mm m* m ^'i ■v.ffc **s v#J&; V^:V*si *■"/' •*~l/j. .0^(?aQ'3.CQX:-QgClcrj!.0-QQ'QGr.>(jQ^C^QQsa;g^ I iV Surgeon General's Office W? <¥i >%} ' ->",p. no /1^7 oo ^ PRESENTED BY W.M. IkQ^yOCt^CQOQO^'Qj^e^CODO'U-DDOetg s.vr< t } 1' L-* '^9~ I ON THE DISEASES OF CHILDREN. PRACTICAL TREATISE DISEASES OF CHILDREN, BY Ns D. FRANCIS QONDIE. M.D., SECEETART OF THE COLLEGE OF PHYSICIANS; MEMBER OF THE AMERICAN MEDICAL ASSOCIATION; MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY, ETC. FOURTH EDITION, REVISED AND AUGMENTED. PHILADELPHIA: BLANCHARD AND LEA. 1854. Ann % vvs \00 C745P 1253 c.2 Entered, according to act of Congress, in the year 1853, BY BLANCHARD & LEA, In the Office of the clerk of the District Court, for the Eastern District of Pennsylvania. WM. 8. TOCNO, PRINTER, REAR OF TEE FRANKLIN HALL, 50 NORTH SIXTH STRICT. PREFACE. The demand for another edition has afforded the author an oppor- tunity of again subjecting the entire treatise to a careful revision, and of incorporating in it every important observation recorded since the appearance of the last edition, in reference to the pathology and therapeutics of the several diseases of which it treats. The leading object of the Author has been to present in each suc- ceeding edition a full and accurate exhibition of the actual state of medical knowledge, in reference to those maladies which most usually occur between birth and puberty—maladies that form in some de- gree a class distinct from those of the adult, and demand for their cure a particular plan of treatment. In the preparation of the present edition, as in those which have preceded, while the author has appropriated to his use every impor- tant 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, he has, nevertheless, relied chiefly upon his own observa- tions and experience, acquired 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 re- vi PREFACE. sponsibility may rest with their respective authors. And, in all cases, in which an opposition of opinion, upon any leading point, exists be- tween medical authorities of equal weight, he has always adopted those views which comport the nearest with his own observations; 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. In reference to the directions given for the management of the se- veral diseases of infancy and childhood, these are almost exclusively based upon the results of the personal experience of the author. To notice every remedy that has been proposed, at different periods, and by different practitioners, the recommendation of which is founded, perhaps, upon the supposed good effects resulting from its use in two, 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 therefore 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 re- commendation of practitioners of unquestionable authority, even al- though he fhay not have had an opportunity of testing its efficacy. Every species of hypothetical reasoning has, a9 much as possible, been avoided. The author has endeavoured throughout the wort to confine himself to a simple statement of well ascertained pathological facts, and plain therapeutical directions—his chief desire being to render it what its title imports jt to be, a practical treatise on the DISEASES OF CHILDREN. He feels persuaded that it will be found a useful and faithful guide to the student, and that the practitioner, also, should he be induced to consult its pages, may derive from them some few facts and practical hints, not altogether unworthy of his notice. Philadelphia, September, 1853. CONTENTS. PART I. CHAPTER I. THE HYGIENIC MANAGEMENT OF CHILDREN. t. Air. Temperature, -------33 2. Cleanliness. Bathing, - - - - - - -37 3. Clothing, - - - - - - - - 41 4. Food, ......... 43 5. Sleep, - - - - -- - - - 57 6. Exercise, - - ' - - - - - - -62 7. Moral Treatment, - - - - - - 69 CHAPTER II. ON THE PECULIARITIES OF ORGANIZATION AND FUNCTION, DURING INFANCY AND CHILD- HOOD-. I. Infancy,- -...-..-79 Organization, - - - - - -- -79 Functions, --..----86 2. Childhood, - .....92 Organization, --------92 Functions, - - - - - - - -93 CHAPTER III. PATHOLOGY OF INFANCY AND CHILDHOOD. - - - 97 CHAPTER IV. SEMEIOLOGY OF THE DISEASES OF INFANCY AND CHILDHOOD. 1. Of the Countenance, - - - - - - - 128 2. Of the Gestures, - - - - - - - 130 viii CONTENTS. 3. The Phenomena During Sleep, - 4. 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 II. 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, - 4. Ulcerative Stomatitis, .... 5. Gengivitis. Inflammation of the gums, ■6. Gangrene of the Mouth, .... 7. Difncult'Dentition, - CHAPTER II. DISEASES OF THE THROAT. 1. Tonsillitis, -.----* - 177 2. Pseudo-membranous Inflammation of the Throat, - 180 3. Gangrene of the Throat, - - - - - - - 183 4. Parotitis. Inflammation of the Parotids. Mumps, - 190 5. Angina Externa, --.,*-- . 191 CHAPTER III. (ESOPHAGITIS. - - * - 194 CHAPTER IV. DISEASES OF THE 8TOMACH. 1. Indigestion, - - - - - * * -195 5. Gastritis. Inflammation of the Stomach, * 203 132 134 135 136 137 140 140 143 144 147 - 148 152 - 158 160 - 161 171 CONTENTS. IX 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, 209 214 232 242 244 247 248 260 264 CHAPTER VI. Peritonitis. Inflammation of the Peritoneum, - 268 CHAPTER VII. The Remittent or Gastric Fever of Infancy, 271 SECTION II. DISEASES OF THE RESPIRATORY ORGANS. 1. Asphyxia, * . - - . 281 2. Coryza, . - 286 3. Bronchitis, . - - - 290 4. Pneumonia, - > 299 Atelectasis Pulmonum, . - . - 316 5. Pleuritis, . > 317 6. Tracheitis. Croup, * * - . 323 7. Spasmodic Croup, * • 341 8. Spasm of the Glottis, • * - - - 346 9. Pertussis. Hooping-Cough, * 361 10. Foreign Bodies in the Larynx ar d Trachea, * * - 380 SECTION III. DISEASES OF THE NERVOUS SYSTEM- 1. Hypertrophy of the Brain, 2. Cerebral Hyperemia and Haemorrhage, 3. Convulsions, ... 4. Acute meningitis, * Meningitis Encephalica, * 5. Epidejnic Meningitis, 6. Subacute Meningitis, - * 7. Chronic Hydrocephalus, 8. Chorea, . » - * - 388 388 392 413 423 424 436 451 453 X CONTENTS. SECTION IV. DISEASES OF THE SKIN. CHAPTER I. ERUPTIVE FEVERS. EXANTHEMATA. 1. Measles, 2. Scarlet Fever. Scarlatina, Inflammatory Scarlatina, - Scarlatina Anginosa, Congestive Scarlatina, 3. Roseola. Scarlet Rash, 4. Variola. Small-pox, 5. Vaccination, - - - Phenomena of Vaccination, Period for Vaccination, Mode of Vaccination, 6. Modified Small-pox. Varioloid, 7. Varicella. Chicken-pox, 465 472 476 478 492 501 503 522 528 529 531 533 536 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, - OIL, - 539 . - 539 . 541 . - 543 . 543 . . 545 . 545 . - 547 . 548 . - 550 . 557 - 561 . 563 - 565 . 566 - 572 . 572 - 573 . 574 - 577 . 579 . - 583 . 583 . - 587 CONTENTS. xi SECTION V. DISEASES OF THE NUTRITIVE FUNCTION. Scrofula, ------- 590 Scrofulous Inflammation of the Lymphatic Glands, .... 596 Ophthalmia, - - - - - - -597 Otitis, - - - - - - . . 600 Discharges from the Vagina, ..... 602 Disease of the Mesenteric Glands. Tabes Mesenterica, - - 602 Disease of the Bones, - - ... - . 603 Rickets, ....... 604 White Swelling, ...... 605 Hip Disease, .-.-.-- 606 Disease of the Spine, ..... 608 Tubercular Depositions, ....... 609 Tuberculization of the Bronchial Glands, - - - - - 613 Lungs, ------- 614 Tubercles of the Brain, - - - - - - -615 Treatment of Scrofula, - - - - - - -617 Scrofulous Enlargement of the Lymphatic Glands, - - 623 Ophthalmia, ------- 624 Otitis, ....... 628 Discharges from the Vagina, .... - 629 Tabes Mesenterica, ------ 629 Disease of the Bones. Rickets, - 630 White Swelling, - - ' - - - - 632 Hip Disease, ------- 633 Disease of the Spine, ------ 634 Tubercular Depositions, - - - - - - 635 SECTION VI. DISEASES OF THE URINARY ORGANS. 1. Dysuria. Painful and Difficult Micturition, .... 636 2. Anuria. Suppression of Urine, - - - - - -641 3. Ischuria. Retention of Urine, ..... 643 4. Enuresis. Incontinency of Urine, ------ 645 5. Diabetes, ....... 650 SECTION VII. CONGENITAL AFFECTIONS, AND ACCIDENTS OCCURRING, MOST GENERALLY, WITHIN THE MONTH. 1. Fractures, .._---- 654 2. Congenital Malformation of the Intestines, ... - 655 3. Tongue-tie, - - ' - - - - 657 4. Haemorrhage from the Navel, ------ 658 5. Cyanosis. Morbus Caeruleanus, .... - 664 6. Spina Bifida. Hydro-Rachis, - - - - - - 671 7. Inflammation and Ulceration of the Navel, ... - 675 xii CONTENTS. 8. Intumescence and Inflammation of the Breasts, 9. Ruptures. Hernise, Arrest of the Testicle, 10. Vaginal Haemorrhage, 11. GEdema of the Prepuce, - 12. Cohesion of the Labia and Nymphep, - 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. Bums and Scalds, 677 678 683 683 684 685 686 687 689 694 698 701 708 709 713 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, arc still substan- tially 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. The proper management of infancy and childhood is still but imperfectly understood, and many erroneous opinions in rela- tion to it, giving birth to practices the most pernicious, are enter- tained, even by physicians. A'gcncral view of the more important par- ticulars connected with the subject would seem, therefore, to be a pro- per and necessary introduction to the consideration of the pathology and treatment of the maladies incident to the early periods of life. 1.—Air. Temperature. 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- ence. But it is not only necessary that the infant should be supplied 3 34 DISEASES OF CHILDREN. 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, and by 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 of its oxygen, or to load it with effluvia of any kind; all of these MANAGEMENT OF CHILDREN. 35 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 accustomed to it for a few times, they evince, even 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 benefit of a pure atmosphere by various practices originating in ig- norance, 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 cur- tain; or when they are taken abroad, by 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 symptoms 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 suffi- ciently 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, provided 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 pas,s 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 resist- ing 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 temperature 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 con- stitution, will suffer discomfort, and have their health impaired by a degree of cold that would be tolerated with impunity by those who are older and more robust. According to Drs. Milne Edwards, and Villerme, of Paris, and Dr. Trevisano, of Castel Franco, in Italy—and the accuracy of these gentlemen's statements is fully confirmed by Drs. Lombard, of Ge- neva, 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 win- ter 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 mortality 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 pre- servation of their health and lives. It will not do, however, for pa- rents or nurses to judge of the temperature required for the well-being of an infant by their own sensations—for what may be sufficiently comfortable 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 —uneasiness, at first sight, is, by a repetition of the cause, almost in- variably 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 dangerous 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 MANAGEMENT OF CHILDREN. 37 them hardy, is not less cruel than absurd. A child of sufficient age and vigour to enable its system to react promptly under the depress- ing influence of cold, and, by an increased evolution of heat, to main- tain its temperature, may, it is true, sustain with impunity, or even derive advantage from exposure for a short period to a moderate de- gree of cold,—but, in all others, so far from an increase of strength and vigour, or the ability to endure without injury sudden vicissi- tudes 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 immediately 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 68° to 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 ven- tilation 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 excur- sions 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 ne- 38 DISEASES OF CHILDREN. cessity of guarding it from whatever is calculated to impede its free anfi 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 fqr 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 re- moval 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 re- marks, "simple warm water will be sufficient to cleanse the surface thoroughly." Notwithstanding the high authorities by which 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 im- portant 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 conse- quently, 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 gene- ral 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 bddy should be subjected 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 ten- der 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 proper 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 irri- tating 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 care- ful surveillance on the part of the parents or guardians. Frequent bathing in tepid water, independently of its removing from the sur- face every source of impurity, benefits the health of the child by pro- moting the functions of the skin and encouraging the free and regu- lar circulation of the blood through its numerous vessels, securing thus the regular growth and full development of every portion of the body. " I consider bathing," remarks Struve, " as the grand arcanum 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 its birth the im- mersion should not continue longer than three or four minutes—the time being gradually prolonged as the child advances in age—conti- nuance in the bath beyond ten or fifteen minutes, is, however, unne- cessary, 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 sub- ject 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 ulce- rations of the skin beneath it of a most obstinate and painful character. Many parents are opposed to frequently washing the head of an infant, from a supposition that it will render it liable to take cold, and be otherwise prejudicial to health; no such fears,however,need be entertained—the child's health will be much more endangered by neglecting to keep its head scrupulously clean than by the too fre- quent application to it of water of a proper temperature. A soft brush should always 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, than when the hair is kept short and thin. The degree of heat, also, MANAGEMENT OF CHILDREN. 41 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." 3. 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 conse- quence 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 en- tire frame; a matter 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 expe- rience the slightest sensation of chilliness, nor, on the other, unne- cessarily 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 mate- rial 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 wea- ther, 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 at- mosphere. 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 se- lected. Even in winter, when from any unusual sensibility of the surface, the contact of the flannel excites an irritation of the skin, or 42 DISEASES OF CHILDREN. produces profuse perspiration, 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 bronchitis, or even inflammation of the lungs, are often in- duced by this irrational custom; and it is not improbable that*the foundation of pulmonary consumption is often thus laid during child- hood. 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 whenever the child is placed upon the floor, to protect its feet from being injured by any sharp substance with which they may acci- dentally 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 tempera- ture, a soft woollen shawl, thrown loosely around the infant's neck and shoulders, 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 u vascularity, it is prone to hyperaemia 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 considerable uneasiness to the child. By covering and confining the ears, and compressing them against the side of the head, the cap, even if it occasion no other injury, is apt to produce pain and inflam- mation of these organs, or a disgusting, sometimes dangerous, sore- ness and running 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. 43 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 com- pression 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, be- ing 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, however, 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 re- main 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 imbedded 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 de- prived 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.—(Jinnnles ef 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 without 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. Merri- man, "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 mortality 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 par- take daily of substances, to the digestion of which the powers of its stomach arc 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 counte- racted, while the infant is subjected to many of the dangers resulting from dry nursing; the functions of its digestive organs become al- most 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 convul- sions, 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 addi- tion to the food it receives from the breast, the infant may be sup- plied, 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 re- marks, 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 wa m water, and well sweetened with the best loaf sugar. Neither stale nor skimmed milk, nor that which has the slightest tendency to acidity should, on any consideration, be em- ployed; nor should any greater quantity of the mixture be made than will be required 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 nou- rishment by precisely 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 ob- tains 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 wTell with the stomach, and in most situa- tions 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 re- commended by many of the continental writers for the nourishment of infants, while a late writer, Carault, (Guide des Meres,) gives the preference to rennet 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, frequent 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 ir- ritation 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 manifesta- tions of irritation of the digestive organs. Let the infant's stomach be once or twice filled during 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, vomit- ing, 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 constitutional infirmity. After four or five months of flatulence, griping, and disordered bowels, the digestive powers gradually be- come inured to the impressions of the food, and a considerable de- gree 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 unma- nageable diarrhoea, emaciation, slow fever, enlarged mesenteric glands, dropsy in the brain, scrofula, chronic affections of the liver, epilepsy, and other dangerous 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 dis- agree with the stomach, than one simple article when properly se- lected, in every instance in which the infant appears to be well nou- rished, 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 diges- tion is effected requires the stomach to be supplied with food at very short intervals; but as the infant increases in age, these intervals are gradually 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 partake 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 prac- ' tice 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, arrow-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 po- tatoes reduced 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. LTntil 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 increase 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 un- frequently 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 sen- sation they experience; while a few spoonfuls of water would im- mediately 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 properties 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, how- ever, a matter 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-essential requisite, upon which the due support of the infant and its future health, in a very great decree depend. No female, there- fore, should be selected as a child's nurse, who is labouring under any bodily infirmity; or who is even strongly predisposed to consump- tion, scrofula, 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 en- tirely suspended. Her milk, also, should be as nearly adapted to the age of the infant as possible; a slight difference is, however, no MANAGEMENT OF CHILDREN. 49 objection; and the fact of her milk being adapted to a somewhat younger infant than the one she is about to suckle, is of less import- ance 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, like- wise, great mildness of disposition, considerable cheerfulness of tem- per, 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 delete- rious 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, jealousv, 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 im- pressions, 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 intrust 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 con- siderable 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 pro- pensity 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, hoAvever homely, are suddenly transformed into fastidious and dainty beings, considering their wants and wishes of the greatest importance. 1 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, pre- serve her health, the result of which will be a plentiful secretion of milk. I consider meat one'e 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 nou- rishment 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 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, FeVy, 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 bein^; 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 perfect 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 *)2 DISEASES OF CHILDREN. increased. Hence the spring or autumn should, if possible, be invaria- bly made choice of for the period of weaning; 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 with perfect case 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 ac- customed 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, however, nothing occurs to prohibit it, the infant's safety from dis- ease will more certainly be secured, if the period of weaning be post- poned 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 disturbing 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 !>-ruel—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. During 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; we 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 preparations 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, po- tatoes, carrots, turnips, beets, and cauliflowers, will be found the most wholesome; they should all be of good quality, and, with the exception of the potatoes, should be well boiled. In general, the po- tato is most easy of digestion, and agrees best with the stomach, when roasted; it, as well as the turnip, should be eaten without being re- duced 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 calculated effectually to quench thirst, and promote a free and healthy discharge 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 produce, they endanger the occurrence of fever, indigestion, inflam- mation, or convulsions, to say nothing of the danger of a taste for "these pleasing poisons" being induced, leading, in after life, to habits of confirmed and beastly intemperance. The period of a child's meals should be so regulated, that the in- tervals 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 intro- duction 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 pos- sible after they have risen, and have been properly washed and combed; their stomachs are then empty, and the appetite is, in gene- ral, 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 lighest articles of food, and be taken an hour or two before bed-time. 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 appetite 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 appe- tite 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 inter- rupted in its regular routine of function, consequently the appetite will be either irregular or capricious; in the second case, all the evils attendant upon an over-distention 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 in- jurious habit of requiring food at improper times, by which the di- gestion 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 ac- tually demand it;" but we nevertheless believe it far better that the child should be accustomed to partake of food only at regular periods; and this is very soon effected, when those periods are made to corres- pond 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 prevented from engaging in any pastime or occupation that requires considerable bodily exertion; and, as they should be early accus- tomed 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 firm- ness, 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, destructive to the teeth, and otherwise prejudicial to the health of the system. How such an opinion could have originated it is cer- tainly very difficult to imagine; so far from any bad effects being pro- duced by the free use of sugar, at least under the ordinary circum- stances 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 nutritive 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 infancy." Whether, however, pure sugar can be eaten by itself, with perfect safety, is somewhat doubtful. To ensure 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 thil- 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 deci- dedly injurious—as well on account of its being almost entirely indi- gestible, as from the injury inflicted upon the stomach by the crude acid juices it contains. All fruits that are invested with a firm cuti- cle 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 strawberries, blackberries, whortleberries, 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 ex- cite considerable 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 arc capable of producing violent, and even fatal impres- sions 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, unconquerable 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 perfor- mance 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. when 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 ir 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 .■>.*> DISEASES OF CHILDREN. or even more dangerous affections, when, upon its awaking, it is ex- posed 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 employed 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 infant, 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 inter- fere 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. 59 that it is suffering from cold or heat, or from a too confined or impure atmosphere. It will be readily perceived, therefore, that the only proper 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 apart- ment, or placed in a direct line with the eyes, that the child will acquire a permanent 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 enveloped 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 prevented. The face of an infant should never be entirely covered, nor so im- 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 well-constructed hair mattress, with a proper amount of light, soft bed-clothes, is to be pre- ferred. Independently of the undue degree of heat which is gene- rated by a feather or down bed and pillow, and the exhaustion which thence ensues, the attitude into which the infant's body falls during 60 DISEASES OF CHILDREN. sleep may induce, when it is resumed every night, a permanent dis- tortion. A feather pillow, also, by keeping the head too warm, not unfrequently becomes the remote or exciting cause of catarrhal af- fections, inflammations of the ear, eruptions, pain of the head, or even more serious disease. For the same reason, children should be ac- customed, from an early age, to sleep with the head bare—the cover- ing with which nature has, in general, so plentifully supplied this por- tion 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 curtains 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 middle of the room, and raised some feet from the floor. From the vitiated 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 chil- dren 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 remo- val of a rheumatic affection. The child until then had been perfectly 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 question. 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 (The 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 involved 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 up 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 object. 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 excite- ment, of long continuance, and difficult to subdue. Children should be accustomed, from a very early age, to retire to G2 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 communicate 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 neg- lected, we are to recollect, that every species of dandling and toss- ing—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 set 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. Themotion 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 it- self 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 general, 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 ten- dency. The freshness, beauty and variety of the scenes of nature, are highly attractive, even at a very early period of life; and independ- ently of the healthful influence of a pure and unconfined atmosphere, the impressions 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 per- manently 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 infant, it is important that it be not confined exclusively to one breast, but nourished alternately, from both—as well to prevent its contracting a crookedness of form. as to guard against its acquiring a habit of squinting, from one of its eyes, while nursing, being constantly directed towards one point. Infants, in generalvderive 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 carefully 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 mattress, with the head slightly elevated, and so confined at the sides as to prevent them from rolling when in motion. After the child has acquired some degree of strength, it should be placed in a semi-recumbent posture, with its head and back 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- IU DISEASES OF CHILDREN. iniv 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 covcrcd, since from the passiveness of their situation, they will re- quire 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 hazardous 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 in- terfere with their regular habits of repose. (Dewees.) 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 Avho 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 support has a tendency to produce an unnatural elevation of the shoulders, while the infant, depending upon it, almost alone, for maintaining the upright position of its body, is accustomed to bend too much forward, or to one side. By this may be laid the founda- tion of a permanent deformity, 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 ought 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; after- wards the little traveller may run towards its mother, or nurse, who, with extended arms, stoops to receive it. As the infant improves in its efforts to walk alone, the chairs may be placed at a greater dis- tance 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 uncommon. 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 distance. The practice cannot be too strongly condemned. Some of the most violent and troublesome affections of the elbow and shoulder joints that w,e 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 mi- nute direction 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 ac- quire tricks of involuntary motion. Twitching of the features, ges- ticulations 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 occur- rence in the physical education of boys. But how often has an over- anxiety for delicacy of complexion in a daughter, or the apprehen- sion that her limbs may become coarse and ungraceful, and her ha- 5 66 DISEASES OF CHILDREN. bits vulgar, been the means of debarring her from the enjoyment of either air or exercise, to an extent sufficient to insure the due deve- lopment, 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 vi- gour of body and cheerfulness of mind, which will enable their va- rious organs to perform, regularly and perfectly, their respective functions; and by which alone their health and comfort can be con- firmed. Girls should not, therefore, be confined to a sedentary life, within the precincts 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 free- dom of their motions, or an over-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 transferring them to the green-house, 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 require him to fix his attention, hour after hour, upon tasks, al- ways without interest, and often beyond his comprehension, may be a certain way to train up innervated puppets, or to produce, per- chance, a short-lived prodigy of learning; but it is illy calculated to form healthy, well-informed, 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, elo- cution, music, or drawing. Debarred from the healthful and joyous 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 cheerfulness 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 cul- tivation 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 pursuits; 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, with 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 differ- ence 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 disinclination to remain long in a state of quiet, have not been counteracted 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 that 68 DISEASES OF CHILDREN. ought to be sedulously encouraged, and the necessary articles for their pursuit supplied. The latter, however, should be simple, and of 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 Avheelbarrow, 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 dis- tinction between the sexes, which condemns female children, from the cradle, to a sedentary life, by permitting them scarcely any other playthings 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 purchased 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 con- structing 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 un- necessary 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 un- duly timid, helpless, and irresolute in their actions. Exaggerating the dangers incident to the usual sports of children, and plying them continually with admonitory injunctions against accidents when they are engaged 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 t6 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 eun. 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 de- gree of exercise as the latter; but when allowed to follow their own inclinations, 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 induced 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 exposure to the open air. As a general rule the very op- posite of this course should be pursued: the robust being best able to bear up against the pernicious effects of that confinement and in- activity, 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. Athough 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- 70 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 be- fore 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 com- plain 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 un- comfortable—is often induced by unkindness, impatience, or want of temper on the part of the mother or nurse. An infant whose natural inclinations are continually thwarted—who is placed in the cradle and attempted to be forced to sleep, when it would be awake and play- ful—and whose disinclination to repose, and the cries by which this is expressed, expose it to angry chidings—a passionate slap, or a rough shaking from its attendant—or whose calls for its natural food, or desire to be nursed or diverted, are repelled by equally injudi- cious 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 smiling 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 caress 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 caro 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 arc 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 Avho 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, Avhile they act prejudicially upon the health of the little sufferer. The young infant is often reputed obstinate, because it cannot conform its Avants 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 Avhen 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 quies- cent for any length of time, however repeatedly he may be commanded to do so. Thq child in this instance evinces neither obstinacy nor disobedience; he is merely folloAving the natural instinct of his age for bodily action; and if an attempt be made to restrain this by pu- nishment, 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 talk- ing, if he be suddenly commanded to desist, he is unable instantly to obey. The inability to desist suddenly from any occupation, is often Bo painful to children, that, to avoid that pain, they become obstinate. It is, therefore, better to stop them by presenting new objects to their attention, 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 Avilful, 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, unfortu- nately, 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 instructors; whereas, to attempt to command obedience by severe measures, will often confirm and strengthen the very fault for the correction of which these are resorted 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 cor- rection 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 me- nacing gestures—or whose puny fits of displeasure with its attendants or playthings are encouraged or even excited, can scarcely fail to be- come angry and resentful at whatever opposes its desires, or gives it momentary uneasiness; and the emotions thus brought into play ac- quire, in a short time, a force which the best-directed efforts seldom succeed in effectually counteracting. Crying, screaming, and various gesticulations of the limbs and body, are the means by Avhich the passion of anger, and other violent emo- tions, are generally expressed in infancy. Children, it is true, fre- quently cry from pain or uneasiness; while, not unfrequently, particu- larly 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 con- trary, when from any cause, whether improper food or clothing, a con- fined or impure atmosphere, neglect of cleanliness, pain or passion, an infant is throAvn into frequent paroxysms of crying, particularly when these paroxysms are of long continuance, as is generally the case Avhen 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 unfrequently 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, Avhere they are left crying, almost to con- A-ulsions, 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 sooth- ing 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 overloaded, 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 action of opium, so that it is scarcely possible to give them the most insignificant dose with safety, when the use of opiates is once com- menced 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 established. 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 ge- neral condition of the system altogether adverse to the healthful dis- charge 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, Avhen 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 pronounced by Struve to be "a positive crime against nature." The intellectual 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 edu- cate it, is deprived of much of that capacity for depth and vigour of reflection, to Avhich 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 Avell-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 knoA\rledge. 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 fonvard 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, Avould be to make no positive attempts at culti\-ating the intellectual poAvers of children previous to the fourth year. hep them rejoice, till then, in their ex- istence, without confining their limbs, damping their spirits, or bur- dening their memories Avith things which are seldom more than loosely connected 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, use- fulness, and, to a certain extent, over the health of every human be- ing, and which commences the moment the child is able to form even the simplest ideas; it is the education of circumstances—of examples; insensible education, as a popular writer correctly terms it; the re- sults of which, like those of the insensible operations going on in the physical world, are often more striking and more permanent, than of such as are open and apparent. To this education every thing con- tributes by which the child is surrounded,—the example, the conver- sation, the manners, the opinions, the prejudices of his parents, and of those in Avhose 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 Avere it advisable, to withdraw their children; but it is in their power to surround them Avith such influences, only, as are calculated to give to the mind in early life that proper moral bias, which no light temptation, in their future intercourse with the world, will be able to destroy. ' "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, Avhich we considered the least important, may, in the mind of a child two or three years old, soav 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 ca- sual occurrence, to connect the practice of the virtues with the viva- city of pleasurable sensation,—to render truth, fidelity, benevolence, generosity, firmness and strict integrity dispositions essential to {he 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 Avho preaching up tempe- » MANAGEMENT OF CHILDREN. T\ ranee, is himself intemperate. This holds in all actions, however in- considerable, as we knoAv 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 Avords, the import of Avhich 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 Avords, 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 instinctiArely acquires the disposition to revenge himself on whatever gives him uneasiness or inconvenience, 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 idle- ness, negligence, prodigality, cruelty, &c, Avhen practised or counte- nanced by parents in the presence of their children; who thus, in fact, while truly wishing them to do well, by their own example, im- plant 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 ex- hibited in all its operations, his moral faculties, equally with his in- tellectual, are cultivated and improved. This kind of mental culture is effected without 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 hill- 78 DISEASES OF CHILDREN. side, or by old ocean's shore," where every object elicits attention; and while it amuses, it excites the mind to reflection, and the better prepares it for future intellectual 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 neg- lected, 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 eA'ery 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 consequence of previous self-conviction,—its OAvn original powers of acquisition 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 patho- logy and therapeutics of infancy and childhood. It is to the physio- logical condition of the several tissues and organs—their successive development and relative activity—that the predisposition to parti- cular forms of morbid action, as well as the various modifications which the phenomena, inarch, 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 therapeutical 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 constant supply of appropriate nourishment, render, under the influence of various disturbing circumstances, the occurrence of errors of nutrition, or of disease dependent upon deficient or im- proper food, of frequent occurrence. The great size and vascula- rity of the brain, 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 serious 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 intestinal mucous membrane, as the teeth make their appearance, render both, at this particular period, espe- cially prone to disease from slight causes. The excessive nervous excitability of the infant gives to its dis- eases a peculiar character of mobility—that is to say, morbid irrita- tions occurring in one organ are quickly reflected upon others; and from the great vascularity of every part, especially the abundance of arterial capillaries with Avhich all are supplied, during the pro- gress 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 re- quiring to be administered in diminished doses, graduated by the par- ticular age of the patient. Some remedies have, likewise, a peculi- arity 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 frequently 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 life includes three distinct physiological epochs; the first, extending from birth to the commencement of the first year; the second, comprehending the period occupied in the process of dentition; and the third, extending to the appearance of the perma- nent teeth. Organization.—At birth, as already remarked, the entire organism is but imperfectly developed. The body measures from seventeen to RO 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 Avith nerves than in after life. At the end of a feAV Aveeks, it loses its deep red tint, changing, by degrees, to a dirty yellow^ and finally assuming a degree of Avhiteness 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 Ave can distinguish dark complexioaed children from those that are fair. At a much earlier period, the liair has assumed its proper hue, but it is only at the third month that the skin on the body be- comes dark or light-coloured, the face either pale or ruddy, and the traits peculiar to each constitution 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 poAvder. During the entire period of infancy, the skin exhibits great irritability, and is very liberally sup- plied Avith blood. The articulations retain, for a short time after birth, a semiflexed 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- A^ances the fat diminishes, and the cellular tissue becomes more dense, while the exudation into its areola is lessened; the outlines of the muscles 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 dispro- portionately 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 developed. The bones of the skull and the ribs are, however, much more advanced in ossification than those destined for muscular at- tachment 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 in- troduced 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 pos- terior 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 ex- hibits, on different parts of its surface, large patches of a yellow hue, oAving probably to the action of the bile. When all the liquid parts of the intestinal tube, in early infancA*. 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 mem- I irane itself. This layer never remains except for a short time; detach- ing 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 re- moA-al 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 um- bilicus, in place of tranSA'ersely, as in the adult. The omentum i* peculiarly 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 caliber is relatively less. The valvulse conniventes are scarcely apparent:. some separate mucous follicles, about the size of a pin's head, and of a Avhite colour, often exist in the jejunum, and in the ileum, follicular plexuses, white and projecting, and often Avith a slight black point or* the top, as in the adult. The coecum 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, froiu 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 £•2 DISEASES OF CHILDREN. sions and prominences of the caecum 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 residue of the abdominal organs; at birth, it fills nearly one-third of the abdominal cavity, descending eA*en 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 di- minishes, by 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 pe- culiar 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 infant, 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, Avhich 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 re- taining it during infancy. The respiratory organs are well developed in the infant. At the pe- riod of birth, the cartilages and bones, as avcII 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 Avith blood. The mucous membrane of these parts is soft, thick, very vascular, and abundantly supplied Avith 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 at- tended Avith exudation upon, or tumefaction of, their mucous mem- brane, so eminently dangerous, from the complete closure of the glottis that then takes place. The bronchi are perfectly formed, but small. in the infant; 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 foetus were small, dense, and of a brownish colour, expand immediately after birth to double their former balk. and become soft, crepitant, and of a rosy hue. Though of less spe- cific gravity than in the foetal state, in consequence of the air Avhich pervades 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 uni- formly 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 differs—those of the right being usually of a deep violet, Avhile those of the left are red. After the closure of the foramen ovale, and the obliteration 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 con- siderably that of the left. Every portion of the body, during infancy, is more plentifully sup- plied wjth 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 groAvth 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 pro- portion of albuminous matter and water. During infancy, the brain is large in size, and nearly resembles, in s 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 superfices of the cerebrum, throughout its convolutions. In the cere- bellum, though the two portions are less marked than in the adult, they are, nevertheless, more so than in the cerebrum. The medullary sub- ♦ 'stance of the brain is generally of a reddish colour in the infant, having a number of blood-vessels ramifying through it. The con- volutions are less prominent, and apparently less numerous than in after life. The cerebellum, as well as the medulla oblongata, is 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 Avith the pia mater, it is more vascular. The latter, where it envelops the medulla oblongata, is more dense and cellular than upon the brain. The connexion of the tunica arach- noidca Avith 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 tAvelfth 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 mednllary 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, causing a very marked change in the form of the head, by the in- creased 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, betAveen the fourth and sixth years the sutures are all firmly united. In the infant, the medulla spinalis is white, its cineritious centre being Avell 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 Avith a yellow serosity, the consistence of which is sometimes gela- tinous.—(Billard.) The network of spinal veins is, in the infant, almost always engorged with blood. The annular portions of the vertebrae which form the canal for the spinal marrow, are fully ossified at birth, while the solid portion of these bones, upon Avhich 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 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 Avith 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 appre- ciable 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 fossae 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 nymphas of the female arc 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 organization 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 extremities become longer, and more fully developed. The softness of the tissues diminishes gradually, and they acquire a greater de- gree of density. The fat and serosity become reduced in quantity, and although the temperament is still decidedly lymphatic, the predomi- nance of the white fluids over the blood diminishes, as the termina- tion of infancy 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, augment in bulk and density, and acquire more and more of the deep red colour Avhich distinguishes them in after life; while the aponeurotic sheaths, and tendinous appendages, become more and more fully developed. 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, augment 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 ac- quired, very nearly, their complete organization, and differ but little from those of the adult. The disproportion in the size of the liver, especially of its middle lobe, decreases gradually; it recedes more toAvards the ribs, and its parenchyma becomes of a darker colour. The gall-bladder augments in capacity, and the urinary bladder as- sumes more of an ovoid form, and sinks lower into the pelvis. The lungs gradually develop 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 ar- teries over the veins, and the extent of the capillary system is but little changed. The blood, hoAvevcr, towards the close of this period, presents 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 colour less red; the proportion of its medullary matter is increased, its cortical portion is more distinctly marked, the bulk of the whole of the cerebrum is increased, and by the termination of infancy, it is found to have acquired, very nearly, that form and organization which it retains during the remainder of life. With the growth of the body in height, there is a corresponding elongation of the spinal marrow, Avhich 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 develop- ment beyond that of the brain, the changes which take place in it are less extensive and striking. During infancy, but little apparent change takes place in the or- gans of hearing, of sight, and of taste; the cavities of the nose, as Avell as of the mouth, however, become more deAreloped, 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, Avho has investigated this subject with great care, the Aveight of the male infant at birth is about half a pound greater than that of the female, and the length about an inch. The annual growth of the first is greater than that of the last, while the progress of de- velopment is reversed. Immediately subsequent to birth, the Aveight of the infant diminishes, 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 approaches its fourth or fifth year, diminishing appa- rently, 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 subsequently it goes on in a tolerably regular progression. Functions.—Immediately after birth, the function of respiration commences. The lungs and chest dilate, and the external air rushes into and distends the pulmonary cells, while the closure of the communi- cation, 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 Avhole 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. 57 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,hoAvever,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 respi- ration 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 at this period of life, is to be considered the principal respira- tory orifice. The circulation, Avhich 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, Avith the approach of youth.1 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 M filler. At birth,.....140 to 130. During the first year, . . 180 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. De V 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 Geburtshuljlkhe exploration. Halle, 1833. Dr. Gorliam 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 w,hich 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 sigu of disease in infants. s* 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 sys- tem are equally active with those of digestion. The process of as- similation predominates considerably over that of decomposition, as is eA'inced 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 fetor. 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 EdAvards, and later observers, several degrees less than in the subsequent periods of life. For several months after birth the infant suffers severely from the in- fluence of a cold atmosphere, and the proper temperature of its sur- face can be maintained only by sufficient clothing, and other artificial means. By degrees, however, the process of calorification acquires a greater degree of energy, and the body becomes less sensible 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 Avill 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 throAvn. PECULIARITIES OF ORGANIZATION. S9 They Avould 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 arc 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 Avithin its grasp; and it is soon found to avoid such as are not agreeable, and to be attracted by those Avhich afford pleasure. We often see very young infants seize Avith eagerness a finger or coral presented to their notice. Almost all Avill place the hand in that of the nurse; or, introducing one or more fingers into the mouth, occupy themselves Avith sucking. During the first few weeks of life, the external senses are but slightly developed; the infant is, nevertheless, sensible to the impres- sion of cold, and experiences pain when the skin is irritated or wounded: very soon, hoAvever, the existence of the sense of touch is manifested. The sense of taste is also exercised very early; that of smell, hoAvever, is but imperfectly developed until a later period, in consequence of the incomplete state of the nasal cavities, and the li- mited extent of the Schneiderian membrane. It is not until about the third or fourth Aveek that any indication is presented of the exercise of sight or hearing; but subsequently to this period these senses speedily acquire their full development. Vi- vidly 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 in- fant, which seems naturally to dislike darkness; but a very bright light is annoying as well as injurious to the eye at this period. Hunger and thirst, and the instinctive desire for the constant ad- mission of fresh air into the lungs, are among the internal sensations which are.first experienced; they have, during infancy, the same ge- neral 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 ad- vances, the first of these sensations is more intense, perhaps, than in the after ages of existence. So soon as the muscles become sufficiently deA^eloped, and the locomotive organs generally have acquired ade- quate 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 pilloAV, to either side upon which a brilliant object is presented. • At the age of six Aveeks, 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 !)0 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 ossi- fication 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 ossi- fication of the bodies of the vertebra?, and of the processes for mus- cular 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 feAv Aveeks later, to support its body with tolerable firmness in the sitting posture. The Avidening 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 backAvards, 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 poAver to assume the several attitudes, and to exercise the various movements 0/ which the human body is capable, is quickly acquired; and, from the very great sup- pleness 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 Avalk at too early a period. A neglect of these precautions is often productive of serious inconvenience, and eA'en permanent deformity. During the first few weeks of existence, the moral and intellectual faculties are entirely wanting. The whole external Avorld 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 Avhich 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 Avhich 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 Avhich 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 Aveeks old—but usually it is not, according to Billard, until about the age of one month that an in- fant 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 ges- tures 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 Avhich 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 interArals 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 particularly acute—all impressions are vividly felt, though usually transient 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 Avith great rapidity. The senses soon acquire their utmost degree of activity, and the perceptions become prompt and rapid. The memory has at this period a very great activity and extent—enabling the in- fant not only to treasure up the ideas excited by the physical and other properties of the thousand objects Avhich surround him, but the Avords, also, or the names Avhich have been affixed to them, as well as those by which the various sensations and Avants, which he himself experiences, are expressed. A knowledge of the prominent qualities of external objects, and of language, is, in fact, acquired, almost ex- clusively, 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 Avant of reflection, judgment, and experience, the infant is credulous, docile, and ingenuous:—he is pleased Avith trifles, and lives, as it were, for the present moment only. All the affective faculties, if we except those connected with the reproductive instinct, manifest themselves in a striking manner during the latter stages of infancy, and give rise to their appro- priate expressions and gestures. Thus the young being exhibits, from an early period, the feelings of attachment and aversion, of anger, A'anity, jealousy, pride, and shame; and the frequent and un- restrained indulgence of one or the other of these passions, unless a judicious moral culture is early commenced, causes it to obtain a pre- dominance, which Avill 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. 2.—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, be- comes 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 development; the joints their permanent forms, and increased firmness; the permanent cartilages assume a greater degree of den- sity, 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 pu- berty it presents, in the male, a considerable prominence at the an- terior part of the neck; Avhich, however, is more marked in some sub- jects 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 perfected during childhood. About the period of puberty, the cere- bellum 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 per- fected 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 childhood, much of the softness of infancy; the predominance of the white fluids, hoAvever, gradually diminishes; but the various tissues are still liberally supplied Avith arterial blood, and the capillary sys- tem is still more extensively expanded than in after life. Functions.—The whole of the vital functions proceed rapidly during childhood toAvards 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 de- manded. 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 childhood, as well in consequence of the more solid and sti- mulating character of the food that is eaten, as from the greater waste of the watery portion of the blood, by the active muscular ex- ercise 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 in- crease 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 date as the twenty-fifth year; and we have reason to belieA^e, 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 de- gree 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 tena- cious. 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 betAveen right and wrong, virtue and vice, and of understanding, to a certain extent, at least, his several duties, Avhether of a natural, civil, or religious character, lie 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 Aveeks, 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 Avhich, in colder regions, the individual is still scarcely emerged from infancy. In fact, all those circumstances Avhich exert a stimulating influence upon the nervous system, or which tend to call earty 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 Avith equal rapidity, and the decrepitude of old age is experienced, often, Avhen, 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 someyvhat similar influence. On the other hand, in cold climates, and by deficient or unnutritious food, the want of proper moral and intellectual culture, and other depressing causes. the development of the body is retarded, and its complete organiza- tion, with the full and vigorous exercise of its functions, if attained at all, is attained only by sIoav 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 sm; 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 haematosis 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 loAver 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 present no strongly marked temperament—the development of the several organs being nearly equal; or, on the other hand, more than one of the above temperaments may occur in the same individual. In in- fancy 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 deA'elopment, while the sanguineous belongs, 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 alloAv 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 exer- cise,—promoting the development, at the proper season, of those which are deficient in activity, and removing every unnecessary sti- mulant from such as exhibit a tendency to a disproportionate develop- ment 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- Bition 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 Aveeks 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 poAvcrs 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 import- ant 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; Avhile the exalted activity of the capillary system during the progress of development, and especially in those organs in \vhich nutrition for the time predominates, is quickly transformed, by any accidental irritation, into inflammatory action.2 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. a 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 25-01 per cent, of the entire no., and 47- of those under 15. Between land 2 years, 5,570 or 1143 " " 27- •' " 2and5 " 6,470 or 11- " " 27. " " 5 and 10 " 2,308 or 4-74 " " 87 " " 10 and 15 " 606 or 1-42 " " 2-7 " 7 DS 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 Avhere 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 in\rolved 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 oc- curring, and thus diminishing the chance of a speedy and favourable termination. As Barthez and Rilliet very correctly remark, this first complication 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, Avhich 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 extend 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 is not found to extend to some distance into the oesophagus, or into the larynx. The diphtheritic or pseudo-membranous angina of child- hood, is confined, in but a very feAv 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 oesopha- gus; 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 intes- tinal 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 serum in the brain; Avhile towards the commencement of dentition, when the muciparous follicles of the intestines become developed, any acci- dental cause exciting these to an increased activity of function, will produce the most profuse watery discharge from the bowels. Upon both the serous and mucous membranes, inflammation during infancy has a tendency to produce exudations of lymph;—the production of diphtheritic exudations upon the mucous surfaces would "appear to be, in some measure, a result of inflammatory action peculiar to in- fancy. Not only do these occur upon the throat and respiratory tubes, but upon the apertures of the genito-urinary organs; the con- tour of the anus; the external meatus of the ears; the folds of the groin, and other similar parts, when these are in a state of excori- ation or ulceration.—(Trousseau.) The delicacy of the skin during the earlier stages of infancy, its extreme irritability, and very great vascularity, render its several tissues peculiarly liable to disease of \Tarious grades, from the sim- plest rash, to the most violent inflammation, terminating rapidly in extensive disorganization; and from the action of causes, Avhich 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 cuta- neous diseases occurring at this period, are evidently dependent upon a morbid condition of the digestive organs; others are produced bv a neglect of cleanliness, and a few, without including the febrile ex- anthemata, 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 Avith in the adult.1 The respiratory mucous membrane is liable, in-the infant, to vari- ous grades of inflammation; in general, hoAvever, of a very acute character, 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 affections of the respiratory organs are, in general, produced by the influence of cold, and often from the improper exposure of the upper portion 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 man- ner as to leave no part of the breast and loAver portion of the neck exposed, Dr. Eberle met Avith 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 Avith 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 pneu- monia is more common in children beyond this age. According to Gerhard, 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 1 In Philadelphia, during the ten years preceding 1845, 2154 deaths occurred from acarlatina, in individuals under 15 years of age, viz.: 122 in infants under 1 year; 400 in those between 1 and 2 years; 1083 in those between 2 and 5; 403 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 1 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 com- prised rather more than one-ninth of the whole number of deaths, within the same period, in individuals under 15 years of age. So far as we can judge from the number of deaths that occur, small-pox is less ex- clusively a disease of early life; for within the above period, 841 deaths took place from this disease, of which 257 were of individuals over 15 years of age. PATHOLOGY OF INFANCY AND CHILDHOOD. 101 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 peculiarcondition here referred to, maybe distinguished from patches of true hepatization, the result of lobular inflammation, by insufflation, which reproduces, more or less completely, the natu- ral condition of the lobules. Lobular pneumonia is certainly very common 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 fi>e; 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 underthe heads of lobar, lobu- lar, 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 between 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 betAveen 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 Avould be inferred from their statements, and that finally, lobular .pneumonia, at whatever age it occurs, is, in the ma- 102 DISEASES OF CHILDREN. jority 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 by 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 Avith lobular pneu- monia. But not unfrequently, even Avhen 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 whooping-cough and laryngismus, stridulus; the first rarely occurring 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 whooping-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, confined and impure atmosphere, or by the reflex action of irritation 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 Avhich many pathologists suppose it to be produced, is to be viewed, we sus- pect, in nearly every instance, merely as an accidental occurrence.1 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 distentions of the abdomen, and the other phenomena of irrita- tion, and of acute or chronic inflammation of the stomach and bowels. 1 In Philadelphia, during the period referred to 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 vear. 2 years. years. years. years. From Bronchitis, 1172 643 276 201 47 6 " Croup, 1149 319 238 474 112 6 " Pneumonia, 1592 693 414 345 115 25 " Hooping Cough, 781 371 208 171 30 1 Other diseases of the Respiratory Organs 283 123 56 57 35 12 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 Avhich 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- tion 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 symptoms 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 distention 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.1 Drs. Friedleben and Flesh, 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, Avith 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- 1 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 fol- lows :— Under one Between 1 and 2 and 5 5 and 10 10 and 15 year. 2 years. years. years. years. From Diarrhoea, 832 535 205 79 8 5 " Dysentery, 546 151 169 117 85 24 " Infantile Cholera, 2583 1706 752 125 " Inflammation of A " the Stomach and V 825 411 163 131 85 35 '' Intestines I " Marasmus, 930 596 210 100 22 2 " Aphthae, 43 33 9 1 " Worms, 57 4 12 21 8 1 " Colic, 21 19 1 1 Other affections of Sto-\ n,n no, mach and Intestines,} 241 134 47 34 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 G180. Being about one-fourth of all the deaths in individuals under 15 years. 104 MANAGEMENT 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 Avas 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 Avails, 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, hoAvever, 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, Avithoutsimultaneousdiminution of its consistence, large pieces of the mucous membrane may be sepa- rated from the subjacent cellular tissue. Both the solitary glands, of the small intestines and of the colon, are invisible to the naked eye. As to those of the colon, however, Ave 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 opacity 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-ccecal valve, Avhere they may be distinguished by their marked limits. The number of the patches varies as much as from thirteen to thirty-six. The cases in Avhich they are found to be only from one to six, are regarded by the authors as referrible 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 obserArations 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. 105 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 Avere 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 adifference of form. 9. In the 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, Arc. 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 Avell 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 Avith the simultaneous, but far more serious, alterations of the mucous membrane of the small intestines. 15. The mesenteric glands, Avith 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 Avere infiltrated with tuberculous matter, but even then their enlargement could not be felt through the abdominal Avails. 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 fre- quent diseases of infancy. Fow 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 disease, to occur in the course or towards the termination of nearly all the affections of infancy. FeAv of the neiwous affections, properly so called, occur during infancy, notAvithstanding the extreme susceptibility of their nervous system, and its liability to disturbance from direct as Avell 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 irrita- tions transmitted to these parts from the digestive organs; and it is often surprising, from how slight a cause they will result, and Iioav promptly they cease upon its removal. Epilepsy and chorea gene- rally occur during the latter period of infancy, and the early stages of childhood.1 The extreme development and activity of the Avhole 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,. Avould appear to be, in some respects, peculiar to the period of in- fancy. It often prevails as an epidemic, and is attended with several peculiarities, Avhich give it someAvhat of a specific character. It sel- dom occurs more than once in the same individual; and has always a strong tendency to cease suddenly and be immediately folloAved by an inflammation of the testicle in the male, and of the mammas in the female, generally of the same side as that on Avhich the disease in the neck is seated. (Edematous SAvellings of various parts of the body, are very com- 1 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 10 T , . and 15years. oa' year. and 2 years. and 5 years. and 10 years. 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 ) onn the Brain, / /uu 135 124 71 22 552 3180 1343 1118 449 96 6186 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 incontroA^ertible cases of it. It is usually a mild dis- ease, attended with a distinct, though slight febrile movement, and seldom or never 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 be- ing unattended by febrile symptoms, in giving rise to but few general symptoms, and causing great enlargement of the cavities or 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.)1 A very peculiar condition of the cellular tissue occasionally occurs in young infants, from an extensive effusion of scrum, giving to the parts affected a feeling of hardness, as if an induration of the subcu- taneous tissue had already 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 ve- nous blood in the tissues; and a dry state of the skin previous to the exfoliation of the epidermis; Avhile the frninediate causes are, an ob- struction of the circulation of the blood, from over-distention of the vessels; its engorgement in the cellular tissue; and lastly, the action of external agents of 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 adArancement, to complete soft- ening, has been detected. During the latter part of infancy, tubercles occur Arery frequently in the lungs, pulmonary consumption being, at this period, a common 1 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.1 The disease often assumes a very acute form, and rapidly destroys the patient, Avhile 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 childhood. Sir James Clark, in his work on consumption, states, that he does not recollect to have met Avith any case in which it was pre- sent. Though a less frequent accompaniment of phthisis in children than in the adult, it is by no means invariably absent. We have ob- served its occurrence in numerous cases; and in 118 cases of pulmo- nary tubercle in children, observed consecutively, and within the same year, by Dr. Hennis Green, Avith the view of forming a ground- work for the history of phthisis in children, h/j met with five ex- amples of haemoptysis, and in a few other cases the parents of pa- tients 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 consecutively, 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 Avhich 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 other portions of the small intestines were found, upon examination after death, to be filled Avith enormous clots of blood, which were moulded over their internal surface. Tavo cases some- what similar to this have fallen under our own notice. A form of pulmonary hemorrhage 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 hemorrhage, but the artery was so completely flat- tened between two masses of diseased bronchial glands, that the pas- sage of the blood was interrupted, and death took place as from dis- ease of the heart. 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 and2,206; 2 and 5, 256; 5 and 10,140; 10 and 15, 136.—Total 963. Being 3.7 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 tuberculization of the lungs in chil- dren is distinguished from that of adults, is the much larger surface of the lung it occupies, its more rapid secretion, and its more frequent complication with tubercular disease of other organs. Hence, chil- dren often sink under phthisis before the complaint has arrived at its third stage, Avhile, on the other hand, the modifications produced by an extensive diffusion of tubercular matter, often render the diag- nosis obscure and difficult. We have, in addition, the peculiarities occasionally induced 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 de- cide 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 Adscera; in the brain it may excite hydrocephalus or meningitis; beneath the serous membrane of the chest, pleurisy; in the abdomen, peritonitis; in the intestines, ulcera- tion. These complications rarely fail to undermine the resisting power of the little patient; diarrhoea sets in, and death ensues long be- fore the period at which a fatal termination takes place in the adult. The symptoms which constitute hectic fever in the adult are sel- dom 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 qnce. In the bronchial glands, tubercles Avere 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 boAvels, six- teen 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, Avere 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- fine 1. 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. Oless, 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 cliil- 110 DISEASES OF CHILDREN. dren, he only found the lungs free from tubercles once. This was in a boy 11 vears of age, Avho, besides a considerable serous effusion into the ventricles of the brain, had tAVO 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 Avhom the disease Avas not confined exclusively to the lungs. In children, M. Cless found only three cases out of twenty in which all other organs Avere free. In 146 adults, in Avhom the lungs were dis- eased, vomicae Avere found 105 times. In children there Avere 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, Avhich causes death be- fore passing onto suppuration; moreover, young children are fre- quently carried off by other diseases superadded to the tubercular deposit, such as acute hydrocephalus, &v. 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 Avere tubercles in the pleura. In 61 adults, and four children, the tubercles Avere limited to the peri- toneum eight times. The four children were betAveen six months and ten years of age. In 152 adults affected Avith tubercles, the small intestines were affected 83 times, and the large intestines 37 times,—and in 21 chil- dren 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 pa- renchyma 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 Avithin 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 in five 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. Ill 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, ;i rubbing sound or a bellows murmur, during the first sound of the heart. It is not considered a A-ery grave affection, especially when partial and occurring Avith rheumatism; it is more so when general. The occurrence of pericarditis, as a complication of scarlatina, is noticed by Drs. Joy, Burrows, Bird, Von Amnion, and others, and attention has been recently directed to the fact in a paper by Dr. Alison: Ave doubt, hoAvever, 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, Avere 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 giA-en by Rilliet and Barthez. By these the two affections would appear to be of very nearly equal frequency. Those gentlemen, however, are of opinion that children are much more disposed to dilatation than to hy- pertrophy of the heart—Avhich 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. CarsAvell tu- bercle 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 dark, muddy complexion, with hazel eyes, and black hair. In 1 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 groAv 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 Avant of ventilation, by humidity, or by impurities; from long-continued exposure to a degree of cold, insufficient to pro- duce inflammation; from neglect of j)ersonal cleanliness, and from de- ficient 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 Aveight 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 arc 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 con- junctiva; and of inflammation of the external meatus or deep-seated portions of the ear, giving rise to long-continued and highly offen- sive discharges from that organ, and often to a complete destruc- tion 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 Barthez. Agree- ably to the observations of these gentlemen a very remarkable diffe- rence 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. 113 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 Avere putrescent. In a twelfth case, the existence of granulations was detected 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 abscesses. 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 eveir 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 Avhich 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 com- plications, to produce a fatal termination.1 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 1 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 6, 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. Genuine diabetes is said to occur in infants, accompanied with a co- pious diarrhoea, intense thirst, and rapid emaciation. Cases are men- tioned by Isenflamin,1 Morton,2 McGregor,3 Willis,4 Venables,5 Mott,fl and others; we have never met with them. During the twenty years. preceding 1845, but one death is reported to have occurred in Phila- delphia from diabetes, in an infant under five years, and one in a child between 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 remedied 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 en- dure the presence of its contents, until they are evacuated by a Arolun- tary 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 h 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 0Arer the sphincters of the bladder; or to a morbid irritability of the bladder itself, causing it to expel the urine almost as soon as it reaches its cavity. We have seen many instances, in Avhich incontinence of urine was a con- genital affection—the urine dropping constantly from the urethra; in 1 Uber die Eingeweide, 1784. * Phthisiologiae, Lib. I. cap. viii. 1697. ' Lond. Med. Gaz. vol. xx. 4 On Urinary Diseases. • On Diabetes, 1825. • Amer. Med. and Philos. Register, v. i. p. 387. PATHOLOGY OF INFANCY AND CHILDHOOD. 115 a majority of these cases, the patients died early, from disease of the brain. Most of the acute diseases of infancy and childhood are attended Avith more or less febrile reaction, Avhich usually assumes the remit- tent type, with exacerbations towards evening, or during the night. Gastro-intestinal irritation or inflammation, Avhich,* 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 peculiar to children; and attributed, by many of them, to the pre- sence 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 Avith it. The same is true of the bilious and yelloAv fevers. It is more than probable that typhoid fe\*er 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 considered as enteritis in children, as well as of that form of fever Avhich has been vaguely denominated AArorm 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 attacked, and fall victims to the disease.1 A most interesting paper on the typhoid fever of infants occurs in the Archives fur Physiologische Heilkunde. It is by Dr. Friedleben. and presents the results of his obser\Tations during four epidemics of the disease: the first extending from February to April, 1844, and from July to August in the same year. Then in January and Feb- ruary, 1846, and during July and August, of the same year. During the months of January and February, 1846, the fever was confined almost exclusively to children, affecting the adult more particularly during April and May. In the course of the three years from 1844 1 In Philadelphia during the ten years preceding 1845, the deaths of children from "ever are as follows:— Umler 1 Between 1 Between 2 Between 5 Between 10 ., T year. and i years. and 5 years. and 10 years. and 15years. lulal,(- Intermittent, 4 2 6 3 1 16 Remittent, 20 14 37 43 14 128 Bilious, 3 6 11 8 8 o<; Typlius, 4 2 18 -22 23 69 Typhoid, 4 5 12 22 14 57 Congestive, 9 3 5 3 1 21 Inflammatory, 8 0 0 3 0 c, Brain, 3 1 . 2 1 0 7 Mesenteric, 0 0 1 0 0 1 Miliary, 0 1 1 0 0 2 Hectic, 1 1 2 1 1 6 Fever, without any dis- J58 25 42 16 5 146 tinctive appellation, 109 59 137 122 67 494 116 DISEASES OF CHILDREN. i to 1846, both inclusive, Dr. Friedleben had under his charge 1842 children, (880 boys, and 962 girls,) of which 98 cases were of typhoid fever, namely, 46 boys and 52 girls. Among these only one was under one year, 23 ranged from two to five, 32 from five to eight, 22 from eight to eleven, 12 from eleven to fourteen, and 8 were above fourteen. The epidemic, therefore, fell with its greatest force on children between the second and eleventh years, and was more pre- valent in winter and summer than in autumn and spring. The pathological characters of the disease, as exhibited in those Avho fell victims to it, are thus described by Dr. Friedleben. The glands of Peyer were much swollen, some of them being a line and a half in thickness. The swelling was not, however, always uniform,—the centre being frequently more elevated than the mar- gins. Their surface was unequal, owing to the presence of capsules, which gave them the appearance of ulceration. The number of the diseased glands varied from six to twenty. They were of a bluish- livid tint, soft, and easily detached. No change seemed to have oc- curred in the other coats of the intestine, with the exception of the sub-glandular cellular tissue, which presented the appearance of soft- ening. Such were the appearances noticed in cases which proved fatal before the twenty-third day. When the disease was protracted beyond that period, induration of the glands occurred. According to Dr. Friedleben, all the glands which became deve- loped before the twenty-first day were the soft (follicles,) those later, the hard (glands of Peyer.) His observations establish the views of Rilliet and Barthez, as also those of Barrier, on the progress of in- flammation of the glands. Severe ulceration of these may occur in exceedingly young subjects,—they were witnessed in the case of a child only tAvo years and a half old. They may take place at a very early period of the disease, even on the eighth day, but cicatrization does not begin before the twenty-first day,—its progress is found to be more rapid than in adults. The mucous membrane is usually sound, being changed in appear- ance only in the immediate vicinity of the glands. In one instance, the mucous membrane of the stomach was observed to be inflamed. The submucous cellular tissue was always natural. Changes were invariably discovered in the mesenteric glands,—they were usually red and SAvollen, particularly at the beginning of the disease,—infil- tration and softening were rare,—and, in the opinion of Dr. Fried- leben, the former only occurs in very serious cases, where there has been disorganization of the condition of the blood. The general conclusions are as follows:— 1. The glands of Peyer, and, as a consequence, the mesenteric, are the local seat of the typhoid fever of the infant. 2. During the first three weeks there is only simple inflammation of the follicles. 3. This may terminate in resolution without ulceration. 4. When ulceration takes place, the progress of cicatrization is very rapid. PATHOLOGY OF INFANCY AND CHILDHOOD. 117 5. When the morbid action extends beyond the twenty-first day, infiltration of the glands of Peyer may occur. 6. The infiltration begins in the glands in the proximity of the great intestine. 7. This leads necessarily to ulceration. 8. In this form of ulceration cicatrization takes place very slowly. 9. After the twenty-first day, the two forms of ulceration may be discovered in conjunction. 10. In all the cases terminating favourably, and in the generality of those ending in death, the mesenteric glands are only affected by a simple inflammatory softening. 11. Changes in the spleen occur simultaneously with those above described. 12. All the complications which happen before the twenty-first day are of a very distinct inflammatory character. 13. The chemical character of the blood agrees with that state. The general observations, made in reference to the diseases inci- dent to infancy, will equally apply to those of the earlier period of childhood. Though cutaneous affections are still frequent, yet the skin is less liable to disease, than during the preceding stage of exist- ence. Furunculi, or circumscribed phlegmonous inflammations of the skin, are common at this age. The respiratory mucous mem- brane, as well as that of the alimentary canal, become readily irri- tated and inflamed. The brain, also, from the great activity of its functions, is now peculiarly exposed to disease; hence, violent pains of the head, and 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 hyperemia, and to irrita- tion 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 scrofulous 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. Dr. Fuller, in his very excellent Treatise on Rheumatism, Gout, etc., sets down the period of life during which acute rheumatism generally occurs as that between fifteen and fifty—feAv cases occur- ring either earlier or later in life. We have, however, observed well marked attacks of rheumatism to occur quite frequently in young children,—so frequently, indeed, as to lead us to a belief that it is a more common disease in early life than is generally supposed. Dr. Fuller reports sixteen cases as occurring in pa- tients between five and fifteen years of age. In one instance only was the patient under the age of ten. He has had, howeA-er, under his care at the hospital, a child only eight years old, suffering 118 DISEASES OF CHILDREN. from dropsv and diseased heart, the result of two attacks of rheuma- tism, one of which occurred at the age of two years and nine months, and the other at the age of six years and four months. # Dr. Heber- den reports that " rheumatism had appeared as early as in a child of four years old.7' Dr. Watson states in his Lectures that he has "frequently seen it in children, sometimes as early as the third or fourth year;" and Dr. Davis states, (Medico-Chirurg. Rev., Oct., 1817,) that "several cases of acute rheumatism were admitted, oc- curring in children of three, four, five, six, and seven years, and upwards." We have met with many cases of the disease in children between two and ten years of age. The heart readily sympathizes with the various irritations that occur in the other organs; hence, most of the diseases which then take place during childhood, are accompanied with febrile symptoms of a more intense character than in infancy. The causes of disease are nearly the same during infancy and child- hood, as in the subsequent periods of life—from but feAv 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 boAvels, inflammation of the different organs; hydro- cephalus, 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 operative in the infant; and are seldom the cause of serious disturbance in the child. Violent excitement of the nervous system, howeA'er, 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. NotAvithstanding the lively and cheerful disposition, so common in childhood, its quick forgetfulness of past suffering, its little anxiety for the future, and its perfect contentment Avith 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. 119 and over-rigid discipline—confinement from childish amusements and exercises—indiscreet ridicule of faults or imperfections, and the withholding every species of encouragement; the spirits, even of the ehild, may be depressed, and discontent, hatred, jealousy, may be engendered, and become the remote or exciting causes of serious dis- ease, 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, transmitted 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 where no such deterioration of the milk is suspected, the health of the female being apparently unimpaired. A very interesting paper on this subject, by M. Girard, has recently appeared in the Archives Generates deMedecine; in Avhich is pointed out the importance of testing the character of the milk by a microscopic examination in all cases in which the infant, when nourished solely by the breast, becomes affected with symptoms of indigestion. 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 stimulating diet; the use of vinous or distilled liquors, more espe- cially if taken in excess, and articles of food of difficult digestion, can- not fail to affect the secretion of milk, and render the latter unfitted for the nutriment of the infant Avho partakes of it; milk thus deteri- orated Avill 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 con- sequence of the milk containing an amount of caseum, to the diges- tion of which the stomach of the younger child is inadequate; the proportion of caseum in the milk of the human female always aug- menting Avith 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 Avho partakes of it. When the catamenia are sus- pended during the first eight or nine months subsequent to parturition, and then reappear, there Avill, 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 Avill very generally suffer if it be continued at the breast. But Ave are by no means convinced that every occurrence of the menses, during lactation, is calculated to produce similar effects upon the milk. We have knoAvn scA'cral females avIio menstruated % 120 DISEASES OF CHILDREN. 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. 121 diately upon the nervous system. The convulsions which occur with- in the first two or three months—trismus nascentium, spasm of the glottis, in young infants, and other spasmodic diseases,—seem evi- dently to result from the action of impure air upon the nerA'es. In children exposed, for any length of time, to the influence of a corrupted or confined atmosphere, the powers of life become de- pressed ; 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 imperfect- ly lighted apartments, even where no cause exists capable of impart- ing 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 Avell 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 coun- try situations, compared with those who are brought up entirely with- in the confines of a large and crowded city. Alison and Baudelocque ascribe more influence in the production 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 influence of even a slight impression of cold. Exposure to too Ioav a degree of atmospheric temperature; to draughts of cool air, Avhen 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 Avhich, in children, the heat of the surface is reduced, and the organism subjected to the deleterious influence of cold, and inflammations of the alimen- tary 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 Ioav, 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 they occupied during the day; by their throAving off the clothes, during sleep, Avhen heated or in a state of 122 DISEASES OF CHILDREN. perspiration, or by the cradle or bed, in which they repose, being placed in a draught or current of air. The injurious effects of cold and dampness are not always exhibit- ed in the immediate production of acute disease. Continued expo- sure to a cold and damp atmosphere, in early life, by depressing the vital powers of the organism, may gradually undermine the health of the system, or give rise to chronic affections, the existence of which is 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 Avhich children are liable, and invariably render it more unmanageable. Intense heat, which is ahvays more or less injurious to infants, be- comes, under certain circumstances, a fruitful source of disease in early life. Thus, Avhen succeeded by a sudden reduction of tempera- ture, or Avhen the body is accidentally exposed to any cause by Avhich 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 in- fected 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 dis- eases; 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 most commonly during the autumnal months. The spring or autumn is the season during which the epidemics of scar- latina, measles, and hooping-cough, usually prevail; while small-pox is more common during the Avinter. 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 ther- mometer averaging from 32° to 35°. The smallest amount of mortality occurred in the months of April, May, October, and November, namely, 4sl5j the mean of the thermometer ranging from 45° to 65°. The relative mortality of children under five years, compared Avith 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, 123 March, inclusive, 45-32 per cent., and during the remaining four months, 41-39 per cent. The folloAving 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 iind Total number of deaths at all ages. No. Total deaths in children under fif-teen years. Julv3297 Aug. 2709 June 2080 Jan. 1<67 Mar. 1869 Apr. 1092 Sep. 1638 Feb. 1534 May 1495 Oct. 1350 Dec 1214 Nov. 1143 In Child'n under 1 year. Between 1 and 2. Between 2 and 5. Between 5 and 10. Between 10 and 15. July, 77° 4631 August, 75° 4604 January, 32° 3627 March, 40° 33'9 June, 70u 3 '72 April, 50" 3179 February, 32° 3171 May, 60° 3063 September. 65° 2904 October, 55° 2854 Voveinber, 45° 2537 December, 35° 2489, July 1869 Aug. 1310 June 1052 Jan. 861 Mar. 762 Apr. 674 Sept. 642 Feb. COS May 557 Oct. 480 Dec. 457 Nov. 429 Aug. 733 Jan. 409 July 715 Mar. 4i^ Sep. 430 July 402 Mar. 354 | Apr. 381 June 351 i June 378 Jan 344 ; May 366 Apr. 330 : Aug. 357 Feb. 318 Feb. 323 Oct. 288 Oct. 317 Sept. 283 Sept. 312 Dec. 217 Dec. 292 Nov. 201 , Nov. 291 Mar. 191 Apr. I'll Aug. 18r-; Jan. 170 June 166 Feb. 161 July 159 May 155 Oct. 144 Dec. 130 Sept. 129 Nov. 113 May 64 June f-3 July 62 Feb. 56 Sept. 55 JAug. 53 Jan. 53 Oct. 55 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 Avith 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 respective mortality: Ratio of children to whole | mortality. j Ratio in infants under Ratio in infants under one year. two years. June, 61-7 per cent. July, 61- " , Aug. 58-8 " I Sept. 56-5 " Mar. 55-3 " April. 53- « . May, 48-8 " Jan. 48.7 " Dec. 48-7'/ " Feb. 48-37 " Oct. 47-3 " ! Nov. 45- « July, 40-7 per cent. June, 31-37 « Aug. 28-4 " Jan. 23-46 « Mar. 22-55 " Sept. 22- « Apr. 21- " Feb. 19- " Dec. 18-3 « May, 18- " Nov. J 6-9 « Oct. 16-8 " July, 56- per cent. Aug. 44-37 " June, 4L-6 " Sept. 36- " Jan. 33- " Apr. 31-58 " Mar. 30- " Feb. 29. « May, 27-42 " Dec. 27- « Oct. 26-9 « 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 124 DISEASES OF CHILDREN. tirely independent of the presence of these animals, and may con- tinue, notwithstanding the destruction or removal of the latter. The first dentition is frequently accused of being the immediate cause of the diseases Avhich 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 in- variably 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 pe- riod, 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 boAvels have been brought previously into a state of morbid irritability, excessive vomiting and purging, fever and other symptoms of more severe disease may be induced. In other cases, Avhen 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 ex- posure to a cold, damp, and confined atmosphere, or by deficient or improper food, the irritation, developed during the process of teething, f may induce the peculiar gangrene of the mouth of children, to which the terms cancrum oris, water canker, &c, have been applied. In Philadelphia, and other large and croAvded 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 irritation of the stomach and bowels, but in consequence of the in- creased amount of blood which it attracts to the vessels of the head and face, the tendency to disease in these parts is increased; hence, convulsions, ophthalmia, inflammation of the glands of the neck, ul- cerations behind the ears, eruptions of the face and scalp, meningitis, and hydrocephalus, 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 pre- vent the development of certain parts of the body, and by too early attempts 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, wc 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 occurrence than after the period of puberty. SEMEIOLOGY OF INFANCY AND CHILDHOOD. 125 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 se- cretions and excretions, the appearance of the eye, the manner in which respiration is performed, have the same amount of value, as in- dications 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 expe- rience—constituting, in many cases of disease, an important patholo- gical feature—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 modification's, dependent upon the peculiar state of the organization, differ, nevertheless, but little from-those observed in the a^ult. There are, hoAvever, 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 Avith 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- 12G DISEASES OF CHILDREN. spective functions. It is only from the nature and extent of the de- viations from the normal standard, that, in many cases, he Avill he en- abled to .appreciate the \Talue of the morbid phenomena that exist, either individually or collectiArely. 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 inA'estigated; and it is curious, that not a feAv of the phenomena Avhich Avriters 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. AVe 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, Avhen 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 uneasi- ness. 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 t<> as much activity as its limbs will permit, and exhibits a surprising springiness and rapidity in all its movements. It delights to be played with and carried about, and, when old enough, to roll and craAvl 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 ap- peased, Avithout our being able to detect any apparent cause of suf- fering, and without any interruption to the full nutrition, and regular development of their bodies. Every deviation from Avhat 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. 127 meagerness—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 suspi- cious eye, and be the signal for a careful examination into the con- dition of its several organs; in one or other of which, some com- mencing disturbance 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 un- wonted 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—unaccus- tomed fretfulness—frequently repeated or prolonged fits of crying. or a marked change in the character of the cry—frequent or constant corrugation of the brow—twitching of the muscles of the face—re- jection of the breast, or of food—unusual moA'ements of the head and limbs—and crying or moaning Avhen the body is moved or handled, are inA-ariably 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 sudden- ness with which some of the most violent affections of this period of life are enveloped, and the rapid occurrence of effusion or of disor- ganization, in the tissues and organs in Avhich morbid action is seated, give to every indication by which the inception of disease can be de- tected, even a greater degree of importance than in after life. In their commencement many of the maladies of infancy may be promptly arrested by simple remedies, that if allowed to become fully deve- loped, are scarcely Avithin the control of the most judicious and active plan of treatment. A slight irritation of the gastro-intestinal mucous membrane of the infant, Avill often, by being suddenly reflected upon the brain, give rise to a violent convulsive attack, or produce some other and equally se- rious train of symptoms, Avhich 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 arc 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,- 12* DISEASES OF CHILDREN. at a period when it is still within the control of appropriate reme- dial 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 condition 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, Ave 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, Avhich 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, Ave may determine the location of its diseases, in one or other of the great splanchnic cavi- ties—the disturbed expression of the upper part of the face, the fore- head, eyes, and brows, indicating disease of the brain, or of the ner- vous system; the altered features of the middle portion of the face, particularly 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 Ave are convinced that from the condition of the countenance alone —often from some indescribable expression of suffering—the obser- ving physician will be able to detect, at once, the existence of dis- ease, 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 re- action, 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 liATer, 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 at- tacks, or of acute meningitis. In extreme cases of exhaustion, particularly from profuse evacua- tions from the boAvels, 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 Avith dark-coloured blood; the cor- SEMEIOLOGY OF INFANCY AND CHILDHOOD. 129 nea covered with a thin film of mucus; and the orbitar circle is of a livid or dark-broAvn colour. In the acute affections of the head, the face is usually flushed, somewhat 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 pro- tracted cases of cholera infantum. Deep blueness of the countenance, in young children, is indicative of morbus cceruleanus, arising from an impediment to the free circula- tion of the venous blood. It usually exists from birth, and is in- creased 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 ahvays 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 boAvels, the nose and upper lip are often tumefied. A peculiar puckering of the corners of the lips is frequently 9 130 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 Avrinkles, 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 pro- jecting. The whole countenance presents, indeed, a faithful minia- ture 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 frequently, and it is only from its fixed or permanent dilatation, or contraction, 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, hoAvever, to temporary strabismus. 2-—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 Avhen 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 countenance, are successful. The cooing, chirruping sound, with which they expressed their feeling of satisfaction or delight, gives place to perfect silence, or to a short querulous plaint Avhen 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 be- ing continued, and the position assumed by the body and limbs is expressive of extreme languor. When in suffering, particularly in cases of intense abdominal pain, SEMEIOLOGY OF INFANCY AND CHILDHOOD. 131 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 limb 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 Avalk- ing, 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; particularly if he exhibit, at the same time, great languor and list- lessness, and complain of frequent pain and twitchings in his thighs, we may suspect some disease of the lower portion of the spine, proba- bly caries 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 may be 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 in- dication of convulsions. An opposite condition, or when the fingers and toes are forcibly extended, whilst the first are semiflexed upon the metacarpus, and this, at times, upon the carpus, and in the same manner the toes upon the metatarsus, is a common attendant upon laryngismus 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 jaAv. This condition has been attributed to retention of the meco- nium, or to inflammation of the vessels of the cord:—it is more ge- 132 DISEASES OF CHILDREN. nerally, Ave suspect, produced by a confined and impure air, or cer- min conditions of the atmosphere, endemic to particular localities. Durin"- 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 ge- neral 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 tAvo, 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 paralyzed 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 precur- sors 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, Avhen they occur in the course of protracted maladies, unfavourable symptoms, and depend upon disease of some portion of the brain. 3.—The Phenomena during Sleep. In a healthy infant, sleep is calm and profound; the position is, generally, upon the side, Avith the limbs perfectly relaxed; the respi- ration is full, slow, regular, and quiet. The eyelids are never for- cibly 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. 133 supply the previous deficiency in the function. This has sometimes been mistaken for an indication of disease; it is, howeArer, 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 tAvo, the intervals of waking and repose be- come 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 conva- lescence from acute affections. Sudden starting from sleep, with a wild, alarmed expression of countenance, or Avithout 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, Avithout awaking, the child sobs, or utters words or indistinct sentences; this is, generally, produced by the occurrence of dreams, excited by in- testinal irritation, or by the presence of too much or improper food in the stomach. An unusual degree of somnolency in general indicates hyperasmia 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 134 DISEASES OF CHILDREN. or morose, is, very generally, an indication of disease of the alimen- tary canal. 4.—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 crying, or the continued plaintive cry of distress. In new-born infants, loud and vigorous crying is always an un- equiArocal 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 become 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, Avhen 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, with- out 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, Avith, 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, croAving, and difficult respiration, 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 engorge- SEMEIOLOGY OF INFANCY AND CHILDHOOD. 135 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 alow, sibi- lant prolongation, there in general exists some disease of the glottis. Fretfulness, or peevishness, when habitual, or occurring in children Avho 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 dis- ease. Habitual fretfulness, or its sudden occurrence, should, there- fore, 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 diffi- cult from the increase of pain to which it gives rise. Difficult respiration, attended Avith 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 indi- cation 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 hyperemia of the lungs, and in cases of exhaustion, or debility of the respiratory muscles. The 136 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; Avhen rare, there in general exists debility of the muscles of respiration; a quick and rare respiration exists in plcu- ritis, or it may occur from exhaustion, from violent exertion of the re- spiratory muscles; it is also present in pneumonia, chronic bronchitis, 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 induration 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 respi- ratory organs from the alimentary canal, or from disease of the brain. In the first case, it is generally attended with mucous expec- toration; in the second, it is usually dry and irritative; and in the last, spasmodic. A short, hacking cough, with little expectoration, is present in pleurisy, and in the incipient stage of tubercular phthisis. Con- tinued cough accompanies inflammations of the larynx, trachea, bronchi, and lungs. Intermittent cough is a symptom of croup, laryngismus stridulus, and hooping-cough. In the commencement of inflammation of the respiratory organs the cough is dry, but is soon accompanied Avith 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 pe- culiar barking, or crowing sound; in hooping-cough, a loud shriek- ing sound; and in the early stage of bronchial inflammation, previ- ous to the occurrence of effusion within the bronchi, it has a whiz- zing 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. Hiccough 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. 137 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 pa- rietes 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. Aphthae of the tongue and mouth, are the result of follicular in- flammation; they may depend upon improper food and vitiated or confined air; or they may be developed by dentition, or be symp- tomatic 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 children. A diminished secretion of saliva takes place in most of the acute and febrile affections that occur during childhood. Great dryness of the mouth, Avith 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, 138 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, ahvays 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 loAver 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, irrita- tions of the alimentary canal, or irritation of the lungs connected Avith tubercles. A uniform redness, or rosy hue of the surface, is the indication of health in infancy; when, hoAvever, the lymphatic temperament is strongly marked, the skin, particularly of the face, may be pallid and puffy, Avithout the existence of positive disease. Such a condition of the skin should, hoAvever, be always a Avarning for additional precau- tions in the hygienic management of the child, lest a scrofulous con- dition of the lymphatic glands, or tubercular depositions occur. This state of the skin is common in children who are too much confined Avithin 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 in- flammation 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 Ave have knoAvn 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 AArhich prevents the oxygenation of the blood in the function of respiration. YelloAvness 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 yelloAv 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. 139 In protracted diseases of the liamentary canal—chronic diarrhoea, cholera infantum, &c.—the skin assumes a sallow, dirty yelloAV, or broAvnish 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, Avith increased redness, and subsequently with a shining whiteness, is an indication of one of the most common vari- eties of gangrene of the mouth. Tension of the abdominal integuments, Avhen 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 Avithin 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, Avherever 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, Avith an abatement of their respective symptoms, is, in general, a favourable indication; but Avhen 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, Avith sunken eyes, a livid hue of the coun- tenance, and short, sIoav, imperfect respiration, is a sign of great prostration, and is always an unfavourable occurrence. The natural odour of the SAveat in young children is acid; in the miliary eruption, the acidity is very decided. In particular forms of cutaneous eruption, the SAveat 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- 140 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 generally connected with disease, either acute or chronic, of the di- gestive 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 diarrhoea, and in protracted cases of cholera infantum. Petechias 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 pricking of the skin are produced by gastric derange- ments or intestinal irritation. Itching of the nose is a common symptom 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 dis- turbance of the digestive function. When the breath of an infant is decidedly acjd, it is usuallynn con- sequence of imperfect digestion of the food, and hence the occurrence of an acid breath is generally accompanied, sooner or later, with diarrhoea 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 fetid state of the breath may arise from indigestion, from dis- ease 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 scar- latina anginosa. A rancid smell of the breath is, ordinarily, the result of indiges- tion, 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 ease, being decidedly SEMEIOLOGY OF INFANCY AND CHILDHOOD. 141 acid. Repeated vomiting is, in general, hoAvever, 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 any thing 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 bowels, is common in infants during the heat of summer, particularly at the period of Aveaning, or during dentition:—Avhen 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, ema- ciation, is common in infants who are deprived at an early period of thq 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 boAvels 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 boAvels. 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 or- gan. When profuse or long continued, it often proves fatal by the great exhaustion produced. Immediately after birth, the discharges from the bowels are of a very dark green or black colour1—the meconium. During the early period of infancy, the discharges are of a soft, curdy consistence and appearance, occasionally tinged with bile and Avithout fetor; during 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 func- tion; generally from over-feeding or improper food. Discharges of slimy mucus occur in irritations of the bowels, from i 142 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 impres- sion 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 fetor, 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 sto- mach 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 fetid. In cases of worms, and in certain cases of intestinal irritation from other causes, the discharges from the boAvels 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 Avith a diminished secretion of bile. Worms are occasionally passed with the stools, during the latter period of infancy, and in childhood, AArithout any symptoms having been present to indicate their existence. A diminution in the number of stools, Avhen diarrhoea occurs as a symptom of the diseases of children, Avith 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 infantile 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 substance 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 boAvels, 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 faeces, 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 in- flammation of the intestines. Constipation often exists in the early period of many of the acute SEMEIOLOGY OF INFANCY AND CHILDHOOD. 143 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, Avhile in other cases partial or ge- neral conA-ulsions 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 fre- quently 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 in- creased floAv 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 Avith 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 knoAvn it, also, to be a symptom of Avorms in the rectum. Scanty urine occurring towards the decline of scarlatina, and other 144 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 di- mension of the long bones, particularly, if, at the same time, there is not a correspondent but rather a deficient de\Telopment in the dimen- sions of the chest, very generally indicates a predisposition to tuber- cular disease of the lungs. A rapid increase of the osseous structure in length, is a very fre- quent occurrence toAvards the decline or immediately after fevers, especially the febrile exanthemata. With this direction of the nutri- tive process, the deA-elopment of rachitis and tubercles, so generally consequent upon rapid growth, Avould 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 occa- sionally occurs in the upper extremities, from imprudently lifting an infant by the arms. Curvature of the bones is also one of the symp- toms 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 equi- librium 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. ON THE DISEASES OE CHILDREN, PART II. 10 A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. SECTION I. DISEASES OP THE DIGESTIVE ORGANS. CHAPTER I. DISEASES OF THE MOUTH. STOMATITIS.—INFLAMMATION OF THE MOUTH. 1.—Erythematic Stomatitis. Erythematic inflammation of the 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 prompt- ly—while in others it assumes a considerable degree of severity, and causes intense 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 pain 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, refusing 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 crack, and not unfrequently becomes affected with herpes. 14S 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 du- ration, 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 OA-er-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 emol- lient 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 de- gree of severity, it may be necessary to apply a leech or two at the angle of the jaws. In aggraA-ated cases of the disease, we have de- rived advantage from Avashing the parts affected with a Aveak solu- tion of acetate 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 the latter. 2.—Erythematic Stomatitis with curd-like Exudation. A common result of erythematic stomatitis is the secretion of a Avhite matter, which appears, usually, in the form of small points or patches, resembling minute portions of curd, adhering to the surface of the inflamed membrane; this is particularly the oase 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 aphthce 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 the latter 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- mach and bowels. If the mouth be now examined, the Avhole of its DISEASES OF THE DIGESTIVE ORGANS. 149 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, Avhich often extends jnto the fauces, pharynx, and in some cases into the larynx. The general symptoms connected Avith this form of stomatitis vary Avith 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 Avhen this is warm or in the slightest degree stimulating. 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, Avith 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 Avith 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 malignant character, and is then attended with very considerable danger. The patches of exudation acquire a dark colour—the breath becomes fetid—the submaxillary glands enlarge and become painful __and the face swollen, and of a dusky red. The lips and gums be- come tumid and bleed upon the slightest touch—while a fetid sani- ous saliva Aoavs constantly from the mouth—diarrhoea, also, often attends, the discharges being dark-coloured and highly offensive— the surface of the body becomes dry and hot, and the child sleepless 150 DISEASES OF CHILDREN. and restless: finally, the patient sinks; death being occasionally pre- ceded by a deep comatose 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, ill-ventilated rooms. By some Avriters it has been supposed to be communicated by con- tagion; Ave know of no facts, hoAvever, 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, hoAvever, 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 Ave have already remarked, with aphthae, in connexion with which it occasionally occurs. Breschet, Guersent, Veron, Lelut, and Billard, have studied both diseases Avith 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. Tpon the separation of these morbid exudations, the membrane be- neath is found to be smooth, and without solution of continuity; this fact we have tested in numerous examinations. According to Guer- sent, the morbid curd-like exudation is deposited beneath the epithe- lium, 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 Avhole 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. 151 a case in which the disease Avas 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 Avith stomatitis Avith 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, Gucrsent advises a fourth part of chloride of soda to be added to the mucilaginous wash, and Billard a small quantity of alum; while Dr. Darling speaks in the highest terms of the solution of chlorate of soda, as one of the best means of subduing irritations of the lining membrane of the mouth and fauces. The application Avhich 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 saliA'a, 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, SAveetened 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 Avith 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,1 or of a strong decoction of Peruvian bark with chloride of soda;2 a mixture of creasote and mucilage,3 or of vinegar and alcohol,4 or a solution of nitrate of silver, 1 R.—Mucilag. acaciae, §j. ' Creasot. gtt. iv. Calcis chlorin. gr. xv. ad xxx. Mucilag. G. acaciaj, gss. Syrup, cort. aurantgss.—M. {Angelot.) Aq. Camphorse, gyiij.—M. a Decoct, cinchonae, ,^iij. * Aceti, 3J. Syrup, cort. aurant. ^j. Alcohol, giij. Sodse chlorin. §j.—M. (Guersent.) Syrup, simpl. £j. Aquae, ]§iij.—M. 152 DISEASES OF CHILDREN. (from tAVo 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,1 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;2 and in those in which the exudation in the mouth assumes a gangrenous aspect, quinia should be adminis- tered.3 1 Magnes. calcinat. ^j. s Calomel, gr. ij. ad iij. Rhei pulv. $j. .Magnes. calc. vel Cretoe ppt. gr. xxxvj. Ipecacuanhas pulv. gr. j. ad J^U- M. f. ch. No. iv. One to be given daily or Ipecacuanhae, gr. iij.—M. f. ch. No. oftener. xij. One to be given every two or three hours. s Aq. purse, ^iij. Sulph. quiniae, gr. viij. ad xij. Sulph. acid, dilut. gr. xv. ad xx. Syrup, simpl. |j.—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. 3.—Follicular Stomatitis. APHTHA. 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 Avhom 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 elcA^ated, and usually surrounded by a red circle, more or less decided. They may be few in number, and irregularly dispersed OArer the angles and inner sur- face 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 por- tion 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. 153 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 Avhitish matter exudes from their centre and ulceration taking place, a superficial ulcer is produced, with slightly elevated edges, and sur- rounded by a circle of inflammation. From these ulcers, there is often secreted a white curdy matter, adherent, at first, to their sur- faces; but subsequently 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 portion of blood, which forms upon them a dark-co- loured crust, that has not unfrequently been mistaken for a gangre- nous slough. Upon the disappearance of the inflammation, the ulcerated follicles readily cicatrize Avithout leaving any permanent scar. When the aphthous crusts, formed by the ulcerated follicles, be- come 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, Avhile the general layer of curdy matter continues adherent for Aveeks. 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 in- creased; 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 Avhen 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 ex- tent of the lining membrane of the mouth, the general symptoms are usually much more violent. There is then great restlessness; con- siderable pain is experienced in the act of sucking; the infant seizes the nipple eagerly, but instantly relinquishes it and expresses its suf- fering by its cries. The mouth is dry and hot, but in the course of the disease there generally occurs a profuse ptyalisin, with painful intume- scence of the salivary glands; the nipple of the nurse quickly ex- periences a sense of heat and irritation, and becomes excoriated and excessively tender. The child is troubled Avith frequent acid eructa- tions, 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 considerable peevishness or distress; emaciation quickly ensues,and is often extreme; the child is Avakeful; and occa- sionally great restlessness is alternated with dulness or some degree 154 DISEASES OF CHILDREN. of stupor. In some cases the attack is ushered in by extreme droAv- siness. 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 knoAvn extensive erysipelatous inflammation of the nates to ensue. The abdomen is generally SAvollen, 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 boAvels. 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. Occasionally, the apthous 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 fetid—saliva. The countenance becomes pale and puffy; the pulse is feeble; and the entire surface of the body, pallid, and deficient in sensibility. Fre- quent vomiting, profuse diarrhoea, and a tympanitic condition of the abdomen, generally occur; and occasionally hiccup, and frequent eructations; and the child finally dies without febrile reaction, or cerebral excitement. The termination of this form of the disease is very generally 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 pro- perties, or otherwise of a bad quality. It more frequently occurs, however, in infants, who are attempted to be nourished upon other food than the milk of a healthy nurse; or who have been premature- ly deprived of the breast. Improper or deteriorated food is, indeed, among its most common exciting causes. In infants at the breast, aphthae may result from their being at the same time imprudently fed, on thick, farinaceous substances—pap; paste composed of flour boiled Avith milk; crackers soaked in milk—especially if these are over-sweetened with broAvn sugar or molasses. Children born before the full period, or of weakly women, are said by DeAvees to be more liable to aphthous inflammation of the mouth, than children 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. 155 victuals; while as soon as all attempts at suckling are abandoned, and the infant is confined entirely to other appropriate and Avholesome food, the disease disappears, and the general health rapidly improves. The tendency to the disease is increased by every thing that impairs the general health of the infant, and impedes haematosis; as a neglect of personal cleanliness, and to remove, daily, Avith a piece of soft linen and fresh water, the sordes Avhich collect in the mouth; an im- pure and confined, or a cold, damp atmosphere; exclusion from the light; neglect of exercise; and, according to Underwood, by allow- ing the infant to sleep constantly Avith 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 common occurrence in the course of nearly all the pro- longed 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 prevailing 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 mu- cous membrane of the mouth; and Girelli states, that in the foundling hospital of Brescia, he has known the disease to be communicated to healthy infants, who had been suckled at the same breast with one la- bouring 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 EA'anson. 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, Avhite, miliary tumours; the second, of superficial ulcers. This latter view of the disease, we are led, from our OAvn 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- 156 DISEASES OF CHILDREN. tating nature of the discharges; it is a frequent occurrence, also, in cases Avhere no aphthae are present. Manv Avriters 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 Avith curd-like exudation, which is a disease seldom, if ever, met Avith, ex- cepting in young infants:—follicular stomatitis Ave 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 derived, the breast of a healthy nurse should be substituted for that of the mother; and if the infant be weaned, its food should consist, al- most exclusively, of barley or rice Avater, SAveetened 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 feAv 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- dered, in conjunction with the daily washing of the mouth Avith cool, fresh water, as a very powerful means of preventing the occurrence of the disease. An occasional dose of magnesia, or of magnesia and rhubarb, Avill, in general, be required, and will tend to remove, in part, the acid Avhich generally abounds in the stomach and boAvels. 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 Aveak 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 Avhat he terms, Cachexia Aphthosa. Of the perfect safety with which it may be employed, in this manner, and of its good ef- fects, in allaying the pain and inflammation, our own experience has fully satisfied us. In cases attended with considerable stupor, ac- cording 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 poAvder, 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. 157 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 Avater; and Billard advises the ulcers to be touched Avith 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 tAvo 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 Avith 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 o soda. Pitshaft (Hufeland's 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 tAvo 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.1 Under the use of this combination, the irritation of the boAvels is very often quickly diminished, the griping stools are suspended, and the general symptoms of the case improved. 1 Acetat. plumbi, gr. vj. ad xij. Calomel, gr. iij. Ipecacuanhae 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 boAvels, 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 an infusion of the bark of slippery elm; and after being Avell dried, the parts which appear red and irritated, may be smeared with a little perfectly fresh lard. When the irritation is considera- ble, 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 administered. In prolonged cases of aphthous ulceration, the use of iodine, and other alteratives, with change of air, and a well-regulated diet, will, in 158 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 phlegmonous 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 Avithin a much shorter period—becomes softened, and of a yellowish hue, and, finally, a small ulcer is formed, at first superficial, 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 superfi- cial, having the appearance, rather, of slight excoriations. After ulceration has taken place, there occurs, in general, a pro- fuse 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 rapidly 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 Avill occur, which slowly extend in size and depth, and exhibit no disposition to heal; the little patient, at the same time, wasting aAvay 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 faAvn 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. 159 able appetite, offensive breath, inertness of disposition, a pale puffy complexion, and hard tumid abdomen. " It may also occur in the course of other acute or chronic dis- eases, as pneumonia, eruptive fevers, &c, which entail constitutional injury. It is endemic in certain wards of the Hopital des Enfans Trouves, according to M. Taupan, who also believes it to be contagious—that is, to be communicable by using the same spoon for feeding, &c. And occasionally, also, it would appear to prevail as an epidemic." (Churchill, Diseases of Infants and Children.) The treatment differs but little from that directed for aphthous ulceration. When unattended with serious derangement of the di- gestive 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 Aveak 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. Cinchonse, gij. " G. Acaciae, 3J. Mellis, gij. Aq. purae, ^iij.—M. With this wash the ulcers are to be touched twice a day, with the point of a camel's hair pencil. Dr. F. W. Mackenzie of London, in cases of ulcerative stomatitis, gives the preference to the folloAving method of treatment. It con- sists in removing, in the first place, any apparent cause of irritation, such as a decayed tooth, should it exist, and in applying daily, the dilute nitric acid of the pharmacopoeia, to the whole of the ulcerated surfaces, by means of a sponge, or camel's hair pencil, whilst, at the same time, the sesquicarbonate of ammonia is given in full doses, combined with citrate of iron. When the tongue is coated, and the alvine discharges are unhealthy, it is necessary to premise an emetic of ipecacuanha and squills, as well as a purgative of calomel and rhubarb. It is also necessary that the patient should be well sup- ported by a nutritious diet, and an adequate allowance of malt liquor or wine. The application of the dilute nitric acid, Dr. Mackenzie remarks, appears to have a remarkable influence in improving the character of the ulceration and arresting its progress. The sloughy, dirty, yellowish appearance, which it generally presents is soon changed for a florid, healthy, granulating surface, and this result would appear to depend upon the moderately stimulating properties of the remedy which are not disproportionate to the exhausted vital powers of the ulcerated tissues. 160 DISEASES OF CHILDREN. When accompanied with extensive derangement of the alimen- tary 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 di- gestive organs are restored to a healthy condition, and the nutrition of the system generally is improved. 5.—Gengivitis.—Inflammation of the Gums. The gums, from the period Avhen dentition commences, until the completion of the first set of teeth, are liable to become inflamed, independently of the residue of the buccal cavity. In some cases, the inflammation is but slight, and of short duration; but in others, particularly when it occurs in children whose general health has be- come impaired, in consequence of a deranged state of the digestive organs, the inflammation is often seAere,and productive of extensive ulceration, 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 pain- ful; 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, impaired appetite, and considerable thirst. The tongue is usu- ally covered with a thick yellowish fur. The patient's sleep is seldom much disturbed, 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 the destruction of the teeth. In other cases the ulceration occurs at the edge of the gum, and extends rapidly dowmvards. In every case in Avhich 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 fetid saliva, the breath becomes extremely -offensive, and the counte- nance of the child assumes a pale, salloAv hue; a bloody fluid oozes from the gums upon the least pressure, and often a very profuse di- arrhoea 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 Avith more or less—often with very extensive— derangement of the digestive organs. In the early stage of the complaint, the proper remedies are, mild emollient washes to the gums, Avith, tAvice or thrice a day, a wash of a solution of acetate of lead, (five grains to an ounce of Avater,) applied by means of a soft sponge, or dossil of lint. If the inflammation i s 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- \-ise the gums to be freely scarified, and in many instances, Avhen Avell timed, Ave have seen advantage to result from this procedure. DISEASES OF THE DIGESTIVE ORGANS. 161 The bowels should be freely opened by the administration of a few grains of calomel, combined with magnesia, and folloAved, 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. When ulceration ha's 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,1 we have found peculiarly advantageous; the chloride of lime will, also, in many cases, speedily arrest the ul- ceration; or, we may employ, as a wash, diluted hydrochlorfc acid.2 We have often found a solution of the sulphate of copper to succeed, howeA-er, when other topical applications have failed. 1 R-—Corticis Querci. gj. » R.—Acid Hydrochlor. ^ss. ad 3J. Aquai, Oss. Mellis, Boil to a pound and strain, then add— Aquae Rosae, ai ^j.—M. Sulph. Alumin. Qj. 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 sulphate of quinia may be administered; and will often very materi- ally 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. 6.—Gangrene of the Mouth. (CANCRUM ORIS—GANGRiENOPSIS—CANKER 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, preA'ailed 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 162 DISEASES OF CHILDREN. 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 sharp pains in his mouth and gums; his breath becomes more or less fetid, and there is an increased discharge of saliA'a. A sense of itching or pricking, and heat is experienced in the gums, Avhich 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 knoAvn 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 eA*ening, 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- 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, Avith the teeth, are separated and thrown off. From the gums, the gangrene, sooner or later, extends to the lips and cheeks, Avhich 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 offen- sive odour. DISEASES OF THE DIGESTIVE ORGANS. 163 The fever, which noAv often augments in intensity, presents a ner- a-ous or hectic character, and the child dies upon the eighth, or, at farthest, on the fourteenth day from the commencement of the gan- grene, his body presenting all the indications of a general colliquation. 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 Avhom 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, hoAveA*er, 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 obserAred 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 hy 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 tumor, assumes a gangrenous appear- ance, and an extremely offensive odour is exhaled from the mouth, 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 redness of the lip or cheek soon becomes paler, livid, then of a gray- ish 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, ^at 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 has reported to have been employed with advantage, were evidently those from defective or disturbed nutrition, unattended witn 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 neg- lected. The surface should be preserved of a comfortable and equal temperature, by appropriate clothing, and by rooms properly warmed and ventilated m cold weather, and cooled by the admission of a current of air, and the exclusion of the sun's rays, during the heat 01 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 excep- tion of the administration of such articles as have been found to sus- pend the action of, or to neutralize whatever poison has been taken the same remedies precisely are demanded, as in the cases of ordinal gastritis. J CHAPTER V. DISEASES OF THE INTESTINES. 1—Enteralgia—Colic Intense pain of the bowels is of frequent occurrence during in- fancy. We have already noticed its connexion with indigestion, and the means best adapted for its relief, in such cases. Enteralgia, how- ever, 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 be- 14 216 DISEASES OF CHILDREN. tween four and six o'clock, p. M.; while others have noticed its oc- currence at a regular period, 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 tympa- nitic state of the abdomen is very considerable. In other cases, how- ever, little or no flatulence is perceptible, the paroxysms of pain oc- curring 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 long 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- 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 dis- turbed or interrupted, and the general health seems, often, actually to improve; as Dr. Dewees very correctly remarks, some of the fattest and healthiest 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 v DISEASES OF THE DIGESTIVE ORGANS. 211 is generally very abundant, producing, often, a tympanitic swelling of the abdomen. The peculiarity of this variety of enteralgia consists in its being accompanied 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. Occa- sionally, two or more of these convulsive attacks will occur in quick succession, and then days and weeks will elapse before their return. If not arrested, however, they become more frequent and distressing; and at length the infant 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 contracted, being reduced, in some parts, for more than an inch in extent, to the size of a goose-quill; in other parts, the caliber 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 unfortunately 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 in- testines. 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 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 habitually constipated state of the bowels, and the paroxysms are often excited by allowing the feet to become wet and cold. The disease is not necessarily connected with any degree of inflammation of the alimentary 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 Avarm water, and enclosed in a thin gauze bag. The bowels should 212 DISEASES OF CHILDREN. be opened by an injection of warm water, to which a few grains of asafoetida, dissolved in milk, may be advantageously added. Inter- nally Ave 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, tAvo, 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 filtered, ten grains of bioarbonate of soda are to be added; of this, ten drops may be given to a child within the month, in a little sweetened aniseed water—the same dose being repeated after an hour, if necessary. 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, antispas- modics, particularly the asafoetida, to be given by the mouth, and as an enema. According to the age of the child, from two to five grains of asafoetida 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 asafoetida is not retained upon the stomach, or produces, when injected into the rectum, an unpleasant irritation, the rectified oil of amber, two to five drops, rubbed up with gum acacia, loaf sugar, and cinna- mon water, may be substituted. If there should be intense pain, a few drops of laudanum may be combined with the asafoetida or oil of amber, or from four to eight drops of laudanum may be injected into the rectum. Dr. Parrish likeAvise 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 distention of the bowels being at the same time relieved, by abstracting the accumulated gas by means of a syringe introduced per anum. In the few cases which we have seen of this form of enteralgia, Ave have succeeded in affording very speedy relief, by the use of the Avarm bath, followed by warm fomentations to the abdomen, injections composed of asafoetida 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. i DISEASES OF THE DIGESTIVE ORGANS. 21S From the evident tendency to cerebral disease in these cases, Ave 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- 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 beneficial in procuring a regular state of the bowels. We have derived the best effects, as well in counteracting a 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 doses. R.—Ext. hyoscyami, gr. iv. ad vj. Magnes. calc. gr. xxiv. ad xlviij. Ipecacuanhae, 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 ra- ther than to remove the inert state of the bowels. Care should be taken to keep the child's feet dry and warm, by proper 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- 214 DISEASES OF CHILDREN. 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 combina- tion 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; at- tention 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 exist acidity of the stomach and bowels, the frequent adminis- tration of some alkaline remedy. Dr. Parrish prefers the alkaline infusion of Physick, diluted to suit the palate of the infant, in doses of a teaspoonful every two or three hours:—we should certainly pre- fer, in these cases, calcined magnesia, or carbonate of soda. The following will be found to be a very excellent prescription in most instances. R—Mucil. G. Acaciae, ,^iij. Sacch. Alb. pur. ziij. Spir. Terebinth, zj. 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. 2.—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 in- flammation; U would seem necessary, therefore, to consider it se- parately, 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 gastro-intestinal mucous membrane, by im- proper articles of diet, by excess in feeding, by cold and damp, by the irritation 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 feAv minutes, and continue, with little or no abatement, for a considerable length of time; exhausting DISEASES OF THE DIGESTIVE ORGANS. 215 the strength of the patient, and producing extreme emaciation, with- out, in many cases, the occurrence of any inflammatory affection of the intestines. When, however, the diarrhoea assumes a protracted form, it Avill, 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 appearance, and of a decidedly acid odour, or they may be almost entirely fluid, of a bright yellow or greenish hue, and often mixed with blood: these are the general conditions of the evacuations oc- curring in early infancy. In older children, the discharges may be thin and feculent, yel- low, green, or dark brown; or they may consist, at first, of portions of undigested food, very acid, and often, when the diarrhoea has re- sulted from the use of crude acescent vegetables, in a state of fer- mentation. Occasionally the discharges are very thin and watery, with- out any decided smell, and nearly colourless; or they may be com- posed of a fluid mixed with bile, of a yellow or green colour. In many cases, particularly during dentition, the stools consist, almost exclusively, of a thick, jelly-like, semi-transparent mucus. In the more prolonged forms of diarrhoea, the discharges are, in general, very thin, small in quantity, of a dark colour, and extremely offen- sive. 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 af- fected, and the appetite remains unimpaired. Increased thirst com- monly attends, and some degree of griping generally precedes and follows each discharge from the bowels. Occasionally, there is some degree of flatulence and severe paroxysms of colic. The skin is ordinarily dry, and the countenance pale and languid. The abdo- men may be swollen, when the diarrhoea is connected with an over- loaded 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 tem- perature 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; occa- sionally they are suspended for a day or two. They vary in colour and appearance, but are generally very thin and dark-coloured, and are often intolerably fetid. 216 DISEASES OF CHILDREN. 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 controlled by appropriate remedies. Whenever, 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 consequently, very few examinations have been made of the pathological condition of the intestines. In the more prolonged cases, the intestinal mu- cous membrane has often presented no marks of disease, with the exception, perhaps, of unusual paleness, and, occasionally, of soften- ing to a greater or less extent. The parietes of the intestines have, in a few instances, been found of unusual thinness, almost trans- parent and easily torn. A contracted state of the tube at different parts, and its distention at others with gas, is a common occurrence. In children who die whilst labouring under serous or mucous diar- rhoea unattended 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 mu- cous membrane is thickened, often softened or ulcerated, and, occa- sionally, presents large patches of a livid or slate colour. The mu- cous glands are generally found enlarged, inflamed or ulcerated, or of a dark, nearly black colour. The mesenteric glands are often inflamed, enlarged, or indurated. The gall-bladder sometimes con- tains greenish bile, and the liver is occasionally more vascular than natural. (Brunner, Stark, 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 over-feeding, from the bad quality of the mo- ther's or nurse's milk, or from some change produced in it by acci- dental 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 nourishment. 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 resulting in an obstinate diarrhoea of some continuance. Ordi- narily no kind of nourishment is requisite until the child can be ap- plied 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. DISEASES OF THE DIGESTIVE ORGANS. 217 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 over-loaded, 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 at- tack 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, colicky 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 spon- taneously in a short time, if the cause by which it has been produced is at once removed; but, if this be continued, the discharges become more frequent, thin and watery, often intensely green, the functions of the alimentary canal are imperfectly performed, or entirely sus- pended—the food and drinks taken pass through the bowels un- changed ; great emaciation is produced, and the infant dies, sooner or later, from extreme exhaustion; or an acute, or subacute inflamma- tion 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 re- sult 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 218 DISEASES OF CHILDREN. 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 cause no further inconvenience than nausea, vomiting, and a rather profuse diarrhoea, ceasing spontaneously soon after the offending substances are expelled. But when excess in eating, or improper food is habitually indulged in, a much more serious disorder.' of the alimentary canal ensues; the diarrhoea, often, then becomes profuse, and, if not promptly and judiciously treated, inflammation of the bowels is liable to be produced, running, generally, into a chro- nic form, and producing death from marasmus; or disease of the brain is excited, terminating, most generally, in serous effusion. The application of cold to the surface of the body, and especially exposure to cold or 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- 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, occasionally, 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 DISEASES OF THE DIGESTIVE ORGANS. 219 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 pe- riod of dentition, upon a strict regimen, and closely watching, lest inflammation 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 indications 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 country, but occasionally prevails to a considerable extent, in low, marshy, or what are usually termed miasmatic districts. The discharges are, at first, feculent, 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 attend- ed 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 comparatively 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 220 DISEASES OF CHILDREN. serous fluid, at first of a yellowish or greenish colour, but, subsequent- ly, almost colourless. At the same time, not unfrequently, the abdo- men 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, whatever 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 hydroce- phalus; in other cases, the diarrhoea assumes a chronic form, and the child, after becoming reduced, literally, to "skin and bones," and to a state of extreme 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 tube were frequently observed, and in a few instances, numerous invaginations. The small intestines were generally empty, 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 diar- rhoea had assumed a somewhat protracted or chronic form, by no means of so decided a character; and in a few cases, the only indica- tions of disease were unusual paleness of the mucous membrane, with enlargement 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 chy- lous 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 appeared to us to be merely a variety of the mucous diarrhoea of children, the peculiar condition of the stools arising, probably, DISEASES OF THE DIGESTIVE ORGANS. 221 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 alimentary canal and other abdominal organs in this form of diarrhoea, never having met with it in any case that ter- minated fatally; it is one, indeed, judging from our own experience, of not very frequent occurrence 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 intestines, 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 through- out 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 re- moved, and it be, in this manner, promptly suspended. Under whatever circumstances, 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- 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 important indication is, to remove the cause by which it has been produced. 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 substituted; 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 stomach, by taking too much at a time, or being fed with it at too short intervals. When diarrhoea occurs at the period of weaning, the utmost at- tention should be paid to the food of the patient, agreeably to the directions given in our chapter on the diet of infants, care being taken, at the same time, to observe the effects of any particular ar- ticle of diet, which although in itself perfectly wholesome, may, from some peculiar idiosyncrasy in the child, disagree with its stomach, 222 DISEASES OF CHILDREN. 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 perfectly well with them. In older children it will be proper, upon the occurrence of diar- rhoea, to suspend every species of solid aliment, and to confine them entirely, for a short period, to moderate quantities of some prepara- tion of rice with milk, to water 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 com- mencement of the attack, will be proper in most cases, to remove any irritating matters that may be retained in the alimentary canal. The repeated exhibition of active purgatives is, however, not only unnecessary, but positively injurious, by increasing and prolonging the irritation by which the disordered action of the bowels is pro- duced. 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 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. R.-"Calomel, gr. ij. ad vj. Cretae ppt. gr. xviij. Ipecacuanhas pulv. gr. y. 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 intes- tines 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 oc- curs, 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 Avith an ecfual portion of new milk, or a few grains of prepared chalk, combined 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 DISEASES OF THE DIGESTIVE ORGANS. 223 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. R.—Catechu pulv. zjj. Cinnamom. contus. gss. Aq. bullient. jf v. 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 pa- tient, 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 maculatum, or of the blackberry (rubus villosus,)- especially the for- mer, 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 diarrncea, the dis- ease 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 soda,1 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. 1 R.—Opii pulv. gr. j. Ipecac, pulv. gr. iij. ad iv. Carb. Sodae, £)j.—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 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;2 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 discharges, even the mother's milk will, sometimes, be found to irri- tate the bowels, and increase the disease. Hence it is better to con- fine the patient always to simple mucilaginous fluids. * R.—Calomel, gr. j. ad ij. Ipecacuanhas, gr. y. ad iij. Sacch. alb.gij.—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 Avarm 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. 224 DISEASES OF CHILDREN. 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.1 Ample ex- perience has taught us that the acetate of lead may be given with the most perfect safety to children: in the combination just stated, we knoAv of no more effectual means of arresting the profuse serous discharges Avhich 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. 1 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 de- tected, op distinct febrile excitement occurs, it will be proper to apply le'eches to the abdomen, in numbers proportioned to the age of the pa- tient, and the urgency of the symptoms; followed by warm fomen- tations, or an emollient cataplasm. As soon as the inflammatory ac- tion 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 good deal of straining. They consist, chiefly, of a transparent, occa- sionally jelly-like mucus, sometimes perfectly white, at others, of a dirty yelloAv, 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 strain- ing 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 eases, and have often witnessed the best effects from its use. The form in which we have generally given it is as follows: R.—Bals. Copaibae. 3j. Magnes. calc. gr. x. Spir, aether, nitr. Jjiij. Sacch. alb. Jjiij. Aq. cinnamom. 3iij.—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. DISEASES OF THE DIGESTIVE ORGANS. 225 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, Avith milk and a small quantity of loaf sugar; in some instances, these will, how- 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 stimulating 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 con- tinue moderate in quantity, and unattended by any unusual symptom. When, however, they are profuse, when emaciation ensues, or symptoms of intestinal inflammation present themselves, the diarrhoea de- mands immediate 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, tenacious, 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 na- tural condition of the stools, and removing the principal symptoms 15 226 DISEASES OF CHILDREN. of the disease, by the administration of turpentine in emulsion, fol- lowed by light astringents, the use of the Avarm bath daily, and a careful regulation of the diet and regimen. R.—Mucil. G. acacia?, § iij. Sacch. alb. pur. £vj. Spir. aether, nitr. ^iij. Spir. terebinth. z,ij. Magnes. calc. gr. xiij. Lavend. spir. comp. z,ij.—M. Dose, a teaspoonful, repeated three times 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 reference to the presence of worms in the intestines:—the remedies usually employed for the destruction and expulsion of the latter would be calculated to increase the diarrhoea, or even to induce severe inflammation 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 Aveather, to the external air, in the most healthy and open situa- 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 ve- hicle, or by sailing in an open boat, properly shaded from the sun, or in one of the steamboats, which, in 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 immersed daily in a tepid or warm bath, according as the tempe- rature 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 temperature. This treatment will be sufficient, in a large number of cases, in Avhich 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 calo- mel, calcined magnesia, ipecacuanha, and extract of hyoscyamus, will generally produce the desired effect.1 Under the use of this combi- nation, the discharges will generally assume, in a short time, a faecal character, and be diminished in quantity. If there exists irritability of stomach or vomiting, the calomel should be given alone. DISEASES OF THE DIGESTIVE ORGANS. 227 1 R.—Calomel, gr. ij. ad iij. Magnesiae calc. gr. xxiv. ad xxxvj, Ipecacuanhae, 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, un- less the disease assumes a chronic form, unattended with inflamma- tion. 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 treatment of mucous diarrhoea, is the remedy which we have found the most frequently to succeed in arresting the disease. When the discharges are profuse, and the patient becomes rapidly exhausted, a small portion of opium may be substituted for the extract of hyos- cyamus; 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 dis- charges 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 appear- ance, they'still continue thin and frequent, some of the astringents already mentioned, as the catechu, the geranium maculatum, or kino. will be proper, A\rith 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 infantum. In many cases, it is probable that the following prescrip- tion will be found advantageous:—it is recommended by Evanson as one of the most useful compounds in protracted cases of diarrhoea.1 We have ourselves never employed it, but have seen good effects re- sult from the administration, in these cases, of nitrous acid, in com- bination Avith aqua camphorata and opium, or with hyoscyamus.2 1 R.—Infusi simaroubae, ^jss. Acidi nitrici dil. Tfyij. ad iv. Syrupi caryophyl. giv. Tine, opii, Tfyvj.—M. One or two teaspoonfuls, in a little barley water, to be repeated three or four times a day. JR.—Acid, nitros. Tfyviij. ad xv. Or, R.—Acid, nitros. Tfyx. ad xv. Aquas camphor, gj. Sacch. alb. znj. Tine, opii, TTJ^vj.—M. Ext. hyoscyami, gr. vj. A teaspoonful every three hours. Aq. cinnamom. gj.—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 Avell 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, folloAved 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 228 DISEASES OF CHILDREN. 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; avc 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 j 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 Avhich 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 oc- casionally resorted to them, but have never been pleased with their effect^; in some instances they were evidently decidedly injurious. After the inflammatory action has been somewhat reduced by leeching, a combination of calomel, extract of hyoscyamus, and ipe- cacuanha, 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 favourable 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 folli- cles. 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 condition of the liver, with a vitiated state of the bile, as well as of the other secretions poured into the intestines. The manage- ment of these cases is attended with great difficulty, and the best-di- rected plan of treatment 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, DISEASES OF THE DIGESTIVE ORGANS. 229 reddish-brown, or yellowish colour, and in some instances, they con- sist 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 fetid. The discharges are not generally large in quantity, and vary much in regard to frequency—a number often taking place in quick suc- cession, and then a considerable interval occurring Avithout 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 continu- ance, and Avhen enlargement of the mesenteric glands occurs:—occa- sionally, extreme tympanitic distention takes place at an early period. There is always great emaciation, with dryness and harshness of the surface and discoloration 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 produced, 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- 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 re- sumed their natural action, strict attention to the diet of the child is essential to prevent relapse. Even indulgence in articles which, under other circumstances, would be considered perfectly wholesome and appropriate, 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 bow- els. 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 Avater, 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 impor- tant remedy; it may be repeated daily, and in many cases every morning and evening, with decided advantage. 230 DISEASES OF CHILDREN. In those cases in which the discharges indicate a disordered state of the biliary secretion, small doses of calomel should be adminis- tered twice or thrice a day, or oftener, according to the circum- stances of the case, and the effects produced by the remedy. Clarke, Cheyne, Underwood, and Marley administer the calomel by itself, DeAvees in combination with prepared chalk and opium, and Eberle, Seele, and Jiiger, with opium alone. We prefer its administration in combination with prepared chalk, ipecacuanha, and extract of hy- oscyamus. R.—Calomel, gr. ij. ad. vj. Cretae ppt. gr. xxxvj. Ipecacuanhae, 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 dis- charges assume a more natural appearance. In many cases, we have experienced the best effects from the em- ployment of turpentine in the following formula. R.—Mucil. G. acaciae, §iij. Sacch. alb, pur. giij. Spir. terebinth, gij. Magnes. calc. gr. xiij. Tinct. opii camph. gij.—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 intestines, even when this has been the seat of a subacute inflamma- tion, we have found it to produce a directly soothing influence. 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 Avith 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, generalby produces a very beneficial effect. In all cases of chronic diarrhoea, the derivative ef- fects of blisters to the abdomen are adATantageous, often very deci- dedly 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. R.—Cretae ppt. zj. Or, R.—Cretae ppt. zij. Calomel, gr. iij. Sacch. alb. pur. gij. Ipecacuanhas, gr. iij. Mucil. G. acaciae. ^ss. Ext. hyoscyami, gr. viij.—M. Aq. cinnamom. gij. f. chart. No. xij. Tine, opii camph. ,zj.—M. One to be given three times a day. A teaspoonful to be given every three or four hours. DISEASES OF THE DIGESTIVE ORGANS. 231 When the acidity is accompanied Avith 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 in- testines, 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. R.—Acetat. plumbi, gr. vj. ad xij. Pulv. ipecacuanhae, 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 poAArder. 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. gallae, gr. xxxvj. ad zj. Camphor, pulv. gr. iij.—iv. Sacch, alb. gr, xxv.—M. f. ch. No. xij. 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 diarrhoea in adults, appears to us well deserving of a trial in the cases occur- ring in children, which often bear a strong resemblance to those de- scribed 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 serum tinged with bile, the combination of the acetate of lead, ipecacuanha, and opium, may be commenced with at once. It is in such cases, Ave suspect, that the most advantage will be derived, from the combination of nitric acid, with the infusion of simarouba, 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 232 DISEASES OF CHILDREN. the advanced stage of the diarrhoea of newly weaned infants, when emaciation and prostration were extreme, and the evacuations were frequent, fetid, and wanting altogether the faecal character, consisting ofaA-ariously coloured, sometimes greenish or bloody mucus; andAvhen aphthous ulcerations pervaded the mouth, he gave it in the following formula. R.—Argent, nitrat. crystall. gr. ^. Aquae distill, gij. Gum. acaciae, Qij. Sacch. alb. z,ij.—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 Nouveau-nh) 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. We have employed the nitrate of silver in a number of cases of chronic diarrhoea in children, and have invariably been pleased with its effects. To patients under two years of age, we give one sixth of a grain every three hours; and to older children from one fifth to one fourth of a grain, at the same intervals. During the continuance of the disease, daily exercise in the open air, Avhen 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 diar- rhoea being treated by calomel, ipecacuanha, and extract of hyoscya- mus. 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 pro- fuse evacuations from the bowels. In this case, the diarrhoea should be arrested as speedily as possible, and the strength of the child re- stored by some tonic, as the sulphate of quinia, or the persesquini- trate of iron, with a nourishing but bland and easily digested diet. 3.—Cholera Infantum. (THE SUMMER COMPLAINT OF INFANTS.) The cholera infantum is a disease that has, with great propriety, been considered 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 Avith none that resembles, in DISEASES OF THE DIGESTIVE ORGANS. 233 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 appears 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 com- monly confined to the period of the first dentition. So generally is this the case, that an infant's second summer is considered by mothers 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 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 diar- rhoea, the stools being often of a green or yellow colour, but more commonly, light-coloured, and very thin. The diarrhoea seldom con- tinues for any length of time before an extreme irritability of the stomach manifests itself; every thing taken into it being immediately rejected, often with great violence. In other cases, the infant is af- fected 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 Avith a white, slimy mucus. The skin is, in general, dry and harsh; the 234 DISEASES OF CHILDREN. head and abdomen are hot, while the extremities retain their natu- ral temperature, or, Avhen the attack is violent, are decidedly cold. There is always intense thirst, but whatever fluid is taken is almost immediately ejected from the stomach. ToAvards evening, there oc- curs, 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 some- what tumid, and tender to the touch. In many cases, the excessive irritability of the stomach continues throughout the attack; but not unfrequently, the A'oniiting 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 Avhatever 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 at- tack, with delirium; his eyes become injected and Avild; 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 child lies constantly in an imperfect dose, with half-closed eyelids, and so insensible to external impressions, that we have repeatedly seen flies light upon the half-exposed eyeballs, without the patient exhibiting 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 surface 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 abdo- men becomes more or less tympanitic, and the hands and feet pallid. or of a leaden hue, and oedematous. The discharges from the bowels are now generally frequent and profuse, dark-coloured and very of- fensive—resembling the washings of stale meat; in many cases, how- ever, they are small in quantity, and composed entirely of dark- coloured mucus, mixed with 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, Avith all the symptoms of acute hydrocephalus. DISEASES OF THE DIGESTIVE ORGANS. 235 In most of the protracted cases, an eruption occurs upon the .breast, of very minute, white 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 extensive and distinct. The examination of the bodies of those who have fallen victims to cholera infantum, exhibits various lesions, chiefly of the alimen- tary canal. When death occurs early in the attack, the only morbid appearance 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, in- creased 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, gene- rally, of minute extravasations of blood. At other parts of the boAvels, these points occur in clusters:—the patches vary in size, but are never very large, and are often slightly elevated, from a thick- ening of the mucous tissue at the part where they are situated. Oc- casionally, 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 caliber 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. Dr. Horner describes the appearance of the enlarged follicles in the large intestines as resembling a sprinkling of white sand upon the surface 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 detected 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, Hor- ner, 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, Avithout indications of inflammatory action, but in others, with thickening and opacity of the arachnoid mem- brane. 236 DISEASES OF CHILDREN. 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 ana- tomical 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 extend- ing occasionally to all the coats. The lining membrane of the stomach is not unfrequently 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 membrane 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 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 pre- sented nothing remarkable. The small intestines contained a con- siderable 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 ar- borescent 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 Avere seen to radiate to the surrounding membrane, occupying the entire surface of the intestine, shoAving 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, DISEASES OF THE DIGESTIVE ORGANS. 237 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 com- pletely riddled with them. The mucous membrane was more or less softened in the greater number of cases; in one instance it was thick- ened and intensely inflamed. The coats of the intestine were covered Avith a layer of mucus, sometimes so thick as to diminish consider- ably its caliber. It ordinarily contained a quantity of grayish-co- loured faeces, of the consistence 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 dis- tended with dark-coloured bile; the mesenteric glands, spleen, and kidneys presented nothing remarkable. 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 injected, for the most part confined to the larger ramifications of the vessels; the membrane was easily removed by traction from the surface of the brain. The substance of the brain was natural, excepting in two cases, in Avhich it was in- jected; in the one at its central, 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 ap- peared quite dry, as if wiped with a cloth. In the third stage, marked by an unusual disposition to drowsi- ness 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 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 con- fined either to the cortical or central portions of the brain and cere- bellum. It may be to such a degree as to cause the brain readily to give Avay 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 ap- pear to depend, in its earlier stages, upon hyperaemia of the mucous membrane, 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 follicles, as in the mucous tissue, from accidental sources of irritation. The disease is evidently dependent for its production, upon the action 238 DISEASES OF CHILDREN. of a heated, confined, and impure atmosphere, directly upon the skin, and indirectly upon the digestive mucous surface, at an age Avhen the latter is already strongly predisposed to morbid action, from the ef- fects 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—feAv cases occurring beyond the second, and none beyond the fifth year. During tAventy years, the deaths from cholera infantum, in Phila- delphia, amounted to 3576: namely, in infants under one year of age, 2122; between one and tAvo years, 1186; between tAvo 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 tAventy years of age, 173; under twenty years, 63. The influence of a high atmospheric temperature, in the produc- tion of cholera infantum, is shown by the fact, that its prevalence is always in proportion to the heat of the summer—increasing and be- coming more fatal, Avith 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 npt 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 at- mosphere Avould 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 croAvded cities of the middle and southern states; and in these it is especially prevalent, and destructive to life, among the children of the poorer classes, inhabiting small, ill- ventilated houses, situated in narrow, confined lanes, courts and al- leys, or in situations abounding Avith accumulations of filth. When it occurs in the country, which is rarely the case, it is almost exclu- sively in low, damp, and otlienvise 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 DISEASES OF THE DIGESTIVE ORGANS. 239 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 Avhich 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, hoAvever, are of unfrequent occurrence; sufficient time being in general afforded for carrying into effect a proper remedial course of treatment. EA_en after the disease has continued for many days, and reduced the patient to a state in which a fatal termination seems to be inevitable, In- 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 Avith 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, Avith milk, and immersed daily in a bath, warm or tepid, according as the temperature of the skin is deficient or increased, the disease may generally be arrested without the administration of any remedy in- ternally; excepting, perhaps, some cool, perfectly bland, slightly mu- cilaginous drink, as gum water, or, what Ave 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 benefit may be derived from carrying the patient frequently into the air, in any open and healthy situation in the neighbourhood of his residence, 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 Ave 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 accom- plished, 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 over- heat 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 flan- nel, or soft, coarse muslin, Avorn 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 mattress, or on a blanket, folded and laid upon the sacking-bottom of the bedstead, or upon the floor of the crib, his body being de- fended by a light, loose covering. 240 DISEASES OF CHILDREN. 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 gentle 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, ordinarily, 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.1 Dr. Cain, of Charleston, S.C., recommends creasote as a remedy admirably adapt- ed to check simultaneously both the vomiting and purging. 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 re- moving the irritability of the stomach by the administration of the acetate of lead in solution.2 A blister may, at the same time, be ap- plied over the epigastrium for two or three hours, and then taken off and replaced by a bread-and-milk, or flaxseed poultice. 1 R.—Camphor, zj. 3 R,_Aq. purae, gj. iEther. sulphuric, ^j.—M. Acetat. plumbi, gr. v. Acid, acetat. impur. IT^v. Sacch. alb. pur. ijiij.—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 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. The effects of fomentations to the abdomen of a strong infusion or decoction of hops, have been spoken of by many practitioners, as pecu- liarly beneficial. The tepid bath should be repeated night and morn- ing. 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 fifth 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 Avild and in- jected state of the eye; aversion from light, with delirium, or other symptoms of cerebral irritation, leeches should be applied to the DISEASES OF THE DIGESTIVE ORGANS. 241 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 Avlrich 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. R.—Calomel, gr. iij. Cretae ppt. gr. xxxvj. Acetat. plumbi, gr. xij. Ipecacuanhae 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 farinaceous articles with milk, we have, in gene- ral, found the inordinate discharges from the boAvels to be quickly sus- pended, and replaced by natural, regular evacuations. As soon as the frequent Avatery 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, Avith 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; anodyne injections, composed of 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 prostration. 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 5iij- tine, kino, or 16 242 DISEASES OF CHILDREN. 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 pulverized charcoal; we have usually administered it in com- bination with powdered rhubarb, ipecacuanha, and extract of hyos- cyamus. R.—Tartrat, Ferri, gr, xl.— R.—Carbon. Ligni, zj. to sjij. Aq. purae, j|ij. Pulv. Rhei, J)ij. Syrup. Zingiber, gss.—M. Ipecacuanhas, 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 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 pro- truded beyond the rectum, with a sense of bearing down and smart- ing, that continues until the protruded membrane is returned, which may take place either spontaneously, or upon the slightest pres- 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 conncx- DISEASES OF THE DIGESTIVE ORGANS. 243 ions, in consequence of the imperfect development of the neighbour- ing organs, the slighter curvature of the sacrum, and the perfect mo- bility 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 being placed upon his back, gentle pressure is to be applied upon the protruded portion of intestine with the thumbs or forefingers, previously smeared with fresh lard or dipped in sweet oil, the pres- sure being made in such a direction as shall tend to return the tu- mour 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 re- turn, every time, and as soon after the prolapsus occurs as possible. If the patient is affected with a disposition to bear down subse- quent to the reduction of the intestine, an anodyne enema, composed of a small portion of opium and three grains of acetate of lead, in- timately 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 be proper, 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 Avater, or suddenly dipping the 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 dis- ease. In such cases, however, astringent washes and injections of a tepid warmth will often produce a beneficial effect. R.—Ojiereus cort. contus. £j. 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 practitioners. 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 pos- 244 DISEASES OF CHILDREN. ture. In such cases, the intestine must be retained by a soft com- press, applied upon the anus, and supported by a T bandage. By this means, and the use of astringent injections, and a proper atten- tion to the state of the bowels, a radical cure may often be effected. But should the prolapsus continue still to recur, notwithstanding the employment of these means for a reasonable length of time, the pro- priety of an operation should be considered. The nature of the ope- ration will depend, in a great measure, upon the particular circum- stances of each case:—whether the removal of a portion of the pro- jecting 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 membrane of the rectum, as recommended by Hey and Macfarlane; or the application of the ac- tual cautery to the margin of the anus, as recommended by Mr. Ben- jamin 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. 5.—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, someAvhat 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- theless, much more so than physicians would appear to be aware of. Several instances have fallen under our notice; and although they Avere generally presented to us as cases of prolapsus ani, yet, upoifa 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- tientis 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 DISEASES OF THE DIGESTIVE ORGANS. 245 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 en- tirely without the sphincter, and appears at the first view as if it were attached, 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 de- tected 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 paina 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 loAver 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 folloAved 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— producing frequent bloody discharges, which, after remedies of vari- ous kinds have been tried without success, suddenly cease in conse- quence 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 Avho 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. 246 DISEASES OF CHILDREN. 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 Avere 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 Droke 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, Avhich would, at first sight, seem to prove that the polypi Averenot 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, conclusiA-ely, that it is to the vessels which traverse the pedicle, that the sanguineous exu- dations and haemorrhages, by which polypi of the rectum in children are so commonly attended, are due. 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 ealls to evacuate the bowels. From hemorrhoids 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 poly- pous 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 far- ther, so as to get at the pedicle, which is readily effected in conse- quence of the lax condition of the mucous membrane in children. It is often somewhat difficult to distinguish where the pedicle ends and the mucous membrane commences, in consequence of the colour of both being the same. It is necessary, hoAvever, to pay some atten- tion to this, in order that as little as possible of the mucous mem- DISEASES OF THE DIGESTIVE ORGANS. 247 brane may be included in the ligature. A waxed ligature is to be passed around the pedicle, but not drawn too tightly, for fear of rup- turing it. It is better, after the ligature is properly applied, to return the whole into the rectum, without dividing the pedicle be- low the ligature, as in one case, A\'hich fell under the notice of Dr. Gigon, in which excision was practised, a troublesome 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 acci- dent. 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 or 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 with- out occasional haemorrhage, which may be of considerable amount. A somewhat similar form of the disease is described by Dr. Bour- geois in the Bulletin General de THrapeutique Med. et Chirurg. In the removal of the tumour, Mr. Syme has always employed the liga- ture, 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. 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 in- \raginations give rise to no symptoms during the lifetime of the patient, and after death are reducible with perfect ease. Occasion- ally, however, the invagination, occurring in children, gives rise to symptoms of the most serious character, and speedily destroys the life of the patient. 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 inflammation in the intestine, at the part Avhere the invagination has occurred, in consequence of which, an adhesion of the peritoneal sur- 248 DISEASES OF CHILDREN. faces that are brought into contact, takes place, and in this manner, not only is the caliber 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, Yery 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 peritoneal coat. At the inAraginated portion, the mucous surface is often highly inflamed, of a dark red colour, and thickened, and co- vered frequently 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 re- peated—leeches and warm fomentations to the abdomen, and absti- nence 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, Avith the view of restoring the natural condition of the intestine, pre- vious to the occurrence of inflammation. We know of no instance, hoAArever, 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 re- mains 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 one party, the existence of worms is deemed invariably detrimental to health; by another they are regarded as always the effect, and not the cause of disease; while a third, with Dr. Rush, DISEASES OF THE DIGESTIVE ORGANS. 249 consider their presence as altogether innoxious, if not, to a certain extent, beneficial. This much is certain; namely, that there is no single symptom, or catenation of symptoms, which indicate positively the existence of worms in the intestines, independently of their pre- sence 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 tricocephalus, Bremser has met with in nearly every body he has opened, and we haA-e 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 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 eause 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 tricocephalus dispar, the oxyuris vermicularis, the ascaris lumbricoides, and the bothrioce- phalus latus. The tricocephalus 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 indi- viduals. 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. The oxyuris vermicularis—the ascaris of Rudolphi and most writers —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 Avith mucus. The ascaris lumbricoides.—This is the worm most commonly met with in the small intestines 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 in length, and varying in diameter from a line to two or three. Its usual colour is white, but changes with that of the substances it swallows. When dead, it becomes perfectly stiff- This worm frequently finds its way into the stomach, and may be discharged by the mouth or through the nostrils. 250 DISEASES OF CHILDREN. The bothriocephalus latus—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 upAvards of a hundred feet. (Bremser, Robin, Frank, Geoze, Sibbargarrde.) It is of a dirty white colour; and becomes grayish when immersed in alcohol. It has a large head, with two lateral grooves, which are considered by Rudolphi to be the organs for the absorption of nou- rishment. 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 some- times 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 cucurbitani. This worm in- habits 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, 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 cer- tain 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 hospitals, Europeans are very liable to worms in India, and Africans even more so. Few post-mortem examinations are made without dis- covering 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 DISEASES OF THE DIGESTIVE ORGANS. 251 species of worms; thus, in Switzerland, Poland, Russia, and in some parts of France, the bothriocephalus latus is most commonly met with; Avhile 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 during the other seasons of the year. The poor, likewise, who are badly nourished and lodged, and filthy in their persons and habi- tations, 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 true; for it has been invariably found that the same causes which dis- turb the healthy functions of the digestive organs, and predispose them to disease, are precisely those which favour the production 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 Avith 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 lumbri- coides and trichocephali—in only a very small number of the autop- sies performed by him in cases of death from fever; they were very numerous in one case, but very few in the others; he deemed them merely an accidental complication of the disease. In one instance, they coincided 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 num- ber of worms; and the same, according to Thibault, was observed in a species of mucous fever Avhich, 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 enve- 252 DISEASES OF CHILDREN. loped in a viscid mucus, or mixed with faecal matter precisely simi- lar 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 dimi- nution in the consistence of the mucous membrane Avas very rarely met with. As these slight alterations of that membrane existed only at the point where a number of lumbrici Avere collected, and noAvhere 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 in- tensity, 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 pos- sible 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 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 followingare 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 sac- charine articles of diet, and of fresh milk. Some attribute them to the Avant 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 intes- tines, excepting so far as it has the tendency to disorder or interrupt the functions of the digestive organs. When, from any cause, digestion becomes impaired, 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, generally associated with a disordered state of the digestive function, that they are then apt to give rise to a variety of morbid phenomena. Worms so frequently exist in early life, without any—even the slight- est—indication of disease, that we can only consider them as produc- tive of injury from their numbers, or from some co-existing patholo- gical 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- petri&re, the hospital at Paris for the reception of patients advancedin DISEASES OF THE DIGESTIVE ORGANS. 253 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, hiccough, and gnaw- ing pains of the stomach or intestines; their breath is foul; their tongue more or less coated; their appetite is irregular and capricious, often 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 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 on 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, the removal of an irritation of the intestines totally inde- pendent of the presence of worms. 254 DISEASES OF CHILDREN. 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 though 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 perforation may be the result of an inflammation, followed by soften- ing or ulceration, excited by the presence of worms in the intestines, is a question difficult of solution. So far as our own observations ex- tend, we should unquestionably assume the negative. With Dr. Evan- son, we believe that worms may exist at the same time with intesti- nal inflammation 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 disease, it is important, at the very outset, to determine, not only the fact of the actual existence of worms, but, if they do exist, whe- ther they are, in any degree, concerned in the production of the morbid phenomena 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 dis- charge of worms occasionally produced by them, exhibits no improve- ment, 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 irri- tation of the alimentary canal, and may occur without their exis- tence; and, that even in those cases in which the presence of worms is established by their appearance in the discharges, there is no cer- tainty 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 DISEASES OF THE DIGESTIVE ORGANS. 255 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 generally. We have been in the habit of pursuing this plan for a number of years, and have seldom been disappointed in promptly and effectually relieving our patients, and have had but little necessity for resorting to either of the articles which strictly appertain to the class of anthelmintics. 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 decided, 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 beefsteak, 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 spe- cies of confectionary should be interdicted. 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 situ- ation should be made choice of for this exercise, in which dryness is combined with perfect purity of atmosphere. Nothing is better calculated, by invigorating the functions of the digestive organs, and improving the health of the body generally, to prevent the develop- ment of worms in the intestines,- and the inconveniences thence re- sulting, 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 indolence and inertness of disposition, as from the prejudices and misplaced 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 frictions 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 irrita- tion, or of inflammation, whether acute or subacute, it will be neces- sary, before resorting to the administration of any internal remedy, 256 DISEASES OF CHILDREN. to allay the irritation or inflammation, by leeches, fomentations, and cool mucilaginous drinks. There are feAv 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 re- / peated doses, combined with ipecacuanha and extract of hyoscyamus. Three grains of calomel, with half a grain of ipecacuanha and the same quantity of hyoscyamus, given three times a day, will seldom fail to act as a pretty effectual purgative; and we have knoAvn 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 Avill 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 in- flammation, avc have found this to act very favourably. The article, however, from which Ave have derived the most deci- 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, Avould 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 Avhich worms usually occur. The rectified spirits should be directed and may be given in sweetened milk, in molasses, or in the following mixture.1 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 isva 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, gij. Sacch. alb. z,x. Spir. a3ther. nitr. ^iij. Spir. terebenth. rec. ziij. Magnes. calcinat. ^j. Aq. menthae, gj.—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.2 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 pre- DISEASES OF THE DIGESTIVE ORGANS. 257 vent any portion from being spilled upon the lips, face, breast, or arms of the patient. R.—Spicular. Dolichi, zj. Or, R.—Spicular. Dolichi, 9j. Mellis vel sacchari liquid, impur. Syrup, cort. aurant. gj.—M. f. q. s. ut fiat electuarium. electuarium. Dose.—A teaspoonful to be given every Dose.—A teaspoonful to be given three morning, fasting, for three successive times a day, for two or three succes- days, and then followed by a brisk sive days, and then followed by a cathartic. purgative. The oleum chenopodii is a remedy in considerable repute with Ame- rican practitioners; we have employed it in some cases with decided advantage. R.—01. chenopodii, zj. Sacch. alb. pur. Gum. acaciae, aa. J5Jss.—M. dein adde Aq. menth. sativae, ^ijss. 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 suspect the existence of inflammation of the intestines, or that is ac- companied 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 §ss. Rad. valerian, pulv. zjj. " Jalapae " zjss. Sulphat. potassae, zjj. Oxymel. scillas 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 ali- mentary canal, favourable to the production of worms. An ounce of the helminthocorton, 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 morning, 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 of worms in their excretions. It is particularly beneficial in cases attended with the usual symptoms of worms, with want of appetite, and mucous diar- 17 258 DISEASES OF CHILDREN. rhoea, arising from mere debility of the digestive organs, and a vitia- tion 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 whenever we have been able to induce children to take it in a suffi- cient dose, we have never been disappointed in its effects; an ordi- nary-sized teaspoonful, dissolved in a wine-glassful 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 of the German practitioners have recommended the ethereal 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 150 cases of lumbricoides, tricocephali, 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. Recently the seeds of the common garden pumpkin have been re- commended as an effectual anthelmintic, especially in cases of tenia. Half an ounce of the recent seeds, beat up into a pulp with sugar, may be given every one, two, or three hours, according to the age of the child, the urgency of the case, and the effects produced. After the removal of the worms, some light bitter infusion, or a chalybeate 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 DISEASES OF THE DIGESTIVE ORGANS. 259 into the rectum. A great variety have been recommended for this purpose, among the most effectual of Avhich may be ranked a solution of common salt, turpentine,1 aloes,2 an infusion of helminthocorton,3 lime water and milk, camphor,4 a solution of sulphate of iron,5 or a solution of asafoetida in milk.6 1 R.—Spir. terebenth. rec. zj. * R.—Fuc. helminthocorton, £j. Lactis, £iv.—M. Aquae, Oj. Or, R.—Spir. terebenth. rec. zj. Boil to one-half. Vitell. ovi, * R.—Camphor, gr. xv. Aquae, ^iv.—M. Olei olivae, giv.—M. 9 R.—Decoct, aloes, ^iij. 5 R.—Ferri sulphat. zj. Lactis, !|j.—M. Aquae, £iv.—M. Or, R.—Gum. aloes, gss. * R.—Asafoetidae, ^ij. Lactis, giv.—M. Lactis, giv.—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- vert to be a most efficacious means for the destruction of the ox- yures. 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. R.—Mass. f, pil. hyd, Terebenth. Venet. Aloes, gr. aa xxxvj. Extract, hyoscyami, gr. xx.—M. f. pil. 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 insuppor- table titillation and itching about the anus. This is generally expe- rienced 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 inflammation about the anus, and convulsions; the first may, perhaps, be occasioned by the frequent rubbing and scratching of the part by the child, to allay the inordinate itching;—the second we have never witnessed. 260 DISEASES OF CHILDREN. 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 generally supposed. The diarrhoea, as well as vomiting, so common in the earlier stages of life, is, as we have already seen, in a large number 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 ablactatorum, as our own examinations have fully proved; and the enumeration 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 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, unless some degree of gastritis occurs, it does not take place immediately after the ingestion of food or drinks. When the in- flammation affects the ileo-caecal 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 ab- domen, Avith pain, or at least tenderness upon pressure, are very common 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 ahvays expressive of great distress. The skin is usually hot and dry, and the increase of temperature is 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 mu- cus; the redness and dryness of the tongue, howeA^er, 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 aug- mented thirst, a decided febrile reaction is seldom met with in cases of enteritis occurring previous to dentition; subsequently, however, DISEASES OF THE DIGESTIVE ORGANS. 261 the' disease is often attended with fever of a remittent form, with evident exacerbations towards evening. There is also considerable and rapid prostration 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 de- creases; the skin assumes an ashy hue, and becomes cool, particu- larly at the extremities, which are often decidedly cold; great ema- ciation ensues, the cheeks become hollowed, the eyes sunken, and the face wrinkled and contracted; which, when the teeth are not yet de- veloped, 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 af- fections, in consequence, as Dr. Stokes has pointed out, of the propa- gation of disease along the course of the lymphatics, from the mu- cous surface of the intestines, to the mesenteric ganglia. 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 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 generally, will be found the evidences, if not of existing, at least of preceding inflammation. This is not a matter of merely theoretical nicety, but has a very important practical bearing—the usual treat- ment pursued in cases of tabes mesenterica being one rather calcu- lated to augment, 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 me- senteric affection, and even where the latter has already occurred, it is the only one calculated 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 pa- tient, in a state of extreme marasmus, dies from exhaustion; occa- sionally, however, the disease assumes an acute form, and death occurs at an early period, from violent peritonitis, the result of a per- foration 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 af- fection is not to be overlooked, lest it run into inflammation of the 262 DISEASES OF CHILDREN. 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 af- fection is with great difficulty effected. The pathological appearances observed after death in cases of enteritis, 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, however, it is confined to the duodenum, when the free edges of the valvulae conniventes will be found more or less intensely red- dened. In the more violent cases of enteritis it is in the mucous membrane of the ileum, particularly in the neighbourhood of the ileo-caecal 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, in- differently situated, either in a depending or non-depending portion of the tube. These patches are generally accompanied with tume- faction 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 mu- cous membrane is studded with flakes of curd-like matter, generally of a yellow or greenish colour; these flakes adhere 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 ulcera- tion. 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 granu- lations, 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 deA-eloped 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 in- testinal 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, B6clard, Cloquet, and others, describe a species of gangre- nous ulceration, as one of the terminations of enteritis; thus certain DISEASES OF THE DIGESTIVE ORGANS. 263 ulcerations of the ileo-caecal 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 projecting 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 in- testines, and prevent an escape of the contents of the 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 con- verted 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 im- pure and confined state of the atmosphere. They are the same with those usually noted as productive of diarrhoea in infancy and child- hood. In fact, in a large number of cases, the disease commences with an attack of ordinary diarrhoea, which, being neglected or mis- managed, tenderness or pain of the abdomen, heat and dryness of the surface, with the other symptoms of intestinal inflammation, are successively 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; no- thing 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 symp- toms of the disease, and tend to allay the local tension and pain. In most cases, leeching will be proper: the leeches should be ap- plied over the surface of the abdomen, and graduated in number, ac- cording to the intensity of the local symptoms. Some degree of judgment, however, will be demanded, in the employment of leeches, in inflammations 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 ab- domen 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 cau- tious, 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 dis- 264 DISEASES OF CHILDREN. ease 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.1 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. Ipecacuanhas, aa gr. ij. Ext. hyoscyami, gr. iv.—vj. Acetat. plumbi, gr. viij.—xij.—M. f. pill No. 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 by a bread and milk poultice. In very acute cases, warm synapised pediluvia, or sinapisms to the extremities, will generally be produc- tive of good effects. In chronic cases, the warm bath, blisters to the abdomen, the in- ternal exhibition of calomel, ipecacuanha, and extract of hyoscya- mus, Avith the addition, when diarrhoea is present, of the acetate of lead; and when the discharges are thin and offensive, the use of tur- pentine, are the remedies from which the greatest amount of relief will be obtained. The diet should be mild, unirritating, and taken in small quantities, 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 sup- porting the patient's strength, which, in cases of chronic enteritis, is very apt to be greatly prostrated. By some practitioners, it is con- sidered beneficial to dress the blisters upon the abdomen with mer- curial ointment, or to apply this by friction over the abdominal sur- face in cases where blisters have not been applied. When a state of convalescence has been procured, the skin be- coming soft and moist, the tongue clean, the stools more regular and natural in appearance, with a disappearance of the tenderness and tumefaction of the abdomen, and a return of the natural appetite, the administration of some light tonic will, in general, be found beneficial,—more rapidly restoring the patient's strength, and ren- dering 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 occa- sionally accompanied with more or less gastro-enteritis. It is chiefly distinguished from ordinary enteritis, by frequent small discharges DISEASES OF THE DIGESTIVE ORGANS. 265 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 feculent, 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 chil- dren of a year old and upwards, distinct febrile reaction, with even- ing exacerbations, 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 be- come, 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 fol- lowed by tormina. There is seldom any appearance of feculent matter in the stools, though occasionally it is passed in hardened masses, of various sizes, with blood and mucus. If the disease is not arrested, the anus becomes red, hot, and ex- ceedingly 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 symptoms 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 inten- sity 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 Avith 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 greater or less extent. Dr. Crampton has observed, in cases of children who died of dys- enteric symptoms, the mucous membrane of the intestines, in many places, to be highly vascular, and covered with granulations of a yellow, or dirty yellow colour, as if from a coating of wax; in several, ul- cerations 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 honey-comb. 266 DISEASES OF CHILDREN. Colitis would appear, in the majority of cases, to be the result of sudden transitions of atmospherical temperature, particularly the sudden change from warm and dry, to cold and damp weather. It is most prevalent during the latter part of summer, or the com- mencement of autumn, when the days are hot, but the nights chilly and damp. It is apt to prove endemic in unhealthy localities, espe- cially those favourable to the production of intermittent and remit- tent fevers, and often prevails epidemically with fevers of a catarrhal character. A few days of cool, rainy weather, occurring in the sum- mer, will often cause the prevailing bowel complaints of children to assume a dysenteric 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 other intestinal inflammations. All solid, stimulating, and indigestible 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- 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. The patient should be kept at perfect rest in a recumbent posture, and not allowed to rise every time he feels an inclination to evacuate his boAvels; nor should he be permitted to sit for a long period, in- effectually straining, when, probably, only a drop or two of bloody mucus is discharged. 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 abate- ment. 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 symptoms 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 gas- tritis are present, leeches should also be applied to the epigastrium. In robust children, over one year of age, when the disease is accom- panied 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 Avith- out an addition of laudanum, we are decidedly opposed; we have seen much injury result from it, and cannot understand the princi- ples 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 hyoscyamus, agreeably to the plan pursued by many of the Ger- DISEASES OF THE DIGESTIVE ORGANS. 267 man physicians, forms an admirable addition.1 The relief derived from this combination is often prompt and considerable, while a fa- vourable change is produced, in a very short time, in the character of the discharges. 1 R-—Calomel, gr. iv. ad xij. Ipecacuanhae, 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 Avith a third of a grain of ipecacuanha, one grain of extract of hyoscyamus, or a twelfth of a grain of opium, and a sixth of a grain of calomel, repeated every three hours, and have seldom been disappointed in effecting by it the entire removal of the dis- ease. The nitrate of silver, in from a sixth to a quarter of/a grain doses, made into a pill with extract of gentian, and repeated every two or three hours, will often be found to produce prompt relief at this pe- riod 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, blackberry-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. ,^ss. Fol. achill. millefol. z,iij. To be boiled in Oj. of milk. A dessert-spoonful to be given frequently. 268 DISEASES OF CHILDREN. 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 tuber- cular granulations of the peritoneum, that we are perhaps to include peritonitis 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 dis- ease 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, consti- pation, 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, 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 prostration 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 vomit- ing—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. DISEASES OF THE DIGESTIVE ORGANS. 269 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 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 bowels 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. 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 offensi\Te 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 the patient, in a state of extreme marasmus, sinks gradually into his grave. 270 DISEASES OF CHILDREN. The appearances discovered after death, in cases of peritonitis, arc redness and thickening of the peritoneum, particularly of that portion enveloping 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- minous matter. Very generally the cavity of the abdomen contains 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 intestine 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 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 reme- dies from which, if judiciously managed, and perseveringly employed, 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 feAv 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 THE REMITTENT FEVER OF INFANCY. 271 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 folloAving 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. 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 272 DISEASES OF CHILDREN. 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 coun- tenance 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 ahvays 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 languor 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. In the course of the morning, the remaining symptoms abate or dis- appear, and the child becomes more lively and playful, but still exhi- bits a degree of languor and peevishness, which, in general, increase towards evening, when a febrile paroxysm occurs, as on the preceding night; and is again succeeded in the morning by a more or less per- fect remission. In this manner, with daily exacerbations and remis- sions, 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 duration, 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 THE REMITTENT FEVER OF INFANCY. 273 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 tormina and tenesmus—the evacuations consisting of little else than mucus, often mixed with blood. The symptoms of such cases 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 offensh-e. The stomach is gene- rally very irritable, and rejects, immediately, every thing 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- 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 Avith diarrhoea, the dejections being always unhealthy in appearance, and fetid. The tongue is thickly coated upon its upper surface with a yellowish broAvnish 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 sedi- ment, particularly during the remissions; the skin is dry, harsh, and of a salloAV or dirty hue; the countenance is contracted and wrinkled, presenting the appearance of premature old age. The appetite is oc- casionally unimpaired, and, in some cases, even voracious; in gene- ral, however, it is altogether lost. The child is very generally affected Avith a short, hacking, and frequent cough. Most commonly *therc 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 18 274 DISEASES OF CHILDREN. 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 a species of stupor, in which he remains for hours, as in a doze, 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 gain flesh and strength, but the abdomen still remains tumid, and the bowels irregular; and these alternations 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 intes- tinal 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 removal in a few hours; in other instances, however, a cure is less easily effected; and in children of a strongly marked lymphatic temperament, in whom there is a tendency to the development of tubercles in the lungs, to a diseased condition of the mesenteric glands, or to tubercular 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 intestinal 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 reco- very may be effected by an appropriate treatment. Frequent re- THE REMITTENT FEVER OF INFANCY. 275 lapses, which are liable to be produced by slight errors in diet, ex- posure to cold or damp, or over exertion during convalescence, pro- duce 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 diges- tive mucous membrane—in some instances, of the stomach and upper portion 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 generally thickened and softened, or ulcerated. The isolated mu- ciparous 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 frequently enlarged—sometimes enormously so; occasion- ally 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 Avith tubercles. In some instances acute peritoneal inflammation seems to have been the immediate cause of death, and to have result- ed 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 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 mor- bid appearance is increased redness of the bronchial mucous mem- brane, the bronchial ramifications and air-cells being filled Avith 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 Avith. Infantile remittent fever is, in every case, the result of inflamma- tion, most commonly subacute, of some portion of the digestive rau- cous membrane; the inflammation of other organs, so frequently met Avith, 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 morbid condition of the mucous membrane of the alimentary canal that we are to look for the pathology of the disease; and to the re- moval 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- 276 DISEASES OF CHILDREN. 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 affect- ed. 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 abdo- men will be present, as in inflammation of the small intestines, and the discharges from the bowels will consist of a muddy, loose, offen- sive feculent matter, or of a little mucus mixed with blood, the abdomen, in all these cases, being more or less tense and hot. Some- times there is a torpid condition of the colon, with great distention, from retained fecal 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 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 wc 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, confectionary, crude fruits and vegetables, and various compound dishes—or swallowing food rapidly, and, consequently, without due mastication, are enumerated by Avriters upon the subject, as the usual causes of the disease. According to the experience of Locock and Merriman, 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 encouraged in this by the foolishness of parents and friends. The disease may likewise be produced by cold and damp, and hence it very frequently 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 af- fected by them, in consequence of the over-stimulation of the skin, and of the organs Avhich sympathize most closely with it, by the heat of the preceding season, which often still continues during the middle THE REMITTENT FEVER OF INFANCY. 277 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, Avhich is usually attended with increased irritability of the digestiATe mucous mem- brane, particularly of its muciparous glands and follicles, no doubt often predisposes to inflammation of the alimentary canal, and of course to remittent fever; of the agency of the latter in its produc- tion, we have not, in any case, the slightest evidence. Among the more common causes of the disease are the neglect or mismanagement of the bowel affections of children generally; more especially the abuse of purgatives on the one hand, and of stimu- lating remedies and diet on the other. Infantile remittent fever is said to prevail occasionally as an epi- demic, or, more properly speaking, as an endemic. Of this there can be little doubt. By some it is supposed, particularly in its Ioav ty- phoid or chronic form, in other words, when connected with subacute inflammation and ulceration of the mucous glands and follicles of the intestines, to be propagated by contagion. The production of dis- ease of the boAvels in children by an impure and confined atmosphere, particularly Avhen 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 be- come affected, from this cause, with some of the worst forms of intes- tinal inflammation, accompanied with the phenomena ascribed to the Ioav 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 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 under- stood from what has been advanced in relation to its pathology. De- pendent for its production and continuance upon inflammation, more or less extensive, and of an acute, subacute, or chronic character, of the mucous membrane of the alimentary canal—it is to the removal of this inflammation that our remedies must be directed; and just in proportion as they are adapted to effect this object, will be our suc- cess 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 with- held; 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 quantities 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 mucilaginous drinks, a moderate portion of some plain farinaceous food, with or without the addition of milk, may be.alkrvved, at proper intervals. Occasionally, in very chronic cases, Ave have found beef 278 DISEASES OF CHILDREN. tea, chicken water, or plain mutton broth with rice, to agree better with the stomach, and to produce a less amount of irritation than fa- rinaceous preparations. On this point, of course, the judgment of the physician, guided by a knoAvledge of the pathology of the dis- ease, and the particular circumstances of each case, must be exercised. The only general rule that can be given is, to prohibit every article of diet of a stimulating or indigestible character, as well as all solid food; and not to allow even that which is proper to be given at im- proper 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 folloAved, in the course of a few hours, by an appro- priate dose of castor oil, or a simple laxative enema. This will ge- nerally bring away a large amount of undigested matter and vitiated secretions, with a manifest improvement in the condition of the pa- tient. As to the propriety of repeating the purgative, this will de- pend upon the particular circumstances of the case. If the attack has been evidently 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 ir- ritation to the mucous membrane, is all-important; if, therefore, pretty free discharges have not been produced by the first purgative, an ad- ditional dose of castor oil, or of magnesia and rhubarb, may be given on the succeeding 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 to remove its more prominent and dangerous symptoms. We are persuaded, however, that the administration, at short intervals, of alterative 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 tenderness upon pressure, with tension and heat of the abdomen: when well timed, and in sufficient numbers to reduce the local inflam- mation, they are the remedy upon which most dependence is to be placed in the treatment of these cases. Even in the protracted and THE REMITTENT FEVER OF INFANCY. 279 chronic forms of the disease, pain, heat, and tension in the epigastric, umbilical, or hypogastric regions, or in either hypochondrium, should be the signal for their application, in numbers adapted to the circum- stances 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 treatment, 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 Avarm bath is, as in the case of gas- tro-intestinal inflammations generally, a very valuable remedy. When the 6kin 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 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- 280 DISEASES OF CHILDREN. panitis, and vitiated, mucous, or dark offensive discharges, one of the remedies from which we have deriA-ed 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 Avhich 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 mesen- teric glands differs in nothing from that already laid down. As soon, however, as the symptoms of intestinal inflammation are reduced, the administration of some of the milder preparations of iodine may be entered 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- 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 Avarm 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 ventila- tion, and by artificial heat when necessary. DISEASES OF THE RESPIRATORY ORGANS. 281 SECTION II. DISEASES OF THE RESPIRATORY ORGANS. 1. Asphyxia. 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, pre\-ious 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 poAvers 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 means, persevered in for a sufficient length of time, complete resusci- tation may be effected.1 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 betAveen 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 ex- hausted. Asphyxia is likewise observed in cases of very rapid de- livery, Avhen the infant is protruded by a quick succession of severe uterine contractions. ' 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 termination of the full period of utero-gestation, and is born dead, it shall be reported as a case of still-birth. 282 DISEASES OF CHILDREN. 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 attendants, the necessary means are not adopted for the preserA-ation 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 and feeble. 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 quantity of thick, tenacious mucus in the mouth, fauces or Avindpipe; 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 distention 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 or- gans, which is essential to the proper performance of their functions, and which must necessarily cause the death of the infant, unless res- piration be promptly established by artificial means, and the due vi- talization 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 exhi- bits a few imperfect respiratory efforts, a smart slap upon the but- tocks, or a few drops of cold water sprinkled upon the chest and ab- domen, 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 DISEASES OF THE RESPIRATORY ORGANS. 283 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 pre- vented. 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 Avriters, "with the view of disengaging any mucus that may be lodged in the trachea," is one that we cannot be- lieve to be either safe or useful. In all cases in which the asphyxia is unaccompanied with s}-mptoms 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 pulsa- tion has ceased, or has become quite feeble. The premature applica- tion 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 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 mi- nutes; 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 Avould also prevent the access of the atmospheric air to the surface of the body, which always exerts a very powerful vivify- ing influence. When the child is removed from the bath, gentle fric- tion 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 resusci- tation. 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 tem- perature of about 60°, were twice dashed over it, strong friction being at the same time applied to the parietes of the chest, active respira- tion Avas quickly established; the infant was then removed from the tub, well dried, and wrapt in flannel; in both cases, an entire reco- very was effected. In the Journal fur Kinderkrankheiten it is stated by Dr. Tott, that 284 DISEASES OF CHILDREN. he has often succeeded in restoring life in cases of asphyxia asthenica infantum after the failure of the usual means, by causing a person standing on a table to pour cold water from the spout of a tea kettle on the pit of the stomach of the asphyxiated infant. In this way, it is added, Professor Hasselberg has saved many lives. But of all the means that have been employed in the asphyxia of infants, inflation of the lungs is the one upon Avhich, experience has taught us, the most confidence is to be placed, if early resorted to, ju- diciously 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 Avithdrawn, 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 res- piration 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 feAv 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 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 inspiration, will materially assist the recovery, and has a better effect than introducing 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 shoAvn to be impossible, by unequivocal signs. Toogood continued it for forty-five minutes, in several cases, before DISEASES OF THE RESPIRATORY ORGANS. 285 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 and 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 Avant 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- tremity, very 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. The infant may, at the same time, be immersed in a warm bath to the hips, Avhile cold water is applied to its scalp. In those cases in Avhich 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 respira- tion. We are in no instance hastily to pronounce success impossible. Many a foetus, Dr. Blundell 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 286 DISEASES OF CHILDREN. 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, its 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 oftens 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 Avhich 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. 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 Avhich ensues. The first indication of the disease is frequent sneezing; the inner surface of the nostril soon after becomes red, dry, and SAvollen, and the cry of the infant is altered, from the impediment to the free pas- sage of the air through the nose; a watery, or thin muculent fluid DISEASES OF THE RESPIRATORY ORGANS. 287 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 fetid 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, from the diminution of the nasal cavities, caused by the submucous infiltration, resulting from the inflammation of their lining membrane; 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 impossibility 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-con- ditioned ulceration. Dr. C. D. Meigs believes that the chief danger to the young infant affected with coryza results from one of two causes; of which the first and the most common is the filling up of the nostrils with a plug of dried viscid mucus, and the other, the submucous infiltration, causing the sides of the cavity to collapse. Now as the nostrils are the principal—Dr. Meigs considers them to be the only—instinctive respiratory orifices in the young infant, it is evident, that so long as their obstruction from either of the above causes continues, the aera- tion of the blood in the lungs must be imperfectly performed. As a necessary consequence, the vitality of every tissue must become impaired, and the functions of the several organs impeded or de- ranged. 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, 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 288 DISEASES OF CHILDREN. other instances, the svmptoms 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 tena- city of the excreted fluid. When the inflammation is slight, and the mucus of the nose is only a little more abundant and ropy than natu- ral, 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 proportion 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 Avhole 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 instances the exudation covers the whole interior surface of the nares, and extends from the superior part of the glottis, upAvards, towards the sinus and cornua of the nose; the mucous membrane be- neath, to which it firmly adheres, being much tumefied, and of a vivid red colour; softening of the mucous membrane, and extensive ulcera- tion are frequently present. In chronic cases, various morbific affec- tions of the alimentary canal, lungs, and brain, are frequently met Avith. The disease, when it occurs, as a primary affection, is usually the result of exposure to a cold or damp 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, exposure 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 ob- served that they sneeze, and are affected with a discharge from the nose. We apprehend, 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.1 In some instances we have found the administration of a few grains of calomel, followed by a dose of castor oil, highly advantageous. A small blister to the nape of the neck will, also, often produce very considerable relief. In all cases great benefit will be derived from anointing occasionally the inner surface of the nostrils by means of a DISEASES. OF THE RESPIRATORY ORGANS. 289 camel's hair pencil, with a few drops of glycerine, or of the oil of SAveet almonds. 1 R.—Hydrochlor. ammoniae, gr. xxvj. ad xlviij. Pulv. ipecacuanhae, 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. Dr. C. D. Meigs' plan of treating coryza is to keep the interior of the nostrils, after they have been carefully freed from mucus, con- stantly anointed Avith some of the finer animal oils, or, what he be- lieves well adapted to the case, the ointment of cucumbers. The effect of this application would be, Dr. Meigs remarks, to cover the lower part of the aperture with a thin glazing of oil, upon which the viscosities will not rest and dry, but fall outwards upon the lip, whence they may be readily wiped away, whereas upon the dry epithelial surface of the orifice, the viscosities adhere, become inspis- sated, and convert themselves into hard, dry, and solid crusts or scabs. Dr. Meigs also directs that a light flannel cap, fitting closely to the infant's head, should be applied and worn until the coryza disappears. This he has found to be alone sufficient, in a large number of instances, to cure the malady. There can be little doubt that in the majority of cases of simple coryza, occurring in young infants, the plan of treat- ment here recommended will be all that is necessary. 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 ca- lomel, 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 Aveak infusion of bark, the sulphate of qui- nia, or the persesquinitrate of iron, will, however, in most cases be found a better tonic than the oak bark. 1 R.—Calomel, gr. iij. Ipecac, pulv. gr. iij. Cretae ppt. gr. xxxvj. Ext. Hyoscyami, gr. iv.—M. f. chart. No. xij. One to be given every three hours. 19 290 DISEASES OF CHILDREN. 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 nape 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. 3.—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 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 fre- quent 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, hoAvever, 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 adA-ances. 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 at- tended 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 ac- celerated, but when the inflammation 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 aA'idity, it cannot suck for more than ten or fifteen seconds, Avhen it will suddenly quit the breast, and throw its head backwards, and continue in this position for some time, even after the cough has pro- duced an expulsion of mucus. DISEASES OF THE RESPIRATORY ORGANS. 291 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 expecto- ration consists, at first, of a thin, transparent sero-mucous fluid, or of a yellowish 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 gene- rally sAvallowed, or retained for some time in the throat. In some feAv 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- Avise, often occurs in occasional fits, at irregular, and generally short intervals. As the expectoration becomes more copious, each fit of coughing is often attended by a paroxysm of suffocation, ending in Aromiting. 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 ^lightly flushed; in the progress of the disease, howeArer, 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 in- crease ; 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 acquires 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 292 DISEASES OF CHILDREN. the chest, Avhich is thus rendered peculiarly insidious and dangerous. A close attention will, hoAvever, 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 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 ca- tarrhal 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 bron- chitis of many writers, the general symptoms are of a much more se- vere character than in the simple acute form of the disease. There is a greater degree of restlessness and irritability; more decided fe- brile 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 oc- curs in frequent short paroxysms, and is, occasionally, attended by a decided stridulous or croupy sound, and hence, the disease is denomi- nated, by some authors, bronchial croup. The cough is not unfre- quently painful, and, although at first very generally dry, it is usually attended, after a few days, by an expectoration of a tough, yellowish matter, and occasionally, of fragments of a pseudo-membranous ap- pearance. If the disease is protracted, and increases in intensity, the respira- tions become still more oppressed, frequent and irregular, and attended with A'iolent 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- DISEASES OF THE RESPIRATORY ORGANS. 293 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- 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 Avith in children under five years of age, without at the same time traces of pneumonia being present—the latter being sometimes a secondary, at others a primitive or concomi- tant 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 pneu- monia, its presence may still be suspected. When the crepitant rhon- chus is heard, Rilliet and Barthez have invariably found, with one ex- ception, 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 young 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 Avill be apt to be misled in his prognosis in regard to it, unless he early makes himself acquainted with 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 294 DISEASES OF CHILDREN. 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 yields 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 indications 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. 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 ahvays 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 Avith 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 Avell 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 Avhite 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. Be- neath these membranous concretions, the mucous membrane is occa- sionally 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 inflammation 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. DISEASES OF THE RESPIRATORY ORGANS. 295 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 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. Of- ten 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 Avhich they are united, and there will then result a small induration, of the size sometimes of a lentil, the section of which presents, after a discharge of a fluid, a number of granulations or of depressed points. This constitutes lobular pneumo- nia, Avhich forms the connecting link betAveen 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 Mamma- tion—often ulceration. In severe and protracted cases it is not un- common to meet Avith 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 296 DISEASES OF CHILDREN. 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 Avith mucus, nothing will be found to give more prompt re- lief. In infants and young children we invariably prefer the ipecacu- anha as an emetic, to the tartarized antimony; the effects of the 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 Avhen 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 DISEASES OF THE RESPIRATORY ORGANS. 297 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 feAv leeches to the epigas- trium will ahvays 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, 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 adA-isable, 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 byr 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 Avith intestinal inflammation, there is more or less diarrhoea, Avith vitiated discharges. In the commencement it will be proper to administer some purgative, and perhaps the best is a full dose of calo- mel, folloAved by a portion of castor oil. The use of the combination ^ 298 DISEASES OF CHILDREN. 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 folloAving combination.1 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. 1 R.—Infus. polygalse, %'iy. 0 Vin. ipecacuanha, gij. Oxy. scillse, ^iij. Tinct. hyoscyami, 3J.—M. A teaspoonful to be given every three hours. M. Valleix directs attention to the importance of mechanically re- moving the mucus from the throat of the patient, in the suffocative paroxysms that occur in the generalized bronchitis so fatal to young children. As soon as the infant's countenance assumes a violaceous as- pect, and suffocation seenls imminent, the little finger should be passed along the back of the tongue. The child will close its jaws and resist violently, but the finger should be gradually advanced. When it reaches the isthmus, the child opens its mouth, and we should then pass the finger on behind the epiglottis, so as to bring the pulp of the finger several times over the orifice of the larynx. This produces efforts at coughing and vomiting, and the mucus is expelled from the air passages, a part being drawn out by the finger, and the rest swallowed. The child appears, after the operation, much flushed and agitated, and almost suffocated, but it soon becomes calm, until renewed signs of asphyxia call for a repetition of the procedure. In a case related by M. Val- leix, apparent death, after one of these paroxysms, was successfully treated by artificial respiration, the employment of which he strongly recommends in similar cases. When there is much prostration, with a small and feeble pulse, and a degree of droAvsiness, the carbonate of ammonia will often produce considerable relief.2 In such cases, wine whey, in small quantities, judiciously administered, will be occasionally serviceable; the patient being sometimes so weak and languid that he cannot make any volun- tary efforts to cough, upon which, perhaps, his life depends. Hoff- mann, and some other of the German practitioners, speak very favour- ably of a combination of benzoin and camphor,3 in cases attended with great debility; it is said to have produced complete relief, under cir- cumstances to all appearances hopeless. a R-—Carb. ammoniae, 9ij. Or, R.—Asafoetidse, ^ss. Ext. glycyrrh. sjij.' Liq. ammoniae acetat. Aquae, ^iv. Aquae menth. aa £ij.—M. Oxymel scillse, giv.—M. A teaspoonful to be given every three A teaspoonful to be given every two or hours. three hours. DISEASES OF THE RESPIRATORY ORGANS. 299 * R.—Flor. benjoin. gr. iij. ad iv. Camphor, gr. iv. ad vj. Sacch. alb. gss.—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 Avater sweetened Avith 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 Avhey; 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. 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 appear, in a large number of cases, to be the consequence of exten- sive bronchial inflammation, and is probably,in these, very generally produced by the extension of inflammation from the extreme rami- fications of the bronchi to the substance of the lung: in very many instances, hoAvever, 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. ♦ 300 DISEASES OF CHILDREN. The attack, which is often preceded, in infants, by symptoms of a slight bronchitis, usually commences Avith 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 agi- tation and anxiety, or drowsiness, more rarely Avith convulsions. Ac- cording 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, Avhich are sometimes violent and re- peated, 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, Avhich, 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 become affected, even when no other symptom exists than general febrile disturbance, and perhaps vomiting, 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 preter- natural dryness, and the same inability to respire through the nares causes the child to suck by starts. The infant seizes the breast eager- ly, 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 be- yond seventy, in a minute; there is also a peculiar abruptness in the inspiration, it occurring suddenly, before the expiratory movement is completed; the nostrils during the act of inspiration being more or less dilated. The acceleration of respiration does not ahvays corre- spond in extent with the violence of the disease, nor does it in all cases progressively increase fromNthe onset of the attack to its fatal termination. It is often absent or very slight in the pneumonia that 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-pneu- monia, the dyspnoea being so great in some cases as to threaten suffo- cation. 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 unat- tended 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 as- sumes, finally, its normal rhythm, the appetite returns, the cough rapidly diminishes, and in a few days convalescence is fully established. DISEASES OF THE RESPIRATORY ORGANS. 301 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 tAvelfth; 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 Avith 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, howe\rer, 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; though, 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 observed, and when it is, we have generally found it to be an unfa- vourable 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 aug- ments 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, Avhen it diminishes rapidly, and finally disappears. Should, how- ever, 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 ex- pectoration. In some cases, 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 enteritis, there is seldom much cough; occasionally, indeed, it is en- 302 DISEASES OF CHILDREN. tirely absent: the skin in these cases is pale and cool, the pulse small, and the face and extremities oedematous. The disease, in fact, is often so destitute of leading symptoms, that its existence might be over- looked, 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;— Avhile these, with diminished sonorosity of the chest, are always at- tended 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 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 heard; 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 respiration becomes intense, and is accompanied with bronchophony, 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. DISEASES OF THE RESPIRATORY ORGANS. 303 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. The mucous rhonchus is heard in most cases of broncho-pneumonia, 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 loAver 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 Avithout 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, Avhen it is usually louder than the inspiration. The signs indicative of inflammation of the parenchyma of the lung are often entirely ob- scured by the mucous rhonchi of bronchitis. (Gerhard.) When lobular inflammation of the lungs is more generally diffused, upon percussion, the sound, on both sides of the chest, posteriorly, will be dull, compared with that of a healthy child; more or less so, ac- cording to the extent of the induration. 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- tense from the onset of the disease—the pulse is extremely small, the 304 DISEASES OF CHILDREN. face pallid, with a violet tinge of the lips, and at the summit of the cheeks. The general symptoms augment Avith the progress of the 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 far- ther increase, but remain stationary; or, more generally, while the ac- celeration of the pulse, and a frequent, difficult, and painful cough, with loss of appetite and some degree of thirst continue, the fever abates, 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 termina- tion may be hastened by the occurrence of pleurisy, measles, gangrene of the mouth, &c. Acute pneumonia, occurring in the course of some other acute dis- ease, was found by Rilliet and Barthez to seldom continue beyond the twenty-fifth day. The progress of chronic pneumonia is very gene- rally sIoav; the disease may continue for three or four Aveeks, or even longer. The pathological anatomy of pneumonia in children has of late years attracted much attention. Among those who have investigated it with the greatest care are to be ranked Rufz, Valliex, Lanoix, La Berge, 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 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 upon the chest being opened. In some cases the marbled appearance of" the 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- DISEASES OF THE RESPIRATORY ORG ANS . 305 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 scat 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 tAA-o 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 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 caA-ity is increased at the expense of the inner zone. At a later period, an incision through the diseased part reveals caA'ities 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 Avith the pus. 20' 306 DISEASES OF CHILDREN. At first, these cavities are formed by a layer of hepatized pulmonary tissue, lined Avith 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, analogous to a serous membrane. The abscesses sometimes freely communicate 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- ceding variety. There is no distinct limit 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 generalized lobular pneumonia, which, when it has reached the third degree, 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 DISEASES OF THE RESPIRATORY ORGANS. 307 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 disse- minated, 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 Avell-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 superior lobes. Partial pneumonia is often disseminated through all the three lobes; it is more frequently met with, however, in the infe- rior. Mammelonnated pneumonia is ordinarily equally diffused in both the right and left lung, while generalized pneumonia predomi- nates in the left. Mammelonnated pneumonia is of much more rare occurrence beyond the sixth year than partial pneumonia, while ge- neralized pneumonia is still more rare than the former between the sixth and fifteenth years. (Maladies des Enfans, T. i. p. 61.) It has been doubted Avhether 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- 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. VieAvs similar to those of Hasse are adopted by Dr. West in his very excellent monograph on the pneumonia of children. More re- 308 DISEASES OF CHILDREN. eentlv, the subject has been minutely investigated by MM. Bailly and Legendre, the'results 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 netAvork 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 Avith inflammation, yet, in by far the majority of cases, this condition becomes developed under the influence of catarrh and catarrhal pneu- monia. When unattended Avith catarrh, and involving only isolated lobules, it cannot be detected until after death, but in the neAv-born infant it usually assumes the lobar form, is attended by the physical signs of deficient respiration, and associated Avith the absence of all signs of constitutional reaction. Lobular pneumonia has, they main- tain, strictly speaking, no existence; the action of inflammation never being confined to a single lobule. Partial pneumonia would therefore be a fitter term. Insufflation does not modify the patches of true he- patization, and the bronchi leading to such hepatized nodules are exempt from catarrh; two characters which distinguish partial pneu- monia from the lobular engorgements of partial broncho-pneumonia. True partial pneumonia, according to MM. Bailly and Legendre, is by no means common in 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 pneu- monia at that age, must be taken as referring to the foetal state of the lung. Broncho-pneumonia may affect healthy lobules, or those in the foetal state. In the latter case it gives rise to appearances which have led to the supposition that these lobules were the seat of a parenchy- matous inflammation. Dr. West has repeated the experiments of MM. Bailly and Legendre on many occasions, and fully substantiates the correctness of their statements. Dr. Fuchs, in his very excellent monograph on the Bronchitis of Children, published at Leipzig, in 1849, denies that, in children under five years of age, he has ever met with an instance of true pneumonic condensation, and adduces conclusive evidence of the connexion of what has been denominated lobular pneumonia with bronchitis, and of its relation to bronchial obstruction. This connexion and relation has also been ably illustrated in a treatise On the Pathological Ana- tomy of Bronchitis, and the Diseases of the Lung connected with Bronchial Obstruction, by Dr. W. T. Gairdner, of Edinburgh. (Edin- burgh, 1850.) DISEASES OF THE RESPIRATORY ORGANS. 309 The general results to which he has been led from a careful series of observations are, 1st, that in all cases of collapse of the lung, as well rn the adult as in children, not caused by external pressure, the bronchi have presented unequivocal appearances of obstruction; 2d, that in most, if not all, the instances of severe and fatal bronchitis, especially if the secretions had become ropy or inspissated, more or less collapse of the pulmonary texture has also been present—that, under peculiar circumstances, a much less amount of obstruction may be attended with collapse of the pulmonary texture, the symptoms in such cases probably attracting little attention. In reference to the mechanism and causes of bronchitic collapse, Dr. Gairdner remarks, " It is clear, from experiment, as Avell as from pa- thological observation, that the most usual and most direct effect of obstruction, or of diminished caliber of the bronchi, however caused, is not accumulation, but diminution in quantity, of the air beyond the obstructed point. It is probable that this is due in part to the com- parative weakness of the inspiratory poAver, and that the proposition of Laennec may, therefore, correctly enough be inverted. There is also, however, another mechanical condition which comes into play in producing collapse from obstruction, especially in the case of a viscid plug of mucus, A\-hich is most commonly, in bronchitis, the source of this affection. This condition is found in the form of the tubes. " The bronchi are a series of gradually diminishing cylinders, di- viding, for the most part, dichotoneously. If a plug of any kind, but especially one closely adapted to the form of the tube, and possessing considerable tenacity, be lodged in any portion of such a cylinder, it will move with much more difficulty towards the smaller end, and in doing so Avill close up the tapering tube much more tightly against the passage of air, than Avhen moved in the opposite direction into a Avider space. If such a plug be placed over a bifurcation, it Avill, even if freely moving in the larger space in Avhich it lies, be of sufficient bulk to fall back upon one or other of the subdivisions during inspira- tion, in the manner of a ball valve upon the orifice of a syringe, and thus completely to occlude it. The consequence of this mechanical arrangement must inevitably be, that at every expiration a portion of air Avill be expelled, which in inspiration is not restored, partly owing to the comparative weakness of the inspiratory force, and in part to the valvular action of the plug. If cough supervene, the plug may be entirely dislodged from its position, or expectorated, the air of course returning freely into the obstructed part; but if the expiratory force is only sufficient slightly to displace the plug, so as to allow of the outAvard passage of air, the inspiration Avill again bring it back to its former position, and the repetition of this process must, after a time, end in perfect collapse of the portion of lung usually fed -with air by the obstructed bronchus."—"In considering, as a whole, the causes Avhich tend to produce bronchitic collapse, they seem to resolve themselves into the following: firstly, the existence of mucus in the bronchi, AA-hich is more liable to produce obstruction according as it is tenacious and A'iscid; secondly, Aveakness or inefficiency of the inspi- ratory poAver, hoAvever caused; thirdly, inability to cough and expec- 310 DISEASES OF CHILDREN. torate, and thus to remove the obstructing mucus. Of these condi- tions, the first must be considered as the immediate exciting cause, the others, as predisposing causes, co-operating with the first, but in- capable, without it, of producing collapse." The circumstances producing inefficiency of the inspiratory act Dr. Gairdner considers to be Aveakness of the muscles of inspiration, usu- ally concurring with general debility; distention of the abdomen, im- peding the descent of the diaphragm; and, finally, which is one of the greatest importance in relation to this subject, Avant of due resistance on the part of the thoracic parietes. The full dilatation of the lungs is only effected when the depression of the diaphragm is accompanied by the elevation of the ribs and widening of the thorax; and if the bones of the latter be very yielding, the external muscles of inspira- tion cannot, of course, act effectively under an obstruction. This is obviously the reason of the greater tendency in children to collapse of the lung as a consequence of bronchitis. The respiration of the child is at all times, even in health, more diaphragmatic than that of the adult; and the observations of Rilliet and Barthez afford satis- factory evidence of the comparatively small dilatation of the thorax in children, particularly of its lower part. When any obstruction exists to the entrance of air into the chest, even this small dilatation ceases, and collapse of the lung very readily takes place. Under such circumstances, Dr. Rees (on Atelectasis Pulmonum, London, 1850) has pointed out that in very young children the motions of the chest are absolutely reversed, and instead of the descent of the diaphragm being accompanied by expansion of the chest, the ribs give way be- neath the exhaustion caused by it within the thoracic cavity, and bend inwards to accommodate themselves to the collapsed lung in inspira- tion. This altered movement of the chest in infants is regarded by Dr. Rees as pathognomonic of atelectasis. It is also a prolific source of that permanent deformity of the chest which, in the early years of life, is often ascribed, Avith too little discrimination, to rickets.1 ^ The origin of the minute abscesses which so often occur in the por- tions of lung supposed to be in a state of hepatization from lobular pneumonia, Dr. Gairdner explains as follows: When pus accumulates in the central bronchi of a collapsed lobule, the evacuation of that pus is preATented from occurring, firstly, in consequence of the absence of the expiratory vis a tergo; and secondly, from the resistance opposed by the thickened mucous membrane and its secretion, closing up the bronchus in front. The coats of the ultimate bronchi, therefore, soft- ened and injured by disease, gradually give way to ulceration, and the pus, which thus accumulates in still larger quantity, may at first scarcely be circumscribed, but soon begins to be surrounded by a false membrane exactly similar to that of an abscess in any other part of the body. The continuity of the membrane with that of the original bronchus may be either maintained from its first formation, or it may be secondarily established. It is asserted by M. Bouchut, that even true hepatization may be removed by insufflation; in this, however, he is decidedly wrong. 1 Gairdner, op. cit., pp. 33, 34. DISEASES OF THE RESPIRATORY ORGANS. 311 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. Dr. Gairdner remarks, however, that he does not believe that inflation alone is applicable to the determi- nation of the presence or absence of true hepatization in those mixed cases in which alone there is any difficulty. For he has observed that on the one hand, the partially pneumonic lung may be inflated when the affection is recent, and combined, as it frequently is, with bron- chitic collapse; and on the other, that in the latter lesion in its purest forms, complete inflation is often very difficult or impossible after the collapsed state has been of some duration. In fact, the lung then begins to undergo a modification in its nutrition and structure, which ultimately leads to permanent atrophy. 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 fre- quently in the right than in the left. It is most generally accompa- nied with pleuritis, 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 Avith 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 of a very intense degree. Emphysema of the lung is not unfrequently met with; its extent is in direct proportion with the extent of the pneumonic and bronchial affections, their violence, and the amount of dyspnoea Avith which they are attended. It generally occupies the summit of the organ, or its sharp edge. It is commonly double; when 312 DISEASES OF CHILDREN. on one side only it is confined to the inflamed lung, and is here ahvays most considerable. By a few Avriters, 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 beon shown that al- though more frequent, perhaps, in young children, lobular pneumonia may, nevertheless, occur at any period of childhood; a fact Avhich our own observations very fully confirm. It has been asserted that pneumonia in children 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 bron- chitis, 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 pneu- monia; but that it is incontestable that lobular pneumonia, mam- melonnated, 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 preA'ious disease, unless complicated by some secondary affection, is not a very fatal disease, 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 A\ith measles, and perhaps Avith 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 prevalent during spring, autumn, and winter—and among the chil- dren of those classes who are most liable to be exposed to cold or to sudden alternations of temperature. Cases, however, occur at all sea- sons of the year, but comparatively seldom during those months the temperature 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, Go 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 preA'ious attacks, namely, 21, once; 4, tvvice; 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 DISEASES OF THE RESPIRATORY ORGANS. 313 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 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 ATiolence of the symptoms, and the age and strength of the patient, will, in general, suffice; but in older children, whenever it can be effected, we should prefer, in severe cases of pneumonia, bleeding from thejarm, which has always appeared to us to produce a more decided impression upon the dis- ease, 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 Avell- timed, and carried to a sufficient extent, a second will not generally be required. Whenever, however, the leading symptoms, particularly the dyspnoea, continue with little abatement, Ave should never hesi- tate 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, hoAV- ever, in the early period of the attack alone, that Ave 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 application 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, Avill 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 occur- ring in children, as in that of adults, either in conjunction with blood- letting, or as the sole remedy; and cases have been published by Guersent and others in proof of its efficacy. M. Herard, in a paper published in L'Union 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, Avhich 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 exclusively by large doses of tartar emetic by MM. Baudelocque and Blache, in the Hospital for Infants in Paris, seven died; of these, two fell victims to tubercular pneumonia, and in the other five, lobular pneumonia Avas very extensive. This form of pneumonia Dr. Herard considers as far less amenable to tartar emetic than the lobar, Avhile cases of broncho- 314 DISEASES OF CHILDREN. 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 Avith which convalescence 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, Ave 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 Avithout very decided advantage.1 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.2 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. 1 R-—Calomel, gr. iv. ad vj. ° R.—Mucil. G. acaciae, £iv. Ipecac, gr. iij.—iv. Vin. ipecac, gj. Pulv. digitalis, gr. iij.—iv.—M. Tinct. hyoscyami, ?5J. f. chart. No. xij. Sacch. alb. pur. giij.—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 has 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; Avhen 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 Avith powdered mustard. DISEASES OF THE RESPIRATORY ORGANS. 315 Warm pediluvia, witli the addition of mustard, or sinapised hip baths, 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 ex- hausted, and the employment of calomel is forbidden 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 em- ployment, and the solid lung become once more permeable to air. In chronic cases, our chief dependence is upon revulshes, applied either upon the chest, or upon the surface generally, and perhaps upon a judicious mercurial course, particularly by inunction. WThen 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;1 but, under such circum- stances, there can be but little hope of the patient's recovery. 1 R.—Decoct, senegse, 3iij. Carb. ammoniae, 3J. ad 3Jss. Sacch. alb. Jij.—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, should be confined, almost exclush7ely, to plain mucilaginous fluids, or whey; in the more prolonged cases, hoAvever, after the violence of the disease has been subdued, plain water gruel, arrow-root, or tapioca, may be alloAved. When the disease occurs in infants, they should be ahArays taken from the breast, and the mother's milk given to them in moderate quantities by means of a spoon, as Avell 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- 316 DISEASES OF CHILDREN. able, uniform temperature, and, at the same time, the purity "of the air should be secured by proper ventilation, and a strict attention to cleanliness. The patient should be placed always in a half-recum- bent posture, in order to render the respiration more easy, and to prevent the injurious consequences resulting from the stasis of fluids in the posterior 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 AVith 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, indigestible, 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 Avhich has been denominated by Jorg Atelectasis Pulmonum, it may be proper to give a short notice of the disease, for the informa- tion of such of our readers as may not have met with that gentle- man's work, Die Fbtuslunge 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 nor pressure is any crepitation pro- duced. It presents, when incised, a smooth red surface, from Avhich a bloody serum may be squeezed, but in which no air bubbles can be . detected; Avhen 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 in- flammation or effusion, but is the result of imperfect respiration, which prevents 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 un- common at the age at Avhich death from atelectasis occurs. The causes assigned for this affection are, a very rapid and easy DISEASES OF THE RESPIRATORY ORGANS. 317 delivery, or a too strong compression of the head of the child during parturition;—both of which circumstances are common causes of as- phyxia in neAv-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 con- sideration. 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 ele- vation of the ribs and sternum, often a livid or blue colour, with cold- ness of the surface, a weak languid pulse, and symptoms of general prostration. In consequence of the imperfect respiration, and im- peded circulation, nutrition is always impaired, and hence, if the child survive, it becomes emaciated, and cannot bear the slightest motion or exercise. In some cases congestion of the brain is produced, and convulsions; or, from the violence of the respiratory efforts, inflamma- tion 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 di- rected in the section on asphyxia. Rubbing the chest and back with sulphuric ether, and introducing it into the nostrils and mouth, im- mersion in an aromatic Avarm 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 en- gorgement of the vessels of the brain, are, indeed, strongly contra- indicated Avhen the brain has been injured during labour; in these cases a feAv grains of calomel, and stimulants to the loAver extremities, cool lotions to the head, and even leeches to the latter, will often be found of advantage. 5.—Pleuritis. Inflammation 6f 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 Avith 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 Avere detected. In five it Avas combined with 318 DISEASES OF CHILDREN. pneumonia; in one it was complicated with pericarditis; in another 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 detec- tion in young children than in the adult, and is especially liable to escape observation in infantile life, where many valuable signs, ob- tainable in more advanced life, are wanting; still, when the inflam- mation is confined 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 in- creasing 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 symp- toms 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 abdomi- nal muscles and diaphragm; the motion of the chest being instinc- tively 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 gene- rally 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 coun- tenance that peculiar contraction which is the common expression of suffering in children. If the disease is arrested in its first stages, the pain and dysp- noea generally abate; the last, as well as the fever, often entirely DISEASES OF THE RESPIRATORY ORGANS. 319 disappearing. The cough, in the course of the disease, becomes more moist, and a little viscid mucus is often raised by it: expectoration, however, is seldom attendant upon pleurisy, unless when complicated with bronchitis 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 exacerbations. Effusion in the pleural cavity takes place to a very considerable 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 tAventy-seventh day. In favourable cases, most generally, the bron- chial inspiration is replaced, at variable periods, by a feebleness of the respiratory murmur, more rarely by the friction sound, and some- times by the normal respiration. It is in the more acute cases, in Avhich effusion probably occurs very promptly, that the bronchial ex- piration 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 de- tected as late as the fourth day of the disease; it sometimes disap- pears and again returns. It is present only in cases attended with serous effusion, when this is very abundant, or when thick false mem- branes are formed. It is often present in infants of two or three years, but is more distinct in older children. 320 DISEASES OF CHILDREN. 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 thegchest, and then higher and higher; the obscuration extending, finally, over the Avhole 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, folloAving in its march and in its extent the obscuration of the respiratory murmur. In very acute cases the dulness Avill 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 effu- sion has taken place will be found to be confined in their movements, while the intercostal spaces are enlarged. When the effusion is very considerable 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 Avhich 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, of 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, Avith yellowish lymph, forming, in some cases, a coating of considerable 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 occupy the most depending portions of the pleural cavity; they are occasionally col- lected in separate cavities formed by recent false membranes or ad- hesions of the pleura. The most common lesion met with after death from pleurisy is unquestionably false membranes; they most frequently cover the costal pleura, often the pulmonary, and frequently both. In DISEASES OF THE RESPIRATORY ORGANS. 321 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, Avhen 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 others it assumes as serious a character as the accompanying pulmonary in- flammation. 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 betAveen the pleura costalis and pulmonalis, in chronic oases, 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, folloAved by soft Avarm cataplasms, will often produce a very decided abatement of the disease. In the commencement of the attack, the boAvels 21 322 DISEASES OF CHILDREN. 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.1 The tartarized antimony, combined with nitre and calomel,* 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. ' R—Nitrat. potassae, 3J. l R.—Nitrat. potassae, 3J. Tart. ant. gr. ij. Tart. ant. gr. j. Aquae, sjiv. Calomel, gr. iv.—M. f. chart. No. xij. Sacch. alb. ^ij.—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 benefit will be derived from small doses of the combined powder of ipecacuanha, 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 well 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,3 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 potassa4, or a mixture of the syrup and oxy- mel of squill,5 with sweet spirits of nitre, will prove highly efficacious. 'R.—Pulv. scillae, gr. iij. ad. iv. 4R.—Bi-tart. potass, Jjiij. 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. 5 R.—Syrup, scillae, ^vj. Oxy. scillse, gij. Spir. aeth. nitr. 5Jvj.—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 pa- tient 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 DISEASES OF THE RESPIRATORY ORGANS. 323 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—Croup. CTNANCHE TRACHEALIS—ANGINA POLYPOSA VEL MEMBRANACEA—LARYNGEO-TRACHEITIS. 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 yrears 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.x The croup is, strictly speaking, an inflammation of the mucous mem- brane of the larynx and trachea, 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 feArer, 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. The distinguishing symptoms of croup are: dyspnoea, a peculiar hoarseness of the voice, a loud ringing cough, sibilant inspiration, and 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- 1 Entire mortality of London during 1840,45,284; and of the whole of England, 8-!>9,561. In Paris, the deaths from croup in 1838, were 187 ; in 1839, 286; and in 1840,32(5. 324 DISEASES OF CHILDREN. 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; Avhile 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 com- plains of a sense of constriction in the throat, and sometimes of pain about the larynx. In general, these symptoms, after a short period, gradually 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 symp- toms 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 resonant. 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 the 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 yoice, 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 sAA-eat. There is now but little, if any, cough or ex- DISEASES OF THE RESPIRATORY ORGANS. 325 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 ac- tual 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 inten- sity. Its duration Avill 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 seventy-two 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 cither 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. The diagnostic symptoms of croup are: the hoarseness of the voice, the peculiar deep ringing cough, and the loud wheezing or sibilant inspiration. The hoarseness of the voice is generally among the first symptoms that occur; even, in many cases, being observed previous to the dysp- noea, 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 326 DISEASES OF CHILDREN. the cases that are preceded for some days by simple catarrhal symp- toms, the peculiar hoarseness of the voice will early warn the ob- serving 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 sIoAvly 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 Avith 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 com- pared to the crowing of a young cock, to 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 retains its croupal sound, but is less violent. ToAvards the close of the disease, when the natural functions of the respiratory tube have become 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, speak- ing, 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 Avith 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 glotti- dis and upper portion of the trachea, in consequence, in the first in- stance, of the thickening of the inflamed mucous membrane of these parts, and subsequently, of the pseudo-membranous exudation Avith which they become covered. But the circumstance of these symp- toms, in many cases becoming aggravated at irregular intervals, di- vided by distinct remissions, thus constituting, as it Avere, paroxysms, that commence suddenly, and decline with equal abruptness, have in- duced many to suppose that the peculiar symptoms of croup are, to a DISEASES OF THE RESPIRATORY ORGANS. 327 certain extent due to a spasmodic constriction of the muscles of the larynx and glottis. It is probable, however, that it is chiefly the ex- treme 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, Avith 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; Avhen, during the paroxysms, it is only by the utmost efforts that the child appears to be capable of effecting the respiratory movements. The muscles 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 backwards, 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 in- variably the case, and hence, as Royer-Collard Arery 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 res- piration 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 inwards, towards the spine, and at the next, return suddenly to their former position. Ordinarily, inspiration is long and almost continuous, en- dangering, every instant, the suffocation of the patient. In the se- cond, 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 Avhat have been termed spurious croups, the laryngeo'-bronchial variety of Duges, there is often, especially in young children, no symptoms 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 character, and increased upon external pressure; in slight cases, how- ever, this symptom may be wanting. By some writers, a swelling of the neck, at the upper part of the trachea, 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 328 DISEASES OF CHILDREN. the patient: it must, however, be of very rare occurrence, as we have never had an opportunity of obsen-ing 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 of the most active emetics. Occasionally, hoAvever, vomiting will be provoked 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; drowsiness 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 Caillcau, 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, Ave 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 the 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 jnuco-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, DISEASES OF THE RESPIRATORY ORGANS. 329 attached to the posterior surface of the tube; or the trachea is filled Avith a mucuform fluid, containing small masses of a more solid con- sistence. These same appearances are occasionally present in the up- per part of the bronchi; but more frequently in the bronchial tubes there is only found 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, separated 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 be- ing filled in their final ramifications with a thick, ropy mucus. (Royer- Collar d.) 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 portion 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- 330 DISEASES OF CHILDREN. 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 is 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 otherAvise 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. DISEASES OF THE RESPIRATORY ORGANS. 331 The investigations of modern pathologists have shown that the dis- ease is an inflammation of the mucous membrane, and probably, ac- cording 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 bronchi, often throughout their ramifications, and to the tissue of the lung itself. It gives rise, more or less rapidly, to the exuda- tion of an albuminous fluid, which most generally forms a pseudo-mem- branous coating upon the larynx, trachea, and commencement of the bronchi. The collapse or adynamic symptoms of the third stage, re- sult from the interruption to the function of respiration, and the con- sequent imperfect haematosis, caused by the presence of the exudation, and the congestion of the lungs. As Ave have already remarked, nearly all the characteristic phenomena of croup indicate that there also exists a spasmodic affection of the glottis, which, however, is the result of the increased irritability of the parts labouring under inflam- mation, and probably of the irritation of the morbid secretion, and not, as some pathologists have supposed, the chief cause of the promi- nent 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 Avell 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 feAv, if any cases, in Avhich it is confined to the trachea alone. Jurine has attempted to shoAV, 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 haA-e taught us, that in cases attended Avith violent symptoms, sudden in their onset, and rapid in their progress, there exists, most generally, considerable inflammation, Avith pseudo-membranous exudation, about the larynx, glottis, and up- per portion of the trachea, to a much greater extent ahvays, than in those cases especially, in Avhich 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 Avith decided 332 DISEASES OF CHILDREN. febrile reaction, firm pulse, pain in the larynx, and other indications of severe inflammation; the disease usually occurring as a primary affection. The second form, occurring in debilitated and cachectic children, or those reduced by previous disease, and attended witli a Ioav, 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 tuber- cular 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-membra- niform exudations in all the inflammations of the mucous surfaces, espe- cially those of the respiratory organs, which readily assume, in par- ticular 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 «» DISEASES OF THE RESPIRATORY ORGANS. 333 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, Avhen, by the improper fashion of their dress, their neck, shoulders, upper portion of their breast, and the greater part of their arms, areleft entirely bare, or only slightly covered. The chief exciting cause of croup is, unquestionably, the impression upon the Body of a cold and damp atmosphere, or sudden transitions of temperature; hence, we find the disease most prevalent during the variable, damp, and chilly weather which prevails in the commence- ment of spring and close of autumn. It is also of much more frequent occurrence, in situations naturally abounding in moisture, 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 temperature. 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 subsequent 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 deglutition is more or less difficult, the breath fetid, 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 boAvels, Avith 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 someAvhat, 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 Avarm 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 334 DISEASES OF CHILDREN. 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 jiever 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, are 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 \-iolence, 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 be 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 symptoms should again recur with any degree of violence, the bleed- ing should be repeated, or leeches should be applied around the throat, in numbers proportioned to the age and strength of the pa- tient, and the intensity of the disease. The repetition of the bleed- ing must be governed 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 repe- tition 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 will have passed, and in those cases in which it is strongly indicated, DISEASES OF THE RESPIRATORY ORGANS. 335 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, Avill 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. R.—Calomel, gss. ad gj. Tart. ant. gr. j. Hydrochlor. ammon. ^ijss.—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 oavh experience, scarcely too strong. Stokes places it even above bloodletting. Steinmitz trusted to it alone in the second stage, as also did Jadelot, Avho combined the tartarized antimony with ipecacuanha, squill, and senega.1 Cheyne also speaks highly of the efficacy of the 1 R.—Infus. senegae, ^iv. Syrup, ipecac, gj. Oxy. scillae. giij. 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 of a quarter or a third of a grain every hour, until a decided impres- 336 DISEASES OF CHILDREN. sion is produced upon the symptoms, and subsequently every two hours. Combining the article Avith 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; Avhile 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 enor- mous doses, far greater than we should be inclined to prescribe; we nevertheless believe that the good effects of the remedy, in a disease of such rapid progress as croup, can be obtained only from its free administration. 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, hoAvever, 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 ef- fusions; we have employed it pretty extensively for many years in croup, and have always been pleased with its effects. Chamerlat re- commends 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 doAvn as an invariable rule to make such examination when- ever 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 Avith the plastic exuda- tion, 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 Avooden tongue depressor. For fear of DISEASES OF THE RESPIRATORY ORGANS. 337 accident, the caustic should project only A-ery 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 Avater—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 Avax. 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, Avhich must be fixed upon a strong Avhalebone, 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 Avas 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 re- duced by bleeding and leeching. DeAvrees doubts their utility; and Goodlad, Stokes, and Porter, condemn them entirely. We have oc- casionally employed them, but cannot say that we have perceived anv benefit to result from their use. Rubefacients, followed by Avarm 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 haAre generally employed: its action upon the skin is prompt and sufficiently powerful: a strip of flannel wet with tur- pentine 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 A'iolent cases, in the incipient stage of the disease, even rubefacients should not be resorted to until after blood- letting. A German physician, Dr. Willige, states (Schmidts Jahrbilcher, 18-17,) 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 mean? 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 Avhich he believes 22 338 DISEASES OF CHILDREN. that by the external application of the iodine, he succeeded in avert- ing 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 Avatched, 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 lo- belia will often be found advantageous; or, perhaps, the infusion of the Sanguinaria Canadensis.1 We know nothing of the latter remedy from our own experience; it comes to us, however, very highly re- commended 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 produced, even by very considerable doses of antimony; it has under these circumstances been recommended to employ the sulphate of zinc or of copper in solution, alone,2 or combined with ipecacuanha. ' R.—Had. sanguinar. canadensis, pulv. J)j. s R.—Sulph. zinci vel cupri, ,^ij. Aquae calidas, ,^iij.—M. Aquae, gj.—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, re- mains, a strong decoction of senega will be often found a useful aux- iliary to the other remedies. R.—Rad. polygalae senegie, %j. Aq. bullient. Oj, Simmer to ^xij. then add Mellis, Jjiij. 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 clotha wet with hot turpentine, or the decoction of turpentine and cantharides, DISEASES OF THE RESPIRATORY ORGANS. 339 may at the same time be applied to the extremities, and internally a strong decoction of senega, with the addition of camphor and asa- foetida, may be resorted to; and if there is great and increasing ex- haustion, it Avill be proper to support the patient's strength by am- monia or Avine 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, ghren in large doses, from twelve to tAventy-four grains in the course of twenty-four hours, in the latter stage of croup, we have certainly very strong testimony. Asafoetida, likewise, has been extolled, given as well by the mouth, as by injec- tion 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 in- ducing severe bronchitis or an excessive secretion of mucus in the bronchi, pneumonia, or convulsions; while in many cases the patient died immediately after the operation, without any local lesion exist- ing, 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, saAe the life of the patient, we have the most unquestionable evidence. In a statement of Trousseau of the result of the operation in one hun- dred 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- 340 DISEASES OF CHILDREN. cians of Philadelphia.—(Summary of Transactions, vol. ii. page 275.) 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 seAreral days back, the disease haA-ing advanced slowly—whatever may be the extent of the false membranes in the trachea and bronchi, the child either recovers, or, at least, liA-es several days after the operation. 2d. If the child has been subject to chronic catarrhs, and Avhen 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 occasioned by the displacement of mucosity, there is nothing to fear; but when the respiration is attended with a sound like that produced by the saAv- 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 superArene. 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 someAvhat bloated, Avithout 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. 9th. The more deeply, the false membranes have extended, the greater, cceteris 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. 11th. 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 sud- den sinking of the wound is a mortal sign. 13th. Should the Avound become covered with false membranes; if after withdraAving the cannula, it remains gaping for a long time, or if, after having become completely cicatrized, it reopens largely, the child is in danger. DISEASES OF THE RESPIRATORY ORGANS. 341 14th. Agitation and sleeplessness are bad signs, so is also the oc- currence of convulsions. The younger the patients, and the more blood they haA-e 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 cannula 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 Avarm 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 feA-er after the fourth day, agitation, sink- ing of the Avound, dryness of the trachea, frequency of the respiratory movements, and attempts to cough, announce the in\-asion 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 hoAvever exclude blisters, because they too often become covered Avith false membranes. We have said nothing, as yet, on the subject of diet in croup. During 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; Avhile 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 Avarni bath, and daily exercise in the open air, during mild and dry weather, should never be neglected. 9 7.—Spasmodic Croup. aiillar's asthma.—spasmodic laryngitis.—false crocp.—catarrhal croup. There is a form of disease of frequent occurrence during childhood, Avhich has very generally been confounded Avith 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 a false membrane, in the air passages. The disease to which Ave allude has been variously named by different 342 DISEASES OF CHILDREN. writers. Millar, who was the first that directed attention to it, de- nominated it Asthma, which name was retained by Wichmaun and others; Bretonneau named it Stridulous Angina, Guersant, Laryngis- mus Stridulus, while Rilliet and Barthez prefer the denomination Spasmodic Laryngitis, as indicating Avhat they believe to be the true character 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 oc- casionally takes place during the day. The child is, generally, sud- denly awoke from sleep by a sense of impending suffocation. He starts up in a sitting posture, or throAvs 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 sur- round, 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 continuing 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 continues during the ensuing day tolerably avcII, though in many cases affected with hoarseness, and a frequent short, barking cough, with or with- out expectoration, and during the night following is again attacked with a paroxysm of suffocation. The disease may continue 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 continued for a long time after the cessation of the disease. In some cases, the pa- roxysms continue to recur, and at the same time to augment in inten- sity, 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 vomit- ing, with great exhaustion, and a small frequent pulse, and soon sinks. Usually, howeA'er, 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 Avhen the child was two years old, the second when it Avas five, and then in the 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 DISEASES OF THE RESPIRATORY ORGANS. 343 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 reaction 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, Avhen 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 unfavourable termination is to be apprehended. The true pathology of this affection has not yet been very accu- rately made out. Millar, and after him most of the German physi- cians, 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. Guer- sant supposes 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 consists in an actual inflammation of the larynx, and they found their opinion upon the fact of the attack being generally the result of sudden exposure to cold; the disease being usually pre- ceded by coryza, watering of the eyes, oppression, &c, and attended by some degree of febrile excitement: in connexion -with this mild laryngitis, they presume that there occurs a spasmodic affection of the glottis, by which the sudden paroxysms of suffocation which cha- racterize 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 part exists, its secre- tion 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 glot- tis, and the consequent asphyxia. The spasmodic croup is essentially a disease of children; according to Guersant 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 Avhich all the children when they attained the age of betAveen two and three years were successively affected with it. This predisposition is said, in many instances, to be 344 DISEASES OF CHILDREN. 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 of the atmosphere. 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 Avell—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 ahvays an important remedy; it may be employed 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 DISEASES OF THE RESPIRATORY ORGANS. 345 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, Ave 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 exhibi- tion of an emetic will be found advantageous—generally removing very promptly the remaining symptoms, and preventing the recur- rence 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 hesi- tated 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 iiiA-ariably been much pleased Avith its effects. In mild cases, small repeated doses of the mel scillae compositum of the United States Pharmacopoeia, may be advanta- geously substituted for the ipecacuanha. Blisters upon the chest or between the shoulders are recommended by some writers—AA-hen 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 sel- dom, hoAvever, seen much good result from the application of blisters in cases of spasmodic croup. Covering the breast, hoAvever, with a hemlock or asafoetida plaster, has appeared to us very generally to have a decidedly beneficial effect. Purgatives are only required in those cases in which their use is indicated by a costhre or torpid state of the boAvels. Here a dose of calomel, followed by castor oil or magnesia, will be proper, and a free state of the boAvels should be subsequently maintained by an occasional dose of some mild laxative. Asafoetida, 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 feAv hours after the paroxysm has terminated. Wichmann recommends the musk as a specific in this disease; Henko, Wendt, Goelis, and others, speak also in strong terms of its curative poAvers. Wendt gave it in the dose of a grain every hour. It is all-important that the child affected with spasmodic croup 346 DISEASES OF CHILDREN. should be kept in a state of perfect tranquillity, warmly clad, and in 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. (LARYNGISMUS STRIDULUS.—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 sup- posed. 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 during or upon awaking from sleep, or in taking drink or food, or upon being teased or irri- tated, 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, somewhat similar to the ringing inspiration of 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 up- Avards, and the Avhole countenance expresses the utmost anxiety and suffering. The head is thrown backwards, and the chest upwards; the diaphragm and abdominal muscles contract violently, and eAren the extremities 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 forehead and temples, which, according to Ley, may continue long after the cessation of the paroxysms. The backs of the hands and in- steps are often swollen and hard; the thumbs are rigidly contracted, and locked across the palms of the hands, and the toes are bent down towards 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 have a very singular appearance, and in the opinion of Rees, are characteristic of the disease; the fingers are 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 laryngismus 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 DISEASES OF THE RESPIRATORY ORGANS. 347 Aveeks 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 instances, 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 often that which would result from an increased 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. Laryngismus is to be distinguished from spasmodic croup by the absence of all catarrhal symptoms, febrile excitement, and cough, by the respiration being unaffected during the intervals of the pa- roxysms, and by the contractions observed in the extremities. The crowing inspiration also, of laryngismus, is not marked by the peculiar hoarse, rough and grating sound peculiar to the inspiratory effort in croup. From hooping cough, laryngismus may be distinguished by the ab- sence of the convulsive cough, and the retching, vomiting or free ex- pectoration of glairy matter, by which the paroxysms of pertussis are so generally terminated. Hooping cough is also more gradual in its approach, the characteristic paroxysmal cough being in general pre- ceded by catarrhal and febrile symptoms. Dr. James Reid of London, who has written a very instructive trea- tise on Infantile Laryngismus, describes it as occurring under four different forms. The first is caused by a slight constriction of the edges of the rima glottidis, which occurs suddenly, and in a transient manner, causing, for an instant, an exertion on the part of the infant to recover its breath, and producing a feeling of oppression and alarm, indicated by a short cry, and the anxiety depicted on its coun- tenance. This slight and temporary spasm of the glottis is not asso- ciated with convulsive action of any part of the body. The attacks come on at irregular intervals, and at uncertain times, although most generally whilst the infant is asleep, or at the moment of awaking. So little importance is generally attached to this symptom by nurses, that the physician, when called upon at a later period to treat the 348 DISEASES OF CHILDREN. more severe form of the disease, finds that the "catching" alluded to is often not mentioned until questions are put, Avhich at once recall the recollection of its having been of frequent occurrence, though ahA-ays arrested immediately upon the child being lifted from the re- cumbent to an erect position. In the second form of laryngismus, according to Dr. Reid, the area of the glottis is still more diminished by the nearer approximation of its edges, the closure, however, not being perfect except perhaps for a moment. In this form of the disease there is a much longer interruption of the respiratory function, and the symptoms of impending suffocation are more imminent: there is a violent effort to inspire through the contracted aperture of the windpipe. The countenance exhibits the characteristics of great anxiety and distress, becoming at first red, but soon changing to the purple hue of strangulation; the face, and, in some cases, the tongue also become turgid and swollen. In other instances there is an ashy paleness of the face. The arms are throAvn out; the eyes are either wide open and staring, or, more rarely, turned up in their sockets; the nostrils are dilated; the head is thrown back; the limbs become rigid, and the abdominal muscles contracted. There is frequently, also, a convulsive and violent action of other muscles, especially of the flexors, causing a peculiar contraction of the wrists and ankles, a state which has been called the carpo pedal spasm. Occasionally, the body itself is bent suddenly backwards, as if by a violent effort, and it appears to the bystanders as if nature could hold out no longer, Avhen, at length, the attempt at respiration is partially successful, being attended by a shrill whooping noise, which has been termed crowing, although it more closely resembles the concluding rising note produced by the clucking of a hen. This sound is not of so full and sonorous a character as that of hooping cough, but seems more acute, and it is without the rough hoarseness of croup. It is often an indication that the paroxysm has terminated, but sometimes a succession of incomplete or interrupted, shrill, sibi- lant catches supervenes before a full and complete inhalation takes place, as if the margin of the glottis were for a time somewhat re- laxed, becoming immediately again constricted, so that the expirations bear, in some degree, a resemblance to the short and feeble bleating of an animal. When respiration is again properly re-established, the infant most commonly bursts into a fit of crying, and falls asleep; when, hoAV- ever, the attack is unusually severe, a listlessness and torpor often remain for a short period afterwards, Avhilst in rarer instances of the disease, the child continues, during some hours, in an anxious state of distress. These paroxysms vary much in their frequency, duration, and se- verity; there is no regularity in the intervals between the attacks, but as the complaint advances, they generally become shorter, and, in some instances, do not continue beyond an hour at a time, or even half that period, the slightest noise or emotion being quite sufficient to produce a paroxysm. The breathlessness, or struggling for air, U DISEASES OF THE RESPIRATORY ORGANS. 349 apparently relieved, in some cases, by a violent expulsion of wind from the stomach or per anum, Avhich is succeeded by a fit of scream- ing ; occasionally, also, there are inA-oluntary evacuations during the paroxysms. Repeated attacks of this nature may occur, without the accom- panying crowing noise, especially when the disease becomes less severe in its character. An acute plaintive cry frequently commences or terminates the paroxysm; when the child remains quiet and sub- dued for some minutes, after which period, it resumes its natural cheerfulness and aspect, enjoying perfect health in the interA-als. The duration of the paroxysm varies from a few seconds to three or four minutes, but in the latter description of cases, it is more a succession of,paroxysms; air occasionally gaining admittance into the lungs, during the slight and almost imperceptible intervals be- tween them. Remissions and exacerbations often take place for weeks, and sometimes for months, before a complete cure can be ef- fected ; whilst in other cases, on the contrary, the complaint suddenly disappears. Dr. Reid describes the third form of laryngismus as a combination of the foregoing variety of the disease, with the addition of general or cerebral convulsions, which, in all probability, are sometimes pro- duced by the blood supplied to the brain being imperfectly decar- bonized, in consequence of partial asphyxia. In the fourth form of laryngismus, according to Dr. Reid, there is complete asphyxia produced by a sudden and convulsive closure of the glottis, Avhich proves as speedily fatal as if the infant were plunged under water, or strangled by a cord around its neck. No crowing sound is audible, as inspiration is totally suspended, and the face of the child, instead of being flushed and turgid, exhibits often a cadaverous aspect, similar to that of persons asphyxiated by car- bonic acid gas, or other noxious vapours. An infant, Dr. Reid re- marks, may have passed through repeated severe attacks of the dis- ease, combined with cerebral convulsions; it may be also, perhaps, improving otherwise in general health, at the same time that the pa- roxysms have latterly occurred at longer intervals, yet, notwithstand- ing all the apparent amendment, it is sometimes carried off by this form of the disease, Avithout any previous warning. The infant may be laughing at the time, or quietly observing the occurrences taking place around it, without the slightest precursory symptoms being per- ceived. 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 Avith 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 occur- rence ; tubercles of the brain are often met Avith, and occasionally, hypertrophy or induration of its substance. The foramen ovale is often found open, and not unfrequently, there exists more or less dis- ease of the gastro-intestinal, and in some cases, of the respiratory 350 DISEASES OF CHILDREN. mucous membrane. 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 Avhich have, however, been adduced to support particular pathological views, Ave ought to enumerate enlargement of the thymus body, and effu- sion within the cranium, as among those most commonly met with; Ave suspect, however, that upon a more minute inquiry it will be found that enlargement of the thymus body is a much less frequent accom- paniment of the disease than has been asserted. Dr. Reid states that on several occasions he has sought for indications of disease, but has been unable to detect any, even in the spinal cord. As a gene- ral rule, it may be stated, he remarks, that no unusual appearances are found to exist in the glottis itself, or in the adjacent parts; no trace of oedema, inflammatory action, or persistent constriction. Dr. Reid has never met with any enlargement of the neighbouring glands suf- ficient to account for a fatal termination. 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 common- ly it occurs between the fourth and tenth month: Mr. Robertson, (London Med. Gaz., Jan. 1849,) has found the accession of the dis- ease 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 they beyond fifteen months of age. Dr. Reid, in common with the majority of those who treat of the disease, states, in regard to the age of infants most liable to its attacks, that it corresponds, with few exceptions, to the period of dentition. An affection, he remarks, closely resembling spasm of the glottis, if not identically the same complaint, may be caused at any period of life by local or mechanical agency; but it must, he thinks, be considered a peculiar disease of infantile life, when it fol- Ioavs as the result of constitutional irritation. Most of the Avriters enumerate the lymphatic temperament as one of the predisposing causes of the disease; it is in consequence of this that we find it to at- tack 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 attacks 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 la- bouring classes, who are abroad in almost all kinds of weather, daily, throughout the year, would seem to favour. Dr. Reid considers that infants of a nervous temperament, who are easily excited, who are awakened by slight noises, and who are not satisfied unless they arc DISEASES OF THE RESPIRATORY ORGANS. 351 kept constantly "on the move," are those most susceptible to laryn- gismus. As exciting causes Mr. Robertson enumerates the irritation of teething, disturbance of the digestive organs, and any sudden ex- citement. Dentition is, unquestionably, one of its most common pre- disposing-causes; nearly 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 con- dition of the atmosphere; exposure to a current of cold air, efforts to swallow, or even suddenly stooping to pick something from the ground. According to Dr. Reid, and his views are fully borne out by our own experience, one of the most common causes of laryngismus is a deranged state of the stomach and bowels. He has never known more than two instances of the complaint to occur without the pre- sence of such derangement, as indicated by constipation, a morbid con- dition of the stools, flatulence, &c. And it is seldom, he adds, that we observe decided signs of amelioration in the little patients, until the secretions become of a more healthy character. In fact, most of the writers upon the disease, whatever may be the difference in their views as regards its pathology, admit that a vitiated state of the al- vine secretions is a prominent symptom, some describing this as ag- gravating the disease, whilst others view the disordered condition of the bowels as a primary cause. Another cause, which experience convinces us, if it be not alone sufficient to originate laryngismus, at least materially aids in keep- ing up the irritation which has been produced by other causes, is atmospheric influence. This is proved by the fact that, in many cases of the disease, on a change of air, the symptoms have imme- diately ceased, but recurred when the infant was brought back to its former residence. The rare occurrence of the complaint in rural dis- tricts, as compared with its prevalence in crowded towns, is, Dr. Reid remarks, a proof that atmospheric influence is concerned, in the majority of cases, as one of the exciting causes. He adduces the returns of the mortality in 117 districts of England, to prove that the morta- lity of infants, during the ages of teething, is six times greater in town than that met with in an equal population of a country district. It has been supposed that a damp or low locality, even in the coun- try, is apt to give rise to laryngismus. Dr. Reid considers that under certain circumstances, it may, perhaps, have some effect, in combina- tion with other causes, but that its influence cannot be very powerful. Some, as yet undetected, local influence has, at all times, no doubt, much to do in assisting to generate the disease in certain situations. Dr. Hall mentioned at a discussion of the London Medical Society, that he had known of three fatal cases of laryngismus occurring in a family who resided upwards of four miles from a large country town; the other infants of the same family were, on this account, removed from the place, and thus escaped the disease. Dr. Reid can find no decisive evidence that cold weather has any 352 DISEASES OF CHILDREN. prejudicial influence on cases of laryngismus. In more than one case he has knoAvn a removal from town to Hampstead Heath, or to" the coast, during the cold bleak Avinds of spring, immediately to arrest the complaint. In one instance it was found that exposure to the open air in cold weather, invariably stopped the paroxysms, and that one of them never occurred during such exposure. Peculiar odours seem occasionally to act as a sufficient cause for inducing the paroxysms of laryngismus. Cases are referred to in Avhich the paroxysms were caused by the fumes of alcohol, the atmo- sphere of a newly painted room. A great number of similar eases could be cited. Dr. Reid considers that the most frequent, and in the majority of cases the combined exciting causes of laryngismus, are the improper description of food Avhich is administered to the infant, and the im- pure and irritating atmosphere Avhich it breathes. Under the head of improper food, may, in certain circumstances, be included the breast milk of the mother or nurse. That is, Avhen from any cause this has become deteriorated. Dr. Reid believes, however, that comparatively few cases of laryngismus occur in infants who are fed altogether upon breast milk. Of the numerous instances which have come under his notice at various times, the disease occurred in two infants only who were not fed by hand, either altogether or partially: one of them was a child six months old, Avho had a wet nurse. By a curious coincidence, the nurse herself, tAvo nights pre- viously to the child being affected, had a similar spasmodic affection of the" glottis, caused by hysteria, and the sound produced by it so precisely resembled that Avhich the father of the infant, a medical practitioner, had been accustomed to hear whilst his elder children had suffered from laryngismus, that he hastened up stairs, thinking the infant was also attacked by it. Two days subsequently, the child, for the first time, did shoAv symptoms of the disease, although they Avere slight, and of short duration, compared with those of the other children. North includes laryngismus 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 OAvn experience. Goelis describes all its symptoms as occurring in the advanced stage of chronic hydrocephalus. Dr. Reid believen it may be fairly inferred that laryngismus is sometimes complicated Avith, or folloAved by hydrocephalus, but that in very rare instances does the latter act as a cause of the disease. 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 sus- pend, for a feAv seconds, the respiration entirely. Mr. Ley, hoAvever, 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 Avant of innervation, in consequence of" pressure upon the nerves by diseased glandulae con- catenates. From the same cause, he conceives that the transverse DISEASES OF THE RESPIRATORY ORGANS. 353 fibres, behind and connecting the rings of the trachea, lose their con- tractile power, and alloAv the sputa to accumulate, giving rise to the rattling sound heard in the upper part of the trachea, particularly when the patient is asleep. Fcav, hoAvever, have adopted these views of Mr. Ley,—the spasmodic character of the disease being admitted by the generality of those avIio have studied its phenomena with care. Upon the nature of the cause by which the spasmodic affection of the glottis is produced, there, hoAvever, 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 con- dition of the thymus gland, and numerous observations have been re- corded, in support of this hypothesis, by Kopp, Frank, Kirmaul, Hirsch, Ecke, Van Velson, Most, Kyll, Montgomery, Hughes, Flackman, Rees, Mitchell, 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, Avhen 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 vi- cinity, such a degree of pressure or irritation as would produce the phe- nomena of the disease under consideration. M. Trousseau, who refers the disease to a spasmodic condition, Avith 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, Avhich 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, Avith 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 Avas either not at all affected, or was actually below the size Avhich it frequently presents in perfectly healthy children at the same age. We are to recollect, also, as Dr. Hall correctly re- marks, 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 pro- tracted labour; the eyes to become bloodshot from hooping-cough; the eyelids to be distended with blood from epilepsy, and from the 23 354 DISEASES OF CHILDREN. efforts of vomiting and of parturition. In this manner wo can readily understand hoAv 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,) 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 at 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 se- cond 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 cere- bral 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, Pagenstechcr, Ley, Hall, Merriman, Fricke, Oppenheim, Cheyne, and Clarke. Mr. Ley attributes the disease to a suspended or impeded state of the functions of that portion of the eighth pair of nerves Avhich is distributed to the larynx, caused by pressure from enlarged cervical and bronchial glands; Avhile Marsh DISEASES OF THE RESPIRATORY ORGANS. 355 refers it to an irritation seated at the origin of the pneumogastric nerve, and others, with Clarke, Cheyne, Beatty, Rullman, Fricke, and Oppenheim, to disease of the brain." Were pressure from enlarged thymus or cervical glands a frequent cause of laryngismus, it is difficult, Dr. Reid remarks, to comprehend why the attacks are often separated by long intervals in some cases, al- though the pressure continues the same. Such continued pressure would also act as a direct mechanical cause, whereas the history of the disease proves it evidently to be the effect of reflex action. Dr. Marshall Hall asserts, moreover, " that such pressure would cause per- manent paralysis and constant closure of the glottis." The experiments of modern physiologists show that the inferior or recurrent laryngeal nerves, which alone govern the muscles of the glottis, are exclusively motor nerves, and that irritation, applied even to them, will produce convulshre closure of that aperture, whilst cut- ting or compressing them renders the glottis and movements of the arytenoid cartilages inert or passive, but does not prevent ingress or egress of air, although they impede the former. The sudden manner in which the paroxysm is resolved, in many se- vere cases of laryngismus, upon a change of air, the cutting of a tooth, the discharge of worms, or of large unhealthy stools, or the exhibi- tion of antispasmodics, is inconsistent with the supposition of its de- pendence upon pressure from an enlarged and indurated gland. 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, and they are those advocated by Dr. Reid. In one case related by Mr. Ryland, however, he is inclined to believe that the main cause of the paroxysms was to be referred to bronchial inflammation, which Mr. Ley also enumerates as an occasional exciting cause of the disease. Our own observations incline us to adopt the Ariews of Dr. Burgess, namely, that the disease is simply a spasmodic affection of the respi- ratory muscles; its chief exciting causes, when it occurs during the earlier period of dentition or previously to its occurrence, being an irritation of the digestive organs, a cold, confined, or impure atmo- sphere, and dentition; but that when it occurs during, or 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, invariably to en- largement of the thymus gland, or enlarged agglomerated glands in the vicinity of the recurrent nerves; but observes, that one remark- able point in these cases is, the dependence of the paroxysms of dysp- noea upon the state of the digestive organs; whenever these are out of order, the intensity of the attacks being increased, Avhich it seems difficult to account for, " since," he adds, " the affection so evidently depends upon a mechanical cause." The same difficulty, he further re- 356 DISEASES OF CHILDREN. marks, presents itself in accounting for the constant and immediate good effects obtained from a change of air. The difficulty, hoAvever, arises solely from the attention of the observer haying been too exclu- sively directed to the supposed agency of glandular enlargement in the production of the disease. We have, in repeated instances, seen the most severe attacks of laryngismus 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 at- mosphere, 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 un- til after 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 inter\-als, dull, heavy, listless, and droAvsy; 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 ahvays liable to supervene; carpo-pedal spasms also frequently occur. These lat- ter are generally attended Avith considerable derangement of the gas- tro-intestinal mucous membrane. Dr. Reid, while he admits that cerebral or general convulsions are often associated with laryngismus, and that a paroxysm of the latter may sometimes terminate in the former, denies, however, that laryngis- mus is dependent upon primary disease of the brain. If, he remarks, careful observation be made respecting this point, I think it will be found, in all cases not complicated with cerebral convulsions, First, that there are not present the usual symptoms of congestion of the brain: secondly, that, in the great majority of cases, no unusual pa- thological appearances in the brain are met with after a fatal termi- nation from spasm of the glottis; and, Thirdly, that the remedies most successful in this complaint are not those which are usually em- ployed in cerebral congestion, whilst, on the contrary, those which are indicated have frequently been productive of great injury in the treatment of laryngismus. 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, Avhich, nevertheless, could not have produced sufficient pressure upon the larynx to interfere, in the least, Avith 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 require an operation to preserve life. The prognosis will depend entirely upon the nature of the lesion by Avhich 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 DISEASES OF THE RESPIRATORY ORGANS. 357 proper change of diet or air; but when symptomatic of disease of the brain, or of any permanent irritation of other organs, or when it occurs in infants in Avhom there is an undue excitability of the nervous centres, it is always to be considered as a serious affection, and very frequently proves fatal. Nevertheless, the prognosis must in every case be somewhat uncer- tain, for the disease occasionally proceeds in a mild manner for a time, and then suddenly assumes the most dangerous form. There are no regular intervals between the attacks, and a sudden and very severe paroxysm may unoxpectedly occur at any moment, particularly during the period of dentition. The principal dangers to be appre- hended are suffocation and cerebral convulsions. Thus, the prognosis will be worse when the child is constantly dull and heavy, with slug- gish pupil, and indications of venous congestion about the head. Should there be any family tendency to cerebral disease, the prog- nosis assumes a still worse aspect. An unhealthy state of the mesen- teric glands is said to augment the danger of the disease, as also the occurrence of acute bronchitis; though, in a case narrated by Dr. Reid, the croAving noise disappeared during an attack of bronchitis, and re- turned after it was subdued. The duration of laryngismus is variable—the patient may be carried off by the first attack, although this is a rare occurrence: in other in- stances, as in one related by Rullman, the infant may struggle through the disease for twenty months, and then fall a victim to its effects. The mortality in this complaint varies considerably in the state- ments of the authors Avho have described.it. Dr. Gooch states that the disease proves fatal in one-third of those attacked. In Sir H. Marsh's cases, five recovered, and two proved fatal. In Hirsch's cases, three out of five died—one complicated with hooping cough, and the other with general convulsions. Dr. Ley considers the dis- ease to be " not very commonly fatal;" Avhilst Dr. Davies states it to be frequently so, especially when complicated with convulsions; he also considers the danger from the disease to be greater during the period of dentition, which accords with the experience of Dr. Reid, as well as our OAvn. The latter gentleman reports six fatal cases of laryngismus out of fifty that came under his observation. His expe- rience leads him to consider the disease more likely to prove fatal in male children than in female; but according to Pagenstecher, Hack- man, and others, it attacks boys much more frequently than girls. It is astonishing, remarks Dr. Reid, in some cases, how many at- tacks of the spasms and convulsions combined may take place during the tAventy-four hours, without proving fatal. He has known them to occur on every slight noise in the room, so that the mere gentle displacement of any article on the table would cause a paroxysm, and yet a favourable termination of the disease ensue. The treatment during the paroxysm consists in placing the patient in an upright position, with the head slightly inclined fonvards, and exposed to a full draught of fresh, cool air, AA'hile cool water is, at the same time, sprinkled over the face. Every means should be taken to remoA-e, as far as possible, compression from the vessels of the neck. 358 DISEASES OF CHILDREN. Slapping the child slightly on the back and nates, will occasionally aid in removing the spasm; frictions along the spine should, also, be resorted to. If the paroxysm does not yield to these means, the patient should be placed in a warm bath; Avhilst in the bath, cold Avater should be sprinkled on the face, which Avill 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 or ether to the nostrils. Irritation of the pharynx, by a feather, will sometimes induce vomiting, which Avill, of course, soh-e the spasm of the glottis. Dr. Charles D. Meigs recommends the application of a piece of ice, Avrapped in a cloth, to the epigastrium and loAver part of the sternum. This procedure will often cause a speedy solution of the paroxysm. An enema, with the addition of asafoetida or turpen- tine, will be useful, in violent attacks. If the dyspnoea continue un- abated, and death from asphyxia is threatened, artificial respiration should be resorted to, by bloAving at intervals into the child's mouth, closing at the same time the nostrils, pressing the trachea against the oesophagus, and afterwards compressing the thorax and abdo- men with the hands—thus alternating an imitation of inspiration and expiration. If by this means, hoAvever, the patient is not speedily aroused, the operation of tracheotomy should be immediately per- formed. If, during the paroxysm, there is evident congestion of the brain, a few leeches behind the ears, with cold lotions to the seal}), Avill 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, doAvn 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 Avhich 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 avc must also be careful not to produce severe purging, which, by ex- hausting the patient, will augment the susceptibility to subsequent at- tacks. 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, Avith tartrate of potass and manna, will in general, ansAver 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. DISEASES OF THE RESPIRATORY ORGANS. 359 1 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. Dr. Reid considers both the internal and external use of antispas- modics as invaluable in the treatment of laryngismus. Asafoetida or musk, he remarks, occasionally succeeded in arresting the symptoms in some cases of simple convulsions arising from teething, Avhen leech- ing and purging have not alone had the desired effect. In those cases where the boAvels are in a very irritable state, the exhibition of small doses of hyoscyamus, Dover's powder, the hydro- cyanic acid, ammonia, or a combination of them, will often, according to Dr. Reid, produce a most striking effect in subduing the tendency to the spasmodic paroxysm. The following prescription is one which he has been in the habit of employing with excellent results: B/.— Spir. ammoniae foetidi, 3ss.; tinct. hyoscyami, gtt. x.; syrup, aurantii, gss.; spir. anisi, 3j.; acid, hydrocyanic! diluti, gtt. v.; aquae, |j.— M. A teaspoonful to be given, three times a day, to a child ten or tAvelve months old—the doses being graduated according to the age of the patient. Should the above not prove speedily efficacious, the following may be tried: B/.—Pulv. Valeriani, 3ij-; ammoniae sesqui- carbonatis, gr. viij.; syrup, aurantii, ^ss.; aq. carui, |jss.—M. To be rubbed together. The sixth part to be taken as a dose three times a day. A stimulating embrocation, with the addition of some narcotic, ap- plied to the spine, chest, and abdomen, Dr. Reid recommends as pro- ductive of decided benefit; especially when the hands and feet are affected with spasmodic contractions. The following is Dr. Reid's usual formula: I£.—Tinct. opii, 3jss.; tincturae lyttae, 3J-5 liniment. saponis, ^jss.—M. To be applied two or three times a day. The ad- dition of four grains of the extract of belladonna, or 3ss. of the tinc- ture of aconite, in obstinate cases, will increase the effect. " In the secondary part of the treatment," Dr. Reid remarks, " tonics will frequently be found to possess great influence in removing the lingering symptoms of laryngismus. The different preparations of iron and bark are those best adapted for the purpose, when purgatives and antispasmodic medicines have previously prepared the way for their employment. Some judgment, hoAvever, is requisite in selecting the appropriate time for commencing their use." Among the different preparations of iron, Dr. Reid prefers the vi- num ferri of the old London Pharmacopoeia; but the ammonio-citrate and the potassio-tartrate are, owing to their comparative slight taste, eligible forms of the same mineral, as they do not nauseate the little patient. In those cases which are actually combined with a scrofulous taint, the syrupus ferri iodidi may be advantageously employed. The importance of an attention to the diet of a patient need not be insisted on; nor need Ave, after Avhat has been already said in many of the preceding sections, lay doAvn any precise directions in regard to the proper articles to be employed. The repetition of the attack, remarks Dr. Hall, Avhose therapeutical directions in respect to the dis- 360 DISEASES OF CHILDREN. ease under consideration are replete with good sense, has so often, Avithin 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 confinement of the infant to the breast-milk of a healthy nurse, during the ordinary period of suckling, cannot be too strongly insisted on. In individual cases, it will be adAisable to continue this mode of nourishment even beyond the usual period. If the mother or nurse's milk is suspected to be deteriorated in quality, no time should be lost in placing it at a breast from which it will be supplied with a more healthy nutriment. 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 violent 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 pa- tient has been long free from attacks, a sudden change of the Avind 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 suspension 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 hap- pen whcneA'er 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 rencAval 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 Avea- 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- DISEASES OF THE RESPIRATORY ORGANS. 361 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, should be carefully avoided. It should be addressed, invariably, in a spft soothing tone of voice; in a word, every source of mental emo- tion should be carefully avoided. This advice should be strongly enforced 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 \-iolent parox- ysms, though in none attended with a fatal result, excited solely by mental emotion and fright; hence we should be cautious not to irri- tate it by unnecessary examinations; the mere act of looking at the gums, by forcibly opening its mouth, will sometimes induce a seA^ere attack. It has been suggested by Dr. Hall, that the morbid suscep- tibility 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 Avater, applied to the surface by sponging, is also highly benefi- cial. 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 Ave-direct our attention to the congested condition of the brain, which is so liable to occur during paroxysms, we shall perceive the impor- tance of adopting measures to counteract it. Under ordinary cir- cumstances, the spirit lotion applied to the head, and repeated seve- ral times in the course of the day, is an efficacious means of effect- ing this, and perhaps a much safer remedy than depletion, which, un- less there is an absolute necessity for resorting to it, should be avoided, in consequence 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; 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 bleed- ings, issues on the chest, frequent, active purgatives, mercury, anti- monials, cicuta, digitalis, animal charcoal, and iodine, internally and externally. To the greater part of these we object, as altogether unadapted to the disease, or positively prejudicial; while the recom- mendation of others is evidently based upon an erroneous pathology, and even by the strongest supporters of that pathology, they are ad- mitted to be of doubtful efficacy. 9.—Pertussis.—Hooping Cough. 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 362 DISEASES OF CHILDREN. period previous to puberty, is unquestionably true; we have, never- theless, repeatedly met with it in adults, particularly Avhen it has pre- vailed epidemically; and the memory of every practitioner will fur- nish him with instances of its occurrence, in even elderly subjects. Heberden saw it in a female of seventy, and in a man of eighty years of age, and Eberle notices tA\-o cases occurring in individuals over fifty years of age. Instances, also, of its recurrence in the same in- dividual are, by no means, unfrequent; we have seen several, and the same fact is noticed by various writers. As to its contagious nature, notwithstanding 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, Avho have particularly directed their attention to the subject. The hooping cough most commonly 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 neccessary to show, that when sporadic cases occur, the disease spreads from these, or that patients affected Avith it, when removed to distant places, communicate it there toothers, 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, coiiAulsive 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, convulsh-e, 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 convulsh-e stage, and the stage of decrement; and by Blache and Williams, into the inflammatory, the congestive and ner- vous, and the simple nervous stage. DISEASES OF THE RESPIRATORY ORGANS. 363 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 A-aries considerably: it maybe followed by the characteristic symptoms of hooping cough, in a 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 cases, the catarrhal phenomena have been entirely wanting, the pecu- liar symptoms of the disease occurring, as it were, suddenly: while during the preATalence of hooping cough, as an epidemic, many chil- dren 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 in- tervals 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, Avhich 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 any thing within his reach, for support, during the paroxysms. The duration of the paroxysms is very various; in some instances, they last scarcely a minute, Avhile in others they are prolonged for five or six minutes, or even longer. The intervals between the pa- roxysms 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 terminates by the discharge of a large quantity of viscid mu- cus, generally by vomiting, resulting probably from the compression of the stomach, by the forcible contraction of the abdominal muscles Avhich occurs during the violent effort at inspiration. The disposition to vomit is apparently increased by habit; and consequently as the disease 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 perfectly cheerful, and returns to his ordinary amusements. When, however, the paroxysms are frequent, of long duration, and marked by great violence, the patient recovers from his distress only by de- grees, remaining exhausted for some time, with hurried or panting respiration, and complains, if old enough, of a tensive pain in the fore- head, and pain or soreness of the chest. In some instances, the vio- lence of the paroxysm is such as to produce a loss of consciousness from temporary asphyxia; or the asphyxia may be complete, and 364 DISEASES OF CHILDREN. death ensue. In other cases, conv-ulsions, or cerebral congestion and deep coma may occur. The paroxysms often recur Avith 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, amusement, 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- vulsive period of the disease, and but little functional disturbance in the intervals of the paroxysms; but, usually, the presence of the so- norous and mucous rhonchus, particularly before and after the cough, and the mucus 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 feAv cases, diarrhoea is present, Avith vitiated discharges, a loaded tongue, nausea, loss of appetite, epigas- tric 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 folloAved 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 distinctive physical signs. Lobular pneumonia, and pleuritic inflam- mation, 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, ^j. 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, Randham, Riecken, and others, confine its use to the more advanced periods of the attack. The sulphur is given to children betAveen 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 Avhich, 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 Avhom the first stage is often attended with considerable febrile excitement, by small doses of sulphate of magnesia, will not be found advantage- ous. 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 DISEASES OF THE RESPIRATORY ORGANS. 371 calomel ns a mild purgative in the first, and during the acute period of the second stage of hooping cough. We are accustomed to com- bine Avith 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, wheneA-er the same indications present themselves at a later period of the disease, preA-ious, 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 betAveen the shoulders, will be sufficient in young children; but in those who are older, and when the symptoms are severe, it will be better to have recourse to the lancet, folloAved, 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 expe- rience, we have in its favour that of nearly every authoritative writer on the disease. Mackintosh applied leeches over the' larynx, and speaks confidently 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 Arentilated. 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 Avarm 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.1 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 372 DISEASES OF CHILDREN. 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. If the eruption is very painful, the best ap- plication is fomentations with a decoction of hemlock. Luroth em- ploy ed 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,2 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 betAveen the shoulders. Nearly the same remarks are made, in relation to the remedy, by Mackintosh. We know nothing of its effects, from our OAvn experience; in the feAv cases in Avhich 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, Iioav- ever, that in severe cases, it may prove a very valuable derivative. We have generally resorted to blisters, and frictions Avith turpentine, the compound camphorated liniment, or a liniment of the oil of amber and oil of rosemary, to the spine,3 and with the best results. 1 R.—Tart. ant. J^j.ss. a R.—Empl. conii, 2 pts. Axung. ^j.—AI. Empl. picis abietinae, 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. » R._01. oliv. giv. — succini, gij. — rosmarin. gij.—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 Avas 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 ghre 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 Ave have succeeded in removing the inflammatory symptoms, DISEASES OF THE RESPIRATORY ORGANS. 373 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 narcotics, anti- spasmodics, and tonics. Nearly every article upon the lists, has been recommended by different Avriters, 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 epipiricism, 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 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 importance of confining the child to bland, nutritious food, keep- ing 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, Avhen the weather is perfectly mild and dry; under the use of these means we shall invariably find the violence of the paroxysms to decrease, and in mild attacks, often gradually to cease. There are, neverthe- less, few cases of hooping cough, in which the continuance of the dis- ease Avill not be very materially shortened, and convalescence hastened and confirmed, by the judicious employment, in conjunction with the hygienic measures 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 recommend- ed by many, either alone, or in combination with tonics and expecto- rants. We have employed an aqueous solution of opium, with some benefit;1 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 dis- ease. 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 OA-er those oc- ' R.—Opii pulv. 3j. Aq. bullient. giij. Lot it stand for three hours, then strain, and add 3j. bi-carbonate of soda. Dose, for a child two years old, a teaspoonful every three hours. 374 DISEASES OF CHILDREN. curring during the day; this is precisely the result of our experience, in relation to the effects of the aqueous solution of opium. Mor- phia has been employed endermically, and according to Meyer, with good effect; a blister is applied over the praecordia, and Avhen the cuticle is remoA^ed, the blistered surface is sprinkled every evening Avith half a grain of morphia, rubbed up Avith dry starch. 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 poAvdered root, or from one-eighth to one-fourth of a grain of the extract, twice or thrice a day. Kah- leiss administered the belladonna, in combination with Dover's pow- der and sulphur,1 and between each dose, a mixture containing hy- drocyanic acid.2 We have given to the belladonna a very fair trial, and have in many cases been pleased with the prompt and decided re- lief produced by it, Avhile, in other instances, it has appeared.to exert no influence whatever. A similar remark is made by Vondembush and Lombard. 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. ? R.—Had. belladonnse pulv. gr. v. 2R.—Aquse chamomil. ^ss. Pulv. ipecac, compos, gr. x. Syrupi simpl. jjij. Sulphur. prjEt'ip. Jjss. Acid, hydrocyanic, ttyxij. Sacchar. alb. J)ij.—.AI. 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 Avith the ex- tract of belladonna, dissolved in salh-a. In children of six months, he rubs in one grain of the extract thus dissolved, augmenting gra- dually the dose. Other narcotics have been recommended, as the camphor, the co- nium maculatum, the hyoscyamus, the stramonium, and the extract of nicotiana. Of the effects of these, with the exception of the hyoscy- amus, we have no experience. The hyoscyamus we have repeatedly employed from a very early period in the attack, ahvays in combina- tion 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, Avith no other alteration than a gradual increase of the dose, until the disease is sub- dued. Dr. Roe is convinced, that in Avarm weather, it will cure al- most 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 Avhere it does not cure, it will, at least, materially relieve the severity DISEASES OF THE RESPIRATORY ORGANS. 375 of the cough.1 Dr. Atlee, of Lancaster, has, in a number of cases, effected a cure, in from four to fourteen da)rs, by its use;2—he restricts 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 tAventy-four hours, in cases in which there Avas much irritation, and a great variety of nerA'ous symptoms. Employed, comparatively, on a brother, Avhose sister was taking the sub-carbonate of iron, this last remedy had, hoAvever, a most undoubted advantage. J R.—Acid, hydrocyanic. (Scheele's)lT)txij. a R.—Syrup, simpl. gj. Liquor, antimon. tartarisat. 3J. Acid, hydrocyanic. Tfyj.—M. Tinct. opii camphorat. .^ijss. A teaspoonful morning and evening; and if Misturse caniphorae, ^vijss.—M. no uneasiness, dizziness or sickness, is Dose.—A tablespoonful every four hours, in produced' within forty-eigbt 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 child, five years old, he directed— repeated the dose more than four times R.—Acid, hydrocyanic, (Scheele's) m^ xx. a day. Liq. antimon. tartarisat— Vini ipecacuanha;, 5a £jss. Aquse ^xiij.—M. Dose.—A teaspoonful every two hours. In the feAv cases in Avhich 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 demand a more extended trial, particularly in the more violent cases of the disease. Of the antispasmodics that have been recommended in the treat- ment of hooping cough, the asafoetida, zinc, and sesquioxide of iron, appear to be those most deserving of trial. The asafoetida 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 Avatery solution of opium. Dr. Lombard states that he has often knoAvn frictions to the spine with the tincture of asafoetida, of great service, and avc have found a plaster of asafoetida 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 Avill, 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 Avas 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 oavii 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- 376 DISEASES OF CHILDREN. mended by Dr. Steymann, who directed tAvo and a half grains every three hours, increasing one grain for each year of the child's age be- yond the first. Dr. Lombard, hoAvever, gave it to the extent of from twenty-four to thirty-six grains, in Avater 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 Aveeks, and generally leaves them weak, low, and exhausted. In some patients I have seen it cause, during the first day or two after it Avas 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 own experience. In the few cases in Avhich Ave 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 Avith 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 symp- toms have subsided, and when, with a tolerably cool skin and clean tongue, the patient is still severely distressed by the more or less co- pious secretion 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 chil- dren from one to ten years of age. For a child of two or three years he employed generally the following formula:— DISEASES OF THE RESPIRATORY ORGANS. 377 £. Aluminis gr. xxv.; extr. conii gr. xij.; syrup, rhaedos. 3IJ-; aq. anethi, |iij, M. Dose, a medium-sized spoonful, every sixth hour. Dr. B. has never met with any inconvenience from the effects of the remedy 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. Davis, 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 Avhich, 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 Avould not preclude its use, should this state not have yielded to other remedies. It generally keeps the bowels in proper order, no aperient being required during its use. The dose for an infant is tAvo 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 Avater. We haAre 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 Therapeutic 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 ef- fects of the remedies ordinarily employed, Avas induced to administer the nitrate of silver, from Avhich he has obtained results singularly beneficial, lie prescribes it in doses of from a sixteenth to a twelfth of a grain, at first three times, and aftenvards four times a day; of course the remedy should not be administered in cases Avhere 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, Avell 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 per- tussis. Dr. Simpson of Edinburgh has recently recommended the. inhala- tion of chloroform as an effectual means of arresting and controlling the paroxysms of violent spasmodic cough in the more severe cases of hooping cough. "Soon after the discovery of the anaesthetic effects of sulphuric acid, it struck me," remarks Dr. Churchill (Diseases of Infants and Children) " that it Avould be likely to modify or suspend the spasm in hooping cough; and having a case under my care, I directed a little (I suppose about half a drachm) should be spilled upon the nurse's hand, and held before the child's nose and mouth, at the commence- 378 DISEASES OF CHILDREN. ment of a fit of coughing. I preferred this simple mode of adminis- tration (and do so still,) because of the impossibility of thereby giving an over dose. The effect surpassed my expectation: most gene- rally the paroxysm was shortened more than one-half—often stopped immediately—and the duration of the disease unquestionably consi- derably diminished. Since then I have tried the ether in tAvelve or fourteen cases", and chloroform in six. In one or two eases, no bene- fit accrued, in others great mitigation of the spasm, and in three or four, almost complete relief when the ether Avas applied at the be- ginning of a fit of coughing. Decidedly, also, in two-thirds of the cases, the course of the disease Avas much shortened, so that I look upon this as a valuable addition to our remedies. In no instance was insensibility or the least inconvenience occasioned." Dr. Arnoldi of Canada has recently communicated his experience in favour of nitric acid as a powerful remedy in hooping cough. At Avhatever age the disease occurs, whether in a child at the breast or a full-grown adult, he administers nitric acid in solution, as strong as lemon juice, sweetened ad libitum. "I have given, he remarks, to a child of two years of age as much as one drachm and a half of con- centrated nitric acid, in the above manner, per diem, and I have never known the disease to resist its use beyond three weeks." In some in- stances under its employment he has seen the disease cured in eight or ten days. The topical application of a strong solution of the nitrate of silver to the larynx has been strongly recommended as an efficacious remedy in hooping cough. Dr. E.Watson of Glasgow informs us that he has employed it with the best results, when the disease Avas at its height, the paroxysms of coughing recurring every fifteen minutes. Under the use of the remedy the spasmodic whoop was generally arrested within eight or ten days, an obvious mitigation ensuing upon the first ap- plication of the nitrate of silver. The remedy was also employed by him in cases where the disease appeared to be commencing—the pa- tients being the members of families in which it prevailed, and exhibiting the usual precursory symptoms of an attack: in these the development of the disease was arrested. Dr. Watson employed the nitrate of silver in the proportion of from fifteen to forty grains to an ounce of distilled water—applying the solution every second day, first to the fauces, and finally to the larynx. He adduces in favour of the remedy, the experience of M. Joubert, of Chorion, who has employed it in sixty-eight cases of hooping cough, of which number a speedy cure was effected in 40; great relief and shortness of the disease in 20, and no benefit occurred in 8. The cases of the disease treated by Dr. Watson from beginning to end with the local application of the nitrate of silver, were fifty-seven; in all of which, he states, a more or less speedy cure was effected— namely, in 38 cases, in from 10 to 14 days; and in 19 cases, in from three to four Aveeks. " Combining these two tables," he remarks, '•we have, in the first place, 125 cases of hooping cough treated in this manner without one death. Only eight of the whole number re- sisted the treatment. Of the remainder, 78 were speedily cured, and DISEASES OF THE RESPIRATORY ORGANS. 379 39 were greatly relieved and shortened. What better^proof can be asked of the efficacy of the topical treatment of hooping cough? Am I not Avarranted in believing that, Avere it generally adopted, much suffering Avould be saved, and many lives Avould be prolonged beyond the first, the most interesting, but perhaps, also, the most dangerous epoch of human existence." During the employment of whatever narcotic or antispasmodic re- medy we may adopt, its effects should be carefully Avatched, 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 Avatching 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, Ave 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. ToAvards 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 sulphate of quinia, has been highly extolled at this particular junc- ture. 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, Avill be proper, and if the discharges are thin or vitiated, small doses of calomel, combined Avith chalk, ipecacuanha, and extract of hyoscyamus, the Avarm bath, and a regulated diet. In some cases, sponging the body daily Avith tepid salt Avater,has been found decidedly beneficial. The principal Avriters 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 Avill give to the patient a chance of recovery. In many eases 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 380 DISEASES OF CHILDREN. productive of the best effects. Where a permanent removal cannot be effected, daily exercise in the open air should not be neglected, ahvays 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 AA-hich 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, Avith 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 tracheotomy, 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. 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. LTpon dissection, a small metal button was found firmly fixed, toAvards the middle of the right bronchus. Both lungs Avere 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 Avith 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 traces of tubercles. In another case, after six Aveeks, during which the patient's symptoms Avere precisely those of chronic DISEASES OF THE RESPIRATORY ORGANS. 381 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 thoso of croup; while in numerous instances, the only symptom present is a violent, conArulsive, 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 inter\-als, 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 dysp- noea 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 eA'en greater violence, and thus continue to intermit and recur, irregularly, Ave may suspect the presence of some foreign body in the larynx or trachea. When in the former, hoAvever, 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- 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, OAving to the accumu- lation of fluid, in consequence of the irritation which has been induced. When the foreign body is moArable, as a button, plum-stone, &c, AA-ould be, its motion up and down the trachea will be occasionally heard, as Avell as a valve-like sound, produced by its being driven in expiration against the rima glottidis. There may also be perceh-ed, at times, a temporary interruption to respiration in one lung, Avhen the body happens to be impacted in the corresponding bronchus; the res- piratory murmur again returning, when the obstruction has been re- moved by 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 Ave shall most frequently observe the obstruction of respiration.— (Maunsell.) 382 DISEASES OF CHILDREN. After some time has elapsed, however, should the foreign body not be expelled by a violent fit of coughing, bronchitis, or trachco-bron- chitis will ensue, and our only guide will then be the history of the case, as the stethoscopic signs Avill 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 res- piration, and a short hacking cough, Avhich 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, Avas 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 Avas 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 Bouil- laud; while its occasional presence, in patients that have died of epi- lepsy, and other chronic diseases, is noticed by a feAv of the earlier Avriters. It is chiefly, however, to the observations of Andral, Munch- meyer, Sims, Green, Lees, and Mauthner, 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 Avhich the latter has attracted little or no attention; Avhile 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 DISEASES OF THE RESPIRATORY ORGANS. 383 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 any thing is to be done to arrest its progress, it must be before the brain has acquired any eonsiderable 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 habit- ual headache, with severe exacerbations. The only instance we have met with in which the intellectual faculties were increased in develop- ment and activity, is that of Dr. Elliotson; the patient, a lad of twelve years of age,:' used," Ave are told, " always to seek the company of per- sons older than himself; and nothing pleased him more, than to converse on the best forms of human governments. Political economy was his delight." The patient died of apoplexy. Another diagnostic sign, noticed by Sims and Green, as occasionally present in cases of hyper- trophy of the brain, is, a sensation of firmness communicated to the fin- ger, on pressure being made over the fontanelles. In one ease 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,Avere frequent falls, occasioned by the weight of the head—which Avas carried forAvard whenever the patient wished to run—and a great tendency to sleep, Avhen he remained quiet. The patient died of acute enteritis, and the brain exhibited a great develop- 384 DISEASES OF CHILDREN. 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, AvheneA'er the hypertrophy is of any extent, much more serious conse- quences Avill 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 complete apoplexy, Avith extravasa- tion of blood in the substance of the brain. Children with excessive enlargement of the head, Ave 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 Avhen 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 Avhen the growth of the cranium and brain go on simul- taneously, or nearly so. In these cases, the symptoms usually present are, intense, habitual headache, augmented at irregular inten-als; 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 conA'ulsive 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 characteris- tics of epilepsy. 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. Mauthner has remarked a frequent coinci- dence of enlargement of the thymus gland, the left side of the heart, and the liver. Death, in the majority of cases of hypertrophy of the brain, has occurred suddenly, during a convulsive attack; it has,how- ever, 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; DISEASES OF THE NERVOUS SYSTEM. 385 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 Avhich 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 but little suffering or inconvenience, Avhile 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 convrolutions, 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, blanc-mange, or cream cheese. Sometimes, accord- 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, 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 ex- aminations, 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 AArhich hypertrophy of the brain is apt to be confounded, is chronic hydrocephalus, to which its phenomena 25 386 DISEASES OF CHILDREN. 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 suav a child who had been condemned to death by a medical man, as having water on the brain, but which Avas 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. Mautimer (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 Avith 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- tions of hypertrophy of the brain, but seldom occur until 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- 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 the nutrition of the body generally. Frequent contusions of the head have been enumerated by Dance, as an occasional exciting cause. By Laennec, Papavoine, and Rilliet and Barthez, the causes of colica pie- tonum have been supposed to have a very great influence on the de- velopment of the disease. M. Laennec states, that he has never seen a case of fatal saturnine epilepsy, in which there did not exist an evi- dent 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 hyper- trophy 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 DISEASES OF THE NERVOUS SYSTEM. 387 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, hoAvever, 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 vieAv 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 Ave find nothing satisfactory in the published observations of others. 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 doAvn 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 child 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 evolution 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 Avhenever the swelling or inflammation of the gums recurs. When the child is more adAranced in age, a serious question will 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. 388 DISEASES OJP CHILDREN. 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. 2.—Cerebral Hyperaemia and Haemorrhage. APOPLEXY.--PARALYSIS. 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.1 M. Lasserro 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 respiration, 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 sensation on either side of the body, or on 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 1 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. 389 organic change in its structure, resulting ultimately in death, or in an impairment or destruction of the intellectual faculties, or in a perma- nent 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 cha- racter, often proving immediately fatal, in consequence of extravasa- tion of blood at the base or upon the surface of the brain, and occa- sionally 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 medullaryr 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, Ave should more frequently meet with permanent paralysis in the in- fant, whereas this 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, Serres, Legendre, Schleifer.) When the hyperaemia, and effusion of serum or blood, is principally confined to the spine, constituting what has been denominated spinal 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 conA-ulsions, drowsiness bordering on stupor, lividity of the face, drawing doAvn 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. 390 DISEASES OF CHILDREN. Paralysis may occur in infants, independent of disease of the brain or spinal marrow, from local injury inflicted upon the nerves of the parts paralyzed. Examples of this Ave have in injury of the portio dura, as in face presentations, or w-here 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 Avithout any preATious 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 poAverless—in which case, it gradually Avastes aAvay, and becomes, finally, greatly reduced in size. Cerebral haemorrhage, hoAvever, 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, vrith all the phenomena of cerebral inflamma- 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 ap- petite. 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 disease, 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 de- gree of strabismus. The bowels are, in general, regular, and the stools natural in appearance. The child is often seen to carry his hands continually, but apparently unconsciously, to some part of the head. There soon occurs a permanent contraction of the feet and DISEASES OF THE NERVOUS SYSTEM. 391 hands, followed by convulsions, either tonic or clonic; during which there is an abolition of sensibility and consciousness, and an increased turgescence 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, toAvards the close of fatal cases, they are almost continual, or rather, the patient is affected Avith a constant tremor, with momentary con- vulsive paroxysms, during which, the injection of the face is increased. and the pulse and respiration accelerated. In no instance has para- lysis been observed during the acute stage. When death takes place, it is generally at the end of eight or twelve days. The occurrence of thoracic 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 conside- rable prominence. In many cases the patient is affected with strabis- mus and his countenance assumes a vacant expression. The pupils are usually dilated, the dilatation being equal in both eyes: vision, accord- ing to Berard, is occasionally destroyed. In most cases the intellect of the patient diminishes as the head augments in bulk, and may finally be destroyed. It is, generally, hoAvever, 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 Avidely open. Cutaneous sensibility is not impaired, even in those instances in which a complete abolition of intelligence and movement takes place. The moAreinents 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 garments and bedclothes, and sAvallowed them. During the Avhole of this chronic state the patients, in general, eat and drink with avidity whatever is presented to them. There is never any indication of partial paralysis, nor any diarrhoea; the boAv- els are usually constipated. In the greater number of the cases that 392 DISEASES OF CHILDREN. have been observed, death Avas, 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 accidental cause were to occur to accelerate the death of the pa- tient. Cerebral haemorrhage is not necessarily fatal. In the acute stage the symptoms produced by it may be entirely removed, and the pa- tient restored to health Avithout the danger of his becoming subse- quently hydrocephalic. In those cases in which the haemorrhage is to a slight extent, the blood, very probably, may be entirely removed by absorption; but when a large amount of blood is effused, an or- ganized cyst is formed around it, and the disease acquires then a chronic form. Even Avhen this is the case, however, as soon as the disease has arrived at its height, it has, according to Legendre, a na- tural tendency to decline, and may disappear entirely:—the serous fluid and clots in the brain being absorbed, and the cyst containing them gradually obliterated, 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 ahvays 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 in- variably found within the arachnoid cavityT. 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. 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-twelfth 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. DISEASES OF THE NERVOUS SYSTEM. 393 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 in- timately 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 sur- face of the brain, excepting by numerous small branches of blood- vessels which pass over it to the latter. (Baillarger, Legendre.) The contents of the cyst are coagula of blood and a bloody serum, but more generally the last only, which is then always in considerable quan- tity. (Berard, Poumeau, Legendre?) The blood is sometimes in the form of soft, red coagula; at others, the cyst contains a brownish, tur- bid serum, in the midst of Avhich 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, extend- ing 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, produced 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 blood is unmixed with serosity, and there is no trace of an organ- ized 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 hyperaeniia resulting from this irritation terminating in an effusion, more or less considerable, of blood and serum, upon the surface of the brain, Avithout giving rise to meningeal or cerebral inflammation. 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, 394 DISEASES OF CHILDREN. but more especially of violent and repeated convulsh-e paroxysms, fol- lowed by more or less drowsiness, indicate the period Avhen 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 deA-eloped previous to the sixth year, or at least not until a period beyond that at which the form of cerebral haemorrhage Avith Av-hich it can alone be confounded, occurs. Tuberculous menin- gitis is, also, seldom accompanied by the intense febrile reaction ob- served in cerebral haemorrhage. Repeated bilious vomiting and ob- stinate constipation are likeAvise 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 hae- morrhage, is never congenital, but commences, ordinarily, about the tenth month, or at the period of dentition; the head increases in size gradually, but never acquires so great a volume as in chronic hydro- cephalus; the disease is, finally, preceded invariably by repeated con- vulsions, or symptoms of encephalic disease, Avhich mark the period of the occurrence 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 Avith 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 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, hoAvever, the symptoms of the DISEASES OF THE NERVOUS SYSTEM. 395 acute stage are of considerable intensity, the febrile reaction violent, and the convulsive paroxysms occur at short 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-distention of the blood- vessels of the brain, Avhich 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 tA\-o 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 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 condition 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 be 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 Avith a minute portion of ipecacuanha. When a purgath-e cannot be administered by the mouth, Ave must resort to 396 DISEASES OF CHILDREN. purgative enemata: one composed of tepid water, salt and molasses with the addition of castor oil, Avill usually be sufficient; but Avhere the symptoms are urgent, an addition of turpentine to the enema will be proper: or it may be composed entirely of castor oil and turpentine. In all cases of extensive hyperaemia of the brain, a pretty smart impression made upon the lower portion of the intestines will invraria- bly be found to be attended with the most decidedly good effects. Immersion of the loAver half of the body in Avarm water while cold lotions are applied to the scalp, when judiciously managed, Avill 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 Avith 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 preventing its return. In that form of meningeal haemorrhage, in which the blood is ef- fused in the cavity of the arachnoid, during the acute stage, the same treatment as above will be demanded. The immediate safety of the patient, and the prevention of the chronic state of the disease, will de- pend upon our being able to remove the cerebral hyperaemia, before haemorrhage 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 actiA^e purges, warm sinapised pediluvia, and cold applications to the head, will be the remedies, upon which we are chiefly to depend, during the early period of the acute stage. After the boAvels are smartly opened by purgatives, (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,2 every three hours. Blisters to the nape of the neck, or between the shoulders, will occasionally be found useful, after the fe- brile symptoms have been somewhat reduced. ' R.—Fol. senna?, ^ss. 2 ]J.—Calomel, gr. vj. ad xij. Manns, gij. Antimon. tartarisat. gr. j. Sem. Foenelic. ^ss. Pulv. nitri. gr. xxxvj. ad xlviij.—M. f. Sulph. magnes. ^iv.—M. chart. No. xij. Infuse in half a pint of boiling water, of which a child of two years may take a small wineglassful. 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 Ave 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 DISEASES OF THE NERVOUS SYSTEM. 397 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 be 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 sAvollen or 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. Un- _ der 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 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. 398 DISEASES OF CHILDREN. When the disease has attained its chronic stage, we haA-e to contend against a condition of the brain very much resembling chronic hydro- cephalus, but from which, judging from the feAv 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 purgatives, and by the daily use of the Avarm or tepid bath, according as the existing temperature of the patient's surface is depressed, or otherwise. 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 hyper- trophy. 3.—Convulsions. 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 Avhich 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 and spinal cord, arising originally in those organs, or in some other organ, especially the alimentary canal. Their fre- quency and the danger by which they are very generally attended, de- mand for them a separate consideration.1 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 Avith 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 on the other. The conA-ulsions 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; Avith injection of the eyes, which are often turned upwards or to one side; with a co- pious perspiration about the head, forehead, and temples, and occa- 1 The number of deaths from convulsions, in children under ten years of age, that occurred 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. 399 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 very 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, Avhich 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 Avith 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 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 she soon after began to articulate. When attacks of convulsions are frequently repeated, they may as- sume 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- emia 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 sur- face near the fire. 400 DISEASES OF CHILDREN. The paroxysms of convulsions we have knoAvn 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 had been resorted to without effect, oease 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 Avhich 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, Avhen the con- vulsive paroxysms are slight, short in duration, and arc succeeded by a state of cheerfulness and general health, ultimate danger is seldom to be apprehended; but Avhen 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 speedy repetition of the attack. Immediate danger to life, during the conArulshre 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 irritations are, in general, much more manageable and less fatal than those dependent upon direct irritation, or disease of the brain or spinal cord. 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 deter- mining the immediate cause of the convulsive symptoms; it is only in those cases where the convulsions present themselves as the princi- pal 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: avc can only say, however, that in every instance in which Ave have examined the brain after DISEASES OF THE NERVOUS SYSTEM. 401 death from convulsions, more or less disease of that organ, or of the medulla oblongata or spinalis, Avas 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 Avere 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 appear- ances recorded by some of the older physicians. Effusion of serum, vascularturgescence, tumours attached to the membranes or embedded within the substance of the brain, are noticed by more recent writers. Turgescence of the vessels, a deep red colour of the dura and pia mater, and effusion of blood beneath the cranium, are the appearances described 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, extravasa- tion 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 appearances Avith extreme mollescence of the brain, in another. Tur- gescence of the vessels of the brain, its substance of a pink colour, Avith 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 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 ex- tensive 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, Avithout any ap- preciable lesion of the brain being discoverable after death. Convulsions mav occur, at any period, from the moment of birth 26 402 DISEASES OF CHILDREN. up to puberty. The first few weeks of the infant's life, the period of weaning, and that of dentition, constitute the stages of infancy, at Avhich convulsions are most liable to occur. From accidental causes, hoAvever, 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 one 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 unques- tionably owing to the greater susceptibility of every part of the sys- tem at this age, than subsequently; the greater activity of all the or- ganic functions; the large size of the brain compared with the rest of the body, and the very great development and activity of its ca- pillary system engaged in the perfection of its growth and organiza- tion. 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 under- stand 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 indi- cations of the existence of irritation—an overloaded state of its blood-vessels, and an injection, often very considerable, of its sub- stance—these lesions frequently extending, also, to the medulla ob- longata 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 are thrown into a state of tremop, 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 diffi- culty, amused; their sleep is disturbed by dreams or frequent stag- ings ; their faces flush, and turn pale suddenly, from causes of the most trifling character, and their whole deportment, the mobility of their facial expression, and their shrinking, quick, timid glance, in the pre- sence of strangers or of unfamiliar objects, indicate the morbid exci- tability of their nervous system. Such children are said, also, to pre- sent an unusual development of brain, and precocity of intelligence. The fact, that children, born with large heads, or whose heads increase in size disproportionately to the rest of their bodies, are particularly DISEASES OF THE NERVOUS SYSTEM. 403 liable to convulsions and other cerebral affections, the result of our own observations 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 disturb- ance in early childhood, is pointed out by Mauthner, and he shoAvs how the tendency to venous congestion, which is so characteristic of early childhood, explains this occurrence. Somewhat similar are the remarks 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. 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 un- due nervous excitability which predisposes to convulsions. Although no climate nor latitude appears to afford protection against an attack of convulsions, they are unquestionably of much more fre- 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, described by Claubry; the epilepsy, that occurred at Copenhagen, and 404 DISEASES OF CHILDREN. 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 produced, in young infants, by exposure to cold, or to a vivid or powerful light, or by the effects of a confined and impure atmo- sphere. In infants who are liable to violent attacks of spasmodic colic, convulsions 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 convulsions, are errors in diet, with respect both to its quantity and quality. From the moment of birth up to the termination of child- hood, convulsions are liable to be produced by this cause. The ani- mal, Dr. Graves remarks, which, but a short time before, was nourished by the placenta, is, immediately after birth, supported by ingesta; and hence, from this sudden change, if there be any source of irritation exist- ing in the system of the child, or in the nature of its food, an unhealthy state 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 al- lowed 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 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 maybe 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 marked DISEASES OF THE NERVOUS SYSTEM. 405 instance of the kind has ever fallen under our notice; Lieutaud, Braehct, 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;—we 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 haemorrhage, 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, Avhich 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 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, Avhile 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 406 DISEASES OF CHILDREN. 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 Avith 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 tOAvards 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 Avill roll its head from side to side. Deglutition appears to be performed with difficulty when 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;—Avhen, hoAvever, 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 tOAvards arresting it. This, however, is an error, and if generally acted upon, would prove, in many instances, a very serious one. Frequently, the only time Ave 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 vio- lence 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 over-loaded state of the ves- sels of the brain, our first and most important remedy is direct deple- tion. We may either open a vein in the arm, if the child is old enough, or Ave 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, Ave 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 Avith 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 draAvn in sufficient DISEASES OF THE NERVOUS SYSTEM. 407 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 doAvn any general rule, as to the exact quantity of blood to be draAvn;—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, hoAvever, in Avhich 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 th'e 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, Avill 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 purgath'e, while it would appear also to pro- duce a decidedly beneficial impression upon the diseased gastro-intes- tinal mucous membrane. R.—Spirit, terebenth, gj. Olei ricini, j^iv. Mucil. gum acaciae, giv. Aq. fcenil. gij.—M. A teaspoonful may be given to an infant three or four months old, and double that quantity to a child a year old. In those cases in which active depletion is called for, sponging the whole of the scalp frequently with cold Avater, 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 reneAved 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. EA-en in cases in which bleeding may not be thought advisable, sponging the head with cold water, will be found to be almost inA-ariably producthe of good effects; 408 DISEASES OF CHILDREN. 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 Avhile 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- tation, sinapisms may be applied to the extremities, and some rubefa- cient liniment to the spine. We prefer, with the generality of Ger- man practitioners, the application of sinapisms upon the extremities, to blisters. They will be 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 sw-elling 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 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, will, in general, very promptly effect a cure. When convulsions are the result of excessive evacuations, either of R.—Extract, hyoscyami, gr. j.—ij. Magnes. calcinate, gr. iv.—M. For an infant of two or three months; the dose to be increased in older children. DISEASES OF THE NERVOUS SYSTEM. 409 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 Avater, and small doses of some gentle stimulant, combined with a narcotic, as the carbonate of ammonia, or wine whey, Avith 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. Dr. Simpson, of Edinburgh, in a severe and protracted case of con- vulsions occurring in an infant of only one month, succeeded in ar- resting permanently the recurrence of the convulsions, after all the other usual remedies had failed, by placing the patient under the in- fluence of the inhalation of chloroform for many hours, allowing the infant to awaken, hoAvever, at the termination of every two or three hours for the purpose of suction and nourishment. Dr. Simpson states that he has known the inhalation of chloroform similarly useful in other cases in arresting infantile convulsions, but in none in which the patient was so young as in that just referred to. 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 endanger a return of the paroxysms from the slightest cause. After the paroxysm of convulsions has been suspended, the subse- quent treatment will depend entirely uppn 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, and the warm hip bath, and we 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. 410 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 indigestipn, 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 become of a deadly pallor; the pulse is small and rapid; the counte- nance is ordinarily pale and distressed, and the forehead Avrinkled. The carotids often throb violently for a moment or two, and then their action becomes sIoav 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 Avith 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 beef 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 thoso 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. 411 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.2 Schmidt gave it in conjunction Avith the oil of valerian, and carbonate of soda,3 and North combined it with sulphate of quinia.4 1 R.—Infus. gentian. £j. 9 R.—Oxyd. zinci, gr. xxiv. Syrup, rhei, 5S8. Ext. hyoscyami, gr. xij.—M. Tinct. hyoscyami, HJlxxx. f. chart. No. xij. Bi-carb. sodae, 3J.—M. One to be given every two or three hours. A teaspoonful every three hours. ' R.—Carbonat. sodae, 3J. Or, R.—Pulv. calombse, ?jj.—Jij. Syrup, rhei aromat. ^ij. Pulv. zingiber, 9y. 01. valerian. Ttyxvj. Ext. hyoscyami, gr, xij. Ext. hyoscyami, gr. xvj.—M. Magnes. calc. ^ij—M. A teaspoonful to be given as a dose, three f. chart. No. xij. times a day. One every three hours. * R.—Aq. Cinnamom. ,^jss. Sulph. quinise, gr. viij. Acid, sulphuric, dilut. TT)(yiij. 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 Avhich is so commonly met Avith 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 deter- mination to the head, of acute irritation of the brain, or of general febrile excitement, has been subdued, and every source of irritation removed from the alimentary canal. The worst consequences are to be apprehended 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 com-ul- sive attack; they are precisely the same as those directed in cases o£ 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 re- commended. 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- Avhat similar to the attacks of emprosthotonos. In one case, related by AVest, these bowings were repeated at intervals of a few seconds, ten, tAventy, 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 Bennett, in their general 412 DISEASES OF CHILDREN. symptoms, differ in no degree from that of Mr. West, with the excep- . tion of that of Dr. Bennett, in which the disease presented a more aggravated form. Sir Charles Clarke has seen four cases of the dis- ease, 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 para- lytic 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 com-ulsions in children, it may be proper to say a Avord or two upon a form of convulsive disease, that has been lately described by Jadelot and Guersant, 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 ner- vous 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 bont 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 tOAvards 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 Guersant, 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. DISEASES OF THE NERVOUS SYSTEM. 413 Essential contractions of the muscles in children are sometimes gene- ral, and sometimes local; among these last, M. Guersant 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 Avhen 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. Guersant 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 Avarm or vapour baths, and friction with oil of almonds or narcotic liniments; dry friction of the skin, the application 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. Guersant 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. 4—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- ningeal 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, 414 DISEASES OF CHILDREN. preceded by a decided chill. The skin is dry, and generally increased in temperature; the pulse and respiration are accelerated, but often 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 Avhitish 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, Avith 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 generally full and hard; the respiration is accelerated, but often inter- rupted 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- DISEASES OF THE NERVOUS SYSTEM. 415 turee shrunk; the eyes assume a dull and sunken appearance, and in the progress of the disease, perfect blindness most generally ensues. Con- 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 slow, as soon as the exertion ceases. Often, imme- diately preceding dissolution, the pulse suddenly acquires a remarka- ble increase of frequency, beating often with great regularity, from 120 to 160 strokes and upwards, in a minute. The respiration also becomes 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 termi- nation, there usually occur involuntary discharges of the faeces, as well as of the urine. There frequently occurs more or less tympanitic ten- sion of the abdomen. The patient continues for a long time able to swallow, 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 suddenly terminate, at an early period, by the occurrence of violent, general convulsions, succeeded by deep coma and death. When the meningitis is seated at the base of the brain, the disease 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- 416 DISEASES OF CHILDREN. lysis, or by the occasional and often repeated alternation of a state of stupor with the phenomena of excitement. The occurrence of acute meningitis in the course of a febrile dis- ease is marked, according to the observations of Rilliet and Barthez, by excessive agitation, without appreciable pain of the head, and un- attended with vomiting. If diarrhoea was present, it persists; the pulse, from being regular, becomes unequal, irregular and diminished in frequency; 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 intensity, continues until death, Avhich 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 Avithin the ventricles. In place of these injections, the membrane may present a slight degree of thickening and opacity, Avhich 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. In some cases 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 reddened, and occasionally softened to a greater or less extent. Among the predisposing causes of acute meningitis the most im- portant is evidently the age of childhood. It unquestionably occurs more repeatedly anterior than subsequent to puberty. Guersant places the most common age for its occurrence between the fifth and fifteenth DISEASES OF THE NERVOUS SYSTEM. 417 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- 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 in- flammation of various grades. This predisposition is increased by a plethoric habit, hereditary irritability of the nervous system, and by precocity of intellectual development, subjecting the brain to prema- ture 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 per- tussis. Deep-seated inflammations of the ear very generally ter- minate, 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 the 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 re- turn of natural, quiet sleep; the recurrence of the normal secretions, the tongue becoming moist and clean, the skin soft and cool, the bow- els open, and the evacuations natural; the urine more copious and lighter coloured; the pulse more soft, slow and equable, and the res- piration less frequent and more regular; together with an abatement of the heat, pain, and tension of the head, and a return of the ordi- nary expression 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 Avhich 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 27 418 DISEASES OF CHILDREN. the patient against an attack that, were it to occur, would in all pro- bability prove promptly fatal. 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 in- flamed, should be freely ecarified, 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, com- bined with ipecacuanha and magnesia, at proper intervals; with an occasional dose of castor oil, will, in many cases, be required to in- sure 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 to- wards the brain, nothing is better calculated to equalize the circula- tion, and moderate 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 ten- dency to chilliness, the bath should be decidedly Avarm. 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 regu- lated 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 Aveather, 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 atmospherical 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 DISEASES OF THE NERVOUS SYSTEM. 419 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 Avould advise the ipecacuanha to be employed in preference to the tartarized antimony. After the stomach and bowels are freely eA'acuated, 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 con- dition 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 should retire to rest early in the evening, and rise early in the morning. The imprudent practice of keeping chil- dren up late at night, more especially when they are exposed, at the same time, to the excitement of lighted and crowded apartments, va- rious 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 eventuates 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 symp- toms of approaching syncope are induced; and should the symptoms of reaction, with active determination to the brain again return, the bleeding should be repeated without delay, and carried to the same extent When we are unable, in consequence of the age of the pa- tient, to procure 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 im- mersion 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 reaction 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 depletion in the early stage of all the more violent and acute attacks of meningeal inflammation, particularly when occurring in robust, plethoric 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 circumstances of each case, and the effects produced by the re- medy. Every thing depends upon the judgment of the practitioner, the correctness of his diagnosis, and the closeness and care with which the phenomena of the disease are watched. The bleeding should al- ways be carried to a sufficient extent to prevent the occurrence of re- 420 DISEASES OF CHILDREN. action, and to keep down any active determination to the brain: if suspended before this is accomplished, the remedy Avill be of little or no benefit; if continued beyond this point, injury will very generally be produced. 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 constitu- tion, simply sponging the head with cold Avater 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 at- tack, a full dose of calomel and rhubarb, and accelerate its operation by purgative enemata, (the best of which, in violent cases, is a mix- ture 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. R.—Calomel, gr. vj. ad xij. Ipecac, pulv. gr. iij.—iv. Cretae ppt. gss. Digitalis, pulv. gr. iij.—iv,—M. f. chart. No. xij. 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 irri- tation 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 ite use, especially in cerebral inflammation; on the other hand, we can 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. When the disease occurs in the latter period of childhood, and is marked by symptoms of great acuteness, for the ipecacuanha and DISEASES OF THE NERVOUS SYSTEM. 421 digitalis, an eighth of a grain of tartarized antimony may be sub- stituted. The tartarized antimony, in such cases, often proAres 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 good result from it, while often its effects have been positively preju- dicial. After full bleeding, and the action of a brisk purgative, external revulsants 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 even in a smaller stream. In- fants, however, seldom bear this well, and even older children are liable to become greatly alarmed upon its use; Ave have, therefore, very generally^ preferred the ice cap, cold sponging, or the application of a cloth wet with some evaporating lotion. The application of blisters, Avhen Avell timed, is very generally ad- vantageous. They should never be employed until after the inflam- matory excitement has been reduced by active depletion; as soon, how- ever, as this has been accomplished, their effects are always salutary, and often 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; Ave*prefer in every case, a 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 de- sired. In 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; in- stances of recovery being extremely rare. By the majority of practitioners it has been advised, in every se- vere case of meningitis, to place the system as quickly as possible un- der the influence of mercury: and with that view, in conjunction Avith the internal 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 tAvo, 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 poAverful an auxiliary it may prove, it i*. upon active depletion, in the early period of the acute stage, alone, 422 DISEASES OF CHILDREN. that our chief dependence is to be placed for the cure of acute me- ningeal inflammation. If the gums should become in the slightest degree affected, the use of the mercury must be at once suspended; the bowels being kept regu- larly open by mild aperients. When a decided improvement in the symptoms of the case becomes apparent, the use of the mercury, both internally and externally, should be gradually suspended; care being observed neither to discontinue it too early, nor 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 Avater. 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 allowred. 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 uncovered, wdiile the covering of the body should be light, but suffi- cient to protect it from the slightest sensation of chilliness; it is parti- cularly necessary to attend to this in the progress of the disease, as the temperature of the surface is very apt to sink, upon slight exposure. In cases attended with delirium, or Avhen 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. Stillicidium Avill occasionally occur, which may mislead the practi- 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 cos- tiveness 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 conse- quence, should be placed under a judicious hygienic course of treat- ment, until 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 DISEASES OF THE NERVOUS SYSTEM. 423 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 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 delirium from exhaustion, and even here they should not be pushed to too great an extent; if they do not, when given in moderate doses, quickly produce a state of calmness and refreshing sleep, they should be discontinued. Strong beef or mutton broth, wine whey, or wine itself, in small 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 delirium 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 it to 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 hydroce- phalic patients is wanting. Two pathognomonic symptoms, however, indicate the occurrence of the stage of effusion. One of these is deaf- ness ; 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 af- fection of the tongue usually occur suddenly; sometimes they are first 424 DISEASES OF CHILDREN. observed upon the child awaking from a quiet sleep. They arc, ac- cording 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—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 cerebelldm; 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. 5.—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, Avould seem to demand some notice of it in a work devoted to the consideration of the diseases of children. DISEASES OF THE NERVOUS SYSTEM. 425 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 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- petite 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, Avith 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, Avith the employment, at least, of any justifiable force. The 426 DISEASES OF CHILDREN. countenance, at this period, often assumes very much the tetanic 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 tonic contraction of the flexors of the forearm, and of the recti mus- cles of the abdomen, as occasional symptoms of the disease as it oc- curred in Montgomery, Alabama. Dr. White, of Tennessee, describes, in the cases observed by him, a rigidity of the abdominal muscles, spasmodic twitchings of the flexors of the extremities, and a disposi- tion to a constant motion of the legs from side to side, alternately. (New Orleans Med. and Surg. Journal.) In the same journal, Dr. Hicks, of Vicksburg, notices, as a striking feature of the disease, re- traction and rigidity 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: preventing, in many instances, the patient from lying upon his back. Dr. Ames describes the muscles of the neck, when not in a state of tetanic contraction, as being, 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 voluntarily, as the easiest position. Dr. I. J. Roberts, in describing the disease as it prevailed in and near San Augustine, Texas, in the spring of 1852, (Western Journal of Med. and Surg., vol. xi. p. 465,) states that difficulty of prehension was present in many cases; it being with the utmost difficulty that the patient could take a glass and drink water from it without assistance. In some eases there were involuntary twitchings of the muscles when the patient attempted to move or seize any thing, as if he were un- der the influence of strychnia. Dr. Roberts describes the contrac- tion and rigidity of the neck, as being to such an extent in some cases, that " by taking hold of the pillow by the ends and raising it up, the whole body of the patient might be raised without bending the neck." 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 there is rachialgia, more or less intense. This latter symptom, ac- cording to M. Tourdes, is absent only in the purely cephalalgic 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 DISEASES OF THE NERVOUS SYSTEM. 427 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- tion of the pupils, or, occasionally, dilatation of one pupil and con- traction of the other; ptosis of the eyelids, with ecchymosis, under the eyes, and on the surface of the body. The delirium is generally 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 Avas 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 Avas not complained of. Dr. Roberts remarks, that during the initia- tory chill, imperfect vision was present—objects appearing double or only half an object being seen, or, in other cases, every thing seeming surrounded by a mist. Dr. Ames, in the epidemic at Montgomery, Alabama, observed the conjunctivae to be generally injected, and the eyes glittering and watery. An exalted sensibility of the cutaneous surface generally, is often observed; the patient being "sore all over," and wincing upon the slightest touch, or refusing to change his position in bed, from the pain 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, petechiae make their appearance upon the arms, over the eyelids, and upon the inferior extremities. An exanthema- tous 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 beloAv twenty-one in the minute; the breathing Avas stertorous 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. Dr. Roberts notices a ringing in the ears as being very generally complained of from an early period of the attack. 428 DISEASES OF CHILDREN. The disease is often marked by continued irritability of stomach, insatiable thirst, and marked tenderness of the epigastrium upon pres- sure. These symptoms Avould seem to indicate disease of the stomach; and yet Dr. Mayne has found the A\rhole of the abdominal viscera ab- solutely healthy in the post mortem examination of tAvo cases, in which they persisted in a very marked degree to the close. Dr. Ames noticed acute pain of the abdomen in three cases, and in only one, tympani- tic distention 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, 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 patient 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 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- bouring, the powers of speech and deglutition fail, the tongue becomes dry, and the lips encrusted; the stools are passed involuntarily, while the bladder becomes distended with urine, or is continually allowing it to escape, and death finally closes the scene, often preceded by pa- ralysis of one side of the body, or of one or other extremity. DISEASES OF THE RESPIRATORY ORGANS. 429 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 a disease marked by the above symptoms occurs epidemically, we shall have little difficulty in deciding it to be cerebro-spinal meningitis. The prognosis is, generally speaking, unfavourable. Whenever 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, dry and clammy, and in several places the membrane is slightly opaque. Lymph and other inflammatory effusion is seldom met with 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; many of the cerebral nerves being, at their origin, im- bedded in it. The effusion is spread over the anfractuosities, which it 430 DISEASES OF CHILDREN. rarely penetrates. In the spinal cavity, this puriform matter extends, in bands, along the anterior or posterior face of the medulla, and, in 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 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 is 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 Meningi- tes 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 are present. Dr. Ames, who describes this latter lesion, mentions also four autopsies in which were found enlargement, and in one case DISEASES OF THE NERVOUS SYSTEM. 431 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, 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 At San Augustine, Texas, according to Dr. Roberts, the disease at- tacked almost exclusively the most healthy, robust young persons. There were but two or three instances of individuals over eighteen years of age being attacked—most generally the patients were under fifteen; and, he adds, "what is more extraordinary, there was not a single instance of the disease appearing in a female, though seemingly exposed to the same causes as the males, so far as epidemic influences 432 DISEASES OF CHILDREN. were concerned; neither was there an instance of the disease occur- ring in negroes, avIio Avere probably more exposed to the vicissitudes of the weather than the Avhites." 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 Avhich the attack commences Avith 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 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 re- open the vein a few hours subsequently, should the pulse again rise, and the face become once more flushed. We are not, however, to proportion our bleeding to the degree of cerebral restlessness and de- lirium. These violent states of nervous erethism quickly exhaust the powers of life, and were a copious venesection to be resorted to, a sudden and speedily 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. DISEASES OF THE NERVOUS SYSTEM. 433 The most common sensible effect was relief of the cephalalgia. Still, 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. According to Dr. Roberts the disease, as it occurred at San Augustine, Texas, did not appear to be much influenced by treatment, the result being the same—the death of the patient. The most marked differ- ence, he adds, was that those patients who were actively depleted in the early stage of the attack lived longer than those that were not; the cases in which depletion was not resorted to frequently terminating fatally in from four to eight days, while those patients who were ac- tively depleted in the early stage of the disease lived generally twelve, fifteen or twenty days. So fatal did the disease prove, that there was but a single instance of recovery out of twelve or fifteen cases, and in this instance the patient was bled two hundred ounces in the first two or three days: he was a young man, of full habit, seventeen years of age. 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 Avater, 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 surfaoe 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 be carefully watched, and should it exceed the proper grade, imme- diate resort must be had to general and local bloodletting, to an ex- tent proportioned to the violence of 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 emploved. Dr. Mayne speaks favourably of the early and free exhibition of mercurv, both by the skin and stomach, with the view of producing *28 434 DISEASES OF CHILDREN. promptly its specific action. By the French physicians, however. mercurial frictions are condemned, more, Ave 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 effi- cient 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 occa- sionally, when produced early in the attack, failed to produce any perceptible influence. Dr. Roberts remarks that the specific effects of mercury were early induced, in most cases of the disease as it occurred in Texas, but without producing much effect upon its symptoms and progress. 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 employ- ment 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. R.—Antimonii tart. grs. ij. Pulv. camphorae, Xij. Mucil. g. acacioe, £vj.—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 pro- duce a sedative influence, some of the former employed, subsequent to antiphlogisties and revulsives, the water of the cherry laurel and that of valerian, combined with mucilage. M. Maihle recommends, in preference, the distilled water of bitter almonds, as furnishing more definite 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 correctly. 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 sub- sequent to venesection, and the other antiphlogistic remedies. M. Forget commenced with its use between the fifth and seventh days of the disease, 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. Chau- DISEASES OF THE NERVOUS SYSTEM. 435 fard states that the early employment of the most energetic antiphlo- gistic 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, Ave are told, only one case was cured out of thirty; but after- Avards the disease was even less fatal than in its sporadic form. M. Tourdes admits, with M. Chaufard,*that the usual antiphlogistic means Avere 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 congestive malignant cases. In the other forms of the disease, he esteems it to be a safe and very valuable remedy. Dr. Roberts informs us that at S. Augustine, Texas, opium and morphia were tried in a few cases, but without any good result; they appeared rather to increase the stupor, without relieving the pain and restless- ness. Dr. Ames 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 phy- sicians, 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. potassae, §ij. Iodin. grs. viij. Syr. sarsapar. ^iv.—M. Given in doses of a teaspoonful, every four hours, in a little water. It should be continued for some days, unless found to produce gas- tric 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 perma- nently relieved, and in others, its exhibition was followed by a prompt reduction of arterial excitement, and the removal of intense cepha- lalgia and other symptoms of head disease. It is said that ethereal inspiration was practised by M. Basseron, physician-in-chief to the Military Hospital of Mustapha, in Algeria, with the best effects. 436 DISEASES OF CHILDREN. 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 probably the most frequent form of cerebral inflammation occurring 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 hy- drocephalus of Cheyne; the ataxic of Guersant; the tumultuous or hyper- acute of Monro and Golis; and the inflammatory of Brachet and Hop- fengartner; 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. But, notwithstanding 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 regarding serous effusion within the cranium as an essential character of the dis- ease, 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 pro- ducing, 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, In- most subsequent writers, as an occasional complication of the disease, and, by Guersant, Dance, and-a few others, as a distinct variety of meningitis. It was not until more accurate researches had estab- lished the fact, that the very general and intimate connexion between tuberculous deposits upon the membranes and in the substance of the brain, and the most frequent form of subacute meningitis in children, commonly described as hydrocephalus, was recognised. Subacute meningitis occurs chiefly in delicate, scrofulous children, especially in those distinguished by great irritability of the brain and nervous system, with large heads and precocity of intellectual deve- lopment. DISEASES OF THE NERVOUS SYSTEM. 437 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 indif- ferent 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 impa- tiently withdraws his eyes, Avhen they are accidentally directed to- Ayards the light; even in the ordinary light of his chamber, the eye- lids arc often but half unclosed, and the brows drawn down, giving to the countenance a kind of habitual frown. The pupils are most generally contracted, and occasionally there is an injected state of the conjunctiva. Strabismus, or a rolling of the eyes upwards and out- wards, is sometimes 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 ob- ject. Headache is occasionally present; more generally, however, the patient complains of a sense of weight over the forehead, or of gid- diness. In some cases, Avith these symptoms, there is a morbid acute- ness of the external senses, or, on the contrary, there may exist more or less obtuseness of sensation. In most cases, there is some degree of febrile excitement, especially tOAvards 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 capri- cious. 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 offensive 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 ab- domen, with tenderness of the epigastrium upon pressure. The attack is most generally preceded for some length of time, va- rying in different cases, by most or all of the premonitory symptoms just detailed. 438 DISEASES OF CHILDREN. The disease A-ery 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, Avith 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 someAvhat above the na- tural temperature; the pulse is frequent, quick, and tense, but seldom full. The tongue may be either perfectly clean and slightly red- dened, 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 Avith gastro-intestinal irritation or inflammation, the tongue generally becomes, at an early period, loaded with a dark brown incrustation of some thickness, which, towards the close of the disease, becomes black, dry, and rough. The appetite is occasionally unimpaired; at other times it is voracious; but, most generally, it is destroyed. The bowels are usually costive or torpid; but when gas- tro-intestinal disease is present, they are ordinarily relaxed, and the discharges are unnatural in colour and consistence. The pain of the head is, in general, seated in the forehead, shooting backAvards 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, AA-hich 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 eases the pain 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 dis- turbed; 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 in- terrupted 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 Avhen the patient's attention is roused, he is able, ordinarily, to give correct ansAvers to the questions put to him. After an indefinite duration, shorter or longer in diffe- rent cases, the delirium becomes more frequent, and of longer conti- nuance ; the countenance assumes a peculiar expression of stupor and surprise, very difficult to describe, but very characteristic. There is very considerable torpor or inertness of the intellectual faculties, with an apparent difficulty of directing them to any object; so that the patient's attention can scarcely be arrested, or he be induced to utter DISEASES OF THE NERVOUS SYSTEM. 439 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 un- der the inner edge of the upper eyelid. Strabismus is a common symptom, particularly tOAvards the period when deep coma and para- lysis 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 feAv 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. M. Trousseau mentions as a diagnostic sign of tubercular menin- gitis, the appearance of a remarkable red line remaining upon the skin of the forehead or of the abdomen, after draAving the finger across it. In a female patient in the Massachusetts General Hospital, who died of the disease, the presence of this sign was pointed out by Dr. Slade of Boston. 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 extre- mities, 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 para- plegia ensues. Not unfrequently the arm of the opposite side is kept in a state of constant oscillatory motion or is continually saAving the air. The pupil of one or of both eyes is usually now permanently dilated and insensible to light, and strabismus, with paralysis of the muscles of the eyelids, is almost invariably present. According to Dr. Hennis Green, a temporary but firm contraction of the eyelid often occurs at this period, Avhich 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- 440 DISEASES OF CHILDREN. roxysm of convulsions supervenes, or the patient again sinks into a state of fatal coma, followed, more or less quickly, by death. Con- vulsive 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- 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 hearing; the sense of touch, however, very generally continues unimpaired up to the last moment. The patient Avill 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 become cold, the respiration un- equal 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 maybe 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 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, DISEASES OF THE NERVOUS SYSTEM. 441 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 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 Avho 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, hoAvever, 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 mammelonated mass, enclosing portions of the pia mater, more or less changed, occur, comparatively more frequently, 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, embedded in the gray matter of the brain, where they are often surrounded by a halo of redness, generally connected with an enlarged vessel, ramifying from the pia mater. (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 co\-ered Avith a pseudo-membranous exudation, or AA-ithnu- 442 DISEASES OF CHILDREN. merous white flocculi, which become very apparent when the mem- brane is immersed in Avater. 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. 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 Avith 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, AA-hey-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- DISEASES OF THE NERVOUS SYSTEM. 443 give 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 caliber of the intestines, and invaginations have been repeatedly met with, and, occasionally, softening of the inner coat of the stomach. 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 shorter 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 bloAvs 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 com- monly stated to be between two and seA-cn. According to Rilliet and Barthez, the disease is most frequent betAveen the age of six and ten years; its order of frequency being first, betAveen three and five, then betAveen 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 Philadel- phia, during the ten years preceding 1845, 1906 deaths took place from hydrocephalus; of these, 992, or more than one-half, occurred in 444 DISEASES OF CHILDREN. children between one and five years of age; 748 in infants under ono 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, must be always extremely unfavourable. It is by directing our efforts towards the prevention of the disease, by the prompt and judicious management 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 excitement, and counteracting any undue 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 and of hyperaemia are strongly marked, it constitutes one of our most efficient remedies, and will often, when promptly and judiciously practised, succeed in arrest- ing the progress 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 indications 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 commencing paleness of the countenance of the patient warns us to desist. In infants, the application of leeches to the hands or feet, and encouraging the flow of blood, by immersing these parts in warm water, will very generally produce similar results to those derived from venesection 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 DISEASES OF THE NERVOUS SYSTEM. 445 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 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 decidedly 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 it may still be advisable, must be practised with much greater caution, and carried to a much less extent: here, leeching or cupping, propor- tioned to the extent and violence of the symptoms, should be preferred to general 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 se- cond application of the cups or leeches, and probably to the same ex- tent 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 fre- quently repeated, it may, on the other hand, be productive of much injury. There may even occur cases, where the symptoms of exhaus- tion, and the general condition of the patient, will render bloodletting, to any extent, improper. In cases accompanied with much tenderness of the epigastrium, cups or leeches to this part will always be proper, and, in many instances, 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 Avhich the bowels are torpid, or the eva- cuations unnatural in appearance; but we are to recollect, that the 446 DISEASES OF CHILDREN. 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 Avith constipation or torpor of the bowels, we should be inclined to 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 sul- phate of magnesia, or purgative enemata, to fail in producing the de- sired 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. DISEASES OF THE NERVOUS SYSTEM. 447 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 di- rected in acute meningitis, and continued until the increased heat of 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 appli- cations to the head. The frequency of their repetition must be de- termined 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 ipecacu- anha, (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. 448 DISEASES OF CHILDREN. 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, 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 mercury, as well as in those cases in which the use of the calomel in- ternally produces constant nausea and vomiting, or frequent griping, with repeated 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 blis- tered surfaces, 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, Perciv-al, 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 judi- cious 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 invariably 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 DISEASES OF THE NERVOUS SYSTEM. 449 iodine, has been recommended, with a A-iew of promoting the ab- sorption of the fluid from the cav-ities 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 spoken of the use of digitalis; the squill, in combination with calomel, has also 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 diuretic 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, ahvays 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 fre- quently repeated doses,1 is said by Roser to have proved successful in cases where paralysis had already occurred, and death appeared im- pending. We have employed the iodine in the manner recommended by Dr. Christie, and in several cases its beneficial effects were striking- ly displayed; in others, however, no apparent advantage was derived from its use. 1 R.—Iodid. potass. 3J. Aquae destill. t|ss.—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 disease: Ave believe that it will frequently be found of decided ad- vantage, after the stage of excitement has passed. Various symptoms occurring in the course of the disease, will occa- 29 450 DISEASES OF CHILDREN. 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- ally relieved by minute doses of calomel combined with magnesia and ipecacuanha,1 and the application to the epigastrium of a sina- pism, or of frictions 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 un- necessary movements of the patient should be avoided; and the ut- most kindness should be invariably observed by the attendants in their deportment 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 DISEASES OF THE NERVOUS SYSTEM. 451 body daily Avith 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 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 reme- dies are positively injurious. The strength of the patient should be supported by the breast-milk of a healthy nurse, or if weaned, by beef tea, plain mutton or chicken broth, and similar articles of nou- rishment. Where the exhaustion is very great, wine whey, the car- bonate of ammonia, 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 calo- mel, 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 re- cumbent posture, and where he may enjoy the advantages of a free circulation of air, and the temperature of his extremities should be maintained 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. 7.—Chronic Hydrocephalus. (DROPSY OF THE BRAIN.) This form of disease is very generally congenital, or is developed soon after birth. It consists in an accumulation of a serous fluid, often to an enormous extent, generally within the ventricles of the brain, but occasionally upon its surface. 452 DISEASES OF CHILDREN. When the disease occurs subsequently to birth, it is generally de- veloped sloAvly 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, presenting, as it were, tense, semi-transparent tumours, in Avhich a distinct fluctuation is perceptible upon pressure. The head gradually enlarges, as the effusion increases within the 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 Avith chronic hydrocephalus may live for many years, without any very decided impairment of the intellectual facul- ties. Occasionally, the sense of sight, hearing, and taste, are de- stroyed permanently, 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 a more accurate examination, it is found that no portion of the brain is destroyed, its convolutions being merely deployed. In other cases. 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 medullary matter to Avhich it is attached. Chronic hydrocephalus is not a very frequent disease in Philadel- phia. In a practice of thirty-six years we have seen but two con- genital cases, and only one that was developed subsequent to birth. In the treatment of chronic hydrocephalus, our chief object must \ DISEASES OF THE NERVOUS SYSTEM. 453 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 boAvels 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- bility, safety, and success of Avhich, 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 trocar into one of the lateral ventricles, and drawing off as much fluid as the poAvers of the constitution will admit of. The most eligi- ble spot at which the trocar 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 trocar, the water will not flow until a probe has been passed along the cannula, 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 ex- citement folloAvs 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. 8.—Chorea. Chorea is a A-ery 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 neckband 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 454 DISEASES OF CHILDREN. 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 Avalking, 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 Sancti Viti—the Dance of Saint Vitus,) is derived from the circumstance of the patients affected with it formerly repairing annually to the chapel of St. Vitus, near the city of Ulin, 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 Avhose 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 eAren complete fatuity has been known to ensue. Fatuity, however, is by no means a very common sequel of chorea, even in its most violent and chronic forms. Many instances are on record, and DISEASES OF THE NERVOUS SYSTEM. 455 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- rally the result of gastro-intestinal irritation, or some accidental affec- tion. When the disease is very violent and protracted there in general occur 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. Pain, remarks Dr. Churchill, is seldom complained of by patients affected with chorea, and but little general distress. Out of twenty cases related by M. Dufosse, eight suffered from slight headache, six from palpitations, and two from a pain, increased by pressure upon the spinous processes. M. Richard states that most of the girls he has seen affected with the disease presented a lateral curvature of the spine, and he seems inclined to attribute the chorea to an overstretch- ing of the nerves. 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 affected, 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 Hos- pital, is due the merit of having first made known the morbid condi- tion 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 paralyzed; 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 hemaeplegic, and will resemble very closely hemae- 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 pa- ralvtic state as a consequence of violent attacks of chorea, but have not found it so common a sequel of the disease as stated by Dr. Todd. Chorea has been defined by some writers to be an irregular motion of the muscles, when excitedinto action by the will: the disease con- 456 DISEASES OF CHILDREN. 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, consequently, been supposed to result from some lesion of the cerebellum. This de- finition would, however, exclude a number of cases, in Avhich the con- 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 Avhich 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. It 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, 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 upAvards: 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, andher 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. Rufz mentions a case in which the child threw itself out of bed, and crawled about the room like a worm. ^ _ To this same class belong 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. It is very possible, remarks Dr. Churchill, (on the Diseases of Infants and Children,) that while some cases of stam- mering may in fact be a vocal species of chorea, the same is true also DISEASES OF THE NERVOUS SYSTEM. 457 of those cases of incessant winking or twitching of the nose or mouth, which we meet with occasionally, and which are so difficult to cure, although they often get well. I have, he adds, at this moment under my care a little boy, very nervous, but healthy, who ordinarily winks about tAvice as often as other children, but if it be noticed, or if he be unusually earnest about any thing, the eyelids are in incessant mo- tion, and closed with unusual force. Chorea, as it ordinarily presents itself in children, will be readily recognised by the symptoms we have detailed. 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 establishment of the catamenia in girls. When recent, and occurring in children possessed of some degree of constitutional vigour, it may often be en- tirely 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 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; AAdiile in others it increased at first, but aftenvards 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 throAvs 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, Rilliet and Barthez;) while those which have been recorded by A-arious writers, are evidently ac- cidental lesions, or to be regarded rather as effects than causes of the complaint; such as inflammation of various parts of the brain (Clut- terbuck, Serres;) turgescence of its vessels, Avith effusions of serum (Coxe, Patterson, Roser, Willan, Copland;) hypertrophy and injection 458 DISEASES OF CHILDREN. of the brain and spinal cord (Monad, Hutin;) turgescence of the ves- sels of the brain and spinal cord, with several bony plates upon the pia mater, half-way up the spine (Bright;) a concretion in the medul- lary substance of the left hemisphere of the brain (Brown;) a tumour pressing on the corpora quadrigemina, inflammation of these parts, with sanguineous 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 (Schrode.) 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 characterizedKchorea 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 ac- tion in the performance of certain movements. According to the most probable view of the functions of the cerebellum, it would seem that this organ is the chief seat of the disease; the morbid phenomena, 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 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 any thing 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 Avould seem to Dr. Elam to indicate, that whilst volition has but little influence of 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 confined to a periodical twitching of one or more muscles of the face or eyeballs. In one case, both eyeballs Avere 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 af- DISEASES OF THE NERVOUS SYSTEM. 459 fection 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 mo- tions, 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 sys- tem. 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 it is to the latter cause that the production of chorea must be almost invariably attributed. In nearly every case the cause must be looked for in some local or general excitability (perhaps from irregular distribution of blood,) in the ex- tremities of the excito-motor nerves, compelling them to respond in a more vigorous, and consequently irregular manner, to the ordinary physical agents. It seems probable, too, that this excitability is al- most exclusively 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 are 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 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. M. Trousseau is accustomed to point out to his class the correla- tion so often observed between disease of the heart and chorea; so that examination of this organ, and inquiry into the history of the case as regards rheumatism, should never be neglected; inasmuch as such correlation supports the views of those who regard the disease as rheumatic or rheumatoid. 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 Avell as certain 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 ex- perience. Like all other convulsive diseases, chorea may unques- 460 DISEASES OF CHILDREN. tionably be excited 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. "According to some authors, for example, Mezerai, Cullen, and Hecker, chorea has occurred epidemically. Albers, cited by Frank, mentions a school in which it appeared as an epidemic, and Rilliet and Barthez, a village in the Tyrol, in Avhich it occurred recently. Dr. Copland has given an interesting lecture on nervous disorders, resembling chorea; as, the effect of the bite of the tarantula, the leaping ague of Scotland, and an affection which spread rapidly among a sect of religious enthusiasts in Tennessee and Kentucky, de- scribed by. Dr. Robertson, &c. &c., which strikingly resemble chorea, and the extensive prevalence of which may have originated the idea of an epidemic." (Churchill—Diseases of Infants and Children.) 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. Bleeding 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 indica- tions 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 re- medies. Such cases, hoAvever, 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 pro- duce 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- 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, hoAvever, 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 Avill DISEASES OF THE NERVOUS SYSTEM. 461 demand the more active purgatives, given in successive doses, in such a manner as to produce a full and continued operation. Not only, however, 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 combinations 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 castor oil. We have employed it pretty extensively, preceding its use by a full dose of calomel, and in very few instances without de- cided advantage. R.—01. ricini, Or, R.—01. ricini, Spir. terebenth. aa gss.—M. Spir. terebenth. aa ^ss. It may be given in doses of a tea or dessert- Tinct. senna?, ^iij. spoonful, according to the age of the pa- Syrup, zingib. fjij.—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 effica- cious. Pustulation Avith the croton oil along the spine, has, also, been recommended, 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, however, as the representation of the vegetable tonics, while m re- gard 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 proto- 462 DISEASES OF CHILDREN. carbonate of iron in large doses, and of the sulphate of zinc are per- haps 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 recom- mended by Zollickoffer. M. Faivre D'Esnans states in the Journal de Medecine et Chirurgie Pratiques, that he has obtained the happiest results from the cyanuret of iron in chorea and epilepsy, and he gives several cases where the cure was obtained in between four and eight days. He employs the following formula: cyanuret of iron, grs. xv.; extract of valerian, grs. xlv. Make into twenty-four pills: one pill to be given three times a day, at six hours' interval, each pill to be fol- lowed by a wineglassful of infusion of valerian. The cyanuret of zinc, in the dose of one-third of a grain, twice a day, gradually in- creased 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 particular 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 suspend its use, and sub- stitute 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, the valerianate of zinc, and nitrate of silver, in combination with some one of the vege- table 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 slightest effect, when, on substituting a third, the morbid phenomena have been very quickly and permanently con- trolled. 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 pre- scribed in the cases of children in doses sufficiently large, or be con- tinued sufficiently 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 mo- ment that any sickness, or griping pains, or intumescence of the face or extremities occur, we have found it to be a perfectly safe and DISEASES OF THE NERVOUS SYSTEM. 463 manageable article. The testimonies in favour of its efficacy are numerous and positive. Very decided testimony has been presented by Young, of Penn- sylvania, Lindsly, of Washington, Hilddreth, of Ohio, Kirkbride and Professor Wood, of Philadelphia, and Beadle, of New York, in 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 hy- drocyanic 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 ^iijss.; of this two and a half drachms are given daily in three doses; and the quantity is every day increased 3ji, until itching of the scalp and slight muscular stiff- 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 asafoetida, 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 464 DISEASES OF CHILDREN. by daily sponging the entire surface with salt water, at first Avarm, 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- phuret of potassa in about twelve bucketsfull of Avater, and repeated daily, have been employed Avith 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 Avell 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 fiATe 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 oc- casional mild cathartics; which, in conjunction with other remedies, had been used previously without advantage. The electricity Avas 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 appeared, which is often caused by electricity when applied in this manner. From the transmission of electric shocks along the affected limbs no good Avhatever 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 DISEASES OF THE SKIN. 465 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. SECTION IV. DISEASES OF THE SKIN. CHAPTER I. ERUPTIVE FEVERS — EXANTHEMATA. 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. 1.—Measles. RUBEOLA—MORBILLI. 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 bv increased heat of the skin, thirst, loss of appe- 30 466 DISEASES OF CHILDREN. 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 costive, 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 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 place upon the decline of the eruption, and is usually attended with a troublesome itching of the skin. The eruption is not confined to the skin, but extends also to the mu- cous membrane; the fauces and mouth being covered, at the height of the disease, with reddish, slightly elevated spots; which are 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, in- tense 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 ac- celerated. 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 ronchi 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 DISEASES OF THE SKIN. 467 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, 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 alimen- tary 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 sinefebre of others. An interval of many 468 DISEASES OF CHILDREN. 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 the subsequent continuance of the epidemic, but Ave 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 Avhen the eruption Avas 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 DISEASES OF THE SKIN. 469 indicate more or less bronchial affection, the exact nature and extent of this it is impossible to determine Avith 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, Avith 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. 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, Avith 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 wdiich 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, op- pressed 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. 470 DISEASES OF CHILDREN. 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: particularly on assuming an erect posture. I'he 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 tho 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, howeA-cr, 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 knoAv 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 obsen'ations, 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. DISEASES OF THE SKIN. 471 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 individuals 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 is some evidence, 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 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 ap- pears, 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. * Dr. M'Girr of Chicago, Illinois, reports the results of inoculation for measles in fourteen cases. The operation was performed by in- serting blood, drawn from a vivid exanthematous patch, into the arm. In the inoculated patients the disease was less severe and dangerous than in those in the same institution—the Catholic Orphan Asylum— who contracted the disease in the ordinary way, during the period the effects of inoculation were tested by him. 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-marked catarrhal symptoms by Avhich the eruption in measles is preceded and accompanied, and their absence in scarlatina; the appearance of the 472 DISEASES OF CHILDREN. 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 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.1 When the catarrhal symp- toms are very severe, the same remedies will be necessary as in severe cases of ordinary catarrh. ' R.—Mucilag. g. acaciae, ^iij. Or R.—Liquor, acetat. ammoniae, £tj. Syrup, limonis, gj. Spir. reth. nitr. Spir. aeth. nitr. giij. Vini antimonii,' aa giij. Tart, antimon. gr. j.—M. Syrup, limonis, ^ij.—M. Dose, a teaspoonful every three hours. Dose, the same as the above. Or R.—Ammoniae hydrochlor. Pulv. ext. glycyrrh. aa giij. Tart, antimon. gr. j. Aquae, 3;viij. Dose, a teaspoonful every three hours, for a child under two years of age, and a des- sertspoonful every two or three hours, for one over two years of age. In regard to the employment of bloodletting in severe cases of mea- DISEASES OF THE SKIN. 473 sles, there appears to be 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 doAvn. 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, Avith 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 reliev-e 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, 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 internal 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. 3d, 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,1 or of the acetate of ammonia, aqua camphorata, wine of ipecacuanha, and tincture of hy- oscyamus,2 will be proper; the patient, at the same time, drinking 474 DISEASES OF CHILDREN. freely of some tepid fluid. 5th, Bleeding. In a large number of the congestive cases of measles, a cautious abstraction of blood, cither 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, hoAvever, 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 becomes 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. i R._Pulv. camphor, gr. iv.—vj. 2 R.—Acetat. ammoniae liquor, giy. Magnes. calc. gijss. Aquae camphorae, gij. Pulv. ipecac, gr. iij. Vin. ipecac. 31J. Ext. hyoscyami, gr. vj.—viij.—M. f. ch. Tinct. hyoscyami, ^iij. No. xij. Syrup, zingiber, gj.—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, ac- cording 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 beneficial; 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- DISEASES OF THE SKIN. 475 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- 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. 2—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 seA-ere affection of the throat, or of some one or other of the internal organs, by Avhich its symptoms and progress are very considerably modified, and the dis- 476 DISEASES OF CHILDREN. 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 Avhich 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 scarlatina maligna. The last of these denominations is particularly objectionable. The term malignant is, to say the least of it, indefinite; while from its former, and even noAv 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, Avithout any eruption occurring upon the skin. This, hoAvever, 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 rigour, 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 Aveak 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, Avithin 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 DISEASES OF THE SKIN. 477 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 vesicles 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 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 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, hoAvever, either suddenly or by degrees, symptoms of 478 DISEASES OF CHILDREN. 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 SAvollen, 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 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, increase 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; but 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 foe tor of the breath; painful indurations of the glands of the neck ensue, and the patient is troubled with griping DISEASES OF THE SKIN. 479 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, remark 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 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. In other cases of scarlatina, symptoms of severe abdominal inflam- mation ensue; considerable pain, increased upon pressure, with ten- sion, fulness, and heat of the abdomen; short, quick, anxious respira- tion; very quick, contracted pulse; considerable irritability of the 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 480 DISEASES OF CHILDREN. organs—the trachea, bronchi, pleura, or lungs. Whatever may be 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 tono-ue 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 loAver extremities; frequently, complete anasarca ensues after the disappearance of the eruption. Effusion Avithin 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 Avith albuminous urine, and no doubt with a diseased condition of the kidneys. In 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 of albuminous nephritis in the production of the dropsies consequent 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 Avho have been exposed to cold, there will occur 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 the dropsy and of the' nephritic disease. Consequently, it is particu- larly against exposure to a cold and damp atmosphere during the latter stages of scarlatina, and during the period of convalescence, that we should especially guard. Of the occasional occurrence of albuminous urine consequent upon nephritic disease in the dropsy succeeding to scarlatina, there can be no doubt. Some writers have gone so far as to assert that an albumi- nous condition of the urine is almost invariably to be detected in the course of the fever. Professor Bennet, of London, believes that the DISEASES OF THE SKIN. 481 * coagulability of the urine observed in scarlatina, as well as various deposits which appear in it on critical days, are to be considered as an evidence of the excretion of the morbid products which have cir- culated in the blood. Hence it is common, not only in scarlatina, but in all inflammatory affections, as well as fevers. Dr. Newbigging (London Monthly Journal, Sept. 1849) states, that in an early stage of the disease, even at the time when the eruption was just declining, having instituted an examination of the urine, he ascertained that, in every case, the albuminous haze was distinctly present, and remarkably so during the progress of the desquamation. That this appearance occurred without alteration, either in the spe- cific gravity, except to a very small extent, or in the quantity of the secretion, and that it continued from a period varying from four or five to ten days, gradually becoming less defined, and finally disap- pearing altogether. This occurred in cases in which the urine main- tained its normal standard as to quantity, where the patients were well, and certainly unaffected by any dropsical symptoms. It is worthy of remark, that the quantity of urine voided at the period of desquamation is even greater than in health, although it may contain albumen; and this Dr. Newbigging considers to be an in- teresting fact, as in dropsy occurring, it may be, subsequently, in the same case, the amount of the urine is greatly diminished, sometimes altogether suppressed, so that any diminution of this secretion, with- out apparent increase of albumen, may be almost certainly considered as the forerunner of anasarca. These observations correspond with those of Martin Solon, who as- certained the presence of albumen in twenty-two out of twenty-three cases, but are irreconcilable with those of some other authors: thus, Philippe states that, although the succeeding dropsy was very com- mon in the mild epidemic which he witnessed, yet in sixty cases of the disease, in which he tested the urine for albumen by both heat and nitric acid, no trace of that principle was discovered. Dr. Scott Alison, on the other hand, remarks, that he has observed dropsy to ensue more frequently after a severe attack of scarlatina than when the symptoms were of a more moderate character. That the urine in some cases, according to his analysis, was of a specific gravity of 1.005, while in others it was as high as 1.030; and he is of opinion that the kidney becomes organically affected at an early period of the disease. In the great majority of cases, the dropsical symptoms are by no 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 eruptions, 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 fetid discharges from the ears; inflammation of the testicles; chronic bron- chitis; tubercular phthisis; or inflammation of the mucous membrane of the intestines, have also been observed as consequences of severe 31 482 DISEASES OF CHILDREN. 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- 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 Avithin 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 arc 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 called the attention of the profession to the not uncommon occurrence of this complication in cases of scarlatina. Scarlatina most commonly occurs as an epidemic, often of wide ex- tent, and it is very generally believed that it is capable of being pro- pagated by a specific contagion, emanating from the bodies of those labouring under the disease. Upon this point, however, there is some difference of opinion among physicians. It is certain that in many epidemics we find the disease to prevail extensively in a particular locality, while in those immediately adjoining, and between which and the one where the disease prevails, there is the most unrestricted in- DISEASES OF THE SKIN. 483 tercourse, scarcely a single case will occur. Often, upon its decline or cessation in the locality where it first appeared, it will make its ap- pearance in one or other of those adjoining, and thus passing from locality to locality, successively travel, as it were, over a large city; a fact that would seem to militate against the idea of its eminently contagious character. Dr. Charles D. Meigs remarks, that one might well venture to resist the general assertion of the contagion of scar- latina, seeing that it so very often breaks forth fearfully in places where no suspicion of human intervention can be indulged, and that it often enters populous households, affecting only one or two, and sparing three, or six, or eight other members of the family, eyen where not the slightest precaution against its propagation is taken by way of quarantine, disinfectant, or other means. Dr. M. F. Colby, of Canada East, states that in 1832 the disease prevailed within a circuit of fifty miles around him, "ever occurring in isolated families." On the other hand, however, we are presented with the experiments of Sir B. Harwood, who, it is asserted, succeeded in producing the disease by inoculation Avith the fluid from the vesicles which were in- termingled with the eruption of scarlatina, although he was disap- pointed in producing a milder disease. Dr. Copland met with a case in which the disease was supposed to be induced by the contact of a small quantity of the discharge from the throat of a patient affected with the malignant anginous scarlatina. M. Miguel de l'Amboise is also said to have succeeded in producing the disease by inoculating with the blood of a patient labouring under it. If no error shall be discovered in regard to these several statements, we then are willing to admit, with Dr. Churchill, (Diseases of Infants and Children,) that whatever doubt may have existed in regard to the contagious character of scarlatina, must .be entirely removed. There is, it is asserted, abundant evidence that a febrile affection, attended with scarlet eruption, and possessing all the other characters 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 sus- pect, however, that the cases referred to by Dr. Gregory were severe cases of roseola, or the rotheln 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 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- 4.s4 DISEASES OF CHILDREN. 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 causes of scarlatina appear 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 im- portant modification in the subsequent features of the case; and fre- quently 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 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 DISEASES OF THE SKIN. 485 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 feAv 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 calomel, and the same quantity of calcined magnesia, every other night, and during the day, a teaspoonful, every three hours, of a saline mixture with the addition of a small portion of tartarized antimony.1 Under this treatment, the milder forms of the disease will, very gene- rally, be conducted to a favourable termination. • R.—Aquae, giv. Sulph. magnes. 373. Tart. ant. gr. j. Spir. aeth. nitr.^iv. Syrup, limon. 5SS.—M. 486 DISEASES OF CHILDREN. In the milder cases of the anginose form of scarlatina, active pur- gation during the stage of excitement Avill 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.1 The hydrochloride of ammonia is a favourite pre- scription of some of the German physicians, in these cases. 1 R.—Aquae, ;|iv. Sulph. magnes. gv. Hydrochlor. ammoniae, 3U- Tart. ant. gr. j. Syrup, limon. ^ss.—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. W~e are to recollect, hoAArever, 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 and extract of hyoscyamus or camphor, will be required to preserve a regular condition of the bowels, eA^en 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 Avith 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, DISEASES OF THE SKIN. 487 and arrest their fatal tendency. The abstraction of a very moderate quantity 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 acquired any degree of intensity, particularly if the patient is of a plethoric and robust habit, and the febrile reaction is violent, the bleeding 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 period of the stage 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 re- ducing the violence of the reaction, or of controlling internal inflamma- tion, 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 repetition 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 treatment of the disease. In many instances, as remarked by Bate- man, it is almost the only febrifuge, diaphoretic, and anodyne, that will not disappoint the expectations of the practitioner. When re- sorted 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, refresh- ing sleep. It has been even said, that in many instances, when re- sorted to in the commencement of the stage of excitement, it has had the effect of cutting 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 pre- sent. It should be freely used at short intervals, day and night, until the heat of the surface 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. 488 DISEASES OF CHILDREN. While in every case in which we are permitted to employ it, avo believe that in the application of cold to the surface, affusion is the mode from which the most benefit is to be derived; yet Avhen 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 cal- culated 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 necessary, 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 affusion 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 brain is much affected, cold affusions 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, • DISEASES OF THE SKIN. 489 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. Dr. Stewart of Berks county, Penn., (Transactions of the State Me- dical Society, vol. ii. p. 100,) recommends in all cases of scarlatina the application of a sinapism to the throat. " Regarding," he remarks, " scarlet fever as one of a family of diseases for which there is no as- certained specific, all he has aimed at has been to take care of the throat, and attend to other local symptoms as they presented them- selves, and to keep the system in proper order. With this view, in or- dinary cases, he has, for the last four years, prescribed nothing beyond castor oil, to keep the bowels open, and, once or twice a day, during the continuance of the disease, a sinapism to the throat,—and he can truthfully say, that within that period he has not had a single case which ended in sore throat. Even in cases in which this was threat- ened, the mustard prevented its occurrence." 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. Thie 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. Dr. M. F. Colby, of Canada East, in a communication on the nature and treatment of scarlatina, published in the Boston Med. & Surg. Journ. June 15,1853, speaks in strong terms of belladonna as a remedy in this disease. He employs the German solution of the extract— three grains to the ounce, and continues its use during the whole pro- gress of the case. " I am confident," he remarks, " that no physician who has not given the belladonna a thorough trial, is aware of its good effects. It lessens the violence of the disease, keeps out the eruption, and effectually equalizes the circulation in the capillary vessels." 490 DISEASES OF CHILDREN. 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. In the year 1849, Dr. Schneemann, physician at the Court of the King of Hanover, recommended the inunction of the entire surface, with the exception of the face and scalp, as an effectual means of pre- venting the injurious effects of the exanthem on the functions of the skin; the inunction so modifying the eruption that scarcely any des- quamation takes place; and the skin thus continuing in a state of comparative integrity, so beneficial an influence is produced on the several organs implicated in the disease, particularly the throat, that their normal condition is, in every case, and in every part, speedily restored. Dr. Schneemann directs the patient to be rubbed, every moraine and evening, over the whole body, except the face and hairy scalp, with a portion of bacon, in such a manner that the skin may be regu- larly but not too quickly saturated with fat. This simple plan of treating scarlatina has attracted no little atten- tion. Some of those who have given it a more or less extensive trial, speak of it favourably, while others believe it to be productive of little or no benefit. Dr. Lindsly, who resorted to it during a very severe epidemic of scarlatina, concludes, that it " will probably be found the most im- portant improvement that has been made for many years in the ma- nagement of scarlet fever." Dr. Ebert employed inunction during an epidemic of scarlatina in Berlin, and the result, according to his account, was tolerably en- couraging : of twenty-eight severe cases six terminated fatally; of these six, five had not been subjected to inunction; the remaining one was an infant who died suddenly after one inunction. According to Dr. Ebert, the inunction of the surface appeared to hasten rather than to prevent the appearance of the> exanthem. In those cases which were assiduously anointed, no desquamation occurred, neither were any of the sequelae, as anasarca, abscesses, &c, observed. The anointing was also thought to prevent infection. Dr. Paul F. Eve, of Augusta, Geo., has resorted to inunction in scarlatina, and reports favourably of its effects, as does also Dr. Cain, of Charleston, S. C. In the reports on epidemics, made to the American Medical As- sociation, as well as to the Pennsylvania State Medical Society, at their session of 1852, the inunction of the surface with clean lard in cases of scarlatina, is occasionally spoken of in very favourable terms. As yet we have not in our possession a sufficient amount of evidence, in regard to the general results of the practice, to enable us to form any correct opinion in respect to it. We have had no opportunity of testing its effects in our own practice, but from the decided bene- fit we have invariably derived, in cases of erysipelas, from covering DISEASES OF THE SKIN. 491 the inflamed surface with a thick coating of fresh lard, we should in- fer that the same practice might be beneficial, also, in scarlatina. 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 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. We have found, in many cases of scarlatina attended with disease of the throat, much advantage from the use of hydrochloric acid in- ternally. Our common prescription is a drachm of the acid to five ounces of water, well sweetened with sugar: of this we direct a tea- spoonful to be given every two or three hours. Dr. J. P. Hiester, and Dr. Beaver, of Berks county, Pa., both speak favourably of the effects of diluted hydrochloric acid in scarlet fever, when freely ad- ministered. (Trans. State Med.»Soc, vol. ii. pp. 96, 98.) In the fourth volume of the Medical Gazette of London, there is a communication from Messrs. Tayton and Williams, in praise of chlo- rine as a remedy in scarlatina. The chlorine is procured by dis- solving two drachms of the chlorate of potass in two ounces of hydro- chloric acid, diluted with two ounces of distilled water. The solu- tion 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, accord- ing to the age of the patient, may be given for a dose frequently. 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. 492 DISEASES OF CHILDREN. 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 tAvo 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 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, &c, 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 mor£ 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 at- tended 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 DISEASES OF THE SKIN.""] 493 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 instance^ 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- 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 op- pressed, but with the effort at reaction, it becomes quick and varia- ble," 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 or- gans 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 heaA'iness, 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 sIoav and laborious. The paleness of the countenance is often mixed with a degree of lividness: the eyes are dull, though oc- 494 DISEASES OF CHILDREN. casionally 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 dis- ease 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. 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 are, 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 petechiae, 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 described, are evidently dependent upon a lesion of the nervous sys- tem 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 paralyzed, 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 important organs are predisposed to serious lesions, from the irregu- DISEASES OF THE SKIN. 495 lar determinations 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 inflammation. 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 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 calomel 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 repeat 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 adapt- ed 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 excel- lent purgative: the turpentine, combined with castor oil, is the one we have generally employed, and it has appeared to us to be benefi- cial, independently 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 496 DISEASES OF CHILDREN. 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 slight- est appearance 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 ad- visable. During the flow of blood, the skin should be well rubbed -with a 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- DISEASES OF THE SKIN. 497 luting 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,1 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. 1 R.—Pulv. camphor, gr. iv.—vj. " ipecacuanhoe, gr. iij. Hydrochlor. ammoniae, Qijss.—M. f. ch. No. xij. One to be given every three hours. In scarlatina maligna, Dr. Peart recommends the carbonate of am- 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 Avith 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, Avill 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 in- tervals. Close attention and much judgment will be demanded pro- perly 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 j 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, 32 498 DISEASES OF CHILDREN. 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 symptoms which then show themselves." The " bold and indiscrimi- nate use of the lancet" we should certainly strongly object to; but of the beneficial effects of a cautious employment of bloodletting, in the manner and under the circumstances directed, we speak from ac- tual 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 cir- cumstances 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 DISEASES OF THE SKIN. 499 are attested by numerous writers. Combinations of calomel, nitrate of potassa, and digitalis,1 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. 1 R.—Calomel, gr. xij. ^ R.—Aquae, gvj. Nitrat. potassae, gj. Sulph. magnesiae, giv. Pulv. digitalis, gr. iv.—M. f. ch. Spir. aeth. nitr. ^iv. No. xij. Nitrat. potassae.^ij. One to be given, for a dose, every two, Tart, antimonii, gr. j.—M. three, or four hours. Dose, a teaspoonful every three hours. 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. When the effusion is connected with a relaxed and debilitated con- dition of the system, bleeding will be improper. If the bowels are confined, they should be freely evacuated by calomel, followed by some gentle aperient. As diuretics, the squill, spirits of turpentine, and tincture 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 fetid 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, at bed-time, and mild aperients during the day. R.—Cretae 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. 500 DISEASES OF CHILDREN. 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 Avith 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 pre- sented 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 character. In a small village of 250 individuals, the belladonna was 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. None 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 Avas 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 proportion to those from ten to four- teen, and one grain of the powdered root, twice a day to adults. These small doses, it is stated, never produced the toxicological effects of belladonna; in fact, they scarcely ever exhibited any marked action. In five or six cases, Dr. Stievenart'observed a rash similar to 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 resemblance to that of scarlatina anginosa. The use of the remedy was generally continued from nine to ten days, and in some instances, for fifteen days. Dr. Stievenart considers this period to be sufficiently long to place the system completely under its pro- phylactic influence; but he recommends the use of the belladonna to be resumed, if the epidemic should return, or break out again with renewed violence. DISEASES OF THE SKIN. 501 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, and troublesome from itching. In those families, the members of which were not placed under the influence of this prophylactic, the disease 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 epi- demic, exhibited belladonna, and observed it to exert similar protec- tive powers. Dr. Rufus Hammond, of Indiana, also bears strong testimony in favour of the prophylactic poAvers of belladonna, based upon ample opportunities for observation. 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 miti- gating the character, or preventing the occurrence of scarlatina. The experiments were made during the prevalence of the disease, and in numerous instances the subjects of them were attacked. In one case, the efflorescence was kept up, by the use of the 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 papulae 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 eases, 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. 3.—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 502 DISEASES OF CHILDREN. is diffused over a large surface; in others, it assumes the form of rings and spots, Avhile in others again, irregular lines of a darker colour have their interstices filled up by a lighter shade of red. The disease is frequently ushered in by a slight degree of febrile ex- citement, Avhich abates as the efflorescence makes its appearance, and disappears Avith it. The pharynx often presents a similar efflores- cence to that upon the skin, and the patient feels a sense of dryness and roughness in swallowing. The efflorescence upon the surface gradu- ally 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 de- clines again and again, without any perceptible cause, or in conse- quence 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 in- tervals of sound skin between them, is sometimes with difficulty distin- guished from measles, the difficulty being increased in many cases by the presence of catarrhal symptoms. The recession of the efflorescence is frequently attended by some derangement of the stomach, headache, and more or less of languor 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 DISEASES OF THE SKIN. 503 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, Avithout 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 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 eases 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, 504 DISEASES OF CHILDREN. 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 any thing 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 rigour, 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 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 coun- tenance. 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 DISEASES OF THE SKIN. 505 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 con- tinues until about the sixth day. As the vesicle becomes more com- pletely distended, and of a more globular form, the indentation dis- appears; 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 broAvn, and, Avhen' perfectly dry, a very dark broAvn, 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 matutation, 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- 506 DISEASES OF CHILDREN. 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 inflam- mation 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, 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 writers, 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 w-hich 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- DISEASES OF THE SKIN. 507 face is cold, his pulse feeble; the eruption is slow in appearing, sel- dom 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 w-ith 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- 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 Avhich the cells are first distended, 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 distention of the vesicle, the central filamentous attachment is destroyed, and the cen- tral depression is no longer observed. The pustule now acuminates and finally bursts, discharging a purulent matter, of a yellowish co- lour, and of the consistence 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 re- newed inflammatory affection of the skin, or the occurrence of in- flammation of one or other of the internal organs. Thus the breast, back or extremities, may become covered with an efflorescence very similar to that of scarlatina:—the tongue being at the same time 508 DISEASES OF CHILDREN. 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 extremi- ties. In other instances, boils, abscesses, and carbuncles, form in the neck, axillae, groins, elbows, and thighs; or a gangrenous inflamma- tion 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 destruc- tion 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 become 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 Avith difficulty. Ophthalmia is a very frequent accompaniment of the secondary fever, and is almost always coincident Avith 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, 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 rigours, 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, very 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. DISEASES OF THE SKIN. 509 During the period of convalescence from an attack of small-pox, either strumous 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, af- fections 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 indicath-e 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 A-arious 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- pressed, and of a leaden or taAvny hue. At an early period, petechiae, 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 petechiae scattered between them. This variety has been termed the black pock (variola nigra.) In many cases, no ma- turation 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, A^ery 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 back 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 Avho have been vaccinated, or who had previously had the small-pox. That the dis- 510 DISEASES OF CHILDREN. 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 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 Avith 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 DISEASES OP THE SKIN. 511 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. 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- elusion. 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 mu- cous 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 had 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 512 DISEASES OF CHILDREN. 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- 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 DISEASES OF THE SKIN. 513 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, hoAvever, 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- mious diet, aqueous drinks, bleeding or purgation during the stage of incubation, diminishes the quantity of eruption. 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 system, and vitiate the blood, imparts to the small-pox an adynamic and malignant character; and this is one of the chief causes of the prevalence of the worst forms 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, Avhose 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 Avith 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, boAvels, &c, or to scrofulous or tubercular affections, will give rise to serious complications in those attackedwith 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. 33 514 DISEASES OF CHILDREN. Small-pox is unquestionably one of the most destructive diseases to Avhich 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- 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, Avas 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, Avhen small- pox occurs as an epidemic of wide extent, it is more violent and fatal, DISEASES OF THE SKIN. 515 and less under the control of remedies, than Avhen 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; Avhile 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, previously to the attack, the powers of life have been impaired by intemperate and licentious lives, or by exposure, bad food, and uncleanly habits, small- pox is very apt to assume an adynamic, haemorrhagic, or congestive character, and very generally terminates fatally. In persons of a ple- thoric habit, it very generally assumes an aggravated form, and is often fatal. A predisposition to scrofulous or tubercular disease, is very apt to render the sequelae of the disease particularly severe and unmanageable. When many patients are crowded together in a small space, even with the advantages of free ventilation, it always increases its malignancy, or endangers the occurrence of some fatal malacly during its 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 Ave have already seen, it 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. Gregory,) for taking small-pox, is from the seventh to the fourteenth year, when the poAvers of life are in full vigour, without the risk of plethora. This does not, however, conform with our own experience; we have met, almost invariably, w-ith 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 deaths took place are as follows:— Under one year 425 Between forty and fifty 121 Between one and two 262 " fifty and sixty 41 " two and five 452 " sixty and seventy 14 " five and ten 235 " seventy and hundred and ten 10 " ten and twenty 170 ---- " twenty and thirty 460 Total 2465 " thirty and forty 272 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, A'ibices, 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, 516 DISEASES OF CHILDREN. particularly at night, and symptoms of extensive gastro-enteric dis- ease. The favourable or unfavourable termination of the ease will, of course, be greatly influenced by the period of the attack at Avhich a judicious plan of treatment is commenced; and by the physician having 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 gangrene 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. 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 such cases, 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 per- sons 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 second- ary attacks, the disease was confluent, and terminated fatally. In no instance 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 breasts or arms of nurses who had previously had the disease, whilst taking 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, DISEASES OF THE SKIN. 517 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 dAvelling 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- 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 A-isccral 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 purgath-e 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 mattress, 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 Avill 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 employment, to an extent commensurate Avith 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 518 DISEASES OF CHILDREN. the eruption, to interfere with its regular progress, and to prevent its maturation. It has, hoAvever, under the circumstances referred to, recehred the sanction of many of the most distinguished practitioners, from the time of Sydenham to the present day. It is only, hoAvever, 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 Aoav, but never to the extent of inducing the slightest approach to syncope. In the more malignant forms of the disease, attended from the onset with evident depression of the vital poAvers, bleeding should never be resorted to: mild aperients may, nevertheless, be demanded, together with a free exposure to the fresh air,Avithout, hoAvever, alloAving 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, eAren 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 Avater gruel, Avith cool toast water, gently acidulated, for drink. In regard to ven- tilation, tepid sponging, &c, the same remarks Avill 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, Avhile, 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 bowels regular, by gentle purgatives; confining him, at the same time, to a spare unstimulatingdiet; 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, Avith a sharp, active pulse, the infusion of senna with the addition of sulphate of magnesia, or the compound powder of jalap, or magnesia and rhubarb, should be administered in such doses and intervals, as to produce free purgation, without, howeArer, irritating the bowels, or reducing, DISEASES OF THE SKIN. 519 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 Avould appear to possess peculiar powers in moderating the violence of the disease. Saline draughts in a state of efferArescence, or the liquor ammoniae acetatis, may be administered at short intervals; or, in cases unat- tended with 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. R.—Pulv. hydrochlor. ammonite, gr. xxxvj.—xlviij. " Ipecacuanhae, gr. iij. " Sacchar. pur. Qj.—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 Avarm 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. acaciae, giij. Or, R.—Pulv. ipecac, gr. iij. Syrup, scillaj, 3J. Magnesiae calc. gr. xxxvj. Spir. nitr. aeth. giij. Ext. hyoscyami, gr. vj.—viij. Vin. ipecac. 3J. M. f. ch. No. xij. Tinct. opii camph. £j.—M. One to be given every two or three hours. Dose, a teaspoonful every two or three hours. Or, R.—Vin. antimon. Ityx. Spir. aeth. nitr. Tfyxv. Tinct. opii camph. Ttyxv. Syrup, simpl. gss.—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 520 DISEASES OF CHILDREN. and painful to the touch, cooling lotions should be applied, or a few leeches upon the parts Avhere 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- lated 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 Avarm:—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 Avater, 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 poAvers of life, diffusible stimulants will be demanded; 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 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, to prevent pitting, and the permanent deformity thence resulting. It has been asserted by Velpeau and Meyreux, that if the pustules be opened on the first or second day of their appearance, and touched 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 surface with mercurial ointment. Dr. Stewardson, formerly physician to the Small-Pox Hospital at Bush Hill, instituted a number of experi- 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 DISEASES OF THE SKIN. 521 completely their perfect maturation, and diminishing the concomitant SAvelling and soreness; the process of desiccation being completed without the formation of thick scabs, and the resulting cicatrices being less marked than Avhen 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 Avater, preA-ious 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- ling the eruptions with the tincture of iodine, and relate several in- stances in Avhich abortion of the cutaneous affection was in this manner produced. The favourable results of either practice require confir- mation from a more extended series of observations. More recently the application of collodion to the pustules has been recommended as an effectual means of producing their abortion, and thus shortening the duration of the disease and preventing deformity. It has been employed to this intent by Dr. Brinkerhoff, of Pennsylvania, by Drs. Aran and Valleix, of France, by Drs. Storer and Bowditch, of Boston, Mass., all of whom speak favourably of its effects. Dr. Christen, Assistant Physician to the Prague General Hospital, has given to the local application of collodion a very full trial in small- pox; and the result of his observations has led him to believe that its employment is not merely useless, but also directly injurious; that when extensively applied, it exercises an unfavourable influence on the general course of the disease, by. suppressing the functions of the skin; and that by arresting the evaporation and confining a large amount of fluid matter, it promotes, in a great degree, the absorption of the pus, and thus favours that state of phyaemia Avhich is so apt to occur when the eruption is extensive. The period of desiccation, in the milder forms of small-pox, requires no particular treatment. The boAvels 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 ensues. 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 prin- ciples, 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 diaphoretics with minute doses of antimony, when these are not con- tra-indicated bv the condition of the digestive mucous membrane. 522 DISEASES OF CHILDREN. The occurrence of local disease will require the use of the remedies appropriate to the character and extent of the latter; while a state of positive adynamia will demand the cautious employment of stimu- lants and tonics. The same remarks will equally apply to the various sequelae of small-pox. In regard to the character of the remedies em- ployed, and the extent to Avhich they are to be carried, due attention must be paid to the greater or less degree of exhaustion, resulting from the preceding disease;—for though in many of the affections which occasionally occur subsequent to small-pox, depletion by the lancet, by cups or leeches, or by purgatives will be demanded, yet we 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 patient; the warm bath, or sponging with tepid salt and Avater, fol- lowed by friction of the surface, will frequently improve the digestion, invigorate the capillaries of the surface, render the functions of haema- tosis and nutrition more regular and perfect, and remove the danger of extensive disease of the glands, lungs, and serous membranes. As a means of rendering the small-pox milder and more manage- able, 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, 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 Avithout 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 DISEASES OF THE SKIN. 523 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 coav, and found that on those AA-hom he had infected Avith 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 became at once awakened to the subject; and although the introduc- tion of vaccination was at first violently opposed in different quarters, it Avas 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 Avith 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- Avise 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 variolce vaccinae, as he termed it,) and small-pox are identical in their nature,—the vaccine infection being only a milder form of inoculated small-pox. This opinion he ever after 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, af- fords hiin the same protection against the A-ariolous infection. This fact was early noticed by Reiter and Gassner, but for its full estab- lishment we are chiefly indebted to the more recent experiments of Theile, of Russia, 1836-8; of Ceely, of London, 1839; and of Martin, of Massachusetts, performed 1835, published 1841. In his first publication, Jenner announced his conviction, that the cow-pox, Avhen it has once passed in a perfect form through the hu- man body, leaves the constitution for ever after secure from the infec- tion of small-pox. This was, also, the opinion generally entertained by the phvsicians of Europe and America, until the year 1818. During this and the succeeding year, an epidemic small-pox pervaded Scot- land, and many persons avIio had been vaccinated were attacked with a mild form of the disease. The same thing occurred in the subse- 524 DISEASES OF CHILDREN. quent epidemics of small-pox which prevailed in various parts of Eu- rope, America, 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 Avho 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 vieAvs 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, in the greater number of cases, completely protected 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, hoAvever, 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 many instances, spurious matter may have been employed, and, in others, that which had undergone some change capable of impairing 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 unquestionably true. By some, however, it is maintained, that the sup- position of the vaccine matter, in general use, having become, in any degree 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 pre- cisely the same as those obtained from the use of matter more re- cently derived 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 constitutional symptoms more decided. 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 Ave 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 DISEASES OF THE SKIN. 525 impaired, as the individuals aa-Iio have been subjected to its influence, advance in age, until, finally, they become anew susceptible to the contagion of small-pox. Brown, of Edinburgh, Gregory, of London, Mold, 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 protection against the occurrence of small-pox, which is unimpaired with the lapse of time. The question as to the propriety and advan- tage of revaccination is, nevertheless, a very important one. That among a given number of those who have been apparently success- fully vaccinated, there will be found many, in whom, from some cause not well ascertained, a greater or less degree of susceptibility to variolous infection is left unextinguished, and which susceptibility aug- ments in time, is a fact that would appear to be well established; and such individuals will be found to be, also, susceptible to re-infection by the vaccine virus. Now, the question presents itself, Will it be possible, by subjecting such persons to revaccination, to protect them from an attack of small-pox? In order to test this question, re-vacci- nation 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 498,325 revaccinations performed by different individuals in Europe and this country: in about 37 per cent, of these the revaccination is stated to have been successful; while in 81,252 cases, in which a second revaccination was performed, in about 11 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 in- dividuals 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 526 DISEASES OF CHILDREN. 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, notAvith- standing it has been repeatedly subjected to its influence. To the re- port for 1841, we find attached the following important statement: The poAverful influence of revaccination, in the diminution of vario- lous 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 A-aricella. 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, avIio had not been revaccinated; and the third, in a non-commissioned officer, who had been revaccinated some years before, but Avithout 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- 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 symp- toms 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 poAver 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. DISEASES OF THE SKIN. 527 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 epi- demic of small-pox. At a recent meeting of the London Epidemiological Society, Dr. Waller Lewis read a highly interesting and valuable paper on the Re- lations of Vaccination and Inoculation to Small Pox. From the facts and cases adduced by him the author drew the following gene- ral conclusions, which correspond with those at which we had pre- A'iously arrived from the results of our own observations. 1. That vaccination is a most eminent protection against small-pox. 2. That when perfectly performed it is almost, and, in some instances. more protective than inoculation or small-pox itself. 3. That it appears to render some exanthemata, as, for example, measles, milder than they would have been otherwise. 4. That neither vaccination, inoculation, nor small-pox, guaranty the individual in every instance from small-pox. 5. That small-pox attacks some persons three times, or oftener. 6. That there exist certain individuals who have perfect immunity from vaccination, inoculation, and small-pox. 7. That great susceptibility to, or perfect immunity from, small-pox, is sometimes found to be common to several members of the same family. 8. That sanatary conditions have a very powerful effect on the spread of small-pox in common with other epidemics. It appears, Dr. LeAvis remarks from the cases adduced by him, and the deductions therefrom, that the laws which regulate the apparent mysteries of small-pox are as follow:— A. Small-pox is a disease to which almost every person is liable once in his lifetime unless protected. B. But there is a small fraction of the community who appear to enjoy an exemption from this law, no degree of exposure, either to vaccination, inoculation, or casual small-pox, causing them to take vaccinea or variola. C. That there is a certain portion, on the other hand, in the exactly opposite condition. These individuals, whose systems appear to pre- sent a soil peculiarly favourable to the development and spread of small-pox virus, are eminently susceptible of the disease. It is to this class that those persons belong who have repeated attacks of variola; who take small-pox after being inoculated or vaccinated. For such persons there is no safety but in repeated vaccination. D. And lastly, that between this latter class, and that favoured portion of the community that possess perfect immunity, there exists every shade and degree of susceptibility. These laws explain the apparent inconsistency in the views held 528 DISEASES OF CHILDREN. respecting the protective powers of A-accination. Thus, all those indi- viduals, forming an enormous majority of mankind, Avho possess an ordi- nary, moderate degree of liability to small-pox, are completely guarded against the influence of small-pox virus, either by perfect vaccination, inoculation, or a previous attack of small-pox; while others, who have a much greater susceptibility, will be protected by neither one nor the other. Phenomena of vaccination.—On the third day after the insertion of the matter in the arm, there appears, at the point Avhere the matter Avas 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 someAvhat flattened, and with a small de- pression in the centre, rather darker than the rest of its surface. It continues to enlarge in circumference, but not so much in elevation, until the eighth day, when it is at its height. Its margin is then tur- gid and prominent, and it contains a greater or less amount of fluid. When closely examined, the vesicle exhibits acellulated 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 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 cir- cumference ; 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 cir- cumference, but still adheres at the centre, and does not fall off until between 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- DISEASES OF THE SKIN. 529 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 Avhich 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, Avithout 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 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 in- fection 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 immedi- ately after birth, and that it succeeds equally well at whatever age the matter is inserted. At a discussion upon this subject before the Mcdico-Chirurgical Society of London, Dr. Gregory gave it as his opinion, that, provided a good vesicle and areola Avere 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 34 530 DISEASES OF CHILDREN. of infantile life vaccination can be practised, so as most certainly to 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 susceptibility in the patient, but from the difficulty of inserting the lymph properly: this difficulty is more or ^ess present until about the fourth month, and hence, this is the period usually chosen; for not only is the arm then generally plump, but there are, also no contend- ing influences, such as teething, present. Mr. Ceely agreed, in the main, with Dr. Gregory. It was stated by Dr. T. Thompson, at a dis- cussion before the Medical Society of London, that at the Foundling 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 as from the result of our own experience, we should be inclined to agree with Dr. Gregory, as to the proper period for vaccination, when there exists no urgent necessity for its more early performance. We 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 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 per- formance of the operation; nor, when a disease of a genuine charac- ter is produced, is any medical treatment necessary during its pro- gress, 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 pro- duced in the character and progress of the vaccine infection, as to de- stroy its prophylactic powers: this, however, is denied by Capuron, Avhile Valentin and Husson assert, that the vaccine infection has the effect of completely 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 dis- ease 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 revaccination. 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 Avinter have been moderated by the influence of spring, or until the heat of summer has given way to the coolness of autumn. DISEASES OF THE SKIN. 531 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 the 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 presented; 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. 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- nicated by it will seldom be found genuine, while the virus obtained from children labouring under cutaneous affections is supposed to en- 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; 532 DISEASES OF CHILDREN. 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 Ave invariably practise, and which we first proposed thirty years ago, 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 in- cisions 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 operation, 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 in- cisions, 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, previously 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, that is by no means beneath the notice of the practitioner. Subsequent to vaccination, the arm should be guarded from irrita- 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 de- pendence 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 DISEASES OF THE SKIN. 533 be 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 cica- trices ^ 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 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 varfoloid affections, during the last thirty 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. 534 DISEASES OF CHILDREN. Soon after the introduction of vaccination, it was noticed that some of those who had undergone the disease, were attacked Avith a vesicu- lar eruption, of a very mild character: this, hoAvever, 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 Avas fully established. The true character of the varioloid affections is noAv very generally recognised. Upon examining, with attention, the whole of the facts connected Avith 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 attri- buting to one common origin the entire family of vesicular and pus- tular 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 modifications 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 diminished. The several eruptions alluded to, run into each other by almost 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, 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 prac- tical results. Confining ourselves, therefore, to the varioloid affec- tion as it occurs in persons who have been vaccinated, we shall pre- sent 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 consider- able 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, un- less 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 some 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, DISEASES OF THE SKIN. 535 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, w-hich 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 Aveek, or even longer. Occasionally, the fluid contained in the vesi- cles retains its serous character for four or five days, and then be- comes puriform: in Avhich state it may remain for several days, be- fore the desiccation 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 be even 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- 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 Avere attached, small red disks, or slight eleva- tions, 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 avIio have been vaccinated more or less perfectly; and others, again, Avho 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 cha- racter of the disease will be that of discrete or confluent variola, varying only in intensity. In a" few instances, hoAvever, Ave shall meet with cases of varioloid eruption, closely resembling chicken-pox, in the unprotected. It is this latter circumstance Avhich gave rise to the doctrine of the vario- loid disease being the result of a peculiar contagion, altogether dis- tinct from that of small-pox; the occurrence of the tAvo diseases during 536 DISEASES OF CHILDREN. 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 individuals, 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 pa- tient to his chamber; Avhile others are marked by symptoms Avhich occasionally call for the employment of bloodletting; in general, how- ever, all that is necessary will be, rest, a cooling regimen, a spare, unirritating 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 maybe 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 gene- rally appears 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 general erythematous efflorescence, and is accompanied, in most cases, by a disagreeable tingling or itching of the skin. The erup- tion of veeicles 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 ad- vanced, 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 con- tain a limpid serum; on the second day, they are more distended, sur- DISEASES OF THE SKIN. 537 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 ap- pearance. The scabs generally separate in four or five days; those containing purulent matter leaving pits in the skin. A fresh crop of vesicles usually appears on the second and third days, each crop run- ning the same regular course;—the eruptive stage is consequently prolonged 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, Avhich 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 Avhiter 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 occa- sionally grow within the latter, while according to Heiin, they never do in those of the former. Varicella rarely occurs more than once in the same individual. It may appear sporadically, but generally prevails as an epidemic of nioderate 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. By Vidius, Senertus, Riverius, Morton, Sydenham, Harvey, Mead, Hoffman, and most of the earlier writers, the disease was considered to be a spurious or bastard form of variola; while, by subsequent wri- ters, 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 independence of varicella and variola, with few exceptions, was adopted by the profession generally, until about the year 1816, when the discussion 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. To disprove the common qrigin of varicella and small-pox, the fol- lowing arguments have been adduced: 1st. That the symptoms of va- ricella are peculiar and distinctive, and run ahvays a regular course peculiar to that disease. 2d. That small pox often occurs without va- ricella, and varicella independent of small-pox. 3d. That varicella occurs equally, and with the same characteristic symptoms, in those who have had the small-pox, in those Avho have been vaccinated, and 538 DISEASES OF CHILDREN. in those 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, Avhen 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 Avhich 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 sporadic cases of it would frequently occur, occasionally indepen- dently 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 erup- tion has been known to differ materially, it is not unreasonable to sup- pose 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 Thomp- son, occurs much more frequently in those who have been variolated or vaccinated, than in the unprotected; while its symptoms differ ma- terially 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 intense 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 asserted by Reil, that small-pox is generally much milder when it occurs subsequent to a severe attack of varicella, than when it occurs in those who have not been affected with the latter disease. 5th. Varicella, like small-pox, according to Willan, Bateman, Thomp- son, and Heim, is capable of being communicated by inoculation. 6th. The fact of its more frequent occurrence since the general introduc- tion of vaccination, is an evidence in proof of varicella being but a modification of small-pox. Previously there was a more general sus- ceptibility to the genuine forms of variola, Avhereas now, by the ge- neral practice of vaccination, Avhole communities are, in a great mca- DISEASES OF THE SKIN. 539 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-Avhite colour —of a somewhat moist consistence, and easily broken or crushed. When broken it exhibits a someAvhat 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 in- clude 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 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 tra- versed by small vessels. The miliary tubercles and yellow infiltration very often, after a time, become confounded; the first, by agglomeration, forming large masses, when they can be distinguished from the latter only by the presence 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 beneath 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 ves- sel. 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 parenchyma of the organ. Their substance is usually homo- geneous; occasionally, however, a black point exists in their centre, —or they are surrounded by a circle of black matter, disposed in very fine ramifications. 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 between the miliary tubercles, in the form of a fine gelatinous infil- tration, either colourless or sanguinolent. The yellow granulation is a small body, softer, and of a clearer yel- Ioav colour than the crude tubercle. It has the appearance of a false ISEASES OF THE NUTRITIVE FUNCTION. 611 d^SSf™ «, Can-n+° be br,°ken orcrushed under the nail. Its form ?ne,;t« \G res!stance of the tissue in which it is developed; thus, n hP EwY I tiSSUeS lt is rounded'in the serous> lenticular heshie ofrt r°rd-f °nT ^e Side of the brain> and flatt«ned on tissues bv 1 ^aChl°ld; J* '5 in™ria% B^rounded, in the serous e therdSmnt f? ?f blood-vessels- These granulations occulf either distinct from each other, or united in small groups. a formoVtnt 1 ?Z describe'. un<*er the name of tuberculous dust, JZ^ of t.ube/cuVa*10n' occurring under the appearance of numer- ous very minute white or yellow points, not sufficiently close together to constitute a continuous yellow surface, but strewed throughout the tissue, which is almost invariably invaded by an acute or chronic inflammation, sometimes by gray infiltrations. According to Rilliet and Barthez, the origin of the yellow tuber- culous matter is either, -^ ei 1st. The gray granulation, which passes into the yellow granula- tion, and afterwards into the miliary tubercle, or yellow infiltration. I he gray granulation may also pass into the gray infiltration. M. the gray infiltration, which gives birth indifferently to the yellow granulation the miliary tubercle, or the yellow infiltration. infiltr ti erculous dust' which ma7 be the origin of the yellow 4th. The yellow granulation, which may appear originally. 5th. Ihe 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. m 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 tubercu- lous 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 soft- ening 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 oc- 612 DISEASES OF CHILDREN. casioned 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 disor- ganization 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, 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 child- ren, we find, occasionally, all the organs studded with small, gray granulations, which, if united in one organ, would form a consider- able 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 pre- sent in several organs, causing at times a degree of disorganization which is surprising. These three forms may be partial or general, —the latter most frequently partial, the others more usually gene- ral. 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 Avould appear, however, to predispose it to the occurrence of inflammation of a sub- acute character, and of Avhich 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 Ave have met with them after death, in cases in Avhich, 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. DISEASES OF THE NUTRITIVE FUNCTION. 613 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 extremities, or scrotum. Usually, in the course of protracted cases, hectic fever occurs, with circumscribed redness of the cheeks, eve- ning 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 Avas com- 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 considerably, 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, Avhich 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 intermittent. 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 614 DISEASES OF CHILDREN. 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 considerable degree of development, without acting on the sur- rounding 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; while 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 are superadded to the rational signs of phthisis, we can have little hesitation 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 Avhich 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 de- cide 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 com- plications 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. There is an important modification that should guide the practi- tioner when he seeks to determine the existence of a cavern in young children, 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 DISEASES OF THE NUTRITIVE FUNCTION. 615 the lungs. Haemoptysis is hence an exceedingly rare symptom. The phenomena 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 to be most common between the third and seventh years. " In thirty-four cases noticed by Barrier, sixteen were under five years, thirteen from five to ten, and five only from ten to fifteen years. Of Dr. Green's thirty cases, in thirteen it occurred between two and four years; and in seventy- five cases, he states that it occurred most frequently in children from three to seven years. Of Rilliet and Barthez's twelve cases, six were from three to five years; four from six to ten and a half; and two from eleven to fifteen years, and eight were boys. Dr. Mauthner found, in seventeen out of thirty-two, that the age did not exceed six years, Avhich was the case in seven out of eight cases observed by Dr. West." (Churchill.) The sex of the child does not appear to have any influence in the production of the disease. The majority of Dr. Green's cases were females; the majority of Rilliet and Barthez's cases males. In many instances they give rise to no symptom during life; in others, merely to a periodical headache or to deafness, combined Avith purulent discharges from the ear. The most common symptoms, how- ever, to which tuberculous depositions in the brains of children give rise, are headache, vomiting, convulsions, amaurosis, paralysis, and diminution of the intellectual faculties. Death generally takes place from acute hydrocephalus, softening of the brain, consumption 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 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: they recur on each exacerbation of the pain, and are independent of any disorder of the digestive organs. Consti- pation 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 paralysis of one or more of the limbs; in other cases, we have merely a weakness of certain muscles, not amounting to paralysis—the child 616 DISEASES OF CHILDREN. stumbles as it walks, and progression is much impeded; particular muscles, also, may be affected; thus, there may be a peculiar convul- sive moA-ement 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 stand- ing, 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 fol- lowed by a peculiar rotary motion of the head, and in others, by squinting, and a lateral motion of the lower jaw. According to Green, the convulsive attacks are rarely attended with either vomiting or constipation; our own observations would, however, lead us to a diffe- rent conclusion: 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 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 substance 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 tuber- culation of the meninges, producing a marked influence upon the general symptoms of the case. The tubercles are often single, often numerous; twenty to fifty have been observed by Green in one brain; but by Rilliet 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 neryous 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. DISEASES OF THE NUTRITIVE FUNCTION. 617 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 injec- tion, 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 ventricles, which it distends; and traversing the ventri- cular membrane, infiltrates and softens the cerebral substance. In a feAv rare examples, on the contrary, Green describes the surround- ing 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 tuber- cle, is rarely, if ever, observed. 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 suc- ceed to acute or chronic affections of the gastro-intestinal mucous membrane, 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, imper- fectly performed:—if the whole of the organic functions are inactive; it is evident that our endeavours should be entirely directed to im- prove 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 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 influence 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 exercise, cleanliness, and proper clothing, in conjunction with a due regulation of the moral and intellectual powers, when sufficiently early resorted to, the most prompt and decided benefit will be inva- riably derived; and without their influence, under no circumstances can we expect to prevent the inroads of painful and destructive dis- ease, 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 tem- perament with languid circulation, and a predominance of the white fluids and tissues, they become doubly important; their neglect will 618 DISEASES OF CHILDREN. 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 nu- trition more active and healthy. We have, in the commencement of the present treatise, entered, with sufficient minuteness, into a consideration of the hygienic ma- nagement of children, to render it unnecessary, in this place, to go into further 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 invasion 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 spe- cies of animal food, and the manner in which it is cooked, require, also, to be attended to. Beef, mutton, venison, chicken, 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 occasionally 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, 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 pur- pose 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 par- taken 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 sup- posed 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. DISEASES OF THE NUTRITIVE FUNCTION. 619 By most of the English physicians, an occasional glass of good beer, porter or wine is recommended, but to this we must positively ob- ject. Alcoholic drinks, whether fermented or distilled, are not, in any degree, calculated to promote digestion, nor to improve the nu- trition 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 advantages of a fresh and pure air may be afforded it by proper ven- tilation, the strictest attention to domestic cleanliness, and by guard- ing against over-crowded apartments, by night as well as by day. Where we can command it, the atmosphere of a dry elevated situa- tion 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, with scarcely a boy among them, and this, from the cir- cumstance 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 Avith exercise; but it can never supply fully the place of the latter, Avhen taken in a pure fresh atmosphere. For young children, the usual sports of their age—riding occasion- ally in an open carriage—short Avalks 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 in- nocent 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 sustain the regular actions of the cutaneous exhalants. The Avarm bath should be employed Avhen the temperature of the surface is deficient, with considerable 620 DISEASES OF CHILDREN. languor of the circulation; but in patients possessed of greater vi- gour, and in Avhom the temperature of the skin is better maintained, the tepid bath may be substituted. Sponging the surface Avith tepid water, or with salt and water, followed by brisk friction, will also be 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 six- teen or twenty minutes; after which friction to the skin may be em- ployed, 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 cir- cumstances under which the reaction it gives rise to invariably oc- curs. To immerse a weakly child in cold water, Avould 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 win- ter, 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 re- moved. When there exist 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 hand3 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 EASES OF THE NUTRITIVE FUNCTION. 621 noHnl; Un^i ! U-SG We have known the h*alt* and strength of the mpnhS !'l! f W™™, and his attenuated limbs to become aug- tho llrZtt ' an? lnc]reased in fi™ness. Of course, the doses Sf be JK3pJ ! e«P oyed, and the frequency of their repetition, must sa: ^rc^1^^ °f the c™ the diseased surface, has been recommended by Dupuytren and Iiynd: 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 occurrence, that no winter passes without our seeing a number of children who have suffered from them. They occasionally happen under circum- stances 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 Avere 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 great variety in the character and extent of these accidents, which require 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 integumeuts 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, com- plains 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 poAvers, which con- tinues for some time before reaction takes place; while, in other cases, no reaction whatever takes place; the patient falls into a deep coma- tose sleep, from which he never awakes. The danger in burns is ahvays in proportion to their extent, taken in connexion with their depth;—but 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. AVhen nothing else is at hand, the common potato, scraped or mashed 714 DISEASES OF CHILDREN. 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 the 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. AVhen 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 sub- sides, when, as well as in cases in which the ulceration of the skin is unattended with any considerable degree of inflammation, the parts may be dressed with the ceratum oxyd. zinci, or the simple cerate, intimately 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 surrounding 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 i drawing of the latter out of their proper place; for one of the peculiari- ties of the cicatrices of burns is, the formation of firm, elevated ridges, CONGENITAL AFFECTIONS, ETC. 715 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 prevent this occurring to a certain degree; nevertheless, the extent of the deformity may be greatly diminished by proper care and at- tention. AVhen the burn is seated upon the hand or foot, or in the vicinity of the ear, caution must also be observed to prevent the un- natural 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 fun- gous granulations very commonly takes place; nor is it possible en- tirely to restrain them by the application of pressure, caustics, or other escharotics. The first, however, we have found, in general, the most successful; 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 adhesive strips and bandage will answer 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 application. 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, shiA-er 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, com- bined, may be 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 character, 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. V LIST OF AUTHORS AND WORKS REFERRED TO. Abkrle. De Tussi Convulsiva. Vindobona, 1843. Abercrombie. On the Nature and Origin of Tubercular Disease. Edinburgh Medico- Chirurgical Transactions, vol. i. Albers. De Tracheitide Infantum. Berlin, 1816. Alibert. Description des Maladies de la Peau. Paris, 1814. Alibert. Precis Theorique et Pratique sur les Maladies de la Peau. Paris, 1810. Alderson. On the Pathology of Hooping-Cough. London Medico-Chirurgical Trans- actions, 1830. Alison. On the Pathology of Scrofulous Diseases. Edinburgh Medico-Chirurgical Transactions, vol. i. Andry. Memoire sur les Maladies du Foetus et ses Annexes. Journal des Progres, 1830. Archer. A Treatise on Croup. Philadelphia, 1798. Armstrong, G. On the Diseases most fatal to Infants. London, 1767. Armstrong. Practical Illustrations on the Scarlet Fever, Measles, and Pulmonary Consumption. London, 1818. Asiiburner, J. On Dentition and some Coincident Disorders. London, 1834. Atlee, E. P. Observations on the use of Hydrocyanic Acid in Hooping-Cough. American Journal of the Medical Sciences, 1832. Autenrieth. Versuche fur die Praktische Heilkunde. Gbttingen, 1768. Babington, B. G. On Chorea. Guy's Hospital Reports, 1841. Badham. Essay on Bronchitis. London, 1814. Bailly and Legendre. Nouvelles Recherches sur quelques Maladies du Poumon. Ar- chives Generates de Medecine, 1844. Bampfield. Essay on Curvatures and Diseases of the Spine. London, 1824. Bard. Inquiries into the Nature and Treatment of Angina Suffocans. New York, 1771. Barnard. Cases of Chronic Hydrocephalus. London, 1839. Baron. Memoire sur une Affection de la Bouche. Bulletin de la Faculte de Medecine, 1816. Baron, Ch. De la Pleurisie dans L'Enfance. Paris, 1841. Barrier, F. Traite Pratique des Maladies de l'Enfance. Paris, 1815. Bateman. A Practical Synopsis of Cutaneous Diseases. London, 1814. Battersby. On Hare Lip. Dublin Quarterly Journal of Med. Sciences, 1846. Baumes. Memoire sur le Traitement de la Maladies Scrofuleuse. Paris, 1805. Baumes. Traite de l'Ictere, ou Jaunesse des Enfans. Paris, 1805. Baumes. Traite des Convulsions dans l'Enfance. Paris, 1805. Beck, J. B. Essays on Infantile Therapeutics. New York, 1849. Becquerel. Recherches Cliniques sur la Meningite des Enfans. Paris, 1845. Bednar. Die Krankheiten der Neugebornen und Sauglinge. Wein, 1850. Bell, Luther V. An attempt to investigate some obscure and undecided Doctrines in relation to Small-pox, Varioloid, and Vaccination. Boston, 1836. Beurend. On the Periodic Nocturnal Cough of Children. Journal der Kinderkrank- Aet'mPtom8> ! We venture to predict that the work will be de- Wlncri riaveiullen to the lot of but few, either in 8ervedlv nnnnlar »ml soon become like Watson's h-i own or any other country. He has'carefully , p'S anPinu soens-fblenecesshv tothe D«£ti- systemat.zed the results of his observation of over , JiOTer —!lV A Med Journal AM twelve thousand patients, and by his diligence and uoner—N- A- md Journal, April, 1X58. judicious classification, the profession has been An inestimable work of reference for the young presented with the most convenient and reliable practitioner and student.—Nashville Med. Journal, work on the subject of Diagnosis that it has been our good fortune ever to examine; we can, there- fore, say of Dr. Barclay's work, that, from his sys May, 1858. We hope the volume will have an extensive cir- culation, not among students of medicine only, but tematic manner of arrangement, his work is one of ; practitioners also. "They will never regret a faith the best works "for reference" in the daily emer- j ful study of its pages.— Cincinnati Lancet. Mar. '58. geneies of the practitioner, with which we are ac- quainted ; but, at the same time, we would recom- mend our readers, especially the younger ones, to read thoroughly and study diligently the whole work, und the "emergencies" will not occur so often.— Southern Med. and Surg. Journ., March, 1858. To give this inf irmation, to supply this admitted porter, March, 1858 This Manual of Medical Diagnosis is one of the most scientific, useful, and instructive works of its j kind that we have ever read, and Dr. Barclay has i done good service to medical science in collecting, ' arranging, and analyzing the signs and symptoms 1 of so many diseases. — N. J. Med. and Surg. Re- BARLOW* (GEORGE H.), M. D. Physician to Guy's Hospital, London, Ice. A MANUAL OF THE PRACTICE OF MEDICINE With Additions by D. F. Condie, M. D., author of "A Practical Treatise on Diseases of Children," &c. In one hand- some octavo volume, leather, of over 600 pages. $2 75. We recommend Dr. Barlow's Manual in the warm- est manner as a most valuable vade-mecum. We have had frequent occasion to consult it, and have found it clear, concise, practical, and sound. It is eminently a practical work, containing all that is essential, and avoiding useless theoretical discus sion. The work supplies what has been for some time wanting, a manual of practice based upon mo- dern discoveries in pathology and rational views of treatment of disease. It is especially intended for Uie use of students and junior practitioners, but it will be found hardly less useful to the experienced physician. The American editor has added to the work three chapters—on Cholera Infantum, Yellow Fever, and Cerebro-spinal Meningitis. These addi- tions, the two first of which are indispensable to a work on practice destined for the profession in this country, are executed with great judgment and fi- delity, by Dr. Condie, who has also succeeded hap- pily in imitating the conciseness and clearness of style which are such agreeable characteristics of the original book.—Boston Med. and Surg. Journal. BARTLETT (ELISHA), M. D. THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS OF THE UNITED STATES. A new and revised edition. By Alonzo Clark, M. D., Prof. of" Pathology and Practical Medicine in the N. Y. College of Physicians and Surgeons, &c. In one octavo volume, of six hundred pages, extra cloth. Price $3 00. It is the best work on fevers which' has emanated i logy. His annotations add much to the interest ot from the American press, and the present editor has ! the work, and have brought it well up to the condi- carefully availed himself of all information exist- [ tion of the science as it exists at the present day ing upon the subject in the Old and New World, so | in regard to this class of diseases.—Southern Med. that the doctrines advanced are brought down to the and Surg. Journal, Mar. 1857. latest date in the progress of this department of | it is a work of great practical value and interest Medical Science.—London Med. Times and Gazette, i containing much that is new relative to the several May 2, 1857. diseases of which it treats, and, with the additions This excellent monograph on febrile disease, has j of the editor, is fully up to the times. The distinct- stood deservedly high since its first publication. It ivefeaturesof the different forms of fever are plainly will be seen that it has now reached its fourth edi- | and forcibly portrayed, and the lines of demarcation tion under the supervision of Prof. A. Clark, a gen- carefully and accurately drawn, and to the Ameri- tleman who, from the nature of his studies and pur- ! can practitioner is a mora valuable and safe guide suits, is well calculated to appreciate and discuss | than any work on fever extant.—Ohio Med. and the many intricate and difficult questions in patho- I Surg Journal, May, 1857. BROWN (ISAAC BAKER), Surgeon-Accoucheur to St. Mary's Hospital, &c. ON SOME DISEASES OF WOMEN ADMITTING OF SURGICAL TREAT- MENT. With handsome illustrations. One vol. 8vo., extra cloth, pp. 276. $1 60. Mr Brown has earned for himself a high reputa- and merit the careful attention of every surgeon- tion in the operative treatment of sundry diseases j accoucheur.—Association Journal. We Sn^^KsT» ™ S2S -ommending this book ^SSryob.£t,i«l literature. The operative | ?J&e^^«^^uS*«£m addition to obstetrical »>"""" v- —t . .„__„-„ ,.Pu;„i, xi- R.,.,.r„ Ho lemaie complaints a parcoi i 6 BLANCHARD de LEA'S MEDICAL CARPENTER (WILLIAM B.), M. D., F. R. S., Sec, Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applicationa fco Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. A new Americun, from the last and revised London edition. With nearly three hundred illustrations. Edited, with addi- tions, by Francis Gurney Smith, M. D., Professor ofthe Institutes of Medicine in the Pennsyl- vania Medical College, &c. In one very large and beautiful octavo volume, of about nine hundred large pages, handsomely printed and strongly bound in leather, with raised bands. $4 25. In the preparation of this new edition, the author ha* spared no labor to render it, as heretofore, a complete and lucid exposition ofthe most advanced condition of its important subject. The amount ofthe additions required to effect this object thoroughly, joined to the former large size oi the volume, presenting objections arising from the unwieldy bulk of the work, he has omitted all those portions not bearing directly upon Human Physiology, designing to incorporate ihem in his forthcoming Treatise on General Physiology. As a full and accurate text-book on the Phy- siology of Man, the work in its present condition therefore presents even greater claims upon the .-tudent and physician than those which have heretofore won for it the very wide and distin- guished favor which it has so long enjoyed. The additions of Prof. Smith will be found to supply wha.ever may have been wanting to the American student, while the introduction of many new illu>trations, and the most careful mechanical execution, render the volume one of the most at- tractive as yet issued. For upwards of thirteen years Dr. Carpenter's I To eulogize this great work would be superfluous work has been considered by the profession geno- We should observe, however, that in this edition rally, both in this country and England, as the most j the author has remodelled a large portion of the valuable compendium on the subject of physiology j former, and the editor has added much matter of in- in our language. This distinction it owes to the high terest, especially in the form of illustrations. We attainments and unwearied industry of its accom- may confidently recommend it as the most complete filished author. The present edition (which, like the ast American one, was prepared by the author him- self), is the result of such extensive revision, that it may almost be considered a new work. We need hardly say, in concluding this brief notice, that while the work is indispensable to every student of medi- cine in this country, it will amply repay the practi- tioner for its perusal by the interest and value of its contents.—Boston Med. and Surg. Journal. This is a standard work—the text-book used by all medical students who read the English language. It has passed through several editions in order to keep puce with the rapidly growing science of Phy- siology. Nothing need be said in its praise, for its merits are universally known; we have nothing to say of its defects, for they only appear where the science of which it treats is incomplete.—Western Lancet. The most complete exposition of physiology which any language can at present give.—Brit, and For. Med.-Chirurg. Review. The greatest, the most reliable, and the best book on the subject which we know of in the English language.—Stethoscope. work on Human Physiology in our language.— /Southern Med. and Surg Journal, December, 1855. The most complete work on the science in our language.—Am. Med. Journal. The most complete work now extant in our lan- guage.—N. O. Med. Register. The best text-book in the language on this ex- tensive subject.—London Med. Times. A complete cyclopaedia of this branch of science. —iV. Y. Med. Times. The profession of this country, and perhaps also of Europe, have anx iously and for some time awaited the announcement of this new edition of Carpenter's Human Physiology. His former editions have for many years been almost the only text-book on Phy- siology in all our medical schools, and its circula- tion among the profession has been unsurpassed by any work in any department of medical science. It is quite unnecessary for us to speak of this work as its merits would justify. The mere an- nouncement of its appearance will afford the highest pleasure to every student of Physiology, while its perusal will be of infinite service in advancing physiological science.—Ohio Med. and Surg. Jomm. by the same author. (Lately Issued.) PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New American, from the Fourth and Revised London edition. In one large and handsome octavo volume, with ovei three hundred beautiful illustrations, pp. 752. Extra cloth, $4 80; leather, raised bands, $5 25. The delay which has existed in the appearance of this work has been caused by the very thorough revision and remodelling which it has undergone at the hands ofthe author, and the large number of new illustrations which have been prepared for it. It will, therefore, be found almost a new work, and fully up to the day in every department of the subject, rendering it a reliable text-book for all students engaged in this branch of science. Every effort has been made to render it* typo- graphical finish and mechanical execution worthy of its exalted reputation, and creditable to the mechanical arts of this country. This book should not only be read but thoroughly studied by every member of the profession. None are too wise or old, to be benefited thereby. But especially to the younger class would we cordially commend it as best fitted of any work in the English language to qualify them for the reception and com- prehension of those truths which are daily being de- veloped in physiology.—Medical Counsellor. Without pretending to it, it is an encyclopedia of the subject, accurate and complete in all respects— a truthful reflection of the advanced state at which the science has now arrived.—Dublin Quarterly Journal of Medical Scienct. A truly magnificent work—in itself a perfect phy- siological study.—Ranking's Abstract. This work stands without its fellow. It is one few men in Europe could have undertaken; it is one no man, we believe, could have brought to so suc- cessful an issue as Dr. Carpenter, ft required for its production a physiologist at once deeply read in the labors of others, capable of taking a general, critical, and unprejudiced view of those labors ana of combining the varied, heterogeneous materials at his disposal, so as to form an harmonious whole. We feel that this abstract can give the reader a very imperfect idea of the fulness of this work, and no idea of its unity, of the admirable manner in which material has been brought, from the most various sources, to conduce to its completeness, of the lucid- ity of the reasoning it contains, or of the clearness of language in which the whole is clothed. Not the profession only, but the scientific world at largo, must feel deeply indebted to Dr. Carpenter for this treat work. It must, indeed, add largely even to is high reputation.—Medical Times. AND SCIENTIFIC PUBLICATIONS 7 CARPENTER (WILLIAM B.), M. D., F. R. S., Examiner in Physiology and Comparative Anatomy in the University of London. THE MICROSCOPE AND ITS REVELATIONS. With an Appendix con- taining the Applications of the Microscope to Clinical Medicine &c. By F. G. Smith, M. D. Illustrated by tour hundred and thirty-four beautiful engravings on wood. In one large and verj- handsome octavo volume, of 724 pages, extra cloth, $4 00 ; leather, $4 50. Dr. Carpenter's position as a microscopist and physiologist, and his great experience as a teacher eminently qualify him to produce what has long been wanted—a good lexi-book on the practical use of the microscope. In the present volume his object has been, as stated in his Preface, << to combine, within a moderate compass, that information with regard to the use of his ' tools,' which is most essential to the working microscopist, with such an account of the objects best fitted for his study, as might qualify him to comprehend what he observes, and might thus prepare him to benefit science, whilst expanding and refreshing his own mind " That he has succeeded in accom- plishing this, no one acquainted with his previous labors can doubt. The great importance of the microscope as a means of diagnosis, and the number of microsco- pists who are also physicians, have induced the American publishers, with the author's approval, to add an Appendix, carefully prepared by Professor Smith, on the applications of the instrument to clinical medicine, together with an account of American Microscopes, their modifications and accessories. This portion of the work is illustrated with nearly one hundred wood-cuts, and, it is (toped, will adapt the volume more particularly to the use of the American student. Every care has been taken in the mechanical execution of the work, which is confidently pre- sented as in no respect interior to the choicest productions of the London press. The mode in which the author has executed his intentions may be gathered from the following condensed synopsis of the CONTENTS. Introduction—History of the Microscope. Chap. I. Optical Principles of the Microscope. Chap. II. Construction of the Microscope. Chap. III. Accessory Apparatus. Chap. IV. Management of the Microscope Chap. V. Preparation, Mounting, and Col.ection of Objects. Chap. VI. Microscopic Forms of Vegetable Life—Protophytes. Chap. VII. Higher Cryptoga- mia. Chap. VIII. Phanerogamic Plants. Chap. IX. Microscopic Forms'of Animal Life—Pro- tozoa—Animalcules. Chap. X. Foraminifera, Polycystina, and Sponges. Chap. XI. Zoophytes. Chap. XII. Echinodermata. Chap. XIII. Polyzoa and Compound Tunicata. Chap. XIV. Molluscous Animals Generally. Chap. XV. Annulosa. Chap. XVI. Crustacea. Chap. XVII. Insects and Arachnida. Chap.XVIII. Vertebrated Animals. Chap. XIX. Applications of the Microscope to Geology. Chap. XX. Inorganic or Mineral Kingdom—Polarization. Appendix. Microscope as a means of Diagnosis—Injections—Microscopes of American Manufacture. Those who are acquainted with Dr. Carpenter's previous writings on Animal and Vegetable Physio- logy, will fully understand how vast a store of know- ledge he is able to bring to bear upon so comprehen- sive a subject as the revelations of the microscope ; and even those who have no previous acquaintance with the construction or uses of this instrument, will find abundance of information conveyed in clear and simple language.—Med. Times and Gazette. Although originally not intended as a strictly medical work, the additions by Prof. Smith give it a positive claim upon the profession, for which we doubt not he will receive their sincere thanks. In- deed, we know not where the student of medicine will find such a complete and satisfactory collection of microscopic facts bearing upon physiology and practical medicine as is contained in Prof. Smith's appendix; and this of itself, it seems to us, is fully worth the cost of the volume.—Louisville Medical Review, Nov. 1856. BY THE SAME AUTHOE. ELEMENTS (OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIO- LOGICAL ANATOMY. Second American, from a new and revised London edition. With one hundred and ninety illustrations. In one very handsome octavo volume, leather, pp. 566. $3 00. To say that it is the best manual of Physiology now before the public, would notdo sufficient justice to the author.—Buffalo Medical Journal. In his former workB it would seem that he had exhausted the subjectof Physiology. In the present, he gives theessence, as it were, ofthe whole.—N. x. Journal of Medicine. Those who have occasion for an elementary trea- tise on Physiology, cannot do better than to possess themselves ofthe manual of Dr. Carpenter.—Medical Examiner. The best and most complete expose of modem Physiology, in one volume, extant in the English language.—St. Louis Medical Journal. BY the same author. (Preparing.) PRINCIPLES OF GENERAL PHYSIOLOGY, INCLUDING ORGANIC CHEMISTRY AND HISTOLOGY. With a General Sketch of the Vegetable and Animal Kingdom. In one large and very handsome octavo volume, with several hundred illustrations. The subject of general physiology having been omitted in the last editions oi the author's " Com- parative Phvsiologv" and " Human Physiology," he has undertaken to prepare a volume which shall present it more thoroughly and fully than has yet been attempted, and which may be regarded as an introduction to his other works. EY THE SAME ATTTHOH. A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTH AND DISEASE New edition, with a Preface by D. F. Condie, M. D., and explanations oT scientific words. In one neat 12mo. volume, extra cloth, pp. 178. 50 cents. 8 BLANCHARD & LEA'S MEDICAL CONDIE (O. F.), M. O., &c. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Fourth edition, revised and augmented. In one large volume, 8vo., leather, of nearly 750 pages. S3 00. From the Author's Preface. The demand for another edition has afforded the author an opportunity of again subjecting the entire treatise to a careful revision, and of incorporating in it every important observation recorded since the appearance ofthe last edition, in reference to the pathology and therapeutics ofthe several diseases oi which it treats. In the preparation of the present edition, as in those which have preceded, while the author has appropriated to his use every important fact that he has found recorded in the work> 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 anu America, he has, nevertheless, relied chiefly upon his own observations and experience, acquired during a long and somewhat extensive practice, and under circumstances pe- culiarly well adapted for the clinical study ofthe diseases of early fife. Every species of hypothetical reasoning has, as much as possible, been avoided. The author hu5> endeavored throughout the work to confine him>elt to a simple statement of well-ascertained patho- logical facts, and plain therapeutical directions—his chief desire being to render it what its title imports it to be, a practical treatise on the diseases of children. We feel assured from actual experience that no physician's library can be complete without a copy of this work.—iV. V. Journal of Medicine. Dr. Condie's scholarship, acumen, industry, and practical sense are manifested in this, as in all his numerous 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 practitioner in this country will rise with the great- est satisfaction.—Western Journal of Medicine and Surgery. One of the best works upon the Diseases of Chil- dren in the English language.— Western Lancet. Perhaps the most full and complete work now be- fore the profession ofthe United States; indeed, we may say in the English language. It is vastly supe- i language, and, notwithstanding all that has bee* rior to most of its predecessors.—Transylvania Med. published, we still regard it in that light.—Medical Journal. \ Examiner. A veritable pediatric encyclopaedia, and an honoT to American medical literatnre.—Ohio Medical and Surgical Journal. We feel persuaded that the American medical pro- fession 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 the best work on the diseases of children in the English CHRISTISON (ROBERT), M. D., V. P. R. S. E., Ac. A DISPENSATORY; or, Commentary on the Pharmacopoeias of Great Britain and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Ac- tions, Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and im- proved, with u Supplement containing the most important New Remedies. With copious Addi- tions, and two hundred and thirteen large wood-engravings. By R. Eglbsfeld Griffith, M. D. In one very large and handsome octavo volume, leather, raised bands, of over 1000 pages. $3 50. COOPER (BRANSBY B.), F. R. S. LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. In one very large octavo volume, extra cloth, of 750 pages. $3 00. COOPER ON DISLOCATIONS AND FRAC- TURES OF THE JOINTS —Edited by Bransby B. Cooper, F. R. S., &c. With additional Ob- servations by Prof. J. C. Warren. A new Ame- rican edition. In one handsome octavo volume, extra cloth, of about 500 pages, with numerous illustrations on wood. $3 25. COOPER ON THE ANATOMY AND DISKASES OF THE BREAST, with twenty-five Miscellane- ous and Surgical Papers. One large volume, im- perial 8vo., extra cloth, with 252 figures, on 36 plates. $2 50. COOPER ON THE STRUCTURE AND DIS- EASES OF THE TESTIS, AND ON THE THYMUS GLAND. One vol. imperial8vo., ex- tra cloth, with 177 figures on 29 plates. $2 00. COPLAND ON THE CAUSES, NATURE, AND TREATMENT OF PALSY AND APOPLEXY. In one volume, royal 12mo., extra cloth, pp. 326. 60 cents. CLYMER ON FEVERS; THEIR DIAGNOSIS, PATHOLOGY, AND TREATMENT in one octavo volume, leather, of 600 pages. $1 50. COLOMBAT DE L'ISERE ON THE DISEASES OF FEMALES, and on the special Hygiene of their Sex. Translated, with many Notes and Ad- ditions, by C. D. Meigs, M. D. Second edition, revised and improved. In one large volume, oc- tavo, leather, with numerous wood-cuts. pp. 720. 83 50. CARSON (JOSEPH), M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA MEDICA AND PHARMACY, delivered in the University of Pennsylvania. Second and revised edi- tion. In one very neat octavo volume, extra cloth, of 208 pages. 81 50. CURLING (T. BJ, F. R.S., Burgeon to the London Hospital, President of the Hunterian Society, dec. A PRACTICAL TREATISE ON DISEASES OF THE TESTIS, SPERMA- TIC CORD, AND SCROTUM. Second American, from the second and enlarged English edi- tion. In one handsome octavo volume, extra cloth, with numerous illustrations, pp. 420. $2 00. AND SCIENTIFIC PUBLICATIONS. 9 CHURCHILL (FLEETWOOD), M. D., M. R. I. A. ON THE THEORY AND PRACTICE OF MIDWIFERY. Edited, with Notes and Additions, by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Children," dec. With 139 illustrations. In one very handsome octavo volume, leather, pp.510. $3 00. To bestow praise on a book that has received such marked approbation would be superfluous. We need only say, therefore, that if the first edition was thought worthy of a favorable reception by the medical public, we can confidently affirm that this will be found much more so. The lecturer, the practitioner, and the student, may all have recourse to its pages, and derive from their perusal much in- terest and instruction in everything relating to theo- retical and practical midwifery.— Dublin Quarterly Journal of Medical Science. A work of very great merit, and such as we can confidently recommend to the study of every obste- tric practitioner.—London Medical Gazette. This is certainly the most perfect system extant. ft 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 Med. Journal. Were we reduced to the necessity of having but site work on midwifery, and permitted to choose, we would unhesitatingly take Churchill.— Western Med. and Surg. Journal. It is impossible to conceive a more useful and elegant manual than Dr. Churchill's Practice of Midwifery.—Provincial Medical Journal. Certainly, in our opinion, the very best work on the subject which exists.—JV. Y. Annalist. BY the same author. (Just Issued.) ON THE DISEASES OF [NFANTS AND CHILDREN. Second American Edition, revised and enlarged by the author. Edited, with Notes, by W. V. Keating, M. D. In one large and handsome volume, extra cloth, of over 700 pages. $3 00, or in leather, $3 25. In preparing this work a second time for the American profession, the author has spared no labor in giving it a very thorough revision, introducing several new chapters, and rewriting others, while every portion of the volume has been subjected to a severe scrutiny. The efforts of the American editor have been directed to supplying such information relative to matters peculiar to this country as might have escaped the attention of the author, and the whole may, there- fore, be safely pronounced one of the most complete works on the subject accessible to the Ame- rican Profession. By an alteration in the size of the page, these very extensive additions have been accommodated without unduly increasing the size of the work. contribution for the illustration of its topics. The material thus derived has been used with consummate skill, and the result has been a work creditable alike to the author and his country.—JV. A. Medico-Chir. No work holds a higher position, or is more de- serving of being placed in the hands of the tyro. the advanced student, or the practitioner.—Medical Examiner. Previous editions, under the editorial supervision of Prof R. M. Huston, have been received with marked favor, and they deserved it; but this, re- printed from a very late Dublin edition, carefully revised and brought up by the author to the present time, does present an unusually accurate and able exposition of every important particular embraced in the department of midwifery. * * The clearness, directness, and precision of its teachings, together with the great amount of statistical research which its text exhibits, have served to place it already in the foremost rank of works in this department of re- medial science.—N. O. Med. and Surg. Journal. In our opinion, it forms one of the best if not the very best text-book and epitome of obstetric science which we at present possess in the English lan- guage.— Monthly Journal of Medical Science. The clearness and precision of style in which it is written, and the great amount of statistical research which it contains, have served to place it in the first rank of works in this departmentof medical science. — N. Y. Journal of Medicine. Few treatises will be found better adapted as a text-book for the student, or as a manual for the frequent consultation of the young practitioner.— American Medical Journal. This work contains a vast amount of interesting matter, which is so well ananged and so curtly worded that the book may be regarded as an ency- clopaedia of information upon the subject of which it treats. It is certainly also a monument of Dr. ChurchilPs untiring industry, inasmuch as there is not a single work upon the diseases of children with which we are acquainted that is not fully referred to and quoted from in its pages, and scarcely a con- tribution of the least importance to any British or Foreign Medical Journal, for some years past, which is not dilly noticed.—London Lancet, Feb. 20, 1858. Availing himself of every fresh source of informa- tion, Dr. Churchill endeavored, with his accustomed industry and perseverance, to bring his work up to the present state of medical knowledge in all the subjects of which it treats; and in this endeavor he has, we feel bound to say, been eminently success- ful. Besides the addition of more than one hundred and thir'y oages of matter, we observe that some entirely new and important chapters are introduced, viz: on paralysis, syphilis, phthisis, sclerema, &c. &c Ar the work now stands, it is, we believe, the most comprehensive in the English language upon thediseases incident to early life.—Dublin Quarterly Journal, Feb. ie58. It brings before the reader an amount of informa- tion nol comprised in any similar production in the language. The amount of labor consumed upon its production can only be conceived by th >se who have been similarly occupied, every work of note pub- lished witnin the lasc twentv-five years in the dif- ferent languages of Europe having been laid under BY THE SAME AUTHOR. ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- CULIAR TO WOMEN. Selected from the writingsof British Authors previous to the close of the Eighteenth Century. In one neat octavo volume, extra cloth, of about 450 pages. $2 50. Review, May, 1858. After this meagre, and we know, very imperfect notice of Dr. Churchill's work, we shall conclude by saying, that it is one that cannot fail from its co- piousness, extensive research, and general accuracy, to exalt still higher the reputation of the author in this country. The American reader will be particu- larly pleased to find that Dr. Churchill has done full justice throughout his work to the various A merican authors on this subject. The names of Dewees, Eberle, Condie, and Stewart, occur on nearly every page, and these authors are constantly referred toby the author in terms of the highest praise, and with the most liberal courtesy.—The Medical Examiner. We recommend the work of Dr. Churchill most cordially, both to students and practitioners, as a valuableand.'reliable guide in the treatment of the dis- eases of children.—Am. Journ. of the Med. Sciences. We know of no work on this department of Prac- tical Medicine which presents so candid and unpre- judiced a statement or posting up of our actual knowledge as this.—N. Y. Journal of Medicine. Its claims to merit both as a scientific and practi- cal work, are of the highest order. Whilst we would not elevate it above every other treatise on the same subject, we certainly believe that very few are equal to it, and none superior.—Southern Med. and Surgical Journal. 16 BLANCHARD & LEA'S MEDICAL CHURCHILL (FLEETWOOD), M. D., M. R. I. A., «tc. ON THE DISEASES OF WOMEN; including those of Pregnanoy and Child- bed. A new American edition, revised by the Author. With Notes and Additions, bv D Fran- cis Condie, M. D., author ot "A Practical Treatise on the Diseases of Children." With nume- rous illustrations In one large and handsome octavo volume, leather, of 768 pages. (Just Issued, 18.77.) $3 00. This edition of Dr. Churchill's very popular treatise may almost be termed a new work, so thoroughly has he revised it in every portion. It will be found greatly enlarged, and thoroughly brought up to the mo^t recent condition of the subject, while the very handsome series of illustra- tions introduced, representing such pathological conditions as can be accurately portrayed, presenl a novel feature, and afford valuable assistance to the young practitioner. Such additions as ap- peared desirable for Ihe American student have been made by the editor, Dr. Condie, while a marked improvement in the mechanical execution keeps pace with the advance in all other respects which the volume has undergone, while the price has been kept at the former very moderate rate. It comprises, unquestionably, one of the most ex- act and comprehensive expositions of the present state of medical knowledge in respect to the diseases of women that has yet been published.—Am. Journ. Med. Sciences, July, 1857. We hail with much pleasure the volume before us, thoroughly revised, corrected, and brought up to the latest date, by Dr. Churchill himself, and rendered still more valuable by notes, from the ex- perienced and able pen of Dr. D F. Condie, of Phil- adelphia.— Southern Med. and Surg. Journal, Oct. 1&57. This work is the most reliable which we possess on this subjtct; and is deservedly popular with the profession—Charleston Med Journal, July, 1857. Dr. Churchill's treatise on the Diseases of Women is, perhaps, the most popular of his works with the profession in this country. It has been very gene- rally received both as a text-book and manual of practice. The present edition has undergone the most elaborate revision, and addition- of an import- ant character have been made, to render it a com- plete exponent of ihe present state of our knowledge of these diseases—iV. Y. Journ. of Med., Sept. 1857. We now regretfully take leave of Dr. Churchill's book. Had our typographical limits permitted, we should gladly have borrowed more from its richly Stored pages In conclusion, we heartily recom- mend it to the profession, and would at the same time express our firm conviction that, itwill not only add to the reputation of its author, but will prove a work of great and extensive utility to obstetric practitioners.— Dublin Medical Pr««.s. We know of no author who deserves that appro- bation, on "the diseases of females," to the same extent that Dr. Churchill does. His, indeed, is the only thorough treatise we know of on the subject; and it may be commended to practitioners and stu- dents as a masterpiece in its particular department. The former editions of this work have been com- mended strongly in this journal, and they have won 'heir wav to an extended, and a well-deserved popu- larity. This fifth edition, before us, is well calcu- lated to maintain Dr. Churchill's high reputation. It was revised and enlarged by the author, for his American publishers, and it seems to us that there ia scarcely any species of desirable information on its subjects that may not be, found in this work.—Th* Western Journal of Medicine and Surgery. We are gratified to announce a new and revised edition of Dr. Churchill's valuable work on the dis- eases of females We have ever regarded it as one of the very best works on the subjects embraced within its scope, in the English language; and the present edition, enlarged and revised by the author, renders it still more entitled to the confidence of the profession. The valuable notes of Prof Huston have been retained, and contribute, in no small de- gree, to enhance the value of the work. It is a source of congratulation that the publishers have permitted the author to be, in this instance, his own editor, thus securing all the revision which an author alone is capable of making.—The Western Lancet. As a comprehensive manual for students, or a work of reference for practitioners, we only speak with common justice when we say that it surpasses any other that has ever issued on the same sub- ject from the British press.—The Dublin Quarterly Journal. DICKSON (S. H.), M. D., Professor of Practice of Medicine in the Jefferson Medical College, Philadelphia. ELEMENTS OF MEDICINE; a Compendious View of Pathology and Thera- peutic*. or the History and Treatment of Diseases. Ill one large and handsome octavo volume, of 750 pages, leather. $3 75. As an American text-book on the Practice of Medicine for the student, and as a condensed work of reference for the practitioner, this volume will have strong claims on the attention ofthe profession. Few physicians have had wider opportunities than the author for observation and experience, and few perhaps have used them better. As the result of a life of study and practice, therefore, the present volume will doubtless be received with the welcome it deserves. This book is eminently what it professes to be; a distinguished merit ia these days. Designed for " Teachers and Students of Medicine," and admira- bly suited totheir wants, we think itwill be received, on its own merits, with a hearty welcome.—Boston Med. and Surg. Journal. Indited by one of the most accomplished writers of our country, as well as by one who has long held a high position among teachers and practitioners of medicine, this work is entitled to patronage and careful study. The learned author has endeavored to condense in this volume most of the practical matter contained in his former productions so as to adapt it to the use of those who have not time to devote to more extensive works —Southern Med. and Surg. Journal Prof Dickson's work supplies, to a great extent. a desideratum long felt in American medicine.—N O. Med and Surg Journal. Estimating this work according to the purpose foi which it is designed, we must think highly of its merits, and we have no hesitation in predicting for it a favorable reception by both students and teachers. Not professing to be a complete and comprehensive treatise, it will not be found full in detail, nor filled with diseuBsions of theories and opinions, but em- bracing all that is essential in theory and practice, it is admirably adapted to the wants of the American Btudent. Avoiding nil that is uncertain, it presents more clearly to the mind ofthe reader that which is established and verified by experience. The varied and extensive reading of the author is conspicuously apparent, and all the recent improvements and dis- coveries in therapeutics and pathology are chroni- cled in its pages.— Charleston Med. Journal. In the first part of the work the subject of gene- ral pathology is presented in outline, giving a btau- tiful picture of its distinguishing features, and throughout the succeeding chapters we find that he has kept scrupulously within the bounds of sound reasoning and legitimate deduction. Upon the whole, we do not hesitate to pronounce it a superior work in its class, and that Dr. Dickson merits a place in the first rank of American writers.—Western Lancet. AND SCIENTIFIC PUBLICATIONS. 11 DRUITT (ROBERT), M.R. C.S., «tc. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. 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, leather, of 576 large pages. $3 00. Dr. Druitt's researches into the literature of his ■abject have been not only extensive, but well di- rected ; the most discordant authors are fairly and impartially quoted, and, while due credit is given to each, their respective merits are weighed with an unprejudiced hand. The grain of wheat is pre- served, and the chafT is unmercifully stripped off. The arrangement is simple and philosophical, and the style, though clear and interesting, is so precise, that the book contains more information condensed into a few words than any other surgical work with which we are acquainted.—London Medical Times and Gazette. No work, in our opinion, equals it in presenting so much valuable surgical matter in so small a compass.—St. Louis Med. and Surgical Journal. Druitt's Surgery is too well known to the Ameri- can medical profession to require its announcement anywhere. Probably no work of the kind has ever been more cordially received and extensively circu- lated than this. The fact that it comprehends in a comparatively small compass, all the essential ele- ments of theoretical and practical Surgery—that it is found to contain reliable and authentic informa- tion on the nature and treatment of nearly all surgi- cal affections—is a sufficient reason for the liberal patronage it has obtained. The editor, Dr. F. W. Sargent, has contributed much to enhance the value of the work, by such American improvements as are calculated more perfectly to adapt it to our own views and practice in this country. It abounds everywhere with spirited and life-like illustrations, which to the young surgeon, especially, are of no minor consideration. Every medical man frequently aoeds just such a work as this, for immediate refer- ence in moments of sudden emergency, when he has not time to consult more elaborate treatises.—The Ohio Medical and Surgical Journal. Druitt's work, condensed, systematic, lucid, arid practical as it is, beyond most works on Surgery accessible to the American student, has had much currency in this country, and under its present au- spices promises to rise to yet higher favor.—The Western Journal of Medicine and Surgery. A better book on the principles Hnd practice of Surgery as now understood in England and America, has not been given to the profession.—Boston Medi- cal and Surgical Journal. It may be said with truth that the work of Mr. Druitt affords a complete, though brief and con- densed view, of the entire field of modern surgery. We know of no work on the same subject having the appearnnce of a manual, which includes so many topics of interest to the surgeon j and the terse man- ner in which each has been treated evinces a most enviable quality of mind on the part of the author, who seems to have an innate power of searching out and grasping the leading facts and features of the most elaborate productions of the pen. It is a useful handbook for the practitioner, and we should deem a teacher of surgery unpardonable who did not recommend it to his pupils. In our own opinion, it is admirably adapted to the wants of the student.— Provincial Medical and Surgical Journal. DALTON, JR (J. C), M. D. Professor of Physiology in the College of Physicians, New York. HUMAN PHYSIOLOGY DESIGNED FOR MEDICAL STUDENTS. In one very handso'me octavo volume, with about two hundred and fifty original illustrations. (Pre- paring.) DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &c. &c. In four large super-royal octavo volumes, of 3254 double-columned pages, strongly and handsomely bound, with raised bands. $12 00. ##* This work contains no less than four hundred and eighteen distinct treatises, contributed by sixty-eight distinguished physicians, rendering it a complete library of reference for the country practitioner. The most complete work on Practical Medicine I titioner. This estimate of it has not been formed extant; or, at least, in our language.—Buffalo ' from a hasty examination, but after an intimate ac- Medical and Surgical Journal. I quaintance derived from frequent consultation of it I during the past nine or ten years. The editors are practitioners of established reputation, and the list j of contributors embraces many of the most eminent One of the most valuable medical publications of i professors and teachers of London, Edinburgh, Dub- theday—as a work of reference it is invaluable.— l lin, and Glasgow. It is, indeed, the great merit of Western Journal of Medicine and Surgery. | this work that the principal articles have been fur- It has been to us, both as learner and teacher, a rushed by practitioners who have not only devoted work for ready and frequent reference, one in which especial attention to the diseases about which they modern English medicine is exhibited in the most have written, but have also enjoyed opportunities advantageous light.—Medical Examiner. for an extensive practical acquaintance with them, ^ and whose reputation carries the assurance of their We rejoice that this work is to be placed within | competency justly to appreciate the opinions of the reach of the profession in this country, it being I others, while it stamps their own doctrines with unquestionably one of very great value to the prac- I high and just authority.—American Medical Journ. For reference, it is above all price to every prac- titioner.—Western Lancet. DEWEES'S COMPREHENSIVE SYSTEM OF MIDWIFERY. Illustrated by occasional cases and many engravings. Twelfth edition, with the author's last improvements and corrections In one octavo volume, extra cloth, of 600 pages. S3 20. DEWEES'S TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILD- REN. The last edition In one volume, octavo, extra cloth, 548 pages. $2 80. DEWEES'S TREATISE ON THE DISEASES OF FEMALES. Tenth edition. In one volume, octavo, extra cloth, 532 pages, with plates. $3 00. DANA ON ZOOPHYTES AND CORALS. In one volume, imperial quarto, extra cloth, with wood- cuts. S15 00. Also, AN ATLAS, in one volume. imperial folio, with sixty-one magnificent colored plates. Bound in half morocco $30 00 IDE LA BECHE'S GEOLOGICAL OBSERVER. Inone very large and handsome octavo volume, ex- | tracloth,of 700 pages, with 300 wood-cuts $4 00. FRICK ON RENAL AFFECTIONS; their Diag- nosis and Pathology. With illustrations. On« volume, royal 12mo., extra cloth. 75 cents. 12 BLANCHARD & LEA'S MEDICAL DUNGLISON (ROBLEY), M.D., Ptofessor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. NEW AND ENLARGED EDITION, Now Ready, 1858. MEDICAL LEXICON; a Dictionary of Medical Science, containing a concise Explanation ofthe various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics Pharmacology, Pharmacy. Surgery, Obstetrics, Medical Jurisprudence, Dentistry. Src. Notices of Climate and of Mineral Waters; Formulae for Officinal, Empirical, and Dietetic Preparations, &c. With French and other Synonymes. Fifteenth edition, revised and very greatly enlarged. In one very large and handsome octavo volume, of 992 double-columned pages, in small type; strongly bound in leather, with raised bands. Price $4 00. Especial care has been devoted in the preparation of this edition to render it in every respect worthy a continuance of the very remarkable favor which it has hitherto enjoyed. The rapid sale of Fifteen large editions, and the constantly increasing demand, show that it is regarded by the profession as the standard authority. Stimulated by this fact, the author has endeavored in the present.revision to introduce whatever might be necessary "to make it a satisfactory and desira- ble—if not indispensable—lexicon, in which the student may search without disappointment for every term that has been legitimated in the nomenclature of the science." To accomplish this, large additions have been found requisite, and Ihe extent of the author's labors may be esiimated from the fact that about Six Thousand subjects and terms have been introduced throughout, ren- dering the whole number of definitions about Sixty Thousand, to accommodate which, the num- ber of pages has been increased by nearly a hundred, notwithstanding an enlargement in the size ofthe page. The medical press, both in this country and in England, has pronounced the work in- dispensable to all medical students and practitioners, and the piesent improved edition will not lose that enviable reputation. The publishers have endeavored to render the mechanical execution worthy of a volume of such universal use in daily reference. The greatest care hns been exercised to obtain the typographical accuracy so necessary in a work of the kind. By the small but exceedingly clear type employed, an immense amount of matter is condensed in its thousand ample pages, while the binding will be found strong and durable. With all these improvements and enlargements, the price has been kepi at the former very moderate rate, placing it within the reach of all. This work, the appearance of the fifteenth edition of which, it has become our duty and pleasure to announce, is perhaps the most stupendous monument of labor and erudition in medical literature. One would hardly suppose after constant use of the pre- ceding editions, where we have never failed to find a sufficiently full explanation of ever} medical term, that in this edition "about six thousand subjects and terms have been added," with a careful revision and correction of the entire work. It is only neces- Bary to announce the advent of this edition to make it occupy the place of the preceding one on the table of every medical man, as it is without doubt the best and most comprehensive work of the kind which has ever appeared.—Buffalo Med. Journ., Jan. 1858. The work is a monument of patient research, skilful judgment, and vast physical labor, that will perpetuate the name of the author more effectually than any possible device of stone or metal. Dr. Dunglison deserves the thanks not only of the Ame- rican profession, but of the whole medical world.— North Am. Medico-Chir. Review, Jan. 1858. A Medical Dictionary better adapted for Ihe wants of the profession than any other with which we are acquainted, and of a character which places it far above comparison and competition.—Am. Journ. Med. Sciences, Jan. 1858. We need only say, that the addition of 6,000 new terms, with their accompanying definitions, maj be said to constitute a new work, by itself. We have examined the Dictionary attentively, and are most happy to pronounce it unrivalled of its kind. The erudition displayed, and the extraordinary industry which must have been demanded, in its preparation and perfection, redound to the lasting credit of its author, and have furnished us with a volume indis- pensable at the present day, to all who would find themselves au niveau with the highest standards of medical information.—Boston Medical and Surgical Journal, Dec. 31, 1857. Good lexicons and encyclopedic works generally, are the most labor-saving contrivances which lite- rary men enjoy; and the labor which is required to produce them in the perfect manner of this example is something appalling to contemplate. The author tells us in his preface that he has added about six thousand terms and subjects to this edition, which, before, was considered universally as the best work of the kind in any language.—Silliman's Journal, March, 1858. He has razed his gigantic structure to the founda- tions, and remodelled and reconstructed the entire pile. No less than six thousand additional subjects and terms are illustrated and analyzed in this new edition, swelling the grand aggregate to beyond sixty thousand ! Thus is placed before the profes- sion a complete and thorough exponent of medical terminology, without rival or possibility of rivalry. —Nashville Journ. of Med. and Surg., Jan. 1858. It is universally acknowledged, we believe, that this work is incomparably the best and most com- plete Medical Lexicon in the English language. The amount of labor which the distinguished author has bestowed upon it is truly wonderful, and the learning and research displayed in its preparation are equally remarkable. Comment and commenda- tion are unnecessary, as no one at the present day thinks of purchasing any other Medical Dictionary than this.—St. Louis Med. and Surg. Journ., Jan. 1858. It is the foundation stone of a good medical libra- ry, and should always be included in the first list of books purchased by the medical student.—Am. Med. Monthly, Jan. 1858. A very perfect work of the kind, undoubtedly the most perfect in the English language.—Med. and Surg. Reporter, Jan. 1808. It is now emphatically the Medical Dictionary of the English language, and for it there is no substi- tute.— N. H. Med. Journ., Jan. 1858. It is scarcely necessary to remark that any medi- cal library wanting a copy of Duntrlison's Lexicon must be imperfect.—Cin. Lancet, Jan. 1858. We have ever considered it the bes* authority pub- lished, and the present edition we may safely say has no equal in the world—Peninsular Med. Journal, Jan.1858. The most complete authority on the subject to be foundin any language.— Va. Med. Journal, Feb. '58. BY THE SAME AUTHOR. THE PRACTICE OF MEDICINE. A Treatise on Special Pathology and The- rapeutics. Third Edition. In two large octavo volumes, leather, of 1,500 pages. S' 25. AND SCIENTIFIC PUBLICATIONS. 13 DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and exten- sively modified and enlarged, with five hundred and thirty-two illustrations. In two large and handsomely printed octavo volumes, leather, of about 1500 pages. $7 00. In revising this work for its eighth appearance, the author ha* spared no labor to render it worthy a continuance ofthe very great favor which has been extended to it by the profession. The whole contents have been rearranged, and to a great extent remodelled; the inve>tigations which of late years have been so numerous and so important, have been carefully examined and incoip >rated, and the work in every respect has been brought up to a level with the present state of the subject. The object of the author has been to render it a concise but comprehensive treatise, containing the whole body of physiological science, to which the student and man of >cience can at all times refer with the certainty of finding whatever they are in search of, fully presented in all its aspects; and on no former edition has the author bestowed more labor to secure this result. We believe that it can truly be said, no more com- , The best work of the kind in the English Ian- plete repertory of facts upon the subject treated, guage—Si/Ztmajt's Journal. fr»»*2rTJT-M? ^OU!ldi The*uthor 'iaf; moreover, Th(J t editi„n h auth„r has a„ f , ■ inV^rf ? description and that facility mirror^f the 8eie,,ee as ir. is at the present hour. ^ln4h./fe„P/i.eES",n W.hlCh r«der him peculiarly A8 a work up(m physiology proper, the science of Thi.P£™u th„e 8Ua-; °- the,?tadT',.re^er- thefanctionsperfclrmedbythebody.ihestudei.twill J,.v«ft.1!fc.lV,eqrS k° ■?"»«*/"'■*'?'"•? find it alt he vrisUes.-Nashville Journ. of Med. graver and less attractive subjects, lends additional , gent jggg J charms to one always fascinating.—Boston Med. ' and Surg. Journal, Sept. 1856. The most complete and satisfactory Bystein of Physiology in the English language.—Amer. Med Journal. That he haB succeeded, most admirably succeeded in his purpose, is apparent from the appearance of an eighth edition. It is now the great encyclopaedia on the subject, and worthy of a place in every phy- sician's library.— Western Lancet, Sept. 1856. BY THE SAME author. (Now Ready.) GENERAL THERAPEUTICS AND MATERIA MEDICA; adapted for a Medical Text-book. With Indexes of Remedies and of Diseases and their Remedies. Sixth Edition, revised and improved. With one hundred and ninety-three illustrations. In two large and handsomely printed octavo vols., leather, of about 1100 pages. $6 00. From the Author's Preface. " Another edition of this work being called for, the author has subjected it to a thorough and careful revision. It has been gratifying to him lhat it ha> been found so extensively useful by those for whom it was especially intended, as to require that a.sixth edition should be issued in so short a time afier the publication of a fifth. Grateful for the favorable reception ofthe work by the profession, he has bestowed on the preparation of the present edition all those cares which were demanded by the former editions, and has spared no pains to render it a faithful epitome of General Therapeutics and Materia Medica. The copious Indexes of Remedies and of Diseases and their Remedies can- not fail, the author conceives, to add materially to the value of the work." This work is too widely and too favorably known to require more than the assurance that the author has revised it with his customary industry, introducing whatever has been found necessary to bring it on a level with the most advanced condition ofthe subject. The number of illustrations has been somewhat enlarged, and the mechanical execution of the volumes will be found to have undergone a decided improvement. In announcing a new edition of Dr. Dunglison's i The work will, we have little doubt, be bought General Therapeutics and Materia Medica, we have [ and read by the majority of medical students; its no words of commendation to bestow upon a work . size, arrangement, and reliability recommend it to whose merits have been heretofore so often and so all; no one, we venture to predict, will study it justly extolled. It must not be supposed, however, | without profit, and there are few to whom it will that the present is a mere reprint of the previous ' edition: the character of the author for laborious research, judicious analysis, and clearness of ex- pression, is fully sustained by the numerous addi- tions he has made to the work, and the careful re- vision to which he has subjected the whole.—N. A. . view, Jan. 1858. Medico-Chir. Review, Jan. 1858. ' BY THE same author. (.4 new Edition.) NEW REMEDIES, WITH FORMULAS FOR THEIR PREPARATION AND ADMINISTRATION. Seventh edition, with extensive Additions. In one very large octavo volume, leather, of 770 pages. $3 75. Another edition of the " New Remedies" having been called for, the author has endesvored to add everything of moment that has appeared since the publication of the last edition. The articles treated of in the former editions will be found to have undergone considerable ex- pansion in this, in order that the author might be enabled to introduce, as far as practicable, the results of the subsequent experience of others, as well as of his own observation and reflection; and to make the work still more deserving of the extended circulation with which the preceding editions have been favored by the profession. By an enlargement of the page, the numerous addi- tions have been incorporated without greatly increasing the bulk of the volume.—Preface. not be in some measure useful as a work of refer- ence. The young practitioner, more especially, will find the copious indexes appendid to this edition of great assistance in the selection and preparation of suitable formulas.—Charleston Med. Journ. and Re- One of the most useful of the author's works.— Southern Medical and Surgical Journal. This elaborate and useful volume should be found in every medical library, for as a book of re- ference, for physicians, it is unsurpassed by any other work in existence, and the double index for Hig^MBPH and for remedies, will be found greatly to - enhancl its value—A^ York Med. Gazette. 1}™™^*™* papers—Tke Ame™an J°"™al The great learning of the author, and his remark- able industry in pushing his researches into every source whence information is derivable,have enabled him to throw together an extensive mass of facts and statements, accompanied by full reference to authorities; which last feature renders the work practically valuable to investigators who desire to 14 BLANCHARD & LEA'S MEDICAL ERICHSEN (JOHN), Professor of Surgery in University College, London, Ice. THE SCIENCE AND ART OF SURGERY; beino a Treatise on Suroioal Injuries, Diseases, and Operations. Edited by John H. Brinton, M. D. Illustrated with three hundred and eleven engravings on wood. In one large and handsome octavo volume, of over nine hundred closely printed pages, leather, raised bands. $4 25. rarely encounter cases requiring surgical manage- ment.—Stethoscope. Embracing, as will be perceived, the whole surei- cal domain, and each division of itself almost corn- It is, in our humble judgment decidedly the best book of the kind in the English language. Strange that jusl such books are notofiener produced by pub- lic teacher? of surgery in this country and Oreat Britain Indeed, it is a matter of great astonishment but no lees true than astonishing, that of the many works on surgery republished in this country within the last fifteen or twenty years a« textbooks for medical students, thi-is the only one that even ap plete and perfect, each chapter full and explicit, each subject faithfully exhibited, we can only express our estimate of it in the aggregate. We consider it an excellent contribution to surgery, as probably the be.*' single volume now extant on Ihe subject, and proximatesto the fulfilment ofthe peculiar wants of j with great pleasure we add it to our text books — young men just entering upon the study of this branch l Nashville Journal of Medicine and Surgery ofthe profession.— Western Jour, of Med. anil Surgery. ' Its value is greatly enhanced by a very copious well-arranged index. We regard this as one of the most valuable contributions to modern surgery. To one entering his novitiate of practice, we regard il the most serviceable guide which he can consult. He will find a fulness of detail leadinghim through every step ofthe operation, and not deserting him unlil the final issue ofthe case is decided For the some rea- son w recommend it to those whose routine of prac- tice lies in such parts of the country that they must Prof. Erichsen's work, for its size, has not been surpnssed; his nine hundred and eight pages, pro- fusely illustrated, are rich in physiological, patholo- gical, and operative suggestions, doctrines, details, and processes; and will prove a reliable resource for information, both to physician and surgeon, in the liour of peril.— N. 0. Med. and Surg. Journal. We are acquainted with no other work wherein so much good sense, sound principle, and practical inferences, stamp every page.—American Lancet. ELLIS (BENJAMIN), M.D. THE MEDICAL FORMULARY: being a Collection of Prescriptions, derived from the writings and practice of many of the most eminent physicians of America and Europe. Together with the u-ual Dietetic Preparations and Antidotes for Poisons. To which is added an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Tenth edition, revised and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one neat octavo volume, citra cloth, of '29(i pages. $1 75. After an examination of the new matter and the alterations, we believe the reputation of the -work built up by the author, and the late distinguished editor, will continue to flourish under the auspices ofthe present editor, who has the industry and accu- racy, and, we would say, conscientiousness requi- site for the responsible task.—Am. Jour, of Pharm. It will prove particularly useful to students and young practitioners, as the most important prescrip- tions employed in modern practice, which lie scat- tered through our medical literature, are here col- lected and conveniently arranged for reference.— Charleston Med. Journal and Review. FOWNES (GEORGE), PH. D., &.C. ELEMENTARY CHEMISTRY; Theoretical and Practical. With numerous illustrations. Edited, with Additions, by Robert Bridges, M. D. In one large royal 12mo. volume, of over 550 pages, with 181 wood-culs. In leather, $ 1 50; extra cloth, $1 35. We know of no better text-book, especially in the difficult department of organic chemistry, upon which it is particularly full and satisfactory. We would recommend it to preceptors as a capital " office book" for their students who are beginners in Chemistry. It is copiously illustrated with ex- cellent wood-cuts, and altogether admirably "got up."—iV. J. Medical Reporter. A standard manual, which has long enjoyed the reputation of embodying much knowledge in a small space. The author hasachieved the difficult task of condensation with masterly tact. His book is con- cise without being dry, and brief without being too dogmatical or general.— Virginia Med. and Surgical Journal. The work of Dr. Fownes has long been before the public, and its merits have been fully appreci- ated as the best text-book on chemistry now in existence. We do not, of course, place it in a rank superior to the works of Brande, Graham, Turner, Gregory, or Gmelin, but we say that, as a work for students, it is preferable to any of them.—Lon- don Journal of Medicine. A work well adapted to the wants of the student It is an excellent exposition of the chief doctrines and facts of modern chemistry. Thesizeof the work, and still more the condensed yet perspicuous style in which it is written, absolve it from the charges very properly urged against most manuals termed popular.—Edinburgh Journal of Medical Science. FISKE FUND PRIZE ESSAYS. THE EFFECTS OF CLIMATE ON TUBERCULOUS DISEASE By Et>win Lee, M. R. C. S., London, and THE INFLUENCE OF PREGN\NCY ON THE DEVELOP- MENT OF TUBERCLES. By Edward Warren, M. D., of Edenton, N. C. Together in one neat octavo volume, extra cloth. $1 00. (Just Ready.) FERGUSSON (WILLIAM), F. R. S., Professor of Surgery in King's College, London, &c. A SYSTEM OF PRACTICAL SURGERY. Fourth American, from the third und enlarged London edition. In one large and beautifully printed octavo volume, of about 700 pages, with 393 handsome illustrations, leather. $3 00. No work was ever written which more nearly I The addition of many new pages makes this work comprehended the necessities of the. student nnd | more than ever indispensable to the student and prac- practitioner, and was more carefully arranged tary an Appendix, embodying the numerous and important investigations and dis- coveries of the last few years in the subjects contained in Part I. This occupies a large portion of Part II., and will be found to present a complete abstract of the most recent researches in the general principles ofthe science, as well as all details necessary to bring the whole work thoroughly up to the present time in all departments of Inorganic Chemistry. Gentlemen desirous of completing their copies of the work are requested to apply for Part II. without delay. It will be sent by mail, prepaid, on receipt of the amount, $2 50. From Prof. J. L. Crawcour, New Orleans School of Medicine, May 9, 1858. It is beyond all question the best systematic work on Chemistry in the English language, and I am gratified to find that an American edition at a mo- derate price has been issued, so as to place it within the means of students Itwill be the only text-book 1 shall now recommend to my class. From Prof. Wolco't Gihbs, N. Y. Free Academy, May 25, 1858. The work is an admirable one in all respects, and its republication here cannot fail to exert a positive influence upon the progress of science in this country. From Prof. E. N. Horsford. Harvard College, April 27, 1859. It has, in its earlier and less perfect editions, been famil'ar to me, and the excellence of its plan and the clearness and completeness of its discussions, have long been my admiration. It is a very acceptable addition to the library of standard books of every chemical student. Mr Walts,well knr wn as the translator ofthe Cavendish Society edition of Gmelin's Chemistry, has made in the supplement an able resume of the progress of the science since the publication of the first volume. It is plain from the number and importance of the topics there discussed, lhat great progress has been made in the interval, both in chemical physics and in areneral inorganic chemistry. No reader of Eng- lish works on this science can afford to be without thiseditionof Prof. Graham's Elements.—Silliman's Journal, March, 1658. From Prof. O. P Hubbard, Dartmouth College, N. H , May 20, 1858. I am impressed with the great amount and variety of its contents, and its great value to chemists who have not access to all the current literature of the day in chemistry. Its appendix embraces a great deal of recent investigation not found in any other American republication. GRIFFITH (ROBERT E.), M. D., &.C. A UNIVERSAL FORMULARY, containing the methods of Preparing and Ad- ministering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceu- tists. Second Edition, thoroughly revised, with numerous additions, by Robert P. Thomas, M D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large and handsome octavo volume, extra cloth, of 650 pages, double columns. $3 00; or bound in sheep, $3 25. Il was a work requiring much perseverance, and when published was looked upon as by far the be*l work of its kind thai had issued from the American press. Prof Thoma* ha= certainly "improved" as well a* added o'his Formulary, and has rendered it additionally deserving o( the confidence of pharma- ceutists and physicians.—Am Journal of Pharmacy. We are happy to announce a new and improved edition of this, one ofthe most valuable and useful works that have emanated from an American pen. It would do credit to any coumr>. and will be found of daily usefulness to practitioners of medicine; it is better adapted to their purposes Ihau tho dispensato ries - Southern Med and Surg Journal |i is one ofthe most useful books a country practi- tioner can possibly have in his possession.—Medica* Chronicle Thi is a work of six hundred and fifty one pages embracing all on the subject of preparing and admi nistering medicines that can be desired by the physi- cian and pharmaceutist.— Western Lancet The amount of useful, every-day matter, for a prac ticine physician, is really immense.— Boston Med. and Surg. Journal. vVe predict a great sale for this work, and we espe- ciallv recommend it to all medical teachers.—Rich- mond Stethoscope. This edition of Dr. Griffith's work has been greatly improved by the revision and ample additions of Dr. Thomas, and is now, we believe, one of the most complete works of it* kind in any language. The additions amount to about seventy pages, and no effort has been spared to include in them all the re- '■enl improvements which have been published in medical journals, and systematic treatises. A work of tnU kind appears to us indispensable to the physi- eian. and there is none we can more cordially recom- mend.—JV. Y. Journal of Medicine. 16 BLANCHARD be a"y criterion for the greater satisfaction than ever. The American editor, iuruie,tneDinaing will soon have to be renewed, even ' Dr. Havs, has made many very valuable additions. with careful handling. We find thai Dr. Hays has -N.J. Med. Reporter. trtrrous'labTs" ^S^Z^ SSS&lnnl , T° *^ "" "^ ^ 7"*$ ?*" "nT? eminently suited to our merlie Vi ,„;h,^" if V3! I from this cause, we know of no dictionary better nology.—Boston Med. and Surg. Journal. and yet large enough to make a respectable appear- ance in the library of a physician.—Western Lancet. To both practitioner and student, we recommend this dictionary as being convenient in size, accurate in definition, and sufficiently full and complete for „ ordinary consultation.—Charleston Med. Journ. and I Southern Med. and Surg. Journal Review. Hoblyn's Dictionary has long been a favorite with us. It is the best book of definitions we have, and ought always to be upon the student's table.— HOLLAND (SIR HENRY), BART., M.D.,F. R. 8., Physician in Ordinary to the Queen of England, &c. MEDICAL NOTES AND REFLECTIONS. From the third London edition. In one handsome octavo volume, extra cloth. $3 00. As the work of a thoughtful and observant physician, embodying the results of forty years' ac- tive professional experience, on topics of the highest interest, this volume is commended to the American practitioner as well worthy his attention. Few will rise from its perusal without feel- ing their convictions strengthened, and armed with new weapons for the daily struggle with disease. HABERSHON . $2 00. (Just Issued, LS57.) In again passing thi> work through his hands, the author has endeavored to render it a correct exposition of the present condition of the science, making such alterations and additions as have been dictated by further experience, or as the progress of investigation has rendered desirable. In every point of mechanical execution tne publishers have sought to make it superior to former edi- tions', and at the very low price at which it is offered, it will be found one of the handsomest and cheapest volumes before the profession. In making these improvements, care has been exercised not unduly to increase its size, thus maintaining its distinctive characteristic of presenting within a moderate compass a clear and con- nected view of its subjects, sufficient for the wants of the student. One of the very best handbooks of Physiology we possess—presenting just such an outline of the sci- This is a new and very much improved edition of Dr. Kirkes' well-known Handbook of Physiology. Originally constructed on the basis of the admirable treatise of Muller, it has in successive editions de- veloped itself into an almost original work, though no change has been made in the plan or arrangement. It combines conciseness with completeness, and is, therefore, admirably adapted for consultation by the busy practitioner.—Dublin Quarterly Journal, Feb. 1857. Its excellence is in its compactness, its clearness, and its carefully cited authorities. It is the most convenient of text-books. These gentlemen, Messrs Kirkes and Paget, have really an immense talent for silence, which is not so common or so cheap as prat- ing people fancy. They have the gift of telling us what we want to know, without thinking it neces- sary to tell us all they know.—Boston Med and Surg. Journal, May li, 1857. ence, comprising an account of its leading facts and generally admitted principles, aB the student requires during his attendance upon a course of lectures, or for reference whilst preparing for examination.— Am. Medical Journal. We need only say, that, without entering into dis- cussions of unsettled questions, it contains all the recent improvements in this department of medical science. For the student beginning this study, and the pructitioner who has but leisure to refresh his memory, this book is invaluable, as it contains all that it is important to know, without special details, which are read with interest only by those who would make a specialty, or desire to possess a criti- cal knowledge of the subject.—Charleston Medical Journal. KNAPP'S TECHNOLOGY ; or, Chemistry applied I to the Arts and to Manufactures. Edited, with numerous Notes and Additions, by Dr. Edmund Ronalds and Dr. Thomas Richardson. First American edition, with Notes and Additions, by Prof. Walter R. Johnson. In two handsome octavo volumes, extra cloth, with about 500 wood- engravings. $6 00. LUDLOW (J. L.), M. D. A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics. To which is added a Medical Formulary. Designed for Students of Medicine throughout the United States. Third edition, thoroughly revised and greatly extended and enlarged. With three hundred and seventy illustrations. In one large and handsome royal 12mo. volume, leather, of over 800 closely printed pages (Just Issued.) $2 50. The great popularity of this volume, and the numerous demands for it during the two years in which it has been out of print, have induced the author in its revision to -pare no pains to render it a correct and accurate digest ofthe most recent condition of all ihe branches of medical science. In many respects it may, therefore, be regarded rather as a new book than a new edition, an entire section on Physiology having been added, as also one on Organic Chemistry, and many portions having been rewritten. A very complete series of illustrations has been introduced, and every care hus been taken in the mechanical execution to render it a convenient and satisfactory book for study or reference. The arrangement of the volume in the form of question and answer renders it especially suited for the office examination of Mudents and for those preparing for graduation. We know of no better companion for the student I crammed into his head by the various professors to during the hours spent in the lecture room, or to re- whom he is compelled to listen.__Western Lancet. fresh, at a glance, his memory of the various topics | May, 1857. AND SCIENTIFIC PUBLICATIONS. 19 LEHMANN (C. G.) PHYSIOLOGICAL CHEMISTRY. Translated from the second edition hy Georgk E. Day, M. D., F. R. S., &c , edited by R. E. Rogers, M. D., Professor of Chemistry in the Medical Department of the University of Pennsylvania, with illustrations selected from !! k \A as °^ Physiological Chemistry, and an Appendix of plates. Complete in two large and handsome octavo volumes, extra cloth, containing 1200 pages, with nearly two hundred illus- trations. $6 00. This great work, universally acknowledged as the most complete and authoritative exposition of the principles and details of Zoochemistry, in its passage through the press, has received from Professor Rogers such care as was necessary to present it in a correct and reliable form. To such a work additions were deemed superfluous, but several years having elapsed between the appear- ance in Germany of the fir-t and last volume, the latter contained a supplement, embodying nume- rous corrections and additions resulting from the advance ofthe science These have all been incor- porated in the text in their appropriate places, while the subjects have been still furtner elucidated by the insertion of illustrations from the Atlas of Dr. OttoFunke. With the view of supplying the student with the means of convenient comparison, a large number of wood-cuts, from works on kindred subjects, have also been added in the form of an Appendix of Plates. The work is, therefore, pre- sented as in every way worthy the attention of all who desire to be familiar with the modern facts and doctrines of Physiological Science. The most important contribution as yet made to • it treats.—Edinburgh Monthly Journal of Medical Physiological Chemistry—Am. Journal Med. Sci- | Science. ences, Jan. 1856. . ■ j ,, , . , . iU | Already well known and appreciated by the seien- I he present volumes belong to the small class of | tific world, Professor Lehmann's great work re- medical literature which comprises elaborate works I quires no laudatory sentences, as, under a new garb, of the highestorderof merit.—Montreal Med. Chron- icle, Jan. 1856. The work of Lehmann stands unrivalled as the most comprehensive book of reference and informa- tion extant on every branch of the subject on which BY THE SAME AUTHOR. (Just Issued.) MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German, with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory Essay on Vital Force, by Samuel Jackson, M. D., Professor of the Institutes of Medicine in the University of Pennvylvania. With illustrations on wood. In one very handsome octavo volume, extra cloth, of 336 pages. $2 25. Froxz Prof. Jackson's Introductory Essay. In adopting the handbook of Dr Lehmann as a manual of Organic Chemistry for the use of the students of the University, and in recommending his original work of Physiological Chemistry for their more mature studies, the high value of his researches, and the great weight of his autho- rity in that important department of medical science are fully recognized. LAWRENCE (W.), F. R. S., Sec. A TREATISE ON DISEASES OF THE EYE. A new edition, edited, with numerous additions, and 243 illustrations, by Isaac Hays, M. D., Surgeon to Will's Hospi- tal, &c. In one very large and handsome octavo volume, of 950 pages, strongly bound in leather with raised bands. $5 00. This admirable treatise—the safest guide and most | likely that this great work will cease to merit the comprehensive work of reference, which is within l confidence and preference of students or practition- the reach of the profession.—Stethoscope. I irs. Its ample extent—nearly one thousand large octavo pages—has enabled both author and editor to This standard text-book on the department of i do justice to all the details of this subject, and con- whieh it treats, has not been superseded, by any or i dense in this single volume the present state of our all of the numerous publications on the subject knowledge of the whole science in this department, heretofore issued. Nor with the multiplied improve- | whereby its practical value cciinut be excelled.—N. ments of Dr. Hays, the American editor, is it at all I Y Med. Gaz. t is now presented to us. The little space at our command would ill suffice to set forth even a small portion of its excellences.—Boston Med. and Surg. Journal, Dec. 1855. LAYCOCK (THOMAS), M. D., F. R. S. E., Professor of Practical and Clinical Medicine in the University of Edinburgh, tec. LECTURES ON THE PRINCIPLES AND METHODS OF MEDICAL OBSERVATION AND RESEARCH. For the Use of Advanced Students and Junior Prac- titioners. In one very neat royal 12mo. volume, extra cloth. Price $1 00. LALLEMAND AND WILSON. A PRACTICAL TREATISE ON THE CAUSES, SYMPTOMS, AND TREATMENT OF SPERMATORRHOEA. By M. Lallemand. Translated and edited by Henry J McDougall. Third American edition. To which is added-----ON DISEASES OF THE VESICULiE SEMINALES; and their associated organs. With special refer- ence to ihe Morbid Secretions of the Prostatic and Urethral Mucous Membrane. By Marris Wilson, M. D. In one neat octavo volume, of about 400 pp., extra cloth. $2 00. (Now Ready.) Although the views of M. Lallemand on Spermatorrhoea hrve unquestionably exercised a very great influence, and the treatment advocated by him has been very generally adopted, still, a num- ber of years having elapsed since his work was given to the world, the publishers have thought that the value of the present edition would he enhanced by the addition of 'he little treatise of Dr. Marris Wilson. . In it the causfs of the different varieties of Spermatorrhoea are investigated with the aid of modern pathology, from which, combined with the most recent experience of the pro- fession, the attempt is made to deduce a rational system of curative treatment. Whatever defi- ciencies may have been caused in the work of M. Lallemand by the progress of medical science, will, it is hoped, be in this manner supplied. 20 BLANCHARD & LEA'S MEDICAL LA ROCHE (R.), M. D., &.c. YELLOW FEVER, considered in its Historical, Pathological, Etiological, and Therapeutical Relations. Including a Sketch of the Disease as it has occurred in Philadelphia from 1699 to 1N">1, with an examination ofthe connections between it and the fevers known under the same name in other parts of temperate as well a* in tropical regions. In two large and handsome octavo volumes of nearly 1500 pages, extra cloth. $7 00. arduous research and careful study, and the result is such as will reflect the highest honor upon the author and our country.— Southern Med. and Surg. From Professor S. H. Dickson, Charleston, S. C, September IS, 1855. A monument of intelligent and well applied re- search, almost without example. It is, indeed, in itself, a large library, and is destined to constitute the special resort as a book of reference, in the subject of which it treats, to all future time. We have not time at present, engaged as we are, by day and by night, in the work of combating this very disease, now prevailing in our city, to do more than give this cursory notice of what we consider as undoubtedly the most able and erudite medical publication our country has yet produced But in view of the startling fact, that this, the most malig- nant and unmanageable disease of modern times, has for several years been prevailing in our country to a greater extent than ever before; that it is no longer confined to either large or small cities, but penetrates country villages, plantations, and farm- houses; that it is treated with scarcely better suc- cess now than thirty or forty years ago; that there is vast mischief done by ignorant pretenders to know- ledge in regard to the disease, and in view of the pro- bability that a majority of southern physicians will be called upon to treat the disease, we trust that this able and comprehensive treatise will he very gene- rally read in the south.—Memphis Med. Recorder. This is decidedly the great American medical work of the day—a full, complete, and systematic treatise, unequalled by any other upon the all-important sub- ject of Yellow Fever. The laborious, indefatigable, and learned author has devoted to it many years of Journal. The genius and scholarship of this great physician could not have been better employed than in the erection of this towering monument to his own fame, and to the glory of the medical literature of his own country. It is destined to remain the great autho- rity upon the subject of Yellow Fever The student and physician will find in these volumes a rtsumt of the sum total of the knowledge of the world upon the awful scourge which they so elaborately discuss. The style is so soft and so pure as to refresh and in- vigorate the mind while absorbing the thoughts of the gifted author, while the publishers have suc- ceeded in bringing the externals into a most felicitous harmony with the inspiration that dwells within. Take it all in all, it is a book we have often dreamed of, but dreamed not that it would ever meet our waking eye as a tangible reality.—Nashville Journal of Medicine. We deem it fortunate that the splendid work of Dr. La Roche should have been issued from the press at this particular time. The want of a reliable di- gest of all that is known in relation to this frightful malady has long been felt—a want very satisfactorily met in the work before us. We deem it but faint praise to say that Dr. La Riche has succeeded in presenting the profession with an able and complete monograph, one which will find its way into every well ordered library.— Va. Stethoscope. BY THE SAME AUTHOR. PNEUMONIA; its Supposed Connection, Pathological and Etiological, with Au- tumnal Fever*, including an Inquiry into the Existence and Morbid Agency of Malaria. In one handsome octavo volume, extra cloth, of 500 pages. $3 00. MILLER (HENRY), M.D., Professor of Obstetrics and Diseases of Women and Children in the University of Louisville. PRINCIPLES AND PRACTICE OF OBSTETRICS, &c.j including the Treat- ment of Chronic Inflammation of the Cervix and Body of the Uterus considered as a frequent cause of Abortion. With about one hundred illustrations on wood. In one very handsome oc- tavo volume, of over 600 pages. (Now Ready.) $3 75. The reputation of Dr. Miller as an obstetrician is too widely spread to require the attention of the profession to be specially called to a volume containing the experience of his long and extensive practice. The very favorable reception accorded to his " T realise on Human Parturition," issued some years since, is an earnest that the present work will fulfil the author's intention of providing Mjilhin a moderate compass a complete and trustworthy text-book for the student, and book of re- ference for the practitioner. Based to a certain extent upon the former work, but enlarged to more than double its size, and almost wholly rewritten, it presents, besides the matured experience ol the author, the most recent views and investigations of modern obstetric writers, such as Dubois, Cazeaux, Simpson, Xyler Smith, &c, thus embodying the results not only of the American, but also ofthe Paris, the London, and the Edinburgh obstetric schools. The author's position for so many years as a teacheft of his favorite branch, has given him a familiarity with the wants of stu- dents and a facility of conveying instruction, which cannot fail to render the volume eminently adapted to its purposes. We Congratulate the author that the task is done. I In fact, this volume must take its place among the We congratulate him that he has given to the medi- ' standard systematic treatises on obstetrics ; a posi- cal public a work which will secure for him a high I tion to which its merits justly entitle it. The style and permanent position among the standard autho- is such that the deseriptionsare clear, and each sub- rities on the principles and practice of obstetrics.' ject is discussed and elucidated with due regard to Congratulations are not less due to the medical pro- j its practical bearings, which cannot fail to make it fession of this country, on the acquisition of a trea- acceptable and valuable to both students nntl prac- tise embodying the results of the studies, reflections, \ titioners. We cannot, however, close this brief and experience of Prof. Miller. Few men, if any, I notice without congratulating the author and Ihe in this country, are more competent than he to write j profession on the production of such an excellent on thisdepartmentof medicine. Engaged for thirty- treatise. The author is a western man of whom we five years in an extended practice of obstetrics, for | feel proud, und we cannot but think that his book many years a teacher of this branch of instruction will find many readers and warm admirers wherever in one of the largest of our institutions, a diligent obstetrics is taught and studied as a science und an student as well asa careful observer, an originaland art.—The Cincinnati Lancetand Observer, Feb. 1858. independent thinker, wedded to no hobbies, ever A most respecUlble und valunble addition to our ready to consider without prejudice new views,.and home mei|ical literature, and one reflecting credit to adopt innovations ifthey are really improvements, alike on the author and ihe institution to wnich he and withal a clear, agreeable writer, a practica. ig attaciled. The student will find in this work a treatise from his pen could not fail to possess great | mogt useful ide t0 nis 8tudles the country prac. value. Returning to Prof. Miller's work we have only to add that we hope most sincerely it will be in 'he hands of every reading and thinking practitioner his country.—Buffalo Med Journal, Mar. 1858 titioner, rusty in his reading, can obtain from its pages a fair resume of the modern literature of the se. ence; and we hope to gee this American produc- tion generally consulted by the profession.—Va. Med. Journal, Feb. 1858. AND SCIENTIFIC PUBLICATIONS. 21 MEIGS (CHARLES D.), M. D., Professor of Obstetrics, &c. in the Jefferson Medical College, Philadelphia. OBSTETRICS: THE SCIENCE AND THE ART. Third edition, revised and improved. With one hundred and twenty-nine illustration* In one beautifully printed octavo volume, leather, of seven hundred and fifty-two large pages. $3 75. The rapid demand for another edition of this work is a sufficient expression of the favorable verdict of the profession. In thus preparing it a third time for the press, the author has endeavored to render it in every respect worthy of the favor which it has received. To accomplish this he has thoroughly revised it in every part. Some portions have been rewritten, others added, new illustrations have been in many instances substituted for such as were not deemed satisfactory, while, by an alteration in the typographical arrangement, the size of the work has not been increased, and the price remains unaltered. In its present improved form, it is, therefore, hoped that the work will continue to meet the wants of the American profession as a sound, practical, and extended System of Midwifery. Though the work has received only five pages of enlargement, its chapters throughout wear the im- press of careful revision. Expunging nnd rewriting, remodelling its sentences, with occasional new ma- terial, all evince a lively desire that it shall deserve to be regarded as improved in manner as well as matter. In the matter, every stroke of the pen has increased the value of the book, both in expungings and additions —Western Lancet, Jan. 1857. The best American work on Midwifery that is accessible to the student and practitioner—JV. W. Med. and Surg. Journal, Jan. 1857. This is a standard work by a great American Ob- stetrician. It is the third and last edition, and, in the language of the preface, the author has "brought the subject up to the latest dates of real improve- ment in our art and Science."—Nashville Journ. of Med. and Surg., May, 1857. by the same author. (Lately Issued.) WOMAN: HER DISEASES AND THEIR REMEDIES. A Series of Lec- tures to his Class. Third and Improved edition. In one large and beautifully printed octavo volume, leather. pp. 672. $3 60. The gratifying appreciation of his labors, as evinced by the exhaustion of two large impressions of this work within a few years, has not been lost upon the author, who has endeavored in every way to render it worthy of the favor with which it has been received. The opportunity thus afforded for a second revision has been improved, and the work is now presented as in every way superior to its predecessors, additions and alterations having been made whenever the advance of science has rendered them desirable. The typographical execution of the work will also be found to have undergone a similar improvement, and the work is now confidently presented as in every way worthy the position it has acquired as the standard American text-book on the Diseases of Females. such bold relief, as to produce distinct impressions upon the mind and memory ofthe reader.— The Charleston Med. Journal. It contains a vast amount of practical knowledge. by one who has accurately observed and retained the experience of many years, and who tells the re- sult in a free, familiar, and pleasant manner.—Dub- lin Quarterly Journal. There is an off-hand fervor, a glow, and a warm- heartedness infecting the effjrt of Dr. Meigs, which is entirely captivating, and which absolutely hur- ries the reader through from beginning to end. Be- sides, the book teems with solid instruction, and it shows the very highest evidence of ability, viz., the clearness with which the information is pre- sented. We know of no better test of one's under- standing a subject than the evidence of the power of lucidly explaining it. The most elementary, as well as the obscurest subjects, under the pencil of Prof. Meigs, are isolated and made to stand out in Professor Meigs has enlarged and amended this great work, for such it unquestionably is, having passed the ordeal of criticism at home and abroad, but been improved thereby ; for in this new edition the author has introduced real improvements, and increased the value and utility of the book im- measurably. It presents so many novel, bright, and sparkling thoughts; such an exuberance of new ideas on almost every page, that we confess our- selves to have become enamored with the book and its author; and*cannot withhold our congratu- lations from our Philadelphia confreres, that such a teacher is in their service.—JV. Y. Med. Gazette. BY THE SAME AUTHOR. ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED FEVER. In a Series of Letters addressed to the Students of his Class. In one handsome octavo volume, extra cloth, of 365 pages. $2 50. This book will add more to his fame than either of those which bear his name. Indeed we doubt whether any material improvement will be made on the teachings of this volume for a century to come, since it is so eminently practical, and based on pro- found knowledge of the science and consummate skill in the art of healing, and ratified by an ample and extensive experience, such as few men have the industry or good fortune to acquire__N. Y. Med. Gazette. The instructive and interesting author of this work, whose previous labors in the department of medicine which he so sedulously cultivates, have placed his countrymen under deep and abiding obli- gations, again challenges their admiration in the fresh and vigorous, attractive and racy pages before us. It is a delectable book. * * * This treatise upon child-bed fevers will have an extensive sale, being destined, as it deserves, to find a place in the library of every practitioner who scorns to lag in the rear.—Nashville Journal of Medi-.ine and Surgery. BY THE SAME AUTHOR ] WITH COLORED PLATES. A TREATISE ON ACUTE AND CHRONIC DISEASES OF THE NECK OF THE UTERUS. With numerous plates, drawn and colored from nature in the highest style of art. In one handsome octavo volume, extra cloth. $4 50. MAYNE'S DISPENSATORY AND THERA- PEUTICAL REMEMBRANCER. Comprising the entire lists of Materia Medica, with every Practical Formula contained in the three British Pharmacopoeias. Edited, with the addition of the Formulas of the U. S. Pharmacopoeia, by R. E. Griffith,M.D. 112mo. vol. ex.cl.,300pp. 75 e. MALGAIGNE'S OPERATIVE SURGERY, based on Normal and Pathological Anatomy. Trans- lated from the French by Frederick Brittan, A. B.,M. D. With numerous illustrations on wood. In one handsome octavo volume, extra cloth, of nearly six hundred pages. $2 95. 22 BLANCHARD & LEA'S MEDICAL MACLISE (JOSEPH), SURGEON. SURGICAL ANATOMY. Forming one volume, very large imperial auarto. With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored. Con- taining one hundred and ninety Figures, many of them the $5 25. The treatise of Dr. Mackenzie indisputably holds the first place, and forms, in respect of learning and research, *n Encyclopaedia unequalled in extent by any other work of the kind, either English or foreign. —Dixon on Diseases ofthe Eye. Few modern books on any department of medicine or surgery have met with such extended circulation, or have procured for their authors a like amount of European celebrity. The immense research which it displayed, the thorough acquaintance with the Bubject, practically as well as theoretically,and the able manner in which the author's stores of learning and experience were rendered available for general use, at once procured for the first edition, as well on the continent as in this country, that high position as a standard work which each successive edition has more firml) established, in spite of the attrac- tions of several rivals of no mean ability. We con- sider it the duty of every one who has the love of his profession and the welfare of his patient at heart, to make himself familiar with this the most complete work in the English language upon the diseases of the eye.—Med. Times and Gazette. The fourth edition of this standard work will no doubt be as fully appreciated as the three former edi- tions. It is unnecessary to say a word in its praise, for the verdict has already been passed upon it by the most competent judges, and " Mackenzie on the Eye" has justly obtained a reputation which it is no figure of speech to call world-wide.—British and Foreign Medico-Chirurgical Review. This new edition of Dr. Mackenzie's celebrated treatise on diseases of the eya, i* truly a miracle of industry and learning. We need scarcely say that he has en tirely exhausted the subject of his specialty. —Dublin Quarterly Journal. AND SCIENTIFIC PUBLICATIONS. 23 MILLER (JAMES), F. R. S. E., Professor of Surgery in the University of Edinburgh, Ac. PRINCIPLES OF SURGERY. Fourth American, from the third and revised Edinburgh edition. In one large and very beautiful volume, leather, of 700 pages, with two hundred and forty exquisite illustrations on wood. $3 75. The extended reputation enjoyed by this work will be fully maintained by the present edition. Thoroughly revised by the author, it will be found a clear and compendious exposition of surgical science in its most advanced condition. In connection with the recently issued third edition ofthe Author's "Practice of Surgery," it forms a very complete system of Surgery in all its branches. The work of Mr. Miller is too well and too favor- ably known among us, as one of our best text-books, to render any further notice of it necessary than the announcement of a new edition, the fourth in our country, a proof of its extensive circulation among us. As a concise and reliable exposition of the sci- ence of modern surgery, it stands deservedly high— we know not its superior.—Boston Med. and Surg. Journal. It presents the most satisfactory exposition ofthe modern doctrines ofthe principles of surgery to be found in any volume in any language.—JV. Y. Journal of Medicine. The work takes rank with Watson's Practice of Physic; it certainly does not fall behind that great work in soundness of principle or depth of reason- ing and research. No physician who values his re- by the same author. (Now Ready.) THE PRACTICE OF SURGERY. Fourth American from the last Eiin- burgh edition. Revised by the American editor. Illustrated by three hundred and sixty four engravings on wood. In one large octavo volume, leather, of nearly 700 pages. $3 75. putation, or seeks the interests of his elients, can acquit himself before his God and the world without making himself familiar with the sound and philo- sophical views developed in the foregoing book.— New Orleans Med. and Surg. Journal. Without doubt the ablest exposition of the prin- ciples of thiit branch of the healing art in any lan- guage. This opinion, deliberately formed after a careful study of the first edition, we have had no cause to change on examining the second This edition has undergone thorough revision by the au- thor; many expressions have been modified, and a mass of new matter introduced. The book is got up in the finest style, and is an evidence of the progress of typography in our country.—Charleston Medical Journal and Review. No encomium of ours could add to the popularity of Miller's Surgery. Its reputation in this country is unsurpassed by that of any other work, and, when taken in connection with the author's Principles of Surgery, constitutes a whole, without reference to which no conscientious surgeon would be willing to practice his art. The additions, by Dr. Sargent, have materially enhanced the value of the work.— Southern Medical and Surgical Journal. It is seldom that two volumes have ever made so profound an impression in so short a time as the "Principles" and the "Practice" of Surgery by Mr. Miller—or so richly merited the reputation they have acquired. The author is an eminently sensi- ble, practical, and well-informed man, who knows exactly what he is talking about and exactly how to talk it.—Kentucky Medical Recorder. his works, both on the principles and practice of surgery have been assigned the highest rank. If we were limited to but one work on surgery, that one should be Miller's, as we regard it as superior to all others.—St. Louis Med. and Surg. Journal The author, distinguished alike as a practitioner and writer, has in this and his " Principles,'' pre- sented to the profession one of the most complete and reliable systems of Surgery extant His style of writing is original, impressive, and engaging, ener- getic, concise, and lucid Few have the faculty of condensing so much in small space, and at the same time so persistently holding the attention: indeed, he appears to make the very process of condensation a means of eliminating attractions Whether as a text-book tor students or a book of reference for practitioners, it cannot be too strongly recommend- By the almost unanimous voice of the profession, > ed.—Southern Journal of Med. and Phys. Sciences MONTGOMERY (W. F.), M. D., M. R. I. A., &c, Professor of Midwifery in the King and Queen's College of Physicians in Ireland, &c. AN EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREGNANCY. With some other Papers on Subjects connected with Midwifery. From the second and enlarged English edition. With two exquisite colored plates, and numerous wood-cuts, [n one very handsome octavo volume, extra cloth, of nearly 600 pages. (Just Issued, 1857.) $3 75 The present edition of this classical volume is fairly entitled to be regarded as anew work, every sentence having been carefully rewritten, and the whole increased to more than double ihe original size. The title ofthe work scarcely does justice to the extent and importance of the topics brought under consideration, embracing, with the exception of the operative procedures of mid- wifery, almost everything connected with obstetrics, either directly or incidenlally ; and there are few physicians who will not find in its pages much that will prove of great interest and value in their daily practice. The special Essays on the Period of Human Gestation, the Signs of Delivery, and the Spontaneous Amputation and other Lesions of the Foetus in Utero present topics ofthe highest interest fully treated and beautifully illustrated. In every point of mechanical execution the work will be found one of the handsomest yet issued from the American press. A book unusually rich in practical suggestions.— Am Journal Med. Sciences, Jan. 1857. These several subjects so interesting in them- selves, and so important, every one of them, to the most delicate and precious of social relations, con- trolling often the honor and domestic peace of a family, the legitimacy of offspring, or the life of its parent, are all treated with an elegance of diction, fulness of illustrations, acutenessand justice of rea- soning, unparalleled in obstetrics, and unsurpassed in medicine. The reader's interest can never flag, so fresh, and vigorous, and classical is our author's style; und one forgets, in the renewed charm ot every page, that it, and every line, and every word has been weighed and reweighed through vears of preparation; that this is of all others the hook of Obstetric Law, on each of its several topics; on all points connected with pregnancy, to be everywhere received as a manual of special jurisprudence, at once announcing fact, affording argument, establish- ing precedent, and governing alike the juryman, ad- vocate, and judge. It is not merely in its legal re- lations that we find this work si interesting Hardly a page but that has its hints or facts important to the general practitioner; and not a chapter without especial matter for the anatomist, physiologist, or pathologist. — JV. A. Mtd.-Chir. Review, March, 1857. 24 BLANCHARD & LEA'S MEDICAL NEILL (JOHN), M. D., Surgeon to the Pennsylvania Hospital, tec; and FRANCIS GURNEY SMITH, M. D., Professor of Institutes of Medicine in the Pennsylvania Medical College. AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE ; for the Use and Examination of Students. A new edition, revised and improved. In one very large and handsomely printed royal 12mo. volume, of about one thousand pages, with 374 wood-cuts. Strongly bound in leather, with raised bands. $3 00. The very nattering reception which has been accorded to this work, and the high estimate placed upon it by the profession, as evinced by the constant and increasing demand which has rapidly ex- hausted two large editions, have stimulated the authors to render the volume in its present revision more worthy of the success which has attended it. It has accordingly been thoroughly examined, and such errors as had on former occasions escaped observation have been corrected, and whatever additions were necessary to maintain it on a level with the advance of science have been introduced. The extended series of illustrations has been still further increased and much improved, while, by •a slight enlargement ofthe page, these various additions have been incorporated without increasing the bulk of the volume. The work is, therefore, again presented as eminently worthy of the favor with which it has hitherto been received. As a book for daily reference by the student requiring a guide to his more elaborate text-books, as a manual for preceptors desiring to stimulate their students by frequent and accurate examination, or as a source from which the practitioners of older date may easily and cheaply acquire a knowledge ofthe changes and improvement in professional science, its reputation is permanently established. The best work of the kind with which we are I the students is heavy, and review necessary for an acquainted.—Med. Examiner Having made free use of this volume in our ex- aminations of pupils, we can speak from experi- ence in recommending it aa an admirable compend for students, and as especially useful to preceptors who examine their pupils. It will save the teacher much labor by enabling him readily to recall all of the points upon which his pupils should be ex- amined . A work of this sort should be in the hands of every one who takes pupils into his office with a view of examining them; and this is unquestionably the best of its class.—Transylvania Med. Journal In the rapid course of lectures, where work for NEILL (JOHN), M. D., Professor of Surgery in the Pennsylvania Medical College, &c. OUTLINES OF THE VEINS AND LYMPHATICS. With handsome colored plates. 1 vol., cloth. $1 25. OUTLINES OF THE NERVES. With handsome plates. 1 vol., cloth. $1 25. examination, a compend is not only valuable, but it is almost a sine qua non. The one before us is, in most of the divisions, the most unexceptionable of all books of the kind that we know of. The newest and soundest doctrines and the latest im- provements and discoveries are explicitly, though concisely, laid before the student. There is a class to whom we very sincerely commend this cheap book as worth its weigh t in silver—that class is the gradu- ates in medicine of more than ten years' standing, who have not studied medicine since. They will perhaps Ind out from it that the science is not exactly now what it was when they left it off.—The Stetho- scope NELIGAN (J. MOORE), M. D.f M. R. I.A., &c. (A splendid^ work. Just Issued.) ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, extra cloth, with splendid colored plates, presenting nearly one hundred elaborate representations of disease. $4 50. This beautiful volume is intended as a complete and accurate representation of all the varieties of Diseases of the Skin. While it can be consulted in conjunction with any work on Practice, it has especial reference to the author's " Treatise on Diseases ofthe Skin," so favorably received by the profession some years since. The publishers feel justified in saying that few more beautifully exe- cuted plates have ever been presented to the profession of this country. A compend which will very much aid the praeti- \ long existent desideratum much felt by the largest tioner in this difficult branch of diagnosis. Taken i class of our profession. It presents, in quarto size, with the beautiful plates of the Atlaf, which are 16 plates, each containing from 3 to 6 figures, and remarkable for their accuracy and beauty of color- | forming in all a total of 90 distinct representations ing, it constitutes a very valuable addition to the ! of the different species of skin affections, grouped library of a practical man - Buffalo Med. Journal, I together in genera or families. The illustrations Sept. 1856. | have been taken from nature, and have teen copied with such fidelity that they present a striking picture of life; in which the reduced scale aptly serves to give, at a coup d'ail, the remarkable peculiarities Nothing is often more difficult than the diagnosis of disease ofthe skin; and hitherto, the only works containing illustrations have been at rather incon- venimt prices—prices, indeed, that prevented gene- ral use. The work before us will supply a want lone felt, and minister to a more perfect acquaintance of each individual variety. And while thus the dis ease is rendered more definable, there is yet no loss of proportion incurred by the necessary concentra- with the nature and treatment of a very frequent i 'lon- Each figure is highly colored, and so truthful and troublesome form of disease.—Ohio Med. and j na8 tne artist been that the mostfastid ous observer Surg. Journal, July, 1856. could not justly take exception to the correctness of Kr . ... ,„ „ the execution of the pictures under his scrutiny.— Neligan's Atlas of Cutaneous Diseases supplies a I Montreal Med. Chronicle. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON DISEASES OF THE SKIN. Second American edition. In one neat royal 12mo. volume, extra cloth, of 334 pages. $1 00. S&- The two volumes will be sent by mail on receipt of Flue Dollars. OWEN ON THE DIFFERENT FORMS OF I One vol. royal 12mo., extra cloth, with numerons THE SKELETON, AND OF THE TEETH. | illustration.. 81 25. ' ' AND SCIENTIFIC PUBLICATIONS. 25 PEASLEE (E. R.), M. D., Professor of Physiology and General Pathology in the New York Medical College. HUMAN HISTOLOGY, in its relations to Anatomy, Physiology, and Pathology; for the use of Medical Students With four hundred and thirty four illustrations. In one hand- some octavo volume, of over 600 pages. (Now Ready, 1858.) $3 75. In undertaking this task, the author has endeavored to present his extensive subject in the man- ner most likely to interest and benefit ihe physician confident that in these details will be found the basis of true medical science. The very large number of illustrations introduced throughout, serves amply to elucidate the text, while the typography of the volume will in every respect be found of the handsomest description. It embraces a library upon the topics discussed , preparation of our lectures, and also of recommend- within itself, and is just what the teacher and learner j ing its further perusal most cordially to our alumni; a recommendation which we now extend to our readers.—Memphis Med. Recorder, Jan. 1858. This volume meets the wants of the profession, and we heartily commend it to ail those who would be- come thoroughly acquainted with the minute and beautiful structures of the human body. — Chicago Med. Journal, April, 1858. We would recommend it to the medical student and practitioner, as containing a summary of all that is known ofthe important subjects which it treats; of all that is contained in the great works of Simon and Lehmann, and the organic chemists in general. Master this one volume, we would say to the medical student and practitioner—master tt is book and vou know all that is known of the great fundamental principles of medicine, and we have lo hesitation in saying that it is an honor to the American medi- cal profession that one of its members should have produced it.—St. Louis Med. and Surg. Journal, March, 1858. This work treats of the foundation of things, and deserves a careful perusal by all those who wish to be respectably intormed in their profession.—Ohio Med. and Surg. Journal, May, 1858. need. Another advantage, by no means to be over- looked, everything of real value in the wide rai.ge which it embraces, is with great skill compressed into an octavo volume of but little more thun six hundred pages We have not only the whole sub- ject of Histology, interesting in itself, ably and fully discussed, but what is of infinitely greater interest to the student, because of greater practical value, are its relations to Anatomy, Physiology, and Pa- thology, which are here fully and satisfactorily set forth. These great supporting branches of practical medicine are thus linked together, and while estab- lishing and illustrating each other, are interwoven into a harmonious whole. We commend the work to students and physicians generally. — Nashville Journ. of Med. and Surgery, Dec. 1857. It far surpasses our expectation. We never con- ceived the possibility of compressing so much valu- able information into so compact a form. We will not consume space with commendations. We re- ceive this contribution to physiological science, " Not with vain thanks, but with acceptance boun- teous." We have already paid it the practical compliment of making abundant use of it in the PEREIRA (JONATHAN), M. D., F. R. S., AND L. S. THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. Third American edition, enlarged and improved by the author; including Notices of most of the Medicinal Substances in use in the civilized world, and forming an Encyclopasdia of Materia Medica. Edited, with Additions, by Joseph Carson, M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. In two very large octavo volumes of 2100 pages, on small type, with about 500 illustrations on stone and wood, strongly bound in leather, with raised bands. $9 00. Gentlemen who have the first volume are recommended to complete their copies without delay. The first volume will no longer be sold separate. Price of Vol. II. $5 00 The third edition of his " Elements of Materia Medica, although completed under the supervision ol others, is by far the most elaborate treatise in the English language, and will, while medical literature is cherished, continue a monument alike honorable to his genius, as to his learning and industry.— American Journal of Pharmacy. Our own opinion of its merits is that of its editors, and also that of the whole profession, both of this and foreign countries—namely, " that in copious- ness of details, in extent, variety, and accuracy of information, and in lucid explanation of difficult and recondite subjects, it surpasses all other works on Materia Medica hitherto published." We can- not close this notice without alluding to the special additions of the American editor, which pertain to the prominent vegetable productions of this country, and to the directions of the United States Pharma- copoeia, in connection with all the articles contained in the volume which are referred to by it. The il- lustrations have been increased, and this edition by Dr. Carson cannot well be regarded in any other light than that of a treasure which should be found in the library-of every physician.—New York Journ- al of Medical and Collateral Science. PI RRIE (WILLIAM), F. R. S. E., Professor of Surgery in the University of Aberdeen. THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill M D Professor of Surgery in the Penna. Medical College, Surgeon to the Pennsylvania Hospital, &c.'' In one very handsome octavo volume, leather, of 780 pages, with 316 illustrations. $3 15. We know of no other surgical work of a reason- able size, wherein there is so much theory and prac- tice, or where subjects are more soundly or clearly taught.—The Stethoscope. There is scarcely a disease of the bones or soft nartB fracture, or dislocation, that is not illustrated by accurate wood-engravings. Then, again, every instrument employed by the surgeon is thus repre- sented These engravings are not only correct, but really beautiful, showing the astonishing degree of perfection to which the art of wood-eneraving has arrived. Prof. Pirne, in the work before us, has elaborately discussed the principles of surgery, and a safe and effectual practice predicated upon them. Perhaps no work upon this subject heretofore issued is so full upon the science of the art of surgery.— Nashville Journal of Medicine and Surgery. PARKER (LANGSTON), Surgeon to the Queen's Hospital, Birmingham. THE MODERN TREATMENT OF SYPHILITIC DISEASES, BOTH PRI- marV AND SECONDARY; comprising the Treatment of Constitutional and Confirmed Syphi- rThva safe and successful method. With numerous Cases, Formulae, and Clinical Observa- tions From the Third and entirely rewritten London edition. In one neat octavo volume, extra cloth, of 316 pages. $1 75. 26 BLANCHARD & LEA'S MEDICAL PARRISH (EDWARD), Lecturer on Practical Pharmacy and Materia Medica in the Pennsylvania Academy of Medicine, *c. AN INTRODUCTION TO PRACTICAL PHARMACY. Designed as a Text- Book lor the Student, and as a Guide for the Physiciun and Pharmaceutist. With many For- mulae and Prescriptions. In one handsome octavo volume, extra cloth, of 550 pages, with U43 Illustrations. $2 75. A careful examination of this work enables us to speak of it in the highest terms, as being the best treatise on practical pharmacy with which we are acquainted, and an invaluable vade-mecum, not only t» the apothecary and to those practitioners who are accustomed to prepare their own medicines, but to every medical man and medical student Through- out the work are interspersed valuable tables, useful formula;, and practical hints, and the whole is illus- trated by a large number of excellent wood-engrav- ings.—Boston Med. and Surg. Journal. This is altogether one of the most useful books we have seen. It is just what we have long felt to be needed by apothecaries, students, and practitioners of medicine, most of whom in this country have to put up their own prescriptions. It bears, upon every page, the impress of practical knowledge, conveyed in a plain common sense manner, and adapted to the comprehension of all who may read it. No detail has been omitted, however trivial it may seem, al- though really important to the dispenser of medicine. —Southern Med. and Surg. Journal. To both the country practitioner and the city apo- thecary this work of Mr. Parrish is a godsend. A careful study of its contents will give the young graduate a familiarity with the value and mode of administering his prescnptions, which will he of as much use to his patient as to himself.— Va. Med. Journal. .Mr. Parrish has rendered a very acceptable service to the practitioner and student, by furnishing this book, which contains the leading facts and principles of the science of Pharmacy, conveniently arranged for study, and with special reference to those features of the subject which possess on especial practical in- terest to the physician. It furnishes the student, at the commencement of his studies, with that infor- mation which is of the greatest importance in ini- tiating him into the domain of Chemistry and Materia Medica; it familiarizes him with the compounding of drugs, nnd supplies those minutiae which but few practitioners can impart. The junior practitioner will, also, find this volume replete with instruction. —Charleston Med. Journal and Review, Mar. 1856. There is no useful information in the details of the apothecary's or country physician's office conducted according to science that is omitted. The young physiciun will find it an encyclopedia of indispensa- ble medical knowledge, from the purchase of a spa- tula to the compounding of the most learned pre- scriptions. The work is by the ablest pharmaceutist in the United States, and must meet with nn im- mense sale.—Nashville Journal of Medicine, April, 1856. We are glad to receive this excel'ent work. It will supply a want long felt by the profession, and especially by the student of Pharmacy. A large majority of physicians are obliged to compound their own medicines, and to them a work of this kind is indispensable.—N. O. Medical and Surgical Journal. We cannot say but that this volume is one of the most welcome and appropriate which has for a long time been issued from the press. It is a work which we doubt not will at once secure an extensive cir- culation, as it is designed not only for the druggist and pharmaceutist, but also for the great body of practitioners throughout the country, who not only have to prescribe medicines, but in the majority of instances have to rely upon their own resources— whatever these may be—not only to compound, but also to manufacture the remedies they are called upon to administer. The nuthor has not mistaken the idea in writing this volume, as it is alike useful and invaluable to those engaged in the active pur- suits ofthe profession, and to those preparing to en- ter upon the field of professional labors.—American Lancet, March 24, 1856. RICORD (P.), M. D., A TREATISE ON THE VENEREAL DISEASE. By John Hunter, F. R. S, With copious Additions, by Ph. Ricord, M. D. Edited, with Notes, by Freeman J. Bumstead, M. D. In one handsome octavo volume, extra cloth, of 520 pages, with plates. $3 25. Kvery one will recognize the attractiveness and value which this work derives from Ihus presenting the opinions of these two manters side by side. But, it must be admitted, what has made the fortune of the book, is the fact that it contains the "most com- plete embodiment of the veritable doctrines of the Hopital du Midi," which has ever been mtide public. The doctrinal ideas of M. Ricord, ideas which, if not universally adopted, are incoiitestably dominant, have heretofore only been interpreted by inoreor less skilful secretaries, sometimes accredited and sometimes not. In the notes to Hunter, the master substitutes him- self for his interpreters, and gives hisoriginul thoughts to the world in a lucid and perfectly intelligible man- ner. In conclusion we can say thai this is incon- testably the best treatise on syphilis with which we are acquainted, and, as we do not often employ the phrase, we may be excused for expressing the hope that it may find a place in the library of every phy- sician.— Virginia Med. and Surg. Journal. BY THE SAME AUTHOR. RICORD'S LETTERS ON SYPHILIS. Translated by W. P. Lattimore, M. D. In one neat octavo volume, of 270 pages, extra cloth. $2 00. RIGBY (EDWARD), M. D., Senior Physician to the General Lying-in Hospital, tec A SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations. Second American Edition. One volume octavo, extra cloth, 422 pages. $2 50. by the same author. (Now Ready, 1857.) ON THE CONSTITUTIONAL TREATMENT OF FEMALE DISEASES. In one neat royal 12mo. volume, extra cloth, of about 250 pages. $l 00. The aim of the author has been throughout to present sound practical views of the importunt subjects under consideration ; and without entering into theoretical disputations and disquisitions to embody the results of his long and extended experience in such a condensed form as would be easily accessible to the practitioner. ROYLE'S MATERIA MEDICA AND THERAPEUTICS; including the Preparations of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United Stated. With many new medicines. Edited by Joseph Carson, M. D. With ninety-««rht illustration* In one large octavo volume, extra cloth, of about 700 pages. $3 00 AND SCIENTIFIC PUBLICATIONS, 27 RAMSBOTHAM (FRANCIS H.ij M.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND SURGERY, in reference to the Proces> of Parturition. A new and enlarged edition, thoroughly revised by the Author. With Additions by W V. Keating, M. D. In one large and handsome imperial octavo volume, of650 pages, strongly bound in leather, with raised bands; with sixty- four beautiful Plates, and numerous Wood-cuts in the text, containing in all nearly two hundred large and beautiful figures. $5 00. In calling the attention of the profession to the new edition of this standard work, the publishers would remark that no efforts have been spared to secure for it a continuance and extension of the remarkable favor with which it ha> been received. The last London issue, which was considera- bly enlarged, has received a further revision from the author, especially for this country. Its pas- sage through the press here has been supervised by Dr. Keating, who has made numerous addi- tions with a view of presenting more fully whatever was necessary to adapt it thoroughly to American modes of practice. In its mechanical execution, n like superiority over former editions will be found. From Prof. Hodge, of the University of Pa. 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. The publishers have shown their appreciation of the merits of this work and secured its success by the truly elegant style in which they have brought it out, excelling themselves in its production, espe- cially in its plates. It is dedicated to Prof. Meigs, and has the emphatic endorsement of Prof. Hodge, as the best exponent of British Midwifery. We know of no text-book which deserves in all respects to be more highly recommended to students, and we could wish to see it in the hands of every practitioner, for they will find it invaluable for reference.—Med. Gazette. But once in a long time some brilliant genius rears his head above the horizon of science, and illumi- nates and purifies every department that he investi- gates; and his works become types, by which innu- merable imitators model their feeble productions. Such a genius we find in the younger Ramsbotham, and such a type we find in the work now before us. The binding, paper, type, the engravings and wood- cuts are all so excellent as to make this book one of the finest specimens of the art of printing that have given such a world-wide reputation to its enter- prising and liberal publishers. We welcome Rams- botham's Principles and Practice of Obstetric Medi- cine and Surgery to our library, and confidently recommend it to our readers, with the assurance that it will not disappoint their most sanguine ex- pectations.—Western Lancet. It is unnecessary to say anything in regard to the utility of this work. It is already appreciated in our country for the value of the matter, the clearness of its style, and the fulness of its illustrations. To the physician's library it is indispensable, while to the student as a text-book, from which to extract the material for laying the foundation of an education on obstetrical science, it has no superior.—Ohio Med. and Surg. Journal. We will only add that the student will learn from it all he need to know, and the practitioner will find it, as a book of reference, surpassed by none other.— Stethoscope. The character and merits of Dr. Ramsbotham'a work are so well known and thoroughly established, that comment is unnecessary and praise superfluous. The illustrations, which are numerous and accurate, are executed in the highest style of art. We cannot too highly recommend the work to our readers.—St. Louis Med and Surg. Journal. ROKITANSKY (CARL), M.D., Curator of the Imperial Pathological Museum, and Professor at the University of Vienna, &c. A MANUAL OF PATHOLOGICAL ANATOMY. Four volumes, octavo, bound in two. extra cloth, of about 1200 pages. Translated by W. E. Swaine, Edward Sieve- king, C. H. Moore, and G. E. Day. $5 50 To render this large and important work more easy of reference, and at the same time less cum- brous and costly, the four volumes have been arranged in two, retaining, however, the separate paging, «fec. The publishers feel much pleasure in presenting to the profession of the United States the great work of Prof. Rokitansky, which is universally referred to a> the standard of authority by the pa- thologists of all nations. Under the auspices of the Sydenham Society of London, the combined labor of four translators has at length overcome the almost insuperable difficulties which have so long prevented the appearance of the work in an English dress. To a work so widely known, eulogy is unnecessary, and the publishers would merely stale that it is said to coniain ihe results of not less than thirty thousand post-mortem examinations made by the author, diligently com- pared, generalized, and wrought into one complete and harmonious system The profession is too well acquainted with the re nutation of Rokitansky's work to need our assur- ance that this is one of the most profound, thorough. and valuable books ever issued from the medical press. It is sui generis, and has no standard of com- parison. It is only necessary to announce that it is issued in a form as cheap as is compatible with its size and preservation, and its sale follows as a matter of course. No library can be called com- plete without it.—Buffalo Med. Journal. An attempt to give our readers any adequate idea of the vast amount of instruction accumulated in these volumes, would be feeble and hopeless. The effort of the distinguished author to concentrate in a small space his great fund of knowledge, has bo charged his text with valuable truths, that any attempt of a reviewer to epitomize is at once para- lyzed, and must end in a failure.—Western Lancet. As this is the highest source of knowledge upon the important subject of which it treats, no real student can afford to be without it. The American publishers have entitled themselves to the thanks of the profession of their country, for this timeous and beautiful edition.—Nashville Journal of Medicine. As a book of reference, therefore, this work must prove of inestimable value, and we cannot too highly recommend it. to the profession.— Charleston Med. Journal and Review. This book is a necessity to every practitioner.— Am Med. Monthly. SCHOEDLER (FRIEDRICH), PH.D., Professor ofthe Natural Sciences at Worms, &c. THE BOOK OF NATURE; an Elementary Introduction to the Sciences of Physics, Astronomy, Chemistry, Mineralogy, Geology, Botany, Zoology, and Physiology. First American edition, with a Glossary and other Additions and Improvements; from the second A_mcricfl.fi **» English edition. Translated from the sixth German edition, by Henry Mgdlock, F. C. S., &c. In one volume, small octavo, extra cloth, pp. 692, with 679 illustrations. $1 80. ■28 BLANCHARD & LEA'S MEDICAL SMITH (HENRY H.)f M.D., Professor of Surgery in the University of Pennsylvania, tec. MINOR SURGERY; or, Hints on the Every-day Duties of the Surgeon. Illus- trated by two hundred and forty-seven illustrations. Third and enlarged edition. In one hand- some royal 12mo. volume, pp. 456. In leather, $2 25; extra cloth, $2 00. And a capital little book it is. . . Minor Surgery, we repeat, is really Major Surgery, and anything which teaches it is worth having. So we cordially recommend this little book of Dr. Smith's.—Med.- Chir. Review. This beautiful little work has been compiled with a view to the wants of the profession in the matter of bandaging, &c.,and well and ably has the author performed his labors. Well adapted to give the requisite information on the subjects of which it treats.—Medical Examiner. The directions are plain, and illustrated through- out 'with clear engravings.—London Lancet. One of the best works they can consult on the Bubject of which it treats.—Southern Journal of Medicine and Pharmacy. A work such as the present is therefore highly useful to the student, and we commend this one to their attention.—American Journal of Medical Sciences. No operator, however eminent, need hesitate to consult this unpretending yet excellent book. Those who are young in the business would find Dr. Smith's treatise a necessary companion, after once under- standing its true character.—Boston Med. and Surg. Journal. No young practitioner should be without this little volume; and we venture to assert, that it may be consulted by the senior members of the profession with more real benefit, than the more voluminous works.— Western Lancet. BY THE SAME AUTHOR, AND HORNER (WILLIAM E.), M. D., Late Professor of Anatomy in the University of Pennsylvania. AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful figures. $3 00. These figures are well selected, and present a complete and accurate representation of that won- derful 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 congratu- late 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, tfce very beau- tiful manner in which it is " got up" is bo creditable to the country as to be flattering to our national pride.—American Medical Journal. SARGENT (F. W.), M. D. ON BANDAGING AND OTHER OPERATIONS OF MINOR SURGERY. Second edition, enlarged. One handsome royal 12mo. vol., of nearly 400 pages, with 182 wood- - cuts. Extra cloth, $1 40; leather, $1 50. This very useful little work has long been a favor- ite with practitioners und students. The recent call for a new edition has induced its author to make numerous important additions. A slight alteration in the size of the page has enabled him to introduce the new matter, to the extent of some fifty pages of the former edition, at the same time that his volume is rendered still more compact than its less compre- hensive predecessor. Adoublegain in thus effected. which, in a vade-mecum of this kind, is a material improvement.—Am. Medical Journal. Sargent's Minor Surgery has always been popular, and deservedly so. It furnishes that knowledge of the most frequently requisite performances of surgical art which cannot be entirely understood by attend- ing clinical lectures. The art of bandaging, which Is regularly taught in Europe, is very frequently overlooked by teachers in this country; the student and junior practitioner, therefore, may often require that knowledge which this little volume so tersely and happily supplies. It is neatly printed and copi- ously illustrated by the enterprising publishers, and should be possessed by all who desire to be thorough- ly conversant with the details of this branch of our art.—Charleston Med. Journ. and Review, March, 1856. A work that has been so long and favorably known to the profession as Dr. Sargent's Minor Surgery, needs no commendation from us. We would remark, however, in this connection, that minor surgery sel- dom gets that attention in our schools that its im- portance deserves. Our larger works are also very defective in their teaching on these small practical points. This little book will supply the void which all must feel who have not studied its pages.— West- ern Lancet, March, 1856. We confess our indebtedness to this little volume on many occasions, and can warmly recommend it to our readers, as it is not above the consideration of the oldest and most experienced.—American Lan- cet, March, 1856. SKEY'S OPERATIVE SURGERY. In one very nandsome octavo volume, extra cloth, of over 650 pages, with about one hundred wood-cuts. $3 25. STANLEY'S TREATISE ON DISEASES OF THE BONES. In one volume, octavo, extra cloth, '286 pages. $1 50. SO I.LYON THE HUMAN BRAIN; its Structure, Physiology, and Diseases. From the Second and much enlarged London edition. In one octavo volume, extra cloth, of 500 pages, with 120 wood- cuts. $2 00. SIMON'S GENERAL PATHOLOGY, as conduc- ive to the Establishment of Rational Principles for the prevention and Cure of Disease. In one neat octuvo volume, extra cloth, of 212 paies. SI 25. 8 SMITH (W. TYLER), M. D., Physician Accoucheur to St. Mary's Hospital, 4c. ON PARTURITION, AND THE PRINCIPLES AND PRACTICE OF OBSTETRICS. In one royal 12mo. volume, extra cloth, of 400 pages. % 1 25. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON THE PATHOLOGY AND TREATMENT OF LEUCORRHC5A. With numerous illustrations. In one very handsome octavo volume extra eloth, of about 250 pages. $1 50. ' AND SCIENTIFIC PUBLICATIONS. 29 SHARPEY (WILLIAM), M.D., JONES QUAIN, M.D., AND RICHARD QUAIN, F. R. S., &c. HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidt, M. D., Professor of Anatomy in the University of Pennsylvania. Complete in two large octavo volumes, leather, of about thirteen hundred pages. Beautifully illustrated with over five hundred engravings on wood. $6 00. It is indeed a work calculated to make an era in anatomical study, by placing before the student every department 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 excuse fo? ne" ect ng or I *Mt °n ^atomy as the most complete on that sub- undervaluing any important particulars connected jeCl ln til? Ln&h,sh l*»*autS*l. a"dK the °£7 °»f» with the structure of the humn frame and j P?**p; ,in, an>l ^"fl*", which brings the state whether the bias of his mind lead him in a more I °f kni,w'f^' forwar'i £ «"> "\(f "*?"' dlS,C°' especial manner to surgery, physic, or physmlog" , venes—™e Edinburgh Med. and Surg. Journal. he will find here a work at once so comprehensive and practical as to defend him from exclusiveness on the one hand, and pedantry on the other.— Journal and Retrospect of the Medical Sciences. We have no hesitation in recommending this trea- TAYLOR (ALFRED S.), M. D., F. R. S., Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital. MEDICAL JURISPRUDENCE. Fourth American Euition. With Notes and References to American Decisions, by Edward Hartshorne, M. D. In one large octavo volume, leather, of over seven hundred pages. $3 00. This Mandard work has lately received a very thorough revision at the hands ofthe author, who has introduced whatever was necessury to render it complete and satisfactory in carrying out the objects in view. The editor has likewise used every exertion to make it equally thorough with regard to all matter- relating to the practice of this country. In doing this, he has carefully ex- amined all that has appeared on the subject since the publication ofthe last edition, and has incorpo- rated all the new information thus presented. The work has thus been considerably increased m Mze, notwithstanding which, it has been kept at its former very moderate price, and in every respect it will be found worthy of a continuance of the remarkable favor which has carried it through so many editions on both sides of the Atlantic. A few notices of the former editions are appended We know of no work on Medical Jurisprudence which contains in the same space anything like the same umount of valuable matter —N. Y. Journal of Medicine. No work upon the subject can be put into the hands of students either of law or medicine which will engage them more closely or profitably; and none could be offered to the busy practitioner of either calling, for the purpose of casual or hasty reference, that would be more likely to afford the aid desired. We therefore recommend itas the best and safest manual for daily use.—American Journal of Medical Sciences. This work of Dr. Taylor's is generally acknow- ledged to be one of the ablest extant on the subject of medical jurisprudence. It is certainly one ofthe most attractive books that we have met with; sup- plying so much both to inierest and instruct, that we do not hesitate to affirm that after having once commenced its perusal, few could be prevailed upon to desist before completing it. In the last London edition, all the newly observed und accurately re- corded facts have been inserted, including much that is recent of Chemical, Microscopical, and Patholo- gical research, besides papers on numerous subjects never before published.-Charleston Medical Journal and Review. It is not excess of praise to say that the volume before us is the very best treatise extant on Medical Jurisprudence. In saying this, we do not wish to be understood as detracting from the merits of the excellent works of Beck, Ryan, Traill, Guy, and others; but in interest and value we think it must be conceded that Taylor is superior to anything that has preceded it.—JV. W. Medical and Surg, lournal. BY THE SAME AUTHOR. ON POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. Edited, with Notes and Additions, by R. E. Griffith, M. D. In one large octavo volume, leather, of 688 pages. $3 00 TANNER (T. H.), M. D., Physician to the Hospital for Women, &c. A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS. To which is added The Code of Ethics of the American Medical Association. Second American Edition. In one neat volume, small 12mo. Price in extra cloth, 87| cents; flexible style, for the pocket, 80 cents. The work is an honor to its writer, and must ob- tain a wide circulation by its intrinsic merit alone. Suited alike to the wants of students and practi- tioners, it has only to be seen, to win for itself a place upon the shelves of every medical library. Nor will it be " shelved" long at a time; if we mis- take not, it will be found, in the best sense of the homely but expressive word, " handy." The style is admirably clear, while it is so sententious as not to burden the memory. The. arrangement is, to our mind, unexceptionable. The work, in short, de- serves the heartiest commendation.—Boston Med. and Surg. Journal. TUKE (DANIEL H.), M. D. ANEW 'WORK ON INSANITY. A MANUAL OF PSYCHOLOGICAL MEDICINE; containing the History, Nosology, Description, Statistics, Diagno>is, Pathology, and Treatment of Insanity. With an Appendix of Cases. By John Chakles Bucknill. M. D., and Damiel H. Tuke, M. D. page 4. See 30 BLANCHARD & LEA'S MEDICAL Now Complete (April, 1857.) TODD (ROBERT BENTLEYI, M. D., F. R. S., Professor of Physiology in King's College, London; und WILLIAM BOWMAN, F. R. S., Demonstrator of Anatomy in King's College, London. THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With about three hundred large and beautiful illustrations on wood. Complete in one large octavo volume, of 950 pages, leather. Price * I 50. \5qT Gentlemen who have received portions of this work, as published in the " Medical News and Library," can now complete their copies, if immediate application be made. It will be fur- nished as follows, free by mail, in paper covers, with cloth backs. Parts I., II., III. (pp. 25 to 552). $2 50. Part IV. (pp. 553 to end, with Title, Preface, Contents, &c), $2 00. Or, Part IV., Section II. (pp. 725 to end, with Title, Preface, Contents, &c), $1 25. A magnificent contribution to British meuicine, One of the very best books ever issued from any medical press. We think it indispensahle to every reading medica' mun.and it may, with all propriety, and with the utmost advantage be ma< ea text-Doox by any student who would thoroughly comprehend the groundwork of medicine.—N. O. Med. News, June, 1857. Our notice, though it conveys but a very feeble and imperfe. t idea of the magnitude and importance ofthe work now under consideration, already tran- scends our limits ; and, wiih the induig- nee of our readers, :md the hope that they will peruse the book for themselves, as we feel we can with confidence recommend it, we leave it in their hands for them ro judge of its merits.—The Northwestern Med. and Surg. Journal. Oct. 1857. It has been a far more pleasant task to us to point out its features of remarkable excellence, and to show in how many particulars the results which it embodies of skilful and zeHlous research do the highest credit to its able and accomplished authors. It would be a serious omission were we not to take special notice of the admirable and copious illustra- tions, the execution of which (by Mr. Vasey) is in the very finest style of wood-engraving.—Brit, and For. Medico-Chir. Review, Jan. 1853. and the American physician who shall fail to pei use it, wil have failed to read one of the most instruc- tive books of the nineieenih century.—N. O. Med and Surg. Journal, Sept. 1857. It is more concise thun Carpenter's Principles, and more modern than the accessible edition of Mailer's Elements; its details are brief, but sufficieit; in descripiions vivid ; its illustrations exact and copi- ous ; and its language terse and perspicuous.— Charleston Med. Journal, Juiy, 1S57. We recommend this work not only for its many origital investigations especially into the minute anatomy and physiology of man, but we admire the constant association of anatomy with physiology. The motive power is studied in its connections and adaptations to the machine it is destined to guide, and the student feels constantly impressed with the necessity for an accurate knowledge of the (structure of the human body before he can make himself mas ter of its functions.— Va. Med. Journal, June, 1857 We know of n> work on the subject of physiology so well adapted to the wants of the medic.il student. Its completion has been thus long delayed, that the authors might secure accuracy uy personal observa- tion.—St. Louis Med. and Surg. Journal, Sept. '57. TODD (R. B.), M. D., F. R. S., &c. CLTNICAL LECTURES ON CERTAIN DISEASES OF THE URINARY ORGANS AND ON DROPSIES. In one octavo volume. (Now Ready, 1857.) $1 50 The valuable practical nature of Dr. Todd's writing:< have deservedly rendered them favorites with the pro ession, and the present volume, embodying the medical aspects of a class of diseases not elsewhere to be found similarly treated, can hardly fail to supply a want long felt by the prac- titioner WATSON (THOMAS), M.D., «tc. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Third American edition, revised, with Additions, by D. Francis Condie. M.D., author of a "Treatise on the Di>ea>e* of Children," &o. In one octavo volume, of nearly eleven hundred large pages, strongly bound with rai:-ed bands. $3 25. To say that it is the very best work on the sub- ject now extant, is but to echo the sentiment of the medical press throughout the country. — N. O. Medical Journal. Ofthe text-books recently republished Watson is very justly the principal favorite.—Holmes's Rep. to Nat. Med. Assoc. By universal consent the work ranks among the very best text-books in our language.—Illinois and Indiana Med. Journal. Confessedly one of the very best works on the principles and practice of physic in the English or any other language.—Med. Examiner. Asa text-book it has no equal; as a compendium of pathology and practice no superior.—New York 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. Regarded on all hands as one of the very best, if One of the most practically useful books that not the very best, systematic treatise on practical ever was presented to the dtoident___N. Y. Med. medicine extant.—St. Louis Med. Journal. \ Journal AT THE BEDSIDE WHAT TO OBSERVE AND AFTER DEATH, IN MEDICAL CASES. Published under the authority ofthe London Society for Medical Observation. A new American from the second and revised London edition. In one very handsome volume, royal 12mo., extra cloth. $1 00. To the observer who prefers accuracy to blunders I One of the finest aids to a young practitioner we and precision to carelessness, this little book is in- have ever seen.—Peninsular Journal of Medicine. valuable.—N. H. Journal of Medicine. \ WILDE (W. R.), Surgeon to St. Mark's Ophthalmic and Aural Hospital, Dublin. AURAL SURGERY, AND THE NATURE AND TREATMENT OF DIS- EASES OF THE EAR. In one handsome octavo volume, extra cloth, of 476 pages, with illustrations. $2 80. AND SCIENTIFIC PUBLICATIONS. 31 WILSON (ERASMUS), M.D., F. R. S., a. airci Lecturer on Anatomy, London. A SYSTEM OF HUMAN ANATOMY, General and Special. Fourth Ameri- dred al? fir* 'ast EnSlish edition. Edited by Paul B. Godoard, A. M., M D. With two hun- «.;■» u.. j , ^ Mostrations. Beautifully printed, in one large octavo volume, leather, of nearly six hundred pages. $3 00. be exnectMH- StUdent tt" the assistance that cac , which will greatly facilitate his progress in the l eairom Buch a work.— Medical Examiner. ' study of Practical Anatomy.—New York Journal of hasnb^eom„if n0t a" tlle c"'"eges of the Union, it ; Medicine. is sufficient! " 8tiin"a.ro now be found a collection of Selected Formula, consisting for the most part of prescriptions ot whu-h the author has tested the value. The writings of AVilson, upon diseases of the skin, are by tar the most scientific and practical that have ever been presented to the medical world on this subject. The present edition is a great improve- ment on all its predecessors. To dwell upon all the great merits and high claims ofthe work before us. seriatim, would ind. ed De an agreeable service; it would be a mental homage which we could freely offer, hut we should thus occupy an undue amount ot space in this Journal. We will, howtver look at some of the more salient points with which it abounds, and wh.ch make ii incomparably superior in excellence to all other treatises on the subject of der- matology. No mere speculative views are allowed a place in this volume, which, without n doubt will, for a very long period, be acknowledged as the chief standard work on dermatology. The principles of an enlightened and rational tnerapeia are introduced on every appropriate occasion. The general prac- titioner and surgeon who, peradventure, may have for years regarded cutaneous maladi»s as scarcely worthy their attention, because, forsooth, they are not fatal in their tendency; or who, if they'have attempted their cure, have followed the blind guid- ance of empiricism, will almost assuredly be roused to a new und becoming interest in this department of practice, through the inspiring agency of this book.—Am. Jour. Med. Science, Oct. 1857. ALSO, NOW READY, A SERIES OF PLATES ILLUSTRATING WILSON ON DISEASES OF THE SKIN ; consisting of nineteen beautifully executed plates, of which twelve are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and containing accurate re- presentations of about one hundred varieties of disease, most of them the size of nature. Price in cloth $4 25. In beauty of drawing and accuracy and finish of coloring these plates will be found equal to anything of the kind as yet issued in this country. The plates by which this edition is accompanied | tioner a very correct idea of the disease he is study- leave nothing to be desired, so far as excellence of ing. We know of no work so well adapted to the wants of the general practitioner as Wilson's, with the accompanying plates. — Med. and Surg. Re- porter, May, 1B58. We have already expressed our high appreciation of Mr. Wilson's treatise on Diseases of the Skin. The plates are comprised in a separate volume, which we counsel all those who possess the text to purchase. It is a btautiful specimen of color print- ing, and the repiesentations of the various forms of skin disease are as faithful as is possible in plates of the size.—Boston Med. and Surg. Journal, April 8, 1858. delineation and perfect accuracy of illustration are concerned.—Meaico-Chirurgical Review. Of these plates it is impossible to speak toohighly. The representations ot the various forms of cutane- ous disease are singularly accurate, and the coloring exceeds almost anything we have met with in point of delicacy and finish.—British and Foreign Medical Review. One of the best specimens of colored lithographic illustrations that have ever been published m this country. The representations of diseases of the *kin, even to the most minute shade of coloring, are remarkably accurate, giving the student or practi- BY THE 8AME AUTHOR. ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON SYPHILITIC ERUPTIONS. In one small octavo volume, extra cloth, beautifully printed, with four exquisite colored plates, presenting more than thirty varieties of syphilitic eruptions. $2 25. BY THE SAME AUTHOR. HEALTHY SKIN; A Popular Treatise on the Skin and Hair, their Preserva- tion and Management. Second American, from the fourth London edition. One neat volume, royal l2mo., extru cloth, of about 300 page*, with numerous illustrations. $1 00; paper ooVer, 75 cents. 31 BLANCHARD & LEAS MEDICAL PUBLICATIONS. WEST (CHARLES), M. D., Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hospital for !| . i>. 11-*: «3 ^^ ,;V, ^#K A A j; <■>'.