; 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