
being well aware that a softening of the tissues of the stomach, and of
other parts of the alimentary canal, may be produced by causes affect-
ing the nutrition, and impairing the  cohesion of the various  tissues,
altogether independent  of inflammation, we are still convinced, from
the result of our own observations, that the gelatinous  softening, so
frequently observed in children that have died  of  acute gastritis, is in-
variably the effect of intense  inflammation of the mucous and other
tissues  of the stomach.
   Increased redness  and softening of the gastric mucous membrane,
remark MM. Rilliet and Barthez, when  they occur together, are suffi- 
            DISEASES OF THE DIGESTIVE ORGANS.         203

cient indications of inflammation, of the existence of which there can
be no doubt, when to these is added a thickening of the mucous mem-
brane.   In  general, the thickened parts project slightly above the
healthy portions of the membrane, but without its limits being marked
by a decided boundary.   The thickening often occupies several very
small portions of the membrane, very near to each other.  It may be
described as a swelling of the villi, rendering them projecting, firm,
and enlarged.  The surface of the mucous  membrane  is, in conse-
quence,  rendered rough or granulated like chagrin.  This appearance
coincides most frequently with a more general thickening of the  mu-
cous membrane, and indicates a violent inflammation.
   The subjacent tissues of the stomach are not involved  in the  thick-
ening.  Under certain circumstances, however, particularly when the
inflammation is of a  chronic character, the submucous tissue becomes
somewhat hypertrophied, fibrous,  hard, and  resistent, the  part feels
heavy, and  as if its substance were increased.
   The treatment of gastritis, is that proper in cases of inflammation
generally, modified, somewhat, by the seat of the disease, and by the
age of the  patient.  Leeches should be applied to the epigastrium, in
numbers proportionate to  the violence of the symptoms; and  if the
attack be one  of  considerable  intensity,  occurring in  a robust  and
plethoric child, and not too young to permit a vein to be opened  in the
arm, general bloodletting will be found of advantage.  The necessity
for a repetition of the leeches, will depend upon the particular charac-
ter of the attack,  and the effects produced  by the first application.
Should the tenderness and heat of the  epigastrium continue, with little
abatement, after the first  application of leeches, it will be proper to
renew them.  In general, however, a less  number will be required than
at first.  The leeches should be followed by warm fomentations, or by
a soft emollient cataplasm, over the epigastrium;—the  fomentations
and cataplasm  being renewed at short intervals.  The occasional use
of pediluvia of warm water, with the addition of a small quantity of
mustard, will, in general, be productive  of good effects, and  should
not be neglected.
  The diet and drink of the child should be  composed exclusively of
some simple mucilage, as  gum-water, or water in  which the  pith of
sassafras, or the slippery elm  bark has been infused.  These should be
given cold, and in  small portions at a time.   The occasional adminis-
tration of a spoonful of cold water, we have found to be peculiarly
grateful to the patient, and  often  to remain upon the stomach, when
everything  else is instantly rejected.   It is  hardly necessary to say,
that if the child is  at the breast, it  should  not be allowed to suck so
long as the inflammation of the stomach  continues, excepting at long
intervals, and for a very short period each time.
  A considerable difference of opinion exists, as to the  propriety of
administering remedies internally, in this disease;  some proscribing
them  entirely, trusting the cure of the inflammation exclusively to
external means; while others think it very necessary to administer, in
the  early stage of the attack, some mild purgative,  especially if a
costive state of the bowels  exists. 
204                DISEASES OF CHILDREN.
  We have been  in  the habit, immediately after the  application of
leeches  to  the  epigastrium, or the  employment of general bleeding,
when this  has  been indicated and  admissible, to  administer to the
patient calomel in small doses, repeated  at  short intervals—say from
the sixth to the  half of a grain everyone or  two hours.  This we have
known,  in a  large  number of cases, to suspend, very promptly, the
irritability of the stomach, and to produce a favourable change in the
symptoms, generally.   In cases attended with frequent thin, acid eva-
cuations from the bowTels, the  calomel we have found very generally
to arrest the diarrhoea, and render the stools of  a more  consistent and
natural  appearance.   We  ordinarily combine  with each dose of the
calomel, a grain or two of calcined magnesia, and  give it mixed  in a
little mucilage; but where  there exists a very great irritability of the
stomach, we direct the calomel, combined with a few grains of pow-
dered gum  acacia, to be placed dry upon the tongue, the child being
shortly afterwards given to drink a spoonful of  thin mucilage.
  After the  inflammation  of  the stomach  is somewhat reduced,  a
blister to the epigastrium will often be found of essential service ; when
too early applied, blisters, however, have appeared to  us to do more
harm than good.  The blister  should be kept on only sufficiently long
to produce  a redness of the skin, and then  removed, and the epigas-
trium covered  with a  common bread-and-milk poultice.  In  young
children, great  inconvenience,  and often severe  and protracted suffer-
ing have been the result of a blister being  allowed  to remain on until
vesication occurs.
  Inflammation of the stomach in its most acute form is often attended
with a condition of the pulse  and surface,  and a degree of extreme
prostration, which have induced the inexperienced practitioner to sup-
pose that some  remedy adapted to support the strength of the patient,
was demanded; in  every instance, however, its use will be found to
aggravate the symptoms, and  hurry on  a fatal result.   In these cases
of extreme prostration, with a cool skin, and small thready pulse, we
have repeatedly seen the  most beneficial results, from the use of the
warm bath, repeated daily—in some instances,  night and morning.
   The chronic  form of gastritis, is to be treated by a mild, unirritating
diet, of some farinaceous preparation, with milk—by the warm bath—
and blisters to the  epigastrium, frequently repeated.  In this form  of
the disease, we have derived great advantage from  small doses of ca-
lomel, combined with  ipecacuanha and extract of hyoscyamus.*  If
a frequent and  troublesome diarrhoea is  present, from  half a grain to
a grain of acetate of lead  may be added to each dose.
                   * R.—Calomel, gr. iij.—iv.
                         Magnes. calc. gr. xxxvj.
                        Ipecacuanhas, gr. ij.—iij.
                        Ext. hyosciami, gr. iv.—vj.—M. f. chart. No. xij.
                   One to be given every three hours.
   In that form of the disease, which is attended with gelatinous soften-
ing of the stomach—the  occurrence  of which, sooner or later,  may
be suspected, from the severity of the  symptoms at  the very com-
mencement of  the attack; the yellowish or greenish  matters ejected 
DISEASES OF  THE DIGESTIVE ORGANS.         205
from the stomach and bowels, the latter particularly being often ex-
tremely acid ;  the coldness of the extremities;  the habitual expression
of suffering which the countenance  of the  patient  assumes, and the
general state  of prostration that early ensues—the most  energetic
treatment is demanded, from  the very onset of the disease.  The
remedies differ in nothing from those  proper  in other cases of acute
gastritis.  The early and judicious detraction of blood, from the arm,
or by leeches, to an extent  commensurate  with the violence of the
disease,  and the age of the patient, will often promptly abate the
intensity of the inflammation, and prevent  the occurrence of disor-
ganization of  the stomach or limit its extent.
   In cases attended with repeated vomiting, or copious diarrhoea, and
with a rapid depression of the powers of life—where there is every rea-
son to fear a gelertiniform softening of the stomach,—Rilliet and Barthez
recommend the administration of the gummy extract of opium, either
in a pill or  dissolved in  water, in doses of one centigramme every two
hours, until three centigrammes (not  quite half  a grain) shall be taken
during the day.  When no accident results, and when the age of the
child will permit of it, they give the opium every hour in the  same
dose, stopping when five centigrammes (rather more than three-quarters
of a grain) have been taken.  When  any obstacle exists to the admi-
nistration of the remedy by the mouth, they recommend to sprinkle,
twice  a day, over a small  blistered  surface upon the epigastrium half
a centigramme (about one-twelfth of a grain)  of the hydrochlorate of
morphia.
   It is hardly necessary to  say, that the hydrochloride of iron, recom-
mended by Pommer, Hergt, and others in gelatinous softening of the
stomach, is not adapted to the softening from acute gastritis; the cases
in which it is reported  to have been  employed with  advantage, were
evidently those  from defective or disturbed  nutrition, unattended with
 inflammation.
   The utmost  care  should  be paid  to the diet and regimen of the
patient, for a  long period after his recovery from an attack of gastritis,
as the disease is one very liable to a relapse, from slight causes, but par-
ticularly, from  errors in diet.   The food should consist, if not of the
breast-milk of the  mother or a healthy nurse, chiefly of milk and fari-
naceous articles, in moderate quantities.  Gentle exercise, at first of a
passive kind, should be taken  daily,  when the weather is  fine, in the
open air.   The daily use of the  warm bath should  not  be neglected.
 The surface should be preserved of a comfortable and equal tempera-
ture, by appropriate clothing, and by rooms  properly warmed and ven-
tilated in cold weather, and cooled by the  admission of a  current of
 air, and the exclusion of the sun's rays, during the heat of summer.
   We have said nothing of the treatment of  gastritis from  the acci-
dental ingestion of poisonous substances into  the  stomach, which oc-
casionally happens during infancy and childhood:—with the exception
of the administration of such articles as  have been  found to suspend
the action  of, or  to  neutralize whatever poison has been taken, the
same  remedies precisely are demanded, as in the  cases of ordinary
gastritis. 
206
DISEASES OF CHILDREN.
                       CHAPTER V.

                  DISEASES OF THE INTESTINES.

                    1. — Enteralgia — Colic,

  Intense pain of the bowels is of frequent occurrence during infancy.
We have already noticed its connexion with indigestion, and the means
best adapted  for its relief, in  such cases.  Enteralgia, however, often
occurs during infancy, under circumstances where we have no reason
to suspect, as its cause, any disturbance  of the digestive function from
the bad quality, or undue quantity of the food.  We have known it to
occur  daily, during the first  month or  two,  and nearly at the same
period of the day—generally towards the latter part of the afternoon.
Dewees remarks that it generally occurs between four and six o'clock,
p. m. ;  while others have noticed  its occurrence at a regular poriod, in
the morning or forenoon.
  In most cases, this species of colic is attended with the formation of
gas within the intestines, and, occasionally, the tumid and tympanitic
state of the abdomen is  very considerable.  In other  cases, however,
little or no flatulence is perceptible, the  paroxysms of pain occurring
at irregular intervals, and being readily  induced by the feet becoming
cold or wet.
  We have not been able to examine the pathological condition of the
alimentary canal in cases  of simple enteralgia, never  having  known
death  to occur from it.
  In slight attacks of colic, the infant becomes suddenly very  fretful,
draws up its knees, cries for a few  minutes,  and then resumes its usual
quiet state, as though nothing had  occurred.   These attacks may be
repeated at shorter or longer intervals, and seldom cease permanently,
or for  any length of time, until a portion of gas is discharged  by the
mouth or per anum, or an  evacuation of faeces, often thin and  frothy,
takes  place.
  In  more violent  attacks, the  infant commences, suddenly, to utter
sharp, piercing screams, which are often lornz  continued, or only inter-
rupted by a few moments of quiet; the knees  are forcibly drawn up,
or the legs are drawn up and  extended in rapid succession; the trunk
of the body is occasionally forcibly extended, with the head thrown
back,  and  the hands firmly clenched.  The expression of the counte-
nance indicates severe suffering; the face being  occasionally flushed,
or covered with large drops  of perspiration.   The abdomen is often
distended, tense, and tympanitic, or presents  an  irregular  or knotted
surface.  No pain is induced  by pressure upon any part of the abdo-
men ;  gentle  pressure and  frictions appear, indeed, in most  cases, to
afford decided relief.
  Notwithstanding the severity of the paroxysms, in this form of infan- 
            DISEASES OF THE DIGESTIVE  ORGANS.         207

tile colic, the child, immediately upon their cessation, becomes quiet,
cheerful, and playful, and exhibits nothing in its appearance, to indi-
cate the  severity of  its recent sufferings.  Its  appetite  is seldom im-
paired, the digestive and nutritive functions are, in no degree, disturbed
or interrupted, and the general health seems, often, actually to improve;
as, Dr. Dewees very correctly remarks, some of the fattest and  heal-
thiest children are those affected with  it.  It is a popular nursery
opinion, that boys are more subject  to this species of colic than girls;
but we have not observed it to occur more frequently in one sex than
in the other.
   Dr. Parrish has described  a species  of enteralgia which we have
occasionally met with.  The child often screams out suddenly, throws
itself back,  and  stiffens its body, as in  cases  of flatulent colic ; the
paroxysm ceases, generally, in a few moments, and is succeeded by a
state of perfect ease.  Even when the pain is less severe, the peculiar
motions and complaints of the infant are such, as experienced mothers
and  nurses  immediately attribute to  uneasiness  in  the cavity of the
abdomen.  Flatulent discharges by the mouth or anus  are frequently
productive of great relief.   The formation of gas within the intestines
is generally  very abundant, producing, often, a  tympanitic swelling of
the abdomen.
   The peculiarity of this variety of enteralgia, consists in its being ac-
companied  by a species of  convulsion, resembling an epileptic fit;
from which  it  differs, however, in the patient, immediately on its ces-
sation, becoming quite sensible, and sometimes even playful. Occasion-
ally, two or more of these  convulsive attacks will occur in quick suc-
cession, and then days and weeks will elapse  before their return.   If
not arrested, however, they become  more frequent and distressing; and
at length, the  infint  is  almost  constantly affected with  severe spasms
or partial convulsions, and finally sinks  under the disease.
   This form of enteralgia occurs usually in infants, between five and
twelve months of age.  According  to the observations of Dr. Parrish,
if the child survive the period of dentition,  it is  usually safe.
   In the  only case in which a post-mortem examination was made,
the greater portion of the small intestines were found irregularly con-
tracted, being  reduced, in some parts, for more  than  an  inch in extent,
to the size of a goose-quill; in other parts, the calibre of the intestine
was almost  entirely obliterated, as  if it had been tied  with a thread.
The omentum was folded up in the form  of a thick twine  or small
rope, and lay upon the arch of the colon.   The gall-bladder was filled
with a light-coloured, glairy fluid.  No other indication  of disease was
detected  in the cavity of the abdomen or thorax.  The  brain unfortu-
nately was not examined.
   The peculiar phenomena of the species  of enteralgia described  by
Dr. Parrish, evidently result from some degree of cerebral or spinal
irritation being combined with the neurosthenic condition of the intes-
tines.
   The occasional causes of  enteralgia are but little understood.   A
very attentive study of the  disease has  not enabled  us  to detect any
particular circumstances under which it is most liable to occur.   It 
208
DISEASES OF CHILDREN.
may appear at any period, between birth to the termination of the first
dentition; but we have met  with  it, most frequently, within the first
three or four months.   It is very commonly attended with an habitu-
ally constipated state of the bowels, and  the paroxysms are  often ex-
cited  by allowing the feet to become wet and cold.  The disease is not
necessarily connected with any degree of inflammation of the alimen-
tary canal, though, in very severe cases, we have known enteritis to
become developed at an early period.
  Dr Parrish, who refers that form of enteralgia described by him, to
" intestinal spasm," remarks, that " there can be no doubt, that  it is
greatly aggravated by difficult dentition."
  The treatment of enteralgia may be divided into that proper during
the paroxysms, in order to  allay the violence  of the pain,  and  that
during the intervals, to prevent their recurrence.
  During the paroxysms, the warm bath and  warm  fomentations to
the abdomen are among our most valuable remedies.  We have found
prompt relief often to be produced, by applying to the  abdomen, after
immersion in the warm  bath, a cataplasm formed of hops steeped in
warm water, and enclosed in a thin gauze bag.  The bowels should
be opened by an  injection of warm water, to  which  a few grains of
assafoetida, dissolved in milk, may be advantageously added.  Inter-
nally  we  have  occasionally administered, with prompt relief, a  few
drops of aqua camphorata, or of spirits of turpentine, rubbed up with
sugar.  Three to five drops  of spirits of turpentine may be  given to
an infant,  and repeated, every one, two, or three hours, according to
the urgency of the case.
  When, however, the  paroxysm is one  of uncommon severity, and
does not promptly yield to the means that have been enumerated, we
have never hesitated to administer an opiate, either by injection or by
the mouth, graduating the dose according to the age of the infant, and
carefully watching its effects before venturing upon its repetition.  We
have  been much pleased with the effects, in the colic  of infants, of a
watery  infusion of opium.  Five grains of opium may be infused, for
three hours, in two fluid ounces of hot water; the infusion being then fil-
tered, ten  grains of bicarbonate of soda are to be added; of this, ten
drops may be a given to a child, within the month, in a little sweetened
aniseed water—the same dose being repeated after an hour  if neces-
sary.   When the bowels are distended with gas, prompt relief may be
occasionally obtained  by the introduction  into the rectum, of a large
gum elastic catheter, or a common enema syringe.
  In the species of enteralgia described by Dr.  Parrish, he directs the
bowels to be freely evacuated by castor oil, magnesia, or some other
gentle cathartic; blood  to be taken from the arm, or, by leeches, from
the abdomen; the child to be immersed in a warm bath, and  antispas-
modics, particularly the assafoetida, to be  given  by the  mouth, and as
an enema.  According to the age of the child, from two to five grains
of assafoetida may be administered by the mouth every two  hours in
the form of emulsion, and from ten to twenty grains as an enema, re-
peated,  more or less frequently, according to circumstances. If  the
assafoetida is not retained upon the stomach, or produces, when injected 
           DISEASES OF THE  DIGESTIVE  ORGANS.       209

into the rectum, an unpleasant irritation, the rectified oil of amber, two
to five drops, rubbed up with gum acacia, loaf  sugar, and cinnamon
water, may be substituted.  If there should  be intense pain, a few drops
of laudanum may be combined with the assafoetida or oil of amber, or
from four to eight drops of laudanum may be injected into the rectum.
Dr. Parrish likewise directs frictions along the  spine with a liniment
composed of oil of amber and laudanum, of each a teaspoonful, and olive
oil and brandy, of each a table-spoonful; and, in severe cases, a large
blister to the abdomen:—the distension of the bowels being, at the same
time  relieved, by abstracting the accumulated gas by means  of a sy-
ringe introduced per anum.
   In  the  few cases which we have seen of this form of enteralgia,
we have succeeded in affording very speedy relief, by the use  of the
warm bath, followed by warm fomentations to the abdomen, injections
composed of assafoetida  dissolved in milk, and the administration of
a few drops of aqua camphorata, or of spirits of turpentine, in a spoon-
ful of sweetened aniseed water.  In severe cases, the application  of a
few leeches behind each of the ears, we have invariably found  to pro-
duce  a decidedly beneficial effect.
   From the evident tendency to  cerebral  disease in these cases, we
have  been deterred from the use of opium,  and have never  seen any
advantage to result from the application of a  blister or any stimulating
embrocation to  the abdomen.  A cataplasm of hops steeped  in hot
water, or cloths wrung out of warm water, and then sprinkled freely
with  laudanum, has  occasionally been followed with very decided
relief.  Frictions along the spine, with the oil of amber, as directed
above, and the removal  of the gas from the bowels by a tube or sy-
ringe, introduced into the anus, are unquestionably productive of good
effects.
   In the intervals of the  paroxysms, of that form  of enteralgia which
ordinarily occurs in young infants, we feel at a loss to say what ought
to be done to prevent their recurrence.  The child appears to enjoy
perfect health; the functions of its organs generally are regularly per-
formed ; and in the majority of cases, it is  difficult to detect any cause
to which the production of the disease can be referred. . There is fre-
quently, however, an habitually inert condition of the bowels; this we
should endeavour to counteract by a proper regulation of the  diet of
the mother, which should be composed principally of articles of a laxa-
tive character, and the child should be immersed daily in a warm bath,
followed  by gentle frictions over the abdomen.   The occasional use of
laxative enemata will often counteract the inert  state of the  child's
bowels; a very good one is that composed of milk and molasses,  with
a slight addition of chloride of sodium ; or a suppository, formed of
the common resinous soap, about one inch long, and a quarter of an
inch thick, shaped  round  and slightly tapering to  a point, may, after
being dipped in water, be passed within the  anus.  The  introduction
of a large-sized urethra bougie a few inches up the rectum, will gene-
rally cause an evacuation, and is attended  with  less irritation and in-
convenience than either injections or suppositories.  In some cases of
habitual costiveness, according to Merriman, frictions over the abdo-
                               14 
210
DISEASES OF  CHILDREN.
 men, daily, with a mixture of one  ounce of soap liniment and half an
 ounce of the compound tincture of aloes, have been found very bene-
 ficial in procuring a regular state of the bowels.
   We have derived the best effects, as well  in counteracting an habi-
 tually costive habit in infants, as  in preventing the recurrence of pa-
 roxysms of colic, from the use of a combination of extract of hyoscy-
 amus, ipecacuanha, and magnesia, in small does.1
                * R.—Ext. hyoscyami, gr. iv. ad vj.
                     Magnes. calc. gr. xxiv. ad xlviij.
                     Ipecacuanhas, gr. ij. ad iij.—M. f. ch. No. xij.
                 One to be given every three hours.

   Castor oil, which is usually given to  obviate  the  costiveness of in-
 fants and young children, will in most cases be found to increase rather
 than to remove the inert state of the bowels.
   Care should be taken to keep the child's feet dry  and warm, by pro-
 per clothing, and by changing the stockings or socks the moment  they
 become  wet,  and thoroughly drying  the feet  before the fire or by
 gentle friction with a soft cloth, previously to putting others  on.
   Dr. Dewees, viewing the disease as one of a strictly periodical  cha-
 racter, administered a decoction of bark,  in many cases with the  hap-
 piest effect; in others, however, no benefit resulted from its  use.  Dr.
Eberle has seen good effects from  the cyanuret of iron, in com-
bination with powdered valerian, in the proportion of half a grain of
the first, to three grains of the latter, for a  child between two  and three
months old ; the dose to be repeated every three or four hours, during
 the intervals of the paroxysms.
   To prevent the recurrence of the convulsive form of enteralgia, Dr.
Parrish directs a proper  regulation of the diet of the child; attention
to the state of the gums, which, if inflamed, are to be  freely lanced,
and the operation repeated whenever  the incisions heal, so long as the
continuance of the inflammation may  render  it advisable ; with blisters
behind  the ears, kept open by some  stimulating  dressing;  and, if
there exists acidity of the stomach  and bowels, the frequent adminis-
tration of some alkaline remedy.   Dr. Parrish prefers the alkaline in-
fusion of Physick, diluted to suit the palate of the infant, in doses of a
teaspoonful every two or three hours:—we should  certainly prefer, in
these cases, calcined magnesia, or carbonate of soda,   'the follow-
ing will be found to  be a  very excellent  prescription  in most in-
stances.*

                    * R.—Mucil. G. Acaciae, giij.
                         Sacch Alb. pur. 3iij.
                         Spir. Terebenih. 3j.
                         Magnes. calc. gr. vij.—M.
                 A. teaspoonful to be given  every three hours.

   In every case of  severe colic occurring in children, the symptoms
 should be carefully scrutinized, and attentively watched; inflammation
of the bowels being very apt to  occur, which, the  moment it is de-
tected, should be met by its appropriate remedies. 
           DISEASES OF THE  DIGESTIVE  ORGANS.       %\\


                        3. — Diarrhoea.
  Notwithstanding that diarrhoea  is one of the  common symptoms of
inflammation of the alimentary canal, it, nevertheless, occurs in a large
number of  cases, from a degree of irritation of the  intestinal mucous
membrane, which cannot  be considered  as amounting to inflamma-
tion ;  it would  seem necessary, therefore, to consider it separately, as
its treatment differs in many important particulars from that proper in
the diarrhoea attendant upon enteritis.
  In infancy, diarrhoea may be caused, independently of inflammation
of any portion of the gastrointestinal mucous membrane,  by improper
articles of  diet, by excess in feeding, by cold and damp, by the irrita-
tion of  teething, and by excessive heat, combined with an impure and
stagnant state of the atmosphere.
   The excitable  condition of  the alimentary canal in infants, renders
them particularly liable to the occurrence of  diarrhoea from  slight
causes; it  is, consequently, an affection of far  more frequent occur-
rence during the  early period of life, than at any subsequent age.  It
may last for only a few hours, and then cease spontaneously, or the
evacuations may occur every  few minutes, and  continue,  with little or
no abatement, for a considerable length of time; exhausting the strength
of the patient,  and producing extreme emaciation, without, in  many
cases, the  occurrence of any  inflammatory affection of the intestines.
When,  however,  the diarrhoea assumes a protracted form, it will, very
generally, be found  to be dependent upon subacute inflammation of
the intestinal mucous membrane.
   In the diarrhoea of infants, the  discharges from the bowels may be
more or less thin, of a dirty white or grayish colour, of a curdled ap-
pearance, and  of a  decidedly acid  odour,  or they may be almost en-
tirely fluid, of  a  bright yellow or greenish hue, and often mixed with
blood;  these are the general  conditions  of the evacuations occurring
in early infancy.
   In  older children, the discharges  may  be thin and feculent, yellow,
green, or dark  brown ; or they may consist, at  first, of portions  of un-
digested food,  very  acid, and  often, when  the diarrhoea  has  resulted
from  the use of crude and ascescent vegetables, in a state of fermenta-
tion.   Occasionally  the discharges are very thin and watery, without
any decided smell, and nearly colourless;  or they may be composed
of a  fluid  mixed with bile, of a yellow or green colour.   In  many
cases, particularly during dentition, the  stools  consist, almost  exclu-
sively,  of a thick, jelly-like, semi-transparent mucus.  In the more pro-
longed forms of diarrhoea,  the discharges are, in general, very thin,
small in quantity, of a dark colour, and extremely offensive.
   Diarrhoea in children is usually attended with loss or irregularity of
appetite, and often with more or  less  nausea and vomiting; in  many
instances,  however, the stomach is not in  the least degree affected, and
the appetite remains unimpaired.   Increased thirst commonly attends,
and some  degree of griping generally precedes and follows each dis-
charge from the bowels.  Occasionally,  there is some degree of flatu-
lence and  severe paroxysms of colic.   The skin is ordinarily dry, and 
212
DISEASES  OF CHILDREN.
            the countenance pale and languid.  The abdomen  may be swollen,
            when the diarrhoea  is connected with an overloaded condition of the
            bowels, or when a  development of gas takes place, but it is seldom
            tense or tender to the touch, nor is its temperature increased.
               Whenever pain is excited by moderate pressure upon the abdomen,
            especially when accompanied by  tension,  and increased heat of its
            surface, the diarrhoea will be found to be dependent  upon enteritis.
            In such cases, there is usually more or less  heat of the surface gene-
            rally, dryness, with  a sense of heat or burning of the palms of the
            hands, and other symptoms of febrile excitement, with evident exa-
            cerbations towards  evening.
               When the diarrhoea is  prolonged, or  assumes a chronic form, the
            skin becomes dry, harsh, and  discoloured; great emaciation ensues;
            the countenance becomes wrinkled, of a dirty yellow  or brownish hue,
            and assumes the appearance of premature old age; while the discharges
            from the bowels are frequent, but small in quantity; occasionally they
            are suspended for  a day or two.  They vary in  colour and appear-
            ance, but are generally very thin  and dark-coloured, and are often
            intolerably foetid.
               Simple diarrhoea is not  often a very troublesome or  unmanageable
            complaint; with the removal of the cause  by which it  has been pro-
            duced, it will, in many cases, cease spontaneously, or may be readily
\,k*vhZMj   controlled by appropriate remedies. CWhen«p#, however,)from any
-~          cause, the diarrhoea is prolonged, it may produce so great a degree of
            exhaustion, and so far disturb the nutrition of the system, as to render a
            permanent cure difficult, and, sooner or later, to cause the death of the
            patient; or, at an earlier period, an acute or chronic inflammation, or
            extensive  disorganization  of the mucous membrane  of the intestines
            may occur, and a fatal termination rapidly ensue.
               Death  seldom occurs in cases of simple  diarrhoea; and, conse-
            quently, very few examinations  have been made  of the pathological
            condition of the intestines.  In the more prolonged cases, the intestinal
            mucous membrane  has  often presented  no marks of disease, with the
            exception, perhaps, of unusual paleness, and, occasionally, of softening
            to  a greater or less extent.   The parietes of the intestines have, in a
            few instances, been found  of unusual thinness, almost transparent, and
            easily torn.  A contracted state of the tube at different parts, and its
            distension at others with gas, is a common occurrence.  In  children
            who die  whilst labouring under serous or  mucous diarrhoea, unat-
            tended with symptoms  of inflammation, the follicles  of the intestines
            will be found greatly developed, studding the surface of the intestines
            with small, white  projections, or  occurring in  distinct clusters, or
            plexuses.   In most cases of chronic diarrhoea, the mucous membrane
            is  thickened, often  softened or ulcerated, and, occasionally, presents
            large patches of a livid  or slate colour.  The mucous glands are gene-
            rally found enlarged, inflamed, or ulcerated, or of a dark, nearly black
            colour.  The mesenteric glands are often inflamed, enlarged, or indu-
            rated.  The gall-bladder  sometimes contains greenish bile, and the
            liver is occasionally more vascular  than  natural.  (Brunner, Stark, 
           DISEASES  OF  THE DIGESTIVE  ORGANS.       213

Bang, Andral, Copland.)  The most usual seat of the lesions in chronic
diarrhoea, are the ileum, especially its lowest third, and the coecum.
  The most common form of diarrhoea in infants and young children,
is that resulting from overfeeding, from the bad quality of the mother's
or nurse's milk, or from  some change  produced in  it by accidental
causes, or from improper  articles of food.
  The foundation of diarrhoea is often laid during the  first twenty-four
hours  after birth,  by  the reprehensible, but too common practice  of
gorging the infant's stomach with alimentary substances,  often of the
worst kind, previous to the secretion of its natural and congenial nourish-
ment.  Nurses are always fearful that the infant will suffer from the
want  of nourishment,  previously to  the appearance  of the mother's
milk,  and, very generally,  introduce into  its  stomach a quantity  of
food, which cannot fail to produce a degree of irritation, often  result-
ing in an obstinate diarrhoea of some  continuance.  Ordinarily no kind
of nourishment is  requisite until  the child can be applied to the breast.
Should the secretion of milk, however,  not  take  place for one or two
days, as  is occasionally the case, a little  new milk, with the addition of
about  one-third warm water, and sweetened with loaf sugar, may  be
given, and repeated, if necessary.
  Infants who are partly  nourished by artificial food,  as well as those
brought up by the hand, are particularly liable to attacks of diarrhoea,
often of  a very obstinate character.   In these cases,  the  irritation  of
the alimentary canal is frequently produced, less by the improper cha-
racter of the food employed, than from the stomach of the  infant being
habitually overloaded, by the food being given to it in too great quan-
tity, or at too short intervals.
  The quality of  the mother's milk is  often the cause  of diarrhoea.
Under the same circumstances as the breast-milk produces indigestion
in the child that partakes of it, will it be liable, also, to cause an attack
of diarrhoea.
   There  is a curious circumstance in relation  to the effects of parti-
cular  articles of  food upon the stomach and  bowels of infants and
young children, which should be kept constantly in mind  in directing
their diet, in every case in which it becomes necessary to allow other
food  than the breast-milk;—it  is that  some  infants are invariably
purged by particular kinds of food, which agree perfectly well with
others;—thus arrow-root, so generally recommended  as  an appropri-
ate article of diet for infants, particularly when labouring under bowel
complaints, we have so often found to produce purging, that we have
almost entirely ceased from directing it.
   The diarrhoea which results, in infants, from improper or too much
food, is generally  attended with  vomiting, the generation  of an undue
amount of acid in the stomach and intestines, colicy pains, paleness of
the face, and general relaxation of the muscles.   The discharges are
thin, curdled, of a bright yellow or greenish colour, and often decidedly
acid.  The disorder of the bowels generally ceases spontaneously in a
short time, if the  cause by which  it  has been produced is at once  re-
moved ;  but, if this be continued, the discharges become more frequent,
thin, and watery, often intensely green, the functions of the alimentary 
214
DISEASES OF  CHILDREN.
canal are imperfectly performed, or entirely suspended—the  food and
drinks taken, pass through the bowels unchanged; great emaciation is
produced, and the infant dies, sooner or later, from extreme exhaus-
tion;  or an acute, or subacute inflammation of the mucous membrane
of the intestines  is developed,  by  which the child is more  or less
promptly destroyed.
  The blood which is often mixed, sometimes in considerable quan-
tity, with the discharges, in the diarrhoea of young infants, is  the result
of a true haemorrhagic effusion, caused  by the state of hyperaemia of
the intestinal mucous membrane, which, almost invariably, exists for
a short period  after birth.
  Improper articles  of  food, or excess in eating, are among the most
common causes of diarrhoea, subsequent to  the  period of  weaning.
Unless the utmost attention is paid  to the proper regulation  of the in-
fant's diet, for  some time after it is taken from the breast, more or less
disorder of the bowels invariably results.  Often an excessive  diarrhoea
occurs,  the discharges  being at first feculent, or faeces mixed with
imperfectly digested food, but speedily becoming composed of a serous
fluid,  of  a  dirty yellow, or greenish yellow.  Intestinal inflammation
is early developed, or the diarrhoea  assumes a chronic  and peculiarly
unmanageable form. It  is this diarrhoea which is described by Cheyne
as a new and peculiar form of disease, under the name of " atrophia
ablactatorum"
  In  older children, diarrhoea is generally produced by errors  in diet.
The appetite at this age is keen and very liable  to  lead to  excess in
eating, and especially to an indulgence in rich food—pastry, fruits, and
confectionary—the inordinate quantities of these that are devoured by
children who are uncontrolled in their diet by those who have the care
of them, often produce  the most  deleterious  effects.   An occasional
excess, may produce no further inconvenience than nausea,  vomiting,
and  a pretty profuse diarrhoea, ceasing spontaneously soon  after the
offending substances are expelled.   But  when excess in eating, or im-
proper food is  habitually indulged in, a much  more serious disorder of
the alimentary canal ensues; the diarrhoea then, often, becomes pro-
fuse, and, if not promptly and judiciously treated, inflammation of the
bowels is liable to be produced, running, generally, into a chronic  form,
and producing death from marasmus; or disease of the brain is ex-
cited, terminating, most generally, in serous effusion.
   The application of cold to the surface of the body, and  especially
exposure to cold and damp, or a sudden transition  from a  close and
heated, to a chilly and  humid  atmosphere, will, in many cases, give
rise, in  children, to a more or less  profuse diarrhoea, with mucous or
thin watery discharges.  These cases are often  attended with  more
or less  febrile excitement, and tenderness and heat of the  abdomen,
indicating  the existence of some  degree of intestinal inflammation.
Slight catarrhal symptoms are frequently present; and, in some cases,
the latter precede the diarrhoea; hence the  common  observation of
nurses, that " the cold is working itself off by the  bowels."  This form
of diarrhoea, if its true character is  overlooked, and  it is,  in conse-
quence, improperly treated in its commencement, is very liable to be- 
           DISEASES  OF THE DIGESTIVE ORGANS.        215

come a serious disease,  giving rise to extensive disorganization of the
intestines, or early involving the brain.
  Some degree  of diarrhoea  is usually attendant  upon the process of
dentition.  When moderate, its effects are salutary; but, when  exces-
sive, or of long continuance, particularly if the infant becomes ex-
hausted, or considerable febrile excitement, with tension, heat, and
pain of the abdomen occurs, it should not  be  allowed to  go on, but
should be promptly arrested by an appropriate course of treatment. In
the diarrhoea which occurs during dentition, the discharges are, occa-
sionally, faecal, of a  bright yellow or green colour, and more or less
acid, but more commonly they consist of thin mucus, often mixed with
a portion  of faeces or bile.
   It has been very correctly  remarked by Billard, that the frequency
of these thin mucous discharges about the period of dentition, is in
consequence of the rapid development and increased activity of the
muciparous follicles of the intestines, which takes place  about the
same time.  The degree of irritation communicated to the digestive
mucous membrane during the normal development  of the  teeth, is
sufficient, with the existing condition of the muciparous  follicles, to
cause an undue amount  of fluid to be poured into  the intestines, which
is  still  further  augmented, if the cutting of the  teeth be  tedious, or
attended with  difficulty.  Although this morbid development and acti-
vity of the muciparous  follicles is not an inflammatory action, it is,
nevertheless, one bordering closely upon it, and hence the propriety of
always keeping children affected with mucous diarrhoea at the period
of dentition, upon a strict regimen, and closely watching, lest inflam-
mation should suddenly  occur.
   We have repeatedly  seen cases of mucous diarrhoea, occasionally
of a very severe and protracted character, ensue upon  the sudden
disappearance of cutaneous eruptions, or the drying up of the discharge
from ulcerations behind the ears.  These cases appeared to be, in the
majority of instances, accompanied with  some degree of inflammation
of the intestinal mucous membrane.
   Repeated mucous discharges are  often accompanied with the pre-
sence of intestinal worms;  whether, however, they are in any instance
attributable to an irritation produced by the latter is a question still in
dispute.  Of the  existence of worms  in the intestines, we  have no
positive evidence, excepting that derived  from their appearance in the
discharges.  A superabundance of viscid mucus in the bowels, and its
copious discharge by stool, being generally enumerated as  leading in-
dications of their presence, the latter is often inferred, merely  from the
fact, that a child is affected with mucous diarrhoea, particularly in its
chronic form.
  Atmospheric heat, particularly when combined with the influence
of a  confined and impure atmosphere, is a common cause of diarrhoea.
During the summer months, in our large cities, few children escape a
slight attack ;  and among the  children of those who inhabit  the con-
fined houses situated in narrow, ill-ventilated courts, lanes, and  alleys,
the disease prevails in  a form of uncommon  severity.  It is of less
frequent occurrence  in  high, elevated, and healthy situations  in the 
216
DISEASES  OF CHILDREN.
country, but occasionally prevails to a considerable  extent, in  low,
marshy, or, what are usually termed  miasmatic districts.
  The discharges are, at first, faeculent, but soon become almost exclu-
sively composed of a thin mucus, mixed with bile, of a bright yellow,
or green colour: they are extremely copious, and are generally attended
with nausea, often with  bilious vomiting, and  more or less  griping.
This latter symptom is, however, absent in a large  number of cases;
the  discharges taking place as it were involuntarily.
  In slight cases, occurring in children properly nursed, and resident
in comparative healthy localities, the disease often ceases, in a short
time, spontaneously.   In  those who  are exposed  to the constant in-
fluence of a heated and confined atmosphere, the diarrhoea will  con-
tinue, with occasional temporary cessations, for many  days;  the urine
becoming tinged with bile, and the skin and whites of the eyes of a
yellowish hue;  or  the  discharges from the bowels are often attended
with a sense of heat or scalding, and it is not uncommon for an exco-
riation of the anus to take place.
  In such cases, symptoms of cholera infantum may quickly develope
themselves, or,  after a few days, and sometimes  earlier, the bilious
discharges may cease, and frequent  copious evacuations  occur, of a
serous fluid, at first of a yellowish or greenish colour, but, subsequently,
almost colourless.  At the same time, not unfrequently, the  abdomen
becomes tense, hot, and painful upon pressure; the skin dry and harsh;
the  tongue red at the tip and edges, and covered on its surface with a
dirty white or yellowish mucus; great thirst is experienced, and, what-
ever fluid is taken, is instantly expelled, and often  with great  violence;
aphthae frequently appear upon the parietes of the mouth, and rapid
emaciation ensues.  The brain is, in some  cases, early affected, and
the patient expires with all the symptoms of hydrocephalus ; in other
cases, the diarrhoea  assumes a chronic form, and the child, after be-
coming reduced, literally to  " skin and bones," and to a  state of ex-
treme exhaustion, expires apparently from inanition.
  The bilious diarrhoea of hot seasons, in its simplest form, appears to
be produced  by an undue secretion of bile, the result of the  excessive
stimulation of the  skin by atmospheric heat;  but in the more violent
cases, the presence of acute  inflammation of the mucous membrane of
the stomach, and upper portion of the intestinal tube,  or of  the lower
portion of the small intestines, is indicated, as well by the symptoms
during life, as by the pathological changes observed after death.
  We have frequently detected in our autopsies,  increased redness of
the stomach and duodenum, occurring in points grouped  together, in
irregular striae, in large patches, or irregularly diffused, and presenting
a kind of elevation  from the thickening of the  mucous  membrane.
Follicular inflammation was occasionally detected in the stomach, but
more frequently in the ileum.  Distinct  ulcerations and  softening of
the mucous membrane,  were of common occurrence.   In  repeated
instances, the follicles of the intestines were considerably  enlarged,
without appearing to  be  inflamed.  Contractions  of different parts of
the intestinal lube, were frequently observed, and in a few instances,
numerous invaginations.   The small intestines were generally empty, 
           DISEASES OF THE  DIGESTIVE ORGANS.       217

while the  mucous  coat of the large intestines, was  frequently coated
with a thick tenacious mucus, and often contained a frothy mucus, of
a grayish or yellowish  colour.  The liver was  usually in  a state of
hyperaemia, while  the gall-bladder  contained  more or less thin and
very light yellow or greenish bile.   The marks of inflammation were,
however,  in a  number of instances, particularly when the diarrhoea
had assumed a somewhat protracted or chronic form, by no means of
so decided a character;  and, in a few cases,  the only indications of
disease, were unusual  paleness of the mucous membrane, with enlarge-
ment of the muciparous follicles.
  The discharges, in some cases of diarrhoea, occurring during child-
hood, are of a very white, opaque  appearance,  having some  resem-
blance to  a mixture of chalk and water.   This constitutes the chylous
diarrhoea  of many authors ; chyle, however, never being present in the
intestines, could scarcely be expelled by stool, especially in quantities
sufficient to account for  the  copious, white, milk-like evacuations we
often observe to take  place; neither do the physical appearances of
the discharges bear any  resemblance to  those of chyle.   It  has  ap-
peared to us to be  merely a variety of the mucous  diarrhoea of chil-
dren, the peculiar condition of the stools arising, probably, from some
morbid change in the  intestinal secretions.  Some have supposed it to
depend upon irritation, with altered  secretion of the  pancreatic gland.
We have  had no opportunity of observing the condition of the alimen-
tary canal and other abdominal organs in  this form of diarrhoea, never
having met with it  in any case that terminated  fatally; it  is one, in-
deed, judging from  our own  experience, of not very frequent  occur-
rence in this country.
  From the preceding description of the  several species of diarrhoea
occurring in infants, it will be perceived  how intimately all of them
are connected with intestinal inflammation of  an acute, subacute,  or
chronic character.
  It is true, as  already remarked, that in  its commencement diarrhoea
may be the result simply of an increased  peristaltic action of  the in-
testines, with augmented  secretion from  the mucous membrane, and
from the liver, without the slightest indication of inflammatory action.
It may even continue  for a long period, and finally produce the death
of the patient by suspending the assimilative and nutritive functions,
and  still  no indications  of  inflammation be present throughout  the
attack. It  must,  nevertheless, be  kept  steadily in  mind, that  not
unfrequently the diarrhoea may be dependent upon inflammation of the
intestines, from its  very commencement, and that there is  a tendency
to the development of inflammation of a more or less acute form, in
every case, unless the cause of the diarrhoea be early remoyed, and it
be, in this manner, promptly suspended.
  Under  whatever circumstance, therefore, diarrhoea occurs, a close
scrutiny into, and careful analysis of all the accompanying symptoms,
should be made, and if the case be a protracted or obstinate  one, the
state of the abdomen as to tension, heat, and tenderness upon pressure,
should be cautiously examined ;—and if intestinal inflammation be de- 
218
DISEASES OF CHILDREN.
tected, its removal by a judicious course of treatment  is  essential to
the cure of the diarrhoea, and to secure the safety of the patient.
  In the treatment of every form of diarrhoea, the first and most im-
portant indication is, to remove the cause by which it has been  pro-
duced.  In that caused by improper food, or excessive  feeding, the
aliment should be at once improved in quality, or reduced in quantity.
If the mother's  milk be in fault, that of a healthy nurse should be sub-
stituted;  or, if this be impracticable, the infant may be nourished upon
diluted milk, with the addition of the best loaf sugar, by means of the
sucking-bottle.   If the infant be fed by the hand, in those instances in
which the breast of the mother does not afford a sufficient supply of
nourishment, the additional aliment should be the same  as directed
above; taking care that the child be not allowed  to overload its sto-
mach, by taking too much at  a time, or by being fed with it at too
short intervals.
  When diarrhoea occurs at the period of weaning, the utmost atten-
tion should be paid to the food  of the patient, agreeably to the direc-
tions given in our chapter on the diet of  infants.  Care being taken, at
the same time, to observe the effects of any particular article of  diet,
which, although in itself perfectly wholesome, may, from some peculiar
idiosyncrasy in  the child, disagree with its stomach, and  cause more
or less purging; whenever this  is found to be the  case, its use should
at once be relinquished, and another  kind of food substituted.  We
have known the bowels of infants, immediately after weaning, to be
disordered by all the ordinary farinaceous preparations, and by milk,
while meat broths, with the addition of rice or crackers,  agreed per-
fectly well with them.
  In older children, it will be proper, upon the occurrence of diarrhoea,
to suspend every species of solid aliment, and to confine them entirely,
for a short period, to moderate  quantities of some preparation of rice
with milk, to w7ater gruel, or to crackers and milk.  Fruits of every
kind—pastry, confectionary,  sweetmeats, and every  species  of fresh
vegetables, should be entirely prohibited.
  For drink, cold  water, or cold toast, rice, or gum water,  may be
given in small quantities at a time.
  The proper regulation of the diet, with the use  of the warm or tepid
bath daily, and gentle exercise  in the open air, will, in a large number
of cases, be all that is necessary for the cure of this form of diarrhoea;
and without such regulation of diet is carried strictly into effect,—and
in so doing, the physician will find himself constantly opposed by the
prejudices and  inattention of  parents and nurses,—it  is in  vain to
attempt its removal by the administration of medicine.
   The exhibition of some mild but active purgative, in the commence-
ment of  the attack, will be proper, in most cases, to remove any irri-
tating matters that may be retained in the alimentary canal.   The re-
peated exhibition of active purgatives is, however, not only unneces-
sary, but positively injurious, by increasing and prolonging the irrita-
tion by which the disordered action of the bowels is produced.
   If the diarrhoea is not quickly suspended by a  proper regulation of
the infant's diet, and the use of the warm bath—particularly if the 
            DISEASES OF  THE  DIGESTIVE ORGANS.       219

 stools are attended with griping—we have found a dose  or two  of a
 combination of calomel, prepared  chalk, ipecacuanha, and extract of
 hyoscyamus, to be attended with the best effects.3
                 1 R.—Calomel, gr. ij. ad vj.
                     Cretae ppt. gr. xviij.
                     Ipecacuanha pulv. gr. ij.
                     Extract. Hyoscyami, gr. iij. ad vj.—M. f. chart. No. vj.
      One to be repeated every two, three, or four hours, according to circumstances.

   Under the  use of this  combination, we have generally found the
 stools to become less  frequent,  more  natural, and of greater consis-
 tence ; the digestion to  be improved, and the irritability of the intestines
 diminished.
   It sometimes happens, in cases of simple  diarrhoea from errors  in
 diet, that a large amount of acid  is generated in the stomach, which
 appears to  keep up the discharges  from the bowels. When this occurs,
 a few grains of carbonate of soda  in solution ; a teaspoonful or  two,
 according to the age of the child, of  the aqua calcis, combined  with
 an equal portion of new milk,  or a few grains of prepared chalk, com-
 bined with  a quarter to a third of a grain of ipecacuanha, and the half
 of a grain to a grain of extract of hyoscyamus, may be given twice or
 thrice a  day;  with some slight astringent  every three  hours.   The
 tincture of kino, or catechu, or either  of these substances in powder,
 or the compound infusion of catechu,*  may be  given.
                       1 R.—Catechu pulv. 3ij.
                            Cinnamon, contus. 3ss.
                            Aq.  Bullient. gv.
            Macerate for an hour in a closely  covered vessel, and strain.
 Dose.—A teaspoonful every two, three, or four hours, according to the age of the patient, or
                          the nature of the case.
   With  many  American physicians,  we prefer  as an  astringent,  in
 cases of simple diarrhoea, a decoction  of the root of the geranium ma-
 culatum, or of the  blackberry (rubus villosus), especially the former,
 which, when the decoction is made with milk, is a very excellent and
 agreeable astringent, well adapted to  relieve the irritable state of the    ♦
 bowels, by  which, in many cases of ordinary diarrhoea,  the disease is
 liable to be kept up, after the original cause has been removed.
   The opiates  generally recommended in  this form of diarrhoea, are
 seldom,  if ever, required.  If, however, in consequence of the sleep
 being disturbed  by frequent evacuations occurring during the night-
 time, an opiate is indicated, an injection  composed of thin starch and
 a few drops of laudanum, or a small portion  of opium, combined  with
 ipecacuanha, and carbonate of sodae,* by the mouth, may be given in
 the evening.  But it is better, if possible, to dispense altogether  with
 the use of opiates in every form.

                    * R.—Opii pulv. gr. j.
                        Ipecac, pulv. gr. iij. ad iv.
                        Carb. Sodce, 9j.—M. f. ch. No. xij.
 For a child over one year of age, the proportion of opium may be somewhat increased.

  The treatment of mild  cases  of mucous  or serous diarrhoea, will
consist, principally, in the substitution of mild mucilaginous fluids, as 
220
DISEASES OF  CHILDREN.
rice water, gum water, or an infusion  of slippery elm bark, for the
ordinary food and drink of the patient: in  the use of the warm bath
morning and evening, and the exhibition of^a combination of ipecacu-
anha and calomel, every two or three hours;1 and as soon as the dis-
charges have become less frequent, and of a natural appearance, the
administration of some light astringent, as directed  above.  It  is all-
important, that every species of solid food be abstained from.  In cases
in which the  diarrhoea is attended with thin  mucous  or serous dis-
charges, even the mother's milk will, sometimes, be found to irrritate
the bowels, and increase the disease.  Hence it is better to confine the
patient always to simple mucilaginous fluids.
                   a R.—Calomel, gr. j. ad ij.
                        Ipecacuanha?, gr. ij. ad iij.
                        Sacch. alb. 9ij.—M. f. ch. No. xij.
      One to be given every two or three hours, according to the age of the child.

   As the disease arises, in most cases, from the effects of cold and
dampness, the warm bath will be found  an admirable remedy, particu-
larly if  followed by gentle friction over the abdomen, and surface of
the body generally.  The common practice of administering frequent
doses of castor oil in mucous diarrhoea, is one calculated to  increase
the irritation of the  intestines, and in this manner render the disease
more protracted and difficult to manage.
   When the discharges from the bowels are very profuse, and con-
sist, principally, of a thin, often nearly  colourless, serous fluid, the use
of small doses of calomel, ipecacuanha, acetate of lead, and  extract
of hyoscyamus, will be found  promptly  to arrest them.*   Ample expe-
rience has taught  us, that the acetate of lead may be given with the
most  perfect safety  to  children;  in the  combination just stated, we
know of no more effectual means of arresting the profuse serous dis-
charges which  often occur in the diarrhoea of infancy, which, if al-
lowed to continue, would  produce in a very short  time, a degree of
exhaustion,  that is not unfrequently fatal.
                   ■ R.—Calomel, gr. j. ad  ij.
                        Ipecacuanhae, gr. ij. ad iij.
                        Acetat. plumbi. gr. vj. ad xij.
                         Ext. Hyoscyami, gr. iv. ad. vj.—M. f. ch. No. xij.
One to be given every two or three hours.  The proportion of the several ingredients and
         the frequency of repetition  being regulated by the age of the patient.

   In every case of mucous diarrhoea, the liability to the development
of intestinal inflammation should be kept constantly in  mind;  and the
moment that tension, heat, and tenderness of the abdomen are detected,
or distinct febrile excitement occurs, it  will be proper to apply leeches
to the abdomen, in numbers proportioned to the age of the patient, and
the urgency of the symptoms; followed by warm fomentations, or an
emollient cataplasm.   As soon as the inflammatory action is subdued,
if the discharges from the bowels still  continue to be frequent, and of
a serous character, the combination of  acetate of  lead directed above,
may  be advantageously administered.
   In  some  cases, mucous diarrhoea assumes a kind of chronic  form,
the discharges being frequent, small in quantity,  and attended with  a 
           DISEASES  OF THE DIGESTIVE ORGANS.       221

good deal of straining.  They consist, chiefly, of a transparent, occa-
sionally,  jelly-like mucus, sometimes  perfectly white, at  others,  of a
dirty yellow, grayish, or green colour.   The bowels  are occasionally
distended with gas, but  the  abdomen is  seldom painful to  the touch
or exhibits  any increase  of  temperature.  There is, generally, great
emaciation, and sometimes, diminished  temperature of the  surface of
the body, or of the extremities.   In  these cases, we have found the
calomel and ipecacuanha, as directed above, to produce  an excellent
effect.  Mucilaginous injections, with a suitable addition of opium, or
the combination  of opium, ipecacuanha, and  soda, noticed under the
head  of simple  diarrhoea, will be required, to relieve the straining
frequently attendant upon the discharges.  Dr. Eberle recommends in
this chronic form  of the disease, from five to ten  drops  of balsam
copaiba, in the form of emulsion, with  the addition of a few drops of
tincture  of opium,  or  given in conjunction with minute portions of
Dover's  powder; we have likewise administered the  copaiba in many
cases, and have  often  witnessed the best  effects  from its  use.  The
form in which we have generally  given  it is as folkrws :*
                     * R.—Bals. Copaibae, 3j.
                          Magnes. calc. gr. x.
                          Spir. aether, nitr. 3nj.
                          Sacch. alb. 3iij.
                          Aq. cinnamon, giij.—M.
Dose.—One teaspoonful every two or three hours :  each dose to be followed in the course
              of an hour  by the fifth of a grain of Dover's powder.

   The frequent repetition of the  warm  bath  will be found advanta-
geous in these cases. The abdomen should be kept covered constantly
with a broad flannel roller.   Blisters to the abdomen have been recom-
mended, we have seldom, however, seen much advantage from  their
use.  The diet  in  this chronic  form  of the disease, should  consist
chiefly, of  very thin preparations of rice flour or tapioca, with  milk
and a small quantity of loaf sugat;; in some instances, these will, how-    v  I
ever, be found to disagree with the patient,  when probably,  simple
chicken  water, with or without rice, may be advantageously substi-
tuted.
   When mucous diarrhoea proceeds  from  the  sudden disappearance
of cutaneous eruptions, or  from  the drying up  of  discharges from
behind the ears, the treatment is the same as directed above. We have
never seen any good effects  result from attempts to  renew by stimu-
lating applications, the irritation of the skin, or the  ulceration  behind
the ears.
   When diarrhoea occurs during the  process of dentition, it is, occa-
sionally, merely faecal, but more frequently mucous, or serous.  When
moderate, and occurring in children of  a robust  and  plethoric habit,
the  proper treatment  is, a  careful  regulation of  the   diet—which
should be restricted to preparations of the farinacea with milk—cool
mucilaginous  drinks—the warm bath, and attention to the gums—the
protrusion of the  teeth, if tardy, particularly if the gum covering them
is hard, tense, and swollen, being promoted by incisions.  No attempt
should be made  to  arrest the  discharges, so long  as they continue 
222
DISEASES OF  CHILDREN.
moderate in quantity, and unattended by any unqsual symptom.  When,
however, they are profuse, when emaciation ensues, or symptoms of
intestinal inflammation present themselves, the diarrhoea demands im-
mediate attention; it should then be treated in the same manner as
though it had occurred independently of dentition.
  The mucous diarrhoea so frequent in cases of intestinal worms, has
generally been ascribed to the irritation produced by the  presence of
the latter.  How far this opinion is correct it is somewhat difficult, as
we have already remarked, to determine.
  We have, it is true, in numerous instances where worms have been
discharged in great numbers from  the intestines, observed  the children
to labour under a species of diarrhoea, attended with stools rather more
frequent than usual, and  composed entirely  of a  mass of thick, tena-
cious, diaphanous mucus, which  Appeared  to  come  away at once,
without straining, or any unusual effort.  These discharges frequently
alternate with  regular, healthy stools, or  those composed, in a great
measure, of natural faeces.   They are always unattended  with febrile
excitement, or the slightest indication  of inflammation.   The  children
are generally pale, of a lymphatic temperament,  with  capricious ap-
petites, and tumid, but soft abdomens; their breath  has,  generally, a
sickly, disagreeable odour; their tongue is coated with a thin  layer of
slimy mucus;  their urinary  discharge is copious, and light-coloured;
and in many cases, more or less oedema of the feet, and about  the eye-
lids occurs. We have  generally  succeeded in restoring the  natural
condition of the stools, and removing  the principal symptoms of  the
disease, by the administration  of  turpentine in emulsion,  followed  by
light astringents, the use of the warm  bath daily, and a careful regula-
tion of the  diet and regimen.1
                    * R.—Mucil. G. acaciae, 3iij.
                         Sacch. alb. pur.,3vj.
                         Spir. aether, nitr. 3iij.
                         Spir. terebmth. 3ij.             /
                         Magnes. Kile. gr. xiij.           ;  -
                         Lavend. spir. comp. 3ij.—M.
Dose, a teaspoonful, repeated three limes a day, or  oftener, when the child is over  two
                            years of age.
  When ordinary mucous diarrhoea occurs in a child suspected to have
worms, and especially when  it assumes an acute form, it should be
treated by the  means proper in that form of the disease, without refer-
ence  to  the presence of worms in the intestines:—the remedies usu-
ally employed for the destruction and  expulsion of the latter would be
calculated  to increase the diarrhoea, or even to induce severe  inflam-
mation of the intestinal mucous membrane.
   In the treatment of bilious  diarrhoea, the first indication is to  re-
move the cause  by which the  morbid  secretion of bile has been pro-
duced.  As this  is  usually intense heat, with a stagnant  and impure
state of the atmosphere, the prompt removal of the child to  a more
free, and cooler  atmosphere is essential to insure its recovery.   When
such a removal  cannot be effected, domestic cleanliness and free ven-
tilation should be enforced, as well as the free exposure of the child,
in dry weather,  to the external air, in  the most healthy and open situa- 
DISEASES OF  THE DIGESTIVE ORGANS.        223
tions, in its immediate neighbourhood.  It may be either carried out in
the arms, in an open hand-carriage, or by riding  in any open vehicle,
or by sailing in an open boat, properly shaded from the sun, or in one of
the steamboats, which,  fn  most of our  large  cities, make repeated
short trips  in the course of the day.
   The diet and drinks of the patient should consist exclusively of gum
water, rice water, or infusion of slippery elm bark—taken  cold, and
in small quantities at a time, but at short intervals.  It should be im-
mersed daily in a tepid  or  warm bath, according as the temperature
of its  surface is augmented  or depressed, and  its clothing should be
light and loose, and so adapted,  in the materials  of which it is com-
posed, as not unduly to augment the heat of the body, but, at the same
time, to guard  it fully from the effects of sudden transitions of tempe-
rature.
   This treatment will be sufficient, in a large number of cases, in
which  the disease consists  simply in  an  undue  secretion  of bile, to
arrest the diarrhoea,,  and restore the discharges to their natural condi-
tion.  If, however, these still continue with little or no abatement, and
neither fever nor intestinal inflammation exists, small doses of calomel,
calcined magnesia, ipecacuanha, and extract of hyoscyamus, will gene-
rally produce the desired effect.*  Under the use of  this combination,
the discharges will generally assume, in a short time, a faecal charac-
ter, and be diminished  in quantity.  If there exists irritability of sto-
mach or vomiting, the calomel should be given alone.
                  a R.—Calomel, gr. ij. ad iij.
                       Magnesiae calc. gr. xxiv. ad xxxvj.
                       Ipecacuanhas, gr. ij. ad iij.
                       Ext.  hyoscyami, gr. iv. ad vj.—M. f. ch. No. xij.
                  One to be given every two or three hours.
   Purgatives,  opiates, and astringents  are seldom  proper—never,
unless the  disease assumes  a chronic form, unattended  with inflam-
mation.
   When the discharges lose their bilious character, and become thin
and serous, if no tension, pain, or heat of the  abdomen is observed,
the acetate of lead, in the formula directed when speaking of the treat-
ment of mucous diarrhoea,  is the remedy which we  have found the
most frequently to succeed in arresting the disease.   When the  dis-
charges are profuse, and the patient becomes  rapidly  exhausted,  a
small portion of opium may be  substituted for the extract of hyoscya-
mus;  and  a solution of the acetate of lead, with such an  addition of
laudanum  as is adapted to the age and condition of the patient, may
be thrown into the rectum.   As soon as  the profuse serous discharges
are suspended, the calomel in small doses, combined with ipecacuanha
and extract of hyoscyamus, will, in general, complete  the cure; or,  if
after the discharges  assume a more natural appearance, they still con-
tinue thin  and  frequent, some of the astringents already mentioned, as
the catechu, the, geranium maculatum, or kino, will be proper, with  a
dose of Dover's powder at  night.
   This form  of diarrhoea occasionally assumes  a chronic character,
when the treatment will be the same as in the chronic stage of cholera 
224
DISEASES OF  CHILDREN.
infantum.  In many cases, it is probable that the following prescription
will be found advantageous:—it is recommended, by Evanson, as one
of the most useful compounds in protracted cases of diarrhoea.'  We
have ourselves never  employed it, but have  seen good  effects  result
from the administration, in these cases, of nitrous acid, in combination
with aqua camphorata and opium, or with hyoscyamus.b

                     1 R.—Infusi samaroubae, 3jss.
                         Acidi nitrici dil. ftfij. ad iv.
                         Svrupi caryophyl. 3iv.
                         Tine, opii, fO/vj.—M.
One or two teaspoonfuls, in  a little barley water, to be repeated, three or  four times a day.

   b R.—Acid, nitros. m/viij. ad xv.          Or, R.—Acid, nitros.  fl[fx. ad xv.
         Aquae camphor. 3j.                     Sacch. alb. 3iij.
         Tine, opii, Tf vj.—M.                    Ext. hyoscyami, gr. vj.
  A teaspoonful every three hours.                   Aq. cinnamon. 3j.—M.
                                             Dose, the same.

  As we have already remarked, in a large number of'cases, bilious
diarrhoea is accompanied with evident symptoms of intestinal inflam-
mation.  In this form of the disease, the safety of the patient, as well
as the cure of the diarrhoea, will depend upon  a correct diagnosis
being early made, and the appropriate remedies for the control of the
inflammation promptly resorted to—plain mucilaginous drinks, leeches
to the epigastrium, followed  by warm fomentations or  an emollient
cataplasm, and warm sinapised pediluvia.  When extreme irritability
of the stomach or vomiting is present, we are in the habit of adminis-
tering minute doses of calomel; placing them upon the tongue in a
dry form, if they are  quickly ejected from the stomach when admi-
nistered in the usual manner.   From an eighth to a sixth of a grain
may be given, every  half hour or  every hour, according to  circum-
stances ; we have seldom been disappointed in quieting the stomach,
by this means, in a few  hours.
  After the inflammatory symptoms are subdued, the case  may be
treated as an ordinary attack of bilious  diarrhoea; a  careful  watch
being, however,  kept upon the symptoms, lest intestinal  inflammation
be renewed; should this  happen, the propriety of a re-application of
leeches will depend upon the strength of  the  patient, and the urgency
of the symptoms.   It  is probable that, in  most cases, a blister over the
abdomen will be sufficient to remove the inflammation, without again
resorting to leeches.  Even when the latter are considered  necessary
and proper, they should be followed, in a short time, by a blister, left on
only so long as to produce a decided redness of the skin ; the part to
which it has been applied being then covered with a common bread-
and-milk poultice.  During the continuance of the diarrhoea, the utmost
attention should  be  paid  to the diet and regimen of the patient; the
slightest error or neglect  in this  respect being always attended with
very serious consequences.
  By many physicians, the exhibition of opiates has been strongly ad-
vocated, in the inflammatory form of bilious diarrhoea; we have occa-
sionally resorted to them, but have never been pleased with their
effects;  in some instances they were evidently decidedly injurious. 
          DISEASES OF THE DIGESTIVE ORGANS.       225

  After the inflammatory action has been somewhat reduced by leech-
ing, a  combination of calomel, extract of hyoscyamus, and  ipeca-
cuanha, in small doses—from a fourth to half a grain of the first two,
and from a  sixth to  a  third of a  grain of the  last—repeated every
three hours, will be found, in many cases, to  produce a very favour-
able change in the symptoms of the disease.
  It is not  very easy  to lay down the  proper treatment of chronic
diarrhoea, without a reference to the condition, in each case, of the
mucous membrane of the alimentary canal, the state of the liver, and
of the other organs that are liable to become  involved in disease.
  In many cases of prolonged diarrhoea, no other morbid condition of
the intestines would appear to be present than an undue irritability of
their mucous membrane, with increased exhalation from its follicles.
Here the cure of the  disease is readily effected  by a judicious course
of astringent remedies, in conjunction with a well-regulated diet and
regimen.  But  much  more frequently,  the diarrhoea is  kept  up by
chronic inflammation  of the  alimentary canal, and a  diseased condi-
tion of the liver, with  a vitiated state of the bile, as well as of the other
secretions poured into the  intestines.   The management of these cases
is attended with great difficulty, and the best-directed plan of treat-
ment is very frequently  unsuccessful.
  The discharges in chronic diarrhoea  may  be composed of  a  thick,
tenacious, jelly-like mucus, of a dark green, chocolate, or black colour,
or of a thick, tenacious matter, resembling tar.   In other cases, they
have the appearance  of light clay or thin mortar; while  in others,
again, they are  composed  of a thin  fluid of a  dirty green, reddish-
brown, or yellowish colour, and in some instances, they consist of the
food  or drinks  taken, which pass  immediately through the bowels
without having  undergone the least change.  The stools have often a
peculiar rancid  odour, but are generally more or less foetid.  The dis-
charges are not generally large in quantity, and  vary much in regard
to frequency—a number often taking place in quick succession, and
then  a considerable  interval occurring without any.  More or  less
griping may precede  and  accompany the discharges, though in many
cases the patient appears to suffer no  pain. The  abdomen is generally
swollen, particularly in  cases of long continuance, and when enlarge-
ment of the  mesenteric glands occurs:—occasionally, extreme tym-
panitic distension takes place  at an  early period.  There is always
great emaciation, with dryness and harshness of the  surface and  dis-
coloration of the skin, which acquires, in severe cases, a dark brown
hue.   The features are shrivelled, and the countenance assumes the
wrinkled, haggard  look of premature old age.   The patient finally
sinks from extreme exhaustion, from  perforation of the intestines, the
result of softening or  inflammation, or the brain may become affected,
and effusion within its cavities take place sooner or later.
   Chronic diarrhoea is generally the  result of neglect or mismanage-
ment of the  ordinary forms of the disease, or it may be produced by
a continuance of the causes by which the diarrhoea was originally
pi'oduced, or by its repeated recurrence, in  the same child, within  a
short  period of time.   In the great majority of cases, it may be re-
                               15 
226
DISEASES  OF CHILDREN.
ferred to a neglect of dietetic management, or to a recurrence to the
use of improper food, immediately after recovery from an  attack of
ordinary diarrhoea.  For a long time after the bowels have resumed
their natural action, strict attention to the diet of the child is essential
to prevent a relapse.  Even indulgence in articles which, under other
circumstances, would be considered perfectly wholesome and  appro-
priate, will not  unfrequently produce a  return  of the  diarrhoea, and
each recurrence of the disease will be found to be more unmanageable
than the preceding, and more liable to assume a chronic form.
   In the treatment of chronic diarrhoea,  the child should be confined
entirely to some plain, farinaceous article of food, with or without
milk, according as the latter is found to affect the stomach and bowels.
Rice, or rice flour, with milk, we  have found in most cases  to agree
best with  children labouring under the chronic form of the disease—
though  occasionally even  this will aggravate  it; beef tea or plain
chicken water may then be tried, or a mixture of fresh cow's milk with
a further  addition of cream.  In some  instances we  have found that
no diet could be taken by the patient, without increasing  the disorder
of the bowels, excepting gum water, fresh rennet whey, or an infusion
of the slippery elm bark.  For drink, gum, rice, or toast water, taken
cold, should be the only fluids allowed.
   In all cases of chronic diarrhoea, the warm bath forms an  important
remedy; it may be repeated daily, and in many cases  every morning
and evening, with decided advantage.
   In those cases in which the discharges indicate a disordered state of
the biliary secretion, small doses of calomel should be administered
twice or thrice  a day, or oftener, according to the circumstances of
the case,  and  the effects produced by the remedy.  Clarke, Cheyne,
Underwood, and Marley administer the calomel by itself, Dewees in
combination with prepared chalk  and opium, and Eberle, Seele, and
Jager, with opium alone. We prefer its administration in combination
with prepared chalk, ipecacuanha, and extract of hyoscyamus.*
                   * R.—Calomel, gr. ij. ad vj.
                        Cretae ppt. gr. xxxvj.
                        Ipecacuanhas, gr. ij. ad iv.
                        Ext. Hyoscyami, gr. iv. ad vj.—M. f. ch. No. xij.
   The use of this combination should be continued until  the discharges
assume a more natural appearance.
   In many cases, we have  experienced the  best effects  from the em-
ployment  of turpentine in the following formula.1
                   1 R.—Mucil. G. acaciae, giij.
                        Sacch. alb. pur. 3iij.
                        Spir. terebinth. 3ij.
                        Magnes. calc. gr. xiij.
                        Tinct. opii cam ph. 3ij.—M.
      Dose, a teaspoonful every three or four hours, according to circumstances.
   Under the use of the turpentine  we have found the discharges to be
speedily reduced in frequency, and improved in appearance.  So far
from augmenting the irritation of the mucous membrane of  the intes-
tines, even when this has been the seat of a subacute  inflammation,
we have found it to produce a directly soothing  influence. 
DISEASES OF  THE DIGESTIVE ORGANS.       227
  When there is much tenderness of  the  abdomen,  and the  child
evinces the existence of pain by its fretfulness or almost constant whin-
ing cry, or by drawing up its knees towards the abdomen when lying;
more especially if,there is redness and dryness of the tongue, and an
occasional circumscribed flush of one or both cheeks, with a suffering
expression of countenance, it will often be found advantageous to ap-
ply a few leeches to the abdomen, and  upon their  removal to cover
this part with a large emollient  cataplasm.   After a few- hours, the
leeches may be followed by a blister, which, when properly managed,
according to the directions already given, generally produces a very
beneficial  effect.  In all  cases of chronic  diarrhoea, the  derivative
effects of blisters to  the  abdomen  are advantageous, often  very de-
cidedly so, and in many cases the blister may be repeated as soon as
the first heals.
   When acidity prevails in the  alimentary canal, the  occasional use
of  some alkaline preparation will be proper; a few grains of  bicarbo-
nate of soda, or  a few drops  of aqua  ammonia, may be given in a
weak infusion of hops,  or we may employ the prepared chalk.1
  1 R.—Cretsa ppt. 3j.                 Or, R.—Cretae ppt. 3ij.
       Calomel, gr. iij.                      Sacch. alb. pur. 3ij.
       Ipecacuanha?, gr. iij.                 Mucil. G. acaciae, 3ss.
       Ext. hyoscyami, gr. viij.—M.           Aq. cinnamon. 3ij.
        f. chart. No. xij.                    Tine, opii camph. 3j.—M.
  One to be given, three times a day.        A teaspoonful, to be given every three
                                             or four hours.

   When the acidity is  accompanied  with much flatulence,  we have
found the turpentine, in the formula given above, to produce the most
prompt and effectual relief.  In cases of extreme tympanitis, we may
succeed, in many cases, in drawing off the gas from the intestines, by
the introduction of an elastic tube into the anus, or by  the use of the
syringe, as noticed in the section on enteralgia.
   When the patient's sleep is disturbed and restless,  or frequent eva-
cuations from the bowels occur at night, a dose of Dover's powder, or
an  anodyne enema may be given in the evening.
  As soon as the inflammatory symptoms are removed,  and  the dis-
charges assume a more healthy  appearance, the exhibition  of  some
astringent may be ventured upon.  The one which,  in our hands, has
succeeded in the  greatest number of cases, is the acetate of lead, com-
bined with ipecacuanha and  opium.*
                   1 R.—Acetat. plumbi, gr. vj. ad xij.
                       Pulv. ipecacuanhas, gr. iij.
                       Opii pulv. gr. j.—M. f. ch. No. xij.
            One to be repeated, three times a day, or oftener, if required.

  Next to the acetate of lead, the best  astringent,  according to our
experience, in the chronic diarrhoea of children, is the galls in  powder.
It may be given, in the  dose of from three to five grains, three times a
day, in combination with a small portion of camphor.*

                   * R.—Pulv. Gallee, gr. xxxvj. ad 3j.
                        Camphor,  pulv. gr.  iij.—iv.
                        Sacch. alb. gr. xxv.—M. f. ch. No. xij. 
228
DISEASES OF CHILDREN.
   A great variety of other astringents have been recommended, as the
 kino, catechu, and the blackberry and geranium roots.  The perses-
 quinitrate of iron, which is spoken of in  the  highest terms  by Kerr,
 Kopp,  and Graves, as  a  remedy  in certain forms of chronic diar-
 rhoea in adults, appears to us well deserving of a  trial  in  the cases
 occurring in children, which often bear a strong resemblance to those
 described in the clinical  lectures of Dr. Graves.  Two to three drops
 of the liq. ferri persesquinitratis may be  given, every three hours, in
 sugar and water ; the dose being  gradually augmented.
  From the use of astringents, in chronic diarrhoea, we shall be con-
 stantly disappointed in obtaining any permanent good effects, if they
 be entered upon  previously to a change being procured in the appear-
ance of the discharges.   So long as these continue of a decidedly  un-
healthy appearance, to attempt to suspend the morbid irritability of the
intestinal canal by opiate or astringent remedies, is merely to prolong
the disease.
  In those cases, however, in which the evacuations  are, in a great
measure, composed of thin, faecal matter, or of serum tinged with bile,
the combination  of acetate of lead, ipecacuanha, and  opium, may be
commenced with at once.   It is in such cases,  we suspect, that  the
most advantage will be derived, from the combination of nitric acid,
with the infusion of samarouba, and from the persesquinitrate of iron.*
  Recently, the  nitrate of silver has been strongly recommended as
a remedy  in  obstinate  cases of diarrhoea  in  children.  Hirsch  of
Konigsberg (Hufeland's Journal), found  it particularly efficacious in
the advanced stage of the diarrhoea of  newly weaned infants, when
emaciation and prostration were extreme,  and the  evacuations were
frequent, foetid, and wanting altogether the fcecal character, consisting
of a variously coloured,  sometimes greenish or bloody  mucus;  and
when aphthous  ulcerations pervaded the  mouth, he gave it in  the
following formula.*
                   1 R.—Argent, nitrat. crystall. gr. \
                        Aquae, destill.  3 ij.
                        Gum. acaciae, 9ij.
                        Sacch. alb. 3ij.—M.
                 A teaspoonful to be given, every two hours.

  He also administered the  nitrate of silver in the form of enemata,
 containing each,  a quarter of a grain of the  salt, with mucilage and
 a little opium.  The good effects of this treatment, he  remarks,  were
 occasionally visible in a few hours,  sometimes not until the second
 day.   He pronounces the nitrate  of silver, thus administered, a speci-
 fic  in the diarrhoea of infants.  Canstatt, also, extols it in the diarrhoea
 ablactatorum.  The efficacy of this article in the diarrhoea of infants
 is also acknowledged by Bouchart (Manuel Pratique des JVouveau-nes)
 as  well as by Troupeau, and in a communication of Mr.  Aiken (Dub-
 lin Med. Press.  Sept.  1847), a case is  given  in which  the remedy
 proved promptly successful in arresting a severe and protracted diar-
 rhoea in an infant one year  old, after all the ordinary remedies had
 failed.
   During the continuance of the  disease, daily exercise in the open 
DISEASES  OF THE DIGESTIVE ORGANS.        229
 air, when the weather will permit, to an extent adapted to the strength
 of the patient, with proper clothing, should not be neglected.
   The state of the brain must be carefully  and closely watched.  If
 any degree of cerebral disease is detected, leeches should be applied to
 the temples, blisters behind the ears or to the nape of the neck, and
 warm, sinapised pediluvia repeated night and morning; the diarrhoea
 being treated by calomel, ipecacuanha, and  extract of hyoscyamus.
 We are to recollect, however, that stupor, and other symptoms of an
 affection of the brain, terminating rapidly in effusion, may be produced
 by extreme exhaustion, the result of the frequent and profuse evacua-
 tions from the bowels.  In this case, the diarrhoea should  be  arrested
 as speedily as possible, and the strength of the child restored by some
 tonic, as the  sulphate of quinia, or the persesquinitrate of iron, with a
 nourishing but bland and  easily  digested diet.

                    I — Cho_Lera Infantum.

                 (the summer complaint of infants.) *X c ^. if^ / Vr/C
   The cholera infantum  is a disease that has, with great propriety,
 been  considered as indigenous to the United States.  It is certain that
 in the various and minute descriptions that have been published of the
 bowel  complaints  of children,  which  ordinarily occur  in  different
 parts of Europe, or elsewhere, we meet with none that resembles,  in
 all its features, the infantile cholera of this  country:—certainly none
 that prevails  to so great an extent, and produces an equal amount  of
 mortality.
  The disease occurs, as  an endemic, in all the large cities, through-
 out the  middle and  southern,  and most  of the western states, during
 the season of the greatest  heat;  making  its  appearance and ceasing,
 earlier or later, according as  the summer varies,  in the period of its
 commencement and close.   Thus,  in Pennsylvania, Maryland, Vir-
 ginia, Kentucky, and Ohio,  it  commences  sometimes early in  the
 month of June, and continues until October; prevailing to  the greatest
 extent in July and August: whilst in the  more southern states,  it ap-
 pears as early as April  and May, and  frequently cases of it  occur
 until late in November.
  Its  only subjects are infants; chiefly those between four  and twenty
 months   of age;  seldom  attacking  those younger  or older;  being
 commonly confined to the period of the  first dentition.   So generally
 is this the case, that an infant's second summer is considered by  mo-
 thers  as one of unusual peril; and should  it escape at that age an
 attack of cholera, or pass  safely  through the disease, it is considered
 to have a fair chance of surviving the period of infancy.
  Cholera infantum is unquestionably one of the most fatal affections
to which infants are subject,  in  the United  States.   In Philadelphia,
during a period of ten years, from  1835 to 1844, inclusive, 2583  in-
fants perished from this complaint;  being nearly  eleven per  cent, of
the whole number of infants under five years of age, who  died during
that period, and 5-3 per cent, of the entire mortality of the city.   The
cause of the large amount of deaths produced by cholera infantum, is 
230                DISEASES OF CHILDREN.
    to be attributed, mainly, to the continued action of the endemic causes
    by which the disease is generated, from the influence of which, in the
    greater number of instances, it is very  difficult, if not impossible, to
    remove the infants who become attacked.
      Cholera infantum most usually commences with  a profuse diarrhoea,
    the stools  being often of a green  or  yellow colour, but more  com-
    monly, light-coloured, and very thin.  The diarrhoea seldom continues
    for any length of time before an  extreme irritability of the stomach
    manifests itself; everything taken into it being immediately rejected,
    often with great violence.  In other cases, the infant  is affected with
    almost constant vomiting and purging; the discharges  from the bowels
    being, ordinarily, a perfectly colourless and inodorous fluid, containing
    minute mucous flocculi.  They are sometimes small in quantity, and
    squirted, as it were,  from  the anus; but occasionally, they  are very
    copious, and passed without the least effort.
      In  whatever manner the disease commences,  the child  soon be-
    comes affected with  great languor and  prostration,  and is rapidly
»*♦ /emaciated—being reduced  in a few  days, often  hours,  to  an extent
    that to those  who are not familiar with  the disease, would appear
    almost incredible.
      The pulse,  in the  commencement of the attack, is usually quick,
    frequent, small, and often tense.  The tongue is covered with a white,
    slimy  mucus.   The skin is, in general, dry and harsh; the head and
    abdomen are hot, while the extremities retain their natural tempera-
    ture,  or, when the attack is  violent,  are decidedly  cold.   There  is
    always intense thirst; whatever fluid is taken, being, however, almost
    immediately ejected  from  the  stomach.   Towards evening,  there
    occurs, in most cases, a decided febrile exacerbation.  The child fre-
    quently suffers more  or less pain, as  indicated by its fretfulness, low
    moaning cries, frequent change of posture, the drawing up of its knees,
    and its occasional acute screams.   The abdomen is  often somewhat
    tumid, and tender to  the touch.
      In many cases, the excessive irritability of the stomach continues
    throughout the  attack; but not unfrequently, the vomiting becomes
    suspended at  a more or  less early period, while the diarrhoea con-
    tinues unabated, or  increases in violence; the  irritability  of the in-
    testinal canal being  often such, as to cause whatever food or drink
    that is taken to pass off rapidly, without having undergone the slightest
    change.
      Occasionally, the patient becomes affected, very early in the attack,
    with delirium; his eyes become injected and wild; his head  is tossed
    violently backwards  and forwards; and he frequently attempts to bite
    or scratch his attendants.
      In very violent attacks, the  prostration which suddenly ensues, is so
    great, as to destroy the patient within  twenty-four^hours.   In general,
    however, the disease  runs a much  more protracted course.   The ema-
    ciation becomes extreme; the eyes languid, hollow, and glassy;  the
    countenance pale and shrunken; the nose sharp and pointed; and the
    lips thin, dry, and shrivelled—the skin  upon the  forehead becoming
    smooth and shining, as if tightly stretched over the frontal bone.   The 
           DISEASES  OF THE DIGESTIVE ORGANS.        231

child lies constantly in an imperfect doze, with half-closed eyelids, and
so insensible to  external  impressions,  that we have repeatedly seen
flies alight upon  the half-exposed eyeballs,  without  the patient exhibit-
ing the least consciousness of their presence.
  The surface of the body is now cool  and clammy, of a dark brown-
ish hue, and often covered with petechiae; the tongue is dark-coloured,
smooth, and shining, or covered, as well as the whole of the inner sur-
face of the mouth, with aphthae.  At this stage  of the disease, the
fauces frequently become dry, causing a difficulty in deglutition, and
inducing the patient to  thrust  his hand deep into the mouth, as if to
remove some offending substance  from  the  throat.  The  abdomen
becomes more or less tympanitic, and  the hands and feet pallid, or of
a leaden hue, and ©edematous.  The discharges from the bowels are
now generally frequent and profuse, dark-coloured, and very offensive,
—resembling the washings of stale meat; in many cases, however,
they are small  in quantity, and  composed entirely  of dark-coloured
mucus, mixed with the food or drinks that  have been taken.   The
infant  becomes  more and more exhausted, rolls its  head about when
awake, and utters constant short, plaintive, hardly audible cries.  He
falls, at length, into a state of  complete coma, death being, in many
cases, preceded  by a convulsive attack.  Not  unfrequently, at a much
earlier period of the disease, effusion takes place in the brain, and the
patient dies, with all the symptoms of acute hydrocephalus.
  In most of the protracted cases, an eruption occurs upon  the breast,
of very minute, while  vesicles.  This Dr. Dewees considers to be
invariably a fatal symptom;  but we have, in  many instances, known
the patient to recover, even when this  eruption has been the most ex-
tensive and distinct.
   The examination of the bodies of those who have fallen victims to
cholera infantum, exhibits various lesions, chiefly of the alimentary
canal.  When  death  occurs early  in  the attack,  the only morbid ap-
pearance discovered,  is  often an unusual paleness of the mucous coat
of the stomach and intestines, with more or less congestion of the liver.
Where the disease has continued for a longer period, increased redness
in points or patches, in  different parts of the stomach and intestines, is
often present.
   The red points are  sometimes very minute and isolated, and  spread
over a considerable portion of the stomach and duodenum, or over the
small  intestines  only.   They  have the appearance, generally, of mi-
nute extravasations of blood.   At other  parts of the bowels, these
points occur in clusters:—the patches vary in  size, but are never very
large, and are often slightly elevated, from  a thickening of the mucous
tissue at the part where they are situated.  Occasionally,  portions of
the mucous membrane, either of the stomach or intestines, are more or
less  softened—often without the slightest  trace of inflammation. In
other instances, increased redness of some portion of the intestines
exists, with contraction of their calibre, to such an extent, as scarcely
to permit the insertion of a small-sized quill.
  The  muciparous follicles of the intestines  are  very generally en-
larged, often in a state of inflammation,  and occasionally ulcerated. 
232
DISEASES OF CHILDREN.
Dr. Horner describes  the  appearance of the enlarged follicles in the
large intestines, as resembling a sprinkling of white sand upon the sur-
face of the mucous membrane. The intestines are in general empty, or
contain merely a small amount of thick, tenacious mucus.  Dr. Page
describes the appearance of dark spots upon the mucous membrane of
the stomach, about its pyloric orifice, but  particularly of the duodenum ;
and Dr. Lindsly mentions  a similar appearance;—we have never de-
tected it.
  The liver is, in general, enlarged, and more or less congested; while
the gall-bladder is filled with dark  green  bile, or with a pale and nearly
colourless fluid.  The enlarged and congested state of the liver  is
noticed by most writers upon the disease.  Dewees,  Horner, James,
Jackson, and Lindsly, describe the enlargement  as being in some cases
immense.  Page states it to be much enlarged, soft, and spongy;  and
Horner describes it as usually of a light yellow or mottled colour:—
we have always found it to be more or  less enlarged, but not often to
the extent  noticed  by most  writers,  and  seldom  much changed  in
colour.
   In a  large  number of the  more protracted cases, serous  effusion,
upon  the surface, at the base, or in the  ventricles of the brain, is pre-
sent—in many instances, without  indications of inflammatory action,
but in others, with thickening and opacity  of the arachnoid membrane.
   A very excellent paper on endemic follicular  gastro-enteritis, or
summer complaint of children, by Dr. E. Hallowell, of Philadelphia, is
contained in the American Journ. of the Med. Sciences, for July, 1847.
The author divides  the disease into three  stages based upon its anato-
mical  characters.   Those, in the  first  or  early stage of the disease,
consist in an undue development of the follicles of both the  stomach
and intestines, or of one only of these organs, without inflammation of
the mucous membrane.  Children rarely  die of cholera in this early
stage, consequently,  opportunities  seldom occur  for observing  the
morbid appearances.
   In  the  second, more advanced or  chronic  stage, the anatomical
characters consist  essentially in inflammation with  softening of the
mucous membrane, and ulceration of the follicles, more especially of
the large intestines.  The mucous membrane of the stomach  in many
cases presents its usual appearance and  consistence; in others, it is
more or less injected and softened, the softening extending occasionally
to all the coats.  The lining membrane of the  stomach is not unfre-
quently covered with a layer of whitish opaque mucus, easily scraped
off with the  handle of the scalpel; the mucous follicles  both of the
stomach and  intestines are more or less apparent; the mucous mem-
brane of the small intestines is occasionally softened, and for  the most
part pale in the greater portion of its extent.
   In  one case the  lower portion  of the  ileum presented a brickdust
colour, with alternations of a pale yellow, mottled with red; in some
points  minute vessels were seen  freely  inosculating with each other;
in other portions, the inosculations were less distinct, the reddish  tinge
being uniform.  In another case, the inflamed portion was of a dull
red, or brickdust  colour, minutely injected with red vessels, and in 
           DISEASES OF  THE DIGESTIVE ORGANS.        233

 several points, especially upon the surface of the valvulae conniventes,
 presented a dotted  appearance; it occupied a portion of the intestine
 four inches in extent from the  pylorus.  In another case, the duode-
 num, at its upper portion, presented a slight shade of pink, with a few
 minute arborizations; and in several other instances there was a slight
 degree of inflammation, affecting the duodenum at its upper extremity.
 There was also a slight inflammation of the glands of Peyer in one or
 two cases, but for the most part these bodies presented nothing remarka-
 ble.  The small intestines contained a considerable quantity of orange-
 coloured  mucus.  The large intestine was  more or less inflamed, and
 softened, in almost  every instance; the inflammation existed in the
 form of bands, and presented a dotted arborescent appearance; in one
 case these bands were longitudinal.
   In most cases the redness was diffused, with occasional  ramifica-
 tions ; in one  instance the inflammation  occupied the whole extent of
 the colon; it was of a vivid red throughout, and the membrane was
 much thickened.  From  the  margin of the follicles,  minute vessels
 were  seen to radiate to the surrounding  membrane,  occupying the
 entire surface of the  intestine, showing that the inflammation com-
 menced in the follicles and extended subsequently to the mucous mem-
 brane.  The follicles were often found to be more or  less ulcerated,
 the ulcerations sometimes extending as far as the muscular coat; they
 were more or  less numerous, and penetrated more deeply in the rectum
 than in other portions of the intestine;  the rectum was often completely
 riddled with them.  The mucous membrane was more or less softened
 in the greater number of cases; in one instance it was thickened and in-
 tensely inflamed.  The coats of the intestine were covered with a layer
 of mucus,  sometimes so thick as to diminish considerably its calibre.
 It ordinarily contained a quantity of grayish-coloured faeces, of the con-
 sistence of gruel. In uncomplicated cases the lungs presented nothing
 remarkable, except a slight engorgement posteriorly. The peritoneum
 was healthy.  The  liver was  greatly enlarged in only one  instance;
 the gall-bladder was more or less distended with  dark-coloured  bile;
 the mesenteric glands, spleen, and kidneys presented nothing remark-
 able.   In nearly all  the cases, the veins of the pia mater were more  ,
 or less distended; the  arachnoid was pale and moist, except in  one
 case, in which there was  a  slight opacity at  the base  of the brain.
 There was more or less effusion in the subarachnoid cellular tissue; for
 the most part limpid ;  occasionally it presented a whitish, opalescent,
 or citron-coloured appearance.   The pia mater was more or less in-
jected, for  the most  part confined to the larger ramifications of the
 vessels; the membrane was easily removed by traction from the sur-
face of the brain.  The substance of the brain was natural, excepting in
two  cases, in which  it was injected; in the  one at its centra], and in
the other at both its  central and vertical portions; it was softened in
four cases.  There was little or no effusion in the ventricles; in  one
case the lateral ventricles appeared quite dry, as if wiped with a cloth.
  In the third stage, marked by an unusual disposition to drowsiness
or stupor, rolling of the head, and a chewing motion of the under jaw,
succeeded by convulsive movements, or rigidity of one  or more of the 
234
DISEASES  OF CHILDREN.
extremities, followed by paralysis, the anatomical characters  consist,
essentially, in disorganization of the brain from softening of its tissue.
The softening is sometimes general, but  more often confined either  to
the cortical or central portions of the brain and  cerebellum.  It may
be to such a degree as to cause the brain readily to give way on slight
pressure, or to render it quite diffluent.   When cut into, the substance
of the brain usually presents numerous red spots from effusion of blood.
The pia mater is more or less injected, and its veins much distended.
There  is also  effusion of serum in the subarachnoid tissue, and, to a
greater or less extent, in the lateral ventricles.—Sometimes, however,
these are quite dry.
   Cholera infantum, comparing the symptoms during the lifetime  of
the patient, with the appearances discovered after death, would appear
to depend, in its earlier  stages, upon hyperaemia of the mucous mem-
brane,  with an augmentation in the size and activity of function of the
muciparous  follicles of the  alimentary canal—inflammatory action
being frequently excited, in  the course of the disease, as well in the fol-
licles, as in the mucous tissue, from accidental sources of irritation.
   The disease is evidently dependent for its production, upon the action
of a heated, confined, and  impure  atmosphere, directly upon the skin,
and indirectly upon the  digestive mucous surface, at an age when the
latter is already strongly predisposed to morbid action, from the effects
of dentition, and from the  increased development and activity of the
muciparous follicles, which takes place at that period.
   It is an affection  exclusively  confined to the stage of infancy—few
cases  occurring beyond the second, and none beyond the fifth year.
During twenty  years, the  deaths from cholera  infantum, in  Phila-
delphia,  amounted  to  3576: namely,  in  infants under  one  year of
age, 2122; between one and two years, 1186; between two  and five
years,  268.  The entire number of cases of cholera morbus,  that oc-
curred during the same period, was 236: namely, in individuals over
twenty years of age, 173 ;  under twenty years, 63.
   The influence of  a high atmospheric temperature, in the production
of cholera infantum, is shown by the fact, that its prevalence is always
in proportion to the heat of the  summer—increasing, and becoming
more fatal, with the rise of the thermometer, and declining with the
first appearance of  cool weather in the autumn.   A few hot days in
succession, in  the month of May,  are sufficient to produce it;  while,
during the height  of its prevalence, a  short period of cool  weather
will diminish, if not entirely suppress it.
   In those infants, who have been  prematurely deprived of their natu-
ral aliment, or whose diet is composed of crude, indigestible, stimu-
lating, or otherwise unwholesome  articles,  a heated  and  confined
atmosphere would appear to be alone sufficient for the production of
the disease.  But the extensive prevalence of the cholera of infants
during the summer months, is not  dependent  alone upon the influence
of heat; but upon the combined influence of  a high atmospheric tem-
perature, and confined and impure air.  Hence it is almost exclusively
confined to the larger  and more  crowded cities of the middle and
southern states: and in these, it is especially prevalent, and destructive 
           DISEASES OF THE DIGESTIVE ORGANS.        235

to life, among the children of the poorer classes, inhabiting small, ill-
ventilated houses, situated in narrow, confined lanes, courts and alleys,
or in situations abounding with accumulations of filth. When it occurs
in the country, which is rarely the case, it is almost exclusively in low,
damp, and otherwise unhealthy situations.
   By many writers, dentition and errors in diet are enumerated among
the causes of cholera infantum. They are unquestionably to be viewed,
in many cases, as predisposing, and in others, as exciting causes;  but
we have, in no instance, known an attack of genuine cholera infantum
to occur, without exposure to the influence of a heated, stagnant, and
more or less  impure atmosphere; and this alone, in the great majority
of cases, would appear to be the  sole cause of the attack.
   The prognosis in cholera infantum will depend, in a great measure,
upon our ability to abstract  the patient from the continued effects of
the endemic  influence by which the disease has been produced and
is kept up, as well as upon the period of the attack at which the treat-
ment is commenced.  According to our experience, the disease  is  one
very readily  controlled, whenever we are enabled, at an early period,
to carry into effect  the proper remedial measures.  The  chief  cause
of the great  mortality produced by it,  being the  impossibility, in  the
majority of instances, of removing the patients from the influence of
the  heated and impure  atmosphere by  which the disease has been
generated. Without this removal, it is  scarcely possible,  in any in-
stance, to effect a permanent cure; while in most cases, in  their com-
mencement at least, little else is required to arrest the disease;  and
even at  a later period, its effects are often evinced in the rapid  im-
provement of the patient, from almost  the very moment the removal
takes place.              *
   In very violent  attacks, it occasionally  happens  that  the patient
sinks at once,—death ensuing in a few hours.  Such cases, however,
are of unfrequent occurrence; sufficient time being in general afforded
for carrying into effect a proper remedial course of treatment.  Even
after the disease has continued for  many days, and reduced  the patient
to a state in which a fatal termination seems  to be inevitable, by
appropriate  remedies, a  very rapid cure  may often be effected.  This
we have witnessed, not in a few rare instances, but repeatedly.
   It is all-important, the  moment  an infant is attacked with cholera
infantum, that he be removed from the heated, confined, and impure
atmosphere by which the disease  has  been  generated, to  a situation
where he may enjoy the   advantages of free ventilation, and cool air.
Whenever this can be done in  the commencement of the  attack, the
patient being at the same time, confined exclusively to the breast, or
if weaned, to a diet of  tapioca, pure  arrow-root, or  rice  flour, with
 milk, and immersed daily in a bath, warm or tepid, according  as the
temperature  of the skin is deficient or increased, the disease may gene-
rally be arrested without the administration  of any remedy internally;
excepting, perhaps, some cool, perfectly  bland, and slightly mucilagi-
nous drink, as gum water, or,  what we prefer,  rennet whey, with a
slight addition of gum acacia.   Even  in cases in which a  removal to
a healthy and airy situation in the country is  impracticable, much 
236
DISEASES OF  CHILDREN.
benefit may be derived from carrying  the patient frequently into the
air, in any open and healthy situation in the neighbourhood of his resi-
dence, in a carriage, or in the arms; or where his residence is near a
large river, by sailing daily  in an open  boat.   At whatever period of
the attack we may be called to the patient, his removal to the country
should, if possible, be effected ;  or,- if this be  impracticable, as free an
exposure to  a pure and open  atmosphere as can  be accomplished,
should be insisted on.
  The apartment occupied by the patient should be kept strictly clean
and dry, and freely ventilated.   His clothing, besides  being perfectly
clean and dry, should neither be too  warm, so as to overheat the body,
nor so thin and flimsy as to  expose  it to the  influence of every slight
change in the temperature of the air: fine, soft flannel, or soft, coarse
muslin, worn next the skin, will be proper in most cases.   The room
occupied by the patient at night should be as large and airy a one as
can be commanded: he should sleep upon a mattrass, or on a blanket,
folded  and  laid upon the sacking-bottom of the  bedstead, or upon the
floor of the crib, his body being defended by  a light, loose covering.
  In every instance, a careful  examination should be  made into the
condition of the gums, and  if they are  found to be hot, swollen, and
inflamed, they should be freely lanced.
  When the  disease commences with  a simple diarrhoea,  the warm
bath repeated daily, or even night and morning, and followed by gen-
tle friction  over the entire surface of the body, with the hand or a soft
dry cloth;  cold, mucilaginous drinks, and  a combination of calomel,
one-sixth of a grain, and acetate of lead, half a grain,  with  about four
grains of prepared chalk, repeated every two or three hours, will, or-
dinarily, very quickly arrest it.
  If there  exists great irritability of the stomach,  everything taken
into it being  quickly rejected, minute doses  of calomel, from  a  sixth
to a quarter of a grain, rubbed up  with a little dry  loaf sugar, and
sprinkled upon the tongue, will  in general be  retained, and  speedily
quiet the stomach,  so that other  remedies may  be  administered.
When, however, the vomiting persists,  we have found a few drops of
spirits  of turpentine, or of a solution of camphor, in sulphuric aether,'
repeated at short intervals, seldom to fail  in  removing it.  When the
vomiting is violent and frequent, the application of a few leeches to the
epigastrium will be found decidedly  advantageous.   When everything
else fails, we have very seldom been disappointed in removing the irri-
tability of the stomach  by the administration of the acetate of lead in
solution.b  A blister may, at the same  time, be applied over the epi-
gastrium for two or three hours, and then  taken off and replaced by
a bread-and-milk, or flaxseed poultice.
      » R.—Camphor. 3j.               b R.—Aq. puree, 3j.
           ^Ether. sulphuric. 3j.—M.         Acetat. plumbi. gr. v.
                                       Acid, acetat. impur. fffv.
                                       Sacch. alb. pur. 3iij.—M.
                                      A teaspoonful to be given  every hour or
                                       two,  until the vomiting is suspended.

   When the  patient appears to suffer much  pain, with increased heat 
DISEASES OF THE DIGESTIVE ORGANS.        237
of the skin, particularly about the  head and  over  the abdomen, the
latter being tumid, and tender to the touch, leeches should be applied
to the epigastrium, in numbers proportioned to the age and strength of
the infant, and the violence of the  symptoms, and  followed  by light,
emollient cataplasms, or warm fomentations over the whole abdomen. tf^-r^firA*^
The effects of fomentations to the  abdomen of a strong infusion orft*-/KAX**l'i!
decoction  of  hops, have  been spoken of by  many practitioners, as-^^trgrV*^   )
peculiarly beneficial.   The tepid  bath should  be repeated night and/CT^C****^' «
morning.   A  teaspoonful of cold water may be allowed  every fifteen
or  twenty minutes;  but the ordinary drink of the  patient should be
toast, rice, or  gum water.  In these cases, small doses of calomel, the             ^
fourth of a grain, combined with three or four grains of calcined mag-
nesia, administered every three hours, will  usually be productive of
good effects.
   When there exists much heat about the head; with a  wild  and in-
jected state of the eye; aversion from  light,  with  delirium,  or other
symptoms  of  cerebral  irritation, leeches should  be applied  to the
temples, or behind the  ears, with cold  lotions to the scalp, and some
stimulating embrocation to  the lower extremities, or warm sinapised
pediluvia.  In all instances in which there appears to exist a tendency
to disease of the  brain, blisters behind the ears, kept open by the use
of some irritating ointment, will be found decidedly beneficial.
   As soon as the irritability of the stomach is  sufficiently quieted to
allow of  its administration, the  remedy which we  have found the
most certainly and promptly to restrain the disordered  action of the
bowels, and complete the  cure, is a combination of  calomel, prepared
chalk, acetate of lead, and ipecacuanha/
                     a R.—Calomel, gr. iij,
                          Cretae ppt. gr. xxxvj.
                          Acetat. plumbi, gr. xij.
                          Ipecacuanhas pulv. gr. iij.—M. f. ch. No. xij.
                         One to be given every three hours.
   Under  the  use of this  prescription, with the daily use of the warm
bath, exposure to a dry, cool, and pure atmosphere, and a diet com-
posed  exclusively  of farinaceous1 articles with milk, we have, in
general, found the inordinate discharges from the bowels to be quickly
suspended, and replaced by natural, regular evacuations.
   As soon as the frequent, watery discharges  from the bowels are
arrested, we are  accustomed to suspend the use of the acetate of lead,
continuing the calomel, prepared  chalk, and ipecacuanha, in  the same
proportions as above, with the addition of half a grain to  a  grain of
extract of hyoscyamus to each dose, until regular  and  healthy stools
are procured. The use of  some one of the light astringents, directed
in  cases of ordinary diarrhoea, continued for a few days, is  always
beneficial, by giving tone to the bowels, and preventing the danger of
a relapse.
   When  cholera infantum  has been allowed to run  into a chronic
form, its  treatment  then, will differ  but  little from that  of chronic
diarrhoea.   The  most efficient remedies are, the warm bath, frequently
repeated ;  blisters over the abdomen; aqojjyne injections, composed of n,Jvu#. 
238
DISEASES OF  CHILDREN.
" V
   thin starch, and a few drops of laudanum; light astringents, as kino,
   decoction of dewberry root or of geranium maculatum, with a change
   of air, and a diet of boiled milk, thickened with rice flour, or of plain
   beef tea or chicken water.  Dr. Eberle speaks favourably of the effects
'  * of a solution of the tartrate of iron.* The persesquinitrate of iron, may
*' likewise be administered, with good  effect.   In many cases, the sul-
   phate of quinia, in solution, besides exerting a beneficial influence upon
* the disordered condition of the bowels, will be found useful in restoring
   strength to the patient, who is  always in a  state of  extreme prostra-
   tion.
     When  the  discharges  from the bowels are thin,  small in quantity,
   dark-coloured, and highly offensive, with flatulence, and a tendency to
   a tympanitic condition of the abdomen ; or when frequent griping pains
   are experienced, we have derived the best effects  from the use of the
   turpentine mixture, as directed in the treatment of chronic diarrhoea.
   When great irritability of the bowels  is present, we usually direct  the
   addition to the turpentine  mixture, of 3iij. tine, kino, or catechu, and
   the same proportion of the camphorated tincture of opium.
     In chronic cases of cholera infantum, with acrid, offensive, and dark-
   coloured discharges, much advantage will often be derived from  the
   use of pulverised charcoal: we have  usually  administered it in combi-
   nation  with  powdered rhubarb, ipecacuanha,  and  extract  of hyo-
   scyamus.1'

      » R.—Tartrat. Ferri. gr. xl.              b R.—Carbon. Ligni, 3j. to 3ij.
           Aq. purae, 3ij.                        Pulv. Rhei. 9ij.
           Syrup. Zingiber, gss.—M.               Ipecacuanha?, gr. iv. ad xij.
      Dose 20 to 40 drops every three hours.           Ext. Hyoscyami, gr. xij.—M.
                                                f. ch. No. xij.
                                         One  to be given every 3 or 4 hours.

     When, by a judicious treatment, the disease  has  been  entirely re-
   moved, the  full restoration of  the  patient's  strength, and  the  preven-
   tion of a  relapse are only to be insured by the influence of a cool and
   pure atmosphere, a  mild, unirritating diet,  and the most  scrupulous
   cleanliness of his person and clothing.

                         4.—Prolapsus  Ani.

     A prolapsus, or protrusion of the mucous  membrane of the rectum,
   or of the rectum  itself,  is a frequent consequence of long-continued
   diarrhoea in children; it may, however, result from the irritation of
   worms, or from costiveness, and we have  occasionally met with it
   where the only cause appeared to be  a relaxed condition of the sphinc-
   ter ani; the prolapsus occurring, not only every time the  patient had
   an evacuation from his bowels, but even  when  he continued for any
   length of time in the erect posture.
     In slight cases, a  very small  portion of the  mucous membrane is
   protruded beyond the rectum, with   a  sense of bearing down  and
   smarting, that continues  until the protruded membrane is returned,
   which may take place either spontaneously,  or upon the slightest pres-
4 J    V • •'"*» 
           DISEASES  OF THE  DIGESTIVE ORGANS.        239

sure being made upon it.  In other cases,  a considerable  portion of
the mucous membrane is protruded, in the form of a small,  coiled, py-
ramidal tumour, of a bright red colour, and is with  difficulty returned
—being firmly embraced by the sphincter.  If it be allowed to remain
protruded for any length of time, the tumour becomes often more and
more swollen, of a darker red, or even purple hue, and  inflammation,
terminating in ulceration or sloughing of the protruded  portion of the
intestine, may rapidly take place.  Occasionally, a considerable por-
tion of the rectum may become prolapsed, and if allowed  to inflame,
can no longer  be reduced, but subjects the patient to much inconve-
nience and suffering; his digestion becomes disturbed, and  death may
finally result  from impaired nutrition, and long-continued irritation.
   The prolapsus may, occasionally, be the result of an invagination of
the upper portion of the rectum, or even, of a portion of the colon ; in
these cases the prognosis is generally unfavourable, though cases are
on record, in which the invaginated portion has become  separated, and
discharged per anum.
   Children are peculiarly disposed to prolapsus  of the anus, as well
from the greater mobility of the intestine, its less extensive connexions,
in consequence of the imperfect development of the neighbouring or-
gans, the slighter curvature of the sacrum, and the perfect  mobility of
the os coccyx:  as from the general laxity of all the  tissues, and the
deficient resistent powers at this period of life.
   In the generality of cases, if the prolapsus is attended to on its first
occurrence, its reduction is seldom attended with much difficulty.  The
child beifrg placed upon his  back, gentle pressure is to be applied upon
the protruded portion of intestine with the thumbs or forefingers, pre-
viously smeared with fresh lard or dipped in sweet oil, the  pressure
being made  in  such a  direction as shall tend to return the tumour
within  the sphincter;  or the forefinger may  be introduced into the
 gut, in order to remove the resistance of the sphincter, when gentle,
 well-directed pressure will generally cause the protrusion to  pass within
it.  The utmost-care should be taken  to effect the return,  every time,
and as soon after the prolapsus occurs as possible.
   If the patient is affected with a disposition to bear down subsequent
to  the reduction of the intestine, an anodyne enema, composed of  a
small portion of opium  and three grains of acetate of lead, intimately
combined with a little thin mucilage, should be administered.  Proper
means are of course to  be pursued, for the removal of the cause by
which the prolapsus is produced.
   If the prolapsed portion of the intestine  should  become swollen or
inflamed, the application to it of cold water, or a  solution of acetate of
lead, or a few leeches, will bejproper, previous  to  any attempt being
made to reduce it.
   When the prolapsus  is the result of violent straining, incident to  a
costive state of the bowels, some gentle laxative, as ripe fruit stewed
in molasses,  or rye mush and molasses, should be given daily, and the
child caused to evacuate his bowels in an erect posture.
   Washing  the anus daily with cold water, or  suddenly  dipping the 
240
DISEASES OF  CHILDREN.
nates in cold water, night and morning, has been  recommended as a
means  of preventing the recurrence of the prolapsus, and when there
is nothing to forbid its employment, it may be practised, perhaps, with
advantage;  but it will not be proper in  delicate children, in those in
whom  there is a predisposition to catarrhal affections, or who are in a
state of exhaustion, from  long-continued  diarrhoea, or other disease.
In such cases, however, astringent  washes and  injections of a tepid
warmth will often produce a beneficial effect.*
                     * R.—Quercus cort. contus. 3j.
                          Aquae purae, Oij.
                               Coque ad Oj.

  The  decoction of oak bark may be used alone, or with the addition
of half a drachm of alum;  or a solution of alum alone may be used,
in the proportion of ten grains to the ounce of water.  A decoction of
galls, with or without the addition of alum, is preferred by some prac-
titioners.
  When the prolapsus continues to recur at short intervals, for any
length  of time, the sphincter becomes, finally, so much relaxed, that the
intestine comes down, often to a considerable extent, upon the patient
making the slightest exertion, or  even assuming  an erect posture.   In
such cases, the intestine must be retained  by a soft compress, applied
upon the anus, and supported  by a  T bandage.  By this means, and
the  use of astringent injections, and a proper attention to the state of
the  bowels, a radical cure may often be effected.   But should the pro-
lapsus  continue still to recur, notwithstanding the employment of these
means  for a  reasonable length of time, the propriety of an  operation
should  be considered. The nature of the operation will depend in a great
measure, upon the particular circumstances of each  case:—whether
the  removal of a portion of the projecting folds of the skin, at the verge
of the  anus, as practised  by Dupuytren—the excision of the circular
fold of loose skin around the anus, with a portion of the mucous mem-
brane  of the rectum, as  recommended by Hey and  Macfarlane;  or
the  application of the actual cautery to the margin of the anus, as re-
commended by Mr. Benjamin Phillips, and practised by him on a child
of three years of age, with complete success.
  It has been recommended,  that children  subject to prolapsus ani,
should  be made to sit on  a hard, flat-bottomed stool or chair, without
arms, and of such a height, that their feet may not  touch the ground.

                  §. —Polypus of  the Rectum.

  The  attention of the profession was a few years  since directed,  by
Dr. Stolz, of Strasburg, to the circumstance of the occasional occur-
rence of a polypous tumour within the rectum of children.  Polypus, in
this situation, had previously been very generally overlooked, it being,
probably, mistaken for prolapsus ani, to which it  bears a very close
resemblance.  It is, nevertheless, somewhat remarkable, that it should
have escaped the  notice of almost every modern writer on the diseases
of children—for, although of not very frequent occurrence, it is, never- 
             DISEASES OF  THE DIGESTIVE ORGANS.        241

 theless, much more so than  physicians would appear to be aware of.
 Several instances  have fallen under our notice; and  although  they
 were generally presented to  us as cases of prolapsus ani, yet, upon  a
 careful and minute examination,—a neglect of which, in such cases,
 would be unpardonable—we  have never  found the least difficulty in
 detecting the true character  of the complaint.
   In its commencement, polypus of the rectum in children, is marked
 by few symptoms indicative of its presence.  After it has attained
 some size, however, there is, most commonly, an exudation, or even  a
 flow of blood by the  anus, with  some degree of tenesmus; the faecal
 matters are then stained, and sometimes bathed in  and softened by
 pure blood, without any admixture of mucus.
   When the polypous tumour increases still more in size, the little pa-
 tient is usually troubled, at intervals, with  a repeated, often ineffectual,
 desire  to evacuate the bowels, generally attended with considerable
 straining; during which, sooner  or later, and finally, every  time the
 straining recurs, a red, smooth  tumour is protruded from the anus—
 varying in size, in different  cases, from that of a cherry, to that of  a
 large hickory nut.
   The tumour, is  usually, of a bright, or dark  red  colour, but often
 white, or of a dirty yellow; it is, in most cases, thickly covered with
 a tenacious, bloody mucus.   When of a dark red, or purple hue, it  is
 apt to  bleed  freely, especially when handled  or  irritated.  When the
 tumour is protruded, it is situated in the centre of the anus, and entirely
 without the sphincter, and appears at the first view as if it were at-
 tached, all around, to the edge of the anus.  On passing the finger into
 the rectum, a slender pedicle is found to proceed from the base of the
 tumour, for a short distance within the gut, to the inner surface of which
* it is attached.  In  some cases, in consequence of the shortness of the
 pedicle, or  from its being attached very high  up, the polypus does not
 protrude without the  anus, and  its presence  can only be detected by
 the introduction of the finger, or  by the speculum ani.
   When the polypus is of  considerable  size, the straining efforts to
 evacuate the  bowels  are often very violent, and  attended, sometimes,
 with considerable  pain, and  often with the discharge from the anus of
 more or less  blood.  The little patient is usually affected with loss of
 appetite, paleness of complexion, and emaciation.
   When the polypus is finally protruded, it is found to be surrounded
 by a slight eversion of the lower  portion of the rectum.   In one of the
 cases that came under our  notice, the tumour, which was of a large
 size,  separated, and came away spontaneously, the haemorrhage which
 followed was very slight, and soon ceased, without the  necessity of
 our resorting to even  a compress. In the other cases, the tumours were
 readily removed by ligatures—in the application  of which there is not
 the least difficulty—without the occurrence of any severe or untoward
 symptom.
   In  consequence  of the readiness with which these polypi become
 spontaneously detached, after they have attained a certain size, it is
 probable that they are occasionally present without being detected—
                                16 
242
DISEASES OF CHILDREN.
producing frequent bloody discharges, which, after remedies of various
kinds have been tried without success, suddenly cease, in consequence
of the spontaneous expulsion of the tumour.
  Authors  are not  agreed upon the nature of these growths.  Some
consider them to be of a fibro-cellular structure,—others, on the con-
trary, believe them to be always of a  mucous texture.  M. Stoltz sup-
poses, that  in  many cases, they are the  result of frequently repeated
prolapsus ani,  a portion of mucous  membrane, incarcerated within the
ring of  the sphincters, becoming congested, swollen, and, after a cer-
tain period, pediculated.   Such may, perhaps, be in some  cases, the
manner in which the polypus is generated, but there are many excep-
tions.  Polypus of the rectum has repeatedly been  observed in sub-
jects who had never suffered from prolapsus ani;  while, again, in
some instances, the  insertion of the pedicle in  the mucous membrane
of the rectum is  too high up to admit of our explaining the production
of the  polypus in such cases  according to  the  theory of M. Stoltz.
M.  Guersant has usually  found  these polypi to  consist of a mucous
sheath borrowed from the mucous  membrane of the rectum, envelop-
ing a spongy texture.
  In the number of L'Experience for June, 1843, Dr. Gigon has re-
lated the history of  six cases of polypus  of the rectum in young chil-
dren, three of  which were  under his own care, and three under that
of his colleague, M. Brun.
  The polypi in these cases were fleshy, of a red colour, resembling a
large cherry deprived of  its epidermis,  and  with a  bleeding surface.
They were  suspended by  a narrow pedicle  or stalk.  When cut in
pieces they were found to be fleshy, of variable consistence, but usually
having about the firmness of a  portion of liver. To the naked eye they
presented no appearance of vessels  or of fibres; in one case, by the aid
of the microscope, some traces of  vascularity were discovered, while
in another, in which the polypus had existed  for a long period, a well-
marked fibrous disposition was detected.
  The pedicles were  membranous, smooth, soft,  and of a grayish co-
lour.   They were insensible, and had but little firmness.   In one case
the pedicle broke upon the application of the ligature, and in another
was ruptured during the passage of hardened faeces.
  The pedicles were implanted within the anus, at a distance varying
from a few lines  to two inches or  more.  The rupture of the pedicle
was often unattended with haemorrhage, which would, at first sight,
seem to prove that the polypi were not vascular, and that the discharge
of blood which  so  often  accompanies the disease, comes from the
rectum, and is produced by the irritation  attendant upon the presence
of the polypus.  In one instance, however, after  applying a ligature,
blood no longer exuded, notwithstanding the continued presence of the
tumour in the rectum, and in another, the excision of the pedicle was
followed by severe haemorrhage, showing conclusively, that it is to the
vessels which traverse the  pedicle, that the sanguineous exudations and
haemorrhages, by which polypi of the rectum in  children are so com-
monly attended, are due. 
DISEASES OF THE  DIGESTIVE ORGANS.         243
   According, to Dr. Gigon, the diseases with which polypus  of the
rectum may possibly be confounded, are dysentery, haemorrhoids, and
prolapsus of the rectum.
   From  dysentery it may readily be distinguished by the absence of
the glairy matter  in the stools, of abdominal pain, of fever, and, in
fact, of every symptom of the  latter disease, excepting  the presence
of blood in the evacuations, and, perhaps, frequent ineffectual calls to
evacuate the bowels.
   From  haemorrhoids it may be distinguished by the colour and gene-
ral appearance of  the tumour, and its place of insertion:—the  age of
the patient will also serve as a diagnostic mark.
   A careful  examination will,  as we have  already  remarked, very
readily enable the practitioner  to distinguish a protruding polypus of
the rectum from a prolapsus of  the intestine.
   In the application of the ligature for the removal of these polypous
tumours, Dr. Gigon directs the child to be placed on his stomach, and
made to strain, so as to protrude the tumour beyond the anus: it is then
to be seized with a pair of forceps and drawn  out still farther, so as to
get at  the pedicle,  which is readily effected in consequence of the lax
condition of the mucous membrane in children.  It is often somewhat
difficult to distinguish where the pedicle ends and the mucous  mem-
brane  commences, in consequence of the colour of both being the
same.  It is necessary, however, to pay some attention to  this, in order
that as little as possible of the mucous membrane may be included in
the ligature.  A waxed ligature  is to be passed around the pedicle, but
not drawn too tightly, for fear  of rupturing it.   It is better, after the
ligature is properly applied, to return the whole into the rectum, without
dividing the pedicle below the ligature, as in one case, which fell under
the notice of Dr. Gigon, in which excision was practised, a trouble-
some haemorrhage followed.  The tumour, in  general, comes away on
the second or third day after the operation, which is  unattended with
pain, and when properly performed, is not liable to be followed by any
accident.
   Dr.  James Syme (London and Edinburgh Jour, of Med.  Science,
July, 1845), describes a form of polypus of the rectum,  of which he
has met  with only one case in children  beyond the ninth or tenth
year.
   The polypus  is extremely soft and vascular, of a florid red colour,
and either of a cylindrical form, two to  four inches in length, or re-
sembling somewhat a strawberry, with a connecting footstalk, two or
three  inches long.   It  seldom protrudes  except when the bowels are
evacuated, and then admits of ready replacement, though not without
occasional haemorrhage, which  may be  of considerable  amount.  A
somewhat similar  form of the disease is  described by Dr. Bourgeois
in the  Bulletin General de Therapeutique Med. and Chirurg.   In the
removal of the tumour, Mr. Syme has always employed the ligature,
and though the soft  texture readily gives way when the thread is
drawn, bleeding has never occurred in a single instance, nor any other
symptom in the least degree disagreeable. 
244
DISEASES OF CHILDREN.
               6.—Invagination of the  Intestines.

   Intestinal invaginations or intussusceptions, that is, the passage of
one  portion of the  intestine within that above  or below it,  are  often
met  with in children who have died of various diseases, and  appear to
take place in the act of dying,  from some convulsive  or  irregular
movement of the muscular fibres  of the intestinal canal.  These  inva-
ginations give rise to no symptoms during the lifetime of the patient,
and  after  death are reducible with perfect ease.  Occasionally,  how-
ever, the invagination, occurring  in children, gives rise to symptoms
of the  most serious character, and speedily destroys the life of the pa-
tient.
   The symptoms of invagination are obstinate costiveness, progres-
sive  tumefaction of the abdomen,  with tenderness upon pressure,  often
repeated paroxysms of acute pain, vomiting of food and  drinks, and
subsequently of faecal  matter, with coldness of the extremities; the
case terminating sooner or later, in death.
   The cause of the obstruction to the onward passage of the faeces in
cases of invagination, as  well as of the other symptoms by which they
are ordinarily attended, is, in all probability, the occurrence of inflam-
mation  in  the  intestine,  at  the part where  the invagination has oc-
curred, in consequence of which, an  adhesion  of the peritoneal sur-
faces that are brought into  contact, takes place, and in this manner,
not only is the calibre of the intestine narrowed, but its regular peri-
staltic action is impeded  or destroyed.
   Invagination may take place in any part of the intestinal canal, but
is most generally seated near the  termination of the ileum. Cases are
related in which the invaginated  portion  has sloughed off,  and been
discharged by the rectum; this seldom occurs, however, in children.
  The disease is, very generally,  fatal; in no instance, that has fallen
within  our own observations, has  a case, in which the symptoms con-
sequent upon invagination were present, terminated favourably.
  The appearances exhibited upon dissection, are those of inflamma-
tion of the mucous membrane of the intestines, and often of their  peri-
toneal coat.  At the invaginated  portion, the mucous surface is often
highly inflamed, of a dark red colour,  and thickened, and covered fre-
quently with a dark red effusion, intermixed with  portions resembling
coagulable lymph;  the two serous surfaces in  contact are likewise
inflamed, with exudation  and adhesion.
  In the treatment of invagination, such remedies should be employed
as are calculated to prevent or reduce inflammation, and to restore the
natural action of the intestines :—the warm bath, frequently repeated—
leeches and warm fomentations to  the  abdomen, and abstinence from
food  and drinks.
  The  forcible injection of large quantities of warm water, or of air,
by the rectum, has been strongly advised in cases  of invagination,
with the view of restoring the natural condition of the intestine, pre-
vious to the occurrence of inflammation.   We  know of no  instance, 
            DISEASES OF  THE DIGESTIVE ORGANS.        245
                                                                             *
however, in which this means has been crowned with success;—after
the occurrence of inflammation it will necessarily fail, and  may even
be productive of  mischievous effects.
  In cases in which the invagination has been  preceded by costive-
ness of the bowels, the injection of a large quantity of warm milk and
water, through a long  elastic tube  passed into the sigmoid flexure of
the colon, may do good, by removing from the intestines any hardened
and impacted faeces, by the retention of which we have reason to be-
lieve invagination is occasionally produced.

                    7.—Intestinal Worms.                  .*#..,

   At one period, and that not a very remote  one, nearly all the dis-
eases of infancy  and early childhood, were  ascribed  to the presence            \
of  worms in the  intestines.  Although a  better acquaintance with the
pathology of the diseases of early life, especially  those of the digestive
organs, has shown that intestinal worms play  a  much less  important
part in their production than was supposed, it, nevertheless, still remains
a matter of dispute  to what extent they are to  be  considered as the  '••"'***■
causes of certain  phenomena, that are very generally, but by no means
constantly, associated with their presence.
  While by onejHi|v, the  existence of worms  is deemed invariably
detrimental to9  K by another  they are regarded as always  the            j
effect, and not tn^^ause of disease; while a third, with  Dr. Rush,
consider their presence as altogether innoxious, if not,  to a certain ex-
tent, beneficial.   This much is certain ; namely, that there is no single        p    \
symptom, or catenation  of symptoms, which  indicate positively  the ^/l^/u^ ;
existence of worms  in the  intestines, independently of their presence *> £^#*/%p
in  the evacuations.  They  have repeatedly been discharged during
life, or discovered after death, in cases in which their presence was             ;
not suspected.  One species in fact, the trichocephalus, Bremser has
met with in nearly every body he  has opened, and we  have seldom
failed, in any instance, to detect it.  In other cases, in which the most
unequivocal indications of the existence of  worms were supposed to             j
be present, a careful  examination of the evacuations gave no evidence
of their discharge during the lifetime of the  patient, and not a single
trace of  them could  be discovered  in the  intestinal canal after death.
  Worms are of very common occurrence  in the intestines of chil-
dren,  and may, unquestionably, under certain circumstances, become
a cause of severe irritation;—but much  less frequently than is gene-
rally supposed.  It is important to  recollect, that even when the pre-
sence of worms is established beyond doubt, by their appearance in
the discharges, the  symptoms of disease under which the patient             !
labours, may be produced by causes totally independent of  them, and
continue, or even augment in violence, though  we  should succeed in
effecting the complete expulsion or destruction  of the worms.
  The worms that infest the intestines are, the trichocephalus dispar, t/h Xc<>-
the  oxyuris  vermicularis, the ascaris lumbricoides, and the  bothrioce- TKttXe*.
phalus latus.
 
246
DISEASES OF CHILDREN.
              The  trichocephalus  dispar—the  trichuris  or long thread-worm of
            some writers—is commonly from an inch and a half to two inches in
            length; having the anterior two-thirds of  its body slender, like a hair,
            while  the  remaining third is  much  thicker; it  is  white, or of the
            colour of the substances it has  swallowed. The sexes are in different
            individuals. The mouth is at the capillary extremity, which is always
            found adhering to the surface of the intestine.  This worm is met with
            in the large intestines—most commonly in the caecum—which seems
            to be its natural locality.  Frequently but a single individual exists
            there;  and, in almost every instance, a very  small number.  It is the
            worm most universally met with.
Jel t*Jl sA+*+.y The oxyuris vermicularis—the ascaris of Rudolphi and most writers
StJ:>,i.«Lt..   —popularly the maw or thread-worm—is  from a line to four or five
            lines long, white, slender, and  elastic, blunt  at the anterior end, and
            with a  rounded  mouth.   It is found in the large intestines, and parti-
            cularly in the  rectum of children.  This worm generally exists in
            great numbers ; often in the form of a ball, thickly coated or invested
            with mucus.
 lum.mAtKvHM, **. The  ascaris  lumbricoides—this is the  worm most commonly met
 *v*l+*v't   with in the smalfTntestines of  children.   It  sometimes exists in great
            numbers ;  occasionally congregated in the form of  a ball.   The lum-
            bricoides is usually from  three  to twelve  inches mdlfcgth, and varying
            in diameter, from a line to two or three.   Its  usifl   Bur is white, but
            changes with that of the substances it swallows^^v hen dead, it be-
            comes  perfectly stiff.   This worm  frequently finds its way into the
            stomach, and may be discharged by the mouth or through the nostrils.
 v\* »TX*   ^ne bothriocephalus lotus—the taenia  lata, or broad tape-worm of
  «         many writers, is thinner, and generally wider than the common taenia;
        ' ** it is often twenty feet long, and may greatly exceed this length, reach-
            ing, in some cases, it is said, to sixty, and in others to  upwards of a
            hundred feet. (Bremser, Robin, Frank, Geoze, Sibbargarrde.)  It is of
            a dirty white colour; and becomes grayish when  immersed in alcohol.   t
            It has  a large  head, with two lateral grooves, which are  considered
            by Rudolphi to  be the  organs for the absorption of nourishment.  It is
            found  in the small intestines.  It  is seldom met with in the United
            States, either in children or in adults, but  is said  to be common in
            Poland, Russia, Switzerland, and in some parts of France.
              The taenia solium or common tape-worm, is of a white colour, and of
            a flat form, with the posterior extremity rounded, and the anterior long
            and slender, terminating in an extremely narrow neck, with a minute
            head, armed with four suckers, between  which there may sometimes
            be  discovered a small mouth, surrounded by a  circle of  five hooks.
            The joints that separate from the posterior extremity of the taenia so-
            lium, have received the  denomination  of  cucurbilani.   This worm
            inhabits the small intestines, and sometimes attains an enormous length.
            Several taenia are not unfrequently found in the same individual, and
            according to Rosen, in conjunction with other species of worms.  The
            fact of the head, or smaller extremity of the taenia solium not being
            discovered in the faecal discharges is no evidence, as Bremser remarks, 
DISEASES OF THE  DIGESTIVE  ORGANS.         247
that the entire destruction of the worm has not been  effected, as it is
extremely easy to overlook so diminutive an object in  such a medium.
The taenia is very seldom met with in children under five years of age;
it has, nevertheless, been found in the intestines of new-born  infants.
It is said by Fortassin to occur most frequently in persons engaged in
preparing materials from fresh animal substances.
  It is unnecessary to enter into an examination of the several theories
that have been advanced to account for the production of worms, in
the intestinal canal of man and other animals—whether they are pro-
duced by ova received from without, or are the result of spontaneous
generation.   The question is one involved  in  the deepest obscurity;
from which it would be in vain to attempt, with the  few imperfectly
observed  facts in our possession, its extrication.
   The prevalence of intestinal  worms would appear to be much more
common in certain districts of country than in others.  In Savoy and
Chambray, in France, throughout Holland, Switzerland, and in certain
districts of Germany and Russia, they are stated, by Dauquin and
Bremser,  to  be  of frequent  occurrence among nearly all classes  of
society.  According to Mr. Marshall, deputy inspector-general of hos-
pitals, Europeans are very liable to worms in India, and Africans even
more so.  Few post-mortem examinations are made without disco-
vering them.  One negro  passed forty lumbrici in a  day, and in  the
course of seven days, two hundred.  The Hindoos are so infested with
worms, according to Annesley, that scarcely one in ten is to be found
free from  them.
  Different districts of country are liable to the prevalence of different
species of worms; thus, in Switzerland, Poland, Russia, and  in some
parts of France, the bothriocephalus latus is most commonly met with;'
while in Egypt, Holland, Germany, and in the greater part of France,
Italy, and Sweden, the taenia solium, is the most frequent worm, (Ru-
dolphi, Bremser, Hasselquist, Merat, Rosen.)   The lumbricoides  and
oxyuris, are  the worms most usually met with in the United States,
Great Britain, India, and among the negroes of the West  Indies.
  According to Bremser, worms are more  common in cities than  in
the country—a statement which our own experience has not confirmed.
They are  also said to be more  prevalent in cold, damp, low, confined,
and unhealthy situations, than in those which are temperate, dry, well-
ventilated, and elevated; and during the spring and autumn, than dur-
ing the other seasons of the year.  The poor, likewise, who are badly
nourished and lodged, and filthy in their persons and  habitations, are
reputed to be more liable to intestinal worms, than those in comfortable
circumstances and of cleanly  habits.   We are not aware, however,
that these statements are founded upon any very accurate observation
of facts.
  So long as worms are considered a principal agent in the production
of intestinal diseases, they will, of course, be reputed  to be most  pre-
valent in those situations, and among those classes of society, in which
such diseases are most liable to occur.   And this to a certain extent is,
in  fact, true; for it has been invariably found that the same causes 
248
DISEASES OF CHILDREN.
 which disturb the healthy functions of the digestive organs, and pre-
 dispose them to disease, are precisely those which favour the produc-
 tion and increase of worms.
   Worms have been said occasionally to prevail epidemically.   It is
 certain, that at particular periods they have been met with much more
 frequently and in greater numbers than at  others.
   Many authors have described an epidemic of verminous fever; that
 is to say, fever of a gastric, mucous, or bilious character, accompa-
 nied with the  presence of worms, often in  considerable quantities.   Of
 the  real nature and cause of this fever we have no means of forming
 a positive  judgment; we think it probable, however, that it was  one
 connected with disease  of the alimentary canal; one  of the  conse-
 quences, rather than the cause of which was  a discharge of worms
 already existing. Andral met with worms—the ascarides lumbricoides
 and trichocephali—in only a very small number of the autopsies per-
 formed by him in  cases of death from fever;  they were very  nume-
 rous in one case, but very few in the others;  he deemed them merely
 an accidental complication  of the disease.  In one instance, they co-
 incided with most of the symptoms characterizing mucous fever.  In
 the  intestines  of most of those who died of the epidemic mucous fever
 of Gottingen, Rcederer and Wagler found a great  number of worms;
 and the same, according  to  Thibault, was  observed in  a species of
 mucous fever  which, in 1836, prevailed, in conjunction with the cholera,
 at Naples.
   Rilliet and  Barthez state, (tome iii. 605,) that in the greater number
 of cases, they found the mucous membrane  in contact with the lum-
 bricoides, in  a perfectly healthy condition.   The worms  were en-
»veloped in a  viscid mucus,  or mixed with faecal  matter precisely
 similar to  that found in other parts of the intestinal tube, and in subjects
 unaffected with worms.  In some cases a fine vascular injection was
 detected, similar to that observed in erythematic enteritis;  a diminu-
 tion in the consistence of the mucous membrane was very rarely met
 with.   As these slight alterations of that membrane existed only at
 the  point where  a  number  of lumbrici were collected,  and nowheres
 else;  it is inferred  that they were the result of the local irritation  pro-
 duced by the  worms.
   From the frequency of worms, in cases of intestinal  inflammation,
 Broussais considered them as most generally the product of the altered
 condition  of  the intestinal  mucus, and the  heat, of greater or less
 intensity, which results from gastro-enteric inflammation. This doctrine
 is by no means supported by the evidence of facts; for it has been
 proved, that  worms may exist in connexion not only with  every
 possible pathological condition of the intestinal canal, but also, where
 this is  free from the slightest trace of disease.  Andral met with them
 in all conditions of the intestines, whether they were red  or  pale, dry
 or  covered with mucus; they were  most commonly enveloped  in  a
 quantity of mucus, and there was some redness of the part where they
 were lodged,  but this appeared rather the effect of their  presence, than
 their cause.   I believe it to be a fact, remarks Dr. Stokes, that persons 
DISEASES OF THE  DIGESTIVE ORGANS.         249
 in excellent health, and with  the intestinal  canal  in the normal state,
 may have worms. It has been shown, by the observations of Sarconi,
 that in cases  of epidemic  mucous fever, worms are  not always
 present.
   As remote causes of worms, the following are generally enumerated:
 —too  rapid growth; a scrofulous habit; a sedentary inactive mode of
 life; habitual exposure to a damp, confined atmosphere; indulgence in
 crude unripe fruits; the abundant use of fat, farinaceous, and saccharine
 articles of diet, and of fresh milk.   Some  attribute them to the want
 of a sufficient  quantity of  salt being taken with the food eaten.  We
 do not believe  that any particular  articles of food, or course of life,
 has a  tendency to promote  the formation of worms in the intestines,
 excepting so far as it has a tendency to disorder or interrupt the func-
 tions of the digestive  organs.
   When digestion becomes  impaired, from whatever  cause, we  have
 the most  unquestionable evidence  that an increased development of
 worms in  the  intestines is especially liable to take place;  and it is
 from the increased irritability of the intestinal  mucous membrane, so
 frequently  associated with  a  disordered ^state of the digestive function,
 that they are then so apt  to give  rise to a variety of morbid pheno-
 mena.  Worms so frequently exist in early life, without any—even
 the slightest indication of disease, that we  can only consider them  as
 productive  of  injury  from  their numbers,  or from some co-existing
 pathological condition of the  alimentary canal.
   Though worms may occur at any period of life, they are most com-
 monly met with during infancy and childhood; more  particularly the
 oxyures and lumbricoides.   It is stated by J. Cloquet, that at La Sal-
 petriere, the hospital at Paris for the reception of patients advanced in
 life, worms are scarcely ever met with in the bodies of those who die;
 while  in the Foundling Hospital of  the same city, they are very com-
 monly present, and often in great numbers, in the same body.
   The number of lumbricoides  that are occasionally discharged by
 children, or are found in their intestines after  death, is often  almost
 incredible.   Eighty lumbricoides have  been expelled  during a  fever,
 and the whole  intestinal canal has often  been completely filled with
 them.   (Frank.)   We have known one hundred  and twenty lumbri-
 coides to be voided by a child  five years  old, in a single day, and
 have  seen  the  rectum literally crammed  with  an immense mass  of
 oxyures.
   Worms seldom occur in children who are confined to the breast.
 Dewees has never seen them  in those under ten months of age; others,
 however, have detected them in the youngest infants, even in still-born
 foetuses.
  Children  who are affected with worms, are said to  be  usually of a
pale or sallow complexion, with a bluish circle around  the  eyes, and a
more or less tumid abdomen.   They are troubled with itching at the
nose and anus, headache, foul breath,  nausea,  hiccup, and  gnawing
pains of the stomach  or  intestines;  their breath is  foul, their tongue
more or less coated; their appetite is irregular and capricious, often 
250
DISEASES OF CHILDREN.
voracious; and their  bowels are either affected with costiveness  or
with diarrhoea.   Whatever kind or amount of nourishment  is taken,
they are generally thin and pale, and of an indolent and languid habit,
while their sleep is often  disturbed by frequent startings and grinding
of the teeth.  So far, however, from any  or all of these symptoms
being diagnostic of the presence of worms in the intestinal canal, they
have  been observed in numerous  cases in which, after death, not a
single worm was detected.  According to Rosen, one  of  the  most
     ••••                                .,11
certain indications of worms, is the relief experienced by the patient
after having discharged  portions of  them, or after  taking a glass of
cold water, while according to  Monro, the most positive indication is
a dilatation of the pupils, especially when the  dilatation is unequal.
  We are furnished by medical writers with a long list of sympathetic
affections, all of which are said to have been  repeatedly produced  by
the irritation of intestinal worms, and to cease upon the expulsion or
destruction of the latter.   To this cause have been ascribed epilepsy,
hysteria, chorea, convulsions, dilatation of the pupils, perverted vision,
amaurosis, convulsive laughter, spasmodic closure of the glottis, hy-
drophobia, aphonia,  and haemoptysis;  it is even asserted that symp-
toms simulating those of hydrocephalus, disease of the heart and lungs,
croup, and pertussis, have been produced by worms.
  That  the several  morbid conditions here enumerated, are capable
of being produced by intestinal irritation, we  are perfectly aware;
how far, however, they are attributable  to  the presence  of worms, it
is somewhat difficult to decide.   In many cases, the very remedies to
which the expulsion or destruction of the latter is attributed, may effect
the cure of the morbid symptoms with which  the patient was affected,
by the removal of an irritation  of  the intestines totally independent of
the presence of worms.
  A number of cases are related, in which the most violent paroxysms
of dyspnoea and  spasmodic cough were produced  by the passage of
lumbricoides from the stomach into the posterior fauces;  they have
occasionally also found  their way into the trachea and  bronchi, and
caused the death of the patient.
  By many writers worms are supposed,  in some cases, to destroy
life, by perforating the coats of the  intestine; Rilliet  and Barthez, to
our surprise, are inclined to admit the correctness of this opinion.  We
have, in  more than one instance, detected lumbricoides  in the cavity
of the peritoneum, the intestine  being perforated at one or more points:
we have seen them likewise in the act of  passing through a perfora-
tion of the intestine, and apparently so firmly fixed in the opening as
to be unable to proceed further.  In  all  these cases, a close examina-
tion has  convinced us, that the perforation was the result of disease,
either softening or ulceration, and not produced by the worms.  It has
indeed  been denied, and very  correctly, that worms are capable of
perforating the intestinal coats.  Rodolphi declares that they possess
no apparatus for effecting  a passage through any continuous mem-
brane;  and Andral  remarks, that there is no  well-authenticated  in-
stance on record of  such an occurrence.  How far, in any case,  the 
DISEASES OF  THE DIGESTIVE ORGANS.
251
 perforation may be the result of an inflammation, followed by softening
 or ulceration, excited by the presence of worms in the intestines, is a
 question  difficult of solution.   So far as our own observations extend,
 we should unquestionably assume the  negative.  With Dr. Evanson,
 we believe that worms may exist at the same time with intestinal in-
 flammation or  ulceration, as  these affections  are  common  in those
 children  who are most subject to worms; and, should the intestines be
 perforated by softening or ulceration, the lumbricoides, if present,  will
 often pass through, and be found in the peritoneal cavity; but this  is a
 consequence, and not the cause of the perforation.
   In proceeding to the treatment of a supposed  case of verminous  dis-
 ease, it is important, at the very outset, to determine, not only the  fact
 of the  actual existence of wTorms, but  if they do exist, whether they
 are, in any degree, concerned  in the production of the morbid pheno-
 mena under which the patient  labours.   Both of these circumstances,
 but particularly the latter,  are too often taken for granted,  and the
 most serious errors are in consequence  committed.   The  real  disease
 is  overlooked, and one vermifuge  after another is  resorted to, while
 the patient, notwithstanding  the  abundant discharge of worms occa-
 sionally produced by them, exhibits no  improvement, but sinks, more
 or less  rapidly, into a state of suffering and debility, the termination of
 which is  death.
   We are to recollect, that almost every symptom said to indicate the
 presence  of worms in the intestines, may be produced by irritation of
 the alimentary canal, and may  occur without their existence; and, that
 even in those cases in which the presence of worms is established by
 their appearance in the discharges, there is no certainty that they  are
 the cause of the symptoms which exist, or that they are not a mere
 coincidence.
   In every supposed verminous case, therefore,  we would advise that
 all heating and irritating vermifuges be abstained  from, and that  our
 treatment be directed chiefly to  restore the regular healthy action of
 the  digestive organs, and the  strength  and vigour of  the body gene-
 rally.   We have been in the habit of pursuing this plan for a number
 of years,  and have seldom been disappointed in promptly and effectu-
 ally relieving our patients, and  have had but  little necessity for resort-
 ing to either of the articles which strictly appertain to the class of an-
 thelmintics. AVCL-,  £? fi/*+IS' *-****** **"•
   A regulation of diet is of the  first importance in every case, and  the
 articles of which it should be composed will, in a great measure, depend
 upon the condition of the alimentary canal. If this is  in a state of severe
 irritation, or of subacute inflammation, the diet should consist solely of
 rice water, or of rice with milk; but where  the irritation is less  de-
 cided, the child may be allowed stale wheat bread with milk, night and
 morning,  and  in the  middle of the day some fresh animal food, as
 mutton chop, boiled fowl, or beef steak, in small quantity, with bread or
crackers.   To this may be added, plain beef, mutton or chicken broth,
with rice, or plain rice pudding. Fresh vegetables, fruit, pastry, salted
food, tea and coffee, and every species of confectionary should be  in-
terdicted. 
252
DISEASES  OF CHILDREN.
  It will frequently be found  difficult, at  first, to induce children who
have been  indulged with all kinds of improper food, to restrict them-
selves to so plain  a diet; but it is better to let the child fast, than to
deviate from it.  With a proper degree of firmness on the  part of the
parents and attendants, the period of abstinence will seldom be a  very
protracted  one.
  The child should be allowed and encouraged to exercise in the  open
air, for  several hours every day;  and, as far as possible, a situation
should be  made choice of for this exercise, in which dryness is com-
bined with perfect purity of atmosphere.   Nothing is  better calcu-
lated, by invigorating the  functions of the  digestive organs, and im-
proving the health of the body generally, to prevent the development
of worms  in  the  intestines, and the inconveniences thence resulting,
than a  sufficient  amount of  active out-door exercise;  and  yet, the
weakly, debilitated child, in whom worms are most apt  to occur, and
to produce the greatest amount of mischief, as well from  his own in-
dolence and inertness of disposition, as from the prejudices and  mis-
placed tenderness of parents, is the one most generally kept  inactive
and within doors.
  Next  to diet, exercise, and  exposure to fresh, pure air, nothing is so
important in these cases, as frequent warm  bathing—followed by fric-
tions to the surface; the functions of the  skin are promoted by it, the
circulation of  the blood is equalized, and  the  stomach and bowels, in
common with  every internal organ, become invigorated.
  In  regard  to the employment  of medicinal  articles, in cases of
worms, the propriety, as well as the character of these, will depend
very much upon  the  condition of the digestive organs.  If the symp-
toms present indicate that the latter are in a state of severe irritation,
or  of inflammation,  whether acute or  subacute, it will  be necessary,
before resorting to the administration of any internal remedy, to  allay
the irritation  or  inflammation, by  leeches, fomentations,  and  cool
mucilaginous drinks.
  There are few cases in which, however, we  may not venture upon
the administration of calomel, either in a full dose, followed,  in a few
hours, by a portion of castor  oil, or in smaller and frequently repeated
doses, combined with ipecacuanha and extract of hyoscyamus. Three
grains of  calomel, with half a  grain  of ipecacuanha  and the  same
quantity of hyoscyamus,  g'ive'ri three  \imW a day, will  seldom fail
to  act  as  a  pretty  effectual purgative; and we have known  it  to
bring away large  quantities of lumbricoides.  If nothing is present  to
forbid its use, we may give a purgative of calomel, rhubarb, and  jalap,
 —the proportions  of each ingredient being adapted to  the age of the
child; or,  perhaps,  a better combination will be, calomel, jalap, and
scammony, given at first in a full dose, and repeated subsequently,
in  small alterative doses, on every  alternate night, at bedtime, suc-
 ceeded, on the following morning, by  a  small  dose  of castor oil.
 (Alexander.)  In  cases of lumbricoides, attended  with a disordered
 condition  of the stomach and bowels, without any evidence of inflam-
 mation, we have found this to act very favourably.
    The article, however, from which we have derived the most deci- 
             DISEASES OF THE  DIGESTIVE  ORGANS.         253

dedly beneficial effects in verminous cases, is the spirits of turpentine.
It may be given when there exists considerable  irritation of the ali-
mentary canal, or even subacute inflammation, without any fear of its
increasing either;  and while we  have found  it,  more certainly than
almost any other article, to effect the destruction of the worms, it, at
the same time, would appear to produce a beneficial action  upon the
digestive organs, and to aid in restoring them  to a healthy condition.
The turpentine may be given with perfect  safety,  to the youngest child
in which worms usually occur.  The rectified spirits should be directed
and may be given  in sweetened milk, in molasses, or in  the  following
mixture.*  It is generally recommended to be given  in much  larger
doses, from half a drachm to a drachm, combined with or followed by
castor oil;  we have preferred, however,  smaller doses; either from
fifteen to thirty drops upon a piece of loaf sugar, three times  a day,
or  in the mixture  referred  to.  The spirits of turpentine is  a remedy
equally  adapted to all  the  varieties  of worms, and of all the anthel-
mintics  it is the one, in favour of the  efficacy of which the greatest
amount  of evidence can be adduced.
                   * R.—Mucilag. G. acaciae, 3ij.
                        Sacch. alb. 3x.
                       Spir. aether, nitr.  3iij.
                        Spir. terebinth, rec. 3iij.
                        Magnes. 'calcinat. 9j.
                       Aq. menthae,  3j.—M.
                 Dose.—A dessert-spoonful every  three hours.

   The cowhage or down of the dolichos pruriens, is recommended as
a  safe and  useful  remedy for the expulsion of worms,  especially the
lumbricoides and oxyures.1   We know nothing of the  article from our
own experience, having never employed it. In its use, care should be
taken  to combine  it intimately with honey or syrup, and to prevent
any portion, from being spilled upon  the lips, face, breast, or arms of
the patient.

  » R.—Spicular. Dolichi, 3j.            Or, R.—Spicular. Dolichi, 9j.
       Mellis vel sacchari liquid, impur.          Syrup, cort. aurant. gj.—M. f. elec
         q. s. ut fiat electuarium.                 tuar.
Dose.—A  teaspoonful to be given every  Dose.—A  teaspoonful  to be given three times
    morning, fasting, for three successive     a  day, for two or three successive days,
    days, and  then followed by a brisk     and then followed by a. purgative.
    cathartic.

   The  oleum chenopodii  is a  remedy in  considerable repute with
American practitioners; we have employed  it  in some cases with
decided advantage.*

                     * R.—Ol. chenopodii, 3j.
                         Sacch. alb. pur.
                         Gum. acacia?, aa 3jss.—M. dien adde
                         Aq. menth. sativse, 3ijss.
      Dose.—A teaspoonful every three hours, for two days in succession, to be
                   followed then by a dose of castor oil.

   It should not be given  in any case in which we  have  reason to 
254
DISEASES OF  CHILDREN.
 suspect  the existence  of inflammation of  the  intestines, or that  is
 accompanied with febrile excitement.
   The following formula is strongly  recommended  by Bremser, in
 cases of lumbricoides: it has  been employed by  Eberle in several
 cases, with complete success.  He considers, that when it is exhibited
 to  such  an extent  as to produce  frequent and watery evacuations, it
 does far less good, than when so managed as to procure three or four
 consistent stools daily.*

               * R.—Sem. Santon.
                   Fol.  tanaceti vulgar, contus. aa gss.
                   Rad. valerian, pulv. 3ij.
                    "  Jalapae   "   3jss.
                   Sulphat. potassae, jij.
                   Oxymel. scillae q. s. ut ft. electuarium.
       Dose.—A teaspoonful two or three times  a day, for six or seven days.

   The fucus helminthocorton is a favourite  anthelmintic with most of
 the French physicians; Dr. James Johnson, of London, declares it to
 be one of the most powerful  of all  anthelmintics.  A strong decoction
 thrown into the rectum,  destroys, he remarks, any worms domicili-
 ating there, as effectually as  choke-damp would  destroy the life of a
 miner.   A  strong decoction  of  the helminthocorton has appeared, to
 Dr. Eberle, not only valuable as a vermifuge, but particularly so, as a
 corrective of that deranged and debilitated condition of the alimentary
 canal, favourable to the production of worms.  An ounce of the hel-
 minthocorton, with a drachm of valerian, should be  boiled  in a pint of
 water down to a gill; of this, a teaspoonful may be given every morn-
 ing, noon,  and evening,  with peculiar advantage.   Dr. Eberle has
 known several instances,  in which children, apparently suffering from
 verminous irritation, were restored to perfect health  by the use of this
 remedy,  without  any appearance ot worms  in their  excretions.  It is
 particularly beneficial in  cases attended with the usual symptoms of
 worms, with want of appetite,  and  mucous  diarrhoea, arising from
 mere debility of the digestive organs, and a vitiation of the secretions
 of the bowels.
  Common salt is, perhaps, one of the best anthelmintics we possess;
 it has often succeeded in  the destruction of worms when other reme-
 dies have failed.  It was a favourite remedy with Dr. Rush, and when-
 ever we  have been able to  induce children to take it in a sufficient
 dose, we have never been  disappointed in its effects;  an ordinary-sized
 teaspoonful, dissolved in a wineglassful of water, is the proper dose for
 a child two or three years old.
  A number of other anthelmintics might  be noticed, as garlic, tin
 filings, Spigelia Marilandica, the green rind of unripe walnuts.  Those
 we  have enumerated above, are, perhaps, among the  best  and most
 successful we possess.
  Several German  practitioners have lately recommended the etherial
tincture of the buds of the male fern, (polypodium filix mas,) as a most
effectual  remedy in cases  of  intestinal worms.  Peschier, of Geneva,
is the discoverer of this  tincture; his brother asserts,  that he has cured 
DISEASES OF THE DIGESTIVE ORGANS.         255
150 cases of lumbricoides, trichocephali,, and teniae,  in nine  months,
with this remedy alone.  Dr. Fosbroke appears also to have had great
success with the remedy; dose—from one to ten drops in pills, or on
sugar.
  After the removal of the worms, some light bitter infusion, or a cha-
lybeate will be proper to restore tone  to the stomach and intestines.
The infusion of gentian or calomba, with  an equal portion of an infu-
sion of rhubarb, and a few drops of the compound spirit of ammonia,
is recommended by Marley; we may, however, employ the tincture
of the sesquichloride of iron, by itself, or in combination with an equal
quantity of the tincture of aloes, as  recommended by Stokes; the dose
of this combination  is twenty drops, three or four times a day.  The
carbonate  of  iron was a favourite prescription of Dr.  Rush, in the
dose of five to ten grains to  a child a year old, every morning.   Dr.
Dewees considers a combination of equal parts of carbonate of iron
and common  salt, from  ten to thirty grains, according  to the age of
the child, to be  one  of our best tonics, in cases in which  there is a
strong disposition to the generation of worms.  The powders should
be given in syrup or molasses, in the morning, fasting, for twelve suc-
cessive days.
  In cases in which  children are infested with oxyures, the same gene-
ral treatment  will be  proper, as in  the  other  varieties  of intestinal
worms.  As these, however,  almost invariably inhabit the lower por-
tion of the rectum, and their presence can generally be detected by
the inordinate itching at  the  anus,  to which they give rise, as well as
by their appearance, often in immense numbers, in the discharges, or
by their passage from  the rectum, while the child is asleep in bed, we
have it in our power to dislodge or destroy them by injections thrown
into the rectum.  A great variety have  been recommended for this
purpose; among  the most effectual  of which may be ranked a solution
of common salt,  turpentine,* aloes,b an infusion of helminthocorton,0
lime water and milk, camphor,"5 a  solution of sulphate of iron,6 or a
solution of assafoetida  in milk.f
■ R.—Spir. terebenth. rec. 3j.
     Lactis, 3iv.—M.
Or, R.—Spir. terebenth. rec. 3j.
      Vitell. ovi,
      Aquae, 3iv.—M.
b R.—Decoct, aloes, 3iij.
     Lactis, gj.—M.
Or, R.—Gum. aloes, 3ss.
      Lactis, 3iv.—M.
c R.—Fuc. helminthocorton, 3j.
     Aquae, Oj.
          Boil to one-half.
d R.—Camphor, gr. xv.
     Olei olivae, 3iv.—M.
e R.—Ferri sulphat 3j.
     AquEe, giv.—M.
1 R.—Assafostidae, 9ij.
     Lactis, 3iv.—M.
  Dr.  Schultz speaks highly in praise of the  quassia  amara, in the
form of injection as a means of effecting the discharge of these worms.
He prepares each injection with four drachms of quassia to four ounces
of fluid.
  A bougie smeared over with strong mercurial ointment, and intro-
duced  into the rectum, will often prove successful;  while the precipi-
tated sulphur, taken for a few mornings in succession, is said by Von- 
256
DISEASES  OF CHILDREN.
 vert to be  a  most efficacious  means  for  the  destruction  of the
 oxyures.
   The complete removal of these worms is a work of no little difficulty.
 They are surprisingly productive, and even after thousands have been
 discharged, they are found within a very short period, to have re-ac-
 cumulated to the same extent  as before.  By pursuing  at the same
 time a course of treatment calculated to restore the healthy functions
 of the  alimentary canal, we may very generally, however, succeed in
 preventing, finally, their reproduction, by the use of purgatives com-
 posed of blue mass, aloes, Venice turpentine, and extract of hyoscya-
 mus,* and the occasional use of either of the enemata just enumerated.

                     a R.—Mass. f. pil. hyd.
                          Terebenth. Venet.
                          Aloes, gr. aa xxxvj.
                          Extract, hyoscyami, gr. xx.—M. f. pill. No. xxv.
      Two to be given every three hours, until an active purgative effect is produced.

   These worms are chiefly annoying from their becoming involved in
 the pouches and folds at the lower part of the rectum, and giving rise,
 occasionally, to  violent tenesmus, or more commonly, to an insupporta-
 ble titillation and itching about the anus.  This is generally experienced
 to the greatest extent towards evening, or soon  after the child is put to
 bed; often preventing sleep, and producing a  considerable degree of
 nervous irritability.  They are said occasionally to give rise to inflam-
 mation about the anus, and convulsions;  the first may, perhaps, be oc-
 casioned by the frequent rubbing  and scratching of the  part, by the
 child to allay the inordinate itching;—the second we have never wit-
 nessed.

 8. —Enteritis. —Inflammation  of the  Small Intestines. —
                             Ileitis.

  Inflammation  of the small intestines, either alone or  combined with
 inflammation of the stomach, or of the large intestines, is a much more
 frequent disease  during infancy and childhood, than is even now gene-
 rally  supposed.  The diarrhoea, as well as vomiting, so  common  in
 the earlier stages of life, is, as we  have already seen, in a large num-
 ber of cases, the  indication of enteritis, or gastro-enteritis; while many
 of the groups of morbid phenomena  described  by  the leading  writers
 on the affections of children, as distinct diseases, are, in fact, the result
 of different grades of inflammation, seated in the mucous membrane
 of the small intestines:—this is unquestionably  true, as has been ably
 pointed out  by Drs. Cheyne, Marsh, Mackintosh,  and  Stokes, of the
 intermittent or worm fever of infants, and of the tabes  mesenterica in
its most usual form.   The  same is true, likewise, of the atrophia ab-
lactatorum, as our own examinations have fully proved; and the enu-
 meration might,  if necessary, be extended much further.
  The leading symptoms of infantile enteritis are vomiting, diarrhoea,
tension, and tenderness or  pain of the abdomen upon pressure, often 
DISEASES OF THE DIGESTIVE ORGANS.         257
 accompanied  by augmented heat of its surface, tympanitis,  redness
 and dryness of the tongue, and general heat and dryness of the skin.
   The matters vomited are usually of a yellow colour, and  of a frothy
 appearance.   Vomiting is not, however, invariably present, and, un-
 less some degree of gastritis occurs, it does not take place immediately
 after the ingestion of food or drinks.  When the inflammation affects
 the  ileo-coecal valve, the  consequent  tumefaction  may prevent, or so
 far obstruct the passage of the faeces, as to give rise to faecal vomiting,
 as in other cases of intestinal obstruction.
   Diarrhoea is  more  generally  present than vomiting—with it the
 disease often commences, or it occurs at  an early period of the attack.
 The discharges are  usually more or less fluid,  of  a green or yellow
 colour, and sometimes bloody.   Some degree of tension of the abdo-
 men, with pain,  or at least tenderness upon pressure, are  very com-
 mon indications of enteritis.  The tenderness or pain is situated lower
 down than in  cases of gastritis;  it is also more diffused, and  seldom
 so intense.  The patient, in general, lies upon his back, with his knees
 drawn up, and his countenance is always expressive of great distress.
 The skin is usually hot and dry, and thejn crease of temperature is *;\ I •»*■ ^1
 often most striking over the surface of the abdomen.  The tongue is      •■■•-...
 in some  cases red at  its point and edges, dry and coated on its upper, *• ^ . >  .,.».*
 surface, with a layer  of white or  yellowish mucus; the redness and   -
 dryness of the tongue, however, are most marked in cases of gastro-
 enteritis;  in those of simple enteritis, the tongue is in  general moist,
 and often of its natural colour.
  There is commonly  more or  less thirst; but the desire for cold
 drinks is not so evident as in the acute febrile affections.   Notwith-
 standing the increased heat and dryness of the skin, and the augmented
 thirst, a decided febrile reaction is seldom met with in cases  of enteritis
 occurring previous to dentition ; subsequently, however, the disease is
 often attended with fever of a remittent form, with evident exacerba-
 tions towards evening.  There  is, also, considerable  and rapid pros-
 tration of  strength—far greater  than can be  accounted for  by any
 degree of diarrhoea that usually attends the disease.
  In the advanced stage of enteritis, the diarrhoea in general  decreases;
 the skin assumes  an  ashy hue, and becomes cool, particularly at the
 extremities, which are often decidedly cold; great emaciation ensues,
 the cheeks become hollowed, the eyes sunken, and  the face wrinkled
 and contracted; which,  when the teeth are not yet developed, gives to
 it the appearance of premature old age.   The whole expression of the
 countenance  is that of prolonged suffering; and to the experienced
 observer affords  a very certain indication of  the  existence of  long-
 continued and extensive intestinal disease.
  In the chronic  forms  of  enteritis, it is not uncommon for very con-
 siderable enlargement of the mesenteric glands to take place.   This  is
 particularly the case in  children of a very decided lymphatic tempe-
 rament, but it may occur without this predisposition to glandular affec-
tions, in consequence, as Dr. Stokes has pointed out, of the propagation
of disease along the course  of the lymphatics, from the mucous surface
of the intestines, to the mesenteric ganglia.
                                17 
258
DISEASES OF CHILDREN.
                In the great majority of instances, tabes mesenterica is, in fact, the
              result of chronic or subacute enteritis.  This connexion of the two
              diseases was long since pointed out by Cheyne, and will  be evident to
I              any one who will trace back the  history of each case to its earlier
              stages, and carefully examine, in the event of a fatal  termination, the
              condition of the mucous membrane of the ileum; in which, very  gene-
              rally, will be found  the evidences, if not of existing, at least of prece-
              ding inflammation.  This is not a matter of merely theoretical nicety,
              but has a very important practical  bearing,—the  usual treatment pur-
              sued in cases of tabes mesenterica, being one rather calculated to aug-
              ment, than to  remove the disease; whereas, the  treatment  proper in
              cases of enteritis, if pursued from the commencement of the attack,
              will, very generally, prevent the occurrence of the  mesenteric affection,
              and even where the latter has already occurred, it is the  only one cal-
              culated to effect its  removal.   This statement we make as the result of
              a tolerably extensive experience, among a  class of patients  who are
              generally reputed to be most liable to tabes mesenterica.
                 Most commonly, enteritis is more or less prolonged, and the patient,
Jt«/r**lt\j in a state of extreme marasmus, dies  from exhaustion ; occasionally,
>^«v*#*s' >**   however, the disease  assumes an acute form, and death  occurs  at an
■ #t*vt ***r*y»early period, from violent peritonitis, the result of a perforation of the
           "  coats of the intestines  from ulceration or softening.
                It is important to bear in mind the fact that in cases of  enteritis,
              irritation of the brain, or of the lungs, is very liable to take place; and
              when these irritations  are somewhat  intense, they are apt to obscure
              the original disease, and cause it to be entirely overlooked.  It is
              essential to the safety of the patient,  that the true character of  these
              cases should be well understood; for  while the secondary affection is
              not to be overlooked, lest it run  into inflammation of the  organ in
              which it is seated, and  produce effusion  or disorganization; at the
              same time, the original disease should not be neglected, for so long as
              this continues  unabated, the removal of the secondary affection is with
              great difficulty effected.
                The pathological appearances, observed  after death, in cases of en-
              teritis, are various.  It is  seldom that the inflammation is  seated at the
              upper portion of the intestinal tube; in a few of the milder cases,  how-
              ever, it is confined  to  the  duodenum, when the free edges of the val-
              vulae  conniventes will  be  found  more or less intensely reddened.  In
              the more violent cases of enteritis it is in the mucous membrane of the
              ileum, particularly in  the neighbourhood of the ileo-ccecal valve, that
              the marks of inflammation are most usually detected.   There is either
              a uniform redness of the membrane, or the redness occurs in  irregular
              patches, of greater or less extent, indifferently situated, either in  a de-
              pending or non-depending portion of the tube.   These patches are ge-
              nerally accompanied with tumefaction of the tissue, at the parts where
              they are situated, and often  by a  softened or friable condition of the
              latter; there is, at  the same  time,  often, more or  less blood effused in
              the intestinal canal—often of a dark, dissolved appearance.   In many
              cases, the intestinal mucous membrane is studded with flakes of  curd-
              like matter, generally of  a yellow or greenish colour; these flakes ad- 
DISEASES OF  THE DIGESTIVE ORGANS.         259
here to the surface of the membrane, and cannot be separated without
a slight degree of force.  The muciparous follicles  of the intestines
are often enlarged;  occasionally they are also red, and frequently in a
state of ulceration.   The inflammation may occur also in the isolated
follicles, or in the follicular plexuses.
  In the first case the follicles are elevated, of a rounded appearance,
feeling, when the finger is passed over  them, like small, soft granula-
tions, which differ in size from the head of an ordinary pin to that of a
hemp seed.  They are usually pale and more transparent than the rest
of the membrane, and are often surrounded by a small red areola.
   When the inflammation affects the patches  of Peyer, they become
swollen, red, and soft.   In some cases their surface presents small red
projections, in others, it is unequal and rugous.   Occasionally some of
the areolae remain more depressed and broader  than others, presenting
the  appearance of ulcers.  The intermediate partitions may become
so far developed in  a single direction as to resemble valves imbricated
from above downwards. (Rilliet and Barthez.)
   In chronic cases, dark purple or slate-coloured patches or striae,
upon some portion  of the intestinal mucous membrane, are not un-
common.   Softening of the mucous membrane, to a slight degree, is
very often present; but, in  chronic cases, the tissue is occasionally
reduced to a soft, reddish, sometimes diffluent mass.  The ulcerations,
as  well as the softening, may implicate the entire  thickness of the
intestinal coats, giving rise to perforations, with escape into the peri-
toneal cavity of the contents of the bowels;  in such  cases, death
quickly ensues, in consequence  of the occurrence of acute peritonitis.
   Billard, Beclard, Cloquet, and others, describe  a species of gangrenous
ulceration, as one of the terminations of enteritis;  thus certain ulcera-
tions of the  ileo-ccecal region, occasionally exhibit the same black,
soot-like edges, that occur in ulcerated  aphthae of  the mouth, or some
circumscribed points of the mucous membrane become changed to a
grayish pulp, which, on separating, gives place to an ulcer with pro-
jecting edges.  The bottom of the ulcer  is destroyed  more or less
quickly, and a complete perforation of the intestine ensues ; adhesions
are often  promptly formed between  the  peritoneal  surface of  the
intestines,  and prevent an  escape  of the  contents of th*  bowels.
We have never met with the particular lesion here referred to.
   Ulcerations are  extremely common, in all  protracted cases; they
are sometimes very numerous throughout the whole of  the ileum, and
vary in diameter from that of a  split pea, to that of a sixpence.
The mesenteric glands are frequently enlarged,  and very vascular,
and, in chronic cases, are often in a state of suppuration, or converted
into a cheese-like matter, of greater or less firmness.
   The causes of enteritis are, in  general, overloading the stomach  \
with food, improper articles of diet, the  influence  of cold,  and  an
impure and confined  state  of the  atmosphere.  They are the  same
with those usually noted as productive of diarrhoea in infancy and
childhood.  In fact, in a large number of cases, the disease commences
with an attack of ordinary~diarrhcea, which, being neglected or mis- 
260
DISEASES  OF CHILDREN
managed, tenderness or pain of the abdomen, heat and dryness of the
surface, with the other symptoms of intestinal inflammation, are suc-
cessively developed.
  The treatment of enteritis differs but  little  from that of gastritis.
The diet should be  restricted to  some  mild  mucilaginous fluid, as
rice water, gum water, infusion of the bark of slippery elm, or  milk
diluted with barley water, and sweetened with a small quantity of
loaf sugar.  The warm  or tepid  bath is an  all-important remedy;
nothing in all the inflammatory affections of the alimentary canal pro-
duces so soothing and tranquillizing  an effect.   The  bath  should be
repeated daily, or,  in severe cases, even oftener;—its  temperature
should be regulated  according  to  the  state  of the  child's  surface—
being decidedly warm, when the  heat of the skin is deficient,  and of
tepid  warmth, when it is augmented.   Warm, emollient cataplasms
upon the abdomen exert likewise a beneficial effect upon the symptoms
of the disease, and tend to allay the local tension and pain.
  In most cases, leeching will be proper; the leeches should  be applied
over the surface of the abdomen, and graduated in number,  according
to the intensity of the local symptoms.  Some  degree of  judgment,
however, will  be demanded, in the employment of leeches, in inflam-
mations of the intestines, especially in children.  Few cases  occur,
in which  a moderate application  of them will not be proper and
beneficial;  and whenever the pain, heat,  and tension of the abdomen
are considerable, they should be more freely employed, and may be
repeated, if the first application fails to produce a decided abatement
of the symptoms just enumerated.   While  we are  cautious, in no
instance, to carry  the  depletion to  such an extent,  as  greatly to
increase the prostration of the patient's strength, we should recollect
that, in violent cases, a favourable termination of the  disease will, in
a great measure, depend upon the early employment  of a sufficient
number of leeches.
  To allay the diarrhoea, which, in  numerous  cases, is a  prominent
and very troublesome symptom, many physicians recommend the em-
ployment of opiate injections; but in acute cases, we are by no means
convinced of their propriety.  We have,  however, derived advantage
from the exhibition of minute doses of calomel, ipecacuanha, extract
of hyoscyamus, and acetate of lead in combination.*   This we  have
found not only to arrest the diarrhoea, but to have a beneficial effect
upon the intestinal disease, allaying pain and irritation, and  producing
natural and regular evacuations.   If, from any cause, this combination
should be considered as unadapted to the case, the  acetate  of lead in
solution may be given by the mouth, or in the form of enemata.
                   1 R.—Calomel,
                        Ipecacuanha?, aa gr. ij.
                        Ext. hyoscyami, gr. iv.—vj.
                        Acetat. plurnbi, gr. viij.—xij.—M. f. pirfNo. xij.
                     One to be given every three hours.     ?

  Blisters to the abdomen will often be found advantageous, especially
in protracted cases; they should be kept on a few hours, and followed 
            DISEASES  OF THE  DIGESTIVE  ORGANS.         261

by a bread-and-milk  poultice.   In very acute cases,  warm sinapised
pediluvia, or sinapisms to the extremities, will generally be productive
of good effects.
  In chronic cases, the warm  bath, blisters  to the abdomen, the in-
ternal exhibition of calomel, ipecacuanha, and extract of hyoscyamus,
with the addition, when  diarrhoea is present, of the  acetate of lead;
and when the discharges are thin and offensive, the use of turpentine,
are the remedies, from which the greatest amount of relief will be ob-
tained.  The diet should be mild, unirritating, and taken in small quan-
tities, at properly regulated periods.   Plain chicken water, arrow-root,
tapioca, and milk, or beef tea,  will, in most  cases,  be proper articles
of food—producing but  little irritation, and supporting the patient's
strength, which, in cases of chronic enteritis, is very  apt to be greatly
prostrated.  By some practitioners, it is considered beneficial to dress
the blisters upon the  abdomen  with  mercurial ointment, or to apply
this by friction over  the abdominal  surface in cases where blisters
have not been applied.
   When a state of convalescence has been procured, the skin becom-
ing soft and moist, the tongue  clean, the stools more regular, and na-
tural in appearance, with a  disappearance of the tenderness and tume-
faction of the abdomen,  and a  return of the natural appetite, the admi-
nistration  of some light tonic will, in general, be found beneficial,—
more rapidly restoring the patient's  strength, and rendering a relapse
less liable to occur.

10.—Colitis.—Inflammation of  the   Large  Intestines. —
                           Dysentery.

   Inflammation of the large intestines seldom occurs  independently of
some degree of inflammation of the small intestines, and is occasion-
ally  accompanied with more or less  gastro-enteritis.  It is  chiefly
distinguished from ordinary enteritis,  by frequent  small  discharges
from the bowels of mucus, generally mixed with  more or  less blood,
and accompanied with severe tormina and tenesmus.
  In children, dysentery generally commences with the  symptoms of
simple diarrhoea, the  discharges being at first  faeculent, but soon be-
coming serous, with an admixture of blood.  There is often tension of
the abdomen, with pain  or tenderness upon pressure along  the  course
of the colon; the skin is  generally dry and hot, and,  in children  of a
year old and upwards, distinct febrile reaction, with  evening exacer-
bations, is often present, with  redness  of the  tongue and increased
thirst;  nausea and vomiting are occasionally observed, but are seldom
frequent or severe, unless the stomach is the seat of some degree of
inflammation.   The discharges from the bowels become, at an early
period  of the disease,  very frequent, but small in quantity, and composed
entirely of a little bloody mucus.   They  are generally preceded by
more or less tenesmus, and attended and followed by  tormina.  There
is seldom any appearance of faeculent matter in the stools, though, oc-
casionally, it is passed  in  hardened masses, of various  sizes,  with
blood and mucus. 
262
DISEASES  OF QHILDREN.
  If the disease is not arrested, the anus becomes red, hot, and exceed-
ingly  painful—and the abdomen  hot, swollen, and  tympanitic, and
often affected with severe pain, or  it is excessively sore to the touch;
the surface of the body becomes cool, and the extremities cold;  the
discharges from the bowels become dark-coloured and offensive ; great
prostration of strength ensues, and the patient exhibits all the symp-
toms of chronic intestinal disease.  The mouth often becomes covered
with aphthae, which also occasionally appear about the verge of the
anus.
  Colitis may terminate in death at an early period, from the intensity
of the inflammation, but, in general, it runs a protracted course, and
the patient sinks finally from extreme prostration; or a state of coma
ensues, and death is preceded by symptoms of encephalic effusion.
  The appearances upon dissection differ in nothing from those that
occur in cases of enteritis, excepting in their seat; the mucous  mem-
brane of the colon and rectum is affected with red elevated patches or
striae, and with friability or softening of the tissue, at the part where
they are situated.  The surface of the colon and rectum are occasion-
ally covered with filaments, varying in size, of a curd-like matter.
Enlargement, inflammation, and ulceration of the muciparous glands
and follicles are very commonly met with;  gangrenous ulceration is
occasionally present, and, in chronic cases especially, thickening, with
a dark purple or a slate colour, of the mucous membrane of the colon
or rectum, in patches of a greater or less extent.
   Dr. Crampton has observed, in cases of children who died of dysen-
teric  symptoms, the mucous  membrane  of the  intestines,  in  many
places, to be highly vascular, and  covered with granulations of a yel-
low, or dirty yellow colour, as if from a coating of  wax; in several,
ulcerations had taken place; these ulcers  were disposed  in patches,
with  well-defined edges.   In cases that terminated favourably, a quan-
tity of yellowish, branny scales, were seen floating in the discharges
from  the bowels, like minute portions of wax from honeycomb.
   Colitis would appear, in the majority of cases,  to  be the result of
sudden transitions of atmospherical temperature, particularly the  sud-
den change from warm and  dry,  to cold and damp weather.  It is
most  prevalent during the latter part of summer, or the  commence-
ment of autumn, when the days are hot, but the nights chilly and damp.
It is apt to prove endemic, in unhealthy localities, especially those fa-
vourable to the  production of intermittent and  remittent fevers, and
often prevails epidemically with fevers of a  catarrhal character.   A
few days of cool, rainy weather, occurring in the summer,  will often
cause the prevailing bowel complaints of children to assume a  dysen-
teric  character.
   Colitis may, however, be produced by the same causes which  give
rise to inflammation in other portions of the alimentary canal.
   In  the treatment of colitis, the same general directions are applicable
as in  the otheiMntestinal inflammations.  All solid, stimulating, and in-
digestible food should be avoided.   The patient may be allowed to take
pretty freely of mild  mucilaginous  drinks;  but  even with these he
should not be allowed to overload his stomach.  The free use of but- 
DISEASES OF  THE DIGESTIVE ORGANS.         263
termilk has been found advantageous, in many cases of dysentery in
children.  The warm bath and warm fomentations  or  cataplasms to
the abdomen, are  equally beneficial here as in cases of enteritis.
Leeches should be applied, along the course of the colon, in numbers
proportioned to the violence of the disease, and the strength and age
of the patient, and repeated, if, after their first application, the symptoms
remain without considerable abatement. By some practitioners, leeches
are directed to be applied  to the verge of the anus.   Occasionally, this
will be found to produce a very favourable impression upon the symp-
toms of the case; but, as  a general  rule,  we cannot recommend the
application of leeches to this part in children; we have occasionally
found the haemorrhage produced by them  continue  for some  time
after their removal, and to be with difficulty controlled.  In cases in
which symptoms of gastritis are present, leeches should also be applied
to the epigastrium.  In robust children, over one  year of age,  when
the disease is accompanied by symptoms of any  degree of intensity,
blood may be taken from the arm.
   In regard to the use of  internal remedies, there exists a very great
diversity of  opinion, among practitioners.  To the common practice
of giving small and repeated doses of castor oil, either with or without
an  addition  of laudanum,  we  are decidedly opposed;  we have seen
much injury result from it, and cannot understand the principles upon
which the treatment is founded.  From the  administration of small
doses of calomel, in combination with ipecacuanha, we have derived
the best effects, and believe that a small portion of extract of hyoscya-
mus, agreeably to the plan pursued by many of the German physicians,
forms an admirable addition.11   The relief  derived from this combina-
tion, is often prompt and  considerable, while  a favourable  change is
produced, in a very short time, in the character of the discharges.
                   a R.—Calomel, gr. iv. ad xij.
                        Ipecacuanha?, gr. iij.—iv.
                        Ext. hyoscyami, gr. iv.—vj.
                       Cretae ppt. gr. xxxvj.—M.  f. pulv. No. xij.
                     One to be given every three hours.

  In protracted cases, the application of a blister  over the  abdomen,
as directed  in enteritis, we have repeatedly seen  productive of very
beneficial results.
  Injections into the rectum, of a solution of  acetate of lead, with or
without laudanum, are calculated to  allay the tormina and tenesmus,
and may be  repeated with advantage.   We must recollect, however,
that much caution is to be observed  in the  use of opium and its prepa-
rations,  in the form of enemata, in the diseases of children.  Expe-
rience early taught  us, that very small  portions of laudanum thrown
into the rectum, will  often produce a  degree of  narcotism, which
would be scarcely  anticipated from a similar  quantity given by the
mouth;  the  same fact has  been noticed by other practitioners.
  As soon as the more acute symptoms of the disease have been sub-
dued, we are in the habit of giving the acetate of  lead, in the dose of
one grain, combined with a third of a grain of ipecacuanha, one grain
of extract of hyoscyamus,  or a twelfth of a grain of opium, and a sixth 
264
DISEASES OF  CHILDREN.
of a grain of calomel, repeated every three hours, and have  seldom
been disappointed in effecting by it the entire removal of the disease.
  In chronic cases of colitis, the same  treatment is  applicable, as in
chronic diarrhoea.   The spirits of turpentine  will, in such  cases, be
often found a very valuable remedy.
  During convalescence  from colitis,  more  especially in  its  more
protracted and chronic forms, the vegetable astringents will be found
advantageous, in restoring tone to the  intestines, and facilitating the
recovery of the patient's strength.
  In  an epidemic of  dysentery  that  occurred  among children, in
Washington county, New York, an infusion of white oak bark, black-
berry-root, and  yarrow, in  milk,  with  the addition  of  sugar,1  was
found, according to Dr. Cogswell, to  be productive of the best effects.
The persesquinitrate of iron is also spoken of  by Williams and others
as a useful remedy, in cases of dysentery occurring in children.

                   1 R.—Cort. querci alb.
                        Rad. Rub. villosi, aa. gss.
                         Fol. achill. millefol. 3iij.
                         To be boiled in Oj. of milk.
                A dessert-spoonful, to be given frequently.
                      CHAPTER  VI.

      PERITONITIS—INFLAMMATION OF THE PERITONEUM.

  Inflammation of the peritoneum may occur in  children, even from
the earliest periods after birth.  In still-born infants, as well as in those
who have  died a few hours after birth, so frequently has there been
found to exist redness and opacity of the peritoneum, with serous or
puriform effusion; a coating of coagulable lymph, either in the form
of flocculi  or membranous shreds;  adhesions between the intestinal
convolutions and  other abdominal viscera, some slight and recent, and
others very firm  and apparently  of  long continuance;  or  tubercular
granulations of the peritoneum, that we are perhaps to include perito-
nitis, among the most common and fatal of the  diseases, to which the
foetus in utero, or the child immediately after  birth is liable.
  Peritonitis, in an acute form, is by no means a very frequent disease
of children.  It may, however,  occur as a primary affection, but  is
more frequently developed  in the course of some  other disease.   It is
indicated by tension and pain of the  abdomen, more or  less acute, and
invariably  increased upon  pressure; restlessness,  constipation, and a
peculiar contracted and distressed expression  of the face.
  The pain of the abdomen is constant, and often extremely acute,
and  the tenderness, in severe  cases, is such as to cause the  slightest
pressure, even  that of the  clothes, or  the  coverings of the bed, to be
insupportable.  The child lies upon his back with  his knees drawn up, 
DISEASES OF THE DIGESTIVE ORGANS.         265
 and exhibits extreme restlessness;—his cries  are  often  constant and
 acute.  The abdomen is commonly tense and swollen, rising in a point
 towards the umbilicus.   The tension  is sometimes perfectly circum-
 scribed, and upon palpation  a painful  tumour is detected, without any
 change in the colour of the  skin, and presenting a dull sound upon
 percussion.   (Rilliet and Barthez.) The  bowels  are usually  consti-
 pated, and the skin dry, but seldom hot.
   In  children  of two or  three years  of age, we have often seen the
 disease attended with very considerable febrile excitement.  The pulse
 is generally very small  and frequent, and  there is always great pros-
 tration of strength, with a contracted and  suffering expression of the
 countenance,  and not  unfrequently considerable  dyspnoea.  As  the
 disease advances, there is generally frequent eructation or vomiting—
 coldness of the  surface, particularly at  the extremities, and often  a
 livid  or dusky appearance of  the face.
   Peritoneal inflammation, occurring in children, requires the  closest
 attention and  tact on the part of the physician, to distinguish it from
 inflammation of the intestinal  tube,  with which it is often complicated.
 Peritonitis may be  distinguished from  pleurisy by the  absence  of  the
 physical signs of the latter;  and from severe paroxysms of colic, by
 the pain being continued, and increased upon pressure, while, in cases
 of colic, the pain is remittent, and is very generally diminished by    . \  »  •.'-,
 pressure upon the abdomen.                                         »•   ^*» i
  In acute peritonitis, death often occurs  at a very early period, the •* * }»*> .■■*
 patient appearing to sink from exhaustion.   In many cases, however,   •»  ,*,..  ,
 the peritonitis  of children assumes a chronic form, when it constitutes.v  •»•• • '•«»•
 probably one of the most insidious affections of early life, its real cha-
 racter being very often  overlooked, and  a  most injudicious course of
 treatment pursued.
   In  chronic peritonitis  there is generally pain in the abdomen, seldom
 severe  or continued, but  occurring,  most commonly,  in short  pa-
 roxysms. More usually, however,  there is only tenderness upon pres-
 sure—the patient shrinking or crying out, upon being lifted or handled.
 The appetite is irregular, or but  little affected; the bowTels are gene-
 rally costive, but occasionally there is more or less  diarrhoea, alter-
 nating with  constipation.  The child is, in general, peevish, dull, and
 disinclined to exercise;  the pulse is small and quick ; and the tongue
 covered with a whitish  or yellowish mucus.  The heat of the surface
 is often somewhat increased, and occasionally, the disease is attended
 with fever of an  intermittent  form. The face is  usually pale  or sal-
 low, and the expression  of the countenance that of distress.  The ab-
 domen  is generally  more or  less distended, and  very  often exhibits
 some  degree of tympanitis.   The emaciation is always  considerable,
 particularly in children  over two years of age.
  In  the early  stage of chronic  peritonitis,  the  symptoms are fre-
quently so slight, and of so obscure a  character, that but little atten-
tion is paid to them by the parents; or  the child  is supposed to be
labouring under worms, the serious character of the disease being en-
tirely  unsuspected, and a few, often  improper domestic remedies, are
all that are prescribed. 
266
DISEASES OF CHILDREN.
              The progress of the disease is generally marked by increasing, and
            often extreme emaciation and debility;  with a small, frequent pulse;
            hectic fever;  night sweats; often diarrhoea, with  thin, dark-coloured,
            and offensive discharges, and  the patient finally sinks from exhaustion.
            In other cases, a serous  effusion takes  place within the cavity of the
            abdomen; the effusion being entirely confined to the peritoneal cavity,
            and unattended with oedema  of  the extremities  even  in protracted
            cases.
              The tumefaction of the abdomen caused by the effusion, is some-
            times  so inconsiderable at first, that it is easily overlooked, especially
            in young children, in whom there is naturally a  considerable promi-
            nence of abdomen.  The fluctuation of the contained fluid can always,
            however, be distinctly perceived by the usual means.
              The effusion increases daily in extent, and causes a gradual augmen-
            tation in  the  size of the  abdomen.  Every portion of the body, with
            the exception of the face, becomes, at the same time, more  and  more
            emaciated, and the  exhaustion of the patient rapidly increases; the
            appetite often, however, continues unimpaired, or is sometimes even
            increased.  The bowels are variable ; being at one time affected with
            diarrhoea, and at  others, constipated, or at  least  seldom  opened.   A
            febrile excitement of an intermittent form  now generally occurs, and
 L*//i*+f+(f'~\he patient, in a state of extreme  marasmus, sinks gradually into his
 p if?/'/** ""grave.
p«.±vtvf 4*   The appearances discovered after death, in cases of peritonitis, are
 «*ro#*-**   redness and thickening of the peritoneum, particularly of that portion
 -*M'*u **wjrtenveloping the intestines;  the redness  is occasionally confined to the
            larger omentum,  or  to the peritoneum covering the right iliac  fossa
            (Rilliet and Barthez) ; adhesions, more or less extensive, of the convo-
            lutions of the intestines to each other, or of these  to the surface of the
            abdomen, or to the other viscera, are frequently  present.  The  intes-
            tines are often coated with a layer of purulent, and at others of albu-
i            minous matter.   Very generally the cavity of the  abdomen contains
i            more or  less serum of a whitish or citrine  colour, sometimes with
            small  albuminous flocculi diffused throughout it.   In  chronic cases,
            circumscribed collections of puriform  matter occasionally exist  be-
            tween the convolutions of the intestines.   The  peritoneum is  often
            studded with tubercles.  The mucous coat of the  intestines presents
            frequently the indications of chronic inflammation, particularly ulcera-
            tions, to  a greater or less  extent.
               Peritonitis is usually the result of cold:—it may, however, particu-
            larly  in its chronic form, supervene upon slight attacks of any of the
            acute affections of the alimentary canal, or upon other febrile diseases,
            as measles, or scarlatina.   It may attack children of any age, but is
            more common after the fifth  year than  previously.  An acute  attack
            of peritonitis may be the result of perforation of the intestines, from
            disease of the alimentary canal.
               In  the treatment of peritonitis, a careful regulation of the  diet  is all-
,            important:—thin gruel, or any of the mucilaginous fluids directed in
            enteritis, may be allowed. As early as possible in the attack, leeches
|           should be applied to the abdomen, especially in the neighbourhood of 
            DISEASES OF  THE DIGESTIVE ORGANS.        267

 the umbilicus, in numbers proportioned to  the age of the patient, and
 the extent and violence of the local symptoms; and if the first appli-
 cation does not effect the removal of the pain and tenderness of the
 abdomen, they should be repeated after a  short interval. The warm
 bath  and fomentations,  or  warm cataplasms to the  abdomen,  are
 remedies from which, if judiciously managed, and perseveringly em-
 ployed, the very best effects may be anticipated.
   Internally, it is generally proper to administer at the commencement
 of the  attack a  full dose of calomel, followed, in a few hours, by a
 dose of castor oil, or some simple purgative enema; after the  opera-
 tion of which small doses of calomel, combined with ipecacuanha and
 extract of hyoscyamus, may be given every three hours.
   In children  over two years of age, affected with a severe attack of
 acute peritonitis, some blood may be taken from the  arm, and, if ne-
 cessary, followed by leeches to the abdomen. In most cases, in which
 the symptoms are of any degree of violence, sinapised  pediluvia will
 be found advantageous.
   After leeching has  been  carried as far as  is thought advisable, a
 blister over the abdomen, as directed in enteritis, will often  cut short
 the disease.
   On the subject of local depletion, it will  be proper to  remark  that
 the indications for its employment, and the extent to which it is to  be
 carried, as well as for its repetition, are to be drawn chiefly from  the
 intensity of the local symptoms: when there is pain or tenderness of
 the abdomen, leeches  should be applied in  proportion to the surface
 over which it extends; and so long as it  continues without decided
 abatement, the repetition of the leeches should not be neglected.  The
 frequent absence, in peritonitis, of febrile excitement, and the exhaus-
 tion of  the patient, will often mislead the inexperienced  practitioner,
 and induce him to omit this important remedy, from  the  early and
 judicious employment of which more is to be expected  than from any
 other.   Even in the  chronic form of the disease, pain  and tenderness
 of the abdomen, call for the employment of leeches, which,  if applied
 in sufficient numbers, will often produce a very marked change in the
 character of the case.
   The  warm  bath, fomentations and  blisters to the  abdomen, are
 equally  important in the chronic, as in  the  acute form, as is also  the
 internal use of calomel, with ipecacuanha and extract of hyoscyamus.
 In cases of chronic peritonitis, after effusion has taken place, we have
 derived the best effects from the addition to this prescription  of minute
 doses of powdered digitalis.  Wolff recommends, in these  cases, the
 digitalis with the bitartrite of potass, in small doses, frequently repeat-
 ed.  Even when considerable diarrhoea is  present, he  states  that he
 has observed, under  the use of the remedy, a gradual abatement of
 all  the symptoms of the disease to take place;  and by following it
 with a course of mild bitters, in conjunction with digitalis, and an in-
fusion of roasted acorns, he has, in a large number of instances, effected
a perfect cure, even in cases  which, when they were first presented  to
him, he had almost despaired of being able by any means to save the
life of the patient. 
268
DISEASES OF CHILDREN.
  During convalescence from attacks  of peritonitis, whether in its
acute or chronic form, it is all-important to place the patient upon a
well-regulated, mild, and digestible diet, composed chiefly of farina-
ceous articles and milk.  Flannel should be worn next to the skin, and
the arms and legs carefully protected from cold and damp.  A change
of air, particularly a  change from a damp and chilly atmosphere to
one that is mild and dry, will often expedite the patient's recovery.
                      CHAPTER  VII.

        THE REMITTENT OR GASTRIC FEVER OF INFANCY.

  The inflammatory affections of the  alimentary canal, occurring in
infants subsequent to dentition, are frequently accompanied  by febrile
symptoms, that usually assume a remittent form, with distinct exacer-
bations  towards evening.  This constitutes  the remittent fever of in-
fancy, the worm  fever of some writers, and the  mesenteric fever of
others.  It is, in  fact, in every instance, either a gastro-enteritis, an
ileitis, or  an entero-colitis,  accompanied  with febrile  reaction; and
were  it not that it is noticed as a distinct affection, in  almost every
work on the diseases of children, we  should content ourselves with
referring  to the account already given of the inflammations of the
digestive organs, for its pathology and treatment;  but as this, no doubt,
would be  considered by many a  serious defect in our treatise, we
shall, in obedience to general custom, devote a section  to the conside-
ration of the febrile forms of the several gastro-enteric inflammations
of infancy.
  The invasion of infantile remittent fever is occasionally very sudden.
A child, apparently in good health, shortly after retiring to bed, is at-
tacked  with  a severe  febrile paroxysm: the skin  becomes  hot,  the
countenance flushed, the eyes injected, and the pulse quick and frequent.
The thirst is generally intense; the tongue dry, and often thickly coated
on its surface with a layer of white mucus, but  red at its point  and
edges.  There is always great restlessness, and often transient delirium.
The patient generally complains of pain over the eyes, and of pain or
soreness of the abdomen, which is more  or less tender to the touch, and
hot.  There  is, not unfrequently, nausea, or vomiting  of a yellow or
greenish fluid, and of a sour or offensive smell.
  Towards morning  these  symptoms  gradually  abate; the  skin be-
comes cooler, the pulse less quick and frequent, and the tongue moister.
There is still, however, dryness of the skin; the tongue continues coated;
the pulse is quicker than natural; the child exhibits more or less lan-
guor and  fretfulness, and  is without   appetite;  the abdomen is  still
often painful or tender, and the urine scanty and high-coloured, often
depositing a  white sediment. 
            THE REMITTENT  FEVER OF INFANCY.         269

  In the course of the morning, the remaining symptoms abate or dis-
appear, and the child becomes more lively and playful, but still exhibits
a degree  of  languor  and  peevishness,  which, in general,  increase
towards evening, when  a  febrile paroxysm occurs, as on the precede
ing night; and  is  again  succeeded in the morning by a more or less
perfect remission.   In this manner, with daily exacerbations and  re-
missions, the  disease, unless cut short by appropriate remedies, runs
on  for many days, and often assumes a chronic and very protracted
form.
  The disease more  generally, however, commences  less suddenly.
The child is observed, for  several days, to be languid and fretful, with
loss of appetite, augmented thirst, and some heat of the  skin, particu-
larly at night—when he is also restless and  uneasy.   These symptoms
increase, gradually, in intensity, and  towards evening, the  heat and
dryness of the skin become more marked; the thirst and restlessness
greater; the breathing becomes somewhat  hurried ; the pulse more
quick and frequent:—towards morning, the skin becomes again moist
and cool,  and the patient falls into a short, disturbed sleep. Each night
the febrile paroxysm is  more and  more distinct, and of longer dura-
tion, and the morning remission less complete.
  In the commencement of the attack, the bowels are ordinarily con-
stipated ;  in  some  cases,  however, there is diarrhoea, or a frequent
inclination to go to  stool without much being passed.  When evacua-
tions from the bowels occur, they are  always unnatural, and  highly
offensive ; being dark-coloured, or clay-like, or of the appearance and
consistence of tar: they are often mixed with mucus, and  occasionally
bloody.  The vitiated secretions from the intestines, liver, and perhaps
the pancreas, are frequently accumulated in the bowels in large quan-
tities, and constitute the morbid and  offensive  discharges which  are
so commonly produced by the action of purgatives.   Not unfrequently
there occur repeated evacuations from the bowels, accompanied with     •
violent tofgnina  and tenesmus—the evacuations consisting of little else  At**^-4'
than mucus,  often mixed with blood.  The  symptoms  of such cases fyf*^? '
are evidently dependent upon inflammation seated  in  the  large intes-
tines, and constitute the dysenteric fever of some writers.
   There is in most  cases  more or less pain or tenderness experienced
upon pressure of the abdomen, which is also often hot to the touch,
while the extremities are cool, or cold—even during the febrile exa-
cerbations, when the face  is flushed, and the residue of the  body  dry
and parched. The patient usually lies  upon his back, with  his knees
drawn up—cries frequently, and exhibits that peculiar expression of
countenance  indicative of abdominal distress.
   The breath, from an early period in the attack, has a peculiar sickly
odour, and often becomes  decidedly offensive.   The stomach is gene-
rally very irritable, and rejects, immediately, everything taken into  it
—frequent vomiting is not unusual.   The tongue becomes, in the pro-
gress of the disease, more coated, dry, and pointed.  The breathing  is
often quick and hurried, and a short, hacking cough, is a very frequent
symptom.  In many cases an eruption of rose-coloured lenticular spots
occurs upon  the abdomen  or inner surface of the thighs, and occasion- 
270
DISEASES OF CHILDREN.
      ally sudamina appear upon the abdomen, or along the  front and sides
      of the neck.
        Infantile remittent fever often assumes a chronic form; the exacer-
      bations being of longer duration, but marked  by symptoms  of less in-
      tensity, than in  the more acute attacks of the disease;  the remissions
      are also less distinct.  The abdomen is usually tender and hot, and
      generally tympanitic; the bowels are often  affected with diarrhoea, the
      dejections being always unhealthy in appearance,  and foetid.   The
      tongue is thickly coated upon its upper surface, with a yellowish  or
      brownish mucus, and red and dry at its point and edges; the teeth are
      often covered with sordes, and the lips parched and cracked; the urine
      is  scanty and  high-coloured, depositing a  copious white  sediment,
      particularly during the remissions; the  skin  is  dry, harsh, and of a
      sallow or dirty hue; the countenance  is contracted  and wrinkled,
      presenting  the  appearance of premature  old age.   The appetite is
      occasionally unimpaired, and, in some cases, even voracious ; in gene-
      ral, however, it is altogether lost.  The child is very generally affected
      with a short, hacking, and frequent cough.   Most commonly there is
      urgent thirst.  There is always more or less fretfulness, and the usual
      indications of suffering; and the patient exhibits a disposition to pick,
      almost constantly, at some portions of its face or body, or at the bed-
      clothes, or face  and arms of its attendants.  If, as remarked by Locock,
      there be an accidental pimple on the skin, this will  usually  be picked
      until a  sore is  produced, the edges of  which are still more  eagerly
      attacked, so that the fingers are constantly stained with blood.  This
      picking is, by many, considered as one of the diagnostic symptoms  of
      infantile  remittent fever ;—it is, however, a common phenomenon in
      all the chronic affections of childhood, and is  often observed when no
      disease whatever is present.
        The emaciation  and prostration of strength are  usually very con-
 »     siderable. In the advanced stages, the child is sometimes affected with
 t. i a species of stupor, in which  he remains for hours,  as in ajjoze, with
»    » half-closed eyelids; he is, however, readily aroused, but quickly falls
      into the same state again, when undisturbed.  This  condition is often
      mistaken for that resulting from effusion in the brain; there is, how-
      ever, no increased heat of  the head, no affection of the pupil, nor any
      of the other symptoms characteristic of  effusion within the cranium.
      Disease of the  brain may, however, occur,  either  in  the  acute  or
      chronic form of the remittent  fever of  children, and give rise,  if
      neglected, to tubercular  meningitis, with serous effusion, or to  acute
      meningitis.
        In other cases, the respiration, which has been hurried from the first,
      becomes laborious, a troublesome  short cough  occurs, and very fre-
      quently, upon examination, a more or less extensive inflammation  of
      the bronchial mucous membrane will be detected; and if the disease
      be not subdued, wheezing, expectoration, and the other symptoms  of
      bronchial inflammation, or of a tuberculous  condition of  the lungs,
      finally ensue.
        Occasionally the symptoms will appear to abate for a few weeks,
      and then suddenly recur; during these remissions, the patient will often 
           THE REMITTENT FEVER OF  INFANCY.        271

gain flesh and strength, but the abdomen still  remains tumid, and  the
bowels irregular; and these  alterations of improvement and relapse
may continue until the mesenteric glands become  enlarged, or  serous
effusion takes place  within  the abdomen.  The emaciation now in-
creases ; the exacerbations of fever are entirely confined to the night,
and  are followed, towards morning, by profuse perspiration,  and a
complete  intermission; the  appetite is occasionally  voracious—the
case, in fact, presenting all the symptoms of tabes mesenterica.
   The duration of infantile remittent fever, will  depend,  in a  great
measure, upon the character and extent of the lesions of the intestinal
canal, by which it has been produced,  the constitution of  the patient,
and  the treatment  pursued.   In many cases, an appropriate treatment
commenced in  the  early stage of the disease, will effect its entire re-
moval in a few hours; in other instances, however, a cure is less easily
effected;  and in children of a strongly marked  lymphatic tempera-
ment, in whom there is a tendency to the  development of tubercles in
the lungs, to a diseased condition of the mesenteric glands, or to tuber-
cular  meningitis or peritonitis, the  termination of the fever is very
generally fatal.
   Death may take  place at an early period, from the extent of the in-
testinal inflammation, or, in  chronic* cases, the child may sink from
mere exhaustion.  Often, however, even in the more protracted cases,
attended with great emaciation and debility, a complete recovery may
be effected  by an  appropriate treatment.  Frequent relapses, which
are liable to be produced by  slight errors in diet, exposure to cold or
damp, or over exertion during convalescence, produce  ordinarily a
chronic form of the disease, which is particularly unmanageable, and
seldom permanently removed.
   The lesions  discovered after death  from infantile  remittent fever,
vary, according to  the longer or shorter duration of the disease.  They
are  chiefly inflammation, more or less extended, of the digestive mu-
cous membrane—in some instances, of the stomach  and  upper por-
tion of the small intestines—most commonly of the ileum,  at its lower
part, and in some instances, of both the ileum and  colon. The mucous
membrane is either reddened in patches, points, or striae, and is gene-
rally thickened and softened, or ulcerated.   The  isolated  muciparous
follicles, as well as the follicular plexuses, are often  found tumefied,
reddened and ulcerated.  The mucous membrane is often covered with
a thick layer of tenacious mucus.   Dark, livid patches of the lining
membrane of the small, but more commonly of the  large intestines,
are frequently met with, and occasionally, gelatinous softening, with
perforation of all  the coats.  The  mesenteric glands are very  fre-
quently enlarged—sometimes enormously so;  occasionally in  a state
of suppuration, but more commonly converted into a cheesy matter.
Peritoneal inflammation is sometimes  present, and, in chronic cases,
the  peritoneum is not unfrequently thickly studded with tubercles.   In
some instances acute peritoneal inflammation seems to have been the
immediate cause of death, and to have  resulted from perforation of the
intestines.   The liver is usually enlarged, and in a state of extreme
hyperaemia; sometimes changed in texture, and  at other times, of a 
272
DISEASES OF CHILDREN.
           lighter colour than natural.  In the brain there is often  more or less
           effusion, between the membranes, and into the ventricles, with opacity
           of the arachnoid membrane, and tubercles of the substance or meninges.
           In the thorax, the most common morbid appearance is increased red-
           ness of the bronchial mucous membrane;  the bronchial ramifications,
           and air-cells being filled with mucus.  The lungs occasionally display
           traces of inflammation ; and in protracted cases, tubercles in the lungs,
           and upon the surface of the pleura, are frequently met with.
             Infantile remittent fever is in every case, the result of inflammation,
           most commonly  subacute, of some portion of the  digestive mucous
           membrane;  the inflammations of other organs so frequently met with,
           being mere  complications, occurring in the  course of  the disease.
           This is rendered  evident, by the  phenomena which are described as
           constituting infantile remittent  fever,  all of which,  upon  a close ana-
           lysis, will be found to point to the mucous surface, as the original seat
           of morbid action.  The result of numerous autopsies, have placed  this
           fact beyond the possibility of doubt;  it is, therefore, chiefly to a mor-
           bid condition of the mucous  membrane of the alimentary canal that
           we are to look for the  pathology of the disease; and to  the removal of
           this condition, are our  remedies to be  primarily and  mainly directed.
             When the stomach  is the seat of inflammation, of a subacute cha-
           racter, there will  be  pain on pressure at  the epigastrium;  a vivid red-
           ness  of the point of the tongue, extending some distance round  its
           edges ; and generally  a loathing of food ; nausea, retching, or vomit-
           ing are sometimes observed.
             When the inflammation is  seated in the mucous  membrane of the
           small  intestines, it is generally in the lower part of the  ileum.  We
           have then the same  appearance of the tongue, with  the papillae more
           prominent  and  distinct than natural.  Pain will be excited by pressure
           lower down than when the inflammation is seated in the stomach; the
           discharges from the bowels will be more  mucous than natural, often
           resembling thin oily  paint, mixed  occasionally with  distinct masses of
           mucus.  Nausea, retching or vomiting rarely occur ; excepting when
           the stomach, and  upper portion  of the small intestines are also affected.
             When the inflammation extends to the large intestines, its seat is
           almost always  at the upper part of the  colon.  The tongue will then
           present the same appearance, and the same tenderness of the abdomen
           will be present, as in inflammation of  the small intestines, and the  dis-
           charges from the bowels will consist of a muddy, loose, offensive faecu-
           lent matter, or  of a little mucus mixed with blood.  The abdomen, in
           all these cases, being more or less tense and hot.  Sometimes there is
ktk/j^e  /  a torpid condition of the colon, with great distension, from retained
U\6-fu.i**<6Sseca\ matter.
             When the liver is  affected, we  have pain or tenderness when pres-
           sure is made in the region of that viscus, and the discharges from the
           bowels will show a deficiency, or depraved  state of the biliary secre-
           tion.   From the sympathy which exists  between the skin  and mucous
           membrane of the  digestive organs, an irritation is experienced either
           at the external termination of the mucous orifices, or upon some part 
              THE REMITTENT FEVER OF  INFANCY.         273

 of the surface, and it is  to remove or abate this, that  the  child is
 prompted to pick incessantly at the nose, mouth, eyes, face, &c.
    The causes of  infantile remittent fever  are the same to which we
 have, in the  preceding sections, referred the production of gastro-in-
 testinal inflammation.   In perhaps the majority of instances, it is the
 result of too much, improper, or unwholesome food.  Long habits of
 indulging in stimulating and indigestible articles of food,—pastry, con-
 fectionary, crude fruits and vegetables, and various compound dishes
 —or swallowing food rapidly, and, consequently, without due mastica-
 tion, are enumerated by writers upon the  subject, as the  usual causes
 of the disease.  According to the experience of Locock and Merri-
 man, the acute form of gastric remittent fever is most prevalent about
 the  period of Christmas,  when the rich and indigestible fare of the
 season is partaken of to  excess by children, who are too often en-
 couraged in this by the foolishness  of parents and friends.  The disease
 may likewise be  produced by cold and damp, and hence it very fre-
 quently occurs towards the close of summer, and early part of autumn,
 when transitions of atmospherical  temperature are most frequent, and
 when the system of the child is more liable to be affected by  them, in
 consequence of the over-stimulation of the skin, and of the organs
 which sympathize most closely with it, by the heat of the  preceding
 season, which often still  continues during the middle portion of the
 day, and contrasts strongly with the coolness,  often chilliness  and
 dampness of the night.
    Teething and worms have been  generally set down among the pro-
 ducing causes of infantile remittent fever; the first, which is usually
 attended with increased irritability of the digestive mucous membrane,
 particularly of its muciparous glands and follicles, no doubt often pre-
 disposes to inflammation of the alimentary canal, and of course to re-
 mittent fever; of the agency of the  latter in its production, we have
 not, in any case, the slightest evidence.
    Among the more common causes of the disease, is the  neglect or
 mismanagement of the bowel affections of children  generally ; more
 especially the abuse of purgatives on the one hand, and of stimulating
 remedies and diet on the other.
    Infantile remittent fever is said to prevail occasionally as an epidemic,
• or, more properly speaking, as an  endemic.  Of this there can be little
 doubt.  By some it is supposed,  particularly in its  low typhoid or
 chronic form, in other words, when connected with subacute  inflam-
 mation and ulceration of  the mucous glands and follicles of the intes-
 tines, to be propagated by contagion.   The  production of disease of
 the bowels in children by an impure and  confined atmosphere, parti-
 cularly when combined with  a neglect of personal  cleanliness,  and
 unwholesome diet,  has been too much overlooked.  We have known
 nearly all the children of a family or neighbourhood, to become affected
 from this cause, with some of the  worst forms of intestinal inflamma-
 tion, accompanied with the phenomena ascribed to the low or typhoid
 remittent fever, the progress of which could only be stayed by removal
 from the infected air in which it was generated, by an improved diet,
 and a strict enforcement of cleanliness of  person and clothing.  It is
                                18 
274
DISEASES  OF CHILDREN.
no doubt under such circumstances that the fever has  been reputed
contagious: in  a strict  sense, however,  we  do not  believe that the
disease is ever propagated by contagion.
  The treatment of infantile remittent fever will be readily understood
from what  has been advanced in relation to its pathology. Dependent
for its production and continuance upon inflammation more or less ex-
tensive, and of an acute, subacute, or chronic character of the mucous
membrane  of the alimentary canal—it is to the removal of this inflam-
mation that our remedies must be directed ;  and just in  proportion as
they are adapted to effect this object, will be our success in the cure
of the disease.
  A proper regulation of the patient's diet is  all-important.  In the
more recent and acute cases, every species of food should be withheld;
the child may be allowed, however,  some cold mucilaginous  fluid as a
drink—any of those directed in gastro-enteric inflammation will  be
proper—but even of these, the patient should not be allowed such quan-
tities as to  unduly distend the stomach; this is particularly necessary,
if the case  be attended with symptoms of gastric disease. In the more
protracted  and chronic forms of the fever, in addition to the  mucilagi-
nous drinks, a moderate portion of  some plain farinaceous food, with
or without  the addition of milk, may  be allowed, at  proper  intervals.
Occasionally, in very chronic cases, we have found beef tea, chicken
water, or plain mutton  broth with rice, to agree better with the sto-
mach, and  to produce a less amount of irritation than farinaceous pre-
parations.  On this point, of course, the judgment of the physician,
guided by a knowledge of the pathology of the disease,  and  the parti-
cular circumstances of each case, must be exercised.  The only gene-
ral rule  that can be given is, to  prohibit every article of diet of a sti-
mulating or indigestible character, as well as all  solid food; and not
to allow even that which is proper, to be  given at improper  hours, or
in too great quantity.
  In recent cases, the treatment may be commenced by the adminis-
tration of a full dose of calomel, with  magnesia, (five grains  of each,)
which should be followed, in the course of a fewr hours, by an appro-
priate dose of castor oil, or a simple laxative enema.   This will gene-
rally bring  away a large amount of undigested  matter and vitiated
secretions,  with a manifest improvement in the condition of the patient. *
As to the propriety of repeating the purgative, this will  depend upon
the particular circumstances of the  case.  If the attack has  been evi-
dently the result of  excess in eating, or improper food, the evacuation
of the undigested matter with which the intestines are, in such cases,
often loaded, and which is a constant source of irritation to the mu-
cous membrane, is all-important; if, therefore, pretty free discharges
have not been produced by  the first purgative, an additional dose of
castor oil,  or of magnesia and rhubarb, may be given on the succeed-
ing day.
  The repeated administration  of active purgatives, so  generally re-
commended  in  this disease, and their continuance from day to day,
until healthy stools are procured, is founded  upon incorrect views of
the pathology of the disease, and is  rather calculated to augment than 
THE REMITTENT FEVER  OF INFANCY.
275
to remove its more prominent and dangerous symptoms.  We  are
persuaded, however, that the administration, at short intervals, of alte-
rative doses of calomel, combined with chalk and ipecacuanha, is a
good practice in infantile remittent fever.   Calomel in this form and
combination, keeps up a gentle laxative action upon the bowels;  while
under its use the discharges become more natural in appearance, the
skin softer, the tongue more moist and clean, the pulse slower and
more developed, the exacerbations shorter, and the remissions  more
perfect.  In the more protracted and chronic cases, we  are accus-
tomed to add to each dose a small portion of extract of hyoscyamus,
which has the advantage of allaying irritation  without binding  the
bowels.
   In every case in which the exacerbations of fever are marked by
symptoms of any degree of intensity, the abstraction  of a few ounces
of blood from the arm, in children over five years of age,  will  be ad-
visable ;  or leeches may be applied to the abdomen, in numbers pro-
portioned to the violence of the symptoms and age of the patient.  The
application of leeches will be demanded whenever there is pain or ten-
derness upon pressure, with tension and heat of the abdomen;  when
well timed, and in sufficient numbers to reduce the local inflammation,
they are  the remedy upon which most dependence is  to be placed in
the treatment of these  cases.   Even  in the protracted and chronic
forms of the disease, pain, heat, and tension in the epigastric, umbili-
cal, or hypogastric regions, or in either hypochondrium, should be the
signal for their application, in numbers  adapted to the-circumstances
of each case.   From the fact that the disease is  one attended with so
much exhaustion, and liable to be protracted, the abstraction of any
amount of blood  has been condemned by many; but an active treat-
ment, judiciously pursued in its  early stage,  and  in its more  acute
forms, is  unquestionably the best adapted speedily to  arrest the  dis-
ease, and prevent the exhaustion consequent upon its more protracted
forms.   The  intermissions  will  usually become more distinct, the
tongue moister, the skin softer and more pliable, and the evacuations
more regular and natural, after the local abstraction of blood;  and at
a later period, when the indications for its use are present, it is often
followed by an improvement in  the pulse, the  skin, and in the ap-
pearance of the stools, the very reverse of those from increased de-
pression.
   It has been suggested by Dr. Eberle, and with a good deal of plau-
sibility, that the intestinal torpor that  so  frequently exists  in the  dis-
ease, is often the result  of hyperaemia of the brain; and hence it is
that an efficient abstraction of blood  almost always increases the sus-
ceptibility of the bowels to the action of mild aperients.
   In every instance the  tepid or warm bath is, as in  the case of gas-
tro-intestinal inflammations generally, a very valuable remedy.  When
the skin is hot and parched, sponging  the entire surface frequently
with tepid water, will often produce a pleasant coolness and moisture,
and relieve entirely the restlessness of the patient.  In the  intervals of
the paroxysms, as well as in those cases in which the temperature of
the surface is not increased or is reduced, the warm bath by immersion 
276
DISEASES  OF CHILDREN.
should be preferred.  Fomentations to the abdomen, or warm emol-
lient cataplasms, perseveringly employed, as well as warm or sinapised
pediluvia, especially when there is a tendency to coldness of the ex-
tremities, or to irritation of the brain, will always be found to produce
a decidedly beneficial effect.   In protracted or chronic cases, blisters
to the abdomen, as directed in enteritis, will be proper, and, in general,
are followed by a marked improvement in the condition of the bowels.
   When delirium, increased heat of the head, aversion from light, an
injected state of the eyes, or stupor ensues, a few leeches  may be ap-
plied behind the  ears, and cold washes  or lotions to the scalp, while at
the same time, stimulating  pediluvia or frictions to  the lower extre-
mities are employed.   Cough, and hurried laborious  respiration, will
demand  mucilaginous  drinks, blisters to the thorax, and if the symp-
toms of bronchial inflammation are distinctly marked, and of any de-
gree of severity, leeches should be applied about the clavicles.  In these
cases, small doses  of calomel, ipecacuanha, digitalis, and extract of
hyoscyamus will be found a useful remedy.*
                * R.—Calomel, gr. iij. ad iv.
                    Ipecac, pulv. gr. iij.
                    Digitalis pulv. gr. iij. ad iv.
                    Ext. hyoscyami, gr. iv. ad viij.—M. f. chart. No. xij.
                One to be given every three hours.

   In the chronic forms of infantile remittent fever, attended with tym-
panitis,  and vitiated, mucous, or dark offensive discharges, one of the
remedies from which we have derived the  most decidedly  beneficial
effects is the spirits  of turpentine; it may be given in doses of from ten
to fifteen drops, three  or four times daily, in a  little sugar,  or in the
form of a mixture, as recommended in  cases of chronic diarrhoea.  It
has not  only the effect  of exciting the  bowels to contract and  expel
the gas  by which they are  distended, but it generally exerts a benefi-
cial influence  upon the morbid state of the intestinal mucous mem-
brane, allaying irritation, and producing a decided improvement in the
excretions.  We have employed this  remedy very extensively, in  all
the chronic affections of the bowels in  children, and have always had
occasion to be pleased  with its operation.
   If there be  evidences of serous effusion within  the abdomen, with
scanty secretion of urine, the same treatment should be pursued as di-
rected in cases of chronic peritonitis.
   The treatment of cases attended with enlargement of the mesenteric
glands, differs in nothing from that already laid down.   As soon, how-
ever, as the symptoms of intestinal inflammation are reduced, the ad-
ministration of some of the milder preparations of iodine may be en-
tered upon, with the inunction of the same, in  the form of ointment,
about the groins and over the surface of the abdomen; the hydriodate
of potassa, is the preparation we have generally employed, and occa-
sionally with very great advantage.
   In all cases, after the symptoms of the disease  have subsided, the
discharges from the bowels have become more regular and healthy in
appearance, and the tongue cleaner and more  moist, some light bitter,
as a weak infusion of cinchona or calomba, may be given, in combi- 
          DISEASES OF THE RESPIRATORY ORGANS.       277

nation with the sulphuric or hydrochloric acids, and, as convalescence
advances, the  sulphate of quinia, the tincture of the sesquichloride or
the persesquinitrate of iron; the bowels, at the same time, being kept
regularly open by gentle aperients, and the diet slowly and cautiously
improved.  By this course, aided by the tepid or warm bath, daily re-
peated, and  followed  by friction of the surface, the  functions of the
digestive organs will be very rapidly improved, and the strength of the
patient promptly restored.  As soon as  the patient is able to bear it,
gentle exercise in the open air, at first  passive, and subsequently of a
more active kind, will confirm the cure.  When the  case has been of
a  protracted  character, change of air will often produce the  most
beneficial effects.
   Great  caution, however, must be observed,  not to commence too
early upon the use of tonics, or to improve too rapidly the diet of the
patient.  During the stage of convalescence the  utmost circumspection
should be observed, as well in  regard to the quantity, as to the quality
of the food  that is allowed.  A slight excess, a premature indulgence
in solid food, or the use of that which is indigestible, or which has any
tendency to oppress the stomach, will endanger  a serious relapse.  The
surface of the body should be  carefully guarded from the impression
of cold or damp, by appropriate clothing, and due precaution; and the
proper temperature, dryness,  and purity of the air of the  apartment
occupied by the convalescent, should be maintained by due ventilation,
and by artificial heat when necessary.
                       SECTION  II.

          DISEASES OF THE RESPIRATORY ORGANS.

                          1. —Asphyxia. +rf<i'J<'+*+-*»" -#^^/fcy>^"

  Cases of still-born infants are very common: and although  it may
not be strictly correct to say that the infant is, in such cases, invariably
in a state of asphyxia, yet the term seems as little exceptionable as any
other, provided proper attention be  paid  to the cause by which the
establishment of the respiratory function is prevented.  This may, in
some cases, arise either  from the imperfect  development or  malfor-
mation of the heart and  circulatory organs, of the lungs and respi-
ratory apparatus, or of some portion of the nervous system; or from
the extinction of life in  the foetus, previous to, or during parturition,
either from  congenital disease, or from injuries  inflicted upon it in
its passage through the pelvis.  In all these cases, as well as in those
in which the powers of life in the foetus are too feeble to  carry on the
functions  of  the organism in the independent state of existence, no
hopes can be entertained of resuscitation being effected or the dura-
tion  of life prolonged, by any course of treatment.  But, in a large
proportion of the cases  in which  the infant is apparently dead-born,
there is merely a suspension of the respiratory function, and by proper 
278
DISEASES OF CHILDREN.
means, persevered  in for a sufficient length of time, complete resusci-
tation may be effected.*
  The most common causes of asphyxia in new-born infants, are:
tedious  and  protracted  labour, from defective  uterine  efforts,  from
rigidity of the os uteri, or from a disproportion between the size of the
foetal head and the dimensions  of  the pelvis; the cord being twisted
around the neck of the infant, or around some other part of  its  body;
the cord, from its prolapsus, being subjected to pressure  between the
head of the infant and the walls of the pelvis; the placenta becoming
partially or entirely detached before the expulsion  of the infant; the
os uteri or  the constrictor muscle  of the vagina being spasmodically
contracted around  the neck of the infant, as is apt  to occur  in a  first
labour, particularly when ergot is injudiciously administered  to expe-
dite  delivery; the  infant being born with the face  invested with the
membranes; the mouth and fauces being filled with viscid mucus, or,
as sometimes happens, the  tongue  falling backwards, and closing up
the fauces; or, finally, the infant being exceedingly feeble and exhausted.
Asphyxia is likewise observed  in  cases of very rapid delivery, when
the infant is protruded by a quick succession of severe  uterine con-
tractions.
  Asphyxia in  new-born infants  may  occur  after birth, and even
after the  infant  has breathed and  uttered some feeble  cries,  when,
from the ignorance, or the wilful neglect  of the practitioner or atten-
dants, the necessary means are  not adopted for the  preservation of its
life;  and occasionally, from causes the nature and operation of which
it is  very difficult to understand.
  In some  cases of asphyxia,  the  infant, when born, is pallid, with
open and flaccid mouth, relaxed limbs, and with  only a feeble, obscure
pulsation, sometimes none at  all, at the heart or in  the cord; in other
cases the  face is swollen, livid or purple, with or without pulsation of
the foetal heart  or of the cord; occasionally,  however, the cord  is
tense and pulsates  strongly, while  the pulsation at  the heart is slow
atoalffeeble.  » v j* *  . .    „«,
  The state of  asphyxia may be more or less  complete.  The foetus
may neither cry nor respire, and present no appreciable motion of the
umbilical  arteries or heart, being, to  all appearances, actually dead;
or, while no  effort at  respiration occurs, the heart  and cord may
pulsate with more or less vigour, while, again, a few ineffectual respi-
ratory efforts may be made, or  even  faint cries may  be  uttered, and
then a complete state of asphyxia ensue.
  All the causes to which  the asphyxia of new-born  infants is  to be
immediately referred, have not  been investigated with sufficient accu-
racy.  Some are, it is true, very evident, being causes which directly
impede  the  passage of the air  into  the lungs, as the existence of a
  * In the 10 years preceding 1845, of the 81,324 children born, 3,679, or about 4-5, were
dead.  How many of these latter were premature births, or to what particular cause the
death of the foetus was owing, we have no means of ascertaining.  The law requires that
in every instance in which the foetus has arrived at the term of six months, or at the ter-
mination of the full period of utero-gestation, and is born dead, it shall be reported as a case
of still-birth. 
           DISEASES OF THE RESPIRATORY  ORGANS.       279

 quantity of thick, tenacious mucus in the mouth, fauces  or windpipe;
 or which  prevent the dilatation of the chest and  other respiratory
 movements, by suspending innervation—as an apoplectic condition  of
 the brain.   In those cases, however, of not unfrequent occurrence, in
 which there exists no impediment to the passage  of  air into the lungs,
 and no undue distension of the vessels of the brain, it  is  difficult  to
 assign  the real cause for the non-establishment of respiration. Some
 have supposed the asphyxia, in  these cases,  to arise from a  state  of
 extreme debility; others  from anaemia, or from  the functions of the
 placenta having become suspended a short time  previous to delivery,
 by which the  condition of the blood is so changed, that it can no longer
 produce that  degree of  stimulation  of  the brain and other  organs,
 which  is essential to the proper performance of their functions, and
 which must necessarily cause the death of the infant, unless respiration
 be promptly established  by artificial  means,  and the due vitalization
 of the  blood  is  in this  manner  effected.  This  latter,  which is the
 opinion of Velpeau, seems to us the most plausible.
   When a new-born infant opens its eyes, moves its limbs, and  exhibits
 a few imperfect respiratory efforts, a  smart slap upon the buttocks,  or
 a few drops of cold water sprinkled upon the chest and abdomen, will
 very generally cause it instantly to breathe, and to cry out lustily.
   In all cases, immediate attention should  be  paid to remove at once,
 any viscid mucus which  may exist in  the mouth and throat.  This
 may be readily done with the  finger, surrounded with a  piece of soft
 linen.  The infant should  be subsequently placed upon its side,  in such
 a position that if any of the mucus remains it  may flow from the
 mouth, at the  same time that its entrance into the  trachea is prevented.
 The practice  of turning  the child upon its face,  slapping it between
 the shoulders, and gently shaking it, as recommended by  a few highly
 respectable writers, " with the view of disengaging any mucus that
 may be lodged in  the trachea," is one  that we cannot believe to be
 either safe or  useful.
   In all cases in which the asphyxia is unaccompanied with symptoms
 of cerebral congestion—a puffy  and dark  purple or livid appearance
 of the face—it is not proper to tie the umbilical cord,  until its pulsation
 has ceased, or has become quite  feeble.  The premature application
 of a ligature to the cord has, we believe, in  many  instances, given rise
 to asphyxia.
   The dashing of a little cold water or spirits,  upon the  chest and
 abdomen, will, in many cases of simple asphyxia,  almost  immediately
 excite the  respiratory action,—with loud and vigorous cries,—when
 the cord may  be divided, and the  infant  suffered to remain quiet, until
 its strength is, in some degree, recruited.
   The plan pursued by Velpeau, in imitation of Desormeaux, is a very
excellent means of rousing the infant from a state  of asphyxia.  A
portion of  some spirituous liquor being held for a moment or  two in
the mouth, is then spirted with force, in the  form of a douche, upon the
breast of the child.
   Immersion in the warm bath is  often a very  successful  means of re-
suscitation  in cases of asphyxia.  The use of the warm bath in these 
280                DISEASES OF CHILDREN.
cases, however, requires some little management, to derive from it any
advantage.  The object of the bath is to excite the action of the heart
and respiratory muscles;  if, however, within  a very short time after
immersion, neither respiration nor circulation ensues, the child should
be taken out,  as the  effect  of  the bath is then decidedly injurious.
Even when  respiration is  produced, as it often will be, by the action
of the bath, the immersion should not be continued over a few minutes;
a prolonged continuance in the bath would, by raising the temperature
of the infant, render it less capable of enduring the state of asphyxia,
and would also prevent the access of  the atmospheric air to the  sur-
face of the body, which  always exerts a very powerful vivifying influ-
ence.   When the child is removed from the bath, gentle friction should
be applied to the surface of its body with a warm dry flannel cloth.
  Cold affusion has been resorted to, in cases of asphyxia in new-born
infants, and there is no doubt, when it is judiciously managed, it may
often prove a  very powerful and successful means of resuscitation. In
two cases, related by Dr. Patterson, of Dublin, in which the infant was
placed in a tub, and three quarts of water, at  a temperature of about
60°, were twice dashed  over it, strong friction being at the same time
applied to the parietes of the  chest, active respiration was  quickly
established; the  infant was then removed from the tub, well dried, and
wrapt in flannel; in  both  cases, an entire recovery was effected.
  But of all the means that have been employed in  the asphyxia of
infants, inflation of the  lungs is the  one upon which, experience  has
taught us, the  most confidence is to be placed, if early resorted to, judi-
ciously practised, and persevered in for a sufficient length of time.
  In inflating  the lungs, the  mouth of the operator  should  be  applied
to the  mouth of the  infant, the latter being first covered with a  silk
handkerchief,  or soft  napkin; its nostrils should be  closed with one of
his hands, while the other is applied upon its thorax.  By a moderate,
but uniform force of insufflation, the lungs will be very readily filled
with air, when  the mouth of the operator is  to be  withdrawn, and
gentle pressure made upon the chest,  so as to expel the  air by which
the lungs of the infant have  been inflated; in this manner, artificial re-
spiration should be kept up for some time.   If the cord be examined,
at a short distance from the abdomen, it will be often found to pulsate
soon after the commencement of the operation, or the heart  may be
felt to beat  beneath  the ribs.  The first symptom of returning life is,
generally, a tremulous  motion of the respiratory organs; the infant
next makes a  feeble attempt to inspire, and the cheeks  begin to  redden;
when  these marks of returning life are observed, if the inflation be
suspended, the infant will frequently be  found  to  make a spontaneous
effort at respiration;  a deep sigh  is the first breath it draws, and in  a
few seconds it breathes again.   Now, if on suspending the artificial
respiration, the heart continues to beat vigorously, the cord to pulsate,
and the respiration to increase in frequency and depth, it need not be
resumed ;  but should the pulsation stop in the heart and  cord, and
the respiration cease, or become more feeble, it must then be imme-
diately resumed, and  this repeatedly, as the case requires—at one time,
the natural powers of the infant to carry on respiration being tested, at 
           DISEASES OF THE RESPIRATORY ORGANS.       281

 another, the  respiration being supported by artificial means.  As the
 efforts at spontaneous respiration increase, ammonia, or cologne water
 rubbed upon the hand, and held over the mouth of the infant during in-
 spiration, will materially assist the recovery, and  has a better effect
 than introduding stimulants into the stomach.  A few smart slaps on
 the gluteal muscles, will now generally complete the recovery.
   In favour of the efficacy of artificial respiration, in cases of asphyxia
 occurring at or soon after birth, we have the most incontestable  testi-
 mony.   Blundell trusted to it alone, with  the aid of the warm bath.
 Toogood declares that he never found any other means necessary, and
 believes that, if actively employed, and steadily persevered in, it will,
 in the majority of cases, be successful.  We may add our  own expe-
 rience, which is decidedly in  favour of this  means of resuscitation.
 But it must, to be generally successful, be  persevered in until the na-
 tural action of  the  respiratory organs is fully established, or until  the
 recovery of the infant is showrn to be impossible, by unequivocal signs.
 Toogood continued it for forty-five  minutes, in several cases, before
 respiration was fully established; and in a communication of Sir James
 Eyre, in the London Medical Gazette, March, 1840, a case is referred
 to in which the artificial means were persevered in, for from  thirty to
 forty minutes, and to two cases in  which they were continued by Mr.
 Terry of Northampton—in  one for one hour and a half, and in the
 other for two hours ana} a half.
   Blundell recommends artificial respiration to be practised by means
 of a tube introduced into the trachea.  We have never had any diffi-
 culty in effecting it  by the mouth alone; this is  also the experience of
 Mr. Toogood; and  in the communication of Sir James Eyre, already
 referred to, he remarks, "I uniformly inflate with my own  breath; in
 this matter, I perfectly agree with Dr. Cape, in a sensible letter of his,
 which appeared in the Medical Gazette, of  October 7, 1837."
   In the cases of suspended animation, occurring in new-born  infants,
 from a congested state of the brain, a somewhat different practice is
 to be pursued.   This form of asphyxia is  usually  met with in large,
 robust, plethoric  infants, after tedious and  difficult labours, where the
 child has remained  for several hours under  the direct influence of the
 uterine contractions, subsequent to  the discharge of the waters; where
 a loop of the cord strictures the neck or thorax; or where the cord is
 itself compressed by any means during labour.  Its immediate cause
 is  the engorgement  or compression of the brain; though in  all proba-
 bility it may also frequently result, like the preceding variety, from the
 want of a proper revivification of the  blood.  It  is, in  many cases,
 produced by  the too early and injudicious use of ergot.
   In the apoplectic  form of asphyxia, the countenance, with often the
 scalp and neck, presents a  dark red or livid, and bloated appearance,
the lips are swollen  and purple,  the eyes prominent, and the surface of
the body warm, red, and somewhat tense.
   When an infant is born in this condition, no time is to be lost.  The
umbilical cord should be immediately divided, and more or  less blood,
according to  circumstances, allowed to flow from it.  If the pulsation
in  the cord has  not  already ceased, as the blood flows from  its cut ex- 
282
DISEASES  OF CHILDREN.
 tremity, yery generally, the lividity and turgid state of the face and
 neck will  disappear, and respiration be very promptly established.
 When the pulsation of the cord  is  slow and  feeble, inflation of the
 lungs  should be resorted to, in addition to the abstraction of blood.
 1 he infant may, at the same time, be  immersed in a warm bath to the
 hips, while cold water is applied to its scalp.
 .. *n !nose cases m which the child is born without any indications of
 life—its  face swollen and livid, its body flaccid, and no pulsation is
 perceptible in the cord, or at the heart—notwithstanding there is  but
 little hope that  resuscitation can be effected, it is nevertheless proper
 that suitable  efforts should be made for the establishment of respiration.
   We are in no instance  hastily to  pronounce success  impossible.
  if"? t fcetUS' Dr' Blunde11  remarks, has  been  laid  aside  as  dead,
 which, by a diligent use of proper means might, in all probability, have
 been saved.
   In the cases  just referred to, it is seldom that a sufficient quantity of
 blood  can be procured from  the cord upon its  division.   We have
 often,  however, found the blood to commence flowing, when the infant
 is immersed in a warm bath, as  directed above, it head being at  the
 same time washed with  brandy and water, and its lungs properly in-
 flated.   It has  been suggested  by Dr. Eberle, with the  view of solicit-
 ing the flow  of  blood from the cord,  to cut the latter short, and apply
 over the navel a wide-mouthed cupping-glass, furnished with an  ex-
 hausting syringe.  It is supposed that by exhausting the cup, a flow of
 blood  may sometimes be obtained from the divided cord, even after
 the heart has ceased to act.   The suggestion is a  very plausible one,
 and  worth a trial.  When it  is impossible to  obtain blood from  the
 cord, Velpeau directs leeches  to be applied behind each ear.
   It often happens, that after we have succeeded  in establishing respi-
 ration, the infant remains for  many hours in a feeble condition;  the
 slightest fatigue or agitation being sufficient to extinguish life.  It is
 of the  utmost importance, therefore, in all cases in which resuscitation
 has been effected,  that the  infant be  allowed  to remain upon the bed
 properly wrapped up, in  a  state of perfect repose, for several hours
 before any attempt is made  to dress it.

                           2.—Coryza.
  The simple catarrh, or inflammation of the  mucous membrane of
 the nares, occurring in infants, has received  various appellations.  It is
 usually described, however, by writers on the diseases of children,
 under the denomination of coryza, gravedo, or snuffles, to which, occa-
 sionally,  the  terms  malignant  or morbid, have been added, to distin-
 guish the more  aggravated form of the disease, or that in which  the
 Schneiderian membrane is affected with diphtheritic or exudative  in-
flammation.
  The disease, though always  troublesome, is in  many cases of little
importance, disappearing  spontaneously after  a few days; while in
other instances,  it is productive of considerable suffering and danger.
The  younger the infant is,  in whom  it occurs, the more severe and
dangerous it in  general proves. 
           DISEASES OF  THE RESPIRATORY ORGANS.       283

   The  mucous  membrane of the  nares  is particularly susceptible  of
 irritation in the  early period of life; and inflammation is excited in it
 often by very slight causes.   It is not uncommon to  hear  an infant
 sneeze soon after birth, or even immediately on the air coming in con-
 tact with the membrane.  There  often occurs, also, at a very early
 period, an abundant secretion of mucus,  which, in some infants, flows
 constantly from the nose, apparently without  being  attended  by any
 degree of inflammation.
   Coryza may be simple, or complicated with the more or less rapid
 formation of a pellicular exudation throughout the whole extent of the
 nasal fossae; or, it may assume a chronic character, and occasion the
 death of the patient, by the disorganization which ensues.
   The  first indication of the  disease is  frequent sneezing;  the inner
 surface of the nostrils soon after becomes red, dry,  and swollen, and
 the cry of the infant is  altered, from the impediment to the free pas-
 sage o"f  the air  through the nose; a watery, or thin  muculent fluid
 soon begins to  flow from the nostrils;  in a short time the discharge
 assumes a thick, white, opaque appearance, subsequently changing to
 a yellow, and becoming finally purulent, exhaling frequently a pecu-
 liar foetid odour.  The child sleeps with  its  mouth open;  the respira-
 tion  is difficult  and  noisy; and instead of the usual rale,  a whistling
 sound occurs in the  nasal fossae;  this becomes greater, and the diffi-
 culty of  respiration increases, in proportion as the discharge from the
 nose becomes thicker and more abundant;  the nose becomes  red ex-
 ternally, and somewhat swollen, while the central portion of the upper
 lip, constantly irritated  by the  discharges from  the nostrils, becomes
 frequently red,  swollen, and  excoriated.   Often it is covered with a
 false membrane.
  In severe cases, the  child  experiences great  difficulty  in sucking,
 from its inability to breathe  through the nose; and as the discharge,
 by drying at the orifices of the nostrils, often completely closes them,
 every attempt to take the breast is  attended with the utmost anxiety;
 the countenance of the infant becomes flushed, and  it  is  obliged, in-
 stantly to quit the nipple, to prevent suffocation.  Its  restlessness and
 cries, as  well as  the expression of its face, indicate the utmost distress
 and suffering; which are increased by its  sense of hunger, and the im-
 possibility it experiences of satisfying it.
  Worn down by fatigue, pain, and deficient nourishment, the  infant
 may perish from inanition; or, the brain  becoming affected, extreme
 prostration and drowsiness may ensue, and sooner  or later terminate
 in death; or death may be preceded by convulsions or acute  menin-
 gitis,  quickly terminating in  effusion.   In  the  more  prolonged, or
 chronic form of  the disease, the mucous membrane of the  nares may
 become softened and destroyed, or the seat of an extensive, ill-condi-
tioned ulceration.
  The difficulty  of respiration in  coryza, is  always greatest in those
cases in which the inflammation of the nasal mucous membrane gives
rise to a pseudo-membranous exudation; in such cases, also, the ton-
sils and fauces occasionally present a swollen and dark red appearance, 
284
DISEASES  OF CHILDREN.
their surface being covered with ash-coloured specks, terminating, in
some cases, in extensive ulcerations.
  In violent cases, death may occur  in  three or four days, while in
other instances, the symptoms are mild from the commencement, the
inflammation  very rapidly abates, the secretion gradually lessens in
quantity  and  in  consistence,  the  respiration improves in  proportion,
and in  a  few days every symptom of the disease disappears.
  The danger is always in proportion to the degree of tumefaction of
the mucous membrane of the nares, and  the abundance and tenacity
of the excreted fluid. When the inflammation is slight, and the mucus
of the  nose is  only a little more abundant  and ropy than natural, the
difficulty of respiration is  but slight, and the infant  is able  to suck
without much  difficulty.  All other things being the same, coryza is,
as already remarked, always more serious and dangerous, in propor-
tion to the tender age of the patient.
  The appearances discovered after  death, in those who have fallen
victims to this disease, are, increased  redness, with  thickening and
softening of the mucous membrane throughout the whole extent of the
nasal fossae, the membranes being generally thickly coated with pus or
an opaque tenacious mucus.  In some cases, small patches of a pseudo-
membranous  exudation are scattered over its surface.   In other in-
stances, the exudation covers the whole interior surface of the nares,
and extends from the superior part of the glottis, upwards, towards the
sinus and cornua of the nose; the mucous membrane beneath, to which
it firmly adheres, being much tumefied, and of a vivid red colour;  soft-
ening  of the  mucous  membrane, and extensive  ulceration,  are fre-
quently present.   In chronic cases, various morbific affections of the
alimentary canal, lungs, and  brain, are frequently  met with.
   The disease, when it occurs as a primary affection, is usually the re-
sult of exposure to  a  cold or daieip atmosphere, or  of neglect in
changing the diaper and clothing of the infant, when these become wet
with the urine.  Billard enumerates, among its common causes, expo-
sure to a strong fire, and particularly to the light and heat of the solar
rays.  When  children  are taken out, he  remarks, for the benefit of
the air, on the return of spring, it is almost always observed, that they
sneeze, and are affected with a discharge from the nose.   We appre-
hend, however, that the exposure to an atmosphere many degrees colder
than that to which the  child has  been accustomed, has more to do in
the production of coryza in children, on their first being  taken out in
the spring, than the action of the sun's rays.
   In light attacks, little treatment is necessary beyond the avoidance
of the occasional causes of the disease, with proper clothing, and con-
finement to rooms of a warm, equable temperature.   The use of the
warm bath, daily, will  be proper, however, in most  cases, with the
occasional use of some mild aperient, as castor oil, or magnesia and
rhubarb.  In  more violent cases, the application of a few leeches to
the root of the nose, will be advisable, with some gentle  diaphoretic.8
In some instances we have found the administration  of a few grains
of calomel, followed by a dose of castor oil, highly advantageous.  A 
         DISEASES OF THE  RESPIRATORY  ORGANS.      285

small blister to the nape of the neck, will, also, often  produce very
considerable relief.
              a R.—Hydrochlor. ammonise, gr. xxvj. ad xlviij.
                   Pulv. ipecacuanha?, gr. ij.—iij.
                   Ext. Hyoscyami, gr. iij.—M. f. chart. No. xij.
       One to be given every three hours, mixed in a little sugar and water.

  The infant  should not be put to  the breast during the stoppage of
the nostrils, but the nurse's milk should be given with a spoon, or fresh
cow's milk, diluted with  barley or rice water, or with  rennet whey,
may be substituted.
   If, after the inflammation is reduced, there should be  formed any
pellicular concretions in the nasal fossae, Billard directs some fine calo-
mel, or a  mixture of sugar and alum finely powdered, to be gently
blown into the nostrils.
   In cases attended with pseudo-membranous exudation, the nitrate of
silver in  solution constitutes  the most efficacious local  application.
Five to ten or fifteen grains may be dissolved in an ounce of water,
and applied to the interior of the nostrils by means of  a camel's-hair
pencil, several times a day, according to the severity of the case.
   In chronic  cases, alterative doses of calomel, with ipecacuanha, pre-
pared chalk, and extract of hyoscyamus1 will, in general, if conjoined
with a proper diet, the  daily use of the warm  bath, and  some light
tonic, effect a cure.  A decoction of oak bark has been highly recom-
mended when the disease  continues for many weeks, and the infant
becomes pallid and very feeble.  Underwood states that it has at once
removed the snuffling, and  given vigour to the patient in the course of
a few days.  A  weak infusion of bark, the sulphate of quinia, or the
persesquinitrate of iron, will, however, in most cases be found a better
tonic than the oak bark.
                    ■ R.—Calomel, gr. iij.
                         Ipecac, pulv. gr. iij.
                         Cretan ppt. gr. xxxvj.
                         Ext. Hyoscyami, gr. iv.—M. f. chart. No. xij.
                    One to be given every three hours.

   When, in the course of the disease, symptoms of cerebral congestion
or irritation, or  convulsions occur,  these are to be combated by their
appropriate remedies—leeches behind the ears, or to the  temples, warm
sinapised pediluvia, cold applications to  the scalp, blisters to the n<fpe
of the neck, and purgative doses of calomel, followed by castor oil,
the sulphate of magnesia, or purgative enemata.
   During convalescence from the more  chronic cases,  the restoration
of the  patient's  strength is to be promoted by a well-regulated diet,
gentle daily exercise in the open air, and appropriate clothing.

                          I—Bronchitis.

   Bronchial  inflammation, varying  in extent and  intensity, is a very
common  disease throughout  every period of infancy and childhood.
Its leading symptoms are  cough, hoarseness, difficulty of respiration,
and more or less febrile excitement.   To these symptoms, in many 
286
DISEASES OF  CHILDREN.
cases,  are conjoined,  soreness  of the throat,  running at the  nose,
sneezing,  and a red and watery appearance of  the eyes.
   The disease, in general, commences with a  slight degree of chilli-
ness, or a complete chill, and some degree of languor, depression, and
drowsiness;  followed, after a short  period, by more or less febrile re-
action.   The patient,  if old  enough, now  complains  of dull, aching
pains in the  head, back, and  extremities; the pulse becomes frequent,
full, and  somewhat tense; the face  is slightly flushed ; the surface is
dry and   harsh,  but is seldom  much  increased  in temperature;  the
bowels are, in general, constipated, and the urine is small in quantity,
and high-coloured.  The eyes  are often  red and suffused, and a thin
transparent mucus is discharged from the nostrils, attended with frequent
sneezing.  Cough and some degree of hoarseness, with soreness or a sense
of roughness in the throat, are usually present from the commencement
of  the attack.  Frequently, however, the  cough is not developed until
the second or third day, and while its violence is always  in proportion
to the extent and intensity of the inflammation,  it generally becomes
more frequent and severe as the disease advances.  In some cases the
cough is  attended with pain of the thorax, or at the base of the sternum.
The respiration is, in general, more or less short, difficult, and oppressed
from  an  early period of the  attack, and is attended with a wheezing
or rattling sound, heard first in the throat, and extending,  subsequently,
over  the  upper portion,  and finally,  over the whole of the  chest.
The respiration in mild cases is  but little accelerated, but when the in-
flammation is intense and extended, it is always frequent, amounting
sometimes, to one hundred  in  a  minute;  the act of inspiration, in
severe cases, being attended with a dilatation of the  nostrils, and a
heaving motion of the chest.   The  respiration  becomes  always  more
frequent in the progress of the disease.
  During the first period of the  disease, the infant at the breast sucks
without much difficulty; but subsequently, although it seizes the nipple
with avidity, it cannot suck for more than ten or fifteen seconds, when
it will suddenly quit the breast, and throw its head backwards, and con-
tinue in this position for some time, even after the cough has produced
an expulsion  of mucus.
  The cough is at first dry, frequent, and distressing; but, in the course
of the  disease, is  attended with an  expectoration of mucus, at first
scanty, but subsequently, more free and copious.  The expectoration
consists, at first, of a thin, transparent sero-mucous fluid, or of a yel-
lowish frothy mucus, but subsequently of  masses of a viscid, opaque,
muco-purulent matter, of a yellowish or greenish colour.  In young
children, the matter brought up from the lungs is most generally swal-
lowed, or retained for some time in the throat.  In some few cases,
the matter expectorated is found to contain thin, white, soft fragments
of a membranous appearance.
  The difficulty of respiration is not uniform throughout the attack ;
the breathing being, occasionally, for a short period, tolerably easy,
and then  becoming suddenly extremely oppressed.  The  cough,  like-
wise, often occurs in occasional fits, at  irregular, and generally, short
intervals.   As the expectoration becomes more copious, each  fit  of 
          DISEASES OF  THE RESPIRATORY ORGANS.       287

coughing  is often  attended by a paroxysm  of suffocation, ending in
vomiting.
  The cough, difficulty of respiration,  and febrile excitement, gene-
rally  increase towards evening,  and in the commencement of the
disease, there is a distinct remission of the fever in the morning, though
usually of very short duration.
  Upon percussion at the commencement of the attack, the chest will
usually be found'sonorous  throughout; but at a later period, a circum-
scribed dulness may  often  be detected at some part.
  When the child is  old enough to  describe its sensations, a feeling of
weight, tightness, and soreness of  the chest is generally complained
of, but seldom any  positive pain.  When the paroxysms of cough are
severe, infants are  often known to scream, as if from pain, and the in-
spirations are, occasionally, suddenly arrested, and attended  with an
expression of suffering in the countenance, probably from an accom-
panying pleuritic inflammation.  The countenance in the milder cases,
does  not  exhibit any  particular change—the cheeks  are generally
slightly flushed ; in  the progress of the disease, however, the  eyes be-
come surrounded with  a  dark circle,  the  countenance  assumes an
anxious, suffering expression, and the nostrils are  dry  and crusted—
the lips are pale, but  at intervals acquire a violet hue, especially  after
a violent paroxysm of coughing.   Delirium occasionally occurs, par-
ticularly towards the close of the day, and at night.
  As the disease advances,  the  cough  and  difficulty  of respiration
increase; the physical signs, resulting from the impediment to the free
passage of the air through the bronchial ramifications,  in consequence
of the amount of mucus by which they are  filled, become extensive
and evident;  the child  is  unable  to assume the recumbent posture
without an increase of suffering; he becomes drowsy,  his  face ac-
quires a pale or livid hue,  and  the  expression of  his countenance  is
that  of the utmost  anxiety and distress.  Death  finally  occurs,  often
preceded by a state of complete coma, or by convulsions.
  In young children, a certain amount of drowsiness or stupor is pre-
sent  from the commencement of the attack, and by  preventing the
patient from  complaining or  coughing is apt to  mask  the disease  of
the chest, which is thus rendered peculiarly insidious and dangerous.
A close attention will, however, detect an augmented frequency in the
breathing, and on applying the ear  to the thorax, the universal rhonchi,
sibilant and mucous,  at once declare the true nature  of the case.
  The physical  signs of simple  acute bronchitis are,  in very young
subjects, a combination of mucous and sibilant rhonchi—slight, and of
short duration; in  older children these sounds are more decided and
continuous, with a  predominance of the mucous rhonchi. In cases of
greater intensity there is a combination of loud or  sibilant rhonchi and
mucous rhonchi.   In some cases the rhonchi are  sub-crepitant.
  In infants, the epigastrium and right hypochondrium  become,  occa-
sionally, tumid, tense, and tender upon pressure;  the discharges from
the bowels being, generally, small  in quantity, and  whitish  or  clay-
coloured at first, but subsequently containing a large amount of light
green or dark-coloured bile.   In  some cases, the  evacuations from 
288
DISEASES  OF CHILDREN.
 the bowels become thin and muddy or reddish,  and contain more or
 less mucous flocculi, the  abdomen,  at the same time, being greatly
 swollen and tympanitic.  This complication is evidently the result of
 gastro-enteric inflammation, attended with  an engorged  and torpid
 state of the liver.   It is to this form of bronchitis that  the term catar-
 rhal fever has been generally applied.
   In that form of bronchitis in which the inflammation extends to the
 more minute ramifications of the bronchi, giving rise, not unfrequently,
 to a pseudo-membranous exudation, constituting the capillary bronchi-
 tis of many writers, the general symptoms are of a much more severe
 character than in the simple acute form of the disease.  There is a
 greater degree of restlessness and  irritability; more  decided febrile
 symptoms, and a fuller and more frequent pulse.  The face is flushed,
 the  surface dry and hot,  the thirst urgent, and the appetite  entirely
 deficient.  The respiration  is short  and  quick,  the  cough  occurs  in
 frequent short  paroxysms, and is, occasionally, attended by  a decided
 stridulous or croupy  sound, and,  hence, the disease is denominated,
 by some authors, bronchial croup.   The cough is  not unfrequently
 painful, and, although, at  first, very generally dry, it is usually attend-
 ed, after a few days,  by an  expectoration of  a tough,  yellowish mat-
 ter,  and, occasionally, of fragments of a  pseudo-membranous appear-
 ance.
   If the disease is protracted, and increases in intensity, the respira-
 tions become still more oppressed, frequent and irregular, and attended
 with violent action of the alae nasi; the pulse increases  in  frequency
 and  becomes small and irregular.  The  face assumes  a leaden or a
 more or less decidedly livid hue, while the temperature of the entire
 surface of the body is reduced.  The paroxysms of coughing are fre-
 quent  and  distressing, and the  expectoration  scanty and difficult.
 The patient cannot assume the recumbent position without causing an
 increase of the difficulty of respiration.
   In the still more protracted cases, there occasionally occur irregular
 and  deceptive remissions  of the leading  symptoms, but,  finally, the
 difficulty of respiration augments, the pulse becomes almost impercep-
 tible, the countenance a peculiar anxious  expression—the extremities
 become cold—while the patient is in a constant state of jactitation or
 falls into a soporose condition, and death  very quickly ensues.
   The duration of capillary bronchitis is  various.  When severe, and
 occurring in very young infants, it may terminate fatally within a few
 hours.   In children at the breast its usual duration is from two to six
 days; in older children it may continue from one to three weeks.
   Bronchitis in children is not unfrequently  complicated  with pneu-
 monia, giving rise to hepatization, to a greater or less  extent, of the
 lower and posterior portions of the lungs.  This is, in  fact,  the ordi-
nary form of lobular pneumonia, as it  occurs in children under two
years of age; it is a common complication of the bronchitis incident
to the acute exanthemata,  and to hooping cough.  In a very interest-
ing paper by Dr. West, of London, on  the pneumonia  of infants, he
remarks, that the evidences of bronchial inflammation are very com- 
          DISEASES OF THE RESPIRATORY ORGANS.       289

monly met with in children who have fallen victims  to lobular pneu-
monia, especially where the latter supervenes upon pertussis.
  Rilliet and Barthez state that the  anatomical characters of acute
bronchitis are rarely met with in children under five years of age, with-
out at the same time traces of pneumonia being present—the latter
being sometimes a  secondary, at others a primitive or concomitant
disease.  Hence the value of the sub-crepitant rhonchus, as a diagnostic
sign of bronchitis, differs with the age of the child.  If, in those under
five years of age, the sound is heard on one or both sides of the chest,
there is danger that the bronchitis  is  complicated  with pneumonia—
whilst, in older children,  there is less probability that such is the case,
though from the tendency even then to lobular pneumonia, its presence
may still be suspected.  When the crepitant rhonchus is heard, Rilliet
and  Barthez have invariably found, with one exception, that  portions
of the lungs were affected with pneumonia.
   The bronchitis of children occasionally assumes a  chronic form, at-
tended with copious perspirations  and hectic fever, the exacerbations
occurring in the evening, when its  symptoms closely resemble those
of phthisis.
   A very common and dangerous form of bronchitis, which is referred
by Mackintosh to a subacute inflammation of the bronchial mucous
membrane throughout both lungs, is of common occurrence in yonng
children.  The cough and dyspnoea are but slight, and attract but little
attention, so long as the expectoration is free, and the excreted matter
is discharged with ease ;  but if, from any cause, the secretion of mucus
in the bronchi  is increased, and the cough arrested, speedy death
from suffocation inevitably results, unless the air-passages can be freed
from the accumulated mucus, by the administration of an emetic. An
unfavourable change in these cases  is  often produced by  exposure to
cold.  This form of the disease we have repeatedly met with;  it is one
often neglected by parents in its early stage, and even the practitioner
will  be apt to be misled in his prognosis in regard to it, unless  he early
makes himself acquainted w7ith its true character, by an attention to the
physical signs to be derived from a careful examination of the chest.
  The prognosis in cases of bronchitis is to be  drawn from a careful
estimate of the general and local symptoms; the age  and condition of
the child in  whom it occurs, and  the hygienic  circumstances  under
which it is placed.  In many cases  the disease is of little intensity  or
extent, and readily cedes to an appropriate treatment.  In attacks  of
greater intensity, however,  the disease is often more  protracted—
even when the termination is favourable.  The respiration  becoming
less frequent and laborious ;  the febrile symptoms  abating;  the skin
becoming softer and moist;  the cough less frequent, prolonged, and
suffocative, and attended  with a free expectoration, are the general in-
dications of the decline of the disease.  The occurrence  of  convul-
sions, and of great somnolency or drowsiness, with increased difficulty
of respiration, accompanied with a feeling of suffocation, and with livi-
dity of the cheeks and lips, and coldness of the extremities, are all un-
favourable symptoms, that are but too generally quickly followed by a
fatal termination.
                               19 
290
DISEASES  OF CHILDREM.
  From the facility with which the inflammation extends to the whole
of the  bronchial tubes,  even to the  minutest  ramifications, and  the
danger of  its  becoming complicated with pneumonia, bronchitis is
always to be considered a serious affection, which requires to be care-
fully watched  and promptly treated.   Capillary Bronchitis,  or that
form of the disease in which, from the commencement of the attack,
the entire extent of the bronchi are inflamed, even to their smallest
ramifications, is invariably attended  with very  considerable  danger.
When there is  intense fever, great acceleration of the respiration, and
severe dyspnoea, with a copious purulent or pseudo-membranous secre-
tion, it is an extremely unmanageable affection.  Under such circum-
stances, according to the experience  of MM. Rilliet and Barthez, as
well as that of M. Fauvel, its termination is very generally in  death.
  The appearances  discovered after  death  from bronchitis, are a
bright redness  of the bronchial  mucous membrane, either in patches,
and  partial in extent, or more diffused, and  of  a  brownish or  violet
shade, with more or less thickening and roughness of  the membrane,
and occasionally softening.  The bronchial ramifications are generally
filled with a quantity of frothy viscid mucus, sometimes transparent, at
others  opaque  and yellow, and occasionally  sanguinolent, or with a
muco-purulent fluid, the presence of which, by preventing the escape
of the  air  from the lungs, is the reason why these, in many cases of
bronchitis,  do not collapse when the thorax is opened.
  In some cases, the more minute ramifications of the bronchi are lined
with a pseudo-membranous concretion, very soft, and slightly adherent;
of a white colour, and  of variable thickness.  This occurs in some
cases, only at certain portions of the bronchial tubes, while in others
it occupies  the whole of the  bronchial ramifications.  Beneath these
membranous concretions, the mucous membrane is occasionally firm,
and remarkably pale, at other times it is red, softened, and rugous.
  It is in the bronchi of the inferior lobes that the fluid products of in-
flammation are ordinarily  most abundant.
  The bronchi are in many cases dilated, either in some portion of their
branches, or at their extremities.  The dilatation is occasionally very
considerable.
  When the bronchi are dilated at their extremities, a section of the
lung presents an areolated surface, formed by the presence of  a num-
ber of small rounded cavities, communicating with each other, and
with the bronchi of which they appear to  be the continuation.   The
most part  of these cavities are central, some of them, however, exist
at the surface of the lungs, and are formed by the pleura, lined by the
thinned membranes of the dilated bronchi.  These produce upon the
exterior of the lung slight rounded transparent projections, which  col-
lapse when punctured,  and  simulate  emphysema.   The interior of
these cavities contain the same fluid as is found  in the bronchi; their
parietes are smooth and thin, and they are lined by a continuation of
the lining membrane of the bronchi.
   In cases of vesicular bronchitis, the  lungs are flaccid  and soft at their
surface, and more  or less shrunken, according to the extent of the  dis-
ease.  A section presents a large number of granulations, about  the 
          DISEASES OF THE RESPIRATORY  ORGANS.        291

size of a millet seed, of a grayish colour, inclining slightly to yellow.
These  may  at first view be readily mistaken for miliary tubercles;
from these they are readily distinguished by their giving discharge to
a drop  of purulent liquid, and becoming immediately effaced, when
punctured by the point of the  scalpel, leaving in their centre a small
depressed point,  which  is  sometimes,  however, difficult  to  detect.
Often a very narrow canal  with  smooth parietes may be  traced for
some lines, being no doubt a small  bronchial tube, the termination of
which  is at the central depression of the granulation.
  In these cases  it is probable that the inflammation is seated only in
the extremities of the bronchial tubes, and that  a certain  number of
pulmonary vesicles, separately inflamed, have  become filled with  a
puriform fluid  and dilated, without the surrounding cellular tissue being
involved in the disease.
- If several neighbouring vesicles become inflamed, the inflammation
may extend also to the tissue by which they are united, and there will
then result a small induration, of the size sometimes of a lentil, the sec-
tion of which presents, after  the discharge of a fluid, a  number of
granulations or of depressed points.   This constitutes lobular pneumo-
nia, which forms  the connecting link between bronchitis and the latter
disease.  (Rilliet  and Barthez, vol. i. p. 21.)
  When the disease succeeds to the pustular exanthemata, the lining
membrane of  the bronchi often presents traces of follicular inflamma-
tion—often ulceration.   In severe and protracted cases it is not un-
common to meet with distinct  patches of red hepatization, particularly
at the lower and posterior portion of the lungs.
  Bronchitis is generally produced  by exposure to cold and damp;  it
is hence most liable to occur during  the raw,  variable,  and  humid
weather that so frequently prevails late in autumn, or in the commence-
ment of spring; it is common, also, in winter, from accidental expo-
sure, more especially when the season is  mild  and damp.  It often
occurs, likewise, during the summer, in consequence of the  sudden
occurrence  of rain, attended  with  a reduction  of the atmospherical
temperature, after a long continuance of intense heat and dryness.  It
may result, also, from the application of cold and damp to the surface
of the child's body, by wet clothing, or exposure to a draft  of air while
in a state of profuse perspiration; it is an almost constant symptom in
measles, and probably in pertussis,  and it not unfrequently  supervenes
on  variola, and scarlatina, and, occasionally, upon  gastro-enteric in-
flammation.   It sometimes  prevails epidemically,  affecting as  well
children as adults, or confined, in a great measure, to the former.
  The treatment  of bronchitis will  differ somewhat, according to the
violence of the disease, and  in its different stages.  In  mild cases, an
emetic, administered in the commencement of the attack, particularly
if followed by a warm  pediluvium, will very  often  be sufficient to
arrest the disease.  In all cases of bronchitis occurring in  children, an
emetic  given  at  the beginning of the  attack will be found decidedly
beneficial;  and even at a later  period, when great oppression at the
chest, with severe dyspnoea  occurs, from the clogging up of the bron-
chial tubes with mucus, nothing will be found to give more prompt re- 
292
DISEASES  OF CHILDREN.
 lief.  In infants and young children we invariably prefer the ipecacu-
 anha as an emetic, to the tartarized antimony; the effects of which
 latter, being, in early life, often peculiarly prejudicial.  The powdered
 ipecacuanha, mixed with sugar and water, or the wine or syrup, may
 be employed;  the dose being proportioned to the age of the patient.
   Whenever bronchial inflammation is attended with symptoms of any
 degree of severity, more especially when it occurs in robust, plethoric
 children, bloodletting is the remedy upon which alone  our chief reli-
 ance should be placed.   It should be resorted to as soon after the in-
 flammation is developed  as possible;  if it be delayed until a copious
 secretion from the lining membrane of the bronchi has  taken place, it
 is always  far  less efficacious, while in  some cases its effects will be
 even decidedly prejudicial.
   In robust and plethoric children, over two years of age, particularly
 when the pulse is full and active, and the disease is attended with con*
 siderable acceleration of respiration, a dry, hard cough, dyspnoea, and
 much febrile excitement, blood should be taken from the arm to an
 extent proportioned to the  condition of the child, and the violence of
 the case; and subsequently, if rendered necessary by the continuance
 of the inflammation, leeches may be applied upon the fore part of the
 chest, or cups  between the shoulders.  It is better, however, in most
 cases, to carry our first bleeding  to a sufficient extent  to make a de-
 cided impression upon the action  of the heart:—we shall be much
 more likely, in this manner, to cut short the disease, than by a repe-
 tition of the bleeding from the arm, or by the application of leeches.
   Although, as a general rule, bleeding is not advisable in  the ad-
 vanced stages of bronchitis, still there occasionally takes place a sud-
 den recurrence of inflammatory symptoms, or a congested condition
 of the  lungs, in which a  prompt  and judicious application of leeches
 or  cups to  the chest, will be productive of the very best effects.  In
 young children, and in cases of little severity, the abstraction of blood
 by leeches  or cups will be sufficient.
  The employment, extent, and repetition  of bloodletting in cases of
 bronchitis,  whether by the  lancet or by local means, demand the ut-
 most judgment on  the part of the practitioner.  In severe attacks, a
 cure can scarcely be anticipated without the abstraction of a sufficient
 amount of blood during the early  periods of the disease.
  In those  instances in which  the disease is complicated with gastro-
 intestinal inflammation, the application of a few leeches to the epigas-
 trium will always be found highly beneficial.
  By most writers, tartarized  antimony is recommended as being,
 next to  bloodletting, the most efficacious remedy in  the  bronchitis of
 children.   It is probable that, in severe cases, after the  immediate
 effects  of bloodletting  have subsided, should  the  fever  and dyspnoea
 not be materially relieved, a twelfth to an eighth of a grain of tartar-
 ized antimony, according to the  age of the patient, given every hour
until vomiting or faintness is produced, may render a repetition of the
bleeding unnecessary;  but it is under these circumstances  alone, that
we should be inclined to recommend the employment of tartar emetic
in infantile  bronchitis; experience  having taught us that it is a remedy, 
           DISEASES  OF THE  RESPIRATORY ORGANS.        293

 the operation of which  is borne with great difficulty in the early periods
 of life.  In  the generality of cases we prefer  the  administration of
 small doses of ipecacuanha.  After the first  bleeding, we are accus-
 tomed to  direct from  a fourth to a half grain,  in combination with a
 quarter of a grain of calomel  and from four to five grains of hydro-
 chlorate of ammonia, and have always found it to produce a very de-
 cided impression upon  the symptoms of the disease.   When the cough
 continues  dry, and the surface hot, with quickness  and frequency of
 pulse, we  have repeatedly added to this prescription a quarter of a
 grain of powdered digitalis; and notwithstanding its general condem-
 nation, we are persuaded that, under the circumstances just  referred
 to, it will  in most cases be found a highly useful remedy.
   After the occurrence of expectoration, the ipecacuanha may be em-
 ployed, combined with  extract of hyoscyamus,  which latter, while  it
 has a tendency to relieve irritation, is unattended with any of the dis-
 agreeable  effects  that  so  frequently result from  the  employment of
 opiates in  the diseases of young children.
   The warm bath, especially when confined to  the lower extremities,
 the child being immersed only to the hips, is, in all cases of bronchitis,
 productive of the  best  effects.   In mild cases it may be employed at
 the very commencement of the  attack, subsequent to the operation of
 an emetic; but in cases of considerable  severity, it should invariably
 be preceded  by bleeding, or the  application of leeches.
   When bleeding, either general or local, has  been carried  as far as
 is thought advisable, there is, perhaps, no remedy from which  more
 decided relief will be derived, than from a blister applied to the upper
 part of the chest, or between the  shoulders; it  should be allowed to
 remain on until  the skin is uniformly reddened, and  then be  replaced
 by a large emollient cataplasm.
   In the generality of cases of bronchial inflammation, the bowels are
 constipated, or at least  inactive, although occasionally, when accom-
 panied with  intestinal inflammation, there is  more or less diarrhoea,
 with vitiated discharges.   In the commencement it will be proper to
 administer some purgative, and perhaps the best is a full dose of calo-
 mel, followed by a  portion of castor oil.   The use of the combination
 of ipecacuanha  and calomel, already  recommended, will render the
 repetition of purgatives  unnecessary.
   The administration of expectorants will seldom  be found of any
 benefit in the first stages, of the disease, but  in the latter period, after
 the inflammatory symptoms have been reduced, and a copious secre-
 tion has taken place in the bronchi, they are occasionally of advan-
 tage ; the mel scillce compositum of the United States Pharmacopoeia,
 may be employed,  or the  following combination.4  When, however,
 the oppression of the  chest is very considerable, from the amount of
 mucus filling  the bronchial tubes, an occasional emetic will  produce
 far more prompt  and decided relief than will be derived from  any
other expectorant.
                   a R.—Infus. polygalee, 3iv.
                        Vin. ipecacuanha?, gij.
                        Oxy. scillse, 3iij-
                        Tinct. hyoscyami, 3j.—M.
                A teaspoonful to be given every three hours. 
294
DISEASES OF CHILDREN.
  When there is much  prostration, with a small and feeble  pulse,
and a degree of drowsiness, the carbonate of ammonia will often pro-
duce considerable relief*   In such cases, wine whey, in small quanti-
ties, judiciously administered, will be occasionally serviceable;  the
patient being  sometimes so weak and languid that he cannot  make
any voluntary efforts to cough, upon which, perhaps, his life depends.
Hoffmann, and some  other of the  German  practitioners, speak very
favourably of a combination  of benjoin  and camphor,b in cases  at-
tended with great debility; it is said to have produced complete  relief,
under circumstances to all  appearances hopeless.
  a R.—Carb. ammonia;, Qij.              Or,  R.—Assafcetidre, 3ss.
       Ext. glycyrrh. 3ij.                       Liq- ammonia? acetat.
       Aquae, 3iv.                            Aqute menth. aa gij.—M.
       Oxymel scillee, giv.—M.              A teaspoonful to be given every three
   A teaspoonful to be given every two or                 hours.
            three hours.
                   b R.—Flor. benjoin. gr. iij. ad iv.
                        Camphor, gr. iv. ad. vj.
                        Sacch. alb. 3ss.—M. f. chart. No. xij.
                 One to be given every two or three hours.
  The diet, throughout the early  stages of the disease, should be mild
and  unirritating.   Infants at the breast may be allowed, occasionally,
fresh whey, or gum or barley water sweetened with loaf sugar, and
prevented from sucking more than once or twice in the course of the
day; the diet of older children may consist of thin water gruel, barley
or rice water, or  fresh whey; and as a  drink,  cold  toast water or
weak lemonade.  During  convalescence, the diet should be gradually
and cautiously improved;  milk and preparations  of  the usual farina-
ceous substances should, however, constitute the chief food of the  pa-
tient, for a considerable period  after the  disease] has  been removed.
The child should be carefully guarded from exposure to cold or damp-
ness, and  from any sudden alternation of temperature; the air of the
apartment he occupies should be kept perfectly pure, by attention to
strict cleanliness and free  ventilation. As soon  as  he is  sufficiently
recovered, much benefit will be  derived from  gentle exercise in  the
open air, during dry mild weather; the patient's body being protected
by appropriate clothing.
  During convalescence, the same directions are applicable  as were
given when treating of coryza.

                        4. — Pneumonia. n.vi,v,Mt*^i/' y^—^^r^f*.
  Inflammation of the substance of the lung ranks  among the most
frequent diseases of children; as a primitive or secondary affection, it
may occur at any period, from birth upwards, differing greatly in its
extent and violence in different cases.  The inflammation may com-
mence in the minute lobules  of  the  lung, constituting what has been
denominated lobular pneumonia,  or  it may take  place in  one of the
pulmonary lobes, constituting lobar pneumonia. In both cases the dis-
ease will vary considerably  in extent; it may be confined to a very small
portion of one lung, or involve nearly the whole  of one or both.  In
young children, or  those under six  years of age, the disease would 
           DISEASES  OF THE  RESPIRATORY ORGANS.       295

appear, in a large number of cases, to be the consequence of extensive
bronchial  inflammation, and is probably, in these, very generally pro-
duced by  the extension of inflammation from  the extreme ramifica-
tions of the  bronchi to  the  substance of the lung; in very many in-
stances, however, the inflammation of the bronchi and of the lungs is
unquestionably simultaneous.  In  older children, the disease  more
commonly commences in  the lung, and the  circumscribed bronchial
inflammation, which so  generally attends  it, is,  in all probability, a
secondary affection.
   The general symptoms of pneumonia, in very young children, are
often extremely obscure in the  onset of the disease, and even  when
most strongly marked, they differ but little from  those of bronchitis.
There is invariably more or less cough, some degree of dyspnoea, in-
creased frequency of  respiration, and fever.   There is seldom any
very decided pain of the thorax.
   The attack, which is  often preceded, in infants, by symptoms of a
slight bronchitis, usually commences with a chill, more or  less severe
and prolonged, followed by  increased heat and dryness of the skin,
increased frequency of pulse, accelerated respiration, dyspnoea, and a
slight dry cough; which symptoms very quickly increase in intensity;
often at the very onset of the disease  there is vomiting, and in young
children, diarrhoea. Many cases are attended with considerable agita-
tion and anxiety, or drowsiness, more rarely with convulsions.  Accord-
ing  to  the observations  of Rilliet  and  Barthez, it is in pneumonia
occurring at the summit of the lungs,  in young infants, that the attack
commences with convulsions, which are sometimes violent and repeated,
and followed often by loss of consciousness.  The lips are usually of
a bright red, the tongue of a florid hue, somewhat dry, and frequently
coated along its centre with  a thick white fur.
   Dr. West describes  a  peculiarity in the mode of sucking and respi-
ration, which, in  the early stage of the disease, when it occurs  in in-
fants at the breast, affords a valuable  indication of its true  character.
So soon, he remarks, as the lungs becomes affected, even when no other
symptom exists  than general febrile  disturbance, and perhaps vomit-
ing, the infant will be seen  no longer to  breathe solely through the
nose as in health, but to  lie with the mouth partly open, and drawing
in air through it.  This imparts to the tongue its  preternatural dryness,
and the same inability  to respire through the nares causes the child to
suck by starts.  The infant seizes the breast eagerly, sucks for a few
moments with greediness, and then suddenly drops the nipple, and in
many instances begins to cry.
   The respiration in pneumonia is invariably accelerated, the number of
inspirations being generally upwards of thirty, and sometimes  beyond
seventy, in a minute; there is also a peculiar abruptness in the inspi-
ration, it occurring suddenly, before the expiratory movement  is  com-
pleted ; the nostrils during the act of inspiration  being more  or less
dilated.  The acceleration of respiration does not  always correspond
in extent with the violence  of the disease, nor  does it  in all cases
progressively increase  from the onset of the attack to its fatal termi-
nation.   It is  often absent or very slight  in the  pneumonia  that so 
296
DISEASES OF CHILDREN.
 frequently occurs in the course  of chronic  enteritis, and it may  be
 masked by the symptoms of abdominal or cerebral disease.  Accelera-
 tion of respiration  is often strongly  marked in cases of broncho-
 pneumonia, the dyspnoea being so great in some  cases as to threaten
 suffocation.  This symptom follows ordinarily the same course as the
 pulse,  increasing  with it, and  diminishing  at  the  period when it
 diminishes.
   In  cases of primitive pneumonia,  the acceleration of  the  pulse
 and respiration obtain their greatest intensity generally by the end of
 the fourth or fifth day.   By  the seventh, or at the furthest by  the
 ninth day, in favourable  cases, the heat of the skin  and frequency of
 the pulse diminish, the inspiratory movements  become less frequent and
 unattended with dilatation of the nostrils; and the cough more free and
 moist; the fever now quickly disappears, the face becomes paler, and
 the expression of the countenance more natural.   The respiration
 assumes,  finally,  its normal rhythm, the  appetite returns, the cough
 rapidly diminishes, and in a few days convalescence is fully established.
   In  all  the cases, except one, which  fell under the notice of Rilliet
 and Barthez, and  terminated favourably,  the earliest period at which
 the acceleration of  respiration disappeared  was  the sixth day, and
 the latest  the twelfth; the general period of its disappearance being the
 seventh, eighth, or ninth.
   In pneumonia of the summit of the  lungs, occurring in infants,  ac-
 cording to the  last-mentioned  authors,  there  is an inequality to be  ob-
 served in the respiration, it being effected by short, abrupt, broken efforts.
   There is always more or less dyspnoea, which is proportionate to the
 violence and extent  of the pulmonary affection, and goes on increas-
 ing, with  the progress of the disease, and  is often attended with great
 anxiety, and, in severe cases, with  a sense of impending suffocation,
 rendering a recumbent position insupportable.
   The cough, which is at first frequent, short, dry,  and painful, soon
 becomes moist; the expectoration, when it occurs, which is seldom  the
 case in young children, is, at first, slight, and  consists of a whitish,
 viscid mucus, but becomes subsequently reddish; it is rarely, however,
 rust-coloured.  Pain of the chest is not invariably present; when it
 occurs it  is generally acute, though sometimes dull;  it  is commonly
 felt, according to Dr. Gerhard, at the anterior margin of the axillae;
 it is augmented by the cough, and often declines long before the other
 symptoms disappear.
   There  is generally a diminution or entire  loss of  appetite, and  in-
 creased thirst.  The bowels are commonly torpid ; ihough, occasionally,
 when the  disease  is complicated with intestinal inflammation, profuse
diarrhoea  may be present  throughout the disease.  There is often an
anxious expression of the countenance.   In cases occurring in  the
course of chronic enteritis, the skin becomes, occasionally, covered
 with furunculi  or ecchymoses, while the parts to which blisters  have
 been applied are liable to become  ulcerated. When the pneumonia
is  severe  and extensive,  the patient exhibits  considerable dulness or
drowsiness, often amounting to complete stupor.  Delirium  is not often 
DISEASES OF THE RESPIRATORY ORGANS.       297
 observed, and when it is, we have generally found it to be an unfavour-
 able symptom.
   The cough varies greatly in violence and frequency, according to the
 extent and intensity  of the pulmonary inflammation, the stage of the
 disease,  and various concomitant circumstances.  It usually augments
 from the first day, but as it becomes more moist, in favourable cases,
 it gradually declines in violence, until towards the eighth or ninth  day,
 when it  diminishes rapidly, and finally disappears.   Should, however,
 the pneumonia become more diffused, or occur in the course of some
 acute affection, and in children not much debilitated, the cough is  very
 frequent and intense,  and is rarely attended with a free expectoration.
   In somecases,in which the inflammation of the lungs is extensive, there
 is a sense of suffocation, with  a dark violet hue of the lips and tongue,
 analogous to what is  observed in capillary bronchitis.  In the attacks
 of pneumonia that so frequently occur in the course of chronic ente-
 ritis, there  is seldom  much cough; occasionally, indeed,  it  is entirely
 absent;  the skin  in these cases  is pale and cool, the pulse  small, and
 the face and extremities cedematous.   The disease, in fact, is often so
 destitute of leading symptoms, that its existence might be overlooked,
 were it not for the physical signs revealed by auscultation.
   The peculiarities which distinguish  that form of pneumonia  which
 is preceded by bronchitis, are very accurately sketched by Dr. West
 of London.  The disease often comes on insidiously, and developes
 itself gradually without its being possible for us, in most cases, to fix
 the exact date of its attack.   Occasionally, however, there  is a well-
 marked  accession of fever  and dyspnoea, and  an aggravation  of all
 the symptoms, sufficient to mark the time when the pneumonia  super-
 venes.  The fever and heat of skin are less than in the other forms of
 the disease, but the dyspnoea and distress are usually greater, and the
 face presents, from the first, a  more livid hue.   The cough is less hard,
 but often comes  on in paroxysms, which greatly distress the patient;
 the respiration is more hurried  and more irregular; the irregularity
 coming on  at an earlier stage  of the disease.  Head symptoms  are
 more frequent; the patient's sleep is disturbed, and he often mutters in
 his sleep, and has far more restlessness and jactitation when awake.
 Convulsions  and   coma  more frequently precede  death, and  death
 occurs at an earlier period than in the other forms of pneumonia.
  It is almost exclusively from  the physical condition of the  chest,
 that our diagnosis is to be derived in this disease.  The physical signs
 are the same as in the pneumonia of adults,—crepitant rhonchus, bron-
 chial  respiration, and a flat sound upon percussion.  Fine, crepitant
 rhonchus is seldom, if ever, present without bronchial respiration;—
 while  these, with diminished sonorosity of the chest,  are always
 attended  with bronchophony.  The crepitus is generally larger in chil-
 dren ;  and if, for  a short time,  it  is not heard, it may be generally re-
 produced, by causing the child to cough,  when it is  again distin-
guished, in the strong  inspiration that succeeds the cough, giving  rise
to a sound like the cracking of a whip.  (Gerhard.)                *
  In cases of simple primitive pneumonia, if  of the  lobar form, even
from the  very onset of the disease, crepitant  or subcrepitant rhonchi 
298
DISEASES OF CHILDREN.
       may be detected, and  often bronchial respiration on one  side of the
       thorax towards its base. In the lobular form, the subcrepitant rhonchi
       are more generally diffused, while the bronchial respiration is rarely
       tieard; the extent of the latter increases with the increase of the dis-
       ease, while the rhonchi decrease.  By the time the acceleration of the
       respiration  and of the pulse has attained its maximum, the bronchial
VA// respiration  becomes intense, and is accompanied with bronchophony,
'<w-    or with a ringing sound of the voice, and extensive dulness of the
/     chest.  As the  symptoms diminish in intensity, and the cough becomes
       more moist, the subcrepitant  rhonchi are very abundant, the ringing
       sound of the voice is heard over a greater space, the bronchial expira-
       tion continues, but the dulness of the chest is much less marked.  Even
       after convalescence has been established, a slight prolongation of the
       expiration is still to be detected, as well as a diffused ringing sound of
       the voice.  The respiration continues feeble for several days, and does
       not for a long  time recover its proper vesicular tones.
          When the inflammation is of a still more violent character from the
       first, humid rhonchi are heard throughout the  chest, intermixed with
       others of a drier character, or with bronchial expiration and a diffused
       ringing of the voice.  Bronchial respiration, as Dr. West has remarked,
       must always  be  regarded  as a very grave  sign.   In eleven out of
       twenty cases of pneumonia in children where it was detected by that
       gentleman, the disease had a fatal termination.
<tf/V 4^   The mucous rhonchus is heard in most cases of broncho-pneumonia,
,£VW, and in cases of lobar  pneumonia in the neighbourhood of  the subcre-
   '   pitant rhonchus, and, occasionally, where distinct bronchial respiration
       exists, and it often persists for a  long time after  every other sign of
       disease has disappeared.
          The physical signs of lobular  pneumonia,  as  it usually occurs in
       young children,  are at first limited  to the mucous  and subcrepitant
       rhonchus, dependent upon the  secretion of mucus in the bronchi.   The
       subcrepitant rhonchus is frequently continued throughout the disease,
       being often the only stethoscopic symptom present; it is rarely re-
       placed by the  fine crepitant rhonchus, as  in the pneumonia of adults.
       When induration has  extended to a  considerable portion of the paren-
       chyma of the  lung, bronchial  respiration becomes developed, chiefly at
       the upper and  middle portions of their posterior part; it is rarely heard
       in the lower lobe, from the  comparative smallness  of the bronchi, and
       their early obliteration, by the progress of the  disease.  The respira-
       tory  sounds are  very peculiar;  the inspiratory murmur,  instead of
       being full and expansive, as in a healthy child, is  short, obscure, and
       almost without the vesicular murmur, and may or  may not be accom-
       panied with the mucous or subcrepitant  rhonchus; the expiration is
       rarely distinct, unless the bronchial respiration is fully developed,  when
       it is usually louder than the inspiration.   The  signs indicative of in-
£/ ^V^fkmmation of the parenchyma of the lung are often entirely obscured
/ T*5^-by the mucous rhonchi of bronchitis.   (Gerhard.)
\/<V0fipjt* When lobular inflammation of the lungs is more generally diffused,
y/t&L', upon percussion, the sound, on both sides of the chest, posteriorly, will 
DISEASES OF THE  RESPIRATORY ORGANS.       299
       be dull, compared with that of a healthy child;  more or less so, ac-
       cording to the extent of the induialinrj, t\\j eLoJ^, <&^\*-K*404tV%
         The duration of pneumonia in children, will, in a great measure, de-
       pend upon the severity of the attack ;  the extent  of the inflammation ;
       the nature of the treatment; and the period at which it is commenced.
       In very violent attacks, the disease implicating a considerable portion
       of the lung, death  may take place very promptly ; in other cases, the
       fatal  termination may occur at a much later  period, from extensive
       disorganization of the lungs. We have seen the disease, in what were
       evidently very severe attacks, promptly cut short, by appropriate re-
       medies ;  but in general, even in cases where recovery takes place, the
       disease is of some continuance.  In the cases reported by Dr. Gerhard,
       in which the commencement and termination of the symptoms were
       ascertained, the mean duration of the pneumonia was nearly fifteen days.
          In the more severe and unfavourable cases the dyspnoea is very in-
    m  tense from  the onset of the disease—the pulse is extremely small, the
  * m  face pallid, with a violet tinge of the lips, and at the summit of the
       cheeks.  The general  symptoms augment with the progress  of the
 y?   local disease, and death may occur upon the third or fourth day.  In
  ''  ^  other cases, after the fifth or sixth days, the symptoms exhibit no farther
Ig     increase, but remain stationary; or, more generally, while the accele-
 ....  ;  ration  of the pulse, and a frequent, difficult, and painful  cough, with
 v'    loss of appetite and some degree  of thirst continue, the fever abates,
  7  the face becomes  pale, a wasting diarrhoea sets in, the child becomes
       rapidly emaciated, and, in a state of the utmost debility, at  the termi-
  ,   *  nation of perhaps three or four weeks, expires.   The fatal termination
  '     may be hastened by the occurrence of pleurisy, measles,  gangrene of
 £/   the mouth,  &c.
w       Acute pneumonia, occurring in the  course of some other  acute dis-
       tease, was found by Rilliet and Barthez to seldom continue beyond the
       twenty-fifth day.   The progress of chronic pneumonia is very gene-
       rally slow ;  the disease may continue for three  or four weeks, or even
       longer.
   f      The pathological anatomy of pneumonia in children has of late years
 jr   attracted much attention.  Among those who have investigated  it with
   *  the greatest care are to  be  ranked Rufz, Valliex, Lanoix, La Berge,
    0 t Barrier, Becquerel, Billard, Rilliet and Barthez, Bailly and Legendre,
 . ''   of France, West, of England, Albers, Jorg,  Succow, of Germany, and
   " •  Dr. Gerhard, of Philadelphia.
   ♦     The anatomical lesions  differ very materially, according  as  the
       pneumonia  is lobular or lobar,  and according to the period of the dis-
       ease when death takes place.
         The lung affected with  lobular pneumonia is generally soft  and
  •'   flaccid; externally it presents a  mottled  appearance;  portions of a
       deep red or violet colour being interspersed  in  the midst  of  others
  p*  having the natural grayish-red tint.  The  dark red  or violet patches
    '•  are usually distinctly circumscribed, and of a  circular or oval form,
       slightly projecting, and hard to the touch.   They are most commonly
       situated at the inferior edge of the lung, but may occur at other por-
       tions of its  surface.   The part occupied by them does not collapse 
300
DISEASES OF CHILDREN.
 upon the chest being opened.  In some cases the marbled appearance
• of% fclje lung is  absent, but spots of induration, more  or less deeply
 seated, may be detected by the finger, the lung having an uneven or
 knotted feel.
    A section of the diseased lung presents the same  marbled appear-
 ance as the exterior.  In the first stage of the disease, the dark red or
 violet portions  are more or less accurately circumscribed;  they are
 somewhat firmer than the surrounding parts, swim when  thrown into
 water, crepitate beneath the finger, and however carefully separated
 from the sound portions of the lung, they yield, upon pressure, a red-
 dish fluid intimately mixed with  air.  In  the  second stage, the  dark
 red portions form nodules of a firmer and more compact consistence.
 Their  cut  surface  is smooth, and when carefully detached from the
 surrounding parts, they crepitate none or but slightly, and sink rapidly
 when placed in water.  When the central portion alone of the nodule
 is subjected to pressure, a red sanious fluid escapes, without any ad-
 mixture of air.   It is comparatively rare, that single lobules are found
 affected, the indurated portions usually comprising four or five, which
 together form a mass of the size  of a nut or  almond.   If the patient
 lives for some time, the intervening substance usually becomes affected,
 and the lobular is thus converted into lobar pneumonia.  This change
 does not appear to take place from  the gradual extension of disease,
 from  each inflamed  lobule,  as  from so many distinct  centres; but,
 sooner or  later, the whole intervening pulmonary substance  seems at
 once to become the seat of inflammatory action, which runs its course,
 as in ordinary lobar pneumonia.
    In the third stage of the disease, the section of the lung presents a
 grayish  colour, inclining more  or  less  to  yellow, in  different  cases.
 The pulmonary tissue is very friable, and when pressed gives dis-
 charge to a purulent fluid, its tissue being infiltrated with  pus.  If the
 inflamed portions of lung are attentively examined, it will be seen that
 some of the lobules are more projecting than others, and  that here the
 vesicles  are not compressed as in  the surrounding parts.  When the
 lobules are pressed, they give discharge to a purulent fluid.
    Rilliet and Barthez describe two  forms, or rather varieties of lobu-
 lar pneumonia, the mammelonnated and the partial.   In the first, there   %
 exists a nodule of hepatization, differing but little in colour or appear-
 ance from the surrounding tissue.  Its limits are clearly circumscribed,
 even when the neighbouring tissue is engorged.  It is sometimes com-
 pletely surrounded by a layer of about half a line in thickness, white,
 firm, and of a fibrous appearance.  The hepatized nodule slightly pro-
 jects  above the surface of the  incised lung, from the collapse of the
 surrounding air-cells.  The  nodule  varies in size from  that of a  hemp
 seed  to  that of a  pigeon's egg.   It is spheroidal in form, and has
 usually a regular  surface.   There  may exist but a single nodule, in
 one lung, or they may amount to twenty, thirty, or more.              ^
    This  form  of lobular pneumonia results, according to Rilliet and   *
 Barthez, from the inflammation being confined to one or  more lobules.
 They have found invariably the hepatized  nodules to be surrounded by
 a circle of pulmonary tissue in a state of engorgement.   The disease 
DISEASES OF THE RESPIRATORY ORGANS.       2Q\
very generally runs on to the third stage, and terminates in the forma-
tion of an abscess.  In  the same lung there may be detected circum-
scribed nodules of hepatization in the first and second stages, and, also,
rounded masses of a  straw-colour, very humid when cut into.  At a
more advanced stage, the pus, which was at first deposited in the in-
terstices of the pulmonary tissues, becomes collected in the  centre of
the nodule.  This minute collection of pus is  surrounded  by  two con-
centric zones, the  internal one yellow—hepatization  of the  third  de-
gree ; the external one red—hepatization of the second degree.  At a
later period, the exterior zone passes into suppuration, and the size
of the central cavity is  increased at the expense  of the inner zone.
At a later period, an incision through the diseased part reveals cavities
varying in size from a few lines to four  or six.  They are, in general,
round, more rarely oval, and contain usually a thick tenacious yellow
or greenish pus, perfectly free from any admixture  of air.   Sometimes
small coagula of blood are mixed with the pus.
   At first, these cavities are  formed by a layer of hepatized pulmonary
tissue, lined with a layer of concrete pus, or, in some cases, with a
false membrane, yellow, soft, and readily detached.   Subsequently this
membrane becomes changed into a thin, smooth, polished tissue, ana-   »
logous to a serous membrane.
   The abscesses sometimes communicate freely with each other, and
at the point where the  bronchus penetrates their  cavity, its mucous
membrane presents a true solution of continuity.
   When the inflammation invades separately several neighbouring no-
dules, the cavity of the abscess is multilocular, each cell being isolated
by a lamina of hepatized pulmonary tissue, upon the rupture  of which
the different abscesses communicate with each other.
   These abscesses may occur in different parts  of the lung; they have
generally, however, a tendency to approach the  surface.  It often hap-
pens that an adhesion takes place between the opposing surfaces  of the
pleura, or the pleura of the lung becomes gradually  thinned, and finally
perforated, giving rise to a true pneumo-thorax.
   In  a  single case, Rilliet  and  Barthez have seen an adhesion take
place between the base of the left lung and the diaphragm, the abscess
of the lung communicating, by a perforation of the diaphragm, with
the peritoneal  cavity.
   The pulmonary abscesses are often  completely isolated, and, with
the exception of a thin layer of hepatized parenchyma, in their imme-
diate vicinity, surrounded by perfectly healthy pulmonary tissue. Oc-
casionally, however, the greater  portion or "the whole of one of the
lobes may have been invaded by the inflammation.
   The number of abscesses is very variable; sometimes there  is but
one; at others, but very rarely, they are so numerous  that we cannot
count them.   Their size is usually in inverse proportion to their num-
bers.  They  are, in  far the greater number  of cases, confined to a
single lung; and they more frequently occur in the left than in  the
right.  They are met with most commonly in subjects under six years
of age.
   Partial lobular pneumonia is much less circumscribed than the pre- 
302
DISEASES OF CHILDREN.
ceding variety.  There is no distinct limits between the healthy and
diseased portions.   In extent, the disease very generally exceeds  the
mammelonnated.  Its form is not always regular.  The diseased por-
tions may throughout have reached the second stage, or at the centre
alone, the circumference being still in the first stage.  In the last case,
the circumference  may be in contact with  several other parts of  the
lung, in a diseased  condition, so that nearly the whole of an entire lobe
may present an intermixture of the characteristics of pneumonia in the
first and second stages.  This Rilliet and Barthez denominate gene-
ralized  lobular pneumonia, which, when it  has reached the third  de-
gree, is strictly lobar.
  There is, according to  the observations  of  Rilliet and Barthez, a
difference between lobar pneumonia and generalized partial pneumo-
nia. Although in  both there is a union of the several stages, yet they
are differently  disposed.  Thus, in  ordinary lobar pneumonia, when
the inflammation commences at the base, it successively invades  the
superior portions of the lung, and while the base passes to the second
stage, the superior  portions are in the first, and when these last have
arrived at the  second, the first have attained the third; in the case of
generalized partial pneumonia, many lobules, indiscriminately dissemi-
nated, become  inflamed and finally unite.  Sometimes, however,  the
partial pneumonia, in becoming  general, does  not pass  to  the third
stage.   But even here we find ordinarily in the same lung,  or in that
of the  opposite side, lobules in the second stage  of inflammation,  the
remains of well-marked lobular pneumonia.
  The lobular pneumonia is of much more frequent occurrence than
lobar pneumonia;  partial and generalized lobular pneumonia is more
frequent  than the  mammelonnated form; partial pneumonia is more
common than generalized pneumonia.
  In the great majority of  cases lobular pneumonia is  double.  Fre-
quently the pneumonia is much  more extensive on one side than  the
other.  Thus it is partial in one lung, generalized lobular in  the other.
A union of the three forms of pneumonia—mammelonnated, partial,
and general—is often  found in the same patient.   Mammelonnated
pneumonia is equally frequent in  every  portion  of both lungs, while
generalized pneumonia is far more frequent in the inferior than the  su-
perior lobes.  Partial pneumonia is often disseminated through all  the
three lobes;  it is more frequently met with, however, in the inferior.
Mammelonnated pneumonia is ordinarily equally diffused in both  the
right and left lung, while generalized pneumonia  predominates in  the
left. Mammelonnated pneumonia is of much more rare occurrence
beyond the sixth year than partial pneumonia, while generalized pneu-
monia is still more  rare than the former between the sixth and fifteenth
years.   (Maladies  des Enfans, T. i.  p. 61.)
  It has been doubted whether  all the changes in the  texture of  the
lungs described as  characteristic  of  lobular pneumonia  are  really  the
result of inflammation.  Hasse, in his Pathological Anatomy, refers
many of these changes to the persistence of the foetal state of the lung
subsequent to birth;  a condition which Jorg has  described under the
name of atelectasis pulmonum, and has pointed out the distinction be- 
DISEASES OF  THE RESPIRATORY  ORGANS.       303
tween the latter, and the changes in the pulmonary tissue produced by
inflammation.
  In atelectasis, the colour of the diseased portions of the lung always
approaches more to  a violet, their  exterior appearing smooth and
shining, contrasting thus with the dull, brown-red surface of inflamma-
tion.  In inflammation, again, the diseased portions are preternaturally
distended, whilst in atelectasis they are collapsed, and inferior in  vo-
lume even  to the healthy texture, but susceptible, provided the condi-
tion has not lasted too long, of artificial inflation, and in this manner,
of acquiring a perfectly natural appearance.  In inflammation, the pul-
monary tissue is softened; in atelectasis it is hard, and the  cut surface
is smooth, not granular.  In short, we have nothing like pneumonia,
excepting the solid, non-crepitant mass, which has  been confounded
with red hepatization.
  Views similar to those of Hasse are adopted by Dr. West  in  his
very excellent monograph on  the pneumonia  of children.   More re-
cently, the  subject has been minutely investigated by MM. Bailly and
Legendre, the result of whose observations  are published in the  Ar-
chives Gen. de Med. for February and March,  1844.
  These gentlemen deny the generally received opinion of the inflam-
matory nature of what has been termed lobular pneumonia, and  main-
tain that, in every instance, it is a peculiar state of condensation of the
lung, similar to that of the foetal state.  It consists in an occlusion of
the  pulmonary vesicles, which  may result from the mere contractility
of the tissue, or may depend on congestion of the vascular network
exterior to the vesicles.  The  former is the simple, the latter the con-
gestive form of this affection.  The congestive form is usually met with
along the posterior border of the lungs, and  generally accompanies
catarrhal inflammation of the vesicles.  In either of these forms  of the
foetal lung, insufflation reproduces, more or less completely, the natural
condition of the lobules.  Though occasionally met with unassociated
with inflammation, yet, in by far the majority of cases, this  condition
becomes developed under the influence of catarrh and catarrhal pneu-
monia.   When unattended with catarrh, and  involving only isolated
lobules,  it cannot be detected until after death,  but in the new-born in-
fant it usually assumes the lobar form, is attended by the physical signs
of deficient respiration, and associated with the absence of all signs of
constitutional reaction.  Lobular pneumonia has, they maintain, strictly
speaking, no  existence; the action of inflammation never being con-
fined to  a single lobule.  Partial pneumonia would therefore be a fitter
term. Insufflation does not modify the patches of true hepatization, and
the  bronchi leading to such hepatized nodules are exempt from catarrh;
two characters which distinguish partial pneumonia from the lobular
engorgements of partial broncho-pneumonia.  True partial pneumonia,
according to  MM.  Bailly and Legendre, is  by no means common in  "* ?v  •
children, though when hepatization does occur in those under five years    '  »\
of age,  it almost always affects the partial form.   The  statements,  »\
therefore, that have been made with reference  to the variety of lobar
pneumonia in infancy are correct; but almost all that  has been said
about the extreme  frequency of lobular pneumonia at that  age, must 
304
DISEASES OF CHILDREN.
             be taken as referring to  the foetal state of the lung.  Broncho-pneu-
             monia may affect healthy lobules, or those in the foetal state.  In the
             latter case it gives rise to appearances which have led to the supposi-
             tion that these lobules were the seat of a  parenchymatous  inflamma-
             tion.  Dr. West has repeated the experiments of MM. Bailly and Le-
             gendre on many occasions, and  fully substantiates the correctness of
             their statements.
               It  is asserted by M. Bouchut, that even true  hepatization  may be
             removed by insufflation; in  this, however, he  is  decidedly wrong.
             The  hepatized  portion may sometimes be made to assume a brighter
             colour, but not to resume the texture of healthy lung, as is the  case
             with lung in the foetal state.
               The anatomical characters of the lobar pneumonia of children are
             identical with  those of the  same disease in adults; it is unnecessary
             for us, therefore, to detail them here.  We meet with the evidences of
             inflammation in the stage of engorgement and hepatization, both red
             and  gray, these lesions proceeding ordinarily from the base to the
             summit.  The  termination in abscess is rarely met with.   The disease
             is most generally confined to one lung, and occurs more  frequently in
             the right than in the left.  It is most generally accompanied with  pleu-
             ritis, to a greater or less extent.
               Beside the lesions already  described, there are others  which occa-
             sionally occur  in the lungs of  those who die of pneumonia.   Portions
             of the surface  of the lung are found to be without crepitation, de-
             pressed, soft, and flaccid.  Their colour is violet, or pale  red, marked
             by white lines  disposed in  lozenges or  squares, which designate the
             lobes.  Their section presents a smooth surface, of a red colour, and
             somewhat firm texture, resembling a portion of muscle. When pressed,
             they give discharge to  a  serous, bloody fluid, without any mixture of
             air.   The carnified portion is often found around the lower edge of
             one of the lungs, or it may occupy a considerable portion of one  lobe,
             or the individual lobules.   It is as frequent in one lung as in the other,
             and is very generally confined to one.
               There is  some difference of opinion as to the exact character of this
             lesion; the supposed carnification is no doubt, in  many cases, merely
             portions of persisting foetal lung.  True carnification, Rilliet and  Bar-
             thez refer to the effects of inflammation, and in this  opinion Dr. West
             would seem to coincide, and, we believe, very properly.
               Inflammation of the bronchi, from a simple injection with increased
             mucous  secretion, to a dilatation of the bronchi with purulent effusion,
             or the formation of  false membrane, is a common complication of
             pneumonia.  It is very generally confined to the smaller bronchial
             ramifications.
               Pleurisy  is also a frequent complication of pneumonia, and is often
*J4*<6* fc^jfp^f a very intense degree.  Emphysema of the lung is not unfrequently
f,uAv4**£> met  with;  its  extent is  in  direct proportion with  the extent of the
\Av+it/£*4Z pneumonic  and bronchial affections, their violence, and the amount of
      '       dyspnoea with  which they are attended.   It generally  occupies the
             summit  of the  organ, or its sharp edge.   It is commonly double; when
             on one side only it is confined to the inflamed lung, and is  here always
             most considerable. 
          DISEASES OF  THE RESPIRATORY ORGANS.       305

  By a few writers, lobular pneumonia was supposed to be peculiar to
children under five years of age; but by the investigations of Dr. West,
Rilliet and Barthez, and others, it has been shown that although more
frequent, perhaps, in young children, lobular pneumonia may, neverthe-
less, occur at any period of childhood, a fact which our own observa-
tions very fully confirm.  It has been asserted that pneumonia in chil-
dren under five years is invariably preceded by bronchitis. The result
of the  more  recent researches of Rilliet and Barthez has convinced
them that lobar pneumonia, without bronchitis, occurs more frequently
in children under five years  than  they supposed in 1838, the date of
their first publication ;  that lobular broncho-pneumonia is much more
frequent than simple lobular pneumonia, but that it is incontestable  that
lobular pneumonia, mammelonnated, partial, or generalized,  may exist
in children without bronchitis; and, finally, that inflammation of the
bronchi and of the lungs is, in  some cases, simultaneous.
   The lobular form of pneumonia is not only the most frequent during
childhood, but it is also the most serious.  Lobar pneumonia,  when it
occupies only one lung, and occurs  in children between six and fifteen
years,  whose health has not been  impaired  by previous disease, un-
less  complicated  by some secondary affection, is not a very fatal dis-
ease, if a judicious course of treatment be commenced with in its
early stages.   Its serious character is  greatly enhanced by its being
complicated with certain other diseases.  The most common of these
are  measles,  hooping cough, chronic enteritis, and small-pox.   The
most fatal of its complications is that with measles, and  perhaps with
chronic inflammation of the bowels, and with small-pox.
   Pneumonia in  children may be produced by any of the  causes
which  ordinarily give rise to bronchitis.  It is, consequently, most  pre-
valent  during spring, autumn, and winter—and among the children of
those classes who are most liable  to be exposed to cold or  to sudden
alternations of  temperature.  Cases, however, occur at all seasons of
the year, but comparatively seldom during  those months the tempe-
rature  of which is mild and equable.
   The disease occurs in both sexes, but  most frequently in  boys.   Of
245  cases which  are noticed by Rilliet and  Barthez, 150 occurred in
boys and 95  in girls; in 118 observed by Dr. West, 65 were in boys,
and  53 in girls; and in 104 cases, of which  an accurate account has
been kept by ourselves, 60 were in boys, and 44 in girls.  In Phila-
delphia, during the ten years preceding 1845, of sixteen  hundred  and
fifteen  deaths from pneumonia, 872 were in boys, and 743 in girls.
   Pneumonia is very liable to recur in the same child, after a shorter
or longer interval.  Of seventy-eight children who came under the
care of Dr. West, with inflammation of the  lungs,  31  are reported to
have had previous attacks, namely, 21,  once; 4, twice; 2, four times;
and 4, several times, the exact number of attacks not being mentioned.
   The treatment  of pneumonia in  children  must be, in a great mea-
sure, governed  by the  particular circumstances of each case.  The
employment  of bloodletting will very generally be found beneficial ;
and, in children over three years of age, in the commencement of the
disease, when carried to a proper extent, it will not only greatly and
                               20 
306
DISEASES  OF CHILDREN.
promptly relieve the dyspnoea and cough, but have a tendency to ma-
terially shorten the duration of the attack.   In young children leeches
or cups to the anterior parietes of the chest, or  between the scapulae,
in numbers proportioned to the violence of the symptoms, and the age
and strength of the patient, will, in general, suffice; but in older chil-
dren, whenever it can be effected, we should prefer, in severe cases of
pneumonia, bleeding from the arm, which  has always appeared to us
to produce a more decided impression upon the disease, than the more
gradual abstraction of blood by leeches  or cups.  The propriety of
repeating the bleeding must be left entirely  to the judgment of  the
practitioner;  when the first bleeding has been well-timed, and carried
to a sufficient extent, a second  will not generally be required.  When-
ever, however, the leading symptoms, particularly the dyspnoea, con-
tinue  with  little  abatement, we should  never hesitate to repeat  the
bleeding, either from the arm, or by leeches or cups, according to  the
violence of the remaining symptoms, the age of the patient, and  the
amount of  strength remaining.   It is, however,  in  the early period of
the attack  alone, that we are to expect any very decided advantage
from  bloodletting; in the more advanced stages of the disease, it is
seldom beneficial or admissible; though  we  have, occasionally, met
with cases  that had existed several days, in which the cautious appli-
cation of  cups between  the shoulders has been  attended with very
marked relief.
   In all cases, the exhibition  of some mucilaginous drink, in  small
portions, and at  short intervals, will be found to abate, very sensibly,
the cough, and  relieve the  dryness of the  fauces, which, in the early
stage of the disease, is often a harassing symptom.  A solution of gum,
or the mucilage  of the elm bark, or pith of sassafras sweetened, will
be the best we can employ.
   By many physicians, the employment of tartarized  antimony, in
large doses, has  been recommended in the treatment of pneumonia
occurring in  children, as in that of adults, either in conjunction with
bloodletting, or as the sole remedy;  and cases have  been  published
by Guersent and others in proof its efficacy.  M.  Herard, in a paper
published  in VUnion Medicate, Nos.  127, 131, considers that tartar
emetic, in large doses, should be regarded as  almost the exclusive re-
medy in  children over  two years of age; although, in exceptional
cases, one  or two emissions of blood or a blister may be required.
He does not believe that the injurious effects upon the alimentary canal,
which are said to result  from  the continued administration of tartar
emetic to  young children, are of so common  occurrence as has been
supposed.  In thirty-one cases of pneumonia in children treated exclu-
sively by large doses of tartar emetic by MM. Baudelocque and Blache,
in Hospital for Infants, in Paris, seven died; of these, two fell victims
to tubercular pueumonia, and in the other five, lobular pneumonia was
very extensive.  This form of pneumonia Dr.  Herard considers as far
less amenable to tartar emetic than the lobar,  while cases of broncho-
pneumonia, occurring in children under two years of age are,  gene-
rally, far more efficaciously treated by emetics than by antimony given
in contra-stimulant doses.  The rapidity with  which convalescence 
DISEASES  OF THE RESPIRATORY  ORGANS.
307
takes place, is, he remarks, one of the most striking and advantageous
results of the use of antimony.  Given as an emetic, in the commence-
ment of  severe cases, we have often derived advantage from the em-
ployment of tartarized antimony; and the same appears to have been
the experience of others.  In young infants, we have never employed
the  remedy in any form, believing it  to be, at best, one of doubtful
propriety at this period of life; but in the pneumonia of older children,
we have repeatedly given it in divided  doses, subsequently to bleeding,
and often with very great benefit.
   In the cases, occurring in infants under three years of age, small
doses of ipecacuanha, combined with  calomel, may be given ; it is a
remedy, with  the effects of which we have  had cause to be much
pleased.   In numerous instances, we have combined with it a small
portion of  powdered digitalis, and we  think not without very decided
advantage.*  In many cases, we may  add  to the mucilaginous drinks
of the patient, a small quantity of the wine  of ipecacuanha, and of the
tincture of hyoscyamus.b  This will often be found, after bloodletting,
to aid very materially, in allaying  the cough,  dyspnoea, and general
restlessness.   If the calomel  should purge, as  is sometimes the case,
this  may be  obviated  by combining  it with  a portion of Dover's
powder.

* R.—Calomel, gr. iv. ad vj.                 b R.—Mucil. G. acaciae, giv.
      Ipecac, gr. iij.—iv.                        Vin. ipecac. 3j.
      Pulv. digitalis, gr. iij.—iv.—M. f.             Tinct. hyoscyami, 3j.
         chart. No. xij.                       Sacch. alb. pur. 3iij.—M.
One to be given every three hours.            A teaspoonful  to be given every two,
                                         three, or four hours, according to
                                          the age of the infant.

   In the commencement of pneumonia, if  the bowels of the child are
costive or  torpid, it is proper to administer a  full dose of calomel, to
be followed, in a few hours, by a dose of castor oil; or,  in robust chil-
dren, over three years of age, a dose of  equal  parts of  magnesia and
sulphate of magnesia.   Subsequently the bowels should be preserved
regularly open by enemata, or occasional doses of some mild purga-
tive ; a grain of calomel, with  half a grain each of ipecacuanha and
extract of hyoscyamus, administered twice or  three times a day, will
usually effect this object.  Costiveness is not, however,  very common
in the pneumonia of children ;  an opposite condition of the bowels is a
more frequent and troublesome symptom.
   Blisters are remedies from which much  advantage will  be derived
in most of  the cases of pneumonia  occurring in children. ' In violent
cases, or in those attended with much  febrile excitement, they should
not be applied, until the violence of the symptoms have been abated,
by direct depletion, and they should never  be  allowed  to remain on
longer than is necessary to produce a general redness of the skin;
when removed, they should be immediately replaced by an emollient
cataplasm.   In slight cases,  a weak sinapism may  be  employed,
instead of a blister; a very good one consists of a thick  slice of bread,
dipped in vinegar, and lightly sprinkled with powdered mustard.
   Warm pediluvia, with the addition of mustard, or sinapised hipbaths, 
308
DISEASES OF CHILDREN.
          produce always a favourable revulsion from the lungs, and should not
          be overlooked" in the treatment of the pneumonia of children.
            After the  violence of the disease has been somewhat abated, we
          have found great advantage from the administration of small doses of
          calomel, ipecacuanha, and extract of  hyoscyamus, every three hours.
          Under the same circumstances, the compound honey of squill may be
          administered ;  given in divided doses  throughout the day, it forms an
          excellent expectorant in cases of children.
            Dr. West  speaks highly of mercurial  inunction in  stubborn cases.
          Under its employment, he has seen recovery to take place even where
          circumstances  had seemed to warrant a most unfavourable prognosis.
          It is especially, he remarks, in cases  of  neglected pneumonia, where
          the time for  depletion has long gone by, the patient having become
          exhausted, and the employment of calomel is forbid by the presence of
          diarrhoea, that  the full value of mercurial inunction is seen.  Dr. West
          employs it in the proportion of one drachm, rubbed into the thighs and
          axilla every four hours in children of four years of age.  He  has never
          observed salivation to be induced by it, but he has seen the symptoms
          of the disease  gradually diminish in  severity during its employment,
          and the solid lung become once more  permeable to air.
            In chronic cases, our chief dependence is  upon revulsives, applied
          either upon the chest, or upon the surface generally, and perhaps upon
          a judicious mercurial course, particularly by inunction.
            When  in  the advanced stage of the disease, there is great exhaus-
          tion, with symptoms of impending suffocation, the use of carbonate of
          ammonia has been  strongly recommended ;a but,  under  such circum-
          stances, there can be but little hope of the patient's recovery.
                              » R.—Decoct, senegffi, 3iij.
                                   Carb. ammonia?, 3j. ad 3jss.
                                   Sacch. alb. 3ij.—M.
                        A teaspoonful to be given every three or four hours.
            It must be evident, that in severe cases, our chief hopes of a favour-
          able termination must be founded upon an early detection of the true
          character and  extent of the disease, and the judicious employment, in
          the commencement of the attack, of  bleeding, and the other antiphlo-
          gistic remedies adapted to the age of  the patient, and the violence of
          the symptoms.  After a  change  has occurred in the texture of the
          lungs,  we can do  but little beyond  moderating  the  more pressing
          symptoms.
            The diet of  the patient, in the early period of the more acute cases,
J&sv-^  ,shaH-be confined, almost exclusively, to plain mucilaginous fluids, or
          whey*; in the more prolonged cases, however, after the violence  of the
          disease has  been subdued, plain water gruel, arrow-root, or tapioca,
          mav be  allowed.  When the disease occurs in  infants, they should
          be always taken from the breast, and the mother's milk given to them
          in moderate quantities by means of a spoon, as  well to prevent their
          stomach from being overloaded, as to guard against the mischievous
          effects of the violent exertion of the respiratory function in sucking.
             The apartment occupied by the patient should be kept of a comfort-
          able, uniform temperature, and, at the same time, the purity of the air 
         DISEASES OF  THE RESPIRATORY ORGANS.      309

should be  secured by proper ventilation, and  a strict  attention  to
cleanliness.  The patient should be placed always in a half-recumbent
posture, in  order to render the respiration more  easy, and  to  prevent
the injurious  consequences resulting from the  stasis of fluids in  the pos-
terior portions of the lungs.
   Dr. West has given  another very important 'precaution, that should
never be neglected, which is, when the disease has reached an  ad-
vanced stage, or  involves a considerable extent of the lungs, to  move
the little patient with the greatest care and gentleness, lest convulsions
should be  brought on.  He has  known instances in which children
have been  seized  with  convulsions  immediately  on being lifted some-
what hastily  from bed, and placed in a sitting posture.
   After convalescence is fully established, gentle exercise in the open
air, in mild dry weather, may be taken with  great  propriety, but for
a  long period,  the utmost care  should be observed,  by appropriate
clothing, and other precautionary measures, to guard the patient from
exposure to  cold  and  damp;   and, while a  gradual improvement is
made in his diet, rich, undigestible, and irritating food must be avoided,
as well as excess in the use of those articles that are allowed.
  Having alluded, in the foregoing section, to  that condition of the
lung which  has been denominated by Jorg, Atelectasis Pulmonum, it
may be proper to give a short notice of the disease, for the information
of such of our readers, as may not have met with  that  gentleman's
work, Die Fotuslunge in gebornen kinde.
  The disease consists in a compression  or obliteration, to a greater
or  less extent, of  the  pulmonary cells,  but especially  the  inferior
lobes of one  or both lungs, and  the posterior half of the  remain-
ing lobes.  It is  usually  most extensive in the right  lung.  The por-
tion of the  lung  in which the obliteration  of the cells exists, is de-
pressed below  the level  of the  surrounding tissue, of a dark red or
violet hue, and neither by incision or pressure is any crepitation pro-
duced.  It presents, when  incised, a smooth red surface, from which
a bloody serum may be squeezed, but in which no air bubbles can be
detected;  when separated from the sound tissue, and placed in water,
it sinks to the bottom.  When the diseased portions are artificially in-
flated, the cells become dilated, and they  assume the same condition
as the surrounding parts.   This condensation of the tissue of the lung,
from compression of the air cells, is not produced by either inflamma-
tion or effusion, but is the  result of imperfect respiration, which pre-
vents the air from penetrating and distending all  the cells of the lungs ;
the parts  affected, consequently, retain the colour and  density of the
foetal lung, and sink when  placed in water.   In  infants  who had  died
of atelectasis, Jorg invariably found the foramen  ovale of the heart still
open ;  this  fact is confirmed  by Hasse, who, however, very correctly
remarks, that the patulence of the foramen  is not  uncommon at the age
at which death from atelectasis occurs.
  The causes assigned for this  affection  are, a very rapid  and easy 
310                DISEASES  OF CHILDREN.

delivery, or a too strong compression of the head of the child  during
parturition; — both of which  circumstances are common causes of
asphyxia in new-born infants;—or, when respiration does take place,
they prevent it from being sufficiently full  to  dilate the whole of the
texture of the  lungs, and, hence, give rise to the disease under consi-
deration.
  The affection is  especially  characterized by an imperfect, short,
anxious, and sometimes scarcely perceptible or intermittent respira-
tion ;  a feeble, plaintive, cry, difficulty of sucking, an imperfect eleva-
tion of the ribs and sternum, often a livid or blue colour, with coldness
of the surface, a weak languid pulse, and symptoms of general pros-
tration.  In consequence of the imperfect respiration, and impeded cir-
culation, nutrition is always impaired, and hence, if the child survive,
it becomes emaciated, and  cannot  bear the slightest motion or exer-
cise.  In some cases congestion of the brain is produced, and convul-
sions; or, from the violence of the  respiratory efforts, inflammation of
the bronchi and lungs.
  The endeavour of the obstetrician should be, as early after delivery as
possible to induce  in the infant a deep, full, vigorous inspiration;  for,
if the respiration be allowed to continue weak,  and  the lungs to be but
imperfectly expanded, the infant seldom survives  for  any length of
time.  The mouth of the  infant should, therefore,  be cleared of any
mucus that may be present in it;  and by smart slaps upon the glutei
muscles, or upon the palms of the hands and feet, respiration will often
be fully  established, or we may proceed as directed in the section on
asphyxia.  Rubbing the chest and back with sulphuric ether, and  in-
troducing it into the  nostrils  and  mouth, immersion in an aromatic
warm bath, and repeated  clysters  and emetics are recommended by
Jorg, all of which, however, are of doubtful propriety.  Emetics, and
all means which tend to increase the engorgement of the vessels of the
brain, are, indeed, strongly contra-indicated when  the  brain has been
injured during labour; in these cases a few grains of calomel, and sti-
mulants to the lower extremities,  cool lotions  to  the head, and even
leeches to the latter, will often be found of advantage.

                          §.—Plenritis.
  Inflammation of the pleura  is not an unfrequent disease of infancy
and childhood.   It may occur at any period, from birth upwards ; but
it  is more frequently met with  in children over  two years of age.
According to Rilliet and Barthez the primitive  acute form of the  dis-
ease is very rarely met with in children under six years of age.   In
younger children, pleurisy is most  generally a  complication of severe
bronchitis or pneumonia, though it  may occasionally occur alone.
   Mr. Crisp, in a paper read before the South London Medical Society,
(Lancet, January 1847), has  shown, however, that pleurisy is by  no
means of so rare  occurrence  in infants as is  generally believed.   In
forty-one post-mortem examinations made by him, of  children under
two  years of age—the greater number under one year—six cases of in-
flammation of the pleura were detected. In five it was  combined with
pneumonia; in one it was complicated with pericarditis; in another 
         DISEASES OF  THE RESPIRATORY ORGANS.      3JJ

with peritonitis  and hydrocephalus; in one case only did the pleura
alone appear to be affected.
  Although in some instances the disease is more difficult of detection
in young children than in the adult, and is especially liable to escape
observation in  infantile life, where many valuable signs, obtainable in
more advanced life, are wanting, still, when the inflammation is con-
fined chiefly to  the  pleura,  he  believes it may be easily recognised:
even when complicated with pneumonia, attention to the auscultatory
signs will enable us to ascertain its existence.
  The  symptoms  observed by Mr. Crisp in infantile pleurisy were:
great restlessness, violent screaming  at the onset of the attack, very
quick pulse, hot and  dry skin, glassy eye, dry, unfrequent cough;
the head thrown back, and great apparent pain on placing the child
erect.   On  auscultation a dry, rubbing sound  was heard.  Many of
these symptoms may be present in other diseases, as pneumonia, thus
increasing the difficulty of the diagnosis;  but when the dry, rubbing
sound is heard, with frequent screaming, and an apparent increase of
pain on elevating the head, he considers the existence of pleurisy to be
pretty clearly indicated. If, in addition, mucous and crepitating rhonchi
are heard, and only a small portion of the serous membrane is inflamed,
the diagnosis is  more obscure;  but  the disease  may still, he remarks,
be recognised by careful investigation.
  In older children  the symptoms  of pleurisy  are more marked and
characteristic.  The disease generally commences with a chill, in some
cases slight, in others more severe, which is soon succeeded by more
or less  febrile reaction; the  skin being usually dry and hot, the face
flushed, and the  pulse, frequent, full, and strong.  To these symptoms
are soon added  cough, dyspnoea, and  acute pain of some portion of
the  chest.   In many cases there is vomiting  of bilious  matter, and
sometimes pain of the head.  The respiration is  short, quick,  and
somewhat oppressed ;  the oppression being aggravated when the pa-
tient is  in a recumbent posture.
  The respiration  is performed chiefly by the action of the abdominal
muscles and diaphragm, the motion  of the chest being instinctively
restrained by the patient,  in consequence of the pain attendant upon
the elevation of  the ribs;  sometimes each inspiration gives rise to a
sharp cry or moan, and an expression of countenance indicative of
suffering.  The cough is at first short, dry, and stifled ; it is generally
increased when  the  child is  lying down, and more so when lying on
one  side than on the other.   When both pleurae are affected, the only
position in which  ease can be obtained, is upon the back, with the
head and shoulders elevated.
  Pain  is generally complained of, and usually referred to one side or
other of the thorax, sometimes to both.  The pain is increased by the
cough, and  on  inspiration;  and, when intense, gives to the counte-
nance that peculiar contraction, which is the  common expression of
suffering in children.
  If the disease is not arrested in its  first stages, the pain and dyspnoea
generally abate; the last, as well as the fever, often entirely disappear-
ing.   The cough,  in the course of  the disease, becomes more  moist, 
312
DISEASES OF CHILDREN.
and a little viscid mucus is often raised by it; expectoration, however,
is seldom attendant upon pleurisy, unless when complicated with bron-
chitis or pneumonia.
  When pleurisy occurs in the course of some acute disease in young
infants, its onset is occasionally marked by an attack of convulsions or
of suffocation,  and in older children, by acute  pain of the  thorax.
The dyspnoea and acceleration of pulse are often  very considerable.
  The duration of pleurisy, when  the disease is properly treated, is
generally short, and its termination favourable.   When accompanied
with bronchial  or pneumonic inflammation, it is somewhat difficult to
ascertain with precision, either its commencement or termination.  In
such cases it is  usually very acute, and terminates much more promptly
than when  it occurs alone. Pleurisy may assume  a very chronic form,
and is then marked, at  first, with very obscure symptoms.  There  is
some degree of pain in the side—often a slight fever, with evening ex-
acerbations.  Effusion in the pleural cavity takes  place to a very con-
siderable extent, and  the  form of the chest becomes changed.  The
patient  loses his  appetite,  becomes  pale,  languid, and emaciated;
evening exacerbations of  fever,  and copious night-sweats ensue, and
after being reduced, in the course of one or several months, to a state
of extreme marasmus, expires; or,  in more favourable cases, the fluid
effused  into the chest is  absorbed, or being evacuated by a surgical
operation, the patient may recover  his ordinary health.
  The physical signs of pleuritis in infants, are  extremely equivocal.
According, however, to the observations of Rilliet and  Barthez, the
disease, whatever  is  the age  of the patient, is marked from  its very
onset by the  presence of bronchial respiration.   It is  heard at  first
during very strong inspirations, superficial or  profound, and having a
peculiar metallic tone.  It is usually detected in  the posterior part of
the chest on a single side; at first at the  superior portion of the chest,
subsequently only  in  the  neighbourhood  of the inferior angle of the
scapula, or between the scapulae.  It may  disappear on the first, second,
or third day, or it may continue for a longer period, when it is heard
in both  the movements of respiration, or only during expiration or in-
spiration.   Rilliet and Barthez  have known it to continue until the
twenty-seventh day.  In favourable cases, most generally, the bronchial
inspiration is replaced, at variable periods, by a feebleness of the respi-
ratory murmur, more rarely by the friction sound, and sometimes by
the normal respiration.   It is in the more acute  cases, in which effu-
sion  probably occurs very promptly, that the  bronchial  expiration is
most decided;  when, on the contrary, the inflammation is slow in  its
progress, and the effusion takes place gradually, it has been entirely
absent.   Bronchial respiration is often accompanied with aegophony,
heard at the posterior part of the chest, below the interscapular space,
and at the inferior dorsal  region.  It  may be delected  as late as  the
fourth day of the disease; it sometimes disappears and again returns.
It is present only in cases attended  with  serous effusion, when this is
very abundant, or when thick false membranes are formed.  It is often
present in  infants  of two or three years,  but is more distinct in older
children. 
         DISEASES OF  THE RESPIRATORY ORGANS.      313

  In cases of subacute or chronic pleurisy, when the effusion takes
place gradually, and, as it collects, forces upwards the lung, or in cases
occurring in debilitated subjects, with little reaction and tardy respi-
ratory movements, the respiratory murmur becomes gradually ob-
scured, at first at the base of the chest, and  then higher and higher, the
obscuration extending, finally, over the whole of one side of the thorax,
and at length being lost entirely.   In very acute cases, the absence of
the respiratory murmur may occur at  the very onset of the attack,
and over a large portion of one side  of  the chest, and very soon the
respiration can be heard only at the interscapular region.  The obscu-
rity of the respiratory sound in these cases disappears early; in the
more chronic cases it may persist in some part of the chest for several
months.
  In very acute cases, upon percussion, the chest is tolerably sonorous.
When the disease is prolonged  or is of a chronic form, the dull sound
of the chest becomes  more  and  more  considerable,  following in its
march and  in  its extent  the obscuration of the respiratory murmur.
In very acute cases, the  dulness  will disappear sometimes  very  sud-
denly, at the same time that the respiratory sound becomes  perfectly
free.
  When the chest is inspected, the ribs of the side on which the effusion
has taken place will be found to be confined in their movements, while
the intercostal spaces  are enlarged.  When the effusion is very con-
siderable, the chest on  that side is  more or  less dilated.
  Rilliet and Barthez lay it down as a principle, that when a pleuritic
attack occurs in a child labouring under hepatization  of the  posterior
part of the lung, all the abnormal sounds  that were perceived at the
level of the diseased point become considerably exaggerated, and the
sonorosity disappears.  This occurs, however, only in cases sufficiently
extensive and profound to prevent the lung from collapsing.   Thus it
may be inferred,  that if an entire  absence of the respiratory murmur
succeeds the symptoms of a well-determined pneumonia, the hepatiza-
tion was of slight extent,  and but little profound ; whilst, on the other
hand, if the bronchial  expiration, the resonance of the voice,  and the
dulness of the chest are suddenly increased, the pneumonia to which
the pleuritic effusion has just been  added, occupies a large extent both
in depth and surface.   (Maladies des  Enfans, T. i. 148.)
  Upon examination  after death, in patients who have  fallen victims
to pleurisy, the appearances discovered are, adhesions  of the pleura,
more or less  recent;  the  pleura covered, to a greater or less extent,
with yellowish  lymph,  forming, in  some cases, a coating of considera-
ble thickness;  effusions  into the  cavity of the  pleura of a  serous or
sero-purulent fluid, or of serum mixed with numerous small flakes of
lymph.   The serum is, sometimes, perfectly transparent, but at others
is troubled and more or less opaque.  The  fluid secretions usually oc-
cupy  the  most depending portions of  the  pleural cavity;  they are
occasionally collected in separate cavities formed by recent false mem-
branes or adhesions of the pleura.  The most common lesion met with
after death from pleurisy, is unquestionable false membranes; they most
frequently cover the costal pleura, often the pulmonary, and frequently 
314
DISEASES OF CHILDREN.
both.   In some instances, the pleura is studded with numerous small
red points, arising from ecchymoses beneath the membrane; we have
observed this occasionally upon the costal pleura, but more frequently
upon that of the lungs.  The pleura is not unfrequently thickly studded
with minute tubercles, the lungs generally being in a similar condition;
we have met with tubercles of the pleura, however, where none existed
in the lungs.  The pleuritis is most commonly confined to one side of
the chest, but may affect  both.  It is more frequent on the right than
on the left side.  According to the observations of Rilliet and Barthez,
when the pleurisy complicates pneumonia, it  is, however, more fre-
quently on the left than on the right.
  Pleurisy, especially as a primitive disease, occurs more frequently
in boys than in girls.   It  is a common  complication of pneumonia;
often, however, it is in such cases of little  intensity, though in other
cases it assumes as serious a character as the accompanying pulmonary
inflammation.  It is a frequent  complication of rheumatism, scarlatina,
and Bright's disease.  It  is of more frequent occurrence in spring,
autumn, and winter, than in summer, or seasons of  moderate, equable
temperature.
   Pleurisy is not, of itself, a  very fatal  disease, and  is readily con-
trolled  by an appropriate  treatment.  We have never seen a case in
which the  disease terminated fatally in  its  acute stage.  Even when
extensive effusion  has taken place in the  cavity of the chest,  this will
often be entirely absorbed, if it consists  chiefly of serum; but when
purulent, it frequently produces considerable uneasiness and suffering,
and, sooner or later, causes the death of the patient.  When extensive
adhesions occur between the pleura costalis and pulmonalis, in chronic
cases, a very marked contraction of the chest takes place, on the side
on which the adhesions exist, productive, when of  any extent, of de-
cided deformity.
   In cases  of copious effusion into the cavity of the pleura, the lung
is more or less pressed upwards, and its  functions impeded.   If, after
this condition has existed for  some time, a rapid  absorption of the
effused fluid takes place, the lung not expanding with sufficient celerity
to fill the chest, the ribs  will  consequently contract upon the com-
pressed lung, and  more or less contraction of the chest will be pro-
duced.  This deformity often  disappears during the  growth of the
child; though occasionally it may exist,  to  a certain extent, through-
out life.
   Of the treatment of pleurisy, but little  need be said,  as it differs in
no important particular from that proper in cases of bronchitis and
pneumonia.
   The  remedy upon which the  chief dependence  is to be placed, is
bloodletting, early employed, and carried to  a sufficient extent to pro-
duce a decided impression  upon the symptoms of  the disease.   Pre-
cisely the same remarks that were made in relation  to the employment
of  this  remedy in cases of pneumonia, are  applicable  to the disease
before us.   In young children, a few leeches to the chest, followed by
soft warm  cataplasms, will often produce a very  decided abatement
of  the  disease.  In the commencement of the  attack, the bowels 
          DISEASES  OF THE RESPIRATORY  ORGANS.      315

 should be freely opened by a purgative of calomel, followed by castor
 oil, or sulphate of magnesia, and kept in a regular condition, by small
 doses of ipecacuanha and calomel, repeated daily.
   In the latter period of childhood, when pleurisy is most apt to occur
 independently of inflammation of the lungs, the tartarized antimony,
 either alone  or combined with nitre, will  often be found a powerful
 auxiliary  to  bloodletting, in  arresting the  progress  of the disease."
 The  tartarized antimony, combined with nitre and  calomel,b is particu-
 larly advantageous in  those cases in which, after bloodletting, the skin
 remains hot and dry, and the  cough short and frequent.  Under the
 same circumstances, the warm hip-bath, and warm pediluvia act bene-
 ficially.
 a R.—Nitrat. potassse, gj.                 b R.—Nitrat. potasses, 3j.
      Tart. ant. gr. ij.                         Tart. ant. gr. j.
      Aquae, 3iv.                            Calomel, gr.iv.—M.f. chart. No. xij.
      Sacch. alb. 3ij-—M.                 One to be given, mixed in sugar and water,
 A teaspoonful to be given every two or three     every three hours.
   hours, according to the age of the patient.
   As soon as the violence  of the disease has been subdued by direct
 depletion, a blister to the chest, as directed in cases of pneumonia, will,
 often, very promptly relieve the cough,  pain, and dyspnoea.   Under
 the same circumstances  that  blisters become proper,  considerable be-
 nefit  will be derived from small doses of the combined powder of ipe-
 cacuanha, particularly in the evening; when well-timed, nothing will
 be found more  effectually to relieve the cough and  restlessness, and
 promote the healthy action of the cutaneous exhalants, particularly if,
 at the same time, a warm pediluvium be employed.
   When effusion to any extent has occurred within the chest, and the
 fluid  is not speedily removed,  after the inflammation of the pleura has
 been  subdued, its presence being indicated by auscultation as w7ell as
 by the inability  of the child to assume a recumbent  posture without
 experiencing  more or less dyspnoea and cough, small doses of calomel,
 squill, and digitalis,* given every three or four hours, will often cause
 the effused fluid  to be absorbed.   In some cases, a  combination of
 digitalis  and bi-tartrate of potassa,b or a mixture of the syrup and oxy-
 mel of squill,0 with sweet spirits of nitre, will prove highly efficacious.
 * R.—Pulv. scillee, gr. iij. ad. iv.      b R.—Bi-tart. potass. 3iij.
     Calomel, gr. iij.                   Pulv. digitalis, gr. iv.—M. f. chart. No. xij.
      Digitalis, gr. iij.—M. f. chart. No. xij.   One to be given every  three or four hours.
                     c R.—Syrup scillee, gvj.
                          Oxy. scillee, 3ij.
                          Spir. aeth. nitr. 3vj.—M.
              Dose, twenty-five drops, three or four times a day.

   The same rules are to be observed in regard to the diet of the  patient
 as were  directed in  pneumonia.
   In  chronic  pleuritis, our chief remedies are a mild unirritating diet,
 composed principally of the farinacea and milk, counter-irritants to the
parietes of the chest, and internally, calomel in  small doses, combined
with some of the diuretics, of which, perhaps, digitalis and squill  are
the best,  though occasionally the tincture of Sanguinaria Canadensis,
will  be found a very valuable  remedy in  these cases, in the dose  of 
316
DISEASES OF  CHILDREN.
              from  two to ten drops,  according to  the  age of the  child, repeated
              three times a day.   In some cases mercurial inunction, employed  in
              the same manner as was directed in pneumonia, will produce a benefi-
              cial effect.  The bowels should be kept open by mild laxatives, or pur-
              gative enemata.  Iodine, both internally and externally, may, in some
              cases, be productive of benefit.
                 When effusion of pus has taken place in the pleura,  the case, as we
              have already remarked, is  generally  hopeless; nevertheless, we are
              assured by Herpin, that by an  operation, the pus has been evacuated,
              even  in a  child only seven years  of age, and entire recovery has en-
              sued, with  the exception  of a slight contraction of the chest on the
              affected side.
                 During convalescence  from chronic pleuritis, change of air will
              often be advisable, especially the  removal from  a cold,  damp, and
              variable climate, to one warmer and more equable.

                                   6. — Tracheitis. — Cronp.

 Kt/y&fX?//  CYNANCHE TRACHEALIS--ANGINA POLYPOSA VEL MEMBRANACEA--LARYNGEO-
\ «.c>Ctt-e+£c*\j  Kt/<X>YjrLfy, *K.\^X.^y t  tracheitis. r^a^l/cSs ,*L«f**-^>-4

X                 If we take  into consideration its frequency, the rapidity  of its pro-
              gress, the distressing  and painful  symptoms by which  it is  accompa-
              nied, and the amount of mortality produced by it, tracheitis or croup
              must be regarded as  one of the most formidable of the diseases pecu-
              liar to infancy and childhood.  In Philadelphia, during the ten  years
              preceding  1845, there occurred  1150 deaths from croup, being an
              average of 115 per  annum;  in London, 391 deaths from this disease
              are reported in 1840; and in the whole of England, during the same
              year, 4,336.1
                 The croup is, strictly speaking, an inflammation of the mucous mem-
              brane of the larynx and  tracheal, the former being, in  the great  majo-
              rity of cases, the part first  affected.   The peculiarity of the disease
              consists  in  the  early occurrence of an exudation  upon the surface of
              the inflamed  surfaces, forming, in many cases, a  pseudo-membrane,
;              which extends often from the larynx throughout the larger, and even
              sometimes into the smaller divisions of the bronchi.  It has been sup-
              posed by Blaud, Duges, and others, that in certain mild cases, of fre-
              quent occurrence, unattended with fever, and readily cured by simple
              means, the pseudo-membranous exudation does not take place.  These
              cases of simple laryngeo-tracheitis, have  been denominated by  Guer-
              sent and Bertin spurious croup; they are evidently cases of spasmodic
              laryngitis.
             /  ,°rhe distinguishing symptoms of croup are, dyspnoea,  a  peculiar
              hoarseness of the voice, a loud ringing cough, sibilant  inspiration, and
              v fever.
                 In the  majority of cases, the disease is preceded by symptoms of
              catarrh or bronchitis. The patient is affected with more or less  chilli-
u              --------------------------------------------------------------------_
                 a Entire mortality of London during 1840, 45,284; and of the whole of England, 359,561.
H'             In Paris, the deaths from croup in 1838, were 187; in 1839, 286; and in 1840, 326. 
         DISEASES  OF THE  RESPIRATORY ORGANS.      317

ness, succeeded by increased heat of the surface, lassitude, loss of ap-
petite, and  cough.  These  symptoms vary in intensity and duration;
in some cases presenting simply the characteristics of a slight catarrh
for several days; while in others, the tendency to  croup  is exhibited
from the commencement of the attack.
   It is usually during the night that the  proper symptoms of the dis-
ease are developed.  The child, after retiring to rest, suddenly awakes
from  his sleep with difficult and wheezing  respiration, and frequent
paroxysms of a loud, ringing cough; his  skin is intensely hot, his face
flushed, and his voice hoarse and indistinct.  Frequently he complains
of a sense of constriction in the throat, and  sometimes of pain  about
the larynx.   In general, these symptoms, after a short period, gradu-
ally abate, the respiration becomes  more free, the  patient falls again
into sleep, and on awaking  in the morning, with the exception of some
degree of hoarseness and a slight cough,  presents no symptoms of any
serious disease:—the pulse, however, will, in general, still be found to
be more  frequent than  natural, and the  cough more hoarse  and re-
sonant.
   On the ensuing evening the respiration  becomes  again suddenly dif-
ficult, loud, and wheezing, and the cough convulsive and ringing; the
patient  experiences a sensation of impending suffocation, and  often
carries  his hand to his throat, as if to remove the cause of his suffering.
His face becomes swollen and flushed, his pulse hard and frequent, and
his voice hoarse and almost inaudible.  The  cough is unattended with
expectoration, or perhaps causes  the discharge of a small amount of
glairy mucus, streaked  with blood.  The violence of the foregoing
symptoms  may, after a time, moderate; but  if so, soon again increase
in violence, and usually continue, with slight  remissions, and exacerba-
tions of augmented severity, during the night. Sleep appears to favour
their return; or if the patient remains awake,  they are excited  by his
cries, or by the slightest paroxysm of coughing.
   Unless the disease  be arrested  by an appropriate treatment, the
symptoms  constantly augment in intensity, and the remissions become
slighter and  of shorter duration; the cough loses, however, its acute
ringing sound, while  the loud  wheezing  respiration  of the patient is
heard even beyond the apartment he occupies.  The dyspnoea becomes
excessive, the patient is in a constant state of agitation, his face swollen
and livid, his lips purple, and his forehead covered  with large drops of
perspiration.  The skin becomes cool, and the pulse small, feeble, and
extremely  rapid.  The thirst is often excessive, and not the least diffi-
culty is experienced  in swallowing tfie  fluids presented.   There is
often expelled by the cough, or by vomiting, at this period, a quantity
of thick, ropy mucus, sometimes mixed with fragments of a membra-
nous appearance.
   These symptoms may continue for a  longer or shorter period, ac-
cording to their intensity.   The voice,  however, soon becomes ex-
tinct, the  respiration short and convulsive, and the patient  is every
moment in danger of suffocation;  his face becomes  pale or  livid, his
eyes  dull  and  inanimate, and his head, face, and  neck are bathed in
a cold, clammy sweat.  There is  now but little, if any, cough or ex- 
318
DISEASES  OF CHILDREN.
pectoration, the pulse is feeble, irregular, and intermittent, and  the
patient  at  length ceases  to breathe,—the intellect being, in general,
unaffected  throughout the attack.
   In  other cases, however, the disease  commences  much more  ab-
ruptly, and proceeds with greater rapidity and violence.  The patient,
who  retired to  bed apparently in perfect health, is  suddenly awoke
from  his sleep with  a violent fit of loud, ringing  cough ; his respiration
is loud, wheezing, and oppressed, and attended with  a feeling of  im-
mediate suffocation ; there is the utmost anxiety and restlessness ;  the
face  is  tumid, and  of a  dark-red  colour, the eyes injected and pro-
truding, and the pulse frequent and hard.  These symptoms  present
not the  slightest remission, but increase in intensity,  and the  patient,
in the midst of the most frightful agony, perishes as though from actual
strangulation.  In these  extreme cases, death  may occur in a  few
hours, or the attack may be prolonged for one or more days.
   Between the two forms of  the disease we have described—that in
which it is gradually  developed and  of some  duration, and  that in
which it occurs suddenly, with symptoms of  the utmost  severity, and
runs  a  rapid  course—croup may  present very various shades of  in-
tensity.
   Its  duration will vary in different  cases, according to the intensity
of the disease, the age and constitution of the patient, and the nature
of the treatment pursued.  When attacked in its early stages by  ap-
propriate remedies,  even  in the more violent cases, the disease will  oc-
casionally be removed within a short period.  The ordinary  duration of
the disease is from twenty-four to thirty-six hours; though  cases have
been related in which it has been protracted until the twelfth day from
its invasion; or the  disease assuming a chronic  character, it may, it is
asserted, continue for two or  three weeks.  We very  much doubt,
however, the correctness of the diagnosis in these latter cases.
   The disease is usually  described as one peculiarly liable to recur in
the same individual, after a longer or shorter interval; this statement
is made by nearly every writer upon the  disease; it has, according to
Jurine and  Albers, been known to recur seven, and even nine times in
the same individual. The subsequent attacks are described as vary-
ing in intensity in different cases; an infant, it is said, may promptly
recover  from one, two, or three consecutive attacks, and finally  be
destroyed by a fourth, exceeding in intensity either of the  preceding.
We have never met ourselves with what  could,  with any propriety, be
denominated a second  attack  of croup.   We suspect that what  are
reported to have been repeated  attacks of croup, were in fact cases of
the false or spasmodic form of the disease.
f The diagnostic symptoms of croup are, the hoarseness of the voice,
the peculiar deep ringing cough, and the  loud wheezing or  sibilant  in-
spiration./
   The hoarseness of the  voice  is generally among the first symptoms
that occur; even, in many cases, being observed previous to the dys-
pnoea, cough,  or febrile reaction. It is at first slight, but becomes more
marked in  the progress of the disease ; not unfrequently, in  the second
and third stages, amounting to  an entire  extinction of the  voice.   In 
         DISEASES OF THE  RESPIRATORY ORGANS.      319

the cases that are preceded for some days by simple catarrhal  symp-
toms, the peculiar hoarseness of the voice will early warn the observ-
ing physician of the true character of the attack.   The roughness or
hoarseness of the voice, to a certain extent at least, often continues for
some time after the disease has  been entirely removed,  and only
slowly disappears.
   It  is extremely difficult to present a  correct description of the dis-
tinguishing croupal cough.   In cases preceded by catarrhal symptoms,
a cough is present from the onset of the disease, differing in nothing
from the ordinary cough of bronchitis  ; but from the moment that in-
flammation of the larynx is developed, the cough  becomes  deep and
hoarse, and with the first accession of  the phenomena dependent upon
the laryngeo-tracheitis,  it assumes the peculiar loud, ringing  sound,
constituting the proper  croupal cough.   This sound has been compar-
ed to the crowing of a  young cock, the barking of a hound, or to a
cough heard through a brazen trumpet; these comparisons,  however,
but illy characterize its deep, ringing resonance.  It must be heard, to
form a correct idea of  it;  and, when  once heard, it will scarcely be
possible afterwards to confound it with any other.
   During the paroxysms of the disease, the cough occurs by fits, more
or less violent and prolonged ;  during the intervals the cough still re-
tains its croupal sound, but is less violent.  Towards the close  of the
disease, when the natural functions of the respiratory tube have be-
come nearly destroyed, the cough is always  entirely suppressed, and
loses its peculiar characteristics.  In the event of a favourable  termi-
nation, the cough very  frequently disappears entirely; or, as is more
commonly the case, resumes its catarrhal character, and continues to
recur for a longer or shorter period.  The paroxysms of coughing, are
excited by the most trifling cause, as  the act of drinking,  speaking,
crying, and the like.
   The respiration is more or less short and hurried  from  the com-
mencement of the attack, and the dyspnoea augments in intensity with
the progress of the disease, being  sometimes  so great as to  threaten,
every moment, strangulation.   During the paroxysms, inspiration is
prolonged, and attended with a loud wheezing, in some cases, amount-
ing almost to a  low, lengthened whistle.  This wheezing  inspiration
continues throughout the attack, being less intense, however,  during
the intervals, and disappearing entirely with the disappearance of the
disease.
   The hoarseness of the voice, the peculiar croupal cough, and the
loud, wheezing,  and prolonged respiration, are evidently dependent, in
a  great measure, upon the diminished capacity of the rima glottidis and
upper portion of the trachea, in consequence, in the first  instance, of
the thickening of the inflamed mucous membrane of these parts,  and
subsequently, of the pseudo-membranous exudation  with  which they
become covered.  But  the circumstance of these symptoms, in many
cases, becoming aggravated at irregular intervals, divided by distinct
remissions, thus constituting, as it were, paroxysms, that  commence
suddenly, and decline with  equal abruptness, have induced many to
suppose, that the peculiar symptoms of croup are, to a certain  extent, 
320
DISEASES OF CHILDREN.
du'e to a spasmodic constriction of the muscles of the larynx and glot-
tis.   It is probable, however, that it is chiefly the extreme dyspnoea of
croup, that is the result of this spasm, and which gives to the disease
its apparent paroxysmal character.
  In the more violent attacks of croup, the dyspnoea commences with
the very onset of the disease, and continues with little abatement, until
its close.   When, however, the attack is preceded  for  some days by
catarrhal symptoms, the dyspnoea does not occur until somewhat later,
and attains  its peculiar character  only in  the second  stage;  when,
during the paroxysms, it is only by the utmost efforts that the child ap-
pears to be capable of effecting the respiratory movements. The mus-
cles of the face,  neck, shoulders, chest, and abdomen, are thrown into
violent, almost convulsive  action ;  the  mouth  and  nostrils dilate, the
larynx ascends and descends rapidly, the entire thorax is elevated, and
the shoulders are drawn up at every  inspiration.   In most  cases, the
dyspnoea is increased by the horizontal position, and the patient in  a
state of the most violent  agitation, throws  his body successively in
every position to obtain ease.   Very generally the  head is bent  back-
wards, as it were to augment the size of the larynx, and thus to give to
the air a  more free passage into the lungs ; this, however, is not inva-
riably the case, and  hence, as Royer-Collard very  properly remarks,
cannot be considered as one of the diagnostic phenomena of the dis-
ease.
  In the final stage of croup, the dyspnoea is equally intense ; but re-
spiration  is effected almost entirely  by the  action  of the diaphragm,
the contractions  of which are violent and convulsive; the cartilages of
the ribs, and the abdominal muscles,  are, at  one moment,  drawn in-
wards towards the spine, and at the next, return  suddenly to their for-
mer position.  Ordinarily  inspiration is long and  almost continuous,
endangering, every instant, the suffocation of the patient.  In the second,
and even at the commencement of the third stage,  the  dyspnoea may
present very distinct remissions.  These remissions occasionally are
so complete, that the disease appears to be  suddenly suspended, and
the parents have rejoiced in the speedy recovery of the child ; nothing,
however, is more insidious than this sudden occurrence  of a deceitful
calm.
  Fever is very generally present in croup; it is in some cases strongly
marked, commences with  the disease, and continues until its closing
stage; in other cases, the febrile excitement is less intense; and  again,
in what have been termed spurious croups, the laryngeo-bronchial va-
riety of Duges, there is often, especially in young  children, no  symp-
toms whatever of  fever.
  In the  more violent attacks of croup, there is frequently pain  of the
larynx and trachea, in general of an obtuse rather  than  an acute cha-
racter, and increased upon external pressure; in slight cases, however,
this symptom may be wanting.
  By some writers, a swelling of the neck, at the upper part  of the
trachda, has been described as frequently occurring.  The swelling  is
represented as varying in size in different cases, of an oedematous cha-
racter, and disappearing immediately upon  the  recovery or death of 
          DISEASES OF THE  RESPIRATORY ORGANS.      321

 the patient; it must, however, be of very rare occurrence, as we have
 never had an opportunity of observing it.
   Vomiting occasionally occurs on the accession of the  disease, but
 is not an  invariable symptom, as  has been supposed  by Albers and
 others, even in the more violent  cases.  The fact is, that in these latter
 cases vomiting is  with  difficulty excited, even by the administration
 bf the most active emetics.   Occasionally, however, vomiting will be
 Vovoked by the violent fits of coughing which occur during the height
 of the disease.  The matters vomited in these cases, are usually a
 thick, viscid mucus, or muco-purulent matter,  mixed with shreds of
 false membrane, sometimes in the  form of tubes or portions of tubes.
 The  discharge of these  matters, when copious, is followed by a very
 marked relief of the dyspnoea and  cough, which, however, is never of
 long  duration.
   The condition of the  bowels is various; but in the majority of cases,
 according to our experience, they are more or less torpid. The urine
 is sometimes clear, pale, and abundant, and at others, small in quantity,
 thick, and deep-coloured; it is very often whitish  and turbid, particu-
 larly towards the  close of the second  period.   This condition of the
 urine, however, is neither diagnostic of the disease, nor critical.
   There is often a disposition to somnolency in  the commencement of
 the disease, which, in some cases, amounts to complete stupor, arising,
 probably, from a slight congestion of the brain;  drowsinesss or stupor,
 however,  is by no means an invariable—we should  think not even a
 frequent—attendant upon croup,  as has been supposed, especially in its
 first  and  second  stages.  Some, with Cailleau,  have described the
 senses, as well as the intellectual powers of the patient, to be increased
 in activity; although we  have seldom  seen the mental powers much
 impaired  throughout an attack of croup, we cannot say that we have
 ever observed any increase in their activity.
   The pathological changes presented by the bodies of those who
 have  fallen victims to croup, are  principally confined  to the larynx,
 trachea, bronchi, and lungs.   One or other, or  all of  these, invariably
 present traces of disease, differing somewhat, according to the inten-
 sity exhibited by the symptoms during the life of the  subject, and ihe
 period at which death has taken place.  The  lesion most commonly
 observed, is a pseudo-membranous exudation, covering  some portion
 of the mucous  membrane of the respiratory tube, and an effusion of
 mucus or muco-purulent matter, filling the larger  and sometimes the
 smaller bronchial ramifications.  In cases that have terminated rapidly
 in death, the exudation is found only in the larynx and upper portion
 of the trachea, or  is confined to  the latter situation;  when death  has
 occurred at a later period, it is in the trachea alone, or in the trachea
 and bronchi that it is detected; it never exists in the bronchi alone.
   In the  larynx, the exudation is often in the form of a thin coating,
extending over the whole of its internal surface, but  more frequently
it is disposed in membraniform patches, or is found upon the inferior
surface of the epiglottis alone. In the trachea, it often lines the whole
of the tube, and varies  in consistence and  thickness; or it occurs in
detached patches, or in the form of  soft  concretions, resembling polypi,
                               21 
322
DISEASES  OF CHILDREN.
attached  to the posterior surface of the tube; or the trachea is  filled
with a mucuform fluid, containing small masses of a more solid con-
sistence.  These same appearances are occasionally present in the upper
part of the bronchi; but, more frequently, in the bronchial tubes there
is found only a viscid  mucus, more or less fluid, and containing often
albuminous flocculi.
  In those cases in which the invasion of the disease has been sudden
and violent, and  its termination in death rapid, it is rare, according to
Martinet, to find the exudation assuming  a pseudo-membranous ap-
pearance; the respiratory tubes in such cases containing only mucus,
somewhat more abundant  and viscid than natural.  The  larynx and
trachea have, however, been found, according to Blaud, lined with  a
pseudo-membranous concretion, in cases in which the entire duration
of the disease did not exceed twenty-four hours.
  When  the fatal termination occurs towards the close of the second
stage, the pseudo-membranous exudation  very  frequently  lines the
whole of the trachea, and sometimes even  the larynx and upper por-
tion of the bronchi, and presents, throughout nearly the whole of their
extent, considerable firmness.
  In cases in which  death occurs at a still later  period, in the upper
portion of the trachea there is seldom found anything but a quantity of
viscid mucus, which becomes more consistent at the lower part of the
tube, and often forms here a  more or  less  complete membrane, sepa-
rated  from the mucous membrane by an abundant layer of fluid matter.
In the bronchi this pseudo-membrane becomes much softer, and  soon
loses entirely its  membraniform character, the bronchi being filled in
their final ramifications with a thick, ropy mucus.  (Royer-Collard.)
  The colour of the  membraniform exudation, is either whitish, yel-
lowish, or gray;  the part applied to the surface of the respiratory tubes
is often marked by slight, bloody striae  or points.  It is sometimes very
closely adherent to the mucous membrane, but in other cases, there is
interposed between it and the surface of the tube  a layer of mucus or
puriform  fluid.  It is in some cases soft,  and readily torn, while  in
others it has considerable firmness; it is,  in general, most thick and
firm in the trachea, particularly at its posterior part.
  Vanberger, Bohmer, and a few other writers  on the disease have
described the pseudo-membrane of croup as an  organized substance,
possessing minute fibres and blood-vessels;  a supposition which is con-
tradicted by the most conclusive testimony.  That in some cases, after
the  cessation of the disease, a portion of  the membrane intimately
attached  to  the  mucous membrane  of the trachea, may remain, and
become organized, has, however, been  placed beyond doubt.
  The chemical composition of the  pseudo-membranous exudation of
croup, is  the same as that of the diphtheritic inflammations generally,
and of the pseudo-membranes of serous surfaces, it being composed
chiefly of albumen.   According to Dr. Seitz, upon a microscopic ex-
amination of a porfTQii of the pseudo-membranous exudation of croup,
of about half a line in thickness, and of slight consistence, it was found
to be  composed almost entirely of pus globules, mixed with inflamma- 
         DISEASES  OF THE RESPIRATORY ORGANS.      323

tion corpuscles, and a species of cell double the size of the  pus glo-
bule, but in other respects similar to it.
  When the pseudo-membranous exudation, and the viscid mucus are
removed from the surface of the respiratory tubes, the mucous mem-
brane of the larynx, trachea, and bronchi are generally found to be in
a state  of  inflammation throughout the greater part  of its extent,
though in many cases it has been found free from  any mark of dis-
ease.   When death takes place in the early stage of the more violent
cases, the larynx  and  upper portion of the trachea are of a deep red
colour  and more or  less thickened, and  sometimes  more or less
softened.  When the  disease has continued  for a  longer  period, the
redness is less intense; the blood-vessels of the mucous membrane are,
however, strongly developed, and when the mucus is scraped from its
surface by the scalpel, is of a reddish colour.  At a still later period of
the disease, traces of  inflammation are less perceptible, and often en-
tirely absent.  The affection of  the bronchi  is in  proportion  to the
extent and  duration of the disease;  the earlier in the attack the death
of the patient occurs,  the less marks of disease are presented by them;
the later in the disease the fatal  termination takes place, the more ex-
tensively do they  appear to be involved. Cases not unfrequently occur
in which their minutest ramifications are filled with a pulpy matter.
  Pneumonia is not an unfrequent complication of croup;  portions of
the lungs being in a state of inflammatory engorgement and hepatiza-
tion;  pleuritic inflammation is also occasionally met with, as well as
interlobular and sub-pleural emphysema.
  The physical signs  of croup  are not of a very positive character. In
the early period of the disease, it is said that the stridulous respiration
may be detected  by the stethoscope, applied to the trachea, before it is
otherwise distinct.  According to Barth,  when  the stethoscope is ap-
plied upon the trachea, there is perceived a  kind of tremulous vibra-
tion, as  though  a thin, movable partition was  agitated by the air.
This indicates the presence of floating portions of false membrane, and
when confined to the  larynx, is not an  unfavourable symptom; if, on
the contrary, it extends  to the trachea and bronchial tubes, it indicates
that the false membranes occupy the greater portion of these tubes. So
long as  the disease is  confined to the  larynx  and trachea, upon  per-
cussion, no dulness will  be found to exist.   When bronchitis or pneu-
monia is present, it will be indicated by its appropriate  signs; these,
however, may in  a great measure be obscured  by  the loud  sound of
the tracheal respiration.  In the early stage of the disease, or after
vomiting, the tracheal sound being less, the  sonorous breathing and
rhonchi of bronchitis, and  the crepitation of pneumonia, may  be de-
tected, if present.  (Stokes.)  When the pseudo-membrane in the tra-
chea is  partially detached, it is said by Maunsel, that we may have a
clapper or valve-like  sound, upon inspiration, when the upper, and
upon expiration, when the lower extremity is the one detached and
moved by the passage of the air through the larynx.  We have never,
ourselves, observed this sound.
  It is  unnecessary to enter into an examination of the  various hy-
potheses that have been emitted  in reference  to  the nature of  croup. 
324
DISEASES  OF CHILDREN.
The investigations of modern pathologists have shown that the disease
is an inflammation of the mucous membrane, and probably, according
to Ryland, of the submucous cellular tissue of the larynx and trachea,
and  in many cases of the bronchi also.  The inflammation, in the early
stage of the disease being, in most  cases, confined  to the larynx and
upper portion of the trachea, but  extending subsequently to the bron-
chi,  often throughout their ramifications, and to  the tissue of the lung
itself.  It gives rise,  more or less rapidly, to the exudation of an albu-
minous fluid, which most generally forms a pseudo-membranous coat-
ing upon the larynx, trachea, and commencement of the bronchi.  The
collapse or adynamic symptoms of  the third stage, result from the in-
terruption to the function of  respiration, and the  consequent imperfect
haematosis, caused by the  presence  of the exudation, and the conges-
tion  of the lungs.  As we have already remarked, nearly all the cha-
racteristic phenomena of croup indicate that there also exists a spas-
modic affection of the  glottis,  which, however, is the result of the
increased irritability of the  parts labouring under inflammation, and
probably of the irritation of the  morbid secretion, and not, as some pa-
thologists have supposed, the chief cause of the  prominent  symptoms
of the disease.
  Various divisions of croup have been attempted, by different writers.
By Blaud, it has been  divided  into three  forms, dependent  upon the
intensity of  the inflammation, and the character of the secretion from
the inflamed mucous surfaces.  The first being a mild form,  with the
secretion  of a  moderate quantity of thin,  limpid, frothy mucus; the
second, a more aggravated  form, but still  comparatively mild in its
progress, and favourable in  its termination, with  opaque and puriform
secretion; and the third, the  most  aggravated form, with pseudo-mem-
branous exudation.   This division, which is of little benefit in a practi-
cal point of view, even were  it well founded, is not borne out by the re-
sults obtained from autopsical examinations.  By others, croup has been
divided into the laryngeal, laryngeo-tracheal, and laryngeo-bronchial,
according as the inflammation is confined  to, or  predominates in the
larynx, trachea, or bronchi; this division is a  much more accurate
one than the preceding.   It is probable, that in many cases, the bron-
chi  are the part first affected; in  the great majority,  however, the
disease evidently commences in the larynx, and  we suspect there are
few, if any cases, in which it is  confined to the trachea alone.  Jurine
has attempted  to show, that  in the ordinary form of croup, the disease
is, in its first stages, a  tracheitis  alone,  and that in the more violent
form, (suffocating  croup,) it  is  simply a laryngitis.  Although this is
not correct in  fact, yet our  observations have taught us, that in cases
attended with violent symptoms, sudden in  their onset, and  rapid in
their progress, there  exists most generally, considerable  inflammation,
with pseudo-membranous exudation, about the larynx, glottis, and up-
per portion of the trachea, to a much greater extent always, than  in
those cases especially, in which  the disease succeeds to bronchitis, and
pursues a less  violent and more protracted course.
  Another division of croup  is into the sthenic and asthenic.  The first
occurring in robust and plethoric  children,  and attended with decided 
         DISEASES OF THE  RESPIRATORS ORGANS.      325

febrile reaction, firm pulse, pain  in the larynx, and other indications of
severe inflammation; the disease usually occurring as a primary affec-
tion.  The second form, occurring in debilitated and  cachectic chil-
dren, or those reduced by previous  disease,  and attended with a low,
obscure fever, feeble pulse,  early collapse,  and other indications  of
asthenia.  The first, or sthenic form, corresponds very nearly with  the
primary croup, and the second,  or asthenic form, with the secondary
croup of medical writers—the second,  very  generally, resulting from
the extension of pseudo-membranous inflammation from the fauces into
the larynx and air-tubes.
   Upon the  termination of the  symptoms characteristic of croup, the
patient is  frequently perfectly convalescent within a very short period;
more commonly, however,  they are succeeded by those of a mild
bronchitis, which continues  for many days; in other cases the bron-
chitis becomes chronic, and occasionally terminates finally in tubercular
disease of the lungs.
   Age is  evidently the  chief predisposing cause of croup; the disease
being principally confined to children under ten years of  age, seldom
occurring beyond that period as a primary affection.  It is rare in the
first months of life, but is met with most frequently in children between
one and  seven years old.  By  numerous writers,  the occurrence of
croup previously to the seventh  month,  has been denied. Others, how-
ever, declare that they have met with it repeatedly, as a  primary dis-
ease in children at the breast.   In Philadelphia, during the ten years
preceding 1845,475 deaths are reported from croup, in infants between
2  and 5 years;  238 in those between  1 and  2 years; 319 in those
under one year ;  112 in those between  5 and 10 years; and 6 in chil-
dren over 10 years of age.  Of 330 cases of croup, presented in a
tabular form, by Andral,  141 occurred in infants between  2 and 5
years old; 71  between  5 and 8; 61 between  1 and 2;  36  over 8; and
21 under one year of age.   The  earlier the children are  weaned, the
more liable, according to Home, they are to attacks of the disease.
   Judging from our own experience, we should say that the croup oc-
curs more frequently between  the tenth month and  fifth year from
birth, than at any other period.   This is the  period of childhood when
there exists a peculiar tendency to the formation of pseudo-membrani-
form exudations in all the inflammations of the mucous surfaces, espe-
cially those  of the respiratory organs, which readily assume, in parti-
cular constitutions, the croupal  character, rendered  still more marked
and dangerous, by the imperfect development in early life of the larynx
and trachea, and the small size  of the glottis.
   Boys would appear to be more frequently  affected with the disease
than girls.  Of 543 cases of true and  false croup,  collected by Guer-
sent, 325  occurred  in  males, and 218  in females;  of the 1150 fatal
cases of croup reported to  the  Health  Office  at Philadelphia, during
the ten years preceding 1845, 612 occurred  in boys, and  538 in girls.
The deaths from croup in the London Hospitals during 1840, were, in
the male sex 3 to 1  in the female.
   Children of a sanguineous temperament, of  a florid complexion, in-
clined  to  fat, and apparently in the  enjoyment of  perfect health, are 
326
DISEASES OF CHILDREN.
those in whom the croup is most liable to occur as a primary disease,
and hence we find of those families  in which  this temperament pre-
vails, almost every infant attacked with the disease, as it reaches its
first or second year.  Children are rendered more liable to an attack
of croup, when  by the improper fashion of their dress, their  neck,
shoulders, upper  portion of their breast, and the greater part of their
arms, are left entirely bare, or only slightly covered.
  The chief exciting cause of croup is, unquestionably, the impres-
sion upon the body, of a cold and damp atmosphere, or sudden tran-
sitions of temperature;  hence, we  find  the disease  most prevalent
during the variable,  damp, and chilly weather which prevails  in  the
commencement of spring and close  of autumn.  It  is also of  much
more frequent occurrence, in  situations naturally abounding in  mois-
ture, than in those of an opposite character.  It may be considered as,
to a certain extent, endemic in valleys surrounded by high mountains,
and in the vicinity of lakes  and large rivers.  It may be produced,
however, at any season of  the  year, by sudden alterations of tempe-
rature.  Sitting  or lying down on a  damp grass-plat, or in a current
of air,  after the body has been heated by exercise, or a sudden chilling
of the  body from any other cause, is very apt to induce the disease.  It
is also particularly apt to occur, in the course of, or immediately sub-
sequent to, an attack of measles or of pneumonia.
  Croup is said, occasionally, to prevail epidemically.  In such  cases,
however, we suspect that the disease was not primary, but secondary
croup, resulting  from pseudo-membranous angina.  The latter differs,
in some degree,  from primary croup.   Independently of the inflamma-
tion of the larynx and trachea, being secondary to disease of the pha-
rynx and throat, and its occurring always in the course of some other
affection, the symptoms are usually of an asthenic character;  the de-
glutition is more or less difficult, the breath foetid, and  instead of a
tendency appearing in the course of the attack  to acute pneumonic  in-
flammation, it is disease of the mucous membrane of the stomach and
bowels, with which, in  cases of  secondary croup,  the laryngeo-tra-
cheitis is most commonly complicated. Stokes enumerates other points
of difference, which  we do not recognise, as, for instance, the  conta-
giousness of secondary croup, and its chiefly affecting adults.   Under
no circumstances, do we believe croup to be contagious;—even when
it accompanies or succeeds to small-pox, measles, or scarlatina, it is
scarcely correct to refer it to contagion, merely because the affection
which it accidentally complicates, is  in this manner propagated.
   The treatment of  croup varies somewhat, according to the stage of
the disease, and the violence of the  attack.  In mild cases, or  in  the
early, or forming stage, an active emetic, followed by immersion in
the warm bath, and subsequently the  exhibition  of small doses of
antimony combined with calomel, will, in many instances, put  a stop
to its  further progress.  Nearly every writer  upon the disease, has
spoken of the good effects of emetics, administered in the  cases and
at the period noticed:  much discrepancy of opinion, however, exists
as to the best emetic to be employed; by the  majority of physicians,
the tartarized antimony is preferred; others refer a  peculiar efficacy 
         DISEASES OE THE RESPIRATORY  ORGANS.     327

to the sulphate of copper; while others, again, prefer the sulphate of
zinc.   Some of the  American practitioners esteem the Sanguinaria
Canadensis, in  infusion, as almost a specific, while a few prefer the
Lobelia inflata.  Dr. Meigs considers that  alum in powder, from the
certainty  and speediness of its  operation,  forms the  best emetic  in
cases of croup; and Dr. Hubbard, of Maine, recommends the turpeth
mineral, the yellow sulphate of mercury, as an emetic in this disease,
in consequence of its promptness and certainty, and its  never pro-
ducing catharsis, or being followed by the prostration caused by tartar
emetic.
   The great objects to be kept in view, in our choice of an emetic in
croup, is the promptness, certainty, and activity of its operation; and
these properties being combined  in the  tartarized antimony, we have
invariably preferred it in the commencement of the attack. In many
of the milder cases, the compound honey of squill,  given in a sufficient
quantity to operate freely as an emetic, and continued subsequently in
nauseating doses, will, very effectually,  cut short the disease.  The
only writer whom we have met with, that  condemns emetics in the
treatment of croup, is Goodlad.
   In  cases of greater violence, or in which the emetic, given in the
forming  stage, has  failed  to  arrest the disease, our most effectual
remedy is, unquestionably, bloodletting.   In many cases, the applica-
tion of leeches to the throat will be sufficient, but  in every instance in
which the disease is marked by symptoms of considerable  severity, or
the patient is  robust and  plethoric, the pulse  hard and full, and the
dyspnoea very considerable, blood should he drawn from the arm to  an
extent sufficient to make a decided impression upon the symptoms, but
never if possible, to the extent of inducing syncope; and if the symp-
toms  should again recur  with any  degree of violence, the bleeding
should be repeated, or leeches should be applied around  the throat, in
numbers proportioned to the  age and strength of the patient, and the
intensity of the disease.  The repetition of the bleeding must  be go-
verned by circumstances;  in  some  cases,  one bleeding in the early
period of  the attack, will most effectually control the symptoms; but
in others,  when the system reacts with force, the pulse continues firm,
the skin warm, and the dyspnoea  considerable,  a repetition  of the
bleeding will be proper.
   There is  certainly no disease, in which bleeding, when  well timed,
and carried to a sufficient extent, is calculated to  produce more bene-
ficial effects than in croup.   The practitioner, who in violent  cases,
neglects this important  measure, and places his hopes on any other
remedy, or combination of remedies, will have  but  little reason to
flatter himself upon  his success  in  the management  of the  disease.
This  assertion is based upon a tolerably extended personal  experience,
as well as upon the  recorded experience of nearly every American
practitioner, and a majority of the most authoritative of the  practi-
tioners of Europe.  But, it must be recollected, that it is  only in the
first stages, the beneficial effects of bloodletting are to be obtained; if
it  be  then neglected, or timidly practised, the time for its employment 
328
DISEASES OF CHILDREN.
will have passed, and in those cases in which  it is strongly indicated,
there will then be but little hopes of arresting the fatal termination, by
whatever other remedial measures may be resorted to.
  From the difficulty often  experienced in obtaining blood from the
arm, in  young children, it  has been recommended by Cheyne  and
Goodlad, to open one of the jugular veins; others, however, have ob-
jected  to the operation, from  the difficulty of measuring the quantity
of blood drawn, and of arresting the bleeding when a sufficiency has
been obtained.   We have repeatedly drawn blood from the jugular
veins,  in violent  cases  of croup, and with very decided advantage;
the promptness of the relief has occasionally been  very striking.  We
have never experienced any difficulty in performing the operation, or
in arresting the haemorrhage;  and as to the extent of the bleeding, this
being measured not by  the number of ounces  of  blood drawn, but
solely by its effects upon the disease, we have had no more trouble in
judging of this  when  the jugular vein was opened, than when the
bleeding has been performed from a vein in the arm, back of the hand,
or foot.
  Immediately  after the first bleeding, the exhibition of an emetic and
immersion  in the warm bath will prove powerful auxiliaries.  It often
happens that  an emetic, exhibited  upon the accession of the disease,
will not operate, sometimes not even excite nausea, until the patient is
bled  and the warm bath employed, when  immediately copious vomit-
ing will occur, and render the  repetition of the emetic unnecessary.
  After  the patient is removed from  the warm bath, he should be
placed in bed and enveloped in blankets,  the perspiration induced by
the bath and emetic being encouraged by  the employment  of divided
doses of tartarized antimony.  We  generally  combine the antimony
with calomel and hydrochlorate of ammonia.*
                  a R.—Calomel. 3ss. ad 3j.
                      Tart. ant. gr. j.
                      Hydrochlor. ammon. 9ijss.—M. f. chart. No. xij.
                  One to be given every two hours.
  The employment of  nauseating doses of antimony in croup, subse-
quently to full vomiting and  sufficient depletion by the lancet, has the
sanction of the best writers upon the disease.   Cheyne declares, that
he has  found no other  remedy worthy of confidence in the  second
stage, an assertion which we consider, judging from the result of our
own  experience, scarcely too  strong.   Stokes places it even  above
bloodletting.  Steinmitz trusted to it alone in the second stage, as also
did Jadelot, who combined the tartarized antimony with ipecacuanha,
squill, and senega.*  Cheyne also speaks highly of the efficacy of the
                       a It.—Infus. senegae, giv.
                           Syrup, ipecac. 3j.
                           Oxy. scillae. 3iij.
                           Tart. ant. gr. jss.—M.
                     A teaspoonful every ten minutes.

tartarized antimony, both as an emetic, and in nauseating doses through-
out the first and second stages of croup.   A recent  writer (C. Wilson)
gives the tartarized antimony throughout  the disease, at first in doses 
         DISEASES OF  THE RESPIRATORY ORGANS.      329

of a quarter or a third of  a grain every hour, until a decided impres-
sion is  produced  upon the symptoms, and subsequently  every two
hours.  Combining the article with calomel, we have certainly found
to increase very materially its efficacy.
   Of the  good* effects of  calomel  in croup, we have abundant  testi-
mony.  Given in  large doses and at short intervals, it is the remedy
upon which many physicians have almost exclusively depended for the
cure of the disease; while in somewhat smaller doses, after bleeding,
an emetic, and the warm  bath, it is strongly recommended by a host
of authorities.  By some practitioners calomel is directed in enormous
doses, far greater than we should be inclined to prescribe; we never-
theless believe that the good effects of the remedy, in a disease of such
rapid progress as croup, can  be  obtained only from its free adminis-
tration.
   After the first  bleeding, the operation of an  emetic, and immersion
in  the warm  bath, from  two  to five grains of calomel may be pre-
scribed every two hours, so long as the  symptoms of the disease con-
tinue with  any degree of violence; as  these subside, the dose of the
remedy may be reduced, or it may be  exhibited at longer intervals.
We have generally found, however, that when the  use of the calomel
produces at an early period, deep green discharges from the bowels,
it  is better to reduce the dose;  or if frequent green discharges still
occur under its use, to discontinue it entirely. We have in no instance
seen any bad effects from  the employment of calomel in this  manner,
but often  the most  decided  benefit.   Its tendency is to  reduce the
laryngeo-tracheal  inflammation, and thus to counteract the pseudo-
membranous exudation.
   The hydrochlorate of ammonia appears to us to be a remedy well
adapted to nearly all the inflammations  attended with diphtheritic effu-
sions; we have employed it pretty extensively for many years in croup,
and have always been pleased with its effects.  Chamerlat recommends
it as almost a specific, when employed  as a wash or gargle.
   In  the early stage of those  cases of croup in which  the disease is
preceded by pseudo-membranous angina, M. Guersant, Jr., (Gazette des
Hopitaux, Nos. 48-52), strongly recommends the local application  of
the nitrate of silver.  In  the  cases referred to, the symptoms are  at
first but little urgent; and  a physician who is not accustomed to treat
children, will often neglect to examine the throat. M. Guersant lays it
down as an invariable rule to make such examination whenever a child
manifests any febrile reaction ; and in this manner he  has frequently been
enabled to detect the approaching disease, the presence of which would
not, otherwise, have been  suspected.   At first, and while  the tonsils
alone are covered with the plastic exudation, although the  symptoms,
as already remarked, are not severe—it is, nevertheless, according  to
M. Guersant, a precious moment  for the  physician, as he may now
frequently arrest a disease, which, if allowed to go on, is usually fatal.
  While employing the solid caustic, M. Guersant directs the child  to
be held by  a strong assistant, the tongue to be depressed  by a  broad
instrument, as a very large spatula, or the handle of a large spoon, or
what  M. G. prefers, a  large wooden tongue depressor.  For fear  of 
330
DISEASES  OF CHILDREN.
accident, the caustic  should project only very slightly from its  case.
Many  practitioners  prefer the  caustic  in solution.  In the  earliest
stage of the disease a weak solution, applied  three  times a day, will
suffice, but in serious cases the solution must be very strong—1 part
to 3 or 4 of water—and need, then, be used only once a day.  It may
be applied by means of a sponge fixed to the  end of a piece of whale-
bone by sealing wax.  To prevent the  extension of the  false  mem-
brane, the caustic should be applied  beyond its margin as well as upon
it.   The application,  M. Guersant remarks,  frequently  dissipates the
exudation from the  tonsils, and yet  it may  extend to  the epiglottis.
The caustic is still our best remedy.   A larger sponge is now required,
which  must be  fixed  upon  a strong whalebone, bent  at an obtuse angle.
The operator places  himself on  one side, and, introducing  the sponge
directly to the  base  of the tongue, executes  some  semi-rotary move-
ments.  Sometimes the  epiglottis is raised, and the  fragments of false
membrane are  detached from its inferior surface, which may be known
by the paroxysm of dyspnoea this gives rise to.  The caustic, in these
cases, requires  to  be repeated three  or four times  in the twenty-four
hours.
   A number of cases are  on  record in which the  treatment here re-
commended was pursued with entire success.  In those cases in which
the  pseudo-membranous exudation is still confined to the  pharynx, it
is certainly deserving of a fair trial.
   Blisters  to the throat are  strongly recommended  by many practi-
tioners in the treatment  of croup.   Mackintosh confines their applica-
tion to the first stage, after the violence of the  disease has been reduced
by bleeding and leeching.  Dewees doubts their utility; and Goodlad,
Stokes, and  Porter, condemn  them entirely.   We  have occasionally
employed them, but cannot say that we have perceived any benefit to
result from their use.
   Rubefacients, followed by  warm  fomentations  or emollient  cata-
plasms to the throat, will, in the forming stage of the  disease,  be often
productive of the  best effects.   As  a  rubefacient, the  spirits of turpen-
tine is the one  we have generally employed:  its action  upon the skin
is prompt and  sufficiently powerful; a strip of flannel  wet with turpen-
tine should be  applied  around the neck, and kept on  for ten or  fifteen
minutes;  it may be reapplied  at short intervals, from time to time, if
necessary.   In very violent cases, in the incipient stage of the disease,
even rubefacients should not be resorted to until after bloodletting.
   A German  physician,  Dr.  Willige,  states  (Schmidts  Jahrbiicher,
 1847),  that  he has been very successful in the treatment of  severe
cases of croup by the external application of iodine  to the upper part
of the neck.  He  directs the tincture of iodine to be applied by  means
of a feather over the front portion of the neck, corresponding to the
larynx and trachea, and repeated several times, at intervals of about
four hours, until irritation and  redness of the skin are produced.  In
 most cases, he declares this to be followed by a subsidence of the diffi-
 culty of respiration, the spasmodic affection of the glottis, and the other
distressing symptoms.  He details three cases in which  he  believes 
          DISEASES OF  THE RESPIRATORY ORGANS.     331

 that by the external application of the iodine, he succeeded in averting
 impending death.
   When the disease persists, after the use of the lancet, leeches, eme-
 tics, and calomel, very great advantage will  often be derived from a
 tobacco cataplasm,  composed  of the moistened leaves  of tobacco,
 mixed with the  crumb of stale bread or ground flaxseed, and applied
 around the throat.  The effects of the  cataplasm should  be carefully
 watched, lest its depressing effects be carried too far.
   After the pseudo-membranous exudation  has occurred,  our  chief
 dependence is to be placed on the use of calomel and tartrate of anti-
 mony; the latter being occasionally carried to a sufficient extent to ex-
 cite vomiting.  The administration of repeated emetics in  this stage,
 was  the practice pursued by Jadelot, Steinmitz, Cheyne, and Currie,
 and the result of their experience is certainly decidedly in  its favour.
 Tartrate of antimony was the  article  employed by these physicians;
 and Cheyne states, that the only cases he saw recover from the second
 stage of the disease, were those in which the patient was kept under
 its effects  for two or three days.  Fielitz, Hoffman, and Droste em-
 ployed the sulphate of copper, in  the dose of one-fourth to one-half of
 a grain  every two hours.  It is in this stage that the tincture of lobelia
 will often be found advantageous; or, perhaps the infusion of the San-
 guinaria Canadensis.*  We  know nothing of the latter remedy from
 our own experience; it comes to us,  however, very  highly recom-
 mended by respectable practitioners.
   It often happens, from the impediment to haematosis, produced by the
 effusion within the respiratory tubes, and the deficient innervation from
 the venous  congestion of the brain, that emesis is with difficulty pro-  £ H£cc>
 duced,  even by  very considerable  doses of antimony; it has under^ ~vc-+~>1 >
 these circumstances been recommended to employ the sulphate of zinc
 or of copper in solution, alone,b or combined with ipecacuanha.
   a R.—Rad. sanguinar. canadensis, pulv. 9j.  b R.—Sulph. zinci vel cupri, 3ij.
       Aquae calidae, 3iij-—M.                Aquae, 3j.—M.
  Dose.—A teaspoonful every half hour.     Dose.—A teaspoonful every twenty minutes.
   In conjunction with emetics, either in full or nauseating doses, and
 calomel, the frequent use  of  warm sinapised pediluvia will generally
 be found advantageous.
   After the violence of the disease  has been to a considerable extent
 reduced, or the case  has  assumed a somewhat chronic character—
 when a dry, hoarse cough, with oppressed breathing, increased at in-
 tervals, but with little febrile excitement or tenseness of pulse, remains,
 a strong decoction of senega  will be often found a  useful  auxiliary to
 the other remedies.*
                     a R.—Rad. polygalae senegre, gj.
                          Aq. bullient. Oj.
                     Simmer to 3xij. then add Mellis, 3iij-
      Dose.—One, two, or three teaspoonfuls, every one or two hours; according
            to the age of the patient, and the urgency of the symptoms.

   In the third  stage of the disease, blisters  may be applied upon the
upper part of the chest, or between the shoulders; sinapisms, or cloths
wet with hot turpentine, or the decoction of turpentine and cantharides, 
332
DISEASES OF CHILDREN.
may at the same time be applied  to the extremities, and internally a
strong decoction of senega, with the addition of camphor and assafoe-
tida, may be resorted to; and if there is great and increasing exhaus-
tion, it will be proper to support the patient's strength by ammonia or
wine whey.  Occasionally, even under apparently the most desperate
circumstances, recovery will ensue; but seldom, when the disease has
reached this stage, will its fatal termination be arrested by any course
of treatment.
  Of the  good effects of musk, given  in  large doses, from  twelve to
twenty-four grains in the course  of twenty-four hours, in  the latter
stage of croup, we have certainly  very strong testimony. Assafoetida,
likewise, has been extolled, given as well by the  mouth, as by injection
into the rectum,  to the extent of half a drachm to a drachm a day.
  By some of the European physicians, the employment of cold affu-
sions upon the back, from the occiput to the sacrum, has been strongly
recommended in cases where every other remedy has failed to afford
relief.  The immediate effects ascribed to the cold  affusion, are cer-
tainly surprising, but the result of  the practice is not such as strongly
to press it upon our attention.
   The operation of tracheotomy has been suggested by some as a last
resource in cases  of  croup, and  by others as a measure that should
only be resorted to before effusion has  taken  place  in the trachea.
Among the advocates of the  operation are Home, Huxham, Caron,
Maingault,  Hosack, Farre, Maslhieurat, Berard,  Petel, Trousseau,
Valleix; while it is opposed by Crawford, Ferriar, Cheyne, Vieusseux,
Double, Albers, Jurine, Royer-Collard, Porter, Bricheteau,  Becquerel,
Boudet, and others.
   In the cases in which tracheotomy was performed by Guersant and
the hospital internes, in the Parisian Hospital for Children, during the
year 1841, the operation, while it was of no advantage whatever when
the pseudo-membranous exudation extended into the bronchi, appeared,
in many cases, to accelerate the fatal termination, by inducing severe
bronchitis or an  excessive secretion of mucus in the bronchi, pneumo-
nia, or convulsions; while in many cases the patient died immediately
after the  operation, without any  local lesion existing, to which the
fatal termination could be referred.
   The subject of tracheotomy in croup is  certainly one of considerable
interest.   That it  may, in many  cases, when timely performed, save
the life of the patient, we have the most unquestionable evidence.   In
a statement of Trousseau  of the result of the operation in one hundred
and fifty cases, the  patients recovered  in thirty-nine, and  M. Valleix
gives seventeen  cases  of  recovery out of fifty-four, of unquestionable
pseudo-membranous croup, in which the operation was performed.  In
the case of his own child, three weeks old, published by Dr. Scoutetten,
the operation was performed  on  the third day of the disease, under
circumstances apparently the  most desperate,  with  complete success
—the infant recovering in a short time from the effects of the opera-
tion, as  well as from every  symptom of the croup.  A  somewhat
similar case was related by Dr. C. D. Meigs to the  College of Physi-
cians of Philadelphia.—(Summary of Transactions, vol. ii. page 275.) 
         DISEASES  OF THE RESPIRATORY  ORGANS.     333

The class of cases, the period and particular  circumstances of the
disease, in which the operation is most likely to afford relief, are ques-
tions of no little importance, and it is more  than  probable  that much
of the want of success experienced from the operation, is to be attri-
buted to  its  having been resorted  to  under  improper circumstances.
M.  Trousseau, whose experience on this  subject  has been  somewhat
extensive, has presented the following  as a summary of the prognosis
of tracheotomy in croup.
  1st.  If the commencement of the attack  dates several days back, the
disease having advanced slowly—whatever  may be the extent of the
false membranes in  the trachea and bronchi, the child either recovers,
or,  at least, lives several days after the operation.
  2d.  If the child has  been subject to chronic catarrhs, and when  he
has been suffering  from a cold  for some time before the attack of
croup, the operation is more successful.
  3d.  So long as the respiration  is silent, or the noise is only occasion-
ed by the displacement of mucosity, there is nothing to fear ; but when
the respiration is attended with a sound like that produced by the saw-
ing of stone, death is certain.
  4th. If the croup supervene upon measles, scarlatina, small-pox or
pertussis—tracheotomy does not  succeed.
  5th. There is no  reason to despair of the  patient, even if an attack
of pneumonia or pleurisy should  supervene.
  6th.  When the disease has been very rapid, even though at the time
of the operation the  false membranes do not extend beyond the larynx,
the child dies very quickly.
  7th. When, previous to the operation, the false membranes have ex-
tended to the nares, or if they cover the blistered  surfaces—when the
child is pale, and somewhat  bloated, without having taken mercury or
been bled—or when he has lost much blood, there is little to  be expect-
ed from the operation.
  8th. When, previously to  the operation, the pulse is moderately fre-
quent ; and  if, after it the pulse remains  calm, hopes may be enter-
tained.
  Oth. The  more deeply the false membranes  have extended,  the
greater, caeteris paribus, the  danger.
  10th. It is a bad sign, if, immediately after the  operation, the respi-
ration  becomes very frequent, without or with very little cough; even
when all is going on favourably, the occurrence  of a very great fre-
quency of respiration is a bad sign.
  I lth. More boys than girls recover after the  operation; but chil-
dren under two and over six years of age  seldom  recover.
  12th. The more rapid and energetic the  inflammation which attacks
the wound in the trachea, the more are   the chances of success; a
sudden sinking of the wound is a mortal sign.
  13th. Should the  wound become covered with false membranes ;  if
after withdrawing the canula, it  remains gaping for a long time, or if,
after having become completely cicatrized, it reopens largely, the child
is in danger.
  14th. Agitation and sleeplessness are bad signs, so is also the oc- 
334
DISEASES  OF CHILDREN.
currence of convulsions.   The younger  the patients, and  the  more
blood they have lost before or during the operation, the more liable are
convulsions to supervene.
   15th. The  sooner after  the operation the larynx is  disembarrassed,
the sooner may the canula be removed, and the more rapid and cer-
tain the cure.
   16th. If the  expectoration becomes mucous and catarrhal by the
third day after the operation, the child will recover.   If there  is  no
expectoration, or  it is  serous, or like half-dried portions of gum arabic,
he will die.
   17th. If the  patient reacts vigorously under  the injections into the
trachea,  of warm water  or a  solution of nitrate of silver, and the
sponging out of the trachea,  we should not despair, however unfavour-
able the other symptoms.
   18th. When, after  the  tenth day, the  drinks pass  almost entirely
from the pharynx into the larynx and trachea, even if they are readily
rejected, the child most generally dies.
   19th. The  increase of the fever after the fourth day, agitation, sink-
ing of the wound, dryness of the trachea, frequency of the respiratory
movements, and attempts  to  cough, announce the invasion of pneumo-
nia, which, at first lobular, becomes sometimes pseudo-lobar, and is to
be treated by the same means as are employed  in the pneumonia of
children ;  we should  however exclude blisters,  because they too often
become covered with  false membranes.
  We have said nothing, as  yet, on the subject of diet in  croup.  Du-
ring the forming stage, the diet should be the same as in violent cases
of bronchitis: during  the  height  of the disease, little  or  nothing else
should be allowed, than some mild,  mucilaginous fluid, in  small por-
tions at a time; while after the disease has  been  subdued, and through-
out  the  period of convalescence, the child should  be'  allowed the
mildest and  most  unirritating articles of food, care being taken that
even in regard  to  these, no excess be committed.
  For a long time after recovery, there is very considerable danger
of a relapse, upon the slightest exposure to cold or moisture, or to the
most trifling transitions of  temperature; from these, therefore, the child
who has recently  recovered from  an  attack of croup, should be care-
fully guarded, by  appropriate clothing, and  every other judicious pre-
caution.  The daily use of the warm bath, and daily  exercise in the
open air, during mild and  dry weather, should never be neglected.

                     7. — Spasmodic Croup.
 millar's asthma.—laryngismus stridulus.—spasmodic laryngitis.—
                           false croup.
  There is a  form of disease of frequent occurrence during childhood,
which has very generally been confounded with croup, to  which it
bears a strong resemblance  in some  of its features, but differs from it
nevertheless, in its less serious character, and the absence of any ten-
dency to the formation of  false membranes in the air-passages.   The
disease to which  we  allude has  been variously  named  by different 
         DISEASES OF THE RESPIRATORY ORGANS.     335

writers.  Millar, who was the first that directed attention to it, deno-
minated  it Asthma, which name was retained by Wichmann and
others; Bretonneau named it Stridulous Angina, Guersent, Laryngis-
mus Stridulus, while Rilliet and Barthez prefer the denomination Spas-
modic Laryngitis, as indicating what they believe to be the true cha-
racter of the disease.
  The attack of spasmodic croup is usually preceded, for a day or two,
by slight catarrhal symptoms; coryza, watering at the eyes, a sense
of chilliness followed by flushes of heat; slight hoarseness, and cough.
The paroxysm usually occurs during the night, though  it occasionally
takes place during the day.  The child is, generally, suddenly awoke
from sleep by a sense of impending suffocation.  He starts up in a sitting
posture, or throws himself upon his knees, with the body bent forward.
He cries out that he is suffocating, tears away every covering from
his  throat, and pushes away those who  surround, or  offer to assist
him.  The face becomes congested, and  of a red or  violet hue, the
eyes projecting and  humid, and the expression of the  countenance
anxious in the  extreme.  The respiration has  a peculiar prolonged
hissing sound, which is occasionally so loud that it may be heard in a
neighbouring apartment.  There is  at the same time a frequent hoarse
cough.  The voice is constrained, but seldom whispering or abolished.
There is great quickness of pulse and heat of the skin.  After continu-
ing for a short time the paroxysm ceases suddenly, and the child falls
asleep.
  The disease may be confined to a single attack,  or a second attack
may succeed  upon  the  same  night;  more usually,  the child con-
tinues during the ensuing day tolerably well, though  in many cases
affected with hoarseness, and a  frequent  short, barking  cough, with,
or without expectoration, and  during the night following is  again
attacked with a  paroxysm of suffocation.  The disease may con-
tinue  in  this manner for several  days, and then the paroxysms cease
to recur, and the cough  and remaining symptoms speedily disappear.
In a case detailed by Jurine, a  decided alteration of  the voice con-
tinued  for a long  time  after the cessation of the disease.  In some
cases, the paroxysms continue to recur, and at the same time to aug-
ment in intensity, and death finally takes place from asphyxia.  In
other  instances, after one  or more  paroxysms have taken place, the
patient becomes affected with the utmost  inquietude, constant nausea,
repeated vomiting, with great exhaustion, and  a small  frequent pulse,
and soon sinks.   Usually, however, the disease is one readily managed,
and having very seldom a fatal termination.
  Spasmodic croup is one very liable to return.  According to  Rilliet
and Barthez, its recurrence may take  place at the end  of six months
or of one or two years.   In a case reported by  Vidal,  the first attack
occurred when the child was two years old, the second when  it was
five, and then in a space of three months, it had three attacks.   We
have seen it more frequently recur at intervals of nine and twelve
months, than at shorter periods; we have known it, however, to attack
three times within the same year.
  The prognosis in  spasmodic croup  is to be drawn chiefly from the 
336
DISEASES  OF CHILDREN.
progressive  violence of the  paroxysms, and  the  short  intervals at
which they  recur.   When they do not continue  to  recur beyond
the second or  third day—and gradually decrease in intensity—when
the voice is  but little affected—the cough moist—and the febrile reac-
tion slight—a favourable termination may be anticipated.  When, on
the contrary, the paroxysms are protracted beyond the third day, and
gradually increase in violence; and particularly, when the paroxysms
are succeeded by a state of great restlessness, nausea, and vomiting;
when the pulse continues soft and feeble, when a  suffocative cough
remains, and when the patient's strength gradually diminishes, an un-
favourable termination is to be apprehended.
  The true pathology of this affection has not as yet been very accurately
made out.   Millar, and after him most of the German physicians, have
considered it to be a purely spasmodic disease, somewhat resembling
hooping cough, while  Desruelles  and  Bricheteau  believe  it to  be
merely the first stage, or a very mild form of croup.   Guersent sup-
poses it to consist in a transient inflammation of the mucous membrane
of the larynx; Bretonneau considers the local affection to consist in
mere congestion of short continuance; a simple, transient intumescence
of the rima glottidis.  Rilliet and Barthez believe that the disease con-
sists in an  actual inflammation of the  larynx, and they found their
opinion upon the fact of the attack  being generally the result of a sud-
den exposure to cold; the disease  being  usually preceded by coryza,
watering of  the eyes,  oppression, &c, and attended by some degree
of febrile excitement; in connexion with this mild laryngitis, they pre-
sume that there occurs a spasmodic affection of the glottis, by which
the sudden paroxysms of suffocation which  characterize the disease,
and which are excited by the slightest causes, are produced.   The
correctness of this opinion is borne out by our own observations.
  That the  disease is  connected with some degree of laryngeal in-
flammation is proved by the result of post-mortem examinations.  For
although these have been but  few in number,— the disease rarely  ter-
minating in  death—yet not unfrequently  traces, more or less decided,
of inflammation of the mucous membrane of the larynx, are to be de-
tected ; even when  no increased redness of this exists, its  secretion
will  generally be found augmented, and of an opaque yellowish  or
reddish  colour.  When death takes place with great suddenness, it is
probable that it is the result of the spasmodic closure of the glottis, and
the consequent asphyxia.
  The spasmodic croup is essentially a disease of children; according
to Guersent  it occurs most frequently between two and seven years,
and according to Rilliet and  Barthez between three and eight.  We
have met with it in children of nine or ten months, but less frequently
than in those between two and eight years.
  There is  unquestionably, in many instances, a peculiar predisposi-
tion  to the  attacks  of spasmodic  croup in the children  of  the same
family; we  have  known families  in  which  all the  children when
they attained the age  of between  two and  three years  successively
affected with it.   This predisposition is said, in many instances, to be 
          DISEASES OF THE RESPIRATORY  ORGANS.     337

 hereditary.   The disease occurs more frequently in boys  than  in
 girls.
   Though generally sporadic, it occasionally prevails as an epidemic.
 Jurine describes  an  epidemic of  spasmodic croup which occurred  in
 Geneva in 1808.
   Its occasional  cause  is, almost exclusively,  exposure  to  cold, or a
 sudden alteration of the temperature.  After an attack has happened,
 the occurrence of any sudden or violent mental emotion  is liable to
 excite a paroxysm.
   The disease with which spasmodic croup may most readily be con-
 founded, is tracheitis  or genuine  croup.  The following comparative
 diagnostic peculiarities, borrowed partly from Valleix, and partly from
 Rilliet and Barthez, will  enable the two  diseases, very readily to be
 distinguished.
   In Genuine Croup.  The disease commences with fever of variable
 intensity, and, most generally, pseudo-membranous angina, and  slight
 hoarseness.
   There is a gradual increase of the hoarseness, to which, sooner or
 later, there is added  a hoarse ringing cough.
   The fever does not remit; the cough becomes  hollow and feeble,
 and the voice faint or extinct.
   There is occasionally an expectoration of false membrane.
   The dyspnoea  constantly increases in intensity—the croupal sound
 continues during  the intervals of the paroxysms—finally, the voice and
 cough become extinct.
   In Spasmodic Croup.   The  symptoms of invasion are slight—there
 is generally  a slight catarrh, and  a  cough  somewhat hoarse—the
 throat is unaffected—sometimes there are no prodroma.
   The paroxysms attack suddenly—usually at  night.
   Between the  paroxysms the patient appears tolerably well—the
 fever disappears or declines—the  voice may be hoarse, but  never be-
 comes extinct.
   There is an expectoration of mucus.
   The paroxysms gradually decrease in violence.
   The remedies  to be employed  in  a  case of spasmodic croup will
 depend pretty much  upon  the violence of  the  attack, and on the age
 and  condition of  the patient.  When the indications of  laryngeal in-
 flammation are strongly marked, and when the spasmodic paroxysms
 are very violent and prolonged, the application  of leeches to the throat,
 in numbers proportioned to the age and strength of the child, will be
 demanded.   When the  patient is over  five years  of  age, and of a
 robust habit,  a bleeding  from the arm will  often be attended with the
 best effects.  In no case, however, should the amount of  blood drawn
 from the arm or by leeches be considerable, nor the  operation repeated
 at short intervals, or too late in the disease.
   The warm bath is always  an  important  remedy; it  maybe em-
ployed in the  commencement of the attack, or subsequent to bleeding.
   Lehmann advises, at  the very onset of the paroxysm, the applica-
tion of a sponge,  of the  size of the fist, dipped  in very hot water, and
then carefully squeezed  in the hand, to the fore part of  the neck; it
                              22 
338
DISEASES OF CHILDREN.
being left a moment in contact with the skin and  its application re-
newed at short intervals.   This produces a redness of the neck, and a
general perspiration, which is to be promoted by the exhibition of the
infusion of elder  and  camomile.   By  this  means, we  are  told, the
paroxysm is  cut  short, and all the leading symptoms of the disease
quickly removed.
  When the  paroxysm  is very violent and long continued, and there
is danger of asphyxia occurring unless immediate relief be obtained,
the operation of tracheotomy should be performed without delay.
  An emetic given on the  first accession of the disease, will often,
when followed by the warm bath and  sinapisms to the extremities,
have the effect of abating  the violence of the paroxysm and shorten-
ing its continuance.  When considerable hoarseness of the voice, and
a short barking cough continue during the intermissions, the exhibition
of an emetic will be found  advantageous—generally removing very
promptly the remaining symptoms, and preventing a recurrence  of a
paroxysm.
  We have usually preferred, in the cases  occurring in young  chil-
dren, the ipecacuanha to the emetic tartar—excepting where this, as
is often the case, fails to produce a prompt and full operation; under
these circumstances,  as well as in  older  children,  we have never
hesitated to prescribe the tartarized antimony.  We are in  the habit
of giving  the ipecacuanha in small  nauseating  doses, every two or
three hours, either alone or  combined with extract  of hyoscyamus,
in the intervals of the paroxysms, and have invariably been much
pleased with its  effects.   In mild  cases, small  repeated  doses of the
mel scillse  compositum of the United States  Pharmacopoeia, may be
advantageously substituted for the ipecacuanha.
  Blisters upon the chest or between  the shoulders are recommended
by some writers—when employed, they should  be allowed to remain
on only long enough to redden the skin, when the parts occupied by
them should be  covered  by a soft  emollient  poultice.  We have
seldom, however, seen  much  good  result  from  the  application  of
blisters in cases of spasmodic croup.  Covering the  breast, however,
with a hemlock or assafoetida plaster, has  appeared to us very gene-
rally to have a decidedly beneficial effect.
  Purgatives are only required in those cases  in which their use is
indicated  by a costive  or  torpid state of the bowels.   Here a dose of
calomel, followed by castor oil or magnesia, will be proper, and a free
state of the bowels should be subsequently maintained  by an occasional
dose of some mild laxative.
   Assafoetida, either by the mouth  or by enema, is  unquestionably a
remedy from which the best effects are to  be  anticipated in violent
cases of the  disease, subsequent to depletion and the  use of the warm
bath.  It should  be administered a few hours after the paroxysm has
terminated.
   Wichmann recommends the musk as  a specific  in this disease;
Henke, Wendt, Goelis, and  others, speak also in strong terms of its
curative powers; Wendt gave it in the dose of a grain every hour.
   It  is all-important  that the  child  affected with spasmodic croup
should be kept in a state of perfect tranquillity, warmly clad, and in 
          DISEASES OF THE RESPIRATORY  ORGANS.       339

an apartment where the atmosphere is pure and of moderate and equa-
ble temperature.  During the paroxysms he should  be supported in an
erect posture and all covering or  ligatures should be immediately re-
moved from  about the neck.   His food should be light and of easy
digestion—his drinks should not  be given cold—tepid  lemonade or
barley water slightly acidulated, will perhaps be  the best.

                    8.—Spasm of  the  Glottis.
                 (THYMIC ASTHMA.--KOPP's ASTHMA.)
   This disease, which consists in  a sudden  spasmodic closure of the
glottis, giving rise to a severe  paroxysm of dyspnoea, and  a peculiar
crowing sound in inspiration,  as  if from strangulation, but without
fever,  and often  without any  material  derangement of the general
health, is of much more frequent occurrence than is generally supposed.
It has often been mistaken for and treated as croup, and in its  milder
form it has received the vague term of "inward fits."
   The disease generally comes on suddenly.  The child, apparently
in perfect health,  is suddenly seized, either upon  awaking from sleep
or in taking drink or food, or upon being teased or irritated,  with a
difficulty of respiration;  inspiration being often entirely suspended for
a  few  seconds.   After violent, even  convulsive struggles, he  finally
succeeds in getting breath, with a shrill crowing sound, not unlike the
ringing inspiration of the hooping cough.
   In severe attacks, during the vehement efforts  at inspiration, the
whole of the respiratory muscles are thrown into violent action.  The
nostrils are dilated, the mouth is extended, the eyes are rolled upwards,
and the whole countenance expresses the utmost anxiety and suffering.
The head is thrown backwards;  and the chest upwards; the dia-
phragm  and abdominal muscles contract violently,  and  even the ex-
tremities become rigid, while the feet and  hands are cold.  The face
is commonly pale, or of a livid cadaverous hue, and the external veins,
turgid with highly carbonized blood, form black streaks upon the fore-
head and temples, which, according to Ley, may continue  long after
the cessation of the paroxysms.  The backs of  the hands and  insteps
are often swollen and hard; the thumbs are rigidly contracted, and
locked across the palms of the hands, and the toes  are bent down to-
waids the soles of the feet; the wrists and  ankles  being rigidly and
permanently bent by the  action of the flexor muscles.  In many cases
these carpo-pedal contractions are  of a very singular appearance, and
in the opinion of Rees, characteristic of the disease; the fingers being
extended  upon themselves, but semiflexed upon  the metacarpus, and
this at times upon the carpus;  in the same manner  the toes  are  flexed
upon the metatarsus.
   The attacks of the disease are paroxysmal, and vary in duration and
intensity.   At first a single paroxysm may occur, and  after a short
time, often a few minutes, cease spontaneously,  and the breathing, at
first somewhat hurried, soon become  perfectly free and  regular, and
the child present  no apparent indications of disease.  Days, and even
weeks may pass without the occurrence of a second paroxysm ; but in
other cases, the paroxysms recur  with  alarming frequency, and  are
protracted to fifteen or thirty minutes, or even longer; while, in many 
340
DISEASES OF CHILDREN.
cases, the paroxysms recur with such rapidity that there is scarcely a
complete interval; their intensity and duration  increasing, generally,
with their frequency. In the early periods of the disease, the paroxysms
usually occur  in the night, or after  a tranquil  sleep,  from which the
child awakes as it were in a fright, and the difficulty of inspiration im-
mediately ensues; but when the disease is more fully established, the
paroxysms take place at all times of the day or  night.
  Other symptoms are described as of constant or occasional occur-
rence, thus, Kopp has noticed a thrusting out of the tongue between
the lips, which is also  present to a certain extent during the  intervals
of the paroxysms;  Hirsch, an involuntary discharge of the  contents
of the bladder  and bowels; and, in severe cases, Caspar has observed
a convulsive contraction of  the muscles of the  hands, and abductors
of the thumbs, during the intermissions.
  Immediately preceding, as well as subsequently to, a paroxysm, the
sound of the patient's breathing is that which would result from an in-
creased secretion of mucus in the respiratory tubes.
  The patient  may expire during the first paroxysm of asphyxia; or
the disease may be  protracted to many days, weeks, or months, and
death be preceded by epileptic convulsions, deep coma, hydrocephalic
symptoms, or  those of acute meningitis.
  Spasm of the glottis is to be distinguished from spasmodic croup by
the absence of all catarrhal symptoms, febrile excitement, and cough,
and by the contractions observed in  the extremities.
  The appearances upon dissection are very various.  The  thymus
and. cervical glands are often  enlarged or in a state of disease.   The
heart is  often  found empty  and flaccid.  The lungs are generally
gorged with dark-coloured blood.   The vessels of the brain are also
often unduly distended, and serous effusion between the membranes, in
the ventricles,  or at the  base  of the brain, is  of frequent occurrence;
tubercles of the brain  are often met with, and occasionally, hyper-
trophy, or  induration of its  substance.  The foramen ovale is often
found open, and not unfrequently, there exists more or less disease of
the gastro-intestinal, and in some cases, of the respiratory mucous mem-
brane.   No one of these morbid appearances is, however, constantly
present in the  bodies of those who have died of spasm of the glottis.
Perhaps, judging from the cases on record, most of which have, how-
ever, been adduced to support particular pathological views, we ought
to enumerate enlargement of the thymus hody, and effusion within the
cranium, as among those most commonly met with; but upon a more
minute inquiry, we suspect that enlargement of the thymus body will
be found a  much less frequent accompaniment of the disease than has
been asserted.
  Spasm of the glottis is almost exclusively  confined to the period of
infancy  and childhood; it may attack, according to Kerr, at any
period from within  a few days after  birth, to three years, but most
commonly  it occurs between the fourth and tenth month; Mr. Robert-
son,  (London Med.  Gaz., Jan.  1849,) has found the accession of the
disease  to  be  most  frequent from about the fifth to the twelfth month.
Of twenty-one cases related by him, in three only did the disease occur
in infants beyond twelve, and in none were the infants beyond fifteen 
                  DISEASES OF  THE RESPIRATORY  ORGANS.       34j

       months of age.  Most of the writers enumerate the lymphatic tempe-
       rament as one of the predisposing causes of the disease;  it is in con-
       sequence of this that we find it to attack almost all the children  of
       some families,  while  those of others  are  entirely exempted  from  it.
       The predisposition from organization may also account for its greater
       prevalence in  some localities than in others.   Thus it  is generally
       admitted that the disease prevails much more in cold and damp, than
       in temperate or warm climates.   In Mr. Robertson's cases the attack
       occurred between the months of October  and  May.  As the patients
       belonged to that class of society the infants of which  are at this season
       of the year in a great measure confined within the limits of the nursery,
       he thinks it probable that it is by this seclusion from the  external air
       the predisposition to the occurrence of spasm of the glottis is induced,
       a conclusion which the fact of the disease being one rarely observed
       in the infants of the labouring classes, who are abroad in almost  all
       kinds of weather, daily, throughout the  year, would seem to favour.
       As exciting causes  he enumerates the irritation of teething, disturbance
       of  the  digestive organs,  and any  sudden excitements.  Dentition
       is,  unquestionably,  one  of its  most  common  predisposing  causes;
$      nearlyt all  the  cases  upon record occurred during, or  immediately
       preceding the evolution of the first set of teeth; and we have but few
       instances of the disease occurring beyond this period.   Among the
       exciting causes may be enumerated sudden  motions, or any agitation
       of the  body, improper food, fright, or any violent or sudden mental
       excitement; impure, confined, or  some particular condition of the at-
       mosphere ; exposure to  a current of  cold air, efforts to  swallow,  or
       even suddenly stooping to  pick something from the ground.
         North includes it among the premonitory symptoms of  convulsions,
       and Beatty considers it in many instances to  be one of the earliest
       symptoms  of incipient hydrocephalus, which accords with our own
       experience.  Goelis describes all its symptoms as occurring in the ad-
       vanced stage of chronic hydrocephalus.
         Laryngismus stridulus, as we have already remarked, consists essen-
       tially, in a spasmodic closure of the glottis, impeding the ingress  of air
       into the lungs, and sometimes so completely closing it, as to suspend,
       for a few seconds, the respiration  entirely.   Mr. Ley, however, denies
       that the difficulty of inspiration is owing to a spasmodic closure  of the
       glottis, but maintains that it is due rather to the inability of this part to
       enlarge to its normal size,  from a want of  innervation, in  consequence
       of pressure upon the nerves by diseased glandulee concatenatae.  From
       the same cause he conceives, that  the transverse fibres, behind and
       connecting the  rings of the trachea, lose their contractile power, and
       allow the sputa to accumulate, giving  rise  to the rattling  sound  heard
       in the upper part of the trachea, particularly when the patient is asleep.
       Few, however, have adopted these views of Mr. Ley,—the spasmodic
       character of the disease being admitted by  the generality of those who
       have studied its phenomena with care.
         Upon the nature of the cause by which the spasmodic affection of
       the glottis  is produced, there  exists a  very great diversity of  opinion.
       By the greater  part of the German medical writers, and many of those
       of Great Britain, it  is referred to an enlarged or  diseased condition of 
342
DISEASES OF CHILDREN.
the thymus gland, and numerous observations have been recorded, in
support of this hypothesis, by Kopp, Frank, Kirmaul, Hirsch, Ecke,
Van Velson, Most, Kyll, Montgomery, Hughes, Flackman, Rees, Mit-
chell, Pury, and others.  This  view of  the pathology of the disease
would  appear to be very fully  made out, were we  to  take only  the
quantity, without reference to the quality of the evidence upon which
it rests.  But, when  closely investigated, this will be found defective
in many important points.
  There has not been adduced  a single well-established fact, to show
that a hypertrophied condition of the thymus gland is capable, under any
circumstances, of exerting upon the nerves which pass in its vicinity,
such a degree of pressure or irritation as would produce  the pheno-
mena of the disease  under  consideration.   M. Trousseau, who refers
the disease to a spasmodic  condition, with want of harmony in the  ac-
tion of the respiratory muscles,  states, that during the six years he  has
been at the head of  the wards of his hospital, he has not in a single
instance, met with the thymus  gland sufficiently enlarged to give rise
to the slightest inconvenience.   We have numerous observations upon
record, which prove that the thymus gland may be greatly enlarged,
and that numerous enlarged lymphatic glands may exist in  the course,
and in immediate contact with  the laryngeal  nerves, without the  oc-
currence of the disease, even in its mildest form.  We are, in fact, so
little acquainted with what constitutes the exact normal  size of  the
thymus gland—it being found  to vary materially in bulk and weight,
in different subjects,  during a state of apparently perfect health—that
it is very difficult to determine,  with certainty, when it is  to be consi-
dered of abnormal size.
   From our own observations upon the  relative size of the thymus, at
different ages, from  birth to puberty, we  are strongly inclined to  be-
lieve that in many of the cases  recorded as instances of enlarged thy-
mus, the gland was  either  not  at all affected, or was actually below
the size which it frequently  presents in perfectly healthy children at the
same age.  We  are  to recollect, also, as Dr. Hall correctly remarks,
that its enlargement, even  when it occurs, may be the  effect and not
the cause of  the morbid phenomena.  It may be the natural result of
the violent convulsive  efforts  at  inspiration, observed  in this  terrific
malady.  The  thyroid gland has been known to become and remain
enlarged, in like manner, after the efforts of severe and protracted  la-
bour: the eyes to become  bloodshot from hooping cough; the  eyelids
to be distended with blood  from epilepsy, and  from the  efforts of vo-
miting and of parturition.   In this manner we can readily understand
how enlargement of the thymus may  be an effect of a  spasmodic
closure of the glottis, and   subside with  the disease, which would not
be the case if it was dependent on  change of structure.   Numerous
cases  are recorded  by Beatty, Rullman,  Toogood, Burgess, Ryland,
Marsh, Rees, and others, in which the disease was produced, entirely
independent of the slightest enlargement of the  thymus, or of any of
the cervical glands.
   Dr. Corrigan considers inflammation  of the cervical portion of the
spinal cord to be the cause of spasm of the glottis, and has published
an interesting case in the London Medical and Surgical Journal, (1836,) 
           DISEASES  OF THE  RESPIRATORY ORGANS.        343

to illustrate this position.  But this case, in which spinal irritation seems
evidently to have produced the disease, is a solitary one, and while  it
compels us to  admit that  spinal irritation may occasionally induce
spasmodic contraction of the glottis, does not prove it to be its only cause.
   Dr. Herard has made the disease the subject of an inaugural thesis.
He observed numerous cases of it in the Children's Hospital, af Paris.
He believes it to be the  result of spasm of the glottis,  or of the  dia-
phragm, and describes three forms of it, according as one or other, or
both of these organs are affected.   When  the  spasmodic  attack  is
limited to the glottis, the respiration is simply arrested  for a few se-
conds, and is restored  without the production of the special cry pro-
duced  by  inspiration  during  convulsions of  the diaphragm.  In  the
second form, in which the diaphragm alone enters into spasmodic action,
the attack  is marked by several successive and sonorous inspirations;
the symptoms of asphyxia are by no means so well marked  as  in the
first variety.  In the third form, both the glottis and the diaphragm are
simultaneously convulsed; respiration is first suspended, and one or
more sonorous inspirations are  heard, which, not being followed by
expiration, asphyxia is soon imminent.   These sonorous inspirations
resemble the crowing of hooping cough, and are produced by the same
cause.  Death may occur during the attack from asphyxia, from cerebral
disease, or  it may be the consequence of gradually increasing debility.
   On the examination  of the  bodies of children who have died of this
disorder, Dr. Herard asserts, that no characteristic alteration can be
detected.   As to the hypertrophy of the thymus gland, he refuses to
admit that it has anything to do with the production of the disease,
and shows from carefully drawn  up  statistics, that the volume of the
gland is in harmony with the states of health or the strength  or  weak-
ness of the constitution,  and not with the presence of asthma.  Dr.
H. attributes the large size which the thymus sometimes attains entirely
to the vigorous constitution of the child.
   The agency of hypertrophy of the thymus gland in its production,
is denied also by Caspar, Pagenstecher, Ley, Hall, Merriman, Fricke,
Oppenheim, Cheyne, and Clarke.   Mr. Ley attributes it to a suspended
or impeded state of the functions of that portion of the  eighth pair of
nerves, which  is distributed to the larynx, caused  by pressure from
enlarged cervical, and bronchial glands; while  Marsh  refers it to an
irritation seated at  the origin of  the pneumogastric nerve, and others,
with Clarke, Cheyne, Beatty, Rullman, Fricke, and Oppenheim, to dis-
ease of the brain.
   According to Dr. Hall, the disposition to spasm of the glottis con-
sists in a  peculiar  susceptibility of the excito-motor  property  of the
nervous system.  The immediate cause of the attacks being the  action
of sources of irritation or  excitement of this property; the  most ob-
vious of which are  dentition, indigestible food, morbid alvine matters,
external  agents,  and mental  emotions.  Nearly the same views  are
expressed by Mr. Ryland.  In one case related by him, however, the
latter is inclined to  believe, that the main cause of the paroxysms was
to be referred to bronchial  inflammation, which Mr. Ley also enume-
rates as an occasional exciting cause of the disease.
   Our own observations incline us to adopt the views of Dr. Burgess, 
344
DISEASES OF CHILDREN.
namely, that the disease is simply a spasmodic affection of the respira-
tory muscles;  its  chief exciting causes, when it occurs previous to
dentition, being an irritation of the digestive  organs, a cold, confined,
or impure atmosphere, and dentition;  but  that when it occurs during
and  subsequent  to  dentition, it is  almost invariably symptomatic of
cerebral disease.  Nearly the same views are expressed by Mr. Rees;
this gentleman refers, it is  true, the disease, previous to dentition, in-
variably to enlargement of the thymus gland, or  enlarged agglome.
rated glands in the vicinity of the recurrent nerves; but observes, that
one  remarkable point in these cases is, the dependence of  the parox-
ysms of dyspnoea upon the state of the  digestive organs; whenever
these are out of order, the intensity of the attacks being  increased,
which  it seems difficult to  account for, since, he adds, "the affection
so evidently depends upon a mechanical cause."  The same difficulty,
he further remarks, presents itself  in accounting for the constant and
immediate good effects obtained from a change of air.  The difficulty,
however, arises solely from the attention of the observer having been
too exclusively directed to the supposed agency  of glandular enlarge-
ment in the production of the disease.
   We  have, in repeated  instances, seen  the most  severe  attacks of
spasm  of the glottis produced solely from irritation  of the alimentary
canal,  resulting from indigestible and improper food, and other  errors
of diet, or  from the influence of an  impure, irritating, and confined
atmosphere, the disease being promptly and  effectually relieved, in its
early stages, by getting rid of the exciting cause in the stomach and
bowels, or by  removal to a pure and  wholesome  atmosphere.
   The  cases  combined with  cerebral disease, are seldom  met with
until dentition has  commenced; it is remarked by Rees, that if the
patient survive the appearance of the first molar teeth, the case gene-
rally terminates favourably.   In this form of the  disease,  the patient
usually remains, during the intervals, dull, heavy, listless, and drowsy;
the pupil of the eye is dilated; the head hot, and  frequently held  ex-
tended on the spine; and unless appropriate  remedies be resorted to,
an attack of convulsions or inflammation of the  brain is always liable
to supervene;  carpo-pedal spasms also frequently occur.  These latter
are generally  attended with considerable  derangement of the  gastro-
intestinal mucous membrane.
   Several cases are recorded, in which spasm of the glottis was evi-
dently  induced by an irritation caused by the arrest of  some foreign
body in the  oesophagus, which, nevertheless, could not have produced
sufficient pressure upon the  larynx to interfere, in the least, with the
freedom of  respiration, but must have excited,  by some remote, and
as yet  unexplained influence, a spasmodic closure of the glottis; giving
rise, in many  of the cases, to symptoms  of  such  intensity, as to re-
quire an operation to preserve life.
   The prognosis will depend entirely  upon the nature of the lesion by
which  the spasm of the glottis is produced.  In cases  in which  the
disease has resulted from a  temporary irritation  of the alimentary
canal, or other slight functional disturbance, the paroxysm may be  but
of short duration, and the attack cease spontaneously, or upon a  pro-
per change  of diet or air; but when symptomatic  of disease  of the 
           DISEASES OF  THE RESPIRATORY  ORGANS.       345

brain, or of any permanent irritation of other  organs, it is always to
be considered as a serious affection, and very frequently proves fatal.
  The treatment during the paroxysm, consists in placing  the patient
in an upright position, with the head slightly inclined forwards, and
exposed to a full draught of fresh, cool air, while cool water is, at the
same time, sprinkled over the face.  Every means should be taken to
remove, as far as possible, compression from the vessels of the  neck.
Slapping the child slightly on the back, will occasionally aid in remov-
ing the spasm; frictions along the spine may, also, be resorted to.
   If the paroxysm does not yield to these means, the patient should be
placed in a warm bath ; whilst in the bath, cold water should be sprin-
kled on the face, which will generally cause a  strong inspiration and
lengthened expiration, followed by a scream that usually puts a period
to the paroxysm.  It may  be also useful to apply ammonia, if at hand,
to the nostrils.   Irritation of the pharynx, by a feather, will sometimes
induce  vomiting, which will, of course, solve the spasm of the glottis.
An enema, with the addition of assafoetida or turpentine, will be useful,
in violent attacks.  If the dyspnoea continue unabated, and death from
asphyxia is threatened, the operation  of tracheotomy should be imme-
diately performed.   If, during the paroxysm, there is evident conges-
tion of the brain, a few leeches behind the  ears,  with cold lotions  to
the scalp, will be found advantageous.
  The moment the fit is over, an  examination of the  gums should  be
made, and if these are found to be, at any part, swollen  or inflamed,
a free incision should be made, down to the tooth.   Dr.  Hall recom-
mends incision of the gums, not only in cases of actual dentition, but
in cases in which no immediate appearance of the teeth is expected,
or even in cases in which  all  the teeth have already appeared.   He
directs this for the purpose of correcting a  state  of the  blood-vessels
and nerves of the gums, which, though physiological, still borders on a
pathological character; and hence  he orders the incisions to  be re-
peated,  for several successive days.
  The bowels of the  patient should be well moved daily.   But, in  ac-
complishing this, all irritating remedies should be avoided, and we must
also be careful not to produce severe purging, which, by  exhausting
the patient, will augment the susceptibility to subsequent attacks.  When
the discharges from the bowels are of an  unhealthy character, small
doses of calomel, or of the blue mass, combined with ipecacuanha and
extract  of hyoscyamus,1 repeated at short intervals, and an occasional
dose of the infusion of rhubarb, with  tartrate  of potass  and  manna,
will in general, answer our purpose.  To the last-mentioned prescription,
it has been recommended to add a few drops of tincture of hyoscyamus,
and of the aromatic spirits of ammonia, and a little of the syrup of ginger.
  Dr. Hall considers  a most important  remedy in these cases, espe-
cially when the evacuations are clay-coloured,  to be the repeated  use
of enemata of warm water or barley  water.

                   * R.—Calomel, gr. vj. ad xij.
                        Ipecac, pulv. gr. iij.
                        Ext. hyoscyami, gr. iv.—M. f. chart. No. xij";
                  One to be given every three hours. •
        Or, Mass. f. pill, hydrarg. gr. xij. may be substituted for the calomel. 
346
DISEASES OF CHILDREN.
  The importance of an attention to the diet of the patient need not be
insisted on;  nor need  we, after what has been already said  in many
of the preceding sections, lay down any precise  directions in regard
to the proper articles to be employed.   The  repetition of the attack
remarks Dr. Hall, whose therapeutical directions in  respect to the dis-
ease under consideration are replete with  good sense, has  so often,
within my own experience, been the  result of improper and  indiges-
tible food, that I invariably fix upon some one article or kind of diet,
of the most unquestionable character, to the exclusion  of all others.
  The importance of  a pure, fresh, dry, and cool atmosphere, in this
disease, is recognised  by nearly  every  writer who  has treated of it.
A very slight vitiation of the air will  frequently bring on the most vio-
lent attacks, which are as quickly terminated by its removal ; in one
case, related by Marsh, a paroxysm was induced, whenever the child
was brought into a newly-painted house.  When the little patient  has
been long free from attacks, a sudden change of the wind to the north-
east frequently induces a return  of them; and even when  they have
been long obstinately repeated, and have become,  as it were,  chronic,
a change  of air, Dr. Hall remarks, has  induced  as suddenly a suspen-
sion of them.  We have known  a recurrence of the paroxysms  to  be
kept off, so long as the patient  remained in the city,  and to happen
whenever the child was taken into the country.
  In the cases treated by Mr. Robertson he employed as  one of his
principal means of cure, more especially in  the aggravated forms of
the disease, free exposure to a cool dry atmosphere, and  with  the
most decided good effects.
  Change of air, with a  well-regulated diet, is often  more  effectual
than any other means, in  preventing the renewal of  the paroxysms;
but where this cannot be effected, the child should be taken out  daily,
in mild, dry weather; and the apartment it occupies should  be  freely
ventilated, and kept strictly clean; care  being  taken,  in  so doing, to
prevent exposure to partial currents,  and to  guard against  dampness.
The clothing of the child should be adapted to  the  state  of the  wea-
ther, and  temperature of the season, and so made as to  guard the
breast, shoulders, and arms, against exposure to cold or draughts of
air.   The use of the warm  bath daily, as in most of the diseases of
children, is an important curative as  well as prophylactic means.
  Mr. Robertson recommends cold sponging night and morning.  In
cases  of excessive irritability the cautious use of this  remedy may be
found  advantageous.
  There is one cause capable of exciting a spasmodic closure of the
glottis in  infants, which, though too often overlooked, should be kept
constantly in mind by the medical practitioner; namely, sudden, men-
tal  emotion, and especially fright, or that state of nervous excitement
into which infants are often thrown,  when thwarted, teased, or vexed.
The infant should not be suddenly awoke out  of sleep,  nor slapped,
nor harshly scolded by  an  angry nurse.   When the latter is out of
temper, there is frequently a double source of injury—her rude treat-
ment of the infant, and the unwholesomeness of her milk.  The slightest
alarm is still more serious in  its effects; all sudden  noises,  all rapid
movements in nursing, every attempt to frighten or surprise the infant, 
DISEASES OF  THE RESPIRATORY ORGANS.       347
should be carefully avoided.  It should be addressed invariably, in a
soft, soothing tone of voice; in a word, every source of mental  emo-
tion should be carefully avoided.  This advice should be strongly  en-
forced by the physician, for though  important  in  reference to every
infant, it becomes doubly so in  reference to such  as are predisposed
to, or have already suffered from an  attack of spasm of the glottis.
It has happened to us to see in several instances, most violent parox-
ysms, though in none attended with  a fatal result, excited  solely by
mental emotion and  fright.  It has been suggested  by  Dr. Hall, that
the morbid susceptibility of the patient's  system may be subdued by
keeping him for some time constantly under the gentle influence of the
tincture of hyoscyamus, and the infusion  of hops.   The tonic influence
of tepid salt water, applied to the surface by sponging, is  also highly
beneficial.                                                       .
   In those  cases in which there is  an evident tendency to cerebral
disease, the proper remedies indicated by the nature and extent of the
latter, should be immediately resorted to.  In all  cases, indeed, if we
direct our attention  to the congested condition of the brain, which is
so  liable to occur during the paroxysms, we shall  perceive the impor-
tance of adopting measures to counteract it. Under ordinary circum-
stances, the spirit  lotion applied  to the head, and repeated several
times, in the course of the day, is an efficacious  means of effecting this,
and perhaps a much safer remedy than depletion,  which, unless there
is an absolute necessity for resorting to  it, should be avoided, in con-
sequence of its tendency to increase the susceptibility of the nervous
system, and consequently the disposition to an attack. In severe cases,
Hall suggests the application of the  ice cap.
   A variety of remedies have been recommended, with  the  view of
 controlling the spasmodic affection of the throat, as the aq. lauro-cerasi
 in  small and graduated doses;  musk, and the  oxide and cyanuret of
 zinc; as well  as others for destroying the predisposition to and cause
 of the disease, as a very low diet, copious and repeated local bleedings,
 issues on the chest, frequent, active purgatives, mercury, antimonials,
 cicuta,  digitalis, animal  charcoal,  and  iodine, internally and  exter-
 nally.  To the greater part of these we object, as altogether unadapted
 to  the disease, or positively prejudicial;  while  the recommendation of
 others is evidently based upon  an erroneous pathology, and  even by
 the strongest supporters of that pathology, they are admitted to be of
 doubtful efficacy.

                 9.—Pertussis.—Hooping Coogh.
    The  hooping cough is usually described as a  disease peculiar to
 childhood ; occurring but once in the same individual, and propagated
 by  a specific contagion.   That it  occurs most  commonly,  at some
 period  previous to  puberty, is unquestionably true; we  have, never-
 theless, repeatedly met with it  in adults, particularly when it has pre-
 vailed epidemically ; and the memory of every practitioner will furnish
 him with instances of its occurrence, in even elderly subjects.  Her-
 berden  saw it in a female of seventy, and in a man of eighty years of
 age.   Instances, also, of its recurrence  in the  same individual are, by
 no  means, unfrequent; we have seen several, and the  same  fact is 
348               DISEASES OF CHILDREN.
noticed  by various writers.  As  to  its contagious nature, notwith-
standing it is so considered by the generality of writers on the disease,
the fact  is very far from being fully established, and is positively denied
by  a large  number of  accurate  observers, who have  particularly
directed their attention to the subject.  The hooping cough most com-
monly prevails  as an epidemic, and hence a number of individuals
may be  attacked at the same time, or in quick succession;  but to prove
its contagiousness, it is necessary to show, that when sporadic cases
occur, the disease spreads from these, or that patients affected with it,
when removed to distant  places, communicate it there to others, which
we have never known to occur;  and the same remark  is made by
Desruelles and others.
  The diagnostic symptom of hooping cough is a suffocating convul-
sive  cough,  returning in  paroxysms, terminating in an excretion of
thick, glairy mucus, which is frequently discharged by vomiting.  The
cough is marked by a prolonged, stridulous, convulsive  inspiration,
attended with a rattling in the trachea, and succeeded by several short
efforts at expiration, which follow each other in quick succession.  The
long, convulsive, hooping inspiration  is again almost immediately re-
peated,  and the paroxysm continues, often, for  many minutes,  until
a discharge  occurs of a portion of thick, slimy mucus, by expectora-
tion  or vomiting, when the respiration becomes again  comparatively
free.
   During the paroxysms  of coughing, the child often exhibits all the
symptoms of impending suffocation, redness and swelling of the face,
injection of the conjunctiva, shedding of tears, profuse  perspiration
about the head  and forehead, and violent spasmodic action of all the
respiratory muscles.  The agitation of the whole  body is such, that
the child is obliged to lay hold of something to support him.   In vio-
lent  cases, a discharge of blood from  the nostrils, and involuntary
evacuations from the bladder and bowels are  not unfrequent.
   Nearly all writers, since Rosen, have  divided the hooping cough
into different periods.  In  its development and progress,  the disease
unquestionably  exhibits several stages, but these present, in different
cases, so many important variations, in  their  symptoms and duration,
that it is difficult, as remarked by Billard,  to assign to each its proper
limits or  distinctive characters.  By Desruelles and  Lombard, it is
divided  into the  period  of invasion, the period  of increase, and the
period  of decline; by others,  into the  catarrhal stage,  the nervous,
spasmodic, or convulsive stage, and the stage of decrement;  and by
Blache  and  Williams, into  the  inflammatory, the congestive and ner-
vous, and the simple nervous stage.
   The  disease is very generally preceded  by the symptoms of catarrh
or mild bronchitis.  There is  a dry cough, hoarseness, some sense of
constriction  in the chest, and  a  feeling of weight or dull pain of the
head, redness and suffusion of the eyes, and some degree of febrile ex-
citement with exacerbations towards evening.  The duration of this
stage varies considerably;  it  may be followed  by the characteristic
symptoms of hooping cough, in few days, or be prolonged for a week
or two, or  even longer; the  cough, however, increases from day to
day, and becomes gradually more convulsive and resonant.  In  some 
          DISEASES OF  THE RESPIRATORY  ORGANS.       349

cases, the catarrhal phenomena have been entirely wanting, the pecu-
liar symptoms of the disease  occurring, as it were, suddenly: while
during the prevalence of hooping cough, as an epidemic, many children
will exhibit no other symptoms than those of the  catarrhal stage.
  Sooner or later, however, the cough  assumes its peculiar, convul-
sive, and suffocating character, and shrill hooping sound.  It occurs
in paroxysms, at irregular periods, during the day and night; the inter-
vals being,  in general longer, during the period of increase, in the day,
and during the decline of the disease, at night. The cough is generally
preceded by  a  mucous  rhonchus, which is  more  evident, as  the
paroxysms become more frequent.
  The patient is, in general, aware of the approach of a paroxysm, by
a sense of chilliness of the surface  of the body, and a tickling in the
fauces, succeeded  by a sense of  constriction about the throat and
chest, and a dread of suffocation, which induces him to fly to his nurse,
or to lay hold of anything within  his  reach, for support, during the
paroxysms.
   The duration  of the paroxysm is very various; in some instances,
they last scarcely a minute, while in others they are prolonged for five
or six minutes, or even longer.  The intervals between the paroxysms
vary from half  an hour to three  or  four hours; but in very violent
cases, at the height of the  disease,  the paroxysms are often divided by
intervals of only a few minutes' duration.  The paroxysm usually ter-
minates by the discharge of a large quantity of viscid mucus, gene-
rally by vomiting, resulting probably from the compression of the sto-
mach, by  the forcible contraction of the abdominal muscles which
occurs during the  violent effort at inspiration.   The disposition  to
vomit is apparently increased by habit; and consequently as the dis-
ease advances, the paroxysms of cough  terminate more frequently and
speedily by vomiting  or retching.
   Immediately  after  the fit, the child  appears  entirely relieved, and a
 craving for food is often experienced ; after this is satisfied, he is per-
fectly cheerful,  and returns to his  ordinary amusements.  When, how-
ever, the paroxysms are  frequent, of long duration,  and marked  by   <» •
great violence, the patient recovers from  his distress only by degrees,      »
remaining exhausted for some time, with hurried or panting respira-    . ^<
tion, and complains,  if old enough, of  a tensive pain in the  forehead,
 and pain or soreness  of the chest.   In some instances, the violence of
 the paroxysm is such as to produce a loss of consciousness from tem-
porary asphyxia ;  or the asphyxia may be complete, and death ensue.
 In  other cases,  convulsions, or cerebral congestion  and deep coma
 may occur.
   The paroxysms  often recur with some degree of periodicity; but
they may be induced at any time by too much, or improper food, ex-
citement of the  mind, or  exposure to cold, or a confined and impure
atmosphere.  They may also  be excited, by seeing  another attacked
by one.  It is probable, as remarked by Lombard, that motion, amuse-
ment, and  the open air, contribute to lessen the cough; while rest,the
horizontal  position, and the close  air of sleeping apartments, increase
the tendency to its return.
   In slight attacks, there may be but little or no fever during the con- 
350
DISEASES  OF CHILDREN.
vulsive period of the disease, and but little  functional  disturbance in
the intervals of the paroxysms; but, usually, the presence of the sono-
rous and  mucous rhonchus, particularly before and  after the cough,
and the mucous expectoration in which the cough generally terminates,
indicate  that  in  conjunction with the nervous affection, upon which
the spasmodic, stridulous respiration, and sonorous cough depend, there
still exists more or less bronchitic, or catarrhal disease: in fact, as the
stage declines, the expectoration generally assumes the more consis-
tent  and opaque  form which characterizes the concocted sputa  of a
terminating bronchitis. (Williams.)
   The bowels are variously affected in hooping cough. Though often
perfectly regular, and  the discharges natural, yet, occasionally, they
are costive or sluggish, and in a few cases, diarrhoea is present,  with
vitiated discharges, a loaded tongue, nausea, loss of appetite, epigastric
fulness and tenderness, and other symptoms of gastro-intestinal disease.
   In the cases accompanied by severe bronchial inflammation, there
is  generally more or less cough between the paroxysms, and  conside-
rable febrile excitement;  and the convulsive, hooping, cough, is gene-
rally preceded and followed by considerable uneasiness, or oppression
and pain of the chest.  The bronchial inflammation, in these cases, is apt
to  run into pneumonia, which is hence a frequent complication of the
disease.  When this occurs, we have the general symptoms of the latter
affection, superadded to those of hooping cough, as well as its distinc-
tive physical signs.  Lobular pneumonia, and pleuritic inflammation,
are common occurrences in this disease.
   Hydrocephalus is one of the most serious complications of hooping
cough, and a very frequent one.  It is marked by its  usual symptoms
—grinding of the teeth, rolling of the head, intolerance of light, con-
tracted pupil; followed by squinting, vomiting, screaming, insensibi-
lity, &c.   We have, in a few instances, seen a state  of deep coma
occur in the course of hooping cough ;  the brain, after death, exhibit-
ing extensive serous effusion, without any of the symptoms of menin-
gitis or hydrocephalus having presented  themselves.
   Anasarca is also one of the frequent complications of hooping cough.
In  mosToTthe more violent cases, there is a slight degree of oedema of
the face and arms; but in some cases, serous effusion occurs through-
out the  cellular  tissue, and  in the cavities.   An attack of croup will
often supervene during hooping cough,  particularly in its early stage.
Children of robust, plethoric habits, are most subject to this complication.
   The duration of the second stage is very various;  it may continue
for a very short time, or be prolonged for three or four weeks, or even
longer; the symptoms then gradually diminish in intensity; the expec-
toration becomes more abundant, opaque, and thicker; the cough loses,
by degrees, its convulsive character;  the  paroxysms are  of less fre-
quent occurrence, and of shorter duration; and, finally, by the end of
two or three months from the commencement of the disease, it disap-
pears, with the assemblage of other symptoms.   The period when the
symptoms begin gradually to decline, to  their final termination, consti-
tutes, what has been termed, the third stage of the disease.
   It often happens, that after a very decided  abatement of the symp-
toms has taken place, the cough again returns, with considerable vio- 
          DISEASES OF  THE RESPIRATORY  ORGANS.       351

lence; this relapse, though  occasionally prolonged, is generally of short
duration;  usually after two or three days, the regular decrease will
occur and continue its course.
  The disease, in many cases, assumes  a kind of chronic  form, and
may be protracted to a very long period, the paroxysms being well
marked, but occurring at considerable intervals, and of little intensity
or duration; or they may  be induced, in  those who have lately reco-
vered  from  the disease, by the occurrence of the slightest catarrhal
affection.   A curious case is  related by Percival, in which the hoop-
ing cough assumed a periodical form, a paroxysm occurring  daily, at
a certain hour, for several months, and returning  at the same season
for two years.
   In children of a  lymphatic temperament, strongly predisposed to
tubercular disease, and in those in whom the formation of tubercles in
the lungs  has  already commenced, the occurrence of hooping cough
in a severe and protracted form, very rarely fails to  develope pulmo-
nary consumption; the progress of which is often very rapid, upon the
decline of the acute  stage of the attack.
   The physical signs of hooping  cough are  those of mild bronchitis;
variable sonorous, sibilant, and mucous rhonchi, in the upper and middle
portions of the chest. During the height of the paroxysm, there is di-
minished  sound of respiration within the chest.  When  complicated
with pneumonia, the  mucous and crepitant rhonchi, with partial absence
of the respiratory murmur, and dulness on percussion, will indicate the
existence and extent of the pulmonary disease.
   The appearances upon dissection vary with  the  violence of the
attack, the period at which death has taken  place, and the simple or
complicated character of the case.  Nearly every writer who has
given the result of his autopsical examinations, mentions the existence
of more or less of the indications of inflammation of the mucous mem-
 brane of the bronchi, and often of the  trachea; as, injection  of the
 blood-vessels, thickening  of the  membrane, and the existence upon its
 surface of a layer of thick mucus, and  occasionally a muco-purulent
fluid filling the ramifications of  the bronchi.  Ulcerations about the
glottis, and in the larynx  and trachea, are noticed by Astruc, Mackin-
tosh, and Alcock.
   When death is caused  by asphyxia, in the early period  of the attack,
 the  mucous membrane of the respiratory tubes  is of a  dark red or
 bluish appearance;  the lungs are gorged with  dark-coloured blood;
 the  whole substance of the brain is a little more livid than natural, and
 the  bronchial  tubes contain a little mucus, occasionally stained with
 blood.  A  very common lesion  in  severe cases is dilatation  of the
 bronchu   Inflammation of the lungs, especially lobular inflammation,
 is of comtnon occurrence, and  very frequently inflammation  of the
 pleura, with exudation  or effusion.   To these lesions may be added,
 tumefaction and redness of the bronchial glands, and emphysema of
 the  lungs.  In a large number of cases, inflammation of  the meninges
 of the brain, and effusion beneath the membranes, and into the ventri-
 cles, have been observed.  A diseased condition of the phrenic and pneu-
 mogastric nerves, is noticed by Clarus, Holzhausen, Hufeland, Breschet,
 Bauer, Kilian, and Autenreith.  There is some doubt, however, as  to 
352
DISEASES OF CHILDREN.
the correctness of these latter observations; it is certain, at least, that
a lesion of the nerves just mentioned, is of very unfrequent occurrence.
   Hooping cough most generally occurs as an epidemic, but generally
of very limited extent, its influence being confined, usually, to a single
city or district, and  often to a part, only, of these.   Seldom, if ever,
has it extended, either  at once, or gradually, over large territories, as
is  the case with most other epidemics.  If, however, we are to receive
as correct the accounts of the epidemics of 1510, 1557, 1580,  1757,
1767, and 1769, as given by De Thou, Sennertus, Sauvages, Riverius,
Diversus, Conario, Geller, and Arrand, we find that these were of wide
extent, many of them prevailing throughout the greater part of Europe.
   The disease occurs at all seasons, and in all climates;  but the spring
and  autumn, especially when  cold and damp, and  cold, variable  cli-
mates, are admitted, by nearly all writers, to he the most favourable to
its prevalence; and it is in these seasons and climates  that the hooping
cough proves most fatal,  from its being most usually complicated with
severe bronchial, pneumonic, or laryngeo-tracheal inflammation.  The
general production  of the  disease, by  the joint influence of a cold
and  moist atmosphere, is insisted upon  by Klinge, Richter, Marcus,
Desreulles, and Vondembush.   It has been found frequently to prevail
most extensively, either immediately before, during, or  subsequent  to
the occurrence of epidemic  measles.   Its prevalence at  the same time
with epidemic catarrh, has also been repeatedly  observed.
  Children of all ages  are liable  to its attacks;  infants  at the breast
are,  however, less liable to  it than those who are weaned: indeed, so
generally does  the disease  attack during  the period of  dentition, that
many have supposed this to be its most common predisposing cause.
Boys and  girls are equally liable to it, though, perhaps, a greater num-
ber of the former will generally be found to escape an attack, than of
the latter.  Children labouring under chronic cutaneous eruptions, have
been supposed to  be rarely affected with the disease; or when attacked,
to  have it but lightly.   The  fact,  however, is  denied  by  Hoffman,
Haase, and others, and it is not sustained by the general  result of more
recent observations.
  In regard  to the  true  pathology of hooping cough, much diversity
of opinion has existed, and still continues to exist.
  A majority of the  most authoritative writers  refer it to bronchial  in-
flammation, which, by  a few, is considered to be of a  specific charac-
ter.  By some, however,  who  have written very ably  upon the dis-
ease, the bronchial affection  is viewed as a mere concomitant, or effect
of the hooping cough, and not, in  any degree, essential to its existence.
Most of the writers refer it either to disease of the  pneumogastric or
phrenic nerve, or to  disease of the brain, affecting the origin of the
respiratory nerves, whilst others  consider the cerebral irritation to be
secondary to the bronchial disease, and often absent.
  That the essential symptoms of hooping cough  are the result of a
spasmodic closure of the glottis, there can he little doubt; but whether
this is owing to an irritation seated in  the larynx and trachea, or  in
the brain,  it is difficult  to determine.  In the greater number of cases,
the disease commences as a simple, and  often very mild  bronchitis;
and it is not until  after the bronchial inflammation has existed for some 
          DISEASES OF  THE RESPIRATORY ORGANS.       353

time, that the irritation is transmitted to the laryngeal nerves, and the
convulsive cough and difficulty of respiration occur.  Desreulles has
attempted to show that these latter symptoms are  the result of an in-
termittent irritation and congestion of the brain, which precedes each
paroxysm, ceases with the latter, but soon returns, giving rise to a re-
newal of the paroxysm, and  hence, that the disease consists in a reci-
procal irritation of the brain  and of the respiratory apparatus; the
latter, upon the one hand, acting upon the brain through the medium
of the eighth pair of nerves, the phrenic nerves, and those branches
which are distributed to the  muscles of the thorax; while on the other
hand, the brain reacts upon  these muscles, the glottis and diaphragm.
This  much is very certain, that we cannot account very readily for
the phenomena of the disease, excepting by referring them to irritation
of the laryngeal nerves, as well as to disease of the respiratory mucous
membrane.
   When hooping cough is unaccompanied with  severe  symptoms of
bronchitis, and is uncomplicated with pneumonia, or tracheitis, or with
congestion  or inflammation of the  brain, it is seldom  attended with
much danger; but in its more severe and complicated forms, it is with
difficulty managed, and very frequently fatal.   The younger the pa-
tient, also, as a general rule, the more danger attends it.  Very fre-
quently, as  remarked by Guersent, when it occurs in infants  at the
breast, it is accompanied with cerebral congestion  from its very onset,
and  is then particularly fatal.   We have also  found, that when, in
young children, it is accompanied with an excessive serous diarrhoea,
it is seldom recovered from; a similar remark is made by Richter.
   In many of the more extensive epidemics, the mortality from hoop-
ing cough has  been very considerable.   Thus, in Sweden, during the
sixteen years, from  1749 to 1764, 43,393 deaths  occurred from the
disease; and of these, 5,832 took place in the year 1755 alone.  (Rosen.)
In Glasgow, the deaths have been pretty nearly 5J per cent, of the en-
tire mortality; and in one  year, (1809,) they amounted to  11| per
cent.  (Watt.)  In Prussian Pomerania, the deaths were as 1 to 25£ of
the entire mortality.   In Neumarck, 1 to 21 i.  In  Brandenburg, 1 to
291.  In Sweden and Finland, 1  to 13£.  In  Strasburg, 1 to 94.  In
Boston, 1 to 82.  In  Charleston, 1 to 46-6.  In Baltimore, 1 to 95-38.
In New York, 1 to 64-7; and in Philadelphia, 1  to  63-1.
   There are  two affections with which the hooping  may  be con-
founded; namely, acute bronchitis with paroxysmal cough, and tuber-
culation of the bronchial  ganglions.   The diagnosis between  these
affections, has been very ably drawn by Rilliet and Barthez.   (Mala-
dies des Enfans, T. ii. 223.)
   In Hooping  Cough; in the great majority of cases, the paroxysms
of cough are preceded by catarrhal symptoms.
   The paroxysms, more or less intense,  are accompanied with a pro-
longed hissing sound, and succeeded by an expectoration of a  tena-
cious  mucus, and very generally, by vomiting.
  In its simple form, it is in general unattended with fever, and during
the intervals, there is neither acceleration or  other change in the re-
spiration.
                               23 
354
DISEASES  OF CHILDREN.
  The paroxysms continue, more or less frequently, without change of
character, and  then  decrease ;  and the cough assumes a simple ca-
tarrhal character, and the child, if the attack is without complications,
becomes convalescent.
  There are no relapses.
  The acute  bronchitis with paroxysmal cough, commences suddenly
with paroxysms of cough.  These are in general shorter, less intense ;
the  hissing sound is very unfrequent, or in the few cases  in which it
occurs it is intermittent;  there is little or no expectoration, and no vo-
mitting.
  The attack is attended  from its onset with intense fever, and accele-
ration of respiration, which constantly augments in intensity—sibilant
and mucous rhonchi afterwards subcrepitant.
  The pulse  is very small, the dyspnoea is extreme, and  these, with
pallor of the face, appear, persist, or augment, and  the disease termi-
nates almost  invariahly in  death within a variable  period, often very
short.
  Relapses are possible.
  In their more chronic stages, these two diseases are attended by the
same symptoms.
  The diagnosis between the hooping cough and tuberculization of the
bronchial glands is still more difficult, than  between  it  and  the disease
just  referred  to.  The characters which constitute  the diagnosis are
the following:
  Hooping cough—frequently epidemic—contagious.
  Three distinct periods, of which the second alone is attended with
a paroxysmal cough.   The paroxysms attended with a hissing sound,
expectoration of viscid mucus and vomiting.
  Respiration and pulse natural in the intervals, when the disease is
simple.
  The voice natural.
  Progress most commonly acute.
   Tuberculization of the  bronchial ganglions.  Always sporadic; not
contagious; without distinct periods.
  Paroxysms  of cough  generally very short—without any hissing
sound—without viscous expectoration or vomiting.
  Physical symptoms  of ganglionary  tuberculization,  but  in certain
cases an absence of these signs.
   An access of  asthma  in  certain cases, alternating with the pa-
roxysms of cough—continued fever,  with evening exacerbations—
night-sweats—progressive emaciation,  &c.
   Occasionally a change in the tone of the voice.
   Progress chronic.
   To complete the diagnosis, the age of the subject should  be carefully
inquired into, and the causes under the influence of which  the disease
has  occurred.  We should examine whether, by the constitution or the
descent of the patient, we may presume the existence of tuberculization
—whether before the  commencement of the paroxysmal  cough the
child had become pale  and emaciated—whether he was subject to
cough, &c.  It is during the second period that the two diseases  above 
          DISEASES OF THE RESPIRATORY  ORGANS.       355

alluded  to may be confounded with hooping  cough.   But there are
others which it is not always easy to distinguish from it  during  its
first  and third periods.   A slight attack of bronchitis  does not differ
in any of its  symptoms from  the prodroma of hooping cough.  The
nature of the disease may, however, be suspected from the character
of the reigning epidemic, and the circumstances preceding the attack.
  When the hooping cough becomes chronic, and the paroxysms, after
having diminished in intensity, become more rare and unattended with
the  hissing inspiration,  or when the  cough is simply  catarrhal—the
disease, or rather the dilatation of the bronchi by which these secondary
symptoms are induced, may be readily confounded with pulmonary or
ganglionary tuberculization.  The diagnosis is the more difficult, as it is
precisely at this period that phthisis is liable to succeed to hooping cough.
The emaciation, hectic fever, pallor of the skin, the sweats, all the col-
lection of general symptoms, in fact, are the same; auscultation alone
can  throw light upon the nature of the disease.   Still,  however, even
here there is difficulty in establishing the diagnosis with any exactness.
The dilatation of the bronchi, by which the fever  is kept up, and gives
to the child the appearance of one labouring under phthisis, simulates
so closely pulmonary or ganglionary consumption that  it may be mis-
taken for it.  The ulterior progress of the disease, is  often the only
criterion by which the true character of the complication can be de-
termined.  If the child regains his  flesh—recovers his  gaiety and his
strength—if the paleness of the skin disappears, and the fever or sweats
cease, it  is more than probable  that tubercles  are not present.   If,  on
the contrary, the fever persists, the  emaciation augments, and  the ap-
petite is lost; if copious diarrhoea occurs, and each day the symptoms
become more unfavourable, it is then but too certain that tuberculization
exists and makes  daily progress.
  The treatment  of hooping cough will differ, according to the stage
of the  disease, the violence of the  attack, its  simple or complicated
character, and the age and vigour of the patient.
  The remedies  proper  in the  first or catarrhal  stage are the same,
precisely, as  in simple bronchitis.  It is chiefly upon the proper ma-
nagement of  this  stage  that will depend, in many cases, the safety of
the patient;  his diminished liability to the occurrence of severe bron-
chial or pneumonic inflammation, as well as to  the danger attendant
upon intense cephalic congestion being induced during the paroxysms
in the second stage.
  We believe that in  all cases, very great relief will  be afforded  by
the  administration of an  emetic at the  very  commencement of the
attack, and the continuance of the remedy, subsequently, in nauseating
doses.   In  robust children, over two years of age, tartrate  of anti-
mony should be preferred; but in younger children, in whom this arti-
cle is seldom a very safe one, we would prefer the ipecacuanha.  By
many practitioners, the  latter article is considered to be particularly
adapted  to the treatment of  hooping cough.  They prescribe it in the
first, and during the acute period of the second stage, occasionally as
an emetic, and  subsequently in small doses,  the fourth of a grain
every three or four hours, either alone or in combination with sulphur 
356
DISEASES  OF CHILDREN.
or with sulphur and belladonna.  We have followed this practice in a
very large number of cases with the happiest effects: we have usually
combined the ipecacuanha with sulphur and extract of hyoscyamus."
                a R.—Pulv. ipecac, gr. iij. ad iv.
                     Sulph. praecip. 3ss.—3j.
                     Ext. hyoscyami, gr. iv.—xij.—M. f. chart. No. xij.
              One to be repeated every three or four hours.
  Horst recommends the flowers of  sulphur as almost  a specific in
hooping cough.   He gives  it throughout the disease, from its  onset
until its termination.  Schneider, Kopp, Randhan, Riecken, and others,
confine its use to the more advanced periods of the attack.  The sul-
phur  is given to children between two and four  years of age, in the
dose of from 6 to 8  grains, two or three times a  day,  and to  older
children in doses of from 15  to 20 grains;  in both cases the dose being
gradually augmented.  Jadelot is said by Rilliet and Barthez to have
derived the best effects from the sulphur as a remedy in hooping cough,
and in bronchitis  unattended with fever.
  There are few cases in which,  at the onset of the disease, after an
emetic  and the warm bath, the exhibition of a full dose of calomel,
followed, in a few hours, by some mild purgative,  as castor oil, rhu-
barb  and  magnesia, or  in children over two years of age, in whom
the first stage is often attended with considerable febrile excitement, by
small doses of sulphate of magnesia, will  not be found  advantageous.
The bowels being kept subsequently in a regular  state, by occasional
doses of some mild unirritating  purgative,  or by simple enemata.
  Perhaps the best purgative we can employ in hooping cough, parti-
cularly  in its first or catarrhal stage, is calomel: an occasional small
dose,  say from two to five grains, given in the evening, and followed
in the morning by a small quantity of castor oil, will generally have
the effect of preserving a free, regular condition of  the  bowels, with-
out unduly irritating them, or inducing  severe  purgation—an  occur-
rence which should be always  carefully avoided.   Whatever opinion
we may adopt of its mode of action,  we  are certain of  the utility of
calomel as a mild purgative in  the first, and  during  the acute  period
of the second stage of hooping cough.  We are accustomed to com-
bine with the evening dose of calomel, a third of a  grain of ipecacu-
anha, and the same quantity of the extract of hyoscyamus, and  have
seldom found it necessary to give any purgative in the morning to in-
sure its  operation.
  In every case  in which, during  the first stage, severe  bronchial or
pulmonic  inflammation  is present or threatened, particularly if the
patient be of a plethoric  or  robust habit,  bleeding becomes an indis-
pensable remedy, and it should be resorted  to, also, whenever, the
same  indications present themselves at  a  later period of the disease,
previous, at least, to the occurrence of extensive effusion in the bron-
chi.   The extent of the bleeding should always be proportioned to the
violence of the symptoms, and the strength of the patient;—upon our
promptitude and  decision in the  use of  this  remedy his  recovery
will often depend.  Leeches to the chest and about the clavicles,
or cups between the  shoulders, will  be sufficient in young children; 
           DISEASES OF  THE RESPIRATORY  ORGANS.       357

 but in  those who are older, and when the  symptoms are severe, it
 will be better to have recourse to the lancet, followed, if necessary, by
 leeches. We are aware that bloodletting has been considered by some
 an improper remedy in the treatment of hooping cough, and by others
 as of doubtful propriety;  but  independently of our own experience,
 we have in its favour that of nearly every authoritative writer on the
 disease.  Mackintosh applied leeches over the larynx, and speaks con-
 fidently of the  success of the practice.
   Whenever there is a decided tendency to an affection of the brain,
 whether of a congestive or irritative character, blisters to the temples,
 or behind the ears, cold lotions to the scalp, and warm sinapised pedi-
 luvia or sinapisms to the feet, should be immediately resorted to.
   During the whole of the first, as well as during the  acute period  of
 the second stage, the patient should be confined to his chamber, which
 should be kept of  a proper temperature, but well ventilated.  Nothing
 has a  more deleterious tendency than sudden transitions of tempera-
 ture, or exposure to cold and damp;  almost invariably will these ag-
 gravate the paroxysms of cough, and  endanger  inflammation of the
 respiratory tubes or lungs.  The diet should be perfectly mild and un-
 irritating, and  in violent cases  should consist entirely of some simple
 mucilaginous drink.   The occasional use of the warm bath should not
 be neglected.
   As  soon  as  the acute  character of  the disease is  reduced, some
 counter-irritant applied to the chest or  between the shoulders, will be
 found  highly beneficial; blisters are recommended by some, and  if
 properly managed, produce, certainly, a very excellent effect; but
 a few  of the European as  well as of the American practitioners prefer
 the production  of a more  powerful and permanent irritation, such as
 results  from the ointment  of the tartrate of antimony.   Autenreith
 states  that,  in  two severe epidemics, in which he employed  frictions
 with tartar emetic ointment, he lost not a single patient.'
   In  order  to  insure the efficacy of this  plan of treatment, we must
 not, we are told, be satisfied with merely  producing  pustules; the use
 of the ointment should be continued until small ulcerations occur in the
 intervals between  the crusts.   The treatment should be persisted in
 for eight or  twelve days.    U the eruption is very painful, the best ap-
 plication is  fomentations with a decoction of hemlock.  Luroth em-
 ployed the ointment in this manner, in a very fatal epidemic of hoop-
 ing cough, with, we are assured, the most gratifying results.  Corsin
 also employed the emetic tartar, as an external irritant, during an epi-
 demic of the disease, and, according to his  statement, with decided
 benefit in every case.  He  prefers, however, its application in the form
 of a plaster,b which is to be worn upon the epigastrium, or between the
 shoulders, as long as the  patient can endure it.   Dr.  Dewees thinks
 that he observed more advantage to result from the use of the oint-
 ment of the tartrate of antimony, than from any other  external appli-
 cation.   He used it of the same strength as directed  by Autenreith,
with the addition  of  fifteen drops of oil  of  lavender, or essence of
lemon, and  applied it high up  between the  shoulders.  Nearly the
same  remarks  are made,  in relation  to the remedy, by Mackintosh. 
358
DISEASES OF CHILDREN.
We know nothing of its effects, from our own experience; in the few
cases in which we have employed it, we could never persist in its use,
(and this is said  to be essential to its efficacy,)  in consequence of the
severe pain, and deep ulceration produced.   We have no doubt,  how-
ever, that in severe cases, it may prove a very valuable derivative.  We
have  generally resorted to blisters, and frictions with turpentine, the
compound camphorated liniment, or a liniment of the oil of amber and
oil of rosemary, to the spine,c and with the best  results.
   1 R.—Tart. ant. 3jss.              b K.—Empl. conii, 2 pts.
        Axung. 3j-—M.                  Empl. picis abietinse, 1 pt.
  A portion of the ointment of the size of       Dyachylon, 1 pt.
   a nut, is to be rubbed on the epigas-      Spread on leather, and sprinkle the sur-
   trium, three times a day.               face with  from  6 to 12 grs. of the
                                     tartar emetic.
                     c R.—Ol. oliv. giv.
                          — succini, 3ij.
                          — rosmarin. 3ij.—M.
  In  many cases, a plaster of  Burgundy pitch,  worn  upon the chest,
or between the shoulders, produces a very powerful  rubefacient effect,
and will, consequently, prove highly beneficial.
  At the meeting of the medical section of the  British  Association, in
1840, it was stated by Dr. Hannay, that  rubbing the  chest with cold
water, two or three times a day, with so much  activity as to produce
a rubefacient effect, has been found  of very great efficacy, in cases of
hooping  cough; and that this practice may be resorted to, even  when
the case is attended with bronchitis.  We have no  doubt of the effi-
cacy of  the  friction, but should  certainly prefer olive oil to the cold
water, which can have no other good effect, than to prevent abrasion
of the cuticle.
  An occasional emetic of ipecacuanha, will often give great relief at
this period;  and  we  have generally found the administration of  small
doses of ipecacuanha, extract of hyoscyamus, and magnesia, repeated
every three hours, of unquestionable efficacy.
  When we have succeeded in removing the inflammatory symptoms,
or  these have been  so  far  abated, that  the   paroxysms  are  kept
up chiefly by nervous irritation, and  there exists  no decided tendency to
cerebral disease,  we  may commence with the  use of  narcojtics, anti-
spasmodics, and  tonics.   Nearly every article upon the lists, has been
recommended by  different  writers, as  almost  a specific, in certain
stages of the complaint, and  as strongly reprobated by others, as either
ineffectual, or positively injurious.   It is  certainly true, that the  treat-
ment of hooping cough has been, in  too many instances, marked by the
grossest empiricism, without any reference whatever to the true patho-
logy of the disease, or to its  occasional complications with encephalic,
thoracic, and abdominal disease, and that not a  few of the articles de-
tailed in the books as certain remedies, are calculated, often,  to do
more harm than  good, while others are perfectly inert.
   In regard  to narcotics, strongly objected to  by some, evidence of
too conclusive a character has been presented  in favour of their em-
ployment, to leave any reasonable doubt as to their beneficial influence
after the acute stage has passed by,  and  the paroxysms of convulsive 
            DISEASES OF THE  RESPIRATORY ORGANS.       359

 cough are kept up from nervous irritation alone.  We are constantly
 in the habit of prescribing them, and would certainly find it very dif-
 ficult to control the cough in the spasmodic stage of many of the more
 violent cases, without their aid.  It is true, that much may be effected
 in this stage,  by a proper regulation of the diet, bowels, and clothing,
 and by a change of air.  We agree with Mackintosh, as to the im-
 portance of confitring the child  to bland, nutritious  food, keeping his
 bowels gently open by mild  aperients, and protecting the surface by
 flannel, together with the occasional use  of the warm bath, followed
 by frictions, and free daily exposure to the open air, when  the weather
 is perfectly mild and dry; under the use of  these means we shall in-
 variably find  the violence of the paroxysms to decrease, and in mild
 attacks, often  gradually to cease.  There are, nevertheless, few cases of
 hooping cough, in which the continuance of the disease  will  not be
 very materially shortened, and convalescence hastened and confirmed,
 by the judicious employment, in conjunction with  the  hygienic mea-
 sures  referred to, of narcotics,  antispasmodics, and occasionally of
 tonics.
   There exists among writers, some difference  of opinion as  to the
 narcotic best adapted to hooping cough ; opium has  been recommended
 by many, either alone, or in combination with tonics and expectorants.
 We have employed an aqueous solution of opium, with some benefit;3
 and Lombard recommends the syrup of the white poppy,  in the dose
 of a teaspoonful, once, twice, or three times a day.  In some cases, the
 syrup  of poppy has been found to remove only the more troublesome
 symptoms,  without shortening the duration of the disease.  It is said
 to have proved particularly beneficial, in diminishing the number of
 paroxysms  during  the night, by  inducing sleep, but even then,  it has
 appeared to exert  but little influence over those  occurring during the
 day; this is precisely the result of our experience, in relation  to the
 effects of the aqueous solution of opium.  Morphia has been employed
 endermically,  and  according  to  Meyer, with good effect;  a blister is
 applied over the praecordia, and when  the cuticle is removed, the blis-
 tered surface is sprinkled every evening with half a grain of morphia,
 rubbed up with dry starch.
                   a R.—Opii pulv. 3j.
                        Aq. bullient. 3 iij.
       Let it stand for three hours, then  strain, and add 3j. bi-carbonate of soda.
          Dose, for a child two years old, a tdaspoonful every three hours.
  The narcotic from which, however, the  greatest amount of benefit
 is to be anticipated in this disease, is unquestionably the belladonna ; it
 has been very extensively employed, and the evidence in its favour is
 strong and conclusive.  It has been given in  doses of from  one half to
 one  or two grains  of the powdered root, or  from one-eighth to one-
 fourth  of a  grain of the  extract,  twice or thrice a day.  Kahleiss ad-
 ministered  the belladonna, in  combination with Dover's powder and
 sulphur,1 and  between each dose, a mixture containing hydrocyanic
 acid.b  We  have given to the belladonna a very fair trial, and  have,
 in many cases, been pleased with the prompt and decided relief pro-
duced by it, while in other instances, it has appeared to exert no  influ- 
360
DISEASES  OF  CHILDREN.
ence whatever.  A similar remark is made by Vondembush and Lom-
bard.  We have generally employed the extract, in  the dose of from
one-eighth to one-sixth of a grain, two or three times  a day, sometimes
oftener,  combined with  from one-fourth to one-third  of  a grain  of
ipecacuanha.
     * K.—Rad. belladonna? pulv. gr. v.        b R.—Aqua? chamomil. gss.
           Pulv. ipecac, compos, gr. x.              Syrupi«impl. oij.
           Sulphur, praecip. 3ss.                   Acid, hydrocyanic. fU/xij.
           Sacchar. alb. 9ij.—M.          Twelve drops to be given between each
             f. ch. No. xx.                dose of the belladonna.
    One to be given every three hours to a
     child two years old.
  Dr. Pieper recommends frictions  upon the epigastrium with  the ex-
tract of belladonna, dissolved in saliva.   In children  of six months, he
rubs in one grain of the  extract thus dissolved, augmenting gradually
the dose.
  Other  narcotics  have been  recommended,  as the  camphor, the
conium maculatum, the hyoscyamus, the stramonium, and  the  extract
of nicotiana.  Of the effects  of these, with the  exception of the hyos-
cyamus, we  have no experience.   The hyoscyamus we have  repeat-
edly employed from  a very early period in the attack, always in  com-
bination with  ipecacuanha,  and have invariably derived  advantage
from its use.
  The hydrocyanic acid has been strongly recommended, as a remedy
in hooping cough, by Muhrbeck, Kahleiss, Volk, Heller, Granville, and
others: by some, it is considered  to possess  a " specific power"  over
the disease.  Professor Thompson  regards it as  the sheet anchor  of
the practitioner;  he  commences its use, immediately after the opera-
tion of an emetic and brisk purgative, and continues it, with no  other
alteration than a gradual increase of the dose, until the disease is sub-
dued.   Dr. Roe is  convinced, that in warm  weather, it will  cure
almost any case of simple hooping  cough, in a  short time;  that  in all
seasons, it will abridge its duration, and  that in almost every instance
where it does not cure, it will, at least, materially relieve the severity
of the cough.a   Dr. Atlee, of Lancaster, has, in  a number of cases,
effected  a cure, in from  four to fourteen days, by its use ;b—he restricts
* R.—Acid, hydrocyanic. (Scheele's)  tflxij.      b R.—Syrup, simpl. 3j.
     Liquor, antimon. tartarisat. 3j.                Acid, hydrocyanic, m/j.—M.
     Tinct. opii. camphorat. 3ijss.         A teaspoonful morning and evening; and if
     Misturre camphorse, 3vijss.—M. '     no uneasiness, dizziness or sickness, is
Dose, a tablespoonful every four hours, in    produced within forty-eight hours, the
  some  warm drink; the patient to  remain    dose  to be repeated, three times  a day.
  in a warm room, and to live upon light   This  prescription  is  for  a  child six'
  pudding  and broth.  This  prescription,   months old; one drop more of the acid
  Dr. Roe directed for a  delicate boy, four   being added  for each year of the  child's
  years old.  For a healthy-looking female    age, beyond one year.  He has  never re-
  child, five years old, he directed—         peated the dose more  than four times a
R.—Acid, hydrocyanic, (Scheele's) fO/xx.      day.
    Liq. antimon. tartarisat—
    Vini ipecacuanha?, aa. 3jss.
    Aquoe, 3xiij.—M.
Dose, a teaspoonful every two hours.
it, however,  to  the second stage of the  disease.   Dr. Lombard  gave
from half  a  grain to a  grain of the hydrocyanuret  of potass, in the 
          DISEASES OF THE RESPIRATORY ORGANS.     361

 twenty-four hours, in cases in which there was much irritation, and a
 great variety of nervous symptoms.  Employed, comparatively,  on a
 brother, whose sister was taking the sub-carbonate of iron, this last
 remedy had, however, a most undoubted advantage.
   In the few cases in which we have prescribed the hydrocyanic acid,
 the  remedy certainly produced very favourable effects;  but we never
 trusted to it alone, and hence, it is difficult to say, whether all, or how
 much  of the benefit  derived could, with propriety, be attributed to the
 acid.   It comes to us, however, too strongly recommended, not to de-
 mand  a more extended trial, particularly in the more violent cases  of
 the disease.
   Of the antispasmodics that have been recommended in the treatment
 of hooping cough, the assafoetida, zinc, and sesquioxide of iron, appear
 to be those most deserving of  trial.  The assafoetida has in its favour
 very strong testimony.   We have employed  it, extensively, and have
 always  been pleased with its effects ; we have given it, by  itself in
 solution, or in combination with the tincture of hyoscyamus, or the
 watery solution of opium. Dr. Lombard states that he has often known
 frictions to the spine with the  tincture of assafoetida, of great service,
 and we have found a  plaster of assafoetida  applied  on the chest,
 promptly to relieve the cough  which is liable to remain after the more
 acute symptoms have abated.
   The oxide of zinc will, in many cases, be found a useful remedy in
 arresting the spasmodic cough, in the second stage of the disease.  Dr.
 Lombard has employed the  remedy extensively, in the dose  of from
 four to  twelve grains a day ; he found it generally to abate the violence
 of the paroxysms, and  has  seen  complete cures effected by it alone.
 In two  very young infants, whose cough was attended with symptoms
 resembling epilepsy,  the oxide of  zinc stopped both the cough and the
 fits.  Dr. L. has never seen  any bad effects  result from its use; our
 own experience is decidedly  in its favour.   But the remedy which
 appears to claim, above all others, our attention, is the precipitated
 sub-carbonate of  iron, (sesquioxydum  Ferri.)   This was first recom-
 mended by Dr. Steymann, who directed two and a half grains every
 three hours, increasing one grain for each year of the child's age be-
 yond the first.  Dr. Lombard, however, gave it to the extent of from
 twenty-four  to thirty-six grains, in water and syrup, or some cough
 mixture.  " I think," Dr. L.  remarks, " I may assert with confidence,
 that  the sub-carbonate of iron  enjoys a remarkable property to lessen
 the violence of the paroxysms, to diminish their frequency, and after a
 certain  number of days, to cure  entirely, the hooping cough.   It en-
joys, besides, the advantage of strengthening the little patients, and  thus
gives them the force  to resist a complaint, which sometimes lasts for
weeks, and generally leaves them weak, low, and exhausted.   In some
patients I have seen it cause, during the first  day or two after it  was
commenced with, a temporary increase of the cough, but this always
subsided after two or three days, and did not prevent the good effects
of the remedy."
   We have not yet had an opportunity of fully testing the  powers of
this remedy, and can, therefore, say nothing in regard to it, from  our 
362                DISEASES OF CHILDREN.
                                                            #
own experience.  In the few cases in which we have employed it, its
effects were not very striking.
  A great variety of other remedies have been proposed, for the cure
of hooping cough;  as, the tincture of  cantharides, either alone, or
combined with the tincture of bark, with quassia or with cicuta, &c;
by Lettsom, Sutcliff, Chalmer, Shafer,  Pearson,  Beatty, Millar,  and
Bucholtz; the musk, by Stoll,  Hufeland, Gesner, Lobel, and Dewees;
sulphuret of potass, ten grains  mixed with honey, morning  and even-
ing, by Blaud; the liquor subacetatis plumbi, by Forbes; garlic, inter-
nally  and externally, by Hufeland and Dewees; the arsenical solution,
by Ferriar, Simmons, and Eberle; the  lobelia inflata,  by Eberle  and
Andrews;  and various  fumigations,  as of benzoin, tar, galbanum,
nitrous acid vapour, &c, by Dohm, Watt, and Eberle.
  The lobelia inflata is spoken of in terms of the highest commenda-
tion.  Eberle states that he prescribed it for five or six years, in a very
considerable number of cases,  generally with some advantage, and in
several instances, with the most decided  success, it not only  mitigating
the violence of the cough, but abbreviating, in  many cases, the course
of the disease.  He  prescribed  the saturated tincture, in  union with the
syrup of squills, in  doses of ten drops each, four  or five  times daily,
to a child two years old;  and  has raised  the  dose in  some cases to
twenty drops.
  Dr. Golding Bird  remarks (Guy's Hospital  Reports, April, 1845),  that
in the second stage of pertussis — after all inflammatory  symptoms
have  subsided ; and  when, with a tolerably cool skin and clean tongue,
the patient is still  severely distressed by  the more or less copious secre-
tion of viscid mucus in the bronchi; each attempt to get rid of which,
produces the exhausting and  characteristic cough ; he knows of no
remedy which will be found to  give such marked and often rapid relief
to the child as alum.  Dr. Bird gives  the  alum in doses of from  two
to six grains, repeated every four or six  hours,  to children from one to
ten years of age.  For a child of two or three years he employed gene-
rally  the following formula:—
  R.  Aluminis gr. xxv.;  extr.  conii gr.  xij.; syrup, rhaedos. 3ij.; aq.
anethi, 3iij. M. Dose, a medium-sized spoonful, every sixth  hour.  Dr.
B. has never met with  any inconvenience from the effects  of the re-
medy on the bowels ;  on the contrary,  in more  than one instance it
produced diarrhoea.  The only  obvious effects resulting from its use
were, diminished  secretion, and of a less viscid mucus,  with a marked
diminution in the  frequency and severity of the spasmodic paroxysms.
   In  a recent edition of Underwood's Treatise, edited  by Dr. Davies,
of London, that gentleman remarks that, after a long  trial, he is dis-
posed to  attach  more importance  to alum, as a remedy in  hooping
cough, than to any other form of  tonic or antispasmodic.  He  has
been  surprised at the speed with which, in many cases, it  arrests the
severe spasmodic fits of  coughing; it seems equally applicable to all
ages, and almost  to all conditions of the patient.   The  fittest stage for
its administration, he believes to be the moist condition of the air-pas-
sages, and freedom from cerebral congestion; but an opposite condi-
tion would not preclude its use, should  this state not have  yielded to 
          DISEASES OF THE RESPIRATORY ORGANS.       363

other remedies.   It generally keeps the  bowels in proper order,  no
aperient being required during its use.  The dose for an infant is two
grains three  times daily; and to  older children four, five, and  up  to
ten or twelve  grains may be given, mixed with syrupus rhoeados and
water.
   We have prescribed the alum during the second stage of pertussis,
in a large number of cases, and  invariably with the most  decided
benefit.
   In the Annuaire de  Therapeutie for 1846, it is stated that M. Berger,
in the convulsive stage of hooping cough, in which the indication is
to  combat nervous irritation,  having become  dissatisfied with  the
effects of the remedies ordinarily employed, was induced to administer
the nitrate of silver, from which  he  has obtained  results  singularly
beneficial.  He prescribes it in doses of  from a sixteenth to a twelfth
of  a  grain, at first three times, and afterwards  four times a  day;  of
course the remedy should not be administered in cases where the state
of the digestive organs contra-indicates its employment.
   M.Jules Guyot, in the  Union Medicate  for April, 1849, recommends
a strong infusion  of coffee, well sweetened, in  the dose of a teaspoon-
ful for a child of  two years, and a dessert-spoonful for a child of four
years, repeated four  times or oftener daily, as an effectual means  of
arresting the  paroxysms of coughing in the chronic stage of pertussis.
   During  the employment of whatever narcotic or antispasmodic re-
medy we  may adopt, its effects  should  be carefully watched, and if
any symptoms appear, threatening the occurrence  of disease of the
brain or lungs; or if the  tongue becomes more and more red, the dis-
charges from the bowels more and  more frequent, thin and  vitiated,
and tenderness of the epigastrium is observed  upon pressure, it should
be at once omitted, and leeches or cups should be applied to  the tem-
ples, nape of  the  neck, or epigastrium, according to the seat of  irrita-
tion, together with warm sinapised  pediluvia, and the other remedies
which the character  and extent of the symptoms may indicate.  By
watching  thus the incursions of disease  in  those organs most liable
to be affected in the course of the attack, and meeting it in its onset
by an appropriate treatment, we shall  save  many patients, which  by
neglect, or by keeping the attention too  much fixed upon the parox-
ysms of spasmodic cough, would be most certainly lost.
   Towards the close of  the disease, the patient will often be  much
benefited,  and his convalescence  confirmed, by  the administration of
some mild tonic;  the  bark, either in substance or infusion, or the sul-
phate of quinia, has been highly extolled at this particular juncture.
It is  probable, however,  that the use of  the sesquioxide of iron may
render the use of  other tonics unnecessary.
   During  convalescence, the utmost attention should be paid to  the
clothing, diet, and exercise of the patient. Exposure to cold, indiges-
tible food, or overfeeding, will be  liable to produce a relapse.   If the
bowels are costive or  sluggish, they should be kept  regular by  gentle
laxatives; if  diarrhoea attend, Dover's powder, or some light astrin-
gent, will  be  proper, and  if the discharges are thin or vitiated, small
doses of calomel, combined with  chalk,  ipecacuanha,  and extract of 
364
DISEASES  OF CHILDREN.
hyoscyamus, the warm bath, and a  regulated diet.  In some cases,
sponging the body daily with tepid salt water, has been found decidedly
beneficial.
  The principal writers on the disease, agree as to the importance,
towards  its  decline, of change of air.  It is, in fact, as remarked by
Gregory, often, particularly after severe and protracted cases, the only
thing that will give  to the patient a chance of recovery.  In many
cases that had baffled  all  attempts to stop the cough, a change of air
has accomplished  the  cure.   It  has been found equally  indifferent,
whether the patient be  removed out of or into town, provided  there is
a change, and even a removal to a very short distance has been suffi-
cient.  The change, if possible, should be to the sea-coast, or  to a
high, dry situation  in the country; this change, however, unless it be
to a warmer  climate,  is improper so long as the weather continues
cold or changeable, but in the latter part of spring, during the continu-
ance of summer, and in this  climate, until late in autumn, it will be
productive of  the best  effects.   Where a permanent removal cannot
be effected,  daily exercise in  the open  air should not be neglected,
always taking care to  guard against cold and dampness, by proper
clothing,  and all other suitable precautions.

      10.— Foreign Bodies in  the Larynx and Trachea,
  Although  it is not our intention to consider all the surgical affections
of children,  yet as the phenomena which result from the  accidental
introduction of foreign  substances into the larynx and trachea, often
simulate very closely the symptoms of some of the  more violent dis-
eases of the respiratory organs  to which  children are liable, it seems
proper to notice, in this place, the signs upon which the diagnosis  may
be founded.
  When  the child  is  known to  have introduced into its mouth some
small body,  which  has  accidentally fallen into the trachea,  giving rise
immediately to severe dyspnoea, with stridulous inspiration, convulsive
cough, and the other  symptoms usually resulting from the existence of
any impediment to the  free ingress and egress of air into and from the
lungs, of course the only question to decide, is the proper measures to
be taken  to relieve the respiration, and remove the impediment.  If the
foreign body be completely within the larynx or have passed into the
trachea, the propriety and  probable success of the operation of trache-
otomy, should be fairly and cautiously considered.
  That the operation, when early  resorted  to, has repeatedly  suc-
ceeded in affording  complete relief, there is sufficient evidence upon
record, and  hence, when it has  been decided  upon, no time should be
lost previous to its performance, for we have seen, in more than one
case, so violent a bronchitis ensue at an early period after the occur-
rence of the accident, as to render the operation unavailing, even when
the foreign  body has been extracted.  In some cases, however, the
body having passed  into one of the bronchi, cannot be extracted by
any instrument introduced through the opening in the trachea, and
is not dislodged, notwithstanding the violent fits of  convulsive  cough
to which its presence gives rise. 
          DISEASES OF  THE RESPIRATORY ORGANS.       365

  In one of these cases which  fell under our notice, the child lived
three  months, and exhibited before death nearly all the symptoms of
consumption of the lungs.   Upon dissection, a small metal button was
found firmly fixed, towards the middle of the right bronchus.   Both
lungs were affected with lobular pneumonia, and the right with  exten-
sive vesicular bronchitis; on being cut into, the lung appeared to con-
sist of an immense congeries of minute abscesses.  In the  left lung,
there existed extensive interlobular and sub-pleural emphysema.   The
mucous membrane of the right  bronchus was thickened, and covered
with  a  thick layer of dense, almost membranous mucus;  traces of
which were found, also, in  the lower part of the trachea, and left bron-
chus ; at the part where the button was lodged,  the membrane was
softened and ulcerated to a considerable extent; no part of  the  lungs
presented any trace of  tubercles.  In another case, after six weeks,
during which the patient's symptoms were precisely those of chronic
bronchitis, the foreign body, a large bead, was expelled, and the child
gradually regained his health.
   In  many cases, however, the circumstance of a foreign body having
passed into the  larynx or trachea, may not be suspected, and then it is
only by a close and careful scrutiny into all the circumstances—the
symptoms under which the child labours, and the  signs derived from
auscultation and percussion—that we are able to detect the real  nature
of the accident.  The symptoms produced  by a  foreign body in the
larynx or trachea, are often those of laryngismus stridulus, or spasm
of the glottis; in other cases, after a few  days are passed, they become
more nearly those of croup; while in  numerous  instances, the  only
symptom present is a violent,  convulsive, ringing cough, coming on
at irregular intervals, but without the stridulous respiration  or  severe
dyspnoea of either croup or hooping cough; the child, in the intervals,
being apparently^ free from every symptom of disease.
   When a child,  that has presented  nothing to indicate the approach
of any serious disease, is suddenly attacked with violent dyspnoea  and
convulsive cough, and symptoms of  impending suffocation—the dys-
pnoea being greater during expiration than inspiration—which symp-
toms, after continuing for a longer or shorter period, suddenly cease,
and the child appears tolerably well, with the exception, probably, of
a  hoarseness of respiration:—but, after a time, the same phenomena
return,  with similar, or even greater violence, and thus continue to in-
termit and  recur, irregularly, we may suspect the  presence of some
foreign body in the larynx or trachea.  When in the former, however,
the paroxysms  of dyspnoea and convulsive cough, are of much greater
violence, and of longer  continuance, than when the body has  passed
into the trachea; the intermissions, also, are shorter and  less perfect.
When  the foreign  body is in  the trachea, or probably  in one of the
bronchi, we have known many hours, and even entire days to  elapse,
without the recurrence of a paroxysm.
   The  stethoscopic signs are chiefly valuable at  the commencement,
before inflammation of the bronchi has set in.  When the foreign body
is fixed in the larynx, as is likely, if it be a  fish-bone or other pointed
substance, the  healthy respiratory murmur will be plainly distinguish- 
366
DISEASES  OF CHILDREN.
able throughout the whole extent of the thorax, which will also return
a clear sound upon percussion.  Some mucous rhonchus will probably
be audible in the upper portion of the trachea, owing to the accumula-
tion of fluid, in consequence of the irritation which has been induced.
When the  foreign  body is movable, as a  button,  plum-stone, &c,
would be, its motion  up and down the trachea will be occasionally
heard, as well  as a valve-like sound, produced by its being driven  in
expiration against the rima glotlidis.  There may also be perceived,
at times, a temporary  interruption to respiration  in one lung, when the
body happens to be impacted in the corresponding bronchus; the re-
spiratory murmur again returning, when the obstruction has been re-
moved by a  violent expiration.   It is said that the foreign body is most
likely to pass into the  right bronchus, and that hence, it is in the right
lung we shall most frequently observe the obstruction of respiration.—
(Maunsell.)
  After some time has elapsed, however, should the foreign body not
be  expelled  by a violent fit  of coughing, bronchitis, or tracheo-bron-
chilis will ensue, and  our only guide will then  be the history of the
case, as the  stethoscopic signs  will  not assist us in our diagnosis.
  The most obscure cases are those in which a small, smooth, rounded
body has passed into  the trachea,  and lodged in one of the  bronchi.
We have known a case of this kind, in which, after the first day, there
was a complete intermission of the  dyspnoea, spasmodic cough, and
every other  symptom, the child continuing for very nearly a week ap-
parently free from all  disease, except an occasional  hoarseness of re-
spiration, and a short  hacking  cough, which recurred at  short inter-
vals; these  symptoms gradually increased,  and a  violent attack of
pneumonia, confined principally to the right lung, occurred, and termi-
nated fatally in five days; when, upon dissection, a small glass ball, of
the size of a large bead, was discovered, deep in the right bronchus,
the presence of which had not been suspected during the  lifetime of
the patient, though, upon inquiry subsequent to the autopsy, it was as-
certained that it had been given to the child to amuse him, on the day
he was first  attacked,  and had  been missed from that period.
                     SECTION  III.

            DISEASES OF THE NERVOUS SYSTEM.

                1. —Hypertrophy of the Brain.

  Enlargement of the brain, from a simple increase of organic par-
ticles, without any appreciable change of structure, is a very common
occurrence in infancy. Its existence has been cursorily referred to by
Portal, Otto, Hufeland, Scoutettin, Dance, Laennec, Jadelot, and Bou- 
DISEASES OF  THE NERVOUS SYSTEM.         367
illaud; while its occasional presence, in patients that have died of epi-
lepsy, and other chronic diseases, is  noticed by  a  few of the earlier
writers.  It is chiefly, however, to the observations of Andral, Munch-
meyer, Sims, Green, and Lees, that we are indebted for any accurate
views in relation to its phenomena, diagnosis, and general pathology;
upon  each of which particulars  there still, nevertheless, exists much
uncertainty.
  It can scarcely be doubted that the phenomena resulting from  par-
tial or general hypertrophy of the brain, are almost daily ascribed to
causes, which have no existence at the time, while their actual source
is entirely overlooked.   Convulsions, epileptic attacks, idiocy, active
inflammation of the brain, terminating in softening  and apoplexy, are
often induced by cerebral  hypertrophy, in  cases in which the  latter
has attracted little or no attention; while in other instances the patient
is supposed to be  labouring under chronic  hydrocephalus, and when,
as  is not unfrequently the  case,  the hypertrophy terminates  in serous
effusion, the post-mortem appearances are  adduced as conclusive evi-
dence of the correctness of the diagnosis.
   It is of some importance that an accurate diagnosis should be esta-
blished in this affection, in order  that we may be  enabled  to detect  its
existence at as early a period as possible ; for if anything is to be done
to arrest its progress, it must be before the brain has acquired any
considerable augmentation in size.   It is to be recollected, that cere-
bral hypertrophy is almost invariably developed  slowly;  that the pe-
culiar phenomena  produced  by it, very generally present themselves
so  gradually, as to excite but little attention  or  alarm in the earlier
stages of the disease, or if noticed, they are seldom referred to their true
cause, until they have acquired an extent and character when they are
no longer under the control of remedies.
   Hypertrophy of the brain, or at  least  a condition of that organ
strongly predisposing it to undue, and  more or less rapid, augmenta-
tion in  bulk, is very frequently congenital.  Children are often  born
with  heads, the dimensions of which far exceed  the normal  standard,
and greatly disproportioned  to the residue of  the body:  in  other  in-
stances, the head  at  birth   presents nothing  remarkable in its bulk
or form, but soon  after, rapidly  increases in size, and often attains,
within a short period, an enormous magnitude.  In many of these
cases, the cranium being developed in the same  ratio with the brain,
no morbid symptoms are produced, or but slight ones.  So far as our
 own observations extend, however, we have, in  every case, observed
more or less apathy, dulness and drowsiness, to accompany undue de-
velopment of the brain, and this at a very early period.
   At a  later period, and particularly when  the growth  of the cranium
is slower than that of the brain, the symptoms  that have been most
generally observed, in  addition to the  undue size of the  head, and a
peculiar projection of  the parietal  protuberances, are, obtuseness of
intellect, characterized chiefly by apathy  to external objects, a very
great irritability of temper, inordinate appetite, giddiness,  and habitual
headache, with severe exacerbations.  The only instance  we have met
with in which the intellectual faculties were increased in  development 
368
DISEASES OF  CHILDREN.
and activity, is that of Dr. Elliotson; the patient, a lad of twelve years
of age, " used," we are told, " always to seek the company of persons
older than himself; and nothing pleased him  more, than to converse of
the best forms of human governments.  Political economy was his de-
light."  The patient died of apoplexy.  Another diagnostic sign, noticed
by Sims and Green, as occasionally present in cases of hypertrophy of
the brain, is, a sensation of firmness communicated  to the finger, on
pressure being made over the fontanelles.
  In one case of cerebral hypertrophy, in a child between five and six
years of age, the skull was enlarged  to such a degree,  that the  head
acquired a magnitude equal to that of an adult, and  yet the functions
of the brain were undisturbed, and the only phenomena which the  child
presented during life, were frequent falls, occasioned  by  the weight of
the head—which was carried forward whenever the patient wished to
run—and a great tendency to sleep, when he remained quiet.  The
patient died of acute enteritis, and the brain exhibited a great develop-
ment of all  its parts, with only a small quantity of reddish serum in
the ventricles.
  It must be evident that children labouring under hypertrophy of the
brain, will  be particularly  predisposed  to cerebral disease ;  in  such
cerebral  hyperaemia is readily produced by trifling causes, and  from
the degree of compression to which the brain is constantly subjected,
whenever the hypertrophy is  of any extent, much more serious conse-
quences will result from a slight increase of  blood in its vessels, than
when the organ is in its normal condition.   Apoplectic seizures  have
been noticed as  preceding, accompanying, or resulting, from  hyper-
trophy of the  brain.  We  have repeatedly  observed deep comatose
seizures of some duration, and of complete apoplexy, with extravasa-
tion of blood into the substance of the brain.   Children with excessive
enlargement of the  head, we have found, also, to be  particularly pre-
disposed  to convulsions,  acute  meningitis, and hydrocephalus,  from
either direct or remote irritations.
  When the capacity of  the  cranium does not increase with the in-
creased  development  of  the  brain, or when the hypertrophy  com-
mences at a period when the ossification of the skull  has been nearly
completed, the phenomena produced are of a much more decided  cha-
racter, than when the growth of the cranium and brain go on simulta-
neously, or nearly so.  In these  cases, the  symptoms usually present
are, intense, habitual headache, augmented at irregular intervals; ver-
tigo, or a sense of dizziness; increased dulness of intellect, amounting,
in many instances, to complete idiocy; and debility of the limbs, par-
ticularly of  the inferior extremities, which  goes on increasing, until,
finally, general paralysis  results.   There ordinarily occur convulsive
movements or twitchings of the muscles, at first slight, and occurring
at long irregular intervals,  but becoming gradually more severe and
frequent, until regular convulsive  paroxysms ensue, during one of
which, death often takes place ; or a state of coma may ensue, termi-
nating  sooner or  later  in  death.   The  convulsions  attendant upon
hypertrophy of the brain not unfrequently assume all the characteristics
of epilepsy. 
DISEASES OF  THE NERVOUS  SYSTEM.          369
  In some cases, there suddenly ensues a considerable reduction, and,
occasionally, entire abolition of sensibility.  In other instances, the
patient is suddenly attacked with  acute delirium, or deep coma, more
or less quickly followed by death.   Mania was observed by Andral in
one case.  There is, generally, an  inordinate appetite; a torpid  state
of the bowels; and, occasionally, a marked slowness of the pulse.  In
the majority of cases  that have fallen under our notice, the patients
have been inclined to fat, and often every part of their bodies, was ex-
cessively loaded with  it.   Death,  in  the  majority of cases,  occurred
suddenly, during a convulsive attack; it has, however, been repeatedly
preceded by an attack  of genuine  apoplexy, with effusion of blood in
the substance of the brain; and in some cases, by all the symptoms of
acute hydrocephalus.
  The disease is divided by Andral into two stages : 1st. The chronic;
marked by few symptoms, or simply by slight obtuseness of intellect,
more or less headache, either permanent or intermittent, vertigo, apathy,
drowsiness,  and convulsions at intervals.   All of these symptoms may
occur in the same individual, simultaneously or successively, or only
one or  more of them  may be observed.   2d. The acute stage; the
phenomena  of  which are, sudden  attacks of violent  convulsions,
idiocy, epileptic paroxysms, deep coma, or symptoms of acute hydro-
cephalus.
  The duration of life in children affected with hypertrophy of the
brain, is extremely variable.  Many arrive  at puberty with hut little
suffering or  inconvenience, while others die at an early age from the
accidental occurrence  of hyperaemia of the brain, convulsions, or cere-
bral inflammation, or from symptoms resembling acute hydrocephalus.
In some instances, death occurs suddenly, without  being preceded by
any particular  symptoms of disease; and occasionally death  takes
place from diseases unattended throughout with any indication of cere-
bral affection.
  The prognosis, according to Dr. Lees, is not necessarily unfavoura-
ble, for, as the affection is rather an error of development than an ac-
tual disease, there is a natural tendency in the brain to return to the
normal state.  The chief danger results from the very  great suscepti-
bility of the hypertrophied brain to disease, especially upon the occur-
rence of the affections incident to dentition, of pertussis, or of either
of the febrile exanthemata.
  The appearance of the brain upon dissection is that of simple en-
largement, with flattening of  the  convolutions, diminished amount of
blood in its  vessels, little  or no serum in the ventricles,  or beneath the
membranes, and morbid paleness of the cortical substance.  The sub-
stance of the brain is in many cases increased  in density, resembling . .      ^
boiled  albumen, blajjc-mange, or cream cheese.  Sometimes, accord-J-10* -i*,"*"J(
ing to Sims, the hypertrophy is confined to one lobe, or to the corpora
striata or thalami. Whether these  partial hypertrophies are marked
by any peculiarity of phenomena,  we are  unable to  say.   In all cases
the hypertrophy is chiefly confined to the cerebrum, the cerebellum
being seldom much, if at all affected.  In some instances, the brain, or
rather the vessels of the pia mater, are injected  with blood; in others,
                               24 
370
DISEASES  OF CHILDREN.
        a slight amount of reddish serum is found at the base of the brain;  in
        others, again, a clot of blood, with rupture of the fibres of the medul-
        lary portion, will be detected; whilst in a few, we have more or less
        extensive softening  of  the substance of the organ;  but  in  all  these
        cases, death will have been generally preceded by symptoms of cere-
        bral disease, in addition to those which properly belong to hypertrophy
        of the brain.
          Professor Rokitansky states,  as the result  of  many microscopic
        examinations, that the augmentation  in the bulk of the  brain is not the
        result of a development of new nervous fibrils, nor of the enlargement
        of those already existing, but that it  is due to an increase of the  inter-
        mediate granular matter.
          The principal affection with which hypertrophy of the brain  is apt
        to be  confounded, is chronic hydrocephalus, to which its phenomena
        bear a strong  resemblance, and with  which it has unquestionably been
        repeatedly confounded.  This occurred in the cases  referred  to by
        Hufeland, Jadelot, Laennec, and Scouttetin.  In the  first case related
        by  Dr. Sims,  the mother of the child  informed him, that they had
        wished to tap  the head at one of the  hospitals;  and Dr. Hennis Green
        saw a child who had been condemned to death by a medical man, as
        having water  on the brain, but which was a case of simple hypertro-
        phy, that did not interfere with the health of the patient.
         It has been  suggested by Dr. Lees, that the peculiar projection of
        the parietal protuberances on which  Munchmeyer particularly insists,
        may  prove a valuable guide in aiding us to discriminate  cerebral
        hypertrophy from chronic hydrocephalus.   The sensation  of firmness
        communicated to the  finger on pressure being made over  the fon-
        tanelles, in cases of hypertrophy, as contrasted with  the  fluctuating
        feel, in cases of chronic hydrocephalus, has also been proposed by Dr.
        Green as a diagnostic sign; but this, it is evident, cannot apply, except-
        ing in  very young subjects, or in extreme cases.
         Dr. Mauthner (Krankheiten des Gehirns. Vienna, 1844,)  lays down
        the following diagnosis between hypertrophy of the brain and chronic
        hydrocephalus:—In  hypertrophy, it is the  posterior part of the  skull
        which is observed first to become unnaturally prominent, the projec-
        tion of the forehead  occurring subsequently, while in chronic hydro-
        cephalus the projection of the forehead is one of the first results of the
        disease.  The latter affection is usually associated with a generally
        emaciated  condition; the former with a leuco-phlegmatic  habit, and
        with  increased deposits of fat.   The  constitutional symptoms of the
        two  affections likewise  differ;  convulsions, sopor,  and restlessness
        attend the  early  stages of chronic hydrocephalus, while  spasmodic
        affections of the  respiratory muscles  are  among the earliest indica-
k  •■>>   tions of hypertrophy  of the brain, but seldom occuruntil an advanced
       stage of hydrocephalus.
         Hypertrophy of the brain has been  most frequently  observed in chil-
       dren of a lymphatic temperament, or  in those affected with rickets.  It
       may be present at birth, or be developed at any period subsequently,
       up to  puberty.  Its  most  usual exciting causes have  not been  very
       clearly made  out; there is no doubt, however, that it may, as re- 
DISEASES OF  THE NERVOUS SYSTEM.
371
   marked by Sims, be more or less quickly induced by any cause capa-
   ble of exciting the brain itself, or that  is calculated  to increase {he
   nutrition of the body generally.  Frequent contusions of the head have
   been  enumerated by  Dance, as  an  occasional  exciting  cause.  By
   Laennec and  Papavoine,  the causes of colica  pictonum  have been
   supposed to have a very great influence on the development of the
   disease.  M. Laennec states, that he has never seen a case of fatal
   saturnine epilepsy,  in which there did  not exist an evident cerebral
   hypertrophy.  Extensive disease  of the heart  and lungs, by impeding
   the return of blood from  the brain, or obstructing its circulation, has
   been  suggested  by  Sims as a probable cause of hypertrophy of the
   latter. But, we confess we are at  a loss  to understand in what manner
   a  state of venous congestion of any organ  is  likely  to increase its
   nutrition; it is much  more reasonable to suppose with Mauthner, that
   the hypertrophy is  the result of the  repeated occurrence  of cerebral
   hyperaemia, from any cause  attracting  to the vessels of,the brain an
   abnormal amount of blood.  It  must be recollected, however,  that
   hypertrophy of the brain does not invariably result, in cases in which
   hyperaemia has  repeatedly occurred  at  short intervals, and that it  is
   frequently met with, where no hyperaemia has been observed.
      In the cases that  have fallen under our notice, we  have  sought  in
   vain for any cause for the excessive development of the brain, beyond
   a congenital tendency to excessive nutrition of that organ.
      In  regard to the  treatment,  whether preventive,  or that proper
   during the height of the  disease, with the view  of reducing the ex-
   cessive size of the brain, we have very little to  say.   Our own expe-
   rience .affords  us no positive results, and we find nothing  satisfactory
»'-> fn'rBepublis'hed'obsesr^ations of others.       A  <l*.  \ %*||i *7  i
      When, in an infant, a tendency  to  excessive development  of the
   brain is observed, it will be  prudent  carefully to avoid the slightest
   cause of increased excitement and determination to that organ. Every
   precaution should be taken to prevent, as much  as possible, frequent
   or prolonged paroxysms of crying.   The bowels should be kept freely
   open, and the  body immersed daily in a tepid bath,  followed imme-
   diately by brisk friction to  the  whole  surface.   Sponging the  scalp
   frequently with cold water, appears to be a judicious means of keeping
   down any undue activity in the organic functions of the brain; while,
   at the same time, the  head should be invariably kept uncovered within
   doors, and be  but lightly clothed when the child  is taken abroad; even
   a luxurious growth of hair should be kept down  by frequent cutting.
      The appetite of these children is generally craving ; it should, there-
   fore,  be kept under a  cautious restraint; and, after the chjd is weaned,
   his diet should consist solely of a moderate quantity of  farinaceous
   food, with milk.  Daily exercise in the open air, to  an extent propor-
   tioned to the age and  strength of the child,  should be insisted upon.
   When teething commences, the evolutions of the teeth  should be daily
   and cautiously watched, and the slightest indication of undue swelling,
   or inflammation of the gums, should be met by free scarifications, re-
   peated whenever the swelling or inflammation of the gums recurs.
     When the child is more advanced in age,  a  serious question  will 
372
DISEASES OF CHILDREN.
arise as to its education.  This should not be commenced too soon.
To tax a brain in a state  of hypertrophy,  and predisposed, from the
slightest cause, to hyperaemia  and undue  excitement, with even the
smallest amount of mental labour, would certainly be a very dangerous
experiment:—hence, when the hypertrophy is  advancing with  con-
siderable  rapidity, every degree of  mental  application should  be
positively prohibited ; and those means employed, particularly bodily
exercise, as will have a tendency to direct nutrition  to the muscular
system, and thus, if possible, to suspend its activity in the brain.
   The slightest indication of undue excitement  or  hyperaemia of the
cerebral vessels, should be a signal for the application of leeches to
the head,  cold lotions to the scalp, the exhibition of brisk purgatives,
and the application of counter-irritants to the  extremities, as warm
sinapised pediluvia, or sinapisms, &c.
   We believe that our chief efforts are to  be directed to prevent the
increase of the undue  cerebral development;—after  it has attained a
certain height, we are unaware of any means capable of reducing it,
without endangering the life or health  of the patient.
   When the  growth of the cranium ceases, while that  of the brain
continues, the morbid  phenomena resulting  from the compression of
the brain, which  invariably results, may  certainly be,  to a  certain
extent, abated, the comfort of the patient increased, and life prolonged,
by a proper  hygienic course of treatment—but all hopes of effecting
a  cure must  be abandoned.

        I, — Cerebral Hyperaemia and  Haemorrhage.

71 \y 0^^^WS>JUpOPLEXY.--PARALYSIS. JO*V*  A <S"#* 'M>~U>f?X+

  Apoplexy and paralysis are of much more frequent occurrence during
infancy and childhood than is generally supposed. We have met with
these affections at every age, from one or two days subsequent to birth,
up to the period of puberty.*  M. Lasserre has  very  satisfactorily
shown the not unfrequent occurrence of apoplexy  in infants  immedi-
ately after birth.   A very considerable proportion of  the deaths annu-
ally reported as  from  convulsions,  disease of the brain, and acute
hydrocephalus in children, we have  reason to  believe,  are,  in fact,
fatal cases of apoplexy.
   When apoplexy occurs in infancy, the attack  is generally  sudden;
but, in many instances, it may be preceded for some days by a de-
ranged condition of the bowels; or  it may  occur after  an attack  of
convulsions,  or in the course of some  other  disease.   The symptoms
are, invariably, more or less complete stupor, with a tumid, and livid
appearance  of the face, contraction  and insensibility of the pupils,
laborious or  stertorous rospiration, and occasionally,  convulsions, or a
spastic rigidity of the neck  and  lower extremities.  On recovering
from the  state of stupor, the child may exhibit no lesion of motion or

   * During the 38 years preceding 1845, there occurred in Philadelphia, in children under
ten years of age, 69 deaths from apoplexy; namely, in those under  one year of age, 27 ;
between 1 and 2, 16; between 2 and 5,14 ; and between 5 and 10, 12. 
DISEASES OF  THE NERVOUS SYSTEM.          373
sensation on either  side  of the body,  or  one side,  or the upper or
lower extremity of one or the other side, may be in a state of complete
or partial paralysis.
  In other  cases, the cerebral haemorrhage is attended by  scarcely
any other symptoms than frequent, intense, or  long-continued  convul-
sive  paroxysms; thus  Dr. Schleifer,  in  the  Foundling Hospital of
Prague, has detected,  in cases  of convulsions, in young infants, a
haemorrhage on the dura mater, rarely between the  membranes, and
never in the substance of the brain.
   In very young infants, if proper remedies are promptly resorted to,
the brain  may,  in  general,  be  very speedily  relieved  of  its state
of hyperaemia, and the  patients restored to perfect health; but if
the disease be allowed to continue too long, or recurs repeatedly at
short intervals, should the child survive the immediate effects of the
attack, serous effusion is very liable to occur in the brain,  or some
organic change in its structure, resulting ultimately in death,  or in an
impairment or destruction of the intellectual faculties, or in a permanent
lesion of motion or sensibility, of some part of the body.   In  children
somewhat more advanced in age, apoplectic and paralytic attacks are
generally of a much more unmanageable  and fatal character, often
proving immediately fatal, in  consequence of extravasation  of blood
at the base or upon  the surface of the brain, and occasionally within
its texture.
   The appearances upon dissection in fatal cases, are usually—tumes-
cence of the vessels and  sinuses of the brain, with sanguineous oozing
from the medullary substance of  the organ, exhibited in a number of
small bloody  points upon the surface of incisions made in it, and occa-
sionally, serous effusion beneath the arachnoid, at the base of the skull,
in the ventricles, or in the theca of the spinal cord.  The hyperaemia
is occasionally found to  affect the vessels and substance of the spinal
marrow, equally with those of the brain.   Even in cases of paralysis
occurring  in children, whether they have  been preceded or not by
symptoms of apoplexy, haemorrhage of the brain from rupture of the
vessels, disrupture of the texture  of the organ, or even  serous effusion,
is met with much more rarely than in the adult.  In the generality of
cases, the only appreciable lesion is extensive hyperaemia  of the vessels
of the brain and spinal column, and of the meninges and the  roots of
the spinal nerves.  (Cazanvieilh,  Kennedy.)  If lesions of the texture
of the brain occurred  in these cases  as often as they do in the adult,
we should  more frequently meet with permanent paralysis in the in-
fant, whereas  it is of very rare  occurrence. (Kennedy.)  We have,
nevertheless, in children over two years of age, repeatedly  detected
haemorrhage within the substance  of the brain after attacks of apoplexy,
and, in many cases, persistent paralysis.
  Effusion  of blood either at the base  of the brain, upon the surface of
its hemispheres or into the ventricles, and  along  the whole course of
the spinal  cord, is  occasionally observed in children.  (Abercrombie,
Serines, Legendre, Schleifer.)
  When the hyperaemia, and effusion of serum or blood, is principally
confined to the spine, constituting what has been denominated spinal 
374
DISEASES  OF CHILDREN.
apoplexy,  the phenomena differ  somewhat from those generally ob-
served in connexion with similar lesions of the brain.
  When there is simply turgescence of the vessels and texture of the
medulla spinalis, the symptoms that have been observed are, occasion-
ally convulsions, drowsiness bordering on stupor, lividity of the face,
drawing down of the  corners of the  mouth, and the fixation of the
arms  firmly against  the sides.  The symptoms from  serous effusion,
vary somewhat in different cases; thus, in one instance, we may have
severe pain in the back, and paralysis of the inferior extremities.  In
another, opisthotonos, difficult deglutition, and coma.   In another, vio-
lent convulsions, coma, and distortion of the eyes.  In another, con-
vulsions, followed by coma, with a permanent clenching of the hands.
When blood  is effused  in the spinal canal, the  symptoms  are, pain in
the back, and general convulsions, or trismus, and  convulsions,  either
tonic or clonic.
  Paralysis may occur in infants, independent of disease of the brain
or spinal marrow, from local injury inflicted  upon the nerves of the
parts  paralysed.  Examples of this we have  in injury of the  portio
dura,  as in face presentations, or where the  head has been long pressed
in the  pelvis  against the projecting ischiatic spines; the paralysis in
these cases very generally subsides in  a short time.
  Dr. West, of London, divides paralysis, as it occurs during infancy
and childhood, into three forms, according as it is congenital, as it suc-
ceeds to symptoms of cerebral disease, or as it comes on without any
previous indication of disorder of the  brain.
  It usually presents the form of hemiplegia—the leg being more fre-
quently affected than the arm.   Sensation is not impaired; occasion-
ally, it would seem to  be even morbidly increased.  The first variety
is usually associated with  imperfect nutrition of the affected limbs;
and, as might be expected, is incurable.   Cases of the second variety,
for  the most  part, do well  eventually; they are often associated with
constitutional  disturbance, dependent on  the process of dentition.
Cases of the  third variety occur in debilitated  children, and occasion-
ally succeed  to the eruptive fevers.   They often run an extremely
chronic course, and the patient's recovery is in many cases only par-
tial; or, notwithstanding his  general  health may become robust, the
affected limb will continue  powerless—in which case,  it gradually
wastes away, and becomes, finally, greatly reduced in size.
  Cerebral haemorrhage, however, often  presents itself,  attended  by
symptoms very different from those of ordinary apoplexy, and  which
have been very generally ascribed  to other lesions of the brain.   For
the investigation of the pathology of this form of disease, we are  in-
debted almost exclusively to the labours of recent observers, particu-
larly to those of Legendre.  It generally occurs in children between
one and two  years of age, and is seldom observed after the third year.
The symptoms in the early stage are rather those of encephalic irrita-
tion, than of apoplexy; and  in the latter  stage, of protracted  cases,
they differ but little from those of chronic hydrocephalus.
  The attack sometimes commences  with  repeated convulsive parox-
ysms; at  other times,  with all the phenomena of cerebral inflamma- 
4            DISEASES OF  THE NERVOUS SYSTEM.          375

tion;  and, in numerous instances, the disease has  unquestionably been
mistaken for acute hydrocephalus.
   The child may be affected  with vomiting, though in the majority of
cases this symptom is  not observed.  There is, very generally, in the
commencement, severe febrile excitement, with flushed face, hot skin,
and a frequent, full, and hard pulse, increased thirst, and loss of appe-             j
tite.  The pulse, at first, amounts to 100 or upwards in a minute, and
soon  increases to 120 or 140, and, in the advanced stages of the dis-
ease, becomes so rapid as scarcely to be counted.
   Very early in the attack, the patient is affected with slight convul-             <
sive movements, particularly  of the eyeballs, followed by some degree
of strabismus.  The  bowels  are, in general, regular, and the stools ■£•/**&#// f j
naturafTn appearance.  The child is  often seen  to carry his  hands^6 ^Uh^X\
continually, but  apparently unconsciously,  to some part of the nead.jtyjLrC*     \
There soon occurs a  permanent contraction of the feet  and hands,
followed by convulsions, either tonic or clonic; during which there is
an abolition  of sensibility and consciousness, and  an  increased tur-             '
gescence  and coloration of the face.  Sometimes the  convulsions
affect the whole of one side of the body, sometimes the upper limb of
one side only; not unfrequently, both sides are affected, but unequally;
the convulsive movements  being always  greater in one than  in the
other.  After continuing  for a  few moments, the convulsions  cease,
and the patient remains in a state of drowsiness, which increases with
the progress of the disease.   The febrile symptoms continue through-
out the attack, and augment in intensity as death  approaches.
   The convulsive paroxysms occur, at first, after irregular intervals
of some length, but  become  gradually more frequent, until finally, to-
wards the close of fatal cases, they are  almost continual, or rather, the
patient is affected with a constant tremor, with momentary convulsive
paroxysms, during which, the injection of  the face is increased, and
the pulse  and respiration accelerated.   In  no instance has paralysis
been  observed during the acute stage.   When death takes  place, it is
generally at the end of eight  or twelve  days.  The occurrence of tho-
racic inflammation would appear,  according to  the observation of
Legendre, to be in many cases the cause of death in the acute stage.
   Very often the disease runs a much  more protracted course.   The
convulsive paroxysms abate  in violence, or cease entirely ; the febrile
symptoms diminish in intensity,  and finally disappear; the cranium
gradually increases in  size, and often attains to a very great bulk; the
sutures and anterior fontanelle remaining unossified; and the parietal
projections, as well as the forehead, acquire a very considerable pro-
minence.  In many cases the patient is affected with strabismus, and
his countenance assumes a vacant expression.  The pupils are usually
dilated, the dilatation  being equal in both  eyes:  vision, according to
Berard, is occasionally destroyed.
   In most cases the intellect of the patient diminishes as the head aug-
ments in bulk, and may finally  be  destroyed.  It is, generally, how-
ever,  only  weakened,  and the patient  becomes,  to a certain extent,
idiotic; in  these cases, he sometimes  utters, particularly during the
night, prolonged piercing screams, during which, he extends his mouth 
       376                DISEASES OF CHILDREN.                  ^

       widely open.  Cutaneous sensibility is not impaired, even in those in-
       stances  in which a complete abolition of intelligence and movement
       takes place.   The movements of the body are, however, seldom de-
       stroyed ; the patients  sometimes roll their heads constantly from one
       side  to the  other upon the pillow, or when seated, rock continually
       from side to side  the upper part of their bodies.   Occasionally  they
       strike violently their head with the clenched fist, or dash it against the
       sides of the  cradle.   Grinding the teeth is a  common  symptom, and
       one case is noticed  by Legendre, in which the patient, exhibiting the
       physiognomy of an idiot, tore off with  his teeth, portions of his  gar-
       ments and bedclothes, and swallowed them.
►   .\ .    During the whole of this  chronic  state the patients, in general, eat
t.  ... and drink with  avidity whatever is presented to them.  There is never
*. .• »#ny indication of partial paralysis, nor  any diarrhoea; the bowels are
       usually constipated.   In  the greater number of the  cases  that  have
       been  observed, death was, according to Legendre, the result of some
       accidental disease, unconnected with the affection  of the brain.
         The chronic  stage of the disease is generally protracted from eight
       to thirty  months, and would probably continue much longer, if no ac-
       cidental cause were to occur to accelerate the death of the patient.
         Cerebral haemorrhage is not necessarily fatal.   In the acute stage
       the symptoms produced by it may be entirely removed, and the patient
       restored  to  health without the  danger of his  becoming subsequently
       hydrocephalic.  In those cases in which the haemorrhage is to a slight
       extent, the blood, very probably, may be entirely removed by absorp-
       tion ;  but when a large amount of blood is effused, an organized cyst
       is formed around it,  and the disease acquires then  a chronic form.
       Even when  this is the case, however, as soon  as the disease  has ar-
       rived at its height, it has, according to Legendre, a natural tendency
       to decline, and may disappear entirely:—the serous fluid and  clots in
       the brain being absorbed, and the cyst  containing them gradually ob-
       literated, the cranium will contract  in size, and  the fontanelles and
       sutures become completely ossified.  The movements and sensation of
       the body may be  fully regained in these cases, but  it is  probable that
       there will always remain a certain degree of fatuity or idiocy.
         The appearances upon dissection,  when death  takes place in the
       acute stage, are either a simple effusion of bloody serum, or more fre-
       quently, of a bloody serum containing small, thin, reddish clots of blood,
       the whole enclosed in a kind of sac, formed by a soft, thin membrane,
       attached to the  lower surface of the arachnoid.  The effusion is inva-
       riably found within the arachnoid cavity.  In the  sub-arachnoid cel-
       lular  membrane, and  in the ventricles, there generally exists  a small
       quantity  of  perfectly  limpid,  or  light  citrine-coloured  serum.  The
       effusion  most commonly occurs upon the surface  of both  the hemi-
       spheres.  It is  sometimes, however, confined to  one, and it rarely
       occurs upon the cerebellum.   (Legendre, Boudet.)  The  coagula are
       usually very thin, from two inches and a quarter to two inches and a
       half in extent;  they are soft, and of a bright  red colour when  recent,
       but become, subsequently, brownish or greenish, and are the  more firm
       the longer the period  that has elapsed since the  effusion took place. 
DISEASES OF THE NERVOUS  SYSTEM.          377
They may exist on a level with the anterior or middle  fossae of the
base of the brain, but more generally occur, according to the observa-
tions of Legendre, upon the upper surface of the hemispheres.  They
are invariably enclosed within a reddish, elastic, soft, delicate  mem-
brane, but of some degree of firmness, and about one-tenth of an inch
in thickness; it may be detached from the under surface of the arach-
noid in small shreds.   This membrane  always becomes more elastic
and firm the longer the effusion has existed.   Most writers  refer its
production to a mechanical separation of the  fibrinous portion of the
effused blood, which,  deposited on the under surface of the arachnoid,
becomes gradually organized;—the first vestiges of organization, ac-
cording to Baillarger, present  themselves about the  fifth day after the
effusion has occurred.
   The veins of the surface of the hemispheres are occasionally gorged
with blood,  and the cortical substance of a very bright reddish-gray;
the incised surface of the brain becoming quickly studded with nume-
rous bloody points.   The convolutions are not sensibly flattened, nor
the brain  in a  state of hypertrophy (Legendre); the brain has  been
supposed by Berard, to be in some cases, even reduced in size, which
is, probably, however, a mistake.   Not the slightest  trace has  been
discovered by Legendre, in any case, of gray, semi-transparent granu-
lations on  the  pia mater throughout its extent, nor the least appear-
ance of tubercle in any part of the brain.
  When death  occurs at a later period, the coagula are found enclosed
in a true  organized  cyst, with transparent parietes,  which  adheres
intimately to the lower surface of the arachnoid, by means of a very
fine, delicate cellular  tissue, that is very easily torn, and permits the
cyst to be detached entire.  The cyst has no attachment to the surface
of the brain, excepting by numerous small branches of blood-vessels
which pass over it to the latter. (Baillarger, Legendre.)  The con-
tents of the cyst  are  coagula  of blood and a bloody serum, but more
generally  the last only, which  is then always in considerable quantity.
(Berard, Poumeau, Legendre.)  The  blood is sometimes in the form
of soft, red  coagula;  at  others, the cyst contains a brownish, turbid
serum, in the midst of which float filaments of a soft,  somewhat elastic,
grayish-red  substance, having  a close resemblance to fibrine.   The
cavity of the cyst is at first single, but subsequently it becomes, by the
approximation of its sides at different points, divided into a  number of
small  cells, (Poumeau.)   There is generally, according  to  Legendre,
one triangular cavity  of an inch or two in length, extending along the
falciform process of the dura mater.
  The etiology of the form of cerebral haemorrhage just described, is
but little understood; age appears to be its chief predisposing cause;
it has seldom been seen in infants under one year of age, and still less
frequently in those over three years.   In the great majority of cases the
haemorrhage is the result of a  simple exhalation from the vessels, pro-
duced by repeated recurrences  of hyperaemia of the brain. It is seldom
the result of rupture of a blood-vessel.   When the effusion of blood is
produced  by the latter,  death takes  place almost immediately, the 
378
DISEASES  OF CHILDREN.
blood is unmixed with serosity, and there is no trace of an organized
membrane around it.
  In the cases that have been observed by Legendre, the greater num-
ber occurred in the  winter, whereas those that  have occurred under
our notice, occurred in summer, and at least one-third of them could
be traced to the effects of insolation.
  The disease has appeared to us to be in all cases a true irritation of
the brain, the hyperaemia resulting from this irritation terminating in
an effusion, more  or less  considerable, of blood and serum,  upon the
surface of the  brain, without giving rise to meningeal or cerebral in-
flammation.   We agree, therefore, with the suggestion of Legendre,
that the febrile  excitement and slight convulsive movements by which
the commencement  of the attack is accompanied, mark  the  period of
simple hyperaemia, while the occurrence of carpo-pedal contractions,
but more especially  of violent and repeated  convulsive paroxysms, fol-
lowed by more or less drowsiness, indicate  the  period when the  san-
guineous exhalation in the cavity of the arachnoid has taken place.
  Cerebral haemorrhage  is to be distinguished  from tuberculous dis-
ease  of the  brain by the early age at which  it occurs.  The latter
being seldom developed previous to the sixth year, or at least not until
a period beyond that at which the  form of  cerebral haemorrhage with
which it can alone be confounded, occurs.  Tuberculous meningitis is,
also, seldom accompanied by the intense  febrile reaction observed in
cerebral haemorrhage.   Repeated  bilious vomiting and obstinate con-
stipation are likewise common in the first, but very rare in the latter;
while  the convulsive  attacks  are  neither so constant nor  so frequent.
The permanent carpo-pedal contraction is absent in  the tubercular
affection, and constantly present, to a greater  or  less extent, in the
haemorrhage of the  arachnoidal cavity.
   In its chronic form, this form of cerebral haemorrhage is with diffi-
culty distinguished from chronic hydrocephalus of the ventricles of the
brain, the symptoms of the two  being nearly the same.  The latter
affection, however,  is often  congenital, and commences, in  all cases,
soon after birth, without  any appreciable cause;  the head  augmenting
in  size gradually, and acquiring,  often,  an enormous  bulk. On the
other hand, arachnoidal hydrocephalus, resulting from cerebral haemor-
rhage, is never congenital, but commences, ordinarily, about the  tenth
month, or at the period of dentition; the  head increases in size gradu-
ally, but never acquires so great a volume as in chronic hydrocephalus;
the disease is, finally, preceded invariably by repeated convulsions, or
symptoms of encephalic disease, which mark the period of the occur-
rence of the haemorrhage.
   It may be distinguished from hypertrophy of the brain by the aug-
mentation of the size of  the skull, in the latter, preceding  the develop-
ment of morbid symptoms;  whereas, it is only in the chronic stage of
cerebral haemorrhage  that  the head increases in  size.   It is proper,
however, to remark, that children affected with  hypertrophy of the
brain are strongly predisposed to  cerebral hyperaemia, as well  as to
 meningeal haemorrhage.
    The prognosis in cases of meningeal haemorrhage  must be based 
DISEASES OF  THE NERVOUS  SYSTEM.
379
 upon the  source  of the sanguineous  effusion, the  period  at which it
 occurs, the nature of the phenomena by which it is accompanied, and
 the circumstances under which the patient is placed.
   The source of the haemorrhage is all-important in forming our prog-
 nosis; if from a ruptured vessel, it is always promptly fatal.  There is
 great difficulty in distinguishing this  form of haemorrhage from  that
 which is produced by simple exhalation, excepting by its rapid  termi-
 nation in death.   The  age, however, of the patient,  may  afford us
 some aid; in young children, haemorrhage of the brain, from  a  rup-
 tured vessel, being comparatively rare.
   When  the case is recent, the  prognosis is the most favourable, for
 by a judicious plan of treatment, it is then  possible to cause the ab-
 sorption of  the effused fluid, and prevent, thus, the occurrence  of the
 chronic form of the disease.  When, however,  the symptoms  of the
 acute stage are of considerable intensity, the  febrile reaction violent,
 and the convulsive'paroxysms occur at shorf intervals, the hopes of a
 favourable termination are but slender; and according  to the observa-
 tions of Legendre, should the patient be attacked with pulmonary in-
 flammation, a fatal termination is almost  inevitable.
   In its chronic  stage, meningeal  haemorrhage is always  a  serious
 disease; for even under  the most favourable circumstances, it may
 produce serious lesions of motion, and more certainly of the intellect.
 When both these functions are completely abolished, the  prognosis is
 still more unfavourable:  there being  little hope  of either  being again
 recovered, or, the probability is,  that before any amendment  can
 occur, death will  ensue from some other affection.
   Under  all circumstances, there'is greater hope to be entertained of
 a final recovery when the patient is placed under favourable hygienic
 conditions, than under opposite circumstances. In the public hospitals
 of  Europe,  the disease, according to  Baudelocque and Legendre, is
 almost invariably fatal.
   In relation to the treatment of cerebral hyperaemia and haemorrhage,
 notwithstanding the  results of clinical experience  furnish us with  but
 little positive information,  there cannot be much  difficulty in deciding
 upon the plan best adapted to control the  disease, at least in its earlier
 stages.
   In the form of apoplexy from  simple over-distension of the  blood-
 vessels of the brain, which is that most commonly met with in  young
 infants, leeches to the head will almost invariably be demanded.  The
 safety of  the patient requires that  the overloaded  state of  the brain
 should promptly be  reduced, whether it occur as  the original affection,
 or as a consequence of some pre-existing disease ;  and in young chil-
 dren leeching appears to be one of the  safest, easiest, and most effectual
 means of effecting this.  A leech  or two will  be borne  by a  new-born
 infant, and the happiest effects will often  result from their application,
in  cases of hyperaemia, or undue irritation of the brain.
  The extent of local depletion must, however, be left to the  judgment
of the practitioner; it is  to be governed, in  a great measure,  by  the
age and strength  of the patient, and  the  urgency of the  symptoms;
and while everything depends upon the  depletion being sufficient to 
380
DISEASES OF CHILDREN.
relieve the oppression of the  brain, the utmost caution should be ob-
served not to  carry it  too far, as  this  may produce a very serious
degree of debility, and actually augment, rather than reduce, the con-
dition of the brain it is intended  to  remedy.  Should, however, the
loss of blood produce pallor of the countenance, a quick pulse, and a
state  approaching  to complete syncope, the administration of some
stimulant, as wine whey, should he immediately resorted to,  in order
to prevent the  serious and even fatal  consequences, that might other-
wise result.
  If the patient is able to swallow, we should administer, immediately,
a brisk purgative, of which the best will  probably be calomel, followed
by castor oil; the  calomel being  repeated, subsequently, in  frequent
small  doses, combined with a minute portion of ipecacuanha.  When
a purgative cannot  be administered by  the mouth, we must resort to
purgative enemata ; one composed of tepid water, salt and molasses
with the  addition of  castor oil will usually be sufficient;  but where
the  symptoms  are urgent, an  addition of turpentine to the enema will
be proper: or it may be composed entirely of castor oil  and turpen-
tine.  In all cases of extensive hyperaemia of the brain, a pretty smart
impression made upon the lower portion of the intestines will  invaria-
bly  be found to be attended with the most decided good effects.
  Immersion of the lower half of the body in warm water while cold
lotions are applied  to the scalp, when  judiciously managed, will often
promptly rouse the  patient from his state of stupor, and it may subse-
quently be  repeated, if any tendency is  observed to a recurrence of
the  hyperaemia.  Stimulating embrocations to the lower extremities,
and along the spine, we have employed  in many cases with very de-
cided  advantage. Blisters behind the ears, although of little use during
the  apoplectic  attack, have  appeared  to us to be often useful in pre-
venting its return.
  In that form of meningeal haemorrhage, in which the blood is effused
in the cavity of the  arachnoid, during the acute stage, the same treat-
ment  as above will  be demanded.   The  immediate safety of the pa-
tient,  and the prevention of the chronic state of the disease will depend
upon  our being able to remove the cerebral hyperaemia, before haemor-
rhage has occurred, and, subsequently, to obtain the absorption of the
effused blood and serum, before it  becomes enveloped by an organized
membrane.  Leeching,  or when the patient is old enough, bleeding
from  the arm,  to an extent proportioned  to his age and strength, and
the  violence of the symptoms present, followed by active purges, warm
sinapised pediluvia, and  cold applications to the head, will  be the re-
medies, upon which we are chiefly to depend, during the early period
of the acute stage.   After the bowels are smartly opened by purga-
tives,  (full doses of  calomel, followed by an infusion of senna  with the
addition of sulphate of  magnesia,1) benefit may be derived from the
administration  of  small  doses of  calomel,  tartarized antimony and
nitre,b every three hours.  Blisters  to the nape of the neck, or  between
the  shoulders, will occasionally be found useful, after the febrile symp-
toms  have been somewhat reduced. 
DISEASES OF THE NERVOUS SYSTEM.          381
  » R._Fol. senna?, 3ss.                 b R.—Calomel, gr. vj. ad xij.
       Manna;, 3ij.                         Antimon. tartarisat. gr.j.
       Sem. fcenelic. 3ss.                    Pulv. nitri. gr. xxxvj. ad xlvnj.—M.
       Sulph. magnes. 3iv.—M.                 f. chart. No. xij.
Infuse in half a pint of boiling water, of
  which a child of two years may take
  a small wineglassfull.
  In nearly all the acute affections of the brain in children, cold lotions
to the scalp are, subsequent to direct depletion, one of the most power-
ful  remedies we can  employ; simply sponging the scalp with cold
water will answer as well, perhaps, as any other lotion, or we may
add to the water a portion  of vinegar, alcohol, or camphorated spirits ;
it is, however, upon their abstraction of heat alone, that the  good
effects of these lotions depend.
  In regard to the extent to which the depletion is to be carried, the
amount of purgation to  which the patient is to be subjected, and the
nature of the other antiphlogistic, counter-irritant, and derivative re-
medies to be employed,  and the proper period and intervals for  their
administration, much must be left  to the judgment of the practitioner ;
no general rules can be  given, as  important  modifications will be de-
manded  by the character of individual  cases.  But,  there will be but
little difficulty in deciding correctly in relation  to  the proper indica-
tions, and the  remedies, by which  these are to be fulfilled, if the patho-
logy of the disease  be kept  constantly in mind.   It is to reduce the
irritation and  consequent  hyperaemia  of the brain, and to prevent its
termination in effusion, that our remedial measures are to he  directed
in the first period of the acute stage ; the activity of  these measures
being commensurate with the intensity of the symptoms, in each case.
  The diet of the patient should be of the mildest and least irritating
character.  During the height of  the disease, it will be proper to pro-
scribe  every article of food,  and confine the child  entirely  to  some
simple mucilaginous drink, given cold.
  Whether, in any  instance, meningeal haemorrhage,  or rather the
irritation  of the brain by which it is induced, is  the effect of difficult
dentition, we are  unable to say;  but,  as the  attacks  most frequently
occur at the period of the  eruption of  the teeth, it  is important to pay
attention, in every case,  to the condition of the gums, and if they are
found sw^lJerLor- inflamed, to relieve this by free incisions.
  After  the occurrence  of haemorrhage within  the arachnoid mem-
brane, the  treatment  must be governed by the nature and extent  of
the symptoms present.   If depletion has been carried to a  sufficient
extent in the early period of the attack, leeching or bleeding from the
arm will  seldom be  necessary; but should the acute  symptoms still
continue with any degree of violence, the application of a few leeches
to the head, or of cups to the nape  of the neck, will  be prudent.  Under
all  circumstances the bowels should  be kept freely  open;  and pro-
bably the best means for doing this, will be by the use of a  combina-
tion of calomel, tartarized antimony, and nitre, at stated intervals; this
combination, at the same time that it keeps up a sufficient action upon
the  bowels, tends  to  diminish  undue  arterial excitement.  The cold
lotions to the head will, also, be proper, and the  repetition of warm 
382                DISEASES OF  CHILDREN.
pediluvia, and blisters behind the ears, will  generally be productive of
good effects.  The diet should still be mild  and unirritating;  the only
food allowed, in  addition to the mucilaginous drinks already recom-
mended, being plain water gruel, or milk and water.
  Throughout the whole of the acute stage, the patient should be kept
as quiet as possible, and guarded, as much  as  may be, against every-
thing capable of  irritating or exciting  him.  The temperature of  his
apartment, and the quality and quantity of his clothing, should be such
as will keep  his  body of a comfortable warmth, and protect him
against the effects of sudden transitions of temperature; but, at  the
same time, the air he breathes should be preserved perfectly  pure, by
free  but cautious ventilation.  We are to recollect the danger inva-
riably attendant upon the  occurrence of any new disease in the course
of this  affection, and, especially, the liability of the patients to lobular
pneumonia from  slight causes.
  When the disease has attained its chronic stage, we have to contend
against a condition of the brain very much  resembling chronic hydro-
cephalus, but from which, judging from  the few facts in our possession,
there is  a much  greater  probability of the patient's recovery; there
being a natural tendency  to absorption  of the effused fluids, and to an
obliteration of the sac in which they are contained.
  The treatment  will consist in guarding  against a recurrence of
cerebral irritation,  and promoting the absorption of the abnormal
fluids from  the arachnoid cavity.   The  first is to be accomplished,
chiefly by judicious  hygienic measures, exposure of the patient to a
pure, fresh atmosphere,—a  mild unirritating diet—a proper tempera-
ture of the body;  by preserving the bowels regularly open by mild pur-
gatives, and by the daily use of  the warm or tepid bath, according as
the existing temperature of the patient's surface is depressed, or other-
wise.  How far  we may be able to promote  the absorption of  the
effused fluid, by the employment  of diuretics combined with calomel;
iodine, internally  and externally, and the judicious use  of tonics,  we
must wait for the results of  a more extended experience to determine.
  The  prophylaxis is all-important; children peculiarly predisposed to
irritation and hyperaemia of the brain, should be placed under the same
hygienic treatment, as directed in the section on cerebral hypertrophy.

                        3. — Convulsions. iuM&>bp^A*--
  From  birth up to the termination of the stage of infancy, convul-
sions are of very frequent  occurrence;  they  may take  place in  the
course of almost every disease which attacks at this period of life, and
are, in  fact, the common precursors of death, in  all of them. They  are
often, however, the sole phenomena that are produced by certain irri-
tations of the brain, arising originally in  that organ, or in some other
organ,  especially  the  alimentary canal.   Their frequency  and  the
danger by which they are very  generally attended, demand  for them
a separate consideration.*

  * The number of deaths from convulsions, in children under ten years of nge, that occur.
red in Philadelphia, during the thirty-eight years preceding 1845, was 8182, or an average
of 215 per annum—namely, in infants under one year of age, 5934; between 1 and 2,
1126; 2  and 5, 840; 5 and 10, 282. 
DISEASES OF THE  NERVOUS, SYSTEM.         333
   The parts most generally subject to convulsive movements, are the
 eyes, the  muscles of the  face, those of the superior and  inferior ex-
 tremities, and those of respiration.  Each part of the body may be
 separately or successively affected with  convulsions, or the whole of
 the voluntary muscles may be simultaneously  attacked.   Most com-
 monly, however, the convulsive movements are confined  to  a single
 limb, or to one side of the body, or, if they occur on both sides, they
 are always more violent on one side than the other.
   The convulsions  are very generally attended with foaming at the
 mouth, often with a peculiar  hissing respiration, with flushing of the
 face, the  muscles of which are variously contorted, with  injection of
 the  eyes, which  are often turned upwards  or to one side; with a
 copious perspiration about the head, forehead, and temples, and occa-
 sionally with a livid appearance of the contour of the eyes and mouth.
 The head is usually thrown backwards by a  rigid contraction of the
 muscles,  and occasionally it  is turned  on one side.  There is often
 complete trismus, or repeated grinding  of the  teeth.  In yery violent
 cases there is often an involuntary discharge of the urine and faeces.
 The pulse is generally contracted,  and extremely rapid.  In violent
 paroxysms, the  tongue is often wounded by  its  being protruded be-
 tween the teeth;  discharges of blood from the nose are not  uncommon,
 and occasionally extensive ecchymoses of the  adnata of the eyes.
 The jugular veins are generally distended during the fit, as well as the
 veins about the head and  forehead.
   The violence of the paroxysms is very various;  in some cases the
 muscles are affected with a trembling vibratory motion, rather than
 with  convulsive contractions and  extensions,  while in other cases the
 muscles are  in the most rapid and constant state of contraction and
 relaxation;—the  contractions of the limbs are occasionally so forcible
 as to render it impossible  to restrain them.
   The duration of the paroxysms is very various.   They may cease
 after a few minutes, or continue for hours or even days.   In all cases,
 however, the paroxysms are marked by partial remissions of the con-
 vulsive movements, which either abate in violence for a short time, or
 cease altogether  for a  moment or two, and are then repeated  with
 equal or increased violence.
   When the paroxysm goes off, the cessation, in slight attacks, or in
 those of short duration, may occur suddenly;  but in the more severe
 attacks, and those which  have  lasted for any length of time,  the con-
 vulsive  movements  become gradually less  violent and frequent, the
 eyes assume a more natural expression;  the countenance acquires  its
 usual  look; and the patient appears altogether unconscious  of what
 had occurred.  He merely evinces more or less lassitude, and, if able
 to speak,  complains, perhaps, of headache.  A long, refreshing sleep
frequently succeeds.  In many cases, however, there remains for some
time after the paroxysm has ceased, a tonic contraction,  or  a loss of
power in some of the voluntary  muscles, or the child may be affected
with complete paralysis of one limb, or of an  entire side of the body.
A curious case is related  by Thompson,  of entire loss of speech and
hearing, consequent  upon  a sudden  attack of convulsions, in  a child 
384
DISfEASES OF CHILDREN.
eighteen months old.   The patient  regained her vivacity and general
health, but continued  deaf and dumb until she reached her sixteenth
year, when, after the noise of a public rejoicing, she was  observed to
recover her sense of hearing, and  slje soon after began to articulate.
When attacks of convulsions  are frequently repeated, they may assume
finally the character of genuine epilepsy.
  Children frequently die during the convulsive paroxysm; when this
takes place, it is, in the majority of cases, the result of extensive hyper-
aemia of the brain, or of asphyxia caused by excessive engorgement of
the vessels of the lungs.   Brachet describes a  state of syncope as oc-
casionally supervening upon  convulsions,  simulating death; in an in-
stance related by Johnson, a child in this state, after being laid out for
interment, was recovered by friction diligently applied  to its surface
near the fire.
  The paroxysms of convulsions we  have known frequently to cease
upon the occurrence of a haemorrhage from the nose.  Their termina-
tion by a copious  diarrhoea  is very  common.  Vomiting, also, very
frequently causes the cessation  of convulsions, by removing from the
stomach the offending matter, by the irritation resulting  from which
they have been produced.   We should keep this  important fact con-
stantly in mind,  in deciding upon  the treatment of the  convulsive
paroxysm.   We have repeatedly seen the  most violent attacks of con-
vulsions, in which bleeding, sinapisms, injections, and the  warm  bath
have been resorted to without effect, cease immediately when, by the
operation of an emetic, a quantity of  undigested matter has been dis-
charged from the stomach.
  It is scarcely possible to determine, from  any of the symptoms which
occur during the convulsive paroxysm, either its" probable  duration or
ultimate result.  The most violent paroxysms frequently cease within
a short period, without any immediate injury to the health of the child;
or the subsequent occurrence of any disease traceable  to them.  In
other instances, the attack, apparently slight in its commencement,
either destroys the child in a few hours, or is the precursor of some
serious affection of the brain, by which death is produced  or the mental
and physical powers of the patient are considerably and permanently im-
paired.  The onset of many of the most serious diseases of childhood is,
indeed, marked by convulsions.  In  general, however,  when the con-
vulsive paroxysms are slight,  short in  duration, and  are succeeded  by
a state of cheerfulness and  general health, ultimate danger is seldom to
be apprehended ;  but when they are marked by great violence in  their
onset,  or gradually increase  in violence;  when they  are long  con-
tinued, or recur frequently at  short intervals, there is great danger of
a fatal termination. When the child is dull, heavy, listless, and peevish
after the cessation of the  paroxysm,  we have cause to apprehend a
speeedy repetition of the attack.  Immediate danger to life, during the
convulsive attack, is much less to be feared, when the paroxysms are
separated by long intervals, than when they recur after  short and im-
perfect intermissions; there is reason, however, to apprehend  in these
cases, a permanent affection of the  brain,  from which, at some future
period, serious mischief may result.  Convulsions produced by remote 
DISEASES OF  THE NERVOUS SYSTEM.          385
irritations are, in genera], much  more manageable and less fatal than
those dependent upon direct irritation, or disease of the brain or spinal
marrow.
  The appearances presented by the bodies of those who have  died
from convulsions, are very various.  Of course, in those cases in which
the convulsive attack occurs during the course of  some disease of the
brain, the pathological  appearances are of no value in determining the
immediate cause of the convulsive symptoms; it is only in those cases
where the convulsions present themselves as the principal phenomena,
that the autopsical lesions are of any importance.
   It is said, that in many cases of  death from convulsions, the brain
and nervous system present no traces of disease whatever.   This
statement we  are  not  permitted to deny; we can only say, however,
that  in every instance in which we have examined  the brain  after
death from convulsions, more or less disease of that organ, or of the
medulla oblongata or spinalis, was present.   In most cases, this-**
amounted to simple, but very extensive hyperaemia, with slight effu-
sion  of serum beneath the membranes, or within the ventricles; in
other  cases, partial softening  of the brain was very evident; tubercles
were  frequently detected, either  meningeal or within the substance of
the brain, and in a few cases, effusion of blood upon the surface of the
brain  at its basis, or within the  theca of the spinal marrow.
   Inflammation of the membranes of the brain, sharp spiculae of bony
matter formed in  the dura mater, abscesses in the  brain,, or effusion of
blood  into its substance  from external violence, are the appearances
recorded by some of the older physicians.  Effusion of serum, vascular
turgescence, tumours attached to the membranes  or embedded within
the substance of the brain, are noticed  by more recent  writers.   Tur-
gescence of the vessels, a deep red colour of the  dura  and pia mater,
and effusion  of blood  beneath  the  cranium, are the appearances de-
scribed by De Claubry; vascular  turgescence,  at the origin of the
nerves distributed  to the muscles  that had been affected  with convul-
sive movements, has been noticed by Moulson.  Effusion of serum, or
of a gelatinous matter, engorgement of the blood-vessels, extravasation
of blood, abscesses, tumours,  and inflammation of the meninges of the
brain, are the lesions described by others.  Effusion of  blood within
the spinal canal, engorgement of the vessels of the brain,  and extreme
venous congestion of the entire substance of the brain, with serous
effusion, were met with by Horner, in one case; and the same appear-
ances with extreme mollescence of the brain, in another.  Turgescence
of the vessels of the brain, its substance of a pink colour, with serous
effusion into the ventricles, at the base of the cranium,  and within the
theca of the spine, are noticed by Kennedy.
   Schmidt, who appears to  have  collated, with a good deal of care,
the observations of the German pathologists on the subject of convul-
sions, gives as the general result of their autopsies, extensive hyperae-
mia of the brain and spinal marrow; serous effusion  into  the ventri-
cles, upon the surface, and  at the  base of the  brain, or within the
vertebral  canal;  in a few cases, effusion of a gelatinous  matter upon
the surface of the brain, and within the spinal theca; in still fewer
                               25 
386
DISEASES OF CHILDREN.
            cases, effusion of blood upon the hemispheres of the brain, or within
            the spinal canal: indications of meningeal inflammation, circumscribed
            softening of the brain, and abscesses, were observed, in a very few
            instances.
              It must be evident, from the results of the most accurate and exten-
            sive series of pathological  observations, that, in the great majority of
            instances, convulsions  are intimately connected with disease  of  the
            brain or medulla spinalis.   We can, however, easily conceive that, in
            consequence of  an intense irritation, occurring either primarily in  the
            brain, or affecting it secondarily, from disease of the alimentary canal
            or other organs, a severe attack of convulsions may occur, and produce
            almost immediately the death of the  patient, without any appreciable
            lesion of the brain being discoverable after death.
              Convulsions  may  occur, at any period, from the  moment of birth
  -,         up to puberty.   The first  few weeks of the infant's  life, the period of
/fdlVpw 6**'weaning, and that  of  dentition, constitute the  stages of infancy, at
            wfnch  convulsions are most liable to occur.  From accidental causes,
            however, they may be produced subsequent  to  the  latter  period,  but
            the tendency to their occurrence gradually decreases, from the second
            period  up to puberty ;  thus we find  that the greatest  number of deaths
            from convulsions occur within the first year—the next greatest, be-
            tween  tone and  two years; the next, between two and five; and  the
            smallest number, between five and ten;  after this, the falling off in the
            amount is so considerable, that the number is not worth noticing.
               The frequent occurrence of convulsions in infancy, is unquestionably
            owing to the greater susceptibility of every part of the  system at  this
            age, than subsequently; the greater activity of all the organic func-
            tions ;  the large size of the brain compared with the rest of the body,
            and the very great development and activity of its capillary system
            engaged in the perfection of its growth and organization.   Irritations
            are  quickly reflected from the other organs upon the brain, and  the
            habitual  hyperaemia of the latter, during  infancy, is readily increased
            by slight causes, and  though we  may not understand why irritation
            and hyperaemia of  the brain should, more readily in infancy than in
            after life, stimulate the muscles to irregular and inordinate action, there
            can be little doubt  as to the fact.   Few of the cerebral affections of
            this age are unattended,  either in  their commencement or progress,
            with convulsions; and we have seen, that in those who die of disease,
            the  only observable phenomena of which are convulsive paroxysms,
            the  brain almost invariably presents indications  of the existence of
            irritation—an overloaded  state of its blood-vessels, and an injection,
            often very considerable, of its  substance—these lesions frequently ex-
            tending, also, to the medulla oblongata  and spinalis.
               There can be no doubt that, from various causes, the very great
            susceptibility to impressions in the nervous system of the infant, is, in
            many  cases, still further augmented, and  that, with  this augmentation
            of susceptibility, the predisposition to convulsive attacks will likewise
            be increased.   That this is, in fact, the case, daily experience teaches
            us.  Thus, some children are known to be far more excited  than others
            by sensations communicated to them through the external  senses,  and 
DISEASES OF THE NERVOUS SYSTEM.          397
are thrown into a state of tremor, almost amounting to convulsions, by
unusual objects, sounds, and odours, which, upon others, produce little
or no  effect.   Such children  are  liable to be suddenly affrighted or
alarmed, to be peevish, fretful, and discontented, and, with difficulty,
amused; their sleep is  disturbed by dreams or frequent startings; their
faces flush, and turn pale suddenly, from causes of the most trifling
character, and their  whole deportment, the mobility of their facial  ex-
pression, and  their  shrinking, quick, timid glance, in the presence of
strangers or of unfamiliar objects, indicate the morbid excitability of
their nervous system.  Such children are said, also, to present an  un-
usual development of brain, and precocity of intelligence.   The fact, l±M<&+\ ;
that children, born with  large  heads, or whose heads  increase in size 4*-<M*4iy  4T
disproportionately to the rest of their bodies,  are particularly liable to.o<^,
convulsions and other cerebral affections, the result of  our own obser-
vations confirms; we have not, however, observed that such children
present, in general, an  earlier development of intellect than others.
   The fact that convulsions are a frequent result of febrile disturbance
in early childhood, is pointed out by Mauthner, and he shows how  the
tendency  to venous  congestion, which is so characteristic of  early
childhood, explains this  occurrence.  Somewhat similar are the  re-
marks of Dr. Morell  (New York Journ. of Med.)  on the same subject.
   A hereditary predisposition to convulsions has been noticed by  many
respectable authorities; this is not improbable, though we have seen
no positive facts in confirmation of it.   It is  a  common occurrence,
however,  to find a predisposition to convulsions, to exist  in all  the
children of the same family; this  is, no doubt, the result of similarity
of organization, in all probability, transmitted  to them by their parents.
It is stated by North, that the  children of parents who marry at  too
early or too advanced  an age, are  more liable to convulsions, than  the
offspring of those who marry in the prime of life; and  it is  certain,
that children, born of  females  in whom  the health of  the constitution
has  been  impaired by  luxurious habits, late hours, deficient exercise,
stimulating, and otherwise improper diet, or intemperance of any kind,
are more predisposed  to convulsive  affections  than  the offspring of
mothers, who are in good health, and live regular, active, and tempe-
rate lives.  And this is probably one of the reasons why convulsions
are of far more frequent occurrence, in large  and crowded cities, than
in the open country.  We are to recollect, however, that the stagnant
and  impure air  of cities acts equally prejudicially upon the infantile
organism  as upon that  of the adult, and  may develope in  it subsequent
to birth, a predisposition  to convulsive affections, while the fresh and
pure air of the open country, by invigorating the vital powers of  the
infant, and diminishing nervous excitability, renders it  less susceptible
to the impression of the ordinary exciting causes of convulsions.
   In older children, a  neglect  of  exercise, confinement within doors,
too early and  long-continued mental application, or  the excitement
produced  by night parties, and  crowded rooms, will develope  the
undue nervous excitability which predisposes  to convulsions.
   Although no climate or latitude  appears to  afford protection against
an attack of convulsions, they are unquestionably of much more fre- 
388
DISEASES OF CHILDREN.
       quent occurrence  in warm and very variable climates, and unhealthy
       localities generally.
         Those forms of convulsive disease in children, depending upon at-
       mosphere or climate, such as prevail in the West Indies, or in crowd-
       ed hospitals, ill-ventilated suburban districts, or the narrow streets,
       courts, and alleys of large  cities, often exhibit peculiar phenomena,
       marking them, in  a certain sense, as specific diseases;  like all affec-
       tions  that owe their existence,  in a  great  measure, to atmospheric
       causes,  they assume, often, peculiar types and characteristics, and
       prove, generally, more fatal  in their tendencies.  Under this head may
,.   ,#>. • be classed,  the epidemic convulsions, which occurred  at Paris,  de-
      • scribed by Claubry; the epilepsy,~that occurred at Copenhagen, and
  * f  * destroyed, according to Lange, in  thirteen years, nearly thirteen thou-
       sand  children; the trismus nascentium, of the West Indies, and  the
       infantile  convulsions, which,  previous  to the year  1792, destroyed,
       as stated  by Clarke, every  sixth  child born in the Dublin Lying-in
       Hospital.
         That  convulsions may occur, both as an endemic and epidemic,
       there  can be no doubt.
         The exciting causes  of convulsions are very numerous.  In  new-
       born  infants, they occasionally  result from  the  excessive and  long-
       continued pressure, to which the  head  has  been subjected, during a
       protracted and difficult labour; and more particularly, when ergot has
       been injudiciously  administered to  accelerate the birth of the child. In
       children born in a  state of partial or complete asphyxia,  respiration is
       often  but  imperfectly established,  and death is very liable to result
       from  an attack of  general convulsions.  Convulsions may also be pro-
       duced, in young infants, by exposure to cold, or to a vivid or powerful
       light,  or by the effects  of a  confined  and  impure atmosphere.  In
       infants, who are liable to violent attacks of spasmodic  colic, convul-
       sions  are of frequent occurrence.
         The most common causes, however, of those derangements of health
       in infants, which either immediately or eventually lead to attacks of con-
       vulsions, are errors in diet, with respect both to its quantity and quality.
       From the moment of birth up to the termination of childhood, convul-
       sions  are liable to be produced by this cause.  The animal, Dr. Graves
       remarks, which, but a short time before, was nourished by the pla-
       centa, is immediately  after  birth, supported  by  ingesta; and hence,
       from  this sudden  change, if there be any source of irritation existing
       in the system of the child, or in the nature  of its food,  an unhealthy
       stale of the bowels rapidly ensues, and gives  rise to convulsive move-
       ments. To these, nurses have given the name of nine-day convulsions.
       Again, when another change is made, and the nurse's milk is left off,
       children are also liable to convulsive fits, and  these are the convulsions
       of ablactation.  In  fact, at any period during the first year, infants are
       predisposed to convulsions from  various causes, that act  primarily, by
       inducing  an irritation of the digestive  organs;—as when they  are
       allowed improper  food, in addition to the breast-milk—or when this is
       rendered unwholesome, by the  improper food or drink of the  mother
       or nurse; by her becoming strongly affected by passion or any mental 
             DISEASES OF THE  NERVOUS SYSTEM.         38Q

emotion; by over-exertion or exposure  to the sun, or  by her  health,
from any cause, becoming impaired.
  Subsequent to weaning, improper, or too much food, may be ranked,
also, among the most common exciting causes of convulsions.
  Difficult dentition, is  unquestionably a frequent cause of convulsive
attacks.  A child has been known to suffer from the time it first begins
to cut  its  teeth repeated paroxysms of convulsions, in consequence of
which  its life has been despaired of from day to day, and from week
to week;  yet, after the  lapse of several months, has recovered com-
pletely, upon the appearance of the first  molar teeth.
  Intestinal worms are very generally accused, as a frequent cause of
convulsions; but we suspect this is but rarely the case;  no well-mark-
ed  instance of  the kind has  ever fallen  under our notice;  Lieutaud,
Brachet, North, and others, make nearly a similar statement.
  The imprudent  or long-continued administration of  opium and its
preparations, to infants and young children, is to be ranked, rather as
a predisposing,  than exciting cause of convulsions.   It  is unquestion-
able, that a very small dose of opium given to an infant, will often be
promptly followed by a  convulsive paroxysm, and  that its  continued
use will produce a  state of debility,  and increased irritability, that
strongly favours  the occurrence  of convulsions from  slight causes.
The sudden suppression of chronic diseases of the skin, or the drying
up of the  discharge from long-continued ulcerations  behind the ears,
has been known, in numerous instances, to  give rise to an attack of
convulsive disease.
  We  have already noticed, among the causes of convulsions, an im-
pure and  confined  atmosphere;—rwe  have  known them  likewise, in'
repeated instances, to be produced by  insolation.
  Convulsions  in children  are  often  induced, also, by moral causes,
as intense fear,  or horror, or sudden surprise; violent  anger, and long-
continued fits of crying.
  Although we  believe that in the majority of cases, convulsions  are
dependent upon irritation with hyperaemia of the brain  or spinal mar-
row, or upon inflammation, acute or chronic, of its membranes or sub-
stance, we admit that in some instances, they may result  from exces-
sive evacuations, or from deficient nourishment.  Thus, excessive de-
pletion, by bleeding or active purgation, extensive hemorrhage, and
long-continued or profuse serous diarrhoea,  not  unfrequently give rise
to convulsive paroxysms of great violence.   But even  in these cases,
it is probable that the convulsions are preceded by very  considerable
turgescence of the vessels of the brain.
  Although, in  numerous instances, convulsions  occur suddenly, in
children apparently in perfect health, they are frequently preceded by
certain symptoms, which have been supposed by North and others to
indicate that state of increased excitability of the  nervous system,
which  predisposes to convulsive  attacks, but which, in  our opinion,
are the phenomena resulting from a certain degree of irritation of the
brain, most commonly connected with gastro-intestinal disease.
  These symptoms are, sudden starting from trifling, or  no appreciable
cause; uneasy  sleep, disturbed by sudden cries; a state of drowsiness 
390
DISEASES  OF CHILDREN.
           during the day, and restlessness at night; a fretful, peevish disposition;
           disinclination  to  play  or  be amused;  frequent  fixation  of the eyes,
           without their  being, apparently, directed to any particular object, or
           they are  thrown upwards,  and steadily fixed upon  the ceiling;  rapid
           and frequent contraction and dilatation of the pupils; when a candle
           is held to the eyes, during the contraction of the pupils, they will sud-
           denly dilate, and, again, as suddenly contract, the light being steadily
           continued close to the  eye.   The effect of the light upon both eyes  is
           not always similar; one may remain fully dilated, while the other con-
           tracts ; or one may remain stationary, the other being alternately con-
           tracted and dilated.  When the child is asleep, the limbs are frequently
           rigidly extended, the great toe and thumb being turned inwards.  There
           is a rapid alternation of paleness and flushing of the cheeks; at one
           moment  the countenance expresses great animation, at  the next, the
           utmost languor.  The breathing is irregular; long, deep, apparently
           difficult inspirations are alternated with quick, short, catching expira-
           tions.  This is usually accompanied by fulness of the upper lip, and a
           contracted  appearance of the  alae nasi.   The  hands are frequently
           directed  towards the  nose, apparently involuntarily;  the  fingers are
           either  in  frequent and sudden  motion, or are firmly pressed towards
           the palm of the hand;  more frequently, the thumb is contracted upon
           the palm, and  the fingers extended,  and separated from each other.
           When the child is put  to the breast, it will suck eagerly for a moment,
           and then cease suddenly, and throw  its head backwards, with an ex-
           pression of anxiety in its countenance; or perhaps it will roll its head
           from side to side.  Deglutition appears to be performed with difficulty,
^.^^.c^/itwhen these symptoms  occur.   Hiccup^is not unfrequent, as well as a
           slight convulsive movement of the muscles of the face, particularly
           during sleep,  which  gives to the  countenance an  appearance of
           smiling.
              It is not pretended that all of these phenomena are  invariably pre-
           sent in the same child, or  that they are necessarily the premonitors of
           a convulsive attack;—when, however, several of them present them-
           selves, there is a reasonable cause  to apprehend the occurrence of
           convulsions, and a  necessity  for adopting  the  requisite preventive
           measures.
              The treatment  of convulsions must vary according  to  the circum-
           stances of each case.   During the convulsive paroxysm, it has been
           supposed, by North, Eberle, and a few others, that little or nothing can
           be done towards arresting it.  This, however, is an error, and if gene-
           rally acted upon, would prove,  in many instances, a very serious one.
           Frequently, the only time we have to act is during a paroxysm, which,
           unless we are enabled  to arrest it, or moderate its violence, will often
           terminate only with the life  of the patient.   That the  violence  of the
           convulsive  attack may be  reduced, and that, frequently, its duration
           may be shortened, by  a prompt and  judicious treatment, we are well
           convinced, from the result of our own experience.
              When the convulsions are very violent, and occur in a  robust, ple-
           thoric child, with evident  symptoms of an overloaded state of the ves-
           sels of the brain, our first and most important remedy is  direct  deple- 
DISEASES OF  THE NERVOUS  SYSTEM.          391
tion. We may either open a vein in the arm, if the child is old enough,
or we may apply leeches to the temples or behind the ears, in numbers
adapted to the age of the patient, and the character and extent of the
symptoms  present.   In numerous instances,  we have seen  the best
effects result, when convulsions  have occurred about the period of
dentition, or subsequently, from cups to the nape of the  neck, or be-
tween the shoulders.
   In cases attended with  heat of the head, an injected countenance,
throbbing  of the  carotids,  a projecting,  sparkling eye  during the
paroxysms, and a state of deep drowsiness during the remissions, it is
all-important that a speedy and prompt  impression be made  upon the
vessels of the brain; here, provided blood cannot be drawn in sufficient
quantity from the arm, it is probable, that  a division of the  temporal
arteries, opening the jugular vein, or cups to the temples or behind the
ears, should be preferred to leeches.   It is impossible, in  these violent
cases, to lay  down  any  general rule, as to the  exact quantity  of blood
to be drawn;—this must be left entirely to the judgment of the practi-
tioner.  We have seen, in some cases, the loss of a very small amount
of blood  produce  an almost  immediate resolution of the convulsive
paroxysm; while in others, this has not been effected, until the  bleed-
ing was carried as  far as the age and strength of the patient rendered
prudent.  Even in  those  cases, however, in which the symptoms of
cerebral hyperaemia are less strongly marked, if the patient be strong
and robust, bleeding to a moderate extent will be proper, as a precau-
tionary measure; for, though  the nervous  centres  may at first suffer
only from simple irritation, yet, by the continuance  or frequent repeti-
tion of the paroxysms, the brain  is very liable to become the seat of
permanent disease.
   Next in importance to bleeding, in the majority of cases, are active
purgatives; these do good, as well by determining  the undue amount
of blood from  the brain, as by the removal of any cause of  irritation
that may exist  in the  bowels.  When  the child  can swallow, a full
dose of calomel should therefore be early administered, and followed,
in a short time, by castor oil, magnesia, and rhubarb, or an infusion of
senna.   When purgatives cannot be administered by the  mouth, pur-
gative enemata are to be resorted to.  The common domestic enema
of salt, warm water, and molasses, with the addition of sweet oil, will
generally answer; or if a more active one is required,  a mixture of
castor oil and spirits of turpentine, will probably be the  best we can
employ.
   In all cases of convulsions  dependent upon  derangement of the ali-
mentary canal, spirits of turpentine will be found a very useful remedy,
and when the  patient can swallow, given  by the mouth, nothing will
act more promptly  as a purgative,1 while it would appear also to pro-
duce a  decidedly beneficial impression upon the diseased gastro-intes-
tinal mucous membrane.
                  1 R.—Spirit, terebenth. 3j.
                       Olei ricini, 3iv.
                       Mucil. gum acaciee, 3iv.
                       Aq. fenil. 3ij.—M.
   A teaspoonful may be given to an infant three or four months old, and double that
                      quantity to a child a year old. 
392
DISEASES OF  CHILDREN
  In those cases  in which  active depletion is called for, sponging the
whole of the scalp frequently with cold water, is a measure  from which
much benefit will result.  In violent cases, pounded ice enclosed in  a
bladder may be applied.  The cold applications to the head should be
continued, until the cheeks become pale, and the scalp cool, and they
should be renewed if the flushing of the cheeks, and  the  heat of the
head  return.  During the application of cold to the head, the rest of
the body should  be kept carefully warm.   Even  in  cases  in which
bleeding may not be thought  advisable, sponging the head with cold
water, will be found to be almost invariably productive of good effects;
and, during the intervals of the convulsive  paroxysms, as well as in
children who are  strongly  predisposed  to their occurrence,  it forms
one of our best means of diminishing the irritation of the brain, and,
in this manner, preventing their accession.
  Warm sinapised pediluvia, or immersing the lower part  of the body
in a warm  bath, subsequent  to active depletion, in those cases in which
this is indicated, or, at an early period of the attack, in cases in which
bleeding is not considered advisable, will always be highly beneficial.
During the use of the pediluvium, or  while the patient is  in the bath,
cold water, or even ice, may be applied to the head with the best effects.
Cold water  dashed or poured upon the head  will, in some  of the more
violent convulsive attacks, produce a more prompt and powerful effect
than its simple application.
  Upon the same principle  that we employ the pediluvia and hip bath,
to determine the blood from the brain, and counteract its state of irri-
tion, sinapisms may be applied to the extremities, and some rubefacient
liniment to the  spine.   We prefer,  with the  generality  of  German
practitioners, the  application  of sinapisms  upon  the extremities, to
blisters. They will he found, in many cases, to act as  powerful auxili-
aries to the  other remedies.  In  some of the more chronic cases, we
have seen good effects result from  blisters behind the ears, or between
the shoulders; and, at an earlier period, when the convulsions appeared
to be unconnected with any considerable engorgement of the vessels
of the brain, a large blister, applied over the epigastrium, has appeared
to us to have a very  powerful influence in cutting short the paroxysms.
We have  never applied  blisters to the scalp.
   In every  case,  as early as possible after the occurrence  of  the con-
vulsions, an examination should be made of the state of the gums, and
if they are swollen or inflamed, even though there  exists no indication
that any of the teeth are upon the point  of protruding, they should be
freely scarified; and  the scarification should  be repeated daily, so long
as  the swelling  or inflammation remains unabated.  When  the gum
appears firmly distended by an approaching tooth, its free incision  at
this point, will frequently prevent a threatened, and almost  instantly
relieve a present, paroxysm.
   In attacks of convulsions evidently dependent upon irritating matters
or undigested food in the  stomach, or where we  have strong reason
for suspecting this to  be the case, an emetic will always be proper,
and will often quickly suspend the paroxysms.  In infants and young
children we should always prefer as an emetic the ipecacuanha, but 
DISEASES OF  THE NERVOUS SYSTEM.
393
if the infant  is robust, or  in older children, the tartarized antimony
may be employed.   In such cases, following the emetic by a full dose
of calomel, and after this  has  operated, administering some gentle
narcotic, as the aqueous  solution of opium, or a dose of the extract of
hyoscyamus  with magnesia,3 will, in general,  very  promptly effect  a
cure.
                  a R.—Extract, hyoscyami, gr. j.—ij.
                      Magnes.calcinatae, gr. iv.—M.
    For an infant of two or three months; the dose to be increased in older children.

   When convulsions are the result of excessive evacuations, either of
blood or of serum, as in  the copious diarrhoeas  with  which infants are
frequently  affected, the head of  the patient should be considerably ele-
vated, and kept constantly wet  with cold water, and small doses of
some gentle  stimulant, combined with a  narcotic, as the carbonate of
ammonia,  or wine  whey, with extract or tincture of  hyoscyamus,
should be given, carefully adapted  in quantity and frequency of repe-
tition, to the age of the  child.   The utmost tranquillity  of mind and
body should  be enforced,  and  the chamber kept darkened.  Where
much debility remains after the  convulsions  cease, some gentle tonic,
as the  sulphate of quinia, the protocarbonate of iron, or the oxide of
zinc, combined with small  doses of hyoscyamus, will be proper,  with
a mild nutritive diet.   Where  the  bowels are much  affected, and the
serous discharges are very copious, injections of a solution of acetate
of lead, with the addition of the tincture of opium, should be resorted
to, and  repeated  at  proper intervals, until the  inordinate  discharges
from the bowels are suspended.
   Artificial respiration was resorted to by Cape, in a case of long-
continued convulsions, in an infant  five days old, with the most happy
result.
   In every case of convulsions occurring in children, during the inter-
missions of the paroxysms, as well as upon their cessation, it is impor-
tant that the patient be kept perfectly quiet, and  free from every species
of excitement; a convulsive attack being invariably succeeded  by  a
degree  of  morbid irritability of the  nervous system, which will en-
danger a return of the paroxysms  from the slightest cause.
  After the paroxysm of convulsions has been suspended, the subse-
quent treatment will depend entirely upon the character  of the symp-
toms which remain.  If  any indication of disease of the  alimentary
canal be present, this should be treated  by its appropriate remedies,
which it is not necessary to recapitulate here.   If decided symptoms
of a continued irritation of the brain exist, we should persist in the use
of the cold applications to the head, of the warm hip bath, and should
consider the propriety of blisters to the temples, behind the ears, or to
the nape of the neck;  the bowels  should be kept regularly open, and
the healthy state of the secretions  poured into them  promoted  by the
administration of small doses of calomel, at regular intervals.  Com-
bining the  calomel in these cases with a portion of ipecacuanha, ex-
tract of hyoscyamus, and  calcined magnesia, will very generally be
found to increase its efficacy.1 
394
DISEASES OF  CHILDREN.
                * R.—Calomel, gr. vj. ad xij.
                    Ipecac, pulv. gr. iij.
                    Ext. hyoscyami, gr.  iij.—iv.
                    Magnes. calc. gr. xxxvj.—M. f. ch. No. xij.
   One to be given every two, three, or four hours, according to the age of the patient.

  The diet of the patient should invariably be light, unstimulating, easy
of digestion, and given only in moderate quantities.  Animal food, in
every form, should be prohibited, so long as there remains the slightest
danger of a recurrence of irritation or hyperaemia of the brain.
  It  is unquestionably true, that many cases of convulsions  occurring
in young infants, are dependent upon  indigestion, in which milk, even
that  of the maternal breast, but more generally of the cow, seems par-
ticularly  to disagree with the patient, the  curd  remaining  in the sto-
mach undigested, and producing irritation of the  alimentary  canal, and
secondarily of  the brain.  In such cases, milk must  be entirely prohi-
bited, and the  child may be allowed in its stead, rennet whey, with
stale bread or crackers, chicken or barley water, plain veal  or mutton
broth, or thin  panada;  and this  diet should be continued until  the
digestive organs have regained their healthy action.
  It  frequently happens, that for some time  after the convulsive  pa-
roxysms  have  been suspended, there  will remain a very great degree
of nervous excitability.   The child continues to be peevish, fretful, and
listless; the cheeks are occasionally flushed for a moment and then be-
come of  a deadly pallor;  the pulse is small  and rapid; the counte-
nance  is ordinarily pale and distressed, and  the forehead  wrinkled.
The  carotids often throb violently for  a moment  or two, and then their
action becomes slow and languid;  and upon close examination, slight
momentary twitchings of  different muscles will  be detected.  This
condition of the patient calls for the employment of sedatives and light
tonics.   The Dover's powder in small doses,  the extract of cicuta or
hyoscyamus, in conjunction with alkalies or the  oxide of zinc, and the
infusion  of calomba or gentian, or the sulphate of quinia,  have been
recommended.
   There are, unquestionably, many cases in which the use  of opiates,
particularly in  the form of the compound  powder of ipecacuanha or
Dover's powder, will have  a very beneficial effect, in quelling the ner-
vous excitability consequent upon an attack of convulsions.   Their
employment, however,  in infants  and young children, must be care-
fully watched;  small doses being given at first, and gradually increased,
if their effects are found to be of a soothing character.  Opiates have
been extolled by some practitioners, as an effectual means of arresting
the paroxysm,  when given during its  presence.  Dr. Blundell, restricts
them to  cases verging to the chronic  form, and  attended  with distress
and  restlessness; they  may probably be advantageous, also, in those
cases in  which  the  convulsions appear to be excited by intense pain of
the intestinal canal; they are, however, invariably a doubtful remedy
during the presence of the convulsive paroxysms.   Even in that state
of nervous excitability already described as sometimes remaining after
the cessation of the convulsions, we  should, as  a general rule, prefer
either the tincture or extract of hyoscyamus; which may be given in 
DISEASES OF THE  NERVOUS  SYSTEM.          395
 conjunction with alkalies  and light tonics.1   Brachet employed the
 hyoscyamus in combination with the oxide  of zinc, varying the dose
 according to the intensity of the symptoms,  and the age of the child.b
 Schmidt gave it in  conjunction with the oil of valerian, and carbonate
 of soda,0 and North combined it with sulphate of quinia."1
      1 R.—Infus. gentian. 3j.          b R.—Oxyd. zinci, gr. xxiv.
            Syrup, rhei, 3ss.                Ext. hyoscyami, gr. xij.—M.
            Tinr.t. hyoscyami, n^ixxx.           f. chart. No. xij.
            Bicarb, sodae, 3j.—M.       One to be given every two or three hours.
      A teaspoonful every three hours.       c R.—Carbonat. sodas, 3j.
     Or, R.—Pulv. calombse, 3j.—3ij.            Syrup, rhei aromat. 3y-
            Pulv. zingiber. 9ij.                 Ol. valerian, m/xvj.
            Ext. hyoscyami, gr. xij.             Ext. hyoscyami, gr. xvj.—M.
            Magnes. calc. 9ij.—M.        A teaspoonful to be given as a dose, three
             f. chart. No. xij.            times a day.
      One every three hours.
                      d R.—Aq. Cinnamom. 3jss.
                           Sulph. quinise, gr. viij.
                           Acid, sulphuric, dilut.  Tfviij.
                           Syrup, zingiber. §ss.
                           Ext. hyoscyami, gr. xvj.—M.
                      Dose, a teaspoonful every three hours.
   Beneficial as we  know from experience narcotics and tonics to  be
 during that state of prostration  and nervous  excitability which is  so
 commonly met with after the subsidence of severe attacks of convul-
 sions in children, we would  caution, in the strongest terms, against their
 being commenced with before every symptom of undue determination
 to the head, of acute  irritation of the brain,  or of general febrile ex-
 citement, has been  subdued, and every source of irritation  removed
 from the alimentary canal.  The worst consequences are to be appre-
 hended from the too  early administration of narcotics and  tonics in
 cases of infantile convulsions.
   Nothing need be said in relation to the  hygienic  measures  to  be
 pursued, in order to restore  health  and vigour  to  the  system of the
 patient, and to guard  against a subsequent recurrence  of the  convul-
 sive attack ; they are precisely the same as  those directed in cases of
 predisposition  to hypertrophy of the brain.
   Where a paroxysm of convulsions is threatened,  in cases in  which
 bloodletting is not  indicated,  compression of the  carotids has  been
 recommended.  Drs. Blaud and Stroehlin both report cases  in  which
 it was perfectly successful.
   A very peculiar form of infantile convulsions has recently been ob-
 served.  It consists  in repeated bobbings of  the head forward, at first
 slight and  occasional, but becoming, in process of time, so frequent
 and  powerful,  as to  cause a heaving of the head forwards towards the
 knees, succeeded by an  immediate return to the upright position, some-
 what similar to the  attacks of emprosthotonos.   In  one case, related
 by West, these bowings were repeated at intervals of a few  seconds,
 ten, twenty, or more times each attack, which continued from two to
three minutes,  and recurred, twice,  thrice, or oftener, in the  day; the
attack occurring whether the patient was sitting or lying. During the
attack,  the  child retained  his  consciousness.   The cases that have
been  since  recorded  by Drs.  Barton  and Bennet, in their general
symptoms, differ in  no degree from that of Mr. West, with the excep- 
396                DISEASES OF CHILDREN.
tion of that of Dr. Bennett, in which the disease presented a more ag-
gravated form.  Sir Charles Clarke has seen four cases of the disease,
and from the peculiar bowing of the head, has named it the Salaam
Convulsion; Dr.  Locock has seen two  cases.  One of Sir Charles
Clarke's  cases recovered perfectly,  the other  became paralytic and
idiotic, and died at the age of seventeen.   Mr. West has heard of two
other cases—one of  the patients lived  to  the age of seventeen; the
other to nineteen,—both  became idiotic.   The sex  and ages  of the
patients whose cases are on record, are one female of seven years, and
two boys of one and six  years—death did not occur  in either;  in the
female and one of the boys the disease appears to have ceased.
  Of this strange form of convulsions, the pathology is still a  subject
for future investigation;  and until that is ascertained, its  treatment
must be tentative and experimental.
  Previously to leaving the subject of convulsions in children, it may
be proper to say a word  or two upon a form of convulsive disease, that
has been lately described  by Jadelot and Guersent, consisting in a
powerful tonic contraction of the muscles of the extremities.  It prin-
cipally attacks young infants,  and children approaching the age of
puberty, and is unattended  with any  appreciable lesion of the nervous
system.  The  muscles of the parts affected are rigid and tense, and
are often distinctly marked, and prominent, beneath the skin.
  This convulsive  contraction  of the muscles gives a  remarkable
rigidity to the wrists and fingers;  the former are slightly bent on the
fore-arm, and  the latter upon the carpus,  and separated from one an-
other, requiring force  to bend or straighten them.   The disease  is
sometimes  limited to the  superior  extremities, but  most frequently
affects also the inferior ;  in these latter, the same phenomena are then
observed, as in the former, excepting that the feet are forcibly stretched
on the leg, instead of being bent.
  The contraction of the muscles may persist for several hours, days,
or even sometimes for several years, and  then cease spontaneously;
after a time, however, it  may reappear, and this may occur repeatedly.
The muscles of the  other parts of the body are ordinarily unaffected,
as are also the  intellectual  faculties, respiration, and the digestive
functions.  The pulse is sometimes  accelerated,  but in  general it is
natural.
  The disease is most liable to occur in  children of a  nervous and
irritable temperament; and appears to be sympathetically produced
by intestinal worms, difficult dentition, or some gastro-intestinal irri-
tation.  It sometimes occurs in females towards the  period  when the
catamenia are about to  be established ; it may terminate fatally, but
most frequently, according to Jadelot, the result  is  favourable.  The
most careful autopsy has detected no appreciable alteration, either in
the brain or spinal marrow,  nor in  any  of the  nervous trunks.   In
the examinations made by  Guersent, the  affected  muscles were gene-
rally found to be in a state  of hypertrophy, their  pale  tissue  being
filled with a considerable amount of fat.
   Essential contractions  of the muscles in children are sometimes gene- 
DISEASES OF  THE NERVOUS  SYSTEM.          397
 ral, and sometimes local; among these last, M. Guersent ranges torti-
 collis, cramps, tonic  spasms of the muscles  of the side, &c.
   Tonic spasm of the muscles of the  flanks,  with  shortening of the
 corresponding lower extremity, has been observed in children of seven
 or eight years of age, and, according to  Beclard, has been mistaken
 for an affection of the hip joint.   Sometimes the muscular contractions
 are almost general, and the patient  is affected  with  immobility and
 stiffness of  the trunk and limbs, as though the  body was composed
 altogether of hard and solid parts.  This contraction, so long as it is
 produced by an affection of the spinal nerves only, does not endanger
 the life of the patient,  but  it becomes more serious  when it  results
 from disease of the encephalon-and ganglionic nerves, as in traumatic
 tetanus.
   Among the causes of these essential contractions, as he terms them,
 M. Guersent enumerates exposure to cold while the body is in a state
 of perspiration, and the presence of worms.
   The treatment of  this form of tonic convulsion will consist in  a
 great measure, in the use of warm or vapour baths, and friction with
 oil of almonds or narcotic liniments; dry friction of  the skin, the  ap-
 plication of bags filled with warm ashes, and  gentle purgatives.  M.
 Jadelot recommends also, cold affusions;  internally, camphor or vale-
 rian, and  friction  with  ether or with  the tincture of digitalis.  M.
 Guersent directs friction with a liniment containing laudanum,  and if
 this is unsuccessful, but not otherwise, opium internally.   Diaphoretics,
 as infusions of borage, and the acetate of ammonia, have been recom-
 mended, as  also the  sesquicarbonate of iron, in large doses.  If the
 patient is of a plethoric and vigorous habit,  and  the muscular contrac-
 tion has occurred suddenly, we should not hesitate to  resort to  vene-
 section.   Contrivances to produce extension  of the contracted parts
 have been tried,  and  have succeeded  in some cases, when seconded by
 the employment of baths, emollients, &c.  The section of the con-
 tracted muscles, has,  also, been proposed,  but  the success attending
 this measure is not such  as to recommend its general employment.

                    L — Acute Meningitis.
  The whole of the inflammatory affections of the brain are, by many
 writers on diseases of children, included under the  general term of
 hydrocephalus.   This, however, is incorrect; the acute forms of me-
 ningial inflammation  occurring in children,  are not invariably produc-
 tive of extensive serous  effusion, and their  phenomena differ in many
 important particulars  from those by which that form of cerebral dis-
 ease to which the  term  hydrocephalus is more strictly applicable, is
 ordinarily accompanied.   In the early periods of life, acute meningi-
 tis, it is true, is not of very frequent occurrence, as an original disease;
 it  is nevertheless, a very frequent consequence of many of the  affec-
 tions peculiar to infancy  and childhood.
  Almost invariably, when the disease occurs as a primary affection,
 it commences with strongly marked  symptoms of febrile excitement,
preceded by a decided chill.  The skin is  dry, and generally increased
in  temperature; the pulse  and  respiration  are accelerated, but often 
398
DISEASES OF  CHILDREN.
variable;  the  lips  are dry and frequently cracked;  and the child re-
peatedly picks or rubs his nose and mouth.  There is  usually increased
thirst and loss of  appetite.   The tongue is coated with a whitish or
yellow mucus, and  is often red at its edges and  apex.   There is very
generally copious and repeated vomitings of a bilious matter.  Occa-
sionally, the  attack commences with  vomiting.  The bowels  are in
some cases  obstinately costive, while in others they are affected with
diarrhoea, the discharges being composed of a sour, frothy mucus, of
either  a green, almost black, or  pale colour.   The urine  is usually
spare in quantity, and  high-coloured.  The face is ordinarily red and
turgid.  There  is  an  anxious, suffering expression  of countenance,
with contracted brows, and most commonly, intolerance of light and
sound, contraction of the pupils, and injection  of the eyes.
  The pain of the head,  which is principally referred to the forehead
and temples, though occasionally it is seated in the upper or back part
of the head, is often accompanied by a violent throbbing,  and a sense
of constriction around the forehead.   It increases in violence at short
intervals, and then excites the peculiar, sharp, wild scream, so charac-
teristic of acute affections of the brain in children.  During the exacer-
bations of pain, there is  increased flushing of the face, as well as an
increase of the peculiar suffering expression of  countenance.  In the
intervals of these  exacerbations,  the child often rolls  his  head from
side  to side, and saws the air with his arms, moaning, or complaining
of his  suffering, or he falls into a state of partial stupor, and  grinds
violently his teeth.
  The countenance is generally flushed, but in  some cases  the flushing
occurs only during the exacerbations of pain, the face in the intervals
being  decidedly pale.  Vertigo is   often present.  The eyelids are
generally firmly closed, and, in some cases, the  patient resists every
attempt to open them.  Slight twitchings of the muscles of the face are
not unfrequent.  The pulse is increased in frequency, and most gene-
rally full and hard ; the respiration is accelerated, but often interrupted
by long deep sighs.
  If the disease is not arrested, the  patient becomes more and more
drowsy, and, finally, completely comatose.   In some cases, from the
first  day of the attack there  occurs  an alternation of stupor and vio-
lent  agitation, or of coma and acute delirium.  The delirium may
not,  however, occur until a later period.  In the  progress of the case,
the increased heat  of the surface disappears, and frequently a degree
of chilliness supervenes; diminished temperature of the  extremities
is often a very early symptom.   The external  senses lose,  by degrees,
their abnormal acuteness, and  finally become morbidly obtuse.  The
pupils are at first alternately contracted and dilated, but at length be-
come permanently dilated, and  insensible to the  brightest  light.  The
eyes are often affected with  strabismus, or the eyeballs have a rolling
tremulous motion, or are  permanently turned upwards and  outwards.
The hearing becomes more and more dull, and,  finally there is a total
insensibility to sound.  The face becomes pale and cold, and the fea-
tures shrunk ; the eyes assume a dull and sunken appearance, and in the
progress of the disease, perfect blindness most generally ensues.   Con- 
DISEASES OF  THE NERVOUS  SYSTEM.          399
      vulsive twitchings of the muscles of the face and extremities, are now
      more frequent and violent.   Convulsions of the limbs, alternating with
      a state approaching to  paralysis, or convulsive movements of certain
      sets of muscles, with imperfect paralysis of others, are not unfrequent;
      but in the progress of the case, when complete coma ensues, the  whole
      of the voluntary muscles become completely relaxed.  The pulse de-
      creases in frequency, and becomes weak and  soft, but  at the same
      time, extremely variable; being at one moment increased  in frequency
      or in strength, and at the next remarkable for its slowness and feeble-
      ness ;  it frequently becomes greatly accelerated  upon the slightest ex-
      ertion, and again slows as soon as the  exertion  ceases.   Often, imme-
      diately preceding dissolution, the pulse  suddenly acquires a remarkable
      increase of frequency, beating  often with great regularity, from  120
    » to 160  strokes and upwards, in a minute.   The respiration also be-
  *,   comes  quick and irregular, but  at the moment of dissolution  again
    "• slow, and often stertorous.
   ,^    The respiration is marked by irregularity and inequality.   Long
      deep sighs are often succeeded, after a pause of some  duration, by
 * "•   frequent, short, quick respirations ; or there is a regular alternation of
 ** > a number of slow, and a number of quick, gasping respirations.  The
 • "   tongue becomes of a dark brown colour, and  more loaded, dry, and
  . -^  parched; the lips and  teeth are covered with  dark-coloured sordes,
/  /  and the bowels are obstinately costive; but towards the fatal termina-
      tion, there usually occur involuntary discharges  of the faeces, as well as
   ,*  of the urine.   There frequently occurs more or less tympanitic tension
    '  of the abdomen.   The patient continues for a long time able to swal-
      low, and before  the  coma  has  become complete, will  often take food
      with apparent greediness, if it  be placed, by means of a spoon, upon
      the back part of  the tongue.
  £ *    As  the period of dissolution approaches, the surface becomes icy
      cold;  cold clammy perspirations break out,  and the face  assumes a
 ^»  sunken, ghastly  aspect.  The fatal event is frequently  preceded by
      convulsions.
         When the inflammation involves a considerable extent  of the mem-
      branes over the superior surface of both hemispheres, the disease may
   j  ■ suddenly terminate, at  an early period, by the  occurrence of violent,
   q  general convulsions, succeeded by deep coma and death.
    -    When the meningitis is seated at the base of the brain, the disease
   f  often continues for a longer period.  The  patient exhibits greater and
      more  constant drowsiness, verging, at an early period, into complete
    • coma, and the latter stages are marked  by more frequent convulsive
      movements, or tonic contractions of the muscles, alternating with par-
      tial paralysis, and succeeded finally by complete muscular relaxation.
   ►  .   The regular course of the disease, commencing with  symptoms of
   #   more  or  less excitement, succeeded, after a shorter or longer  period,
  • . by those of depression, and finally of complete  collapse, is not unfre-
      quently interrupted, either by the rapid occurrence in  the  same case,
      of  violent febrile excitement, convulsions, stupor, and partial para-
      lysis, or by the occasional and often repeated alternation  of a state of
      stupor with the phenomena of excitement.
>
 *
0
• 
400
DISEASES OF CHILDREN.
   The occurrence of acute meningitis in the course of a febrile disease
is marked, according  to the observations of Rilliet and  Barthez, by
excessive agitation, without appreciable pain of the  head, and  unat-
tended with vomiting.   If diarrhoea was present, it persists; the pulse
from being regular, becomes unequal, irregular, and diminished in fre-
quency; or it remains equal,  frequent, and excessively small.  The
inspirations, if already accelerated, become slower.  The  face is pale,
the countenance anxious.  The agitation, without diminishing in inten-
sity, continues until death, which early ensues.  (Maladies des Enfans,
t. i., 634.)
   The appearances presented  upon dissection, in cases of death from
acute meningitis, are,  chiefly,  injections of the arachnoid membrane
and pia mater, with effusions of serum, lymph, or pus.  The injections
of the arachnoid are, in general, of very limited  extent, and occur at \
a few points only; either  at the upper  surface or  base of the brain,
and occasionally within the ventricles.   In place of these injections,
the membrane may present a slight degree of thickening and opacity,
which gives  to  it  an  opalescent  or milky appearance.  When death
occurs at the onset of the inflammation,  it is often unusually dry.
   The injections of the pia  mater, are  in  the form either of distinct
vascular arborescences, or of a bright, uniform redness, diffused or in
circumscribed patches, according to the  less or greater intensity of
the inflammation.  Effusion  may exist in  the cellular  tissue, between
the pia  mater and arachnoid  membrane,  either of clear serum, albu-
minous  serum, or of pus.  When the serum contains  much albumen,
in place of gradually oozing out, when the arachnoid  is punctured, it
is  detained  in the meshes of  the subarachnoid  cellular  membrane,
which gives to it a gelatinous appearance.
  When the disease has  continued for a longer  period, more or less
effusion will be observed  upon the upper surface of  the  membrane;
most commonly of a limpid, serous  fluid, but occasionally flocculent
and turbid, from an admixture of lymph  or pus.  Occasionally, the
arachnoid upon the  surface of the hemispheres, or at the base of the
brain, is covered  with a pseudo-membranous layer,  of  a greenish
white colour.  This is  often  of considerable thickness.  When  pus is
effused,  it may be either  liquid or concrete.   When  the effusion of <
lymph or pus is in  considerable quantity, it often separates the convo-
lutions,  and penetrates to their  utmost depths.  This occurs most com-
monly at the vertex and base of the  brain, and about the junction of
the optic  nerves, where there  exists a  considerable amount of loose
cellular  tissue.  There are very often adhesions between the pia mater
and surface of the brain, preventing  the former from  being detached
without lacerating the  cortical substance, which is not unfrequently \C^
reddened, and occasionally softened to a greater or less extent.       _^
  Among the predisposing causes of acute meningitis the most im-\V
portant  is evidently the age of childhood.  It unquestionably occurs V**
more repeatedly anterior than subsequent to puberty.  Guersent places
the most common age for its occurrence between the fifth and fifteenth
years;—so far as we are enabled  to form  a conclusion from the data
within our reach, it would appear  to occur more frequently in Phila- 
DISEASES OF  THE NERVOUS  SYSTEM.          4Q1
  delphia between the seventh month and seventh year.  The condition
  of the brain at this  age, and the facility with which irritations may be
  excited in it from various causes, render it peculiarly liable to inflam-
  mation of various grades.  This predisposition is increased by a ple-
  thoric  habit, hereditary irritability of the nervous system, and by pre-
  cocity of intellectual  development, subjecting the  brain to premature
  excitement.
     The exciting causes  are external  injuries of the head  from blows,
  concussions, falls, &c,  violent  and long-continued paroxysms of cry-
  ing, difficult dentition,  the sudden suppression of chronic  cutaneous
  eruptions, especially those which occur about the  head and face, and
  the imprudent  drying up of a long-continued discharge from ulcera-
  tions behind the ears.   In the  majority of cases, however, acute me-
  ningitis in children, occurs in the course, or towards the conclusion
  of other diseases, as the various  forms of irritation and  inflammation
  of the alimentary canal, pneumonia,  scarlatina, rubeola, and pertussis.
  Deep-seated inflammations of the ear, very generally  terminate  in
  children, in acute meningitis.  We  have repeatedly seen the disease,
  also, produced in children by insolation.
     Acute meningitis is, under  all circumstances,  a  serious affection;
  especially when it occurs in the course of, or subsequent to, other dis-
  eases;  when the patient is already exhausted, and active treatment is
  inadmissible to the extent which is necessary for the cure of every
  form of acute inflammation  of the  brain; in many cases, also, the
  course of the disease is so extremely rapid as  scarcely to allow time
  for the employment of ihe appropriate remedies, even when it is  de-
  tected  in its earliest  stage.  Nevertheless, in robust  children, whose
  vital powers are unimpaired by pre-existing disease, or exposure to
  depressing hygienic influences, a vigorous treatment, commenced early
  in the acute stage, will very often quickly arrest the progress of the
  inflammation and preserve the life of the patient.
     The favourable indications are, an early abatement of the peculiar
  symptoms of the disease; a reduction of the morbid  acuteness of the
  external senses: the disappearance of the febrile excitement; the return
  of natural, quiet  sleep; the recurrence of the normal secretions; the
<■  tongue becoming moist and  clean, the skin soft and cool, the bowels
  open, and the evacuations natural; the urine more copious and lighter
  coloured; the pulse more soft, slow, and equable, and the  respiration
  less  frequent and  more regular; together  with  an abatement of the
  heat, pain, and tension  of the head, and a return of the ordinary ex-
  pression of the patient's countenance.
     There are few diseases that  occur during childhood, in which it is
  more  important  to watch the slightest premonitory symptoms, than
  those which affect the brain.   Their onset may, in many instances, be
  prevented, when  their cure, after they have become fully established,
  is doubtful if, perchance, possible.  This is particularly  true of  acute
  meningitis; a careful attention to the early symptoms  indicative  of
  irritation and  hyperaemia of the  brain, will often enable us to guard
  the patient against  an attack that, were it to occur, would, in all  pro-
  bability, prove promptly fatal.
                                  26 
402
DISEASES OF CHILDREN.
   The  treatment  of the premonitory stage will  depend, in  a great
measure, upon the  nature of the particular exciting cause in each case.
When the attack occurs at the period of dentition, the gums should be
carefully examined from day to day, and if swollen or inflamed, should
be freely scarified, or divided down to any tooth that may be advancing
towards the surface.  At the same time, attention  should be paid to
the bowels, which, if costive, should be freely opened  by a brisk but
mild, unirritating purgative; a full dose of calomel, followed by castor
oil, magnesia, and rhubarb, or  simple enemata, should be preferred;
and, subsequently, small doses of calomel, combined with ipecacuanha
and  magnesia, at proper intervals,  with an occasional dose of castor
oil, will, in many cases, be required to insure their regular evacuation.
   The daily use of the warm bath, followed by gentle friction of the
surface, will form a powerful auxiliary to the other remedies.  In cases
of undue nervous excitement, with determination of blood towards the
brain, nothing is better calculated to equalize the circulation, and mo-
derate the morbid  irritability of  the system, and  at the same time to
promote the  regular healthy action of the  stomach and bowels;  its
effects are in all cases  beneficial, and in many  it is the  very best tonic
and anodyne we can employ.  The temperature of the bath should be
regulated  by that of the patient's surface; when the latter is warm and
dry, a tepid bath will be proper;  but if the temperature of the  surface
is  the least reduced, or there is any tendency to chilliness, the bath
should be  decidedly warm.
  The patient's head should be  kept cool by cutting or thinning the
hair, if  this be thick and long;  and by sponging  the scalp with cold
water, daily, or oftener, according  to the degree of increased  heat of
this part, and the greater or  less indications of  cerebral excitement, or
hyperaemia.   At the  same time his  diet should  be  carefully regulated,
as well in respect to quantity as to quality; no food but the mildest and
least  stimulating should be given;  regard being  had  in the  articles
allowed, to the age of the patient and to the particular condition of his
stomach;  many articles, perfectly unexceptionable in themselves, will
be found to disagree with one child, but to produce not the slightest
inconvenience when  taken by another.
  The mind of the patient should  be  kept free from excitement of every
kind; the necessity of gentle daily exercise in the open air, in pleasant
weather, should be insisted  on, and attention  should  be  paid to his
clothing, that it does  not overheat the body on the one hand, or expose
it, on the other, to a sudden reduction of temperature from slight atmo-
spherical changes.
  When the symptoms of nervous excitability or depression appear to
be connected with an  overloaded  state of the stomach  and bowels,
from  excess in eating, or from the use of improper articles of food,  an
emetic will be advisable, followed by a smart purgative.   For infants
and  young children the ipecacuanha should be  preferred as an emetic;
the wine  or  syrup is  very readily administered, and when given  in
proper doses, is sufficiently prompt  in its operation; even in older chil-
dren, whenever irritation of the alimentary canal  is present, or appre-
hended, we would advise the ipecacuanha to be  employed in preference 
           DISEASES  OF THE NERVOUS SYSTEM.         403

id the tartarized antimony.   After the stomach and bowels are freely
evacuated, and the stools have assumed  a natural  appearance, the
warm or tepid bath, daily, with a regulation of the diet, exercise, and
clothing of the patient, will, very generally, restore the healthful condi-
tion of the nervous functions.
  In every case where  premonitory symptoms of encephalic disease
present themselves, in conjunction with the other measures, it is im-
portant that the child  retire to rest early in  the evening, and rise early
in the morning.  The imprudent  practice of keeping children up late
at night, more  especially when they are exposed, at the same time, to
the  excitement of lighted and crowded apartments, various noises, and
probably improper food, is one of the most effectual means of inducing
that state of the brain and nervous  system, which so generally even-
tuates in cerebral inflammation.
  When  inflammation  of the brain has actually occurred, the  only
remedies  to be depended  upon, are active depletion by bleeding and
purgatives, cold applications to the scalp, and derivatives to the ex-
tremities.
  Bleeding should be resorted  to upon the  very  onset of the disease,
and carried, within as short a time  as possible, to an extent  commen-
surate with the violence of the symptoms,  and  the age and  vigour of
the  patient.   If the child is old enough, a vein should be opened in the
arm, while the patient is in an erect or sitting posture, and the  blood
drawn in  a full stream,  until  paleness of the face, or other symptoms
of approaching syncope are induced;  and should the symptoms of re-
action with active determination  to the brain again return, the bleed-
ing  should be repeated without delay, and  carried to the  same extent.
When we are unable, in consequence  of the age  of the patient, to pro-
cure blood from the veins of the arm,  we may open one of the jugular
veins, or apply a sufficient number of  leeches to the hands or feet, and
promote the flow of blood from their  bites  by immersion of the parts
in warm water.
  When bleeding has, in this manner, been carried to as  great an ex-
tent as is thought prudent or necessary, and still  a slight degree of re-
action or  cerebral determination remains  or recurs, cups or leeches
should be applied to the temples, behind the ears, or to the nape of the
neck.  It  is upon the prompt  and energetic employment of active de-
pletion in  the early stage of all the  more violent  and acute attacks of
meningeal inflammation, particularly when occurring in  robust, pletho-
ric children, that  the  safety of the patient will entirely depend.   The
extent to which active depletion by bleeding or leeches is to be carried,
and the frequency of  its repetition,  will depend  entirely upon the cir-
cumstances of each case, and the  effects  produced tj>y  the remedy.
Everything depends upon  the judgment of the practitioner, the cor-
rectness of his  diagnosis, and the  closeness and  care with which the
phenomena of the disease are watched.  The bleeding  should always
be carried to a  sufficient extent to prevent the occurrence of reaction,
and to keep down any active determination to the brain;  if suspended
before this is accomplished, the remedy will be of little or no benefit;
if continued beyond this point, injury will very generally be produced. 
404
DISEASES  OF CHILDREN.
  Cold applications to the scalp should  be early resorted to, the hair
being previously cut short, or removed  with a razor.   Ice  powdered
and enclosed in a bladder, which is made to envelope the head like a
cap, is a very effectual means of applying cold.   The ice cap should
not, however, be continued on for too  long a time; it should be re-
moved every fifteen or  twenty minutes, and a fold of linen, wet with
some evaporating lotion, as two parts of water and one of alcohol or
camphorated spirits, substituted; should,  however, the heat of the head,
with  flushing of the face, return, the ice  cap may be reapplied.  In
cases occurring in young children,  or in those of a feeble constitution,
simply sponging the head with cold water or  with  an evaporating
lotion, or keeping it covered with a fold of linen, constantly wet with
the latter, is preferable to the application of  ice.
  Active  purging  should immediately  succeed the first bleeding, in
every case in which this measure is not  counter-indicated by the pre-
sence of gastro-enteric inflammation, and even here, calomel may be
employed in small  doses, occasionally repeated, with  the best effects.
We  may,  in most cases,  administer in  the commencement of the
attack, a full dose of calomel and rhubarb, and accelerate its operation
by purgative enemata, (the best of which, in  violent cases, is a mixture
of molasses, water, castor  oil, and turpentine,)  and subsequently  by
proper doses of castor oil or senna tea, with the addition of the sulphate
of magnesia.
  After the  bowels have,  by this means been  actively purged, we
may continue the use of the calomel in small doses, every two or three
hours, according to the urgency of the  case.  We are in the habit of
combining the calomel with ipecacuanha, prepared chalk and digitalis.8
The dose of the calomel, and the frequency of its administration must
be regulated by the character of the symptoms.  In very acute  and
violent cases, from  half a grain to two grains, according to the age of
the patient, may be given, every one, two, or  three hours.  If irrita-
tion of the bowels,  with  frequent purging, ensue  under the use of the
remedy, we may add to each  dose of the calomel, from one-third of a
grain to a grain of the extract of  hyoscyamus.   The employment of
digitalis in the acute affections of children, is very generally objected
to, and  very specious reasons have been adduced in  opposition to its
use, especially in cerebral  inflammation;  on the  other hand, we can
only adduce our own experience in favour of its perfect safety, when
cautiously administered,  and  its effects  are  carefully watched, and of
the beneficial influence it occasionally exerts over the  disease.
                   * R.—Calomel, gr. vj. ad xij.
                        Ipecac, pulv. gr. iij.—iv.
                        Cretae ppt. 3ss.
              *•         Digitalis, pulv. gr.  iij.—iv.—M. f. chart. No. xij.
   When the disease occurs in the latter  period of childhood, and  is
marked by  symptoms of great acuteness,  for the ipecacuanha  and
digitalis,  an eighth  of a grain of tartarized antimony may be sub-
stituted.  The tartarized antimony in such cases, often proves an ex-
cellent remedy.   We have seldom  employed it, however, in the cases
of young children or infants; in  whom  we have never  seen much 
DISEASES  OF THE NERVOUS SYSTEM.         495
good  result from it, while often its effects have been positively preju-
dicial.
  After full bleeding, and the action of a brisk purgative, external re-
vulsants may be resorted to with great advantage.  The feet  of the
patient may be immersed in a warm sinapised  pediluvium;  or they
may be enveloped  in a  blanket wrung out  of hot water, in which  a
portion of  mustard has  been  infused.   During the use of the warm
pediluvia, cold water or ice may be applied to the  head, or, in severe
cases, it  has  been recommended that cold water be poured upon the
head  from the spout of a  tea-pot, or e*e«»in a smaller stream.  Infants,
however, seldom bear this well, and even older children are  liable to
become greatly alarmed, upon its use; we have, therefore, very gene-
rally  preferred the ice cap, cold sponging, or the application of a cloth
wet with some evaporating lotion.
  The application of blisters, when well  timed, is very generally ad-
vantageous.  They should never be employed until  after the inflamma-
tory excitement  has been reduced by active depletion;  as soon, how-
ever,  as this has been accomplished, their effects are always salutary,
and oftdfh surprisingly prompt.  They should be applied to the nape of
the neck, and behind the  ears; we have never been in  favour of their
application to the scalp, or of keeping up a discharge from the  blistered
surface, by means of irritating ointments; we prefer in every case, a1
succession of blisters.   The blisters, in young children, should be kept
on  until redness of the skin is produced, and then  followed by a light
emollient  poultice; as  soon  as the  blistered  surface heals, it may be
covered with another blister, and in this manner the blisters should be
continued so  long as their derivative influence may be desired.
  [n the latter stage of the disease,  after collapse has taken place, the
application of blisters and sinapisms to the extremities has been ad-
vised, with the view of rousing the sinking energies of the system ; but
we apprehend that at this period of the disease little permanent benefit
need be anticipated from blisters, or any other remedy; instances of
recovery being extremely rare.
  By the majority of practitioners it has been advised, in every severe
case of meningitis, to place the system as quickly as possible under the
influence of mercury: and with that view, in conjunction with the in-
ternal use of calomel, as we have directed above, to employ mercurial
inunction, either by rubbing the strong mercurial  ointment  upon the
thighs and groins, to the extent of two or three drachms daily, or by
dressing, with mercurial  ointment, the blistered  surfaces; continuing
the inunction for two, three, or more  days, according to the effects
produced.  The evidence in favour of this treatment, is too strong and
decided,  not  to  recommend it to our attention; recollecting, at the
same  time, that however  powerful an auxiliary it may prove, it is upon
active depletion, in the early period  of the acute stage,  alone,  that our
chief  dependence is to be placed for the cure of acute meningeal in-
flammation.
  If, during the use of the mercury,  the gums should become affected,
it must be at once suspended; the bowels being kept  regularly open
by mild aperients.  When a decided improvement in the symptoms of 
406
DISEASES OF CHILDREN.
            the case become apparent, the use of the mercury, both internally and
            externally, should be gradually suspended ; care being observed neither
            to discontinue it too  early, or to continue it too long.
              During the continuance of the  acute stage, every species of food
            should be prohibited; the thirst of the patient may be allayed  by the
            use of cold toast, gum, or barley water.  If the child is old enough, a
            small portion of ice  held  in the mouth, will prove refreshing, and ob-
            viate the necessity of large quantities  of drink being taken.  After the
        \    acute stage has passed, a small quantity of plain gruel or panada, may
            be allowed.
               The  patient should be kept perfectly  quiet, and free from every
            species of excitement; his chamber should be darkened, and of a mo-
            derate temperature,  due  attention  being paid to preserve the air fresh
            and pure  by proper ventilation.  His  head should be elevated and un-
            covered, while the covering of the body should be light, but sufficient
            to protect it from the slightest sensation of chilliness; it is particularly
            necessary to attend  to this in the  progress of the disease, as the tem-
            perature of the surface is very apt to  sink, upon slight exposure.
               In cases attended  with delirium, or when  coma ensues, the" state of
            the bladder should be ascertained by actual inspection, twice or thrice
            a day, and if distended, the urine should be drawn off by the catheter.
 t&UUs. «>*<^.Stilficidium will occasionally  occur, which  may mislead the  practi-
 ce*'  *v 4*& tioner as to  the state of the  bladder, unless its condition be examined
            by the hand.
               During convalescence the diet  of the patient should  be cautiously
            regulated ; for a long time he should be confined to farinaceous pre-
            parations, plainly cooked, and  taken in great moderation, their effects
            upon the digestive  organs  being  carefully  watched.   Excitement of
            every kind,  as  well as  too  long  continued  application of the mind,
            should  be avoided;  only the gentlest  exercise should be  undertaken at
            first, and the utmost precaution observed to prevent fatigue. The state
            of the bowels should be  regulated by gentle aperients, if costiveness be
            present; or if diarrhoea occur, by  some gentle astringent.  For a long
            period  after recovery, the danger of a relapse  from  slight  causes,
            should  be kept  constantly in mind, and the patient, in consequence,
 #*^tf t«vye&<jp&hould  be placed under a judicious hygienic course of treatment, until
 Ccfi<<tf&&u#'his health is firmly established.
 *^^»         It occasionally happens, that after  active depletion has been  carried
             as far  as the circumstances of the case will warrant, and the acute
             symptoms are entirely removed, the patient sinks into a state of deep
             coma,  with  a small, rapid, and feeble pulse, paleness  of the  counte-
             nance, and reduced temperature of the whole surface.   In such cases,
             the practitioner must, by a cautious investigation  of every circum-
             stance, decide whether these symptoms are the result of an inflamma-
             tory condition of the brain, or arise  from mere exhaustion.   If from
             the latter, the cautious  administration of opiates, and  even diffusible
             stimulants, with a  nourishing diet should be commenced, and if the
             patient improves, a more  free  but  judicious  employment of these
I             means, will, in  a short time, restore his health.  Opiates are not, how-
             ever, so generally useful in  the comatose condition, as  in the  state of 
DISEASES OF THE NERVOUS SYSTEM.
407
delirium from exhaustion, and even here they should not be pushed to
too great  rn extent;  if they do not, when given in moderate  dose>,
quickly produce a state of calmness and refreshing sleep, they should
be discontinued.  Mrong beef or  mutton broth, wine  whey, or wine
itself, in  smr.ll  and frequent doses, in general, prove more  efficient
remedies  in these cases.   Blisters  to the nape of the neck, and sina-
pisms  to the extremities, will often act as valuable auxiliaries.  The
practitioner must recollect, however, that whilst it is important to rouse
the patient from the state of exhaustion upon which his coma or deli-
rium depends, over-stimulation  must be guarded against, lest in the
irritable state of the brain, we suddenly excite an undue action of its
vessels, which may rapidly terminate in extensive serous effusion.
   Meningitis encephalica.  Dr. Brockman has recently described, un-
der this name, a peculiar form of  acute cerebral disease incidental to
childhood, in which the membranes of the medulla oblongata and pons
varolii are chiefly affected.
   Dr. Brockman has met with fourteen cases of this affection.  It was
at first observed by him as a sequel of scarlatina, but subsequently he
has seen it4o-occur most frequently as an idiopathic affection.
   It is sometimes associated with general  disease of the brain;  at
others, it is uncomplicated.  Notwithstanding, in its earlier  stages, it
is unattended by any serious symptoms, it is an affection fully as dan-
gerous as cerebral meningitis.   The  first  stage, or that of simple
hyperaemia, generally continues  for one or  two days.  The  child  is
dull  and heavy, and the occiput is often hot; the bowels, however, are
regular;  there  is no vomiting;  no intolerance  of  light, nor  any dis-
turbance  of sleep.   The general  dulness of the patient,  and vague
complaints of some uneasy sensation in the  head, increase as the in-
flammatory stage sets in; the heat of the  occiput is augmented; the
head becomes  retracted, as  in the  ordinary cases of acute  menin-
gitis;  and convulsive twitchings  of the limbs occur, similar to the
effects of  slight electric shocks, which recur every few minutes while
the patient is awake, but  cease during sleep.  The  general  febrile
symptoms continue during  the third  stage; the pulse, however, dimi-
nishes in frequency and fulness, but does not become either irregular
or intermittent.  The general disquietude of the child subsides, by de-
grees, into a comatose condition, in which the head becomes still more
retracted, but unattended with strabismus, or any morbid condition of
the pupil; the peculiar air of stupidity that characterizes hydrocephalic
patients is wanting.   Two pathognomonic symptoms,  however, indi-
cate the occurrence of the stage of effusion.   One of these is deafness;
the other is difficult articulation, and  difficulty in moving the tongue—
both of which latter occur at the same time, probably from paralysis
of the motor nerves of the  tongue.  The  deafness and affection of the
tongue usually occur suddenly; sometimes they are first observed upon
the child  awaking from a quiet  sleep.   They  are, according to Dr.
Brockman, the  earliest and most certain indications of the occurrence
of effusion.   This stage continues sometimes for three, and sometimes
for fourteen days.  Its termination  is  in fatal paralysis, the occurrence
of which is often preceded by various singular nervous phenomena— 
408
DISEASES OF CHILDREN.
as sudden pauses  in  the  respiration, or equally sudden syncope.  In
some cases, however,  the paralysis does not follow, but the anomalous
symptoms subside, and the patients  gradually recover; until, indeed,
the paralytic  stage is fully established, the recovery of the patient is
still possible.
  In the uncomplicated  cases of the disease, upon examination  after
death, the cerebrum in general presents an extremely pallid and  anae-
mic  condition, in striking contrast with the cerebellum; the vessels of
which  are turgid with blood, while  its substance, also, is often  in a
state of marked hyperaemia.  The hyperaemia  increases in intensity
towards the central portions of the encephalon; and the membranes
covering the pons varolii and medulla  oblongata are found in a  most
decided state of inflammation; the portion of inflamed membrane is
perfectly isolated, and not more, usually, than a square inch in extent
—the membrane of the cerebellum being entirely free from any indi-
cations  of inflammation.   There is ordinarily an effusion of a serous
fluid into the subarachnoidal tissue; sometimes to the extent of several
ounces; occasionally a  gelatinous  matter is effused, and, in  some
cases, the effusion  is of a purulent character.
  This  form  of disease is most frequently observed in children  from
three to ten  years of age, and  who had previously enjoyed  good
health.
  The  treatment  recommended  by  Dr.  Brockman, in its  first two
stages, is depletion, by leeches to the posterior part of the head, cold
applications to the  scalp, and the free administration of calomel, which
latter may be continued during the stage of effusion.   Here, however,
it becomes necessary to  support the  strength of the patient: for this
purpose ammonia  is directed by Dr. Brockman, but he remarks  that,
in some cases, the administration of  wine may be required.   Accord-
ing  to  his experience powerful counter-irritants, as a large blister, or
the actual cautery, prove, also, sometimes beneficial.

                   §. —Epidemic  Meningitis.
  Acute meningitis, or, to speak more correctly, cerebrospinal menin-
gitis, has, within the  last ten or twelve years, occurred in  different
parts of the  world, as an epidemic of a very formidable character.
In the  several portions of France where  the disease has prevailed, it
was, in a  great  measure, confined to the younger portion of the sol-
diery, particularly the new recruits; while in Gibraltar, as well  as in
those parts of Ireland and of the United States, in which the epidemic
has  occurred, it has principally attacked children from  five  to fifteen
years of age.   This circumstance, and the fact that when the disease
occurs  sporadically, it is very generally in individuals under the age of
puberty, would seem  to demand some notice  of it  in a work devoted
to the consideration of the diseases of children.
   The  attack of epidemic meningitis is often preceded by pain of the
head—generally continuous, but occasionally remittent or intermittent.
It is commonly seated in the forehead, temples, over one or both  eyes,
or in the occiput: or, occupying the whole head, it is most  acute at
the occipital  and frontal regions.  In some instances, there is also pain 
            DISEASES OF  THE NERVOUS  SYSTEM.        499

in the back of the  neck, and along the course of the spine, soreness
in the muscles and joints, facial neuralgia, and, very rarely, giddiness,
with or without dimness of vision. In few cases is the attack preceded
by any impairment of strength, or sense of general malaise.  The ap-
petitite is seldom much affected, though occasionally it is entirely lost,
or greatly diminished.  In a number of instances, the disease occurs
suddenly, without the slightest premonition.
   The  attack may be ushered in by a sensation  of chilliness,  suc-
ceeded by moderate  heat of the surface, and pain, commencing be-
tween the shoulders, and extending to the occipital  region, with more
or less stiffness of the posterior cervical muscles.  In other cases, the
patients are attacked with a sense of chilliness, pallid countenance, cold
extremities, low moaning, or muttering delirium, followed, in  a short
period, by restlessness, flushing of the face, frequent pulse, a wild and
frantic expression of the eyes,  and  hot and dry skin.  In some in-
stances, the patients complain, at first, of lassitude, a sense of uneasi-
ness, great  prostration, and a dull, heavy pain  of the head ; the  eyes
are  dull and half closed, the speech  is  indistinct and laborious, and
there is more or less vertigo, especially when the patient attempts to
assume the erect position.   After a  period  of variable duration, these
symptoms are replaced by a  state of violent agitation, or by complete
stupor, with a slow, occasionally full  pulse, and dilated and immovable
pupils.   In  some cases, contact with any part of the patient's  body
causes him  to emit  a  short plaintive cry—in others, the state of stupor
is interrupted, from time to time, by acute cries, the patient frequently
carrying  his hand  to  his head.  More commonly, the patient, when
suddenly called by name, will exhibit a degree of consciousness, by a
motion of his head, by endeavouring to articulate, or by half opening
his eyelids, which close again almost instantly.  In some cases, the
patient, without any chill, will  be suddenly attacked with deep coma
or apoplexy—or  by a degree  of stupor not amounting to coma, accom-
panied by a feeling of excessive debility, giddiness, dimness of sight,
or double vision.  In  many cases, the attack commences with severe
pain in the abdomen, followed, immediately, by vomiting, and, not
.unfrequently, by  purging.  In  the worst  cases, these symptoms are
accompanied by  marked collapse; the extremities are cold, and of a
bluish colour, while the pulse is a mere thread.   After the lapse of a
few hours, reaction, more or less perfect, ensues. The muscular system
presents characters, which, according to Dr. Mayne, (Dublin Quar-
terly Journ. of Med. Scien., August, 1846,) may be considered almost
pathognomonic.  The muscles of the extremities,  and  those of the
neck in particular, become remarkably rigid ; the head is drawn back
upon the vertebral column, and  firmly fixed in that position ; no efforts
of the patient can bend it forwards, neither can it  be, by the atten-
dants with  the employment,  at least,  of any justifiable force.   The
countenance, at this period, often assumes very much the tetafiic ex-
pression ; the patient  loses, in a great measure, the power of moving
his extremities, so that he is quite unable to assume the erect position.
Dr. Ames describes quivering of the muscles of the face, tremors of
the hands, and embarrassment of the movements  of the  arms,  and 
410
DISEASES  OF CHILDREN.
            tonic contraction of the  flexors of the forearm, and of the recti
            muscles of the abdomen, as occasional symptoms of the disease as it
            occurred  in  Montgomery, Alabama.  Dr. White, of  Tennessee,  de-
            scribes, in the cases observed  by him, a rigidity of the abdominal
            muscles, spasmodic twitchings of the flexors of the extremities, and a
            disposition to a constant motion of the  legs from side to side, alter-
            nately.  (New Orleans Med. and Surg. Journal.)  In  the same journal,
            Dr. Hicks, of Vicksburg, notices, as a striking feature  of the disease,
            retraction and rigdity of the spinal muscles, with a  loss of power in
            one or other of the upper  and lower extremities, followed by convul-
            sions of great severity, instantly excited by touching  or raising  the
            inferior extremities.   Dr. Phillips, of Missouri, (Med. Examiner, vol. x.
            p. 604,) describes the retraction of the neck, in many cases, as amount-
            ing to an angle of 45° from its natural position.  Dr. Richardson (West.
            Journ. of Med. and Surg., 1842,) states, that in nearly all the bad cases,
            the head was drawn back upon the shoulders, and the whole spine,
            from the head to the sacrum, was bent like a well-strung bow:  pre-
            venting, in many instances, the patient from lying upon his back.   Dr.
            Ames states,  that the muscles  of the neck, when not in a state of
            tetanic contraction, were,  in  many cases, stiff and  sore.  In  a few,
            the stiffness was confined to the  sterno-mastoid muscles of one or both
            sides; but, in  others, the  extensors were principally  concerned,  the
            head being kept  steadily in its natural erect  position, either involun-
            tarily or voluntary, as the  easiest position.
               There is great irregularity  in the period at which the tetanic symp-
            toms appear,  being, in some cases, observed as  early as the  first  day
            of the attack; in others, not until after several.
               Pain of the head is a very constant symptom, and in  nearly all cases
/'Vi/X*^> <"< there is rachialgia,  more  or  less intense.  This latter symptom, ac-
 e-ji+'nt,*   cording to M. Tourdes, is  absent only in the purely cephalaigic form
            of the disease, and cases which terminate rapidly in death.  Dr. Ames
            observed  that pressure applied to the cervical portion of the spine  pro-
            duced pain  in the head, frequently darting to the forehead, eyes,  and
            temples, and  also pain at the top of the sternum.  Pressure  on  the
            dorsal vertebrae produced  pain  in the middle of the sternum, at  the
            epigastrium, or about the  umbilicus, as it was made higher or lower.
            The  pain was often violent, and continued  sometimes for  several
            minutes.
               Delirium is very commonly  present  from an early period of the
            attack.  Dr. White describes it  as  being accompanied with contrac-
    ^w       tion  of the pupils, or, occasionally, dilatation of one  pupil  and  con-
 111 fi, <fvf, traction of the other; ptosis of the  eyelids, with ecchymosis, under
 n,irir*.-, <*& tne eyes> an(i on the surface  of the body.  The delirium is generally
^ir*^ '       of transient  duration—coming and going at intervals.  Dr. Ames de-
            scribes the mind as usually desponding and apprehensive.
               Great intolerance of light and sound is a common symptom; in some
             cases it exists to such an extent, that the slightest ray of light, or the
             least unusual sound is apt  to excite convulsive movements.  Dr. Ames
.             found in three cases, the  eyes  insensible to light from coma, and in
             two without  loss of consciousness.   In  both these last, perfect vision 
DISEASES  OF THE NERVOUS SYSTEM.        41]
was restored in  a few hours.   Double vision occurred in six  cases;
photophobia, in six cases; in a number of others, the ordinary light
was disagreeable, but in far the  greater number, the strongest light
was not complained of.
  Dr. Ames, in  the epidemic  at  Montgomery, Alabama, observed
the conjunctivae to be generally injected, and  the eyes glittering and
watery.
  Anexalted  sensibility of the cutaneous surface  generally, is often
observed; the patient being " sore  all over,"  and  wincing upon  thel*^ 4*^
slightest  touch, or refusing to change his position in bed, from the pain«A^ ,
consequent  upon every attempt at motion: even the smallest amount
of  clothing  is sometimes  intolerable.  In a large number of cases,
however, according to Dr. Mayne, a diminution of tactile sensibility,
and confirmed  stupor are present, affording  grounds for  the worst
anticipations.
   In  many of the more violent cases, within a few  hours after  the
patients are attacked, petechias make their appearance upon the arms,
over the eyelids, and upon the inferior extremities.  An exanthematous
eruption  is occasionally observed.
   Dr. White describes a difficulty in expanding the lungs, with respi-
ration chiefly  through  the nostrils, as a common symptom of the  dis-
ease.  Dr. Mayne, more than  once,  noticed  irregular and laboured
respiration as  a  leading symptom.  Dr. Ames describes the breathing
as generally regular, in the cases  seen by him.  The number of respi-
rations, in very  few cases, was below twenty-one in the  minute;  the
breathing was sterterous in only a few cases.
   In the cases observed by Dr. White, violent inflammation of one or
other eye was not an unfrequent occurrence.   Blindness of  one eye is
noticed by  Dr. Phillips, while Dr. Richardson met with partial deaf-
ness in almost every case, and blindness in many.
   The disease is often marked by continued irritability of stomach,
insatiable thirst, and marked tenderness of the epigastrium upon pres-
sure. These symptoms would seem to indicate disease of the stomach;
and yet Dr. Mayne has found  the whole of the abdominal viscera ab-
solutely healthy in the post mortem examination of two cases, in which
these symptoms persisted in a very marked degree to the close.   Dr.
Ames noticed acute pain of the abdomen  in three cases, and in only
one, tympanitic  distension with tenderness on pressure.
   Constipation and suspended secretions are common symptoms of the
disease.   In the  more grave and  malignant  forms of the disease, Dr.
Ames observed  the  tongue  to  be broad and  flabby—sometimes  im-
peding articulation, in consequence of its enlargement, and indented
around its edge, by pressing upon the teeth.   It was invariably more
or less coated, with a pale ash, or white, and sometimes yellowish  fur.
In all cases, he remarked an increased flow of viscid saliva.
   Notwithstanding, in a large  number of cases, epidemic  meningitis
is marked by pain, more or less intense, rachialgia, heat of the scalp,
congestion  of the conjunctiva, some degree  of intolerance of light,
and exalted  sensibility of the cutaneous surface generally, yet, in many
instances, no very decided evidences of serious disease  are present, 
412
DISEASES OF CHILDREN.
     until the  laboured pulse, the dilated pupil, the profound coma, or the
     severe  convulsive attacks indicate, but too plainly, that the death-
     struggle is at hand.
       Not  unfrequently, from  the very onset of the disease, symptoms of
     a most formidable character supervene.  Thus, the p;itient  may  be
     seized with general convulsions of frightful severity, requiring personal
     restraint  to  protect him from injury;  or, he may sink  into  a semi-
     comatose  condition,  constantly moaning  and  grinding  his  teeth,  or
1 • .« crying incessantly.
  >•    The pulse in the  stage  of excitement is usually full and  frequent,
     from 120 to  140 in the minute;  often, however, it is very slow—sink-
     ing, in a few cases, to 48 or 50  beats in the minute.  In the disease as
     it occurred  at Montgomery, Alabama, the pulse, according to Dr.
     Ames, was always soft, and generally slow, and very irregular in the
     number of its beats  at different periods of the day.  The slowness,
     softness, and irregularity of pulse were observed  in the very mildest
     attacks, as in the more violent and malignant.
       Intermission, with  perfect periodicity, is not uncommon.  The sub-
     sidence or intermission of all the  prominent symptoms has  been  so
     decided in many cases, as to lead to the hope of entire recovery, the
     fallacy of which was shown by the return of the exacerbation on the
     following day.
       In the great majority of cases, unless the patient is quickly destroy-
     ed by the violence  of the attack, he merges, towards the close of the
     disease, into a state of perfect coma, the pulse becomes  slow  and  la-
     boured, the powers of speech and deglutition fail, the tongue becomes
     dry, and the lips encrusted ; the stools  are passed involuntary, while
     the  bladder becomes distended with urine, or is  continually  allowing
     it to escape,  and death  finally closes the scene, often preceded by para-
     lysis of one side of the  body, or of one or other extremity.
       The duration of  the disease is  variable.  Death may occur  in a
     surprisingly  short space of time.   Examples are on record of a fatal
     termination  within twelve, fifteen or twenty-four hours from  the onset
     of the attack.   The greater number of cases terminate about the fourth
     day, whilst some few are  prolonged over two or three weeks or  even
     to fifty days.  In those who recover, according to the experience of
     the  French physicians, secondary diseases are apt to occur,  termina-
     ting, sooner or later, in  death.  Convalescence is usually slow and
     lingering.
       The diagnosis in  epidemic meningitis  is somewhat obscure.   No
     one symptom or series of  symptoms can be  considered as strictly pa-
     thognomonic. The leading characteristics of the disease  are acute and
     fixed pain of the head ; pain and stiffness of the posterior cervical mus-
     cles; often  rigidity  of the  large extensors of the  spine; spasmodic
     twitchings or tremors  of  the muscles,  particularly of the face;  trac-
     tion of the occiput downwards ; aversion from light; tetanic convul-
     sions; injection of the conjunctiva, acute cries; increased sensibility of
     the surface;  delirium or coma and low muttering delirium.  Rachialgia,
     according to M. Tourdes, is absent only in the purely cephalalgic form
     of the disease,  and in cases which terminate rapidly in death.  When 
DISEASES OF  THE NERVOUS  SYSTEM.
413
a disease marked by these symptoms occurs epidemically, we shall
have little difficulty in deciding it to be cerebro-spinal meningitis.
  The prognosis is, generally speaking unfavourable.  Wherever the
disease has prevailed it has terminated unfavourably in the great ma-
jority of cases.   Where the patient is affected, at the commencement
of the attack, with great prostration, somnolency, and other symptoms
of collapse, death sometimes takes place in a few hours, and  before
the occurrence of reaction.  According to Dr. White,  but few cases
recovered after tetanic  symptoms  presented  themselves.  In France,
the disease destroyed about one-half of those  attacked.  In the United
States, the mortality has been  even  greater.   In some  parts of Mis-
souri, five-sixths of the  patients died ; in Tennessee, three-fourths ; in
Mississippi, at least one-half, and in Alabama, full sixty per cent.
  The  lesions detected  after death from epidemic meningitis are
chiefly confined  to the cerebro-spinal meninges.  The pia mater is
deeply injected with blood, and the large vessels and sinuses  are re-
markably turgid.  The free surface of the  arachnoid is, generally,X'-«w|wU^^
dry and clammy, and in several  places the membrane is  slightly Aaaa/ki 4&
opaque.   Lymph and other inflammatory effusion is seldom met with&tt^ct-
within the cavity of the arachnoid, but, between the  latter membrane
and the pia mater there is, in many cases, more or less serosity, either
lactescent or turbid, yellowish, and often semi-gelatinous.  In others,
there is  met with, disseminated along the course of the vessels, drops,
varying  in size, of a yellowish colour and purulent appearance.  More
generally, patches or bands of a consistent substance, of a yellowish
or greenish colour, resembling  concrete pus,  exist beneath the  arach-
noid, on the  upper and lateral portions of the hemispheres, but espe-
cially at the base of the brain,  in the space corresponding to the circle
of Willis; where many of the cerebral nerves are, at their origin, im-
bedded in it.  The effusion is spread over the anfractuosities, which it <? tx^Kfrt&y,
rarely penetrates.  In the spinal cavity, this  puriform matter extends, ^^tvi, .%/*<***
in bands, along the anterior or posterior face of the  medulla,  and,  in 4»<tc,i*tj ,CW-
some instances, entirely envelopes  it, and extends, often, to the lowest-^, «^..
extremity of the cauda equina; investing each of the spinal nerves at
its source.  In some cases, true purulent collections  are present.  As
in the  cranium, so also in  the vertebral canal, these morbid deposits
are confined to the subarachnoid space.   The substance of the brain
and spinal marrow are usually free from any decided lesion.  In a             ,
few cases, however,  the brain and  spinal marrow  have been  found
implicated.  In some, the ventricles of the brain contained inflamma-
tory effusions, and the  choroid plexus appeared unusually vascular;
in others, more or less of the substance of the brain  and spinal mar-
row was found in a state of softening;  in others, again, sero-purulent
effusion  was detected at the base of the brain, and in the theca verte-
bralis ; but, in every instance, the  serous  membrane was the part es-
sentially diseased.  In a great  majority of the fatal  cases,  in which
great disorder of the cerebral functions was  manifested,  after death,
the substance of the brain  was found to be either not at all or only             <
slightly affected.   Dr. Ames, however, in all the cases examined by 
414
DISEASES OF  CHILDREN.
            him, found, on cutting into the substance of the brain, besides the red
            points  commonly present in cases of congestion and inflammation, an
            infinite number of red vessels, containing sometimes fluid, and at others
            coagulated  blood.  They  were  seen,  likewise, upon  removing the
            membranes, ramifying over the base of the brain, and the floors and
            walls of  the  ventricles, as well as on sections  of these  parts.  The
            gray and white matter had a pink colour, dependent on  the  presence
            of vessels that were separately visible.   Of these alterations, the cere-
            bellum partook, to a greater or less extent, in every case.  Still  there
            is reason to  conclude  that when the brain or spinal marrow are found
            affected,  it  is only secondarily—the disease having  been propagated
            to the substance of the cerebro-spinal axis from its meningeal invest-
            ments.
              In all cases in which pus was detected on the spinal medulla,  it ex-
            isted, also, in the brain ; occasionally, however, it was confined entire-
            ly to the latter.   M.  Tourdes, hence  infers, that the inflammation
      .<   / commences  invariably in the encephalon, and extends from thence to
           /the spinal marrow.
              The rapidity with which  suppuration may occur in cases of epide-
            mic meningitis is somewhat surprising; M. Leonard, of Toulon, reports
            an instance in which the disease ran its course to suppuration in fif-
            teen hours, and cases are recorded by M. Broussais (Hist, des Mening-
            ites Cerebro-spinales)  in which  suppuration occurred in  thirty-six and
            forty-eight hours.
              Slight  redness of different portions of the gastro-intestinal mucous
            membrane is occasionally met with, in the form  of patches, arboriza-
            tions, or dots.   In  some  instances,  a diseased condition of the fol-
            licles, in  others reddening, thickening or softening, to a greater or less
            extent, of portions of the  mucous membrane of the stomach and ileum
  •  », ,  i   are present.   Dr. Ames, who describes this latter lesion, mentions also
•  .  ., .-,.,.  four autopsies in which  were  found enlargement, and  in  one  case
     .^ M.*%. ulceration, of the agminated and solitary glands of the lower portion
           , of the ileum, with  enlargement, reddening, and, in one case, softening
            of the mesenteric glands.
              These  lesions of the digestive  organs have seldom  been observed
            excepting in patients who survived the  first few  days of the attack,
            and, consequently,  can be viewed only as  the result  of an accidental
            or secondary affection.
              In regard to the condition of the blood  in epidemic meningitis, M.
            Faure-Villars found, in the post mortem examinations  made at  Ver-
            sailles, in 1839, the left cavities of the  heart almost entirely empty,
            while those of the right side were filled with large fibrinous  coagula,
            of a yellow  colour, and some consistence.   The same thing  was ob-
            served by the physicians  in other parts of France, especially in cases
            in which the blood drawn during the lifetime of the patient was buffy,
            and contained but little serosity.  In four  analyses of the blood, pro-
            cured in  two cases at the first venesection, in one at the second, and
            in another at the third, M. Tourdes states, that the principal alteration
            detected  was an increase of the globules and of the fibrine, but espe-
            cially of  the former.   Dr. Ames found the blood drawn from the arm, 
DISEASES  OF THE NERVOUS SYSTEM.        415
  and by cups, to form large, loose coagula, in which all  the red  glo-
  bules were rarely included.  The serum separated slowly, and in small
  quantity.   The colour was generally bright—in a few cases approach-
  ing to  that of arterial blood.  Of thirty cases, it was  buffed  only in
  four.  It presented an excess of fibrine.
    The  causes of cerebro-spinal meningitis are involved  in great ob-
  scurity.  Its production would appear  to be altogether independent of
  any morbific agency  dependent upon season or locality.  Although
  sporadic cases are occasionally met with, still the  disease has chiefly
  attracted attention from its repeated occurrence of late  years as an
  epidemic, sometimes confined to comparatively narrow limits, and at
  others, as was the case in France, between the years 1837 and 1842,
  spreading successively over extensive regions.  Age, and to a certain
  extent, sex, would  appear to rank as predisposing  causes.   As we
  have already remarked,  young persons of the male  sex  are  those in
  whom  the disease has been principally observed.   In Ireland, it  was
  boys under twelve years of age who were almost exclusively affected.
  In Gibraltar, in the great majority of cases, it occurred  in  persons
  (chiefly males) between two and fifteen years of age.  In Tennessee,
  its principal subjects were children  between the age of six  and fifteen
  years.  In  Missouri, children between ten and fifteen  years  old.  In
  Alabama, however, the majority of those  attacked were beyond twenty
  years  of age—viz., over fifty per  cent.  Fifty-four per cent,  were
  males.
    We  have no  evidence, whatever, that the  disease is communicable
  by contagion  or infection, but, on the  contrary, much that would ap-
  pear, very satisfactorily, to establish its non-contagious character.
    Although there can be but  one opinion as  to the plan  of treatment
  demanded in  the different forms and  stages of cerebro-spinal  menin-
  gitis, yet, at the height of the epidemic, in those  cases, especially, in
  which the  attack commences with symptoms  of extreme  violence, the
  most judicious  and best-directed remedies will very generally fail to
  arrest the fatal termination.  When symptoms denoting extreme  col-
  lapse present themselves  at  the very onset  of the disease, it is con-
  ceded   by nearly all who  have written upon  the disease, that the re-
  sources of our art will prove of little avail.
    In favour of the propriety and efficacy of direct depletion in the
  commencement of  the attack,  when symptoms of prostration and of
  stupor are absent, as well as  during the early period of the  stage of
  excitement, there is considerable unanimity of opinion. In cases where
s the initial stage is that of excitement, and in  children over five years
  of age, free bleeding from the  arm is unquestionably the most efficient
  remedy for controlling the disease.  The  amount of blood to be drawn
  is  to be measured by the age and condition of the patient, and the
  effects  produced.  If, as M. Broussais very properly  remarks,  a weak
  pulse rise, or a strong pulse  retain its character  "during the  flow of
  blood, this may be allowed to  continue; but when  the pulse becomes
  weak, a moisture breaks out upon the surface, and the face becomes
  pallid, indicating approaching syncope, the flow of blood should be at
  once arrested, even though we may be  required to reopen the vein 
416                DISEASES OF CHILDREN.
             a few hours subsequently, should the pulse again rise, and the face be-
             come once  more flushed.  We are not,  however, to  proportion our
 >   *        bleeding to  the degree of cerebral  restlessness and delirium.   These
 tfyfl&H <V> violent states of nervous erethism quickly exhaust the  powers of life,
4.K^tU&*-•** and were a  copious venesection to be resorted to, a sudden  and speed-
             ily fatal collapse would be liable to ensue.
             '  The French army-surgeons speak strongly in favour of  the benefi-
             cial effects of bloodletting  in the forming stage of the disease, when
             the premonitory symptoms  only are present.
               Subsequently to general bleeding, cups should be applied to the back
             of the neck, and along the spine, and  leeches to the  temples, to the
             neck, and behind the ears,  and repeated at short intervals, so  long as
             any indication for direct depletion remains.
               According to the experience of Dr. Ames, the effects of bleeding,
             in the epidemic at Montgomery, Ala., were not so satisfactory as might
             have been expected.   The  pulse, in congestive cases, rarely filled up,
             or became  regular;  in some  instances, it became quicker  and more
             feeble, during or soon after a rather small bleeding, on  the first day of
             the attack.   In the  inflammatory form of  the  disease the same thing
             was occasionally observed, though an improved state of the pulse was,
             here, more frequently the immediate consequence of the loss of blood.
 *" A yfJ°/  The most common sensible effect was relief of the cephalajgia.  Still,
 ^-wt^v •     prompt and  free bleeding, in the very onset of the disease, in both the
             congestive and inflammatory forms, was, he believes, beneficial, in con-
             sequence of the time  gained  by it for  other remedies more obviously
             beneficial.
               After  bloodletting has been carried  to a proper extent, an  active
             mercurial cathartic should  be administered, and cold  applied to the
             head  by means  of a bladder  half filled with  ice, or cloths wet with
             iced water, or iced water  and vinegar.  At  the same time, the  legs
             should be immersed in hot water, and sinapisms applied to the feet and
             ankles.
               When the attack  commences with symptoms of collapse, or these
             quickly ensue after a transient and imperfect reaction,  the prompt ap-
             plication of  the most  powerful excitants to the surface is demanded.
             Mustard, ammonia, or turpentine, aided by heat and friction, should
             be applied  along the  spine, and to the extremities, and perseveringly
             employed at short  intervals,  until  the torpid  sensibility is aroused.
             Under the circumstances in which these remedies are demanded,  it is
             probable that the actual cautery, as employed by M.  Rollet, will be
             found advantageous.  The  iron, at  a white heat, is passed six, eight,
             or more times, at as many different points, on each side of the spinal
             processes.   It is stated by M. Rollet, that, in the worst cases, the  first
             application of the actual cautery does not elicit from the patient  any
             indication of sensibility; it is only  at  the  third, fourth, or even  fifth
             application that a slight muscular movement proves that pain is expe-
             rienced.  Some  utter cries during  the  last applications, but relapse
             immediately into their original comatose condition.  It is, in general,
             an hour or two after cauterization that reaction begins.
               When we have succeeded in establishing reaction, the patient should 
             DISEASES  OF THE NERVOUS SYSTEM.         417

 be carefully watched, and should it exceed the proper grade, immediate
 resort must be had to general and local  bloodletting, to an extent pro-
 portioned to the violenceof the symptoms,and the strength of the patient;
 at the  same  time, cold applications should  be made to the head,  and
 the other means of keeping down excessive reaction employed.
   Dr. Mayne speaks favourably of the early and free exhibition of
 mercury, both by the skin and stomach, with the view of producing
 promptly its  specific action.  By the French physicians,  however,
 mercurial frictions are  condemned, more, we suspect, from prejudice,
 than from any experience of their prejudicial effects.
   Mercury, according  to Dr.  Ames, employed to produce its specific
 effects, proved, in the cases which fell under his notice, a more efficient
 remedy than bloodletting, as well in the promptness as in the permanence
 of its beneficial  effects.  In some instances, however, though  rarely,
 its specific  influence could not be  obtained, and, occasionally, when
 produced early in  the  attack, failed to produce  any perceptible in-
 fluence.
   In conjunction with  active depletion by the lancet, purgatives will,
 unquestionably, be found  a valuable remedy,  by producing a  revulsion
 from the diseased  organs.   It is only in the  few cases in which some
 degree  of gastro-enteric inflammation is present, that their employment
 is contra-indicated.
   In the  early stage of excitement,  tartar emetic, in divided doses,
 combined with the saline diaphoretics, will no doubt prove beneficial.
 Dr. Hicks gives the following prescription as one which was found to
 be of advantage in the disease, as it occurred at Vicksburg, Miss.a
                     *  R.—Antimonii tart. grs. ij.
                          Pulv. camphors, 3ij.
                          Mucil. g. acacise, 3vj.—M.
               To be given in tablespoonful doses every two hours.
   The  French  and Irish physicians do  not appear to have employed
 the tartar emetic in the  treatment of epidemic meningitis.  To produce
 a sedative influence, some of the former  employed, subsequent to anti-
 phlogistics and revulsives, the water of  the  cherry laurel  and  that of
 valerian, combined  with mucilage.  M. Maihle recommends, in  pre-
 ference, the  distilled water of bitter  almonds, as furnishing more defi-
 nite proportions of hydrocyanic acid.
   After the  free  employment of bloodletting, especially if the patient
 falls into a  state of coma, with  feeble pulse and deficient reaction,
 blisters  along  the whole course of the spine will often be productive of
 good effects.  By some writers on the disease, their application to  the
 scalp is recommended,  and by others condemned, and we think cor-
 rectly.  Dr. Mayne directs the blistered surface  to be  dressed with
 mercurial ointment.  According  to Dr.  Ames, blisters  to the upper
 portion  of the  spine were found,  in mild and grave cases, seldom to
 fail in removing or greatly relieving the cephalalgia, even when bleed-
 ing had failed to do so.   In the  malignant  forms of the disease,  the
 relief afforded by them  was very great.
   By several of the French practitioners, opium was employed subse-
quent to venesection, and the other antiphlogistic remedies.  M. Forget
                               27 
418
DISEASES  OF CHILDREN.
commenced with its use between the fifth and seventh days of the dis-
ease, in the form of a syrup containing about half a grain of opium as
a dose  for an adult.  This  he  found to relieve the pain of the head,
and to calm the delirium and muscular spasms.  M. Chaufard states
that the early employment of the most energetic antiphlogistic  means
failed, in his hands, to cure the disease, but he found it promptly arrested
by opium in large doses: the opium was, in many cases, advantageously
combined with quinia.  Before  this plan was  adopted, we are told,
only one case  was cured out of thirty;  but afterwards the disease was
even less fatal than in its sporadic form.  M. Tourdes admits, with
M. Chaufard, that the usual antiphlogistic means were of no avail, but
cannot  agree with  all the latter has said  in praise of the  curative
powers of opium.  Dr. Ames does not  consider the latter as generally
safe in the more violent inflammatory cases, nor of any use  in the con-
gestive malignant cases.   In the other forms of the disease,  he esteems
it to be a safe and very valuable remedy.  He frequently employed
the quinia  in  the grave  form of epidemic meningitis, and sometimes
with partial success.  When the  disease was  attended with a fever
which was regularly remittent, quinia he found  occasionally to arrest
the paroxysms.   In  the other forms of the disease, he found it, if not
hazardous, to  afford not much  encouragement for its repetition.  By
some of the French army physicians, however, the quinia is described
as a most efficacious remedy, while, by the majority, it is  denounced
as positively injurious.  There are no doubt cases,  as pointed  out by
Dr. Ames, to which the remedy is adapted,  while there are others in
which its administration would be improper.
  According to Dr. Hicks, the following was found to be the most
beneficial tonic, after the violence of the disease  had abated,  for re-
lieving the inertia of the nervous system  that  remained in every in-
stance of recovery.*
                     • R.—Iod. ferri, 9j.
                          Iod. potasses, 3ij.
                          Iodin. grs. viij.
                          Syr. sarsapar. 3iv.—M.
         Given in doses of a teaspoonful, every four hours, in a litUe water.

   It should be continued for some days, unless found to produce  gastric
distress, in which case some mild vegetable bitter infusion should be
substituted.
   Dr. Ames speaks highly of the effects of potassa in this disease.  It
was given to  children in doses of from three  to five grains, repeated
every two hours.  No case proved fatal in his  practice, nor, so far as
he could learn, in that of either of his professional brethren, in which
the potassa was freely and continuously employed.  In many cases in
which  there were  no febrile symptoms, properly so called, present,
under its administration, the cephalalgia was speedily and permanently
relieved, and in others, its exhibition was followed by a prompt reduc-
tion of arterial excitement, and the removal of  intense cephalalgia a nd
other symptoms of head disease.
   It is said that etherial inspiration was practised by M. Basseron, 
DISEASES  OF THE NERVOUS SYSTEM.
419
physician-in-chief to the Military Hospital of Mustapha, in Algeria,
with the best effects.
  During the period of excitement, cooling drinks should be allowed,
and a strictly antiphlogistic diet enjoined.  Perfect rest and quiet, with
the exclusion of light, as far as is consistent with due ventilation, are
all-important.  In the comatose cases, and during the stage of collapse,
care should  be taken to prevent  an  accumulation  of  urine in the
bladder.
  Convalescence from epidemic  meningitis is usually protracted, and
relapses are  liable  to occur, from  slight errors in  diet and regimen;
hence, the greatest watchfulness is to be observed until the health and
strength of the  patient is fully re-established.

                   6. —Subacute Meningitis.

  TUBERCULAR  MENINGITIS--ACUTE HYDROCEPHALUS--DROPSY OF THE BRAIN.

   Subacute meningitis, particularly with tubercular deposition, is pro-
bably the most frequent form  of cerebral inflammation that occurs
during childhood.   It is that to which the term hydrocephalus is now
most generally applied  by medical writers.  By  many,  however, all
the forms of  meningeal inflammation, without  distinction, have been
described as hydrocephalus.  Thus, the more intense form of acute
meningitis terminating  speedily  in  effusion,  constitutes  the rapid       ,
hydrocephalus of Cheyne;  the ataxic of Guersent; the tumultuous or ^A^tv.
hyper-acute of Monro and Golis; ana" the inflammatory of Brachet and I*?*/*,tote*
Hopfengartner; while  the  subacute  form of meningitis has  been
described by Cheyne as the  slow  or gradual  hydrocephalus; by Hall
as the strumous; and by Brachet and Hopfengartner as the  nervous.
Nevertheless, with all these subdivisions, the pathology of that form of
meningitis to which the term  hydrocephalus is  usually applied, was
not, until  recently, accurately made out.  The error has been in re-
garding serous effusion within the cranium  as an essential character
of the disease, upon which  its  distinguishing  phenomena are mainly
dependent, when, in  fact it is a mere consequence, and often is either
entirely absent, or takes place to  so slight an extent, as to be capable
of producing, of itself, little or no  effect.
   Laennec was among the first who pointed out the frequent presence
of tuberculous  formations upon the pia  mater and arachnoid mem-
brane, and more rarely within the  medullary substance of the brain,
in cases of meningeal inflammation ; these  were viewed, however, by
most subsequent writers, as an occasional complication of the disease,
and, by Guersent, Dance, and a few others, as  a  distinct variety of
meningitis.  It was not until more accurate researches had established
the fact, that the very general and intimate connexion between tuber-
culous deposits upon the membranes and in the substance of the brain,
and  the most frequent form of subacute  meningitis in children,  com-
monly described as hydrocephalus, was recognised.
   Subacute  meningitis  occurs chiefly in delicate, scrofulous children,
especially in  those distinguished by great irritability of the brain and 
420
DISEASES OF CHILDREN.
  nervous system,  with  large heads and precocity of intellectual de-
  velopment.
    Among its earliest symptoms, is a marked change in the disposition
  and deportment of the child. He becomes listless and inactive, peevish,
  fretful, and restless, with a vacant, abstracted air and look;  is indiffe-
  rent  to the objects which  before  most attracted his  attention, and is
  with difficulty soothed  and diverted.   He  is unusually wakeful, or if
  he falls into a doze, this is broken by repeated starts and cries.  The
  external senses become morbidly acute ; the child starts and cries at the
  slightest noise;  is averse to being touched or handled, and impatiently
  withdraws his eyes, when they are accidentally directed towards the
  light; even in the ordinary light of his chamber,  the eyelids are often
  but half unclosed, and  the brows drawn down, giving  to the counte-
  nance a kind of habitual frown.  The pupils are most generally con-
  tracted, and occasionally there is an injected  state of  the conjunctiva.
  Strabismus, or a rolling of the  eyes upwards  and outwards, is some-
  times observed.
    When the child is old enough to give an account of his sensations,
  he complains of frequent, often continued, headache, while the younger
  infant will carry its hand repeatedly to  the head, or roll the latter from
  side  to side upon the  pillow or nurse's lap.  Frequent  twitchings of
  the muscles are not uncommon.   There is in  some cases a rigid ex-
  tension of the upper or  lower extremities, or more frequently a clench-
  ing of the hand, with the  thumb  bent firmly upon  the  palm, or a
'  drawing of the head back, with  rigidity of the muscles of  the neck.
* In other cases, the patient exhibits a state of apathy and  inertness.
  He is constantly dull and listless, and frequently moans, gapes, or sighs,
  and when aroused, is fretful and  morose.   His sleep  is disturbed and
  broken. The countenance is habitually pale and sunken, though often
  marked with transient flushes.  If the child is able to  walk, his gait is
  feeble and staggering, and, according to Golis, he is frequently observed,
  in advancing, to raise the foot, as if stepping over some object.  Head-
  ache is occasionally present;  more generally, however,  the patient
  complains of a sense of weight  over the forehead, or of giddiness.  In
  some cases, with these symptoms, there is a morbid acuteness of the
  external senses, or, on  the  contrary, there may exist more or less ob-
  tuseness of sensation.
    In most cases, there  is some degree of febrile excitement, especially
  towards evening.  The skin is  dry, but not much increased in tempe-
  rature ; the  pulse and  respiration are accelerated, but often variable;
  the lips are dry and often cracked; and the child frequently picks or
  rubs the nose and  mouth.  There is usually increased  thirst and loss
  of appetite, though occasionally the appetite is voracious or capricious.
  The  tongue presents upon its  surface a coating of whitish  or yellow
  mucus, and is often red at its edges and apex; the breath has a sickly
  foetid odour.  The  bowels are in some cases obstinately costive, and
  in others  are affected  with diarrhoea,  the discharges being composed
  of a sour, frothy mucus, of either a green,  almost black, or of a pale
  colour.  There  is frequently more or less tension of the abdomen, with
  tenderness of the epigastrium upon pressure. 
             DISEASES  OF THE NERVOUS SYSTEM.         421

   The attack is most generally preceded for some length of time, vary-
 ing in different  cases, by  most or all of the premonitory symptoms just
 detailed.
   The disease very generally commences with an increase of the rest-
 lessness and irritability of temper.   Although the face is usually pale,
 there  is often an occasional flush of one or both cheeks.  There is
 more  or less increased heat of the  scalp, with transient, acute, shoot-
 ing pains of the head, and often acute, transient pains of the abdomen.
 The surface of the body  is usually dry, and somewhat  above the na-
 tural  temperature;  the pulse is frequent, quick, and tense, but seldom
 full.  The tongue may be either perfectly clean and slightly reddened,
 or covered with a thin layer of whitish mucus, with increased redness
 about its point and edges.  When, however, the disease of the brain
 is attended with gastro-intestinal irritation or inflammation, the tongue
 generally becomes, at an early period, loaded with a dark brown  in-
 crustation of some thickness, which, towards the close  of the disease,
• becomes  black, dry, and rough.   The appetite is  occasionally unim-
 paired ; at  other  times it is voracious; but,  most generally, it is de-
 stroyed.  The bowels are usually costive or torpid; but when gastro-
 intestinal disease is present, they are ordinarily relaxed,  and the dis-
 charges are unnatural in  colour and consistence.
   The pain of the head is, in general, seated in the forehead, shooting
 backwards towards the  temples and vertex.  It  most commonly in-
 creases in intensity with the progress of the disease: it is seldom, how-
 ever, continuous, but occasionally remits, and then exacerbates ;—the
 exacerbations causing the patient to utter a peculiar sharp, quick cry,
 which has  been considered in some  degree  diagnostic.   The  infant
 also manifests  his sufferings by  carrying  his  hands frequently to the
 forehead, and sometimes by keeping them constantly applied to the
 temples.
   The stomach is very generally irritable, the patient  being affected
 with repeated retching or vomiting, particularly on rising  from the
 recumbent position.   This symptom is seldom absent.   In some cases
 the  riaih**in  the head  and vomiting alternate; the former ceasing, as
 soon as the latter occurs, and recurring with its discontinuance.  In
 general, the abdomen  is  collapsed or flattened, and often tender upon
 pressure.   The patient's sleep is short, imperfect, broken and disturbed;
 he tosses his hands about; rolls his head constantly from side to side;
 frequently grinds  his teeth, or moans, or whines, as if from  suffering.
 The respiration is quick and irregular, and repeatedly interrupted by
 deep,  prolonged sighs, which  occur more frequently as the disease
 verges towards the period of effusion.
   Delirium is occasionally observed towards the latter period of the
 stage  of inflammation; it is generally,  however, calm, very seldom
 violent or furious, and so slight, that when the patient's attention  is
 roused, he is able, ordinarily, to give correct answers to the  questions
 put  to him.  After an indefinite duration, shorter or longer in different
 cases, the delirium becomes more frequent, and of longer continuance;
 the countenance assumes a peculiar expression of stupor and surprise,
 very difficult to describe, but very characteristic.   There is very con- 
422
DISEASES  OF CHILDREN.
            siderable torpor or inertness of the intellectual faculties, with an appa-
            rent difficulty of directing them to  any object; so that the  patient's
            attention can scarcely be arrested, or he be induced to utter more  than
            monosyllables,  in  reply to  the questions put to him.   The eyes are
            morbidly sensible  to  light, the conjunctiva is injected, and the pupils
            either strongly  contracted, or alternately, or irregularly, contracted
            and dilated.  During sleep the eyeballs are generally turned  upwards
            and inwards, so as completely to hide the cornea under the inner  edge
            of the upper eyelid.  Strabismus is  a common symptom, particularly
            towards the period when deep coma and paralysis are about to ensue.
              The patient soon manifests  a constant disposition to drowsiness; he
            becomes inattentive to surrounding objects; and, when roused from
            his  stupor, soon relapses into  it  again.  The pulse decreases in fre-
            quency, until  it attains its natural standard, or falls  below it;  it is,
            however, readily accelerated  by any slight exertion, as by raising the
            patient to  a sitting  position,  or  from the bed; the increased rapidity
            ceasing almost immediately upon his resuming the horizontal posture;
            the pulse is also  irregular, and of unequal force.  The sensibility of
            the system  is diminished; the eyes are  dull, heavy, and vacant; the
            countenance pale  and sunken, and in a few cases oedematous.   The
            nose is dry, and the lips pale,  dry, and cracked; and the countenance
            acquires a peculiar vacant, stupid look, which has been considered by
            Golis as pathognomonic.
              Constant drowsiness is the  most common  and distinctive symptom
            of the advanced stage of the  disease; as it increases,  the patient lies
            in a soporose  state, with half-closed eyelids; rousing, however, occa-
            sionally, and  uttering an imperfect exclamation  or a wild  piercing
            cry. The drowsiness is finally succeeded by a state of complete coma.
            Preceding this, very generally, paralysis of one of the  extremities, or
            of one side of the body occurs.  Commonly, a tremulous motion of
            one arm  is observed, with the fingers firmly bent inwards, and the
            hand upon the wrist; the power of motion in the arm and leg of the
            same side is  gradually lessened, and  very soon complete ^Egrarplegia
      /     ensues.  Not  unfrequently the arm of the opposite side is Kepr in  a
 etyJ&MWr  state of constant oscijlatory motion  or is continually sawing  the air.
0fyJ&<41     The pupils of one or both  eyes are usually now permanently dilated
 lJL*4j      and insensible to light, and  strabismus, with  paralysis of the muscles
#:«.Aa#%£   of the eyelids, is almost invariably present.  According to Dr. Hennis
 ,/^^W^i  Green, a temporary but firm  contraction of the eyelid often occurs at
            this period, which for a time prevents us from exposing the eyeball.
              It is very common, towards the period when the inflammatory stage
            of the disease terminates by effusion in the brain, for a sudden amend-
            ment in all the more prominent symptoms  to  occur; the patient, in
            fact, often appears to be quickly verging  towards convalescence; the
            deceitful  calm is, however, of short duration;  sooner or later, a pa-
            roxysm of convulsions  supervenes, or he again sinks  into a state of
            fatal coma, followed, more  or  less  quickly, by death.  Convulsive
            movements are very generally observed at this period, if they have not
            occurred  previously.
              The pulse, which in  the early stages of the attack, was quick, fre- 
            DISEASES OF THE  NERVOUS SYSTEM.        423

quent and tense, when stupor comes on, becomes slow, full, and irre-
gular, or even intermittent; and when paralysis, and especially con-
vulsions supervene, it becomes again very much increased in frequency,
and  not  uncommonly small and corded.  In  the latter stage of  the
disease, the patient is often  affected with a total loss of sight and hear-
ing ; the sense of touch, however, very generally continues unimpaired
up to the  last moment.  The patient will occasionally lay hold of  the
nipple, and suck greedily, even when in a  state of constant stupor, and
deprived entirely of the sense of vision.  At length the extremities be-
come cold, the respiration  unequal and stertorous, the pulse weaker
and  weaker, and death takes place, often preceded by convulsions.
   The disease does not invariably attack in the same  gradual manner,
nor is it always preceded by the train of symptoms we have described.
In many cases, the child, after a few  days  of languor and peevish-
ness, is seized with symptoms of a  decided febrile reaction, attended
with pain of the head, flushing of the countenance, and tenderness of
the abdomen; the febrile symptoms being marked by frequent, irregu-
lar intermissions.  During  the exacerbations, the  patient is generally
affected with considerable  stupor, marked by an occasional  starting
up, and screaming, as though he were in a state of the utmost apparent
alarm and agitation; vomiting is frequent, and often excited by a mere
change of position; the bowels are generally obstinately costive, and
the expression of the countenance that of terror and suffering, or of
dejection and intellectual torpor.
  In some cases, without any previous manifestations of febrile excite-
ment, the disease is ushered in by an attack of convulsions.   In gene-
ral, however, in  such cases, there is more or  less  evidence of impaired
health, existing previously to  the occurrence of the convulsions; as a
peevish and  fretful, or impatient temper; deficient or  variable appe-
tite ; irregular bowels; tumid abdomen ; foul breath; restless and dis-
turbed sleep, with grinding  of the teeth and frequent starting.
   There is, in fact, a very  great diversity in the  mode  of commence-
ment, as well as in the progress of the chronic  forms of meningitis.
The order of the symptoms may be changed ; some may be absent, or
only slightly marked, and others prominent  and  long continued.   In
some cases, the only symptoms indicative of the occurrence of the dis-
ease have been coma, with  deep sighing, coldness of the extremities,
pallor of the countenance,  and partial  paralysis; while in others  the  ♦«  *
disease, according to Quin,  Rush, Monro, and Eberle,  has commenced;' ;*»  *^
and  run its course, with scarcely any other important symptom than   *v > t
drowsiness,  a slight  febrile excitement, with  little or no pain of the
head, but a frequent desire to urinate, the urine being voided in very
small quantities, and with difficulty.
   Equal irregularity marks the disease in  regard  to its entire duration,
and  that of its several stages.  The first or premonitory stage may
exist for a few days, or many weeks;  the period of excitement, from
a few hours to one or two days, or even longer; that of oppression,
from four or five  days, to  two weeks; and  the paralytic stage, from
an hour or two, to ten or twelve days.  The disease, in general, how-
ever, runs a protracted course.  Rilliet  and Barthez have never known 
424
DISEASES OF  CHILDREN.
          death to occur before the seventh day—most commonly it occurred from
          the eleventh to the twentieth day; in some cases the patients lived sixty
          to sixty-seven days.   Of 117 cases collected by Dr. Green, 31 died
          before the seventh day; 49  before the fourteenth; 31 before the twen-
          tieth, and 6 after the twentieth.  Of 30 cases noted by Dr. West, of
          London, the  average duration was twenty days and a half.  In one,
          death  took place in five days; in ten, before the fourteenth day; in
          eleven, during the third week, and in three, during the  fourth week.
             The appearances detected  after death,  in the  brains of those who
          have fallen victims to chronic meningitis, are, indications, to a greater
          or less extent, of inflammation of the  membranes, principally at  the
          basis of the brain, and within  the ventricles.
             The arachnoid membrane is often dry, thickened, and opaque;  the
          vessels of the subarachnoid cellular tissue, considerably injected, and
          its meshes filled with serum of a whitish colour, or mixed with lymph,
          and occasionally with pus.   The pia mater is often greatly injected,
          and, in some cases, more adherent  to  the surface of  the  brain than
          natural.   Its external  surface is almost invariably found studded with
          tubercles, varying in size from that of a pin's head to that of a pea ;—
          they are generally hard, semi-transparent,  and of a gray or yellowish
          colour.  Sometimes they present themselves in patches of an inch or
          more in extent, but, in  general, are scattered irregularly over the mem-
          brane, as well as over the  surface of the  brain,  between  the convo-
          lutions, and at its base.
             According to the observations of Rilliet  and Barthez, they are more
          frequent, however, upon the hemispheres than at the base.  When they
          occur in patches they are usually surrounded by traces of  inflamma-
          tion, either acute or chronic.
             The miliary tubercles, either isolated or collected together, so as to
          form an irregular mammelonnated mass, enclosing portions of the pia
           mater, more or  less changed,  occur, comparatively more frequent, ac-
           cording to Rilliet and  Barthez, on the convexity of the hemispheres,
           than at  the  base, and upon the  left hemisphere  than upon the  right.
           They rarely occupy the depressions of Sylvius.   As they become de-
           veloped, they are  surrounded with  a network of vessels, and subse-
           quently with a cyst formed at the expense  of the pia mater.
             Tubercles are met  with, also, emhedded in the gray matter of the
 U, <~--4^vkbrain, where they are often surrounded by  a halo of redness, generally
^l^'/^-^w^eonnected with  an enlarged vessel, ramifying from  the  pia mater.
4Uv&*4*   (Bennett.)  More rarely they are detected in the  medullary portion of
           the brain, where they are  often overlooked in consequence of their
           pale, semi-transparent, yellow tint.
             The lining membrane of  the  ventricles  is occasionally injected,
           opaque, or covered with a pseudo-membranous exudation, or with nu-
           merous white flocculi, which  become  very apparent when the  mem-
           brane is immersed in water.  It is often easily separated from the
           cerebral  substance.   The  convolutions of the brain are  sometimes
           flattened, apparently from pressure  against the skull.  A case  is re-
           lated  by Golis, in which, upon opening the skull, the whole brain ex-
|           panded, so that it could not again be replaced within the cranium. 
            DISEASES OF THE  NERVOUS SYSTEM.        425

   The  gray substance of  the convolutions,  when  the subarachnoid
tissue is strongly injected, is usually of a pale rose, or bright red colour,
from morbid injection.  When the brain is cut into, very frequently
the  surface of the incision is studded with numerous bloody points.
Sometimes,however,the brain is  paler and less vascular than natural;
—it occasionally presents an  appearance as though  its substance was
infiltrated with  serum.  The  plexus  choroides is very often injected,
thickened, or covered with  tubercles; sometimes it  is pale and disco-
loured, and beset with small hydatiform cysts; this  latter appearance
has also been found in the cellular texture of the pituitary gland.
   Traces of inflammation in the membranes or substance of the brain,
or, in  other words, increased vascularity, or thickening of the mem-
branes, and pseudo-membranous,  or purulent effusion, are by no means
invariably detected  in cases of chronic meningitis.   In some cases,
the  substance of the brain has been found of a firmer consistence  than
natural, and, to a certain  extent, hypertrophied.  (Laennec,  Jadelot,
Bricheteau, Golis, Schmidt.)   We have seen many such instances, but
invariably accompanied with decided indications of meningeal inflam-
mation.
   One of the  most common lesions detected, is serous effusion, either
in the  arachnoid or  subarachnoid  cavities, or in the ventricles, or in
all these parts at  the same  time.   It may be to  only a small extent,
or in such quantity as to separate  the convolutions  from each other,
and greatly to distend the ventricles.   The greatest amount is gene-
rally met with in the lateral ventricles; and  here it may occur to  such
an extent as to enlarge the  posterior cornua, elevate the  fornix, rup-
ture the septum lucidum, and  thus establish a free communication be-
tween all the ventricles.  The cellular tissue of the choroid plexus,  may
also be distended with serum. The serum varies in quantity from one
ounce to several; but seldom, it is said, exceeds six.   Many cases are
attended with a much less  amount of serous  effusion, and, in some,
there has been scarcely a trace discovered.  When the serous effusion
in the brain is considerable, it is often found, also, in the spinal canal.
The effused serum may be  clear,  colourless, thin, and transparent;  or
bluish, reddish, greenish, or of a citrine hue; or it may be opaque,
whey-like, turbid, or  puriform.  It  occasionally contains albuminous
flocculi.   In many cases it is uncoagulable,  but in others coagulable.
   The substance of  the brain is, most generally, softer in consistence
than natural, particularly the medullary matter in the immediate neigh-
bourhood of the ventricles, including the septum  lucidum, and fornix.
This softening is of various degrees, from a slight deviation from the
normal consistence, to a perfectly fluid  condition  of the brain, the
white substance resembling cream.
   Very generally, the abdominal viscera exhibit more or  less exten-
sive evidences of disease, the liver is often inflamed, with tubercles
upon its surface or in its substance, or is otherwise diseased.   Inflam-
mation, particularly  follicular, of  the  mucous coat of the alimentary
canal; contraction of the calibre of the intestines and invaginations
have been repeatedly met  with,  and, occasionally, softening of the
inner coat of the stomach. 
426
DISEASES  OF CHILDREN.
  Tubercles  are  very commonly present  in  the  serous  membranes
of the thorax and abdomen and in the lungs.
  A strong predisposition to the occurrence of chronic meningitis, par-
ticularly the  tubercular form, which, in children, is by far the most
frequent, is manifestly hereditary  or constitutional, in perhaps the ma-
jority of instances.  The peculiar liability to the disease in some fami-
lies; is often strikingly exemplified ; in many, all the children dying of
it, as they successively arrive at a certain age.
  It would be more correct, perhaps, to say, that peculiarities of here-
ditary organization, predispose to the  disease; more especially the
lymphatic temperament or  scrofulous diathesis, characterized  by a
large head, delicate, irritable, and often beautiful frame of body, pro-
minence of the external lymphatic glands,  with acuteness of intellect,
and liveliness, or  rather fitfulness  of disposition.
  The  most common exciting causes are, irritations  reflected from
other organs upon the brain.  In perhaps the majority of instances,
the disease is preceded, for a longer or  snorter time, by gastro-intesti-
nal irritation; this constitutes the symptomatic form of hydrocephalus
of  Cheyne and other writers.   Subacute meningitis  may, however,
be  induced by blows or falls upon the head, violent mental emotion, or
too early and close application of the  mind  to  intellectual pursuits;
violent, long-continued, and frequently repeated paroxysms  of crying;
the  sudden suppression of spontaneous or  habitual evacuations; the
sudden  drying up of ulcerations behind  the ears, or of various chronic
eruptions, as those which occur about the head during dentition.
   The  irritation  attendant upon  difficult dentition is  a very frequent
exciting cause.  The disease is  often produced  by the deep-seated
chronic inflammations of the ear, so common in scrofulous children.
It  may occur, also, in the  course of, or during convalescence from,
various other diseases.   We have  already noticed its frequent  con-
nexion  with  gastro-intestinal affections;  it  is likewise often developed
during  or subsequent to, scarlatina, measles, bronchitis, pneumonia,
croup,  hooping cough, &c.   The hydrocephalic form of chronic me-
ningitis, is said to have occurred occasionally as an epidemic.
   The  age most  liable to  the occurrence of chronic  meningitis, is
commonly stated to be between two and seven.  According to Rilliet
and Barthez, the disease is most frequent  between the age of  six and
ten years.   Its order of frequency being first, between three and five,
then between eleven and fifteen, and lastly, between one and two years.
 Sex appears to exert but little influence in  regard to the predisposition
 to  the disease; it  has been asserted, however, that during the first ten
 years it is most common in boys, but after that, in  girls.  In Phila-
 delphia, during  the  ten years  preceding 1845,  1906  deaths  took
 place from hydrocephalus; of these 992,  or  more  than  one-half, oc-
 curred in children between one and five years of age; 748 in infants
 under one year;  166, between five and fifteen; 1020 were males, and
 886 females. Under ten years, 998 were in males, and 838  in females.
    The  prognosis in cases of subacute arachnitis, particularly  when
 combined with the development  of tubercles in the  brain—as is  most
 commonly the case in children—and after the disease is fully developed, 
DISEASES OF  THE NERVOUS  SYSTEM.         427
 must be always extremely unfavourable.  It is by directing our efforts
 towards the prevention of the disease, by the prompt and judicious ma-
 nagement of its preliminary and early stages, that we shall be the most
 likely to secure the safety  of our  patient.  After  it  is fully formed,
 there  is but little chance of arresting its  fatal  course by any plan of
 treatment. It is nevertheless true, that cases of recovery have occurred
 under the most unfavourable circumstances; and it is  said, even in the
 latter stages.
   The treatment of the preliminary stage is to be governed by the na-
 ture of the  symptoms present in each case.  Our great object should
 be to procure a regular and healthy condition of the various functions,
 and to restore a due degree of  tone to  the several  organs;  guarding,
 at the same time, the brain from undue excitement,  and counteracting
 any determination of blood to it, by removing, as far as lies in  our
 power, every cause  that may have a tendency  to produce this effect.
 It is unnecessary to  repeat here  the remarks made in  reference to this
 subject, when treating of the preliminary stage of acute meningitis.
   The treatment of subacute meningitis, in its early stage, must be
 governed by the age  and vigour of the patient, and  the nature  and
 extent of the symptoms present.
   Bloodletting is very generally recommended,  at the  onset of the
 disease, and during  the period  of excitement; and there  can be no
 doubt that, in robust children, and when the pulse is tense, quick, and
 active, and the symptoms of cerebral excitement of hyperaemia strongly
 marked, it constitutes one of our most efficient remedies, and will often,
 when  promptly and judiciously practised, succeed in arresting the pro-
 gress of the inflammation.  It is to be recollected that, in the cases to
 which it  is adapted, the  earlier the remedy is resorted  to, and the
 more quickly it is carried to  the extent  judged  advisable, the  greater
 is the  chance of its proving beneficial.  When, therefore, the  indica-
 tions for the employment of bloodletting are strongly marked, and the
 age of the child will admit of it, a vein should  be opened in the arm,
 and a  sufficient amount of blood drawn off at once, to  make a decided
 impression upon the prominent  symptoms of the case, or until com-
 mencing paleness of the countenance of the patient warns us to desist.
 In infants, the application of leeches to the hands or feet, and  encou-
 raging the flow of blood, by immersing these  parts in warm  water,
 will very generally produce similar results to those derived from vene-
 section in older patients.
   With respect to the quantity  of blood to be  taken  away, and the
 propriety of repeating  the bleeding, no general  rule can be laid down.
 It has  been said that, in infants of a year old, the abstraction of three
 ounces is sufficient; and that the bleeding, to a similar extent, may be
 repeated in  twelve  hours, if necessary.  In judging of the extent of
 direct  depletion, the physician, however, must be governed entirely by
 the character of the symptoms, and the effects of the remedy; it should
 be sufficient to reduce the tension  and quickness of  the pulse, or to
produce a decided diminution of the heat and pain or sense of con-
striction in  the head, unless symptoms of approaching syncope pre-
viously occur.  If, after the first bleeding, the  symptoms of cerebral 
428
DISEASES  OF CHILDREN.
excitement again recur with equal, or nearly equal violence, it should
be repeated, without delay, to the same extent.  In most cases, how-
ever, in place of a repetition of the general bleeding, the  application
of leeches or cups about the head should be preferred.   There is rea-
son for believing, that these two modes of  bloodletting, when succes-
sively employed, make a greater impression on the disease than either
of them is capable of effecting when singly had recourse  to.  By some,
cupping is preferred to leeches, and we think, from our own experience,
that much more prompt and decided good  effects result from the ap-
plication of cups than  from leeching; they may be applied to the tem-
ples, behind the ears, and to the occiput and nape of the neck.
   In those cases in which the symptoms of the first stage are of a less
violent character, or the patient is possessed of little vigour of consti-
tution, or has been debilitated by previous disease, bleeding, though
still advisable, must be practised with much greater caution, and car-
ried to a much less extent; here, leeching or cupping, proportioned to
the extent and violence  of the symptoms, should be preferred to gene-
ral bloodletting.  The repetition of the local depletion must be governed
by circumstances;  if  the pulse again rise, or the heat and pain of the
head recur, it may be  necessary to have recourse to a second applica-
tion of the cups or leeches, and probably to the same extent, as in the
first instance.  The utmost caution and judgment will, however, be
required in the  employment of bloodletting, in the cases  referred to.
Within certain  limits it is unquestionably calculated to  produce the
very best effects; but when carried too far or too frequently repeated,
it may, on the other hand, be productive of much injury.  There may
even occur cases, where the symptoms of exhaustion, and the general
condition of the patient, will  render bloodletting,  to any extent, im-
proper.
   In  cases accompanied  with much  tenderness of the epigastrium,
cups or leeches  to  this  part, will always be proper, and, in many in-
stances, will prove strikingly beneficial.
   Next to bloodletting, active purgatives  are,  perhaps, the  remedy
from  which the most  good will  be derived in the early  stage of the
disease.   Their importance, in all cases, but especially in those  in
which active depletion is indicated, is admitted by nearly every prac-
titioner.  Independently of removing from the  bowels  any irritation
that may  result from accumulation of  faeces or vitiated secretions,
they tend to counteract the afflux of blood to the brain, and to reduce
excitement.  In cerebral  affections generally they are  considered by
Abercrombie, as a remedy scarcely inferior to bloodletting.
   The repeated use of active purges has been recommended by Cheyne
and others  in every case in which the bowels are torpid, or the eva-
cuations  unnatural in appearance; but we are to recollect, that the
unnatural condition of  the alvine  discharges is not always  dependent
upon functional disorder  of the alimentary canal and  liver, but is, in
many cases, connected with  a diseased condition of the mucous  mem-
 brane of the stomach  and bowels, which repeated active  purgation
 cannot fail to aggravate.  While, therefore, in ordinary cases, attended
 with constipation or torpor of the bowels, we  should  be inclined to 
            DISEASES OF THE  NERVOUS SYSTEM.        429

advocate  active purging, we are  convinced, that, in  cases in which
decided symptoms of acute or subacute inflammation of the alimen-
tary canal are present, the mildest purgatives alone  should  be em-
ployed, and only to a sufficient extent to remove  from the intestines
any faeces, or other irritating matters,  they may contain.
  Calomel is, under all  circumstances, the best purgative we can em-
ploy ; from three to six grains, according to the age of the  patient,
should be early administered, and followed, in a short time, by a dose
of  castor  oil, or  sulphate of magnesia.  Subsequently, the  calomel
should be given  in small doses, and the freedom of the bowels main-
tained by the occasional use of castor  oil, or mild, laxative enemata.
  When the calomel alone does not prove sufficiently active as a pur-
gative, it  may be combined with jalap, which, when  toasted, is said
by  Golis not to  be so liable  to cause griping pains; with extract  of
colocynth and gamboge;  with scammony, or with rhubarb.   Elate-
rium has been recommended by Elliotson, in  the  more violent forms
of  the disease, and the croton  oil by Abercrombie.   The first, how-
ever, is very unmanageable, often producing severe watery  purging
attended with sickness and vomiting, and the second, though strongly
recommended, by the smallness of its dose, and  the ease with which
it may be administered  to  children, we have found to be very uncer-
tain in its operation—in some instances producing little or no effect,
and in others, acting with the utmost  violence.
  In cases in which the stomach is very irritable, it has been recom-
mended by Cheyne, to give one or two drachms  of  magnesia, satu-
rated with lemon juice, every two or three hours; and when calomel
produces  considerable intestinal irritation, it has  been proposed  by
A.  T. Thomson, to substitute the hydrarg. cum creta, with powdered
colchicum.   We have seldom, however, found calomel, administered,
at first, in a  full dose, and repeated in smaller doses, daily or oftener,
with the occasional interposition of castor oil, a  solution of the
sulphate of magnesia, or purgative enemata, to fail in  producing the
desired effect.  Small doses of calomel, combined with magnesia, and
the third or fourth of a  grain of ipecacuanha, will rarely be  rejected
by  the stomach, or  produce irritation of the alimentary canal.  In
many cases of the disease, particularly in those attended with vitiated
discharges from the bowels, we have repeatedly found the spirits of
turpentine by the  mouth, or in the form of enema, a  very  valuable
purgative, and even  in cases attended with obstinate  torpor of the
bowels, combined with castor oil, it has appeared to us to agree better
with the stomach, and to  aid more effectually the action of calomel
than most other articles. -
   Independently of its  action  upon the bowels as  a purgative,  the
alterative effects of calomel, if  early obtained, are often in the highest
degree beneficial.
   Under precisely the  same circumstances,  as demand the employ-
ment of direct depletion, cold  applications to the head will be found
particularly  advantageous.  Cloths wet with  cold  water, the  ice cap,
or  evaporating lotions,  may  be employed in the same  manner  as
directed in acute meningitis, and  continued until the increased heat of 
430
DISEASES  OF CHILDREN.
the head is permanently reduced.  Even in cases which do not admit
of bloodletting or active purgation, frequently sponging the head with
cold water alone, or with  the addition of a small portion of alcohol or
camphorated spirits, will be found  advantageous. Pouring water in a.
small stream  upon the head, has  been  recommended as particularly
efficacious, in the early stage of the more violent cases, or even after
coma or convulsions have occurred.
   The tartrate of antimony, in combination with calomel, has been
recommended in the treatment  of the subacute form of meningeal in-
flammation  by many of the writers on the disease.   James's powder
is, however,  the preparation of antimony most generally  employed.
The addition of the antimony is, in  many cases,  a very valuable one;
it is chiefly adapted, however, to the early stages. Large doses of the
tartrate of antimony have been employed by a few  physicians, and
their effects are reported to have been decidedly advantageous.  But
in cases attended with  gastro-enteric disease, they cannot fail to do
more or  less  harm, and  should  be  resorted  to with  the  greatest
caution.
   Subsequent to bleeding, in the more severe cases, warm, sinapised
pediluvia constitute an efficient means of derivation from the brain, and
may be advantageously employed  in  conjunction with  cold applica-
tions to the  head.   The frequency of their repetition  must  be  deter-
mined by the circumstances of each case.
   After the stage of excitement has passed by, blisters will often prove
highly advantageous.  They should be applied behind the ears, or to the
nape of the neck; and we believe, that in all cases, a  succession of
blisters  is preferable to keeping up an  irritation of the  blistered sur-
face by the savine, or any other ointment.   When there exists a con-
siderable degree of tenderness of the abdomen, after the application of
leeches, a blister over the part will  often prove advantageous.  As de-
rivatives, the ointment  of tartarized antimony, moxas, and various sti-
mulating embrocations have been recommended, and may be resorted
to, in many cases, with the best effects.
  Digitalis has been employed,  as well during the stage of excitement
with a view to its sedative effects, as after effusion has taken place, to
promote  the  absorption of the  fluid by its diuretic  properties.  It is
given in the form of tincture, in the dose of eight or ten drops, every
six hours, increasing it gradually, by two or three drops at a time, until
its effects are fully produced;  or,  in powder combined with calomel
and opium.  The tincture  we have seldom employed, having found it
very uncertain in its effects, but from the employment of the digitalis
in the form of powder, combined with  calomel and ipecacuanha, (one-
fourth of a grain of each every three or four hours,) we are  convinced
that, during the early stages of the disease, we have frequently derived
very considerable advantage.
  Mercury early resorted to, and pushed to an extent sufficient to pro-
duce  its specific effects, is unquestionably one of the  remedies from
the effects of which the greatest advantage is to  be anticipated.   The
evidence adduced  in its favour by Percival, Dobson,  Rush, Currie, 
            DISEASES OF THE NERVOUS  SYSTEM.         431

Cheyne, Chapman, Mills, Schmidt, and  Golis,  is of the most unequi-
vocal character.
  From half a grain to one or two grains of calomel should be given
every two, three, or four hours, according to circumstances, and con-
tinued daily, until swelling or tenderness of the gums, or foetor of  the
breath,  or a  decided  improvement  in  the symptoms of the disease
occur, when the calomel should be discontinued for a day or two, and
afterwards, if necessary, repeated in smaller doses, and at longer inter-
vals, until the disease is completely subdued.   The good effects of
mercury,  in subacute  meningitis, would appear to be altogether inde-
pendent of salivation,  which should, as far as possible,  be guarded
against.   The effects of the calomel  are often  increased by the addi-
tion of small portions of ipecacuanha or James's powder.   With the
view of placing the system more quickly under the influence of the mer-
cury, as well as in those cases in which the use of the calomel internally
produces  constant nausea and vomiting, or frequent griping, with re-
peated greenish, slimy discharges from the bowels, one or two scruples
or more of the strongest mercurial ointment, may be rubbed upon the
neck, arms, and legs of the patient, as well as upon the blistered sur-
faces, night and morning, until the effects of the remedy are obtained.
   It has been recommended by Cheyne, Mills, and others, to combine
the  calomel with opium.   The good effects of this combination  are
said to depend upon its power of equalizing the circulation, increasing
the secretions, and exciting the healthy action of the cutaneous vessels.
The watery extract is the preparation of opium which should  be pre-
ferred in  the disease before us, inasmuch as it  procures rest, by dimi-
nishing pain and irritation, without exhibiting,  to any great extent, the
narcotic or nauseating properties of the drug in its ordinary forms.
   The Dover's powder has likewise been strongly advocated as a re-
medy,  in subacute  meningitis, by  Brooke,  Percival, Cheyne,  and
Crampton. There can be no doubt that, in many cases, after bleeding
and active purgation have been carried to a sufficient extent, a judicious
employment of opium, especially in combination with calomel  and
ipecacuanha, will be  beneficial, by  diminishing any irritation of the
bowels, and abating undue nervous excitability; but, in the early stages
of the more violent cases, opiates, even in the  minutest doses, will in-
variably do harm by increasing the congestion of the brain.  In cases
in which  opium is found to produce disagreeable effects, some of the
earlier German writers strongly recommend the substitution of mode-
rate doses of hyoscyamus  in powder or extract;  and  from a pretty
extensive use  of  the  article, we are  persuaded  that,  in  the  disease
under consideration, as well as in most of the  affections of childhood,
where, we desire to allay pain and irritation or undue nervous excita-
bility, it will often prove a very valuable remedy.
   After effusion has taken place, the use of various diuretics, and of
iodine,  has  been  recommended, with  a view of promoting  the ab-
sorption of the fluid from the cavities of the  brain; of their success,
under these circumstances, we cannot speak from experience.  They
may, however, prove, in some cases, valuable  auxiliaries  to the other
remedies  employed, and hence  are worth a trial.  We have already 
432
DISEASES OF CHILDREN.
 spoken of the use of digitalis; the squill, in combination with calomel,
 has been strongly recommended by Percival, Bricheteau, and Schmidt.
 By Kleber and Bischkofft the vinum scillae, in combination with the
 tincture, has been used externally, in the form of friction to the scalp.
 By others, the turpentine  in enemata, or formed into a liniment, and
 rubbed into the scalp, has been considered  as the most powerful diu-
 retic in hydrocephalic cases.  It unquestionably, in many instances, will
 produce a very good effect; we have used it internally, in enemata, and
 in the  form of liniment to the  epigastrium,  and along the spine, and,
 we think, always with advantage.  The iodine,  either in the form of
 the proto-ioduret of mercury externally, or of the iodide of potassium,
 combined with diuretics,  is said to have proved successful, in many
 cases.   Christie of Scotland, and Woniger  of Hamburg, report each
 a case of acute hydrocephalus, in which the cure was effected after the
 disease had  reached  the paralytic stage,  by  the administration  of
 iodine.   By the first  a solution  of grs. xvj. of iodide of potassium, and
 four grains of iodine  in one ounce of water, was employed, given  in
 the dose of a teaspoonful every four hours; at the same time a weak
 ointment  of  the biniodide of mercury  was rubbed upon  the scalp.
 Woniger employed a  solution of one drachm of iodide of potassium,
 dissolved  in half an ounce of water, in  the  dose of forty, and, subse-
 quently, fifty  drops every  two hours.  In Dr. Christie's  case, the first
 indication of  improvement occurred in thirty-six hours after the use of
 the iodine was commenced with,—but in Dr. Woniger's case, not until
 after the end of seventy-two hours.   In both the recovery was complete
 and  permanent.   The iodide of potassium, in large and  frequently  re-
 peated doses,* is said by  Roser to  have proved successful  in cases
 where  paralysis had already occurred, and death appeared impending.
 We  have employed  the iodine in  the manner recommended by Dr.
 Christie, and  in several cases its beneficial effects were strikingly dis-
 played; in others, however, no apparent advantage was derived from
 its use.
                   a R.—Iodid. potass. 3j.
                        Aquae destill. 3ss.—M.
                   Thirty drops to be given  every hour.
  The colchicum, the  sweet spirits of nitre, the compound spirits of
juniper, and various other diuretics, have been  recommended, but  the
 evidence in their favour is not  sufficient to recommend them strongly
 to our  notice.
  The simple vapour-bath or the vapour-bath impregnated with vine-
 gar,  has been noticed, the former by A. Hunter, the latter by Itard, as a
 remedy of very considerable power, even in the last stage of the dis-
 ease; we  believe that it will frequently be found of decided advantage,
 after the stage of excitement has passed.
  Various symptoms occurring in the course of the disease, will occa-
 sionally require  particular remedies.  When considerable  tenderness
 of the  abdomen occurs, we have already noticed the propriety of ap-
 plying  to this  part leeches followed by blisters.  In milder cases, warm,
 emollient  cataplasms will  supersede the  necessity of blisters.  Vomit-
 ing is often a distressing symptom; it will, in many cases, be effectu- 
DISEASES OF  THE NERVOUS  SYSTEM.        433
ally  relieved by  minute doses of calomel combined with  magnesia
and  ipecacuanha,1 and the application to the epigastrium of a sina-
pism, or  friction  with spirits  of turpentine.  Ten,  fifteen, or twenty
drops of  the spirits of turpentine  internally, or half a drachm of tur-
pentine mixed up with thin starch, and administered as an enema, we
have repeatedly found to allay very promptly the  irritability of the
stomach, in this disease.
                   » R.—Calomel, gr. iij.
                        Magnes. calc. gr. xxiv.
                        Ipecac, pulv. gr. ij.—M. f. chart. No. xij.
                 One to be given every one, two, or three hours.

   Convulsions  may be relieved by cups to  the nape of the neck, fric-
tion along the spine, warm pediluvia, cold affusion upon the head, and
turpentine enemata.
   From  the very onset of the disease, the  patient should be confined
to his chamber, which should be kept darkened, well ventilated, and
of a moderate temperature, and every possible means should be adopted
to screen him from noise of every kind, and from all other causes of
excitement.
   He should lie upon a hair mattress, with his head somewhat ele-
vated, and be covered with no more clothing than is sufficient to keep
him of a comfortable temperature.  All sudden, or, indeed, all unne-
cessary movements of the patient should be avoided; and the utmost
kindness should be invariably observed by the  attendants in their de-
portment towards him.
   His diet and drink, in  severe cases, and during the stage  of excite-
ment, should be restricted pretty much to simple mucilaginous fluids,
given cool.
   At a later period, after the stage of excitement has fully passed,
plain water gruel or panada  may be allowed;  and in the last stage,
when  collapse has occurred, the diet should be nourishing, but  mild
and easy of digestion, as beef tea, plain chicken  or mutton broth,
animal jellies, &c; at the same time, we may attempt to support the
strength  of  the patient, by the cautious use of ammonia, wine whey,
valerian, or camphor, combined with infusion of gentian, calombo, or
quassia.
   During convalescence, the  utmost care  should be observed to pre-
vent a relapse.   The bowels  should be kept regularly open by gentle
laxatives ; the diet should be of the mildest and  least irritating articles,
but, at the same  time, sufficiently  nourishing;  the patient's clothing
should be cautiously adapted to the temperature of the season, and, in
quantity  and material, calculated to prevent the influence  of sudden
changes  in the weather; every source  of fatigue or excitement should
be avoided ; but, at the same time,, daily gentle exercise, in a dry, pure
air,  will  be attended  with the best effects.   Sponging the body daily
with warm salt water, the temperature  being  gradually reduced as the
activity and  tone of the  patient's system is  gradually increased, will
act  as a safe and very powerful tonic.  The patient's hair should be
kept short, and only a light covering worn  upon the head.
   In cases in which  there is  a strong predisposition to  a renewal of
                                28 
434
DISEASES OF CHILDREN.
disease in the brain, it  has been recommended, and the recommenda-
tion is certainly a judicious one, to insert an  issue in the neck, or  to
keep up a constant irritation, for a considerable period, at this part, by
the use of the ointment of tartarized antimony.
   Several writers  have described a morbid affection incident to the
period of infancy, resembling, in  nearly all its symptoms, the  latter
stages of subacute arachnitis, but resulting invariably*from exhaustion,
and which Hall has proposed to designate by the term hydrencephaloid.
We believe, however, as has been already pointed out by Bennett, that
this affection differs only from that described above, in its occurring  in
children  labouring under considerable exhaustion and debility.
   This  variety of  the disease  unquestionably demands, however, a
very important modification of treatment.  All debilitating remedies
are positively  injurious.   The strength of the patient should be sup-
ported by the  breast-milk  of  a  healthy nurse, or  if weaned, by beef
tea, plain mutton or chicken broth, and similar articles of nourishment.
Where the exhaustion  is very great, wine whey, the  carbonate of am-
monia, or even wine itself, may be required: —these should be exhibited,
however, in moderate  portions, and  their  effects closely and carefully
watched.
   In young children, the  exhaustion is very frequently the result  of
extensive serous diarrhoea ; this, if it continue, should be checked  as
quickly as possible, and we believe the remedy, upon which, in these
cases, the most dependence is to be placed, is the acetate of lead  given
in solution, in  the  dose of a grain, every two or  three hours, by the
mouth and to  the extent  of three or four grains, as  an enema.   In
many cases, however,  the chalk mixture, with the addition of catechu,
or the decoction of the dewberry root, will succeed.  After the diar-
rhoea has  ceased,  the bowels  may be  regulated by small doses  of
calomel, prepared chalk, ipecacuanha, and extract of hyoscyamus.
   The warm bath will  be found, in most cases, a very valuable remedy,
and should be repeated daily.   The patient should be kept in a recum-
bent posture, and where he may enjoy the advantages of a free circu-
lation of air, and the temperature of his extremities should be  main-
tained by dry  friction  and  flannel. If the patient sink into a comatose
condition, blisters  or sinapisms should be applied to the nape of the
neck, and to  the  lower extremities, and  frictions  made with some
stimulating liniment along the spine.
   Chronic Hydrocephalus. This form of disease is very generally con-
genital, or is developed soon after birth.   It consists  in an accumula-
tion of a serous fluid,  often to an enormous  extent,  generally within
the ventricles of the brain, but occasionally  upon its surface.
   When the disease occurs subsequently to birth, it is generally de-
veloped  slowly and  insensibly; being seldom preceded by any very
marked  symptoms;  the first thing that attracts attention being an en-
largement of the whole head, which sometimes acquires an immense
size—the sutures become  separated, and the fontanelles enlarged, pre-
senting,  as it  were,  tense, semi-transparent tumours, in which  a dis-
tinct fluctuation is perceptible upon pressure.
   The head gradually enlarges, as  the effusion increases within the 
DISEASES OF  THE NERVOUS SYSTEM.          435
 cranium, until, in many instances, its size becomes  so  great, that the
 patient is no longer able to support it erect, and it droops continually
 upon the shoulder, or forwards  upon the chest, when he is in the up-
 right position;  the face at the same  time, retaining its natural size,
 the physiognomy of the patient acquires a very peculiar expression.
 As the  disease  advances, the  senses  become  blunted, the intellect
 impaired, and  the muscular  power so  much enfeebled, as to prevent
 the patient from moving about, or using  the least exertion.  Convul-
 sive movements, paralysis, and coma, occasionally  occur ; but gene-
 rally the patient sinks into a state of deep stupor,  which terminates,
 sooner or later, in death.
    In some instances, in place of a general enlargement  of the head,
 a large tumour gradually  forms at the situation of the posterior fon-
 tanelle, or somewhat  lower, pressure  upon which produces coma or
 convulsions.
    Patients affected with  chronic hydrocephalus may  live for many
 years, without any very decided impairment of the intellectual faculties.
 Occasionally, the sense of sight, hearing, and taste,  are destroyed per-
 manently, or only for a time; in other cases, one sense only, is affected;
 in others, two or  more, the rest  remaining entire.   Emaciation  is a
 common  symptom, as is  also  some degree of giddiness in the erect
 posture.  Strabismus is frequently, and opacities of the cornea, are
 occasionally, seen in those affected with  the disease.   Death often
 takes place from the intervention of other  affections; very frequently
 from ulceration of the bowels, sometimes from phthisis pulmonalis, and
 occasionally, from inflammation of the tissues of the lungs.
    Upon examination after death, the brain presents the appearance of
 an extended bag, with thin parietes, filled with a serous fluid.   It was
 supposed that, in these cases, the substance of the brain had  become
 absorbed, in consequence of the pressure of the fluid within, but upon
t a more accurate examination, it  is found that no portion of the brain
 'is HeVtroyed, its'conVolutions being merely deployed-.;;  In other"eases,1 *  *» v
 however, the brain has been found in  a perfectly  rudimentary state.
 (Gall, Spurzheim, Cruveilhier, Breschet, Billard.)   The lining mem-
 brane of the ventricles is occasionally vascular, and  frequently very
 much thickened, and easily separated from the medullar)'- matter  to
 which it is attached.
    Chronic hydrocephalus  is not a very frequent disease in Philadelphia.
 We have never seen a case, either congenital or developed subsequent
 to birth.
    In  the treatment of chronic hydrocephalus, our chief object must
 be, to palliate the symptoms as they occur, by the occasional  applica-
 tion of leeches, and the use of repeated blisters, the  tartar emetic  oint-
 ment or issues.   The bowels should be kept regularly  open, by gentle
 aperients, and  the diet of the  patient carefully regulated.  Mercury
 has been strongly recommended, and is deserving of a fair trial.
    The radical  cure  of the disease has been attempted, by properly
 regulated and  continued  pressure applied to the head ; and  cases of
 success, from  this plan of treatment,  have been published by Blane,
 Barnard, Engleman, and  others.   But the plan in favour of the feasi- 
436
DISEASES  OF CHILDREN.
bility, safety, and success of which, the greatest amount of evidence
has been adduced, is that of drawing off the effused  fluid by punc-
turing  the  brain, and preventing its re-accumulation, by pressure ap-
plied round the head.
  The operation consists in passing a small and delicately constructed
trochar into one of the lateral  ventricles, and drawing off as much
fluid as the powers of the constitution will admit of.  The most eligi-
ble spot at which the trochar can be introduced, is in the course of the
coronal suture, about midway between the crista galli  process of the
ethmoid bone, and the anterior fontanelle, so that the danger of wound-
ing the corpus striatum is avoided  on the one hand,  and the longitudi-
nal sinus on the other.   The instrument usually penetrates about two
inches, and in most cases the serum discharged is colourless, but occa-
sionally it is tinged with blood. Sometimes on withdrawing the trochar,
the water will not flow until a probe has been passed along the canula,
to remove portions of brain which  block it up. After taking away all
the fluid that can be  removed consistently with safety, the head, which
should  always be steadily compressed  by an assistant during the ope-
ration, may be strapped with adhesive plaster, so as to retain its dimi-
nished  size, and avert  the fearful consequences of suddenly removing
long-continued pressure from the brain.  In no instance, however, has
a clearly-marked congenital case been  permanently benefited ;  the
cases in which  the operation has been most successful, according  to
Conquest, are those in which the effusion has manifestly resulted from
an inflammatory condition of the brain, and in which cerebral excite-
ment follows the operation.
  It is proper to remark, however, that even in these, the operation
has been found unsuccessful in numerous instances; and that it has
been pronounced by high authority, (Golis, Heister, Hecher, Porten-
schlag,) as  one, in all cases, both cruel and useless.

,  ^X^^A-5?,        7. —Chorea, x ****"•> •** *±<*«&*
  Chorea is a very common disease of childhood, occurring more fre-
quently between the eighth and fourteenth years, than at any other
period  of life.   It consists in involuntary convulsive  movements of the
voluntary muscles, particularly of the  face and extremities, and occa-
sionally, of those of  the  neck and trunk.   In some cases, nearly the
whole of the voluntary muscles  are more or less affected with convul-
sive or  irregular movements;  while in others, these are confined  to
one side, to the face  or neck, or to a single extremity.
  The distinguishing characteristic of the disease  is  an incomplete
subservience of the muscles of voluntary motion to the will, by which
their actions are rendered irregular and uncertain.   Thus, the  patient
intending to approach a cup of water to his lips, will involuntarily cast
it from him, or throw its contents over his shoulder; or, in attempting
to advance his foot forward, in the act of walking, carries it in  every
possible direction excepting the right one.   The  movements of the
face, arms, and hands, often resemble the gesticulations of buffoonery.
  The name of the  disease, (Chorea Santi Viti—the Dance of Saint
Vitus,)  is derived from the circumstance of the patients affected with 
DISEASES OF  THE NERVOUS  SYSTEM.          437
 it, formerly repairing annually to the chapel of St. Vitus, near the city
 of Ulm, in Swabia, where  they danced day and night, as a means of
 effecting their cure.
   Chorea  affects children of both sexes, but more frequently girls, par-
 ticularly those of a weakly constitution, or whose health and vigour
 have been impaired by confinement, impure air, improper or deficient
 nutriment, or preceding disease.
   Previous to its  occurrence, the patient is, in general, affected with
 the ordinary symptoms of derangement  of the  digestive organs,—a
 depraved, variable, or defective appetite,  tumid abdomen, constipated
 bowels, and  a loss of his previous vivacity and playfulness.
   The attack in general commences with slight, irregular, involuntary
 movements of different muscles, particularly those of  the face, which
 are often  mistaken for voluntary grimaces; these, after a shorter or
 longer period, are succeeded by the more constant and general move-
 ments by which the disease is characterized.  Any one set, or all of
 the muscles of voluntary motion, may be affected in  different cases.
 Usually, the first  indications of the disease are an  unsteadiness in the
 patient's gait, which is marked, often,  by  a peculiar jumping or start-
 ing; or one  leg is dragged along, in place of being lifted in the usual
 manner; while the arms are moved about, as if the patient  were per-
 forming various intentional gesticulations.  He is often unable to per-
 form the common and  necessary movements with the affected arm,
 the  involuntary actions of the  muscles entirely counteracting those
 directed by the will.   These convulsive movements are more or less
 violent, and  are often constant while  the  patient is awake;—during
 sleep, in most cases, they cease entirely.   Although, occasionally, dif-
 ferent muscles  become successively affected, yet in the generality of
 cases, it is in those first attacked, that the convulsive  movements re-
 main throughout the disease.
   In consequence of the affection of  the muscles  of the tongue and
 throat,  in some instances, articulation  and deglutition are impeded or
 performed with difficulty.  In extreme cases, the eyes lose their lustre
 and intelligence,  the face  becomes pale, and  the expression  of the
 countenance is that of vacancy, indifference, and languor.  The mouth
 is often distorted, so as to give to the face the appearance of a habitual,
 silly grin.  The patient acquires,  in fact, the features of idiocy.  In a
 few cases,  indeed, when the disease has continued for a length of time,
 partial, or even complete fatuity has been known to ensue.   Fatuity,^j4ma^9/
 however, is by no means a very common  sequel of chorea, even in its ^^CCt^,,
 most violent and chronic forms.  Many instances are  on record, and     '
 similar  ones  have  fallen  under  our own notice, in which the  disease
 has continued, with but slight intermissions, from childhood  to an ad-
 vanced age, without the integrity of  the intellect being  much, if at all,
 impaired.  In some cases, the patients are  affected with a species of
 melancholy, or with the peculiar nervous temperament that commonly
 accompanies hysteria.
   Throughout the attack the bowels  are generally costive, and the
appetite defective, capricious or  ravenous.  Febrile  reaction  is not
necessarily an attendant upon chorea, and when it does occur, is gene- 
438
DISEASES OF  CHILDREN.
   rally the result of gastro-intestinal irritation, or some accidental affec-
   tion.  When the disease is very violent and protracted there in general
   occurs great emaciation, a flaccid state of the muscles, great depres-
   sion of strength, paleness and discoloration of the skin, and the other
   indications of impaired energy of the digestive and nutritive functions.
      The heart is, according to Dr. Todd, (Lumlean Lectures, for  1849,)
   very frequently morbidly affected in chorea;  and  this morbid affec-
   tion shows  itself not in any disturbance of the rhythm of the  heart,
   which, so far  as  his observation extends, never is  disturbed, but in a
   derangement of its sounds.   A bellows sound is frequently found, and
   is either aortic systolic, when it is almost  always an  accompaniment
   of the anaemic state of the  patient, or, much  more frequently, mitral
   systolic, or regurgitant.   This condition  of the cardiac sounds in
   chorea was described by Dr. Todd  in the  Croonean Lectures on the
   pathology of  rheumatism in  1843.  But  to  Dr. Addison, of  Guy's
   Hospital, is due, the merit of having first made known the morbid con-
   dition of the sounds of the heart in this disease.
      Epilepsy  and hemiplegia are not uncommon results of chorea; and
   in many of the cases that have fallen  under our notice the patients
   have died from tubercular meningitis—the lungs and  serous tissues of
   the thorax and abdomen exhibiting, also, tubercular depositions.
      According  to  Dr.  Todd,  the  choreic convulsion is frequently suc-
   ceeded by  a  paralytic state of the limbs previously convulsed ; the
   convulsive  movements cease, and the limbs remain  paralysed; the
   paralysis is seldom complete, although considerable.  When the choreic
   convulsion has affected one  side, the paralysis will  likewise affect the
   same side ; it  will be haemiplegic, and will resemble  very closely haemi-
   plegia from diseased brain, for which it is very apt to be mistaken by those
   not aware of  the fact.  We have occasionally met  with this  paralytic
   state as  a corfsequence of violent attacks of chorea,  but cannot believe
   it to be so frequent as stated by Dr. Todd.
      Chorea has been defined by some writers, to be an irregular motion
   of the muscles, when excited into action by the will;  the disease con-
   sisting in a loss of  the power of volition over their mode of  action—
   that is, of directing and combining their action, for  the  accomplish-
   ment  of any  particular  movement.   The  disease  has, consequen'.ly,
   been supposed to result from some lesion of the cerebellum.  This de-
   finition would, however, exclude a number of cases, in which the con-
•h vulsive  movements of the muscles  certainly occur independently  of
»   . the will, and  unassociated with consciousness, differing from convul-
   sions  only in  the orderly nature of  the motions.   Such are cases of
   malleation, in which  the convulsive  paroxysm consists, principally, in
   a constant striking the knees with one or both hands, as with a ham-
   mer ;—or of rotation  of the  whole or a part of the body, as in the case
   described  by Watt,  in an  early  volume of  the Medico-Chirurgical
   Transactions.  In  this case the patient, a girl ten  years of  age, was
   seized with an irresistible propensity to turn  round on her feet like  a
   top, then to lie down, and roll rapidly backwards and forwards; in  a
   more  advanced  stage of her disease, while lying  upon her  back, to
   bend herself up like a bow, by drawing her head  and  heels  together, 
DISEASES OF THE NERVOUS  SYSTEM.          439
and then suddenly to separate them, so as to cause the buttocks to fall
with considerable force upon the bed ; and to repeat this continually,
for hours;  at a still later  period she was  seized with a propensity to
stand upon her head, with her feet perpendicularly upwards: as soon
as her feet gained the perpendicular all muscular action ceased, and
her body fell as if dead, her knees first striking the bed, and her but-
tocks striking her heels; this was  no sooner done than she instantly
mounted up as before, and continued these evolutions, sometimes for
fifteen hours consecutively, at the rate of twelve to fifteen times in the
minute.
  To this same  class belongs also the salaam convulsions, noticed in
a previous  section.   But it would  be impossible to  describe all the
various forms under which the disease occasionally presents itself; in
many of which, no description can convey an adequate idea of the odd
appearance, and strange  gesticulations of the patients;  so  that we
need  not be the least surprised, that in times of ignorance and super-
stition it was ascribed  to  supernatural causes, and the agency of de-
mons. It is more than probable, as remarked by Carpenter, that many
cases of stammering are to  be regarded as a species of chorea of the
muscles of the voice.
  Allied to the movements of chorea, remarks Dr. Todd,  are the fid-
gets of children, and, perhaps, also those of grown persons.  In  some
children, these fidgety  movements are so  excessive, that the  child be-
comes almost a nuisance  in a room.   All the  muscles are affected ;
the child incessantly makes grimaces of the most various kinds; every
minute  he  assumes a new attitude; if anything comes in  his way, he
must handle or touch it: and these irregularities are always the greater
when there  is derangement of the general health.  Children thus af-
fected might readily be thrown into  the  convulsions of chorea by a
strong mental emotion.
  The disease as it ordinarily presents itself in children, will be readily
recognised by the symptoms already laid down.
  It  usually occurs,  as already remarked, between  the  eighth and
fourteenth  years, but is by  no means confined to this period.  The
convulsive actions may be continuous, intermittent, or remittent; they
are excited and increased  by observation, contradiction, ridicule, or
any other cause of  irritation, and especially, by any attempt, forcibly
to restrain them.
  Chorea is, of itself,  seldom fatal; it frequently terminates sponta-
neously about  the period of puberty in boys,  or upon the establish-
ment of the  catamenia  in  girls.   When  recent, and occurring in
children possessed  of  some degree of constitutional vigour, it may
often be entirely removed by an appropriate treatment; though not
unfrequently the patient preserves during life, a tendency to involuntary
twitching of the muscles of the eye, eyelids, face, and even of the limbs.
  The mean duration of chorea is stated by M. Rufz, to be thirty-one
days.  M. Dufosse, however, extends it to fifty-seven  days, while, ac-
cording to Rilliet and Barthez, it ranges from six weeks to two months.
  Relapses are very frequent. Dr. Copland observed it to occur three 
440
DISEASES  OF CHILDREN.
times in one patient, M. Rufz, six times, and Rilliet and Barthez notice
its recurrence, once, twice, and thrice, in nineteen cases.
  According to Rilliet and Barthez, when a patient labouring  under
chorea is attacked with measles, scarlatina, variola, or  other of the
acute febrile  diseases  of childhood,  the chorea will be generally dimi-
nished in intensity or entirely removed.  They state that out of nine-
teen cases, nine were attacked by other diseases, and eight were evi-
dently influenced by them; sometimes the chorea  diminished from the
commencement; while in others it  increased at  first, but afterwards
disappeared.   M. Rufz, on the other hand, denies that the concurrent
disease exercises any  influence upon either the duration or intensity of
the chorea.
  Pathological anatomy throws but little light upon the true nature of
chorea, so far, at least, as regards the nature and seat of the lesions of
the nervous centres upon which the phenomena of  the disease imme-
diately depend.  In a  large number of cases, after  the  most minute
examination, no morbid  changes are detected that  can  be regarded
as necessarily  connected with the  disease  (Duges,  Oliver,  Hawkins,
Rufz, Gerhard, Hache, Vielde, Rostan, Lawrence); while those which
have  been recorded by various writers, are evidently accidental le-
sions, or  to be regarded rather as effects than causes of the complaint;
such  as  inflammation  of various  parts of the  brain   (Clutterbuck,
Serres) ;  turgescence  of its vessels, with effusions of serum (Coxe,
Patterson, Rbser, Willan, Copland): hypertrophy  and injection of the
brain and spinal cord (Monad, Hutin) ;  turgescence of the vessels of
the brain and spinal cord, with several bony plates upon the pia mater,
half-way up  the spine (Bright); a  concretion in the medullary sub-
stance of the left hemisphere of the brain (Brown); a tumour pressing
on the corpora  quadrigemina, inflammation of these  parts, with san-
guineous effusion (Serres);  ecchymosis of the membranes, and a pulpy
condition of the spinal cord (Keir); and, in  a single case, an abscess
within the cerebellum  (Schrbde).
  In the  absence of positive facts, speculations upon the nature of any
disease are of little value.  Reasoning from  the nature of the pheno-
mena by which the disease is characterized, chorea  has been referred
by M. Hall to  lesions of the spinal system of nerves ; but this, it has
been  remarked by Carpenter, can  scarcely  be  regarded  as a correct
conclusion.   Although there is often considerable  irregularity in the
ordinary reflex actions, yet the disease mainly consists in an absence,
or deficiency of the  controlling power of the will  over the actions
of the muscles of animal  life, and  in many cases,  in a spontaneity
of action in  the performance of certain  movements. According to
the most probable  view of the functions of the cerebellum, it is proba-
ble that this organ is the chief seat  of the disease.  The morbid phe-
nomena,  however, in  the majority  of cases, not resulting from any
direct lesion of the cerebellum, but  from remote  irritations, in which
it participates sympathetically.
  Dr. Elam, in a  very interesting paper in the Provincial Med. and
Surg. Journal, February, 1849, maintains that the movements of the
muscles in chorea  are of an automatic character.  He relates the case 
             DISEASES OF THE  NERVOUS SYSTEM.         441

 of a child nine years of age, who had been three weeks suffering from
 the disease, as showing the peculiar distinction between the voluntary
 and automatic motions.   Whilst eating, the right arm of the child
 acted regularly in carrying the spoon to the mouth, whilst the left arm
 and both legs were violently convulsed, yet not a drop of food was
 spilled.  The  patient,  instead of acting instinctively, as it  may be
 termed, when  directed to  do anything with the right arm,  or  asked
 to give her hand, she did it always in the jerking irregular manner so
 characteristic of the disease.
   The effect of music upon the ancient form of St. "Vitus's dance would
 seem to Dr. Elam to indicate, that whilst volition has but little influence in
 itself in controlling the irregular actions of the muscles, yet by external
 agencies, acting through the senses, an instinctive modification of these
 actions may take place, and if persevered in, the habit may be broken
 altogether.   Another peculiarity of these motions,  he remarks, is that
 in defiance of  their apparent irregularity, there is a sort of rhythm or
 order—a series of actions recurring with greater  or  less constancy.
 This is most manifest in  the milder forms.   In some cases it is con-
 fined to a periodical  twitching of one or more muscles of the face or
 eyeballs.   In one case, both eyeballs were turned so far upwards and
 laterally, as almost to hide the iris.  This and a corresponding twitch
 of the orbicularis, were the constant and only symptoms, and  recurred
 with tolerable  regularity every  forty seconds.  We  have  met with
 many such cases.  As, however, the affection becomes more violent,
 the regularity of the motions becomes less evident, one  class of spasms
 interfering with and  modifying the others;  in  one very violent and
 fatal case, the recurring character of the convulsive  movements was
 evident almost to the last.
   According to Dr. Elam, for the production of these automatic motions,
 if they are acknowledged to be of this  character, there must be a
 stimulus acting upon the extremities of the excito-motor nerve, and  the
 impulse reflected from the  motor centres upon the muscular  system.
 In health, stimuli of a  certain character are constantly applied to  the
 extremities of these nerves.   To produce disease,  either the stimulus
 must be increased  in intensity, or the extremities of the nerves must
 be in a  more irritable condition,  and to the latter cause must  the pro-
 duction of chorea be almost invariably  attributed.   In  almost every
 case the cause  must be looked for in some local or general excitabi-
 lity (perhaps from  irregular distribution of blood),  in  the extremities
 of the excito-motor nerves, compelling  them to respond in  a  more
 vigorous,  and consequently irregular manner, to the ordinary physi-
 cal agents.   It seems probable, too, that this excitability is almost  ex-
 clusively manifested in the alimentary canal, the uterus, or the skin.
   Dr. Elam notices the great similarity between chorea and tic dolou-
 reux, both as to their causes and the plan of treatment most successful
 in both.  One attacks the motor, and the other the sentient nerves; both
are chiefly dependent on derangement of the intestinal or uterine func-
tions,—both ^tre generally diseases of debility—both are relieved  by
tonics, and both are almost incapable of relief by narcotics.
  Dr. Copland  has shown by post mortem examination, the  frequent 
442
DISEASES  OF CHILDREN.
complication of chorea with rheumatism, rheumatic pericarditis, and
disease  of the membranes of the  spine, and  his observations have
since  been  confirmed by Drs. Pritchard and Roser.  Todd, in  the
Lumlean Lectures for 1849, has pointed out its relationship to rheu-
matism, and the liability to  the occurrence in those affected by it of
rheumatic endocarditis.
  The most common predisposing causes of the disease, would appear
to be  the period of childhood ;  bad  nursing;  impure and confined air;
unnutritious or improper  articles of diet, and  deficient exercise; and
a disordered condition of the  digestive organs.   The  usual exciting
causes, are  irritations seated  in the stomach or intestines; retained
faeces, worms, &c.;  fright, violent  fits  of anger, injuries of the head,
difficult dentition, rheumatism, and  improper excitement as well as cer-
tain affections of the genital organs.  It has been stated that, in some
cases, a predisposition  to the  disease may be transmitted from parent
to child ; and this corresponds with the result of our own experience.
Like  all other convulsive diseases, chorea  may unquestionably be ex-
cited  by imitation, notwithstanding the fact has been  denied by recent
observers.
   The disease  has not  appeared to us to be much affected by atmo-
spherical influences ; it  is said, however, to be most  common in sum-
mer.   It appears to occur rarely in the southern hemisphere.  It is not
a very frequent disease  in Philadelphia.
   In  the treatment of chorea, the  first and  most important indication
is the removal or avoidance, as far as possible, of the exciting causes.
The means  for effecting this will, of course, depend upon  the circum-
stances of each case.
   The  remedies  that have  the greatest amount of evidence in their
favour  for the removal of the disease, are bleeding, active purging,
counter-irritants, antispasmodics, and tonics.
   L'leeding  from the arm, or from  the  foot, or by leeches from the
head  and upper part of the spine, has received the sanction of several
eminent practitioners, and cases have been published  in  evidence of
its  efficacy.  There will be found, we apprehend, but  few cases,
however, in which bleeding  will be indicated.  That the disease may
occur under circumstances and accompanied  by symptoms in which
the detraction of blood  will be demanded, we admit; thus, when it
attacks children of a plethoric habit, and is  attended by the indications
of cerebral  inflammation or hyperaemia,  a judicious and timely resort
to general or local bleeding will, no doubt, be productive of immediate
benefit, and  prepare the system for the action of other remedies. Such
cases, however, are of rare occurrence.
   Purgatives are a remedy of much  less  doubtful propriety.  As a
valuable adjuvant  to the  other means employed, there are few cases
in which they will not be indicated, while  in  those connected with a
torpid and loaded condition of the bowels, they will invariably produce
a decided alleviation, and in many, an entire removal of the symptoms.
From the time of Sydenham, there are few writers  on the disease,
by whom their employment is not strongly insisted on, while, by a few,
they are considered as almost  the only  remedy.
  In the early period of the attack, and in light cases, any of the pur- 
DISEASES OF THE NERVOUS SYSTEM.         443
 gatives which have the effect of promptly unloading the bowels with-
 out producing  much irritation or occasioning watery stools, will  be
 proper.  In the more advanced periods of the disease, however, and
 in the more severe cases, the  bowels are very apt to be affected with
 a very considerable degree of torpor, and for their evacuation will de-
 mand the more active purgatives, given in successive doses, in such a
 manner as to produce a full and continued operation.  Not only, how-
 ever, is it  necessary  in these cases,  effectually to  unload the bowels,
 but by a judicious use of purgatives, to maintain their regular action;
 not a day should  be allowed to pass, without one or two full evacua-
 tions being obtained.
    In the early stages  and ordinary forms of the disease, calomel, com-
 bined  with rhubarb or jalap, and followed by castor  oil, or infusion of
 senna,  with the addition of any of the neutral salts,  will answer;  but
 where  these are not found sufficiently active, the croton oil, or combi-
 nations of aloes, scammony, colocynth, gamboge and blue mass, may
 be employed.   A  very certain and  effectual  purgative,  in  cases  of
 chorea, is the spirits of turpentine, either alone or combined with cas-
 tor oil.   We have employed it pretty extensively, preceding its use by
 a full dose of calomel, and in  very few instances without  decided ad-
 vantage.3

    * R.—01. ricini,                    Or, R.—01.  ricini,
         Spir. terebenth. aa gss.—M.            Spir. terebenth. aa gss.
 It may be given in doses of a tea or dessert-          Tinct. sennas, giij.
   spoonful, according to the age of the pa-          Syrup, zingib. ijij.—M.
   tient, and repeated three  times a day or    ' Given in the same manner.
   oftener.

   In conjunction with  active purging, the use  of tartarized antimony
 has been suggested by Breschet, in as large doses as the stomach will
 bear without exciting  vomiting, which is carefully to be avoided.   By
 others, emetics repeated every other day, for a longer  or shorter period,
 according to the violence and obstinacy of the case, have been strongly
 recommended. We have no experience as to the efficacy of either plan
 of treatment, but  can  easily  conceive that cases  may occur, where
 the disease is either produced  or aggravated  by an  overloaded state
 of the  stomach, or the presence of  some  irritating  matter in that
 organ,  in which great benefit  may  result from emetics.   They can
 scarcely be considered, however, as  a remedy generally applicable to
 chorea.
   Counter-irritants have  been extensively employed  in the treatment
 of the disease, and doubtless in many cases, their effects will be found
 decidedly beneficial.   Blisters along  the spine are recommended  by
 Stiebel, Chisholm, and  a few others; but friction with  the tartar emetic
 ointment appears to be better adapted to produce a counter-irritant
 effect in cases of chorea.  It  is more prompt  in  its effects and more
 easily managed than blisters, and is, perhaps  even more  efficacious.
 Pustulation  with the croton oil along  the spine, has, also, been recom-
 mended, as  a valuable remedy  in chronic cases.
   In the treatment of chorea nearly the whole  list of tonics have been
prescribed, and  for the superior efficacy of each article the highest
authorities may  be cited.  Bark, and the salts of quinia, may be taken, 
444                DISEASES OF CHILDREN.
however, as the representation of the vegetable tonics, while in regard
to the mineral articles, the sesquioxide and  sulphate of iron, sulphate
of copper, oxide and sulphate of zinc, nitrate of silver, and  arsenite of
potassa, have, in different hands, been all found eminently  successful.
The testimonies in favour of  the  sesquioxide or protocarbonate of
iron in large doses, and of the sulphate of zinc, are perhaps the strongest.
The cyanuret of iron, in  the dose of three grains, three times a day,
in the form of a pill, has also been strongly recommended by Zollick-
offer.   The  cyanuret of zinc, in the dose  of one-third of a grain, twice
a day, gradually increased to fourteen grains in the twenty-four hours,
has recently been  highly  spoken of by the  physicians  of Berlin  and
elsewhere.   There is a very great  difficulty in pointing out the par-
ticular cases to which the one or other of these remedies  is the best
adapted.  Perhaps the safest  rule is to make trial of one, and if it does
not succeed, after it has been continued for a reasonable time, to sus-
pend  its use, and substitute another.   To derive any good from the
employment of either of them, will,  in general, require a perseverance
in its  use for some length  of time.
   With the exception of the arsenite of potassa, to  be noticed here-
after,  the sesquioxide of iron, the oxide of zinc, and nitrate of silver,
in combination with some one of the vegetable tonics, and occasionally
with a narcotic, are the articles which, in our hands, have  succeeded
the most promptly and generally in the removal of the disease.  We
have,  nevertheless, found  many cases to occur, in which the use of
one, and then of another, has appeared to  be unproductive of the slight-
est effect, when, on substituting a third,  the  morbid phenomena have
been very quickly, and permanently controlled.
   It is stated  by Dr. Babington, that the sulphate of zinc has seldom
failed in his  hands in curing the disease.   He found it necessary to
administer much larger doses, however, than are usually given; good
effects being seldom perceptible until twelve or fifteen  grains are taken
three  times   a  day.  By gradually increasing the quantity,  a  single
grain  at a time, even  much larger doses may, generally, be given,
without exciting sickness, and with the best effect.   Sulphate of zinc,
however, will not be  borne by some stomachs, in the  smallest dose;
and even the other mineral tonics can with difficulty be prescribed in
the cases of children in doses sufficiently large, or be continued suffi-
ciently long to derive from them in this disease a decided remedial
effect.  In such cases, the liquor potassae arsenitis, in doses of three
drops, gradually augmented to twelve, fifteen, or twenty, two or three
times  a day, according to  the age and strength of the patient and other
concomitant circumstances, may be prescribed;  it is certainly one of
the most powerful remedies we  possess, in cases of chorea: and when
cautiously employed, desisting from its use the moment  that any sick-
ness,  or griping pains, or intumescence of the  face or extremities
occur, we have found it to be a  perfectly safe and manageable article.
The testimonies in favour of its efficacy are numerous and  positive.
   Recently, very decided testimony has  been presented by Young, of
Pennsylvania, Lindsly, of Washington, Hilddreth, of Ohio, Kirkbride
and Professor  Wood, of Philadelphia, and  Beadle, of New York, in 
DISEASES OF THE  NERVOUS SYSTEM.         445
favour of the efficacy of the cimicifuga, in cases of chorea.  It may
be given in the dose of half a teaspoonful of the powdered root three
times a day;  or from one to two drachms of the saturated tincture, or
a wineglassful of the decoction.   We have prescribed it in a  number
of cases, and have been much pleased with its effects.
  Iodine has likewise been  employed, and it is said, with advantage.
  Nearly all the narcotics have been recommended by different writers,
and, for the relief of certain symptoms, their use would  appear to be
occasionally  beneficial.
  Opium was employed by Sydenham, after bleeding and purging, as
an anodyne at bedtime, and Cullen declares, from a good deal of expe-
rience, that opiates are  very generally successful in the  cure of chorea.
Opium^in the hands of other physicians, has, however, entirely failed
in producing any decided  relief; we cannot say that we have ever
known  it to  produce any good  effect in cases occurring in children.
Camphor has been  found  by Wilson, Richter, and Poissonnier, to be
beneficial in some cases, in  combination with tonics and the cold bath.
We  have occasionally employed it, in combination with the protocar-
bonate of iron, and extract  of gentian, with unquestionable advantage.
The belladonna, stramonium, and hyoscyamus, are all highly extolled,
especially by the German writers.  The latter we have employed very
extensively, as well in  combination with purgatives, as with the  me-
tallic salts; it is certainly, in most cases, a very valuable  adjuvant.
Graves employed it, in one  case, with the best effect.  The  strychnia
has been employed by Romberg, the veratria by Ebers, and the hydro-
cyanic acid by Stuart; of their  value we know nothing from our own
experience.
  Trousseau has  recently treated thirteen cases of chorea with strych-
nia,  ten of  them with complete success. He employs  the sulphate of
strychnia dissolved in  syrup, one grain to Siijss.; of  this two and a
half drachms are given daily in  three doses;  and the quantity is every
day  increased 3j|-, until itching of the scalp and slight muscular still-
ness are observed.  The cure is generally completed in one  month.
  The  tincture of the nux vomica we have  repeatedly employed, in
the dose of six  drops three times a day, and we are  persuaded with
decided advantage.
  In favour of the effects of  assafoetida, in large doses, we have very
strong testimony.
  In conjunction with the foregoing remedies, the cold  bath, especially
in the form of douche, will be found an important auxiliary.  Cases
are recorded by Crampton, Stiebel, Dupuytren, and  Rufz, in which it
was evidently productive of very great advantage.  Stiebel directs the
douche to be applied to the spine.  When too  severe a shock is  pro-
duced by the cold douche, the tepid or  warm  douche, or simple tepid
bathing, may be substituted.  We have seen the best effects produced
by daily sponging the entire surface with salt water, at  first warm, and
gradually reduced in temperature, until it can be used perfectly cold.
The whole surface of the body being submitted, immediately after the
sponging, to  brisk friction with flannel  or a flesh-brush.
  Sulphurous baths, made by dissolving about four ounces of the sul- 
446
DISEASES  OF CHILDREN.
phuret of potassa in about twelve bucketsful of water, and repeated
daily, have been employed with very decided success.
  A^ number of cases are cited by  Dehaen, Underwood, Fothergill,
Gordon, Baumes, Addison, and Bird, in which the entire and  perma-
nent cure of chorea is referred to electricity.  Its success in numerous
instances, appears now to be very well established.  In  the hands of
Dr. Bird, it is said to have cured twenty-nine out of thirty-six, and to
have produced relief in five of the remaining cases;  in one no benefit
was experienced, and one patient left, alarmed by the remedy.  In the
majority of instances, nothing else was  prescribed, excepting occa-
sional mild cathartics; which, in conjunction with other remedies, had
been used previously without advantage.   The electricity was  applied
in the form of sparks, taken in the  course of the spinal column, every
other day, for about five minutes  each time, or until an eruption ap-
peared which is  often caused by electricity when applied in this  man-
ner.  From the transmission  of  electric shocks along the affected
limbs no good whatever resulted, but on  the contrary, the involuntary
movements  were,  in every instance increased, often to  an  alarming
extent; and if the shocks were employed after the patient was conva-
lescent,  they invariably aggravated  every symptom, and  frequently
rendered the disease  as  severe as when  the patient was first placed
under treatment.
  In the paralysis which occasionally succeeds to chorea, the  proper
treatment will be  a course of tonics, particularly the preparations of
iron, shower-baths, and the regular exercise of the affected limbs.
  During the whole course of the disease, the diet should be light and
easy of  digestion ;  in cases attended  with hyperaemia, or evidences of
cerebral excitement, it should, of course, be very moderate in quantity,
and consist chiefly of  simple farinaceous articles; but in those  cases
in which tonics are indicated, it should be nourishing and more libe-
rally supplied.   Daily exercise in  the  open air, whenever it  can be
taken, is all-important to the success of the  cure.   A properly  regu-
lated course of gymnastic exercises, it is reasonable to  suppose, may
aid  the success of whatever remedies are employed, independently of
its  invigorating  influence, by  engaging  the attention of the  patient,
and teaching, as it were, the muscles to obey the direction of the will,
and to combine properly their actions.   A country residence is  to be
preferred to one in a  large city;  and  it would be still  better  if, with
the advantages of country air, the patient  could command those of
sea-bathing.
  The utmost caution must be observed, as well during the  disease
as  for some considerable time subsequent to recovery, to guard the
patient against the occurrence of  any of its exciting causes, whether
of a mental or  physical character.   If  the attack occur during the
period of dentition, a close attention  should  be paid to the condition
of the gums, and irritation from this  source counteracted by repeated
scarification.
  It is  hardly necessary to say, that any  disease with which the
attack of chorea may be complicated is to be  treated by its appro-
priate remedies,  and that the general remedial management of the case
must be modified accordingly. 
DISEASES OF  THE SKIN.
447
      SECTION   IV.

DISEASES OF THE  SKIN.
                        CHAPTER  I.

    ,       ERUPTIVE FEVERS —EXANTHEMATA. HO w+^t&j £ JpSUt-**' "

                          1.—Me^asles. Q.*,«***., * ^a*+.
   /|^£w>i«40</* *****   (RUBEOLA--MORBILLI.) 4H^4^M^>

   The eruptive or exanthematous fevers are characterized by a febrile
excitement, succeeded or accompanied by a specific eruption upon the
skin; which, in the majority of instances, appears, in each disease,
constantly  at a stated period, and runs a regular and definite course.
   The most  prominent of these  diseases,  the  measles, scarlet fever,
chicken-pox,  and small-pox,  are  manifestly capable of being propa-
gated by contagion; and the individual in whom any one  of  them
has occurred, is, as a general rule, ever afterwards sheltered  from its
recurrence, though he still remains equally liable to be attacked by all
the other affections of the class.   The only exception to this rule we
know of, is the well-established fact, that  the vaccine disease consti-
tutes a preventive to the occurrence of small-pox; though, if the  iden-
tity of the  two latter affections shall be established, as there is every            \
reason to believe it will be, if it has not been already, even this will,
in fact, form  no exception.

   The measles, strictly speaking, is a catarrhal fever, attended with a
specific eruption upon the skin.  It is, for the most part, a disease con-
fined to childhood;  though adults, who  have  passed through that pe-
riod, without being  attacked, are by no means exempted  from its oc-
currence.
   The disease is ushered in by the usual  febrile symptoms;  languor,
shivering, succeeded by increased heat of the skin, thirst, loss of  appe-
tite, &c.   To these are quickly added all  the usual phenomena of an
ordinary catarrh:—tenderness, injection,  and watering  of  the  eyes,
with a slight turgescence of the eyelids; the discharge  of a serous
fluid from the nostrils; frequent sneezing;  some degree of hoarseness,
with a sense of roughness or slight soreness of the fauces; a harsh, dry
cough, and some difficulty of respiration.  The head is affected with
pain, or a sense of stupor or drowsiness; the bowels are generally cos-
tive, and the  stomach not unfrequently rejects its contents.
   About the  fourth day, an eruption makes its  appearance upon the
skin ; first  about the forehead and chin, and then over the rest of the
face.   On the succeeding morning it is visible, also, on the neck and
breast, and by the evening it has spread  over the trunk, and finally 
448
DISEASES OF  CHILDREN.
  over the extremities.  The eruption on the face is most vivid, generally
  about the fifth day, and on  the sixth  begins  to fade.  By the seventh
  day the eruption on the body, which is at its  height on the sixth, be-
  gins to subside; while that  on the backs of the hands, which was the
  latest in appearing, is likewise the latest in subsiding, seldom begin-
  ning to fade before the eighth day.  By the ninth day, all that usually
  remains of the eruption on  any part of the body, is a  slight discolora-
  tion of the surface, that commonly disappears before the end of the
  tenth day.
    A desquamation, in the form of very minute scales, occasionally takes
 f place.upon the decline of the eruption, and  is usually  attended with a
k troublesome^ itching of4he\skin.   • >\, *.. ,.  »    v .,  ,   .    ,. i'v*i
    The eruption is,not cqqfined to the skin, but  extends also to the mu- •
  cous membrane; the fauces and  mouth being covered, at the height of
  the  disease, 'with' rebMish,  sligJitly elevated spots; which" are"1 often
  strikingly  visible upon the surface of the tongue.
    With the appearance of  the eruption, most  commonly, there is an
  increase of the cough and pain of the head,  and often  of the  fever,
  while the  difficulty of respiration, the injection and  suffusion of the
  eyes, and  the  other accessory symptoms, remain  without abatement
  until the eruption has finished its course.
    During  the  height of the disease there is usually a quick, frequent,
  full pulse, great.heat and dryness of the surface, loss of appetite, intense
  thirst, and a swollen, red appearance  of the face.  The eyelids are red
  at their edges, the conjunctiva is injected, the eyes humid  and brilliant,
  the nostrils dry and slightly reddened.  Breathing  through the nose  is
  attended with difficulty.  The respiration is but little accelerated.  The
  cough is hoarse and sonorous, or dry and frequent.  By  auscultation,
  sonorous or humid rhonchi may be detected.  There is sometimes slight
  soreness or pain of the throat, some degree of diarrhoea, and the nights
  are agitated or wakeful.  In severe  cases the evening exacerbations
  of fever are often attended  with delirium.
    As the eruption declines  the febrile symptoms  abate, the skin often
  becomes  moist, the cough  generally loses  its hoarseness, while the
  hoarseness of the voice continues, or is now for the first time apparent.
  The  rhonchi may still  be heard, or  they may augment  and become
  more humid.  The appetite now gradually returns, the thirst diminishes,
  the bowels become regular. The skin continues still to be marked by
  patches of a faded red or coppery hue, which  do  not disappear upon
  pressure.
    Upon the declension of the eruption, in many cases, a diarrhoea oc-
  curs—if it had not existed at an earlier period—which often appears
  to afford relief to the remaining symptoms.
    The above description applies  to the more marked cases of measles,
  uncomplicated with any other affection.  Not unfrequently, from undue
  exposure or other accidental causes,  at a more or less early period  of
  the disease, laryngitis, pneumonia, or  bronchitis, often of a very intense
  grade, occurs.  In these cases there is an augmentation of the cough,
  a continuation of the fever subsequent to the declension of the eruption, 
DISEASES OF THE  SKIN.
449
with, at the same time, a development of the phenomena proper to the
accessory disease.
  Occasionally a more or less copious diarrhoea comes on immediately
preceding the disappearance of the eruption, with pain or tenderness
of the abdomen, indicating the occurrence of disease of the alimentary
canal.
  In some cases the eruption  is  preceded by coma, or by partial or
general convulsions, and the other indications of encephalic disease.
  In some instances, when  the eruption disappears, the fever abates,
the child sits up, and has some return of appetite, but in place of con-
valescence becoming confirmed, the cough continues, the face becomes
pale, the patient weak, and gradually emaciated, the bowels are regu-
lar or affected with diarrhoea, and there occurs, towards  evening, a
slight febrile exacerbation.   These symptoms mark the  origin of some
chronic affection of the thorax or abdomen, which, after  running  a
longer or shorter course, terminates in death.
  In children of a scrofulous habit, there is apt  to  occur chronic in-
flammation of the deep-seated structure of the ear, and of the eyes and
edges of the eyelids;  with painful swellings of the lymphatic glands,
occasionally terminating in  suppuration, and followed by tedious and
extensive ulceration.  Meningitis, either  acute or subacute, may super-
vene in cases of measles; and the disease is liable to be succeeded by
gangrenous stomatitis, and  in  girls,  by a  peculiar ulceration of the
pudendum.
  In some cases the eruption occurs at a  very early period, as  upon
the second day ; whilst in others, the catarrhal symptoms continue for
two weeks or longer,  previous to the appearance of the rash.  Occa-
sionally, the eruption makes its appearance first upon the body, and
subsequently extends to the face; while, in a few instances, it has been
entirely confined to the face and trunk throughout the attack.  Cases
are referred to  by Frank, Willan, and Conolly, in which  the eruption
has declined, and then suddenly reappeared, together with the febrile
and catarrhal symptoms.
  By Vogel, Stanbach, Metgyer, and a few other writers, a variety of
measles is described, in which there is an absence of  fever, catarrh,
ophthalmia, &c, and which leaves  behind it a susceptibility to the
future occurrence of the genuine or febrile  variety.   This is the false
measles of most of the  German  writers, the rubeola sine catarrho of
Willan, and the rubeola sine febre of others.  An interval of many
months, even two years, may elapse between  the  occurrence of this
and the subsequent febrile rubeola; but  the latter, according to Bate-
man, more frequently occurs about three or  four days after the non-
febrile eruption.  Many of  the cases described as false or non-febrile
measles, were,  we suspect, cases of roseola.
  According to the observations of Dehaen, Morton,  Richter, Cons-
bruck, and Vogel, a rubeolous fever may occur unattended  by any cu-
taneous eruption; in other words, during the prevalence  of epidemic
measles, some  patients  are  affected with catarrhal fever,  without
measles.  If  the  observations of  Richter are to be depended  upon,
such patients are usually exempted from an attack of measles during
                               29 
450
DISEASES OF CHILDREN.
the subsequent continuance of the  epidemic, but we have no evidence
that they are less liable than the unprotected to the occurrence of the
disease subsequently.
   As the diagnosis in measles depends pretty much upon the character
of the eruption upon the skin, a close attention to its form and  general
appearance is of some importance.  The eruption usually shows itself
first in the form  of distinct, red, and nearly circular spots, resembling
in their general  appearance, very  nearly, the areola of ordinary flea-
bites, though probably not quite so large.  As these spots increase in
number, they coalesce, forming  small, irregular patches, approaching
the nearest in shape to semicircles or  crescents; these patches are in-
termixed with the single circular spots, and separated  by interstices in
which the  skin  retains its natural hue.   The redness disappears on
pressure, and returns immediately afterwards.  On the face  especially,
the eruption is slightly raised above the surface of the cuticle, so as to
give a feeling of roughness or inequality of surface to the finger when
passed over the skin.  The whole  face is often sensibly swelled at the
height of the eruption; and  occasionally, in violent cases, the tume-
faction of the eyelids is so great as to close the eyes for a day or two.
In many cases, miliary vesicles appear upon the neck, breast, and arms,
during the height of the eruption; while papulae occasionally occur on
the wrists, hands, and fingers.
   Before the eruption disappears its redness becomes fainter, and more
dusky, and it is diminished in extent, leaving, upon pressure, a yellow
spot.
   Heim notices a peculiar odour as attendant upon the measles during
its first six days.  He compares it to the smell of the feathers of the
goose  recently plucked.   Heyfelder states that he perceived  it, par-
ticularly  when a number of patients were collected  in a small apart-
ment, and when  the  eruption was  intense.  He describes  it as more
decided in the morning than in the evening.  Meissner,  Wildberg,
Rilliet and  Barthez  never perceived it, and  we may say the same
for ourselves.
   The autopsical appearances will vary, of course, according to the
period when death has taken place, and the nature of the concomitant
disease by which the fatal event has been produced.
   Measles  in its simple  form, uncomplicated  with  any severe pul-
monary,  gastro-intestinal, or  cerebral  affection, is seldom, of itself, the
cause of death.   Although the symptoms attendant upon the disease,
indicate more or less bronchial affection, the exact nature  and extent
of this, it is impossible  to determine with any degree of certainty.
The mucous membrane of the trachea, oesophagus, and the  surfaces
of the abdominal viscera generally, have been said to present, when
the case has terminated  fatally during the eruptive  stage, the same
species of exantheme as  the skin.
   In some cases, effusion of lymph mixed with blood or pus, has been
found in the cavity of the thorax; in  others, inflammation of the sub-
stance of the lungs, with extensive effusion in  their texture; in others,
extensive bronchial or pneumonic inflammation; and in others, again,
condensation of the pulmonary tissue, as in cases of pneumonia. 
                    DISEASES OF THE  SKIN.                451
                                                               •
  The morbid  appearances present in  the cases examined  by our-
selves, were, the various lesions observable in severe cases of bron-
chitis, and of lobar and lobular pneumonia; oedema of the lungs, ex-
tensive engorgement  of their blood-vessels, with  effusion  of bloody
serum  in the air-cells and minute bronchial ramifications;  tubercula-
tion  of the  lungs, and  of  the  serous membranes generally;  gastro-
enteric inflammation; follicular inflammation, and occasionally ulcera-
tion  of the  ileum  and colon; enlargement of the mesenteric glands,
and  meningeal inflammation, particularly  at the basis of the brain,
with  tubercular deposition,  and effusion  within  the  ventricles and
arachnoid cavity.  There was no case in which some degree of bron-
chial or pulmonary disease did not exist; in a very large number there
also existed indications  of more or less disease of the gastro-intestinal
mucous membrane.  The indications of cerebral disease were the least
frequent.
   The most usual forms under which measles presents itself, are the
simple catarrhal, which we have described—the congestive, and the
gastro-intestinal.
   The congestive  form of the disease is marked by imperfect reaction,
and  occasionally its entire  absence;  a general depression of the ener-
gies of the system; pallor  of the face;  a sunken and anxious expres-
sion of the countenance; torpidity  of  the bowels;  a slow, weak,
oppressed pulse; slow and oppressed respiration, and  coldness of the
extremities.  The  eruption may not appear, or  it occurs- slowly on
some portions  only of  the surface.   If reaction does  not  take place
spontaneously,  or  is not induced by an appropriate treatment, stupor
or deep coma,  and occasionally, convulsions, ensue.  In some cases,
symptoms of congestion ensue after the eruption has made its appear-
ance; in these cases, the  latter either  becomes of a pallid or livid
hue, or entirely disappears.  In those instances in which an autopsic
examination has  been  made,  extensive engorgement of the pulmo-
nary vessels, and, generally, of the  vessels of  the brain,  also, were
detected.
   The congestive  form of  measles is said to occur most commonly in
infants, and children of a feeble and relaxed habit.  We have not, how-
ever, found it to be confined to any particular age or constitution.  In
some epidemics it occurs  much more frequently than in others; we
have met  with it more often,  however, in confined  and unhealthy
neighbourhoods, than in those of an opposite description.
   When measles  is complicated with  gastro-intestinal disease, it  is
ordinarily accompanied by a less decided febrile reaction, a small and
feeble, though  generally frequent pulse, and considerable  pain of the
forehead.  A sense of  tension and  fulness is  usually  experienced at
the epigastrium, which  is more or less tender upon pressure.  Vomit-
ing  and profuse diarrhoea  often precede  or follow the appearance of
the eruption, which is pale, and often indistinct.  The skin is dry and
harsh, but  seldom  much increased in temperature.  The tongue is dry
and brown, and often the patient complains of frequent sharp pains in
the  abdomen.  There  is considerable thirst,  and occasionally great
restlessness, dyspnoea,  and  an anxious expression of countenance; 
452
DISEASES  OF CHILDREN.
particularly on assuming an erect posture.  The cough  is short, dry,
and almost incessant.
  In some cases, particularly in young and irritable children, great
difficulty of respiration, and a sense of oppression  in the chest, will
suddenly ensue.
  The patient may sink under the ordinary symptoms of fatal gastro-
intestinal  disease, or  of pulmonary inflammation; or  symptoms  of
cerebral  inflammation  may ensue, quickly terminating in coma, con-
vulsions, and  death.
  In its  simple,  uncomplicated form, measles  is ordinarily a disease
attended with very little danger; and so mild  in its  symptoms as  to
run its course and terminate favourably, without the necessity of any
very active interference on the part  of the practitioner.   Although  in
every case it is  requisite  to employ a precautionary  treatment,  to
guard  against the occurrence of violent  or unfavourable symptoms,
yet, as a  general rule, active remedies will neither be necessary nor
proper.  When, however, the disease becomes complicated with severe
affections of  the respiratory organs, alimentary canal, or brain, it  is
invariably attended  with considerable danger, and will often  prove
fatal even under the  most prompt, judicious, and energetic  course  of
treatment; while its occurrence, under all circumstances, in children
of a feeble and debilitated constitution, or who, from any cause, are
strongly predisposed to disease of the lungs or brain, is  to be viewed
in an unfavourable light, as in such, it is very apt to prove the exciting
cause of some of the most unmanageable and fatal maladies to which
the infant constitution is liable.
  As  a  general rule, an  individual who has  suffered  an  attack  of
measles,  is not subsequently liable to reinfection; instances, however,
have occurred of a second attack, several of which have fallen  under
our own  notice.
  Measles usually occurs as an epidemic, often of very considerable
extent.  Of the particular state or condition of the atmosphere upon
which the production of the disease depends, we know nothing.  Epi-
demics of measles are said by Sydenham to commence, generally,  in
the  month of January, and to cease soon after the  summer solstice.
According to our observations, they are very apt to occur at the same
seasons, and  under nearly the same sensible conditions  of the  atmo-
sphere, as epidemic catarrh.  Sporadic cases of the disease may occur
in almost every month of the year:—they have occurred in the midst
of summer.
  Whether measles is capable of being propagated by contagion, is
still a disputed question ; although the affirmative is generally assumed,
there are many who  maintain  the negative.  The disease, it  is said,
occurs always as an epidemic, and on its first appearance a number
of individvals are invariably simultaneously affected; while it cannot
be traced from house to house, or from street to street, as in small pox
and scarlatina.   There can be no doubt, however, that measles may
be communicated by inoculation.   Dr. Hume, for this purpose, drew
blood from a cutaneous vein where  the eruption was most confluent,
and applied a dossil of lint impregnated with this, to a wound made  in 
DISEASES OF THE SKIN.
453
 the arm of the individual to whom the infection was intended to be
 communicated.   Of the general certainty and value of the operation,
 it is impossible to form any positive conclusions from the few instances
 in which it has been practised.
   By a recent notice in one of the Austrian medical journals, it appears,
 however, that Dr. Katona, of Borsoder,  in Hungary, has tested, in a
 large, number of  cases, the efficacy of inoculation for measles.  In a
 very fatal  and wide-spread  epidemic, which  prevailed during the
 winter of 1841,  he inoculated 1122  persons with a drop of fluid
 from a vesicle, (?) or with a drop of  the tears  of  a patient affected
 with the  disease; the fluid being inserted in the same manner as the
 virus in vaccination.  The operation succeeded  in  about 93 per cent.
 of the cases in which it was performed—producing a mild attack of
 measles.  A red  areola at first formed around the puncture by which
 the  fluid was inserted, but soon disappeared.   On  the seventh day,
 fever commenced, with the usual  prodromi of measles;  on the ninth
 or  tenth  day, the eruption made its appearance; on the fourteenth,
 desquamation commenced, with a decrease of the  febrile symptoms,
 and by the seventeenth day the patients were very generally perfectly
 well.  In no one of the  inoculated  cases did the  disease terminate
 fatally.
  Although no age is absolutely exempt from an attack of  measles,
 the most common period  of its occurrence is from that of weaning to
 the age of puberty; after which latter period, the older the patient the
 more troublesome and dangerous it is generally said the disease proves.
 A late writer (Montgomery) dissents  from this  doctrine, and  states,
 that from his own observations he should pronounce a directly oppo-
 site opinion; which corresponds precisely with our own experience.
   The only  disease with which there  is any risk of  confounding
 measles,  is scarlatina; from  which, however, it may be very readily
 distinguished by the following circumstances:—The distinctly-imarked
 catarrhal symptoms by which the eruption in measles is preceded and
 accompanied, and their absence in scarlatina; the appearance  of the
 eruption  in measles being seldom  very evident until the  fourth day;
 whereas that of scarlatina  usually appears on the second day of the
 fever.  In measles, the colour of the eruption is dark scarlet, or of a
 raspberry hue ; while in scarlatina, it is of a vivid red, resembling the
 hue of the lobster after boiling ; the eruption in the latter is also much
 more full and extended than in the former, forming large, irregular
 patches, which often coalesce, so as to cause a uniform  redness over
 a considerable extent of surface.
  In the  treatment of an ordinary case of measles, the attention of the
 practitioner should be chiefly directed to the fever and catarrhal symp-
toms, which, when they are mild, the eruption  at the  same time follow-
ing a regular course, will demand little  else than a cautious attention to
preserve  the body of the patient of an equable temperature,  and to
prevent exposure  to cold or damp; to place him  upon a spare, simple,
and unirritating diet, and to keep his bowels regular, by the occasional
use of mild purgatives; while we endeavour to mitigate his cough by 
454
DISEASES OF CHILDREN.
plain demulcent drinks, rendered more palatable by the addition of a
small portion of some vegetable acid, as lemon juice, or the like.
  The patient  should  be kept at rest, and in a large, well-ventilated
apartment, of a suitable  temperature, and free  from currents of cold
air.  His drinks should  be taken rather of tepid warmth  than cold.
When the cough is troublesome, the inhalation of the steam of warm
water, will, in many cases, if the patient is sufficiently old to conduct
the inhalation properly, prove an excellent palliative.   In some cases,
a pediluvium at bed-time, followed by a dose of Dover's powder, will
cause the patient to sleep, and mitigate the more troublesome catarrhal
symptoms.
  We are persuaded  that in all cases, an emetic of ipecacuanha or
tartarized  antimony, administered in  the early period  of the attack,
and followed by a full  dose of calomel combined with  magnesia—the
operation of the calomel being promoted by a dose of castor oil given
a few hours  subsequently—will  be found beneficial, by rendering the
course of the disease  milder, and the  occurrence of severe bronchial
or  pulmonary inflammation  less frequent.  It is a  practice we have
followed for many years, and invariably with the best effects.
   When the febrile excitement is considerable, with a  good deal of
dryness and heat of the skin, the  employment of antimonials, or  the
milder diaphoretics will be  demanded.*  When the catarrhal symp-
toms are  very severe,  the  same remedies  will be necessary as in
severe cases of ordinary catarrh.
* R.—Mucilag. g. acacise, 3"j.                Or R.—Liquor, acetat. ammonia, 3vj.
     Syrup. Timonis, gj.                          Spir. seth. nitr.
 -   Spir. seth. nitr. 3iij.                         Vini antimonii, aa 3nj.
     Tart, antimon. gr. j.—M.                     Syrup, limonis, 3 ij-—M.
Dose, a teaspoonful every three hours.           Dose, the same as the above.
                  Or R.—Ammonias hydrochlor.
                        Pulv. ext. glycyrrh. aa 3iij-
                        Tart, antimon. gr. j.
                        Aquae, gviij.
 Dose, a teaspoonful every three hours, for a child under two years of age, and a dessert-
          spoonful every two or three hours, for one over two years of age.

   In regard to  the employment of bloodletting in severe cases of mea-
sles, there appears to he very little difference of opinion; most practi-
tioners concurring in its  recommendation.  Some difference of senti-
ment has, however, existed  as to the most appropriate  period for its
employment; some directing it  only during the height  of the eruption;
others postponing it until the eruption has subsided; while others again
consider it equally proper at any period of the disease, when symp-
toms are present which call  for its use.   The proper rule, however, is
easily laid down.  Whenever great shortness or difficulty  of respira-
tion; a  full, hard, and quick pulse; great heat and dryness  of the sur-
face ; a frequent  dry, harassing cough, with severe pain in the chest
or head; and, more  particularly, if the physical  signs of extensive
bronchial or pulmonary inflammation are  present—the abstraction of
 blood to an extent sufficient to relieve these symptoms, will be proper
at any stage of the disease,  but more particularly if the above symp-
 toms supervene at the period when the eruption disappears.  Of course, 
DISEASES OF THE  SKIN.
455
 in  directing the  extent and  repetition of the bleeding, due attention
 must be paid to the age and  vigour of the patient.
   Under the circumstances just recited, not only general bleeding, but
 cups to the chest, antimonials, and blisters—in  fact, all  the remedies
 demanded  in ordinary cases of severe bronchial and pneumonic in-
 flammation will  be necessary, and upon  their prompt and judicious
 employment will the safety of the patient in  a great measure depend.
   Exposure to cold air, or even the use of the cold affusion, which has
 been found so  beneficial in scarlatina and other of the exanthemata,
 has likewise been recommended in  measles.   In  the latter disease,
 however, it  is a remedy of, to say the least, very doubtful propriety.
 It certainly would appear to  us to be calculated to augment the catar-
 rhal and pulmonary affections, which, in the great majority of cases,
 are unquestionably the most  serious features of the disease.
   In the congestive form of measles, the remedies best adapted to pro-
 mote reaction, and to relieve the oppressed state of the interna] organs,
 are, 1st, Emetics, the action  of which  has been found among the  very
 best means of  favouring the  eruption upon the surface, and unloading
 the engorged vessels of the lungs.  2d, The warm bath.   Immersion
 in the bath should succeed the operation of the emetic, and be followed
 by brisk friction  over the whole surface, with the hand, or  a soft flan-
 nel.  3, Blisters or sinapisms to the extremities, and to different parts
 of  the surface, particularly in the neighbourhood  of the organs which
 appear to be the most oppressed.  There are few of the more violent
 cases of congestive measles, in which these remedies will not be found
 of decided advantage.   In their application in young children, and in
 debilitated subjects, caution should be observed not to allow them, par-
 ticularly the blisters, to remain on too long, but to remove them  in one
 or two hours, the sinapisms in a much shorter period, and to substitute
 large  emollient cataplasms.  4th, Diaphoretics.  The choice of the
 diaphoretic will  depend, in a great  measure, on the urgency of the
 symptoms.  In most cases,  the Dover's  powder, a combination of cam-
 phor, ipecacuanha, and extract of hyoscyamus,a or of the  acetate of
 ammonia, aqua camphorata, wine of ipecacuanha, and tincture of hy-
 oscyamus,1' will be proper; the patient,  at  the  same  time, drinking
 freely of some tepid fluid.  5th, Bleeding.  In a large number of the
 congestive cases of measles, a  cautious  abstraction of blood, either
 from the arm, or  by cups, from about the head and chest, particularly
 after the operation of an emetic, and the warm bath, will often produce
 very decided relief.  The  effects of the bleeding, however, should be
 carefully watched; and the quantity of blood abstracted, or the neces-
 sity for the immediate cessation of the bleeding,  should be governed
 by the degree of relief obtained, and the effects upon the pulse.   If the
 symptoms  of oppression are  evidently diminished, and the pulse be-
 comes fuller and  more free under  the  bleeding,  it may be  continued,
 within moderate  limits; but  if the oppression is augmented, the ex-
haustion  of the patient increased, or the pulse sinks, these are signals
for the immediate suspension of the operation, and the administration
of some  gentle stimulant, of which the  best is, perhaps, the carbonate
of ammonia, in combination with camphor. 
456
DISEASES OF CHILDREN.
* R.—Pulv. camphor, gr. iv.—vj.          b R.—Acetat. ammonim liquor. 3iij.
     Magnes. calc. Qijss.                   Aqua camphorce, 3ij.
     Pulv. ipecac, gr. iij.                    Vin. ipecac. 3ij.
     Ext. hyoscyami, gr. vj.—viij.—M. f. ch.     Tinct. hyoscyami, 3"j.
       No. xij.                           Syrup, zingiber, 3j.—M.
One for a dose, to be repeated every one, two   A teaspoonful for a dose; to be repeated
 or three hours, according to circumstances.     every one, two, or three hours, accord-
                                      ing to circumstances.

  When, in the course of the disease, the eruption suddenly recedes,
or becomes of  a pale or  livid hue, and symptoms of severe oppression
of either of the internal  viscera occur, nearly the same remedies will
be demanded.  Bleeding  will, in such cases, when cautiously employed,
generally be found benefioial; and if a state of deep coma ensue, cups
to the  head, sinapised pediluvia, followed by sinapisms or blisters to
 the extremities, should not be neglected.
  In regard to  the  administration of stimulants, to bring out, as it is
termed, the eruption, some degree of caution is invariably to be ob-
served.  That  there may occur cases  in which, from a deficiency of
vital energy, the specific action upon the surface of the body does not
take place, or suddenly  ceases, and  symptoms of a very violent cha-
racter  ensue, we are not inclined to deny, though such cases  have
never fallen under our notice.   Under such  circumstances, the warm
bath, and a judicious use of external and internal stimulants, would
unquestionably be demanded, to remove the  extreme danger there ex-
ists of the patient speedily sinking.  But before venturing upon the use
of stimulants, the practitioner should  be very certain that the non-ap-
pearance, or retrocession of the eruption, and the symptoms of oppres-
sion, do not depend rather upon extensive central congestion, than upon
 mere debility;  recollecting that  in  cases of congestive measles, the
incautious  administration of active stimulants internally, is, in nearly
every instance, positively mischievous.
  It occasionally happens that about the seventh or eighth day of the
eruption, the latter  suddenly assumes upon different parts of the body
 a livid appearance, with an intermixture of yellow.  This  constitutes
the rubeola nigra, of some writers.   Such an occurrence has caused
often much alarm, it being viewed as the indication of imminent dan-
 ger ; we are  assured, however,  that such  symptoms very speedily
 give way,  under the use of the mineral  acids.
   The gastro-intestinal symptoms with which  measles are occasion-
 ally complicated, require to be treated on  general principles.   The
 warm  bath, leeches  to the epigastrium or to  the surface  of the  abdo-
 men, followed  by emollient cataplasms; with small doses of calomel,
 ipecacuanha, and extract of hyoscyamus, in combination, and  a pro-
 perly regulated diet, are the chief remedies demanded.   When a pro-
 fuse serous diarrhoea occurs, this should be  promptly arrested, by the
 administration  of the acetate of lead, by the  mouth or in  enema.  We
 should recollect,  however, that  a  moderate  diarrhoea  is, generally
 speaking, rather beneficial than injurious, particularly when it occurs
 towards the termination of the eruption ; we should, therefore, unless
 it be attended by prominent symptoms of gastro-intestinal disease, re- 
DISEASES OF THE  SKIN.
457
 frain from interfering with it, especially in robust and plethoric sub-
 jects.
   During convalescence, the utmost care should be taken to  guard
 the patient from  the influence of cold and damp.  Even during the
 warm season, he should  not be allowed to go out of doors, excepting
 in the middle of the day, and in dry weather.  His diet should be light,
 nourishing, and unirritating; every  species of stimulating drink should
 be avoided.  The use of the warm  or tepid bath daily, will always be
 advantageous.
   It is said that when any cutaneous disease occurs after measles, the
 internal  organs are seldom liable to become affected;  and that even
 when some internal disorder has already  existed, it has disappeared
 on the occurrence of a spontaneous eruption  upon  the skin.  We
 should, therefore, be cautious  in interfering with  vesicles, pustules,
 boils, and the like, when  they occur subsequent to an  attack of mea-
 sles.
   Various diseases may  remain  or occur upon the decline of the erup-
 tion,  which require great  attention,  as  they  are often exceedingly
 troublesome, and attended with even greater danger than the  original
 malady.   They are usually bronchial or  pulmonic inflammation, and,
 occasionally, inflammation,  either acute or subacute, of the intestinal
 canal.  In a large number of instances, these may be entirely prevent-
 ed, or rendered more manageable when they do occur, by a proper
 treatment of the measles from its commencement.   When they present
 themselves, they must be treated in  accordance  with their  character,
 extent, and violence, and the condition of the patient's strength.

               I.—Scarlet Fever.—Scarlatina,
   Scarlatina, in its mildest and most simple form, is a  febrile  exan-
 theme, characterized by  a diffused  efflorescence, of a  bright  scarlet
 colour, which appears upon the  surface of the body,  usually on the
 second day after the occurrence of  the fever, and terminates in  a des-
 quamation of the cuticle,  at the end of about five days.  Most com-
 monly, however, it is accompanied with a  severe  affection of the
 throat, or of some one or other of the internal  organs,  by which  its
 symptoms and progress are  very considerably modified, and the dis-
 ease, which in its regular and uncomplicated form, scarcely demands
 the interference of the physician, becomes  then one of the most unma-
 nageable and destructive  to which children are liable.
  In consequence of the various modifications under which it presents
 itself, in the same, or in different epidemics, scarlatina has been divided
 by practical writers into several varieties.  Those most commonly re-
 cognised are, the scarlatina  simplex  ; the scarlatina anginosa ; and the£ ^%^ms
 scarlatina maligna.   The last of these denominations is particularly JbWJjL
 objectionable.  The term malignant is, to say the least of it, indefinite; jjjj^fo
 while from its former, and even now very common application, it is
extremely apt to lead to erroneous views, in regard to the nature and
proper treatment of those affections it is employed to designate.  To
the above varieties, some writers add a fourth,  in  which, from expo-
sure to the contagion of scarlatina, the throat alone becomes affected, 
458
DISEASES  OF CHILDREN.
without any eruption occurring upon the skin.   This, however, cannot,
with strict propriety, be considered as scarlet fever.
   The malignant form of scarlatina has, with an approach to greater
clearness and precision, been divided by Armstrong into three  varie-
ties: the highly inflammatory, the highly congestive, and the irregular
congestive.
   We propose to consider the disease under two divisions only:—1st.
The  inflammatory,  including the simple  and anginose  varieties of
Willan, and the  highly inflammatory of Armstrong.   2d.   The con-
gestive.

                  Inflammatory  Scarlatina,
   To distinguish the different modifications of this form of scarlatina,
and the consequent variations of treatment  that is demanded, we shall
describe it as it  occurs:—1st. Under the form of simple excitement;
2d. Attended with inflammation of the fauces; and 3d. With inflam-
mation of one or more of the internal organs.
   The disease seldom  manifests itself until  from about the third to the
fifth day subsequent to exposure.
   In its mildest  form it is usually ushered in  without  much rigor, or
disturbance of the stomach;  but there is always present more or  less
pain, or uneasy  sensation in the head, restlessness, and lassitude, with
paleness of the face, and a weak pulse.  These symptoms may con-
tinue from one to three days, when they are succeeded by a general
febrile reaction.
   It is usually on the second  day after the occurrence  of the febrile
excitement, that the efflorescence upon the  skin begins to  show itself,
first about the face and neck, in innumerable red points, which, within
the space of twenty-four hours, are to be seen over the whole surface
of the body.  As the points multiply,  they coalesce  into  small irre-
gular patches; and, by the third day, the eruption presents a  diffuse
and continuous efflorescence over  the limbs, and  around the fingers,
giving to the skin a colour somewhat similar to that of the shell of a
boiled lobster.
   Upon the body, the  efflorescence is seldom continuous, but is distri-
buted  in  diffused irregular patches;  the scarlet hue being most vivid
about the flexures of the joints, and  around the loins.  The efflores-
cence is often accompanied with  a perceptible  roughness of  the skin,
which  is most  evident  upon the extremities, and front of the body,
giving a sensation as if the surface was covered with  granules.  This
is caused by an enlargement of the cutaneous papillae.
   Where the redness of the skin is most intense, and particularly when
the  patient has been  subjected to a heating  regimen, small miliary
tvesicles occasionally appear upon different  parts, more generally upon
the trunk.  About the  fourth or fifth day of the efflorescence, an erup-
tion of semi-globular vesicles, filled with a thin pearl-coloured  serum,
is occasionally  observed about the forehead, neck, chest, shoulders,
and extremities. They vary in size, and succeed one another without
determinate order.
   The efflorescence is not confined  to  the surface, but extends over 
DISEASES OF THE SKIN.
459
the mucous membrane of the mouth and fauces, and even of the nos-
trils, and is occasionally visible upon  the adnata  of the eyes.  The
papillae  of  the tongue, also, are considerably elongated, and  project
their scarlet  points through the white  coat with which the surface of
the tongue  is covered.
   On the fourth  day, the eruption is usually at its height; and  on the
fifth, begins to decline by interstices, leaving the small  patches as at
first;  on the sixth it  is very indistinct, and is generally entirely gone
before the termination of the seventh day; a desquamation of  the en-
tire cuticle taking place, which often occupies many days before it is
entirely completed.
   Early in the stage of excitement, there is most generally experienced
some degree  of soreness, or a  sense of fulness in the throat, and the
voice is not quite so clear and  sonorous as ordinary.
   The skin, from the excessive injection of its blood-vessels, becomes
morbidly sensible, dry,  and hot.  Its  temperature seldom, however,
exceeds  103 degrees of Fahrenheit.  The lips are of a  vivid red ; the
face is  flushed and somewhat tumid, and the tongue is covered upon
its centre with a  white mucus,  but is red around the edges.  The pulse
is, in  general, increased in  strength and quickness, but seldom  rises
above 100 or 110 in the minute.   The thirst is seldom very urgent;
the appetite is lost, and the bowels are  costive; and when evacuations
are obtained, they are frequently of a  much darker hue than natural.
The febrile symptoms slightly remit towards morning, but gradually
increase during the course of the day,  and  attain their  greatest inten-
sity in the evening, when some degree  of delirium is often present.
   The stage  of excitement seldom continues longer than  from  four to
five days, when it gradually subsides;  the pulse becoming slower and
softer, and  the skin cooler and more relaxed.
   The foregoing description is that of  the most  usual form of simple
scarlet fever; which seldom continues  longer than  fourteen days, and
is occasionally of shorter duration.   Its termination is very generally
favourable; the  first stage being attended with but a slight degree of
visceral  congestion, the second  being  marked with general, but short
and moderate excitement, which is succeeded by no serious collapse.
   In its course, however, either suddenly or by degrees, symptoms of
a more decidedly inflammatory character may become developed, and
the throat being  now more deeply affected, the case assumes the angi-
nose form of scarlatina.
   Scarlatina anginosa commences nearly in the same  manner as the
simple form.   It  is generally ushered in, however, by a greater  degree
of chilliness,  headache, and  restlessness.  There is a sense  of greater
oppression at the praecordium, with prostration of the voluntary powers,
nausea,  retching or vomiting.  The eruption  upon the skin generally ,
appears within the  first three  days, and about  the same period the
fauces become red and swollen, and the patient complains of a stiff-
ness in  the neck and jaws, and a fulness and soreness of the  throat,
particularly in speaking or swallowing.  The  pulse is quicker  than in
the preceding form, there is also greater thirst, and more  uneasiness
of the head; the tongue is drier and redder at its edges, and the heat 
460
DISEASES OF CHILDREN.
of the  surface is  more elevated, ranging from  106° to 108° or 112°.
The discharges from the bowels are darker, and of a more bilious ap-
pearance.  The evening  exacerbations are more intense, and  more
often attended with delirium, during which the patient, if alone or  in
the dark, talks much to himself.
  The efflorescence does  not pervade so generally the surface of the
body, in  the anginose as  in the simple form; but  usually occurs,  in
scattered patches, on the  chest and arms.   In some cases, it is con-
fined to the back of the hands and wrists, and sometimes entirely dis-
appears on the second day, and  partially reappears at uncertain pe-
riods.  When  the eruption is slight, or speedily disappears, it is often
not succeeded  by desquamation.   In other instances, however, des-
quamation continues often to the end of the third week, or even longer;
large portions  of the cuticle occasionally separating, particularly from
the hands and  feet.
  When the  febrile symptoms  begin to abate within  the first four  or
five days, the tonsils and fauces are seldom covered with membranous
exudations; there is merely an increased secretion of tenacious mucus,
some of which often adheres to  the fauces; and the constant efforts
made by the patient to expel this, increases his sufferings.  But, when
there is  a longer  continuance or higher grade of febrile excitement,
small patches of a grayish hue  are observed  upon  the tonsils and
fauces, which  are often  mistaken for sloughs;  hut by gargling the
throat of the patient, the exudation may frequently be removed, when
the mucous membrane beneath will be found entire.  The exudation is
renewed from time to time, and  frequently  extends  into the lateral
parts of the pharynx and oesophagus, but seldom into  the larynx or
trachea.  As  the  fever  declines,  which is frequently about the eighth
day, the patches of exudation separate, and leave the fauces somewhat
redder than natural, but free from ulceration.
   It occasionally happens, however, that instead of so favourable a
termination, symptoms of a much  more alarming  character arise in
the progress of the disease;  the patches in the throat acquire a darker
colour, and the secretions from the fauces and nostrils become highly
offensive, causing  considerable foetor of the breath; painful indurations
of the glands of the neck ensue, and the patient is troubled with griping
pains of the abdomen, with tenesmus, or diarrhoea.   In  some cases, a
state of collapse quickly ensues, and terminates promptly in death.
   One of the  most common and remarkable accompaniments of scar-
latina anginosa, remarks Rilliet and Barthez, is an inflammatory intu-
mescence of the submaxillary glands, which  in general  presents itself
the day subsequent to  that  upon which the swelling  occurs  in  the
pharynx.  There then takes place a swelling, painful to  the touch, and
 sometimes tense and red.  The inflammation is at first confined  to  the
 glands, but in many cases  soon  extends to  the  surrounding cellular
 tissue, often producing an enormous tumefaction, reaching around  the
 front of the throat from ear to ear, and preventing the jaw from  being
 opened wider than just to permit the  tip of  the patient's tongue to be
 protruded.  Ordinarily,  the  swelling is  produced  by an oedematous
 condition of the cellular tissue of the throat, and quickly  disappears as 
DISEASES OF THE SKIN.                46]
the inflammation of the glands diminishes.  Occasionally, however, a
suppuration  takes  place, commencing either  in the glands or in the
cellular membrane, and an abscess occurs, which is always a very un-
favourable result.  The inflammation sometimes attacks the skin, when
suppuration  takes place still more readily.
   In other cases, during the stage of excitement, symptoms of cerebral
disease manifest themselves, and the patient dies comatose, about the
end of the second week.  Not unfrequently, also, there  occur  slight
pain, tenderness, and tumefaction at  some  part of the abdomen, with
increased frequency of the  pulse  and respiration.  The pain and ten-
derness of the abdomen quickly increase in intensity, and are, at length,
attended with vomiting, eructation, general restlessness, and a tympa-
nitic condition of the abdomen.                                             \
   At the end of six, seven,  or  eight days, the pain and tenderness
diminish or disappear; the pulse  grows more rapid and feeble; the
respiration more anxious, and  the vomiting more urgent. Cold, clammy
sweats, and universal collapse now speedily ensue, and are the imme-
diate precursors of death.
   In  many cases, there is  a  much greater tendency to inflammations
of the serous membranes of the brain or of the thoracic or abdominal
regions, than of the substance of the  organs.
   Not unfrequently, the anginose form of scarlatina, is attended with
a very intense degree of febrile  excitement; the inflammation  of the
throat runs very quickly into a  gangrenous condition;  and  there  is
often severe cerebral excitement, with redness of the eyes, intolerance
of light, and a throbbing pain of the head, with tinnitus aurium, watch-
fulness, confusion  of  mind, and  delirium.  To these symptoms, there,.
may succeed a state of stupor, occasionally interrupted by loud screams, •  *  * »* •<
or by fits of violence or of fretfulness.                                * x * * v
   In other cases of scarlatina, symptoms of severe  abdominal inflam-  *<^ "»"»V
 mation  ensue; considerable  pain, increased upon pressure, with ten-       0$
sion, fulness, and heat of the abdomen;  short, quick, anxious respira^   ».1
tion ;  very  quick, contracted pulse; considerable  irritability of the   »l»«v'*»
stomach, and either a costive state of the bowels or diarrhoea.
   In other cases, again, neither the head  nor abdomen seems so deci-
dedly affected ; but the greatest uneasiness is referred to the respiratory
organs—the trachea, bronchi, pleura, or lungs.  Whatever maybe the
organ or organs affected, the stage of excitement is of short duration,
and is succeeded by a greater or less degree of collapse ; in which the
heat of the  surface is diminished, the energies of the system  sink ; the
pulse  becomes  weaker and more quick ; the  skin relaxed ; the tongue
fouler;  the  respiration  more laborious; and finally, the patient  is
 attacked with  convulsions, violent vomiting, or symptoms of suffoca-
tion, according to the organ  principally affected, which quickly termi-
nate in death.
   The anginose form of scarlatina,  and  that accompanied with acute
or subacute inflammation of  the  central organs, differ only in the seat,
 and the greater or less violence of the attendant affections.
   One of the most frequent of the sequelae of  scarlatina is an oedema-
 tous  affection of the eyelids, face, and lower  extremities; frequently, 
462                DISEASES OF CHILDREN.
             complete  anasarca ensues after  the  disappearance of the eruption.
             Effusion within the serous cavities, is  also, not unfrequent.   In cases
             of general anasarca, a sudden effusion sometimes takes place into the
             cavity of the chest, or into the ventricles of the  brain, by which the
             patient is destroyed in a few hours.
               The dropsical effusion is usually produced  by  an imprudent expo-
             sure to cold.   In  many cases, however, it is attended with albuminous
             urine, and no doubt with a diseased condition of the kidneys.  More
             than one half the  cases which fell under the notice of Rilliet and Bar-
             thez, the patients were affected with anasarca, more than two-thirds of
             which presented  after death a characteristic lesion of the kidneys.
             To understand correctly the double influence  of the action of cold and
 VJ/?s0</^>*t of albuminous neplirilis  in the production of the dropsies consequent
ju!stw+"  upon scarlatina, the  authors just  quoted, point to  the  following well-
       *    established facts:   1st.  Albuminous nephritis may exist as  a sequela
             of scarlatina, without producing  dropsy.   2d. The dropsy  may exist
             without  albuminuria and without albuminous nephritis.'  3d.  In  the
             great majority of cases, the action of cold in the production  of the
             dropsy is  manifest, and in many cases, an exposure to this cause is im-
             mediately followed by anasarca.   4th. In many  patients  who have
             been exposed to  cold,  there will oocur an  albuminous nephritis, of
             which the action of cold and humidity has been shown to be one of the
             causes.  5th. The action of cold in the production of the dropsy  can-
             not always be proved.   It hence results that we cannot deny the influ-
             ence of cold and  of  nephritic disease, which  often concur in the  pro-
             duction of the dropsy.   The influence of  the first is  probably more
    /         general than that of nephritis; it is in many cases the cause both of
 Mj«#M^**<^»the dropsy and of the  nephritic disease.   Consequently, it  is particu-
 wdfccd y* larly against exposure to a cold  and damp atmosphere during the latter
 ftSc^JifP stages of scarlatina, and during the period of convalescence, that we
 ^^.✓<«/^should especially  guard.
 ^i+^.*£j +ift*&»ln the  great majority of cases, the  dropsical symptoms  are by no
J*n/U+/**7' means unmanageable, but very generally  yield to  a  simple plan of
  *^     '  treatment.
               Not unfrequently, spasmodic asthma, chorea, epilepsy, and neural-
             gic pains of the extremities are met with, as  sequelae to the inflamma-
             tory forms of scarlatina.  In  other cases, chronic cutaneous erup-
             tions, rheumatic pains of the joints, abscess and enlargement  of the
             tonsils, enlargement  and suppuration of the parotids and other  glands
             of the neck, chronic ophthalmia, otitis with deep-seated abscess of and
             foetid discharges from the ears; inflammation of the testicles; chronic
             bronchitis; tubercular phthisis; or inflammation of the mucous mem-
             brane  of the intestines, have also been -observed as consequences of
             severe cases of scarlatina.  A complete  loss of the hair, which never
             grows well again, is likewise a frequent consequence of the disease.
               The  autopsical appearances in fatal cases  of scarlatina, are very
             dissimilar in different cases.  Rilliet  and Barthez have attempted to
             show that one of the most common results of scarlatina, is a change
             in the  condition of the blood.   In the observations made by them, the
             blood  contained, whether in the heart  or  blood-vessels, was  some- 
DISEASES OF THE  SKIN.
463
times liquid and very fluid, dark-coloured, and in other cases, serous
and  clear.   It  seldom presented  in  any situation abundant  or firm
coagula.   Those which  occurred, were soft  and easily  broken, or
gelatinous and pale.   Sometimes  the blood was effused to a conside-
rable extent in  the tissues, as we see in cases of variola.  Sometimes,
on the contrary, but  rarely, certain  organs were pale  and contained
little blood.
  According to Tweedie, in  those instances in which the contagion
appears to have been of so intense  a character as to destroy life
within a short period, and without the occurrence of reaction, or with
only partial and imperfect reaction, there are often no apparent lesions
discoverable.  In other instances,  the mucous membrane of the mouth,
fauces, pharynx, trachea, and bronchi, is found to be strongly injected,
and  of a deep red colour.  There is often more or less intumescence
of the tonsils and fauces, which  are  frequently covered, to a greater
or  less  extent, with membraniform exudations.  Occasionally, the
mucous membrane of the  fauces is of a dark livid hue, and covered
with dark-coloured, ragged patches of exudation.  Indications of vio-
lent  inflammation of the mucous membrane of the larynx, trachea, and
bronchi, and of lobar or lobular pneumonia, are very frequent.   ,*
  In many cases, the mucous membrane  of the intestines  presents
various grades of inflammation;  follicular inflammation of the ileum,
and  occasionally of the  colon, we have met with, in cases in which
but slight indications of  inflammation of the throat, or of the respira-
tory tubes, were observed. When symptoms of cerebral  disease are
present previous to death, injection of the membranes and substance
of the  brain, thickening and opacity of the arachnoid membrane, with
effusion of transparent or lactescent  serum, are the  lesions generally
met with.  In cases succeeded by dropsical effusion, the kidneys occa-
sionally present the same change  of structure, as occurs in the  morbus
Brightii.   Purulent deposits have also been observed  in the cavity of
the joints, without inflammation of the synovial membrane.
  Not unfrequently,  indications  of pericarditis  are met with.  Dr.
Alison has recently called the attention of the profession to  the not
uncommon occurrence of this complication in cases of scarlatina.
  Scarlatina very generally  occurs  as an epidemic, often  of wide
extent, and is  evidently capable of  being propagated by a  specific
contagion, emanating from the bodies of those  labouring under the
disease.  There is, it is asserted, abundant evidence that a febrile affec-
tion, attended with scarlet eruption, and possessing all  the other cha-
racters of scarlatina, occasionally results from exposure to cold.  That
the disease may result from atmospherical causes, totally  independent
of contagion, we know from repeated observations of our own;—we
suspect, however, that the cases referred to  by Dr.  Gregory, were
severe cases of roseola,  or the rbtheln of the German writers, which,
when  of some  intensity,  strongly  resembles scarlatina.
   In scarlatina, the period of the greatest activity of the contagion,
is said by Cazenave to be the period of desquamation.
   The disease, most  generally, affects individuals but once during life.
Second  attacks have certainly been observed,  but  are of very  rare 
464
DISEASES  OF CHILDREN.
 occurrence, and are merely to be viewed as exceptions to the general
 rule.
   The subjects of scarlatina are, for the most part, children;  adults
 are by  no means exempt from  the  disease, though much  less sus-
 ceptible  to it than  the  former.   In a few epidemics, however, it has
 been chiefly confined to subjects beyond the age of puberty. In adults,
 the disease is said not to occur at so early a period after exposure to
 its contagion, as in  children.   It seldom attacks infants previous to
 weaning; and there is scarcely an instance  upon record of its attack-
 ing persons advanced in life. Females are said to be more susceptible
 to it than males; this does not, however, correspond with the results
 of our own experience.   It  is a curious circumstance, that there are
 certain individuals who  appear to be entirely unsusceptible to the dis-
 ease, never becoming affected, though fully and repeatedly exposed to
 its causes.
   Scarlatina prevails at all seasons, but a warm, humid state of the
 atmosphere,  and low, marshy districts,  would appear to promote its
 dissemination, and increase  its violence.  Great irregularity at times,
 marks the  progress of the disease, when epidemic.   After raging ex-
 tensively with great violence,  it will occasionally suddenly abate or
 nearly disappear, and then recur with symptoms of greater malignancy
 than before.  The contagion appears  sometimes to linger for several
 years in a certain  district,  affecting  from time to time, only a few
 individuals.
   Treatment of the inflammatory form of scarlatina.—In simple and
 uncomplicated cases, no very active remedies will  be demanded.  It
 is the duty of the physician,  however, to watch closely the disease
 throughout its entire course; for even, in apparently the mildest form,
 symptoms of a  severe  and  dangerous  character, are very liable to
 become suddenly or slowly developed,  and  which it is all-important
 to attack at once by appropriate remedies.   We cannot be too much
 upon our guard  against unexpected and unfavourable changes;  even
 in the mildest cases, as  Armstrong very justly remarks, the diligentia
 medici should never be  lost  sight of.  It is  important, also,  that the
 treatment of every  case of  scarlatina be commenced, if possible, at
 the very onset of the attack.  By the simplest remedies, administered
 at this period, we will  have it often  in our power to  effect a very
 important modification  in the  subsequent features  of the case;  and
 frequently to  render mild and extremely manageable an attack, which
 if neglected, might have proved one of extreme violence and danger.
   In every case  of inflammatory  scarlatina,  we should never  hesitate,
 upon the occurrence of  violent symptoms, to reduce them at  once by
 a cautious resort to  direct depletion, recollecting always, that when
 demanded,  the earlier it  is resorted to, the more efficient it will prove,
 and the less doubtful is its propriety; and, that while morbid action in
 its early  stage is frequently with ease subdued, after the lapse  of even
 a few days, when it has become more  firmly seated in important or-
gans, it is with difficulty, and too  often ineffectually, combated.   This
is particularly true in reference to the more violent and  complicated
forms of scarlatina.   The stage of excitement is often excessive, and 
DISEASES OF  THE SKIN.
465
of short duration ; extensive disorganization of some important organ
is rapidly effected, and an  irretrievable exhaustion of the vital power
is thus early induced. It  is this speedy occurrence of collapse that has
induced practitioners to  forbid bleeding and every evacuant, in the
treatment of scarlatina,  and to administer, from its very onset, cor-
dials  and tonics, in order to prevent the occurrence of debility, or
subsequently to recover the patient from it.
  It unfortunately happens, that the physician is seldom called in until
the stage of excitement  is fully developed.  Whenever, however, he
has it in his power, the treatment of scarlatina should be commenced
during the forming stage, by the administration of an emetic of ipeca-
cuanha or tartarized antimony, followed by the warm bath, and a brisk
cathartic—calomel succeeded  by castor oil.   The patient immediately
upon his  coming out of the bath, being lightly covered in bed, and
given to drink plentifully of some bland and tepid diluent.
  The early exhibition of an emetic, in all cases of scarlatina, has the
recommendation of nearly every one who  has written on the disease.
Our own experience is decidedly in favour of the practice.   Dr.  Rush
combined the emetic with  a  cathartic, by adding  to  five  grains of
calomel one grain of tartarized antimony, or five of ipecacuanha, and
in many cases this will be found an excellent plan.
  Should any symptoms occur indicating a state of engorgement of
either of the internal organs,  immersing the patient in a warm bath
strongly impregnated with  salt, and immediately afterwards applying
a few leeches  in the immediate vicinity of the affected organ, or ab-
stracting  a  few ounces of  blood from the arm, and subsequently ad-
ministering a brisk cathartic, will not only produce  immediate relief,
but in nearly  every case, will moderate the subsequent reaction, and
save from disease important organs. We have repeatedly experienced
the good  effects of this  practice.   The abstraction of blood, at this
early period of the disease, is proper, only, however, when unequivocal
indications of an overloaded condition of  some internal organ exists;
and even then, should be practised cautiously, and to a very moderate
extent.
  The treatment proper, after the occurrence of febrile reaction, will
in a great measure depend upon the extent of the excitement, and the
simple or complicated  character of each case.  In the simple form of
the disease, with a  moderate degree of febrile excitement, and but
slight affection of the  throat  or of any of the internal organs, little
else will be required than an active purgative, some gentle diaphoretic,
the free exposure of the patient to a cool, dry atmosphere, cool drinks,
and a spare, light, unirritating diet, composed  entirely of farinaceous
articles.
  The purgative should be so  administered, as to procure full and free
discharges from the bowels  throughout  the  stage  of  excitement.
Calomel is unquestionably the  best article we can employ; it should be
prescribed in  a full  dose, in  combination  with jalap or rhubarb, and
followed by divided doses of  a solution of the sulphate of magnesia,
or of the  infusion of senna with the addition of any of the saline ca-
thartics.  We are in the habit of directing from three to six grains of
                               30 
466
DISEASES OF CHILDREN
 calomel,  and the same quantity of calcined  magnesia, every other
 night, and during the day, a teaspoonful, every three hours, of a saline
 mixture wTith the addition of a small portion of tartarized antimony.'
 Under this treatment, the milder forms of the disease will, very gene-
 rally, be conducted to a favourable termination.
                     1 R.—Aquae, 3iv.
                          Sulph. magnes. 3vj.
                          Tart. ant. gr. j.
                          Spir. ceth. nitr. 3iv.
                          Syrup, limon. 3ss.—M.
   In the  milder cases of the anginose form  of scarlatina, active pur-
 gation during the stage of excitement, will generally be found  equally
 efficacious in subduing  the  pungent heat of the  surface, the  violent
 pain of the head, the turgescence and flushing of the countenance, and
 the full, quick pulse, which mark the disease, and in preventing any ex-
 tensive pseudo-membranous  exudation  in the throat.   Calomel should
 invariably be preferred; it  not  only effectually unloads  the  bowels
 and diminishes  the  morbid  excitement, but exerts an influence over
 the whole capillary  system, by  which  the  circulation  through it is
 equalized, and  morbid action  prevented or subdued.  The calomel
 may be administered  in the same manner  as  in the simple  form of
 scarlatina.
   When  considerable inflammation and tumefaction of the throat
 occur, we have  found very decided  benefit  to result from a combina-
 tion of the hydrochloride of ammonia and tartarized antimony, given,
 in repeated doses.8  The hydrochloride of ammonia is a favourite pre-
 scription of some of the German physicians, in these cases.
                   a R.—Aquae, giv.
                        Sulph.  magnes. gv.
                        Hydrochlor. ammoniae, 3ij.
                        Tart. ant. gr. j.
                        Syrup,  limon. gss.—M.
                   Dose, a teaspoonful every three hours.
   Whenever the febrile excitement is very intense, and the inflamma-
 tion  and tumefaction of the  fauces  considerable, there should be no
 hesitation in directing the abstraction of blood, to an extent commensu-
 rate with the age and vigour of the patient, and the violence of the
 symptoms.  To  trust such cases to the effects of purgatives, antimo-
 nials, and  cold applications to the skin, will, if it do not endanger the
 life of the  patient, prolong, at  least, the duration  of the  disease, and
 allow  the  development  of various affections of the  internal  organs,
 difficult to manage, and the effects of which are always of long dura-
 tion, and may continue for the remainder of the patient's life.
   The bleeding, in these cases, should be either from the arm, or by
 leeches upon the sides and over the anterior part of the throat.   After
 the loss of a proper amount of blood, the purgative plan will often suc-
 ceed  in very readily subduing the remaining symptoms, and insure a
prompt and favourable convalescence.   We  are to recollect, however,
that  bloodletting, purging, and all other depleting remedies, are to be
confined to the early period  of  the stage of excitement;—though the
occasional use of calomel in  small doses, combined with ipecacuanha 
DISEASES OF  THE SKIN.
467
and extract of hyoscyamus or camphor, will be required to preserve a
regular condition of the bowels, even after the  state of collapse  has
set in.
  In all the  more  violent cases  of scarlatina, especially in those in
which  the brain or the thoracic or abdominal organs are threatened
with inflammation, or in which some internal inflammation has already
commenced,  bloodletting, carried  to a proper extent, is essential to the
safety  of the patient.   Properly timed, and judiciously practised, it is
the only remedy calculated to reduce the violence of these cases, and
arrest  their fatal tendency.  The abstraction of a very moderate quan-
tity of blood, in the early period of the stage of excitement, or upon
the first appearance of the slightest symptoms indicative of visceral
inflammation, will, in general, be  sufficient; but if the  latter  has  ac-
quired any degree of intensity, particularly if the  patient is of a ple-
thoric  and robust habit, and  the  febrile reaction is violent, the bleed-
ing should be more copious, and  followed  by leeches or cups in  the
vicinity of the affected organ.
  The local  phlegmasiae which arise in the  course of scarlatina, are
often  of a subacute  character,  and may be overlooked, unless  the
practitioner watch closely the case.  When  they  are detected in the
early stage of the period of excitement, a moderate bleeding from  the
arm will perhaps be advisable, but in the generality of cases, and at a
later period, leeches or cups should be preferred  to the lancet.
  Whenever the symptoms of the case are  such as to indicate  the
necessity of direct depletion, the earlier it is resorted to the better; and
the more promptly it is carried to the extent required for reducing the
violence of the reaction, or of controlling internal  inflammation, the
more  certain will be its beneficial results, and the greater our hopes
of arresting the destructive march of the disease.
  Should the first  bleeding not be found  permanently to reduce the
violence of the prominent symptoms; after a short  interval, it may,
in a few cases, be proper to repeat it, but it will  seldom be prudent or
necessary to  carry our second bleeding to an equal extent with  the
first.   In  most cases,  indeed, the necessity of repeating the  general
bleeding, may be obviated by the  application of leeches or  cups, in
the immediate vicinity of the organ chiefly affected.  If possible, a re-
petition of the bleeding, either general or  local, should be avoided, by
a sufficient depletion in the first instance.
  In tepid and cold  affusion, or sponging, we have a remedy, which, in
most  cases of inflammatory  scarlatina, is equally  efficacious with
bloodletting,  and one much more generally applicable  in the treat-
ment of the disease.  In many instances, as remarked by Bateman,  it
is  almost the only febrifuge, diaphoretic,  and anodyne, that will  not
disappoint the expectations of the practitioner.   When resorted to
under  appropriate circumstances, and at  a  proper period, it will be
found very speedily to diminish the frequency of the pulse, to abate the
thirst, render the tongue  moist, the  skin soft and  cool, and the  eyes
bright, and to be speedily followed  by a  calm, refreshing sleep.  It
has been  even said, that in many instances, when resorted to in  the
commencement of the stage of excitement, it has had the effect of cut- 
468
DISEASES OF CHILDREN.
ting short the disease.   It may be employed in  all cases, during the
early period of the stage of excitement, when the heat of the  entire
surface is steadily above the  natural standard, and at  the  same time
dry, and when  there is no sense of chilliness present.  It should  be
freely used at short intervals, day and night, until the heat of the sur-
face is permanently subdued; as a  general  rule, it will require to  be
repeated from four to six  times, during at  least the first twenty-four
hours of the stage of excitement, to  be  productive of any permanent
advantage.
  While in every case in  which we are  permitted to employ it, we
believe that in the application of cold to the surface, affusion is the mode
from which the most  benefit is to be derived; yet when in conse-
quence of the fears of the patient, the prejudices of his  friends, or any
other circumstance, we are prevented from resorting  to  it, we must
content ourselves  with free and repeated sponging  of the  entire
surface with cold water, or cold water  and vinegar.   It is only in
the commencement of the  stage of excitement, however, that we are
to expect from cold affusion  or sponging, any decided advantage :—
after the third  day, it will, in general, be prudent to substitute the tepid
for  cold affusion, which may be repeated daily, until towards the ter-
mination of the excitement.  Many practitioners prefer tepid affusion
or sponging from the  commencement, in cases in which the throat is
much affected; we are convinced, however, when the heat of the sur-
face  is  very considerable,  regularly diffused, and unattended with
moisture, the application of cold water is preferable in the commence-
ment; it is certainly much  more efficacious than tepid water.
  By some, the warm  bath is recommended in the  treatment of scar-
latina.  It will, unquestionably, be  found  in many instances  a very
valuable remedial agent.   It may be employed  in all cases to which
the tepid affusion is adapted;  and in those accompanied by symptoms
of abdominal disease,  it should invariably be preferred to either cold
or tepid affusion.  Covering, in these' cases, the abdomen with a warm
emollient poultice, when the patient is taken  out of the  bath, is calcu-
lated to increase the efficacy of the latter.
  In the advanced stage of even the more violent cases of inflamma-
tory scarlatina, neither the cold nor tepid affusions will  be proper.  At
this period, the first especially, would prove decidedly injurious.  When
the patient is much exhausted,  it will be prudent to avoid the fatigue
incident to the employment of even the warm bath.   If judged neces-
sary, partial ablutions with  tepid vinegar and water may, however, be
practised; at the same time  that cool, fresh air is freely admitted into
the patient's chamber.
  In cases of scarlatina attended with visceral inflammation, cold affu-
sion  has been  recommended in the commencement of the stage of
excitement. We are not prepared to assent to  the propriety of this
recommendation.  There may  occur cases,  we admit,  in which tepid
affusion will be found useful, as a means of  reducing the morbid heat
of the skin, and in this manner moderating  the violence of reaction;
but,  as a general  rule, we  believe that the tepid or warm bath is an
agent much better adapted to  this form  of the disease.  When the 
DISEASES OF THE  SKIN.
469
brain is much affected, cold affusion upon  the head, or sponging the
scalp with cold water, will generally be productive of good effects, and
may be employed in conjunction with the warm or tepid bath.
  When there is a considerable degree of inflammation and swelling
of the tonsils and fauces, by which the act of swallowing is rendered
difficult, the application of a blister to the  throat, it  is said, has  been
occasionally found decidedly beneficial.  We confess, however, that
we have not found this practice one from which, in such cases, much
advantage has in general resulted:—this is the experience, likewise, of
Sims, Withering, Armstrong, and other writers on  the disease.  In
most cases, the early and judicious application of leeches to the throat,
will render the use of blisters unnecessary.
   When the affection of the throat is attended with considerable  diffi-
culty of swallowing and of respiration, the inhalation of the vapour of
warm water and vinegar, will, generally, procure  relief.   An emetic
we have  often found, under these circumstances, productive of good
results.  We are, also, accustomed to have the throat washed with a
pretty strong solution of the acetate of lead, and always with the best
effects.  When  the  fauces  and throat  are extensively covered  with
patches of pseudo-membranous exudation, for the local treatment pro-
per in  such cases, we refer to  our section  on  pseudo-membranous in-
flammation of the throat.
   In  the simple anginose form of scarlatina, when  the pulse is soft
and feeble, Dr. Watson recommends the citrate of ammonia,  with an
excess of the carbonate, so  that  four or five grains  may remain, in
each dose, unsaturated by the lemon juice.  The use of the carbonate
of ammonia in scarlet fever was first advocated by Strahl, and it is
now employed as a most important remedy by M. Baudelocque, at the
Hospital for Infants, in Paris, as well  in the mild as in the more ma-
lignant forms of the disease, and  also in cases in which  the eruption
has receded.   He  states that he has derived great advantage from its
employment in irregular scarlatina with cerebral disorder, and depres-
sion of the vital power; in scarlatina with  the production  of  false
membranes on the  different mucous surfaces;  in haemorrhagic scarla-
tina, and  in the  consecutive dropsy, whether this be confined to the
cellular tissue, or extended to  the serous cavities.  He administers it
in the  form of mixture, simple  or aromatized, and in gradually aug-
mented doses.
   In cases of scarlatina complicated with visceral  inflammation, blis-
ters over the affected organ will often have a favourable influence upon
the local  affection.   In the  advanced  stage of  the disease, however,
they should seldom be employed, in  consequence of the general irrita-
tion they sometimes produce, and from the danger  of their  causing
gangrene of the part upon which  they are applied.
   Throughout the attack, the  patient should  be confined to a large,
well-ventilated apartment, the  utmost attention being paid to insure
the strictest cleanliness of the chamber, as well as of  the bed-clothing,
and of the garments worn by the patient.  His diet should be  adapted
to the degree and stage of the  disease, but should be invariably spare,
light, and easy of digestion—being  composed entirely of farinaceous 
470                DISEASES  OF CHILDREN.
articles, boiled in water.  His drinks should be given cool, and slightly
mucilaginous; the addition of a small portion of lemon juice will ren-
der them more palatable, and at the same time, as many suppose,
somewhat remedial.  In the anginose form of the disease, the dilute
mineral acids have  been considered advantageous.  The free use of
diluted sulphuric acid, is said, by Steiglitz and Wolff, to produce  an
excellent effect; while, by Montsey, and a few other practitioners, the
hydrochloric acid, largely diluted with water, is recommended both
as a drink and  as a  medicine.  In the fourth volume of the  Medical
Gazette of London, there is a communication from Messrs. Tayton and
Williams, in praise of chlorine as a remedy in scarlatina.  The chlo-
rine is procured by dissolving two drachms of the chlorate of potass
in two ounces of hydrochloric acid, diluted with two ounces of distilled
water.  The solution is to be immediately put into a stoppered bottle,
and kept in  a dark  place.   Two drachms of the solution are to be
mixed with  a pint of distilled water, and one or two tablespoonfuls of
this, according to  the age of the patient, may be given for a dose fre-
quently.  The plain soda water of the shops affords, in many cases, a
very grateful and refreshing drink.
   The bowels  of  the patient should be kept  regularly open, by any
mild laxative.  The daily use of  the tepid or warm bath will always
be found advantageous.
  After the disappearance of the eruption, it will  be necessary to allow
a more nutritious diet; but at the same time, we  should be cautious to
proscribe all indigestible  and stimulating articles of food, and to pre-
vent too  much  of  even the lightest and most appropriate  from being
taken.  Daily exercise in the open air, in  mild, dry weather, will  be
proper, as soon as the patient is sufficiently strong to attempt it.   In
some cases,  it will  be necessary to aid in the restoration of the patient's
strength, by the administration of some gentle tonic;  the cold infusion
of cinchona, the sulphate of  quinia, or an infusion of wild cherry-tree
bark, may, in such cases, be employed with advantage.  The more
stimulating  tonics, and wine  should be avoided.
   For some considerable time subsequent to  his recovery, the patient
should be carefully guarded against exposure to  cold or damp, which
is very apt,  even after recovery from  attacks of  the mildest and  most
simple character, to produce  dropsical effusion, and other disagreeable
consequences.
   To promote the growth of the hair, which is  liable to fall out after
an attack of scarlatina of any severity, the head, during convalescence,
should be shaved two or three times, and frequently washed with warm
water, followed by smart friction with a brush or coarse towel—care
being  taken, in cold and  changeable weather, to preserve the head
moderately  warm by a light cap.

                    Congestive Scarlatina.
   It is this form of the disease which constitutes the malignant scarla-
tina of most writers.  The suddenness of the attack, in the more violent
cases, the extreme faintness, and  the pale and sunken countenance of
the patient;  the dark livid or dusky appearance of the eruption ; the 
DISEASES OF  THE  SKIN.
471
 absence of any decided reaction; the dark, gangrenous appearance of
 the throat;  the rapid occurrence of a general depression of the vital
 powers, with the dissolved state  of the blood, the petechiae, vibices,
 «fec, have all  concurred to deceive physicians  in regard to the real
 character of the disease, and  lead  them to view it as one bearing the
 unequivocal stamp of putridity, and  requiring for its  cure, the most
 active stimulants, antiseptics, and tonics.   Sounder notions of general
 pathology have led, however, to more correct views in regard to the
 nature of this form of scarlatina, and its appropriate treatment.
   The  congestive form of scarlatina has, with great  propriety, been
 divided by Armstrong, into the regular and irregular.  The first being
 unattended with any marked reaction, while in the latter, a partial and
 irregular reaction is manifested.   The more violent cases of the first
 variety, run  their course with  extreme  rapidity,  and  are  always
 attended  with the utmost danger.   Often has the patient been known,
 when the disease prevails epidemically, to sink, almost immediately,
 upon exposure to its infection, into a state of complete insensibility,
 terminating shortly in death.   The irregular form of congestive scar-
 latina, though confessedly a very formidable malady, is, however, by
 no means so  dangerous as the former, nor so rapid in  its progress:
 and as it  forms a kind of intermediate link between the inflammatory
 and purely congestive varieties, it will be first considered.
   It attacks pretty much in the same manner as the  inflammatory;
 with a sense of chilliness, headache, sickness and lassitude, &c; which
 symptoms, after  continuing for a  much  longer period than  in  the
 former, are succeeded  by a partial  reaction—the heat being prin-
 cipally  confined  to the trunk and  upper portions of the extremities,
 while the wrists,  hands,  ankles, and  feet  are often cool, or at least
 remain  of the natural temperature.  Throughout the day, the patient
 complains, at one time of a sense of heat, and at another of chilliness;
 the latter being often complained  of, when  the surface of the body
 feels hot to the touch of another person.  During the period of imper-
 fect excitement, the  eruption upon  the skin becomes more florid, and
 again fades as the reaction  subsides.  The  fauces become more or
 less red  and swollen, and in a  few  days, grayish specks appear upon
 their mucous membrane, and assume a dark, gangrenous appearance,
 often  as early as  the end of the first week, but more commonly, not
 until the second week.
   The efflorescence upon the skin  is  less diffuse, and of  a duller hue,
 than in the inflammatory form; it is also more liable to disappear,
 leaving  the  face of a sickly pallid  colour; the lips and edges of the
 tongue,  also, are  less intensely red.   Early in the attack, the patient
 often evinces an appearance of dejection or alarm, which is strongly
 expressed in his countenance;  occasionally, he sinks early into a state
 of dulness or stupor—of confusion  or indifference;—the eyes  having
 a dull, vacant look, with dilatation  of the pupils.  In some instances,
 the mind remains for a time perfectly clear; though there is invariably
a sense of uneasiness in the head, and often of oppression and anxiety
at the region of the heart.  Delirium is not common in the early stage,
but very  generally ensues at  a later period, and  is usually  a con- 
472
DISEASES OF  CHILDREN.
spicuous symptom in the advanced stage of the disease.  The bowels
are irregular, and the discharges always unnatural in colour and odour,
indicating either a deficient or morbid secretion of bile.
  At the commencement of the attack, the pulse is slow and oppressed,
but with the effort at reaction, it becomes quick and variable, though
it rarely acquires much  firmness or fulness.
  When uninterrupted in its progress, this variety of scarlatina often
runs on to the end of  the second week, and sometimes for a much
longer period.  When it terminates  favourably, the patient recovers
very slowly.   Unless properly treated in its early stage, symptoms in-
dicative of some serious affection of one or more of the internal  organs,
most generally ensue, which, if not promptly arrested, augment in
violence, and coma,  low muttering delirium, extreme difficulty of
respiration, or violent vomiting and  purging  occur, and speedily ter-
minate in death.  Towards  the  close of the  disease,  indications of a
dissolved state of the blood  often ensue; such as dark-coloured pete-
chiae, oozing of  dark-coloured blood   from the  mouth,  nostrils,
bowels, &c.
  In this variety of scarlatina, there  is, throughout, an imperfect effort
at reaction;  the  stage of excitement, however, being never fully de-
veloped.   In  the purely congestive variety, next to be  described, there
is, as it were, but one continued stage of oppression, which gradually
augments, until life is extinguished.
  The patient is for the most part, attacked suddenly, with  paleness of
the face, faintness and nausea;  he  complains chiefly  of  a sense of
heaviness, pain and dizziness of the head; great oppression, and con-
siderable uneasiness at the praecordia.   Occasionally  he sinks  at once
into  a state of depression, with the utmost confusion and torpor of the
intellect, and makes but little complaint.   In other cases, he may con-
tinue about, for one or  two  days, in a languid, listless  condition, and
then take to his bed, as  though worn out by great fatigue.
  When the  disease is fully formed, the respiration becomes quick and
anxious, or slow and  laborious.   The  paleness of the countenance  is
often mixed with a degree of lividness: the eyes are dull, though occa-
sionally they have a  glassy appearance, and  acquire a vacant or
drunken expression in the course of the disease.  Delirium soon en-
sues ; or, there is an indifference to surrounding objects, succeeded by
a state of stupor, in which the patient, expires.  From the commence-
ment of the attack, the pulse  is ordinarily low, impeded, and irregular,
and  generally continues  unchanged  to the close of the disease.  The
tongue is, at  first, commonly paler than natural, whitish in the centre,
and  thickly  covered  with a  ropy mucus;  towards  the close of the
disease it often  assumes a rough and  darkish aspect.  The breath is
usually more or less offensive.  The bowels  are  commonly distended
with flatus; they are costive or irregular, in the first stage,  but are fre-
quently affected with  diarrhoea, in the last, the discharges being either
of a darker or lighter colour than natural.   There is often great irri-
tability of the stomach; occasionally, however, it retains whatever is
taken into it.  As the disease advances, deglutition becomes more and
more difficult. 
DISEASES OF THE  SKIN.
473
   The efflorescence, from its first appearance, is of a purplish, cop-
 pery, or livid hue, which  becomes deeper as the disease proceeds ; oc-
 casionally, it quickly recedes, without again returning.  In some very
 rapid and fatal cases, the  throat is but little affected ;—when, however,
 the  disease continues beyond  the fourth day, and the vital powers
 begin  rapidly to sink,  the  fauces are generally covered  with  dark-
 coloured specks.  The heat of the surface is' usually rather below, than
 above the natural standard; and even when the central portions  of the
 body are warm, or perhaps hot, the extremities are1, for the most part,
 cold.
   This form of scarlatina frequently runs its fatal course in two, three,
 or four days from the occurrence  of  the symptoms of general depres-
 sion.  Its final  stage is  almost invariably attended  with petechias,
 oozing of dark-coloured  blood  from  the mouth or  nostrils,  and dis-
 charges of the same kind from the bowels or  bladder.  A few  hours
 previous to dissolution, there is often a transient glow over the body, a
 dark flushing of the face, great difficulty of respiration, accelerated
 pulse,  and partial or general perspiration;—the excitement, however,
 quickly subsides, the  extremities become cold, the face of a cadave-
 rous hue, and where the  skin is pale, it has often the smooth waxen
 appearance of a corpse.  Under such circumstances, life seldom lingers
 long.
   The prominent symptoms of both the varieties of scarlatina just de-
 scribed, are evidently dependent upon a lesion of the nervous system
 giving rise to extensive engorgement  of the central organs, and of the
 large venous trunks.  The abortive efforts at reaction, in the one case,
 producing a  degree of irregular and transient excitement, while in the
 other, the organic functions of the brain and nervous system appear to
 be completely paralysed, the patient sinking from a gradual extinction
 of the powers of life, in  consequence of the organs being unable  to
 react under the load by which they are oppressed.
   In the irregular congestive variety, the congestion is seldom to such
 an extent as  to occasion any immediate danger; still the more impor-
 tant organs are predisposed  to  serious lesions, from the irregular de-
 terminations  of blood which are liable to take place during the stage
 of imperfect  reaction.  The brain, the lungs,  and  abdominal organs
 are those which most commonly suffer, and present, after death, either
 an injected state of their vessels, or the indications of subacute inflam-
 mation.   In  the regular congestive variety, the brain, the  lungs, and
 the liver, as well  as the heart, and the large vessels in its vicinity, are
 found to be extensively engorged with dark-coloured grumous blood,
 without any vestiges of inflammatory  action.
   In congestive scarlatina, it is only in the  early period of  the case
 that we can expect any decided benefit to result from medical  treat-
 ment.  Called, therefore, to  a child that has been  recently attacked,
 we should direct him to be at once immersed in a warm bath, and his
 body, at the same time, to be briskly rubbed with the hand or a flannel
cloth.  On coming out of the bath, he should be carefully wrapped in
a blanket, and have sinapisms applied to the extremities, and  over the
epigastrium.   In violent cases, if a warm bath  cannot be immediately 
474
DISEASES OF CHILDREN.
prepared, no time should  be lost in waiting for it; but friction of the
surface, with a warm flannel cloth, impregnated with any warm, stimu-
lating liquor, as vinegar, common spirits, cologne water, bay rum,&c,
should be instantly employed;  while  bottles  or  bladders  filled with
warm water, are  applied to the lower  extremities.  A full dose of ca-
lomel should be administered without delay, and followed, in a few
hours, by a proper dose of infusion of senna with  the  addition of
sulphate of magnesia, or of the compound powder of jalap;—and if
these be tardy  in  their operation, some active purgative enema should
be resorted to.
  During the  first day or two, it  is important to repeal the  bath, at
least twice in  the twenty-four hours; and in severe cases, its action
may be augmented by the addition of salt,  or a small quantity of pow-
dered mustard;—subsequently, the warm  bath should be used daily,
until symptoms of recovery ensue.
  Calomel  would appear,  in  most cases, to be the purgative  best
adapted to this form  of scarlatina:—it unloads the liver of its undue
amount of blood; excites the mucous membrane of the  intestines to a
more healthy  secretion;  and seems to  produce  throughout,  a more
equable and healthy action of the capillary system.  The  calomel
should be administered at first in  full doses, and followed by such ca-
thartics as will insure its  full action upon the bowels.
  As soon, however, as the pulse becomes more free and full, the skin
of a moderate  and equable warmth, and  the  discharges from the
bowels  of a more healthy appearance,  the calomel  may be  omitted,
and  castor oil, magnesia  and rhubarb, or any other mild laxative sub-
stituted ; calcined magnesia,  saturated with  lemon juice, is  said by
Armstrong, to  be, under the circumstances  referred to, a very excellent
purgative: the turpentine, combined with castor oil, is  the one we have
generally employed, and  it has appeared to us to  be beneficial, inde-
pendently of its action upon the bowels.
  It is  important to recollect, that until convalescence is  fully esta-
blished, a free and regular condition  of the bowels  should  be main-
tained,  without, however,  endangering  the occurrence of excessive
purgation;—a neglect of this precaution,  may cause a recurrence of
all the more serious symptoms.
  Every case  of  congestive scarlatina should be closely watched, and
if symptoms ensue indicative of considerable oppression of the brain,
lungs, or other important organ, the cautious abstraction of a small
quantity of blood, by leeches  or cups, from the neighbourhood of the
affected part, will, in general, produce great  relief, and often insure a
permanent, moderate, and  general reaction.  Much  judgment will be
demanded in the  employment of bloodletting, in these cases; its effects
upon the pulse should be  carefully watched, and if the slightest appear-
ance of sinking occurs, it should be immediately suspended.   The best
time for bleeding is  immediately upon the patient coming  out of the
bath, or it may be performed whilst the patient remains in the bath :—
the amount  taken away  should, under all circumstances, be moderate,
even though a repetition  of the  bleeding be thought advisable.
   During the flow of blood, the  skin should be  well rubbed with  a 
DISEASES OF  THE SKIN.
475
 coarse cloth or flesh-brush dipped in warm vinegar, in which a quantity
 of salt has been dissolved.   The finger should be kept constantly upon
 the pulse, and if this become more full, free, and regular, the bleeding
 may be continued; but if, on the contrary, the pulse becomes weaker,
 or seems disposed to sink, the orifice  should be immediately closed;
 though, subsequently, it may be again proper to try the effects of bleed-
 ing, with similar precautions.   It is all-important, however, that  the
 bleeding be not carried too far, even when the pulse rises under the
 flow of blood, otherwise a dangerous state of collapse may be induced;
 above all, the slightest approach to syncope should be avoided.
   It must be recollected, also, that  bloodletting is proper only in the
 early period of  the attack, unless violent reaction, as is sometimes the
 case, should occur, when the treatment should be precisely the same
 as in any other  acute form of disease.
   In numerous cases, bleeding  constitutes, unquestionably, a most  im-
 portant remedy  in congestive scarlet  fever, upon  the  cautious and
 judicious  employment of which,  the safety of the  patient will often
 mainly depend; and  hence, while it should be unhesitatingly resorted
 to whenever the brain or lungs exhibit symptoms of serious oppression,
 we must, at the same time, recollect that it  is not a remedy equally
 applicable  to every case, and  that in none can it be employed with
 the same freedom as in diseases of a purely inflammatory character.
   In  cases  in which drawing  blood from  the arm is  considered of
 doubtful  propriety, cups may be  applied in the vicinity  of the organ
 which appears to labour  under the greatest amount of oppression;
 sinapisms upon  the  extremities, and friction to the surface generally,
 being  at the same time resorted  to.  The great object of the prac-
 titioner should be, to relieve, as quickly as possible, the brain from its
 undue  load of blood; by so  doing, he will increase the  nervous ener-
 gies of the other organs, and enable  them the better to  relieve them-
 selves  of the oppression under which they labour.
   In violent  attacks, after the warm bath, friction of the surface, and
 the cautious abstraction of blood, the administration of a large stimu-
 lating enema will often produce prompt relief, by unloading the lower
 portion of the intestinal canal, and diminishing the  irritability of  the
 stomach.  The ordinary domestic enema, with the addition of turpen-
 tine, may be employed.
   In conjunction with the remedies  already recited, some gentle dia-
 phoretic will often be found beneficial; the liquor acetatis ammoniae,
 or a combination of camphor, ipecacuanha, and hydrochloride of am-
 monia," may be  employed.   In some  instances, a weak  infusion  of
 serpentaria, or small and repeated  doses of the carbonate of ammonia,
 will be found to produce a gentle and  universal diaphoresis, which
contributes  materially to the relief of the overloaded organs, and, in
this manner, to occasion a gentle and permanent reaction.
                * R.—Pulv. camphor, gr. iv.—vj.
                    ---- ipecacuanha?, gr. iij.
                    Hydrochlor. ammonias, 9ijss.—M. f. ch. No. xij.
                 One to be given every three hours.
  In scarlatina maligna, Dr. Peart recommends the carbonate of am- 
476
DISEASES  OF CHILDREN.
monia, in  doses  of five or six  grains every second or third  hour, as
somewhat of a specific.
  The patient may be allowed to partake of any warm, diluent drink,
as thin gruel, panada,  chicken water, or the like; when given imme-
diately upon his removal from the bath, it tends to promote reaction.
The same kind of drink may be continued at regular intervals through-
out the disease.   When, however, the skin remains cool, and  reaction
is  with difficulty established, it will  be proper to  allow  the patient
small and repeated portions of warm wine whey, or warm wine and
water; but the moment that reaction ensues, every species  of diffusible
stimuli  should be immediately  discontinued, and warm diluent drinks
substituted.
   When a state of collapse begins to manifest itself, it will be neces-
sary, in most cases, to  administer moderate portions of some diffusible
stimulant, as warm wine whey, or a little  Madeira wine diluted with
milk.  It  is probable, also, that the infusion of serpentaria, and small
doses of the carbonate of ammonia, will, in such cases, prove bene-
ficial.   But, while these  remedies,  under  the  circumstances  referred
to, will often be  demanded to support the patient's strength, it must be
recollected that nothing  can  be productive of worse consequences
than a too  early resort, in congestive scarlatina, to the use of stimu-
lants;  even  after the stage of collapse has set in, we should still be
cautious not to give them in too large quantities, or at  too short inter-
vals.   Close attention and much judgment will be demanded  properly
to time their use, and graduate the proper extent to which they should
be carried.
   If, from neglect, or from a  timid  and injudicious treatment of the
early period of the attack, an organic lesion of some important organ
has been allowed to occur, we have but little to expect from the effects
of any class of  remedies.  Wine  and other stimulants, in particular,
should then be withheld, as they invariably augment all the more dan-
gerous symptoms.
   When, by an  energetic and well-directed treatment,  a general, free,
and moderate reaction  has been brought about, the stage of collapse
will be slight, and of short duration, and  require no difference  in its
management from that following the inflammatory form of scarlatina.
The utmost care should  be taken to guard against exposure to cold or
damp, to  avoid  every  species of stimulating food or drink, and to pre-
serve  the bowels in a free, regular condition.  By a neglect of these
precautions, dropsical  effusion—of more frequent occurrence after the
congestive than after the other varieties of the  disease—will very gene-
rally be produced, or the occurrence of a subacute inflammation, par-
ticularly of the brain  or alimentary canal, of long continuance, and
difficult to manage, will be endangered.
   We have had a full opportunity, in the  course of several severe epi-
demics, to test the value of the practice  above recommended,  and have
no hesitation in saying,  that, when judiciously carried into execution,
it is calculated to disarm the disease of its malignancy, and to prevent
the necessity,  in the  advanced period of the attack, of a  resort  to
" powerful  cordials, tonics, and antiseptics," to remove " the putrid 
DISEASES OF  THE SKIN.
477
symptoms which then show themselves."   The " bold  and indiscrimi-
nate use of the lancet" we should, certainly, strongly object to; but of
the good effects of a cautious employment of bloodletting, in the manner
and  under the  circumstances directed, is  calculated to produce, we
speak from actual observation; it is unquestionably, in  a large number
of cases, the only "restorative and tonic," upon which  any confidence
can be placed.
   The discredit into which bloodletting has fallen, in the  treatment of
all the forms of scarlet fever, has, we  suspect, arisen  altogether from
the want of due attention to the circumstances under which it is alone
proper.  It  is a  remedy of great efficacy, for  good  or  for evil.  If
used  at random, and without a careful discrimination of the circum-
stances of each  case, the  reprobation that  has  been thrown upon
it  by Currie, will most assuredly be justified; it may then  prove, in
many instances, " a fatal practice."  If, on the  other  hand, it  is em-
ployed at the proper time, and in sufficient quantity, it will prove, as
Dewar has very correctly remarked, a means of cure, safe and suc-
cessful, far beyond any other with which we are acquainted.
   Before  quitting the  subject of scarlatina, it will be  proper to say a
few words in relation  to some of its most common  sequelae.  One of
the most frequent is anasarca, either local or general;  in  many cases,
effusion takes place likewise, in the brain and serous cavities generally,
and this occasionally after the mildest cases; usually,  however, it oc-
curs only after an attack  of the more violent forms of the disease.  The
effusion is, in a large number of instances, the  result  of exposure to
cold and damp, or of an injudicious administration  of stimulants and
restoratives, during the period  of convalescence.   It  may, however,
occasionally occur, according to Reil, as  a strictly  complemental af-
fection.  It is  seldom  attended with  much danger,  and is readily re-
moved by an appropriate treatment.
   In many cases, the  effusion is accompanied with  a  quick, frequent,
tense, and  sometimes full pulse; a hot and dry skin,  costive bowels,
and scanty, high-coloured, and albuminous urine; under these circum-
stances, bloodletting, will, in general, be demanded, and its good effects
are attested by numerous writers.  Combinations of calomel, nitrate
of potassa, and digitalis,* will  be  found often to remove the effused
fluid with great  rapidity.  Calomel alone, in large  doses, five to ten
grains daily, is strongly recommended in these  cases,  by Richter and
Kreisig.   As a drink, a weak solution of the bitartrate of potassa will
be among the best we can give. In some cases, benefit will be derived
from the following mixture.b The daily use of the tepid bath followed
by friction  of  the surface, will always  be  advantageous.  Perfect
quietude should be enjoined, in a dry, freely ventilated  apartment, and
every precaution should  be taken against exposure to cold or damp.
The mildest farinaceous  diet should be the only  one  allowed.
  1 R.—Calomel, gr.  xij.                  b R.—Aquae, 3vj.
       Nitrat. potassae, 3j.                      Sulph. magnesias, 3iv.
       Pulv.  digitalis, gr.  iv.—M. f. ch.          Spir. aeth.  nitr. 3iv.
        No. xij.                            Nitrat. potassae, 3ij.
  One to be given, for a dose, every two,          Tart, antimonii, gr. j.—M.
        three, or four hours.             Dose, a teaspoonful, every three hours. 
478
DISEASES OF CHILDREN.
   When the effusion is connected with  a  relaxed and debilitated con-
dition of the system, bleeding will be improper. If the bowels are con-
fined, they should  be freely evacuated  by calomel, followed by some
gentle aperient.  As diuretics, the squill, spirits of turpentine, and tinc-
ture of cantharides, have been highly recommended.  The sulphate of
quinia, the proto-carbonate and tincture of the sesquichloride of  iron,
will often be found decidedly advantageous.
   Scarlatina, particularly the anginose variety, is often succeeded by
a deep-seated  pain in one or both ears, with deafness, followed, in a
short time, by a discharge of either pus or a foetid serous fluid.   This
in general, arises from the inflammation of the throat extending, along
the Eustachian tube, to the internal ear.  When violent, long continued,
or neglected, this inflammation sometimes terminates in an entire de-
struction of the  organ of  hearing.  In the early period of this variety
of otitis, leeches should be  applied behind  the external  ear, followed
by repeated blisters, and  the  bowels  should  be kept in a regular,
healthy condition,  by small doses of calomel, prepared chalk, extract
of hyoscyamus, and ipecacuanha,3 at bed-time,  and mild  aperients,
during the day.
                     a R.—Crete ppt. gr. xxxvj.
                          Calomel, gr. xij.
                          Pulv. ipecac, gr. iv.
                          Ext. hyoscyami, gr. vj.—M. f. ch. No. xij.
   When a discharge from the ear has occurred, the meatus should be
frequently syringed with tepid barley water or other bland  mucilagi-
nous fluid ;  or when the discharge is dark-coloured and offensive, the
ear may be injected twice a day, with a weak solution of the chloride
of soda, or  a  decoction of black  oak bark.  The patient  should be
confined to a light, nourishing diet, and have regular exercise daily,
in the open air, whenever the weather  is mild and clear.  Repeated
blisters  behind the affected ear,  we have found, in many cases, to ar-
rest the discharge, and occasionally, under  their use, the function of
the ear  has  become fully restored.
   From the severe and fatal character of scarlatina, particularly when
it occurs as an  extensive epidemic, various plans of  prevention have
been proposed.  The one which has attracted most attention, is that
suggested, upwards of thirty years  ago, by  the celebrated founder of
homoeopathy.  When given  in small and repeated doses, it was long
known that belladonna would cause a heat and dryness in the  throat,
and an efflorescence upon the skin, having a  very close resemblance to
that of scarlatina;  Hahnemann hence maintained, in accordance with
one of the fundamental principles of his  system, that when  adminis-
tered so as to give  rise to these symptoms, it would prove a certain
preventive against  the occurrence of the latter; and in proof that such
is  actually  the  case, a  considerable  amount of testimony has been
presented from various sources.
   The strongest evidence  in favour of the prophylactic powers of the
belladonna is  that of Dr. Stievenart, of Valenciennes.   During the
winter  of  1840-1, several villages  in  the  neighbourhood of Valen-
ciennes,  were visited by  an epidemic  of scarlatina, of a very fatal 
                    DISEASES  OF THE  SKIN.                479

character.  In a small village  of 250 individuals, the belladonna was              J
administered  by Dr. Stievenart to  200 persons, all of whom escaped
the disease; of the  remaining  fifty, 14 were attacked, and four died.
In another  village, he placed the  majority of the children at the public
school under the influence of the belladonna, allowing them to continue
their lessons, and to have free  communication with the  other children
of the place.  No one of these were affected with scarlet fever, while
a few who refused to take it were attacked.
   Dr. Stievenart  administered the  belladonna either in  solution or  in
powder.   The  solution was made  by dissolving two grains of  the re-
cent alcoholic extract in one ounce of any aromatic infusion;  of this
two drops were given to a child of one year old, daily, for  nine or ten
days, and an additional  drop for  every additional year of the patient's
age.  The largest daily dose was, however, limited to twelve drops.
When the belladonna was given  in the form of powder, half a grain
of the powdered root was mixed with a small quantity of sugar, and
divided  into ten doses;  one of which was administered  morning and
evening to  children of from one to  two years old, double the  quantity
to those from three to five, treble  the quantity to  those from  six to nine,
a quadruple portion to those from ten to fourteen, and one grain of the
powdered root, twice a  day, to adults.
   These small doses, it is stated, never  produced the toxicological              i
effects of belladonna; in  fact, they scarcely ever exhibited any marked              |
action.   In five or six cases, Dr.  Stievenart observed a rash similar to              1
that of measles, and in a few others, headache,  with dilatation of the              |
pupils, and  dryness and slight soreness of the throat, but which  had no          -   j
resemblance to that of scarlatina anginosa. The use»f the rercfe'rJy        *#
was  generally continued for from  nine to ten  days, and in some in-
stances, for fifteen days.  Dr. Stievenart  considers this period to be
sufficiently long to place the system completely  under its prophylactic tJ>af9//f<-~
influence; but he  recommends  the use of the belladonna to be resumed, ft Zik*S/
if the epidemic should  return, or break out again with  renewed vio- ^1/A**&&']
lence.                                                            **IK«*«m»#h. ,
   In an epidemic of scarlatina which occurred in South Carolina, Dr.
Irwin made a very extensive  trial of the  prophylactic  properties  of
belladonna.  Three grains of the extract were dissolved in one ounce
of cinnamon  water, and two  or  three drops of the solution  given,
morning and night, to a child  under one year old, and one drop more
for every year above that age.   Of two  hundred and  fifty children
who took the belladonna, less  than half a dozen had the disease, and
that very mildly.  After eight  or ten days' use of the medicine, there
occurred an eruption over most of  the  surface, in some cases profuse,              i
and  troublesome  from  itching.  In those  families, the members  of
which were not placed under the  influence of this prophylactic, the dis-
ease occurred with scarcely an  exception.  A poor woman,  with a
family of sixteen children, used  it carefully according to  directions,
and her family, it is stated, alone  escaped, when  hundreds around them
were  attacked.   Dr. M'Kee, in the extension of the same epidemic,
exhibited  belladonna, and  observed it  to exert  similar  protective              j
powers. 
480
DISEASES  OF CHILDREN.
       We have, in repeated instances, tested the  prophylactic powers of
     belladonna, but although redness and  dryness  of the throat, and a dif-
     fuse scarlet efflorescence were  produced in the majority of the cases,
     we never found it, in any, to exert the slightest influence in mitigating
     the character, or preventing the occurrence of scarlatina.  The expe-
     riments were made, during the prevalence of  the disease, and, in nu-
     merous instances  the subjects of them were attacked.   In one case,
     the efflorescence was kept up by the use  of belladonna,  for forty-eight
     hours;  in  a week afterwards, this  individual  took  the  disease, in its
     most violent form, and died on the fourth day.
       It has been asserted, that  the scarlatina, like many other analogous
     diseases, may be  inoculated so as to determine a local  inflammation
     which has little  reaction on the economy, but is preservative  in the
     same manner as the vaccine virus against small-pox.  M. Miguel em-
     ployed the matter procured by pricking  several  papullae with lancets,
     which was inserted in incisions made in the arm of  the child,  intended
     to be infected.  In three cases, he states that  he was enabled in this
     manner, to produce a local  disease, which followed the march of the
     scarlatinous inflammation.
       Although  not  invariably  successful, yet it  will  be prudent, in  all
     cases, to endeavour to prevent  the spread of the disease by the seclu-
     sion of  the sick, by free ventilation, by frequent changes of linen, and
     by the strictest cleanliness.

                    B. — Roseola. — Scarlet  Rash.
       Roseola consists in a  rose-coloured or scarlet efflorescence, without
     wheals or papulae, not contagious, and sometimes accompanied by a
     sensation of  tingling or  itching.  The efflorescence may be  confined
     to the face, neck, and upper extremities, or  it may occasionally ex-
 '-. '.tend over the greater part of the body.  In some  cases,  the redness is
*   '. diffused over a large surface;  in others,  it assumes the  form  of  rings
k * and  spots, while,  in  others  again, irregular lines of a darker colour
 » vhave their  interstices filled up by a lighter shade of  red.
       The disease is frequently ushered in by a slight degree of febrile ex-
     citement, which abates as the efflorescence makes its appearance, and
     disappears with it. The pharynx often presents a similar efflorescence
     to that  upon the  skin, and  the patient feels a sense of dryness and
     roughness  in swallowing.  The efflorescence  upon the  surface gra-
     dually declines after the second day, and, in  general, disappears by
    the fifth.  It seldom continues longer than a week, and is not followed
    by desquamation of the cuticle.  It occasionally reappears and declines,
    again and again, without any  perceptible cause, or in  consequence
    of any undue excitement, or the use of heating food or drinks.  The
    efflorescence often occurs, in succession, on different  parts of the body,
    and, if generally diffused, in the form  of small patches, with intervals
    of sound skin between them, is sometimes, with difficulty, distinguished
    from measles, the difficulty being increased in  many cases by  the pre-
    sence of catarrhal symptoms.
      The recession  of the efflorescence is  frequently  attended by some
    derangement of the stomach, headache, and more or less of  languor 
DISEASES OF THE  SKIN.
481
and lassitude, which immediately cease, upon the reappearance of the
eruption.  In a number of instances, we have  found the eruption at-
tended by very decided catarrhal symptoms, and to be preceded and
followed by pains of the limbs, and  sometimes by slight redness and
tumefaction of  the joints.
  Roseola is peculiar to no age or sex; it is, however, much more
frequent, during infancy and childhood, than subsequently.  In infants,
the peculiar irritability of the skin, and of the constitution,  predis-
poses to its  occurrence from the most trifling causes.  It is most com-
monly observed during  the period of dentition, or in connexion with
the ordinary intestinal and  febrile affections of infancy.  But  it  may
originate from  any slight irritation of  the  stomach or of the alimen-
tary canal  generally.   It is more common during the summer and
autumnal seasons, than  at any other period of the year.'
  Roseola has  been divided, by Willan and others, into  several varie-
ties, founded upon the age or season at which  it most generally pre-
vails, and upon  some slight difference in the appearance of the eruption.
This  division is more apt, however, to perplex and mislead, than to
serve any useful purpose.
  The affection is one  of little or no importance; requiring in many
cases, no treatment,  and in none  any further interference  than  to
relieve the bowels of any cause of irritation which may exist, by some
gentle laxative, to moderate the  tingling or itching sensation of the
surface by the use of the tepid or warm bath, and to place the patient
upon  a mild, unirritating diet.  When the disease becomes chronic, or
returns several  seasons in succession, and continues for many months,
attention to the condition of the  alimentary canal will be demanded,
with sea bathing, and the use of the mineral acids.
  We have deemed  it necessary to  notice the disease, in this place,
from  the fact of its having been repeatedly mistaken for a mild attack
of measles or scarlatina, and in this manner has given rise to some of
the reported cases of a second  attack of the latter diseases. So closely,
do some of the forms of roseola resemble  measles, that it has been
questioned by Sydenham, Rayer, and others, whether it  is not, in fact,
a modification or variety of that disease, without catarrh; and Orlov,
Seiler, Heim, and Stromeyer, have thought it necessary  to devote dis-
tinct  treatises, to determine the diagnosis between  it, scarlatina, and
measles.  We  cannot suppose, that any difficulty will be experienced
by an attentive observer, in readily distinguishing roseola from the
other febrile exanthemata, as well from the difference in the appear-
ance of the eruption—the patches of which are more  regularly circu-
lar in shape, and more circumscribed than  those of either measles or
scarlatina, while they are larger than those of the former, and smaller
than those of the latter—as from the  general  symptoms, which are
very distinct.   The most careless would hardly confound  the  slight
evanescent  febrile excitement of roseola, with the  severe catarrhal
fever  of  measles, or the intense febrile reaction  of scarlatina.

                    4.—Variola.—Small-pox.
  This " loathsome malady," though no longer the same scourge of
                               31 
482
DISEASES  OF CHILDREN.
 infancy, as it was previous to the discovery of vaccination, is still of
 sufficient frequency to demand a close attention to its pathology and
 treatment on the part of the practitioner.  Notwithstanding the means
 for its entire extirpation is within the reach of every community, yet,
 from an  almost criminal  supineness upon the part of our legislative
 bodies, and ignorance and prejudice on the part of a  large portion of
 the community, it is still allowed to prevail, destroying throughout the
 world many thousands annually, and  stamping, with deformity, the
 countenances of those who are  fortunate enough  to  pass through it
 without loss of life.   Hence, the physician is obliged  to make himself
 fully acquainted with  its pathological character, and  proper mode of
 treatment, for he knows not at what moment he may be called  upon
 to watch its progress, and lend his aid  to  mitigate the sufferings it
 entails, and, if possible, prevent its destroying  those to whom he has
 not been permitted to  afford a certain protection  against its attack.
   Variola is an eruptive  fever, marked by the occurrence  of  pus-
 tules over the  entire surface  of the body, which appear at a definite
 period, run  a regular course, and upon  separating in the form of dry
 crusts, frequently leave a deep and indelible cicatrix.  It is propagated
 by contagion, but often prevails as an epidemic—the first cases being
 traceable to no focus  of infection.  As  a general rule,- to which the
 exceptions are comparatively rare, variola affects  an individual but
 once during life.
   Like other  febrile  affections, variola commences  with chills, or
 rigors, succeeded by a febrile reaction, of more or less intensity, which
 may continue for  two or three days before the eruption upon the skin
 appears.
   The attack is very generally preceded by pains, more or less intense,
 in the back and limbs; often, for many days, by some degree of languor
 or lassitude; the patient feels depressed;  his nights are often restless,
 and his digestion somewhat impaired. This constitutes what has been
 termed the  stage of incubation, the duration of which has been vari-
 ously stated, as from one  to two weeks; to fix  its limits  is, in most
 cases, however, impossible.
   It has been said, that the moment of infection is often marked by
 some disagreeable sensation—giddiness, sickness, or an inward feeling
 of alarm.  We cannot say that we have  observed anything of the
 kind.  Frequently the  infection remains for a long period latent in the
 system:  thus we have  known an individual to  continue in apparent
 health, in the midst of an epidemic of  small-pox,  by which nearly
 every unprotected person  in  the  same dwelling and neighbourhood
 with himself were infected, and after the epidemic had  entirely ceased,
 and no  cases had occurred for weeks, to be suddenly attacked  with
 the disease in its most virulent form.
   Often  the period of incubation is marked by no particular symp-
 toms, either of  a general or local character; the first indication of in-
 fection being a severe  long-continued chill, or several slight attacks of
 rigor, occurring at short and irregular intervals, and speedily followed
 by a febrile  reaction, often  of considerable intensity, during which the
pulse is quickened, and the  skin becomes hot and dry, or disposed to 
DISEASES OF THE SKIN.
483
perspiration.   The patient often complains of pain, or a sense of sore-
ness in the limbs, and, generally, of severe pain, or a feeling of weak-
ness in the back.  There is commonly pain in some part of  the head,
particularly in the temples  and forehead.   The child frequently ex-
hibits a degree of drowsiness, and usually awakes with a start, or in a
state  of alarm.   There  is  commonly  considerable prostration  of
strength,  and, in many cases,  an anxious, suffering expression of
countenance.
   In  some  instances, the attack is marked,  in  its  early stages, by
great irritability of stomach, frequent vomiting, oppression at the prae-
cordia, and  a pungent pain at the epigastrium, increased upon pres-
sure.  Not unfrequently, there occurs considerable difficulty of respi-
ration, with cough, wheezing, and  other indications of bronchial or
pneumonic disease.
   Occasionally,  the reaction is  slight  and  imperfect; or  the  disease
commences with a state almost approaching to complete collapse; the
surface of the body being pale, cold,  and  relaxed;  the pulse feeble,
and the countenance anxious and contracted.
   The eruption is frequently preceded by a severe epileptic paroxysm.
   Many of the foregoing symptoms may abate in violence, or entirely
disappear, upon  the occurrence of the eruption, while others continue,
with greater or less intensity.
   The eruption upon the skin  usually occurs at the end of forty-eight
hours from the occurrence of the chill, the pain in the back, or gastric
distress.  In delicate subjects, and in those who have been debilitated
by loss of blood, long-continued vomiting, or severe  purging, or from
exposure  to cold, the appearance of the  eruption  is  not  unfrequently
delayed;—its  occurrence previous to the third day being extremely
rare.
   The  eruption   first appears upon  the face, in the form of small
red papulae, elevated above  the  surface of the skin.  Subsequently,
similar papulae occur on the neck and wrists, and then upon the trunk
and thighs, and, finally, upon the  feet.   By the end  of the  first or
second day the  eruption  usually extends over the entire surface of
the body; but, occasionally, not before the end of three or four days.
It is seldom that  it occurs to the same extent over every portion of
the surface:—it  being  generally most considerable about  the folds
of  the joints,  and such parts of the body  as are kept permanently
warm.
   The  eruption   has been known, in  a  few instances, to commence
upon some part of the body, or  upon the inferior extremities, and oc-
casionally one or two papulae  may appear about the face,  and assume
the vesicular form, previously to the occurrence of the general erup-
tion.
   The papulae become rapidly more and more distinct, and by the end
of the first day, they are of a decided  red  colour,  and sensibly ele-
vated ;  by the third day, a small vesicle forms upon each papula, filled
with a thin transparent fluid, and surrounded with an  inflamed circular
margin.  The vesicle soon  becomes  depressed in the centre, and so
continues until about the sixth  day.   As the  vesicle becomes more 
484
DISEASES OF CHILDREN
completely distended, and  of  a  more globular form, the indentation
disappears ; the vesicle now assumes a yellowish-white, or pearly ap-
pearance, and instead of being  filled, as at first, with  a transparent
fluid, it is now distended  with a yellowish puriform matter, of the con-
sistence of cream.
  When the pustules are numerous,  the parts upon which  they are
situated become swollen, and the surrounding skin assumes a deep red
colour, from the extension to it of the inflammation.  The swelling is
usually to the greatest extent in the face, hands, and feet.
  About the seventh day, some of the pustules on the face burst, and
upon the  eighth  or ninth, they begin to dry, and become converted
into scabs; the pustules successively assuming a yellow, then a brown,
and, when perfectly dry, a  very  dark  brown, or almost  black colour.
The scab adheres for a few days, and then  falls off, leaving, in gene-
ral, especially upon the face, a deep pit, or  depressed cicatrix.  The
skin usually remains,  after the scab falls off, of a  dark brown mottled
appearance, and it is  often  many weeks, or even  months, before it re-
gains its natural hue.
  From the appearance of the papulae, to their complete maturation,
there generally intervenes a period of seven days.   But as the papulae
do  not appear  simultaneously upon every  part of the  surface, their
maturation  takes place  successively;—thus, upon the face,  they as-
sume the pustular form, burst, and are converted  into scabs, first;
then  upon the  trunk  and the upper extremities; and, finally, upon the
lower extremities.  As many as four or five days may intervene, be-
tween the complete maturation of those upon the face, and those upon
the  feet.
  During the  stage of maturation, the  surface of the  body emits a
sickly, disgusting odour,  which is peculiar to the disease.
  At the  period when the  eruption appears, the throat generally be-
comes more or less affected, and most commonly redder than natural;
in severe cases, it is often considerably inflamed, and frequently covered
with aphthous ulcerations.  The latter, however, generally precede the
eruption on the  surface, and  often disappear earlier.  When the in-
flammation of the throat is extensive, the entire mucous membrane of
the  respiratory tubes is very liable to be likewise affected.
  During the  eruptive fever, the tongue is  generally covered with a
thin layer of white mucus; when  the eruption is  completed, this is
partially removed, and, at its tip, a few eruptions usually appear.  It
is commonly moist, excepting when the patient is confined to a close
and impure atmosphere,  when it may become dry and dark-coloured.
  With the complete  maturation of the eruption, the febrile symptoms
in general subside or entirely disappear:—frequently, however, some
degree of febrile excitement continues, until scabs are formed over the
greater part of the surface.   When the eruption is at its height, there
is always  more or less tenderness of the  skin; which  is so considerable
in some cases, as to occasion great distress to the patient.  Frequently,
there is considerable  itching of the surface, which causes the patient,
unless restrained, to scratch and rupture the vesicles, by which, gene-
rally, his suffering, as well as the danger  of deformity, from deep, 
DISEASES OF THE SKIN.
485
 large, and irregular cicatrices,  is increased.   When the eruption is
 finished? there is, very commonly, some degree of salivation, in con-
 sequence of the affection of the  mucous membrane of the mouth and
 fauces.
   The bowels are usually constipated throughout the disease.   Some-
 times, however, they are affected with more or less diarrhoea; which
 occasionally results  from some  degree  of inflammation  of  the ileum
 and colon.
   The extent of the eruption is very various ; in some cases only a few
 papulae appear, scattered over different  parts of the body, which run
 their course, and are converted into pustules, that dry and fall off, with-
 out any further affection of the skin.  In other cases, although the erup-
 tion occupies the greater portion of  the surface, each pustule remains
 distinct  and separate from the  others;—while in other  cases, again,
 they  are very numerous, and  so close  together, as to run one into the
 other.  The first two constitute the distinct small-pox of  medical  wri-
 ters,  and the last the confluent.
   The violence of the disease is generally in proportion to  the extent
 of the eruption  upon the skin.  Thus in  the  confluent form, all  the
 precursory symptoms are more severe;  the eruptive fever is more in-
 tense; the difficulty of respiration, and the pain, and uneasiness at the
 epigastrium, greater;  convulsions and delirium are  likewise more
 common than in the distinct form.   There is also more  danger, from
 the intense inflammation by which it is attended, of extensive slough-
 ing, or ulceration of the skin; while, in general, the  affection of the
 throat, and respiratory mucous membrane, is more extensive  and more
 liable to  give rise to  troublesome and dangerous complications.
   There  is  still another form  of small-pox—the congestive; in which
 the reaction is incomplete or absent.  The patient labours under symp-
 toms of severe oppression, and great difficulty of respiration;  his sur-
 face is cold, his pulse feeble; the eruption is slow in appearing, seldom
 very  extensive,  and  when  vesicles form,  these are flat, flaccid,  and
 never properly mature.
   We have remarked, that the severity of the febrile symptoms during
 the stage of maturation, is always in proportion to the number of pus-
 tules.  Their severity is, also,  in  some degree  influenced by the con-
 dition of the patient, and certain external circumstances.  Thus, in
 persons of a healthy, but not plethoric constitution, of a tranquil dispo-
 sition, and temperate habits, occupying large, cool, and well-ventilated
 apartments, and subjected to a proper diet and  regimen,  the eruption,
 although extensive, may maturate with the occurrence  of only a  mo-
 derate degree of febrile excitement; while, under opposite circum-
 stances, even a  less  amount of  eruption may  be attended by severe
 fever, and other unfavourable symptoms.
   Considerable attention has  been paid, by several modern observers,
 to the structure, or anatomical characters of the variolous vesicle.
   The inflamed  spot with which the eruption commences, is  seated in
the cutis vera.   It commences at a central  point, spreads by radiation
on the surface, and penetrates to a greater or  less depth in different
cases.  A substance  of a pulpy consistence, forming a kind of pseudo- 
486
DISEASES OF CHILDREN.
membranous  layer, is secreted  immediately beneath the epidermis,
which  it slightly elevates.  The vesicle is  cellulated, or  divided into
numerous cavities, having for its floor the  papillated  structure of the
cutis, elevated and marked with fissures and chinks, and,  at the height
of suppuration, swelled and moist like a sponge.  At the central point,
the  corion and epidermis adhere, causing the central depression on the
surface of the vesicle.  The  lymph  by which the cells  are first  dis-
tended, and subsequently, the purulent matter, is furnished by vessels
which  shoot from  the central point.   The lymph distends, at first, the
sides of the vesicle, which it raises above the level of the surrounding
skin; at length, with the more full distension of the vesicle, the central
filamentous attachment is destroyed, and the central depression is no
longer observed.  The pustule now acuminates and finally bursts, dis-
charging  a purulent matter, of a yellowish colour, and of the consis-
tence of cream.
  The inflammation of the cutis vera, is surrounded by a damask red
areola, more or less vivid according to circumstances, and  extending
to some distance beyond the margin of the  vesicle.
  Between the ninth  and eleventh days there takes  place  in all the
more violent forms of variola, an accession of febrile excitement; the
heat of the skin becomes increased, the pulse quicker, and the patient
more thirsty and  restless.   This is the secondary fever of medical
writers.
  In  many cases,  this secondary fever is comparatively  light  and
manageable;  but  in  cases of  confluent  small-pox, it  is  generally
marked by symptoms of very great violence, resulting from a renewed
inflammatory  affection of the skin, or the occurrence of  inflammation
of one or other of the internal organs.  Thus the breast, back, or extre-
mities, may become covered with an efflorescence  very similar to that
of scarlatina:—the tongue being at the same time morbidly red, and
the throat red, swollen, and painful.  In other cases, an  erythematous
eruption, sometimes passing into confirmed erysipelas, with extensive
vesications, occurs upon the head, trunk, or extremities.  In other in-
stances,  boils, abscesses, and carbuncles,  form in  the  neck, axillae,
groins, elbows, and thighs; or  a gangrenous  inflammation  attacks a
large extent of the skin, especially of the legs and feet, and in a few
days, lays bare the subjacent bones and muscles; or it may  attack the
scrotum and prepuce, and produce a rapid destruction of those parts.
Diffuse cellular inflammation may occur in  the scalp, or deep-seated
abscesses in various  parts of the body;  or the larger joints may be-
come  filled with  purulent matter.   The surface, and particularly the
cellular membrane under the lower eyelids, may be occupied  with an
ecthymatous eruption, giving rise to ulcers that pour out a thin ichor,
and heal  with difficulty.
  Ophthalmia is  a  very frequent accompaniment of the  secondary
fever,  and is almost always coincident with abscesses, or extensive de-
struction of the surface in some distant part.  It is of a very intense
character, setting in,  generally, about the  tenth  day, and rapidly in-
volving in more or less complete destruction, some one,  or  all of the
tissues of the  eyeball.  Sometimes it causes a sloughing of the cornea, 
DISEASES OF THE  SKIN.
487
followed by prolapsus of the iris; at others, thickening and opacity of
the cornea; occasionally, the whole globe of the eye is violently in-
flamed, and converted into one immense protruding abscess.  The in-
flammation is most generally confined  to one eye.  It is not produced,
as many suppose, by pustules upon the cornea or conjunctiva;  these
may be traced just within the inner edge of the eyelids, but never be-
yond it.                                                       .
   The brain not unfrequently suffers.  Children are observed to grind
their teeth, and squint; by degrees, symptoms of cerebral inflamma-
tion are developed, and the patients die, either from convulsions, or in
a state of coma.  The same affection  of the nervous  system  that  fol-
lows the destruction of large portions  of the skin by  burns or scalds,
often occurs.  The  symptoms are severe—repeated  rigors, followed
by general tremors; low delirium; a  quick,  thready, and tremulous
pulse; a dry, brown tongue; collapse of the features ; cold extremities;
subsultus tendinum, and death.
   The thoracic viscera are not unfrequently the seat of disease.  Most
frequently, inflammation of the pleura, as  well  costal as pulmonary,
occurs.   Its course is, usually, very rapid, terminating in death on
the third or fourth day, or even earlier.  The symptoms are, for  the
most part, verv severe and unequivocal; in  some cases they are, how-
ever, less violent; presenting, at first, the characters of pleurodynia or
thoracic rheumatism ; and frequently the disease  is chronic and latent,
and to be detected only by its physical signs.  The substance  of the
lungs is occasionally affected with inflammation,  and sometimes symp-
toms of croup occur.
   The abdominal viscera are not unfrequently affected ; either the pe-
ritoneum,  particularly that portion  investing the liver, is inflamed; or,
more generally, the mucous membrane of the ileum and colon become
the seat of inflammation, attended with tenderness of  the  abdomen,
diarrhoea, and red and aphthous tongue.
   During the period of convalescence from  an  attack  of small-pox,
either stnimous ophthalmia, or enlargement of the glands of the neck,
terminating in suppuration, or continuing in  an  indolent state  for a
long period, occurs in  the predisposed,  while in other  cases, severe,
deep-seated otitis, or  all the symptoms  of incipient  or confirmed
phthisis ensue.  There is, in fact",  nothing which is so liable  to  deve-
lope, in individuals of a strongly marked lymphatic temperament, affec-
tions of a scrofulous or tubercular character, as an attack of any of
the severer forms of small-pox.
   The  confluent form of small-pox may  present itself accompanied
with symptoms indicative of an adynamic condition of the system, or
of more or less extensive engorgement of  one or other  of the internal
viscera.  This constitutes the malignant, petechial, typhoid, or conges-
tive variola of various authors.
   In this  form of the disease, the  temperature of the surface  seldom
rises above^the natural  standard;  the pulse  is  slow, feeble,  and op-
pressed ;  the strength of the patient is greatly depressed ;  the respira-
tion is weak and panting; the tongue  becomes quickly dry and brown;
the teeth  covered with sordes;  the countenance contracted and  de- 
488
DISEASES OF  CHILDR&N.
pressed, and of a leaden or tawny hue.  At an early period, petechia?,
or subcutaneous ecchymoses, of large extent, or dark-coloured haemor-
rhages from the nose, mouth, stomach, or bowels, occur.   The eye is
often the seat, also, of extensive ecchymoses.   The gums  bleed upon
the slightest touch, and  often profusely.  In some cases death takes
place previously to the appearance of the eruption ; in others, the erup-
tion is pale, or copper-coloured, or dusky, with a leaden hue of the lips,
and a dark appearance of the face.  When  vesicles  form,  they  are
often  filled  with  a dirty,  turbid,  red fluid, or dark-coloured blood,
and there are often petechias scattered between  them.  This variety
has been termed the black pock (variola nigra).   In  many cases, no
maturation of the  vesicles takes place.
   Symptoms of extensive bronchial disease very  often present them-
selves from the commencement of  the attack : there  is then  a feeble,
inefficient cough; difficult  and  oppressed respiration ;  a leaden or
dusky hue of the lips  and cheeks;  great drowsiness; a suffering,
anxious expression of countenance ; a feeble, compressible pulse; cool-
ness of  the surface, and great prostration of strength; and the patient
often dies in a state approaching to asphyxia.
   Delirium, or a degree  of stupor, bordering  upon coma, very fre-
quently   occurs;  though in many cases of petechial  small-pox,  the
mind remains perfectly clear throughout.
   During the prevalence of epidemic small-pox, numerous cases of a
febrile affection frequently occur, marked by tenderness of the epigas-
trium;  pain in the hack  and limbs ; some degree of  soreness of the
throat;  salivation; profuse perspiration, from which no relief results;
and, not unfrequently, petechiae.  This has been  denominated vario-
lous fever without  eruption.   This  fever generally begins and ends at
the same time with the variolous epidemic.  We  have repeatedly met
with such cases, as well in the unprotected, as in  those who have been
vaccinated, or who had previously had the small-pox.  That the dis-
ease results from  the  same  infection  as  the  small-pox, we  have no
doubt:—how far  it affords  subsequent immunity from the latter, we
have had no opportunity of judging.
   A number of other  varieties of small-pox, founded upon some slight
modification in the form or  distribution of the eruption, are described
by medical writers; but as they are distinguished by no striking patho-
logical  characters, we  have thought it unnecessary to present a de-
scription of them.
   The  appearances after death, in fatal cases of  small-pox, vary con-
siderably, according  to  the period at which  death has occurred, and
the particular organs that  have become affected in the course of the
disease.  The lesions peculiar to small-pox are observed chiefly in the
skin and mucous membrane of the mouth, fauces, and respiratory tubes.
In many instances, these are the only lesions that exist, excepting, per-
haps, an overloaded state of the great venous trunks,  and of the pari-
etes and parenchyma of the internal  organs,  resulting, probably, from
the impediment which the disease  presents to the free  performance of
the functions  of the skin and lungs.
   Very generally, excepting perhaps  upon the palms of the hands, and 
DISEASES OF THE  SKIN.
489
soles of the feet, at the base of each pock there exists a small depres-
sion or orifice, resulting from the rupture of the excretory duct of one
of the cutaneous glands.  Where the cutis is not occupied with pocks,
it is often loaded with a white puriform matter.  At an early period of
the  disease, the inferior layers of the epidermis are in a softened state;
at a later period the connexion between  the epidermis and cutis is en-
tirely destroyed.   The cutaneous glands are invariably enlarged,  and
increased in vascularity, and their excretory ducts are often distended
with  the secretion of the glands.   The epithelium of the tongue  and
mouth is much softened.  The subjacent mucous membrane frequently
exhibits erosions, varying in depth.  The mucous follicles of the tongue
and tonsils are greatly distended; their orifices being sufficiently wide
to admit readily the introduction of a large probe.
  When death takes place previously to the twelfth day, the mucous
membrane of the  larynx  and trachea is deeply injected with  blood,
and covered with a copious viscid secretion of a purulent or puriform
fluid,  of a gray or  brownish colour.   When this is removed, the mem-
brane is found to  be thickened, pulpy, and, in severe cases, black or
sloughy.  The surface of the epithelium  exhibits, at an early stage of
the disease, a number of dull, rounded spots, of the size  of a lentil, pro-
duced by the exudation of a fluid beneath it.  In the progress of the
disease, this effusion becomes more  copious, and raises  the epithelium,
which may then be stripped off, exposing  the  inflamed, sometimes
ulcerated, mucous  membrane.  The ulcerations vary in number  and
depth, extending sometimes to the  submucous cellular tissue.  The
marks of disease in the trachea are not always uniformly diffused over
its whole surface, though the epithelium may be easily separated, even
in  the unaffected  parts.  Disorganization of the  bronchial  mucous
membrane, may be traced into the third series of branches.  The oeso-
phagus has been found, in some instances, studded with minute eleva-
tions, which have  been described  as pocks.  By many writers,  the
mucous membrane of the  intestinal canal is  described  as  presenting
numerous  small circular ulcerations; by some these have been sup-
posed to be true variolous  pustules; others, however, with greater
accuracy, regard  them as  enlarged or ulcerated follicles.   Variolous
vesicles have been seen upon the mucous membrane of the rectum, in
cases of prolapsus; and upon the granulations of the dura mater, in a
case of fractured skull.
  The several  organs are  more or less congested with blood,  which,
particularly in the  cavities of the heart and in the large blood-vessels,
is very fluid, and often of the colour of the dregs of wine.   If coagula
exist, these are small, black, soft, and diffluent.  They are rarely pale
and fibrinous, excepting when there co-exists an acute inflammation
of an  important organ, of some intensity.
  Indications of pulmonary inflammation are occasionally met with,
or of  pleuritis, generally confined to one side, and accompanied with
sero-purulent exudation. The brain and its membranes often exhibit
an  overloaded  state of their  blood-vessels.  In  many cases there is
found an effusion of turbid serum between the membranes of the brain,
and in the theca of the medulla spinalis. 
490
DISEASES OF CHILDREN.
  It has been stated by Dr. G. Gregory, that morbid appearances are
very rarely detected in the mucous membrane of the alimentary canal;
our own observations would lead us, however, to a very different con-
clusion.  In the majority of the cases we have examined after death,
diffused or  follicular inflammation, ulceration,  or softening  of the
mucous membrane of the stomach and duodenum, but more frequently
of the lower portion of the ileum, and upper portion of the colon, was
observed.   In  the post-mortem examinations made at the Small-pox
Hospital, during the variolous epidemic which prevailed at Philadel-
phia, in the years 1823-24, in nearly every case, more  or less disease
of the stomach and  upper portion of the  small intestines was observed.
Drs. Bell and  Mitchell, in their report of the epidemic referred to, re-
marked that, " we cannot refuse our assent to the belief, that the mucous
surface on which the preparatory process of digestion takes place, is
mainly  affected," in small-pox.
   In relation to the causes of small-pox, we possess little positive know-
ledge.   That the disease may prevail epidemically, spreading rapidly
over large communities, and even over extensive districts of country,
is a fact well established; and that the disease is capable of being pro-
pagated by contagion or infection, is equally certain. But  whether, in
any instance, it is possible for the small-pox to originate spontaneously,
or to be produced by certain electric, or other conditions of the atmo-
sphere, independent of a specific contagion emanating from the bodies
of the sick, is a question that has  excited very considerable dispute,
and the settlement of which is attended with no little difficulty.  And
yet, the sudden occurrence of the disease in a vicinity where no cases
hpd been observed for  many years; its appearing simultaneously in
distant parts of the same  city, without  the possibility of tracing it, in
either, to  an original source of infection, as was the case in the epi-
demic of  1823; the rapidity with which it spreads; its greater viru-
lence when it prevails as an extensive epidemic, than under ordinary
circumstances, as well as its  sudden cessation,  incline us to  believe
that small-pox may originate now, as it must have in the first instance,
solely from  atmospherical causes.
   During the entire course of the  disease, there emanates from the
body of a small-pox patient a contagion,  which,  by combining with
the air  of the chamber in which  he is confined, renders it capable of
 infecting those who respire it.  The  contagion  is capable,  also, of
attaching itself  to the bed and its coverings, and to the clothes of the
patient, provided these be closely wrapped up and  excluded from the
atmosphere; and probably, also,  to the walls of the apartment, when
free ventilation and a process of purification have not been resorted
to; and in this  manner may communicate the disease at a distance
from the  source of contagion, and after a considerable lapse of time.
But free  exposure  to the  air,  and the ordinary means of  purification,
will very quickly destroy the infecting property.   The contagion of
small-pox may likewise be communicated  by the  matter of the pus-
tules;  or even  by the scabs, applied to  the  skin, or  to  the mucous
 membrane of the nose, or still more  certainly, when applied to a wound
 or abrasion of the cuticle.  The dry scab retains the contagious prin- 
DISEASES OF THE SKIN.
491
ciple for a long period; experience has also shown, that for a conside-
rable time after the death of the patient, the matter of the pustules con-
tinues energetic ;  thus the air may be infected by the body of a patient
affected with confluent small-pox for at least ten  or twelve days after
death.
   Small-pox may prevail at all seasons of the year,  and it  attacks
alike individuals of both  sexes, and of every age.   According to our
own observations, it is much  more liable, however, to occur during
the colder  months, than during the other portions of the year.  In
Philadelphia, at least, the influence of the summer months in diminish-
ing the frequency of the disease, is very apparent.
   Some pains have been taken in order to determine to what distance
the contagious effluvium may extend, beyond the individual from whose
body it emanates; and it  has been concluded, that in all cases  its
sphere of action  is limited to the circumference of a  few feet.  We
are inclined to believe that the distance  differs under particular cir-
cumstances.  Thus in  close, foul, and  unventilated  apartments, every
portion of the air appears to become charged with the contagion;  so,
also, in confined and narrow courts, lanes, and alleys, in which the  air
becomes stagnant and impure, the contagious miasm extends to a much
greater distance than in situations differently circumstanced.   Hence,
in all epidemics, it is among the poorer classes, and in the least  salu-
brious  districts, that the disease prevails the most extensively and in
its severest  forms, and to which, under ordinary circumstances, it is
almost exclusively confined.
   Notwithstanding no period of life is exempt from the attack of small-
pox, it is very evident that the great majority of its subjects are  chil-
dren.  Some individuals appear much more susceptible to the contagion
of the  disease than others;  but from what that  susceptibility arises, it
is impossible to say.   In Philadelphia, it has been remarked that  the
blacks are  peculiarly obnoxious  to  the  disease, and that in  them it
is more fatal than in the whites; our own observations have confirmed
the truth of this observation.  In very severe epidemics, this difference
of susceptibility is not, however, observed so generally, as in an ordi-
nary occurrence of the disease.  Under all circumstances, it has  ap-
peared to us that  a neglect of personal cleanliness, habits  of intempe-
rance,  and fear, or a timid, desponding state of mind, strongly predis-
pose to an attack.
   The extent of  the eruption  upon the skin, and the intensity of  the
accompanying symptoms, are in no degree influenced by the character
of the  disease in  the individual from whom the infection has been  re-
ceived; thus, the  contagion from a confluent case will often produce
the small-pox in its mildest form, whilst infection from  the latter may
give rise to  the disease in its confluent  and most malignant character.
   The quantity of eruption is mainly  determined by the  state of  the
surface, at the period of its development.   Whatever has a tendency
to augment  the cuticular circulation, whether  too much  clothing,  ex-
ternal  heat, irritating substances directly applied to  the  surface, or
stimulating food, drinks, or remedies, taken into the stomach, increases
the extent of the  eruption; while whatever has a tendency to reduce
the determination of blood to the surface, as cold, a plain and abste- 
492
DISEASES OF CHILDREN.
mious diet, aqueous drinks, bleeding or purgation during the stage of
incubation, diminishes the quantity of papulae.  A plethoric state of
the body increases the intensity of the disease, and according to Gre-
gory  is  mainly instrumental  in occasioning cellular  complication.
Whatever has a tendency to impair the health and vigour of the sys-
tem, and vitiate the blood, imparts also to the small-pox an adynamic
and malignant  character; and this is one of the  chief causes  of the
prevalence of the worst form of the disease among the poor, ill-clothed,
ill-lodged, badly-fed, dissolute and intemperate classes of society.
   There is observed in many persons, and even in some of the mem-
bers of the same family, an  undefinable constitutional tendency to
suffer more severely than others from, and a greater liability to sink
under, even slight attacks of this, as well as  of most other affections,
while there are others, whose constitutions seem  to react favourably
under the severest forms of the disease, and to resist successfully, their
fatal tendency.
   It is a curious circumstance that, while in one  epidemic  nearly all
the cases are distinct and mild, in another they are almost all confluent
and malignant; the modifying cause being evidently connected with
some unappreciable morbid condition of the atmosphere.  In  South
America, according to Humboldt, these  epidemic varieties have been
strikingly evinced; at  one time, small-pox occurring as a mild and
comparatively harmless affection; whilst  at another, nearly all attacked
fall victims  to it.
   A strong predisposition to disease of particular organs, as the brain,
lungs, bowels, &c, or to scrofulous or tubercular affections, will  give
rise to serious complications in those attacked with small pox, altering
in some  degree its character, and increasing  its fatality.
   The influence of vaccination, as a protective against small-pox, will
be considered hereafter.
   Small-pox is unquestionably one of the most destructive diseases to
which man is  liable.   Prior  to the introduction of vaccination, the
average mortality is usually stated to have  been one in four of those
attacked, or twenty-five per cent.  At the London Small-pox Hospital,
according to Dr.  Gregory, the average of twenty-five years  gave
thirty-two per cent. In Germany it is stated by Heim to be twenty per
cent.  In Philadelphia, the average relative mortality, from 1786 to
1802, inclusive, was one in fourteen, nearly, or  about 7-28  per  cent.
From the years 1807 to  1811, inclusive, variolous inoculation being
still permitted, and  extensively practised, the deaths from small-pox
were to  the entire mortality of the city and suburbs, as one to twenty-
five, or four per cent.   In  1811, variolous inoculation was  prohibited
by an act of the legislature, and during  the succeeding four years, no
death from small-pox occurred.  From 1816 to 1841, the deaths from
small-pox  amounted to  1864;  giving a relative mortality of  one to
sixty-six, or about 1*66 per cent.   In  England, prior to 1800,  that is,
before the period when  vaccination influenced the results, the deaths
by small-pox were  to the  total deaths, both  in town and  country, as
 16 to 100.   From the report  of the Registrar-General of England, it
appears that, in 1837, there were only five diseases more fatal in Eng- 
DISEASES OF THE SKIN.
493
land than small-pox; and  that the deaths throughout England and
Wales by that disorder, amount now, annually, to about 12,000.
  The greatest  mortality  from  small-pox in  the  unprotected, takes
place in children between two and five years of age.  It is  computed
by Haygarth, that at Chester, (England,) during the latter part of the
last century, one-half of the deaths in children below ten years of age,
was due to small-pox.  In Philadelphia, during the 40 years  preceding
1845, 3022 deaths from small-pox occurred in  persons of all ages ; of
these, 1810, or more than one-half, occurred in children under 10 years
of age, namely:  under 1 year, 555;  between 1 and 2, 335; between
2 and 5, 624; between 5 and 10, 296.
  Death may take place at any period of the disease—even prior to
the appearance of the eruption; or the disease may run its course, and
death may then occur from some one of its ordinary sequelae.   Most
commonly, however, a fatal termination  is to be anticipated between
the eighth and twelfth days from its invasion.  In a table of 168 fatal
cases of small-pox, given by Dr.  Gregory, it appears that in 32, death
took place between  the third  and seventh days; in 83, between the
eighth and twelfth days; in 39, between the eighth and twentieth days;
and in 16, between the twenty-second and thirty-eighth days.
  The danger from small-pox varies  materially  in different cases.
Distinct  small-pox is ordinarily a  disease of very little danger; and
under a simple treatment, very generally terminates favourably. Con-
fluent small-pox, on the  other hand, is always attended with danger,
particularly when the confluence occurs about the  head and face;  in
such cases, death often takes  place suddenly and  unexpectedly.  In
every attack the danger is in proportion to the amount of the eruption,
and the accompanying affection of the throat and respiratory organs.
  As a general rule, liable,  however, to some exceptions, when small-
pox occurs as an epidemic of wide extent, it is more violent  and fatal,
and less under the control of remedies, than when but a few isolated
cases make their  appearance.   In patients  occupying large, comfort-
able apartments, or  airy, healthy  neighbourhoods, the  disease is at-
tended with much less danger than in those placed under opposite cir-
cumstances.  In the cellars  of London, Dr. Armstrong remarks, small-
pox is almost invariably confluent and violent; while in garrets, espe-
cially in open streets where there is a free ventilation of air,  it is often
distinct, and generally more mild.  A similar remark may be made in
reference to Philadelphia.
  In individuals of a  broken-down constitution, or in whom the powers
of life have been impaired by intemperate  and licentious lives, previous
sickness, or by exposure, bad  food, and uncleanly habits, the  disease
is very apt to assume an adynamic, haemorrhagic,  or congestive cha-
racter, and very  generally terminates  fatally.  In persons  of a ple-
thoric habit, small-pox  generally assumes an aggravated form, and is
often  fatal.   A predisposition  to  scrofulous or tubercular  disease, is
very apt to render  the  sequelae of small-pox  particularly severe and
unmanageable. When many patients are crowded together in a small
space, even with the  advantages of free ventilation, it always increases 
494
DISEASES OF CHILDREN.
Under one year Between one and	two	425 262
" two "	five	452
" five «	ten	235
" ten " " twenty" " thirty "	twenty thirty forty	170 460 272
the malignancy of the disease, or endangers the occurrence of some
fatal malady during the latter stages.
   The age of the patient has likewise a considerable influence in in-
creasing or diminishing the danger of an attack of small-pox :—as we
have  already seen, the disease is much more fatal in children under
ten years of  age, than in the middle  periods of life; the same is true,
also, of persons advanced in  years.   The most  favourable age, it is
said by one of the most authoritative writers on the disease, (G. Gre-
gory,) for taking small-pox, is from the seventh to the fourteenth year,
when the powers of life are in full vigour, without the risk of plethora.
This does not, however, conform with  our experience;  we  have met,
almost invariably, with  the mildest cases, and the smallest number of
deaths, even  in the more violent  forms of the disease, between  the
ages of ten  and twenty.   In a table of 2465 cases, copied from  the
official records of the  Health Office, at Philadelphia, the ages at which
the death took place are as follows:—

                                 Between forty  and fifty          124
                                   "    fifty   "  sixty           41
                                   "    sixty  "  seventy        14
                                   "    seventy"  hundred and ten  10

                                                        Total 2465
   The  unfavourable  symptoms in small-pox, are confluence, a flat,
flaccid condition of the distinct vesicles, with a dark-coloured areola;
imperfect,  deficient, or excessive reaction;  extensive disease of the
throat and mouth, and early hoarseness of voice; a suffocating cough,
and difficult, panting, laborious respiration;  a dark appearance of the
vesicles, from their being filled with a bloody fluid; petechiae, vibices,
and a haemorrhagic tendency generally; prominent symptoms of ady-
namia ;  great nervous excitement, with a tendency to cerebral disease ;
fear  and despondency on the part of the patient;  great  restlessness,
particularly at night, and symptoms  of extensive  gastro-enteric dis-
ease.  The favourable or unfavourable termination of the  case  will,
of course, be greatly influenced by the period of the attack at which a
judicious plan of treatment is commenced; and  by the physician  hav-
ing it in his power to  remove, at once, the patient from the influence
of a foul and confined atmosphere and other injurious agencies.
   The immediate causes of death  in small-pox  are, a state of great
depression or collapse occurring at the onset of the disease, the powers
of life sinking at once, without an effort, or but an ineffectual one, to
react:—after the  seventh day, violent and extensive disease of the re-
spiratory mucous  membrane; during the period of secondary fever,
the occurrence of cerebral effusion, pleurisy, pneumonia,  laryngeo-
tracheitis, gastro-enteritis, or extensive grangrene of the skin ; at a still
later  period, death may occur  from erysipelas, tubercular phthisis,
effusion into the chest or brain; or it may arise from excessive ex-
haustion.   Many, however, of these latter results, are to be  attributed
to mismanagement of the earlier stages, or to imprudences committed
by the patient or his friends. 
DISEASES OF  THE SKIN.
495
  Although,  as  a general rule, an attack of small-pox protects the
system  from the influence of the disease throughout the remainder of
life, yet, though  the instances are comparatively rare, cases have oc-
curred in  which a second attack has taken place.  We have ourselves
met with several, and still more frequently with those in which patients
who had,  at  a former period, passed through  the small-pox, suffered,
during  an epidemic of  the latter, a pretty severe attack of variolous
fever, without eruption.   It is stated by Gilbert Blane, that all the well-
authenticated cases of secondary small-pox, have been of persons who,
in the first instance, had it  severely.   In three-fourths of the cases
which have fallen under our notice, the individuals were deeply pitted,
and  otherwise deformed  by the first attack; in the remaining cases,
there existed indubitable proofs  of  the  previous attack, but  not the
same evidence of its severity.  In one-third nearly of these secondary
attacks, the disease was confluent, and terminated fatally.  In no in-
stance  have  we  met with the recurrence of the disease, excepting in
those in whom the attack, in the  first instance, was spontaneous, and
not from inoculation.
  It is no unfrequent  occurrence for a  local effect to result from the
application of variolous  matter to the bodies of those who have  already
undergone small-pox.   We have  repeatedly seen well-formed small-
pox pustules  upon the breast or  arms of nurses who had the care of
infants  affected with the disease; in two instances there was  marked
febrile excitement.
  The treatment of small-pox naturally divides itself into that proper
during the several periods of incubation, eruption, maturation, desicca-
tion, and convalescence.
  As we are seldom  able to determine the exact period of infection,
we should act upon the  supposition that every unprotected individual,
who has  been exposed to the  contagion of small-pox, is already in-
fected, and without alarming his  fears, immediately subject him to a
proper hygienic  course  of treatment; placing him on a moderate, plain,
and unirritating  diet,  with aqueous drinks, keeping his bowels regular,
freely  exposing  him  to a cool, fresh atmosphere,  while  his  body  is
properly protected by clothing suited to the season of the year; guard-
ing him from the night air, and from  every species of undue excite-
ment ;  and, whenever it is possible, removing him from a confined and
unhealthy dwelling or district, to one of an opposite character.
  The diet must of course be modified according to the  state of health
and constitution  of each individual.  The robust and plethoric should
be confined to farinaceous articles and  milk, in moderate quantities;
while the  feeble  and delicate should be allowed a more nourishing, but
equally unstimulating diet.  In  purgatives and emetics  as  prophylac-
tics, we have no great faith:—if  the bowels are costive, a brisk but
mild purgative will be proper;  or if the stomach be overloaded with
undigested food, an emetic will be demanded;—but neither is to be
employed solely  with reference to the possibility of an attack of small-
pox.  The tepid or warm bath—the one or the  other being used ac-
cording as the temperature of the  surface is sustained or depressed—
will, in  most cases, be advisable;  it has a powerful influence in equa- 
496
DISEASES  OF CHILDREN.
lizing the circulation, and overcoming any tendency which may exist
to local hyperaemia.
  During  the  eruptive fever, we must be guided in our remedies by
the  degree of reaction, and the presence or absence of indications of
visceral disease.
  In the ordinary cases of distinct small-pox, the symptoms are gene-
rally mild, and demand but little interference on the part of the physi-
cian beyond the administration of some mild purgative to open the
bowels  freely,  and the direction of a mild, bland  diet, and cooling
drinks; the body of the patient, at the same time, being kept cool, by a
free ventilation of the apartment he occupies, without, however, ex-
posing him to  the influence of a direct current of air;  and by causing
him to  lie upon a  hair mattrass, but lightly  covered with  bed-clothes.
Sponging  the surface of his body with tepid water, will generally be
attended with good effect.  The saline effervescing  draught will be
proper, if  there be considerable heat and dryness of the skin.  When
intense  pain in the head is complained of, leeches applied to the tem-
ples will afford great relief, and should not be neglected; in cases, also,
attended with considerable pain and tenderness of the abdomen, leeches
to this part will be demanded.
  When,  however, the febrile action is intense, with great heat of the
surface, a tense, or full, labouring pulse, severe pain of the head, back,
or  epigastrium, great irritability of stomach,  oppressed breathing, or
other symptoms of local inflammation  or hyperaemia, a  much  more
energetic  practice is  demanded.   Bloodletting, general  and local,
is  here our  most important remedy, and  upon its prompt  employ-
ment, to an extent commensurate with the violence of the symptoms,
will mainly, if not  entirely depend, the safety of the patient.
  Upon no subject connected with the treatment of disease, has there
existed a  greater  discrepancy  of opinion than in  relation to the pro-
priety of bleeding  in  small-pox.  By some  it has been entirely con-
demned in every case, as a measure calculated to retard  or prevent
the eruption, to interfere with its regular progress, and to  prevent its
maturation.   It has, however, under the circumstances  referred to,
received the sanction  of many of the most distinguished practitioners,
from the time  of Sydenham to  the present  day.  It is only, however,
for the reduction of excessive excitement, or for the removal of local
inflammation or hyperaemia, that the loss of blood is demanded in any
case of small-pox.
  The extent  to which bloodletting should be carried, must be decided
by  the violence of the symptoms which indicate its employment, and
the effects of the remedy.  In cases of congestive variola, in particular,
the abstraction of  blood should be performed with great caution, and
with the finger upon the pulse; if the latter sinks, the operation should
be  at once suspended; if it becomes  fuller and stronger, the blood may
be  allowed to  flow, but never to the extent of inducing the  slightest ap-
proach to syncope.
  In the more malignant forms of the disease, attended from the  onset
with evident depression of the vital powers,  bleeding should never be 
DISEASES OF THE SKIN.
497
resorted to; mild aperients may, nevertheless, be demanded, together
with a free exposure to the fresh air, without, however, allowing the body
of the patient to become chilled.  The warm bath will, in many cases,
prove a valuable remedy; and if there be evidences of a rapid sinking
of the patient's strength, even diffusible stimulants, as warm wine whey,
warm  wine and  water, ammonia and  camphor, will  be demanded.
These  must, however, be administered with caution, and their effects
carefully watched:—if, under their use, the skin becomes hot and dry,
the  tongue  parched, and the pulse quick and frequent, they should  be
immediately discontinued.
  In those  cases  in which bleeding is indicated, the bowels should  be
kept open every day, by the occasional administration  of some mild
purgative, and the diet should consist exclusively of thin water gruel,
with cool toast water, gently acidulated, for drink.  In regard to ven-
tilation, tepid sponging, &c, the same remarks will apply, as  in the
mild, distinct form.
  In all the  more severe cases of small-pox, the hair  should be cut
close.   This  diminishes the amount of eruption  about the scalp, the
tendency to cellular inflammation of this part, to inflammation  of the
eyes, and to cerebral disease or violent delirium, while, at the same
time, perfect  cleanliness is the better secured.
  During the stage of maturation, in mild cases, and when the erup-
tion is  perfectly  distinct, we have little  to do beyond  keeping  the
patient cool, his apartment perfectly clean and well ventilated, and his
howels regular, by gentle purgatives; confining him, at the same time,
to a spare, unstimulating diet;* allowing him the  free use  of cool,
aqueous drinks;  keeping him perfectly quiet, and his body and mind
free from exertion or excitement.
  Should there be much heat and dryness of the skin, with a  sharp,
active pulse, the  infusion of senna with  the addition  of sulphate of
magnesia, or the compound powder of jalap, or magnesia  and rhu-
barb, should be administered, in such doses and intervals, as to produce
free purgation, without, however, irritating the bowels, or reducing,
too rapidly, the strength  of the patient: — while a free state  of the
bowels  is all-important in these cases, very active purging  is to  be
avoided.  When the saline cathartics produce  griping pains, and re-
peated watery stools, calomel  combined with magnesia, and followed
by castor oil, should be substituted, or the calomel may be combined
with the compound extract of colocynth.  Although calomel has been
condemned after the appearance of the eruption, we still believe that,
in many cases, it is  one of the best purgatives we can employ; it is
sufficiently mild in its operation, and would appear to possess  peculiar
powers in moderating the violence of the disease.
  Saline draughts in a state of effervescence, or the liquor ammonias
acetatis, may be  administered  at short intervals; or,  in cases unat-
tended wdth gastro-intestinal  disease, small doses of nitre and tartarized
antimony, the sweet spirits of nitre with antimonial wine, or a combi-
nation of hydrochloride of ammonia and ipecacuanha,* will be found
to assist in moderating the violence of the febrile excitement.
                               32 
495
DISEASES OF CHILDREN
              » R.—Pulv. hydrochlor. ammonise, gr. xxxvj.—xlviij.
                    "  lpecacuanhffi, gr. iij.
                    "  Sacchar. pur. ^j— M. f ch. No. xij.
                 One to be given every three hours.

  When there exists considerable pain of the throat,  with difficulty of
swallowing, leeches should be applied to the neck, and if necessary,
their bleeding encouraged by fomentations with warm water.   When
there is great difficulty of breathing, cough, copious  expectoration  of
mucus or muco-purulent  matter, and other indications of inflamma-
tion of  the bronchi or lungs, provided there is no sinking of the pulse
or symptoms of great  exhaustion present, blood should be taken from
the arm, to an extent  sufficient to control the  local  disease.  Subse-
quently the citrate of potassa,  in solution, with the addition of antimo-
nial wine, may be administered ; and if the cough continues to harass
the patient, and prevents his sleeping at  night, an opiate administered
in the evening, will  generally  afford relief.  Either  of the  following
may be given.*
* R.—Mucilag. g. acacia?, giij.           Or, R.—Pulv. ipecac, gr. iij.
    Syrup, scillaj, 3j.                        Magnesiae calc. gr. xxxvj.
    Spir. nitr. eeth. 3iij.                      Ext. hyoscyami, gr. vj.—viij.—M.
    Vin. ipecac. 3j.                          f. ch. No. xij.
    Tine, opii camph. 3j.—M.            One to be given every two or three hours.
  Dose, a teaspoonful every two or three
hours.
                      Or, R.—Vin. antimon. fU/x.
                            Spir. aeth. nitr. ftfxv.
                            Tinct. opii camph. fft/xv.
                            Syrup, simpl. 3ss.—M.
                                For a dose.

  When symptoms present themselves indicative of  cerebral disease;
as intense pain of the  head, flushing of the face, an  injected state  of
the eyes, delirium, and violent pulsation of the carotid and temporal
arteries, blood should  be drawn from the arm, leeches or cups applied  ^
to the temples and nape of the neck, and the bowels  freely purged, by
some  active cathartic, as calomel and jalap, or  calomel  followed by'
castor oil, infusion  of senna,  &c.  When the surface is very tender
and painful  to the touch, cooling lotions  should be  applied, or a few
leeches upon the parts where the  inflammation is  the most intense. '
Inflammation of  the eyes should be  treated by leeches, active purga-
tives, and emollient lotions.
   In some cases  the eruption does  not come out freely, and the patient  ,
is affected  with great  irritability of stomach, frequent vomiting, a feel-
ing of great  oppression at  the  praecordia, and  a small, feeble pulse.  •
These symptoms will  generally be relieved, and,  at the same time, the
eruption upon the skin promoted,  by the warm bath, warm pediluvia,
or hot bottles to the feet, with  sinapisms to the epigastrium and extre-
mities, and purgative injections.   If any symptoms exist indicative of  *
a congested  state of either of the internal organs, the  cautious employ-
ment  of bloodletting, will  frequently be productive of the best effects.
   In malignant cases of small-pox, with a flaccid, dark condition  of
the vesicles, petechiae, haemorrhages, a livid complexion, coldness  of
the extremities, and evident exhaustion, the treatment must be regu- 
DISEASES  OF THE SKIN.
499
      Iated according to the urgency of the  symptoms  in each case.  The
      utmost attention should be paid  to insure a free ventilation of the
      apartment occupied by the patient, at the same time  that his body is
      kept warm :—his bowels should be kept gently open by mild aperients,
      or simple enemata.
        In the petechial and haemorrhagic cases, the vegetable and mineral
      acids have been highly recommended, but particularly the sulphuric,
      the chloric and the hydrochloric, and the juice of lemons.  These may
      be given freely, diluted with water, or in combination with the decoc-
      tion of bark or solution of quinia. When, however, there is a tendency
      to a rapid failure of the powers of life, diffusible stimulants will be de-
      manded; the mildest  should be  first tried, and if they fail, recourse
      should be had  to those of greater power; thus, warm wine whey,
      warm wine  and water, ammonia  and camphor should be first admi-
      nistered,  and  if stronger  stimulants  are  required, milk punch, port
      wine, or  brandy, may then be given.   They should all, however, be
    0 used with caution, and in doses proportioned to  the condition of the
 ^   patient.   Their effects are to  be carefully watched, and if they aug-
 .   * ment the  heat of the surface, quicken the pulse, and render the tongue
   *  dry, or bring on a state of deep stupor or coma, their use should be
•     immediately abandoned.
^      Various plans have been resorted to, during the  stage of maturation,
J*  ~to prevent pitting, and the permanent deformity  thence resulting.   It
   f  has  been asserted by Velpeau and Meyreux, that if the pustules be
      opened on the  first or second day of their appearance, and touched
 r-"% with a pointed pencil of nitrate of silver, they will  be wholly destroyed,
      and  leave no  marks.   The most effectual means, however, for ob-
      taining this  desirable result, is that of keeping the patient in a dark
   / } apartment, or covering his face with a linen mask, smeared on its inner
ff^  surface with mercurial ointment.  Dr. Stewardson, formerly physician
 f|   to the Small-pox Hospital  at Bush Hill, instituted a number of experi-
 T   ments to  test the effects of this practice; from the result of which, he
 ^-'remarks,  it seems  pretty evident that the mercurial ointment has a de-
      cided influence upon  the  small-pox pustules, preventing more or less
 f~%  completely their perfect maturation, and diminishing the concomitant
      swelling  and soreness;  the process of desiccation being completed
      without the formation of thick scabs, and the resulting cicatrices being
      <less marked  than when the process of suppuration is left to pursue its
      natural course.  It  is also apparent that  this influence is chiefly ob-
      servable  in cases  where the eruption  has not  advanced  beyond the
      third  or  fourth day.  Dr. Stewardson ascertained, by  comparative
      trials, that the  same results do not happen  when simple cerate is used
      instead of the  mercurial ointment.
        It  has  been  proposed by Serres and Olliffe, to  pencil  the  eruption
   .-with a strong solution of nitrate of silver, 15 to 45 grains to the ounce
   •   of distilled water, previous to its assuming the pustular form.  Mida-
      vaine employed frictions with sulphur ointment,  made of a drachm
      and a half to  two drachms, to an ounce of lard, over the parts co-
      vered with pustules, and recently, Dr. Crawford, of Montreal, and Dr.
      Jackson,  late of Northumberland, now of this city, recommend pencil-
 
500
DISEASES  OF CHILDREN.
ling  the eruptions  with the tincture  of  iodine, and  relate several
instances  in  which abortion of the cutaneous affection was in this
manner produced.  The favourable results of either practice require
confirmation from a more extended series  of observations.
   The period of desiccation in the milder  forms of small-pox, requires
no particular treatment.  The  bowels of  the  patient should be kept
regularly  open  by mild aperients; his diet should  be  gradually ren-
dered more nourishing, care being taken, however, that it be com-
posed of articles  of ready digestion, and not too stimulating, and that
the most trifling  excess be  not committed ; the same rules  being ob-
served  until complete convalescence  ensue.  During the period of
convalescence, the daily use of the warm  bath will be advisable.
   When secondary fever ensues, it must be treated  on general princi-
ples, and according to the nature  of the complications with which it is
accompanied.  Violent excitement should be reduced by low diet, cool
acidulated drinks, free ventilation, purgatives, and  by the saline dia-
phoretics  with  minute doses of antimony, when  these are not contra-
indicated  by the  condition of the digestive mucous membrane.  The
occurrence of local disease will require the use of the remedies appro-
priate to the character and extent of the latter;  while a state of posi-
tive adynamia, will demand the cautious employment of stimulants
and tonics.  The same remarks will  equally apply to  the various
sequelae of small-pox.  In regard  to  the character of the remedies* 1
employed, and  the  extent to which  they  are to  be carried, due atten-\T
tion must be paid to the greater or less degree of exhaustion, resulting  ^
from the  preceding disease;—for though in  many of the  affections^V
which occasionally occur subsequent  to  small-pox, depletion  by the\ ^
lancet, by cups or leeches, or by purgatives will  be demanded, yet we A
are  seldom  able to employ it with the same freedom we  should in **
similar forms of  disease, occurring under any other circumstances.
   When the attack of small-pox  has developed symptoms of scrofu-
lous disease—although in some instances,  sarsaparilla,  mild  mercurial.
alteratives, or perhaps some of the preparations of iodine, may be found
serviceable—a prudent hygienic  course of treatment, is the one most
to be relied on.   A change of air; appropriate clothing ; a well-regu-
lated diet, and  daily exercise, proportioned to the strength of the pa-
tient ; the warm bath, or sponging with tepid salt and water, followed
■by friction of the surface, will frequently  improve the digestion, invi-
gorate the capillaries of the  surface, render the functions of haematosis
and nutrition more  regular and perfect, and remove the danger of ex-
tensive  disease of the glands, lungs, and serous membranes.
   As a means of rendering  the small-pox milder and more  managea- ^
ble,  and in this manner decreasing its mortality,  the inoculation of the*
disease, had been practised by some of the nations of the East,  proba-\^
bly for  a  considerable period  before the  practice became  known to^
Europeans.  It was not, however, until the beginning of the year 1721,^
that it was  introduced into England, by the energy and perseverance
of the celebrated  Lady Mary Wortley  Montague, whose husband had
been English ambassador at Constantinople.  In June of the same year, 
DISEASES  OF THE SKIN.
501
     it was introduced into America, by the Rev. Cotton Mather, under the
     directions of Dr.  Boylston, of Boston.
       Inoculation was unquestionably a most valuable discovery,  and had        «
     the effect, when  it came to be extensively practised, of disarming the
     disease of some  of  its  most frightful features, and  of sensibly dimi-
     nishing its ravages.   At the same time, however, it had a tendency to
     perpetuate the small-pox, and by multiplying foci of contagion, to ren-
     der  the disease,  which  had previously  only  occurred at intervals, a
     frequent epidemic.   Happily, the subsequent",  and far more important
     discovery of Jenner has rendered a resort to inoculation unnecessary,
     as a means of protection from  the infection of small-pox, and as, in
     most of the  states,  the performance of inoculation is  prohibited by
     law, while there  appears no just grounds for believing that the neces-
     sity  will ever occur  for  its  revival, we may dismiss the subject without
     any more extended notice.

                            5. — Vaccination,
       It was long known, in the principal dairy counties of England, that
     cows are subject to  a pustular eruption; and  it was the popular belief
     in those counties, that when this was communicated to the  hands of
     milkers, it rendered them, ever after, insusceptible of the variolous in-
     fection.  To this circumstance, the attention of Dr. Edward Jenner
     became directed  very early in life.  In 1796, he made successful ex-
     periments with the matter obtained from  the cow, and found that on
     those whom he had infected with this matter, the variolous inoculation
     took no effect.   It was not, however, until  two years subsequently,
     that  he published  the result of his investigations.  Public attention be-
     came at once awakened to the subject;  and although the introduction
     of vaccination was  at  first violently opposed  in different quarters, it
*''   was hailed, very  generally, as a means of certain security against a
     loathsome and dreaded disease, and as one that would  ultimately re-
     sult in annihilating one of  the most dreadful  scourges of the human
     species.  The knowledge and practice of  vaccination spread rapidly
     throughout Europe and America; and there is now no civilized nation
     on the earth,  by whom it has not been adopted.
       In regard to the origin and nature of the vaccine disease in the cow,
     numerous opinions have been expressed.  Jenner at  first ascribed its
     source to  the grease, a  disease which affects the feet of horses, and
     which is communicated  to  the udder of the cow, by the hands of the
  ■   milkers and farm  servants.   It has been asserted, that a  pustular dis-
     ease, in every respect similar to the vaccine affection, may be  pro-
     duced  in the human subject, as well as in the cow, by inoculation with
     the matter of grease.  Sheep are likewise subject to a pustular disease
    about the head  and  mouth, which, it is  said, when communicated to
     the human system, affords  security against the small-pox. It has  like-
    wise been asserted by Lisa, that the inoculation of sheep with vario-
    lous  matter, effectually protects  them from the pustular disease  just
    alluded to.
      Jenner on  the  first announcement of his  discovery, advanced the
    opinion, that  cow-pox (or  the variolae vaccinae,  as  he termed  it),  and 
502
DISEASES  OF CHILDREN
         small-pox are identical in  their nature,—the vaccine infection  being
         only a milder form of inoculated small-pox.  This opinion he ever after
I        maintained ;  and its correctness would appear to be confirmed by the
         well-established fact, that  when variolous  matter  is inserted  in  the
         udder of the cow, it produces an affection identical in all respects, with
         the cow-pox, and which, communicated to the human  subject, affords
         him the same protection against the variolous infection.  This fact was
         early noticed by Reiter and Gassner, but for its  full establishment, we
         are chiefly indebted to the  more  recent  experiments of Theile, of
         Russia, 1836-38; of Ceely, of London, 1839; and of Martin, of Mas-
         sachusetts, performed  1835, published  1841.
            In his first publication, Jenner announced his conviction, that  the
         cow-pox, when it has once  passed in a perfect form through the human
         body, leaves the constitution for ever after secure from the infection of
         small-pox.   This was, also, the  opinion generally entertained by  the
         physicians of Europe and America, until the year 1818.  During this
         and the  succeeding year,  an epidemic small-pox pervaded Scotland,
         and many persons who had been vaccinated, wrere attacked with a mild
         form of  the disease.  The  same thing occurred  in the subsequent epi-
         demics of small-pox which prevailed in various parts of Europe, Ame-
         rica, and the East Indies; and in  not a  few instances, very violent
         attacks of  the disease, in its  most  unmitigated  forms, and of a fatal
         termination, were reported to have occurred in  those who had been
         previously successfully vaccinated.
            These facts have very forcibly directed the attention of the profes-
         sion to a  more close  investigation of the extent  of the protection
         afforded  by the vaccine infection.   Although the result of this investi-
         gation has, it is believed, shaken the confidence of a few in its prophy-
         lactic value,  the majority,  notwithstanding  their views in  relation to
         vaccination have been slightly modified, still believe that, when  the
         system has been placed fully under the influence of the vaccine virus,
         it is completely protected, in the greater number of cases, against a
         subsequent attack of small-pox; and  that,  even in those, to whom it
         has failed  to afford this complete  protection, the small-pox, when it
         does occur, is so far modified in its character, as to become a disease
         of little severity, and seldom, if ever, fatal.
            The most accurate series of observations in relation to the protective
         powers of vaccination, have  been recorded  during the few past years,
         by physicians in different parts  of  the world, possessing opportunities
         particularly favourable for  their prosecution; all  of which observations
         fully bear out this latter estimate of the value of vaccination.
            It is true, however, that  in  certain cases, vaccination  has failed
         to afford full protection against the infection of small-pox, and various
         opinions have been advanced to account for the fact.  By some, it has
         been ascribed  to a gradual deterioration of the  vaccine virus, in con-
         sequence of  its transmission  from person to person, and  they strongly
         urge the necessity of recurring, at short intervals, to the cow, for fresh
         matter, in  order to secure its complete prophylactic powers.  That, in
         some instances,  spurious matter may have been employed, and, in
         others, that which had undergone some change  capable of impairing 
DISEASES OF THE SKIN.
503
its protective influence, and that  the  infection resulting from  such
spurious  or deteriorated matter may have been mistaken by ignorant,
careless,  or inexperienced practitioners, for genuine vaccination,  is
probably true.  By many, however, it  is maintained, that the supposi-
tion of the vaccine matter, in general  use, having become, in any de-
gree, deteriorated, is disproved by  the fact, that the appearance of the
vesicle produced by it—the period of its incubation—its progress, and
the distinctive  characteristics of its successive stages, are precisely
the same as those obtained  from  the use of matter more recently de-
rived from the cow.   It is nevertheless certain, that, when the latter
is employed, a marked  improvement is perceptible  in  the resulting
vesicles; the local inflammation is also more severe; and  the consti-
tutional symptoms more violent.
   We have for some years past been in the habit of using vaccine
matter recently obtained from the  cow, supplied to us by a friend  in
Europe, and we have found it to be much more energetic and efficient
than that in common use in this city.
   By many physicians, of  great respectability, it has been  supposed,
that the protective powers of the vaccine infection become gradually
impaired, as the individuals who have  been subjected  to  its  influence,
advance  in age, until, finally, they become anew susceptible to the con-
tagion of small-pox. Brown, of Edinburgh, Gregory, of London, Mohl,
of Copenhagen, Heim, of Wirtemberg, and some few of the physicians
of this country, advocate  this  opinion; all  of  whom insist upon  the
necessity of revaccination, as a means of restoring to the system  its
immunity from variolous infection.
   We have collated with no little  care the leading facts, which bear,
either  directly  or  indirectly, upon  this question, especially those  re-
corded during  the last  ten years; all  of which, in our  opinion, very
fully sustain the position of Jenner, that, in every instance in which  the
system can be fully infected with the vaccine disease, it affords a pro-
tection against the occurrence of small-pox, which is unimpaired with
the lapse of time.   The question as to the propriety and  advantage of
revaccination is, nevertheless, a very important one.  That, among a
given  number  of those who have  been apparently successfully vacci-
nated, there will be found many, in whom, from  some cause not well
ascertained, a greater or less degree of susceptibility to variolous infec-
tion is left unextinguished, and which  susceptibility augments in time,
is a fact that would appear to be well established; and such  indivi-
duals, will be found to be,  also, susceptible to re-infection by the vac-
cine virus.  Now, the question presents itself, Will it  be possible, by
subjecting these individuals to revaccination, to protect  them from  an
attack of  smail-pox?  In  order  to test this question, revaccination
has, for  some  years past,  been very  extensively practised in many
parts of Europe, and the  results obtained thus far, are curious and
interesting.
   We have  collected together the results  of 358,291 revaccinations
performed by  different Individuals  in Europe and this country;  in
about 39 per cent, of these the revaccination is  stated to have been 
504
DISEASES  OF  CHILDREN.
successful; while in 70,500 cases,  in which a second revaccination
was performed, in 10-5 per cent, the operation is reported as successful.
  We are not, however, to conclude, that, in every case in which re-
vaccination is successful, the individual has  been previously  well vac-
cinated.  In,  perhaps, the  majority of instances,  we have  no other
evidence of the primary vaccination, and of its character, than the
report of the individuals themselves, and the presence  of a more or
less perfect cicatrix upon  the arm, neither of which  is to be received
as conclusive.   But,  after  making  a  reasonable deduction  for  such
cases as may be supposed to have been imperfectly vaccinated in the
first instance, there still remains a  large number  of cases  (about 33
per cent) in which the primary vaccination,  though to all appear-
ances regular and complete, fails, from some peculiarity of constitu-
tion, to afford  a perfect security from  subsequent  variolous  infection,
and in which a revaccination  is essential, in order to  insure to the
individuals a full protection.
  If, therefore,  the facts upon record are perfectly  accurate, and there
is no  reason  for suspecting them to be  otherwise,  they afford conclu-
sive evidence of the necessity and importance of revaccination, in all
cases in which persons are liable to be exposed  to the  infection of
small-pox; not, however, from any fear that the protective power of
the primary vaccination, when the system has been placed fully under
its influence, may be  impaired by time, but  simply as a test whether
the susceptibility of the individuals to variolous disease has  been fully
extinguished.
  Had  we no  other  proof of  the importance  of  revaccination,  that
derived from the results of the  operation, among  the soldiers of the
Prussian army, would be sufficient.  The whole army now  enjoys an
almost  entire  immunity from  the  contagion of small-pox, notwith-
standing it has been repeatedly subjected to its influence.  To the re-
port for 1841,  we  find attached the following important statement:
The powerful influence of revaccination, in the diminution of vari-
olous diseases,  at the different military hospitals, is  most  remarkable.
During the year 1841, there occurred but 50 cases, of which 10 were
genuine variola, 24 modified small-pox  or varioloid, and 16 varicella.
Three of the patients died; of these, one had not been vaccinated, on
his admission into the army, but his certificate indicated that he had
been  a  short  time previously; the second occurred in  a recruit, who
had not been  revaccinated;  and the  third, in a non-commissioned
officer, who  had been  revaccinated some years  before, but without
success.  Before the order for revaccination was  issued, the different
barracks used to be a prey to varioloid disease, which has now almost
entirely disappeared.
  A few years since  a prize was offered by  the Academy of Sciences
of France, for  the most satisfactory essay in reply to certain queries
relating to the preservative power of vaccination,  the necessity of re-
newing the vaccine virus from  the cow, and the necessity of revacci-
nation.   The various essays sent in by the  competitors for the prize,
were referred  to a committee of the  Academy,  whose  report,  sub- 
DISEASES  OF THE SKIN.
505
mitted in  February, 1845, concludes with the following general sum-
mary deduced from the facts presented by the authors of the essays.
   1st. The preservative power of vaccination is absolute for the ma-
jority, and temporary for  a small number; even  in the  latter it is ab-
solute until adolescence.
   2d.  Small-pox rarely attacks those who have been  vaccinated in
infancy before the age  of ten or twelve; from  which  age, however,
until  thirty or  thirty-five, the vaccinated are  particularly liable to
small-pox.
   3d.  In  addition to its protective power, vaccination so modifies the
animal economy, that it  attenuates the  symptoms of small-pox, abridges
its duration, and considerably diminishes its danger.
   4th. Vaccine  matter taken directly from  the cow,  causes local
symptoms of greater intensity, while  its  effects are also more certain
than those of old vaccine  matter, but after being transmitted for a few
weeks through the human subject the  local intensity disappears.
   5th. The preservative power of vaccine matter does not seem to be
intimately connected with the intensity of  the local effects  produced
by it; nevertheless, it is  prudent,  in order effectually to  preserve its
protective power, to procure new matter from  the cow as frequently
as possible.
   6th. Revaccination is the only known method of distinguishing those
of the vaccinated, who remain protected, from those who do not.
   7th. Successful revaccination is not a  certain proof that the  person
in whom it succeeds was  liable to  contract small-pox; it merely esta-
blishes a  tolerably  strong presumption that they were  more  or less
liable to be so.
   8th. In ordinary periods, revaccination should be practised after the
first fourteen years, but sooner during the  prevalence of an epidemic
of small-pox.
   Phenomena of vaccination.—On the third day after the insertion of
the matter in  the arm,  there appears, at the point where the  matter
was inserted, a red  and  slightly elevated papula, which, on the fourth
day, is surrounded by a very faint and  narrow inflamed base, or areola.
By the aid of the microscope, the efflorescence surrounding  the in-
flamed point, will be distinctly visible.  On the fifth day the cuticle is
elevated  into a  pearl-coloured vesicle, filled with a small quantity of
perfectly transparent fluid. The form of the vesicle is circular or oval,
according to  the manner in which  the  introduction of the virus is
effected.   The vesicle is somewhat flattened, and  with a small depres-
sion in the centre, rather  darker than the rest of its surface.   It con-
tinues to enlarge in  circumference, but not so much in elevation, until
the eighth day, when it  is  at its height.   Its margin is then turgid and
prominent, and it contains a greater or less amount of fluid.
   When  closely examined, the vesicle exhibits a cellulated structure.
By the floor of  the  cells,  which are from ten  to  fourteen in number,
is secreted the specific matter of the disease.  Between the eighth and
ninth days, some degree of febrile  excitement very generally occurs :
—the glands of the  axilla  become,  in some  cases, swollen and painful,
and a state of general lassitude and drowsiness, with slight creeping 
506
DISEASES OF CHILDREN.
chills, alternating with flushes of heat, is observed ;—in  other  cases,
the febrile excitement is much slighter, and, in many instances, scarcely
perceptible.
  On the evening of the eighth day, the slight circle of inflammation,
which surrounds the vesicle on its  first formation, begins to spread,
until, by the tenth day, it forms a broad areola, surrounding the vesicle,
of a bright  red colour,  and of a  perfectly  circumscribed, circular
form ; the parts occupied by it being tense and painful.  By the eleventh
day, the depressed centre of the vesicle begins to assume a darker
hue, and this darkness gradually extends towards the circumference;
and, by the fourteenth day, the entire surface of the pock is converted
into a dark  brown  scab.   By degrees this becomes harder and of a
darker  colour;  in a  few days it begins to separate at the circum-
ference, but still adheres at the centre, and does not fall off until be-
tween the eighteenth and twenty-first day, and sometimes even later;
leaving, upon its separation, a cicatrix of a form and size  proportioned
to the previous inflammation, and  marked with radiations and  inden-
tations.
   In a few instances  the vesicle is  developed  at  a somewhat earlier
period ; and in other cases, a number of days elapse, after the insertion
of the matter, before the appearance of the vesicle.  According to Dr.
Gregory, the period of retardation never exceeds sixteen  days.  It not
unfrequently happens, that on the day after the matter is inserted, con-
siderable inflammation and  swelling occur at  the place of insertion,
which,  after continuing  for a day or two, subside rapidly without
leaving any local affection.
   Most commonly but one vesicle is developed at the point where the
matter is inserted ;—occasionally, however, one or more smaller vesi-
cles appear, in  the immediate vicinity of the primary  one;  and in-
stances have occurred, in which numerous vaccine vesicles presented
themselves on different parts of the body, the matter taken from which
communicated the disease to other persons, as effectually as that de-
rived from the  primary  vesicle on the arm.   (Report of the  Central
Vaccine Committee of France, for 1818-19.)
   In many cases, the wound made  by the insertion of the matter be-
comes at an early period,  very red and itching, and  a  small acumi-
nated, conoid pustule occurs on the eighth day, surrounded by an im-
perfect, irregular areola;—the pustule is filled with an opaque, straw-
coloured fluid, and forms a small, light-coloured scab, which separates
prematurely.   Such cases  are always to be regarded as instances of
doubtful vaccination.
   In other instances, instead of a circumscribed  areola,  an inflamma-
tion of an  erysipelatous  character extends over the whole arm, from
the  elbow to  the shoulder:—the vesicle, in place of being converted
into a hard scab, causes a large ulcer, which discharges profusely, and
is occasionally difficult to heal;—the resulting scar is large and  irre-
gular, without either radiations or pittings.  In these cases, also, there
is  a  doubt whether  the system is placed fully under the influence of
the vaccine infection.
   Another  irregularity is, when, about the sixth  or  seventh day, the 
DISEASES OF  THE SKIN.
507
     vesicle becomes partially inflamed and  scaly, and  surrounded by a
     species of psoriasis in place of an areola.  This is an unquestionable
     indication of spurious vaccination.
       Between the ninth and twelfth day, in robust, plethoric children, it
     sometimes  happens  that  the  body  becomes generally or partially
     covered with a papular eruption, which,  however,  in no degree inter-
     feres with the effects of the vaccination.
       Period for vaccination.—Not a little discussion  has recently taken
     place, as to the proper age for the performance of vaccination.   By
     some, its postponement until after the child is one year old, is strongly-
     insisted  on, under the supposition that, previously to this age, the infec-
     tion of the system is  apt to be imperfect, or, at best, not permanent:
     —others have considered the disease to be more regular, and accom-
     panied with less febrile irritation, in infants  from  two to  six months
     old; while others again maintain that it may be performed immediately
     after birth, and that it succeeds equally well at whatever age the matter        f
     is inserted, jfc,. ^G^W-* Xy--•**'**-*-+>*+•**+*-*^U*  €-+**>* st**Xt^*>** *+*
       At a  discussion upon  this subject, before the  Medico-Cbirurgical^'*^**-5**-
     Society  of London, Dr. Gregory  gave it as his opinion, that, provided tm •         i
     a good vesicle and areola were  produced, with a  due  degree of con-
     stitutional effect, it matters  not whether vaccination  be performed at
     the second or third month, or the second, third, or fourth year.  He
     considered the true question for consideration to be, at  what period of
     infantile life vaccination  can  be practised, so as  most certainly to             j
     insure success, and avoid inconvenience to  the parties.  In the first             •
     week or ten days after birth, before the infant has attained any degree
     of plumpness, it is very difficult to vaccinate, not  from any want of             j
     susceptibility  in  the patient, but from  the difficulty of inserting the             ,
     lymph properly; this  difficulty is more or less present  until about the             j
     fourth month,  and hence, this is the  period usually chosen; for not             1
     only is the arm  then generally plump, but there are,  also, no contending             j
     influences, such as teething, present.   Mr. Ceely agreed, in the main,             $
   ywfth I}r. Gregory.  It was stated by Dr. T» Tho.muson. at a discussion             j
^ ^petere.the J^ediuf *^^ciety bf*Lona\)n'Thaf*$uVth'e FSundlmg' Hospital,            |
     Paris, all the children were vaccinated within  the month, and the
     operation was generally successful.
      From the facts recently adduced in relation to this subject, as well             j
     as from  the result of our own experience,  we should be inclined to            j
     agree with Dr. Gregory, as to the proper period for vaccination, when            1
     there exists no urgent necessity for its more  early performance.  We            I
     have  found, however, that in very young subjects, there  is often a great
     difficulty in communicating the vaccine infection;  nevertheless, when
     we have succeeded in placing the system, at this age, effectually under
     its influence, as evidenced by the  character and progress of the vesicle
     upon  the arm, its prophylactic powers were as fully obtained, as when
     vaccination is delayed until a later period.
      While we choose, generally, the fourth month as  the most conve-
     nient  age for vaccination, nevertheless, should the prevalence of  small-
     pox endanger the life of the infant, or a necessity present itself for the
     immediate removal of the  latter to a  situation where pure vaccine 
508                 DISEASES OF CHILDREN.
        matter can with difficulty be procured, we never hesitate to vaccinate
        at any period, even within a few days after birth.
          No preparation of the system is demanded previously to the perform-
        ance of the operation; nor, when the disease produced is of a genuine
        character, is any medical treatment necessary during its progress, nor
        subsequently.   In cases, however, in which children are affected with
        herpetic and other eruptions upon the skin, it has  been supposed by
        Jenner, Willan, and others, that so entire  a change is produced in the
        character and progress of the vaccine infection, as to destroy its pro-
        phylactic powers;  this,  however, is denied by Capuron, while Valen-
        tin and Husson assert, that the vaccine infection  has the effect of com-
        pletely  removing whatever  cutaneous disease the  child  may at the
        time be affected with.  The safest course is, if there be no immediate
        necessity for vaccinating, to defer it  until any eruptive disease upon
        the skin is removed; but if small-pox is prevailing at the time, to  insert
        the matter, and subsequently to subject the child to  the test of revac-
...    ^cination..  >  »   .    >. v». •    .    •         .«-   .     . #\
',  ^^ •*  Vaccination  adds nothing to the danger, nor in any degree  inter-
    , '^ feres with the process of dentition; and  it may safely be performed
        during every season of  the  year; though, as a  general rule, where it
        can be done conveniently, it is better to wait until the rigours of winter
        have been moderated by the influence of spring, or until the heat of
        summer has given  way  to the coolness of autumn.
          Mode of vaccination.—By the generality of European physicians, in
        vaccinating, the recent  lymph, obtained  from the vesicle between the
        fifth  and eighth days, is employed;  the  experience, however, of the
        great body of  American practitioners has confirmed  them  in giving
        to the  dry crust or scab the  preference over the recent lymph, as a
        means of propagating the disease.  While equally efficacious with the
        latter, the scab is much more manageable, and more readily preserved;
        its employment also obviates  the necessity of interfering with the
        regular progress of  the vaccine vesicle, a circumstance of  very con-
        siderable importance in reference to the  certainty of the  child's in-  .
        fection.i*> A^r£*A^^ ~*"~ '^'^i^B^^wSl*
          In regard to the appearance  of the scab, when  we are certain that
        it is the product of the genuine disease, and has not deteriorated from
        keeping, nothing of course need be said;  but as this cannot always be
        the case, it is important to  be aware  of  the appearance presented  by
        the true vaccine crust.  This is of a dark mahogany or walnut colour,
        hard, and perfectly opaque, somewhat thick in the centre, and thinner
        at the edges,  and  nearly level, or only slightly concave  at its under
        surface or base; when  cut  into thin slices, it presents a dirty, brown-
        ish appearance; it is rather tough—being with  difficulty reduced  to
        a powder, but  readily soluble  in water.   A scab  produced by a ve-
        sicle, the  regular  progress of which has been  interfered with  by the
        irritation of the clothing, accidental violence, or  other cause, or one
        procured from a child  affected at the  time with  any disease of the
        skin, should not be made  use of for vaccinating;  the disease commu-
        municated by it will seldom be found genuine, while the virus obtained
        from children labouring under  cutaneous affections, is supposed to en- 
DISEASES  OF THE SKIN.
509
danger  the communication of these to the  individuals in whose arm
it is inserted.
  In preserving the scab for use, the greatest care should be taken to
keep it excluded as much as possible from the air, and from the slight-
est degree of moisture.   With due precaution, the  scab  may be pre-
served throughout the year, without in the slightest degree losing its
activity.
  Previous to its insertion, a small portion of the dry scab should be
reduced, by means of pure cool water, into a paste of about the con-
sistence of cream ; for this purpose a square of window glass, or the
bottom of a china plate or saucer, and a lancet or pen-knife, constitute
everything that is necessary.   When, as is customary, the physician
carries  with him a portion of glass upon which to form the paste, two
precautions are absolutely necessary:  which are, each time the glass
is used, to clean and dry it perfectly before it is put away; and, on no
account whatever, to preserve the  portion of dissolved matter remain-
ing from one vaccination, for a subsequent one :—virus thus kept, will
be a constant source of disappointment to the practitioner, and of dan-
ger to the patient.
  The common plan of inserting  the  matter in the arm is, to take a
small portion of it upon the point of a sharp lancet, which latter is then
introduced obliquely, for a short distance  beneath the cuticle.   We
have found, however, this mode of vaccinating to be very unsuccessful;
however pure and fresh the matter may be, often no infection is com-
municated until after the operation has been several times repeated.
This arises from two causes:—either the matter being entirely wiped
off from the point of the lancet, in passing the  latter under the skin, so
that not a particle is introduced;  or so much blood is caused to flow
by the puncture, as to wash out  the matter after it has been deposited
beneath the cuticle.   The plan we  invariably practise, and which we
first proposed twenty-five years  since, is to make, at the place where
the matter is to be inserted, several parallel  incisions with the blade
of a common spring lancet: taking care, however, that these incisions
penetrate no deeper  than  is necessary to divide the cuticle; and then
to cross them, at right angles, by others of a similar depth. This ope-
ration when properly performed, will be found to cause a slight blush
of redness upon the  part, and, most commonly, the appearance of a
very few minute specks of blood; the less blood, however, that is thus
occasioned to flow, the better.  A portion of the dissolved crust is now
to be taken on the point of a lancet, and  smeared  over  the incisions,
and allowed to dry.   To render the insertion of the matter still more
certain, it has  been  proposed  to smear the matter upon the arm, pre-
viously to dividing the cuticle.
   One recommendation in favour of the foregoing plan, independent of
its certainty, is, its being productive of so little pain, that it may be
performed while the infant is asleep, without awaking it, or even when
it is awake, almost without its knowledge,—a circumstance, however
trivial it may appear, which is by  no means beneath the notice of the
practitioner.
   Subsequent  to vaccination, the  arm should be guarded from irrita- 
510
DISEASES  OF CHILDREN.
tion by the fingers of the  patient, its clothing, or accidental violence.
To effect this, the best means is, to enclose the whole arm in a wide
sleeve of linen or fine muslin, drawn at the shoulder and wrist.  This
is a precaution of some importance, as well to obtain a genuine, effec-
tive scab, as from the fact, that the certainty of the child's being placed
fully under the influence of the vaccine disease  may be jeoparded by
its neglect.
   While in this  country, physicians, generally speaking, are  content
with the production of a single vesicle upon the arm,  many of  the
practitioners of Europe, and especially those of Germany, advocate
strongly  the insertion of the vaccine matter, either in both arms at  the
same time, or by a number of incisions or punctures in the  same arm,
as a necessary precaution, in order to  insure the full influence of  the
vaccine  infection.   A very  expert vaccinator,  (Mr.  Leese,) stated
recently, at one of the meetings of the London Medical Society, that
he  never knew a case of consecutive  small-pox to occur in  an indi-
vidual in whose  arm there were above four  cicatrices  from the pri-
mary  vaccination;  and  we  are  informed  by  another  practitioner,
(Dr. Chowne,) that  in the Small-pox Hospital at London, so great a
dependence is placed upon the number of the cicatrices present, that
the character of  the consecutive disease, is  generally prognosticated
from that circumstance alone.   It  is recommended by Dr. Gregory,
that with lymph of ordinary intensity, three or four vesicles should he
raised, and that these should be at such a distance from each other,
as  not to  become confluent in their advance to maturation.  Other
practitioners, of equal authority, maintain, that  a single vesicle, if it
proceed  regularly through its several  stages, and  produce a proper
degree of constitutional effect, as indicated  by the  febrile excitement
about the eighth day, is as effectual as twenty ; many of these, how-
ever, admit,  that the appearance of several  well-defined  vaccine
cicatrices, affords strong  presumptive evidence that the due degree of
infection  has  been produced; and  this corresponds with our own ex-
perience.
   In ordinary cases, nothing  is necessary during the progress  of vac-
cination,  excepting the observance of the same hygienic rules which
are equally proper even had  vaccination not been performed.   If the
febrile excitement which occurs  about  the eighth or ninth day, is con-
siderable, a slight reduction  of  diet, with some gentle aperient, and
cool diluent drinks, is all  that is required.  If the inflammation  spreads
to an undue extent over  the  arm, lotions of cold water, or of a solu-
tion of the  acetate of lead, will, in  general,  speedily reduce it; but if
it be of a very intense character, a few leeches may be necessary.

    6,—Modified Small-pox.—Varioloid.—Mitigated  Small-pox.

  It is now well ascertained,  that persons who have been vaccinated,
when exposed to the contagion of small-pox, become,- in many  in-
stances, attacked with an eruptive  disease, more or less similar in its
leading characters, to genuine variola; but  generally attended with
much milder symptoms, less  protracted in its duration, and  far less 
DISEASES OF  THE SKIN.
511
fatal in its results.   This disease has been shown, by facts the most
incontestable and conclusive, to  be  small-pox, modified in character,
and  mitigated in violence, in consequence of the change produced
in the  constitution  of the patient by the vaccine  infection.  As  the
modifying influence of the vaccine disease is more or less extensive in
different individuals, we have, consequently, a corresponding difference
in the character and intensity of the varioloid  affection; which, in
some cases, is of so trifling a nature, and of  such short duration, as
scarcely to confine the patient at home, or, at furthest, not beyond a
day  or two;  while in others, it approaches closely, in its features and
in severity, to unmitigated variola.
   On tracing back the history of small-pox to  our earliest records, we
find  that the occurrence of the disease in a  modified form, has been
repeatedly noticed in  former  years, during the prevalence of variolous
epidemics, under the  denomination of vesicular,  abortive, or spurious
small-pox;  the genuine and  spurious forms of the disease appearing
during the same epidemic, and both ceasing with  its termination.  The
more extensive  prevalence of the varioloid affections, during the last
twenty-five years, is evidently owing to the existence of a more exten-
sive modifying  cause, in the general practice of vaccination, which,
while it affords, as we have shown, in the greater number of cases, a
full protection against the contagion of small-pox, in many, only par-
tially destroys the  susceptibility  to that disease, and still  leaves  the
system  liable to be affected by it, in a more or less  modified form.
   Soon after the introduction of vaccination, it was noticed that some
of those who had undergone the  disease were attacked with a vesicu-
lar eruption, of a very mild  character; this, however, attracted  but
little attention, as the disease was considered  to be  merely chicken-
pox, against  which, neither inoculation nor vaccination was considered
to afford  any  security.  Subsequently, however,  when  the disease
began to  prevail epidemically, it was held by many  to be a new ma-
lady, and  to originate from a peculiar  or  specific  contagion; but,
finally, its identity with  small-pox  was fully  established.  The true
character of the varioloid affections  is now very generally recognised.
   Upon examining, with  attention, the whole of the facts  connected
with the prevalence of small-pox, from the earliest period of its history,
and comparing  them  with those which  have  been developed since the
introduction  of  vaccination,  we find many strong reasons  for attribu-
ting to  one common origin the entire family of vesicular and pustular
eruptions—the small-pox, chicken-pox, sheep-pox, stone-pox, horn-pox,
and a  host  of  others.   The distinctive characters  of these several
eruptions being the result of various, and perhaps successive modifi-
cations that  the original virus has undergone, as well  as of a difference
in its  effects upon different  constitutions, produced  by causes from
which their  susceptibility to  its  influence is either increased or dimi-
nished.  The several eruptions alluded to, run into each other, by al-
most imperceptible gradations; while all, or the greatest part of them,
are  very apt to prevail during the same variolous epidemic.
   Under so  great a variety of grades, and accompanied  by so  much
diversity in  the appearance, progress,  and duration of the eruption, 
512
DISEASES OF  CHILDREN.
and in the character of the concurrent symptoms, does modified small-
pox present itself, at different times and in different individuals, that it
is-.impossible to give any general description of it;  while to enter into
a detail of all the varieties it presents, would lead to no useful practical
results.   Confining  ourselves, therefore, to the varioloid affection as it
occurs in persons who have  been vaccinated,  we shall  present  the
more important of its leading characteristics.
  The varioloid eruption is, in  some cases, preceded by little or no
fever; while in others, the febrile excitement is marked by a conside-
rable degree of intensity.   The eruption may occur as early as  the
second day, or not until  the fourth or fifth:—frequently it is preceded
by a transient, uniform  efflorescence of the  skin, or by a rash closely
resembling that of measles.
  The eruption manifests itself in the form of minute papulae, of a more
or less  red colour:—with the appearance of  these papulae, all febrile
symptoms  almost  invariably cease, and  do not  again recur, unless in
consequence of some accidental cause, entirely unconnected with  the
disease.  Many  of the  papulae become dry and  disappear  soon after
their  appearance;  whilst  others of them  become converted, in  the
course of the first  or second day, into vesicles filled with  a limpid
watery fluid,  which gradually becomes thicker, and of a whey-like
appearance.   Frequently som§?of  the more prominent vesicles (more
or less  in  different cases), are  surrounded  by a small, faint areola.
About the  third or fourth day, the vesicles burst,  or become dry,
forming  small, light-coloured crusts, which  soon separate, and either
leave no mark upon  the skin, or a  slight prominence at  the points  oc-
cupied by the  vesicles, which speedily disappears.  In other cases, the
vesicles become  filled with a puruloid fluid, and are slightly depressed
in the centre.
  The crusts formed by the drying of the vesicles, generally fall off in
two or three days, though they have been known to adhere for a week,
or even  longer.   Occasionally,  the fluid contained in the vesicles re-
tains its serous character for four or five days, and then  becomes puri-
form ; in which state if may remain for several days, before the desic-
cation of the pustules commences.  It is not  uncommon for papular,
vesicular, and pustular eruptions,  in close  proximity, to exist at  the
same time  upon the surface.  The  pustule and its areola, in some cases
of varioloid disease, exhibit a  striking resemblance to those resulting
from vaccination.
  In other cases, during the eruptive stage, the attack approaches, in
its violence and general character, so nearly to one of genuine variola,
as to be  scarcely distinguishable  from  the latter; and the eruption
may even be so abundant, as to resemble the primary stage of con-
fluent small-pox.  Varioloid may, however, be generally distinguished
from unmodified variola, by the eruption appearing in successive clus-
ters, and at irregular  periods, between the second  and fifth days; by
the absence of fever in all but the most violent cases ; by the smallness
of the vesicles, and the whey-like character of their contents; by their
early desiccation without being converted into pustules; or, when their
desiccation occurs at  a later  period, by their not entering  into com- 
DISEASES OF THE SKIN.
513
plete  suppuration, as in small-pox;  by the early separation of  the
scabs, which are of a lighter colour than those of variola, and leave,
at the parts  to which  they were attached, small, red disks, or slight
elevations, instead of pits.
  That the disease just described results from the contagion of small-
pox, acting upon constitutions  in which the susceptibility to its  influ-
ence  is, to a certain extent, reduced, either from previous disease, or
from  idiosyncrasy, is now so generally admitted that  it is scarcely
necessary to enter here into a review of the arguments by which the
fact is  fully established.   In almost every community, in which epi-
demic small-pox occurs, there are many individuals who have  already
had the disease; a much  larger number who have been vaccinated
more or less perfectly; and others, again, who are wholly unpro-
tected, either by variolation or vaccination.  In those of the first two
classes who are attacked by the epidemic, the disease will, in the great
majority of  cases, assume the  varioloid, or  modified form; while in
those of the  latter class, with but few exceptions, the character of the
disease will  be that  of discrete or confluent variola, varying  only in
intensity.
   In  a few instances, however, we shall meet with cases  of varioloid
eruption, closely resembling chicken-pox, in the unprotected.  It is this
latter circumstance,  which  gave rise to the doctrine of the varioloid
disease being the result of a peculiar  contagion,  altogether  distinct
from that  of small-pox—the occurrence  of the two  diseases during
the same epidemic, being considered  as merely accidental.  The fal-
sity of this doctrine is, however, fully shown, by the matter taken from
the vesicles of  the varioloid disease as it occurs in unprotected indivi-
duals, communicating to others  similarly situated, genuine small-pox;
a fact which we have verified by actual experiment.
   The treatment of modified small-pox  is to be conducted on the same
general principles as that of the disease in its unmodified form.  Many
cases are so slight as scarcely to require the confinement of the patient
to his chamber;  while  others are marked by  symptoms which occa-
sionally call for the employment of bloodletting;  in general, however,
all that is necessary  will be, rest, a cooling regimen, a spare, unirrita-
ting diet, cool, acidulated drinks, and the administration of some active
purgative, in such doses, and at such intervals, as will keep the bowels
freely open.

                 7.—Varicella. —Chicken-pox.
   Varicella  may be  defined, a febrile, vesicular eruption; the  vesicles
desiccating  without  maturation, and often  leaving cicatrices or  pits
upon the separation of the crusts.
   The eruption in varicella is generally attended with some degree of
febrile excitement; in many cases, however, this is so slight as scarcely
to  attract attention; whilst in others,  it is  of considerable  severity,
continuing for two  or three days, and attended with  severe pain of
the back, head, and extremities.  The eruption, which generally ap-
pears first on  the breast and back, then on  the  face and scalp, and
finally, on the extremities, is often preceded, for a few hours, by a gene-
                                 33 
514
DISEASES OF CHILDREN.
ral erythematous efflorescence, and is accompanied, in most cases, by
a disagreeable tingling or itching of the skin.  The eruption of vesicles
usually appears in  succession, during three or four days; so that while
some are just appearing, others are fully formed;  others, again, are
beginning to shrivel; and others, still further advanced, are completely
dry, and in the form of crusts.
  From  a difference in the form and appearance of the vesicle, vari-
cella has been divided into three varieties, the lenticular, the conoidal,
and the globular, or swine-pox.
  In the lenticular variety, the eruption appears very early, in the
form  of small, somewhat  oblong, flat, red, and shining elevations,
having in the centre a minute,-vesicle, which enlarges, and by  the end
of the second day  is filled with a whitish fluid.   On the third day, the
fluid in the vesicle acquires a  pale yellow colour; and on the fourth
day, the vesicle becomes shrivelled; and in two days more, is con-
verted into a small, brown crust, which separates about  the ninth or
tenth day, leaving a red mark,  which  soon disappears, without  any
cicatrix or depression remaining.
  The duration of the disease is often protracted, by the  appearance
of fresh vesicles on two  or three  successive days, which  go through
the same stages as the first.
  In the conoidal variety, the vesicles appear suddenly, surrounded by
a slightly inflamed margin.  They are elevated, pointed,  and  contain
a limpid serum;  on the second day, they  are  more distended,  sur-
rounded by a broader areola, and contain  a pale yellowish fluid; on
the third day, many of them contain a purulent matter; they now be-
come shrivelled, and on the ensuing day, scabs begin to  form; some
having a dark brown, and others a yellowish, semi-transparent  appear-
ance.  The scabs generally separate in four or five days; those con-
taining purulent matter, leaving pits in the skin.   A fresh crop of vesi-
cles usually appears on  the second and third days, each crop running
the same regular  course: — the  eruptive stage is  consequently  pro-
longed until the sixth day, and the separation of the scabs is not finished
until the eleventh or twelfth day.
  In the globular variety, the vesicles are large  and  globose, with an
irregular base, and surrounded by  an  inflamed margin.   They are
filled with a  transparent fluid, which assumes, on the second day, a
whey-like  appearance:  on the  third day, they begin to  shrivel, and
assume  a yellowish appearance, from a small quantity of pus being
mixed with their  contents.  Scabbing commences on the fourth  day,
and the scabs separate in four or five days.
   Varicella is never attended with secondary  fever.   The scabs, upon
separating, occasionally leave indelible cicatrices or depressions in the
skin, which  differ, in some respects, from  those of small-pox, being
whiter  than  the  rest of  the skin,  and quite smooth  or flat, with an
even, rounded margin;  whereas, the cicatrices from  small-pox are of
the colour of the surrounding skin, and uneven, like the surface of an
orange,  with  an indented  or angulated  margin.  Hairs  occasionally
grow within the  latter, while, according to Heim,  they  never do  in
those of the  former. 
DISEASES OF THE  SKIN.
515
     Varicella rarely occurs more than once in the same individual.  It
I  may appear sporadically, but  generally prevails as an  epidemic of
  moderate extent.  It is capable of being propagated by contagion or
  infection.  Its subjects are  usually children, although  adults are fre-
  quently attacked by it.
    Much controversy has taken place as to the true nature of varicella.
1 By Vidius, Senertus,  Riverius, Morton, Sydenham,  Harvey, Mead,
I Hoffman, and most of the earlier writers, the disease was considered to
I be a spurious or bastard form of variola; while by subsequent writers,
 | it was attributed to a contagion entirely distinct from that of small-pox,
  and great  pains were  taken to point out the specific characters by
 | which the two diseases are distinguishable.   The doctrine of the inde-
 \ pendence of varicella  and variola, with few exceptions, was adopted
  \by the  profession  generally, until about the  year 1816, when the dis-
  cussion was renewed,  and the identity of the two affections was again
  asserted, and many facts and arguments adduced in support of it, by
  Frank, Berard,  Delavit, Thompson, and others.
   I To  disprove  the  common origin  of varicella and small-pox,  the
  fdillowing arguments have been adduced: 1st. That the  symptoms of
  varicella are peculiar and distinctive, and run always a regular course
  pelculiar to that disease.  2d.  That  small-pox  often  occurs without
  varicella, and varicella independent of small-pox.  3d. That varicella
  occHirs equally, and with the same characteristic symptoms, in  those
  who, have  had the small-pox, in those who  have been vaccinated, and
  in th\ose who are  entirely unprotected by either.  4th. That the pre-
  vious\ occurrence of small-pox does not prevent or modify varicella,
  nor varicella small-pox.  5th.  That varicella is incommunicable by
  inoculation; and 6th. That varicella is more common  now than before
  vaccination was so extensively practised, when  small-pox was much
  more prevalent.
     To  these arguments  it has  been replied, by  the advocates  of the
  identity of the diseases: 1st. That very little or no  difference exists
  between the milder forms of small-pox and ordinary cases of varicella;
  and that even between cases of the two diseases of greater intensity,
  the difference is in the extent of violence, rather than  in the character
  of the symptoms.   That in  some epidemics it is frequently impossible
  to  say which cases are varicellous, and which  variolous.  2d. That
  the varicella has almost invariably occurred either before, during, or
   immediately after small-pox epidemics.  We have no well-authenti?
   cated accounts  of the occurrence of varicella unconnected with small-
   pox,  before the  introduction of inoculation;  and none to be relied on
   previous to the  general practice of vaccination; now if the varicella be
   not a modified form of variola, it was reasonable to  expect that spo-
   radic cases of  it  would frequently occur, occasionally independently
   of the  latter; though the fact of the extensive independent prevalence
  of chicken-pox, has not yet been well established. But when we know
   that, from  some inappreciable  difference in its epidemic  causes, the
   small-pox assumes a very great dissimilarity of  character at different
   periods; some epidemics being mild, others severe, and others peculiarly
   malignant; and that even the character of the eruption has been known 
 516               DISEASES OF CHILDREN.

 to differ materially, it is not unreasonable to suppose that in the same
 manner it  may appear  at one  time as a mild or severe varicella, and
 at another, invariably under its more aggravated forms.  3d. Varicella,
 according to Bryce, Abercrombie,  and Thompson, occurs much more
 frequently in those who have  been variolated or vaccinated, than  in
 the unprotected: while its symptoms differ materially in different cases;
 the vesicles desiccating early in some, no  cicatrices  being  left upon
 the separation  of the scabs; whilst in others, some of the vesicles are
 more or less fully maturated, the scabs adhere  for a longer time, and
 on falling off, leave indelible pits in  the skin.  Some  cases are marked
 by scarcely any eruptive  fever; others by  a febrile reaction as in-
 tense as in the severer forms of small-pox.   4th. Persons who have
 suffered an attack  of small-pox have, according to Thompson, been
 observed  to be  seldom  affected with varicella;  while it  has  been as-
 serted by Reil, that small-pox is generally much  milder when  it occurs
 subsequent to a severe attack of varicella, than when it occurs in thos
 who have not  been affected with  the latter disease.  5th. Varicella
 like small-pox,  according to Willan, Bateman, Thompson,  and Heim,,
 is capable  of being communicated by inoculation.  6th. The fact of i/ts
 more frequent  occurrence  since the general  introduction of  vaccinia-
 lion, is  an evidence in  proof of varicella being but  a modificationjof
 small-pox.   Previously  there was a more general susceptibility to ,the
 genuine forms of variola, whereas now, by the general practice;  of
 vaccination, whole communities are, in  a great  measure, prote/cted
 from the latter, though from various causes, many individuals still re-
 main  susceptible of infection, to a certain extent, and hence  the; very
 extensive prevalence of  varicella, in common with various oth-er mo-
 dified forms of small-pox, known by the  name of varioloid, is readily
 accounted  for.
   M. Delpech considers that the separate individuality of varicella is
 proved, by its existing in an isolated state, free from all variolous com-
 plication, both sporadically and epidemically; by its  occurring almost
 exclusively  in  children;  by the perfect indifference  wi\h which  it
 attacks  all  individuals, whether vaccinated or not, whether they have
 had variola or  not, even when labouring under varioloid  disease, or
 when recently convalescent from it; by  the complete  absence of all
 modification in  the manifestations of the affection in  those who are or
 have been under the influence of variolous affections; by the absence
 of all immunity conferred by varicella from variola or cow-pox;  by
 the possible combination and  simultaneous development of varicella
 and variola;  by the impossibility  of variola transmitting  or  giving
 rise to varicella, or of varicella transmitting or giving rise to variola;
 the doubtful possibility of transmitting varicella by  inoculation,  not-
 withstanding the experiments of Willan,  which  have been disproved
 by nearly all subsequent experimentalists; and, lastly, by the decided
 and constant difference in the form and symptoms of  the two diseases.
  Upon the treatment of varicella, the same remarks may be made as
 were  made in  reference to the management of modified  small-pox.
The disease seldom requires much medical attention.  A restricted diet,
cool drinks, and gentle  aperients, will be proper in all cases.   If the 
DISEASES OF  THE SKIN.
517
eruptive  fever is very severe, and the child robust and  plethoric, a
small bleeding from the arm, with saline purgatives, and a low diet,
will suffice to moderate its violence.
                        CHAPTER  II.

                CUTANEOUS  ERUPTIONS.

  ERUPTIONS OCCURRING PREVIOUS TO WEANING AND DURING
                           DENTITION.

                         1. — Strophulus.

   An  eruption  of  pimples, generally appearing first upon  the face,
neck, shoulders, hands, and arms, but occasionally on other parts of
the body. (S. Intertinctus.)
   When the pimples have a florid, red appearance, the term red gum
is familiarly applied to the eruption.  When of a paler hue, exhibiting
a less degree of irritation, it is denominated white gum. (S. Albidus.)
   In its simplest and most common form, strophulus consists of a few
pimples irregularly distributed, and now and then mixed with diffused
patches of redness. When, from any cause, the irritation of the skin is
considerably augmented, these patches are very numerous; the pimples
are of a  large size, and many of them present  a vesicular appearance,
which, however, soon disappears. When strophulus occurs during denti-
tion, the pimples are harder, and occur in patches, with considerable red-
ness of the skin; they  are also  more generally diffused over different
parts of the body. (S. Confertus.) When, from any cause, there is consi-
derable derangement of the secretions, or the child has been  improperly
fed, the erilption'is attended with itching, pain, and excoriation,  resem-
bling,  on*the lower parts of the  body,  the intertrigo  of  infants, or
the irritation of the skin, with  abrasion of the cuticle, produced by
the stimulus of the urine; and it is, occasionally, like  the  latter, pro-
duced  by not changing the diapers as soon as they become wet, or re-
applying those that have become saturated with the urine, without
washing.  In all cases of strophulus in which, from bad management
or accidental causes, any degree of febrile excitement is produced, the
eruption  is increased in extent and severity, and constitutes the S.  Vo-
laticus.
  The eruption in strophulus is generally described as papular;  but
Plum be would rather refer it  to an over-distension of the  cutaneous
vessels, giving rise  to the escape of minute  portions of lymph beneath
the cuticle.
  The predisposition to this affection  consists in the greater degree of
vascularity and  irritability of the skin, and the extreme delicacy of the
cuticle, during infancy.  The exciting causes  are, over-feeding, a  too 
518
DISEASES OF CHILDREN.
stimulating diet, too rough and warm clothing, the  irritation of teeth-
ing, or  any circumstance  calculated to quicken the circulation, and
promote undue determination to the skin.
   In the treatment of strophulus, the extent and intensity of the erup-
tion must be taken into consideration.
   In the milder cases, and where the eruption is of little extent,  no-
thing is required beyond a proper regulation of the  patient's  diet and
clothing, gentle aperients, and the occasional use of the warm bath.
During dentition, the gums should be attended to, and if inflamed or
swollen, they should be freely scarified. When the disease  is con-
nected with derangement of the digestive organs, the same treatment
will be required as would be proper were no eruption present.   In  ag-
gravated cases, accompanied by much  febrile excitement, an emetic,
followed by mild aperients and minute doses of calomel, ipecacuanha,
and nitre in combination, with  the tepid bath, and a mild, unirritating
diet, will generally succeed in relieving  the violence of the symptoms.
   If strophulus frequently recur during suckling, it will be judicious to
change the nurse.   When the eruption  is attended  with itching, pain,
and excoriation, much relief will he obtained by bathing the parts fre-
quently with any simple, mucilaginous wash, as bran tea, infusion of
slippery elm bark, or of the pith of sassafras.
   In cases in which the eruption  continues  for  a  long  time, or fre-
quently recurs  at  short intervals, the health of the  patient is liable to
become much  deranged;  and  clusters  of pimples  of a dark colour,
often arise on different parts of the body, terminating in  brown exfo-
liations, and  accompanied by  febrile symptoms; a brown, scabrous
condition of the skin succeeding, often of long duration.   This condi-
tion is generally connected with more or less  disease of the digestive
organs, and  demands for its  removal minute  doses of calomel, com-
bined with magnesia and ipecacuanha,  and some light tonic, with  the
daily use of the warm bath, and a well-regulated diet.  Occasionally,
change of air is attended with the best effects.

                          2,—Prurigo, c*^. ^teJ^Uy,/' r^u^

   An eruption of pimples, differing  but  little from those of  strophulus,
but usually less distinct, and flatter, and mostly confined  to the  outer
surface of the limbs and trunk.
   Prurigo is attended  by a sense of itching, which is aggravated  by
whatever induces an undue determination to the surface.  By scratch-
ing to relieve the intolerable pruritus which ensues when the patient is
heated or excited, or warmly covered in bed, considerable heat and
redness of the surrounding  skin is produced, and the pimples becoming
abraded, there issues from them a  transparent or bloody fluid, which,
concreting on the surface, forms  thin  crusts, of a brown or black
colour.  When the crusts separate, a dull, crimson mark often remains
for some time.   In children of a  full,  gross habit, the irritation of
scratching or friction, gives rise, occasionally, to  a  superficial ulcera-
tion, or  a pustule, terminating in the crust of impetigo.
   In the more aggravated form of prurigo (P. Formicans), the itching
is  intense and constant, resembling the crawling or stinging of insects; 
DISEASES  OF THE  SKIN.
519
this is increased by heat, and by warm, stimulating food.   Occasion-
ally white wheals and dark-brown crusts appear  over  different parts
of the body, attended often with a  degree of tumefaction about the
arms  and legs, by which the freedom of their movements is impeded.
  Prurigo  is most troublesome in the spring, and at the  commence-
ment  of summer, and is apt to recur for months, and even years.  It
is usually accompanied by symptoms indicative of more  or  less de-
rangement of the digestive organs.   It is commonly produced by ex-
cess of food,  or that which  is indigestible,  or has undergone some
change by which  its wholesomeness is impaired.  Fish or  oysters,
when out of season, will  often produce it; it has occurred,  in some
cases, after a draught of cold water, or some acid drink.   In certain
constitutions, it will result from a  very slight irritation of the  stomach
or bowels, and in others without  any evident cause, excepting a sud-
den change in the temperature of the season,  from cold to warm.
  In the greater number of cases of prurigo  which occur in children,
the disease would readily give way to  an emetic, followed by a mild
cathartic, and a properly regulated  diet, could we prevent the patient
from  constantly irritating the pimples by scratching and rubbing with
his hands, which might generally be accomplished, by  muffling or se-
curing the hands, and frequently bathing the eruption with tepid water,
or some mucilaginous wash.   A watery solution of opium has  occa-
sionally succeeded,  in our hands, in  allaying the irritation  on the skin.
  In robust, plethoric habits, purgatives and a plain vegetable diet will,
occasionally, be proper; and in violent cases, even the loss of a few
ounces of blood may be demanded.   In cases attended with derange-
ment  of the digestive functions, such  remedies should be resorted to as
are calculated to restore the latter to a  healthy condition.
  The decoction of dulcamara, the hydrochloric acid, and the arsenite
of potassa internally; touching the more prominent pimples with aro-
matic vinegar, or a solution of hydrochloride of ammonia; lotions of
the sulphate of potassa,  the chlorate of lime, or of a solution, in water,
of the extract of belladonna, or ointments of sulphur, have been recom-
mended for the cure of inveterate cases; we have, however, seen  no
case occurring in children in which we have found it necessary to re-
sort to either of these remedies.
  A moderate, wholesome diet, a cooling regimen, attention to the
state of the bowels and digestive organs,  the daily use of the warm
bath,  and, as local  applications to allay itching, and subdue irritation,
frequent lotions with tepid water, or  some  simple mucilaginous wash,
and occasionally with a watery  solution of  opium; and  in  cases in
which there was nothing present to forbid its use, an anodyne at night,
are the remedies, which, in our hands, have never failed to subdue the
prurigo in children.

                       I — Crust a Lactea.

IMPETIGO LARVALIS VEL MUCOSA--PORRIGO LACTEA VEL LARVALIS--TINEA
                    MUCIELUA--ECZEMA  LACTEA.

  This eruption generally occurs upon some portion of the face, espe-
cially upon the cheeks, and is more  frequent  during dentition than at 
520
DISEASES OF CHILDREN.
any other period.  It usually commences in one or more distinct red
blotches, which  become studded with numerous, small, yellowish pus-
tules,  nearly  confluent, and  attended  with  considerable itching;  and
preceded and accompanied,  in severe cases, by some degree of erysi-
pelatous inflammation.  At the end of three or four days, and some-
times  earlier, the pustules burst, and  discharge their  contents, which
dries upon the skin, forming concretions of a whitish yellow or green-
ish tinge, semi-transparent, and very friable.  The crusts lie in laminae,
some  overlapping others, or they are intersected  by narrow pink or
olive-coloured fissures.  The discharge  continues to ooze  from under
the scab, which  grows constantly thicker.
   The incrustations may be  confined to a small space, or occur on
several parts of the face at the same time; or they may extend over
nearly the whole face, covering it as with a mask.  When the  crusts
are detached, the surface of the  skin  beneath  them is found to  be red
and inflamed, and studded with numerous  minute pores, from which
the discharge proceeds.
   The crusts usually remain attached from two to four weeks, when
the secretion of matter diminishes,  and the crusts separate,  and fall off
gradually, leaving a red, shining, and very tender surface, which, upon
the slightest  irritation, is  liable again  to  form pustules,  and  repro-
duce the disease.  In this manner, by fresh crops of pustules occurring
after the separation of the scabs, the disease may be prolonged for an
indefinite period;—in such cases, deep chaps, and  even  ulcerations of
the skin are liable to ensue.
   In prolonged cases of crusta lactea, occurring in children of a lym-
phatic temperament, with fair hair, pale, delicate skin,  and  languid cir-
culation, some degree of intumescence of the parotid, submaxillary, or
cervical glands,  will often occur.
   The matter discharged from beneath the scabs would  appear to pos-
sess some degree of acrimony, for the part of the child's breast which is
brought frequently in contact with the diseased chin, when this is  the
seat of the eruption, soon becomes red, and exhibits an eruption of pus-
tules,  which terminate, as on the face, in a  superficial  ulceration.  A
similar effect is produced, occasionally, on the arms of the nurse who
attends a child affected with crusta lactea.
   Even in the severest  forms of the disease, no permanent marks are
left upon the skin.
   The treatment will depend very  much  upon  the period at which the
disease is first" seen by the physician.  In ordinary cases,  and  in  the
earlier stages of the eruption, it will generally yield, very readily,  to a
proper regulation of the diet, in conjunction with mild aperients, minute
doses  of calomel, magnesia, and ipecacuanha, the daily use of the warm
bath, and  exposure to a fresh, pure atmosphere.  The  diet of children
affected with crusta lactea should consist, either of the  breast-milk of
a  healthy nurse, or, after weaning, chiefly of the farinacea, with or
without milk, according as this is found to  agree or not with the sto-
mach of the patient. The best local applications are emollient washes,
and the  watery solution of opium.   When, however, from the long
continuance of the eruption, the general health of the patient has  begun 
DISEASES  OF THE SKIN.
521
to suffer, it may be found  necessary, in  conjunction with a cautious
course of alteratives, to administer some of the lighter mineral  and
vegetable tonics—as, the tartrate of iron, the cold infusion of bark, or
the infusion of gentian, cascarilla, or calomba.
   When the inflammation  has entirely subsided  in the neighbourhood
of the eruption, we have found one of the best local applications to be
the unguentum nitratis hydrargyri, diluted by the addition of one-third
portion of simple cerate.

                         L — Impctigo.  /»  W>P-

               CRUSTED TETTER--HUMID TETTER--SCALL.

   An incrustation of an umber, sienna brown, or olive colour, appear-
ing either in defined patches, (figurata,) or scattered over the surface,
(sparsa.)
   This eruption appears in  the form of minute pustules, collected toge-
ther in clusters, or dispersed irregularly over the surface.  It generally
occurs upon  the  extremities; the  clusters of pustules being  usually
smaller and  more circular on the upper, and larger, oval, and more
irregular upon the lower.
   The pustules appear either upon  an  inflamed surface, of from two to
four days' duration, or in clusters, with a defined  inflamed margin, and
are accompanied with heat and  smarting, in proportion to the extent
and intensity of the inflammation.  The pustules are slightly elevated,
and, in two or three days after their formation, burst and discharge
their contents, leaving a red and  shining surface; the matter being
evacuated through numerous minute orifices.  When  the pustules ap-
pear in clusters, a crust is soon formed by the inspissation of the mat-
ter; from beneath the crusts there is a constant oozing of a thin fluid,
while around their edges fresh pustules often appear.
   When, from  neglect or  mismanagement, the disease is allowed to
proceed, it may extend over the whole limb,  which  becomes encased
in an almost continuous rugose covering.  (/. Scabida.)  The crust at
the same time assuming a grayish-brown colour, surrounded by a lake-
coloured margin.   There is considerable heat and itching in the limb,
and its motions are impeded, or completely obstructed.  After a time,
the incrustation presents deep cracks  or  fissures, through which the
matter exudes, and drying, increases the  thickness of the scabrous
coating of the limb.  When the disease extends  to  the hands or feet,
an ulceration of a purplish hue takes place around  the roots of the
nails, which often drop off,  and are succeeded by others of an irregu-
lar form.
   The erythematous inflammation surrounding the eruption, increasing
in intensity, will occasionally give rise to  slight vesications (/. erysi-
pelatoides);  and in these cases, the subcutaneous  cellular membrane
becoming involved in disease, the affection is one of  considerable seve-
rity and danger.
   The crusts in impetigo may separate as early as at the end of  two
weeks, or not until the termination of four or five.  The healing pro-
cess generally commences at the  centre of the  patches, and extends 
522
DISEASES OF  CHILDREN.
towards the circumference.  On the dull crimson surface left  by the
separation of the crusts, small, elevated spots, occasionally occur, ap-
parently vesicular, but in reality formed by indurated follicles.
  Impetigo is often combined with other forms of eruptive disease;
thus, eczematous vesicles are  often interspersed (Eczema impetigino-
des); these  are attended with  little  redness, but  by great irritation,
heat, and itching.
  The incrustations of impetigo differ from those of porrigo, by being
slower of inspissation, more circular, thinner, browner, and  less adhe-
rent, and by  their '^cc^rring, most generally, upon the extremities.
The matter discharged is also  p'urulent and glutinous—that of impetigo
more thin  and ichorous.   The interspersion of vesicles causes some
resemblance between  impetigo and lymphatic scabies; for the vesicles
of the former are slower in their progress,  attended  rather with heat
and smarting, than with itching; while the cuticle  is redder and more
fissured, and the ichorous exudation more copious than in scabies.
  In mild  cases of impetigo a simple, unirritating  diet, a  mercurial
purgative, followed by a dose  of the sulphate of magnesia, or of mag-
nesia and precipitated sulphur, with the local  application of lotions of
tepid water, or some mild, mucilaginous fluid, or a  thin bread-and-milk
poultice, with the occasional use of a watery  solution of opium, com-
prises the whole treatment that is necessary.  If any derangement of
the  digestive organs exists, this  should be removed by an appropriate
treatment.
  When the local inflammation in the neighbourhood of the eruption
is severe  and extensive, especially  in  plethoric habits, bleeding by
leeches, or from  the arm, will be demanded,  with  saline purgatives,
and a very restricted diet;  the inflamed part being covered with a soft
linen rag, wet with the liq. plumb, acet. dilut.  In cases attended  with
considerable irritation, a few drops of the tincture of hyoscyamus may
be given, two or three times a day; or a pill composed of from one to
two grains of the extract of hyoscyamus, with the third of  a grain of
ipecacuanha, and one or two of carbonate  of soda,  may be given at
bed-time.
  In the more severe  forms of the disease, one of the best local appli-
cations is the hydrocyanic acid, combined with alcohol,1 and applied,
by keeping the  parts covered with  portions  of linen constantly wet
with the mixture; care being taken  to  remove entirely, by frequent
ablutions with tepid water, the morbid secretions, so as to admit the
lotion to be applied directly to the diseased surface; nothing, we are
assured by Plumbe, is  more efficacious in subduing  the irritation ac-
companying the eruption.   Perseveringly employed,  it will sometimes
rapidly remove every vestige of the disease.

                     1 R.—Acid, hydrocyanic. 3iij.
                          Aq. destil. Svijss.
                          Alcohol. 3ss.—M.

  In the more obstinate cases, the internal exhibition of  sulphur, or of
the  sulphuret of potassa, from five to ten grains, three times a day, in
milk,—the decoction of dulcamara,—Plummer's pill, or the hydrargy- 
DISEASES  OF THE SKIN.
523
 rum cum creta—with the external use of the sulphur baths, or sulphur
 vapour baths, should  be resorted to.
   When, from the long continuance of the disease, a degree of debi-
 lity ensues, the  decoction  of sarsaparilla, or the infusion of gentian,
 cascarilla, or calomba, with the hydrochloric acid, may be resorted to.
 A pure, fresh air, and the utmost cleanliness of person, are important
 auxiliaries in all cases.

    ERUPTIONS CHIEFLY CONNECTED WITH GASTRO-ENTERIC
                            DISEASE.

                          5. — Erythema.
   A slight continuous redness of the skin, varying in extent and shape,
 and continuing from two or three, to ten or  twelve days.
   Erythema may occur in patches, successively on the  arms, neck,
 breast, and face.  (E.fugax.) This variety is usually observed  in the
 progress of some febrile disease, or at the  period of dentition; or  it
 may be  produced by slight irritations of the  digestive organs.  In
 other cases, the eruption appears in the form of bright  red, irregular
 patches, chiefly on the arms, neck, breast, back part of the forearm, and
 back of the hand. The patches are at first somewhat papulated. (E.
 papulatum.)  The slight swelling decreases within thirty-six or forty-
 eight hours; but the redness continues somewhat longer, and assumes,
 gradually, a bluish tint. The general disorder is usually trifling, though it
 is sometimes attended by symptoms of depression, and a quick, irritated
 pulse.  The eruption sometimes  assumes the form of a rose-coloured
 tuberculated swelling  (E.  tuberculatum); or of  a  raised, indurated
 efflorescence; this variety generally continues seven or  eight days,
 and is attended by considerable heat of the skin, and some degree  of
 febrile excitement.
  Erythema frequently occurs in large oval patches, of a deep red colour,
 upon the anterior part of the leg, in females towards the coming on of
 the menses, and in boys of a lymphatic temperament.  The patches
 vary in  number in different  cases, and  rise gradually above  the level
 of the skin, (E. nodosum,) and are more or less painful when touched.
 They soften and subside in  the course of eight or ten days; the red-
 ness slowly disappears, assuming in  its decline a whitish tint.  The
 tumours never suppurate.
  Erythema sometimes commences on the face, by a small, circular,
 red spot, slightly papulous, which gradually extends in circumference,
 and may, in this way, spread over the whole face.  (E. centrifugum.)
 The patches are usually about an inch  in diameter:—there is con-
 siderable redness as well as heat, principally at their margins, which
 are elevated, whilst the centre is depressed, and of the natural colour
 of the skin.  They are attended with neither pain nor itching, and
generally leave a slight depression of the part affected.  The disease
is usually of some continuance.
  Erythema may be produced, in children of a robust and  plethoric
habit, by external irritation; it is more generally,  however, dependent
upon some  affection of the alimentary canal.  Certain articles of diet, 
524                DISEASES OF  CHILDREN.
of an indigestible or unwholesome quality, will, in some constitutions,
cause its  sudden appearance;  it occasionally occurs, also, upon the
use of some  medicinal substances;—as rhubarb, balsam of copaiba,
opium, &c.  The eruption in these cases is generally of short duration.
When it results from gastro-intestinal  disease, it is commonly more
severe and* of  longer duration.  In languid and unhealthy  constitu-
tions, the eruption  sometimes assumes a deep crimson, or a dull, dark
purple hue, and is accompanied by symptoms of a  typhoid character.
  In  the slighter cases of erythema, little else is required, in the way
of treatment, excepting a removal  of the exciting cause, a  proper
regulation of diet, mild aperients, and the tepid or warm bath.  When
the eruption is  attended with considerable irritation, heat, and itching,
dusting the  part with dry powdered  starch, or  bathing it frequently
with  tepid water,  or  any simple,  mucilaginous wash, will  usually
afford prompt  relief.  When  the disease has arisen from an over-
loaded state of the stomach, or improper food, an  emetic of ipecacu-
anha should be administered.   If it occur during teething, the state of
the gums should be inquired into, and if swollen  or inflamed, freely
lanced. Whatever irritation may exist  in the alimentary canal should
be combated by an appropriate course of treatment.
   Severe cases, occurring in robust, plethoric habits, and accompanied
by considerable local heat, pain, and swelling, with symptoms of febrile
excitement, will demand  the  application  of leeches, or even bleeding
from the  arm, with saline purgatives,  a  restricted diet, and  cooling
lotions to the  part affected;  the patient,  at the same time, being kept
quiet and free  from excitement.  In  languid habits, a course of mild
alteratives, and light vegetable tonics, should be prescribed, with pure,
fresh air,  a nourishing diet, of plain digestible food, and the daily use
of the warm bath followed by friction of the surface.  At the close of
all severe cases, light tonics  will be proper.

                           6. — E c z e m a.

                           PRICKLY HEAT.
   An eruption of small,  pearl-coloured, or  brownish-coloured pink
vesicles, with a very light rose-coloured base, preceded by a sense of
heat  or tingling.
   The delicate and irritable skins of children, render them peculiarly
liable to the  production of this form of vesicular  eruption, on parts
exposed,  for  a very short period, to the heat  of the sun. (E. solare.)
The  application of heat from  any  other  source, will also produce the
disease;  and it frequently arises from irritations, seated in the alimen-
tary  canal.   When the vesicles of eczema occur between the fingers,
especially if aggravated by scratching, they may be mistaken for those
of scabies; but, the suddenness of the eruption, the more pointed vesicle,
and the sensation of smarting, rather  than of itching, readily distinguish
them from the latter.
   When  the eruption is more  generally  and extensively diffused,  the
vesicles occurring in closer proximity to  each other, with their inter-
stices of a bright  red colour, it constitutes the eczema rubrum. 
DISEASES  OF THE SKIN.                525
  Between the sixth and eighth days, and sometimes earlier, the red-
ness diminishes, the serosity is absorbed, the vesicles shrivel up, and a
slight desquamation takes  place, leaving,  however, the skin redder
than natural, and presenting, when carefully  examined, a  number of
minute, round spots, surrounded by a thin, white, ragged rim of cuticle,
which indicates the extent of desquamation of each  vesicle.
  The milder cases of eczema may quickly subside, without the oc-
currence of desquamation,  the lymph of the vesicles becoming opaque,
and being then absorbed.   In other cases, new vesicles arise, of larger
dimensions;  upon  the  rupture  of which, a  brownish  scab  forms,
leaving the skin  in  a  rugose  state.  In the  more  aggravated  cases,
there occur febrile  symptoms, and a general derangement of health,
from  the extent and persistence of the  irritation.   (E. impetiginodes.)
By long and  repeated application of the exciting cause, the  eruption
may become more  permanent, and  less inclined  to yield to  simple
remedies.  (Chronic eczema.)   The  chronic form is,  however, of
unfrequent occurrence in children.
  Vesicles resembling those of eczema, are often produced, by the ap-
plication to the skin of plasters, ointments, and poultices.
   In  the slighter  cases, the treatment  will consist  in the removal of
the exciting cause,  the exhibition of mild aperients, a  well-regulated
diet, and the use  of the warm or tepid  bath, with slightly acidulated
barley or toast water for drink.  As local applications, tepid  water,
mucilaginous washes, or simple bread  poultices are the best.   Where
there exists gastro-intestinal disease, this will demand  its appropriate
remedies.
   In  the acute stage of  the more severe forms, occurring in  robust
and plethoric habits, leeches, as well as bleeding from the arm, with
saline cathartics, diaphoretics,  and  the antiphlogistic  regimen gene-
rally, will be often  required.   In protracted cases, the  alkaline  bath
may  be tried ; or,  as a  local application,  the hydrocyanic acid and
alcohol, as directed in impetigo, with the cautious internal use  of dul-
camara.   When great irritation, and loss of sleep occur, the tincture
of hyoscyamus may be given  during the day, or an opiate at bed-time.
In the impetiginous form,  when the eruption has  become chronic,  a
weak solution of alum, or of the acetate or sulphate of zinc, in  diluted
alcohol, will be found useful.
   In all cases, the patient  should be exposed to a pure atmosphere;
his linen  should  be repeatedly  changed, and friction of  the surface
carefully avoided.
   When, on the  subsidence of the eruption, the patient remains in a
languid, debilitated state, light tonics should be administered,  with  a
plain, wholesome, nutritious diet.  Change of air,  under such circum-
stances will  be advisable.

                 7.—Urticaria—Nettle Rash.
   An eruption of red, inflamed patches, irregularly distributed  upon
different, and often distant parts of the body;—sometimes small in
extent and number, and at others, occupying a considerable portion of
the skin. 
526
DISEASES OF  CHILDREN.
  At the centre of each patch, is situated a white irregularly formed
spot, sometimes long and narrow, at others, broad or round, consider-
ably elevated above the surrounding  cuticle, and generally  attended
with a severe sense of itching, smarting, and tingling.  The margin
of the colourless  tumour is very irregular, and when the  finger is
passed lightly over it, it presents to  the touch considerable inequality
of surface.
  The tumours, in the smaller patches of inflammation, are not unfre-
quently in the form of small, distinct, circular tubercles, about the size
of a spangle; but  when several occur upon the same spot,  they gene-
rally coalesce, and form a  lengthened streak or wheal.  The larger
spots  or wheals are  mostty formed by  the clustering  together of a
number of the circular white tubercles; and in proportion to their size,
they are surrounded by  a  more or  less  vivid  inflammatory  redness;
and a corresponding  degree  of heat, itching, and smarting attends
them.   When punctured with a finely-pointed instrument, there escapes
from the white  tubercles,  a thin, transparent fluid, and the  swelling
immediately disappears.
  The eruption, in the simple forms of the disease, seldom continues
long, and  is frequently so evanescent,  as  to disappear, after a few mo-
ments' continuance, from one part of  the body,  leaving no vestige of
its existence; while, almost immediately afterwards, a distant  part will
be found occupied by it to a considerable extent.  (U. evanida.)
  In very severe  cases, suddenly produced by eating certain  kinds of
food, the tumefaction  about the neck and  face is often  very consider-
able ;  not  unfrequently closing up the eyes, and obliterating every  ves-
tige of the natural features.   Even  in these cases, the  irritation  and
tumefaction will generally begin to  subside at the end of thirty-six or
forty-eight hours.
  The symptoms of the febrile form of urticaria (U.febrilis), are much
more  violent, and its  duration  longer.  In this  form, the eruption is
preceded by pain and sickness of stomach, headache, great languor or
faintness—a sense of drowsiness and anxiety ; there is increased quick-
ness of pulse, and a white coating  upon  the tongue.   In two days, or
later,  a coldness and shivering are experienced, and patches of a vivid
red, or even  crimson hue, appear  upon  various parts of the surface,
attended with a most troublesome itching or tingling, greatly increased
when  the  patient is in bed or heated from any cause.  On the appear-
ance of the eruption, the pain and sickness of the stomach are in gene-
ral relieved.
  The patches  often  coalesce, so as to produce a continuous redness,
particularly on  the shoulders, loins,  nates, thighs, and about the knees.
They are often  elevated above the surrounding cuticle, and form dense
tumours, with a hard  distinct  border—the interstices being of a dull
white colour.  (U. tuberosa.)   The patches appear and disappear irre-
gularly, first  on one  part, then on  another; they may  be  excited, on
any part  of the  skin, by strong friction, or scratching.   When  the
patches are numerous, the face or the limb occupied by them  appears
tense,  and considerably swollen.  Towards the close of the  disease, 
DISEASES OF  THE SKIN.
527
the eyelids are often red and tumefied, and swelling and inflammation
occur on the sides of the feet.
  During the day, the redness of the  eruption fades, and the wheals,
in general, subside;  but  both  increase, with a slight febrile exacerba-
tion, in the evening.
  As the eruption declines, the tongue becomes clean, the pulse natu-
ral, and the diseased state of the functions generally, ceases: the efflo-
rescence assumes a light purple or pink appearance, and then gradu-
ally  disappears, being followed by a slight exfoliation of the cuticle.
   The whole duration of the  febrile nettle rash is from seven to eight
days.
   The exciting  causes  of  urticaria are  various; — emotions of the
mind; exposure  to  excessive heat, or  over-exertion; in certain con-
stitutions, particular kinds of food or  drink, as  almonds, kernels of
nuts, mushrooms, cheese, cucumbers, pie-crust, honey, different kinds
of fruit,  or food  rendered unwholesome from being out of  season, or
from having undergone certain changes, as mussels, clams, oysters,
lobsters,  crabs, and certain  kinds of fish.   In individuals whose skins
are peculiarly irritable,  slight external irritations will give rise to  it:
in such, particularly when of a full habit of body, simple excess in any
kind of food, will act as its exciting cause.
   The treatment of urticaria will  depend upon  the nature of the at-
tack, and in some degree, also, upon the nature of  the exciting cause.
The milder cases require little else than rest, a cooling regimen, diluent
drinks, gentle aperients, and tepid baths.   Where  it  has arisen  from
the ingestion of certain articles of food, a brisk  emetic, (the sulphate
of copper,) followed by a dose of purgative medicine, (calomel  and
jalap,) should be administered; and if accompanied with severe  ner-
vous symptoms,  the sulphuric aether, in doses of from  five to twenty
drops, according to the age of the patient, given every half hour, will
generally  be found very efficacious.   When it  becomes chronic, or
repeatedly occurs in the same individual,  great attention should be paid
to the articles of food that  are eaten, omitting  first one, and then an-
other, until the one by which the eruption is produced  is ascertained.
In chronic cases, the alkaline baths will often be found useful; or, oc-
casional laxatives, the mineral acids, and vapour-baths.
   In the febrile form, particularly when occurring in robust, plethoric
habits, leeches, or the lancet, will often be required, with saline  pur-
gatives,  and nitre,  a restricted  diet, and the antiphlogistic regimen
generally.
   When,  from a sudden disappearance of the eruption, sickness and
pain of  the stomach, or faintness,  or  symptoms of some  local affec-
tion, with an increase of the general  febrile symptoms, and delirium
or coma ensue:—in the first instance, the warm bath, sinapisms to the
extremities, and  small doses of aether or ammonia, will be required, and
in the latter, bleeding, blisters, and pediluvia.
   When urticaria  occurs  in debilitated  constitutions, or when  it as-
sumes an intermittent  type,  the bark  or sulphate of quinia must  be
prescribed; and should this fail, much benefit will, in many cases, be 
528
DISEASES OF  CHILDREN.
obtained from the use of the solution of arsenite of potassa, given in
small doses gradually increased.

                         8.—Erysipelas.
  The proper infantile erysipelas of medical writers, is happily of un-
frequent  occurrence in  this country.   It usually occurs  within a few
days after birth, and is,  in many instances, of intrauterine origin.  It
seldom makes its appearance after the fourth or fifth week, though a
few  cases have been observed  as late as the  sixth or  even  twelfth
month.
  The invasion of  the disease is often  extremely insidious.  The in-
fant appears  somewhat  morose;  his sleep  is slightly diminished and
disturbed, and  he sucks rather  less  than  before;  with  these trifling
symptoms, there is associated  a  small  patch of redness  on the lower
parts of the body, particularly about the nates, pubes, groins, and um-
bilicus, which is painful  upon pressure, and changes subsequently to a
purplish or livid hue.  In  new-born infants, according to the observa-
tions  of Meckel  and Osiander, occasionally, its origin  is umbilical
phlebitis.
  The inflammation spreads gradually and irregularly over the abdo-
men,  along the  back, and on the inside of the thighs; the parts occu-
pied  by the inflammation being swollen, hard, and extremely tender to
the touch, as indicated by the movements and cries of the child. Gene-
rally, at the end of twenty-four  hours, there arise  upon  the inflamed
surface a few scattered  vesicles, with inflamed  livid  bases, which ter-
minate  rapidly in gangrenous ulcerations.  The vesicles  appear, in
some cases,  upon the first occurrence of  the   inflammation,  and in
others, not until this has continued several days; occasionally, vesica-
tion does  not take  place, and the disease  is then  of little danger or
duration, the inflammation subsiding in two or three days.  In  those
instances  in  which the  inflammation is not very  intense, it  spreads
rapidly in one direction, while the disease ceases in  the parts originally
affected ; or suddenly disappearing in the part first attacked, it speedily
reappears on some other,  and,  perhaps, remote portion of the  sur-
face, and  in  this manner, may successively invade every part of the
skin.
  In  many cases, the skin surrounding the inflammation, to the dis-
tance of nearly an inch from its margin, is hard  to  the  touch, and
cannot be pinched up or moved over the subjacent parts, as in a state
of health.  In the majority of cases, this results from the infiltration
with serum of the cellular membrane surrounding the inflammation.
  When vesications appear early, the gangrene generally spreads
rapidly, and  the  case soon acquires  a very dangerous  and hopeless
character.   This is  more apt to be the case when the inflammation
occurs  upon the abdomen; on the extremities  and  nates  it is  more
liable to terminate in deep-seated suppuration, with destruction of the
subcutaneous cellular structure.   When suppuration occurs the pus is
of a  grayish colour, and of a very thin sanious character; it penetrates
through  the cellular membrane, beneath  the  skin, and  between the
muscles.  Small portions of the  skin  finally slough off, and give exit 
DISEASES OF THE SKIN.
529
to the  confined matter, mixed with flocculi and large shreds of spha-
celated cellular membrane. The genital organs, in some cases, sphace-
late when the disease  extends  to them, and  in many acquire  an em-
physematous appearance.
  In some rare instances the disease has been known to continue  for
fourteen or fifteen days, with but little vesication, and no diffused sup-
puration.
  In the more violent cases, the cessation of the gangrene is marked,
in the  early stages, by a white  line of  demarcation; and in the latter
stages of the more  protracted cases,  by a secretion of healthy pus
taking the place of the ichorous or sanious discharge.
   In  many cases the  disease would appear to be  at first perfectly
local.  Several days elapse before  any remarkable degree of  general
restlessness, crossness, and fever present themselves.
   In the first period of the disease, there is often considerable febrile
reaction,  which,  upon  the occurrence of vesication, assumes a low
typhoid character; upon the approach of suppuration, there is always
more or  less depression of the vital energies—though, in many cases,
the tendency to  sinking  is evident from the commencement of  the
attack.
   Frequently the colour and  expression of the countenance remain for
some days without exhibiting any striking change; when suddenly an
ashy,  cadaverous paleness is ohserved; the child cries incessantly;
there  is  constant jactitation and complete loss of sleep, with frequent
pulse and increased  heat of the skin.  These symptoms are succeeded,
more or less rapidly, by stupor and death.
   Few cases occur in which the  indications of gastro-intestinal dis-
ease  are  wholly absent.  There is generally more or less tenderness
of  the epigastrium—griping colicy pains—constipation,  or  frequent
discharges from the bowels of  a thin, grass-green fluid, preceded and
accompanied with griping.  Convulsions are not  unfrequent.   Those
portions of the surface of the body which are not occupied by  the ery-
sipelatous inflammation, often present a slightly jaundiced appearance,
and the urine usually contains  bile.
   A very common form of erysipelas in infants, according to our ex-
perience, is that described by Dr. Friebe in the Journal for the Diseases
of Children, under the name of Omphalitis exsudativa.  It commences
about the umbilicus, within a few weeks after birth, and is frequently
accompanied with ulceration of the navel, and infiltration of lymph or
pus into  the subcutaneous cellular tissue, and deposits of a similar
nature in the partially obliterated umbilical vessels.  It is attended by
great and rapidly increasing exhaustion, and occasionally convulsive
symptoms of more or less  severity.  It usually proves fatal; often
within the  course of forty-eight hours, and without having extended
more  than three fingers' breadth around  the navel.
   Dr. Friebe is  inclined to view  the  disease as  a  variety of partial
induration of the cellular substance, in consequence of the cachectic
condition of the  infants in whom he has seen it occur, and the  erysi-
pelatous  character  of the inflammation; while  the circumstance of
the umbilical vessels being in part converted into fibrous cords, pre-
                                34 
530
DISEASES  OF CHILDREN.
viously to the commencement of the disease, leads him to believe that
it cannot arise from umbilical phlebitis.  He appears to have seen but
three cases.  We have met with it among the infants of the poor much
more frequently, and our observations have convinced  us  that, in the
majority of cases at least, it is dependent upon phlebitis of the umbilical
veins; the evidences of inflammation of the latter were unquestionably
present in almost every instance in which  we have made an examina-
tion.  M. Trousseau remarks that  the  umbilical vein  is often found
inflamed and filled with pus, as far as the  transverse furrow of the
liver, while  inflammatory exudations are  found on the peritoneal sur-
face of  the  abdominal viscera.  M. Trousseau has observed  that, in
infants predisposed to erysipelas, the umbilical cicatrix does not  form
readily, and the ulceration which results is sometimes the occasional,
the local cause of the cutaneous disease.
  In older and  more robust children, erysipelas presents itself under
the same forms as in the adult.  A bright scarlet, shining efflorescence
appears upon some portion of the skin, preceded for a day or  two by
heat, and a sense  of tingling, and  some  degree of febrile reaction.
The disease occasionally declines by the  third or fourth day, the skin
assuming a yellowish hue, and desquamating.   In  other instances, the
disease  runs a more protracted course; vesications, more or  less ex-
tensive, form  upon  the inflamed surface, which  sometimes become
filled with a purulent fluid.  The vesications  rupture in the course of
two or  three days, and give discharge to a  thin,  glutinous fluid.  In
other  cases, the inflammation extends  more deeply, and  is attended
with symptoms of greater severity.  Rigors and severe febrile reaction
precede the local disease, which is attended with considerable swelling
of an cedematous character: suppuration early occurs, and  a thin,
purulent sanies  is formed, which travels  along the cellular structure,
beneath the skin, and among the muscles and  tendons, mixed  often
with clots of thin, grumous blood.   The  disease, unless energetically
treated in its early stages, is now very liable to assume a gangrenous
character, attended  with great depression of the vital energies, and
most commonly terminating in death.  In the acute stage, inflamma-
tion of the cutaneous vessels is occasionally  observed, and often puru-
lent depositions take place, in the serous cavities, and in the lungs.
  In the examinations that have been made of infants who have died
from erysipelas, phlebitis of the umbilical vessels has been occasionally
met with ; we have observed it in several  cases.  Inflammation of the
peritoneum, with puruloid or serous effusion into the cavity of the ab-
domen, is more commonly  met with.  Pleuritic inflammation, with
effusion, is more rare—pneumonia,  vesicular, lobar, and lobular,  is
very  frequent;  enteritis  is  the most  common morbid appearance,
although  gastro-enteritis not unfrequently  occurs.
   Various opinions have been advanced  in  regard to the causes  of
infantile erysipelas.  So far  as our own  observations extend, the dis-
ease would appear to originate, almost exclusively, in infants exposed
to a confined and impure atmosphere, or  in  the nursing of  whom pro-
per attention is not paid to cleanliness of person, bedding, and clothing
—in young children who are  allowed to lay for hours with  diapers 
DISEASES OF  THE SKIN.
531
imbued with excrement  and urine, or  if their  diapers  are removed
more frequently, having them hastily exchanged, without the surface
being properly washed and dried, for others that have  been worn
already, and merely dried.   Bad  nutriment, no doubt, contributes, in
the majority of cases, to the production of the disease.
  Erysipelas of infants very commonly occurs during the prevalence
of epidemic puerperal fever—children of mothers who become affected
with the fever, are often  born with erysipelatous inflammation; others
are attacked almost immediately after birth.  Whether, in these cases,
the disease is to be referred to a morbid matter  applied to the skin in
the womb, or to the same epidemic or endemic  influence which gives
rise to the disease of the parent,  it is difficult to  say.   According to
M. Trousseau, infantile erysipelas is  principally observed when puer-
peral fever prevails in the wards of the lying-in  hospitals of Paris.
The infants  appear to  him, to  inherit from their mother a purulent
diathesis, and seem to be still, within certain  limits, subject to the same
maladies as the mother.
   In the treatment of erysipelas, as it occurs during infancy and child-
hood, the nature of our remedies must be  governed by the stage of the
disease, and the character of the symptoms in each case.   In a large
number of cases, every remedy  of a debilitating character is strongly
counter-indicated, and the  early symptoms of prostration which  pre-
sent themselves, force us at once  to  resort to such measures only as
are calculated to support the patient's strength.
   In every instance, it will be proper to pay attention, from the onset
of the disease, to the condition of the bowels.   A  grain  or two of
calomel, followed in  a few hours by a  teaspoonful of castor oil, or
laxative enemata, will be sufficient to procure a free evacuation of the
intestines, without much irritation, and they  may be kept in a regular
state subsequently, by the exhibition, every three  hours, of divided doses
of calomel, combined with ipecacuanha and extract of hyoscyamus*—
the addition of the latter is calculated to prevent or allay irritation,
without  interfering with the aperient action  of  the other  articles.
When the skin  is warm  and dry, the liquor ammoniae acetatis alone,
or combined with antimonal wine,  will often be found beneficial.b   Un-
der the same circumstances, the occasional use of the warm or tepid
bath will prove highly advantageous.

    * R.—Calomel, gr. iij.—iv.               b R.—Liquor, acetat. amnion. 3ij.
         Ipecac, pulv. gr. iij.                    Vin. antimonii, ru/xxxv.—xlv.
         Carb. sodae, gr. xij.                     Aq. cort. aurant. 3j.
         Ext. hyoscyami, gr. iv.—vj.—M.          Sacchar. puris. gij-—M.
           f. ch. No. xij.             Ten to thirty drops, every two or three hours,
  One for a dose.                      may be given.

   If, with a hot  and dry skin, there should occur symptoms of cerebral
irritation, as intolerance of light, screaming, or convulsions, a leech or
two should be applied to the temples, cold applications to the scalp—
the bowels should be freely opened by castor oil, with the  addition of
turpentine, and warm pediluvia  should be resorted  to.
   There cannot be a doubt that cases of erysipelas frequently occur,
in young  children, which  in their  early stage are accompanied by 
532
DISEASES OF  CHILDREN
symptoms that indicate the employment of local depletion, and that in
these, a few leeches applied upon the sound skin in the neighbourhood
of the inflamed parts, will prove positively beneficial;  we have repeat-
edly met with such cases,  and proved the good effects of the practice.
Much judgment, however,  is required, to discriminate the kind of cases
which are likely to benefited by local depletion, and  to determine to
what extent  it may be prudently carried ;—as a general  rule, a very
moderate abstraction of blood will be sufficient.
  When a tendency to gangrene is  obvious, and the  disease  assumes
a low typhoid character, it will be necessary  to resort, at once, to the
use of the carbonate of ammonia, in doses  adapted to the  age of the
patient, and  the  urgency  of the  symptoms;  and, at the same time,
the child  should  be nourished at the  breast of a  healthy nurse, or, if
weaned, its  diet  should consist  of  animal  jellies dissolved in water,
beef tea, chicken water, or sago.  Where  the symptoms of prostra-
tion are more considerable, we may combine the use  of the ammonia
with the sulphate of quinia and the extract of hyoscyamus.8
                 * R.—Sulph. quinise, gr. ij.—iij.
                     Extract, hyoscyami, gr. ij.—iij.
                     Magnesioe calcinat. gr. xxxvj.—M. f. ch.  No. xij.
              One to be given for a dose every two  or three hours.
  It is  hardly necessary  to  say, that our  chance  of success  in  the
treatment of  these cases will be greatly diminished, unless we have it
in our power to remove the  patient to a healthy situation, where he
may enjoy the tonic influence of a pure, free atmosphere.
  Should  diarrhoea ensue after suppuration  has taken place, it should
be immediately checked by the cretaceous  mixture, with the addition
of tincture of kino and laudanum; or, if this should not succeed, the
acetate  of lead, ipecacuanha, and opium may be substituted."
                 1 R.—Acetat. plumbi, gr. xij.
                       Ipecac, pulv. gr. iv.
                       Opii. pulv. gr. j.—M. f. ch. No. xiv.
                 One to be given for a dose three times a day.
  When the  discharges from the bowels are of a vitiated  character,
or attended with griping or colicy pains, a few drops  of turpentine,
three times a day,  will be found a very valuable  remedy.  The tur-
pentine  may  be combined with the tincture  of kino and laudanum.3
                     *  R.—Aq. cinnamon, 3iij.
                          Tinct. kino, 3ij.
                          Spir. terebenth. 3j.
                          Magnesia calc. gr. viij___M.
        A teaspoonful may be given at a time, three times a day, or oftener.
  Various local  applications have  been recommended, by different
practitioners, as highly  beneficial in the treatment of infantile erysipe-
las, while  by  many  these are  denounced as invariably injurious.
Washing  the parts  frequently with tepid water, or some mucilaginous
fluid, will, in many cases, be productive of very great  relief to  the
patient, and we think that  we have  seen an abatement of the disease
take place under its use; in the intervals, the parts may be dusted with
powdered starch, or covered with carded cotton. 
DISEASES OF  THE SKIN.
533
   When the disease is attended with considerable  distension of the
 skin, a lotion composed  of the  acetate of lead  and  subcarbonate of
 ammonia, (half a drachm of each dissolved in eight ounces of water,)
 has been highly recommended.   Other washes have  been proposed as
 occasionally very beneficial, but of the effects of which we  have no
 experience—as the camphorated  tincture, applied  by covering the
 diseased parts with rags wet with it; a solution of corrosive sublimate,
 three grains to an ounce of water, applied in  the same manner; a so-
 lution of nitrate of silver, three grains to the ounce of water, similarly
 applied.  Applying, once or twice, a very strong solution of the nitrate
 of silver, by means of a pencil, upon the sound skin, for about an inch
 around the margin of the diseased parts, has  been said to effectually
 arrest the progress of the disease.  The chloride of lime, in solution,
 half a drachm to the pint of water, and applied by folds of linen satu-
 rated with it, is said to be one of the best washes, in cases which early
 show a tendency to gangrene.   A  solution of the sulphate of iron, half
 an ounce to eight  ounces of water, has also been employed with ad-
 vantage by Velpeau.  This is said to have  subdued the erysipelatous
 inflammation in two days.
   We have used a wash of acetate of lead, ten grains to the ounce of
 water, in many cases of infantile erysipelas, with the very best effects,
 but our favourite application, in  the ordinary cases of the disease oc-
 curring in children, is fresh lard, with the addition of  acetate of lead,
 in  the proportion of ten grains  to  the ounce.  To those cases which
 exhibit, from the first, a decided tendency to gangrene, this application
 is not adapted.  The local remedies just recited are to be employed in
 the  early stage, previous  to  the  rupture of the vesications, and to the
 occurrence of suppuration or gangrene.
   Among the local remedies which  appear to be the most  generally
 applicable to erysipelas occurring  in children, is a blister, sufficiently
 large to extend over the diseased surface, and for a short distance be-
 yond it; after vesication has been produced, the serum should be eva-
 cuated, and the vesicated surface dressed with fresh lard.  When the
 erysipelas occurs  upon the extremities, a blister applied around the
 limb, beyond  the affected  surface,  will frequently arrest the progress
 of the disease in that  direction.   In  the  cases in which we  have re-
 sorted to blistering, we have usually applied strips of leather, spread
 with blistering ointment, along the edges of the inflamed part, partly
 on  the latter, and partly upon the sound skin, and at  the end of three
 hours, have removed them, and immediately covered  the parts with a
 soft, emollient poultice, with the addition of lard.  The most important
 result which we have derived from the use of blisters, is the prevention
 of the spread of the disease.
  The  mercurial  ointment has  been  strongly recommended in the
treatment  of  infantile  erysipelas, as  wrell as  in that of  adults, by
Dewees and Metmeyhr.  The mode in which  it is applied, is to cover
the diseased surface with a piece of soft  linen, with the ointment
spread upon it; we know nothing of the effects of this remedy from
our own experience, having never employed it.
  In many cases, attended with an intolerable sensation of burning, we 
534                DISEASES OF CHILDREN.
have seen some good  to  result from the use, as a lotion, of a watery
solution of opium.
  In those instances in which the disease is attended with considerable
restlessness, and when  the patient is prevented  from sleeping at night,
a few grains of the Dover's powder, or a  dose of the camphorated
tincture of opium, adapted to the age of the  patient, should be given at
bed-time.
  When erysipelas terminates in gangrene, washes of a solution of
the chloride of lime or soda, of a few drops of creasote, diffused in
water, or of a  strong decoction of galls or  black oak bark, should be
immediately employed; or  the sphacelated surface may be covered
with either the charcoal or yeast poultice.  Pencilling the edges of the
gangrenous ulceration  which often ensues, with the creasote wash, or
the balsam of  tolu, will  occasionally arrest its progress.   We have
#een, we think, good effects result, in some instances, from washing
the gangrenous surface with a very strong  solution of the sulphate of
copper.
  In all cases in which the cellular membrane is involved in disease,
free incision should be  early made, as well to unload the vessels, and
relieve the swelling and distension, as to give exit to the purulent fluid
and dead portions of cellular structure.  The pus, if allowed  to remain,
by  making its way beneath the skin,  and  between the  muscles and
tendons, has a  tendency to increase the extent of the  disease, and to
cause  the  death of the patient, by the  irritation and exhaustion to
which it gives  rise.  After  the incisions, the parts should be covered
with a soft  emollient  poultice.  The  patient, or the affected  limb,
should be  kept at rest, and the inflamed part, if possible,  somewhat
elevated, so that the flow of the blood from it may be facilitated by
gravity.
  Should indications of pulmonary or cerebral disease occur in cases
of erysipelas, these will demand their appropriate remedies.
  When convalescence has been established,  and a degree of weak-
ness and languor remains, some light mineral  tonic, with the mineral
acids, should be administered, and the child  should be allowed a nutri-
tious, but mild  and easily digested diet; he should be  immersed daily
in the warm or tepid  bath, and enjoy a dry, fresh, wholesome atmo-
sphere.

                    9.—Phlegmonous  Tnmonrs.
  These occur on various  parts of the body, and in different tissues,
either as indications of internal disease, or  of some constitutional de-
rangement.  They are often critical when they occur at the decline of
acute febrile diseases.
   They have received a  great variety of appellations, but may all be
included under the general denomination, phlegmon.
   There are two leading  species: the one involving the cutis, and the
cellular tissue  beneath, often to a great extent; while the other is con-
fined to, and only involves, in  the  suppurative process, the substance
of  the cutis.
   The first appears in the form of a painful, dark-red, circumscribed 
DISEASES  OF THE SKIN.
535
tumour, of a somewhat conical form, excessively painful to the touch,
and often attended with more or less febrile excitement.   At the apex
of  the cone, a  little  white  speck or slough is generally  observed,
which, when picked off, is not followed  by the discharge of matter,
but leaves an excavation of a corresponding size and shape.  It is very
probable, Plumbe remarks, that the matter is formed in this species of
phlegmon, within a very few days after the occurrence of the disease,
deeply embedded in the cutis,  and is prevented from making its way
to the surface, in consequence  of the thickening of the superincumbent
structure, from adhesive inflammation.
   The second species of phlegmon is in the form of a dark-red, len-
ticular swelling, very painful  to the touch, and slow in maturating.
When pressure is applied to the sides of  one of these small  tumours,
soon  after suppuration has  commenced, a transparent  serum exudes.
Pus first appears in a minute yellow elevation on the centre of  the
tumour, the surrounding parts  of the latter being hard, solid, and pain-
ful.  The abscess seldom gives discharge  to much matter, and in most
cases, where the inflammation is not very obvious  at  the surface, a
small portion of the cutis is destroyed, and comes away in the form of
a slough.  After the excavation, formed by the separation of the latter,
is  filled up, and the inflammation has subsided, a thickened and hard-
ened condition of the part, which is of a bluish colour, remains, and is
only slowly removed.   These  phlegmons appear in the greatest num-
ber upon  some portion of the  trunk, particularly the abdomen, while
the first species occurs most commonly on the arms, thighs, and nates.
(Fosbrooke, Plumbe.)   We have very frequently seen the latter in chil-
dren of a gross habit of body,  upon the back part of the neck, and  be-
tween the shoulders.
   The second species of phlegmon is always of a chronic character,
and very generally a new crop makes its appearance as fast as the first
subsides, and it thus continues to occur until the diseased condition of
the system, by which the local affection is produced, is overcome.
   Children of full, gross habits, and who are fed upon coarse and rich
food,  are most subject to phlegmonous tumours.  They are more com-
mon during the spring and summer than at the other seasons of  the
year.  When extensive, they often give rise to a greater or less degree
of febrile excitement.
   The treatment of the disease  consists in placing the patient upon a
plain  vegetable diet;  the evacuation of the  bowels by a dose of calo-
mel, followed by a saline cathartic,  and free exposure to a fresh, pure
atmosphere ; and when the phlegmonous tumour is very extensive, hard
and painful, particularly when accompanied by febrile symptoms,  the
application of a few leeches to its centre.
   The early suppuration of the tumour should  be encouraged by  the
application of large emollient  poultices, of which the best  are those
composed of the crumb of stale bread, or linseed meal, boiled in milk,
with the  addition of lard. When  suppuration has taken  place, and  the
matter does not readily find its way to the surface, the abscess may be
opened with a lancet, and the  application of the poultices continued.
In  general, in a few days, the excavation will be filled up with healthy 
536
DISEASES OF CHILDREN.
granulations, and completely cicatrized.  If, after the abscess bursts,
or is opened, it exhibits no disposition to heal, it should be dressed with
the common resinous ointment.
   In the second  species of phlegmon, the use of the  sulphuric acid  in-
ternally, continued for a length of time, has been said to prove pecu-
liarly efficacious. It should he used largely diluted with water, and in
as large doses as is compatible with the age of the patient.  Under its
use, we are  assured by Fosbrooke, that the pain of the tumours is
deadened, and the latter gradually absorbed, without suppuration.  An
alterative  course of treatment, continued for  many weeks, with the
use of the compound decoction of sarsaparilla, will, in general, be re-
quired.
   Children who  are subject to boils, should  be restricted to a light, un-
irritating diet, composed chiefly of farinaceous substances; they should
use daily exercise in the open air, and be daily immersed in the warm
or tepid bath.
   Children are often affected with a phlegmonous inflammation  of the
glands of the neck and groin, unconnected  with indications of scrofu-
lous disease, and occurring under the same circumstances as the cuti-
cular phlegmon.
   Its treatment differs in nothing from that recommended for the more
extensive forms  of the latter;  low diet, saline purgatives, and the ap-
plication of leeches, and of cooling applications when a considerable
degree of inflammation is present; and when  the  tendency to suppu-
ration is evident, emollient poultices frequently repeated.
   In many cases, the inflammation and swelling of the glands are of
an indolent character, and will often remain for a  considerable time
without either increase or diminution.  In these cases, we have gene-
rally found the application of a blister to cause a rapid suppuration to
ensue.
   When an abscess forms, it should be early opened  by a free inci-
sion, and  the application  of the poultices continued, until  the  cavity
is filled up by granulations, and a disposition to  cicatrization is appa-
rent.
   There is a form of phlegmonous abscess of  common  occurrence in
children, which  we have not seen noticed by any writer.  It is  conse-
quent upon a deep-seated inflammation beneath the fascia, upon the an-
terior part of the thigh, or upon the lower part of the back; sometimes,
immediately above the hip.  It may, perhaps, occur in other parts, but
the above are the only ones in which we have seen it.  The disease
generally  occurs in children of a lymphatic temperament.
   The first symptoms are usually deep-seated, dull pains at  the part
where the inflammation occurs, which are often increased at night, and
always upon the application of pressure.  If the inflammation occur in
the thigh, or upon the hip, the child walks lame;  in  many cases, when
in the latter situation, the symptoms bear a strong resemblance to those
of morbus coxarius, for which the disease may be mistaken by an in-
experienced physician.  There is at first no redness or increased heat
of the part, and but  little or no  swelling;—by degrees, however, a
swelling is perceived, which gradually  increases  in extent, and finally, 
DISEASES OF THE  SKIN.
537
 upon a cautious examination, a fluctuation of matter may be detected.
 The skin over the  tumour is smooth and  shining, and very tense, and
 a deep-seated, throbbing pain, increased by paroxysms, is complained
 of;—it is often so severe as to deprive the child of his rest.
    In children over four years of age, we have seen, after suppuration
 has occurred, a well-marked, hectic fever, with two exacerbations in
 the course of the twenty-four hours, profuse perspirations at  night, and
 occasionally colliquative diarrhoea.  We have never observed any dis-
 position  in these  abscesses to approach  the surface; this has usually
 been prevented by the matter forming beneath the aponeurosis or fascia
 enveloping the muscles.  Occasionally, the matter in the thigh has tra-
 velled downwards, arid given rise to a swelling in the neighbourhood
 of the knee; and in one  case in which the abscess formed  in the lower
 part of the back, the matter found its way to the groin, where it formed
 a fluctuating tumour of considerable size.  When the contents of these
 abscesses is discharged by an incision, it is of a healthy  appearance,
 though occasionally containing flocculi, and large fragments of dead
 cellular matter.
   The treatment we have  pursued in these cases is, in the early stage,
 the application of leeches  over the seat of  inflammation, followed by
 blisters—a dose of calomel, succeeded by saline cathartics, and if  the
 discharges from the bowels are of an unhealthy appearance, the admi-
 nistration, three or four times a day, of small doses of calomel, in com-
 bination with ipecacuanha, extract of hyoscyamus, and magnesia. The
 moment matter is formed,  we consider it all-important to  make a free
 incision down  to the  abscess, and  then  to dress with emollient poul-
 tices.   This gives relief  to the pain, and the patient, in general, very
 quickly recovers his usual health; though, in cases in which  there
 exists  considerable exhaustion, the administration of  some light tonic
 will be proper.
   In one case, occurring in a lad between eight and nine years of age,
 attended with hectic fever, night sweats, and a profuse diarrhoea, the
 stools  being thin, dark-coloured, and very foetid, upon a free incision
 being  made to give discharge to the  contents of the abscess,  which
 was seated  upon the anterior surface of the left thigh, a manifest im-
 provement in  the  condition of  the patient  was almost  immediately
 manifested.  For the relief of the diarrhoea, a powder composed of the
 sixth of a grain of sulphate of copper, subsequently increased to one-
 fourth  of a grain, the third  of a grain of opium,  and two grains of the
 extract of quinia, was  administered every  three  hours.
   On the fourth day, the evacuations from the bowels were reduced
 to two in  the twenty-four hours, and became of  a natural appearance;
 all  symptoms of fever were gone, and the appetite and strength of the
 patient considerably improved.  In a week, he was able to walk about,
 and quickly regained his normal degree of health.  The left thigh, how-
 ever, remained for some  time longer, less in size, and the whole limb
 much weaker than the other.
  Inflammation followed  by suppuration, frequently attacks the ciliary
and  follicular  glands of the eyelids, in which case  a  small  dark-red
tumour forms upon  the tarsal edge of one of the eyelids, attended with 
538
DISEASES OF  CHILDREN.
some swelling and redness of the lid, redness and injection of the eye,
aversion from light, and  considerable soreness, increased by the mo-
tions of the eye or eyelids, (hordeolum, stye.)  The disease usually oc-
curs under the same general circumstances as the other phlegmonous
tumours.  After the inflammation has continued for a shorter or longer
period, a white or yellow speck forms at its centre, which, on bursting,
gives discharge to a small quantity of pus, when the inflammation and
swelling quickly subside, and finally disappear.  It is very usual for a
succession of these little phlegmonous tumours of the eyelids to occur;
no sooner one set disappears, than another makes its appearance, and
runs the same course.
  When the inflammation  and swelling are considerable, a leech or
two should  be applied to the lid, and calomel, followed by  saline ape-
rients, administered, so as to procure a free discharge from the bowels;
the diet being, at the same time, carefully regulated.  Very warm water
applied frequently to the  inflamed lid, by means of a sponge, or a soft
poultice of crumb of bread  and milk applied over the closed eye, may
be  used to promote suppuration;—as soon  as this takes  plaee, the
minute abscess should be  opened by means of a  fine sharp-pointed
lancet, and  the stye then cautiously touched with the point  of a pencil
of lunar caustic.  This causes the quick subsidence of whatever inflam-
mation and swelling may remain, and prevents the induration and red-
ness, which often continue  for a considerable time, especially in chil-
dren of a  weakly or lymphatic temperament.   Should the latter, how-
ever, occur, they may be moderated by a  poultice composed of crumb
of bread,  a grain or two of the extract of belladonna, and the campho-
rated tincture; or, perhaps, what is better, by touching the part with
lunar caustic.
  A chronic inflammation of the ciliary  bulbs  not unfrequently takes
place, which by degrees pervades the entire ciliary circle,  and, if not
checked in its early stage, terminates in a chronic inflammation of the
edges of the eyelids, accompanied by a  slight glutinous  discharge from
the ciliary glands.  In time the bulbs lose their power of secreting the
eyelashes, which fall out;  and the  loss of these,  with  the  permanent
red circle which surrounds  the eye, causes no inconsiderable deformity.
(Tinea ciliaris, lippitudo, chronic stye.)
  This affection most generally occurs in  children of a weakly, un-
healthy constitution, and of a lymphatic temperament, and it is very
commonly conjoined with  a  more or less disordered condition of  the
digestive  organs.
   In the early period of the inflammation, leeches should be applied in
the vicinity of the lashes, followed by the application of warm water,
or  soft emollient poultices, and after fhe disease has assumed a chronic
form, the unguentum hyd. nitratis diluted, or the  cautious use of the
nitrate of silver will generally effect a cure.  But these local remedies
will be of little service, unless attention  be directed to the condition of
the genera]  health of the  patient,  and to the state of  the digestive
organs.   The first should be strengthened and invigorated by a proper
diet, daily exercise in the  open air, the warm or tepid bath followed
by friction of the surface, or by sponging the skin daily with salt water 
DISEASES OF  THE SKIN.
539
of tepid warmth, followed  by friction, and  by the administration of
light  tonics and alteratives.  The healthy  functions of the  digestive
organs should  be restored  by a course of treatment adapted to their
particular condition,—which it is unnecessary here to particularize.

                           10. — H ejj e s.  tJ*K 4j*/ tf &-<<?/u^jlkjl-^
   An eruption of transparent vesicles, varying in size, from that of a
millet seed to that  of  a pea ;  either distributed like a belt around, or
partly around the body, (H. zoster, zona,) or in defined clusters, (H.
phlyctamodes,) or in circular patches around an inflamed area, the sur-
face  of which desquamates as the vesicles  decline (H. circinnatus);
or, very rarely, in three or  four concentric circles, or rings of varied
and beautiful colours, and elevated above the surface of the surround-
ing skin.  When herpes occurs around the lips, as it often does towards
the decline of catarrhal fevers, or in the course of various disorders of
the digestive organs, it has been denominated herpes labialis.
   Herpes occurs on various parts of the  body, and is  generally pre-
ceded by some degree of febrile excitement, which is often so slight as
scarcely to attract attention;  or by pain in the epigastrium, and other
symptoms  of disease of the digestive organs.   The fever and other
symptoms,—particularly languor,  loss of appetite, headache, nausea,
pain of the abdomen, heat of the  surface, and  hurried  circulation,—
generally remain as long as  fresh vesicles continue to  be produced.
The abdominal pain generally pursues the course of the eruption, being
felt at the regions of the stomach, liver, &c, when it extends around
the waist;  and when  the eruption occurs  upon  the shoulder, deep-
seated pain of the scapula, spine, or os humeri, is complained of, as it
extends down the arm.
   At the seat of the eruption, there first appears a bright red efflores-
cence, accompanied by a  sense of heat and tingling.  The redness is
distributed in patches,  varying in size, and separated from each other
by a greater or less extent of the  surface retaining its natural colour.
Upon the largest of these patches, near its centre, a few small vesicles
arise, and still fewer  upon  the adjoining patches, and  upon the next,
perhaps none, or only a minute pimple, which, in an hour or  two, be-
comes a perfectly formed  vesicle.  Slight pressure at this period pro-
duces a sensation of prickling; but, as the  disease advances, it is at-
tended with a severe smarting pain.   Within twenty-four hours,  the
vesicles that first appeared, attain the size of small pearls, and several
of those which are the closest together, coalesce,  and  form a  large
irregular blister, the areola of inflamed skin being also increased.
   The eruption  extends, in  an irregular line, from the  spot where it
first commenced, to distant parts of the surface, by the occurrence of a
succession of inflamed  patches and vesicles, which continue to appear
for four or five days; at the end of this period, the  first formed vesi-
cles  become opaque, shrivel up, and  terminate in a brown scab, that
is gradually extended by a similar change taking  place in the  other
vesicles of the same cluster:—the inflamed patch upon which they are
situated, at the same time, acquires a bluish  tint, and loses all appear-
ance of heat and irritation.  In about two weeks from the appearance 
    540                DISEASES OF CHILDREN.

    of the eruption, the scabs separate,  and leave a tender, discoloured
    state of the skin, which gradually disappears; in some cases, however,
    the disease is protracted to twenty or twenty-seven days.
       When the  constitution of the patient is much diseased, or the erup-
    tion  has been improperly treated, small white  sloughs occasionally
^ * 'form  at'lhe points™cCupied  by the vesicles, leaving permanent pits or
    scars upon the skin, after the healing process is completed.
       A slight eruption of herpes, and  one  limited in extent, is apt to as-
    sume a circular form, and hence has  obtained  the popular appellation
    of ringworm.   In such  cases, the vesicles are sometimes extremely
    minute, and they generally soon dry up, the cuticle falling off, in a few
    days,  in the form  of small exfoliations,  leaving a  reddened scurfy
    areola.  This form of herpes  occurs on different parts of the body,
    and seldom requires much attention.
       Herpes labialis is not often a very  troublesome form of the disease;
    it generally goes through its course, in a week or ten days ; the vesi-
    cles becoming first turbid and yellow, then drying up, and ultimately
    falling off, in the form of scales.  The  posterior part of the fauces  is
    sometimes affected, when the disease appears  suddenly, after checked
    perspiration and cold ; a few vesicles being distributed upon this part,
    surrounded by an erysipelatous redness.
       The causes of the herpetic eruption have not been very accurately de-
    termined.  It is most commonly met with in persons of a lymphatic
    temperament, and  is  most  prevalent in warm  climates and seasons,
    and in the neighbourhood of marshes.  It sometimes prevails epidemi-
    cally.   We have already  noticed  the  occurrence of  one variety,
    towards the close, or during the course of catarrhal and gastro-intesti-
    nal disease.  It is  often observed in infants, during the period of den-
    tition.  Sudden suppression  of perspiration—sudden changes in diet
    and regimen—the habitual use of food of  a fatty or oily nature, or of
    fish, and inattention to personal cleanliness, have been enumerated,  as
    common exciting causes of herpes.  Like  erysipelas, the disease  is
    said, by some authors, to occur after violent paroxysms of anger.
       The different varieties of herpes require but little  treatment.   It
    would be useless, if not dangerous, to attempt to suppress the eruption.
    The tingling, smarting, aching, and burning, by which it is accompanied,
     may, however, be  allayed,  and, in this  manner, the  patient rendered
     more comfortable, by lotions composed of a solution of acetate of lead
     with a slight addition of alcohol,  or  by  the application to  the part of
     the ungt. plumbi acetatis.   In the more severe cases, the strictest rest
     should be enjoined, with the antiphlogistic regimen generally, the tepid
     bath, and occasional  doses of some mild  aperient, as  sulphur and
     bitartrate of potassa, or sulphur and magnesia.  When the eruption is
     confined to a very small space, and  the vesicles  are very  minute, the
     application of substances possessing slightly caustic or powerfully  as-
     tringent properties, will often speedily effect its removal, as the  juice
     of the green rind of walnuts, tincture of galls, or a strong solution of
     the sulphate or acetate of copper; but, under all other circumstances,
     such applications will prove decidedly injurious.
       If  each vesicle  is  carefully punctured, so as to allow the escape of 
DISEASES OF THE  SKIN.
541
its fluid contents, the pain will be much diminished, and  the irritation
more  speedily subside; but the vesicles must  not  be cut, or  rudely
broken.
  It is  stated by Plumbe, that  the  spreading of the eruption may be
prevented, and the progress of the disease shortened by the application
of a small  blister  upon the uninflamed skin, at the part to which the
eruption seems  disposed to extend.   The  blister should never be ap-
plied  upon the vesicles themselves, as this  may cause a sloughing of
the integuments at the seat of the latter, followed by small irritable
ulcers, which heal with difficulty, and leave permanent marks upon
the skin.
   When herpes occurs as a concomitant of other diseases, the treat-
ment should be exclusively directed to the removal of the latter, with-
out any attention being paid to  the eruption.
   The decoction of dulcamara, and, in very severe cases, the arsenite
of ammonia dissolved in. distilled water, in the dose of the one-twenty-
fourth of a grain,  have been recommended as peculiarly efficacious.
   In some cases of uncommon  severity, or  where the disease has been
improperly treated in  its early stages, a rupture of the vesicles takes
place, followed  by ragged  ulcers, which spread,  often with great ra-
pidity, (H. exedens.)   These ulcers  should  be treated by carrot poul-
tices, or touched with a weak solution of nitrate of silver, or chloride
of soda.
                   11. — P s o r i a s i s.

JfUfi* SCALLY TETTER--DRY SCALL--LEPRA ALPHOIDES. \&i%J&A'* 7\&fCtgF
  This form of squamous eruption consists in a rough and  scaly con-  **Ap*'*tJm
dition of the cuticle, sometimes in separate patches, varying  in size,  H?A<
and of irregular form, and sometimes occupying continuously a large 0k  §\ .
portion of the surface.  For the most part, psoriasis is accompanied §S &JL&0*}
with rhagades or fissures of the skin.                                #£ dr^JP
  Soon after  the appearance of reddish points or projections on  the
skin, small white or pearl-like scales appear, either separate or in clus-
ters, or  surrounding a central  pink-coloured space, with a slight dis-
coloration of the surrounding skin.  In other cases, the patches  are
of a reddish or brownish colour, interspersed with  fissures, and accom-
panied with intense itching, or  a  sense of burning, increased  by heat
or friction; sometimes producing ulceration, and the discharge of a
purulent fluid, which, intermixed with the scales, on becoming con-
crete, forms a more elevated crust.  The scales are usually surrounded
by a circle of a deep rose-colour, which is increased  in intensity by
exertion, or by food of a stimulating quality; beneath the scales, the
skin is red and irritable.   When  the patient is in  bed, the scales often
become detached in great quantities, and, by their friction, aggravate
the  tingling and itching.
  When the disease occurs in the neighbourhood  of joints, or parts
endowed with considerable motion, blood frequently issues from  the
fissures, accompanied by severe pain and smarting. 
542
DISEASES OF CHILDREN.
               Psoriasis  is, occasionally, at its commencement, formed  of small
             distinct patches, with  irregular circumferences (P. guttata).  These
             appear on almost every part of the body, even on the face.  In other
             cases, the patches are of some extent, and  also irregularly circum-
             scribed (P.  diffusa).  The patches, in other cases, again, present a
             tortuous  or  serpentine appearance (P. gyrata); while,  in some in-
             stances, the  patches, at first separate and irregular, become, in a short
             time, confluent, until at length the disease covers the greater part of
             the surface of the  body, with  a universal scaliness, interspersed with
             deep furrows, and  a harsh, stiff, and thickened state of the epidermis
             (P. inveterate).
               In infants, the disease very commonly  affects the cheeks, chin, fore-
             head, nates,  abdomen, &c.   When the face is affected, the  eyes some-
             times partake of the inflammation, and generally the mucous membrane
             of the  nose  becomes inflamed  and thickened, causing snuffling, diffi-
             culty of respiration,  and some discharge  from the nostrils.
               In protracted cases, there is often great emaciation, which rapidly
             increases  until death takes  place.  The  disease, in early life, is com-
             monly  attended with more or less affection of the alimentary canal,
             which  may  have been the primary cause of the eruption, or  may im-
             pede its cure.
               Psoriasis generally occurs among the children of the  poor, who in-
             habit unhealthy localities, and is mainly to be attributed to bad food
             and bad nursing, in conjunction with the  morbific influence of an im-
             pure  and confined atmosphere, and a neglect of personal and domestic
             cleanliness.
  wi\lA . Jlffche.tijeatment of psoriasis, a change to a more wh oletojHj^a|pl^
  » >V^*V sphere, an improved diet, proper clothing, anafrequent tepid  bathing,
»»  . ."*/.  *% with  a  course of treatment adapted to restore to their healthful  condi-
 ^^%t> * * tion the functions of the digestive organs, are the first steps to be taken,
"WtftVJt  ffcand with  frequent ablutions of the more irritable  parts, with  warm
NM»\& Nfcwater or  mucilaginous fluids, will, in  general, be sufficient to accom-
  •j^W^^plish  a cure.  If there be  much irritation, with constant  fretfulness,
          ^and want of sleep, the parts may be bathed with the watery solution
           ^of opium, and the  same, with the addition of the carbonate  of soda,
             may be administered internally, should there be nothing to forbid its
             use. When severe  local inflammation  exists, leeches  around the edges
             of the squamous patches will be proper.
               On the  subsidence of the local irritation, the sulphur-bath may be
             employed, and repeated every two  or  three  days, provided it  is not
             found to increase the irritation of the skin.   If the latter effect result,
             the bath should be at once suspended, and gentle purgatives adminis-
             tered, at  such intervals as will  be  sufficient to preserve the bowels
             freely open:  the following has been recommended, as one well adapted
             to these cases:
                                R.—Sulph. prsecip. 3j.
                                   Magnes. calc. 3ss.
                                   Pulv. rhcei, gr. xxiv.
                                   Bi-tart. potassae, gr. xxiv.—M.  f. ch. No. xij.
               In  the chronic stage of psoriasis, the decoction of dulcamara, and 
DISEASES OF THE SKIN.
543
small doses, three times a day, of the solution of the arsenite of potassa,
will be proper; or in cases attended with considerable derangement of
the alimentary canal, with unhealthy discharges  from the bowels, in
which, of course, the arsenical solution would be improper, the decoc-
tion of dulcamara may be employed, in conjunction with the spirits of
turpentine; three to eight drops or more of the latter, according to the
age  of the patient, may be given three times a day, dropped  on a
piece of mint candy.
   When the scales do not readily separate,  they may be carefully
touched with  the liquor potassae, or dilute hydrochloric  acid; or  the
ointment of the nitrate of mercury may  be used, taking  care to  wash
off that already applied, before it is renewed.
   If the disease is attended with a state of considerable prostration,
and especially if the skin, at the seat of  the eruption, acquires a dark
or violet hue,  the  sulphate of quinia  should be administered, or  some
one of the preparations of iron, or the  tincture of iodine in  doses of
from two  to eight drops, twice or thrice  in the course of the day.  A
pure, fresh  atmosphere,  and the daily use of the warm bath, are, in
these cases, all-important.
   When psoriasis occurs simply as a concomitant of other diseases,
our whole attention should be directed to the removal of the latter; as
the disappearance of these will very generally be  followed by that of
the cutaneous affection.   This is a rule which will apply generally to
all of the  diseases of the skin.

                    12. — Follicular  Warts.
  *IJard, white, and rather shining elevations  of the skin, usually oc-
curring on  the cheeks and  forehead;  they are often stationary for
some time, but, in some instances,  one or  more  of  them become
enlarged,  of  a pale  pink colour, and  surrounded by  an  inflamed
margin.
   These tumours ordinarily result from  an obstruction of the cuticular *
follicles, preventing the discharge of their sebaceous secretion, which,
accumulating in the follicles, and concreting, causes their distension,
and, ultimately, excites an inflammation, that often involves for a short
distance the neighbouring skin.   Soon  after  inflammation occurs,  a
suppurative process commences in the follicle, and the sebaceous mat-
ter is dislodged;  and  speedily all disease disappears;  but, occasion-
ally,  the  matter accumulates within  the  follicles, and an  abscess of
considerable size is produced; from a  small  opening in which, an
exudation of cheesy matter,  mixed with pus, continues for some time,
or concreting upon the surface, forms a crust.
   This affection generally occurs towards the close of childhood, in
both sexes, but more  commonly in  boys, and  is  ordinarily produced
by derangement of the digestive  organs; in females, it is frequently
connected with that condition of the digestive and assimilating func-
tions, which gives rise, at a later period, to chlorosis.
   A proper regulation of the diet, brisk but gentle purgatives, pure air,
and the warm or tepid bath, followed by  brisk  friction of the surface,
are  the only  remedies  required; excepting  in  cases  in  which  the 
544
DISEASES OF CHILDREN.
   derangement of the bowels is of a more  serious and extensive cha-
   racter, when the proper treatment adapted to the particular character
   of the intestinal disease present in each case will be demanded.
     When the tumours are large, few in number, and of an indolent
   character, they may be seized by a pair of forceps, and excised by a
   sharp  scissors; or the inspissated matter by which they are filled, may
   be expelled by  gentle pressure. When inflammation takes place, sup-
   puration should be promoted by warm  fomentations, or a  small poul-
   tice ; and as soon  as  matter  is formed, it should be allowed early to
   escape by  a slight incision.
     In some cases, towards the period of puberty, these tumours become
   the seat of chronic inflammation, and the  face then becomes studded
   with hard, dull, red, and painful pimples,  (A. indurata,) which continue
   for a  long time.   They are generally connected  with very considera-
   ble derangement of the digestive organs; and until these are restored
   to a  healthy condition, very seldom disappear.   Various local  appli-
   cations have been recommended  for these  pimples, but we must con-
   fess we have, in no instance, seen  any advantage derived from their
   use.  A course of treatment adapted to the  condition of the alimentary
   canal, with an  appropriate diet and regimen, is the only means which,
   in our hands, has succeeded  in freeing the patient from the deformity
   consequent upon acne indurata.

                            13.—Porrigo,

   TINEA  FAVOSA--FAVUS--TINEA CAPITIS--SCABIES  CAPITIS FAVOSA--TEIGIJE
                 FAVEUSE--HONEYCOMB SCALL--SCALD-HEAD.

     This is one of the most obstinate, disgusting, and infectious, of the
   simple cutaneous affections of childhood.  There are several varieties
   of the disease.  In one,  (P. lupinosa,) an eruption of minute, flat,  umbi-
  ■ licated vesicles, of a yellow colour, occurs upon the scalp, attended by
   more or less itching.  The contents of these pustules, by speedily de-
   siccating, form a number of small circular scabs, of a yellow or fawn
   colour; each scab being hollowed in its centre, and raised at its edges,
   and having its base deeply embedded in the skin, and strongly adhering
   to it.  The scabs gradually increase in size, but still preserve their cir-
   cular and cupped form.
     When the pustules of porrigo occur in clusters on different parts of
   the scalp, the edges of the scabs formed by them,  approach each  other,
   and by their aggregation  give rise to crusts of considerable extent; in
   which, however, the cup-like form  of the individual scabs is readily
   detected, giving to the crusts some resemblance to honeycomb.  Some-
   times, the  cutis is  deeply  involved in  the irritation of the disease, and
   fissures of considerable extent are formed, from which an ichorous or
   purulent matter is discharged; and occasionally,  according to Alibert,
   in severe  and  protracted cases,  the  cutis, and  sub-cuticular cellular
   membrane are destroyed, and the bone of the  skull laid bare.  Be-
   tween the  different clusters of scabs, the skin is covered with furfura-
   ceous  scales.
'/ 
                    DISEASES OF THE  SKIN.                545

  In some individuals the disease extends to the forehead, temples, and
neck; or occurs upon other and remote parts of the body.
  The attendant itching is,  in some  cases, almost intolerable, and   - %
causes the patient to scratch himself incessantly and severely.   Pedi- 9tfmi%f,
culi, which multiply in great numbers under the edges of and between
the scabs, add  farther to this  irritation.  The smell emitted  by the
scalp, is peculiar and disgusting, resembling that of the urine of the
male cat.                                                                 - f
  When the crusts are removed by the application of emollient poul- *«*-#• *0€m4^
tices, the epidermis is found  to be destroyed, and the reticular structure#w4|K»'^ <*
beneath red and inflamed.   A yellow, viscous, and foetid  discharge 0gjf 0R, s/
exudes from numerous ulcerations;—a  number of  small abscesses are 0$t gmktygHft'
seen dispersed over different  parts of the  scalp, of a lenticular form,
and appearing as so many centres of inflammation.  When the disease
is neglected and allowed to proceed, it  is finally attended by an  almost
universal falling out of the  hair, leaving the skin smooth and shining;
the few hairs that remain being thin, languid, and altered in colour and
structure.
  When the scabs in this form of porrigo  are allowed to become per-
fectly dry, they assume a white appearance, wear off, break, and de-
tach themselves  from the scalp; their  remains presenting no  regular
form.
  In another, and very common form  of  the  disease, (P.furfurans,)
there is, at first,  a slight desquamation of the cuticle of the scalp, often
attended with considerable itching.   There  is discharged from the
affected surface, an  ichorous  matter, which dries, and forms a scurfy
covering to the scalp; the disease gradually and slowly spreads  over
the greater part  of the scalp;  the layers of scurf thicken, and resemble
a coating of bran, or  coarse flour, the lower surface of which is satu-
rated with fluid.  Upon freeing the scalp from this adhesive substance,
it is found to be divested of its cuticle, presenting a smooth  shining
surface, like varnish, and usually of a  pink colour.   The hair, in this
form of porrigo, becomes matted and  glued  together; and, when the
finger is pressed upon it, the whole  mass has, in nearly every  part, a
soft  yielding feel.
  The disease is chiefly confined to the scalp, but sometimes extends
to a slight distance  upon the  forehead, in  the  form  of crusts,  resem-
bling a portion of bran, cemented by some adhesive fluid, the edges of
which are sometimes dry, and perfectly white.  Much itching attends
the disease, and great numbers of pediculi, range freely over the affected
parts ; ulcerations to a small extent occur  here and there, from which
a fluid is discharged.  The  scalp emits  the smell of sour milk.
  In other cases, the disease  presents  itself  in the form of numerous
small, deeply-seated, yellow pustules, of a  circular form, and umbili-
cated, seated upon a circular red  patch, which precedes them.  The
pustules are crowded together, especially around the circumference of
the patches.  They are commonly each traversed by a hair, and are
attended by intense itching (P. scutulata);—their contents soon  con-
crete, forming a small cupped scab, which adheres by its edges to the    ^  cv
adjoining scabs,  producing  thus a continuous  crust, of the  form ancT^QMty.")  .

                               35                                Y»!k  *y 
              546                DISEASES OF  CHILDREN.

              dimensions of the patch upon which the pustules arose.  The indivi-
              dual scabs, in coalescing, lose their cupped form.
        , ^      Around  the circumference of the patches, new crops of pustules
      \ %*fc« successively  arise, and, forming  scabs, cause the greater portion  of
              the scalp to become covered with a continuous, thick  incrustation, of
              a whitish  colour, around which, portions of the original blotches,'in
It              the form of semicircles, or segments of circles, are perceived. In these
t   ,           cases, there is no hair, except around this incrustation, where the few
  >H^%a »v '■» remaining hairs form  a sort of crown.  (P. decalvans.)  Portions of
 ** |fc^W*t* tne scalp are frequently covered with circular patches, varying in size,
   • ~.«h W^ showing the disease in a more or less advanced stage, with here and
^Nf%£^W»%« there a white and shining space, entirely bald ;—the intervening por-
              tions of skin being covered, to a greater or less extent, with  a furfura-
              ceous desquamation.   This form  of porrigo, may extend to the fore-
              head and neck.
                In other cases, the disease is more circumscribed ;  the pustules on
              drying, form  small brownish, or dark-gray crusts, varying in form and
              size, and strongly resembling fragments of old  mortar, or the plaster
              from walls discoloured by damp and dust;—they are often very hard,
              even of a stony consistence.  (P. granulata.)  The patches of disease
              are generally separated from each other, and are not so deeply imbed-
              ded in the dermoid tissue, as those of the P. lupinosa ;—they are some-
              times surrounded by thin, dry, furfuraceous scales.
                The disease is attended with  severe itching;  and, upon the separa-
              tion of the crusts, the parts  beneath are found to be red and inflamed,
              smooth, polished, and often swollen.  Here and there, small, depressed,
              whitish  abscesses occur, from which issues a small quantity of a vis-
              cous, colourless fluid, which thickens and  dries, forming new crusts,
              analogous to  those which preceded.  Before the matter becomes per-
              fectly dry, it  exhales a nauseous smell, somewhat resembling rancid
              butter, or milk beginning to turn.  (Plumbe.)  This form of porrigo is
              confined to the scalp and parts immediately adjacent.
                When porrigo furfurans occurs in children possessed of a less degree
              of irritability  of skin, the disease is of a much  more chronic character;
              there is less disposition to pustulation, or to the exudation of fluid.  A
              constantly repeated exfoliation of the epidermis, in  the form of minute,
              dry scales, takes place; and the cuticular sheath which envelopes
              each hair for a short distance beyond its exit from the scalp, becomes
              more elongated, opaque, dry, and  shining;  giving  to the hair, near its
              root, a  shining silvery appearance, resembling the fibres of asbestos.
              (Teigne amiantacee of  Alibert.)   When  the diseased hairs are cut off
              with the scissors, the skin appears furrowed,  and  somewhat red and
              inflamed.  The itching sensation  is  inconsiderable; and, as the dis-
              eased parts are usually destitute of moisture, no unpleasant smell  is
             emitted.
                In severe or  neglected cases, the  lymphatic glands at the back of
             the head and  of the neck, sometimes becomes enlarged ; occasionally
             the tongue has been seen studded with patches and vesicles.  (Dendy.)
             When it spreads in the direction of the eyes, porrigo will occasionally
      • JMp^produce severe ophthalmia.  Tinea ciliaris will, in other cases, be pro- 
DISEASES OF THE SKIN.
547
duced, with an oedematous state of the puncta  lacrymalia, and a dis-
charge of the tears over the cheek; or, even, in  very protracted cases,
ectrojgium, especially of the lower lid, may finally ensue. £ ft ?/^£ f* •
  Porrigo is capable of being propagated by inoculation or contact;. 4 , .
the disease, however, frequently occurs spontaneously, in  children of
unhealthy constitutions, fed upon coarse, fat food, and in whom no
attention is paid to preserve the head, and body generally, perfectly
clean.  It  is under these circumstances, and  particularly when the
disease, in  its early stages, has been neglected, or treated by improper
remedies, that  the" most obstinate and  aggravated cases  of porrigo.,  .,
occur.   The  disease is said to be  of most frequent occurrence, in
low, marshy, and otherwise unhealthy situations.  In  the  children of
those  in comfortable  circumstances, to  whose personal  cleanliness
daily attention is paid, the disease is  generally produced by contagion,
or results from a deranged state of the digestive, assimilating, and nu-
tritive functions, the consequence of  excess  in the use of rich, fat, or
oily food:—in such children, the eruption is generally small in extent,
and without difficulty removed.
   With respect to the treatment of porrigo, in  every case, the condi-
tion of the patient's general health, and  the state of the digestive or-
gans particularly,  should be first attended to;  and whatever indica-
tions of internal derangement or disease exist,  should be met by their
appropriate remedies;  the local treatment being restricted  to frequent
ablutions of the head with warm water,  the hair being  previously re-
moved from and around the affected portions of the scalp, by a pair of
sharp scissors, and any loose hairs  detached  by the forceps.  This
simple treatment, in recent cases, and where the general health, or that
of the assimilating organs, is not extensively impaired, will very often
succeed in effecting the complete removal of the cutaneous affection.
   The entire removal from the scalp of the incrustations produced by
the desiccation of  the morbid discharges, and the matting of the hair,
is all-essential to the entire and speedy eradication of the disease; and,
hence, when these have been allowed to accumulate, the head  should
be repeated!)'  washed with tepid water, and the diseased parts  cover-
ed  with simple emollient poultices.   When, by these means, however,
we do not  readily  succeed in softening and detaching the crusts, alka-
line washes may be employed, made stronger or weaker according to
the greater or less thickness and firmness of the crusts.  From half a
drachm, to one or  two, or even three drachms,  of the  subcarbonate of
potassa, may be employed, according to circumstances.  In detaching
the crusts, no  violence should be employed.   The removal of the dead
and loosened hairs, is also a  matter  of some importance,  and  should
not be neglected: the best plan is to pull them out by means of a small
forceps.
   After all local irritation has been removed by emollient  washes and
poultices, we have seldom failed, in slight and recent  cases,  to cause
the speedy removal of the disease, by the application, night and morn-
ing, of the unguentum hydrargyri nitratis,  or  of an  ointment of the
hydriodate of potassa, (one drachm to two ounces of  lard,) applied in
the same manner.   The parts being  well washed with tepid  water in 
548
DISEASES OF CHILDREN.
     which a small portion of castile soap has  been dissolved,  previous  to
     the re-application of either ointment. In some recent cases, touching the
• >> vdrgel^Wjl flails Wlln lne n'trate of silver, will often cause an immediate
 » # arrest of the disease.  The ointment  of  the  ioduret of sulphur has
     been recommended by Biett and Schedel  as a very efficacious local
     application;  improving  the  condition  of the scalp, preventing the
     formation of fresh  pustules, and causing  a healthy  growth of hair.
     But so long as any irritation of the scalp exists, all irritating applica-
     tions are injurious; emollient poultices, and washes of tepid warmth,
    ,.are then  alone  proper, and they  should  be immediately resorted to,
     should any degree of  local irritation occur during the employment  of ,
     any of the ointments or lotions recommended.
       Care should be  taken  to prevent the contact of the diseased dis-
     charges from the scalp, with the healthy skin; as, in this manner, the
     disease may be extended and kept up for a considerable time.
       During the treatment, the patient should be put on a diet composed
     principally of farinaceous substances; he should be afforded the benefit
     of a pure atmosphere, and have his bowels regulated by the occasional
     use of mild aperients; while the healthy action of the cutaneous capil-
     laries is promoted and maintained by  the daily use of the warm or
     tepid bath, according  as the heat of the surface is deficient or increas-
     ed.  In  many cases, sulphurous baths, and gentle sulphurous douches
     every morning, will prove very useful adjuvants.
       In chronic cases, a variety of lotions have  been recommended; as
     solutions of the  sulphate of copper or of zinc ; of the deuto-chloruret  of
     mercury, or of  the nitrate  of silver, or the sulphuric, nitric or hydro-
     chloric  acids, more or less diluted.   Quickly washing the diseased
     portions  of the scalp with diluted nitric or hydrochloric acid, by
     means of a feather* and then pouring  water on the parts,  to  prevent
     the action of the acid from penetrating too deeply, we are assured by
     Schedel will very certainly cause the removal of the disease.  By the
     same authority, touching the diseased parts with  a small  hair pencil,
     dipped in creasote, and subsequently applying  an ointment of creasote,
     (twenty grains to an ounce of lard,) is asserted to have succeeded  in
     the eradication  of the malady, in  cases where  many  other means had
     been ineffectually employed.
        By Dr. A. L. Wigan, of London, a plan of  treating the disease has
     been proposed, which  is described as prompt in its effects, and uniform-
     ly successful.   The whole of the scalp is,  in the first place, to be care-
     fully shaved twice, unless the quantity of hair is very small, and offers
     no obstacle to the complete examination of the skin.   This, according
     to Dr. Wrigan, is all-important, inasmuch as when the scalp is covered
     with even a moderate quantity of hair, in parts that have become in-
     fected, the disease may gradually progress, whilst the whole attention
     is paid to those in which it is already apparent.   A narrow circlet  of
     hair  may be left around the face, as a concession to parental vanity,
     if there  be no indications of the disease at this part, and it is carefully
     washed with hot vinegar.        >
        The scalp being denuded of hair, is to be washed with  the pyrolig-
     neous or concentrated acetic acid.  In its first application, Dr. Wigan 
DISEASES OF  THE SKIN.
549
i
employs the acid diluted with three times its weight in water.  This
wash generally causes a number of red  patches  to  appear upon por-
tions of the scalp, which before its application looked perfectly heal'thy         |l>   I
—showing that these parts had become infected, but without the dis-
ease having gone through its stages, which Dr. Wigan supposes, from
a large number of observations, to require a  space of eight days.
   The whole extent of the disease being thus determined, with a piece
of fine sponge tied to the end of a stick, or held in a pair of silver sugar              j
tongs,  each spot is to be  thoroughly  imbued with  the concentrated
acid, for the space of three or four minutes; when, according to Dr.
Wigan, the  disease will be fully arrested.  He has often  applied the
acid a  second time, but he firmly believes  that this is unnecessary
whenever the  scalp has been  completely denuded of its hair, and the
extent of the  infection tested by  the preliminary application of the              j
diluted acid.
   The  crusts  are gradually raised up with  the  growth of the hair,
which soon sprouts again if the eruption  be recent.  As sOon as a pair
of fine scissors can be inserted beneath them, they should be  removed
by clipping the hair; but we are warned not to  do this prematurely,
lest a sore place be produced.
   We confess, we have seldom met with  much trouble in curing cases              j
of porriginous disease of the scalp, excepting in constitutions of a very
unhealthy character ; particularly those  strongly predisposed to scro-
fulous or tubercular disease.   Our success we have mainly attributed
to the attention we pay to the complete cleansing of the scalp, by re-
peated ablutions with warm water, and the occasional use  of alkaline
lotions; to the early removal of the hair by the  scissors, and the re-
moval of loosened and diseased hairs by the forceps ; to the constant        l|
attention we direct to the condition of the digestive, assimilating, and
nutritive processes, with  the view of detecting and removing  any de-
rangement which may exist in either. This course, with perfect clean-
liness of the patient's person  and habiliments, free exposure to pure,
fresh air, with a  well-regulated diet,  and appropriate  exercise, has
enabled us, in a very large number of cases, to succeed in the removal
of the diseased condition of the scalp, with no further local application
than the emollient washes and poultices above referred to; or the ap-
plication for one or two days of the citrine  ointment, diluted or undi-
diluted; or of  the ointment of the hydriodate  of potassa.  The disease,              \
however, is  not one of very frequent occurrence in Philadelphia, at
least in its more aggravated forms.                                              1


  ERUPTIONS  CONNECTED WITH LANGUID CUTANEOUS ACTION.

                        14.—Pityriasis.
                            dajsdJff. (/* M* £+1, *L^*+4f t4ufr*"*~

  Exfoliations  of the  cuticle in different parts of the body, but in in-
fants chiefly occurring on  the hairy scalp,  unaccompanied by much
irritation or fluid secretion. 
                                                         ^3
550               DISEASES OF CHILDREN.

   We are to recollect that in all infants, for some days after birth, a
slight  exfoliation of the cuticle takes place; which .is always to be
considered a healthy natural process.  Dandrijf, however, is the pro-
gressive desquamation of thin  scales from the scalp, succeeding light,
pink, unelevated patches; attended, in most cases, by a trifling degree
of chronic inflammation of the vessels secreting the cuticle, but with-
out the discharge of  fluid.
   If the infant in whom this  affection occurs, is not very much ne-
glected in regard to cleanliness, it usually disappears in a few weeks;
but now and then, under  different circumstances, and  particularly,
when, at the same  time, there is derangement of the alimentary canal,
from improper or  unwholesome food, it is  followed by considerable
irritation of the scalp, a fluid secretion, and scabbing, (P. scdoida,) or
a state  resembling the porrigo furfurans.  Under circumstances of
peculiar aggravation, according to Plumbe, there  is, in fact, no  real
difference between the two affections.  In these  severe cases, too, the
hair often falls off,  and  the eyelids, likewise, occasionally become dis-
eased.
   On  the  breasts of children, about the  tenth year, are often seen a
few light, yellowish scales, scattered here and there, and sometimes so
indistinct as scarcely to be perceived, (P. versicolor.) In this situation,
they sometimes resemble  freckles, or light yellow stains; upon more
minute examination, however, their squamous character will be readily
detected.  In children of unhealthy constitutions, the  spots will occa-
sionally assume a  dark or livid hue, (P. nigra, melasma;) this  will
often be observed in children, more especially, who have  become de-
bilitated by a residence in warm or tropical climates.
   When the dandrirf occurs upon the scalp of infants, it is, no doubt,
 in very  many instances, dependent on the disposition to determination
to the head, so common at this age; and, it is not improbable, when
attended by much irritation and fluid secretion, hyperaemia of the cere-
bral vessels may be prevented by it. (Plumbe.)   The condition of the
patient's health,  therefore, requires  to be  closely considered,  in de-
 ciding upon its treatment.  Sedative applications are seldom  advisable,
 or even safe; and those  of an irritating character should never be
 employed.
    Upon whatever  part of the  body the disease may present  itself, it
 will demand little  attention beyond what may be necessary to restore
 the patient's general health, and  the regular action of the digestive
 functions ; with strict attention to  cleanliness of the surface  generally.
 The  exfoliation will usually  be quickly checked, by simply washing
 with warm water.   In  more obstinate cases, a weak alkaline solution,
 as one drachm of the liq. potassae to four ounces rose water, may  be
 gently rubbed upon the part.

\Vfc.,*v r, %|\».\.  4^5£^r IW UlJ 0 S i S.
                          FISH-SKIN DISEASE.

    A  morbid thickening, with a dry and hard condition of the cuticle,
 evidently dependent upon chronic inflammation of the vessels by which 
DISEASES OF  THE SKIN.
551
the cuticle is  produced.   Ichthyosis is  unattended, at first, by any
uneasy  sensations, but,  as  the thickening of the cuticle increases, a
sensartion of increased heat, with redness, and other marks of more or
less irritation  are observed on the healthy skin, around the margin of
the diseased part.  When the thickening  of the cuticle causes it to rise
above the surrounding surface, it begins  to exhibit the appearance of
minute and innumerable fissures, which soon increase in length; and
extensive cracks form, intersecting each other, and dividing the surface
into innumerable fragments, of which each, considered separately, ex-
hibits a great  similarity in  structure, to the common wart.  The dis-
eased cuticle  now assumes  a dusky, dark-brown colour, which  gra-
dually approaches  to blackness.  This discoloration results from the
entanglement  of dirt by the  rough and  fissured surface of the skin,
which even frequent ablutions will not prevent.   On drawing the
finger over the diseased surface, the sensation is the same  as though
the part was covered with large warts of long standing.
   The arms and legs are the most common situations of this disease;
it very rarely  occurs upon the face.
   The skin of those infants in whom the disease is subsequently de-
veloped, instead  of the usual smooth and soft texture, has, according to
Rayer, a sallow, dry, shagreen-like appearance.   The cuticle, during
the first or second  month, becomes more  rough, and of a grayish hue,
communicating to the touch a feeling like that produced in many cases
by the skin of the aged.  This condition may  continue throughout life,
or it may increase with the progress of years.    <  i*Jl v-wV>.
   The appearance of the skin in  cases>of ichthyosis is more like that
of the legs of fowls, than the scales of fishes, orof s'eVpentlf and, when '
the thickening of the  epidermis  is  very  considerable, it  has  been
likened by Rayer,  to  the bark  of certain trees.  The skin may be-
come, in some cases, so rough that the hand  when passed over  it, ex-
periences a sensation similar to what is felt when a file or shagreen,
or the skin of certain fishes is handled.
   The squamae formed  by  the  diseased cuticle, may, with the excep-
tion of the largest, be detached without causing pain, or any unplea-
sant sensation.  When  detached by friction, or in any other manner,
they are speedily reproduced, with the same characters as before.
   Desquamation of the  diseased  cuticle  often takes place during the
summer season; but the disease again constantly recurs, on the return
of autumn.   On the  separation of  the squamae, the  skin is found to
retain its natural colour; its furrows, however, are more marked than
natural, and its  exhalations and  secretions are  found to  be entirely
suspended.
   The disease is often congenital; and is then seldom got rid of during
life.  Its remote and exciting causes, are equally involved in obscurity.
In numerous cases, where it  has been studied with the utmost care, it
was found impossible to trace it t# any  pre-existing derangement of
health, or local  irritation.   Acqording  to' Girdlestone, Martin, and
Rayer, it is frequently hereditary;  but it  as freajWrltly occurs in chil-
dren whose parents, and grandparents, have presented no traces of the 
552
DISEASES OF CHILDREN.
disease.  Neither climate, nor season, nor locality, nor  mode of life,
would seem to exercise any marked influence upon its production.
  When local, of small extent, and occurring subsequent to birth, in
the children of healthy parents, there is some hopes of effecting a cure.
Repeated blisters, and topical stimulants, have succeeded in removing
the disease in some  cases.  In two instances, in  which it was limited
to the  legs, Plumbe succeeded in effecting  a cure by  strapping the
affected parts tightly with adhesive plaster, and applying a long roller,
kept constantly moistened with cold water.  The  straps being renewed
every fourth or fifth day.
  When the disease is  of greater extent, we must content ourselves
with the frequent use of emollient washes, mucilaginous  and soothing
fomentations, the warm  bath, frequently repeated, the vapour-bath, and
the occasional use of alkaline baths.  Internal remedies have not been
found to produce any good effect.
  In a practice of twenty-six years, we have met with but two cases
of well-marked  ichthyosis; in one, the disease  was hereditary, and
resisted every means employed; in the other, it was of  small extent;
the parts affected were daily washed with diluted nitric acid, by which
the squamae were rendered much thinner; a  succession of blisters was
then  resorted to, and in ten  weeks from the commencement of the
treatment, a complete cure was effected.   Eighteen years have  now
elapsed  without any indication of the disease returning.
 tKrir<i^«/ ***»*1&f 16. — Ecthfma.— Rnpia.

V F-W«rW *-  ■»"-*-*—                 ATONIC ULC
ATONIC ULCER.
  Ecthyma is an eruption of hard, red elevations, painful upon pres-
sure, and with inflamed bases; the elevations, in a few days, increase
irregularly in size, and pus is formed at their  apex.  The eruption is
occasionally attended by a violent smarting pain.
  The pustules occur in  irregular groups of various dimensions, and
suppuration proceeds with greater or less rapidity, in different cases.
In some, we have a large inflamed  base, with a  small pustule in the
centre; in others, the pustules are in the form of blebs, with a central
spot.   In three or four days, the matter of the pustules becomes dry,
and forms thick, brown  scabs, which fall off in the course of a week
or ten days, leaving a dark-red stain, or superficial cicatrix.  In in-
fants, the elevations slowly disappear, without suppuration, by cuticular
desquamation.
  When ecthyma is confined to a particular part of the  surface, the
eruption may come  out at once;  but in other cases there is generally
a succession  of pustules.  The  duration  of  the  disease, in the first
case, is from one to two weeks, but in the latter it may continue for
months.   It occurs  most frequently  upon the extremities, shoulders,
and  nates.
  Several varieties of the disease are described by Willan and others,
as the E. vulgare, the E. infantile, the  E. luridum, and the E. cachec-
ticum; but as these varieties are the  mere results of different degrees 
DISEASES OF THE SKIN.
553
 of constitutional debility, or of irritability of the skin, it is unnecessary
 to describe their individual characteristics.
   Rupia  is the eruption of one or more flattened blebs, of the size of
 a shilling, containing a serous, transparent fluid.   The blebs soon  be-
 come  flaccid, their contents increase in consistence, and become tur-
 bid, and finally drying, form  scabs of a dark-brown colour, rough on
 the  surface, thick  and prominent in the centre, and adhering, at their
 edges, to the surrounding cuticle, which is there slightly elevated.  (R.
 simplex.)   On  the separation of the scab, a superficial ulceration  of
 the  skin remains, which usually heals  rapidly, though it may remain
 for a time open, sometimes covered with a scab, and sometimes with-
 out one.  The  ulcer generally leaves behind it a deep red stain.
   In some cases the blebs are much larger, and are surrounded by an
 inflamed margin, several lines wide.  The blebs are very quickly con-
 verted into rough scabs of a very dark colour, which are also  sur-
 rounded by an  inflamed areola;  from this the cuticle is raised by  suc-
 cessive formations of matter and  bloody serum, which, upon  drying,
 add to the size  and thickness of  the scat), with  the increase of which
 the areola  advances, and, by continually forming new rings of matter,
 increases  the primitive scab in  width  and thickness, until  it acquires
 the size, and almost the shape and appearance of  the outer surface of
 a small limpet  or oyster shell.  (R. prominens.) (Baieman.)  The scabs
 in this variety, which is usually confined  to the  lower extremities,
 often adhere for a long time;  when they separate, they leave an ulce-
 rated  surface,  which has  often a bad appearance.   Sometimes the
 scabs are reproduced; in other cases, the ulcer remains open, extend-
 ing constantly  in depth, and is with difficulty healed;  and when cica-
 trized, leaves a dark-coloured, livid mark upon the skin, which  dis-
 appears very slowly, if at all.
   In other cases, the disease commences with slightly raised  patches
 of a dark livid colour, upon  which flattened, irregular-shaped blebs
 soon form, surrounded by a dusky red  margin.   The fluid contained
 in the blebs is thick and dark-coloured, which, in place  of drying,
 escapes by the bursting of the blebs, and  an excoriation of the skin
 remains, attended with pain, which soon degenerates  into an  ill-con-
 ditioned ulcer,  which spreads rapidly in extent and depth.  (R. escha-
 rotica.) Successive blebs arise and burst, and in this manner multiply
 the points of unhealthy ulceration.  Cicatrization is always slow and
 protracted.  This variety generally occurs on the loins, thighs,  and
 lower extremities.
  Ecthyma and rupia occur only in children who have been subjected
 to causes, the operation of which have a tendency to reduce the ener-
 gies of their system, and to produce a languid state of the vitality of
 the skin; hence impure and confined air, a cold and damp atmosphere,
 and  deficient or impure  food on the one hand, or a state of debility,
 from  preceding diseases, on the other, are their usual predisposing
and  exciting causes.   Both forms of disease  are very apt to occur
after  measles,  scarlatina, small-pox, and other severe affections of
childhood; and in nearly every case of any severity, they are accom-
panied by a low, irritative fever,—frequently assuming a hectic cha- 
554
DISEASES OF CHILDREN.
racter—by a general wasting of the body, and by the utmost languor
and debility.
  In  the treatment of these affections, our attention should be chiefly
directed to  the  restoration of the general health and vigour of the
patient's system.  When this restoration can be effected, the local dis-
ease  will seldom demand much attention, it being  generally  soon
arrested, the scabs separating, and the ulcerations assuming a healthy
aspect,  and  rapidly  cicatrizing.  The  means by  which  this object
is to  be obtained, will, in some measure, be governed by the circum-
stances of individual  cases; as a general rule, they will consist in  pure,
fresh  air, cleanliness of  person,  appropriate  clothing, a wholesome,
nourishing diet, consisting of meat, gravy or  jellies, chicken, beef, or
mutton broth; and when the exhaustion of the  patient is extreme, wine
whey, or wine and water.  The cold infusion  of bark, the sulphate of
quinia,  and  other vegetable tonics,  may, in some cases, be employed
with  advantage;  they are best adapted to the more severe and pro-
tracted forms of these diseases.
   In  the early stage  of most cases, gentle purgatives, occasional  doses
of a  mercurial  alterative,* and the warm  bath daily, will generally be
required.  In more protracted cases, if the discharges from the bowels
are of a vitiated character, the spirits of turpentine will often be  found
to produce a beneficial effect.  In such cases, we must be cautious in
the administration of mercury in  any form.  Good  air, wholesome
food, and the sea-air and  sea-bathing, with, perhaps, some  light  tonic,
will  generally  succeed  in effecting a cure,  unless  the  health of the
patient is completely impaired. A cautious use of weak  alkaline baths
has, in numerous instances, been  found of benefit.

  • R.—Mass. f. pill. hyd. gr. iv. ad. xij.     Or, R.—Calomel, gr. vj.
        Ipecacuanha, gr.  ij.—iij.                Magnesias calc. gr. xxiv.
        Ext. hyoscyami, gr. iij.—vj.              Ipecac, pulv. gr. iij.
        Carb. sodas, 9j.—3ss.—M. f. pill.          Ext. hyoscyami, gr. iij.—M. f.
             No. xij.                             chart. No. xij.
  One to be given for a dose, every evening.      To be given as above.

   In regard to the  local treatment, so long as the pustules or ulcera-
 tions present a  decidedly irritable condition, emollient washes and ap-
 plications are  alone to be employed.   When the ulcers are tardy in
 cicatrizing,  a lotion  of red wine and water, or of red wine and honey,
 may be employed.
   When the ulcerations  of rupia are of an indolent character, a wash
 of the bitartrate of potassa, or dusting their surface with this substance
 in a  dry state, is  said by Willan to  answer very well.  If the above ap-
 plications do not succeed, the ulcers may be washed with a solution  of
 nitrate of silver, or of sulphate of copper.  If much itching or pain is
 present, an ointment of  hydrocyanic acid and sugar  of lead has been
 recommended.*  The ointment of  the  nitrate of mercury has,  in our
 hands, very generally  proved successful.  Washing the ulcers with
 diluted nitric or hydrochloric acid, will often  be a  means calculated  to
 improve their condition, and promote their cicatrization ; the degree  of
 dilution necessary will depend upon the more or less  indolent and un-
 healthy condition of the ulceration.  Ointments of the proto-ioduret,  or 
DISEASES OF  THE SKIN.
555
of the deuto-ioduret of mercury have likewise been used, according
to Biett, with great success, in obstinate cases.
                     a R.—Acid, hydrocyanic. 3j.
                          Plumbi. acetat. gr. xv.
                          Ungt. cetacei, 3ij-—M.

   For the more malignant ulcerations, the chlorides of lime and soda,
as an external application, and the latter internally, may  be tried.  But
we are to recollect, that in no case, but especially in those  in which
the disease is of an extensive and aggravated character, will external
applications be of much  avail, unless the general health  of the patient
be at the same  time improved by a proper diet  and regimen, and by
the cautious employment  of  invigorating remedies; in many cases,
when  this can be effected, the local disease very readily disappears,
with very simple applications.  When we fail in our attempt to restore
the vigour of the system, the  most  active topical applications will be
unproductive of good.

                        17. —Pemphigus.

           POMPHOLYX.--BULLAE FEBEtlMS.--PEMPHIGOID FEVER.

   The  eruption of large bullae, preceded and accompanied by febrile
phenomena, which generally assume a typhoid  character;  the disease,
in its progress, having many features in  common with the gangrenous
form of infantile erysipelas.
   The  eruption is  usually preceded, for several days, by a sense of
chilliness or  shivering, followed by pain  in  the head and epigastrium,
increased  heat of the  surface, and a frequent, feeble, irritable pulse,
with  great languor and fretfulness.  A dull erythematous  blush, or
patches, sometimes of a livid  hue, and slightly elevated above the  sur-
rounding parts, appear on various parts of the body, but  chiefly on the
neck,  upper  part of the breast,  inner surface of the  thighs, and the
groins; a very common  situation for them is behind the  ears.
   Large, irregular vesications now quickly make  their appearance;
they are generally flattened on the top, and at first filled  with a trans-
parent fluid,  which,  as the vesicles  enlarge rapidly in size, becomes
turbid, and of a purplish hue.  The vesicles are usually surrounded by
an inflamed border, of a livid red colour.   The fever now assumes a
typhoid character, with a dry, brownish  tongue,  and  a  rapid sinking
of the pulse.  When the vesications break, and discharge their  con-
tents, an  ulcerated surface is left, which is extremely  painful,  and
spreads over the surrounding surface, often with great rapidity.  The
discharge  is  often foetid, and  large in quantity, and  the  edges of the
ulceration acquire a livid  hue.  When  situated  behind  the  ears, the
connexion of the posterior cartilage with the cranium, may be de-
stroyed, the ulceration  extending  often to the meatus auditorius, to the
eyes,—the sight of which becomes destroyed,—and  even to the vertex.
(Stokes.)  When the disease occurs upon the hands, exfoliation of the
hones of the  fingers sometimes takes place.
  In other cases,  vesications arise  in rapid succession, on different 
556
DISEASES OF CHILDREN.
parts of the body, followed by gangrenous ulcerations, and the patient
sinks  in  a  few days, from the pain, loss of sleep, and  intense fever.
Death, it is stated by Dr. Stokes, generally takes place about the tenth
or twelfth day; it is often preceded by convulsions.
  Pemphigus may occur at any period, from, a few days after birth to
the ninth year:—it is  most frequent, however, according  to Willan,
within the  first year.  Its  causes  are  evidently impure and confined
air, neglect of domestic and personal cleanliness, deficient or unwhole-
some  nutriment, and the effects of cold  and damp:—it is hence almost
exclusively confined to the offspring of the poorest classes,  among
whom it often prevails epidemically. There is reason to believe, how-
ever, that like infantile erysipelas, the disease is in some way connected
with puerperal fever, affecting particularly the offspring of mothers
who become attacked with the latter disease.
  It is said by Stokes to be more prevalent in summer than in winter.
This,  however, is contrary to  our  experience, the few cases we have
met with—the disease being one of comparatively rare  occurrence in
Philadelphia and its vicinity—all occurred in the winter.
  The treatment of pemphigus, as it  occurs in children, should be
commenced by the removal of the patient, whenever it is possible, to
a pure, fresh atmosphere, cleansing his skin by the use of the warm or
tepid bath,  and if there is no affection  of the digestive organs present
to forbid it, furnishing him with wholesome, nourishing food.
  If the disease is seen in its earliest stage, and tenderness of the epi-
gastrium, with derangement of the bowels, are  found to exist, a few
leeches should be applied to the abdomen, and followed by warm fomen-
tations or the application of a warm, emollient cataplasm, and  inter-
nally, small doses  of calomel, ipecacuanha, and  extract of hyoscya-
mus,  and an occasional dose of castor oil  may be given; if,  at the
same  time, there exist  much  heat and dryness of the surface, some
gentle diaphoretic* will be proper,  with frequent tepid sponging.

                      * R.—Acetat. ammoniae, 3V'U-
                          Aq. camphorae, 3 ij.
                          Vin. ipecac. 3j.
                          Tine, hyoscyami, 3j.
                          Syrup, limon. 3ij.—M.
          Dose, a teaspoonful every three hours, for a child two years old.

  On the formation of vesications, the warm bath and fomentations of
an  infusion of camomile, with  the sulphate of quinia internally, in con-
junction with  the mineral acids, if the state of the bowels will permit
of their use, should  be administered. If the vesications are very large,
they should be punctured, and the ulcerated surface washed with  a
very  weak solution of the nitrate of  silver:—at the same  time the
patient should be put upon a mild, but nourishing diet.
   In  the gangrenous or phagedenic form of the disease, an ointment
prepared from the great fig-wort (Scrofularia nodosa) has, we are as-
sured by Maunsell, been found particularly successful in causing the
ulcers to assume a healthy condition, and cicatrize.  This remedy was
introduced by Dr. Stokes, the elder, of Dublin, who found it  in use
among the Irish peasantry.  His practice was, at first, to apply a car- 
DISEASES OF  THE SKIN.
557
rot poultice  or one of porter and oatmeal:  this was kept on for about
eight hours; when removed, the ulcerated  surface was gently wiped
with lint, and the ointment of scrofularia, previously melted, was
spread over it  carefully, by means of a soft feather; the ulcer was then
dressed with the ointment, to which  an eighth part of wax had been
added, the dressing being  repeated  in  severe cases, every fourth or
sixth hour.   Dr. Stokes also directed the interna] use of yeast, which
he believed to  be of service.
  In a comparatively chronic form of pemphigus, Dr. Maunsell states
that the employment of iodine has been found to be attended with the
most decided benefit.

                         18.—Purpura.
  A subcuticular extravasation of blood, occurring  without external
violence,and not disappearing upon pressure; sometimes accompanied
with haemorrhage from one or other of the internal organs, and ap-
pearing either with or without febrile reaction.
  The appearance of the  skin at the parts  at which the extravasation
takes place,  differs in different cases; thus,  the extravasation may ap-
pear in the form of minute red, or  violet-coloured spots, (petechias,) or
of patches of  a  ruddy violet colour, often  livid, and sometimes  quite
black; generally of a deeper hue  in the centre than at the circumfe-
rence,  and  varying in diameter from  a few  lines to  several  inches,
(ecchymoses.)  Both  varieties of extravasation are very generally ob-
served in all cases of purpura.
  In  some  cases, purpura  occurs without  being  preceded by any
marked disturbance of health, though usually the patients  exhibit for
some days previous to its  appearance considerable lassitude, dejection,
and fretfulness, with indications of general debility.  It is  unattended
throughout with any degree of febrile excitement.  (P. simplex.)
  The subcuticular  extravasation may consist entirely of petechias,
having some  resemblance to flea-bites, but not quite so large, unsur-
rounded by an areola of inflammation, and uneffaceable upon pressure;
or the  petechias  may be  intermixed with ecchymoses—occasionally,
but very rarely, the extravasation appears only in the latter  form. The
petechiae may occur only  upon particular regions, or be disseminated
over nearly the whole surface of the body; they may occur in every
part at the  same time, or appear  successively during several days—
when in place of being all of the same hue, they will vary from a red-
dish-purple, or brown, to a clear or  faint yellow.   Petechiae occur
principally  upon the legs,  but often appear  upon  the face also,  in
which  case, a number of ecchymoses are frequently seen upon the
conjunctivae.
   The extravasations constituting P. simplex, are always  unattended
with  local heat or pain, or any febrile excitement,  and occasionally,
without the least apparent disturbance  of either of the principal func-
tions of the system.
   Soon after  their formation, the petechiae undergo a change of colour,
passing from  reddish-brown, through various intermediate shades, to
yellow ; and most commonly, the blood is entirely reabsorbed in twelve 
558
DISEASES  OF CHILDREN.
or fourteen days.  Occasionally, as remarked by Rayer, the spots of
extravasation form a slight eminence, of the size of a pin's head, caused
by a minute drop of blood being effused immediately beneath the cu-
ticle, which it raises.  On the drying of the blood, a small dark crust
is formed.
  When the eruption of petechiae is considerable, they are sometimes,
at particular parts of the surface, collected into irregular clusters.  In
a few very rare cases, there is observed, interspersed among the pete-
chiae, a kind of marbling of a light violet  colour, like  the eruption in
rubeola nigra.   Occasionally, there are very few or no petechiae, but
ecchymoses, in considerable numbers, are  disseminated over the body
and limbs, particularly over the dorsal surface of the feet and hands, and
the inner surface of the extremities.  They resemble often the  marks
left by the strokes of a whip: their colour, which is of a dark or livid
blue, fading very slowly.  These ecchymoses are, in some cases, suc-
ceeded by an exfoliation of the cuticle, particularly when the latter has
become detached by the quantity of sanguinolent serum effused beneath
it.  In some instances, the effusion is to so great an extent as to pro-
duce bullae or phlyctenae.
  The blood, in certain cases, is effused into the  subcutaneous and in-
termuscular tissues, and then the skin commonly presents a number of
broad, slightly prominent spots, dark in the centre, and of a greenish-
yellow towards the circumference, and unattended with  pain.  Some-
times the backs of the hands are affected with a  species  of oedema.
  In a  few instances, the subcuticular extravasation  is preceded by
somewhat prominent, reddish, oval, or circular spots, accompanied by
a smarting or tingling sensation, similar to, but not  so decided as that
of urticaria.  (P. urticans.)   These  spots,  at the end of two or three
days, sink to a  level with  the surrounding skin,  and acquire a dark-
red, or liver colour; new spots  at the same time  making their appear-
ance.  They are sometimes intermixed with true petechiae.  P. urti-
cans occurs  most frequently upon the legs, which are often  at the
same time oedematous, or affected with a sensation of stiffness or hea-
viness.   The eruption generally continues  for a month, but  may be of
longer duration.
  Immediately  after the  disappearance of the petechiae and  ecchy-
moses, in cases of P. simplex, they in some cases return suddenly, in
a single night.  These haemorrhagic phenomena  may be repeated se-
veral times at  very short  intervals, prolonging the duration of the
disease to several months.
  When P. simplex presents itself  under  the form  of ecchymoses, it
is generally a more serious disease than  when  it  appears  under the
petechial form;  the P. urticans is the least important of all the forms
of the disease.
  A much more serious form  of purpura is that  accompanied with
haemorrhage.  The body is often covered  with  livid spots, similar to
those that  follow bruises; actual  thrombus occasionally forms under
the hairy scalp, and the blood has even been seen exuding from behind
the ears, and from the vertex; the subcuticular and  cutaneous effusion
covering nearly the whole surface. 
DISEASES OF THE  SKIN.
559
  The disposition to haemorrhage in some patients is so great that the
mere act of feeling the pulse, the pressure of a loose ligature, or the
weight of the body in sitting, leaning, or lying  down, is sufficient to
cause actual ecchymoses.  In  such cases, the  slightest puncture, the
mere grazing of the skin, is followed by a copious and continued dis-
charge of blood; and most commonly, either from the commencement,
or in the  course of the  disease,  haemorrhages  occur, to a greater or
less extent, from  the nose, bowels, stomach, or lungs. (P. hemorrha-
gica)  In some of these cases, the  whole of the fauces are of a dark-
red colour, and blood issues from every part of them.   P. haemorrha-
gica is sometimes, according to Rayer, complicated with angina mem-
branacea;  occasionally,  the gums  are livid and  spongy, and blood
exudes from their surface; the tongue is swollen, livid, and blackish;
the inner surface of the cheeks presents some blackish and soft patches,
with which the palate is also  covered.  On all these  parts, irregular
phlyctenae, or bullae  appear, filled with dark-coloured blood;  when
these  burst, a discharge of blood takes place from the excoriated  sur-
face;  deeper ulceration sometimes occurs, with haemorrhage to a much
greater extent.  Children have been known to die in a single night,
from the haemorrhage, in such cases.
  When, in P.  haemorrhagica, the discharge of blood is very conside-
rable, or recurs frequently, the feet and legs become oedematous, the
face blanched, and the surface of  the body generally, of  a yellowish,
or  livid hue;  the petechiae and ecchymoses increase in number, and
acquire a deep brown tint; the blood becomes more and more serous;
the temperature of the body, but  particularly of the extremities, sinks;
the pulse becomes small  and  feeble, and the  strength of the patient
completely prostrated.   Convulsive movements, tremors of the whole
body, or fainting fits, sometimes occur.  The  patient  finally dies ex-
sanguine, unless febrile  symptoms, or serious  internal disease should
ensue previously to death.
   Purpura is occasionally accompanied by febrile reaction. (P. febri-
lis.)  The occurrence of petechiae and ecchymoses, in  this form of the
disease, is preceded  by a sense  of extreme  lassitude and  depression,
and by shivering fits, of longer or shorter duration, succeeded by in-
creased heat of the skin, pains in the back and limbs, headache, quick-
ness of pulse, nausea, retching, or vomiting.  The subcuticular extra-
vasations appear between the third and sixth days, sometimes with
haemorrhage from the mucous membranes, and at others,  preceded by
exanthematous spots, similar to those of urticaria febrilis.  Febrile pur-
pura  may appear under the form  of ecchymoses.  In some cases, it
is  attended with  haemorrhages from the nose, throat, stomach, intes-
tines, &c; in other cases, these latter occur without the  subcuticular
haemorrhage.
   Febrile purpura may present, from the commencement, very serious
symptoms, and prove fatal in a few days, in  consequence of sangui-
 neous effusion  in the lungs, or substance of the brain; or it  may ter-
 minate in death more slowly,  in consequence of the extent of the hae-
morrhage, or the gradual draining away of the blood.
   The causes of purpura are extremely obscure.  It is of much more
frequent occurrence before than after the period of puberty, and at- 
560
DISEASES  OF CHILDREN.
tacks, as remarked by Willan, Graves, and others, most generally,
such children as are exposed to the debilitating influence of an impure
and confined, or cold and damp atmosphere, and who are badly fed, or
on improper food, and  debarred from sufficient exercise;  it is, never-
theless, not unfrequently met with  in robust children, of full habits, and
apparently in the enjoyment of perfect health.  Some children appear
to be peculiarly predisposed to attacks of purpura, and  this often hap-
pens in all the children  of the same family, as we have  repeatedly
observed.   It has been supposed, in some  cases, to be hereditary.  It
occasionally occurs subsequent to small-pox, measles, and  other acute
affections.
  It has been maintained by Mills, Parry, and Combe, that in all cases,
venous plethora is necessary to the production of purpura;  and  in
many cases, there  certainly exist  strong evidences of  an  overloaded
state of the  portal system, with more or  less derangement of the di-
gestive organs; the bowels are often torpid, or in a state of constipation,
and when evacuations  are procured, these are often of a most vitiated
character.   Pain of the epigastrium, or hypochondria, or tenderness
upon pressure, with swelling and  tension of these  parts, are also fre-
quent symptoms of the haemorrhagic cases.
  In mild cases of purpura simplex, a  proper regulation  of the diet
and regimen, with the warm or tepid bath  daily, a full dose of calomel,
followed by castor oil,  or the citrate of magnesia; and when, by these
means, the bowels have been fully evacuated, small doses  of calomel,
calcined  magnesia, and ipecacuanha, in combination,  three  times a
day, with free exposure to a fresh, pure atmosphere, will,  in general,
be sufficient to effect a cure.
  In the more  severe  cases of P. haemorrhagica  and  P.  febrilis, the
remedies must be adapted to the circumstances of each case. Where
there  exist evident indications of  hyperaemia, or venous plethora; or
much local pain or tenderness, with  fulness  and tension of the abdo-
men generally,  or at the epigastrium, or hypochondria,  a cautious ab-
straction of  blood from the arm, or locally, by leeches, will occasion-
ally be advisable.  It must be admitted that, in young children, bleeding
is a remedy not generally adapted  to this disease; when  leeches are
employed, we have often known them to give rise to a long-continued
haemorrhage, by which, probably, a fatal result was  caused, in cases,
where, had the  leeches not been applied, the disease might have  been
cured; on the  other hand, when  blood is drawn  from the arm, we
have  known the loss of a few ounces  to  be followed  by so great a
degree of exhaustion, as to demand an immediate resort to stimulants,
to prevent the death of the patient; at the  same time, in children over
ten years of age, we have certainly seen  the very best  effects result,
in the early stage of the disease, from the cautious abstraction of blood,
particularly  by  the lancet.
  In every case, our chief attention should  be directed to the condition
of the bowels.  Full doses of calomel, in  combination with  magnesia
or jalap, and followed, in a few hours, by  a mixture of castor oil and
turpentine, will  have the effect, very generally, of bringing  away large
quantities of vitiated secretions; of unloading the portal system, and ex- 
DISEASES OF THE  SKIN.
561
citing a more healthy action throughout the entire extent of the gastro-
intestinal mucous membrane; and by the continuance of the turpen-
tine, in tolerably large doses, with  an occasional dose of  calomel, we
shall soon correct the character of the  intestinal evacuations, and at
the same time effect a cure of the disease.  Under the purgative treat-
ment, we have  seen the most rapid change  produced in  all the more
serious phenomena of purpura haemorrhagica, and a striking amend-
ment in the condition of the patient generally occurs the moment that
large evacuations are procured from the  bowels, of a dark olive-green,
and highly offensive faeces.
   The drinks of the  patient may be acidulated with lemon juice, and
they should  be  given perfectly cold; the diet should be light and  un-
irritating, and composed of articles of a nourishing kind.
   When decided  debility exists, the sulphate of quinia,  the  dilute
mineral acids, and a  nourishing diet,  with, perhaps, in  extreme  cases,
wine whey, or  wine and  water, or  diluted  malt liquors, will  be  de-
manded ; attention being, at the same time, paid to the bowels; in such
cases, the spirits of turpentine and castor oil will  form the most effi-
cient and appropriate  purgative.  Care must be taken, however, not
to mistake  mere  oppression of the vital functions for debility, or to
commence with tonics or stimulants too early, in any case; when  this
is done,  we  have repeatedly seen the  tonic treatment increase  the
number of petechiae, augment the haemorrhage from the mucous mem-
branes, and  excite a  violent febrile reaction, quickly followed by col-
lapse and death.

     FROM INFECTION INDEPENDENT OF VISCERAL DISEASE.

                  19.—Psora—Scabies—Itch.
   The  itch  makes its  first  appearance, usually  between the fingers,
about  the wrists, and  upon  the backs of the hands,  in  the form of
minute vesicles, filled with a colourless, transparent fluid, intermixed
with small  papulae, which  latter likewise assume, in a short time, the
vesicular character.   The eruption is attended by intense  itching,
which is always increased by whatever elevates the temperature of the
part.  Frequent friction and scratching, to allay the itching, produce
speedily an inflammation and rupture of the  vesicles, by which means
the disease is extended to  the surrounding  skin.
   When the skin is  very  irritable, the vesicles of psora soon assume
an opaque appearance, and are converted  into true  pustules,  which
sometimes  attain a very considerable size.  Hence, when the malady
is of some standing, there may exist, at the same time, papulae, vesicles,
and pustules, of various dimensions, interspersed:—a feature  which,
in connexion with the excessive itching and irritation, will readily dis-
tinguish the itch from any other  cutaneous affection.
   Though  in its commencement, the disease, in the majority of cases,
is confined to the fingers,  wrists, and hands, it may, however, extend
to nearly every part of the body; in such  cases, being  most  severe
and troublesome about the trunk, margins  of the  arm-pits, and flexures
of the joints, in consequence of the warmth generated by  the clothing, 
562
DISEASES OF CHILDREN.
and the friction excited by the motions of the body.  The papulae, ve-
sicles and pustules, often give rise to dark points, or dark-brown crusts;
caused by the desiccation of the matter discharged by them.   The pus-
tules sometimes, when neglected, coalesce, and, when  ruptured, form
ulcerations, upon which dark-brown scabs are apt to form.
  Psora, in the great  majority of cases,  is unquestionably produced
from the direct conlact of the fluid matter of the vesicles, by the touch
of an infected person, by handling or wearing his clothes, sleeping in
the same bed, &c.   It is increased in extent and virulence, by a neglect
of personal cleanliness, either  in regard to repeated ablutions of the
surface, or frequent changes of linen;  and, by this  means, many sup-
pose that the  disease may be generated, independent of infection.
  In its early stages, psora is entirely unconnected with any other dis-
ease.   When, however, it occurs in children who  are  dehilitated, or
otherwise unhealthy, it not unfrequently gives rise  to a troublesome
impetiginous  affection of the skin, which  may continue long after its
specific character has been destroyed.   (S. cachectica.)  Psora is said
never, or at  least very rarely, to terminate  spontaneously; when not
subjected to  a  proper remedial treatment it may continue during the
lifetime of the patient, which it seldom tends to shorten.
  Psora, presents itself under its most aggravated  forms, almost ex-
clusively among the miserably poor;  it is, however, met with  more
frequently in  some countries, and situations, than in others.   It is, in
some degree, endemic  in all cold and mountainous regions.
  In many cases of psora, particularly when neglected,  an insect is to
be seen, in or near  the vesicles (scabies vermicularis, acarus vel sar-
coptes scabiei).
  It  is  usually  found beneath the cuticle, in a small spot close to a
vesicle, to  which it is connected  by  an irregular dotted line, that
marks the burrowing course of the insect. If this spot be punctured,
upon  careful  examination, the insect, somewhat  resembling a cheese
mite, may be detected, and abstracted upon the point of a needle.  Of
the existence of these  insects, there can be no reasonable doubt;  but
how far they  are essential to the disease, and whether the latter is pro-
duced  by them, are questions not so readily solved.  The affirmative
has been, recently,  strongly maintained by several of the French and
German physicians; while there are  others who consider the insect
as a mere parasite,  in no way concerned in the production of the dis-
ease; the supposed cases in which the itch  has been communicated
by transferring the acarus to the skin of sound persons, being ascribed
alone to the virus adhering to it.  This latter we feel disposed to  adopt
as the correct view; for it is extremely difficult  to reconcile the ease
with which the disease is communicated by  mere  contact, with the
notion that the transfer of one of the  insects  is necessary to produce
it; especially when we are told  of the difficulty of extracting  these
from  their burrows beneath the cuticle.   It is  said by Mouronval,
Lugol, and Gras, that  the disease cannot be communicated by inocu-
lation with the fluid of the vesicle:  this we believe, however, to  be an
error:—we knew the disease to be produced in  one case, by an  indi-
vidual who put on  a pair of gloves that had  been worn four months 
DISEASES OF  THE SKIN.
563
previously by a person affected with the itch, and which had lain in a
drawer from that period.
  It is supposed by some, that itch maybe communicated to man from
the  dog and other domestic animals.   Several workmen at the Jardin
des  Plantes, of Paris, are said to have contracted  the  disease, by at-
tending upon a diseased camel. (Andral, Cazenave.)
  Psora may be communicated to infants and children at any period
from birth to puberty; it generally occurs about four or five days sub-
sequent to exposure to its contagion.
  A great variety of external as well  as  internal remedies have been
proposed for the cure of this affection.  They have all, no doubt, fre-
quently succeeded;  they are all, however, inferior  in certainty, in the
ordinary forms of the disease, to  the external  application of sulphur,
either in  the form of ointment, or fumigation; and  its internal  use, in
the form of the precipitated sulphur, mixed with milk or molasses.   In
the cases of psora usually occurring in children, the ordinary unguen-
tum sulphuris of the  shops, will answer every purpose; but in more
obstinate cases, the  compound sulphur ointment of the United States
Pharmacopoeia,  may be employed.   An ointment composed  of one
part carbonate of potassa, two of sulphur, and eight  of lard, is pre-
ferred by many of the French practitioners.
  Whichever of these ointments is used,  it  should be well rubbed into
the affected parts, night and  morning, for the space of one week; by
which time, or  perhaps earlier, in slight cases, the disease will be en-
tirely cured. On ceasing the use of the ointment,  the child should be
immersed in a warm  bath, and the entire  surface of the  body well
washed with soap.  In children of four or five years, and upwards, the
common soft soap may be used, which, by some of the recent German
physicians,  is asserted to be itself, an excellent remedy in cases of in-
veterate itch.
  During the external employment of the sulphur, a portion of it—from
ten grains to half a drachm, according to the age of the child—should
be  given, night and morning, in milk or molasses.  In plethoric or ro-
bust children, over  two years of age,  an  equal portion of the bitartrite
of potassa, may  be  added to the sulphur, and given in simple syrup or
molasses.  The diet of the patient should be perfectly plain and  easy
of  digestion.  After the cure is effected, no portion of  the clothing or
bedding  that was in contact with the patient whilst he laboured under
the disease, should  be used, until it has been thoroughly purified, and
well aired.
   In  many  cases of psora, an ointment of  the hydriodate of  potassa,
made  by adding one drachm to one ounce of lard, will prove a very
efficient  remedy ; we have used it with complete and prompt success,
in numerous instances.  An ointment composed of half a drachm of
sulphuret of lime, mixed with a  little  olive  oil, and rubbed upon the
palms of the hands, twice a day, for ten  or fifteen  minutes each time,
will, it is said, prove, also, an efficient remedy.  (Joy.)
  The sulphurous water-bath has occasionally been employed ; but is
by  no means so prompt and certain in  its effects, as the sulphur va-
pour-bath ;  this constitutes  the principal  remedy of Gales, and it has 
564
DISEASES OF  CHILDREN.
been strongly recommended by Horn, De Carro, Wallace, and  other
physicians, who have subsequently employed it.   In  children of eight,
ten, and twelve years of age,  we occasionally meet  with cases of the
disease, in which, from neglect, and personal uncleanliness, it has been
allowed to spread over a considerable portion of the  body,  and in a
form  of considerable severity;—to these cases, the sulphur vapour-
bath is well adapted.  The number of fumigations necessary, will  de-
pend very much upon the character of the disease  in each  case, the
degree of irritability of the skin, &c.  When a proper apparatus can
be procured, this should  be invariably employed; but if this  is not at
hand, blankets maybe saturated with the vapour of sulphur, by means
of sulphur strewed upon  burning coals, enclosed in a warming-pan;
the patient  being  placed between  the  blankets,  naked,  and covered
closely up to the throat.
  A great variety of  other modes of treatment, and various forms of
ointment have been proposed,  none of which, however, in the case of
children, are equal in efficacy to  those detailed.   It is  asserted by
Pentzlin, that an ointment composed of one part of tar, and  two parts
of salt butter, melted together, with  the addition, while fluid, of one
part of carbonate of  potassa,  will remove the disease, if applied once
in twenty-four hours,  in seven  days.
  The following ointments have been found  occasionally very useful,
in the treatment of psora in infants.   We annex them, not because we
prefer them to  those we have already given, but because cases may
occur, in which, from a variety of circumstances, it  may be  useful to
resort to one or other of them.

    R.—Creasot. fftxxx.                   R.—Calcis Chlorid. 3ij.
       Cerati,                            Adipis, gviij.—M.
       01. Amygdal. dulc. aa 3j.—M.
                                     R.—Carb. potassoe, 3ij. solve in
    R.—Hyd. Oxyd. alb. 9j.                   Aquas, 3j. dein adde,
       Adipis, giv.—M.                     Ol. Olivae, 3iv.
                                        Camphorse, 3ij.—M.

  In every case of the disease occurring in robust and plethoric chil-
dren, if there  exists  considerable irritation  of the skin  at  the  parts
affected with the disease, it will be  proper to commence the treatment
by emollient poultices, warm fomentations, and brisk purgation ; and
should the  local symptoms be very considerable, the application of
leeches, or even the drawing of  a few ounces of blood from the arm.
The same treatment will be proper, should any considerable degree of
local irritation or inflammation occur during the use of the sulphur or
other ointments.  These latter will always be found to  act more effec-
tually, by the reduction, in this manner, of the irritation.
   If the child  affected with itch be  debilitated, or labour under any
other disease, the remedies adapted for the latter should be combined
with the treatment required for the removal of the former.

                  30. —Syphilitic Eruptions,

  Infants are liable to become infected with syphilis, either before birth,
during birth, or during  lactation.   Infants born of mothers who  are 
DISEASES OF  THE SKIN.
565
labouring under the venereal disease, may exhibit indications of syphi-
lis at birth ;  or  the disease may not appear for  many days, weeks,
or months subsequently.  Syphilitic children  are frequently born pre-
maturely or dead, with the cuticle separated,  or peeling from  different
parts of their bodies, or in a state of gangrene; abortion is a very fre-
quent consequence of intra-uterine infection.
  It is a curious circumstance, that during the entire period of gesta-
tion, at the period  of  conception,  or  even  for some time previous,
neither parent may have exhibited  any symptoms of  disease, and yet
the foetus may become infected in consequence of an attack of syphilis,
in one or other parent, which had, to all appearances, been fully eradi-
cated, years before  marriage.  In cases like these, where  there exists
so many powerful  motives for concealment,  or  deception,  there must
of course, always remain considerable doubt as to the fact of the entire
freedom from disease of the parents, at the period  of impregnation, or
during gestation; we have nevertheless met  with  repeated instances,
in which we had every reason to believe that such was actually the
case;  and  a  similar statement is  made by Burns, Veggio, Maunsell,
Dendy, and others.  It is probable, however, that, in some of the nume-
rous cases  recorded in  the continental journals, of syphilitic  children
born of parents in whom no vestige of the disease existed, eruptions of
the skin of a non-venereal character may have been mistaken for those
of syphilis. How far confidence is to be placed in the statements made,
of the foetus being liable to infection, in consequence of the father being,
or  having  been  diseased, while  the mother  is, and always has been,
perfectly healthy, we are not  prepared  to  offer  any positive  opinion;
we have, however, certainly met with cases which would appear to
establish very fully  the  fact, and  Mr. Acton, surgeon to the Islington
Dispensatory, England, adduces three  cases,  in which constitutional
syphilis in  the father, was the cause of repeated  abortions, and, subse-
quently, of infection of  the foetus born at the full period—the mother
remaining  throughout wholly free from disease.
   Mr. A. gives an abridged account of two other cases of secondary
syphilis in  men,  whose wives were  free from  all disease, but had mis-
carried.
   Intra-uterine syphilis generally presents itself in the form of red,
brown, or fawn-coloured blotches, varying in size, and slightly raised
above the level of the surrounding  skin.  From the surface of these
blotches, a very slight moisture exudes, which, in parts exposed to the
air, on drying, gives to  them a scaly appearance, and at length forms
thin scabs, of a  dark yellow, or  brownish  colour,  which reappear as
often as they are detached. The eruption usually occurs first upon the
lower  extremities, buttocks and loins, but subsequently, extends to the
rest of the body, as well as to the face.   When the  blotches appear
about the verge of the anus, between the buttocks, and in the folds of
the thighs and neck, the continual moisture and  friction of the parts,
prevent the formation  of crusts, but  irregular  tubercular swellings
(condylomas), occur.
  With the progress of the disease,  the skin becomes throughout, of a
reddish-brown or fawn-colour.  The infant is, at the same time, fever- 
566
DISEASES OF CHILDREN.
ish, fretful, and gradually wastes away; its voice becomes feeble and
hoarse, and there is a constant discharge from the nostrils, of a yellow,
viscid mucus, which quickly dries about the external orifices; the nose
becomes swollen, and perpendicular fissures  occur in the lips, giving
a very peculiar  appearance to the mouth.   The whole countenance
assumes at length a wrinkled, dejected appearance,  and the infant  ex-
hibits evident  indications of suffering, from deep-seated pains in  the
cylindrical bones; it becomes more and more feeble  and emaciated ;
ulcerations present themselves upon various parts of the skin; the in-
side of the mouth, and surface of the tongue, are often  covered with
aphthae, and the patient finally dies, in a state of extreme debility and
excessive emaciation.
  Such are the usual  phenomena and progress of syphilitic eruptions,
from intra-uterine infection;—though we have  known infants born of
diseased parents to present irregular ulcerations, or large vesications
on different parts of the surface, filled with a yellow, turbid, or dark-
coloured fluid, and which, upon rupturing, left ulcerations of  the skin,
that became quickly covered with thin, dark crusts,  and surrounded
with a dark-red or purplish margin.
  It has been doubted whether the venereal disease is ever communi-
cated to the infant during birth;  the vernix caseosa being supposed to
afford  a sufficient protection to the skin  against  infection.   It is cer-
tainly not very common to  find the disease communicated in this man-
ner ; and we believe,  that when  such is the case,  it  will  present itself,
most generally, under the form of purulent ophthalmia.
  Transmission by the nipple of a  diseased nurse is a very frequent
mode in which infants are  infected with syphilis.  Ulcers, in this case,
are generally formed in the mouth of the child, which  are often entirely
overlooked; or, when first noticed, are liable to be mistaken, even by
the physician, for the ordinary eruption so common  in infants during
lactation.  Thus, the true  character of the  disease not being recog-
nised in its first stage, it seldom comes under treatment until blotches
and ulcerations have  made their appearance upon  the  skin, when its
characters are the same precisely as those described  above.
   It is very common for syphilitic eruptions in infants to entirely dis-
appear under an appropriate treatment, but again to return, sooner or
later, after the treatment is suspended, and  thus to recur repeatedly,
until, finally, every vestige of the disease  is  eradicated.  This should
serve  as  a  caution to  the  young practitioner not to pronounce  the
child entirely cured,  until  several months have  elapsed without  any
symptoms of the disease reappearing.
   The diagnosis of syphilitic eruptions in infants  is not always very
easy; they, in many  cases, resembling very  closely psoriasis or lepra,
or  some of the more inveterate forms of scabies.   The physician who
has seen  a good deal of the disease will seldom  be deceived; but the
young practitioner must depend altogether upon a cautious investiga-
tion of its history, at the same time, without, if possible, exciting sus-
picion in  the minds of those interested; an incautious hint, or imprudent
question, might, have the  effect of destroying domestic peace, or, at
least, of deeply wounding the feelings of a mother, in cases where the 
DISEASES OF  THE SKIN.
567
conduct of neither parent is in the  slightest degree  concerned in the
production of their infant's malady.  In every instance, indeed, the ex-
pression of opinion should be very guarded.
   The treatment of infantile  syphilis  is extremely simple, and, when
judiciously carried into effect  at an  early stage of  the complaint, is,
very generally, successful in its eradication.   One  or two grains of
hydrargyrum cum creta, two, three, or four times a  day, according to
the age of the child; or a third or fourth of a grain of calomel, com-
bined with chalk, ipecacuanha, and extract of hyoscyamus;1 with the
external  application  of the black wash, or dilute citrine  ointment,b to
the crusts, ulcers, or  condylomae,  twice or thrice  a  day,  should be
directed, and continued until  the eruption and the discharge from the
nostrils disappear;  and, at longer intervals,  for one, two, or three
weeks subsequently.
* R.—Calomel, gr. iij.—iv.                 b R.—Ungt. hyd. nit. 3iij.
     Pulv. ipecac, gr. ij.—iij.                   Cerat. simpl. 3ij.—M.
     Cretas. ppt. 3ss.
     Ext. hyoscyami, gr. iij.—iv.—M. f. chart.
       No. xij.
  One to be given twice  a  day, or every 3 or
     4 hours, according to  the age of the pa-
     tient.
   By this plan of treatment, we have generally succeeded in the re-
moval of the disease in one month, in recent cases; but in those which
have been neglected in their earlier stages, it will seldom effect a cure
under two, three, or  even four months.  We are to recollect, also, the
liability of the  eruption to recur, after, to all  appearance, it has been
entirely eradicated;  when the same treatment is to be again resumed.
   Should  the mercury, when given  by the mouth, produce griping and
purging—which, however, we have seldom found it to do when com-
bined with the chalk, ipecacuanha,  and hyoscyamus—a small portion
of Dover's powder may be added to each  dose; carefully, however,
watching the effects of the opiate, which, in  infants, often gives rise,
even in the smallest doses, to very serious effects.  When the gastro-
intestinal irritation produced by the calomel cannot be controlled by
such doses of opium  as it would be prudent or  safe to administer to an
infant, it has been advised to  omit its use, and resort to the external
application of mercury, in the  form of ointment. Fifteen  grains of the
unguentum hydrargyri mitis may be rubbed upon the inner surface of
the thighs alternately, once in two days, until  the mouth becomes hot,
when it is to be intermitted, and again resumed after a proper interval,
should it be necessary.
   In children under two years of age, salivation is rarely, if ever, pro-
duced ; it is necessary, nevertheless, to watch  the effects of the mer-
cury upon the gums, and if these become hot, slightly swollen, or livid,
its use should be at once  suspended, as in some cases gangrene has
been known to result from its continuance under these circumstances.
This result, however,  is seldom  witnessed, excepting in very feeble
children.
   When the external  sores are very indolent, they may be washed 
568                DISEASES OF CHILDREN.
with a weak solution of the sulphate of copper, or of the nitrate of
silver.
  If we have reason to suppose that the mother or  nurse is labouring
under disease of a syphilitic character, and we must recollect, that for
very obvious reasons, it would be imprudent either to wean the infant,
or to suckle it at the breast of a  healthy nurse, we  should administer
to her the ioduret of mercury, with the decoction or syrup of sarsapa-
rilla.  It is true, that the milk may be thus rendered less adapted for
the nourishment  of the  child, but  it seems,  nevertheless, absolutely
necessary for  the effectual  eradication of the disease in the infant.
We would remark, however, that we recommend this course only in
the case of the mother being actually syphilitic; we are opposed  to the
plan of attempting the  cure of the  infant by giving  mercury to the
nurse, as was formerly practised.
  During the course of treatment, both mother and child should enjoy
the benefit of a pure, fresh atmosphere;  the diet of  the former should
be plain, mild, and sufficiently nourishing, and her drink, water alone;
it is important, also, that she take sufficient daily exercise in the open
air, and observe regularity in her hours of repose.
                       SECTION  V.

          DISEASES OF THE NUTRITIVE FUNCTION.

                           SCROFULA.

  Scrofula is a  very common  affection  of infancy and childhood,
being itself often the cause of various morbid phenomena; more fre-
quently, however, it acts as a predisposing cause of disease, or gives
to the other affections, common to the earlier stages of life, a peculiar
character, as well in reference to their symptoms, as to their progress
and termination.
  It is very difficult to give a correct, and at the same time a concise
and  comprehensive definition of  scrofula, and hence the somewhat
vague term scrofulous or strumous  diathesis, has been very generally
adopted by physicians;  the various  manifestations of this morbid con-
dition  being described as individual diseases.   This plan, while it is
productive of no  little confusion, is but illy calculated to lead to cor-
rect views in  regard to either the  pathology, prophylaxis, or thera-
peutical management of the scrofulous  affections.
  Scrofula is unquestionably dependent upon an abnormal condition
of the organic functions, in  consequence of which there is imperfect
sanguification and a  defective organization of the several tissues.  In
those children in whom the scrofulous predisposition is strongly marked,
there is a deficiency  of fibrine in the blood ; there is a predominance of
the white fluids and tissues over the red; the several organs are  pale, 
          DISEASES OF  THE NUTRITIVE FUNCTION.      559

 small in size, loose in texture, and perform languidly  their respective
 functions.   There is usually a peculiar fragility of the whole  frame;
 the skin is, in most cases,  thin and delicate, and by allowing the  ves-
 sels beneath to be distinctly seen, gives to the complexion an appear-
 ance of great  delicacy and beauty:  the limbs are often small,  soft,
 and rounded, but with  large joints; the fingers are long  and slender,
 but commonly broad and flat at the extremities; the chest is contracted;
 the head usually large, and the hair fine, silky, and often light-coloured ;
 the eyelashes are long, the eyes prominent, though languid in  expres-
 sion, and the pupils large; the lips are ordinarily thick and prominent.
 The whole frame exhibits  an appearance of languor and  debility; ex-
 ercise of every kind quickly tires.  Notwithstanding there is generally
 a want of muscular development, yet,  in many cases, the body and
 limbs have an appearance  of plumpness,  resulting from the infiltrated
 state of the cellular tissue.  The action of the  heart, though usually
 languid and feeble,  is easily excited, and a degree of febrile  excite-
 ment will be apt to result from the slightest causes.  The feelings are
 quick, warm, and ardent; and in many  cases  there is very  decided
 quickness and precocity of intellect.
   The  countenance in children of a scrofulous habit, is, however, not
 unfrequently swollen, and of a sallow  hue; the cheeks full, tumid, and
 flaccid ; the hair coarse, and dark-coloured; the lips thick,coarse, and
 liable to chap ; the skin thick, harsh, and subject to eruptions; the eyes
 dull and watery; the eyelids  full and  drooping, and  the general ex-
 pression, dull, heavy, and  stupid.
   Digestion in scrofulous subjects is ordinarily slow and imperfect, and
 liable to frequent derangement.  The bowels are  torpid or irregular;
 cold and heat are alike borne with difficulty ; while the effects  of  any
 of the usual morbific causes are more certain to be experienced by an
 organization such as we have described, than by one of greater health
 and vigour; evinced, however, in the production  rather of chronic
 than of acute disease.
   Inflammation occurring  in scrofulous habits, is slow in  its progress,
 and  often unattended by very manifest symptoms,  unless when it is
 externally  seated.  When  adhesions occur, the adhesive matter, in-
 stead of being firm, is of a  curd-like  consistence and appearance, very
 soft, and easily broken,  and with few, if any, blood-vessels penetra-
 ting it.   Suppuration is attended with the formation, instead of  genu-
 ine pus, of a thin, puruloid  fluid, containing curd-like matter.  Ulcera-
 tion  is slow in its progress, granulations are tedious in forming,  and
 unequal; and cicatrization, which is  very tardy in taking place, leaves
 an uneven, deep, and unsightly scar.   Softening of the internal tissues
 is very common, as well as tumefaction,  suppuration, or  disorganiza-
 tion of  the  lymphatic glands.
  Throughout almost every tissue of the body there is a  tendency to
tuberculous depositions, varying somewhat in  their character, pro-
gress, and termination, according to  the different tissues in which they
occur;  whilst in the bony structure we have a disposition  to softening
from a defect of the ossific process, and in the skin a predisposition to
various chronic eruptions. 
570                 DISEASES OF  CHILDREN.
  Children are often born with  this particular organization, or  with
a somewhat less decided lymphatic temperament, and very early ex-
hibit its influence, in  their greater proneness to disease,  or  in the
modified phenomena of the ordinary maladies  of infancy.  This is
particularly the case when they  are placed under influences calcula-
ted still further to impede the  functions of digestion, assimilation, and
sanguification.  Under opposite  circumstances, or  by a judicious
course of hygienic treatment,  the organic functions may be roused into
greater activity, and the organization of the tissues so far improved, as
to destroy their tendency to disease, or to allow the individual to pass
through life, with a delicate constitution,  but  without  the  occurrence
of any morbid phenomena calculated to produce  suffering, or materi-
ally to impair his comfort.
   The question has been long discussed as to  the hereditary character
of scrofula.   Upon a cautious review of all the  facts that have  been
adduced, and  a reference to the  professional experience of every ob-
serving physician, it appears to  us to be a question very easy of  solu-
tion.  There cannot be a doubt, that the children of parents who  have
laboured under the  disease, are more  peculiarly liable to its occur-
rence, all other things being the same, than those born of individuals
who were free from  it.  In the foetus  in  utero,  scrofulous affections
have not unfrequently been developed, when one or other of the pa-
rents have been diseased; but, ordinarily, all thai the child inherits is
a particular organization, which predisposes it subsequently to birth to
affections of this character.
   This temperament or predisposition may be derived  not only  from
scrofulous parents,  but from  such  as have never manifested, during
their whole lives, any trace of the  disease.  Thus, the  predisposition
in the child may result from  a  morbid  condition of  the parents, pro-
duced either by disordered digestion, chronic  disease, intemperance of
various kinds, a luxurious and indolent  life, too late  or premature
marriage, or the indulgence of any of the depressing passions.  Inter-
marriages between  near blood  relations have probably, also, a  very
powerful  tendency  to produce a  predisposition to  scrofula in the
offspring.
   While children born with the organization,  and consequent predis-
position just alluded to, will, under all circumstances, be most liable to
the  occurrence of scrofulous disease, it  is,  nevertheless, true, that the
scrofulous  tendency may be developed  subsequent to  birth, even in
children exhibiting no traces of a lymphatic temperament, and born of
perfectly healthy parents.
   The causes which produce this development are various; the most
important are improper or deficient food—impure and confined  air—
defect  of exercise—cold and dampness—imperfect  clothing—defect
 of personal  cleanliness—over-fatigue—and  the  depressing  passions
 generally.
   Improper or deficient food  is  no doubt of itself sufficient to produce
 that particular condition of the organic functions upon  which the de-
 velopment  of scrofulous disease depends.  The  origin  of scrofula in 
DISEASES OF THE NUTRITIVE FUNCTION.
571
 disorder of the digestive organs, is of so frequent occurrence, that many
 pathologists have considered this to be  its invariable cause.
   Both improper and deficient  food will give rise to  imperfect  diges-
 tion, defective assimilation, and incomplete  sanguification; the blood
 in consequence, becomes deficient in fibrine, and the nutrition of all the
 tissues suffers.   The  child becomes  pale and loses flesh, its strength
 sinks, and a general unhealthy condition of the whole organism quickly
 ensues.
   All this may occur to the  infant at the breast, from the bad quality
 or insufficient  quantity of the mother's milk: it  is moreiikely, how-
 ever, to take place when the  deficiency is attempted to be supplied, by
 rearing the child, partially or entirely,  by the hand, and still more so,
 after weaning, by the insufficient amount, indigestibility, or unnutri-
 tious properties of the diet upon which  it is attempted to be  nourished.
 Poverty may  prevent  a greater quantity, or  a better quality of food
 being allowed, and, in such cases, other causes very generally concur
 to undermine  the health and vigour of  the constitution.  But, even in
 families  where food  is plenty,  " children are often starved into dis-
 ease," by that which  is given to  them being altogether unadapted to
 the condition of their digestive organs,  and in consequence, not under-
 going, to a sufficient extent, those changes which are essential to  afford
 an adequate supply of materials fitted for  nutrition. A robust, healthy
 child, in the enjoyment of pure air and  active exercise, may often, for
 a considerable time, exhibit in no very  striking degree, the bad  effects
 of an improper diet; but even such a one  must eventually suffer  under
 it; whilst the feeble and delicate child, or one exposed at the same time
 to the influence of an impure and confined atmosphere, and debarred
 from sufficient exercise, will quickly evince all the phenomena of de-
 fective nutrition.  We do not  mean to  say that  in  every instance
 scrofula will be developed;  but only  that this is  one of the  causes
 which concur in its development.   In the predisposed, it is often  the
 chief cause.
  Impure and confined air is also an efficient agent in the production
 of scrofulous disease.  It acts not only in preventing the due oxygena-
 tion  of the blood by the lungs;  but also the important changes  which
 are effected in  it by the functions of the skin.
  Children confined in ill-ventilated apartments, particularly when the
 air  of such apartments is still  further  vitiated by the numbers who
 breathe it, or by the neglect of cleanliness,  are  uniformly pale, deli-
 cate, and unhealthy;  and if, at the same time,  the apartments are
 badly lighted,  the  baneful influence  exerted  upon the  health  of its
 inmates, is still more manifest.   The effect which the solar rays exer-
 cise  upon the  atmosphere,  or upon  the  functions  of life, it  is perhaps
 impossible to discover; all we know is,  that they are, in some manner,
 essential to the wholesomeness of the first, and to the due performance
 of the latter.
  From  the many causes by which, in  large  and crowded cities, the
 purity of the atmosphere is impaired, and its free circulation impeded,
the children who are brought up in them, have invariably paler com-
plexions, and  very generally smaller muscles, less developed forms, 
572
DISEASES  OF CHILDREN.
and a far inferior degree of vigour than those reared in open, healthy
situations in the country.  And when the deleterious tendency of the
city air is not fully counteracted  by  a sufficiency of wholesome food,
regular active exercise out of doors, and personal and domestic clean-
liness, a scrofulous tendency is very apt to be generated.
  A want of sufficient  exercise is likewise to be ranked among the
causes of that  defect of nutrition, upon which the tendency to scro-
fulous disease depends;  its effects  are very generally increased by its
being combined with those of an impure and confined atmosphere.  It
is chiefly by these two  causes that the health of those children  is so
quickly impaired, who are confined for many hours, daily, in crowded
school-rooms, or are made to toil  from  morning until night, and often
late  in the night, in sedentary occupations.  Nutrition  in  children so
circumstanced, is quickly and deeply impaired,  by defective digestion,
by imperfect  assimilation, by deficient oxygenation of the blood, and
by a too languid circulation through  the capillaries.
  Cold and damp are invariably injurious  to the infant.  In the pre-
disposed, they are among the most powerful exciting causes of scro-
fula, and even  in the healthy, when  long continued, they impair, to a
very considerable degree, the nutrition  of their bodies; and this, too,
when in a degree far less than is  necessary to  produce a  sensation of
chilliness  in the adult.  In  the damp  and chilly hovels of the poor,
during the colder season of the year, the children seldom escape more
or less  suffering and disease, and if death  is  not the speedy conse-
quence, the health and energy of their system are impaired, and some
form of scrofula being developed, they  ultimately become its victims.
But  it is .not among the poor  only, that  cold  and damp exert their
morbific influence; even the children of the  more opulent  are made to
suffer from them, in  consequence of fashion rather than good sense
dictating the form and material of their clothing, and leaving entirely
bare or only flimsily covered, portions of  the body that require at
least equally with the others to be  kept warm.   The effects of the cold
to which the  child is thus exposed, are not more certain, because pro-
duced often slowly and  insidiously.
  Conjointly with a  bad or insufficient diet,  foul and stagnant air, and
deficient exercise, personal  uncleanliness is  a powerful cause of that
state of impaired health in  children,  which lays the  foundation  for
scrofulous disease.
  Children are, we  suspect,  but  seldom subjected  in  this country to
over-fatigue from laborious  occupations.   In  Europe  they are fre-
quently, however, exhausted by being kept steadily upon their feet, for
many hours,  day and night, at occupations, which, without being labo-
rious, fatigue as well by their monotony, as by the  constant attention
they demand.  In some of our newspaper offices, we have known the
health of the boys who wait upon the press, often during the entire
night, to  become  seriously impaired;  and in  certain of our schools,
where young children are kept seated at  their forms,  engaged in un-
interesting tasks,  for many hours of the  day,  a degree of fatigue is
induced, often  very  serious in its  results.  Fatigue in children impairs 
DISEASES OF  THE NUTRITIVE FUNCTION.
573
the energies of the system, increases the irritability of all the organs,
and thus concurs in the production of the scrofulous predisposition.
  The depressing  passions, happily, are not easily excited in children,
and yet they are more frequently a cause of impaired health, at this
period of life, than is generally supposed.   Neglect or ill usage on the
part of parents, ridicule for personal  defects, constant  thwarting of
their childish but natural inclinations; the rude repulsing of their affec-
tions, and a  variety of other errors and  improprieties,  in  the moral
education of children,  will  often,  in those  of peculiarly  susceptible
minds, produce a state of such deep depression as sensibly to impair
their  health,  and with  the  seclusion and  inactivity to which such de-
pression leads, lay the  foundation for disease, which will be very liable
to assume the scrofulous character.
   In the predisposed, almost anyone of the causes enumerated will be
sufficient to produce some one or other of the forms of scrofula, while
even in those born with  the  marks of  health, the  combined  action of
several of them may produce the predisposition to its occurrence.
   Children who possess, from  their birth,  a strongly marked lym-
phatic temperament,  and  in whom the  predisposition  to  scrofulous
affections is consequently congenita], may, in the majority of cases, by
a proper course of hygienic treatment, be preserved  from  the attack
of  disease, and  have their health and vigour greatly improved.  Un-
less, however, such a  course is early commenced, and perseveringly
carried out, they will be constantly liable to a variety of ailments, until
some confirmed and serious  malady is finally developed. Their diges-
tion becomes, from slight  and often  inappreciable causes,  frequently
deranged;  their appetite is  often excessive, though, in numerous  in-
stances, deficient  or irregular;  their  bowels are often confined, their
discharges being unhealthy in colour and consistence; or a torpid con-
dition of the intestines will alternate, at irregular intervals, with diar-
rhoea, the stools being  light-coloured and slimy or dark, and of a jelly-
like consistence.  The flesh  becomes soft and flabby, and the bones
indisposed  to perfect  ossification.  The  child is late in assuming the
erect position, or  in attempting to walk, or if put upon his  feet, the
bones  of the  lowrer  extremities become curved  and distorted.  The
joints are large  and prominent, but lpose and infirm.  Dentition is pro-
tracted,  slow, and difficult, and the teeth  soon become black and de-
cayed.   The child is  often  fretful and peevish, has a languid, heavy
appearance,  is indisposed to  play, and soon becomes fatigued.   His
sleep is often  disturbed,  and  broken by signs of distress or  startings,
as if from fright. The  functions of the skin are imperfectly performed,
and, frequently, eruptions of a transient or permanent duration occur.
The tongue is either soft, flabby, and  repeatedly covered with a thick
tenacious mucus, or uniformly red, or maculated.
   In  many instances the child exhibits early symptoms of intelligence,
but is  more often dull,  heavy, and stupid.
   As the child advances in years, the throat, fauces, and tonsils exhibit
symptoms of disease.  The latter, especially from slight attacks of in-
flammation, become greatly  swollen,  and of a ragged, uneven shape,
and often remain permanently enlarged  for a considerable length of 
574
DISEASES  OF CHILDREN.
 time, though seldom very painful.  The only inconvenience resulting
 from the enlargement being an impediment to the freedom of respira-
 tion,  particularly when  the child is  asleep,  some  slight difficulty in
 swallowing,  a  dullness of hearing, and a peculiar  intonation  of the
 voice in speaking.  The eyes  are often  the seat of slow inflammation;
 the edges of the  eyelids are affected with chronic disease, increased
 exudation from the  follicles, stye, &c.  The glands of the neck become
 enlarged,  and after remaining long in an indolent state, frequently in-
 flame, suppurate, and  give rise to ulcerations, slow in  healing, and
 which often  leave  fistulous openings, from which  a  thin discharge
 takes place, for many months, or even years.
   The term scrofula has generally been restricted to a chronic enlarge-
 ment of the lymphatic glands, terminating finally in their inflammation
 and  a species of imperfect suppuration, forming abscesses filled with a
 pale, whey-like fluid, that gradually becomes  thicker, of  a yellowish
 colour, and intermixed with portions of curd-like matter.  When the
 abscess is opened or ruptures, it gives  rise to an irregular, ragged
 ulcer, in which large,  spongy granulations slowly  form, of different
 heights at the different parts of the ulcerated  surface, and when cica-
 trization, finally, takes  place, an uneven, puckered, and often deep, in-
 delible scar is left.
   The swelling of the  lymphatic glands  may be detected when they
 are no  larger than a pea.   They are then, hard, movable, and with-
 out pain or even tenderness when  touched  or handled.  They often
 continue, for a great length of time, without increase, forming a chain
 of small tumours, extending from  ear to ear. Occasionally, one  of the
 salivary glands, or the thyroid  body becomes affected.  When the
 glands commence to augment in size, the progress of the swelling is,
 generally, extremely slow, and often months  or years elapse, before
 the skin over the  tumour inflames.  Occasionally, the swelling subsides
 before this takes place;  but, in  general, it has a tendency to soften,
 forming a species of encysted  tumour filled with a whey-like or  curdy
 fluid.  Even, at  this stage, absorption will sometimes take place, and
the swelling disappear.    Usually,  however,  suppuration  proceeds
 slowly ; the whole structure of the diseased gland becomes destroyed,
 and a large  abscess is formed, that finally hursts, forming an  ulcer,
 varying in size, with indurated edges, and uneven surface,  from which
 is  discharged a thin watery fluid, mixed  with flakes  of curdy matter,
and occasionally small masses of a  tuberculous appearance.
   In other cases, the diseased gland is less uniformly softened, and be-
comes converted  into a curd-like  substance, intermixed with a softer,
less opaque matter, of a light yellow colour, with a small collection of
pus near  its  centre.  Sometimes a  number of small abscesses  occur
in  the body of the diseased  gland, each filled with curdy matter.   The
gland finally becomes a large abscess.  Inflammation subsequently
attacks the tissues surrounding the gland; which  latter is eventually
entirely destroyed by  suppuration;—suppuration  sometimes  taking
place around the new-formed matter within the gland.  The  gland
may continue, however, for a number  of years in a diseased  state,
without suppuration taking place. 
DISEASES  OF THE NUTRITIVE  FUNCTION.      575
  The scrofulous ulcer  is always  slow and difficult to  heal; it  may
often remain open  for months;  or it may heal in one part and  extend
in another.  When cicatrization does take place, it is irregular, puck-
ered, often crossed  by projecting bands, and of a peculiar white, un-
healthy colour.
  The intumescence of the glands is frequently the effect of exposure
to cold,  or occurs in conjunction with more or less disease  of the
digestive organs.  It is sometimes connected with cutaneous eruptions
about the head and face; but occasionally comes on without any very
evident exciting cause.  It  is generally confined to  the glands about
the neck, though the lymphatic glands of the axilla and groin may
become  diseased in the same  manner.  We  have seen well-marked
scrofulous disease of the  axillary glands, but  have never  met with a
case in which those of  the groin were affected.
   Scrofulous  disease of the glands of the neck most commonly occurs
after the fourth year; it may occur, however, much earlier; we have
seen it previously  to the first year, and repeatedly between the second
 and fourth. It seldom, however, tends to suppuration in children under
 two years of age.   When the disease occurs in this form, unconnected
 with any serious  affection of the internal  organs, though tedious and
 troublesome,  and  often resulting in very considerable  deformity, it is
 seldom, if ever, fatal.   It has even been proposed, in cases in which a
 tendency to tuberculous depositions in the lungs presents itself, to over-
 come this by exciting disease in one of the glands of the neck, by the
 insertion of'vaccine matter  in numerous points  over the gland;  and
 instances are related, by the late Dr.  Parrish, of Philadelphia, of the
 presumed successful result of this procedure.
   Scrofulous Ophthalmia.—Inflammation of the eye is a very common
  affection  in  children  of  a  strongly-marked lymphatic temperament;
  and is often the first indication which presents itself of the scrofulous
  predisposition.                                               .
    Very generally, the edges of the eyelids are first  affected with a
  deo-ree of soreness, and  soon become red and  slightly thickened;  the
  secretion from their  follicles  is increased, and  drying during sleep,
  causes  the lids to become  agglutinated.  Upon everting the eyelids,
  their inner surface is  found to be somewhat reddened, and a few red
  vessels are observed  upon the globe of the eye.  The redness of the
  conjunctiva  is at first  slight, and, in many cases, confined entirely to
  the  lids.  There is generally, however, an abundant secretion of the
  tears, and very great  intolerance of light; so that the patient  cannot
  be persuaded to raise his eyes to the light, but walks with the face in-
  clined  downwards, and often shades the eyes with the hands.
    This intolerance of light is usually most severe in the early part of
  the day; in the afternoon it will, occasionally, so far remit as to per-
  mit the patient to open his eyes.  The presence of daylight, as  Taylor
  remarks, would  appear to produce a spasmodic action of the  orbicu-
  laris muscles, so  that even when the  child is willing, he is unable to
  unclose the  eyelids during daylight; or, if he does succeed, by a kind
  of convulsive effort, the cornea is immediately rolled upward beneath
  the margin  of the tarsus, so as to be completely hid  from view.  As 
576
DISEASES  OF CHILDREN.
the disease augments, the redness of the conjunctiva increases in ex-
tent and intensity.
  In the commencement, the disease is not attended with  much pain;
though, occasionally, severe pain is experienced during the night, by
which sleep is often  broken or prevented.   In some  cases, the vessels
running from the conjunctiva to the cornea  are somewhat  injected,
whilst in other cases, several enlarged vessels are perceived; the red-
ness of the conjunctiva of the eye itself is, however, not usually very
strongly marked.  In recent and  acute  cases, an  effusion of serum
sometimes occurs beneath  the  conjunctiva  immediately  around the
cornea, forming an elevated oedematous circle, of a peculiar reddish-
brown appearance, and about a  line or more in thickness.
  In all cases of true scrofulous ophthalmia, there exists a strong dis-
position to the formation of pustules, which  appear  upon many points
of the eyelids, and along the edge of the tarsus, and often  produce
ulcerations,  attended with  considerable  irritation.   The  skin  imme-
diately beneath the eye, is also very commonly inflamed and  covered
with a minute pustular eruption.
  In the majority of cases, small vesicles or pustules appear upon the
conjunctiva  and cornea.   They vary in number and  size, hut are
generally  smaller upon the cornea; at the same  time, a  pencil of red
vessels is often developed on the  latter. The vesicles or pustules, upon
rupturing, form small, round, superficial, or funnel-shaped ulcers. The
vesicles, or pustules,  may be absorbed previously to  bursting, and then
they leave, in the cornea, a slight degree of  cloudiness, which  disap-
pears in time.   Sometimes, upon  the removal of this,  a  transparent
dimple remains,  which  is long in filling up.  In some cases, the cloudi-
ness spreads over the cornea, and large red vessels run into it, forming
a vascular speck, which is  always a very tedious  and troublesome
symptom. Occasionally, a general cloudiness or a permanent opacity
of the cornea may also be produced.
  Dr.  Maunsell  describes  the ulceration of the cornea  as  sometimes
presenting an appearance, as if a small portion of its conjunctival layer
had been  removed by a sharp chisel, leaving a distinct facet, some-
times level,  and  in other instances concave: this condition  may re-
main  unaltered for a considerable length of time, and  is unattended
with opacity of the cornea.  We  have  met with this  form of ulceration
in many cases.
  The ulcers of  the  cornea, particularly when superficial, often cica-
trize, leaving an  opaque, permanent  cicatrix, which may become les-
sened  in time, but never entirely obliterated.  When the ulcerations
are of some depth, they are often attended with considerable irritation
and pain  upon every motion of the  eyelids.  They sometimes pene-
trate entirely through the cornea, and a  protrusion of the membrane
of the aqueous humour takes place, in  the form of a small vesicle;
when this gives way, the aqueous humour escapes, the iris is prolapsed,
and a  dense, opaque cicatrix is the result;  or the ulcer  may at once
penetrate the anterior chamber, with a similar result.
  When the ulceration of the cornea is of considerable size, and the
iris extensively  prolapsed, the pseudo-cornea which forms over the 
DISEASES OF  THE NUTRITIVE FUNCTION.
577
protruded portion of the iris, sometimes give way before the pressure
of the humours, forming a partial staphyloma.  A general protrusion
of the whole cornea may take place from the same cause, when its tex-
ture has become weakened by inflammation, and the iris is adherent to
its  posterior  surface.  The transparency of the  cornea may also  be
impaired by a ramification of red vessels, forming a vascular network,
in its conjunctival layer.
   The  inflammation may be propagated from the cornea to the scle-
rotica and iris, or even to the more deeply-seated structures of the eye,
producing extensive disorganization of the interior of the globe, parti-
cularly when  the disease is of long  standing, or has repeatedly re-
curred.  Hydrophthalmia  may be induced by increased secretion of
the humours; or, occasionally, the eye  may become atrophied, appa-
rently from interrupted nutrition.
   Scrofulous iritis is generally of a chronic form, and unattended with
symptoms of any severity; it may, in the course of time extend to, and
cause disorganization of the surrounding tissues,  terminating in amau-
rosis and atrophy of the globe.
   Scrofulous  ophthalmia  occasionally assumes a  much milder form.
Its principal feature is the occurrence of pustules  upon the conjunctiva,
usually a line  or two from the margin  of the cornea. (Pustular ophthal-
mia.)   The pustules are generally of considerable size, and filled with
an opaque, yellow matter: they are accompanied with a fascicular in-
jection of the  conjunctiva in their immediate  vicinity.  Occasionally,
the injection of the conjunctiva  is more  diffused, and accompanied
with ecchymosis.   On the pustules bursting, they form broad, elevated
ulcers, which, after a time, cicatrize.  There is little or no intolerance
of light, and an entire absence of the spasmodic contraction of the lids
observed in the ordinary form of scrofulous ophthalmia; and the trans-
parent textures of the eye are unaffected.  It is often combined with
catarrhal conjunctivitis.  This form of ophthalmia, is, according to our
experience, of much more common occurrence, than the more violent
one described above.
   The local disease is  generally attended with some degree of febrile
reaction—a fretful and irritable temper, and a disordered condition of
the alimentary canal.  Frequently, the  abdomen is tumid and tense,
the breath very offensive, and the alvine  discharges of an  unnatural
appearance.   When the case is one of long continuance, there is con-
siderable  emaciation, particularly of the extremities, with  a  general
manifestation of feebleness and irritability.
   Scrofulous ophthalmia is frequently preceded by eruptive  affections
of the head and face, and ulcerations behind the ears, which disap-
pear soon after the  inflammation of the eye is fully developed.  When
associated with these eruptive affections, the disease has been described
by Wardrop and Christian, as exanthematous, or porriginous ophthal-
mia.
  Scrofulous  ophthalmia  usually  attacks both eyes, though seldom in
an equal degree;  or the disease may occur, first in one eye, and then
extend to the other; or, it may attack the two eyes alternately.
  The disease most generally occurs during childhood, rarely in adults,
                                37 
578
DISEASES OF  CHILDREN.
and  never, unless  they have previously suffered from it.  The most
common period for its attack is between the first and fourteenth years
of life.
   It  is produced by the usual causes of ophthalmia—cold, irritating va-
pours, or other substances admitted  into the eye.  It frequently occurs
also, about the period of dentition, or subsequently to an attack of one
or other of the febrile exanthemata.
   Scrofulous Otitis.—This is a very common affection during child-
hood.  The inflammation may be confined to the lining membrane of
the external meatus; when  it very generally assumes a chronic form.
The  inflamed membrane  becomes, sooner  or later, studded with mi-
nute  pustules, upon the rupture of  which, ulcers form, and give dis-
charge to thin, unhealthy, and  often very foetid pus.   The discharge
from the ear usually  continues for a great length of time, and the lining
membrane of the meatus very frequently assumes a thick, spongy, and
highly-irritable  condition, and  presents an  appearance as though it
were covered with a kind  of  curdy exudation.  In  other cases, the
discharge ceases, for a longer or shorter period, and  then again sud-
denly recurs.  Sometimes the suppression of the discharge is followed
by scrofulous ophthalmia, porriginous eruptions upon the scalp, intu-
mescence of the glands of the neck, &c.   The disease may cause
finally a destruction of the membrana tympani, and of the ossicula of
the ear, and thus occasion permanent deafness.
   In other cases, the inflammation affects the deep-seated structure of
the ear;  or this  may become affected in consequence  of the extension
of the disease from the external  meatus.  This form of otitis is attended
with more or less dull  pain, which  often extends over the side of the
head, alternating, occasionally, with very severe paroxysms of more
acute suffering; with deafness, singing, humming, or other noises in
the ear;  disturbed sleep, fretfulness  and irritability of temper, and, oc-
casionally, with  some degree of febrile reaction.  When a discharge
takes place, it is of a thin, grayish, dirty-coloured fluid, often more or
less  sanguinolent, and exhaling a peculiar, but, generally,  very foetid
odour.  It is often acrid, and causes irritation, and more or less swell-
ing,  of the lobe of the ear, and of such parts of the skin as it comes in
contact  with. In the progress of the disease, the discharge from the
ear will often contain small  fragments of carious bone.
   The mastoid cells are very often affected in cases of scrofulous otitis.
When this occurs, a  dull pain is felt over the mastoid process, which is
tender upon pressure;—the skin covering this part, becomes reddened,
slightly  swollen, and an accumulation of matter takes place beneath
it. After a time, the skin assumes a  more dusky or violet hue, becomes
gradually more and more  thin, and, finally, ulcerates, giving discharge
to a  fluid, similar to that from  the ear.  The cellular structure  of the
mastoid process is now found to be destroyed, to a greater or less ex-
tent, and  infiltrated  with  matter, while a  fistulous communication is
formed between the external surface, and the cavity of the tympanum.
Occasionally the matter  travels downwards, between the muscles at-
tached to the mastoid process, and opens low down in the neck.  In
other cases, the whole cellular structure of the mastoid process becomes 
           DISEASES OF THE NUTRITIVE FUNCTION.      '579

 disorganized and broken down, and  is discharged from the external
 meatus, mixed with a sanious fluid, and the mastoid projection disap-
 pears without the skin becoming affected.  In other cases, again, the
 pus and disorganized matter of the cells, find their way from the mas-
 toid process through the Eustachian  tube;—the arrival of the matter  '
 in the fauces being attended with coughing and expectoration, a nau-
 seous, disgusting taste, loss of appetite, and occasionally vomiting.   In
 some cases, the mastoid  process is enlarged, and converted into a soft
 homogeneous mass, readily cut, like cheese, with a knife.
   The  petrous portion of the temporal  bone is occasionally affected.
 In  some instances, the facial nerve is involved in the disease, and acute
 pains in the ears are experienced, with spasmodic  contractions of the
 muscles of the face, on the side  affected, terminating, finally, in
 paralysis.   Several  cases of this  kind are  noticed  by  Lallemand,
 Berard, and others, and we had one under our care, in which, besides
 paralysis of the muscles of the left side of the face, there was a loss of
 the power  of articulating. In this case, which was in a boy seven years
 of age,  the otitis occurred subsequent  to a very severe attack of scarlet
 fever.   In  many instances,  the disease of the petrous portion of the
 temporal bone  involves  the  brain, and various  symptoms of cerebral
 disease are produced.
   One  or two cases are referred to by Lallemand,  in which the disease
 extended to the occipital bone  and  involved the first two cervical
 vertebrae.  Caries of the bones, at  the basis of the cranium has like-
 wise been observed by Krukenberg.
   Scrofulous otitis is, most generally, a disease of childhood;  it com-
 monly affects but one ear, though we have seen a  few  cases in which
 it occurred simultaneously  in both.  It  may be produced by any of
 the ordinary causes of inflammation.   It  is  frequently  observed about
 the period of dentition;  and, in a  large  number  of instances, subse-
 quent to attacks of one or other of the acute exanthemata. The disease
 is frequently preceded by ulcerations behind the ears, erysipelas  of
 the face, porriginous eruptions  about the head and face, and, as these
 frequently disappear when the inflammation  of the ear takes  place, it
 has been generally attributed to their being  suddenly  dried, up or re-
 pelled—in  most  instances,  however, as Krukenberg  very justly  re-
 marks,  with very little foundation.
  Scrofulous otitis is frequently accompanied  by  more or less febrile
 reaction, and  by the same  disordered  condition  of the  alimentary
 canal, noticed when treating of scrofulous ophthalmia.
  Discharges from the Vagina.—These not unfrequently take place in
 female children, even at an early period of infancy, and, occasionally,
 about the  fifth year. They result  from a subacute inflammation of
 the mucous membrane within the labia, and  are,  in  many cases, at-
 tended with aphthous ulceration.  The matter discharged is various in
 its character, being often a thin sanious fluid, containing small flocculi,
of a curdy  appearance; not unfrequently, however, the  discharge is of
a thicker, more opaque,  somewhat  purulent  appearance, and is often
so acrid as to produce redness and irritation, and a  slight pustular
eruption of those portions of the skin  with which it comes in contact.
The discharge is sometimes  very slight. 
580
DISEASES OF  CHILDREN.
   This affection  has been repeatedly mistaken  for gonorrhoea, com-
municated by infection from the parents; or, in older children,—for
the disease, when neglected, may even continue, according to Dewees,
up to  puberty—it is  apt  to give rise to  suspicions of a very grave
character, which  the physician is occasionally called upon, by his pro-
fessional opinion,  to  remove.  The  true nature of the affection is, in
most  cases, rendered evident, by the patient labouring, at the same
time,  under other decidedly scrofulous symptoms, or which indicate
a very strong predisposition to affections  of that character.  A very
striking case is related by Dr. Ferriar, which shows the importance,
in a medico-legal point of view, of  a correct knowledge of the nature
of this affection.
   The disease just described, is a very different one from that noticed
by Boivin, Duges, Kinderwood, Mackintosh, and others, as affecting the
labia  of female children,  and  terminating in gangrene, though con-
founded with it by Churchill.
   Tabes Mesenterica.—Scrofulous  disease of the mesenteric glands.
The glands of  the mesentery are said to be, after those of the neck,
the most  common seat of scrofulous disease.   From the  frequency
with which, in  those predisposed to scrofula, subacute or chronic in-
flammation of the alimentary mucous membrane occurs, there can be
no  doubt  that disease of  the mesenteric  glands, is  a very common
indication  of  such  predisposition.   The  error  committed  by most
pathologists, until  a  very  late  period, has been, in attributing to the
diseased condition of these glands, the  entire chain of symptoms by
which it is preceded and accompanied;  when  the affection of the
glands is  probably, in the majority of instances,  the consequence of
gastro-intestinal irritation.
   Contrary, however, to  the generally received opinion, Rilliet and
Barthez do not consider tuberculization of the mesenteric glands to be a
frequent  affection of the  first  period of childhood.  It  occurred to a
considerable extent in only about one-seventh of the cases where the
mesenteric glands were affected, and in only about one-sixteenth of all
the children who presented tubercles in other parts of the body.  In but
one-half the cases of tuberculous children, the mesenteric glands were
found affected,  and then only slightly.  Rilliet and Barthez  state that
the disease scarcely ever  attacks children under three years of age—
that it is slighter the  younger the child is, and that it reaches its maxi-
mum  of development between five and ten years, after which it is very
rare.   The reason why it has  been  generally considered so frequent
among children,  is, they conceive, because other diseases, as tubercu-
lous peritonitis, enteritis, &c, have  been mistaken for it.
   The most common characteristic of tuberculization of the mesenteric
glands is prominence of the abdomen, with emaciation, particularly of
the limbs.   Its only  certain diagnostic, however, is the perception of
the enlarged glands, by manual examination, through the parietes of
the abdomen.   It may, however, be suspected wherever chronic dis-
ease of the alimentary canal occurs in children of a strongly marked
lymphatic  temperament, especially  if such disease becomes attended
in its  course with a fulness and irregular hardness of the abdomen. 
           DISEASES OF THE  NUTRITIVE  FUNCTION.        59]

  The glands exhibit, in the various  stages of the disease, nearly the
same changes that occur in  scrofulous glands of other parts; in some
cases, being simply increased in size  and density, in others, enlarged,
reddened, and softer than natural; while in others again, their texture
is changed, and they become filled with  a  soft, white, curdy matter,
sometimes mixed  with a purulent fluid.  When the disease is pro-
tracted, the patient generally dies in  a state of complete marasmus;
and, not unfrequently, tuberculous  depositions  are found in  the lungs
and other organs.
  Scrofulous Disease of the Bones.—In that condition of the system,
which during childhood predisposes  to the occurrence of scrofulous
affections, the bones are always slow in attaining the firmness of ossi-
fication which is necessary to fit them for their respective offices.
There is, in fact, a deficiency of the phosphate of lime throughout the
entire osseous system.   This deficiency has been referred to a want of
sufficient energy in the circulation, which may undoubtedly concur, to
a certain extent, in producing the retardation of the  ossific process;
the true cause of the latter, however,  is to be sought for in some defi-
ciency in  the healthy constitution of  the  blood, and in  an abnormal
state  of the nutritive process generally.
  The bones not being possessed of  sufficient firmness, become bent
and distorted by the action of the  muscles, the weight of the body, or
the pressure of  the ordinary clothing.  Those of the extremities are
curved, often  to a  very great extent; the pelvis becomes narrowed
by the lateral pressure of the heads of the thigh bones; the spine is
curved in one or other direction, diminishing permanently the height
of the body, and causing very considerable and serious deformity.  The
scapulae become prominent  and projecting, and the shoulders so far
thrown upwards, as to give an appearance as though the head  had
sunk  between them; the ribs become flattened, or unnaturally curved,
sometimes on both sides, but  more generally to  a greater extent on
one side than on the other.   The anterior part of the chest is projected
forwards, and the  sternum forms a  prominent ridge,  or it is  sunk
between  the cartilages of  the  ribs,  the  anterior  curvature of the
latter forming a ridge on one or  both  sides of it.  The head is often
greatly enlarged, and the sutures and fontanelles remain long unconso-
lidated.   The chin is usually prominent, and the sides of the face flat-
tened. The heads of the bones are large, and unusually spongy, and
the joints loose, and destitute of firmness.  Dentition is long in taking
place, and  when it commences is slow and protracted, and the teeth
soon  decay.   There  is generally  great and progressive emaciation,
from  diminished nutrition of  the  soft parts, and, in  many cases, the
softened state of the bones is accompanied by a diseased condition of
the glands of the neck and of the  mesentery, and it seldom exists long
without some part of the bony structure—either the spine, the knee, or
hip-joint—becoming the seat of  disorganization; or without  tubercu-
lous  depositions occurring in the brain or lungs.   The phenomena
now described, constitutes the affection known by the name of rachitis
or rickets, which is fortunately one of  rare occurrence in this country. 
582
DISEASES  OF CHILDREN.
    When death does not take place during infancy, but, the bones be-
  come more  firmly ossified, and the patient  attains to adult, or, as  is
  occasionally the case,  advanced  age,  his body is generally  perma-
  nently deformed, and often crippled, if disease do not occur to add to
  the deformity, positive suffering.   The  subjects of rickets, to whatever
  age they may attain, have always  debilitated frames, and are con-
  stantly liable to the occurrence of convulsions, or tubercular affections,
  particularly of the lungs.  In the female, contortion of the pelvis may
  give  rise to tedious or difficult  labour, or it may render the birth of the
  child impossible.
    Independently of the defective ossification of the bones, in children
  predisposed to scrofulous disease, their  structure is peculiarly liable to
  become  the  seat of a morbid  action, by which  portions of them are
  often  completely  disorganized.  The   spongy bones,  as  well  as the
  spongy heads and extremities of the long bones, are especially the seat
  of this process of disease.
    There is, at first, increased  vascularity of the bony structure, with
  a diminution of the earthy constituents ; the cancelli become filled with
  a transparent fluid, which is subsequently replaced by the deposit of
  a cheese-like matter.   The morbid change  often  commences at the
  centre of  the bone, the exterior  remaining unaffected.  In general,
  however, the affected bone becomes softer and more spongy, the car-
  tilage is either detached entire, and becomes  gradually softened, or it
  is detached slowly, and in layers,  or irregularly absorbed.  A  portion
  of the diseased bone sometimes exfoliates; and sometimes the  disease
  extends  to the shaft of the cylindrical bones, so as  to convert them
  into a thin shell of earthy matter, the  whole interior structure being
'  disorganized.
    In  the progress  of the disease, inflammation, generally of a subacute
  character, takes place in the  cellular  membrane surrounding  the af-
  fected joint, with the effusion, at first of serum, and afterwards of
  coagulable lymph; causing a puffy, elastic swelling, which becomes,
  subsequently, oedematous.  The ligaments and synovial membrane are
  finally involved  in the  disease, and an external opening, or  several
  openings taking place, a  discharge of matter occurs, and numerous
  circuitous sinuses extend  from the cavity of the joint into the neigh-
  bouring cellular tissue.
    White Swelling.—When the affection of the  bones  we have just
  described, occurs  at the joint of  the  knee, ankle, elbow, or  wrist, it
  constitutes the disease  denominated white swelling.   The first symp-
  tom  is usually a weakness of  the joint;  this is  succeeded by a dull,
  heavy pain, which is generally increased by the motion of the joint,
  and sometimes when the patient is warm in  bed.  In the  commence-
  ment the pain is often very slight, though occasionally of considerable
  severity.  It is very uniformly referred to the centre of the articula-
  tion.   The pain in many cases is  continued, in  others irregularly in-
  termittent, and in  others again, somewhat periodical.
    There is, at first, very little or no swelling of the joint; sooner or later,
  however, more or less fulness is perceived, which gradually increasing, 
DISEASES OF  THE NUTRITIVE  FUNCTION.
583
 causes the  joint, in time, to acquire a very considerable  magnitude.
 The swelling, at first, sometimes yields slightly to pressure, but never
 pits, and is always sufficiently firm to lead the inexperienced to suppose
 that it is produced  by an enlargement of the ends of the bones.   The
 enlargement of the joint appears greater  than it really is, in conse-
 quence of the emaciation  of the  limb  above and below.   The  skin
 enveloping  the  diseased articulation is not changed in colour,  but
 becomes tense, smooth, and transparent, the veins being visible beneath
 it.  The pain is now generally increased, though it may still be com-
 paratively trifling, amounting, in many instances, rather to a sense of
 uneasiness than of actual pain.
   When  the swelling is seated in one of the lower extremities, the
 child is observed to limp occasionally.  As the  disease increases, the
 patient is unable to bear his weight upon  the affected limb, in conse-
 quence of the great  increase of pain which it  occasions; he conse-
 quently acquires the  habit of touching  the ground with the points of
 the toes only, and the knee being thus kept constantly bent, soon loses
 the power  of being  fully  extended.   A collection of  matter finally
 forms about the joint.   The pain now usually becomes more  severe
 and continued, and the skin more tense, and of a darker,  and finally
 purplish colour.
   Suppuration proceeds very slowly, and when  at length,  the matter
 reaches the surface, one or  more,  generally several, openings  are
 formed, which  give discharge to  a  thin, serous pus, with  portions of
 curdy matter floating in it;  as the discharge decreases  in quantity, it
 becomes thicker, and ultimately assumes the same appearance as the
 matter found in scrofulous glands.   Sometimes sinuses are formed,
 and the matter is discharged at a distance from the joint. From these
 openings, not unfrequently, small pieces of bone escape.
   Occasionally, abscesses form around the  affected joint within a few
 months from the invasion of the disease, while, on the other hand, the
 disease may continue for many years, without the occurrence of  sup-
 puration.
   The openings sometimes heal  up very speedily, but other  collections
 of matter generally form, and new openings take place, and this may
 continue to occur for a  long period.
  Disease of the bones may exist for many months, and even  longer,
 without the occurrence of other than the local phenomena described.
 But, very generally, hectic  fever, with profuse night  sweats, and  col-
 liquative diarrhoea, sooner  or  later  ensue, under which  the  patient
 speedily sinks.   In  some cases, however, the diseased  action in the
 bony  structure  is arrested, a curative action results, and  the  patient
 recovers, with anchylosis of the joint.  Unless the disease  is arrested
 in its  first stages, the cure is always  difficult and tedious, and the  mo-
 tion of the joint is invariably lost.  When the bones of the carpus or
 tarsus are the seat of the disease, it is always more difficult to manage,
 from the facility with which the  disease extends from one to the other
of the small  bones of these parts.
  Very often, white swelling is  accompanied with a scrofulous affec-
tion of the  glands  of the neck, and  frequently, when the  knee-joint 
584
DISEASES OF CHILDREN.
is the seat of the disease, enlargement of the lymphatic glands in the
groin occurs; the  latter affection, however, is seldom  very trouble-
some.
  The disease  may occur without  any very evident  exciting cause,
but is generally attributable to the effects of cold or damp, to violence,
or to over-exertion of the joint.
  Hip Disease.—Morbus Coxarius.—When  the disease of the bones
is seated at the hip joint, the symptoms to which  it  gives rise, are, in
the earlier stages, extremely obscure, and very apt to mislead the inex-
perienced physician in regard to the real nature of the case.
  The first thing that usually attracts attention, is a slight limp in the
gait of the child.   More  or  less uneasiness, scarcely  amounting to
pain, is soon experienced  by  the patient, but this  is almost invariably
referred  to the knee, the hip being seldom complained of:—in many
cases, however, there is a fixed pain behind  the great trochanter, and
in others, the patients complain of a painful sensation in the  groin,
shooting down, in the course of the  vastus externus, to the knee.
  From an early period, the  limb on the  affected side becomes ema-
ciated, and very decidedly diminishes in diameter.  The natural ful-
ness and convexity of the  nates become diminished, and  that part
which is usually most prominent, soon  becomes  flattened.  Pressure
on the front of the hip joint, a little  on the outside of the femoral ar-
tery, below the pubis, will give rise to severe pain. The motion of the
joint is evidently impeded; extension is performed with difficulty, and
the heel of the diseased limb scarcely rests upon the ground; there is,
also, great difficulty in flexion; hence, when the child attempts to stoop,
he bends only the knee.  If desired to raise  his foot upon a  chair, the
effort is so painful  that he cannot accomplish the  movement; while
the  rotation of the  joint, especially inwards, is impeded, and  cannot
be accomplished without great pain.
   In consequence of the  weight of the body being chiefly  supported
upon the sound limb, the pelvis is thrown downwards upon the affected
side, so as to give to the limb, on this side, an appearance of increased
length.   If the patient be placed upon his back, and a line drawn from
the  spinous process of one ilium to  that of the other, there will be
found  to exist a difference of an inch or more between the height of
the two.
   The patient soon acquires  the habit of throwing the entire weight
of the body upon the sound limb, while  the  thigh of the affected  side
is bent somewhat forwards, and the knee flexed, so  that only the toes
come in contact with the ground.   This position is  found to be the
most comfortable, and every attempt  to extend the limb is attended
with considerable pain.
   In some  cases, the parts  surrounding the diseased joint become
somewhat swollen, tense, and extremely painful,  and  occasionally the
skin is reddened, and severe febrile reaction occurs;  a circumscribed
tumour forms in the vicinity of the joint,  a  fluctuation of fluid is per-
ceived, the skin bursts, and a discharge of matter takes place.
   More generally, suppuration within the cavity of the joint occurs
slowly ; the pain becomes less intense, but more continued; a thicken- 
          DISEASES OF  THE NUTRITIVE  FUNCTION.        595

ing of the capsular ligament  and synovial membrane gradually takes
place; the articular cartilages are,  to  a greater or  less  extent, de-
stroyed ;  the  round ligament  becomes detached from the head of the
femur, which is finally pushed  out of the articular cavity, until it passes
beyond the acetabulum, and lodges upon the dorsum of the ilium, the
foramen ovale, or the ramus of the pubis.  The two  latter modes of
luxation are, however, extremely rare;—the  dislocation being, in ge-
neral, upwards and outwards; the affected limb is consequently short-
ened, the toes are turned inwards, the great trochanter is approximated
to the crest of the ilium,  and the leg is in a state of  flexion.  When
shortening of the limb results from destruction of the head and neck of
the bone, the toes are turned outwards, while the limb may remain
parallel  with  the trunk.
  Dislocation of the femur may occur, and  the disease terminate in
anchylosis, long  before  any suppuration  takes  place in the parts sur-
rounding the joint.  Very frequently,  however, abscesses form, and
the matter travels, generally, down the thigh, between the trochanters
and integuments, but, in other cases, in  the  direction of the femoral
artery, and by its pressure  may occasion  the absorption of a con-
siderable portion of the vessel.  When these abscesses burst externally,
they continue, in general, to discharge, for a considerable time, an un-
healthy, thin, purulent matter, often mixed with curdy flakes.
  After it  has existed for some time, the disease of the  hip is very
generally attended with hectic symptoms, and considerable emaciation.
In some patients these symptoms occur at an early period; in others,
however, not until  late, or only in very protracted  cases  of the dis-
ease.
  Sometimes, before the head of the  bone is dislocated, it is partly ob-
sorbed; at other times it remains entire.
  In the dissections that have  been  made, at  an early period of the
attack, inflammation of the head of the thigh bone, with slight thick-
ening of the  capsular ligament,  has been observed.   A small quantity
of matter has been found in the cavity of the joint, and slight erosions
of the articular cartilage lining the acetabulum, with disease  of the in-
nominata.  In more protracted cases, the parts surrounding the joint
contain a quantity of adhesive matter, with destruction of the cartilages
and ligaments of  the  articulation; the bony structure composing the
acetabulum being extensively diseased, and in part  absorbed, as well
as the head and neck of the femoris.  In general, some surgeons say
invariably, the bones of the  pelvis exhibit more extensive  marks of
disease than the head of the thigh bone.
  In many cases the disease appears to occur, as it were, spontane-
ously ; in others it is brought on by external violence, cold and damp,
or too long-continued, or violent exercise of the joint.
  Disease of the Spine.—When  the bones  of the spine become the
seat of  scrofulous disease, the child  becomes languid, listless,  disin-
clined to play or move about, and is  quickly tired when he attempts
it.   He  frequently trips and  stumbles, and when he  moves hastily or
unguardedly, his  legs cross  each other involuntarily, and he is thus
often suddenly thrown down.  If he endeavour to stand by himself, 
586
DISEASES OF CHILDREN.
still and upright, his knees totter under him.  He cannot, with any de-
gree of precision or certainty, direct either of his feet to any particular
point, but in attempting to do so, one will be brought across the other.
He soon begins to complain of frequent pains  and twitchings  in  the
thighs, particularly when in bed, and of an uneasy sensation at the pit
of the stomach.  When he sits  upon a chair, his legs are almost inva-
riably drawn across each  other, and up  under the seat;  finally, the
child loses entirely the power of walking.
   If the disease be in one or more of the  cervical vertebrae, the child
finds it inconvenient and painful to support his head erect, and is desi-
rous of leaning it on a table or pillow.  If seated in the  dorsal verte-
brae, there is often a  dry, hard cough, laborious  respiration, and  the
early occurrence of hectic symptoms; and frequently, the arms  are
affected  with  spasmodic twitchings,  involuntary  contractions,  and
finally, entire loss of motion.  When the lumbar vertebrae are affected,
there is often difficulty in voiding the urine,  and the faeces will at
length be  discharged involuntarily.
   In some cases, the  loss of motion in the lower extremities is com-
plete ; in other cases, the patients are able to move about with the aid
of crutches, or by grasping the thighs just above the knees, with both
hands; some patients  can sit  in  an arm-chair, without much trouble
or fatigue; others cannot sit up at all.
   The first  indication of the  disease is, very generally, when the pa-
tient is old  enough to describe his feelings, a fixed pain in some part
of the spine, extending in the direction of the nerves which arise from
the affected  portion.   There is, at the same time, a sense of weakness
in the back, and pain  in  the  sides, more marked in one than in the
other.  Sooner or later, there  takes place a destruction of the bodies
of one or more of the vertebrae, producing an incurvation of the spinal
column forwards, and a corresponding projection backwards.
   A wasting of the muscles of the back very  generally precedes the
spinal  curvature, which is evinced by the child's head being inclined
forwards  more than  natural, by one  shoulder  being raised above the
other, and by a disposition to lean or recline, when sitting down.  This,
however, is much more common in cases of lateral curvature, in which
the bones are not primarily affected with disease, but which results, in
the  majority of instances, from a want of power in the muscles in-
serted in the spine, than in angular curvature,  which is invariably de-
pendent upon the destruction of the bodies of one or more of the ver-
tebrae.  We  have occasionally noticed, however, this wasting of the
dorsal muscles to take place early, in cases of  the latter.   The lateral
curvature may, and often does, occur in children predisposed to scro-
fula, from defective nutrition of the muscles, but  is not connected, ne-
cessarily, with scrofulous disease of the bony structure of the spine.
   The spinal cord becomes incurvated with  the vertebrae, and sub-
jected to  more or less pressure, from which there results, in the pro-
gress of the disease, irritation and inflammation  of  the spinal nerves,
chronic inflammation of the membranes of the cord, and occasionally
of the cord itself.  In  some  cases, the cord becomes so  much com-
pressed  as to deprive the parts which receive  nerves from below the 
         DISEASES OF  THE NUTRITIVE FUNCTION.      587

point at which the pressure exists, almost entirely, of motion and sen-
sation.
  The natural cure of the disease of the spinal structure is by anchy-
losis, produced by the deposition of osseous matter, so as to  attach to-
gether the surfaces of sound bone, which are brought into contact.
  Caries of the spine is very frequently the cause of psoas and lumbar
abscess.
  The danger of the disease will depend, in a great measure, upon its
extent, and the nature  of its complications, and  the  period at which
the treatment is commenced.
  Where only one or  two of the vertebrae  are  affected, and  the dis-
ease is placed  under proper medical, care  in its early stages, a cure
may,  in many instances, be effected, and  little or no deformity remain.
When several of  the vertebrae are involved in disease, even though  a
cure should be effected, very extensive deformity will nevertheless be
the consequence,  rendering the patient, perhaps, a cripple for life. In
those cases in which the disease of the  spine is complicated with tu-
bercular disease  of  the lungs, or with  psoas or lumbar  abscess, the
event is generally sooner or later fatal.
  Tubercular Depositions.—Under precisely the same circumstances
as produce a predisposition to scrofulous disease, and, most  generally,
associated  with the latter,  we find to take place, in  the  texture  of
nearly all the organs, as well as upon the surface of the  mucous and
serous membranes, the formation of tubercles, varying in size and ap-
pearance, either in their different stages, or according to the  particular
tissue in which they occur.   Various opinions have  been entertained
as to their nature and origin, the merits of which it is not our province,
on  the present occasion, to examine into.
  Tuberculous matter has been detected in the blood, a morbid con-
stituent of  which  it  would appear, therefore, to be;  and  it has been
plausibly suggested,  by Carswell, that this matter is  deposited  in the
tissues during the imperfect process of nutrition which takes place in
certain constitutions, or that it is separated  from the blood with the
secretions.
  Rilliet and Barthez, who  have given, in the third volume of their
work on the diseases of children, the most complete and accurate ac-
count of tubercles, as they occur  in early life, describe the crude tu-
bercle as a solid,  homogeneous mass, of  a dull yellowish-white colour
—of  a somewhat moist consistence, and easily  broken or crushed.
When broken it exhibits a somewhat granulated surface.
  Miliary tubercles consist of quite small granules of a round or oval
shape, either perfectly distinct from each other, or collected together
in groups.  In the latter case they gradually augment in size, and often
form  masses of considerable extent, which  not unfrequently include a
portion,  more or  less extensive, of the surrounding tissue.
  The miliary tubercle is most  generally surrounded with a vascular
network, which,  after the  tubercle has  become considerably enlarged,
unites with the surrounding cellular tissue, and forms a kind of fibrous
cyst,  more or less dense.
   Yellow tuberculous infiltration  occurs in the form of  an irregular 
588
DISEASES OF CHILDREN.
mass, the edges of which are confounded with the neighbouring tissue.
The edges extend themselves, by irregular prolongations, in different
directions.   In  their neighbourhood, irregular tubercles  often occur,
which sooner or later become united with one of the prolongations of
the former.  Sometimes  the yellow infiltration assumes more or  less
of a rosy tint, which gives to it the appearance of being traversed by
small vessels.
  The miliary tubercle and yellow infiltration very often, after a time,
become confounded.   The  first, by agglomeration,  forming large
masses, when they can be distinguished  from the first only by the  pre-
sence of the network of vessels by which they  are surrounded.
   Gray granulations occur under the form of very minute bodies, either
spheroidal, or oval,  or flattened and almost lenticular.  They feel be-
neath the  finger like a  small grain, which  is with difficulty crushed
under  the  nail.  Occasionally they  contain a drop of serous fluid.
They may, in some  cases, be detached readily from the tissue in which
they are formed, leaving a small  smooth cavity; in other  cases they
have been found appended to a  filament resembling a vessel.  Their
colour is a decided  gray; but  when removed from the  tissue in which
they are seated, they are  more clear and transparent.   They have this
latter appearance in the  liver, even  when surrounded by the paren-
chyma of the organ.  Their substance is usually homogeneous; occa-
sionally, however, a black point exists  in their  centre,—or they are
surrounded by a circle of black matter, disposed  in very fine ramifica-
tions.  They now and then occur in groups of from three to twenty,
scarcely separated by the tissue of the organ ; thus forming small hard
masses.
   Laennec describes a form of tubercle as occasionally occurring be-
tween the miliary tubercles, in the form of a fine gelatinous infiltration,
either colourless or  sanguinolent.
   The yellow granulation is a  small body, softer, and of a clearer yel-
low colour than the crude tubercle.  It  has  the appearance of a false
membrane.  It cannot be broken  or crushed under the nail.  Its form
depends on the resistance of the  tissue in which it is  developed; thus,
in the parenchymatous tissues it  is rounded, in the  serous, lenticular,
in the pia  mater rounded on the  side of  the brain, and flattened on the
side of the arachnoid. It is invariably surrounded, in the serous tissues,
by a network of blood-vessels.   These  granulations  occur either dis-
tinct from each other, or united in small groups.
   Rilliet and Barthez describe, under the  name of tuberculous dust, a
form  of tuberculation, occurring under  the  appearance of numerous
very minute white or yellow points, not sufficiently close together to
constitute a continuous yellow surface, but strewed through the tissue,
which is almost invariably invaded by an acute  or chronic inflamma-
tion, sometimes by gray infiltrations.
   Rilliet and Barthez state, that  the  origin  of the yellow tuberculous
matter, is  either
   1st.  The gray granulation, which passes into the yellow granulation,
and afterwards into the  miliary tubercle, or yellow infiltration.   The
gray granulation may also pass into the gray infiltration. 
         DISEASES OF  THE NUTRITIVE FUNCTION.      599

  2d. The gray infiltration, which gives birth indifferently to the yel-
low granulation, the miliary tubercle, or the yellow infiltration.
  3d. The tuberculous dust, which may be the origin of the yellow in-
filtration.
  4th.  The yellow granulation, which may appear originally.
  5th.  The formation from the first of crude yellow matter.
  The inflammation, acute or  subacute, of the  organs, precedes, in
a large number of cases, their passage into the condition of the semi-
transparent gray tissue.
  In retracing these facts in a different order, we perceive that the
miliary tubercle may occur originally, or in the gray infiltration, or
succeed to the granulation, gray or yellow.
  The yellow infiltration may occur either originally, or in the gray
infiltration, or it may result from the union of the yellow granulations
or the tuberculous dust. The large tuberculous masses result from the
development  and union of the partial infiltrations, or of the miliary
tubercles.   The crude yellow tubercle  succeeds  to an inflammation,
only through  the intermedium of the semi-transparent gray tuberculous
matter, and perhaps of the tuberculous powder.
  The yellow tuberculous matter may soften and  become  reduced to
a fluid state, or it may become dry and pass  to the stony or cretaceous
condition.
  When the  tubercle becomes softened,  and  an inflammation, followed
by suppuration, occurs in the surrounding tissue, there results a  cavity
varying in extent and  form, the parietes of which  may be lined with
a soft tuberculous tissue, and  its  cavity filled with a  mixture of pus,
tuberculous matter,  and the debris of the organ in which the cavern is
seated.
  In the serous membranes, tubercles manifest less tendency to  soften-
ing than in other situations, and it is a  remarkable fact, which Rilliet
and Barthez  have found to be invariable, that perforation of the  serous
membranes resulting from the softening of tubercles, is occasioned by
the softening of those seated on their external surface, which also have
a tendency to perforate the natural  canals with which  they  are in
contact.
  More extended consideration of the successive changes which take
place in the several forms of tubercles,  and  the various causes which
tend to promote their growth and softening, belongs  to a  treatise on
general pathology.
  Tubercles  are  incapable of  organization, but appear to have the
power of exciting certain morbid actions in the parts in which they are
seated, which affect their own softening, while it produces disorgani-
zation of the  latter.
  It has been supposed by some, that in every instance of scrofulous
disease, the peculiarities of the latter result from the deposition, in the
affected tissues, of tuberculous matter, modified  in its appearance and
mode of deposition by the particular structure in which it occurs.
  Tubercles  may occur, during childhood, in almost every organ and
tissue of the  body.
  The organs which most frequently  present tubercles, are also those, 
590
DISEASES  OF CHILDREN.
in general, where tubercles occur to the greatest extent.  These are, in
the order of their frequency, the lungs, the  bronchial glands,—then,
at a  long  distance,  the  mesenteric  or  abdominal glands, the  small
intestines, liver, &c.
   As regards the general distribution of tubercles in  the  different or-
gans, the more nearly children approach the  age of puberty, the more
generally do we find tubercles limited to the  lungs and intestines, and
to present the same aspect as in  the  adult.  In younger children, we
find occasionally, all the  organs studded with  small, gray granulations,
which, if united in  one  organ, would form a considerable mass, but
disseminated throughout, they do not profoundly alter any one; or,
miliary tubercles of a uniform size occur in all the organs, constituting
a larger  mass than in the previous case; or, in a third  set of cases,
considerable quantities of yellow granulations are present in  several
organs, causing at times a degree of disorganization which is sur-
prising.   These three forms  may be partial or general,—the  latter
most  frequently partial,  the others more frequently  general.  As an
almost invariable rule, the number of organs at the same time invaded
by tubercles, is greater in children than in adults, and certain organs,
which at a more advanced age  are  rarely the  seat of tubercles, are
particularly so  in children.
  The pathological  influence of  tubercles upon the  tissue in which
they are  deposited, it is not easy  to understand;—they would appear,
however, to predispose it to the occurrence of inflammation of a sub-
acute character, and of which it modifies, to a certain extent, the phe-
nomena,  progress, and results.
  Whether, in  any instance, tubercles  can be considered as an ex-
citing cause of disease, is uncertain.   In numerous instances we have
met with them after death, in cases  in which, during life, there  were
no indications to lead us to suspect their existence.   They are,  more
probably, in  many cases, the result, rather than  the cause of diseased
action.
  The general  symptoms indicative of the existence of tubercles vary
somewhat  with the  organs in which they chiefly occur.  Usually,
however, there  is paleness of countenance, general progressive  ema-
ciation and debility, a dry, rough, harsh  state of the skin ; often  re-
peated desquamations of  the cuticle, and oedema of the face, lower ex-
tremities, or scrotum.    Usually,  in  the course of protracted  cases,
hectic fever occurs, with  circumscribed redness of the cheeks, evening
exacerbations, and more  or less profuse night sweats.
  Tuberculization of the Bronchial Glands is almost peculiar to
childhood.   It is a frequent and serious affection, giving rise to symp-
toms with difficulty distinguishable from those of tubercular phthisis.
  The enlarged bronchial glands  may act mechanically on the neigh-
bouring organs contained  in  the  chest, or they may perforate them.
Hence result a variety  of symptoms depending  on  the position or
function of the injured part.  Thus, the aorta and pulmonary artery,
the vena  cava,  or the pulmonary  veins, may be compressed by the tu-
berculated  glands, and the flow of blood be more or less impaired.
M. Tonnelle has related  a case in which the  superior cava was com- 
DISEASES  OF THE NUTRITIVE FUNCTION.
591
pletely obstructed, and Dr. Green  has  seen  one where the pulmonary
artery was perfectly flattened between two enormous glands.   From
this compression of vessels may arise, pulmonary apoplexy, fatal hae-
morrhage, effusions of serum, or symptoms closely resembling those of
organic disease of the heart. The trachea, bronchial tubes, and lungs,
may be compressed, and in such cases the symptoms will vary consi-
derably, according  to the seat  and extent  of the mechanical lesion.
When the  enlarged glands  act on the lower portion of the trachea,
Rilliet and Barthez have  noticed  the existence  of  a loud, sonorous
rhonchus, which persists for a considerable length of time.  In other
cases, the pressure on the large bronchial  tubes causes more or less
feebleness of the respiratory  murmur, which is remarkable in being in-
termittent.
  Pressure on  the eighth pair of nerves or its branches, is often at-
tended by very peculiar modifications of the voice, and cough.  The
former is hoarse or  occasionally subdued, and even lost, or the  hoarse-
ness and loss of voice may alternate.  The cough, also is frequently
hoarse, or  occurs in fits, which bear a close resemblance to  those of
hooping cough, but are not followed by vomiting; or  the fits may
simulate an access of  asthma, with  great  oppression of breathing,
anxiety, agitation, congestion of the head, and cold viscid sweats.
  The enlarged or  softened glands may  give rise to another order of
symptoms, by perforation of the neighbouring parts.  Thus, fatal hae-
morrhage may arise from perforation of  the pulmonary artery; pneu-
mothorax, from perforation of the lung;  difficulty of deglutition, and
an access of cough on swallowing, from perforation of the oesophagus;
but we should  observe, that these symptoms may equally depend on
the pressure of tubercular matter, or of a cavern in  the lungs.
  On the subject of the diagnosis of this form of phthisis, Dr. Green
remarks :—Whenever a child presents  several of the rational symp-
toms of consumption, without our being able to  detect  any physical
signs of the presence of tubercles in the lungs or abdomen, we have
good reason to suspect that the bronchial glands are tuberculated. As
long  as the case continues to present this simple aspect, we cannot go
beyond suspicion; but it rarely happens that the glands acquire a con-
siderable degree of development,  without acting on  the surrounding
parts or tissues.
  As these become  successively involved we have a series of  varying
symptoms, which could  not arise from any other source.   The eyelids
become oedematous, and in proportion to  the degree  of pressure on the
vena  cava, the oedema extends to the  whole of the face, which  is
sometimes pale, sometimes tinged with venous injection.  This oedema
will appear and disappear several times  during the course of  the dis-
ease.  The cough suddenly  changes  its  character, and occurs in fits,
like those of hooping cough; the voice gets hoarse, and for days may
be altogether lost; fits of asthma or of suffocation, as if the heart were
diseased, occur.
  On examining the chest, we hear a loud sonorous rhonchus, which
persists for a length of time, and  then disappears, or is replaced by
other rhonchi  of.an  anomalous character.   When  these symptoms 
592
DISEASES  OF CHILDREN.
are superadded to the rational signs of phthisis, we can have little hesi-
tation in deciding that they arise from tubercular enlargement of the
bronchial glands.
   Tuberculization of the Lungs.—All the forms of tubercular matter
may be developed  in the lungs of children.  Pulmonary phthisis is, in
fact, a very common complaint at this age.
   The main character which  distinguishes  the phthisis of children
from that of adults, is the much larger surface  of the lung the tuber-
cular deposition occupies, its more rapid secretion, and its more fre-
quent complication with  tubercular disease of other organs.   Hence,
children affected with phthisis  often  die before the complaint has ar-
rived at its third stage, while the modifications produced by an exten-
sive diffusion of tubercular matter, often render the diagnosis obscure
and  difficult.   We  have, in addition, the peculiarities  occasionally
induced by extensive tuberculization of the bronchial glands.
   The physical signs are rarely as well marked as in the adult, and
the young child frequently dies before the practitioner is able to decide
whether the lung is actually the seat of  cavern  or not.   The  cause of
this is, the tendency of the  tubercular matter in children to implicate
many important viscera; thus in the brain it may excite meningitis;
beneath the serous  membrane of the chest, pleurisy; in the abdomen,
peritonitis ;  in  the intestines, ulceration.   These complications rarely
fail to undermine the resisting  power of the little  patient; diarrhoea
sets in, and death ensues, long before the period at which a fatal termi-
nation takes place in the adult.
   There is an important modification that should guide the practitioner
when he seeks to determine  the existence of a cavern in young chil-
dren,  viz.: that  under  five years of age, the cavernous excavation is
generally  seated in the lower or  middle lobes,  and is almost  always
confined to one side of the chest.
   Infants  and children  under five years of age, hardly ever expecto-
rate.  They swallow everything that comes up into the mouth from
the lungs. Haemoptysis is an exceedingly rare symptom. The pheno-
mena which constitute  hectic fever,  are, also,  seldom  present in so
marked degree as in the adult.
   Tubercles occur very  frequently in the  brains of children, and are
intimately connected with many of their cerebral diseases.  They may
form at almost any period of infancy or childhood, but  are  rarely met
with previous  to the first year, and would appear, according to the
observations  of Green, to be most common hetween the third  and
seventh years.   In  many cases, they give rise to no symptom during
life; in  others,  merely to a periodical headache or to  deafness, com-
bined with purulent discharges from the ear. The most common symp-
toms, however, to which tuberculous depositions in the brains of chil-
dren give rise, are  headache, vomiting, convulsions, amaurosis, para-
lysis,  and diminution of the intellectual faculties.   Death generally
takes  place from  acute  hydrocephalus, softening of the  brain, con-
sumption  of the lungs, or from the occurrence of some  accidental
disease, as small-pox, &c.
   The chronic stage of cerebral tubercles varies in duration from a 
DISEASES OF THE  NUTRITIVE FUNCTION.
593
few weeks to two years.  In one class of cases, the disease commences
with headache, followed  by various lesions of sensibility, or of mus-
cular power.  The headache  is often very severe and obstinate, pre-
venting sleep, rendering the  child fretful, peevish,  or  morose, and
causing sometimes the  utterance of acute cries, similar to those  in
cases of hydrocephalus.  The pain is  commonly seated  in the fore-
head;  in a  few cases, however,  in which the  tubercles occupy the
cerebellum,  it is experienced  in  the occiput,  and extends downwards
towards the neck.  The  attacks  of headache are, occasionally, asso-
ciated  with  vomiting, which recurs on each exacerbation  of the pain,
and is  independent of any disorder of the digestive organs.  Constipa-
tion occasionally occurs, but less frequently than  vomiting.
  The symptoms which succeed, consist, chiefly, in lesions  of the
senses, of the muscular power, or of the intellectual faculties; as, loss
of hearing,  dimness  or  total  loss of vision, and a diminution of the
cutaneous sensibility on one side of the body.  Convulsive movements
may occur at irregular intervals, and terminate in partial or total para-
lysis of one or more of  the limbs; in other cases, we have merely a
weakness of certain muscles, not amounting  to paralysis—the child
stumbles as it  walks, and progression is  much impeded;  particular
muscles, also, may be affected; thus, there may be a  peculiar convul-
sive  movement of the muscles of the  eyeball:—in a few cases, stra-
bismus occurs.  The child's  temper may undergo a  notable  change,
and  the  intellectual powers may become dull; but the disturbance  or
loss of the latter is rarely observed, except in cases of long standing,
and towards the close of the disease.
  The various symptoms just noticed, are  seldom  permanent; the
headache often disappears, after having existed several  months, and
again returns;  the strabismus and amaurosis  may also disappear, but
the paralysis is generally permanent, especially when it occurs in the
limbs.
  In another class of cases, there is a  sudden occurrence of convul-
sions, or an attack of true epilepsy; these recur  at regular intervals,
and gradually terminate  in paralysis or coma.  The convulsions may
be general or partial, and are often followed by contraction of one  or
both extremities of the  same side, or, the head may be drawn on one
side, and remain in  that position for a considerable length of time.
Sometimes the convulsions commence with a  nervous tremor  of one
arm, which may last  for several weeks, and then terminate in epilepsy.
In other cases, several  attacks of convulsions may be followed by a
peculiar rotatory motion of the head, and in others, by squinting, and
a lateral motion of the  lower jaw.  According to Green, the  convul-
sive attacks are rarely attended with either vomiting  or constipation;
our own observations would, however, lead us to a different  conclu-
sion: vomiting we have certainly found  to be as frequent in these  as
in the former cases.
  In a third class of  cases, the first symptom of disease is a paralytic
affection of  one or more  muscles, or organs of sense.
  In the acute forms of cerebral tubercle, there is  a succession  of
symptoms of an irregular character, and more or less allied to those
                               38 
594                DISEASES  OF CHILDREN.
of acute  hydrocephalus,  or softening of the brain.  Sometimes an
attack of general convulsions terminates in fatal coma, or it may be
so violent as to cut off the patient in a few hours.
  Upon dissection,  tubercles, varying in  size from that of a small nut
or bean, to  that  of a hen's egg, are found, most generally, in the sub-
stance of the hemispheres, either of the cerebrum or cerebellum, or of
both, and occasionally in  the cerebellum and pons varolii, or in the
latter alone.  Tubercles of the brain often coincide  with tuberculation
of the meninges, producing a marked influence upon the general symp-
toms of the  case.  The tubercles are often single, often  numerous;
twenty to fifty have been observed by Green in one brain;  but by Ril-
liet and Barthez,  never more than from fifteen to twenty.
  In many  cases, even when the tubercles are of considerable  size,
we are unable to discover the slightest change in  the surrounding
nervous  substance,  or  in  the neighbouring membranes.  The gradual
development of the tubercular mass  seems to pass unheeded  by the
central nervous system.  In other cases,  the membranes  adhere to the
cortical substance,  over the site of the tubercle, and are more or less
infiltrated and thickened.   Sometimes, when the tubercle is large, the
convolutions are flattened or completely effaced.
  The colour and consistence  of the nervous substance, immediately
surrounding the tubercle, present a great variety of modifications:—
there may be slight injection and softening to the depth of  a few lines
only ; or the softening of the nervous tissue, with  or without injection,
may extend to the  central parts of the brain; in some  cases, nearly
the whole of the cerebellum is reduced to a mere pulp. In these cases,
effusion, often to a very considerable extent, takes place within the ven-
tricles, which it distends;  and traversing the ventricular  membrane,
infiltrates and softens the cerebral substance. In a few rare examples,
on the contrary,  Green describes the surrounding  nervous tissue as
being more  pale,  and  of a denser structure than natural;  sometimes
it is soft, and of  a  straw  colour.  Abscess, or true  infiltration of  pus,
in the immediate vicinity of cerebral  tubercle, is rarely, if ever  ob-
served.
  Tubercles of the brain  are  very generally associated  with other
scrofulous indications.   The first dentition would appear  to be their
principal epoch, though in many cases, they will  be found  to succeed
to acute or chronic affections of the  gastro-intestinal mucous mem-
brane, or to the exanthematous fevers.
  Treatment of Scrofula.—There is no specific for the cure of scro-
fula.  If we are correct in our views, in regard to its pathology—if
the morbid  condition of the system  depends upon  a defective assi-
milation and sanguification, by which  the blood is  rendered deficient
in its healthy organization,  and nutrition is, in consequence, imperfectly
performed:—if the whole of the organic functions are inactive;  it is
evident that our endeavours should be entirely directed to improve the
condition of the blood, and render nutrition more active and perfect,
and, in  this manner, to correct the  morbid constitution of the body,
which constitutes the essential foundation of the disease.
  Medicinal agents, however important  and essential they may often 
         DISEASES OF  THE NUTRITIVE FUNCTION.      595

become, for the removal of certain  morbid symptoms, are not to be
considered as those upon which our chief dependence is to be placed
in effecting that change in  the  condition of  the  organic functions,
which is essential in order to improve the general tone and vigour of
the system;—this can only be done by placing the  body under the in-
fluence of those natural agents, by which alone its healthful action is
to be promoted and sustained.  From alteratives and tonics, we can
expect but little, but from a proper diet, pure fresh air, sufficient exer-
cise, cleanliness, and proper clothing, in  conjunction with a due regu-
lation of the moral and intellectual  powers,—when sufficiently early
resorted to, the most prompt and decided benefit  will be invariably
derived; and without their influence, under no circumstances, can we
expect to prevent the inroads of painful and destructive disease, or to
arrest its progress,  after it has occurred.
   In regard to every child, the same hygienic agents are  essential to
preserve and  promote the health, vigour, and regular development of
its frame; but in one who is delicate from birth, or who  exhibits, at
an early period, the striking characteristics of the lymphatic tempera-
ment, with languid  circulation, and a predominance of the white fluids
and tissues, they become doubly important; their neglect will then
endanger  the  occurrence, sooner or later, of serious and even fatal
disease, while proper and unremitting attention  to them will  seldom
fail to improve the constitution of the blood, and render nutrition more
active and healthy.
   We have, in the commencement  of the present treatise, entered,
with sufficient minuteness, into a consideration of the hygienic manage-
ment of children, to render it unnecessary, in this place, to go into fur-
ther details;—we need  only add a few remarks, in  regard  to it, so far
as it respects such patients as already present indications of the inva-
sion of scrofulous disease.
   Air, exercise, and proper nourishment are, in these cases, our chief
remedial  agents.  Animal food,  with a proper mixture of the more
readily-digested farinaceous vegetables, will, in general, be  essential,
after the child  is weaned; but previously to this, the  only  appropriate
diet is the breast-milk of a perfectly healthy nurse.  The proper species
of animal food, and the manner in which it is cooked, require, also, to
be attended to.  Beef,  mutton, venison, chickens,  turkeys, and most
kinds of  game, fresh  laid  eggs, and  fresh  milk, with stale bread,
crackers, potatoes, and rice, should constitute almost the  exclusive
diet, in the cases referred to.  In regard to cookery, the meats should
be plainly roasted,  broiled, or boiled, or the beef  may be eaten, in the
form of steak, and the  mutton, in that of chops.  The milk may be
taken without any preparation,  or  simply boiled,  according as it is
found to agree with the patient's stomach; it may, also, be  taken occa-
sionally with  mush, boiled with rice and sweetened, or with eggs, in
the form of plain custard, or with rice or bread, in the form of plain
pudding.   The eggs should be boiled, but not hard.   The bread should
be of wheat, or  wheat and Indian,  and not eaten until  twenty-four
hours after it  is baked.  The potatoes should be roasted,  in  which
form they are easier of digestion, and agree better with the stomach, 
596
DISEASES OF CHILDREN.
 than when boiled.  In  regard to  condiments, these should consist of
 salt and cayenne pepper  for  the animal  food, and of sugar, and per-
 haps cinnamon or nutmeg for the preparations of milk.   The condi-
 ments, however, should be  used  in  moderation,  and rather with the
 view of imparting an agreeable relish to the food, than for the purpose
 of stimulating the appetite.
   While  a  sufficiency  of food is allowed properly to nourish the sys-
 tem, caution must invariably be exercised to prevent its being partaken
 of  in too great quantities at  a time, or too frequently.  No general
 rule can be laid down in respect to these important points;  much will
 depend, in regard as well to the quantity of food, as to the frequency
 of the meals, upon the condition of the patient's stomach, his age, and
 the particular circumstances of his case.
   For drink, nothing  should be allowed but pure water or toast water;
 we  say pure water, for there  can be  no  doubt, that impure, water is
 decidedly prejudicial to health, and some have  even supposed, that
 hard water is a cause of scrofula.  The effects of the water habitually
 used as  drink, like that of the air we breathe, though  insensible, are
 not the less certain  and powerful:—the quality of the water made use
 of,  during health as well as in disease, merits more attention than has
 generally been paid to it.
  By most of the English  physicians, an occasional glass of good beer,
 porter, or wine is recommended, but to this we must positively object.
 Alcoholic drinks, whether  fermented or distilled, are not in any degree,
 calculated to  promote  digestion, nor to improve the nutrition of the
 organs, while they have a decided tendency to promote habits, which,
 in after-life, may even  prove  a greater curse than  the worst effects
 that can result from  that defective  state  of the organic structure, in
 which we have presumed  the  tendency to  scrofulous disease mainly, if
 not entirely, to consist.
  Pure  and fresh air  is as essential  as proper and sufficient nourish-
 ment.  It is  too much  the custom to confine, within doors, the weak
 and delicate, whereas of all persons they the  most  demand frequent
 exposure to the open  air;  and, with  proper clothing and due precau-
 tion, such exposure  may, with  great propriety and decided advantage,
 take place in children of four  or five years of age, even in the colder
 season of the year, during perfectly clear weather.  Even when the
 weather  is such as to prevent the child from being taken out, the ad-
 vantages of a fresh  and pure air may be afforded it by proper ventila-
 tion, the  strictest attention to  domestic cleanliness, and by guarding
 against over-crowded apartments, by night as well as by day.  Where
 we can  command it, the atmosphere of  a dry elevated  situation in the
 country should always  be preferred to the atmosphere of a large or
 crowded city.
  In connexion with  the  subject  of  air, is that of  exercise, a proper
 daily amount of which should  invariably be taken out of doors.   The
 exercise  must, of course,  be adapted  to the strength and  age of the
 child, but should always  be as active as can be  allowed,  without the
fear of its inducing undue fatigue.  Sir Astley Cooper states, that he
has seen five hundred cases of scrofula, in the course of a single year, 
          DISEASES OF THE  NUTRITIVE FUNCTION.      597

with scarcely a boy among them, and this, from the circumstance that
boys will take exercise, while girls are not allowed to.
   As a  substitute for exercise, in  cases in which the debility of the
patient is so great as to render a sufficient amount of such as is of a
more active kind impossible, friction  of the surface, repeated daily,
either with the hand, or a proper  flesh-brush or cloth, will be useful;
and, in all cases,  it will be proper, even  in  connexion with  exercise;
but it can never supply fully the  place of the latter, when taken in a
pure fresh atmosphere.
   For young  children, the usual sports of their age—riding occasion-
ally in an open carriage—short walks or jaunts, with some  pleasing
and moderate occupation of the  mind,  in  the intervals, will suffice.
For older children, various recreations present themselves, of an inno-
cent character, which call  into sufficient exercise the muscles of the
body.  Riding on horseback is a very admirable  mode of exercise for
those sufficiently old  to partake of it with safety; especially for girls,
who cannot easily obtain a sufficient amount in any other manner.
   Frequent bathing will be necessary,  as well for the  maintenance of
personal  cleanliness, as to promote and maintain the  regular actions
of  the cutaneous exhalants.  The warm bath should  be employed,
when the temperature of the surface  is deficient, with considerable
languor of the circulation ; but in patients possessed of greater vigour,
and in whom the temperature  of the skin is  better  maintained, the
tepid bath may be substituted.  Sponging the surface with tepid water
or with salt  and water, followed by brisk friction, will also he  highly
beneficial.
   A bath of sea-water, when practicable, may be taken three times a
week, at eleven o'clock in the morning.  The temperature of the bath
should be ninety-four  degrees, and  the child  may remain in sixteen or
twenty minutes;  after which friction to the  skin may be employed, or
a walk taken.   A child may be brought to bear the bath by sponging
or sprinkling the surface daily with tepid water.   Bathing in the open
sea, when it can  be  borne  without producing  languor  or chilliness,
will unquestionably be proper, in the generality of cases.
   Against cold bathing, which is  recommended by writers of even a
recent date,  we most positively protest; the idea of its exerting a direct
tonic effect has originated in false  views, as well of the  action of cold
upon the human system generally,  as of  the particular circumstances
under which  the  reaction it gives  rise to, invariably occurs.   To im-
merse a  weakly child in cold water, would be more likely to produce
and increase  the tendency to scrofulous disease, than to prevent it, if
it did not cause more immediate, and even more dangerous results.
   In regard  to clothing, this  should be  accommodated to the tempe-
rature of the  season,  and  adapted in quantity, material, and  form, to
preserve, as far as possible, a uniform  temperature of the surface:—
guarding against  the slightest sensation of chilliness in cold or change-
able weather,  and too much  heat or excessive perspiration during the
summer.   As  a  general rule,  liable, however, to some exceptions,
flannel  next the skin should be worn  during the autumn and winter, 
598
DISEASES OF  CHILDREN.
and late in the spring;  for the remainder of the  year, coarse muslin
may be substituted.
  The mind should be occupied and amused, without being fatigued,
or too  much excited;  and every means calculated to promote cheer-
fulness, buoyancy of disposition, and equanimity of temper, should be
put in requisition, and every depressing influence carefully removed.
  When there exists considerable  torpor of the digestive  functions,
and constipation of the  bowels, with dark-coloured, or pale, clay-like,
unhealthy evacuations, it will  be proper, at  an early period, to endea-
vour  to excite the whole alimentary canal  to a more healthy action.
Purgatives will, in general, be required.  Rhubarb and  magnesia, the
compound powder of jalap, or in older children, the blue mass, com-
bined with rhubarb and ipecacuanha, will generally answer our pur-
pose, or an occasional dose of calomel combined with magnesia, and
followed by moderate doses of senna tea, of the compound powder of
jalap, or of the sulphate of magnesia, may be employed.  The article
which has answered best in our hands, has been the compound powder
of jalap.  This was a favourite prescription  with Dr. Physick, in scro-
fulous  disease of the hip joint:—he  gave  it every day or every second
day, so as to keep up  a steady and tolerably brisk action upon the
bowels; under its use we have known the health and strength of the
patient rapidly to improve, and his  attenuated limbs  to become aug-
mented in bulk, and  increased in  firmness.  Of course, the doses of
the purgatives employed, and the  frequency of their repetition, must
be governed entirely by  the  age  of the child, the condition  of the
bowels, and the effects produced.
   In many cases, after the bowels have become more regular, and the
stools of a more healthy appearance, some  light  tonic  may be given,
with the view of improving the digestive  powers of the stomach.  The
proto-carbonate of iron may  be administered, in the dose of a few
grains combined with the sulphate of quinia, daily, for a short  time;
or, we may give the carbonate of  iron with  rhubarb, and a  little
orange peel ;a or the following, which is a good preparation for the
same purpose.b   We  may remark,  that preparations of iron appear to
constitute the best tonic, in that state of the  constitution which predis-
poses to scrofula.

* R.—Carb. ferri, gr. xxxvj.—3j.          b R.—Sub. carb.  sodae desiccat. gr. xlviij.—
     Pulv. rhcei, gr. xxiv.—3ss.                9iijss.
     ----cort. aurant. 9ij.—M. f.             Pulv. calombse, gij.
       chart. No. xij.                      ----rhcei, 3ss.—M. f.
  One for a dose daily, or twice a day.           ch. No. xij. (A. Cooper.)
                                           To be given as the last.

   During the exhibition of these remedies, whether purgative or tonic,
constant attention  should be  paid  to the diet, and general hygienic
management of the child.
   We have, heretofore, presumed that the symptoms of local disease
have  not presented themselves; that the  child is  merely labouring
under  a state of general debility, the result of imperfect assimilation
and haematosis, and deranged or deficient nutrition; and that our only
indication is to improve digestion, render sanguification more perfect, 
DISEASES OF  THE NUTRITIVE FUNCTION.
599
      and the nutrition of the solids more regular and complete.  It is true,
      that, in every case and stage of scrofulous disease, this indication is
      still to be fulfilled; but the mode of fulfilling it will demand some im-
      portant modifications, according to the  particular circumstances of
      each individual case.
         When the usual symptoms of gastro-intestinal disease are present—
      tenderness of the epigastrium or right  hypochondrium, loss of appe-
      tite, nausea, irregularity of bowels, dryness and increased heat of the
      surface, and  a red dry tongue—animal food  should  be forbidden—a
      moderate quantity of some of the  lighter farinaceous preparations—
      weak chicken water or whey, with gum, barley, rice, or toast water
      for drink—should constitute the diet, until the above symptoms are re-
      moved.  The treatment of the gastro-intestinal disease is to be con-
      'ducted on general principles—leeches, according to  circumstances—
   *  warm fomentations—minute doses  of calomel  and  ipecacuanha,  with
     • the occasional interposition of a saline purgative, among which one of
    s the best is probably the citrate of magnesia.
 ,■        The nitrate of potassa  has  been  highly spoken of as a remedy in
      cases of gastro-intestinal disease occurring in subjects presenting a
 i*    tendency  to scrofula, and it is asserted by Todd, that, when combined
 £   ^ with mercurials, the efficacy of the latter is increased.  We have used
      it, in many cases, in small and repeated doses, with certainly  very
      good effects.
 ,  "^    During the continuance of  disease of the digestive mucous  mem-
i     brane, active exercise will be improper; indeed, friction of the surface,
      repeated daily, will, in the majority of cases,  have to  be substituted
  y*  for exercise of every species.
 ■   *     After we have succeeded in completely removing  the  irritation or
|y|    subacute inflammation of the alimentary canal, the diet of the patient
 u   should  be gradually and cautiously improved—chicken  water, beef
 %   tea, afterwards the gravy of meat,  then broths, then small portions of
  'p> I chicken, or mutton, or beef, may be allowed until a full  animal  diet
 ff  ' can be taken, with safety.  At the  same time,  the use of tonics  may
  ¥   be entered upon, with benefit,  when, if they had been given previously,
  (** they would have rather tended to  augment  and confirm than to re-
   *' move effectually the debility of the system.  The chalybeates, as already
      remarked, either alone or conjoined with weak cold infusions of bark,
    # infusion of chamomile, or the colomba in substance, will be among the
 •J  best tonics, in these cases.  The proto-carbonate or the ferrum  tarta-
    * risatum, or a combination of the latter  with small doses of carbonate
  ,. ■%, of iron, or the nitrate or sulphate of potassa, may be given, or the tinc-
     „ ture of the sesquichloride of iron combined with iodine;1  or we  may
      employ the iodide of iron.
 Cm                        d R.—Tinct. ferri sesquichlor.
 '"  *                         Tinct. iodine, aa. 3ij.
   ^                            Aquae puree, 3ss.—M. (Todd.)
      Dose,—thirty drops, three times a day, for a child ten years of age,  and a smaller portion
                                 for those younger.

        These articles should be administered for several days in succession
      and then intermitted for a day or two, the bowels being, in the  mean 
600
DISEASES  OF  CHILDREN.
time, kept regularly open, by means of occasional doses of some mild
purgative; and at the same time, the  child should  be placed upon  a
proper hygienic treatment, without which tonics, however judiciously
selected or long continued—and in general, to derive from them their
full effects, they must be  persevered in for a length of time—will  be
productive of little  or no  good.
   By Dr. Phillips, the curative power of barium, in scrofula, is consi-
dered as little, if at all inferior to those of iodine.   Its field of useful-
ness is, however, more limited.   The  barium seems to him  to be  a
more certain stimulant, or he might even say irritant, than iodine, and
consequently its use is clearly contra-indicated where there is  much
inflammatory excitability of the system;  but, in cases marked  by  a
tallow-like complexion, pale tongue, languid  circulation, and  irritabi-
lity of the mucous  surfaces, its good effects will  often be very decided.^v
Dr. Phillips usually gives it in solution, one grain to an ounce of dis-  f
tilled water, with ten drops of compound tincture of gentian.  Of this V\
solution he commences with half an ounce, twice a day;  on no occa-  -^-^
sion has he exceeded three grains in the  day, and he has never expe-
rienced any check  in the administration of the remedy.
   The solution of caustic potassa, the same gentleman is satisfied, has,
in many instances, exercised a salutary influence, and these are most-
ly cases in which  much acidity pervaded the  secretions,  and acted
upon the general economy.
   There is scarcely any  form of scrofula he has not seen  to improve
under the use of cod-liver oil, but he seldom was able  to  carry it far
enough to produce any considerable amelioration; he considers that
its good effects result from  its improving digestion and nutrition.
   Cod-liver oil as  a remedy  in  scrofula is  spoken of in favourable
terms by many  practitioners.  According to Rilliet  and Barthez,  it
possesses at once tonic and discutient properties.  Notwithstanding its
disagreeable taste  and odour, children exhibit  to  it  no great repug-
nance.   It may be given to children three years of age in the dose off
from one to two dessert-spoonsful, and from three to four, to older chil-
dren, combined with some aromatic.
   The following are the  formulae recommended by Tourtual.
  R.—01. jecoris aselli,  3ij.—5iij.           R.—01. jecoris aselli, 3j.
      Gum. acaciae, q. s.                     Liq. carb. sodae, gij.
      Aq. fbenelic. 3j.                       Ol. calam. aromat. f^fiij.
      Syrup, cort. aurantii, 3ss.—M.           Syrup, cort. aurantii, gj.—M.
  Dose, a teaspoonful every three hours.     Dose, one to two teaspoonfuls, morning and
                                                evening.
                       R.—01. jecoris aselli, 3ij.
                           Vitell. ovi, No. j.
                           Syrup, menthi,                              * ~*
                             "   flor. aurant. aa. gij.—M.                 .
                      Dose, a dessertspoonful three times a day.              ^^h
   The remedy should be continued, in order to derive from it its  re-^\
medial effects, for  many  weeks or even months.                        ^

   When  enlargement of  the  lymphatic glands occurs, so long  as the
swellings remain  indolent, no other treatment  is  required than that
which is  calculated to improve the general condition  of the system.
* 
DISEASES OF THE NUTRITIVE FUNCTION.       gQl
   Iodine, both internally and locally, has, by many writers, been con-
sidered almost a specific, in  these, as well  as in most of the  local
affections of a  scrofulous character, while others  consider it of very
little  value in any of  them.  We have never, certainly, seen those
striking effects  produced  by its use, reported  to have been  observed
by others; the evidence in its favour is  too strong, however, to allow
of our doubting its curative powers  in many cases.
   The solution of Lugol is,  perhaps, the best form  in which the iodine
can be given  internally," or  we may employ the iodide of iron.b  Ex-
ternally, iodine may  be used, in the  form of solution,0 or of ointment.d
  a R.—Iodin. 9j.                       b r,—Ferri iodid. gr. v.
       Potassi iodidi, 9ij.                     Aquae destillat. gj.—M.
       Aquae destillat. 3viij.—M.         Dose, a  teaspoonful, three times a day, in
For children under 6even  years, the dose is   sugared water;  gradually increased by
  two drops, twice a day, gradually increas-   adding ten drops, daily,  to each dose,
  ed to five drops.  From  the age of seven   until the dose amounts to two teaspoons.
  to fourteen, sixteen drops, twice daily, in   ful.
  sweetened water.
   c R.—Iodin. 3ij.                      d R.—Iodin. gr. xij.
       Potassii iodidi, 3iv.                     Potassii iodidi, 3ss,
       AquEe destillat. 3v.—M.                Axung. 3ij.—M.

   The state of the bowels  should be attended to, agreeably to the  di-
rections already given.
   When the enlarged glands become painful and sore to the touch, the
ordinary  local applications for the removal of  inflammation should be
resorted  to.   In many cases, a  few leeches  will  be  useful;  but, in
general, we may trust  to  cooling or evaporating  lotions, or the solu-
tion of the acetate of lead.
   As soon as a tendency  to suppuration is evinced, an ordinary emol-
lient poultice  should  be applied, and when a distinct fluctuation is de-
tected, an opening, transversely,  in the direction  of  the  folds of the
neck, should be made with a lancet:—this will often prevent extensive
ulceration, and its consequent  unsightly scar.  It is true, that even
after  suppuration has taken place, the contents of  the abscess will oc-
casionally be  absorbed, and the tumour disappear without rupturing;
we are not, however, perfectly convinced, that this result  is always to
be desired:—after matter is formed  in a scrofulous  gland, we confess,
that we should  prefer its discharge  to its absorption.   After the open-
ing of the abscess, a common poultice is one of the best applications
that can be made to  the part.
   When  ulcerations  form and show no disposition  to cicatrize, a solu-
tion of the sulphate of zinc—one grain to the ounce  of  water—will
often  be  found useful  to  promote their healing; in some cases, how-
ever,  it will  be necessary to touch the edges of  the ulcer with the
nitrate of silver.  When very irritable, the ulcer may be washed with
a weak solution of the nitrate of silver, and then covered  with a  poul-
tice of  bread  and  water.   In these cases, poultices  of the  leaves of
hemlock, or of sea-weed,  have been recommended; but our great ob-
ject should be to correct the condition of the general system, for until
this is effected, the  ulcers  seldom,  if ever, are found to  assume a
healthy appearance,  and to heal perfectly. 
602                DISEASES OF  CHILDREN.
  A hard, indolent  tumour will  sometimes remain subsequent to the
cicatrization of the ulcer, the discussion of which  may be  attempted
by some one of the various ointments of iodine; so long  as any pain
or tenderness remains in the part, however, the  use of these will be
improper; and, if pain or irritation arise during their use, they should
be immediately discontinued, and soothing  applications resorted to.
  In cases of Scrofulous Ophthalmia;  if the affection of the eye is recent
and acute, the application of a few leeches to the temples, and  to the
external angles of the eye, will often  be advantageous; but in -cases of
a decidedly chronic character, or which have already existed for some
time, leeching will not only be  useless, but often decidedly injurious.
In cases of a very acute character, in which there exist considerable
redness and  pain of the eye, and a decided febrile reaction, it may be
even necessary to repeat the leeches; but,  in every instance, we must
be cautious not to carry the depletion too far.
  The best local application, when the eyes are very red  and painful,
is the crumb of bread wet with cold  water, during the day, and a por-
tion of alum curd, enclosed in a fine muslin bag, during the night.  The
eyes should  be invariably shielded from the direct rays of light, by a
broad, deep-green silk shade, so shaped that it may stand out well from
the forehead, and admit the access of  air to the eyes.  This management
of the shade is of great importance;  as those usually employed, which
are small and lie close to the eyes, do more harm than good.  (Maun-
sell.)   All local  applications of an astringent or stimulating  character
are not only wholly useless, but  decidedly improper; we have repeat-
edly seen them keep up the pain and redness of the eyes,  which have
rapidly improved in appearance so soon  as  such applications were
discontinued, and a poultice of bread and water substituted.
  When the appetite is variable  and capricious, with a hot, dry skin,
quick pulse, and coated tongue,  considerable advantage will often be
derived from  an emetic early administered.   An aqueous solution of
tartar emetic would  appear to be the best article in these cases; the
emetic may be followed up with minute doses of tartarized antimony
combined with the sulphate of magnesia.*  This treatment, however, is
more particularly adapted to the acute form of the disease, occurring
in children over  ten years of age.  In place of the combination just
mentioned, we may administer minute portions of calomel  and pulvis
antimonialis, to  which,  when there is  very  great irritability, and
want of rest at night, a small portion of Dover's powder may be ad-
vantageously added.b
  * R.—Sulph. magnes. 3iij.               b R.—Calomel, gr. ij.
       Antimonii tart. gr. j.                    Pulv. antimonialis,
       Aquae, 3iij.—M.                        "  Doveri, aa gr. vj.—M. f. ch.
Dose.—A teaspoonful every two or three                    No. xij.
        hours.                       One of which may be given every three or
                                       four hours.

  In many cases of the disease, there is a loaded and torpid condition
of the alimentary canal, with a  hard and tumid abdomen, irregularity
of the bowels, and an  unnatural appearance  of the discharges.  In
these, active purgatives will be found of advantage; by their action, 
DISEASES OF THE NUTRITIVE FUNCTION.
a  large amount of unhealthy-looking faeces is often brought away, to
the manifest improvement of the condition of the patient.
   A dose of calomel, combined with rhubarb and magnesia, may be
given, and repeated every two or three days,  so as to produce a brisk
action upon the bowels; or we may administer a few grains of calo-
mel in the evening, and on the succeeding day, the compound powder
of jalap, castor oil, and turpentine, or  an infusion of senna, with the
addition of the sulphate of magnesia.   After the bowels have  been
well evacuated, they should  be kept regularly open by occasional small
doses of calomel, followed  by the  compound powder of jalap, or by
the use of this latter alone.  We are to  recollect, however, that, while
the most decided  advantage  is to  be derived from the judicious em-
ployment of purgatives, too violent or long-continued purgation is in-
variably prejudicial.
   After a more healthy and regular condition of the alimentary canal
has been produced, the carbonates of soda and potassa, either by them-
selves, or combined with rhubarb, colomba,  or a weak  infusion  of
chamomile, quassia, or bark, will often be productive of the best effects.
The sulphate of quinia is, however, probably the tonic best adapted to
these cases,1 and when administered after the disordered  condition of
the digestive organs  has been removed, will, generally, very quickly
effect a complete  cure.   The preparations of iodine will  also, in the
more chronic cases, be found beneficial, particularly the iodide of iron.
   The  hydrochloride of barytes  is very strongly recommended  by a
few writers in the disease before us, as well as in  the other forms of
scrofulous disease; it may be employed in solution.15   We know no-
thing of its effects from our own experience.
  ■ R.—Aq. cinnamon, giij.               b R.—Hydrochlor. baryt. 3j.
       Sulph. quiniae, gr. vj.—x.                Aq. destillat. 3ij.—M.
       Acid, sulph. dilut. «Xf iv.—vj.         Dose.—From ten to twenty drops, two or
       Sacch. alb. 3iij.—M.                     three times a day, to a child be-
Dose.—A teaspoonful every four hours, for            tween three and seven years of
       a child from three to seven years             age, in the syrup of sarsaparilla.
       of age.
  The diet of the child should be carefully attended  to during the acute
stage.   In the more violent forms of the disease, he should be confined
exclusively to some simple farinaceous article of food, with toast, bar-
ley, or rice water for drink.   He  should be immersed daily in a tepid
bath, or have  the  whole surface sponged daily with tepid salt water.
Friction of  the surface, with the hand or flesh-brush, will also be im-
portant.
   The purity and dryness of the  air which the patient breathes, is  a
matter of very great importance, and  should never be neglected;  a
patient with scrofulous ophthalmia, will rapidly improve  in a dry, fresh
atmosphere, with very few remedies beyond those of a  hygienic  cha-
racter, while one confined in  a close, impure, and  damp atmosphere,
will exhibit but slight indications of amendment, under whatever  plan
of treatment we may adopt.
   The body of the patient should be sufficiently, but not too warmly,
clothed; the hair should be cut short, and the head  and  neck sponged
with tepid water every morning, and then thoroughly dried. 
604
DISEASES OF CHILDREN.
  He should not, when it can be prevented, be allowed to keep his bed
during the day, nor, at night, to lie with his face buried in the pillow.
It is not proper to confine the patient, for any length of time, to a dark-
ened room ;  with the shade for the eyes already described, free expo-
sure to the open air, whenever the weather is  perfectly clear and mild,
is of  advantage, and will  contribute very powerfully to the cure.   It
is one of the best  means  of removing  the  morbid sensibility of the
retina which forms so prominent and troublesome a symptom of scro-
fulous ophthalmia.
  Blisters to the nape of the neck, or  behind the ears, kept on for a
few hours, and then  removed; the  blister being reapplied  as soon as
the  inflammation produced by the  first has subsided, are  directed  by
Travers, and will, in most cases, be found advantageous.
  In mild, recent cases, the occasional use of a collyrium, composed
of a solution of the  sulphate of zinc or alumine  in rose-water, from
three  to five grains to the ounce, will occasionally be found useful; or
we  may employ a very weak solution (one grain to  eight ounces) of
the  bichloride of mercury, in pure water, or rose-water.
  When the pain and  intolerance of light are very severe, warm  fo-
mentations to the  eye, as hot as  they can be borne, will often  afford
very decided relief;  a pledget of soft muslin, or of lint, or a piece of
soft sponge, saturated with warm water, or an infusion of poppy-heads
or chamomile  flowers, may be applied upon the eye during the day,
and replaced  by warm bread-and-water  poultices during the night.
The anodyne effects of the vapour of laudanum, or of a vinous tincture
of belladonna will often prove heneficial;  either of these being mingled
with a cupful of hot  water,  the eye should be exposed to  the vapour
two or three times a day.
  After the intolerance of light and  spasmodic contraction of the orbi-
cular muscle have so far subsided as  to permit the patient to unclose
his eyes in a moderate light, scarification of the conjunctiva of the lids
will often be followed by very considerable relief; the operation may
even  be repeated  a  few times, after intervals of two or  three days,
until the increased fulness of the vessels, and the thickening of the lid
is  removed.   Subsequent to the scarification, benefit will generally
result, in cases of a  very obstinate character, from  inserting a small
piece of the ointment of the peroxide of mercury (fifteen grains to  the
ounce of lard) within the eyelids.  The introduction of the ointment
may be repeated at bedtime, every night, or  every second night.  In
severe and obstinate cases,  this will be found a useful practice, even
when scarification has not  been  resorted to; or, a few drops of the
solution of nitrate of silver, (two grains to the ounce of water,) or of
the vinous  tincture of opium, may be  instilled into  the eye, daily, or
every other day.  These applications have a very decided effect in
diminishing the irritability  of the  diseased  organ, in promoting  the
healing of  the  ulcerations of the cornea, and in dispersing any opaci-
ties which these may have occasioned.
  When a granular condition of the  conjunctiva  occurs, in  chronic
cases, collyria of a solution of the  nitrate of silver or of  a solution of 
         DISEASES OF THE  NUTRITIVE FUNCTION.      605

sulphate  of  copper,  (four grains to the ounce of water,) will be re-
quired.
  In cases where there exists considerable disease of the tarsal edges
of the eyelids, this may be relieved by the application of the ointment
of the peroxide of mercury, or, what is still better, of the ointment of
the nitrate of mercury, diluted with one-half or one-third of its weight
of fresh  lard; this being rendered soft, should be applied by means of
a hair pencil, along the edges of the lids every evening.
  Large  ulcerations of the cornea, which  exhibit any tardiness  in
healing,  may be touched by means of a hair pencil,  with a solution of
nitrate of silver; or, when the ulcer is small, deep, and funnel-shaped,
with a pencil of lunar caustic, cut to a fine point.  When prolapsus of
the iris occurs, the protruding portion should be touched every second
or third  day with the caustic.
  In cases of deep central ulceration, with adhesion of the iris, the ex-
tract of belladonna, reduced by the addition of water to the consistence
of a thin paste, and  smeared  upon the forehead, over the eyebrow, by
causing  the  dilatation of the pupil, will either have a tendency to free
the iris, or to elongate to such an extent its attachment, as to prevent
the loss of vision.
  When a vascular speck occurs, its progress may often  be arrested
by  removing a portion of the  enlarged vessels running into it.
  Let it  be  recollected, however, that in every case  of scrofulous oph-
thalmia,  and  during every stage of the disease, our chief attention
should be directed to correct  the morbid state of the general system;
without this can be effected, remedies  directed solely to the local dis-
ease are worse than useless:  while, by restoring  health and vigour to
the organic functions, and thus improving the strength and tone of the
whole body, cures have been  repeatedly effected, without a single local
application, or so called, specific remedy.
   Scrofulous  inflammations of the  ear, require the  same  unremitting
attention to the condition of the digestive organs; the same course of
treatment, directed  to  render assimilation,  haematosis, and nutrition
more active and complete, as is demanded in the disease we  have
just considered.  The same  general remedies—purgatives  when the
bowels  are  loaded  and sluggish, followed by mild laxatives, or small,
repeated doses of calomel, with the occasional interposition of a mild
laxative, and succeeded, when a more healthy and  regular condition
of the bowels has been obtained, by similar tonics to those directed in
cases of scrofulous  ophthalmia, will be called for.
   In  regard to the treatment of the local disease, this  must be con-
ducted upon general principles.   In cases attended  with  symptoms of
a good deal of severity, leeches, a mild, unirritating diet, and the use
of the tartarized antimony, with nitre and calomel, or with the sulphate
of  magnesia in solution, as directed in scrofulous ophthalmia, will be
proper.
   The local applications consist in the injection into the ear of simple
tepid and emollient fluids, and the application, externally, of an emol-
lient poultice.  When the meatus externus is hot, and its lining mem-
brane red and swollen, warm fomentations should be assiduously ap- 
606
DISEASES OF CHILDREN.
plied  to the ear and side  of the  head, and  leeches behind  the  ear.
Blisters to the nape of the neck, or behind the ear, frequently repeated,
are all-important remedies.
  In the more deep-seated inflammations of the ear, the tartar emetic
ointment may be rubbed  upon the  mastoid process, until local  irrita-
tion is produced.   In the more chronic cases of the disease, slight as-
tringent injections  may be resorted to, at first of tepid rose-water, and
subsequently  of a  very weak solution of the acetate of lead, two or
three  grains to the ounce of water, or of the acetate of zinc, of similar
strength, or of the  nitrate  of silver, one  grain  to  the  ounce.   The
strength of these injections may be gradually and cautiously increased;
but in all cases we must  be careful not to arrest too early or suddenly
the discharge from  the ear, nor until the health of the general  sys-
tem is considerably improved.  If the  discharge becomes offensive,
a few drops of the chloride of soda, in  an ounce of water, may be
injected.
  Whenever, during the  use  of astringent injections,  the discharge be-
gins rapidly to diminish, it is  as well to desist for a time from their use,
and resort to those of a simple emollient character.   Should the arrest
of the discharge  be followed by any unpleasant symptoms, warm fo-
mentations, and simple bread poultices should be applied to the ear, as
hot as they can be borne.
  The Discharge  from the Vagina, in scrofulous girls, requires little
treatment beyond that which is demanded for the improvement of the
general health of the system.   Frequently washing the parts with some
mild  emollient, or  slightly astringent  fluid, will be proper.  In most
cases, the condition of the alimentary canal will  indicate a course of
purgatives and alterative doses of  calomel, as in the  last two diseases.
   Tabes Mesenterica.—The particular treatment of scrofulous enlarge-
ment  of the mesenteric glands, is  of secondary importance to that of
the gastro-intestinal disease, with  which it is almost invariably  con-
nected.   This demands precisely the same remedies as when it occurs
in a patient in whom no predisposition to scrofula exists, with this  only
exception,—that the extent to which the depletory treatment is to be
carried, must be governed by the condition of the patient's system, as
well as by the urgency of  the symptoms  present;—in other words, it
must  be constantly borne in mind,  that in patients  in whom there exists
a decided tendency to scrofulous disease, remedial  measures of a de-
bilitating character, even with the  same violence of symptoms, cannot
be  carried as far  as in  a patient in whom no such predisposition is
present.
  As soon as the disease of the  mucous membrane of the  alimentary
canal is  subdued, the child should be  put upon an  improved  diet.
Meat broths, prepared with particular reference to their nutritive and
digestible properties, may be given as soon  as prudence will permit,
and at the  same  time, a course of purgatives should be commenced
with.  The carbonate of potassa or soda, with some light bitter  infu-
sion, or, where there is a tendency to constipation, combined with  rhu-
barb  and nitre, may be commenced with at an earlier period, perhaps, 
         DISEASES OF THE  NUTRITIVE FUNCTION.      gQ7

than more active tonic remedies, and will be very useful so far as the
disease of the glands is concerned.
  Iodine, both internally  and externally, would appear to be the reme-
dy best adapted to the cure of enlarged mesenteric glands occurring in
children  of scrofulous habits.  Lugol's solution may be given, in doses
of from three to six drops, two to three times a day;  or, we may em-
ploy the  hydriodate of potassa, in the dose of  half a  grain to a grain,
in a spoonful of the decoction of sarsaparilla, two or three times a day.
The hydriodate of potassa is the preparation  that will, in most cases,
agree best with  the bowels;—if these are in the least degree irritable,
the addition of a small portion of the syrup of white  poppy, or of the
tincture of opium, to each  dose, will lessen its  liability to disagree.
The iodide of iron may, in many cases, be advantageously employed
instead of, or in alternation with the foregoing. If, however, under the
internal use of iodine, irritation of the digestive organs should ensue, it
should be at once suspended, and the means for allaying the irritation
resorted  to.
   The best form for  the external application of iodine, is that of the
ointment of the iodide of lead, (half  a drachm to the ounce of lard.)
When, however, its use can be persisted in sufficiently long, without
inducing considerable irritation of  the skin, we have experienced the
very best effects from  the ointment of the hydriodate of potassa, (half
a drachm to the ounce of lard.)  The ioduretted baths we have never
employed ;  of their effects,  therefore, we know nothing from our own
experience; they are, however, highly recommended  by  others, and
will, in some cases, no doubt, be found  of benefit.   These baths are
formed  by  dissolving  one grain of iodine  and two  of hydriodate  of
potassa  in a gallon of water.
   In protracted cases,  change of air, frequent bathing in tepid salt
 water, or daily sponging with simple warm or salt water, followed by
 brisk frictions to the surface, a cautious  course of chalybeates, and a
 well-regulated  diet, constitute  the plan  of treatment to be pursued.
 When, however, the disease has been of long continuance, little hopes
 are left  of  effecting a cure.   Very generally the patient sinks under
 hectic fever, night  sweats,  and colliquative  diarrhoea, or  tubercular
 depositions  take place  in the lungs  or other important organs, and
 sooner or later, by impeding their  functions, terminate the  life  of the
 patient.
    In the Scrofulous Disease of the Bones, denominated rickets, little
 else is demanded than a strict attention to those hygienic  measures
 that are adapted to improve digestion, and render more vigorous and
 perfect  the whole of the organic functions.  A proper  diet, pure air,
 the tepid bath,  and sponging with  tepid salt water, together with fric-
 tion of  the surface, daily but cautiously  performed, are  the  agents
 from which the greatest amount of good  is  to  be anticipated.   The
 diet of  a rickety child,  should be light, easy of digestion, and abound-
 ing in nutritive matter.  Previous  to weaning, the breast-milk  of a
 healthy nurse is invariably to  be  preferred; and, subsequently, meat
 broths,  with the farinaceous vegetables, or  beef and mutton plainly
 cooked. 
608
DISEASES OF  CHILDREN.
   Children suffering from rickets, are  unfortunately precluded from
active exercise; the utmost care should indeed be taken, not to allow
them too soon to assume the  erect position, or  to  attempt to  walk.
They may, however, be  passively exercised, by being carried abroad
in a carriage, or in the arms of an attendant.
   In  carrying or even handling a rickety child,  or  one strongly pre-
disposed to  become so,  great  pains must be taken to avoid undue
pressure upon any part of the body,  or  to place it in any position by
which the spine or  either of the long  bones may become distorted.
Its clothing, also, should  be perfectly free and loose.  In the soft and
yielding condition of the entire bony structure, any part of the clothes
being allowed to bind, or to compress  unduly the chest or limbs, by
preventing the full development of the  first, and  producing a change
of shape in the latter, may, independently of the deformity to which it
gives rise, cause permanent decrepitude, or a serious interference with
the free and regular action of important organs.   The child should not
even be allowed to lie  too long in the same position,  in order to guard
against too much and constant pressure on particular bones.
   Any symptoms of  local  disease  which  may occur in patients
affected  with  rickets,  must be combated by their appropriate reme-
dies.   The sluggish and deranged state  of  the bowels will  very gene-
rally call for purgatives,  and the  employment of  calomel in alterative
doses ; carefully, however, guarding against the production  of its spe-
cific effects.   As soon as the regular  and healthy condition  of the
alimentary canal  has  been established, tonics, as in other cases of
scrofulous disease, may be administered, and will often be  productive
of very decided advantage.  The chalybeates and iodine,  and, occa-
sionally, the sulphate of quinia, constitute our best tonics in these cases;
—it is in these, also, that the hydrochloride of barytes is said to be par-
ticularly beneficial.  During  the whole  treatment, the tepid salt-water
bath, sponging with salt-water, and brisk friction to the surface should
be daily  resorted to.
   Various plans of support and of machinery have, at different times,
been proposed to prevent  the occurrence of distortion and deformity
in the bones,  and  to remove it after it has taken place; we believe
them all, however, to be worse than useless; indeed, every mechanical
means, adapted  to effect  the former object, will  be  absolutely perni-
cious—invariably increasing the evil it was intended  to avert.  Those
which have been resorted to to effect the second object, are generally
unsuccessful, and are occasionally attended with mischievous effects.
   It has  been recommended, upon the authority of Dupuytren, to place
children whose breasts  have become wedge-shaped, frotn the effects of
rickets, against a flat resisting surface, and then to press with the palm
of the hand  upon the projecting sternum, so as to  flatten  the thorax in
its antero-posterior diameter, and  by increasing thus the convexity of
the ribs,  to augment  its capacity  laterally.   In the success of such a
procedure, we have  not  the least confidence.  We  believe, with Dr.
Maunsell, that much more may be effected by a  course of well-regu-
lated  gymnastic exercises, commenced  with after the strength of the
patient is well established, and he is sufficiently old to permit of their 
DISEASES OF  THE NUTRITIVE FUNCTION.
609
being put in practice.  It will be evident to  any one acquainted with
the mechanism of the  human frame, and the mechanical effects pro-
duced upon it by the continued action of particular muscles, that modes
of exercise could be easily devised, which, if repeated sufficiently often,
would  have a very powerful tendency to remedy many of the distor-
tions consequent upon  rickets.
   In scrofulous disease of the ends of the long bones, independently of
the general treatment adapted alike to all cases of  scrofulous disease,
it is essential that the limb be kept in a state of perfect rest, which can
scarcely be effected without the aid of  appropriate splints and ban-
dages;—and, although these, when the disease is seated in the bones
of the lower extremities, will prevent the patient from taking exercise,
they cannot be avoided.  When inflammation lakes place, this is to  be
removed by moderate  local  depletion in the commencement, aided  by
evaporating lotions, as a mixture of water and alcohol, or water and
camphorated spirits, or a solution  of the  acetate of lead.   In  many
cases, blisters, applied  in the immediate neighbourhood of the affected
joint, frictions with  a  solution of hydriodate of potassa, or with  the
ointment of the latter, or with the tartar  emetic ointment, will often
prove beneficial.   It has been  recommended to keep  open the blister,
by dressing it with the unguentum  sabinae, or other irritating applica-
tions ;  we  are  persuaded, however, that a frequent repetition of the
blister is a far preferable practice.  Purging will be found, in  most  in-
stances, to be demanded, in  consequence of the torpid and loaded con-
dition  of  the bowels; and,  in  general, it  will  produce, also, a good
effect upon the diseased condition of the joint.
   So long  as a disposition to suppuration continues, it  is probable that
blisters to or in the neighbourhood  of the joint, with the use of iodine
internally,  will  constitute the  most prudent  and judicious  practice.
When the disposition to suppuration has subsided, gentle pressure upon
the joint,  by means of strips of soap-plaster, should  be applied, and
continued for some time.  Motion of the joint must not be attempted
so long as  the least degree of irritation remains, or the slightest pain
is  excited.   In  all scrofulous diseases of the joints, motion should  be
delayed for a  much longer period  than in  almost any other of the
affections in which the bones of the extremities are  implicated.
   As soon as the  limb becomes perfectly free  from irritation, it is
necessary to  subject it daily to gentle friction.
   In the management of the  scrofulous affections of the joints, the
utmost  patience, caution, and  perseverance will  invariably be de-
manded ;  a too early desire  to  permit the natural use of the affected
limb, may eventuate in complete anchylosis, or  more serious injury;
while,  in even severe cases,  by prudent  and judicious  management, a
complete cure may sometimes be effected.
   The treatment of  White   Swelling consists in perfect rest of  the
affected joint.  When this  is hot and  painful, or tender upon  being
handled, leeches, lotions of a solution of the acetate of lead, or evapo-
rating  washes,  brisk purgation, and a  light, unirritating  diet will  be
demanded.   When  the swelling is  indolent, presenting no increased
heat, nor  tenderness upon pressure, blisters will, in general, be  found
                                39 
610
DISEASES OF  CHILDREN.
the most efficacious application;  though, in some cases, benefit  has
been derived from dry friction, or by friction with the iodine in solu-
tion, or in  the form  of ointment.  According to  Latta, applying a
blister, first  upon one side of  the joint, and then upon the other, and
thus repeated alternately, until the pain and  swelling are  reduced, has,
in many cases been found more  successful than when  the  blister is
made to envelope the whole  joint.  When blistering induces an in-
crease of the heat and pain, an issue upon each side of the joint,  may
be substituted.
  In cases in which the parts involved  in  the swelling become infil-
trated with matter, encircling the joint with strips of adhesive plaster,
applied pretty tight, has  been  found in  many cases, highly beneficial.
This practice is equally proper after abscesses or  sinuses  have formed.
  In many patients a cautious use of opiates will be demanded, to re-
lieve the pain, and procure sleep at night, and in the latter  stages of
protracted and severe cases, to arrest the copious diarrhoea which  then
so generally prevails; in  this latter case, they should be combined with
the acetate of lead.
  Splints, in cases where the disease is seated  in the knee, are neces-
sary, as well to prevent  motion, as to counteract the tendency which
exists in these cases to permanent flexure of the joint.  When  the
elbow joint  is affected, and anchylosis cannot be prevented, angular
splints should be applied, in order that the limb may become  flexed so
far as to render it as serviceable as possible to the patient.
  The question of the  propriety of amputation,  in  cases  of white
swelling, is a purely surgical one;  its discussion  does not fall within
the scope of the present treatise.
  Hip Disease—morbus  coxarius.—In relation to the special treatment
of this affection, nearly the same remarks will apply, as in the case of
white swelling.   The most perfect rest of  the affected  joint is abso-
lutely necessary to the accomplishment of  a cure in all cases;  and
this can only be  maintained by a splint, so  carved or modelled, as to
fit accurately the side of the pelvis, as well as the thigh and leg of the
side on which the disease exists;—such  a splint, properly padded,
while it  prevents motion, produces no  injurious  pressure about  the
joint, nor at any part of the limb.
  Whenever there is much heat, pain, or tenderness, leeches will be
proper, with the same cooling and evaporating lotions as were directed
in cases of white  swelling.  Some surgeons prefer the application of
cups to leeching. In  many cases, in  the  earlier stages of the com-
plaint, previous to the  soft parts  about the joint  becoming affected
with any considerable amount of inflammation, we have been more
pleased with  the effects of cupping,  than  with those  derived from
leeching ; but we have been repeatedly called to cases, at a later stage
of  the complaint, in which, although  local bleeding was demanded,
the extreme tenderness of the diseased  joint prevented the application
of cups, and obliged us to resort to leeches.
  In this affection, we know of no practice  which will be found more
generally  beneficial, than  pretty active  purging with the  compound
powder of jalap, as pursued  by the late Dr. Physick.   Under this 
         DISEASES OF THE NUTRITIVE FUNCTION.      611

treatment, with perfect rest of the limb, leeches, and cooling lotions,
we have repeatedly seen the general health of the patient rapidly im-
prove, and a perfect cure effected.
  The diet of the patient, in the early stages, should be light and easy
of digestion.  Milk, with any of the farinaceous substances, or light
meat broths, in moderation, may be allowed.
  Blisters are unquestionably useful in the early period of the disease.
We prefer repeated blisters, to keeping up a discharging surface by
stimulating  ointments.  In very chronic cases, a  caustic issue, just
before and  below the  great trochanter, will, probably, be more bene-
ficial than blisters.
  Frictions with iodine in the form of solution or ointment, in conjunc-
tion with its internal use, will often produce very happy results.
  When suppuration is about to occur, or an abscess or abscesses have
already formed, the effects of gentle, continued pressure may be tried.
We think that in  a few instances we have seen it beneficial.
  When abscesses form, it is better to avoid, if possible, opening them,
lest we cause the cavity of the joint to become exposed.
   In regard to general treatment, this is  to be conducted upon pre-
cisely the same plan as in any other case of scrofulous disease.
  Disease  of the Spine.—Children of a delicate, enfeebled frame  of
body, particularly females, when approaching  the period of puberty,
are liable to curvature of the spine, entirely independent of disease of
the vertebrae; though, when long-continued, disease of these, as well
as of the intervertebral cartilages, is liable to take place.   The spe-
cies of curvature we now refer to, is the result of a defect of power
in the muscles by which the erect  position  of the trunk is maintained.
It is often increased, if not produced, by improper articles  of dress,
which furnish an artificial support to the upper part of the body, and
thus deprive the muscles  of the trunk of their proper office; these con-
sequently obey the general physiological law—by which muscles long
disused diminish in bulk, and finally lose entirely their power of acting.
Stays, corsets, and braces produce this effect, under all circumstances,
when worn during the period of youth, and, in too many instances,
the mischief is increased by the undue pressure they exert upon the
muscles and bony structure of the  chest.
   The general plan for giving increased vigour and tone to the whole
system, by improving its  nutrition, must be pursued in these cases;  at
the same time a loose style of dress should be adopted,  and  artificial
supports of every kind abandoned.
   The power of the muscles  about the spine and chest may be  very
materially increased, and even considerable curvatures  of the spine
removed, by a proper course of calisthenic exercises, daily practised,
and firmly persevered in. Such exercises as gradually accustom the
patient to support the entire weight of the body by the arms, in climb-
ing, swinging, and the  like movements, have a  tendency to give de-
velopment,  strength,  and activity to the  muscles  upon  the  chest, as
well as to those of the back and spine, concerned in maintaining the
body in its erect position, while, at the same time, when carried on in
the  open air, they promote the general health of the system.  Fric- 
612
DISEASES OF  CHILDREN.
tions with the hand or flesh-brush over the entire surface of the back,
employed daily, as well as sponging with tepid salt water, a well-regu-
lated diet, and daily general exercise, are all-important measures, which
should never be neglected.
   In the proper spinal disease, from an affection of one or more of the
vertebrae, exercise, either general or regulated, is out of the question;
perfect rest in the recumbent position must be enjoined, and perse-
veringly maintained,  until the disease of the bones is fully arrested.
Various contrivances have been devised to takeoff the pressure of the
head and upper portion of the trunk from the spine, when the patient
is in the upright position, and by this  means to allow  him to exercise
his body by walking about.  We confess that we have seen but little
good result from these contrivances,  and, in many cases, positive in-
jury;—we prefer the  recumbent  posture, until the cure of the local
disease is considerably advanced, when, probably, the  machine in-
vented for cases of diseased  spine, by  Dr. J. K. Mitchell, of Philadel-
phia, may be resorted to,  for a short time daily, with advantage.
   From diseased vertebrae, a certain  amount of angular curvature is
inevitable; though, by a  prudent and judicious  course of treatment,
early commenced with, we may be enabled to diminish, very materi-
ally, the extent of the deformity.
   The great  object of the practitioner, in these  cases, should be, to
give, as  quickly as possible,  increased tone and vigour to the whole
system ;  for when  this can be readily  effected, the disease of the ver-
tebrae is  very generally arrested, and their complete consolidation pro-
duced.   The  morbid  condition of the system  is to be removed hy a
nourishing diet, friction of the surface, and the internal use of tonics;
—the different preparations of iron, as  the carbonate, proto-carbonate,
ferrum  tartarisatum,  the  tincture of  the sesquichloride  of iron, the
iodide  of iron, the  hydrochloride  of barytes, iodine, and  the sulphate
of quinia-, are  to be preferred.
   Iodine, externally  and   internally,  has, unquestionably, in a large
number  of cases,  been attended  with the most happy effects; even
when the disease of ihe bones has made considerable progress, its use
has appeared  to arrest the disease, and allow anchylosis to take place.
With the administration  of iodine by  the mouth, the diseased portion
of the spine should  be rubbed daily with the ointment or solution.
   During the  treatment, the bowels should be kept freely open by mild
aperients.  In  the  early  stage of many cases of the disease, active
purgatives, particularly the compound of jalap and bitartrate of po-
tassa, will be found of advantage.
   After  all, however, we  believe  that  the plan of treating the disease
with caustic issues, formed along the spine, on  each  side of the  dis-
eased  vertebrae, as originally recommended  by Pott, should not be
neglected; we have  unquestionably strong  evidence in favour of its
success.  We have  seen the most decided benefit result from  it in
numerous instances;  and  by resorting to it, we in no degree preclude
ourselves from whatever advantages are to be derived  from rest in the
recumbent position, purgatives, the local application of iodine, or its
internal  use either alone,  or in conjunction with tonics. 
            DISEASES OF THE  URINARY ORGANS.        glo

  The time necessary for the cure of diseased vertebrae is very various
in different cases; in some, complete consolidation of the  spine may
take place at the end of a month or  two; in others, not until after
many months.  In all cases it is important that the patient should  not
resume the upright position until we are certain  that anchylosis  has
made considerable progress; nor should it be retained at first, for any
length  of  time, and  on  no account should much active exercise be
attempted.  So soon, however, as  anchylosis has taken place, gentle
daily exercise, at first by the aid of crutches, subsequently without any
support but that  derived  from a cane, and finally, entirely  without
support, should be commenced; by this means the natural  strength
and movements of the muscles of the  lower limbs will  be gradually
regained,  and the general health of the body improved.
  In cases marked by a strong predisposition to tubercular depositions,
the best that the physician has it in his power to do, is  to endeavour
to prevent the formation of the tubercles, by means adapted to restore
health, strength, and  vigour to  every portion of the system;  or when
they have already formed, by  the use and proper regulation of  the
same  means, to endeavour to  prevent  their subsequent  development,
and the irritation produced by them in the tissues in which they  are
seated.  Whatever  symptoms  are produced by them, when  they  are
seated  in the lungs or brain, must be treated upon general principles;
always recollecting, however, that the particular constitutions  in which
tubercular depositions ordinarily take place, will not bear either deple-
tion being carried to so great  an  extent, nor  so  restricted a diet, as
many of the symptoms  which  arise, would often seem to demand, or
which  would be proper,  were they to occur in other constitutions.
  We  have no means of positively judging of the presence of tubercles
in the brain, and most of the other organs, during the lifetime of  the
patient: we may suspect their  presence, however, whenever chronic
and anomalous affections  of any of the organs occur in individuals
who exhibit a very strong  predisposition to affections of a scrofulous
character.
                SECTION  VI.

DISEASES OF  THE  URINARY ORGANS.
         I.—Dysuria—Painfnl  and Difficult Micturition.

  Infants and young children are not unfrequently affected with pain
and difficulty in voiding urine. It is often observed, to a slight extent,
as a symptom of any febrile excitement under which they may labour,
and is very common about the period of dentition.  The child  has a
frequent desire to  urinate, but passes a very small  quantity at a time, 
614
DISEASES OF CHILDREN.
and with evident distress and uneasiness. This, though generally only
a temporary inconvenience, may nevertheless  continue for a conside-
rable length of time, and result, ultimately, in severe and dangerous
disease.
  In some cases  the  discharge of urine is attended with  such severe
paroxysms of  pain, as to throw the child  into violent agitation, and
cause him to  utter uninterrupted  shrieks, until the discharge is com-
pleted, when the pain instantly ceases, and the child, if old enough, re-
turns to his play as though nothing had  occurred.
  Dysuria in  children is very generally attended with a morbid con-
dition of the urinary secretion; most commonly, the urine  contains an
excess of lithic acid, though, in  some cases, it is highly charged with
phosphatic sedimentous matter.
  There is a form of dysuria which is of frequent occurrence in young
infants, and always a source of intense suffering during  its continu-
ance,—if it do not, sooner or later, terminate in a complete suppres-
sion of the urinary secretion; it is described by some of the continental
writers, under the denomination  of urodialysis neonatorum.
  In this form of dysuria the urine is passed in  very small quantities,
often only a few drops at a time, and, evidently, with intense  pain, as
indicated by the screams of the patient,  the drawing up of his legs to-
wards the abdomen, the  flushing of the countenance, and  the general
agitation of the whole body. The  urine is always  very high-coloured,
and stains the diaper or linen of the child, of a deep reddish-yellow,
or orange hue.  It produces an irritation or scalding of the surfaces
over which it passes, and, finally, excites inflammation of  the lining
membrane of  the  bladder, and probably of the  urethra also, as indi-
cated by the mucus with which the urine becomes charged.
  The patient, usually, exhibits  more or less febrile excitement;—the
skin is increased  in temperature, and dry, the thirst augmented, and
the bowels constipated.  When  a discharge  of faeces  is obtained,
these are commonly in  the form  of small rounded masses, like mar-
bles.   The  digestive function  is  invariably  deranged;—the breath
having a very decided acid odour.  There  is, generally, considerable
irritability of the skin; while inflammation  and superficial ulceration,
attended with a thin,  acrid, foetid  discharge, by which the mischief is
extended to  the neighbouring  parts,  are  almost certain  to occur,
wherever two surfaces  are in contact.  Cutaneous eruptions, of va-
rious kinds, are also very common; sometimes assuming the form of
psydracious (impetiginous) pustules, scattered over different  parts of
the body, and  especially in the folds of the neck, axillae,  groins, &c,
giving rise to superficial ulcerations of  a very troublesome  character.
  The more violent forms  of dysuria occurring in children, are, very
generally, accompanied  with more or  less derangement of the diges-
tive process, and the formation of acid in the alimentary canal.  Severe
attacks of the disease will, most commonly, be met with  in those
children who have been  indulged,  from  an early period of infancy, in
animal food, rich  gravies,  and similar highly azotised articles, and in
whom, with imperfect digestion, there  coexists  an insatiable appetite
for food of a rich, stimulating quality.  " Children," to adopt the  Ian- 
DISEASES OF THE URINARY ORGANS.
615
guage of the elder Schimdt, " who, according to the short-sighted esti-
mate of their parents, are in the enjoyment of the most robust health,
while, in fact, disease, already commenced, only awaits, in them, some
trifling cause, to rouse it into more open and rapid action."
  There is no  doubt that deranged digestion, and the consequent pro-
duction of an excess of acid in the fluids of the body, giving rise to an
increased secretion  of lithic acid  by the  kidneys, and thus changing
the normal constitution of the urine, may,  during childhood  and in-
fancy, be the cause of a very considerable degree of irritation about
the neck of the bladder—then easy to  be excited, from the physiolo-
gical condition in early life of the  mucous tissue generally—attended
by pain and difficulty in passing the urine; and  that the urine will, in
these cases, indicate by its physical properties, and  the usual tests, a
predominance of the acid in question.   But this is not the only cause
of painful and difficult micturition  in children.   In many cases, parti-
cularly in  those which occur during dentition, or during slight febrile
attacks, the dysuria  is evidently the result of the increased irritability
which the lining membrane of the bladder experiences,  in common
with the other mucous tissues, and, although the urine may, also, con-
tain a slight excess of acidity, this is in too small a quantity to produce
the degree of dysuria experienced, without the former.
  Various intestinal irritations are an occasional cause of difficult and
painful micturition in young children.  We have seen it often  con-
nected with the presence of oxyures in the rectum; in these cases, the
urine generally forms deposits of an alkaline character; we have known,
also, an ordinary attack of dysentery in a  child, to be accompanied
with severe dysuria.
  In  a  few cases that have fallen  under our notice, we have had rea-
son to believe the dysuria depended  upon a degree of inflammation
about the  neck of the bladder.  The urine, in these  cases, notwith-
standing the calls to void it were very frequent, was passed with more
or less pain, in  very small quantities, and loaded with mucus ;—partial
retention of urine is common in such cases.
  According to Eberle, in female children, a very common cause of
dysuria, and one very often overlooked,  is an inflamed condition of the
orifice of the  urethra.  This  is often red, swollen, and so extremely
sensible, that it cannot be even lightly touched, without  causing the
child to shrink, and shriek with pain.   In cases  of this kind, the urine
presents nothing abnormal, and the pain, accompanied  by considera-
ble  smarting, remains for some short time after the discharge of urine
has ceased.  We  have met with  this  state of the  female urethra so
frequently, that we are never called to a case of dysuria occurring in
a girl, without making an examination.
  There does not appear to be any source of difficulty in the diagnosis
of dysuria. Even in the youngest child, its symptoms are sufficiently
evident, to  prevent the disease from  being  mistaken for  almost any
other; and yet we have known it to  be confounded with colic, and
treated for several days accordingly.   If, however, a child is found to
become affected with spells of severe suffering only during the period 
616
DISEASES OF  CHILDREN.
it  is voiding its  urine, the pain commencing and  ceasing  with the
act, the true cause of the paroxysms is at once pointed out.
  Happily, in the majority of cases, the remote and exciting causes of
dysuria are only of temporary duration, and, hence,  the affection is
seldom productive of any very serious  or permanent  injury.  When,
however, the disease is connected with long-continued disturbance of
the assimilative process, it may produce disease of the kidneys, ureters,
or bladder, giving rise to a complete suppression of urine, or it may be
the cause of gravelly or calculous concretions.
  Gravel, in children, is of more frequent  occurrence than is  gene-
rally suspected;  and,  when formed in the pelvis of the  kidney,  its
occasional  passage through  the  ureters, is  attended  with  sudden, in-
tense  attacks of pain, which continue until  the particle of gravel has
found its way into the bladder.  These attacks, the cause of which is at
first not  very evident,  may give rise to convulsions.  Occasionally
the urine voided immediately after the cessation of the pain, is slightly
bloody.
  In the treatment of dysuria, we must be governed by the peculiar
character of each case.  When dependent  upon  disordered  assimila-
tion, it is important to employ such means as  are calculated to render
the digestive process more prompt and regular.  Previous to weaning,
the breast-milk of a healthy nurse, pure air, the warm bath daily, fol-
lowed  by friction to the surface, will, in general effect this; in older
children, beef tea,  or  chicken water, should  constitute pretty  much
their ordinary diet, and all  articles of a  saccharine and ascescent kind
should be entirely prohibited;  at  the same time, daily exercise should
be taken in the open air; cold and dampness  being  carefully guarded
against, and the functions of the skin promoted and maintained by the
tepid bath and friction.
  In all cases, the bowels should be, at once, freely evacuated by suf-
ficient  doses of magnesia  and rhubarb, aided by emollient enemata,
and their regular action subsequently  maintained by small doses of
calomel, magnesia, and ipecacuanha, with or without the  addition of
extract of hyoscyamus,* repeated once, twice  or thrice a day, as may
be necessary.
                1 R.—Calomel, gr. vj.—xij.
                    Pulv. ipecac, gr. iij.
                    Magnes. calc. gr. xxxvj.
                    Ext. hyoscyami, gr. iv.—vj.—M. f. ch. No. xij.

  When there is a strong tendency to acidity  of  the stomach and
bowels, the best prescription will be,  either  magnesia and milk, in
small,  frequently repeated doses, or, what is calculated in  these cases
to produce  the greatest amount  of benefit, the bi-carbonate of soda.
This may be given in doses of from two to  six grains, according to
the age  of the child, once, twice, or thrice daily.   It should be  dis-
solved in about half a drachm of a weak infusion of colomba, or cha-
momile, and then diluted with barley, rice, or  gum water.
  When dysuria occurs during dentition, the state of the gums should
be  carefully watched, and  inflammation, distension,  and pain of these
promptly removed, by free incisions, repeated daily, if necessary.  The 
DISEASES OF THE  URINARY ORGANS.         617
bowels should be kept freely open, by occasional doses of magnesia
and rhubarb, and, if any febrile excitement exists, as it generally does,
the daily use of the tepid bath, and, internally, the acetate of ammonia,
with  the addition of  a small quantity of the sweet spirits of nitre will
be proper.
  During the paroxysms  of pain, should they be of any continuance,
the best means of alleviation is the hip-bath, used tolerably warm, and,
internally, a few drops of turpentine, sweet  spirits  of nitre, and the
camphorated  tincture of opium, in combination.*  In  ordinary cases,
however, the duration of the paroxysms is too short to allow time for
the preparation of the bath ;  we must content ourselves, therefore, with
the administration of the latter.

                      * R.—Aq. cinnamon. 3ij.
                          Spir. terebenth. 3jss.
                          Magnes. calc. gr. viij.
                          Spir. aeth. nitr. 3iij.
                          Tinct. opii camph. 3ij.—M.

  When dysuria is attended with a  copious secretion of the phosphate
of magnesia and ammonia, with pale or  light-coloured urine, which
deposits, upon  cooling, a whitish or yellowish sediment, and becomes
rapidly putrid when suffered to remain at rest, the diet of the  child,
if weaned, should be mild but nutritious, and  taken in  moderate quan-
tities, so as not to endanger the  overloading of the stomach, or the
disturbance of its functions.  In addition to milk, and the usual farina-
ceous preparations, the child may, with propriety, be allowed a mode-
rate portion, daily, of beef,  mutton, venison,  chicken,  turkey, or any
other meat of easy digestion,—which should be  fresh,  not too fat, and
plainly cooked, without much seasoning.   For  drink,  we  may direct
weak lemonade, or water sweetened with the acidulous lemon syrup.
  The bowels, in these cases, are  generally irregular, and the func-
tions of the entire alimentary canal more or less deranged.   To remove
this condition of the digestive organs, the bowels should be freely eva-
cuated with rhubarb, castor oil, and turpentine, or the compound infu-
sion of senna, and kept freely open by the occasional use of the latter,
or by mild, purgative enemata.
  To allay the general irritability of the system, by which this form of
dysuria is generally accompanied, either the Dover's powder,1 in small
doses,  or a combination of  ipecacuanha and extract of hyoscyamus,b
will, very frequently, be found beneficial.

* R.—Pulv. Doveri, gr. vj.               b R.—Pulv. ipecac, gr. iij.
     Pulv. valerian, gr. xij.—M. f. ch. No.       Ext. hyoscyami, gr. iv.—vj.—M. f. ch.
       xij. (Eberle.)                       No. xij.
Of these, one may be given every six hours,          One  every three hours.
  to a  child between two and five years of
  age.

  After the bowels have become regular, and their discharges natural,
benefit may be derived from the administration of the tincture  of
the  sesquichloride of iron, in small doses, or of the protocarbonate of
iron.
  Daily exercise in  the open air, the tepid bath, and  frictions of the 
618
DISEASES OF CHILDREN.
surface, are all-important  measures, and should never  be neglected.
All alkaline substances are improper.
  When dysuria appears to he dependent  upon a  morbid degree of
irritability in the lining membrane of the bladder, the condition of the
urine being normal, or very nearly so, the treatment should consist of
a mild, unirritating diet, the use of the warm or tepid bath daily, and
the plentiful use of diluents, of a mucilaginous character.  The free-
dom of the bowels should be maintained by occasional doses of castor
oil, or by laxative enemata;  and if there is nothing present  to  forbid
its use, a dose, adapted to  the age  of the patient, of Dover's powder
may be given at night, or the extract of hyoscyamus and ipecacuanha,
as directed above, three or four times a day.  A weak infusion of the
seeds of wild carrot, or  of the root of parsley, mixed with an equal
portion of the  mucilage of the inner bark of the slippery elm,* has been
found, in some of  these cases, peculiarly beneficial.
* R.—Sem. dauc. carotae, 3ij.             Or, R.—Rad. apii petroselini, 3ij-
     Aq. bullient. 3viij.—M.                  Aqu» bullient. 3viij.
                                    Let it stand until cold, then strain, and add
                                       half a pint of the mucilage.

  Very active exercise will not be proper; but a short walk, or ride
in a carriage, should be taken every day,  when the weather is dry,
and sufficiently mild.  In  this, as well as  in all the other forms of
dysuria, it is  important to defend the surface against cold and damp,
and hence the importance of flannel being worn next the skin.
  When dysuria is  connected with inflammation of the neck of the
bladder, a  leech or two may be applied to  the perineum; the bowels
should be kept freely open by the  mildest laxative  enemata, and the
warm hip-bath should be used every evening; in  other respects, the
treatment differs in nothing from that directed for irritability of the
bladder.
  In the  cases of painful micturition, occurring in female  children
from inflammation of the  orifice of the  urethra, we have frequently
found speedy relief to be derived from washing the part, three times a
day, with  a  solution  of acetate  of lead, keeping  the  bowels freely
open by mild  laxatives, putting the patient  upon a mild, unirritating
diet, and using the warm  or  tepid bath daily.  Covering well the
inflamed part, with perfectly  fresh lard  or spermaceti ointment,  by
protecting it  from the contact of the urine, will often enable the  in-
flammation to heal, if it  be of a simple erythematous or phlegmonous
character.
  Some prefer, as a wash,  a strong  solution of the  borate of soda.
In many cases, there exists a slight pustular eruption around the orifice
of the urethra, often occupying the whole  of the fossa in which  the
urethral orifice is situated; in these cases, the diluted citrine ointment,"
will seldom fail to effect a speedy cure.
                   * R.—Ungt. nitrat. hydrarg. 3j.
                        Axung. porcinae, 3j.—M.

   In every case in which there occurs dysuria, or any other symptom
most generally connected with a change in the composition of the uri- 
DISEASES OF  THE URINARY ORGANS.
619
nary secretion, it is all-important to pay strict attention to the condi-
tion of the urine voided, and to ascertain with accuracy its prevailing
character, and according as this  indicates an excess of'the lithic  acid,
or of phosphatic matter, to direct such a course of treatment as will be
calculated to  arrest the secretion  of either.  By these means, perse-
veringly carried out, the formation of stone in the bladder may be al-
most certainly prevented ; while,  by their neglect, or the careless  man-
ner in  which they are pursued, the  child may be subjected, even before
he  attains to  adult  age, to all the  pain and suffering attendant  upon
calculous formations.

             %, — Anuria, — Suppression of  Urine.
   The kidneys  perform their  secretive function previously  to birth;
and, very generally, the moment the child  is born, or, at least, within
a very few hours subsequently, a discharge  of a pale-coloured,  inodor-
ous urine takes place from the bladder.   It is by no  means uncommon,
however, for six, twelve, twenty-four, thirty-six, and even forty-eight
hours  to elapse, before the infant passes any water;  in these cases, it
is  reasonable to suppose, that the function of the kidney has  not been
established.  The infant exhibits  no uneasiness whatever, that  can be
referred to this cause, and the discharge,  when it occurs, generally
goes on regularly.
   The physician need give himself little uneasiness, in consequence of
the child's not urinating for the first twelve hours after birth.  If the
discharge does not then take place, however, it will be proper, in the
generality of  cases, to attempt to excite the action  of the kidneys by
some simple means.  The bowels  should be freely evacuated, by means
of castor oil, or laxative enemata, the child  should be immersed to the
hips in a warm bath, and a few drops of the sweet spirits of nitre may
be given every half hour, in a dessert-spoonful of the infusion of  parsley
root, or of wild carrot seed. When these simple means fail, we confess,
that we have seldom  seen any good result from those of a more active
character.  We are recommended, however, to employ frictions over
the loins  and hypogastric region,  with warm vinegar of squills, or a
mixture  of juniper oil and sweet  oil, or with the expressed juice of
onions, diluted with water;  and, internally,  to exhibit  a  few  drops of
the vinegar of squill, or a drop of spirits of turpentine, in  a teaspoonful
of milk, or four or five drops of the expressed juice of roasted  onions,
every  thirty or forty  minutes; in conjunction with  warm  bathing,
laxatives, and, if necessary, laxative enemata.
  So long as the child exhibits no unusual drowsiness, or restlessness,
there is a possibility of the kidneys commencing their secretory func-
tion, and the child doing well.    We  have repeatedly known the
urinary discharge to be suspended  for upwards of twenty-four hours,
without the least injury resulting.
  In some cases, however, the suppression   of the  urinary discharge
in young infants, is the result of  congenital  malformation of the kid-
neys, ureters, or bladder,  or a disorganization  of the kidneys  from
intra-uterine disease.   Absence  of the kidneys, ureters, or bladder,
though of very rare  occurrence,  has  been occasionally observed ; 
620
DISEASES  OF CHILDREN.
occlusion of the ureters, or of the urethra, is more common, and many
cases are related, in  which, at birth, there was softening of the  kid-
neys, or the pelves were entirely filled with calculous concretions; or
the kidneys were converted  into cysts, or filled with  hydatids.  The
absence of the  urinary secretion has, in  many cases, been dependent
upon congenital disease of the spinal marrow.   We have met with one
or more of these cases.
   When the suppression of the urine  is  dependent on  malformation,
extensive disease, or disorganization of the kidneys, or of the urinary
organs generally, of course nothing  can  be done for the relief of the
patient, who seldom survives more than a day or two; he quickly falls
into a state of stupor, which sooner or later terminates in death.
   Anuria  may occur at any period during infancy and childhood, from
disease of the kidneys.  In many of their acute febrile affections, the
secretion of urine is very considerably diminished, or, for a  time, en-
tirely suspended.  Complete anuria, is  a common  symptom of the
latter stage of hydrocephalus, as well as of other affections of the brain,
or of the spinal marrow.   In such instances, of course, the reinstate-
ment of the function of the  kidneys is dependent upon the reduction or
removal of the  disease with which it is connected.
   In a very interesting case, related by Fosbroke, of suppression of the
urinary discharge in a child, in which the anuria was preceded by
diarrhoea, aphthae of the mouth, cough, strabismus, stupor, and con-
vulsions, the kidneys were found upon dissection, to be  very  vascular,
the papillae projected through the infundibula, and were of a bright red
colour, while the pelves and  ureters contained a quantity of sabulous
matter and tenacious mucus.

             S. — Ischuria. — Retention  of  Urine.
   In ischuria, the urine is regularly secreted by the kidneys, and con-
veyed into  the  bladder,  but its discharge being  prevented  by some
affection of the latter organ, or of the urethra, it accumulates in the
bladder,  causing  it to become  greatly  distended,  with other very
serious, and often painful consequences.
   Complete or partial retention of  the urine may occur in the new-
born infant, in consequence of  an obstruction existing  at the neck  of
the bladder, or in the course of the urethra, from inspissated mucus.
This species of retention is said  to be very common;  but we should
not infer it  to  be so  from our own  experience, having met with but
one or two cases of  it, in  upwards of thirty years' practice  as an ob-
stetrician.   A much more common cause of retention in new-born in-
fants, is  that from occlusion of the urethra, either by a thin, semi-
transparent membrane, situated at its orifice, or a short distance within
it, or by an adhesion of the  lips of the external orifice.   In some cases,
the  retention is caused by a complete closure  of the prepuce.  In other
cases, the cause of retention has appeared  to  be a spasmodic contrac-
tion of the bulb of the urethra.
   In cases of ischuria in the new-born infant, as the urine  gradually
 accumulates in  the bladder, this becomes more and more distended,
 and may, at length, be distinctly felt, forming a circumscribed tumour 
DISEASES  OF THE URINARY ORGANS.
621
above the pubes.  The infant very soon exhibits indications of more or
less pain and distress, which are increased by pressure upon the hypo-
gastrium. The little patient becomes very restless and fretful, his coun-
tenance has  an expression of suffering, and his  legs are constantly
drawn up towards the  abdomen; while the latter, if the impediment
to the discharge of urine be not removed, becomes often enormously
distended, and the skin covering it, acquires  a smooth  shining appear-
ance, as in  cases of ascites;  the superficial veins  being, at  the same
time, greatly enlarged and gorged with blood.
  If the accumulation within the bladder be  allowed to go on, rupture
of the latter may, sooner or later, take place, and quickly destroy the
patient;  or  the  urine,  after enormously distending the  bladder, may
accumulate  within, and produce distension of the  ureters, and, finally,
of the pelves of the kidneys.  In some of these cases, the kidney itself
becomes expanded into a kind of cyst, filled  with urine.
  Inflammation of the peritoneum, effusion into the  cavities of the
brain, and other  serious  consequences,  may result from irremediable
obstructions to the discharge of the urine—altogether  independent of
rupture of the bladder, which we have not found to be a very common
occurrence.
  It is surprising to what an extent, in some of these  cases, the  blad-
der will  become distended ; it  has  been found by Billard, to  fill the
whole cavity of the abdomen, and by Howship, Parrish, and others, to
contain from eight  to twenty ounces of urine, sometimes  mixed with
mucus or albuminous flocculi.   The ureters  have, in some cases, been
so far dilated as to  present a diameter of from half an inch  to one or
more inches.
  In all cases of ischuria, in which  a permanent and irremediable ob-
struction  to the exit of the  urine from  the bladder exists, death must,
necessarily, sooner or later, take place.  In  those, however, depending
upon occlusion of the external orifice of the  urethra, or the want of an
opening in the prepuce, the obstruction may be very readily remedied
by a very simple operation.
  In every  instance in which a new-born  infant is found not to  have
an evacuation of urine within twelve hours, at the furthest—or sooner,
if any  indications of pain or distress exist—the physician should make
a cautious examination of the urethra, by the careful introduction of a
small bougie, by which any obstruction in  that part will  at once  be
detected; and if this result from inspissated  mucus, it will at the same
time be removed.  If the urethra is found to be pervious, and the  in-
troduction of the bougie is not followed  by a flow of  urine, a small
flexible catheter  should, with the utmost  caution, be  passed into the
bladder—for there is reason to believe, that, in some instances, the  re-
tention is caused by a spasmodic action of the  membranous portion of
the urethra, or, when the bladder has been allowed to  become greatly
distended, that  its contractile power may have become temporarily
impaired.   In  this latter case, it will, in general, be prudent to pass
the  catheter daily, until it is found that the  bladder  has regained
sufficient power to completely evacuate itself without artificial assist-
ance, and no tendency to a reaccumulation  remains. 
622
DISEASES OF  CHILDREN.
  Whenever, in cases of retention  of urine occurring in infants, no
obstruction to the  exit of the  urine can  be detected in the urethra or
at the neck of  the bladder, the bowels of the  patient should be freely
opened  by purgative enemata, after  which he should be immersed to
the  hips in a warm bath, and, at the same time, gentle  friction  may
be made over the pubic region with the hand, or with a little campho-
rated oil.   This will  often be sufficient  to  procure the  discharge of
urine, especially should it happen to depend upon a spasmodic affection
of those muscles of the urethra which act as a sphincter vesicae.
  During the whole of infancy, and the  earlier period of childhood,
suppression of  urine is liable to occur from this latter cause.   The in-
ability to evacuate the bladder  may occur suddenly after exposure to
cold, but, more commonly, it results  from some irritation seated in the
rectum, as the oxyures,  or other worms.   In these cases, the warm
bath, an active cathartic, as castor  oil or infusion of senna, followed
by an anodyne injection, and  frictions over the perineum with cam-
phorated oil, with the addition  of a very small  portion of extract of
belladonna, will be the proper treatment.   We have met with a num-
ber of cases of suppression of urine in children about the period of den-
tition, arising evidently from this cause;  and the practice detailed has
always been productive of prompt and entire relief.
  Occasionally, retention of urine in children results from an inflam-
mation of the neck of the bladder.   When this is the case, leeches to
the  perineum, emollient and-laxative enemata, the  hip-bath, and small
doses of Dover's  powder and  ipecacuanha, or of extract of hyoscya-
mus and ipecacuanha, are the remedies indicated.  If by these means
the  ischuria is not quickly relieved, the urine must be drawn off by the
cautious introduction of a small catheter.
  It is scarcely necessary to say, that all remedies, that act directly
upon the kidneys, are improper in cases of retention of  urine ;  they
augment the distress  and danger of  the patient,  by increasing the
amount  of fluid  secreted, and consequently the  distension of the
bladder.
  Under ordinary circumstances,  there  is  scarcely a  possibility for
any  mistake  being made in  the diagnosis of ischuria;  nevertheless,
when the obstruction to the discharge from the bladder is only partial,
after the latter has become  distended to a certain extent, small  por-
tions of urine  are, occasionally, evacuated, notwithstanding a  con-
stantly increasing  accumulation is, in fact, taking  place; and, unless
the  physician  makes,  himself,  an examination of the condition of the
bladder, he will be very liable  to be deceived  by the report of the
mother or nurse, and  attribute  the  suffering of the patient, to  other
causes.  Cases have  occurred, in  which the  bladder  was  finally
ruptured by over-distension, and death ensued from peritoneal inflam-
mation,  when  relief might  have  been afforded, had a retention of
urine been suspected  to exist;  a small  discharge from  the  bladder
deceived the attendants, and  by incautiously depending upon  their
report, the physician was led to form a very erroneous, and unhappily
fatal diagnosis.
  Whenever we are called to  a young infant, who is restless and  fret- 
DISEASES OF THE URINARY ORGANS.         623
ful, and persists in keeping its legs drawn up towards its abdomen, we
are scarcely free from censure if, notwithstanding the assurances of
those about it, that it passes its  urine  regularly, we neglect to make a
cautious examination of the abdomen, by which, if retention of  urine
exists, the fact may be readily detected.

            4.—Enuresis.—Incontinence of  Urine.
   In early infancy, the discharge of the urine, as well as of the faeces,
takes place involuntarily.  As the infant increases in age, and soon
after it assumes the erect position and has learned to walk alone, with
a very little precaution, it will  acquire  a  command over the sphinc-
ters of the rectum and bladder, and  be able to retain the contents of
either, until a proper place and opportunity is offered for their evacua-
tion.
   Children whose parents have  neglected to teach  them regular and
cleanly habits in regard to their evacuations, will often, even after they
have arrived at two or three years of age, void their urine and faeces
the moment the desire is felt;  and what at first resulted from a mere
inattention to restrain, under any circumstances, the natural calls, will
at length degenerate into a partial loss  of the controlling power of the
will  over the sphincters of the rectum or bladder—more particularly
 over the latter—and  the children finally may  become affected with
 real incontinence of urine.  Happily,  however, a  sense of decency,
 which children early acquire, the ridicule of companions, or other in-
 fluences, prevent this latter occurrence, excepting under very particu-
 lar circumstances.
    Still, incontinence is of very common occurrence  among  children oi
 all ages, even up to the period of puberty, and sometimes until  late in
 life.  In some cases, it  evidently originates from  paralysis of those
 muscles by which the  expulsive  action of the bladder is resisted; or
 perhaps from paralysis  also of the bladder; in these cases, of  which
 we have seen  many, the urine dribbles away constantly, being dis-
 charged,  guttatim, as it reaches the bladder.  Some of the patients
 thus affected passed from under our  notice ; some survived until their
 fourteenth, sixteenth, and eighteenth  years, and then died of other dis-
 eases,—in the  majority  of cases of a tubercular  character,—while
 others became  early affected  with  paralysis, hemiplegia, or paraple-
 gia;  and when  they died, exhibited  extensive  lesions of the brain or
 spinal marrow;  one died with all the symptoms of genuine tetanus,
  more  probably, however, the  result  of an overdose  of strychnia, exhi-
  bited by an empiric of the homoeopathic school.
    But  the most common form of incontinence of urine is  that which
  presents itself  in a discharge of urine at  night, while the patient is
  asleep in bed.                                    .
    There are few young children, who, during the intense nocturnal
  slumber peculiar to their  age of life, do not occasionally pass their
  urine in bed, particularly if care has not been taken to cause them to
  urinate just  before going to sleep;  or, if they have been indulged  in
  the use of tea or other  fluids  late in the evening.   But this does not 
624
DISEASES OF  CHILDREN.
constitute a case  of incontinence, properly speaking, though it may
become so by neglect.
  Children affected with enuresis, at  first occasionally, but very soon
habitually, and very generally at a  particular hour of the night or
morning, discharge their urine whilst asleep.
  It is  not  true that incontinence of urine occurs only during  sleep:
not only are the calls to urinate at all times, more frequent and  press-
ing than in health, but the urine, according to Willis, is always more
copious, and of lower specific gravity; it very rarely contains the due
proportion of  characteristic animal ingredients, but is colourless  and
watery.
  This  is  unquestionably true in  the  majority of cases of enuresis in
children;  it is not, however, invariably so;  in numerous instances, as
Prout remarks, the urine contains an  excess of sedimentitious matter,
particularly lithic acid and its compounds, which impart to it an acrid
and irritating  character.   The patient has, at all times, frequent calls
to pass his urine, and is unable to retain  it for any time after the  desire
is experienced.
  It is  probable that the discharge, during sleep, in many cases, par-
ticularly when it  has  become habitual, is entirely involuntary,  and
takes place without the patient being  at  all  conscious of the act.   In
numerous instances, however, there  is no  doubt, as Prout very justly
remarks, that  the discharge  is a voluntary effort, excited  by a  lively
dream ; the dream being prompted either by the distension  of the blad-
der, or by the stimulating properties of the urine.
  It has been  said, that a discharge of urine never  takes place during
sleep, excepting when  the individual  is  lying on his back; the  urine,
in this  position, gravitating  in such  a direction as to press directly
upon the  " sensible  spot—the  master spring" of the  muscles of the
bladder, " situated a  little  behind and  below its orifice."  (Charles
Bell.)  This statement is by no means correct; from personal  obser-
vations, made under circumstances peculiarly favourable for arriving
at correct conclusions, we  know, as rematked by  a late judicious
writer  on urinary diseases—Willis—that children  affected with noc-
turnal incontinence of urine, pass their  water while sleeping in  any
position, probably, even more frequently when they  happen to be lying
on their face, than  in any other posture.  Whoever, therefore, trusts to
position alone  for the cure of incontinence of urine in children, will be
sure to be disappointed.
  That the affection, whatever may have originated it, is very com-
monly continued and confirmed  by habit, is proved by the fact,  that
by watching the patient, to ascertain  the particular hour at which the
discharge takes place, and waking him just before it arrives, to enable
him to evacuate his bladder, he will in a  very  short time either awake
of himself, and  thus the wetting  of the  bed be prevented, or he  will
acquire, in time, the power  of retaining his  urine during the  entire
night.
  Though a trifling malady in itself, so far as the general health  of the
individual is concerned, incontinence of urine is often  one of serious
importance, from the physical suffering and moral misery it occasions, 
DISEASES  OF THE URINARY ORGANS.         g25
when the child arrives at an age capable of feeling the shame so gene-
rally attached to his infirmity, and the scorn and ridicule heaped upon
him for, what in the production of which he had as little agency as he
has power to prevent its continuance.   Boys, remarks Willis, have
been  known, who had been  beaten  unmercifully for wetting the bed,
to sleep, or rather pass the night, in  their  clothes, on the floor or in a
chair, for several nights afterwards, till, worn out with fatigue, they
found themselves  compelled to undress, and take natural rest; hoping,
as they had escaped  one or  two nights, passed  between sleeping and
waking, they might possibly get through another, and yet sleep soundly.
But in vain: the very first night after betaking themselves to their bed,
they were as unfortunate  as ever; and then  came the renewed beating,
and, far worse to bear, the ridicule and scoffing of companions, or the
other members of the family.  It is the duty of physicians to point out,
on every proper  occasion, the serious consequences which  such  im-
proper and cruel  means,  originating  in an entire misconception of the
nature of the complaint, are capable of producing.
   It is curious, that in relation to an affection of every-day occurrence,
so great  a difference should exist  as  to  the  sex in which it is most
commonly observed; thus, by Wardrop, it is said to occur only in
boys; by  Steward that girls are more  subject to it than boys; while
Millar affirms that it is equally common in children of both sexes. Now
the fact is, that neither sex is exempt from its  occurrence, although,
according to  our own experience, it is certainly far more frequent in
the male than in the female.
   In regard to the treatment of  nocturnal enuresis in children, we  be-
lieve the general want of success, attendant on the various plans that
have been proposed  for its cure, has arisen from an entire mistake in
regard to the true nature of the  disease, and from  the remedies being
directed to remove  some supposed  morbid condition of the  bladder,
which seldom or ever exists.  Our own observation has taught us  the
entire correctness of the views of those writers, who refer the disease,
primarily, to a derangement  of the digestive and assimilative organs,
and a consequent morbid change in the constitution of the urine.  We
have seldom  seen a case of  nocturnal incontinence of urine, without
its being accompanied by more or less derangement of the digestive
organs; and have very generally found, that when this is removed,  the
involuntary discharge of urine ceases.
   In those cases  in which the urine contains an evident excess of lithic
acid, the course  of treatment directed, under  similar  circumstances,
for the cure of dysuria, will be equally proper here.  Daily exercise in
a pure, dry air;  avoidance of cold and dampness;  a diet composed of
a moderate  portion of plainly-cooked beef, mutton, or chicken, with
the least  ascescent of the farinaceous  preparations, and the daily  use
of the  warm or tepid bath, with  friction to the surface, and a prudent
use of alkaline carbonates, as  magnesia, the bicarbonate of soda, or
the  carbonate of potassa, with  light bitters and tonics, and a gentle
purgative and well-directed  alterative course, will in most  cases  be
found sufficient  to improve  the condition of the digestive organs, as
well as of the urinary secretion; and as these changes take place, the
                                 40 
626
DISEASES OF CHILDREN.
involuntary discharge of urine during sleep will become less frequent,
and finally cease entirely.
  When the condition  of the urine  is that pointed  out by Willis—
namely, pale and watery, of diminished specific gravity, and deficient
in its usual animal ingredients, the same attention should be directed
to restore the healthy function of the digestive organs, and bring back
the urinary secretion to its normal state.  Any light bitter infusion,
acidulated with hydrochloric  acid, with the addition of a very small
proportion of the tincture of opium, will be found a useful remedy in
these cases;  or we may administer, as directed by Willis, a couple of
tablespoonsful of the concentrated decoction of uva ursi, with the ad-
dition of ten drops of the tincture of the sesquichloride of iron, two or
three times a day.   The dose of the latter remedy here directed, is that
adapted to a child of five or six years of age; but a  younger patient
will  seldom bear more than a teaspoonful at a time of the decoction,
and  from  three to five drops of the  tincture of the sesquichloride of
iron, which may be repeated, if necessary, three times in the course of
the day.   Cold, or in very young and delicate children,  repeated tepid
sponging of the perineum and pubes, has been found beneficial in some
cases. In  others, according to Willis, a blister  to the sacrum has suc-
ceeded in relieving the complaint; we have used the blister frequently,
occasionally  with  complete success;  in  others, with  no advantage
whatever.
  Success has  more  than once followed the use of  sedatives, as
camphor, digitalis, nitrate of potassa, benzoic acid, &c, where tonics
and stimulants, which at first appeared to be rationally indicated, have
failed.
  Children, as  a general rule,  but more especially when affected with
nocturnal incontinence of urine, should not be allowed  to partake of
large quantities of any kind of fluid, either as drink or food, in the latter
part  of the afternoon and evening.  They should indeed be prohibited
from the use of every species  of food a short  time before retiring to
rest.   The caution should be observed to cause them to evacuate the
bladder just before being put to bed; and to wake them for this purpose
at regular intervals during the night.
  Cases, however, occasionally occur, in which none of the means em-
ployed is productive of any permanent benefit.  In these obstinate cases,
it has been supposed that the infirmity could be traced to a congenital
deficiency of control  over the sphincter of the bladder, the children
wetting themselves whenever  sharply spoken  to,  or frightened:—we
have repeatedly met with such cases in children of an eminently  ner-
vous constitution.   But the most obstinate cases have appeared  to us
to occur in very profound sleepers, and to be kept up by the bladder
having acquired a confirmed habit of evacuating its  contents at a
particular hour.  The bladder may acquire this habit, so that, even in
the day-time, when the patient is perfectly awake, he finds the utmost
difficulty to retain his urine beyond the particular period when its dis-
charge has been accustomed to take place.
  It  is in these cases that the exhibition of the  tincture of cantharides
will be found beneficial.   By the  irritation it produces about the neck 
DISEASES OF THE URIJNARY ORGANS.
627
 of the bladder, the moment the urine begins to flow, a degree of stran-
 gury occurs, sufficient  to awaken  the patient, and  thus prevent the
 evacuation taking place in bed.  This effect being repeated for several
 nights in succession, the habit upon which the involuntary discharge
 takes place, is entirely  broken up,  or  the child  will become accus-
 tomed to awake when the desire to urinate occurs,  and thus all the
 disagreeable consequences resulting from his unfortunate infirmity be
 prevented.  From three or six, to ten or fifteen drops of the tincture
 of cantharides, according to  the age of the child, may be given three
 times in the course of the day, and the dose should  be  gradually in-
 creased, until a  degree of  strangury  is  experienced in voiding the
 urine.  The moment  this  effect  is produced, the medicine should be
 given only in small occasional doses, so as to keep up, for a few nights,
 a slight degree of irritation at the neck of the bladder.  Of course the
 employment of the cantharides is proper only  in protracted cases, un-
 connected with derangement of the digestive organs, and a  morbid
 state of the urinary secretion.  Should too violent a degree of strangury
 ensue from the action of the cantharides, it may be abated by the  free
 use of emollient enemata and mild mucilaginous drinks, small doses of
 camphor  in the form of emulsion,  and the warm hip-bath.  If these
 means are not immediately  successful, an anodyne enema  may be
 given.
  Morand has  long been  in the  habit  of  employing belladonna,
 internally,  in  nocturnal incontinence of urine in children, and  with
 very satisfactory  results.  It  is, however, only  when  the incontinence
 results  from debility  that it  is beneficial.  He gives it in gradually
 increased doses.  A pill containing three-fifths of a grain is  at  first
 given to children between four and  six years of age, night and morn-
 ing.   If no effect is produced at the end of a week, a  third pill is
 given at noon ; and, after fourteen days, a fourth, if necessary.  In this
 manner the remedy must  sometimes be continued for two, three, or
 four months in succession.  In cases of children between eight  and
 fifteen years he begins with three pills, increasing the number as above.
 If signs of narcotism supervene, the  medicine must, of course, be for a
 time suspended.
  Dr.  Berengieur, in cases  of  incontinence of urine succeeding to
 obstinate  attacks of intermittent fever, in children between  seven
 and fourteen years of age, found the most successful remedies to be a
 combination of copaiba, laudanum,  and protoxide of iron, made  into
 pills, in the proportion of three parts by weight of the former, to six
 of the latter.  Of this  mass one pill,  weighing from two to three grains,
 was  given morning, noon, and evening; and after every two or three
 days, an additional pill,'  until  the patient takes ten  daily. ,  Along with
 the pills, an infusion of  the folia juglandis was ordered as a common
 drink.
  The employment of strychnine has been recommended in cases of
 enuresis occurring in children,  by  Moudiere,  Cherchiare,  Lendrich,
 Schnatz, and others.   Upon what principle it is supposed to prove bene-
ficial, we are unable to  conceive : we have given  it a trial, but found
it, when administered in very small  doses, to do no  good; and  when 
628
DISEASES OF CHILDREN.
given in larger doses, its effects upon the nervous  system have  been
too violent to warrant a continuance in its use.
   When everything else fails, we may resort, in the male, to mechani-
cal contrivances for  compressing the urethra,  and thus prevent the
escape of the urine.  The best  is  that  recommended by  Willis, in
which a firm, but not hard pad, is kept applied by means of a spring to
the membranous portion of the urethra.  This  should not, however,
be permitted to be worn habitually; it may be used, occasionally, with
perhaps considerable benefit;  and  when children are visiting  from
home, will insure from  the shame  and mortification incident  to this
infirmity.  Ligatures to the penis, or the use of jugums,  should never
be permitted, as much mischief is liable to result from them.
   In not a few  instances,  incontinence of urine  is kept up by the irri-
tation of the oxyures  worm in the rectum.  When this is the case, an
enema of aloes, or assafoetida,  dissolved in milk, or of turpentine dif-
fused in mucilage, will destroy  the worms, and a well-regulated  diet,
exercise, the warm or tepid bath, and friction of the  surface will, in
general, tend to prevent their return.  Should,  however, the rectum
become  again  infested with them,  a repetition of  similar enemata
should not be neglected.

                          5. — Diabetes.
   There can be no doubt that children are frequently affected  with a
species of hyperuresis, in  which the urine discharged differs but  little
in its sensible qualities from  common water, being perfectly  limpid,
entirely colourless, with scarcely any odour, and  after standing for
ten or twelve hours, becoming slightly opalescent or milky.
   This affection usually occurs in children of debilitated constitutions,
emaciated, or quickly becoming emaciated, with  soft protuberant abdo-
mens, and listless, torpid, indolent dispositions.   The appetite is gene-
rally  voracious, and the  thirst incessant and insatiable.  The child
desires everything of an eatable kind  that he sees, and is constantly
crying for water, large quantities of which he will swallow at a time,
if not restrained.   The bowels are usually constipated or irregular, and
the digestive process is disturbed, as well  by a  diseased condition of
the stomach, as by the amount of food, often, of a  crude and  insolu-
ble kind, with which this organ  is always overloaded.  It is not uncom-
mon for the discharges from  the bowels to be mixed with portions of
undigested aliment, particularly of the vegetable substances that have
been swallowed, whether cooked or uncooked.
   Mellituria.—Diabetes mellitis is a  much  more rare disease  during
childhood ; that it occasionally occurs there can be no doubt.  It has
been observed by M'Gregor and Willis, in boys of three and five years
of age, and in both boys and girls about twelve.  In  one of the cases
referred  to by  Morton (Phthisisologia), we are expressly told that the
urine was mellea dulcedo; while in the disease described by Venables,
as tabes diuretica,  the urine was evidently insipid.
   Diabetes in children seldom occurs during lactation. It would appear
to depend, very generally, upon derangement  of the digestive and assi-
milative  functions, consequent upon the  use of improper  food,  subse- 
DISEASES OF THE  URINARY ORGANS.
629
quent to weaning.   A confined, damp, or impure atmosphere, the want
of sufficient exercise, and a congenital infirmity of constitution, are, no
doubt, also very common exciting or predisposing causes.
   The child exhibits at first, no striking symptoms of disease, but be-
comes gradually dull, listless, and fretful;  loses  its usual playful and
active disposition, and exhibits an uneasy, discontented, and anxious
expression of countenance.  The  bowels  are generally regular, with
little or no deviation from the  natural and healthy appearance of the
discharges. The  tongue has  a  natural  appearance.  At  an early
period, however, there is an increased  discharge of  urine, increased
thirst, and a more  craving appetite than usual;  and these symptoms,
with the  gradual emaciation, and dry, harsh  state of  the skin, are in
general referred to the presence of worms in the intestines, for which
the child is treated—the real nature of the disease being entirely over-
looked.
   The emaciation goes on increasing, while the abdomen becomes
more tumid, but without much tenderness or tension.   The tongue be-
comes coated with a thick layer of mucus; the bowels become consti-
pated or  irregular, and the  stools  acquire an unnatural appearance,
being occasionally slimy and green, or  mixed with portions of undi-
gested food; while occasionally they are frothy, light-coloured, and
apparently in a state of fermentation.
   The thirst rapidly increases, as well as the craving  for food, and at
the same  time the  discharge of urine augments rapidly in quantity, be-
coming often enormous;  exceeding at times, perhaps very generally,
the amount of fluid taken.  The emaciation goes on with increasing
rapidity, and is attended often with extreme  debility; while  the skin
becomes uniformly dry, and  very  harsh.   There  is almost invariably a
gnawing  sensation at  the pit of  the stomach, and increasing dulness,
inactivity of disposition, and depression of mind. The pulse, which
was at first somewhat accelerated, becomes now small, quick, and
hard.
   The latter stage of  the disease is often accompanied with a con-
siderable  degree of febrile excitement, often  attended with  headache,
vertigo, and temporary delirium.   In cases of long continuance, oede-
matous swellings of the lower extremities, or even general dropsy have
been known to occur.  The  child gradually sinks, apparently from  an
entire suspension of the nutritive  process; in other  cases, a  state of
deep coma precedes the fatal event.
   The urine discharged is generally pale, perfectly limpid, without the
least trace of sedimentitious matter; in some cases, however, it is of
a  milky appearance, and  slightly turbid, and  occasionally of a very
light-yellow or  greenish hue,  having a  very close  resemblance  to
whey.
   Diabetes is always to be  considered  as a  serious  disease.  When
detected in its early stages, it is very possible that, by  a proper course
of treatment, its fatal  termination  may be very generally prevented;
but, unfortunately, it is seldom  that the disease falls under the notice
of the practitioner, until it has  existed for some  time—the discharge
of urine  increases so slowly in amount, that it is entirely overlooked 
630
DISEASES OF CHILDREN.
by the parents of the child, or if  noticed, is ascribed to the enormous
amount of fluids which his morbid thirst prompts him to take.  Even
when a physician is consulted, the case is too often considered as one
of worms, mesenteric disease, marasmus, or dropsy of the brain; and
an  improper  course of treatment  adds  then to the fatality of  the
disease.
  The first attention of the physician should be directed to restore the
healthy action of the digestive and assimilative organs;  for unless this
can be accomplished, there is very little hopes of arresting the inordi-
nate and unhealthy action of the kidneys.
  The child should be put upon a strictly regulated diet, composed of
the more digestible kinds of animal food, plainly cooked, with prepa-
rations of milk, eggs,  and rice or oatmeal, without  sugar; crackers
should be given in preference to bread, or if bread be eaten, it should
be well toasted.   In the quantity  of food taken, the patient should be
so far restrained  as to prevent the stomach from becoming at any
time overloaded; probably four meals a day, at stated  hours, a very
moderate quantity being eaten  at each,  will be most advisable.   The
patient  should  be positively restrained  from the use  of  all crude,
ascescent, or saccharine  vegetables  or  fruits;  and  for his drink, he
may take  toast-water, slightly acidulated with hydrochloric or nitric
acid, but  in no larger  quantities  than  is absolutely necessary to allay
thirst; tea, coffee, lemonade, thin gruel, whey, and the  like,  must be
absolutely prohibited.
   With this diet, a due amount of exercise should be taken  daily, in
a dry, pure, temperate atmosphere:—the patient should be allured out
of doors  for  a  short walk, or if  too torpid or debilitated for walking,
he  should ride, or sail upon the water  every day, when the weather
will permit.
  The  functions  of the skin appear to be, in a great  measure, sus-
pended, in cases of diabetes; hence,  the  warm  bath, and  friction of
the surface,   become  important  measures, and should be daily re-
peated.
  The bowels should be freely purged, and kept open, subsequently, by
gentle aperients.  In the first instance, we may give  a comhination of
aloes, rhubarb, and the bicarbonate of soda ;a or aloes,  gamboge, car-
bonate of soda, and extract of hyoscyamus.b   When the bowels have
been  fully evacuated by either of the  foregoing  purgatives, they may
be kept regularly open by a  combination of calomel, extract of hyos-
cyamus, magnesia and ipecacuanha.'
    * R.—Aloes, gr. xij.                   b R.—Aloes, gr. xij.
        Pulv. rhcei, gr. xxxvj.                  Gambog. gr.  xij.
        Bi-carb. sodse, gr. xxiv. — M.  f.         Bi-carb. sodae, gr. xxxvj.
            pill. No. xiij.                     Ext. hyoscyami, gr. xij.—M. f.
Of which one, or two, or three, may be given,            pill. No. xiij.
  according to the age of the child, every  This forms a very prompt, gentle and effec-
  three hours, until they operate freely.        tual purgative,  when  one pill is given
                                     every three hours.
                    c R.—Calomel, gr. xij.
                         Magnesias, gr. xxxvj.
                         Ipecac, pulv. gr. iij.
                         Ext. hyoscyami, gr. vj.—M. f. ch. No. xij.
               One to be given once or twice a day, as may be necessary. 
DISEASES  OF THE URINARY ORGANS.          Q%\
  In  some  cases, according to Richter, emetics  of ipecacuanha, re-
peated  daily, for two  or three days,  in the  commencement of the
disease, have been found beneficial.
  Occasional small doses, say one grain to a  child between one and
two years old, of the compound powder of ipecacuanha, may be given
two or  three times a day, after the bowels have been fully evacuated.
Combining  the opiate with uva  ursi, or  the carbonate or phosphate of
iron,* is said, by Venables and Reirson,  to be attended, in many cases,
with the most decided benefit.   A  combination of uva ursi, carbonate
of soda, extract of hyoscyamus, and  carbonate of iron, will likewise
be found  a  very valuable remedy ;b or the uva ursi, extract of  hyoscy-
amus, and iron  may be prescribed in a fluid form,c which is preferable,
generally, in cases of the  disease in children.
     * R.—Pulv. ipecac, comp. gr. xij.          b R.—Pulv. uvae ursi, 3ss.
          Pulv. uvae ursi, 3ss.—3j.—M. f.          Bi-carb. sodse, gr. xxiv.
             pulv. xij.                         Ext. hyoscyami, gr. xij.
                                            Carb. ferri, gr. xxiv.—M. f. ch.
   Or, R.—Pulv. ipecac, comp. gr. xij.                  No. xij.
          Carb. ferri, 3ijss.—3j.—M. f.        One to be given three times a day.
             pulv. xij.
                                        c R.—Extract, hyoscyami, Qj.
   Or, R.—Pulv. ipecac, comp. gr. xij.'              Aquae, 3j.—M.
          Phosphat. ferri, gr. xxiv.—xxxvj.  Five drops of this  solution, and the same
             —M. f. pulv. xij.            quantity of  the tincture  of the scsqui-
One of either of these formulae may be given    chloride of iron, may be given three times
  to a child between one or two years of    a day, in a teaspoonful of an infusion of
  age, every four hours.                    uva ursi, one ounce to the pint of boiling
                                      water.
   Infusions of colomba, gentian, or quassia, may be used occasionally,
with  very good effect.
   During the period of dentition,  careful attention should be  paid to
the condition of the gums, and if  these be  swollen, painful, and red,
they should be  freely scarified.
   By Dewees, the external application of the spirits of turpentine is re-
commended in cases of diabetes in children. There can be no doubt, that
in nearly all the diseases of childhood dependent upon a highly deranged
state of the alimentary canal,  of a chronic  character, turpentine  con-
stitutes, when judiciously employed, one of  our most beneficial reme-
dies ; and,  so far as the disease of the digestive organs is concerned,
we have  no doubt it would  prove an appropriate remedy internally, in
the species of  hyperuresis  under  consideration.   We   have been  de-
terred  from prescribing it, however, lest its action upon  the  kidneys
might prove prejudicial.
   The  tannin has been used by Giadorou in some cases of diabetes,
with  success;  and  is worth a  trial, in a disease, which, in children, it
is particularly difficult to control.3
                          a R.—Tannin, £j.
                               Ext. hyoscyami, gr. iv.—M. f. ch. No. xij.
One of these may be given to a child over one year of age, every three hours, the quantity
        of tannin in each dose being gradually  increased to ten or fifteen grains. 
632
DISEASES  OF CHILDREN.
                   SECTION  VII.

CONGENITAL AFFECTIONS, AND ACCIDENTS OCCURRING,
        MOST GENERALLY, WITHIN THE MONTH.
                        1. —Fractures.

  Fractures of the bones of the extremities are sometimes produced
during birth, especially in cases  where, from a mal-position or presen-
tation, turning, or other manual interference, is  required; we have
known the fracture of the humerus repeatedly  take place by improper
and unskilful attempts to bring  down the arm after the protrusion of
the head in cases of ordinary labour.
  In all instances in which this accident has unfortunately taken place,
the fact should be at once explained  to those who have  the care of
the infant, and measures immediately taken, after  the child is washed,
to secure the fractured extremities in apposition, by a proper bandage
and splints.  What we have found to  answer perfectly well, even in
fractures of the thigh in the  new-born  infant, are, narrow strips of
thin pasteboard, well moistened  in warm water, then neatly enveloped
in soft linen, applied to the limb, after the proper adjustment of the
latter, and secured in their place by a proper bandage.  These splints,
if made sufficiently soft, mould  themselves to the shape of the 'limb,
and when they again dry, present a sufficient resistance to the feeble
action of the  infant's muscles.   It is necessary,  however, to watch
carefully the limb until the drying of the splints,  lest in handling the
child it be accidentally bent at the place of fracture, or the fractured
extremities of  the bone otherwise displaced.
   Fractures in infants heal  rapidly and promptly,  and give little incon-
venience, if properly secured.   As nutrition at this period  is rapid,
reparation takes place also readily; a child may suffer  more, observes
Blundell, and incur more danger from cutting a tooth, than  a new-born
infant from fracture of the femur or of  the humerus.

    2.—Congenital  Malformations  of  the  Intestines.
   Congenital malformations of the intestines being of frequent occur-
rence, and capable of being removed or relieved, in many  cases, by an
operation, a treatise on the  diseases of children w7ould  seem  to be  in-
complete without some notice of these affections.
   The malformation may consist in the constriction of the calibre of
the intestines,  at different points—in the entire closure of the canal by
transverse membranes—in its division into separate parts—in the ab-
sence of the lower portion of the rectum, and  in its termination in the 
CONGENITAL AFFECTIONS,  ETC.
633
 vagina in the female, or in the bladder in the male—or in the occlusion
 of the anus,  by a membrane of greater or less thickness.
   The first three of these species of malformation are necessarily and
 promptly mortal.  Neither meconium  nor excrement is voided—the
 milk  and other fluids taken, are  speedily vomited, and  in  many in-
 stances, there is  discharged from the  stomach a yellowish or dark-
 brown fluid or  meconium.  Death may occur in a  few hours, or not
 until  the  termination of  several days—the child often becoming ex-
 tremely emaciated.
   A more frequent species of malformation, is the closure of the anus
 by a  membrane, differing in density and thickness, in different  cases.
 This  malformation is readily detected by the absence of any external
 opening—and the distension of the anus by the meconium accumulated
 in the rectum;  this distension  is more apparent when the child  cries;
 at which  time, also, a fluctuation can be very readily felt beneath the
 occluding membrane.
   As  soon as  this malformation is detected,  a crucial incision should
 be  made, with a sharp-pointed  bistoury, through the  membrane by
 which the anus is closed—care being taken not to divide the sphincter
 ani, as this may give rise to a troublesome and long-continued invo-
 luntary discharge of the  faeces.
   Occasionally, the imperforation is  situated  some distance within the
 anus, the  latter being perfectly formed.  Whenever no discharge takes
 place from the  infant's bowels within a few hours after birth, a careful
 examination  should be made  into the state of the rectum;  and if the
 imperforation exists at the lower portion of  the gut, it will generally
 be detected by the introduction of a gum elastic catheter.  The ob-
 struction  may,  in many cases, be removed by an operation;  the nature
 of which  will, in a great  measure, be governed by the  circumstances
 of each case—whether  by the introduction of a trochar and canula,
 as directed by some, or  by the straight-pointed bistoury, as directed
 by others. The greatest  caution should he observed in the introduc-
 tion of the instruments, as well  as in the division of the obstructing
 membrane, lest the sides of the intestine be  wounded, or an opening
 be made  into the bladder or vagina.
  We have lately seen a case of this species of malformation, in which
 the obstruction, consisting of a transverse membrane, existed about an
 inch and a half within the anus, the lower portion of the rectum being,
 in all respects,  perfectly formed.  The child lived four days, and, until
 within a few  hours previous to its death, presented no indication of the
 existence  of the obstruction, excepting the absence of all discharges
 from  the bowels.   Shortly before death, great tumefaction of the ab-
 domen from the development of gas took place,  with evident pain on
 pressure of any portion of the abdomen; no  operation was permitted
 by the parents.  An examination of the body revealed  the nature of
 the obstruction—a firm, membranous partition, existing about one  and
 a half inches  above the termination of the'gut, and forming a complete
obstacle to the further passage  of the contents of the bowels.   The
small  intestines were perfectly  empty, greatly  contracted, and free
from the  least  trace of disease; the  colon was enormously distended 
634
DISEASES  OF CHILDREN.
with gas, and, throughout its whole  extent, injected with  blood;  the
upper portion of the rectum was likewise greatly distended, and con-
tained nearly eight fluid ounces of meconium and thick, ropy mucus;
its mucous coat presented very  decided marks of inflammation.
  The colon, as well as the rectum,  was found  congenitally deficient
in a case recorded by Lehman; the  ileum, on  arriving at the place
where  the colon  should have commenced, terminated  in a'blind  sac
filled with meconium.
  Another common malformation of the rectum is a firm adhesion of
its sides, often for many inches above its natural  termination, with a
total absence of any trace of anus or of sphincter muscle.  The skin
retains  its natural colour over  the whole space between the  parts of
generation and the coccyx, without being elevated in one place more
than in  another, and having the same firm, fleshy feel throughout.   In
such cases,  the intestine sometimes  terminates in  a cul de sac, about
an inch above the ordinary situation of the anus, or it may not descend
lower than the projection or upper portion of the  sacrum; occasion-
ally, it  opens  into the bladder or vagina.   We have seen a case in
which the gut, upon reaching the top of the sacrum, suddenly became
contracted to the size of one of the ureters, and passed obliquely  for-
wards  and  downwards  to  the fundus of the  bladder, into which it
opened  by an  orifice that would scarcely admit a large bristle.
   In  these  cases, it has been  advised to  make an incision, about an
inch long, in the situation where the anus ought to have existed,  and
then gradully to  deepen it  in the natural  direction of the rectum, by
successive strokes of the scalpel, the index finger of the left hand being
used as a  difector.   By this  means, the  end of the rectum  may be
often reached, and a  discharge of the fasces procured;  and, by keep-
ing the artificial passage permanently dilated by tents of oiled linen or
bougies, of a proper size, the life of the child may be preserved.   It is
seldom, however, that the patient will acquire the  power of retaining
the faeces, or that the use of the tents can be abandoned, at any time
subsequently,  without a contraction of the  passage  speedily  taking
place.
   If the termination of the rectum cannot be reached by the operation
just described, it has been advised—as death must inevitably follow—
after the incisions have been carried as far as the  finger can reach, to
introduce upon the latter a long trochar, in such a direction as will be
best calculated  for finding the termination of the rectum.  We have
seen this tried in several cases, but never with  any success.
   When an outlet for the faeces cannot be  procured  by either of the
above means, it has been proposed by Littre  and Sabatier, to make an
opening into the abdomen above the pubes, near one of the groins; by
Duret in the left iliac region;  by Callisen and Amussat in the lumbar
region, between  the  posterior  border and crest of the ilium, parallel
 with the posterior edge of the quadratus muscle, or perpendicularly, in
 order to get at the colon, and form an artificial anus, in one or other
 situation.   Duret is said to have performed  the operation in  the  iliac
 region, and Amussat in the  lumbar region, with success, in several
 cases. 
CONGENITAL  AFFECTIONS, ETC.
635
   A case is related by Roux, in which the rectum opened in the ure-
thra, and  others by Dubreuilh, and  by Steele of New York, in which
the rectum was entirely wanting, the colon opening into the neck  or
summit of the bladder.  The case of Roux was successfully treated  by
incisions from the natural position of the anus, in the direction of the
rectum.
   It has been supposed by many surgeons of eminence, that inconti-
nence of faeces must be an inevitable result of an artificial anus esta-
blished  in the  perineum or coccygeal region, not in connexion with
the sphincter ani.  The inaccuracy of this supposition is  proved by the
case of a patient operated on some years ago by Amussat of Paris.
This patient has been under  the care of Sir P. Crampton, up to the
present period, and he states that no such infirmity exists.

                        I — Tongue Tie.

   Physicians are frequently called upon to  relieve, by an incision, the
tied  tongue  of infants; an accident supposed  to be  produced by  a
malformation of the fraenum linguae.  It often happens, that in young
infants, the fraenum approaches  very near to the apex of the tongue;
and it is possible that, in some instances, the impediment  to the free
motion of the tongue thence resulting, may render sucking very diffi-
cult, or even impossible.  We confess that we have never  met with
such a case; though, if nurses are to  be  believed, it is a thing of the
most common occurrence.  Infants occasionally appear to suck with
difficulty,frequently letting go and reseizing the nipple; in other cases,
the act of sucking is accompanied with a kind  of clucking  sound:—
this is almost invariably attributed to the tongue being tied.  We have,
however,  repeatedly examined the tongue in such cases, and have de-
tected no  malformation of it, or  of its fraenum:—nothing, in fact, to
interfere with its movements.  Burns declares that he has not seen two
instances  in which a malformation of the fraenum rendered any opera-
tion really necessary.  Marley has  seen  but one; the operation Un-
derwood declares to be very rarely necessary; and the same observa-
tion is repeated by Maunsel.  The tongue is sufficiently free for all its
functions, if the tip can be advanced  beyond the outer margin of the
lip, or  placed  upon the roof  of the mouth.  An operation is requisite
only, in cases where the confinement is  such as to prevent either of
these movements.
   When an  operation is absolutely  necessary, it consists in dividing,
with a knife or scissors, the anterior edge of the fraenum; taking care
that the incision be not carried so far as to  endanger a division of the
lingual vessels, and thus give  rise to a troublesome and dangerous hae-
morrhage.
   The head of the child being held  firmly, with the face upwards, the
operator, standing behind the top of the head, inserts the first and second
fingers of the left hand into the mouth, beneath the tongue,  and places
one on each side of the fraenum, when the latter may be cautiously
divided, to the extent deemed necessary.
   Of the accidents that have  been said to result, in some cases, from 
636
DISEASES  OF CHILDREN.
  this operation, we  need  not speak;—by proper caution and skill on
  the part of the operator, they can, in every instance, be very readily
  avoided.

               4. — Haemorrhage  from the Navel.
     Haemorrhage may take place from the cut end of the cord, in con-
  sequence of the imperfect manner in which this has been tied, or the
  improper materials of which the ligature is  composed, or from impro-
  per handling on the part  of the nurse in adjusting the dressing of the
  navel, by which the ligature  is  displaced;  or, more rarely, from the
  thick, firm, gelatinous matter with which the  vessels of  the cord are
  enveloped,  preventing the ligature from  acting with sufficient force
  upon them to cause their closure; the  prevention and  remedy in this
  form of haemorrhage are  sufficiently evident.
     The haemorrhage does  not, however,  always result from the divided
  end of the cord.  We have, in several  instances, found  the umbilical
  vessels perfectly secured,  but a constant oozing or percolation of blood
  to take place around the  root of  the cord, at  the part where it is im-
  planted in the walls of the abdomen, and in only one instance were we
  able to arrest the  flow of blood; in all the other cases the patients
  perished exanguinous. In the instances  alluded to, we directed a pow-
  der to be formed of starch, two parts,  sugar one  part, with an addi-
  tion of powdered acetate of lead, amounting to one half the quantity
  of sugar;  this powder was applied around the  cord, at the seat of the
  haemorrhage, and an additional quantity constantly added as the blood
  penetrated  through the  former;  after  three hours close watching, a
  firm crust was formed, through which the blood no longer penetrated,
  at the end of twenty-four hours, the crust separated, without the hae-
  morrhage returning.  We tried this plan in  another case without  suc-
  cess ;  the blood flowed too freely to allow of the proper hardening and
  adhesion of the  paste formed by its mixture, but flowed through, as
< well as beneath it.
     Another, though  more rare, still  not uncommon form of umbilical
  haemorrhage in young infants, is described by Dewees; in this, the
  flow of blood takes place from the side of the cord, in  consequence of
  a rupture or ulceration of one of the varicose dilatations of the umbi-
  lical veins.  We have seen one or two  such cases.   The arrest of the
  haemorrhage is, in  general, very easily effected by the application of a
  ligature around  the cord, below the place  at which the blood is dis-
  charged.   In one instance, however, from this being situated near the
  base of the cord, we found  a good deal of difficulty in applying the
  ligature, and only succeeded, finally, by drawing out the  cord until the
  skin surrounding it was put upon the stretch.   The ligature appeared
  at first to  cause no inconvenience to the infant, but towards the close
  of the second day, so great a degree of pain  was evidently produced
  by it, that we were induced to  divide  it; the  haemorrhage, however,
  did not return.
     There is still another form of haemorrhage that  occasionally occurs
  at the navel, and is sometimes  attended with  a good deal of trouble,
  and often  endangers the life of the child.  This takes  place after the 
CONGENITAL  AFFECTIONS, ETC.
637
separation of the cord.  In place of the navel cicatrizing, it remains
open, and a soft fungus rises from its centre, from which  there is a
constant oozing of blood that may continue for a long time, causing,
by the extent of the haemorrhage, the utmost debility of the child, and
putting his life often  in imminent danger.   The application of lunar
caustic may stop, for a time, the discharge of blood, hut we have never
known it effectually to arrest it.  We have occasionally succeeded by
pursuing the plan recommended by Underwood, namely, the application
of a dossil of lint, kept in its place by cross strips of adhesive plaster,
and  secured by the  proper adjustment of the belly-band;  more fre-
quently, however, we have found that covering the navel with a pow-
der of starch, sugar, and acetate  of lead, and  then applying over this a
graduated compress, secured by  a broad bandage passing around  the
child, will more effectually prevent the discharge of blood, and allow
the navel to cicatrize.
   However trifling these  haemorrhages may appear when  described
in books, and  however easy it  may  seem  to  the inexperienced to
arrest them, they,  nevertheless, are among  the  most  troublesome
accidents occurring  in young infants that  the  practitioner is  called
upon to treat, and will often foil  the best-directed efforts for their re-
moval.                        *

     5.— Cyanosis — Morbns  Cffirnfeanus — Blue Disease,
   Cyanosis is marked by a blue, purple, or leaden  tinge, more or  less
deep, of the entire surface of the body, but particularly marked in the
lips, cheeks, and nails; accompanied with a  reduction of temperature
and occasional paroxysms of difficult respiration, approaching to com-
plete asphyxia, during which the  blueness of the skin becomes more
intense, and more generally diffused over every part of the surface.
   The paroxysms are brought on by whatever hurries the circulation
—as a quick motion of the body, crying, and, when the infant survives
long enough to be able to walk, by going up or coming down stairs,
by emotions of the mind, &c. When the paroxysms are severe, there
is a cessation of respiration and circulation, the extremities become
perfectly cold, and the patient falls into a state resembling death. After
a few moments' rest,  however, the  infant again  breathes, the circula-
tion is restored, the colour of the  skin becomes lighter,  and he recovers
his ordinary state of health; finally, however, a paroxysm more severe
than usual occurs, during  which life is extinguished.   In some infants,
even the effort  of sucking often induces so great an embarrassment of
the  respiration  and  circulation,  as to bring on paroxysms, which  are
occasionally accompanied  with convulsive movements.
   When the patient  affected with  cyanosis has arrived at the age of
childhood, he is indisposed, and often unable  to participate in the sports
of other children, but even in summer crouches over the fire, languid,
chilly, and dispirited.  The ends of the fingers and toes are often bul-
bous as  well as discoloured; there is a  tendency  to cough on the least
muscular exertion, and congestion of the lungs very frequently mani-
fests itself under the  influence of slight exciting causes.   The discolo- 
638
DISEASES OF CHILDREN.
 ration of the skin and interior of the mouth is sometimes  as deep as
 the stain of the small black cherry.
   Notwithstanding the majority of cases terminate fatally at an early
 period of infancy, or at furthest, during  childhood, there are instances
 on record,  in which  patients labouring under  cyanosis  have lived
 twenty, forty, and even fifty-seven years, death being produced  by the
 supervention of some other disease.
   Cyanosis is, in the majority of cases,  evident from  the  moment of
 birth, or presents itself within a day or two subsequently.   There are
 cases, however, upon  record, in which it first made its appearance in
 the adult, after  severe falls, or  blows, prolonged  fits of coughing, or
 violent and fatiguing muscular efforts.   One very curious case is re-
 lated  by Hufeland, in which the disease occurred suddenly on the ninth
 day after birth, subsequent to a convulsive attack, and completely dis-
 appeared upon the twelfth day after its invasion.
   The production of cyanosis has very generally been attributed to an
 admixture of the arterial  and venous  blood, in consequence of  a per-
 sistence of the communication which exists, in the foetal state, between
 the auricles, or of some malformation of the heart or of the main arte-
 rial or venous trunks.  That in the great majority of the cases of cya-
 nosis, there  exists an abnormal structure of the heart or blood-vessels,
 or a mal-arrangement of  the  latter, is proved by the results  of  nume-
 rous dissections.  The most  common lesions of the heart and  great
 vessels, are, the  origin of the aorta  from both ventricles; a  patulous
 condition of the ductus  arteriosus; imperfection of the  ventricular
 septum; obliteration of the pulmonary artery; a  transposition of the
 origin of the aorta and pulmonary artery, with  an  open state of the
 foramen ovale, and in a few, of  the ductus arteriosus also; in one the
 aorta was obliterated.  The right cavities of the heart were frequently
 found  dilated, hypertrophied, or both.  The hypertrophy  is always
 most  considerable in  cases in which there exists contraction of the
 pulmonary orifice.   The  total absence of the ventricular  septum has
 been  noticed in some cases.  The heart has been found to consist of
 a  single cavity;  the pulmonary artery to arise from both ventricles,
 and send off the descending aorta;  the  right auricle to open into the
 left ventricle, and a free communication  to exist between the two ven-
 tricles, and  the two auricles; in other cases, the right ventricle was
 bifid; in others the arch of the aorta was double; the coronary  veins
 have  been found to open into the left ventricle; the inferior or the
 superior cava into the left auricle.  The foramen ovale has  been  found
 closed in the foetus; in some cases  the  valves of the heart  adhered
 along their  edges, and were consolidated into one substance, leaving
 only a small central  aperture, or  they were perforated  by numerous
 holes,  or  altogether absent.   The instances of a single auricle and
 single ventricle are very numerous.  Considerable contraction of the
pulmonary artery, particularly at  its  origin, is also a very common
lesion.  In a few cases, the pulmonary  artery has been found  com-
pletely impervious,  or the artery has been  found entirely absent, the
bronchial arteries appearing to  supply its place; and in one case, the
aorta terminated near the heart, in a  cul-de-sac.  In one  case  there 
CONGENITAL AFFECTIONS, ETC.
639
was an entire absence of the right lung, the septum between the ven-
tricles of the heart was imperfect, the foramen ovale and ductus arte-
riosus were both open: the aorta communicated with both ventricles;
the pulmonary artery was imperforate  at the base of the heart;  the
lung being supplied with  blood  by the arterial duct:—the child lived
six weeks.   (Wockenschrift fur die gesammte Heilkunde, 1837.)
   M. Aberle, of Vienna, gives the following conclusions as the result
of the analysis of 180 cases of cyanosis.
   In 100 cases there was a defect in  the partition of the ventricles;
in 87 of these cases, there was also  an abnormal  communication of
the ventricle with the aorta; in 22, the foramen ovale was closed, and
in 65, it was open.  In four cases only, the  pulmonary artery arose
from both  ventricles.   In  the 87 cases  in which  the aorta arose from
both ventricles, the pulmonary artery was 37 times strictured, or even
quite closed.   Of the 180  cases, two-thirds were  males.
   Sufficient evidence is thus afforded, that abnormal communications
between the cavities of the heart, particularly the auricles, by the non-
closure of  the foramen ovale, and various  malformations of the heart,
and of the main arterial and venous trunks, occur, in perhaps the ma-
jority of cases of cyanosis.
   The mixture of the arterial and venous blood, which is supposed to
result from the free communication between the two auricles, in con-
sequence of the patency of the foramen ovale is evidently inadequate
to explain the  blue colour of the skin, inasmuch  as no such discolora-
tion takes place in the foetus; while the communication exists in the
majority of infants  for many days after birth, without a single symp-
tom indicative of cyanosis being present.   The foetal openings in the
heart, and the communication between the aorta and pulmonary artery,
by means of the ductus arteriosus, are  not usually obliterated before
the eighth day subsequent to birth, and  have even been found open as
late as the third week  in  infants who have died  of disease totally un-
connected  with any disturbance of  the respiratory  apparatus in the
slightest  degree resembling that which occurs  in  cyanosis.   It has
been shown, that in repeated instances the foramen ovale has remained
open for a very considerable period, without the occurrence of cyanosis;
while the foramen has been found closed before birth, the foetus never-
theless presenting all the symptoms of cyanosis.   An interesting case
is related  by Mr. H. J. Johnson, in the London Lancet, for February,
1843, of an adult female  who died in  St.  George's Hospital of erysi-
pelas, and  in whom  upon dissection, the foramen ovale was found so
patent as to admit of two  fingers being  passed through it from one au-
ricle to the other.  The heart was large, flabby, and somewhat dilated.
During  the lifetime  of this patient she presented  no symptom from
which the nonclosure of the foramen could be inferred.  It has indeed
been denied by Cloquet and Louis, that any admixture of venous and
arterial blood can take place, even with  a free opening between the
two auricles, from nonclosure of the foramen, so long as the commu-
nicating cavities are of equal strength, or provided all the orifices are
free.
   It has been supposed by Louis, Frank, and  others, that the contrac- 
640
DISEASES OF CHILDREN.
 tion of the pulmonary artery, which is so commonly met with in those
 who have perished after labouring under symptoms of cyanosis, is the '
 chief cause of the non-closure of the foramen ovale, in consequence of
 the constant state of over-distension which it keeps up in  the right
 cavities of the heart.
   In a paper contained in the Edinburgh Medical and Surgical Jour-
 nal, for  October,  1843,  this  point is  very fully considered by  Dr.
 Cragie.  This gentleman states  that from the facts of the case related
 in the paper referred to, and of  several others, he is satisfied of three
 circumstances, namely :first, that the open state of the foramen ovale
 is rarely a  primary and  solitary lesion ; secondly, that  when it is a
 solitary lesion it is not attended with any injurious effects, and that the
 venous blood of the right auricle is not thereby necessarily mixed
 with  the arterial blood of the left auricle; and thirdly, that, in opposi-
 tion to what has been hitherto  usually taught, the open state of the
foramen  ovale  is, in a large proportion of cases, the means of pro-
 longing life.
   However paradoxical, Dr.  Cragie  remarks, the  latter conclusion
 may appear, and however opposed to the usually received dogmas, it
 flows almost directly from the  facts which may be traced  in every
 case  of open foramen ovale.   It is not, in fact,  the  primary lesion.
 From  the  phenomena of the  cases on record, on  the contrary, and
 from the frequency of the arctated  or contracted  state of the pulmo-
 nary  artery, it must be inferred that  the primary lesion is the  ob-
 structed state of that artery; and that it is this which is the cause, not
 only of the  open state of the foramen  ovale, but of  the  hypertrophy,
 also, of the right ventricle.  This is the result, whether the pulmonary
 artery is only greatly narrowed in calibre, or terminates in a cul de
 sac, or is obstructed by a membranous partition formed by a coalition
 of the semilunar valves.
   The effect of such an impediment is manifest.  The blood cannot
 pass into the pulmonary artery with the requisite freedom and facility,
 there is, consequently, over-distension, first, of the right ventricle, and
 excessive labour of its muscular apparatus; secondly, of the right au-
 ricle, and excessive labour of its muscular  apparatus, with extreme
 dilatation of its membranous portion; thirdly, over-distension and con-
 gestion of the whole venous system throughout the body.  The lungs,
 meanwhile, receive  little  or no  blood, and, consequently, the blood is
 not duly aerated.   This is doubtless a very serious evil; but Bichat
 has obscurely  suggested, and Drs. Williams  and Kay  have clearly
 shown, that dark-coloured blood, or that which is venous, is adequate
 to maintain vital  action.  Everything that we now know of the cases
 of cyanosis shows that  the obstruction to the circulation through the
 pulmonary artery, must be the main cause of the uncertain and tran-
 sitory  existence of persons labouring  under  this severe  lesion, and
 that the open state of the foramen ovale, instead of being  as William
 Hunter imagined, and most subsequent writers have taught, the cause
 of death, furnishes, in fact, the only means by which life can be pro-
 longed ; while  a  function  so important as that through the lungs is
 impeded. 
CONGENITAL  AFFECTIONS, ETC.
641
  Dr. Cragie considers himself further entitled to infer  from various
facts  in  the history  of the development of the ovum,  that  the  ob-
structed, or it may be, the undeveloped state of the pulmonary artery,
is the anatomical cause of the perforated septum, and of the origin of
the aorta from the two ventricles when that malformation is observed.
  Dr. Stille, in a very able paper on cyanosis, contained in the Ameri-
can Journal of the Medical Sciences,  (vol. viii. p. 25,) maintains, that
in every instance cyanosis is dependent upon congestion of the gene-
ral venous system resulting from a partial or complete contraction or
obstruction, or upon an imperforation, of the pulmonary artery; that
this lesion alone will account satisfactorily for  the discoloration of the
skin and the dyspnoea;  that it is present in almost every case of cya-
nosis—or, if absent, that  there  is always  some other efficient cause
for the disturbance of  the  pulmonary circulation ;  and, finally, that
the lesion referred to never exists without the concurrence of cyanosis.
  These several positions are  very fully  borne out by the  series of
facts adduced in the paper referred to.
  That the  disease is caused invariably by delay to the passage of the
blood through  the lungs,  resulting from the presence of  a fixed impe-
diment to the circulation, is the  opinion advocated by the leading pa-
thologists of the present day.
  Morgagni appears  to have  been  the first who attributed the intense
lividity of cyanosis to obstruction in the trunk of the pulmonary artery.
.Louis  ascribed it to some  obstacle to the  circulation  of the blood
through the veins, and MM. Bertin  and Berard, and more  recently,
Professor Rokitansky, of  Vienna, agree in referring the blue appear-
ance of the surface, in those affected  with abnormal apertures in the
cardiac septa, to a stasis of the blood in the right cavities of the heart,
and the consequent difficulty with which the venous blood circulates;
and, though it be complicated, in many cases, with  the mixture of the
two kinds of blood, still it is not produced  by this mixture.
  Dr.  Chevers, in a very able  paper  published in the  London Med.
Gaz., March, 1847, states that the results of his investigations into the
causes of cyanosis, are almost entirely confirmatory of the general
conclusions of  Dr. Stille.   Cases of cyanosis will very rarely occur,
in which  the  morbid anatomist will  fail  to discover some  organic
cause which acts virtually as an impediment to the pulmonary circu-
lation.  Dr. Stille, he remarks,  has, perhaps, referred somewhat  too
exclusively  to the right side of the heart and the pulmonary artery as
the seats of the mechanical obstacle to the circulation in these cases;
for it will occasionally, though rarely, be found that the physical im-
pediment to the circulation exists in the pulmonary tissue, or is even
external to the lungs, as in  Dr.  Marcet's well-known case (Ed. Med.
and Surg.  Journ.,  vol.  i., p. 412;)  and  in  some  few  instances  the
cause of obstruction  is  seated either in the left heart, or in the aorta.
Still, in every  case of  cyanosis, there will  be found to exist some
cause or other which tends essentially to prevent  the free and com-
plete circulation of the  blood through the  lungs, to retard its passage
through the venous system, and, consequently, to render the process
of its arterialization slow  and incomplete.
                                41 
642
DISEASES OF CHILDREN.
  Dr. Stills has also  argued that obstruction to the pulmonary artery
is never found without the concurrence of cyanosis.  This is perfectly
true, as regards most of the cases of congenital  narrowing  of this
vessel, but it does not hold good in all; for instance, where congenital
imperfection of the pulmonary valves does not become seriously ob-
structive until  late in life, the symptoms which it produces are not
necessarily those of cyanosis. Dr. Chevers cites an instance in which
extreme  narrowing of the pulmonary artifice, the  result of endocar-
ditis, occurring at the adult period,  was not attended with the slightest
appearance of  lividity of the surface; in fact, it appears that, for the
complete establishment of that generally dilated condition  of the en-
tire venous system which attends cyanosis, the obstruction  to the cir-
culation  must have been present either at or before birth, when the
capillary vessels are  naturally more capacious than they are in the
adult; or it must become confirmed previously to the full development
of the body, while the  entire vascular system is pliant and dilatable,
and is still  capable of readily adapting itself to permanent changes  in
the circulation.
  It is well known  that various kinds of obstructive disease of the
heart and lungs, occurring in adult life, are liable to produce extreme
internal venous congestion,  and considerable  lividity of the surface;
but Dr. C. is not acquainted with  any instance in  which an impedi-
ment of this kind, coming into  operation subsequently to the  age  of
twenty-five  years, has produced that general  and intense blueness  of
the entire surface which forms the  characteristic feature of true cya-
nosis depending upon congenital malformation of the heart.
  In extreme  cases of original  defect of the cardiac apparatus, such
as those in which the ascending pulmonary trunk is obliterated or ab-
sent, the cyanosis appears to be due less to  the circuitous  course by
which the  lungs are supplied with  blood, than to the  unnatural nar-
rowness  of the pulmonary  vessels,  which are almost invariably far
less capacious  than  in the  ordinary condition; hence the pulmonary
veins  and  left auricle are  usually more or  less contracted in these
cases, while the lungs are either badly developed and  imperfectly ex-
panded, or present the evidences of chronic impediment in the  dilated
condition of their tubes.
   There are still a few pathologists who  adhere to the old opinion, that
cyanosis mainly depends upon the  circulation  of carbonized blood
through  the arterial  system, insisting upon the fact that, in the great
majority of cases of  cyanosis, the septa of the heart are more or less
deficient.  It  is now established that cyanosis may exist quite inde-
pendently of imperfection of the cardiac partitions, or  of  admixture
of the venous  and arterial blood;  still, Dr.  C.  apprehends that M.
Berard and Dr. Stille have argued somewhat  too exclusively in main-
taining that admixture of the two currents has no influence whatever
in producing  cyanosis, as it  appears by no  means  unreasonable  to
conclude, that, in extreme cases of this kind, where the impediment
to the pulmonary circulation is great, and where a large quantity of
venous blood  evidently passes into  the  aorta  at every systole of the
ventricles,  the discoloration of the surface, and especially the lividity 
CONGENITAL  AFFECTIONS, ETC.
643
of the mucous membranes, which is so frequently observed  in these
cases, is in part, at least, due to the dark hue and impure condition of
the arterial blood.   Admitting this,  it must be borne  in mind that
the principal reason why cyanosis is generally present in  cases  of
extensive  communication between the  cavities of the heart, will  be
found in the fact, that a cause  of  obstruction which  is capable of
preventing the natural closure of the septa, will  rarely fail  to  occa-
sion permanent and severe impediment to the circulation.  Where  an
abnormal opening is discovered in the cardiac apparatus of one who
has only lately become cyanosed, or where such an aperture presents
traces of recent enlargement, it must not be at once concluded that
the presence  or  augmentation of  this communication has occasioned
the cyanosis;  but the  first cause of the disease must be sought for,
and  this will  generally be  discovered in the  form of some manifest
impediment to the circulation which has determined the patency of
the opening from birth, and which, having become recently aggravated,
has produced  the cyanosis at the same time that it has increased the
size of the abnormal foramen.
   Cyanosis, whether congenital or acquired, is very rarely recovered
from.  If, as already remarked, the  infant survive  the first few days
or weeks, it may live on to puberty.  An aggravation of the symp-
toms  every now and  then will take  place, and these  paroxysms  are
liable to be very severe at the period of weaning, during dentition, or
when the child begins to walk, and at puberty; if this  latter period be
passed, the patient may live  to eighteen,  twenty, thirty, forty, sixty
years, or even to extreme old age. The chances of life depend pretty
much upon the nature of the  organic disease  present, and of the ac-
cessory morbid phenomena;  thus, in a child whose pulmonary artery
was found completely obstructed, death took place on  the thirteenth
day from birth; while in three patients, in whom  the  foramen ovale
and ductus arteriosus were simultaneously patescent, one lived seven-
teen, another twenty-nine, and the last forty-two years.
   The duration of life in the cases of cyanosis analyzed by M. Aberle,
is indicated by the following list:
   Death  occurred, in the first twenty-four hours, in 4 cases; within
the first fourteen days, in 16;  before  the end of the first month, in  7 ;
from the second to the third  month, in 6; from the third to the sixth
month, in  8; from  six  to  twelve months, in   12; from one to two
years, in 7; from two to three years, in 9; from three to six years,
in 11  ; from six  to eight years, in 11 ; from eight to eleven years, in
13; from   thirteen to  sixteen years,  in 12; from  sixteen to twenty
years, in 8;  from twenty to  twenty-five years, in 10  ; from  twenty-
five to thirty  years, in 6; from thirty to thirty-five years, in 5; from
thirty-five to  forty-five years,  in 5; from forty-five  to  sixty years, in
4; and at  eighty years in  1 case.  In 10 cases, the age is  not indi-
cated.
   A few cases are  on record, in which  the phenomena of cyanosis,
after  continuing for  a very considerable time,  finally,  entirely disap-
peared ; and  in  cases connected with certain affections of the lungs,
intestinal canal, uterus, and brain or spinal marrow, the cyanosis has 
644
DISEASES  OF CHILDREN.
disappeared with the cure of the pulmonary, gastro-intestinal, uterine,
and cerebral disease.   As a general rule, however, the disease  is en-
tirely beyond the control of medicine.  It  is  said  to  prove more
quickly fatal in males  than in females;  and the mortality is certainly
greater in winter than  in summer.  (Jour. Hebdom. No. 113.)
  It is unnecessary to  say anything on the treatment of cyanosis.  If
the pathology of each case be attentively and carefully examined, and
the true character of  the disease  be kept in mind, it will be easy to
adapt our palliatives to the most urgent distress.  The patient, in every
instance, should  be kept  as  much  as  possible in a state of rest, and
everything should be avoided, liable  to produce mental or physical
excitement, or which in  any manner has a tendency  to hurry the re-
spiration or circulation.   He  should enjoy a pure, fresh  atmosphere,
gentle, passive exercise,  and  be  allowed a mild, easily-digested diet;
his  bowels should be kept perfectly free, and his body  be  carefully
protected from cold or damp.
  When cyanosis appears in  a  new-born child, and persists after re-
spiration is established, it has  been recommended by Corvisart to em-
ploy gentle  frictions over the head and body with a warm, soft  cloth,
while the infant  is held near the fire.   The frictions should  be  perse-
veringly continued, attention being, at the same time, paid to procure
a free evacuation of the meconium.

             6. — Spina Bifida. — Hydro-Raehis.
  Hydro-rachis  is,  strictly  speaking, an  abnormal accumulation  of
fluid within  the spinal column; it is, in  almost every instance, a con-
genital affection, and may be associated with either hydrocephalus  or
spina bifida.
  In the  latter  case, one or more  tumours  will  be found to exist
upon the spine, generally in its lumbar, occasionally in its dorsal and
sacral, and very rarely in its cervical portion.  These tumours vary
in size, from that of a hazel-nut to that of the adult head,  or the entire
spine  being, bifid, the  tumour may occupy  its whole length.   The
tumour  is usually globular or ovoid in shape, having either a large base
or narrow neck;  in one case, recorded by Brewerton, it was bi-lobed.
It may  be  invested  by the common integuments, in a healthy, unin-
flamed condition, or the skin covering it may be thin, almost transpa-
rent, and crossed by purplish lines, and as if about to rupture, with a
sero-sanguineous  fluid exuding through it; or, the tumour  may be rup-
tured, its contents having escaped through a very small,  ulcerated
opening, which is surrounded by a red, rugous, unequal  elevation of
the skin and subcutaneous tissue.   The two latter conditions of the
tumour  are much more common than that in which it is covered by
healthy skin, and far more dangerous.
  The tumour  is always situated  over  a deficiency in the vertebrae,
arising, most commonly, from an  imperfect development of the late-
ral  arches;  occasionally, however, the  lateral arches may exist, but
remain ununited, or, still  more rarely, there may be a complete divi-
sion of the whole vertebrae, body as well as processes.
  The opening in the vertebrae may be confined to one bone, or extend 
CONGENITAL  AFFECTIONS, ETC.
645
 to two or more, or it may occur at different parts of the spine, giving
 rise  to  several tumours, or,  as  we  have already seen, it  may exist
 throughout the whole extent of the spine.
    The tumour itself is formed by a cyst, communicating with the spi-
 nal cavity, and filled by a fluid secreted within the latter.  In the most
 favourable cases, its parietes are composed of one or both layers, consist-
 ing of the arachnoid membrane, the dura mater, and the common inte-
 guments, in a  natural condition; more generally, however, its parietes
 are thickened, inflamed, ulcerated, gangrenous, or covered  with fun-
 gous granulations, or tufts of  hair.
    To the touch, the tumour  is tense and protuberant, whenever the
 position of the infant is such as to  allow  the fluid from within the
 spinal canal to gravitate towards it, but it  is more or less soft and
 flaccid under  opposite circumstances.   By gradual pressure, its bulk
 may be diminished, and if of small size,  the whole of its contents may
 be forced  back into the spinal cavity, when the margin of the opening
 through the vertebrae may  be felt with  the finger.  Pressure upon the
 tumour very frequently induces a state of coma, or convulsions, and
 in one case, referred to by Dr. M. Hall, pressure, even that resulting
 from the supine recumbent position of the child, invariably produced
 attacks similar to the croup-like convulsions of laryngismus.
   In  some cases, the tumour has been observed to expand during ex-
 piration, and sink during   inspiration.   The  contents  of  the tumour
 may  be either  a limpid, colourless serosity, or a turbid fluid, often con-
 taining albuminous flocculi, or a  purulent matter.  The fluid  of the
 tumour communicates freely with that collected within the cavity of
 the spine; and in many cases, there is a free communication, between
 the ventricles of the  brain, the intercranial arachnoid cavity, the entire
 canal of the spine, and the  cavity of the external tumour, so  that pres-
 sure made upon the latter may force the fluid back upon the brain, and
 cause more or less compression of that organ.
   Children affected  with spina bifida often  present other malforma-
 tions, as imperforate anus, imperfect  or irregular development of the
 alimentary canal, &c.
   When  there  exists no external opening  in the tumour,  it  being
 covered by the  common integuments, and when  the accumulation of
 fluid within the vertebral canal exercises no pressure upon the brain,
 or spinal marrow, sufficient to interfere  with the free exercise of their
 functions, individuals affected with spina bifida, though  generally of a
 weak and  infirm constitution, may exhibit no particular symptoms of
 disease, and even live to an advanced age, without the occurrence
 of any serious  evil that  immediately  results  from the  spinal tumour.
 Cases of individuals labouring under spina bifida of almost every age,
 from ten years  to fifty, and upwards, have been observed.
  Generally speaking, however, from  a greater or less deficiency in
 the spinal cord, or other  morbid conditions  of  it or of  the brain, the
infants labouring under spina bifida are liable'to be affected with para-
lysis of the lower extremities, convulsions, an open state of the sphinc-
ters, and difficulty of respiration.  They  are* occasionally unable to
take  the breast, and become  gradually more  and more exhausted, 
646
DISEASES  OF CHILDREN.
their feet and legs become cold and oedematous, their cries more and
more feeble, their pulse extremely quick and  feeble, their  breathing
more and more difficult, and often  stertorous, and, finally, death takes
place, preceded by convulsions or coma.  The larger the tumour, the
more intense and rapid is this train of symptoms.  When, in particular,
the tumour  bursts,  inflammation of the membranes of the  cord, in
general very rapidly ensues, and we have  then  all  the symptoms of
spinal meningitis, and, in most cases, the patient is  very quickly de-
stroyed.
  If, however, the opening in the tumour is very small, notwithstand-
ing a portion of fluid is constantly  escaping, no very important suffer-
ing may result for a length of time.  But,  very  commonly,  the fluid
discharged becomes more or less turbid, purulent, or even foetid, and
symptoms of spinal  inflammation soon occur.  When the tumour is of
considerable size, its sudden rupture may produce a  paroxysm of con-
vulsions, terminating almost immediately in death.
  It has been  asserted, by  Duges,  that a rupture of the tumour has
taken place  in utero, and the opening has again closed, previously to
birth.  This appears to  us, however, to be very doubtful;  the  case
cited in confirmation of it is certainly very  far from  being conclusive.
  After death, the most common appearance met with is a more or
less copious effusion of serosity, either between the  pia mater and the
arachnoid membrane of the spinal marrow, in the  arachnoid cavity,
or between the dura mater and bony wall of the spinal cavity.  When
in the first two situations, the effused fluid very generally communicates
freely with the ventricles of the brain, and  with the arachnoid cavity
within the cranium, in which there also exists a morbid effusion of
serum.
  Occasionally, when the tumour is small  in size, and covered with
the common integuments, in a normal state, the  brain  is found to be
perfectly healthy, the effusion of serum being confined  entirely to the
spinal  canal.  Even  the  medulla  spinalis  may  present  no  apparent
indications of disease.
   The effused fluid  is usually perfectly limpid, excepting when menin-
gitis has occurred,  when it is generally  thick, turbid,  and flocculent.
It may be of a light yellow, greenish, or dark  hue, and is often mixed
with pus, or with more  or less blood.
   When an effusion of fluid exists, at the same time, in the  cavity of
the cranium, and in that of the spine, the fluid in the former has been
found to be of a different colour from that  in  the latter,  showing the
two to be perfectly  distinct.  In other cases, the fluid  was prevented
from escaping from the fourth ventricle into the  subarachnoid cavity,
by a firm, reddish  membrane, which formed  a  cul-de-sac  below the
inferior angle of the ventricle.
   The spinal cord may either present congenital deficiencies, or mal-
formations, or more or  less traces of disease.   The substance  of the
cord has been found entirely wanting, the membranes alone remaining;
forming sometimes a closed sac, filled with a fluid.   It may be  dimi-
nished in size, divided into two parts, or expanded  into a membrane.
It is often, according  to  Olivier,  preternaturally  long.  The  spinal 
CONGENITAL  AFFECTIONS, ETC.
647
nerves have been seen floating in the fluid of the tumour.   They have
been found, also, distributed on the inside of the tumour, forming,  oc-
casionally, a kind of nervous network.  More  commonly, however,
the substance of the cord is softened, like the walls of the cerebral
ventricles in  hydrocephalus; and very generally, traces of meningitis
of the spine exist, often extending even to the brain.
  In  regard  to  the pathology of hydro-rachis,  numerous discordant
opinions have been entertained.   The disease is evidently a true con-
genital dropsy, either of the spine, or of the spine and brain; the defi-
ciency in the vertebrae, as well as the external tumour, being the result
of the accumulation and pressure of the fluid within the cavities of the
cranium and spine.
  When  the tumour  in the spine  is  not  formed, the  child usually
perishes soon after birth, with symptoms of hydrocephalus ; or tumours,
in some instances, form upon the head, in all respects similar to those
of spina bifida, the fluid protruding the dura mater and a layer of the
arachnoid membrane, through an opening in one of the bones of the
cranium.   Dropsy of the  spine, with the formation of an external
tumour,  has  succeeded to  hydrocephalus,  produced by contusion of
the head ; or has resulted from disease of the spinal cord.
  In regard to the treatment of  spina bifida, it  would appear, from a
careful examination of all the facts  upon record, and from the  result
of the few cases which have fallen under our own notice, that,  when
the tumour is small, and more especially when it is covered with  the
common integuments in a sound state, and  the infant, as  is generally
the case, suffers  little or no inconvenience, the  most prudent course is
to let it alone, merely guarding the tumour from accidental pressure,
and from every source of irritation.   So  long as the tumour remains
unopened, there  is, comparatively little danger, but soon  after it be-
comes opened, meningeal  inflammation, with  all its train  of  fearful
consequences, soon sets in, and quickly destroys the child.
  The opening of the tumour is  always, therefore, to be considered a
most unfortunate circumstance.   Hence, if the infant be born with an
ulcerated tumour, but incompletely perforated, it ought not to be opened
for the purpose of allowing the discharge of its contents.  It is true
that the operation first practised  by Ruysch, and revived by Aberne-
thy, of puncturing the tumour with a fine needle, and afterwards em-
ploying gentle pressure, has been performed, and it is said, in several
cases, with success.   Very recently, two cases are related by Dubourg,
in which a perfect cure was effected  by cutting off the tumour, and
then bringing the edges of  the divided skin together,  and retaining
them so by means of  the twisted suture, until union took place,  great
care being taken to prevent the entrance  of air into the  spinal  canal,
and as much as possible, the escape of the spinal fluid.   The applica-
tion of gradual and gentle pressure, as recommended by Abercrombie
and Sir Astley Cooper, is unquestionably the  treatment that  will be
found the best adapted to the generality of cases of spina bifida; it is
said to have produced  a radical cure in some instances.  It has been
very correctly remarked, that when the tumour is very large, puncture
should not be attempted, while in cases where the fluid effused  in  the 
648
DISEASES OF CHILDREN.
spine communicates with the ventricles of the brain, pressure must •al-
ways be of very doubtful propriety.
  In all cases of spina bifida, much benefit will unquestionably be de-
rived from placing the patient under such a hygienic course of treat-
ment as will be adapted to improve the health and nutrition of the body
generally.  Hence, the importance of changing the milk of the mother,
if the quality of this be doubted, for that of a healthy nurse; of remov-
ing the infant from the confined and  impure air of the city, to a dry,
healthy situation in the country; of clothing it warmly, and carrying
it abroad, every fine day, in the open air; of sponging its body daily
with warm water, and using frictions over  its entire surface, and of
keeping its bowels regular by gentle aperients.
  It has been proposed to apply repeated small blisters above the tu-
mour, in the course of the spine, each being kept on so long as to cause
a rubefacient effect only, with a view, in  this  manner, to promote the
absorption of the fluid. The preparations of  iodine  may also be ad-
ministered with the same intent.
  When the disease  is associated with hydrocephalus, or with menin-
geal inflammation, either of the brain or cord, the treatment adapted
to the latter affections  will, of course, become necessary.

      7, —Inflammation  and Ulceration of the  Navel.
  Within the first nine or ten days  after birth, inflammation followed
by  ulceration of the  navel  is very liable to occur, if the utmost atten-
tion is not paid to  prevent it.  Upon  the separation of the cord, instead
of a quick and perfect cicatrization succeeding, the navel in some cases
remains raw, and soon becomes irritated and inflamed, presenting a
deep, red, ulcerated  surface, with an inflamed condition, to a greater
or less extent, of the surrounding skin. A thin, purulent, and often offen-
sive discharge takes place from the surface of the ulcer, and the infant
evidently  suffers considerable pain, as is evinced by its general fretful-
ness, and  its cries when the  ulcer is examined  or accidentally touched.
Not unfrequently the navel presents an elevated, ulcerated surface, with
somewhat prominent edges; in these cases, the discharge is generally
the most profuse.  In  other cases, a kind of fungous excrescence, of a
dark-red colour, protrudes  from the centre of the  navel, without any
appearance of ulceration, and with  but little discharge,  and scarcely
any inflammation of  the surrounding skin.   We  have often, indeed,
seen the skin, up to the very edge of the umbilical depression, remain
perfectly natural.
   The fungoid tumour, which  generally bleeds upon  the slightest irri-
tation, may either present a narrow base with a round, expanded head,
like a cherry, or a broad base, tapering gradually towards the summit,
being more or less conical in form.
   Ulceration of the  navel, as we have already  remarked, is very gene-
rally the  result of neglect or mismanagement on the part of those who
wash and tend the infant.   In a few instances, it is true, it may result
from a slow and  imperfect  separation  of the cord, in consequence of
 which  it remains long attached by a thin, firm filament, and causes a
 constant irritation, by which the healing of the navel is prevented, and 
CONGENITAL AFFECTIONS, ETC.
649
ulceration induced.  More commonly, however, it is produced by rude
management in washing and dressing the child, previous to the coming
off of the cord, or by rude dragging, or other injudicious attempts to
facilitate its separation, or by the ridiculous practice of dressing the
navel subsequently, with a burnt rag, grease, and even more improper
applications.  It may, also, arise from inattention to cleanliness, in the
first washing  of the child, in  consequence of which a quantity of the
vernix caseosa is  left upon the skin, surrounding the umbilicus, which
soon acquires an irritating character.  From a peculiar irritability of
the skin, some infants are more liable to  ulceration, or rather  tardy
and imperfect healing of the navel, than others.
   In all cases, the utmost attention should be paid to cleanliness.  The
navel and surrounding skin should be carefully washed, at least  twice
a day, with  lukewarm water, and then wiped perfectly dry with  a soft
linen cloth.   If the cord still remains attached by a thin filament, the
division of this, and the removal  of the cord, will  often, as stated by
Dewees, be sufficient to allay the irritation, and thus allow the navel to
cicatrize.
   When the ulceration is superficial, without much inflammation, wash-
ing it with a little  rose water, twice a day, and dressing it as often with
the ceratum zinci oxydi impur. spread upon a soft rag, wjll often cause
it  promptly to heal; or, if this should not succeed in causing cicatriza-
tion, the ulcer may be washed daily with a solution  of sulphate of cop-
per (ten grains to  an ounce of water), and  then dressed with the same
salve.   In slight cases, by sprinkling the ulcerated surface with finely-
powdered oak bark or galls, we have repeatedly found  cicatrization to
take place very promptly, without any other dressing.
   If the ulceration should  still show no disposition  to heal, it  may be
washed  by a weak  solution of the  nitrate of silver, and then dressed
with  an ointment  formed  of one  scruple of the acetate of  lead, inti-
mately combined with an ounce of lard.  In aggravated cases of ulce-
ration of the  navel, prompt and very decided benefit, is said by Dr.
Eberle, to be derived from applying to the ulcerated surface, three or
four times daily, by means of a soft hair pencil or  feather, a liniment
made  by slowly simmering the coarsely-powdered root of the  wild
indigo, (baptisia tinctoria,) in cream,  and  afterwards squeezing it
through a thick piece of muslin or flannel.
   In all cases, however, in which  the ulceration is  attended  with con-
siderable inflammation  extending to the surrounding skin, stimulating
applications of every kind  should  be withheld  until the inflammation
is  reduced by  soft, emollient poultices, and  frequent  washing of the in-
flamed skin  with a solution of the acetate of lead.   In some instances,
we have seen  the inflammation, in cases of ulceration of the navel, so
extensive as to demand the application of a few leeches.
   It is not unfrequent for the bowels of infants affected with  ulcerated
navel, to be considerably disturbed, the passages being frequent, thin,
and attended with  griping;—whenever this is the case, the administra-
tion of very minute doses of calomel and ipecacuanha, combined  with
a few grains of magnesia,  with the  daily use of the warm  bath, will
be demanded. 
650
DISEASES  OF CHILDREN.
  When a fungoid tumour'forms or protrudes from the navel after the
separation of the cord, if it  have a narrow base, we may readily re-
move it by a ligature applied  around its pedicle, sufficiently tight to
arrest the circulation, without cutting into its substance.  The tumour
usually separates in the course of a few days, when the ulcerated sur-
face may be washed with a solution of sulphate of zinc, (fifteen grains
to an ounce of water,) or dressed with the ointment of acetate of lead.
  It is seldom, however, that the separation of the tumour by means
of the ligature, is attended with any permanent benefit; very generally,
the  fungous growth will recur to as great an extent as at  first.   It is
better, therefore, to treat  it at once by astringent applications, as the
decoction of galls or oak bark, or solutions of the sulphate of copper or
zinc, in the proportion of one drachm to the ounce of water;  or, we
may sprinkle the surface of the tumour with finely powdered oak bark
or galls, and wash carefully, night and morning, with lukewarm water.
It is said that the root of the sanguinaria canadensis, in fine powder,
is an admirable  application for the removal of these fungoid growths.
  When the tumour is soft  and spongy, and not  invested by a mem-
brane, applying to its surface daily, by means of a camel's  hair pencil,
a pretty strong solution of the nitrate of silver will generally destroy it
in a few days, and allow the navel to cicatrize.

  8.—Intumescence  and  Inflammation of  the  Breasts.
  Infants of  both sexes are very liable to a tumid, hard,  and  painful
condition of the breasts, which  is occasionally present at birth, but
more generally presents itself a day or two  subsequently, and  is, in
some cases, attended with a  degree of redness and inflammation of the
external skin.
   This affection, even when the swelling and  hardness are very con-
siderable, after  continuing for a week or two without any sensible
abatement, will  then, very generally, subside entirely.  Unfortunately,
however, a vulgar notion is  prevalent among mothers and nurses, that
the swelling, in the female at least, is the result of milk  in the breasts,
which it is necessary, by all means, to draw or squeeze out; an opinion
that  is confirmed, as they  suppose,  by the escape, sometimes, of a
white-coloured fluid, resembling milk, at the nipple, and which induces
them, not  unfrequently, to resort to very rude measures to get rid of
the offending fluid,  in order that the infant's breasts  may be  cured.
 The consequence is, in not a few cases, severe inflammation, followed
 by suppuration, and the formation of an abscess; many instances of
 this are on record, and we have ourselves met with a number.   Even
 the entire substance of the female mammae has, in this manner, been
 destroyed.
    This intumescence in  the breasts of young infants would appear to
 be the result of a subacute inflammation, attended with  serous infiltra-
 tion of the cellular tissue of the part.  Occasionally, the inflammation
 extends to  the  substance of the mamma, and the  skin by which the
 gland is covered, becomes very tense, shining, and of a dark-red colour.
 Even this aggravated form  of the disease will  very generally give way
 in  a few days to the simplest treatment; and we  do not recollect hav- 
CONGENITAL AFFECTIONS,  ETC.
651
ing ever seen a case which was attended with any degree of trouble,
or any great or prolonged suffering, and certainly no one which showed
any tendency to terminate in  suppuration, excepting when the tumour
has been subjected to the rude and unjustifiable processes adopted for
the removal of the stagnant milk.
   All that would seem to be required, in the generality of cases, is to
anoint the  tumour daily with a  little sweet-oil, or fresh  lard, and to
cover it with a piece of tolerably thick, soft muslin.   When, from any
cause, considerable inflammation, pain, and  swelling  of the breasts
take place, the case should be treated by a few leeches, and the  appli-
cation of soft emollient poultices.
   A weak solution of the hydrochlorate of ammonia in diluted vine-
gar,1 has  been  proposed as a  prompt and certain, application  in the
ordinary form of this" affection;  we have  never used it ourselves, but
we have no doubt that it will prove beneficial.
                     1 R.—Hydrochlorat. ammonire, 3ss.
                         AquEe,
                         Acid. acet. impur. aa gij.—M.
     To be applied warm, by moistening pieces of soft linen rag with it, and laying
                   them upon the affected parts. (Eberle.)

   It would  be well  for the  practitioner himself to examine daily, for
the first three or four days after birth, the  breasts of the infant, in order
to detect immediately any swelling that may  occur; and when it does
appear, to direct  the proper measures to be pursued,  forbidding, posi-
tively, at  the same  time, any attempt being  made on the part of the
nurse or other attendants, to squeeze or draw  out " the stagnant milk,"
which, in their opinion, is the  cause of the swelling.

                    9. — Ruptures. — Herniae.

   Hernia is, by no means, unfrequent in early infancy.  Children have
even been born with an  umbilical, inguinal, or scrotal hernia, or with
two or more hernial protrusions.  More commonly, however, the pro-
trusion takes place within the  first few days or weeks after birth, and
it is important that it should receive early attention, as well to protect
the infant  from suffering or danger,  as from the circumstance, that,
by  proper  treatment, a  radical  cure  may  then,  in  many  cases, be
effected,  and thus the patient saved, in  after life, from all the serious
consequences  invariably attendant upon  this infirmity, in  whatever
region of the abdomen it may be located.
  The most frequent form  of hernia met with in the infant is that
of the umbilicus, (exomphalus.)  This  results from  the circumstance of
the base of the umbilical cord, in early foetal  life, forming a  portion of
the anterior parietes of the abdomen, and containing the greater part
of the intestinal tube.  In proportion  as the development of the  foetus
is perfected, the base of  the cord contracts, the convolutions of  intes-
tine, at the same time, retire within the cavity of the abdomen, and an
aponeurotic sheath  surrounds, and further contracts the base of the
cord, allowing only  a sufficient opening for the  passage of  the latter,
with the  urachus  and umbilical  vessels.  In some  instances, however, 
652
DISEASES OF CHILDREN.
the commencement of the cord remains of a large size, and some of
the convolutions of intestine continue  within  it, forming  at  birth a
hernial sac of a round or rather conical form; the summit correspond-
ing with  the proper commencement of the cord, and the base, to the
circumference of the  aponeurotic ring at the umbilicus, which  is of
larger size than natural.  The hernial  sac is composed  in these cases
of the peritoneum with the skin and cellular tissue  more or less con-
densed.
  This form of hernia, though strictly congenital, may not be percep-
tible until some days after birth, when the intestines become distended
by aliment, and  crowded downwards towards the umbilicus by the
contractions of the diaphragm during  inspiration, and the act of  cry-
ing.  The bulk of the protrusion varies  very much; ordinarily, it is
about the size of a hickory nut, but  may increase to that of a walnut,
or even  beyond.  It generally contains a convolution of intestine, but
may contain only omentum ;—it is always larger and more tense when
the infant cries or coughs.  Upon relaxing the abdominal muscles, and
using gentle pressure, the contents  of the sac may be readily forced
back into the cavity of the abdomen, when, through the parietes of the
empty sac, an aperture  into which  the point  of the finger can be in-
serted, is perceptible in the linea alba.
  Until  the separation of the cord,  and the cicatrization of the navel,
it is unnecessary to do anything more than to  apply, in addition to the
usual bandage, a compress formed of  a few folds of soft linen imme-
diately over  the umbilicus.  As soon, however, as cicatrization is com-
pleted, a more effectual course of treatment must be commenced ; and
the earlier this can be done,  the greater will be our chances of effect-
ing a radical cure.  Our object is to keep the  protruding bowels com-
pletely and permanently within the abdomen, so as  to permit the natu-
ral closure of the opening through  which they escape  to  take place.
The best means for effecting this we have found to be a portion of gum
elastic of a conical shape, and about an inch  in thickness;  this being
neatly covered with a portion  of soft muslin,  is to  be stitched to the
centre  of the  ordinary  belly-band.  The apex, which should  not be
larger than the umbilical opening, is to be accurately applied over the
latter, and the band fastened in the usual way.  This compress should
be  kept  on  constantly, for it is only by long continuance, that we can
expect any benefit to result from its employment.  In proportion, how-
ever, as  the infant  advances in age, the umbilical  opening  contracts,
and at the same time the intestines acquire a greater volume, so that
they cease to pass through it, and finally, the  use of the compress and
bandage may be  discontinued.   We  have,  in  numerous  instances,
effected a complete cure, by the means here described.
   Another mode of treating umbilical hernia in infants, and one that
will no doubt be found admirably adapted to prevent the protrusion of
the intestines, is that described by Dr. Maunsell.  It consists in the ap-
plication of a graduated compress, formed of white leather, spread
with adhesive plaster, over  the opening, and  above this, the common
flannel roller.   The apex of the compress, which is to be applied next
the navel, should be,  as nearly as possible, of the size of the opening. 
CONGENITAL  AFFECTIONS, ETC.
653
The compress should consist of three or four pieces, the largest being
about three inches in diameter; and a double stitch should be passed
through them, and knotted externally, so as to keep each piece in situ.
We should always adjust the compress with our own hands, as great
care is necessary to insure the complete return of the hernia; and un-
less the child exhibits marks of uneasiness, it should not be removed,
until the plaster loses its  adhesive quality, and  then a new one  should
immediately  be  applied.   In  conducting  the  case, patience  will be
greatly exercised, as months will be required for the completion of the
cure, and  this should be explained to the friends at the beginning.
  It has been recommended by A. Cooper to  apply a section of an
ivory ball over the umbilicus, and retain it there by adhesive plaster
and a bandage.   To maintain an equal and constant compression, an
elastic belt and pad might be found useful,  in all cases.
  A plan, originally adopted by Mr. Woodroofe, of Cork, answers, we
are informed by Dr. Maunsell, very well, when there is a small open-
ing with  a considerably  elongated sac; it is, after reducing the  con-
tents, to hold the pouch firmly between the fingers, and  then to wind
around it a narrow strip  of adhesive plaster, commencing as close as
possible to the abdomen,  and continuing to the apex.  This  plan  may
succeed, by causing adhesion of the walls  of the sac, which will  thus
form a natural truss, and  prevent protrusion through the opening in the
linea alba; it cannot be employed, however, when the hernial  tumour
is broad and flat.
  It has been proposed by Desault and Dupuytren to apply a ligature
around the base of the tumour, with the view of inducing  inflammation
and adhesion of the sides of the hernial sac.  This plan, which is the
one described by Celsus, though apparently well adapted to effect a
permanent cure,  has, nevertheless, been abandoned by most  modern
surgeons, in consequence of it being found, that the patients in whom
it was tried, are  liable  subsequently to a return of the hernia.
  In the male, congenital inguinal hernia is, by no means, unfrequent.
It may exist  upon one or both sides.   In passing out of the abdomen
of the foetus, through the abdominal ring, the testicles always carry
with them a portion of the  peritoneum, by which they become enve-
loped, and which also  forms the vaginal sac,  in which they are con-
tained.  This  sac may become perfectly closed at its upper  part, so
as to cut off all communication between it and  the cavity of the omen-
tum;  often,  however,  it  remains partially or  entirely open, so as to
allow a convolution of intestine, or a portion of omentum, to descend
into  it, the bowel being  in  contact with  the  testicle, and becoming
sometimes  adherent to it.  The communication between the vaginal
cavity of the scrotum  and  the abdomen, may, however, exist without
giving rise to hernia;  and  it is possible for a portion of intestine or
omentum  to  descend  to  the bottom of the sac, although the testicle
may still remain  within  the abdomen,  or have descended no farther
than the ring; while, again, ordinary, non-congenital, inguinal hernia,
with strangulation, has been observed, according to Lawrence, in an
infant of fourteen months.
  It is no uncommon occurrence for the testicle, at the period of birth, 
654
DISEASES  OF CHILDREN.
to be arrested at the ring> or to have just passed through it, forming a
hard  rounded tumour in the groin ; we must be cautious not to mistake
this  for hernia, and as the testicle may remain in this position, even
while a portion of intestine has descended into the sac, this fact should
always he kept in  mind; as no truss  should be ever applied, until the
testicle has passed fully into the scrotum.
   Scrotal hernia  should not be confounded with hydrocele, which is
of common occurrence in infants.   The  latter may  be  distinguished
by its transparency, and by our being unable to feel the cylinder of the
intestine rolling under our fingers, within the sac.   The fluid distend-
ing the vaginal sac of  the  scrotum, we are to recollect, may in many
instances, be returned into  the cavity of the abdomen, and when this
is the case, the size of the hydrocele will  be  increased when  the infant
cries  or coughs; but with a very little care  such  swellings  may very
readily be  distinguished  from congenital or accidental hernia.   As a
general rule, there can be  very little certainty as to the existence of
the latter until the  testicle has descended  into the scrotum.
   A curious  case  is related by Billard, of congenital inguinal hernia in
a female infant.   There  existed in  this instance, in the left inguinal
region, a rounded  tumour about the size of a filbert, rather hard to the
touch, and incapable of being returned into the abdomen or diminished
by pressure, neither was  it enlarged by the crying of the child.   The
tumour was directed obliquely towards the  labium of the same side,
but did not quite reach to it.   The child  died  from pneumonia, when
it was found  that the tumour  was a  real hernial sac, containing the
left ovarium,  with  the fimbriated extremity of the fallopian tube, a little
reddened and swollen.  These had descended and passed through the
inguinal canal and ring—which latter was much larger than it usually
is in  the female infant—and  were  contained in  a sac  formed  of  a
prolongation  of the peritoneum, with the cavity of which it communi-
cated.  There were no convolutions of intestine adhering to the  sur-
rounding parts:—the right ovarium  was  in its usual situation;—the
round ligament of  the uterus  on  the  side at which the ovarium had
descended, was much  shorter than that on  the opposite side, and ter-
minated in the labium by an aponeurotic expansion, instead of losing
itself  in loose filaments,  as usual.   Hence, it  would  appear, that the
shorter and more firmly attached ligament had first caused  the uterus
to incline  towards  the left side of the bladder, and then drew with  it
the ovarium through the inguinal ring.
  In  the  treatment of congenital inguinal  hernia, the same objects
precisely,  are to  be had  in view, as in  the treatment of that of the
umbilicus, namely, to retain permanently  the protruding bowel within
the cavity of the  abdomen, and to favour the natural closure of the
ring.   The child should be kept as tranquil  as possible; it should be
restrained by every means in our power from violent  paroxysms of
crying, and from all exertion likely to increase the protrusion.
  When the hernia is present at the  period of birth, or  appears  soon
after, it should be  at once reduced and a temporary bandage applied,
with a small compress  upon the abdominal ring.   But little  compres-
sion, however, should be at first resorted to, and the bandage and com- 
CONGENITAL AFFECTIONS, ETC.
655
press should be frequently changed, as well from  a due attention to
cleanliness, as to prevent the irritation of the skin, which would other-
wise speedily result from their being constantly wet, and soiled by the
natural discharges.  As soon, however,  as the  infant is of sufficient
age to allow of it, a properly constructed truss should be applied, and
constantly worn.
   From the smallness of the pelvis, before the  end of the first year,
and  the difficulty of keeping the  straps  from being continually wet,
and  causing in consequence, chafing  of the  parts  with which they
are in contact, it is scarcely possible to get any  truss to fit, or to keep
it on sufficiently constant, previous to that period, and even then we
will  often be completely foiled.  We have, in fact, seldom  seen  much
good result from a truss,  or any other retentive apparatus, excepting
a simple bandage and compress, before the third or fourth year.
   Attention should be paid to preserve the bowels of children  affected
with hernia freely and regularly open.
   If the hernia  should become the  seat of  inflammation, indicated
by increased tumefaction, pain, and tenderness  upon pressure, leeches
should be immediately applied, in numbers adapted to the  age and
strength of the child ; the warm bath should be employed;  the tumour
covered with a light emollient poultice, and the bowels freely evacuated
by castor oil or mild laxative enemata.
   Should the  hernia become  strangulated, an operation will  become
necessary; provided we  are  unable  to  procure  a reduction of the
 tumour by the ordinary means.
   Besides the herniae resulting from  the escape  of a portion of the
 bowels at one or other of what are termed  the natural  openings in
 the  walls of the abdomen, they may also be produced by a congenital
 deficiency in  the parietes of this cavity.  This usually occurs near the
 umbilicus, and on the  median  line.  The integuments are sometimes
 wanting around the umbilicus and the sac, enclosing a portion of in-
 testine, is formed by the base of the cord alone; this covering is some-
 times so thin that the intestine may be seen  through it.   In a case of
 this  kind, a permanent occlusion of the umbilical opening was pro-
 duced by reducing  the intestines, the return of which was prevented
 by an assistant compressing the  cord close to  the abdomen; when a
 compress, formed of circular  pieces of  leather spread with adhesive
 plaster, laid one upon another in a conical form, was placed upon the
 navel;  the skin upon each side of the aperture was brought into con-
 tact, one lip slightly overlapping the other, and  the whole was secured
 by  a linen belt with  a thick  quilted  pad, of a circular form, applied
 over the navel.   The  bandage was  renewed occasionally.  By these
 means, the intestine was  securely retained within the abdomen, and at
 the expiration of a fortnight after the separation of the funis, the aper-
 ture  at  the navel  was so far contracted, that not the least protrusion
  was occasioned even by  the crying of the child.
   This case will sufficiently indicate the general plan upon which the
 irregular herniae, occurring  during  infancy, are to be managed; of
 course, slight modifications will be required in particular cases, which
 the  good sense  of the practitioner  will readily suggest.   Early and 
656
DISEASES  OF CHILDREN.
judiciously treated, nearly all of these herniae may be permanently re-
moved ; whereas, if neglected or improperly managed, they may entail
a serious infirmity that will last as long as the individual lives.
  Arrest of the  Testicle.—As closely connected with the subject of con-
genital inguinal hernia, a- few words will be proper,  in this  place, in
relation to a  not unfrequent occurrence, from which we  have repeat-
edly seen  a very considerable amount of suffering result; we allude to
the arrest of the testicle  at the abdominal ring, or in the groin, in its
passage from the abdomen.   In  this situation,  it  frequently becomes
inflamed,  which after causing severe pain, sometimes  of several days,
continuance, attended with considerable febrile reaction, and ocasion-
ally with tension and tenderness of the abdomen, nausea, or vomiting,
obstinate  constipation, and the other symptoms of peritoneal inflam-
mation, produces, in the groin, or at the ring, a small, intensely red
tumour, exquisitely  painful to the  touch and upon every motion of the
patient's body; in  this, suppuration, sooner or later, occurs, forming
an abscess of considerable size.   This inflammation is often  attended
with complete disorganization  of the testicle.
  The treatment consists in leeching, warm bathing, and emollient
poultices  to the groin, laxatives by  the  mouth,  and gentle purgative
enemata.  The  child should be kept as much as possible at rest, and
as soon as an abscess forms  it  should be opened.

                  10. —Vaginal Hae m orrhagc.
  In many cases, a discharge of red fluid blood  takes place from the
vulva of the  new-born female infant, and continues, without interrup-
tion, for several days or even weeks  after birth.   This sanguineous
discharge  is unattended  by redness, swelling, or  any other indication
of the existence of  the least degree of  irritation  in the vagina, or ex-
ternal parts of  generation; nor do the functions and general health of
the  child appear to  suffer any derangement.
  It is very difficult to understand the  cause of  this discharge.  The
whole of the  mucous surfaces are, it is  true, during the early period of
infancy, in a  state of extreme  vascularity, amounting often to perfect
hyperaemia ;  but we can trace the excretion of  blood by the vaginal
membrane of the infant to no very evident exciting cause.  The hae-
morrhage, in these  cases, has  been attributed by Ollivier, of Angers,
to the same physiological cause which, in after life, produces the cata-
menial discharge—nature appearing  to anticipate, in some  degree, the
establishment of a  function  which is fully developed and regulated,
only, at a  much later period  of life.   This suggestion would appear to
derive some support from the character of the discharge,  which  has
certainly much  resemblance to the catamenial flux  in the adult female.
  The discharge always ceases of itself, and requires  no particular
treatment; the preservation of perfect cleanliness  by repeated ablutions
of the vulva  will, of course,  be necessary.
  The alarm and anxiety which  this haemorrhage  almost  invariably
excites in  the mother, and those about the child,  should be  quieted by
an assurance that it is unattended with  danger.   In no instance, so far
as we are aware, certainly  in no instance that  has fallen under our 
CONGENITAL  AFFECTIONS, ETC.
657
notice, has any inconvenience resulted from it; nor has  it ever  con-
tinued beyond the first few weeks after birth.

                 11.—(Edema  of  the  Prepuce.
  The cellular structure of the  prepuce, in the male infant, is occa-
sionally the seat of a serous effusion, by which this part becomes some-
times enormously distended, and very hard  to  the  feel;  in a few in-
stances, we have found  the whole of the integuments of the penis to
be similarly affected.  When the prepuce is at the same time retracted
behind the glans penis, a species of paraphymosis  is produced, and we
have known  considerable difficulty to  he experienced in the  passage
of the urine, from the stricture upon the  urethra  which  is thus occa-
sioned.   A similar difficulty may also result, when  the tumefied  parts
envelope the glands, from the closure of the prepuce; ordinarily,  how-
ever, the intumescence gives little or no trouble, and is unattended with
pain or suffering, and generally  disappears spontaneously.  We  have
known it, however, to continue for a long time,  with little or no abate-
ment.
   Although we have arranged oedema of the prepuce among the dis-
eases occurring within  the month, it  is by no  means confined to this
period; we  have met with it frequently in  children from one to six
years of age.
   The causes of this affection it is, in  many cases, somewhat difficult
to trace.   It would  appear to be occasionally  produced  by an irrita-
tion seated within the urethra, as a stone  sticking in the canal, or a.
small splinter of wood or fragment of straw, introduced by the  child.
In one case,  we saw it produced by a portion of thread that the  child
had wound round the end of  the penis.  It is occasionally connected
with  an  erysipelatous  affection of the integuments of the penis and
scrotum,  and not unfrequently we have found  it  accompanied with a
herpetic eruption around the external skin of the prepuce at the  point
of duplicature.
   In some cases it is attended by a discharge from within the prepuce,
resembling a strong lather of soap, or the  froth of milk; this is evi-
dently caused by the retention of the  natural  discharges of the part,
rendered  perhaps more  copious  from the irritation of the urine, which
,often fills the cavity of  the prepuce before it is  discharged externally;
the discharge almost invariably  disappears as soon as the tumefaction
subsides.
   In the  treatment of  this affection,  if  the tumefaction be not very
extensive, and it presents  no difficulty or impediment to the discharge
of the urine, little else is required than to wash the part frequently
with camphorated spirits, and  an equal' quantity  of water, or with
two parts of the  aqua camphorata  and vinegar, or to  envelope the
prepuce  in crumb of bread moistened with a weak solution of the
acetate of lead.  In all cases  it  will be proper to  examine the urethra,
and if a  stone  or other foreign substance be found in the passage, to
extract it.   If the cedema be very extensive, and  the free discharge
of the urine is interfered  with, the best plan is to  slightly scarify the
                                42 
658
DISEASES OF  CHILDREN.
skin at the most depending portion of the tumour, and foment it freely
with tepid water.
  When connected with an erysipelatous inflammation of the  penis
and scrotum, this  should be treated by its  appropriate remedies; and
in cases in which an herpetic eruption is present, the application to this,
night and morning, of a little of the unguentum nitratis hydrargyri,
diluted with  an equal quantity of fresh hog's lard, we have found to be
generally sufficient for its speedy removal.

         12.— Cohesion of  the Labia and Nymphs.

  In female  infants there is, occasionally, an  adhesion  of either the
labia or nymphae;  but much more  frequently of the latter.    This
cohesion may be congenital, or occur some time after birth.
  The cohesion of the labia, when present, is easily detected. In some
cases it is so slight as to give way upon  the mere separation of the
labia;  in others, it is produced by a very firm  but  delicate and trans-
parent  membrane, extending across  from  the  inner  surface of one
labium  to that of the other, for the  division of which, the  aid of the
knife will become necessary; in other  cases, again, the adhesion of
the labia is  more intimate and extensive, and requires a cautious use
of the  knife  for its removal;  finally, there may occur  a complete
occlusion of the  external  orifice of the  vagina, which is  usually
connected with a  deficiency of some one or all of  the internal sexual
organs.
  In all these cases of cohesion of the labia, excepting the last, the
sooner it is  removed  the better; but when a complete  closure of the
vagina happens from  a congenital and perfect fusion of the  two labia,
no operation should be attempted previously to puberty, unless we are
able to determine with certainty  that  the vagina or  uterus is not
wanting, inasmuch as the child would otherwise be subjected  to a
severe and fruitless operation.   By waiting, however, until the period
of puberty,  we shall then be  able to decide with tolerable  accuracy,
as to the existence or non-existence of the internal organs, and, con-
sequently, as to the propriety or non-necessity of an operation.
  Adhesion of the nymphae is  much more common than cohesion of
the labia, and requires for  its  detection, a  much closer inspection.
When  the nymphae cohere, upon the  separation of the labia, they are
extended in  such  a manner as to form a  flat, continuous covering to
the origin of the vagina, and by the  blood being  pressed out of their
tissues when they are thus put upon the stretch, they become  pale,
and  scarcely to be distinguished from the surrounding surface; hence,
at first view, it appears as  though the nymphae  were  wanting, and
there existed no  vagina; but by gradually approximating  the  labia,
the nymphae assume their usual form and situation ; a probe may also
be passed behind them, and if the cohesion  was  not congenital, we
may learn from the nurse, that the opening  into the vagina  was the
same, at first, as it is in other infants.
  Cohesion  of the nymphae, the same as of  the labia,  may often be
destroyed  by the mere separation  of the labia; or a probe  being 
CONGENITAL  AFFECTIONS, ETC.
659
passed behind the coherent nymphae, and made to bear upon the line of
juncture, this may often be gently torn asunder, by merely drawing the
instrument towards  us;  in some cases, however, the adhesion is  so
intimate and  firm  as to require the aid  of the knife.    Care must
always be taken by the interposition of a  portion of soft linen, moist-
ened  with sweet oil, or fresh  lard, to prevent  the divided  surfaces
from again adhering.
   Simple cohesions of the nymphae  should be  remedied  at  an early
period.  The longer they are left, the more difficult, in general, does
their removal become.

                         13. — Hare-Li p.
   It is not our province to enter into a description of the several forms
of hare-lip, nor of the surgical  operations by which they are  to be  re-
medied.  The only question in  relation to them we  propose to notice,
is, at what period should any operation be performed.  This question
will be often put to the physician, and it is important that he should be
able to answer it understandingly.
   As  the deformity is  always  considerable, a natural feeling on the
part of the parents urges them to desire its early removal, and, in many
cases, an immediate operation is absolutely necessary, in order to pre-
serve  the life of the little patient—the abnormal  division of the lip,
complicated, perhaps, with a division or deficiency  of the bony palate,
preventing the child from sucking.   Here, whatever may be the risk
attendant upon an early operation, it must be encountered, as the re-
moval of the deformity is the only means  we have of saving the infant
from a lingering  death from inanition.  If the deformity, however,
does  not interfere with suckling, we believe it will be better, in all
cases, to defer the operation until the child has attained an age when
it will be attended with  less  danger of inducing convulsions, or other
dangerous consequences, and when there is a  greater chance of its
proving successful.
   The question nevertheless, still presents itself, how long is  it proper
to wait  before performing the  operation, or, in other words, what is
the earliest period at which it may be  undertaken, without danger  to
the child, or of its failure in the removal of the deformity.  The end
of the first or second year, is the time usually adopted for the opera-
tion.    A much earlier  period, however, has recently been recom-
mended by Dr. Houston, as the most suitable for its safe and efficient
performance, and several cases are adduced by him to prove the resi-
lience of a young infant, under the  operation, and  the  strength of its
reparative powers.   The age  which the gentleman just  referred  to
considers the best for undertaking it is about the third month;—he has
 never  seen  convulsions follow its  performance at this age, and he
 knows of no other evil consequences, that the young infant is liable
 to, to which it is not liable when a year or two  older.
   Dr. Hullihen, of Wheeling, Virginia, is decidedly in favour of ope-
 rating early.  He states that he has operated on thirteen cases before
 dentition had commenced; three of the infants were only four weeks
 old.   He remarks, that he has yet to witness the first untoward event, 
660
DISEASES  OF CHILDREN.
or  the slightest unfavourable indication resulting from the operation
when thus early performed.  Paul Dubois, in a paper read  before the
French Academy of Medicine, in May, 1845, adduces his experience
in favour of an early operation for hare-lip.  He details a number of
cases operated on by himself or his friends, at intervals varying from
a few minutes, to several days  or weeks after birth, all of which had
proved  completely successful.  Dr. Dawson, in a paper in the Dublin
Medical Press, for 1842, advocates the same practice, and relates two
cases, one of  a child four days old,  and the other of a  child seven
hours old, in which he operated successfully.
  Guersent, the younger, agrees with  Dubois in believing that the best
time for  the operation is  immediately after birth; and  that  if this
favourable opportunity be allowed to  pass by, it is better to wait until
the eighth, tenth, or twelfth year.
  Malgaigne  has  operated nine  hours after birth, on a child with
simple hare-lip, complicated with a wide fissure of the palate,  and of
the alveolar process.  The operation succeeded perfectly, but the child
died on the sixteenth day, from diarrhoea and aphthae.  The cicatrix
was found to  be admirable, and the  separation of the bones w:as so
much lessened, that,  had death not  occurred,  the fissure would  un-
doubtedly have been quite obliterated.   Baudon has operated, and with
success, in a case of double hare-lip and fissure of the palate, in an in-
fant aged four days.  He operated first on the right, and at the  end of
a fortnight on the left side.  Mestenhauser, of Raaste, in Silesia, during
a practice of thirty-two years, operated for hare-lip eighty times, and
prefers the children to be at least ten or twelve weeks  old before it is
undertaken.  Dieffenbach has  operated  upon a thousand  cases, and
states that, while union has taken place at every age, from a few days
after birth up to extreme old age, it is better to wait until  dentition is
accomplished, as when performed very early,  the cicatrix is  apt to
yield as growth advances.
  If it were not  for the danger supposed to  attend  upon an early
operation, there would be no question at all as to the importance of
remedying the defect, at the earliest age  possible; the effectual  re-
moval of the deformity, and the inconvenience attendant on it, being
then more easily and certainly effected, than when the operation is  de-
ferred to a  later  period.   We  are persuaded with Dr. Houston, that
the dangers and difficulties attendant  upon  early operations  are, how-
ever, greatly overrated.  Several instances of the successful removal
of simple hare-lip, at ages varying from a few days  up  to as many
months, have  been  recorded within the  last few years, and we have
so repeatedly seen the operation performed in children, from  six  weeks
to four months old, with perfect success, and without the  occurrence
of the slightest untoward symptom, that we feel it our  duty  to recom-
mend its adoption very generally at the termination of the third month,
or where the deformity is very  great,  at even an earlier period.

                   14. — Clnb-foot.—Talipes.
  Children are frequently born  with various deformities of the feet, to
which the popular denomination, club-foot, has been applied.  The foot 
CONGENITAL  AFFECTIONS, ETC.
661
may either be turned outwards, so as to allow its inner margin to rest
upon  the  ground, (valgus, talipes valgus;) or inwards, its outer edge
being directed to the  ground, (varus, talipes varus;) or the heel may
be drawn up, so as to direct the toes downwards, and extend the foot,
causing it to  approach a right line with the leg, (pes equinus, talipes
equinus.)  A fourth variety has been described by Little, in which the
foot is flexed upon the  leg, and the  heel only is applied to the ground.
This distortion is caused by a contraction of the muscles in front of
the leg.
  These deformities are, in general, apparent from birth, but increase
in extent  as the  child grows older, particularly as it approaches the
period when it should  walk.   If they are not remedied  at an early
period, the child is, in general, doomed to lameness  and deformity for
the residue of its life.
  Much attention has been directed, of late years, to the investigation
of the pathology and mode of remedying the various  congenital dis-
tortions  of the feet, by  several distinguished  surgeons  and physicians
of Europe and America.  Their immediate cause would appear to  be
a shortening of the gastrocnemii and other extensor muscles, or of
those which rotate the  foot outwards.
  The pes equinus, or extended foot, from shortening of the  extensor
muscles, is probably the most common form of distortion, the twisting
of the foot inwards being produced  secondarily, in consequence of the
natural inclination of the os calcis, and the normal action upon this of
the  gastrocnemii, causing the foot to turn somewhat in  that direction.
As the turning inwards of the foot increases, the plantar muscles, liga-
ments, and aponeuroses become more  and  more contracted, the de-
formity increases, and first, the side  of the foot, and finally, its dorsum,
is applied to the ground; the bones of the tarsus are at the same time
thrown into an unnatural position, and after the child begins to walk,
being subjected to continual pressure, become altered in shape, in con-
sequence of which  the  deformity, which in the first instance might,
with due care, have been removed, becomes permanent.  The twisting
of the foot outwards, which is of comparatively unfrequent occurrence,
is produced by a shortening of the abductor  muscles.
  The remote cause of club-foot is to be referred to a defect in  the
nerves distributed  to the muscles of the leg, in consequence of which
there is  a  want of balance in the development and action of the anta-
gonist muscles.
  Distortions of the feet have been  met with in foetuses of from three
to five  months, with co-existing deficiencies, and  malformations  in
the  brain  and  spinal cord;  in anencephalous and hemicephalous em-
bryos, the  hands, as well as the feet,  have exhibited  similar distor-
tions.  Children born with a deficiency or disease of the spinal mar-
row, are also very commonly affected with club-foot; the deformity is
hence a  common accompaniment of spina  bifida.   It  may also take
place subsequent  to birth, when from disease of the spine, temporary
paralysis of the muscles of the extremities is produced, and on a par-
tial recovery  taking place, the  flexor muscles acquire more power
than the extensors. 
662
DISEASES  OF CHILDREN.
  Distortions of the feet  are said to be hereditary, in consequence of
the transmission of a morbid irritability of the nervous system, pre-
disposing  to convulsive and spasmodic contractions of  the muscles.
We have no doubt that this may occasionally be the case, but of all
the numerous cases of club-foot  that have  fallen under our notice, no
one occurred in children born of parents, either of whom were simi-
larly affected.
   In the treatment of club-foot, the grand  object to be effected is to
extend those muscles, the inordinate contraction or shortening of which
has produced the distortion, and to increase the action and power of
their antagonists.  The first must  be effected by mechanical contri-
vances, adapted to preserve the feet  in their  natural position, and coun-
teract  the force by which they are drawn  out. of it;  and the second,
chiefly by friction of the limbs, and  a well-conducted general hygienic
treatment, calculated to reduce the excitability of the nervous system,
and to give tone to the body generally.
   A variety of mechanical contrivances have been  suggested, in the
form of splints, stocks, and shoes, to retain  the foot in its  natural posi-
tion, and counteract the distorting force.
   It is not within the province  of the present work  to present a de-
scription of these several apparatus, or to enter into a discussion of the
question, as to  which of them is the best adapted  to effect the object
for which they are employed;  we would  merely remark, that what-
ever contrivance we adopt, simplicity and lightness are of the first im-
portance, as well as such a form as will prevent any undue pressure
upon the part that is made the point d'appui.
   The form  of the apparatus will  vary somewhat,  according  to the
species and degree of distortion, in order to enable it to act effectually
upon the shortened muscles, which should be gradually and gently, but
constantly extended.
   When the shortening of the  muscles  is very considerable,  or  the
force they exert in drawing the foot in an unnatural position, too power-
ful to  be overcome by any mechanical  means that  it would be pru-
dent to employ, it is probable that  a division of the  tendons might be
advantageously resorted to, but we must recollect that  such division
will not  be sufficient  to effect a cure: in no case can this be accom-
plished without a long-continued  use of appropriate mechanical means;
—while  the latter alone, if commenced  with sufficiently early, when
the parts involved in the deformity are still sufficiently flexible and the
ligaments, aponeuroses, and bones of the foot have  undergone no  im-
portant changes, and when the  confinement  of the foot  can be borne
with greater ease  than at a later period, will, in most cases, be fully
adequate to produce a complete removal of the deformity.

             U.—Induration  of the  Cellular Tissue.

   INDURCISSEMENT DU TISSU  CELLULAIRE--CEDEMA CELLULARIS--SKIN-
                               BOUND.
   A peculiar hardness and tension of the skin of the  lower extremities,
often of the  trunk, and occasionally of the face, with coldness and  a 
                 CONGENITAL  AFFECTIONS, ETC.            qq%

 yellowish or wax-like appearance, or a pale red or purple colour of the
 ariected parts, are often observed in infancy, during the few first days
 or weeks after birth.                              '
   The disease sometimes commences at the feet, but  more generally
 about the pubic region, and inner surface of the thighs; from  whence
 it gradually extends over a  considerable portion, and  in  some cases,
 over the whole of the surface of the body.   The affected parts  be-
 come swollen, hard, and incompressible; the skin is tense, and  adheres
 nrmly to the parts beneath, so as not to  allow  of its being pinched up
 or moved over them ; it is at the same time dry, harsh, and decidedly
 cold to  the touch, and,  in  some  cases,  presents a yellowish,  or
 waxen appearance;  whilst in others, it is of a pale red, purple or
 livid hue.   In  the latter case, the swelling is the  most considerable;
 whilst the firmness and tension of the parts are the greatest when the
 skin assumes a pale yellowish colour.  The diminution of temperature
 is always remarkable; and when the disease extends over the  greater
 part of the  surface, the body is  acted upon by external  heat in the
 same manner as so much dead matter.
   M. Rogers (Archives Gen. de Med.) states that in 19  cases he found
 the  temperature to be  less than 91°, in 7 it sank below 78°, while the
 mean of 52 observations was  only 87-8°.   In extreme cases the tem-
 perature may sink to 77°, 74°, 72°, and in one  instance it  was  as low
 as 71-6°.   According to M. Rogers, a diminution  of temperature pre-
 cedes the occurrence of induration, or at least exists in a very marked
 degree while the induration is still very slight.  The reduction of the
 temperature is  always in direct proportion to the degree of induration,
 and consequently,  forms an important element  in  the prognosis.  Re-
 covery took place in only a single case after the temperature had sunk
 below 90-5°, though life was often prolonged for several days, notwith-
 standing a much greater reduction of temperature.   The slowness  of
 the pulse and respiration likewise bear a direct  relation  to the lowness
 of the temperature and degree of induration, the  former having sunk
 even as low as 60, the latter to 16 or  14.
  The infant labouring under this disease refuses to suck; its counte-
 nance becomes pale and contracted; it is restless; appears unable  to
 make a full inspiration, or  cry  out,  but almost constantly makes a
 peculiar  kind of moaning noise, which has been  compared by Dorf-
 miiller to  the cry of young mice.  Deglutition  appears, in general,  to
 be attended with difficulty, and is sometimes impossible.  The pulse is
 usually small, rapid, and irregular;  and there is always more  or less
 disorder of the  alimentary canal, with frequent discharges of a bright
 green, or whitish, or clay-coloured appearance.  There is generally a
 deficient secretion of urine;  though to a greater extent  in some cases
 than in others.
  Respiration becomes gradually more and more difficult, until death
ensues; usually before the fourth day, but sometimes not until a much
 later period.  In  some cases, tetanic  spasms supervene towards the
close of the disease ; the head and trunk being occasionally bent  rigidly
backwards, and the jaws firmly locked.
  The disease  is unattended,  throughout, with any degree of  febrile 
664
DISEASES OF CHILDREN.
reaction ;  though in some cases a degree  of febrile excitement may
precede its occurrence.   Occasionally it is accompanied with a jaun-
diced condition of the entire surface.
  Induration of the skin in infants is  an affection which is always of a
dangerous character; generally terminating fatally, within one, two, or,
at farthest, three weeks.  In slight cases, in  which the morbid condi-
tion of the integuments is of limited  extent, sometimes, in a few days,
the respiration of the infant improves, the parts  affected increase  in
temperature, and become softer, and  by slow degrees an entire reco-
very takes place.
  On the  examination of the bodies of infants who have  died of indu-
ration of the skin, the subcutaneous cellular tissue is usually found  to
be thickened, condensed, and  loaded with serum.  It is often of a
reddish or granular appearance, not unlike a portion of hepatized lung.
In many cases the adipose substance  is firm, hard, and indurated; with
or without infiltration of the cellular tissue.   The whole  of the tissues
are engorged with venous blood,  with which  every organ is unusually
loaded.
  The most frequent lesion of the viscera is inflammation of the ali-
mentary canal, with more or less morbid change  of the liver.
  The lymphatic glands are frequently found indurated and enlarged;
more especially those of the mesentery.  In  general, the serous infil-
tration is  not confined to the subcutaneous cellular tissue; it  has been
observed in the subperitoneal tissue,  in the cavity of the  mediastinum,
and in the plexus choroides;  we  have met with  it in the interlobular
structure  of the lungs, at the base of the brain, and along the whole of
the spinal marrow.  When free  incisions are made through the skin,
the serum gradually flows out, and  the  swelling and hardness of the
diseased parts disappear, excepting  in those  cases in which there co-
exists with the serous infiltration, a hardening of the adipose tissue.
(Andry, Auvity, Denis, Duges, Wolff, Billard.)
   Induration of the skin usually occurs soon after birth; occasionally
it is congenital.  It is more frequent in winter than in summer.  It
prevails to the greatest extent  in hospitals appropriated  to the recep-
tion of children, and among the offspring of the  impoverished classes
of  society, who  inhabit unhealthy localities, and small, ill-ventilated,
and filthy habitations.  It has been observed by Caspar, Billard, Wolff,
and others, that infants reared by the hand are more  liable to  the dis-
ease, under air circumstances, than those who are nourished at the
breast.
   Although  the disease  may attack  infants apparently  in  perfect
health, yet, in the great majority of instances, those who  become  the
subjects of it, are  observed  to be feeble or languid from birth; or to
labour under more or less disorder of the alimentary canal previously
to the occurrence of the cutaneous affection.   We should hence be in-
clined to  refer the disease to gastro-intestinal disease, and  a  generally
languid and debilitated  condition of  the  organism, the result of conta-
 minated  air, and  improper  or unwholesome diet; and probably, in
 some instances, an additional morbific cause, a cold and humid atmo-
sphere, may concur in its  production.  The connexion of the disease 
CONGENITAL AFFECTIONS,  ETC.
665
with gastro-intestinal irritation, had  already been  noticed by Denis;
and it  is further proved, by the fact  of the frequency with which, in
post-mortem examinations, inflammation of the mucous membrane of
the digestive organs is detected.
  The causes  of the disease appear to differ but little from those
which  give rise to infantile erysipelas, to which it has a very close re-
semblance.   It is often  attended with a condition of the skin not very
dissimilar from that which occurs in erysipelas;  while the latter is
frequently associated with  considerable induration  of the surface, for
some distance beyond the inflamed margin.
  The morbid  condition of the surface is evidently dependent upon the
simple infiltration of the cellular membrane with a serous fluid ;  this is
proved by the  appearance of the subcutaneous tissue after death, as
well as by the  fact, that when, during the lifetime of the patient, inci-
sions are  made into the indurated parts, and pressure is applied, the
serum  is discharged, and  the  swelling, tension, and  hardness, entirely
disappear.   It would appear,  therefore, that  the disease is, in  fact, a
genuine oedema;  the extreme  hardness of the skin resulting from the
less  loose and  yielding nature of  its tissues in early infancy.  The
oedema has  been referred, by Billard, to a  languid  circulation, the
result of a venous plethora, and the action of such external agents as
have the  effect of suspending the cutaneous transpiration, and thus
favouring the  accumulation of serosity in  the  subcutaneous  cellular
tissue.
  When the oedema is  general, and the venous congestion exists to a
very great degree,  all  the organs abundantly  supplied with  cellular
tissue  have their  functions more or  less disturbed, in consequence of
the infiltration of serum.  Thus, the glottis becoming oedematous, while
the lungs are overloaded with venous blood,  the cry of the infant is
rendered  painful, acute, and smothered.  The coldness of the surface
is the result of the languid state  of the capillary circulation, the defi-
cient oxygenation of the blood in the lungs, and the general debility of
the patient.
  All this is no doubt true, so  far as it regards a certain class of cases;
in others, however,  which have  fallen under  our  notice, the  venous
congestion, and consequent serous infiltration  of the subcutaneous cel-
lular tissue, were evidently the result of  an imperfect distension of the
lungs  at birth, and the consequent production of  the condition de-
nominated atelectasis by Jorg.  The  probability of this as a frequent
cause of the disease was  suggested by Dr. Maunsell;  its certain oc-
currence  in  several  cases, we have established by the result of our
autopsies.   M. Rogers  notices the  frequency  with which partial indu-
rations of the lungs are  met with  in the induration of the cellular tissue
of infants.  He conceives that  the pulmonary affection  must differ very
essentially from true inflammation of the lungs—while in the latter the
temperature rises even to 105°, in that peculiar condition of the lungs
which accompanies induration of the cellular tissue, it sinks as low as
71°, the pulse and respiration  at the same time being slow, in place of
accelerated.
   We believe  that  there is still  another  class of cases, by no  means 
666
DISEASES OF  CHILDREN.
unfrequent, in which the serous effusion into the subcutaneous cellular
tissue is the result of a  subacute inflammation of the latter, consecu-
tive, most frequently, to irritation of the alimentary canal.
  There are, evidently, two distinct varieties of induration of the skin ;
that from serous infiltration of the cellular tissue,  and another from
induration or concretion of the adipose matter.  The latter may exist
with or without general infiltration of the subcutaneous cellular tissue.
It is usually seated  in the cheeks, nates, calves of the legs, or back,
and occurs with or without derangement of the circulation or respira-
tion, and is seldom attended with symptoms of a nervous character.
(Billard, Rostan, Wolff.)
  When the adipose tissue is alone diseased, the affected parts are but
little swollen, and have the firm feel, and  yellowish-white appearance
of wax, or  concrete suet; in  the latter stages of the disease they are
said to be  sonorous upon percussion, and are  perfectly cold  to  the
touch.  In these cases, upon dissection, the subcutaneous adipose sub-
stance is found hardened and  condensed like suet, with the skin  con-
tracted, and firmly adherent to it.
  In this country, induration of the skin is an extremely rare disease.
Although connected, as physician, for eighteen years, with one of the
largest medical charities, perhaps, in this country, we met with  but
twelve cases of the  disease during that period.  In  the hospitals for
children, in Europe, it is, however, of more common occurrence.  In
the Foundling  Hospital of Paris, 645 cases  occurred  between  the
years  1808, and 1811: of which number,  567 terminated fatally;  and
in  1826, there  occurred in the same  institution 240 cases, of which
fifty died.
   The disease is described by the generality of the writers on the sub-
ject, as being but little under the control of medical treatment, and as
terminating fatally in the majority of cases.  The  condition of the
skin, however, appears to  be of less importance than that of the system
generally;  and death more seldom results, according to  Billard, from
the morbid state of  the integuments, than from  the serious diseases of
the internal organs—the  alimentary canal, the lungs and the brain—
with which it is commonly associated.
   When limited in extent, and occurring  in infants possessed of some
vigour of constitution, or  even when general, but not of an aggravated
character, and uncomplicated with severe visceral disease, it will often
yield to very simple remedies.
   The proper treatment of induration of the skin  in infants, will de-
pend pretty much upon the particular character of each case. In some,
there  is no doubt  that the  general plethora or local accumulations of
blood, will demand  the employment of leeches, cups, or even general
 bloodletting, and  gentle purgatives;  and  that  a cautious use of these
 remedies will be  attended with the best effects.  Friction of the sur-
 face with  the hand, or warm  flannel, and the use of flannel garments
 next  the skin,  are  all-important  remedies in the generality of cases,
 and  should not  be  neglected.  Blisters  have been  strongly recom-
 mended by Richter, and  according  to the experience of Dr.  Eberle,
 when early applied  to the affected parts, they would appear to remove 
CONGENITAL  AFFECTIONS, ETC.
667
the sanguineous engorgement of the subcutaneous tissues, promote the
absorption of the effused serum, and prevent its undue  accumulation.
We  have, in  several instances, seen good effects  result from a well-
timed blister:—it should be  kept on  about three hours; immediately
upon its removal, the part being covered with a large emollient poul-
tice.
   The exhibition of an emetic of ipecacuanha, for the  purpose of re-
lieving the air-passages from accumulations of mucus, and  unloading
the vessels of the lungs, has been recommended; and we have no doubt
that  it will prove, in most cases, highly beneficial.
   The vapour-bath has been considered by some practitioners, one of
the most effectual remedies that can  be employed in this disease; and
when it is dependent upon subacute inflammation of the subcutaneous
tissues,  or gastro-intestinal  irritation, will no  doubt prove advanta-
geous ;  but it is  not a remedy adapted to the generality of cases; in
many, dry heat, and friction of the surface, as  directed  by Baron, will
have a  far better effect.  In  some cases, tbe  respiration, during the
continuance of the patient  in the bath, is painfully accelerated, and
congestion and effusion in the lungs or brain have, it is asserted by
Billard, occasionally followed its use.
   Incisions through the  skin, at the seat of the disease, have been sug-
gested by Andry, Wolff, and others, as a means of relieving the over-
loaded  state of the  subcutaneous vessels, and of  giving exit to the
serum distending the areola of the subcutaneous cellular tissue.  We
are not aware that this procedure has been practised to any great ex-
tent  ; nor are we acquainted with the results of the cases in which it
has  been tried; we can, however, see no valid objection to it.
   In cases attended with  derangement of the alimentary canal, small
doses of calomel in combination with ipecacuanha, three or  four times
a  day, with the  occasional interposition of a  dose of  castor oil and
turpentine, as recommended in infantile erysipelas,  should  be  admi-
nistered.  If, however, the symptoms indicate that the gastro-intestinal
mucous membrane is the seat of acute or subacute inflammation, a
few  leeches should be applied to the epigastrium, or wherever the ten-
derness is most decided, and followed by large emollient cataplasms.
   Where there exists very  great debility, wine whey, or even ammo-
nia in combination with the aqua camphorata, with friction  of the sur-
face with camphorated spirits, or  the  oil of amber, followed by  the
application of a  flannel envelope, will be the most appropriate treat-
ment.

                           16.—Na;vus.
   Children  are  often born  with  permanent spots or marks upon  the
skin, varying  in  extent, and very materially in their nature and im-
portance.  The whole of these have been generally included under  the
vague denomination of ncevi materni.
   A very common form of naevus is that of a mole or slightly elevated
tumour, differing in size in different cases; generally of a dark colour,
and  often covered thickly with fine, short, silky hair, of the same colour
as the mole.   These naevi may occur upon any part  of  the body, and 
668
DISEASES  OF CHILDREN.
when seated upon the face or neck, or upon the shoulder or breast in
the female, produce very considerable deformity.  They often increase
slowly in  size, and  acquire a  darker colour, until towards puberty;
after which period they commonly remain  stationary for the  remain-
der of life, and are unattended  with pain or inconvenience.  They are
generally  attributed to some alteration in the structure of the rete mu-
cosum; their true nature does  not appear, however, to be as yet, well
understood.   It  is not customary to interfere with  them;  they could
certainly be dissected out without much difficulty, but the deformity
resulting from this procedure, would probably be as great, as that  it
was intended to  remove.
   Another very  common form of naevus is a dark-red circumscribed
stain, which generally appears upon one side of the face, and is some-
times of considerable extent.  It is perfectly superficial, and has been
supposed to result from  a  simple dilatation of the subcuticular capil-
lary  vessels at  the  part affected; it would  appear  to us, however,
rather to depend upon a local abnormal condition of the  rete muco-
sum.  Like  the  former, it sometimes increases  in extent until about
the period of puberty, when it undergoes no further change throughout
the remainder of life;—being attended  with  no  other inconvenience
than its unsightliness.   We have known it, however, to disappear en-
tirely during childhood.  It has been proposed by Frankel to diminish
the deformity by tattooing the  part affected with a white pigment.
   The naevus appears frequently in  the  form of a slight dilatation of
the capillaries;  in  some cases  superficial, and  in others extending
deeply into the mucous membrane of the lips.  In some instances the
dilated  capillaries appear as  tortuous, wide-spread lines, proceeding
from a small round spot, like the legs of the spider from its body; in
others, they form small, defined, granular tumours, of a  bright red
colour; in other  cases again, the naevus  is composed of a congeries of
venous capillaries, and is of a deep blue, or bluish-red colour.   These
sometimes disappear before puberty;  at  others, they continue sta-
tionary, neither  enlarging  nor diminishing  during  life.  They are
never troublesome,  constitute  but a very inconsiderable  deformity,
and, as a  general rule, should not be interfered with.
   The  most important of the naevi is that which appears in the form
of a  deep red-coloured, slightly elevated  spot,  which often  rapidly
augments in size, with a well-defined margin, and a granular surface;
it  is  obliterated by pressure,  but rapidly rises  again when  this  is
removed.  It  is formed of an  erectile, vascular tissue, and if acci-
dentally wounded, often gives rise to copious, prolonged, and dangerous
haemorrhage.  When seated near to an arterial trunk of  any size, it
pulsates powerfully  beneath the finger,  and is  attended by a thrilling
purr, synchronous with the action of the heart.   (Aneurism by anasto-
mosis.)
   Various plans have  been proposed for the removal of the vascular
naevus.
   1st. The  application of cold  and pressure. (Abernethy.)  This will
frequently succeed when the naevus  is  small, and not disposed  to in-
crease rapidly in size, and when it is seated over a bone;  but in those 
CONGENITAL AFFECTIONS, ETC.
669
of larger  size, of rapid growth, and  seated over soft parts, it is alto-
gether inefficient.
  2d. Vaccination over the surface of the tumour. (Hodgson.)  This
will  frequently succeed;  it is always, however, productive of a con-
siderable  scar, and if ulceration or sloughing occur, as is sometimes
the case,  the scar is often large, and forms a very decided deformity
in parts exposed to view.
  3d. Caustic.  (Wardrop.)  This  will also repeatedly succeed when
the vascular tumour is of small size, and inactive.   A portion of adhe-
sive plaster, with an orifice in its centre, of less diameter than that of
the naevus, should be applied closely around  the  tumour.  The  kali
purum is  then to be  rubbed upon the surface of the naevus, until slight
discoloration takes  place; the whole is then  to be covered with ad-
hesive plaster, and  suffered to remain some days.  When the tumour
is flat, one of its  largest vessels may be punctured, and a stick of the
caustic, finely-pointed, passed into the orifice,  vinegar being immedi-
ately applied to prevent the too extensive action of the  caustic.   The
caustic will not  succeed  in the removal of large, diffused, or deeply-
seated naevi; it  cannot be applied in those seated in the immediate
vicinity of the eye, and however carefully performed, is productive of
an unsightly scar.
   4th. Ligature. (Bell,  White, Lawrence.)   There  are  several modes
of applying the ligature.  When the base of the tumour is very narrow,
the simple ligature may succeed;  but when the base is large, a needle
armed with a double ligature may be passed  beneath the tumour, and
one portion tied around each hemisphere, and tightened, as it becomes
loosened  by ulceration; or, two double ligatures may be passed be-
neath the tumour, one  in the direction  of each of the  diameters, and
the tumour strangulated at four different points by tying  together the
 single ends of the ligatures nearest  to  each  other;  or a hare-lip pin
 may be passed under the naevus, and then a double ligature under that
 at right angles; the separate ligatures are then to be tied lightly, and
 twisted round the pin twice or thrice.  In both of the latter methods,
 it is as well to  divide  freely the substance of the naevus  above the
 ligatures.  A new plan for applying the ligature has been proposed by
 Mr. Christopher, and practised  by him in six cases with perfect  suc-
 cess.  (Lond. Med.  Gaz., Dec, 1848.) A strong silk, half a  yard long,
 one half  of which has been dyed  black by dipping it in  ink, after being
 well waxed, is to be passed through the eye of a  needle so as to  leave
 the ends  equal.   The needle is then to be passed beneath the centre of
 the part  to be removed.  The ligature being divided in the middle,  so
 as to leave the needle on the black portion, the latter is  to be passed
 through  the skin, immediately below the part to be strangulated.   The
 superior, or white half of the ligature being now armed with the needle,
 this is to be passed through the  skin in an opposite direction to the
 black ligature, immediately  above the part to be strangulated.   The
 needle being removed, the two ends of the black loop that includes the
 inferior half of the  naevus, are to  be tightly tied, and then the two ends
 of the white loop, including the superior half of the naevus.   The four
 ends remaining, two  black and  two white, are now to be tied  alter- 
670                DISEASES OF CHILDREN.

nately and tightly, the one to the other.   The whole mass  to be re-
moved is thus completely and entirely inclosed in a double circle, both
from  within  and without,  and is most  effectually and permanently
strangulated.  We  have seen the ligature often perfectly successful;
it is generally, however, attended with considerable  pain, and  cases
are recorded in which it was productive of convulsions.  It is always
tedious, and leaves, generally, a  large, irregular scar.  According  to
Mr. Christopher, the plan proposed by  him is productive of little pain,
and in the cases in which he has put  it in practice, it has been unat-
tended by any untoward accident.
  5th. Setons.  (Adams.)  Twelve or fourteen threads passed through
the tumour at different points without tying.  This is said  to succeed
perfectly in the removal of the naevus.
  6th. Ligature of the principal arterial trunk which supplies the
naevus.  (Travers.)   This will unquestionably succeed in some cases,
and in the more extensive and distinctly-marked aneurism by anasto-
mosis, is, in fact,  the only operation that  can be depended on ; it  is,
however, a very serious one, and has been  found repeatedly unsuc-
cessful.  In the ordinary forms of vascular naevi, it is unnecessary  to
resort to it.
  7th. A plan of treatment has been suggested  by M. Hall,  which  is
said effectually to remove these tumours, to be applicable in all cases,
without reference to size or locality, to be without danger of haemor-
rhage, and to be unattended with the inconvenience of ulceration  or
sloughing, and consequent deformity.   It consists in passing  a  mode-
rately-sized needle,  with cutting edges, through the naevus so frequent-
ly as  to induce adhesive inflammation  with the deposit of lymph, and
thus to obliterate and consolidate  the vessels of which it is composed,
yet so seldom as not to incur the risk of inducing  sloughing.  The
needle must be passed in several directions from one point in the cir-
cumference of the naevus, to several points more or less opposite; near
the surface, in the superficial arterial naevus, but more  deeply in the
deeper-seated capillary naevus.  The operation is to be repeated at in-
tervals of two, three, or four months, according to the  state of the case,
and the progress of the cure.   We know nothing, personally, of the
merits of this operation, never having  seen it performed.
  8th. Excision.  (Bell.)   This is the  plan which we have invariably
adopted in all true arterial naevi that have fallen under our notice, and
have  repeatedly seen it performed by others.  It is said by Wardrop
to  be frequently dangerous, from haemorrhage,  and to have even
proved fatal.   We have never found any injury to result from it. The
incision through the skin should be made  at  some distance  from the
margin of the tumour, which should be dissected out beneath its base;
but little haemorrhage has resulted in the majority of cases,  and this
was readily commanded by pressure;  occasionally,  however, one  or
two small arterial branches  had to be secured by ligature.   By ap-
proximating and securing the edges of the wound, a very small cica-
trix is produced.
  9th. Lafargue recommends five or six punctures to be made on and
around the naevus, with a lancet dipped in croton  oil, as in  vaccina- 
CONGENITAL  AFFECTIONS, ETC.
671
tion.  By each puncture a pimple is immediately produced, which be-
comes, in thirty-six hours, a little boil.   The several boils unite and
form a painful, burning tumour, covered with  white crusts, and re-
sembling a small carbuncle.   Two days afterwards  the scabs sepa-
rate, and in place of the naevus is seen an ulcer, which is to be treated
on general principles.  M. Lafargue considers that it would be dange-
rous to make more than six punctures on a very young  infant, as the
irritation  and fever that result are considerable.
  Whatever operation is adopted, it is important that the child should
have attained its third year previous to its performance, and at the
same time, be in tolerable health, and free from fever, or other  posi-
tive disease.  If considerable pain, restlessness, or fever result  from
the operation, these should be treated by their appropriate remedies.

             17.— Jaundice —Icterus Infantilis.
  In infants, two or three days after birth, it is not unusual for the
whole surface  of the body,  as well as the tunica conjunctiva,  to
acquire a yellow hue, more or less intense, which, in the course of a
few days,  in  general, gradually  disappears.  (Icterus  neonatorum.)
Generally speaking, this is an  affection of very little importance, ap-
pearing to depend upon a temporary excess of the colouring matter of
the bile in the serum of  the blood, and to be unattended with disease
of the liver, or any of the  other organs.  In some cases, it has ap-
peared to us, to be connected  with the want of a free  evacuation  of
the meconium.  Occasionally, this discoloration of the skin  we have
known to be accompanied  with a good deal of drowsiness, and an
evident sense of uneasiness in the skin.   Nothing more is required in
any case, than  a  dose  of  castor oil, or a  grain, or two of calomel,
and the  same  quantity of rhubarb, with the daily use  of the warm
bath.
   In some instances, the skin of the  infant  will  be marked by dull
yellow, irregular blotches, (maculae hepatica?,) more or less extensive,
and sometimes  occupying the greater part of the surface.  The colour
of  these blotches varies very  much in intensity; and in cases where
there exists considerable derangement of the alimentary canal, they
occasionally assume a very dark hue (melasma)—in some  instances,
they are accompanied with a  prickling or tingling sensation.
   The disease appears to be most generally connected  with  derange-
ment of the digestive organs,—the colour of the skin being dependent
upon a morbid  secretion from the  cutaneous vessels :—it has little  or
no affinity with jaundice.   Considerable debility and languor, and in-
dications of a disordered state of the alimentary  canal generally, pre-
cede its occurrence.
   Its removal is to be effected by such means  as are  calculated to
restore the regular and healthy functions of the digestive organs, and
to improve the health of the infant generally;  in all cases, the breast-
milk of  a healthy nurse, a  pure,  fresh  air,  and the daily use of the
warm bath, with gentle friction of the surface, are important parts of
 the treatment.
   Genuine jaundice, with intense  yellowness  of  the skin and tunica 
672
DISEASES OF CHILDREN.
conjunctiva, nausea or vomiting, costiveness—the evacuations, when
procured, being white or clay-coloured—and a deep yellow colour of
the urine, may occur in infants, from congenital obstruction or malfor-
mation of the biliary ducts.  Under such circumstances, the disease is
incurable, and sooner  or later will prove fatal.
  In the Northern Journal of Medicine, Dr. A. B. Campbell  relates
three cases of icterus  in new-born infants, all of which terminated fa-
tally.  In two, the disease was found to depend on congenital absence
of the hepatic and cystic  ducts, and in the  other  upon obstruction of
the common biliary duct  by inspissated bile.  In the first  case  the
jaundiced hue  of  the  skin appeared the day  after birth;  the  infant,
however, continued well until the ninth  day—though  the evacuations
from the bowels were white; a haemorrhage from the umbilicus then
occurred, and  returned on the following day, when the child died. The
gall-bladder was found to  be a shut  sac, the hepatic and cystic ducts
being both wanting—the blood was tinged  with bile.   In  the  second
case, the symptoms occurred early—no haemorrhage took place.  The
infant wasted away, while  its abdomen enlarged in  hoth hypochondriac
regions.   The patient lived until the sixth month,  being attacked  im-
mediately preceding its death with violent diarrhoea, and vomiting of
a fluid like coffee  grounds.  The liver was large—the  gall bladder, as
well as the ducts,  were absent,—the blood  and various tissues were
tinged with bile.  The third case closely resembled the first; haemor-
rhage from the umbilicus occurred on the seventh day, and  returned
at intervals until the eleventh,  when the child sunk into a comatose
state and died.  The whole  amount of blood discharged did not  ex-
ceed an ounce and a half.  The gall-bladder  was  full of bile,  the
escape of  which  was  prevented, however, by a  plug of inspissated
bile, which filled the common duct.   The brother of this  infant died
at the same age and with  similar symptoms.
  The  same morbid phenomena, with the addition of pain and tender-
ness of the epigastrium, vomiting of the food soon after it is swallowed,
or, if retained, violent  paroxysms of pain, occurring an hour  or two
after it is taken, may be produced  in infants, by  inflammation, acute
or subacute, of the  mucous membrane of the duodenum.  Here  the
treatment must be directed entirely to the removal of the latter disease:
mild mucilaginous fluids, in small quantities, a few leeches to the epi-
gastrium, followed by warm fomentations, or an emollient cataplasm;
and, after the inflammation has been, in this manner, reduced, a blister
to the epigastrium, for  a  couple or three  hours, succeeded  by a soft
bread-and-milk poultice, and internally, very minute doses of calomel
and ipecacuanha,  three or four times a day.
  In many cases,  however,—we have certainly met with a great num-
ber—the jaundice of infants is dependent upon a state of hyperaemia,
or of subacute  inflammation of  the liver.   In these cases, the colour
of the skin and eye is of a  dirty yellow—the surface is harsh  and dry;
the urine is charged with bilious matter; the stools are dry and clay-
coloured; the  countenance has an anxious,  distressed  expression, and
the infant is  apt  to fall into a languid, drowsy state; there is con-
siderable thirst, acidity of stomach, flatulence, and frequent griping or 
CONGENITAL  AFFECTIONS, ETC.
673
 colicy pains; and with these  symptoms, there is always more or less
 fulness of the right hypochondriac region, with great tenderness  upon
 pressure.
   The disease, in general, assumes a chronic character, and is attended
 with considerable and  progressive emaciation, and with tumefaction
 and hardness of the abdomen;  frequently with oedema of the lower
 extremities, and sometimes with  effusion within the peritoneal cavity.
 The tongue, which was at first coated with a thin  layer of yellowish
 mucus, becomes, in  the progress of the  disease, dry, and of a dark-
 brown  colour.  It is  occasionally accompanied by induration of the
 subcutaneous cellular texture, and more frequently, with purpura, either
 simple or haemorrhagic.
   The disease is, in general, produced by the same causes which  give
 rise, in infancy, to derangement of the digestive organs.  When de-
 pending upon hyperaemia of the liver, it is usually connected with the
 indications of a general plethoric condition of the system, and a  very
 languid circulation.  It has  been supposed  by Eberle, that this  condi-
 tion is most apt to  occur in infants who, when born, present a turgid
 and livid appearance of the face and body, and an oppressed  state of
 the brain, and which have  not been sufficiently relieved by a  flow of
 blood from the divided vessels of the cord.
   In the treatment of the jaundice of infants, our remedies will depend
 upon the character of the  symptoms  in each case.   When  simple
 hyperaemia  of the  liver exists, an  emetic of ipecacuanha should be
 given, and repeated, in a day or  two, if circumstances require it.  The
 emetic should be succeeded  by the warm bath, and gentle friction  over
 the whole surface of the abdomen, and a grain or two of calomel, fol-
 lowed by castor oil, or magnesia and rhubarb.   The bowels should be
 kept regularly open, by divided  doses of calomel, magnesia, and  ipe-
 cacuanha, given three times a day, with an occasional dose of castor
 oil, the activity of which may be increased by a few drops of turpen-
 tine.  The warm bath should be repeated daily, and the infant allowed
 the benefit of a free, pure atmosphere.
   When the case is marked  by symptoms indicative of hepatic in-
 flammation, a few leeches  should be  applied to  the right  hypochon-
 drium, and followed by an emollient cataplasm.   The leeches may be
 repeated, after a short  interval, if the fulness  and  tenderness of the
 right hypochondrium continue with little abatement.  Calomel should
 be  administered in the same manner as directed  above.   After the
 hepatic inflammation has been  somewhat reduced, the warm bath,
 followed by a blister over the liver, will, in general, be found  of de-
 cided advantage; the  blister  should be removed in three hours,  and
 the part to which it had been applied, covered with a soft emollient
 poultice.  When the calomel produces irritation of the intestines, we
 may combine it with small doses  of the extract of hyoscyamus,* which
 in no degree interferes with its action upon the bowels.  The use of
the calomel, with an occasional purgative of castor oil and turpentine,
should be continued, until natural, bilious, stools are procured, when it
should be suspended, and the freedom of the bowels maintained by the
use of the citrate of magnesia and rhubarb, or castor oil.
                               43 
674
DISEASES OF CHILDREN.
                     » R.—Calomel, gr. iij.
                          Ipecac, pulv. gr. ij.
                          Magnes. calc. gr. xxxvj.
                          Ext. hyoscyami, gr. iv.—M. f. ch. No. xij.
  In the chronic form of infantile jaundice, the warm  bath, followed
by frictions, blisters to the right hypochondrium, and a cautious use
of calomel and ipecacuanha, in alterative doses, are the remedies from
which the  most benefit is  to be anticipated.  The carbonate of soda
may, in many cases, be administered with  advantage; a grain or two
should be given every two  or three hours, dissolved in a teaspoonful of
carbonated water, or in the same quantity of a weak infusion of hops;
or, it may be given in  combination with  taraxacum.8   We have seen
very striking advantage result, in many of the chronic  cases of jaun-
dice occurring  in infants, from the  taraxacum, in combination with
the vegetable alkalies; whilst in other cases, again, we have given it
in tolerably large doses, and continued its use for some time, without
any benefit whatever.
  When, in the chronic form of infantile jaundice, there is considerable
flatulence of the intestines, with  frequent griping or colicy pains, the
turpentine  has, in our hands, succeeded the best, in removing the ten-
dency to the formation of gas, and  relieving  the suffering of the pa-
tient.   We have, generally, at the same time that we administered the
turpentine—in the dose of from five to ten drops, according to the age
of the patient, every three  hours—directed a dose of extract of hyos-
cyamus, in combination with ipecacuanha and carbonate of soda, three
times a day,b and a camphorated mercurial plaster over the whole of
the right hypochondrium.
   1 R.—Taraxaci, 3ij.                  b R.—Extr. hyoscyami, gr. iv.—vj.
         Bicarb, soda;, gr. xxiv.—xxx.            Pulv. ipecac, gr. ij.—iij.
         Aquae, 3ij.                          Bicarb, sodse, gr. xxiv.—xxxvj.
         Syrup, limon, 3ij.—M.                  —M. f. pill. No. xij.
  Dose, a teaspoonful every four hours.
  When we have succeeded in procuring  natural, bilious, discharges
from  the bowels, and the skin  begins to  assume its natural hue, the
restoration of  the  patient's strength  may be promoted by some light
tonic; either the cold infusion of bark, or the  sulphate of quinia, or
the proto-carbonate or tincture of the sesquichloride of iron, with a
light vegetable diet, the warm bath  daily, gentle exercise in the open
air, and occasional doses of some mild purgative, to keep the bowels
regular if they are inclined to costiveness.

  18.—Purulent Ophthalmia.—Ophthalmia neonatorum—
                   Infantile Conjunctivitis.

  The purulent ophthalmia  of infants commences, usually, within a few
days after  birth—generally between  the third and seventh.  We have
seen it, however, upon the  second day, and occasionally, not until the
third  week.
  The first indication of the disease is, generally, the eyelids becoming
glued together during the night, with swelling and redness externally.
When the lid is raised there occurs  a gush of tears, and its conjunc- 
CONGENITAL  AFFECTIONS, ETC.
675
tiva is found to be uniformly red, and slightly thickened, and covered
often with a somewhat tenacious, transparent coating.
  As  the disease proceeds, the lids become more constantly aggluti-
nated, and an increased secretion from the surface of the  inflamed
conjunctiva takes place, of a thick, purulent matter, a portion of which
exudes from between the lids, but the greater part is retained, causing
a considerable bulging of the palpebrae—the integuments of which as-
sume  a  dark-red hue.   The child becomes fretful and uneasy, and
manifests the utmost intolerance  of light—keeping the eyes firmly and
constantly closed, and  averted from  the light.  The tumefaction and
redness of the conjunctiva rapidly increase, and extend over the globe
of the eye.   Every separation of the eyelids is attended with a gush
of purulent matter, which sometimes is so copiously effused as to burst
open the firmly closed lids, and  run down the  cheek in large drops.
The  thickening of the conjunctiva often becomes  so considerable, in
the  course of three or four days, as to rise up around  the  cornea,
nearly concealing it, or causing it to appear as if sunk deep into the eye.
  The intumescence of the conjunctiva causes  it to become  everted
upon every attempt to  examine the affected organ,  or every time the
child cries; not unfrequently, the constant pressure of the orbicularis
muscle renders the eversion permanent.
  The discharge from the eye is generally of a pale straw-colour; but
sometimes of a  deeper yellow;  and, not  unfrequently, it  assumes  a
greenish hue; it is said, in  some cases, to be ichorous, or mixed with
blood.   An ichorous state of the discharge we have never seen;  but
occasionally, have  known  a  small amount of blood  to  be   mixed
with it.
  A slight hazy condition of the cornea  very generally occurs, and
this  may continue for  a week or longer, without any permanent de-
struction of its  transparency.  About the tenth or twelfth days,  some-
times later, purulent infiltration  of the cornea, however, takes place ;
or, an interstitial deposit in the conjunctival  layer or substance  of the
cornea.
  When purulent infiltration occurs, ulceration may ensue, either of
the entire  cornea, or  of a small, circumscribed portion of it, giving
place to prolapsus of  the humours, or of the iris only.  When  an in-
terstitial deposit  takes place, complete opacity of a part, or  of the
whole of the cornea may result,  or a  thin, bluish-gray film  may form
over its  surface.  When a considerable portion of the cornea  is de-
stroyed by ulceration, the  humours of the eye ordinarily escape, and
the globe collapses.
  There appears to be two forms of purulent ophthalmia, as it occurs
in children:  one in which the inflammation is confined exclusively to
the conjunctiva of the lids; another in which  the conjunctiva  of the
eyeball  becomes equally involved in the disease.  In the first, the dis-
ease is of a much milder character, and is seldom  attended with any
very serious  injury to  the  eye;  occasionally, however, the disease is
equally severe in  its symptoms, and protracted in its course as when
the inflammation affects  the whole of the conjunctiva.  We have re- 
676
DISEASES OF CHILDREN.
peatedly seen the disease confined,  for  a number of  days,  to  the
palpebral  conjunctiva, and then suddenly to  extend over the ball of
the eye, and  he  quickly followed by infiltration  and ulceration of the
cornea.
   In cases unattended with complete opacity or extensive ulceration
of the cornea, adhesion of the iris to the latter may take place; or an
opaque spot, not larger than the head of a small  pin, may be formed in
the centre of the anterior  hemisphere of the capsule of the lens.
   Both eyes are generally attacked, either simultaneously, or  within a
very short interval of each other.
   The result, favourable  or  unfavourable, of infantile  purulent oph-
thalmia, will  depend pretty much upon the greater or less violence of
the attack, and the period at which the  treatment is commenced.  In
its early stages, the disease is by no means difficult to cure;  but in its
advanced stages, it is seldom arrested, until more or less injury to the
eye has taken place.
   So long as the cornea retains  its transparency, there is a possibility
of saving the eye; but when ulceration or purulent infiltration of the
cornea has occurred, although the inflammation may still be removed,
the sight will be permanently destroyed.
  Opacity of the cornea, resulting from a thickening of its conjunctival
covering, may disappear  completely in the course of time,  but  that
from superficial ulceration is generally permanent, and may interfere,
to a greater or less extent, with vision.
   Protrusion and adhesions of the iris may impede or totally destroy
vision, according to the part at which these occur; while the loss of
vision resulting, at first, from central opacity of the capsule of the lens,
may in time, with the enlargement of the pupil, which takes place with
the growth of the child, disappear in part; but permanent short-sight-
edness may remain.
   Not a little discrepancy of opinion has existed, and still exists, as to
the true  character  and cause of purulent ophthalmia.   By some, the
disease has been supposed to be of a specific character—an erysipela-
tous affection of the  conjunctiva; others believe it to be simple catar-
rhal inflammation,  occurring in children  of unhealthy constitutions.
By the majority of authors, however, it is referred to some acrid or
morbid matter secreted in the vagina of the mother, and applied to the
infant's eyes during birth.
   It is unquestionably true, that children  born of mothers labouring
under  leucorrhcea, are far more liable to be affected with  purulent
ophthalmia after birth, than those born of women who are entirely free
from  disease; yet so many cases of the  disease occur  in the latter,
that those physicians certainly err, who refer it invariably to morbid
vaginal discharges in the mother.
   During twelve months, Cerderschjold informs us, three hundred and
sixty women were delivered in the General Lying-in Hospital of Stock-
holm, and subtracting those of whom the children were dead-born, or
died within a day or two  after birth, of the remaining three  hundred
and twenty-eight, one hundred and forty-seven laboured under leucor-
rhcea, and the remaining one hundred and eighty-one were free from 
CONGENITAL  AFFECTIONS, ETC.
677
 disease.  Thirty of the children were affected with purulent ophthalmia,
 namely, twenty of those whose mothers had the discharge, and ten of
 those whose mothers had none.
   From these facts it would appear, that discharges  from the genitals
 are  extremely common  among pregnant women; that women may
 labour under them without causing purulent ophthalmia in their chil-
 dren ; and that infants may be affected with this disease, notwithstand-
 ing their mothers have no discharge:  it is evident, therefore, that the
 ophthalmia  is not necessarily produced by infection received from the
 mother.   Nevertheless, when we  consider that twenty out of the one
 hundred and forty-seven children born of  mothers in whom a vaginal
 discharge existed, or about one in seven, suffered from  ophthalmia,
 while only  ten in one hundred and eighty-one, or one in  eighteen, of
 those whose mothers were unaffected, had the disease—the proportion
 of the former being nearly three times greater than the latter—we must
 conclude, that a discharge from the genitals of the mother, though not
 the sole  cause of purulent ophthalmia in new-born infants, is, at least,
 a very frequent one.
   The disease is attributed by some to  the too early and unguarded
 admission of light and heat  to the eyes of the new-born infant.   We
 cannot say that we have been able to trace purulent ophthalmia to this
 cause, though we admit that the practice of placing an infant, as soon
 as it is born, and day after day subsequently, on the nurse's lap, before
 a bright fire, with its face turned  towards the latter, and with perhaps
 a candle or lamp at no great distance, and keeping it there, not only
 during the time necessary for  dressing or  changing it, but frequently,
 long after this is completed,  is  certainly one very liable  to produce
 injury to the eyes.
  Impurities of the atmosphere, particularly smoke and other irritating
 vapours  diffused in the air, are, no doubt,  common causes of purulent
 ophthalmia; cold and dampness  may also produce  it;  and, perhaps,
 slight mechanical injuries of the conjunctiva.
   Purulent ophthalmia is a common affection of infants  in almshouses
 and  children's asylums, where the inmates are crowded  together,
 without  sufficient  attention being  paid to cleanliness,  and to the se-
 curing at all times, a due supply of fresh air; and it is among the chil-
 dren of the miserably poor, by whom little care is taken of the hygienic
 management of their offspring, that, in private practice, we most fre-
 quently meet with the disease.  Contaminated air, with its often asso-
 ciated  morbific causes, neglect of cleanliness, defective nourishment,
 and want of sufficient exercise, is  liable to produce a general tendency
 to disease, in the  mucous tissues of children; the mouth, anus, and
 vulva, under such circumstances, being alike liable to affections  ter-
 minating rapidly in gangrenous ulceration.
  In cases of purulent ophthalmia, it is said by Morrell, that the vagina
is  liable  to be affected with  a purulent discharge, precisely similar to
that from the conjunctiva.
  By some  physicians, purulent  ophthalmia is supposed to be conta-
gious; and numerous instances are referred to, in  which the disease is
said to have been communicated to the nurse, by the  accidental  appli- 
678
DISEASES OF CHILDREN.
cation of the matter from the eye of the infant to hers.  Our "oppor-
tunities for observation on this subject have been tolerably extensive,"
but we have never met with such an occurrence.  The disease occa-
sionally occurs epidemically, generally  at  periods when catarrhal
affections  prevail; being produced, probably, by the same causes as
the latter.
  After the first three or four days, there is always a very great diffi-
culty in obtaining a viewr of the ball of the affected eye, particularly
of the cornea, in consequence of the thickening and disposition to ever-
sion of the conjunctiva; and the irritation produced by every attempt
to force open the lids, sufficiently to enable the  practitioner to ascer-
tain distinctly the actual condition of the affected  organ, has induced
us to forego it entirely, and trust to " what information can be obtained
from the external condition of the lids, and the nature of the discharge
which issues from beneath them."  (Taylor.)   At the same time, how-
ever, we  consider it  absolutely necessary to open the  lids  once or
twice a day, first sopping them well with a little warm water, or milk
and wrater, so as to soften the matter which glues them together, in
order to give discharge to the morbid  secretion which  accumulates
behind them ; an object which may be further  promoted  by the cau-
tious injection of tepid water, or an infusion of pith of sassafras be-
tween the lids.   The agglutination  of the lids may be prevented, by
covering the eyes, as the patient  lies upon his back, with  a small por-
tion of soft linen rag, and dropping upon the inner canthus, occasion-
ally, a little warm milk and water.
  In the commencement of mild cases, we have  seen the  disease very
quickly arrested, in numerous instances, by warm fomentations, assidu-
ously applied to the eye externally, and the occasional use of a wash
formed of a strong infusion of common green tea, great attention being
paid at the same time to the condition of the bowels, which are very
generally deranged.  They are occasionally constipated, when a grain
or  two of calomel, followed by castor oil, should be administered;
much more frequently, however,  there is diarrhoea, with green, watery
discharges; in  such cases, small doses of calomel, ipecacuanha, and
magnesia,* and  the daily use of the warm bath will be required.
  When, however, there is general and decided redness and  swelling
of the conjunctiva, or if the eyelids are much swollen, and red exter-
nally, local  depletion by leeches will  be  absolutely necessary; and if
not  resorted to sufficiently early, and carried at once to a proper ex-
tent, the only opportunity of saving the sight of the child may be lost.
The number of leeches—which  should be applied as  near as possible
to the  eye—will depend altogether upon  the strength and vigour of
the child, and their size; the best  rule, perhaps, is to draw as much
blood in this manner as will be  sufficient to produce a slight paleness
of the patient's skin.  If the first application has not been sufficient to
arrest  the  inflammation, the  leeches should be repeated after a short
interval.
   The leeches should be followed by purgatives, of which  the best is
calomel, succeeded by castor oil; or, the combination of calomel and
ipecacuanha, as directed above.   By some practitioners, a combina- 
CONGENITAL AFFECTIONS,  ETC.
679
tion  of calomel and  the  pulvis antimonialis  is considered peculiarly
beneficial in this disease.b

  * R.—Calomel, gr. ij.                 b R.—Calomel, gr. iij.
       Pulv. ipecac, gr. ij.                  Pulv. antimonial. gr. xij.—M. f. chart.
       Magnes. calc. gr. xxxvj.—M. f.           No. xij.
         ch. No. xij.                 One to be given every three hours.
One to be given every three or four hours.
  There can be no doubt that in  all cases, minute  doses of calomel,
repeated daily, will be productive of the best effects, and that  their
efficacy will  be increased by  the  addition of either the ipecacuanha
or antimonial  powder.   If by  this means  the bowels  are not  kept
sufficiently open, an occasional dose of castor oil, or of magnesia and
rhubarb  may be given.   If  there  be continued derangement of the
alimentary canal,  the  spirits  of  turpentine,  in small doses,  by the
mouth, or in  the form of enema, will often be particularly serviceable.
  The  patient should be kept in  a dark, well-ventilated room; the
eyes should be repeatedly fomented with warm water, or with a warm
infusion  of pith of sassafras, or of  poppy-heads, and  the directions
already given to keep the eyes free from the purulent discharge, con-
stantly attended to.
  After the violence of the inflammation is reduced, it has been directed
to apply blisters to the temples or over the closed eyelids; the latter
mode of applying them is certainly to be preferred, and we have occa-
sionally seen the best effects derived from their use.   In  young chil-
dren, particularly when of a weakly and debilitated constitution, blisters
must, however, be employed with  the utmost caution, otherwise very
dangerous consequences are  apt to result from them.
  At that particular period of the disease when alone blisters,  if they
are  resorted  to, should be applied—that is, after the intensity of the
inflammation has been considerably mitigated by leeches, purgatives,
emollient applications, and a general antiphlogistic regimen—lightly
scarifying the thickened conjunctiva, the  eyelids being first carefully
everted, and  by this means  procuring a free  discharge of blood  from
its enlarged vessels, is considered by some, as among the  most effec-
tual  means for the complete  removal of the disease; by  Saunders and
others, however, it is  condemned as in all cases injurious.   In chronic
cases,  attended with very great vascularity of the conjunctiva, we have
known scarification to prove of the  utmost  service; we have never
employed it,  however, in  the acute stage of the disease.
  We* shall be obliged in most cases  of purulent ophthalmia, to judge
of the effects of our  remedies upon  the disease, by the diminution of
the general symptoms, and  the quietness of the infant, and by the re-
duced  redness  and tumefaction of the palpebral, the diminished amount
of the discharge, and by the child being able to open to a certain ex-
tent, and  for a longer or shorter period, his eyes; but to determine
properly this latter, it is necessary to watch the motions of the patient
before fight is admitted into the apartment; because the moment this
takes place, the eyes will  be  very generally closed, and he will forcibly
resist their being opened.  Whenever it can be done without inducing
considerable  pain, or  an increase of irritation, it is always  important, 
680
DISEASES OF CHILDREN.
however, that the state of the eye should be ascertained by actual in-
spection.
  By an early resort to the treatment just recommended, and by its
judicious employment, we shall generally find that about the third,
fourth, or fifth day of the attack, the pain, swelling and irritation of the
eye, will begin very rapidly to subside ;  the discharge at the same time
becoming much less in quantity, and of a thin, gleety nature, and the
conjunctiva of a paler and  more flabby appearance,  but with its ves-
sels still gorged with a considerable amount  of  blood.  Mild astrin-
gent applications will now be proper.   Various formulae for these have
been recommended by different practitioners ; each one recommending
his own as the best.  Solutions of the acetate of  zinc, (one scruple to
four ounces of rose water,) or of the acetate of lead, (five grains to an
ounce of water,) of the bi-chloride of mercury,3  of alum, (five  grains
to an ounce of water,)  or of  the nitrate of silver, (four grains to an
ounce of water,) may be employed.  With either  of the first three, the
eyes should be bathed  three or  four times in the twenty-four  hours,
and a portion carefully injected into the eye.  Previously, however,
to their use, the lids should be gently everted and the  discharge care-
fully and cautiously wiped from their inner surface, by means of a soft
sponge, wrung out of warm water.  The solution of  nitrate of silver
may be applied once daily,  with a  large  hair pencil, over the  whole
of the inflamed conjunctiva; it may be used in conjunction with either
of the other collyria.
                    1 R.—Bi-cblorid. hydrarg. gr. j.
                         Hydrochlorid. ammoniae, gr.  vj.
                         Aquae, 3vi'j-—M.  (Mackenzie.)
  The chloride of lime, (one scruple to two ounces of  water,) has been
strongly recommended in the treatment of the purulent ophthalmia of
infants, and deserves a trial.
  The conjunctiva continues  often, after the inflammation has been
subdued, in a relaxed puffy condition;  when a wash of a strong solu-
tion of zinc, or alum, may be used; or the conjunctiva may be touched
daily with  the  vinous tincture of opium.  When the membrane  be-
comes soft, spongy and granular,  the  solid  nitrate of  silver,  or the
ointment, (composed of ten grains to one ounce of lard,) may be ap-
plied.
  When ulceration or disorganization of the cornea is threatened, it is
all-important to support the patient's  strength, by the  use of tonics,
which will also be proper after ulceration or disorganization has taken
place.  The most  convenient tonic will be, the sulphate  of  quinia,
which may be given in divided portions, to the amount of one, two or
three grains daily, according to the extent of the exhaustion under
which the  patient labours.
  It is all-important, in every case of purulent ophthalmia, and during
the entire continuance of the disease, that the patient should enjoy  a
free,  pure  atmosphere; and  be defended  from  cold  or damp, and
from the  influence of domestic  and  personal  filth.  He  should be
nourished at the breast of a healthy nurse.
   Although not convinced of the infectious character of the discharge 
CONGENITAL  AFFECTIONS, ETC.
681
 from the eye in this disease,  we think it proper, however, not to run
 any risks; and hence, the attendants should be cautioned against in-
 curring the danger of communicating the  infection to themselves or
 others, by the accidental contact of the matter with their eyes, which
 may be easily prevented by the most  scrupulous cleanliness.

                         19. — Hydrocele.
   Hydrocele in infants may result from the distension of the vaginal
 sac of the scrotum with serum; the communication between this sac
 and the cavity of the abdomen being obliterated,  or still continuing
 open ;—or, the accumulation of serum may be confined to the vaginal
 tunic of the cord, without any  communication with  the scrotum  or
 abdomen, or with a free communication with the latter.  The diagno-
 sis is somewhat different in these different cases.
   In hydrocele of the vaginal sac of the scrotum, the tumour is semi-
 diaphanous, and the testicle, if it has descended, may be felt near  its
 inferior posterior part.  If no communication exists  between the sac
 and abdomen,  the  swelling undergoes no change in its  dimensions
 during crying or coughing; it usually gradually augments in size, pre-
 senting a kind of pyramidal form, with the apex towards the ring; and
 when the integuments of  the scrotum  are put upon the stretch,  their
 natural rugosity is obliterated, and they become smooth, pale-coloured,
 and shining.
   If, however, a communication still  exists between  the scrotal and
 abdominal cavities, the tumour  will increase in size  when the child
 coughs or cries, and pressure upon the tumour will cause the serum by
 which it is distended, in great part or entirely, to pass upwards into
 the abdomen ; but it immediately returns upon the  pressure being re-
 moved.  In this case, our diagnosis is  to be  founded  upon the  semi-
 diaphanous  character of the swelling, the  presence  of fluctuation,
 and the inability to feel within it any fold  of intestine, or portion  of
 omentum.
   In hydrocele of the cord, the tumour most generally occupies a situa-
 tion midway between the  testicle and groin;  it is of an oblong figure,
 perfectly circumscribed, and generally very tense;—it undergoes no
 alteration from change  of posture, or  during coughing or sneezing.
 It may be accompanied by an inguinal hernia, and hy hydrocele of the
 scrotal sac, in which case the  true character of the disease is rendered
 very obscure, and its existence is, with difficulty, detected.   When the
 hydrocele is situated higher up upon the cord, it often extends upwards
 within the ring, or by gentle and continued pressure may be made to
 recede within it, but the swelling immediately returns upon the  pres-
 sure being removed.  With the exception of a slight  dragging sensa-
 tion, which is the greatest when the hydrocele is  low  down upon the
 cord or in the scrotal sac, these tumours are unaccompanied by either
 pain or uneasiness.
   The hydrocele is very generally confined to one side; occasionally,
however, it occurs on both.
   In some cases, children  are born affected with hydrocele either of
the scrotum  or cord; but most generally, it is not noticed until four or 
682
DISEASES OF CHILDREN.
five days, and sometimes even longer, after birth.  Children are also
liable to the occurrence of hydrocele at a later period, from the same
causes which produce it  in the adult.   Notwithstanding the alarm to
which these swellings, when they occur in infants and young children,
give rise in the minds  of the parents and those  connected with the
patient, they are  seldom of  much  importance,  and often  disappear,
after a time, spontaneously.
  In young infants, frequently sponging the tumour with a weak solu-
tion of the acetate of  lead, or with a  mixture  of two parts  of aqua
camphorata and one of vinegar is, perhaps, the only treatment thatjt
is proper to pursue. If, under this treatment, the swelling does not dis-
appear, when the  child has arrived at  twelve or eighteen months of
age, as well as in those cases in which the swelling appears late in in-
fancy or during childhood, the affusion of cold water—the water being
poured upon the hydrocele out of a tea-pot, and from  a height—four or
five  times a day, will very generally cause its dispersion.  The affu-
sion must be unremittingly persevered in for a considerable time.  In
this manner we have, in repeated instances, effected a complete cure.
The effects of the cold water may be increased, in children over two
years of age, by brisk  purging,*  and a simple farinaceous diet.
                     * R.—Bitart. potassa?, gij.
                          Pulv. jalap, 3j— M. f. ch. No. xij.
 One of which may be given every day, or every other day, according to the effects pro-
                        duced upon the bowels.
  Where the hydrocele is of considerable size, and,  in place of dimi-
nishing, continues steadily to increase in bulk, we  have  found  that
puncturing the tumour, and allowing the water gradually to drain off,
has, after one or two repetitions, produced a  radical  cure.  We have
also seen the introduction, through the tumour, of a seton composed
of a few threads of floss silk, effect a perfect cure, as well in cases of
scrotal hydrocele, as of hydrocele of  the cord, without the occurrence
of much pain, or any disagreeable symptoms.  The ends of the seton
should be loosely  tied  together,  and a thread drawn out every second
or third day, until the  whole is removed.
   The discussion  as to  the  particular  circumstances under  which it
may become necessary and proper to resort to the usual surgical means
for effecting a cure of hydrocele in the child, by causing the oblitera-
tion of the  cavity of the tunica  vaginalis, does not  come within the
scope of the present treatise.

                        SO.—Paronychia.
              ONYCHIA--PANARITIUM--WHITLOW--FELON.
   Children are very liable to an  inflammation, occurring usually near
the end of one of the fingers or toes, or about the edge or root of the nail.
It may be seated in the cutis, in the subcutaneous cellular tissue, or in
the thecae or synovial  sheaths of the tendons, particularly on the inside
of  the fingers.
   When the inflammation occurs in the cutis, we have usually the
 symptoms of a  slight phlegmon,—heat, pain, tension, and redness of
 the part, with some degree of febrile  excitement.  The inflammation 
^CONGENITAL AFFECTIONS,  ETC.
683
terminates quickly in suppuration, marked by a  semi-transparent ele-
vation of  the cuticle.  The pus frequently travels around the finger,
separating the cuticle to a considerable extent.
  When the inflammation is seated in the subcutaneous cellular mem-
brane, the local symptoms are more severe, and there is often  a de-
cided febrile reaction, attended with distinct rigors.   The suppuration
occurs early, but the matter is slow in reaching the  surface, and  often
extends laterally, burrowing beneath the nail.  This form of parony-
chia is generally attended with very severe pain throughout its course.
  The affection is of a still more severe character when seated in the
thecae  or  synovial sheaths.  The pain  is deep-seated, and generally
intense.   There is  often  severe rigors, followed  by  very  decided
symptoms of febrile reaction from the very  commencement.  The
swelling is more extensive than  in the  other  forms, often  spreading
over the whole hand or foot, and even to the forearm or  leg:  distinct
red lines or streaks of inflammation—probably inflamed absorbents—
extending to the axilla or groin.  At  this period, in  very excitable
children, convulsive  action often  ensues, and very  generally extreme
restlessness, or delirium.  From  the unyielding  nature of the tissues,
the matter formed, in place of reaching the surface, passes along the
synovial sheaths, or tendinous thecae, to  the palm of the hand or wrist,
or to the sole of the foot; producing intense suffering for  weeks, causing
the death  of the tendons, and destroying the motion of the joints, or
even, in some cases,  affecting the periosteum, and producing caries of
the subjacent bone.
  In children of a lymphatic temperament, or of a  plethoric,  but un-
healthy condition of body, the inflammation  is often  seated in the
matrix  and  soft parts at  the root of the  nail.   (Onychia maligna.)
The disease  commences with redness, swelling, heat,  and  tension at
the root of the  nail; attended with a dull, throbbing pain, great ten-
derness upon the slightest pressure, and shivering, succeeded by febrile
excitement.   From the sulcus at the lower part of the nail, there soon
takes place an oozing of a thin, ichorous fluid, succeeded by ulceration,
which spreads round the semicircular edge of the soft  parts covering
the root of the  nail; the ulcer is  of an unhealthy appearance, with
thin, flabby edges, and covered with a dirty-yellow lymph; the skin is
separated  from the nail, which becomes exposed to its very root, and
discoloured.  The ulceration extending beneath the  nail, this becomes
gradually detached from  the  parts beneath.  The surrounding soft
parts are swollen, of a dusky red or purplish hue, and  intensely  sore;
bleeding profusely upon the slightest touch.  When allowed to proceed,
the toe  or finger becomes a  deformed, bulbous, ulcerated  mass, and
may continue so for  months; exhibiting not the slightest disposition to
heal, so long as  any  portion of the nail remains attached.
  Paronychia often occurs in  perfectly  healthy children, without any
very apparent cause; in many cases it would appear to be  intimately
connected with derangement  of the digestive and assimilative organs;
but its most common cause is either external injury, puncture, contu-
sions or slight wounds, cold, or the retention of some  acrid or extra-
neous substance about the nail. 
684
DISEASES OF  CHILDREN.
  During the inflammatory stage of paronychia, if any  extraneous
substance is present, it should be extracted, or  removed by repeated
ablutions with warm water and a sponge, according to its  nature.  In
the superficial variety, the best application  is, probably, the common
bread-and-milk poultice, frequently repeated, with a brisk purgative
internally, and  a mild restricted diet.  In the cases in which the in-
flammation is more deeply seated, leeches, saline purgatives, low diet,
and perfect rest are required.
  If the local  inflammation  is  very considerable, and attended with
much febrile reaction, in robust, plethoric children, a few ounces  of
blood should  be taken from the arm, and some saline diaphoretic with
antimony administered.*  The free application  of leeches  to the seat
of the disease, is the most effectual means of abating the inflammation,
and in this manner relieving the extreme pain.   The early  application
of a blister around the affected  finger or toe, has often arrested the
progress of the disease.
                     * R.—Sulph. magnes. giv.
                          Pulv. nitri, 3j.
                          Tart. ant. gr. j.
                          Spir. teth. nitr. 3iv.
                          Aquae, 3iv.—M.
             Of which a teaspoonful may be given every three hours.

  Various rubefacients have been recommended, as hot water, hot ley,
hot turpentine, &c, these will, when applied sufficiently early, often  do
good ; we believe, however, that the blister should always be preferred.
It is hardly necessary to say, that  any derangement of the digestive
organs that may be present, will require the appropriate remedies for
its removal.
  In  subcuticular paronychia, when suppuration has commenced, it
is to be promoted by frequent  poultices, and when the cuticle is raised
by  the  formation of matter  it should  be  freely  divided, and then
cautiously removed as far  as  it  has become separated from the skin
beneath.  This is an important precaution, as suppuration is very apt
to continue, if  any portion of  the detached cuticle is allowed to  re-
main ; and the disease  thus travels around and over a considerable
portion  of the  finger or  toe.   After the separation of the  cuticle, the
parts may be dressed with simple cerate, or the cerate of the oxide of
zinc, and they, in general, heal very promptly.
   In the more  deeply seated  forms of paronychia, when we find that
we  are unable to arrest the course of  the  disease, an early and free
incision is all-important. If we wait until suppuration has taken place,
we not  only prolong, unnecessarily, the  patient's sufferings, but endan-
ger the loss of motion in the affected finger or toe, if not more serious
injury.   The incision should be  made freely, and through  the cellular
texture  of the  part, down to the periosteum, and when the tendinous
theca is affected, this should be  freely divided with the knife.   If  the
matter  has burrowed beneath the  nail, this should be scraped very         i
thin, and  then  divided with a pointed  bistoury.  The incision  gives
almost  immediate  relief, allows the escape of  whatever  matter may 
CONGENITAL  AFFECTIONS, ETC.
685
have already formed, or if suppuration has not  commenced, prevents
it by arresting the inflammation.   After the incision, the parts  should
be dressed with  soft bread-and-milk poultices until they heal.
  If we have not been called to the case until deep-seated suppuration
has taken place, and one, or perhaps several openings have been formed
externally, through which fungous granulations  extend and spread out
in the  form of mushrooms, free  incisions are essential to  the cure.
If the  tendons or thecae are found  to be  dead or sloughing, the  dis-
eased portion should be clipped off with a scissors, with  a small por-
tion of that which is yet sound;  if the bone is  found to be  in  a state
of caries, it  should be extracted as soon as it becomes sufficiently
loose.   The best local application in these cases is a common bread-
and-milk or carrot poultice.   When the dead bone and tendons  are
removed, we have never seen  much delay in  the  healing of the parts.
   Onychia maligna requires  a somewhat different treatment.  It is,
according to our  experience, one of the  most frequent forms under
which the disease presents itself in children, and  unless properly ma-
naged, is apt to produce a troublesome, painful  ulceration, which may
continue, without the slightest appearance of  amendment,  for many
 months, and when finally  healed, leave a very disagreeable deformity
 of the finger or toe, upon which a nail is seldom reproduced.
   The child is to be placed upon  a well-regulated  diet, composed
 chiefly of farinaceous  articles and  milk.  It should be  exposed  to a
 pure,  fresh atmosphere, and take such exercise daily in the open air,
 as is adapted to its age and strength.  Mild purgatives should be ad-
 ministered according to circumstances; and if the  alimentary canal
 exhibit very considerable  derangement, a mild, alterative course, with
 occasional light tonics, and the warm or tepid  bath every morning.
    The local treatment consists in the  application of leeches, followed
 by emollient poultices.  After ulceration has occurred, in some cases,
 benefit will be  derived from  an ointment composed of the ungt. hy-
 drarg. peroxyd. and sulphate of zinc ;a or of the sulphate of zinc and
 corrosive sublimate; but, whenever  the ulceration has extended be-
 neath the nail and exposed its root, we have never seen any treatment
 in the least degree beneficial, until the whole  of the nail is removed.
 This  is certainly a  very severe operation; but when skilfully and
 quickly  performed, the suffering produced by it is infinitely less than
 that  resulting from the long-continued  painful ulceration  kept  up by
  the dead and partly detached nail.  Upon the removal of the nail, the
  ointment just  mentioned, or the black wash, or a weak  solution of
  nitrate of silver, with a continuance of poultices, will quickly effect a
cure.
* R.—Ungt. hyd. peroxyd. 3j.          b H.—Sulph..anci,
     Sulph. zinci,gr. xv.                  Chlordhydrarg.aa9j.-M
     Cerat. simpl.3j.-M.          To be  sprinkled th.ckly upon  the diseased
            v  OJ                surface, and then covered with a pledget of
                                 lint,  wet with tincture of opium. (Perkins,
                                 Physick.)
The removal of the diseased
matrix of the nail, by making a deep 
686
DISEASES  OF CHILDREN.
 incision down to the bone, about three or four lines below the lower
 edge of the ulcer, and then carrying it around so as to dissect out en-
 tirely the diseased surface, has been recommended by Dupuytren and
 Rynd;  we prefer, however, the removal of the whole nail, as a more
 effectual,  and even less painful operation.


                    21. —Burns and  Scalds.

   Burns and scalds are among the most frequent accidents that occur
 during the latter  period of infancy, and during childhood.   The care-
 lessness of parents and servants, the natural temerity and incautious-
 ness of children, and  the necessity, in the ordinary mode of  warming
 apartments, of their  being  brought  in close proximity to  the open
 fire, or  heated stoves, render these accidents of such frequent occur-
 rence, that no winter  passes without our seeing a number of children
 who have suffered from them.   They occasionally happen under cir-
 cumstances where they were the  least to be anticipated:—infants being
 left for a few moments alone, have crawled or climbed to parts of the
 room where  vessels of heated water were standing, which they have
 overturned upon themselves;—some of the most serious scalds in chil-
 dren  that we have been called upon to treat, have  been produced  in
 this manner.
   There is a very great variety in the character  and extent of these
 accidents, which requires some modification in  their treatment.  The
 burn or scald may produce a simple  and very circumscribed inflam-
 mation of the skin; or an  inflammation accompanied with vesication;
 or the cuticle may be completely removed to some extent; or the whole
 of the integuments of a part may be entirely destroyed.
   The pain and  suffering are always greater in  superficial burns than
 in those attended with an entire destruction of the cuticle.  Burns
 which involve a  very large portion of the surface, would appear to be
 attended with no pain whatever;—the patient, if old enough, complains
 of a feeling of chilliness or cold, and is strongly inclined to sleep.
   There is, in all extensive burns, immediately upon their occurrence,
 a very great depression of the whole of the vital powers, which con-
 tinues for  some time before reaction takes place; while, in other cases,
 no reaction whatever takes places; the patient falls into a deep coma-
 tose sleep, from which  he never awakes.
  The danger from burns is always in proportion to their extent, taken
 in connexion  with their depth ;—hut even superficial burns, seated on
 certain portions of the  body, are attended with very great, and some-
 times immediate danger.   Thus a burn, of even  small extent, upon the
 head or stomach, has been known to produce very speedy death.
  In superficial burns, in which there is produced a simple redness  of
 the skin, the best  immediate application is, cold water, vinegar, or any
 alcoholic liquor.   The application of these fluids must be unremittingly
persevered in; they always relieve the  intense smarting with which the
burn  is  attended ; and often  very speedily allay the inflammation.
When nothing else is at hand, the common potato, scraped or mashed 
CONGENITAL  AFFECTIONS, ETC.
687
into  a pulp, in  its raw  state,  will often  be found beneficial.  After
the cold application has been continued  for  some time, the injured
part  may be lightly covered or wrapped with loose cotton.  This has
always a soothing effect.
  If any considerable degree of inflammation still continue, we have
found th^ best application to be a liniment composed of fresh lard and
acetate of lead (twenty grains to one ounce of lard).   After all, how-
ever, even  in  the  most superficial  burns, our own experience would
lead  us  to  recommend, in all cases, the immediate application of the
spirits of turpentine;—it removes, at once, the smarting pain, prevents
vesication,  and  we have often  been surprised at the rapidity with
which, under  its use, the  inflammation  entirely-subsides.   To derive,
however, these  advantages from  the turpentine,  it must  be applied
without the  least delay.   In extensive burns, it ought, invariably, to be
preferred to every other local application.
  When vesication is produced  by the  burn or scald, the same treat-
ment should be  pursued.   If the vesicles are large, it is best to punc-
ture  them, to allow of the escape of the serum, but without removing
any  portion of the cuticle.
  In burns attended with extensive  vesication, in general, suppuration,
with a copious discharge of matter ensues.   If the suppurating surface
continues red  and inflamed, the common bread-and-milk poultice, with
a proper attention to the state of the bowels, and, if the child is weaned,
a light farinaceous diet, will be proper, until  the inflammation subsides,
when, as well as in cases in which the  ulceration of the skin is unat-
tended with any considerable degree of inflammation, the parts may
be dressed with the ceratum. oxyd. zinci, or the simple  cerate, inti-
mately combined with a portion of prepared chalk.
   In deep burns, attended with a destruction of the integuments, warm
emollient poultices should be applied until  the inflammation of the sur-
rounding skin is entirely  removed, when the burnt  part should be
covered  with  a pledget of lint, thickly spread with the common resi-
nous ointment, mixed with an  equal portion of spirits of turpentine;
which dressing should  be continued until the dead portions of integu-
ment slough out.  We have found, in deep  burns, attended with con-
siderable inflammation of the surrounding  parts, the  usual domestic
application, of common lamp oil and molasses, spread on cotton, to be
often a very useful one.  When the dead parts are entirely separated,
a simple bread-and-milk poultice should  be applied, until granulations
begin to  form, when the ulcer may be dressed with the ointment of the
oxide of zinc; and if cicatrization is long  in  taking  place, adhesive
strips should be applied, and the part subjected to the pressure of an
appropriate bandage.
   In all burns situated near joints, or  in the neighbourhood of parts
possessing a good deal of motion, care should be taken during the pro-
cess of  healing,  to prevent, as much as possible, by the use of splints
and  bandages, any deformity, from the  contraction of the first, or the
drawing of the latter out of their proper  place; for one of the peculiar-
ities of the cicatrices of burns is, the formation of firm, elevated ridges, 
688
DISEASES OF CHILDREN.
 by the gradual contraction of which, the utmost deformity, or even the
 entire loss of the use of a limb may be occasioned.   Even by the best-
 devised  means, it will often be impossible, in extensive burns, to pre-
 vent this occurring to a certain degree;  nevertheless, the extent of the
 deformity  may be greatly diminished by  proper  care and  attention.
 When the  burn is seated upon the hand or foot, or in the vicinity of the
 ear, caution must also be observed to prevent the unnatural adhesion
 of the fingers to each other, or of the ear to the side of the head.
   During the healing of extensive burns, a rapid formation of fungous
 granulations very commonly takes place;  nor is it possible entirely to
 restrain them by the  application of pressure, caustics, or other escha-
 rotics.   The first, however, we have found, in general, the most suc-
 cessful; it may be applied, by covering the ulcer with a pledget of dry
 lint, and then enveloping  it with a bandage; in some cases, the adhe-
 sive strips and  bandage will answrer very well.  If an escharotic is
 used,  the best will be, perhaps, the nitrate  of silver; we must confess,
 however, that we have seldom seen much good result from its applica-
 tion.
  As  we have already remarked, in all extensive burns or scalds, there
 is a very great depression of the vital energies; the patient complains
 of a feeling of chilliness, and is usually inclined to sleep; we have seen
 a child,  immediately  after being scalded,  shiver as though he were
 exposed  to a very considerable degree of cold.  In such cases, a dose
 of the camphorated  tincture  of opium, adapted  to the  age of the
 patient, will be  proper; or if the depression is  very great, a few drops
 of Hoffman's  anodyne and  spirits of camphor, combined,- may he
 given, and  the child should be placed in a room of a moderately warm
 temperature.   The moment that  reaction takes  place,  everything,
 whether  in the  form of food, drinks or medicine, of a stimulating cha-
 racter, should be withheld.
  In some  cases, a restricted diet, purgatives,  and  even bleeding, will
be required, in consequence of the extent of the local inflammation, and
the degree  of febrile reaction with which it is  attended. 
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Cafuron.  Traite des Maladies des Enfans.
Carrault.  Guide des Meres.  Paris, 1828.
Cartwright.  Pathology and Treatment of Cholera Infantum. Amer. Med. Record, 1826.
Cazenave and Schedel.  A Practical Synopsis of Cutaneous Diseases. Philadelphia Ed.,
  1829.
Cazenave and Schedel.  Abrege Pratique des Maladies de la Peau.  Paris, 1828.
Chambon.   Maladies des Enfans.   Paris, 1799.
Chapman, N.  On Croup.  Philadelphia Journ. of the Med. and Phys. Sciences, vol. i.
Cheyne.   On Croup.   Cyclopaedia of Practical Medicine.
Cheyne.   Essays on Hydrocephalus Acutus, or Water in the Brain.   London, 1819.
Cheyne,  J.  Essay on Cynanche Trachealis, or Croup.  Edinburgh, 1801.
Cheyne,  J.  Essays on the Diseases of Children.  Edinburgh, 1802.
Cheyne,  J.  Pathology of the Membrane of the Larynx ana Bronchia.  London,  1809.
Chevers.  On the Causes of Cyanosis.  London Medical Gazette, 1847.
Clark, Jas.  Treatise  on Pulmonary Consumption and Scrofula.
Clarke,  Jno.  Commentaries on the Diseases of Children. London, 1798.
Cloquet. Anatomie des Vers Intestinaux.  Paris, 1824.
Coates.  Description of the Gangrenous Ulcer of the  Mouths of Children.  N. A. Medi-
  cal and Surgical Journ. 1826.
Coindet.  Memoire sur l'Hydrencephale.  Geneva, 1818.
Coley.   A Practical  Treatise on the Diseases of Children.  London, 1846.
Cook.  Apoplexia Hydrocephalica, or Hydrocephalus Internus.  Treatise on Nervous
  Diseases.
Combe, A.  On  the Management of Infancy and Childhood.   Philadelphia Ed.  Edited
  by J. Bell, M.  D., 1840.
Coxe, Jno. R.  On Croup.  Amer. Journ. of the Med. Sciences, vol.  iii.
Coxe, Jno. R.   On Chorea.   Philadelphia Med. and  Phys. Journ. vols, xiii.-xviii.
Coxe, Jno. R.  Observations on Vaccination.  N. A. Med. and Surg. Journ.  1828.
Crampton.  On  Cyanosis.  Cyclopaedia of Practical Medicine.
Cragie.  On Cyanosis.  Ed. Med. and Surg. Journal, 1843.
Crampton.  On  Hydrocephalus.  Trans, of the King and Queen's College in Ireland, 1817.
Crisp.  On Infantile  Pleurisy.  London Medical Gazette, 1846.
Cuming,  Thos.  Observations on  the Peripneumonia of Children.  Trans, of King and
  Queen's College, Ireland, vol. v.
Cumin.   On Rickets and Scrofula.  Cyclopaedia of Practical Medicine.
Currie,  Wm. Hydrocephalus.  Croup.  Cholera  of Infants. Diseases  of the United
  States.   Philadelphia, 1811.

Dance.   Observations pour Servir a l'Histoire de l'Hypertrophie du Cerveau.
Danz, F. G. Versuche  Einer Algemeine Geschichte des Keickhustens.  Marbourg, 1791.
Davis, D. D. Acute  Hydrocephalus, or  Water in the Head,  an Inflammatory  Disease.
  American Ed., 1840.
Dendy.   Practical Remarks on the Diseases of the Skin.  London, 1837.
Denis, R. S. Recherches AnatomiqueetPhysiologiques sur Quelques Maladies des Enfans.
  Comercy, 1816.  Paris, 1824.
De Salle.   Traite des Maladies des Enfans.
Desreulles. Traite  Theorique et Pratique du Croup. Paris, 1822.
Desreulles. Traite  de la Coqueluche.  Paris, 1827.
Detmold.  Essay on Club Foot.  New York, 1840. 
LIST OF AUTHORS AND  WORKS REFERRED  TO.       691
Dewees.  A Treatise on the Physical and Medical Treatment of Children.  Philadelphia,
  1844.   8th Ed.                                                             £.
Dismelles.  Traite Therapeutique et Pratique du Croup.
Donne.  On Certain Pathological Conditions of the Milk as a cause of disease in Infants.
  Lours de Microscopic  Paris, 1844.
Deoste.   On Gelatinous Softening ef the Stomach in Children.  Zeitschrift fur die Ge-
  sammte Medicin, vol. i.
Duncan, Jas.   On the Epidemic Ulceration of the Gums in Children.  Dublin Journal of
  Medical Sciences, 1845.
Duges.   Recherches sur les Maladies les plus Importantes et les Moins Connues des En-
  fans Nouveaux-nes.  Paris, 1821.   .
Dunglison, R.   Commentaries on the Diseases of the Stomach and Bowels in Children.
  London, 1823.
Duplay.  On  Inflammation of the  Umbilical Vein in Infants. Medico-Chirurgical Re-
  view, 1838.

Eberle.  A Treatise on the Diseases and Physical Education of Children.  Philadelphia,
  1839.   Cincinnati, 1833.
Ebelung.  Dissertatio de Tussi Infantum Convulsiva.  Gottingen, 1768.
Edwards, W. F. G.  On the  Influence of Physical Agents upon Life.  Philadelphia Ed.
  1838.
Eisenmann.  On the Exanthemata.   Hufeland's Journal, 1840.
Elam.  On Chorea.  Provincial  Medical and Surgical Journal, 1849.
Elsasser.  Die Magenerweichung der Sauglinge.  Stuttgard, 1846.
Emangard. Memoire sur l'Angine Epidemique ou Diptherite.  Paris, 1829.
Englehard.  Ueber Der Croup.  Berlin, 1829.
Englemann.  On the Treatment of Hydrocephalus by Compression.  Chelius and Naegele' s
  Medicinische Annalen, vol. viii.
Evanson and Maunsell.  A  Practical Treatise on the Management and Diseases of Chil-
  dren, 5th Ed.   London, 1847.

Farre.  On Worms in the  Intestines.  Tweedie's Library.
Faubel.  Recherches sur la Bronchite Capillaire, 1840.  And Memoires de  la Societe
  Medicale d'Observation.  Tome 2d, 1844.
Feiler.  Paediatrik oder Anleitung zur Erkenntniss und Heilung der Kinderkrankheiten,
  1814.
Francis.   On Croup.  New York Med. and Phys. Journ. vol. iii.
Friedleben and Fleisch. On the Pathology of the Intestinal Mucous Membrane in young
  Infants.  Zeitschrift filr Rationelle Medicin.  Heidelberg, 1846.
Fuchs.   Historische Untersuchung iiber Angina Maligna.  Wurtzbourg, 1828.

Gardien.  Des Maladies des Enfans.
Gas.  Recherches sur l'Acarus ou Scarpote de la Gale. Paris, 1834.
Geddings. On  Pseudo-membranous Inflammation of the Throat.  Amer. Journ. Med.
  Sciences, 1839.
Gerhard, W. W.  On Pneumonia in Children.  Tweedie's Library.  Amer. Journ. Med.
  Sciences, 1834.
Gerhard, W. W.  On the  Cerebral Affections  of Children.  American Journal of the
  Medical Sciences, 1834.
Girard.  On the Influence of the Quality of the Nurse's Milk on the Health of the Infant.
  Journal de Pharmacie, 1845.
Girtanner.  Ueber de Krankheiten der Kindern.  Berlin, 1794.
Glover.  On the Pathology and  Treatment of Scrofula.  London, 1846.
Gintrac, E.  Observations  et Recherches sur la Cyanose.  Paris, 1824.
Goelis.  Treatise on Acute  Hydrocephalus.   Translated by Robert Gooch, M. D.  Lon-
  don, 1821.
Go'elis.  De rite Cognescenda. et Sananda Angina Membranacea.  Vienna.
Goelis.  Pracktische Abhandlungen.  Vienna, 1820.
Gregory.  On  Smallpox, Chickenpox, and Vaccination.  Cyclopaedia Prac. Med.  See
  also Tweedie's Library.
Gregory.  On  Vaccination.  London Med. Gaz., 1827-28.
Gregory.  On  Vaccination and  Smallpox.   Medico- Chirurg. Trans,  vol. vi.  See also
  London Lancet, 1841.
Green.  A Practical Compend of the Diseases of the Skin.  London, 1835.
Green.   Contributions on the  Pathology of Children.   London Lancet, vol. ii. et seq.
Green.   On Nervous Tremors in Children.  Provincial Med. and Surg. Journ., 1844.
Green, Hennis. On Hypertrophy of the Brain.  Provincial Med. and Surg. Journ., 1840.
Green, Hennis. On Tubercle of the Brain in Children. Medico- Chirurg.  Trans., vol. xxv.
Graves.   Clinical Lectures.  American Edition, 1842.
Graves.   On Infantile Convulsions.   London Med. and Surg. Journ., 1833.
Grissolle.  Traite Pratique de la Pneumonie aux differens Ages.  Paris, 1841, 
692       LIST  OF AUTHORS AND WORKS REFERRED  TO.

Guersent.  OnMuguet; on Gangrenous Angina;  on Croup.  Dictionnaire de Midecine.
Guersent et Blache.  Smallpox.  Dictionnaire de Midecine.
Guersent.  On Tonic Convulsions of Children.  Gazette Midicale, 1832.
Guibert.  Recherches Nouvelles et Observations Pratiques sur le Croup et la Coqueluche.
  Paris, 1824.
Guibert.   Observations  sur  l'Hydropericarde  chez  les Enfans.   Journal des Progrls,
  1830.

Hall, Marshall.  On the Diseases and Derangements of the Nervous System. London,
  1841.
Hall, Marshall.  On Scarification of the Gums during Dentition.  London Lancet, 1844.
Hall, Marshall  On the Nature and Treatment of Stridulous Convulsions in Infants.
  London Lancet, 1842.
Hallowell, Ed.   On the Endemic Follicular Gastro-enteritis, or Summer Complaint of
  Children.  American Journal of the Medical Sciences, 1847.
Hamilton, Robt.   Observations on Scrofulous Diseases.   London, 1791.
Hamilton. Jas.  Hints for the Treatment of the Principal Diseases of Infancy and Child-
  hood.  London,1809.
Hamilton.  On the Treatment of Scarlatina Anginosa.   Edinburgh Med. and  Surg.
  Journal, 1839.
Hamernjk.  On Tubercular Meningitis.  Schmidts Jahrbucher, 1845.
Harris.  De Morbis Acutis Infantum.  London, 1689.
Harrison.  On Hydrocephalus.  Transylvania  Journal of Medicine, 1831.
Hache.  Maladies des Enfans.  Paris.
Heilborn.  Zur der Charakteristik derKuhpocken Narben.  Rust's Magazine, 1829.
Henke.  Handbuch der Kinderkrankheiten.  Berlin, 1813.
Heine.  On Revaccination.  London Medical Gazette, 1834.
Herard.  On Tartar Emetic in the Pneumonia of Children. British and Foreign Medico-
  Chirurg. Review,  1848.
Herrick.  Beobachtungen und Bemerkungen iiber den Rasch Verlaufenden Wasserkoff.
  1847.
Hesse. Ueber die erweichung der Gewebe und Organe der Menschliken Korpers. Leipsic,
  1827.
Heyfelder.   Beobachtungen iiber der Krankheiten der Neugebornen, 1822.
Hildreth, C. C. Practical  Observations on Chorea.  American Journal of the Medical
  Sciences, 1848.
Home. Medical  Facts and Experiments.   London, 1759.
Hood. A  Practical Treatise on the Diseases most fatal to Children.  London, 1745.
Horner, W. A. An Inquiry into the Anatomical Characters of Infantile Follicular In-
  flammation of the Gastro-intestinal Mucous Membrane. American Journal of Medical
  Sciences, 1829.
Horner, W. A. Contribution to the Pathology of Infantile Convulsions. Amer. Journ.
  of the Med. Sciences, 1831.
Hosack, D.  Observations on Croup, or Hives.  American Medical and Physical Register.
  New York, 1812.
Hueter.  Beobachtungen und Bemerken  iiber den Wasserkrebs.  Berlin, 1829.
Hufeland.  Ueber Verschiedene Kinderkrankheiten,  1798.
Hufeland.  Neues System der Kinderkrankheiten,  1803.
Hufeland.  A  Treatise on Scrofulous Diseases.  Translated by  C. D. Meigs,  M.D.
  Philadelphia,  1829.
Hullihen.   On Hare Lip.  American Journal of Dental Science, 1844.
Hurtleloup.   Sur l'lnflammation de  la Membrane Muc. Gastro-pulmonaire chez les
  Nouveau-nes.  Paris, 1823.
Hunter.  On Rotatio  or Chorea.   Ed. Med. and Surg. Journ., 1825.

Iselin.  On the Softening of the Stomach in Infants.  Edinburgh Med. and Surg. Journ.,
  1840.
Isnard. Dissertation sur une Affection Gangreneuse Particuliere aux Enfans.
Itard.  Sur l'Hydrocephale Aigue. Diet, des Sciences Med.

Jackson.  On Gangraenopsis.  Amer. Med. Recorder,  1827.
Jackson.  On Cholera Infantum.  N. E.  Journ. of Med., vol. i.
Jansecowich.   Einige Bemerkungen fiber den Croup.  0estereichische Jahrbuch, 1837.
Jaeger.  On the Softening of the Stomach in Infants.   Hufeland's Journal, 1811.
Joerg.  Handbuch zum Erkennen  und Heilen der Kinderkrankheiten, 1836.
Joerg.  Die Foetus Lunge in Gebornenkinde.  Grimma, 1836.
Johnson. On Carpo-pedal Spasms.  Medico-Chirurg.  Review, vol. iii.
Johnson.  On Hooping-Cough.  Ibid.
Joy.  Tabes Mesenterica—Disorders of  Dentition—Worms—Hydrocephalus—Infantile
  Remittent Fever.  Cyclopaedia of Prac.  Med.
Judd, W. H.  On the Structure of the Smallpox Pustule.  London Lancet, 1841.

Katona, M. Von.   On the Inoculation of Measles.   Oesterreiche Medicinische Wocken-
  schrift, 1842. 
           LIST OF AUTHORS  AND WORKS REFERRED  TO.       693

 Kennedy, E.  On the Apoplexy, Paralysis, and Convulsions of New-born Infants. Guy's
   Hospital Reports, 1836 ; and Dublin Joujnal of Medical Sciences, 1836.
 Kennedy. Account of the Epidemics of Scarlatina in Dublin from 1834 to 1842.  Dublin,
   1843.
 Kenedy.   On the Management of Children.   Glasgow, 1825.
 Kerr.  On Laryngismus Stridulus.  Ed. Med. and Surg. Journ., vol. lviii.
 Kirkland.  De Pertussi.   Edinburgh, 1772.
 Kirkbride.  On the Employment of Cimicifuga in the Treatment of Chorea.  American
   Journ. of the Med. Sciences, 1840.
 Kopp.  Dissertatio de Asthmate Puerorum.  Frankford, 1830.
 Kopp.  Denkwiirdigkeiten in der arztlichen Praxis. Frankford,  1830.
 Krukenberg.  On Hydrocephalus—Inflammation of the Ear—Hooping-Cough—Measles
   and Scarlet Fever.  Jahrbiicher der Ambulaterischen Klinik zu  Halle, 2 vols., 1824.

 Laennec  Observations pour Servir  l'Histoire  de l'Hypertrophie du Cerveau.  Revue
   Midicale, 1828.
 Lallemand.  Recherches Anatomico-Pathologiques sur l'Encephalite et ses Dependances.
   Paris, 1825.
 Landouzy.  Sur l'Hemiplegie Faciale chez les Enfans Nouveaux-nes.  Paris, 1839.
 Langenbeck.   On Purulent Ophthalmia.  Neuve Chirurg. Bibliothe.
 Lasserre.  On  Apoplexy in the  Fcetus and  New-born Child.  Journal de Midecine de
   Toulouse, 1845.
 Lee, Chas. A.   On the Thymus  Gland;  its Morbid Affections and the  Diseases which
   arise from its Abnormal Enlargement.  American Journal of the Medical Sciences, 1842.
 Lees, C.  On Hypertrophy of the Brain.  Dublin Journal of  the  Medical Sciences, 1842.
 Leger.  Sur la Pneumonie des Enfans. Paris, 1823.
 Legendre.  Recherches Anatomico-pathologiques sur Quelques Maladies de l'Enfance.
   Paris, 1846.
 Lenhosseck.  Einige Bemerkungen iiber die Erweichung des Magens. Vienna,  1823.
 Leroy.  On Pertussis.  Midecine Maternelle.   Paris, 1803.
 Ley.   Essay on the Laryngismus Stridulus or Croup-like Inspiration of Infants.  London,
   1836.
 Lindsley.  On Cholera Infantum.  Amer. Journ. of Med. Sciences, 1839.
 Lloyd.  Treatise on the Nature and Treatment of Scrofula.  London, 1821.
 Locock.  On Infantile Convulsions.  Cyclopaedia of Prac. Med.
 Lombard.  On Hooping-Cough.  Dublin Journal of Medical Sciences,  1838.
 Louis, P. C. A.  Recherches Anatomique et Pathologique sur le Croup.  Paris,  1826.
 Louis.  Recherches sur la Gastro-enterite.   Paris, 1829.
 Louis.  Memoires, ou Recherches Anatomico-Pathologiques. Paris, 1826.
 Luders.  Versuch einer Kritischen Geschichte der bei Vaccinirten Beobachtungen Men-
   schenblattern. Altona, 1824.

 Mackensie.  A Practical Treatise on the Diseases of the Eye.   London,  1832.
 Macilwain.  Clinical Observations on the Constitutional Origin of the Various Forms of
   Porrigo. London, 1834.
 Magill.  On Scarlet Fever. American Journ. of Med. Sciences, 1839.
 Malins.  De Cynanche Tracheali.  Edinburgh, 1830.
 Marcus.  Derkeichhusten; iiber Seine Erkenntniss, Natur,  und Behandlung. Bamberg,
   1816.
 Marcus, A. F.   Traite de la Coqueluche.   French Translation by M. Jacques.  Paris,
   1816.
 Marley, M.   On the Nature and Treatment of the most frequent Diseases of Children.
   London,1830.
 Martin, J. C.   On the Identity of Cowpox and  Variola.   Boston  Medical and Surgical
   Journal, 1841.
 Mathey.   Memoire sur l'Hydrocephale.  Paris, 1818.
 Mauthner.  Die Kranken des Gehirns und Riichenmarks bei Kindern.  Vienna,  1844.
 Mende.  Analekten iiber Kinderkrankheiten.  Stuttgard, 1834.
 Meigs, J.  Forsyth.  A Practical Treatise  on the Diseases  of Children.  Philadelphia,
   1848.
 Michaelis, F.  De Angina Polyposa.  Gb'ttingen,  1779.
 Miller, Ed.   Cholera or Bilious Diarrhoea of Infants.  Medical Works, New York, 1814.
 Millar.  Observations on the Asthma, and  on the Hooping-Cough.  London, 1769.
 Miguel.  On the means of Preventing Scarlatina.  Transactions of the Royal Academy of
  Medicine, 1834.
 Mills.  On Hydrocephalus.  Trans, of the King and Queen's College in Ireland,  vol. v.
 Mitchell and Bell.  History of the Natural and  Modified Smallpox as it prevailed in
  Philadelphia in the years 1823, 1824.  N. A. Med. and Surg. Journ., 1826.
Mitchell, J. K.  Observations on the Treatment of Curvature of the Spine.  JV. A. Med.
  and Surg. Journ., 1827.
Mohl.  De Varioloidibus et Varicellis.   Copenhagen, 1827.
Monro.  Morbid Anatomy of the Brain, vol.  i.  Hydrocephalus.   Edinburgh and London,
  1827. 
694      LIST 0F AUTHORS AND WORKS REFERRED TO.

Monro, A. L.   On Smallpox.  Edinburgh, 1818.
Moss.  On the Management and Nursing of Children.  London, 1782.
Montgomery.   On Rubeola.  Cyclopaedia of Prac. Med.
Montgomery.   On the Sudden Death of Children  from  Enlargement of the Thymus
  Gland.  Dublin Journal of the Medical Sciences. 1836.
Morton, Richard.  Opera Medica.  London, 1697.
Musgrove. Essay on the Nature and Treatment of the, so called, Worm Fever. London,
  1776.
Mutter.  A Lecture on Loxarthus, or Club Foot.  Philadelphia, 1839.

Naumann. On Pseudo-membranous Inflammation.   Handbuch der Med. Klinik, vol. iv.
Neumann. Krankheiten des Menschen, 1836.
North.  Practical Observations on the Convulsions of Infants.  London, 1826.


Odier.  Manuel de Medecine Pratique.  Geneva, 1821.
Oesterlen. iEtiologie und Pathologie der Krankheiten Neugebornen Kindern.  Heidel-
  berger Klinische Annalen, 1831.
Olliffe.  On the Treatment of Variola by the Ectrotic Method.  London Lancet, 1841.
Oppenheim. Ueber die Punction der Chronischen Innerren Wasserkopf. Rust's Magazine,
  1827.
Otto.  On Pertussis.  Nyehygaea,  1824.
Ozanam.  Histoire Medicale, Generate et  Particuliere des  Maladies Epidemiques, &c.
  Paris, 1817.

Page.  Essay on Diseases of Children.  Amer. Med. Recorder, 1829.
Papavoine. Sur les Tubercles Consideres Specialement chez les Enfans.  Journ. des
  Progres, 1830.
Papavoine. Observations, des Convulsions chez les  Enfans.  Journal des Progres, 1830.
Parrish, I. Observations on a Particular Complaint in  Children.  N. A. Medical and
  Surgical Journal, 1827.
Parrish, I. On Infantile Convulsions, arising from Spasms of the Intestines.  N. A.
  Medical and Surgical Journ.,  1827.
Paldam, V. H.  L.  Ueber die Stickhusten. Halle, 1805.
Parent-Duchatelet et Martinet. Recherches sur l'lnnammationde l'Arachnoide Cere-
  brate et Spinale.  Paris, 1819.
Penada, G. Memoria sulla Tusse Convulsiva.  Verona, 1815.
Pearson.   Medical Dissertations on Chincough.
Pemberton.  A Practical Treatise on the Various  Diseases of the Abdominal Viscera.
  London, 1806.
Phillips.  Scrofula, its Causes, its Prevention, and the Principles of Treatment. London,
  1846.
Plumbe.  A Practical Treatise on the Diseases of the Skin.   London, 1824.
Pohl.   Analogia inter Morbillos et Tussim Convulsivam.   Leipsic, 1809.
Porter, W. H.  Observations  on the  Surgical Pathology of the  Larynx and Trachea.
  London and Edinburgh, 1826.
Porter.  On Spasm of the Glottis.  Dublin Medical Press, 1840.
Piorry, P. A.   De 1'Irritation  Encephalique des Enfans.  Paris, 1823.

Quin.   De Apoplexia Hydrocephalica.  Dublin, 1799.

Raciborski.  On the Influence of Menstruation on the Milk of Nurses.  Dublin Medical
  Press, 1843.
Ramisch.  De Gastromalacia et Gastropathia  Infantum.  Prague, 1824.
Raspail.   Sur  1'Histoire de 1'Insect de la Gale de l'Homme.  Paris, 1834.
Rayer.  Traite Theorique et Pratique de la Maladies de la Peau, 1826.
Rayer.   Traite des Maladies des Reins.   Paris, 1839.
Rees.   Treatise on Diseases of Children.   London,  1817.
Rees, G. A.  On Laryngismus Stridulus.  London Lancet,  1841.
Reid.   On Infantile Laryngismus.  London, 1849.
Renucci.  On the Itch Insect.   London  Lancet, 1834.
Richter.  Der Wasserkrebs der Kinder.  Berlin, 1828.
Rilliet and Barthez.  Traite Clinique et Pratique des Maladies des Enfans.  Paris, 1843.
Ritscher.  Pneumonia Infantilis.  Rust's Magazine, 1830.
Roberton. On the  Physical Management of Children.  London, 1827.
Robertson.  On Aphthae.  Cyclopaedia of Practical Medicine.
Roberts, W. C.  On Thymic Enlargement.   New  York Medical  Gazette, 1842.
Roe, G. H.  Treatise on the Nature and Treatment of Hooping-Cough.  London, 1838.
Roesch.   On Scrofula.  Haeser's Archives, 1841.
Roger.  De la Temperature chez les Enfants.  Paris, 1844.
 Roger.   On the ffidema of New-born Infants.  Archives Ginirales, 1845.
 Rokitansky.   Pathologische Anatomie, 1848. 
LIST OF AUTHORS AND  WORKS  REFERRED TO.
695
Romberg.  Einige Fiille von Magenerweichung, Wasserkrebs, und  Rose bei Kindern.
  Rust's Magazine, 1830.
Rosen Von Rosenstein.  Anweisung  zur Kenntniss und Kur der Kinderkrankheiten.
  GSttingen, 1798.
Rosen Von Rosenstein.  Treatise on Diseases of Children.  Translated from the Swedish.
  London,1776.
Rosseau.   Hydrops Capitis Infantum.   American Medical Recorder, 1819.
Royard, Collard.  On Croup.  Dictionnaire des  Sciences Midicales.
Rudolphi.  Entozoor, sive Verminum Intestinum Historia Naturalia. Amsterdam, 1811.
Rufz.  Researches on some Points of the History of Chorea in Children.  Archives Gini-
  rales, 1834.
Rush.  On Dropsy of the Brain, and Croup.  Med. Inq. and Observations, vol. ii.
Ryland.   On Laryngismus Stridulus. Provincial Medical and Surg. Journ., 1842.


Salle. French Translation of Underwood, with Notes.  Paris, 1823.
Schedel.   On the Diseases of the Skin.  Tweedie's Library.
Schaeffer.  On Vaccination.  Medicinische Zeitung, 1844.
Schmid. De Angina.  Vienna, 1790.
Schmidt.  Convulsiones Infantum.  Berlin, 1826.
Soutteten.  Hypertrophy of the Brain.  Archives  Ginirales, vol. vii.
Senn.  Recherches Anatomico-pathologiques sur la Meningitis.  Paris, 1825.
Shatter.  On Scrofula.  Tweedie's Library.
Sidey, Chas.   On Epidemic Scarlet Fever.  Edinburgh Med. and Surg. Journ., 1839.
Sims.  On Hypertrophy of the Brain.   Medico- Chirurgical Trans., 1835.
Smith, Thos.   On the Nature, Causes, Prevention, and Cure of Acute Hydrocephalus,
  or Water-brain Fever.  London, 1845.
Smyth.  On Rickets and Hydrocephalus.  Miscellaneous Contributions to Pathology and
  Therapeutics.  London, 1844.
Stiebel.  On St. Vitus's Dance.  Wochenschrift filr die Gesammte Heilkunde, 1837.
Steinbrenner.  Traite sur la Vaccine.  1846.
Stewart, James.  A Practical Treatise on the Diseases of Children.  New York, 1846.
Stille, Moreton.  On Cyanosis.  American Journ. of Medical Sciences, 1844.
Streeter.  On the Nature and Seat of Hooping-Cough.  London Med. Gazette, 1844.
Stuart, Jno.   On the  Use of Hydrocyanic Acid in Chorea.  Edinburgh Medical and Sur-
  gical Journal, 1827.
Symonds.  On Diseases of the Mouth.  Tweedie's Library.


Tait.  On the Treatment of Scarlatina.  London Medical  Gazette, 1837.
Taupin.  On  Vaccination.  Dictionnaire de Midecine.
Taupin.  Clinical Researches on Typhoid Fever in Children.  Journal des Connaissances
  Midico-Chirurgicales, 1839-40.
Taupin.  On Gangrenous Inflammation of the Mouth.   Ibid., 1838.
Thilenius. Medicinische Chirurgische Bemerkungen.
Thompson. On the Varioloid Epidemic.  Edinburgh, 1820.
Thompson.  On Chorea and Tabes Mesenterica.  Tweedie's Library.
Thore.  De la Peritonite chez les Nouveau-nes.  Archives Gin. de Mid., 1846.
Tonnelle.  On Tonic Convulsions of Children.  Gazette Midicale, 1832.
Troccon.  Sur la Maladie  Connue sous le nom  d'Endurcissement du Tissue Cellulaire,
  1814.
Trousseau.  On Infantile Syphilis.   Archives Ginirales de Mid., 1847.
Trousseau.  On Pneumonia in Infants.  Medical Times, 1846.
Trousseau.  On Diphtheritis.  Dictionnaire de Mid.
Trousseau.  On Thymic Asthma.  Journal de Midecine,  1845.
Trousseau.  Croup.  Tracheotomy.  Dictionnaire de Midecine.
Tweedie.  On Scarlatina.   Cyclopaedia of Practical Medicine.

Uldall.  De Dentitione Infantile.  Copenhagen, 1833.
Underwood.   Treatise on the Diseases of Children, with Notes by S. Merriman, M.D.,
  and Marshall Hall, M.D., and John Bell, M.D.  Philadelphia, 1841.

Vaidy. Hydrocephale  Aigue Essentielle et Symptomatique. Diet, des Sciences Mid.
Vieusseux.  Memoire sur le Croup.   Paris, 1812.
Valleix.   Clinique des Maladies des Enfans Nouveau-nes.  Paris, 1838.
Valleix.   On Croup.  Bulletin Ginirale de Thirapeutique.  Paris, 1843.
Valentin, L.   Sur le Croup.  Paris, 1812.
Veron.  Observations sur les Maladies des Enfans.  Paris, 1821.
Volz.   On Hooping-Cough.   Haeser's Archives, vol. iv.
VondemBusch.  German Translation  of  Desreulles on Croup, with Notes.   Bremen,
  1828.
Vrolik.  Traite sur 1'Hydrocephalic Interne.   Amsterdam, 1839. 
696       LIST  OF AUTHORS AND WORKS REFERRED TO.

Watt, R.  Treatise on the History and Treatment of Chincough.  Glasgow, 1813.
Wendt.  Die Kinderkrankheiten Systematische Dargestellt.   Vienna, 1827.
West.  On Pneumonia in Children.   British and Foreign Medical Review, 1843.
West, J. W.  On the Salaam Convulsion.   London Lancet, 1841.
West, Chas.  Lectures on the Diseases of Infancy and Childhood.  Philadelphia Edition,
  1850.
Whatton.   On the Pathology and Treatment of Pertussis.  London Lancet, 1831.
Whitlock, N.  Practical  Remarks on Disordered States of the Cerebral Structures occur-
  ring in Infants.  London,  1821.
Whytt.  Observations on the Dropsy in the Brain.  Edinburgh, 1768.
Willan, Robt.  On Vaccine Inoculation.  London, 1806.
Williams.   On Croup, Laryngismus, and Hooping-Cough.   Tweedie's Library.
Willis.  Urinary Diseases and their Treatment.  London, 1838.
Wilson.  A Practical and Theoretical Treatise on the Diagnosis, Pathology, and Treat-
  ment of the Diseases of the Skin.   London, 1842.
Winter.  On Softening of the Stomach.  Rust's Magazine, 1830.
Wolff.  Beitrag zu der  Lehre von den Kinderkrankheiten.   Hufeland and  Osann's
  Journal, 1831.
Wood.  On Scarlet Fever.  Edinburgh Med. and Surg. Journ., 1839.
Worcester, N.  A Synopsis  of the  Symptoms, Diagnosis, and Treatment of the more
  common and important Diseases of the Skin.  Philadelphia, 1845.
Worthington.   On Gangraenopsis.  American Medical Recorder, 1828.

Yeats.  A Statement of the Early Symptoms which lead to the Disease termed Water in
  the  Brain. 1817-1819.

Zangert.   Uber die Convulsionem in Kinderlichen Alter.   Vienna, 1834.
Zeller.  Dissertatione de Natura Morbi Ventriculo Infantum Perforantes.  Tubingen,
  1818.
Zeroni.  Practical  Remarks on Croup.   Henle and Pfeuffer's Zeitschrift fitr Rationally
  Medizin, 1847.
Zichner.  De Angina Membranacea. Berlin, 1825. 
INDEX.
                    A.

Accidents occurring within the month, 632.
Adipous tissue, induration of the, 663.
Affective faculties, state of, in infancy, 92.
Air, importance of pure, 33, 113, 571.
       cold  and damp, injurious effects of,
         36, 118, 571.
       overheated,  injurious effects of, 37,
         120.
       impure  and  stagnant,  productive of
         disease, 113, 571.
Albuminous nephritis in children, 112.
Alimentary canal, state of, in infancy, 81.
Amusements for children, 67.
Aneurism by anastomosis, 668.
Anger, bad effects of, in children, 73.
Angina externa, 188.
       pseudo-membranous, 176, 181.
       malignant, 179, 188.
       polyposa or membranacea, 316.
Anginose scarlatina, 459.
Ani, prolapsus, 238.
Anuria, 619.
Anus,  imperforate, 632.
Aphtha lactumina,  146.
Aphtha?, 150.
       deaths from, 103.
Apoplexy, 372.
       deaths from, 106.
Arachnoid cavity, haemorrhage  of the, 374.
Asphyxia, 277.
Asthma, Kopp's, 339.
       Millar's, 334.
       thymic, 339.
Atelectasis pulmonum, 302, 309.
Atmosphere, impure, injurious effects of, 34,
         571.
       cold  and damp, injurious effects of,
         36,118..
       overheated, injurious effects  of, 37,
         120.
Atonic ulcer, 552.
Atrophia ablactatornm, 214.
B.
Bilious diarrhoea, 216.
Black pock, 488.
Bladder, urinary, state of, in infancy, 82.
Blood, in infancy and childhood, 83.
Blue disease, 637.
Bones, state of,  in  infancy and childhood,
         80,93.
      indications of disease from state of,
         142.
      scrofulous disease of the, 580,  584,
         607.
Bowels, indications of disease from the dis-
  charges from the, 138.
Brain, organization of, in infancy and child.
         hood, 83, 93.
      liability of, to disease, in infants, 105.
      deaths from diseases of the, 106.
      hypertrophy of the, 366.
      hyperaemia of the, 372.
      haemorrhage of the, 373.
      inflammation of the, 397, 419.
      dropsy of the, 419.
      tubercles of the, 111, 419, 592.
Breasts, intumescence of the, 650.
Breath, indications of disease from the state
  of the, 138.
Bronchi, inflammation of the, 285.
Bronchial croup, 288.
      glands, tuberculization of, 590.
Bronchitis, 285.
      capillary,  288.
      vesicular,  290.
      deaths from, in children, 102,
Broncho-pneumonia, 288,295.
Bullae febrilis, 555.
Burns and scalds, 686.
                   C.

Calorification, state of, in infancy, 88.
Cancrum oris, 159.
Capillary system, state of, in infancy, 83.
       bronchitis, 288.
Caps, injurious, 42.
Caries of the vertebrae, 585.
Carrying infants, caution  to be observed in,
  63, 74.
Carriages for infants,  63.
Catamenia, influence on milk, 117.
Bathing, importance of, 39.
Beds, proper for infants and children, 57. 
698
INDEX.
Catarrhal fever, 288.
Cellular tissue, induration of the, 662.
Cerebral hyperaemia and haemorrhage, 872.
       tubercles, 111,419,592.
Cerebro-spinal meningitis, 408.
Chicken-pox, 513.
Childhood, organization of, 92.
       functions of, 93.
Cholera infantum, 229.
       deaths from, 103.
Chorea, 436.
Chylous diarrhoea, 217.
Circulatory organs, state of, in infancy, 83.
Circulation, state of, in infancy, 87.
Cleanliness, domestic, importance of, 34.
       personal, importance of, 34.
Clothing of infants and children, 41.
Club-foot, 660.
Cold, its injurious effects on infants, 36.
       and dampness a cause of disease, 119,
         571.
       diarrhoea from,  214.
Cold-bath, improper during infancy, 39.
Colic, 206.
       deaths from, 103.
Colitis, 261.
Colon, inflammation of the, 261.
Confinement of children, injurious effects of,
   47, 66.
Confined air, a cause of disease, 116, 571.
Congenital affections,  632.
Congestion of the brain, deaths from, 106.
Congestive measles, 451.
       scarlatina, 470.
       small-pox,  485.
Conjunctivitis, infantile, 487.
Consumption in children, 107, 592.
       deaths from, 108.
Contagion, susceptibility of infants to, 122.
Convulsions, 106, 382.
       deaths from, 106, 382.
        nine-day, 388.
        salaam, 395.
       tonic, 396.
Convulsive enteralgia, 207.
Coryza, 282.
Couch, sleeping, proper for young infants, 57.
        management of, 59.
Countenance, indications of disease from, 126.
Cradles, the use and abuse of, 58.
Croup, 316.
        bronchial, 288.
        false, 334.
        spasmodic, 334.
        deaths from, 102, 316.
 Crusta lactea, 519.
 Crusted tetter, 521.
 Crying in infants, causes and morbid effects,
   74.
 Cry, indications of disease from the, 132.
 Curd-like exudation, stomatitis with, 146.
 Cutaneous disease,frequency of, in infancy,99.
        eruptions, 517.
 Cyanosis, 637.
 Cynanche trachealis,  306.
                   D.

Damp  and cold, injurious  effects  of, in in-
  fancy, 36, 119, 571.
Dandriff, 549.
Debility, deaths of children from, 97.
Dentition, 92.
       as a cause of disease, 122.
       difficult, 169.
       diarrhoea from, 215.
       cutaneous eruptions during, 517.
Diabetes, 628.
       mellitus, 628.
Diagnosis of disease in infancy, 123.
Diarrhoea, 221.
       deaths from, in children, 103.
       bilious, 216, 222.
       chylous, 217.
       chronic, 212, 220.
       mucous, 215, 219.
       from cold, 214.
           dentition, 215, 221.
           errors in diet, 213, 218.
           excessive heat, 215.
Diet of infants and children, 43, 52.
       a wet nurse, 49.
     diarrhoea from errors in, 213,  218.
Digestive organs, condition of, in infancy and
         childhood, 81, 87, 93.
       diseases of the,  145.
       deaths from affections of the, 103.
Diphtheritic  inflammation of the throat, 176.
Discharges from stomach and bowels, indi-
   cations of disease from,  138.
Disease, causes of, in infancy and  childhood,
         116.
        seldom simple in children,  98.
Diseased persons, impropriety of children
   sleeping with, 60.
Drink of infants and children, 48, 53.
Dropsy in children, 107.
        of the brain, 419.
        deaths from, 106.
Dry scall, 541.
Dysentery, 261.
        deaths from, 103.
 Dysuria, 113, 613.

                    E.

Ear, inflammation of the,  578, 605.
Ecchymoses, 557.
 Ecthyma, 552.
 Eczema, 524.
        lactea, 519.
 Education, too early attempts at mental, im-
          proper, 66, 75.
        moral, 69.
 Effusion of serum or lymph in children, 99.
 Emotions of the mind, influence of, on nurse's
   milk, 118.
 Endocarditis in children,  111.
 Enteralgia,  206.
 Enteritis, 256, 261.
        deaths from, 103. 
INDEX.
699
1
Enuresis, 623.
Epidemic meningitis, 408.
Eruptions,  cutaneous, 517.
       syphilitic, 564.
       from gastro-enteric disease, 523.
       during lactation and  dentition, 517.
       with languid cutaneous action, 549.
       from infection, independent of visce-
         ral disease, 561.
       frequency of, in infancy, 99.
Eruptive fevers, 447.
Erysipelas, 528.
Erythema, 523.
Erythematic stomatitis, 145.
Evacuations,  indications of  disease  from
   state of the,  138.
Example, its powerful influence, 76.
Exanthemata, 447.
Exanthematous ophthalmia, 577.
Exercise, its importance during  childhood,
         62, 65.
        precautions in regard to, 68.
        defective, a cause of disease, 572.
External senses, state of, during infancy and
   childhood, 84, 89, 94.
 Eye, inflammation of the, 575.

i
y.
Fauces, diphtheritic inflammation of the, 176.
Favus, 544.
Fear, injurious effects of, in children, 71.
Feeding of infants, artificial, 44.
Feet, defence of, in infants, 42.
Felon, 643.
Fever in children, 115.
       deaths from, 115.
       the remittent or gastric, of infancy,
         268.
       catarrhal, 288.
       eruptive, 447.
       rubeolous, 449.
       scarlet, 457.
       pemphigoid, 555.
       verminous, 268.
Fish-skin disease, 550.
Flannel, importance of, for children, 41.
Follicular gastro-enteritis, 232.
       stomatitis, 150.
       warts, 543.
Food of infancy and childhood, 43.
       as a cause of disease, 117, 570.
       of the nurse, influence of, on her milk,
          117.
Foreign bodies  in  the larynx and trachea,
   364.
Fractures, 632.
Fruits, the use of, by children, 56.
Functions, state of the, during infancy and
   childhood, 78, 8C, 93.
                    G.

Gall-bladder, during infancy, 83.
Ganglionic system, during infancy, 84.
Gangraenopsis, 159.
Gangrene of the mouth, 159.
       throat, 179.
Gastro-enteric disease, eruptions connected
         with, 523.
       liability of infants to, 102.
       enteritis,  follicular, 232.
Gastro-malacia,  103,195.
Gastric fever of  infancy, 268.
Gastritis, 199.
       deaths from, 103.
Gelatinous softening of the stomach, 195,
  202.
Genital organs, state of, in infancy, 84.
Gengivitis, 157.
Gestures, indications of disease from, 128.
Girls, exercise of, 66.
Glands, bronchial, tuberculization of, 590.
       lymphatic, disease of, 574, 600.
       mesenteric, disease of, 580, 609.
Glottis, spasm of the, 339.
Gravedo, 282.
Gravel, 114, 616.
Gray granulations, 588.
Growth of the body, 88.
Gum, the red, 517;
        white, 517.
Gums, inflammation of the, 157.
H.
Haemoptysis, rare in infants, 108.
Haemorrhage, cerebral, 372.
       vaginal, 656.
       from the navel, 636.
       of the brain, 372.
Haemorrhagic  purpura, 558.
Hair, management of, in infancy and child-
  hood, 40.
Hare-lip, 659.
Harsh treatment of children, morbid effects
  of, 71.
Healthy child, its appearance, 123.
Heart, condition of, in infancy, 83, 85.
       disease of the, in children, 110.
       malformations of, in infants, 638.
       deaths  from diseases of, 111.
Heat, importance of, to infants, 35.
       excessive, morbid effects of, 36,120.
       diarrhoea from, 215.
Head, covering proper for, in infants, 42.
Herniae, 651.
Herpes, 539.
Hip-disease, 584, 610.
Honeycomb scall, 544.
Hooping-cough, 347.
       deaths  from, 102.
Hordeolum, 538.
Humid tetter, 521.
Hygienic management of children, 33.
Hydrencephaloid disease, 434.
Hydrocele, 642. 
700
INDEX.
Hydrocephalus, acute, 419.
       chronic, 434.
       false, 434.
Hydro-rachis, 644.
Hyperaemia, frequency of, in infancy, 97.
       of the brain, 372.
Hypertrophy of the brain, 366.
Hyperuresis, 628.
Ichthyosis, 550.
Icterus infantilis, 671.
Ileitis, 256.
Impetigo, 519, 521.
      larvalis vel mucosa, 519.
Impure air, morbid effects of, in infancy, 34,
  118, 571.
Indigestion, 192.
Induration of the cellular tissue, 662.
Indurcissement du tissu cellulaire, 662.
Infancy,  period of, 79.
Infant, picture of a healthy, 123.
Infants, cautions in handling, 62.
      cautions in carrying, 63.
Inflammation of the brain, 397.
             deaths from, 106.
      breasts of infants, 650.
      bronchi, 285.
      colon, 261.
      digestive organs, deaths from, 103.
      fauces, 173.
      ear, 578, 605.
      eye, 575.
      gums, 157.
      intestines, 256, 261.
      lungs, 294.
      mammae, in infants, 650.
      mouth, 135.
      nares, 282.
      navel, 648.
      oesophagus, 190.
       pleura, 310.
       parotids, 186.
      peritoneum, 264.
       stomach, 199.
       tonsils, 173.
       throat, 173, 176.
      trachea, 316.
Intellectual faculties, state of, during infancy
         and childhood, 81, 92, 94.
       injury from  too early exercise of, 66,
         75.
Intestinal mucous membrane, pathology of,
   in infants, 103.
Intestines, state of, in  infancy, 81.
       diseases of the, 206.
       congenital malformations of the, 632.
       deaths from disease of, 103.
       inflammation of the, 256, 261.
       invagination of the, 103, 244.
       worms in the, 245.
Intumescence of the breasts in infants, 650.
Intus-susception, 103, 244.
Invagination of the intestines, 103, 244.
Iritis, scrofulous, 577.
Ischuria, 620.
Itch, 561.
Jaundice, 46, 671.
Joints, scrofulous disease of the, 582, 584.
K.
Ranker of the mouth, 159.
Kidneys, state of, in infancy, 82.
       inflammation of, in infancy, 112.
Kopp's asthma, 339.
L.
Labia, adhesion of the, 658.
Lactation, cutaneous eruptions during, 517.
       injury from protracted, 118.
Larynx, state of, during infancy, 82.
       foreign bodies in the, 364.
Laryngeo-tracheitis, 306.
Laryngismus stridulus, 334.
Laryngitis, spasmodic, 334.
Laudanum,  danger of  its  administration
  during infancy, 57, 75.
Lepra alphoides, 541.
Light, influence of, on health of infants, 119.
Lippitudo, 588.
Liver,  state of, in infancy, 82.
Lobar  pneumonia, 100, 304.
Lobular pneumonia, 100, 299.
Lungs, state of, during infancy, 82.
       inflammation of the, 294.
       imperfect dilatation of the, 300, 309.
       tuberculization of the, 107, 592.
Lymph, effusion of, in  diseases of infancy,
  99.
Lymphatic glands, scrofulous disease of, 574,
         600.
       system,  liable to disease in  infants,
         106.
M.
Maculae hepaticae, 632.
Malformations of the intestines, 632.
Mammae, intumescence of the, 650.
Marasmus, deaths from, 103.
Meals of children, regulation of, 53.
Measles, 447.
       false, 449.
       deaths from, 100.
Medulla spinalis, during infancy,  83.
Melasma, 632.
Mellituria, 628.
Meningitis, acute, 397.
       subacute, 419. 
INDEX.
701
Meningitis, tubercular, 419.
       encephalica, 407.
       epidemic, 408.
Menstruation, its influence on the milk, 117.
Mental emotions, influence on milk, 118.
Mesenteric glands, disease of the, 103, 580,
  606.
Micturition, difficult, 613.
Miliary tubercles, 587.
Milk  of the  nurse, a cause of disease, 117,
         571.
       influence of menstruation on the, 117.
              pregnancy, on the, 118.
              mental emotions, on the  118.
              food on, 117.
Millar's asthma, 334.
Modified small-pox, 510.
Months, mortality of children  during  the
  different, 121.
Moral treatment of children, 69.
       faculties, state of, in children, 90.
Morbilli, 447.
Morbus coeruleanus, 637.
       coxarius, 584, 610.
Mortality of children in Philadelphia, 120.
Mouth, condition of, in infancy, 81.
       indications of disease  from state of,
         134.
       diseases of the, 145.
       inflammation of the, 145.
       sore, of children,  146.
       gangrene  of the, 159.
       kanker of the, 159.
Mucous membrane, state of, in infancy, 81.
       liable to disease, in infants, 100, 102.
       diarrhoea, 215, 219.
Muguet, 146.
Mumps, 186.
Muscles, in infancy and childhood, 80, 93.
       morbid contraction of the, 396.
                    N.

Naevus, 667.
Narcotics, dangerous during infancy, 57, 75.
Nares, inflammation of the, 282.
Navel, inflammation of the, 648.
       haemorrhage from the, 636.
Nephritis in children, 113.
Nerves, state of, in infancy, 84.
Nervous excitement a cause of disease, 116.
       functions, in infants, 91.
       system, diseases of the, 366.
Nettle rash, 525.
New-born infants, washing of, 38.
Night-dress of infants, 43.
Nine-day convulsions, 388.
Nursery, proper location of the, 34, 60.
       management of, 60.
Nurse, choice of a wet, 48.
       diet of a     "  49.
       drink of a   "  50.
       residence ofa"  51.
Nursing, protracted, a cause of disease,
Nutritive functions in infants  and children,
         88, 94.
       disease of the, 568.
Nymphae, cohesion of, 658.
                   O.

Obstinacy in children, its management, 72.
ffidema cellularis, 662.
       of the prepuce, 657.
Oesophagitis, 190.
Oesophagus, inflammation of the, 190.
Old  persons,  danger of  children  sleeping
  with, 60.
Omphalitis exsudativa, 529.
Onychia, 643.
       maligna, 644.
Opiates, dangerous during infancy, 57, 75.
Ophthalmia, scrofulous, 575, 602.
       purulent, 635.
Organization, during infancy and childhood,
  79, 92.
Organic disease, blueness of skin from, 637.
       nerves, state of, during infancy, 84.
Organs, their development during  infancy,
  85.
Otitis, 578,  605.
Over-fatigue a cause of disease, 572.
                   P.

Palsy, 374.
Panaritium, 682.
Paralysis, 372.
Paronychia, 682.
Parotitis, 186.
Parotids, inflammation of the, 186.
Passions in infancy, 69.
       depressive, a cause of disease, 116,
         573.
Pathology of infancy and childhood, 97.
Peevishness, its causes and treatment, 70.
Pemphigus, 555.
Pemphigoid fever, 555.
Perceptive faculties of children, 77.
Pericarditis in children, 111.
Peritonitis, 264.
       chronic, 265.
Peritoneum, inflammation of the, 264.
Pertussis, 347.
Petechiae, 557.
Petechial small-pox, 487.
Phlegmonous tumours, 534.
Phlegmone parotidea, 188.
Phthisis in children, 107, 592.
Pityriasis, 549.
Pleura, inflammation of the, 310.
Pleuritis, 310.
Pneumonia, 100, 294.
       lobular, 299.
       lobar, 304.
       partial, 303.
       deaths from, in children, 102. 
702
INDEX.
Polypus of the rectum, 240.
Pompholyx, 555.
Porrigo, 519, 544.
Porriginous ophthalmia, 577.
Pregnancy, influence of, on the milk, 118.
Prepuce, oedema of the, 657.
Prickly heat, 524.
Primary  and secondary diseases of children,
  98.
Prolapsus ani, 238.
Prurigo, 518.
Pseudo-membranous  inflammation of the
  throat, 176, 181.
Psora, 561.
Psoriasis, 541.
Pulmonary cells, obliteration of the, 302, 309.
       consumption, in children, 107.
Pulse, state of, in infancy, 87.
Purpura, 557.
       haemorrhagica, 558.
       febrilis, 559.
Purulent ophthalmia, 635.
Pustular ophthalmia, 577.
R.
Rachitis, 581.
Rash, the scarlet, 480.
Rectum, polypus of the, 240.
Red gum, 517.
Relation, functions of, during infancy, 88.
Remittent fever of infants, 268.
Repose of infants, 58.
Respiratory organs, during infancy, 82.
      diseases of the, 277.
      function, during infancy and child-
         hood, 86, 94.
Respiratory mucous  membrane, its liability
         to disease in infants, 98, 100.
      deaths from disease of, 102.
Respiration, indication of disease from the
  state of, 133.
Revaccination, 503.
Rickets, 581, 607.
Ringworm, 540.
Roseola, 480.
Rubeola, 447.
Rubeolous fever, 449.
Rupia, 552.
Ruptures, 651.
Salaam convulsions, 395.
Scabies, 544, 561.
Scald head, 544.
Scalds, burns and, 686.
Scall, 521, 541, 544.
Scarlatina, 457.
       inflammatory, 458, 464.
       anginosa, 459.
       congestive, 470.
       deaths from, 100.
 Scarlet fever, 457.
       rash, 480.
 Scrofula, 568, 594.
 Scrofulous ophthalmia, 575, 602.
       disease of lymphatic glands, 574, 600,
       otitis, 578,  605.
       discharge from the vagina, 579, 606.
       disease of the mesenteric glands, 580.
             bones, 581,585, 609.
 Seasons, influence of the, upon  the  health
   and mortality of infants, 120.
 Semeiology of disease in infancy, 123.
 Senses, external, in  infancy and childhood,
   89, 94.
 Serous effusion, common in diseases of chil-
   dren, 106.
 Sickly persons, danger of children sleeping
   with, 60.
 Skin, state of, during infancy, 80.
       its liability  to disease in infancy, 99.
       diseases of the, 447.
       induration of the, 107, 662.
       bound, 662.
 Skull, state of during infancy, 84.
 Sleep of infants and children, 57, 91, 95.
       indications  of disease from the phe-
         nomena of, 130.
 Small-pox, 481.
       distinct, 485.
       confluent, 485.
       congestive,  485, 487.
       malignant,  487.
       modified, 510.
       mitigated, 510.
       deaths from, 100.
Snuffles, 282.
Softening of the stomach, 195, 202.
Sore mouth of children, 146.
Spasmodic  colic, 207.
       croup, 334.
       laryngitis, 334.
Spasm of the glottis, 339.
Speech in infancy, 91.
Spina bifida, 644.
Spinal apoplexy, 373.
       marrow, state of, in infancy, 84.
Spine, disease of the, 584, 611.
Spleen, state  of, in  infancy, 82.
Still-born infants, treatment of, 279.
       number of, in Philadelphia, 278.
Stomach, state of, during infancy, 81.
       deaths from diseases of, 103.
       discharges  from, as  indications of
         disease, 188.
       diseases of the, 192.
       softening of the, 195..202.
       inflammation of the, 199.
Stomatitis,  follicular, 150.
       simple erythematic, 145.
       with curd-like  exudation, 146.
       ulcerative, 156.
Stools, indications of disease from the, 138.
Stridulous laryngismus, 334.
Strophulus, 517.
Strumous diathesis, 112. 
INDEX.
703
Study, injury from too early application to,
  66, 75.
Stye, 538.
Sugar, the use of, by children, 55.
Summer complaint of infants, 229.
Surface, indications of disease from state of,
  135.
Swine-pox, 514.
Syphilitic eruptions, 564.
T.
Urinary organs, diseases of, in children, 112.
      diseases of the, 613.
      discharge, indications of disease from
        state of, 141.
Urinary bladder, state of, in infancy, 82.
      secretion in infants, 88.
Urine, suppression  of the,  619.
      retention of the, C20.
      incontinence of the, 114, 623.
Urodialysis neonatorum, 614.
Urticaria, 525.
Tabes mesenterica, 103, 258, 271, 580, 606
Talipes, 660.
Teething, 85, 92,169.
      as a cause of disease, 122.
      deaths from, 103.
Temperature proper for infants, 35.
Temperaments, 96.
Testicle, arrest of the, 656.
Tetter, crusted, 521.
       humid, 521.
       scally, 541.
Thirst in infants, 48.
Thorax, its form in infancy, 82.
Throat, disease of the, 173.
       gangrene of the, 179.
       inflammation of the, 176.
       diphtheritic inflammation of, 176.
 Thrush, 146.
 Thymte asthma, 339.
 Tinea muciflua, 519.
       capitis, 544.
       ciliaris, 538.
       favosa, 544.
 Tongue, indications of disease from state of,
   134.
 Tongue-tie, 635.
 Tonsillitis, 173.
 Tonsils, inflammation of the, 173.
 Trachea, foreign bodies in the, 364.
        inflammation of the, 316.
 Tracheitis, 316.
 Tracheotomy in croup, 332.
 Trismus nascentium, 388.
 Tubercles, liability of children to, 107.
        of the brain, 111, 419, 592.
 Tubercular meningitis, 419.
        depositions, 587, 613.
 Tuberculous infiltration, 587.
        dust, 588.
  Tumours, phlegmonous, 534.
  Typhoid fever in children, 115.
U.
Ulcer, atonic, 552.
      scrofulous, 575, 601.
Ulceration of the navel, 648
Ulcerative stomatitis, 156.
Vaccination, 501.
      phenomena of, 505.
      period for, 507.
      mode of, 508.
Vagina, discharges from, 579, 606.
      haemorrhage from, 656.
Varicella, 513.
Variola, 481.
      distinct, 485.
      confluent, 485.
      congestive, 485, 487.
      malignant, 487.
      nigra, 488.
      vaccina, 501.
 Varioloid, 510.
 Ventilation, importance of, 34, 571.
 Verminous fever, 268.
 Vertebrae, state of, in infancy, 84.
      disease of the, 585.
 Vesicular bronchitis, 290.
 Vomiting, indications of disease from dis-
         charges by, 138.
       of infants at the breast, 192.


                   W.

 Walk, precautions in teaching to, 64, 90.
 Warmth, necessary to infants, 36, 41.
 Wart, follicular, 543.
 Washing infants, mode of, 38.
 Water kanker, 159.
 Weaning, proper period for, 51.
       mode of, 52.
 Wet-nurse, on the choice of a, 48.
 White gum, 517.
       swelling, 582, 609.
 Whitlow, 682.
 Worm fever, 248.
 Worms, intestinal, 245.
       as a cause of disease, 121, 245, 250.
       diarrhoea from, 222.
        deaths from, 103.
Yellow granulations, 588.
»yf/»«f£.
/^C-f?,?. 
> ^.x '*
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                PHYSIOLOGY.
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Carpenter's Elements, or Manual of Physiology,
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 Bird on Urinary Deposits, 8vo., 228 pages, cuts.
 Hasse's Pathological  Anatomy, 8vo.,  379 pages.
 Hope on  the  Heart, by Pennock, a new edition,
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 Hughes on the Lungs and  Heart, 1 vol. 12mo.,
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 Lallemand on Spermatorrhoea; 1 vol.8vo.,320 pp.
 Mitchell on Fevers, 1 vol. 12mo., 138 pages.
 Philip on Protracted  Indigestion, 8vo., 240 pp.
 Philips on Scrofula, 1 vol. 8vo., 35Q>pages.
      2
Prout on the Stomach and Renal Diseases, 1 vol.
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Ricord on Venereal, new ed., 1 vol. 8vo., 256 pp.
Vb'gel's Pathological  Anatomy  of  the Human
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Walshe on the Lungs, 1 vol. 12mo., 310 pages.
Wilson on  the Skin, 1 vol. 8vo., new ed., 440 pp.
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Whitehead on Sterility and Abortion, 1 vol.8vo.,
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Williams' Principles of Medicine, by Clymer, 2d
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Williams on the  Respiratory Organs, by Clymer,
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Bartlett on  Fevers, 2d edition, 550 pages.
Benedict's  Compendium of Chapman's Lectures,
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Chapman on Fevers, Gout, Dropsy, &c. &c, 1 vol.
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Colombat de L'Isere on Females, translated and
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Condie on the Diseases of Children, 2d edition,!
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Churchill on the  Diseases of Females, by Huston,
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Clymer and others on Fevers, a complete work
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Day on Old Age, 1 vol. 8vo., 226 pages.
Dewees on  Children, 9th ed., 1 vol. Svo., 548 pp.
Dewees on  Females, 9th edition, 1 vol.8vo.,532
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Dunglison's Practice  of Medicine,  3d edition,
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Esquirol  on Insanity,  by Hunt, 8vo.,  496 pages.
Meigs' Letters on Diseases  of Females,  1 vol.
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Meigs on Certain Diseases of Infancy,  1 vol 8vo.
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Thomson on the Sick Room,  &c,  1  vol. large
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Watson's Principles and Practice of Physic, 3d
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West's Lectures on the Diseases of Infancy and
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Cooper on Dislocations and Fractures, 1 vol. 8vo .
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Dufton on Deafness and Disease ofthe Ear, 1 vol.
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Durlacher on Corns, Bunions, &c.,12mo., 134 pp.
Fergusson's Practical Surgery^ 1 vol. 8vo., 3d
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Jones' Ophthalmic  Medicine  and Surgery, by
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Liston's Lectures on Surgery, by Mutter, 1 vol.
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Lawrence on the  Eye, by  Hays, new  edition,
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Lawrence on Ruptures, 1 vol. 8vo., 480  pages.
Miller's Principles  of Surgery, 2d edition, 1 vol.
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Miller's Practice of  Surgery, 1 vol. 8vo., 496 pp.
Maury's Dental Surgery, 1 vol. 8vo., 286 pages,
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Robertson on the Teeth, 1 vol. Svo., 230 pp., pts.
Sargent's Minor Surgery, 1 vol. royal l2mo., 380
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Ellis' Medical Formulary, 9th ed., much improv-
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Taylor on Poisons, by Griffith, 1 vol.8vo.,688pp.
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  THE  GREAT  AMERICAN  MEDICAL,  DICTIONARY,
             NEW  AND  ENLARGED  EDITION.—Lately Issued.



         MEDICAL'LEXTCON;


   A   DICTIONARY   OF  MEDICAL  SCIENCE,

                                     CONTAINING

CONCISE EXPLANATIONS OF THE VARIOUS SUBJECTS AND  TERMS, WITH
   THE FRENCH AND OTHER SYNONYMES;  NOTICES OF CLIMATE  AND
     OF CELEBRATED MINERAL  WATERS:  FORMULAE FOR  VARIOUS
              OFFICINAL  AND EMPIRICAL PREPARATIONS, ETC.


              BY ROBLEY DUNGLISON,  M. D.,  &c.

                       SEVENTH   EDITION,
                 CAREFULLY REVISED AND GREATLY ENLARGED,

In One very large and beautifully printed Octavo Volume of over Nine Hundred Pages, closely printed
                in double columns.  Strongly bound in  leather, with raised bands.

   This edition is not a mere reprint ofthe last.  To show the manner  in which the author has la-
bored to keep it up to the wants ofthe day, it may be stated  to contain over  SIX THOUSAND
WORDS AND TERMS more than the fifth edition, embracing altogether satisfactory definitions of

           OVER   FORTY-FIVE   THOUSAND   WORDS.
   Every means has  been employed in  the preparation of the present edition, to render its me-
chanical execution and typographical accuracy in every way  worthy its  extended reputation and
universal use.  The size of the page has been enlarged, and the work itself increased more than
a hundred pages;  the press has been watched  with great care; a new font of type has been used,
procured for the purpose; and the whole printed on fine  clear white paper, manufactured expressly.
Notwithstanding this marked  improvement over all former editions, the price is retained at the
original low rate, placing it within the reach of all who may have occasion  to  refer  to its pages,
and enabling it to retain the position which it has so long occupied, as
             THE STANDARD AMERICAN MEDICAL DICTIONARY.
  We have examined the Lexicon for alarge number of words, including such terms as Anaesthetic, Otiatria,
Pyelitis, Mastitis, and Stomatitis, which are not commonly met with  in medical dictionaries, and on which
medical readers occasionally require information;  and we have found them  with an  explanation of their
classical origin, and  the signification under  which  they  are employed.  Dr. Dunglison's Lexicon has
the rare merit that it certainly has no rival in the English language for accuracy and  extent of references.
The  terms generally  includu short physiological and pathological  descriptions, so that, as  the author
justly observes, the reader does not possess in this work a mere dictionary, but a hook, which, while it in-
structs him in medical etymology, fumi.-hes him with a large amount of useful information.  That we are not
over-estimating the merits of this publication, is proved by the fact that we have now before us the seventii
edition.  This, at any rate, shows that the author's labors have been  properly appreciated by his own coun-
 trymen ; and we can only confirm their judgment, by recommending this most useful volume to the notice of
our cisatlantic readers.  No medical library will be complete  without it.—The London Med. Gazette. Dec. 18K
   It is certainly more complete and comprehensive than any with which we  are acquainted in tlieEnglish
language.  Few, in fact, could be found better qualified than  Dr Dunglison for the production of such a work.
Learned, industrious, persevering, and accurate, he brings to the task all the peculiar talents necessary for
 sis successful performance: while, at the same time, his familiarity with the writings of the ancient and modern
 '■masters of our art," renders him skilful 10 note the exact usage ofthe several terms of science, and the va-
 rious modifications which medical terminology has undergone with the change of theories or the progress v.
 improvement.—American Journal of the Medical Sciences.
   One ofthe most complete and copious known to the cultivators of  medical science.—Boston Med. Journal.
   This most complete medical Lexicon—certainly one of  the best works of the kind in the language.—
 Charleston Medical Journal.
   The most complete Medical Dictionary in the English language.—Western Lancet.
   Dr. Dunglison's Dictionary has not its superior, if indeed lis equal, in the English language.—St. Louis Med.
 and Surg. Journal.
   Familiar with nearly all the medical dictionaries now  in print, we consider the one before us the most
 complete, and an indispensable adjunct to every medical library.—British American Medical Journal.
   Admitted by all good judges, both in this counlry and in Europe, to be equal, and in many respects superior
 to any other work ofthe kind yet published.—Northwestern Mtdical and Surgical Journal. January, 1849.
   We repeat our former delaration that this is the best Medical Dictionary in the English language.— Western
 Lancet. December, 1843.
   We have no hesitaiion to pronounce it the very best Medical Dictionary now extant.—Southern Medical
 and Surgical Journal, December, l>4ri.
   The most coml>rehensive and best English Dictionary of medical terms extant.—Buffalo Med. Journal.
   Whence the terms have all been derived we find it rather difficult to imagine.  We can only say that, after
 looking for every new and strange word we could think of, we have not been disappointed it) regard to more
 than a few of most recent introduction, such as those designations given by Frofe**or Owen to the component
 parts of a Vertebra—British and Foreign Medico- Chirurgical Review, January, 1:49.
   Dr. Dunglison's masterpiece of literary labor.—N. Y. Journal of Medicine.

                      HOBLYN'S  MEDICAlTdiCTIONARY.

    A  DICTIONARY  OP THE  TERMS USED  IU MEDICINE.

                     AND  THE  COLLATERAL  SCIENCES.

               BY  RICHAKD  D.   HOBLYN,  A. M., Oxon.
      REVISED, WITH NUMEROUS ADDITIONS, FROM THE SECOND LONDON EDITION,
  BY ISAAC  HAYS, M. D., &c.  In one large royal 12mo. volume of 402  pages, double columns.

   We cannot too strongly recommend this small and cheap volume to the library of every student and prac-
  titioner.—Medieo-Chirurgical Review. 
LEA &  BLANCHARD'S PUBLICATIONS— (Anatomy.)             5
     SHARPEY AND  QUAIN'S ANATOMY.   Now Ready.


         HUMAN    ANATOMY.

               BY   JONES   QUAIN,    M.D.
           FROM   THE   FIFTH   LONDON   EDITION.
                                      EDITED BY
                          RICHARD QUAIN,  F.R. S.,
                                          AND
                   WILLIAM  SHARPEY, M.D., F.R.S.,
            Professors of Anatomy and Physiology  in University College, London.
       REVISED,  WITH  NOTES  AWD ADDITIONS,

                     BY JOSEPH  LEIDY,  M.  D.
          Complete in Two large Octavo Volumes, of about Thirteen Hundred Pages.
                         BEAUTIFULLY ILLUSTRATED,
               With  Five Hundred  Engravings on Wood.
  A specimen ofthe wood-cuts, but not ofthe paper or print, may be seen on the next page.

  The delay which has  occurred in  the  appearance of this great work has arisen from the very
extensive alterations and additions, which render it essentially a new book.
  " Quain's Anatomy," which forms its basis, has long been known as one of the most complete
and useful systems before the profession.   As it at present  stands, enlarged and rewritten by the
distinguished  anatomists  whose names appear on  the  title-page, it  is undoubtedly the  most
thorough and exact treatise on the subject which  has  yet  appeared in England; while the care
and attention of Dr. Leidy have been devoted to adapting the work to the wants of this country, and
to adding whatever recent investigations  of his own or of other anatomists appeared necessary
to place it entirely on a level with the science ofthe day.
  In its scope and design, this work  is more extended than  others at present claiming the at-
tention of the  profession.  Each division of Special Anatomy is preceded by an elaborate chapter
on the General, Microscopical, and Physiological Anatomy of that  portion of the body ; Surgical
Anatomy, a subject of great practical importance, has also received  much more notice than is
usually bestowed  on  it, and two chapters  will be found devoted especially to it, with reference to
the Arteries and  to  Hernia. In dealing with these various  subjects, the work has not only had
the advantage of the collaboration of  the distinguished men  above mentioned, but  also, under the
supervision of the editors, special subjects have been treated of by Mr. Ellis, the late Mr. Potter,
and  Mr. Marshall, gentlemen well known for  their attainments in the  various departments of
Anatomy.
  In completeness, accuracy, and beauty of illustration, this work is equal if not superior to,anything
ofthe kind as yet  attempted in this country.  A large number ofthe illustrations are from original
designs by the editors, and present an Unequalled series of anatomical drawings. Many new ones
have been introduced  by Dr. Leidy, and the whole are engraved on  wood in the best style of the
present day, while the typographical and general mechanical execution of the work  is in the highest
style of art.
  We believe that any country might safely be challenged to produce a treatise on anatomy so readable, so
clear, and so full upon all,important topics.—British and Foreign Medico-Chirurgical Review, April, 1849.
  It is indeed a work calculated to make an era in anatomical study, by placing before the student every de-
partment of his science, with a view to the relative importance of  each; and so skilfully have the different
parts been interwoven, that no one who makes this work the basis of his studies will hereafter have any ex-
cuse for neglecting or undervaluing  any  important particulars connected with the structure  of the human
frame; and whether the bias of his mind lead him in a more especial manner to surgery, physic, or physiolo-
gy, he will find here a work at once so comprehensive and practical as to defend him from exclusiveness on
trie one hand, and pedantry on the other.—Monthly Journal and Retrospect of the Medical Sciences.
  In general, descriptive, and surgical anatomy, it contains all the information which a 3tudent can desire.—
London Medical Gazette.
  We have no hesitation in recommending this treatise on anatomy as the  most complete on that subject in
the English language ; and the only one, perhaps, in any language, which brings the state of knowledge for-
ward to the most recent discoveries.— The Edinburgh Medical and Surgical Journal.
  One of the most valuable works to which the  medical student can apply for assistance in the prosecution
of his studies.—Medico-Chirurgical Review.
  Admirably calculated tp fulfil the object for which it is intended.—Provincial Medical Journal.
  The most complete Treatise on Anatomy in the English language.—Edinburgh Medical Journal.
  There is no work  in the English language to be preferred to  Dr. Quain's Elements of Anatomy.—London
Journal of Medicine.

WILSON'S DISSECTOR; OR, PRACTICAL AND SURGICAL ANATOMY.
                             BY ERASMUS  WILSON, M. D.,
                    Modified and re-arranged by PAUL B. GODDARD, M. D.
           In one volume, royal 12mo., of four hundred and forty pages, with 106 wood-cuts.

                             HORNER'S  DISSECTOR

         THE   UNITED  STATES   DISSECTOR;
           Being  a new edition, with extensive modifications, and almost re-written, of
                     "HORNER'S PRACTICAL  ANATOMY."
      In one very neat volume, royal  12mo., of 440 pages, with many illustrations on  wood. 
LEA & BLANCHARD'S PUBLICATIONS.^™^)________
SPECIMEN OF
SHARPEY & CUMIN'S  ANATOMY.
 
                     THE  STUDENT'S TEXT-BOOK  OF ANATOMY.

              New and Improved Edition. Just Issued.



  A   SYSTEM   OF    HUMAN   ANATOMY,


              GENERAL    AND   SPECIAL.

                       BY ERASMUS WILSON, M. D.

       FOURTH AMERICAN, FROM THE LAST ENGLISH EDITION.

                EDITED BY PAUL B.  GODDARD, A.M., M.D.,

                   With Two Hundred and Fifty  Illustrations.

        Beautifully printed in One large  Octavo  Volume of nearly Six Hundred Pages.
  In many, if not all the Colleges ofthe Union, it has become a standard text-book. This, of itself, is sufficiently
expressive of its value.  A work very desirable to the student; one, the possession of which will greatly
facilitate his progress in the study of Practical Anatomy.—New York Journal of Medicine.
  Its author ranks with the highest on Anatomy.—Southern Medical and Surgical Journal.
  It offers to the student all the assistance that can be expected from such a work.—Medical Examiner.
  The most complete and convenient manual for the student we possess.—-American Journal of Med. Science.
  In every respect this work, as an anatomical guide for the student and practitioner, merits our warmest
and most decided praise.—London Medical Gazette.


                            HORNER'S ANATOMY.


       SPECIAL   ANATOMY  AND  HISTOLOGY.

                     BY WILLIAM E.  HORNER,  M. D.,
              Professor of Anatomy in the University of Pennsylvania, &c. &c.
                                   SEVENTH EDITION.
With many improvements and additions.  In two 8vo. vols, of 1130 pages, with illustrations on wood.
  It is altogether unnecessary now to inquire into the particular merits of a work which has been so long be-
fore the profession, and is so well known as the present one ; but in announcing a new edition, it is proper to
state that it has undergone several modifications, and has been much extended, so as to place it on a level
with the existing advanced state of anatomy.  The histological portion has been  remodelled and rewritten
since the last edition ; numerous wood-cuts have been introduced, and specific  references are made through-
out the work to the beautiful figures in the Anatomical Atlas, by Dr. H. H. Smith.— The American Medical
Journal.                                     ^™^~^

               SMITH & HORNER'S ANATOMICAL  ATLAS.


           AN  ANATOMICAL   ATLAS,

ILLUSTRATIVE OF  THE  STRUCTURE OF THE  HUMAN  BODY.

                     BY HENRY  H.  SMITH,  M. D., &c.

                              UNDER THE SUPERVISION OF

                       WILLIAM  E.  HORNER, M. D.,
                    Professor of Anatomy in the University of Pennsylvania.

            In one large imperial octavo volume, with about 650 beautiful figures.
  These figures  are well selected, and present a complete and accurate representation of that wonderful
fabric the human body. The plan of this Atlas, which renders it so peculiarly convenient for the student,
and its superb artistical execution, have been already pointed out. We must congratulate the student upon
the completion of this Atlas, as it is the most convenient work of the kind that has yet appeared ; and we
must add, the very beautiful manner in which it is ' got up' is so creditable to the  country, as to be flattering
to our national pride.—American Medical Journal.


               MACLISE'S  SURGICAL  ANATOMY.


   Now  Ready,  Part I.  of SURGICAL  ANATOMY,

                     BY JOSEPH MACLISE,  Surgeon.
  To be complete in Eight Parts, Imperial Quarto, with Eight Colored Plates and  Sixteen Pages of
        Letter-press each;  forming, when complete, a large Imperial  Quarto Volume,

With Sixty-four beautiful colored Plates, drawn on Stone, in the best style of art.
  Mr Maclise's work bids fair to redeem our country from the stigma of possessing no original work on sur-
gical anatomy fhlt could take rank in regard to completeness and beauty of execution with many continental
gicai an.alomy'"*l.~",!" „"'H   Wp nlrticularlv armrove ofthe  manner in which the parts are brought into
vie^bvTsucces^fn 'ifp^Jii^^imL^l^u^ much, but those parts only being dismayed
Xhr  brou/htTnto v?ew a one time by a°goc-d dissection.  Thus as a gu.de to the dissector, these plates
wiU befar morfvahiaWe than such as endeavor to display the whole anatomy of a complicated region in
7nlortXrawings-Mr.Maclise has presented us  with adm.rable delineations and excellent descnp-
?£n*-TheBritish and Foreign Medico-Chirurgical Review, January, 1849.
  His and ifmust be, unique, &' the practical knowledge ofthe surgeon, the patience and skill of the dissector.

in'co^

^he'drfw*"
is done in 7uch a manner as to reflect high credit on the artist.-itfedtca* Times, April, 1849. 
8             LEA  &  BLANCHARD'S  PUBLICATIONS.—(Physiology.)
                    DUNGLISON'S HUMAN PHYSIOLOGY.




  HUMAN      PHYSIOLOGY.

    WITH  THREE  HUNDRED AND  SEVENTY  ILLUSTRATIONS.

                      BY  ROBLEY  DUNGLISON,  M.  D.,

  PROFESSOR OF THE INSTITUTES OF MEDICINE IN THE JEFFERSON MEDICAL COLLEGE, PHILADELPHIA., ETC., ETC.

                            SIXTH EDITION, GREATLY IMPROVED,

                 In two large octavo volumes, containing nearly 1350 pages.

  It has long since taken rank as one of the medical classics of our language. To say that it is by far the best
text-book of physiology ever published in this country, is but echoing the general testimony ofthe profession.
—N. Y. Journal of Medicine.
  The most full and complete system of Physiology in our language.— Western Lancet.
  The most complete and satisfactory system of Physiology in the English language.—Amer. Med. Journal
  The best work ofthe kind in the English language.—Suliman's Journal.
  We have, on two former occasions, brought this excellent work under the notice of our readers, and we
have now only to say that, instead of falling behind in the rapid march of physiological science, each edition
brings it nearer to the van.—British and Foreign Medical Revieiv.
  A review of such a well-known work would be out of place at the present time.  We have looked over it,
and find, what we knew would be the case, that Dr. Dunglison has kept pace with  the science  to which he
has devoted so much study, and of which he is one ofthe living ornaments.  We recommend the work to the
medical student as a valuable text-book, and to all inquirers into Natural Science, as one, which will well
and delightfully repay perusal.—The New Orleans Medical and Surgical Journal.
              CARPENTER'S  HUMAN PHYSIOLOGY.

                                LATELY  ISSUED.


       A NEW,  MUCH  IMPROVED AND ENLARGED EDITION OF



   HE  PRINCIPLES  OF HUflAH  PHYSIOLOGY.

   WITH THEIR CHIE^ APPLICATIONS TO PATHOLOGY, HYGIENE,  AND FORENSIC MEDICINE.

              BY WILLIAM  B.  CARPENTER,  M.  L\,  F. K. S.,

Fullerian Professor of Physiology in the Royal Institution of Great Britain ; author of " ElementE
     of Physiology," " Principles of General and Comparative Physiology," " Principles of
                              Animal Physiology," &c. &c.

                THIRD AMERICAN FROM THE LAST LONDON EDITION,

                              WITH NOTES AND ADDITIONS BT

                         MEKEDITH CLYMER,  M. D.,

                  Consulting Physician to the Philadelphia Hospital, &c, &c.

             Containing  317  Wood-cut  and  other  Illustrations.

 In one large and beautifully printed octavo volume of over seven hundred and fifty pages, strongly bound

  This incomparable work.—Brit, and Fot. Medical Review.
  As a text-book, it has been received into all our Colleges, and, from a careful perusal of this edition wc
can recommend it to the student and to the professional large, as the best exposition ofthe present condition
ot Physiology within their reach.—N. Y. Journal of Medicine.
  The work, as it now stands, is the only treatise on Physiology in the English language, which exhibits a
clear and connected, and comprehensive view ofthe present condition of that science.—London and Edin-
burgh Monthly Journal.                                                               -"»«•
  The standard English treatise on Physiology.—London Medical Gazette.
  Dr. Carpenter's productions justly hold the first rank in Physiology, and should be read by all who wish to
beep pace with the rapid advances of the study.—Southern Medical and Surgical Journal
  Second to no work extant upon the subject of which it treats.-J«. and Ind. Medical and Surgical Journal
  We know ot no work in our language from which the recent views on Physiology can be so well obtained'
nor any in which the subjects are so ably discussed.—St. Louis Medical and Surgical Journal
  Peculiarly adapted to the Medical Student.—Medical Examiner.
  We have, much satisfaction in declaring our  opinion, that this  work  is the best systematic treatise on
Physiology in our own lauguage, and the best adapted to the student in any language.—Medico Chururgicak

T,A»£r!c,t0Dwhich l.her?JhJas been none P«W«b.ed of equal value in the department of which it treats.-
jQrjmmtlt's Retrospective Address.

                          From Professor Caldwell, of Louisville, Ky.
  •' 1 have already recommended it, and will continue to do so» to my class, as one of the richest and sound-
reUnP°»    *   Phy81olo8Ical  k"°wledge now in the English or any other language I am capable of 
LEA  &  BLANCHARD'S PUBLICATIONS.—(Physiology.)             9
                COMPENDIUM OF  MULLER'S PHYSIOLOGY.


     A   MANUAL   OF~PHYSIOLOGY,

                   FOR   THE  USE  OF.  STUDENTS.

                BY WILLIAM SENHOUSE KIRKES,  M. D.,

                          Assisted by JAMES PAGET,
             Lecturer on General Anatomy and Physiology in St. Bartholomew's Hospital.

     In One Handsome Volume, Royal 12mo., of Five Hundred and Fifty Pages.
              ILLUSTRATED WITH UPWARDS OF ONE HUNDRED WOOD ENGRAVINGS.
  This is, certainly, a most able  manual of Physiology. The student will find in it, not a meagre outline, a
bare skeleton ofthe leading particulars embraced in the science, but a very complete and accurate—though
at the same time, concise—account ofthe facts and generally  admitted principles of Physiology ; forming an
admirable introduction to the study of that science, as well as a useful compendium for consultation by those
who are preparing for an examination.  The whole of the illustrations are very excellent, and calculated
to render the description of the objects Ihey represent clear  and precise.  To those who stand in need of a
Manual of Physiology—and works of this description have  now become, in a certain sense, indispensable
portions ofthe apparatus of study—we can very confidently recommend the present one as well for its com-
prehensiveness as for its general accuracy.—American Journal ofthe Medical Sciences, April, 1S49.
  An excellent work, and for students one ofthe best within  reach.—Boston Medical and Surgical Journal.
  A work very much wanted, bringing modern Physiology more within the student's grasp than its prede-
cessors.—Dublin Medical Press.
  One ofthe best little books on  Physiology which we possess.— BraithwaiWs Retrospect.
  The authors have succeeded in producing a work well adapted for students.—Monthly Journal and Retro-
spect ofthe Medical Sciences.
  Particularly adapted to those who desire to possess a concise digest of the facts of Human  Physiology.—
British and Foreign Med.-Chirurg. Review.
  One ofthe best treatises on Physiology which can be put into the hands of the student.—London Medical
Gazette, March, ie49.
  We conscientiously recommend it to our readers as an admirable "Handbook of Physiology."—London
Journal of Medicine.
  As an introduction to the study of the larger works, or as a reference for those who desire to "brush up"
their knowledge, we most cordially recommend the manual of Kirkes and Paget to both practitioner and stu-
dent, with the firm conviction that they will not be disappointed in the end they desire to  attain.— The Medical
Examiner.

                           CARPENTER'S ELEMENTS.

             ELEMENTS   OF  PHYSIOLOGY,

        Including Physiological  Anatomy.—For  the use  of the  Medical Student.
                     BY WILLIAM  B. CARPENTER,  M. D., F. R. S.,
             Fullerian Professor of Physiology in the Royal Institution of Great Britain, &c.
                      With one hundred and eighty Illustrations.

                             In one octavo volume of 566 pages.

               Elegantly printed, to match his " Principles of Human Physiology."
  The  author has shown singular skill in preserving so marked a line of distinction  between the present
 Manual and the "Principles of Physiology" previously published by him.  They are both on precisely the
 same subject; but the one is neither a copy, nor an abstract,  nor an abridgment of the other.  In one thing,
 however they are exactly alike—in their general excellence, and in their perfect adaptation to their respec-
 tive purposes.—British and Foreign Medical Review.


                             SOLLY  ON  THE  BRAIN.


                      THE   HUMAN    BRAIN;

        ITS  STRUCTURE, PHYSIOLOGY,  AND  DISEASES.

     WITH A DESCRIPTION OF THE  TYPICAL FORM OF THE BRAIN IN THE  ANIMAL KINGDOM.

                      BY  SAMUEL   SOLLY, F. R. S., &c,
                   Senior Assistant Surgeon to the St. Thomas' Hospital, &c.
                      FROM THE SECOND AND MUCH ENLARGED LONDON EDITION.
              In One Octavo Volume; with One  Hundred and Twenty Wood-cuts.
  The most complete account of the anatomy,  physiology, and  pathology of the brain that has hitherto ap-
 peared.  We earnestly  advise  all our professional brethren to enrich their libraries with this admirable
 treatise.—Medico- Chirurgical Review.

 HARRISON ON THE NERVES.—An Essay towards a  correct theory of the Nervous System.  In one
  octavo volume, 292 pages.
 MATTEUCCI ON LIVING BEINGS.-Lectures on the Physical Phenomena of Living Beings.  Edited
  by Pereira.  In one neat royal 12mo. volume, extra cloth, with cuts—388 pages.
 ROGET'S PHYSIOLOGY.—A Treatise on Animal and Vegetable Physiology, with over 400 illustrations on
  wood. In two octavo volumes, cloth.
 ROGET'S OUTLINES—Outlines of Physiology and Phrenology.  In one octavo volume, cloth—51$ pages.
 ON THE CONNECTION  BETWEEN  PHYSIOLOGY  AND  INTELLECTUAL SCIENCE.  In one
  12mo. volume, paper, price 25 cents.
 TODD & BOWMAN'S PHYSIOLOGY.—Physiological Anatomy and Physiology of Man. With numerous
  handsome wood-cuts.  Three-fourths of  this  work have appeared in the Medical News and Library; the
  conclusion may be expected this year, when those who have the commencement will be enabled to procure
  the completion 
10            LEA  &  BLANCHARD'S  PUBLICATIONS —(Pathology.)
            WILLIAMS' PRINCIPLES—New and Enlarged Edition.


       PRINCIPLES    OF    MEDICINE;

            Comprising General Pathology and Therapeutics,
                                         AND A

 Brief general view of Etiology, Nosology, Semeiology, Diagnosis, Prognosis, and Hygienics,

              BY CHARLES  J.  B. WILLIAMS,  M. D., F. R. S.,
                         Fellow ofthe Royal College of Physicians. &c.
               Edited, with Additions, BY MEREDITH CLYMER, M. D.3
                    Consulting Pliysician to the Philadelphia Hospital, &c. &c
                THIRD AMERICAN, FROM THE SECOND AND ENLARGED LONDON  EDITION.
                           In one volume, octavo, of 440 pages.
  The best exposition in our language, or, we believe, in any language, of Rational Medicine, in its present
 improved and rapidly improving state.—British and Foreign Medico-Chirurg. Review.
  We recommend every part of Dr. Williams' excellent  Principles of Pathology to the diligent perusal of
 every physician who is not familiar with the accessions which have been made  to medical science withia
 the last few years.— Western Journal of Medicine and Surgery.
                              From Professor Thayer, of Boston.
  It fills the place for which it was intended better than any other work.
                          From Professor S. H. Dickson, of New York.
  I shall be truly glad to know that a copy of it is in the hands of every member of our profession. As a
 public teacher, I know not how I could dispense with it.


     MANUALS  ON   TmE^LOOD  AND  URINE:
                                     CONSISTING OF

 I. A Practical Manual, containing a description ofthe General, Chemical, and Microscopical Char-
  acters ofthe Blood and Secretions ofthe Human Body, as well as of their compounds, including
  both their healthy and diseased states; with the best method of separating and estimating their
  ingredients.  Also, a succinct account of the various concretions occasionally found in the body,
  and forming calculi.  BY JOHN WILLIAM GRIFFITH,  M. D., F. L. S., &c.
 II. On  the Analysis ofthe Blood and Urine in health and  disease, and on  the treatment of Urinary
  diseases.   BY  G. OWEN REESE, M. D., F. R. S., &c. &c.
 III. A  guide to the examination ofthe Urine in health and disease, for the use of students.  BY
  ALFRED MARKWICK.

       The whole forming one large royal 12mo. volume, of four hundred and sixty pages,
                         With about one hundred figures on five plates.
  Although addressed especially to students, it contains almost  all the information upon these matters which
 the practitioner requires.—Dublin Medical Press.
  The chemical processes recommended are simple, yet scientific; and the work will be very useful to the
 medical alumni for whom it is intended.—Medical Times.
  The author must be admitted to have attained his object in presenting a convenient bedside companion —
 Dr. Ranking^ Abstract.


 THE  PATHOLOGICAL ANATOMY  OF  THE HUMAN  BODY.

                        BY JULIUS VOGEL,  M. D., &c.
                TRANSLATED FROM THE GERMAN, WITH ADDITIONS,
                           BY GEORGE E. DAY, M. D., &c.

             Illustrated by upwards of One Hundred Plain and Colored Engravings.
                              In one neat octavo volume.
  It is decidedly the best work on the subject of which it treats,  in the English language; and Dr. Day, whose
 translation is well executed, has enhanced its value by a judicious selection of the most important figures
 from the atlas, which are neatly engraved.—The London Medical Gazette.


 ALISON'S PATHOLOGY.—Outlines of Pathology and Practice of Medicine; containing Preliminary Ob-
  servations, Inflammatory  and Febrile Diseases, and Chronic or non-Febrile Diseases.  In one neat Svo
  volume, pp. 420.

 ABERCROMBIE  ON THE STOMACH -Pathological  and Practical Researches on Diseases of the
  Stomach, Intestinal Canal, &c.  Fourth Edition.  One small 8vo. volume, pp. 320.
ABERCROMBIE ON THE BRAIN.-Pathological and Practical Researches on Diseases of the Brain and
  Spinal Cord.  A new edition, in one small 8vo. volume, pp. 324.
BURROWS ON CEREBRAL CIRCULATION.-On Disorders of the Cerebral Circulation, and on the
  Connection between Affections of the Brain and Diseases ofthe Heart. InoneSvo.vol with colored plates
  pp.216.                                                              "'          v    '

BLAKISTON ON THE CHEST.-Practical Observations on certain Diseases of the Chest, and on the
  Principles of Auscultation.  In one volume, 8vo., pp. 384.

BILLING'S PRINCIPLES.-The First Principles of Medicine. From the Fourth London Edition  In one
  volume, 8vo., pp. 304.
BIRD ON URINARY DEPOSITS.-Urinary Deposits, their Diagnosis, Pathology, and Therapeutical Indi-
  cations. In one volume, 8vo., pp. 228.                                           r

HASSE'S PATHOLOGICAL ANATOMY.-An Anatomical Description of the Diseases of Respiration and
  Circulation. Translated and Edited by Swaine.  In one  volume, Svo., pp. 379
HUGHES ON THE LUNGS AND HEART.-Clinical Introduction to the Practice of Ausculation,  and
  other modes of Physical Diagnosis. Intended to simplify the study ofthe Diseases ofthe Heart and Lungs.
  In one 12mo. volume, with a plate, pp. 270.                                                6

WALSHE ON THE LUNGS.—Physical Diagnosis ofthe Diseases of the Lungs. In one 12mo vol., pp. 310. 
     DUNGLISON'S  PRACTICE  OF   MEDICINE.
                  ENLARGED  AND  IMPROVED  EDITION.

    THE    PRACTICE~OF   MEDICINE;
                                     A TREATISE ON

SPECIAL   PATHOLOGY   AND  THERAPEUTICS.
                                    THIRD EDITION.
                       BY  ROBLEY DUNGLISON,  M.  D.?
  Professor ofthe Institutes of Medicine in the Jefferson Medical College; Lecturer on Clinical Medicine, SfC
                     In Two large Octavo Volumes of Fifteen Hundred Pages.
  In Dr. Dunglison's  volumes, there is a kind of pervading exactness on every page, that is at once
recognized; and, in fact, the medical  public has long since decided that implicit reliance may be
placed in any work  which  he permits to  appear with his  name upon  the title-page. A third
edition of his treatise on Special Pathology and Therapeutics has just been published.  It has pass-
ed through so many careful examinations, and  received so many improvements, under the vigilant
eye ofthe indefatigable  man who first gave it  existence, that  it  would be an anomaly in medical
literature if it had not grown better and  better.  The student of medicine will find, in  these two
elegant volumes, a mine of facts, a gathering of precepts and advice from the  world'of experience,
that will nerve him with courage, and faithfully direct him in his efforts to relieve the physical suf-
ferings ofthe race.—Boston Medical and Surgical Journal.
  Upon every topic embraced in the work the  latest information will be found carefully posted up.
Medical Examiner.
  Professor Dunglison's work  has rapidly passed to the third edition, and is now presented to the
profession as probably the most complete work on the Practice of Medicine that has appeared in
our country.  It is especially characterized by  extensive and laborious research, minute and accu-
rate pathological, semeiological, and therapeutical descriptions, together with  that fulness of detail
which is so important to the student.
  The  present edition has been considerably  enlarged; indeed the  indefatigable author seems to
have explored all  ofthe labyrinths of knowledge, from which important facts and opinions could be
gleaned, for the instruction of his readers.  We cheerfully commend the work to those who are not
already familiar with its  merits.
  It is  certainly the most complete treatise of which we have any knowledge.   There is scarcely a
disease which the student will not find noticed.—Western Journal of Medicine  and Surgery.
  One  ofthe most elaborate treatises of the kind we have.—Southern Medical and Surg. Journal.
  The  work of Dr. Dunglison is too well known, to require at our hands, at the present time, an
analysis of its contents.  The call for a third edition within five years from the  appearance of the
first, is, of itself, a sufficient  evidence of the opinion formed of it by the medical profession of our
country.   That it  is well adapted as a text-book for the use ofthe student, and at the same time as
a book of reference for the practitioner, is very generally admitted; in both points of view, for accu-
racy and completeness, it will bear a very advantageous comparison with any  of the numerous co-
temporary  publications  on the practice of medicine, that have appeared in  this country or in
Europe.  The edition before us bears the evidence of the author's untiring industry, his familiarity
with the various additions which are constantly being made to our pathological  and therapeutical
knowledge, and his impartiality in  crediting the general sources from  which his materials  have
been derived. Several pathological affections, omitted  in the former editions, are inserted in the
present, while every portion of the work has undergone a very thorough revision. It may with
truth be said, that nothing  of importance that  has been recorded since the publication of the last
edition, has escaped  the attention of  the author ; the present edition may, therefore, be regarded
as an adequate exponent of the existing condition of knowledge on the  important departments of
medicine of which it  treats.—The American Journal of the Medical Sciences.
  The  Physician cannot get a better work of the kind than this, and when he masters its contents,
he will have mastered  all that such treatises can afford him.—St. Louis Med. Sc Surg. Journal,
June, 1848.
  In the volumes  before us, Dr. Dunglison has  proved that his acquaintance with the present facts
and doctrines, wheresoever originating,  is most extensive and intimate; and the judgment, skill, and
impartiality with which the materials ofthe work have been collected, weighed, arranged, and ex-
posed, are strikingly  manifested in every chapter.  Great care is everywhere taken to indicate the
Bource of information, and  under the head of treatment, formula? ofthe most appropriate remedies
are everywhere introduced.  In conclusion, we congratulate the students and  junior practitioners
of America on possessing in the present volumes a work of standard merit, to which they may con-
fidently refer in their doubts  and difficulties.—Brit, and For. Med. Review.
  Since the foregoing observations were written, we have received a  second edition of Dunglison's
work, a sufficient indication of  the high character it has already attained in America, and justly
attained.—Ibid.

                        DAY ON  OLD  AGE—Now Ready.

  A PRACTICAL  TREATISE ON THE  DOMESTIC MANAGEMENT  AND MORE IMPORTANT

                       DISEASES OF  ADVANCED LIFE.
With an Appendix, containing a series of cases  illustrative of a new and successful mode of treating
                     Lumbago, and other forms of Chronic Rheumatism.
               BY  GEORGE E. DAY, M. D.   In One Octavo Volume.
  A more satisfactory and truly rational train of excellent suggestions have not been  ushered into being for
a "long time than are contained in this work.—Boston Med. # Surg. Journal. 
12      LEA & BLANCHARD'S  PUBLICATIONS.—(Practice of Medicine.)
                  WATSON'S PRACTICE OF MEDICINE—New Edition.


                         lectures"  on   the


  PRINCIPLES  AND  PRACTICE  OF   PHYSIC.

                     DELIVERED AT KING'S COLLEGE, LONDON,

                BY  THOMAS WATSON,   M.D., &c. &c.

          Third American, from the last  London Edition.

      REVISED, WITH ADDITIONS, BY D.  FRANCIS CONDIE, M. D.,
                  Author of a Work on the " Diseases of Children," &c.

                              In One Octavo Volume,
      Of nearly ELEVEN HUNDRED LARGE PAGES, strongly bound with raised bands.
  To say that it is the very best work on the subject now extant, is but to echo the sentiment of the medical
press throughout the country.—N. O. Medical Journal.
  Of the text-books recently republished Watson is very justly the principal favorite.—Holmes' Report to
Nat. Med. Assoc.
  By universal consent the work ranks among the very best text-books in our language.—III. and Ind. Med.
Journal.
  Regarded on all hands as one of the very best, if not the very best, systematic treatise on practical medi-
cine extant.—St. Louis Med. Journal:
  Confessedly one ofthe very best works on the principles and practice of physic in the English or any other
language.—Med. Examiner.
  As a text-book it has no equal; as a compendium of pathology and practice no superior.—IV. Y. Annalist.
  We know of no work better calculated for being placed in the hands of the student, and for a text-book.
On every important point the author seems to have posted up his knowledge to the day.—Amer. Med. Journal.
  One of the most practically useful books that ever was presented to the student—indeed, a more admirable
summary of general and special pathology, and of the application of therapeutics to diseases, we are free to
say, has not appeared for very many years. The lecturer proceeds through the whole classification of human
ills, a capite ad calcem, showing at every step an extensive knowledge of his subject, with the ability of com-
municating his  precise ideas in a style remarkable for its clearness and simplicity.—N. Y. Journal of Medi-
cine and Surgery.
  A careful examination of this volume has satisfied us that it merits all the commendation bestowed on it in
this country and at home. It is a work adapted to the wants of young practitioners, combining, as it does,
sound principles and substantial practice.  It is not too much to say that it is a representative of the actual
state of medicine as taught and practised by the most eminent physicians of the present day, and as such we
would advise every one about embarking in the practice of physic to provide himself with a copy of it.—
Western Journal of Medicine and Surgery.
  We have for several years considered this one of the best works extant on the Principles and Practice of
Medicine.  Its style is adapted to all classes of readers, and the views of the author are sound and practical.
—Mo: Med. and Surg. Journal.
  Whoever owns this book will have an acknowledged treasure, if the combined wisdom of the highest au-
thorities is appreciated.—Boston Med. and Surg. Journal.
  It has now become, beyond all  question, the standard work on  the subject of which it treats; it is in the
hands of every physician, surgeon, and senior medical student in  every country in which the English lan-
guage is spoken; it has passed scathless through the perils of criticism.  Never, within the memory of authors
or publishers,has a medical work in two thick octavo volumes attained the enormous circulation of Watson's
Lectures, a third edition having been called for within the space of five years, and being, we believe, already
nearly exhausted ; and, in addition to this, it must be recollected that these lectures also appeared in the Medi-
cal Gazette, and have been reprinted in America.  We mention these facts as affording a sufficient reason
why, in attempting to do tardy justice to the merits of this work, our notice of it will be comparatively brief.
A work that has passed through so many editions, and that is already so widely diffused through the profes-
sion, is in one point of view, that is to say, in so far as any opinion of ours can influence its popularity, be-
yond the critic's province.—Edinburgh Monthly Journal and Retrospect ofthe Medical Sciences.


             Much  Enlarged Edition of BARTJLETT ON FEVERS.


          THE  HISTORY, DIAGNOSIS,  AND  TREATMENT
                                       OP THE


  FEVERS  OF  THE  UNITED  STATES.

                  BY  BLISHA  BAKTLETT,  M. D.,
Professor of the Theory and Practice of Physic in the Medical Department of Transylvania University, &c.

                      In One Octavo Volume  of 550 Pages,

                         Beautifully printed and strongly bound.
  We  regard it, from the examination we have made of it, the best work on fever extant in our language,
and as such cordially recommend it to the medical public.—St. Louis Med. and Surg. Journal.
  The most complete, methodical, and satisfactory account of our fevers anywhere to be met with.—Charles-
ton Med. Journ. and Review.


                   CLYMER AND  OTHERS ON  FEVERS.


FEVERS; THEIR DIAGNOSIS,  PATHOLOGY,  AND TREATMENT.

               PREPARED AND  EDITED, WITH LARGE ADDITIONS,

   PROM THE ESSAYS ON FEVER IN TWEEDIE'S LIBRARY OF PRACTICAL MEDICINE,

                       BY MEREDITH CLYMER,  M.D.

                    In One Octavo Volume of Six Hundred Pages.
  One of the best works we have on fevers, and especially adapted to the wants of the American physician.
—III. and  Ind. Med. and Surg. Journal. 
           THE   GREAT   MEDICAL   LIBRARY.


     THE  CYCLOPEDIA  OF  PRACTICAL  MEDICINE;

                                       COMPRISING

Treatises on the Nature and Treatment of Diseases, Materia  Medica, and Thera-
   peutics, Diseases of  Women and Children, Medical Jurisprudence, &c. &c.

                                        EDITED BY

       JOHN FORBES, M. D., F. R. S., ALEXANDER TWEEDIE, M. D., F. R. S.,

                             AND  JOHN CONNOLLY, M. D.

                                 Revised, with Additions,

                        BY  ROBLEY DUNGLISON, M. D.

         THIS WORK IS NOW COMPLETE, AND FOKMS FOUR LARGE SUPER-ROYAL OCTAVO VOLUMES,

Containing Thirty-two Hundred and Fifty-four unusually large Pages in Double Columns, Printed on
                          Good Paper, with a  new and clear type.

           THE WHOLE WELL AND STRONGLY BOUND,  WITH RAISED BANDS AND DOUBLE TITLES.

                          Or, to be had in Twenty-four Parts.

                                This work contains no less than
          FOUR HUNDRED  AND EIGHTEEN DISTINCT TREATISES,

             BY SIXTY-EIGHT DISTINGUISHED PHYSICIANS.

  The most complete work on Practical Medicine extant; or, at least, in our language.—Buffalo Medical
and Surgical Journal.
  For reference it is above all price to every practitioner.— Western Lancet.
  One of the  most valuable  medical publications of the day—as a work of reference it is invaluable —
 Western Journal of Medicine and Surgery.
  It has been to us, both as  learner and teacher, a work for ready and frequent reference, one in which
modern English medicine is exhibited in the most advantageous light.—Medical Examiner.
  We rejoice that this work is to be placed within the reach ofthe profession in this country, it being unques-
 tionably one of very great value to the practitioner. This estimate of it has not been formed from a hasty ex-
 amination, but after an intimate acquaintance derived from frequent consultation of it during the past nine or
 ten years.  The editors are practitioners of established reputation, and the list of contributors embraces many
 ofthe most eminent professors and teachers of London, Edinburgh, Dublin, and Glasgow. It is, indeed, the
 great merit of this work that the principal articles have been furnished  by practitioners who have not only
 devoted especial attention to the diseases about which they have written, but have also enjoyed opportunities
 for an extensive practical acquaintance with them,—and whose reputation carries the assurance of their
 competency justly to appreciate the opinions of others, while it stamps their own doctrines with high and just
 authority.—American Medical Journal.

                         WILLIAMS  ON RESPIRATORY ORGANS.

             A PRACTICAL TREATIslToN  DISEASES  OF THE

                     RESPIRATORY  ORGANS.

        INCLUDING DISEASES OF THE LARYNX, TRACHEA, LUNGS, AND PLEURA,

                       BY CHARLES  J. B. WILLIAMS, M. D.,  &c.

                            WITH NUMEROUS ADDITIONS AND NOTES,

                         BY MEREDITH  CLYMER, M.  D.

                   With wood-cuts.  In one octavo volume, with 508 pages.


 BENEDICT'S CHAPMAN.—Compendium of Chapman's Lectures on the Practice of Medicine. One neat
   volume, 8vo., pp. 259
 BUDD ON THE LIVER.—On Diseases ofthe Liver. In one very neat 8vo. vol., with colored plates and
   wood-cuts, pp. 392.
 CHAPMAN'S LECTURES.—Lectures on Fevers, Dropsy, Gout, Rheumatism, &c. &c. In one neat 8vo.
   volume, pp. 450.
 ESQUIROL  ON INS ANITY.—Mental Maladies, considered in relation to Medicine, Hygiene, and Medical
   Jurisprudence. Translated by E. K. Hunt, M. D., &c.  In one 8vo. volume, pp. 496.
 THOMSON ON THE SICK ROOM.—Domestic management of the sick Room, necessary in aid of Medical
   Treatment for the cure of Diseases. Edited by R. E. Griffith, M. D.  In one large royal 12mo. volume, with
   wood-cuts, pp. 360.
 HOPE ON THE HEART.—A Treatise on the Diseases of the Heart and Great Vessels. Edited by Pen-
   nock. In one volume, 8vo., with plates, pp. 572.
 LALLEMAND ON SPERMATORRHOEA.—The Causes, Symptoms, and Treatment of Spermatorrhoea.
   Translated and Edited by Henry J. McDougal.  In one volume, 8vo., pp. 320.
 PROUT ON THE  STOMACH.—On the Nature and Treatment of Stomach and Renal Diseases.  Iu one
   volume,  8vo., with colored  plates, pp. 466.
 PHILIP ON INDIGESTION.—A Treatise on Protracted Indigestion.  In one volume, Svo., pp. 240.
 PHILIPS  ON SCROFULA.—Scrofula: its Nature, its prevalence, its Causes, and the Principles of its
   Treatment.  In one volume, 8vo., with a plate, pp.  350.
 WHITEHEAD ON ABORTION,  &c—The Causes and Treatment of Abortion and Sterility; being the
   Result of an Extended Practical Inquiry into the Physiological and Morbid Conditions of the Uterus. In
   one volume, 8vo., pp. 363.
 BENNET ON THE  UTERUS.—A Practical Treatise on Inflammation, Ulceration, and Induration of me
   Neck ofthe Uterus.  In one small 12mo. volume, pp. 146. 
14      LEA  &. BLANCHARD'S PUBLICATIONS —(Materia Medica, <$-c.)

        ILLUSTRATED  ENCYCLOPEDIA OF  MATERIA MEDICA.
                            THE  ELEMENTS


    OF   MATERIA  MEDICA   AND   THERAPEUTICS.

COMPREHENDING THE  NATURAL HISTORY, PREPARATION, PROPERTIES,  COMPOSITION,

                         EFFECTS,  AND USES OF  MEDICINES.

           BY  JONATHAN PEREIRA, M.  D.,  F. R. S. and L.  S.,

Member ofthe Society of Pharmacy at Paris; Examiner in Materia Medica and Pharmacy in the University
              of London; Lecturer on Materia Medica at the London Hospital, &c. &c.

              Second American Edition, Enlarged  and Improved.

             WITH NOTES AND ADDITIONS, BY JOSEPH CARSON, M.  D.

   In two volumes octavo, containing Fifteen Hundred very large pages, illustrated by Two hundred and
                                 Seventy ;five  Woodcuts.

  Notwithstanding the large size of this work, and  the immense quantity of matter contained in its
closely printed pages, it is offered at a price so low as to place it within the reach of all.
  An Encyclopaedia of knowledge in that department of medical science—by the common consent of the pro-
fession the most elaborate and scientific Treatise on Materia Medica  in our language.— Western Journal of
Medicine and Surgery.
  This Encyclopaedia of Materia Medica, for such it may justly be entitled, gives the fullest and most ample
exposition of Materia Medica and its associate branches of any work heretofore published in the English lan-
guage.— N.  Y. Journal of Medicine.
  The work will be  found an invaluable storehouse of information for the physician and medical teacher, and
we congratulate the profession of this country that it is now placed  within their reach.— Amer. Med. Journal.
  An authoritative and unerring pharmacological guide.—Medical Examiner.
  Any quotations from a work so well known as this, and which has deservedly become one  of the highest
authority in the department of medical science to which it relates, would be superfluous.  The untiring in-
dustry ofthe author, and his extensive researches into the medical literature of every country, are impressed
upon the mind ofthe reader in each page of the volume. Not a fact of any importance, bearing directly or
indirectly upon his subject, is allowed by the author to escape. All are chronicled with accuracy andorder;
and, instead ofthe dry history of a drug, the reader finds himself instructed in philology, natural history, bota-
ny, physiology, or chemistry, so that he can seldom refer for information on one point without acquiring some
knowledge on others which had hitherto escaped his notice.  This work shows that Dr. Pereira is not only
an extensive reader, but a practical man.  He has studiously  endeavored to bring  the present edition up to
the scientific level of the day, and in this we need hardly say he has succeeded.—London Med. Gazette.
  Beyond dispute, the best work on Materia Medica.—Lancet. April, 1849.
  The work will be found an invaluable storehouse of information for the physician and medical teacher, and
we congratulate the profession of this country that it is now placed  within their reach.—Amer. Med. Journal.
ELLIS'S  MEDICAL FORMULARY.  Improved Edition.  Now Ready.   1849.


               THE   MEDICAL"  FORMULARY:

BEING A COLLECTION OF PRESCRIPTIONS, DERIVED FROVt THE WRITINGS AND PRACTICE OF MANY OF THE MOST
                        EMINENT PHYSICIANS OF AMERICA AND EUROPE.

                        TO WHICH IS ADDED AN APPENDIX,
        CONTAINING THE USUAL DIETETIC PREPARATIONS AND ANTIDOTES FOR POISONS.
      THE WHOLE ACCOMPANIED WITH  A FEW BRIEF PHARMACEUTIC AND MEDICAL OBSERVATIONS.

                        BY  BENJAMIN  ELLIS,   M.  D.,

                       NINTH EDITION,  CORRECTED AND EXTENDED,

                  BY SAMUEL  GEORGE MORTON, M.D.

                        In one neat octavo volume, of 268 pages.

  In preparing the new edition of this popular and valuable work, great care has been taken to bring it up to
the advanced science ofthe day.  The size of the page has been increased, thus enlarging the work without
extending its bulk, while the price is kept at the former rate.  A chapter has been added on Ether and Chlo-
roform, the subject of poisons has been rewritten and enlarged, and many new formulas interspersed through-
out the volume.
                     DUNGLISON ON NEW REMEDIES.
                                 NEW  EDITION.


               NEW    REMEDIES,

         BY  ROBLEY DUNGLISON,  M. D.,  &c.  &c.
             Fifth edition, with extensive additions.  In one neat Octavo volume.
  A work like this is obviously not suitable for either critical or analytical review.  It is, so far as it goes, a
dispensatory, in which an account is given ofthe chemical and physical properties of all the articles recently
added to the Materia Medica and their preparations, with a notice of the  diseases for which they are pre-
scribed, the doses, mode of administration, &c.—The Medical Examiner. 
       CIIRISTISOJY X  GRIFFITH'S If IS I* E.VSjUTOWV,  JYow  Ready.



                 A    DISPENSATORY,

                                           OR

COMMENTARY ON  THE  PHARM/VCOPCEIAS  OF  GREAT BRITAIN

                         AND THE UNITED  STATES:

                                      COMPRISING
THE NATURAL HISTORY, DESCRIPTION, CHEMISTRY,  PHARMACY, ACTIONS,  USES
            AND DOSES OF THE ARTICLES OF THE MATERIA MEDICA.

              BY  ROBERT  CHRISTISON, M.D., V.P.R.S.E.,
   PRESIDENT OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH, PROFESSOR OF MATERIA MEDICA IN THE
                                UNIVERSITY OF EDINBURGH, ETC.

                      Second Edition, Revised and Improved,

  WITH  A SUPPLEMENT  CONTAINING THE MOST  IMPORTANT NEW REMEDIES.

                         WITH  COPIOUS ADDITIONS,

         AND TWO HUNDRED  AND THIRTEEN LARGE  WOOD  ENGRAVINGS,

                    BY  R. EGLESFELD GRIFFITH, M. D.,
                           AUTHOR OF "A MEDICAL BOTANY,"  ETC.

 In  One very large and handsome Octavo Volume of over One Thousand closely printed Pages, with
                  numerous Wood-cuts, beautifully printed, on fine white paper.

              Presenting an  immense quantity of matter at  an unusually low price.

  It is enough to say that it appears to us as perfect as a Dispensatory, in the present state of pharmaceuti-
 cal science, could be made. If it omits any details pertaining to this branch of knowledge which the student
 has a right to expect in such a work, we confess the omission has escaped our scrutiny.  We cordially
 recommend this work to such of our readers as are in need of a Dispensatory. They cannot make choice of
 &beuer.—The Western Journal of Medicine and Surgery.
  In conclusion, we need scarcely say that we strongly recommend this work to all classes of our readers.
 As a Dispensatory and commentary on the Pharmacopoeias, it is unrivalled in the English or any other lan-
 guage.—The Dublin Quarterly Journal.                                     .
  We earnestly recommend Dr. Christison's Dispensatory to all our readers, as an indispensable companion,
 not in the Study only, but in the Surgery also.—British and Foreign Medical Review. . .
  It is exactly the work we would give to the student for daily reading, or to the practitioner for regular refer-
 ence.  Without being encumbered with unnecessary detail or research, it is sufficiently explicit in its litera-
 ture to render it an ample encyclopedia of its subject; and at the same time, its practical information is so
 condensed and summary, yet without a sacrifice of even the least  important fact, that to the student it cannot
 but be a text-book invaluable in its kind.  Had we  said less concerning this volume we should have been
 wanting in common duty ; but it is not necessary that we should say more to convince our readers that we
 consider it to be the  best English work extant upon the subject it embraces.—Medical Times.
  There is not in any language a more complete and perfect Treatise.-N. Y. Annalist.
  As nearly complete as possible-a work of great authority and usefulness.—CWestow Medical Journal.
  One ofthe standards of the day, and as such must meet the favor it deserves.—Am. Jour, of the Med. Sciences.
  In advance of most that has been written on the subject- Buffalo Medical Journal.
  As perfect as such an undertaking can well be-Southern Medical and Surgical Journal
  We can heartily recommend this work as one of ihe very best of its kind-NorthwesternMedical Journal
  It should occupy a conspicuous place in the bureau of every physician and apothecary.—N. O. Medical and

 S T^moi? accurate, the best arranged, and the cheapest work of the ]c\nA.—London and Edinburgh Jour-

 WTo4^fwhoSdtnot'possess Wood $ Bache, we would say procure Christison «$• Griffith; and to those who
 do possess the  former, that it would be well to procure the latter  as soon as  convenient.-S2. Louis Medical
 and Surgical Journal.
                              From Professor Rayburn, of St. Louis.
  The most valuable, in my opinion, of all the Dispensatories yet published.



            DUNGLISON'S THERAPEUTICS.   New and much Improved Edition,


        GENERAL  THERAPEUTICS" AMD  MATERIA  MEDICA,

                   With One Hundred and Twenty Illustrations.

                         ADAPTED FOR A  MEDICAL TEXT-BOOK.

                   BY  EOBLEY  DUNGLISON, M.D.,

 Professor of Institutes of Medicine, &c. in Jefferson Medical College ; Late Professor of Materia Medica, &c
            in the Universities of Virginia and Maryland, and in Jefferson Medical College.

            Third edition, revised and improved, in two octavo volumes, well bound.

  The most complete and satisfactory exponent of the existing state of Therapeutical  Science, within the
 moderate limits of a text-book, of any hitherto published.-N. Y. Journal of Medicine.
  Our Junior brethren in America will find in these volumes of Professor Dung lison. .a "Thesaurus Medica-
 minum » more valuable than a large purse of gold.-Zondon Medico-Chirurgical Review.
  No medical student on either side ofthe Atlantic should be without  these  volumes.—British and Foreign
 Medical Review. 
16       LEA &  BLANCHARD'S PUBLICATIONS.—(Materia Medica, $c.)


                    ROYLE'S  MATERIA  MEDICA.


     MATERIA  MEDICA  AND   THERAPEUTICS;
                                    INCLUDING THE

Preparations of the Pharmacopoeias of London, Edinburgh, Dnblin, and of the United State*.

                          WITH MANY NEW MEDICINES.

                   BY  J. FORBES ROYLE, M. D., F. R. S.,
           Professor of Materia Medica and Therapeutics, King's College, London, &c. tec.

                        EDITED BY JOSEPH CARSON, M. D.,
           Professor of Materia Medica in the Philadelphia College of Pharmacy, &c. &c.

                      WITH NINETY-EIGHT ILLUSTRATIONS.

                 In one large octavo volume, of about Seven Hundred Pages.

     Being one of the most beautiful Medical works published in this Country.

  This work is, indeed, a most valuable one, and will fill up an important vacancy that existed between Dr.
Pereira's most learned and complete system of Materia Medica, and the class of productions on the other ex-
treme, which are necessarily imperfect from their small extent.—British and Foreign Medical Review.
  Of the various works on the plan of the one before us, there is none more deserving of commendation.
Every one who can afford it, should possess this excellent work.—Medical Examiner.
  We cannot too highly recommend this valuable work, both to the student and practitioner.—Southern Jour-
nal of Medicine and Pharmacy.
  This work is ably done—the botanical part with great skill; and the chemical, natural history, and thera-
peutic department most perfect and complete.—Edinburgh Medical Journal.
  The subject is well treated, the matter practical and well arranged, and we do not hesitate to recommend it
as a most useful volume to the student and practitioner.—Medical Gazette.
  The wood engravings by which the crystals, the vegetable products, and the medicinal animals are illus-
trated, are better than anything hitherto attempted in Materia Medica, and must prove a great assistance to
the student, appealing as they  do more powerfully to the mind than the most careful verbal descriptions
taken alone could do.—Lancet.
  Each substance is considered in reference to its history, its physical and chemical properties, preparations,
tests, action, uses, and doses.  All of these are briefly sketched in a concise and lucid manner, and in a way
to show that a master-hand was employed in the task.—N. O. Medical and Surgical Journal.


       JVEW JiJYn COMPLETE JIEIUCAJL BOTAJY1T.  Lately Published.


              medical" botany,

OR, A  DESCRIPTION  OF  ALL THE MORE IMPORTANT PLANTS USED  IN  MEDICINE. AND

          OF THEIR  PROPERTIES, USES,  AND MODES  OF ADMINISTRATION.

                BY R.  EGLESFELD  GRIFFITH,  M. D., &c. &c.

In one large octavo volume, of 704 pages, handsomely printed, with nearly three hundred and fifty
                                 illustrations on wood.

  By far the most comprehensive and complete work upon the subject which has been issued from the Ame-
rican press, filling a great vacancy in the medical literature of the country.—III. <$• Ind. Med. and Surg. Jour.
  An admirable work.—Boston Medical and Surgical Journal.
  One ofthe greatest acquisitions to American medical literature. It should by all means be introduced at
the very earliest period, into our medical schools, and occupy a place in the library of every physician in the
land.—Southwestern Medical Advocate.
  Admirably calculated for the physician and student—we have seen no work which promises greater ad-
vantages to the profession —N. O. Medical and Surgical Journal.
  One ofthe few books which supply a positive deficiency in our medical literature.— Western Lancet.
  We hope the day is not distant when this work will not only be a text-book in every medical school and
cullege in the Union, but find a place in the library of every private practitioner.—JV. Y. Jour, of Medicine.


     GRIFFITH'S UNIVERSAL FORMULARY".—To be Ready in August


             THE  UNIVERSAL  FORMULARY;

A SYNOPSIS OF THE PHARMACOPEIAS, DISPENSATORIES, AND FORMULARIES OF
                              EUROPE AND AMERICA.

          With numerous Magisterial Formulas from various sources.

                     BY R.  E. GRIFFITH,  M. J)., &c. &c,
                            Author of "Medical Botany," &c. &c.

                                 In one octavo volume.

  This work is intended to embrace all that is of practical importance in the numerous Pharmacopoeias, Form-
ularies, and Dispensatories of Europe and of this country, as well as such formulas' as appeared deserving of
notice in the Medical Journals, Treatises of Medicine, &c. &c, together with many others derived from pri-
vate sources, which have never been hitherto published.  It will therefore include all that is really useful in
Redwood's Edition of Gray-* Supplement to the Pharmacopoeias, in Jourdan's Pharmacopoeia, and the several
works of Ellis, Fee, Pans, Thomson,  Beasley, Cottereuu, Cooley, Bouchardat, &c.  As, in accordance with
its title of a Universal Formulary it will not be confined solely to medical formulas, the publishers hope  that
the numerous scientific receipts embraced, will render it of much practical importance to the Chemist  and
Manufacturer. It will contain
                     UPWARDS OF SIX THOUSAND FORMULAS.
alphabetically arranged, with copious indexes, pointing out the diseases in which the preparations are to be
used, &c. &c, and thus combining the advantages of all the different modes of arrangement and reference. 
         LkA & HLANCHARD'S PUBLICATIONS.—(Materia Medica, $-c.)        17


            Mohr, Redwood, and Procter's Pharmacy.   Now Ready.


                   practicaiTeharmacy.

 COMPRISING THE ARRANGEMENTS, APPARATUS, AND MANIPULATIONS OF  THE
                     PHARMACEUTICAL SHOP AND LABORATORY.

                          BY  FRANCIS MOHR, Ph.D.,
              Assessor Pharmacise of the Royal Prussian College of Medicine, Coblentz.

                       AND  THEOPHILUS  REDWOOD,
               Professor of Pharmacy in the Pharmaceutical Society of Great Britain.
                         EDITED, WITH EXTENSIVE ADDITIONS,

                        BY PROF.  WM. PROCTER,  Jr.,
                            Of the Philadelphia College of Pharmacy.

  In One handsomely printed Octavo Volume, of Five Hundred and Seventy Pages,  with  over
                             500 beautiful Engravings on Wood.

  In presenting the work of Mohr and Redwood to the American Pharmaceutical public, it is un-
der the impression that the want of a treatise on the apparatus and manipulations of Practical Phar-
macy has long been felt.   The Practice of Pharmacy, as conducted in England and in the United
States, is sufficiently alike to render this work appropriate as a handbook for the American Apoth-
ecary ;  and the eminence ofthe authors in their respective countries, is a guarantee ofthe value ot
the information  it contains.  In passing through the hands  of the Editor,  the book  has been
increased  more  than one-fourth in size, about one hundred wood-cuts  have been added, the
arrangement ofthe subjects materially changed, and the work divided into chapters, each of which
includes either one distinct subject, or several  that have a certain generic relation to each  other.
One subject sought by the change of arrangement has been to fit the work as  a text-book for the
Editor's class in the Philadelphia College of Pharmacy, as far as its nature will admit, and some of
the additions have been made with a view to the same object.—Editor's Preface.
  After a careful examination of this treatise, we have no hesitation in giving it our strongest recommenda-
tion, as excellent both in matter and manner.  The whole of it is marked by a clear sense of the objects to be
gained, by ingenuity in devising means for their accomplishment, and by a facility in explanation which ren-
ders every description  at once intelligible.  The wood engravings are of first-rate execution, and are so pro-
fusely scattered through the volume  as to leave nothing to be desired in the way of illustration.  As we do
not address ourselves to the mere pharmaceutist, we shall not speak ofthe special adaptation of the work to
"his wants; but shall simply say that every medical practitioner who has anything to do with chemical pro-
cesses, whether in the study of chemical pathology, or in the preparation and dispensing of medicines, will
find in it a number of valuable hints, conducive alike to the saving of labor, and to the more effectual perform-
ance of his operations.   Nearly the whole of the latter division has been supplied by Mr. Redwood ; and it
thus possesses the advantage of being in every way adapted to the requirements of the English dispenser,
whilstit furnishes the results of a much more extensive practical acquaintance with the subject, than our
professional writers on Materia Medica and Pharmacology  can be expected to possess.—The British and
Foreign Medico- Chirurgical Review.
  The work is original in its design, and complete in its execution. The most minute  details  are described
with great accuracy; and the illustrations are so well executed and so numerous, that  a cursory inspection
ofthe work is sufficient to convince  the reader of its great practical utility.  It is a kind of work for which
there has long been a demand in this country, comprising a very complete account of all pharmaceutical
operations, with the various modes of conducting them, as well as the apparatus.—Pharmaceutical Journal.
  This work will prove of great value to the English pharmaceutical chemist, as it contains a large amount
of valuable information relaling to every department of his business.  Every person engaged in the pharma-
ceutical profession should  attentively read this Chapter; and we are sure that those who follow the rules
here laid down, will conduct the dispensary business in the best way,  and consequently with the greatest
accuracy and dispatch.  The wood engravings in the book are well executed.—Medical Times.
  It is in all respects well qualified for the purpose proposed.  It presents, in a sensible and judicious form, all
the requisite information as to the details of conducting the business of chemist, druggist, and apothecary, and
will be found a most useful and indispensable guide in the laboratory and manufactory. The volume is alto-
f ether one of great and indispensable utility to the druggist and compounder, and a most useful guide to all
 ranches ofthe profession. It is illustrated with most beautiful  and correct wood-cut figures of the various
sorts of apparatus.—The Edinburgh Medical and Surgical Journal.
                     From Prof. Lewis C. Beck, ofthe Albany Medical College.
  It is a capital book, and ought to be in the hands of every apothecary in the country. I shall strongly recom-
mend it to my class in the Albany Medical College.
                            From Professor C. G. Page, of Washington.
  Truly a valuable work, and one which I have long desired to see.  The authors have been so full and care-
ful in the detail of their illustrations and descriptions, that a careful study of the work would be almost equiva-
lent to an apprenticeship in the laboratory.  It will give me great pleasure to commend it to the profession.


                     DISPENSATORY AND FORMULARY.


     A DISPENSATORY  AND  THERAPEUTICAL   REMEMBRANCER.

              COMPRISING THE ENTIRE LISTS OF MATERIA MEDICA,
          With every Practical Formula contained in the three British Pharmacopoeias.
  WITH RELATIVE TABLES SUBJOINED, ILLUSTRATED BY UPWARDS OF SIX HUNDRED AND SIXTY  EXAMPLES.
        The Extemporaneous Forms and Combinations suitable for the different Medicines.

            BY JOHN  MAYNE, M. D., L. R. C.  S., Edin.,  &c. &c.
    EDITED, WITH THE ADDITION OF THE FORMULAE OF THE  UNITED STATES PHARMACOPEIA,
                         BY R. EGLESFELD GRIFFITH, M. D.,
                   In one 12mo. volume, of over three hundred  large pages.

  The neat typography, convenient size, and low price of this  volume, recommends  it especially
to physicians, apothecaries, and students in want of a pocket manual. 
18           LEA &,  BLANCHARD'S  PUBLICATIONS— (Midwifery.)
            MEIGS'  OBSTETRICS. —Now  Ready.




                     OBSTETRICS:


     THE    SCIENCE   AND     THE    ART.

                      BY CHARLES  D.  MEIGS,  M. D.

   Professor of Midwifery and the Diseases of Women and Children in the Jefferson Medical College,
                                   Philadelphia, &c. &c.

                  With One Hundred and Twenty Illustrations.

      In One beautifully printed Octavo Volume, of Six Hundred and Eighty Large Pages.

  Treatise after treatise on the theory and practice of Midwifery have, within a few years past, issued from
•he press in rapid succession, each excellent in its kind, and the majority bearing the names of the  most
diligent cultivators, and distinguished  practitioners of obstetricy. Amid these, the work of Dr. Meigs will
claim a high and commanding position.  As an elementary treatise—concise, but, withal, clear and compre-
hensive—we know of no one better adapted for the  use  of the student; while the young practitioner will
find in it a body of sound doctrine, and a series of excellent practical directions, adapted to all the condi-
tions  of the various forms of labor and their results, which he will be induced, we are persuaded, again and
again to consult, and always with profit.
  The work of Dr. Meigs bears all the  intrinsic marks of being the production of one who has not only had
ample opportunities for studying the several subjects of which he treats, but who has carefully improved
those opportunities. There is an earnestness in the author's style, as of one having authority.  What he de-
scribes, he has evidently seen—what he directs to be done, he has himself practisedi. From his very manner
of teaching, we perceive that the obstetric science he inculcates has been deduced from, or verified by his
own observations, and that the correctness of the rules of practice laid down by him has been tested by his
own experience.  This, while it constitutes in a great degree  the value of the work, in relation to every
point connected with the science and the art of obstetrics, renders it likewise a more pleasing one to study.
The reader seems rather to be listening to the earnest, truthful, and living voice of one qualified to teach, than
merely perusing the dry details of doctrine and of practice from the printed pages of a book.
  It has seldom been our lot to peruse a work upon the subject, from which we have received greater satis-
faction, and which we believe to be better calculated to  communicate to the student correct and definite
views upon the several topics embraced  within the scope of its teachings. It is unnecessary for us to recom-
mend the work to the favorable notice ofthe profession ; before even our remarks shall reach them, the work,
we are persuaded, will be in the hands  of the major portion of American physicians, as well as of those  who
are destined shortly to become such.—American Journal of the Medical Sciences, April 1849.
  Elsewhere we shall look for an elaborate review of this work—we refer to it now merely to welcome its
appearance, and to assure the student, who may be about to purchase a midwifery, that we are acquainted
with  none of greater practical value.—Boston Medical and Surgical Journal.
  The very minuteness and particularity alluded to by the author constitute one ofthe strong and commend-
able features of the work, not for the student only, but  for practitioners of all grades of experience.  We
most  sincerely recommend it, both to the student and  practitioner, as a more complete and valuable work on
the Science and Art of Midwifery, than any of the numerous reprints and American Editions of European
works on the same subject.—N. Y. Annalist, April 1849.
  The above work will be welcomed most cordially by all who feel an interest in the study of obstetries.
Its author is well  known as a practitioner of vast experience, in matters appertaining to midwifery, and the
diseases of women and children, and  it  is truly surprising how one, who is continually going about doing
good  in his'way, should find time to write so much and so well as does Dr. Meigs.
  In conclusion, we would recommend this treatise on obstetrics to the profession  as one worthy the reputa-
tion of its distinguished author.—Medical Examiner, May 1819.
   TYLER SMITH ON PARTURITION—A Wew Worlt^Iust Ready.


                   ON     PARTURITION

                                       AND  THE

      PRINCIPLES    AND   PRACTICE   OF   OBSTETRICS.

                       By  W.  TYLER SMITH, M.D.
               Lecturer on Obstetrics in the Hunterian School of Medicine, &c. &c.

                       In one large duodecimo volume, of 400 pages

  The work will recommend itself by its intrinsic merit to every member of the profession.
                                                                      Lancet, April, 1849.
  We can imagine the pleasure with which William Hunter or Denman would have welcomed the present
work; certainly the most valuable contribution to obstetrics that has been made since their own day. For
ourselves we consider its appearance as the dawn of a new era in this department of medicine.
  We have thus given a brief, but we believe accurate and succinct, outline of the original views contained
in this volume. At every page of the work itself, practical deductions are drawn from the physiological
doctrines as they are advanced; but we have for the present chiefly confined ourselves to the latter. In a
future bibliographical sketch we shall, with equal care, go over these lectures, which are entirely devoted to
practical points; and we are sure that  the interest of our readers will  not flag while they follow us in our
task. We would observe, that we  do not pledge ourselves to all and  every doctrine promulgated by Dr.
Tyler Smith.  This would be impossible, considering the magnitude of the subject itself, and the great vari-
ety and importance of the topics discussed; but we do most cordially recommend the work  as one absolutely
necessary to be studied by every accoucheur.   It will, we may add, prove equally interesting and instructive
to the student, the general practitioner, and pure obstetrician.  It was a bold undertaking to reclaim parturi-
tion for Reflex Physiology, and it has been well performed.—London Journal of Medicine. 
LUA  &  BLAJNUHARD'S PUBLICATIONS— (Midwifery.)          iy
                      RAMSBOTHAM'S  MIDWIFERY.


                 THE  PRINCIPLES  AND PRACTICE OF


    OBSTETRIC  MEDICINE  AND   SURGERY,

                 In reference to the  Process  of Parturition,

            BY  FRANCIS   H.  RAMSBOTHAM,  M.D.
                      Physician to the Royal Maternity Charity, &c. &c.

                NEW AMERICAN FROM THE LAST LONDON EDITION.

      Illustrated with One Hundred and Forty-eight Figures on Fifty-five Lithographic Plates.

        In one large and handsomely printed volume, imperial octavo, with 520 pages.

                   From Professor Hodge, ofthe University of Pennsylvania.
 To the American public, it is most valuable, from its intrinsic undoubted excellence, and as being the best
authorized exponent of British  Midwifery.   Its circulation will, I trust, be extensive throughout our country.
 We recommend the student,  who desires to master this difficult subject with the least possible trouble, to
possess himself at once of a copy of this work.—American Journal ofthe Medical Sciences.
 Itstands at the head of the long list of excellent obstetric works published in the last few years in Great
Britain, Ireland, and the Continent of Europe.  We consider this book indispensable to the library of every
physician engaged in the practice of Midwifery.—Southern Medical and Surgical Journal
 When the whole profession is thus unanimous in placing such a work in the very first rank as regards the
extent and correctness of all the details of the theory and practice of so important a branch of learning, our
commendation or condemnation would be of little consequence; but, regardingit as the most useful of all works
ofthe kind, we think it but an act of justice to urge its claims upon the profession.—N. O. Med. Journal.
 We are disposed to place it first on the list ofthe numerous publications that have appeared on this subject;
for there is none within our knowledge that displays in so clear and forcible a manner every step in the pro-
cess, and that, too, under all imaginable circumstances — N. Y. Journal of Medicine.



                  New Edition.  Revised for this Country, 1848.


   THEORY  AND   PRACTICE   OF  MIDWIFERY.

                   BY  FLEETWOOD  CHURCHILL,  M. D.,
               Hon. Fellow ofthe Royal College of Physicians of Ireland, &c. &c.

                             WITH NOTES AND ADDITIONS

                        BY ROBERT M. HUSTON, M. D., &c.

            THIRD AMERICAN EDITION, REVISED AND IMPROVED .BY THE AUTHOR.

                 With One Hundred and Twenty-eight Illustrations.

        In  One very handsome Octavo Volume, of Five Hundred and Twenty-Six Pages.
 This is certainly the most perfect system extant.  It is the best adapted for the purposes of a text-book, and
that which he whose  necessities confine him to one book, should.select in preference to all others— Southern
Medical and Surgical Journal.                                                .
 The most popular work on Midwifery ever issued from the American press — Charleston Medical Journal.
 Certainly, in our opinion, the very best work on the subject which exists—N. Y. Annalist.
 Were we reduced to the necessity of having but one work on Midwifery, and permitted to choose, we would
unhesitatingly take Churchill.— Western Medical and Surgical Journal.
 It is impossible to conceive a more useful and elegant Manual than Dr. Churchill's Practice of Midwifery.
— Provincial Medical Journal.                  c            ,.,.,,.,_.    .u  j     a
 No work holds a higher position, or is more deserving of being placed in the hands of the tyro, the advanced
student, or the practitioner.—Medical Examiner.


                      LEE'S CLINICAL MIDWIFERY. Now Ready.


            CLINICAL    MIDWIFERY,

COMPRISING THE HISTORIES  OF FIVE  HUNDRED AND  FORTY-FIVE CASES OF DIFFI-
     CULT, PRETERNATURAL, AND COMPLICATED LABOR, WITH COMMENTARIES.

                  BY ROBERT LEE, M.D.,  F.R. S.,&c

Prom the 2nd London Edition.  In one royal 12mo. vol., extra cloth.  238 pages.

 More instructive to the juvenile practitioner than a score of systematic works.—Lancet.      •
 Will be consulted by every accoucheur who practices his art with the zeal which it merits.—Med. Gazette.
 An invaluable record for the practitioner.—N.  Y. Annalist.
 This admirable book of precedents.—Boston Medical and Surgical Journal.
 A storehouse of valuable facts and precedents.—American Journal ofthe Medical Sciences.


                           DEWEES'S  MIDWIFERY.


      A   COMPREHENSIVE  SYSTEM  OF MIDWIFERY.

           ILLUSTRATED BY OCCASIONAL CASES AND MANY ENGRAVINGS.
                         BY  WILLIAM P. DEWEES,  M. D.,

Tenth Edition, with the Author's last Improvements and Corrections.  In one Octavo Volume, of 660 pages. 
20  LEA  &  BLANCHARD'S PUBLICATIONS— (Diseases of Women and Children.)
                               JUEIGS  O.V FEMALES.




     FEMALES    AND    THEIR    DISEASES;


         A  SERIES  OF  LETTERS  TO  HIS  CLASS.

                          BY  C.  D.   MEIGS,  M.  D.,
Professor of Midwifery and the Diseases of Women and Children in the Jefferson Medical College
                                   of Philadelphia, &c. &c.

               In One large and beautifully printed Octavo Volume of 670 Pages.

  This is a clever, a very clever book.  It is unique in its method, and truly felicitous in its execution.  Fi-
nally, Prof. Meigs has sought in this work to give to his brethren, and especially to his class, b book which
may be read.  We would say, that we think he has not failed.—Boston Medical and Surgical Journal.
  He has evidently seen almost every form and variety of female disease, and not only seen, but observed
and reflected, and if we may judge by the innate evidence afforded by the volume itself, practised success-
fully.  His volume contains many practical hints and suggestions which will repay perusal.—The Charleston
Medical Journal and Review.
  The work is written in a free, animated conversational style, and is replete with sound practical instruc-
tion.—The Western Lancet.
  We warmly commend the work of Professor Meigs as a highly interesting and instructive volume.—N. Y.
Journal of Medicine.
  The remaining affections ofthe womb, included in the volume before us, are treated of very learnedly, and
much valuable instruction is communicated concerning them.  Dr. Meigs' views as to the nature and causes
of these affections are generally correct, while his long and extensive experience gives to his practical direc-
tions no trifling weight.  The work contains a very large fund of valuable matter, and will, in all probability,
become a very popular one.—American Medical Journal.
  His great reputation, the change in the book from the usual manner of writing, and the intrinsic merits with
which the work abounds, will give it a wide-spread circulation, and a very general perusal.—Northern and
Western Medical and Surgical Journal.
  The style is certainly not faultless, but yet it is one which, we venture to believe, will prove acceptable lo
most of the readers to whom it is especially addressed.  It is fresh, buoyant, varied and sprightly, and one is
carried along by it without weariness. "As to the doctrine and the precept of these letters," we think with
the author, that " he has a right, at his time of life, to be heard upon them," and we are quite sure that he will
be heard with great advantage.  Whatever difference of opinion there may be respecting the manner of the
letters, there can be no diversity as lo the matter.  They are full of instruction.  It would be difficult to point
to a volume containing more valuable information relative to females and their diseases.  We take leave of
these Letters with the conviction that they will be productive of great good.  They will be read with atten-
tion by  many who would not have patience to wade through an elaborate, systematic treatise on diseases of
females, and there is something in the dashing, random style which serves to impress their sentiments upon
the memory.  We do not undertake to say that the style is the best; it would probably be hazardous to assert
that it is even a proper one for such a subject; but we must say, that it has contributed its share towards the
pleasure with which we have read this volume.—  The Western Journal of Medicine and Surgery.
  We think that Dr. M. has done to his class and to the profession generally, a service for which they will be
grateful, and for which he merits th6 approbation  of all.  He has endeavored to perform his task, he tells us,
in a spirit of " freedom and abandon," very different from the dullness which has hitherto characterized medi-
cal writings; and we think he has succeeded in producing a very agreeable, amusing, clever, and instructive
book, which will be read with pleasure, and be likely to be impressive.  We feel that in this hasty sketch we
have given the reader scarcely an idea of the vast amount of useful information which the book contains, and
ofthe pleasing style in which, generally, it is conveyed, and most conscientiously advise him to purchase and
read it for himself.  It is, nevertheless, one ofthe  most original and pleasant medical books, and one of the
most agreeable upon the subject, we have ever read ; and we cannot but acknowledge, that Professor Meigs
has rendered by its publication a great service to  his profession, and  done great credit to his own industry
and scholarship, and to his skill as a practitioner, and his ability as a teacher.  As it is, we hope that every
young man will allow himself the recreation and instruction to be derived from its perusal.—The Annalist.
  The body of the book is worthy of extensive  consideration, and  is evidently the production of a clever,
thoughtful, and sagacious physician.  Dr. Meigs' letters on the diseases of the external organs, contain many
interesting and rare cases, and many instructive observalions.  We lake our leave of Dr. Meigs, with a high
opinion of his talents and originality.—The British and Foreign Medico-Chirurgical Review.
  Every chapter is replete with practical instruction, and bears the impress of being the  composition of an
acute and experienced mind.  There is a terseness, and at the same time an accuracy, in his description of
symptoms, and in the rules for diagnosis, which cannot fail to recommend the volume to the attention of the
reader.—Ranking's Abstract.
              ASHWELL ON  THE  DISEASES  OF  FEMALES.

                           A PRACTICAL TREATISE ON THE

   DISEASES   PECULIAR   TO   WOMEN,

      Illustrated by Cases derived from Hospital and Private Practice.

                        BY SAMUEL  ASHWELL, M.  D.,
  Member ofthe Royal College of Physicians ;  Obstetric Physician and Lecturer to Guy's Hospital, &c.
                                    WITH ADDITIONS,
                      BY PAUL  BECK  GODDARD, M. D.,
                              SECOND AMERICAN EDITION.
                  In one octavo volume of Five Hundred and Twenty Pages.
  One ofthe very best works ever issued from the press on the Diseases of Females.— Western Lancet.
  This invaluable work.—Missouri Medical and Surgical Journal.
  We strongly recommend Dr. Ashwell's Treatise to our readers as a valuable book of reference, on an ex-
tensive, complicated, and highly important class of diseases.—Edinburgh Monthly Journal of Med. Sciences. 
jula c* BLA^bHAKU'S f u BL.1UAT1UJN S.—(Diseases of Women and Children.)  21
                   CONDIE  ONCHILDREN.

                          A PRACTICAL TREATISE ON


       THE  DISEASES  OF  CHILDREN.

                     BY D. FRANCIS CONDIE,  M. D.,
       Fellow of the College of Physicians; Member ofthe American Philosophical Society, &c.

     Second Edition. In One large Octavo Volume, of Six Hundred and Fifty-eight Pages.

 We feel persuaded that the American Medical profession will soon regard it, not only as a very good, but
as the very best " Practical Treatise on the Diseases of Children."—American Medical Journal.
 We pronounced the first edition to be Ihe best work on the Diseases of Children in the English language,
and, notwithstanding all that has been published, we still regard it in that light— Medical Examiner.
                       From Professor D. Humphreys Storer, of Boston.             ''
 I consider it to be the best work on the Diseases of Children we have access to, and as such recommend it
to all who ever refer to the subject.

                         From Professor M. M. Fallen, of St. Louis.
 1 consider it the best treatise on the Diseases of Children that we  possess, and as such have been in the
habit of recommending it to my classes.
 Dr. Condie's scholarship, acumen, industry, and practical sense are manifested in this, as in all his nu-
merous contributions to science.—Dr. Holmes's Report to the American Medical Association.
  Taken as a whole, in our judgment. Dr. Condie's Treatise is the one from the perusal of which the practi-
tioner in this country will rise with the greatest satisfaction— Western Journal of Medicine and Surgery.
 One ofthe best works upon the Diseases of Children in the English language— Western Lancet.



                       CHURCHILL.  OA" FEMALES.


              THE  DISEASE^  OF  FEMALES,

        INCLUDING  THOSE OF PREGNANCY AND  CHILDBED,

                   BY FLEETWOOD  CHURCHILL, M. D.,
                     Author of Theory and Practice of Midwifery, &c. &c.

  FOURTH AMERICAN, FROM THE SECOND LONDON EDITION, WITH ILLUSTRATIONS,
                                EDITED, WITH NOTES,

                      BY ROBERT M. HUSTON, M. D., &c. &c.

                          In one octavo volume of 604 pages.
  The rapid sale of three editions of this valuable work, stamp it so emphatically with the approbation of the
profession of this country, that Ihe publishers in presenting a fourth deem it merely necessary to observe,
that every care has been taken by the editor, to supply any deficiencies which may have existed in former
impressions, and to bring the work fully up to the date of publication.
  One great and distinguishing trait of the volume is, lhat it embraces all the diseases peculiar to women,
which can hardly be said of any other publication ; and it is this circumstance that especially recommends it
to practitioners who are without the opportunity of consulting numerous works.—Medical Examiner.


            A.TREATISE  ON  THE  DISEASES  OF  FEMALES.
                             BY W. P. DEWEES,  M. D.
                                  NINTH EDITION.
                         In one volume, 8vo.  532 pages, with plates.


                                    A TREATISE

ON  THE  PHYSICAL AND MEDICAL TREATMENT OF  CHILDREN.
                             BY W. P. DEWEES,  M. D.
                                   NINTH EDITION.

                             In one volume, 8vo. 548 pages.


                         MEIGS'  TRANSLATION OF

      A Treatise on the Diseases of Females, and on the  Special  Hygiene of  their Sex,

                     BY COLOMBAT DE L'ISERE, M. D., &c.

                  In one large octavo volume, of 720 pages.  Many wood-cuts.


             MEIGS ON  CERTAIN  DISEASES  OF  INFANTS.
                          In one octavo volume.  Nearly ready.


                                  CHURCHILL

        On the Management and more Important Diseases of Infancy and Childhood.
                           In one octavo volume. (Preparing.)


                                WEST'S LECTURES

                     ON  THE DISEASES OF INFANTS.
                       (Publishing in the Medical News and Library.) 
22               LEA & BLANCHARD'S PUBLICATIONS— (Surgery.)
           THE  GREAT   SURGICAL  LIBRARY.



   A     SYSTEM     OF     SURGERY.

                            BY  J.  M.   CHELIUS,
   Doctor of Medicine and Surgery, Public Professor of General and Ophthalmic Surgery, &c. &c, in the
                                    University of Heidelberg.
                           TRANSLATED  FROM  THE GERMAN,

          AND ACCOMPANIED WITH ADDITIONAL NOTES AND OBSERVATIONS,
                                    BY JOHN F. SOUTH,
                                 Surgeon to St. Thomas' Hospital.

Now complete in three large 8vo. vols, of nearly 2200 pages, or in seventeen numbers, at 50 cents.
  This great work is within itself a library of reference for the surgical practitioner. Every detail of import-
ance in Minor Surgery, Operative Surgery, and the  Principles of Surgery will be found embodied  in it, sys-
tematically arranged and clearly expressed, together with a copious Surgical Bibliography.  This vast mass
of information is elucidated and rendered easy of reference by an index occupying one hundred and seventy
double columned pages, enabling the surgeon 10 refer at once to the opinions of the best authorities on any
disputed point.   The reputation ofthe original work is sufficiently exemplified by its having passed through
six editions in Germany, and having been translated into eight languages.  The translation of Mr. South was
undertaken with the concurrence and assistance ofthe author, and the translator has made numerous and im-
portant additions to the work, embodying the facts and opinions set forth by all the principal surgeons of Con-
tinental Europe, Great Britain and the United States.  With all these advantages it is confidently presented lo
the profession as the most complete system of Surgical Science in the English language.
  In this work the practitioner wiH find the fullest and ajilest digest extant of all that relates to the present ad-
vanced state of Surgical Pathology.—American Medical Journal.
  If we were confined to a single work on Surgery,  that work should  be Chelius's.— St. Louis Med. Journal.
  As complete as any system of Surgery can well be.—Southern Medical and Surgical Journal.
  The most extensive and complete system of Surgical practice in the  English language.—HI. and Ind. Med-
ical and Surgical Journal.
  The most finished system of Surgery in the English language.— Western Lancet.
  The most learned and complete systematic treatise now extant.—Edinburgh Medical Journal.
  No work in the English language comprises so large an amount of information relative to operative medi-
cine and surgical pathology.—Medical Gazette.
  We have, indeed, seen no work which so nearly comes up to our idea of what such a production should he,
both as a practical guide and as a work of reference, as this ; and the fact that it has  passed through six edi-
tions in Germany, and been translated into seven languages, is sufficiently convincing proof of its value.  It
is methodical and concise, clear and accurate ; omitting all minor details and fruitless speculations, it gives
us all the information we want in the shortest and simplest form.— The New York Journal of Medicine.
  No work on Surgery in our language is so complete both as regards  the general plan and the minutest de-
tails.— Southern Journal of Medicine and Surgery.
  A complete encyclopedia of surgical science—a very complete surgical library—by far the most complete
and scientific system of surgery in the English language.— N.  Y. Journal of Medicine.
  The original text book of Chelius is well known to be one ofthe best of its class ; and the valuable and ex-
tensive notes of Mr. South, in which he  has largely embodied the  results of his own experience, have un-
doubtedly rendered his translation of it one ofthe most complete treatises on Surgery in the English language.
It seems to us to be alike essential to the student and practitioner.—Monthly Journal of Medical Science.
  We feel gratified and proud ofthe work in its English garb, and we do not hesitate to pronounce  it the best
and most comprehensive system of modern Surgery with which we are acquainted, and as such we earnestly
recommend it to the student and practitioner.—Medico-Chirurgical Review.
  It is one of the most learned and practicalwritings extant.  It must at once take a place, wherever it is
known, among the standard surgical authorities —Buffalo Medical Journal.
  The most extensive and comprehensive account of the art and science of Surgery in our language.—Lancet.
  This index adds greatly, in our  opinion, to the value ofthe work, as it enables those with whom time is an
object, at once to obtain an epitome of what is to be found in ihe body ofthe work, or any subject on which
information may be looked for.— Provincial Medical and Surgical Journal.
  The work is closed with a most elaborate and analytical index, which occupies no less than one hundred and
seventy-seven closely printed pages; this forms in itself a most valuable work of reference; and deserves to be
very highly appreciated by every surgeon.  We  consider that this product of the combined experience and
researches of Professors Chelius and South is by far the most important addition that has been made to sur-
gical literature since the publication of Cooper's Surgical Dictionary.—London Medical Gazette.
  May be regarded as the most comprehensive work on  Surgery extant— Medical Examiner.
  The most complete and ample work on Surgery extant.—New Jersey Medical Reporter.
  The work may now be regarded as the most complete which exists in our language on Surgery.  No work
in our language is so complete, both as regards the general plan and the minutest details; and it will be an
imperishable monument to Mr. South's industry, talents, and  attainments.  An  extensive analytical  index
adds much to its value.— Southern Journal of Medicine and Surgery.
  Appended to Chelius is an analytical index of unusual length ; this was essential,  and will be found most
useful in enabling the inquirer to consult any part ofthe work without trouble or loss of time.—Medical Times.
  One ofthe most complete works in surgical literature.— Western Journal of Medicine and Surgery.
  Members ofthe profession who reside  at a distance from the metropolitan centres, or in the colonies, those
who are or purpose to be, connected with our military or naval departments; indeed, all who may desire, or
who, from their position may find it necessary to have a book of reference  at hand, which they  may regard
as an authority, will derive much assistance from this work, as supplying a desideratum long wanted in tha
profession.—Medical Times.             ^__

COOPER (SIR ASTLEY) ON THE ANATOMY AND  TREATMENT OF  ABDOMINAL HERNIA.
  1 large vol., imp. 8vo., with over 130 lithographic figures.
COOPER ON  THE  STRUCTURE  AND DISEASES OF THE TESTIS, AND ON THE THYMUS
  GLAND.  1 vol., imp. 8vo., with 177 figures on 29 plates.
COOPER ON  THE ANATOMY  AND DISEASES OF THE BREAST,  WITH TWENTY-FIVE
  MISCELLANEOUS AND SURGICAL PAPERS.  1 large vol., imp. 8vo., with 252 figures on  36 plates.
COOPER ON DISLOCATIONS AND FRACTURES OF THE JOINTS.—Edited by Bransby Cooper and
  J.C.Warren. 1 vol. 8vo., with 133 cuts.  500 pp.
DURLACHER ON CORNS, BUNIONS, &c.-rA  Treatise on Corns, Bunions, the  Diseases of Nails, and
  the General Management of the Feet.  In one 12mo. volume, cloth.  134 pp.
GUTHRIE ON THE BLADDER, &c—The Anatomy of the Bladder and Urethra, and the Treatment of the
  Obstructions to which those Passages  are liable.  In one vol. 8vo.  150 pp. 
LEA &  BLANCHARD'S PUBLICATIONS.—(Surgery.)            23
              THE  STUDENT'S  TEXT-BOOK  OF SURGERY.
                     JYew and Improved Edition.  Just Issued.


THE  PRINCIPLES AND PRACTICE OF MODERN SURGERY,

                         BY  ROBERT  DRUITT,
                          Fellow ofthe Royal College of Surgeons.

     A New American from the last and  improved London Edition.

                       EDITED  BY F. W. SARGENT, M. D.;
                             Author of "Minor Surgery," &c.
     Illustrated with  One  Hundred and Ninety-three Wood Engravings.

           In one very handsomely printed octavo volume of 576 large pages.

  In preparing the new edition of this popular text-book, every care has been taken so to improve
it in every respect as to raise it still higher in the estimation of the profession.  The edition from
which  this is printed  has  large and important additions by the author; while the present editor,
Dr. Sargent, has added whatever appeared necessary to render the book a correct exponent ofthe
present state of surgical science in this country. The illustrations have been entirely remodelled;
numerous new ones added by both author and editor ; and many superior ones substituted for those
rejected.  The amount of these changes  may be estimated from the fact, that ofthe 193 wood-cuts
at present in this volume, more than one-half have appeared  in  no former American edition.  In
mechanical execution, also, the work will be found much improved; in clear type, white paper, and
handsome printing, it will compare favorably with the best executed works published in the country,
while the price is  still  kept so low as to place it within the reach of all.
  An unsurpassable compendium, not only of Surgical, but of Medical Practice.—London Medical Gazette.
  No work, in our opinion, equals it in presenting so much valuable surgical matter in so small a compass.—
St. Louis Medical and Surgical Journal.
  The author has fully succeeded in producing a complete system of surgical science and practice in the
smallest practicable compass, and at the cheapest possible price.—Edinburgh Monthly Medical Journal.
  It is the most accurate and ample resume' ofthe present state of surgery that we are acquainted with.—
Dublin Medical Journal.
  This is the best work of its size, on the subject of surgery, that has made its appearance on our desk.  For
the use of the general practitioner, it may be preferable to many ofthe larger works, as it has the important
facts he wants, in a more condensed form, from which he can  get his information with less labor and time, if
not -with clearer views ofthe subject.— The Northwestern Medical and Surgical Journal.
  Admirably adapted to the wants ofthe student.—Provincial Medical and Surgical Journal.
  A better book on the principles and practice of surgery has not been given to the profession.—Boston Medi-
cal and Surgical Journal.


            SARGENT'S  MINOR  SURGERY.   A NEW  WORK.


ON  BANDAGING,  AND OTHER  POINTS OF  MINOR  SURGERY.

                           BY F. W. SAKGENT, M. D.

       In one handsome volume, royal 12mo., with nearly 400 Pages, and 128 Wood-cuts.
  The very best manual of Minor Surgery we have seen.—Buffalo Medical and Surgical Journal.
  Admirably adapted to the use ofthe student.— Charleston Medical Journal.
  We can unhesitatingly recommend this volume as one of the very best of its kind.—American Med. Journal.
  We will adopt it as a text-book for the use of our own pupils, and we must recommend our fellow practi-
tioners in all partsof the country to do likewise.—iV. Y. Journal of Medicine.
  Nothing perhaps in the whole routine of practice redounds more decidedly to the upbuilding of a young sur-
geon's reputation, and certainly none contributes more to the comfort ofthe suffering patient, than dexterity
in the performance ofthe minor surgical operations, and the neat and skilful arrangement of dressings.  In
view of these facts,  it is a matter of some degree of astonishment that a due consideration of this subject should
have been deferred  so long.  We strongly recommend Dr. Sargent's treatise to all our readers, believing that
it will prove abundantly  useful to those who  consult its pages  for information upon the important  subjects
therein discussed.—The Ohio Medical and Surgical Journal.


                    LISTON AND  MUTTER'S SURGERY.


      LECTURES  ON   THE  OPERATIONS  OP  SURGERY,
              And on Diseases and Accidents requiring  Operations.
                    DELIVERED AT UNIVERSITY COLLEGE, LONDON.

               BY  KOBERT  LISTON,   Esq., F.  K.  S.,  &c.
  EDITED, WITH NUMEROUS ALTERATIONS AND ADDITIONS, BY T. D. MUTTER, M. D.,  &C. &C.

          In one  large and handsome octavo volume of 566 pages, with 216 Wood-cuts.

  It is a compendium ofthe modern practice of Surgery as complete and accurate as any treatise of similar
dimensions in the English language.— Western Lancet.


LAWRENCE ON  RUPTURES.—A Treatise on Ruptures, from the fifth London Edition.  In one 8vo. vol.
  sheep.  480 pp.
MAURY'S  DENTAL SURGERY.—A Treatise on the Dental Art, founded on  Actual Experience.  Illus-
  trated by 241 lithographic figures and 54 wood-cuts. Translated by J. B. Savier. In 18vo. vol., sheep. 286 pp.
ROBERTSON ON THE TEETH.—A Practical Treatise on the Human  Teeth, with Plates.  One small
  volume, 8vo. 230 pp.
DUFTON ON THE EAR.—The Nature and Treatmentof Deafness and Diseasesof the Ear; and the Treat-
  ment of the Deaf and Dumb.   One small 12mo. volume. 120 pp. 
24            LEA & BLANCHARD'S PUBLICATIONS.—(Surgery.)


       FERGUSSON'S  OPERATIVE_SURGERY.   NEW  EDITION.


  A  SYSTEM   OF   PRACTICAL   SURGERY.

                  BY WILLIAM FERGUSSON, F. R. S. E.,
                    Professor of Surgery in King's College, London, &c. &c.
               THIRD AMERICAN, FROM THE LAST ENGLISH EDITION.
  With Two Hundred and Seventy-four Illustrations, from Drawings by Bagg,
                          Engraved by Gilbert A' Gihon.

      In one large and beautifully printed octavo volume, of six hundred and thirty pages.
  It is with unfeigned satisfaction that we call the attention ofthe profession in this country to this excellent
work.  It richly deserves the reputation conceded to it, of being the best practical Surgery extant, at least in
the English language.—Medical Examiner.
  Professor Fergusson's work, we feel persuaded, will be as great a favorite as it deserves, for it combine*
the powerful recommendations of cheapness and elegance, with a clear, sound, and practical treatment of every
subject in surgical science. The illustrations, by Bagg, are admirable—in his very best style.—Edinburgh
Journal of Medical Science.


                 MILLER'S  PRINCIPLES OF SURGERY.


  THE   PRINCIPLES   OF   SURGERY.

                      BY JAMES MILLER, F. R. S. E.,
                    Professor of Surgery in the University of Edinburgh, &c.
                           SECOND AMERICAN EDITION,
                In one octavo volume of five hundred and thirty-eight pages.
                          BY THB SAME AUTHOR


        THE   PRACTICE   OF   SURGERY.
                           SECOND AMERICAN EDITION.

                      In one octavo volume, of five hundred pages.

These two works are printed and bound to match, forming  together a complete
                               System of Surgery.

 Taken together they form a very condensed and complete system of SuTgery, not surpassed, as a text-book,
by any work with which we are acquainted.—III. and Ind. Medical and Surgical Journal.
 Mr. Miller has said more in a few words than any writer since the days of Celsus.—N. O. Med. and Surg.
Journal.


       LIBRARY OF OPHTH ALM IC_M EDICI N E AND  SURGERY.


  A  TREATISE   ON  THE  DISEASES   OF THE  EYE.

                    BY  W.  LAWRENCE,  E. E. S.,
       Surgeon Extraordinary to the Queen, Surgeon to St. Bartholomew's Hospital, &c. &c.
                                 A NEW EDITION.
    With many Modifications and Additions, and the introduction of nearly two hundred Illustrations.

                          BY ISAAC  HAYS, M.  D.,
In one very large 8vo. vol. of 860 pages, with twelve plates and many wood-cuts through the text.
 This book contains all that is necessary for the student or practitioner to  know.—Dublin Medical Press.
 The work of Mr. Lawrence, with the numerous additions of the American  Editor, is allowedly one of, if
not the best. The library of no medical man can be complete without it.—N. Y. Journal of Medicine.


                            JONES  ON  THE  EYE.


                    THE PRINCIPLES AND PRACTICE


    OF  OPHTHALMIC  MEDICINE  AND  SURGERY.

                BY T.  WHARTON  JONES,  F. R. S., &c. &c.

                        EDITED BY  ISAAC HAYS, M. D., &c.

In one very neat volume, large royal 12mo. of 529 pages, with four plates, plain or colored, and
                          ninety-eight well executed wood-cuts.

                            From Professor Mott, of New York.
 The work on Ophthalmic Surgery, by Jones, is undoubtedly the best on that subject in the English language.
It will give me pleasure to aid in its circulation in every way in my power.
  Mr. Jones'Manual is a very elaborate compilation, and will, in this age of condensing, epitomizing, and
manualizing, doubtless occupy the foremost place.—Medico-Chirurgical Review.

BRODIE'S  SURGICAL LECTURES.—Clinical Lectures on Surgery.  1 vol. 8vo., cloth. 350 pp.
BRODIE ON THE JOINTS—Pathological and Surgical Observations on the Diseases ofthe Joints. 1 vol.
  8vo., cloth. 216 pp.
BRODIE ON URINARY ORGANS.—Lectures on the Diseases of the Urinary Organs. 1 vol. 8vo., cloth.
  214 pp.
          %* These three works  may be had neatly bound together, forming a large volume of" Brodie's
              Surgical Works." 730 pp. 
            L.EA & BLANCHARD'S  PUBLICATIONS.— (Chemistry.)          25


 POWNES' CHEMISTRY  FOR  STUDENTS.  New and Improved Edition..



      ELEMENTARY  CHEMISTRY,

                THEORETICAL  AND  PRACTICAL.

                       BY  GEORGE  FOWNES, Ph. D.,
              Chemical Lecturer in the Middlesex Hospital Medical School, &c. &c.

With Numerous Illustrations.  Second  American Edition.  Edited, with Additions,

                       BY ROBERT BRIDGES,  M.  D.,
  Professor of General and. Pharmaceutical Chemistry in the Philadelphia College of Pharmacy, &c. &c.
            In one large royal 12mo. volume, of 460 pages, sheep or extra cloth.
  We know of no treatise in the language so well calculated to aid the student in becoming familiar with the
numerous facts in the intrinsic science on which it treats, or one better calculated as a text-book for those at-
tending Chemical lectures. * * * * The best text-book on Chemistry that has issued from our press.—Ameri-
can Medical Journal
  We again most cheerfully recommend it as the best text-book for  students in attendance upon Chemical
lectures that we have yet examined.—III. and Ind. Medical and Surgical Journal.
  A first rate work upon a first rate subject.— St. Louis Medical and Surgical Journal.
  No manual of Chemistry which we have met, comes so near meeting the wants ofthe beginner.— Western
Journal of Medicine and Surgery.
  We know of none within the same limits, which has higher claims to  our confidence  as a college  class
book, both for accuracy of detail and scientific arrangement.—'Augusta Medical Journal.


            GARDNER'S MEDICAL CHEMISTRY—Now Ready.


                     MEDICAL  CHEMISTRY,

         FOR   THE  USE  OF STUDENTS  AND  THE PROFESSION;
  BEING A MANUAL  OP TflE SCIENCE,  WITH ITS APPLICATIONS  TO  TOXICOLOGY,
                  PHYSIOLOGY, THERAPEUTICS,  HYGIENE,  &c. &c.

                    BY D. PEREIRA GARDNER,  M. D.,
             Late Professor of Chemistry in the Philadelphia College of Medicine, &c.
                In one handsome royal 12mo. volume of 400 pages, with illustrations.
  By far the greater number of medical students will find  this work of Dr. Gardner belter adapted to their
wants than any other with which we are acquainted.— Ohio Medical and Surgical Journal.
  Admirably adapted to the end and design.   We shall be much disappointed if it is not adopted as a text-
book in all our American Colleges.—N. Y. Journ. of Medicine.
  An excellent work—one likely to be of great use to the student, and of no small value to the practitioner.
— Charleston  Medical Journal.
  It is an admirable exposition ofthe facts of Chemical science in their application to practical medicine in
its various branches.  The work is sufficiently extended, and very accurate in its details, and cannot fail to
prove most useful as a book of study or of reference.— The Lancet, March 10,1849.
  We know of no work exactly like it by any English author.  The reader will find here, in a concise form,
information for which he would otherwise have to seek in many elaborate and expensive treatises.—London
Medical Gazette, March, 1849.


       BOWMM'S  PRACTICAL CHEMISTRY.   Now Ready.


   INTRODUCTION   TO  PRACTICAL  CHEMISTRY,

                    INCLUDING   ANALYSIS.

                           By JOHN  E. BOWMAN,
                         Demonstrator of Chemistry, King's College.

            In one handsome volume, royal 12mo., of over 300 pages.
                    WITH NEARLY ONE HUNDRED ENGRAVINGS ON WOOD.

  One ofthe most complete manuals that has for a long time been given to the medical student.—Athe.nceu/m.
  We regard it as realizing almost everything lo be desired in an introduction lo Practical Chemistry.  It is
by far the best adapted for the Chemical student of any that has yet fallen in our way.—British and Foreign
Medico-Chirurgical Review.
  The best introductory work on the subject with which we are acquainted.—Edinburgh Monthly Journal,
February, 1849.


                  ANIMAL   CH EM I STRY,
       WITH REFERENCE TO THE  PHYSIOLOGY AND PATHOLOGY OF MAN.

                         BY DR.  J.  FRANZ SIMON.
        TRANSLATED AND EDITED BY  GEORGE  E. DAY, M. A. & L. M. CANTAB., &C.

           With plates.  In one octavo volume of over seven hundred  pages, sheep.

  No treatise on physiological Chemistry approaches this in fulness and accuracy of detail.— Western Journal
of Medicine and Surgery.


      New Edition, Preparing.—THE ELEMENTS OF CHEMISTRY,
  INCLUDING THE APPLICATION OF THE SCIENCE TO THE ARTS.   WITH NUMEROUS ILLUSTRATIONS.
               BY THOMAS GRAHAM, F.  Ft. S.,  L. & E. D.
With Notes and Additions, by ROBERT BRIDGES, M. D., &c. &c.   In one very large 8vo. vol. 
26                LEA & BLANCHARD'S PUBLICATIONS.
                         TAYLOR  0.V FOISOJ\'S.



                     ON   KOISONS,

 IN  RELATION TO  MEDICAL  JURISPRUDENCE  AND MEDICINE

                  BY ALFRED  S.  TAYLOR,  F. R.  S., &c.

          Edited, with Notes and  Additions, BY R. E. GRIFFITH, M. D.

                      In one large octavo volume, of 688 pages.
 The most elaborate work on the subject that our literature possesses.—Brit, and For. Medico- Chirur. Review.
 One ofthe most practical and trustworthy works on Poisons in our language.— Western Journal of Med.
 It contains a vast body of facts, which embrace ail that is important in toxicology, all that is necessary to
the guidance ofthe medical jurist, and all that can be desired by the lawyer.—Medico-Chirurgical Review.
 It is, so far as our knowledge extends, incomparably the best upon the subject; in the highest degree credit-
able to the author, entirely trustworthy, and indispensable to the student and practitioner.—N.  Y. Annalist.


               TAYLOR'S MEDICAL JTURISFRUDEJYCE.


        MEDICAL  JURISPRUDENCE.

                        BY ALFRED S. TAYLOR,
            Lecturer on Medical Jurisprudence and Chemistry at Guy's Hospital, &c.
      With numerous Notes and Additions, and references to American Practice and Law.

                          BY R.  E. GRIFFITH, M.  D.

                 In one octavo volume of five hundred and forty pages.
 We recommend Mr. Taylor's work as the ablest, most comprehensive, arid, above all, the most practically
useful book which exists on Ihe subject of legal medicine. Any man of sound judgment, who has mastered
the contents of Taylor's "Medical Jurisprudence," may go into a court of law with the most perfect confi-
dence of being able to acquit himself creditably.—Medico-Chirurgical Review,
 The most elaborate and complete work that has yet appeared.  It contains an immense quantity of cases
lately tried, which entitle it to be considered what Beck was in its day.—Dublin Medical Journal.

TRAILL'S MEDICAL JURISPRUDENCE.—Outlines of a Course of Lectures on Medical Jurisprudence,
 Revised, with numerous Notes. In one small octavo volume of 234 pages.


                  DUJVGLISOjyr OJY  hvmajy  health.


                        HUMAN'HEALTH,
OR THE INFLUENCE OF ATMOSPHERE AND  LOCALITY, CHANGE OF AIR AND CLIMATE, SEASONS, FOOD,
           CLOTHING, BATHING, EXERCISE, SLEEP, &C. &C. &C, ON HEALTHY MAN,

                   CONSTITUTING ELEMENTS OF  HYGIENE.

             Second Edition, with many Modifications and Additions.

                BY  ROBLEY DUNGLISON,  M. D., &c. &c.
                         In one octavo volume of 464 pages.


  MITCHELL ON THE ORIGIN OP FEVERS—A New Work-Just Ready.


                                  ON  THE

  CRYPTOGAMQUS ORIGIN OF MALARIOUS  AND  EPIDEMIC  FEVERS.

                       BY  J.  K. MITCHELL,  M. D.,
        Professor of Practical Medicine in the Jefferson Medical College of Philadelphia, &c.
                     In one small volume of 138 pages, extra cloth.


      BARTLETT  OJY CERTAIJYTY IJY MEDICIJYE—JYbw Ready.


AN  INQUIRY  INTO THE DEGREE OF CERTAINTY  IN MEDICINE,

 AND INTO THE NATURE AND EXTENT OF ITS POWER OVER DISEASE.

                      BY  EtlSHA BARTIETT, M. D.,
         Author of " Fevers of the United States," "Philosophy of Medical Science."
                 In- One small Volume of 84 pages, crown Svo., extra cloth.



      AN  ESSAY  ON THE  PHILOSOPHY OF  MEDICAL  SCIENCE.

 BY  ELISHA BARTLETT,  M. D., Author of " Fevers of the United States."
            In one handsome octavo volume of three hundred and twelve pages.


                             A NEW EDITION OF

      THE MEDICAL STUDENT; Or, Aids to the Study of Medicine.
          A REVISED AND MODIFIED EDITION.  BY ROBLEY DUNGLISON, M. D.
                            In one neat 12mo. volume. 
LEA AND BLANCHARD'S PUBLICATIONS.
27
               MANUALS FOR EXAMINATION.   Now Ready.


                AN  ANALYTICAL  COMPENDIUM

    OF THE VARIOUS  BRANCHES  OF  MEDICAL  SCIENCE,

              FOR THE  USE AND  EXAMINATION OF STUDENTS.

                            BY JOHN  NEILL,  M. D.,
 DEMONSTRATOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, LECTURER ON ANATOMY IN THE MEDICAL
                               INSTITUTE OF PHILADELPHIA, ETC.,

                      FRANCIS GURNEY SMITH,  M.D.,
     LECTURER ON PHYSIOLOGY IN THE PHILADELPHIA ASSOCIATION FOR MEDICAL INSTRUCTION, ETC. ETC.
Forming One very large and handsomely printed Volume in royal duodecimo, of over Nine Hundred
  large Pages, with about Three Hundred and Fifty Wood Engravings, strongly bound in leather,
                                     with raised bands.
  While this work is not offered as a substitute for the regular text-books, for the purpose of study,
its convenient form, and the amount of information condensed in its pages, together with  the ful-
ness' of its illustrations, render  it eminently suited as a work  of reference for the  office  table
of the practitioner.   To render it more  convenient for  the student, it is divided into seven por-
tions, corresponding to the leading divisions of medical and surgical science.  These are paged
separately, and may be had done up in stout covers, each being perfect in itself, and forming con-
venient volumes to carry in the pocket to  the lecture room, or fitting them to  be sent by mail.  It
will thus be seen that this work affords, at a price unprecedentedly low, a series of digests ofthe
medical and surgical sciences, clearly and conveniently arranged, and forming a complete set of

              HANDBOOKS   FOR   STUDENTS,
                                       as  follows:—

ANATOMY:  I80 large pages, with  157 Illustrations.  Price 75 Cents.

PHYSIOLOGY" 134  pages,  with 40 Illustrations.   Price 60 Cents.
SURGERY;  122 pages, with 51  Illustrations.   Price 60 Cents.

OBSTETRICS-  ll* pages, with 37 Illustrations.  Price 50 Cents.

MATERIA MEDICA  AND  THERAPEUTICS;  116 pages, with 29
  Illustrations.   Price 50 Cents.
CH EM  ISTRY"  94  pages, with  19  Illustrations.   Price 40 Cents.
THE PRACTICE  OF  MEDICINE: I52 pages, with 3 Illustrations. 50 Cents.
Any one of which may be had separate; or, the whole will be done up and mailed,  with the postage
prepaid, on the remittance of $4;  or, if $5 is remitted, The Medical News will be  sent in addition.
  It should be noticed that the amount of matter on a page  is unusually large, thus making these
Handbooks not only low priced, but extraordinarily cheap.
  We do not share in the opinion entertained by some, that compendiums of science are not  desirable, or
with the still smaller number, who esteem them useless. On the contrary, when well executed, they are of
essential service to the student; and so far as we have seen, most of them have contained an amount of in-
formation which older individuals—even ihey who disparage them—may be presumed to be far from pos-
sessing.  Taking the work before us, we can  certainly say that no one who lias not occupied  himself with
the different scientific treatises and essays that have appeared recently, and has withal a rare memory, could
pretend to possess the knowledge contained in it;  and  hence we can recommend it to such—as well as to
students especially—for its general accuracy and adequacy for their purposes; and to  the well  informed
practitioner to aid him in recalling what may easily have passed  from his remembrance.  We repeat our
favorable impression as to the value of this book, or series of books; and recommend  it as decidedly useful
to those especially who are commencing the study of their profession.—The Medical Examiner.
  We have  no hesitation in recommending it to students.— Southern Medical and Surgical Journal, Dec. 1P4S.
  Books of this description are most erroneously denounced, from the supposition that they are intended to
the astronomer.  It <nves to the inquirer a key to the object of his pursuit, and enables him to trace out those
 >arts which require°to be especially studied.  We have looked through this compendium, and we find that the
authors have really succeeded in compressing a large amount of valuable information into a very small com-
pass   We recommend this work especially to the notice of our junior readers. To those who are about to
commence their studies in a medical school it will be found a serviceable guide.—London Medical Gazette.
  It aims to <nve a condensed account of every question touching the several branches of medicine, and on
this account°will arrest the attention of every candidate for his doctorate.  It is not simply a work for the in-
struction of the novices, it may be consulted by the general practitioner with infinite advantage.  The different
departments of which it treats are illustrated by handsome plates, and will serve to impress the mind of the
student with clear and definite ideas on the various subjects comprehended in the work.  It is, we think,
an excellent book of the kind, and will no doubt become highly popular with the students throughout the
United Stales  To the medical student it may be confidently recommended as well as to the general prac-
titioner whose constant occupation will not allow him the necessary leisure to read more elaborate  and
comprehensive works.— The New Orleans Medical and Surgical Journal.
  h will matrrially ns*i«t the student and practitioner in refreshing his knowledge  on points previously ac-
quired  but upon which he may have become in a measure, rusty—for this purpose it is admirably adapted,
and we believe will not only prove acceptable to the student of medicine, but also to the  profession at large.
— (V.  Y. Journal of Medicine.

Pi
chemist

a'convenhsnt and use'fuireinembrancer.—American Journal ofthe Medical Sciences. 
28                  LEA  & BLANCHARD'S PUBLICATIONS.



   LIBRARY  OF ILLUSTRATED  SCIENTIFIC  WORKS,

              UNDER THIS TITLE LEA & BLANCHARD ARE PUBLISHING

     A SERIES OF  BEAUTIFULLY ILLUSTRATED  WORKS,
                        ON VARIOUS BRANCHES OF SCIENCE,

BY  THE  MOST  DISTINGUISHED  MEN  IN  THEIR  RESPECTIVE  DEPARTMENTS.

        Printed in the handsomest style, and embellished in the most efficient manner.
  HIT" No expense has been or will be spared to render this series worthy ofthe support of the scientific pub-
lic, while at the same time it is one of the handsomest specimens of typographical and artistic execution
which have appeared in this country.
  Specimens ofthe Engravings and style ofthe volumes may be had on application to the publishers.

                        MULLER'S  PHYSICS—LATELY ISSUED.


                            P KIN  CI P  L E S
                                          OF


    PHYSICS     AND     METEOROLOGY.

                    BY  PROFESSOR J.  MULLER,  M. D.

          EDITED, WITH  ADDITIONS, BY R. EGLESFELD GRIFFITH, M. D.

     In one large and handsome octavo  volume, with 550 wood-cuts, and two colored plates.

  This is a book of no ordinary or ephemeral value.  It is one of a series, now republishing in London, on the
different branches of science, which from its thorough character and extended range, is much needed in
this country.  Its design is to render  more easily accessible an extensive knowledge of the general principles
of physics and meteorology; and the distinguished  author has certainly realized the design to a wonderful
extent.   The subjects treated upon are very numerous—statics,hydrostatics, dynamics, hydrodynamics,pneu-
matics, the laws ofthe motions of waves in general,  sound, the theory of musical notes, the voice and hearing,
geometrical and  physical optics, magnetism, electricity and galvanism, in all their subdivisions, heat and
meteorology.  The size is nevertheless convenient—one handsome octavo volume, of six hundred pages—
in clear, bold type, and profusely illustrated.  In the execution of the illustrations we have rarely seen any
thing equal to this American edition.— N. Y. Commercial.
  This is a large, elegant and most admirable volume—the first of a series of scientific books now passing
through the press in London, and which cannot fail to commend themselves to the favor of all who lake any
interest in the progress of science among the great mass of the people. The author is one of the most distin-
guished scientific men in Germany, and these works have been prepared with the utmost care, and  are put
forth in a form admirably adapted to  secure that wide circulation and universal favor which they deserve.—
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could not have been better supplied.  The work is of surpassing interest. The value of this contribution to
the scientific records of this country may be duly estimated by the fact that the cost ofthe original drawings
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tice successfully and with advantage to himself. No surgeon, thoroughly imbued with the  laws of Physics,
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the publishers, in comparison with other American books of a  similar character, but will stand on equality
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information to the general reader, as it is truly an elegant specimen of typography.

                                    NOW READY.


             PRACTICAL     PHARMACY.

COMPRISING  THE  ARRANGEMENTS, APPARATUS, AND MANIPULATIONS OF  THE
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CONTENTS OF THE
 AMERICAN JOURNAL OF THE  MEDICAL SCIENCES.   April, 1849.

                    ORIGINAL  COMMUNICATIONS.
                                Memoirs and Cases,  pp. 277-410.
  Art. I. Leidy  on the  Intimate Structure and History of the Articular Cartilages.  (With two plates.)
II. Jackson's Observations on Hydrophobia, with cases, in one of which chloroform was administered with a
favorable result.  III. Meigs'History of Five Cases of Pseudo-membranous Laryngitis or true Croup; in
three of which the Operation of Tracheotomy was performed, and in  two successfully.  IV. Parkman's Ex-
tracts from the Records ofthe Boston Society for Medical Improvement.  V. Sargent's Report of the Cases or
Small-Pox received into the Philadelphia City Hospiial in lf-45-6.  VI. Peaslee's Case of Ovarian  Dropsy.
VII. Warren on the Effecis of Chloroform as a Narcotic Agent.  VIII. Bond's Cases of Retroversion ofthe
Uterus, with a description of a New Instrument for its Restoraiion.  (With two wood-cuts.) IX. Ruschenber-
ger's Cases of Extraction of a glass goblet from the Rectum—Fracture of the Penis.  (With a wood-cut.)
                                     Reviews,  pp. 411-441.
  X. Obstetrics, the Science and the Art.  By C D. Meigs, M. D.  With 121 cuts, Svo. pp. 685.  XI. Reports on
Lunacy.
                               Bibliographical Notices,  pp. 442-464.
  XII.  Ames on Epidemic Meningitis   XIII. Mauley's Anniversury Discourse.   XIV. Stevens's Plea of
Humanity in Behalf of Medical Education. XV. Kirkesand Haget's Manual of Physiology. XVI. Bowman's
Introduction to Practical Chemistry, including Analysis  XVII. Morfit and  Muckle's Chemical and Phar-
maceutical Manipulations   XVIII. New York Report on the  subject of Asiatic Cholera.   XIX.  Philadel-
phia Report on Public Hygiene.  XX. Summary of the Transactions of the College ot Physiciansof Philadel-
phia, from September 16, lS48,to January 2,1849, inclusive.

                                  QUARTERLY SUMMARY

        OF THE IMPROVEMENTS  AND DISCOVERIES IN  THE MEDICAL SCIENCES.

                         FOREIGN  INTELLIGENCE.
                              Anatomy and Physiology,  pp. 465-467.
  1. Paget on the Blood Corpuscles of the Human Embryo.  2. Schiffon the Changes in  the  Lungs after Di-
vision ofthe Pneumogastric Nerves.  3. Hamernik on the Mechanism ofthe  Heart.
                                 Organic Chemistry,  pp 467-470.
  4. Lehmann on the Nature of the Gastric Juice.   5. Wohler and Frerichs on the Changes of Organic Sub-
stances on their passage into the Urine.  6. Regnaull and Reiset on the Chemical  Changes of Respiration.
7. Dr.  Bernard on the Source of Sugar in the Animal Economy.
                           Materia Medica and Pharmacy,  pp. 470-476.
  8. Pereira on Cod-Liver Oil.  9. Bouchardat and Stuart-Cooper on the Physiological and Therapeutic Ac-
tion of Atropia.   10. Chavannes  on the advantages of Chloride 6>f Gold as a Caustic. 11. Millon on the
Nutritive Properties of Bran.  12. Donovan on Vegetable Infusions.
            Medical Pathology and Therapeutics and Practical Medicine  pp. 476 499.
   13. Dr. Momberfs Case of Hydrophobia Spontanea.  14. Valleix on Muscular Rheumatism. 15. Solon on
Bilious Pneumonia. 16. Rilliet on  Melaeua Neonatorum.  17  Elam on  Chorea.  18. Schneider on Sangui-
neus Perspiration. 19.  Dr. Pickford^s Case in which the Physical Signs of the position of the Heart were de-
ceptive.  20. Jaksch on the Signs  of Diseased Heart afforded to the hand  laid over the Pnecordium   21.
Bellingham on  Polyform Concretions in the Cavities of the Heart.  22. O'Ferrel  on  Pleuritis simulating
Pericarditis.  23.  Greene  on  Encysted Tubercles in the Lunj*s.  24.  Mayne on Phthisis in the Infant.
25. M. Levy on  Acute  Tubercular  Meningitis in  the  Adult.  26. Patterson's Case of Variola in which  the
Eruption  was  found in the Mucous Membrane  of the Colon.  27.  Watson on Intra-Utenne Small-Pox.
28. Gamberini on Nocturnal Neuralgia of the Forearm.  29. Bennel on Spontaneous cure of Ovarian Dropsy,
by meansof an  Ulcerative Openingof the Cyst into the Bladder.  30. Delasiauveon the Treatmentof Epilepsy.
31. Melsens on Iodide of Potassium  in Saturnine Affections.  32.  WUige on  ihe external use of  Iodine in
 Croup. 33. Koreffon Spigelia Marylandicain Pruritus Ani.  34 Owen Reese on Lemon Juice in Rheumatic
 Gout.  35.  Nevins on the employment of Nux Vomica in the Diarrhoea of Exhaustion.  36. Dr. Pickford on
 the Beneficial Effects of Coffee in Infantile Cholera.  37. Palsy of the Tongue cured by galvano-puncture.
38. Manzolini and Ouaglino on the Injection of various substances into the Veins.
            Surgical Pathology and Therapeutics and Operative Surgery,  pp. 499-503.
   39.  Guthrie on Hospital  Gangrene.  40.  Toynbe.e's Pathological Researches into the Diseases of the Ear.
 41. Till on Ovarian Dropsy. 42.  Hancock on Aneurism ofthe Axillary Artery.  43. Cooper on liigature of
 Subclavian followed by incessant Cough. 44. Willis on Inguinal Aneurism—Ligature ofthe  left external
 Iliac Artery. 45.  Tufnell on Femoral Aneurism—Compression tried without success—Amputation.  46.
 Blandin on Wound of the Right Kidney successfully  treated.  47. Sewell  on  Lateral Transfixture ofthe
 Chest by a Scythe Blade,  followed by complete recovery. 43. Neuhold and Hasserbronc on the Employment
 of Sugar of Lead in Strangulated Hernia. 49. VidaVs New Method of Treating Urethral  Pains following
 Gonorrhoea.  50. Thevenot and Boyer on Luxation ol the Astragalus inwards ; Reduction.  51. Mendoza on
 Vertical Dislocation ofthe Patella.  52  Greenhow on Excision of ihe Os Calcis. 53. Syme on Excision of
 the head of the Femur in Morbus Coxarius.  54. Christophers'1 new mode of removing Naevi.
                                   Ophthalmology, pp. 508-509.
   55. Mackenzie's Case of Cysticercus Cellulosa in the Human Eye 56. Dixon's Case of Foreign Body in the Eye.
                                     Midwifery,  pp. 509-517.
   57. Routh on the Causes of the  Endemic Puerperal Fever of Vienna.  58. Burdon on the Influence ofthe
 Mother's Imagination upon the Production of Monstrous Children.  59. Mitchell on Ulceration of the Os and
 Cervix Uteri treated with Solution of Gun-Cotton.  60. Webster on Ihe Statistics,  Pathology, and Treatment
 of Puerperal Insanity.  61. In what cases (other than of Contracted Pelvis) is it proper to induce abortion or
 Premature  Labor.  By Dubois.  62. Scanzoni on  the  Cause of Hemorrhage  in the latter months of Preg-
 nancy in Cases of Placenta Praevia.  63. Ducrest on Cerebral and Meningeal Phlebitis in Puerperal Women.
                                      Cholera,  pp. 517-W4.
   G4. Taylor on the Chemical Examination ofthe Liquid Vomited during Cholera.  65. Boehm on the Micro-
 scopic Examinations of the Mucous Membrane  of the Stomach and Bowels in Cholera.  66. Lamprey on
 Terchloride of Carbon as a Remedy for Cholera. 67.  Little on Quinine in Cholera.   68.  Robertson on Blood-
 Letting in Cholera  69. Robertson on the Injection of Saline Solution into the Veins in Cholera. 70. Fretlen-
 backer's Conclusion respecting the mode of Propagation of Cholera in Russia, in 1847-48.
                                 Anaesthetic Agents,  pp. 524-530.
   71. Malgaigneon the Action ofChloroform. 72. Deaths from Chloroform.  73. Nunneley on the Chloride of
 defiant Gas as an Anaesthetic.  74. Simpson on Naphtha as an Anaesthetic.  75. Higginson on Antesthesia
 from the local application ofChloroform.  76. Snow on Chloroform in Midwifery.
                        Medical Jurisprudence and Toxicology, pp. 530-532.
   77. Boucheton the Lunatic Asylum, Nantes.  78. Smith on Early Menstruation and Pregnancy.
                                      Miscellaneous, p. 532.
   79. Dr. Spengler on Influenza and Ozone.
                              (For remainder of Contents, see next page.) 
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                  Number for  Aprilj 1849, on the preceding page.


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CONTENTS OF JOURNAL.  (Continued from preceding Page.)

                  AMERICAN  INTELLIGENCE.
                      Original Communications, pp. 533-536.
 Clement's Case of Trismus Nascenlium, illustrative ofthe influence of position of the patient Houstoun's
Case of Ovarian Dropsy cured by the long Abdominal Incision in 1701.
                        Domestic Summary, pp. 536-552.
 Leidy on the Development ofthe Purkinjean Corpuscle in Bone.  Leidy on the Arrangement of the Areolar
Sheath of Muscular Fasciculi and its relation to the Tendon.  Leidy on the Intermaxillary Bone in the Em-
bryo of the Human  Subject.  (With two wood-cuts.) Eve on Lithotomy—117 Calculi weighing H ounces,
successfully rrmoved.  Van  Buren's Case of Inguinal Aneurism—Compression tried without success—
Ligature of the Artery. Holster on Trephining for Epilepsy.  Whitmire on Iodine in the Treatment of Snake-
bites.  Fenner on Cholera in New Orleans.  Iron Rod weighing 13i pounds driven through the Head—Re-
covery. By Dr. Harlow.  Hamilton on Death from pressure of an enlarged Thyroid Gland. Taylor on
Superfcetation and Mixed Births.  Jackson's Case in which a large quantity of Chloroform was used.  Hays
ou Local Anaesthesia in Neuralgia. Stille on Chloroform in Nephritic Cohc.  Army Surgeons.
 Table of Contents, Index, &c, 20 pages. 
 
-^yvvv
NLM023326360