; x? Wpr. Vt ^K 4 «-<-7 J* *J> m J€Q£)rG» .Surgeon General's DfficV f?Tffl&lQ &XM&-X& m •) "=Si U ■ \ y- v. •.:*...-45-.J N« 5J v o:.i,.ffj.:»^y. .^CAi^r ^ ao -^ ■ r v ^ V.' .t I ^ , t ;-' - V •-* T-' JV - 1 1^ > > Sk'V v^- 7- r% ,.■"** - .x. jw* -*\ *" fry < $ TREATISE ON THE DISEASES AND PHYSICAL EDUCATION OF CHILDREN, BY JOHN EBERLE, M. D. PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE IN THE MEDICAL COLLEGI OF^QHIO; MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY; OF THE ACADEMY OF SCIENCES OF PHILADELPHIA; CORRESPONDING MEMBER OF THE MEDICO-CHIRURGICAL SOCIETY OF BERLIN, IN PRUSSIA, &C. &C. THHID EDITION. a; >r> /' liJMlaHclphfa: GRIGG & ELLIOT, 9 NORTH FOURTH STREET. 184 5. Annex EUt Entered according to act of Congress, in the year 1833, by JOHN EBERLE, M. D., in the Clerk's Office of the District of Ohio. KTKREOTYPED flV u. JOII NN.IN. PRINTED BV T. K. & P. O. i;.:U.IN-i. PHIL* DEI.PII U TO N.R. SMITH, M. D., PROFESSOR OF SURGERY IN THE UNIVERSITY OF MARYLAND, &c. &c. THIS WORK IS RESPECTFULLY INSCRIBED, *.S AN HUMBLE ACKNOWLEDGMENT OF THE HIGH REGARD ENTERTAINED FOR HIS PROFESSIONAL TALENTS, AND PRIVATE WORTH, BY HIS FRIEND AND FORMER COLLEAGUE, THE AUTHOR. 3 CONTENTS. BOOK I. OF THE PROPHYLACTIC, AND PHYSICAL MANAGE- MENT OF CHILDREN. CHAP. I. Of the conduct of mothers during PAGES Pregnancy, 1 n. Of the Management of new-born Infants, - 17 HI. Of the Nourishment of Infants, 25 IV. Of Exercise, - 43 V. Air—Temperature—Exposure, 51 VI. The Nursery, - 58 VH. Of Weaning, 61 vm. Cleanliness. Washing. Bathing, 72 BOOK II. OF THE DISEASES OF CHILDREN. CHAP. I. Of Syncope, Asphyxia, and Imper- fect Respiration, H. Of the Meconium, HI. On the Tongue-Tie, IV. Of the Inflammation and Swelling of the Breasts of new-born Infants, 5 1* 77 88 92 94 CONTENTS. PAGES. V. Of Inflammation and Ulceration of the Navel, - 96 VI. Of the Jaundice of Infanjs, Of the Retention and Suppression 99 VII. of Urine, - 109 VIII. Of Dysuria—or Painful and Diffi- cult Micturition, - 115 IX. Of Enuresis—or Incontinence of Urine, - 120 X. Of Dentition, 125 XI. Of the Diabetes of Infants, 145 XII. Of the Erysipelas of Infants, 150 XHI. Induration of the Cellular Membrane and Skin. Skinbound, 162 XIV. Of the Coryza of Infants, 168 XV. Of the Aphthae of Infants. Thrush, 171 XVI. Ulceration of the Mouth, 183 XVII. Of Colic, 187 XVHI. Of Constipation, 201 XIX. Of Vomiting, - 205 XX. Of Diarrhoea, 211 XXI. Of Intestinal Worms, 255 XXII. Of Ophthalmia, 269 xxm. Of Cholera Infantum, 283 XXIV. Of the Remittent Fevers of Infants, 300 XXV. Catarrh. Catarrhal Fever, 318 XXVI. Acute Bronchitis, 327 xxvn. Pleuritis, - 332 xxvm. Parotitis. Mumps, - 336 XXIX. Tonsillitis. Cynanche Tonsillaris.— Quinsy, - 339 XXX. Cynanche Trachealis. Tracheitis. Croup, - 344 6 CONTENTS. PAGES. XXXI. Cynanche Laryngea, 365 xxxn. Arichnitis. Hydrocephalus. Dropsy ,v in the Brain, 370 XXXIH. fferitonitis. Ascites, 391 XXXIV. Vaccina. Vaccine Disease, 396 XXXV. Modified Small Pox, 411 u Sect. 1. Varioloid Disease, 411 t( " 2. Varicella, 417 XXXVI. Rubeola, Morbilli. Measles, 428 XXXVH. Scarlatina. Scarlet Fever, 443 xxxvm. Pertussis. Whooping Cough, 469 XXXIX. Convulsive Affections of Infants, 489 XL. Infantile Epilepsy, 508 XLI. Carpo-Pedal Spasms, 525 XLH. Chronic Eruptive Affections, 533 xlih Inflammation and Abscess within the Ear, - 545 7 BOOK I. OF THE PROPHYLACTIC AND PHYSICAL MANAGEMENT OF CHILDREN. CHAPTER I. OF THE CONDUCT OF MOTHERS DURING PREGNANCY. That the fetus may be variously and injuriously affected, oy causes acting through the medium of the maternal system; and that disease and constitutional infirmity are thus often produced during the uterine stage of life does not appear to admit of a doubt. From the moment, therefore, that conception has taken place, a new and most sacred duty devolves upon the female. She is bound by all the ties of maternal sentiment, of humanity and of moral and religious obligations to protect the nascent being in her womb, against every circumstance under her control, which may have an unfavourable influence on its delicate and uninured organization. Though not in itself a state of disease, pregnancy is evidently attended, in the majority of instances, with a decidedly increased aptitude to morbific influences. Augmented sensibility and irri- tability of the nervous and sanguiferous systems, appears to be a natural concomitant of all great efforts of physical development in the animal organization. We observe it in dentition, and at the age of puberty, and it is, in general, equally strongly marked during the progress of those important developments which take place in the female system, from the commencement to the com- pletion of gestation. When to this we add the remarkable tendency to general plethora, and the rise of the various powerful and pervading sympathies which occur during pregnancy, we have a combination of circumstances peculiarly calculated to in- crease the liability to disease and injury, from the influence of exciting and irritating causes. 2 OF THE CONDUCT OF MOTHERS Without doubt, many instances of pregnancy occur in which good health is enjoyed throughout its whole course, although little or no particular care is taken to avoid the usual sources of injury in such cases. Very frequently, however, the reverse ob- tains; and we daily witness much suffering and danger, both to the mother and child, from the influence of causes which, with proper care, might be avoided or rendered inoffensive. The most serious, and perhaps, most common injurious conse- quence resulting from errors in this respect is abortion. Females are not, in general, sufficiently impressed with the great im- portance of attending to the precautionary measures, which reason ;md experience dictate, in relation to the prevention of this acci- dent. They are apt to look upon abortion, as a temporary evil— an affair of a few hours, or at most of a few days suffering, and generally of no other serious consideration than that which may be due to the premature destruction of the embryo. This con- sideration might, indeed, be deemed a sufficient motive for the exercise of adequate care in this respect; but it may well be doubted, whether it often receives the regard which a proper sense of duty would dictate. In addition, however, to this appeal to the moral sentiment of the mother, there are other circumstances in relation to her own welfare, which when properly presented to her mind, seldom fail to excite a suitable attention to this import- ant subject. Besides the very distressing circumstance that abortion, is in general peculiarly liable to recur, after having once taken place, we may mention the following as among the ordinary evil consequences of this accident—namely leucorrhoea, menorr- hagia, dysmenorrhoea, prolapsus uteri; schirrus uteri, various nervous affections, especially chronic hysteria, dyspepsia, and general debility and ill-health. It is indeed a very rare occurrence to meet with a healthy female who has aborted more than once. Permanent injury to health is much more apt to result from abortion than from regular parturition. The benevolent author of nature has endowed every being with powers adequate under ordinary circumstances, to sustain the natural operations which it is destined to perform, without any particular evil consequences. The premature separation and expulsion of the foetus, however, is an occurrence contrary to the design and regular course of nature and can not take place without more or less violence to the system and consequent disorder and infirmity. But it is not simply with the view of obviating this accident, that the pregnant female is so deeply concerned in guarding against the operation of injurious causes. The future health and vigour of the child may be materially affected by the conduct of the mother in this respect. Organic debility and morbid predispositions may be thus produced, which, m their ultimate DURING PREGNANCY. 3 consequences, may prove more afflicting than abortion itself. It has indeed been supposed, that as there exists no direct or con- tinuous communication between the foetus and the mother, either by the blood vessels or the nerves, the former, probably, never participates to any serious extent, in the general diseases of the latter. It is observed that infants, well nourished, and apparently in good health, are occasionally born of mothers who had laboured under severe and irremediable disease during the whole period of gestasion. This is doubtless the case in many instances; but it should be observed that although the new-born infant may appear to enjoy a good state of health, it frequently happens that the disease or predisposition contracted during gestation, remains latent or dormant for months or even years after birth, before it is de- veloped; and thus, there may be the appearance of a sound and healthful state of the constitution, during infancy, although the seeds of disease may be deeply deposited in the system. The want of a continuous vascular or nervous communication between the foetus and the mother, can not be regarded as a sufficient ground for denying the possibility of the passage of disease from the maternal to the foetal system. The fact that syphilis and small-pox, not to mention various other affections, have been contracted by the foetus in utero, furnishes conclusive evidence of the occasional transmission of disease from the mother to the foetus. In the higher grades of miasmal fever, particularly in yellow fever, miscarriage is by no means uncommon; and in many instances of this kind, the child is born dead, and often with evident marks of having died several days previous to its expulsion from the womb. It is nevertheless probable that the influence of maternal disease, or of injurious causes acting through the mother's system on the foetus, when not sufficiently powerful to excite abortion, is generally confined to the production, rather of organic feebleness and predisposition to disease, than to any active state of morbid excitement or positive malady. Be this as it may, the liability of the child to injurious impresssions, during its uterine existence, is abundantly verified by observation; and experience and reason justify the conclusion, that the welfare of the foetus, in relation both to its physical and moral conditions, is intimately connected with the health and regularity of the ma- ternal system—and consequently, so far under the control of the mother, as she may have it in her power, to avoid the sources of disease and inordinate excitement. I. Of the dietetic regulations proper during pregnancy.—The peculiar tendency to febrile irritation and general plethora, so apt to accompany pregnancy, renders it especially proper to avoid the sources of undue excitation and nourishment during this period. The sensibility of the stomach, too, almost always 4 OF THE CONDUCT OF MOTHERS undergoes peculiar modifications; and the remarkable activity of its sympathies, more especially with the uterine system, attending most instances of pregnancy, presents us with an additional reason for the adoption of proper dietic regulations during the progress of gestation. It is not to be inferred, indeed, that the pregnant female unless labouring under some disease, is to be dieted like a valetudinarian; but admitting a substantial and adequate diet, we are nevertheless warned by experience, to enjoin that moderation and simplicity of food, which would always be best, but which is now especially proper; and to caution against the free use of heating or particu iarly stimulating ingesta. As the appetite is frequently very craving in pregnancy, an inordinate indulgence in rich and high seasoned food is among the most common errors of females during this period. This error is the more apt to be committed, from the erroneous idea which many entertain, that, as the foetus in utero draws its nourishment from the maternal system, a greater quantity of aliment is required in pregnancy than is necessary in the un- impregnated state. Dr. Dewees, in his work on the diseases of children, has placed the fallacy and injurious tendency of this opinion in a very strong light. The eight or ten pounds of animal substance which goes to the composition of the fully developed foetus, being gradually drawn from the mother during a period of nine months, can not, surely, require any particular increase in the nourishment taken by the mother—more especially, " as almost eveiy individual habitually takes more food, than is required for the regular support and health of the system." The evils which are liable to result to pregnant females from er- rors in diet, are various and often exceedingly distressing. Where a predisposition to abortion exists, the free use of very nourishing and stimulating articles of diet, may give rise to this accident, simply by favouring the usually prevailing tendency to general plethora and fever. The occurrence of indigestion and gastric irritation, also, is particularly calculated to produce serious conse- quences in pregnancy. I have known several instances where the use of indigestible and irritating articles of food gave rise to the most alarming irritation of the stomach and bowels, attended with severe vomiting, and followed very speedily by abortion. In one case, a young married woman, in the fourth month of her first pregnancy, was seized with excruciating and obstinate dyspeptic colic, soon after she had eat freely of some very indigestible food. Notwithstanding the great risk and suffering which she had under- gone from this attack, which she could not but refer to its true cause, and while her stomach was still weak and irritable, the Mrong cravings of her appetite led her, in about ten days after, to commit a similar, but still more glaring error. The consequence DURING PREGNANCY. 5 was, another violent attack of colic, followed immediately by in- flammation of the bowels, which in the course of the second day terminated in abortion, and on the following day in the death of the patient. The exercise of caution, in the selection of proper food for pregnant females, appears to be particularly important towards the termination of gestation. The occurrence of gastro-intestinal irritation and dyspeptic colic, at this period, besides its tendency to excite miscarriage, seems to be particularly favourable to the supervention of peritonitis, after the delivery of the child. There is another circumstance in relation to this subject, which appears to be well entitled to attention. There is a chronic form of intes- tinal irritation, which results from the impression of vitiated secretions, or unnatural and inordinately accumulated fcecal matter, and which, though not often manifested by any very conspicuous morbid effects during gestation, often exerts an alarming and fatal influence on the system, within a short period after parturition has taken place. A redundant, mixed, hetero- genous, and not sufficiently digestible diet, is especially apt to lead to this condition of the bowels, where the digestive functions are not very vigorous, and the alvine evacuations insufficient. The consequences which are liable to result from intestinal irritations of this kind, are: great prostration; puerperal convulsions; alarm- ing nervous affections; severe head-ache; pain in the lower part of the abdomen; inability to sleep; and a peculiar and highly dangerous affection, resembling puerperal fever, characterized by a remarkable sinking of the vital energies. That the liability to this very alarming form of puerperal disease, is greatly enhanced by errors in diet,—more especially by excess in the quantity of food taken, during the later stage of gestation admits of no doubt. I have witnessed several instances in which the correctness of this observation seemed to me very strikingly exemplified. A lady who had enjoyed unusually good health previous to her pregnan- cy, but who could not be restrained from indulging her appetite to an improper extent, became affected with severe and painful diarrhoea, about the middle of the last month of gestation. By the adoption of proper dietetic regulations, and the employment of suitable medicines, the disease subsided in the course of seven or eight days. A few days, however, before the termination of the pregnancy, she indulged to excess in eating plum-pie with a full proportion of strong cheese, "to help the stomach to digest" the farrago she had swallowed. Diarrhoea was re-excited; and in a few days after she was delivered of a healthy child. On the second day after parturition, she experienced a slight chill, fol- lowed speedily by symptoms simulating puerperal fever, attended with irresistible prostration and sinking of the vital energies, which 2 f, OF THE CONDUCT OF MOTHERS terminated in death on the fourth day. These violent and dan- gerous effects of intestinal irritation are, fortunately, not very common; but there are many other affections of a discomforting, and often distressing character, which are rarely entirely escaped, by those who neglect a prudent attention to dietetic observances. Flatulency, acid eructations, pains in the stomach and bowels, cephalalgia, hysteria, diarrhoea, a feverish and restless state of the system, depression of spirits, palpitations, not to mention various other disturbing affections, are among the ordinary consequences of a habitual disregard of proper regulations, in relation to the diet. The pregnant female who observes a suitable regimen, will caztcris paribus, always enjoy more tranquility both of mind and body, and incur much less risk of injury to herself and child, than she, who giving a free rein to her appetite, indulges it to excess, or in the use of improper articles of food. With regard to the particular dietetic regulations proper during pregnancy, it may be observed that moderation and simplicity in diet, are in general of more importance to the health and comfort of the female, than any very cautious selection as to the kind of food. This remark is more especially applicable to females en- joying a good state of health or who are free from any particular derangement of the digestive functions. A healthy female may, without risk of injury from this source, continue to take the same kind of nourishment during gestation, to which she was accustom- ed, and by which her health was maintained previous to the occurrence of pregnancy. Where the digestive powers are very active and there exists a decided tendency to plethora and febrile excitement, however, it will be proper to avoid the more stimu- lating and nutritious articles of food. In such cases, a diet con- sisting principally of the more digestible kinds of vegetable aliment should be selected, and all heating or strong stimulating drinks rigidly avoided. In cases attended with a weak and irritable state of the stomach, a continued attention to the selection of suitable articles of nourish- ment is particularly important. In instances of this kind, the most distressing and alarming consequences are apt to result from errors committed in this respect. The necessity of enjoining un- interrupted attention to the choice of proper articles of food, when the digestive organs are in this condition, is the more urgent, from the circumstance that in cases of this kind, the appetite is fre- quently very craving and capricious, requiring a degree of resolution and forbearance which is seldom witnessed, until actual suffering gives efficiency to the counsels of prudence and expe- rience. In general, such cases require the management proper in dyspepsia. Mild, unirritating, digestible and adequately nourish- ing food, must be selected. Rice, barley, arrow-root, oat-meal, DURING PREGNANCY. 7 milk, the lean parts of mutton, lamb, venison, tender beef, soft- boiled eggs, stewed apples and peaches, constitute appropriate articles of nourishment in such cases. It should be observed, moreover, that moderation in eating, as well as simplicity in the variety of the articles of food, are indispensible to the comfort and health of the patient under these circumstances. It matters not how suitable the diet may be as to its character; much, if not all the advantage which might result from it, under a temperate use, will be prevented, if it be taken in larger portions than the stomach is capable of digesting. Coffee and tea, when not made very strong, seldom give rise to any obvious inconvenience or disorder, and may in general, be used with perfect propriety during the period of gestation, by females enjoying an ordinary state of health. In subjects of a decidedly nervous temperament, however, or in such as are labouring under a morbidly irritable state of the ner- vous system, the use of strong coffee, and more especially of strong green tea, should be interdicted as a habitual beverage at meals. In such cases, black tea or well prepared chocolate, may in general be taken with entire safety. Milk, more or less diluted with water, is also an excellent drink in habits of this kind. With regard to vinous or alcoholic drinks, it is scarcely possible to reprobate their habitual use, in terms of censure sufficiently strong. Excepting as mere medicinal agents, regularly prescribed, they ought to be wholly and most rigidly avoided by pregnant fe- males. The temptation, as Dr. Dewees very truly observes, to taking small portions of cordial or brandy, in the early months of gestation, is often very strong. The annoying sensations frequently- experienced in the stomach, and the general uncomfortable feel- ing connected with them, are, usually, allayed or moderated for a time, by the use of these potent stimuli. The unpleasant feelings, however, return, and recourse is again had to the assuaging but insidious stimulus; and thus it is taken again and again, in still increasing portions, until the deplorable habit of solitary dram-drinking is formed, and the health, happiness, and character, of, perhaps, an otherwise amiable and excellent being, immolated to the filthy and devastating demon of inebriety. The frequent or habitual use of spirituous drinks, is particularly apt to favour the occurrence of abortion. In the course of my practice I have met with some very striking exemplifications of this fact. A lady, who, after the birth of her first child, became deeply imbued with this lamentable vice, aborted four times in succession. She then, by the earnest and unremitting exertions of her friends, seconded by her own efforts, succeeded in throwing off the habit of intemperance, and in the course of the following ten years gave birth to four children. These children, however. were remarkably feeble and sickly from their birth, and one only, 8 OF THE CONDUCT OF MOTHERS out of the four, is now living—about six years of age, and mani- festly of a very delicate and infirm constitution. Examples of the very ruinous effects of habitual intoxication on the health and life of the foetus in utero, are unfortunately, but too common. The majority of children born of decidedly intemperate mothers, are weak and sickly, and but few of them arrive at the age of adoles- cence. Many females appear to think, that although these and other melancholy consequences, follow in the train of habitual in- temperance, it is extremely improbable that any injury can result to themselves or the foetus, from the occasional use of small portions of spirituous liquors. Were it indeed absolutely certain, that the use of such potations, would always be restricted to oc- casional small portions, the indulgence would perhaps, rarely occasion any serious consequences. But as no prudence and resolution can be safely regarded as an entire protection against the gradual formation of the habit of intemperance, where such drinks are occasionally taken during gestation, even though it be at very considerable intervals and in very moderate quantities at first, it is far the safest plan, to abstain wholly from every kind of spirituous liquors. The propriety of total abstinence, is the more obvious, from the undeniable fact, that whatever temporary me- lioration of the feelings which may, at times, result from the use of spirituous drinks, they very frequently contribute, ultimately, to increase the infirmity or mischief for which they were taken. Before leaving this part of the present subject, it will be proper to make a few remarks upon that remarkable irregularity of the appetite, or " longing," as it is called, which many females expe- rience during pregnancy. The appetitive sensibilities of the stomach undergo so much derangement in some instances, that articles of food, which previous to the occurrence of pregnancy were very grateful and congenial, become highly disagreeable, and an almost irresistible craving for unnatural and even disgust- ing substances is experienced. In general, this aberration of the appetite, is more apt to occur in weak and delicate females of a nervous temperament, than in such as are of a robust and full habit of body. Different opinions have been expressed with regard to the probable influence, which entirer resistance to these vehement longings or disppointment in satisfying them, may have on the mother and foetus. It is not unreasonable to presume, that the strong mental affection which may be caused by disappointment in this respect, may exert an unfavourable influence on the health of the mother and child, more especially in very nervous and ex- citable females. Disappointment, and its consequent moral affection, from this source, however, has nothing peculiar in its influence, and can be no more injurious in its reaction on the DURING PREGNANCY. 9 system than an equally strong emotion of the mind, from any other source of disappointment or frustrated desire. If the substances longed for be not evidently of an injurious character, they should not be withheld. The mind is always more or less tranquilized by gratification, and, unless the indulgence be carried to an immoderate extent, it will very rarely occasion any particular disturbance. It is very remarkable, indeed, that even unwholesome articles, seldom give rise to any particular inconve- nience or disturbance in the system, where there is a very urgent and persisting desire experienced for them. Still it would not be prudent to trust too much to this power of the stomach to resist the injurious impressions of the substances it calls for; and whenever the appetite is thus directed upon articles of an offensive or hurt- ful nature, means should be used to divert it and determine it to more suitable alimentary substances. In some instances, these "longings" must be regarded as instinctive calls of the stomach, favourable to the health of the individual. If they are not grati- fied, langour, inquietude and other symptoms of deranged health, will be very apt to supervene. Thus when a strong desire for eating chalk, charcoal, clay, &c. is manifested, we are admonished that the digestive powers^are feeble, and that there exists a pre- vailing tendency to acidity in the stomach. In such cases, the appropriate means of relief are alkalines,mild laxatives, and tonic vegetable bitters, with a suitable regimen. Magnesia in combi- nation with some vegetable bitter, or the bi-carbonate of potash with small portions of aloes, or rhubarb, so as to procure one or two free alvine evacuations daily, seldom fail to procure some ad- vantage. If the tongue is bitter and clammy, small doses of blue- pill, with an occasional mild purgative, and moderate portions of sulphuric or nitric acid, three or four times during the day, will tend to bring the stomach back from its aberrations, to a more healthy tone of feeling. It is not common, however, to find these irregular determinations of the appetite so strong or so decidedly injurious in their tendency, as to require any particular medical attention; and we rarely meet with instances which may not be moderately indulged, without injury or inconvenience to the system. II. Of the proper regulations in relation to dress and exercise.—This is a most important subject of attention to females during the period of gestation. Some of the prevailing customs in relation to dress, are so obviously improper during pregnancy, that it would seem very strange that there should be any difficulty in procuring their temporary rejection by females in this condition, did we not know that the imperious commands of fashion are often more sedulously obeyed, than the dictates of humanity and of self preservation. The custom of wearing tightly laced corsets during 10 OF THE CONDUCT OF MOTHERS gestation, can not be too severely censured. It must be evident to the plainest understanding, that serious injury to the health, both of the mother and child, must often result from a continual and forcible compression of the abdomen, whilst nature is at work in gradually enlarging it, for the accommodation and devel- opment of the foetus. By this unnatural practice the circulation of the blood throughout the abdomen is impeded—a circumstance, which together with the mechanical compression of the abdominal organs, is peculiarly calculated to give rise to functional disorder of the stomach and liver, as well as to haemorrhoids, uterine haemor- rhage and abortion. The regular nourishment of the foetus, also, is generally impeded in this way,—a fact which is frequently verified in the remarkably delicate and emaciated condition of infants, born, of mothers who have practised this fashionable folly during gestation. It may be observed, that since the custom of wearing tightly laced corsets has become general among females, certain forms of uterine disease are much more frequent than they were, previous to the re-introduction of this fashion. My expe- rience has satisfied me, that leucorrhoea and prolapsus uteri, are vastly more common at the present day, among unmarried females, than they were sixteen or eighteen years ago. It is indeed aston- ishing, that these disorders are not more frequent even than they appear to be; for we can not conceive of any cause more directly calculated to produce them, than the prevailing practice of pressing the abdominal viscera down upon the womb, and thus forcing it out of its natural position, into the lower part of the pelvis, where the irritation it causes, gives rise to leucorrhasal discharge. Struve observes, in relation to the injurious tendency of wearing corsets during gestation, " that the parts which have suffered from con- stant pressure, become debilitated and incapable of co-operating in the important function of parturition; so that the passage of the child is endangered, the labour rendered more tedious and pain- ful, and all the operations of nature retarded." The pressure of corsets, moreover, must tend to debilitate both the mother and infant, by impeding the function of respiration, and preventing in some degree, the regular decarbonization of the blood. Struve cautions pregnant females against an error, which is not likely to be committed in the present mode of dressing—namely, " to avoid wearing a number of heavy petticoats, by which the abdomen may be depressed, and a bad position of the foetus produced. At the present day, it is much more necessary to caution against the opposite impropriety, of using insufficient clothing to protect the body from the injurious influence of cold and atmospheric vicissi- tudes. The abdomen and feet especially, should be guarded against injury from these causes. In the winter or cold and damp j>easons, the use of a broad flannel or bandage or roller round the DURING PREGNANCY. 11 abdomen, is very useful in this respect, and may be beneficial moreover, by the uniform support which it affords to the abdomen and its consequent tendency to obviate any unfavourable obliqui- ties in the position of the womb, in the advanced periods of gestation. The exercise which it may be proper to use during pregnancy, must of course, vary according to the period of gestation, and the particular condition of the female in relation to constitutional vigour, predisposition to abortion, and other affections, previous habit, and temperament. All kinds of " agitating exercise, such as riding in carriages with rapidity over rough roads, dancing, lifting, or carrying heavy loads, in short, all masculine and fatiguing employments whatever," ought to be avoided by pregnant women. The propriety of avoiding agitating and fatiguing exercise, in- creases in proportion as gestation approaches the term of its regular completion. During the eighth or ninth month of preg- nancy, unusual corporeal exertion or fatigue, is particularly apt to excite premature labour; and where this accident has once taken place the necessity of observing proper caution in this respect, in subsequent pregnancies, is peculiarly urgent. In all instances, where a predisposition exists to abortion at any particular period, it is scarcely possible to prevent its occurrence, unless the utmost degree of care is taken, to avoid exciting or fatiguing exercise, about the time when this accident is apt to take place. In weak, excitable, and nervous females, and in such as are of an unusually plethoric and irritable habit of body, it is particularly proper to observe suitable precautions, in relation to exercise and corporeal exertion. It is to be observed, however, that if injury is apt to result from too much exercise and agitation of the body, there is reason also for apprehending injurious consequences from too much indolence and inactivity. Moderate and gentle exercise is generally decidedly salutary during gestation, and should not be neglected unless some particular reason exists for maintaining a state of rest and bodily composure. Riding, in an easy carriage, on even roads, or moderate walking, may be enjoyed with great pro- priety, and usually with obvious advantage during gestation. III. Of moral influences.—Tranquility and cheerfulness of mind are always highly favourable to the health and regular operations of the animal economy. In pregnancy, the importance of a calm and even temper is especially great; for the re-action of mental agitation or depression, is capable of producing very unfortunate impressions, both upon the mother and foetus. Violent anger, terror, or jealousy seldom fail to produce unpleasant effects during pregnancy; and the consequences are, sometimes, very alarming, and even fatal. Convulsions, severe paroxysms of hysteria, spasms, syncope, insensibility, hasmorrhage, and abortion, may be pro- 12 OF THE CONDUCT OF MOTHERS duced by moral influences of this kind. Not more than ten months ago, I witnessed the occurrence of hysteric convulsions followed, in the course of a few hours by abortion, in consequence of a fit of vehement rage from jealousy. But even when none of these violent affections result from the more agitating emotions, there are various minor evils of a discomforting and distressing charac- ter, which are apt to occur during pregnancy from moral influences of this nature. The functions of the stomach, the heart, the liver, and of the brain itself, are strongly influenced by the mind. The depressing moral affections often exert a highly injurious influence on the organization, particularly on the digestive and biliary organs. Debility, indigestion, jaundice, emaciation, with various other functional disorders, and even organic affections, are fre- quently produced by emotions of this kind; more especially by intense and protracted grief, and mental distress. Unfortunately no effort of the will, or firmness, is always adequate to avoid these distressing affections of the mind. The accidents and misfortunes to which all are liable, sometimes bring grief, and sorrow, and distress, with a force which cannot be sufficiently resisted. There are, however, other causes of mental disturbance, which are more under the control of well constituted minds; and which are almost as detrimental to the welfare of both the mother and child, as the moral affections just referred to. Fretfulness and moroseness of temper; envious and jealous feelings, peevishness, hatred, discon- tent, obstinacy and perverseness of disposition, are under the subjection of reason and a sense of propriety. It is of great im- portance to the regular progress of gestation and to the well-being of the mother and foetus, that every effort which good sense and moral feeling dictate, should be steadfastly made by pregnant fe- males, to keep down these injurious and degrading sentiments and irregularities of temper. The maternal imagination has been accused of producing the most extraordinary effects on the foetus in utero. During the early and middle ages, it was almost universally believed, that malfor- mations, moles, and other unnatural appearances, were very generally produced by the influence of the imagination of mothers; and the opinion continued to prevail with many reflecting and well informed physicians, until within a comparatively late period. A multitude of pretended examples of this kind, are on record__ many of which are of a character so strikingly preposterous and impossible, that they can now be regarded only as extraordinary and humiliating instances of human credulity. We are told, that black children have been born of white parents, in consequence of the maternal imagination having been excited by contempla- ting the portrait of an Ethiopan, and the same effect has been produced, according to some statements, in consequence of preg- DURING PREGNANCY. 13 nant females having contemplated with interest the portiaitof an Ethiopian, or having been frightened by a black man. Damas- cenes assures us, that he saw an infant born with the whole of its body covered thickly with coarse black hair, caused, as he states, by the mother having frequently looked at an image of St. John dressed in a bear's skin. A child was born at Blois in France, with the iris of one of its eyes accurately representing the dial- plate of a watch, in consequence of the mother having experi- enced a very strong desire to have a watch, which from some cause or other could not be gratified. Absurdities of this gross and glaring character are now but little entertained even by the most superstitious and ignorant. There are still, however, some, who fancy that under strong excitement the imagination is capable of producing indelible impressions on the body of the foetus in utero. It is not very uncommon, to hear moles, marks, and various other blemishes and malformations as- cribed to mental influence. Apprehensions of this kind, sometimes seize on the minds of females, with irresistible force; and they often occasion great anxiety and unhappiness during gestation. With weak, ignorant and superstitious females, every unexpected occur- rence, that happens to strike them with sudden alarm, or produces any particular excitement of the imagination, is apt to impress them with alarming apprehensions, as to the effects it may have on the development and conformation of the child in the womb. These distressing illusions are generally much increased by the many ridiculous stories of moles and malformations, occasioned in this way, which seldom fail to reach the ears of those who are pre- disposed to listen to them; for nurses, and gossiping old women, are usually furnished with an ample stock of extraordinary exam- ples of this kind. The evidences upon which such tales are generally founded are never wanting. If a child is born with some blemish on its body, the mother is forthwith closely ques- tioned as to the circumstances which may have attracted her par- ticular attention or excited her mind by sudden surprise or alarm. If any thing of this kind is recollected which bears even a remote similitude, in colour, shape, or otherwise, to the mark or defect observed on the child, it is immediately put down as its indubita- ble cause. Sustained by authorities of this kind, these absurd apprehensions often acquire an ascendency over the minds of pregnant females, which no expostulation or ridicule can entirely subdue, and which sometimes give rise to the utmost degree of anxiety and distress of mind, and occasionally^^en to physical suffering and ill-health. dfl^ I do not propose to enter into a formal reM|^n of this erro- neous and injurious notion. It is now unreservedly rejected as the fantastic offspring of ignorance and superstition, by all sensible. 14 OF THE CONDUCT OF MOTHERS observant, and reflecting physicians; and it is much to be desired that it should be equally repudiated, by those whom it more especially concerns, and upon whose happiness and well-being, it tends to exercise so injurious an influence. But, although the idea that structural blemishes may be pro- duced by tne influence of the mother's imagination, is wholly without foundation, yet it can scarcely be doubted that injurious impressions may be made, in an indirect manner, on the child in the womb, by affections of the maternal imagination. If intense and protracted grief, or violent bursts of passion may exert a detrimental influence on the foetus, we may presume that similar injurious effects may result from strong affections of the imagination. It is well known that disease and even death is sometimes produced by intense excitement and concentration of this mental faculty; and it is equally notorious that severe and long-standing maladies are often effectually removed by its powerful agency. It is evi- dent, therefore, that the foetus in utero must be liable to injurious impressions from inordinate affections of the maternal imagination; for without presuming that the mental affections of the mother can exert any direct and immediate impressions on the system of the foetus, the diseases and functional disturbances to which the mother is liable from influences of this kind, must tend, in some degree, to interfere with the regular nourishment and health of the child. Every kind of mental excitement, when excessive, may prove detrimental to the health, both of the mother and the foetus; and it is probably as important, to guard against the ascendency of an excited imagination, as against the various agitating and depressing emotions already mentioned. IV. Of blood-letting during pregnancy.—Females very generally suppose that the condition of pregnancy is, of itself, a sufficient reason for blood-letting; and that, although unaccompanied by any circumstances, which might be justly deemed an indication, for this evacuation, it is necessary,both for the preservation of the mother's health, and the safe progress and termination of ges- tation. This is a very erroneous opinion, and often leads to decidedly prejudicial consequences. Pregnancy is, indeed, gene- rally attended with a very peculiar tendency to plethora and febrile excitement; and, it may be admitted, that even in a state of apparent good health, blood may often be drawn during pregnancy with a beneficial result. In such cases how- ever, the pulse and other manifestations of general plethora indicate the propriety of depletion; and unless these or some other sympton^kUing for the abstraction of blood be present, it cannot be pHR?ed without the risk of unfavourable conse- quences. Wherr^R symptoms of vascular repletion are not \ c ;y urgent, the plethora may, in general, be much more beiiclicially DURING PREGNANCY. 15 removed, by using a less nutritious and stimulating diet, than by blood-letting. By the former mode, we not only diminish the mass of the blood, but we generally also improve the condition of the alimentary canal, and thereby contribute sen- sibly to the comfort and health of the patient. In weak, nervous, and relaxed habits, even where the manifestations of vascular fulness are conspicuous, the loss of blood, some- times, occasions much debility, and may even contribute to the occurrence of abortion. Pregnant females should not resort to blood-letting, unless mani- fest indications exist for its employment; and, as they cannot be competent judges themselves, of the presence or absence of such indications, the advice of a physician ought always be pro- cured before recourse is had to this measure. To bleed merely because pregnancy exists, is a practice which is sanctioned neither by reason nor experience, and ought to be discarded as a custom calculated to do mischief in some cases at least, whilst it cannot do any good, unless called for by other circumstances than the condition merely of pregnancy. A very severe and troublesome pain is often experienced in the right hypochondrium during the latter period of pregnancy; and this suffering is, almost always, sought to be mitigated or removed by blood-letting. When decided evidences of plethora accompa- ny this painful affection, bleeding will occasionally procure con- siderable temporary relief; but in the majority of instances, no mitigation whatever is obtained from this measure. The relief which is sometimes procured by bleeding, is always of short dura- tion, the pain usually returning in the course of two or three days; and if the bleeding is thus frequently repeated, as is sometimes done, much mischief is apt to be produced, by the general debility and languor which it tends to occasion. When the symptoms of vascular turgescence throughout the system are conspicuous in connection with this pain in the side, it will certainly be proper to diminish the mass of the circulating fluid by venesection; but where no indications of this kind are present, blood ought not to be abstracted merely on account of this affection; for it will most assuredly fail of procuring the desired relief; and may, when not particularly called for, operate unfavourably on the general health of the patient. Moderation in diet, together with a proper atten- tion to the state of the bowels, and the use of gentle exercise by walking, will, in general, do much more towards the removal of this source of uneasiness and suffering, than will result from blood- let; ing, where this evacuation is not especially indicated by the fulness and firmness of the pulse, or by other manifestations of general vascular plethora. 16 OF THE CONDUCT OF MOTHERS The breasts and nipples should be particularly attended to during the latter months of gestation, in order to prepare them for the important function of suckling the infant. To prevent the nipples from becoming excoriated and inflamed, in consequence of the irritation occasioned by the child's lips and tongue, in the act of sucking, means should be used, some weeks before the expected termination of gestation, to render them firm and to diminish their sensibility to irritating impressions. For this purpose the nipples should be daily washed with luke warm water, then dried by ex- posing them to the free air, and afterwards gently rubbed for five or six minutes with a soft piece of flannel or with the extremities of the fingers. Much benefit may also be obtained, from the oc- casional application of a pup to the breasts during the last four or five weeks of gestation. Washing the nipples with brandy and water, and with various stimulating lotions is a very common practice; and where the skin of the nipples is very delicate and sensible, considerable benefit may, at times, be derived from such applications. Dr. Dewees, however, is decidedly opposed to the use of astringent washes, for the purpose of preparing the nipples. My own experience, does not lead me to apprehend any detriment from certain applications of this kind; on the contrary, I have been constantly in the habit of directing the use of a wash, com- posed of two drachms of the tincture of myrhh diluted with two ounces of water, with a drachm of laudanum; and in general the effects have been manifestly advantageous. The nipples should first be bathed in luke warm water, so as to soften and separate the indurated cuticle, then dried, and gently rubbed with soft flannel, as has just been stated, and afterwards washed with the lotion just mentioned. If this course is pursued daily, for several weeks previous to the birth of the child, it will, in general, obviate all difficulties in this respect. Compression of the breasts by corsets, tight jackets, and stays, during pregnancy, is calculated to inter- fere very materially with the function of lactation. The almost constant pressure which is thus made on the nipples, forces them inwards, and frequently buries them in the yielding substance of the breasts, so as to render suckling very difficult, and often v, hollv impracticable. The full and regular development of the mamma- ry glands too, is doubtless much impeded by the pressure which they suffer in this way. It is well known that compression is a very powerful means for promoting absorption; and surgeons often avail themselves of this measure, for reducing glandular and other enlargements on the external parts of the body. We could indeed scarcely adopt more effectual means for restraining the natural growth and development of the breasts than tightly laced jackets, stays, and corsets; and it is, doubtless, to this circumstance that we must ascribe the flat and unfeminine breasts which are s,o OF THE MANAGEMENT OF NEW-BORN INFANTS. 17 common among the young females of the present day. I have been frequently struck with the fact, that in the country, and among the lower classes of females, who do not compress their chests, by corsets, &c. we generally find a much greater propor- tion of full and well developed bosoms than in cities and among fashionable ladies. When the nipples are very small or have been forced inwards by the pressure of corsets, &c, they should be drawn out by means of a suction pump, or with a tobacco pipe, and all undue compression of the breasts carefully avoided. One of the wrhite earthen tobacco pipes, with a large bowl will in general answer this purpose very well. The effort of drawing the nipples out, should be repeated several times daily, until they have acquired a degree of prominency which will enable the child to lay hold of them without difficulty. CHAPTER II. OF THE MANAGEMENT OF NEW-BORN INFANTS. The proper management and nursing of the infant during the first few weeks after its birth, has a most important influence on its future well-being. Previous to its entrance into independent life, the child enjoys a tranquil state of vegetative existence, removed from the multifarious influences of external causes, with but a narrow circle of organic actions to perform, and its sensorial functions in a state of total inactivity. How great the change which takes place at birth! In a moment, a multitude of new and highly important relations, are established between its tender and uninured organization, and the countless objects of external nature. Functions and operations which, up to this period, lay passive and dormant, are now suddenly called into action; and the whole machinery of its system, starts forth in the performances of the harmonious series of vital actions. The air for the first time, comes in contact with its body—it rushes into the cells of the lungs, and respiration is established; the current of the circu- lation finds new channels, and abandons those which were pre- viously the principal conduits of the vital fluid. The senses are awakened, light strikes the eyes, sound the ears, and its taste is delighted with the simple nourishment, formed for it, in the D 3 18 OF THE MANAGEMENT maternal bosom; the sense of touch is acute, it feels the variations of temperature,and is keenly susceptible of pain from injurious im- pressions, and gratification from soothing and agreeable influences. The stomach begins to exercise its instinctive calls for nourish- ment; urine is secreted, the bowels begin to act, and to eliminate their foecal contents, and the various secretions subservient to digestion are established. When we contemplate this remarkable transition of a most helpless and feeble being, from a state of repose and almost total exemption from external impressions, to a mode of existence which subjects its tender and uninured organi- zation to the ceaseless influence of a vast multitude of varying agencies, it would seem truly surprizing, that the new-born infant could prolong its existence, even for a few hours, did we not know that the benovolent author of nature, has endowed every being, with powers adequate, under ordinary circumstances, to sustain the changes and modifications which it is destined to undergo in the progress of its development from the nascent point, to the full state of adult life. It is evident, however, that this power of accommodation can afford no protection against the numberless accidental and unnatural impressions which the new-born infant is liable to suffer; on the contrary, there is no period of life, in which there exists so great a susceptibility to injurious influences, as during the early stages of infancy. Apparently slight errors during the first few weeks after birth, often lay the foundation of permanent constitutional infirmity; and much suffering or early death, is but too common a consequence of improper management in relation particularly to the diet, dress, and exposure of the new- born infant. 1. Of the washing and dressing of the new-born infant.—When the infant is born, and the function of breathing is well established, it must be carefully separated from the mother and secundines, wrapped up in a piece of soft flannel and handed to the nurse. If the child breathes feebly and imperfectly, or exhibits other signs of great feebleness it should not be washed immediately, but suffered to remain as quiet and undisturbed as possible, until the vital actions have assumed some degree of activity. When on the contrary it manifests an active state of the vital powc rs, the washing should be performed as soon as convenient after its sepa- ration from the mother. It is of importance that this duty should be carefully and thoroughly executed. The white caseous sub- stance which is deposited on the surface of the foetus, during its sojourn in the womb, adheres very closely to the skin; and as it is wholly insoluble in water, and but very slightly acted on by soap, it can never be sufficiently removed, unless some other sub- stance is employed which has the property of rendering it soluble. For this purpose, lard, or fresh butter, or the yolk of eggs may be OF NEW-BORN INFANTS. 19 used. Before any wrater is applied to the child's body,* the skin should be smeared and gently rubbed with one of these substances; after which the whole may be readily washed off with warm water and soap. Dr. Dewees advises that the finest soap should be selected, for the stronger soaps, particularly " the brown and stimulating soap, called resin soap," is apt to irritate and inflame the tender skin of the infant, and to give rise to painful and pro- tracted abrasions of the cuticle. When the yolk of eggs is used for this purpose, soap is altogether unnecessary, simple warm water being sufficient to cleanse the surface thoroughly. It has been much disputed whether warm or cold water is most proper for the first ablutions of the infant. Under an impression that the use of cold water is calculated to invigorate the infant, and to inure it early to vicissitudes of atmospheric temperature, and thus to obviate, to a degree, the liability to disease from this source, many physicians have strenuously insisted on the superiority of cold over warm water for this purpose. Although there may ap- pear to be some justice in these views, yet general experience is at present decidedly in favour of the employment of warm water for washing infants; and a correct view of the circumstances con- nected with this subject, gives it also, the decisive sanction of reason and common sense. The infant having never experienced but one uniform degree of temperature, during the whole period of its uterine existence, cannot but receive a painful and often injurious shock when suddenly subjected to the application of cold water; and it cannot be doubted, that the immediate exposure of new-born children to cold air or water is frequently produc- tive of serious maladies. Were an adult confined for nine months to an invariable temparature of 98°, and then suddenly ushered into a medium of the temperature of 60°, is it not extremely pro- bable that it would prove highly detrimental to his health? The occurrence of disease from much less remarkable vicissitudes than the one just supposed, is a matter of almost daily experience. How then can it be reasonably contended that the delicate, feeble, and uninured organization of the new-born babe, should be capable of bearing such a transition without experiencing any injurious impressions. Indeed, the struggles, the pale and con tracted skin, the shrieks, and the trembling which we often wit- ness when the infant is plunged or washed in cold water, afford sufficient evidence that painful, and we may presume, injurious im pressions are made on its system. The propriety of using warm water is particularly urgent when the infant is feeble. Doubtless, with robust and vigorous infants, a salutary reaction often speedi- ly takes place, under the depressing influence of cold ablutions; but where the vital energies are feeble, the reaction may fail, and a degree of depression be produced, which may place the life of 20 OF THE MANAGEMENT the infant in imminent danger. Instead of abstracting heat, we find it much more congenial to the infanticile system to impart a moderate degree of warmth from without: and with very deli- cate and feeble infants the constant application of a comfortable degree of warmth is particularly important. The water used for washing healthy and vigorous infants should be luke-warm; but for such as are weak, water of a higher temperature will be proper, and in cases of extreme feebleness, a small portion of wine may be advantageously added to the water. To remove the unctuous matter already mentioned, a fine and soft cotton or flannel rag should be used for washing. This peculiar substance is in general, most abundant in the folds of the joints, particularly in the groins, and armpits; and it is particularly important to the health and comfort of the child, that every particle of it should be removed from these and other parts of its body. It is some- times impracticable to remove the whole of this matter from the folds of the skin and joints at the first washing, without causing too much irritation by the rubbing, which it is necessary to use to detach it entirely from the skin. When this is the case, the portion that remains may be removed at the second washing. Many are in the habit of bathing the head of the new-born infant, with brandy or some other spirituous liquor, in order as is imagined, to invigorate its system and fortify it against the inju- rious effects of cold and other causes of disease. This practice can serve no useful purpose; and as it may do mischief by over- exciting the system as well as by causing pain and inflammation of the eyes, it ought to be abandoned. When the infant is very feeble and languid, a small portion of some stimulating liquor may be added to the water in which it is washed; but unless such a special reason for stimulating applications be present, plain water is decidedly the most proper. After the child has been tho- roughly washed, it should be well dried, and immediately dressed. Throughout the whole period of infancy the utmost attention should be paid to keeping the child's body in a state of perfect cleanliness. The ablutions should be performed every morning and evening, though in the evening, the lower half of the body only need be washed. It is also a matter of very great conse- quence to the comfort and health of the infant to keep every part of its body dry. This is particularly important with those parts which are subject to friction, from being in contact with each other, as the nates, the armpits, groin, folds of the neck, &c. Excoriations and painful inflammations are apt to occur in these situations, when they are suffered to remain wet or moist. The common practice of dusting fine starch or hair-powder over the body, with the view of keeping the skin dry and soft, is im- proper, and ought not to be adopted. It interferes with the OF NEW-BORN INFANTS. 21 regular transpiration of the skin, and has a tendency to give rise to a troublesome itching and harshness of the cuticle. On the ap- pearance, however, of slight excoriations, a little hair-powder, or prepared tuttia may be dusted on the parts with benefit; but it cannot be used with advantage as a preventive of such affections. II. Of the dress of the child.—The first thing to be done in dressing the infant, is to fix the remains of the navel string by surrounding it with a piece of soft dry rag, and supporting it in a proper position, by means of a roller or bandage, passed round the child's body. A simple strip of flannel, about four inches wide, is the best material for this purpose. Particular care must be taken not to draw this bandage too tight round the abdomen. It should be sufficiently loose to admit of the easy introduction of a finger under it. If it embraces the body too closely, it occasions uneasiness, pain, and difficulty of breathing, by impeding the co- operation of the abdominal muscles, and the free descent of the diaphragm; at the same time that it tends, very strongly, to favour the occurrence of umbilical, and particularly scrotal hernia in male infants, by its necessary effect of compressing the abdominal cavity, which, with the forcible descent of the diaphragm in the act of crying, coughing, and straining, presses the viscera down, and forces them through the natural openings into the abdominal parietes. I have repeatedly known inguinal rupture produced in this way. The bandage should be worn four or five months be- fore it is laid aside; and where the parts about the navel appear to be weak and ready to yield to the pressure of the viscera, it will be proper to continue the use of the bandage a much longer period. Previous to the separation of the remaining piece of navel-string, care must be taken not to pull it; and the parts about the navel should be kept as dry and clean as possible. A neglect in these particulars, is apt to give rise to painful inflammation and excoriation of the umbilicus. " Sometimes the vessels of the um- bilical cord, which before were distended with blood, will collapse, the bandage become loose, and the life of the babe be endangered by excessive bleeding; the state of the bandage must therefore, from time to time, be carefully examined." With regard to the clothing of infants, it may be observed, in a general way, that it should be warm, light, and loose. It is scarcely necessary, to say any thing, in reprobration of the old, absurd, and injurious practice of swaddling infants. This cruel custom is now universally abandoned by every civilized people; and it is surprising that the common sense and humanity of man- kind, should have ever permitted its introduction. To confine and restrain every member and almost every muscle of the body in this manner, during the fragile state of infancy, must be as detrimental to the health and regular developement of the child, as it is cruel and barbarous. 3* 22 OF THE MANAGEMENT The clothing of infants should be managed in such a way, as to protect them against the effects of too high or low a temperature, and against sudden alterations of the air and weather. In the winter, or during cool seasons, flannel forms an essential part of the clothing. The lightest and softest kinds of flannel should be selected. In new-born infants of a feeble and languid habit, the use of flannel next the skin, is particularly useful. During the first few months after birth, warmth is always peculiarly con- genial to the infantile system; and where from feebleness, the developement of the animal temperature is not very rapid, it is particularly necessary to use flannel clothing, so as to favour the accumulation of warmth in the child's body. Besides the useful- ness of flannel as a means for obviating the depressing and injurious effects of cold and atmospheric vicissitudes, benefit may also result from its gentle stimulating impressions on the surface of the body, by which the blood is solicited to the external capilla- ries and unfavourable congestions obviated in the internal organs. During the warm seasons, the flannel should be substituted by muslin; but the moment that any sudden reduction of the atmos- pheric temperature takes place, the use of the flannel should be resumed. Common sense indeed, dictates the propriety of con- stantly accommodating the clothing to the varying states of the weather, and when this obvious duty is not attended to, much disease and suffering is liable to occur, which under a more pru- dent management in this respect, would be prevented. In the summer season, infants are often exposed to unpleasant conse- quences from being too thickly and warmly covered while sleep- ing. The infant with its usual quantity of clothing, is often laid on a bed of feathers or down, into which its body sinks, and a thick cover thrown over it; from which it is generally taken up when it awakes, bathed in a copious perspiration and of course par- ticularly predisposed to receive injury, should it happen to be immediately exposed to a current of fresh and cool air. There can be no doubt that catarrhal and bowel complaints are fre- quently produced in this way. I have known a case of fatal cynanche trachealis speedily excited by carrying a child, taken out of its cradle, in a state of free perspiration, into a draught of cool air. It is proper to observe, that the child should never be suffered to sleep in the flannel which has been worn during the day and in the morning it must again be changed. During the first eight or nine months, the child's clothes should be long enough, to extend considerably beyond the feet, in order that the lower parts of the body may be duly protected, against the effects of cold and the variations of temperature. After this age, however, the feet should be entirely unincumbered by the clothing, so as to permit the free motion of the inferior extremi- OF NEW-BORN INFANTS. 23 ties. During cold weather, fine woollen stockings, sufficiently wide to be easily put on and to prevent every degree of compres- sion, should be worn; but in warm weather light and soft flannel socks will suffice. The shoes should be made of light and pliable materials, and sufficiently large to prevent all constraint of the feet. Some writers object to putting shoes on infants. It is alleged that they tend to cramp the feet and restrain their free motion, and that consequently the child " does not lean: to walk so early, as when the feet are unincumbered by shoes." These objections, however, may be obviated, "byhaving the shoes made large and of the most pliant materials;" and I fully accord with Dr. Dewees in the opinion, " that as shoes afford protection from cold, and security against accident when the child is placed upon the floor, especially on carpeted floors, where pins, needles, and other sharp substances, are often concealed, they can not, with perfect propriety, be dispensed with." The use of shoes is decidedly proper when the child is carried out of doors during cold weather. In very young infants, thin woollen socks will protect the feet sufficiently during the warm seasons; but when they are about learning to walk, it is best, for the reason just quoted, to have the feet invested in shoes made of very soft and light materials. It is highly important that the child should be kept as dry as possible. Wet diapers or stockings, when suffered to remain on the child for some time, are apt to give rise to bowel complaints and febrile affections, more especially during the cold seasons. They tend moreover very strongly to favour the occurrence of ex- coriations, and painful irritations of the skin about the groin and nates. The under-clothes of the child should be frequently examined, and if any part is found to be wet, it should be imme- diately removed and substituted by a dry and clean one. In dressing children there ought to be as few pins used as may be practicable, for the proper adjustment of the clothes. Children are frequently much injured by the points of pins being accidentally directed inwards in handling them, or by their own movements. I have witnessed several instances of very unpleasant consequences from this source; and the instances of slight but painful punctures and scratches from pins used in the dress of infants are very common. Tapes and strings should therefore be used instead of pins, whenever they can be made to answer the purpose. If pins are used at all, the larger kind should always be selected; for the small pins now in general use, are much more apt to slip through the clothes and consequently to wound thn skin than the larger kind (Dewees). Before leaving this subject it will be proper to say something concerning the usual mode of dressing children, so as to leave the 24 OF THE MANAGEMENT neck, upper part of the chest, and forearms perfectly bare. Whilst adults are careful to keep these parts well covered and protected against the influence of cold, children are almost uni- versally suffered to be without such protection; and the nudity of the neck and arms is generally continued, until they are four or five years old. It has been supposed that this custom is one of the principal reasons why inflammatory affections of the respira- tory organs are so much more common during the period of child- hood, than at a more advanced age; and there can be no doubt that its influence, in this respect, is very considerable. Nothing is more common than to see children out of doors, with the arms and upper parts of the chest, completely exposed, even in damp and cold weather; and it cannot be believed that such exposure is unattended with risk of injurious consequences. Croup, inflam- mation of the lungs, catarrh, and general fever are doubtless fre- quently the consequences of this irrational custom; and it is not improbable that the foundation of pulmonary consumption is often thus laid, during the first few years of life. This custom, there- fore, ought to be abandoned, as one of a decidedly injurious tendency, more especially during the cold and variable seasons. During the warm months of summer, the arms, and neck may be left bare, without any particular liability to injurious consequences; but every part of the chest should at all times be protected with suitable clothing. It is generally supposed that the usual mode of dressing children, is calculated to inure them to the impressions of cold, and to obviate the liability to disease from this cause. Doubtless this may be the result with those who survive the ex- periment; but before the system is thus inured, the child may be carried off by some inflammatory affection, produced by such ex- posure. It is certainly a most inconsistent practice to expose the breast and arms during the weak and tender age of childhood, and yet to deem it necessary to keep these parts carefully covered after the system.has acquired firmness and its full powers of vital resistance by a more mature age. The universal custom of covering the infant's head writh a cap, is of very doubtful propriety. There is naturally a strong tendency to a preternatural determination of blood to the head during in- fancy; and the predisposition to inflammatory diseases of the head, is confessedly, much greater during this early age, than at any other period of life. If the rule to " keep the head cool." is ever applicable, it is particularly so during infancy. In cold and damp weather, a very thin and light hat may be proper; but during the warm seasons, it will be conducive to the child's com- fort and health to suffer the head to be wholly uncovered- and even in winter, if the child's head is well covered with hair, and it be confined within doors, caps may be very prudently dis- pensed with. OF THE NOURISHMENT OF INFANTS. 25 CHAPTER III. OF THE NOURISHMENT OF INFANTS. There is probably no single source of disease, during the first few years of life, whose influence is so extensive and destructive, as improper management in relation to the diet. The foundation of irremediable chronic diseases, and of constitutional infirmity, throughout the subsequent period of life, is often laid within the first month, or even first few days after birth, by errors of this kind; and a great amount of the suffering and mortality which occurs during infancy, must be ascribed to the same prevailing source of injury and disorder. The almost universal custom of feeding children with inappropriate articles of food, very soon after birth, is extremely reprehensible. No sooner is the infant washed and dressed, than the nurse is ready with her spoon and cup of gruel, pulverized crackers dissolved in water, or some such prepa- ration, to fill its stomach to the utmost of its capacity; and this process of stuffing is continued with a ruinous degree of diligence and perseverance. The tender and uninured digestive organs of the new-born babe are thus often seriously injured during the first twenty-four hours. Nature herself seems to point out the impropriety of this practice. She withholds the nourishment which she provides, until many hours after birth. It seems highly improbable, if it were necessary that the infant should receive nourishment soon after birth, that the appropriate alimentary fluid should be so tardily furnished. We no where find such an inconsistency in nature. It is true, indeed, that the secretion of milk in the maternal breasts is often delayed a much longer pe- riod, than it would be prudent to withhold nourishment from the infant. Still we perceive, in this arrangement, that aliment is not necessary to the welfare of the child very soon after its birth. It cannot be presumed that the activity of the digestive organs, and a demand by them for nourishment is immediately awakened, on the child's entrance into the world. We no where see a physical want established without the appropriate means being furnished for satisfying it. I do not: indeed, mean to inculcate, that nourishment is to be entirely withheld from the infant until the milk is secreted; but I am persuaded,that with healthy infants, E 26 OF THE NOURISHMENT several hours, at least, should be suffered to pass immediately after birth before any alimentary substances are introduced into its stomach; and 1 would most strenuously insist on the importance of exhibiting but small portions at a time, and at such intervals, as will obviate all risk of overloading or distending the stomach. This lattei error is the most to be deprecated. A few tea-spoonfuls of some very bland and weak fluid, could not be deemed detrimental, though given immediately afterbirth; but the usual practice of fil- ing the stomach to overflowing, and keeping it in this state of ful- ness and distention, is most ruinous to the health and comfort of the child. At every period of life over-distention of the stomach, by food or drink, is one of the most certain and powerful causes of indigestion; and we can scarcely conceive it possible, that the tender and uninured stomach of the new-born infant, can escape serious debility and irritation, when early overcharged with food even of the mildest kind. The digestive powers of the stomach being thus prostrated or enfeebled, all the harassing and painfal conse- quences of indigestion ensue. Acidity, flatulency, colic, diarrhoea, vomiting, green and griping stools, emaciation, not to mention other distressing and dangerous symptoms inevitably supervene. In nine cases out often, perhaps, the griping, flatulency, diarrhoea, and colic which so frequently harass infants, during the first half year after birth, are the results of indigestion, brought on by errors in diet. Not unfrequently the digestive powers are effectively prostrated by the first feeding. Conceiving that, as the child has been fasting during the long period of nine months, it must needs come into the world with an excellent appetite, and an imme- diate demand for nourishment, ignorant nurses—(and the ignorant are incomparably most numerous) deem it their duty, to be most vigilant and industrious in charging the infant's stomach with some alimentary substance—often extremely inappropriate. To relieve the colic, griping, flatulency, diarrhoea, &c. which ensue, recourse is had to cat-mint tea, anniseed tea, Godfrey's cordial, paragoric, or some other palliative or nostrum, and thus an additional source of gastric derangement or indigestion is brought into operation. The screams and restlessness of the infant occasioned by the griping and colic, are frequently regarded as manifestations of hunger. To appease this supposed craving, the stomach is almost constantly kept in a state of distention with food; and thus the helpless" babe has no chance of escaping from the torments and ruinous consequences of its unfortunate condition. Very vigorous and healthy infants often pass through the gastric irritation and dis- tress produced by improper nourishment soon after birth, without sustaining any permanent injury in health or constitutional infir- mity. After four or five months of flatulency, griping, &c, the digestive organs gradually become inured to the impressions of the OF INFANTS. 27 food, and a considerable degree of health is obtained. In many cases, however, the irritation which is thus kept up in the stom- ach and bowels, does not pass off in so favourable a manner.— Jaundice, chronic and unmanageable diarrhoea, emaciation, slow fever, enlarged mesenteric glands, dropsy in the brain, scrofula, chronic affections of the liver, epilepsy, and other dangerous ma- ladies, may, and not unfrequently do, result from this state of the alimentary canal, during infancy. Great' distress and suffering, are sometimes witnessed during the early period of infancy, from indigestion, and consequent gastro-intestinal irritation, even where the child is wholly nourished by the breast. For when, during the time which intervenes between the secretion of milk, and the birth of the child, crude articles of nourishment are superabun- dantly introduced into the infant's stomach, the digestive functions are often, at once, so deranged and impaired, that even the wholesome and congenial fluid furnished by the maternal breasts, will not be easily digested; and acidity, flatulency and colic will continue to harass the child, until the digestive powers gradually acquire a greater degree of vigour. That the jaundice of infants is generally produced by dispep- tic irritation, I have not the slightest doubt. Mucous irritation of the duodenum, is now well known to be an active and fre- quent source of this malady; and this affection is very rarely found to occur in new-born infants without being preceded by decided manifestations of irritation of the digestive organs. Let the child's stomach Jbe once or twice filled during,the first twenty- four hours with gruel, or any of the ordinary preparations em- ployed by nurses for this purpose, and the chances will probably be as ten to one, that acidity, vomiting, colic, griping, and jaun- dice will supervene. There is assuredly no period throughout the whole course of life, in which the observance of caution, in relation to the ingesta is of greater moment than in the compara- tively short interval which passes between the birth of the infant, and the secretion of its natural aliment. If the powers of the stomach are not prostrated during this short interval, which by the customary mode of management is seldom avoided, and the child is fortunate enough to be nourished by its mother's milk, the ordinary gastric disturbances of infancy will rarely super vene. Alimentary ingesta, are not, however, the only sources of direct gastric irritation and indigestion at this early period of life. Much mischief is, doubtless, often done, by the means em- ployed for removing the meconium. Active purgatives are some- times given for this purpose; and there is much reason for belie- ving that the infant's digestive functions are often injured in this manner. I have hitherto dwelled especially on the importance of withholding nourishment from the child, immediately after 28 OF THE NOURISHMENT birth, and before milk is furnished by the maternal breast. I am induced to be the more urgent on this point, because many who would not think of feeding the child, after the breasts supply a sufficient quantity of the appropriate nourishment, consider it ne- cessary to do so before the milk is secreted, lest it may suffer from want of nourishment. I have already stated that there can be no objection to the exhibition of small portions of some very mild and simple fluid to the infant, previous to its receiving nour- ishment from the breast; and when the secretion of milk is consi- derably delayed, this measure will even be proper. A mixture of two parts of fresh cow's-milk, and one part of warm water ap- proaches nearer to the nature of human milk than any thing else that can be conveniently procured. Of this a few teaspoonfuls may be given from time to time, carefully avoiding overcharging the stomach, until the mother's breasts are ready to yield their more congenial nutriment. In order to excite the early secretion of milk, it will be proper to let the child draw the breasts, for a few minutes, soon after the mother is comfortably fixed in bed, provided her health and strength will admit of it. After the se- cretion of milk is once fully established, and furnished in sufficient quantity, the infant should be nourished exclusively by the breast. Not even the mild and simple fluid just mentioned should be al- lowed, unless some special reason exist for the use of additional nourishment. It seldom occurs in healthy mothers, that the quantity of milk supplied by the breast is not sufficient to afford adequate nourishment to the child for the; first two or three months, and in general much longer, without the necessity of any additional artificial food. Should it be otherwise, however, or should there be an inability of suckling the child, in consequence of the mother's ill-health, or disease of the breasts, the mixture of milk and water mentioned above, should constitute the sole aliment, until the primary teeth make their appearance; or what is still more suitable, a healthy and fresh wet-nurse should be procured. There is no substance in nature, nor can there be any thing prepared by art, which forms so congenial and wholesome a nou- rishment, during the early period of infancy, as the human milk. When it is supplied in sufficient quantity, no other alimentary substance ought to be given, during the first three or four months after birth. It seerns, almost superfluous to remark that nature manifestly intended this fluid, as the sole nutriment at this early stage of life. Throughout the whole range of the higher orders of animated beings, the structure of the mouth, particularly in relation to the absence or presence of teeth—their conformation, position and situation,—furnishes unequivocal indications, as to toe kind of food most appropriate and salutary. The same re- OF INFANTS. 29 || lation between the condition of the mouth, in this respect, and the kind of aliment best adapted to the welfare of the system, occurs during infancy; and an attention to this circumstance, affords a good general index, as to the kind of diet best suited to the new-born infant, and the changes which it will be proper to make according as it advances in age. The infant comes into the world with soft and toothless gums,—full and prominent lips, and an instinctive ability and readiness to grasp the nipple with its tongue and lips, and to perform the actions of suction in the most perfect manner. For a considerable time it remains wholly incapable of performing the motions of mastication. It is evi- dently the design of nature, that the infant shall obtain its nutri- ment by suction; and as the maternal breasts with their grateful and congenial lacteous fluid, correspond with this arrangement and intention of nature, it is manifest, that these constitute the only natural and truly appropriate source of nourishment during early infancy. The infant should be nourished exclusively by the breast, until the first teeth make their appearance. No other kind of nou- rishment whatever, should be allowed, anterior to this period, unless from deficiency of milk or some other cause, the use of ad- ditional aliment becomes necessary. After the first teeth have come out, small portions of barley-water, thinly prepared arrow- root, or a mixture of equal parts of cow's-milk and water, may be given two or three times daily, in addition to the nourishment drawn from the breasts. I do not mean to say, that when the child arrives at this stage, it becomes necessary, or even deci- dedly proper, as a general rule, to exhibit any additional articles of food. In general, however, the simple and mild liquids, just mentioned, may be given at this period, with very little risk of unpleasant consequences; for the digestive organs have, by this time, acquired a degree of power and activity sufficient to obvi- ate the painful and disturbing effects which would arise from the use of such food during the first four or five weeks after birth. I have very rarely known any ill consequences to occur, from the moderate use of the articles of nourishment just mentioned, at this period of infancy; and I am satisfied, that when the breasts do not furnish a sufficiently copious supply of milk, they may, in general, be resorted to, with perfect propriety. It is particularly important however, when additional aliment is used, to avoid overloading the stomach; for over-distention, seldom fails to im- pair the tone of the stomach, and to give rise to dyspeptic distur- bances. It is also of much consequence that the food should be introduced into the stomach, as gradually as practicable. In suckling the child receives its nourishment very gradually; and this should be imitated, when artificial food is given by the hand. 4 30 OF THE NOURISHMENT This can be most conveniently done by causing the infant to suck the fluid aliment from a bottle, furnished with the usual silver tube, the mouth-piece of which is pierced with a small orifice. By this contrivance, the child will receive its food in the same gradual manner, as when nourished at the breast, and it will rarely take more than its appetite calls for, an error which is frequently committed when fed with a spoon. After the se- venth month, small portions of the preparations of food just men- tioned, should be given at regular periods, three or four times daily. This will prepare the infant, for the sudden change, which it has to undergo in the character of its food, when it is weaned; and thereby tend to lessen the liability to unpleasant consequences from the change. Infants who have been mode- rately fed with suitable articles of food, sometime previous to weaning, almost always accommodate themselves much more readily and with much less uneasiness to the change, than such as have seldom or never received any other aliment, than that which they draw from the mothers or nurse's breasts. If the appointments of nature, and experience shew that human milk is the appropriate aliment during infancy, it is manifest that the mother's breasts constitute the only genuine fountain from which this delicious and congenial nutriment is to be drawn by the infant. Mothers ought never to delegate the suckling of their infants to others. This sacred office should rest with the mother alone. It is an irremissible duty, which can never be ne- glected or put off, without contravening the wise and benevolent arrangements of Providence. The mother who submits the suck- ling of her infant to another, while her own breasts are ready to furnish an ample supply of milk, can scarcely possess an amiable and moral heart. It is indeed a most extraordinary circumstance, that a duty which is so strongly enforced by the commands of nature, and which is connected with so many delightful and hal- lowed sentiments of the maternal heart, should ever be volunta- rily relinquished. Did we notice this unnatural and cruel prac- tice only among the low and ignorant, we might ascribe it to that blunted sensibility and obtuse moral feeling which is apt to be engendered by the privations and hardships of poverty. But it is not so. It is only among educated, refined and polished fe- males, that we witness the appointments of nature, and the decencies of maternal conduct thus outraged. It would seem as if the higher refinements of civilization tended rather to stifle, than to cherish the pure and instinctive sentiments of the heart, and to substitute the dictates of fashion for the original and uner- ring impulses of nature. As it is manifestly the design of nature, that the infant should draw its food from the mother's breasts, it is reasonable to pre- OF INFANTS. 31 sume that this design cannot be contravened, without subjecting both mother and infant, to an increased liability to injurious con- sequences. It can scarcely be doubted that the mother's milk, is, in general, better adapted to the constitutional temperament of her offspring, than that furnished by others. Besides, when the suckling of the infant is submitted to a nurse, it is liable to vari- ous sources of injury and disorder, which are in a great degree, if not entirely obviated, when this important duty is performed by the mother. The nurse may not be able to furnish a sufficient supply of milk to afford adequate nourishment to the infant. This is by no means uncommon. Nurses often practise great deception in this respect. In order to obtain employment, or retain their situation, they will declare that they have an abundance of milk, when, in truth, the very reverse is the case. To supply this de- ficiency of milk, the wily nurse wrill resort to clandestine feeding; and as this is generally done in a very improper way, the child usually fares much worse, than if it had been, from the beginning, nursed exclusively by appropriate artificial food. The food which is thus secretly hurried into the stomach of the child, never fails to give rise to griping, flatulency, colic, diarrhoea, and fretfulness. To allay these sufferings, carminatives and anodynes are privately resorted to; and thus, whilst the parents suppose that the infant enjoys the advantage of proper nursing, its health, and even life are often sacrificed to the secret practices of a mercenary and unprincipled nurse. The child, also, runs much more risk of receiving bad and unwholesome milk, when suckled by a hired nurse, than when this office is performed by the mother herself. I have known several instances of most serious injury inflicted on the child's health and constitution in this way. That syphilis may be, and has been communicated through the milk of the nurse, I have not the smallest doubt; and the communication of other loathsome diseases, by nurses, to their nurslings, such as itch, tetter, &c, is by no means uncommon. But even where no specific disease of this kind, is contracted, the general health and constitution are often permanently injured by the unwholesome or uncongenial character of the milk furnished by the nurse. When the milk of the nurse is of a bad quality, it usually produces very obvious disturbances in the digestive organs of the infant. The stomach and bowels become weak and irritable. The child vomits fre- quently, or is harassed by painful and watery diarrhoea. It becomes restless, fretful, and peevish; its flesh wastes and becomes flabby; its countenance assumes a distressed, pale, and sickly aspect; its sleep is disturbed by sudden starts; it often cries out suddenly, as if in violent pain; and, in most instances, fatal irritation, and 32 OF THE NOURISHMENT effusion in the brain, finally ensue, and terminate the infant's Bufferings. Besides the foregoing sources of injury to the health and com- fort of the infant, there are many others, scarcely less detrimen- tal in their tendency, incident to wet-nursing, and which can seldom be wholly avoided, when this mode of nursing is adopted. To attend properly to an infant, by day and by night, requires sacrifices of ease and comfort, on the part of the nurse, which are not often fully submitted to by hired nurses. The mother alone can experience those instinctive and anxious promptings, to ad- minister to the wants and comforts of her offspring, which are necessary to secure the faithful performance of this important duty. Children often suffer much from the indolence and care- lessness of nurses. They are suffered, frequently, to lie, for hours, in their wet and soiled diapers, and to remain for days without proper ablutions. Much neglect too, is sometimes prac- tised in suckling the infant. Its stomach is now engorged with milk, that the nurse may have time to walk out, or attend to some of her own affairs, and then, all nourishment is withheld for an unreasonable length of time. At night particularly, the nurse is too indolent or too sleepy to keep the child clean and dry, and to apply it regularly to the breast; and in order that it may not disturb her rest, laudanum, paregoric, or some other anodyne, is clandestinely given to the little victim. The same culpable prac- tice of stupifying the infant with laudanum, is often resorted to during the day, in order that the nurse may attend to some affair of pleasure, or business on her own account. These are not ima- ginary charges. I have repeatedly known them practised, where such mismanagement was not suspected; and too much vigilance cannot be exercised in observing and scrutinizing the conduct of nurses. It is to be observed moreover that the child is liable to very serious injury from irregular habits on the part of the mo- ther. Intemperate nurses are particularly to be reprobated. I have, in several instances, known infants to be very seriously in- jured by nurses of this description. Women who hire themselves out for wret-nurses, appear to be more liable to this vice, than almost any other class of females. Under an idea, that while suckling, they require some stimulus to support their strength and to promote the secretion of milk, they are apt to drink freely of malt liquors, which often leads them, in the end, to resort to the more ardent alcoholic liquors. Thus, the habit of intempe- rance is sometimes formed; and although they may not drink to the extent of producing intoxication, yet the milk will become unwholesome and injurious to the infant nourished by it. From the foregoing remarks, founded on experience and obser- vation, the impropriety of excluding the child from the mother's OF INFANTS. 33 breasts, and submitting it to the nursing of a stranger, is very manifest. To be obliged to procure a wet-nurse is always an evil, and cannot but be viewed as such, by every sensible, hu- mane, and good mother. Unfortunately, however, mothers are not always in a condition which enables them to suckle their own infants; and the employ- ment of a wet-nurse, or recourse to artificial nursing, is unavoida- ble. The causes which may prevent the mother from nursing her child are: 1, A decided deficiency, or total failure in the se- cretion of milk, in consequence of organic disease or functional torpor of the breasts. 2, A bad state of milk, rendering it deci- dedly prejudicial to the health of the child. 3, The presence of a morbid taint, or some communicable chronic disease in the maternal system. 4, When suckling gives rise to painful or dangerous affections in the mother, as colic, cough, distressing nervous affections, great weakness, epilepsy, &c. When causes of this kind render it improper or impracticable for the mother to nurse her child, it then becomes a question whether a wet-nurse should be employed, or artificial nursing resorted to. If a healthy, fresh, and faithful nurse can be pro- cured, this mode of nourishing the infant, is certainly preferable to artificial nursing. It is not often, however, that a nurse can be obtained who is, in all respects, well qualified for this office. In general, a nurse who has no child of her own to take care of, is much to be preferred to one who has this additional charge; more especially when the infant intrusted to her care, is removed from the immediate observations of its parents. The foster-child is always more or less neglected wrhen the nurse has an infant of her own to attend to. If there is a deficiency of milk for both, the promptings of maternal feeling, will be very apt to favour her own child; and, if the latter should become sick, and require particular attention, the foster-babe will seldom receive proper nursing. When the wet-nurse is received into the parents' house, the superintendence of the mother, may, in general, prevent such misconduct on the part of the nurse; but when the child is nursed out of the house, and removed from the presiding care of a watch- ful parent, the probability of its being neglected and maltreated is always very considerable. It would, in general, be much bet- ter to nurse the child artificially, under the eye of its mother, than to place it entirely at the mercy of the wet-nurse. Nurses, doubtless, are sometimes found, to whom a child may be safely intrusted; but experience has but too often shewn that the reverse is much more common. Attention must also be paid to the previous and present health of the nurse. No woman, who has led a debauched course of life, even though reformed, can be regarded as a perfectly safe F 4* 34 OF THE NOURISHMENT. nurse, however careful and attentive she might otherwise be. Females of this description are apt to have their systems contam- inated with some morbid taint, which may give an unwholesome quality to the milk, and injure the child's constitution. The ex- istence of scabby or scaly eruptions on the skin, unless they arc of transient character, and of chronic ulcers, particularly on the legs, should be regarded as sufficient objections to a nurse. A manifest scrofulous habit, also, is decidedly objectionable. The age of the milk is another point of considerable importance. [Vlilk that is six or seven months old, seldom agrees well with infants during the first two or three months after birth. In gen- eral the milk becomes much more rich and nutricious after the fourth month, than it is previous to this period; and hence milk of this kind, from its requiring stronger digestive powers than younger milk, often gives rise to much disturbance of the stom- ach and bowels in new-born infants. As a general rule, there- fore, the age .of the milk, should not vary much from that of the child, up to about the fourth month. After this period, such a relation between the ages of the milk and child is not of much importance; for a child five or six months old and upwards, may be well and safely nourished by a fresh breast. The occurrence of the menstrual evacuation, during lactation is almost invariably attended with diminution and deterioration of the milk; and constitutes a well-grounded objection to a wet- nurse. This is more especially the case during the first three or four months of infancy. When a child, at this early period, is put to the breast of a nurse who menstruates, it rarely fails to experience derangements of the stomach and bowels. After the seventh or eighth month of age, there is much less inconvenience and disorder to be apprehended from this source; but even at this advanced period of infancy, the milk of a nurse, thus circum- stanced, may give rise to disturbances in the digestive organs, and should, if possible, be avoided. Nature, here, as elsewhere, is a safe guide. We perceive that menstruation is almost univer- sally suspended during the period of suckling; and we may pre- sume that this arrangement of nature is designed for some useful purpose—for the well-being, doubtless, of the infant. Nature, therefore, as well as experience, indicates the propriety of with- holding the breast from the child, when from constitutional peculiarity, or some accidental influence, the menses make their appearance in the nurse. A nurse who has but one good breast should never be selected. \ child suckled by one breast only, is apt to contract the habit of squinting, from having its eyes constantly directed to one side- and there is also some risk of its head and shoulders acquiring an oblique or crooked form. Even when both breasts are perfect OF INFANTS. 35 and exuberant, some nurses are disposed to suckle principally with one only. This should not be permitted. The child should be nourished alternately from both breasts. Some attention should also be paid to the nurse's nipples. If they are very small, the child will be apt to fatigue itself in sucking, without being able fully to satisfy its wants. This defect can seldom be pro- perly remedied. The practice of drawing out the nipples by suction, writh a tobacco pipe, will be of advantage; but when the nipples are very small, and deeply imbedded in the breast, it can scarcely remedy the evil. In some instances the nipples yield the milk so freely, that the child is continually harassed by a sense of strangulation, while suckling, from inability to swallow as rapidly as the milk issues into its mouth. This may, in gene- ral, be remedied by passing a piece of fine tape pretty firmly round the base of the nipple; or the nurse may compress the nipple moderately between the first and second fingers, while the child is suckling. Finally, particular regard should be had to the temper and moral habits of the nurse. An irritable, passionate, and sour- tempered female is but illy suited for this important duty. Not only is the child liable to be maltreated by a nurse of this char- acter, during the fits of ill-nature and passion; but the most seri- ous and alarming effects may be produced on its tender organiza- tion, by the milk of such a nurse. It is well known that violent anger, and habitual sourness of temper are peculiarly apt to give a pernicious quality to the milk. Children have been thrown into convulsions, by suckling soon after the nurse has been agita- ted by violent anger or rage; and alarming vomiting and purging is particularly apt to occur from this cause. Indeed every kind of inordinate excitement, or depression of the mind is unfavoura- ble to the secretion of healthy milk. Protracted grief, sorrow, or mental distress and anxiety in the nurse, seldom fail to exert a prejudicial influence on the health of the nursling. This circum- stance ought not to be overlooked, in choosing a wet-nurse. Wo- men, whose domestic relations expose them to moral affections of this kind, cannot be regarded as well adapted for this office. Tranquility of mind, and evenness of temper are particularly desirable in a nurse; and no female ought to be admitted to this duty, who is, either by temperament, or extraneous circumstances, placed in an opposite condition. Artificial Nursing.—Under judicious management, infants will, in general, experience no particular inconvenience from a course of artificial nursing; and, as a general rule, this mode of nourish- ing children, when properly conducted, is upon the whole prefer- able perhaps, to the employment of a wet-nurse whose competency and fitness is equivocal. This preference, however, is founded 36 OF THE NOURISHMENT rather on the greater risk which the child incurs of being mal treated and neglected, when submitted to the exclusive care of a wet-nurse, than when nursed artificially, under the immediate su- perintendence of a parent; for there can be no doubt, that fresh human milk, when uncontaminated, is always the best possible nourishment for infants. There are indeed circumstances, in relation to the condition of the child, which render the employment of a wet-nurse, not- withstanding all the risks that have been mentioned, decidedly preferable to artificial nursing. Very young, and peculiarly del- icate and feeble infants, seldom do well when raised by the hand. Fresh and wholesome milk from the breasts of the mother, or a healthy nurse, is almost indispensable to the well-being of an infant thus circumstanced. The same observations apply to infants, whose stomach and bowels are peculiarly weak and irri- table, and consequently particularly liable to disorder, from even slight sources of gastro-intestinal irritation. Finally, if upon trial, the slightest and most appropriate kinds of artificial aliment are found to disorder the alimentary canal, the life of the infant will very probably depend, on its being nursed by a fresh and wholesome breast. In many instances, however, it is wholly impracticable to pro- cure a suitable wet-nurse, and artificial nursing becomes unavoid- able. Sometimes the mother, though incapable of supplying a sufficient quantity of nourishment by the breast, is still able to furnish small portions of wholesome milk, and when this is the case she ought by all means, to continue suckling the child, in conjunction with the use of artificial nourishment. The kind of aliment which should be employed, and the mode of feeding proper, in cases where there is a deficient secretion of milk in the maternal breasts, have been pointed out. A mixture of two parts of fresh cow's-milk, and one part of warm water, with a very small portion of sugar will, in general, answer the purpose better than any other article of food, that can be contrived. Thin barley-water, or a very liquid preparation of arrow-root, will sometimes be useful as a change of nourishment, where, from accidental weakness, or a prevailing acidity in the stomach, the milk curdles, and causes griping. As has already been men- tioned, the sucking-bottle is decidedly the best mode of feeding the child. Particular care should be taken to keep the bottle perfectly clean and sweet. It should be well washed, both in- side and outside, with hot water, every morning and evening. The same food should not be suffered to remain in the bottle more than three or four hours. When kept too long it is apt to turn sour, and to become injurious to the child's stomach and bowels. After the child has satisfied its appetite, no new supply of food OF INFANTS. 37 should be added to what may have been left. The quantity of nourishment put into the bottle, should not be much greater than what may be deemed fully sufficient for one nursing; and if any remains, it should be emptied and the bottle well rinsed with fresh water. By these precautions the food will always be sweet, and free from offensive or irritating qualities. Dr. Dewees ad- vises that "the extremity from which the child is to suck should be covered with a heifer's teat, in preference to any thing else." Teats of this kind, properly prepared, are not, however, always to be procured; nor do they appear to me preferable to a fewr folds of fine and soft linen drawn over the mouth-piece, with a minute orifice, corresponding with the opening of the tube. The teat is often "too bulky for the child's mouth, and it is very apt to become hard and unyielding, unless removed and immersed in water after each nursing; in which case it is, on the other hand, liable to be- come too flaccid and relaxed. Two or three folds of soft linen are readily applied, and may be taken off and washed, or substi- tuted by a fresh and clean piece, without any inconvenience. A common eight-ounce vial, or a half-pint decanter, furnished with a silver tube having a flat and oblong mouth-piece, will, in gen- eral, answer this purpose very well. When the child uses the bottle, it should be taken up and supported in an easy semi- recumbent position, on the lap or arms of the nurse. The prac- tice of dandling and jolting infants soon after they have taken nourishment, is decidedly improper. The child should be kept quiet for at least thirty or forty minutes after having received its nourishment. Rest is particularly favorable to digestion: more especially during its primary stage. It would seem as if the di- gestive organs required a concentration of the vital energies upon themselves, to enable them to perform this important function with due rapidity and ease. Nature constantly verifies the truth of this observation. All animals manifest an inclination for repose and quietude after a full repast; and experience has shown that, the process of digestion is particularly liable to be impeded by strong mental or corporeal exercise or agitation immediately after a full meal. Children, who are entirely nursed by artificial diet, should be restricted to the use of the milk-and-water mixture mentioned above, until*several teeth have made their appearance. They will, in general, enjoy more perfect health and thrive better, when nourished exclusively with this simple aliment, than under the use of any other nourishment that can be made. After the third month, however, the proportion of milk should be somewhat in- creased : namely, three parts of milk to one part of water. After the first teeth are protruded, the food may be a little more varied and substantial. Grated crackers dissolved in warm water; oat- 38 OF THE NOURISHMENT meal gruel; liquid preparations of arrowroot, tapioca, or sago; milk thickened with rice flour, and thin pap, may be allowed in moderate quantities along with the ordinary milk-and-water mix- ture. When these preparations do not agree with the child's stomach, they should be mixed with an equal portion of weak mutton, chicken, or beef broth, clear and well freed from fat. A mixture of this kind is, in general, easily digested, and rarely causes any unpleasant effects on the alimentary canal, when used after the first teeth have made their appearance. With some children, no form in which cow's milk can be given will agree with the stomach. In such cases, farinaceous decoctions, mixed k with a small portion of cream, are generally digested with perfect ease. Thin oat-meal gruel, or rice flour boiled in water, with the addition of a teaspoonful of cream to each gill of the liquid preparation, will answer very well. After the first grinding teeth arc protruded, weak broths, slightly thickened with oat meal, rice flour, arrowroot, or grated crackers, mixed with milk, constitute, in general, the most appro- priate articles of nourishment. A small portion of stale bread may also be allowed, two or three times daily, at this stage of infancy; but all solid animal food should be withheld until the canine teeth have made their appearance. After these teeth are protruded, small portions of animal food, in a solid state, may be allowed with perfect propriety. " The animal food given to young children should be plainly roasted or boiled. Fried and broiled meats, and all food heated a second time, by hashing or mincing, being less digestible, should be avoided. Many people, from a mistaken expectation of strengthening weakly children. give them more animal food, and sometimes twice or thrice a day; but it will be found much more frequently to add to the debility than to the increase of strength. Those children, on the whole who eat the least animal food, are the most healthy. Nothing i; more absurd than the notion that, in early life, children require ? variety of food. One food only is provided by nature for them and it is too presumptuous to assume that the Creator of the worl< acted in error, and that the ingenuity of man is able to correct it or make any improvement in his works." The peculiarly excitable state of the system during dentition and the consequent tendency to febrile irritation, render the fre< use of animal food decidedly objectionable during this stage of childhood. Small portions of the more digestible meats may bf allowed to healthy children, once daily, with little or no risk ol injury; but they should never be permitted to form the principal part of the food. The lean parts of mutton, lamb, tender beef, game, and fowl, should be selected. Veal, pork, pig, goose, duck' and all kinds of salted meats, being of much more difficult'dices- OF INFANTS, 39 tion, can seldom be used without impeding digestion, and finally injuring the tone of the stomach. Veal is decidedly the most ob- jectionable of all the meats in common use. Fresh fish, boiled, and taken in moderate portions, seldom disagrees with the sto- machs of children, and may be used, occasionally, with perfect propriety. Soft boiled eggs, too, form an appropriate article of nourishment for children after the first teeth have come out. When fried, or boiled hard, they are altogether unsuitable. Strongly seasoned meats, compound dishes, ragouts, hashes, meat pies, and pastry are to be wholly rejected. Simplicity and plain- ness are all-important requisites in the diet of children. Their meals should be made on a (ew plain and simple articles of food. Children who are indulged in the use of a variety of food, and in compound dishes, very rarely escape debility and irritation of the digestive organs. They soon become pale, dyspeptic, irritable, and languid. The introduction of fresh food into the stomach before that which was previously taken is entirely digested, seldom fails to operate injuriously on the alimentary canal. To obviate this cause of mischief, an effort should be made, as soon as the child is weaned, to establish some regularity in the periods of taking nourishment; and sufficient time should be allowed for each meal to be completely digested before fresh food is taken. If the meals are not sufficiently remote from each other, the digestive organs will almost inevitably become weakened, from the constant state of action in which they are kept by the continual supply of food. As a general rule, from three to four hours maybe regarded as a suitable interval between the meals. If the child requires nou- rishment between the regular meals, small portions of liquid ali- ment should be used. When solid animal food forms a part of the diet of children, it should be taken at noon, or in the fore- noon. It should not be taken more than once daily, as a general regulation. Pure water, with or without small portions of milk, constitutes the best drink for children, as it does for adults. The practice of allowing them a little wine, spirits, or malt liquors, is decidedly reprehensible. Children require no stimulus of this kind to excite and sustain their vital functions. The use of such drinks is espe- cially improper during the irritable period of dentition. There exists, naturally, a strong tendency to a preternatural determin- ation of blood to the head, in early childhood,—particularly while the process of dentition is going on. Some of the most fatal dis- eases of infancy are intimately connected with this condition of the circulation; and it is obvious, that the use of alcoholic Jtimu- lants must have a direct tendency to increase this irregular flow 40 OF THE NOURISHMENT of blood to the head, and consequently to increase the liability to inflammatory diseases of the brain. Sweetmeats.—Indulgence in the use of sweetmeats is a copious source of disease and mortality during childhood. Dried fruits preserved with sugar, nuts, baked sugar, &c. are among the most indigestible substances employed as food. There are few individ- uals, even in adult age, whose digestive organs are sufficiently vigorous to digest such articles with facility; and their frequent or abundant use rarely fails to impair the tone of the stomach, and to cause intestinal disturbances. Fruits preserved with their skins, as raisins, are particularly pernicious. The cuticle, or skin, of all fruits is of peculiarly difficult digestion. The most active digestive powers arc, in general, insufficient to digest this portion of fruits. Added to this the hard and insoluble seeds which rai- sins and many other fruits in common use contain, render them highly irritating and injurious to the alimentary canal. In vain are judicious dietetic regulations adopted for the nourishment of children, if articles of this kind are allowed. I have known two or three raisins to produce the most serious and protracted disor- der of the intestinal canal in infants. Three instances have oc- curred to me, in which convulsions and speedy death were, une- quivocally, the consequence of overcharging the stomach with this indigestible and irritating fruit; and my friend, Dr. Cobb, has recently communicated to me a case, which occurred in his own family, of the most alarming character, produced by the same cause. The infant appeared to be well when put to bed. On attending to it about midnight, it was found cold, pulseless, with a deathlike expression of the countenance, and apparently dying. In a short time spontaneous vomiting came on, by which a large quantity of raisins was thrown from the stomach, after which all the alarming symptoms speedily disappeared. The raisins had been given to the child by a servant of the family without the knowledge of its parents. The conduct of parents, in relation to this subject, is often ex- tremely irrational and pernicious in its consequences. They would not themselves venture on the frequent and free use of confection a ries of this kind; and yet will indulge their children without scarcely any restraint, in the use of these pernicious luxu- ries. The sicklier and weaker the child is, the more apt, in gen- eral, is it to be allowed these destructive gratifications. The pale, feeble, and sickly child, whose stomach is hardly able to di- gest the most simple and appropriate aliment, is sought to be ap- peased and delighted by the luscious and scarcely digestible arti- cles of the confectioner. Indigestion, intestinal irritation, termin- ating often in ulceration and incurable diarrhoea, are the frequent consequences of such conduct; and at best, such indulgences must OF INFANTS. 4i Inevitably, prolong the feeble and sickly condition of the child, and not unfrequently eventuate in permanent constitutional infirmity. With regard to the use of fresh fruits, writers, on this subject, have expressed different opinions. Apples, peaches, and apricots, when perfectly ripe and mellow, may be occasionally allowed to children, in moderate portions, with entire safety, unless the sto- mach and bowels be very weak and irritable. In children of a costive habit, the temperate use of these fruits may even have a beneficial effect, by their tendency to excite the action of the bowels. Nothing, however, of this kind is more prejudicial to health than unripe fruits. Unripe apples, so frequently seen in the hands of children, are particularly injurious; both on account of the difficulty with which they are digested, and the peculiar and pernicious quality of the crude juice, or acid, which they contain. Pears, even of the tenderest kinds, appear to be much more indigestible than ripe apples or peaches, and seldom fail, when freely taken, to cause some uneasiness and disturbance in the alimentary canal. Stewed or roasted fruits, particularly the two latter kinds, are, in general, well adapted to the digestive powers of young children, and maybe allowed, occasionally, with perfect propriety, provided they are not very sour. When the acid prevails to such a degree as to require the addition of sugar to render them sufficiently palatable, stewed or roasted fruits of this kind rarely agree well with weak and delicate stomachs, and cannot be allowed to young children without considerable risk of unpleasant consequences. In general, all fruits having a firm cuticle or skin, such as grapes, whortleberries^ &c. are improper articles of food for children. The latter berries, especially, are invested with so firm a cuticle, that even the most energetic digestive powers are insufficient to dissolve it; and it is, doubtless, in part, on this account, that of all fruits of the kind they are the most apt to ex- cite internal irritation and diarrhoea. The pulp of grapes, freed from the seeds, rarely causes disorder in the alimentary canal, when taken in moderation; and children may be safely indulged in the use of small portions of it. When swallowed with the skin and seeds, however, grapes are decidedly hurtful; and, as chil- dren rarely attend properly to the rejection of these parts, this fruit cannot be put into their hands, without considerable risk of injury from this source. Fruit, that contains small, hard and in- soluble seeds—such as strawberries, blackberries, currants, &c. arc particularly apt, when freely taken, to disorder the alimentary canal. The seeds, resisting the digestive powers, irritate the mu- cous membrane of the bowels; and when, from previous causes, this membrane has become enfeebled and irritable, they mav G 5 42 OF THE NOURISHMENT OF INFANTS. readily excite dangerous irritation. Small insoluble bodies oi this kind, frequently remain lodged in the folds of the bowels for many days and even weeks, and give rise to severe and unmanage- able disorders of the alimentary canal. I have known a child to evacuate from its bowels a great many small seeds, three weeks after the fruit which contained them had been eaten; and during all this time it had suffered painful and exhausting diarrhoea. Cherries are among the most pernicious fruits in common use, and ought to be wholly excluded from the list of articles with which children may be occasionally indulged. Even when eat without the stones, they are peculiarly apt to derange the bowels; and when swallowed with the stones, which, with children, is not unfre- quently the case, they are capable of producing violent and even fatal impressions on the alimentary tube. No small number of instances have come under my notice, where the most alarming and, in a few cases, fatal consequences resulted from the irrita- tion of cherry stones lodged in the bowels. Convulsions, inflam- mation, unconquerable constipation, and exhausting and harrass- ing diarrhoea, are among the affections which are apt to arise from this cause. All fresh fruits have a tendency to excite, more or less strongly, the peristaltic action of the bowels. As a gene- ral rule, therefore, every kind of fresh fruit is improper for chil- dren whose digestive organs are weak and irritable, or who are habitually liable to disorder of the bowels. If the digestive pow- ers are vigorous, and there exists no obvious tendency to bowel complaints, small portions of the fruits in common use, the seeds and skins being rejected, may be allowed occasionally, with little or no risk of mischief. It is of much importance, however, that the quantity of such articles taken into the stomach at a time be moderate; and that they should never, with children, be suf- fered to form the whole, or even principal part, of meals. OF EXERCISE. 43 CHAPTER IV. OF EXERCISE. The importance of permitting the infant to have the unre- strained use of its limbs, has already been dwelled on, when speaking of Dress. At first, its spontaneous motions are, indeed, but very limited; for the muscular power, and the command of volition over it, are acquired in a very gradual manner. Uncer- tain and awkward motions of the arms—stamping with the legs, and drawing them up, are the first feeble attempts which the in- fant makes in the use of its muscles. But even these muscular exertions appear to be indispensable to the preservation of its health and the proper developement of its powers; and it should be an especial object of care to allow entire freedom of motion, several hours daily, by avoiding all modes of dress and position tending to restrain the free use of the extremities. With this view, the infant should be taken from its bed and laid on its back upon a soft mattress, or any other level and slightly resisting sur- face, and divested of every thing calculated to restrain the mo- tion of its limbs and body. When thus indulged with freedom of action, it will soon exercise its feeble limbs, by moving them in various directions; and manifest," by its repeated and apparently earnest, efforts, how much it enjoys this exemption from restraint." This should be repeated two or three times daily; and in warm weather the air should be freely admitted. Voluntary exertions of this kind are much more efficient in developing the powers of the muscular system, and bringing it early under the commands of volition, than any of the passive modes of exercise in common use. Children, who are frequently permitted to exercise their muscles in this way, will, cateris paribus, learn to use their limbs and walk earlier and more steadily than those who are seldom allowed this freedom of voluntary action. Carrying.—Besides the exercise which infants thus obtain by their own muscular efforts, passive exercise should be regularly afforded them, by carrying in the arms and riding in an easy car- riage. This kind of motion, when conducted in a proper way, has a highly salutary influence on the developement and vigor of the infantile organization. The use of it should be commenced 44 OF EXERCISE. as early as the second or third day after birth, provided the infant be not unusually feeble; and it should be daily attendea to, as one of the regular and indispensable duties of nursing. The man- ner, however, in which very young children are usually carried or exercised, is extremely reprehensible, as it is calculated to give rise to very unfortunate consequences in relation to the health and regular conformation of the child's body. I allude, particu- larly, to the common practice of carrying infants with their bodies in an erect position, before the spine and muscles have acquired a sufficient degree of firmness and activity, to support the trunk and head in this posture. The child is usually carried by the nurse pressing its thighs and hips, with the left forearm, against her body, whilst its trunk is balanced in an upright posture, by resting lightly against her bosom. Thus the whole weight of the infant's trunk rests upon the feeble and yielding spine, while the unsupported head is, in general, suffered to lean constantly to one side, or to roll about in every direction. It requires but little reflection to perceive, that this mode of carrying infants must in- terfere, very materially, with the regular and symmetrical devel- opement of the body. The feeble spine, yielding to the super- incumbent weight of the head and body, is always curved out- wards while the infant is held or carried in the erect position; and, when this is daily repeated, for several hours, as is frequent- ly the case, the back is liable to become permanently bent or distorted. A habit, too, of leaning the head to one side is some- times contracted by the child; and, from the violent manner in which the head is liable to fall from side to side, serious and even fatal injury may be inflicted on the spinal marrow of the neck— a remarkable instance of which is related in Hufeland's Journal. But even after the spine and its muscles have acquired a sufficient degree of firmness, to enable the child to support its head and body in the erect position, without difficulty, it incurs considera- ble risk of injury from the usual practice of carrying it, almost exclusively on one arm. Nursery-maids are very apt to fall into this error, unless particularly directed to change the arm on which the child is carried. When this precaution is not used, and the child is carried almost wholly on one side, it is apt to acquire the habit of leaning to one side, which it is always very difficult to correct. The child, also, when carried in this manner, usually throws one of its arms around the neck of the nurse, in order to support itself more steadily in the erect position; and of course always with the same arm, when the side on which it is carried is not changed by the nurse. In consequence of this position, the shoulder-blade and side of the chest are liable to be forced up- wards and outwards, which may ultimately result in permanent distortion of these parts. The manner of cuirymg infants is^ in- OF EXERCISE. 45 deed, of far greater moment than seems to be generally supposed. Many a parent has had occasion to lament the unfortunate con- sequences which may result from the errors just mentioned; and yet, it must be confessed, that mothers seldom pay that attention to this subject which reflection and maternal solicitude would seem to suggest. The spine and its muscles seldom acquire sufficient strength and firmness, before the end of the third month, to enable the child to support its body in an upright position, without inconve- nience or risk of injury. Until this power is manifestly acquired, the infant should not be carried, or suffered to sit, with its body erect, without supporting it in such a manner, as to lighten the pressure made on the spine, and aid it in maintaining the upright posture of its head and trunk. But even when thus supported by the nurse, it should not be kept in an erect position more than one or two minutes at a time, and not until it is four or five weeks old. At first (a few days after birth) the infant should be taken from its cradle or bed, two or three times daily, and laid, on its back, upon a pillow, and carried gently about the chamber. Struve observes that, the best mode of carrying very young in- fants is, to lay them into a small oblong basket. By this contri- vance a gentle and agreeable swinging or undulating motion will be communicated to them; and the sides of the basket being three or four inches higher than the child's body, a cover may be thrown over it, without restraining the free motion of its limbs. After the third or fourth week, the child may be carried in a re- clining posture on the arm of a careful nurse, in such a way as to afford entire support to the body and head. This may be done by reclining the infant upon the forearm, the hand embracing the upper and posterior part of the thighs, whilst its body and head are supported by resting against the breast and arm of the nurse. When held in this way, it may be gently moved from side to side, or up and down, while it is carefully carried through a well ventillated room. When it is found that the child has acquired a sufficient degree of muscular power to maintain itself in a sitting posture—which rarely occurs before the completion of the third month—it may be carried about, in this position, for a short time, twice or thrice daily, provided the spine and head be supported by the nurse : an aid which can seldom be pru- dently dispensed with before the child is six or seven months old. " During the first six months," says Struve, " the head of the infant should, in carrying, be supported by the nurse's hand; for the muscles of the neck are, at this tender age, too delicate to pre- serve the head in an erect posture." Mothers are fond of exhib- iting the exploits of their babes, in raising and supporting their heads—" unconscious of the mischief which may be occasioned 5* 46 OF EXERCISE. by this premature experiment." It is painful to see the violent and generally abortive efforts, which the infant makes to steady its head, when raised into a sitting posture. It will sometimes suc- ceed in balancing its head for a moment, to the great delight of the fond mother; but the effort is almost invariably speedily fol- lowed by a sudden and often violent rolling of the head from side to side, which cannot but have an injurious tendency. All rapid, whirling, and concussive motions are calculated to injure the health and delicate organization of infants; and moth- ers should be particularly vigilant in preventing nursery-maids from subjecting their charge to such violence. Running or jump- ing with an infant in the arms—descending rapidly a flight of stairs—whirling round, &c. ought to be rigidly forbidden, as they are attended with much risk of some serious accident, and may interfere with the regular distribution of the circulation, and the healthy action of the brain and other important organs. The practice of supporting very young infants in a sitting posture on the knee, and jolting them violently, cannot be too severely cen- sured. It is not uncommon to see mothers and nurses jolt infants in this manner, with a violence that threatens dislocation, and manifestly occasions them much pain and distress. Tossing them rudely on the arms, though less concussive than jolting on the knee, is equally reprehensible, as it is attended with more risk of injury from falls, blows, &c. These violent agitations, "power- fully affect the delicate organization of infants, and may be pro- ductive of spasms, epilepsy, and appoplectic fits." Gentle and cautious tossing on the arms, affords an agreeable exercise of the body, and may be salutary by the moderate agitation which it causes in the internal organs. Different opinions have been expressed with regard to the pro- priety of rocking infants in cradles. To gentle and cautious rocking, there can be no just objection. The swinging, or rolling motion of the cradle, communicates an agreeable sensation to the system, and disposes to calmness and repose: and when mode- rately practised, and not very often and long continued, it can scarcely give rise to any evil consequences. It is otherwise, how- ever, with violent, rude, and almost constant rocking. Rapid and long-continued rocking motion, instead of merely calming the excitement of the brain and inducing a state of agreeable repose, as is the case when gently and slowly performed, is apt to disor- der the actions of this organ, in a very decided manner, and, through it, to exert an injurious influence on the whole organiza- tion. With infants predisposed to diseases of the head, strong rocking should be particularly avoided. Riding in a Carriage.—This is an excellent mode of affording suitable exercise to infants, and may, with great propriety, be OF EXERCISE. 47 employed as an occasional substitute for carrying in the arms. When cautiously managed, it affords a gentle, uniform, and very agreeable motion, for which children, in general, soon contract a great fondness. The body of the carriage should be long enough to permit the infant to lie down at full length; and the sides ought to be suffi- ciently high to prevent it falling or rolling out. The wheels should be low, in order to lessen the liability of oversetting; and they must be carefully secured " against running off when the carriage is in motion." Like carrying in the arms, this mode of exercising infants is liable to be conducted in a very improper and hazardous manner. This duty is usually entrusted to children or young girls, who being generally more disposed to consult their own sportive inclinations than the comfort and safety of their charge, are apt to draw the carriage along with great rapidity, paying little or no attention to the roughness or unevenness of the ground over which they pass. Such careless conduct ought to be particularly forbidden by parents; and especial instructions given, that the carriage be drawn along with a moderate and steady pace, and over level grounds. Very young infants should be laid down in the carriage, on a pillow or a small and soft mat- tress, with the head slightly elevated, " and so confined at the sides as to prevent them from rolling when in motion." After the child has acquired some degree of strength, it should be placed in a semi-recumbent posture, with its head and back well supported by pillows, &c; and when it is capable of supporting its head, it may be permitted to sit upright in the carriage, being properly secured against being thrown from side to side by the rolling of the carriage. Walking.—After the infant has acquired sufficient strength to support itself in the sitting posture, it should be placed on a soft carpet, several times daily, and surrounded with its toys. When thus left to the free use of its limbs, it will soon learn to crawl— an exercise which should always be freely allowed, and even en- couraged, as the most natural preliminary muscular effort to the more difficult one of walking. The common practice of teaching children to walk, by supporting them, prematurely, on their legs, and leading them forward, without allowing them the advantage of having their muscles previously strengthened and in some de- gree brought under the commands of the will, by the initial loco- motive exercise of crawling, is objectionable on various accounts. It seldom fails to produce more or less unnatural curvature of the legs; and in infants of a scrofulous or ricketty habit, it may readily give rise to distortion of the spine and round shoulder. Children, who are permitted to exercise their muscles by crawling, generally acquire a much firmer step, and enjoy more tobust 48 OF EXERCISE. health, than " those who have been taught to walk without this useful intermediate muscular discipline." " Before infants attempt to walk," says Dr. Struve, " they should first learn to crawl. With this intention, they should be placed on a large carpet, where they will soon busily employ themselves; move and extend their limbs, or roll about to reach their playthings. If the weather is serene, and the ground per- fectly dry, they may be carried out, and placed on a grassplat, where they can range about in all directions; and if they happen to fall, they will not receive material injury on the soft ground, but rather learn to be more cautious in future. While in the nursery, they may be taught to rise from the floor by laying hold of chairs; and, if occasionally supported under the arms, they will easily learn to stand erect; but they should never be raised up by one arm only. At an early age they may be held under both arms; and when thus supported, the hands of the attendant be occasionally withdrawn for a moment, they will soon acquire the power of standing alone. Mild and persuasive language ought to be used in these experiments; while the infant may be en- couraged by some toys placed at a little distance, which will in- duce it to stretch out its little arms, and endeavor to advance to- wards the place containing the desirable objects. By such means it may be allured to visit different parts of the room. The first journey of this description ought to be attempted only from one chair to another; and afterwards, the little traveller may run to- wards its mother, or nurse, who stoops to receive it with extended arms. As the child improves in its efforts to walk alone, the chairs may be placed at a greater distance from each other; and when it sees its older companions run and jump about, it can scarcely be restrained, so anxious is it to be placed on the floor, that it may crawl or waddle after them. At length, parents are gratified with one of the most delightful scenes: they behold their child for the first time walking without any assistance. If we are earnestly desirous of training up our children in such a manner, that they may acquire a firm step, and well-formed limbs, we shall gain our purpose much more certainly and safely, by pursu- ing this gradual and cautious mode of teaching them the use of their legs, than by the more common practice of placing them. prematurely, on their feet, without permitting them the previous exercise of crawling." Leading-strings and go-carts, formerly so much in use, are now, very properly, almost universally abandoned. The former con- trivance is calculated to do very serious injury, by the rude man- ner in which infants are liable to be pulled about by inconside- rate or illnatured nurses; for, when the child makes a false step, or inclines too much forward or to one side, and is in danger of OF EXERCISE. 49 falling, it is usually raised by a sudden and violent pull at one or both strings. Dislocations and other painful injuries have fre- quently been occasioned in this way. Leading-strings, moreover. tend to compress and distort the shoulders; and children are apt to acquire an unsteady and awkward gait, when taught to walk in this manner. Go-carts are still more objectionable. They confine and constrain the body in a very uncomfortable manner; and, as in pushing the machine along the floor, the breast is usu- ally firmly pressed against the circular top, injury may be done to the regular developement and conformation of the upper part of the chest. The very common practice of teaching infants to walk, by holding them by one of their hands, deserves the most decided reprehension. When led in this way, the child's arm is continually, and often forcibly, extended upwards: if it happen to lose its balance, or trip, or if its legs are yet too feeble to sup- port itself long, in the erect posture, the whole weight of its body is often suspended by one arm. Frequently, too, it is entirely raised from the ground by one arm, in order to help it over some obstacle, or to hasten its progress over a rough and difficult piece of ground. It is easy to perceive that this practice must, neces- sarily, and in no inconsiderable degree, tend to draw the shoulder and side of the chest out of their natural position; and, when fre- quently repeated, to give permanent deformity to these parts. From the sudden and violent extension wrhich the arm usually re- ceives when the child stumbles, the shoulder and elbow joints are liable to be dislocated or sprained, or the clavicle may be torn from its attachment with the scapula. I have met with sev- eral instances of dislocation of the shoulder joint, which were occasioned in this manner; and the occurrence of painful sprains —often of several weeks continuance, from violence done in this way, is by no means uncommon. Parents should most earnestly forbid this mode of leading infants, when entrusted to the care of servants out of doors. Nursery-maids seldom exercise sufficient care in this respect. Too indolent to carry the infant in their arms, as they are directed and supposed to do, they are apt, as soon as they are no longer observed, to place the child on the ground, and to hurry, or rather, drag it along, in the most care- less and unfeeling manner. Of a similar, but still more repre- hensible character, is the practice of raising infants from the ground by both arms and swinging them about in the air. Frac- tures, dislocations, sprains, and other dangerous and painful inju- ries, have frequently resulted from this irrational conduct. No prudent parent will knowingly permit such an outrage; but, as the ordinary attendants on children are often thoughtless and rash, they should always be especially cautioned on this point. After children have acquired the entire use of their legs, walk- H 50 OF EXERCISE. ing is decidedly the best exercise they can take. When the weather is fine, they should be taken out daily, and freely in- dulged in running and walking about, under the superintendence of a careful nurse. These little excursions, if prudently conduct- ed, have a highly salutary influence on the infantile system. Chil- dren, who are raised in the country, are in general much more robust, healthy and active, than those who are brought up in cities: and this difference is mainly to be ascribed to the greater freedom which the former usually enjoy, of walking, running, and tumbling about on grassplats—enjoyments often in a great mea- sure denied to the latter. In taking this kind of exercise, children should not be accustomed to rely too much on the assistance of others. If the ground is favorable; that is, if it is soft or covered with grass, and free from stones, timber, &c, they should be per- mitted to have their way. A few falls will do them no injury; but, on the contrary, make them less timid, and teach them better than any other instruction how to avoid a similar accident in future. Children, who are never suffered to surmount the little difficulties which may occur in their sports, by their own efforts, and continually warned against trifling accidents, seldom fail to become unduly timid, helpless and irresolute in their actions. Parents ought not to intimidate their children, by inspiring them with a constant dread of falling or hurting themselves. The cus- tom of exaggerating the dangers incident to their usual sports— and of plying them continually with admonitory injunctions against accidents, when they are engaged in their amusements, is calculated to favor the occurrence of the very accidents which they are meant to obviate, by the timidity which these perpetual lessons of caution and fear almost inevitably inspire. When the ground is soft, it is much better to let the child take the chance of two or three falls, and give it full scope for the exercise of its limbs, by running and gamboling about until it is satisfied. Noth- ing can be more invigorating to the whole organization than this kind of unrestrained exercise, in suitable situation?, and under the superintendence of a prudent nurse. Struve, whose excellent observations on this subject I have already drawn on so fre- quently, observes that, when children happen to fall or hurt themselves, they should not be soothed by expressions of extreme pity and sorrow; for plaintive words and expressions of great sor- row tend very effectually to render them effeminate and timid. Children, who are thus accustomed to excessive cemmisseration, seldom fail to acknowledge this tender sympathy, by straining their little lungs to the utmost by crying, on every slight injury they receive. After children have passed through the period of primary den- tition, they should be encouraged in the pursuit of active amuse- OF EXERCISE. 51 ment out of doors, as an essential and regular part of physical discipline. Nothing contributes more effectually to enfeeble the body, and to lay the foundation of permanent constitutional infir- mity, than confinement within doors and want of active exercise at this tender period of life. The developement of the moral and physical energies of children can in no way be more effectually promoted, than by permitting them to engage freely in the usual sports of childhood, in the fresh and open air. The practice of obliging children to remain within doors, and to con over their lessons, between school hours, is by no means commendable. These intervals should be devoted to innocent amusement and bodily exercise. Trundling the hoop—flying kites—playing at ball, shinny, or simply skipping and running about, with other juvenile sports unattended with danger, have a decided tendency to improve the health and vigor of the system, and should be freely permitted during the hours not necessarily devoted to the school. Girls may amuse themselves with skipping the rope, dancing, walking, shuttlecock, a well constructed and safe swing, riding in a carriage, &c. CHAPTER V. AIR,—TEMPERATURE,—EXPOSURE. That pure air is indispensable to the entire well-being of the human organization, is so well established by the common sense and experience of mankind, that it seems unnecessary to enforce its truth by any especial illustrations. The importance, however, of attending particularly to this point, in the management of children, does not, in many instances, appear to be sufficiently estimated. At no period of life are the effects of confinement in stagnant and impure air, more obviously and lastingly detrimen- tal to the animal economy than during the feeble and susceptible age of childhood. How deeply pernicious a foul and confined air is, in its influence on the human system, is most strikingly illustrated in the pale, feeble, and sickly aspect of those unfortu- nate children who are early placed in manufacturing establish- ments, where they are confined, nearly the whole day, in crowd- ed and ill-ventilated apartments. Children brought up in the crowded and filthy parts of large cities, seldom exhibit a per- fectly healthy and vigorous appearance. Go into the country, 52 OF AIR, &c. and you will everywhere meet with children rioting in the exu- berance of health—plump, ruddy, robust and active. Exercise and simplicity of wholesome diet, doubtless contribute essentially to this healthful condition; but, no regulations of diet—no atten- tions to exercise, and no sanitary observances whatever, are ade- quate to produce a similar fortunate result, when counteracted by the continued depressing influence of a confined and contam- inated atmosphere. Infants ought to be early accustomed to the fresh and open air. The practice of confining them, during the first five or six weeks, to the close and heated air of nurseries, has a direct tendency to impair the energies of the system, and to impede its healthful de- velopement. The daily enjoyment of fresh air, for an hour or two, contributes very essentially to the health and sprightliness of infants; and constitutes one of the most efficient preservatives against that delicate and sickly condition, which is so frequently witnessed in those who are almost constantly confined and pam- pered in nurseries. " Pale countenances, weak eyes, general relaxation of the body, an accumulation of all the inconveniences and sufferings of childhood—at length consumption and early dissolution of life: all these are the natural and frequent conse- quences of such confinement. On the contrary, there is no me- thod, by which children may be more effectually preserved against such unfortunate events, than by permitting them to inhale a fresh and uncontaminated air. Pure air is, indeed, most grateful to the feelings of children. After having been carried out, but a few times, they evince, even at a very early age, a strong desire to return to the open air. While yet on the arms of the nurse, they anxiously point to the door, and make efforts to approach and open it. When they can scarcely crawl, they instinctively advance towards that part of the room from which they have a prospect of escaping. Hence, in the bosom of nature they expe- rience the greatest comfort; and their tears can frequently be stopped in no other way, than by taking them out of doors into the free air." (Struve.) When the weather is clear and of a mild temperature, infants should be carried into the open air, once or twice daily, as soon as they are two weeks old. During cold and humid weather, they should be occasionally conveyed out of the nursery into an adjoining well-aired room: avoiding,however,strong currents of air, and sitting with them near an open window. Important as the enjoyment of fresh air is to the health and comfort of infants, care should be taken to accustom them gradually to the impres- sions of the external air—more especially when the atmosphere is cold and damp. The practice of exposing children, soon after birth, at once to the open and cold air, with the view of "hard- OF AIR, &c. 53 ening them," as it is called, is attended with considerable risk of injury, and should not be permitted by parents, except when the weather is clear and very mild. Catarrhal and other inflamma- tory affections are frequently contracted in this way; and in fee- ble children, low temperature, when thus suddenly applied, is apt to occasion serious depression of the vital energies, and to predispose very strongly to the occurrence of febrile and other dangerous maladies from the subsequent influence of the ordinary exciting causes of disease. Instead, therefore, of exposing any young infants, at once, to the direct impressions of the external air, when the state of the atmosphere is unfavorable, they ought to be gradually inured to such a transition, by carrying them fre- quently out of the nursery into the cooler and less confined air of well-aired and unoccupied rooms. In this way, they will soon become, in some degree, habituated to sudden transitions of tem- perature, and to the more direct impressions of the open air. Even in summer, the infant should not, as a general rule, be car- ried, at once, into the external air, without having been previ- ously accustomed to the air of a well-ventilated chamber. After the child is three or four days old, it ought to be conveyed, sev- eral times daily, out of its nursery, into a room having, at first, only the windows open, and in four or five days afterwards, the doors also, so as to admit of a free circulation of the air through every part of the room. This having been practised for ten or twelve days, the child may then be carried out of doors, and per- mitted to enjoy the pure and open air. At first, it should not be allowed to remain out of doors more than ten or twelve minutes at a time; but the duration of this indulgence must be gradually extended, so as to keep it in correspondence with the progressive developement of the child's organization and energies. After a child has acquired the power of walking, it should be suffered to 6pend a great portion of its time in the open air, and in the pur- suit of its ordinary amusements, provided the weather is suffi- ciently temperate and dry. Nothing affords more real enjoyment to children, and at the same time tends more decidedly to give them a sound and active tone of mind and body, than a liberal indulgence in exercise and their innocent sports out of doors. A country residence possesses many important advantages in this respect, which cannot be had in large cities. There, they con- stantly breathe a delightful and perfectly pure air, and may be safely permitted to run, skip, and tumble about under the shade of trees, and on the soft and green surface of a lawn or grassplat, almost without restraint and risk of receiving any serious hurt or injury. In cities, on the contrary, the atmosphere is always more or less contaminated with impure and noxious exhalations; and children cannot be prudently permitted to enjoy the same freedom 6 54 OF AIR, Sic. of exercise and active amusement out of doors, as in the country. from the constant risk of receiving some injury when suffered to be on the side-walk, and the confined and narrow space of ground usually allotted to the houses. But, although the atmosphere of cities is always far from being perfectly pure, still, the daily enjoy- ment of the open air, impure as it may be, is decidedly beneficial, and should never be withheld, under an idea, that by free ventila- tion and cleanliness the air breathed within may be rendered as pure as it is out of doors. In cities of small extent, children "may be taken to a garden or field near the town;" and the larger cities generally afford public squares, or parks, devoted to the exercise and recreation of the citizens, to which children may be, conve- niently, taken, where they may enjoy a free and fresh air, and amuse themselves by playing and running about on the grass." (Struve.) These little excursions have a very salutary tendency; for, besides the excellent effects of the exercise which they afford, there is something peculiarly enlivening and grateful in the influ- ence of the open air, which children seldom fail to manifest by their expressions and actions. When they have the advantage of a lawn or grassplat, children should be allowed to amuse them- selves freely in their own way. " Boys may be permitted to run about, without their hats, though exposed to the wind and sun. If they do not, spontaneously, complain of heat or cold, it may be considered as a proof that they are in good health; for diseased and debilitated children will speedily return to the nursery. If they cry, and cannot bear the blast of a moderate wind, or a slight degree of cold, it is then proper to return with them to the house, as they are probably indisposed; but if, on the contrary, we find them lively and cheerful, they may be allowed to con- tinue in the air as long as they are comfortable and easy. Chil- dren should not be forced against their inclination to go out of doors, during a fall of snow or the intense heat of summer. If they are once inured to a rough atmosphere, no compulsion will be necessary." During the first two or three years of infancy, no difference need be observed in relation to this subject between boys and girls. Parents are, in general, averse to allowing girls the same freedom of exercise and amusement in the open air that is usually granted to boys, on account of the tendency which free exposure to the atmosphere and the direct rays of the sun has to render the skin dark and harsh. A white and smooth skin, and a delicate organization are, by many, regarded as marks of a genteel education; and these vain distinctions are often sought and obtained at the expense of health and a firm constitution, by too much seclusion from the external air and light of the sun. Girls, like boys, ought to be freely and frequently exposed to the open air and weather. The complexion may not become so del- OF AIR,&c. 55 icate and fair, when this freedom of exposure is permitted; but the more pleasing appearance of florid and robust health, accom- panied with a delightful feeling of buoyancy and vigor, will be obtained in its stead : a result infinitely more valuable than fair- ness and smoothness of skin and delicacy of structure,—and which will extend its salutary influence throughout the whole subse- quent period of life. " Not a day," says Willich, " should be suf- fered to pass without affording children—both boys and girls— the benefit of exercise in the open air. In this instance, custom ought to become second nature; they must be inured to external impressions; and the daily enjoyment of this balm of life should constitute an essential part of their regimen." Although children should be permitted to indulge freely in ex- ercise and active amusement, during their daily excursions in the open air, constant care ought to be had, that they do not lie down or sit on the cool and damp ground, or in a strong current of air in the shade, when they are in a state of perspiration from exer- cise; nor should they, on any account, be permitted to drink cold water, except in very small portions, and at considerable inter- vals, when in this heated condition. A neglect of these precau- tions is apt to give rise to the most serious consequences. Inflam- mation of the brain, lungs, stomach, bowels, liver—catarrhal affec- tions, terminating ultimately in disorganization of the lungs, croup, and violent inflammatory rheumatism, are often suddenly excited by cold and dampness when applied while the body is thus especially predisposed to their morbific influence. Nurses and servants should always be especially instructed on this point; and as soon as children are old enough to comprehend the lessons of caution, they should be earnestly impressed with the evil con- sequences of these practices, and of the necessity of avoiding them as an irremissible condition of their being permitted to run about and play out of doors. It is not enough, however, that children be taken into the open air, for an hour or two daily, in order to secure them the full amount of benefit which may be derived from this source; for unless proper attention be constantly paid to the preservation of a compara- tively pure and fresh air, in the rooms in which they sleep and spend the greater part of their time, the temporary enjoyment of the external air cannot effect a great deal towards the permanent invigoration and health of their systems. Particular care should, therefore, be taken to prevent the air of nurseries from becoming impure and stagnant, by proper at- tentions to cleanliness and ventilation, and the avoidance of every thing which may tend to give rise to unwholesome effluvia. When the atmosphere is mild, the external air ought to be freely admitted into the room, by keeping a window cpen during the 56 OF AIR, &c. day; and at night the chamber door may be left open, or a sash raised, whilst the current of air is intercepted by the closed shutters. In cold and humid weather, the upper sash of a win- dow should be occasionally drawn down a few inches during the day. At night, a window in the adjoining apartment ought to be left open, the fresh air being suffered to enter the nursery, by the door of communication. Chimney boards, as they impede the free circulation of the air in rooms, are decidedly inadmissi- ble in well-regulated nurseries. The same objection exists to "double doors, linings, listings and sand-bags"—all of which,by preventing some degree of ventilation, contribute to an unwhole- some condition of the air. Indeed the maintenance of a proper circulation of air in the apartments appropriated to children, can- not be too strongly urged on the attention of parents. Even where the general atmosphere is impure, as is always the case in large cities, free ventilation should never be neglected; for, how- ever contaminated the external air may be, it soon becomes still more impure and insalubrious, by being breathed in a confined or stagnant state. The practice of using the nursery as a common

n the first washing of the infant; for if the white caseous matter, which is found deposited on its skin, be not carefully washed off from about the umbilicus, it soon acquires a very irritating char- acter, and gives rise to inflammation and excoriation of the navel. This, I am well satisfied is by far the most common source of this disagreeable affection of the navel. Children who are not pro- perly freed of this peculiar caseous deposition, where it occurs in abundance, almost invariably suffer more or less irritation and inflammation about the navel. Of the tendency of this white matter, to inflame and excoriate, the skin, when not properly removed, we often have abundant evidence on various parts of the body—particularly in the folds of the skin about the neck, joints, nates and groins. When the navel becomes irritated and inflamed, it soon acquires a deep red, excoriated and fungoid condition, discharging a thin, offensive and purulent matter, and evidently causes much suffer- ing and uneasiness to the infant. In some instances, the navel presents an elevated ulcerous surface, with an inflamed condition of the surrounding skin, and a copious discharge of thin irritating matter; in other cases, the central part of the navel shoots up a INFLAMMATION AND ULCERATION OF THE NAVEL. 97 kind of fungous excrescence, of a dark-red and excoriated appear- ance, with but little surrounding inflammation or actual ulcera- tion. This fungoid tumor sometimes assumes a button-like form, with a narrow base, and a round expanded head like a cherry; in other cases, the tumor is broad at the base, tapering towards the top, or exhibiting nearly a cylindric form. When the navel becomes excoriated or ulcerous and discharges matter, while the cord remains attached by a filament, the simple division of this slight connexion will often suffice to arrest the pro- gress of the ulceration, and dispose the navel to cicatrize. When- ever the cord is so far separated as to retain only a simple fila- mentous connection with the umbilicus, the separation ought to be completed by clipping the filament with a pair of scissors, whe- ther there be inflammation and ulceration or not; for if this partial connection is suffered to continue after the usual period of separa- tion, it, of course, prevents the healing, and almost invariably causes severe inflammation*and ulceration of the navel. When the fungoid little tumor in the bottom of the umbilical cavity has a narrow base, it may, in general, be speedily removed by passing a ligature round the pedicle, and drawing it sufficiently tight to arrest the circulation, without cutting into its substance. A strong silk thread will answer very well for this purpose. In the course of a few days, the tumor, usually, drops off, after which the part should be dressed with saturnine ointment, spread upon lint. Should the fungus, however, shoot up again, it must be repressed by astringent applications, or destroyed with one of the milder escarotic remedies. I have found the root of the sanguin- aria canadensis very finely powdered, an excellent escarotic in cases of this kind. A small portion of the powder should be put on the fungus, once or twice daily, and covered with lint spread over with a little lead ointment. When the surface and margin of the umbilical cavity are excoriated, and the discharge of mat- ter is copious, advantage may be obtained from the occasional application of a solution of sugar of lead, or what is better, a weak decoction of oak bark. In cases where the tumor is broad at the base, and 'where, of course, ligatures are inapplicable, recourse must be had to suita- ble astringents and escarotics. Dr. Dewees recommends "a O 98 INFLAMMATION AND ULCERATION OF THE NAVEL. pretty strong solution of the nitrate of silver," applied by means of a camel hair pencil, " and repeated until the part heals." The nitrate of silver is an excellent escarotic where the surface of the tumor is ulcerated or raw and spongy. In some instances, how- ever, these excrescences are of rather a firm texture, and covered with a fine membrane—and in such cases, this escarotic is always extremely slow in destroying the tumor. I have occasionally used a strong solution of the sulphate of copper, with a satisfac- tory result in instances of this kind. One drachm of the sulphate should be dissolved in an ounce of water, and applied twice daily by means of a camel-hair pencil or a dossil of lint. We may frequently reduce these tumors without any escarotic applications, by means of strong astringents constantly applied, as is often done with haemorrhoidal excrescences. Very finely pulverized oak bark, or Aleppo galls, sprinkled on the tumors, will sometimes cause them to shrink, at the same time that it tends to subdue the surrounding inflammation and to arrest the purulent discharge from the umbilical cavity. In the last case of this kind which occurred to me, I directed the nurse to drop a pinch of oak-bark powder, upon the excrescence thrice daily, and to wash the parts carefully with lukwarm water, every morning and evening; and the result was perfectly satisfactory. When the navel presents an elevated, ulcerous surface, we may often do much good by touching the ulcerated part very lightly with lunar caustic, and applying saturnine ointment, spread on lint, over it. If there is much inflammation of the navel and adjacent parts, a soft poultice made with lead-water and crumbs of bread, forms an excellent application. A solution of the sulphate of copper, in the proportion of ten grains to an ounce of water, may be applied with much advantage, when there is superficial ulceration, without much inflammation. It should be applied once or twice daily, and the part afterwards covered w ith lead ointment. Sprinkling the ulcerated surface with white lead, or with powdered oak bark or galls, will, in slight cases, frequently restore the parts to a healthy condition, without any other applications. I have seen prompt and very decided benefit derived, in a very aggravated case of ulcerated navel, from wash- ing the part, twice daily, with a decoction of the wild indigo INFLAMMATION AND ULCERATION OF THE NAVEL. 99 root, (baptisia tinctoria). The best, mode of applying this article, however, is in the form of a liniment, made by slowly simmering the coarsely powdered root in cream, and afterwards squeezing it through a thick piece of linen or flannel. This should be ap- plied with a soft pencil or feather, three or four times daily; or a piece of lint may be moistened with it, and laid over the ulcerated surface. I have repeatedly applied this liniment, to excoriated and ulcerated nipples, and generally with great advantage. Cleanliness is an important observance in cases of this kind. Whatever applications may be made, the parts should be care- fully washed with lukewarm water, at least twice daily, and where the discharge is particularly offensive, or copious, the parts imme- diately surrounding the umbilical cavity should be washed or carefully wiped clean, with a soft piece of linen wrung out of warm water, repeatedly during the day. CHAPTER VI. OF THE JAUNDICE OF INFANTS. Newly-born infants are liable to an icteric state of the skin which though generally of a very slight and transient character, requiring little or no attention, sometimes assumes a degree of violence and obstinacy which calls for prompt and active reme- dial measures. In a great majority of infants, this yellowness of the skin comes on within three or four days after birth, unattended by any mani- festations of indisposition; and after having remained stationary, for a few days, gradually disappears, without any unpleasant con- sequences. This peculiar discoloration of the skin is, generally, i-egarded as wholly distinct from jaundice, and altogether inde- pendent of hepatic derangement, or deposition of bilious matter under the cuticle. " It is difficult," observes Dr. Dewees. " to 100 JAUNDICE OF INFANTS. say, to what this yellow tinge may be owing; certain it is, it can- not be attributed to the presence of bile, since neither the urine nor the white of the eyes assume the yellow hue." It may be doubted, however, whether either of these facts can with propri- ety be regarded, as " certain" evidence, that the yellowness in question, is independent of bilious matter, since a temporary secre- tion of the carbonaceous matter which during foetal life is secre- ted by the liver, may it is presumed, take place into the rete-mu- cosum without showing itself either in the urine or in the eyes. Nor does the assertion, that the urine is always free of bilious matter accord with my own observations; for since my attention has been particularly directed to this subject, I have not met with one instance, where the urine did not acquire a slight bilious hue, about the time the yellowness of the skin was going off, although previously of a perfectly natural color. The liver appears to be the principal depurating organ, during the uterine stage of life. As soon as the infant is born, however, a large share of this office is transferred to the lungs and the skin. The skin at the same time, suddenly becomes highly engorged with blood, as is mani- fested by the redness and fulness which usually occurs a short time after birth.—It becomes the principal seat of sensibility and sen- sation, and its transpiratory function, is for the first few days, per- formed in a feeble and imperfect manner. It seems probable, therefore, that whilst these changes in the excretory functions are going on, the blood may become slightly charged with recremen- titious matter of a bilious or carbonaceous character, and that in the irritable and congested condition of the skin to which we have just referred, a portion of this matter may be deposited on the rete-mucosum or cutis, without any actual morbid derange- ments either of the liver, or of the general system. When the infant does not become restless and fretful and takes its nourishment freely, and the alvine discharges are manifestly colored with bile, this yellowness of the skin requires no particular attention, as it will pass off spontaneously, in the course, generally, of three or four days, without any unfavorable effects, either imme- diate or remote. But when the white of the eyes becomes yellow, the urine charged with bilious matter, the bowels costive, and the stools whitish or clay-colored, accompanied with an inclination to JAUNDICE OF INFANTS. 101 vomit, or with actual vomiting, and an anxious and distressed ex- pression of the countenance, the disease is evidently connected with more or less serious disorder of the biliary organs, and should be promptly opposed by a suitable course of remedial measures. When along with these symptoms, there is fever, and a swollen and tender state of the right hypochondriac and epigastric regions, the worst consequences are to be apprehended; for cases of this kind, frequently resist every curative effort that can be made, and proceed with increasing violence to a speedy termination in death, or assume a chronic character, with progressive emaciation of the extremities, and tumefaction and hardness of the abdomen, until the vital powers are consumed. Fortunately, however, these dan- gerous cases-are not common. In by far the greater number of instances, the disease is not attended with any violent and dis- organizing form of hepatic disorder, and, though manifestly de- pendent on biliary derangement, is of a comparatively mild and manageable character. The exciting causes of infantile jaundice are, doubtless, very various, Mr. Baumes thinks that meconial matter unduely re- tained in the bowels, is frequently concerned in the production of the disease; and Mr. Gardien expresses the same opinion. Dr. Underwood does not believe that the meconium can have any part in producing jaundice, except, perhaps, by obstructing the orifice of the biliary duct, for which it seems to be well adapted by its peculiarly viscid and adhesive consistence. I am inclined to think, however, that this writer has not attached sufficient im- portance to this recrementitious substance as a source of jaundice, in newly-born infants. To whatever circumstance it may be as- cribed, I am persuaded that this disease occurs more frequently where there is delay and difficulty experienced in purging off the meconium, than where this substance is easily and entirely evacu- ated during the first twenty-four hours. It is, indeed, not probable that the yellow color of the skin is, in any degree, derived from absorbed meconial matter; and it may well be questioned whether any portion of this recrement is ever absorbed into the circulation. The way, perhaps, in which retained meconial matter contributes to the production of infantile jaundice is, by exciting irritation in the intestines, and, in conjunction with other causes, particularly 10 102 JAUNDICE OF INFANTS. the purgatives that may be employed for the removal of this sub- stance, giving rise to mucous inflammation of the duodenum and consequent functional derangement of the liver, or obstruction to the flow of bile into the bowels. That a morbidly irritable or inflamed condition of the mucous membrane of the duodenum, is apt to give rise to jaundice is well known. "A curious patholo- gical fact," says Dr. Johnson, "has lately been fairly established— namely, that irritation or inflammation of the mucous membrane of the duodenum, will sometimes produce jaundice, where no ob- struction can be detected in the biliary ducts." Cases of this kind are always attended with excruciating paroxysms of pain in the region of the duodenum, an hour or two after taking nourish- ment, resembling the pain produced by the passage of a biliary concretion through the common bile duct. I have met with several cases of this variety of the disease, in adults, which, after all the usual remedies for jaundice had been ineffectually tried, were speedily cured, and without a single recurrence of the pains by an exclusive liquid mucilaginous diet, and the application of a blister to the epigastrium. It is highly probable, that the jaun- diced appearance which occurs in yellow fever, depends, mainly, on the gastro-duodenal inflammation so universally connected with that disease. In relation to infantile jaundice, my own observations have-satisfied me, that, in some instances at least, this disease is the immediate result of mucous inflammation of the upper portion of the intestinal canal. In a dissection which I made about two years ago, of an infant that had died in a state of deep jaundice, apparently in consequence of inflammation of the liver, I found the mucous membrane of the duodenum in a highly diseased con- dition. Some parts of it were of a uniform scarlet color,—others were softened to the consistence of jelly, and of a gray or ashy hue, and in several places it was entirely destroyed and removed, leaving the muscular tunic bare. The orifice of the bile duct was slightly tumified, but the duct was pervious throughout The liver was much engorged with blood, but exhibited no other obvious marks of structural lesion. Improper artificial nourish- ment during the first two or three days after birth, and the exhi- bition of irritating purgatives for the removal of the meconium, ■?re doubtless frequently concerned in the production of this dis- JAUNDICE OF INFANTS. 103 ease. The gastro-duodenal irritation which is apt to be excited in this way, can seldom fail to produce more or less functional de- rangement of the liver; and when the duodenal irritation pas- ses into a state of actual inflammation, jaundice may result, either from spasmodic closure of the mouth of the common bile duct, in consequence of the extremely irritable condition of the duodenum, or from sympathetic irritation with excessive sanguin- eous engorgement of the liver, and consequent functional torpor. In cases attended with a highly irritated or sub-inflamed condition of the duodenum, there is usually much sickness and frequent vomiting of a glairy fluid; the epigastrium is tender to pressure, and the little patient is affected with occasional paroxysms of violent screaming and agitation, particularly some time after tak- ing nourishment. In some instances the disease is unequivocally attended with in- flammation of the liver. The right hypochondrium becomes tu- mid, tense, and tender to the touch. The fever is strong, the respiration short and oppressed, and almost every attempt to move or lift the infant, immediately increases its sufferings and causes it to scream out with anguish. Very frequently, however, the hepatic derangement upon which the jaundice depends is entirely unconnected with inflam- mation. The liver may be in a state of inactivity from excessive sanguineous engorgement; or its torpor may depend on induration with or without enlargement, or on some other form of structional disorder. In cases of this kind there is, in general, but little or no febrile irritation. The infant is apt to fall into a drowsy and languid condition, with weakness of the digestive functions, acidity, vomiting, and flatulent colic pains. The disease usually assumes a chronic character, attended with progressive emaciation, and derangement of the alimentary canal. Instances depending on excessive sanguineous congestion of the liver, are usually at- tended with manifest indications of a general plethoric condition of the system. It has appeared to me that jaundice, from this cause, is most apt to occur in those infants, who are born with a turgid and livid appearance of the face and body, and an oppressed state of the brain—more especially where the vessels are not promptly relieved by abstracting blood from the divided cord. 104 JAUNDICE OF INFANTS. Without doubt, too, infantile jaundice, may in some instances depend on obstruction to the regular flow of the bile, from spas- modic constriction of the biliary canals, wholly independent of any local or general inflammatory excitement. Mr. Gardien, ob- serves that spasmodic constriction of the biliary pores may be oc- casioned by, the sudden exposure of the newly-born infant to cold air or water—the constringing impressions of which, may be sym- pathetically conveyed from the skin to the hepatic system. When we advert to the intimate relation which subsists between these two organs, and the extremely sensible and excitable state of the skin, immediately after birth, we can scarcely doubt that the disease may, be prod ced in this way. Treatment.—It has already been stated that in the ordinary cases of yellowness of the skin—when the infant does not manifest any obvious indications of indisposition, and the alvine discharges continue to be colored with bile, no active treatment is required. The customary warm bathing for preserving a pure and healthful condition of the skin, and a proper attention to the state of the infant's bowels—promoting their action, when they are torpid, and restraining it when there is a tendency to griping and diarrhoea, is in general all that is required in cases of this simple character. When the disease is not attended with an inflamed condition of ' the liver, though obviously connected with derangement of the biliary organs—that is, when the skin and eyes are yellow, the urine bilious, and the stools whitish or clay-colored, without any soreness or tenderness to pressure in the right hypochondriac and epigastric regions, much benefit may sometimes be derived from emetics. In cases of mere congestion and inactivity of the liver, or in hepatic torpor from any cause, the concussive operation of an emetic frequently proves highly beneficial by accelerating the cir- culation in the portal system, exciting the action of the liver, and relieving its congested condition, by determining the blood from the internal to the external parts of the body. A few grains of ipecacuanna should be given every fifteen or twenty minutes until vomiting is produced; and when the disease is obstinate, the emetic mav be advant-.jeously repeated, every other day, until the alvine evacuations acquire a bilious appearance. In all in- TAUNDICE OF INFANTS. 105 stances, However, of a manifestly inflammatory character, attended with fulness, tension and unequivocal soreness of the region of the liver and stomach, emetics cannot be employed without consider- able risk of injurious consequences. The bowels ought to be freely evacuated in the commencement of the treatment; and for this purpose calomel and castor oil appear to be the most suitable means. A fourth of a grain of calomel should be given every two hours, until two or three grains have been taken. If free purging does not ensue, the operation of the calomel must be pro- moted by castor oil, given in teaspoonful doses every hour, until the desired effect is obtained. After the bowels have been once freely evacuated, they must be kept in a loose state, by adminis- tering a fourth of a grain of calomel every morning noon and evening, with an occasional teaspoonful of castor oil, should the torpor of the intestines render an additional purgative necessary. Calomel is a valuable medicine in every modification of infantile jaundice, on account, both of its aperient effects on the bowels, and its specific operation on the biliary organs, and general capil- lary system. In conjunction with these remedies, the daily use of the warm bath, is often decidedly beneficial; and when the in- fant can bear it without manifest suffering, gentle frictions with the bare hand, over the region of the liver and stomach, repeated several times daily, frequently produces an obviously salutary effect in cases of this kind. It need scarcely be observed, that frictions of the abdomen would hardly fail to prove injurious in cases attended with hepatic inflammation or abdominal tender- ness. It is only when the region of the liver and stomach may be pressed without causing the infant to cry or manifest increased distress and sufferings that frictions can be used with propriety— and when this is the case, they almost always prove decidedly beneficial. When infantile jaundice is attended with a febrile condition, and symptoms indicative of hepatic inflammation—such as fulness, and tenderness in the region of the liver—a very scanty secretion of high-colored urine, absence of the respiratory motions of the abdominal muscles, frequent nausea and vomiting, and an expres- sion of pain and suffering in the countenance, a treatment more decidedly antiphlogistic is required. Four or five leeches, if they P 10* 10Q JAUNDICE OF INFANTS. can be procured, ought to be applied to the right hypochondrium. The local abstraction of blood, by leeches, in cases of this kind, is of the utmost importance, and ought never to be omitted, where it is practicable. In violent cases, the application of a small blis- ter to the region of the liver, will often procure very considerable relief. No injurious consequences need be apprehended from a vesicatory, at this early stage of life, if managed with proper care. I have in several instances, where the liver ap- peared to be in a state of inflammation, resorted to the applica- tion of a blister, with unequivocal advantage. The plaster should not be suffered to remain on the skin longer than about two hours. The skin generally becomes slightly inflamed by this time; and if the plaster be now removed, and a soft warm poultice laid over the part, a fine blister will be raised, without harassing the in- fant. The bowels must be freely evacuated with calomel, aided by castor oil. A half a grain of calomel should be given every two hours, until two or three grains are taken, and followed by a teaspoonful of castor oil, every two hours until active purging is produced. When the stomach is very irritable, however, and there is reason to apprehend the existence of a highly irri- tated or subinflammatory condition of the mucous membrane of the stomach and superior portions of the intestinal tube—that is, where there is frequent vomiting of a glairy fluid, with occasional fits of agitated screaming and manifest distress soon after taking nourishment into the stomach, together with tenderness and ten- sion of the epigastrium, it will be better to employ minute doses of calomel and ipecacuanna without the castor oil, and pro- mote their action on the bowels by laxative clysters. I have in a few cases employed these two articles, according to the formula giverv below,* with a very satisfactory result. A dose should be given every two hours, in conjunction with the administration of laxative enemata, until adequate evacuations have been procured. The same powders, or minute portions of calomel without the ipecacuanna, must afterwards be regularly given every morning, noon, and evening, until the alvine discharges become conspicu- » R. Submuriat. Hydrarg. gr. iii: Pulv. Ipecac, gr. ii; Sachcr. Alb. gr. xii. Mix and divide the whole into 12 equal parts. JAUNDICE OF INFANTS. 107 ously bilious. No ill effects need be feared from ipecacuanna in this irritable and irritated state of the primae viae. When exhib- ited in very small doses, so far from exciting or irritating the stomach, it generally exerts a decidedly calming and anti-emetic influence, and almost always promotes, to an evident degree, the aperient operation of the calomel. In cases of this inflammatory character, some advantage may be derived from the application of a large warm emolient poultice over the upper part of the ab- domen, and frequently renewed so as to keep it warm. In some instances the calomel fails to excite the action of the liver, and causes injurious irritation of the mucous membrane of the bowels, giving rise to frequent small turbid watery discharges, attended with severe griping and increased abdominal tenderness. When this occurs, we may sometimes obtain the desired mercurial influence on the liver, by applying a mercurial plaster over the region of this organ, or by the internal use of a quarter of a grain of Dover's powder in union with half a grain of finely powdered dry and hard mercurial mass, exhibited every morning, noon and evening. A fourth of a grain of Dover's powder, in conjunction with a grain of the bi-carbonate of soda, given every three or four hours, is an excellent remedy for allaying the intestinal irritation and exhausting diarrhoea which sometimes occurs in the advanced 6tages of the disease. In general calomel and purgatives are the means upon which our main reliance should be placed in treatment of this malady. The bowels are usually very torpid, and considerable difficulty is often experienced in procuring the necessary evacuations. It is seldom, however, that any more active purgatives are required than the articles already, mentioned, in conjunction with laxative enemata. Should this necessity occur, we may safely, and with almost certain success add from eight to ten drops of spirits of turpentine to the dose of castor oil. I have resorted to this mix- ture, in cases of this kind, with the happiest effect. The vegetable alkalies have a very beneficial tendency in cer- tain modifications of this disease. The bi-carbonate of soda, is especially useful in cases of a chronic character, unattended by Bymptoms of active abdominal inflammation. A grain of this al- kali, dissolved in a teaspoonful of carbonated water, or a teaspoon- 108 JAUNDICE OF INFANTS. ful of the common soda mineral water, (of the strength of sixty grains of soda to ten ounces of carbonated water,) given at inter- vals of two or three hours, is well adapted to do good, where there is a deficiency of bile in the bowels, by its direct tendency to pre- vent fermentation and the consequent generation of acid and other irritating substances in the primae viae, and by promoting the regular peristaltic action of the bowels. After the .alvine dis- charges have become bilious, the regular exhibition of both the soda and calomel should be discontinued, and the bowels kept in a loose state by small doses of castor oil, or the occasional admin- istration of an injection. In chronic cases of infantile jaundice, considerable advantage may, sometimes, be gained, from the use of the extract of dandelion, in union with bi-carbonate of soda. Ten grains of the extract, dissolved in about a teaspoonful of warm water, together with two grains of the soda, may be given three times daily. It generally keeps up a regular action of the bowels—excites the urinary secretion, and appears to produce a salutary effect upon the biliary organs, and general capillary sys- tem, as may be inferred, from the gradual subsidence of the ab- dominal fulness and tension, and the disappearance of the j ellow- ness of the skin, under its use. In a case which 1 attended a few months ago, the disease gradually increased in violence under the use of small doses of calomel, and ipecacuanna. The abdomen became distended and hard, and the skin of a deep yellow color. The calomel was finally omitted, and ten grains of the dandelion with two grains of soda administered three times daily. In a few days after the use of this remedy was commenced, the disease began to abate, and gradually disappeared altogether. In cases attended with severe flatulent and spasmodic pains of the stomach and bowels, three or four grains of assafoetida, dis- solved in a few tablespoonsful of warm water, and injected into the rectum, will generally afford much relief. We may also ad- minister two or three drops of sulphuric aether in a teaspoonful of hop tea, with decided benefit in such cases. The infusion of hops is, indeed, a most excellent palliative in the jaundice of infant9. It does not interfere with the action of the necessary laxatives, and along with its anodyne effects, generally exerts a decidedly favorable influence on the digestive functions. When the disease OF THE RETENTION AND SUPPRESSION OF URINE. 109 depends on engorgement and torpor of the liver, w ithout structural lesion, Gardien recommends the use of the black oxide of iron, with the yolk of an egg. Two or three grains of the former, beat up with a yolk of an egg, given three times daily, is said to produce excellent effects, in some instances of this kind. CHAPTER VII. OF THE RETENTION AND SUPPRESSION OF URINE. Some urine is probably, in most instances, secreted, and de- posited in the bladder, before the infant leaves the womb; for, in the majority of cases, a discharge of urine occurs, within a very short time after birth. Sometimes, however, the kidneys appear to remain inactive, and little or no urine is evacuated for many hours after the birth of the infant. I have met with several in- stances where a period of upwards of twenty hours elapsed before a sufficient quantity of urine was secreted and collected in the bladder to excite an evacuation. It is of great consequence, in cases of this kind, to acertain whether the non-occurrence of the urinary discharges, depends on a suppression of the secretion from torpor or inactivity of the kidneys, or whether the urine though adequately secreted, is retained in the bladder in consequence of some obstruction to its discharge, or deficient contractile power of the bladder. When there is but little or no urine secreted during the first fifteen or twenty hours after birth, the infant seldom manifests any uneasiness that can be referred to this cause; but when the renal inactivity is protracted much beyond this period, the consequences may be very serious and even fatal. Cases of this kind are, indeed, extremely uncommon. I have seen but one instance of very protracted ischuria renalis,m a newly- born infant. The child was born about 10 o'clock in the evening On the following morning I was informed that it had as yet voided 110 OF THE RETENTION AND SUPPRESSION OF URINE. no urine. It appeared to be quite healthy, and free from uneasiness. I ordered a teaspoonful of weak parsly-tea, with two drops of sweet spirits of nitre every twenty minutes. In the evening, I found the child in a drowsy state, and restless. I assured myself that the bladder was empty, by the introduction of a very small catheter. The warm bath was ordered, and frictions over the abdomen and loins, with a mixture of juniper-oil, and tincture of squills. Internally three drops of sweet spirits of nitre, together with four drops of the vinegar of squills were given, every half hour in a teaspoonful of wild carrot-seed tea. Next morning the little patient was in a state of complete stupor—the respiration slow, weak and irregular, and the eyes insensible to light. On the following night it died. I was not permitted to make a post- mortem examination. In general, the action of the kidneys is readily excited, where the urinary secretion is slow, or suppressed, during the first nine or ten hours after birth. A few teaspoon- fuls of parsly or wild carrot-seed tea, with two or three drops of sweet spirits of nitre, given every half hour, and the warm hip bath, (after the bowels have been freely evacuated,) are generally sufficient to excite the secretory action of the kidneys. Should these means fail to produce the desired effect, recourse may be had to friction over the loins and hypogastric region, with warm vinegar of squills, or a mixture of about a drachm of juniper oil with an ounce of sweet oil, or with the expressed juice of onions diluted with water; and internally, to the exhibition of a few drops of the vinegar of squills, a drop of spirits of turpentine in a teaspoonful of milk or four or five drops of the expressed juice of roasted onions, every thirty or forty minutes; in conjunction with warm bathing, laxatives, and if necessary laxative enemata. When there is retention of the urine—that is when the urine is regularly secreted, and conveyed into the bladder, but cannot be discharged in consequence of a spasmodic constriction or mechani- cal obstruction of the urethra, or perhaps, deficient contractile powrer of the muscular coat of the bladder, the phenomena, con- sequences and appropriate mode of management are very different from those which belong to suppression of the urinary secretion. Instances of more or less complete retention of the urine, immedi- ately after birth are by no means uncommon. Obstruction ol OF THE RETENTION AND SUPPRESSION OF URINE. HI the urethra or of the neck of the bladder by viscid and inspissated mucus, is probably the most frequent cause of retention of the urine in newly-born infants. When by the gradual accumulation of the urine, the bladder becomes considerably distended, the in- fant begins to manifest pain and distress, which is obviously in- creased by pressure made with the hand upon the hypogastric region. The distended bladder may be more or less distinctly felt above the pubis; the infant is restless,its countenance has an expression of suffering and distress, and its legs are constantly drawn up, to relieve the pressure of the abdominal muscles. If the obstruction be not removed, the abdomen gradually becomes more and more enlarged by the distended bladder, and acquires, at last, a tense and shining appearance, with the superficial veins, very much enlarged and turgid with blood. If relief be not obtained, rupture of the bladder finally takes place, and death is the inevitable consequence. The bladder sometimes becomes enormously distended before ulceration or rupture takes place. Dr. Dewees gives an account of a very remarkable instance of this kind, in which Dr. Parrish drew at one time eighteen ounces of urine from the bladder. The child did not recover. A few years ago I was called to consult in a case of this kind. The attending physician was a very young man, and tampered with inefficient means until it was too late. Before I arrived the blad der had yielded to the distending force, and the urine was extra vasated into the cavity of the peritoneum. Of this I satisfied my- self by a post-mortem examination. In some cases, after the bladder has become much distended, small portions of urine are, from time to time evacuated, although the quantity retained, is progressively increased; and this occur- rence almost always misleads the nurse, and often even the medi- cal attendant, and removes every suspicion of urinary difficulty. The urine is thus gradually accumulated, and the manifest dis- tress and suffering is ascribed to other causes, until the bladder, at last, gives way, and the infant dies in great agony from peri- toneal inflammation. I am persuaded that infants sometimes dit. in this way, who might easily be saved if the real cause of its suf- ferings did not thus escape the attention of the practitioner. " We have strong reasons to believe," says Dr. Dewees, " that 112 OF THE RETENTION AND SUPPRESSION OF URINE. many have died of suppression (retention) of urine, though we were assured they had passed water—the same was insisted on, for awhile in the case (referred to above) just mentioned, and perhaps there may have been a small discharge, as always happens when the bladder becomes excessively distended." When the infant becomes restless and fretful, and persists in keeping its legs drawn up, and particularly when we are informed that its abdo- men is swollen and hard, the region of the bladder should be carefully examined, and no reliance placed on the nurse's decla- ration, that the urine is regularly evacuated, if there is the slight- est reason on examination, to suspect an accumulation of urine in the bladder. The external urinary passage ought always to be carefully ex- amined in newly-born infants. I was once called into the coun- try, to visit an infant, which, I was told, had not discharged any urine since its birth. I saw it about forty hours after birth, and found it evidently in a state of very great suffering. The bladder was very much distended, and could be easily felt beneath the abdominal muscles. On examining the urethra, for the purpose of introducing a small flexible bougie, I found its orifice closed, by a thin semi-transparent membrane, about the tenth of an inch below the surface, or extremity of the passage. I divided it with a sharp-pointed history, and the urine instantly gushed out with much force. Sometimes the prepuce is entirely closed. I have seen two cases of this kind. In one there was a very small opening, scarcely admitting a pin's head, and altogether in- sufficient to admit of the discharge of the urine; in the other case, tne closure was complete. In both, the difficulty was speedily removed by circumcision. The common practice of exhibiting diuretics, or remedies cal- culated to increase the secretory action of the kidneys, in cases of retention of the urine, is always highly improper, as it cannot, in any way, aid in removing the obstruction, but must necessarily tend to aggravate the distress and danger, by rapidly increasing the fluid in the bladder. When the inability to discharge urine, depends on retention of fhe secretion in the bladder, and the vesical distention and sufferings of the little patient are, as yet, not so great as to require prompt OF THE RETENTION AND SUPPRESSION OF URINE. H3 relief, a trial may be made with the warm bath, purgatives, emo- lient enemata, and gentle frictions with camphorated oil, or tinc- ture of hyosyamus, over the pubic region. Where the obstruction is slight, these measures will sometimes, remove the difficulty and bring on the urinary discharge. They should not, however, be long persisted in, if they do not procure some advantage before the symptoms become more urgent. The bougie and catheter are the proper means for giving relief; and the obstruction is but very rarely of such a character as to render the judicious employ- ment of them necessarily abortive. The introduction of a small bougie will, sometimes, remove the obstruction and procure re- lief. But when the retention arises from a spasmodic constriction of the urethra, or sphincters of the bladder, or when the bladder has lost its power of contraction from over distention, the bougie can do little or no good, and recourse must be had to a proper sized flexible catheter. Great care and delicacy must be prac- tised in the attempt to introduce such an instrument into the bladder of an infant. A very slight force will lacerate the urethra, and form an artificial passage into the cellular tissue of the per- ineum. I once knew a young surgeon, in attempting to introduce the catheter into the bladder of an infant, (male) push it through the membraneous portion of the urethra two or three inches be- fore he discovered that the instrument was not in the natural passage. The child died. When the bladder has been greatly distended, and relieved by the catheter, its contractile power is apt to become temporarily impaired, so as to suffer the urine to re-accumulate to an extent sufficient to keep the infant in a state of constant uneasiness or distress, although a regular and appar- ently sufficiently copious discharge from the bladder takes place. Hence in instances of retention, where there has been great dis- tention of the bladder, it often becomes necessary to use the catheter repeatedly, until the bladder regains sufficient power to evacuate itself, without artificial assistance. Sprinkling a little cold wrater on the lower part of the abdomen will sometimes excite the bladder into action in cases of this kind. The appli cation of camphorated oil, by gentle friction over the pubic re gion, may also aid in restoring a proper tone to the muscular coat of the bladder. Q 11 114 OF THE RETENTION AND SUPPRESSION OF URINE. When there is reason to believe that the retention depends on spasmodic constriction of the urethra, a drop of the muriated tincture of iron, given every twenty or thirty minutes, may be beneficial. In spasmodic retention of urine in adults, this article, sometimes affords speedy relief; and it would doubtless exert a similar beneficial effect in retention of the same character in in- fants. In all cases particular attention ought to be paid to the state of the bowels. The meconial matter should be completely evacuated, if the urinary difficulty occurs during the first few days after birth—and in all instances the bowels ought to be freely evacuated. OF DYSURIA. 115 CHAPTER VIII. OF DYSURIA—OR PAINFUL AND DIFFICULT MICTURITION. Pain and difficulty in voiding urine is a frequent complaint among infants. It is particularly apt to occur during dentition, and sometimes acquires a very distressing degree of violence. The child may, in other respects appear perfectly well and play- ful, but the moment it begins to discharge urine, it becomes agi- tated with excruciating pains, and shrieks uninterruptedly and violently until the evacuation is completed, when it instantly be- comes quiet and as well as usual. Not unfrequently this painful urinary affection goes on for many days, before its true character is detected—the vehement fits of screaming being usually as- cribed to griping or transient colic pains. When an infant is ob- served to have occasional fits of violent shrieking and agitation, without any obvious cause, painful micturition may be suspected: and on proper enquiry it will, probably, be found that these spells of suffering, occur only when the infant is voiding urine—a coin- cidence which will, at once render the nature of the evil manifest. In many instances, however, the pain is much less severe. Instead of the occasional fits of excruciating suffering, the child manifests a very frequent desire to pass urine, which is voided in very small quantities and always with obvious distress and uneasiness. This difficulty sometimes continues for many months—particularly if the child be cutting teeth, and may ultimately lead to very distressing consequences. These affections are almost always attended with an unnatural condition of the urinary secretion. In the majority of cases the urine contains a large portion of lithic acid; and occasionally it is highly charged with phosphatic sedimentous matter. These substances impart a peculiarly irritating quality to the urine- Hg OF DYSURIA. and when they are copious, and the system is in an irritable condition, as it usually is during dentition, they may readily pro- duce a considerable degree of irritation about the neck of the blad- der, and give rise to pain and difficulty in passing urine. Children who are much affected with acidity in the primae viae, are most apt to experience urinary difficulties of this kind. The tendency of acid in the alimentary canal to increase the secretion of lithic acid by the kidneys is well known; and it is equally well ascer- tained that an excess of lithic matter in the urine, seldom fails to manifest itself by some irritation about the neck of the bladder, and more or less painful micturition. Dentition, and a disordered state of the digestive functions con- stitute the principal remote causes of this form of urinary disease. The former by the general irritative condition of the system which it causes, strongly favors the development of the lithic acid diathesis; and, as has already been stated, the generation of acid in the alimentary canal, in consequence of feeble digestive powers, or the use of improper articles of food, appears to furnish the elementary materials, for the formation of lithic deposits in the urine. Intestinal irritation from worms, appears in some in- stances to give rise to painful and difficult micturition—though in cases of this kind the urinary deposits are usually of the alka- line variety. Ascarides frequently occasion considerable irri- tation about the neck of the bladder, and become the source of urinary difficulties. Treatment. When a child becomes affected with pain and dif- ficulty in passing urine, this secretion ought to be carefully exam- ined, both in a recent state, and after it has stood for some time. If the sedimentous matter of the urine be of a red, or reddish color, remedies calculated to counteract the secretion of lithic acid by the kidneys will be indicated and will probably procure speedy relief. The proper treatment in such cases, consists in the employment of means suited to correct the digestive and in- testinal functions, and to keep up a regular action of the cutane- ous emunctorles. The bowels should be freely evacuated with magnesia and rhubarb, and afterwards kept in a moderately loose state by the daily use of small doses of calomel and ipecacuanna. OF DYSURIA. 117 A grain of the former, with a fourth of a grain of the latter, con- stitutes a proper dose for a child under five years of age. Where there is a prevailing tendency to acidity in the primae viae, much benefit may be obtained from the use of the sub-carbonate of pot- ash, in union with a weak infusion of colomba. From two to three grains of the potash dissolved in a teaspoonful of weak in- fusion of colomba, diluted with a small portion of barley water, flaxseed tea, or some other mucilaginous fluid, may be given once, twice, or thrice daily, according to the urgency of the uri- nary affection. The diuretic and antilithic properties of the sub- carbonate of potash, renders it a peculiarly suitable medicine in cases of this kind. Small doses of magnesia, lime-water and milk, and the bi-carbonate of soda, also, frequently procure relief. When the general system is in a slightly febrile condition, as it often is during dentition, considerable advantage may be derived from te- pid bathing, in conjunction with mild diaphoretic remedies; such as the spirit, minderiri, with the addition of a small portion of sweet spirits of nitre, and syrup of squills. Particular attention should be paid to the diet. When the tendency to the forma- tion of acid in the primae viae is very great, beef or chicken tea should be in part substituted for the usual farinaceous nourish- ment, and all saccharine and acescent articles should be avoided. When painful and difficult micturition is attended with a copi- ous secretion of the phosphate of magnesia and ammonia—an oc- currence by no means uncommon, a very different treatment is required. In cases of this kind, the urine is usually pale, rather abundant, depositing a whitish or yellowish white sediment, and peculiarly prone to become putrid when suffered to remain at rest. It is almost always attended with an irritable condition of the general system, and with obvious derangement of the diges- tive organs and irregularity in the action of the bowels. Aperi- ents, mild tonics, opiates, and the vegetable acids, constitute the appropriate remedies in such cases. The bowels, in the first place, should be freely evacuated with rhubarb or caster oil.— Very small doses of Dover's powders, given two or three times daily, generally produce an excellent effect. A half a grain of this article, with a grain of powdered valerian, may be given ev- ery six hours, to a child between two and five years of age. The 11* HQ OF DYSURIA. occasional use of lemonade, or of water sweetened with lemon syrup, will sometimes assist very materially in correcting the uri- nary secretion. The diet should be of the mildest and most nu- tritious kind: considerable benefit may also be derived from the employment of muriated tincture of iron, in cases of this kind. I have known two drops of this tincture, given three times daily, to afford great relief in such a case. The diet should be mild and nutritious, and taken in very moderate quantities. Children who have passed through the period of primary dentition, may be al- lowed small portions of the tender and lean parts of beef, mut- ton, lamb, and chicken; but at an earlier age, the usual farina- cious preparations, mixed with a little of beef or chicken tea, are undoubtedly the most proper. Magnesia and other articles of an alkaline character, are decidedly improper. When pain and difficulty in voiding urine is not attended with a morbid condition of the urine either acid or alkaline, mucilagi- nous and slightly diuretic diluents, in conjunction with laxatives, and the occasional use of the warm bath, may be resorted to with a prospect of advantage. A weak infusion of the wild-carrot seed, or of parsley mixed with an equal portion of flax-seed or water-melon seed tea, will usually do well for this purpose. In some instances, extremely painful micturition depends on an irritable or slightly inflamed state of the extremity or orifice of the urethra. This difficulty is almost wholly confined to female children. I have quite lately witnessed a case of this kind. The child (about two years old) suffered severe pain every time it passed urine. The affection had continued seven or eight days before the source of the urinary difficulty was discovered. The orifice of the urethra was slightly swollen, red, and so extremely sensible, that it could not be even lightly touched, without caus- ing the child to shriek with pain. In cases of this kind, the pain and uneasiness usually continue for several minutes after the urine has ceased to pass off. The case just mentioned was speed- ily relieved by washing the inflamed and tender part with a strong solution of borax. The application of citrin ointment, weakened by mixing it with an equal portion of lard, seldom fails to reduce the inflammation in such cases. I have also used an infusion of galls, together with a watery solution of opium, with OF DYSURIA. 119 an excellect effect in this variety of painful micturition. It should be applied with a dossil of lint. Merely covering the inflamed part with lard, or some mild ointment, will generally protect it from the painful impressions of the urine, and enable it to heal. During dentition the urine sometimes becomes more or less deeply tinged with blood, without any difficulty or pain in void- ing it. The appearance of blood in the urine, always excites con- siderable alarm; but where it is not attended with symptoms of irritation or inflammation in the urinary organs, it generally passes off without any unpleasant consequences. Small doses of the muriated tincture of iron, mild laxatives, and warm bathing, and mucilaginous drinks, seldom fail to remove it speedily. It is of great consequence to attend to the urinary affections of infants, even though they may not appear to be of a serious character in their immediate effects. This is particularly true in relation to those instances of urinary difficulty that are attend- ed with lithic acid, or phosphatic sediments. Dr. Prout ob- serves, that " children in general, and especially the children of dyspeptic and gouty individuals, or who inherit a tendency to urinary diseases, are exceedingly liable to lithic acid deposits in the urine. If the urine be examined, it will always be found .to be very unnatural, and frequently loaded with lithic acid; and should this prove to be the fact, the case requires immediate at- tention, as there is much greater risk, at this period of life, than at any other, of the formation of stone in the bladder." * In an- other place, this highly respectable writer states: every thing in our power ought to be done, " for preventing the effects of (li- thic acid deposits in the urine) and eradicating the disease in early life; and perhaps, it may not be deemed superfluous, here, to insist upon the absolute necessity there is for attending to the subject, when children are concerned." In such cases, it should be constantly borne in mind, that by proper care, the formation of stone in the bladder, may almost certainly be prevented; but by inattention, this dreadful occurrence is as certainly likely to take place. " Prout—Inquiry into the Nature and Treatment of Affections of the Urinary Organ*. Chap. vi. s. ii. 120 OF ENURESIS. CHAPTER IX. OF ENURESIS, OR INCONTINENCE OF URINE. Incontinence of urine—or rather a habit of discharging urine at night, while sleeping in bed, is a very common affection during childhood. Although very rarely attended with any particular uneasiness, or painful urinary irritation, it is always an extremely disagreeable occurrence, and the habit is apt to become so con- firmed, that unless early counteracted by suitable measures, it often continues to the age of puberty, and occasionally, even to adult age. It is generally supposed that the discharge takes place involuntarily, without the least consciousness of its occur- rence; and this is doubtless frequently the case. In the majority of instances, however, the discharge is a voluntary act—the result of an active effort of volition, under the fallacious conceptions of a dream. In children, this disagreeable affection is very often associated with an unnatural condition of the urinary secretion itself. In those cases, especially, where the discharge takes place in consequence of a voluntary effort excited by a lively dream, the urine, almost always contains an excess of sedimentous matter, particularly lithic acid, and its compounds, imparting to it an acrid and irritating character. " Hence," says Dr. Prout, "I have been led to infer, that in this species of urinary incontinence, the acrid properties of the urine are chiefly in fault; and that these, favored, perhaps, by the position of the body, and probably, also, by the morbid sensibility of the bladder, excite so vivid an im- pression on the imagination, as actually to lead to a voluntary effort to discharge the urine." The urine is seldom discharged during sleep, except when the individual is lying on his back. Mr. Charles Bell affirms, that " incontinence of urine never takes place but while the boy is asleep upon his back." In this position the urine gravitates back- wards, and presses immediately on the "sensible spot—the master- OF ENURESIS. 121 epring of the muscles of the bladder, situated a little behind and below its orifice." When children neglect to pass off the urine just before going to bed, the bladder is apt to become distended in the course of the night. The impressions thus made on the bladder, pass to the brain, and awaken a dream occupied with a desire to mictu rite, and the sphincter yields to the voluntary effort prompted by the desire. That incontinence of urine is very frequently, perhaps always in the first instance, excited by an acrid condition of the uri- nary secretion, or by distention of the bladder, in the way just mentioned, admits of no doubt; yet in the majority of protracted cases, the recurrence of the discharge depends mainly on the influence of habit; and in many instances, this is doubtless the sole cause of its repetition. Dr. Prout thinks that " some peculiar morbid condition of the urinary organs" constitutes the most frequent cause of those cases of nocturnal incontinence of urine, in which the discharge takes place involuntarily, and without any consciousness of its occur- rence. Cases of this kind are almost always very obstinate in their course. They often continue for many years, and some- times "even till late in life." It is by no means improbable, that this variety of incontinence sometimes depends on some obscure morbid state of the bladder; but it can scarcely be doubted, that in the majority of such cases, the recurrence of the involuntary urinary discharges, depends chiefly or entirely on the potent in- fluence of habit. That the recurrence of the discharge in pro- tracted cases, frequently depends solely upon habit, seems to be demonstrated by the character of the means, most commonly suc- cessful in arresting its continuance. We may often remove this evil by'exciting a slight degree of irritation about the neck of the bladder; so that the moment the urine begins to flow, painful strangury occurs, by which the person is awakened, and the evacuation is prevented. By repeating this for some time, the habit is broken up, and the involuntary discharge ceases *i recur. I am entirely satisfied that this unpleasant complaint very gen- erally commences in conseauence of an unnatural condition of th*» R 122 OF ENURESIS. urine itself. When the urine becomes unusually irritating, its impressions on the bladder during sleep, when it becomes accu- mulated, are sufficiently strong to affect the sensorium commune in such a way as to excite a desire, and a consequent volition to micturate. It is not improbable that even in cases that are deemed strictly involuntary, and unperceived by the mind, the discharge takes place under an act of volition, which, however, is not remem- bered on waking. Persons who walk about while asleep, unques- tionably exercise conscious volition, though wholly unable to recollect any thing about it when awake. Many things have been done during sleep, manifestly under the control of the will, and probably even under the guidance of the senses, of which not the slightest trace is left on the mind, in the waking state. Treatment.—From what has been said above, it need scarcely be observed, that in prescribing for a case of this kind, particularly when of a recent character, the urine ought to be carefully in- spected, as a preliminary step in the adoption of a suitable plan of management. Should the urine be found to contain much se- dimentous matter, remedies ought to be employed for correcting the urinary secretion. If the lithic acid deposits predominate, small doses of magnesia, lime water, the sub-carbonate of potash, or of the bi-carbonate of soda, should be resorted to, in conjunc- tion with laxatives and other means for improving the digestive and hepatic functions. In cases attended with phosphatic urina- ry deposits, remedies calculated to invigorate the digestive organs, together with opiates, vegetable acids, and acescent articles of nourishment will be proper. By such a course of management, recent cases may sometimes be completely arrested. But should the attempt to remove the evil, in this way, fail, it is always of much consequence to correct the urinary secretion, when it is found to be in an unnatural condition. "When the incontinence of urine in children is associated with gravel, or an excess of se- dimentous matter, it is of the utmost consequence that this cir- cumstance be attended to, and that remedies appropriate for counteracting the formation of these urinary deposits should be employed, before any other means are used to restrain the uri nary incontinence;"' for without this, all other remedies will he OF ENURESIS. 123 useless (Prout). When the urine has been brought to a healthy or natural state, and the incontinence continues to recur; or in cases that seem to continue under the influence of an established habit, recourse must be had to remedies calculated to alter the sensibility of the urinary organs—more especially of the neck of the bladder. There is no article that has been so generally pre- scribed for this purpose, as the tincture of cantharides; and it is doubtless better adapted to produce this effect than any other remedy we possess. Its mode of operation in the case of this af- fection has already been explained above. By producing a slight degree of strangury, the person is awakened by the first efforts to urinate; and by thus repeatedly interrupting the discharge, the habit will finally be destroyed. From ten to fifteen drops, accord- ing to the age of the patient, should be given three times, in the course of twenty-four hours, and the dose daily increased by two or three drops, and continued until a burning pain is experienced at the neck of the bladder on passing urine. When this effect is produced, its use must be omitted, or continued in occasional doses, so as to keep up a slight degree of the urinary irritation. Should the strangury become too violent, suitable doses of laudanum must be given, at proper intervals, with emolient clysters—and the free use of mucilaginous diluents, such as flax-seed, or mellon-seed tea, barley-water, or a solution of gum arabic, and the warm hip-bath. Blisters applied over the sacrum, are sometimes equally beneficial. Incontinence of urine in children sometimes depends on a mor- bidly irritable state of the bladder. The patient is during the day more or less harassed with a frequent desire to urinate, and the discharge is always accompanied with considerable uneasiness, and sometimes with much pain. These cases are usually associ- ated with a morbid condition of the urine—sometimes with an excess of lithic acid, and occasionally with phosphatic deposits. Instances of this kind must be managed in the way stated above. The use of cantharides, or of other remedies calculated to irritate the neck of the bladder, would be highly improper in such cases. An irritable state of the bladder may, however, occur, without any morbid appearances in the urine, and give rise to urinary inconti- nence. Here, the remedies, proper for counteracting the secre- tion of the lithic acid, or phosphatic sediments would, probably, 124 OF ENURESIS. prove injurious. In such cases recourse must be had to the warm bath—cooling laxatives, opiates, particularly Dover's powder, the application of a stimulating plaster over the sacrum, and a mild and digestible diet. When incontinence of urine is attended with irritation of the rectum by ascarides, means should be used to remove these an- noying little worms out of the bowels. I once attended a little girl who was for several months much troubled with uneasiness on passing water, and scarcely a night passed, without a discharge of urine during sleep. I at length learned that she was also greatly annoyed by ascarides. By the use of aloetic injections a large mass of them were brought away from the rectum, and the urinary difficulty and incontinence disappeared, for eight or nine months, when they returned, and were again removed by the same means. Whatever means may be employed for the cure of nocturnal incontinence of urine, care should always be taken to accustom the patient to sleep upon his side or the belly. In this position the urine gravitates towards the fundus of the bladder, and does not rest upon the sensible spot, referred to above; and the patient is therefore not so apt "to be excited to dream of making urine, and to exert a voluntary effort, to urinate, as when he lies on his back." Children should always be required to empty the blad- der just before going to bed, and when they awaken at night they ought to be taught to rise and pass off the urine. By a careful attention to these things, the occurrence of the disordei may generally be prevented. OF DENTITION. 125 CHAPTER X. OF DENTITION. The development and progress of the teeth through the gums, takes place in a very gradual manner. The germs of the teeth present themselves in the form of small follicles, containing a pulpy substance, attached to, or continuous with the fascicle of vessels and nerves which penetrate the cells or alveoli in which they are placed. The period at which these germs first make their appearance in the foetal jaws has not been satisfactorily de- termined. It is sufficiently ascertained, however, that the first traces of ossification, very rarely occur previous to the fourth month; and it is equally uncommon to find the commencement of this process delayed beyond the middle of the fifth month. At birth, the development of the primary teeth is already consid- erably advanced. The wxhoIe crown is formed, but the root is still imperfect, consisting of a short and thick tubular projection, with very thin sides. The number of these primary teeth is twenty—namely, four incisors or cutting teeth, two cuspid or eye teeth, and four grind- ing teeth in each jaw. Between the appearance of the first and the last of the primary or milk teeth,several years usually intervene. The first seldom protrude through the gums before the fourth month, and the last generally make their appearance about the end of the second year. The two middle cutting teeth of the lower jaw, are usually the first that make their appearance. In the course of three or four weeks afterwards, the corresponding incisors of the upper jaw protrude through the gums. These, in a few weeks more, are succeeded by the lateral cutting teeth of the lower jaw; and in a short time afterwards,"the lateral inci- Eors of the upper jaw also pierce the gums. In the course of 12 126 OF DENTITION. from about two to four months after the eight cutting teeth have made their appearance, the anterior grinders of the lower jaw " elevate their white surfaces above the gums,'' leaving vacant spaces between them and the two lateral incisors, for the cuspids or eye teeth. Soon afterwards, the corresponding grinders of the upper jaw also make their appearance. The cuspids or eye teeth next come out, those of the lower jaw preceding the upper ones. Finally, the second grinders pass through the gums, and terminate the process of primary dentition. Although the general progress and order of dentition is such as has just been stated, yet great diversity occurs in different in- dividuals, both in relation to the time at which the teeth pro- trude through the gums, and the order or succession of their appearance. In some instances, the first incisors appear as early as the second month, and in others, they do not make their appear- ance until the seventh or eighth month. The usual period of their appearance, however, is about the fifth or sixth month.— The irregularities, in this respect, are sometimes very great. Infants have been born with one or more well-formed teeth pro- truded. Van Swieten mentions cases of this kind, on the authority of Pliny, Marcellus Donatus, Colombo, &c; and Haller and Voigtel refer to a great number of similar instances. 1 have myself seen an infant furnished with two well-shaped incisors, as early as the fourth week after birth. The instances of very tardy dentition are sometimes equally remarkable. I have a child now under my care, which has, as yet, not a single tooth, although up- wards of eleven months old. Van Swieten mentions an instance, in which the first teeth did not make their appearance until the child was upwards of nineteen months old; and many cases of much greater delay in the appearance of the teeth, are recorded by Haller Voigtel, and other writers. With regard to the order in which the teeth are protruded, deviations from the ordinary course, as slated above, are by no means uncommon. In some instances, the two lateral cutting teeth of the lower jaw, make their appearance before the mid- dle ones. Sometimes the incisors of the upper jaw precede those of the lower; and occasionally the eye teeth come out before the lateral cutting teeth. It is rare, however, to find the eyfc OF DENTITION. 127 teeth advanced through the gums before the first grinders, although, occasionally, this takes place. Instances are sometimes met with in which all the incisors pierce the gums almost simul- taneously. Although a process of physical development, and, therefore, strictly in accordance with the regular progress of nature, denti- tion is, nevertheless, almost invariably attended with more or less obvious deviation from a healthy condition of the system. The progress of the teeth through the gums is usually accompanied with a manifest increase of the general irritability of the system. The mouth is generally very hot, and the saliva secreted in great abundance. In many instances diarrhoea occurs; and in female infants, a slight mucous or leucorrhoeal discharge from the vulva, is not uncommon. The infant evidently experiences an unplea- sant tickling sensation in the gums, as may be inferred from the eagerness with which it bites upon hard substances, and the evi- dent gratification it derives frcm having its gums firmly pressed and rubbed with the point of a finger. The sharp margi» of the gums gradually expands and becomes flatter, and, in difficult cases, inflamed and swollen, as the teeth approach the sur- face. The infant manifests an irritable and fretful temper; slight exciting causes are apt to give rise to febrile irritation, and one or both cheeks are often flushed, more especially towards evening and after a full meal. When asleep, the child frequently starts as from sudden fright, and the expression of the countenance un- dergoes repeated changes. The general and local disturbances accompanying dentition, are, however, often of so slight a character, as to require no atten- tion, or to escape notice altogether. This is most apt io be the case in children whose constitutional habit is healthy, and who have been nourished with mild and appropriate food, and in whom the advance of the teeth through the gums is attended with a free secretion of saliva, and moderate loosness or diarrhoea. These evacuations are, in general, decidedly salutary. The free discharge of saliva has a direct tendency to relieve the irritable and congested capillaries of the gums and mouth, and to derive the blood from the brain, and moderate its irritative condition. The diarrhoea may prove beneficial, by "determining the circu 128 OF DENTITION. lation from the head to the intestines, and particularly by its effects in lessening the quantity of blood in the system, and dimin- ishing the strong action of the heart and arteries." Even the most favorable instances, however, are attended with an increased susceptibility to the injurious influence of irritating or exciting causes; and hence all diseases, whatever may be their cause or origin, are apt to assume a more violent character du- ring dentition than at other periods. There can be no doubt that many complaints, which at other periods would have termi- nated favorably, often acquire a fatal violence from that irritable and irritative condition of the system, which attends difficult den- tition. From this circumstance, as well as from the direct ten- dency of dentition to originate violent affections, the period during which this process is going on, is justly regarded as one of the most perilous stages of life. It has been computed that one tenth, at least, of all the deaths which occur during childhood, may be fairly ascribed to dentition; and it docs not appear to me that this is an exaggerated estimate. When the gums become inflamed, swollen, and painful, and the secretion of saliva scanty, with torpor of the bowels, the whole organization, generally,sympathizes strongly with the local affec- tion, and the nervous system especially is liable to great and dan- gerous irritation. Indeed, when from the influence of previous morbific causes, the system has become feeble, and unnaturally irritable, the most alarming consequences sometimes result from the irritation of the advancing teeth, before any signs of irritation and inflammation are discoverable in the gums. Among the various circumstances which are apt to render den- tition difficult and dangerous in its consequences, a deranged or dyspeptic state of the digestive organs, from errors in diet, is probably the most common and pernicious in its tendency. Chil- dren who are nursed exclusively at the breast, are, in general, much less apt to suffer inconvenience or disease, from dentition, than those who are either wholly, or in part, nourished with arti- ficial ^food. When the digestive organs are habitually disordered, from the use of inappropriate articles of food, the risk of serious consequences from dentition is always very considerable. The general system, usually, becomes enfeebled and morbidly irritable, OF DENTITION. 129 by a continued course of improper nourishment; and in this con- dition the local irritation of the advancing teeth is not only pecu- liarly apt to give rise to general irritative affections, but by its reaction on the stomach and bowels, adds also greatly to the dis- ordered state of these organs, and ultimately, often produces vio- lent and highly dangerous affections. In robust and healthy children, the use of stimulating articles of nourishment and drink is calculated to do much injury, in this respect, independent of its tendency to derange the digestive organs, by increasing the phlogistic condition of the system, and promoting the occurrence of febrile and inflammatory affections, from the local irritation in the gums. A close and contaminated atmosphere, more especially when aided by high temperature, has a decided tendency to increase the difficulty and morbid consequences of dentition.— Children who reside in populous cities, or who are much confined to close and ill-ventilated apartments, are much more liable to unpleasant consequences from teething, than those who enjoy the pure and salubrious air of the country. The tendency of inac- tivity, impure air, and high atmospheric temperature, to increase the irritability of the system, and predispose it to the injurious -nfluence of irritating causes, is well known. Dentition can sel- dom go on without giving rise to considerable disturbances in the system, where these causes are in full and continued operation during fhe process. The practice of keeping the heads of infants very warm, by flannel caps, or "sleeping on very soft pillows, which nearly envelop their heads," may do injury during denti- tion, by favoring the determination of blood to the head, and thereby increasing the liability to inflammatory irritation of the brain, &c. The morbid, sympathetic effects of difficult dentition are very various. In robust, full, and otherwise healthy infants, the general disturbances, usually, consist in slight febrile irritation,particularly towards night, attended with a frequent, quick and sharp pulse; a very warm and somewhat dry skin, more or less costiveness, increased thirst, flushed cheeks, dull and heavy eyes, and a fretful and irritable temper. Cases of this kind are seldom accompanied with a copious secretion of saliva; on the contrary, the free dis- charge of this secretion, or the supervention of moderate diarrhoea, S 12* 130 OF DENTITION. almost invariably mitigates the general irritative condition, to a very obvious degree. In some instances, the brain sympathizes so strongly with the local affection, as to give rise to the usual phenomena of incipient arachnitis or acute dropsy of the head. In cases attended with this state of cerebral erethism, the child generally sleeps with its eyes half open, a circumscribed flush frequently appears on one or both checks, the eyes become slightly injected, and unusually sensible to light; the eye-brows are often contracted into a peculiar frown, accompanied with a discontented and anxious expression of the countenance; and the child is extremely fretful and irascible; when asleep, it often starts suddenly and screams out violently, or moans as if in pain; it is frequently observed to raise its hands and press them against the forehead; vomiting is apt to occur on rising suddenly from a recumbent to a sitting or erect posture, or after taking stimu- lating articles of nourishment; and the bowels are almost invaria- bly in a disordered condition, being either torpid, or disturbed with griping, colic-pains and diarrhoea. The pulse is frequent, quick, and contracted—the temperature of the skin variable, the hands and feet being, at times, remarkably cool, whilst the head and body are preternaturally warm. Cases of this kind are always attended w ith considerable danger. When neglected or mismanaged, particularly in relation to the diet, they are apt to terminate in fatal oppression of the brain, from effusion into its cavities and upon its surface, or disorganization of its structure. In some instances of difficult dentition, attended with an irrita- ted condition of the brain, a remarkable swelling occurs on the hands and feet, which as the case advances, generally becomes associated with symptoms of alarming and frequently fatal ner- vous irritation. This swelling " has a considerable degree of roundness and elevation, and looks like that sort of tumor which might rise, on the same parts, from a blow or contusion. It seems to arise suddenly, as it has, generally, t is roundness and eleva- tion, from fhe time of its first attracting observation." When first observed it has somewhat of a mottled, lived, and purplish color, resembling the chilled hand of a full and healthy child after exposure to a cold and frosty atmosphere. It feels cold, at least it has no '.nfanmit >rv heat and does not appear to be morbidly OF DENTITION. 131 sensible, or to give any pain to the child when handled. It does not pit on pressure, but rather gives the sensation of firmness and resistance. The swellings arc confined to the anconal aspect of the metacarpus of the hands, and the rolular aspect of the meta- tarsus of the feet, terminating abruptly at the carpus and tarsus. The duration of these tumors is very various in different cases. Sometimes they disappear in three or four days—at others they continue for many weeks without cither increase or diminu- tion; and occasionally they disappear and return again, at short intervals for a number of weeks. In some cases these swellings pass off without any unpleasant or alarming consequences. More frequently, however, symptoms of a much more formidable nature ensue—consisting of a peculiar spasmodic affection commencing in the flexors of the hands and feet, and gradually extending itself until it terminates in general convulsions or tetanic spasms of the whole body. The reader is referred to the chapter "On Convul- sions," in this work, where this very singular affection is fully de- scribed under the name of Pedo-carpal Convulsions of Infants.* The occurrence of convulsions from difficult dentition is very common. When they come on suddenly, and are attended with a full and flushed countenance, they are in general, much less dan- gerous, than when they are preceded, for some time, with symp- toms of active cerebral irritation, and accompanied, with a pale and contracted aspect of the countenance. Cases of the former kind generally depend on simple irritation and vascular turges- cence of the brain: whereas the latter are often connected with slow meningeal inflammation, effusion, or disorganization of some portion of the brain. When the child remains in a stale of stupor or partial insensibility, with its eyes half open and turned up under the upper lids, for a considerable time after the parox- ysm has subsided—and particularly when along with these symp- toms, the respiration is very irregular with an occasional deep moaning sigh, and a very slow or extremely rapid and s rail pulse, the chances of a favorable termination are always extremely slendor. When on the other hand the infant, soon after emer- * Notes on the Swelling of the Tops of the Han Is aii:l Feet, Sec. By Geo. Kellie, M. D Edinburg Medical and Surgical Jour. vol. 12. p. 44). 132 OF DENTITION. ging from a fit, takes notice of surrounding objects, and breathes freely and regularly, without any particular manifestations of sen- sorial torpor and drowsiness, the probability of a favorable re- sult, will be very considerable. Nothing tends more strongly to favor the occurrence of convulsions during dentition, than gastric or intestinal irritation, from the use of improper articles of nour- ishment, or from overloading the stomach. Children who are under the influence of difficult dentition, seldom enjoy a perfectly healthy state of the digestive organs, even under the most careful and judicious dietetic management. The stomach during this process, is often morbidly irritable, and hence errors in diet are much more apt to produce injurious consequences during this, than at any other period of life. So far as my own observations enable me to form an opinion, I am inclined to think that, the majority of instances of convulsions, usually ascribed to the sole ir- ritation of dentition, are in fact excited by improper or immoderate alimentary ingesta. When the diarrhoea which frequently accom- panies dentition is suddenly arrested by astringents, opiates &c. the liability to convulsions is always much increased, more espe- cially in robust and plethoric infants. The same t iig occurs, when from cold, or some other cause, the salivary secretion is suddenly checked or suspended, and the bowels remain costive. In general, convulsions are much more apt to occur during the eruption of the first grinders and eye-teeth, than while tiic i.ici- sors are making their way through the gums. This may arise, in part at least, from the circumstance that during the cutting of the incisors, childi en are as yet usually nourished exclusively at the breast; whilst during the latter stage of dentition, when the grin- ders and eye-teeth are advancing through the gums, they are generally weaned, and therefore much more exposed to gastro- intestinal irritation from improper articles of food. Various eruptions on the skin are among the most common morbid consequences of difficult dentition. Of these, the crusta lartea is by far the most disagreeable and unmanageable. That this affection is intimately associated with dentition, is manifest from the fact, that it very rarely makes its appearance previous to the commencement of dentition, and never, I believe, after the process has been completed. Excoriations behind the ears, and OF DENTITION. 133 the various species of strophulus—particularly the strophulus con- fertus or tooth rash, are, also, very common during this period of infancy. The Strophuli are almost invariably accompanied with derangement of the digestive organs, and diarrhoea; but the two former affections, namely crusta lactea and excoriations about the ears are generally attended with a strong appetite and consi- derable torpor of the bowels. Infants are also liable to a peculiar croupy affection during dentition, which is evidently of a spasmodic character, and de- pendent on cerebral irritation. In some instances, the singular swelling of the hands and feet mentioned above, becomes associ- ated with occasional attacks of this croupy affection, about the time that the disease is assuming a distinctly spasmodic character. This form of croup, which has been aptly called "cerebral croup," is most apt to come on at night or early in the morning. It is attended with extremely difficult respiration and the hoarse and sonorous cough of ordinary croup. The attack is always very sudden, and generally of short duration, seldom continuing beyond fifteen or twenty minutes, and often not above a.minute or two. I attended a child about three years ago, which, during the erup- tion of the eye teeth, was seized with an attack of spasmodic croup, almost every night, for six or seven weeks. As soon as the eruption of the eye-teeth was completed, the croupy affection ceased to recur. Under the head of croup, this singular malady is more circumstantially described. Slow and difficult dentition is sometimes attended with a very troublesome spasmodic or " nervous" cough, which comes on in sudden and violent parox- ysms, at irregular and sometimes remote intervals. The breath- ing during the fit, is oppressed and suffocative; and the cough usually continues until the contents of the stomach are thrown off, At night the child is generally very restless, and the breathing peculiarly irregular, being now, extremely hurried and short, and then, slow, interrupted, sighing and moaning. In several remark- able cases of this kind—one of them in my own family,—the uri- nary secretion was unusually small, and frequently voided with evi- dent pain. The cough generally continues to recur, until the teeth are all cut. I have never known it to continue after this process was completed. In many cases of spasmodic cough during diffi 134 OF DENTITION. cult dentition, the principal irritation is evidently located in the stomach. In these instances, the epigastrium is distended, the stomach and bowels disordered and the alvine evacuations glairy and bilious. The fits of coughing are most apt to occur a short time after taking nourishment, and they usually continue until the greater part of what was received into the stomach, is thrown off by vomiting. There is seldom much saliva secreted in cases of this kind, and the tongue, generally, presents a bright red color along the edges and point, with a coat of thin white fur along its middle. In some instances, of painful dentition, the urinary organs sym- pathize strongly with the local irritation in the gums. This is most apt to be the case, when the digestive powers are weak, and the prima? viae habitually charged with acidity. The con- nection between habitual acidity in the stomach and bowels, and urinary difficulties, has already been pointed out in the chapter on "Dysuria." The urine, in such cases is often loaded with an excess of lithic acid, or its compounds, and, on this account fre- quently so irritating, as to give rise to severe burning pain in the neck of the bladder and urethra on being voided. Occasionally, however, an opposite condition of the urine obtains. The urinary deposits are alkaline or earthy, and the urine is secreted in great abundance, assuming the character of diabetes insipidus. This latter condition of the urine, is seldom attended with any manifestations of febrile irritation; the hands and feet are usually cool, the system relaxed and languid, and the countenance pale and expressive of distress or suffering. Fever, as has already been stated, is perhaps the most common sympathetic affection of difficult dentition. It seldom, however, assumes a vehement character, unless there are other sources of febrile irritation present. It is generally slow, irregular, change- able, intermitting or remitting—presenting the usual phenomena of chronic irritative fever, from slight local affections. The ma- jority of instances of fever that occur during dentition, are exci- ted, or at least greatly promoted by other causes. In that irrita- ble state of the system, which usually attends the progress of the teeth through the gums, a slight accession of other sources of febrific irritation, will give rise to fever. OF DENTITION. 135 Management.—Throughout the whole course of dentition partic- ular care should be taken to avoid every source of undue excite- ment or irritation. Even the most regular and mild cases are usually attended with an increased susceptibility to the influence of exciting or irritating causes. The stomach and bowels, especi- ally, are apt to acquire an increased predisposition to the injurious operation of causes of this kind. Slight errors in diet are apt to disorder the digestive organs, during this period; and the occur- rence of gastro-intestinal irritation is always peculiarly unfavora- ble to the easy progress of dentition. In all instances, therefore, the diet ought to be as simple and unirritating as possible. If the nurse furnishes a sufficient quantity of wholesome milk, nothing but this congenial nourishment ought to be allowed during the first period of dentition—that is until all the incisors at least, are pro- truded. Weaning should never be effected during the active pro- gress of dentition. In general the most favorable period for weaning, is soon after all the incisors have made their appear- ance. Should it become necessary to resort to the use of artifi- cial nourishment, in addition to that obtained at the breast, no- thing can be more appropriate than the simple mixture of milk and water mentioned in the chapter " On the Nourishment of In- fants." All solid articles of food ought to be rigidly avoided— more especially during the primary stage of dentition. After all the incisors have made their appearance, the child may occasion- ally take small portions of oatmeal gruel, crackers grated and dissolved in warm milk and water, barley water, and liquid pre- parations of arrow root, tapioca, or sago, provided the general and local irritation be not considerable. Moderation as to quan- tity also, is an important requisite to the proper dietetic manage- ment of infants during dentition. A full diet may do harm by increasing the general plethora and febrile tendency of the sys- tem, or by oppressing the digestive organs and giving rise to a disordered state of the stomach and bowels. The great objects to be kept in view, while dentition is going on, is to guard against every thing which may have a tendency to render the child feeble and morbidly irritable, or increase the fulness and inflammatory diathesis of the system. Regular exercise by gestation in the open air, has an excellcn' 136 OF DENTITION. prophylactic tendency during dentition. When the vvcathcr is sufficiently mild and dry, the infant, if free from fever, ought to be daily exercised in the fresh and cpen air, by carrying, or riding it in a carriage. Inactivity and confinement to an impure and stagnant atmosphere are decidedly unfavorable to the easy and undisturbed progress of dentition. Children who enjoy suita- ble exercise, in the salubrious air of the country, almost always, pass through this period, with less inconvenience and danger than those who are confined to the contaminated atmosphere of popu- lous cities. It is to be observed, however, that exercise is not recommended in cases attended with distinct fever, or with a de- cided tendency to secondary inflammations. It is to be regarded as a preventive measure—as a means for avoiding the occurrence of morbid irritability, and irritation, rather than for removing them when once developed. With this view, much benefit may unquestionably be derived from it. When aided by the influence of a salubrious air, it tends, in no small degree, to fortify the ge- neral powers of the system, and to prevent that feeble and irri- table condition, which is so apt to occur during difficult denti- tion, and so favorable to the occurrence of alarming irritative affections. Care should also be taken to avoid, as much as possible, every thing that may cause a preternatural determination of blood to the brain. The head ought to be kept cooK During warm weather, no caps should be worn; and at night, or when sleeping, the head should be suffered to remain uncovered. A very soft and large pillow of feathers, so as to cause it to lap round the infant's head, is particularly improper. The head must also be carefully se- cured from the direct rays of the sun when the child is carried out into the open air. A light straw hat, is decidedly the best covering for infants during the warm seasons. During cold weather caps, made of very thin materials may be worn within doors; and when the child is taken out, its head should be further protected against the cold, by a thin cloth cap, while the feet are kept as warm as possible by thick flannel stockings and shoes. Costiveness must be obviated by enemata, and the occasional administration of a mild purgative. Much care is required, how- ever, lest, in the anxiety to remedy this state of the bowels, a OF DENTITION. 137 more serious one be not substituted, by harsh and repeated pur- gations. I am certain that I have seen much harm done in this way. At no period of life, perhaps, are strong purges, so apt to give rise to intestinal irritation, as during the active progress of dentition. Habitual costiveness during dentition, is very generally attended with a deficient secretion of bile. The stools frequently present a whitish or clay-colored appearance and the urine is usu- ally loaded with bilious matter. In cases of this kind, a small portion of calomel should be given every third or fourth evening and a moderate dose of castor oil or magnesia on the following morning. From one to two grains of calomel, will in general. suffice for this purpose. During the intermediate periods purga- tive enemata ought to be administered, so as to procure at least two free evacuations every twenty-four hours. Small doses of epsom salts dissolved in some bland and slightly mucilaginous fluid forms an excellent laxative in cases attended with febrile irritation. In the employment of calomel during dentition great care should be taken, that it be not carried to the extent of in- flaming the gums, or producing a general mercurial action on the system. I have witnessed several highly distressing instances of extensive ulceration and sloughing of the gums and cheeks, in consequence of the incautious employment of calomel, while the system was under the influence of dentition. If moderate diarrhoea occurs, it ought not to be checked or ar- rested, unless the child be in a very feeble condition from previous sickness. But even in this case, it should always be subdued in a gradual and gentle manner. Its tendency, as has already been stated, is in general, decidedly favorable, both by moderating the general febrile disposition of the system, and by counteracting the preternatural flow of blood to the head. When suddenly arrested by opiates or astringents, the local and general disturbances sel- dom fail to acquire a more severe and dangerous character. Con- vulsions, fever, and inflammatory affections of the brain, are among the evil consequences which are apt to result from the injudicious interference with the diarrhoeal affection. In many instances, however, the diarrhoea assumes so violent a character, r- to exhaust and disorder the system to a very dangerous extent. In cases of this kind, remedial assistance is indispensable. When T 13 138 OF DENTITION. ever the system is obviously debilitated and relaxed by this affec- tion, measures should be adopted to moderate its violence. Unless the necessity of prompt and energetic measures be decidedly in- dicated, the excessive action of the bowels ought to be moderated in a gradual manner; and when the complaint can be reduced to a mild state, no attempt should be made to arrest its course wholly. Small doses of ipecacuanna, in combination with prepared chalk and minute portions of calomel, have, in general, succeeded bet- ter, in my hands, in cases of this kind, than any other remedy. A powder composed of a fourth of a grain of ipecacuanna, one sixth of a grain of calomel, and four or five grains of prepared chark, should be given every three or four hours until the diarrhoea is sufficiently moderated. By continuing the exhibition of two or three doses daily, the complaint may generally be kept in a suffi- ciently moderate state, until the advancing teeth are protruded. I have rarely known a violent case of diarrhoea wholly arrested during the active progress of dentition, without an obvious increase of the general and local irritation. In cases of decidedly difficult dentition, attended with an irritated state of the nervous and vas- cular systems, it is generally extremely difficult to manage the diarrhoea without either suffering mischief from the exhausting effects of the bowel complaint, or aggravating the general and lo- cal irritative affections by giving it too great and sudden a check. A striking example of the correctness of this observation occurred to me not more than ten days ago. The infant was cutting the first molares, with considerable difficulty, though nothing of a dangerous character occurred except a diarrhoea, which in a short time became extremely violent and prostrating. I prescribed the above powders of ipecac, chalk and calomel, which had the effect of moderating the complaint considerably, though not to a sufficient extent. As this remedy did not seem to do any further good, I advised a decoction of the root of geranium maculatum in milk. This was given, and the bowel complaint was soon entirely arrest- ed. In about ten hours after the complaint was thus stopped, a violent paroxysm of convulsions occurred, which terminated in a torpid or comatose condition; and although an active purgative and repeated enemata were administered, a second fit of convulsions ensued and terminated the life of the little sufferer. OF DENTITION. • 139 The child's mouth ought to be washed out with fresh water every morning. This is always very grateful, and tends to mod- erate the uncomfortable heat and irritation of the mouth. The practice of putting some hard substance into the child's hands, to press and rub its gums with, is proper, and should never be neg- lected. A piece of smooth coral, ivory, orris root, or firm-grained wood may be used for this purpose. The substance ought to be smooth or polished, and of such a size and shape as to enable the child to hold it firmly with the hand, and prevent its slipping back into the fauces or throat. An ivory ring, about an inch and a quarter in diameter, is an excellent contrivance for this purpose. The ring may be suspended round the child's neck, so as to be al- ways within its reach. This practice has been condemned by some writers, on account of its supposed tendency to harden the gums, just as the soles of the feet and palms of the hands are indu- rated by much walking and manual labor. This apprehension is, however, entirely unfounded. The tendency of compression and friction is rather to promote the absorption of the gums, than to consolidate and render them more resisting to the advancing teeth. Indeed the instinctive and apparently irresistible propensity which all children manifest to press and rub their gums firmly, upon every thing they lay hold of; and the very obvious relief and gratification which they derive from it, may be regarded as a suffi- cient warranty that the practice is not only harmless, but decided- ly beneficial and desirable. Friction and pressure manifestly moderate the painful sensations of the gums; and they may do good, also, by promoting the free secretion of saliva, and thereby diminishing the heat and irritation of the mouth. From time to time, the gums should, in all cases, be carefully inspected; and when found to be in an inflamed and swollen con- dition, they ought to be promptly and freely divided with a lan- cet, even though no unpleasant consequences be produced bv the local irritation. When the gums are in this condition, a slight, additional exciting cause, will be apt to give rise to dangerous affections. An error in diet, an accidental derangement of the digestive organs, or a slight cold, may bring on an attack of con- vulsions, of fever, or of profuse and exhausting vomiting and purg- ing. By a timely division of the inflamed and swollen portion of the 140 OF DENTITION. gums, the liability to consequences of this kind, will be much diminished. During the actual presence of these and other affec- tions depending on difficult dentition, a division of the gums should, on no account, be neglected, if they are manifestly distended, or in a state of inflammatory irritation. The diseases of dentition ap- pear to depend, mainly, on the distention of the membrane inves- ting the crown of the teeth, and pressure upon the pulp, nerves and vessels at the bottom of the socket, in consequence of the re- sistance which the advancing teeth experience, from the tension and firmness of superincumbent gums. By dividing the gums, this pressure and distension is moderated, and if no other exciting cause be present, speedy and important relief will frequently en- sue. Little or no advantage, however, can be expected from this operation, so long as the edge of the gums is sharp and wholly free from inflammation. It is not necessary, indeed, that there should be distinct swelling and inflammation present, to render this measure proper or useful. If the part over the advancing teeth is expanded, or thickened and tense, relief may be expected from the operation, although no decided marks of inflammation be present—in other words, if the teeth have approached near the surface, and unpleasant or alarming sympathetic affections occur, it will be proper to divide the gums freely. "Under every cir- cumstance, of indisposition arising from dentition, the lancing of the gums ought never to be omitted. As soon as the gum is lanced, and the membrane is divided, the tooth obtains an increased room, the pressure is immediately taken off from the socket, and the cause of the irritation is removed" (Fox). In reply to the objections that have been urged against the propriety and usefulness of this operation, I offer the following remarks from the writer just quoted. " It is very surprising, that notwithstanding the manifest advantage, which attends the lancing of the gums, in cases of painful dentition, there are persons who entertain strange prejudices against this safe and important source of relief. But the uniform experience of its good effects, and no instance of its doing harm ever having occurred, should produce an unanimous consent for adopting it. Some persons object to the operation, on account of the pain which it will occasion to the child, not considering that the inflammation produced by the re* OF DENTITION. 141 sistance of the gum to the tooth, is far more acute, than dividing the gum with a sharp instrument. Others suppose that the form- ation of the teeth is injured, and that they are more liable to de- cay; but neither of these circumstances can occur; for at the time the tooth is about to pass through, the enamel is completely form- ed, and no injury can be done to the formation of the fang, which is always continued for some time after the appearance of the crown." "When it is necessary to lance the gums sometime before the teeth are quite ready to appear; they unite, and in this case the cicatrix has been said to impede the progress of the tooth, present- ing a greater resistance than the gums, in their natural state; but it is now certainly known that a newly formed part, or cicatrix, always gives way sooner to the process of absorption than the sur- rounding parts, and hence the passage of the tooth is facilitated. The hemorrhage which is occasioned by the operation, is scarcely ever considerable, but is always beneficial: the vessels become un- loaded, and the inflammation is always soon diminished." Under an idea that the cicatrix may impede the protrusion of the tooth, some advise that the division of the gums should be made at the side near the edge, rather than directly over the crown of the advancing teeth. This, however, is not only unnecessary, but unfavorable to success. The incision should be made in the direc- tion of the gums, and immediately over the crown of the teeth. A single incision will be sufficient for the incisors; but when the molares are near protruding, and the gum is swollen and tense, a crucial incision may be advantageous. Mere scarification can afford but little advantage. The gums must be freely divided, down to the teeth. The principal difficulty arises from the dis- tension of the firm membrane stretched over the teeth; and unless this be divided along with the gums, the operation will fail to pro- cure the full benefit which it is capable of affording. When convulsions occur during dentition, the gums should be immediately divided if they exhibit any signs of inflammation or distension from the advancing teeth. Some writers recommend this operation in all instances of convulsions, while the process of teething is going on, whether marks of irritation or distension if the gum be present or not. "The advantages of this operation 142 OF DENTITION. are so great," says Underwood, "that whenever convulsions take place about the usual period of dentition, recourse ought always to be had to it, though by an examination of the gums there be no certain evidence of the convulsions being owing to such a cause. At any rate the operation can do no harm, even at any period; and should the shooting of teeth be only an aggravation of the true cause of the disease, lancing the gums must be attended with advantage." I am, however, convinced from experience, that cutting down through the gums, at so early a period, is always entirely useless; and I have known very troublesome and even alarming hemorrhage to occur from a deep incision, while the teeth were yet far from protruding, and the gum wholly free from the enlargement or distention which accompanies the advanced stage of dentition. It is not necessary, however, that there should be obvious inflammation and swelling present, to render this ope- ration proper, or likely to afford benefit. Whenever, from the fulness of the gum, it appears that the tooth is near the surface, a free incision should undoubtedly be made, if convulsions or other alarming affections supervene. For a full account of the mode of managing convulsions from dentition, the reader is referred to the chapter "On Convulsions." Should the child become affected with cutaneous diseases, while under the influence of dentition, the utmost caution ought to be observed, in the employment of external remedial applications. This is particularly important, in relation to discharging sores be- hind the ears, and scabby eruptions about the head. The appli- cation of astringent, drying, or repelling substances, may lead to the most violent and dangerous consequences. Indeed these affec- tions, like the copious secretion of saliva, may have a favorable effect, by deriving the irritation and preternatural flow of blood, from the brain and other internal organs. If the external affection be suppressed, the sympathetic irritation will not be subdued, but only transferred to some other part of the system. If it falls on the brain, as it often does, convulsions, or meningitis (dropsy of the brain) may be the result; if on the lungs, severe pneumonic or cynancheal affections maybe the consequence; and, if the stom- ach and bowels receive the introverted irritation, rapid and un- manageable diarrhoea or cholera, will probably ensue. This is no OF DENTITION. 143 imaginary view of the evil consequences that may result from an improper meddling with eruptive affections of a scabby or humid character, about the head, during dentition. I have witnessed some very striking examples of this kind, in the course of my prac- tice. An instance occurred to me about eight months ago. Dur- ing the active progress of dentition, a scabby and discharging eruption occurred on the cheeks, forehead, and behind the ears. I directed simple means, merely with the view of moderating the irritation and keeping the parts clean, and urged the impropriety of applying any thing calculated to dry up or remove the disease. The mother nevertheless, could not content herself with seeing the infant's face in so disagreeable a state, and, of her own accord, used astringent washes and other means, to remove the affection. In about a week after these applications were used, I was again called to prescribe for the child. The eruption was now almost entirely removed; the little patient was feverish and extremely restless and fretful. Suitable remedies were resorted to, but in opposition to all my efforts, the disease rapidly increased, and ter- minated in fatal coma, paralysis, and convulsions. See the chap- ters on "Crustea Lactea" and on uSore Ears," for further directions on this subject. The application of blisters behind the ears, or on the back of the neck, is often of essential service in the diseases that arise from difficult dentition. When symptoms of cerebral irritation supervene—such as great fretfulness, flushing of the cheeks, a warm and dry skin, starting and restlessness during sleep, and un- usual sensibility of the eyes to the light, the timely application of blisters behind the ears, or on the back of the neck, may prevent the development of inflammation in the brain or its meninges, or obviate an attack of dangerous diarrhoea, convulsions, &c. &c. In violent and obstinate diarrhoea, from dentition, I have often de- rived unequivocal advantage from this practice. Whatever is cal- culated to diminish cerebral irritation, or to lessen the determina- tion of blood to the brain, may be usefully applied, in the sympa- thetic diseases of dentition; for, with the exception of eruptive af- fections, they are almost always dependent on, or at least connect ed with and aggravated by, cerebral irritation. In the sudden convulsive affections, which are so apt to occur during dentition, 144 OF DENTITION. immersing the feet and legs in warm water, and applying a cloth soaked with cold water to the head, is, in general, more certain and prompt in procuring relief than any other remedy we possess. The simultaneous application of cold to the head and warmth to the feet, has a powerful tendency to diminish sanguineous conges- tion and inordinate excitement in the brain. These two applica- tions should always go together when the brain is in an irritated and congested condition. The propriety of keeping the bowels in a loose state during dentition, has already been mentioned. When violent affections supervene, or when there are indications of the approach of serious sympathetic disorders from dentition, and diarrhoea does not attend, great benefit may frequently be obtained, from active purgatives. By stimulating the bowels in this way, and directing the circulation and excitement upon them? the brain will be relieved, and the diseases depending on its irri- tated condition either prevented or mitigated. When the gums become ulcerated, before the teeth are protru- ded, they should be lanced, and touched occasionally with a solu- tion of sulphate of copper, or of the nitrate of silver. Four grains of either of these articles, dissolved in an ounce of water, and ap- plied with a dossil of lint, forms an excellent application in cases of this kind. A decoction of the root of coptis trifoliata, (golden thread), has frequently done much good in my hands, in ulcerated gums. DIABETES OF INFANTS. 145 CHAPTER XI. OF THE DIABETES OF INFANTS. Diabetes is, probably, a much more frequent disease during infancy than is generally supposed. Since it was first noticed by Moreton, in his Phthisiologia, it has received but little attention, from writers on the diseases of children. Mr. Venables, however, in his recent work on diabetes, has contributed some interesting and valuable information on the diabetic affections of children; and it is from this source, principally, that the following observations are drawn. Infantile diabetes seldom occurs after the second year of age. Dr. Dewees states that "all the children he has seen affected with it, were under fifteen months old." It does not, however, seem apt to come on during lactation; for, according to the observations of Mr. Venables, its appearance previous to weaning is extremely uncommon. In the commencement of the disease, the child loses its usual playful and active disposition, and, although no obvious malady be discernible, it soon becomes dull, languid and fretful, with an uneasy and anxious expression of the countenance. In a short time, its flesh begins to waste; and as the emaciation gradually in- creases, the skin becomes dry, harsh, and so flabby, that "it seems, at length to hang loosely about the body." During the early stage of the disease, "the bowels are regular, and little or no deviation from the natural and healthy appearance of the alvine discharges is to be noticed." The tongue, too, exhibits a natural appearance, in the beginning, but in the advanced stage of the disease, it always becomes more or less conspicuously covered with a coat of white fur, or thick transparent mucus. After the disease has made considerable progress, the bowels begin to act irregularly, and the alvine discharges acquire an unnatural, and, generally, bilious appearance. The skin becomes uniformly dry and very 146 DIABETES OF INFANTS. warm; and emaciation goes on with increasing rapidity. The pulse is at first somewhat accelerated, becoming small, quick, hard and wiry, as the disease advances in its course. The abdo- men, gradually becomes more and more distended, and tense,—a symptom which in connection with the progressive emaciation, "frequently leads to the supposition of mesenteric disease." In the. advanced stage of the complaint, the brain generally becomes more or less affected. "Headach, vertigo, and temporary delir- ium occasionally attend, and when a fatal termination takes place, the patient usually dies comatose and sometimes apoplectic." A considerable degree of fever, generally prevails during the latter periods of the disease; and in cases of long continuance, anasarca, and even general dropsy have been known to occur. "The most remarkable occurrence, however, although it frequently escapes observation, is the inordinate discharge of urine. This discharge increases in quantity so gradually, that it is not usually noticed. By the time it has become more remarkable, great thirst prevails, and hence it is neglected or unnoticed, because parents and friends conceive an excessive discharge of urine and an excessive con- sumption of fluid as naturally associated." The qualities of the urine vary in different cases. In some instances the urine is per- fectly limpid, without any sedimentous matter, or deposit; in others "it is milky, or like a mixture of chalk and water." Occa- sionally the urine is transparent, and "of a pale straw color;" and Mr. Venables saw a case in which it was of a green color. It appears, frequently, to contain a considerable portion of coagula- ble serum; and when the proportion of the coagulable matter is great, and the urinary discharge very copious, "the emaciation is always rapid and extensive."* Mr. Venables does not mention the occurrence of a saccharine condition of the urine, in infantile diabetes. In the case related by Moreton, the urine was very per- ceptibly sweet: I have myself witnessed three very distinctly formed cases of infantile diabetes, in all of which, the urine, though extremely copious, was perfectly insipid. There is reason to believe, as is observed by Mr. Venables, that * A Practical Treatise on Diabetes; with Observations on the tabes diurctica,or Urinary Consumption, especially as it occurs in Children, &c. By R. Venables, M. B. &c. o. 5-16 DIABETES OF INFANTS. 147 many cases that have been regarded as instances of dropsy in the head, marasmus, and mesenteric disease, were in reality cases of diabetes. I am the more persuaded of the correctness of this ob- servation from the error which I committed myself, in this respect, in the first case of this kind I witnessed. The child appeared to me to be laboring under mesenteric disease, and after having treated the case as such, for three or four weeks, the mother casu- ally observed, that the little patient passed a great deal of urine. I now directed my attention to this circumstance, and soon satisfied myself that the quantity of urine discharged was truly excessive. In the course of twenty-four hours, three pints of urine were col- lected, and much was discharged at night, as well as during the day, that could not be collected. The urine was clear, and of a pale straw color, but I neglected to ascertain whether it contained any coagulable matter. The infant was but fifteen months old. Infantile diabetes is, indeed, very rarely recognized, in its incipi- ent, or early stage; "and when it has made considerable progress, it simulates so many other diseases, that the real character of the complaint is not developed till its history is either wholly lost, or so confounded with symptomatic or secondary affections, that it can no longer be unravelled." Too little attention is, in general, paid to the urinary secretion, in the diseases of children. In mal- adies of a protracted character, attended with emaciation, and a general irritative condition, the urine ought always to be carefully inspected. There can be no doubt that serious derangements of this secretion often occur in children, without being suspected. I was quite recently called into consultation, in the case of a child about eighteen months old. It appeared languid, and was much emaciated; its bowels were irregular, the stools slimy and mixed with green bile, and it was evidently harassed with constant thirst. In this case the urinary secretion, on proper inquiry, was found to be pre ternatu rally copious. It could not indeed be regarded as an instance of diabetes; but the quantity of the discharge was such, that it could not fail to contribute materially to the exhaustion and emaciation of the little patient, and manifestly required par- ticular attention in the remedial management of the case. The urine in this patient contained a considerable portion of sedimen- tous matter of the phosphatic variety. From what I have obser- 148 DIABETES OF INFANTS. ved in relation to the urinary affections of children, I am induced to think, that infantile diabetes is frequently attended with an ex- cess of the earthy phosphates in the urine. This state of the uri- nary secretion, says Prout, "frequently occurs in sickly children, in whom the functions of the digestive organs are deranged;" and it is well known, that where this condition of the urine prevails} "symptoms very analogous to those of diabetes are apt to super- vene." From the connection which is known to exist between an excess of urea in the urine, and the symptoms usually denominated diabetes insipidus, in adults, there can be no doubt that a similar state of the urine is sometimes present in the diabetic affections of infants. This disease may, moreover, be associated with an albu- minous or coagulable condition of the urine, since this state of the secretion is sometimes attended with profuse diuresis, at a more advanced age. These circumstances are worthy of notice; and when properly estimated, may aid considerably in instituting a proper course of treatment; for it cannot be doubted that these different conditions of the urine require corresponding modifica- tions of remedial management. Treatment. In the treatment of this affection, much will of course depend, on the character of the urinary secretion. In cases attended with a saccharine state of the urine, recourse must be had to those means which experience has ascertained to be most beneficial in diabetis mellitus. Instead of the usual farina- ceous or milk diet, the nourishment should consist principally of the lighter and more digestible kinds of animal food. If febrile symptoms attend, it may be beneficial to apply six or seven leeches to the lumbar regions. Mild aperients, and the occasional use of the warm bath, will be proper. Opiates are often deci- dedly beneficial in this affection—more especially in the form of Dover's powder. To a child between one and two years old, a grain of this anodyne mixture, with, or without three or four grains of powdered uva ursi may be given two or three times daily. In the diabetes of adults, Mr. Latham used opium and the carbonate of iron with decided advantage; Mr. Venable speaks very favorably of the effects of phosphate of iron, in this com- plaint. Magnesia, given in small and repeated doses, has proved DIABETES OF INFANTS. 149 serviceable; and Richter mentions a case of diabetes, in a child, which yielded to a course of emetics. It is but very rarely, however, that the urine is sweet in the diabetic affections of infants. In the ordinary forms of the dis- ease, mild laxatives, in alternation with Dover's powders and uva ursi, will often procure relief. Small doses of the bi-carbonate of soda, in union with two or three grains of the carbonate of iron, may be resorted to with a prospect of advantage. When the urine deposits a whitish sediment, hyoscyamus, or lauda- num, with uva ursi will sometimes prove beneficial. In one of the cases referred to above, I prescribed a solution of the extract of hyoscyamus, in the proportion of one scruple to an ounce of water, in conjunction with infusion of uva ursi, with manifest ad- vantage. Five drops of the narcotic solution, with a teaspoonful of the uva ursi tea, were given three times daily. Dr. Dewees cured several cases by "keeping the bowels freely open, and put- ting a quantity of the spirits of turpentine upon the clothes of the chidren, so as to keep them in a terebinthinate atmosphere. I have seen much good done in a case of this disease, by a turpen- tine plaster laid over the region of the kidneys. When the dis- ease has advanced so far as to be attended with much intestinal disorder, and a tumid and tense state of the abdomen, consider- able benefit would probably be derived from the internal use of small doses of balsam copaiva, or spirits of turpentine, with an occasional mercurial laxative. In this aggravated state of the disease the diet should consist of the simplest and blandest farina- ceous preparations. Where the digestive powers are good, and there are no manifestations of intestinal irritation, beaf tea or weak chicken broth, mixed with the usual farinaceous nourishment, or a portion of milk, will generally prove most beneficial. The gums should always be attended to, and if they are swollen and the teeth are near protruding, they ought to be divided or scarified with a lancet. When the child is fretful, and evidently harassed by painful sensations about the head and gums, small blisters laid behind the ears will sometimes procure much relief, and aid ma- terially in removing the diabetic affection. In every variety of this disease, it is of much consequence to promote the action of the cutaneous emunctories. The warm bath, and frictions with 14 150 OF THE ERYSIPELAS OF INFANTS. dry flannel, repeated at proper intervals, are very suitable reme- dies for this purpose. CHAPTER XII. OF THE ERYSIPELAS OF INFANTS. Infants are liable to a peculiar erysipelatous inflammation, of a very obstinate and dangerous character. It usually comes on within a few days after birth, and occurs but very rarely after the fourth or fifth week. Dr. Dewees mentions two cases, which came on at a much later period—one after the third and the other after the sixth month. I have witnessed but one instance of its occurrence after the eighth week, and not more than three after the third week. Richter states that children have been born with blotches of erysipelatous inflammation so far advanced as to exhibit vesications and spots of gangrene. I saw a fatal case, about ten years ago, which had come on within five or six hours after birth. The inflammation generally commences, on the lower parts of the body, particularly about the nates, groins, and umbilicus, in the form of a small red blotch, and gradually spreads, irregularly, over the abdomen and along the back and inside of the thighs. The inflamed part is firm and extremely painful to the touch, presenting a swollen, dark-red or purplish surface of irregular shape. Generally, towards the end of the first day, large but thinly scattered vesicles appear, having inflamed livid bases, tend- ing sometimes rapidly to sphacelus. In some instances vesication does not occur until the disease has continued for several days; in others, the vesicles make their appearance, soon after the in- flammation is established. Occasionally no vesication occurs throughout the whole course of the inflammation. When the in- flamed part vesicates early, the disease generally spreads very OF THE ERYSIPELAS OF INFANTS. 151 apidly and soon acquires an extremely dangerous condition. The tendency to gangrene in infantile erysipelas is, indeed always very considerable, except, perhaps, in those mild cases, which re- main free from blistering—a form of the disease, however, which is unfortunately, not often met with. The disposition to sphacelus is particularly great, when the inflammation is seated on the ab- domen; when it affects the extremities, it is more apt to termin- ate in ulcerative suppuration of the subcutaneous cellular struc- ture, but this occurs also, frequently, on the body, particularly about the nates and loins. The pus formed is generally very thin, of a greyish color, and frequently somewhat acrid and sani- ous. It travels along through the meshes of the cellular mem- brane, under the skin and between the muscles, until this tissue (the cellular) is almost entirely destroyed in the affected part. Small portions of the skin, finally slough off, and give exit to the confined matter, which is, usually, mixed with flocculi and shreds of sphacellated cellular membrane. Symptoms of intestinal and hepatic disorder, are seldom wholly absent in infantile erysipelas. The discharges from the bowels are usually frequent, griping and of a grass-green color. In some cases, however, there is con- stipation, with colicky affections, and frequent ejections of acid fluid from the stomach. The whole surface of the body, often presents a slightly jaundiced appearance, and the urine is usually manifestly imbued with bilious matter. Great diversity occurs, in relation to the violence and duration of this malady. In some instances, the inflammation passes off, in two or three days, without any very unfavorable consequences. Cases of this mild character are however very rare. Sometimes, al- though the inflammation is not extensive, it successively invades almost every part of the body. In its erratic passage over the surface of the body, it sometimes travels on by a continuous exten- sion in one direction while the parts previously affected are freed from the inflammation. Occasionally, however, it leaps as it were, from one place to another, disappearing from the part it occupies, and reappearing speedily in some other and perhaps remote part of the body. In some instances the skin surrounding the inflammation, to the distance of nearly an inch from its mar- 152 OF THE ERYSIPELAS OF INFANTS. gin, is peculiarly firm to the touch, and cannot be pinched up or moved over the subjacent parts, as maybe done in a healthy state of the body. Meckel, in examining the body of an infant that had died of this disease, found the umbilical vein, together with a considera- ble extent of the surrounding peritoneum strongly inflamed; and this fact, led him to believe, that inflammation of this vein, occa- sioned by rude management, in cutting and tying the umbilical cord, constituted the primary cause of this malady. Osiander gives an account of a fatal case, which commenced in the geni- tals of a male infant soon after birth. The inflammation spread itself rapidly over the whole abdomen. On dissection, he found the umbilical vein full of thick yellow pus, from the navel to the vena-porta, with other traces of inflammation in the adjacent parts. Inflammation of the umbilical vein, might, perhaps, ac- count for the occurrence of erysipelas in the parts surrounding the navel; but even where the umbilical vein is found to be inflamed on post mortem examination, the correctness of this pathology must be very doubtful, since it is impossible to say, whether, the inflammation of the vein was primary, or the result simply of an extension of the erysipelas, from the external surface along the vein. Nevertheless, the fact, that in a very large majority of in- stances, the disease comes on either before or soon after the ex- tremity of the cord is cast from the navel, leaving this part in a tender and irritable condition, together with the circumstance that the erysipelas almost always makes its first appearance on the lower parts of the body, seems to favor the idea, that this danger- ous affection is frequently in some way or other connected with umbilical irritation. In some peculiar states of the system, the slightest injury of the skin is apt to give rise to erysipelatous in- flammation in adults; and it is not improbable, that a similar pre- disposition, in co-operation with irritation about the umbilicus may be a common source of infantile erysipelas. It may be said that as this disease sometimes occurs long after all irritation about the umbilicus has passed off, this mode of accounting for its occur- rence cannot be correct. It certainly cannot be presumed, that all, or perhaps even a majority of the cases are produced in this way; yet it is by no means improbable, that in some instances, at OF THE ERYSIPELAS OF INFANTS. 153 least, irritation about the navel, in conjunction with a peculiarly depraved or irritable condition of the system, constitutes the ex- citing cause of the disease. It is worthy of notice, that in those cases which occur at an advanced period, after the navel has ac- quired a perfectly firm and healthy condition, the inflammation almost always occurs on the extremities or about the head and shoulders. Irritation and functional disorder of the liver and ali- mentary canal has also been referred to as the primary source of infantile erysipelas. There can be no doubt, that derangement of the biliary and digestive functions frequently co-operate with other causes in the production of this malady. Symptoms of func- tional disorder of the liver, and digestive organs, are seldom wholly absent in this affection, and require especial attention in prescribing for its cure. We can, however, hardly ascribe much influence to hepatic and intestinal derangements as exciting causes of this affection, since functional disorders of the digestive and biliary organs are very common throughout the whole period of infancy, whilst infantile erysipelas occurs but seldom, and is, in a great measure, confined to the first three or four weeks after birth. This latter circumstance justifies the presumption, that there is something peculiar to this early stage of infancy, to which the principal agency in the causation of this malady must belong. The disordered state of the biliary and intestinal functions, is per- haps, in many instances, an effect rather than a cause of the mor- bid condition upon which the erysipelatous affection depends. Its unfavorable influence on the disease, however, cannot be doubted, and a principal part of the remedial treatment consists in restor- ing the healthy action of the liver and alimentary canal. Breath- ing an impure atmosphere, has a very decided tendency to favor the occurrence of this disease. It is on this account, that the dis- ease is so much more apt to occur in lying-in, and foundling hos- pitals, than in private habitations. Dr. Underwood says, that he rarely met with infantile erysipelas #in private practice, but re- peatedly in lying-in Institutions. It has, indeed, often prevailed endemically, in crowded and ill-ventilated hospitals. It does not appear that infantile erysipelas differs in any essen tial point from the erysipelas of adults. It occurs under all the modifications, as to its phenomena and progress, that it is known X 14* 154 OF THE ERYSIPELAS OF INFANTS. to assume at a more advanced age. In some instances, though very rarely, it continues for fourteen or fifteen days, with but little vesication, and no cellular suppuration. In general, however, vesi- cles appear very early; and in such cases, the tendency to suppu- ration and gangrene, is usually very great. In the majority of in- stances, the cellular tissue about the inflamed part becomes much infiltrated with serum. When deep incisions are made into the affected parts after death, a large portion of thin fluid issues, and the skin exhibits a firmer and thicker structure than in the natural state. In the commencement, the febrile reaction is sometimes of a high inflammatory grade; but when vesication begins, it often speedily assumes a low and typhoid character, and in many cases, the tendency to sinking is manifest as soon as the inflammation is established. The approach of suppuration is always attended with an obvious failure of the vital energies; and the instances of recovery after this has taken place are extremely uncommon. Treatment.—Though, in the commencement, often associated with an active grade of febrile excitement, infantile erysipelas rarely admits of very decisive antiphlogistic measures. An ob- vious tendency to prostration often occurs almost as soon as the inflammation makes its appearance, the fever being of a typhoid character from the onset of the malady. Occasionally, however, the fever is of a high or synochal grade, and in cases of this kind direct depletion may be resorted to with much propriety. I have met with but one instance in which it appeared to me, decidedly proper to abstract blood. The infant was unusually robust; and the pulse and general appearance of the little patient, indicated a high degree of febrile reaction. The inflammation occupied the upper part of the right thigh, groin and illiac region, and had not vesicated at the end of the third day. After the use of some purgatives, I directed four leeches to be applied around the in- flamed part, and the result was unquivocally beneficial. If leeches can be procured, they ought always to be used, in pref- erence to venesection, at this early stage of infancy. It is proper to observe, that, when leeching is resorted to in this affec- tion, the leeches should always be applied to the sound skin, surrounding the inflammation. Leeching is most apt to prove OF THE ERYSIPELAS OF INFANTS. 155 beneficial, where the erysipelatous inflammation is of an erythe- matous character—that is, superficial, with but little swelling and infiltration of the subjacent cellular tissue. "A trifling abstraction of blood, will be sufficient to effect every useful purpose, where this measure is indicated." It will very seldom be proper, to ap- ply more than four leeches of the ordinary size; and, in the ma- jority of such instances, two or three leeches will be quite suffi- cient. When the inflammation spreads rapidly, and is attended with vesication, the leeches should be applied to some remote part, as a general depletory measure, if the condition of the sys- tem indicates the propriety of bleeding. I am not disposed, how- ever, to urge the employment of bleeding, whether general or topical, in infantile erysipelas, for although it may doubtless do good in some cases, yet I am entirely satisfied, that an active an- tiphlogistic treatment is attended with much risk of irremediable injury, even in cases that seem to warrant its adoption. The milder antiphlogistic means--more especially laxatives, and diaphoretics are almost always decidedly indicated in the early stage of the disease. From the constant and intimate sym pathy which subsists between the skin, and the mucous membrane of the alimentary canal, there can be no doubt, that intestinal ir- ritation from acrid foeculent matter and morbid secretions must tend to support and aggravate the external erysipelatous inflam- mation. One of the first remedial measures, therefore, should be to evacuate the bowels freely. For this purpose, a grain of calo- mel, followed some hours after, by a teaspoonful of castor oil, generally answers very well. If difficulty occurs in procuring free evacuations, laxative enemata should be resorted to in con- junction with the use of internal purgatives. After the bowels have in the first place been well evacuated, they should be kept in a loose state, by small doses of calomel in combination with rhubarb, or with ipecacuanna. A mixture of calomel, ipe- cacuanna, and bi-carbonate of soda forms a most excellent aperi- ent in this disease. A powder consisting of a fourth of a grain of calomel, the same quantity of ipecacuanna and one grain of the bi- carbonate of soda, rubbed up with a few grains of white sugar, should be given every three or four hours, or at longer intervals, so as to procure three or four alvine discharges in the «ourse of 156 OF THE ERYSIPELAS OF INFANTS. about twenty-four hours. The ipecacuanna promotes the laxa- tive operation of the calomel, and tends to keep up the action of the cutaneous exhalents, whilst the soda counteracts the forma- tion of acid in the primae viae. Mr. Lawrence, recommends the use of a mixture of James's powder and calomel, and there can be no doubt of its being very well adapted for this purpose. One sixth of a grain of the former with a fourth of a grain of the latter may be given three or four times daily. Calomel can seldom be omitted with propriety in the treatment of the early stage of in- fantile erysipelas. The liver is, probably, always more or less disordered in this disease; and calomel is doubtless often benefi- cial, by its operation on the biliary organs, independent of its aperient effects on the bowels. The stools, generally, present a grass-green appearance; and I have seen an instance in which they were black and viscid, like meconial matter, for several days. It is necessary, however, to proceed with caution in the use of calomel at this early period of infancy. When given very freely, it is apt, at this tender age, to give rise to dangerous irritation of the stomach and intestinal canal. Throughout the whole course of infantile erysipelas our principal aim should be to restore the regular action of the liver, alimentary canal and of the skin. Should the small doses of calomel and ipecacuanna fail to keep up the requisite action of the bowels, an occasional dose of castor oil, or of magnesia, should be used; and to promote the regular action of the cutaneous exhalents, warm or tepid bathing may be resorted to with a prospect of advantage. In the erysipelas of adults, attended with symptoms of biliary derangement, Desault, strongly recommends the use of emetics, and from a case which came under my notice, about eight years ago, in an infant nearly four weeks old, I am inclined to think, that the occasional use of emetic doses of ipecacuanna, would often prove serviceable in the early stage of infantile erysipelas. In the child referred to, pretty active vomiting was unintentionally excited by a dose of calomel and ipecacuanna on the third day of the disease; and the erysipe- latous affection almost immediately assumed a more favorable appearance. When the skin is very dry and warm, some benefit may be derived from the use of mild diaphoretics. From fifteen OF THE ERYSIPELAS OF INFANTS. 157 to thirty drops of the following mixture* will usually answer very well for this purpose. Where the tendency to visication and gangrene, is obvious, or where the attending fever is of a low and typhoid character, tonics must be employed at the same time that the bowels are kept in a loose state by the aperients already mentioned. The necessity of resorting to the use of tonics, is especially urgent, when the inflammation is about terminating, or has already ter- minated in suppuration or gangrene. Experience has shown that the sulphate of quinine is decidedly the most valuable tonic we pos- sess in cases of this kind. To an infant within the first month the sixth of a grain of this article, may be given every two or three hours. It may be advantageously united with a suitable portion of the extract of hyoscyamus—a combination which I have found peculiarly beneficial in the typhoid erysipelas of adults. The tenth of a grain of this extract may be given to an infant, two or three times daily. Should diarrhoea occur after suppuration has taken place, it must be immediately checked. For this purpose minute doses of Dover's powder, in union with prepared chalk, is probably the most suitable remedy. The fourth of a grain of Dover's powder, with two or three grains of chalk, mixed with mucilage of gum arabic, should be given every three or four hours until the bowels are quiescent. One or two drops of laudanum, also, given at proper intervals, will often suffice for this purpose. To support the system, where there is a tendency to prostration, some writers speak very favorably of the employment of the car- bonate of ammonia. I have used it in conjunction with quinine, with manifest advantage in a case of infantile erysipelas. Ammo- nia may in general be given earlier, without risk of increasing the inflammation, in cases attended with considerable fever, than qui- nine. When the circumstances are such as to render it doubtful whether stimuli and tonics should be employed or not, the carbon- ate of ammonia ought to be selected, if it be concluded to resort to such remedies. The diaphoretic tendency of this article, renders it more eligible in diseases of a typhoid character, attended with local inflammation, than, perhaps, any other article of the kind * R. Spirit Minderiri Ji. Vin. Antimonii, gtt. xxv. Syrup Lemonis 3ii. M. ft. 158 OF THE ERYSIPELAS OF INFANTS. we possess—more especially where the propriety of such reme- dies may be doubtful. One of my medical friends has informed that, he had in two instances of infantile erysipelas derived un- questionable benefit from the internal use of spirits of turpentine. He gave three drops of it, every four hours, to an infant about six weeks old. In the erysipelas of adults I have in several in- stances, prescribed the turpentine, and, as it appeared to me, with a very good effect. Various opinions have been expressed with regard to the propri- ety or usefulness of attempting to subdue or restrain the erysipela- tous inflammation by local applications. Bateman asserts, that ex- ternal applications, "are in general unnecessary if not prejudicial," in the early stages of the disease; and the same remark is made by some other writers of respectability. The weight of good tes- timony, however, is decidedly in favor of external applications to the affected part; and my own experience has convinced me, that very important advantages may often be obtained from a judicious management of this class of remedies. Cooling applications, such as cold water—lead-water and other soothing means, were for- merly much resorted to in the treatment of erysipelas. Experience however, has not sustained the character of such applications as in general suitable remedies in this variety of inflammation. There evidently exists a close analogy between erysipelatous inflamma- tion, and the inflammation caused by a scald or burn. In both, the inflamed capillaries appear to be in a debilitated and pas- sively distended condition, requiring applications of an exciting character. In the erysipelas of adults, blisters often produce highly beneficial effects, and by proper management they may doubtless be used with equal advantage in the erysipelas of in- fants. Dr. Dewees, seems to place considerable reliance on them in the treatment of this affection. I have not resorted to blister- ing in more than one case, and in this instance it had a very good effect. The blister should be large enough to extend beyond the inflamed part, so as to vesicate a portion of the surrounding sound skin. After the plaster is removed, the blisters should be opened, and the vesicated surface dressed in the usual way, or what I should prefer, with weak mercurial ointment. When the erysip- elas is seated on one of the extremities, a blister round the limb, OF THE ERYSIPELAS OF INFANTS. 159 on the sound skin, will frequently arrest its progress in that direc- tion. Blistering is most apt to prove useful, when the febrile ex- citement is moderate, the tongue moist, and the skin somewhat hot and tense. Of late years, the mercurial ointment has been a good deal employed in erysipelatous inflammation; and Dr. Dewees speaks favorably of its use in the present variety of the disease. In one instance under my care, its effects were obviously beneficial; but in the last case I witnessed, it did no good whatever. It should be applied, by spreading it on pieces of linen, and laying them over the whole of the inflamed part. Dr. Dewees directs, it should be applied only to the inflamed margin, and a portion of the surrounding sound skin, after the vesicles have opened, and the part has become covered with a crust of concrete serum. A weak solution of corrosive sublimate, also, has been frequently employed in this country, as a local application in erysipelas, and I have, in some instances, known it to produce very excellent effects. Three grains of the sublimate to an ounce of water, forms a solution of proper strength for this purpose. Pieces of linen moistened with it, should be laid over the inflamed part, and renewed from time to time, as they become dry, until the inflammation assumes a pale color. The external use of the nitrate of silver, also, will occasionally procure decided benefit in this disease. I have more frequently succeeded in subduing ery- sipelatous inflammation with this application, than writh any other remedy I have employed. The solution, in the proportion of five or six grains to an ounce of water, should be applied over the whole inflamed surface, by strips of linen, in the way just men- tioned. In employing this remedy, the persons about the patient should be informed, that it will give a black color to the skin; for without such premonition, the discoloration of the skin will be apt to be mistaken for mortification, and excite great apprehen- sion and anxiety of mind. A lotion composed of sugar of lead and sub-carbonate of ammo- nia—one drachm of each, and a pint of wrater, is highly recom- mended by Dr. Peart, as a local application in this disease.— Some of the English surgeons speak very favorably of an oint- 160 OF THE ERYSIPELAS OF INFANTS. ment formed of equal parts of ceratum calaminae, ceratum sapo- nis, and unguentum plumbi acetatis. The practice of making free incisions through the inflamed skin, and subjacent cellular and adipose structures, has recently been greatly extolled as a means for arresting the progress of phlegmonous erysipelas. Mr. Lawrence declares, that " these incisions are followed, very quickly, and sometimes almost instan- taneously, by relief, and a cessation of the pain and tension; and a corresponding subsidence of the inflammation almost always ensues. In twenty-four hours, the redness has usually disap- peared, and the skin itself is found wrinkled from the diminution of the general inflammatory tension. The immediate relief, al- though very desirable to the patient, is, however, of less conse- quence than the decided influence of the practice in preventing the further progress of the disorder; and this important result has never failed to occur within my experience, when the case has been a proper one for the practice, and the state of the patient has admitted of its being fairly tried." The incisions ought to he made in the early stages of the complaint, with a view rather of preventing the ultimate consequences of the inflammation, by giving exit to the blood and extravasated serum, than of evacua- ting the puss and sloughed cellular membrane. " It is when the action is beginning, has commenced, or is at its acme; when the heat is burning, the thirst ardent, the tension great, the pulse active, the pain acute, and the texture engorged with blood, that incisions are most apt to prove beneficial." Mr. Lawrence re- commends one long incision, extending from one boundary to the other of the inflamed part. Mr. Hutchinson, on the contrary, thinks it better to make a number of smaller incisions—about an inch or an inch and a half in length, through the skin and subjacent cellular structure. Mr. Lawrence and others have restricted this practice to phlegmonous erysipelas; but it appears from the experience of Dr. Dill, that it may be extended with advantage to other modifications of this disease. I am not aware that this practice has ever been tried in the erysipelas of infants. It is not improbable, that it might be re- sorted to in many cases of this kind, with much advantage. In- fantile erysipelas often presents a well-marked phlegmonous char- OF THE ERYSIPELAS OF INFANTS. 161 acter; and in such cases, if the situation of the inflammation were favorable, I should be much disposed to try the effects of the practice. When suppuration has taken place, an opening should be made into the most depending part of the cavity, so as to give free exit to the purulent fluid and sloughed cellular structure. If the mat- ter is suffered to remain confined, it will make its way between the muscles and tendons, destroying the cellular tissue as it pro- ceeds, until the patient sinks under the general irritation and exhaustion which it produces. When a portion of the inflamed part becomes gangrenous, and offensive ulcers occur, the char- coal poultice is perhaps the best application. A poultice made of crumbs of bread, and a strong decoction of oak-bark, with a small portion of yest, forms a valuable application, where the ulcers assume a phagedenic character. Y 15 162 SKINBOUND. CHAPTER XIII. INDURATION OF THE CELLULAR MEMBRANE AND SKIN. SKINBOUND. In private practice, this remarkable and very dangerous mal- ady is but seldom met with; but in lying-in and foundling hos- pitals, it is of very frequent occurrence. In the Hospice des Enfans Trouves, at Paris, 645 cases took place from 1808 to 1811;* and in 1826, there were 240 instances of it in the same institution.! On an average, one out of every twenty-five infants admitted into this hospital, become affected with this disease; and of those who are affected, not above twelve out of a hundred usually recover. In a vast majority of instances, the disease comes on within the first nine or ten days after birth. Mr. Billard states, that" nearly all the cases that occurred in 1826, in the abovenamed institu- tion, were in children of from one to eight days old, and some were affected from birth." Cases, nevertheless, sometimes occur at a much more advanced period of infancy. Mr. Andrews has recorded a remarkable instance, which occurred in a child eigh- teen months old; and I have seen a case in a child between the sixth and seventh month of age. In some respects, the disease is evidently closely allied to infan- tile erysipelas; and in others, it often manifests an obvious affinity to the convulsive affections. It usually commences on the lower parts of the body, particularly about the pubic region, and on the inner aspect of the thighs, and gradually spreads, becoming more or less conspicuous in different parts, until, in violent cases, the whole surface of the body becomes affected. The affected part is firm and incompressible to the touch, resembling the hardness and tension which occurs in phlegmasia dolens. The skin adheres so firmly to the indurated cellular tissue, that it cannot be pinched * Casper. Characteristick der Franzcesischen Medicine, p. 505. t Billard, Archives Generates de Medicine, Fev. 1827. SKINBOUND. 103 up or moved even where it is usually most loose. In some in- stances, it presents a yellowish or wax-like appearance, and in others, it is of a pale red or purple color. Those parts that are reddish or purple, are generally considerably swollen; yet the swelling does not pit, although firmly pressed on with the finger. When the skin has a pale yellowish appearance, the tumefac- tion is, in general, very slight; but the firmness and tenseness of the part is even greater than where there is lividness. The affected parts of the skin, whether pale or purple, are remarkably cold to the touch, and the surface generally is dry and harsh. The countenance is pale and contracted, and the little patient almost constantly " makes a peculiar kind of moaning noise," and appears to be unable to make a full inspiration and to cry out, from the restrained action of the thorax. Deglutition is generally very difficult, and sometimes wholly impossible. In some cases, tetanic spasms supervene, in the latter stage of the disease; the jaws become locked, and the head and trunk are sometimes rigidly bent backwards. The pulse is usually small, irregular and rapid; and the bowels are almost always disordered—the discharges being sometimes of a bright green, and others of a whitish or clay- colored appearance. The urine is generally freely secreted, although, in some instances, the reverse takes place. Mr. Billard asserts, that there are two distinct varieties of this disease. He considers one variety as depending wholly on the infiltration of coagulable serum into the cellular structure. Cases of this kind are characterized by considerable tumefaction of the affected parts, with a deep red or purplish color of the skin. The other variety, attended with a wax-like appearance of the skin, and but very little swelling, depends upon a hardening of the subcutaneous adipose substance without, and with but little serous infiltration into the cellular structure. The parts where the adi- pose hardening, and consequent tightness of the skin, are usually most conspicuous, are the cheeks, the thighs, the calves of the legs, and the back. On dissection, in cases of this kind, the adipose substance is found as firm and condensed as suet, and the skin contracted and firmly adherent to it. The variety of the disease which arises from serous infiltration, is,according to Mr. Billard's observations, "nothing else than true 154 SKINBOUND. oedema, altogether of the same nature with that which occurs in adults, affected with disease of the heart, or great blood-vessels." The hardness of the skin, he thinks, " is entirely owing to its being much less loose in early infancy than at a maturer age, and consequently yielding less readily to the pressure of the extra- vasated fluid." In making incisions into the indurated part, an abundance of serous fluid flows from the cellular structure; and Mr. Billard affirms, that when this is done at an early stage of the disease, the skin soon loses all its hardness. Very little of a satisfactory character has been brought to light with regard to the exciting or remote cause of this formidable complaint. It has been ascribed to the influence of cold, soon after birth; but its endemic occurrence in certain hospitals, does not favor this opinion. It is evident from this fact, that foul or deteriorated air must have a considerable agency in the produc- tion of the disease. In private practice, it is most commonly met with among the poor, who live in crowded and filthy habita- tions. Children who are nourished with artificial food, appear to be much more liable to the disease, than those who are nourished at the breast. In the Foundling Hospital in Paris, there are always a number of fresh nurses; and it has been observed, that whenever there is a deficiency of wet nurses in the institution, and the children are chiefly or entirely confined to artificial nour- ishment, the disease is most common. These facts, in connec- tion with the circumstance, that the bowels are often much dis- ordered, before the occurrence of the external affection, would seem to indicate that intestinal irritation, in co-operation with that depraved and irritable state of the system, which is apt to arise from breathing a contaminated air, constitutes a principal source of this malady. The causes of this disease differ, proba- bly, very little from those which give rise to infantile erysipelas. This affection is often attended with a condition of the skin very analogous to erysipelas; and we frequently find erysipelatous inflammation associated with considerable induration of the sub- cutaneous cellular tissue, for some distance beyond the inflamed margin. It occurs sometimes in the progress of other diseases— particularly in protracted affections of the bowels, accompanied with biliary disorder. The case related by Mr. Andrew was SKINBOUND. 165 preceded by a feverish and restless state, accompanied with diarr- hoea. The last case but one which I witnessed, was preceded for upwards of two weeks with loose and griping stools, a gen- eral irritated state of the system, and an obstinately dry skin. Hardening of the cellular structure and skin is frequently accom- panied by a jaundiced appearance of the surface. M. Billard states, that in the Parisian foundling institutions, " the most com- mon accompanying disease, is jaundice." On post mortem examination, the cellular tissue is generally found thickened, condensed, engorged with serum, and often of a dense, reddish, and granular appearance, "not unlike a portion of hepatized lung." In many cases, the adipose substance is peculiarly consolidated, with more or less infiltration into the cellular membrane. The lymphatic glands are frequently found indurated and enlarged, more especially those of the mesentery. Out of ninety cases examined by Mr. Billard, there were twenty that presented a decidedly morbid condition of the liver; and fifty, in which there was inflammation of the alimentary canal. In all the cases, there was " a very remarkable general conges- tion. The venous blood especially predominated in the different tissues." Mr. B. thinks that this congestion does not depend on mechanical obstruction in any point of the circulation, but is due to " a general superabundance of blood in the system, or a kind of congenital plethora." From the remarkable and unconquer- able dryness of the skin, there is evidently " some derangement of the capillary circulation;" and this morbid inactivity of the cutaneous exhalents, in conjunction with a general plethoric and irritative condition of the system, constitutes, perhaps, the imme- diate cause of cellular infiltration and tension of the skin. Treatment.—Although an extremely dangerous affection, this singular malady is not so entirely beyond the control of reme- dial treatment as was formerly supposed. Out of 645 cases which occurred in the Hospice des Enfans trouvSs, from 1808 to 1811, there were 78 cured; and the proportion of recoveries has of late years been considerably greater. Mr. Billard thinks that the opinion respecting its fatality, has arisen, in a great degree, from 15* 166 SKINBOUND. the circumstance of its being very frequently associated with other diseases of a dangerous character. The aqueous vapor bath is decidedly the most valuable remedy that has hitherto been recommended for the cure of this affection. As soon as the disease makes its appearance, the infant ought to be subjected to the vapor bath; and this should be repeated every three or four hours, until the skin becomes moist and soft, and the tightness and hardness has disappeared. The heat of the vapor should not exceed 105°; the most comfortable and salutary temperature being from 98 to 100 °. When the child is taken out of the bath, it should be wrapped up in warm and dry flannel, and laid in its bed. The simple application of warm flannel immediately to the skin, and frequently renewed, will sometimes bring on a gentle perspiration, and reduce the local oedema.* If no suitable apparatus for applying the vapor be at hand, the infant should be laid in its bed, and hot bricks wrapped up in wet pieces of flannel, placed a short distance from its body under the covers, supported by hoops or some other contrivance, so as to leave a free space for the accumulation of the vapor. Richter speaks very favorably of the effects of blisters in this complaint. When early applied to the affected parts, they may remove the sanguine- ous engorgement of the sub-cutaneous structures, and arrest the progress of the induration. The only instance of recovery which has occurred in my practice, was effected by the vapor bath, and blistering. The induration commenced on the anterior sur- face of the left thigh and groin. An epispastic was applied over the whole surface of the affected part, and suffered to lie about three hours, when it was substituted by a large emolient poultice. The tumor and hardness of the part were obviously diminished by the blistering, and they did not extend beyond the limits which they occupied when the blister was applied. As the liver and bowels are generally more or less disordered, minute doses of calomel, in union with ipecacuanna, as recommended in infan- tile erysipeias, may be employed with occasional advantage.— Some writers, indeed, look upon calomel as a remedy of indis- * In the foundling hospital at Florence, this disease is treated by the application of •xtemal heat, made by keeping the infant wrapped up in warm flannel, in conjunction with stimulating frictions. SKINBOUND. 167 pensable importance; and there can be no doubt, that when the disease is attended with prominent disorder of the liver, its influ- ence will often be highly salutary. In those cases that are accom- panied by a jaundiced appearance of the skin, mercurials are especially indicated, and can never with propriety be wholly ne- glected. It appears to me not improbable, that free incisions through the skin and subjacent cellular tissue would prove bene- ficial. The engorgement of the subcutaneous capillary vessels ought, perhaps, be removed in this way, and exit given to a portion of the infiltrated serum—effects which could hardly fail doing good, in certain cases of this complaint. The tepid or warm bath, which has been much recommended by some German wri- ters, appears to be much less beneficial than dry warmth, or the vapor bath; and it is even asserted, that warm bathing has fre- quently proved injurious. 168 OF CORYZA. CHAPTER XIV. OF THE CORYZA OF INFANTS. This disease was first described by Underwood, under the name of coryza maligna—an affection, which, he says, " is not only far more severe, but of a very different character," from the complaint which passes under the name of the " snuffles." Dr. Denman, who, afterwards, published a more ample and circum- stantial account of this malady, speaks of it as " a new and very peculiar affection." It appears to occur but very seldom; and it is doubtful whether it has ever been observed in this country. I have met with one case, which appeared, in many respects, to accord with the descriptions given of this complaint by Under- wood and Denman; but it was, probably, nothing more than an aggravated case of the common coryza from cold. It was at first supposed, that it never occurred in infants over a month old; but Underwood states, that he has seen instances of it at a much more advanced age. The disease is characterised by a purulent discharge from the nose, acquiring in some instances, a sanious character, attended with complete stoppage of the nostrils, and great difficulty of breathing, especially during sleep. The infant appears pale and languid, and a singular purple streak encircles the margin of the eyelids, which Mr. Denman was disposed to regard as pathogno- mic. There is usually " a general fulness about the throat and neck externally," which comes on soon after the purulent dis- charge from the nose commences. After these symptoms have continued for some days, the tonsils and fauces present a tumified and dark-red appearance, " with ash-colored specks upon them," terminating, in some cases, in extensive ulcerations. As the dis- ease advances, the infant declines rapidly in strength; and the breathing, often, becomes so difficult, that an attendant " is re. OF CORYZA. 169 quired to watch the little patient, in order to open its mouth as often as it may be requisite to prevent suffocation." The disease usually continues two or three weeks, and when it does not ter- minate in death, is very apt to leave a state of chronic indisposi- tion, attended with much disorder of the alimentary canal. — This appears to be a very dangerous affection. Denman states that of eight cases which he witnessed in the course of about a year, two, only, recovered. Dr. Underwood, however, observes that the cause of its frequent fatality, when it was first noticed, arose, rather from the true nature of the disease having been im- perfectly understood, than from any positive difficulty in control- ling its progress by remedial management. The disease appears to consist in a peculiar inflammatory affection of the mucous membrane of the nasal cavities, extending backwards to the fau- ces and, in some instances, descending into the stomach and bowels, giving rise to painful and exhausting diarrhoea. The alvine evacuations are frequently of a peculiar bluish or green color, par- ticularly after the employment of repealed purges. Mr. Hunter and Mr. Home examined the body of an infant that had died of this malady; but the only morbid appearance they discovered was a dark-red and highly injected state of the lining membrane of the nose. Treatment.—According to the experience of Dr. Denman, the employment of laxatives so as to keep the bowels freely open, and remove from them the acrid matter which descends into the stomach from the nose, constitutes " the grand means of cure." If this be not constantly attended to, painful and rapidly wasting diarrhoea almost invariably arises from the irritating fluid that is continually passing into the stomach. The free use of mucil- aginous drinks, also, will be beneficial in this respect. Harsh purgatives, however, are highly improper, as they could scarcely fail to produce almost as much irritation as the irritating cause which they are intended to remove. " One or more teaspoonfuls of castor oil should be given, every day, so as to procure three or four motions daily. It is remarkable, that even weak infants en- dure purging better under this complaint than under any other, unless it be the fever caused by painful dentition" (Underwood). 170 OF CORYZA. The employment of mild clysters also will be proper,—more espe- cially, when the lower part of the rectum becomes considerably irritated. Dr. Denman states, that he often derived much benefit from small doses of opium, or the syrup of white poppies. There can be no doubt of the great propriety of using narcotics in this affection, for it is evidently attended with an irritative state of the general system, without a very active inflammatory condi- tion, or a tendency to high febrile excitement. Dover's powders, given in small doses, would, probably, have a very beneficial effect, by allaying the morbid irritability and disposing to general diaphoresis. When the disease continues for several weeks, and " the infant becomes pallid and very feeble, a recourse to the de- coction of oak bark has at once removed the snuffling, and given vigor to the infant in the course of a few days." The sulphate of quinine would, doubtless, be a useful remedy in cases attended with much debility and exhaustion. The disease sometimes as- sumes a chronic character, and continues four or five weeks, and occasionally for several months. Such cases are apt to be attended with occasional attacks of spasmodic respiration," as if the infant were dying." This symptom, " as well as the snuffling often recurs some time after the child seemed to be cured:" and even the purulent discharge from the nose, may recur from time to time, after the disease appears to have been wholly subdued. In cases of this kind, Underwood, besides purging, recommends fo- menting applications to the bridge of the nose; and "afterwards to apply some aromatic liniment." The application of a few leeches to the root of the nose would, perhaps, be beneficial in the early as well as in this advanced stage of the disease. There appears to be some risk in using vesicatories in this affection; for Underwood observes, that " the parts on which blisters had been laid in the beginning, and which had been-apparently heal- ed, often sphacelated towards the conclusion." APHTHA OF INFANTS. 171 CHAPTER XV. OF THE APHTHAE OF INFANTS. THRUSH. This is one of the most common diseases of infancy. It is characterised by a peculiar eruption of minute pustules, giving rise to a whitish incrustation of the tongue, and lining membrane of the mouth and fauces. The aphthae sometimes make their appearance without any previous symptoms of general indisposi- tion, or disorder of the alimentary canal. Much more frequently, however, symptoms of disorder of the stomach and bowels, associ- ated with manifest languor and drowsiness, precede the occurrence of the aphthous affection. The aphthae usually appear, first, on the inner surface of the angle of the lips, and about the tip of the tongue, in the form of white specks, resembling small flakes of co- agulated milk. From these parts, the eruption spreads, more or less rapidly, until, in some instances, a continuous aphthous crust is formed, over the whole surface of the tongue, mouth and fauces. In many cases, however, the eruption is much less extensively dif- fused, the aphthae occurring only on the tongue, and central parts of the cheeks; and we occasionally find them scattered in small patches with intervening spaces, over the lining membrane of the mouth and surface of the tongue. In these mild cases the infant seldom experiences any particular uneasiness or disturbance from the local aphthous affection; but when the eruption is extensive, it rarely fails to give rise to more or less suffering and disorder in the system. In cases of this kind, there is, generally, much thirst, restlessness, languor, acid and flatulent eructations, loose, green, and griping stools, drowsiness, pain, and difficulty of sucking, and a copious flow of saliva and mucus from the mouth. The skin is usually dry and harsh; and, in the severer instances of the disease a slight degree of febrile irritation often occurs. The stomach and bowels are almost always prominently disordered in such 172 APHTHA OF INFANTS. cases. The infant is apt to vomit after taking any thing into its stomach, and the milk is generally thrown up, in the form of firm coagula. Profuse watery diarrhoea frequently ensues, and the lit- tle patient is greatly harassed by sour and offensive eructations, griping and colic pains, and tenesmus from the extremely sensible and excoriated condition of the margin of the anus. Under these symptoms emaciation and loss of strength go on rapidly; the child's countenance becomes pale, sunken, and expressive of much suffering and uneasiness. The difficulty of swallowing increases, and at last sometimes becomes altogether impossible. The abdo- men is always sore to the touch, in cases of this violent character, and frequently much distended and tympanitic. If the disease is not arrested, the infant, at length, dies in convulsions, or in a state of stupor and insensibility, resembling the last stage of hydroce- phalus, or from exhaustion. In mild forms of the disease, the aphthous eruption continues of a white or yellowish color throughout; but in severe cases it soon acquires a dark brownish color, and instead of being soft and humid, as in the ordinary instances, it often becomes dry and harsh, as the disease advances. It is generally believed, that the aphthae frequently extend from the mouth, throughout the whole tract of the alimentary canal. Dr. Dewees is disposed to doubt whether such an extension of the eruption does ever occur. He is inclined to believe that it never passes lower down than to the cardiac ex- tremity of the oesophagus. In examining the body of an infant that had died from aphthae, he found "the whole tract of the oeso- phagus literally blocked up with an aphthous incrustation to the valve of the cardia, where it suddenly stopped. Not a trace of aphthae was discovered below this place." 1 have myself had an opportunity of examining the body of an infant, that had died of this disease. In this case, the aphthae were very distinct through out the whole course of the oesophagus. The stomach and bow- els presented nothing that bore any resemblance to this eruption; but there were decided marks of inflammation in the mucous mem- brane of the small intestines, with a vast number of minute super- ficial ulcerations, and larger patches of softening of this tissue, throughout the colon, and lower part of the rectum. The mucous membrane of the alimentary canal, doubtless, always becomes APHTHA OF INFANTS. 173 more or less diseased in the severer forms of this malady. It is probable, however, that the minute pustules, which give rise to the aphthous incrustation on the more dense mucous membrane of the mouth and. oesophagus, terminate speedily in superficial abrasion, or ulceration, in the delicate mucous tissue of the stom- ach and bowels. In the case which I examined, these minute ul- cerative points were very obvious in several portions of the large intestines. The excoriation of the anus, which is generally re- garded as an evidence that the aphthous affection has passed throughout the whole extent of the alimentary canal, arises, per- haps, solely from the irritation produced by the acrid discharges from the bowels. Tenderness and excoriation of the anus is by no means an uncommon consequence of acrid diarrhoeal discharges. The duration of this affection is very various. In slight cases, the aphtha? disappear in a few days, without any unpleasant con- sequences. In some instances, the aphthous eruption continues for several weeks, without becoming very severe, or causing any material deviations from health. Sometimes, the aphthous crust falls off, and is soon succeeded by another one; and these separa- tions and renewals of the eruption, may occur three or four times, in the course of the malady. " The oftener the crust is renewed, the worse it becomes, for each new eruption is usually thicker and less white, than the preceding one." When the crust falls off, it exposes a smooth, red and slightly excoriated surface. The cav- ity of the mouth is always unnaturally hot, and the affected parts are, in general, very sensible and painful when pressed on or touched. Infantile aphthae very rarely occurs a second time in the same infant—at least as an idiopathic affection. It may, indeed, recur frequently, at every stage of life, as a symptomatic effect of other diseases—particularly in the advanced stages of protracted mala- dies attended with irritation of the alimentary canal. But it is ex- tremely doubtful, whether these secondary or symptomatic affec- tions are identical in their character, with the usual aphthoe of infancy. Some writers affirm that the disease is very rarely, if ever, at- tended with fever; whilst others declare that the occurrence of febrile irritation in this complaint, is very common. Hecker di- 16 174 APHTHA OF INFANTS. vides the aphthae of infants into three varieties. His second vari- ety, which he affirms is very common in Germany, is always at- tended with decided febrile symptoms; and he thinks that the dis- ease is closely allied in its nature, to the exanthematous fevers. It commences with manifestations of lassitude, restlessness, drow- siness, and much thirst. The child seizes the nipple eagerly, but immediately leaves it again, and cries, as if the effort of sucking gave it much pain. The cavity of the mouth is hot, dry, red, and very sensible. The child is apt to vomit; frequent watery, green, and painful alvine discharges occur, and the urine becomes scanty, the pulse is accelerated, and the skin preternaturally warm and dry; the voice becomes rough and slightly hoarse; and finally, after these symptoms have run on for three or four days, the aph- thous eruption makes its appearance. Dr. Hecker asserts, that when the disease occurs epidemically, it almost always assumes this febrile character, assuming, in some degree, the regular pro- gress of an exanthematous fever. According to my own observa- tions, the ordinary simple cases of the disease are invariably with- out the slightest manifestations of fever. When the eruption is extensive, however, and there is much disorder of the alimentary canal, slight febrile symptoms are certainly often developed. I am at present attending an infant severely affected with this com- plaint. The aphthous crust extends over the whole surface of the tongue, mouth, and fauces, and from the manifest pain on swal- lowing, probably passes down to a considerable distance into the oesophagus. This child is in a decidedly febrile condition; although before the aphthous eruption appeared, its general health seemed to be good. The febrile symptoms that occasionally attend the ordinary forms of the disease, depend, probably, chiefly on the inflammatory irritation which is apt to occur in the alimentary canal, and are wholly accidental. In hospitals, this disease sometimes assumes a highly dangerous character. In the French foundling institutions, it is said to carry off a great many infants. In these malignant cases, the aphthous crust soon becomes thick and of a dark brown color. When it falls off, it leaves a number of yellowish-brown ulcers, of a corrod- ing character. The diarrhoeal discharges are green, and extreme- ly acrid, and the vital powers sink very rapidly. Is the aphtha? APHTHA OF INFANTS. 175 01 thrush of infants a symptomatic or an idiopathic affection? The general opinion appears to be, that it is altogether symptom- atic—occurring as an accidental consequence of gastro-intestinal disorder. Dr. Dewees, expresses himself in a very ambiguous, or rather contradictory manner, on this point. In the beginning of his chapter on this disease, he says, " that this affection is one of a symptomatic kind—rarely, perhaps never, idiopathic;" yet in a subsequent paragraph, he observes, " the opinion so commonly credited, of its being a symptomatic affection, is very questiona- ble;" and then goes onto give a number of " facts," which he says have "lately" led him "to question the sympathetic origin of aphtha?." Nevertheless, the very next paragraph commences in these words: "This symptomatic affection is not confined to early infancy." The fact is, the arguments which led the Doctor to doubt the correctness of his opinion, that the disease is purely symptomatic, would have convinced him of its entire erroneous- ness, if he had not viewed them through the medium of a contrary sentiment long and thoroughly entertained. It takes a powerful battery of " facts" to knock down an opinion that has become firm by age. For my own part, I am well satisfied that the disease, as it occurs in early infancy, is of a peculiar and strictly idiopathic character; although an aphthous affection of the mouth may, and often does, occur at every stage of life, as a symptomatic or sec- ondary phenomenon of other forms of disease, or morbid condi- tions of the digestive organs. We see this often, in the last stage of phthisis pulmonalis, and in nearly all protracted diseases of a febrile and exhausting character, as they approach a fatal termin- ation. It is, also, frequently observed in children, as an attendant on other maladies; particularly such as are attended with disorder and inflammatory irritation of the alimentary canal. If the aphthae of infants were a purely sympathetic affection, depending on disorder or irritation of the alimentary canal, it could of course never take place without the previous occurrence of gastro-intestinal disorder. Cases, however, do occur, in which no obvious signs of derangement of the digestive or intestinal functions can be noticed. Dr. Dewees states that he has seen two instances, in which the alimentary canal "was in the most perfect order; and I have, certainly, witnessed several cases which i 176 APHTHA OF INFANTS. were entirely free from any manifestations of disorder of the stom- ach and bowels. It may be presumed, too, that were the disease symptomatic in its origin, derangement of the alimentary canal would be much more frequently associated with aphthae, than it is known to be. At every period of life, from early infancy to ad- vanced age, disorder and irritation of the stomach and bowels oc- cur very frequently, and pass through every grade of violence, without giving rise to aphthae. Mere disorder or irritation of the alimentary canal, is very rarely productive of aphthous eruptions in the mouth, unless it be connected with a chronic form of febrile irritation, and general exhaustion. In infantile aphthae, however, the child often appears to enjoy good health, up to the time when the aphthae make their appearance; and in mild instances, there is frequently no material indisposition during the continuance of the aphthous eruption. This, I believe, never occurs in the aph- thous affections which take place at a more advanced age. These cases are always, unequivocally, connected with serious general maladies, and seldom occur, until the diseases of which they are symptomatic phenomena, have acquired a highly dangerous, if not a necessarily fatal degree of violence. The circumstance, how- ever, which seems most clearly to shew that infantile aphthae is a peculiar idiopathic affection, is the fact, that infants who have passed through the disease, very seldom become affected with it a second time, although the stomach and bowels may become re- peatedly disordered, and remain so, during the subsequent period of infancy and childhood. We often see infants affected with aphthae, previous to the third month, with xery little disturbance in the alimentary canal; yet they will not become affected with it again, although they may afterwards be repeatedly and long harassed by disorder of the stomach and bowels. The circum- stance, too, that this affection is almost wholly confined to the age of infancy, would appear to indicate that there is an essential pe- culiarity in its character and mode of origin. If it were an acci- dental sympathetic phenomena of gastro-intestinal irritation, with- out any specific peculiarity in its nature, we should expect to meet with it at every period of life, instead of seeing its occurrence almost entirely restricted to a particular stage of childhood. The occasional appearance of this iriTantile malady in an epidemic APHTHJS OF INFANTS. I77 manner, is also manifestly opposed to the idea of its being a purely symptomatic affection. In some foundling hospitals in Europe, it has frequently prevailed endemically for a season; an occurrence which could not, with the slightest plausibility, be ascribed to any disorder of a symptomatic character. In mild cases, the aphthous affection may often be speedily removed, by local ap- plications to the mouth, alone; and occasionally, even severe in- stances will yield to remedies of this kind, without the employ- ment of any thing for improving the general health, or correcting the morbid condition of the alimentary canal (Dewees.) From a xiew of the foregoing considerations, the idiopathic character of infantile aphthae can, I think, hardly be doubted. It is very manifest, however, that disorder of the stomach and bowels, con- tributes very materially to the production of this disease, either by creating a predisposition to it, or by exciting the latent ten- dency in the infantile system to its occurrence. Feeble and sickly children scarcely ever escape this disease; and they are much more apt to become severely affected with it than those who are of a robust and healthy habit of body. What- ever is capable of disordering the stomach and bowels, may be regarded as an exciting cause of the disease. Unwholesome and indigestible nourishment, and over-distention of the stomach, during the early stage of infancy, almost inevitably lead to the occurrence of aphthas. Bad and old milk, and thick farinacious preparations sweetened with brown sugar or molasses, are espe- cially apt to give rise to the disease. Inattention to keeping the infant's mouth clean by occasionally washing out the sordes with a soft piece of linen and fresh water, and particularly the nau- seous practice of permitting the child to suck portions of food tied up in a piece of cloth in the form of a nipple, contributes greatly to the production of the aphthous eruption. Breathing an impure and deteriorated air, also, appears to have a decided tendency to favor the occurrence of this malady. Children who are kept in crowded and ill-ventilated apartments, or who are suffered to sleep much under the bed-clothes, are especially lia ble to become affected with it. The occasional great prevalency and fatality of the disease in foundling institutions, doubtless arises, in part, fiom this cause. When improper nourishment co- 2 A 16* 178 APHTHE OF INFANTS. operates with foul air, the disease is apt to acquire a highly dan- gerous character. It has been supposed that the apthae of infants is often propagated by a specific contagious virus. Dr. Good is of this opinion, and refers, as some of the German writers do, to the excoriations, which frequently occur on the nurse's nipples, when the nursling is affected with aphthae. There is evidently i very acrid and irritating fluid discharged from the minute pus- tular eruption, which occasions the aphthous crust; and when the nipples are tender, they can scarcely fail to become more or less inflamed and excoriated, by the impressions of this acrimonious Becretion. In hospitals, where several infants often suckle the same nurse in succession, it is not improbable that the occurrence of the disease may sometimes be favored in this way. The natu- ral predisposition to the disease, appears to be much stronger in some families than in others. In my own, consisting of eight children, this affection has never occurred, although all of them suffered from the usual stomach and bowel complaints of infancy. Treatment.—As the alimentary canal is almost invariably more or less deranged in the aphthae of infants, a principal object in the treatment must, of course, Jbe to remedy the disordered con- dition of the stomach and bowels. In general, the ejections from the stomach are sour, and the alvine evacuations of a grass-green color. When this is the case, magnesia, with small portions of rhubarb and powdered valerian, will generally prove very bene- ficial. I have more frequently derived decided advantage from this mixture, than from any other mode of administering magne- sia. From three to four grains of magnesia, with two grains of rhubarb, and one grain of powdered valerian, should be given every two or three hours, until the bowels are freely evacuated. If there is much general irritability and restlessness, the tepid bath, followed by a drop or two of laudanum, should be employed after the magnesia has operated on the bowels. The mucous mem- brane of the intestines is apt to become highly irritated in severe cases, after the aphthous eruption has continued for some days. The alvine evacuations, in such instances, become very frequent, small, watery, with occasional streaks of blood, and painful; and the margin of the anus red and extremely sensible. In cases of APHTHA OF INFANTS. 179 this kind, a large emolient poultice over the abdomen, in con- junction with the internal use of minute portions of Dover's pow- der, with a solution of gum arabic as drink, has frequently proved highly beneficial in my practice. Dr. Dewees speaks very fa- vorably of the oil of butler, when the bowels are much irritated. " The oil of butter is prepared by putting a lump of perfectly sweet butter into a cup, and pouring on it a quantity of boiling water, and agitating it well with a teaspoon, that it may be de- prived of its salt—the oil is then skimmed off, as it is wanted. A teaspoonful may be given three or four times daily." I have used this oil in a few instances, but it did not appear to answer quite so well as a pretty thick solution of gum arabic, given in teaspoonful doses at short intervals. Magnesia, and other purga- tive remedies, seldom fail to do harm in cases attended with much intestinal irritation. In a few instances of extremely obstinate aphthae, accompanied with frequent irritating stools,and an exco- riated state of the anus, I have procured marked benefit from a very weak solution of the nitrate of silver. Incompatible as the article may seem to be with a highly irritated state of the mucous membrane of the bowels, it nevertheless often exerts a very soothing effect on this tissue, when under peculiar forms of irrita- tion. I have given about half a teaspoonful of a solution of a grain of this article to two ounces of water, every four hours, to infants between two and six months old, with unequivocal advan- tage, and without the slightest aggravation of the sufferings of the patient. In cases attended with much acid in the stomach, without a great deal of intestinal irritation, or diarrhoea, lime- water, with a weak infusion of peruvian bark, usually produces an excellent effect. When the acidity of the primae viae is accom- panied with free diarrhoea, without any symptoms of inflammatory irritation of the bowels, prepared chalk, in union with minute portions of Dover's powder, generally proves decidedly useful. From four to six grains of the chalk, with the fourth of a grain of Dover's powder should be given every two or three hours, until the diarrhoea is checked, and the discharges assume a more natu- ral color. I have given powdered borax internally in aggrava- ted cases of infantile aphthae, with very decided advantage. There is nothing in this article that forbids its internal employment 180 APHTH.E OF INFANTS. The Germans use it frequently in this way; and I have, myself, often resorted to it, in bov el complaints, with evident benefit. In the present disease, I am persuaded that it may be given inter- nally, with peculiar advantage, in the severer forms of the com- plaint accompanied with frequent irritating diarrhoeal discharges. I have been in the habit of applying large fomenting poultices over the abdomen, in cases of an aggravated character; and I am satisfied that this application is capable of doing much good. When the disease runs on for a long time, and the little patient becomes much exhausted, mild tonics and stimulants should be employed to support the system. Weak wine whey—infusion of cinchona, or a weak solution of quinine, in moderate portions, may be resorted to for this purpose. If the infant is not weaned, it should receive no other nour- ishment than its mother's milk. If it is nursed with artificial nourishment, nothing but the most bland alimentary prepara- tions ought to be used. A solution of gum arabic, cow's-milk and water, barley-water and weak chicken or beef tea, form proper articles of food for this purpose. If the child is nourished at the breast, an attention to dietetic regulations on the part of the mother, is believed to be of considerable importance. She ought to avoid the ordinary articles of vegetable food, as they favor the generation of acid in the primae viae. All kinds of spirituous and fermented drinks, too, have an unfavorable ten- dency, and ought to be particularly avoided. The more digesti- ble meats, soft-boiled eggs, rice, stale bread or crackers, fresh butter, with weak tea or coffee, constitute appropriate articles of nourishment in cases of this kind. Local applications are generally highly serviceable, and in slight cases, are, by themselves, often sufficient to remove the disease in a few days. Borax is a familiar remedy with nurses and mothers, as well as with the profession, for this purpose; and it is doubtless the most valuable article we possess, as a local remedy in this affection. It may be used in the form of powder or solution. If the former is employed, two or three grains of it, mixed with a small portion of pulverized loaf-sugar, must be thrown into the mouth every two or three hours. If the solution be usea, a drachm of the borax should be dissolved in two ounces APHTHiE OF INFANTS. 181 of water. This may be applied to the mouth, with a soft linen rag, tied to the extremity of a pliable piece of whalebone or wood, or with a soft feather. The powder, however, is the most con- venient mode of applying this remedy. In making local applicat tions, care should be taken that the aphthous crust be not rudely rubbed off. This always causes much pain to the infant; and is calculated to increase the inflammation and keep up the dis- ease. The practice of forcibly rubbing off the aphthous erup- tion with a piece of linen, on the point of a finger—so common with ignorant nurses, is extremely reprehensible. Nothing can be gained by this rude and painful treatment, and much mischief may readily result from it to the little patient. When rubbed off in this way, the crust is, almost always, soon renewed in an aggravated form, and the irritation in the mouth is generally much increased. So long as the aphthous incrustration remains white, the borax may be deemed the most efficient local remedy. When the eruption assumes a yellow or brown color, however, it frequently fails to do any decided good. In such cases, Dr. Dewees generally employs " the armenian bole, in fine powder, with loaf sugar," small portions of which mixture, are, from time to time, thrown into the mouth, as directed above for the borax. "Should this fail," he says, "to give pretty speedy relief, and particularly if the mouth be very red, livid or ulcerated, we then have recourse to a weak decoction of bark." A half ounce of powdered bark, boiled about thirty minutes, in half a pint of water, forms a proper decoction for this purpose. "About the third of a teaspoonful of this is put into the child's mouth, every hour or two." I do not doubt that these remedies are capable of procuring much relief in cases of tnis kind. Instead of the armenian bole, however, I prefer using a weak solution of the nitrate of silver, in the proportion of a grain to an ounce of water, and applying it with a soft piece of linen fixed to the end of a thin piece of whalebone. Nothing need be apprehended from the introduction of a small portion of this fluid into the stomach. On the contrary, its effects on the morbid condition of the mu- cous membrane of the alimentary canal, are often decidedly salutary in cases of this kind. A decoction of oak-bark, par- 182 APHPH.E OF INFANTS. ticularly where there is much diarrhoea, will sometimes produce a very good effect as a local remedy. As the acrid alvine discharges are very apt to inflame and excoriate the parts about the anus, constant attention should be paid to keeping these parts as clean as possible. The nates should be frequently washed with tepid milk and water, or with flax-seed tea; and after they are carefully dried, fresh lard should be applied over the irritated parts, to afford them some degree of protec- tion against the impressions of the acrid evacuations. When the inflammation and sensibility of these parts become very se- vere, they should be occasionally, washed with a weak solution of sugar of lead, mixed with proper portions of a watery solu- tion of opium. ULCERATION OF THE MOUTH. 183 CHAPTER XVI. ULCERATION OF THE MOUTH. CuiLnitEN are liable to an ulcerative affection of the mouth, which is evidently, entirely distinct in its origin and character, from the ordinary aphthous eruption. It consists, in a numoer of small ash-colored and excavated ulcerations, with elevated edges, situated about the froenum, and along the inferior margin of the tongue, the gums, and on the cheeks. The ulcers usually begin in the form of small, red, slightly elevated and painful points. At first they are superficial, and occasionally even somewhat raised above the surrounding skin; but in the course of a day or two, the edges rise up, and the ulcerated surface becomes con siderably excavated. When the ulcers appear on the upper sur face of the tongue, which, however, occurs but seldom, they are generally quite superficial, appearing more like excoriations than actual ulcerations. The disease commences with slight symptoms of febrile irrita- tion. The child manifests some degree of lassitude and restless- ness. The skin becomes warmer and dryer than natural, the pulse somewhat accelerated and sharp, the bowels usually cos- tive; there is generally much thirst; the tongue is coated with a thin white fur, over which, a thick layer of transparent slime is pread, and there is a constant profuse discharge of saliva and mu- cus from the mouth. The mind and body are peculiarly irrita- ble. The child is generally exceedingly fretful and uneasy, "espe- cially when it is about to take the nipple, which it frequently seizes, and then lets go, with a whining cry as if in pain." The febrile symptoms usually continue for two or three days, and often much longer, before the ulceration commences. After the ulcers are formed, however, and the slavering is profuse, the fever generally subsides. In some instances the ulceration of the gums and J 84 ULCERATION OF THE MOUTH. cheeks becomes very extensive. In cases of this kind, a slow, ex- hausting fever is apt to occur, which generally renders the man- agement of the complaint very difficult. I have met with two cases of this disease, in which the gums were almost entirely de- stroyed. In one of them, the whole inferior maxilary bone was at length deadened and separated, and was removed by Dr. McLellan. These aggravated instances of the complaint, are fortu- nately not common, and the disease is, in general, easily managed when early attended to. This affection is almost always associated with weak or disor dered digestive functions, and a bloated and torpid state of the bowels. Children whose breath is offensive, with a variable ap- petite, and a tumid and hard state of the abdomen, are most lia- ble to this complaint. The irritation of dentition, doubtless, con- tributes, in some degree, to the production of the disease; but the primary source of the complaint, appears to be located in the alimentary canal. Treatment.—Purgatives are highly useful remedies in this com- plaint. The bowels should be freely evacuated, though not with harsh or very active purges. A small dose of calomel, followed, in the course of four or five hours, by a suitable dose of castor oil, will answer this purpose very well. The oil without the calomel, or a proper dose of magnesia, should be repeated daily, until the febrile symptoms are subdued. Even where no fever is present, mild laxatives are highly useful, more especially, if the abdomen be full and somewhat tense. I have known much benefit de- rived, from the use of a few mild emetics in cases of this kind. When the breath is offensive, and there is a tendency to nausea and vomiting, the exhibition of an ipecacuanna vomit, will fre- quently do much good. In a case of a severe character, which I saw, about a year ago, I ordered five grains of ipecacuanna, with two grains of calomel. Active vomiting was induced, and three or four alvine evacuations followed. On the following morning, the child's mouth was evidently better; and it continued to im- prove rapidly. The tepid bath, and gestation in the open air, if the weather be mild, will often aid considerably in arresting the local ulcerative affection. After the operation of a purgative, ULCERATION OF THE MOUTH. 185 the general irritability of the system should be allayed, by a few drops of laudanum, or one or two grains of Dover's powder. In using calomel in this affection, great care ought to be taken, lest it affect the giims—an occurrence, which could hardly fail to im- part a dangerous character to the ulcerations. When the febrile irritation is subdued, much advantage maybe procured from local applications. A solution of the sulphate of copper, mixed with a portion of honey, will generally soon im- prove the appearance of the ulcers, and hasten their healing. Ten grains of the sulphate should be dissolved in about three teaspoon- fuls of water, to which four teaspoonfuls of honey must be added. This solution must be applied to the ulcers, once or twice daily, by means of a strong camel's hair pencil. Dr. Dewees advises the addition of two drachms of powdered bark, and a drachm of powdered gum arabic to this solution; but I have not found it to answer better, than the simple solution I have mentioned. Touch- ing the ulcers, with a solution of the nitrate of silver, also, is an excellent local remedy. In several very severe cases, 1 obtained more decided benefit from this application than from the sulphate of copper. In slight instances of the disease, a strong decoction of oak bark, with a small portion of alum dissolved in it will gen- erally suffice to arrest the progress of the ulcers, and dispose them to healing. I have derived evident benefit, in cases of this kind, from the internal use of small portions of powdered charcoal. The diet should be particularly attended to. If the child ia still nourished at the breast, its mother's milk is doubtless the best nourishment. If it has been weaned, however, nothing but the simplest and mildest articles of food should be allowed. If, how- ever, the child has been previously, almost exclusively nourished by farinaceous aliment, it will in general be useful to change it, in part, for beef or chicken tea, or very light and simple broths. Solid food must on no account be allowed; more especially salted meats or fish. Dr. Underwood has described a variety of ulceration of the mouth, under the name of Aphtha gangrenosa, which appears to dif- fer materially from the preceding affection. It seldom oocurs in children under two years old, and has been but rarely noticed after the ninth year of age. It usually commences with a swollen 2 B 17 180 ULCERATION OF THE MOUTH. spongy and dark-colored condition of the gums, attended by "great tenderness of the inside of the cheeks and mouth." In the course of a day or two, small dark-colored ulcers appear on "the gums, the inside of the lips and upon the tongue;" and oc- casionally, ulcers of the same appearance occur on the tonsils and uvula. "Asthe disease proceeds, the cheeks become slightly tu- mefied, and are very tender when touched; and there is often an unusual redness upon that portion of the skin which covers the lower jaw." The tongue is covered with a thick yellowish brown fur, becoming darker as the disease advances, and the teeth are apt to become covered with a black sordes. The breath be- comes extremely offensive after the ulceration has made some progress. There is usually a very copious flow of saliva from the mouth. There is from the commencement of the complaint con- siderable febrile irritation. The child becomes languid and fee- ble, the pulse small and quick, and the skin very warm and dry; the appetite is impaired, but the little patient often sleeps well, and at times appears cheerful and disposed to amuse itself with play. The disease may continue for a period of from two to five or six weeks. Dr. Dewees says that this variety of ulceration of the mouth, occurs only, when children are cutting teeth, particularly when a number of back teeth, are about making their appearance at the same time; and this accords entirely, with my own observations. It is a disease of the gums, arising from cutting the last of the first set of teeth—it therefore never attacks after this process (primary dentition) is completed; or at least not until the teeth of the 6econd dentition are about to appear. The gums at first swell and become dark red and very tender. In the course of two or three days, "the parts of the gums immediately over the teeth about to be protruded give way by ulceration to a greater or less extent" (Dewees.) This disease, though of an alarming appearance, is by no means a dangerous affection. In children of a sickly and scor- butic habit of body, however, it sometimes becomes very trouble- some, and resists, for a long time, the usual remedial applications in diseases of this kind. The swollen parts of the gums ought to be divided down to the advancing teeth; and the child's mouth OF COLIC. 187 frequently washed with a strong decoction of peruvian bark. I have used a solution of the chlorite of lime, with a most excellent effect in several severe instances of this affection. I dissolved a drachm of the chlorite in six ounces of water, and applied it with a soft piece of linen tied to the end of a probe. A decoction of oak bark too, with or without a small portion of alum forms an excellent application. CHAPTER XVII. OF COLIC. There are very few infants who do not suffer more or less from colic pains. In many instances, indeed, they are so slight and transient, that they require no particular remedial attention. Very frequently, however, they become extremely harassing, re- curring often, and with great severity, during the first five or six months of infancy. In some cases, these painful attacks occur several times daily, at uncertain intervals; and in others, they come on at regular periods, assuming a distinctly periodical progress. In slight cases of colic pains, the infant suddenly becomes very fretful, draws up its legs towards the abdomen, and whines or cries for a few moments and then resumes its usual quiet condi- tion. After a very short interval of rest, another attack, of the same kind occurs, and again soon subsides; and thus, it will go on, with alternate spells of crying and quietude, until a volume of wind breaks from the stomach or bowels, or a thin fcecal dis- charge takes place, when entire relief ensues. In many cases, however, these manifestations of suffering are much more vehe- ment and distressing. There is excessive, long-continued and un- appeasable screaming, forcible drawing up of the legs, or violent kicking, flushing of the face, and various writhings of the body 188 OF COLIC. with a distended, tense and tympanitic state of the abdomen. In the majority of instances, these attacks are associated with habit- ual symptoms of indigestion and disorder of the bowels—such as acid eructations, flatulency and diarrhoea. The stools are fre- quently of a grass-green color, or slimy, and occasionally mixed with portions of imperfectly digested food. In some cases, how- ever, the alvine discharges are neither too frequent nor of an un- natural appearance, although the infant almost daily experiences severe paroxysms of colic. The breath often has a peculiarly acid smell, and when vomiting occurs, which, however, is not often the case, the milk, if the child is nourished at the breast, is thrown off in dense coagulated masses. When the colic pains come on frequently, and are attended with prominent symptoms of indigestion and diarrhoea, the general health of the infant al- most always suffers obvious derangement. The child becomes pale, feeble, and fretful, and does not thrive. Sometimes, how- ever, the appetite remains good, and although the child suffers frequent and very severe attacks during a period of two or three months,yet no inroads appear to be made on its general health,and it goes on thriving, as if it were in every respect perfectly healthy. This is most apt to occur in those instances, where the paroxysms of colic recur at regular intervals, or in a periodical manner. This form of the complaint, is seldom connected with any decided manifestations of indigestion; and instead of being attended with loose and griping stools, it is very generally accompanied by con- stipation or slowness in the action of the bowels. Dr. Dewees states, that the paroxysms, usually, occur between four and six o'clock in the afternoon; but in this respect, I have not noticed any particular uniformity in the cases that have come under my own observation. I have known the attack to occur, regularly at a particular period in the forenoon; and I have recently pre- scribed for a case in which the paroxysms, uniformly came on between one and two o'clock every night. There evidently exists a very material difference between these periodical cases, and the ordinary irregular form of the complaint The latter appear to depend on a dyspeptic condition of the ali- mentary canal, and are manifestly greatly under the influence of diet and other causes capable of producing weakness or irritation OF COLIC. 189 of the digestive organs. The immediate cause of the colic pains, in the majority of cases, appears to consist in violent flatulent distention and irritation of some portion of the bowels. That this is the case seems very obvious from the drum-like distention of the abdomen which usually occurs during the paroxysm, and from the relief which almost always follows the free discharge of wind from the bowels. The foundation for this painful affection is frequently laid during the first two or three days after birth. The extremely reprehensible practice of filling the infant's stomach with artificial food immediately afterbirth, before nature furnishes the appropriate nourishment, is, I am persuaded, a very com- mon source of this distressing complaint. The child's stomach is thus often, in the very beginning of life, thrown into a state of irritation and feebleness—so that even the congenial nutriment afforded by the maternal breasts, will pass into the bowels in an imperfectly digested state, and give rise to acid and flatulent disten- tion of the intestines. The exhibition of active purgatives, for the removal of the meconium, also, is well calculated to originate this complaint. After the digestive organs have once been brought into a state of irritation or functional derangement, the mildest and most appropriate nourishment, will not be properly digested; and this state of things must almost necessarily continue until the digestive energies have acquired a considerable degree of devel- opment; for the acid and flatus which are generated in conse- quence of the weakened condition of the stomach tend continual- ly to keep up the deranged state of the digestive functions. Thus when the delicate stomach of the new-born infant is overloaded with any of the usual alimentary preparations, it can scarcely es- cape being, in some degree, weakened and irritated. The very first nourishment which the child afterwards draws from its mother's breast, will, probably, not be duly digested. Acid and wind will, therefore, be generated. These morbid products become additional causes of irritation and disorder of the digestive organs, and thus the complaint, generating as it were its own cause, may go on, for many months, however mild and fitting the nourishment may be. I know from repeated experience, that infants who re- ceive no aliment, or only small portions of suitable nutrient fluids, until the appropriate nourishment is supplied by the maternal 17* 190 OF COLIC. breasts, will, in general, be much less liable to colic and griping pains, during the first two or three months of infancy, than such as are gorged with food, in the usual way, soon after birth. When the digestive organs are thus early disordered, the colic pains usually commence within three or four days after birth. The stools become frequent, green, watery, or curdled, and very pain- ful, and in most cases, aphthae supervene, before the end of the second week. In general, errors ;n diet, constitute the ordinary source of the colic, and griping in infants. Overdistention of the sto- mach, especially with artificial food; or administering nourishment at such short intervals that the stomach is constantly kept in a state of repletion and exercise, is particularly apt to give rise to these harassing complaints. Even the most appropriate articles of food, will not prevent the occurrence of colic and griping, if they are very frequently and superabundantly administered, so as to deprive the digestive organs of the requisite and regular intervals of rest. Not unfrequently, very painful disturbance of the alimentary canal, arises from a bad state of the mother's or nurse's milk. Mental disturbance in the nurse sometimes exerts the most extra- ordinary influence in this respect, by the changes which it causes in her milk. A few years ago, I met with a very striking instance of this kind. I was called to an infant about five months old, extremely harassed with colic pains. Most violent and pro- tracted paroxysms of screaming and agitation occurred, three or four times daily. Its bowels were disordered, and frequent ejec- tions of acid, fluid mixed with coagula of milk, took place from the stomach. The child was nourished exclusively at its mother's breast. I was told that these attacks first came on, about two weeks before I saw the little patient, and soon after the mother had unexpectedly heard of the sudden death of her husband at sea. Previous to this distressing occurrence, the infant appeared to be perfectly healthy. I advised immediate weaning, and the use of two parts of cow's milk with one part of warm water, for its nourishment. In less than twenty-four hours after the child was put on the exclusive use of this food, it was almost entirely freed from its painful attacks; and in a few days more, appeared to be as well as it was, previous to the first accession of the complaint. The children of nervous, fretful, and ill-tempered OF COLIC. 191 women are much more liable to colic and other forms of gastro intestinal disorder, than those of placid and equanimous mothers. Protracted grief, sorrow, or despondency in the nurse, often gives •rise to very severe and continued colic pains in the suckling, which nothing but weaning or a change of the nurse is capable of preventing. Even physical pain in the nurse, when long-continued and ha- rassing—such as tooth-ach and neuralgia, may occasion very ob- stinate and severe disorder of the alimentary canal in the nursling. Dr. Dewees relates a very curious instance of this kind. In the second week after birth, the child began to experience moderate attacks of colic; which gradually increased, in violence and fre- quency, until they became extremely severe and protracted. No relief could be obtained, except from laudanum, given " in large and constantly increasing doses." The fluid thrown from the sto- mach was sour; and the alvine evacuations were griping, thin, and often green. There was much emaciation. "In this situation did things continue, until the child was five months old, by which time it was (without a figure) nothing but skin and bone." In one of his visits the Doctor noticed the mother applying her hand very suddenly to her face and pressing it firmly. On being ask ed the cause of her doing so, she stated that she had been for a long time much tormented with tooth-ach. The Doctor advised her to have the tooth immediately extracted. "This was accordingly done; and from that day the child began to recover, and in a short time was perfectly restored to health." Inattention to proper dietetic regulations, and consequent disor- der of the digestive functions, on the part of the mother or nurse, may also give rise to such alterations in the milk, as will occasion colic pains and griping in the infant. Under the head of wean- ing, several other circumstances, in relation to the mother have al- ready been mentioned, as sources of more or less serious disturb- ance in the stomach and bowels of infants. Of these a deficiency in the quantity of milk furnished by the breasts is a very common indirect cause of this painful affection in infants. To supply this deficiency, artificial nourishment must, of course, be resorted to: and in doing so, the child's stomach is apt to be overloaded with inappropriate articles of food. 192 OF COLIC. Colic pains and griping may also proceed from the influence of cold—particularly from inattention to proper changes of the child's wet and cold linen, and from insufficient clothing and warmth about the abdomen and inferior extremities. It has already been observed above, that the periodical form of this complaint, appears to differ very materially both in its char- acter and mode of origin, from the ordinary cases of irregular flat- ulent colic. It is seldom associated with a dyspeptic condition of the digestive organs; and the beneficial influence of dietetic regu- lations, is certainly much less obvious in cases of this kind, than in the usual instances of the complaint; nor are those remedies which are generally relied on for preventing the generation of acid and wind in the primae viae, or for removing them, capable of pro- curing any decided advantage in these periodical cases. These attacks continue to recur regularly, for several months; their re- currence usually ceasing spontaneously, "as soon as the child reaches the age of three months." Jlr. Dewees thinks that cases of this kind, depend, probably, "upon some constitutional pecu- liarity, over which we have but a temporary control." It appears to me likely that they do not differ from fhe gastralgia of adults —a form of neuralgic affection., which frequently assumes a peri- odical character, and which, like the present complaint, can sel- dom be materially influenced by the ordinary remedies for colic and griping pains. The attack in cases of this kind, generally comes on suddenly, and after having continued with occasional transient remissions for an indefinite period, varying from a few minutes to one or even two hours, it ceases as abruptly as it came on. From a close attention to several instances of this form of the complaint, I have been led to suspect that the pain, in such ca- ses, is generally seated exclusively in the stomach. The pain is not aggravated by taking food or drink into the stomach; and in one instance, which came under my notice, the sufferings were almost always obviously mitigated, by administering a few teaspoonfuls of thin arrow root, barley water, or of a mixture of milk and water. During the attack there is usually a good deal of flatulent noise in the abdomen, attended with epigastric disten- tion, and eructations of air, which, however, possess neither acidi- ty nor fetor. The digestion is nearly always good, and sometimes OF COLIC. 193 even more rapid than in a perfectly healthy condition of the sto- mach and bowels. The colic of infants, as has already been observed, is by no means a dangerous, though always an extremely distressing affection. Nevertheless when the flatulent distention becomes very great, it may so weaken the muscular coat of a portion of the intestines, as to give rise, ultimately, to habitual costiveness of a very trouble- some and unmanageable character. In some cases a highly irri- tated or sub-inflammatory condition of the mucous membrane of the bowels is excited in the progress of the disease, giving rise to painful and exhausting diarrhoea, a hard and tumid state of the abdomen, derangement of the digestive functions, and a general irritable and irritated condition of the sanguiferous and nervous systems. These consequences, however, rarely ensue, except where errors in diet are habitually committed, or where harsh and irritating purgatives and other medicines are frequently employed. Treatment.—In the ordinary cases of infantile colic, associated with derangement of the digestive functions, or with habitual acid- ity and flatulency of the primae viae, judicious dietetic regulations are all-important remedial measures,—without which the most appropriate remedies will, at most, procure but temporary pallia- tion. When there is reason for believing that the mothers milk is unwholesome, an effort should be made to ascertain the cause of its faulty condition, which may, perhaps consist in habitual im- proprieties in diet, or in some accidental and removeable disorder on the part of the mother. Should the first be the case, proper dietetic measures should be immediately adopted by the mother or nurse, and every thing that tends to promote the generation of acid in the alimentary canal carefully avoided. If, notwithstanding a judicious regulation of the mother's diet, the infant continues to be harassed with frequent attacks of colic, some advantage may oc- casionally be obtained by applying it to the breast at long inter- vals, and substituting small portions of suitable artificial nourish- ment—such as very thin arrow-root, barley water, or a mixture of equal parts of cow's milk and water. When the child has been partly nourished by artificial food, in consequence of a deficient becretion of milk, we may sometimes derive much benefit from a •2 C 194 OF COLIC. change of the artificial portion of nourishment. A striking in- stance of the advantage that may occasionally be obtained in this way came under my observation a few weeks ago. The infant about two months old was almost constantly in a state of alarming torment. The mother did not furnish sufficient milk for its sustenance, and it was regularly fed with a mixture of equal parts of cow's milk and water. Arrow-root, barley-water, tapioca, and sago, in suitable preparations were successively tried, but without the least benefit. A mixture of weak chicken-tea and a very thin pre- paration of arrow-root, in the proportion of one part of the former to two parts of the latter, was finally resorted to. By the use of this nourishment, the complaint was soon very obviously mitiga- ted; and under the additional influence of small doses of magne- sia and powdered valerian, yielded almost entirely in the course of nine or ten days. As the error often consists more in the excess; than in the quality of the food, particular attention ought always to be paid to this point. Infants who are partly nourished by artificial food, are par- ticularly liable to be injured by over-feeding. I have repeat- edly known great benefit derived from a mere reduction of the quantity of nourishment habitually taken by the infant—and particularly by lengthening the intervals between the meals so as to avoid the injurious practice of taking fresh food into the sto- mach before that which was previously taken has been fully di- gested and passed into the intestines. There are but few cases of flatulent colic that may not, in some degree be benefited by a ju- dicious management of the diet. Frequently, however, the re- lief obtained from measures of this kind is but small, and recourse must be had to other means for correcting the disordered condi- tion of the stomach and bowels, and especially to temporary pal- liatives for mitigating the violence of the attacks. Magnesia by its antacid and purgative effects, is one of the most useful remedies we possess for the management of this com- plaint. When there is a prevailing tendency to generate acid in the primae viae, small doses of this article, given two or three times daily, almost always produce an obvious abatement in the frequency and violence of the attacks. I have generally given it in union with small portions of powdered valerian root, and when OF COLIC. 195 the bowels are torpid, with the addition of a few grains of rhu- barb. Three grains of magnesia, with two grains of powdered valerian, may be given twice or thrice daily, until the acidity in the stomach is removed. If this do not keep up a sufficient ac- tion of the bowels, the proportion of magnesia should be occasion- ally, increased, or a few grains of rhubarb added to the powders. Valerian is an excellent auxiliary to the magnesia, in cases at- tended with weakness of the digestive powers. I have used a solution of the bi-carbonate of soda in an infusion of valerian root, with very obvious benefit, in cases attended with much acidity. Twenty grains of the bi-carbonate of soda may be dissolved in two ounces of valerian infusion,* to which two or three drachms of ginger syrup may be added. A teaspoonful of this solution may be given several times daily, to an infant of from one to three months old. With the view of invigorating the digestive organs, and thereby impeding the formation of acid and flatus in the ali- mentary canal, small doses of a very weak infusion of colomba or of quassia may be resorted to with a prospect of considerable ad- vantage, in cases associated with general feebleness and relaxa- tion and a dyspeptic condition of the stomach. When the com- plaint is accompanied by thin, green and acid diarrhoeal dis- charges, some advantage may be gained from the occasional ad- ministration of very small doses of calomel, either by itself or in union with minute portions of ipecacuanna. A frequent employ- ment of this article, however,—particularly when given in full doses, is by no means advisable. Some years ago, 1 administered, in several cases of this complaint attended with constant acidity, flatulency, and diarrhoea, a mixture composed of five grains of prepared chalk, three grains of the powdered root of simplo- carpus foetida (skunk cabbage) and two of rhubarb, every morning and evening for five or six days in succession, with unequivocal benefit. The difficulty of procuring the powdered skunk cabbage in our shops, has since that time, prevented me from giving it again; though I am inclined to believe, that it possesses very ex- cellent powers, both as a palliative, and as a means for invigorating * The infusion should be made by macerating one ounce of the valerian root in a pint of warm water, for about twenty-four hours. 196 OF COLIC. the depressed digestive energies of the stomach. When costive- ness prevails, this article may be given in union with magnesia, in the way mentioned above, or with valerian. In cases attended with frequent watery, green, or curdled and sour stools, accompanied with violent griping, antimonial emetics are strongly recommended by Armstrong. When the abdomen is not tender to pressure, and the little patient is free from febrile irritation, an occasional emetic dose of antimonial wine, followed by suitable doses of Dover's powder, will sometimes do much good in such cases. An instance of the usefulness of this practice, came under my notice about six months ago. The infant, about five months old, was extremely harassed with frequent small di- arrhoeal discharges of a watery and grass-green character; and each evacuation was preceded by excessively severe and protrac- ted griping, as was evident from the child's vehement and unap- peasable screaming. An antimonial vomit was given in the morn- ing, followed after its operation by a grain and a half of Dover's powder. The disease was manifestly mitigated by these reme- dies; and by repeating them three times in the course of about a week, and employing, afterwards, small doses of prepared chalk and Dover's powder, in conjunction with the occasional applica- tion of rubefacient embrocations to the abdomen, the bowels were brought to a pretty healthy condition, and the little patient freed of his sufferings. In general, however, emetics are not appropri ate remedies in infantile colic, except in cases where the morbid excitement is concentrated on the large intestines, and the stom- ach is in a languid or inactive condition. As a mere palliative, an emetic dose of ipecacuanna, will sometimes procure considera- ble relief when administered during, or at the commencement of the paroxysm, by expelling the wind and thus removing the dis tressing distentions of the stomach and duodenum. A repetition of emetics, however, could hardly fail, in the ordinary cases of the complaint, to disorder the digestive functions, and to favor the oc- currence of inflammatory irritation in the stomach and bowels. The application of a large warm poultice over the abdomen, having previously rubbed the skin with hartshorn liniment, or, with the common camphorated mixture, will often assist materially in sub- duing the complaint, when it is accompanied with much intestinal OF COLIC. 197 irritation, manifested by frequent small, thin and acrid or very foetid evacuations. As a temporary palliative for lessening the violence and dura- lion of the attacks, Dr. Dewees, relies chiefly on the following mixture,*—which, he asserts " rarely fails to give instant relief, and sometimes even effects an entire cure." Twenty drops of this mixture should be given when the child is in pain, "and if not relieved in half an hour, ten drops more are to be administered." I have found this remedy, to procure prompt relief in some in- stances, but it has not been so uniformly beneficial, in my hands as the following preparation. Dissolve one drachm of camphor in an ounce of sulphuric aether. Take thirty drops of the solu- tion, twenty grains of magnesia, six drops of laudanum, and mix them together with an ounce of fennel-seed tea. Of this mixture a teaspoonful may be given, to an infant from two to six weeks old; and if sufficient relief be not obtained in half an hour, about half a teaspoonful more should be administered. I have fre- quently procured prompt relief by administering two or three drops of the simple ethereal solution of camphor, in a teaspoonful of sweetened water, and I am satisfied that we have not a more efficient palliative, for relieving the distressing pains attending this complaint. When remedies of this kind must be frequently employed, camphor is, in some respects preferable to opium, un- less diarrhoea and much intestinal irritation be present, in which case opiates in some shape or other can hardly be entirely dis- pensed with. Incases associated with diarrhoea and griping, the camphor may be advantageously given in union with laudanum. Two drops of the solution of camphor with half a drop of lauda- num may be given three or four times in the course of a day, when the pains are violent and of protracted duration. Gentle frictions with dry flannel or with the bare hand over the epigastric and umbilical regions, sometimes aids considerably in procuring the expulsion of the confined flatus. The introduction into the rectum, of a soap suppository during the colic attack, frequently produces copious discharges of wind and faeces, with great relief to the little sufferer. When costiveness prevails, lax- • R. Magnes. calcinat. 9i. Tinct. assafoEtidae gtt. lx. Tinct. opii. gtt. xx Aq fontan. Ji. M. 13 198 OF COLIC. ative enemata, with the addition of twenty or thirty drops of tincture of assafcetida, are appropriate and often very efficient means of temporary relief. In the periodical form of the disease, dietetic regulations rarely afford any decided advantage. The diet should nevertheless be carefully attended to; for there can be no question as to the injuri- ous tendency of errors in this respect. The abovenamed pallia- tives may be resorted to with temporary benefit; but the reliei obtained by remedies of this kind, is seldom so prompt and con- siderable in the present as in the common irregular form of the complaint. When employed at all, they ought to be given, " the instant the paroxysm is about to commence;" for when the colic is once fully developed, it very rarely yields in any obvious de- gree, to remedies of this character. The only article that I have found, capable of occasionally producing a decidedly favorable effect, is a few drops of the spirits of turpentine in a teaspoonful of good sweet oil, or milk. In some instances I have known this remedy to effect a speedy subsidence of the pains in this variety of the disease. From three to six drops of the turpentine may be given to a child of from one to three months old, and the dose may be repeated in the course of an hour without the least risk of injury. Viewing it as a strictly periodical complaint, Dr. Dewees has administered a decoction of the bark during the in- tervals of the attacks, and, as he informs us, "with the happiest effect in several instances." Formerly I employed the prussiate of iron in several cases of this kind; and in one instance, the ef- fects of this remedy were surprisingly beneficial. To an infant between one and three months old, a half a grain of this article may be given every three or four hours during the intervals of the paroxysms. In the successful case just referred to, this pre- paration of iron was given in union with powdered valerian. The infant was about two months old. A violent attack of colic occurred about six o'clock, every evening, and generally c©n- tmued for nearly an hour. The child had been affected with the complaint for upwards of three weeks before I saw it. After the bowels were freely evacuated by a dose of a few drops of syrup of rhubarb, I prescribed half a grain of the prussiate of iron with three grains of powdered valerian root to be taken every thiee OF COLIC. 199 hours during the intermission. The first paroxysm after these powders were taken, was perhaps, as severe as any of the pre- ceding ones. The medicine was, however, continued, during the next intermission; and now, the attacks gradually subsided in vio- lence and duration, until, at the end of eight or ten days, the child was almost entirely freed of the complaint. I have, since this case, employed the same combination in another instance; but the effects, though not without obvious advantage, were by no means so promptly and decidedly beneficial as in the former instance. As the bowels are generally torpid in these cases, mild laxatives, must be used from time to time, to keep up the requi- site alvine evacuations. Active purging, however, is not only useless, but often decidedly injurious—a fact which I have, in several instances, seen strikingly verified. It would, I think, in genera] be better to procure the necessary evacuations by laxa- tive enemata, than by aperients taken into the stomach. If the latter be preferred, fresh cold-pressed castor oil, and syrup of rhu- barb, are the most appropriate. The practice, so common with mothers and nurses, of admin- istering various irritating substances of an anodyne or carmina- tive character, is often carried to a highly injurious extent, and cannot be too severely censured. The habitual use of opiates in in- fantile colic, almost always leads to very unfavorable, and often to very distressing and dangerous consequences. In order to ob- tain the requisite degree of anodyne effect, the dose must be pro- gressively increased; and thus a habit is soon formed, which renders the discontinuance of the anodyne a source of inexpressi- ble distress and inquietude, whilst its continuance, in increasing doses never, fails to operate perniciously on the whole organization. Under the habitual use of these treacherous palliatives, consti- pation soon ensues; the appetite and digestive powers fail: the body emaciates and the skin becomes sallow, dingy, and shrivelled -f the countenance acquires an expression of languor and suffering, and a general state of apathy, inactivity and feebleness ensues, which, ultimately, often leads to convulsions, dropsy of the head, glandular indurations, incurable jaundice, or fatal exhaustion of the vital energies. The more immediate effects of opiates, also, are frequently extremely unpleasant, particularly in very young infants. 200 OF COLIC. The pain may indeed be lulled by the anodyne, but though qui- eted, the infant is evidently under the influence of highly disa greeable sensations, as is manifested by the sudden starting, un- natura1 whining cry, and the exceedingly irregular respiration, being now very hurried for a moment, and then slow and moaning with occasional intermissions, of so protracted a duration, that "one would think the breathing had ceased altogether." All the usual soothing mixtures, such as Godfrey's cordial and Dalby's carminative, so much employed for allaying the colic pains, and griping of infants, contain more or less opium; and innumerable infants have been irretrievably injured by the habitual use of these popular nostrums. Heating and irritating articles, such as diluted spirits, infusion of spicy and aromatic substances, soot, and repeated active pur- gatives may do much injury, by irritating the delicate mucous membrane of the stomach and bowels, impairing the digestive powers, and finally exciting a state of chronic inflammation in this structure, which it is always very difficult, and often impos sible to remove by any subsequent care and management. The observations are addressed rather to mothers and nurses than to physicians; for it cannot be questioned that all these remedies, more especially opiates, may, by judicious management be bene- ficially employed in certain instances and conditions of the complaint. OF CONSTIPATION. 201 CHAPTER XVIII. OF CONSTIPATION. Torpor of the bowels, and consequent costiveness, of more or less protracted duration, is of frequent occurrence among infants. In some instances, the bowels are habitually so very inactive, that scarcely any alvine evacuations take place, except when excit- ed by artificial means. This state of the bowels is the result either of a constitutional habit, or of accidental causes. The former va- riety of costiveness is very rarely attended with unpleasant con- sequences, "and indeed children of such a habit of body are fre- quently the most thriving" (Underwood). Dr. Dewees observes, that a period of from two to ten days may intervene between the stools, in constitutional costiveness, "without the child receiv- ing the least injury from this torpor of the bowels." I have re- peatedly met with instances, where not more than two or three evacuations took place in the course of a week, without the slight- est inconvenience to the infant; and Dr. Dewees mentions a case, where the stools occurred " but once in eight or ten days," for a long period, although the infant throve well and appeared to be " in excellent health." Mothers, generally, express much solici- tude, in cases of this kind; and under the apprehension of evil con- sequences from this condition, frequently urge the administration of aperients to a very injurious extent. When the infant mani- fests no symptoms of ill-health, and continues to thrive well, con- stitutional costiveness very seldom requires any remedial interfe- rence, "though it will be prudent carefully to watch it." Where there is a tendency to convulsive affections—a tendency which is sometimes manifested in children of a perfectly healthy and ro- bust appearance, it will undoubtedly be advisable to obviate pro- tracted costiveness by the occasional administration of suitable aperients; for, "fine lusty infants are sometimes seized with vie- 2 D 18* 202 OF CONSTIPATION. lent convulsive fits, without any other apparent cause, than a nat- urally costive state of the bowels, and as uniformly recovered from the fits, merely by procuring stools and breaking off the wind" (Underwood). During dentition, also, it will, in general, be expe- dient to increase the frequency of the alvine evacuations, by arti- ficial means, where there is much intestinal inactivity. The most suitable aperients, in cases of this kind, are castor oil, man- na, and magnesia. I have for many years past, been in the habit of prescribing the following mixture for this purpose. It is cer- tain, and peculiarly mild in its operation, and of so pleasant a taste that children generally take it with little or no reluctance. R.Ol. Ricini - - 3 i Magnesiae calcinat. 3 " Sacchar. Albi, - - 3 "' 01. Anise, - - gtt. ii Mix them intimately, by rubbing them together in a mortar. One or two teaspoonfuls of this mixture may be given at a dose. During the first two or three months of infancy, we may, in gen- eral, keep the bowels sufficiently soluble by the use of manna— an article which is, perhaps, less apt to disagree with the stomach or to cause unpleasant effects in the alimentary canal of infants, than any other aperient we possess. It should be dissolved with warm water, to the consistence of a thick syrup, and given in tea- spoonful doses. Costiveness from accidental causes is a very common affection during infancy. Instances of this kind are, properly, morbid con- ditions, and can seldom be entirely neglected without incurring some risk of injurious consequences. A torpid state of the bowels may occur as a symptom of some obscure deviation from health. If it be not removed it may become an additional source of irritation in the system, and aggravate the latent disorder upon which it depends. Thus a preternatural determination of blood to the brain, may give rise to inactivity of the bowels, without any other obvious signs of ill-health, or disordered function. The costiveness, if it be suffered to continue*, will hardly fail to increase the already preternatural determination of blood to the head, and thus a very serious affection may ultimately be developed in the brain or the alimentary canal, which might have been obviated by a judicious course of aperient remedies. The occurrence of costiveness dur- OF CONSTIPATION. 203 ing dentition, may always be regarded as an unfavorable event. Children almost always suffer much more general irritation, and incur much more risk of convulsions and other dangerous affec- tions from dentition, when the bowels become torpid and consti- pated, than when they are moderately loose during this process. The very reprehensible, and frequently clandestine practice, among nurses of giving opiates to infants, to make them sleep, that they may not require much attention during the night, is a frequent source of obstinate and injurious costiveness.* I met with a remarkable instance of this kind a few years ago. The infant, when about two months old became very costive. Aperi- ents were from time to time, resorted to, but the torpor of the bowels continued, and gradually increased, until no evacuations could be procured except by large doses of the most active pur- gatives. The child became sickly, and much harassed with acid- ity and flatulent pains in the stomach. After I had for nearly a month endeavored to bring the bowels into a more regular condi- tion, without the slightest advantage, it was accidentally ascer- tained that the nurse had been in the habit of giving the infant a dose of laudanum every evening to the extent of at last ten or twelve drops at once. The laudanum was now gradually withheld, and in about two weeks the child's bowels were restored to their former regular state, although its general health continued to be very infirm for several months afterwards. Costiveness may also occur, as a consequence of particular arti- cles of nourishment. Children who are chiefly nourished by pap, or by preparations of rice, are apt to become more or less constipated; and in general, all the usual farinaceous ar- ticles of nourishment have a greater tendency to produce costiveness, than milk and the nutrient animal fluids. In some instances, though rarely, the mother's or nurse's milk, has a constipating effect on the child's bowels: but this, prob- ably, depends more frequently on a peculiar constitutional habit * "Nurses," says Dr. Dewees, "are now so familiar with this drug (laudanum) that it is as regularly carried about them as their scissors or thimble, and is much more indispen sable to their comfort than either of those emblems of industry. If the child does not go to sleep, or if it is even feared it will not, at the exact moment which will suit the arrange- ments of the nurse; or if it cry from any cause, so as to give any additional trouble, laud- anum is given to make 'assurance doubly sure.' " 204 OF CONSTIPATION. on the part of the child, than on the particular qualities of the milk. This was certainly the case in one instance which came under my notice some years ago. The mother, with an abundance of milk, suckled her twin infants, and treated them in exery res- pect precisely alike. One of them was constantly costive, except when nourished principally with cow's milk; whilst the other child was uniformly regular in its bowels. When children are ob- served to become costive, and to continue so under the use of any particular kind of nourishment, an immediate change of food should be made; for a nourishment which is capable of produc- ing this effect, will, in conjunction with the costiveness it has caused, be likely to occasion more serious disturbances in the system if its use be persisted in. Accidental costiveness is usually attended with flatulency and occasional attacks of colic pains. If it be suffered to continue, it may ultimately give rise to inflammatory irritation of the mucous membrane of the bowels, which may manifest itself either by obsti- nate and painful diarrhoea, or swelling, tension and soreness of the abdomen, or finally, by various sympathetic affections of the head, chest or the general system. The aperients already mentioned, will in general procure all advantages that can be derived from remedies of this kind. Cold- pressed castor oil, is an excellent laxative in the ordinary cases of costiveness. When the alvine discharges manifest a deficiency of bile—that is, when they are whitish or clay-colored, much bene- fit may be obtained, from the occasional administration of a small dose of calomel in the evening, followed next morning, by one or two teaspoonfuls of castor oil. Magnesia is the appropriate laxative when the intestinal torpor is accompanied with acidity in the primae viae. In moderate cases of constipation, relief may frequent- ly be obtained from the daily introduction of a soap supposi tory into the anus. Laxative enemata also, may be advantageously em- ployed in cases of this kind. They are especially useful, as occa- sional substitutes for the internal aperients, where the necessity of resorting to artifical means for moving the bowels continues a long time; for a long-continued and frequent employment of even the mildest laxatives, is apt to injure the digestive functions, and to give rise to some degree of intestinal irritation. When the OF VOMITING. 205 abdomen is free from tenderness or soreness to pressure, frictions and gentle kneading of the abdomen with the hand, sometimes produces an excellent effect, both in constitutional and accidental colic. CHAPTER XIX. OF VOMITING. Vomiting occurs more frequently, and, in general, with much less unpleasant consequences during early infancy, than at any other period of life. We often see perfectly healthy infants, who arc in the habit of throwing off a portion of the contents of the stomach, several times daily, without sustaining the least disagree- able consequences from it, whatever. The vomiting in these ca- ses arises solely from an overloaded condition of the stomach, and is not attended either by nausea, or by any strong and disagreeable vomitive efforts. It seems to be almost entirely effected by a sudden momentary contraction of the stomach, with little or no aid from the abdominal muscles and diaphragm. This harmless kind of vomiting is particularly apt to occur, in robust infants who are nourished at exuberant breasts; and it seldom happens except immediately after the infant has sucked. The milk is generally thrown off, in an unchanged condition; and the infant is so little annoy*,:1 by the vomiting that it will often preserve its usual placid and cheerful countenance, whilst the milk is regurgitating from its stomach. This variety of vomiting may therefore be regard- ed, rather as a salutary than a morbid occurrence; for the super- abundant nourishment with which the digestive organs are habit- ually overloaded, would, doubtless, soon give rise to indigestion and its various disagreeable consequences, if the stomach did not regularly relieve itself by throwing off a portion of its oppressive load. So long as the infant remains healthy, and the ejections' 206 OF VOMITING. are, manifestly, mere efforts of the stomach to relieve itself of its over-distended condition, nothing ought to be done, in the way of remedial applications, to prevent the vomiting. Nevertheless, these efforts of the stomach to relieve itself, though obviously salu- tary, show, that the infant is habitually going beyond the proper lim- its of moderation in its nourishment; and as a frequent repetition of this error, however transient in its influence, may ultimately weaken the tone of the digestive organs or establish a habit of immoderate indulgence in eating, it will always be proper, to en- deavor to obviate the cause of the vomiting—namely the over-reple- tion of the stomach, by preventing the infant from taking too much nourishment at a time. With this view, "the child should be taken from the breast, the moment it begins to dally with it, or as soon as it ceases to draw as if it were really gratifying a necessary and pro- per appetite." When the infant has satisfied its appetite, it ought not to be immediately jolted and dandled, but suffered to remain perfectly at rest, for at least thirty minutes, after it has been taken from the breast. The common practice of tossing and jolting infants immediately after they have taken nourishment is highly improper. In cases of the kind now under consideration—where the stomach is usually charged to the utmost of its capacity at each nursing, this practice is particularly objectionable, as it rarely fails to excite vomiting and interfere with the regular progress of digestion. If the child is kept in a state of quietude after its removal from the breast, and the quantity of its nourishment somewhat dimin- ished, in the way just mentioned, the habit of vomiting soon after the reception of its food, may almost always be effectually over- come. The mere cessation of this inconvenience, however, is not the only advantage which may be expected from these mea- sures. Infants who are in the habit of vomiting after sucking, from mere over-distention of the stomach, are peculiarly apt, at a subsequent period, to become affected with habitual torpor of the bowels or costiveness. I have repeatedly noticed this connection between vomiting from repletion during the early period of infan- cy, and habitual costiveness at a more advanced age. It would seem as if the excitability of the alimentary canal became, in a manner concentrated in the stomach. This consequence might, doubtless, be, in a great measure, obviated, by constant attention OF VOMITING. 207 to a suitable moderation in the infant's nourishment. This is the only mode by which we may prudently attempt to prevent the re- currence of this kind of vomiting. All efforts to obviate the vom- iting by medicinal agents, must not only prove abortive, so long as the infant is permitted to fill its stomach to excess, but often decidedly injurious, and should never be attempted in cases of this kind. Morbid Vomiting may be excited by injurious or offensive sub- stances lodged in the stomach, or occur as a symptom of some lo- cal or general affection of the body. Underwood says, that trou- blesome vomiting sometimes occurs in consequence of a "suppres- sion of the discharge behind the ears; and from the sudden dis- appearance of some eruption on the skin." Dr. Dewees, how- ever, doubts whether vomiting ever occurs as a direct consequence of these causes. "We have never witnessed it," he says "from ei- ther of these causes." That such cases do occur, I have had un- equivocal evidence. I attended a child within the present year, affected with frequent vomiting, which was manifestly connected with an excoriation and occasional serous discharge behind both its ears. It was observed, that whenever there was a discharge from these sores, the child was free from vomiting and appeared well; but as soon as the serous discharge ceased, which it occa- sionally did without any obvious cause, the little patient became pale, sickly, and vomited five or six times daily. The infant was about eighteen months old. When I first saw it, there had been no discharge for five or six days. The parts were perfectly dry and scurfy. The child was pale, and threw up almost every thing it took into its stomach. I applied blisters behind the ears and on the following day no vomiting occurred. By the occa- sional application of blisters, and the use of equal parts of lac sul- phuris and magnesia, the child finally regained a good state of health. This is the only case of this kind, I have met with. Dentition is sometimes attended with a very irritable state.of the stomach giving rise to frequent vomiting. This probably de- pends on an extension of the irritation from the mouth to the brain, causing a kind of erithism of this organ—a condition which is almost invariably associated with an irritable stomach and a 208 OF VOMITING. strong disposition to vomit. The best means for checking this spe- cies of vomiting are, blisters applied behind the ears, or on the back of the neck; dividing the gums down to the advancing teeth; warm pediluvium; purgatives, or purgative enemata; and small doses of laudanum. Vomiting is sometimes excited by a bad condition in the nurse's milk. When it arises from this cause, the child generally throws up the milk almost as soon as it is done sucking. We may read- ily satisfy ourselves, whether it depends upon this cause, by put- ting the infant upon the use of some other suitable nourishment, or suffering it to suckle another nurse. If no vomiting occurs af- ter such a change of its nourishment, the source of the evil is man- ifest, and a permanent change must be adopted, unless the vomit- ing be but trifling. One of the most frequent sources of vomiting, however, is a dys- peptic state of the stomach, occasioned by improper articles of nourishment, or immoderate feeding. These cases are generally attended with a prevailing acidity in the primae viae. The milk is thrown up in dense coagula, and has an acid smell; the child is troubled with flatulency, acid eructations, and the stools are, usually green, more or less griping, and sometimes diarrhoeal. In some instances however, the bowels are torpid, and the child expe- riences occasional attacks of slight colic pains. In these cases the milk or food is seldom thrown up, until it has lain some time in the stomach. Dr. DeWees, observes that when the vomiting de- pends on an excess of acid, " the milk is thrown up in a few min- utes after it has been received into the stomach." This does not accord with my own observations. I have seldom known vomiting to ensue in cases of this kind, until the milk had lain, at least, a quarter of an hour in the stomach, and, in many cases, the inter- val between receiving it and throwing it off again, is much longer. In such cases, the diet ought to be carefully regulated, and above all, moderation in the quantity of food taken, rigidly en- joined. If the child has been weaned, much benefit may some- rimes be obtained by mixing its usual farinaceous nourishment or milk, with beef or chicken tea, or weak mutton bioth. Equal parts of barley-water and chicken tea forms an excellent nour- ishment, where there is a strong tendency to acidity in the stom- OF VOMITING. 209 ach. To arrest the vomiting, lime-water, and milk, given in repeated doses, often produces an excellent effect, where the cause of the evil consists in a redundancy of acid in the primae viae. If costiveness or slowness of the bowels attend, small and frequent doses of calcined magnesia, are preferable; and I have occasionally administered the bi-carbonate of soda, dissolved in a very weak infusion of colomba with prompt and complete ad- vantage in instances of this kind. Acid is not, however, always present in cases of vomiting, de- pending on a deranged condition of the digestive organs. In some instances, there is a total deficiency of acid; the milk, com- ing up in a perfectly unchanged state, and wholly free from any acid smell. The vomiting in such cases, seldom takes place, until the nourishment has lain a considerable time in the stomach, and it is generally preceded by very obvious signs of nausea. The child's countenance becomes pale and expressive of great anxiety and distress, and in a moment the contents of the stomach are thrown with great force. In cases of this kind, a teaspoonful of good lisbon or maderia wine, given at proper intervals sometimes pro- duces a very happy effect. A drop or two of nitric acid, in a lit- tle sweetened water, also forms an excellent remedy in such cases. Dr. Dewees, says that he has rarely failed procuring relief, in this condition of the stomach, "by the occasional exhi- bition of small quantities of lemonade." I have used a mixture of the spiritus mendiriri and lemon syrup, in several instances, with prompt and complete success. Three ounces of the former, with an ounce of the latter, forms a good mixture for this purpose. A teaspoonful of this may be given every half hour, or at remoter intervals according to the urgency of the case. When the vomiting is excited by the presence of improper articles of nourishment in the stomach, the exhibition of a mild emetic will often prove decidedly beneficial. Four or five grains of ipecacuanna, may be given without the least risk of injury, and generally with much advantage. I have always preferred this article, to antimonial wine, in the gastric affections of infants when a remedy of this kind was deemed proper. It is much less apt to irritate the mucous membrane of the alimentary canal and to debilitate the system than antimony; and its secondary effects 2E 19 210 OF VOMITING. are, in general, much more salutary, in cases attended with an irritable condition of the stomach, than those of the latter article. We may, howrever, frequently procure the entire evacuation of the offensive substances lodged in the stomach, in cases of this kind, simply by the exhibition of warm water, by which the vom- iting is, at first, promoted, and the stomach freed of its offensive contents. If, after this has been effected, the vomiting does not cease, a few drops of laudanum or of camphorated spirit, given in a little milk, will generally prevent its recurrence. We, however, often meet with cases of vomiting in infants, which are neither excited by an excess of acid, nor by improper articles of food nor by any other offensive substances lodged in the stomach, and for which, in fact, we can assign no other cause than that the stomach has, from some circumstance or other, be- come extremely irritable. In cases of this kind—that is, when the stomach is morbidly irritable and the matter thrown up, con- tains little or no acid, we may sometimes do much good by the administration of minute doses of calomel and ipecacuanna. I have repeatedly succeeded in arresting vomiting, from inordinate gastric irritability in infants, by exhibiting the eighth of a grain of calomel with the one sixth of a grain of ipecacuanna every hour or two, in conjunction with the application of a stimulating poultice or plaster over the epigastrium. The application of a poultice of this kind, is calculated to operate beneficially, what- ever may be the cause of the vomiting. A teaspoonful of pulver- ized cloves, with the same quantity of black-pepper, formed into a poultice with crumbs of bread and water, will, in general, answer this purpose very well. A handful of dried mint, rubbed up and made into a poultice with meal or bread, forms, also, an excellent stimulating application in this condition of the stomach. With the exception of small doses of laudanum, internal stimula- ting remedies seldom procure more than very transient relief, and may readily occasion a great deal of mischief, where there is much irritability of the stomach. The occasional use of laxative enemata, will sometimes assist materially in such cases. When opiates are deemed proper, no preparation, I am inclined to think, is more suitable, in this state of the stomach, than the common jparagoric tincture of the shops. All the purposes however, that OF DIARRHCEA. 211 opium is capable of fulfilling may be fully obtained by applying it externally. One or two grains of morphia sprinkled on the surface of a small plaster of common cerate, and laid over the pit of the stomach, will procure a sufficient degree of narcotic in- fluence. When the skin is broken, this article will operate as promptly, and with nearly the same degree of energy as if it had been received into the stomach. CHAPTER XX. OF DIARRHCEA. Although by no means peculiar to infancy, diarrhoea is, un- questionably, by far more common during this early age, than at any other period of life. From the peculiarly susceptible and uninured state of the alimentary canal, and the general organic feebleness of infancy, it is, also, in general, much more apt to as- sume an unmanageable and dangerous character, at this period, than at a more advanced stage of childhood or adult age. In some instances, the diarrhoeal discharge sare faeculent, and easily managed. In others, the stools consist principally of viscid mu- cus, streaked, occasionally, with a little blood. Sometimes the evacuations are conspicuously bilious. In other cases, the dis- charges present a white or milky appearance, accompanied with rapid emaciation and prostration; and in some instances they consist of a mixture of faeculent matter, mucus and imperfectly digested articles of food. Although irritation of the mucous membrane of the bowels, constitutes the immediate cause of the increased peristaltic action and consequent inordinate discharges, yet each of these modifications in the character and appearance of the evacuations, is essentially connected with peculiar patho- logical conditions, which it is of great practical importance to discriminate. It should be observed, however, that the simplest cr faeculent variety of the disease, may, under improper manage- 212 OF DIARRHOEA. ment or the continued operation of irritating causes pass into any of the other modifications—there being no essential difference between them, except what arises from the degree of inflammato- ry irritation—the portion of the bowels principally affected, and the extent to which the digestive powers, as well as the neigh- boring structures and organs become implicated in the disease. Thus, if there is simple irritation of the alimentary canal without much impairment of the digestive functions, the stools will be faeculent. If the inflammatory irritation is seated principally in the small intestines, and extends itself to the mesenteric glands, the discharges will probably be chylous. Should the irritation be severe, and chiefly located in the large intestines, the stools will be mucous: If the liver becomes unusually excited, bile will manifest itself in the evacuations; and when the stomach be- comes very irritable and the digestive functions depressed por- tions of imperfectly digested food will pass off with the stools. The exciting causes of diarrhoea are extremely various. Some of them act directly on the mucous membrane of the intestinal canal, whilst others affect the bowels, sympathetically, through the medium of the general nervous system. Of the former variety are all irritating substances received into, or generated in the alimentary canal; and of these, by far the most common are: irritating, crude, or inappropriate articles of food and drink; acrid and vitiated secretions from the liver and intestinal exhalents; worms, acid, fresh fruit,—particularly such as are very sweet ut fiat electuar. M. t This oil is made by mixing one part of the fetid spirits of hartshorn with three pant of the spirits of turpentine, and suffering them to digest for four days. The mixture 13 then to be put in a glass retort, and distilled in a sand bath, until three fourths of the whole have passed over into the receiver. This is to be kept for use in small and well closed phials. 2M 266 0F WORMS. calomel, with the powdered roots of spigelia and valerian, may be -employed with advantage. Calomel, however, given in this way, is apt to produce ptyalism, especially as it is necessary to continue its use for several days, to insure its anthelmintic action. The chenopodium anthelminticum is well known in this country, as a vermifuge. By means of syrup, an electuary is sometimes made of the powdered seeds, and given, in doses of a tablespoon- ful, to a child of from two to five years old, twice a day—care be- ing taken to abstain from food several hours. It is generally necessary to repeat the dose four or five days. Beside these arti- cles, the most efficacious medicines, for the destruction and expul- sion of the round worm, are—sem. santonic; garlic; conferva helminthocordon; spirits of turpentine; geoffrea surinamensis; camphor; the green rind of unripe walnuts, and tin filings. The expulsion of lumbrici is not, in general, a very difficult task. But to accomplish this desirable object completely, we should persist for a considerable time in the use of anthelmintic remedies, so as not only to destroy the already existing worms, but the eggs containing the germs of others. Their expulsion being effected, strict regard should now be paid to preventing a reproduction of them. In view of this object, the patient should attend particularly to his diet, living abstemiously on plain food. A free indulgence in saccharine matter, in milk, cheese, or but- ter, must be forbidden. Animal food ought to enter largely into the diet. Whatever tends to invigorate the general system, and bestow a wholesome energy on the stomach, should be carefully enjoined. Recourse must be had to tonics, particularly chalybe- ates, in conjunction with minute doses of aloes. A strong decoc- tion of the helminthocordon has appeared to me, not only valua- ble as a vermifuge, but particularly so, as a corrective of that deranged and debilitated condition of the alimentary canal, favor- ing the production of worms. An ounce of this marine vegetable, with a drachm of valerian, should be boiled in a pint of water down to one gill. Of this a teaspoonful may be given every morning, noon and evening, with peculiar advantage. I have known several instances, in which children, apparently suffering from verminous irritation, were restored to perfect health by the use of this remedy, without any appearance of worms in their ex- OF WORMS. 267 cretions. It is particularly beneficial in cases attended with the usual symptoms of worms, connected with want of appetite and mucous diarrhoea, which arise from mere debility of the digestive organs and a vitiation of the secretion of the bowels. Ascarides.—These worms, in general, are extremely annoying. From their being involved in the folds at the lower part of the rectum, they frequently give rise to inflammation of the anus, tenesmus or haemorrhoids. During the day, they are seldom a source of much uneasiness; but towards evening, and especially after lying down, they occasion a tormenting, an almost insup- portable irritation and titillation about the anus. So distressing indeed is the irritation, that nervous children are not unfrequently thrown into convulsions thereby. In females, they sometimes pass into the vagina, giving rise to extreme uneasiness. Doctor Bremser states, that he knew a case of nymphomania, occasioned by their presence in that passage. They have also been knowrn to enter the bladder and urinary passages. They are generally more troublesome in damp than in dry weather. The complete removal of these worms is a work of great diffi- culty. They are so wonderfully reproductive, that no matter though thousands be brought away, wre may soon have to recom- mence our task. The ordinary vermifuges, too, are of little avail in the destruction of ascarides. Their action is more particularly ex- erted upon the upper portions of the intestinal tube, and at all events lose their virtues before they arrive at the location of these animals. Even the most active cathartics are insufficient to expel them. Aloes, however, from the peculiar influence it exerts over the lower portion of the bowels, frequently causes their expulsion in large quantities, especially if assisted by the action of proper enemata. My usual mode of proceeding for the removal of these troublesome worms, is to prescribe three or four aloetic purga- tives every second day, together with two or three enemata, com- posed of a mixture of lime-water and milk, in equal proportions, daily. Injections of a solution of aloes, or of infusions of any of the abovenamed vegetable anthelmintics, will generally succeed in bringing away great numbers of these little animals. In a few instances, I have procured their expulsion in large quantities, by injections, composed of spirits of turpentine, mixed with milk, in 268 OF WORMS. the proportion of a teaspoonful of the former to a gill of the lattr . Injections of any of the common oils will oftentimes soothe the extreme irritation, and also destroy the worms. According to Nil Rozen, a drachm of refined sugar, dissolved in warm milk, has been injected with great success. Another remedy, highly spoken of, is a bougie, smeared over with mercurial ointment, and introduced into the rectum. Dr. Vanvert asserts, that flowers of sulphur, taken in the morning on an empty stomach, is one of the most efficacious remedies for the destruction and expulsion of ascaridies. In obstinate cases, the fumes of tobacco, or an infusion of the male fern, has been recommended by Dr. Bremser. When these worms have crept into the vagina, the same author states, that injections of cold water, with a small portion of vinegar, is the best remedy we possess. As taenia occur chiefly in the adult, their treatment does not come properly under notice in this work. OF OPHTHALMIA. 269 CHAPTER XXII. OF OPHTHALMIA. Purulent Ophthalmia.—The purulent ophthalmia of infants, generally commences between the fourth and eighth day after birth, though instances of its coming on at a more advanced period are occasionally met with. At first the eye-lids are ob- served to be glued together, in the morning attended with slight swelling and external redness. If the lid is raised, so as to expose its conjunctional surface, it is found of a uniformly red and slightly thickened appearance. As the disease proceeds, the swel- ling of the eye-lids increases; a thick purulent matter begins to issue from the eyes; the child becomes fretful and uneasy, and manifests much intolerance of light, keeping its eyes constantly and firmly closed. In the course of three or four days the con- junctiva becomes highly inflamed and cedematous—rising up around the cornea, so as almost to conceal it, or causing it to appear as if it were sunk deep into the eye. The secretion of pus is now extremely copious, and being confined under the swol- len and firmly closed lids, it bursts forth, from time to time, and runs down the cheeks in large drops. If the disease be not arrest- ed, the lids become distended to the utmost degree, giving rise, sometimes, to eversion and consequent bulging out, or protrusion of the inflamed and highly infiltrated conj unctiva. The cornea, also, has by this time become implicated, and is more or less opake. Should the disease continue, corneal ulceration and sloughing takes place, the aqueous humor escapes, and a total destruction of the organ ensues. Mr. Guthrie states that there are two varieties of infantile, purulent ophthalmia. In one, the inflammation is seated almost exclusively, in the conjunctiva of the lids; whilst in the other variety, the conjunctiva of the eye-ball is equally implicated in the disease. I have repeatedly noticed these diversities in the 24 270 0F OPHTHALMIA. suppurative ophthalmia of infants. When the inflammation is confined to the lids, the disease seldom leads to any very serious injury to the eye; but it is, in general, quite as obstinate, and diffi- cult to be subdued as the latter variety of the complaint. The exciting cause of the suppurative ophthalmia of infants appears to consist of some acrid or morbid secretion in the vagina of the mother, applied to the infant's eyes during its passage from the womb into external life. I have never met with an instance of this disease, where upon enquiry I did not learn that the mother was affected with leucorrhcea or some other morbid vag- inal secretion. The tendency of gonorrhoeal matter, when applied to the eyes, to excite purulent ophthalmia is well known: and I have witnessed some striking examples of the same effect, from the application of leucorrhoeal to the eyes, in adults. The fact, too, that the matter discharged from the eyes in cases of this kind, is capable of producing the same disease when applied to the eyes of others, furnishes strong testimony in favor of this etiology of the disease. Mr. Ryall, whose opportunities for obser- vation on this subject have been very extensive, states, that he has frequently known purulent ophthalmia excited in nurses," by the accidental application of the matter from the infant's eyes to their own." The time of its occurrence, also, affords some evi- dence of its dependence on a cause, connected in some way or other with the birth of the infant. If the disease were excited by intestinal irritation from bile and sordes in the alimentary canal, as some have supposed, it would, doubtless occur at every stage of infancy; whereas, its occurrence is almost universally confined to the two first weeks after birth, and in a vast majority of cases, comes on as early as the fourth day. This disease has also been ascribed to the " too early and unguarded admission of light and heat to the eyes of the new-born infant."* The great and sudden transition from the darkness of the womb to the external light, from the contact of the bland and congenial liquor amnii, to that of the atmospheric air, may, perhaps, at times operate injuriously on the tender eyes of the infant. It may be observed, however, that the good and all-wise author of nature, has endowed every Edin. Med. and Surg. Journal, vol. 4. p. 247. OF OPHTHALMIA. 271 creature with a capacity to accommodate itself to the inevitable changes and transitions, which it is destined to undergo, in the regular progress of its development, and it seems inconsistent with the perfect adaptation of the appointments of Providence that the new-born infant should be liable to serious inconvenience or injury from this cause. It cannot be doubted, indeed that unnecessary exposure of the infant's eyes, to a bright and heated light, may do much mischief. The practice of taking the infant, as soon as it is born, before a blazing fire, with perhaps a candle at no great distance, and keeping it" in this situation, not only during the time necessary for dressing, but often, long after this task is performed, lying on its side, on the nurse's knees, and with the face turned to the fire," is unquestionably very improper, and may be the source of much injury to the eyes. Treatment.—Whenever there is reason to suspect the existence of some morbid vaginal secretion, more especially gonorrhoeal, on the part of the mother, the infant's eyes ought to be immediately wash- ed, in the most careful manner with tepid water. The water should be frequently changed and freely applied, so as to ensure the entire removal of the irritating matter that may adhere to the eyes. In all instances, care should, also, be taken, that the in- fant's eyes be not immediately exposed to a very strong light; for, although this may not, of itself, be capable of exciting this disease, there can be no doubt of its tendency to irritate the eyes, and to favor the occurrence of inflammation from other causes. By these precautionary measures, the disease may often be prevented, even where the most active virus has been applied to the eyes during the birth of the infant. As the inflammation, in this affection is always very violent and rapid, the treatment during the early stage must be strictly and actively antiphlogistic. If leeches can be procured, two or three should be applied to the external angle or on the under lid of each eye; and the bleeding from the leech-bites should, after- wards, be promoted by warm fomentations or by the application of a soft emolient poultice over the eyes. The child should be kept in a dark room, and when the blood has ceased to ooze from the leech-wounds, the poultice and bandages must be removed, 272 OF OPHTHALMIA. and a thin and soft piece of linen, constantly kept moist with a weak solution of the sugar of lead, laid over the eyes. The eye-lids must be prevented from adhering to each other, by washing the tarsi frequently with tepid water, or with thin mu- cilage of quince seed or of the pith of sassafras. If this be not attended to, and the pus be suffered to remain confined under the closed and adhering lids, the risk of blindness, from corneal opacity, or a total destruction of the eye will be greatly increased. Bland and tepid fluids should, from time to time, be cautiously injected under the lids, to wash away the purulent secretion; and for this purpose, a weak decoction of poppy heads, or the muci- laginous fluids just mentioned, or tepid milk and water are most suitable. The bowels should be freely moved by small doses of calomel, in union with ipecacuanna, or pulvis antimonialis, with an occasional dose of castor oil. A powder composed of one fourth of a grain of calomel and one grain of the pulvis antimo- nialis or a half a grain of ipecacuanna may be given four times daily. If these do not keep the bowels sufficiently loose, a tea- spoonful of castor oil should be given, once daily, so as to procure four or five evacuations every twenty-four hours. The addition of antimonial powder to the calomel, has appeared to me peculiarly beneficial in such cases. The nausea and vomiting which is apt to follow the use of this mixture appears, frequently to do much good. Indeed the occasional administration of a gentle emetic in the early stage of the complaint, sometimes proves decidedly ben- eficial. I have, in several instances known immediate and very obvious benefit to result from the operation of an emetic dose of antimonial wine. If in the course of about thirty-six hours the violence of the inflammation be not moderated, ,the leeching ough*nencement of the fever, the pulse is full, active REMITTENTS OF INFANTS. 315 and firm, more especially, when the child is of a robust and pleth- oric habit, or when there are decided indications of strong san- guineous congestion, and irritation in the brain, blood ought to be abstracted, either with the lancet or by leeching. Even in the advanced stages of the disease, blood-letting may sometimes be resorted to with much advantage, when the head is much affected and the pulse is still active and tense. If, after the dis- ease has continued for five or six days, the pulse continues to be full and pretty active during the exacerbations, the abstraction of three or four ounces of blood, seldom fails to make a favorable impression on the disease. When strong delirium or a state of stupor supervene, and the momentum of the general circulation has been moderated, much benefit may occasionally be derived from leeching behind the ears or on the temples. In general, however, more advantage may be obtained, under these circum- stances, from cold applications to the head, than from local de- pletion. I have frequently known, the symptoms of cerebral irri- tation and congestion in cases of this kind, speedily and very greatly moderated by the continued application of cold water or ice to the top and forepart of the head. If the feet are cool, which, in the latter period of the disease is sometimes the case, they ought to be excited by stimulating frictions or by warm ap- plications, at the same time that cold is applied to the head. Besides the remedies already mentioned, diaphoretics also, are very useful means for reducing the febrile reaction. The skin is generally obstinately dry and very hot; and a free action of the cutaneous exhalents is almost invariably attended with obvious abatement of the general febrile irritation. A simple solution of tartar emetic in water, or the antimonial wine, given in small but repeated doses so as to keep up a slight degree of nausea, will frequently do considerable good. I have often employed the following mixtures with unequivocal benefit.* To a child of from three to six years old a dessert spoonful should be given every two hours during the exacerbations of the fever. A mixture of spirit. * R Nitrat potassse Qii; pulv. extract, glycyrrh. 3ii; tart, antimonii, gr. i; spirit, nit dulc. 3'ii; aq. fontanae giv. M. ft. R Muriat. amnion. 3i; or pulv. extract, glycyrrh. 3iii; vin. antimon. 3ii; aq. forta- nm giv. M. ft. 316 REMITTENTS OF INFAISTS. menderiri, and the sweet spirits of nitre, in the proportion of an ounce of the former to a drachm of the latter, and sweetened with lemon syrup, forms also an excellent diaphoretic, in this complaint. One or two teaspoonfuls should be given, every two or three hours, according to the age of the patient. If, after the violence of the febrile reaction has been moderated, the brain continues to be in an irritated or congested condition, that is, if much delirium or stupor be present, blisters applied to the back of the neck, at the same time, that cold applications are made to the head, will sometimes procure very considerable relief. It is often very difficult to determine whether the manifestations of cerebral disturbance arise from incipient inflammation, or from mere sympathetic irritation of the brain. If the former be the case, opiates, are of course wholly inadmissible; but, in instances of the latter condition, they often produce a highly salutary effect. In general, when at an advanced period of the disease, the deli- rium and cerebral disturbance is associated with a small, frequent and feeble pulse, a pale and sunken countenance, great jactitation and cool hands and feet, and especially when with these symptoms the patient can be roused from his stupor or delirium, opium may be employed with a prospect of much advantage. The best mode of using this narcotic is in the form of Dover's powder, in union with small portions of calomel. I have in some instances derived very great benefit from the administration of this remedy, in grain doses repeated every three or four hours. When the cerebral dis- turbance is entirely irritative and symptomatic of gastro-intestinal irritation, the pulse becomes softer and slower, the skin moist and of a natural temperature, and the patient falls into an easy and sound sleep, as soon as the system is under the influence of the opium. When he awakens his mind is usually much tranquillized, and the whole aspect of the disease is sometimes changed for the better. In the latter period of the disease, when the fever is about subsiding, the patient, though not distinctly delirious, is occasion- ally extremely restless, and unable to obtain any sleep during the night. In instances of this kind, two or three grains of Dover's powder, given in the evening, generally produces a very soothing effect. It must be particularly observed however, that, although often highly beneficial in the advanced periods of the disease, REMITTENTS OF INFANTS. 317 opium can very rarely be employed at an early stage, or before the febrile reaction has been considerably moderated by evacuants without incurring much risk of serious injury. In feeble and sick- ly children, I have occasionally administered a few grains of this anodyne, after the free operation of a purge, with evident advan- tage, at an early period of the complaint. In these cases, how- ever, the face was not flushed and the patient was very restless instead of drowsy,as is usually the case,during the exacerbations. When the abdomen becomes tumid and tender to pressure, the application of a few leeches to the epigastrium generally produces a very good effect. A large emolient poultice laid over the whole abdomen, may also be resorted to, with much advantage in cases of this kind. The abdominal tumor in such cases, arises from flatulent distention of the bowels; and hence the expulsion of the confined flatus, frequently affords immediate relief. For this pur- pose injections of a watery solution of assafcetida, may sometimes be used with considerable benefit; but the remedy which has most frequently succeeded, in my hands, in reducing the abdominal distention, is the spirits of turpentine, administered internally, in doses of from eight to twelve drops three or four times daily. In very protracted cases, when the system is much prostrated and the bowels are in an irritated and tympanitic condition this article is indeed a very excellent remedy. It not only excites the bowels to contract, and to expel the confined wind, but it often exerts an evident beneficial influence on the intestinal secretions, and, it would seem, on the irritation of the mucous membrane of the stomach and bowels. After the disease has been in a great measure subdued and the alvine evacuations have acquired a natural appearance, mild tonics may sometimes be used with considerable benefit, during conval- escence. A weak infusion of bark, or of Colombo, will answer well for this purpose. I have in several instances used finely pow- dered charcoal, in union with powdered ginger, with very obvious benefit. From ten to fifteen grains of the former, to six or eight grains of the latter article, may be given three or four times daily. The diet ought to be of the lightest and most unirritating kind possible. During the active stages of the disease, toast water, 2S 318 OF CATARRH. FEVER. thin barley water, or rice water, will be sufficient. Every kind of solid food must be rigidly prohibited. For drink, the patient may use wreak lemonade, toast water, and occasionally a table spoonful or two, of fresh water. During convalescence, chicken, lamb, or mutton broth, boiled rice, arrow root &c. will be proper. CHAPTER XXV. CATARRH. CATARRHAL FEVER. Catarrhal affections under various forms and grades of vio- lence, are among the most common diseases of infancy and childhood. These complaints are particularly apt to occur auring raw, variable, and humid weather, and hence they are most frequently met with in the spring and winter, more especi- ally when the latter season is moist and open. It is also, apt to occur during summer, when after a long spell of damp and clear weather, the atmosphere suddenly becomes dry and very hot. Catarrhal fever sometimes prevails epidemically, and the disease has been known to confine itself, in a great measure, to children. An epidemic of this kind occurred throughout the eastern states in 1821, in which by far the greater number of cases were among children. This malady is characterized by fever, cough, slight hoarseness, some difficulty of breathing, running at the nose, sneezing, and that peculiar watery appearance of the eyes which occurs in the commencement of measles. The disease begins with a slight feeling of chilliness, and occasionally with a distinctly formed chill. The hands and feet become cold, the whole surface of the body pale and contracted, and the patient appears languid and drowsy. This state of depression frequently continues for a whole day before the febrile reaction is fully developed. In OF CATARRH. FEVER. 319 many instances, however, the fever supervenes in a very short time after the first feelings of indisposition. The patient com- plains of aching pains in the extremities and back, the pulse be- comes frequent, somewhat tense and generally full, the cheeks flushed, the eyes suffused with tears, and a thin transparent fluid usually issues from the nose attended in the commencement with frequent sneezing. The skin is dry and husky, though seldom much above the natural temperature. The bowels are torpid, and the urine scanty and high-colored; and, in many instances the alvine evacuations, during the first few days, manifest a defi- cient secretion, and sometimes an entire absence of bile. In some cases, cough with slight hoarseness, is one of the earliest symptoms; more frequently, however, the cough does not come on until the fever is fully developed, and often not until the dis- ease has continued for two or three days. The breathing is not often much oppressed in the early periods of the disease, though frequently attended with considerable rattling in the trachea. In severe cases, however, respiration is frequently difficult and wheezing, almost as soon as the fever is developed, owing to the abundant secretion of mucus into the air cells. This is most apt to be the case in infants, who, from not making any efforts to relieve the lungs by expectoration, suffer the bronchial secretions to accumulate, in the air passages. Hence the operation of an emetic, or spontaneous vomiting, by expelling the mucus from the bronchia, is always followed by an immediate, though but temporary cessation of the pectoral oppression and dyspnoea. In general, the more violent the cough is in the early stage of the disease, the less mucus is secreted and discharged from the lungs; and when the bronchial irritation is about passing.into inflamma- tion, the cough, usually, becomes perfectly dry. In the ordinary form and course of the disease, the expectoration becomes very abundant, after the fever has continued for three or four days; and as the copious secretion of mucus keeps up a constant irri- tation of the bronchia, the cough, usually becomes very frequent as the disease advances. The liver, often, is much affected in this variety of fever. In infants, the epigastrium and right hypochondrium, sometimes, become tumid, tense and sore to pressure—a condition, which 320 OF CATARRH. FEVER. has led to the vulgar notion that the child is " liver grown," as it is called. The liver, in cases of this kind, is evidently greatly engorged with blood, attended with more or less functional tor- por. During the first two or three days, the discharges from the bowels are frequently whitish or clay-colored; but as the dis- ease advances, an abundance of light-green or dark bile appears in the evacuations. In violent cases, delirium sometimes occurs, particularly in the afternoon and at night. There is generally a distinct remission of the febrile symptoms, in the morning, though usually of very short duration. The occurrence of bile in the evacuations, if accompanied with a soft and moist skin, and a more copious secretion of urine, is almost always followed by a speedy declension of the disease. When, on the contrary, the alvine discharges become watery and muddy, or reddish, with shreds and flocculi of mucus, resem- bling the washings of flesh, attended, as these discharges almost invariably are, by a bloated or tympanitic state of the abdomen, and a very dry and harsh condition of the skin, the worst conse- quences are to be apprehended. When death takes place, at an early period, it is generally from engorgement of the lungs and sudden effusion into the air cells, or from the supervention of bronchial or pneumonic inflammation. The occurrence of con- vulsions, in this complaint, is always a highly unfavorable circum- stance. Great somnolency or drowsiness, when attended with difficult breathing, is also very unfavorable, as they indicate strong cerebral and pulmonary congestions. During the declension of the disease, a very copious discharge of thick mucus generally occurs from the nose, and trachea; and this, with the cough, often continues for several weeks after the fever has completely subsided. Treatment.—In prescribing for this disease, we must endeavor to restore the regular action of the skin and liver; to moderate the febrile excitement of the heart and arteries; to allay the irritation of the mucous membrane of the respiratory passages, and to obviate local congestions or inflammations. The bowels should, in the first place, be freely evacuated, by a full dose of calomel, followed, in three or four hours, by a dose of castor oil, magnesia, or infusion of senna and manna. OF CATARRH. FEVER 321 If the pulse is full and active, or when symptoms of severe pulmo- nary congestion or inflammation occur, blood ought to be drawn, so as to make an obvious impression on the circulation, either with the lancet or by leeching. When the child complains of pain in the chest, or when the breathing is laborious, this mea- sure is of great importance, and should never be neglected. In many cases, however, the pectoral symptoms are slight and the pulse is not sufficiently active to require or warrant the abstraction of blood. As soon as the bowels have been well evacuated, re- course should be had to antimonials, and to small doses of calo- mel in union with ipecacuanna, with a view of exciting the cuta- neous and hepatic secretions and keeping up a moderate action of the bowels. From a quarter to a half a grain of calomel, with a half a grain or a grain of ipecacuanna, according to the age of the patient, may be given three or four times daily, until the stools have become distinctly bilious. When this occurs, a dose of cas- tor-oil, or of magnesia should be administered, so as to procure pretty free purging. At the same time that this remedy is em- ployed, small doses of tartar emetic may be very beneficially ad- ministered. The best way, perhaps, of employing antimony in this disease, is to give it in combination with some mild expectorant mix- ture. I have found the following, very excellent mixtures for this purpose.* A teaspoonful may be given to an infant every two or three hours. After the febrile reaction has been moderated, or where it is feeble in the early stage of the complaint, much benefit will often result from the use of small doses of Dover's powder. Where however, the lungs are much oppressed, by too copious a secre- tion of bronchial mucus, and the patient appears drowsy, opiates are decidedly improper in infants; for, if the bronchial irritation is lulled by the use of opium, the cough will be suspended, and suffer the mucus to accumulate to a dangerous extent in the air cells and bronchia. When the breathing is oppressed from this cause in infants, nothing affords more certain and speedy relief than the * R. Muriate of ammonia, gii; Extract. Glycyrrh. 3iii; Aq. fontanae, giii; Tart Antimonii, grs. ii; Syrup. Scillse, 3"i- M. or R. Spirit. Minderiri, gii; Syrup. Scillae, gss; Vin. Antimonii, 3H; Spirit. Nitn Dulc. 3iii; Sacch. Albi gss. M. 2 T 28* 322 OF CATARRH. FEVER. operation of an emetic. The concussive action of vomiting, rare- ly fails to free the lungs from the viscid mucus, that may be lodged in the bronchia and air cells. When the pectoral oppres- sion is severe, a large emolient poultice laid over the breast, will, frequently, procure considerable relief; but when the cough is violent and painful, and the breathing laborious, a blister applied to the chest will be the most effectual means of relief and ought not to be neglected. To promote the action of the cutaneous exhalents, the warm bath is sometimes very beneficial, particularly after the acute symptoms have, in some degree, subsided. During the declension of the disease, expectorants and small doses of opi- ate remedies, are usually of essential service. A mixture of equal parts of tinct. opii. camphoratae, syrup of squills, and sweet spirits of nitre, forms an excellent remedy for this purpose. From twenty to sixty drops, according to the age of the patient, should be given three or four times daily. The hive syrup, and brown mixture,* are also very useful expectorants, in the latter stage of the disease. Congestive Catarrhal Fever.—Infants are liable to a catarrhal affection, in which the prominent symptoms are those of violent pulmonary congestion, with but little or no development of febrile excitement. So far as I know, Dr. Parrish, of Philadelphia, is the first, who has given a particular account of this dangerous ma- lady .t This modification of the disease commences with cough, and the breathing soon becomes laborious and wheezing; the face is very pale, and the whole surface cold, though generally soft or moist. The pulse is considerably accelerated, but is free from tension, quickness, or firmness. The countenance acquires a peculiar expression of distress and anxiety, and in severe cases, the cheeks become very cold even when the other parts of the sur- face, are of a natural temperature. The stomach and bowels are generally inactive, and the urine is small in quantity, but so far * R. Extract, glycyrrh. 3U; Aq. fontanae giv; Vin. Antimonii 3ii; Tinct. Opii. Camph. 3'i- M. Dose from one to two teaspoonfuls every three or four hours, a word- ing to the age of the child. t Observations on a peculiar Catarrhal Complaint in children. By Joseph Parrish, M. D. &c.—See, North American Medical and Surgical Journal, vol. i. p. 24. OF CATARRH. FEVER. 323 as I have observed, nearly of a natural or healthy color. After the disease has continued for some time, a cold perspiration some- times breaks out on the face and neck. The cough is at first dry, attended with a wheezing sound in the chest; but towards the termination of the complaint, it frequently becomes humid or rattling. The pulse, in violent cases, becomes very small and rapid, and the tendency to sinking, is in all instances, very obvi- ous. There is constantly much difficulty of breathing, but at times, the oppression becomes so great as to resemble a violent attack of asthma. Occasionally considerable remissions occur, for a short period, during which the pulse will become somewhat fuller and slower, and the countenance brighter and more calm. When the disease is tending to a fatal termination, the patient becomes drowsy, insensible and comatose, and death takes place, by suffocation, or in a paroxysm of convulsions. This disease seldom continues longer than two or three days, and in very yroung infants, death sometimes takes place, in the course of the first day. It is most frequently met with in infants under a year old, and I have witnessed several cases during the first month. After dentition is completed, catarrhal affections appear to be less apt to assume this congestive character; although vio- lent pulmonary congestion and fatal effusion into the air passages, occur at every period of life as consequences of pneumonia or bronchial inflammation. Dr. Parrish thinks that the dyspnoea, which forms the promi- nent symptom of the disease, " is undoubtedly of a spasmodic character," depending probably on " a constitutional debility of the respiratory organs." My own observations have led me to a very different conclusion. From carefully attending to the phe- nomena and progress of several cases of this kind, I am entirely convinced, that the oppressed respiration and other characteristic symptoms of this disease, depend mainly if not wholly on great sanguineous engorgement of the pulmonary blood-vessels. The disease is manifestly catarrhal; but the lungs are, at once, so entirely oppressed by excessive sanguineous congestion, that the vital energies are too much depressed to admit of the develop- ment of distinct febrile reaction, and local inflammation. It seems to me to bear the same relation to acute bronchitis or 324 OF CATARRH. FEVER. peripneumony, that apoplexy or coma does to phrenitis. It is a kind of apoplexy of the lungs. Extremely oppressed respiration, paleness of countenance, cough, and coolness of the surface, arc precisely the phenomena we should expect to occur, from exces- sive sanguineous engorgement of the lungs. Dr. Parrish uses antispasmodics, particularly assafcetida and the oil of amber in the treatment of this malady; and he seems to regard their apparent usefulness, as an evidence of the correctness of his opinion on this subject—namely, that the "dyspnoea is undoubt- edly of a spasmodic character." It must be observed, however, that he employs, also, emetics, purgatives, blisters to the breast, and the warm bath; and although he regards them only as "use- ful auxiliaries" to the assafoetida and oil of amber, they are just such remedies, as one would place most reliance on for the removal of pulmonary congestion; and I cannot doubt that they were in reality the means which effected the beneficial results in the cases he has reported. Treatment.—The principal object in the treatment of this complaint, is to relieve the congested condition of the lungs, and to prevent the development of inflammation. The child should be immediately placed in a warm bath, and an antimonial emetic administered. Vomiting seldom fails to procure some benefit; but the relief obtained from it, is generally temporary, and in the beginning of the disease, sometimes but very slight. The most effectual means for relieving the lungs, is the application of a large epispastic over the breast, and this should never be omitted when the pectoral oppression is severe. The bowels, also should be freely evacuated; and for this purpose, a full dose of calomel is, perhaps, the most beneficial. Frequent and very active purg- ing, however, has appeared to me injurious in this complaint. After the intestines have, in the first place, been well evacuated, it will, I think, be best to keep them in a loose state, by the exhi- bition of a moderate dose of calomel in the evening, assisted .f necessary, next morning, by a small portion of castor oil. To determine the circulation to the inferior parts of the bodyj some advantage may also be derived from the application of sinapisms to the feet. Dr. Parrish speaks very favorably of the use of assa- OF CATARRH. FEVER. 325 foetida and the oil of amber. He mentions an extreme and an apparently hopeless case, the unexpected recovery of which he ascribes chiefly to the agency of the former of these antispasmo- dics. " I should," he says," have despaired of the case, had I not known under what apparently hopeless circumstances infants sometimes recover. I ordered the warm bath, sinapisms to the feet, a large blister over the breast, and laxative injections con- taining assafcetida. But the remedy on which 1 chiefly relied, was assafoetida rubbed up with mint water, given frequently and in large doses. To the astonishment of every one who witnessed the case, my little patient perfectly recovered." The assafoetida, doubtless, had its share in the production of this fortunate result; but this case certainly cannot be regarded as a fair example of its efficacy, since the other means employed along with it, are by themselves, generally', sufficient to remove the disease. I have never yet employed any antispasmodics in the treatment of this affection—having always relied, principally, on the remedies already mentioned, particularly blistering, the warm bath, and emetics. When the pulse is very feeble, wine-whey, or a weak solution of the carbonate of ammonia may be used with much advantage. I would not, however, say any thing against the free employment of assafcetida; on the contrary, the authority of Dr. Parrish, is sufficient to convince me, that it is a remedy of excel- lent powers in this complaint. I doubt, however, whether its good effects can be justly ascribed to its antispasmodic operation. It is rather by a general stimulant and expectorant influence, I conceive, that it contributes to the reduction of this formidable malady. Dr. P. directs, that one drachm of this gum, be rubbed up with an ounce of mint-water, and given in teaspoonful doses, repeated every two hours. "If this shall be found too strong, it should be diluted, till of such a strength as the child can bear." I have as yet said nothing of blood-letting. When there is considerable fulness and activity in the pulse, the abstraction of a small quantity of blood, with the lancet, is often highly benefi- cial. I have, in some instances, procured prompt and very decided relief by bleeding. When the pulse is very frequent, small, and feeble, as it sometimes is, blood cannot be drawn vvithout considerable risk of increasing the prostration to a fatal 326 0F CATARRH. FEVER. extent. Before bleeding is resorted to, where the state of the pulse does not distinctly indicate the propriety of the measure, it will, in general, be best to premise the use of the warm bath, and the application of sinapisms to the feet. If these do not, in some degree, increase the fulness and force of the pulse, it will be most prudent to abstain from drawing blood. In moderate cases, I have known very obvious benefit to result from the application of a large emolient poultice, renewed every two or three hours, so as to keep it sufficiently warm and moist. When the bronchial exhalents begin to relieve themselves, by secreting an abundance of mucus; or when the respiration and cough are attended with a rattling sound in the chest, the hive syrup, or a decoction of the seneca root, repeated at short inter- vals, until vomiting is produced, will sometimes procure very considerable relief. Opiates are, in general, decidedly improper in this affection, particularly in very young infants, and when the secretion of bronchial mucus is copious. Dr. Parrish, says that the fumes of rosin "are often highly beneficial." I have my- self, in one instance, resorted to the inhalation of these fumes, with an evidently beneficial effect on the breathing. OF ACUTE BRONCHITIS. 327 CHAPTER XXVI. ACUTE BRONCHITIS. This disease, as it occurs in infants, often bears a close resem- blance, in its early stage, to the congestive complaint described in the preceding section. They are, indeed, produced by the same cause; but in the present disease along with the sanguine- ous engorgement of the lungs, more or less inflammation, is developed in the mucous membrane of the bronchia. The disease usually begins, with chilliness, or a cold and con- tracted state of the surface, a languid and pale appearance of the countenance, slight cough, and some difficulty of breathing. After some time, the pulse becomes frequent, quick somewhat full and resisting. The cough increases, is slightly hoarse, and has a stifled sound. The breathing also, rapidly becomes more and more oppressed and laborious. When the child is old enough to give an account of its sensations, it com- plains of a feeling of weight and tightness in the breast, but seldom of any pain. Nevertheless, when the cough is violent, infants sometimes cry out, as if from pain; and the inspirations are occasionally catching and attended with an expression of pain in the countenance. At first the breathing and cough are dry, but in the course of the first twelve hours, and often soon after the commencement of the febrile reaction, a copious secre- tion of transparent, viscid mucus takes place, into the bronchia. In most instances, vomiting occurs during the first twenty-four hours; and the epigastrium frequently becomes distended and elastic. As the disease advances, the mucous secretion into the air cells and bronchia, increases progressively; the child becomes drowsy, the lips livid, and the countenance expressive of great distress, the muscular debility is always very great. When the ^28 OF ACUTE BRONCHITIS. disease is once fully developed, the child often manifests much uneasiness by being placed in the recumbent position. The countenance is very rarely, even slightly, flushed; on the con- trary, throughout the whole disease, it is almost invariably extremely pale and anxious. Towards the fatal termination, the cheeks and lips sometimes acquire a slightly livid hue. The temperature of this surface, is generally somewhat above the natural standard, on the trunk,—but the hands and feet, are fre- quently cool or about the regular temperature. The difficulty of respiration, is not uniform. Occasionally it is pretty easy, for a short period, and then suddenly, becomes, extremely oppressed. The cough too, after the disease has continued, until the secre- tion of bronchial mucus is very copious, becomes, in a manner, paroxysmal—violent spells coming on at irregular, and generally short periods, with comparative exemption from it, during the intervals. The progress of the disease, is generally rapid. In some in- stances it terminates fatally as early as the third day; more frequently, however, its course is protracted to the sixth day. Great drowsiness or coma, almost invariably precedes the fatal termination. But even after the lungs appear to be completely clogged with the effused mucus, and the child has sunk into a comatose state, " gleams of hope sometimes burst upon us. For a short time the difficulty of respiration may seem to subside, and the child to be better. But these hopes are very rarely realized; for even the next exacerbation of dyspnoea may terminate in suffocation." On dissection the lungs do not collapse when the thorax ia opened. The whole structure of the lungs, usually appears, infiltrated, or engorged with a thin viscid fluid. The mucous membrane of the bronchia, is generally of a bright red color, from minute injection of its capillary vessels. The smaller branches of the bronchia, are commonly filled with tough mucus, bloody serum, or purulent matter. In those cases that succeed pustular exanthematous affections, the mucous membrane of the large bronchial tubes, sometimes presents a number of very small ulcerations, and slight fungoid elevations. In severe cases, it is not uncommon to meet with a red hepatized condition, of a OF ACUTE BRONCHITIS. 329 portion of the lungs; and occasionally there is an approach towards the formation of tubercles. The great muscular prostration and somnolent condition which occur in this disease, doubtless, arise from deficient decarboni- r.ation of the blood; for death generally occurs from asphyxia, or suffocation, in consequence of the entire obstruction of the air cells, and smaller bronchial branches, by the viscid mucus so co- piously secreted in this affection. It seems probable, however that death sometimes occurs, also in consequence of the inflamed mucous membrane preventing the atmospheric air from producing the necessary change in the veinous blood. Cases of fatal dysp- noea are related by M. Andral, jr. in which no effusion or redundant secretion of mucus had taken place, nor any lesion of the proper substance of the lungs, discovered on dissection. It seems highly probable, that, whether the oxygen enter into the blood-vessels, or the carbon be thrown out through the mucous membrane, the regu- lar influence of the air, on the veinous blood, will be impeded or perverted when this delicate structure is in a state of intense inflammation. The difficulty of respiration which occurs in the early stage of this complaint, is, perhaps, chiefly attributable to this cause, and not to the clogging of the bronchial cells, by vis- cid secretions, as is generally supposed. Treatment.—Blood-letting is in general a highly valuable means of relief, in the early stage of this affection. In robust and ple- thoric infants, particularly when the pulse is active, prompt and efficient, bleeding, either with the lancet or by leeching, may be deemed indispensable. The period, however, during which this measure may be resorted to with a prospect of advantage is not very long. The blood ought to be abstracted at an early period —as soon after the inflammation is developed, as possible. If it be delayed, until effusion or a copious secretion of bronchial mucus has taken place, the chance of benefit from it, will be but very small, and injury, probably, will be the result. If the cough is dry, and the respiration not attended with a rattling sound in fhe trachea, blood may be drawn, with a fair prospect of advantage; and a sufficient quantity ought to be taken away, at the first bleed- ing, to make an obvious impression on the action of the heart and 2U 29 330 0F ACUTE BRONCHITIS. arteries. Much benefit may be derived from the application of leeches to the chest; more especially, after blood has been ab- stracted with the lancet. No remedy, howrever, contributes more powerfully to the reduction of the bronchial inflammation than blistering. As soon as blood has been efficiently abstracted or at once in the very commencement of the disease if the pulse be small and feeble, a large epispastic ought to be laid over the breast and suffered to remain until the skin is uniformly inflamed. It must then be removed and a large emolient poultice laid over the part. The bowels should be freely evacuated, by a full dose of calomel and rhubarb; and afterwards kept in a loose state by purgative enemata, and small doses of some of the milder laxatives. Half a grain of calomel with the same quantity of ipecacuanna may be advantageously used for this purpose. Emetics also are very use- ful remedies, in this affection. They generally procure immediate relief of the oppression in the chest, by expelling the viscid mucus which clogs the bronchial cells, and diminishing the pulmonary congestion. A mixture of antimonial wine and syrup of squills, in the proportion of one part of the former to three parts of the latter, forms an excellent emetic, for this purpose. A teaspoon- ful of this mixture should be given every twenty minutes, until active vomiting is excited. Expectorants may also be used with advantage in this affection. In the early period of the disease, the more stimulating articles of this kind must be avoided. I have frequently employed the following mixture, for this purpose, with evident benefit.* After the febrile reaction has been moderated and there is much secretion into the bronchia, the more stimula- ting expectorants, will be proper. The following combination, frequently, produces a very good effect, in the advanced periods of the disease.t When there is much prostration, or when the pulse is small and feeble, in the latter stage of the disease, stim- ulants should be used, along with expectorants. The carbonate of ammonia is an excellent remedy in this state of the disease. It * R. Tart, antimonii. gr. ii; sal. tart. 3U? aq. fontanae giiss mel. opt. giss. M. Dose, a tea spoonful every hour or two. t R. G. ammoniac gii; infusio polygala senegae giv; syrup scillae gss. Dose, a tes- spoonful, every two hours. OF ACUTE BRONCHITIS. 331 may be given according to this formula.* Hoffman declares, that he has known a combination of the flowers of benzoin and cam- phor, to procure complete relief, in cases, apparently hopeless. To an infant, of from one to three years old, a quarter of a grain of the former article with half a grain of the latter, rubbed up with a small portion of sugar, may be given every two hours. Opium is seldom beneficial in this disease; and may readily do a great deal of harm, by suspending, for a time, the efforts to ex- pectorate, and thus giving rise to a dangerous accumulation of mucus in the bronchial tubes. When the cough remains dry, (which however, is rarely the case) and the momentum of the cir- culation has been diminished by depiction, considerable benefit may be derived from the judicious employment of this narcotic. In such cases, small doses of Dover's powder,in union with calomel, generally moderate the violence of the cough, and assist expecto- ration. To allay general irritation, and restlessness, during the declens'on of the disease, the tincture of hyoscyamus or of bella- donna is often very useful. Exhibited in doses of from two to four drops every four hours, it seldom fails to tranquillize the ner- vous system, and to moderate the cough. When the skin is slow in resuming its regular perspiratory action, these narcotic tinctures may be very beneficially given in union with antimonial wine. * R. Carbon, ammon. 9ii; ext. glycyrrh. 3"; aq. fontanae, giv, acid, scillas 3°"- M. Dose, a tea spoonful every hour or two. 332 °F PLEIJRITTS. CHAPTER XXVII. PLEURITIS. Inflammation of the pleura is a much more common affection, during infancy than many suppose.* It commences as other in- flammatory affections do, with a feeling of chilliness and a pale and contracted state of the surface. This is soon succeeded by high febrile reaction. The skin becomes very dry and warm, the face flushed, and the pulse frequent, full and strong. The breath- ing is hurried, short and somewhat oppressed, particularly when the patient is lying down. The cough is at first dry and short, and the infant evidently endeavours to stifle it as much as possible, to avoid the pain which it always occasions. When the child is laid down, it generally begins to cough and cry, and the muscles of its countenance are contracted into an expression of pain and suffering. There is also much more cough and uneasiness, when the patient lies on one side than on the other. In some instances, the patient rests easiest when lying on his back, with the head and shoulders raised, both sides being equally affected. Some- times each inspiration is attended with a whine or moan, and the countenance is always expressive of pain. If the disease is not early moderated, or checked in its course, the breathing becomes more and more difficult and painful; and if any of the viscid bron- chial mucus is thrown out, it is frequently found streaked with blood. "The cough is attended with a rattling sound in the trachea; the extremities become cold; the countenance often slightly livid, and the patient finally sinks into a state of drowsi- ness or stupor. The pulse, at last, becomes irregular, and often intermittent, the extremities swell, the breathing becomes short, and a frothy fluid oozes from the mouth." During the whole course of the disease the respiration is performed, chiefly by the * Dr. Burns. OF PLEURITIS. 333 action of the abdominal muscles, and diaphragm—the motion of the chest being instinctively restrained by the patient, on account of the increase of pain which the dilatation of the thorax or eleva- tion of the ribs always occasion in the inflamed pleura. On post mortem examination, the pleura is generally found uni- formly red, or punctuated with an infinitude of red specks of irregular shape, and very close together. In many cases a con- siderable quantity of serum is effused into the cavity of the pleura; and adhesions, more or less extensive, between the costal and pul- monary pleura occur in the majority of instances. Occasionally, some portions of the lungs are found hepatized; and a general infiltration of serum into the pulmonary structure is not un- common. The occurrence of diarrhoea in this disease, is always an ex- tremely unfavorable circumstance; convulsions and coma, too, are no less ominous of a fatal tendency. Great distress and agitation, when placed in recumbent position, particularly when the breath- ing is attended with a wheezing sound in the trachea, and the pulse is small and irregular are extremely unfavorable signs. When the skin becomes uniformly moist, the pulse less frequent and soft, the cough attended with a free discharge or raising of bronchial mucus, and the patient is able to rest on either side, a favorable termination may be confidently expected. Treatment.—Prompt and very efficient blood-letting is indispen- sable in the treatment of this form of pectoral inflammation. Blood should be freely drawn with the lancet, until a decided im- pression is made on the pulse. The early application of leeches to the chest is also a highly important measure. As soon as the momentum of the circulation has been moderated, a blister ought to be laid over the breast, and managed in the way mentioned in the preceding chapter. The bowels must in the first place be freely evacuated, by an efficient dose of calomel and rhubarb, and kept in a loose state throughout the whole course of the disease, by small doses of calomel and ipecacuanna, or suitable portions of epsom salts. The cooling diaphoretics are very useful auxiliary remedies in this affection. The nitrate of potash with minute portions of ai.- 29* 334 OF PLEURITIS. timony generally contributes materially to the reduction of the fe- brile irritation. The following is an excellent mixture for this purpose.* Small doses of the pulvis antimonialis, in union with calomel, may also be employed, with much advantage, when the skin is very dry and warm. With the view both of diminishing the action of the heart and arteries, and of promoting expectora- tion, a simple solution of tartar emetic, given in very small but frequent doses, often proves decidedly beneficial. Dr. Burns says, that antimonials ought never to be given, in this complaint, to the extent of producing "decided sickness." I have witnessed no evil consequences from nauseating doses of tart, emetic, in the present disease, but, on the contrary, often unequivocal bene- fit. I have generally made it a point to administer this arti- cle so as to produce slight manifestations of nausea; and I am persuaded, that in the early stage of the disease, while the pulse is active and the skin hot and dry, much advantage will in general, result, from this mode of employing antimony. As a dia- phoretic expectorant, the kermes mineral, given according to the formula below,! sometimes produce a very good effect, parti- cularly when the cough is dry and harsh. If after the disease has been in a great degree subdued, the cough continues to be very severe, and the patient is restless, considerable benefit may some- times be obtained from the use of small doses of Dover's powder. A few grains administered, once or twice daily, usually has the effect, of improving the expectoration, allaying the pain and rest- lessness, and exciting the regular action of the cutaneous ex- halents. This article is particularly useful, during convalescence from this and other forms of pectoral inflammation, more espe- cially when the pulse is small, and irritated and the skin dry. In the advanced stages of the disease, when (although the local inflammation and fever, appear to be almost entirely subdued,) the child is incapable of resting in a recumbent posture, the employ- ment of diuretic remedies is sometimes attended with marked * Nitrat. potasss, gii; extract, glycyrrh. 3"» ^^ antimonii gr. ii; sacch. albi. gss; aq. fontanae giii. M. Dose, one or two teaspoonfuls, every hour or two, according to the age of the patient. t Kermes mineralis gr. xv; extract, glycyrrh. 3ii; aq. fontanae giii.; syrup Scillae 3ii. M. Dose, a teaspoonful every two or three hours. OF PLEURITIS. 335 benefit. In cases of this kind there is often a considerable quan- tity of serum effused into the cavity of the pleura, so that the mo- ment the child is laid down, with its head low, it becomes agitated and begins to cough, pant, and cry. To promote the absorption of the effused fluid, small doses of squill and calomel, ought to be given three or four times daily, until the child is able to sleep in a horizontal position. The fourth of a grain of dried squills with the same quantity of calomel forms a full dose for a child, of from one to three years old. A mixture of the tincture of digitalis and vinegar of squills, in equal quantities, may also be used for this purpose; and I have known much benefit to result in this respect, from a mixture of equal portions of the syrup of squills and the sweet spirits of nitre, given in doses of from twenty to thirty drops, three or four times in the course of a day. When after the pleu- ritic symptoms have been removed, the child continues to be affected with cough, and a short and uneasy respiration, no reme- dy has appeared to me so valuable as the tincture of sanguinaria Canadensis. I have rarely known it to fail in removing the pul- monary irritation in such cases. From two to four drops may be given three times daily to a child under three years old. 336 OF PAROTITIS. MUMPS. CHAPTER XXVIII. Barotitis, mumps. Parotitis is a specific inflammatory affection, particularly liable to be transferred to the testes in males and mammae in females; propagated by a peculiar contagion, and occurring sometimes spasmodically. Symptoms.—Slight febrile symptoms generally usher in the disease, which is first manifested by a feeling of stiffness about jaws, and a little tumor and pain in one or both parotid glands. The swelling in the beginning is moveable, but it soon becomes widely diffused, frequently involving the maxillary glands. It gradually increases until the fourth day, when the affected gland is very firm, tender and elastic to the touch. The skin over the tumor retains for the most part its natural hue, although in some instances it is changed to a pale red, and occasionally a bright red color. The maxillary glands, are sometimes more largely affected than the parotid. Mastication and deglutition are in all cases attended with considerable pain. The fever is in general mild, though the patient is frequently troubled with considerable restlessness and nervous irritability. The inflammation begins to decline about the fourth day, and very rarely tends to suppura- tion. The other inflammatory symptoms now likewise subside, and about the seventh day from the beginning of the disease, detumescence is complete. Diaphoresis, more or less general, and a red urinary deposition, usually accompany the subsidence of the affection. Metastasis of the disease sometimes occurs upon the decline of the inflammatory symptoms. In females, the breasts, and in males, the testicles are apt to become hard, swollen and more or less painful to the touch. This symptom, according to some respectable writers, is rather favorable than otherwise; for some- times where it has been absent, an exacerbation of the sympto- of mumps. 337 matic fever has taken place, violent cerebral disturbance ensued, and death been the result. Dr. Hamilton relates several instan- ces, in which, after considerable enlargement of the testicles, occurring upon the decline of the disease, this organ wasted entirely away, so that the tunica vaginialis became an empty sack. Improper exposure to cold, will sometimes cause a sudden transi- tion of the affection to these parts, in which case, if the treat- ment be not judicious, suppuration may ensue—a very painful event and one that may terminate fatally. The same cause Bometimes occasions a metastasis of the inflammation to the brain. Coma, or furious delirium now generally supervenes, and death usually follows in the course of a few hours. A case of this kind came under my notice, where in less than an hour, the patient expired in a paroxysm of convulsions. We must not forget that a metastasis of the disease to the mammae or testes is no absolute security against a secondary translation of it to the brain.* Children and young persons are most liable to the attacks of this complaint, its appearance in maturer life being very uncom- mon. It rarely affects the same individual more than once, resem- bling thus the other acute contagious diseases. Parotitis, occurring in advanced life, shows an aptitude at times to take on a chronic form, accompanied by very serious symptoms. This aptitude is most apt to occur in females in whom the menses are about ceasing, and whose general systems are in some measure deranged. Although suppuration is an uncommon termination in this com- plaint, it may yet under circumstances favoring it, take place. With the exception just noted, Parotitis may be said to be nei- ther a severe nor dangerous affection—particularly where the patient avoids exposure to low or variable temperature, and keeps the affected parts moderately and uniformly warm. Treatment.—In mild cases, beside attending to the precau- tions just mentioned, little more is necessary than keeping the bowels open and using gentle diaphoretics. Sometimes the in- flammatory symptoms run high, and we should then resort to • See history of an Endemic Parotitis, &c. Edinburgh Med. and Surg. Journ. Vol. 4, 338 OF MUMPS. active antiphlogistic measures. When the swelling disappears in the neck and shows itself in the testicles, blisters should be applied to the parotids, and every effort made to excite a general diapho- resis. A mild, cooling regimen is to be enjoined, and where the pain is extreme and the symptomatic fever severe, we must have recourse to full purging and sometimes to venesection. Emetics have occasionally been productive of much benefit in such cases. To discuss the hard tumefaction not unfrequently remaining after the disappearance of the inflammatory symptoms, frictions with mercurial ointment, spirits of camphor or rubefacient liniments should be used. QUINSY. 339 CHAPTER XXIX. TONSILLITIS. CYNANCHE TONSILLARIS. QUINSY. Inflammation of the tonsils and fauces, is a frequent complaint among children. It generally commences with a feeling of chilliness, accompanied with a huskiness of voice, an uneasy sen- sation in the fauces, and a stinging or cutting pain, in this part, on swallowing. More or less febrile reaction ensues; and in a few hours a fixed pain is experienced in the region of the tonsils, and the swallowing becomes more and more painful, until at last the action is productive of extreme anguish. On examination, one or both tonsils are found swollen, and the whole surface of the fauces present a tumid and florid aspect. In some instan- ces, the uvula and soft palate, exhibit a highly oedematous and dark red appearance. The tongue is covered with a white fur, through which the florid and enlarged papillae project; and over the whole, a thick layer of tough transparent slime is spread. In severe cases, the face becomes flushed and tumid; the carotids beat strongly; respiration is laborious, hearing obtuse, the pulse frequent, full, and hard, and the voice indistinct or whispering. In general, the patient swallows soft or pultaceous substances with more ease and less suffering, than liquids. Severe pains, usually dart from the fauces into the ears,—particularly when the patient attempts to speak or to swallow; and the mouth is opened with great difficulty and pain. The breathing is much obstructed by the extremely viscid mucus, which is so copiously secreted in the fauces; but in violent cases, the principal and most alarming source of difficult respiration is the enlargement of the tonsils; for when both are inflamed, they sometimes 340 QUINSY. become so much swollen, as to come in contact wtth each other, confining the uvula behind them, or pressing it forward into the mouth. In some instances flakes of coagulable lymph of a whitish color adhere to the inflamed tonsils, resembling superficial sloughs. In cases of this kind, the inflammation is always of a vivid red color, and its tendency is either to resolution or suppura- tion. Occasionally, however, the inflammation assumes more of an erysipelatous character, the affected parts exhibiting a dark livid, and oedematous appearance, w ith small aphthous ulcers of white or grey color on the tonsils and uvula. Instances of this kind, very rarely terminate in suppuration. Inflammation in this disease terminates in resolution or suppur- ation,—gangrene hardly ever occurring, although at times a few sloughy spots are visible in the fauces. In no structure is abscess more frequently the result of inflammatory action, than in the tonsils. Internal suppuration will often take place in a few days, despite of the most active local and general antiphlogistic mea- sures. The quantity of matter formed in a suppurated tonsil is seldom abundant: it is not often very perceptible in the sputa, a portion of it undoubtedly being commonly swallowed with the saliva. Occasionally the abscess has pointed and broken out- wardly, under the angle of the jaw. Dodonaeus relates a case, in which the patient appeared near death, where prompt relief was procured by an external incision in the abscess, and the conse- quent discharge of a large quantity of pus. This disease is never contagious, and though for the most part violent in its character, it is of short duration. In some instances, the inflammation passes down into the larynx, an occurrence that always increases the risk from the affection. Where this disease occurs in the same individual more than once, a predisposition to it is apt to be established. Frequent attacks tend also to occasion permanent enlargement and induration of the tonsils. In cold and variable climates, it is a complaint of frequent occurrence; and although by no means so dangerous as anginose affections of the respiratory passages, it is much more painful, in violent cases always alarming, and sometimes fatal. The young and the san- guine are said to be particularly liable to its attacks. QUINSY. 341 Some individuals are peculiarly predisposed to this disease. This, as before observed, is especially the case with persons, who have suffered once or twice from its invasion. But other causes such as the constitutional influence of mercury, salivation and a strumous habit of body, appear to create or constitute a predisposition to the complaint. Cold and damp air, or cold applied in any manner, so as to give a sudden check to the perspiration, is the ordinary exciting cause; and hence the frequency of its occurrence in spring and autumn, when vicissitudes and variable temperatures are most common. Standing or sitting long on cold and damp ground is particularly apt to give rise to the complaint, in those who are predispo- sed to it. Treatment.—The treatment of this affection must, of course, be strictly antiphlogistic; and, it is of much importance that effi- cient means be employed as soon as the disease is noticed; for, even where the onset of the disease is mild, we have no security that its course will not be marked with extreme violent e. When the pulse is full and active, blood ought to be promptly and effi- ciently drawn. In children, however, the febrile reaction is not often so vehement in the commencement of the disease, as to require a copious abstraction of blood; and in mild cases the inflammation may often be speedily subdued, with counter-irrita- ting applications, purgatives, warm pediluvium, &c, without the aid of direct depletion. Nevertheless, blood-letting, when regu- lated according to the state of the pulse, is always a safe and useful measure, and should never be omitted when the symptoms do not readily yield to other appropriate means. Purgatives are highly beneficial remedies in this affection. An active purge should be administered in the commencement of the treatment, and. repeated daily, until the inflammation is sub- dued, or has terminated in suppuration. For this purpose we may use five or six grains of calomel, followed in an hour or two by a suitable dose of epsom salts. I have known prompt and decided relief obtained from the use of the following emeto- cathartic mixture, given in doses of from a dessert to a table spoonful every hour, according to the age of the patient, untii 30 342 QUINSY. vomiting and purging was produced.* Diaphoretics, also, are useful auxiliaries, in the treatment of this affection. Nitre, in union with antimony, forms an excellent remedy for this purpose. Some advantage may be gained by causing the patient to place the nitre on his tongue, and swallow it as it is gradually dis- solved in the mouth. Much benefit may in general be derived from nauseating doses of tartar emetic. Of two ounces of water, holding a grain of tart, antim. in solution, a teaspoonful is to be taken everyr thirty minutes, so as to keep up a considerable degree of nausea for several hours. I have frequently prescri- bed the medicine in this way with the happiest results. The muriate of ammonia, dissolved in water, with the extract of liquorice, has been particularly recommended, t Emetics were once a good deal employed in tonsillitis, but their effects are much less beneficial in this, than in any of the other anginose affections. In infants, however, they are often highly beneficial, by removing the extremely viscid mucus which ad- heres to the palate, tonsils and fauces, and obstructs respiration. Topical bleeding, by scarifying the tonsils, generally produces excellent effects. Kopp thinks, that blood drawn in this way from the tonsils, is the most certain, prompt and efficacious reme- dial measure we possess. The early application of leeches to the throat or under the ear, although of less value, perhaps, than scarification, should by no means be neglected. Cupping on the back of the neck and under the ears, may, also, be resorted to with advantage. So soon as the momentum of the circulation has been reduced by venesection, a blister should be applied to the throat, or on the back of the neck. In slight cases of the disease, rubefacients, particularly the spirits of turpentine, or a liniment composed of two parts of aq. ammoniae to one of sweet oil, will in general suffice. Emollient poultices are also very useful applications in mild cases. Employed in the commencement of the disease, together with warm pediluvium and a purgative, the further pro- gress of the inflammation, will sometimes be speedily and effectu- * R Sulph. magnesias,......gss. Aq. fontanae,..........gviii. Tart, antimonii,........gr. i. I Leoffler. Bcitacgen Zur Arzn. Wissensch. 1. Th. Leipe. 1791, p. 142. QUINSY. 343 ally arrested. Three or four folds of thick flannel round the neck, in such instances, with the auxiliaries just mentioned, are often sufficient to prevent the developement of the malady. But in every case where inflammation is considerable, immediate recourse must be had to vesication. The early use of astringent and acid gargles has been much recommended. Cullen advises a decoction of oak bark, with alum dissolved in it, as a useful prescription for thi6 purpose. For myself, I generally prefer simple warm water, acidulated with vinegar. The principal advantage of gargles in this com- plaint would seem to be that of dissolving and removing the viscid mucus, adherent to the tonsils and palate; and this is best accomplished by warm water, either alone, or with a portion of 6ome vegetable acid, and perhaps honey. Pringle says, that he never derived any benefit from astringent gargles, and accord- ing to Storch, they have at times been evidently injurious, by checking the exhalation and secretion from the mucous surface of the inflamed parts. The inhalation of certain vapors by any simple machine, is one of the oldest remedies in this affection. The vapor of vinegar and water was used by Hippocrates. If it is obvious that suppuration cannot be prevented, every proper measure should be taken to facilitate this termination. The steam of warm water, or of water impregnated with rose- mary or chamomile leaves, should be inhaled, and astringent gargles should at once be discontinued. When the fluctuation and other symptoms indicate the formation of a tonsillar abscess, it should by all means be immediately pierced with a lancet; as the discharge of the matter will always give instant relief from the pain and difficulty of respiration. After the operation, the patient should continue for a little while, the use of some mild and slightly acidulated or astringent gargle. Occasionally, from the extent and violence of the inflamma- tion in tonsillitis, there has been so much danger of suffocation, that it has been found necessary to make an opening into the trachea; which has been done sometimes as high as the larynx, and sometimes considerably lower; and under both kinds of operation the patient has recovered. (Good.) 344 CROUP. CHAPTER XXX. CYNANCHE TRACHEALIS. TRACHEITIS. CROUP. Cynanche trachealis may be defined: an inflammation in the glottis, larynx and upper part of the trachea, attended with a hoarse and ringing cough, sonorous respiration, and a sense of impending suffocation. This form of cynanche does not appear to have been generally known as a distinct disease, until Home described it in a work published at Edinburg in 1765. It is not at all likely, however? that the disease is one of modern date, since its ordinary causes have always existed, and it cannot be presumed, that at any period of the world, their influence could have been materially different from what it is at the present day. The disease was confounded, no doubt, with other anginose affections, to some of which it bears, indeed, a very close resemblance in many of its prominent phenomena. In the long list of human diseases, there is none which presents a more painful scene of anguish and distress, or which excites more poignant feelings of sympathy in the heart of the physician, than the one now under consideration. I have witnessed the ap- proach of death under a multitude of appalling forms; but in all the death-bed scenes which it has been my misfortune to witness, I have never had my feelings so deeply afflicted as when looking on a blooming child struggling under the ruthless grasp of this terrible disease. In some instances this disease comes on sud- denly, and in a very short time acquires the utmost degree of vio- lence. More frequently, however, it is gradually developed—a dry and hoarse cough, attended with slight difficulty of breathing, roughness of voice, and some degree of languor or lassitude, being the first intimations of its approach. These symptoms sometimes continue for several days, before the disease is fully developed. CROUP. 345 Sooner or later, however, the breathing becomes more difficult, the febrile irritation more obvious, the voice more indistinct and whispering, and the cough more hoarse and sonorous. There is something so peculiar in this hoarsness—such a rough, ringing, and dry sound in the cough, as can never be mistaken by those who have once heard it—and whoever has once heard it in con- nection with the distressing symptoms which characterize the dis- ease in its state of full development, can never hear this croupy cough, without the most anxious apprehensions. The disease now advances rapidly, and in a short time, acquires the most alarming and distressing degree of violence. The countenance is flushed; the eyes prominent, injected and heavy; the pulse fre- quent, tense, and quick; the skin dry and hot; and the respira- tion extremely laborious and anxious. In the commencement of the disease the cough is often quite dry; but in the majority of cases, a very viscid and thick mucus is secreted by the mucous membrane of the fauces and larynx from its very on-set, and which from its spissidity contributes greatly to increase the diffi* culty of breathing. The sound attending the respiration, espe- cially the act of inspiration, is at first ringing and rather clear*, but in the advanced period of the disease, it is characterized by a peculiar wheezing, as if the air were forcibly driven through a very narrow aperture. The act of inspiration is always performed with much more difficulty, and occupies a much longer time than the expiration of the air. This latter act is, comparatively, quick and always unaccompanied with the shrill and wheezing sound which attends inspiration. In the advanced periods of the disease, the cough is in all instances attended with a rattling sound, and the expulsion of extremely tenacious mucus from the trachea. If the progress of the disease be not checked, the difficulty of breathing increases progressively, until, at last, the oppression be- comes inexpressibly distressing. The countenance and motions of the little patient indicate the utmost degree of anguish and suf- fering. The head is thrown backwards, and the mouth kept open to facilitate respiration; the face is of a pale livid hue, the eyes are prominent and half closed; the lips purple, the muscles of the face agitated with the respiratory effort; large drops of sweat 2 Y 30* 346 CROUP. hangon the temples and upper lip; the extremities become cold and clammy; partial insensibility ensues; the breathing becomes fee- ble and interrupted, and the patient finally sinks into a state of total insensibility, which soon puts a termination to the agonizing Struggle. Such are the ordinary course and symptoms of this dangerous affection. Much diversity, however, occurs, in relation to the degree of violence and rapidity of these phenomena. In some instances, the disease proceeds very slowly, the child being trou- bled during the day with some difficulty of breathing and a hoarse and dry cough, while at night an alarming paroxy sm of croup will occur, and continue until towards morning. In this way, the disease will sometimes go on for five or six days; the patient being so free, from any difficulty of breathing during the day, as to induce a belief that the disease has been subdued. At night, however, another attack will, perhaps, occur, and continue, with unceasing violence, and in opposition, often, to all our remedial efforts, until it terminates in death. Occasionally the disease is very gradu- ally developed, and continued for nine or ten days, without at any time acquiring a very alarming degree of violence. In cases of this kind the patient is harassed with a very hoarse cough, and considerable difficulty of breathing, with occasional severe ex- acerbations of the croupy symptoms, both during the day and at night. There is generally a pretty copious secretion of mucus in the trachea in such cases, and the respiration is usually con- stantly attended with a rattling sound in the chest. These pro- tracted and remitting cases of croup are most apt to occur during difficult dentition. It would seem, that in some instances, the predisposition to this disease is congenital; for it is well known, that the children of some families are peculiarly predisposed to this complaint, whilst in other families, it never makes its appearance. It is manifest, also, that there is something peculiar to infancy and childhood, which increases the liability to this affection; for its occurrence is vastly more common between the first and fifth year of age, than in the whole subsequent period of life. This aptitude to the disease during early childhood, has been ascribed to the peculiar condition of the glottis and larynx, at this age; croup. 347 for the existence of some peculiarity in this portion of the respi- ratory passages during infancy and childhood, unconnected, pro- bably, with mere size of aperture, may be inferred from the cha- racteristic voice at this early period, and its remarkable change at the age of puberty. There is another circumstance, how- ever, which may have a share in creating the aptitude in ques- tion, and which has reference to the exciting cause of the disease. The almost univeral mode of clothing infants—with their necks. and upper part of the breast bare, cannot fail to render them more subject to the influence of cold, and the .consequences of this cause, in the parts thus exposed. It is a fact, wh5ch**has been forcibly pressed on my attention, that in the country— especially among the Germans, who are in the habit of cloth- ing their children in such a manner as to leave no part of the breast and lower portion of the neck exposed, cynanche tra- chealis is an exceedingly rare disease. Whereas, in cities, or among people who adopt the modes of dress common in cities, this frightful disease is, in proportion to the population, vastly more frequent. During a practice of six years among this clasa of people, I recollect of having met with but a single case of this affection, and this case occurred in a family, who had adopted the present universal mode of suffering the necks and superior portions of the breasts to remain uncovered. Certain exanthematous affections, also, sometimes give rise to an increased aptitude for this disease. This is especially the case with scar- latina, measles, and miliary fever. Children of robust and full habits, appear to be much more liable to the disease than those who are feeble, relaxed, and sickly. Cold and sudden vicissitudes of atmospheric temperature, constitute the principal exciting causes of this disease; and hence its more frequent occurrence during the variable damp and cold months of autumn and spring, than in the more tempe- rate and uniform season of summer. Sitting or lying down on a damp grass plat, or in a current of air after the body has been over-heated by exercise in the sun, is particularly apt to bring on an attack of this complaint. It has been observed also, that in situations naturally abounding in moisture, cynanche trachealis is a much more common disease, than in localities of an opposite 348 CROUP. character. Under the head of occasional causes may be noticed also, the habit to which I have already adverted; namely, that of suffering the necks and upper part of the brejtsts of children to remain freely exposed to the air. I have more than once known this disease produced, by children throwing off the bed coverings at night, when asleep and in a state of free per- spiration from the warmth of the bed. In general this disease is most apt to occur soon after, or during the prevalence of epi- demic, catarrh, measles or scarlatina. During convalescence from the two latter of these affections, there exists, often, an es- pecial aptitude to cynanche from the influence of cold. It would seem, also, that the predisposition to this disease is much increased by having suffered an attack of it; I have known the same indi- vidual, suffer five or six attacks of this disease during the period of childhood. Cynanche trachealis, is a phlegmasial affection, consisting es- sentially, of inflammation of the mucous /nembrane of the supe- rior portion of the respiratory tube. The correctness of this pathology is confirmed, not only by the known character of its most common exciting cause, but especially, also, by the more di- rect evidence of the symptoms of the disease, and the appear- ances on post-mortem examination. Unequivocal signs of pre- vious inflammation are invariably discovered in the larynx and trachea on dissection. It is indeed surprising, that this disease should still be viewed by some of the German and French patho- logists, as essentially spasmodic in its nature, and wholly indepen- dent either of a general or local inflammatory condition. Several of the late continental writers on this disease, regard the fever and inflammation, which they acknowledge sometimes to exist, as wholly accidental, and as in no manner essential to the perfect constitution of the malady. Professor Nasse regards impaired or disordered functions of the pneumo-gastric nerves, as the proxi- mate cause of this disease. The characteristic symptoms of the disease, he asserts, bear a strong resemblance to those which re- sult from the division of the eighth pair of nerves. The inflam- mation which occurs in the mucous membrane of the trachea, is, according to his view, secondary, and a consequence of the dis- oidered function of the pneumo-gastric nerves. CROUP. 349 There are two varieties of inflammatory croup. In one the inflammation commences in the fauces, and afterwards descends into the larynx and trachea. In cases of this kind, the breathing is, at first, but little affected, but the cough has a peculiarly rough and hoarse sound. On inspecting the fauces, the tonsils, uvula and palate present a swollen and dark red appearance; and the child always complains of considerable difficulty and pain in swallowing. In the other, and most common variety of the com- plaint, the inflammation commences in the larynx or trachea, the fauces remaining entirely free from redness and swelling. The pa- tient experiences no pain in swallowing, and the respiration is much oppressed from the commencement of the disease. The former variety is, generally, much slower in its progress than the latter,— the hoarse cough and occasional spells of difficult breathing, con- tinuing sometimes for four or five days, before the symptoms ac- quire a very alarming degree of violence. The inflammation which occasions the characteristic phenomena of the disease, does not always remain confined to the larynx and trachea. In some instances it extends downwards into the bron- chia, and sometimes even into the smallest ramifications. This extension of the inflammation is always attended with the utmost degree of danger; and when it passes down into the extreme bronchial tubes, the result, indeed, must almost inevitably be fatal. In cases of this kind death usually takes place from effu- sion into the air cells. In many instances the viscid albumenoid fluid, which is so co- piously secreted by the inflamed lining membrane of the larynx and trachea, concretes, over the internal surface of these passages into a sort of membrane; and to this membraneous substance many of the latter and fatal phenomena of the disease are usually ascribed. It must not be supposed, however, that such a pseudo- membrane is formed in all fatal cases; nay, it is quite certain. that it does not occur, even in the majority of cases. In other instances, the inflammation instead of giving rise to a concrete membraneous substance, terminates in the secretion of a muco-purulent fluid, of an opake and yellowish appearance. There are other cases again, and these are probably, the most common, in which the inflammation»produces neither false mem- 350 CROUP. brane nor a puruloid matter, but an extremely copious secretion of a very viscid, transparent and frothy mucus. Blaud thinks that these different modes of termination, constitute good grounds for dividing the disease into three principle varieties, indicating three different grades of inflammation. It is not improbable indeed, that the inflammation is at its highest grade of violence in those cases which are attended with the formation of a false membrane. It would appear to be less intense, when, instead of this coagula- ble exsudation, there is only a muco-purulent secretion formed; and where the secretion consists, simply of tough, transparent and frothy mucus, the inflammation is doubtless at its lowest grade. In the first and most aggravated variety of the disease, the cough and respiration are dry or free from that peculiar rattling sound in the respiratory passages, which occurs when these con- tain viscid secretions. In cases of this kind, the patient generally experiences considerable pain in the larynx, and the fever is usual- ly very strong. The period at which the false membrane is formed, after the commencement of the inflammation, appears to vary considerably? M. Blaud states that he has found the larynx and trachea lined with pseudo-membraneous matter, in cases whose whole course did not occupy more than twenty hours; whilst in other instances several days appeared to elapse before it was formed. Occasionally only a part of the internal surface of larynx is found lined with this concretion; but in some cases it extends down into the bronchia, and even into the smaller ramifi- cations. Sometimes instead of a membraneous expansion, the upper part of the trachea is found almost entirely blocked up with a thick mass of concreted albumenoid secretion; and this is gen- erally located just within the glottis. I have seen an instance of this kind, in which the opening left through this concreted mass would hardly admit a crow's quill. When the cough and respiration become humid or rattling, as soon as the inflammation is developed, we may infer that there will be no membraneous concretion formed. Mr. Blaud thinks, that the viscid mucus which is so copiously secreted in these milder cases, is entirely different in its properties, from the secretion which occurs in the former variety—and that it is incapable of being so inspissated as to give rise to a membra- CROUP. 351 neous concrete. In these cases, the mucus in the larynx and trachea is often so abundant, as to threaten suffocation by obstructing the glottis. Whatever may be thought of M. Blaud's division of this dis- ease, or of his sentiments in relation to the radical distinction between the inflammation and secretion which give rise to mem- braneous structures, and that inflammation and its consequent mucous secretion which occurs in cases unattended with the formation of false membrane, it must be admitted that there ex- ists at least a two fold diversity in relation to the immediate local consequences of the laryngo-tracheal inflammation—name- ly, one variety in which false membrane is formed, and in which the cough and respiration are at first dry, or do not indi- cate the existence of much mucus in the respiratory passages; and another variety in which the cough and respiration are hu- mid, in the early period as well as throughout the disease, and in which a very copious secretion of transparent and extremely viscid mucus occurs. The former are exceedingly dangerous, nay, almost hopeless, unless subdued by the most prompt and powerful antiphlogistic measures in their very onset. The lat- ter are much less dangerous, and may generally be cured by more moderate antiphlogistic measures, and the expulsion from time to time of the tenacious mucus from the larynx and trachea. In nearly all cases the mucous membrane of the larynx and trachea is found very conspicuously injected on dissection; and in those who die under the conjoined symptoms of bronchitis and tracheitis, traces of inflammation present themselves, throughout the wdiole extent of the bronchial ramifications, and in some in- stances, the substance of the lungs is infiltrated with serum, and the air cells are choked up with viscid mucus. In the majority of cases, the glottis is narrowed by a kind of thickening or tumefaction of its lips. Considerable diversity of opinion has been expressed as to the immediate cause of the distressing difficulty of breathing and of death in this disease. In relation to the latter, it is mani- fest, that an impediment to the intromission of atmospheric air into the lungs, is the immediate cause of death, and that, there- fore, death occurs in this disease, from asphyxia. The circum- 352 CROUP. stances which cause the exclusion of the air from the lungs, consist either in a spasmodic closure of the glottis, or in an occlusion of this aperture by tumefaction of its sides, or by the formation of false membrane or a mass of concreted lymph, or finally by an excessive quantity of a very ropy and viscid mucus closing up the passage. Death is also sometimes the immediate consequence of an effusion into, and consequent choking up of the bronchial cells, a mode of termination which almost always occurs when the inflammation descends into the bronchial ram- ifications. Spasmodic contractions of the glottis may be excited by the irritation of the concreted membraneous lymph, immediately within this aperture. It is a remarkable circumstance that the difficulty of drawing the air into the lungs is always much greater, and attended with much more sound than that which accompanies expiration or the act of throwing the air out from the lungs. This cannot be explained, as some have attempted, by supposing that the portion of the false membrane nearest the glottis becomes separated from the sides of the trachea, and that, consequently, more difficulty and noise is produced during inspiration, on account of a portion of the inspired current of air being forced in between the detached membrane and the surface of the larynx, whereby the ingress of the external air is impeded; whilst in the act of expiring the air, the detached extremity of the membrane would be pressed outwards against the sides of the treachea, and offer, therefore no particular impediment to the outward current of air. That such consequences might follow the separation of the superior portion of the membrane, immediately within the glottis, cannot be doubted; but when it is observed that the same relative increased difficulty of the inspiration is present, in all instances, from the very commencement of the disease, and before any membraneous concretions can be formed, we are forced to admit that, the circumstance in question, depends on some other morbid condition of the parts, implicated in the disease. The solution of this problem must I think be sought for in the altered sensibility of the glottis and trachea, in consequence of which the contact of the atmospheric air, produces an irritation croup. 353 which excites spasmodic contraction in the glottis. It is well known how greatly the vital properties are altered by inflamma- tion. In drawing the external air into the trachea, it irritates the mucous membrane, and excites the glottis to contraction, by which the ingress of the air is retarded, and the difficulty in question produced. This is entirely analogous to what occurs in other organs when in a state of inflammation, from the impres sion of their appropriate stimuli. Thus light to a healthy eye, is any thing but disagreeable; yet when this organ is inflamed, even a moderate degree of light, gives rise to pain, and an involuntary contraction, or closing of the eye-lids. When the urethra or the neck of the bladder is inflamed, the contact of the urine often excites so much spasm of this canal, as to prevent the discharge of this secretion altogether. In a similar manner therefore, we may conceive, is the increased difficulty of inspira- tion produced in this affection. 1 wish to be understood, however as referring here only to the comparative difference of the acts of inspiration and expiration, for the dyspnoea taken as a general symptom, is undoubtedly mainly dependent on the circumstances already mentioned—namely, tumefaction—viscid mucus adhering to the glottis, and in the advanced stages concreted pseudo- membraneous substances diminishing the calibre of the respira- tory tubes; and finally effused lymph or mucus into the bronchial cells. During expiration, the air ceases to irritate the glottis in consequence of its more elevated temperature, which is now on a level with that of the inflamed organ; and probably also, in a degree, in consequence of the carbonic acid which it contains and which is well known to be a very considerable sedative to irritable parts. Prognosis.—Cynanche trachealis is always to be regarded as a very dangerous affection. Formerly the majority of cases ter- minated fatally; but under the present improved pathology and mode of treatment the mortality from this disease is greatly di- minished. When early attended to, this complaint is, indeed, as much under the control of vigorous antiphlogistic measures, as any of the more serious phlegmasial affections. In general, the obstinacy and dangerousness of the disease, is proportionate to 2Z 31 354 " CROUP. the intensity of the inflammation, and the extent to which it passes downwards into the lungs. When the fever and croupy symptoms come on suddenly, the danger is, usually, much greater, than where the disease is slowly developed. A sudden attack with- out fever, however,is not,in general, attended with peculiar danger; for in this case, the affection is, probably, purely spasmodic—a form of croup much more manageable than inflammatory or febrile cynanche. The shriller and more sonorous the cough is, the more reason is there to apprehend danger. The prognosis in this affection is, often, extremely uncertain. Sometimes, when the symptoms appear to be in a great degree subdued, and every thing promises a speedyr recovery, a violent exacerbation will sud- denly supervene, and destroy the patient. On the other hand, death may appear to be impending, when, on the sudden expul- sion of a membrane, or even without such an occurrence, a rapid change for the better will ensue, and lead on to full convalescence. Diagnosis.—There is a disease which, in most of its prominent symptoms, bears so close a resemblance to tracheitis, that many have been induced to regard it as the same affection, or at most as only a modification of the disease now under consideration. I allude to the acute asthma of Miller, or the disease which by some pathologists is denominated, and with perfect propriety, spasmodic croup. Although attended with the same extreme difficulty of breathing and sense of impending suffocation which belong to inflammatory croup, spasmodic croup is essentially distinct in its pathological character from the former disease, and of course requires a mode of treatment correspondingly modified. An attention to the following circumstances will enable us to distin- guish these two forms of croup from each other. 1. The approach of cynanche trachealis is generally gradual, and preceded by the usual train of precursory symptoms, which usher in catarrhal affections. Spasmodic croup, on the contrary, almost always comes on suddenly, and is rarely preceded by the ordinary premonitory symptoms of catarrh. It is true, indeed, that in some instances, cynanche trachealis also, supervenes quite sud- denly; but when this is the case, it is always so manifestly of an •nflammatory character, and is attended with so much fever, that croup. ' 355 there can be no difficulty in distinguishing it from the spasmodic variety of the disease. 2. Cynanche trachealis is essentially a febrile disease—the phe- nomena of fever being never absent. Spasmodic croup, on the contrary, is entirely free from fever, except it be present, as an accidental occurrence. In the former, the urine is almost, inva- riably, high-colored and scanty: whereas, in the latter affection, it is usually pale, watery and often copious. 3. Cynanche trachealis is often attended with considerable remissions; but these are generally of very short duration and incomplete. Entire intermissions, except immediately after vom- iting, or on the approach of syncope from bleeding, never occur. In spasmodic croup, the intermissions are often complete and pro- tracted; and this circumstance, perhaps more than any other, characterizes this form of croup. 4. Cynanche is always attended with a peculiar hoarse and ionorous cough, and frequently with a copious secretion of viscid mucus in the trachea. Spasmodic croup is rarely associated with much cough, often none at all, and it is always dry. 5. The peculiar ringing sound of the cough and inspiration, so characteristic of cynanche trachealis, does not occur in the spas- modic form of the disease. 6. In cynanche trachealis the pulse is generally frequent, full, quick and tense, and the skin is hot, except towards the fatal termi- nation of the disease, when from the imperfect performance of the respiratory function, animal heat ceases to be generated with due rapidity, in consequence of which the extremities and surface gen- erally, became cool or cold. In spasmodic croup, on the other hand, the pulse is small, very frequent and feeble, and the skin not above the natural temperature. Dr. Rush has given an account of a post-mortem examination of a child, that had died of spasmodic croup. In this subject, no membrane, nor even any unusual quantity of mucus, was found in the respiratory passages; and the trachea as well as the lungs ex- hibited a perfectly healthy appearance. It is, indeed, sufficiently ascertained, that cases of a purely spasmodic character occur, which in the extreme difficulty of breathing and other phenomena, bear a strong resemblance to cynanche trachealis. This form of 356 croup. the disease is evidently of the nature of spasmodic asthma, and appears to depend on cerebral or dental irritation, by which the functions of the respiratory nerves are thrown into disorder. Treatment.—The principal objects to be kept in view, in the treatment of this affection, are: to subdue the local and general inflammatory irritation; and to promote the discharge of the viscid and concrescible secretions, which are lodged within the su- perior portions of the respiratory tube. Fortunately the remedies which are found most efficient, in the accomplishment of the lat- ter object, are also among the most useful auxiliaries for the re- duction of the febrile excitement and local inflammation. With- out doubt, however, the remedy upon which our principal reliance should be placed, for the removal of the tracheal inflammation is blood-letting. In the whole catalogue of inflammatory affections, there is no disease, in which bleeding when promptly and efficient- ly practised, is more likely to prove beneficial, than in the one now under consideration. He who, in violent cases, neglects this im- portant measure, and places his hopes on one or more of the em- pirical remedies, that have, by different practitioners, been ex- tolled for their supposed specific tendency to counteract the trache- al affection, will, we may be assured have but little reason to flatter himself for his success in the management of this malady. Here, however, as in most of the other phlegmasial diseases, the beneficial effects of bleeding, are limited to the early period of the complaint. If bleeding be neglected, or inefficiently em- ployed in the first stage of the malady, its progress will be ex- tremely perilous, whatever other remedial measures may be adopted. When called to a patient labouring under a severe at- tack of this disease, a vein should be immediately opened, and the blood suffered to flow until a very decided impression is made on the pulse, or until an approach to syncope is induced. When blood is thus efficiently drawn, all the distressing symptoms usually subside for a time; and in some instances this first blow at the dis- ease, subdues its strength so far, as to prevent it from afterwards recovering any alarming degree of violence. More frequently, however, the fever and difficulty of breathing, rise again in the course of an hour or two, and when this happens, and the pulse croup. 357 >e not soft and weak, more blood should be drawn, and again to the extent of producing a very obvious impression on the circula tion and general system. I have been obliged to open a vein three or four times in the course of the first twelve hours, before a per- manent and decisive impression was made on the febrile and in- flammatory symptoms. My usual mode of bleeding in this disease, is to have the patient supported in a sitting posture, with his feet immersed in warm water, whilst a vein is opened in the arm. In this way syncope will be induced much more readily, than when the patient remains in a recumbent posture during the operation. Nothing tends so powerfully and promptly to arrest the progress of inflammation as partial syncope induced by blood-letting. During this state the momentum of the circulation is greatly dimin- ished, and a general relaxation of the cutaneous exhalents ensues; effects which have a direct and powerful influence, in reducing the inflammatory condition of the system. Such copious depletion is, however, demanded only in cases where the local and general inflammatory action is strong; where the pulse is active, firm, quick or tense, attended with a dry and sonorous cough and respiration. Cases of this kind, are apt to terminate in the formation of pseudo-membraneous concretions in the larynx, and our efforts ought to be prompt and vigorous to re- duce the inflammation below the grade necessary for the forma- tion of false membrane. After the effusion which gives rise to these concretions has taken place, bleeding will afford but very little or no advantage. Where the febrile symptoms are moderate, and the pulse is free from tension and hardness, and especially where in connection with moderate febrile irritation, the cough and respiration are accompanied with a copious transparent, and viscid mu- cus, blood-letting need very rarely be carried to the extent that has just been mentioned; and may even, in mild instances, be wholly dispensed with. Next in importance to prompt and decisive blood-letting are emetics. They are, indeed, altogether indispensable in managing this formidable malady, and, when assisted by warm pediluvium, rubefacients to the throat, and mercurial purgatives, they will of- ten subdue mild attacks of the disease, without the aid of direct depletion. When the febrile excitement is strong, however, and 31* 358 CROUP. the breathing is very difficult, with a turgid and flushed appearance of the face, it would be highly imprudent to rely on emetics and their usual auxiliary remedies, without prompt and decisive vene- section. Nevertheless, even where bleeding may be regarded a9 our main stay, emetics are highly useful, and ought always to be employed concomitantly with venesection. They are especially beneficial when the disease is early attended with a copious secre- tion of viscid mucus in the larynx and trachea. Much of the difficulty of breathing in cases of this kind, depends on this vis- cid secretion, obstructing the entrance of the air into the lungs. The occasional expulsion of this glutinous fluid from the trachea, by the operation of an emetic, not only greatly relieves the dis- tressing difficulty of breathing and sense of suffocation, but con- tributes also to obviate the formation of false membrane, by pre- venting the accumulation and removal of the coagulable secretion in the trachea. They tend moreover, to equalize the circulation and to promote the cutaneous exhalation, as well as to diminish the general arterial excitement by the nausea which precedes and accompanies their operation. When the cough and respiration are dry, as they commonly are, during the first stage of highly in- flammatory cases, we seldom derive decided advantage from the operation of an emetic, so long as this dryness of the larynx ana trachea continues. In such cases the proper period for adminis- tering emetics, commences with the appearance of the viscid secre- tions in the respiratory passages. Without doubt, from the general antiphlogistic tendency of nausea and emesis, some benefit may result from the employment of emetics, before any morbid secre- tions occur in the trachea; but the peculiar usefulness of this class of remedies, is always most conspicuously displayed when the up- per portion of the wind pipe is clogged with viscid mucus. In the commencement of the disease, there seldom exists any difficulty in procuring free vomiting; but after the disease has continued for some time, or even in the beginning when the re- spiration is extremely oppressed, there exists, often, so much in- sensibility of the stomach, in consequence of the imperfect decai- bonization oi the blood, and the sanguineous congestion in the brain, that great difficulty is experienced in procuring the opera- CROUP. 359 .ion of emetics. To remove this gastric torpor and procure vomit- ng, we must endeavour to diminish the congestion in the brain; and this may, in general, be readily accomplished, by putting the patient's feet in warm water, and applying a napkin wet with cold water, to the head. The abstraction of blood, also, while the patient is supported in a sitting or erect posture, rarely fails to restore the sensibility of the stomach and to ensure the prompt operation of emetics. The articles I prefer, as an emetic in this disease, are calomel in union with tartar emetic. I commonly administer from five to six grains of the former article with one fourth of a grain of the latter, to a child of two to five years old. This may be repeated every fifteen minutes until vomiting is excited. I have frequently given from eight to ten grains of calomel alone, and have generally found it to excite active vomiting in a very short time. The peculiar advantages, which appear to me to attend this practice, are the protracted nausea, which the calomel pro- duces, an effect which has a powerful antiphlogistic tendency; and the alvine evacuations which almost always speedily ensue. Besides these effects, benefit may also be expected from the early constitutional influence of the calomel—an influence which in the present disease especially is very generally acknowledged to be highly salutary. Tartar emetic, ipecacuanna, sulphate of zinc, squills, and the sulphate of copper, have all been used and recommended in this affection; and where the object is merely to procure the expulsion of the tracheal mucus, or perhaps pseudo- membraneous matter, any of these articles may answer our pur- pose. 1 have in some cases administered the lobelia inflata with a view to its emetic operation with the happiest effect. From its well known powerful influence on the respiratory functions in asthma, independent of its emetic effects, there is reason for pre- suming that, in relation to the present disease, it may possess peculiar virtues, and my limited experience with it, inclines me to this opinion. When the stomach is very torpid, and there is urgent necessity for procuring the immediate expulsion of the viscid secretions .from the trachea, the sulphate of zinc, will m general answer better than any other article of this kind. The following mixture is strongly recommended by M. Jadelot as an 360 CROUP. emetic, in this affection.* In mild cases, a mixture of two parts of the syrup of squills, and one part of antimonial wine, given in tea spoonful doses every fifteen minutes, until vomiting is produc- ed, frequently procures speedy relief. The common hive syrup of the shops, is also an excellent preparation for this purpose. In some instances when the accumulation of the viscid secretions is very rapid, it becomes necessary to repeat the emetic three, four or five times in the course of twenty four hours. Purgatives are useful auxiliary remedies in the treatment of the disease. In the commencement of the treatment the bowels should be freely evacuated, by an active purgative. After this has been effected, it will be best to employ the gentlest articles of this class of remedies, so as to procure two or three evacua- tions daily, until the inflammation is subdued. Very active purging throughout the course of the disease, tends to exhaust the powers of the system, without affording any peculiar benefit, over milder aperients. After the first cathartic, it will in general be sufficient to keep the bowels in a loose state by laxative enemata. Calomel, given with a view to its constitutional influence, has been generally regarded as a highly valuable remedy in this affection. The late Dr. Rush placed great reliance on its pow- ers in croup. When given in large doses in the commencement of the disease and continued afterwards in small doses," the Peruvian Bark," he affirms, " is hardly a more certain remedy in intermittents than calomel in croup." Dr. Hosack, also speaks very favorably of the employment of this article in conjunction with James' powder, given at short intervals, during the second stage of the complaint; and the late Dr. Bard placed much reliance on its powers. That the constitutional influence 01 mercury is calculated to do good in cynanche trachealis, I am weP. persuaded from my own experience. It tends to reduce the * R. Infus. polygalae Seneg. giv. Syrup. Ipecac. . . . 3'- Oxymil. Scillae . . 3'"- Antimon. Tart. . . gr. ss. M. Take a table spoonful every 15 minutes until vomiting is excited. CROUP. 361 local laryngotracheal inflammation, and to counteract, as it would appear, the formation of the pseudo-membraneous concretion. In the more acute and rapid cases, however, many of which run to a fatal termination in less than twenty four hours, the constitu- tional operation of this remedy is much too slow to afford any particular advantages. Where on the contrary the disease is protracted in its course, or assumes somewhat of a chronic char- acter, great benefit may unquestionably be derived from this potent remedy. My usual mode of giving calomel, after the first or second emetic, is to exhibit one grain every hour or two, with about one fourth of a grain of ipecacuanna. Among the remedies that may be usefully employed for the reduction of the tracheal inflammation, the warm bath deserves to be particularly mentioned. Used along with the remedies already mentioned, its benefits are often considerable, more especially when the skin is very dry and harsh. It is to be observed, however, that its usefulness is, in a great measure, confined to the early period of the disease; for in the advanced stages of violent or unsubdued cases, the pulse is not only weak and very frequent, but the surface is generally bathed with a profuse and cold perspiration. Under these circumstances, no advantage but rather injury, would result from the relaxing in- fluence of the warm bath. Rubefacients and blisters are important remedies in the treat- ment of this affection. As soon as blood has been drawn, some irritating liniment, or a blister, ought to be applied to the throat of the patient. In general, the spirits of turpentine answer better for this purpose than anyr other rubefacient we possess. Its action on the skin is very prompt and powerful; and if the derivative powers of such applications be proportionate to the degree of irritation and pain they produce, few articles can equal the pre- sent one in this respect. A piece of flannel may be imbued with the turpentine and applied round the neck. Children seldom bear this application more than twenty or thirty minutes at a time. It should therefore be removed and reapplied, from time to time, according to the violence and permanency' of its effects upon the skin. The oil of the monarda punctata, with an equal proportion 3A 362 croup. of camphorated liniment, forms, also, an excellent rubefacient in this affection. Judging from my own experience, I am induced to prefer the employment of rubefacients to that of epispastics. The former have always appeared to me to do as much good as the latter, and they possess the great advantage of acting with great promp- titude—a circumstance of no small consideration in a disease which often runs its fatal course in a few hours. A blister requires four or five hours before its effects on the skin can be of any par- ticular avail; whereas the impressions of some of the essential oils are almost instantaneous. Nevertheless, where the disease proceeds slowly, blistering will be highly beneficial, and should not be neglected. Local bleeding, by leeching, does not appear to make obvious impression on the tracheal inflammation; and it is now seldom if" ever resorted to, except where the disease is attended with inflam- mation and swelling with the tonsils and palate. In one instance, in a child about six years old, I have known cupping on the hack of the neck to procure manifest relief; but this case, was asso- ciated with conspicuous inflammation in the fauces. Formerly, the root of the polygala senega was held in high esti- mation as a remedy in this disease; and it is unquestionably a very useful medicine in certain states of the disease, although, most as- suredly, far from possessing the powers which were at fir>t ascrib- ed to it by Archer and others. In the commencement of the complaint—more especially in violent cases, this article is objec- tionable on account of its stimulating properties; but after the general and local inflammatory irritation has been to a considera- ble degree subdued, or the disease has lost its acute character, or assumed a chronic form, it is often highly beneficial. When a dry and hoarse cough, with slight difficulty of breathing remains, after the inflammation has been subdued, the polygala will hi general prove more useful than any other remedy we possess. In all chronic croupy affections, and in the catarrhal sequela of this and other accute affections of the respiratory organs, it is a rem- edy of very excellent powers. It should be given in decoction. An ounce of the root to a pidt of boiling water, simmered down to about three gills and sweetened with honey forms a suitable CROUP. 363 preparation. From one to two or three tea spoonfuls of this de- coction should be given every hour or two, according to the age of the patient and the urgency of the symptoms. The hepar sulphuris (deuto-sulfure of potassium) was introduced to the notice of the profession, as a remedy in this disease, about twenty years ago, in a prize essay on cynanche trachealis, pre- sented to the French Ecole de Medicine.* Its introduction was founded on the erroneous doctrine that croup consists essentially in a morbid coagulability of the tracheal mucus, and which, it was asserted the sulphuret of potash had the power of preventing or correcting. It need, scarcely, be observed, however, that a rem- edy, which might possess such a power, without, at the same lime exerting any influence in subduing the inflammation, could afford but little advantage in this affection; and the result of later ex- perience goes to show that this, at first highly lauded remedy, exerts no obvious influence over the tracheal inflammation—and it js accordingly, now, very properly, universally abandoned. When called to a patient labouring under this disease the fauce9 6hould be carefully inspected. It is now well ascertained that the albumenoid exudation which forms the false membrane, often commences on the surface of the inflamed tonsils, and thence spreads along the arches of the palate, and at last descends into larynx and trachea. In such cases the fauces will be found tumefied and of a dark red colour, and whether there be any ap- pearance of false membrane or not, immediate attention should be paid to this inflammation. Dr. Mackensie, states that the ap- plication of a solution of the nitrate of silver, to the tonsils and soft palate, will, in such cases, often remove the membraneous crust completely, and procure speedy and great relief, and ultimately an entire removal of all the dangerous symptoms. "The solution which I employ," says Dr. Mackensie, "is a scruple of the nitrate of silver in an ounce of distilled water. By means of a large camel hair pencil, this solution is to be freely applied, once, or twice a day according to the severity of the symptoms, to the whole lining membranes of the fauces. The surface of the ton- sils, or wherever else the fibrinous crust is actually in view will of • Rapport sur les ouvrages envoyees au concurs, sur le croup, par la commission chargee de l'examen et du jugemeut de ces ouvrages. Paris, 1812. 364 croup. course be particularly attended to; but I do not hesitate to push the pencil to the lower part of the pharynx. This remedy so far frcm being productive of any irritation beyond the mere mechani- cal and temporary one attending its employment, uniformly alle- viates the symptoms of the croup, such as the difficult respira- tion, the barking cough, and the peculiar anxiety of the little patient." In one instance which came under my notice, this application was decidedly beneficial. Laennec has published an account of some cases from which it appears that insufflation of very finely powdered alum, generally affords speedy relief, not only in this variety of the disease, but also in cynanche laryngea and tonsil- laris. I have recently prescribed in a case of this kind, in which I derived unequivocal advantage from this remedy. Four or five grains of finely powdered alum should be introduced into the end of a small tube, (the barrel of a quill will answer,) and forcibly blown into the fauces. This practice appears to me of the utmost importance in cases of this kind, and ought never to be neglected, where the fauces on inspection, present an irritated and inflamed condition. Success in the treatment, must depend materially on the prompt reduction of this primary extra laryn- geal inflammation. With a view of expelling the false membrane, emetics have been recommended in the advanced period of the disease, and the records of medicine are not wanting in instances in which this object was effected by such a measure. It offers, however, but and exceedingly slender foundation to build any hopes upon. The same object has in one or two instances been obtained by exciting violent sneezing by blowing snuff into the nostrils through a small tube. As to the proposed operation of tracheo- tomy in order to detach and remove the membrane, all experience has so far decided against it. CYNANCHE LARYNGEA. 365 CHAPTER XXXI. CYNANCHE LARYNGEA. Tins disease generally commences with a slight sensation of chilliness, alternating with flushes of heat, attended with a feel- ing of soreness in the fauces, more or less tenderness to pressure about the top of the thyroid cartilage, and some pain and diffi- culty of swallowing. The voice soon becomes changed into a thick, hoarse whisper, and on strong inspiration the air seems to enter into the trachea with difficulty, or as if it were forced through a very narrow aperture, and is attended with a dull rough sound. On inspecting the fauces, the tonsils, soft palate, and uvula, present a bright red, and oedematous appearance. There is sel- dom much expectoration, but the saliva is usually abundant and of a very viscid character. The febrile symptoms are not vehe- ment, the face being for the most part pale, and the pulse fre- quent, small and tense. The tongue is covered with a thin white fur, over which a thick layer of transparent mucus is spread. As the disease advances, deglutition becomes more and more painful, and is apt to excite alarming and distressing paroxysms of suffo- cative breathing. The temperature of the surface is very unequal, some parts being very warm, whilst others are preter- naturally cool. Dr. Armstrong observes, that the most peculiar and characteristic symptom of this affection, is the total inability to cough out, as is done in pneumonic and catarrhal complaints; the attempt to do so, resulting in a kind of suppressed or suffocative effort, terminating " in a low, grumbling and almost grunting sort of noise in the throat." The difficulty of breathing increases progressively as the disease advances, with frequent dis- tressing paroxysms of dyspnoea, until, in unsubdued cases, death at last occurs by actual suffocation. The disease sometimes approaches in a very gradual and insidious manner, the symptoms for a day or two, resembling 32 306 CYNANCHE LARYNGEA. those of ordinary catarrh, with slight hoarseness. In some instances, it comes on suddenly and in a very short time acquires a fatal degree of violence. Mr. Porter relates two instances, where the inuividuals went to bed at night, without complaining of any illness, " and were found dead from this affection, the next morning." A case is also reported by M. Leville, which was so marked by erysipelas of the face, as to escape observation until within a few hours of its fatal termination.* Cynanche laryngea may be distinguished from croup, by the following circumstances. In this affection there is always pain experienced in the larynx, generally referred to the top of the thyroid cartilage. Deglutition, too, is invariably painful and difficult, and after the disease is fully developed, often wholly impossible. On inspecting the fauces they are found somewhat swollen and inflamed; and every attempt to swallow brings on a paroxysm of suffocative breathing. None of these symptoms occur in cynanche trachealis, except occasionally swelling and inflammation of the tonsils and palate. " The seat of this affection is more in the cellular tissue con- necting the mucous membrane with the adjacent parts than in the membrane itself, although this latter structure is very frequently in an inflamed condition."t The tonsils, soft palate, larynx, and epiglottis are always tumefied, red, and in some instances vesicated. The rima-glottidis, also, is in general, so much swollen as nearly to close the aperture. The swelling of these parts appears to be oedematous, depending, mainly, on the effusion of serum into the submucous cellular tissue. Sometimes the inflammation is confined to the larynx, but in some cases, it extends down into the trachea and even into the bronchia. (Armstrong.) The principal seat of the inflammation, however, is in the epiglottis, which is usually " red, erect, oedematous, and during life resembles a piece of raw meat." (Porter.) Cases have occurred in which the inflammation terminated in the formation of one or more abscesses in the cellular tissue surrounding the larynx. • Gazette de Sante 1827. t Observations on the Surgical Pathology of the Larynx and Trachea, &c. By Wm. Henry Porter, p. 98. CYNANCHE LARYNGEA. 367 Treatment. Laryngitis is a most rapid and dangerous affection. It often terminates fatally in less than twenty four hours, under the most energetic and judicious course of treatment. Blood- letting does not appear to exert the same degree of influence in arresting the progress in this affection as it generally does in other varieties of tracheal inflammation. Dr. Armstrong declares, that he has known "one hundred and sixty ounces of blood drawn, within the space of six hours" in adult patients, without making the slightest impression on the progress of the malady. In only one out of six cases, he says, did blood-letting appear to afford any obvious advantage. From the occasional vesication of the affected parts, and the serous infiltration into the cellular tissue, it would seem, that the inflammation partakes more of the erysi- pelatous than of the phlegmonous character; and this is probably, the reason why bleeding though prompt and copious, exerts so feeble an influence over its progress. But although blood-letting does not often procure any promi- nent benefit in this affection, it is unquestionably decidedly indi- cated, and ought always to be promptly and efficiently practised. Dr. Beck of New York thinks, that the apparent inefficacy of bleeding in this complaint, is to be ascribed to the inadequate manner in which it has been usually employed. When carried to the extent of producing syncope, he says, it is as likely to do good in this as in other severe inflammatory affections of the respira- tory organs. My own experience, does not, however, entirely accord with this observation. Nevertheless bleeding to the extent of producing fainting, ought to be regarded as an indispensable measure in the treatment of this affection. After blood has been efficiently drawn with the lancet, leeches should be largely ap- plied to the throat. Martinet has reported a case, which termin- ated favorably under the employment of general and local bleed- ing and blistering. Dr. Arnold, has, also, related a case, in which the use of the lancet and leeching was decidedly beneficial.* A blister ought to be early applied to the throat, or to the back of the neck. In a case which I attended about two years ago, very obvious benefit was derived from blistering the back of the neck, while leeches were applied to the throat. It is not necessary or •Med. Chir. Transact, vol 9, p. 31. 368 CYNANCHE LARYNGEA. even advisable to delay the application of the epispastic until the momentum of the. circulation has been moderated by depletion. The earlier the blistering is resorted to, the greater the charfte of deriving advantage from it. Armstrong places more reliance on the repeated employment of antimonial emetics in this com- plaint than on any other remedy. After he had repeatedly failed in subduing the disease by blood-letting and counter-irritating applications, he resolved to try the effects of repeated emetics. He accordingly, resorted to the use of antimonial emetics in five cases, to which he was subsequently called; and, he declares, that "no circumstance in his professional life ever gratified him more than the great and sudden relief which vomiting afforded in these cases. It removed all the urgent symptoms at the time, and, being re-excited as soon as ever the slightest signs of stricture in the larynx returned, it at last completed the recovery." In a well marked case, wrhich I attended a few years ago, in a child about four years old, blood-letting to the extent of producing syncope, followed by a blister to the throat, and three active emetics in the course of about fifteen hours, effected a cure. Pur- gatives, are very useful auxiliaries in the management of this com- plaint. The bowels should, in the first place, be freely evacuated by a full dose of calomel in union with rhubarb or julap; and after- wards kept in a loose state, by enemata, and repeated doses of calomel, both with a view to its aperient and constitutional opera- tion. In the case reported by Dr. Arnold, the symptoms, though checked by blood-letting, did not entirely yield, until the gums be- came sore from the free use of calomel. From what I have witness- ed in a case which occurred to me a few months ago, I am inclined to believe, that great benefit would, in general, be derived from blowing finely powdered alum through a small tube into the fauces. In cynanche trachealis attended with inflammation of the tonsils and palate, this application has within the last three or four years, been much employed with the happiest effect, both in Europe and in this country; and it seems highly probable that an early recourse to it in the present affection, would often do much good. Tracheotomy has in several instances, been performed with en- tire success in this disease; and Dr. Porter strongly recommends CYNANCHE LARYNGEA. 369 the operation whenever the remedies already mentioned do not make an early and decided impression on the laryngeal affec- tion... "There are many reasons," he says, "why the practitioner should decide, at once, on the performance of tracheotomy, if the appropriate antiphlogistic measures do not afford early relief. Thus it allows the organ in which the inflammation is seated, to remain in a state of perfect repose. Considered as a wound, it adds nothing to the patient's danger; and as the relief it affords is, at least for a time, complete, it imparts confidence to the sur- geon, and allows him leisure to examine the symptoms and the remedies accordingly. If however, the operation be not early per- formed, it had much better be let alone altogether." Dr. Cramp- ton has reported a most interesting instance of the successful per- formance of this operation in acute laryngitis. Professor Regnoli, has given an account of two successful instances of tracheotomy in chronic laryngitis. Acute laryngitis, he observes, sometimes terminates in chronic inflammation and oedema of the epiglottis and mucous membrane of the larynx, which ultimately renders respiration extremely difficult, and may even cause death by suf- focation In cases of this kind tracheotomy is the only means of relief >ci our power.* * Nuvo mercurio, delle scienze mediche. Maza 1829. 3B 32* 370 DROPSY IN THE BRAIN. CHAPTER XXXII. ARACHNITIS. HYDROCEPHALUS. DROPSY IN THE BRAIN. Arachnitis often makes its approaches in a very gradual man- ner. In many instances manifestations of an unusually irritable condition of the brain occur, and continue for several weeks be- fore the disease is fully developed. During this irritative stage of the disease, the patient manifests a very irritable and fretful temper; he is wakeful, and when sleeping he grinds his teeth, and often starts or awakes suddenly with violent screaming and a peculiar expression of alarm in the countenance. Infants cry frequently without any apparent cause, and often start at the slightest noise and shrink suddenly as if pricked with a pin. The bowels are generally irregular, and the evacuations of an unnatural appearance. This irritative condition sometimes continues for a considerable time, without passing into actual in- flammation, the child gradually regaining its ordinary state of health. If, however, some additional exciting causes supervene, such as difficult dentition, cold, or gastro-intestinal irritation from improper food or other offensive matters lodged in the alimentary canal, this irritative condition of the brain, is more or less rapid- ly aggravated, until it finally passes into actual inflammation. A new train of symptoms now ensues, which characterizes the in- flammatory stage of the disease. The patient now begins to experience transient pains in the head, and in most cases in the abdomen. These abdominal pains are occasionally very violent, but always very transient. The restlessness, and irritability of temper increase and the counte- nance is expressive of discontent and suffering. The face is usually pale with an occasional flush on one cheek. The eye- brows are, at times, contracted into a peculiar frown; and the eyelids generally kept in a half-closed state on account of the sensibility of the retina. The appetite is variable, in some in- DROPSY IN THE BRAIN. 371 Btances voracious, but more frequently impaired. The state of the bowels also is variable, being sometimes—indeed most general- ly—torpid, and at others relaxed, the stools presenting an unnatu- ral appearance. As the complaint progresses the pains in the head become more and more severe. They are however seldom continuous; becoming occasionally much lighter, and at times for a few minutes entirely absent. The headache is chiefly seated in the forehead, shooting backwards and towards the temples. Children manifest their sufferings from this pain by almost con- stantly putting their hands to the forehead, and I have seen in- stances in which the little patient kept one of the hands contin- ually applied to the head, and would not suffer it to be removed for an instant. At this period of the disease, the stomach is apt to become very irritable—the retching and vomiting being some- times very troublesome, particularly on sitting up or taking any thing into the stomach. Children, affected with this disease, sel- dom bear the erect position without much uneasiness. I have met with many instances, in which the patient manifested no dis- position to vomit while in a recumbent posture, but the moment his head was raised from the pillow, sickness and vomiting en- sued. In the early part of the disease, however, the patient does not, generally, sleep easy with his head low. He is very restless, turning and tossing from one side of the bed to the other, and frequently groans, or whines, as if under the influence of pain. In some instances, the pain in the head, and the sickness and retching alternate with each other, the former ceasing as soon as nausea and vomiting come on. Frequent and deep sighing, is one of the most constant and characteristic symptoms of this mal- ady. It is seldom very conspicuous, however, until the disease has made considerable progress, and is generally most remarka- ble, about the time when the inflammation is terminating in effu- sion, and some degree of cerebral torpor and somnolency are pre sent. Delirium usually, occurs, during the latter part of the in- flammatory stage: but it is never violent or furious, and very rarely so great, that the patient may not be roused from it, so as to give correct answers. Martinet observes that when the arachnoid membrane of the convexity of the brain is the princi- pal seat of the inflammation, the delirium is much more constant 372 DROPSY IN THE BRAIN. and conspicuous, than when the base of this organ is the part chiefly affected. The skin, during this stage is generally dry and above the natural temperature; and the pulse is frequent, quick, and tense or sharp, but seldom full. The tongue, usually, remains clean, or covered only with a thin white fur, with pale red edges; but in cases depending on intestinal irritation, it gene- rally becomes loaded with a thick brown fur, which towards the termination of the disease becomes dark, dry and rough. After these symptoms have continued for an indefinite period, a new series of phenomena ensues, characterizing the third, or somnolent stage of the disease. The delirium now returns more frequently and continues longer; the countenance exhibits a pecu- liar expression of surprise and stupor, which it is impossible to describe, but which when once seen cannot be easily mistaken or forgotten. The conjunctiva, presents a suffused and reddish ap- pearance; the pupils are dilated or much contracted, and the retina, in some cases, is extremely sensible to light. During sleep, the eyes are generally turned up, so as completely to hide the cornea under the upper lids. The patient now manifests a con- stant disposition to sleep; he becomes inattentive to surrounding objects, and when roused from his stupor he soon relapses into the same somnolent state. There is, in nearly all cases, great torpor of the intellectual faculties, or an impossibility, it would seem, of directing them to any object, or bringing them into action, so that the patient can seldom be induced to utter more than monosylla- bles. This mental apathy and torpor does not, however, occur, until disorganization or effusion is about taking place in the brain; for in the earlier periods of the disease, there is often great ac- tivity of the mental faculties. The drowsiness and mental torpor increase more and more, until a complete state of coma ensues. This morbid somnolency is the most constant of all the phenomena of the advanced period of the disease. In no instance where the complaint is not early arrested, does this symptom remain absent. In some cases, after the febrile and inflammatory symptoms have continued for some time, the coma comes on suddenly, in conjunc- tion with paralysis of one side or of one extremity; but, it much more commonly supervenes in the gradual manner just mentioned. Indeed instances occur, in which the febrile irritation is so slight DROPSY IN THE BRAIN. 373 as to escape attention, the first obvious manifestations of the dis- ease, being an unusual drowsiness and mental torpor. In cases of this kind arachnoid inflammation, is no doubt going on without manifesting itself by the usual local and general symptoms of in- flammation. It is a fact, well ascertained, that inflammation sometimes goes on in the brain, even to the extent of producing fatal disorganization, without manifesting its existence either by pain or any other symptom indicative of inflammation. Soon after the somnolent stage supervenes, paralysis generally occurs on one side, or in one extremity. In infants we generally, at first, notice a tremulous motion of one arm with the hand firmly bent inwards. By degrees the powrer of using the arm and leg of one side, becomes much weakened, which, in a short time, ter- minates in complete paralysis. At the same time, one or both the upper eye-lids, usually, become paralyzed, so that the patient, in endeavouring to look at any thing, is unable to raise the lids bj| their proper muscles, and is therefore obliged to draw them up with the integuments of the forehead by the contraction of the occipito-frontalis muscle. Strabismus, almost always occurs, pre- vious to the supervention of paralysis, or deep coma. When the symptoms, last mentioned, namely strabismus, paralysis and coma occur, we mayr presume that disorganization or effusion has taken place in the brain. Soon after the inflammation has terminated in effusion, a sudden amendment, usually, takes place in all the alarming symptoms. The patient seems to have suddenly passed into a state tending to convalescence; and parents and friends, nay even physicians are apt to flatter themselves, that a speedy, though unexpected, recovery is at hand. This flattering calm is, however, almost universally fallacious, and of short continuance; for sooner or later, a paroxysm of convulsions suddenly super- venes, or the patient relapses into a state of fatal coma and stupor, which, at once and forever, puts an end to all hopes of a favora- ble termination. Convulsions rarely, if ever, remain wholly ab- sent towards the fatal termination of this disease. The pulse which in the first and second stages of the complaint, is quick, frequent, and tense, becomes slow, full and generally irregular or intermitting, during the somnolent stage; but when paralysis, and especially convulsions supervene, it again becomes very fre- 374 DROPSY IN THE BRAIN. quent, small, and corded. In the latter stage of the disease, vision, and occasionally hearing are wholly destroyed, yet general sensibility, or the sense of timch, usually remains to the last moment. Infants will sometimes readily lay hold of the nipple, and suck freely, although in a state of continued stupor and wholly deprived of the sense of seeing. The paralysis which occurs in the latter stage of the disease, is almost universally of the hemiple- giac kind. Infants are apt to keep the unaffected arm in con- tinued motion. The disease does not however always come on in the gradual manner or proceed with the train of symptoms just described. In many cases the attack commences and proceeds in a manner very similar to what occurs in the disease described by authors under the name of infantile remittent. In instances of this kind, the patient, after a few days1 languor and drooping is seized with considerable fever attended with head-ache, flushing of the coun- tenance and tenderness of the abdomen. The fever differs from that which occurs in the ordinary form of the disease by being subject to frequent and irregularly recurring intermissions. During the exacerbations there is generally considerable stupor; the patient often screams and starts up, in a state of great alarm and agitation. The stomach is always exceedingly irritable— vomiting being often excited merely by changing the position; and the bowels are in a state of obstinate constipation. The countenance is usually expressive of terror and pain or of dejec- tion and intellectual torpor. In some cases the disease is ushered in by convulsions without any previous manifestations of febrile excitement. In instances which make their invasion in this manner, however, there is always some evidence of ill-health previous to the occurrence of the convulsions—such as a peevish and fretful temper, variable appetite, irregularity of the bowels, tumid abdomen, foul breath, swelled upper lip, starting and grinding of the teeth during sleep—in short, all that train of phenomena which results from gastric irritation in consequence of worms, or other irritating sub- stances lodged in the alimentary canal. I have known the first intimation of the presence of this almost hopeless disease, to be DROPSY IN THE BRAIN. 375 coma, attended with deep sighing, cold hands and feet, pale countenance, and paralysis. Occasionally the disease commences and proceeds to the last stage with scarcely any other symptoms than slight febrile irritation, with little or no pain in the head, but a very frequent desire to pass urine, which is voided in very small quantities and with much difficulty. I attended a case a few years ago, in which not above a gill of urine was discharged in twenty four hours, accompanied with no other manifestations of indisposition, than a slightly feverish, and drowsy condition during the first five or six days. Dr. Monro, observes, that " there are cases in which the little patient has a desire, every hour, to pass urine." The liver almost always suffers considerable functional derange- ment in arachnitis. During the forming stage of the complaint, there is generally a manifest deficiency of bile in the evacuations, but in advanced periods, this secretion generally is not only copi- ous, but decidedly vitiated in its quality. This is particularly observed in the latter period of the second stage, or in the com- mencement of the third stage, when the symptoms of cerebral oppression are about supervening: at this period, the stools, frequently, consist almost wholly of dark bile and intestinal mucus, presenting a very dark green and glairy appearance, resembling, as Dr. Cheyne observes, " chopped spinage," or, in some instances, tar. Diagnosis. The characteristic symptoms of the first stage are: great irritability of temper; irregularity of the bowels; variable appetite; an irritated and quick pulse; wakefulness; and a pecu- liar frowning expression of the countenance. In the second stage: more or less continued pain in the head; torpor of the bowels; nausea and vomiting particularly on rising from the recumbent posture; irregular febrile exacerbations; a peculiar distressed expression of the countenance; sudden waking from sleep; transient and severe pains in the abdomen, alterna- ting frequently with acute pain in the head; a circumscribed flush on one cheek; intolerance of light and sound; a hot and dry skin, with a frequent, tense, and generally active pulse. When the disease has advanced to the third stage it is easily 376 DROPSY IN THE BRAIN. recognized, by great drowsiness, strabimus, hemiphlegia, paralysis of the upper eye-lids, and finally coma and convulsions. The disease with which arachnitis is most apt to be compounders infantile remittent fever. In this latter affection, however, k remissions are regular and generally complete; whereas in arachnitis, there is the utmost irregularity in the recurrence of the exacerbations and remissions, nor are they so perfect as in infantile remittent. Dr. Cheyne observes that the appearance of the stools, also, affords us a good diagnostic sign between these two affections. In infantile remittent the alvine evacua- tions are very fetid, and of a dark brown or mud-like color; whilst in arachnitis, they are usually of a dark green or glairy appearance, resembling the fresh ordure of cows. In idiopathic arachnitis, the abdomen, almost always becomes collapsed or flattened, without an increase of the alvine evacuations; whereas in infantile remittent, the belly is generally tumid, tense, and clastic. This circumstance is much insisted on by Goelis, as a diagnostic sign between these complaints. There is seldom much secretion of saliva, in arachnitis, both the mouth and nose being usually dry. In infantile remittent, on the other hand, the saliva and mucus of the nose are generally abundant. In the former affection, the tip and margin of the tongue are commonly clean and red; whilst in the latter, the whole surface of the tongue is covered with a thick, white fur, which becomes darker, and dry as the disease advances. There is almost invariably severe and continuous pain in the head, in arachnitis; whilst in infantile remittent, or worm fever, headache is a very uncommon occur- rence. In the latter disease, the little patient is almost constantly picking his lips and nose with his fingers; while in the former complaint he is apt to direct his hands to the forehead. In infan- tile remittent, moreover, the patient is often observed to have a movement of the deglutition during sleep, and when awake, he sometimes thrusts his fingers back into the fauces, as if desirous of removing something. These symptoms rarely, if ever occur in idiopathic arachnitis. In the former, the face is usually pale and leaden in the advanced periods of the disease; whereas in the latter, a conspicuous circumscribed flush often appears, on one or both cheeks. In arachnitis the head is generally the hottest DROPSY IN THE BRAIN. 377 part of the body; in infantile remittent, the abdomen is usually the warmest part. " Vomiting is one of the most invariable symp- ^is•in the first stage of arachnitis, and is attended with this uliar characteristic—namely, it comes on unexpectedly and suddenly, without being preceded by much nausea, and is more frequent when the patient is supported in a sitting position, than in a recumbent posture. If a child vomits frequently, at con- siderable intervals, if it be costive or the alvine evacuations are irregular and unnatural in appearance, if the abdomen is collaps- ed or flat and painful to pressure, if the urine be slimy and high colored, if there is much headache, and if the whole state of the disease manifest an obstinate or unmanageable course, then we have great reason for believing that the complaint is principally located in the head, and that, if not subdued, it must result in cerebral oppression." Although these circumstances will frequently enable us to form a satisfactory diagnosis, in relation to these two affections; it must be confessed, that in the commencement, arachnitis, is seldom cognizable; and that there is no symptom, which can be depend- ed on as characteristic of the disease, during its early periods. Dr. Alexander Monro has described a variety of hydrocepha- lus, which he calls the "hyper-acute form" of the disease, a form of very rare occurrence, and simulating in some of its most striking symptoms, inflammatory croup. "This rare form of the disease is very sudden in its attack. There is no previous headache, drowsiness, stupor, nausea, vomiting, paralytic state of any part of the body, or any other symptom denoting a de- rangement of the functions of the nervous system. It begins like croup. The child awakens in the night in a state of extreme agitation, and much flushed, and with a quick pulse; he is hoarse, and the sound of the voice when he inspires is similar to that of croup. The patient, at the onset of the disease, seems in a state of nervous irritation; often starts in his sleep, and in a short time, the disease assumes the appearance rather of a spasmodic affec- tion of the larynx, than of the inflammatory croup. The matter thrown up by vomiting, consists generally of indigested food. The longer the disease continues, the shriller and hoarser the voice becomes." 3C 33 378 DROPSY IN THE BRAIN. In the dissections which were made of children who died of "this form of disease, Dr. Monro found in one instance, the vessels of the pia mater at the corpora quadrigemiiia and tractus obtici, and at the origin of the eighth pair of nerves, much dis- tended with blood. No morbid appearance was discovered in the larynx and trachea." In another case, "the upper part of the brain, particularly the superior part of the posterior lobes, was covered with transparent gelatinous effusion;" and about an ounce of colored serum wras found in the ventricles. "The vessels of the spinal marrow were turgid, those of the cervical portion of a vermillion-red color, and those of the lumbar portion of a dark-red hue. The eighth pair of nerves was of a deep uniform red color along its whole tract, as far as its branches, going to the lungs." Dr. Burns attributes this form of hydrocephalus, " to an affec- tion of the origin of the eighth pair of nerves, induced by the state of the extremity of the fifth pair, in dentition, acting on its origin, which is near the eighth."* Prognosis. The prognosis in this disease must be always ex- tremely unfavorable. The instances of recovery from it are indeed exceedingly few. In the course of twenty years' practice I have known but two fully developed cases, which terminated in health, and it has fallen to my lot to have seen, and prescribed for a very considerable number of patients ill with this appalling dis- ease. I have already adverted to the flattering but illusive truce which sometimes occurs in the latter period of the disease.—Often, in the early period of my professional career have I been induced to think, by this ominous calm, that I had conquered the disease; and to announce to the anxious friends my good hopes of a speedy return to health. These hopes, however, were always blasted; and though taught by previous experience I have again and again thus hoped and thus encouraged, and always with the same painful conviction of the fallaciousness of this delusive interval. It is indeed extremely difficult to see so perfect a freedom from all the previous alarming symptoms, and not to flatter oneself, that • The Morhid Anatomy of the Brain. By A. Monro, M. D. 1827. DROPSY IN THE BRAIN. 379 recovery may ensue. When we see the little patient, emerge from a state of intense suffering and danger, and assume the smile and playfulness of convalescence—when from a state of stupor and unconsciousness, he awakens, as it were, to the feelings and actions of returning health, it is not easy to persuade oneself that all this hope-inspiring change is but the illusive prelude to the last, painful struggle, which inevitably leads to the grave. Post-mortem appearance.—The appearances discovered in the brain, on dissection, are very various. In some instances the arachnoid membrane is minutely injected, presenting a very red appearance, throughout its whole intent; in others this membrane is found considerably thickened and opake. A purulent, sero- purulent, or sero-gelatinous matter, is in many cases found be- tween the arachnoid and pia mater; and in the greater number who die of this conplaint, from one to four or six ounces of serous fluid is effused into the lateral ventricles of the brain.—In some cases, however, very little or no serous fluid is entravasated into the ventricles or between the membranes of the brain. Martinet and Duchatelet, in their interesting work on this disease, state that in eight cases out of twenty-six, there was scarcely a trace of serous effusion discovered within the cranium. In cases of this kind, the substance of the brain, is generally found conspicuously altered, both in consistence and color. Considerable portions of the brain are sometimes completely disorganised and reduced to a pap-like consistence; and instances have occurred, in which a portion of the cerebral substances was found much indurated. Occasionally cases are met with, where no other manifestations of cerebral disease, are detected, than signs of strong sanguineous con- gestion in the brain, with but little serous effusion and no marks of meningeal inflammation or structural lesion. Not unfrequently. unequivocal marks of previous disease in the abdomen, are detect- ed,—sometimes the colon presents an enlarged and distended ap- pearance ; at others, considerable portions of it, are so much con tracted as hardly to admit of the introduction of a large sized bougie. Frequently we find more or less extensive portions of the mucous membrane of the bowels, minutely injected; and I have seen it extremely red, throughout the whole extent of the 380 DROPSY IN THE BRAIN. small intestines. In one case, the lower part of the ileum was of a dark livid color resembling incipient gangrene. Dr. 1. C. Smith has given an account of a case of hydrocephalus, in which on post-mortem examination, the stomach was much contracted, and "on laying it open, an ulcer was found near the cardia, and the mucous and muscular coates, at this place were entirely destroyed, nothing remaining but a greenish mucus." Causes.—A strong predisposition to this disease, is manifestly hereditary, or constitutional, in some instances. The peculiar ap- titude to this affection, in some families, is sometimes strikingly exemplified. I know several families who have lost nearly all their children by this indomitable malady. It is difficult, it not impossible, to sayr in what this predisposition consists. It may be presumed, indeed, that children of an irritable habit of body, with a strong tendency to a preternatural determination of blood to the brain, are more liable to the disease than such as are of an opposite temperament. It has been supposed that children who have very large heads, are peculiarly predisposed to the arachnitis; but the correctness of this opinion is decidedly con- tradicted by experience and observation. It has been affirmed, moreover, that the scrophulous habit is often attended with a par- ticular predisposition to this complaint—an observation which appears, indeed, to be well founded. In a large proportion of instances, Dr. Mills found, on post mortem examination, unequiv- ocal appearances of scrophula; and out of twenty-two cases which came under the observation of Dr. Percival, eleven "were deci- dedly scrophulous." Among the most common exciting causes of this disease in chil- dren, are injuries, inflicted on the head by blows or falls. It has been observed, however, that injuries of this kind, rarely give rise to arachnitis, unless they are sufficiently violent to cause some degree of concussion of the brain, and my experience leads me to think, that there is truth in the observation. Suppressed discharges, and repelled cutaneous eruptions, particularly the sudden drying up of serous discharges behind the ears, is apt to give rise to this affection, more especially, when aided by the •rritation of dentition, and intestinal disorder. A sudden and DROPSY IN THE BRAIN. 381 total suppression of the diarrhoea, which frequently accompanies dentition, sometimes excites arachnoid inflammation, and conse- quent dropsical effusions in the brain. Dentition is often inti- mately concerned in the production of this complaint. This pro- cess, when difficult, is always attended with an irritable and irritated condition of the system, and a preternatural determina- tion of blood to the head. This, in itself, may be sufficient to excite the disease, in subjects who are predisposed to it, by con- stitutional habit, or from previous ill-health. It is probable, however, that dentition is seldom the sole cause of the disease; but that it most commonly acts in conjunction with other causes, especially with irritation in the alimentary canal. If, while den- tition is going on, the digestive functions become disordered from improper diet, or some other circumstance, or if irritation be established in the bowels, there will be a concomitance of causes, peculiarly calculated to develope this fatal malady. The ten- dency of intestinal irritation to occasion an undue determination of blood to the brain, is well known. In infancy, this determi' nation to the head, when long continued, is apt to give rise to inflammation of the brain, or the disease now under consideration. In middle age it frequently terminates in mental derangement; and in the decline of life, it is apt to result in apoplexy or palsy. It is believed by many, that arachnoid inflammation, or hydroce- phalus, during childhood, is very generally the consequence of intestinal irritation; and there are, in fact, many circumstances, which go to confirm this opinion. In very many cases, I think it may be safely asserted, that in a large majority of instances, there are unequivocal signs of intestinal irritation, both previous and during the existence of the disease. The variable appetite—the irregular action of the bowels, with the unnatural appearances of the alvine discharges—the tumid and tender abdomen—the picking of the nose, and the pale and sickly aspect of the coun tenance, which so commonly precede the developement of the disease, all point to the alimentary canal as the original source of the irritation. Where this irritation exists, there is, doubtless, always a strong predisposition to the disease; and if to this be added some other exciting circumstance, such as a blow on the head, or the supervention of painful dentition, or general fever 33* 382 DROPSY IN THE BRAIN. from cold—or, in short, any occurrence which gives rise either to general arterial excitement, or local irritation of the brain, the liability to the disease will be greatly enhanced. Worms, acrid secretions, and an accumulation of fecal matter in the bow- els, are the most common remote causes of this disease, when it depends on intestinal irritation. The strong tendency of intestinal irritation to give rise to arachnitis and consequent serous effusion into the brain is often strikingly illustrated in cholera infantum. When it runs into a chronic or subacute form, this disease fre- quently terminates fatally, under all the characteristic symptoms of the last stage of hydrocephalus. In two instances of this kind, in which I had an opportunity of a post mortem examination, I found the traces of arachnoid inflammation unequivocal, with copious serous effusion into the ventricles, and between the cir- cumvolutions of the brain.* Hooping cough, when it occurs in subjects naturally predis- posed to the disease, more especially, when it is associated with a strumous diathesis, or a loaded and irritated state of the intes- tines, is no uncommon exciting cause of arachnitis. The violent and frequently recurring spells of coughing, forces the blood powerfully into the vessels of the brain, and where the superven- tion of the disease is favored by previous predisposition, or some other concomitant circumstance, may thus readily give rise to arachnitis. During the period of convalescence from measles and scarlatina, children seem to be much predisposed to this disease. While we give all the importance to intestinal irritation, as a cause of arachnoid inflammation, which it unquestionably demands, we must bear in mind, that this same cause sometimes gives rise to a form of cerebral oppression, strongly resembling the last stage of arachnitis, but which is, nevertheless, wholly unconnected with cephalic inflammation. The determination to the head, in such cases, results merely in a state of str ng venous congestion of the brain, giving rise to a somnoler »nd * An interesting and striking case, in which hydrocephalic symDtnins were ; iiiced by organic disease of the intestinal canal, is related in the Med. and Chir. Re July, 1826. p. 102. DROPSY IN THE BRAIN. 383 oppressed state of the system, which may be readily mistaken for hydrocephalus. (Cheyne.)* Treatment.—There are three principal indications to be kept in view in the treatment of arachnoid inflammation—viz. 1. to moderate the general febrile excitement; 2. to obviate sanguine- ous congestion and inflammatory irritation in the brain; 3. to remove those causes of irritation, which tend to produce and sustain a preternatural determination of blood to the brain. The disease is not often detected in its incipient stage, on account of the gradual and insidious manner, in which it usually makes its approaches. When it does become an object of medical attention at this early period of its course, every effort should be made to remove the sources of irritation, and especially to obviate all undue determination of the blood, to the head. With this view, it is of the utmost importance to attend to the state of the alimentary canal; for it is in the stomach and bowels, especially that the primary irritation and exciting cause of the cerebral congestion most commonly exists. Purgatives are, accordingly, the most valuable means we pos- sess, for preventing the full developement of the cephalic inflam- mation at this early period of the disease. The bowels should, in the first place, be freely evacuated, by an efficient mercurial cathartic, and afterwards kept in a loose state by the daily ad- ministration of small doses of calomel, succeeded by a moderate portion of some mild purgative. From three to four grains of blue pills, or a few grains of calomel should be given in the evening, and followed next morning by a weak dose of epsom salts, rhubarb, or of castor oil, and continued until the alvine dis- charges assume a natural appearance. At first, it may be neces- sary to repeat these aperients daily, for four or five days in suc- cession, after which it will, in general, be sufficient to administer them every second, third, or even fourth day, according to the * Some writers contend, that hydrocephalus is almost invariably a sympathetic affection. Dr. Yates in particular, thinks that this disease has almost invariably its origin in the irritation of some organ remote from the brain. Spurzheim admits, that the primary irritation is frequently located in the abdomen; " yet anatomical dissections have con vinced me," he says, " that, in the greater number of cases, the morbid appearances of the abdomen are secondary of the cerebral disease." 384 DROPSY IN THE BRAIN. urgency of the symptoms. Mercurials are particularly useful in the incipient stage of this complaint, not Only as aperients, but as means for correcting the functional torpor of the liver, which almost invariably attends the early stages of the disease. In ad- dition to these means, especial attention must be paid to the proper regulation of the patient's diet. The appetite is some- times very craving, during the incipient stage of the complaint, and it requires much care and vigilance to prevent children from taking improper food, or overloading their stomachs. It is of the utmost importance, to guard against these errors, as they never fail to accelerate the progress of the disease, and to render the most judicious remediate treatment abortive. The most simple, unirritating and digestible articles of nourishment alone must be allowed: such as boiled milk, barley-water, arrow-root, boiled rice, oat-meal gruel, weak beef or chicken tea, &c. All stimu- lating drinks must be carefully avoided. If dentition is going on, and the gums are swollen or inflamed, they should be freely divided down to the advancing teeth. Much benefit may some- times be derived during the initial stage of the disease, from the application of blisters behind the ears, or on the back of the neck; and in cases preceded by the drying up of discharging Bores behind the ears, or on the head, blistering, in this way, should never be neglected. When the disease is once fully developed, prompt and decisive antiphlogistic measures, in conjunction with revulsive and deriva- tive applications are indispensable. Blood-letting ranks, of course, among our most efficient remediate means at this period of the disease, more especially, when the encephalic inflammation has been caused by some injury inflicted on the head, or when it is the consequence of some general cause, such as cold. In instan- ces of this kind, the pulse is almost invariably tense, quick, resist- ing and active; and nothing but prompt and very efficient blood- letting will make any decided impressions on the disease. Whenever the pulse is firm, and active, a sufficient quantity of blood should be taken away at once, to check, conspicuously, the momentum of the circulation. I am inclined to believe, that if bleeding were carried to the extent of producing an approach to syncope in the commencement of the inflammatory stage, our » DROPSY IN THE BRAIN. 395 efforts would be more frequently crowned with success than they unfortunately' are. " The temporal artery, or a vein in the arm, should be opened, and the blood allowed to flow, until a very obvi- ous impression is made on the system, or until the morbid actions of the vascular system of the brain are modified or totally changed. That such an effect has taken place, may be known by a pale- ness of the countenance, a shrinking of the features, and a ten- dency to deliquium; or by a diminution of, or removal of the heat, pain, weight, or uneasiness of the head." (Mills.) The blood-letting ought to be repeated, as soon as the febrile reaction and local inflammatory symptoms rise again. In cases depending on intestinal irritation, the arterial excitement is seldom very active. Here, blood-letting, though ai.vays indicated in the early periods of the inflammatory stage, must be employed with more caution; for copious bleeding, by weakening the energies of the system, is peculiarly apt to increase the morbid sympathetic affec- tions of intestinal irritation. With regard to the utility of local bleeding in this and othei forms of encephalic inflammation, different opinions are expressed by practitioners. Nearly all the French writers on this disease are decidedly in favor of the local abstraction of blood. It ap- pears, indeed^ very reasonable to expect peculiar advantages from a mode of depletion which abstracts the blood more imme- diately from the affected parts; and yet, in relation to the pre- sent disease, a contrary opinion has been expressed by several eminent practitioners. Mr. North, in his work on the convulsive affections of infants, observes, "that he never found well marked symptoms of determination to the head, removed by leeches, however freely they were applied." In cases in which the cephalic determination depends on intestinal irritation, this obser- vation is, perhaps, well founded; for the blood which may be thus removed from the vessels of the head, will be immedi diately replaced by the continued preternatural afflux of this fluid. It must be observed, moreover, that so long as the momen- tum of the general circulation is considerable, local bleeding can scarcely produce any other advantages than such as would result from abstracting the same quantity of blood by means of the lancet. General bleeding is, therefore, an essential preliminary 386 DROPSY IN THE BRAIN. to the beneficial employment of leeches or cupping. After the impetus of the circulation has been moderated by the use of the lancet, leeching the temples, and along the posterior parts of the ears, is a valuable auxiliary in the treatment of arachnitis. It sometimes happens that blood cannot be obtained from a vein in the arm, and occasionally, not even from the temporal artery. In this case, the application of leeches is indispensable. They should be applied in large numbers, to the temples, occiput, and behind the ears, and the flow of blood encouraged, until a very obvious impression is made on the pulse, or a manifest tendency to syncope ensues. Dr. Mills, in his interesting paper on this disease, strongly recommends leeching, immediately after vene- section, "in order to postpone the period of the exacerbation, or break the chain of diseased action. I have observed that these two modes of drawing blood, when successively employed, make a greater impression on the disease than either of them is capa- ble of effecting when singly had recourse to." Purgatives are among our most useful means for subduing this disease. When the bowels are loaded with irritating substan- ces, and the cerebral affection is symptomatic of intestinal irrita- tion, laxatives are, in truth, the main stay of our hopes. They are, indeed, almost equally useful in idiopathic arachnitis; for besides their effect in evacuating irritating causes, they tend, very particularly, to diminish the afflux of blood to the brain, and to moderate the general momentum of the circulation. "Should we ascertain," says Dr. Cheyne, " that the alimentary canal is torpid, and imperfectly performing its functions, admitting an accumulation of feculent matter; or that the secretions flowing into it are vitiated or diminished in quantity—circumstances which we ascertain by the peculiarity in the appearances, or the pungent fetor of the stools, we must, by steadily pursuing the purgative plan, endeavor to effect a change; for while this is produced in the appearance of the stools, we are effecting a most important change in the hepatic system, alimentary canal, and all the parts including every organ essential to life, which is con- nected with them." In symptomatic cases, depending on pri- mary irritation of the alimentary canal, the milder purgatives after the first thorough evacuation of the bowels, will, in general, DROPSY IN THE BRAIN. 387 be more beneficial, than the repeated use of very active purges. Frequent purging, by the more active and irritating cathartics, though at first apparently useful, tend, ultimately, to increase the inflammatory irritation of the bowels, and consequep,th/, the cere- bral affection. It must be recollected that intestinal irritation is not always dependent solely on the presence of acrid or irritating substances in the bowels. The mucous membrane of the alimen- tary canal may be in a state of sub-acute inflammation, or of high vascular irritation. In cases of this kind, the milder laxatives are manifestly more appropriate than the more irritating articles of this class, since they are sufficient to evacuate the contents of the bowels without causing injurious irritation. Undoubtedly, the first purgative should be sufficiently active, to evacuate the intes- tines freely. From five to six grains of calomel, followed in a few hours, by infusion of senna and manna, or a suitable portion of epsom salts, will answer well for this purpose. The bowels must afterwards be regularly evacuated, so as to procure three or four discharges daily, by the use of small doses of calomel, promoted by castor oil, and laxative enemata. In idiopathic arachnitis, however, the intestines are generally very torpid, and ftm seldom be sufficiently moved by the milder purgatives. In cases of this kind, it is often necessary to resort to large doses of the most active cathartics, in order to procure adequate evacuations from the bowels. The same difficulty sometimes occurs, in cases attended with a great accumulation of fecal matter in the intestines. Calomel should always enter largely into the purgatives employed in this disease. Independ- ent of its aperient effects, its constitutional or specific influence, if early obtained, is sometimes attended with great benefit. From one to three grains may be given every three or four hours, according to the age of the patient, with an occasional dose of of castor oil, infusion of senna, or epsom salts. Where there is reason to suspect the presence of worms in the intestines, anthel- mintics should be employed, in conjunction with purgatives. An infusion of spigelia with a small portion of senna, may be used with a prospect of much advantage in such cases. In some instances the stomach is so irritable in this disease, that no arti- cles will be retained a sufficient time to operate on the bowels. 388 DROPSY IN THE BRAIN. Where this state exists, we must endeavor in the first place, to allay the gastric irritability, and this may in general be effected by minute doses of calomel and ipecacuanna: the one sixftr o." a grain of the former, in union with one-fourth or one-third of a grain of the latter, has repeatedly succeeded in my hands to restrain the tendency to vomiting in this disease. Mercury, as has been already observed, is undoubtedly a rem- edy of valuable powers in the treatment of this affection. Doctors Percival, Dobson, Rush, Cheyne, Mills, not to mention many other names of great celebrity, have related instances which yielded to the influence of this potent remedy. Employed with a view to its constitutional operation, mercury often contributes very powerfully to the reduction of visceral inflammation; and experience has shown, that in the present affection, it deserves to be regarded as one of our most valuable remedies. It is, in general extremely difficult to procure the constitutional influence of mercury, to an obvious extent, in very young children; and hence, to obtain this desirable object sufficiently early to derive decided advantage from it, many have advised the use of mer- curial frictions at the same time that calomel is administered in- ternally. Dr. Mills of Dublin, strongly recommends the use of calomel in union with opium, " as soon as a check has been given to the disorder of the head," by venesection, leeching and purga- tives. " The good effects," he says, " of a combination of these remedies, seem to depend on their power of equalizing the circula- tion, increasing the secretions, and exciting the action of the cutaneous vessels." I cannot bring to my recollection a single instance, in which this remedy, when judiciously administered, after depletion, was followed by disagreeable consequences; and in cases unaccompanied by great irritability of the stomach, its powers are occasionally increased by the addition of small quan- tities of ipecacuanna, or antimonial powder."* The " watery extract," he thinks, is decidedly the best preparation of opium for this purpose. " It procures rest, diminishes pain and irrita- tion, and diffuses throughout the frame an agreeable sensation, at the same time that it is devoid of any narcotic or nauseating * Transact, of the King and Queen's College of Physicians in Ireland. Vol. v. DROPSY IN THE BRAIN. 389 quality, and does not cause vertigo, pain, or a sense of fulness in the head." My own experience enables me to bear testimony in fifvor of this preparation; for I have seldom known it to produce the disagreeable effects that are so apt to follow the use of laudanum or opium, in its ordinary state. Dover's powder, also, has found advocates as a remedy in this disease. Drs. Brooke, Percival, Cheyne, and Crampton,* all speak favorably of its employment in hydrocephalus. After adequate depletion and purgation, in cases connected with intestinal irritation, small doses of this composition often prove highly serviceable, by allaying general irritability and inducing a gentle diaphoresis. It should be observed, however, that in the idiopathic form of the disease, opiates of every description, must be carefully avoided, as their tendency to increase the flow of blood to the brain, could hardly fail to prove very injuri- ous. When preternatural determination to the head depends on a remote focus of irritation—as in the mucous membrane of the bowels—opiates, by diminishing nervous excitability as well as local irritation, will frequently reduce, also, the irregular de- terminations which depend on such irritations. It is in cases of this kind only, that we may venture on the exhibition of Dover's powder, and not in these instances until the impetus of the cir- culation has been moderated, and the alimentary canal well evacuated. Dr. Stocker, of Dublin,! speaks very favorably of the use of James'' powder in hydrocephalic affections. According to his observations, it tends, very considerably, to lessen the determina- tion of blood to the brain. It should be given in small but frequent doses, and may be very properly administered in union with calomel. Dr. Monro states that he has cured several cases of this disease by a plaster composed of tartar emetic and wax ointment, applied to the head, in conjunction with the internal use of calomel combined with James' powder. He states, that he has found this combination peculiarly useful, in restoring the healthy action of the bowels. Tartar emetic, also, has been used * Transactions of the Associat. of Fellows and Licentiates of the Queen's Collego of Physic in Ireland. Vol. vii. t Dublin Medical Essays, 1806. 34 390 DROPSY IN THE BRAIN. with great advantage in this disease. Laennec, has reported some cases of acute hydrocephalus, in which he administered twelve grains and more of this article during the day, with com- plete success. Mr. Newnham asserts, that green tea has a strong tendency to lessen morbid vascular excitement in the brain. "In the acute irritation of the membranes of the brain in children," he says, " the efficacy of green tea has been strongly marked in my practice. Exhibited during the early symptoms, as soon as a sufficient quantity of blood has been taken, and before effusion occurs, it has proved a more powerful means than any other we possess, of controlling the morbid action, which, if suffered to proceed to its second stage, is scarcely to be overtaken by any treatment."* Nothing is more common in the treatment of this disease, than the application of blisters to the shaven scalp; but this practice is, I conceive, of very doubtful propriety. I have always pre- ferred placing them on the back of the neck or behind the ears, while ice or cold water is applied to the top of the head, and warm or rubefacient applications made to the feet. Dr. North, whose interesting work I have already mentioned, observes, " that blisters to the head are decidedly prejudicial in the convul- sive diseases of infants;" and the same observation is applicable, I think, to the disease under consideration. The application of ice or iced water, in the manner mentioned in the last chapter, may be accounted a very useful auxiliary in the treatment of arachnitis, and to favor its revulsive influence, warm or stimu- lating applications to the feet may be usefully employed. Dr. Regnault recommends in very strong terms, the application of moxa in this complaint;t and its known efficacy in subduing deep-seated articular inflammation, justifies the expectation of considerable advantage from its use in arachnoid inflammation. Neither this application nor blisters, however, should be resorted to, until the activity of the circulation is reduced by general and local blood-letting. The tartar-emetic ointment also may be verv beneficially applied. (Monro.) * Med. Chir. Rev. July, 1827. t Medical and Physical Journal, Vol. zl. p. 16. PERITONITIS. ASCITES. 391 CHAPTER XXXIII. PERITONITIS. ASCITES.* Subacute or chronic inflammation of the peritoneum, and consequent effusion of serum into the cavity of the abdomen, is not a very uncommon disease among children. Its progress through the first or inflammatory stage, is often so obscure as to escape particular attention, until effusion has taken place, and the abdomen has become tumid and tense. In many instances slight pains are occasionally experienced in some part of the abdo- men, which are usually ascribed to flatulency or disorder of the bowels. The patient manifests a sullen and fretful temper, and is disinclined to engage in the usual amusements and sports of children. When pressure is made on the abdomen, a sensation of soreness is felt, in certain parts, generally about the umbilical region; and the same effect sometimes results from coughing, sneezing, or any sudden concussive motion of the body. At night the patient is restless, and his sleep is broken and " of shorter duration than formerly." The face and whole surface of the body are pale, and the countenance expressive of discontent, suf- fering and languor. The appetite is variable; the tongue cov- ered with a white fur along the middle, with nearly clean and pale-red edges; the bowels are irregular, being sometimes costive, and at others affected with diarrhoea. In cases of this kind, the pulse is seldom perceptibly affected in the forepart of the day; but in the afternoon, and particularly towards evening, it gen- erally becomes somewhat accelerated, contracted, quick and sharp. The surface is seldom above the natural temperature, * Dr. H. Wolff, of Bonn, is I believe, the first who has described this disease, as it occurs in infants. He describes it as " a peculiar form of ascites in children," in a paper published in Hufeland's and Osann's " Journal des practischen Heilkunde" for May, 1829. I have not seen Dr. Wolff's memoir on this subject; and avail myself of an in- teresting review of it, published in the 7th vol. of the North American Medical and Sui- (deal Journal. 392 TERITONITIS. ASCITES. except during the slight evening exacerbations, when it becomes preternaturally warm and dry. The disease does not, however, always commence and proceed in this obscure manner. In some cases, " the pain in the abdo- men is constant, severe, and much increased by external pres- sure, and is attended with vomiting, a hot skin, a quick, firm and contracted pulse," and great muscular debility. After these symptoms have continued for an indefinite period, varying from five to fifteen or twenty days, effusion begins to take place into the cavity of the peritoneum, and the abdomen gradually becomes enlarged. The nature of the abdominal dis- tention is rendered manifest by the fluctuation produced by per- cussion. If the progress of the disease be not interrupted, " the abdomen gradually increases in size; the inferior extremities become emaciated; the skin at the upper and inner part of the thighs, hangs infolds; the fluctuation of the abdomen becomes less perceptible as the disease advances, while the tumefaction continues unabated. Every part of the body, with the exception of the face, becomes emaciated; the little patient loses rapidly its strength; the lower extremities are no longer able to bear the weight of the body: in the midst of these symptoms, the appetite may, however, continue, or even be increased. The bowels are in general variable, being at one time affected with diarrhoea, at another constipated, or at least seldom opened. A febrile ex- citement now occurs, and the child, in a state of extreme maras- mus, sinks gradually into its grave." (Wolff.) The writer just quoted, mentions a peculiar appearance of the countenance occur- ring in the second or hydropic stage, which he regards as one of the most certain diagnostic signs of the disease. " The appear- ance referred to, consists of a tumefaction of the skin at the root of the nose, immediately between the eyes." "The parents of my patients," he says," frequently noticed a change in the expres- sion of the countenance, without being able to say in, what it consisted; but as soon as I directed their attention to the tume- faction of the skin at the spot mentioned, they agreed with me, that the change in the appearance of the child's countenance arose from it, and were surprised, they had not discovered it themselves. PERITONITIS. ASCITES. 393 Causes.—This disease appears to be frequently the consequence of gastro-intestinal irritation; or rather of mucous inflammation of the alimentary canal—the inflammation passing from the mu cous membrane, to the peritoneal covering of the bowels. Crude, irritating and indigestible articles of nourishment, are probably the most common exciting causes of this affection in children. I have witnessed two cases within the present year, both of which were preceded by prominent symptoms of intestinal irri- tation, for many weeks before the peritoneal affection became obvious. In adults, I have met with several very striking instan- ces of subacute peritonitis, and consequent serous effusion into the abdomen, brought on by acute mucous inflammation of the bowels, in consequence of irritating ingesta. There are, doubt- less, various other causes which may give rise to this affection in children. It may be the result of acute or chronic inflamma- tion of the solid abdominal viscera—particularly of the spleen and liver. Blows and other injuries inflicted on the abdomen; repelled cutaneous eruptions; cold, and perhaps protracted con- stipation, may give rise to the disease. When properly treated during the first stage, this disease may, in general, be readily subdued. " Even in the first period of the stage of effusion, it is by no means incapable of being arrested; but when neglected, mismanaged, or submitted to medical treat- ment only in the advanced period of the second stage, as is but too commonly the case, death is the ordinary result." The great difficulty, indeed, arises from the gradual and obscure manner in which the disease frequently advances through its inflamma- tory stage, so that very few cases are recognized or properly un- derstood, until effusion has taken place. During the first or inflam- matory stage, the symptoms are usually ascribed by the parents, to worms. Anthelmintics are accordingly resorted to, which seldom fail to aggravate the disease, and to hasten its progress to an incurable state. Dr. Wolff asserts, that " most of the severe cases which had fallen under his notice, were those in which anthelmintics had been administered, either by the parents, or occasionally by a physician, on the first appearance of the symp- toms, from a supposition that they owed their origin to the exis- tence of worms in the intestines." This practice, he says, is 3 E 34* 394 PERITONITIS. ASCITES. extremely pernicious. "For although, in a few instances, worms may be discharged, yet so far from the patient's disease being removed, every symptom becomes aggravated; the pain of the abdomen increases in intensity, and is rendered more constant; vomiting is excited, the appetite is entirely destroyed, the thirst augments, the febrile symptoms are rendered more marked; and the patient is apt to suffer severe attacks of colic, soon after eating." Treatment.—During the inflammatory stage, local depletion, and counter-irritating applications to the abdomen constitute our principal remedies. After blood has been abstracted by leech- ing, to an extent corresponding with the age of the patient, and violence of the local symptoms,'a large blister should be applied to the abdomen, and kept discharging by dressing it with mercu- rial ointment. I have never in children derived any decided benefit from pustulation with tartar emetic ointment. The warm bath, and fomentations to the abdomen, mayr also be used with advantage. Internally, small doses of calomel and ipecacuanna, should be regularly administered. A fourth of a grain of each may be given three or four times daily; but if no mercurial oint- ment is used externally, the quantity of calomel should be increased to a half a grain. Should the calomel not keep the bowels suffi- ciently loose, a small dose of castor oil must be occasionally ad- ministered. To allay general irritation, a few grains of Dover's powder may be given in the evening with much advantage. Throughout the whole course of the disease, the patient should be restricted to the blandest and simplest articles of nourish- ment. Without strict attention to this important injunction, there can be but little hope of a cure in this affection. Arrow- root, tapioca, sago, rice, boiled milk and crackers, barley water, weak chicken tea, &c, constitute appropriate articles of diet. In the second stage, that is, after effusion has taken place into the abdomen, leeching may still be useful if the abdomen be tender to pressure. At this period of the disease, much benefit may sometimes be derived from frictions on the abdomen, with mercurial ointment. Laennec and Velpeau speak in the most favorable terms of this practice; and my own experience has PERITONITIS. ASCITES. 393 fu» iiished nie with unequivocal evidence of its usefulness. Dr. Wolff strongly recommends calomel, with very minute portions of digitalis; and at a still more advanced period, "digitalis with cream of tartar in the form of powders." He asserts, that under the use of these remedies, most of the patients he treated became convalescent, at the end of two, three, or at most four weeks. Whether mercury be used externally, as recommended by Laen- nec, or internally, digitalis, is doubtless a most important auxil- iary, and should never be omitted after effusion has taken place. Irritating diuretics, and drastic purgatives, are extremely impro- per. They never fail to aggravate the disease. 396 VACCINA. VACCINE DISEASE. CHAPTER XXXIV. VACCINA. VACCINE DISEASE. Much uncertainty still hangs over the origin of the vaccine disease. The opinion that it is derived from the complaint in horses, denominated grease, is sustained by very imposing, though not conclusive, evidence. We have excellent authority for be- lieving, that inoculation with the virus of grease, occasions an eruption in the human subject and cow, precisely similar to that arising from vaccina. Loy, Sacco,* Decarro of Vienna, and Frise, director of vaccine inoculation in Silesia, have all perform- ed this experiment, according to their several statements, with perfect success; and so well assured were the two latter gentle- men, of the identity of the two infections, that it is said they used indiscriminately the matter of grease and of vaccina for inoculation. Cazenane met with two cases in the hospital of St. Louis, of true vaccine disease on the hands of grooms, having the care of horses affected with grease. By the application of the recent blackish matter of this complaint, to the raw surface of a sore on the teat of a cow, Ring succeeded without difficulty in producing genuine vaccina. The same gentleman publishes a letter from Mr. Rankin, wherein is related a case of pustular dis- ease, closely resembling the vaccine affection, produced on the hands and face of a farmer by the virus of the equine disorder. Be- sides, it would seem probable, that persons infected with a pus- tular disease from this source, enjoy an immunity from the con- tagion of small pox. Dr. Jenner has recorded a case of this * Neue Entdeckungen uber die Kuhpocken, die Mauke u. Schaafpocken. Translated from the Italian by W. Sprengel. 1813. VACCINA. VACCINE DISEASE. 397 kind. There can be no doubt, however, that further and more careful observations are requisite to the formation of a correct judgment on this point. Dr. Jenner supposes, that the infection of grease is transmitted through the intervention of the male domestics, who, after dressing the heel of the horse, proceed without cleansing themselves to aid in milking the cow. But, in several countries where vaccina is prevalent, it is well known that the grooms have nothing to do with the offices of the dairy; and in America, where horses and cows are attended to by different persons, the latter are sometimes affected with the dis- ease, though running in pastures from which the horse is exclu- ded. These facts, though they do not disprove the similarity of the two viruses, throw many difficulties in the way of accounting for one as the consequence of the other. It is now well known that sheep are subject to an eruptive disease about the mouth and head, the matter of which being inoculated, will produce effects very similar to those of grease. It is also affirmed, that persons, to whom this infection has been communicated, are rendered insusceptible to the contagion of variola. We find this fact stated in a letter, addressed by Mr. W. Bruce, consul at Bushire, to Erskine of Bombay. After very extensive and cautious enquiry, he felt justified in yielding full credence to the report of several tribes of the natives, that those of them who attended to the flocks, were not unfre- qently affected with an eruptive malady, caught from the sheep amongst whom it widely prevailed, and were thereby completely secured against the attack of small-pox. Sacco and Richter likewise bear testimony, that inoculation with this infection confers on the human subject an exemption from the contagious influence of variola. The curious circumstances we have mentioned in relation to the marked affinity subsisting between the various eruptive dis- orders furnish no slight grounds for the opinion, that they are all essentially identical in their nature, and derived from the same ultimate source. The hypothesis with regard to variola is, that it was originally nothing more than the cow-pock, or the grease of horses in Arabia, transferred casually or otherwise to the hu- man system, and that by such transference and by its continuous 398 VACCINA. VACCINE DISEASE. propagation through the human species, it gradually deteriorated, until it had acquired all the virulence and activity of what is now termed small-pox.* This hypothesis is by no means extravav gant. It would seem from experiment, that the milder sort of small pox under proper management, may be made to assume by successive inoculations so meliorated a form as hardly to be distinguished from vaccina. Dr. Adams inoculated a certain number of children, with lv mph taken from the pustules of a mild variety of variola, denominated by him the pearl sort. With the matter of the mildest of the resulting cases, he inoculated a sec- ond number, and so on, till he produced a small pox so melio- rated as to resemble the vaccine disease. If small pox can thus be made to take on the gentle nature of the vaccine disease, the inference is, that vaccina under certain circumstances may have acquired all the virulence of the variolous contagion. Another argument in favor of the identity of the two affections, grows out of the commonly received fact, that two diseases, arising from es- sentially distinct contagions, cannot exist simultaneously in the same individual. If a subject for example, be inoculated at the same time with the virus of small pox and that of measles, the influence of the one will be entirely suspended, until the other has commenced and finished its course, when it too will develope itself and run its usual career uninterruptedly. Now if the matter of vaccina, and that of variola be inserted at once in sep- arate parts of the same body, the eruptive distemper resulting, will pursue a simultaneous course, exhibiting precisely the same character, as if their respective viruses had been inoculated at different periods. This is probable evidence of their original identity, how dissimilar soever they may have been rendered by accidental circumstances. But positive evidence is not wanting to sustain this point. Cases are recorded where variolous matter inserted in the udders of cows, produced in them a pustular affec- tion, not to be distinguished from cow-pox. This observation is made by Richter on the authority of Garsner.t We may also remark here, on the authority of Da Lisa, that sheep, inoculated with the virus of variola, are protected entirely from what is * Dictionnaire des Sciences Medicales. r Specie!! Therapie. VACCINA. VACCINE DISEASE. 399' called sheep-pox. Inoculation in them is said to produce but one pustule at the point of insertion.* If we may rdy on the correct- ness and veracity of Dr. Ozaman, of Lyons, and more recently, of Dr. Sunderland, of Barman, the original identity of vaccina and variola, is established beyond doubt. The former in a paper read in the French Academy of Medicine, in July, 1830, asserts, that the inoculation of variolus matter, mixed with fresh cow's milk, will develope an eruption similar in all respects to that occasioned by the vaccine virus, and will fully answer for the in- ductions of the usual vaccine disease.t Dr. Sunderland's experi- ments:}; would seem still more conclusive. The following experi- ment performed by him is so interesting, we will give it in detail. A woollen bed cover is permitted to lay on the bed of a patient who has died of small-pox in the suppurative stage, or who, placed in a narrow and badly ventilated apartment, is suffering from the disease in a considerable degree, until it is well saturated with the contagion. It is then rolled up, wrapped in linen, and spread for twenty-four hours on the back of a cow, in such a way that the animal cannot throw it off. In the same manner, it is ex- tended on the back of each of three other cows, for the saVne length of time; after which it is so suspended in their stall, that they may constantly inhale the contagious effluvia as they arise. In the course of a few days the animals become sick and fever- ish; and on the fourth or fifth day, a pustular eruption breaks forth upon the udders and other parts, covered with hard skin and displaying the usual appearance of the vaccine disease, soon becomes filled with lymph. Inoculation with this lymph, which precisely resembles the matter of genuine cow-pock, will produce perfect vaccina. Symptoms and Progress of Vaccina.—There are two varie- ties of vaccina, the casual and inoculated. The casual cow-pock is apt to affect the joints and tips of the fingers of domestics, hav- ing the care of cattle laboring under the vaccine disease. It it always more severe than the inoculated variety, on account of the * Mediz. Chirur. Zeit. 1809. No. xliii. Salsbury. t Rev. Encyclop. Aout. 1830. J Journal der Praktischen Heilskunde, Jannar. 1831. 400 VACCINA. VACCINE DISEASE. number of vesicles produced, and the membranous, rigid struc- ture of the parts involved in the eruption. Inoculated vaccine iS, in general, indicated by one pock alone, and its whole course may be divided iito two periods. 1st. The first period commences towards the close of the second day after the insertion of the virus, at which time may be discern- ed a minute point of inflammation at the spot where the puncture was made. This point is more distinct on the third day, and on the fourth, it has the form of a very small pimple, surrounded by a faint and narrow inflamed areola. There is a gradual enlarge- ment of the pimple, and on the fifth day, it begins to display a perfectly regular and circumscribed outline with a flattened sur- face, and a small depression at the centre, somewhat darker than the rest of the surface,—an appearance it retains throughout its whole subsequent course. The pimple about this time becomes a vesicle, containing a limpid fluid, and presents a dull whitish aspect. From the fifth to the ninth day, the circumference of the pock continues to enlarge, without its elevation being percep- tibly increased, so that its flattened appearance becomes still mope remarkable. 2. The second period begins at the full maturity of the pustule, which takes place on the ninth, when constitutional derangement, if any occurs, is apt to supervene. In some instances, the axil- lary glands at this period become irritated and swollen, and the patient complains of drowsy languor and faint creeping chills, alternating with flushes of heat. Constitutional symptoms arc not unfrequently altogether absent. By the tenth or eleventh day, the belt of inflammation around the pustule, that began on the eighth day to widen, has become a broad, beautiful and viv- idly red areola encircling the pock. The areola is now perfect, and attended with some degree of tumefaction and hardness. The central indentation of the pustule begins, on the eleventh day, to assume a darker hue, and this darkness gradually spreads towards the circumference: so that by the fourteenth day, the surface of the pock is transformed into a brown scab, which grows darker and darker, acquiring a deep brown or mahogany color. In a few days more, the circumference of the scab becomes loos- ened, but the centre still retains its attachment, till between the VACCINA. VACCINE DISEASE. 4qj third and fourth week from the time of vaccination: the whole then falls off, leaving a slight, regularly defined depression in the skin, and a scar which is indelible. Deviations.—Such is the ordinary course of the disease, for it is occasionally subject to deviation. The period, for example, intervening between the insertion of the virus and appearance of the pustule, is sometimes prolonged to the tenth, fifteenth or even twentieth day. In some cases, the whole course of the disease is completed in eight or nine days, well-formed lymph being pro- duced by the fourth day. When the umbilicated indentation in the centre of the pustule is wanting, there may be two pus- tules, partially blending with each other. It is seldom that inoc- ulation produces more than one pock, but occasionally one or more smaller pustules manifest themselves in the vicinity of the primary one. Instances indeed have occurred, where they ap- peared in considerable numbers on different parts of the body. In the report of the central vaccine committee of France in 1818, 19, it is stated that a spontaneous eruption of many pustules had occurred in several cases after vaccination; and moreover, that the matter of this eruption had the power of inducing as perfect a disease as that excited by the virus of the primary pock. Considerable inflammation sometimes supervenes on the day succeeding the vaccination, and an elevation of the cuticle takes place at the point where the puncture was made. In this case, the failure of the operation may be considered certain. The inflammation, after continuing a day or two, speedily subsides, Without leaving any local affection. Instead of a vesicle, a true pustule is occasionally formed, the inflammatory action arising on the day after the vaccination, or, at the furthest, on the succeeding one. A well-defined areola en- circles the pustule, in which instead of a depression, there is a conspicuous elevation of the centre above the ridges. Its increase is rapid, and about the fifth day, it is converted into a yellowish brown scab, which soon disappears without leaving any scar. In this case, also, the operation is abortive and should be repeated. Spurious Pock.—According to Willan, there are three varieties of spurious pock. In the first, though the vesicle is perfect, there 3F 35 402 VACCINA. VACCINE DISEASE. is no areola around it on the ninth or tenth day. In the second, the vesicle is much smaller than the genuine vesicle, and is pearl- colored, flattened, without a rounded or prominent margin, with a hard, inflamed and slightly elevated base, and an areola of a dark-red color. The vesicle in the third variety, is small and pointed, with a very extensive, pale-red areola. The areola in the two latter varieties, are observable on the seventh or eighth day, and disappear about the tenth. A very small scab is then formed, which is not so regular in its shape as that of the true vesicle. The spurious disease may arise from the following causes; 1st. The existence of some cutaneous distemper, capable of counter- acting or perverting the action of the genuine vaccine virus. 2d. Certain idiosyncrasies, or a depraved condition of the system, vitiating or impeding in some way the regular operation of the virus. 3d. Vaccination with spurious matter, or with genuine matter whose virtues have been impaired by long keeping; or with matter taken from a true vesicle at too late a period. Beside these, friction with the clothes, or by other means, so as to cause a rupture of the vesicle, and the frequent abstraction of its lymph by punctures, may be considered as depriving the disease of its genuine character. The spurious and true cow-pox sometimes pursue their course simultaneously in the same individual, in which case it does not seem that the protective power of the genuine virus is in any de- gree diminished. Diagnosis.—In attempting to distinguish true vaccine from false, we should carefully observe the following particulars: 1st. In the genuine disease, inflammation, saving that which occasionally arises from the irritation of the puncture, is scarcely observable until the third day, and sometimes considerably later. On the other hand, the spurious affection is marked by an ele- vation of the cuticle and no slight degree of inflammatory action, so early as the second day. 2d. The small inflamed point, in true vaccina, appearing in two or more days after the insertion of the virus, has a gradual increase until the seventh day after its first manifestation, when it is in a state of perfection. The spurious pustule becomes* ma VACCINA. VACCINE DISEASE. 403 tured, and finishes its course in, a much shorter time; the scab- bing commences on the third or fifth day after the development of inflammation. 3d. A beautiful, circular, and well-defined areola almost always surrounds the pustule of genuine vaccina, and is seldom perfect until the seventh or eighth day. In the false disease, the pus- tule is begirt with an irregular, superficial inflammation, super- vening on the first or second day after the appearance of the pus- tule; and the pustule itself is more like a common festering sore occasioned by a thorn, than a pustule excited by the vaccine virus. 4th. The genuine pustule is perfectly and regularly defined, with a flattened surface, and a slight central indentation, and con- tains a colorless, limpid fluid. The spurious pock is more eleva- ted, not depressed in the centre, is irregularly circumscribed, and contains an opaque purulent matter. Remediate Treatment.—General remediate treatment is rarely required in the inoculated form of vaccina. Febrile excitement occasionally exists, and even a slight exanthema may appear, in which case we should direct a low diet, diluent drinks, and a gen- tle aperient, together with spiritus mindereri or sweet spirits of nitre. The vesicle should be especially shielded from friction, whereby it is apt to be greatly irritated, particularly about the time when the areola is making its appearance. From friction or other cause, the inflammation and swelling around the pustule sometimes become so severe as to demand immediate relief. Cold water, a weak solution of sugar of lead, or poultices made of lead- water, should be applied to the part, to allay pain and inflamma- tion, at the same time that laxatives, with some of the milder refrigerant diaphoretics are given internally to subdue febrile irritation. The relation of Vaccina with other diseases.—I have thought it proper to defer until now, the consideration of the relation of the vaccine disease with other affections, that I might present in a connected form all 1 have to say on this part of our subject. It was early noticed, that the infection of vaccina had a 404 VACCINA. VACCINE DISEASE. tendency to correct a general depravation of the system and to remove various chronic complaints, especially those of the lym- phatic and cutaneous systems. There are well authenticated cases, in which crustea lactea, scrophulous ophthalmia and tumors, and certain varieties of scaly tetter have been entirely cured by the constitutional influence of the vaccine virus. Herpetic erup- tions, after vaccination, not unfrequently assume an appearance resembling that of vaccine pustule, and fade away with the de- siccation and falling off of the scab. Violent whooping cough has been arrested at the moment of the appearance of the eruption, and permanently cured. Of the power of vaccina to mode- rate and abridge the course of pertussis, I have myself witnessed many examples. In this respect, it differs greatly from both casual and inoculated small pox, which have been known to ex- cite the active developement of disorders, to which there existed previously a latent disposition. In accounting for these peculiai effects of the vaccine disease, we can hardly suppose that its in- fluence over other disorders is specific in its nature, otherwise it would be more constantly and uniformly exerted. It may be consid ered rather the result of an irritation, universally diffused through- out the system, penetrating the minutest portion of living fibre; for it is well known that the creation of a comparatively slight gen- eral irritation is sufficient, at times, to relieve a graver disorder already existing. We may observe, that the meliorating influ- ence of vaccina over other complaints, is generally more mani- fest, when a considerable degree of irritation is produced. Hence, when such an influence is desirable, it may be proper to insert the virus by several punctures. The diminution in the prevalence of small pox, occasioned by the general introduction of vaccination, is, if we may be- lieve Dr. Watt, very curiously associated with the increase of measles. His observations, which are restricted to Glasgow, go to prove, that the increase of measles in that city, since the adoption of vaccination, has borne a nearly equal proportion to the decrease of small pox. If such be the fact, it should perhaps be ascribed to peculiar local causes, especially as further obser- vations have afforded no countenance to his opinions. VACCINA. VACCINE DISEASE. 405 As a prophylactick against that terrible scourge the small pox, the virtues of the vaccine disease are now happily and extensively known. Origin of Vaccination.—Dr. Jenner has the inestimable honor of introducing this operation to the notice of the wrorld; but long before his time, it had been known by agriculturists in some parts of England, that an infection in the hands and about the joints of the fingers received from a cow laboring under what is now called vaccina, would confer an immunity against the small pox. Benjamin Jesty, a farmer of Down bay, in the isle of Pur- beek, so early as the year 1774, inoculated himself, wife, and two sons, with virus taken from the pustules on a cow's udders, suf- fering with the vaccine disease. He did this, to protect himself and family from the attack of small pox, at that time prevalent in the vicinity. The operation was perfectly successful.* But the prophylactick power of the vaccine disease had not only been previously known in the dairy counties of England, but also in different parts of Europe, and, if we may rely upon the testimony of Humboldt, even in several districts of South America. It has been attempted, unsuccessfully as we think, to prove that the first suggestion of the expediency of inoculation with vaccine virus, was made by a native of France to an English physician, and by him communicated to Dr. Jenner. But from whatever source this gentleman may have derived the notion of vaccina- tion, to him alone must be awarded the honor of its first intro- duction to general notice. Successful experiments were per- formed by him with vaccine matter, so early as the year 1796, but the result of his enquiries was not, until two years after, an- nounced to the public. From that period on, the knowledge of the virtues of vaccination spread rapidly throughout Europe and this country, and there is now no civilized people on earth, amongst whom its blessings have not been realized and gratefully acknowledged. Prophylactick power.—For a while the prophylactick pow- er of vaccination was generally thought to be complete and * Edinburgh Journal, vol. 1st, p. 513. 35* 400 VACCINA. VACCINE DISEASE. universal, and whoever presumed to hint doubts of its efficacy in any case, was sure to meet with the indignation or contempt of the profession. Since then the general sentiment has undergone a considerable change. From some cause or other, as yet unre-«, vealed, so many well-attested cases of failure in the preventive power of vaccination have taken place, and so remarkable of late years has been the progressive increase of such cases, that the vaccine disease is no longer considered by practitioners a sufti cient safeguard in every case from the variolous contagion. "This circumstance," says Dr. Gregory, " cannot be met by a reference to the fact, that small-pox once gone through does not always pro- tect the subject from a second attack." Cases of variola after vaccination are far more frequent than second attacks of that dis- ease. Dr. Gregory has given a table of the total number of ad- missions into the small-pox hospital, in ten different years. From this statement it appears, that in the year 1810, the proportion of cases of small-pox after vaccination to the whole number of ad- missions, was as 1 to 30, while in 1815, it was as 1 to 17; in 1821 as 1 to 4; and during the year 1823, as 1 to 3*. We may remark, however, that as this is the register of a single hospital, certain local circumstances may have occasioned the augmenting ratio of cases: no general conclusion can therefore be legitimately drawn from the facts set forth. The statement, moreover, may be inex- act, seeing there could be no infallible method of determining whether the vaccination had been genuine and produced its con- stitutional effects. Notwithstanding these facts, vaccination must still be regarded as an invaluable means for lessening the amount of mortality, and as deserving all confidence as a protecting power against small- pox. For although it may not, in many cases, render the system wholly insusceptible to the variolous infection, yet the number of instances in which it affords perfect immunity from small-pox, is beyond all comparison greater than that in which it fails to afford complete protection; and even where it does not entirely subdue the susceptibility to the small-pox, it almost invariably lessens it to such a degree, as to render this latter disease so mild and simple, as in most instances scarcely to require any remediate attention. By many it is believed, that the constitutional influence of the VACCINA. VACCINE DISEASE. 407 vaccine virus gradually wears out, until the system regains its original susceptibility to the contagion of small-pox. In opposi- tion to this hypothesis it is remarked, that variolous cases occur ¥ with nearly equal frequency at all periods after vaccination,—as » many indeed being met writh at one year, as at five, ten or fifteen years subsequently to that operation. The results of experience however, are favorable to the hypothesis. Some have limited the vaccine impression to ten years. Dr. Brown has inferred from his observations, that immediately after vaccination, the antiva- riolous influence of the virus is nearly perfect; that in about three years afterward, the created insusceptibility is so much diminish- ed, as readilyr to allow the operation of the variolous contagion; although the disease then occurring will appear in a mitigated form; that at the period of five or six years, hardly any security from small-pox is enjoyed, and so diminished is the influence of the vaccine virus, that if variola do occur, it will very nearly ap- proach in severity to the natural disease; lastly, that the consti- tutional influence of vaccina cannot be depended upon any longer than six years from the period of vaccination. Dr. Leo Woolff, in an interesting memoir on this subject, has adduced facts and reasonings to show, that the vaccine influence is effaced by the constitutional changes that take place at the period of pu- berty. That the prophylactic power of vaccination progressively diminishes, until it is perhaps entirely worn out, I am myself much inclined to believe, from facts that have come under my own observation. But the attempt to determine its gradual sub- sidence by any accurate, fixed periods, must necessarily be an almost impracticable task; since it may well be supposed, that idiosyncrasies, modes of living, accidental as well as innate pre- dispositions, and perhaps habitual extraneous agencies, may occa- sion many variations in this respect. The general fact or possi- bility of the gradual effacement of the constitutional influence of vaccina, should admonish us of the propriety of re-vaccinating, in order to renew the prophylactic impression. This practice is certain- ly rational, and cannot be detrimental, as a precautionary measure. The manner of Vaccinating.—Vaccination has been perform- ed in three ways—by blistering, incision, and puncture. The 408 VACCINA. VACCINE DISEASE. first, being apt to create an irritation detrimental to the vaccina- tion, and the second, endangering the washing away of the virus by the great flow of blood, are now generally superseded by the method of puncture. The spot usually selected for the operation. is at the lower insertion of the deltoid muscle. The posterior part of the arm of the person to be vaccinated, is to be firmly grasped with one hand, while with the other, the lancet, at whose point is a tangible drop of the virus, is to be inserted a few lines, from above, downwards. It should be continued a few moments in the puncture, and its point pressed against the lower surface of the wound. It is expedient to make several punctures, merely that the chances of a successful operation may be increased. The character of genuine Virus.—The vaccine lymph, up to the time when it begins to desiccate, is a limpid, viscous liquid, colorless, inodorous, and of a salt, acrid taste. Exposed on a smooth, flat surface, it dries rapidly, but without losing its tran- sparency. Chemical observation has taught us, that it is decom- posed and rendered inert by the action of light and heat; and that even at the ordinary temperature, the continued influence of the atmosphere greatly impairs its virtues. To obtain the virus, the edges of the pustule must be punctured in several points. The lymph will then ooze out, and may be collected and preser- ved between glass plates. Jenner recommends that it should be taken just before the appearance of the areola. He thinks its virtues diminished after the manifestation of the efflorescence, and always, if possible, avoided collecting it beyond the eighth day. Of late years, and especially in this country, vaccination is most commonly performed from the scab. The virus may be preserved longer uninjured, in the form of scab, than in any other mode. Matter of six or even ten months old, if kept in this way, will readily communicate the infection. No scab, except from a perfect pustule, should be taken. It ought to be smooth, of a dark-brown, or mahogany color, and rather brittle than tenacious in its texture. When used, the margin, which is of a lighter hue than the rest, should be removed with a knife, and a portion of the remaining dark, hard, internal part reduced to powder on a glass, and moistened or dissolved in a little cold water. VACCINA. VACCINE DISEASE. 409 In whatever way the virus be procured, we ought carefully to examine whether the person, from whom it is taken, be in a healthy state; whether he may not be the subject of some cutane- ous affection, or a vicious constitutional taint. Carelessness on this point may result in incalculable injury. I have several times known obstinate and alarming cutaneous distempers communi- cated to children by vaccination with virus from an unhealthy person. Unprofessional people have a notion, that various trou- blesome eruptions are occasioned by the vaccine disease; and it is somewhat sanctioned by enlightened observation. Accidents of this kind, however, may for the most part be charged upon that carelessness, of which we have just spoken. The condition of the person to be vaccinated.—Age generally would seem to have little or no influence on the success of this operation. Certain idiosyncrasies are occasionally met with in persons of every age, counteracting completely the action of the virus; and sometimes cases occur, in which several successive operations are requisite, before success is obtained. Vaccination is commonly performed in childhood; but, as a general rule, it should not be attempted in children under six weeks old. The constitutional disturbance, occasioned by the agency of the virus, is more considerable in mature years, than early life. The ex- istence of disease does not generally contra-indicate the propriety of the operation, if we except herpetic eruptions and some other cutaneous disorders. Nor does dentition nor pregnancy consti- tute any valid objection to its performance, provided there be no severe derangement of the nervous system. As to the season for vaccination, it appears to be equally suc- cessful throughout the year. It would seem, however, that the course of vaccina is retarded by cold and hastened by hot weather. The fact, that important varieties and modifications of the vac- cine disease are occasioned by the existence of certain cutaneous affections, is well established, and merits particular attention. Dr. James, in a paper published in the sixty-sixth number of the London Medical and Surgical Journal, states that a single serous blotch on the skin, during the progress of the vaccine vesicle 3G 410 VACCINA. VACCINE DISEASE. may cause such irregularity, and deviation from the natural course and character of the disease, that it cannot be depended on as a prophylactic against the variolous infection. In a letter addressed by him to the medical profession generally, in April, 1821, hu observes—" I have observed abrasion of the cuticle produce the same effect,—such, for example, as we find in the nurseries of the opulent, as well as in the cottages of the poor, behind the ears and on many other parts, where the cuticle is tender. We find irre- gularity in the vaccine vesicle, if the skin is beset with herpetic blotches, or even simple serous oozings from an abraded cuticle. A speck behind the ear, that might be covered with a split pea, is capable of disordering the progress of the vaccine vesicle." Test of vaccination.—The increasing number of failures in the protective power of vaccination, has by many been attributed, in great part, to an insufficient inoculation. It is, therefore highly important, to ascertain, in some way, whether the constitutional impression of the virus has been procured. Bryce's method of determining was, to re-vaccinate with matter from the pustule of the first vaccination, at the end of the fifth or beginning of the sixth day after the operation, between thirty six and forty eight hours before the appearance of the areola. If the disease be per- fect, a pustule will arise at the point of the second insertion, but it will become accelerated in its course, so that about the second or third day from its coming forth, it will be surrounded with an areola, increasing and fading away, pari passu, with that of the first pustule. If, on the contrary, the first disease be not sufficient, the irruption from the second insertion will pursue its regular course as in other cases. This is now to be regarded as the pri- mary disease, and the same method of re-vaccination is to be practised, with matter from its pustule,—and so on, until a perfect affection shall be induced. Others have proposed to re-vaccinate about twelve days after the operation. If this has been sufficient, the second vaccination will either not succeed at all, or give rise only to a spurious or an irregular pock. But the most certain test is inoculation with small-pox matter,—a test, from which we derive at once our reliance on the general protective power of the disease, and on its efficacy in the particular case. VARIOLOID DISEASE. 41 j A distinct, circular, radiated, punctulated, and not very large cicatrix is a pretty certain indication, that the vaccine affection was perfect. When the scar " is large, and bears the marks of having been formed by high local inflammation, and wants the distinctive character just mentioned," there is much reason to apprehend, that the system has not been secured against second- ary variolous disease. CHAPTER XXXV. MODIFIED SMALL POX. Sect. 1. Varioloid Disease. The term, varioloid, is applied to certain forms of eruptive disease, resembling small pox in their general character, and supposed to originate from the variolous contagion. We find irregular forms of variola, described in the earlier writers, under the names of vesicular, pustular, spurious small pox; swine pox, sheep-pox, stone-pox, horn-pox, &c. They were developed both in persons who had been affected with the genuine disease, and in those who had never suffered from it, and were all referred to some irregular action of the small pox virus. The introduction of inoculation first, and after it of vaccina- tion, seems to have influenced these anomalous affections in no other way, than by increasing the frequency of their occurrence. Soon after the epoch of vaccination, spurious eruptions of this sort were more particularly observed. A few believed them to possess a specific character, and to arise from a peculiar conta- gion; a majority regarded them as chicken pox; whilst a third 412 MODIFIED SMALL POX. class deemed them nothing more, than the result of variolous contagion, acting upon systems partially protected by the vaccine disease. During the last fifteen years, varioloid distempers have been on the increase. In various countries, they have frequently within this period, prevailed in extensive epidemics,—affording, by the way, a strong presumptive proof of the gradual obliteration of the vaccine impression from the system. As mentioned above, three opinions have been held with regard to the nature and origin of this disease, some identifying it with varicella, a few contending for its specific nature and peculiar origin, and others asserting it to be an imperfect result of the variolous influence. The last opinion is the one now generally adopted by the profession, and its correctness is sufficiently evin- ced by the two following proofs: 1. The varioloid disease is known to have arisen directly and exclusively from the contagion of variola; and inoculation with small pox virus has produced it in its full character, in persons who had been perfectly vaccinated. I, myself, have produced a well-marked varioloid eruption, by in- oculating with variolous matter, an individual who had been sat- isfactorily vaccinated about ten years before: 2. The varioloid does sometimes produce genuine small pox in the unprotected. Two striking examples of this sort I have myself witnessed, and the testimony on this point is abundant and unequivocal. That the disease when acting upon the constitution of persons, who have never undergone the vaccine or variolous infection, does generally reproduce itself in its characteristic form, and not occasion true variola, detracts nothing from the weight of the argument just offered: for it can hardly be doubted, that in a majority of vario- loid cases, the small pox contagion is so modified or meliorated, as to be incaoable of giving rise to the genuine affection, except wnere tne susceptibility to its influence is extremely acute. The works of several recent writers abound in observations, illustrative of the variolous origin of this disease. Dr. Thomp- son, particularly has adduced conclusive evidence on this point; and to his work, as also to my own chapter on varicella, 1 would refer the reader, who may wish to satisfy himself more fully upon the subject. It is evident from what has been said, that small pox, both ca- VARIOLOID DISEASE. 413 sual and inoculated, and the vaccine disease, are the principal agents that modify the action of variolous contagion, in such a man- ner as to give rise to varioloid. Independent, however, of these causes, we must not forget, that certain idiosyncrasies or peculiar atmospheric conditions may exert a similar modifying influence. As the degree and manner, in which these different causes ope- rate, are extremely various, it is obvious that the irregular or varioloid affections, resulting from their action combined with that of small pox virus, must be correspondingly diverse. We accordingly find the diversity so great, that no description can be given of them, that can have more than a general application. I confine myself at present to that form of varioloid disease, re- sulting from small pox virus, modified by previous vaccination. In many instances, as has been already stated, the vaccine af- fection entirely destroys the susceptibility to variolous conta- gion. The system, in other cases, is but partially protected by its influence; or if the susceptibility be temporarily taken away, in the lapse of years, it is again gradually acquired by the constitution. The disease that results from the action of small pox virus upon a system, thus partially deprived of its vari- olous suceptibility, and which of late years has become so com- mon, deviates more or less conspicuously from regular variola; and is in a great measure divested of the dangerous character of the latter affection. Small pox occurring a second time does not so often assume the varioloid character, as when it supervenes after vaccination. But it must be confessed, that its occurrence after vaccination is more common than after casual variola. This may in part be ascribed to some imperfection or disturbance of the vaccine affection, by which its prophlactick powers are impaired or destroyed. Dr. Jenner believed, that in every case where small- pox happens after vaccination, it is owing to an imperfection of the vaccine vesicle, occasioned by one or more of the following circumstances: 1. pre-occupation of the skin by some chronic cu- taneous affection; 2. the use of spurious vaccine matter; 3. incau- tiously depriving the vaccine vesicle of its lymph, or otherwise injuring it by external violence, so as to give rise to common phlegmonous inflammation. Nevertheless, there can be no doubt 36 414 MODIFIED SMALL POX. that modified small pox or a second variolous infection, resulting in a spurious form of the disease, may and often does occur after the most complete and satisfactory vaccination. It would seem from the observation of Dr. Gregory, that the aptitude to vario-» lous infection after vaccination, prevails in an especial degree in some families. The same writer infers from facts which have come under his notice, that modified small pox after the vaccine disease is most apt to occur in persons between the ages of fifteen and twenty-one. My own observation though limited, fully sus- tains this inference: by far the greater number of varioloid cases I have yet seen, were in young persons of the age just mentioned. This accords with the opinion before noticed,—that the vaccine impression is gradually weakened or partially obliterated, during the constitutional changes that take place about puberty The precursory symptoms of this affection are not generally severe. In a large majority of cases the eruptive fever is so mild and inconspicuous, as scarcely to attract attention. Sometimes however, its invasion is marked by as much intensity of febrile excitement, as happens in the severe forms of small pox. The succeeding eruption in these cases is not, as might be looked for, necessarily violent or extensive: but a small crop of little pustules, varying in number from one to twenty, may ensue, and dry up in the course of four or five days. The duration of this stage is no less irregular, terminating sometimes as early as the second day, and at others, not until the fifth day from its commence- ment. In all cases, whether of a mild or severe character, the eruptive fever completely subsides, so soon as the pustules ap- pear; so that the patient no longer finds it necessary to keep his bed. A transient uniform efflorescence precedes in many cases the eruption: a rash, resembling measles, is also not an unfrequent precursor. Sometimes the varioloid exantheme commences on the limbs; frequently it is developed at the same time on differ- ent parts of the body; but generally it makes its first appearance on the face. In the beginning, it almost invariably exhibits the form of small, firm elevated, red papulae. These pursue different courses,—many of them drying off without undergoing any fur- ther change, while the remainder gradually assume the vesicular VARIOLOID DISEASE. 415 or pustular form. The vesicular transformation is completed in the course of the first day; occasionally, not until the second. The vesicles are small, acuminated, filled with a limpid, watery fluid, and in many instances encircled by a faint red areola, so as to resemble in a certain degree the vaccine pock. They usually burst about the third or fourth day, or wither away— without assuming a pustular character, the fluid in them becom- ing whey-like in appearance. "This variety," says Dr. Thom- son, "in the mildness of the eruptive fever; the strictly vesicular character, short duration and mode of disappearance of the erup- tion, corresponded (in the epidemic he described) so exactly with the descriptions usually given of the mildest varieties of chicken pox, as not to have been distinguishable from that disease." In many cases, the vesicles become filled with a puruloid fluid, present a slight central indentation, and, by the third or fourth day, are converted into thin dark scabs. These separate and fall off usually about the sixth or seventh day after the appearance of the eruption, but sometimes not until the tenth or even twelfth day. Occasionally the vesicles remain distended with a colorless lymph for four or five days, and then become pustular containing a pus-like fluid. They usually continue in this state longer, before desic- cation and scabbing commences. In some cases the scales being detached, are replaced, particularly on the face, by elevations in the form of warts, which disappear but slowly and by successive desquamations. (Cazenene.^ The quantity of eruption varies in different instances, from a single one to so great a number, as to cover the whole surface of the body. From the description just given of the course of the disease, it is evident, that papulae, vesicles, pustules, and scabs, are frequently to be seen intermingled upon the same indi- vidual. Where the eruption is successive during several days, as sometimes happens, this appearance is still more conspic- uous. The complaint not unfrequently assumes so nearly the aspect and character of distinct small pox, that it is difficult to decide for the first five or six days, whether it should be regarded as a modified or regular variolous affection. In cases too, where the rarioloid eruption is extremely abundant, it is qui;:e possible to 416 MODIFIED SMALL POX. mistake it sometimes for the confluent form of variola. Ver generally however, the smallness of the pustules, the whey-likc appearance of their contents, and the early period at which de- siccation and scabbing commence, will distinguish such cases from genuine small pox. Dr. Thompson observes, that the areola and its pustule sometimes exhibit a remarkable resemblance to the vesicle and areola of cow pox,—a resemblance that betrays the mixed variolous and vaccine character of the disease. The duration of this complaint is from six to twelve days, and its termination almost always favorable. Varioloid pustules very rarely leave any marks on the skin. When the scabs remain a long time they occasionally leave slight pits, but much more commonly, warts or fungoid elevations. From the foregoing account, we perceive how extremely di- verse are both the local and general phenomena of this affection. In one case it presents the characteristics of varicella, in anoth- er, it can hardly be distinguished from small pox, and in a third it bears a striking resemblance to the vaccine pustule. It differs chiefly from genuine small pox, in its general mildness, its strong tendency to a favorable termination, and in the briefness and ir- regularity of its course. Diagnosis.—The following circumstances may be stated, as its common and characteristic features: 1. The eruption comes forth in successive clusters, at uncertain periods between the second and fifth day. 2. The eruption rarely, if ever, enters into complete suppura- tion, as happens in small pox. 3. The eruption is unaccompanied by fever, except in very violent cases. 4. Desiccation or scabbing invariably occurs much earlier than in regular variola. It commences generally on the fifth or sixth day, and the scabs usually separate by the eighth or ninth day, leaving red disks or tuberculous elevations instead of de- pression. Treatment.—In the milder cases of varioloid affections, little or no remedial treatment is necessary. In all instances, however, VARICELLA. 417 it will be proper to exhibit a mild purgative in the commence- ment of the disease, and throughout the febrile stage, the diet |ind drink ought to be simple, unirritating and cooling. When the irruptive fever is very high, the abstraction of a few ounces of blood will be beneficial. In general, however, the febrile reaction may be sufficiently restrained, by free ventilation, cool drinks, refrigerant diaphoretics, laxatives and rest. Where, in short, the disease is so severe as to demand any medical attention, the treatment is to be conducted on the same plan that is proper in simple small-pox. Sec. 2. Varicella. Chicken-pox. There is, perhaps, no subject in medicine, that has given rise to greater diversities of opinion, than the disease termed Varicella. From the first notice of its existence to the present time, there seems to have been no fixed, general sentiment, with regard to its origin or pathognomic symptoms. The earliest records of va- riola inform us of the occurrence of various exanthematous affec- tions, coincident with the prevalence of small-pox, and analagous to it in character. These affections were at first generally be- lieved to be mere varieties of spurious small-pox, and to derive their origin from variolous contagion. Rhazes, who wrote in the beginning of the tenth century, and has given us the first history of variola, speaks of certain spurious eruptions, of a vario- loid character, whose occurrence in individuals afforded them no protection against epidemic small-pox. In the same uncertain style, we find several succeeding authors, describing such erup- tions under the various names of improper, bastard, lymphatic, crys- talline pox, &c. Viden Vidius, in the sixteenth century, thought himself justified in distinguishing them from small-pox, and he described them under the name of chrystalli. Subsequently, Sennertus noticed certain varieties of variola, eruptions of which instead of being pustular, were vesicular in character, and dried off in the course of a few days. Sheep-pox, horn-pox, and wind- pox, were also enumerated by him, and the two latter terms, he conjectured, designated the same affections as the crystalli of 3 H 36* 418 MODIFIED SMALL-POX. earlier writers. Riverius speaks of these varioloid affections as common in his time, and introduces a description by Ingnassius, of the variety denominated crystalli. The eruption was similar in size and figure to that of variola, but consisted of limpid vesi- cles filled with a watery fluid, and desiccating on the third day without danger. Sydenham, in his description of an epidemic small-pox, alludes to a spurious variety, unconnected with the genuine disease, and inefficient in securing the constitution from variolous contagion. In the latter part of the seventeenth cen- tury', the term chicken-pox, a name in general use out of the pro- fession, was first introduced into medicine by Morton. It was used by him to designate what he regarded as the most benignant form of variola; for it was his opinion, as well as that of the pro- fession generally who had preceded him, that varicella was a mere variety of small-pox. Some, however, even at this period, believed it to be a disease sui generis—but all concurred in the opinion, that its occurrence never conferred an immunity from small-pox. In 1767, Dr. Heberden published his memoir* upon chicken-pox, in which he asserted the specific character of varicella, its identity with swine-pox, and its origin from a pecu- liar contagion, altogether distinct from that of small-pox. Very soon after this we have from Dr. Sims, an account of a certain eruptive disorder, which he termed chicken-pox. The descrip- tion of the eruption as witnessed by him, differs somewhat from the characteristics of the disease as laid down by Dr. Heberden; but they both agree in regarding variola and varicella as radi- cally distinct affections. This soon became the general sentiment of the profession, and so continued till within the last eighteen years, during which its validity has been strongly disputed by sev- eral ingenious writers. MM. Berard and de Lowit,t from obser- vations on a small-pox epidemic during its prevalence at Montpe- lier, came to the conclusion, that variola and varicella, though differing in their outward manifestations, could ultimately be traced to the same contagious principle. Dr. Thomson^ particu- larly, an able investigator of this subject, has in our opinion * Transactions of the College of Physicians, vol. iv. t Essai sur les Anomalies de la Variole et de la Varicella. J An Account of the Varioloid Epidemic, &c. By John Thomson, M. D. VARICELLA. 419 adduced abundant and conclusive evidence to prove, that the various forms of chicken-pox, corresponding to the diverse de- scriptions of the older and more recent writers, may be correctly referred, for their source, to variolous contagion. This view of the subject throws some light upon those multi- form and perplexing exanthematous distempers, that usually pre- cede or accompany epidemic small-pox. We see the same mor- bific principle, modified in its action by different susceptibilities and peculiar circumstances, giving rise to a vast variety of ano- malous eruptions, diverse indeed in many particulars, but of sufficient similitude, on the whole, to point out their family alliance and origin. The plan of this work renders it inexpedient to enter into a full review of the merits of this question: a brief notice may suffice. In favor of the common origin of the two diseases, it is asserted, 1st. That variolous and varicellous epidemics never exist sepa- rately and independently; 2dly. that the two affections mutually give rise to each other; 3dly, that varicella seldom occurs in individuals, who have undergone neither the vaccine nor vario- lous complaint. In objection to these observations the principal arguments are the following: 1. Epidemic small-pox, it is asserted, often rages, without being attended by varicella, and varicella occasionally prevails without the concomitance of small-pox. This, I am inclined to believe, is an unfounded assertion. So far as my enquiries extend, every variolous epidemic, described with any particularity, has been preceded, accompanied, or immediately followed, by variola or varioloid affections, exhibiting the characteristic marks of vari- cella. Dr. Mohl,* it is true, asserts, that from the year 1809 to 1823, small-pox was entirely absent from Copenhagen, whilst cases of chicken-pox were met with every year. But the same author does not deny, that subsequently to this during the preva- lence of a small-pox epidemic in that city, varicellous affections were constantly present. After all, allowing the objection to be true, it does not therefore follow that those affections are rad- * De varioloidibus et variccllis. Scripsit Nic Christianus Mohl, &c. 420 MODIFIED SMALL-POX. ically distinct. It is well known that, at different periods, small- pox assumes very dissimilar appearances. Some epidemics are mild, some severe, and others malignant to a great degree: some- times the pustules become filled with a bloody matter, and at others they are crystalline. These differences, exhibited by" variola at different periods, are scarcely less remarkable than those subsisting between it and varicella. These result, it is probable, from accidental peculiarities in the action of the vari- olous poison, or in the susceptibility of the human system, occa- sioned by unknown causes. It is not, therefore, an irrational supposition, that certain atmospheric conditions, or other circum- stances as yet undiscovered, may so modify the human suscepti- bility, or variolous contagion, over large districts of country, that a spurious or varicellous affection may be the prevailing epidemic. 2. During the prevalence of a small-pox epidemic, it is exceed- ingly difficult to ascertain, whether it be true that varicella may give rise to variola, and this to varicella. Dr. Thompson, how- ever, who had abundant opportunities for observation, in the varioloid epidemic that occurred in Edinburg, asserts, that the varicelloid cases, with the exception of one whose origin was not traced, all occurred in situations, where they could be referred to the agency of variolous contagion alone; and that where varicel- loid cases occurred, small-pox afterwards appeared precisely at the period it ought to appear, on the supposition that varicella may give rise to small-pox. It is stated by Dr. Mohl, indeed, that he never saw chicken-pox occurring in families, where vari- ola prevailed; but at the same time he adds, that in such circum- stances, he observed twice or thrice the occurrence of an erup- tion resembling varicella. We all know the difficulty of draw- ing an accurate diagnosis in such cases, and we may reasonably conclude that the eruption was really variolous. In confirmation of Dr. Thompson's observation, Dr. Luders affirms, that variolous contagion does sometimes give rise to chicken-pox. One of the cases he mentions seems quite conclusive. The circum- stances were of such a nature, that it was quite impossible to suppose the operation of any other contagion than that of small pox, and yet varicella was produced. VARICELLA. 421 Unvaccinated persons, who have never had the small pox, are liable to attacks of varicella, a proof it is affirmed that this affec- tiorois not a mere form of modified small pox. In answer to this we may observe, that it is generally conceded that chicken pox is of far more frequent occurrence after variola or vaccina, than where neither of these has been undergone. Drs. Bryce and Aber- crombie saw but three cases in which the vaccine disease or va- ricella took place in persons, who had not experienced either vaccine disease or variola. But admitting such an occurrence to be more frequent than correct observation warrants us to believe, it could have little influence upon the argument. The question is, not whether varicella be a form of small pox, modified by previous vaccination or variolation, but whether it be an imperfect result of variolous contagion. The vaccine disease and variola seem indeed to be more powerful agents in modifying the subsequent develop- ment of the variolous principle, than any other agents with which we are acquainted. But there can be no doubt, for rea- sons above mentioned, that other circumstances may in a manner we cannot now understand, exert the same kind of modifying in- fluence upon the human system. 4. Again it is asserted that varicella is at present more preva- lent than before the introduction of vaccination, although small pox was then of far more frequent occurrence. This only proves that there are now more systems insusceptible to the full action of the variolous contagion than formerly, and rather sustains the hypothesis of their identity. 5. The occurrence of small pox does not prevent or modify varicella. Of course it is not meant in this objection to af- firm, that chicken pox happening now and then after small pox, would militate against the identity of the two diseases; else upon the same ground, the distinct character of secondary and primary variola might be established. The objection must mean, that the occurrence of small-pox does not generally prevent or modify the varicellous disease. Dr. Thompson, however, as- serts, that out of one hundred and fifty-five persons, whom he saw pass through the small pox, not one was afterwards affected with the vesicular disease." This is the more conclusive, because "upon the supposition of a varicellous and variolous epidemic, 422 MODIFIED SMALL POX. most, if not all of this number have been exposed to the influence of both contagions." By the way we may remark, that if this mode of augmentation be advisable, we must conclude that vac- cina and variola are identical in nature, seeing they usually pre- vent and modify each other. 6. The vaccine disease may be communicated to a patient soon after his recovery from varicella, and it will pursue its regular course; which never occurs after variola. Few experiments have been made upon this point; and we are as yet not justified in asserting, that the result of vaccination after the vesicular dis- ease will be uniformly of the same character, as that stated in the objection. It is, besides, well known that small-pox in fre- quent instances fails to take away the constitutional susceptibility to the infection of cow pox. Many cases are recorded on the best authority, where the insertion of the vaccine virus, sub- sequent to an attack of small pox, has produced all the pheno- mena of perfect vaccina. But even admitting the objection were sustained by general observation, it could be met on the supposi tion, that the vesicular disease being an imperfect result of vario- lous contagion, was incapable of conferring upon the system the same insusceptibility to the vaccine disease, as the fully developed small pox. 7. Varicella, it is maintained, is not communicable by inocula- tion. This would seem to be erroneous. Mr. Bryce, it is true, al- leges that he found it impossible to communicate chicken pox by inoculation, but Heim asserts that it is more communicable than small pox. Dr. Thompson also gives conclusive evidence on this point, and we have the authority of Dr. Heberden, for believing it can be inoculated. For confirmation of the identity of the two diseases, we may introduce here the statement of Reil,* that vari- ola, occurring after varicella, is much milder than where this dis- ease has not been experienced, more especially if the varicellous affection has been severe. So that the occurrence of varicella, would seem to shield the constitution in a partial degree from the virulence of variolous contagion. 8. Small pox and chicken pox are essentially different in their * Erkentnntniss und cur der Ficher. bd. 5. s. 386. VARICELLA. 423 characters and eruptions. This fact will have very little weight when it is considered, how difficult it is to indicate the precise nature of exanthematous affections by the character of their erup- tions, and what confusion has existed in particular, with regard to the specific appearance of varicella, and its diagnosis from small pox or varioloid, even amongst those who believe in its distinct nature. In view of these circumstances, and of the abun- dant evidence derivable from other sources, favoring the iden- tity of these diseases, a mere difference in their external charac- ters can hardly be considered a valid objection, especially as we find no less striking dissimilarities in certain varieties of genuine small pox. Upon the hypothesis advocated, there would seem to be little difficulty in explaining satisfactorily, the occurrence of modified small pox with all its numerous diversities, whether of a varioloid or varicelloid character. Vaccination or variolation, we are aware, does by no means in all cases obliterate the constitutional predisposition to be affected by the variolous contagion. Even after the system has passed through the most perfect form of small pox, a second attack will in some instances ensue; and we cannot for a moment doubt that the same event may take place after vaccination, since it is unreasonable to believe, that the vaccine disease can be a more certain prophylactick against vari- olous contagion, than small pox itself. But facts, illustrative of both these positions are too abundant and conclusive to permit any longer a doubt concerning tHeir truth. Now between that state of the system, induced by vaccine or small pox, which con- fers entire immunity from variolous contagion, and that state in which the susceptibility to its influence, is totally undiminished, numerous degrees of susceptibility undoubtedly take place accor- ding to the individual idiosyncracy, temperament and accidental concomitant influence: and perhaps also the variolous poison may differ in the degree of its virulence and exert its agency under diverse modifications. If, then, after vaccina or variola, the pre- disposition to the latter disease is not etttirely, but only partially destroyed, ought we not to look for an imperfectly developed form of the disease, should a second infection take place—espe- cially too, as in this instance the variolous contagion may have 424 MODIFIED SMALL-POX. been meliorated in its character? It is in this way, we believe, that varioloid affections occur in persons who have undergone the vaccine or variolous disease. As to the occurrence of such affection in those who have never had either of these diseases, it may be observed, that the degrees of natural susceptibility in different individuals are correspondingly diverse. We see in the same family, into which this contagion is introduced, one individual affected so slightly as scarcely to require attention; another perhaps indisposed with only variolous fever, without any eruption; a third seized with a pretty severe attack of distinct small pox; and a fourth sinking under the most aggravated form of confluent variola. The pre- sumption therefore is, that where small pox contagion acts upon a system naturally or accidentally insusceptible to the full influence of its powers, it will produce either an extremely mild variolous eruption, or an irregular modified one;—in other words, a vario- loid or varicellous affection. On a review of the whole argument, I am induced in common with many others, to regard varicella, together with varioloid, as spurious or modified small pox, or at least, as being referable for its ultimate source to genuine variolous contagion. The initial stage of Varicella.—Varicella is generally ushered in by restlessness, thirst, loss of appetite, occasional pain in the epigastrium, increased heat of the surface and acceleration of the pulse. These symptoms may 6ocur in various grades of intensity; but, for the most part, they are by no means severe. In many- cases the febrile excitement is scarcely observable; still it is occa- sionally almost as violent as in the severe varieties of small-pox, being attended with the same pain in the back, head and extrem- ities as this latter affection. A severe cough and soreness of the throat are sometimes accompaniments of the initial fever, and during its continuance infants not unfrequently suffer from con- vulsions. This fever continues from one to three days, ter- minating generally on the appearance of the eruption, al- though in some instances prolonged two or three days after this period. The eruption, which is vesicular in varicella, is often VARICELLA. 425 preceded, for a few hours, by a general erethematous rash, as in small-pox, and is generally accompanied by a vexatious tingling or itching in the skin. It appears first on the breast and back, next on the face and scalp, and lastly on the extremities. An incidental eruption of pustules is sometimes observable among the vesicles. The varicellous vesicles generally come out in sue cession during three or four days, so that at the same time, some will be just appearing, some perfectly matured, others shrivelling, and a fourth set converted into scabs. They are sometimes closely approximated, though seldom confluent. Varieties of the eruption.—The dissimilar forms assumed by the vesicles, in different cases, has given rise to a division of the dis- ease into three varieties. 1st. Lenticular.—The eruption in this variety appears very early. It is characterized by small, red elevations, rather oblong in shape, and having a flat shining surface, in the centre of which is a minute transparent vesicle. The vesicle at the end of the second day, is somewhat enlarged, being now l-10th of an inch in diameter, and is filled with a whitish lymph. The fluid assumes a pale yellowish or straw color on the third day. On the fourth, the vesicle is shrivelled, desiccation commences, and in two days more it is transformed into a thin brown crust. The scab falls off about the ninth or tenth day, leaving a red spot but no depres- sion on the skin. Owing to the successive appearance of the vesicles, this variety is prolonged for two or three days. 2d. Conoidal.—In this form the vesicles come forth suddenly, surrounded by a slightly inflamed border. On the first day, they are acuminated and filled with a bright limpid serum. They are more distended on the second day, containing a very pale yellowish fluid, and the surrounding inflammation is more exten- sive. On the third day, many are shrivelled, but others remain entire, attended with considerable inflammation, and containing a purulent matter. These vesicles generally leave permanent cicatrices. Scabbing commences on the fourth day, some of the scabs assuming a dark brown, others a rounded, yellowish and transparent aspect. " A fresh eruption of vesicles usually takes place on the second and third davs; and as each set has a similar 3 I 37 426 MODIFIED SMALL POX. course, the whole duration of the eruptive stage in this species of varicella, is six days: the last-formed scabs, therefore, are not separated till the eleventh day.*" y Globate, or Swine-pox.—Swine-pox is characterized by large, globose vesicles, with irregular circular bases, and surrounded by an inflammatory areola. At first they contain a transparent fluid, which on the second day of the eruption becomes turbid, or assumes a whey-like appearance. On the succeeding day, they subside, or begin to shrivel, acquiring a yellowish hue, and some of them containing purulent matter. Small, thin, dark-colored scabs appear on the fourth day, and in the course of four or five days fall off, leaving small red marks, which soon disappear. Diagnosis.—Believing, as we do, that varicella and varioloid originate from the same source, and in some instances approxi- mate so nearly in character, as hardly to be distinguished apart, we can give but little credence to the assertion of some authors, that a diagnosis may be drawn, which shall be universally infalli- ble. It may be well, however, to attend to the following diag- nostic marks, which in the general wrill enable us to recognize varicella. 1. The eruptive fever is generally more severe in vari- oloid than in varicella: 2. In chicken-pox, the eruption is for the most part vesicular from the beginning; while in varioloid, it is always pustular, except in the vesicular form, where it is pustular for a day or more: 3. Tuberculous bases are not observable in varicellous vesicles, but in the varioloid eruption they are distin- guishable from its commencement. The varicellous pocks are, by some, believed never to present that central indentation, which frequently occurs in varioloid, but this is discredited by many accurate observers. Dr. Heimt has described a form of varicella, one of the characteristics of which is a slight depression in the centre of the pock. Berad de Hauit and other authors have mentioned the same appearance. If we may believe Dr. Luders, there is a difference in the seats of varicellous and varioloid eruptions—the former affecting the eel * Bateman: Practical Synopsis of Cutaneous Diseases. t Die specielle Therapie nach den hinterlassenen Papieren de« verstorbenen A. G. Richter: B. 2. p. 342.—1817. VARICELLA. 427 lular tissue between the skin and cuticle, and the latter being situate in the true skin. Varicella prevails more frequently in the beginning of the year, or vernal months. Like small-pox, it seldom occurs more than once in the same individual. Secondary fever is of rare occurrence. The scabs, on falling off, not unfrequently leave depressions in the skin; but the cicatrices differ con- siderably from those occasioned by variola. Heim, who regarded these affections as essentially oistinct, has adduced this circum- stance among others in favor of his views. The pits of varicella, he says, are whiter than the rest of the skin, and quite smooth or even; whilst those, left by variolous pustules,-have the color of the surrounding skin, and are uneven, like the surface of an orange. The margin of the varicellous pit is smooth and rounded; that of the variolous pit, generally somewhat indented and angu- lated. Hairs never grow in the disks of the former, in those of the latter they do. Remediate Treatment.—Varicella rarely requires any medicinal application. General aperients, tepid drinks, and an antiphlo- gistic diet, are the principal remedies necessary. 428 MEASLES. CHAPTER XXXVI. RUBEOLA, MORBILLI,—MEASLES. The term rubeola and morbilli are used as mere synonymia by the American, English and French practitioners; but the Ger- man writers universally employ them to designate two distinct diseases,—appropriating the latter term to the present affection, and the former to a different, though somewhat similar complaint (roethlen) described by Willan, under the name of roseola. The contagiousness of measles has by some been denied. Among other circumstances, it is stated that the disease can never be traced from house to house, or from street to street, as may frequently be done in small pox and scarlatina; and that its first appearance is generally simultaneous in several individuals,— both of which facts are opposed to the notion of its being pro- pagated by contagion. But this, together with every other argument of the kind is fully met by the well established truth, that the malady may be communicated by inoculation. Dr. Home succeeded in verifying this fact in a number of instances; and more recent experience has fully demonstrated the practica- bility of morbillious inoculation.* The contagion of measles does not seem to be so active or powerful as that of small pox. During the greatest prevalence *Vogel, Percival, Brown, Manro, and Tissot, recommended inoculation for measles; and Home and Horst practised it with success. Professor Sparanza, more lately, in an Epidemic that prevailed in the territory of Mantua, employed inoculation for measles with decided benefit. Six boys in the House of Industry, and afterwards he himself, were inoculated. A mild and regular morbillious affection was the result in all. Him- self and others subsequently repeated the experiment with equal success. u A slight cut was made into one of The most vivid of the large blotches, with a lancet, the point of which was covered with the blood effused. With this, small incised punctures were made in the arm, and a proper bandage applied."—Edinburgh Med. and Surg. Journal, 1826. See also, Bibliotheca Italiana. Agosto, 1825. MEASLES. 42g of the disease, many individuals entirely escape infection, although exposed to its full influence; and it is no infrequent thing to find in the same family, a few affected and the rest totally unaffected by the malady. It is difficult to say at what period of its pro- gress, measles become infectious. Many believe it incapable of communicating itself, until the appearance of the eruption; but it would seem, from a few well attested cases on record,* that the disease may acquire an infectious power in a day or two before this event. Measles, like small-pox, rarely affect the same individual twice; and indeed a second attack of the former would seem to be less frequent than of the latter complaint.! After a careful obser- vation of more than twenty years, Willan declares that he never met with a secondary attack of febrile rubeola, and I have myself witnessed but one unequivocal example of the kind. Home mentions a singular instance, in which enlargement of some of the lymphatic glands followed an attack of measles. About six months having elapsed, the glandular swelling subsided, and the patient became a second time affected with measles.J Measles rarely occur sporadically; but when they appear, as before mentioned, many individuals usually become affected with them at the same time. As in all other epidemic diseases, the general course and phenomena of this complaint are often strik- ingly modified; and systematic writers have therefore, divided it into several varieties, according to the regularity or irregularity of its symptoms, the nature of the attending fever, and the character and violence of the local affections with which it may be complicated. According to the observations of some, morbillious fever may occur without any exanthematous affection.|| It certainly is not uncommon during the prevalence of epidemic measles, to meet * Edinburgh Med. and Sur. Journal, 1828. + See Dr. Baillie's paper, in the transactions of a society for the improvement of Medical and Chirurgical Knowledge. Vol. iii. J Medical Facts and Experiments. Richter, Specielle Therapie. || Morton mentions a morbillious fever unattended by any exantheme; and De Haen asserts mat cases of this kind frequently occur during the prevalence of epidemic measles. 37* 430 MEASLES. with fevers, attended with the usual catarrhal symptoms of tho malady, but unmarked by its peculiar eruptions. Richtet observes that persons affected by these fevers, are generally exempt from the disease during the subsequent progress of the epidemic. Sometimes the measly exantheme takes place without any fever. The German writers* describe this modification of the disease under the name of false measles, corresponding to the rubeola sine catarrho of Willan, and the rubeola sine febre, of others. It is characterized by a regular measly rash, without fever, catarrh, or ophthalmia. It does not take away the suscepti- bility of the system to a subsequent invasion of febrile rubeola. " An interval of many months, even two years, has been observed between this variety and the subsequent febrile rubeola; but the latter more frequently takes place about three or four days after the non-febrile eruption."—(Bateman.) Peculiar atmospheric constitution evidently exerts considerable influence over this disease; for at one period, its symptoms will be so light as scarcely to require medical attention; at another, it will assume a highly aggravated form; in a third period, it may take place under every grade of violence, from the lightest to the most malignant; and in a fourth, it "will hold a middle course, between the mildest and most dangerous forms of the malady." (Armstrong.) On the whole, however, the regular and moderate cases are infinitely more frequent than the violent and malig- nant ones. Measles appear likewise to be decidedly influenced in their character by constitutional habit or idiosyncrasy. Hence it is that we sometimes meet with the disease under all its grades of intensity, in children of the same family—several very remarka- ble examples of which have come under my own observation. In general, measles are apt to be more regular and mild during the warm and equable, than the cold and variable seasons. The time, intervening between the first impression of the rube- olous contagion and the actual commencement of the resulting disease, varies from a few days to two and even three weeks; but * Vogel, Standback, Bd. 3 p. 203, Metyger, wermischte Schriftcn, Bd. 2, p. 16?i MEASLES. 431 the period of incubation, generally, is from five to seven days. In nearly all the cases inoculated by Home, the eruptive fever commenced about the seventh day from the insertion of the virus. Symptoms of the Eruptive Fever—The initial symptoms of this complaint do not differ from those, which usually mark the inva- sion of catarrhal fever. Transient flushes of heat, alternating with faint creeping chills; slight redness and tenderness of the eyes, with an increased secretion of tears; cough and sneezing, with a watery discharge from the nostrils, are generally among the first symptoms of the morbillious fever/ Sometimes two or three days of febrile excitement elapse, before the supervention of catarrhal symptoms; but in all cases, these symptoms occur sooner or later, in a very manifest form, and may be placed among the specific phenomena of the disease. The cough'in the beginning is dry and harsh, attended with oppressive breathing, and some degree of soreness in the fauces. Not unfrequently, some of the lymphatic glands about the neck, and along the mar- gins of the eyelids, become tumefied and tender. The stomach is apt to become quite irritable about the third day, and sometimes earlier, occasioning considerable nausea and vomiting; and where the febrile symptoms are highly aggravated, slight delirium may ensue in the evening of the same day. The fever is in general a marked synocha, as indicated by the hot and dry skin, and the quick, frequent and hard pulse. The exantheme, generally, makes its appearance between the third and fifth days. This event, in cases of a violent character, is sometimes preceded for a few hours by more or less coma; and in small children, convulsions are by no means uncommon at this period. The eruption comes out first on the forehead, chin, nose and cheeks, and then on the neck, breast, body and extremities successively. It consists of small, red spots, apparently papular, and resembling flea-bites. They soon en- large, and, as their number increases, run into each other, forming larger patches of an irregular or semi-lunar shape;* whilst the * Bateman. 432 MEASLES. skin in the intermediate spaces retains its natural color. Some of the measles on the first dayr exhibit a small vesicle in the centre (Cazenane.) The eruption on the face, during the second day after its ap- pearance, becomes completely developed, and, on the following day begins to fade away; whilst on the rest of the body it con- tinues vividly red. The exantheme, on the face, may be felt slightly elevated above the surface of the skin; but on other parts this elevation is not perceptible. Severe cases are attended with tumefaction of the face, in some instances so great as almost to close the eyelids. The eruption is not confined to the surface of the body: red patches appear on the gums, spread over the mucous membrane of the mouth, extend to the tonsils and uvula, and, acccording to Frank, are visible on the tongue. Leutaud saw the measly exantheme in the oesophagus and upon the mu- cous membrane of the trachea, and even on the surface of the abdominal and thoracic viscera.* The eruption fades away over the body in the same progressive manner in which it came out; so that by the eighth day from the commencement of the fever, it begins to disappear from the back of the hands, where it is wont to remain longest. On the succeeding day, the exantheme acquires a faint yellowish hue. Desquamation now commences on the face, and is completed over the whole body by the tenth or eleventh day. The appearance of the eruption occasions no remission of the fever; but, on the contrary, is commonly attended with a mani- fest aggravation of both the febrile and catarrhal symptoms. The subsidence of the eruption is, generally, marked by an amend- ment of all the symptoms; and for the most part, the fever disap- pears entirely by the time the rash has desquamated. Occasionally, however, both the fever and cough continue, and even become worse after the complete disappearance of the measly exan- theme. It is observed by Dr. Heberden, that in violent cases there is sometimes a recurrence of the coma, after the rash has gone off. During the subsidence of the eruption, the supervention of more or less diarrhoea is by no means infrequent; and when not * Precis de Medee. p. 604. MEASLES. 433 violent, it almost always meliorates the general and local symp- toms. Occasionally a copious diarrhoea comes on just before the appearance of the rash. As it tends to interfere with the regular course of the exantheme, and to occasion a retrocession, it should be considered as an unfavorable occurrence. The period, at which the eruption takes place, is various. It is generally stated to be the fourth day; and for the most part this is correct. Nevertheless, it is important not to lose sight of the fact, that even when the disease is perfectly regular in its character and course, the exantheme sometimes comes out much earlier, and occasionally, later than the period just named. It is observed by Dr. Armstrong, that the rash does not uniformly or generally appear, on the fourth day from the first develop- ment of the reaction. " I have seen," he says, " the eruption come out at all times, between the first and the seventh days; though perhaps, the most common period is between the third and fourth days after the reaction. The aspect, under which this disease has just been described is that which it generally assumes. It appears, however, occasion- ally, under various striking modifications, requiring corresponding modifications in the treatment. Sometimes it pursues its career, unmarked by any serious complications; in a majority of instan- ces, it manifests a considerable tendency to inflammation, partic- ularly of the eyes and respiratory organs; and occasionally, reaction is sluggish and difficult. Hence, according to Dr. Armstrong, we have three varieties or modifications of the disease,—the simple, the inflammatory, and the congestive. To these we may add the typhous and gastric modifications,—the first being characterized by a typhous state of the system, and the last by prominent symptoms of gastro-intestinal irritation. Synochal fever of a high grade is the characteristic of in- flammatory* measles. The pulse is hard, vigorous and accele- rated; the skin dry'and very hot; cephalalgia is severe, attended frequently with considerable delirium through the night; the eyes are very red; the cough is harsh, violent and distressing, with •Strictly speaking, every case of measles is inflammatory; but the general and locai phlogistic phenomena often preponderate to such a degree, that such cases may with propriety V> distinguished by the term inflammatory. 3 K 434 MEASLES. little or no expectoration, and the respiration oppressed and frequently painful. The exantheme for the most part appears early, and is usually of a vivid red. The diseases that are par- ticularly apt to supervene in this variety, are cynanche trachealis, pleuritis, peripneumania with bloody expectoration, bronchitis, cerebral inflammation, and gastro-enteritis. The malady in the congestic form is indicated byr the ordinary symptoms of internal congestion. Reaction is tardy and imper- fect, sometimes wholly deficient. The vital energies of the system are generally much depressed; there is pallor of the countenance; torpidity of the bowels; the pulse labors and is weak; the breathing slow and oppressed; the extremities are cold, and the features sunk and anxious. The eruption does not appear at all, or it comes out slowly on some parts of the body. If reaction be not induced, coma or stupor, and in some instan- ces, convulsions ensue. Young children and persons of a relaxed, delicate habit of body, are peculiarly liable to this form of the complaint. Two cases of this kind were seen by Dr. Armstrong, in which the patients died comatose and convulsed. Autopic examination revealed in both cases great engorgement of the lungs. The pecular symptoms of typhus fever, constitute the typhus, or as some have termed it, the malignant sort of measles. The pulse is generally weak and frequent, sometimes nearly natural; the skin possesses the true calor mordax, communicating a burning or acrid sensation to the hand, and on parts of it not occupied by the measly eruption, petechiae appear. Colliguative hemorrhages, diarrhoea, and profuse sweats often occur, and the energies of the whole system seem to be sinking. It is a happy circumstance, that this variety of measles occurs so rarely, as it is always terribly malignant and fatal. Nevertheless it has occasionally prevailed as an epidemic. Sir William Watson has given us the history of a putrid morbillious epidemic; but it may be doubted whether the affection he describes, was really measles or scarlatina, as these diseases were believed by him to be essentially the same. Nevertheless, the portrait he gives of the complaint, answers more fully the peculiarities of rubeola than of scarlatina.* •Watson.—Medical Observations and Inquiries. Vol. iv. p. 132 MEASLES. 435 4. Gastro-intestinal irritation exerts a marked influence in some cases, giving rise to the gastric modification of measles. The attendant febrile symptoms are not very conspicuous, the pulse being small and feeble, though inordinately frequent. There is severe pain in the forehead; the tongue is brown; a sense of tension and fulness is often experienced in the epigas- trium, or short cutting pains distress the bowels. Violent vom- iting and purging sometimes occur before and immediately after the appearance of the rash, which is pale and often indistinct. The cough is short, tormenting, and almost incessant. In some instances, great difficulty of breathing and a sense of oppression in the chest will suddenly ensue, especially in young and irrit- able children. There is occasionally extreme restlessness, with much jactitation dyspnoea and an anxious expression of counte- nance, particularly on assuming an erect attitude. (Dr. Arm- strong.) Sequela.—The tendency to irregular local determinations, ob- servable throughout the whole course of measles, is more espe- cially manifest during the periods of desquamation and convale- scence. It is therefore a common remark that less is to be ap- prehended from the disease itself than from its sequelae,—and the assertion is generally true, when made in reference to the ordinary or simple form of the complaint. Few, if any, diseases leave the system with so great a susceptibility to the hurtful in- influence of cold or atmospheric vicissitudes; and hence chiefly the frequent supervention of inflammatory and other after affec- tions during convalescence. The most common sequelae of measles are, pneumonia, bron- chitis, croup, otitis, arachnitis, chronic ophthalmia, and rheuma- tism. The development of tubercular action is not an infre- quent result of the disease in phthisical habits; and it is especially apt to bring forth latent disorders of the lymphatic system, and occasion local manifestations of scrofula, where there is a stru- mous diathesis. Hence an attack of it is often followed by scro- phulous ophthalmia and tumors about the neck, with other distem- pers of like character. Porriginous eruptions on the head, and serous ulcerations behind the ears, also frequently occur; and m 436 MEASLES. some instances, induration of the mesenteric glands and maras- mus. Among the occasional consequences, are herpes, boils on different parts of the body, discharges from the ears, and anasar- cous swellings. Diagnosis.—The diagnosis between rubeola and scarlatina is at times attended with much difficulty. Indeed until the time of Withering, in 1793, they were very generally undistinguished.* Nevertheless, the careful observer will always be able to draw a cor- rect diagnosis between the two diseases, from the catarrhal symptoms accompanying measles, and the peculiarities of its eruption. The small vividly red spots, like fleabites; their union into irregular semilunar patches; and the natural color of the intermediate skin, distinguishes the rubeolous exantheme from the large, irregular, more uniform and raspberry colored efflorescence of scarlatina. In measles the rash is characterized by small red spots blending with each other, and displaying central points more vivid than the coalescing margin so as to give a maculated appearance to the skin. In the other affection the blush is more diffuse and uniform, and the eruption consists of innumerable minute red points united together, resembling much the redness of a boiled lobster. The difference in the general course and pro- gress of the two affections is another diagnostic mark. The fourth day from the eruption of the fever, is the usual period of the manifestation of the measly rash. In scarlatina, the eruption generally comes out on the second, and not unfre- quently on the first day. Lastly the catarrhal symptoms, so rarely absent in measles, can hardly fail to confirm the diagnosis. Prognosis.—Measles, when uninterrupted in its regular progress and uncomplicated with internal inflammation, is not to be consider- ed a dangerous malady. However violent in its simple charac- ter, provided it proceed regularly in its course, the hazard is generally but little. Percival calculated, that about one * Bateman says, that the publication of Dr. Withering's Essay on Scarlet Fever—or father the second edition of that work, in 1793—may be considered perhaps as the date of the correct diagnosis of this disease. Synopsis, p. 66. MEASLES. 437 out of fifty cases of rubeola terminated fatally; and of this propor- tion one half took place in subjects under two years old. Rube- olous epidemics, of terrible fatality have indeed been recorded.* Obstinate internal congestion, preventing febrile reaction, are greatly to be apprehended. The sudden retrocession of the rash, either spontaneously or from violent purging, the application of cold or any other cause, is hazardous. It is an alarming inci- dent, when internal inflammation, particularly of the lungs, brain or trachea, supervenes. Laborious respiration, with a wheezing sound in the trachea, indicates much danger in infants. Amongst the most fearful symptoms, are petechiae, great muscular prostra- tion and colliguative hemorrhages. The disease is attended with imminent risk, when it attacks females in the latter period of pregnancy, or in the puerperal state. In general, nervous, de- bilitated, and delicate subjects have more reason to fear danger than persons of robust and healthy constitutions. Treatment.—In relation to the treatment of this disease, Dr. Armstrong makes the following very important observation: "From an impartial consideration of the facts which have come be- fore me, I am convinced that our plan of treating measles, (in its regular form) is too uniformly active when the eruptive fever is developed; and that we should be more fortunate in the main, if we interfered less with the operations of nature, in cases of a mild and regular character." The attention of the practitioner is particularlyly called to this remark. That it is true and high- ly important, I am thoroughly persuaded, both from my own ex- perience, and my observation of the practice of others. An active and antiphlogistic treatment, where no internal local inflammations are present, is generally not only uncalled for, but decidedly in- jurious—even though considerable febrile excitement should mark the eruptive fever. The eruption in this, as in every other exanthematous affection, must be regarded as an effort of the system to relieve itself from the noxious influence of some inter- nal irritation, by a critical or metastastic deposition on the sur- • From the great fatality of these epidemics, the disease acquired its name morbillvi or little plague. Were these epidemics measles? Both smallpox and scarlatina wera formerly confounded with measles. 38 438 MEASLES. face. Whatever materially interferes with the regular course of the precursory fever, tends to disturb the regular appearance and character of the eruption: but the development of this is es- sential to the safe and complete resolution of the disease: there- fore, when the eruptive fever is regular, not very violent, and un- complicated by internal inflammation or congestion, we should abstain from severe measures, and employ a gentle remediate treatment. All that is usually requisite in such cases is to keep the bowels in a soluble condition by the employment of mild lax- atives; to direct the patient to make a free use of tepid diluent drinks; and in instances attended by a very moderate degree of febrile excitement, to prescribe some of the gently stimulating diaphoretic ptisans—such as, infusions of sage, elder blossoms, marjoram, balm, or eupatorium. A high grade of fever undoubt- edly indicates the propriety of moderate venesection; and in this case the refrigerand diaphoretics should by no means be neg- lected, as they often suffice, without bleeding, to procure a pro- per reduction of the general excitement. Small doses of anti- monial wine, with sweet spirits of nitre, the saline effervescent draught, and the ordinary nitrous powder may be employed for this purpose. The subjoined formula* is particularly suitable, but I have generally preferred the following mixture.t When visceral inflammation, oppressive internal congestions or other irregular and alarming symptoms are associated with the disease, our remediate measures must be far more ener- getic. After the initial stage of oppression, if no reaction should ensue and the face remain pale and sunken, the pulse feeble, and the * B> Spirit mindereri, - - gvi Spirit, nitri. dulc. - - 3''ss Vir. antimonii - - - 3'8S Syrup lemonis - - - gii S. dose,—a teaspoonful or two every two hours. t R. Muriatis ammonias - 3'" Pulv.Extract.Glycyrrhii gss Tart. Antimonii - - gr.i Aq. fontanae - - - gviii M. Dose—a dessert spoonful every two hours for a child between two and five years of ago. MEASLES. 439 breathing heavy, with great muscular prostration and torpidity of the sensorial powers, we must endeavor promptly and decisive- ly to obviate the internal congestion, and arouse the action of the heart and arteries. If this be not effected, the eruption will not come out, and fatal stupor or coma will ensue. Dr. Arm- strong, a strenuous advocate of venesection in the congestive form of fevers, recommends the moderate and exceedingly cautious abstraction of blood in congestive measles. Internal congestion however, appears to result from a previous loss of energy in the vital powers, and especially of the extreme vessels. It would therefore seem to be a more efficient and prudent method to impart warmth and vigor to the system, and to recall the circulation to the extreme vessels of the surface. Stimulating frictions to the skin with tincture of capsicum or flannels wrung out of hot bran- dy; sinapisms to the epigastrium; and bottles filled with hot wa- ter applied to different parts of the body and extremities, are the means best calculated to procure these ends. Measures of this kind expose the peculiar advantage of exciting the energies of the system without diminishing its resources, at the same time that they most efficiently tend to equalize the circulation and re- move the congestion. In addition to the above means, we should not neglect the use of warm and gently stimulating drinks. In several instances of congestive measles I have employed cam- phor, suspended in a mucilaginous fluid with obvious benefit. The carbonate of ammonia, in my hands, has proved a very use- ful remedy in a few cases of this kind.* The disease is not so much benefited, by the exhibition of ei- ther of these stimulants, whene the congestive state precedes the exantheme, as when the rash, after appearing, suddenly recedes. In cases of this kind, oppressed respiration, a short, dry cough, a feeble and quick pulse, with an irregular distribution of the ani- mal temperature—'some parts being cool or cold, while others * R. Carbonatis ammon. - 3" Pulv. g. arab. - - - giii Sacch. albi. - - - - gss Aq. fontanae - - - - gviii Tinct. opii. - - - - gtt. xl M. Ft. S. A teaspoonful or two every hour or two. 440 MEASLES. are preternaturally warm—and a death-like paleness of counte- nance,' indicate extreme danger; and unless prompt relief be obtain- ed, "the patient sinks rapidly under an apparent load of phlegm in the bronchia." (Armstrong.) Camphor here is an exceedingly valu- ble remedy. Armstrong recommends in strong terms, a large dose of calomel, combined with camphor, antimonial powder, and a few drops of laudanum. A combination of opium and camphor is the appropriate remedy in cases of retrocession, occasioned by inordinate purging or vomiting; and in conjunction with this remedy, the use of sinapisms, stimulating friction, blisters, the warm bath, or dry warmth to the surface, may be deemed indis- pensable. We should remember, however, that except in very feeble subjects, moderate diarrhoea is rather beneficial than inju- rious; and we should by all means refrain from interfering with it, particularly in robust and plethoric individuals,—unless indeed there be evident symptoms of its hurtful influence upon the reg- ular appearance and course of the rash. (Armstrong.) Inflammatory measles require energetic antiphlogistic and de- pletory measures. Whatever difference of sentiment there may be touching the employment of the lancet in the sim- ple form of rubeola, no one disputes its efficacy, when the mala- dy becomes complicated with visceral inflammation. Prompt and decisive venesection, both generally and locally; epispastics over the region of the affected part; gentle laxatives and nausea- ting doses of the antimonials, are the principal measures on which we should rely. Antimonial emetics, especially in young chil- dren, have frequently an excellent effect, where bronchitis 01 peripneumonia have supervened. Whatever organ, in short, may become the focus of irritation, our measures should be adap- ted to the existing inflammation, without any other reference to the morbillious affection, than to the grade and character of the attendant fever. Certain varieties of inflammatory measles have occasionally occurred in which venesection is reported not only to have effect- ed no good, but to have been absolutely detrimental. Thus the very fatal rubeolous epidemic, that prevailed at Paris in 1828, although nearly always complicated with inflammation of impor- MEASLES. 441 tant organs, particularly of the lungs, was mitigated in no degree by sanguineous evacuations.* Opium and calomel might be use- ful in cases of this sort. I speak doubtfully, as 1 have never had an opportunity of witnessing such violent examples of the disease. Nevertheless I am induced unhesitatingly to recommend the combination in this variety of measles, from the experience I have had of its excellent effect in pneumonia typhoides. Blisters, cup- ping and the warm bath may be regarded as indispensable in such cases. In the remediate management of measles, vicissitudes of tempe- rature must be especially guarded against. An equable temper- ature, and one neither productive of chilliness, nor much warmth, should be preserved. When the eruptive fever is very moderate, and the patient is of a feeble and irritable habit, the air of the sick chamber ought to be so regulated, as to communicate a sen- sation of warmth; and this is particularly requisite in congestive cases. I have already adverted to the many disagreeable and danger- ous sequelae of measles and their frequent dependence on injudi- cious exposure to cold during convalescence. Common sense, therefore, dictates that the patient should during this period re- main within doors, and avoid in every way the noxious influence of a cold and damp atmosphere. " Even in summer, convalescents should not be suffered to go out of doors except in the middle of fine days, and not without additional apparel." (Armstrong.) Stimulating drinks of whatever kind should be positively inhib- ited, during the subsidence of the disease and the period of con- valescence, and the diet must be light and unirritating. There is occasionally dryness of the skin and a slightly febrile pulse after the appearance of the rash. Gentle diaphoretic feb- rifuges are the suitable remedies in these cases, and it will often be expedient to continue their exhibition during convalescence. An excellent diaphoretic of this kiad is the spirits mindereri, in union with a small portion of sweet spirits of nitre and of anti- monial wine. When pectoral symptoms continue troublesome at this stage of the complaint, the muriate of ammonia with vinegar • See Biett's Report, in the Journal Hebdomadaire, No. XLII. 3 L 38* 442 MEASLES. of squills and antimony, is one of our most efficient remedies.* Tonics are almost invariably injurious in convalescence from measles. If the system is left in an exhausted but unirritated condition, a weak infusion of serpentaria may be given; and this with mild and nourishing diet, will soon restore health and vigor to the debilitated frame. The following observation, by Dr. Armstrong, shall conclude what I have to say on this subject: "It is a remarkable fact, that when any cutaneous affections arise after measles, the internal organs generally remain free from disease; and even where some internal disorder has existed, I have not unfrequently seen it disappear, on the occurrence of some spontaneous eruption of the skin. Indeed there are many cases of this nature on record. At all times, we should, therefore, be most wary in meddling with vesicles, pustules, boils and the like, when they come out after the measles; for although they may be temporary blemishes on the surface, they are often the occasion of saving the vital works within. * JR. Muriat ammoni. - - 3"' P. extract, glycyrrh. - gss Aq. fontanae - - - gvii Acid. Scillae - - - gss Vin. Antimon. - - - 3' M. S. Dose—A tablespoonful every four hours for an adult. SCARLATINA. 443 CHAPTER XXXVII. SCARLATINA. SCARLET FEVER. Scarlatina is characterized by fever, a peculiar exantheme, and inflammation in the fauces—rapidly terminating, in some cases, in ulceration and sloughing. General Observations.—Scarlet fever arises from a specific conta- gious miasma; but certain circumstances, it is possible, may con- cur in such a way as to generate the affection independently of contagion. " There is abundant evidence that fever attended with scarlet eruption, and possessing all the other characters of this disease, does occasionally arise from exposure to cold."(Greg ory.) The period of the greatest activity of the contagious virus, is said to be the stage of desquamation. (Cazenane.) From three to five or six days usually intervene between its first impression, and the manifest development of the resulting disease. As in small-pox and measles, one attack of scarlatina secures the system against a subsequent invasion. On this point there has been some diversity of opinion. Withering and Willan never witnessed a second attack of the disease, and they deny the pos- sibility of its occurrence: Bateman, too, observes, " that this fact is now fully ascertained." On the other hand, Bicker,* Neuman,t Burns, and other authorities equally respectable, deny that the susceptibility of the system is invariably taken away by one attack; and they adduce some examples in confirmation of their opinion. It is also observed by Richter, that cases of a second, nay even a third attack of scarlatina have been noticed.J • Beschreibung eines Scharlachfiebers.—Rotterdam, in 1778, and 1779, p. 162. t Aufsatze and Beobachtungen fur Aerzte, p. 284, as quoted by Reid. Soc. cit. t. v 136. J Specielle Therapie, b. d. ii. p. 440. 444 SCARLATINA. The activity of the contagious principle may be influenced by various circumstances; such as constitutional idiosyncrasies, age, sex, climate, accidental predisposition, and peculiar atmospheric temperament. Certain individuals are entirely insusceptible to the contagion, never becoming affected with the disease, though fully exposed to its cause. Females, it is said, (Reid, Richter, Steiglitz,) are more susceptible than males; and it is the voice of general experience, that nurslrngs and old persons are much less liable to the disease than individuals of the intermediate ages. Some epidemics expend nearly all their violence on children; adults and adolescents are principally visited by others. Reid witnessed a malignant epidemic scarlatina, that was almost en- tirely confined to persons between the ages of fifteen and twenty five. The disease prevails at all seasons; but warm, humid wea- ther, and the air of low marshyr districts, would seem to promote its dissemination, and aggravate its violence. Certain peculiari- ties of atmospheric constitution, hitherto unrevealed, appear to exert considerable influence over the intensity of the contagion; as is manifest from the occasional prevalence of the disease in epidemics, and the different grades of severity and many varieties of character these have assumed. Great irregularity at times marks the progress of the epidemic. After raging extensively with much violence, it may suddenly abate so as almost to disap- pear, and then resume its power, and prevail with more malignity than ever. The contagion seems occasionally to linger for several years in a certain district, affecting from time to time only a few individuals. Scarlatina may appear in so simple and gentle a character, as to require nothing but the mildest remediate management; or in a form so severe and malignant, that the promptest and most en- ergetic measures will scarce mitigate its violence. Between these two extremes it occurs under every grade of severity. According to the differences of intensity and character, in relation to the fever, exantheme, and inflammation in the fauces, the disease has been divided into three varieties,—s. simplex, s. san- guina, s, maligna. Symj toms of S. Simplex.—A period, varying from one to three SCARLATINA. 445 or four days, usually intervenes between the manifestations of the ordinary premonitory symptoms of febrile diseases, and the com- mencement of the eruptive fever. At theendof this time,slight chills come on, alternating with transient flushes of heat. The patient complains of depression, nausea, pain in the loins, lower extremi- ties and head; has a hot and dry skin, and a frequent quick pulse. Forty eight hours usually elapse from the commencement of the fever before the appearance of the eruption. This comes out, first on the face, then successively on the neck, trunk and extrem- ities, and finally spreads over the surface of the mouth, fauces and nostrils: in some instances it is visible even on the albuginea. It consists of innumerable red points, which coalescing with each other, give a continuous and diffuse blush to the skin, not unlike the shell of a boiled lobster. (Armstrong.) In some cases, there is a uniform diffusion of the scarlet efflorescence over the whole body; in others, large irregular patches appear, leaving the inter- vening skin of the natural hue. There is commonly some enlarge- ment of the miliary glands and papillae of the skin, whereby the surface, particularly of the breast and extremities, acquires a slight roughness to the touch. On pressure with the point of a finger, the redness vanishes for a moment, leaving a transient spot of white. Coincident with the irruption of the fever, or soon after, the voice becomes thick and less sonorous, and the patient experiences some difficulty in swallowing, together with slight soreness of the fauces. The edges and extremities of the tongue are usually red, while a thick white fur covers the rest of the surface, through which the scarlet points of the enlarged papillae are visible. In most instances the face becomes somewhat swollen; the skin is hot, and the pulse frequent, quick, sometimes tense and vigorous. The thirst is not commonly troublesome, but the appetite is always impaired. The evening exacerbations are attended with considerable restlessness and occasionally slight delirium, both of which generally disappear on the approach of morning. On the fourth day, the full developement of the fever and eruption is gradually accomplished, and their stage of declination commences on the day following. They continue to decline, 446 SCARLATINA. pari passu, till almost the end of the seventh day, when there is an entire disappearance of both. When the eruption is about subsiding, the tenderness of the fauces abates; cutaneous trans- piration is re-established; there is a copious reddish sediment in the urine, and diarrhoea often takes place. Desquamation commences on the eighth day. It is generally attended with considerable itching, and is followed by an unusual sensibility of the skin over the whole body. The appearance of the erup- tion is occasionally attended with a considerable abatement of the febrile symptoms. Sometimes the fever throughout the disease is so slight, as hardly to attract attention; at others so grave as to demand vigorous and decisive measures. It should be borne in mind, that, though the affection mav commence and continue for a day with great mildness, it may suddenly assume all the violent characteristics of the anginose variety.* S. anginosa.—A higher grade of fever and a more severe anginose affection characterize this form of scarlatina. The forming stage is almost invariably attended with considerable headache, precordial oppression, general muscular prostration, nausea and sometimes vomiting. A feeling of stiffness and dull pain in the muscles of the neck and under the ears and angles of the jaw, accompanies the fever from its commencement, and not infrequently precedes it. A red and slightly tumid appear- ance is presented by the fauces, palate, tonsils and uvula. The voice soon becomes hoarse, an unpleasant sense of constric- tion in the throat is felt in respiration, and deglutition is painful and difficult. There is a rapid development of febrile action, the pulse acquiring great quickness and frequency, but rarely * In reference to cases of ihis nature Dr. Armstrong has the following observations: " Simple excitement may readily produce inflammation, and in fact is the most frequent cause of it; for if there be a latent weakness in any organ, the simple excitement, if not timely moderated, is sure to give rise to inflammation there. It is on this account that many diseases merely marked by simple excitement at the beginning, are complicated with inflammation in their progress; and hence it is, that apparently benign seizures of scarlitina may eventually become the cause and concomitants of serious affections of some of the viscera. It is, indeed, only in subjects of the soundest constitution, that we ever see simple excitement uncombinedly exist throughout the disease: and the only reason it su frequently occasions inflammation is, that some tissue or other had been secretly in fault before its occurrence.—On Measles, Scarlatina, &c. p. 157. SCARLATINA. 447 possessing the vigor, tension and fulness, by which it is marked in the simple variety of the disease. The skin is more intensely hot than in any other febrile affection, and there generally7 is very great thirst. According- to Currie and Willan, the heat of the surface has risen to 108 and even 112 degrees of Fahren- heit's thermometer. The tongue becomes dry, its edges are very florid, and on its surface are seen the projecting points of the inflamed papillae. Considerable uneasiness or pain is felt in the head, and the whole course of the disease is marked by much languor, restlessness and prostration. In this variety, the eruption is not manifested so early as in sim- ple scarlatina,—the third day of the fever being the common date of its appearance. It is scattered on different parts of the body, particularly about the elbows, in irregular, not very large patches, but is seldom diffused over the whole surface. Sometimes the rash disappears the day after it has come out, and " reappears partially at uncertain times, but without any corresponding changes in the general disorder; and the whole duration of the complaint is thus lengthened, and the desquamation is less regular." (Bateman.) If the declension of the febrile symptoms takes place as early as the fourth or fifth day, the swelling and inflammation of the fauces generally pass off by resolution with the eruption and fever, without terminating in ulceration. But when, during the first three or four days the excitement is violent, or when it is protracted beyond the period just mentioned, small ulcers are formed about the tonsils and palate, which are rapidly converted into ash-colored, superficial sloughs, a considerable quantity of tenacious mucous is always secreted in the fauces, and concretes very frequently into white flakes, presenting the appearance of ulcers, where in reality there is none. The parts should therefore be carefully examined, before an opinion is expressed as to the existence of ulcers. (Armstrong.) With the subsidence of the fever, the sloughs in the throat separate, leaving red ulcerated surfaces, that usually cicatrize without difficulty. Occasionally, instead of separating about the eighth day, they enlarge, assume a brown color, and discharge an acrid sanious fluid. The glands about the neck, in such cases are hard, swollen and painful; and 448 SCARLATINA. harassing diarrhoea and tenesmus supervene. The inflammation may extend into the trachea, and death ensue under symptoms of acute bronchitis. This form of the disease is not seldom complicated with vis- ceral inflammation. During the eruptive stage, the brain is often deeply involved, and symptoms of severe and fatal coma are exhibited. Abdominal inflammation may likewise take place. " At first there are only slight pain and soreness in some part of the abdomen, with a quickened pulse and hurried respiration; but the pain and soreness gradually increase, and at length are attended with vomiting, eructation, fulness of the belly, and gen- eral restlessness. In six, seven, or eight days, the abdominal soreness and pain abate or disappear, while the pulse grows rapid and feeble, the breathing more anxious, and the vomiting more urgent. Cold, clammy sweats and a universal collapse now spee- dily supervene, and are the immediate precursors of death." (Armstrong.) S. Maligna.—In the beginning, this variety of the disease may wear the aspect of scarlatina anginosa, but it speedily betrays its violent and dangerous character. The eruption comes out at uncertain periods between the second and fourth days. It is usually pale at first, but in the progress of the affection, it acquires gen- erally a dark or livid hue. Great irregularity marks its duration; and it will often vanish soon after its first appearance, and at the end of two or three days reappear on different parts of the body. The pulse, active in the commencement, becomes small and fee- ble in the course of the second day. The heat of the skin is variable, but in general not very intense. At an early period, delirium usually comes on; and, with occasional intermissions and exacerbations, often continues throughout the subsequent course of the disease. In nearly all cases, there is considerable disturbance of the sensorial functions; and in aggravated exam- ples, the eyes become dull and inflamed, and a livid flush over- spreads the cheeks. A brown and dark fur covers the dry tongue and the breath is fetid. In the fauces, on the soft palate and tonsils, may be seen grey-colored sloughs, which soon acquire a brown and finally a dark color. Sometimes, before the ulcera- SCARLATINA. 449 tion becomes severe or extreme, death will take place under symptoms of cerebral oppression. " In general," says Dr. Arm- strong, "it is only when the fever is protracted beyond the fourth day, that the ulcers are converted into ill-conditioned, black and fetid sloughs." A large quantity of very viscid mucus is gene- rally secreted into the fauces, occasioning difficult respiration and a rattling noise in the throat. When the sloughs are extensive and foul, a thin, acrid fluid issues from the nostrils and gives rise to painful irritation and excoriation of the parts over which it flows. Where the disease has assumed a particularly violent character collapse supervenes towards the middle or end of the second week. Great prostration of all the vital energies now ensues; the pulse becomes very frequent and feeble; the heat of the surface sinks; the tongue is dark, brown, or black; exhausting diarrhoea often takes place; and, in some cases, hemorrhages from various parts and petechias occur towards the fatal termination of the complaint. The fever and affection of the fauces may frequently exist without an eruption at any period of the disorder. As early as the second or third day, death sometimes closes the scene; and it is observed by Bateman, that occasionally the symptoms con- tinue to be moderate till an advanced period, when they suddenly assume a malignant and rapidly fatal character. Three modifications of malignant scarlatina have been descri- bed by Dr. Armstrong,—the inflammatory, congestive, and mixed: the latter being characterized at once by much internal conges- tion and a moderate reaction of the heart and arteries. The inflammatory modification corresponds with the putrid variety of Richter.* Its commencement is marked by a high grade of inflammatory excitement, as indicated by the full, hard, and vigorous pulse, the intensely hot skin, and early delirium. For a day or two, it differs little in appearance from scarlatina anginosa, but the early supervention of collapse or a typhous state, and of the gangrenous condition of the throat mentioned above, soon reveal its true character. The eruption comes out early; at first vividly red, but as the disease advances, it acquires a * SpecielleTherapie, bd. ii. p. 466. 3 M 39 450 SCARLATINA. darker or purple hue. The animal powers speedily sink; a burn- ing, acrid sensation is felt on touching the skin; the pulse be- comes weak, small and hurried; the exantheme purplish, and petechiae or a miliary eruption, coliquative diarrhoea and hae- morrhages ensue. The extreme violence of the anginose affec- tion, and its decided early tendency to terminate in extensive gangrenous ulceration, are the principal characteristic phenom- ena of this modification. Inflammatory scarlatina maligna was formerly described under the name of putrid sore throat. The want of reaction distinguishes the congestive variety. The patient is pale, faint, oppressed, and complains of universal pros- tration, giddiness, deep-seated pain, and a sense of weight in the head, nausea, much anxiety and oppression in the praecordia.— " There is often a mixture of lividity and paleness in the face, and the eyes are usually dull, acquiring a fatuous or inebriated ex- pression in the course of the disease. The mind at first alarmed and confused or dejected, soon becomes disordered with delirium; an indifference to surrounding objects and a stupor succeed, under which patients frequently expire." Respiration may be quick and short, or slow and impeded; and the pulse is weak, sluggish, and irregular. The tongue, at first covered with a white fur, becomes rough and brown in the course of the disease. There is torpor of the bowels in the beginning, but in the latter period of fatal cases, diarrhoea nearly always supervenes, attended, not un- frequently, with petechiae, gangrenous spots, and wasting haemorr- hages from the nose, mouth and bowels. The rash, from its first appearance, is pale or copper-colored, acquiring at last a purple hue. This modification of the disease is seldom protracted in its course, but very often terminates as early as the second, third or fourth day. The anginose affection is seldom extreme, and is sup- posed by Dr. Armstrong to have little to do in bringing about a fatal termination. The mortal tendency of the disease he ascribes chiefly to the " venous congestions of the brain, liver, spleen, lungs, and of the vessels of the heart, giving rise to universal collapse and visceral disorganization," and perhaps to a change in the constitution of the blood itself. Diagnosis. Measles and miliary fever are the only two disea SCARLATINA. 451 ses with which this affection is liable to be confounded; and it must be confessed, that a correct diagnosis between them and the simple and anginose varieties of scarlatina is at times attended with very considerable difficulty. No single symptom can be re- garded as peculiar to scarlatina. The eruption is at times wholly or nearly absent, diffused in blotches, and occasionally papular. Irregularity also marks the anginose affection, which may yary from a slight redness to much tumefaction, and occur with or without ulceration and sloughing. Nevertheless, an accurate diagnosis may nearly always be framed, by a contemplation of the following circumstances. In scarlatina, the usual time for the appearance of the eruption is during the first forty eight hours of the fever: the rash, in measles rarely comes out until the third day, and most commonly not until the fourth. The exantheme, in the former affection, consists of innumerable points, intermixed with small papulae, dispersed over the cuticle,—resembling a dif- fuse erethematous blush. The rubeolous rash on the contrary, is made up of small circular dots, like flea-bites, of a more vivid red in the centre than circumference, so that their coalescence presents a less uniform blush than is displayed in scarlatina. These red and slightly elevated dots are generally congregated in clusters and patches, so as to exhibit an irregular crescent shape. " The crescent-like form of the patches of measles, and the more diffuse, and irregular shape of those of scarlatina, will be a mate- rial diagnostic guide." (Bateman.) In scarlatina, the eruption resembles in color the boiled lobster shell, and is generally of a lighter red than that of measles, which also is somewhat inclined to a brownish hue. The most striking diagnostic mark, however, is furnished by the catarrhal symptoms, so very conspicuous in nearly every case of measles, but either entirely absent, or ex- tremely slight and partial in scarlatina. The inflamed eyes, copious weeping, red and tumefied edges of the eyelid, intolerance wf light, coryza, sneezing, strong, harsh, and hoarse cough, so seldom absent in measles, and so rarely present in scarlet fever, will, in general obviate all danger of mistake. Finally, the ulceration and sloughing of the fauces in s. maligna and anginosa, are quite sufficient to distinguish this affection from rubeola. Simple scarlatina, approaches very nearly, at times, to thecha- 452 SCARLATINA. racter of miliary fever, so that a superficial observer, might very easily be led into error. They may be distinguished, by the miliary eruption being almost universally attended with consider- able perspiration, which is not the case in the appearance of the scarlatina efflorescence. The little points composing the exan- theme of the latter affection, rise out of a uniformly erethematous blush of the skin, whilst those of miliary fever appear to be seat- ed on a skin preserving its natural color. Great praecordial anx- iety generally attends the coming of the miliary eruption: and about the period of its subsidence, a second eruption similar to the first may appear, in some instances followed by a third crop of papulae. Prognosis.—As the disease may take place under diverse mod- ifications and every grade ©f severity, from the mildest to the most malign, the prognosis must, of course be extremely va- rious. It should in all cases be formed with a proper degree of caution, even where the disorder at first assumes the least alarming aspect; for the symptoms maybe those of the simple and regular form alone during a few days, and then suddenly give place to others of the most violent and dangerous char- acter: this is more especially apt to be the case when considera- ble severity characterizes the prevailing epidemic. Bearing this in mind, we may remark, that simple scarlatina is rarely attended with any hazard to the patient, unless dangerous secondary affec- tions supervene during the subsidence of the disorder, or the period of convalescence, from cold or accidental causes. Peculiar dan- ger is always connected with the anginose variety of the disease; and, in the malignant form, it is to be ranked among the most fatal of maladies. Generally, and perhaps justly, the hazard from scarlatina is estimated by the character and violence of the anginose affection. Dr. Armstrong seems to hold a con- trary sentiment: at least, the affection of the throat by itself, he regards as but rarely the cause of death—a termination, he thinks, attributable rather to violent internal venous congestion and visceral disorganization, so common in the more violent grades of this disease. When the eruption is brightly red, and uniformly diffused over the whole or a greater part of the body, the progno- SCARLATINA. 453 sis is better than when it is pale or purple or brownish, and ap- pears only here and there in large patches. (Armstrong, Reil.) Irregularity of the eruption is an unfavorable symptom,—as, for example, where it displays by turns a red, pale or brownish aspect; now appears chiefly on one part, then on another; vanishes for a time and again reappears; or at an early period suddenly vanishes altogether. It is remarked that a white streak, passing down along each side of the nose and encircling it below, is a fatal sign. (Reil.) A vivid redness and considerable tumefaction of the fauces, attended with pain or swelling, are better indications than a livid or dark red aspect of the inflamed part, without swelling and painful deglutition. White sloughs in the fauces are also more favorable than cineritious or brown ones. If on a sudden a strong inclination is felt to urinate, and a copious quantity of crude watery urine is voided, the danger may be considered great. (Richter.) The occurrence of gangrenous ulceration in the throat is of course always alarming. The grade and character of the attendant fever, as might be expected, has an important bearing on the prognosis. A mod- erate degree of reaction is favorable; a typhus grade is the reverse; and extreme violence of fever in the commencement, with much angina, is a sufficient reason for apprehending early and hazardous collapse. Where febrile reaction is prevented or much impeded by great internal nervous congestion, there is every thing to fear; and a no less alarming event is the super- vention of visceral inflammation. Collapse soon comes on in these cases; and if death does not speedily ensue, great pros- tration takes place, with the fatal symptoms of coma, con- stant delirium, and cold extremities: if to these be added petechiae, wasting hemorrhages and involuntary discharges from the bowels, a hasty dissolution may with certainty be predicted. Children except when suffering from painful dentition, are apt to be afflicted more lightly than adults with the disease. It is said to be most dangerous when it assails persons between the ages of fifteen and twenty-five.* Peculiar hazard likewise attends it, when it makes its appearance during pregnancy, and particularly in the puerperal state. In general, robust and * Reil. loc. cit. vol. V. p. 138. 39* 454 SCARLATINA. healthy individuals suffer less from scarlatina, than subjects of a feeble, lymphatic and nervous temperament. A regular abatement of the heat and efflorescence of the skin, associated with diminished frequency in the pulse, and a lateritious deposit in the urine; a subsidence of the swelling, with separation of the sloughs, and healthy granulation of the ulcers; and lastly desquamation of the cuticle, are all indicative i of a favorable termination to the disease. Sequela.—Many troublesome and often dangerous disorders ensue on an attack of the scarlet fever. Of these anasarca is by far the most common, there being no other acute disease, that is so liable to be followed by dropsical effusions. This emphatically is true in reference to the anginose variety. Nine or ten days almost always elapse after the disappearance of the eruption, before the anasarca is perceived; and it continues commonly for the space of two or three weeks. It is observed by Bateman, that " when anasarca becomes pretty general, a sudden effusion occasionally takes place into the cavity of the chest, or into the ventricles of the brain, occasioning the death of the patient in a few hours." But, in general we have no reason to apprehend dangerous consequences from the dropsical effusion. At times the disease has given rise to various nervous affections, such as hysteria, spasmodic asthma, chorea, epilepsy,* and neu- ralgic pains in the extremities; and occasionally it has been fol- lowed by strumous disorders, chronic cutaneous eruptions, herpes, gutta serena, and rheumatic pains. The malignant and anginose varieties are moreover sometimes succeeded by tonsillar abscesses, enlargement of the parotids, inflammation of the testicles, ophthal- mia, deafness, otitis, inflammation of the mucous membrane of the bowels, excoriations about the nates, suppuration of the glands of the neck, chronic cough, bronchitis, or other slow suppurative inflammations, with hectic fever and its train of evils Dr. Armstrong and others have observed, that the hair is very apt to come out on the abatement of scarlatina, in which case it will never look or grow well again. * Kreysig. Abhandlung uber des schailackfieber, &c. p. 59. See also Cappel. abhand von Scharlachsauschlage, p. 90. Reil. Fieberlebre. Bd. 5. p. 122. SCARLATINA. 455 The more complete and conspicuous the desquamation, the less liability is there to secondary disease during convalescence. Treatment.—It is evident from the description we have given of scarlatina, that our treatment must be greatly varied, to adapt it properly to the many varieties and modifications the affection is wont to assume. Simple scarlatina requires nothing but the mildest antiphlo- gistic management. One or two gentle aperients or oenemata should be administered; cool or tepid drink prescribed, such as barley water, lemonade or toast water acidulated with lemon juice or muriatic acid; and the patient be restricted to mild unirrita- ting liquid diet. He should also be confined in a room, the temperature of which must be kept at a moderate and an equable degree. In addition to. these measures, nothing more in general is necessary, than the use of slightly astringent and emollient gargles, such as sage tea, with a small portion of alum, and sweetened with honey; or an infusion of green tea. Occasionally the forms of the disease will assume a severe aspect, and present symptoms of very considerable febrile irrita- tion. More vigorous measures are now required, as it may be converted by a continuance of the high vascular excitement into scarlatina anginosa. Although the disease be manifestly simple in its form, if the febrile action be aggravated, it is prudent that we should endeavor promptly to restrain the phlogistic tendency, without interfering too much with the regular, and we may presume, necessary excitement of the heart and arteries. The " nimia diligentia medici" has doubtless been sometimes productive of much harm in simple scarlatina; but to the judicious prac- titioner, the grade of the existing symptoms will be a safe guide, in the employment of antiphlogistic measures. It should moreover, be borne in mind, that from the aspect of the disease in its onset, we cannot always correctly predict its subsequent character—whether it shall be simple or complicated mild or dangerous. However benign therefore, the prevailing epidemic, whenever we are called to a case in the former stage marked by considerable lassitude and oppression, paleness of the face and skin, some headache and nausea, it is expedient to com 456 SCARLATINA. mence the treatment, as if the complaint were about to assume an aggravated character. An emetic, promptly administered, will do much good by removing internal venous congestions and encouraging wholesome reaction. After its operation, it will be proper to exhibit a brisk mercurial purge. Where much affec- tion of the head exists in the forming stage, Dr. Armstrong advi- ses the use of the warm bath strongly impregnated with salt. "This practice," he remarks, "assisted by a brisk purgative, will in general give immediate relief, and contribute powerfully to moderate the subsequent reaction." When the succeeding feb- rile excitement is of a high grade, it should be reduced by purga- tives, tepid effusions, cooling drinks, rest, ventilation, and some of the more gentle diaphoretics—such as spiritus mindereri, sweet spirits of nitre, or small doses of antimony and nitre.* Far more vigorous measures are required in the anginose vari- ety of the disease. Emetics in the beginning of this, as indeed in every other form of scarlatina, are justly regarded by the profession as among our most valuable curative means. The earlier their employment, the more beneficial in general will be their effects: in the forming stage particularly, or at the very onset of the malady, they are most decidedly efficacious.t Given thus early, they often meliorate the whole subsequent course of the disease; and, in some instances, interrupt, almost completely, the train of morbid action. Some have indeed recommended them at every period of the complaint; (Withering,) but almost all practitioners are agreed, that the forming stage is the only proper period for their exhibition. The good effects of an emetic, in the beginning of the disease, depends, probably, chiefly on the centrifugal direction which active vomiting communicates to the circulation, tending, thereby, to obviate internal congestions and secondary visceral inflammation; and, perhaps, also, in part on * Armstrong. Treatise on Scarlatina, Ancerles, &c. t Numerous authorities of great weight might be quoted in evidence of the good effects of emetics in this disease. They are recommended by Tissot, (Anis au-peuple,) Stoll; (Ratio medend. torn. ii. p. 248;) Withering; (account of scarlet fever and sore throat, as it appeared at Birmingham in 1773, and London in 1779, p. 300;) Steiglitz; (Versuch enier pruifung und verbersserung der yezt gewoehnlichen behandlimgs art des scharlacufie- ners, p. 231; Richter; (Specielle Therapie, Bd. ii., p. 480;) Reil; (Feberlehre, torn. v. p. 166;) Armstrong; (on scarlet fever, &c.;) Rush; (Medical Inquiries.) SCARLATINA. 457 the impairment or disturbance of the morbid sympathies, con- nected with the disease. Formerly, there existed much prejudice against the employ- ment of purgatives in this disease, but of late years they have been strongly recommended. Dr. Hamilton* particularly insists upon their efficacy in scarlatina, and the testimony of all modern writers is in accordance with his opinion. My own expe- rience, though limited in this form of the affection, has led me to think very highly of the utility of moderate purgation. With the exception of an antimonial emetic in the beginning, I have, in a majority of cases, confided almost exclusively in the employment of aperients, with cooling applications to the surface, or an anti- phlogistic regimen and the local applications, to be hereafter mentioned. No measure is better calculated to prevent the haz- ardous occurrence of coliquative diarrhoea in the latter period of the disease, than the proper administration of laxatives in the earlier stages. But as a general rule, strong purgation is by no means necessary or expedient. From three to four evacuations in the course of twenty-four hours are sufficient to procure all the advantages derivable from purgatives, t unless cerebral con- gestion exists, when active catharsis is obviously indicated.J The efficacy of antimonials, and the usual refrigerant diapho- retics, does not appear to be very decided in this affection. "In truth," says Dr. Bateman, " the temperature is too high to admit of a diaphoresis; and the only safe and effectual method of pro- ducing this effect, consists in reducing the heat of the surface by the application of external cold." Nevertheless, we have the authority of Richter in favor of the internal use of muriate of ammonia, when the fever is strong after the sufficient evacuation * Treatise on Purgatives. t Bateman, Gregory, Richter, Reil, Willan. By Dr. Armstrong, active purges are preferred to mild ones in anginose scarlatina. \ Rhubarb and calomel; rhubarb and soda, in equal parts; calomel with small por- tions of antimonial powder; (Willan;) calomel, followed by a 6mall dose of magnesia: small portions of the sulphate of soda or magnesia; an occasional dose of two or three grains of calomel, with the daily use of castor oil, or the administration of laxative ene- mata. may be used for this purpose. 458 SCARLATINA. of the bowels.* It should be given in union with emetic tartar, according to the following formula: R. Muriat. amraoniae,.... gss. Pulv. extract, glycyrrh. gi. Tart, antimonii.......gr. i. Aq. fontanae,.........gviii. M. ft. s. A teaspoonful to be given every three or four hours. Notwithstanding the use of the foregoing remedies, the inflam- matory condition will sometimes increase, and the patient become anxious and very restless. Diluted sulphuric acid, in these cases, has been given by Steiglitz in large and frequent doses, with ex- cellent effect. (Abhandl. feur Pract. Arzte. B. xxii. p. 307.) The application of cold water to the surface cannot be too highly estimated in the higher grades of this affection. " We are possessed of no physical agent," says Bateman, " as far as my experience has taught me, (not excepting even the use of blood- letting in acute inflammation) by which the functions of the ani- mal economy are controlled with so much certainty, safety and promptitude, as by the application of cold water to the skin, under the augmented heat of scarlatina and of some other fevers. This expedient combines in itself all the medicinal properties which are indicated in this state of disease, and which we should scarcely, a priori, expect it to possess; for it is not only the most effectual febrifuge (the' febrifugium magnum,' as a reverend au- thor, Dr. Hancoke, long ago called it,) but it is in fact the only sudorific or anodyne which will not disappoint the expectation of the practitioner under these circumstances. I have had the sat- isfaction, in numerous instances, of witnessing the immediate im- provement of the symptoms, and the rapid change in the counte- nance of the patient, produced by washing the skin. Invariably, in the course of a few minutes, the pulse has been diminished in frequency, the thirst abated, the tongue has become moist, a gen- eral free perspiration has broken forth, the skin has become soft and cool, and the eyes have brightened; and these indications of relief have been speedily followed by a calm and refreshing sleep." The only precaution requisite in the application of cold water in this, as in every other febrile affection, is to ascertain that no sense of chilliness is present, and that the skin is dry and * Specielle Therapie, B. ii. p. 490. SCARLATINA. 459 above the natural temperature. Pouring or affusion over the body is the best method of applying the water, where there is excessive vascular action with intense heat of the surface; but where either of these modes is impracticable, or opposed to the wishes of the patient and his friends, we must resort to washing or sponging the skin, every hour or two, until the temperature and circulation be moderated. Cold water simply, or vinegar and water may be used for this purpose. As the disease advances, Dr. Armstrong recommends that tepid affusions be substituted for cold; and, as a general rule, he thinks it prudent to commence with them after the third day of the stage of excitement. It is best, however, to be governed in this matter by the degree of cutaneous heat and arterial excitement present; for at any period of the disease, provided there be a hot and dry skin, cold water may be safely and beneficially employed.* (Dr. Stranger.) Pur- gatives and cold affusions may be employed conjointly. Accord- ing to Armstrong, they are more efficacious in this wayr, particu- larly during the first three days of the stage of excitement, than when employed separately; and my own observation is in favor of this opinion. Within the period just named, blistering may also be beneficial. Where tonsillar inflammation and tumefaction exist to such a degree as to occasion painful deglutition, a blister to the throat will often afford considerable relief. Willan, He- berden, and Rush speak very highly of this practice. The complication of the complaint with visceral inflammation, renders the employment of cold or tepid affusion almost, if not entirely useless; and it is observed by Armstrong, that where these means in conjunction with purgatives are unavailing, the practitioner may be sure of the existence of some latent inflam- mation. In a case of this nature, provided there be no signs of approaching collapse, recourse must be had to sinapisms, blisters, and small general or topical abstractions of blood. When much vascular irritation exists, or incipient phrenitis comse on—as indi- cated by the flushed and turgid countenance, intolerance of light, severe pulsating pain in the head, more or less delirium, and a disposition to somnolency—the patient must be laid in a cool sit- uation with his head elevated, and blood drawn according to the •Willan on Cutaneous Diseases. Note at p. 360. 460 SCARLATINA. state ofthe pulse* In addition to this, an active purgative should be given, warm fomentations or sinapisms applied to the feet, cold water to the head, and cups to the temples, or blisters to the back of the neck. But in all our measures we should never lose sight of the imminent risk of collapse,—as this condition nearly always speedily ensues in this affection, upon the supervention of internal visceral inflammation, and when present, utterly forbids the use of sanguineous or other evacuations. Dr. Armstrong remarks, that " in such examples, the question is simply this—whether is greater danger to be apprehended from the inflammation or from the depletion?" Visceral inflammation, in his opinion, almost invariably terminates fatally, but depletion only occasions de- bility, and rarely is debility the cause of death. He believes it therefore right, even in the stage of collapse, to arrest, if possible, the inflammation, by depletion, wherever it may be seated. It is true, that debility may rarely be "the cause of death"; but that it favors the occurrence of this event can hardly be doubted. Why is visceral inflammation so fatal in these cases? The most rational answer is, because it is associated with universal debility. It is evident, therefore, that whatever augments this debility or prostration, must hasten a fatal termination. Depleting does indeed appear to us to be a desperate practice; and before adopt- ing it, we would do well to recollect, that internal inflammation cannot be materially mitigated by a small bleeding, and that from a large one death must inevitably result. Herein is the reason why cases of this nature are so exceedingly perplexing; the most efficacious remedies for inflammation being sure to increase the prostration. When the inflammation is seated in the brain, we may apply fomentation to the feet, and dry cups to the temples or shaven scalp, at the same time that we exhibit active purgatives in conjunction with carbonate of ammonia or camphor. In other visceral phlegmasiae attended with collapse, I should be disposed to resort to calomel and opium, with dry cupping and large * * Armstrong; Marcus, (Specielle Therapie, torn. iii. p. 272); Lorry, (Hist de la Roc. Roy. de Med. t. ii.); P. Frank, (de Curand. Homin. Morbus) ; Rush; Burserius, (Institut. Med. Pract. vol. ii. p. 72); Heim, (Horn's Archiv. fur Medic. Erfahr. vol. iv. b. 1. p. 150.) ; Richter; and many other eminent authorities may be adduced in favor of prompt bloodletting in such cases. SCARLATINA. 4gj fomenting cataplasms over the region of the affected part. Blis- ters in these cases are almost as hazardous as bleeding: they give rise to much general irritation, and gangrene often takes place in the blistered part. Malignant scarlatina exchanges so speedily its highly phlogistic symptoms for those of a low and typhus state, that physicians were once in the habit of resorting immediately to the use of bark, wine and other stimulating and tonic remedies. " These reme- dies," says Dr. Armstrong, « so forcibly, so indiscriminately, and bo fatally recommended by numerous authors, were once the means upon which, unfortunately, I relied for the cure of this modification of scarlet fever; and from repeated trials of them, I can truly affirm that they are the most pernicious in the first stage, and most destructive in the second." However quickly this variety of the disease may put on a malignant form, its irruption is often marked by highly inflammatory symptoms. The vehe- mence of the attack and the intensity of the excitement rapidly exhaust the vital energies; so that in proportion to the violence of this tumultuous, transient stage, will be the tendency of the complaint to assume a putrid character. Energetic measures are therefore imperiously required promptly to allay the initial febrile commotion. The remark I have already made in reference to the exhibition of emetics, followed by brisk purgation, in the com- mencement of the other forms of scarlatina, are equally applica- ble to this variety. If called sufficiently early, these should always be our first remedies. When, after their operation, the stage of excitement begins with violent symptoms—such as in- tense heat of the skin, a frequent, quick, and tense pulse, severe headach and delirium—prompt and efficient venesection should be practised. (Burserius, Lorry, Armstrong.) As the time allowed us for the prosecution of these vigorous measures is but short, it is highly important to draw blood at once, to the extent of pro- ducing a very decided impression on the system; or, according to Armstrong, until syncope approaches. One such bleeding, with the brisk operation of a purgative, will often so allay the violence of the disease, that its subsequent course shall be divested in a considerable degree of its dangerousness. But it should be borne 40 4(32 SCARLATINA. in mind, that these active depletory remedies must be entirely restricted to the early period of the stage of excitement; for the approach of collapse renders bleeding utterly inadmissible.— (x\rmstrong.) In every form of scarlatina, during the stage of excitement, purgatives may be employed with propriety. Calomel has been particularly recommended, both in the mild and malignant vari- eties;* and by Dr. Rush was administered throughout the whole course of the malady. A combination of calomel, precipitated sulphuret of antimony, and emetic tartar, according to the annex- ed formula,! is recommended in high terms by Seelig: it is said to be a gentle laxative, and an antiphlogistic alterative in the dis- ease under consideration. In conjunction with purgatives, the warm-bath may be advantageously employed, particularly in cases attended with internal inflammation. The collapsed stage of the inflammatory modification of scarlatina, is not apt to be extreme, where a prompt and vigorous antiphlogistic treatment has been pursued in the commencement of the disease. When it takes place after such a treatment, we may in general sufficiently sustain the system by the admin- istration of wine whey, weak solutions of ammonia, infusion of serpentaria and by directing a milk diet, quietness and proper ventilation. (Armstrong.) But when from inefficient or improper measures in the beginning, or a peculiar malignancy of the disease, great and universal collapse ensues, (and such is the result but too frequently, both in the inflammatory and congestive modifica- tions of malignant scarlet fever,) recourse must be had to more decisive stimulating and tonic treatment. The carbonate of ammonia in frequent and active doses; wine; camphor and opium where the brain is not particularly affected; infusions of serpen- * " It is somewhat remarkable," says Armstrong, " that calomel, though given in large and frequent doses,, will hardly ever produce ptyalism in scarlatina." He states, that he has frequently given from six to eight grains of this article to children, twice, thrice, and even four times daily, without having, in a single instance, known it to produce sali- vation. It is considered by him the best purgative in every modification of this disease. t R Calomel,...........9ss. Sulphuret. antimon. praecipit. gr. i. Part, antimon.........gr. ss. M. Divide into twenty equal parts. Dose—one part to be taken by a child six years old, every third or fourth hour. SCARLATINA. 453 taria, with large doses of elixir vitriol; quinine and capsicum are the remedies on which we must rely. Peculiarly excellent effects appear to be derived from the use of capsicum as an excitant in this form of the affection. It was first employed with this view by Dr. Stephens, in a very fatal epidemic of scarlatina maligna, that prevailed at St. Christophers, (West Indies,) in 1787. Since then, many eminent practitioners have borne full testimony to its efficacy. The following is the manner in which it is prepared for use: Take a tablespoonful of small red pepper, a teaspoonful of common Cayenne pepper, and one tea- spoonful of salt: beat them into a paste, and pour upon them half a pint of boiling water. This is to be strained, and about a gill of good vinegar added to it. Of this liquor, when cold, a tea- spoonful is to be taken every half hour, and the throat should be frequently gargled with it. It is stated by Dr. Stephens that he employed this remedy in about four hundred cases, and with sur- prising success: the slough in the fauces was soon thrown off, and the ulcers began to heal; an agreeable sensation of warmth spread throughout the general system, and a more vigorous condition of the vital powers was superinduced. The flowers of arnica are favorably mentioned by Malfatte,* and by Steiglitz they were employed with much advantage in this stage of the complaint. Reil speaks in high terms of large doses of musk, especially where the patient is much harassed by restless- ness and nervous irritation. We may also derive advantage from stimulating frictions with brandy, camphorated spirits, or tincture of capsicum. (Reil, Steiglitz.) The cooling drinks, acidulated with lemon juice, the sulphuric or muriatic acids, which should be freely allowed in the stage of excitement are well sub- stituted during the subsequent stages by infusions of sage, balm or catnep, with sulphuric acid. The treatment proper in the congestive modification of scarla- tina maligna, does not require in this place an extended notice. As the curative principles in all congestive states of febrile diseases are alike, what has already been said in relation to the treatment of congestive measles, is applicable to the present malady when appearing under this modification. Our first • Hufeland's Journal, Bd. 12 at 120. 464 SCARLATINA. efforts, if symptoms of oppressive internal venous congestion should mark the rise and progress of the complaint, must be to rouse the action of the sanguiferous system and recall the blood to the surfa^6», thus relieving the overburthened internal organs. To accompksn' this object, we should make an assiduous use of frictions and warm and stimulating applications to the skin; stimulating ene- mata; warm and gently stimulating ptisms; large doses of calomel, (5-10-15 grains), and small doses of camphor where there is much irritability of stomach. If these measures succeed in bring- ing about a moderate febrile reaction, we may properly com- mence at once with the use of the milder stimulating remedies— such as infusions of serpentaria or calamus, wine whey or carbo- nate of ammonia in small doses. But as the disease advances and collapse approaches, we must resort to the more active ex- citements already noticed, with a vigor correspondent to the degree of prostration present. Local Treatment.—To diminish the tendency in the fauces to ulcerate, to arrest the progress of ulceration, to promote the sepa- ration of the sloughs, and dispose the ulcers to heal, are the ob- jects to be effected by our local applications. Of these a great variety has been recommended. Fumigation with nitrous gas is highly spoken of by Willan; others advise the application of a weak solution of nitrate of silver; and some, of the sulphate of copper, to the sores. They are doubtless all beneficial at times. Various gargles have also been employed, and of these, the infu- sion of Cayenne, mentioned above, is perhaps the best. Dr. Jackson, of Northumberland, Pa. states that he has recently made use of ice and iced water with surprising success. He permits the patient to drink the coldest ice-water, and, enclosing a piece of ice in a gauze bag, he puts it far back into the mouth that it may be dissolved and swallowed. I have seen much good done by a strong infusion of the root of baptisia tinctoria (indigo plant); and the black wash (calomel, gr. xx. lime-water, gviii.) I have also found a very valuable article in several cases of putrid sore throat. An excellent gargle to wash away the acrid matter from the in- flamed and ulcerated fauces, is barley-water, acidulated with sul- phuric or muriatic acid. The same good effect may often be SCARLATINA. 465 derived from a gentle emetic, provided neither collapse in the an- ginose variety, nor visceral inflammation be present. " Emetics," jijiys Armstrong," are the best gargles, where the throat is much 'bbstructed from an accumulation of tenacious mucus; their ope- ration effectually dislodges that morbid secretion for a time; often greatly relieves the respiration; improves the appearance of the ulcers; and they may be repeated where no abdominal inflam- mation exists, at any time, during the continuance of the fever, whenever the respiration and deglutition become much impeded by an accumulation of phlegm." Convalescence.—Convalescence from scarlatina is generally very tedious. During its continuance, light and nourishing diet should be directed, and the patient carefully guarded against cold and vicissitudes. Where much weakness and relaxation are com- plained of, it will be proper to prescribe the usual tonic and cordial remedies—such as weak infusion of serpentaria, colomba, gentian, or calamus aramaticus, with some of the mineral acids, particu- larly the sulphuric. These remedies are wholly inadmissible, where more or less irritation remains, which is sometimes the case during the early part of this period—as indicated by the quick and fre- quent pulse, pale and dry skin, anorexia, disturbed sleep, and inactive bowels. Here, we must resort to gentle aperients, dia- phoretics and warm-bathing; and direct a simple, unirritating diet. Small doses of calomel in union with ipecacuanna, three or four times daily; the muriate of ammonia; digitalis with nitrate of potass; spiritus mindereri with minute portions of emetic tar- tar; infusion of eupatorium or elder blossoms; acidulated diluents, &c. will generally answer well in cases of this kind. As the sus- ceptibility to the harmful influence of vicissitudes is always pe- culiarly great immediately after an attack of this disease, the patient should be extremely careful to avoid taking cold, remain- ing within doors during the whole period of convalescence, unless the weather be warm or mild. The frequent occurrence of dropsy after every modification of scarlatina has been, generally, ascribed to injudicious treatment in the febrile stage of the disease, or to errors in diet, or impru- dent exposure to cold during the period of desquamation and con- 3 0 40* 466 SCARLATINA. valescence. This may be true, in part; but, from the occasional supervention of this sequela, after the most judicious management in all these respects, it would seem that a tendency to hydropic effusion is created by the orignal disease itself, by reason, perhaps of .some irregularity in the development of its train of morbid actions,—in which case the dropsy or some other disorder may accrue as a complemental affection.* These dropical effusions are seldom attended with danger, and in general are easily removed. We may expect, in most examples of the sort, to find a manifestly phlogistic state of the system,—the pulse being quick, sharp, tense, frequent, and sometimes full; the skin dry, harsh, and above the natural temperature; urine small in quantity, high- colored and charged with coagulable serum; and the bowels usually torpid. Every thing indicates the propriety of an antiphlogistic treatment. Venesection is strenuously recommended by Richter and other eminent authors, some of whom are quite recent. In the epidemic scarlatina, described by Burserius, that prevailed at Florence in 1717, the affection readily yielded to the measures advised byr Sydenham. About the twentieth day of convalescence, many became affected with cough, a sense of weight in the chest, and oedema of the face and forepart of the neck. Fever soon ensued; the dropsy became general; the breast was sore; the abdomen distended and painful; the urine very small in quantity, and in some instances entirely suppressed. All who took diuret- ics died. Dissection soon revealed inflammation of the lungs, intestines and kidneys.! Bloodletting was now freely practised, and with uniform success. Gregory does not appear to be deci- ded as to the propriety of venesection. " I have met," says he, "with several cases which appeared to indicate bleeding and purging, but which resisted both, and ultimately yielded to bark and aromatic confection." Where there is an evidently phlogistic diathesis, my own experience is in favor of the measure, not in- deed as a principal curative means, but as an important prepa- ratory step to the use of diuretics, purgatives and diaphoretics. Digitalis, alone or in combination with small portions of calo- mel and nitrate of potass, is the best diuretic in cases of this * Reil, loc. cit. vol. r. p. 186. f Burserius, Institutiones Med. Pract. vol. ii. p. 81. SCARLATINA. 467 nature. In this, as well as every other variety of inflammatory dropsy, I have found the following a very useful prescription.* It possesses at once purgative and diuretic properties. Advantages may also be derived from small doses of tart, antimon. dissolved in a large quantity of some mucilaginous diluent. Calomel in large doses is recommended by Richter, who prescribes from five to ten grains daily to children. Throughout the treatment, quie- tude should be enjoined, and the patient restricted to the mildest farinaceous diet, with cooling acidulated drinks; and the occa- sional use of the tepid bath will often prove beneficial. But febrile irritation is not always associated with these hydro- pic effusions. They may be connected with a relaxed, torpid, and leucophlegmatic state of the system—constituting the hydrops frigidus of the German writers. (Reil.) "The principal remedy," according to Richter, " in cases of this kind, is calomel in doses sufficiently large to evacuate the bowels freely. Decided advan- tage may often be derived from the use of the cinchona bark, and the various medicinal preparations of iron—particularly the black sulphuret. As diuretics in this variety of dropsy, squill, spirits of turpentine,| and the tincture of cantharidies, have been highly recommended, (Hufeland, Buchholz.) The following mixture is said to have done much good in such cases.§ *R Crem. tart, g i. P. sulphat. potassae, 3"i- P. scillae, 3U. Tart, antimon. gr. iss. M. s. Give from four to six grains three or four times daily, to a child of five years old. Kreisig is equally favorable to the use of calomel in this and other morbid conse- quences of scarlatina. " Against the sequela of scarlatina," he remarks, " the powers of calomel are great and cannot be too highly praised." Abhandl. euber das Scharlach- fieber, Sic. p. 107. J R Spirit terebinth, gi., tinct. opii, gtt. 1. M. s. From ten to twenty drops to be given thrice daily to children from five to ten years old. } R P. cinchon. gss. Aq. fement. gxh. coque andremand. gvi. dein adde Rad. polygal. seneg. 3ii. Fol. digitalis, 9i. cola. dein. adde Spirit, nitri dulc. 3"- Syrup cort. aurant. gss. M. s. Take from a tea to a tablespoonful every two hours, according to the age of the patient. 468 SCARLATINA. Prophylactic Measures.—Bella-donna, regularly taken by persons exposed to the contagion of scarlatina, is supposed to protect the system effectually against the disease. Hahnemann, the author of the homaepathic doctrines, was the first who introduced to the profession the prophylactic powers of this narcotic, and since then many statements have been published in Germany and France in confirmation of the fact.* In conformity to his peculiar notion, it was prescribed by him in inflntesimal doses. He gives but forty drops, in seventy two hours, of a solution, of which one drop con- tains no more than the twenty millionth part of a grain of the ex- tract! We may well be sceptical as to the efficacy of these doses; but that small doses of the article do really possess prophylactic virtues, is strongly testified by many respectable authorities. Berndt states, that he gave it with unequivocal advantage in this respect. It was found by Dr. Koreff of Berlin, to protect persons completely against the disease, when taken for eight or ten days before they were exposed to its contagion. Three grains of the extract are to be dissolved in an ounce of cinnamon water, two or three drops of which may be given to children under one year old, and one drop more for every year above this age. It has been found that, seclusion of the sick, free ventilation, frequent changes of linen, and other similar precautions, will pre- vent the spread of the disease even in the same family. Unlike other contagions, the contagious miasm of scarlatina appears to be incapable of attaching itself to clothes: but an intensely infec- tious power is said to reside in the breath of patients laboring un- der the malignant form of the disease,—as also in the matter discharged from the fauces. • Ed. Med. and Surg. Journ. Jan. 1825. WHOOPING COUGH. 469 CHAPTER XXXVIII. PERTUSSIS—WHOOPING COUGH. According to certain writers, whooping cough was brought into Europe from Africa, in the thirteenth century. It would seem, however, that the ancients were by no means unacquainted with this remarkable disease. Hippocrates, in the 6th book on epidemics, and also in the 6th section of his aphorisms, speaks of a cough, which, from the short description he gives of it, may be regarded, I believe, as the same affection that is now known under the name of whooping cough. The first distinct and com- prehensive account we have of the disease, was furnished by Maezray, in the year 1414, in his chronological history of France. Since that period, numerous circumstantial records of its occur- rence in epidemics have been published; and its nature and treatment have been discoursed upon, in not a few elaborate monographs. Symptoms and progress of the disease.—The symptoms of com- mon catarrh usually precede the invasion of whooping cough. In the beginning, lassitude, head-ache and sneezing, with hoarse- ness and occasional oppression of breathing, are experienced in a greater or less degree. Dreams and sudden starts disturb the sleep; there is impairment of the appetite; the bowels become sluggish; and a slightly febrile excitement is evident towards evening. During the first two or three weeks, the cough is almost invariably dry and ringing; and the paroxysms short and unattended by that peculiar convulsive clangor, termed whooping. About the end of this period, the disease begins to manifest a more convulsive or spasmodic character, so far at least as the mere cough is concerned. The frequency and duration of the fits of coughing are increased, aud when the malady is at its height, their violence is sometimes terrific. A sense of tickling 470 WHOOPING COUGH. in the larynx and praecordia, and a feeling of tightness in the breast are the usual precursors of a paroxysm. During its con- tinuance, the inspirations are extremely difficult, slow and stridulous, attended with a sense of obstruction or spasmodic stricture of the glottis, rendering the cough distressingly suffoca- ting, and in a manner convulsive. The face becomes turgid and purple from suffusion; the eye-balls are protruded and swollen; and the whole system violently agitated. So severe, in some instances, is the fit of coughing, that it induces a state of partial insensibility, and a dreadful feeling of impending suffocation. Occasionally, sanguineous determination to the head is so great, that blood bursts from the nostrils and mouth; and it is nothing uncommon for children to be attacked writh convulsions, in con- sequence of cerebral compression, resulting from this cause. The discharge of a large quantity of viscid mucus, in this period of the disease, is the ordinary termination of a paroxysm; and the patient now frequently complains of some pain in the breast. In many cases, the cough continues until the accession of free vomiting, when it is immediately arrested, the patient greatly relieved, and a craving for fresh food experienced. The duration of the fits of coughing is very various: in some instances, being less than half a minute, in others, five or six minutes, and occa- sionally longer. This stage of the complaint commonly lasts from four to six weeks, about which time it begins to abate. The declension is always very gradual, and from two to four weeks longer elapse, before the complete termination of the affection. General Observations.—Fever is not essentially connected with whooping cough, although in many instances an accidental concomitant. Children chiefly are liable to this disease, but adults are not always exempt. Two cases of it have I seen in subjects beyond the fiftieth year of age, and several in individuals, but a few years younger than this. The contagiousness of whobping cough has been denied by Stoll and a few others, but the profession concur generally in regarding it as highly contagious; and the fact is certainly unquestionable, although the range of its con- WHOOPING COUGH. 471 tagion may not be extensive. It is almost always epidemic in its appearance. I have never yet witnessed a sporadic case of this affection, but such instances may undoubtedly occur. The susceptibility of the system to its infection is taken away by one attack, so that it rarely, if ever, affects the same individual twice. As in the case of all other epidemical diseases, various grades of violence mark the different epidemics of this malady. Some- times, it is so gentle, that numbers of those who are still sus- ceptible to its influence, entirely escape, and its treatment can be conducted without difficulty; at others, it assumes a violent and dangerous character, is exceedingly intractable, and lays hold of almost every individual, whether old or young, who has not yet had the disease. It would seem as if some sort of a latent connexion subsisted between this malady and measles; for whoop- ing cough frequently prevails most extensively, either immedi- ately before the occurrence of epidemic measles, or in alternation with them, or directly after their disappearance.* Spring and autumn are most favorable to the prevalence of pertussis; and its invasions during the wet and changeable periods of these seasons, are attended with far more danger, by reason of the pneumonic predispositions and affections occasioned by atmo- spheric vicissitudes. Prognosis.—When whooping cough assumes a periodic form, which, however, is an exceedingly rare occurrence, it will most likely be very intractable. A singular case of this kind is related by Dr. Percival, in which the paroxysm came on daily, at a cer- tain hour, attended with tremor of the whole body, and termina- ting by a shriek rather than a whoop. The complaint was ob- stinate for several months, and returned at the same season for two years. It yielded to no medicine, and was supposed to depend on some morbid condition of the liver. (Good.) A fatal termination of the disease is not to be apprehended, unless by the supervention of bronchitis, pneumonia, cynanche trachealis, hydrocephalus, apoplexy, or marasmus. These secon- dary affections are by no means uncommon, particularly in Richter's Soecielle Therapie. 472 WHOOPING COUGH. variable and humid seasons; the disease, therefore, upon the whole, should be regarded as one of considerable danger. In northern or cold climates, far more violence marks the affec- tion, than in the milder and more equable regions of the middle and southern latitudes. Rosenstein states, that in Sweden there were 43,393 deaths from this disease, between the years 1749 and 1764—and of these, 5,832 deaths occurred in the year 1755 alone. (Richter.) In general, the danger is inversely as the age of the subject. In other words, the younger the patient, the more hazard of a fatal termination. It is observed by Cullen, that by far the greater number of those who die of this disease, are children under three years of age. Much is to be apprehended, when it attacks weak and delicate infants, within the first few months after birth; but even at this early age, robust and healthy infants generally pass through the disease without much difficulty or danger. The supervention of pneumonitis, during its continu- ance, is more common in adults than in children. Its occurrence during pregnancy is to be feared, as not unfre- quently it has occasioned abortion. Frequent haemorrhage is an unfavorable symptom, protracting in almost every case the dis- ease, and where it proceeds from the lungs, often occasioning the development of phthisis. Whooping cough is exceedingly apt to excite the local mani- festations of scrophula in children of a strumous diathesis. Thus, its attacks are often succeeded by scrophulous ophthalmia and glandular tumors in the neck. I know of no complaint whose occurrence is more to be dreaded, in subjects of an hereditary consumptive habit than whooping cough. It rarely fails to develop phthisis pulmonalis, in persons predisposed to the formation of tubercles, or in whom these exist in an incipient and dormant state. Chronic bronchitis is not an unfrequent termination of the dis- ease. This is particularly apt to occur, when the patient takes cold from exposure to a damp and variable atmosphere—a cir- cumstance that always greatly aggravates the violence and danger of the affection. I have seen but few deaths from whooping cough, that were not attended with bronchitis, puru- lent expectoration and hectic symptoms, occasioned by having WHOOPING COUGH. 473 taken cold. In these cases, the matter expectorated, usually resembles, more than any thing else I know, a mixture of cream and mucus. The cough, in some instances, after nearly disappearing, is renewed and protracted for several months by an accidental cold. Cases of this sort often continue for six or seven months. When the disease, either from cold or some other casual circumstance, thus assumes a chronic form, fatal hydrocephalus sometimes ter- minates its career—especially in patients, habitually subject to disordered bowels, or laboring under the irritation of difficult dentition. Cynanche trachealis will often supervene during whooping cough. Children of robust and full habits, in the early stages of the affection, are more particularly liable to this accident. It is almost always the consequence of cold, and attended with the most imminent danger. According to Richter, a profuse watery diarrhoea, supervening suddenly in this disease, in connexion with pneumonic irri- tation, is always to be regarded as one of the most dangerous occurrences. Death, he says, often follows such a discharge very speedily. The appearance of apthae in the mouth and fau- ces, in the latter period of the disease, is inauspicious. (Edem- atous swellings of the feet and face, supervening in the com- mencement of the complaint, portend much danger, more espe- cially when accompanied by a turbid, milky urine; but their occurrence towards its conclusion, which is by no means rare, needs seldom excite any apprehensions. (Richter.) A sudden ces- sation of the cough, it has been remarked, is an unfavorable event, and is frequently followed by pulmonary inflammation. In general, the more fever there is in this affection, the more violent and dangerous may it be considered. Free vomiting, soluble bowels, plenteous expectoration, warm extremities and an open skin are regarded as favorable symp- toms. According to Hufeland, the occurrence of some degree of strangury in the advanced stage of the complaint, is in general soon succeeded by a manifest mitigation of the symptoms. It is said by certain writers, (Hufeland, I. c. p. 420: Lentin, Memorabilia, p. 36: Jahn Kinderkankn. p. 399,) that children 3P 41 474 WHOOPING COUGH. laboring under some chronic cutaneous affection, as tinea, itch, &c, very rarely take this disease; and if they do become affected with it, they almost invariably pass through it in the lightest manner. This is contradicted by others, particularly by Hoffman and Haase. The following are the principal affections that are properly 2alled sequela of this complaint: strumous swellings, dropsy, epilepsy, opthalmia, rickets, general cachexy, aneurism, deafness, dementia, paralysis, and phthisis pulmonalis, ruptures and in- curvations of the spine. A majority of these diseases I have known to ensue as consequences of whooping cough; and amongst them, epilepsy, struma, phthisis pulmonalis and ophthalmia appear of most frequent occurrence. When perfectly free from any adventitious complications, pertussis cannot be considered a disease of much danger, except in very young and feeble subjects. Still, in connexion with the grave sequela above mentioned, and many other consequences by no means uncommon, it assumes a very serious aspect, and is attended with no little hazard. Cause.—The exclusive cause of whooping cough, so far as our knowledge extends, is a peculiar contagion, generated by the disease itself. That this, as well as every other contagious dis- temper must at one time or another have had a cause, inde- pendent of contagion, cannot, it is evident, be denied. But the nature of this cause, together with the period of its origin and the circumstances requisite to its generation, is involved in utter darkness. Nothing, in truth, is more incomprehensible, than the origin of maladies, now engendered and propagated by specific agents alone, which are elaborated by the living body, actually laboring under their influence. The only notion we can offer, (and it is indeed vague as the ancient dogma of fortuitous atoms,) is that, in the infinite combinations of which the material ele- ments of the universe are capable, agents may have been evolved by a peculiar concurrence of circumstances, which had the power of creating these affections in the human system. This is the only plausible explanation that can be given, of the occasional rise of new diseases, which, when once originated, propagate themselves by elaborating their own specific causes;— WHOOPING COUGH. 475 unless, indeed, we choose to refer them directly to the will of the Creator, as their immediate cause. But whatever may be our speculations in relation to this subject, whooping cough now is in all cases the product of a specific contagion. It is observed by Richter, that beside this principal cause, cold in conjunction with humidity may give birth to the affection. The grounds for this opinion are rather insufficient; and it seems to me just as im- probable, as that small pox or measles should arise from acci- dental circumstances. Linnaeus, who at one time advocated the animalcular origin of almost all diseases, maintained that whooping cough was pro- duced by inhaling, with the air of respiration, the minute eggs of a peculiar species of insect. .Riverius, Dessault, Rosenstein and more recently Clesius concur in this opinion; but it seems to have met with but little countenance from the profession generally. Whooping cough does not appear to possess a contagious character, until it has made considerable progress (Richter;) or until the second or convulsive stage has supervened. Its con- tagion, although very active, extends to no great distance beyond the body of the affected person. Accordingly separation of the healthy, from the infected portion of the community, will almost always prevent its influence. Autopsic phenomena.—Various, and often contradictory, are the appearances discovered on post-mortem examination. This might naturally be expected, when it is considered, how diverse are the affections adventitious to this complaint, and at what differ- ent periods of the disease death takes place. We cannot, for example, anticipate the same post-mortem appearances in a case terminating fatally in consequence of pneumonia, as in one, where death results from apoplexy; nor is it reasonable to pre- sume there should be much uniformity, where the immediate cause of death is so various, or dependent on so great a diversity of accidental disorders. The respiratory organs being the parts most obviously impli- cated in whooping cough, pathologists have of course sought an explanation of the nature of the disease, especially in the 476 WHOOPING COUGH. autopsic phenomena they exhibit. Traces of inflammation in the mucous membrane of the bronchia and larynx, have been frequently discovered and particularly described. Strong, Cullen, Astrue, Lettson and Dany, mention these appearances as being by far the most common; and more recently striking examples of the same sort have been adduced by Whatt and Marcus. The former lost three of his own children by this disease, and in each, the marks of previous inflammation in the mucous membrane of the bronchia were very conspicuous throughout its whole extent. Marcus gives but two dissections in which bronchial inflammation was revealed. In one of these, a considerable quantity of pus was discovered in the air passages, the smaller branches of which were in a state of most intense inflammation, approaching in some parts to gangrene. In some instances, no traces whatsoever of bronchitis have been discoverable; but the lungs have been found exceedingly congested, and the air-cells choked up with an extremely viscid mucus. Loboustein Loebel relates a case, in which a consider- able portion of the diaphragm was covered with a number of small pustules containing a purulent fluid.* Various other appearances have at different times been observed, such as adhesions between the pleura pulmonalis and costalis, tubercles in diverse stages of development, enlargement and scrophulus degeneration of the bronchial glands, &c. Sometimes the respiratory organs may be entirely unaffected in their structure, exhibiting not the minutest traces of any disease whatever; whilst the brain presents various striking marks of the previous existence of severe cerebral derangement. In a case related by Dr. Webster of London, the following appearances were observed on post-mortem examination; both hemispheres were extremely vascular, and the convolutions were so pressed together as almost to disappear. A good deal of serous effusion was visible under the piamater, particularly at the anterior and upper part of the brain, where a few spots of coagulable lymph were seen; and the membrane itself was injected with blood. The hemispheres slightly cohered ante- * Richter's Specielle Therapie. WHOOPING COUGH. 477 riorly; the ventricles contained about two ounces of serum, and in the sheath of the medulla oblongata, nearly half an ounce of fluid was discovered. After all, it is incontestible, that in many cases of death from whooping cough, no morbid appearances whatever have been detected on dissection; and there are many reasons for believing that the inflammation and other phenomena, so frequently observable on post-mortem examination, have no essential connexion with the disease, but are altogether adventitious or secondary. Proximate cause.—Concerning the nature or proximate cause of this disease, there has been much diversity of sentiment. By Hoffman it was thought to depend upon an acrid serum in the lungs. Sydenham ascribed it to the influence of irritating effluvia, cast off from the blood into the lungs, in consequence of the insensible transpiration through the skin, being checked by cold and damp air. It was referred by Huxham to some morbid condition of the intestinal canal; to derangement of the liver by Butler, whilst others have considered it the result of gastric irritation, or with Stoll, of crude and bilious matters in the stomach. The opinion, seemingly most prevalent at the present day, is that the disease essentially consists in bronchial inflammation. This inflammation is assumed to be specific in its nature, and capable of giving rise to the peculiar convulsive cough of pertussis; for it is well known that the train of symptoms characteristic of this disease are not induced by bronchitis. The doctrine would seem to receive support from the presence of febrile excitement in most instances of the affection, and from the appearances revealed by autopsic examinations of the mucous membrane of the bronchia and trachea. On a super- ficial view of the subject, the notion does certainly appears plaus- ible; but objections insurmountable in my opinion, may be urged against its validity. In the first place, although fever is a frequent attendant on pertussis, many cases occur, in which not the slight- est febrile movements are perceptible in its early stages; and not a few happen, where, during the whole course of the disease, 41* 478 WHOOPING COUGH. febrile excitement is entirely absent. Again, that traces of inflammation are sometimes manifested on postmortem exam- ination, is not denied; but these appearances are by no means visible in all cases, which ought to be the fact, if the doctrine in question were true. Besides, it is no difficult matter to explain the frequent occurrence of inflammation, without having recourse to this hypothesis. Is it not natural to look for the supervention of bronchitis or other inflammatory affection of the respiratory organs, in a disease that so violently and frequently agitates the thoracic viscera, as does whooping cough? There can be no doubt too, that in many instances, where this cause fails in developing pulmonary inflammation, it may strongly predispose the lungs to the injurious influence of atmospheric vicissitudes, whereby pulmonary catarrh or bronchial irritation are at last super- induced. We therefore have good grounds for concluding, that the signs of phlogosis so frequently detected, on dissection, in the mucous membrane of the respiratory passages, are always adventitious, and by no means essential to the disease. It may be further observed, that bronchial inflammation is probably far from being so common, as autopsic appearances would lead one to think. Death, it must be recollected, takes place princi- pally where unequivocal symptoms of inflammation are present; we may reasonably expect therefore, to find in these cases phlogistic appearances, although in milder instances no such inflammatory condition may exist. To conclude this part of the argument,—if bronchial inflammation be the proximate cause of the disease, it must, of necessity, be present in all cases; no less in the mild than the violent; a circumstance that is decidedly contradicted by almost universal observation. The only dissec- tion I ever witnessed of a victim to this malady, presented no evidence of the existence of previous inflammation in the bronchia. The patient died suddenly of convulsions during a violent paroxysm of coughing. That bronchitis is not the proximate cause of whooping cough, or essential thereto, is further evident from the fact, that the two diseases totally differ in their symptoms. Bronchial inflammation is rarely, if ever, attended with a violent cough, much less the peculiar cough, distinguishing pertussis. Moreover, rapidity of WHOOPING COUGH. 479 course, strong fever, and a continued sense of tightness and oppression in the breast, characterize bronchitis in its acute form. In the chronic form, the expectoration is invariably purulent, and entirely distinct in its character from the ropy and transparent mucus discharged in whooping cough. Almost invariably, too, the usual symptoms of hectic fever are present. Cough, dependent on acute inflammation of the respiratory passages, almost always begins to decline so soon as the secretion of the bronchial mucus becomes copious. In whooping cough, the reverse generally obtains. During the first few weeks of its course, there is seldom much mucus secreted in the bronchia, but so soon as the secretion becomes more abundant, which happens after the second or third week, the cough also acquires more violence, and assumes that convulsive character, which distinguishes it from other varieties of cough. Very commonly, moreover, the slight symptoms of fever that accompany the development and first few weeks of the disease, vanish entirely in the second stage when the cough becomes more spasmodic and violent in its paroxysms. (Richter.) This circumstance most assuredly does not favor the idea, that the disease is of an inflammatory character; for if this were the case, we should expect the cough "to decline with the fever, instead of which, it is always found to acquire much more violence. It appears to me that whooping cough is essentially a spas- modic or nervous affection, the proximate cause of which consists probably in a peculiar irritation of the eighth pair of nerves—or pneumo-gastric. Close attention to the phenomena, that immediately precede and accompany a paroxysm of the disease, has sufficiently con- vinced me of its nervous character. The sense of stricture in the breast and of the glottis, felt just before the fit of coughing—the suddenness and convulsive nature of the cough—the peculiar constrictive feeling in the praecordia—the stridulous respiration— all clearly indicate a spasmodic condition of the respiratory organs. That the irritation which calls forth the convulsive action of the diaphragm and the other parts immediately con- cerned in the act of coughing, is seated in the eighth pair of nerves, may, I believe, be inferred from the known agency these 480 WHOOPING COUGH. have, in the production of the various phenomena manifested by the pulmonary apparatus. Experiment, too, furnishes quite satisfactory evidence on this point. Professor Naase, in a series of experiments, instituted for the purpose of elucidating the pathology of cough, found that, on bruising or strongly pinching the par vagum so as to break down its structure, a violent con- vulsive cough was invariably excited. The same kind of injury inflicted on the diaphragmatic nerve, occasioned no such effect. This experiment proved, that the act of coughing is performed almost wholly by the sudden spasmodic contractions of the diaphragm. By opening the abdomen of various animals, and exposing the lower surface of this muscle, he saw distinctly its violent convulsive motions during the cough, which was excited by bruising with a pair of forceps the pneumo-gastric nerves. The peculiar tone of the cough and sense of constriction of the glottis, may arise from the extension of the irritation to the recurrent branches of the par vagus nerve. That this irritation is peculiar or specific in its character, may be inferred from the nature of its exciting eause. Treatment.—It is generally believed that medicine can only alleviate the symptoms of whooping cough, without materially controlling its progress or shortening its regular course. This, I believe, to be an unfounded notion, the belief of which has largely contributed to render the treatment of the disease uncer- tain and inefficient. Sydenham, Werhoff, Hufeland, and several of the more recent German, Italian and French writers admit that its course may be arrested; but this, it is asserted, can never be done before the fourth week after its commencement. However this may be, my own experience has fully convinced me, of the possibility of abbreviating its progress; and, to sustain this opinion, not a few well-authenticated instances might be adduced from late publications. The propriety of venesection in whooping cough has been frequently questioned. Where inflammation or general fever is present, all concur in advising its adoption; but in every other case it is by some deemed inadmissible, as the severity of spas- modic affection is frequently aggravated by the use of the lancet. WHOOPING COUGH. 481 Now an unusual or preternatural momentum of the circulation may in many instances exist, without giving rise to strictly febrile symptoms; but it should not therefore be regarded as a harmless circumstance, even in diseases purely spasmodic. Let the essen- tial nature of a complaint be what it may, if activity and fulness characterize the pulse, blood-letting cannot be improper, and its employment may be productive of much benefit. The abstrac- tion of blood in the present disease, may be marked by no direct influence on its peculiar symptoms; but it will greatly tend to diminish the liability to the supervention of inflammation, and the danger attendant upon the violent cephalic congestion, in- duced during the paroxysm of coughing. Where bronchial or pneumonic inflammation is present, the lancet is of course indis- pensable. Bleeding in such cases should be prompt and decisive, both in a general and local way. Leeching here is particularly valuable. Tampering with the ordinary remedies now, would be to risk the life of the patient. It is the accidental inflamma- tion, not the original disease, that must claim our attention; for great must be the danger and obstinacy of pulmonitis in an affection, which so frequently and violently agitates and irritates the respiratory organs. The bowels in this, as in every other disorder, should be care- fully attended to. The extensive and intimate sympathetic relations of the intestinal canal with the various organs of the body, cause it to participate more or less in whatever derange- ments may affect the human system. No matter what may be the nature of the malady or of its location, sooner or later the alimentary canal suffers functional derangement, giving rise either to a remora of its recrementitious contents, or of its vitiated secretions. These evils in their turn become sources of intestinal irritation, and it is needless to point out the strong tendency of such irritation to aggravate and continue diseases, whatever may be their primitive origin and character. There is almost invariably a morbid condition of the primae viae in whooping cough; the stools being sometimes bilious, at others, almost entirely mucous, and in many instances, dark and exceed- ingly offensive. These conditions should be rectified by appro- priate purgatives, and a soluble state of the bowels preserved 482 WHOOPING COUGH. throughout the whole course of the complaint. Very active purgation, as it aggravates intestinal irritation, especially when frequently repeated, must by all means be avoided. A grain or two of calomel in the evening, followed by a small quantity of rhubarb, or other unirritating laxative in the morning, will gene- rally answer our purpose. Small doses of sulphate of soda or magnesia are preferable, where much febrile excitement is present. The utility of emetics in the treatment of pulmonary diseases, is fully acknowledged,—especially in affection of the respiratory organs marked by an abundant secretion of bronchial mucus. Much of the suffocative distress occasioned by whooping cough, arises from the lodgment of a large quantity of viscid mucus in the trachea and bronchia; and the removal of this obstacle to respiration is the principal object to be gained by the exhibition of emetics. A part of their beneficial influence may perhaps be attributed to the impression they make on the pneumo-gas- tric nerves in the stomach. They moreover induce a determina- tion to the cutaneous surface, thus exerting a beneficial, derivative influence on the lungs; and also manifest a tendency to disturb the recurrence of the paroxysms. In the whooping cough of infants, they are especially called for; their strength is insuffi- cient to expel the viscid mucus, which sometimes accumulates to such a degree as completely to clog the respiratory passages, when death takes place from suffocation. If, therefore, the cough in very young children is violent, and attended with symptoms of im- pending suffocation, an emetic should be quickly administered, or the fauces irritated with a feather, so as to bring on speedy vom- iting. Sulphate of zinc, by the promptness of its operation, is especially suited to these cases; but I have in general preferred ipecacuanna to any other article of the kind. Dr. Fothergil speaks very highly of the following combination as an emetic in this affection: R. Pulv. chel. cancror. 3SS- Tart antimon. gr. ii. Misce. According to the age of the patient, 1, li or 2 grains of this may be given for a dose. The union of an absorbent with the WHOOPING COUGH. 483 emetic has been thought peculiarly beneficial in this complaint. Syrup of squills is another excellent emetic. I have often prescribed it advantageously, united with a small portion of antimonial wine. The antimonial wine, combined with an emulsion of assafoetida, may be used with considerable benefit as a palliative. Let it, however, never be forgotten, for the sake of the future health of our patient, that weakness and irritation of the stomach are frequent consequences of too long a persistance in the use of emetics, particularly those of the antimonial kind. Some of our most valuable remedies for the treatment of whooping cough are found among narcotics. The belladonna, particularly, has been highly celebrated, and is without doubt by far, the best article of the kind we possess. Professor Borda was the first, 1 believe, who used it as a remedy in this affection, and his belief in its efficacy is almost unlimited. According to his declaration, in numerous instances every symptom of whooping cough was removed in ten or twelve days by its exhibition; and where it failed to eradicate entirely the complaint, it almost always mitigated in a marked degree its severity. Cases came under his notice, that appeared to be beyond the power of med- icine, and yet were relieved by this remedy. Hufeland and Alibert are almost equally decided in their praise of the virtues of this article; and the testimony of many other writers, together with a large mass of evidence adducible from the current medical publications, might be added to establish still more firmly the fact of the efficacy of belladonna in this singular malady. My own experience leads me to testify confidently on this point. I have prescribed it within the last six years, in perhaps twenty cases, and in the majority of them with evident advantage* Since the publication of my work on the materia medica, my good opinion of its powers has been increased. In two cases, both of an exceedingly violent character, it arrested the disease almost entirely in the course of eight days. The principal cir- cumstances that render its exhibition useless or improper, are fever and bronchial inflammation. In these instances, our chief dependance must of course be placed in bleeding general and local, and blisters or frictions with tartar emetic ointment on the 464 WHOOPING COUGH. chest. But in the purely spasmodic form of pertussis, when inflammatory action is absent, it is often singularly efficacious. Dr. Butler speaks highly of the virtues of conium in this com- plaint, and it once possessed perhaps more celebrity than any other narcotic. It is said to delay the recurrence of the par- oxysms and mitigate their violence, and was prescribed by Dr. Butler in every period of the disease, whether complicated or not with other affections. This gentleman states, that he has frequently used the following mixture with marked benefit: R Extract, coni. gr. iii. Magnes. Sulphat. 9 i. Aq. carui. . . 3V- Syrup rhad. . gi. M. take 30 drops 3 times daily. This article has, however, so frequently failed in general practice, that its virtues are not at present very highly estimated by the profession. , Lactuca virosa, hyoscyamus and opium have also been employ- ed as palliatives in whooping cough. Opium has the recommen- dation of many eminent practitioners, but the general sentiment of the profession is opposed to its employment in this affection. It is objectionable both on account of its constipating effect and its tendency to determine the blood to the brain. Ledum palustre, or marsh cistus, according to Linnaeus, is extensively and successfully employed in Westrogotha, as a sedative in whooping cough. This praise of its virtues is sup- ported by Wahlin and other European writers, but I am unable to say any thing concerning it from my own experience. Antispasmodics are often used in this affection, and at times with temporary advantage. Musk has been frequently adminis- tered in every mode and in all proportions, but so uncertain and even contradictory are its effects, that little confidence is now reposed in its efficacy. Assafcetida will occasionally prove quite a valuable palliative, in cases unattended by fever or strong pulmonary irritation. It answers the two-fold purpose of an expectorant and antispasmodic. In a few instances, I have witnessed excellent effects from a mixture of the vinegar of squills and an emulsion of assafcetida. The violence of the symptoms may sometimes be assuaged WHOOPING COUGH. 485 by the use of expectorants. The appended mixture, strongly recommended by Dr. Pearson, I have known to give considera- ble tempoiary relief. Tonics have, in many instances, been found useful. Dr. Cullen strongly recommended the Peruvian bark as a very efficient remedy: " I consider," he says, " the use of this medicine as the most certain means of curing the disease in its second stage; and when there has been little fever present, and a sufficient quan- tity of the bark has been given, it has seldom failed of soon putting an end to the disease. The same remedy is in high repute almost universally among the German physicians, and there can be no doubt that it is frequently very efficacious; but it should not be forgotten, that its good effects are confined chiefly to the latter stages of the disease. In some instances the cough assumes a chronic character, continuing long after the usual period of its termination. These cases are frequently com- plicated with chronic bronchitis, and must be relieved by the most efficient measures; otherwise the constitution will be undermined, the system worn down, and the patient will die in a state of marasmus or under symptoms of phthisis pulmonalis. Strong doses of cinchona or quinine here, are often peculiarly serviceable. This tonic may also be very beneficial in cases of a purely spasmodic character, when the disease becomes protracted, and is kept up by habit. Various other remedies have been employed in this affection, such as lobelia inflata, tincture of cantharides, rhus vernix, lead, arsenic, &c. Of the lobelia I can speak from experience, and to its excellent powers in whooping cough I can testify most fully. I have prescribed it within the last five or six years in a very consid- erable number of cases, generally with some advantage, and in several instances, with the most decided success. It not only * R Aq. fontanae . . . gi. Syrup.....3iii* Sub-carbonat. Soda gr. xxv. Vin. ipecac. . . • 3'- Tinct opii. . gr. vi. M. The sixth part every four or five hours is the proper dose for a child between one .and two years old. 42 486 WHOOPING COUGH. mitigates the violence of the cough, but abbreviates, I believe in many cases, the course of the disease. I have generally administered the saturated tincture in union with the syrup of squills in doses of ten drops of each, four or five times daily to a child two years old. I have given indeed as much as twenty drops of the tincture of lobelia, to several children about this age, and have always found it strongly palliative, when it excited sickness or slight vomiting. Tincture of cantharides is well spoken of by certain writers,* when given to the extent of producing stranguary. Dr. Sutclitl asserts that it will sometimes, in a great measure remove the dis- ease in four or five days. The same practice has the authority of Hufeland and Lettson in its favor. Sutcliff combined it with bark and the camphorated tincture of opium as in the subjoined formula.t The rkus vernix stands upon the authority of many eminent foreign practitioners, and is stated to be a very useful remedy in whooping cough. Dr. Fresnoi asserts, that he has employed the extract of the leaves with decided success. He gave half a grain in half an ounce of syrup, to a child every three hours. According to his statement, the cough generally abated and in most instances, ceased altogether by the time eight or ten doses had been taken. Forty-two children, he adds, were cured at Vallenciennes in 1786, by this practice. Lead was perhaps first introduced to notice as a remedy in whooping cough, by Dr. Forbes of Edinburgh, who used the liquor subacetatis, or Goulard's extract, and who speaks highly of its success. (Good.) It has obtained little credit in this respect with the profession. Of the mineral tonics, arsenic has been most commended for its powers in this affection. Dr. Ferriar placed much dependence on this remedy in cases unattended with fever. His own experi- ence induces him to state, that "arsenic is the only remedy * Armstrong, Chambers, Millar, Bucholtz, Lode, and others, speak much in favor of this remedy in whooping cough. t R Tinct. peruvian spirit gi. Tinct opii. camph. . gii. Tinct. cantharid. . Qii. Two drachms of this mixture to be taken thrice daily. WHOOPING COUGH. 487 which promises to shorten the disorder effectually." " I have," says he, " employed this article in several cases of infirmary pa tients with tolerable success; and I have occasionally given it in private practice with so much advantage, that I think it deser- ving of further trial." I formerly employed this remedy frequently; and in some instances its good effects were obvious. The proper dose for a child, between one and two years old, is two drops of Fowler's solution, twice or thrice daily. I have commonly given it in union with small doses of the extract of belladonna or coni- um. It should be remembered that, in all cases attended with febrile excitement or bronchial inflammation, its use is wholly inadmissible. Calomel, in minute quantities, would seem to possess some effi- cacy in whooping cough. Dr. Gregory states, that he has derived great advantage from small doses of this article, (a grain twice a day) with a few grains of scammony, in the latter stages of the affection, attended with symptoms of marasmus. When the disease, at an advanced period, becomes complicated with chronic bronchitis, balsam copaiva may be employed with good effect. I have prescribed it, in a few examples of this kind, with the most evident advantage; and I am fully persuaded, that no other remedy promises so much as this one, in such cases. The application of local revellents to the chest or along the course of the spine, has been in vogue a long time, and is justly regarded as an excellent remediate means in the treatment of whooping cough. It is particularly valuable in cases complicated with bronchial inflammation or hazardous sanguineous congestion in the head. Dr. Gregory advises the following embrocation to be used on the chest and along the whole chain of the spine.* Frictions with tartar emetic over the praecordial region, will, in many instances, be greatly serviceable. This practice originated with Autenrierth, and has been extensively adopted by the Ger- man physicians. Dr. Meyer, of Minden, speaks highly of sprink- * R Antim. tart.....9ii. Tinct cantharid. . gi. Aq. rosar......gii. M. The tartar emetic is to be dissolved in the rose water, and the tincture of cantharides then added to it. 488 WHOOPING COUGH. ling a small portion of morphia on the raw surface of a blister raised over the praecordia. He directs a small blister to be ap- plied to this region, and the cuticle being detached, half a grain of morphia, rubbed up with starch, to be sprinkled on the exposed surface. The morphia is to be repeated every evening; and, if necessary, the blister may be applied every third day. Five cases, according to his statement, were so far relieved by this treatment in the course of eight days, as to require no further attention. When pneumonic affections complicate the disease, blisters and rubefacients, in conjunction with venesection and especially leeching on the breast, are indispensable. Inhalations of various kinds have been used with considerable success in this disease. The fumes of tar are said to be produc- tive of excellent effects, in cases unattended by inflammatory symp- toms, and where a great accumulation of mucus in the bronchia exists, giving rise to extreme difficulty of breathing. Immediate and copious expectoration and relieved respiration are sometimes the direct effects. The nitrous acid vapour has also been parti- cularly recommended, and I have myself employed it in a few cases with some benefit. Change of air and exercise by gestation have generally an ex- cellent influence in tedious and obstinate cases, attended with much exhaustion. In instances of this kind, a change of air, says Dr. Gregory, " is often the only thing that gives the patient a chance of life." I have seen one very remarkable recovery effect- ed by removal to the country and the free use of milk diet. This measure is inadmissible in cases attended with bronchial inflam- mation, as it rarely fails to aggravate the symptoms immediately. Cold bathing, according to the experience of some, is a very certain and prompt remedial agent; especially where, from never having been used before, it introduces a new action into the sys- tem. A limestone soil would seem to exert a very beneficial influence in the cure of whooping cough. Dr. Ferriar says, that he has had "an opportunity of verifying this fact in some very striking instances." The diet should be light and digestible; and it is particularly important to guard the patient against the influence of a cold, variable and damp atmosphere. CONVULSIONS. 489 CHAPTER XXXIX. CONVULSIVE AFFECTIONS OF INFANTS. At no period of life are convulsions so apt to occur as during the age of infancy. With a nervous system peculiarly ex- citable, infants are subject to so many sources of permanent and transient irritation, that a very large portion of them suffer more or less from convulsive affections; and these constitute an alarming proportion in the catalogue of fatal infantile maladies. According to the statement by the late Dr. Clark of Dublin, it appears that of 17,650 children born in the Dublin lying-in hospital, one sixth part died during the first year; and of those who died, nineteen out of twenty perished by convulsions. This proportion of mortality from convulsions, however, very greatly exceeds that which a similar estimate drawn from private practice would yield. Still the frequency and fatality of this affection, under its various forms, is by no means inconsiderable in every rank of society, and under every variety of climate, and external circumstances. Both the anatomical and physiological peculiarities of the infantile system, are indeed such as to account for the especial aptitude to convulsive maladies during this tender period of life. The mind and body of an infant, not yet inured to the impressions of internal and external causes, possess the most lively susceptibility to the various perturbating and exciting influences to which it is unceasingly subjected. All children, however, are not equally disposed to convulsions. Mr. North observes that " the children of parents who marry at too early or too advanced an age, are more susceptible of convulsions than the progeny of those persons who marry in the prime of life." I have met with several, very striking instances of aptitude to convulsions in families which accord entirely with r 3 R 42* 490 CONVULSIONS. this observation. That the predisposition to convulsive affec- tions is sometimes hereditary, appears to be highly probable. Boerhaave and Lorry, mention instances which strikingly illus- trate this fact. We often meet with families, in which the occurrence of convulsions, is almost a matter of course in all the children as they successfully pass through the process of primary dentition; and on the other hand, in very many families, blessed with a numerous offspring such affections never occur, although the ordinary exciting causes, may be conspicuously present. It would appear also, that convulsions are much more common in cities, and particularly in the higher and more luxurious classes of society, than among those who "are regular in their mode of living and who enjoy the calm tranquillity of a country life." The fresh and pure air of the country, has an especial tendency to invigorate the infantile system, and to diminish nervous irrita- bility, and thus to render the ordinary causes of convulsions less apt to excite such affections. It is, probably, mainly, from the want of pure and wholesome air in hospitals, that convulsive diseases are so much more common in these institutions than elsewhere. The children of mothers, endowed with a very sus- , ceptible, physical and moral constitution—with a quick and lively imagination, great sensitiveness, and mobility of temper, are in general peculiarly apt to suffer convulsive affections, during the period of dentition. Mauricean, Leuret, and others, assert, that children who have very large heads are more liable to convulsions, than those who are less liberally furnished in this way. This observation, however, appears to be wholly with- out any foundation, with regard to children who are healthy. " In ricketty children the size of the head is disproportionally large; and from the general symptoms of rachitis, it is evident that the head and spinal marrow are considerably affected; the brain increases rapidly in size, the senses are usually very acute, and convulsions are very frequent attendants of this dis- tressing malady. It not unfrequently happens, when some children of the same parents are affected with rachitis, that others who are exempted from the disease are at a very early age destroyed by convulsions.* (North.) * Diet, des Sciences Medicales, tome xlvi. p. 602. CONVULSIONS. 491 Whatever may be the source and nature of that condition of the organization which predisposes to convulsive affections, the following circumstances may be regarded as characteristic of " that state of increased irritability, from which their occurrence is to be anticipated. The child is more restless than usual and is apt to start at the most trifling noise. During sleep, he often starts up and cries out suddenly; or he remains restless and almost entirely without sleep throughout the greater part of the night. His natural temper undergoes a change. He becomes peevish, fretful, and discontented; "quarrels with his compan- ions, and derives either no pleasure at all, or but a momentary amusement from his most favorite playthings, which he will suddenly thrust away, after they have for a moment occupied his attention." The pupils are very variable—being often ex- tremely contracted for a moment, and then suddenly dilated to an unusual degree. " I have frequently," says Mr. North, " held a candle close to the eyes of a child when I have anticipated convulsions, in order to remark the effect produced. In some instances, where the pupils had been much contracted at the moment the light was applied, it has suddenly dilated, and as suddenly again contracted, although the light was steadily held close to the eye. The effect of light upon both pupils is not always similar. One may remain fully dilated, while the other contracts. I am inclined to believe from frequent observation, that when a light is applied close to the eyes, and the same effect is not produced upon both pupils, that we have much reason to fear some serious affection of the head." Children who are strongly disposed to convulsions, are apt when asleep, to lie " with their limbs almost rigidly extended, the great toes and thumbs being turned inwards." (Good.) The color and expression of the countenance, varies frequently. At one mo- ment it is pale languid or anxious, and at another flushed and animated. Respiration is irregular, and frequently interrupted by long and deep inspirations, succeeded by " a short and catchy breathing." This disordered respiration, in connection with the preceding train of phenomena has been considered as peculiarly indicative of approaching convulsions. "If we observe the fingers of a child, highly disposed to convulsive diseases, we 492 CONVULSIONS. shall see them either in frequent and sudden motion, or firmly pressed towards the palm of the hand. The thumb is more frequently contracted upon the palm, the fingers at the same time being extended and separated from each other." Every part possessing muscular fibres, is liable to become affected with spasmodic or convulsive contractions. The parts, however, which are most frequently the seat of convulsions, are the face, the superior and inferior extremities and the respira- tory muscles. The countenance is always more or less distorted; and in some instances the convulsive attack is almost entirely con- fined to the muscles of the face. In some instances, the different parts of the body are separately and successively affected; in other cases, the whole system of voluntary muscles, are simultaneously thrown into convulsive agitation. " The most common form of convulsion" (says Dr. Clark) "is that in which there is a universal spasmodic contraction of all the voluntary, and many of the in- voluntary muscles, of the body, accompanied by foaming at the mouth, protrusion of the tongue, staring of the eyes, distortion of the eye-balls, laborious and obstructed respiration, sometimes ac companied with a violent redness of the face and scalp in the beginning of the paroxysm, followed by a purple color of the whole body at the end of it. This latter symptom sometimes continues until the child dies." The redness of the face and scalp, and the foaming at the mouth mentioned by Dr. Clark, are, however, not very common in cases of simple convulsions, "these symptoms are more par- ticularly connected with epilepsy and convulsions depending on organic affections of the brain. It is a remarkable fact, that simple convulsions seldom occur at night, while the child is "sleeping; and in this respect, they differ very materially, from epilepsy, which in a great many instances comes on only al night. Causes.—It is asserted, by many writers, and doubtless very correctly, that the occurrence of convulsions among children is much more common at the present day, than at any former period. This has been ascribed to the increase of luxury and refinement, of late years, and particularly to the vicious system CONVULSIONS. 493 of educating infants so prevalent in modern times. Unques- tionably nervous and convulsive diseases " have increased in proportion as polished education has removed children from bodily freedom, and carelessness of mind, which to a certain extent are so essentially necessary to the preservation of their health." Among the Indian tribes of this country, it is said that convulsions are scarcely known; and among the industrious and frugal inhabitants of the country, where children enjoy an abundance of healthful exercise, and a plain but wholesome diet, convulsive affections are very uncommon. The practice so much favored at the present time, of urging the tender minds of infants, to premature efforts in the acquisition of knowledge, is liable to very serious objections. That it must tend to weaken the general organization, and predispose to bodily infirmities, can hardly be doubted. " It may be a source of consolation to those parents, who are too apt to lament any apparent loss of time in the very early periods of life, to remember, that early acquirements, are not to be gained, without much risk of im- pairing health; and that the future progress and mental powers of the individual depend upon the foundation which is laid in infancy, by judiciously adapting the studies of the child to its age and constitution. By premature efforts to improve the mind, the brain and nervous system becomes over excited, ex- hausted and finally enfeebled. The practitioner, therefore, • cannot too forcibly reprobate precocious studies. The injurious effects arising from the vanity of parents, who are ambitious of holding forth their children as specimens of extraordinary talents, are constantly presenting themselves to our view, in a train of nervous symptoms, and of susceptibility to ordinary im- pressions, which frequently lead to decided paroxysms of con- vulsions." (North.) The exciting causes of convulsions are extremely various. In general, whatever is capable of causing strong sanguineous de- terminations to the brain, or of producing nervous irritation of the organ may give rise to an attack of convulsions. The vas- cular turgescence within the head, which in adults causes coma, or apoplexy, is apt, during infancy, to produce convulsions. Even a moderate degree of sanguineous engorgement of the 494 CONVULSIONS. brain is often sufficient to produce convulsions, in children, who are predisposed, by constitutional habit, or previous enervating causes, to the affection. This is often illustrated by the occur- rence of strong convulsions in fevers of strong vascular reaction, and particularly in the cold and sometimes in the hot stage of intermittents. In infants the paroxysms of an ague are very often ushered in by convulsions. I have met with cases in which the convulsions came on regularly, at the same hour, for four or five days, before the nature of the malady was understood. In some instances, however, convulsions are the immediate consequence of cerebral or nervous irrritation without any ex- traordinary sanguineous determination to the head; and these are, in general, the most serious and unmanageable cases. This cerebral irritation is usually purely sympathetic, depending on a primary local irritation seated either in the alimentary canal, or in some other part, more especially in the gums from dentition. It must be observed, nevertheless, that both intestinal irritation and dentition are very frequently attended with an increased determination of blood to the brain; and the latter, especially, is very rarely unaccompanied by this additional source of cere- bral disturbance. When an attack of convulsions is preceded and attended with a flushed and turgid countenance, dilated pupils, a full and active, or a contracted, frequent and tense pulse, with strong beating of the arteries of the neck and temples, and a warm and dry skin, we have conclusive evidence that the cerebral irrita- tion which causes the convulsions is mainly, if not wholly, pro- duced by vascular turgescence in the brain. In such cases, the child generally remains in a lethargic state, for a longer or shorter time after the subsidence of the convulsions. When, on the contrary, the countenance is pale and the pupils contracted, the skin cool or of the natural temperature, the pulse small, frequent, quick and irregular or feeble, we may infer that the attack is not dependent on sanguineous irritation of the brain, but the result of nervous irritation, transferred to the common sensorium, most probably from a primary nervous irritation located in the intestinal canal. There is no cause to which CONVULSIONS. 495 infantile convulsions, are more apt to be ascribed, than worms. That verminous irritation is capable of exciting convulsions, admits, indeed, of no doubt; but, I am persuaded, that the in- stances which depend upon this cause are, of comparatively rare occurrence; and this accords with the observations of many of the most experienced writers on this subject. "In com- mon" says Mr. North, " with every other practitioner who has had opportunities of seeing much of the diseases of children, many worm cases have fallen under my notice; and I do not remember a single instance where convulsions appeared to de- pend upon the presence of worms in the intestines, or to be relieved by their being discharged." My own practice has furnished me with but few instances of convulsions, that could be fairly ascribed to verminous irritations. Errors in diet, with regard, both to quantity and quality, are unquestionably by far the most common sources of convul- sive affections, in infants; "So long as nurses and mothers believe that children thrive in proportion to the quantity they eat, so long will convulsive diseases be frequent and severe." Over distention of the stomach, with inappropriate articles of food is peculiarly apt to give rise to convulsions. I have known several fatal attacks of this affection, brought on by eating raisins, during convalescence from slight febrile com- plaints. Children whose digestive powers are feeble, or who are affected with a disordered state of the bowels, are peculiarly liable to convulsions, from the reception of substances of this kind into the stomach. During dentition, especially, the utmost care should be taken to prevent errors of this kind; for I am entirely convinced, that many of the cases that are usually ascribed to dental irritation, are the result rather of gastro-intes- tinal irritation from errors in diet or improper ingesta. An instance which I recently saw, brought the truth of this obser- vation forcibly to my mind. The child had for several weeks been a good deal disturbed by painful dentition. While amus- ing itself with its play things it was suddenly seized with a violent paroxysm of convulsions. In a few minutes, it threw from its stomach a large quantity of fluid, containing a mixture of almonds, raisins and sponge cake. I administered an emetic. 496 CONVULSIONS. and brought away no inconsiderable quantity of the same destructive mixture; after which the convulsions gradually subsided. Repelled cutaneous eruptions and suddenly suppressed discharges from ulcers or sores, particularly about the head, or behind the ears, may give rise to convulsive affections. Mr. North doubts, " whether convulsions were ever produced either by the natural or artificial disappearance of cutaneous discharges or eruptions, provided, that a slight action was kept up, for some time upon the bowels, by the assistance of purgatives, and their effect was not allowed suddenly to subside." Undoubtedly, by such precau- tionary measures, the ill effects of drying up discharges or re- pelling eruptions, may generally be obviated; but my experi- ence warrants me to say, that even this course of management will not always suffice to prevent the occurrence of convulsions. It must be observed, however, that children who are not under the influence of difficult dentition, seldom suffer any particular disturbance, from the desiccation of cutaneous discharges; but during the active progress of teething, attended with a general irritative condition of the system, it would most assuredly be extremely hazardous, to dry up serous discharges behind the ears, even though the bowels be regularly acted on by aperients. It does not appear, however, that the sudden drying up of scabby or suppurative eruptions, has any obvious tendency to excite convulsive affections. It is to sores discharging a serous fluid that these observations more especially apply. General plethora, with a predisposition to irregular sanguineous determinations to the brain, may, doubtless, contribute very materially to the oc- currence of convulsions. It is, however, to be regarded, rather as a strongly predisposing or accessary, than an exciting cause of such affections; for it may be doubted whether mere plethora, ever produces simple convulsions, without the concurrence of some other cause capable of producing a preternatural deter- mination of blood to the head, or causing cerebral irritation. Dentition, is incomparably the most frequent source of convulsive affections during infancy. In many instances, it is manifestly the sole cause of the convulsive paroxysm; but it frequently operates only as a strongly predisposing cause, in consequence of CONVULSIONS. 497 which, slight additional sources of irritation may bring on an attack of convulsions. Convulsions not unfrequently occur in the acute exanthematous affections, either just before the eruption is about making its appearance, or in consequence of the sudden reper- cussion of the exantheme, before the period of its regular de- clension. Convulsions may also be excited by a direct or me- chanical injury of the brain. I have known several instances where a fall on the head so as to cause considerable concussion of the brain, almost immediately gave rise to general convul- sions, without any permanent or fatal lesion of the brain. Even severe local injuries, of parts situated remote from the ence- phalon will sometimes excite an attack of convulsions. "In- fants," says Mr. North, "are liable to convulsions, almost immediately after birth; and it cannot be doubted, that they occasionally arise from excessive and long-continued pressure of the head, during protracted labor." Convulsions depending on this cause, seldom continue longer than a minute or two. In some cases, a slow and insidious inflammatory irritation will go on in the brain, or its meninges, with scarcely any decided symptoms of disease, until either an effusion of serum upon the surface, or into the ventricles of the brain or some other cere- bral lesion is effected. In cases of this kind, a paroxysm of convulsions is sometimes the first unequivocal intimation of the child's indisposition; and what was previously considered as mere fretfulness and general irritability of temper, of no serious im- port, now suddenly assumes the character of an almost hopeless form of cerebral disease. Cases of this kind, however, are almost invariably connected with more or less paralysis, and frequently with strabismus, and must be regarded rather as insidious instances of hydrocephalus or of cerebral inflammation, than as convulsions of the ordinary form, of which I am now speaking. Convulsions, may, moreover, be the result of moral causes. The emotion of fear or violent alarm, when suddenly excited, is capable of producing the most violent effects upon the irrita- ble and sensitive frames of children. Mr. North, states that an instance occurred to him, in which a child of four years of age, " who had never previously been affected with convulsions, was 3 S 43 498 CONVULSIONS. suddenly attacked with a violent paroxysm which destroyed him, in consequence of the nurse having improperly threatened to throw him from a window, if he did not cease cryinr four weeks. In some instances, not more than three or four clusters of papulae make their appearance, and these are usually situated on the fore arms and cheeks. Inmany cases, however, as one patch declines, another makes it appearance "at a small distance from it, and in this manner the complaint gradually spreads over the face, body, and limbs." The pulse is generally accelerated, the tongue covered with a white fur, the skin very warm and not disposed to perspire, while the little patient is sometimes unusually restless and uneasy. This eruption seldom occurs during the first nine months after 544 CHRONIC ERUPTIVE AFFECTIONS. birth. Dr. Dewees observes, that "it has always, according to his observations, appeared later than is usually described, or not until the child was about cutting the first jaw teeth." This accords entirely with my own experience. I have never wit- nessed this eruption before the ninth or tenth month, and most commonly about the period mentioned by Dr. D. This affection would seem to be intimately connected with a disordered state of the stomach and bowels; for in most instances, the evacua- tions are either very unnatural, or the child is manifestly troub- led with acidity, flatulency, and griping stools. The diet should be of the simplest and most unirritating kind, more especially, when the eruption is attended with febrile irritation. Milk, arrow root, sago, grated crackers dissolved in warm water, oat-meal gruel, and rice, form appropriate articles of nourishment in this affection. Gentle purgatives will be use- ful throughout the whole course of the complaint. Very small doses of calomel in the evening, with a moderate dose of mag- nesia or castor oil on the following morning, will answer very well for this purpose. The affected parts should be frequently washed with warm milk and water; and when the eruption is severe and obstinate, the application of reduced citrin ointment, or calomel ointment, as directed for crusted lactea, should be resorted to. When the bowels become much affected with griping and diarrhoea, minute portions of calomel in union with ipecacu- anna, should be administered three or four times during the day, with an occasional dose of castor oil, and a few drops of lauda- num in the evening. The warm bath also, is very useful in such cases. When the eruption is about drying up, and the bowels have been properly evacuated, mild chalybeate preparations may be employed with considerable benefit. Bateman recommends a watery solution of the tartrite of iron for this purpose, "as particularly adapted from its tasteless quality to the palates of children and possessed of more efficacy than vinum ferri." INFLAMMATION AND ABSCESS WITHIN THE EAR. 545 CHAPTER XLIII. INFLAMMATION AND ABSCESS WITHIN THE EAR. Infants are sometimes affected with inflammation, terminating often in abscess within the ear, which as they can give no distinct account of their sensations, is apt to be mistaken for some other painful affection, and is consequently often either entirely neg- lected or mismanaged. Children affected in this way are, at times, extremely restless, leaning the head to one side, or moving it from side to side, with frequent spells of vehement and unap- peasable crying, and a countenance expressive of great suffering. At night the child is apt to awake and cry violently for some time, after which it sinks into a sound and quiet sleep, "from which it will, probably, be roused by renewed torture." There is seldom any distinct febrile irritation connected with this pain- ful affection; and it is on this account, probably, that these distressing pains, were formerly generally regarded as of a spasmodic character. This affection may be distinguished from colic, for which it is frequently* mistaken, by the paroxysms of suffering being free from the agitation and retraction of the infe- rior extremities, so constantly observed in severe abdominal pains. The hands and feet too are warm, which is seldom the case in colic. Dr. Dewees observes, "that we have always reason to suspect this pain to arise from an abscess forming in the ear, when the child throws, its head backwards and forward, and indeed in all directions during the paroxysm of pain." One of the most certain indications, however of this affection, is obtained by pressing with the point of a finger, " against the lower portion of the external meatus." If the child shrinks and cries when pressure is thus made and the symptoms already mentioned are present, there can be little if any doubt, that an abscess is forming in the ear. Chil- dren affected in this way, seldom rest easy, when lying on the af- 4 A 47 546 INFLAMMATION AND ABSCESS WITHIN THE EAR. fected side. In some instances, after the abscess has made con- siderable progress, it may be seen by looking into the ear. There can be no doubt however, that extremely violent pains within the ears, often occur, without either inflammation or ab- scess. We frequently meet with cases, which come on sud- denly, and after having continued for some time, with occasional intermissions, as suddenly disappear, without any further inconve- nience. The pain in cases of this kind is usually extremely in- tense, and may in general be speedily relieved by dropping some laudanum into the ear, or taking a full dose internally, and plac- ing the feet in warm water. When the pain depends on inflam- mation or abscess, laudanum procures but slight and temporary relief. When the formation of the abscess is not prevented by prompt and appropriate remedies, it continues to torture the little pa- tient, until it bursts and the mattter issues from the ear. When this occurs, all the pains suddenly subside, and the child becomes perfectly easy. Occasionally, however, when the first abscess has discharged its contents, a second one commences and passes through the same painful course, and thus a third and even a fourth abscess may occur and protract the sufferings of the child, with occasional intermissions, for several months. In some in- stances serious and irremediable injury is done to the organ of hearing. "The small bones of the ear become detached by sup- puration, and are discharged with the pus which constantly flows from the external orifice of the organ." The pus in these cases generally acquires an acrid, thin, and extremely offensive char- acter, inflaming and excoriating the external parts with which it comes in contact. Fortunately, however, these severe and dis- tressing cases are by no means common. In a great majority of instances the abscess heals without much difficulty, and leaves the ear in a perfectly healthy condition. Not unfrequently the posterior part of the meatus becomes excoriated, or affected with chronic superficial ulceration, without any serious injury to the or- gan of hearing; and these cases are attended with a thin sero- purulent discharge from the ear, which often continues for seveal Fears. These chronic discharges from the ear, are almost always INFLAMMATION AND ABSCESS WITHIN THE EAR. 547 attended with dullness of hearing, and in some instances this organ never regains its original acuteness. When there is reason to believe that the sufferings of the child arise from inflammation and the formation of an abscess in the ear, five or six leeches, if practicable, should be applied behind the ears or on the mastoid region. A few drops of laudanum should be instilled into the ear, and an active purgative of calo- mel and rhubarb administered. The application of a blister under or behind the ear, is however, in general more effectual in arresting the progress of the complaint than any other means we possess. By the prompt employment of these remedies, when applied before suppuration has commenced, we may in general, remove the complaint without much difficulty; "but unfortu- nately the time for useful exertion is almost always lost, by a trial of temporizing applications, and we have but too often the mortification to witness only the discharge from the ear." ,-When the disease has advanced to this stage, we must endeavor to promote the healing of the abscess, and to prevent it from degenerating into a chronic discharging ulcer. For this purpose, it is of great importance to keep the affected parts as clean as possible, by repeatedly throwing warm milk and water into the ear with a small syringe. If, after these mild injections have been used for several days, the discharge from the ear continues, a weak infusion of peruvian bark, or warm water mixed with tincture of myrrh, (in the proportion of twenty drops of the latter, to half an ounce of the former) should be thrown into the canal three or four times daily, immediately after the secretions have been washed away with the milk and water injections. Dr. Dewees recommends, for this purpose, a mixture of lime water and milk, with a small portion of the tincture of myrrh.* "This mixture should be prepared only as it is wanted, and thrown into the ear four or five times a day." In cases of an obstinate character, where there is a constant discharge o offensive matter from the ear, without any particular pain or uneasiness from the affection, a weak solution of the nitrate of * Lima water and milk, of each two tea spoonfuls; tincture of myrrh, twenty drops. Mix. 548 INFLAMMATION AND ABSCESS WITHIN THE EAR. silver, as recommended by Curtis, is frequently very beneficial In four or five instances of this kind I have employed this solution with complete success. Four grains to an ounce of water forms a solution of proper strength for this purpose. In obstinate chronic purulent discharges from the ears, Buchanan asserts that he has used a weak mixture of pyroligneous acid, as an injection, "and found it to surpass his most sanguine expectations, in dimin- ishing the discharge, and almost immediately restoring the hear- ing." He states that he has made repeated trials of this injection, and almost uniformly with entire success. "I may venture to say," he continues, "that a more valuable medicine than pyrolig- neous acid, has not been introduced into acoustic surgeryr either in this or the last century." It may be used in children according to the following formula: R acid, pyrolign. 3'- Aq. distillat. gvi. Ft. injectio. The mode of using it, is first to wash out the meatus, with tepid water, and then to inject the mixture " so as to be directly applied to the abraed or ulcerated surface." The insertion of an issue in the arm, or on the back of the neck, has been known to arrest the progress of this affection; and Dr. Dewees " thinks he has seen some advantage derived from the little patient wearing a burgundy pitch plaster under the affected ear." The child should be made to lie on the affected side, when in bed, in order to prevent an accumulation of the offensive matter in the bottom of the meatus. A TABLE EXHIBITING THE DOSES OF MEDICINES, ACCORDING TO DIFFERENT AGES. Aloes, soccotrine........... Antimonial Wine......... Antimonial powder........ Ammonia Carbonate, ) salt of hartshorn $ Aqua Ammonia, spirit ) of hartshorn $ Assafoetida gum.......... Calomel................. Camphor................ Charcoal powder.........., Cream of tartar........... Carbonate of Magnesia Carbonate of potass....... Carolina pink-root, } powdered root $ Carolina pink-root, infusion ) 3ss to one pint of water $ Castor oil................ Chalk, prepared.......... Croton oil............... Dandelion Extract........ Colomba root, powder...... Colocynth, compound ) extract of 3 Corrosive Sublimate, > as an alterative $ Dewberry root, decoction, ) 3j to one pint of water J Dovers powder........... Elixir of Vitriol.......... Emetic tartar, repeated doses Epsom salts............... Essence of peppermint...... Ether sulphuric............ 549 Adult Age. 10 to 15 3ij to 3ss 6gr.- 8 6gr.- 12 10 dr.- 20 10gr.- 10 gr.- 6gr.- 9j to V5j 3j to 3ss 3j to 3ij 10gr.-30gr. 3j - 3ij 3iv to 3viii 3j to 3jss 9j to Bij 1 g«. to 2g« 3j - 3ij 10gr.-30gr 10gr.-20 igr.-rV 3ij - 3iv 8gr.- 12 10 g^-30 g« 2gr.- 3gr. 3j to 3jss 20 g«-- 30 g« 20s:'t-30ff't From 4 to 7 years. 5 to 3 3j to 3ij 2gr.- 4 4gr.- 2 5 dr.- 10 5gr.- 10 5gr.- 10 2 gr.- 4 10 gr.- 20 9j to 3ss Bj to 3j 5gr.- 10 Bj - Bij n 3ss - 3j 10 gr.- 20 lg"- h 9j to 5j 5gr.- 10 6gr.- 10 3J ~ 3jj 4gr.- 6 6g't--15gtt igr.- lgr. 3ij - 3ss 5g«— 10 5 gtt- 10, From 3 to 1 years. 2 to | 20 dr.- igr.- £gr- 1 dr.- 2 3gr.- 1 4gr.- 2 1 gr- £ 10 gr- 4 9j tolOgr 9j tolOgr 5gr.- 2 20 gr- 10 3ij - 3ss 3ij - 3j 6gr.- 3 ig«- tV 9j to 9ss 3gr.- 1 5gr.- 2 3j to 3ij 3gr.- j gr. 5 g«.- 3 g-t drops. igr.- * grain. 3j - Bj 3 git.- lgn.idrops. 4 g"— 2 drops. grains. grains. grains. drops. graina grains. grains. grains. grains. gr- fl. fl. gr. drop. gr. gr. gr. fl. iV A TABLE OF DOSES OF MEDICINES. Extract of butternut, laxative ■------of Belladonna...... ------ Hyoscyamus, henbane ------of Gentian......... Adult Age. Foxglove, digitalis, powder Gamboge—cathartic...... Geranium root, Cranesbill root, decoction, 3j to one pint of milk or water Glauber Salts........... Hartshorn Salt.......... Hive Syrup, as an emetic . Hoffman's Anodyne...... Huxham's tincture of bark Iron filings, tonic........ Iron, Muriated tincture of. Iron, Phosphate of........ Iron, Prussiate of........ Iron, Tartrate of......... Iron sulphate............ Iodine, tincture of— 3j to 3j of alcohol Ipecacuanha powder....... Jalap powder............. Kino, gum powdered...... Lactucarium—lettuce opium Laudanum, tincture of opium Lime water....... Magnesia, calcined. ---------, carbonate 20 gr. 4 2 6 1 1 Manna................. Milk of sulphur......... Morphia................ -------, sulphate of—the same dose as morphia. Nitre—Salt-petre....... Oil of Peppermint....... Oil of Juniper........... Oil of Turpentine........ Oil of Wormseed........, Opium................. Oxyd of Zinc..........., 2 550 -30gr. to jgr. tolOgr. tolOgr. to 4gr. to 4gr. 3ij - 3iv 3j 6gr. 3jss 12 gr. 30 3j 10 10 g»t 20 10 3ss i 10g« B] Bj 10 2 20 g«. 3j 3j 3j 3j 3ij *gr. -40 dr. - 3ij -20 gr. - 20 - 40 - 15 - 3j - 2gr. - 15 - 3ss - 3ss -20gr. - 4gr. - 40 - 3iv - 3ij - 3ij - 3iv - 3iij 10 gr. 10 g" 10 g« 20 gtt. Igr- 2 30 20 20 100 3 6gr. From Lo 7 years. 6 gr.- 15 i to 4 4 -Igr. Igr.- 5 J to | i - 4 3j - 3ij 3ij - 3ss 4 -2gr. 10 -15 dr. 3ss - 3j 5 -10 gr. -10 g'« - 10 20 5 5 4 - 10 gr.- i _ i 3 -5g 8gr- 12 8 gr.- 12 4gr.- 6 h ~ Igr. -10 g« - 3ij - 3j - 3j - 3ss - 3ij 4 - 6gr. 3 g«- 6 3-6 6-12 6 gtt- 10 i _ i * - 4 From 3 to 1 years. 5gr.- i ~ 2gr.- £ _ j 3ss - 3ij grains. grains. grain. gr- gr.v gr. fl. 4 - 30 g«- 8 - 15 dr.- 3 - 4 - 3 - 3 - 6gr.- * " 2 - 5 - 6gr.- 2 - i ? 5g»- 3j " 9j ~ 3j " 3j " 3 ■ 2 • 2 ■ 5 ■ 5g.,, i Tff l ?r 3ss j 10 3 5 1 2 2 1 2 gr- drops. drops. fl. grains. drops. grains. gr. grains. " T5 - 2 - 3ss 10 gr. ■10 gr. ■ Bj ■ Bj i drop. gr. gr. graina grains. drops. fl. gr. 2 1 1 3 2 t 25 1 TO grama dropa drops. drops. drops. graina A TABLE OF DOSES OF MEDICINES. Paragoric Elixir.......... Peruvian Bark........... Pink-root powder........, * Quinine................, Rherbarb, powder......... Snake-root, Senega, deco- tion, 3j to 1 pint of water Soda, Carbonate of ( Soda bi-carbonate Spirit of Camphor.... Sulphur, Flowers of.. Sweet Spirit of Nitre. Syrup of Squills..... Syrup of Rhubarb.... Tinct. of Assafcetida . ----- of Blood-root, j 20 g*- 30 3j — 3ss 3j - 3iij 3j - 3ij 3j - 3iv 20 gtt-- 40 20 g«. - 30 20 g«.- 30 20 g«- - 30 3j — 3ss 3j - 3ij 3ij - 3iv 3ij - White Vitriol, as an emetic Jgr. 10- sanguinaria 5 --- of Foxglove..... --- of Belladonna ... --- of Lobolia inflata --- of Peruvian bark Adult Age. 3j 3j gr-j 3ss 3j 10 gr. - 3iij - 3ij - 3ij - 5 " 3j - 3ij - Bj Uva Ursi,—decoction, 3j to one pint of water Wormseed............ From 4 to 7 years. From 3 to 1 years. 3ss — 3j 3ss - 15 gr.- 3ss 15 gr.- Bj " Bij 4gr.- Igr. 12 gr.- Bj 3jss - 3ss 6gr.- 12 6g... Bj Bj Bj 3j • 10 g«. 12 3j 3j 3j 3ss 20 - 15 6g..- 5 gtt- Bj - Bj - 3ss - Bij - gr-4 - 10 10 3j 3j 3j 3j 6 Bj - i 10 gr.- 3jss - 5j 6gr.- fl. gr- graina gr- graina fl. 5 g't- 2 Bj - 10 9j - 10 Bj -12 g* 3j - ~ 10 g«- 5 6 gtt- 3 3 gr. drops. graina fl. dps. 5g"- 4g»- Bj " Bj " 3ij - Bij " Bj gr. 3 - 2 fl. drops. dropa dropa drops. drops. dropa fl. EXPLANATIONS. The mark 3 signifies ounce. ---drachm, or £ of an ounce. Bj scruple, or £ of a drachm. The letters ss. signify half; thus, 3ss, stands for half an ounce; 3ss, for half a drachm; gtt stands for drops; so also do the letters, dr.; fl, signifies fluid;—thus, 3j fl, means one fluid drachm: gr., stands for grains. 3 551 ) *w. <*^ w _. '■ -' V • .AT "V*i TC 'V >_ ' \ *t-r- ,♦ ^v « **ML*. r~ ~*v -if. NATIONAL LIBRARY OF MEDICINE NLH QlDbfibTS 5 J > ±Jt +< ■mm f'/&V '■■■;••'■ $$< ■ :• "... i ■■?:* \ . NLM010686955