UH!-tMHHv W<;?n\[]'^-U■- • ■:■ ■■ ■ : i } l: i»\ t; >. i. ' :' i . v. . , , : : • > , • U!;'i\\■)■''' ''''\\'.'■';■: ■.■)-;"" |SillBl;;-: W < 'K1 ,i •; i •■ ' • »■ . i i . • - • ■. ^i;»ilt'Li.r,i»»:!^ *■' '■.■:';;': -i:'.s«;ti ,-U; 1 *■ i> ir*. !(' ■• '.■-.•■• ,jf>,uFi;r u ['-in- r •■■■:■<...■;>■■■ ■it:>. *j> ,;»• ;i.»*•...■>;•'' ■ ■ - ii-i^. lili':;;:;:: i ;tv.U->t:-<--!:*r'M5;-"' '.:'■ '•■■ T:tr:s- • '. J ■'*■ / A TREATISE DISEASES OF CHILDREN; WITH DIRECTIONS FOR THE MANAGEMENT OF INFANTS; f BT THE LATE MICHAEL UNDERWOOD, M.D. 1^ FROM THE NINTH ENGLISH EDITION, WITH NOTES, S. MERRIMAN, M.D., AND MARSHALL HALL, M.D., F.R.S.. ETC. /....■ WITH NOTES, BY JOHN BELL, M. D., LECTURER ON MATERIA MEDICA ; FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETT; CORRESPONDING SECRETARY OF THE MEDICAL COLLEGE OF PHILADELPHIA, ETC., ETC. rtrON l""N7'T W74 ^htlatreljiftfa: ED. BARRINGTON & GEO. D. HAS WELL. NEW YORK —J. & H. G. LANGLEY: CHARLESTON, S. C.-WM. H. BERRETT: RICHMOND. VA. —SMITH, DRINKER & MORRIS: CINCINNATI. OHIO-J. A. JAMES. 1842. W'z- U5*t [Entered, according to Act of Congress, in the year 1841, by Barrinoton & Haswelx, in the Clerk's office of the District Court for the Eastern District of Pennsylvania.] PREFACE BY THE AMERICAN EDITOR. In 1819, Doctor Underwood, then far advanced in years, revised the seventh edition of his Treatise on the Diseases of Children. In 1826, Doctor Merriman, so well and advantageously known as a skilful accoucheur and practitioner, prepared a new edition, which he enriched with notes on several points of interest: and in 1835, Doctor Marshall Hall, that popular writer and teacher, performed a similar duty for a succeeding (the ninth) edition. Here we have good evidence, both of the continued success of the work during the life time of its author, and of the estimation in which it is still held by distinguished medical men, as well as by the medical pub- lic at large. In preparing a new American edition of Underwood, its editor has retained, with very few exceptions, all the notes which en- hanced so much the value of the later English editions; and he has himself added numerous ones, in elucidation and enforcement of the pathology and treatment of several of the diseases described in the text. On Croup and its varieties, and on Cholera Infantum,the latter not noticed at all by Dr. Underwood or his English commenta- tors, and Scarlatina, he has enlarged somewhat beyond the limits of ordinary notes; but not, he believes, farther than the gravity and fre- quency of these diseases merited. The note on Vaccination supplies a void left by the author and his former editors. Throughout, he has endeavoured to bring up the Treatise on the Diseases of Chil- dren to the requirements of the day, as far, at least, as regards the main points of treatment. The added matter, although derived from other sources than the personal experience of the editor, on ' Purulent Ophthalmia,' and < Gangrenous Sore Mouth of Children,' will, it is hoped, enlighten the practitioner who, for the first time, may be called upon to treat these formidable maladies. The intrinsic merit of Dr. Underwood's advice for the physical and medical management of children was less evident to the reader, on account of the verbosity and needless expletives, which rendered the perusal of his book irksome and unpleasant. This objection has been, in a great measure, removed by the first of its English edi- tors, Dr. Merriman, who, besides pruning many redundances, 8 PREFACE. has rendered " the language more exact and clear." The text of his edition has been preserved on the present occasion in almost uninterrupted series, until the section on the ' Topical Diseases of Children' was reached. Of these the accounts of the ones more strictly peculiar to infancy have been retained : but no advantage could follow the insertion of notices of others which were quite too meagre for practical guidance ; and which, at the same time, be- longed to surgery, in the treatises on which, ex-professo, or in sepa- rate monographs, they are alone adequately described and treated. Of these latter may be instanced Cataract, Gutta Serena, Morbus Coxarius, Hernia, Hydrocele, Vari and Valgi. To have done jus- tice to them, with the requisite fulness, would have swelled the volume to an inconvenient bulk, and after all have added really nothing new to the treatment of the diseases of children. An explanation of some difference between the two last and preceding English editions, will be best given in the language of Dr. Merriman himself, as follows : —" The later editions of Dr. Underwood's Treatise consisted of three volumes, the third of which was appropriated to directions for the management of in- fants from birth and other subjects, which seemed naturally fitted to precede, rather than to follow, a Treatise on Infants' Diseases. These directions are, therefore, now made the introduction to the single volume 5 in which the whole of Dr. Underwood's work, with the exception of his dissertation on the Properties of Human Milk, is comprised. This dissertation, written principally to con- trovert some opinions advanced by Dr. Joseph Clarke of Dublin, in 1786, it has not been judged necessary to reprint. Nor has the editor deemed it advisable to reprint some rather long controver- sial notes, which might perhaps have been spared when first in- serted, and for the publication of which now, no good reason can be assigned." The notes of Dr. Merriman are marked with the initials (S. M.) of his name. Those of Dr. Hall are in brackets [ ], and have the initials of his name (M. H.); they are mostly printed in the same type, with, and in the body of, the text. The additions by the American editor are indicated by a letter {a) prefixed until the alphabet was exhausted, and then double letters {aa) were em- ployed ; and they may be, also, farther known by their being in a different type from either that of the text, or of the notes of Dr. Merriman. A claim to additional value, as a work of reference, for the present volume, will be found in an Index, which was wanting in the English. CONTENTS. SECTION I. ON INFANTS APPARENTLY STILL-BORN. Notes by the English Editors . SECTION II. ON THE MANAGEMENT OF INFANTS. On Dry-Nursing .... The General Management of Children On the First Clothing of Infants On Air ...... On Short-coating .... Meat and Drink ..... On the choice of Wet-Nurses On Weaning of Infants .... Sleep and Watching .... Motion and Rest ..... On some slight natural Deformities Retention and Secretion .... Retention of Urine in New-born Infants On Retention and Execretion of the Bowels The Passions of the Mind ... SECTION III. ON THE EARLY DETECTION OF DISEASE. By Dr. Hall. On the Countenance ..... On the Gestures ..... On the Sleep ...... On the Respiration, and on the Beat of the Heart 10 CONTENTS. On the Cry On the Tongue and Breath . On the Skin and General Surface PAGE 84 85 86 SECTION IV. ON THE DISEASES OF CHILDREN. Syncope, or Fainting Discoloration of New-Born Infants Retention of the Meconium . On the Intertrigo, or Chafings Tumid Breast of Infants Icteritia, or Infantile Jaundice Infantile Erysipelas Coryza Maligna, or Morbid Snuffles Inward Fits Disorders from Constipation and Wind . Vigiliae, or Watchings Aphtha?, or the Thrush (Follicular Stomatitis) Aphtha Gangrenosa Eruptions on the Skin . The Strophulus, or Red-Gum, {Strophulus Intertinctus. Willan.) Crusta-Lactea, or Lactumen, (Porrigo Larvalis. Willan.) Tooth-Rashes .....< Essera, or Nettie-Rash, {Urticaria. Willan.) . Phlyctaenae, {Pemphigus Infantilis. Willan.) Psora, or the Grocer's Itch, {Psoriasis Infantilis. Willan.) Sore Ears .....•• Vomitus, or Vomiting ..... Cardialgia, or Inflammation of the Stomach Gastritis with Gelatiniform Softening of the Stomach Tormina, or Gripes ..... Diarrhoea ...*.. Lienteria, or Watery Gripes .... Cholera Infantum ..... Incontinence of Stools ..... On Diseases in the Abdomen .... Worms ....... Vermifuges . .... Convulsions ...... Paralysis, or Palsy ..... Skin-bound ....... Tetanus, or Locked-Jawj .... Epileptic Fits ...... Chorea Sancti Viti ..... Aphonia Spasmodica Intermittens, or Temporary Loss of Speech Incubus, or Nightmare Singultus, or Hiccough . Sternutatio, or Sneezing 87 90 91 93 97 98 99 102 104 108 114 1J7 118 124 125 126 128 130 132 133 134 136 138 141 141 142 142 150 153 154 157 157 164 164 174 176 181 183 186 186 187 188 188 CONTENTS. 11 Dentition ..... Fever ..... Remittent Fever .... Typhus, or Low Fever Mesenteric Fever .... Remarks on the above Fevers Hectic Fever, and Marasmus Febris Scarlatina, with or without Ulceration of the Scarlet Fever, its Pathology and Treatment Febris Miliaris, or Miliary Fever Cynanche Parotidea, or Mumps Hydrocephalus .... On the Diseases of the Head On Hydrocephaloid Diseases On the due Use of Bloodletting . Variola and Morbilli, with Note on Bloodletting in Cursory Remarks on Inoculation Inoculation ..... Vaccine Inoculation Vaccination — Varioloid Varicella, or Chicken-Pox . Ague ...... General Observations on Coughs Pertussis, or Hooping-Cough Tussis Spasmodica .... SufFocatio Stridula .... Laryngitis Membranacea Laryngitis Stridulus .... Secondary Croup — Diptheritis On the Effects of Swallowing Boiling Water, &c. On Diseases of the Thorax . Rachitis, or Rickets .... Scrofula . Dysuria ..... Anasarca and Ascites Ischuria Vesicalis e Muco Incontinence of Urine PAGE , 189 198 m . 205 206 t . 207 212 , . 213 Throat . 216 , . 219 220 f . 222 224 , . 233 233 , . 240 Infancy , and 243 # . 246 249 , . 252 253 . . 257 260 , 261 268 , . 270 277 . 284 286 . . 289 292 . . 292 296 , . 301 301 303 304 SECTION V. ON THE TOPICAL DISEASES OF CHILDREN. Tinea, or Scald Head, {Porrigo Scutulata. Scurfiness of the Head, {Pityriasis Capitis Herpes, or Ringworm, {Herpes Circinatus. Herpes Exedens, or Serpigo, {Herpes Phlyctsenodes Herpes Miliaris, {Herpes Zoster. Bateman.) . Ophthalmia ..... Ophthalmia Purulenta .... Purulent Ophthalmia Willan.) . Willan.) Bateman.) Bateman.) 307 309 310 310 311 311 313 314 12 CONTENTS. Psorophthalmia ....:• Venereal Ophthalmia . Hordeolum Steatomatum, or the Stithe, or Stye Deafness ...... Abscess within the Ear . Earache ...... Cancrum Oris ...... Gangrenous Sore Mouth of Children Gangrenous Erosion of the Cheeks Gangrenous Affection of the Pudendum Paralysis of the Lower Extremities, with Curvature of the Spine Debility of the Lower Extremities On Cutting the Fraenum of the Tongue Suffocations from swallowing the Point of the Tongue, and Hemor rhage ...... Hemorrhage of the Nose ..... Hemorrhage from the Navel .... Soreness, or Ulceration of the Navel Unkindly Separation of the Funis Umbilicalis Tumefaction of the Prepuce .... Prolapsus, or Procidentia Ani .... Discharges from the Vagina .... Purulent Gonorrhoea ..... Encephalocele, or Hernia of the Brain Tumours of the Scalp . . Lymphatic Tumours of the Head and Spine Spina Bifida, or Hydro-Rachitis Hepartomphalos, or Ventral Hernia On the Hare-Lip, and other external Blemishes, or Disorders, sup posed to be marks of the Mother Naevi, or Discoloured Spots .... Imperforate Vagina ..... Imperforate Anus ...... Imperforate Penis ..... Squinting ..,,,.„ PAGE 316 316 317 318 319 319 320 321 322 323 324 327 328 329 329 330 331 332 333 334 335 336 338 339 341 342 350 353 358 360 361 363 364 A TREATISE ON THE DISEASES OF CHILDREN. SECTION I. ON INFANTS APPARENTLY STILL-BORN. The present exordium is dedicated to the consideration of the state of apparently still-born children, and to point out the most likely means of their animation. And what I have here to offer is the result of an experience that has been attended with more success than might have been expected; at least from anything recorded by preceding writers. I have, indeed, both at the Lying-in-Hospital, and elsewhere, met with many instances of children born with very little, and others without even the smallest appearance of life; some of whom have remained entirely destitute of any sign of it, for more than a quarter of an hour, and yet have been happily restored. I pretend to little or no skill in this business, not generally practised, and can scarcely guess to what to attribute this success, unless it be an unwearied assiduity and perseverance in my attempts, whensoever there are no certain signs of death, till I conceive nothing is possibly to be expected from them. And this has so often succeeded, that I have been tempted to think its importance may not have been sufficiently attended to by every practitioner. I rest this presump- tion not only upon some fortunate events where I have had little or no previous ground for hope, but where other practitioners had, in some instances, abandoned it. A certain steady perseverance in our attempts to preserve life, as long as the least hope may re- main, is indeed not only a duty we owe to the public, but one successful attempt is an abundant recompense for many failures ; especially as I imagine we shall rarely fail whenever there may be the least positive grounds for hope of a favourable issue. As to the means, they consist only of warmth, clysters, stimu- lants, and especially, blowing forcibly into the trachea. 2 11 UNDERWOOD ON CHILDREN. The ordinary stimulants are the smoke of lighted brown paper, or tobacco; juice of onions ; frictions with hot cloths, and with brandy ; cold brandy poured on the thorax, and on the funis umbi- licalis, where it is inserted into the belly; striking the nates, and the soles of the feet ;* stimulating the nose and pharynx with a feather (drawing out the mucus that may present); with every other similar means calculated to excite a strong effort, especially that of crying; to which, and a consequent free respiration, our attempts ultimately tend. On this account, I believe, no benefit is to be expected from stroking the blood along the funis, or im- mersing the placenta in warm water; the foetal life being extinct, the recovery of the child will depend on the blood passing freely through the lungs, which it cannot do till the child is brought to breathe freely and forcibly ; the continuance of which also is never secure till it begins to cry. To these ends, I have depended above all upon blowing into the trachea, through the mouth ; which I am satisfied may be more effectually done by the moutht of the assist- ant being placed immediately upon the child's, than by means of a blow-pipe ; although the air is certainly less pure ; at the same time preventing the return of the air before it has entered the lungs, by the fingers of one hand placed at the angles of the mouth, and those of the other on each side of the nose. But I have sometimes imagined that I might attribute much of my success not only to the continuance of this, but to the manner of doing it: by attempt- ing to imitate natural respiration, by forcing out the air I have thrown in, by a strong pressure against the pit of the stomach; thus alternately blowing in, and pressing out the air, for a long time together, omitting it only now and then, to make use of some of the above-mentioned means. I believe, however, that these means can do very little to insure the life of the child, until it begins not only to gasp, and that with shorter intervals, but also to breathe in a somewhat uniform manner. At this time, should the child not be disposed to cry, which is frequently the case, nothing seems so likely to succeed as a tobacco,:]: brandy and water, or other very stimulating clysters ; or putting a little Scotch snuff, or other pun- gent powder, up the nose : which latter, if they induce sneezing will soon be followed by a strong cry, and the child be with cer- tainty restored. *A very general excitement of nervous energy is frequently produced bv gently rubbing, and irritating the soles of the feet with a nail or a tooth-brush f Perhaps the warmth imparted to the lungs of the infant by the breath of the operator, may be the means of rendering the vitiated air thus thrown in more efficacious than the more pure, but cooler atmospheric air would prove The objection frequently made, that it must be wrong to breathe into the lungs of a still-born infant from the mouth of the attendant, because the air is contaminated is certainly shown by experience to be invalid. — S. M. i-omaminated, % Tobacco clysters so often produce svneone that it \oarn„ „_» j- should be recommended in such a case asZs AlXA^SlTT^^V7 SeV tobacco is one, are likely to be prejudicial in this ttL.-%lt ' °f "^ ON INFANTS APPARENTLY STILL-BORN. 15 Amongst other means, that of warmth is very essential, to which end, the infant should be entirely covered with very hot cloths, which should be renewed as fast as they become at all cool; or the body may be immersed in a tepid bath of salt and water, or milk, and be well rubbed all over: the cord may likewise be suffered to bleed a little, especially if the face or body do not soon acquire the natural colour — but this ought seldom to be done, nor ought the funis to be divided as long as any pulsation is to be felt in it.* To these means may be added the cautious use of electricity, which appears as likely to be as successful in these, as in most other cases to which it has been applied, but I have never been in a situation to make trial of it in time, or I certainly should ; as I once knew a child happily recovered by it, after being laid out for dead for near two hours, in consequence of a fall from a two-pair of stairs window. The very great success of the means recommended by the Humane Society, in restoring life to drowned persons, after two or more hours have elapsed, may be advanced as a further induce- ment to steady perseverance in the plan proposed. For if an infant be not born positively dead, it is well known that the vital spark, though long dormant, may be roused into action : and the living principle, if respiration be promoted, will extend its influence through the animal frame, nor will fail to support itself, if no vital part has been injured in the birth. But should these several means fail, as a last resource, a very different kind of stimulant may be tried, and instead of laying the infant aside in a warm flannel, it should be exposed to sudden and severe cold; which I remember in one case succeeded, after the life of the child had been entirely despaired of. Mr. Herbolt, of Copenhagen, has conceived that many infants perish from the trachea being filled with water; and that infants in these circum- stances might in general be saved, by placing them in such a posi- tion that the water should run out.t I shall just add, that, amongst other symptoms supposed to prove that the child may have sustained irrecoverable injury in the birth, is that of a discoloured and often fetid, or bloody water * I have never found it beneficial to let the funis bleed, except in that particular case of incomplete animation, where from long continued, or very great sudden pressure, the face and head are tumid,dark coloured, and overloaded with blood; where the pulsation in the funis is heavy and oppressed ; and the heart is labouring to maintain the circulation. Under these circumstances, to let the funis bleed to the extent of two or three table-spoonfuls, is good practice; otherwise it is not expedient to divide the funis, as longr as the circulation between the child and the placenta continues strong. —S. M. f Before any attempt is made to expand the lungs of a child by breathing into them, whatever mucus or fluids may be in the mouth or fauces should beremoved. This may be effected by passing the little finger, covered with the fold of a hand- kerchief or soft napkin, into the mouth, and wiping away what may be there col- lected. This should be repeated occasionally, as fresh mucus may accumulate, after the lungs have been made to expand and respire. — S. M. 16 UNDERWOOD ON CHILDREN. forcing out of the nose, after the lungs have been two or three times artificially inflated. Under these circumstances, however, 1 have succeeded, in two or three instances, so far as to animate children sufficiently both to breathe and to cry ; though they after- wards lay in a moaning state for four or five hours, and then expired. To succeed thus far, indeed, if I am rightly informed, may prove of importance, where the course of a family estate may be pending on a living child. I have, however, been fortunate enough to succeed more completely under the most unfavourable circumstances, and, in one instance, after a great quantity of dis- coloured mucus, and something like meconium, had been forced up both from the throat and nose, restored an unusually large child to life. It will be presumed, I dare say, that the above scrupulous atten- tion is not designed to be inculcated in every instance of apparently still-born infants; but where the death of the child may not only not be certainly ascertained, but there has previously been reason to expect it would be brought alive into the world, every possible exertion should be made and persevered in. The great importance, however, of the subject, it is hoped, will be a sufficient apology with most readers for the length of these directions; and as the attempt to restore infants to life has always been a most pleasing employment to myself, the desire of being an occasion of inducing others to a perseverance in the use of the like means, emboldens me to risk the censure of any who may deem it prolix or super- fluous. [The author's anticipations have been fully confirmed by later experience, and especially by that of my friend, Mr. Toogood, of Bridgewater, who has published some interesting cases in point, in the London Medical and Physical Journal, New Series, vol. iii., p. 99, for August, 1827. They are also in perfect accordance with the well-known physiology of the newly-born and very young animal, compared with the same species of adult age.* I. The first object is to excite respiration; and the means of doing so are these : — 1. The fifth pair of nerves should be excited by forcibly dashing very small quantities of cold water on the face,' or by stimulating the nostrils by ammonia, snuff, pepper, or the point of a needle. 2. The spinal nerves should be excited by forcibly dashing cold water on the thorax, and on the thighs, or by tickling, or stimulating the sides, the buttocks, the arms, the soles of the feet, &c. What the par vagum is, as the medium of excitement of the respiration, in ordinary circumstances, the fifth pair, and the lateral spinal nerves, are in other circumstances: it is certain, at least, that * [See the splendid work of Mr. Edwards ; and a paper by the present Editor, in the Philosophical Transactions, for 1832, p. 321. — M. II.] ' ON INFANTS APPARENTLY STILL-BORN. 17 the means recommended frequently induce an act of inspiration, which proves the first of the series so essential to animal life. II. If these attemps to excite respiration fail, inspiration is to be imitated by artificially distending the lungs. 1. To effect this the practitioner's lips are to be applied to those of the infant, interposing a fold of linen, and he is to propel the air from his own chest, slowly and gradually into that of the infant, closing its nostrils, and gently pressing the trachea upon the oeso- phagus. The chest is then to be pressed to induce a full expiration, and allowed to expand so as, if possible, to effect a degree of inspi- ration. 2. But it is important in doing this, that the practitioner himself should previously make several deep and rapid inspirations, and finally a full inspiration. In this manner the air expelled from his lungs into those of the little patient, will contain more oxygen and less carbonic acid, and consequently be more capable of excit- ing the dying embers of life.* III. 1. In the midst of these efforts it should, in the next place, be the office of two other individuals to maintain or restore the temperature of the little infant, by gently but constantly pressing and rubbing its limbs between their warm hands, passing them upwards in the direction of the venous circulation. 2. When respiration is established, thence must still be freely exposed to the air, whilst the temperature of the limbs and body is carefully sustained. 3. As soon as possible, a little warm liquid, as barley water, at blood heat, should be given by means of the proper bottle fur- nished with leather or soft parchment. A tea-spoon must not be used for fear of choking. If the infant draws the liquid through its own lips, by its own efforts, there is no danger. IV. Lastly, if all these remedies should be tried in vain, I would strongly advise galvanio or electric shocks to be passed from the side of the neck to the pit of the stomach, or in the course of any of the respiratory nerves, and their appropriate muscles. No time should be lost in sending for a proper apparatus ; but should the lapse of an hour, or even more, take place, before it can be ob- tained, still it should be sent for and tried. — M. H.] * [I found this suggestion in an interesting communication by Dr. Faraday, in the London and Edinburgh Philosophical Magazine, vol. Hi., p. 241, for Oct. 1833. It is ascertained that respiration may be suspended longer, as in diving, or in experiments, after such repeated forced inspirations, than in ordinary cir- ciimstances, from the greater purity of the air in the lungs. — M. H.] 2* 18 UNDERWOOD ON CHILDREN. SECTION II. ON THE MANAGEMENT OF INFANTS. ON DRY NURSING. Amongst the multifarious matter brought forward in the follow- ing pages, the aliment most adapted to infancy is one of the first importance. Previously, therefore, to treating of diet more ex- tensively, and the general arrangement of children, I shall enter into a discussion of the case of infants intended to be reared without the breast, or brought up, as it is termed, by hand, — a subject esteemed to be of the first importance by writers and practitioners in every age. An attempt to set forth all the improprieties of this mode of training up infants from the birth, would carry me altogether beyond the limits I have assigned to the work. It would be un- pardonable, however, in a work of this sort, not to insist how inadequate every substitute for the breast has been universally found ; and therefore how proper it is, that every child should be suckled, and always by its own mother, where her health can safely admit of it. Reason, instinct, experience, all conspire to support this opinion ; and whoever will determine to attend only to matters of fact, may soon be convinced of it.* Nature herself points it out: all the nobler part of the irrational creation is quali- fied for it, and by instinct obeys — the human race alone, possessed of nobler powers, and rational discernment, perverts those facul- ties to evade its dictates, and to invent excuses for refusing its claims. But puerile, indeed, are all arguments against it, in the greater number of instances ; and herein Dr. Armstrong! seems to have egregiously erred; for though, apparently, an advocate for suckling, he has laboured for arguments to apologize for the spoon and the boat, in too many instances.:): It were easy, perhaps, to * The duty of suckling has the sanction of almost every writer, as well as of many persons of r*nk; and is distinctly noticed in the remote times of Pliny. Van Swieten remarks, that one of the queens of France suckled her own son, and continued it even during a fever. One of her ladies, however, having, on some occasion, given the child her breast, the Queen was so much disgusted at it, that she forced her finger into her son's mouth to excite vomiting, unwilling that it should receive any nourishment but from herself. t Rules to be observed in the nursing of children, with a particular view to those who are brought up by hand, 1777. t I do not recollect to have seen anywhere such good directions for bringing up children by hand, as those published in a little volume, entitled, " Advice to Young Mothers on the Physical Education of Children. By a Grandmother." [1823.] They are much more appropriate and judicious than those of Dr Arm- strong ; but neither the Grandmother, nor Dr. Armstrong, nor any other of the advocates for dry nursing, seem to be aware of the great fatality which attends ON THE MANAGEMENT OF INFANTS. 19 produce as sound arguments against eating more than once a day, because so many people become diseased from excess. On the other hand, a new and very rational argument in favour of breast- milk, is advanced by Mr. Moss, who observes, that the gastric juices of every animal may be supposed to be the best suited to act upon its respective milks. But not only is the breast-milk the only natural,* and most pro- per food for infants, {experience demonstrating no artificial one to be equally easy of digestion and nutritious,) but suckling conduces likewise to the easy recovery of the mother, though she should not be able wholly to support her child by the breast, nor to continue suckling so long as the infant may require it. But though, from much experience, I venture to give this opinion, I do by no means intend to assert that every mother is able to suckle her child, even for the month, or would do well to attempt it; but I am, never- theless, equally satisfied, that many are very well able who do not; and that several, who have only through fear been discouraged from doing it in two or three lyings-in, having afterwards been prevailed upon to make the attempt, have gone on with it several months, enjoyed better health when they suckled than at any other part of their lives, and their children have thriven perfectly well. Art and management will likewise afford some assistance, when the natural constitution alone may not be fully equal to the task. In this view, besides a suitable diet, air, exercise, and a regular manner of living, I will venture to recommend cold bathing, espe- cially in the sea, if the season of the year should permit; and this not only from my own experience, but that of the writer just quoted, who asserts that it is often found particularly useful in restoring the strength, and increasing the milk in nurses of a weak constitution ; adding, that it can never do any harm to a woman merely as a nurse, where no other reason, independent of that the attempt thus to rear children. It has been a part of my duty to endeavour to ascertain the amount of mortality among infants from this source ; and after much careful inquiry and investigation, I am convinced that the attempt to bring up children by hand, proves fatal, in London, to at least seven out of eight of these miserable sufferers ; and this happens, whether the child has never taken the breast at all, or, having been suckled for three or four weeks only, is then weaned. In the country, the mortality among dry nursed children, is not quite so great as jn London, but it is abundantly greater than is generally imagined. The summer [in Great Britain] is the most favourable season for making the attempt; but if parents were fully aware of the hazard to which their children are exposed, in the endeavour thus to bring them up, they would rarely choose to place them under the care of the dry nurse. — S. M, * In some very northern parts of the world, as those of Greenland, and the neighbouring country of the Esquimaux, the breast appears to be, in the strictest propriety of speech, the only food that nature has provided for infants ; insomuch that, whenever a suckling mother happens to die, her infant is buried with her ; experience (one would hope) having demonstrated the inefficacy of the hard and coarse diet which nature has there so sparingly dealt out, it is esteemed an act of compassion to put an end to an infant's sufferings by plunging it into the sea. 20 UNDERWOOD ON CHILDREN. situation, forbids it. The principal caution necessary, being not to bathe too frequently ; more than twice, or at most three times a week, being often injurious to delicate habits. Thus, besides the advantages derived to infants, it appears that there are others resulting to the suckling mother, and some deserving a fur- ther notice. For by this means, where due care is taken, painful in- flammations and suppurations in the breast may often be prevented, as maybe fairlyconcluded,not only from the rarity of such complaints in the British Lying-in Hospital, where almost every woman suckles her infant, but from the like authority of Dr. Nelson, who reports, that " out of 4,400 women who suckled their children, only four had milk-sores, and that these had either no nipples or former sore breasts." It has likewise long been suspected,and of late years more generally imagined, that some of the worst fevers, and more rare ill effects of child-bearing may be prevented by suffering the milk to flow duly to the breasts, and be freely drawn from them, though only for the month. These advantages, one should hope, might tend to induce ladies of rank to set a general example, by performing this kindest and most pleasant office, at least during the month.* But it would be unjust not to add, that whenever they may pur- pose to assume it for a much longer time, they should determine to do it effectually, or they will but injure their children, as well as forfeit many of the advantages and comforts which, in a due exe- cution of it, they would have a right to expect. For a long time, however, writers have successively complained, that notwithstanding the many encouragements often brought to the ears, and urged upon parents, the tyrant, Fashion, has prevailed over the good sense and natural feelings of many, whose maternal * I cannot agree in opinion with Dr. Underwood, that it is right to recommend ladies to suckle, "though only for the month," if they do not intend, or have already determined, not to persevere in performing that office. On the contrary, I think, if they are to suckle their children "only during the month," that it is better, both for themselves and their infants, who, under these circumstances, are never half suckled, not to make the attempt for that short time. The first month of suckling is confessedly attended with more of uneasiness and suffering than is afterwards felt; indeed, after the first difficulties are over- come, this duty is accompanied with sensations of the greatest pleasure and de- light; and it seems cruel to require of the mother to undergo all the trouble and pain of suckling, when she is to be debarred of all its pleasures, But we are told, " It has long been suspected, and of late years more generally imagined, that some of the worst fevers, and more rare ill effects of child-bearinf, "^bus, causa morbi, et accidentia morbum coml tanna From this fanciful distinction, the epithet non-naturals first arose and has been retained in common use to this day, though it cannot be understood rmprrrietv0onen^?Vby "'f^ P'1^™"8, «*"' l° ™ke an apologv for the impropriety of it. Hoffman, for instance, and some others, when thev annlv imp appellation non-natural to air and aliment, are oblioed to suhioin ,hl f' i • «vn anat nn . u i „ , ■, , ' """gen 10 SUD 0111 the 10 loWlnir explanation . » A vetenbus h* res non-naturales appellantur nuoniamv ? corporis essentiam constitutse sunt." n)e"<»niur, quoniam extra ON THE MANAGEMENT OF INFANTS. 31 These are air; meat and drink ; sleep and watching ; motion and rest; retention and secretion ; and the passions of the mind: a due attention to which may prevent many of the evils incident to the tender age. — To begin with the first of these: — ON AIR. The great importance of this has been set forth when speaking of the diseases of infants: I shall here, in a more particular way, observe, that the age, constitution, and circumstances of the child, and the seasons of the year, ought always to be taken into con- sideration ; that being highly proper on one occasion, which would be very detrimental at another. In general, it has been said that warmth is friendly to very young infants, but they should, never- theless, be inured gradually to endure the cold air, which is ab- solutely essential to their health. I cannot, therefore, agree with Dr. Armstrong, who thinks that the reason of the rich losing fewer children than the poor, is from their being kept warmer. On the other hand, it was aptly said by one, that " a warm nursery fills a cold church-yard." In fact, it is not a mere cold, but damp and confined air, that is so injurious to children, and to which the poor are peculiarly exposed, especially during sleep. Much caution, indeed, is necessary on this head in this unsettled climate, and evinces the necessity of parents superintending those to whose care they intrust infant children, since nurserymaids are often in- discreet in keeping them too long in the air at a time, which is a frequent occasion of their taking cold, and deters many parents from sending them abroad so often as they should. Another, and a worse, as well as a common fault of nurses and servants, is that of standing still, with children in their arms, in a current of air, or either sitting down with other servants, and suffering children who can run about, to play at a little distance by themselves; to sit down on the grass, or in damp places, and such like irregularities; the consequences of which are often a long confinement to a warm room, and either a prohibition against going out so much as they ought, or a fresh cold, owing to repetition of such irregularities. But if children be properly clothed and attended to, they will not only endure a great deal of very cold, but of other inclement weather; it is true that caution and prudence are required in train- ing up infants to withstand the influence of cold, and to profit from being abroad when the air is very cold or moist. Yet it certainly may be accomplished; and it is a known fact, both amongst the higher as well as inferior ranks of people, that those children are the healthiest, and suffer the least from colds, who are accustomed to be abroad in almost all kinds of weather. But to render chil- dren thus strong and healthy, it is not sufficient that they be abroad daily in a coach ; they should be carried on the arm, and be put on their feet at a proper age, and partake of such exercise for a reasonable time, as shall keep them moderately warm, and 32 UNDERWOOD Ox\ CHILDREN. bring them home in a glow, instead of wishing to rush toward a fire the moment they return; such transitions being always im- proper, and only rendering children more liable to take cold. Kruger has some such pertinent remarks on this head, as it will scarce be thought a digression to transcribe: — "The important step," savs he, "a man takes into this world, imparts to him all the privileges thereof, of which this is one — the ability to bear the effects of the air. Why, then, debar him from this privilege? as he is all his life to be encompassed with this air, at one time cold, at another warm, now moist, again dry. For the cold of the air so anxiously avoided, brings along with it the means that secure against its own inclemency ; the great strength of fibres imparted by it to the child, procuring, by means of a brisker circulation, a greater degree of heat, and consequently the reverse of its violent impression. This, indeed, may seem unintelligible to those who imagine the human body to be only an hydraulic machine, consist- ing of innumerable tubes, in which the wheel is moved without a proper power, consequently without a sufficient reason : not to those who can distinguish between the effects of nature and art; who are apprised of the power that moves the animal body, and that the sensations are such a power, which arise without our knowledge and our will. To such only it will be intelligible, in what manner an increased resistance, produced by the cold in the solids and fluids, is capable of bracing the heart, the source of life. From a slight knowledge of mechanics we come to understand, that the resistance diminishes that power which in animal bodies is increased ; come to see, that the most ingenious constructions produce no manner of motion; that all mec'hanical laws are, in- deed, perfectly just, but more accurately to be determined, in order to a proper application of them to the human body, in which the will, imagination, and sensations are the springs of motion, without which all motion would cease, and only leave a machine resem- bling a water-work, to be carried about by wind. We need only appeal to experience, which will teach us that, in order to a health- ful state, we need not be brought up like those who are indulged with a bed of down, and a warm room, but those, of whom no other extraordinary care being taken, are greatly left to their own disposal." I cannot better close these remarks on the benefit of a pure air, than by quoting the remarks of the Rev. John Howlett; who ob- serves, that in consequence of the humane suggestions of Mr. Jonas Hanway, about fifty years ago, an act of Parliament was passed, obliging the parish officers of London and Westminster to send their infant poor to be nursed in the country, at proper distances from town. Before this time not above one in twenty-four poor children received into the workhouses lived to be a year old so that out of two thousand eight-hundred, the average annual imm ber admitted, two thousand six hundred and ninety died • whereas since this measure was adopted, onlv four hundred and fifty out of ON THE MANAGEMENT OF INFANTS. 33 the whole number died; and the greater part of these deaths happen during the three weeks that the children are kept in the workhouses. I am afraid that Mr. Underwood's strongly-expressed opinion of the absolute necessity of inuring very young infants to endure the cold air, as essential to their health, supported as it is by other popular writers, has been productive of great and extensive mischief. That pure air is essential to the health and growth of children, is too evident a proposition to require proof; and that from the open air of temperate quality, all children, even very young in- fants, derive great advantages, is daily manifested by their general healthy appearance, by the colour of their cheeks and lips, and by the firm feel imparted to their muscles. But a belief seems to obtain, that the more cold the temperature of the open air, so much the more pure and bracing will it prove. Now the contrary is rather the fact. It is the temperate quality, not the coldness of the air, which renders it pure and salubrious. Our coldest winds blow from the proverbially unsalutary north and east ;* and during the prevalence of these winds, the most severe pulmonary affections, croups, sore throats, swelled glands, &c, continually occur ; not only among children, but among adults likewise, who are much exposed to their influence. It is rather extraordinary that we should be urged to expose our " young infants " to " very cold and other inclement weather," for the purpose of hardening them, as it is absurdly called, when we find from experience that the young of the " irrational creation " are injured by such exposure. The gardener, well knowing that " the tyrannous breathing of the north shakes all our buds from blowing, carefully preserves his young plants from the bleak weather ; the good housewife secures her young broods of turkeys and other poultry; and the husbandman his tender calves and lambs from the cold and piercing winds : it is our children alone that we voluntarily expose to the chilling and inclement sky. Dr. Underwood, indeed, advises that the children should be properly clothed and attended to ; this will moderate the evil, but will not cure it. Warm clothing alone is not sufficient to sustain the animal temperature; combined with exercise, indeed it admirably answers this purpose, but very young infants are incapable of the necessary exercise ; and though warmly clad, soon suffer under the depress- ing effects of cold. Nor is this consequence of cold upon passive, quiescent subjects confined to infants. Those who drive or ride in open carriages, are usually clothed with as much care to ex- * Wind from the east Is neither good for man nor beast. — Old Proverb. 34 UNDERWOOD ON CHILDREN. elude the cold, as the infants who are carried in their nurses arms; but, notwithstanding, frequently suffer extremely from the degree of cold to which they are exposed ; and why should children, who are less able to bear such effects of cold, be inured to that which even strong men and women cannot sustain with impunity ? True it is that some very robust infants endure the cold in a very remarkable manner, and these are often quoted as examples of the "benefit to be expected from the hardening system ; but a wise man will be cautious how he follows that as an example, which is mentioned only because it is extraordinary. The rules which are to guide our practice should be drawn from what is usual, not from what is uncommon; yet we are too often led away to imitate what is marvellous, and despise that which is more accordant with nature's laws and precepts. Thus, on the evidence of one strong, vigorous infant, the hardening system is applauded and adopted; and we neglect to inquire what numbers have sunk into the silent grave, in the vain attempt to render them, by exposure to the cold, equally vigorous and robust. — S. M. [The author of the " Letters" observes, " there is a degree of temperature which would be incompatible with health, growth, and life. Yet young animals bear heat comparatively much better than older animals, and much better than cold. This is evident in regard to the human species, from the fact that children born under an Indian sun, do well during the first two or three years. They then begin to droop, and it becomes necessary to send them to breathe an European air. Still the heat of a hot summer, and of heated rooms, is extremely injurious to infants, whom it exhausts by its oppressive effects on the sensations and on the respiration, and by inducing profuse transpiration. But it requires still greater precaution to avoid cold than heat, generally speaking; and we have more facts to bear upon this point, that upon the question of the effects of heat. Foals, calves, and lambs brought forth amidst severe cold, do not thrive, but, if not succoured by warmth, pine and remain puny, or die. Chickens hatched under similar circumstances of inclement weather, also pine and become affected with what is termed the 'pip,' the feathers hanging loosely or falling off; and young tur- keys, especially, die in considerable numbers. So of infants born in the early months of winter, or of "summer, I have good reason to suppose that the former die in a much larger proportion than the latter. But if cold be thus pernicious, damp is still more so. It is in a damp season that the young of various animals suffer most and pine, and die. Damp upon the body is, indeed, a perpetual source of cold by evaporation ; and dampness, in the form of vesicular vapour in the atmosphere, becomes equally a source of cold by ON THE MANAGEMENT OF INFANTS. 35 its conducting power, or power of carrying away the heat of the body. Young asses exposed to damp and cold become affected with tubercles in the lungs ; and lambs are affected with the' rot.' From these facts, and from others observed in the human subject, we should learn to guard the infant from these powerful exciting causes of tuberculous disease. On the other hand, exposure to a full and free air has a most invigorating and vivifying influence; and nothing is more inju- rious than close rooms, or crowded apartments. All these circumstances must be taken into consideration, in de- termining the proper mode of treating infants. Exposure to cold or damp is highly pernicious; the respiration and the contact of a free and fresh air are highly beneficial. What plan, then, is to be adopted? The infant should breathe a pure air, — should be taken into the free atmosphere ; but it should be guarded by proper clothing from its inclemencies. The arms and the legs should never be seen purple, from stagnant venous blood. The good effects of a pure and free air should be further secured by conjoin- ing the warmth of the nurse in infancy, and active exercise in later years." " It frequently happens that the infant is affected with coldness of the feet, and, as a consequence, with severe pain of the bowels. The effectual remedy is to hold and press the feet continually with a warm hand. " When the infant is in pain, then let the feet be examined ; if these be cold, it will frequently be found that the pain of the bowels ceases as the temperature of the feet is restored. " But before pain is induced, coldness of the extremities begins to impair the functions of the bowels. Even in adult age, the stomach performs its office well or ill, according as the feet are warm or cold. But in infancy the circulation is feebler, especially at the extreme parts of the system, and, as a natural consequence, the temperature fails. The hand affords a constant source of heat. If your infant look unhappy or be in pain, examine its feet; if they be cold, warm them with the pressure of a warm hand; you will find it answer this pressure by pushing its little feet; its cry will be changed into the cooing before mentioned, the expression of happiness in early infancy." " It is plain, from the beautiful experiments of Mons. Edwards, that the power or faculty of producing heat, is lower in the very young animal than in the adult. The young sooner lose their temperature, as ascertained by the thermometer, than the older ; and have less power of restoration. The powers of infants in this respect should never be tried. Such trials almost always issue in absolute debility, and this in an impaired state of the functions of digestion, nutrition, and growth. If the hardy bear such a trial, the feeble or delicate sicken or sink under it." " From these observations, then, we may fairly conclude that 36 UNDERWOOD ON CHILDREN. infants should always be washed with warm water; not with tepid, still less with cold. The general surface, and especially the feet, should be rubbed, not only until they are perfectly dry, but until they glow with warmth. " Young infants should be taken into the free and open air. But the face should be protected from the too severe impressions of cold ; and the general surface, but especially the arms and legs, from losing their temperature. The whole surface of the body should be covered with flannel, at all times and in all seasons; and the arms and hands, legs and feet, should, instead of being exposed, as they usually are, be defended from the external cold with double care. The rest of the clothing should vary with the temperature and degree of dampness of the external air. " The head alone should be kept cool. The head has, indeed, less disposition to lose its temperature than the other parts, and much less than the extremities. The circulation in the brain is also developed in infancy in a much greater degree, comparatively, than in later years: and we know that this period of life is parti- cularly subject to inflammation and effusion within the head. " Let us further learn a lesson from the habits of the inferior animals. Observe how the dog and the cat protect their little ones from the external cold, and how the hen gathers her chickens under her wings. Observe how these young animals thrive, com- pared with others made the sport of children, and thus frequently taken and exposed to the chilling influence of the air. Observe that indulgent and affectionate creature, the dog: for five or six days, the mother's presence with her puppies is incessant, is unin- terrupted. At this period she begins to leave them to nestle together, and so, for a short time, to preserve their own temperature. In an actual case of this kind, I was surprised one day (the fifth) to meet the mother of my little brood of puppies at the door of the room in which they lay; a few days afterwards, my surprise was no less on meeting the same attentive creature, which nothing could induce to leave her young ones before, at the top of an adjoining staircase ! Even from the little puppies themselves a lesson might be learnt; their contention was not, like that of the world, which should be uppermost, but which should be under the rest, and so protected by them from the chilling influence of the atmosphere. " There is no protection so light, and at the same time so effec- tual, as a lace, muslin, or crape veil. An atmosphere is formed between this and the face or person of the infant, and is the best non-conductor of heat; whilst the limbs are not encumbered by a weight of clothes. Lace, muslin, or crape, may be used, according to the degree of cold. " The air requires to be considered in other relations besides that of its temperature. The difference between the salubrity of the atmosphere of a crowded population, and of the open country and especially of the vicinity of the sea, is very remarkable. Some- ON THE MANAGEMENT OF INFANTS. 37 times this alone is the hidden source of indisposition, pining, or withering, in an infant or young child. I have known a little patient exhibit in its cheeks, flesh, and spirits, the effects of this difference in the short space of a few days."—Pp. 78-82; 136-139 ; 82-8 7. J ON SHORT COATING. It will be advisable, in order to inure infants to the air, that this change in their dress be made as early as the season of the year will permit: but their dress should be still loose and easy. Children are frequently kept without stockings till they are three or four years old, and boys often till they are breeched; but, on many occasions, this exposure of the legs to cold is attended with ill consequences. For want of caution in this particular, tender children suffer exceedingly in severe winters, and are distressed with chilblains, merely for want of proper covering to their limbs. I have seen a child of four years old, the daughter of people of fashion, whose legs were covered with these sores quite up to the knee, and yet her mother could not be prevailed upon in time to suffer stockings to be put on, because strong and healthy children are thought to be better without them. And there is an additional reason for such cautions, from the fashionable mistake of habiting your children indiscriminately too thinly; it is obvious that a mode of dress appropriate to the athletic, may be very hazardous to those of a delicate habit. When boys come to be breeched, it will with more propriety be done at the beginning of winter than in summer, as the dress is, upon the whole, warmer, especially about the chest; and it is always important to keep this part warm, since inflammations of the lungs are often brought on by the exposure of the chest to the cold. We proceed now to the second article under the head of the NON-NATURALS :-- MEAT AND DRINK, Which, is, indeed, worthy of ample discussion. In the first place, it may be remarked, that when an infant is to be suckled by its own mother, it can rarely stand in need of food till the time nature will bring milk into her breast, supposing the child be laid to it in proper time; which ought to be as soon as the mother is, by sleep or otherwise, sufficiently refreshed to under- go the fatigue that an attempt to suckle may occasion. This method, however unusual with some, is the most agreeable to nature, and to observation on the irrational species, which in many things are the very best guides we can follow.* And herein I * This subject is largely and elegantly treated by Dr. Gregory, in his Compa- rative View, before quoted. 4 38 UNDERWOOD ON CHILDREN. am constrained to differ from a late writer,* whom I have more than once quoted with approbation; for, by means of putting the child early to the breast, especially the first time of suckling, the nipple will be formed, and the milk be gradually brought on. Hence much pain and its consequences will be prevented, as well as the frequency of sore nipples,t which in a first lying-in, have been wont to occasion no inconsiderable trouble ; but should this, or even an abscess take place, they are both far less distressing, under proper management, than has been usually imagined ;J and what is of great importance, the latter is attended with a negative good: no woman, I believe, having been seized with puerperal fever who had a milk abscess. [" There are three cogent reasons for a mother being the nurse of her own infant: they are, that, in this manner, a troublesome state of the nipples, present inflammation, and future cancer of the breast, are best prevented. " Generally speaking, the application of the infant to the breast is too tardy : some pretend that it should not be made until the third day ; how those persons became so wise, it is difficult to say. Is nature usually so improvident — so wrong in her calcula- tions ? Do we observe that young animals of necessity pine for three days ? " If the infant be not early applied, the breast becomes swollen, and the nipple drawn in ; and nursing becomes at once difficult and painful to the mother, and a source of fretfulness to the infant. The swollen condition of the breast also frequently passes into inflam- mation, and this often issues in abscess. " Let the infant, then, be applied to the breast, as soon as the fatigue of labour is perfectly over, if its mother be doing well. Its mouth is softer than that of a nurse. The secretion of milk will be * Mr. Moss. f It may be proper to notice in this place, that a colour is sometimes given to an infant's stools, from the blood it has swallowed, when the nipples of the suckling mother have continued to be very sore; a circumstance, indeed, that does not often occur, but it has given alarm for want of the true cause being understood. The stools in this case are of a strange blackish colour, very similar to the first stools of new-born infants. X f>ee the author's Surgical Tracts, in which the milk abscess and sore nipples are fully considered, and a successful and easy method of treatment pointed out. From motives of benevolence, I beg leave to mention here a contrivance, which has succeeded far beyond every former device, for defending the nipples, and enabling women to nourish their own children, that I cannot but wish to extend its advantages by this public recommendation of the nipple-shield. It was con- trived by Mrs. Relf, an intelligent monthly nurse, and is to be procured from any of the surgeon's instrument makers. In Struve's Education and Treatment of Children, published in Hanover, some apparently similar contrivance is mentioned, called the wendehtaedtian, by which it is said that suckling may be accomplished, although the nipples should be very deficient in their formation ; but the writer has given no description of this useful invention. ON THE MANAGEMENT OF INFANTS. 39 gently excited, and the milk secreted will be equally gently re- moved. There will then be no milk abscess, no milk fever, fn many cases in which these must otherwise occur. The latter, as well as the former, is often the effect of the painful, tender, and tumid state of the mammae. " The other fact is also a result of experience. Those mothers who have suckled their own children have been far less subject to cancer, in later life, than those who have not done so. " In recommending mothers to be nurses, it is important, how- ever, to add the remark — that the breast, and the general health, and the infant, all suffer from lactation too long continued. The breast, the strength, and the secretion, become alike morbidly affected." — Letters, p. 135, &c] But should the mother be unable to suckle, and a wet nurse be engaged, it will be proper to put the child to the breast after it has taken a dose of opening medicine, which in such a case should be soon premised; or, if an attempt is to be made to bring it up by hand, a spoonful or two of thin water-gruel or barley water, not too much sweetened, may be given, which will usually set it asleep, after which it will be ready for whatever culinary food shall be thought proper for it. And on this article, a vast crowd of absurdities open upon us at once ; and many of them with the sanction of custom and authority. I shall first advert to the thickness of the food; and it has, indeed, been matter of wonder, how the custom of stuffing new-born in- fants with thick food, whether made of bread or any other sub- stance, could become so universal, or the idea enter the mind of a parent, that such heavy food could be fit for its nourishment. It would be well that all who are entrusted with the management of children, should have more just ideas of the manner in which we are nourished ; and especially, that it is not from the great quan- tity, nor from the nutritious quality of the food, abstractedly con- sidered. Every one, who gives due attention to the subject, may be led to conceive that our nourishment must necessarily arise from the use the stomach makes of the food it receives, which is to pass through such a change in digestion as renders it balsamic, and fit to renew the mass of blood which is daily wasted and con- sumed. An improper kind of food, or too great a quantity taken at a time, or too hastily, before the stomach has duly disposed of its former contents, prevents this work of digestion ; and by mak- ing bad juices, weakens instead of strengthens the habit, and in the end produces worms, convulsions, rickets, scrofula, slow fevers, purging, and a fatal marasmus. Nature, it should be considered, has provided milk alone for supporting the young of all mammiferous animals; and the milk of women is certainly amongst the thinnest of all, but at the same time far more nutritive than bread, and probably than any other milk, as it contains a greater proportion of saccharine matter, 40 UNDBRWOOD ON CHILDREN. which is thought to be that quality in all our food which renders it nutritious. It is true, bread, as it requires more digestion, will remain longer in the stomach both of infants and adults; and hence, probably, because it satisfies the present cravings, it has been con- ceived to afford a greater proportion of nourishment; but bread, when mixed up wholly with water, as is frequently done, is far less nutritive than has been imagined. Children ought to be fre- quently hungry, and as often supplied with light food, of which milk is really the most nourishing that we are acquainted with. This could never be doubted but from its passing so quickly out of the stomach, on which account, indeed, though not the properest food for adults, employed at hard labour, and many hours from home, it is the fittest of all for the sedentary life of a tender infant, who cannot get the whole of that nutriture contained in bread, or other solid food, which the stomach of the adult is able to extract. It must have been for want of attending to this consideration, that Dr. Armstrong has said so much in favour of bread and other thick victuals ; which, by-the-by, he began to make use of for his own children (from its success in whom he ventured to recommend it) at the age of six or seven months; a matter very different from cramming an infant with it almost as soon as it is born. Every- thing the stomach cannot digest, may be justly considered as a poison; which, if not puked up, or very soon avoided by stool, may occasion sickness, gripes, what are called inward fits, and all the train of bowel complaints, which may terminate in one or other of the evils just mentioned. And this is almost daily exem- plified ; new-born infants, after being so fed, and seemingly thriv- ing for a short time, are often suddenly attacked with a dangerous purging, or carried off by fits. Milk itself, like all the other animal juices, is produced from food taken in by the mother, and is the richest part of it. It is in her stomach that the aliment is digested, which, by a combination of powers in the chylopoetic viscera, is so far animalized as to be con- verted into a kind of white blood, from which every animal body is daily recruited. And before an infant has acquired strength enough to convert solid food into this wholesome chyle, the parent, by this wise substitution in nature, has, in a great measure, previously accomplished this work for the infant she is to nourish. During infancy, therefore, both nature and reason most clearly point out the expediency of a milk-diet ;* but how long it ought to be persevered in, or infants wholly confined to it, is not easily ascertained, and will be further considered in its place, with a lati- tudethat the question demands. There is a period in life, indeed, * Whether the parent be able to suckle her own child, or that office be performed by a hired nurse, is not here particularly considered. The design is only to prove that milk is in general the most proper food for an infant. Whe- ther that, indeed, be prepared by its own mother, a nurse, or by such animals as the cow or the ass, is equally to the purpose : where the former cannot be had, the best and most natural substitute should be provided. ON THE MANAGEMENT OF INFANTS. 41 to which this nutriment is more particularly adapted, both experi- ence and theory demonstrating it to be more suitable to young people than adults, as Arbuthnot has remarked; and it has been observed, that it does not appear that the gastric juice of the cow will produce the same change upon milk, as that of the calf does, which is, therefore, constantly made use of in dairies, for separating the curd from the whey. It can scarcely be improper, before I entirely quit the article of suckling, to relate a recent instance, and a remarkable one out of many, as a proof of the degrees to which infants may pine for the breast, even to the great hazard of perishing for the want of it, where the real cause of the disease is not suspected. This little history will likewise further serve to illustrate the preference of human milk, which has been so strongly insisted upon. The infant alluded to was very healthy when it was three months old, and was then weaned, on account of the illness of the wet- nurse ; but soon afterwards ceased to thrive, and had continual bowel complaints. At the age of nine months I was desired to visit it, and was informed that it slept very little, was almost inces- santly crying, and had for many days brought up nearly all its food; it was become very rickety, and had the appearance of an infant almost starved. Trial had been made of every kind of food, except the breast, and the child had been many weeks under the care of an experienced apothecary ; it was constantly in a state of purg- ing, and seemed to have been just keep alive by art. On the first sight of the child, and upon the face of this account, it was very evident that this infant was not nourished by the food it received, and that the complaint lay only in the first passages ; but, reduced as it was, I had little expectation from medicines, and therefore gave as my opinion that either the child still pined for the breast, (in which case, I doubted not, it would take it, though it had now been weaned six months,) or that it ought to be carried immediately into the country, and be supported some time only upon asses' milk, or perhaps be fed now and then with a little good broth. My advice being taken, a good breast was procured, which the infant seized the moment it was put to it; and, after sucking suf- ficiently, soon fell asleep for several hours, waked without scream- ing, and took the breast again. It is sufficient to add, that the child ceased to puke or be purged, and, after sucking eight or nine months longer, became in the end a fine, healthy child. Although this instance has something extraordinary in it, in respect to the length of time the child had been taken from the breast; and though infants are generally completely weaned in six or seven days at the furthest; yet similar occurrences, differing only in degree, are occasionally met with; it being no uncommon thing for children, when ill, to take the breast again after seeming to be thoroughly weaned for three or four weeks. And this cir- cumstance is the more worthy of notice, as it sometimes leads to a 4* 42 UNDERWOOD ON CHILDREN. very fortunate result, and should induce us to make the trial when- ever infants newly weaned may be seized with any complaint, under which a return to the breast may be desirable. Such, par- ticularly, is the hooping-cough ; under which I have known a child of more than a year old, and apparently thoroughly weaned for a month, take to the breast of a stranger very cheerfully, in the presence of its former nurse, with the precaution only of leading it to make the first attempts during the night. Such children for the few first days turn away from the new wet-nurse to their former one, as soon as they have satisfied themselves at the breast, and go back to the nurse again very readily whenever they find an inclination to suck. To return : I am free, then, to lay it down as an axiom, that milk ought to be the chief part of the diet of infants for a certain time, whether it be breast-milk or any other ;* and that it alone will prove sufficiently nourishing for nineteen out of twenty children ; perhaps I might say ninety-nine out of a hundred. Ex- ceptions, I believe,there maybe, but these exceptions will be few in number; and fewer children would perish, if so fed, than are destroyed by rushing into the contrary extreme of feeding them with more viscid food. If, however, a strong child, fed upon milk alone, should, at the end of the month, seem really not satisfied, and always craving the moment after it has fed ; in such a case as this, it may have in addition, a little boiled bread, or other farina- ceous diet, two or three times a day ; but I should be very cautious of extending it further.t In the case, however, of an infant at the breast, if it be always craving as soon as it is taken from it, the occasion of its craving will generally be found to be in the nurse's milk; previously, therefore, to aliow'ing more solid food, the quality of the milk, as well as the state of the nurse's health, should be inquired into, and the milk be changed, if its goodness be suspected ; and, should its quantity be found deficient, its quality is always proportionally inferior. Perhaps, where bread and milk is allowed, whether at a very early or later period, it would be an advantage to boil a piece of roll, together with the upper crust, in a good deal of water, till it is very soft, by which means the bread will part with some of its acescent quality; the water should then be strained off, and the bread be mixed up with the milk, which ought to be boiled if the child is very young, or inclined to a purging.:}: * See Dr. Parsons, who has some judicious observations on this head. f'lnltaly Holland, Turkey, and through the whole Levant, children are rarely allowed any other food than the breast-milk during the first year."- (Buffon.) And the savages in Canada suckle for four or five, and often six or seven years. In some extreme northern climates, (as hath been already re- marked) we know they can have no other food for a long time; and yet there the death of an infant .9 as rare an event as that of a suckling mother % For infants subject to acidity and indigestion, it will be found very advan- tageous to bo, the milk two or three times, waiting after each till the mflk shaU cool sufficiently to allow the curd, or cheesv Darts to ri-„ *l\u nefmilK s,h.aU dh-Hb. ca,eL,y ,aken off; wherebya "acKa!E,"£ i° "'f Sfe lasUv dlgttlible part of ihe m,lk will ,emai„ ,„ offend such J,^ l^hT eas,l)r ON THE MANAGEMENT OF INFANTS. 43 It would, I perceive, lead me beyond all bounds to enter further into this matter ; I shall, therefore, only add, that infants certainly ought not to be fed lying on their backs, but sitting upright, how- soever contrary to long established usage, as they will in this posi- tion swallow their food more easily, as well as more readily perceive when they have had enough. So also children nourished at the breast, ought to be withdrawn from it for a short time, especially just after waking from a long sleep ; whereby, besides other advantages, much undue labour to the stomach may be pre- vented, as well as enabling it to retain what it has received, apart of which is otherwise very frequently thrown up. If milk be the proper food for infants brought up by hand, the next inquiry will naturally be, what milk is the best ? and what is the fittest instrument for feeding with ? And it is from long expe- rience, as well as from reason and analogy, that I venture again to recommend the ingenious contrivance of the late Dr. Hugh Smith, which I shall presently describe. The milk he likewise advises, is cow's milk, in preference to all others, as being the most nourishing, and therefore, in general, the most proper; and I wish to refer the inquisitive reader to such other reasons as the doctor has given,* to which I can add nothing but my own experience of their validity. To the milk should be added a little thin gruel, or barley-water, which forms a very smooth and pleasant nourish- ment ; the latter being more proper if the bowels are too open. A few weeks after birth, and I think in general the sooner the better, instead of the barley-water or gruel, there should be mixed with the milk a small quantity of a light jelly made from harts- horn shavings, boiled in water to the consistence that veal broth acquires when it has stood to be cold.t The design of the jelly is obvious and rational, at once calculated to render the food more nutritive, as well as to correct in some measure the acescency of the milk ; this quality being thought to abound in the milk of dif- ferent animals, in proportion to the quality of vegetables on which they feed.J And the milk of quadrupeds we know is produced from vegetable juices only, whilst breast-milk is formed by a mix- ture of animal and vegetable food. A little Lisbon sugar may be added to this compound of jelly and milk, if the child be not inclined to a purging ; or in that case a little loaf sugar ; but the less of either the better. It will be proper to have the milk and jelly warmed separately, and no more at a time than may be wanted; when it should be put into the sucking pot, which must be very carefully cleansed and scalded, at least once every day, ♦See his Treatise on the Management of Children, in a Series of Letters addressed to Married Women. f There is sometimes a difficulty in making this jelly, on account of the harts- horn being bad ; those who shave it, often mixing the shavings of trotters, which may, however, be distinguished by their brittleness. If the shavings are good, two ounces of them, boiled very slowly in a quart of water to a pint, will make the jelly of a proper consistence. X See Dr. Young, "De Natura et Usu Lactis, in Divereis Animalibus." 44 UNDERWOOD ON CHILDREN. and the spout be thoroughly rinsed, lest any sour curds sncml aid other irregularities of the digestive canal by the acids which it contains ; — to say nothing of the effects of the compound so often sold under the name of port wine. 5 50 UNDERWOOD ON CHILDREN. Perhaps much more has been said on the subject of acidity by some writers than really ought to have been; or it may at least be suspected, that a proper attention has not been paid to me peculiar circumstances of infants, who are all much disposed to it. Acidity, when injurious, is probably oftentimes rather an effect than the first cause of the disorders of infants. It seems, indeed, to be natural to them, arising alike from the weakness of their organs of digestion, and the nature of their food ; though there is no doubt that their complaints are afterwards aggravated by an abounding acid, or rather, probably, from this natural acid be- coming morbidly acrid, through over-feeding, and other errors in their diet, or from its being accidentally confined in the first pas- sages. Nature, however, seems to have designed the food of infants to be acescent; and till the body be disordered, and digestion impaired from one cause or other,* this quality of their food is not likely to be very injurious to them : and probably is far less so, in a general way, than food of a very alkaline nature would be, with a like weak digestion. It is true, indeed, that as many similar com- plaints in adults, who feed on different diets, will, caeterisparibus, have their varieties,and each have some relation to the different qua- lities of their food; so it is not to be wondered at, that the com- plaints of infants should be attended with wind, and other marks of acidity, which in adults are usually the least hurtful of all; and are, indeed, for the most part, pretty easily corrected in children, while that is the only complaint. When they are much troubled with wind, therefore, it cannot be wrong to mix some carminative seeds, or the waters distilled from them, now and then, with their food; such as sweet fennel, or cardamom seeds, bruised very fine; but the aq. anethi is that I have generally recommended, and, being a liquid, is always ready to be added to the food, without loss of time.t * Such cause, it has been observed, may be an over quantity, or too sweet a food, or heavy and indigestible diet; which, indeed, prove more frequent occa- sion of a distempered acidity than anything else. t The practice of mixing spices and carminatives with the food of infants and young children (among the lower classes in London, common gin is the carmi- native always used) is very objectionable; on no account more, than that it soon begets a habit of giving, every day and at every meal, hot and stimulating food. The more simple and plain the diet of children is made, the more will it conduce to establish and maintain good health. Spiced or spirituous food produces an uneasy sensation at the stomach, and great thirst; this occasions the child to cry, and to quiet it more food is given, which it swallows with avidity on account of its thirstiness, and thus much more is received into the stomach than can be properly digested and converted into nourishment. Whatever of cordials or carminatives children may occasionally require, should be given medicinally; and, in my opinion, it is always right to give every kind of medicine distinct from the food.(6) — S. M. (b) We occasionally meet in this country with persons, who have some pretensions to common sense and education too, dosing their children daily, if not at every meal, with cayenne pepper, in the manner reprobated in the preceding note by Dr. Merriman. ON THE MANAGEMENT OF INFANTS. 51 [The real objection to the author's proposition to give carmina- tives is, that they but relieve the effect of a disorder of the stomach or bowels, and leave that disorder unremoved, to induce similar, or other and more serious, effects afterwards. A dose of magnesia given over night, and made operative, if necessary, by the lave- ment the next morning, would render the aqua anethi unnecessary, and secure the little patient, not only from colics, but from more serious and dangerous evils; and, I must say, from experience, that the best mode of administering the magnesia is in the infant's last meal. Having mentioned the warm-water injection, I may further state that it must henceforth rank amongst the most important of our remedies for infants and children. It should be administered whenever the infant's bowels are not fully relieved by half an hour after breakfast. In this way a regular state of the bowels is secured, the morbid effects — wind, and a thousand others of a loaded bowel, are prevented, and the child is kept in health. As a remedy, it is not less efficacious : it has often restored the due secretions of bile, &c, when calomel itself had failed. The proper mode of securing the full effect of the injection is to give a mild aperient over night; this brings the alvine matters into the last intestine, their natural reservoir ; and this is, in its turn, relieved by the lavement. — M. H.] But though such an occasional addition to their food is often exceedingly useful, I cannot help speaking against its being made a constant practice ; by which children not only suffer when by accident, or absence from home, it has been neglected, but it destroys the very end for which it was used, by the stomach becoming accustomed to it. Children, however, become less subject to wind and hurtful acidities as they grow older, and the stomach gets stronger, as it is called. But should these complaints, notwithstanding, continue obstinate, a little fine powder of camomile flowers, or a few drops of tinctura columbo, mixed in water, and warmed with a little ginger, will prove exceedingly bracing to the stomach and bowels, and render them less disposed to acidity. Exercise also, according to the age and strength, is a grand preventive and remedy; and especially making infants break wind after sucking or feeding. And this may generally be effected, as every one knows, by raising the infant up, and gently tapping it on the back, or rubbing its stomach before it be laid in the cradle to sleep. I have only to add, that, when through an abundant acid milk is frequently thrown up curdled, a little prepared oyster-shell powder may be added to it, or a very small quantity of almond- soap, or of common salt, which will not at all injure the flavour, and will prevent this change happening too soon in the sto- mach. 52 UNDERWOOD ON CHILDREN. [" Whenever food is given, it is an essential point to let it be sucked out of the bottle. It is then taken in a natural way. It passes slowly through the mouth, and is intimately mingled with the saliva, the quantity of which is far greater than is usally sup- posed, and its influence on digestion highly important. '• The effects of nursing or giving food should be observed. If the stomach become flatulent, or the bowels pained or disordered, something wrong has been done, and must be corrected. The infant has taken too much or too often, or some improper kind of food. Each infant will thus supply its own peculiar rule of diet, and feeding or nursing. It only requires intelligence and obser- vation on the part of its mother, its natural nurse, to discover it. " I dare say that you are naturalist enough to know that animals have been divided into gnawers, fearers, grinders, &c, according to the kind of teeth with which they are endowed. Now the in- fant is supposed to pass from one of these classes into the other. They first cut the front teeth, termed incisors, or cutters; then fol- low the canine, or tearers, termed also eye-teeth; then the flat grinders, or molares. Until the infant has teeth, suction seems indubitably the natural mode of taking food; when its incisors come through, may it not have something to gnaw? when it puts forth its canine teeth, some animal solid to tear ? and, lastly, vegetable food for its grinders, when these appear ? Some prin- ciple of this sort, at least, is supposed to obtain ; and I think it is worthy of your attention and reflexion. It will preserve you from the error of feeding your infant with a spoon, or giving it minced meat. On the contrary, you will not be content without teaching it to suck, to gnaw, to tear, to grind its own food, as it may be deemed right to give it, with its own lips and teeth. Some per- sons have, from their infancy, gulped down their food, to the over- burdening of the stomach, which has thus more than its own office to perform. Teach your child — and it may easily be taught this, and. everything — to take its food slowly, to retain it long in its mouth, to swallow it tardily ; and it will then, if it be proper food, be digested and assimilated, instead of first annoying the stomach and then disordering the bowels. " The great error committed in regard to the diet of infants, is not so much that of improper kinds of food, as of its undue quan- tity. It is plain that food is the source of strength and nutrition to the body. Short-sighted, unreflecting nurses are apt to imagine that that which confers these benefits in small quantity, must do so still more perfectly in increased quantity. They forget that if overloaded, the stomach does not digest at all, and either rejects the food, or is oppressed under its load, or conveys it in a morbid state into the bowels, which are irritated and disturbed in their turn. They forget too that the stomach requires intervals of re- pose. I believe we do not know the vast advantages of abstinence as a means of the prevention and cure of diseases. Many a case' of flatulency and of griping might be cured by this simple means ON THE MANAGEMENT OF INFANTS. 53 alone ; and it is a far more natural method of treatment than the usual immediate recourse to medicine, every dose of which costs the constitution something. Medicine indeed always acts by sub- stituting one unnatural and morbid condition for another. " To return to the subject of diet. The stomach even of an infant will bear a little improper food with greater impunity than too much of that which is most suitable. I believe few infants, if any, among the rich have suffered from too little food, but an innumerable number have paid with their lives the penalty of overfeeding. It may be truly said, that mothers evince far less thought and judgment in regard to the quantity than with respect to the quality of the food they administer. " It is an important remark, that an infant will take less, the more slowly its food is given. This is an additional motive for feeding it very deliberately. " I have hitherto said nothing about asses' milk. It is doubtless highly proper in many instances; but I have often been disap- pointed in it. Other kinds of diet are nearly, if not quite, as good, and, in cases of emergency, it will not supply the place of a young and healthy nurse. The trial also frequently occasions much loss of precious time." — Letters, p. 64, &c. Two excellent kinds of food for infants are, sago thoroughly boiled in very weak beef tea, with the addition of a little milk, and Leman's rusks, called tops and bottoms, soaked in boiled milk. The former of these has rather a tendency to confine the bowels, and the latter to open them; they may be mixed together in such proportions as effectually to regulate the bowels. — M. H.] It will be proper to include under this head, some observations relating to wet nurses, and to weaning. ON THE CHOICE OF WET-NURSES. The first and essential point'in a wet-nurse is, doubtless, that her milk be good ; to which end it is necessary that she be healthy and young ; not of weak nerves; nor disposed to menstruate while she gives suck : and that her bowels be rather costive than otherwise.* Her nipples should be small, but not short, and the breast promi- nent, and rather oblong than large ; the large fleshy breasts being distended rather from fat, than from milk. The chief marks of good milk, are its being thin, of a bluish colour, rather sweet, and in great quantity ; and if under four months old, it is, doubtless, * Though it is not desirable that the bowels of a wet nurse should be too freely open, yet I cannot at all agree in the opinion, that they should be rather costive than otherwise. .Unless the bowels are relieved once plentifully every day, the milk is rarely good in quantity or quality. — S. M. 5* 54 UNDERWOOD ON CHILDREN. an advantage; and certainly the milk for a young child ought not to exceed six months ;* for after this time it generally becomes too thick for a new-born infant, and is not easily digested, un mis account, though an infant may not be really ill, I have frequently observed it not to thrive, though it take great plenty of such nniK. When the milk is of this age, there is also a greater chance ot its failing before the infant be of a proper age to be weaned. A wet- nurse ought furthermore to have good teeth, at least her gums should be sound, and of a florid colour. She must be perfectly sober, and rather averse from strong liquors ; which young and healthy people seldom [never] need in order to their having plenty of milk. She should be cleanly in her person, good-tempered, careful, fond of children, and watchful in the night, or at least, not liable to suffer in her health from being robbed of her sleep. [The plain and simple rule to be observed in this case is thus expressed in the " Letters :" " It is important in the choice of a nurse, that her infant should be younger than the one for whom her milk is destined ; it may otherwise require greater powers of digestion than the little patient possesses, and will disagree by oppressing the stomach, or irritating the bowels."] The diet proper for wet-nurses is likewise worthy of notice. And here an invariable attention should be paid to natural con- stitution and habit. Due allowance being made for these, it may be said, that milk, broth, and plain white soups, puddings, flesh meats of easy digestion, and a due mixture of vegetables, with plenty of diluting drinks, and such proportion of more generous liquors(c) (spirits excepted) as the variety of circumstances shall * Some ladies are very anxious to procure wet-nurses who have not lain in more than a fortnight or three weeks. I have seldom found the milkof such nurses answer so well as those, whose children are eight or ten weeks old. They are not sufficiently recovered from the effects of parturition to undertake the duties generally required of a wet-nurse. — S. M. (c) As a general rule, the mother when nursing, or a wet-nurse in her place, ought not to use any kind of spirituous or fermented drink. Among the testimonies in support of this position, I may cite here, as I have done elsewhere (See Combe on Infancy; with Notes, and a Sup- plementary Chapter, by John Bell, M.D., p. 161), that of Mr. Couiie- nay, of Ramsgate. This gendeman informs us, that he has resided in Ramsgate during nearly eight years, and has, in that time, attended 1127 mothers in child-bed. He invariably found, that, other circumstances being equal, those mothers who never tasted malt liquors, wine, or spirits, during, and subsequent to the period of labour, have had the easiest labours, the earliest recoveries, and the best health afterwards. Mr. Courtenay adds, that he knows several mothers who never could nurse their children under the ale and porter system without suffering greatlv in health, but who, after relinquishing the use of these baneful stimu- ON THE MANAGEMENT OF INFANTS. 55 direct, will be a proper diet for suckling women. Respecting vegetables, particularly, the strictest regard should be had to con- stitution and habit. Wherever vegetables, or even acids, uniformly agree with the suckling parent or nurse, I believe healthy children will rarely suffer by partaking of them; but, on the contrary, the milk being thereby rendered thin and cooling, will prove more nourishing and salutary, in consequence of being easier of diges- tion. To these regulations should be added an attention to exer- cise, and frequent walks in the open air : to these, hired wet- nurses have been previously accustomed, and are therefore sure to suffer by confinement to warm rooms, equally to the injury of their own health, and of the infants they suckle. [" In reference to the nurse, I would advise, in all cases, that doses of magnesia should be taken from time to time. The milk, as well as the infant, is frequently preserved healthy by this simple means. And in regard to the nurse-maid, I should always insist that she should take a bath, or sponge the surface of the body with warm water frequently. The infant is thus preserved from inhaling a morbid perspiration." — Letters, p. 114. " You will soon learn how often your little infant must be nursed. It is said, at first every three hours; but I believe you will find that to nurse every two hours, during the first and second month, is not more than is required. You will also soon learn to adapt the quantity to the real wants of your infant. If it take too much, its sleep will be heavy and disturbed ; or its stomach may reject what has been swallowed. These events will be indications to you not to allow its stomach to be again overloaded. " On those days on which the bowels are confined or disturbed you must nurse with double care, not to load the stomach. " At a subsequent period, you will readily adopt a plan and system of nursing, which shall be at once best for your infant and most convenient for yourself. The periods should be chosen before the hours of meals and of sleep. The infant should not be nursed during the first period of your own digestion, which itself requires repose, and the undisturbed, uninterrupted energies of the system : neither should your sleep be broken, for this will disorder you and your milk, and through it, the babe, for whose health and nutri- ment it is destined. " This remark leads to another. Every instance of indisposition in the nurse is liable to affect the infant. It is not less important to attend to your own diet, than to that of your infant. Fatigue, watching, and, above all, anxiety of mind, will be extended in its lants, have experienced a perfect freedom from disorder during lactation. Nor was this all : the offspring of such mothers have enjoyed an unpre- cedented immunity from disease also. Thousands of children are, in the opinion of Mr. C, annually cut off by convulsions, &c, from the effects of these beverages acting through the mother. 56 UNDERWOOD ON CHILDREN. effects, through your own to your infant's health and well-being. One lady was greatly disturbed by family affairs. Her infant drooped, was suddenly taken with a fit, and expired within a few hours. Another lady undertook a fatiguing journey. Her infant became affected with diarrhoea, and w~as with difficulty saved by procuring another nurse. There is another source of indisposition. It is when a mother, although nursing, begins again to experience her periodical indisposition. On these occasions, the infant almost always suffers. In every such case, whether the infant has suf- fered or not, efficient aperients, with magnesia, should immedi- ately be taken as a preventive. It is needless to state that this is still more necessary if the infant's health has already become affected. " Your diet must be most plain, most nutritious. Meat should be taken three times daily, in moderate quantities each time. It is [not]* often necessary to add ale, or porter, and other nutritious fluids. It is not less essential to insure repose during the first period of the process of digestion, and exercise in the free open air in the intervals of digestion, and meals. Need I say that a strict and daily attention to the state of the bowels is also incum- bent upon you ? A fter the fourth month the infant may be nursed, or fed, every fourth hour; and after the sixth, every fifth, accord- ing to your strength. Pay great attention not to allow this to fail; otherwise the effect may be fatal to your object of continuing a nurse, or even to your infant's life. " To return to the proper periods at which food should be given, I would say, do not create a morbid appetite for food, by nursing the infant as a lullaby whenever it is cross or peevish, whatever the cause ; neither let it actually pine for want. In all this there will be a perpetual demand upon your own discretion and intelli- gence ; and remember that your infant is intelligent too, and that if it be pampered at one time, it will be fretful and peepish at another. In fact, nurses and mothers have not only too frequently acted automatically themselves, but have imagined that their in- telligent babes were automatons also." —Letters, pp. 61, &c] ON WEANING OP INFANTS. A principal article under this head, is the age at which it should take place; and this will depend greatly upon attending circum- stances. A child ought to be in good health, especially in regard to its bowels; and ought first to have cut, at least, four of its teeth, unless that process should commence very unusually late. This seldom takes place till the child is near a twelvemonth old; and it may be observed that healthy women, who suckle their' own * See preceding note (c). ON THE MANAGEMENT OF INFANTS. 57 children, and take proper exercise, do not usually become preg- nant again in less time, and this, I conceive, may be considered as one intimation of the properest period. We shall not be very wide, therefore, of the order of nature, if we say that children in general ought not to be weaned much earlier than this ; making proper allowances, however, for all just exceptions to general rules,* and especially as far as teething may be concerned. Small and weakly infants, if rather feeble than ill, are oftentimes bene- fited by being weaned; they should, therefore, about this age, be taken from the breast, instead of being, on account of weakness, nourished much longer in that way ; a cautious trial of such a change should, at least, in most instances be made. Any preparation for weaning is generallyneedless, and especially that of feeding children before-hand, though made a common excuse for stuffing them, whilst at the breast, with indigestible food. I have seen many mothers needlessly torturing themselves with the fear of their children being weaned with difficulty, because they could not get them to feed when eight or ten months old, and still at the breast; but I have always found such children wean, and feed, just as well as others, when once wholly taken from it. I never have any fear in that respect, and therefore wish to counteract, if possible, a sentiment encouraged by several writers, which has, I believe, no real foundation in fact, but has too often been productive both of much inconvenience and mischief. But I do not by this intend to say, that a child of eight or ten months old would be injured by a little food, once a day, of a more solid nature than the breast-milk : indeed, at that age children are often benefited by it, as I have intimated before; but when children are weaned much earlier, and are fed almost from the birth merely with that view, (which is often the case,) they may be essentially injured by it. The objections to immediate weaning, which have been brought forward, have arisen, I am persuaded, from fallacious reasonings, and not from facts and experience. I have lived, as it were, in the nursery for many years, and never found any ill effects from the sudden transition from breast-milk to artificial food when pro- perly chosen ;t and as long as I shall continue the pupil of nature, I shall hearken to no argument in favour of adding a less adapted nutriment to that which nature has provided, in order to obviate possible injurious consequences, the existence of which I do not think to have been confirmed by facts. I have remarked, that infants who are indisposed to feed at all while at the breast, are, nevertheless, weaned and feed just as well as others, when once taken wholly from it. There is, however, in a few children, a little difficulty for the first two or three days * Astruc advises children to be suckled till they are two years old, but without giving any sufficient reasons. f Were weaned infants to be immediately crammed with animal food, it might, indeed, bear some analogy to adult persons with dyspepsy, "being all at once forced to live upon Cheshire cheese." 58 UNDERWOOD ON CHILDREN. under any circumstances; but it is remarkable, that the instance attended with the greatest aversion to common food that I ever witnessed, was in an infant who had been allowed a little chicken broth once a day for two months before the weaning was entered upon. The child was very healthy, slept well, and scarcely cried at all upon its being deprived of the breast, and yet would not receive the food it had been accustomed to ; so that for six and thirty hours it continued averse from everything that was offered to it, though it appeared in very good humour. After the second day, however, it took a moderate breakfast, and in a little time it fed as readily as other weaned children. Under these circumstances, if the weaning has been committed to the wet-nurse, or she be still in the house, it will be proper that strict inquiry be made, and the nurse watched; there being in- stances of such hankering after the breast being kept up, by her occasionally indulging the child in that way. It may be further observed, that if the infant be in the least degree costive, a little magnesia and rhubarb should be administered, which, besides opening the bowels, will tend to create an appetite. Such infants also, where there are more young children in the family, should sit at table with them when taking their meals; as they will there- by, through mere imitation, be disposed to take food. When the weaning is once entered upon, a great part of their food ought still to be of milk, with puddings, broths, and but little meat, supposing the infant to be of a fit age to admit of any; and every kind of food, and even drink, should be prohibited in the night, even from the first, supposing them to be weaned at a pro- per age. The mere giving them drink, even only for a few nights, creates the pain and trouble of two weanings instead of one; and if it be continued much longer, it not only breaks the rest, but the child will acquire a habit of being fond of drinking; the consequence of which very often is a large belly, weak bowels, general debility, lax joints, and all the symptoms of rickets. The only need is, that the last feeding be just before the nurse goes to bed, which may generally be done without waking it; and whilst the child seems to enjoy this sleepy meal, it becomes a most pleasant employment to the mother, or nurse, from observing how greedily the child takes its food, and how satisfied it will lie for many hours on the strength of this meal. [I would recommend attention to the following observations con- tained in the " Letters to a Mother." — M. H. " No abrupt transitions are borne by the young infant without risk. At the close of the third month, some other kind of food besides the mother's milk should be tried, and continued, if it agree, — intermitted, or perhaps changed, if it disagree. Still the infant should be more nursed than fed ; and the more, the abler the parent to afford it this best kind of sustenance. At'the end of the sixth month, it may be more fed than nursed. The change of diet should be gradual, — its effects watched."__P. 66.] ON THE MANAGEMENT OF INFANTS. 59 SLEEP AND WATCHING. A few observations only on this subject will be necessary in this place; and first, that healthy children sleep a great deal for the first three or four days after they are born, probably from having been previously accustomed to it. They ought not, however, to be suffered to continue this habit in the day-time to the degree some children are permitted, but should be gradually broken of it; and, indeed, if not indulged, they will not be so much disposed to sleep as is generally imagined, and will, therefore, take more rest in the night, which is mutually beneficial to the child and the mother; who, especially if she suckle, will be less disturbed, at a time when she particularly requires the refreshment of sleep. Therefore, when infants are sleepless in the night, they should be kept more awake, and have as much exercise as possible in the day time, which, though they be ever so young, may be pretty considerable, (as will be directed more at large in its place,) by playing with them or dandling on the knee and otherwise amusing them; and when older, by every kind of exercise they can bear. The child, if healthy, will soon contract a habit of being very much awake while it is light, through that lively and restless spirit pecu- liar to infancy: and by this means another evil will be very much avoided, that of often laying a child down to sleep in the day-time for hours together, loaded with a thick dress, and covered besides with heavy clothes, in a soft cradle, or bed. But, though I am confident these cautions will have their use, I am equally satisfied that many children have much less sleep than they require ; but then this deficiency is chiefly in the night, and is often the consequence of some complaint under which the child labours, and which will be treated of when speaking of the Dis- eases of Infants. Before I quit this article, it may be remarked, that the custom of constantly placing infants on the back, whether in the cradle or bed, is very improper; for, by this means, the superfluous humour secreted in the mouth, which, in the time of teething especially, is very considerable, cannot be freely discharged, and must fall down into the stomach, where its abundance occasions various disorders. Infants should therefore be frequently laid on one side, particularly the right, as favourable to the stomach getting easily rid of its contents: to which side also children, when strong enough, will instinctively turn, if not prevented by the weight or confinement of their own clothes, or those of the cradle or bed. The chief apology for all which is, a fear of the infant's falling, or turning on its face; but this is rather an apology for the neglect of that necessary attention to infants, which, whenever it can be com- manded, should never be spared them. It only remains, under this article, to say something of the cradle, which most writers have spoken against. I believe there is no 60 UNDERWOOD ON CHILDREN. doubt but the custom of laying down children awake, and rocking them in a cradle in the day-time, or at seven or eight o clock in the evening, when they are to go into their night's sleep, as it is called, may be an occasion of making them more wakeful in the night; or at least may cause them to expect that kind of motion whenever they awake. But yet I cannot help thinking, there is something so truly natural, as well as pleasant, in the wavy motion of a cradle, (when made use of at proper times,) and so like what all children are used to before they are born, (being then suspended, and accustomed to ride, as it were, or be gently swung in a soft fluid, upon every motion of the mother, and even during her sleep from the effects of respiration,) that, always wishing to follow nature as I do, I cannot, on the whole, but give an opinion rather in favour of the cradle. It is, at least, among the little things in which we may harmlessly err, and in which every mother may therefore be safely guided by her own opinion, or even by her feelings. And if the child, in consequence of being sometimes rocked to sleep in the day-time, shall expect it when it awakes in the night, it will not be very difficult to find a substitute for it; and, indeed, parents seem, as it were, instinctively and mechani- cally, to pat and gently move a child, whether lying on the lap or the arm, whenever it appears to awake prematurely. The objec- tions to the cradle made by some late writers, militate only against the abuse of it, from any violent rocking; as though infants must necessarily be jumbled in a cradle like travellers in a mail-coach. For I cannot easily persuade myself, that we are in everything become so much wiser than our forefathers, with whom, for some ages, and in distant countries, amongst rich and poor, the cradle has been judged to be a necessary part of family furniture. Since the last edition of this work, some new and stern objec- tions have been offered to the arguments I had advanced, and from very respectable authority; but I conceive, not the result of actual experience of any ill consequences attached to the practice I had ventured to espouse. It is objected, however, that infants, after birth, pass into a very different state from that they had been accustomed to in utero. True; but I have not advised children to be rocked all the time they sleep, like the unborn infant! but have merely said, that as some new-born infants certainly do not sleep so much, nor so long at a time as they ought, and are often with difficulty got into that state, through illness and other causes, I conceive they cannot be injured by gentle rocking, when they are first laid down in the cradle, nor from being gently, and to themselves pleasantly moved, when they may be disposed to awake prematurely. More than this I never intended ; whilst my argument, from the infant having been accustomed to this waving motion in utero, was calculated only to combat the frivolous objec- tion, as I conceived it to be, against this very ancient practice, and not as being a reason in itself for its continuance. But the writer observes, that « no prudent person would recommend any unne- ON THE MANAGEMENT OF INFANTS. 61 Cessary expedient, which may, through inattention, be improperly used." As this argument stands, it must carry conviction with it; but if by unnecessary be meant useless expedient, I beg leave to deny the supposition : and in return, to inquire, what actual evils have resulted from the practice ? For if these be neither frequent nor great, I would ask again, what good thing is there that has not been abused ? or what is there of more importance to children than sleep ? every innoxious inducement to which, it should seem, ought to be encouraged: and if so, the cradle, or some similar means of grateful motion, does not appear to be wholly unneces- sary.* In regard to watchfulness, however, as is observed in another place, it is usually a mere symptom, and should be treated according to its cause ; but in a general way, it may be said, that nothing can so safely and effectually contribute to procure natural rest, as that exercise to be further considered under the next head. MOTION AND REST. It is chiefly the former of these that will claim our attention, as infants ought scarcely to be ever in a perfectly quiescent posture, except when asleep, and, happy for them, that active principle with which nature hath endowed them, is so vigorous and over- flowing, that they reluctantly submit to it. Exercise, like air, is, indeed, of such universal importance that neither children nor adults can possibly be truly healthy without it; whilst for the former, particularly, care should be taken that it be properly suited to their age. The first kind of exercise consists in dandling, as it is called, patting the back after feeding, and gently raising the child up and down in the arms; taking care at first not to toss it very high, infants being very early susceptible of fear, and even capable of being thrown into fits by it. Another exercise adapted to this tender age, and of the utmost advantage, is rubbing them with the hand. This should be done all over, at least twice a-day, when they are dressed and undressed, and especially along the whole course of the spine, and ought to be continued for some time, being peculiarly agreeable to the child, as it constantly testifies by stretch- * The swing cot, as at present very generally employed instead of the cradle, is certainly less objectionable than that old-fashioned contrivance. The motion is more uniform and gentle, and devoid of the many shocks which the cradle too often produces. When the child is in perfect health, neither the cot, nor the cradle, cautiously rocked, is likely to be productive of injury ; but in perfect health, the child rarely needs (and never ought to require) such a means of inducing sleep. When the child is ill and feverish, with the pulse quick, the skin hot, the head burning and throbbing, it has always appeared to me that the rocking of a cradle is likely to occasion an aggravation of the ill symptoms; and the swinging of a cot is then not much less improper. If the adult, labouring under disease, is anxious for the greatest stillness and quietude, I conceive that the ailing child, if it could express its wishes, would equally wish to avoid everything that approaches to jolting, or other unpleasant motion. — S. M. 02 UNDERWOOD ON CHILDREN. ing out its little limbs, and pushing them against the hand, with a smile expressive of the satisfaction it receives from it. Such gen- tle exercise may be partially repeated every time the child's clothes are changed, by rubbing the lower limbs, and every other part within reach. Likewise dashing the face with cold water, in the manner recommended for the rickets, but more lightly, will pro- duce the effects of exercise well adapted to this age. [I do not think this practice, considering the alarm excited and the forcible impression made upon the fifth and respiratory nerves, (the reflex function)* would be .entirely free from the danger of inducing convulsion. — M. H.] When children are older, their exercise should be proportion- ately increased, and as has been observed, they ought never to be carried in a quiescent posture, but the arm that supports them should be continually in such motion as the nurse may be able to continue; for children delight to be in constant motion, and this exuberant activity is given them for the wisest purposes, and ought by no means to be counteracted. And I notice the mode of carrying them, because I have seen children slung carelessly over the arm in such a manner, as neither affords them any exercise, nor allows them to give any motion to themselves ; which lively children will always endeavour to do. And, indeed, the manner of carrying an infant is of more importance than is generally imagined : for, from it, the child will contract a habit, good or bad, that it will not readily give up, and may be as much disposed to become rickety, by improper management in the arms, as if it were lying wet in the cradle. It may be a proper inquiry in this place, at what age children should be put on their feet, a point on which people differ consider- ably ; but I apprehend nothing more is required than to follow nature, whose progress is always gradual, as our imitations of her should be, and we shall then seldom run very wide of her inten- tions. If we take notice of a healthy child, we observe it to be always in motion, and as soon as it gets strength, it will be sup- porting itself by the help of its hands and feet, and be crawling about wherever it is permitted. From this exercise, it will soon acquire an increase of strength ; and whenever it is upheld by the arms, and disentangled from the weight of its clothes at the time of dressing and undressing, it will naturally walk up the waist of its mother or nurse ;t and by the manner of moving its limbs, * See a paper in the Philosophical Transactions, 1833. . t 1 C5!nn°* avoid taking notice here of an imprudence on this occasion, which it is well if it have not been prejudicial oftener than has been suspected ; I mean, that of suffering a child to crawl so high up the neck, as to render the mother or nurse incapable of raising the arms high enough to support it; for not only may a child be suffered to slip out of the hands, but the mother may be injured I have felt much on this occasion, from seeing tender and delicate ladies with their arms on the stretch, suffering a heavy child, perhaps with its shoes on, to crawl over the breasts, distended with milk, and^ squeezing them so forcibly against the edge of the stays, that parents have sometimes cried"u! from the ON THE MANAGEMENT OF INFANTS. G3 and its bearing more or less on the arms, will show what advances it has made. Whenever it is strong enough, it will have attained sufficient knowledge to walk by itself, and will never attempt it till it is fully equal to the task. It will then be perfectly safe to permit it to follow its inclination, at least as far as the straitness of its limbs is concerned ; and I think I may defy any one to pro- duce a single instance of a child getting crooked legs, from being suffered to walk as soon as it is disposed to make the attempt. But in nowise ought nature to be forced; a maxim applicable to every other occasion ; "aware (as a writer before quoted* finely observes) that whatever forms may, by artifice, be intruded upon her, and she compelled to assume, to enlarge, or contract her bias and inclination, she can never be made, eventually, to deviate, without manifest injury to herself, from the station and bounds unalterably impressed upon her by the unerring Power which first created and gave her laws." But the mischief is, we lead on children prematurely to the trial, by back-strings, and go-carts, and other contrivances calculated only to spare idle nursery-maids some trouble; or, what is really pitiable, to allow poor people time to attend to other concerns, who are obliged to work for their bread. But where this is not the case, such contrivances are un- pardonable, and are the consequences of ignorance or idleness, which are productive of great evils ; and then, by way of excuse, it is asked, at what age a child may be put on its feet —a ques- tion, I apprehend, that ought to be replied to only in the manner I have donet — leave children to themselves, and they will afford a satisfactory answer in good time. Dr. Hugh Smith, in his Letters to Married Women, says, that children's legs do not become crooked by putting them too early on their feet; and he asks if any other animal has crooked legs, though they stand on them almost as soon as they are born. But this is running to the contrary extreme; the cases, I apprehend, being widely different; quadrupeds and fowls are designed by nature to be early on their legs, and it is necessary that they should be so. They are accordingly calculated for it, their bones being strongly ossified from their birth; but this is by no means the pain, and yet not been able, at the moment, to bring the infant down into the lap. But the degree of evil attached to this, depends not a little on the fashion which the dress may assume at the time. This note was calculated for an abridged edition of this work, for domestic use ; but as every medical gentleman may not have noticed this injurious custom, by not being often present when ladies are suckling their children, it is thought the caution may not be wholly improper here. * Mr. Moss. f I have seen two children walking alone before they were nine months old, and at ten months carrying a heavy plaything in their hands ; whilst other children, rendered weak and rickety by mismanagement, have been unable to do half as much at two years of age. I have seen a child walking fairly alone, for a few steps, the day before it was eight months old. 61 UNDERWOOD ON CHILDREN. case with the human species, and therefore no argument can be founded upon it without considerable latitude, and making such allowances for the different circumstances of children as have been pointed out.* But if it be meant only to suffer children tojeel their way, if I may so speak, for themselves, they will never deceive us, nor do I think their limbs ever become crooked by their sponta- neous endeavours to support themselves. It is by urging them to stand and walk by means of our own awkward contrivances that the mischief is produced. A note of Dr. Buchan, on the subject of giving exercise to chil- dren, which some people, from their straitened circumstances, can- not spare time to afford them, charmed me exceedingly. The good sense and philanthropy manifested in it, as well as a desire of ex- tending its useful contents, will, I hope, be apology sufficient for transcribing it, especially as it is at present so apposite to my purpose; and though I cannot flatter myself that government, however bene- volently disposed, will, or perhaps can, at this time, adopt such a plan, either from his recommendation or mine, it is, nevertheless, in the power of people of large fortune, both in town and country, to give it very considerable effect, especially if the premium were made double for such children as should be produced in good health. The Doctor's words are : — " If it were made the interest of the poor to keep their children alive, we should lose very few of them. A small premium given every year to each poor family, for every child they have alive at the year's end, would save more infants' lives than if the whole revenue of the crown were expended on hospitals for that purpose. This would make the poor esteem fertility a blessing; whereas many of them think it the greatest curse that can befal them;" and I may add, I have known them express great thankfulness when any of their children have died. The advice contained in this chapter is further worthy of serious attention, from late discoveries of much greater fatality amongst the children of the poor of this metropolis than I ever suspected. To ascertain the fact, an inquiry was set on foot, at the British Lying-in Hospital, at the suggestion of Dr. Combe. Inquiries have likewise been making since, in different ways; and I have no rea- son to suspect that the statement made out from the report of the women offering themselves at the hospital, is at all beyond the fatality in other poor families in London, but indeed rather under it, in regard to still poorer people. The following is a brief statement of the result of the investiga- tion at the hospital, during the first year : — * The very great difference between human beings and quadrupeds in this respect, should always be borne in mind, namely, that the whole weight of the body of the infant, in an erect posture, rests upon its two legs ; whereas in the animal, only one*half of its weight is thus supported. — S. M. ON THE MANAGEMENT OF INFANTS. Several women who had borne 3 children, had lost as many as 2 4 C5 5 4 6 5 7 6 8 7 9 8 10 9 11 8 and 10 12 10 and 11 14 11 And several of the mothers of the different numbers had lost them all. During another long period, only one woman, having borne as many as five children, had reared them all; and one having had twelve, had eight living. But some having had four, had lost three ; and five, had lost four ; and six, five ; and seven, six ; and eight, six and seven ; and ten, seven and nine ; and women having borne eleven andtwelve, had lost eight, nine and ten ; and fourteen, eight; while many who had borne four, five, and six, one twelve, and another twenty-one, had buried them all. In addition to this, may be remarked the sad and rickety state of many of the surviving children.* The above, indeed, contains the most formidable view of this matter, but the most favourable is by no means, such as to coun- terbalance it; there being, during a year and a half, three women, I think, who having borne only three children ; and one woman, lately come from the country, having four children, who had lost none of them. Only one, having had as many as six, had them all living; and another had preserved eight children out of ten. Among the surviving ones, however, it was frequently observed, was the last born ; therefore, one less likely to be reared than an older child. From these different degrees of fatality, further contrasted with the small number of deaths in the hospital, within the month, we may suspect the different care and attention bestowed upon young children, as well as the want of certain accommodations; and may fairly argue on their effects, there being no such fatality amongst the opulent. A singular corroboration of this remark, I have an opportunity of noticing; a lady, who had borne fifteen children, and no more, had them all sitting around her table at dinner ; and in two other families there were twenty-one children at table; and a lady once told me, that the number of her children and grandchildren amounted to forty-seven. * During the time that I was the obstetric physician to the Westminster General Dispensary, I instituted a similar inquiry, and the result was similar; there was scarcely an instance of any woman who had preserved all her children, if she had borne more than three. — S. M. 6* 6(1 UNDERWOOD ON CHILDREN. It would be unpardonable not to add a few words in this place with a peculiar reference to females-, upon whom, besides every infirmity common to the other sex, is imposed the painful task of child-bearing. It is the benefit of the lower class of people, in- deed, that I have here principally in view ; though the caution is not utterly unnecessary elsewhere. The many distressing, and sometimes fatal labours I have been witness to, have led me to regard with a kind of horror, a rickety, distorted female infant, whose parent's or nurse's neglect, or ignorance, is heaping up for it additional sufferings and dangers, to those which are great enough under every advantage that art and good health can con- tribute. From the age of two years, therefore, or rather earlier, this care is especially called for, and besides every caution already pointed out, lays a strict prohibition on girls being suffered to sit for hours together, on a low seat; whereby the pelvis is pressed between the lower extremities and the spine, and is made to grow out of its natural form. The consequences of this change of figure, if it be anywise considerable, cannot fail to be productive of in- creased pain and dangers in parturition, frequently equally fatal both to the parent and her offspring. I am aware that many poor people are not in circumstances to give their children all the exercise they require ; they may, how- ever, suffer them to afford as much as possible to themselves, by allowing them to crawl about on the floor, near an open window or door, instead of compelling them to lie on their backs, or to sit upright, pinned in a chair ; the ill consequences of which are so exceedingly evident. It is hoped no apology maybe thought necessary for these obvious remarks: since no pains should be thought too great if they may present the evils here pointed out, nor can too much be said to inculcate good nursing, (and especially exercise,) which is alone adequate thereto.* A very few words may suffice on the head of Rest ; the irregu- larities therein being far less numerous and important than the former. In a general way, it will be sufficient to notice them in regard to the improper inducement of young children to continue in action after they feel themselves wearied, and in keeping them out of bed beyond a proper hour. Children in health never wish to sit still when they do not actually feel it to be necessary, much less to go to bed over early. But it is to be remembered that young people require more sleep, and to be longer in a recumbent posture than adults : for though they usually rise very early, they get to rest more than proportionally soon, being disposed to fall * A proper attention to this, and many of the preceding articles, has been conceived to be of so much importance, that the benevolent governors of the British Lying-in Hospital, some years ago gave orders that suitable directions on these heads should be drawn up, and given to every mother, on her leaving ON THE MANAGEMENT OF INFANTS. 67 asleep almost the moment they are still; and this is natural to them, and is a demonstration of the advantage of exercise. [On the subject of this chapter I cannot do better than extract the following remarks from the " Letters." — M. H. " Besides the wholesome influence of exposure to a free open air, the benefit accruing from exercise is very great at all ages. The infant should be carried out at stated periods daily; the child should be led to take gentle walks. " Regularity in these points is of the utmost importance. Neither should the system of gentle exercise be intermitted from slight causes, — from slight inclemencies of the weather. An infant or a child will never take cold, if properly clothed and defended from the air, — if it be taken out and brought promptly in, although the weather be intemperate. It is loitering, and lingering, and so ex- posing the infant unduly and for an undue length of time, which are usually the real sources of the evil, when this does accrue from taking it into the open air. Let the minutes of their exercise be counted; but still let the exercise itself not be intermitted, except when the weather is extremely inclement indeed. " This observation leads me to a most important remark. It is, that in the midst of a system of what is deemed exercise, this is sometimes allowed to pass into fatigue. The infant is kept too long exposed to the air, to its kind of fatigue; the child is allowed to be too long upon its feet; exhaustion is induced, growth and nutrition are arrested, and perhaps a febrile attack, or even a state of protracted debility, may be the consequence. " Sometimes the fretfulness and indisposition of after life, some- times pining and consumption, are to be dated from this cause. As I think the circumstance not sufficiently attended to, even by medi- cal gentlemen themselves, I shall insert an interesting case of this kind from the pen of a most intelligent friend : — "A little girl was left to the care and discretion of a nursery-maid. They left home and gossiped from cottage to cottage for four hours. The child naturally active, lively, and happy, amused herself with skipping about, and plucking flowers, but at length said," I am so tired," and wished to go home. This home was at a considerable distance. On entering the house, she took off her bonnet and lay down, refused her tea, and requested to be taken to bed. Before she was undressed, she fell asleep and did not awake for three hours ; she then appeared uncomfortable, refused food, but asked for drink: she became feverish. This febrile state continued for a long time, and even after it had ceased, she never regained her colour or strength, but remained pale and feeble." —Pp. 93-96.] ON SOME SLIGHT NATURAL DEFORMITIES. Prolix as these articles may already have appeared, it may, nevertheless, add a completeness acceptable to the younger part of 08 UNDERWOOD ON CHILDREN. the profession, to comprehend under them other particulars of no small importance, that relate equally to both. These will respect the different modes of motion and rest, in order to point out tne several improprieties that have a natural tendency to induce, or increase, various corresponding deformities. Such will relate to the manner of children's standing, ivalking, sitting, and lying; and will particularly respect the position ol the head and feet, and the form of the back, shoulders, and hips. It may not, therefore, be improper in this place, nor, it is hoped, be thought going out of the true line of my profession, to advert a little to each of these. Indeed, to propose regulations of any kind, merely with a view to graceful standing or walking, would be highly incompatible with the intention of the work; but since this part of it is appropriated to the general management of children, it is hoped the reader may not deem it altogether impertinent that he is invited to pay attention to certain things, which, for want of correction whilst children are young, and frequently under the eye of medical people, may, by the neglect of their ordinary and less intelligent attendants,grow up to real evils. For it is very certain, that, from an improper manner of resting upon any of the extremi- ties, whether in sitting or otherwise, different parts may take an ill form; and what is worse than an awkward appearance, (to which their parents are apt to confine their attention,) children often grow up weak; whereby the poor become unfit for those labours and exercises for which they are designed, and which the necessities of their situation frequently demand. And I here beg leave to remark, that the very means frequently made use of by people of rank, to prevent some of these deformi- ties, may, on the contrary, occasion them. Such are the use of steel collars, various sorts of stiff stays, and other tight bandages. For I am confident, nor am I singular in the opinion, that when recourse is had to these things, before any parts have taken a wrong turn, they are very likely to occasion it. Not that such contrivances are afterwards improper; for when the bones have, by any means, been thrown out of their natural direction, art can frequently rectify it, and point out where to apply, or to take off", pressure. But before this, and while the bones are growing, compression, however properly applied, is, in effect, oftentimes ill-directed, owing to the continual and irregular action of children, especially when they feel any parts unpleasantly confined.* * The very interesting subject of curvature of bones, deformities, debilities, &c, has attracted the attention of several very eminent practical anatomists and sur- geons of great mechanical skill and ingenuity, and much light has in consequence been thrown upon the pathology of these complaints ; and appropriate means of relief have been devised. The writings of the late Mr. Wilson, of Dr. Harrison, Dr. Jarrald, Mr. Ward, and Mr. Copeland, &c, on the diseases of the spine, ought to be consulted by all who undertake the treatment of these calamitous complaints. The practical and scientific works of Mr. Shaw are particularly deserving of attention. — S. M. ON THE MANAGEMENT OF INFANTS. 69 I come now to the circumstances immediately hinted at, and first those which regard the head or neck. ' Many infants come into the world, either with the neck drawn a little to one side, or an awkward turn of the head appears to take place afterwards. In the latter instance it may be the effect of habit, and, amongst other causes, may be owing to children being placed in the cradle, or carried improperly, so that the light, and other objects that forcibly attract their notice, are too frequently on the same side. The remedy in either case, as far as it may become such, is obvious, differing nothing from the intentions noticed in the chapter on squinting : everything should be so contrived as may tend to draw the head to the other side, and especially such things as may have a sudden and forcible operation on the muscles, by producing strong voluntary motions. It may not, perhaps, occur to every one, how much may be effected by such means: several striking instances of it, however, have been met with ;* and we daily observe similar effects of a certain position in flowers and shrubs, which, without any help from the hand, turn about, obe- dient to the air and sun operating upon their internal structure. The next observations respect the back and shoulders. Some young children, naturally well-formed, acquire after a while what is termed round-shoulders; the vertebras of the neck and back projecting too much, and forming an unsightly curve. The morbid affection of this part will be considered in its proper place; I have only to notice here a change arising merely from some bad habit or custom, through an improper manner of sitting or standing. In regard to the former, it may be observed, that the soft, concave-bottomed chairs, in which young children usually sit, are on many accounts improper for their years, who should always make use of a flat and hard seat, and generally without arms, as directed for the prolapsus ani ; which complaint it would have a tendency to prevent. But in the hollow-bottomed chairs children find themselves obliged to recline in one way or other, or to be making certain exertions for keeping themselves upright, and pre- serving an equilibrium of the body ; and it is obvious, that either a bending posture, or the efforts necessary to avoid it, often repeated, may become hurtful to weakly children. An improper manner of standing, though less frequently a source of this kind of mischief, on account of the position being more * An Ambassador from Morocco, being at Paris, went to see the Charity Hospital, where, passing the ward for the wounded, six of them, who had not stirred for several months before, rose up, and came to the ambassador, to the great surprise of the whole hospital :f curiosity or surprise effecting that which the most powerful medicines could not, in so short a time. — The like circum- stance is reported to have taken place, frcrn a fire happening in the house where an elderly lady had long lain bed-ridden ; who, perceiving the fire, suddenly rose up from her bed, without any assistance, and ran into the street. t Histoire de l'Ambassadeur de Moroc, Envoys' au Roi de France, en 1689, 70 UNDERWOOD ON CHILDREN. frequently varied than in sitting, is, nevertheless, capable of giving an awkward turn to the back and shoulders, as well as to the feet. We are creatures of habit, both in respect to our bodies and minds, so that to whatever we may have, for a little while, accustomed ourselves, we have an increasing propensity ; and when the habit is once formed, it is with difficulty broken. Children should, therefore, be early accustomed to stand very upright, instead of being suffered to lean upon whatever may happen to be near them, as they are frequently disposed to do. Should one of the shoulder-blades project more than the other, the child should lie, as much as may be, on the contrary side ; as the shoulder upon which one lies always projects beyond the plane of the back. When the shoulders themselves happen to be too high, a child so disposed should never be suffered to sit in an elbow chair ; nor should any child sit before a table that is either much too high or too low for the seat in which he may be placed, especially if it be for the purpose of reading, writing, or any other employ- ment that may engage him for any length of time. But if one of the shoulders is higher than the other, the child should frequently be directed to stand only upon the foot of that side, at least to bear his weight chiefly upon it; by which means the shoulder that is too high must necessarily fall lower, and the other be raised; or a small weight may be put upon the shoulder that is too low, which will incline the child to raise it up. Or he may be caused frequently to carry a light chair, or such like, or plaything, in the hand of that side, which will have the same effect. The like means should be used when one hip is higher than the other, which is both a very common and peculiarly unfortunate complaint, especially to females. Another easy and efficacious means of rectifying the shoulders, is to make the child support himself with a very short cane on the side where the shoulder is too high, which will oblige him to lower it; and, at other times, to put one that is too long for him into the other hand, which will raise the shoulder on that side. He may likewise often sit in a chair with two arms, one of them being made a little higher than the other. These, and other similar means, may be very easily complied with ; and several of them so managed as to be made a sort of play or amusement to the child ; and, if properly persevered in, will correct many deformities that have originated merely from bad habits, as well as conspire with other contrivances to remedy such as may depend upon a slight malformation. The feet of children are likewise liable to receive an improper turn; and this may arise from habit,as well as from original malformation. Children, when conversing with those with whom they are familiar seldom stand firmly on their feet, but are apt to lean upon one side of them, so as to bear almost upon the ankle, instead of the soles of the feet By degrees, this habit is not only increased, but the tendons themselves are disposed to contract, or those on the opposite ON THE MANAGEMENT OF INFANTS. 71 side become weakened. In the like manner, by standing upon the toes, the tendon of the heel, in time, becomes shorter, as was for- merly very manifest in women who wore very high-heeled shoes. To obviate the former, little more is required than to correct the child's manner of standing, by teaching him to bear firmly on the bottom of his feet; or if a foot be turned very much to either side the sole of the shoe may be thickened upon the side on which the child bears. If by treading upon the toes, the heel is become contracted, the heel-piece should be taken off from that shoe, instead of its being raised, as hath sometimes been very improperly done. Besides this, such children should be frequently caused to walk up steep ascents, by which they will be obliged to raise up the fore part of the foot, whereby the tendon of the leg will be stretched, and the heel must fall lower. Most of the remedies proposed for these little disorders, will have another advantage, as they necessarily inculcate exercise, in favour of which so much has been said; the great neglect of it, especially among the younger children of the poor, is daily lamented by every man of observation and feeling, and the more so, as it is a good they cannot always command. If I had not already far exceeded the bounds I had .intended, I should be induced to say something on the manner in which exer- cise becomes so beneficial to children. Let it suffice, however, to extract a few of the pertinent and elegant remarks of Desessartz* * " La liaison et la dependance que l'auteur supreme de la nature a dtablies entre toutes les parties de ce compose merveilleux, sont si intimes, que le Prince de la Medecine nous a represent^ le corps anime et jouissant de ses functions, comme un cercle dans lequel on ne peut reconnoitre ni commencement ni fin. En effet, les inslrumens destines a la chylification tirent toute leur force des organes de la sanguification, ceux-ci des nerfs et du fluide qu'ils contiennent: et ce fluide (si nous en croyons le systeme le plus universellement adopte, et auquel il manque peu de chose pour etre demontre: ce fluide) tire son origine du sang, et le sang des alimens que nous prenons tous les jours. De la Constance et de la regularite de fonctions aussi differentes et multiplies, dependent notre sante et notre vie. II ne suffit pas de prendre des nourritures, il fautqu'elles soient bien differees, chanjrees en sang, etcesangrdoitetreasseztravaille pour fournir non seule- ment la lymphe nourriciere de tout le corps, mais encore un fluide tres-sublil qu'on appelle fluide animal. Chaque liqueur doit etre se'pare'e dans ses glandes, et celles que la nature rejette co;nme inutiles et dangereuses, doivent etre pous- sees au dehors. " Or, rien n'est plus propre a faciliter et a perfectionner toutes ces operations que I'Exercice. Si nous jettons les yeux sur notre corps, nous y appercevrons une multitude de vaisseauxqui sontentrelacesles uns dans les autres, serpentans entre les fibres musculaires, a la pression successive desquelles ils doivent une grande p^rtie de leur mouvement et de leur action sur les fluides. A mesure que les muscles entrent en jeu, ils produisent des secousses reiterees sur les vaisseaux sanguins, qui se communiquent dans tout le systeme arteriel et veineux. Ces secousses non seuletnent procurent aux fibres la farce, et la souplesse, qui caracterisent leur bonne constitution, mais elles broyent, attenuent et subtilisent les liquides contenus dans lfs vaisseaux, achevent la transmutation du chyle en sang, en lymphe, et en fluide animal ; la circulation est plus libre, les secretions se font mieux, et plus uniformement, etla digestion en devientplus parfaite." — Traite de C Education corporelle des Enfans en bas Age. 72 UNDERWOOD ON CHILDREN. on this head, whilst I more briefly observe, that exercise tends W push forward the blood through the small vessels, and to untold them in the manner nature has designed them to be extended, in order to promote the growth of the infant, whilst it preserves the blood in a proper state of fluidity, and promotes both the secretions and excretions ; which are the next things it was proposed to con- sider. RETENTION AND SECRETION. Every medical reader will be sensible, how greatly health depends upon a due proportion between the daily supplies and the various discharges of the body ; the latter will vary according to the diet, age, and particular mode of life of each individual. The excretions of infants, however, insensible perspiration excepted, are chiefly from the bowels and bladder. The latter is not very liable to dis- orders : as these sometimes take place, however, the subject ought not to be entirely passed over. RETENTION OF URINE IN NEW-BORN INFANTS. Retention of urine during early infancy, is usually removed by applying a bladder of hot water to the belly, and gently rubbing with a little warm brandy, with oil of juniper, and oil'of almonds, or an onion, and throwing up a clyster; or, should these fail, the infant may be put up to the breast in a pan of warm water, and take a spoonful of marsh-mallow, or parsley, or wild carrot tea, sweetened with honey, with the addition of two or three drops of the spirit, aether nitrosi. This, if there be no malformation of parts, will generally produce the desired effect in the course of a few hours :* though cases have occurred in which infants have voided no urine for the space of four days, and have suffered very little inconvenience : I have even known one instance of the sup- pression continuing for five ; and it is remarkable, that two former infants in this family voided no urine for three days. Should the suppression, however, continue for two complete days, the follow- ing cataplasm may be applied warm to the region of the pubes. Take of parsley and mallow-roots, leaves of cresses, and juniper- berries, each a handful, and of the roots of garlic one ounce; boil them slowly in water, or in wine, to the proper consistence for a poultice. On the other hand, the sudden application of cold to * The urethra of new-born infants is sometimes obstructed by inspissated mucus; it may be proper, therefore, when many hours elapse without any water being voided, to pass a small probe, or bougie, in order to ascertain whether there be an actual impediment to the passage. In general, the non-voidance of water arises, not from want of expulsatory power in the bladder, but from want of secretion in the kidneys. In this case, clysters, fomentations over the loins, the warm bath, and emollient diuretics, are the appropriate remedies.__S. M. ON THE MANAGEMENT OF INFANTS. 73 the regio pubis, has sometimes produced an immediate good effect. Where all these means have failed, and the infant been in much pain, I have directed a clyster with a few drops of laudanum, which has presently removed both the pain and suppression. As in adults a suppression of a very distressing kind sometimes occurs, merely from a spasmodic stricture of the urethra, and not only resists, for a length of time, the ordinary means of cure, but is found to recur again after a temporary removal, it may not be amiss just to notice it here, as the complaint may, possibly, be met with in robust youths, although I have never yet seen it. The remedy for it is also very simple, and, I believe, newly-discovered, and first announced by Mr. Cline,* consisting only in the tinctura ferri muriatis, which he advises in the dose of gtt. x. to adult per- sons, every ten minutes, till some relaxation shall take place; which generally happens in the course of an hour.(fl?) Some of the old writers have spoken also of incontinence of urine, arising from weakness of the sphincter of the bladder; but I have never met with it in early infancy. They prescribe agrimony and myrrh, andsdirect astringent fomentations of red wine to the belly, perineum, and loins: for adults, (it being no uncommon complaint in old people,) three grains of camphire in a pill, and fifteen or twenty drops of laudanum in a dose of camphire julep, twice a day, have speedily removed the complaint. ON RETENTION AND EXCRETION OF THE BOWELS. So many particulars relative to these points are discussed in the following pages, as render it needless to say more now, than that (generally speaking) infants are rarely healthy long together, who have not two or three stools every day; or should they be more, for the first three months, if the child be brought up at the breast, and the nurse have a sufficiency of milk, it will generally thrive the better. The stools likewise ought to be loose, of a yellow colour, free from lumps, or curdy matter, neither of a very acid nor fetid smell, and should come away without griping. When children are about a year old, or perhaps earlier, pains should be taken to procure one stool at least every day, as well periodically as constantly ; and for this the morning is most adapted, and after their breakfast, by which the stomach and bowels will be stimu- lated. To this end they should be set on the chair, and not suf- fered to play till they have had an opening, for which they should strain, till at length it becomes customary, which may be easily * Medical Records and Researches. {d) An enema, of oil of turpentine mixed with flaxseed tea, or other mucilaginous fluid, is one of the best means of procuring a free discharge of urine, in cases of suppression. 7 74 UNDERWOOD ON CHILDREN. effected ; by which we shall gain a point with respect to the health of children. On the other hand, if an infant be dry-nursed, the danger generally lies in the other extreme, such children being dis- posed to be purged, and to have griping and sour stools, from the acescent, and oftentimes indigestible nature of their food, especially if fed by the spoon ; and therefore require an early attention when their bowels are disposed to be open, or, on the other hand, the feces are too stiff and clayey ; and their food ought to be changed, in the manner directed under the article of Purging. THE PASSIONS OF THE MIND. This is the last article mentioned as included in the non-naturals, and on which I shall be very brief, it being the happiness of infants to be very little affected by them. This article can, therefore, relate to them merely in regard to their mode of expressing such passions, and principally respects laughter and crying. The former, if long kept up, or very violent, may not only induce the hiccough, but may even throw an infant into fits. The latter is much oftener suspected of being mischievous ; and chiefly by occa- sioning fits, or a rupture ; the excess of both these affections should, therefore, be guarded against. Moderate, and not too frequent crying, however, ought not to be alarming ; and, indeed, a variety of considerations induce me to think, that this expression of the passions in infants is not only much more harmless in itself than is generally imagined, but is also, in some respects, salutary. The first cries it makes we know to be so, and that children recover from the paroxysms of some complaints by an effort of this kind. It is evident, likewise, how very much health depends on a free circulation of the blood through the lungs, and on their free expan- sion from the dilatation of the bronchial vessels. But as new-born infants are incapable of giving themselves any exercise, and, indeed, of receiving that kind which tends to promote such an effect, I have conceived crying to be an effort which nature may have wisely substituted in its stead.* Whatever is truly natural I always conceive to be right, though everything is capable of being abused ; and the most beneficial dictates of nature may be exceeded. I am satisfied, however, that the pacifying of children by improper means, and especially cramming them with food when they are not hungry, occasions far greater evils in thousands of instances, than ever were produced by the irritation from crying. The cries of infants, however, it must be confessed, are, very commonly, plaintive ; and, as they seem to argue distress, cannot but create it in every person of sensibility around them, and merit a strict inquiry into the particular occasion of them. The nurse, oderatus pueris non obest — pectus dilatat et calefacit. — Primeros. tot. Politic, lib. vii. c. 17, where the idea is supported more at large. ON THE EARLY DETECTION OF DISEASES. 75 therefore, who can with calmness hear an infant cry, without attempting to pacify it by every proper means, is a monster in human shape, unfit to be trusted with the care of rational beings; much less with a tender, helpless creature, whose only language, by which it can express its wants or its sufferings, is its tears. I cannot take my leave of the reader, without offering one apology more for having dwelt so long on this, and some other heads less important than the rest; my motive has been the desire of instructing, though in some instances at the risk of tiring, or otherwise displeasing ; but practitioners, who feel as parents, will endeavour by every means to lessen a mother's fears, as far as they may appear to be needless, wherever no other remedy can be offered. I shall conclude by observing, that though the passions of the mind refer so little to infants, they relate very materially to the wet-nurse ; who, besides endeavouring to keep her spirits as calm as possible, ought to be exceedingly careful not to put a child to her breast, when under the influence of undue passion, of what- ever kind it may be, the bad effects of which are instanced under the head of diseases. And I shall think myself well recompensed for the trouble I have had, if the counsel I have been able to offer may prove the means of lessening the dangers of the infant state, and the consequent sad fatality that attends it; as well as of abating the anxiety of the fond mother, who, after having brought her tender charge into the world with sorrow, is pierced with double pangs at its leaving it; an event which, as experience warrants me to say, may, by art and good management, be often prevented, and the author ardently hopes, that both parents and practitioners may have fewer occasions to lament. SECTION III.* ON THE EARLY DETECTION OF DISEASE The subjects of which we have hitherto treated relate principally to points which requires the mother's tender care. Those which come to be next discussed, also first require the nurse's, but espe- cially a mother's, eye, although it eventually devolves upon the physician to take the charge of every serious malady in infants and children. There are many changes, in infants and little children, which the mother alone has an eye and an ear to observe. A nurse never can be supposed to feel the same keen interest in the little infant, or to possess the same quick perception, which shall lead her so to * This section is by Dr. Hall. 76 UNDERWOOD ON CHILDREN. watch it, as to detect those nicer degrees of change, which fre- quently afford the first, and consequently the most important, indi- cations of indisposition in early infancy. The physician is too little familiar with the natural appearance and manner of the individual infant, and his opportunities of ob- serving it are too short, too little sustained, fully to enable him to seize the incipient and fainter shades of symptoms which are the precursors or harbingers of infantile diseases. But the anxious and watchful parent, who duly mingles intelli- gence with her anxiety, and observation with her watchfulness, will promptly observe many changes in the countenance, or in the mode of breathing, for instance, which entirely escape other eyes; and will perceive many changes of tone and manner in the voice, and in the mode of crying, which escape other ears. In this manner it frequently happens that the parent first observes, and then describes to the physician, appearances and changes which might otherwise long — perhaps too long — have escaped attention. The parent detects the symptom, which the physician sees to be the sign of the internal disease. I am disposed to estimate at a high value, the co-operation of the watchful and intelligent parent, in the observation and treat- ment of the diseases of infants and children. The parent should not be her infant's physician, but she should be its watchful nurse. She should not pretend to understand its diseases, which would imply a knowledge of anatomy, physiology, and pathology, which she cannot be supposed to possess; but she should be as one who carefully prepares a brief for his counsel, collecting the evidence, but leaving the inferences, and the decision, to him. To the physician there is not, in the whole circle of his profes- sional studies, a subject of purer or more interesting observation than the diseases of infancy. He should lean over his little patient, and watch the countenance, the attitude, the respiration, &c, as the artist studies a statue of ancient Greece, in order that he may seize and observe all its minuter, finer varieties of surface and contour. Nothing is so calculated to exercise and increase the power and delicacy of observation in the physician, as the careful and sus- tained study of infantile diseases. By it, he learns to read in the face and manner of the little infant, its pains and its sufferings, and the signs of its various diseases. He thus becomes apt, not only in the detection of infantile diseases, but in the minute observation- of the symptoms in the cases of older patients. But still the parent has an advantage which the physician cannot have ; she knows the infant's natural expression of countenance, its manner, its habits. She, and she alone, therefore, has a point or standard of comparison : she alone can perceive, can detect, the slighter, fainter shades of change. Her ear alone is attuned to the music of the natural and healthy voice and cry of her infant; she alone can detect those faint notes of discord, which first denote that some of the chords of this " harp of a thousand strings" are unstrung. That appearance which may be perfectly natural in one ON THE EARLY DETECTION OF DISEASES. infant, may be the sign of disease in another; and this the mother alone can know. A parent may perceive changes in the little infant's countenance, in the attitude, the mode of breathing, of crying, which none else could perceive. A start, a cry, too evanescent for any other observer, will indicate to her the occurrence of pain, or of other disturbed conditions of the sentient system, which will at once warn her that something is wrong, and lead her to fly to the proper means of averting an impending evil. Such events, however apparently trifling, are to be carefully remembered, and commu- nicated to the physician. For want of this, many a life, dear to the parent, has been lost. It is the duty and office of the mother to observe and to describe these symptoms of indisposition in her little infant. She should cultivate the eye, the ear, the habit of observation in regard to her little charge. She should be the first to observe any change in its countenance, in any action, in any function of life. All such changes of the external appearance are significant of some internal change. Even unwonted dulness of the eye, or of the spirits, or unwonted inappetence for food, has its cause, and speaks a language at once intelligible and significant to the watchful mother. She should not observe sleepily, as it were, but be roused at once, by observation, to action : seeing the signs of disorder, rest not until you apply the means of cure. How often — how often, alas! too late do physicians hear that remark of a mother over- whelmed with anxiety and grief— " I can remember that the little child was not well, but 1 did not suspect such a serious state of things !" No indisposition is trifling in infants. Convulsions and hydrencephalus, the most distressing and alarming diseases to which infancy is liable, comes on so suddenly, or so insidiously, and with such slight intimations, that our attention should be ex- cited to the utmost, by every alteration of appearance or manner in infants, however faint, — however fleeting. In order to assist in the early detection of diseases, it may be well to lay down several arrangements of such as are most fre- quent, or most important. This plan will enable the parent or the young physician to disentangle the maze of these diseases; to decypher their language ; and to understand its import. The most frequent diseases of infants, then, are — 1, disorders of the stomach — 2, disorders of the bowels—.3, exhaustion — 4, then come febrile affections—5, then exanthematous diseases, or those diseases which are attended with eruptions on the skin — 6, affections of the head — 7, diseases of the thorax or chest — 8, affections of the abdomen or belly. Disorders of the stomach generally depend on improper diet; or they may be secondary, and the effect of a disordered or confined state of the bowels. They are often detected by acid or fetid eructations and breath, or by the unusually frequent regurgitation or vomiting of food. 7* 78 UNDERWOOD ON CHILDREN. Disorders of the bowels can never be mistaken or overlooked by an attentive nurse, the evacuations, in their number and appear- ance being the perfect index to these disorders. It must never be forgotten that whenever the system has been exposed to sources of exhaustion, this condition may become, in its turn, the source of various morbid affections which are apt to be ascribed to other causes, and treated by improper, and therefore dangerous measures. If the infant has had diarrhoea, or if it has been bled by leeches; or if, without these, its cheeks are pale and cool; and if, under these circumstances, it be taken with symptoms of affection of the head, we must not fail to remember, that this affection may be the result of exhaustion. Some years ago I brought this important subject before the profession ; it seems pre- viously to have been generally misunderstood. Fever is sooner detected. In every such case the little patient should be watched with redoubled care and attention. The skin especially should be examined hour after hour for eruptions. It may be measles, scarlatina, &c. Above all things, let not a contracted brow, an unusual state of the temper or manner, unusual drowsiness, or wakefulness, or starting, and especially unusual vomiting, pass unobserved. We should be alive to any acceleration, or labour, or shortness of the breathing ; or cough ; or sneezing ; or appearance of inflam- mation about the eyes or nostrils. These symptoms may portend inflammation within the chest, hooping-cough, measles, &c. Pain of the belly, with or without vomiting ; or diarrhoea, with or without a morbid state of the bowels, or of the discharges, will also doubtless excite immediate attention. One caution I would give on this subject. Some of the more alarming and fatal affec- tions of the bowels, like some affections of the head, are unattended by acute pain or tenderness; their accession, on the contrary, is insidious; and it will require peculiar attention to detect them early. Another view, and another mode of classification, of the dis- eases of infants, full of interest, full of admonition, is — 1, as they are sudden, or 2, as they are insidious, or 3, as they are interme- diate in the mode of accession between these two extremes. Of the sudden affections are, — fits of every kind, croup, and some kinds of pain, as that of colic. Of the second class are hydrencephalus or water in the brain, and tubercles in the lungs or abdomen, constituting the two kinds of consumption. Fits, again, are cerebral, and arise from disease within the head, or from irritation in the gums, stomach, or bowels, or from exhaus- tion ; or they are cardiac, and depend on some malformation or disease of the heart. Sometimes the attacks assume the character of croup ; there is a crowing cough, and crowing breathing ; or there is difficulty of breathing, and then a crowing inspiration. The former case is generally croup; the latter is in reality a fit dependent on a morbid ON THE EARLY DETECTION OF DISEASES. 79 condition of the brain or spinal marrow, although it takes the appearance of an affection of the organs of respiration. The insidious diseases are to be detected early by a strict observation of the countenance, manner, gestures, &c, of the infant. Anything new—anything strange, should obtain im- mediate attention. It may portend some sad affection of the head. The same remark must be made if the infant fall off in its looks, colour, flesh, &c. This may be the consequence of tubercles, the harbinger of consumption. The infantile diseases which occupy an intermediate rank be- tween the sudden and the insidious, are usually sufficiently marked by their appropriate symptoms, and need no particular notice here. We now proceed to notice the principal sources of the diagnosis of the diseases of children. I.--OF THE COUNTENANCE. The infant's countenance offers to us the most interesting and the most intelligible page in Nature's book. In its calm we read the health and ease of all its organs, — of all its functions. In its smiles we read its happiness of body and mind. In its expressions of uneasiness or pain, we first discover the invasion of disorder or disease; our attention will probably be first attracted by some undefined change, which it will require a stricter observation to decypher and associate with its peculiar cause. But it may be well more distinctly to enter upon the considera- tion of pain, and of its expression in the countenance ; an event so frequent in infancy. Pain may be sudden in its first attack, and in its recurrence. This circumstance will denote that its cause is not permanent in its operation. Such pain has frequently a spasmodic origin, and its seat in the bowels. On each recurrence of spasm, the countenance is painfully contracted, the body gives a sudden start, and the infant utters a sudden cry. Pain of a more permanent kind is frequently more gradual in its invasion. Its expression in the countenance varies with its kind and seat. Pain of the head produces a contracted brow ; pain in the belly occasions an elevation of the upper lip ; whilst pain of the chest is chiefly denoted by sharpness of the nostrils. Again I urge the importance of eagerly seizing every change of expression in the infant's face. Its cause — its origin must be ascertained by other signs. It is of the first importance to know that some indisposition exists. Its kind and nature are to be determined afterwards. But this remark is most important in the case of impending con- vulsion. Long before actual convulsion has taken place, the 80 UNDERWOOD ON CHILDREN. countenance denotes its approach, —the countenance becomes con- vulsive. The old nurses are aware of this, and frequently observe that the infant is convulsed inwardly. How do they know this? They read it in the countenance. " The countenance is convul- sive." I never allow myself to disregard the remarks of these sages, — but especially on this point. They have observed what has been too evanescent for me to observe, — what has not existed at the time of my visit or visits. Some change has been remarked. It cannot be described; but it nevertheless existed. And the infant is vaguely said to be inwardly convulsed. Still there is something in the convulsive countenance which admits of description. The upper lip is drawn,—is bluish or livid; or there is slight squinting, or a singular rotation of the eye upon its own axis. This is often detected by the sensitive parent, or the observant physician. Thus that affection, which of all the diseases of infancy it is most desirable to prevent, may be anticipated in its full accession by the most energetic modes of treatment. The next point to be noticed in the infantile countenance, is its varied degree of suffusion or pallor. Suffusion accompanies and denotes fever, and all diseases of general excitement; a flushed and heated condition of the counte- nance will, therefore, always deserve, and it is so obvious, that it never fails to excite, attention. But there is a class of morbid appearances, which have been too little attended to, until recently, by medical persons. They arise from exhaustion. This exhaustion is chiefly produced by pre- vious diarrhoea, or the abstraction or loss of blood. In such cases the face of the little patient is frequently alter- nately flushed and hot, and pallid and cool, or cold. The flush is transient; the pallor more permanent. With the pallor, the countenance is of various degrees of coolness, and in the more extreme cases the skin has a glazed and waxen appear- ance. It is in such cases that the countenance has been designated the pulse of infancy. Its degree of pallor and coolness denote, indeed, the degree of weakness and exhaustion. In the very extreme cases with the pallid, cold, and glistening cheeks, the eyelids are half closed only, the exposed part of the eye inflamed, the pupil contracted, the cornea covered with a thin film of mucus. There are two other affections of the complexion which deserve a cursory notice in this place. The first is that deep blueness or hvidity which constitutes what physicians term the morbus cceru- leus, and denotes a malformation of the heart;__the other is icterus or jaundice. There are still two other affections of the complexion which it may be well shortly to mention. The first is a state of chronic or continued pallor and waxen hue, which denotes, frequently long ON THE EARLY DETECTION OF DISEASES. 81 before its actual appearance, the accession of purpura, or purple spots, with various kinds of loss of blood, as from the nostrils, mouth, bowels, &c. The other form of morbid complexion is icterode, or like that in jaundice. It arises from various causes ; it may denote defec- tive nourishment, or a long protracted disordered condition of the bowels; or it may arise from the sad habit of giving spirits, and especially anodynes or opiates. It is obvious that it can only arise from defective nursing. II.--OF THE GESTURES. Every change of manner, every unwonted gesture in an infant, speaks to the observant eye a language not to be misun- derstood. Every deviation from the natural attitude is an indication of some change in the strength, or in the internal sensations, and con- sequently in the health. At a certain age the infant begins to support itself, — to sup- port its head. During an attack of disorder there is frequently a degree of muscular weakness which renders the infant inca- pable of doing so. The posture, the movements, are those of languor. At other times the infant experiences a sudden start, or a more lasting rigidity of the muscles. This may arise from pain, or it may be convulsion. In the former case the infant begins to cry violently; in the latter there is frequently an expression of stupor, terror, or surprise, and other symptoms as spasm or convulsion will be detected on a careful observation. The most remarkable of the symptoms just alluded to are a croupy sound in the breathing; an unusual and unnatural contrac- tion of the fingers and toes, and swelling of the hands and feet; the thumb and fingers are drawn into the palms of the hand, the toes towards the soles of the feet, whilst the back part of the hands and feet are puffed and tumid. This indication of convul- sion was thought of sufficient importance, by the late able Dr. Kellie, of Leith, to be made the subject of a distinct communica- tion to a medical journal. Watch therefore the condition of the infant's fingers and toes; especially examine them if there be any other indication of con- vulsion ; and if they are ever observed to be otherwise than ex- panded, fail not to attend to the circumstance in the most prompt and serious manner. Sometimes the head is drawn rigidly backwards ; or one arm is firmly, or at least unnaturally drawn to the side ; or one leg is apt to be drawn upwards. This is also a symptom of convulsive affection. To return to the effects of pain on the gestures. A sharp spas- 82 UNDERWOOD ON CHILDREN. modic pain will induce a sudden contraction of the whole of th6 muscles; the legs are drawn forcibly and suddenly upwards. But the pain of inflammatory affections frequently induces the little patient to avoid every muscular effort. It is alarmed if it be so placed as to call for muscular action. This circumstance should lead to immediate inquiry as to its cause. It will be more apt to escape attention than those sudden starts which pain of a ditterent character is so apt to induce. In pain of the head, the arms and hands are frequently raised ; and in pain in the abdomen the legs are apt to be drawn upwards. Infants have in health certain habits which frequently cease during indisposition. . Yawning, hiccup, a sort of cooing,— evidently the expression of ease and satisfaction, and certain movements of the eyes and of the hands, are of this kind. These are frequently sus- pended during the course of a malady, and their return is amongst the first harbingers of returning health. I have repeatedly known the power over the lower extremities or over one arm or leg to be greatly diminished. This affection will naturally excite alarm and immediate attention. III.--OF THE SLEEP. How many things claim our attention in relation to sleep, in in- fancy ! In the first place, it is during sleep that the physiognomy of infants is most expressive of the milder morbid sensations. In its waking hours, the infant's attention is diverted from its bodily sensations, being attracted by external objects, such as loud noises, or brilliant lights. But during sleep the mind, and consequently the countenance and the gestures, are impressed by the internal sensations, and by them alone. It is on this principle that grinding of the teeth, a symptom highly important to be noticed at every period of life, is scarcely observed except during sleep. Watch the infant's countenance, then, during its sleep. Its ex- pression will be happy, or variously impressed with smiles, if it be well; or it will indicate pain or other suffering, if it be indisposed. Sleeping and dreaming are inseparable. Dreams are impressed on the infantile countenance legibly enough, and thus the attention may often be early excited to some insidious malady, so as to lead to the prevention of diseases which may not admit of cure. The countenance during sleep quickly reveals uneasiness or pain of any kind. The brow is contracted, or the mouth is drawn, or both. The first denotes pain and affection within the head; the second, pain of the bowels ; the last severer pain, and this, gener- ally, in the bowels. Similar observations may be made in regard to the gestures. In health, the sleep of an infant is tranquil and composed. As in- ON THE EARLY DETECTION OF DISEASES. 83 disposition creeps on, the infant begins to evince its uneasy sen- sations by disturbed postures and frequent startings. During sleep, the respiration and the circulation become less perfect. There are fewer respirations in a given time. In deep sleep, imperfect respiration takes place for a time, and then a deeper inspiration or sigh is drawn to supply the previous deficiency of this function. There is no doubt, too, that the faculty of producing heat, and consequently the power of maintaining the temperature, is less during sleep. A remarkable modification of the functions during sleep, is that which obtains in regard to the functions of the skin, a change ob- served in all ages, but especially during infancy. The transpira- tion is much freer than in a waking hour. There is sometimes even profuse perspiration. The skin is moist, and the forehead and neck are frequently studded with globules of perspired fluid. On both these accounts, exposure to cold is trebly injurious and dangerous during sleep. The temperature is not only reduced, and the system enfeebled, but frequently there is an attack of inflammation of some internal organ, from exposure under such circumstances. Even adults are apt to become chill and to take cold, on falling asleep amidst circumstances of exposure to cold or damp, the pores of the skin being open during sleep. Exposure to cold, on the other hand, induces a disposition to sleep, a sort of reciprocity of action and influence observed in other circumstances, and especially in regard to sleep and the process of digestion. I have frequently observed the slightest degree of a febrile parox- ysm in infants and'young children during sleep. There is a degree of chilliness or of proneness to it, then a flush, and lastly, perspi- ration. In this respect, infancy seems allied to some morbid states of the system, such as those observed in weakness and in tuber- culous affections. I have already adverted to the reciprocal influence between sleep and digestion. Unlike the respiration, digestion is more energetic during sleep. Sleep, in its turn, is induced by the digestive process. The well-known experiment of Sir Busick Harwood, illustrates this proposition. Two dogs were fed, and whilst one of them was left to repose and sleep, the other was led to the chace. The digestion of the former was found to be per- fect ; that of the latter, scarcely to be effected at all. Infants are always inclined to sleep after being fed. This asso- ciation between sleep and digestion should be carefully fostered. After the lapse of due intervals, infants should be habitually fed and put to sleep. I have no doubt that similar associations might be effected between feeding and the evacuation of the bowels — a point of the utmost importance to the growth, nutrition, and well- being of infants. Infants pass much of their time in sleep, especially during the 84 UNDERWOOD ON CHILDREN. first weeks after birth. Subsequently, each period spent in sleep augments, whilst each interval also grows longer, and that in an augmented proportion. IV.--OF THE BREATHING, AND OF THE BEAT OF THE HEART. We should frequently apply our ear to the chest of the little infant, and listen, and accustom ourselves to the natural state of its respi- ration, and of the beat of its heart. We shall then be enabled to detect any change in them. Much may be learned from the pulse of an infant; but much more, from the respiration, and from the pulsation of the heart. It is from the latter, indeed, conjoined with the condition of the countenance,* that we are supplied, in infants, with that know- ledge which the pulse affords in adult age. Fever accelerates the respiration. It also adds to the frequency, sound, and impulse of the heart. In inflammation of the air-tubes, we may, by an attentive ear, often detect different rattles, or " r&les," as the French call them, in the breathing. These chiefly resemble what is usually termed a ruttling or wheezing, or the cooing of the turtle-dove. Sometimes the inspirations are checked by pain. Sometimes the breathing is less audible on one side of the chest than the other ; this depends on inflammation of the substance of the lungs, or effusion of water into the chest. Besides the ear, much is to be learnt by the eye, in regard to the respiration. Sometimes an infant breathes more with one side of the chest than with the other; sometimes more with the chest than with the belly, or more with the belly than the chest. There is generally inflammation or disease in the part least moved. And here I must observe that it would be highly advantageous that the infant should be brought to its physician, so loosely clothed, that its chest and belly may be the most easily and accu- rately examined. In some cases of great debility and exhaustion, the infant is apt to arrest its breathing at the end of each respiration. In other instances there is a slight moan, which is of serious omen. I have said nothing of cough, because this is observed even without watching, and cannot be neglected. V.--OF THE CRT. To cry may be justly said to be the first act of that life, which the infant begins to live on entering upon this vale of tears. The sages amongst the tribe of nurses are never so satisfied as when the infant gives a lusty cry. * See page 80. ON THE EARLY DETECTION OF DISEASES. 85 They have much reason for this. By the strength of the cry we may judge of that of the little infant; and by its freedom, of the healthy condition of the most important of the vital organs. Mal- formation or disease of the heart or of the lungs, would effec- tually arrest or modify the little infant's cry. To cry loudly and freely is therefore an unequivocal sign of health and vigour. Perpetual crying, especially the perpetual recurrence of crying in infants not wont to cry much, must, on the contrary, always be taken to denote some continued, or recurrent, uneasy or painful sensation. This fact being clearly perceived, our attention must be forthwith directed to discover its particular source or cause. Violent crying denotes, of course, violent pain. But it is fre- quently the mere effect of passion ; the discerning physician will, however, readily perceive the difference. In some instances violent crying has led to convulsion. Some children will hold their breath in crying passionately, until the recovery of it seems doubtful, and the face becomes livid. To remedy this, a simple mode has often been found to answer, viz., plunging the child's hand into cold water. This induces gasping or sighing, and so the breath is fully drawn. As crying is excited by other pains, so it is checked by pains of an inflammatory character, whether seated in the head, chest, or belly. The crying is also sometimes checked, apparently by the occur- rence of a sense of suffocation from the violence of the effort itself; in other cases, as in disease of the heart, the crying is checked still more promptly and suddenly. Sometimes the little infant is literally too feeble to cry. In some cases the peculiar sound of the cry is the first indication of croup, or of the croup-like convulsion. In other cases, the voice or cry becomes husky. This takes place in cases of an aphthous or erythematous condition of the larynx; it is also one of the symptoms of exhaustion. Moaning requires no description. It is not likely to escape the notice of a tender parent. These observations may be taken as useful hints. Still it is the habit of carefully observing every change in the little infant, which is what I would most earnestly recommend to be cultivated. Many of these changes are very important and easily detected, yet too slight to admit of description. If the child cries as it did not, be assured that it is not well. The cause of this change must be anxiously sought. VI.--OF THE TONGUE AND BREATH. Any change in the breath of the infant, cannot fail to attract our notice. Such changes depend on the condition of the internal mouth, or of the nostrils, and almost always indicate also a dis- ordered condition of the stomach and bowels. 8 86 UNDERWOOD ON CHILDREN. When the breath of an infant is affected, it is usually acid, rather than fetid, as is observed in adults. When the breath in children is fetid, it is frequently from the disease of the gums termed canker. At a later period, the breath becomes tainted from disorders of the stomach and bowels. The condition of the tongue is not so obvious. It will always be found white and loaded. But these appearances are increased by disorder, and others are added. The tip is very apt to become dry during febrile complaints ; and the papillae of the tongue be- come prominent, and appear through the white load, in some cases of protracted disorder. In scarlet fever, the papillae of the tongue become enlarged and prominent, presenting numerous red points, whilst the tongue itself is observed to be red, and the throat to be covered with efflorescence. The tongue, internal mouth, and throat, are frequently aphthous in infants. VII.--OF THE SKIN AND GENERAL SURFACE. To prevent repetition, I may refer to what has been already described under the head of " The Countenance," for some obser- vations which might otherwise have had a place here: The first rule in regard to the general surface, is, in every in- stance of indisposition, to examine and watch carefully for eruptive appearances on the skin. I would particularly observe that the slightest eruptions of the more chronic character, should also attract attention. They always depend upon some indisposition ; — some affection of the stomach and bowels, or of the system generally. The various " gums," as they are popularly termed, the eruption of boils, or of whitlow, the occifrrence of excoriations behind the ears, or of eruptions about the edge of the eyelid, and within the orifice of the nostrils, always denote some more deeply-seated indisposition as their cause. Any unusual heat or dryness of the skin will not fail to attract attention. Unusual coldness or dampness should also be imme- diately noticed, and carefully watched. The appearance of chilblains upon the hands or feet should always be understood to indicate the necessity of still greater care in avoiding cold. — M. H. ON THE DISEASES OF CHILDREN. 87 SECTION IV. ON THE DISEASES OF CHILDREN. The following account of the diseases of children, which in its later editions has made its appearance in a somewhat new form, and less exceptionable to professional men, it is hoped may place this branch of medicine upon a respectable footing, and exhibit a practice as founded and rational as in any other. That no such serious attempt had been previously made, is sufficiently acknow- ledged ; although detached parts, and some of the more important diseases of childhood, have been ably considered at different periods. For the manner in which the work is now executed, the author can only say, that, in addition to a long experience, he has care- fully consulted the most respectable authorities, as well ancient as modern ; while, by a close attention to facts, he has endeavoured to obviate the effects of that peculiar veil,* which is said to obscure infantile disorders. A practical arrangement of them has been studied, comprehending likewise the natural consecution of parts, and the order of time in which the complaints severally appear, that some conformity may be everywhere observed. Regard has also been had to their respective causes and symptoms, tending to elucidate their nature, and render their treatment more obvious than has been generally imagined. To their immediate diseases, is added an account of some of the principal accidents and injuries to which the earlier periods of childhood are peculiar liable; and though such articles may, indeed, be very unimportant to some readers, it is presumed they will have their use ; and may, possibly, prove no small satisfaction to others. And here it may not be improper to observe, that what- ever merit the publications of others may possess, they either form a part of some large systematic work, or else they are far too con- cise, and have omitted complaints of too much importance to be overlooked, as well as been necessarily silent on many, with which the authors themselves were unacquainted. The judicious treatment of infantile disorders demands, indeed, equal attention and experience; close and repeated observation being the great means of supplying the want of that kind of assist- ance, which the personal information of adult patients frequently affords. The disorders of childhood, however, are nowise myste- -* There is nothing to which this peculiar obscurity may be referred, but the incapacity of infants to describe their own feelings. There are, nevertheless, other sources of information, less fallacious, sometimes, than the more literal description of adults, which, in nervous complaints particularly, would tend to perplex the ablest physician, if he should always be led by themj and the like necessary discrimination will serve him equally well in the treatment of infants. 68 UNDERWOOD ON CHILDREN. rious, nor would ever have been thought so, if they had always been submitted to proper hands, and been as carefully investigated as the diseases of adults. Nor is it otherwise with the diseases of the earliest infancy, of which it may be safely asserted, that as they are more obvious than they are generally supposed, so is their number comparatively small, their cause uniform, and the treat- ment of most of them simple and certain.* This is especially true of the disorders of this period, though it may, perhaps, be objected, that their various diseases cannot ail originate from one and the same cause ; nor is it my intention to assert it, though it may be safely advanced in regard to a great number of them. It is to be remarked, likewise, that it is precisely the complaints of early infancy that are here spoken of; though it is, nevertheless, very evident, that there is a greater uniformity also in the causes of the several disorders, even of older children, than there is in those of adults, which have very often various, and dissimilar remote causes, at different times, and in different habits ; e. g., obstructed cala- menia, ascites, &c. . For the proof of these assertions, as well as in order to establish a rational practice, I shall first consider distinctly the causes and diagnostics of their complaints, before I attempt to enter upon their cure. And here I shall not attend to their various remote causes, but I shall confine myself to a practical consideration of the subject, and point out their obvious occasions and symptoms. And, on this account, I shall not take notice of all the changes which Nature herself induces during the growth of infants, as they pass from one stage of life to another; which are, doubtless, remote causes of some of their complaints. A more minute attention, indeed, would lead only to diffuse and uncertain theories, which have been established in one age only to be rejected in the next. In this country at least, such vague theories are now deservedly laid aside; though an era, perhaps, better calculated for their investigation, than those wherein such subjects were agitated with a zeal proportionate to the writers' comparative ignorance of ana- tomy, and those principles of the animal economy, which can be established only by a close observance of facts. A principal cause, mentioned both by ancient and modern writers, is the great moisture and laxity of infants; which is necessary, how- ever, in order to the extension of parts, and the rapid growth of young children. This laxity arises from the vast glandular secre- tion, their glands, in general, being much larger in proportion than those of adults. I might instance in the thymus gland, and parti- cularly in the pancreas and liver. But, besides these, there are innumerable glands situate within the mouth, oesophagus, stomach, and bowels, which are continually pouring out their contents into * Facillime, inquam, in morbos dilabuntur infantes, et nisi aut serius aut im- pentius iractentur, facillime in sanitatem restituuntur. — Harris, de Morbis Acutis Infantum. ON THE DISEASES OF CHILDREN. 89 the first passages. This is, doubtless, a wise provision of nature ; and I cannot, therefore, think with Dr. Armstrong, that the gastric juice renders the chyle less fit for absorption, for without a due proportion of it, no good chyle can be made ; but as even the best things may sometimes exceed, and as we do not strictly follow the dictates of nature in the management of children, as to their food, manner of clothing, sleeping, &c, this abundance of slimy matter may often overload the stomach and bowels, the constant seat of the first complaints in the infant state.* A second cause arises from the great irritability of the nervous system, and the delicacy of the muscular fibres, whereby the serous juices do not readily enough return, but remain longer than is consistent with a free circulation through the extreme parts. The quality of the milk, or other food, with which infants are nourished, may be accounted a third. In addition to these general causes, may be reckoned the want of exercise,t which, at a more advanced age, happily for us, we are obliged to make use of, and which art, in general, does not duly supply in regard to infants. J Hence arises acidities in the first passages, a constant attendant upon all their early complaints.§ Among the first of which may be reckoned the retention of the meconium, and the last (which may be termed a disease peculiar to infants) is the cutting of the teeth, in which likewise the state of the bowels is very much concerned. Upon each of the above heads, it will be necessary to make further observations as occasion may offer, in order to take notice of certain accidental causes arising from mismanagement, or errors in the non-naturals; especially in regard to the quantity of nour- ishment administered to infants, and inattention to the state of their bowels. The symptoms of these first diseases of infants, (by which we * Non quod aetus per se sit causa ullius morbi, est enim res naturalis et tem- poris determinatio, sed quia disponit ad morbos quosdam facilius suscipiendos si causae eorum accesserint. — Primeros : de Morb. Infant. f Exercise is the grand mean of health. The irrational specie3 are capable of affording it to themselves almost as soon as born; and though infant children are not, they are passive, and can be exercised. Nature and instinct point out the expediency of it, and the fond mother, who follows only her own inclination, naturally and insensibly adopts it. On this head see the article of Motion and Rest. X Together with these sources might be noticed another, not mentioned by writers, though not, indeed, an efficient cause of infantile complaints, but an occasion arising from that constitution the Creator appears to have established, as a law of nature running through the animal race ; I mean, the rank which the several species hold in that scale. For, whatever their apparent comparative strength maybe, the more noble and useful amongst them, whether domesticated or wild, (though, indeed, we cannot say precisely what the latter would be in a perfect state of nature,) seem to be liable to far the greater number of evils. It is possible, indeed, some philosophers may be disposed to draw very unbecoming inferences from such a position; but there are others who conceive it to be very justifiable, and analogous to various established facts in the dispensations of Providence towards lapsed creatures. § Sylvius de le Boe, Harris. 8* 90 UNDERWOOD ON CHILDREN. also judge of their nature,) are chiefly retention and excretion; sour belchings ; sickness; vomitings ; purgings; the nature of the matter thrown off; watching; inquietude; contraction and sharp- ness of the features; blueness about the mouth ; turning up of the eyes: thirst; heat; the manner of breathing and of crying; re- traction of the lower extremities; and pustules, or eruptions, external or internal. The pulse and urine are less certain marks in the greater number of their complaints, than they are in older children, and adults. To this may be added, the openness, or firm- ness of the fontanelles, and of the sutures; the size and figure of the head, and the strength of the bones; and the relaxation or contraction of the skin in general, and of the scrotum in particular. Having thus briefly adverted to the general causes and symp- toms, I proceed to the consideration of the disorders themselves, beginning with one hitherto unnoticed by writers; which, though very rare, seems to be the first that can take place after the birth, and is a kind of SYNCOPE, OR FAINTING. Many new-born infants, it is well known, lie, for some time, in a very feeble and uncertain state, with no other sign of animation than a weak pulsation of the heart, and the arteries of the umbili- cal cord. But I have only in one instance seen anything at all resembling the true syncope, after the living powers have once prevailed. In this case, the child was born at the instant its mother was moving from her chair into her bed, and in consequence, un- fortunately, fell with violence on the floor. It, however, very soon cried, and did not appear to be materially injured ; but, a day or two afterwards, fell into a strange, languid state, very different from anything I had been accustomed to see. Stools being pro- cured, it revived, and frequently took plenty of nourishment; but at intervals sunk into its former languor, breathed very faintly, and died about the sixth day. But, with the following case, which comes precisely under the idea of syncope, I have been favoured by the ingenious Mr. Hey, senior surgeon to the infirmary at Leeds. He reports that an infant, born at the full time, lay moaning and languid for four or five hours, and was then seized with a fainting fit, in which it continued for half an hour. In this state Mr. Hey found it. It had ceased to breathe, except now and then giving a gasp, or sob ; and was as pale as a corpse. There was, however, a sensible pulsation of the heart, though feeble and slow; but whether the circulation had been kept up all the time, previous to his visit, could not be ascertained. As soon as Mr. Hey had time to consider the case, he directed the infant's nostrils and temples to be stimulated with the volatile alkali, and when it became capable of swallowing, a few drops DISCOLORATION OF NEW-BORN INFANTS. 91 of the tinctura valerian, volat. were administered in a tea-spoon- ful of water, and repeated at proper intervals ; it likewise took a tea-spoonful of the ol. ricini. The child had three other similar attacks in the course of the day, though it had slept composedly between whiles, and sucked at the breast. It had seven more fainting fits in the night, two of which were severe ones ; but Mr. Hey was not called again till the next morning. He then observes, that reflecting on the case, and comparing it with that of a man whom he had seen thrown into convulsions by a large bleeding, after having hanged himself, which were cured by the above tincture given in wine; Mr. Hey pursued the like plan with the child, and administered the drops in a tea-spoonful of a generous white wine, every two hours. The infant was very sensibly refreshed by the first dose, and had no return of the disorder, except in the slightest degree, and became a very healthy child. The tinct. valer. volat. administered in this manner, is also an excellent remedy in other instances of debility and languor, when the prima; via. have been previously cleansed. A kind of syncope not dissimilar to this, but taking place a few days after birth, has been removed by a very different stimulant, which would not have been had recourse to, if various other means had not failed. Infants in this syncope appear to be dying for several days, and have even been concluded actually dead; but reviving again, relapse as before. In this state, the fume of lighted tobacco has been forced into the mouth with the happiest effect, though at the expense of a considerable struggle, succeeded by a strong convulsion. Upon the spasm subsiding, however, the infant soon falls asleep, and awakes apparently well, and continues so for several hours ; but the syncope returning, the fume should be repeated. If the struggle should return,it will prove slighter than the former: and neither that, nor the convulsion, will probably be renewed after a second recovery. DISCOLORATION OF NEW-BORN INFANTS. An affection of new-born infants, not much more common than the former, is a discoloration of the face and extremities, and some- times of the whole body; and, like the former, seemingly inde- pendent of the circumstances attendant upon the birth. A mere discoloration of the face after laborious deliveries is very common, and gradually disappears, without affording any occasion of alarm. But, in the present instance, the parts are very black, and after- wards turn of a leaden-blue colour ; sometimes appearing at the instant of the birth, and at others not for an hour or two after- wards, or sometimes a day or two. In one instance, I remarked 92 UNDERWOOD ON CHILDREN. the discoloration of the face to be partial, appearing in spots; the greater number being of the size of small peas, but some larger. In some instances, the discoloration abates a little, and in others not; sometimes it goes entirely off, and returns again, and in that case is of more serious consequence, and commonly dangerous. From an examination of the parts after death, I have learned, that this recurring blackness depends upon some .internal malformation or derangement,* and for which nothing that I know of can be attempted,but the general remedies for fits; which indeed usually follow, when none of the subsequent means prove effectual. From the result of this recurring blackness, it seems always to be owing to some fixed cause, excited into action by certain cir- cumstances, particularly any sudden agitation of body or mind. In such cases, the disappearance of the discoloration is followed by a return of the tinge of as deep a colour as at first. But in the innoxious kind, which is the more immediate subject of this chap- ter, though the blackness, in some instances, after abating a little, again returns, it never acquires the deep colour it had at first, and when it has once completely disappeared, it never returns. This discoloration, therefore, probably depends merely on some spasm affecting the external veins, and interrupting the free return of the blood into the larger vessels. Where this is the sole cause, the discoloration, howsoever great, is probably harmless, and would in every case soon abate, and in time entirely disappear; but is removed sooner by proper remedies. The only necessary means seem to be, to procure stools (which should be immediately soli- cited by clysters); to excite vomiting, if the infant appears to be sick at the stomach; and to rub, or gently chafe the body and limbs before the fire. But nothing tends to remove the blackness so suddenly or sensibly, as applying a leech or two upon, or near the livid parts ; and this should therefore always be had recourse to, if the blackness does not very evidently abate in an hour or two after birth, by the help of one or more of the means that have been recommended.t * In one instance, the subject of which died about the tenth day after birth, the malformation was in the stomach ; the pylorus being preternaturally straight, with difficulty permitting the food (which was only breast milk) to pass into the bowels. f The discolorations which are observable soon after the birth of children, if not occasioned by mechanical pressure, or injury during the labour, frequently depend upon deficient formation of the heart or arterial system, and are conse- quently little under the influence of medical treatment. When the discoloration is observed before the pulsation has ceased in the umbilical vessels, it may be useful to divide the funis, so that the blood passing through the umbilical arteries may be received into a cup to the amount of one or two ounces. This, and im- mersing the child in warm water, offer the most probable means of relief, whether the discoloration arises from a permanent or temporary cause. For the discolor- ation which comes on some hours after birth, nothing seems more likely to be useful than the plan recommended by Dr. Underwood. — S. M. RETENTION OF THE MECONIUM. 93 RETENTION OF THE MECONIUM. The meconium is that black, viscid, or tenacious matter, which every infant parts with by stool, for the first two or three days after it is born, or retains with manifest injury. The ordinary source of infantile complaints, originates from something amiss in the first passages, according to the most ancient and modern writers.* And I am satisfied, that a foundation is sometimes laid for them, from not duly attending to an early expul- sion of the meconium, which will sometimes firmly adhere to the coats of the bowels, and remain for many days unaffected even by powerful medicines; sometimes occasioning dangerous complaints from the birth, and at others giving rise to more remote evils ; and therefore, on both accounts, calling for the early attention of prac- titioners. I shall only observe in this place, that though the me- conium should not be all retained, yet a part will often remain much longer than has been usually imagined, and will come away, perhaps unnoticed, at a late period, when no retention of it has been suspected. Of this I can have no doubt, having been called to visit infants after the month has been expired, who have been unwell through all that period, and from whom meconium has still been coming away. A tea-spoonful of ol. ricini, given once or more, has soon carried off a great auantity ; upon which all their complaints have disappeared. The meconium is, probably, no longer of use after the child is come into the world, unless it be to keep the bowels from collaps- ing, till they can be replenished with the aliment the child is soon afterwards to receive. If it be not soon carried off, it will not only change the quality of the milk, or other food, as it descends into the bowels, but will itself also become highly acrid, (the greater part of it being bile,) and cannot fail to produce indigestion, flatulency, pain, purging, or costiveness, and other similar evils ; and the me- conium is further disposed to this acrid state, on another account, viz., from the admixture of atmospheric air ; as well as that which is engendered in the intestines by the food and imperfect digestion. Whilst the infant remains inclosed in the womb it is secured from all contact of air, and therefore the alimentary contents remain harmless and bland, though increasing for many months; but it is well'known how soon every secretion or extravasation will become acrid, upon the admission of air into any cavity where it may be lodged. And it is, doubtless, on these accounts, that provident nature has imparted an opening quality to the colostrum of all animals ; a certain indication to the rational species, to assist the expulsion of this matter, now no longer required. For though a child should even be suckled by its own mother, (in which case there is, doubtless, less occasion for other assistance,) yet we know * Hippoc. Celsus, ^Egineta, Harris, Armstrong, 94 UNDERWOOD ON CHILDREN. that nature doth not, in every instance, always fully accomplish her own designs; and it is from some striking instances of the truth of these observations, that I have said so much on this sub- ject, which I have also been the more inclined to, because so many writers have passed it over almost in silence ; whilst others have opposed our over officiousness. I am not surprised, indeed, that all those who esteem medical people to be officious disturbers of nature, should object to their assistance in this instance, and conclude that she would do the business much better if left to herself. And there are even some physicians of this opinion, amongst whom I find Dr. Buchan, whose abilities and reputation claim particular attention ; though he, per- haps, may not be so much engaged amongst very young infants, as those whose peculiar province it is to attend them from the birth. But there can be no general rule without exceptions ; and as, doubtless, many children would do very well without any such assistance, so have I found others would not, though suckled by the parent herself, of which I shall presently give a very striking instance. On the other hand, I believe no infant can be essenti- ally injured by constantly assisting in this work, provided the means first made use of be lenient, as they ought always to be. It is the province of art to superintend nature, and not only to guard against her excesses, but so to watch over her, as to insure the ac- complishment of her intentions, whenever we perfectly compre- hend, and can effect them without the risk of doing harm. And this intention is as rational as the practice is successful, there being an evident acidity in the meconium, as I have ascertained by re- peated experiments. The red gum and thrush are also much more rank where the symptoms of acidity are most prevalent; and, on the other hand, less commonly take place (as I have for many years observed) where the meconium has been early purged off. For this purpose, amongst others, a new remedy has of late years been recommended, as preferable to any purging medicines whatever.* Mankind has ever delighted in extremes — no sooner has anything, formerly judged to be hurtful, or even poisonous, been found, in certain cases, to be very useful, than it is supposed to be capable of doing everything, and supercedes all that the wis- dom of former ages has proved to be salutary. Hence some ad- vantages experienced from the use ofvinum a?ilimo?iii,'m a variety of children's complaints, as far as they arise from one common cause, have induced some people to extol it as an universal remedy. But wherefore give an emetic, calculated to empty the stomach, in order to expel the meconium from the lower bowels?t * Dr. Armstrong on Diseases most Fatal to Infants, 1767. f On examining the passages of still-born infants (newly-dead) it appears that the large intestines contain the true menconium : the smaller bowel?, only a thin bilious fluid, mixed with a little gastric juice. The stomach contains still less, as no bile can enter it but by regurgitation from the duodenum, and the gastric juice is in small quantity, not enough to be brought up by an emetic without violent straining; which I should imagine it can answer no good end to excite by a vomit, the first hour a child comes into the world. RETENTION OF THE MECONIUM. 95 It is universally allowed, and by this writer also, that emetics are not to be administered when the bowels are full, which, in this in- stance, is precisely the case. It is true, vinum antimonii does not always vomit children, nor will a little matter oftentimes do this ; it is sometimes, indeed, found to act as a purgative : but if this be the intention, why not adhere to the old and more certain method, and direct at once such things whose proper operation may be depended upon ? Not the stomach, but the bowels, are the natural and safe outlet for most infantile complaints, and a want of due attention to this circumstance has been productive of some evils, which many practitioners, I think, are not sufficiently aware of; and of which scarcely too much can be said, it being founded on long experience. It is very evident, that some gentle purgative is indicated on this occasion, and it should be of such a kind as will create as little disturbance as possible, and not be of an offensive, or indigestible nature. In general, indeed, a very little matter will suffice ; per- haps a little syrup of roses, diluted with some thin gruel, and given occasionally by tea-spoonfuls, will answer the end ; will also serve to keep the child quiet, and so prevent the nurse from giving it improper food. But if this should fail to procure stools, a watery infusion of rhubarb, or a dram of castor oil, will be found prefera- ble to the common oils and syrup in general use.* But, as has been observed, the meconium is not always disposed to come away, even by the assistance of common purgative medi- cines. Having, therefore, begun with such as the above, if the child should have no stool for twelve or fourteen hours after birth, and especially if it seem to be in pain, a clyster of gruel and salt ought to be thrown up ; which may be repeated, if necessary, a few hours afterwards. And here I would remark, that in the cases where more powerful remedies are required, scarcely any evacua- tion will be produced by these gentler means; for, whenever I could procure one copious stool by a clyster, or gentle laxative, the rest of the meconium has afterwards come away with little or no further assistance. But as it sometimes happens, that neither clysters nor ordinary purgatives have any sufficient effect for several days, more powerful means must then be made use of; there being reason to suspect a morbid suspension of nervous influence. I shall close this subject with a remarkable instance of this kind, (of which I have seen many,) as a proof that powerful remedies may sometimes be required, and to show how necessary it is to pay attention to this early complaint of infants. A child was born of very healthy parents, (not at all of con- stipated habits,) after a quick, and comparatively easy labour, and appeared to be itself in good health. — To avoid prolixity, I shall briefly observe that the child took a little rhubarb an hour or two after it was born, but having had no stool when I saw it the next * See Harris. 96 UNDERWOOD ON CHILDREN. day, I ordered a clyster to be thrown up. In the evening the child became drowsy and insensible, and when roused, it moaned, but seemed unable to cry. It continued pretty much in this state (except that at times it appeared to be in great pain, and was evidently convulsed) for six days; and was nourished chiefly by breast milk, given by tea-spoonfuls, seldom reviving sufficiently to suck. It had no stools, but such as made only a few spots on the cloths about the size of a shilling, till the sixth day, and then they were very small, hard, and lumpy. The next day it had more of this kind, and had not, till the eighth day, anything like a proper stool, which was also mixed with hard lumps ; but on the eleventh day they were thinner, and on the thirteenth came very freely. In the course of six-and-thirty hours, I prescribed two ounces of the com- mon infusion of senna, two drams of Rochelle salts, four grains of jalap, and a grain of calomel; besides purging clysters, and the use of the warm bath. The next day the child took four grains of ipecacuanha at two doses, and forty drops of vinum antimonii, at four times, (in the course of an hour,) without any effect; and at another period, six drams of castor oil, besides several doses of manna.* Three days after the child had gotten rid of the meco- nium, the thrush made its appearance, which'was slight, but con- tinued above three weeks. From such instances, the expediency of having recourse to some safe and effectual means of purging off the meconium, seems to be evidently pointed out; more especially when we consider the dangerous complaints which are said to arise in some of the hos- pitals in Paris, from an undue retention of this viscid matter, as will be further noticed in another place.f * See a similar instance in the chapter on the Croup. The obvious cause of the inactivity both of emetics and purgatives, which we sometimes meet with in infants, is probably, the great quantity of mucus with which the first passages are lined, together with a deficiency of nervous influence, a frequent concomitant of such a state. f Writers upon the diseases of infants, differ widely in opinion upon the subject of using means to procure a due evacuation of the meconium ; some judge it to be always expedient, if not absolutely necessary, to use artificial means for this purpose: others think that the expulsion may always be left to the ordinary powers of nature: — "of nature," as one of the most urgent recommenders of this method terms her, " all wise, all provident, and all perfect.'''' The truth, as is usual, lies between the two extremes. A free and spontaneous evacuation of the meconium very often takes place as soon as the child is born, and, of course, it is unnecessary in such a case to give purgatives for that purpose; but not unfrequently, there is a torpid state of the bowels, and, in consequence, the meconium is neither not at all or very scantily evacuated. Are we in a case of this kind to be deterred from the use of aperients, by the crv of " Nature is all-sufficient?" A prudent practitioner will not wantonly, or officiously, interfere with the natural processes of the constitution ; nor will he trust to nature, beyond what nature appears able to effect. We sometimes, however, talk about nature with- out knowing exactly what we mean ; no child that is born in these parts of the world can be said to be completely under the dominion of nature. If we were ON THE INTERTRIGO, OR CHAFINGS. 97 ON THE INTERTRIGO, OR CHAFINGS. To obviate these troublesome affections, washing with cold water is certainly useful; but can never call for such severity of treat- ment, as for an infant to be plunged with its feet or nates into a pan full of cold water, and be afterwards dashed all over with it, to its daily discomfort and terror. Cleanliness and bracing the skin are the proper intentions; and, with this view, besides the nates and groins, the arm-pits, folds of the neck, and parts behind the ears, may be occasionally washed with cold water; and, if the discharge be not checked by it, they should be dusted with a little hair powder, the powder of lapis calaminaris, or of ceruse ; or a little white vitriol may be added to the water ; which, if the excoriations are not very considerable, will generally heal them very soon: should these fail, they may be dressed with the red drying oint- ment of Bates's dispensatory. But these drying remedies, should rarely be applied to the ears. In a very acid state of the stomach, during the month, particularly where there is a purging with very green stools, the parts covered by the cloths are often infested with a still more troublesome excoriation, called intertrigo ; and, whilst that state continues, will not be healed by any drying applications. I have found nothing so pleasant and useful in this case, as cover- ing the parts with the thin skin found upon the veal kidney, which softens and cools them, till the cause of the complaint may be re- moved by the use of proper absorbents. There is a mixed affec- tion of this kind, however, in which these parts are not actually excoriated, but are very hard and swollen, as well as painful and inflamed ; and the affection seems to be kept up by the acrid nature of the excretions, though not originally caused by it. In this case, instead of daubing the parts with wetted fuller's earth, gruel, or greasy mixtures, an embrocation of elder-flower water, with as much boiling milk as will render it moderately warm, has been im- mediately efficacious. By the use of these means, the worst cases I have met with have been successfully treated; having never entirely in a state of nature, it is probable that our children, like animals in a state of nature, would be born only at those seasons of the year which are best adapted to the rearing of young creatures. The birth of a child in cold weather, when it is necessary for it to be kept in a room artificially warmed, is, of itself, such a deviation from nature, as may demand the assistance of art towards that child, in more important points, than the giving it a dose of castor oil. I am fully sensible of the great benefit which has been derived to the practice of me- dicine generally, since physicians have more attended to, and been guided by, the regular processes and laws of nature; but we are too much involved in artificial conditions and circumstances, to place implicit confidence in the resources of "all wise, all provident, and all perfect nature." Upon the whole, it may be concluded, that though an aperient soon after the birth of an infant, may be often properly omitted, yet on many occasions it is right to have recourse to such an assistant; especially when the child is fed with spoon victuals, or is suckled by a nurse, whose milk is several weeks or months old. - S. M. 9 98 UNDERWOOD ON CHILDREN seen anything like mortification, or need of administering bark, as recommended by Dr. Armstrong. But one grand means of keep- ing children from chafing, is to preserve them very dry and clean. A vulgar error may here be noticed, which is still too common, that of wearing a pilch, as it is called. This, as it is sometimes used, contributes not a little to make children weak; it was originally designed to be worn only for the few first weeks after birth, but is often continued for as many months. It can answer no possible end but that of saving a little trouble, since, instead of keeping children dry and clean, it has the directly contrary effect; for if it has received any wet through the usual cloth laid under it, it ought itself to be changed as often as the other, or must certainly be damp and uncleanly ; whilst, by heating the loins and lower limbs, it has a manifest tendency to relax, and dispose infants to become rickety. It may be proper to drop a word more, with a view to counteract a vulgar notion, familiar only to common people, that a frequent change of linen has a tendency to weaken new-horn children; an absurd idea, that has not the smallest foundation in reason or fact. It is, indeed, impossible that a child should thrive or be healthy, if the strictest attention be not paid to cleanliness, which is one of the principal articles in which the children of poor people are at a great disadvantage, and which becomes a constant source of rickets and distortions among them. Indeed, infants, if healthy, may oftentimes be so managed as to be much more cleanly than even people of great delicacy have been wont to imagine; so as even to supersede altogether the use of cloths, either by night or day. TUMID BREASTS OF INFANTS. In many children, a day or two after they are born, the breasts become exceedingly tumid, hard, and painful, containing a fluid resembling milk. Ignorant nurses, and the ignorant ones only, imagine that this milk, as they call it, ought to be pressed out; and it is quite grievous to see how rudely some nurses rub and squeeze the breasts for this purpose, although the redness of the part shows that it is already in a state of inflammation, and the screams of the babe demonstrate the severity of its sufferings under so rough an operation. In the case of inflammation, a bit of bread and milk poultice is the properest application; but if the part be not inflamed, it can want nothing at all; or should it be conceived that something ought to be done, a little oil, with a few drops of brandy, may be gently rubbed upon the part; or small pieces of the litharge-plaster may be applied, and lie on the parts till they fall off themselves. I have, indeed, had sufficient evidence of such considerable tume- faction and hardness, as to satisfy me, that when no violence is offered to the parts, the application of a bread and milk poultice will always prevent either suppuration or other unpleasant conse- quence. I have met with instances, in which the tumour has been ICTERITIA, OR INFANTILE JAUNDICE. 99 much larger and harder than I could have suspected on such an occasion ; and yet, after continuing for more than a week, without any sensible diminution or amendment, has soon afterwards sub- sided entirely. ICTERITIA, OR INFANTILE JAUNDICE. The jaundice of infants seems always to have been improperly conceived of. Those who have written only on children's diseases, have usually passed it over in silence, whilst others have con- sidered it always as rather a serious complaint, and have prescribed as for the jaundice of adults. On the other hand, nurses have usu- ally accounted the yellowness that appears about the third day after birth, if unusually deep, (termed by some the yellow-gum,) as the true jaundice. Certainly neither of these opinions is just; for the latter of these appearances requires no attention at all, and though infants are not very often troubled with the true jaundice like adults, they nevertheless are liable to slighter affections of that kind, which claim some attention. These are easily distinguished from the common yellowness, by the tunica albuginea being always very yellow ; but the nails are not tinged, as in the jaundice of adults,* though it is probable they usually would be, if the com- plaint were long neglected, and the child suffered to be costive. I have waited some days to see if the yellowness would go off of itself, as the usual tinge does ; but it has always increased rather than diminished. It arises from viscid matter obstructing the gall ducts, and therefore requires a little emetic. The tartarized wine of antimony is a very proper one on this occasion, as it may likewise procure two or three stools ; but as children in this complaint are not easily made to vomit, should the wine fail, three or four grains of the powder of ipecacuanha may be given, as more certain in its operation ; and the next day, four or five grains of rhubarb. Should the symptoms continue, the emetic ought to be repeated after two or three days, and rhubarb be given about every other day,t till the yellowness disappears ; which, under this treatment, never continues more than ten or twelve days, unless the infant be very costive, or the stools are of a very pale colour, which is but rarely the case. Where an emetic has been objected to, and the whole attention confined to keeping the belly open, the yellow- ness has continued when I have taken my leave at the end of the month, attended with languor, and other symptoms of debility. When the belly is usually costive, and the stools very pale, infants are generally found to have a true jaundice, and require some saponaceous medicines, such as the liquor potassae subcarbon., * See note, page 100. \ The daily exhibition of a few grains of hydrarg. c. creld, with one of jalap, or two or three of rhubarb, commonly answers very well in removing this com- plaint. — S. M. 100 UNDERWOOD ON CHILDREN. together with daily frictions of the stomach and belly, and the use ofthe warm bath. Women long afflicted with jaundice, during any part of their pregnancy, and even actually brought to bed in that state, do not infect their children,* unless they also suckle them; but from striking instances, I have found, that suckling in that state is capable of communicating the true jaundice to a great degree, and that it will not be cured, but by the recovery of the suckling mother or nurse, or unless the nurse be changed, or the infant weaned, as well as properly treated. The true jaundice, distinguished by the skin being everywhere discoloured, as well as the whites of the eyes, seems to be much more common among new-born infants in France, than in this country, as appears from a memoir written by M. Baumes, and to which a prize medal of the faculty of Medicine in Paris has been adjudged. In that work, the various causes and nature of the disease are distinguished ; and a correspondent treatment is pointed out with great accuracy and judgment. Throughout the tract, there seems also to be much ingenious and plausible theory ; though I cannot agree with that able physician, in supposing the jaundice to be occasioned by the retention of the meconium, otherwise than from this viscid matter sometimes obstructing the orifice of the biliary ducts. For in the several instances I have met with, of the most obstinate retention of that secretion, there has not been the least disposition to jaundice ; nor can I conceive, that any part of the meconium is usually absorbed in icteric cases, as M. Baumes has imagined : neither does such an incident appear to be necessary in order to account for the frequency of the disease in that kingdom, or elsewhere. As to the treatment, under the different circumstances there described, I meet with nothing that militates against the more general account I have given of this disease, or the treatment adapted to it, under the form wherein it appears in this country. There are not wanting evidences of this disease, both in the more slight and severe forms of it, being in some families heredi- * I have never met with such an instance; but M. Baumes, who has been very attentive to the disease, is satisfied that he once saw an infant so infected from the womb ; but, in this case, the child died very soon in a very diseased state, the internal part of the liver being in a state of suppuration. Other instances are given, but they are not unexceptionable. Vide A. N. Curios. Dec. 1. A. vj. Obs. 241. Dec. iij. A. ij. Obs. 40. Dr. Delaboe. Silvii, Prax. Med. Lib.]. Cap. 46, No. xi. p. 302. Theod. Kerkring, Spicil. Obs. 57, p. 118. I have, in- deed, seen an infant, (the mother of which, however, was not icteric,) whose finger nails were, at the birth, of a3 deep a yellow as any icteric adult's, and very sensibly from a tinge underneath them; but those of the toes were not at all discoloured, nor had the infant any other symptoms of jaundice. It indeed brought up, by puking, a considerable quantity of yellow matter, apparently bile] very soon after it was born; but the tinge ofthe nails disappeared the next dav! and the infant throve very well. ICTERITIA, OR INFANTILE JAUNDICE. ]fjl tary ; of the former, Morgagni has furnished a remarkable example in his own family ; and ofthe latter, Mr. Pearson has favoured me with a very curious one, which the reader cannot fail to be pleased with, as no such instance, I believe, is to be found upon record. I shall submit the account in his own words, and without any comment; as further experience is necessary to enable us to draw any practical inferences. Mr. Pearson's account runs thus : Mrs. J. had been the mother of eleven children ; on nine of which the jaundice appeared a few days after they were born, and they all died within the period of a month after their birth. The tenth child lived six years, was then afflicted with the jaundice, and died. In May, 1796, Mrs. J. was delivered of her eleventh child : on the third day after its birth, the skin became yellow, and the child was at the same time remarkably torpid and sleepy, and seemed to be slightly convulsed. On the following days, the colour of the skin often varied, being sometimes of a deeper yellow, and at other times nearly regaining its natural colour ; the child continued, how- ever, in the same languid and almost insensible state, but received nourishment, and suckled the breast of its mother, till within a few hours of its death, which took place on the ninth day. I opened the body of this child the day after it died, and shall now proceed to describe the appearances exhibited on dissection. The skin had nearly lost its yellow colour; and the child did not appear at all reduced by the disease. The liver was almost twice its natural size ; the whole concave surface of the right lobe had a livid appearauce, but this dark colour did not penetrate above a line or two, and the internal substance was sound and healthy. The convex part ofthe liver was ofthe natural colour and firmness, except on the margin of both the lobes ; there the thin edge exhibited a highly injected appearance ; the redness was, however, less vivid and remarkable on the left lobe than on the right. There was also a slight adhesion of the lower part of the right lobe to the peritoneum. The gall-bladder was nearly filled with bile, of a deep yellow colour, and its ducts were permeable. The stomach was in a natural state, and the intestines were without any marks of disease. In the thorax, the lungs were of a healthy appearance. The heart seemed to be larger than common, and the bloodvessels on its surface were remarkably turgid. The right auricle was distended with blood, and the peri- cardium contained about a table-spoonful of water. Every person who is conversant with the diseases of children, knows that, although new-born infants are sometimes affected with the true jaundice, requiring its appropriate remedy, this appearance is at others but of little importance, and sometimes even disappears spon- taneously. Morgagni has furnished a remarkable example of this in his own family.— De quindecim filiis meis, cum mox a partu flavi omnes, et nonnulli etiam haud ita leviter, essent facti, cunctis »* MASS. MED-COLLEGE. . 102 UNDERWOOD ON CHILDREN. per se, nullo prorsus artis auxilio, paulatim icterus solutus est. Lib. iij. Epist. 48. Art. 60. INFANTILE ERYSIPELAS. In a former edition it was observed, that this complaint, (noticed under the term, anomalous inflammation,) did not appear to have been distinctly noticed by any preceding writer. But I have since found that Hoffman, thought he makes no mention of any such complaint in his Morbi Infantum, has the following intima- tion in his chapter de Febre Erysipelacea* and it should therefore seem, was acquainted with that species ofthe disease which appears in the more precise form of erysipelas ; but which he had noticed only in the region ofthe belly.—" Umbilicalem regionem ininfan- tibus frequentius infestat, ac hide per abdomen spargitur, cum gravibus pathematibus, funesto ut plurimum eventu." The French have likewise spoken of a somewhat similar affection, combined with different endemic complaints infecting crowded hospitals: and it is certainly sometimes found to follow disorders of the first passages. The disease, however, not appearing to have been any- where noticed in its simple and genuine form, it has seemed neces- sary to give a name to the disease ; which, therefore, in my latter editions, has been termed Infantile Erysipelas. It is a very dangerous species of the spurious or erysipelatous in- flammation, which I have not often met with, but in lying-in hos- pitals. The ordinary time of its attack having been a few days after birth, it was at first thought never to appear later than the month; but this has been since found not to be the case. It seizes the most robust, as well as delicate children, and in an instan- taneous manner; the progress is rapid; the skin turns of a purplish hue, and soon becomes exceedingly hard. The milder species of it often appears on the fingers and hands, or the feet and ankles, and sometimes upon or near the joints; forming matter in a very short time. The more violent kind is generally seated about the pubes, and extends upwards on the belly, and down the thighs and legs; though sometimes it begins in the neck, and is equally fatal. The fact, indeed, seems to be, that it is generally far more dangerous when it seizes, or spreads to any parts of the body, than when confined to the limbs. The swelling is but moderate ; but after becoming hard, the parts turn purple, livid, and very often sphacelate, especially in boys, when it falls on the scrotum ; the penis swells, and the prepuce then puts on that kind of emphysematous appearance which it has when a stone is sticking in the passage ; or in the anasarca ofthe scrotum. Upon examining several bodies after death, the contents of the belly have frequently been found glued together, and their surface • Sec. i. Cap. 31. INFANTILE ERYSIPELAS. 103 covered with inflammatory exudation, exactly similar to that found in women who have died of puerperal fever. In males, the tunicae vaginales have been sometimes filled with matter, which has evi- dently made its way from the cavity of the abdomen, and accounts for the appearances of the organs of generation just now de- scribed : in females, the labia pudendi are affected in like manner, the pus having forced a passage through the abdominal rings. Upon the complaint being first noticed in the British Lying-in Hospital, various means were made use of without success : the progress of the inflammation has seemed, indeed, to be checked for a while by saturnine fomentations and poultices, applied on the very first appearance of the inflammation; but it soon spread, and a gangrene presently came on ; or where matter has been formed, the tender infant has sunk under the discharge. It is now several years since I proposed making a trial of the bark, to which, some- times, a little confectio aromatica has been added: from which period several have recovered. Some time after this, linen compresses, wrung out of camphorated spirit, were applied in the place of the aqua Uthargyri acetati, and have proved more suc- cessful in checking the inflammation in several instances ;* never- theless, the greater number of infants attacked with this disorder sink under its violence, and many of them in a very few days. In a few instances, the disease has been attended with some varieties. Infants have not only come into the world with several hard, and sub-livid inflammatory patches, and ichorous vesications about the belly and thighs, but with other spots already actually in a state of mortification. A large eschar has soon spread upon the spine of the tibia, with smaller ones about other parts of the legs, and on several of the toes and fingers. In such cases, particularly, the bark and cordials must be exhibited liberally, and the inflamed and mortified parts be well fomented, and dressed with warm applications. From the good effects attending these means, particularly on a very copious use of the bark, there is further room to hope, that we may be yet more successful in the treatment of this formidable In two instances, where the bodies of infants dying of this dis- ease were examined by Dr. T. Walshman,the stomach, lungs, and other internal parts were found very much diseased; the former being in so tender a state as to give way upon the slightest pres- sure • whether anything of this kind usually takes place in conse- quence of this disease, further examinations must evince. Such a state of the stomach is, however, by no means peculiar to this disorder, being met with in the examination of scrofulous and hectical children; and occurred also in the body of an infant * Fomentations made of extract of poppies, diffused in warm water, and poul- tices, consisting ofthe same fluid, and crumbs of bread, have been beneficial in many instances. — S_ M. 104 UNDERWOOD ON CHILDREN. which I examined, that had lived to be only six days old ; and in this instance, likewise, the intestines, kidneys, and other parts, were greatly diseased. CORYZA MALIGNA, OR MORBID SNUFFLES. I have given this appellation to an uncommon discharge from the nostrils, taking place in the month, usually in the first or second week after birth ; and in one or two instances the infant has seemed to be born with il. This disease has passed under the name of the snuffles, on account of the kind of noise such infants make in respiration ; but it is not only a far more severe, but a very different complaint from the one commonly intended by that name. The discharge is much more abundant than that arising from taking cold, and is truly purulent from the beginning, and afterwards sanious: though, in a few instances, children affected with every other symptom of this disorder, have no discharge from the nose. But under every form of the disease, infants always appear weakly, though without any precise complaint, and are constantly incommoded from the stoppage of the head, especially in their sleep ; during which they breathe with difficulty. It generally continues for several weeks; and, upon its going off, children who have had the disorder only slightly, have become otherwise unwell, and such as have been brought up by hand, have been dangerously ill in their bowels. The plan of treatment which I adopted in the first instances I met with, was to keep the body cool and open ; or if the infant happened to be over-purged, or was languid, to administer absorb- ents and cordials. I recommended the nurse's diet to be attended to, when the child was suckled, and to keep a little blister open on its head, or on the nape of the neck; but this has since appeared, in some instances, to be hazardous, although no evil ever ensued where I had directed it. I had attained no further knowledge of this complaint, when Dr. Denman obliged the public with a more ample and formidable detail of it; which had fallen more frequently in his way, than it had done in any other practitioner's. His account of it is so accurate, that I shall in this edition like- wise borrow the description of its principal symptoms from him, adding to it such as a later experience has furnished. He remarks, that this disease seemed to be new in its manner, though not in its kind, at the time of its first making its appearance, which was frequently in the summer of the year 1790; in the June of which year it was, that I also first saw it. After mentioning the little varieties noticed in the discharge, and the most formidable symptom of the disease, the difficulty of breath- ing through the nose, he observes, that the latter was not constant, and that when free from it, children appeared to be in no danger; CORYZA MALIGNA, OR MORBID SNUFFLES. ]()5 that the difficulty of breathing was at other times so great, as to require an attendant to watch a child sleeping and waking, in order to open its mouth as often as it might be requisite. Dr. Denman further notices a singular purple streak at the verge ofthe eyelids, which he afterwards considered in a manner patho- gnomonic of the disease ; and, indeed, I have rarely met with the disease without it. He describes also a general fulness about the throat and neck externally, taking place soon after the commence- ment of the complaint, which he seems to date from the appear- ance of the purulent discharge from the nose ; though it has been remarked, that this symptom, although one of the most formidable, may be entirely wanting. That, when these symptoms had continued for some days, according to the strength of the patient, and degree of the disease, children became pale and languid; and that, upon looking into the throat, the tonsils were found tumefied, and of a dark red colour, with ash-coloured specks upon them, and in some there were extensive ulcerations. The parts on which blisters had been applied in the beginning of the disease, and which had been ap- parently healed, often sphacelated towards the conclusion. The infants, he reports, gradually declined in their strength, and had a particular catch in respiration, as if the velum pendulum palati were elongated. They were unable to suck, though not universally ; swallowed with difficulty whatever was given in a spoon; and died in convulsions, or with all the marks of great debility, though not on any particular day of the- disease. Dr. Denman observes, that in the course of eight months he had attended eight children in this disorder, six of whom died; that the body of one of them was afterwards opened by the late Mr. Hunter and Mr. Home, but that nothing was discovered, except that the membrane lining the nose was of a dark red colour, and its bloodvessels more turgid than ordinary. Dr. Denman, by a fortunate occurrence, having discovered the true nature of this disease, has, in consequence, happily adapted a remedy that has proved an almost certain cure for it, if attended to in time. The true source then appears to be a defluxion and inflamma- tion over all that extent of Schneider's membrane, lining the antrum highmorianum, posterior nostrils, and contiguous parts. Hence the copious secretion of purulent matter irritates the trachea, and produces that spasm, and croaking noise, with recurring sense of suffocation, so uniformly observed in this disease. By descending into the stomach and bowels, it disorders these parts ; and if not very soon properly treated, induces such general disease as pre- sently debilitates, and at an uncertain, but generally an early pcriod, carries off the little patient in the maimer that has been already described. The stools, it may be noticed, are sometimes thick and pasty, and when otherwise, after repeated purges, they are of a peculiar green colour, or sometimes blue, different from what I have noticed on almost any other occasion. 106 UNDERWOOD ON CHILDREN. From this account of the disorder, an attention to the state of the bowels, as I intimated in the first instance I had seen of it, is the manifest indication; but with this further light thrown upon it by Dr. Denman, that keeping them very open, so as to prevent the lodgment of the matter falling into them, is the grand mean of cure ; there being much less to be effected by absorbents and antacids to correct the constant sourness and ill-condition of the stools, than by carrying them off speedily and frequently. To this end, one or more tea-spoonfuls of castor oil should be given every day, so as to procure three or four motions daily. If the child should be weakened by this means, some cordial medicine should be occasionally interposed ; or should this prove insufficient to support the infant, the purgative must be somewhat abated ; but it is remarkable, that even weak infants endure purging better under this complaint than any other, unless it be the tooth fever. If a convulsion fit should supervene, as it sometimes does, clysters, and the usual remedies for spasm, should be administered, and especially the cordial, which, breaking off wind from the stomach, and giving tone to the bowels, becomes a very useful one in this case. In several instances, a recourse to opium, or syrup of white poppies, has been attended with good effect; and may, in that case, be administered every night, when the purgative has operated properly. Or a good medicine, in many cases, is Dalby's carmina- tive,* which may be given every six or eight hours; and particu- * Dalby's Carminative and Godfrey's Cordial are medicines very often kept in the nursery, and the opium they contain makes them remedies of great conve- nience to the nurse. They are unquestionably medicines of great power and efficacy, and consequently very unfit for indiscriminate use. No remedies for infants require greater care and judgment in their application — none are so care- lessly and incautiously given. The late Dr. Clarke, in his Commentaries, has mentioned a case which he saw, where " forty drops of Dalby's carminative destroyed an infant." Similar instances are not uncommon. A woman living near Fitzroy-square, thinking her child not quite well, gave it a dose of Godfrey's cordial, which she purchased at a chemist's in the neighbourhood : in a very short time after taking it, the child fell into convulsions, and soon died. In less than a month, the child of another woman in the same house was found to he ill with disordered bowels. The first woman, not at all suspecting that the Godfrey's cordial had produced the con- vulsions in her infant, persuaded her friend to give the same medicine to her child. A dose from the same bottle was given, and this child was likewise attacked almost immediately with convulsions, and also died. Mr. Adams, of Charlotte-street, who was called to the last child, related to me these particulars. — S. M. [I would once more quote the " Letters to a Mother," for a description of the poisoning of opium : "The morbid effects of opiates or anodynes, are seen as the consequence of a single dose, or ofthe habit of giving these medicines. Infants are very susceptible of the effects of the first dose of an opiate. Dozing, and then perhaps convulsion, takes place; the infant lies with the eyes partially closed, and turned upwards ; the breathing is laborious and sighing; there is some tossing about of the arms perhaps ; and the powers of life begin to sink. "The appearances which arise from the habit of giving opiates are very peculiar. They may be seen in the dwindled, pallid, sallow, stupefied counte- nances of the infants of the poor as you pass them in the street. The eye- CORYZA MALIGNA, OR MORBID SNUFFLES. 107 larly when repeated doses ofthe laxative medicine are given through the day. From eight to twenty drops, or more, may, in that case, be given between each dose of the purgative ; and has, in some instances, been considered as a principal mean of cure. Under such treatment, the morbid snuffles has been found to yield in the course of two or three weeks ; some purging medicine being continued as long as the discharge or difficulty of breathing shall remain. It, however, sometimes runs on as much longer, and is attended with a spasm in respiration, as if the infant were dying; this symptom, as well as the snuffling, often recurring some time after an infant has seemed to be cured : and in one case, not only the snuffling, but the discharge occurred more than once, after the discharge seemed wholly to have given way. In such in- stances, besides purging, it has been thought useful to foment the bridge of the nose, and afterwards apply some aromatic liniment.(e) When the disorder is found not only to hang on for many weeks, (as it sometimes will even where it has not been peculiarly violent,) but, together with the continued use of purges, to keep the infant pallid and feeble, notwithstanding the exhibition of cordial medi- cines, a recourse to the decoction of oak-bark has at once removed the snuffling, and given vigour to the child in the course even of a few days. A remedy that does not seem to be sufficiently known, for this and many other complaints. Indeed, where a tonic me- dicine is found necessary, but where either from a febrile diathesis, or a disposition to glandular obstructions, the cortex peruvianus may be thought inexpedient, the oak-bark will generally be found a safe and efficacious medicine. It is only necessary to add, that though this disorder is not usu- ally met with after the month, I have seen it at a more advanced age ; in one, or more instances, however, it has been thought, I lids are red and swollen; the whole face is the miniature of a sickly aged person. " Not dissimilar appearances take place from giving spirits." Dr. Christison observes* — "It appears that very young children are often peculiarly sensible to the poisonous action of opium, so that it is scarcely possible to use the most insignificant doses with safety. Sundeling states in general terms that extremely small doses are very dangerous to infants on account of the rapidity of absorption. This opinion, which I have heard stated by various prac- titioners, is amply supported by several cases." In one " the administration of three drops of laudanum in a chalk mixture for diarrhoea to a stout child fourteen months old, was followed by coma, convulsions, and death in about six hours." In another, " an infant a few weeks old, died with all the symptoms of poisoning with opium, after receiving four drops of laudanum." — M. H.] * Christison on Poisons, second edit. p. 625. (e) In a case of this kind, in which blood was discharged from the nose, I found the application of a few leeches over the lower part of the osfrontis to be of service in mitigating the disease. 108 UNDERWOOD ON CHILDREN. know not how justly, that some slight symptoms of it had, in that case, appeared in the month. INWARD-FITS. It has been already said, that any derangement of the first pas- sages is capable of giving rise to various complaints, among which, that of inward-fits has been taken notice of by some medical people ; but I think scarcely deserves the name of a disease. It demands attention, however, because so much has been said about it as to create apprehensions, lest this subtle disease should be insensibly at work, and insidiously making way for more severe and outward convulsions. This complaint may take place at any period of early infancy, and is thought to be more dangerous the younger the infant may be. A constant symptom in this kind of fit, as it is called, is the infant's mouth being drawn into a smile, which, whoever has noticed it, must have beheld with pleasure. And if the complaint extends no further than this smiling, which is generally while the child is asleep, it arises merely from wind, and is certainly harm- less, because, in this case, the wind is not really confined; and, therefore, an immediate recourse to emetics, or purges, is more likely to do harm, by straining the stomach, or by relaxing the bowels, than to do any good. Everybody is acquainted with the effects of different degrees of irritation of the nerves, from the sen- sation produced by tickling with a feather, to that of a hard gripe, or a violent stroke. The first may be said to be pleasing; and such, I doubt not, is the stimulus in question on the nervous coat of the stomach of infants ; and, therefore, it produces so agreeable a smile, that I could never consider it as an indication of mischief any more than of pain. Indeed, I know of no complaint that ought to be termed inward-fits; and I mention this, because nurses are continually talking to us about them, when children are per- fectly well, and often give the fond parent needless distress, as well as many an unpleasant medicine to the child. They, at the same time, treat the true convulsion,* whilst slight, in the same way, being led into the error by the idea of inward-fits; a term they are ever using, but have no precise ideas of, nor do any two of them intend the same thing. It would be better if the term were * The remedies commonly employed by nurses, and others, for relieving these inward-fits, as they are called, are Dalby's Carminative, Godfrey's Cordial, Soot Drops, Assafoetida Drops, and other stimulants and carminatives, composed of various warm and spicy drugs. These, being found generally efficacious in removing the complaint when it depends upon wind, are considered the best possible remedies for all kinds of fits, and are given with an unsparing hand, in inflammatory attacks, if there be any resemblance, real or supposed, to fits. It is obvious, that when such remedies are employed at the commencement of the true convulsion fits, they must be extremely prejudicial. — S. M. [See the remarks which I have made, p. 51. — M. H.] INWARD-FITS. 1Q9 altogether abolished, and the word fit used only when the child is evidently convulsed. Infants, as well as adults, do sometimes, indeed, die suddenly without any manifest convulsion. But this more frequently happens after over-feeding, and arises from a spasm of the stomach (of which I shall treat at large, in the chapter on true convulsions); or sometimes of the heart or lungs; and infants may then be said to die of inward-fits, there being no ex- ternal convulsion. Infants are likewise carried off suddenly from water in the head, of which I have seen two instances in the same family, (where the disease was ascertained by opening the cranium,) both the children appearing perfectly well only a few minutes before they died; but neither of these was, by any means, the kind of affection usually understood by the term inward-fits. If the infant should sleep too long, and the smiling above-mentioned should often return, the infant may be taken up, gently tapped on the back, and its stomach and belly be well rubbed by the fire, which is all that can be necessary. This gentle exercise will occa- sion a discharge of wind from its stomach, and the child will go to sleep again quietly. This complaint, however, is largely treated of by some writers, and Dr. Armstrong recommends to give a few drops of the wine of antimony; but it is very apparent, that when he considers it as worthy of more attention than I have just now advised, it is either a true convulsion, in which the eyes are distorted, and the mouth is decomposed, instead of putting on a smile ; or else he is prescribing for another disease under the name of inward-fits, which former writers have treated under the head of disorders arising from cos- tiveness and wind. But if this little turn of the features should arise, as frequently happens, from constant over-feeding, it were endless to administer emetics; the cause of the complaint is obvi- ous, and upon the removal of it the remedy must rest. Such has ever been my opinion of this much-talked of complaint; and I have not, after a great deal of attention to infants, seen any- thing sufficient to induce me to alter it; or I should have sup- pressed the preceding observations. As I wish, however, to afford all the information I can on every complaint, I have to observe, that a gentleman of great respectability and experience, has con- ceived, that though the term inward-fits has been often misapplied, there is really such a complaint, and that it generally proves fatal. Besides a little blueness of the lips, and slight turning up of the eyes, often noticed by nurses, this complaint is described as attended with a peculiar sound of the voice, (somewhat like the croup,) and a very quick breathing at intervals ; and is supposed to arise from a spasm in the stomach, lungs, or other vital organ.* A spasm I * The disease here spoken of by Dr. Underwood, is, I conceive, the same that has been so well described by Dr. Clarke, in his Commentaries, under the title of "A peculiar Species of Convulsion in Infant Children." It is by no means an uncommon affection of children, arising generally from improper feeding, and close and confined apartments. If timely attended to, the complaint commonly 10 110 UNDERWOOD ON CHILDREN. have indeed too frequently seen, but certainly very different from that usually accounted inward-fits. These symptoms are said frequently to attack the child in its sleep : and in their commencement will go off upon taking it up from its cradle. They are likewise observed to be induced by sucking or feeding, and to be increased upon any little exertion of body, or transient surprise, and in this manner to recur for a length of time, before they become alarming. The remedies proposed for the cure of this complaint, are an emetic on the first attack, and afterwards volatiles and fetids : but, as it has been observed, very seldom to good effect. These symptoms, indeed, I have frequently met with ; and how- ever alarming their appearance, if they be not accompanied with any other, they have fortunately turned out more favourably than this complaint is reported to do. Hitherto, at least, I have suc- ceeded in removing this extraordinary spasm, in every instance, by treating it, as I had before hinted, as a chronical croup, by admin- istering different antispasmodics; assafoetida, ol. tinct. fulig. musk, or cicuta, being prescribed as particular circumstances have indi- cated ; and so far from its generally proving fatal, I have not been able to learn, by the most diligent inquiries, that any children so affected, excepting two* out ofthe numbers I have attended, have yields to daily aperients, so as to produce at least two copious motions; and continued doses of soda, or a strong infusion of burnt sponge, with proper atten- tion to diet and regimen. When the head is manifestly affected, cupping glasses behind the ears are required; but when the patient has cold, pale, flabby cheeks, as I have, not unfrequently, observed in this disease, abstraction of blood is rather injurious than beneficial. In two cases of this kind, which were under my care nearly at the same time, the children died in the fits. They were both opened by Mr. Sweatman, a very skilful anatomist, but not the slightest appearance of cerebral affection could be discovered in either of them. The principal deranged structure discovered, was a collection of small glandular swellings in the neck, pressing upon the par vagum. — S. M. * One of these infants had very severe and repeated convulsion fits for several days, together with the croup, and was suspected to have water in the head. It appeared, however, to be at length perfectly recovered, so that Dr. Reynolds (who attended with me) and I had taken our leave for about a fortnight. The fits then returned, but were so slight that the apothecary only was sent to; but in one, the most slight of any, the infant almost in an instant expired, very much in the manner described by the gentleman above alluded to. But as infants not unfrequently die suddenly of hydrocephalus,f and as that, or some other morbid affection of the brain had been suspected, and as the infant was not opened, the conclusion on either side is incomplete. Should it be objected, that, although this child had several true convulsion fits, at the same time that it was affected with the crouping noise, and that these returned after the croup had given way; yet it certainly died precisely in the sudden manner that infants are said to do of what has been termed inward-fits; and therefore neither this child, nor others who recovered under the treatment described, had a disorder that ought to be termed a spasmodic croup, but were f See the Chapter on Hydrocephalus. INWARD-FITS. Ill been carried off suddenly, or by anything resembling this com- plaint. I have, indeed, very frequently seen what I have termed the chronical croup, in children of various ages, and indiscrimi- nately in those nourished by the spoon, or the breast. I have known it attended with severe and repeated epileptic fits; (and then the bowels have usually been costive, or the stools very clayey); but in every instance, the crouping noise has yielded, and (with the exceptions above-mentioned) children have continued well, treated in the manner I have described; and I therefore can- not but think the complaint under consideration is of that kind. In regard to costiveness and wind, which have been said to be the parent of what nurses commonly term inward-fits, as they do not always arise from one and the same cause, and are productive of other complaints than those above-mentioned, I shall consider them by themselves; which, it is presumed, will be pursuing a more rational plan, than adhering to a term obscure in itself, and indicative of a disease not well defined, and which, therefore, may tend to mislead the inexperienced reader. [The following is the description of this complaint given by Dr. J. Clarke: — " This convulsive affection occurs by paroxysms, with longer or shorter intervals between them, and of longer or shorter duration in different cases, and in the same case at different times. " It consists in a peculiar mode of inspiration, which it is difficult accurately to describe. " The child having had no apparent warning, is suddenly seized with a spasmodic inspiration, consisting of distinct attempts to fill the chest, between each of which a squeaking noise is often made; the eyes stare, and the child is evidently in great distress; the face and the extremities, if the paroxysm continues long, become purple, the head is thrown backward, and the spine is often bent, as in opisthotonos; at length, a strong expiration takes place, a fit of crying generally succeeds, and the child, evidently much exhausted, often falls asleep. all ill of inward-fits, although only one of them died suddenly as such infants usually do : — should the whole, or any part of this reasoning be granted, (which in my opinion it ought not,) yet is the term inward-fits> equally improper, and nowise descriptive of so singular a disease as is intended by it; and can only lead to an indeterminate use of a term, calculated rather to obscure a dangerous dis- ease, than to lead to any good practical use. The other infant was only five months old, and appeared to be recovering under the use of assafoetida, when it died very suddenly ,• and the body being opened, it was with much surprise that the marks of true apoplexy were met with, there being a coagulum ofblood on the pia mater of nearly four inches wide. This is the only instance I have heard of where an examination has been made after death : but it is not supposed that the brain is the seat of disease in other instances of sudden death, in the disorder that has been termed inward-fits ; such, at least, is the sentiment of the respectable authority, from which the description of it has been given above, but rather, as before observed, that it is a spasm of the lungs, stomach, or other vital organ below the brain. 112 UNDERWOOD ON CHILDREN. " In one of these attacks a child sometimes, but not frequently, dies. " They usually occur many times in the course of the day, and are often brought on by straining, by exercise, and by fretting ; and sometimes they come on from no apparent cause. " They very commonly take place after a full meal, and they often occur immediately upon waking from sleep, though before the time of waking, the child had been lying in a most tranquil state. As the breathing is affected by these paroxysms, the com- plaint is generally referred to the organs of respiration, and it has been sometimes called chronic croup ; but it is very different from croup, and is altogether of a convulsive character, arising from the same causes, and is relieved by the same remedies as other convul- sive affections. " Accompanying these symptoms, a bending of the toes down- wards, clenching of the fist, and the insertion of the thumbs into the palm of the hands, and bending the fingers upon them, is some- times found, not only during the paroxysm, but at other times. " Clenching the fist with the thumb inserted into the palm of the hand, often exists for a long time in children, without being much observed, yet it is always to be considered as an unfavourable symptom, and frequently is a forerunner of convulsive disorders, being itself a spasmodic affection. " It rarely happens that a child recovers from an attack of this sort, unless the progress of the disorder has been interrupted by a timely application of proper remedies, without a general convulsion. Then the friends become alarmed, and a disease, which had existed for two or three months, is for the first time considered to be im- portant enough to require medical assistance, after all the farrago of popular medicines, such as fit-drops, soot-drops, assafoetida, &c, have been ineffectually applied. " Convulsions of this description seldom, if ever, occur after the expiration of the third year of a child's life, and not often in children which have lived by sucking, till they have teeth, and have never taken animal food till the dentes cuspidati have come through the gums; this, however, is liable to some exceptions."*—M. H.] [It has been recently attempted to found the pathology of this interesting disease upon observations, such as that adduced by Dr. Merriman, (p. 141,) but, I think, unsuccessfully. In the first place, as far as my memory and judgment serve me, the cases adduced, to support this view, are not cases in point, but, in reality, cases of other diseases. Secondly, supposing pressure upon the par vagum to exist, it would induce totally different phenomena from those actually * j£Tmentaries on Diseases of Children, by Dr. John Clarke, Part First, INWARD-FITS. 113 observed in this disease ; and it would not explain the series of phenomena which actually occur in it: for, 1. Such pressure would induce simple paralysis. This would, in the first place, affect the recurrent nerve, and the dilator muscles of the larynx; it would induce a partial but constant closure of that orifice, — a permanent state of dyspnoea, such as occurred in the experiments of Legallois, or such as is observed to be excited in horses affected with the " cornage," or roaring. Secondly. It would induce paralysis of the inferior portion of the pneumogastric, with congestion in the lung or lungs, and the well- known effects upon the stomach, of the division of this nerve. 2. The disease in question, on the contrary, variously designated "peculiar convulsion," "spasm of the glottis," &c, is obviously a part of a more general spasmodic affection, and frequently, indeed most frequently, comes on in the midst of the first sleep, in the most sudden manner, receding equally suddenly, to return, perhaps, as before, after various intervals of days, weeks, or even months. Very unlike paralysis from any cause ! 3. It not unfrequently involves, or accompanies, as I have said, other affections, indisputably spasmodic, as distortion of the face, strabismus, contraction ofthe thumbs to the palms ofthe hands, — of the wrists, feet, toes,—general convulsions ! sudden dissolution! — a series of phenomena totally unallied to paralysis. 4. Indeed, the larynx is sometimes absolutely closed, — an effect which paralysis of the recurrent nerve, and of its dilator muscles, cannot effect. 5. Paralysis from the pressure of diseased glands would be a far less curable disease, a far less variable disease, a far less suddenly fatal disease, than the croup-like convulsion. Thirdly. Almost all recent cases are at once relieved by attention to three or four things: viz., the state, 1, ofthe teeth,—2, of the diet, — 3, of the bowels ; and, 4, by change of air ;— they are as obviously produced or reproduced by the agency of errors in one or more of these. Fourthly. In fact, the croup-like convulsion is a spasmodic disease, excited by causes situated in the nervous centres, or eccen- trically from them ; in a case of spina bifida, a croupy and convul- sive inspiration was induced by gentle pressure on the spinal tumour; in cases from teething, the attack has been induced and removed many times, by teething, and by freely lancing the teeth ; by crudi- ties, and by emetics and purgatives; by change of air, &c. Fifthly. There is a series of facts which prove the connection of this disease with other forms of convulsions in children, and with epilepsy in the adult subject. Sixthly. In protracted cases, congestion and effusion within the head occur as effects of this disease. Lastly. Innumerable cases of undoubted croup-like convulsion 10* 114 UNDERWOOD ON CHILDREN. have occurred, in which no enlarged glands could be detected in any part of the course of the pneumogastric nerve. I would not be supposed to speak with undue confidence, when I venture to suggest another view of this matter as nearer the truth : viz., that this disease is induced through the fifth pair of nerves in teething, the eighth in indigestion, and spinal nerves in constipation, as parts of a system of nerves endued with a peculiar function which I have denominated the reflex.* However this may be, the view itself points to the most useful and efficient remedies, and this is highly important: it points to the teeth, in- digestion, and constipation, as causes, and to the well-known means of removing them ; it points to the important objects involved in change of air, mental quiet, &c. If, instead of the popular remedy, (the warm bath,) the gum- lancet, and the full warm water clyster, were instantly admin- istered, many little patients would be saved from the effects of this terrible disease. The diet should be barley-water only. —M. H.] DISORDERS ARISING FROM CONSTIPATION AND WIND. Constipation is either constitutional or accidental, which ought always to be distinguished ; the former being oftentimes harmless, and, indeed, children of such a habit of body are frequently the most thriving. If the mother should be very constipated, her chil- dren often are so ; and such a disposition (whilst they continue in health) ought not to be forcibly counteracted, though it will be prudent carefully to watch it. And this will be especially neces- sary, in the case of children who are subject to fits; fine lusty infants being often seized with violent convulsions, without any other apparent cause than a naturally very costive state of the bowels, and these have uniformly recovered from the fits, merely by procuring stools and breaking off the wind. It is likewise some- times an incitement to recurrent fever, as I have noticed in one of the finest and otherwise healthy children I have seen ; who relapsed for two or three years into repeated fevers, seemingly from no other cause than a naturally very constipated state of the bowels, which it was scarcely possible, either by diet or medicine, duly to counteract. The above-mentioned disposition to fits has taken place long before the ordinary period of teething, and has continued till children have been a twelvemonth old; at which time the solids, and especially the nervous system, have appeared to get stronger. In such habits, a quarter of an ounce of manna, or the like quantity of the syrup of roses, or of senna, may be put into any liquid, and as much of it given by tea-spoonfuls, as shall open the belly. Or should these prove insufficient, a dram of ol. ricini may be taken two or three times a week ; or a few grains of the pulv.fol. sennae, or its extract, with or without a little grated * See the Philosophical Transactions for 1833. DISORDERS ARISING FROM CONSTIPATION AND WIND. H5 nutmeg, or cloves; or a few drops of the tinct. aloes comp. or tinct. jalap, to infants of some months old. But rhubarb will not be a fit purgative, though it be joined with magnesia, which will not sufficiently counteract its restringency, and nurses ought to be cautioned on this head, with whom it is so frequent a prescription, during the month; and whose indiscriminate use of it is sometimes prejudicial. A few grains of magnesia in a spoonful of dill, or common water, and sweetened with a little manna, or syrup of roses, forms a much neater medicine, (which may be quickened and warmed by the addition of a few drops of tincture of senna,) and in costive habits, which usually abound with acidity, answers very well in early infancy. But if the child be otherwise in health, it is, in general, inad- visable to do much to counteract the natural habit of body.* I have, even during the month, directed manna, in the dose of half an ounce at a time, to very little purpose, unless it was almost daily repeated, and have at other times given from three to five grains of jalap ; till I learned that there are some constitutions, even in infants, where the bowels cannot be kept open without a daily exhibition of some purgative medicine, and that many such children are as well left to themselves, or, at least, require only to be watched. If a stool should be wanted, however, a suppository, (or dry-clyster) made of a little slip of paper, or linen-cloth, twisted up, and well moistened with oil, may be very easily introduced, and will generally answer the purpose ; or should this fail, a bit of Castile soap, mallow-root, red beet, or a parsley stalk, may be in- troduced in like manner. These means will be assisted, and a costive habit relieved, by rubbing the stomach and bowels fre- quently every day with a warm hand, or a piece of flannel.t Should such a costive and windy state of the bowels produce griping pains, which may generally be known by the drawing up of the legs, or of the scrotum, and a certain manner of crying, it will be proper to apply external warmth to the stomach and bowels, by means of heated bran, or camomile flowers, put into a soft flannel bag; which will both tend to abate the pain, and assist the operation of the laxative. Or should the costiveness be acci- dental, it must speedily be remedied ; and if the occasion of it be * I have attended in many families of numerous children, all of whom have grown up strong and healthy, but been uncommonly costive, and from their infancy have been for several days without a motion; nor would any gentle means pro- cure it statedly. And on the day when this note was made, I was consulted for an infant of only three weeks old, who had had no stool for five days, and yet was perfectly healthy and easy. This is not mentioned, indeed, to lead prac- titioners to abate of their attention to a costive habit of body in infants; but in proof only of its being in some instances innoxious, and therefore no cause of alarm as long as children are otherwise perfectly well. | In some cases of habitual costiveness, a liniment, consisting of liniment sapon. comp. ^i.; tinct. aloes cornp. ^ss. rubbed over the abdomen every day, for five or ten minutes, has been found very beneficial in keeping the bowels regular. — S. M. 11G UNDERWOOD OX CHILDREN. food of an improper kind, or too thick, which is very often the case, the food must immediately be changed. If the child be not usually costive, rhubarb is, indeed, often the best purgative, as it strengthens the bowels afterwards, infants being much more subject to an over- purging than to almost any other complaint, especially if brought up by hand. It sometimes happens, that much more powerful medicines than rhubarb may be required, whether the child be naturally costive or not: and in such cases, much caution is neces- sary ; for, where a proper dose of senna tea has proved ineffectual, it is surprising what large doses even of rough purges have been given in vain, or sometimes to the injury of the child. On such occasions, I would rather advise a recourse to clysters, and espe- cially those made of socotrine aloes. From five to twenty grains, according to the age of the infant, dissolved in boiled milk, will rarely, if ever, fail of procuring a stool, and will often procure two or three, especially if preceded by the exhibition of a purge. But even drastic clysters should be administered with caution, and ought not to be very often repeated, especially to very young children, though less hazardous, in every view, than the frequent repetition of purges of a similar kind, and when used alternately with gentle purges, become expedient and beneficial. Some writers, particularly the French, have much too frequently advised oil of almonds for infants of such a habit. Mr. Le Febure de Villebrune, therefore, in a note to the translation with which he has honoured my first edition of the Diseases of Children, testifies his preference of oils; but I differ from him, being persuaded there are few cases besides disorders of the chest, in which any kind of unctuous oil, but that of castor, will not be injurious to young infants, and particularly in affections of the first passages. It is dubious, however, whether oil of almonds, or of olives, always proves a laxative, or whether, by diminishing the natural force and action of the intestines, it may not frequently prove the reverse. As there is usually too much acidity in the first passages in cos- tive and windy habits, a little magnesia, or a few drops of liquor potassae subcarbonatis, may be given for a few days after the costiveness has been removed; and if the child be suckled, the nurses's diet must be attended to. If any flatulency should still remain, (which will not often be the case, if it has arisen merely from constipation,) a little dill water, or a few drops of spir. amnion. comp. properly diluted, are very safe and gentle carminatives ; or should one more powerful be expedient, the fluid parts of the warm opening mixture directed in the chapter on diarrhoea may be given, without shaking up the vial. But if the flatulency be an attendant upon a lax state of the bowels and indigestion, its remedy will consist in the removal of those complaints, which will be noticed in their place. Should flatulency, however, continue, it may sometimes prove a real complaint, though it should not happen to be so confined as actually to become an occasion of fits. It is usually, indeed, but a mere symptom of some preceding or VIGILLE, OR WATCHINGS. 117 attending complaint; nor are its troublesome effects either occa- sioned or increased by air taken in with the food, as many people have imagined, atmospheric air being essentially different from that produced by indigestion, whether owing to the weakness of the stomach, as it is called, or the improper quality or quantity of the food taken into it. It may, however, in conjunction with other causes, prove a source of many complaints, and create watch- fulness, startings, hiccoughs, vomitings, and even convulsions, if not timely attended to, especially if the infant be costive. A prin- cipal remedy in that case will consist in keeping the bowels open, with frequent friction of the stomach and abdomen ; means of no small importance in every complaint connected with affections of the first passages. The only instances that I remember to have met with of wind proving of much consequence, when not preceded by other com- plaints, have been in very lusty new-born infants, whose mothers have also been peculiarly distressed by affections of that kind. This is, indeed, a somewhat anile way of speaking, but it states the precise fact; and one instance of an infant suffering in this way was so remarkable, that it may be worth noticing in this place. In this case, the meconium began to pass off soon after birth, but not without repeated clysters, purgatives, and the warm bath, and was peculiarly viscid, as well as in vast quantity. The infant the meanwhile appeared for several days likely to be strangled, and was black in the face, merely through the abundance of wind in the first passages, though it was breaking off both by the mouth and the bowels, and with that peculiar and very loud noise, when it came upwards, observed oftentimes in the hysterical spasm of adults, and continuing, with only short intervals, for several hours together ; so that the infant was several times thought to be dying. The whole face, except the nose, became exceedingly swelled, so that the infant could scarcely open its eyes, though without any discoloration ofthe skin; being, probably, owing to wind diffused through the cellular membrane; (as hath been known to happen in the case of a small wound of the lungs from a fractured rib ;) the tumour subsiding immediately upon getting rid of the wind from the stomach and bowels. These symptoms, however, yielded to carminative juleps, and purging medicines; (which is all that mere windy complaints usually require ;) and the infant, after the meconium was all come away, was freed from every complaint, without any further sem- blance of fits, which before had been frequently apprehended. VIGILIJ3, OR WATCHINGS. Watching, or want of sleep, is frequently a symptom of the foregoing complaints, and in that case, may be removed by open- ing the belly, and afterwards administering a carminative absorb- 118 UNDERWOOD ON CHILDREN. ent julep, which will then frequently act like an opiate,* by re- storing rest. Sometimes, indeed, this succeeds so well when given in large doses, that we are suspected of having really given some narcotic medicine, which, doubtless, would, in these cases, prove exceedingly hurtful, as the watchfulness is generally a mere symp- tom, and not a disease ; though, when very obstinate, it is some- times the harbinger of epilepsy, and then requires purgative medicines. Watchings may arise from worms, purging, or gripings, whether from acrid breast milk, or other food, and from indigestion, as well as from everything capable of producing pain; each of which probable causes should be very attentively inquired into before we prescribe ; and will, therefore, be distinctly considered in their proper place. The usual source may, indeed, be said to be some default in the first passages, and in very young infants is frequently owing to costiveness. I shall only observe further, if watchfulness be confined only to the night, it is probable the child sleeps too long in the day-time, which may be remedied by keeping it moving, and playing with it throughout the day ; of which little matters, more precise notice has been taken in the part devoted to the Management of Infants. APHTHA, OR THE THRUSH.(/) Having considered these lighter early complaints, I proceed to others which equally owe their origin to some affection of the ali- mentary canal, and are oftentimes of a more serious nature. One of the most important of these disorders is the Thrush ; a complaint that, probably, depends not a little upon the different natural habits of infants, as well as upon their management, par- ticularly in regard to food, air, and the statu of the bowels. This seems to be the case, inasmuch as the thrush is sometimes found to seize every infant in certain families, in whatever way the chil- dren may be managed; as well as to occur occasionally in others, upon a want of proper attention to the state of the alimentary canal, where a great number of other children, properly watched, have uniformly escaped it. Instances ofthe latter kind may have been noticed, where the mother happening to be ill, the whole attention of the family has been thereby engaged ; or, where one infant has been put to nurse, whilst all the rest of the children have been carefully brought up at home. It is a vulgar error, that the thrush is a very harmless complaint, and even desirable to a child in the month; for it is said, if it does * See Harris, De Morbis Acutis Infantum. (/) Follicular Stomatitis of late French writers, which consists of an inflammation of the muciparous follicles of the mouth ; and is most apt to attack children who are teething. APHTHAE, OR THE THRUSH. 119 not then make its appearance, it certainly will at a more advanced age, and will then prove fatal. The fact is, the thrush is a disease of debility, and, therefore, attacks very young, and very old sub- jects, especially if otherwise weakened. From the above foolish persuasion of its harmless nature, the disorder is often neglected in the beginning, whereby the acidity in the first passages is suf- fered to increase, which always aggravates the complaint. It is, indeed, a much milder disorder in this island, than on most parts of the Continent, particularly in France, where it reigns as a malig- nant epidemic, especially in the Hotel-Dieu, and Foundling Hospi- tals, and is known by the names of Muguet and Millet* The thrush, however, is as much a disease as any other complaint that appears in the month, and is connected with most of those already described; a proper attention to which may very frequently pre- vent it. This disorder generally appears first in the angles of the lips, and then on the tongue and cheeks, in the form of little white specks, which some writers have termed ulcers. These increasing in number and size, run together more or less, according to the degree of malignity, composing a thin white crust, which, at length, lines the whole inside of the mouth, from the lips even to the oeso- phagus, and is said to extend into the stomach, and through the whole length ofthe intestines ; producing also a redness about the anus. When the crust falls off, it is frequently succeeded by others of a darker colour ; but this is true only in the worst kind of thrush ; for there is a milder sort, that is spread thinly over the lips and tongue, which returns a great many times, and always lasts for several weeks. I have seen this so very often the case, that when I observe a child to have the complaint very slightly, and that it does not increase after two or three days, I venture to pronounce * It has been already remarked, that several hospital diseases in France are more complex than with us, and possibly from their infirmaries receiving a much greater number of patients than ours, and their apartments and beds being con- sequently less clean, as well as the air foul, and disposed to multiply contagion. This is remarkably the case in regard to the diseases of infants, whose tempe- rament is a singular union of debility and spasm, which the French have aptly termed Laxite vibratile. The Muguet is a striking instance of the above-mentioned tendency, it being altogether an hospital disease, which, though distinguished by this name, appears to be a malignant thrush, and is frequently attended with a species of the infantile erysipelas.f When so accompanied, it is said to be constantly fatal, unless the hard and tumid parts terminate in benign abscesses, and suppurate kindly; which is rarely the case, they being more commonly found to mortify.{g) t See Memoires de la Societe Royale de Medecine, anno 1779. {g) Muguet consists in a concretion of mucus on the surface of inflamed mucous membrane. It may be observed in the mouth, oesophagus, sto- mach, and small or large intestine. It occurs most frequently in early infancy. 120 UNDERWOOD ON CHILDREN. it likely to continue a long time, but that it will be of no con- sequence. I have, likewise, seen a return of thrush in a child three months old, and the infant nowise ill, or costive. Care, however, ought always to be taken that children, with any degree of this complaint, be not exposed to cold. It is an old observation, and there is some foundation for it, that unusually long sleeping in the course of the first week or two, is often a forerunner of this com- plaint. The thrush, in its commencement, is said to be generally attended with fever; but I have, by no means, found this to be the case, where the thrush is an original disease. When consequent to severe bowel complaints, erysipelas, and other infantile disorders, it is, indeed, often accompanied with fever; and when so, proves either favourably critical, or the infant usually sinks very soon. In ordinary cases, however, I am confident in nine out of ten, there is not the least fever, though the mouth is often so much heated as to excoriate the nipples of the nurse, and so tender, that the child is often observed to suck with reluctance and caution.* In very bad kinds of thrush, a fever may attend; but even here, it does not appear at the commencement of the complaint, but rather towards the close, the fever also being of the low kind. And this is owing to the general ill health induced by the morbid state of the gastric juices and alimentary canal, in the same manner as the common hectic fever is induced by the long continuance of other bowel complaints. Zuingerus,t indeed, gives an instance of fever accompanying this complaint; but it was in a child of four years of age, and the thrush not the original disease, which serves only to confirm what I have said. Symptoms of slight inflammatory fever had preceded the thrush, which appeared a little the next day, and both that and the fever were increased the day after. On the third, both were considerably abated, and on the fourth day, the child was perfectly well. It has long been a received opinion, that the thrush must appear at the anus, and many people will not admit that it is cured, if it does not; and for the like reason, they always suppose it to be going off when this redness takes place. But the truth is, that its appearance there is only a mark of the degree of the disease, or of the acidity that occasions it, and not in the least of its cure; and is not, therefore, generally to be wished for. The redness about this part is occasioned by the sharpness of the secretions in the bowels, and consequently of the stools, which slightly inflame, and sometimes excoriate the parts about the anus, and, in a bad thrush, will do so long before the complaint is going off; but in the lighter kind, no such effects are produced, or are, at least, very * A very red and shining appearance of the tongue frequently precedes the occurrence of the thrush; in these cases, a febrile state of the system is generally evident. — S. M. | Theod. Zuingeri, Archiatri Basil. Pedojatreja Practica, 1722. APHTHA, OR THE THRUSH. 121 slight. And, indeed, this redness has been so often mentioned to me as an indication that infants must, unobserved, have already had a slight thrush, or, according to others, be likely to suffer by it very soon, where children have, nevertheless, escaped it altogether; that I have ventured to imagine such infants may be least of all liable to it, if otherwise in good health, at least, my experience seems to support the idea. And I have even conceived, that the acidity ofthe first passages, being in some children more confined, may prove a remote cause of such infants being troubled with the thrush ; whilst others, by an open belly, and stronger viscera, may escape it, at the expense only of this soreness of the external parts, which often continues for several days. And this has led some people, on the other hand, to call this simple redness the thrush, and we therefore often hear it said that children have had it only in this part. A principal remote cause of this disease seems to be indigestion, whether occasioned by bad milk, or other unwholesome food, or by the weakness of the stomach. Perhaps thick victuals, particu- larly if taken hot, and made very sweet: also, covering the face of the child when it sleeps, or allowing it to breathe the confined air of the mother's bed, may contribute to bring on the complaint, and ought therefore to be avoided. The proximate cause* is the thickness, or acrimony of the juices secreted from the glands of the mouth, fauces, stomach, &c, producing heat and soreness in these parts. A tea-spoonful of cold water given every morning has been thought a good prophylactic : but keeping the bowels duly open, is certainly a much better. The means of cure must be sufficiently obvious, if due attention be paid to the nature and occasion of the complaint. As a general observation, it may be said, that when the thrush attacks robust infants of a costive habit of body, it is easily cured, and, indeed, requires nothing more than keeping the bowels well open; for which purpose, the daily exhibition of castor oil is usually the fittest means. But, on the other hand, the complaint is attended with some hazard in delicate infants, whose bowels have been previously weak, and especially where the child is nourished only by the spoon. Much has been said in favour of emetics,especially wine of antimony, as being almost a specific for this disease, but I cannot say it has proved so with me, — unless in the slight cases * If such a term, after all that Gaubius and later professors have advanced, may be used in any sense distinguishable from the disease itself, it is presumed that the circumstances enumerated may be distinguished from those termed remote causes. Should this not be allowed of, the term proximate cause seems to be perfectly useless, and one to which we can never affix any precise ideas, the cause and effect being confounded. But I do not mean to enter far into such a controversy, and have touched upon it rather by way of apology for the use I have made of the term, in this and other parts, and to mark an obscurity which I leave those to settle, whose province it may be to take the lead in such matters. It were well, however, if some able pathologist could affix some idea that might be universally adopted, so that when we meet with the term in different authors, no reader might be at a loss for the meaning. 11 122 UNDERWOOD ON CHILDREN. just mentioned; nor can I see any sufficient cause for departing from the more ancient practice, in the treatment of this very com- mon complaint. There can be no objection, after having properly opened the bowels, to administer an emetic, and where the thrush is of a dark colour, and the whole inside of the cheeks is lined with it, I am persuaded it may be useful, by emptying the stomach of the crude juices oozing into it from the glands of this part. But, I think, it would be generally prejudicial, to persevere in the use of emetics for weeks, or even days together, and it is both a severe and an unnatural method of treating a tender infant, whose bowels are always the most natural outlet for its complaints ; on which, there- fore, nature uniformly throws the offending matter on almost every occasion, as appears plainly in teething, in which the first passages cannot be primarily affected. Should the vinum antimonii, indeed, be found useful, not merely as an emetic or purgative, but by any alterative virtues capable of removing certain morbid actions of the glands seated in the first passages, a recourse to it would cer- tainly be rational; but I have myself had no such evidence. I believe, therefore, that where there is no fever, nor any uncom- mon symptom, testaceous powders are the best and safest remedy; which may be joined with a little magnesia, if the body be costive, administered twice or oftener in the day ; or if in the other extreme, and the child is very weakly, three or four grains of the compound powder of contrayerva in its stead. Some such preparation should be administered for three or four days successively, and afterwards something more or less purgative, to carry down the scales as they fall off from the parts. For this purpose rhubarb is generally the best; but when the thrush is very violent, is of a dark colour, has come on very rapidly,and the child is lusty and strong, a grain or two of the pulv. e scammon. cum calomel may be joined wtih it, agree- ably to the idea of Heister, and the testaceous powders be repeated for two or three days as before, till the disorder begins to give way. On the other hand, when an infant with this bad thrush is weak and delicate, a decoction of the Peruvian, or oak bark, with aro- matic confection, is found the best remedy. The choice of the testaceous powders, on which some writers have said so much, is, I believe, of very little importance; the purest and softest are preferable. The design of these medicines being to absorb and correct the predominant acidity,* their effect will be disovered from the kind of stools that succeed, and the dose may therefore be increased or diminished, or they may be altogether discontinued, as circumstances direct. In the meantime, if the child * The French physicians are of opinion that the thrush is owing to what they call a putrid alkaline humour, or something analogous thereto, rather than to an acid. But this cannot be the case in the ordinary thrush, as is manifest both from the appearance and sour smell of the stools, as well as from the more certain remedies for the complaint, which are alkalies and absorbents. The malignant thrush, (already hinted at,) which appears in some of their crowded hospitals, is certainly a very different complaint, and seems, indeed, to be of a putrid nature. APHTHAE, OR THE THRUSH. 123 be suckled, the nurse's diet should be attended to ; and, in general, her usual quantity of porter or ale (which is almost always more than sufficient) should be diminished. In regard to applications to the part, it is necessary to observe, that as they have little to do in curing the complaint, it will be im- proper to have recourse to them very early. I know, indeed, it is very common to begin with them, but they serve only to increase the soreness of the parts, (especially in the manner they are gene- rally used,) and to give a deceitful appearance of amendment. The proper intention of these remedies, at this period, is merely to pre- serve the infant's mouth clean and comfortable, and to prevent, as much as may be, any pain or injury to the wet-nurse. If, there- fore, the inside of the cheeks and tongue are thickly covered with sloughs, it may be convenient to clean the mouth two or three times a day; but otherwise it will in general be improper till the complaint is past the height, the sloughs disposed to fall off, and the parts underneath inclined to heal; which never takes place till the secretions in the first passages are become bland and mild. Proper applications will then have their use, not only by keeping the mouth clean, but by constricting and healing the raw and tender apertures of the excretory vessels. I have, indeed, met with an instance of a very copious thrush disappearing, after cleaning the mouth with borax and honey, at noon and night, on the fourth day of the disease. Until this time it had been increasing, and I expected would become worse; and therefore directed the mouth to be cleaned so early, only to render the infant comfortable, and to prevent, as much as might be, any inconvenience to the wet-nurse. There was but very little appear- ance of thrush, however, the next morning,and not the least after that day. It is, therefore, likely that the parts were rendered per- fectly clean, by the help of the borax, somewhat sooner than they otherwise would have been; though I can by no means conclude that it had any other share in the cure. The like observations I have had occasion to make, in regard to an exceeding slight appearance of thrush, which had continued in the same state for three days; but upon being cleared off by once using the borax and honey, never reappeared. In both cases, the usual internal remedies were administered, both before and after the recourse to topicals. Of the latter of these, also, a variety have been in use, in the form of lotions and gargles, which from the earliest times have all been of an astringent nature ; and, it scarce needs be added, should be of an innoxious kind, as some portion of them will be swal- lowed : and I mention this because Stoll reports the English advise a solution of sacch. saturni, which, for my own part, I never heard of before. Honey of roses and spirit of vitriol, or sea-salt, as recommended by Ettmuller and Dr. Shaw, form a very good one ; but nothing is preferable to borax, which some advise to be mixed up with sugar, in the proportion of one part of the former to seven of the latter: a pinch of this put upon the child's tongue, 124 UNDERWOOD ON CHILDREN. will be licked to all parts of the mouth. But I prefer a mixture of borax and common honey, (two scruples, a dram, or even more of the former, to an ounce of the latter,) which hangs about the fauces better than in the form of powder. Either of these may, at this period, be made use of as often as shall be necessary to keep the parts clean, which they will effectually do, without putting the infant to pain, by being forcibly rubbed on.(A) It only remains to take notice of the black thrush, as it is called, which is, confessedly, a very uncommon complaint in the infant state. The late Dr. Armstrong said he had never met with it among the great number of children brought to his dispensary. I have seen only two instances of it, which were in strong and healthy children; but the parts were not perfectly black, and if that be intended by the name, these cases might not be precisely that complaint: they, however, both proved fatal. After the stomach and bowels have been cleansed, I believe the decoct, cortic. and confec. aromat., as before mentioned, with the addition of tincture of snakeroot, is the most likely medicine to be of service. The bark, especially, should be administered very freely, and the bowels be kept open ; which is more safely done by rhubarb, than any other purge. APHTHA GANGRENOSA. The Aphtha Infantum has been generally regarded as an idio- pathic disease ; but I believe that every other species of aphtha has been considered either as purely symptomatic of fever, dysentery, &c, or as a critical termination of some acute disorder. The aphthous affection which I am now going to describe, does not, however, seem to be the consequence of any preceding general disease; and I am inclined to think that it is the cause, rather than the effect, of those febrile symptoms, which accompany what I shall call by the name of aphtha gangrenosa. This disease most commonly attacks children that are above two years of age, and, I believe, rarely after nine, unless by infection. Its first appearance is marked by a very spongy state of the gums, and a remarkable tenderness of the inside ofthe cheeks and mouth. Soon after this, little aphthous sores, having a dark coloured surface, appear upon the gums, the inside ofthe lips, and upon the tongue: sometimes similar ulcers are seen upon the uvula and tonsils; but this is not always the case. As the disease proceeds, the cheeks become slightly tumefied, and are very tender when touched; and there is often an unusual redness upon that portion of the skin which covers the lower jaw. Besides the aphthae which appear upon the tongue, that part is usually much furred, and the teeth about the edges of the gums are likewise covered with a blackish (h) One ofthe best detergents, in cases of this nature, is a solution of borax in water to which a fourth part of alcohol is added ; and if for use in the mouth, a little sugar. ERUPTIONS ON THE SKIN. 125 fur; the breath is very offensive, and, at this period, the disease is highly infectious, even to adults. In the progress of this complaint the submaxillary glands become enlarged, and slightly painful; and there is generally a preternatural flux of saliva, which is sometimes discharged in considerable quantities from the very beginning of the attack. Sometimes the angles of the mouth are found to be ulcerated, but this is by no means a common appearance. The gangrenous thrush is always accompanied with considerable languor, and sense of debility; an increase of heat; a small, quick pulse ; the appetite is impaired ; but the children do not sleep ill, and they are often cheerful and active, at different parts of the day. The disease does not observe any exact periods ; some children recovering in a fortnight, while others have been more or less affected from a month to six weeks. Formidable as the appearance of this disease may be, it is not found to be dangerous, and the remedies are obvious. The infus. cort. cascarillas, warmed with tinctur. cort. Peruv. comp. should be exhibited three or four times a day, in doses suited to the age; and the parts frequently washed with the decoct, cort. Peruv. ren- dered as sharp with the acid. vitr. dilut. as children can bear it. (i) ERUPTIONS ON THE SKIN. It is by no means my intention to enter largely into this extensive subject, imperfectly understood, even to this day, at least in regard to classification and arrangement; though certainly our knowledge of eruptive diseases has been much improved through the pains taken by Dr. Willan, and, in respect to children, what we know is sufficient for every practical use. In another part of the work I shall treat of the scald-head, and two or three other troublesome affections of the skin, taking place at different ages; but shall at present chiefly confine myself to eruptions peculiar to infancy; adverting first to such as are connected with the state of the first passages.* The earliest of these is — * The description of" the eruptions peculiar to infancy," which Dr. Underwood has given, is far from being clear and explicit. It is indeed a most difficult task, even with the aid of drawings or coloured engravings, to give such exact defini- tions of the manifold eruptions on the skin as shall enable pfactitioners easily to distinguish some from others. Since Dr. Willan's publication on cutaneous diseases, a more exact knowledge of several of these complaints has been obtained, but much remains to be done to accomplish a perfect classification. To some of Dr. Underwood's appellations, I have added the name by which the disease is characterised in Willan's and Bateman's arrangement: but on some occasions I have not been able to satisfy myself, that my appropriation of the name to the disease intended to be described, is quite correct. Whenever I have doubted much, I have marked my doubt by a note of interrogation. —S. M. The reader is referred for further, and accurate details, to Plumbe on Diseases ofthe Skin. (i) A dilute solution of chloride of soda, or of chloride of lime, will be found to be an excellent topical remedy in this as well as in the common aphtha. 11* 126 UNDERWOOD ON CHILDREN. THE STROPHULUS, OR RED-GUM. (Strophulus Intertinctus. Willan.) This eruption has been distinguished by different terms : I speak here ofthe strophulus intertinctus, which is an efflorescence appear- ing usually in small spots, often confined to the face and neck ; but sometimes it extends to the hands and legs, and even the whole body, appearing in very large patches raised above the surface. Eruptions will likewise appear in the form of small pustules, which are filled with a limpid, or sometimes a purulent, or yellow liquor, and frequently turn dry and horny, and scale off; at least I have never known what name to give this kind of eruption, but that of a ranker strophulus, as it happens only in the month, or soon afterwards, and never gives any trouble. This seems to be that termed by some writers strophulus confertus. There is another species as small as pins' heads, or even their points ; firmer than the former; often of a pearl colour, and opaque, which has generally been accounted a kind of red-gum; but it has of late, for distinction's sake, been termed the strophulus albidus, or the white-gum* as the former might be called strophulus subalbus. — Another species appears in small circular patches, and is denomi- nated strophulus volaticus: and a fifth, in which the patches are larger than in any of the foregoing, and are more diffused, ap- pearing chiefly on the loins, shoulders, and the upper part of the arms. Every species of this eruption, like the thrush, is the effect of a predominant acid, but can scarcely be termed a complaint, being a kindly exertion of nature to throw off some acrimony; consequently an evidence ofthe strength of the constitution, as the thrush is, usually, of its weakness. In the former, nature throws off the offending matter on the surface more completely, as well as on less irritable parts, than in the latter, and therefore, when the eruption is slight, requires no assistance. On this account it is, I apprehend, that writers have not usually taken notice o£it; though it should seem requisite, both on account of the various appearances of it, and especially of one species, more rank and extensive than the rest. In general, it is necessary only to give a little testaceous powder, or magnesia, according to the state of the bowels, and to keep the child moderately warm; other- wise, the rash striking in, the acrimony will fall on the first pas- sages, and be succeeded by sickness, or purging, (till the eruption appears again on the skin,) or not unfrequently by the thrush. In the case of sickness at the stomach, or any disposition to fits, upon this * It is to this complaint that Vogelius seems to give the name of achores, but the old writers differ in this respect: of that complaint, however, more will be said in another place, when speaking of disorders described under obsolete terms. THE STROPHULUS, OR RED GUM. 127 eruption being repelled, some light cordial, such as a few drops of the spirit, ammonias comp. should be given two or three times a day, and the child's feet, or perhaps the whole body, be put into warm water, and a blister be applied between the shoulders, if any untoward symptoms should continue. The state of the skin and the bowels have a peculiar sympathy, and on this account, infants whose first passages have been frequently disordered, are always benefited by eruptions on the skin ; and, in such, peculiar care is necessary to guard against their being repelled, as well as to invite their return. Dr. Hamilton speaks of copper-coloured blotches of the size of a sixpence, or shilling-piece, on the nates or soles of the feet, occur- ring in the first or second week after birth, indicating a diseased state of the infant's habit, (ecthyma cachecticum ? Willan,) and requiring the most serious attention. He adds that, if neglected, ulcerations of the palate, throat, and nostrils, follow ; the nurse's nipples, arm-pits, and throat become infected; and if the infant survive for any length of time, (which is not common,) the arms and legs are covered with an ugly scab, which keeps up a constant degree of irritation. He informs us, that the only cure for this affection is mercury, which ought to be exhibited both to the nurse, in such doses as shall affect her milk, and also to the infant, in doses adapted to its strength, and to the virulence of the dis- ease.* I have myself never noticed this eruption, but the statement comes from such authority, I thought it ought not to pass unno- ticed. Infants are peculiarly liable to various anomalous kinds of rash, both in the month, and till the period of teething is over. The early ones may be regarded as a sort of red-gum, and children who are most subject to them generally have their bowels in a better state ; the rash seemingly carrying off, as has been said, the acidityt with which they so much abound. It may be remarked, however, that when infants at the breast * Dr. Hamilton does not intimate a suspicion, that the blotches here spoken of originate from a syphilitic affection. Many of the French writers on children's diseases, however, viz., Alphonse Le Roy, Mahon, Combes Brassard, Capuron, &c, seem to consider the symptoms mentioned by Dr. Hamilton as conclusive evidence of such an origin. The popular opinion in London leans the same way. During eight >years that I was the physician accoucheur to the Westminster General Dispensary, many cases of this nature fell under my care; I have seen several, likewise, at the Middlesex Hospital and in private practice; and in almost every instance the parents or friends were full of suspicion that this was the origin of the disease; and often an admission has been made that one or other of the parents had been deeply imbued with the venereal disease. I do not recol- lect that any case was cured, unless mercury was exhibited in some form or other; frequently, I have given very small doses of the oxymuriate with syrup of sarsaparilla, bttt more commonly small doses of calomel or hydrarg. c. cretd. Unless the mother had evident symptoms of the disease, I have not usually put her under the influence of the specific. — S. M. f See Harris, pp. 22, 23. 128 UNDERWOOD ON CHILDREN. are inclined to frequent returns of some eruption, if the child be always indisposed at such seasons, the rash will often be found owing to some ill quality in the breast-milk, which ought, there- fore, to be examined, and particularly in regard to its taste. On such occasions I have found that milk, which has been above a twelvemonth old, has contracted a very unpleasant flavour ; and that, upon changing the wet-nurse, a very ill-looking rash has immediately abated, and has soon afterwards entirely disappeared, together with the other complaints. I am glad to find Mr. Burns, of Glasgow, of this opinion, whose treatise on midwifery, and the diseases of women and children, I had not seen at the time of the former edition of this work ; and feel gratified by the polite notice of it by so respectable a writer. A work highly worthy of perusal by the younger part of the pro- fession, as containing the sentiments of various ancient and modern writers. CRUSTA-LACTEA, OR LACTUMEN. (Porrigo Larvalis. Willan.) This, it is well known, calls for a little more attention, and has oftentimes a very unpleasant appearance ; but is, notwithstanding, equally innocent with the former, and even prevents other com- plaints. I think I never saw an infant much loaded with it, but it has always been healthy, and cut its teeth remarkably well. In- deed, it falls to the lot of the finest children, and such as are well nourished ; whence some have imagined it owing only to the rich- ness of the milk.* And it is remarkable in this eruption, that howsoever thick and long-continued the scabs may be, the crusta- lactea never excoriates, nor leaves any scar on the parts. It may, possibly, be different in some other climates, though I can- not guess for what reason it should be so on the continent: it is insisted upon, however, by Dr. Carolus Strack, as well as that healthy children long affected with it become unhealthy. He recommends the viola tricolor, Linn, of which a handful of the fresh, or half a dram of the dried leaves, is directed to be boiled in a half-pint of cow's milk, and strained off. This quantity of the decoction is to be taken night and morning. The crusta-lactea appears first on the forehead, and sometimes on the scalp, often extends half-way over the face in the form of large, loose scabs, which, as the disorder increases, appear not very unlike the small-pox, after they are turned. It begins with white vesicles, larger than the itch, which soon become of a dark colour; to which succeed the scabs, with efflux of ichor, and great itching of the affected parts, sometimes covering the head, and, as some say, but I believe improperly, the whole body. It is also said to * See Astruc. CRUSTA-LACTEA, OR LACTUMEN. 129 degenerate into the scald-head ;* but I have never seen anything like the true tinea in young infants. It is sometimes confounded with the crusta serpiginosa, which is a much more obstinate com- plaint. Very little, I believe, is necessary to be done ; but in bad cases a blister is sometimes of service ; and, further, usually answers the grand purpose of abating the itching, which, in some instances, is exceedingly great: for this end, however, the repetition of a blister, if needful, is preferable to keeping one constantly open. Washing the parts, also, with the anile remedy of butter and beer, is sometimes useful, especially when the discharge is hot and acrid. To the like end the ung. picis, (made with the petroleum, instead of pix liquida,) spread thinly on a piece of linen, and ap- plied after the infant has got into its night's sleep, is equally safe ; but should be carefully washed off the next morning. If the urine becomes turbid or fetid, it is thought the rash will be of short dura- tion. At any rate, it usually disappears of itself when the child has cut three or four teeth, though it may sometimes continue for several months, and, in a very few instances, even for years; in such cases, the Harrowgate, or any other sulphureous water, will have a good effect; but the shop medicines commonly prescribed do nothing. I have known testaceous powders, calomel, and other alteratives, administered to no purpose, as people of rank are very anxious to have it removed, if it be possible. This rash will now and then make its appearance very early, and has then been mis- taken, by those who are not much accustomed to attend very young children, for the effects of the venereal disease. Though it more usually dies off upon cutting some teeth, yet I have known it disappear suddenly, previously to any teeth being cut, and after some weeks return more violent than before ; infants remaining all the while in perfect health.f It were almost endless to enumerate the various kinds of rash * Tractatus de Morbis Puerorum. Amstelodami, 1760. — Anonymous. f Though the crusta-Iactea is generally unattended with danger, or ill conse- quences, yet the state of itching or irritation it produces, is sometimes excessively distressing to the child ; and I have known many instances of so much sallow- ness, emaciation, and other evidences of want of health, as to occasion much alarm. Except when such ill symptoms occur, little of internal medicine is required ; yet it is desirable to keep the bowels always regular, perhaps rather active; sometimes a mild mercurial alterative has been serviceable, and some- times I have given with benefit a little draught, twice or thrice a day, with liq. ammon. acet. %i.', liq. antim. tart. m. v. ad x. Where sallowness, languor, and emaciation have come on, the carbonate of soda, with sarsaparilla, decoct, lichenis, or some light bitter, has been employed with advantage. For external applications, washes are generally preferable to unguents; but I have seen marked benefit from the ung. zinci, when the itching has been par- ticularly troublesome. The lotions should be used of a moderate degree of warmth, and are then very soothing. Warm water, with a small proportion of spirit; warm Harrowgate water; or a decoction of poppy-heads, with the addition of a small quantity of liq. ammon. acet., have all proved useful sedatives. — S. M. 130 UNDERWOOD ON CHILDREN. to which infants are liable, but I mean chiefly to confine my re- marks to the more important, or rare ones, and such as may not have been described by preceding writers. Among such are the following, whose unusual appearance is apt to perplex such as are not accustomed to see them. TOOTH-RASHES. The first I shall notice is somewhat anomalous, being, like the former, not confined to dentition. It appears, indeed, under dif- ferent complaints, particularly at the decline of fevers, and severe bowel complaints ; insomuch that, upon a sudden appearance of it during a serious illness, I have often ventured to prognosticate the recovery. This rash very much resembles the itch, both in regard to the little watery heads, and foul blotches ;* and is con- fined to no particular part of the body, though it appears more frequently about the face and neck. Indeed, I have seen the whole body so covered with it, (mixed with an eruption about the face, of a different appearance, and evidently red-gum,) that, in a consultation, it has been by some taken to be the true itch. This eruption is certainly salutary, and even critical, requires nothing but to avoid taking cold, and is mentioned only because it is uncom- mon, and has alarmed such as are not acquainted with it. I have two or three times, during dentition, noticed a rash that has so exactly resembled flea-bites, having even a depressed point in the middle of the elevated spot, that I could not be persuaded by the nurse's account, that it had not been occasioned by the sting of some such insect, until I had made repeated observations, and found it recurring uniformly a little before a tooth has been cut.t Another, a very common rash, appears chiefly in teething chil- dren, which very much resembles the measles, and has been some- times mistaken for it.J It is preceded by sickness at the stomach, but is attended with very little fever; though the rash continues very florid for three days, like the measles, but does not dry off in the manner of that disease. It requires nothing more than the testa- ceous powders, or sometimes the addition of a little nitre, and com- pound powder of contrayerva ; with a dose or two of rhubarb, or other gentle laxative, on the going off of the rash. At this period, especially while the double or eye-teeth are cut- ting, I have noticed a rash which at its first appearance is very similar to the above, and has likewise been mistaken for the mea- sles. It, however, soon spreads into larger spots and patches of a bright red, and afterwards of a darker hue, resembling the ill-look- ing petechiae which appear in bad fevers, but is, nevertheless, of a benign nature. It is, indeed, attended with some fever, arising * {Miliaria. Bateman.) f (Lichen Urticatus. Bateman.) f (Roseole Infantilis. Willan.) TOOTH-RASHES. 131 possibly from the irritation occasioned by teething, and has been followed by small and hard round tumours on the legs, which, softening in two or three days, always appear as if they would suppurate, though I believe they never do ;* as will be further noticed in a similar appearance of boils under the head of fever. The treatment, like that of other rashes at this period, is very sim- ple, requiring little more than an attention to the state of the bowels, or, perhaps, a few grains ofthe compound powder of con- trayerva, unless the fever be considerable, which must then be treated according to the directions given under the different heads of fever and dentition. Should the lumps succeeding this rash not begin to die away in three or four days, a decoction of the bark will be found useful when the fever of dentition may not forbid recourse to it. I have seen a third kind of rash, in appearance resembling the measles, and, like it, covering the whole body, but with larger intermediate patches, like the eruption in the scarlet fever ;t which is mentioned more for its uncommonness, which might prove alarm- ing, than for its being at all dangerous, or important. It was, however, in every instance, preceded by sickness, by purging, pain, and a little fever; the whole subsiding upon the appearance of the rash, which therefore seemed to be critical, or at least, like some other eruptions, consecutive to convalesence. Some infants never cut a tooth without its being preceded by a rash; and sometimes by a very singular one,X the eruption appear- ing in every part of the body: in some parts consisting of hard elevated pimples as large as peas, and in others, of red patches on the fingers, the arms, and about the shoulders and back, as broad as a shilling: but in no case have these eruptions required any particular attention, but, on the other hand, have seemed to pre- vent the more ordinary complaints of teething. An eruption still less frequently met with than most of the above, appears after children have cut their first teeth. I know not what name ought to be given to this kind of eruption, which breaks out in the form of round lumps, as large as middle-sized peas, very hard, with a very red base, and white at the top, as if they con- tained a little lymph.§ They come out suddenly, without previous sickness at the stomach, are not sore, disposed to itch, nor ever give any trouble ; and are seldom seen but on parts that are usually uncovered, and are sometimes there in great numbers, resembling the distinct small-pox ; but are harder, more inflamed, and less purulent. Alarming, as well as unusual, as this appearance may be, I be- lieve the eruption is always perfectly innoxious, if not repelled by * (Erythema Nodosum. Willan.) Both Willan and Bateman speak of this complaint as affecting females only. I have no doubt of having frequently wit- nessed it in children of both sexes. — S. M. f {Urticaria Febrilis. Willan.) % (Urticaria Febrilis. Willan.) \ {Ecthyma Infantile. Bateman.) 132 UNDERWOOD ON CHILDREN. cold, or improper treatment, and will dry away in three or four days; nothing more being necessary than the little remedies directed for the former, and to keep the child within doors, if the weather be cold. There are, however, tumours of the size and hardness described above, and with a red base, which, after continuing many weeks without occasioning either itching or pain, will suddenly inflame at the superior part, and break, though without sensible pain.* These tumours take place in children who have all their first teeth, or nearly so, and who appear in good health, save that they are rather feeble, and possibly of a scrofulous habit. They are slow in healing, and call for a nutritious diet, and the use of a little red wine and bark. An eruption of an appearance equally uncommon, and analogous to the above,! I have met with only in children of at least three or four years of age, and such as have also been affected with slight symptoms of scrofula, though I have not seen it frequently enough to ascertain its being, in any degree, owing to that specific virus. It breaks out suddenly, covering at once the greater part of the body, but occasioning neither pain nor itching ; nor are children sick at the stomach nor otherwise ill with it, though it lasts for two or three weeks. This eruption, therefore, like some others, is taken notice of chiefly for its singular appearance; which, though somewhat like the nettle-rash, is of a different figure ; and may be pretty exactly con- ceived of by the little red lumps left sometimes by the small-pox, after they are turned, and also rubbed, or picked off, especially after the crystalline, or warty species, and where the pustules have been pretty numerous. If the first passages are at alt disturbed, my attention is prin- cipally directed to them, otherwise to the state of the skin ; and in this case, I have usually directed small doses of the pulv. anti- monial. to be taken for a few nights at going to bed, and the poly- chrest salt and rhubarb, occasionally in toe course of the day, with or without the addition of the aqua ammonias acetatae. In the course of a few days the eruption puts on a darker colour, is less prominent, and begins to scale off in a branny scurf, some- what like the measles; but should no such change take place, the vinum antimonii, or the hydrargyr. cum cretd should be taken two or three times a day ; to which, if no amendment should soon be perceived, a few drops of the tinctura cantharidis may be added : a remedy often very efficacious in disorders of the skin, but requiring to be administered with caution. ESSERA, OR NETTLE-RASH. (Urticaria. Willan.) An eruption, with every appearance of the nettle-rash, some- times occurs in children, and more generally under two years of * (Ecthyma Vulgare. Bateman.) f {Ecthyma Luridum? Bateman.) PHLYCT^ENjE. 133 age, and is exceedingly troublesome to the infant, as well as matter of surprise to those about it, from the suddenness of its appearance. Children going to bed perfectly well, awake very uneasy, and frequently continue screaming for some time, before the cause is discovered ; when, upon examining the body, and the lower limbs, they are found covered with large wheals, resembling those arising from the sting of nettles. The essera, or urticaria, in athletic youths and adults, is attended with slight fever; its accession is sometimes preceded by rigor sickness at the stomach, and pains in the head, especially when the sudden consequence of exposure to a very cold wind; but it is never dangerous, and demands particular notice only when it may happen to continue a very long time. The nettle-rash of infants is of still less importance ; and the species now under consideration requires less than any other, and, indeed, often disappears in a few hours. When it continues longer, a few grains of the pulv. contrayervae comp., or other of the milder absorbent powders, with or without a few drops of the spirit, ammoniae comp., may be given two or three times a day, and the bowels kept open. When the body is more covered with the rash, and it continues long, a little more care is required to prevent its being repelled; and if it should be so, the tepid bath and light cordials, as before mentioned, should be had recourse to, in order to procure its return to the surface, which is always of the greatest consequence if the child should continue unwell. In athletic youths, the nettle-rash is sometimes attended with the usual symptoms of fever, during which the patient should be con- fined to the bed. It will also, in some instances, become chronical, and is then not always easy of cure. The following has, in such cases, been found useful. R Hydrarg. sulphuret. rubri Zss., Radic. Serpentar. Virg. pulv. ^j., Syrupi simpl. q. s. ut fiat bolus, bis die sumendus; superbibendo haust. Infusi fior. sambuci. Amongst rashes attended with some little fever, there are various anomalies, and one resembling both the above, and the febris scar- latina, but without the marked symptoms of the latter, or drying off in branny scales, in the usual manner of that eruption. The form and colour of the rash, and degree of fever, however, are more of that kind, than of the nettle-rash. PHLYCT-KN-E. (Pemphigus infantilis. Willan.) Another rash, or rather eruption, takes place both in bowel com- plaints and in teething; and I have seen it in new-born infants, resembling the pemphigus of adults, but seems rather to be what the old writers have termed phlyctasnae, or phlyctides, and always appears to be beneficial. It consists of vesications, or blisters, of different sizes, resembling little scalds or burns, and continues for 12 134 UNDERWOOD ON CHILDREN. several days. They come out in different parts, but chiefly on the belly, ribs, and thighs ; and contain a sharp lymph, which it may be prudent to let out by a puncture with a needle, especially from the larger ones. No medicine is necessary but such as the par- ticular state ofthe bowels may call for, which usually abound with acidity, whenever there is much eruption on the skin. An eruption, vulgarly termed scorbutic,* infesting the face and neck, sometimes also the nates and thighs, and even about the finger-nails, and discharging a sharp ichor that excoriates wherever it runs, will often yield in a short time to the expressed juice of the sium aquaticum. From one to four or five table-spoonfuls maybe given, mixed with one or more spoonfuls of new milk, three times a day, according to the child's age, and the state of its stomach; taking care, at the same time, to keep the bowels open by senna tea, or other common laxative. Should this fail, or not to be pro- cured at some seasons, the calx, hydrarg. alb.t or the hydrargyr. cum creta, may be administered two or three times a day. In some instances, however, and especially in children of a costive habit, purging has done more than anything; in teething children, indeed, the eruption will recur many times, until all the first teeth are cut. To allay the intolerable itching, the application of the unguent picis, prepared as recommended for the crusta lactea, and spread upon linen, is frequently efficacious, and has no tendency to repel. PSORA, OR THE GROCER'S ITCH. (Psoriasis Infantilis. Willan.) 1 have several times met with an eruption resembling the Psora of the Greeks, or what is called amongst us the grocer's itch; whether depending at all upon the weather, it is difficult to say, but it is remarkable, that I have seen it chiefly during a cold sea- son, and have then usually met with several children affected with it about the same time. It often begins about the arms and thighs, but always extends soon afterwards to other parts, and frequently spreads quite from the head to the feet. It appears in some parts in very small eruptions like the points of pins, with watery heads; and in other parts as large as peas, and sometimes in foul blotches ; which, after breaking, form sores, and broad, ugly scabs. These die away, and the like appear, successively, in other parts, sometimes for two or three months, leaving the skin of a dirty, adust hue. In other parts, the eruption has the form of small, hardened pimples, which do not break, nor are at all sore to the touch. * {Herpes Phlyctaenodes ? Bateman.) t I have no knowledge ofthe effect ofthe calx, hydrarg. alb. taken internally. It probably possesses no medicinal virtue superior to that which is found in the more common preparations of mercury. In Powell's Pharmacopoeia, its dose foi adults is stated at from gr. v. to gr. x. PSORA, OR THE GROCER'S ITCH. 135 This eruption occurs in children who have cut all their first teeth, as well as in infants at the breast, though more frequently in teething children, and it then seems to be connected with denti- tion. This appears evident from this fact, that children who had taken a variety of medicines, and continued to have the eruption break out in fresh places, have suddenly got rid of it altogether, upon lancing the gums, and giving freedom to three or four teeth. When this eruption has appeared in infants at the breast, I have several times known the suckling mother, or nurse, affected in a few weeks after with the same complaint: but whether by acci- dental coincidence, or from contagion, I was for a longtime unable to ascertain; but I have now no doubt of its contagious nature like the true itch: yet it does not appear to be communicable by a slight and more distant intercourse. A very useful discrimination in such a disease. I was for a while much puzzled with this ill-looking eruption, the long continuance of which could not fail to be very distressing to the parents, who have sometimes suspected the eruption to be the itch, and at others venereal, which it certainly is not. It has been always benefited for a while by washing the parts with two drams of the aqua kali puri in a pint of water ; which I would always recommend, though it will not alone effect a cure. Various internal remedies, also, which remove other eruptions, have generally failed in this, such as the hydrargyrus cum cretd, and hydrargyrus cum sulphure, given in large doses ; as also the sium aquaticum. The external application, however, of an oint- ment, consisting of the unguentum stclphurts, and unguentum hydrargyri nitrati, with a greater or less proportion of the latter, has hitherto never failed me, together with the internal exhibition of one or other of the forementioned remedies. In some of the more obstinate cutaneous affections, and particularly in this, I have noticed a spontaneous purging taking place upon the decline of the rash, and have always accounted it a good sign, having never observed the child to be weakened by the purging, though it has sometimes continued excessive for two or three weeks. I shall close the account of eruptions with the description of one that is singular enough, resembling very much the herpes, or broad ring-worm, or the adust-coloured spots left on the face after an attack of St. Anthony's fire. I have seen it in various parts, but I think only on such as are more or less liable to be fretted by some part of the infant's dress, especially on the nates and con- tiguous parts covered by the clothes, where the blotches are always the broadest and most rank. Were it to appear nowhere else, it would seem to be occasioned by some sharpness of the urine and stools, as the skin has sometimes a very heated appearance, though the eruption, I believe, is not at all painful. It frequently breaks out before the period of teething, but the bowels are generally somewhat disordered, and the stools voided very green, or else become so very soon afterwards. This I take to be one of those 136 UNDERWOOD ON CHILDREN. eruptions occasioned by some bad quality ofthe breast milk : as, I think, I have never met with it but in young infants whose nurse's milk has been old, and has also contracted a very disagreeable taste. If that should not be the case, the rash will probably re- quire nothing but the light absorbent medicines before mentioned, and to guard against constipation. But if these means should not succeed in a short time, the nurse ought to be changed, lest some worse consequence should ensue, as will be noticed under the head of convulsions. In all the eruptive complaints of infants, exposure to cold ought to be carefully avoided, and great caution be used in regard to all external applications, as well as keeping the belly open. If the child is sick at the stomach, a little magnesia, or testaceous pow- der, with or without the addition of the pulv. contrayervee comp., may be given now and then: or should the rash be hastily struck in, and the child be ill, the remedies before mentioned should be had recourse to ; particularly bathings in warm salt and water, which indeed will expedite the cure in many eruptive complaints of the more permanent kind. The reader is reminded of this, from the great importance of attending to such retrocession; as I have known it, in a previously healthy child of only six months old, followed not only by vomitings and purgings, but by a rapid decline ; and upon examining the body after death, the lungs have been found as replete with tubercles, as I have ever seen them at a more advanced age. Instances of so great marks of disease have, however, occurred to me only in families inclined to scrofu- lous, or hectical affections. Should any scabs become very dry and hard, which the crusta lactea, for example, will sometimes be, especially when they ex- tend to the crown of the head, and seem to give pain, they may be touched with a little cream, or with oil of almonds mixed with a few drops of the aqua kali, but not a large surface at a time. Or should they be very moist, and cause pain by sticking to the cap, they may be dusted with a little common powder, or with the flos sulphuris, and covered with a singed rag ; but I should be very cautious of doing much more with desicative applications, for the reasons above mentioned, especially during the time of teething. SORE EARS. Slight blisters and ulcerations behind the ears of infants are very common, and in general require only to be washed with cold water, or covered with a singed rag, to keep the cap from sticking to them, and thereby giving the child pain. They are, moreover, very often beneficial, especially during bowel complaints, or the irruption of the teeth; and will sometimes get well and break out again into very foul sores, several times, without any cause of alarm. But in children of a gross habit of body, and especially about the time of teething, there is a species of ulcer that often SORE EARS. 137 requires attention, on account of its extending low down in the neck, occasioning great pain, and spreading into large and deep sores; insomuch that a gangrene has sometimes come on, and even the processus mastoideus become carious. Here fomentations will be necessary, especially those of bark ; and its powder should be administered internally. Such cases, however, do not very frequently occur ; but whenever the sores are large and painful, fomentations of white poppy-heads boiled in milk, will be bene- ficial. If such ulcers are very foul, the cure should be begun by a blister on "the back, in order to draw off the heated serum that flows to the parts. Where the bark has not been indicated, I have usually given an opening powder of testacea and rhubarb, with a little nutmeg, or sometimes nitre, to which is added either calomel, cinnabar of antimony, or hydrargyrus cum sulphure, the latter of which I think I have found more serviceable in some eruptive complaints in young children, than seems to be imagined; but then it must be administered in much larger doses than it usually is. But, above all, if this species of ulcer be not soon disposed to heal after such treatment, some mercurial application should be made use of, which, though the sores are often apparently inflamed, never offends them. A very clean and elegant preparation of this kind is the following: — R Calomelan. 5J- ad 5'J- Ung. Sambuci ^j. m. ft, linimentum. A little of this liniment spread on each side of a piece of doubled linen cloth, and applied twice a day, will do more than all the fomentations, or healing ointments, that I have ever seen used; and, indeed, has always succeeded with me, though I have often been told, that the sores had spread deeper from day to day under various other applications. From such treatment I have never found the least ill effects, but children have preserved their health as well as if the sores had kept open; which, when benign, are certainly designed by nature as a preservative from other complaints, espe- cially those of the stomach and bowels, which are the next in order to be noticed.(A?) (k) Very often the irritation and discharge behind the ears are kept up by the heat and pressure from a cap, the removal of which 1 have found in many cases to be followed by a disappearance of the disease, that had proved intractable to various remedies. The danger to the child from the sudden drying up of discharges be- hind the ears, by means of astringent or repellent applications, ought to be present to the mind of every practitioner. Neglect in this matter has been followed by serious diseases of the stomach and bowels, or still more alarming ones of the brain and its membranes, — manifested by convulsions and the symptoms of hydrocephalus. 12* 138 UNDERWOOD ON CHILDREN. DISORDERS OF THE ALIMENTARY CANAL. VOMITUS, OR VOMITING. I come now to the several disorders of the alimentary canal, and first of those of the stomach. Vomiting, considered as a disease, is certainly not a common complaint of infants, unless it be attendant upon some other malady, of which, indeed, it is then rather a symptom, or the consequence of such disease improperly treated. Neither are infants in health disposed to vomit frequently, unless the stomach is overloaded; the milk is then usually ejected as soon as it is taken, and comes up unchanged. Nor is this to be considered as a disease, or as calling for the discipline recommended by some writers. Where- fore should the residue ofthe aliment be forced off the stomach by an emetic, when nature has already parted with all the oppressive abundance ? This spontaneous puking is not attended with any violence to the stomach : the milk, or other food, comes up without any sensible action of the part, or the child being actually sick. Nay, it is so common to some of the finest children, that it is a saying with some experienced nurses, that a puking child is a thriving child; and when such ejection comes only soon after suckling or feeding, and the aliment is cast up scarcely changed, matter of fact verifies the observation.* I have even known clotted bloodt thrown up, without any apparent effort, in an infant not two days old, and without the least ill effect. But if the food remains some time on the stomach, it will then be thrown up in a curdled state, which is an indication to attend to it if it happens frequently. Not that the milk ought not to curdle on the stomach, which it always must, in order to a due separation of its compo- nent parts, and is the chief, if not the only digestion, it undergoes in the stomach. The whey and the rich oil are there separated from the curdy and earthy particles, the former being taken up by the lacteals, is converted into blood; whilst the bulk of the latter is carried down and expelled with the other excrementitious parts of the food, and gastric juices, for which nature has no longer any use. This curdling of the milk, therefore, is the natural course of digestion, though many writers have not been sufficiently atten- tive to it, and Harris has asserted that it is owing to a predomi- nant acid; implying that an undue acid is the only cause of the separation; which it certainly is not. It may, indeed, occasion it * See Primeros: De Morbis Infant. f It is not a very unusual thing for blood to be drawn by the child from the nipple of the mother, and the blood so received into the stomach is generally vomited up by the infant. Unless the clotted blood proceeded from such a source as this, it could hardly occur without injury to the child. — S. M. VOMITUS, OR VOMITING. 139 to take place too suddenly, or form too hard a curd, and give rise to various ill consequences, although such separation ought to be made, as the natural and proper effect of mixing duly with the gastric juice. When infants, therefore, not over-fed, throw up the milk uncurdled, after it has been some time in the stomach, it is always a worse sign: but when the milk comes up in a curdled stale, it proves that the stomach having digested what it has re- ceived, has not power to push it forward into the bowels, and therefore throws up a part of it.* If this be the case, and the infant be not immediately relieved by it, the stomach may perhaps require to be emptied of its whole contents, which may then be easily done by giving a little warm water, or camomile tea. The cause of the indigestion was an accidental repletion : that removed, together with the consequent foulness, or bad juices of the stomach, the effect also will generally cease ; and unless the vomiting re- turns, from any further injury the repletion may have occasioned, it requires nothing more. To distress the child, on every such occasion, with a sickening emetic, or drench it with rhubarb or magnesia, is as needless as it would be to awake a patient out of a sound sleep to give him an opiate. Only let the child fast a little after having emptied the stomach of its load, and the nurse be careful not to overfill it for the future, and it will rarely want any other assistance. If the vomiting, on the other hand, has arisen from acrid diet, a little further discipline may be requisite, because some half-digested food has got into the bowels, perhaps for several days together. In this case, a gentle laxative, and change of food for one of a milder kind, is all that is generally necessary ; or if there be a prevailing acidity in the stomach, either the testaceous powders or magnesia, (according to the state of the bowels,) may be mixed with the food, or be otherwise administered for two or three days, as the occasion may require. Or a drop or two of the aqua kali, or a little Castile, or almond soap, are excellent remedies, especially when the stools are unusually green or clayey; not only as they will correct acidity,t but promote the secretion of bile, as well as a generous warmth in the first passages, and assist the digestion. For which purposes also, myrrh is an excellent remedy, when infants are a few months old. Should the vomiting be a symptom attending some other disease, its remedy will turn on the proper treatment of its cause. Should it follow upon a suppression of discharge behind the ears, and more especially if consequent upon the use of drying applica- tions, a return of the discharge should be solicited. Or if the cause * I have known children throw up a piece of curd full as large as the thumb of a grown person, and as firm as a piece of dough, and be perfectly well the next minute: though it might, doubtless, have done much injury, if it had remained on the stomach. | It is well known, how small a quantity of soap put into a churn, will firevent a due separation ofthe component parts ofthe milk, so as to allow very ittle or no butter to be made ; whereas a little vinegar effects the separation almost instantaneously, and saves a vast deal of trouble. 140 UNDERWOOD ON CHILDREN. be the sudden disappearance of some eruption on the skin, appro- priate remedies must be employed ; the infant should be put to bed, and some light cordial be administered ; and if the vomiting continues, an emetic should be given, and afterwards a blister, or warm plaster, applied to the pit of the stomach. Having mentioned emetics, I shall take this occasion to observe, that the choice of them will be always best determined by the nature of the complaints for which they are administered. In those of the first passages, ipecacuanha is generally the best; but if a fever should attend, or it be wished to promote a gentle perspira- tion, those of antimony are preferable ; or lastly, in disorders of the breast, the oxymel, conserve, or tincture of squills. But a more troublesome vomiting will sometimes arise in un- healthy children, from too great a sensibility, or too great an irri- tability of the nerves of the stomach. Such medicines are then indicated as will brace, or strengthen that organ, and abate its sen- sibility. For the former, a cold infusion of the bark, or of camo- mile flowers, with orange-peel and ginger, and sometimes a little rhubarb ; for the latter, a saline mixture with a drop or two of laudanum. And the benefit of these may be increased by aromatic and spirituous fomentations to the pit of the stomach, or by the labdanum plaster, with a little theriaca* added to it; or the emplas- train cumini may be applied. Also the following: — R Ung. simpl. 3iij. Olei Macis (diet.) —— Rorismarini, aa 3ss. Bals. Peruv. ^ij. M. F. Unguent, quo tota quotidie Regio Stomar-hi atque Umbilici calide inungatur, supraponendo ultenus mor9um lanulae. Lastly, a vomiting may arise from a strangulated hernia. When, therefore, scarcely anything is found to stay on the stomach, or all the above remedies fail to remove a frequent disposition to vomit, practitioners will be aware of it, and make a due examination of the several parts where ruptures appear. [The unusual occurrence of vomiting should lead us very care- fully to watch the head ; it is frequently the first symptom of hydrocephalus. — M. H.] * The theriaca andromachi is seldom to be procured now, but the confect opii forms a very excellent substitute. The emp. labdani is also superseded by the emp picis comp. Dr. Underwood had given in this place a prescription for a plaster, difficult to be prepared, and not at all superior in efficacy to the emp. cumini, which I have therefore substituted. All plasters are apt to produce about the parts they cover, an eruption of pimples which are often thought beneficial, and are at least not injurious. The most efficacious mode of applying spicy opiates to the abdomen of children, is either to rub them upon the part in the form of liniment, or to make a confection of oil of mace, camphor, and opium. Of this a proper quantity may be spread upon leather, with a margin of emp. plumb, c. resina, and immediately applied over the part, — S. M. CARDIALGIA, OR INFLAMMATION OF THE STOMACH. 141 CARDIALGIA [GASTRITIS], OR INFLAMMATION OP THE STOMACH. This is a disease very seldom met with, I believe, in this country, but is common in France, as appears by a paper read before the Royal Society of Medicine, in Paris, by Mr. Saillant, and is said to attack children of four or five years of age. The pathognomonic symptoms of this disease are, great pain in the region of the stomach, sometimes recurring every quarter of an hour; violent contortions of the child ; and the application of a hand to the seat of the disease. Mr. Saillant, in the first instance, suspected these symptoms to be owing to worms, and prescribed accordingly; but that child dying in a few days, the body was afterwards opened, and the presence of genuine inflammation of the stomach, and of part of the intestinal canal, was clearly de- monstrated. The treatment of this dreadful disease is, however, represented as very simple, consisting only in cooling and laxative remedies, which, when administered in good time, are said to be usually successful. For this purpose, Mr. Saillant has generally adminis- tered the juice of lettuce, by spoonfuls every hours; an idea he took up from Baglivi, who directed the juice of the sow thistle in the hemitritasos, under symptoms analogous to those of the car- dialgia. The juice of lettuce was generally found to relieve the pains in a short time, and some infants who had been judged to be in an hopeless state, and even at the point of death, were perfectly recovered. * Mr. Andrij has done me the kindness of acquainting me, that he has sometimes met with this complaint in the Hospice des Enfans Trouves, especially during the summer, and at such other times as infants have been obliged to continue there without the breast, from the want of wet-nurses, (who are usually otherwise engaged in the harvest and vintage seasons,) as well as during a hard frost. In the instances Mr. Andrij has seen, the infants were found to vomit up everything that was given them, which, it is probable, must generally be the case where the stomach is actually inflamed. In such instances, perhaps, fomentations, or a blister to the stomach, and the use of a warm bath, together with castor oil, or other demulcent laxative, ought also to be made trial of.(/) (/) Gastritis with Gelatiniform Softening of the Stomach. Of late years a disease of infants of a very unmanageable character, and the chief autopsic feature of which is softening of the mucous membrane ofthe stomach, has been described by different medical writers. It occurs most frequently soon after birth. The symptoms are similar at first to those of gastritis, with, occasionally, diarrhoea — the stools being green like the matter ejected from the stomach. The expression ofthe face is thatof pain; the features are wrinkled as if the child was crying — the cry, partaking somewhat of a low moan, indicates pain ; the respiration 142 UNDERWOOD ON CHILDREN. TORMINA, OR GRIPES. The Gripes is a very common term amongst nurses, and some writers on children's diseases have treated of it under a distinct head ; but this serves to perplex matters, instead of explaining them. If a child be not hungry, nor hurt by some parts of its dress, there will always be symptoms attending to account for its crying, and other expressions of pain. The cause is, indeed, very commonly in the bowels, and may be increased by costiveness and wind, which have already been treated of; but more commonly manifests itself by a purging, which comes next in order to be con- sidered. I shall only previously observe, that children, when very much griped, sometimes refuse taking the breast, though offered them repeatedly, when placed, in the usual manner, on the nurse's arm, but will take it, nevertheless, very readily, if they are held upright before her. The reason of this perhaps is, that the offen- sive and irritating matters in the stomach then descend from the cardia, which is exceedingly sensible from its numerous nerves; and this may further manifest the impropriety of infants being so uniformly fed in an horizontal posture, which I have noticed else- where. DIARRHOEA. Under the article of vomiting it was observed, that frequent puking is oftentimes an attendant upon some other complaint, and then demands a peculiar attention, and is to be treated agreeably to the nature of such complaints ; and there is, perhaps, none which it more frequently accompanies than a diarrhoea. Both vomiting and purging very often arise from unwholesome milk or other food, and from a moist, cold air ; as well as from the sudden disappearance of some eruption on the skin. The purging is not then nastily to be stopped, nor even absorbent powders to be given, till the offensive matter be first carried off; and if a vomiting attend, the cure should begin by administering an emetic. But though the purging ought not to be checked without pre- vious evacuations, nor to be stopped hastily, yet it is not to be treated with a daily exhibition of rhubarb, especially in very young infants, howsoever small the dose ; which, though a corn- is jerking. There is subsequently a state of prostration and insensibility, alternated occasionally by restlessness and pain. The little patient finally sinks in a period varying from eight to twelve and fifteen days, exhausted by pain, wakefulness, and continued vomiting. In very young infants there is often no fever. The treatment, at first, is that for simple gastritis ; but the evacuation, as by a few leeches, must be less, and the abstinence course less persevered in. Great stress has been laid by some practitioners on preparations of iron, early resorted to in this disease. DIARRHCEA. 143 mon practice with many, serves to prolong a purging after the cause has been removed, by keeping up a continued stimulus, as I have frequently seen. The diarrhoea, indeed, is a complaint often as difficult to treat as any in the infant state, and therefore demands the most precise directions. In a general way it may be said, that a sufficient dose or two of rhubarb should be administered in the beginning, and afterwards absorbents. If the purging should still continue, an emetic will be necessary, as purges do not always lie long enough in the stomach to carry off the offensive matter it contains. After this, it is often necessary that the child be purged again : for it should be always remembered, that many complaints of infants, whether seated only in the first passages, or attended with fever, will frequently seem to be giving way upon procuring stools freely, but will soon return if the same means be not re- peated, till the whole irritating matter be carried down. Should such repetition fail of success, though the diet has been carefully attended to, the use of them at present should be laid aside, and recourse be again had to absorbents, and if there be no fever, to light cordials, and even to opiates; without the latter of which, many bowel complaints will not admit of a lasting cure, owing to the great irritability of infants. Such medicines are not, indeed, very often required, till children are some months old: but when they are found necessary, not only may syrup of white poppies, but even laudanum be given with the most perfect safety ; though from the time of Galen, (who cautions against giving theriaca to children,) till of late years, many physicians have been fearful of directing them, (arguing from their abuse against their use,) and especially Harris, who, in other respects, has written so well on their diseases. I remember being called to see an infant of only two days old, who, through a mistake, had taken, some hours before, four drops of laudanum. The parents were greatly alarmed at the child's lying in a comatose state, without being able to take the breast, or open its eyes. I advised, therefore, to get a jlittle breast-milk down with a tea-spoon, and encouraged them to believe that the laudanum would do no kind of harm; the infant having no disorder for which that medicine was improper. Accordingly, though the child lay sleeping above six-and-thirty hours, it after- wards awoke perfectly well.* This is mentioned, however, only * Infants, as well as adults, vary much in their capability of bearing opiates. In some, a very small dose is followed by very alarming symptoms; and death has not uncommonly ensued from the incautious exhibition of some preparations of opium. The children mentioned at p. 106, (note,) probably had not taken so much as four drops each of laudanum, yet both became convulsed and died. I once saw a child in the month thrown into a state of excessive stupor, by taking one dose only of a mixture, in which were four drops of laudanum : the actual quantity swallowed could scarcely amount to a single drop. In the exhibition of many medicines, we find that children bear a larger proportionate dose than adults ; as is the case with calomel, scammony, jalap, &c, but with opium, and other narcotics, they generally can only bear a smaller proportionate dose : it is best, therefore, not to give, in the usual diseases of children, a full dose of laudanum. — S. M. 144 UNDERWOOD ON CHILDREN. by way of encouragement to such as may be fearful of adminis- tering opiates, even where they are necessary. They are, never- theless, very powerful medicines, and should be prescribed with due caution for patients of every age, especially for infants, and particularly when a purging is connected with teething, or is at- tended with fever; in which cases, I am almost daily seeing the fatal effects of arresting a purging. A like caution may be neces- sary in regard to cordials ; which are, nevertheless, in many cases equally proper, notwithstanding a modern prejudice against them. There is a certain coldness and languor in infants when they are ill, especially under some bowel complaints; and whenever they may be in that state, a judicious use of that class of medicines will have a very happy effect. It will be remembered, however, that a purging is not always a disease ; but, on the contrary, a remedy, and a very common and important one. The bowels are the great natural and critical out- let in infants, as the pores of the skin, and the kidneys are in adults; although in both, from their vast extent of surface, they spread a very broad mark for the shafts of disease. Not the mere discharge, therefore, but the cause of it is, in the first instance, to be removed; whilst the ill effects are to be guarded against by keeping the purging within bounds. For this purpose, the chalk julep, as it is an astringent only by absorbing the acrid, or changing the acid and irritating matter, is as safe as it is useful; becomes an excellent anodyne : and after the bowels have been well cleansed, and the irritating cause removed, will usually accomplish the cure. Dr. Armstrong takes occasion to speak against the use of ab- sorbent powders, and prefers wine of antimony, from a suspicion he has entertained of the great dependence that modern writers appear to have placed in them, previous to the exhibition of purges, on account of their known property of correcting acidity: and says, that in case of extreme danger, a physician who is called in late, should, according to this practice, often find no opportunity of purging at all. But surely this is scarcely an argument to prove the superiority of his method, since no writer that I know of, ever designed it as a rule without exception ; and Harris, who has said as much as any man in commendation of the absorbent powders, does not deny the expediency of sometimes beginning with pur- gative medicines. But had it been otherwise, the argument goes no further than to prove, that in cases of great danger, the wine of antimony being both an emetic and a purge, ought to precede the use of the testaceous powders. Instead of this, Dr. Armstrong slides into a general conclusion from premises evidently limited, though he has advanced nothing against an established and success- ful method of treatment. And I may add, that whilst he is fearful that the absorbent powders (which nobody prescribes without some purging medicines) should check the looseness, and thereby increase the fever, he ventures, after a repetition of the antimony, to ad- minister what he calls a gentle paregoric, or opiate, to appease the DIARRHCEA. 145 pain; consisting of a dram of syrup of white poppies, repeated every three or four hours, till that end be obtained. So that if the pain should continue for nine hours, a child will take half an ounce ofthe syrup ; and this, Dr. Armstrong observes, is the only medicine he gives, except wine of antimony, which (notwithstanding the opiate) he supposes to be the efficient remedy—but how much more powerful a restringent, in its ultimate effect, the syrup is, than the absorbent powders, it is unnecessary to say. It is an improper exhibition of absorbents, I apprehend, rather than their dose, that has made some practitioners so averse to them; for they certainly ought, in many cases, to "be given in large quan- tities ; but if administered too early, and long continued, the stools may become like plaster of paris, and be with difficulty excreted. Such an instance is mentioned by Boerhaave, who had, neverthe- less, a very favourable opinion of them, as will be noticed here- after. There is, however, some fallacy in regard to the colour of the stools, as this kind is observed, on different occasions, in children, who have never taken any of the testacea, if the secretion of the bile be obstructed, (as in jaundiced adults,) and will be noticed in its place. In his second edition, Dr. Armstrong mentions another method he has fallen upon for curing this disorder; which, however, ap- pears to be recurring to the ancient method of treating bowel complaints ; and seems, indeed, to overturn the idea he had enter- tained, of the superiority of wine of antimony over every other medicine. This method, he tells us, is by cleansing the bowels, by means of proper purgatives, joined with anodynes, intermixed in such a manner as to correct the griping quality of the medicines, and lessen the stimulus occasioned by the acrimony of the stools : a plan worthy of imitation; and, though not likely to be proper in all cases, yet, as an occasional practice, safe and beneficial. Regard is to be paid to the kind of stools that come away, which are seldom healthy and natural, and are usually distinguished into the sour and curdled, slimy, mucous, green, pale, clayey, watery, over-tenacious, and bloody,* some of which are at times also fetid. Under some of these, and particularly the latter two, some powerful purgative, such as senna tea, is generally necessary, if the child is not very young. True, bloody stools are less common in infants than adults, and seldom occur but in the last stage of the disease ; but a few streaks of blood may sometimes be mixed with the.faeces, which, arising only from the hemorrhoidal veins, is a matter of no consequence. Watery stools will be considered apart, under the head of the true watery gripes : I shall here anticipate only to say, that very threatening appearances of that affection, when green and curdled matters are purging off,are sometimes happily removed, in a day or two, by a gentle emetic, and such a warm purge as * On fseces discoloured by blood, or otherwise blackish, particular notice has been taken under the head of Fever. 13 14G UNDERWOOD ON CHILDREN. that noticed below. When the stools appear very slimy, and more especially sour, or curdled, or when the child is much disposed to hiccough, the magnesia, and other absorbent powders, are calcu- lated to afford peculiar assistance, and may be warmed by any suitable aromatic. When the stools are very green, or white and clayey, a drop or two ofthe aqua kali may be occasionally put into the other medicines, or a little almond soap be dissolved in the clysters, which are essentially necessary when much griping attends this complaint. Some light cordial is also frequently useful, and the child's belly may be rubbed with a little warm brandy, or be fomented with a decoction of chamomile flowers, or white poppy- heads. But if the tormina be great, clysters of the whey of cows' or asses' milk, as advised by Hoffman, will often be found very useful; and should the infant be much emaciated, a portion of the sugar of milk* should be added to them. Where anodynes are judged proper, the tinct. hyosciami is often preferable to lau- danum. It may be observed in this place, as a pretty general indication, that purgatives for infants ought to be made potentially warm, by the addition of a little ginger, pounded cardamom-seed, carraway tea, or dill water, which is of more consequence than is usually apprehended. I have, indeed, known a careful attention to this circumstance alone, happily suppress complaints in the bowels, which had long continued obstinate, though in other respects pro- perly treated. On this account, I venture to recommed the follow- ing as an excellent general remedy, especially as infants are pleased with it, and it will keep for a great length of time. R Pulv. Rhei gr. xv. Magnes. albae §ss. Aq. Fceniculi. — Anaethiaa ^vj. Syrupi Rosae, ^ss. fs. Spir. Ammonia; comp. gtt. xv. ad xxx. ft. mistura, cujus sumantur Cochl. ij. vel iij. minima, bis, terve in die, vel ut opus sit. Or, R Pulv. Rhei. Nucis myrist. Magnes. albae aa gr. iij. vel iv. Sit pro pulvere, deglutiendo e coch- leari minimo syrupi Rosae. Should purgings return frequently, it will be very useful (especi- ally at the time of teething, or upon the striking in of some eruption on the skin) to procure a little discharge behind the ears, or to apply a Burgundy-pitch plaster to the back. For the former pur- pose, some finely pounded Spanish flies may be rubbed on the part, till a slight excoriation, or rawness is produced ; or perhaps a better method, which I have long recommended, is to draw a piece of coarse double worsted, or a bit of narrow tape, through a * The sugar of milk may be procured by evaporating the whey by slow boiling; and may be made more pure by first clarifying it by the white of eggs. DIARRHCEA. 147 piece ofthe emplast. lyttas, and lay it close behind the ears Where they rise from the head, and repeating it occasionally ; which will produce a discharge exactly from the spot where it is wont natu- rally to arise. The following preparation is highly extolled by Boerhaave,* as an almost universal medicine in the diseases of infants ; and is certainly a good remedy, especially in their bowel complaints, and particularly when attended with green stools, after the exhibition of proper opening medicines: — R Sapon. dur. Hisp. 5'j- Margarit ppt. $\. Syr. Alth.gss. Chel. Cancr. ppt. Jiss. Aq. Menth. sativae. — Fceniculi aa J iij. ft. mistura, cujus sumatur cochl. infantum octava quaq. hora. Notice is taken in another place,t of pale stools being no uncom- mon occurrence when children are breeding their teeth. They are also met with in fevers, as well as in simple disorders of the bowels; and therefore might be introduced under either of the former heads, instead of this place ; but as the stools are very numerous and watery, and the purging itself is the first occurrence, it has seemed, upon the whole, proper to give it a formal discussion under the present article. The complaint, however, has been found the most obstinate in children who are turned of a year old, and cutting their double teeth. The stools are not only clayey, thin, and very white, but curdled like those of very young infants at the breast. In the be- ginning, it is seldom attended with any degree of pain, or other complaint, except it be the loss of appetite ; and this has led pa- rents, and sometimes other people, to think, that the discharge ought to be checked by absorbents or opiates. But nothing can be more improper : the skin soon becoming hot, the tongue white, and the disorder rarely yielding to any treatment under two or three weeks. This is almost always the case, if teething be anywise concerned in the complaint, unless the teeth happen to be nearly cut through ; though a purging with pale stools, as has been said, is met with in fevers of another kind, where the cause is confined wholly to the first passages. Whatever the age of children may be, they are always somewise indisposed, while the alvine discharges are of this colour ; and whether there be either fever or purging, or not, children lose their flesh ; as it is, indeed, likely they should, from this clay-like matter sticking to the coats of the intestines, and preventing the due ab- sorption of the nutritious parts of their food. This is especially true when the stools are thick as well as pale ; or if they be of a leaden blue colour, and very adhesive, or pasty, and in amazing quantity, as is sometimes the case. * Epist. 1 : ad J. B. Bassand, a physician at Vienna. f See the chapter on Teething. MS UNDERWOOD ON CHILDREN. Under these last circumstances, particularly, small doses of calo- mel, administered as an alterative, is an admirable remedy. The safety of the use of this medicine for any length of time, has, however, been disputed by Dr. Curzons, of Birmingham ;' but his opinion seems rather to be supported by theory than established by facts, the Doctor, asserting only that " many children have fallen a sacri- fice to the improper exhibition of this medicine" — and of what medicine may not this be said ? On the other hand, I am persuaded that the benefits derived from a proper, though long-continued use of this drug, are, at least, equally numerous. In confirmation of this sentiment, I take the present occasion of observing, that since I left London, and have had leisure to admit all the poor in the neighbourhood to receive my advice, I have had abundant evidence of the expediency of repeatedly administering laxative medicines in these cases, even when children have been in a very debile state, and of the great benefit especially of calo- mel : having thereby both shortened the diseases, and preserved the lives of many children, who have previously had what they thought the best advice in the neighbourhood. It being also more frequently the children of the lower orders of society, that suffer and perish under disorders ofthe first passages; and to which the want of good air in their apartments, taking too little exercise, and the administering improper and indigestible food, contribute con- siderably. Whether teething be materially concerned or not, purging, by one mean or other, is the proper and principal remedy, unless the gums are in a state to be lanced, or the stools should continue a long time very pale, or clayey, after the fever and purging disap- pear. In the latter case, some saponaceous medicine will prove serviceable, such as the aqua kali prasparali, or a few drops of spiritus ammonite compositus, taken two or three times a day; the bowels being still carefully kept open. Where dentition is the probable source of irritation, and of these pale stools, and lancing the gums has not accelerated the irruption of the teeth, or the period is too early to expect benefit from it; children are oftentimes not only free from fever, but are, on the other hand, cold and languid, and should, therefore, be purged less frequently. Some cordial medicine should also be administered on the intermediate days, as well as on the evenings after the physic has operated. In the early part of the disease, the active purges are the most proper, such as castor oil, senna, and frequently calomel; or if the fever be considerable, an infusion of burnt sponge and senna; a preparation equally adapted both to the fever, and this kind of purging. Another bad kind of stools appears sometimes during teething, that has been alarming to many, as nothing like it, that I know * Medical and Physical Journal, vol. iv. No. 21. DIARRHOEA. 149 of, appears spontaneously in infants at any other period ; though it is not uncommon in adults, and especially, I think, in females. This is a discharge of a very thick mucus, which appears in great quantities, and sometimes accompanied with a little blood. Neither of these discharges, however, do any harm, if the bowels be kept a little more than usually open, by some soft purgative, and some light cordial interposed, or the test, ostreor ppt. if found necessary, in order to strengthen the bowels. The cause of this appearance seems to be ofthe same kind with that in adults, and from mere irritation falling on the glands of the bowels, and keeping up an increased secretion of their natural mucus ; and it is well-known, that the time of teething is that in which the bowels are peculiarly liable to irritation. To the various observations that have been made, I shall briefly add, that there is a disordered state of bowels, which frequently occurs, and is disposed to continue a long time, during which, infants, though not often precisely ill, do not thrive, nor look well. The stools are said to be always bad, being sometimes of a green colour, at others of a pasty consistence ; sometimes very numerous, and at others, infants are for several days very costive. In this, as well as other bowel affections before described, when laxative, alkaline, and absorbent medicines have been found to procure no permanent good effect, calomel often proves a sove- reign remedy; and may be given in the dose of half a grain, or more, to infants in the month, for two, three, or four successive nights. In general nothing purgative should be administered the following mornings, but the murcury be left to its proper action. It is certain that this mineral has a marked operation on the liver,. obviating a morbid action, and acting as a stimulant, when the functions of the liver are inert: and is an equally well known de- obstruent for all the glandular system, and will be found a very safe and efficacious medicine ; infants being known to bear mer- cury much better even than many adults. When purgings have continued a long time without any amend- ment, a peculiar tightness of the skin will sometimes take place in the last stage of the disease, affording always an unfavourable prognostic ; and of which notice has been taken under the article of Skin-hound.* * In treating all cases of purging in infants, our attention should be especially directed to two objects: first, the feel and appearance of the abdomen ; secondly, the character and kind of the evacuations. Upon feeling the abdomen, (which should be done when the child is in an easy posture and not crying,) if it be found full, hard, or irregular in its shape, a purgative will almost certainly be required, notwithstanding the frequent evacuation of fecal matters. The most effectual purgative in such cases is a grain or two of calomel, either combined with jalap or scammony, or rhubarb, or given by itself, and followed in an hour or two by a dose of castor oil, or solution of salts in almond emulsion. This purgative is to be repeated according to circumstances, and in the meantime a cretaceous mixture may be given at intervals, or what is often preferable, a solu- tion of carbonate of soda or potassa, in mucilage or emulsion. If the evacuations be hard, lumpy, scyballous, or pasty, or of a green, or leaden, 13« 150 UNDERWOOD ON CHILDREN. LIENTERIA, OR WATERY GRIPES. I come, lastly, to treat of the Lientery, or true Watery Gripes, so called, which is esteemed the most dangerous of all purgings, and is often fatal; but if properly treated, children may recover from this as well as from excessive purgings of any other kind, unless it happen after some other illness, or to very small and ten- der infants during the month, especially when attempted to be brought up by hand. It is not the having a few very thin stools, however, that is an evidence of the true watery gripes, for in almost every purging of a few days continuance, the stools are very thin as well as numerous. But in this case, they are thin very early in the disease ; the child looks wretchedly, and everything it takes runs almost immediately through it, with very little change, as in the lientery of adults. It should likewise be remarked, that these symptoms continue, and are increased as the disease advances. A distinction should be made between purgings in which the stools are very watery, and the true watery gripes. In the first, the stools, though equally or more numerous, are more perfectly fluid than in the true watery gripes, and are tinged only with the bile ; the thin stools arising from a violent, but ineffectual effort of nature to get rid of offensive matter; and upon exhibiting a warm purgative, calomel, or castor oil, several very thick, and always clayey stools are brought away. In the true watery gripes, the cure should be begun by adminis- tering one or more emetics, especially when the stools are of a dark colour and fetid ; as they frequently are in the early periods ofthe complaint. And to this end, a pretty strong one should be prepared, which should be given in divided doses, at about a or blackish colour, the same plan is required ; and the aperients must be con- tinned daily, or as often as may be found necessary, till the evacuations become of a better consistence and better colour. When the use ofthe more active purgatives shall have relieved the complaint, the cure must be perfected by giving a small portion of ipecacuanha, a grain or two of rhubarb, and a few grains of chalk, with the addition of a little aromatic, twice or thrice a day. But when the abdomen is not full, hard or irregular in shape and feel, but flabby and collapsed ; and when the stools are thin and watery, pale coloured, or white and frothy like yeast, the use of calomel and purgatives is to be rejected, and other more appropriate means must be employed. The case now requires the use of cretaceous medicines, kino and catechu;* opiates must be occasionally interposed ; and an attempt must be made to improve the secretions, by three or four grains of hydrarg. c. creta, or a grain of pil. hydrarg. rubbed into a powder with four or five grains of carbonate of magnesia: sometimes a combination of ipecacuanha, rhubarb, and soda, very effectually answers this purpose. Change of diet, as Dr. Underwood recommends, is indispensable, and change of air is sometimes to be recommended___S. M. * A better remedy than any of these is the decoction of may be taken frequently.— M. H. LIENTERIA, OR WATERY GRIPES. 151 quarter of an hour's distance, till a proper effect is produced ; and some hours afterwards a warm purge with rhubarb should be administered, if the disease be not very far advanced. After the first passages have been cleared, the eighth part of a grain, or less, of ipecacuanha, or a drop or two of wine of antimony, given every three or four hours, with a few grains of the testaceous powders, or the aromatic confection, appear to me amongst the best remedies in the earlier periods of the complaint. Indeed, ipecacuanha in very small doses, especially if duly guarded by some gentle aro- matic, is both so useful and safe a remedy, that it should not be hastily laid aside; and when persevered in for some time, will effect wonders, not only in long purgings, but in other chronical complaints. The like may be said of the vinum antimonii, which in the less aggravated watery gripes, or where a purging is for a long time attended with very bad stools, forbidding the use of restringents, as well- as in some little feverish complaints, I have found equally useful, and even sometimes more manageable as an alterative than ipecacuanha, because less disposed to nauseate infants, where an emetic may not be directly intended. There being also cases in which the physician wishes a medicine may operate as a corrector of the secretions in the first passages, or to expel their contents, either upwards or downwards, as may be ultimately most useful; antimonials seem in this view likewise to claim a preference to all other medicines. In the more advanced stages of the watery gripes, and where the child is not very young, the following old medicine is a very good one. Of Locatelli's balsam, one ounce, and conserve of red roses, two ounces : from the quantity of a horse-bean to that of a nutmeg, may be given three or four times a day, according to the age of the child. Others have advised red bole, and gum tragacanth. — The labdanum and other plasters likewise, as directed for vomit- ings, or the following, may be applied to the parts above the navel, especially in case of great pain. R Theriac. Venet. £j. Olei expressi Macis diet. J'j- Olei N. Mosch. gtt. iij. Misce, ft. Empl. alut. indue. Or, R Axung. Anserin. Jij. Olei expressi Macis diet. Jj. ----Menthae sativae, 9j. ----Bacc. Junip. ----Chamomael. aa ^ss. Misce ft Linimentum. Inungatur eo bis vel ter quotidie Stomachi et Umbilici Regio, Warm flannel, with or without heated bran, may be afterwards laid over the whole belly, and renewed frequently. Should these means fail, I have known the repetition of a vomit give an immediate check to the complaint, especially where the stools continue to be remarkable sour. As long as this is the case, 152 UNDERWOOD ON CHILDREN. it would be both vain and hazardous to exhibit opiates, or power- ful restringents; the acidity must be first carried off by warm purges, and be corrected by absorbents; the latter of which must be given in large and repeated doses, and frequently their powers be augmented by the addition of liquor potassae subcarbonatis, or tinctura myrrhae. And an excellent remedy sometimes, as an ant-acid, is the spiritus ammonias succinatus. The acidity once removed, a starch clyster may be thrown up, two or three times a day, with or without a few drops of laudanum, according to the number of the stools, and weakness of the infant. A drop or two of laudanum likewise, may now be given, once or more in the day, (according to the age of the child,) either joined with some purga- tive, or in any of the afore-mentioned medicines, or in the chalk- julep, made warm with tincture of cinnamon, or of cardamoms; and in cases of extremity, in the decoction of log-wood, which agrees very well with young children : or a medicine now out of use, I mean the rob of sloes ; a few grains of which, with a little grated nutmeg, and a small quantity of rhubarb, p. r. n., I have found immediately successful, after opium, decoct, campechens, and every ordinary restringent have failed of any lasting benefit. In the advanced stage of watery gripes, or in case of great debility, the liberal exhibition of aromatics and opiates is essentially neces- sary. Bowel complaints, it is to be remembered, are frequently owing to improper food, which, on this account, should at all times be peculiarly attended to ; and when a purging has taken place, ought to be suited to the nature of the stools. In the introductory re- marks, ample notice has been taken of children's food ; at present I shall only observe, that cow's milk is often found to disagree with them when their bowels are disposed to be too open, at which times a little lean mutton-broth, or beef-tea, is abundantly prefer- able. On the same account, rusks and biscuit-powder are more suitable than bread ; but at other times, I believe, either the Ux- bridge, or the French roll, which are already half-digested by a previous fermentation, are more easily dissolved in the stomach, if there be not a predominant acid in the first passages. But where there is an habitual disposition to a purging, I know of no diet so proper for infants who do not suck, or who cannot have enough of the breast, as flour slowly baked for a long time, till it breaks into a soft, greyish-coloured powder,* and afterwards mixed with boiled cow's milk, the scum being first taken off; the flour and milk should then be boiled a little time together, till the whole appears like a thin custard. This is a very light and soft food, and sufficiently restringent; and I have often known more good from it, than from all the absorbent medicines ever devised, and have received more thanks for the prescription, as it proves a permanent * To this end, the flour should be put into a small jar, properly covered ; and taken out of the oven several times, and stirred up from the bottom and sides of the jar, that it may not run into hard lumps, but the whole be equally baked. CHOLERA INFANTUM. 153 remedy. The powder of arrow root, also, boiled in water, and then mixed with milk, is an admirable remedy when it can be procured genuine. When the watery gripes, or indeed any violent purging, attacks very young children at the breast, no other food than breast milk ought to be administered ; but if the acidity and purging con- tinue many days, and medicines do not take a proper effect, it may be proper to change the wet-nurse. If infants ill of watery gripes are brought up by hand, the strictest attention must be paid to their food, which must be changed from one kind to another, and especially trial be made of broths, as long as the food shall be disposed to turn very acid on the stomach. In one case, I think, I saved a child by Bates's julepum vita;, lowered with water, when nothing else would stay on the stomach. This served both for food and medicine ; for the former of which it was still further diluted. When children who are weaned, are attacked with repeated purgings, and even broth is found to run through them, I have observed no food so generally useful as a bit ofthe white of chicken, not over-boiled, and afterwards lightly bruised in a mortar with the chicken liquor, and a very little bread, into a kind of light jelly, or panada. But this should not be given oftener than twice, or at most, three times a day. In all bowel complaints, it has been already remarked, that infants are disposed to eruptions on the skin ; by which they are so frequently benefited, that if any kind of rash appears during long and severe purgings, a recovery may almost with certainty be prognosticated. — The like good effects have been noticed from a purging taking place in some obstinate cutaneous eruptions.(m) (ni) CHOLERA INFANTUM. We are surprised that this disease, which is certainly not unknown in the British Islands, although not so common as in portions of our own country, should have been unnoticed both by Dr. Underwood and his intelligent and experienced editors, Drs. Merriman and Hall. Although it exhibits vomiting and purging, it is not susceptible of being described and of an appropriate treatment being laid down under the heads of vomitus and diarrhoea separately. In some of its features infantile cholera partakes of the character of atrophia ablactatorum, or weaning-brash, so carefully described by Dr. Cheyne ; but in general its symptoms are more violent in their onset, and its progress more rapid than those of the latter. It is so far analogous to the disease on which Dr. Cheyne has written, that its appearance, in general, depends on the conjoined effect of weaning and teething with a particular season ; summer being commonly the exciting cause of cholera, and autumn of weaning-brash. In our cities, cholera infantum comes on with the first heats of June ; it continues its ravages to the succeeding period of July and August, and gradually abates as the weather becomes cooler in September. The in- fluence of the other causes, weaning and teething, is shown in the fact of children thus exposed being the chief victims to the disease 154 UNDERWOOD ON CHILDREN. INCONTINENCE OF STOOLS. The long-continuance of the last-mentioned complaint, as well as others which may debilitate the habit, may prove an occasion of that now under consideration. Children who are accustomed at all times to have a very open belly being especially liable to during the summer months. Weaning is followed by a change in the diet of the little being, and the introduction of unaccustomed, and often disproportionately strong nutritive, and even other stimulants into its diges- tive canal, perhaps already irritable by the pain of teething and conse- quent morbid impression on the nervous system. But even these causes combined, powerful as they would seem to be in the production of dis- ease, and at times fully adequate to bring it about, are borne with rela- tive impunity by a majority of children, as far as the digestive function is concerned, unless the irritation of high and continued heat, with its too common associate of close and confined air be added. Teething and high atmospheric heat frequently give rise to the disease. A simple announcement of the causes of cholera infantum must, at once, point out a prophylaxis, and, to a certain extent, at least as far as hygienic agents can operate, a suitable treatment. This will consist— 1, in a resto- ration, if possible, ofthe infant to the breast, or the administration of food of an analogous nature to its mother's milk, or of semifluid nutriment as little irritating as possible to the alimentary canal of the little sufferer; 2, in diminishing excessive sensibility of its nervous system, and, consequently, the excessive irritation from teething — both by soothing and sedative agents, and by diminishing or removing the local irritation of the gums; 3, in removing the existing irritation, of whatever kind, in the alimentary canal, and thus to save the brain, which is apt to become, consecutively, a sufferer in an advanced stage of the disease. The structural changes are not identical in all; some exhibiting follicular inflammation with redness of the mucous membrane of the intestines; others, a softening of this membrane with scarcely a trace of inflammation. A congested and enlarged liver is a frequent accompaniment to the morbid condition ofthe intestinal canal. By some, the hepatic affection is regarded as a distinct and chief cause ofthe disease ; although, for my own part, I am disposed to view it as an effect of the preexistent derangement in the intestinal circulation ; but which may soon become itself a secondary and powerfully disturbing cause. I shall not enter into a detail of the symptoms of this disease, painfully manifest as they soon become, to the physician and attendants of the patient. Sometimes the disease is ushered in by diarrhoea, on which vomiting supervenes; sometimes vomiting announces the incipient stage; but, soon, the two are conjoined, if the causes continue to operate, or a suita- ble treatment be neglected. At other times, again, the cholera form ia announced at once, and the prostration is early and extreme. More important than a minute detail of symptoms is a knowledge ofthe difference of these, and of the different diagnostic value of some of thesame ones, in the several stages ofthe disease. Heat of the skin, and a burn- ing heat of that over the abdomen, a frequent and somewhat active pulse, INCONTINENCE OF STOOLS. 155 lose the faculty of properly retaining their stools, and need a ser- vant continually to attend them, even at two or three years of age. restlessness, intense thirst, scanty urine, bilious and acrid discharges, will call for a different treatment from a cold and clammy skin, small and feeble pulse, watery and nearly colourless discharges or scourings from the bowels, a moist tongue and aphthae, and heaviness and somno- lency approaching to stupor — even though in both we have vomiting The modifications depending on temperament and primary constitution, are not to be lost sight of: they will form elements in our calculations as to the intensity of the disease and the propriety both of selecting certain remedial means, and of insisting with more or less freedom on their use. In the first stage, or that of more manifest gastro-intestinal irritation with exalted sensibility, our treatment will consist in a prompt withdrawal of all but the simplest nutritive articles, and an avoidance of medicinal irritants. The drinks should be cool, mild, and mucilaginous ; the lungs should be subjected to fresh air; the skin to tepid bathing. Suspicion of indigestible substances having been recently given will authorise a mild emetic, or the state of the stomach forbidding this, a laxative enema ; to be followed by simple mucilaginous ones. Vascular excitement being manifest, a few leeches over the epigastrium will be of service, and the application to be followed by light emollient cataplasm or warm stupes, extending over the abdomen; or if the temperature of the surface be unequal the warm bath should be used. The state of the gums will early engage attention, and if they are swollen and inflamed, or spongy, and the teeth may reasonably be expected, the former should be freely lanced. The more obvious and probable causes of irritation in the gums and contents of the stomach and bowels being removed, and any tendency to high irritation or inflammatory action being abated or subdued, recourse, if need be, is proper to different medicines and prescriptions, with a view of quieting the stomach. Of these the simplest are to be preferred, such as mucilage of gum-arabic, alone or mixed with lime-water, or mint, or peppermint, or camphor water; then small doses of the alkaline carbonates with mucilage, or chalk powders or mixtures, to which opium or laudanum may be added, if the former fail to allay the gastro-intestinal irritation and to soothe the nervous system, a no uncommon effect of their operation. Sometimes, relief is obtained at once, though seldom a cure, unless suitable prophylaxis be attended to, by the administration of minute doses of calomel, of an eight to a twelfth of a grain, mixed with five grains of gum arabic every three or four hours. Of late years I pre- scribe, in place of the gum, about the same quantity of prepared chalk to be carefully mixed with the calomel, on which it exerts of course a chemical, and, in reference to its therapeutical activity, what might be called a reducing power. A practice, occasionally successful, consists, in giving in the early stage, in advance indeed of any other remedy, one to two or three grains of calomel, regardless of its causing a sickness of stomach and vomiting itself, as these soon subside : the subsequent purging and evacuation of green, slimy, and bilious stools are regarded as proofs of beneficial action on the liver, by exciting it to freer secretion, and thus unloading it of congestion. With similar therapeutical intentions, small fractional doses of calomel, as above, are used by many practitioners, especially in Philadelphia. There is not, I 156 UNDERWOOD ON CHILDREN. No very appropriate remedy, I believe, is likely to be necessary. I have never ordered anything more than dashing the parts, daily, believe, any one remedy which displays such strikingly curative powers, in either arresting the disease or mitigating its violence as this does : but a recurrence or relapse is frequent after its use, and then a repetition of the remedy will not be followed by the same sanative effect as before. The vomiting once checked, and the more immediate distress of sto- mach removed, there is often such an abatement of the other symptoms as to promise speedy convalescence. This result cannot, however, be considered permanent, so long as the great heats of summer prevail and the irritation of teething is continued. The risk is, that the complaint, after a temporary cessation, will assume the character of a diarrhoea, varying in its appearance, in its being sometimes bilious, but more com- monly serous or mucous, and gradually by its persistence wearing out the strength ofthe patient. If it continue, the symptoms of cerebral disease increase, and towards the fatal conclusion of the disease, they might impose on a person, who had seen the case only in this stage, a belief of its being a dropsical effusion on the membranes of the brain. It is not necessary to enumerate the different remedies and their com- binations which are supposed to be applicable at this time, as most of them have been noticed in the text under the head of' Diarrhoea.' Of those which may be considered as of more recent introduction and use in cholera infantum, sugar of lead stands high in the opinion of some prac- titioners, — both in the first cholera stage and, still more, in the second or diarrhoeal. In this last, after the subsidence of febrile irritation, the skin is often cold and of a clammy moisture, and the prostration and torpor of the system considerable. It is now that animal broths, especially beef and chicken, from which the fat has been carefully skimmed, can be given with advantage ; but not to the exclusion of the farinaceous food heretofore used by the patient. At this time I have myself derived the best effects from sulphate of quinine administered in solution. It invigorates the patient, serves to correct the morbid state ofthe bowels, and every way exerts a cordial effect. Its use does not, of course, prohibit the con- tinuance of a recourse to other remedies adapted to particular symptoms, — such as the chalk mixture, Dover's powder, or ipecacuanha and mag- nesia. Oil of turpentine is used, in the advanced stage, with benefit, and even in the earlier stages sometimes quiets the irritability of the stomach. The warm, or if there be any reaction the tepid bath, to be followed by assiduous frictions over the body and particularly the abdomen, along the spine, and the lower limbs, is an exceedingly useful adjunct to the remedies already indicated. Rubefacients over the epigastrium or other parts of the abdominal surface are to be preferred to vesication, from which, and especially if repeated, I have seldom seen good to result. The tincture of the sesquichloride of iron, the linctura ferri muriatis, I have found to check obstinate diarrhoea in children. The restorative effects of fresh air in cholera infantum, are strikingly evinced in the relief procured by many hundreds of children every summer in Philadel- phia, by their simply crossing and recrossing the river Delaware in steam- boats once or twice a day. New life is restored to the little beings, who on leaving their homes in the city seemed almost exanimate and in the last stage of incurable exhaustion. WORMS. 157 with cold water, or at the most administering aqua calcis, or other absorbent; the complaint always wearing off as such children grow up, though oftentimes not entirely for several years. [Diseases within the abdomen are seated 1. In the Stomach. 1. Erythema. 2. Aphthae. 3. Softening. 4. Ulcerations. 2. In the Intestines. 1. Erythema. 2. Aphthae. 3. Softening. 4. Ulcerations. 3. In the Peritonaeum. 1. Effusion of Serum or Lymph. 2. Tubercles. 4. In the Mesenteric Glands, 8?c. 1. Enlargement. 2. Tubercles.* The first series are distinguished by vomitings, and pain,expresed in the countenance, on pressing the epigastrium. The second, by pain, tenderness, and diarrhoea, with mucous, per* haps sanguineous discharges. The third, by pain and tenderness. The fourth, by tumidity of the abdomen, general emaciation, and hectic. ' The mode of treatment of the first two classes of these diseases consists principally in giving barley water, or arrow root in water for the only diet, and in giving slight opiates to allay irritation. Peritonitis requires and bears the detraction of blood : leeches may be applied and allowed to bleed until the little patient's lips or cheeks turn pale, the erect posture being assumed and retained. The next remedy is mercury, so as to influence the system. — M. IL] WORMS. Worms may, probably, exist in almost any part of the body, as well as in the stomach and bowels. They have, accordingly, been found in the pericardium, bladder, the nose, and sinuses of the head, and even in the lungs, liver, and other solid parts.t But as we neither know how they are produced, nor how to dislodge them from these recesses, which they also more rarely occupy in young children, it is quite sufficient to notice the fact; our inquiries being properly confined to worms in the first passages. It is on this account that the complaint is noticed in this place, especially as worms are said to have been voided by infants of only a few weeks old. It is even reportedt that Van Doeveren has * See a valuable paper by Dr. Gregory in the Med. Chir. Trans, vol. xi. p. 258. f Baglivi reports, that worms are found in the heart; Ruysch in the lungs, the spleen, the kidneys, in the gonorrhceal discharge, and even in the marrow of the bones ; Schenkius in the urinary bladder; Bianchi in the uterus and in ulcers; Hippocrates in the vagina; and they are said to be frequently found under the skin of the Negroes in our West India islands. X Philosophical Transactions. — The same author reports that a peasant, after taking an emetic, brought up forty Dutch ells of tape worm, and yet left some part remaining, having, through his agony, bitten the worm off. 14 158 UNDERWOOD ON CHILDREN. discovered them in the still-born foetus. This indeed is much doubted by others, it being a very old observation, that worms are never voided by infants who are nourished only at the breast; and if so, it is not likely they can be generated before birth. Mr. De Lille, however, disputes this, asserting that worms were ex- pelled from his own daughter, when only eleven weeks old, and living entirely at the breast. However this may be, it is evident that worms are much oftener suspected to be the cause of children's complaints than positively ascertained : and of this, practitioners who deal in secret medicines have, in every age, made their advantage ; it being certain, that a mere foulness of the bowels will produce most of the evils attri- buted to worms. Neither are all children equally affected by them where they are actually met with : some infant children (as well as quadrupeds) continuing very healthy, though they are seldom free from them, and others parting with great numbers, unex- pectedly, without any previous indisposition: whilst some children are very ill who have apparently very few. The pains and other complaints in such case, arise from some other source, of which I have seen an instance in a girl of twelve years of age, long subject to excruciating pains of the stomach, for which she took various worm medicines, and actually parted with several large lumbrici, but without the least relief to her pain, which afterwards imme- diately yielded to antispasmodic remedies. 1, nevertheless, cannot agree with Dr. Butter, that worms in the human intestines are altogether innoxious, much less, as he seems to think, useful, and intended as " nature's remedy for destroying the superabounding morbid humours, and for stimulating the first passages by their crawling motions, and thereby assisting the peristaltic motion of the guts to carry off what remains of the offending load."* For I think children who are most troubled with worms are generally of a costive habit. Worms become hurtful chiefly from their numbers. First, when they obstruct the bowels, or compress the adjacent parts by their bulk. Secondly, by sucking up the chyle designed for the nourish- ment of the child. Thirdly, by irritation. Fourthly, by actually destroying the parts; though this is certainly a very rare occurrence, and a far less frequent source of injury than those before mentioned. Worms have, however, been said to eat their way through the intestines; and Lister relates,! that some resembling the teretes, but of a whiter colour, have been seen coming from an abscess on the ankle. They are likewise said to have occasioned sudden suffocation, by rising up into the throat and lodging there.J They have been usually accounted to be of four kinds; or, to * Butter on Remittent Fever. Page 36, et seq. f Philosoph. Trans. See also lleister. Their appearance on a sore may, however, be otherwise accounted for, than by supposing them to have made their way from beneath the ulcer. X Mr. Le Febure de Villebrune. WORMS. 159 speak more correctly, according to Drs. Baillie and R. Hooper, the native human intestinal worms are divisible into two orders, round and flat; the former comprehending, 1, the Ascaris Lumbrico'ides, or Teres (the long round worm, resembling the earth-worm); 2, iflscaris Vermicularis (the maw, or thread-worm); 3, Trichuris Vulgaris (the long thread-worm). The second order embraces, 1. Taenia osculis marginalibus (the tape, or long joint worm, solium). It is the separate joints of this species which constitutes the taenia cucurbitina, or gourd worm, from its resemblance to the seeds of the gourd, or water- melon. 2. Taenia osculis superficialibus (the broad tape-worm). This species seldom separates into joints. It is very seldom met with in England, but is endemic in Switzerland and Russia, and very common in Germany and other parts of Europe. Linnaeus enumerates another species, which, he says, has two oscula, one on each side, and which he terms taenia vulgaris, but which is thought by some to be merely a variety of the other. The taenia, it is well known, is often many yards long, is the most hurtful of all, and most difficult of cure, because it will remain long in the bowels even after it is dead, and is then seldom brought away but in pieces, and that by very powerful medicines ; though I think I have seen dead portions of this worm come away where no kind of purgative has been administered. But as this kind of worm is certainly not common in children, though it may some- times have been met with ; and as it generally occasions a variety of symptoms resembling other complaints, for which many different medicines may be required, little more than the mention of it may suffice.* The symptoms of worms are various, and many of them very equivocal; I shall name only the more constant, and less uncertain ones. Such are fetid breath, especially in the morning; bad gums; itching ofthe nose, and ofthe anus, especially from the ascarides; a very irregular appetite, always in extremes, whether of hunger or of loathing ; a large hard belly ; pains at the stomach ; sometimes vomiting, oftener costiveness, or irregular purging, with slimy stools ;t irregular colics ; thirst; dullness; peculiarly unhealthy and bloated countenance, with a dark hollow circle around the eyes; startings in the sleep, and grinding of the teeth. To these symptoms are often added, slow fever, with a small and irregular pulse, pale, or whitish urine, a short and dry cough, (which is an almost con- * It is so uncommon to find more than one of this kind, that it has acquired the name of the solitary worm, yet it is said there are a few instances in which several of them have been met with ; but, perhaps, attention enough may not have been given in the examination of them, it being well known that this worm will live a long time after it has been broken into several parts. See Letter of Dr. Nitret to De Haen, Act. Med. xij. 219. The head, and probably that alone, has the property of forming the joints, so that, if that be left after the rest ofthe worm has been voided, fresh ones will be produced. t The peristaltic motion ofthe intestines being increased, the secretion ofthe mucus must consequently be in larger quantity. 160 UNDERWOOD ON CHILDREN. stant symptom where the complaint is of long standing, and has injured" the health,) sometimes even convulsions, tetanus, epilepsies, and partial palsies ofthe lower extremities. In the case of convul- sions, if there be a small pulse, attended with hiccough, it is an almost certain sign that the convulsions are occasioned by worms. The like may be said of pain at the stomach, if it be very violent, sudden, attended with great anxiety, and a hardness and soreness of the parts above the navel. But more especially, according to Home, an cedematous swelling of the upper lip, and of the nostrils, is a certain token of worms. The cause of this troublesome complaint is not, perhaps, cer- tainly known ; but the great moisture of young persons is thought to be an occasion of their being more infested with them than older people; and children, whose digestion is weak, are more liable to them than others. Hence, debility seems as much a cause, as it is an effect of worms. Since the doctrine of equivocal gene- ration has been justly exploded, it has, however, been generally imagined, that worms are engendered from the eggs of insects, which float in the air, or are swallowed with some part of our food, such as summer fruits, vegetables, cheese, and some kinds of flesh meats. But, perhaps, this is not altogether so certain as it may seem at first sight, unless we are to imagine that these sup- posed eggs produce very different insects, from being taken into the stomach and bowels, than they would if deposited elsewhere ; since it is generally thought, that insects of this kind, especially the tape-worm, are not met with anywhere else ;* neither will it account for their existence in the unborn foetus, if that be really a fact. It is, however, more than probable, that they were destined by nature to be generated, and to live in the bodies of other ani- mals, as observed by Dr. Blackt and Rosen. But whatever be the cause, the general intention of cure is ob- vious enough, which is to bring them away in the most easy and expeditious manner, whether alive or dead ; the difficulty chiefly consisting in dislodging them from their firm attachment to the sides of the bowels. In this view, systematic writers state the indications to be, first, * Although this seems to be the fact, there are not a few learned men of a different opinion. Many travellers, and others, better acquainted with natural history than 1 am, have reported, that the very same kind of worms may be met with amongst vegetables, in the earth, and both in standing and running waters. That the tape-worm, particularly, has been seen in the waters above Constanti- nople, where the complaint is very common ; and that natives of northern climates, who have resided for any length of time in Turkey, are very frequently afflicted with the taenia, as it is supposed, in consequence of drinking of the foul standing waters of that hot climate. Linnaeus also, and others, have thought the teretes, or lumbrici, to be the same with the common earth-worm ; but Tyson has, by dissections, demonstrated the contrary. — Pkilosopk. Trans. t Treatise on the Generation of Intestinal Worms, and on the means of de- stroying them. See also Dissert, of J. Mathieu Gesner, Mem. Gotting. An. 1751, WORMS. 161 to destroy the nidus, and secondly, to kill and expel the worms. The first may be effected by alkalies, as potassae subcarbon. sapo venet. bitter aromatics, and mercury ; or by resolvents, as the gums assafoetida, galbanum, and such like. Secondly, worms are killed by oils in clysters, especially with the addition of the infusion of the semina santonici; by honey, and by indigestible substances, as the testaceous powders, steel, and tin ; and by poisons, as pre- parations of mercury, which at the same time expel them. To these ends, indeed, a variety of medicines, pretty much of the same kind, have been devised, and have served the cause of empiricism in every age ; most of which consist either of the bitter purges, or mercurials. Worms existing in the bowels can, indeed, only be carried away by purging ; and very active purges are indicated when the time of life and the constitution do not forbid. But when these are tender, gentle purges given daily for some time, by the constancy of their operation produce, without harm, an effect, equally, or perhaps more beneficial and lasting, than the active purges. These are often joined, or administered alternately with bitters; and hence have arisen the family receipts, as worm-seed, tansy, and such like, given in treacle or honey ; or joined with rhubarb, senna, or other gentle laxative. With many, and especially French wri- ters, the male fern, alone, is reckoned a specific. Olive oil, like- wise, has been said to be a good remedy, as being destructive to worms ; but castor oil is preferable, which, by its purgative quality, also carries them off by stool. Dr. Parr, in his Medical Dictionary, recommends the helleborus fetidus, as a specific. Agreeably to the above view of gradually ridding the habit of these vermin, children of a delicate frame, and such as have not been long infested with them, may begin by taking a small dose of infus. sennae every other morning ; but should this prove insuf- ficient, a few grains of pulv. e scammon. cum calomel, may be given the over-night, once or twice a week, according to the age or strength of the child ; and some tonic medicine be interposed. If purging much should, on any account, be found improper, the following is very safe and often effectual. R. Limattir Stanni ^ij. Hydrargyr. Jiij. Misce, fiat amalgama. Eight or ten grains of this powder, with three or four grains of rhubarb, and as much unwashed calx of antimony, may be taken every morning in a little honey, for a week together; after which, a clyster of succotorine aloes, dissolved in warm milk, should be thrown up over night, and a proper dose of rhubarb, or senna tea, be taken the next morning; which course may be repeated, as the obstinacy of the complaint, or the strength of the child shall re- quire. — Volatile alkalies also, in some debilitated habits, will prove serviceable, and valerian, especially if it be occasionally joined with jalap. But one of the most powerful means, long in use with 162 UNDERWOOD ON CHILDREN. country practitioners, and strongly recommended by the late Mr. Chamberlaine, is the dolichus pruriens, variously prepared ; but the most simple form, that of giving it mixed up with treacle, is, perhaps, the best of all. It should be taken night and morning for three or four days, and then be purged off with senna tea, or jalap ; and this course be repeated as occasion may require. Amongst other means, especially for such as may be at a dis- tance from medical assistance, is a mixture of pewter filings and treacle, of which children of four or five years old may take seve- ral tea-spoonfuls in a day, which they will readily do, for the sake of the treacle. At the same time, from five to ten grains of jalap, with as much of the hydrargyrus cum sulphure, should be given twice every week, to purge off the dead worms. Dr. Rush, of Phi- ladelphia, strongly recommends the rust of iron, from five grains to half a drachm, for infants from one year old to five, exhibiting a purge every fourth or fifth day, to carry the worms down, as they die. To answer the last purpose, the following plaster is some- times sufficient: R Aloes succotorin. Pulv. flor. Chamsem. aa 3j. Tereb. venet. Q. S. ut ft. Emplastrum (cum margine emplast. adhaesivi) apud regionem umbilici adrnovendum; sed ante appJicationem, inv ponatur loco umbilici morsum gossipii. Or equal parts of bullock's gall, and powdered aloes, may be mixed up with any unctuous substance, and the parts below the navel be anointed with it, two or three times a week: or succotorine aloes and powder of dried rue, made into a plaster with Venice treacle, and applied round the navel, first covering that part with a little cotton. — I mention these things with a view to the coun- try poor, whom the benevolence of practitioners may incline them to assist, and who may, by these easy means, do it at little expense to themselves. If the complaint, however, has been of long standing, and the child not very young, mercurial purges are a more expeditious, and a safe remedy ; though the hydrargyrus cum sulphure taken for a length of time, and occasionally purging with senna, has sometimes succeeded, even where there have been the severest convulsions. For which likewise, or obstinate contractions of the limbs, the warm bath is often essentially necessary. Throughout the cure, and indeed afterwards, the diet should be strictly attended to, and all fat and greasy aliments abstained from. The child should live upon milk, broths, and meats of easy diges- tion, with toasted bread, and honey instead of butter, which is ex- ceedingly pernicious. To prevent a return of the complaint in older children, or grown people, chalybeate waters and bitters may be made use of. As it is not my intention to enter formally into the distinct treat- ment often necessary for the taenia, (which, indeed, I have some- times seen brought away by very gentle means,) I shall do no WORMS. 163 more than refer to Shmucker's medicine, the celebrated remedy of Madame Nouffer, said to be made use of with great success in France and Geneva; as I have also known it to be, two or three times, in this country. It can in nowise, however, be proper for young children, though it may, possibly, be safely had recourse to for robust youths, growing up to manhood. It is intended to ope- rate very powerfully on the bowels for many hours, the patient being supported the while by repeated large draughts of broth, or green tea. The preparation of the preceding day, and some other precise directions, are equally needless in this place, and perhaps the pre- vious exhibition of two or three drachms of the Radix Filicis mas- culini, is of as little importance. — For a full account of the process, the reader is referred to Madame Nouffer's Treatise, published by Dr. Simmons, anno 1787. The purge is as follows: R Calomel. Resin Scammonii elect, 3L. gr. x. Gambogia? gr. vj. vel vij. Conserv. Cynosb. q. s. ut ft. bolus. The Cevedella, or Indian Caustic Barley, is recommended by Shmucker in the fifth volume of the Journal de Petersburgh,* as an almost infallible remedy for the taenia. He directs a drachm of the seeds, in fine powder,to be given every morning, fasting, mixed with honey ; and to exhibit on the fifth morning a drastic purgative. Mathews, late apothecary at Berlin, received an annual premium from the King of Prussia, (1801,) for his arcanum for the tape- worm, viz. :—■ R Limat. Stanni. angl. pur. §i. pulv. rad. filicis maris dr. vj. pulv. semin. Cynre ^ss. pulv. rad. jalappae resinosae, salis polychresti aa Ji. Misce, ft. cum mellis commun. sufficiente quantitate electuarium. R Pulv. rad. jalappae resinos. salis polychr. aa ^iij. scammonii aleppensis 9j.; Gummi gultae gr. x. Misce ft. cum melle communi, electuarium. He directs a spare diet of only broths and vegetables before the exhibition of the medicine, of which a tea-spoonful is to be taken every two hours, for two or three days, till the worm is felt moving in the bowels: the patient is then to take of the purgative elec- tuary likewise a tea-spoonful, every two hours, till the worm passes off. If it should not, castor oil is to be taken with it, or to be admin- istered in clysters. — These remedies should be proportioned to the age and constitution, and under the eye of a physician. The goodness of the fern is an important matter, viz., the root of the polypodium filix mas, which, when reduced to powder, is of a * Mr. Loefler, the author ofthe Journal, assures us, that it may be taken thus with perfect safety ; and annexes cases of its success in expelling worms of different kinds. A very powerful remedy, much used in the West Indies, par- ticularly for the lumbrici,is theSpigelia Anthelmintica, a species of Indian pink ; but it has not been much used in this country. 164 UNDERWOOD ON CHILDREN. reddish colour. —(Saltzburg Medical Chirurgical Gazette, in Ger- man, No. 39.*) The late Dr. James Sims succeeded with the ol. tereb., of which the patient for another complaint had taken two drachms as a dose : but possibly that disorder might concur with the medicine in expell- ing the worm.t(n) CONVULSIONS. Convulsions may be induced by the last-mentioned, and by seve- ral of the preceding complaints. They are of two kinds; the symp- * Medical and Physical Journal, No. 26, for April, 1601. | The oleum terebinthinae has, on many occasions, very effectually expelled the tape-worm; and in some other cases of worms has been useful. For tire tape-worm it should be taken into the stomach undiluted, in doses for adults of six or eight fluid drachms. For ascarides it may be given in clysters. — S. M. (n) Of the vermifuges recommended by the author, exception may properly be taken to the Cevedella, the active principle of which, veralria, renders it quite unfit to be used for children. Akin to the Spigelia Anthelmintica, is the Spigelia Marilandica, or Pink Root, of the virtues of which we, in the United States, are better prepared to speak, than ofthe South American variety. The root, powdered, is given in doses often to twenty grains to a child three years old, morning and evening successively for some days, and then followed by a purge. The more common and convenient form of administration is by infusion, to which senna is frequently conjoined. The proportions for simple infusion are, one ounce of spigelia root to one ounce of boiling water; after two hours, strain. The dose, for a child three years old, is from half an ounce to an ounce. There is a composition commonly sold in Philadelphia by the druggists, for the preparation of what is called •' worm tea;" it consists of pink-root, senna, manna and savine, in vary- ing proportions to suit the views of the prescriber. Narcotic effects some- times ensue on the administration of spigelia, which are seldom productive of inconvenience, if the dose of the medicine is not pushed beyond measure. Wormseed, {Chenopodium anthelminticum— Semina,) is regarded as one of our best indigenous anthelmintics, particularly for the lumbrici of children. The seeds reduced to a fine powder, and mixed with melas- ses, or other syrup, are administered in doses of one to two scruples to a child two or three years old. Still more efficacious, at least of more uniform strength, is the essential oil, the dose of which to a child of the age already specified, is from two to five drops well incorporated with sugar or mucilage. In Europe the name wormseed is applied to the Artemesia santonica, a very different plant from that under notice. Pride of China, (Azederach) is used in the southern states, as an anthelmintic. It is administered in the form of decoction, of which a child will take half an ounce every two or three hours till it operates, or night and morning; a cathartic is then to be prescribed. The root of the Punica granatum, or Pomegranate, given in decoction, has acquired reputation for the cure of taenia in adults. It is rarely pre- scribed to children. CONVULSIONS. 165 tomatic, and the idiopathic; though the distinction may not, perhaps, be perfectly philosophical, or accurate. It is for want of some such discrimination, however, that writers have had occasion to observe, that children are much oftener supposed to die of convulsions than they really do : for though a convulsion frequently closes the scene, it has generally risen from the great irritability of their nerves, and violence of the disease under which they have laboured. On the other hand, should it be granted, that the convulsions of children are generally symptomatic, infants may, nevertheless, be said to die of them more frequently than certain authors have allowed ; for where a disease is disposed to produce some violent convulsion, that, though a mere symptom, may carry off the patient: and as it may sometimes be prevented or removed, by its proper remedies, (the disease which occasioned it being at the same time properly treated,) infants may often be recovered, who would otherwise expire in a convulsion fit. Such original cause may be a rash, improperly repelled ; but the source of fits is much oftener seated in the gums, in the time of teething ; or in the first passages, where some undigested matter, or merely pent-up wind, irritates the coats of the intestines, and produces irregular motions throughout the whole nervous system. Zimmerman* relates an instance of this kind, of a child who, during the first months of its life, had frequent attacks of violent convul- sions, which disappeared entirely upon the prohibition of meal pap. Indeed, too much caution can scarcely be given on this head, thick victuals being a very frequent occasion of convulsions in young children. Many infants can bear no kind of thickening in their food; any sort of bread, rusk, &c, disordering their bowels, by occasioning their contents to turn pasty, and cleave to the coats of the intes- tines, whereby a due absorption of the nutritious part of the aliment is prevented, so that children, in the daily habit of taking sufficient food, are nevertheless emaciated.t Weak and tender as they are, they in this state require repeated purges, especially of castor oil, with some light cordial on the intermediate days, and a total absti- nence from farinaceous food. For such children, veal tea, mixed with milk, is amongst the most innocent and nutritious. Any offen- sive load, whether from too great a quantity, or bad quality of the food, by occasioning a faulty secretion, must act like a poison; and that the convulsions are owing to this cause, may often be known by the complaints that have preceded them, such as loathings, cos- tiveness, purging, pale countenance, large belly, and disturbed sleep. If the child is two or three years old, any load at the stomach may * Acta Societatis Zyrick, vol. 2. f It is a very common practice to give arrow root, biscuit powder, or other farinaceous substances, mixed only with water, and sweetened with sugar, as the usual food of infants, and a more improper practice can hardly exist. If the food thus made be very thin, it is not sufficiently nutritive for a healthy infant: if it be made thick, it almost constantly disorders the digestive organs, and occasions disorder in the bowels. The cautious addition of milk, or weak broth, to such farinaceous diet, renders it generally much more wholesome.—S. M. 166 UNDERWOOD ON CHILDREN. be more readily discovered; the tongue will be foul, the skin hot, and the pulse quick and weak. Any matter capable of irritating the nervous system, will induce symptomatic convulsions in some infants, whilst others will with- stand a great deal. For such habits as the former, the cold bath will sometimes be found of a good preventive. Every young infant is, however, more or less, predisposed to this complaint; and the disposition continues throughout childhood, in proportion to the tender age, and delicacy of the habit. The younger and more irritable, therefore, an infant may be, so much the more liable it will be to the symptomatic convulsion, especially from any con- siderable disturbance in the first passages, as was mentioned before; particularly the bad quality, or over-thickness of the breast milk, or other food; and from frights of the wet-nurse. Of this I remember a remarkable instance in a patient of my own, in whose house a visiter suddenly dropped down dead. The mother of the child, which was six months old, was exceedingly alarmed; but her attention being for a moment called off by its crying, she incau- tiously put it to her breast. It was not an hour afterwards that the infant was seized with a fit, and lay either convulsed or coma- tose, without so much as taking the breast, for the space of six-and- thirty hours; though it was at length happily recovered. Among the various causes of convulsions, (though equally an occasion of many other complaints,) may be mentioned that of foul air, and want of cleanliness in the dress, and other accommoda- tions of infants: against which, the lower class of people cannot be cautioned too often, or too earnestly. Such a source of con- vulsions has been peculiarly exemplified in a disorder whose attack being within the first nine days after birth, has been denomi- nated the nine-days' disease. Readers desirous of a full account of it, are referred to a paper of Dr. Clarke, of Dublin, published in the Transactions of the Royal Irish Academy, for the year 1789, by which it appears that Dr. Clarke considered it as altogether an endemic in the Dublin Lymg-in Hospital, where it raged for many years, and carried off some thousand children. But after awhile the Doctor was led to think the disorder might probably be entirely owing to bad air, and want of cleanliness, he was therefore at great pains to remedy these local defects ; and thereby prevented these very frequent attacks of a disease, which, under the former circumstances, none of the physicians had been able to cure, in a single instance. Of the like kind, possibly, was the following somewhat curious case. The infant was seized with fits when scarcely a fortnight old, and had many severe ones for three days ; when, becoming more frequent, I was desired to see it. The child was suckled by its mother; but she being veryjfeeble, and having a little fever at the time, her milk was diminished; which occasioned the child to be fed with bread victuals, especially in the night. This I directed to be changed for cow's milk and gruel: and in a day or two a CONVULSIONS. 167 wet nurse was taken to assist the mother in suckling; who, in consequence of getting rest, was soon able to nourish her infant entirely. The child's stools being thick and pasty, castor oil, and after- wards calomel, were given repeatedly, and the fits became less frequent. In a few days, however, they again became numerous, and afterwards increased to twenty and thirty in twenty-four hours; and some of them were very violent. When the infant was five weeks old, the fits became almost constant: so that, except an hour or two at a time that the child was sleeping, it was seldom five minutes out of a fit, some of which were long, and from which the infant recovered in a kind of struggle, as if it were suffocating: but the greater number of the fits were short and slight. Almost every medicine that I have ever thought useful in fits, was carefully administered for full five weeks that I attended statedly once or oftener every day : particularly oil of amber, musk, and laudanum, were given very freely; and seemed at first to be useful, except that the latter no otherwise abated the fits, than by procuring sleep, from which, however, the child often awoke in a convulsion. Leeches at this time were applied to the temples, and a blister in the direction of the longitudinal sinus. Every means appearing to be in vain, all medicine was given up during the last week of my attendance, except when necessary to obviate costiveness ; but the fits continued exactly the same, and the infant, in a very emaciated state, was expected to expire from one hour to another. The curious part of this case is, that when the child was eight weeks old, it was taken two or three miles into the country, at a time that its fits were almost constant. It left town in the even- ing, and had many fits the ensuing night; but the next day had only two, and from this time they ceased entirely, without recur- ring to the use of any medicine. This sudden change, and speedy entire recovery, can only be attributed, I imagine, to a change of air ; which is the more pro- bable, because the infant was removed from a bad one, the child's parents keeping a liquor house, the lower parts of which had always a very strong and disagreeable smell of ardent spirit. The mother, however, had borne other children in the same house, none of whom had any kind of fit. May it not seem probable, that though such an unwholesome air might not be sufficient to induce convulsions in a healthy child; yet the habit being once formed, such an atmosphere might keep it up in a debilitated infant?* ♦ In another part of Dr. Underwood's Treatise, the following paragraph re- specting this child was inserted : " After this child's health was fully restored, and it was thriving well, it was suddenly seized with a kind of spasm on the chest, and died in two or three seconds of time, in the bar-room of the liquor shop 168 UNDERWOOD ON CHILDREN. Another peculiarity may be noticed in this place, that in some instances of the severest convulsions, one side of the body has been much more affected than the other ; and from which some affeQ- tion of the head is justly suspected, whether primarily or otherwise; therefore bleeding with leeches, and afterwards the application of a blister to the head on the side most affected, has appeared to be useful. The cure of every kind of convulsion will consist, principally, in removing the exciting causes, which must, therefore, be inquired into. If from improper food and indigestion, a gentle emetic should be given. If the irritation be in the bowels, whatever will carry down their acrid contents will cure the convulsions, if admin- istered in time ; and we ought generally to begin with a clyster. If the stools appear very foul after common purges, (in which case there will frequently be some difficulty of breathing,) a few grains of the pulv. e* scammon. cum calomel, may be given with great propriety. But if the disposition to convulsions continues, after the bowels have been properly cleansed, and no new irritation of them may be apprehended, antispasmodics should be adminis- tered ;t such as tinclura fuliginis, castor, spir. cornu cervi, ol. succi?ii rectifi, a drop or two of tinct. opii, or hyosciami, or of ol. rutae ; which, though an obsolete medicine, is a very excellent one ; as likewise, in some instances, is the aq. kali, as advised by Dr. Hargens of Kiel: but to begin with such remedies, as is some- times done, is as hazardous as empirical. The continuance of the convulsions here treated of, frequently depends on the debilitated state, or tender age of the infant. The oil seems to act by invigo- in which it3 parents resided."f And Dr. Underwood in commenting upon it, considered that this case illustrates an observation of Moschion, who directs, that children shall not be exposed to strong odours of any kind, believing them to be always injurious to infants. — S. M. f I speak from my own experience of the efficacy of such remedies, and it may not be amiss to observe, that Harris, who is extremely cautious of giving heating medicines to infants, speaks favourably of some of these. — " Usus horum (says he) haud prosus improbandu3 est, vel in tenellis; nempe quia acidum absorbendi facultate excellunt. Verum summa cautione," &c. —— Great caution is cer- tainly necessary in regard to every medicine prescribed for infants, and especially for those of a heating quality; nevertheless, it may be repeated, that in proportion as the disorders of infants become more attended to, I doubt not, it will appear that, in this country at least, cordial and volatile medicines are frequently both more expedient and useful than many people have imagined.§ [X Compare with an observation of Dr. Marsh, Trans, ofthe Col. of Phys. in Ireland, vol. v. p. 611. In this case reiterated attacks of spasm of the glottis were induced by reiterated exposure to the atmosphere of a room newly painted. — M. H.] § This opinion ofthe advantage to be expected from cordial and volatile medi- cines, seems to be advanced with less limitation than is to be wished. In some ofthe diseases of infants, especially such as are dependent upon what is called a leucophlegmatic temperament, cordials and volatiles may be required ; but in the great majority of infant's diseases, cordials, particularly at the commencement of the complaint, would often prove very injurious. — S. M. CONVULSIONS. 169 rating and restoring a due tone to the alimentary canal, the grand spring of good health. A remedy less common than those above- mentioned, but in some instances given with the best effect, is the sulphate of zinc. This administered in a proper dose usually acts as an emetic, and if it should, must be continued afterwards in smaller doses. Dr. Cooke very strongly recommends a mixture with spermaceti and ol. anisi, and perhaps such a medicine, from its sheathing and warm carminative qualities, may be as proper as many others; though the style of the author is not likely to recom- mend his prescriptions very strongly in the present day.* Rub- bing the spine, the ribs, palms of the hands, and soles of the feet, with oleum succini, or the aqua ammonias, has likewise had a good effect; as well as frictions over the whole body; which, from the consent of parts, seems to afford more benefit than might be imagined. — A very common cause of recurring convulsions, has been said to be worms; and where no other probable one may appear, ought to be suspected; the cure will then depend on the proper treatment of that complaint, the symptoms of which have been already sufficiently pointed out. Should the convulsions arise from the disappearance of a rash, or of a discharge behind the ears, the warm bath, blisters,! gentle purges, or a few drops of the spiritus ammonia, comp. joined with sal. succini, will be proper remedies. But when the cause is unknown, as the approach of small-pox, measles, or other eruptive complaints, bathing the feet in warm water, and throwing up a clyster, are the safest means. If from teething, after gentle evacuations, and other means directed under that head, blisters, oleum rutce, laudanum, or the spiritus aitheris vitriolici comp., and especially lancing the gums, are the grand remedies. And in a view to the latter, it may not be improper in this place, to repeat some of the directions for doing this most salutary operation J more effectually than it usually is, especially in the case of convulsions. It is pretty well known, indeed, that it is not sufficient to cut down * After having looked into almost every work that has fallen in my way, on the subject of infantile diseases, I did not expect to meet with anything of so late a date as 17C9, that could reflect any such disgrace on the praatice of physic, as the very anile performance of this writer. | Blisters may be dressed with the common white cerate, rubbed down till it becomes smooth, and spread upon a double linen cloth, instead ofthe hard plasters commonly made use of, which are v«ry harsh to the tender excoriated surface. — Blisters will sometimes inflame, or be for many weeks indisposed to heal up, in children as well as in adults ; in either of these cases covering the part with a collard or other soft cabbage leaf, (with the hard fibres on the back part cut off, and gently bruised with a kitchen rolling-pin,) will often remove the inflam- mation sooner than any other application. Dusting the surface afterwards with very finely levigated powder of lapis calaminaris will frequently dispose the ill- conditioned ulcer to heal. [Jili.titers, in infants, should never be allowed to remain on longer than the period at which small vesications appear ,- and they should be examined every hour, other- wise gangrene may be induced. They may be then removed, and the part covered with a bread and milk poultice. — M. II.] X See the chapter on Teething. 15 170 UNDERWOOD ON CHILDREN. boldly to the tooth, and liberate it in every part; nor merely to free all such teeth as are manifestly making their way ; but that others also must not be overlooked, which, though less evidently, have oftentimes a share in the mischief. But that which I would here also insist upon, is to repeat the operation frequently, till either the teeth make their way, or the convulsions disappear. And as no harm can arise from the repetition, I wish to enforce the idea very strongly, in every instance, where teething is regarded as the cause of convulsion : a perfect cure of very obstinate fits being some- times effected by lancing the gums for five or six days successively. The obvious reason of this direction is, that the divided parts often tumify, or heal up again, and give rise to sufficient irritation, in certain habits, to keep up convulsions, which, on the other hand, yield upon securing the nervous parts from fresh irritation occa- sioned by the continued protrusion of the teeth. In this view it will sometimes be proper to lance the gum across, as for the double teeth, suggested by Mr. Ware in the case of ophthalmia occasioned by difficult dentition. When repeated convulsions, connected with some disorder in the first passages, and recurring for several months, withstand all the above means of cure, and are suspected to arise from some fault in the brain, they will sometimes disappear of themselves as the infant gets older. At other times, the appearance of some other complaint has put an end to the convulsions ; and, not unfrequently, changing the wet-nurse ; and sometimes even weaning the children, when six or eight months old, has evidently removed the complaint. If convulsions come on without any of the preceding symptoms, they have been generally concluded to be a primary disease, and to proceed immediately from the brain. Some derivation from the head is therefore to be attempted, by bleeding with the lancet, if the child seems able to bear it; or by leeches behind the ears, on the temples, or inside of the arms ; by blisters ; purging; bathing the feet in warm water ; friction of the legs, and rubbing the soles of the feet with aqua ammoniae. If children of two or three years old are subject to slight and frequent fits, issues or setons should be made between the shoulders, or in the neck, and be kept open for a length of time: and in weakly children chalybeate waters may be useful. The idiopathic convulsion, if not removed in a few days, is that from which future bad consequences may sometimes be expected, being followed by a temporary loss either of the sight, or hearing, and sometimes of the intellects. In this case the child has an un- meaning countenance, and a constant stare and motion of the eyes. If water in the head be not particularly suspected, and the common nervous medicines, with purges and blisters, have had no good effect, bleeding* with leeches, and repeated emetics should be had * Bleeding should rather precede than follow these remedies, since there is a much greater probability of relief from bloodletting in the early, than in the after stages of this complaint. Drawing blood by cupping-glasses is generally preferable to the application of leeches. — S. M. CONVULSIONS. 171 recourse to; and if the bowels continue in a good state, the aqua kali ppt. as a diuretic, may be made trial of. Such are the usual remedies to which recourse has been had for the idiopathic convulsion; but of late years I have been led to make trial of musk ; and, from no small success, think I am war- ranted in strongly recommending it to the notice of physicians. And I am the rather led to this, because I conceive it to have been long out of repute as a remedy for children, and probably one that has never had a proper trial in their nervous affections; as in that case, we should expect it would have been noticed more particu- larly by the older writers.* In some of the worst cases, however, of long-continued convul- sions and fits, apparently truly epileptic, not to be attributed to the usual causes of infantile irritation ; as well as where all the customary remedies have been previously and unsuccessfully tried, a free exhibition of musk has restored children to health. And this not only where the long continuance of the fits has led good physicians to pronounce them idiopathic; but where the convul- sions have also induced total blindness, or otherwise deranged the faculties, for several months. At least, I may assert that an imme- diate abatement of the fits has followed the exhibition of this medicine, and, in the end, the removal of all its ill consequences. But when the idiopathic convulsion attacks very young children, it generally terminates very soon, sometimes, indeed, instantly; and in many is fatal before any means can be made use of; espe- cially in the case of hydrocephalus. I have, however, often imagined, that we are frequently mistaken in regard to such hasty deaths, and that when convulsions prove so suddenly fatal, they are more commonly symptomatic, and are occasioned much oftener than is suspected by over-feeding. I have known some of the largest and finest infants I have ever seen, die suddenly in the month, immediately after the nurse had boasted of their having eaten three boats full of victuals !!! In this view of the disease, a few words more may not be wholly unnecessary, especially as they will hold out much comfort in regard to this alarming complaint; by which, I am, however, assured, many infants have perished merely from its not being properly distinguished. For though, indeed, all convulsion fits are in their appearance exceedingly alarming, yet under proper treat- ment they are much less frequently fatal than is commonly ima- * It is not my intention, however, to assert that musk, has, at no time, been frequently administered in these cases; though it is probable not very lately. I am not ignorant that many valuable medicines have long been neglected, in favour of others of the same class, and been taken up again at a future age. Practitioners, nevertheless, ought to state what has been their own experience of any medicine, in preference to others, after a fair trial of several, in particular complaints. Dr. W. Heberden, however, though he acknowledges this drug to be frequently useful, conceives I have extolled it too much ; but if I have spoken • from personal experience, it is hoped I may be justified in stating it. 172 UNDERWOOD ON CHILDREN. gined, however often they may recur ;* neither is the frequency of their returns during infancy, nor the long continuance of such a disposition, an indication of future evils, if the fits themselves be of the kind here supposed.t But though experience warrants my speaking with confidence on this head, with a view to prevent any unnecessary distress, yet would I by no means put the practitioner off his guard; since the recovery, in many cases, depends so en- tirely upon an expeditious use of the remedy, that even the time lost in sending abroad for a remedy may be fatal to the infant. Fits of this kind are, indeed, pretty generally known to arise from irritating matter confined in the first passages, as has been already explained ; but I believe it is not so generally understood, how often such matters are lodged in the stomach, (perhaps the pylorus itself,) or very low down in the rectum. Instances of the latter are not want- ing, wherein the hardened faeces have lain so low, as to dilate the sphincter ani sufficiently to expose them to view, and yet the infant been dead before a clyster could be procured from a neighbouring apothecary's; whereas such fits cease immediately after a plenti- ful evacuation from the bowels, artificially induced : so also I have seen an infant in the month, lying torpid for an hour together, in a kind of fit, and apparently in the very article of death, brought out of it entirely, after a large and spontaneous discharge of thick fseces. In like manner sudden death has taken place when the load has been in the stomach ; whilst other children have been saved by spontaneously throwing it up. Whether, in the former case, the nox- ious irritation be in the rectum, which may possibly be doubted, or, from the obstruction there, acrid matter be confined higher up, is not of any particular importance ; the confined fseces below, and their timely removal, being, alike, the certain occasion and remedy of the evil. After what has been said, it would be scarcely necessary to point out the remedies in a formal way, but for the sake of direct- ing the most expeditious manner of applying them. In the first instance, the obvious means are a soap clyster, with two or more tea-spoonfuls of salt, (such articles being always at' hand,) and afterwards administering one or other of the purges formerly direct- ed ; which it may often be necessary to repeat for some days, per- haps with an interval between. But when an infant falls suddenly into a convulsion very soon after sucking or feeding, especially if on anything actually improper, and the bowels have been for some days in an orderly sate, it may reasonably be presumed that the irritation is in the stomach, especially if there be an un- usual paleness of the countenance, indicating sickness; or, on the * The account in the yearly bills of mortality is especially erroneous in regard to this complaint, and has, perhaps, added to the alarm which the appearance of a convulsion universally occasions. t The above observation is, I believe, strictly true in regard to such kind of fits; and though in some others, as hinted before, the intellects have appeared afterwards to be impaired, yet are the instances so very few, that there is, upon the whole, little room for alarm in the apprehension of such consequences. CONVULSIONS. 173 contrary, any considerable blackness, with symptoms of suffocation ; which I think do not come so soon when the obstruction is in the bowels. And it should here be remarked, that it is not necessary, that the load in the stomach should be considerable in quantity in order to induce such sudden and alarming convulsions ; it is suffi- cient that the stomach be really oppressed by it to a certain degree; nor does it always appear to arise so much from an oppressive abundance, as from a small piece of undigested food, irritating, and perhaps confined, in the pylorus, (o) In the case here described, it would be improper to think of a formal emetic, at least without making trial of some more expedi- tious means, such as irritating the pharynx with the finger, or a feather, or forcing in the smoke of tobacco, if that be at hand ; (the latter of which should, however, be cautiously done;) either of which often instantly produces vomiting, and puts an end to the fit. To this end, the child should be supported by a hand, placed under its stomach and belly, whilst the feather or other means are made use of; in which position the infant will be made to vomit more readily, and with less straining, than in any other. — It is hoped that the importance of the subject, as well as the very frequent success attending the plans last recommended, under the most alarming appearances, may be thought an apology for the length of this chap- ter, as well as the sort of repetitions made use of. It is further to be noted, that symptomatic convulsions are some- times the effect of a salutary effect of nature, to produce a crisis in some disease the child labours under : in whieh case great caution should be used not to be over officious ; bathing the feet in warm water, however, as mentioned before, will be perfectly safe, and generally useful. — Having spoken of opiates, I shall just observe, that though they are often very serviceable, when judiciously prescribed, they become very hurtful if improperly administered. They will, however, always be safe, where convulsions continue after the first exciting cause has been removed; or where the convulsions are so violent as to become an obstacle to administering proper remedies; or when the original complaint is of a spasmodic nature; and, perhaps, particularly where the hands are constantly (o) When the child is old enough to have been allowed other food besides that from the breast, the physician called in suddenly to prescribe for con- vulsions, and without prior knowledge of the case or of the character of the nurse, or ofthe common sense ofthe mother, may generally suspect that some indigestible substance has found its way into the stomach. Sometimes he will elicit, by inquiry, an acknowledgment that the little sufferer had eaten, or swallowed without eating, some resins, or a piece of apple, or of meat, &c. Hence, he would see at once the propriety, indeed the urgent necessity, of emptying the stomach by means of an emetic, such as of mustard, salt and water, ipecacuanha, or tartar emetic, if the more simple means indicated in the text fail to bring about the de- sired result. 15* 174 UNDERWOOD ON CHILDREN. clinched,and the thumbs drawn down; in which case, (after pro- perly clearing the primae viae,) infants will often be benefited by large and repeated doses. When arising from debility and languor, the tinct. valer. volat. administered in some generous white-wine, has been found a successful remedy. Amongst the latter remedies, fixed alkalies, particularly the carbonates of soda and potassa, have been recommended, and sometimes the volatile alkali, and it should seem with success. When convulsions occur many times in a day, it is of importance to attend to the distance of the paroxysms; from which a much better indication may be had of their immediate danger, than from the forcible contraction of the muscles during the fit. For where the intervals are short, though the fit itself be not long, nor violent, the disease is generally more dangerous than where severe parox- ysms are attended with long intervals. [Instead of the division of convulsions into the idiopathic and symptomatic, I would propose that they should be viewed as re- sulting from disease of the nervous centres, or in parts eccentric in the nervous system. The former class would comprise all diseases of the brain and spinal marrow, complicated with convulsion. The latter, all those convulsive diseases which arise from teeth-* ing, indigestion, and deranged bowels, and which probably act through the fifth pair, the eighth pair, and the spinal nerves respec- tively, and constitute a part of a more comprehensive class of dis- eases, embracing affections of a series of nerves of what I have designated the reflex function. See p. 16 and p. 108. — M. H.] PARALYSIS, OR PALSY. Paralysis is a more common disorder in infants and young chil- dren, than writers seem to have imagined : it is confined to no age, (having been seen as early as the third day after birth,) and attacks children in very different degrees, in the manner it does adult persons. It, accordingly, sometimes seizes the upper, and some- times the lower, extremities ; in some instances, it takes away the entire use ofthe limbs it has attacked, and in others, only weakens them. Sometimes the speech is very much affected, and at others not at all; the intellect is also greatly impaired in some instances, and in others is only torpid; for though children may be dull and heavy, like other paralytics, yet, when roused, their imagination is found to be fully awake to the common objects around them. The palsy more commonly appears in the form of hemiplegia: but if it be neither fatal, nor soon cured, it is often found to steal imperceptibly upon the other side of the body. In one instance, I was witness to the paralytic affection quitting one side, to seize the other, only two days before the child died. In any case, the treatment of palsy is much the same in young subjects as in adults; and being usually attended with costiveness, PARALYSIS, OR PALSY. 175 calls for brisk purges in the first instance, and a repetition of open- ing medicines throughout the course of the complaint. And, indeed, if cathartics and blisters do not soon afford relief, the disorder usually becomes chronical, and the child sinks gradually in the course of a few months, or drags on a miserable life of ten or twelve years, with more or less debility of the arm or legs; but very rarely arrives at manhood. Indeed, the causes of palsy, particularly in young people, who are still growing, are so numer- ous, and are often so entirely out of the reach of art, as well from their nature as their seat, being frequently in the nerves themselves, or the brain, that such an event cannot be wondered at. But where no morbid change of parts has taken place, perhaps infants and young children are oftener perfectly cured than those more advanced in years, by the mere exhibition of two or three brisk purges, whereof calomel often forms a necessary part, as the palsy frequently originates from foul matters in the first passages. After purging, blisters should be applied, and if no fever attends, nervous medicines be administered, such as valerian, castor, am- monia praeparata, and the spiritus aetheris vitriolici compositus. In some instances, the bark and steel have proved useful; or frictions with flannel and aromatics, or ether, and the use of the waters at Bath; and as frequently as any other mean, electricity, especially, if instead of giving shocks, the electric aura only be applied, or sparks drawn from the body, seated in the insulating chair. In regard to electricity, it has been thought, that it is much more likely to succeed, if had recourse to previous to the application of blisters. If the head should be much affected, a small blister, or leeches applied to the temples, may he proper in certain habits. When the palsy becomes chronical, more general remedies will be called for, according to the particular symptoms that may occur ; but more commonly, remedies of the warmer class. The palsy is sometimes occasioned or succeeded by water in the head; and in the former case, the sutures of the skull being generally still open, and allowing of distension, the symptoms of compressed brain will not appear so soon as they otherwise would. In the suspicion of hydrocephalus, mercury and diuretic medi cines may be made use of; though, it is to be feared, with but little prospect of success, when the original disease has proceeded thus far. I have noticed a few instances of a partial paralysis of one, or all the extremities; but this has always given way very soon. Besides teething infants, whom it has been said to attack, I have seen it in others who are older, and the finest children, and it is then generally attended with a foul state of the bowels. In any case, the only remedies I have found necessary have been calomel, or some other purgative; sometimes an emetic, aromatics and bitters, and volatile embrocation to the limbs. Electricity has been advised ; and if the complaint should not otherwise yield, may as 176 UNDERWOOD ON CHILDREN. properly be had recourse to in this, as the former instances. If these means should fail, the whole course of the spine should be carefully examined; and if any curvature be discovered, recourse must be had to one or other of the means recommended for the paralysis of the lower extremities; and it may be remarked here, that the seat of the disease, having been high up in the neck, close to the head, has sometimes been overlooked.(p) SKIN-BOUND. This being a spasmodic affection, and sometimes attended with the tetanus, may be here noticed, as introductory to that convulsion. It is a disorder but little known either to ancient or modern writers, and has been less understood ; being only twice publicly noticed, that I know of, until a few years ago. The one, at the beginning of the last century, in a still-born infant, in the hospital at Stock- holm, and the other about forty years ago, in a Neapolitan girl of seventeen years of age, in the Royal Hospital at Naples; the suc- cessful treatment of whom, I think, may throw some light on this disease, hitherto so little known. The former is accurately described by Uzenbezius, and recorded in Schurigii Embryologia, (de fietu frigido et rigido,*) but without adverting at all to its treatment. The case, as I since find, is transcribed into the Ephemerid. Academ. Naturae Curiosor. Cent. ix. The above is related in a manner importing it to be an uncom- mon occurrence, and the disease at that time little, if at all, known; and though recorded in two distinct works (the latter of which is rather consulted than regularly perused), the case seems to have been generally overlooked, and consequently the true nature of the disease remained nearly in its original obscurity. It was, indeed, not till a twelvemonth after my short account of it appeared, that this disorder began to engage the attention ofthe French physicians, in consequence of Monsieur Andrij being called upon to take the charge of the Hospice des Enfans Trouves, at Paris. The disease, indeed, had been often seen both in that hospital and at the Hotel * The midwife is reported to have said, that this infant, though born alive, felt as intensely cold and rigid when it came into the world, as a piece of ice. How this might be, 1 leave to the Academy of the curious to determine. (p) A morbid condition of the spine may exist without curvature, but be manifested by great tenderness of a particular portion. In such a case, leeches on each side ofthe vertebrae, and subsequently small blisters, are called for. If there be irtitatiou in the intercostal spaces near the spine, the same remedies will be of service ; or in place of the blisters, irritation of the skin may be kept up by croton oil, tartar emetic, &c. Of the internal remedies, iodine and strychnia have been prescribed with advantage in paralysis. In the case of a child, great caution ought to be exercised in the use of the strychnia, or of nux vomica, if the latter be preferred. SKIN-BOUND. 177 Dieu, but having always proved fatal, little attention had been for a long time paid to it, till Dr. Andrij was elected physician to the first-mentioned charity; since which time, no pains seem to have been spared in the investigation of it; and the subject having since been taken up by the Royal Society of Medicine, it is hoped ad- ditional light will be thrown upon it. That the present account of the disease may be clearly stated, in the manner I had long ago intended, and had actually drawn up, before I was favoured with some further description of it by Dr. Andrij, I shall first consider it as it has appeared in this country. It has, indeed, been much less common in this kingdom than on the continent, but is equally an hospital disease, and seldom met with but accompanied with some bowel complaint, and still more rarely appearing at the birth. It was first spoken of in public, I believe, by my friend Dr. Denman, when a teacher of midwifery, and physician to the Middlesex Hospital; whose unwearied atten- tion to it there, though not with all the desired effect, does him more honour than could have been derived from the most suc- cessful treatment of a disease less fatal than this has proved, wherever it has appeared. The British Lying-in Hospital has been very little infested with it: possibly, by being solely appropriated to the reception of pregnant women, which the Middlesex* is not, the air may, on that account, be more pure and salutary. "The following symptoms (Dr. Denman observes) have been considered as pathognomonic, or characteristic of the disease : 1st. The skin is always of a yellowish-white colour, giving the idea of soft wax. 2d. The feel of the skin and flesh is hard and resisting, but not cedematous.t 3d. The cellular membrane is fixed in such a manner, that the skin will not slide over the subjacent muscles; not even on the back of the hands, where it is usually very loose and pliable. 4th. This stricture often extends over the whole body ; but the skin is peculiarly rigid in the parts about the face, and on the ex- tremities. 5th. The child is always cold. 6th. The infant makes a peculiar kind of moaning noise, which is often very feeble, and never cries like other children. 7th. Whatever number of days such children may survive, they always have the appearance of being dying." This disorder commences at no regular period, unless where it appears as an original disease, and in that case more commonly within the first ten days after birth: a few children, it has been said, have been born with it, and such have never survived many * Since this was written, the reception of lying-in women into the Middlesex Hospital has been altogether discontinued. — S. M. f To me the appearance and feel ofthe skin have exactly resembled that of a person who has died during a very hard frost. 178 UNDERWOOD ON CHILDREN. days. Whenever it takes place, it attacks several infants within a short time; and chiefly those who may be in the last stage of obstinate bowel complaints, in which the stools are of a waxey or clayey consistence. I have seen the rigidity extending beyond the cellular membrane, so as to affect the muscles, but only those ofthe lower jaw, which became perfectly rigid; but this spasm, or tetanus, does not seem to be a frequent symptom, nor do convulsions extend to the extre- mities, as they are found to do in France ; nor have I discovered any extravasation in the cellular membrane after death, reported to be constantly met with in that country. Moreover, in no instance, that I have heard of, has the disease been attended with the erysi- pelatous affections uniformly noticed there. The cause of this dreadful complaint, when either congenite, or evidently supervenient to disorders of the first passages, seems to me to be a spasm depending very much upon a certain morbid state of those parts, and with which the skin is well known to have a peculiar sympathy. But when, though an original disease, it does not take place till some days after birth, which, I believe, is rarely the case except in large hospitals, and other crowded apartments, the irritating cause, in such instances, is probably seated in the sebaceous glands; and the disease seems to be an endemic of cer- tain seasons, arising from that unwholesome air to which such places are peculiarly liable. The means of cure in this country, (where, it has been said, the disorder is more simple,) have been different from those that have lately been found successful in France ; but instances of recovery have been very few in either. When the disorder was first noticed, its treatment was confined to a strict attention to the state of the bowels, and rendering the several medicines very warm by means of the compound spirit of ammonia, which was administered every four or six hours ; and was the only plan attended with any suc- cess. Together with this, I after some time directed the frequent use of a warm bath, and chafing the whole body afterwards with warm flannel; means which have since appeared to have been attended with the first instances of success in France, as will be noticed below. As the disease raging so much in France differs in many respects from ours, it is very doubtful how far the plan of cure adopted there may be applicable in this country, and my own experience has hitherto not gone beyond the means I have mentioned ; but I would venture to suggest, that, in many cases, trial might be safely and properly made, not only of carminative clysters, but also of a grain of calomel, previous to the infant being put in a vapour bath; and after a sufficient number of stools shall have been procured by these means, exhibiting other volatile and cordial remedies, besides the spirit of ammonia; as well as antispasmodics of different kinds. After the description given of this disorder as it appears in SKIN-BOUND. 179 London, little more will be necessary, I apprehend, than to select the circumstances in which that in France is found to differ. It has already been said, that it is more frequently attended with tetanus, and never occurs without those appearances mentioned under the article Infantile Erysipelas, especially the redness and hardness about the pubes, accompanied further with tumour, and redness of the soles of the feet. But these parts, it seems, though of a purple red, are intensely cold; very rarely suppurate, but sometimes mortify.* In one instance, however, the infant was not cold,t but, on the contrary, exceedingly hot. The legs, thighs, and soles of the feet were red and hard; but no mention being made of a general tightness of the skin, it is probable this child was affected only with the infantile erysipelas which appears amongst us. Besides the above variations, the infants are said to swallow with extreme pain ; the extremities, especially the legs, are much enlarged, and attended with a serous effusion in the cellular mem- brane, which we have not hitherto noticed; and the disorder is said to rage most in the hotter months. One instance, however, of difficulty of swallowing, fell under my notice ; the child, at least, refused the breast, and swallowed unwillingly whatever was offered it; but this infant scarcely survived the attack fifteen hours. — In France, it is further observed, that the infants die about the third or fourth day, or at furthest, on the seventh from the birth. It is probable, there is another and very material variation, in respect to the degree of stricture and immobility of the skin, which is not clearly expressed to be either so considerable or extensive, as in the disease I have been describing; but is more confined to those parts which become red and tumid. But in the instance recorded by Schurigius it was clearly otherwise, the infant being said to feel, from head to foot, like a piece of flesh dried in the smoke. This child survived a complete day, during which time it took no sort of nourishment, and never cried, nor made any kind of noise. Upon examining a great number of dead bodies at the Enfans Trouves, the serous extravasation is constantly met with; is of a deep yellow colour and fluid, but coagulates with heat; the fat is peculiarly solid; the glands and lymphatics, especially those of the mesentery, are found stuffed, and the liver uncommonly large, with a great quantity of deep-coloured bile in the gall-bladder; and the lungs are said to be loaded with blood, as well as to contain an unusual quantity of air. The supposed cause of this disease amongst them seems to me * This is said to be the case in four or five children out of twenty, all of whom are found to die in a few hours after the gangrene has taken place; and become so putrid, that by the next day the skin separates from every part ofthe body, 90 as to adhere to the hands of those who have occasion to touch them. f One instance of this kind also occurred at the British Lying-in Hospital; and in this case there was likewise tumour, hardness, and redness about the pubes, and different parts ofthe extremities. 180 UNDERWOOD ON CHILDREN. but ill accounted for; the complaint being attributed to the improper diet ofthe mother or her infant; or to cold which it has taken at the birth: whereas the coldness and rigidity of the skin seem to be but mere symptoms, and not the disease; especially as their children, like ours, are but rarely attacked from the birth. The disease appears to be a true endemic, arising from foul air, espe- cially as it is found only to attack the poor, and particularly to infest the two large hospitals that are crowded above all others, and receive the lowest and most wretched part of them; of whose new-born children, it is supposed, one out of twenty is visited with this disease.^) It has been hinted that, for a long while, little attention was paid to this complaint, on account of its constant fatality, six hundred infants sinking under it every year, in a single hospital; about four hundred of which are born in the Hotel-Dieu. But since Dr. Andrij's election to the Hospice des Infans Trouvis, various means have been attempted both by himself and his col- league, Mr. Auvety; and amongst other means, the warm bath, (q) Skin-Bound is properly an infiltration of the cellular tissue, with often a discoloration of the skin, and other symptoms of jaundice. The tightness of the skin and apparent hardness of the cellular tissue, which are represented to be pathognomonic symptoms of the disease, are in fact only caused by the pressure from the infiltrated serum dis- tending the spaces of the cellular tissue, and condensing in conse- quence the filamentous portion of it. If (says M. Billard) an incision be made in the infiltrated limbs of a child, the slightest pressure will cause an abundant discharge of serous drops, after which the hitherto engorged, distended, and hardened cellular tissue returns to its softened state, and the limbs are no longer hard. The writer just quoted tells us, that this oedema of the cellular tissue is more common in winter than in summer, and more frequent in infants soon after birth (from the first to the eighth day) than afterwards. The predisposing causes are, 1 st, the natural feebleness of the child ; 2d, a state of general and congenital plethora ; 3d, a superabundance of venous blood in the tissues ; 4th, a dry state of the skin before the exfoliation of the epidermis. The immediate causes are, 1st, an obstruction in the course of the blood, resulting from its quantity in the circulating apparatus ; 2d, its engorgement in the cellular tissue, to which it furnishes too much ma- terials for secretion ; 3d, and lastly, the action of external agents on the skin, which, without condensing the serous fluid, as has been asserted, are yet capable of suspending the cutaneous transpiration, and thus favour the accumulation of serosity in the cellular tissue. The curative indications deduced from the above views, are, 1st, to relieve, by suitable evacuations, the general plethora; 2d, to excite the skin by irritating frictions, by the use of woollen garments next to the skin, and the adoption of all means proper to establish cutaneous trans- piration. The vapour bath has not, according to the experience of M. Baron, so good an effect as frictions and the application of woollen to the skin. M. Billard has often seen the latter to succeed perfectly.— (Stewart's Translation, p. 154-5.) TETANUS, OR LOCKED-JAW. 181 which appears to have saved the first child that was known to re- cover. Trial has since been made of blisters to the extremities, which succeeded also in the very first instance, as well as since in several others: so that, in the last year, they are reported to have saved five infants out of every hundred, more than in the preceding one. Monsieur Souville, surgeon to the Military Hospital at Calais, has also given some account of this disease in the Journal de Medecine, under the name of JEdematie Concrete, and observes, that it is a very common disorder in the provinces as well as. in Paris. Under his direction, likewise, a warm, or rather vapour bath, succeeded in the only instance wherein he had made trial of it. And this part of the treatment agrees with the account of the Neapolitan girl to which I have alluded, as well as with the result of our further experience at the British Lying-in Hospital; where the warm bath, in one instance, however, was thought to hasten the death of the infant. The former was read before the Royal Society, May 16th, 1754. The disease was in this young woman exceedingly severe, the skin being so very rigid over the whole body, from head to foot, that she could scarcely move her eyelids, or open her mouth ; nor could she move any of her limbs without pain, as well as difficulty, though the rigidity was evidently in the skin and adipose mem- brane, and not in the muscles. It may be sufficient to say, that the patient recovered, but not under a twelvemonth. The means had recourse to were the warm, and vapour bath, mercury, sarsaparilla, and friction of the skin. The warm-bath gave her so great pain (as it was supposed, from the weight ofthe fluid) that after a few trials, she fell into convul- sions, through her dread of it, as they were about to put her into it But the warm vapour very soon afforded relief by relaxing the skin, yet very little or no perspiration was produced ; nor had she ever had the least from the commencement of the disease ; but it was after the vapour-bath considerably promoted by the internal exhibition of twelve grains of quicksilver every day, with a decoc- tion of sarsaparilla, assisted by constant warm air, and frictions of the limbs. How far any part, or the whole of this treatment, may be suc- cessful in infants, to whom the complaint seems to be confined in this country, experience only can prove ; but it is presumed, that the means are worthy of trial. TETANUS, OR LOCKED-JAW. The Tetanus* of infants is an equally fatal complaint, and in this country nearly as little known as the foregoing. It is either idiopa- * This is the species which nosologists have termed, Trismus maxilla? infe- rioris rigiditas spastica. Species prima. Trismus nascentium infantes intra duas primas a nativitate septimanas corripiens. — Vide Cullen, G lxix 16 182 UNDERWOOD ON CHILDREN. thic or symptomatic; which distinction is of more importance in hot climates, where the latter is always found to be incurable. In some instances, it has been confined to the jaw only, as in Jamaica; in others, it has been attended with contraction and rigidity of other muscles of the face, and a peculiar fixedness of its features. Some- times the rigidity has extended to the neck ; and in one instance so completely over the whole body, that the limbs of the infant could not be bent so as to place it advantageously in a vessel, somewhat too small, appropriated to a warm bath. In such instances of tetanus as I have met with, the attack has not been earlier than the sixth, nor later than the ninth day from the birth,* and as far as I could learn, the infants had not been costive, (which Dr. Evans reports to be usually the case in Jamaica,) nor apparently unhealthy; some, I remember, were remarkably strong and lusty children. It seems somewhat to differ, therefore, from the disease termed Jaw-fallen, in the West Indies ; and in one instance appeared to have some resemblance to the catalepsy. The rigidity has stolen on in a more gradual way in some instances than in others, but has always been very great as far as it extended, from the moment it has been discovered; so that in instances where the mouth has continued sufficiently open to admit my finger, I could not thereby depress the jaw. In some, the eyes have been bloated, and the whole countenance much swollen. The cause of this complaint has been differently conceived of. Dr. Evans, who has been very conversant with it, attributes it to costiveness, and thinks he has greatly prevented its frequency amongst the negro infants, by purging them from the birth. Dr. Bartram, of Philadelphia,! attributes this fatal disease to a want of swathing, or proper bandage to new-born infants, and to the appli- cation of scorched linen to the navel; but his reasoning, to say the least of it, appears to be very inconclusive. It has also been attributed to the cord being divided by instruments not sufficiently sharp. But the cause has at length been clearly ascertained, and happily its prevention, by Dr. James Clark,J who, perceiving, that those houses were free from this disease, in which there were no fires, very soon demonstrated it to be owing to the smoke from burning wood ; the negro-houses having no chimneys to carry it off. It does not in this country seem to arise from constipation, or neglect of purging off the meconium, and much less for want of swathing; but is owing (as I have always stated, and has since been demonstrated, as above remarked) to a certain state of the air; and the more so, as the disease appeared only once in the * In the West Indies also never later than the ninth day. — (Dr. James Clark.) In France, however, it is said to attack much older children, though rarely after two years of age. — (Memoire de la Societe Royale de Medecine, Ann. 1787 and 8.) f See the Transactions of the College of Physicians at Philadelphia. I See his Treatise on the Yellow Fever, &c. 1797. EPILEPTIC-FITS. 183 British Lying-in Hospital during a great number of years, and then attacked several infants in a short time. — It has appeared again, however, in six instances since the above account of it was given in former editions. In older children, as in adults, it may arise from various sources of irritation, and particularly from worms ; especially, it is said, from a certain species of taenia. The remedies attempted at the hospital were the warm bath; fomentations to the rigid parts; frictions with oil and camphire, and Bates's anodyne balsam ; blisters behind the ears, and to the nape of the neck; and assafoetida, opium, calomel, the bark, and aromatic confection, have been given internally. It remains, however, to make trial of more cordial and tonic remedies, as recommended by physicians in North America, where the disease is more common than it is here : such are the oleum succini, musk, wine, and the cold bath ; though concerning the latter, writers differ, Dr. Clark asserting, that it has in no instance succeeded. One infant, in whom the complaint was confined to the jaw, and who had less rigidity than any of the others, never looked ill, and had no convulsions in its limbs, died rather sooner than the rest, excepting one, which was a remarkably large and healthy infant: this child, after being five minutes in a tepid bath of salt and water, fell into a more profuse sweat than I had ever noticed in any young infant, and died in a few hours afterwards, and only twenty-four from the attack. I have known only one child survive the third day, and that was not seized till the ninth from its birth, and at the end of the third week seemed to be recovering; but it had never been able to take the breast after the attack, and died when six weeks old, though, possibly, not altogether from this complaint. EPILEPTIC-FITS. This and some of the following complaints, as well as the two or three immediately preceding, which relate, some to the more early, and the others to later periods of childhood, are noticed suc- cessively in this place, on account of their falling under the general class of convulsions; and it is presumed less improperly, on the whole, than ranking them according to their importance, or the different periods of time in which they might take place. The state of dentition, as so materially connected with nervous affections, will then be considered, which will lead to pyrexiae, in the different forms they assume in children. In regard to epilepsy, very few words, however, may suffice, as it is either pretty easily cured, or usually continues through life : and is too well known to require a particular description. An account of the various precurrent symptoms would be equally use- less. — It may just be noticed, that the patient falls suddenly to the ground, and sometimes without any perceptible warning, or at all sufficient to secure him from injury; and is usually much convulsed, 184 UNDERWOOD ON CHILDREN. especially on coming out of the fit, but frequently retains his senses the whole time.* The means of cure must be adapted to the different causes of the complaint. It sometimes takes its rise merely from foul bowels ; and certainly more commonly attacks children of a costive habit of body : it should then be treated agreeably to the directions already given in such cases, and especially with active and mer- curial purges; after which, the cortex peruv. sulphas zinci, chaly- beates, and other tonic remedies, may be serviceable ; and espe- cially sea-bathing. In other instances, especially in more advanced life, and towards the time of puberty, the epilepsy seems to be owing rather to a more sensibly nervous irritation. In such cases, blisters to the back of the neck may be useful; and I have expe- rienced much benefit from large doses of the powder of valerian, and from opium; and in one instance, from an infusion of savine, fennel seeds, and juniper berries ; but I could never entirely con- quer the complaint by these means, when become chronical: but the oleum succini has, in several instances, perfected a cure in young subjects; and where that has failed, I have succeeded with musk. In the worst cases I ever met with, in which the fits were very long and violent, and sometimes to the number of twenty or thirty in a day, and the disorder of many years standing, electricity has very soon rendered them weaker, reduced their number to three or four in a day, and gradually to one in six weeks: but has not entirely removed them. In such obstinate cases, it is generally supposed that the brain is affected by some local or permanent cause, and a perfect cure is consequently despaired of: though I have known the fits abate greatly after having continued for twenty years,and the subject of them afterwards become the mother of several children. But parturition, as well as whatever else may tend to debilitate the system, I have always found increase the number of the fits for a certain time. When this disease has attacked children of five or six years of age, and where no treatment has been serviceable, the complaint has very frequently disappeared suddenly about the time of puberty, and sometimes a year or two sooner. Where it does not, it will probably continue through life, and now and then prove suddenly fatal. Dr. John Wilson, of Spalding, has lately strongly recommended * I have never known an instance of epilepsy in which the patient retained his senses during the fit; such an occurrence must, therefore, I think, be very unfrequent. — S. M. (r) (r) However uncommon, I have seen in a patient, an adult, under my care, this retention of his senses during an epilectic paroxysm. It was the last severe one he had : since then, during a period of nine months, he has been exempt from an attack of the disease. EPILEPTIC-FITS. 1Q5 the internal use of the argentum nitratum, in doses of gr. ijss. three times a day. And iu the Medical and Chirurgical Journal, edited by Professor Hufeland, is an account of a cure effected in a case of three years standing, by the cuprum ammoniatum, given in the dose of half a grain a day, and increased to five grains daily. When the patient can foretell the approach of an attack, it has been recommended to exhibit an emetic of blue vitriol, as soon as the patient's feelings announce the approaching paroxysm. The curative powers of the two former of these remedies, however, have been disputed by Dr. J. Magennis, of Plymouth.* In the late Dr. Clarke's last publication on hydrocephalus, in- flammations of the brain, and epilepsy, are some good practical observations that ought not to be withheld from the readers of this work. The intervals of the paroxysms, the Doctor observes, may be increased, at least, by a spare diet, and avoiding all animal food and fermented liquors. He also very properly recommends the sleeping with the head very much elevated ; early rising ; the hair being cut short, and the head being kept cold, and the rest of the body very warm, carefully avoiding its exposure to cold ; and a constant free course of the bowels; also setons and issues; the daily use of a tepid bath, from 80 to 94 degrees, at first for five minutes, and gradually to an hour at a time, if it should not relax. He advises ant-acids, where acidity prevails, and often bitters, but forbids steel. Emetics of zinc sulph. with ipecacuanha, he thinks often very useful. In plethoric patients with torpor,, cupping or leeches, and V. S. of the jugular veins —he is averse from cold bathings. Upon examining the brain after death, I have sometimes found water in the ventricles, and at others, a small point of bone, as sharp as a needle, standing out from the internal part of the os frontis, or from the cella turcica, (of which Boerhaave and others have recorded several instances,) and which was, doubtless, the true cause of the disease.(s) [Epilepsy sometimes depends upon disease of the brain or spi- nal marrow, the nervous centres ; and sometimes upon sources of irritation distant from them, — as teething, indigestion, constipa- tion. The former are far less curable than the latter, and the dis- tinction should be carefully made before the treatment is adopted. In epilepsy of eccentric origin, the removal of the irritation, the regulation of the diet, exercise, hours, and air, and tonic remedies, sometimes succeed in the most satisfactory manner; fits may occur, however, during the general amendment. — M. H.] * See Medical and Physical Journal, vol. iv. No. 21. (s) Oil of turpentine and nitrate of silver are the two remedies most entitled to confidence in the long list of those recorded for the cure of epilepsy. But most reliance is to be placed on the general treatment, the chief aid to which will be small blisters along the spine, or irritation by tartar emetic or croton oil to the same parts. 16* 186 UNDERWOOD ON CHILDREN. CHOREA SANCTI VITI. I shall be very brief, also, on this untoward disorder, which is equally well known : and though not often fatal, is, like the former, I believe, rarely cured but in young subjects. Worms, and other foulness of the bowels in children, are fre- quent causes of this strange convulsion : in which different parts, and especially the extremities, are put into continual motion, giving the patient a very awkward appearance, particularly in his walk. If the first passages are the seat of irritation, the complaint must be treated in the manner noticed under the preceding article : and indeed, in most cases, the cure should be begun by administering aloetic, or mercurial purges. But should the disorder appear to be owing rather to relaxation, as it sometimes is, the cortex peru- vianas, chalybeates, and other tonics; especially the vitriolum album, and sea-bathing, are indicated, and are very frequently successful. I have also known it immediately yield to electricity : but, in this case, it has been attended with other symptoms of palsy, which have come on suddenly. Electricity, also, proved useful in a very extraordinary instance ; but the eomplaint return- ing, yielded afterwards to a perpetual blister on the os saerum, directed by Dr. Delarive, of the Public Dispensary. The pilulce cupri were administered at the same time, in the dose of gr. ss ; but no benefit was perceived till the blister was applied. Dry- cupping has also been thought useful. Dr. Hamilton, in his treatise on the disorders of infants, observes, that his father, as well as Dr. Parr, of Exeter, adopted the idea of irritation of the stomach and bowels long continued, producing this disorder in its chronic form ; and that Dr. Parr has succeeded in fifty-nine out of sixty cases in the cure of it, by giving repeated and powerful purgatives. [Dr. Hamilton, of Edinburgh, has recommended the use of pur- gative medicines in the treatment of Chorea, in his beautiful and philosophical treatise. Dr. Batemen recommends the oxide of iron with rhubarb. Mr. Salter, in a valuable communication in the tenth volume of the Med. Chir. Trans, has detailed the success of the liquor arsenici, which a recent case in my own practice, and another in that of Dr. Heming, have recently confirmed. In one case, the cold bath was found useful. I believe the true secret of the cure consists in prudently conjoining the plan of Dr Hamilton with tonic remedies — M. H.] APHONIA SPASMODICA INTERMITTENS, OR TEMPORARY LOSS OF SPEECH. This, though an uncommon complaint, sometimes occurs in children between the fourth and seventh years of age. It is a tran- INCUBUS, OR NIGHT-MARE. 187 sient loss of speech, and is a harmless affection ; for though it may continue for a length of time, I believe it never degenerates into a permanent disease. It is rather a difficulty in articulating, than a perfect loss of speech; lasts only for a few minutes, or at most a quarter of an hour; and recurs frequently in the course of a day. It is thought to be somewhat of the nature of the chorea sancti viti, and to be occasioned by worms, or other irritation in the bowels; and sometimes by teething. If neither the irruption of teeth, nor the exhibition of mercurial purges, and other remedies for worms, should produce a speedy good effect, any advantage from other medicines is more doubtful; but the long use of the cold-bath, or perhaps time only, whereby a child may acquire more strength, may be expected to remove the complaint. It may be proper, however, to make a trial of local applications of a stimulating kind, during the paroxysm, or fit; of which remedies the most innocent is a lump of sugar wetted with lavender drops ; and amongst the stronger, a decoction of the pel- litory of Spain, as a lotion to the mouth. Should these remedies do nothing, and the complaint anywise increase, it should seem that electricity may be had recourse to with safety and propriety; but the disorder is too rarely met with to have furnished the oppor- tunity of saying much from experience.* INCUBTJS, OR NIGHT-MARE. It will be sufficient barely to notice this affection, children either out-growing the complaint altogether, or any occasional return of it, when older, being esteemed rather as constituting an unpleasant moment, than a disease requiring medical treatment. The incubus, probably, arises from a spasmodic constriction of the diaphragm and muscles of the chest, taking place during sleep, and occasions a sense and dread of suffocation, and of some huge weight lying across the breast. When children, who happen to sleep with a bedfellow, awake under the paroxysm, they are wont to say that their companion has lain with all his weight for a long time across them. The cause of this complaint seems to be flatulency in the stomach, and indigestion, and it chiefly attacks children or young people of a delicate habit, and such as eat too freely of fruits, and especially such as are unripe, or who are in the habit of eating much supper, a short time before going to rest. The paroxysms are of different duration, some children lying a much longer time in this unpleasant state than others; but in all, some degree of palpitation of the heart, lightness of the head, tremor, anxiety, or lassitude, remains for some time afterwards. * The most severe case of aphonia in a child, which has occurred within my experience, was cured by the daily use of calomel and jalap, with a little pulv. aromatic. This procured two or three stools daily, and the course was continued for at least three weeks. — S. M. 188 UNDERWOOD ON CHILDREN. The curative indications are to rouse and fortify. During the fit, volatiles and fetids may be applied to the nostrils ; and, as soon as may be, some antispasmodic should be administered internally. Afterwards, clysters, bitter purges, or emetics should be exhibited, as the state ofthe first passages may indicate, and the cordial volatile medicines be continued. To these should be added proper sto- machics, assisted by a nutritious diet of easy digestion, and cold bathing, if not otherwise improper. SINGULTUS, OR HICCOUGH. This has been ranked among children's diseases, but it is, by no means, a complaint of consequence, as it sometimes is in adults, though it is, indeed, a true convulsion; and may, therefore, be noticed in this place. It occurs very frequently in infancy, but seldom requires much attention; as it more commonly comes on only after over-feeding, or in consequence of the over-thickness or sweetness of the food, and is one of their most harmless conse- quences ; it offers another argument, however, for their prohibition. But when it depends on an acid state of the juices of the stomach, or occurs in long bowel complaints, the testaceous powders should be administered very freely. Should it, however, continue for a length of time, the emplast. ladani may be applied to the pit of the stomach. The hiccough is an affection very incident also to more advanced childhood : but is equally harmless as in infants. It is well known, that it may be generally removed for the present, by any little cir- cumstance that may serve powerfully to divert the child's attention at the moment, in a way of surprise, or otherwise. And it may not be amiss to attempt it whenever the hiccough may return, in order to obviate the influence of habit, by which this affection may be increased. Caution, however, should be had not to make use of such violent means as might occasion any considerable alarm; which in children of an irritable habit, who are the more common subjects of the hiccough, might induce some greater evil than the one intended to be removed. A less known, and pretty certain remedy, is a small quantity of any powerful acid; lemon juice generally answers very well; but a tea-spoonful of vinegar seldom or never fails in the accidental hiccough of youth, or of very old people. STERNUTATIO, OR SNEEZING. This has likewise been mentioned by some writers as a com- plaint of young children, for which Rhazes prescribes refrigerants and anodynes ; but it is certainly not a common one, and, indeed, I have never met with it in the form of a disease. Should it so occur, however, some of the antispasmodics, such as musk, castor, or camphor, may probably be exhibited to advantage. It may be occasioned by looking too long against any strong light, as the fire, and especially the sun, or other very luminous DENTITION. 189 body. It is a well-known symptom of the measles, and of many common colds, but in neither, I believe, requires any particular attention. It is mentioned here, only because I would not pass over a complaint that has at any time been ranked among the dis- orders of children. But knowing nothing further of it myself, and having no idea of its being a complaint of much consequence in this country, I have not chosen, under such circumstances, to be a mere copyer from others. If violent, however, it may be further worthy of attention: when in conjunction with other causes, it may lead to the rupture of some small vessels of the nose; which will be noticed in its place. DENTITION. The complaints arising during dentition are next to be consi- dered : many of the foregoing, it has been noticed, being blended with it, the first passages and the nervous system being always more or less affected. The process of dentition is likewise not unfrequently an occasion of many complaints afterwards to be mentioned, such as cough, fever, the rickets, and even pulmonary consumption and marasmus; under each of which heads, there- fore, occasional references will be made to what will be advanced under this. The time of teething is a most important period of the infant state, and subjects it to manifold complaints and dangers. Some writers, however, and particularly Dr. Cadogan,* and Dr. Arm- strong, seem to think otherwise ; and that teething is scarcely to be ranked amongst the diseases of infants. They have ima- gined that children, if otherwise healthy, would cut their teeth with no more danger than adults, who often cut the dentes sapi- entiae, so called, without any difficulty, and always without hazard ; they likewise observe, that many children get their teeth easily. But this argument must suppose the healthiest, and best-nutured children to be, in all respects, in the same circumstances with adults; which is by no means the case ; as they are liable to fever, dangerous purgings, and even convulsions, from causes that would in nowise affect the latter ; nor can they stand under some of those complaints so long as adults, nor endure the necessary remedies. For the same reason, the measles and small-pox carry off numbers of infants, when attacked by them a little more severely than common, whilst young, and healthy adult subjects, often struggle through the most dangerous and complicated kinds, when properly treated. Not to mention that very few infants who are unhappily affected with lues venerea, recover under any treatment, whilst adults are cured in the most advanced stages of the com- plaint. I have, therefore, no doubt, that the time of teething ought to be ranked amongst the most hazardous to infants, and that the * See his Essay on Nursing, &c, and Armstrong on the Diseases of Infants. 190 UNDERWOOD ON CHILDREN. greatest attention ought to be paid to it; though, it is probable, on the other hand, that Dr. Arbuthnot overrates its fatality, when he says that one child in ten may be supposed to sink under it; at least, I believe this is not the case where the symptoms are timely attended to. Some late writers, and particularly M. Le Febure De Villebrune, have conceived this to be a mere dispute about words; but the dif- ference, indeed, extends much further. For though I would, by no means, assert dentition itself to be a disease, and have made use of any such like expression merely in a popular way, yet am I confident it induces disease in very many infants of every habit of body, and more especially, however strange it may seem, in the apparently healthy and robust. Indeed weak, and even rickety children commonly cut their teeth easily, though often very late ; or if they should be harassed by a purging, and other complaints, they, nevertheless, escape with their lives, while very lusty, strong children are frequently carried off suddenly at this period, unless the teeth happen to find a very easy passage through the gums. The system, during dentition, being disposed to inflammation, such children much oftener fall into fever than the tender and delicate ; like athletic adults, who are more disposed to inflammatory com- plaints, than those who are of a colder, but less healthy tempera- ment : and it is by acute fever, or convulsions, that infants are carried off, who are well known to survive a thousand lingering and vexatious complaints, if their viscera are sound. It may, how- ever, be observed, that convulsions more rarely take place where a fever attends. There are also other circumstances that affect the process of den- tition, among which the three noticed by Hippocrates, I believe, are well founded: " That infants cut their teeth more readily in winter than in summer; that such as are rather inclined to be lean, cut them more easily than those that are very fat; and children who are loose in their belly the most safely of all." Rhazes* and Primeros are of a different opinion in regard to the fittest season : but of the truth of the last of these observations there can be no doubt. This period usually commences between the fifth and tenth months, and the process of the first teething commonly continues to the sixteenth at the least, and sometimes much longer. It almost invariably begins with the incisors of the lower jaw. Usually two of these are cut, and then the corresponding ones in the upper jaw. After two teeth in each jaw have appeared, it is, in some instances, a considerable time before the contiguous ones come out; but sometimes, though not often, six or eight are cut in a hasty succession. The incisores are succeeded by the four molares, then the canini, and the last of all of an infant's first teeth, their antagonists, or the eye-teeth, making in all sixteen. This, it is * Apud Sennert. de Dentit. in Prognost. Sect. v. Sennertus, however, en- deavours to reconcile the two opinions, sect. v. of the above work. DENTITION. 191 well known, is the ordinary number of children's first teeth, as they are called; but some infants cut four double teeth in each jaw, instead of only two, making the whole number twenty; though this is by no means so frequent an occurrence as has been asserted. I have, however, known & more rare irregularity, that of a child cutting twenty-four teeth. The above wonted order in cutting the four incisores, appears to be owing to those of the lower jaw being less deep in the alveolar process, as well as thinner and sharper at their points, and there- fore likely to force their way before those in the upper jaw ; accord- ingly, at least one of the incisores in the former is usually the first cut. The one opposed thereto in the upper jaw sometimes appear- ing next, rather than the contiguous one in the lower, seems to be occasioned by the friction of the prominent tooth, against that part of the upper jaw at which its antagonist is to appear. This attrition, repeated every time the jaw closes, derives a greater portion of fluids to that part, increasing its natural action, and thereby forwarding the growth of the tooth; while,by the forcible and frequent pressure ofthe gums and periosteum against it, as soon as it has made its way through the bone, its irruption is further assisted. If the succession be otherwise, and a second tooth in the lower jaw be cut before one appear in the upper,as, for the reason first given, is more com- monly the case, it is not unfrequently before many days : and the two corresponding teeth, in that case, either follow in two or three weeks in consequence of attrition, or else do not appear for some months ; but whatever the period may be, they generally come for- ward before any more teeth are cut in the under jaw. It is usually some weeks before the other two front teeth in the lower jaw are cut, and in a week or two afterwards, if there be no constitutional impediment, the corresponding ones in the upper jaw are commonly pushed forward, and for the reasons given for the early appearance of the antagonists to the two first-cut teeth. In children who are strong and healthy, this process goes on pretty much as above described, and the teeth are cut both easily and soon; but in unhealthy and weakly infants, the process is both slow and uncertain. Accordingly, children sometimes cut their teeth irregularly, or cross, as it is called, both by the teeth ap- pearing first in the upper jaw, and also at a distance, instead of being contiguous to each other : this is accounted, and with some reason, an indication of difficult, or painful dentition. It may also be remarked, that the ease or difficulty of dentition may be guessed at, by the circumstances under which the two first teeth shall hap- pen to be cut; the succeeding ones frequently making their way in a correspondent manner. To all these general positions there are, however, various exceptions. Teething is usually preceded and accompanied with various symptoms: the child drivels; the gums swell, spread, and become hot ; there is often a circumscribed redness in the cheeks, and erup- tio ns on the skin, especially on the face and scalp; a looseness, 192 UNDERWOOD ON CHILDREN. gripings ; green or pale stools, or of a leaden-blue colour, sometimes mucous, often thick and pasty; watchings, startings in the sleep, and spasms of particular parts; a diminution, or increased secretion of the urine, sometimes of a milky colour, at others, staining the cloths in patches, as if it deposited a brown powder ; a discharge of matter, with pain in making water, (imitating exactly a virulent gonorrhoea,) which often mitigates the fever; in almost all cases the child shrieks often, and thrusts its fingers into its mouth. The difficulty in micturition however, is sometimes very troublesome, and the pain apparently very great, attended with long and vehe- ment shrieks, for some time before the urine has passed. Demulcent remedies, such as are recommended in the chapter on Ischuria, can scarcely be given, to infants of only four or five months old, in sufficient quantities to be of much service, and are indeed but little required, if the infant be suckled; but if nourished by the spoon, they may be made trial of, as they sometimes suc- ceed. But should they fail in any case, recourse should be had to the means prescribed in the chapter on Dysuria. A symptom less common than any of the foregoing, and appearing only in certain habits, is a swelling of the tops of the feet and hands: it is seldom, however, of much importance, and goes away upon the appearance of the teeth. I have never met with it but in infants who cut them painfully; and being seldom accompanied with a purging, it is likely may (in its stead) prevent that fever which is otherwise so apt to attend. In some instances, however, this symptom has been accompanied with considerable fever, but in such, children have either been costive, or the stools been fetid and clayey, and the swelling of the extremities very considerable. In such cases, purging with calomel will be proper; and it may some- times be necessary to give a few drops of tinct. scillae. Never- theless, if there be no internal disease, this affection proceeds no further ; but whenever it may, it must be treated as the anasarca, which will be noticed in its place. I have likewise, in a few instances, met with a transient palsy of the arms or legs,, which in one instance recurred as often as teeth were making their way. The above-mentioned symptoms are often followed by a cough, difficult breathing, fits, fever, scrofula, and marasmus ; and some- times by hydrocephalus. A symptom of less consequence, though alarming to parents, is the tumefying of one or more ofthe glands of the neck ; but this is rarely followed by suppuration — a bread and milk poultice, or an embrocation of volatile liniment, is all that is usually required. Strong and healthy children cut their teeth earlier than the weak and tender: I have, indeed, known a weak and rickety child without a tooth at twenty-two months old,* though it lived to grow up ; but at the age of five years, became scrofulous. The robust, however, are more subject to fever, and for the reasons already * Primeros speaks of it being as late as the third, or even fourth year. DENTITION. 193 assigned. The fact, indeed, is, that the extremes of high health, and of debility, are both dangerous; the one being exposed to acute fever, or convulsions, the other to a slow hectic and marasmus. Therefore, air, exercise, food of easy digestion in small quantities, and taken frequently; an open belly, and everything that has a tendency to promote general health, and to guard against fever, will greatly contribute to the safety of dentition, and to children passing quickly through this hazardous period. Difficult teething is to be treated nearly as other acute diseases with local inflammation. If the body be at all bound, some opening medicine should be administered, and, it has been observed, that even a considerable degree of looseness is useful. Diluting drinks are likewise very necessary, especially if the child does not suck. If much fever attends, the loss of a little blood will be necessary; though children do not endure bleeding so well as they do other evacuations. If the propriety of bleeding with the lancet be doubted, a leech or two, as Harris advises, may be applied behind the ears, and is generally serviceable. Clysters are also very useful, especially if there be retention of urine, which will likewise call for the use ofthe warm bath. Gentle diaphoretics are also serviceable, particularly vinum antimonii, or the liq. antimon. tartarisat., which, besides opening the belly, often operate in this way: a blister should likewise be applied between the shoulders, especially if there be any disposition to fits. And, indeed, if stools do not afford some considerable relief, there should generally be some discharge from the skin; since a purging, and eruptions on the skin, when spon- taneous, are the grand means of easy dentition. A little discharge should, therefore, be kept up behind the ears, by rubbing the parts with Spanish flies, applying a thread as before directed, or putting on a small blister ; which may be kept open. A Burgundy-pitch plaster laid on the back will sometimes suffice, which should be renewed every ten or twelve days, till the symptoms disappear, or the teeth come into sight. Even before this period, slight scarifi- cations of the gums are very useful, by taking off the tension; or if the teeth are at all to be felt, lancing them. I shall close what I have to offer on the general plan of treat- ment, by observing, that the indications certainly are to assist the irruption of the teeth, and to moderate the inflammatory and other symptoms; which must be treated according to their kind; all parts of the body readily consenting with the gums at the time of teehing, but the nerves, the bowels, and lungs more particularly and importantly than the rest. It has been observed, that a purging is beneficial, and it is, indeed, surprising how considerable a diarrhoea children will stand on this occasion, and how very bad the stools will often be for many weeks together, and a child happily struggle through ; though at another time, an equal degree of purging, with such bad stools, and constant fever, would prove infallibly fatal. The diarrhoea is therefore not only to be cautiously treated according to the directions already given under the article 17 194 UNDERWOOD ON CHILDREN. of purging, but is generally rather to be encouraged than suppressed. Very pale stools are not uncommon at this time, and are some- times in vast quantity: I have known an infant have fifty in one night, at least by the account of a careful and discreet nursery- maid ; and from the quantity of faeces that I saw the next morning, I had no reason to dispute it. For the fever of dentition, besides bleeding, the absorbent powders are eminently useful, and are, in various respects, calcu- lated to afford relief. To these, sometimes, a grain or two of Dr. James's powder may be added at bedtime. Nitre is very often useful, joined with the testaceous powders, or the pulvis e contra- yerva comp., as there may happen to be more or less fever. Sydenham directs the compound spirit of ammonia in a spoonful of water every four hours, for four or five times, and I have thought it very serviceable after proper evacuations. Nor is a drop or two of laudanum to be feared, if the bowels have been pre- viously opened, the pain be very great, and the breathing not difficult. A free discharge from the bowels, however, must above all be preserved, when children cut their teeth with fever; and the testaceous powder therefore not be administered too frequently. The state of their gums must also be carefully attended to, or their fevers will be mistaken, and attributed to cold, or other causes, when the source of irritation is wholly in the gums.(tf) The lungs is one of those parts on which the irritation from teething is apt to fall, and when fixed there, the symptoms bear an alarming aspect. A precise acquaintance with their true cause is therefore of the greatest importance; or for the want of it, an unsuccessful plan of cure will be adopted. I speak this from much experience, having known good physicians overlook the true cause ofthe inflammatory symptoms; especially when children have cut the usual number of first-teeth. This, it should be remembered, is sixteen; but some children cut four of the molares in each jaw, instead of only two, making the whole number twenty. One instance of this number was very curious, the child having only three dentes incisores in the upper jaw ; but at two years of age, cut a third grinder tooth, on the side of the under jaw, thus making up twenty teeth. After this period of the usual first teething, I have met with the most alarming peripneumonic symptoms; soreness of the chest, cough, and great difficulty of breathing, with loss of appetite, continual fever, and the appearance of general decay. In this state, purging the bowels, and properly lancing all the suspected {t) As contributing both to the general health through the whole period of infancy and to the prevention of the sufferings from dentition, the daily use of the tepid bath, in the morning, should be specially enjoined. For the mitigation and relief of pain and of the accompanying fever at the time, the warm bath of about 96° F. is entitled to our confidence. DENTITION. 195 teeth, has given immediate relief; and by keeping up the purg- ing for three or four days, every threatening symptom has so thoroughly subsided, that in a fortnight's time, a child expected from day to day to die of inflammation, or fall into marasmus, has been restored to its former health and spirits. A principal indication is to assist the irruption of the teeth. This may be done by cooling, sedative, and demulcent applications made to the gums ; by rubbing them with some hard polished body, such as the coral; or by dividing them with the lancet: which last is the only mean to be depended upon. Rubbing the gums, how- ever, I apprehend, not only somewhat appeases pain, as adults sometimes experience in the common tooth-ache, but it also for- wards the growth of the teeth, by drawing more nourishment to them ; as well as assists their irruption, by pressing the gum and periosteum firmly against their points. Suitable applications on this occasion may be, either mel. com. or syr. papaver. albi: or the honey may be lightly acidulated with elixir of vitriol. Besides the coral, a crust of bread, or a piece of liquorice-root, may be often carried to the mouth, and may sometimes be preferable, as they will yield a little to the pressure of the gums. These means, nevertheless, and especially the coral, have been objected to by some modern refiners ; but the objections are cer- tainly groundless, as in giving this direction we are only following nature. For the young of all animals who suck, as soon as the teeth begin to shoot, are always strongly inclined to gnaw such things as afford a little resistance. This may be every day observed in domestic animals ; to prevent which in puppies, recourse is had to a ridiculous operation of worming, as it is called, which rendering the mouth sore, may prevent them for a time from gnawing every- thing that comes in their way : and if their gums become easy, or teeth are cut the mean while, they have no longer any desire for it, but what arises from the playfulness of youth. When it is found necessary to lance the gums, (which is ever, at least, a safe operation,) it should always be done effectually, with a proper gum-lancet; that both the gum, and the strong membrane that covers the teeth, may be sufficiently divided. The lancet should always be carried quite down to them, and even drawn across the double teeth. It is certain that this little operation gives scarcely any pain, and the relief is at the same time so con- siderable that the child immediately manifests it, by smiling, and by squeezing the jaws and grinding them together forcibly; which proves that the gums are not very sensible. The most painful part of dentition, and that in which children are most exposed to convulsions, is usually from the teeth cutting through the periosteum. This, I apprehend, in difficult dentition is often not cut through, but is forced up before the teeth, when they are even in sight under the thin gum ; hence it is, that cutting through the gum is so very often useful, and takes off fever and convulsions, which severe symptoms could not arise merely from teeth piercing the gum, which is not a very sensible part. At other 196 UNDERWOOD ON CHILDREN. times the pain and fever seem to arise from almost the very first shooting of the teeth within the jaw, and then they will very often not appear for some weeks after the gums have been lanced; and parents are therefore apt to conclude, the lancing has been unne- cessary, if not improper. I am, however, convinced, from expe- rience, that this little operation, though not in the general esteem it ought to be, and by the French physicians perfectly dreaded,* is often inexpressibly useful, and appears to have saved many lives, after the most dangerous symptoms had taken place, and every other means of cure had been made use of. The mere bleeding from the gums is capable of affording some relief, as it is frequently found to do in adult persons distressed by the tooth-ache. And I cannot here forbear expressing my surprise at the fears some people' entertain of lancing the gums, and their delaying it so long, if not altogether rejecting it, though no evil can possibly arise from the operation. On the other hand its advantages are so great, that whenever convulsions take place about the usual period of den- tition, recourse ought to be had to it, after an unsuccessful use of other means, though by an examination of the gums there may be no certain evidence of the convulsions being owing to such a cause ; the irritation from teething sometimes taking place in the very early stage of the process. At any rate, the operation can do no harm, even at any period ; and should the shooting of teeth be only an aggravation to the true cause of the disease, lancing the gums must be attended with advantage. But should teething be the proper and sole cause, it is evident how fruitless any other mean of relief must frequently be: for should convulsions, for instance, take place from a thorn run into the finger, or toe, the proper indication of cure by an immediate extraction of the thorn, and the futility of other means, must be equally obvious. The operation may also be safely repeated, the scars doing no kind of harm. This, however contrary to popular prejudice, may be readily proved, not only from the fact of infants cutting their first teeth very easily some weeks after being lanced, but also from the circumstances under which the second teeth are often cut. At this period, children from their more advanced age, and decreased irritability, are less subject to fever, and evidently appear to suffer far less pain, than in the first teething, though the second teeth often have to make their way through much more considerable scars than have been made by a lancet, from the gums having been lanced prematurely. This fact is likewise established from the many instances in which dentists have thought it expedient to draw out the first teeth long before the second are prepared to take their placet The objection to lancing the gums, from any appre- * See Lieutaud. t This practice is by no means adduced in a way of approbation, but merely for the sake of the inference drawn from the fact; the writer being persuaded, that the succeeding teeth are thereby frequently ill-placed, by one tooth ap- pearing long before others, and growing so large as not to allow proper space for the rest. DENTITION. 197 hension arising from the scars, is, therefore, altogether ill-founded ; and, indeed, it will be frequently necessary to lance the gums several times, especially on account of the extraordinary difficulty with which some infants cut their double teeth, which are furnished with two or more knobs or points. Purging, fever, and even con- vulsions, will sometimes arise from only one point of a large tooth offending the periosteum that covers it; and being nearer the surface than the other points, the lancet may sometimes not completely divide the membrane that lies over the rest; and this part not being injured by the tooth, the symptoms subside on having divided that portion of the membrane that was inflamed. But in a little time, another point of the same tooth is found to irritate the periosteum, and calls for the like assistance of the lancet, which again removes all the complaints. This, at least, I have conceived to be the process, when I have found lancing a large tooth immediately remove every terrible symptom, though the fever and other com- plaints have "returned, and the whole of the tooth not appeared till the operation has been three or four times repeated. I have seen the like good effect from it, when children have been cutting a number of teeth in succession, and have bred them all without convulsions, nothing having relieved or prevented these terrible symptoms but lancing the gums, which has removed them every time it has been done, one or more teeth appearing a day or two after each operation.* In such cases, it will often be proper to draw the lancet along a great part of one, or even both the jaws, instead of over only one or two teeth, as is commonly done; as well as sometimes to lance the incisores by a crucial incision, as is commonly done for the molares. Some writers, however, and Dr. Millar particularly, have advised not to cut quite down to the teeth, but only to scarify the gums, unless the teeth are very near. He suspects that the instrument often injures them, and produces caries, which he thinks will be communicated to the succeeding set of teeth ; but this is a mistaken theory,t owing to inattention to the true state of the teeth, which are perfect bone, and covered with a strong enamel, long before they get through the gums. The manner of the second teething of children likewise forbids such a fear; for though the first set (which are designed by nature to be only of short duration) should actually be injured by the lancet, the suc- ceeding ones are not at all likely to be affected by the carious state of the former. For the first teeth of infants constantly become carious at the roots, and are loosened and expelled by that means, when left to nature alone; and though, in many instances, the upper parts of the new teeth are for some time nearly in contact with the carious bottoms of the first set, they never suffer from • Precisely similar remarks have been made by Mr. Hunter. See his Practical Treatise on the Diseases of the Teeth, p. 121. f Such instances manifest the great impropriety of establishing practice from theory, instead of deducing theories from facts. 17* • 198 UNDERWOOD ON CHILDREN. this circumstance. I have dwelt the longer on this head, because writers are not agreed on this subject, and it is a matter oftentimes of no small importance. I have, however, written from experi- ence ; and am perfectly satisfied of the propriety and safety of what I have ventured to recommend. Children sometimes have ulcerated gums in teething, and more frequently where they have not been lanced ; these ulcers are easily cured by keeping the body open, and touching them with astringent applications. As much white vitriol, or roche alum, as will give a moderate roughness to a little honey, is usually suffi- cient for this purpose. But should this fail in any case, it must be treated as directed under the head of Canker. The diet of infants at this period remains to be noticed ; and it should be a pretty general rule during the time of teething, to abate a little of the usual quantity ofthe food, and to increase the quantity of drink, unless the child is very weakly, or everything is going on perfectly well; or if the child be at the breast, a simi- lar regard ought to be paid to the diet of the nurse. FEVER. Having considered the more early disorders of children, and especially such as are sometimes connected with pyrexiae, it will now be proper to treat more distinctly on the species of fever induced by them, or otherwise incident to childhood. In a view to the latter, however, it may be observed, that though some writers have supposed infants to be as liable to fevers as adults, and from the same causes, I have by no means found it so; having observed for many years, as well in the hospital as in private prac- tice, that infants do not readily take common fevers, though exposed for a long time to that contagion which has appeared to affect adults* all around them. Their fevers are also of a short duration if properly treated, unless the few that arise from some more per- manent irritating cause. Young children, however, are disposed to certain febrile com- plaints, and to some peculiar to themselves; which I shall bestow some pains in specifying, as well as pointing out the treatment most adapted to each. * Every physician attending lying-in hospitals, must not only have known many infants suckled, without injury, through the whole stage of bad fevers from which mothers have recovered, but also, in other instances, sucking greedily within an hour or two of their mothers' death.f f There seems something so barbarous and inhuman, as well as absurd, in putting a child to ils mother's breast, within an hour or two ofthe poor woman's death, that it may be hoped the practice is quite discontinued in every lying-in hospital. Long before the last fatal stage of bad fevers has arrived, every drop of milk must have left the breast; and to put the unfortunate child to suck greedily under such circumstances cannot be too much reprobated. — S. M. • FEVER. jgg The more frequent causes of fever, are teething, foul bowels, worms, glandular diseases, some eruptive complaints, or exposure to cold. To begin with the last-mentioned cause, as one often suspected : if the cold be severest will be easily distinguishable, as the febrile heat will always be attended with a cough, and hoarseness, and some difficulty of breathing, and often with running at the nose and eyes, which is noticed in no other fever, in its commencement, except it be the measles; which will be attended likewise with violent sneezing, and a peculiar appearance of the eyes, not often met with in a common cold. The treatment of this fever in children is usually as manifest as its cause. Should the heat be considerable, the cough violent, and the difficulty of breathing very great, a blister* will always be safe and expedient, and may be applied at the pit of the stomach instead of the back: as being both less painful under any motion of the body, and more readily got at to be dressed, or for the appli- cation of fresh cloths, where the discharge happens to be consider- able. But if the fever and difficulty of breathing should not be very much abated by the blister, children, though within the twelvemonth, will bear, and even be greatly benefited by, the loss of a little blood ;t and if not by the lancet, at least by the appli- * I cannot omit this opportunity of expressing my opinion, that the common practice of applying a blister to the chest, as a first remedy, in cases of active inflammation, is very injudicious and detrimental. Blisters, as my experience teaches, possess very little, if any power of subduing active inflammation. The proper time for applying blisters, is after the more pressing symptoms have been counteracted by the loss of blood, by purgatives, antimonials, nitre, &c. The application of a blister in the first instance produces great irritation, frequently masks the symptoms, and occasions delay in the use of other remedies, at a time, too, when delay can never be safely admitted ; for every possible means should be promptly adopted to mitigate symptoms, which in a very few hours may be- come irresistible. — S. M. f In mittendo sanguine, non tarn annos medicus numerare,quam vires aegrotantis estimare debet. — Celsus, lib. it. cap. 10. p. 78. Galen, indeed, forbad bleeding till after fourteen years of age ; but since the time of Celsus, that absurd idea has been exploded. Rhazes permitted cupping after three or four months ; Avicenna, at a year old. Some allowed of bleeding in the feet or legs, though not in the upper parts; but this useful operation is now justly unconfined, and extended, occasionally, to every period of life J X As it is always difficult, and sometimes impossible, in very young subjects, to draw blood by opening a vein with a lancet, it is usual to employ either leeches or cupping-glasses for this purpose. Leeches are commonly preferred, being thought a less severe remedy than cupping, though, in fact, they frequently prove more severe and troublesome. The chief objections to the use of leeches are— 1st. The difficulty of applying them. 2dly. The length of time which is consumed while they are drawing, and afterwards while a sufficient quantity of blood is flowing from the orifices ; a length of time during which the active employment of other indispensable remedies is prevented. 3dly. The great uncertainty as to the quantity of blood obtained, this being sometimes so inconsiderable as not at all to answer the pur- • 200 UNDERWOOD ON CHILDREN. cation of two or three leeches, especially if the head be affected ; and I mention this again,because it has been thought so highly improper for infants. But I can venture to say, they will be much less re- duced by it, than by the continuance of the fever, which the loss of a little blood will, in many cases, shorten by two or three days; it is also sometimes absolutely necessary, as in peripneumonic cases, in which it may even be repeated with safety and advan- tage.* Indeed, in some instances, the only means of saving an infant's life, is taking away at once a sufficient quantity of blood, at the commencement of the peripneumonic symptoms. And this becomes the more expedient, from the consideration that not only inflammation, but true tubercles ofthe lungs are formed at a very early age. Oily medicines, likewise, made into a neat emulsion, are often useful, especially if the child be not suckled; but they should be preceded by an emetic of wine of antimony, as there is usually much phlegm on the stomach; children never coughing it up. In many cases it is also necessary to repeat the emetic, as often as the phlegm in the throat is collected in such a quantity as seems to impede respiration. But if the cough be dry or convulsive, Bates's spirit. sal ammoniaci succinat. may be safely and usefully administered, if there be not much fever. The body at the same time should be kept perfectly open, and this purpose is usually well answered by smaller doses of wine of antimony, or of Dr. James's powder; pose; at other times so great and uncontrollable, as to exhaust and debilitate the patient excessively. Instances are not rare, in which, from the neglect of put- ting a timely stop to the flow of blood, infants have been actually destroyed by the gradual, but overwhelming loss. Whenever a good cupper is to be met with, this mode of procuring blood is greatly to be preferred. He can apply his cups upon any part that may be re- quired, and will draw blood from infants, even during the month, with great address and expedition. He will take away the exact quantity prescribed, even to a quarter of an ounce. The operation is quickly over, and of course the advan- tage of taking away the necessary quantity at once is obtained. There is no delay in employing other appropriate remedies, nor is there the fear that, through the practitioner's absence, the child will sink under the profuse discharge of blood, which has sometimes oozed, unobserved or unattended to, from the bites of leeches. In determining the quantity of blood to be taken away, so much depends upon the peculiar case to be treated, as well as upon the constitutional and relative strength ofthe child, that no precise rule can possibly be laid down. The attend- ing practitioner must exercise his best judgment in directing the proper quantity, and he will often find it expedient personally to superintend the operation of cupping, in order to insure the complete effect which he expects from the loss of blood. It may, however, be useful to remark, that during the first six weeks of life, from five drachms to an ounce of blood will commonly relieve the inflamma- tory symptoms; from six weeks to three or four months, one ounce or one ounce and a half will answer the purpose; and in this proportion bleedings may be adopted at subsequent periods of infantile life.— S. M. [See a note upon this subject at the close of the chapter on Hydrocephalus and Hydrencephaloid diseases. — M. H.] * Multa in priecipiti periculo recte fiunt, alias omittenda. — Celsus, lib. Hi. cap. 18, p. 150. • FEVER. 201 but if they should fail to procure stools, as they sometimes will, where there is much fever they rather do harm than good, unless a little manna or rhubarb be joined with them. Should the head be much affected, putting the feet into warm water, or applying a milt* to them just taken from the animal, are admirable remedies; and I think have sometimes saved a life after all hopes had been given up. Or a little fresh leaven, or dough, as advised by Mr. Le Febure de Villebrune, may be spread thinly over the soles of the feet. If the fever be accompanied with much cough, and attended with difficulty of breathing, which comes on by fits, both may be greatly relieved by the compound spirit of vitriolic ether, given three or four times a day. Though the severer treatment above mentioned is indispensable when the cough, difficulty of breathing, and degree of fever are considerable, it is proper here to remark, that I have known chil- dren of two or three years old seized with a sudden difficulty of breathing, in coughs arising from common colds, where the fever has not been proportionate to the other symptoms. In such cases the difficulty of breathing may arise from bile on the stomach; and it may therefore be prudent, previously to bleeding and a blister, to give a small dose of James's powder, which will pretty certainly act as a vomit, if our suspicion has been just; and will remove that threatening symptom very soon. It is scarcely necessary to remind the reader, that preparations of antimony are very powerful medicines, and not to be prescribed indiscriminately, as they sometimes are, by those who are, in no wise, competent judges,t and against which practitioners will do well in offering a caution in the nursery. But where such medi- cines are found to agree, and keep the belly open, children fre- quently stand in need of no other: though where the fever has been very considerable, I have given nitre to advantage to infants of only a few months old. In the little fevers arising from taking cold, to which some children are very liable, I often join it with Dr. James's powder, and a few grains of the compound powder of contrayerva, lowered with testacea; which I find to be a medicine exceedingly useful, when given in time. If the fever be not owing to taking cold, to worms, teething, or some eruptive complaint, it will generally be found to arise from some foulness in the first passages; in which case opening the belly, and afterwards giving an emetic, and the testaceous powders, usually remove it. On this account, great attention ought to be paid to the state of the bowels, and not only in regard to the number of stools, but their kind. This should be a maxim with all those who have the superintendence of children, especially infants, under * From this still popular remedy, I have never seen the slightest good effect; and I am not a little surprised, that in a work which so often sneers at anile remedies, so strong a recommendation of this should appear. —S. M. f A nurse very lately proposed giving half a grain of tartarised antimony to an infant of a few days old. 202 UNDERWOOD ON CHILDREN. whatever complaint they may labour; as a principal indication must be taken from the state of their bowels. In the present in- stance, if a laxative and emetic have not removed the fever, open- ing medicines must be continued a while longer, especially castor- oil ; but if the stools are very fetid, the pulvis e scammonio cum calomel, or small doses of calomel alone, are the fittest purge. I have known not only convulsions, dilated pupils, and drowsiness, but also paralytic affections, attended with great pain and continual fever, induced merely by a fonl state of the bowels; where, after the complaint had been unsuccessfully treated as a fever of another kind, all the symptoms have been removed at once by an active purge. At other times, infants of only three or four months old will often have very considerable fever and fits, with so costive a state of the bowels, as to require strong purgative medicines to be repeated for several successive days, with clysters and the warm bath, before the obstruction can be removed, or the fever will at all abate ; and I doubt not it may be matter of surprise to those who may not frequently have met with such cases, to find how great a quantity of purging medicines have been taken by a tender infant, before one proper stool can be procured,* and how certainly a relapse will take place, if the opening plan be not persevered in, in the manner recommended. In less urgent cases, and especially in very young subjects, much gentler means will usually succeed; and after the belly has been once or more well opened, many com- mon fevers will nearly subside ; after which it will frequently be proper to return to the testaceous powders, in one form or other. These will compose an admirable medicine for very young chil- dren, as well under slight fevers, as for almost all their complaints not attended with costiveness. This the judicious Harris was so sensible of, that he thinks them alone sufficient to effect almost everything during the infant state, and has done unspeakable service by abolishing that indiscriminate recourse to cordial, and other heating and rough medicines, such as mercury, aurum ful- minans, theriaca, &c, together with various anile and superstitious remedies, which the ancient writers frequently recommended on occasions peculiarly improper. And though absorbents will not do everything he has imagined, yet are there very few medicines of such general use. But should the fever withstand these common remedies, or be found to increase, it will be necessary to give some of those before recommended ; or, what is often very useful, little draughts of succus limon. and carb. potassae, in which the latter is left a little predominant; or a few drops of the spirit, ammoniae comp. four or five times a day, as recommended for the fever of dentition. In many fevers of infants, where the cause has not been so obvious as it commonly is, I have experienced very good effects from persevering in the use of small doses of the vinum antimonii, * See page 96. FEVER. 203 given in a saline draught; this medicine sometimes acting as an emetic or purge, and at others as a stimulant and diaphoretic, pos- sesses peculiar advantages. There is a fever to which children, long after the time of teeth- ing, are liable, that is of no marked type ; which, though it turns out to be owing to foulness of the primae viae, arises more from the acrid secretions from the liver, or other glands, than from a collection of faeces, or a costive habit: and is more remarkable for the great pain in the bowels than for any other symptom. It commences like other fevers in children, and is of uncertain duration. The pulse is oftentimes exceedingly quick; the breath- ing bad; the tongue dry and brown, with a cough more or less violent throughout the complaint. On this account, it is in the beginning often suspected to be owing to taking cold ; but the cause, I believe, is always in the first passages. Though procuring stools freely for several days is found to abate the fever, yet the child is at no time entirely free from it; though it frequently remits; which may assist us to distinguish this fever from others. The stools, which at first are very fetid, in a little time become very numerous, mixed with a great quantity of slimy matter, and are attended, or followed, by very great pain. This has sometimes discouraged practitioners from further purging ; but where no other source of fever is discovered, and cooling and antimonial medicines are found to afford no essential relief, thf exhibition of repeated purges has proved the surest remedy. To this end, two or three grains of calomel, taken every night, and infus. sennae the next morning, has seemed to have the best effect, in the earliest stage of the disorder ; but after the severe pain and slimy stools have taken place, castor-oil may be substituted, and given only every second or third day ; composing the bowels, and taking off the spasmodic pains, by repeated doses of laudanum, on the intermediate days, and especially on the nights after the operation of purgatives. This plan should be continued until the fever entirely subsides, (which will sometimes run out to two or even three weeks,) and the appetite for food returns. Previously to which, some light bitter, given in a saline draught, or lac amygd. or pulv. e traga- canth. comp. in the intervals of purging, will tend to comfort the bowels, and hasten the natural inclination for food, from which there is often a long aversion. There is a fever which may be just hinted at in this place, which will be more particularly noticed in the chapter on hydrocephalus, for which also repeated purging is the remedy. — The symptoms strongly resemble those of water in the head, but the stools are of a very uncommon appearance, resembling meconium; which, however, resist common, purges, but are brought away in great quantities, and for a considerable time, by calomel; the fever and stupor abating in proportion as this kind of stool is brought away. 204 UNDERWOOD ON CHILDREN. I have sometimes met with a fever, more remarkable for its being attended with inflamed and sometimes painful tumours, than for any other symptom peculiar to it. These are seated chiefly on the legs, and particularly along the spine of the tibiae ; and rise in a day or two to the size of a nutmeg. They are marked with all the appearance of abscesses, feeling as if they contained matter; and, on this account, they put on a formidable aspect to such as may not often have seen the disease •, but, what is remark- able, they never, I believe,come to suppuration, unless irritated by the clothes or other means, but disappear again in a few days, though the fever sometimes continues. The like appearances have been met with in adults, especially females, though perhaps more commonly in children from three to ten years of age ; but are not peculiar to scrofulous habits, though the tumours have very much of a scrofulous appearance and feel. As far as my experience has gone, (for I believe it is not a very common complaint,) they are conjoined more frequently with that fever which attends a foul state of the bowels, than with any other ; which therefore requires repeated purging especially with calomel; and on this account, the pulvis e scammon. cum calomel, becomes a convenient prepa- ration. Saline draughts, with the spir. aetheris sulphurici comp. may be given on the intermediate days, and in the end the bark is commonly useful. These appearances have sometimes been preceded by scarlet spots, or patches, resembling the petechiae observed in malignant fevers, as was noticed under the article of rashes. On the decline of some fevers, especially those arising from foul bowels, it is not uncommon to see an eruption on the skin, re- sembling that called the red-gum, in the mouth; and sometimes even the thrush will make its appearance, though the infant may have had that complaint before ; which are marks of the great dis- turbance the first passages have suffered, and of the consent they have with the skin: the former is a favourable indication, but the observation is far from holding good in regard to the thrush. At the decline also of certain anomalous fevers, that have lasted ten or twelve days, (and sometimes after the febris scarlatina,) great pain of the neck has taken place, attended with a little tumour of the part, and great rigidity of the muscles, drawing the head forcibly to one side. A general debility and want of appetite has continued, though the bark has been administered, and seemed no wise to disagree. In this state, fomentations and poultices applied to the neck, together with some volatile embrocation, has soon re- moved the contraction and pain; after which children have re- covered, as on a sudden, their appetite and spirits. During very cold weather, however, I have known a slighter degree of pain and stiffness of the neck, with a little fever, return a week or two afterwards; possibly from taking cold, and, as I have thought, from improper food. The antimonial powder, with saline draughts, REMITTENT FEVER. 205 and a repetition of the topical applications, have in such cases had an immediate good effect. Fevers in children of three or four years old, particularly in certain seasons, are found tedious of cure by any of the above means, and, like those of adults, require the bark, (especially under the recurrence of the thrush,) which should be administered in a light decoction, three or four times a day, in such doses as the symptoms may require. REMITTENT FEVER. Notwithstanding what has been observed respecting the remittent fever, as described by Drs. Armstrong and Butter, there is cer- tainly a fever of that type that deserves a cursory consideration in respect to a peculiar symptom, which, I believe, always attends it; though the fever itself certainly arises merely from an affection of the primae viae. Indeed, it is well known to practitioners much conversant with the disorders of children, that various febrile affections, differing in degree, and the time of their continuance, originate from the state of their first passages; but as the treatment is similar in them all, varying chiefly in regard to the strength, or other circumstance, of the purging medicines exhibited, it would be equally unnecessary and perplexing to multiply names, where no essential distinction subsists. The present chapter therefore is added only to denote a fever of this kind, which constantly remits and increases again, sometimes for three or four weeks, or sometimes much longer, and is attended with the remarkable symptom of picking at various parts of the body until they are made to bleed, and even become sore, parti- cularly the fingers, the nose, lips, or the tongue. But this fever being equally remarkable for being always, I believe, void of danger, it is necessary only to remark, that it seldom attacks children under four years of age, nor upwards of ten ; and that, although it has been distinguished into the acute, slow, and low infantile remit- tent, it requires much less variety of treatment than such distinc- tions seem to import. The proper, and always successful plan, being confined to the repeated exhibition of some gentle purgative medi- cine, or light cordials, when accompanied with much languor, as is not unfrequently the case.* * The Infantile Fever, the Infantile Remittent, the Bilious Remittent of Infants, or as it is sometimes, but improperly, called, the Worm Fever, generally arises from indigestion, occasioned by food of an improper quality, or too abundant in quantity. It is very frequently produced in children during the holidays from school, by various kinds of pastry in which they are then indulged, with perhaps a glass of wine or punch, or a drop of brandy or other spirit. It is a disease so far from being "void of danger," that it frequently excites the greatest appre- hensions, and sometimes it proves fatal, or lays the foundation for other disorders, that are ultimately to terminate fatally. This complaint is apt to creep on very 6lowly and insidiously; the child is generally in a drooping state, some time 18 200 UNDERWOOD ON CHILDREN. TYPHTJS, OR LOW FEVER. A fever of much importance, however, is mentioned by Dr. Hamilton, and is a true low-fever, or Typhus. It is very accurately described by him, and particularly as commencing generally rather with marks of languor and fatigue, than with any distinct rigour. The stomach is frequently sick, which is soon succeeded by pain in the head, and great thirst and restlessness. On the second day there is an evident remission, which is at the first very regular, and continues, though in a less degree, till the termination of the fever, which will run on to three weeks, and sometimes five ; and yet, as far as my experience has gone, the little patient recovers, if duly supported ! and, I think, I once saved the life of a child of seven years old, by sitting at the bed-side, with my hand on the pulse, and as often as that sunk, (as it often did so much as not even to be felt,) supplying the child with burnt brandy and other cordials; though at times it was doubted whether it was able to swallow. The attempts were at such times, of course, made with great caution, before its illness calls for very decided attention. Not uncommonly, slight relief is obtained by the occasional purgatives, which are sometimes given, but they are seldom continued with sufficient perseverance to effect a cure. At length the loss of appetite, the fever, the thirst, the restlessness, the starting in the sleep, the pallid countenance, and the tumid belly of the child, attract more direct attention ; medical aid is sought for, and the physician finds his patient with a dry hot skin ; generally drowsy and unwilling to exert himself; his tongue coated entirely over with a firm white fur; his nose pinched in, a bluish tinge about his mouth and eyes; pulse quick, and the belly tumid, hard, and irregular in shape and feel. In the treatment of this complaint, it is of great importance to keep up a regular, daily, but not profuse purgation, by the use of calomel, jalap, scammony, rhubarb, sulphate of potass, senna, and castor oil, varied or combined according to circum- stances. — Calomel, or some other mercurial preparation, being one ofthe indis- pensable articles. Some practitioners seem to rely upon purgatives alone; but the saline mixture, nitre, and antimonials, assist so much in abating the disease, that they ought not to be omitted : and in cases of great irritability, small doses of the milder narcotics are to be employed ; nor ought the advantages to be over- looked, which may be gained by pediluvia, fomentations to the abdomen, and ablutions with tepid water. As the disease advances, bitters, ammonia, bark, the mineral acids, &c, may be required. It is seldom necessary to take away blood, when this disease pursues its regular and simple course; but it sometimes becomes complicated with.affections of the head and chest, which may make both bloodletting and blisters essential remedies. This disease, and the three fevers next in order enumerated, seem to be so nearly allied, that they may be considered as one and the same complaint, at different periods, and under somewhat different modifications. The Remittent is the more simple form of fever, originating in a deranged state of the stomach and bowels. The Typhus, or low fever, next mentioned, is a more aggravated form of the Remiitent, with increased debility. The Mesenteric Fever is the same complaint, with so much further derangement, as for the mesenteric glands to be enlarged, obstructed, and diseased : and the Marasmus is the most aggravated form of all, much less likely to be cured ; but out of which, under very careful and unremitting- attention, continued for many months, some infants have happily escaped^ — S. M. MESENTERIC FEVER. 207 by administering only a tea-spoonful at a time, which was some- times retained a while in the mouth, and at others swallowed with avidity ; the pulse always rising in consequence. It will be obvious, that if called in pretty early in the disease, a powerful emetic should be administered, and perhaps ipecacuanha is one of the most certain, and best; and some purgative medicine administered soon afterwards. Washing the body, and the head, if the pain be extreme, with cold vinegar and water ; whilst dilu- ting sub-acid liquors should be taken freely, as long as the thirst is intense ; and whenever an evident remission takes place, recourse should be had to cordials, and sometimes the bark. On the other hand, if the pain in the head should increase, or the nose be dis- posed to bleed, the early application of leeches is indicated, previous to the recourse to cordials, or application of external cold. The bowels should, in every case, be kept open, and when the stools are green, or very fetid, active purges should be administered : the air of the apartment should be cool, and a window frequently be opened in that, or an adjoining room, according t« the season of the year, and other circumstances. When the vital powers sen- sibly fail, besides the free exhibition of cordials, blisters or sina- pisms should be applied to the feet, and be left on long enough to become rubefacients ; and be repeated again as the degree of de- bility may require. MESENTERIC FEVER. Another cause of fever is obstructed glands, especially the me- senteric ; and is often the forerunner of the true hectic fever, or fatal marasmus. It, indeed, frequently arises from scrofula, which then discovers itself by other marks; and will require its peculiar treatment. But there is an early stage of glandular obstruction in the mesentery, and of the fever here alluded to, that is often falsely attributed to worms ; but will not yield to mere purgative medi- cines, as that disorder usually does. It attacks children from the age of three or four years, the fever remitting, and sometimes in- termitting, irregularly ; is attended with loss of appetite, swelled belly, and pain in the bowels; the latter sometimes taking place, more or less every day, or is generally more violent if the child be a day or two free from it. After opening the bowels, half a grain or a grain of calomel may be given with advantage, two or three times a week, and on the intermediate days small doses of the natron ppt., either alone, or neutralized with the juice of lemons, or in some instances partially so. If the belly be very costive, as it often is, an infusion of spong. ust. and senna is more effectual than anything; and is an excellent remedy for many little fevers, in older children, when the primae viae are particularly concerned. When the glandular fever, just now mentioned, has abated, some light bitter, as of chamomile flowers, is useful to brace the stomach and bowels ; and to prevent 208 UNDERWOOD ON CHILDREN. a relapse, it will often be found necessary to administer some cha- lybeate, of which the tincturaferri ammoniatis is one of the fittest for children; if it should offend the stomach, a few drops of the tincture of cardamoms, or other stomachic, should be joined with it. But as the mesenteric fever, from its great fatality and frequency, has lately very much engaged the attention of writers, it may be proper to consider it a little more distinctly in some of its principal stages; in each of which its nature and treatment sometimes mate- rially differ. For before the mesenteric glands become much enlarged, or the fever continual; whilst the appetite continues, and the first digestion is but little impaired, and no purging has taken place; the opening mixture of sponge and senna, with a few doses of calomel, and afterwards bitters and chalybeates, are the only remedies very likely to be called for, and almost always succeed, if duly persevered in. In this state, the disorder may still be con- sidered as in its first stage, and of which an unusual costiveness, the hardness and recurring pains in the belly, and a remitting fever, are the principal symptoms. The limits of this work, however, will not allow of a particular detail of the many others that attend this fever through its various stages ; and it is presumed they are so well known, as to render it unnecessary. But in general it may be said, that indigestion, costiveness or purging, irregular appetite, flushed cheeks, or a total loss of colour, impaired strength and spirits, remitting fever, and a hard and tumid belly, with ema- ciated limbs, are amongst the more constant symptoms, attending at one period or other of the disease. This being a glandular complaint, not only are the glands of the mesentery affected, but I have found those of other parts, and especially of the lungs, in a very morbid state, before any of those symptoms of inflammation have been noticed, which are constantly met with, in similar cases, in older subjects.* This fever will sometimes take place in infants at the breast, and children are liable to it till they become eight or ten years old, (and in scrofulous habits much longer,) it being often a consequence ofthe protraction of almost any ofthe preceding complaints, espe- cially those of the first passages and dentition, as well as of the measles, and a few others : of which that from teething will be separately considered. Among the poor, it is too frequently owing * In examining the viscera of more than one infant of only a few months old, I have found tubercles, and even purulent matter in the lungs, which have not been preceded by any manifest symptoms of such mischief, and even where there has been no cough nor difficulty of breathing, until a few days before death, and then only so slight as to be scarcely noticed. In one instance I found, in some part of the lungs, tubercles as large as nutmegs, and in others, clusters of smaller ones, (and particularly about the superior and back part of the mediastinum,) some of which were hard and others full of matter. Such appearances seem, therefore, to be common in all glandular diseases, to rickets, and similar disorders arising from cachochymy ; Glisson has remarked that he seldom examined the bodies of infants, dying of rickets, without meeting with such appearances in the lungs. MESENTERIC FEVER. 209 to a coarse and unwholesome diet, and the want of proper exercise and rubbing : indigestion at the stomach, and a consequent vitiated chyle, with infarction, or obstructions in some of the internal glands, or lymphatics, being among the primary remote causes of the dis- ease. As prophylactics, therefore, good air, exercise, gentle frictions, an easy dress, frequent washings of the body of young children with soap and warm water,* the cold bath in older children ; and especially a light and nutritious diet, with such mild aromatics as may assist digestion, (before the commencement of fever,) are some ofthe principal and most efficacious means. In regard to friction, it may be remarked, that it is as proper as a means of cure as a prophylactic; and should be regularly had recourse to, at least night and morning. But when this disease is completely formed, it calls for the most powerful remedies ; and such have happily succeeded in several instances, wherein formerly little hope had been entertained. As I have passed over many less important symptoms, occurring in the different stages of this long disease, especially such as arise from some peculiarity of habit, I shall, for the like reason, confine these observations to the more general plan of treatment, without particularly noticing a variety of occasional remedies, which such symptoms may at different periods require. In a general way, the principal indications are to remove the obstructions in the lymphatic system, and effect a resolution of the indurated glands of the mesentery ; to carry off this viscid matter ; and lastly, to strengthen the system, and establish a good digestion, as well by means of proper diet as by medicine. To accomplish these intentions, attenuants and deobstruents, purges, emetics, and tonics, must be had recourse to, in an obvious order. Amongst the first, and as general deobstruents, are mercurial and antimonial remedies ; neutral salts, soap, steel, and the cicuta ; to which, with propriety, I think, may be added electricity. In regard to the efficacy of mercury and steel in this disease, a vast crowd of testimonies appears among writerst in almost every part of Europe. And a very rational idea has been suggested on this head by Mr. Royer, that of administering mercury clyster- wise ; inasmuch as the resolution of local and partial obstructions does not so much require an exertion of the collected force of the system, as deriving all the influence of proper remedies to the seat of the disease : an idea of late years pretty generally received, and, in some instances, successfully adapted to the cure of scrofula, as well as some other chronical disorders. Calomel is, perhaps, one of the fittest remedies of this class, and when administered by the mouth, may be combined with, or fol- * This idea is as ancient as the time of Hippocrates, who strongly advises it. —De Salubri Diaela, § ix. f White, Hartmann, Worholf, Theden, Burchard, Baume, Baumes, Roseen, Fouquet, &c, 18* 210 UNDERWOOD ON CHILDREN. lowed by, some purgative medicine, and given for several weeks, till there shall be some favourable change in the feel and size of the belly ; though it will, indeed, be sometimes proper both to ex- hibit this powerful deobstruent in large doses, and to continue it for a much longer time, and afterwards in very small doses, which I frequently direct in the following form : R Calomelan : gr. 1. Sachari albi Ji. caute misceantur et divid. in Chartulas duodecim e quibua sumat unam mane meridie et hora somni quotidie. The lightest preparations of steel are usually preferable, such as its tinctures, or the salt, or merely some chalybeate water, which will act both as aperitives and tonics. Amongst antimonials, the kermes mineral* is found by experience to be more generally use- ful than any other preparation. The evacuants proper in this disease are emetics and purges, to which may be added diaphoretics. The two former are more essentially necessary, but must be adapted, and carefully dosed, agreeably to the state of the bowels of the patient. As a purge, rhubarb and tartarised kali are generally the safest and most effectual, and may be persevered in for the greatest length of time; or the composition which, in regard to many cases, has been de- servedly extolled by Sir William Fordyce, rhubarb and poly- chrestt salt; which, whenever mercury may not be preferred, should be exhibited daily for several weeks, and will sometimes restore the patient without recourse to any other means, when the disorder is not of long standing, being at once both a purge and an effica- cious deobstruent. As a diaphoretic, sarsaparilla, or a more compound decoction of the woods, may be taken together with any of the above-men- tioned remedies. The last means recommended are tonics, which can very rarely be dispensed with ; since, although the obstructions should actually be removed, the emaciated state to which the patient is generally reduced, peculiarly calls for bracing remedies, especially with a view to strengthen the stomach and alimentary canal, and promoting a good digestion ; the only means of obtaining a bland and nutri- tious chyle, by which the body may be conserved in good health. * (Sulphur Aurat. Antimonii.) f The following is the formula published by Sir William Fordyce in his Treatise on Fevers, J773. i£. Sal. Polychrest ^ss. pulv. rad. rhab.gr. iij.iv. v. vi. vel vii. M. pro una dosi omni mane sumend. per 14 dies, vel donee cesserit febris hectica aut tumor abdominus. Calomel, or hydrarg. c. creta, or pil. hydrarg. may with great propriety be added to the above composition, if the physician think such an addition advisable. The good effects of rhubarb and potassse sulphas, with or without a small quan- tity of calomel, or other preparation of mercury, and generally, perhaps, with the addition of a little spice, or half a drop of essential oil of anise or caraway, or mint, are, in many cases of tumid abdomen, extremely great, if persevered in daily for three or four weeks. The dose should be managed so as not to produce profuse purging, but one or two copious stools every day. — S. M. MESENTERIC FEVER. 211 To this end, the bark, steel, the cold bath, (which, however, and especially the latter, should not be ventured upon till the obstruc- tions are removed) light bitters, and aromatics, are the principal remedies ; to one or more of which, recourse may be had, as the degree of remaining fever, and the state of the bowels, or the debility of the patient, may point out. To these may be joined daily frictions, especially of the belly, limbs, and spine ; or the common soap plaster, or one composed of ointment of marsh-mal- lows, gum ammoniac, and oil of chamomile, may be applied over the whole belly; or the body be covered all over with sea-salt, reduced to a very fine powder. It has been already hinted, that the diet ought to be of the lightest and most nutritious kind, and carefully adapted to the age and other circumstances of the child ; who, if at a due age, ought in many instances to partake of light white meats, as well as vege- tables and plain jellies, but always avoiding fat and greasy aliments, pastry, and whatever may not be duly, as well as quickly digested, or will not form a bland and nutritious chyle, however readily they may get out ofthe stomach. Though it has been said, that merely purging with calomel or rhubarb for a length of time, will in some instances succeed, and in others, some of the above remedies may be more adapted to the patient than the rest; yet more commonly, as before noticed, each of them will be useful at one period or other ofthe complaint, and sometimes the union of several; but above all, purging is always the most essential to the cure of this dangerous disease. And though it is oftentimes attended with costiveness, and a voracious appetite, it is, at others, accompanied with a loathing of all food, and frequent stools, which do not reduce the belly, but too often deter practitioners from the use of active, or repeated purges; without which, however, experience proves there can be no pros- pect of success, after the belly has once become enlarged. And I wish here to add, as the result of experience, that I have been equally surprised at the great quantity of purgative medicines, especially calomel, and at the success attending the protracted use of them, in cases wherein I had myself at first despaired of being of any use. I shall close these observations with offering the fol- lowing form, which, in a general way, I have found very suitable. It should be continued for a length of time, taking care that the bowels be kept properly open. H Calomelan. gr. j. ad. ij. Pulv. Ipecac.gr. ss. ad gr. j. Zingiber, gr. vj. Misce, ft. Pilulse iv. cum quantitat sufficient, vel Conf. aromatics, vel Conf. opiatae, ut alvi status postulet. E qtiibus sumatur j singulis autalternis noctibus, vel omni nocte maneque. Post aliquod tempus addentur pulv. rad columbse grana octo vel decern.—Together with this pill, the cicuta will sometimes be very serviceable. Since I quitted general practice in London, the solutio arsenka 212 UNDERWOOD ON CHILDREN. has been used with considerable success in this disease : but, cer- tainly, to children should be administered only in the smallest doses.(u) (u) Dr. Merriman has correctly said, in a preceding note, that there is a family resemblance among the fevers just described, viz., re- mittent, typhous, and mesenteric; the differences depending more on the temperament, and regimen of the children, and atmospherical exposures to which they are subjected, than to any primary and essential characters, whether of symptoms or of organic alteration. The great stress laid by Dr. Underwood on the purgative treatment, and his repeated advice to renew the administration of purges at different periods of remittent fever, call for some qualifying remarks. The disturbance and impairment of the digestive functions, as pointed out in the text, have a great share in the production of these fevers; but not by mere accumulation of secre- tions and of fecal and viscid matters in the intestines. The state of the mucous membrane demands our serious attention — irritated, and, at times, inflamed, as we know it often to be on these occasions. Hence, although evacuations may be required, it is not a matter of indifference by what means they are procured. Calomel, rhubarb and magnesia, and castor oil, ought to have a preference over the resinous and drastic purgatives. Of these, jalap, in a state of minute division, with sulphate of potassa, or bitartrate of potassa, is the least objectionable : indeed, in this state its operation is mild and effective. But according to our view of the chief pathological state in remittent and mesenteric fevers, we ought to ab- stain from much and continued purging, and be content to keep the bowels open by enemata or a mild laxative. No unfrequent accompaniment of the fevers in question, is a tumid and even tympanitic abdomen, with such soreness on pressure as, taken in connexion with the flexion of lower limbs, to induce a belief of peritonitis. I have, in such cases, found small bleedings from the arm, or leeches followed by fomentations to the abdomen, to contribute not' a little to remove the local or membranous disease, and with it the febrile phe- nomena which more generally engage the attention of the practitioner. The blue pill, in doses which shall exert a laxative effect on the bowels, or equivalent proportions of calomel, is a good adjuvant to the first part of the treatment. These same remedies, with the addition of ipecacuanha, diluents, and the warm bath, will determine actively and advantageously to the skin, and in this way serve still farther to abate the fever. In the secondary stage, after evacuations by bloodletting and purgatives and the mixed treatment just described, opiates, such as Dover's powder, or acetate of ammonia with laudanum, will come in quite appropriately. Free dilution by aqueous drinks, or with slight additions of mucilage and acids, whilst it allays thirst, tends not a little to mitigate the violence ofthe disease by exerting an influence of a much more kindly nature on the gastro-intestinal surface than could ensue from forced evacuations by the continued or frequently repeated use of purgatives. Without denying the utility of tonics in infantile remittent and me- senteric fevers, sustained as these are by gastro-intestinal, and at times peritoneal inflammation, I cannot but think, judging from my own expe- rience, that more reserve should be practised in the exhibition of this class of remedies. So soon as the existing irritation, whether sustained. HECTIC FEVER, AND MARASMUS. 213 HECTIC FEVER, AND MARASMUS. Not a few, both of the preceding and following complaints, are sometimes found to induce a confirmed hectic fever, and marasmus, called by some writers atrophia lactantium, though it often comes on too late properly to admit of the name. I have nothing new, indeed, to offer on this disease when it is far advanced, unless it be by way of encouragement to hope for a better issue in the hectic fever, under certain circumstances, than we are wont to expect. This fever, as it is apt to arise from other complaints, is very by inflammation or not, is removed, the digestive apparatus and the other organs of nutrition act with great readiness and energy in children ; and hence we are required to do little more than present adequate supplies of nutriment, in order that the functions shall recover their tone, and con- valescence be rendered complete. Next to food, the best and natural reme- dies are fresh air, with bathing in tepid water, frictions, and very moderate exercise, — that of a mixed kind, or riding in a carriage, being preferable. Ofthe alterative class, mineral waters, natural or factitious, are the best. Enlargements and indurations of the mesenteric glands—a symp- tom which has given a name to the fever, are themselves but the effects of prior inflammation and ulcerations of the intestinal mucous membrane. Little progress can, of course, be made towards the cure of the first mentioned morbid state until the latter is removed. An ad- mission of this pathology of the disease will prevent recourse to the various special remedies, or modes of treatment, which have been, at different times, considered to be indispensable for the resolution of the tumefied mesenteric glands. Seldom, however, are the lacteal glands alone affected in children who are the victims of mesenteric fever and tabes mesenterica: the lymphatic glands are also diseased, and we have clear evidences of scrofula and the development of that which is termed the strumous dia- thesis. For the recovery of this class of subjects, some of whom have at the same time symptoms which are supposed to indicate the presence of worms, active but not repeated purging will constitute a proper if not indispensable preliminary to the other parts of the treatment. These cannot, however, be laid down with much minuteness of specification, varying, as they must, according to the predominance of gastro-enteric or of cerebral or pulmonary irritation and the modifications caused by the degree of fever present at the time. Cough and hectic fever readily inducing suspicion, and at times with too much truth, of pulmonary tubercles, are found at others to be merely symptomatic of disease in some ofthe abdominal viscera, and of these, chiefly, the intestinal mucous mem- brane and the mesenteric glands. When the stage for the exhibition of alteratives is reached in mesenteric fever and in tabes mesenterica, the medicine on which I place the greatest reliance is iodine; and of its various preparations, the best and safest is the ioduret of potassium (hy- driodate of potassa). Useful adjuvants are procured from the class of simple bitters and from sarsaparilla. Inunction of the ointment of the ioduret on the inguinal regions and lower part of the abdomen will be one of the means for its introduction into the system. 214 UNDERWOOD ON CHILDREN. often owing to their having been imprudently treated, or imper- fectly cured, especially by suppressing some eruption or discharge from the skin, or incautiously stopping a purging during the time of teething. In such cases, and, indeed, whenever the hectic fever is of some standing, the mesenteric glands become indurated, greatly increased in size, and often suppurate; the belly getting large, though the limbs and other parts become emaciated, which state has been considered in the former chapter, and has been shown to be curable, or otherwise, according to the degree of induration, and the length of time it has existed. But there is sometimes a threaten- ing appearance of hectic fever, where, nevertheless, nature effects a salutary and wonderful change, and will restore the emaciated infant as from the very jaws of death. And this, indeed, is often the work only of nature, art doing no more than superintending, and preventing her being counteracted by the use of improper medicines or diet. Nature alone will, indeed, oftentimes effect wonders for infants, and far beyond anything to be expected in adults, if she be not officiously counteracted. And the reason is obvious; it being well observed by a late equally good writer and physician,* that " there is, in truth, a greater luxuriancy of life and health in infancy, than in any other period in life. Infants, it is acknowledged, are more delicately sensible to injury than those advanced in life; but to compensate this, their fibres and vessels are more capable of dis- tension, their whole system is more flexible, their fluids are less acrid, and less disposed to putrescence ; they bear all evacuations more easily, except that of blood ; and, which is an important cir- cumstance in their favour, they never suffer from the terrors of a distracted imagination. Their spirits are lively and equal; they quickly forget their past sufferings, and never anticipate the future. In consequence of these advantages, children recover from diseases under such unfavourable symptoms as are never survived by adults. If they waste more quickly under sickness, their recovery from it is quick in proportion, and generally more complete than in older people ; as diseases seldom leave those baneful effects on their constitutions, so frequent in adults. In short, a physician ought scarcely ever to despair of a child's life, while it continues to breathe." In further support of this sentiment, it may be observed, that their complaints are not often attended with acute fever, like those of adults; which, however salutary in some instances, is, from mismanagement or otherwise, more commonly disposed to break-up the system, than to rectify the machine. The above-mentioned salutary turns in the true hectic fever, as far as I have observed, are chiefly in that species of it arising from worms, or teething ; and in which I have known recoveries after hope had long been given up, and all attempts been laid aside. * Dr. Gregory— Comparative View of the State and Faculties of Man with those ofthe Animal World. 1785. HECTIC FEVER, AND MARASMUS. 215 There is, indeed, an atrophy in infants for want of the breast, or from the unsuitableness of it, (which is the true atrophia lactan- tium,) or of whatever else maybe the child's ordinary food, as I have instanced in another place; but this is not usually attended with fever, and is to be cured merely by making that change, which the nature of the different occasions points out. Harris recounts some remarkable recoveries in what he calls the atrophia verminosa, and attributes the cure to the free use of the hydrargyrus cum sulphure, carefully prepared, but I have seen none so marvellous as in the atrophia dententium. In this I have known children,after being reduced by purging, and other complaints, lying for three months together in the cradle, scarcely fit to be moved, with continual fever, flushed cheeks, emaciated countenance and limbs, a large belly, incessant cough, and almost without taken any nourishment, re- cover, as it were, in a few days, upon rapidly cutting half a dozen teeth. After what I have said on the true hectic fever, it will not be expected that I should offer much on the head of medicines; I shall, therefore, only observe, that the chief object in this advanced stage of the disease is an attention to the state of the bowels. This will be found to vary frequently; sometimes calling for restringents, and at others, opening remedies. In a view to the former, Syden- ham's rhubarb-beer* is a very good medicine. Also, purging with mercury, if that has not already been done, should even now be attempted, since children in this state will often bear stronger doses of purging medicines, and more frequently repeated, than under any other circumstances; to these may be added, the artificial Seltzer, or soda water. Attention,like wise, should be paid to the diet, which ought chiefly to be of milk, rice, semolina, and such like, with light puddings ; but, above all, children should enjoy plenty of fresh air, and take as much exercise as their degree of debility may admit of. In Dr. Armstrong's second edition, is a pretty long chapter on the hectic fever of teething children, wherein several medicines are prescribed, which the Doctor apprehends may be very serviceable early in the disease. He speaks of it as a very common complaint, beginning like other fevers, and gradually becoming remitting; then a slow continual fever, and terminating in a fatal hectic. Dr. Butter likewise expresses himself much in the like manner, in an accurate account he has given of a fever that frequently made its appearance, as it should seem, in Derbyshire, which he terms the infantile remittent fever, of which further notice will be taken in its place. * Take of choice rhubarb sliced, two drachms ; let it be put into a glass bottle, well stopped, with a quart of small beer, or any other liquor the child may make use of. This medicated beer is to be his ordinary drink. When this quantity is drank, a second, and a third quart of beer may be poured on, as before ; after which the rhubarb will commonly have lost its virtue. Should the beer first poured on be too much impregnated with rhubarb, and purge too much, another pint may be added presently after the first is drank up. 216 UNDERWOOD ON CHILDREN. It is very probable, that a fever of the description given by Dr. Armstrong, may be common among paupers, relieved at dispensa- ries, and may deserve such a name; but, I believe, it will be rarely met with in higher ranks of life, and if so, perhaps, that ought to have been intimated in a popular work. It seems to me, (and both Dr. Butter and Dr. Armstrong, indeed, say as much,) to arise from improper food and nursing, joined with crudities and a costive state of the bowels, and has nothing uncommon in it. When advice is sought for in proper time, it, accordingly, appears to be nothing more than the fever I have described, arising from a foul state of the bowels, aggravated by neglect; and is easily cured by such medicines as are best calculated to clear the first passages. Should this, however, not be attended to, it may degenerate into a con- tinual fever, but it is not even then peculiar to the age Dr. Arm- strong has specified, nor, by any means, the common hectic fever of dentition. At this period, indeed, children call for more exercise, air, and general attention, than common people can procure for them; it is, therefore, not to be wondered at, if neglected and costive, they should at this time fall into slow fevers, whether aggravated or not, by the shooting of their teeth. FEBRIS SCARLATINA--WITH OR WITHOUT ULCERATION OF THE THROAT. Whenever the scarlet fever becomes epidemic among adults, children rarely fail being attacked by it, in great numbers, and frequently sink under it. It is, indeed, rather a child's disease, and very contagious among them, but is not often* communicated from them to adults. It has engaged the pen of the most able phy- sicians, and is therefore well understood in this day, and needs only, on this occasion, to be adverted to as one very incident to children, and its most approved method of treatment briefly pointed out. The scarlet fever, with ulcerated throat, has, perhaps, been distinguished in too refined a manner, by some writers, into the scarlet fever, with malignant ulcerated throat, and the malignant sore throat, with efflorescence, or redness on the skin. But such distinction, it is apprehended, is needless, since the experienced practitioner will always be guided by the degree of tendency in the system either to an inflammatory or putrid diathesis; and the less experienced will only be perplexed by multiplied distinctions. One observation, indeed, may be offered on this head, which is, the propriety of distinguishing the mild scarlet fever (in which the throat is much inflamed, and slightly affected with superficial and * This observation appears to be incorrect ; very many instances of the com- munication of Scarlet Fever from infants to adults having happened : every necessary precaution, therefore, ought to be taken to prevent the spreading of the infection. — S. M. FEBRIS SCARLATINA. 217 white foulness, rather than slough,) from the more malignant kind, in which the tonsils are less swelled and florid, and exhibit the precise complaint by some practitioners termed the angina maligna, with efflorescence on the skin. An error in this respect, has cer- tainly led less experienced practitioners to administer both bark and wine too early and liberally in the mild scarlet fever, which has thereby degenerated into a low remittent, bordering on hectic ; and unless the treatment has been changed in a little time, has endan- gered the life of the patient. The mildest species of scarlatina anginosa should also be care- fully distinguished from the true inflammatory affection of the tonsils, which it will sometimes resemble in its first stages: but the genuine marks of the two diseases, and the cast of the epidemics reigning at that time, will direct the attentive practitioner, who will, in less certain cases, take a middle course in his method of treat- ment, till the characteristic symptoms of either shall become more evident. There is, however, a scarlet fever that is not attended with any affection of the throat, and was long ago described by Sydenham,* though not much insisted upon by later writers, which is attended with a harder pulse, and other symptoms of an inflammatory dis- position, but nevertheless, in every instance that I have met with, calls for the same general treatment, only more cautiously adapting the necessary cordials and tonics to the degree of fever, especially in the commencement of the complaint. The febris scarlatina of every species begins with the common symptoms of fever, often with languor and disposition to fainting, sickness, a quick pulse, and pain in the head. The eyes are in- flamed, and where the throat is affected, there is frequently a stiffness of the muscles ofthe neck very early in the disease, which is soon followed by some difficulty in swallowing. The affection of the neck should be carefully inquired into, especially in younger chil* dren ; the soreness of the throat being sometimes not complained of in the most severe attacks ofthe disease, until but little prospect remains of any mode of treatment being attended with success; a circumstance I was early in practice much astonished at by find- ing children swallowing with apparent ease, and denying having any soreness of the throat, when I have found the tonsils both tumid and covered with specks. The fever generally increases in the evening, and is often accompanied with transient fits of delirium; but some remission takes place towards morning, with sweating : and on the second or third day, the efflorescence appears on the skin, and generally first on the face, neck, and breast. At this time the parts tumefy, especially the hands and feet; and the patient complains much of pain in the head; is comatose, or very restless, and is at times delirious; the tongue is in the beginning very white and dry, afterwards becomes foul, and then * See also Withering and Cullen, 19 218 UNDERWOOD ON CHILDREN. of a florid red. About the fifth day, there is usually a remission of fever, and the eruption then beginning to scale off, disappears about the seventh. If the disease has been violent, the patient is about seven days more in a low state ; and it is oftentimes a fortnight longer before he recovers his strength and spirits, and in some cases, is distressed with foul abscesses on the outside of the neck. In other instances, after the efflorescence has dried off kindly, an appearance resembling the true gangrene has sometimes seized the whole palatum molle, and the fever has been rekindled; but the parts recover their natural appearance after a few days, without any eschar being thrown off. The limits of this work allow me only to observe, that the method of cure being directed to the two indications ofthe general diathesis, and the affections of the throat, the nature and extent of these must ever be kept in view, and the system be duly supported. Should the body be costive at the time ofthe attack, an opening medicine should be given previous to the administering of bark or cordials. The throat should be often gargled, or rather syringed, with mucilaginous infusions or decoctions, rendered more or less stimu- lant ; such as the decoct, hord. with mel. rosse, warmed with spir. ammon. comp. tinct. myrrhas, decoct, rad. serpent, or other such like preparations: though the quality of the gargle is, perhaps, of far less importance, than its being frequently made use of, which is absolutely necessary, especially in young children, in order to keep the mouth tolerably clean ; otherwise the difficulty of deglutition will be greatly increased, as well as the morbid mucus be conveyed into the stomach. On this account, also, the patient ought to wash his mouth previously to taking his medicines or drink. — In many cases, where the parts are in constant pain, syringing the throat frequently with warm water, is found to administer immediate relief. This fever, especially when epidemic, being almost constantly of a low type, the physician must not trust to saline draughts, or other medicines of that class, without the addition of the conf. aro- matica, radix serpent., or the bark, in one form or other. A mo- derate quantity of wine, likewise, according to the age and other circumstances of the patient, should be given with the food, which should consist of whey, caudle, and such like thin and nutritious aliments, with plenty of barley-water, or gruel, with a view to pro- mote a moderate perspiration. Should the affection ofthe throat, therefore, be evidently inflam- matory, or should a case occur where the fever may seem to be of that kind, (which may be better ascertained by the hardness of the pulse than any other symptom,) it will very rarely bear bleeding, even in the beginning of the disease ; as symptoms of debility gen- erally attend in some period of the scarlet fever, and will allow only of that middle course of treatment, hinted above. In a general way, a cordial plan is required throughout the dis- ease, and where the throat is much affected, either with sloughs, FEBRIS SCARLATINA. 219 or total blackness, the bark is indispensably necessary, however thick and florid the rash, or however hot and dry the skin may be ; the bark, in moderate doses, as it were, extinguishing the fever in the milder species, above every other remedy, (when evidently called for,) and in the more malignant it supports the system, till the regular stages of the fever are accomplished, and a perfect crisis is formed. Young children take it very well, especially the soft ex- tract, dissolved in a strong decoction. Should it be disposed to purge the child, a little of the spirit cinnamomi, or a drop or two of the tinctura opii, should be added to it; or if the child, on the other hand, should be two or three days without a stool, a laxative clyster should be injected. Where delirium attends, a few drops of laudanum are often very serviceable. If there is much exter- nal swelling about the neck, blisters to the part are frequently very useful. A very unpleasant turn of the complaint is a secondary fever, which has already been hinted at, as being sometimes the conse- quence of administering bark and wine too early, or too liberally, in the milder scarlatina. In such case, upon the disappearance ofthe rash, the limbs, especially the hands, continue swollen, and a general soreness takes place; the patient loses all appetite and strength, and a tendency to hectic fever supervenes. The bark in this case is no longer useful; but soft demulcent medicines, and light cordials, should be administered, with asses' milk, and a light nourishing diet (if the pulse be not full) ; costiveness should likewise be ob- viated, and country air had recourse to, if the patient should not soon appear convalescent. If the fever be considerable, purging with calomel, of which I can scarcely speak too highly, is acknow- ledged also, by most physicians, to have an immediate good effect, and should be repeated as long as the fever continues : a small bleeding also, where the pulse is full, or hard, is sometimes neces- sary ; and a critical bleeding from the nose, though in a very small quantity, having sometimes instantly abated the fever, when the state of the child has appeared very hazardous, and the prostration of strength been considerable. In some foreign parts, particularly Sweden, convalescents from this fever are many of them seized with a partial, and some, a more general anasarca, which often proves fatal. Whether this be the natural course of the disease, or the consequence of improper treat- ment, may be doubted, as their best physicians seem to consider it too much of a kind with the measles; and therefore may direct too cooling a regimen and medicines.* * The consequences of scarlet fever here mentioned are not confined to Sweden. Anasarcous swellings of the extremities, and sudden effusions into the cavities of the chest and abdomen, are by no means uncommon terminations of scarlatina in this country, particularly among the poorer classes of society, where the accommodations and diet of the sick are not favourable to good recovery.— S. M.(t>) (v) The objection which will be brought by many readers against the treatment of scarlet fever, as set forth in the text, is its exclusiveness. In 220 UNDERWOOD ON CHILDREN. FEBRIS MILIARIS, OR MILIARY FEVER. I shall be brief on this complaint, which does not seem to be so strictly a disorder of young children as of adults, unless from con- presenting a different view I shall not claim for it, as some with more zeal than discretion have done for their particular modes of practice, cer- tainty of favourable issue and unquestionable superiority over all others. It is but right, however, that young physicians should be made aware of the important fact, that scarlet fever assumes very different characters in different years : being at one time decidedly inflammatory, and requiring an antiphlogistic treatment, — at another asthenic, and calling for revul- sives and stimulants — differences these in its pathological character which we must expect to meet with during any period of epidemic visi- tation, in children of different temperaments and constitutions. The treatment which at different years I carried out with very satis- factory success, both in extensive public, and in no inconsiderable number of cases in private practice, may be briefly summed up as follows: — If there was nausea, or any efforts to vomit, an emetic of ipecacuanha was administered; but more generally the first prescription was a mercurial purge — calomel and rhubarb, or calomel followed by oil, or rhubarb and magnesia, or epsom salts. If the fever and the difficulty of degluti- tion, with swelling of the tonsils, and a pulse with some degree of resist- ance under the finger, were manifest, I directed a small bleeding from the arm, or leeches to the throat at the part outside corresponding as near as could be with the tonsils inside. Following this was the neutral mixture, or the acetate of potassa, or of ammonia with tarter emetic, given at intervals of one to three hours, according to the exigency of the case. As the fever abated, but restlessness, wakefulness and dry skin remaining, Dover's powder in moderate dose was given with good effect. The drinks were, for the most part, cool, and acidulated either with lemon juice or cream of tartar, unless those of a different temperature and flavour were particu- larly desired by the patient. Attention was paid to the state of the bowels, so that they should be daily moved. Sometimes this object was obtained by laxative enemata, or by salt dissolved in warm water — more frequently a laxative was given similar to those already mentioned. The sick chamber was kept well ventilated, and, unless in the very midst of winter, fire was forbidden. Gargles of different kinds were prescribed ; but, as most physicians will readily believe, who have attended children sick with scarlatina, much oftener prescribed than applied. But the remedy on which I placed the greatest reliance, and one which more unequivocally checked, and abated where it did not check, the fever, and soothed most the feelings of heat and thirst of the patient, was the cold bath, — used sometimes by immersion, but more frequently by affu- sion. The temperature of the water, being that of the river, varied from sixty to seventy degrees, according to the season — summer or autumn. The conditions (which 1 prescribed to myself) for the use of the cold bath, were, chiefly, a diffused eruption over the skin, and a high heat of this surface, — with frequency of pulse, thirst, dry tongue and great rest- lessness. Difficulty of deglutition was rather an impelling motive than otherwise for the use of the cold bath. In cases of less vascular and cuta- neous excitement, occurring primarily or in a somewhat advanced state FEBRIS MILIARIS, OR MILIARY FEVER. 221 tagion : though I have seen one or more instances of it, where no other person in the family has been so affected, and without its spreading to any other. of the disease, sponging the surface with cold water, or affusion with tepid, was practised with pleasurable and salutary results to the patient. Perhaps the reader will not find amiss my repeating here the language which I used some years ago in my work on Baths and Mineral Waters: " In scarlet fever, cold bathing has displayed the best effects. Here a priori we should anticipate much from it. The skin of an acrid heat, high mem- branous irritation involving the reticulated capillary and nervous tissues, without corresponding excitement of the general bloodvessel system, is a state of things calling for the sedation of cold, without allowing of exten- sive sanguineous depletion. The disease is almost purely membranous, and restricted to the muco-cutaneous surfaces : on these the cold bath operates with promptness and decisive effects, since the impression pro- duced on the skin is felt almost at the same moment throughout the diges- tive mucous surface." p. 131. That we are often imposed on by the simulation of inflammation in scarlatina, and are led to a wrong practice in consequence, is too well known to every physician of common experience. The interruption to the pulmonary circulation and to the decarbonation of the blood, by the mucous membrane being the seat of an analogous change to that in the skin, gives rise to hurried and laboured respiration, frequent pulse, a deep suffusion of the face and lustrous eyes ; but which are not here the results or the concomitants of inflammation. In some anemic subjects, the poison seems to act more immediately on the brain and nervous system, causing an alarming and often incurable prostration and stupor, which the most powerful stimulants are inadequate to remove. Still less is to be hoped for from depletion by bloodletting and purging, which some have recourse to under these circumstances, from a belief that there is cerebral congestion. I have been not a little surprised, in a post mor- tem examination of some of these cases, to find no alteration either of the brain or its meninges, nor, in fact, any lesion of membrane or viscus in other parts. If we propose, after a survey of cases of this description, to employ the stimulant plan, this ought to be used with great caution, having a greater reliance on revulsives applied to the cutaneous surface after the administration of a mild emetic, than on internal diffusible stimulants. The warm bath, rendered more stimulant with mustard, or chlorine intro- duced by the addition to the water of chloride of soda, or of lime, will answer a good purpose. Frictions along the spine and of the extremities will contribute to the same endT With internal stimuli, as ammonia, Hoffman's liquor, wine whey, &c, we may advantageously combine cer- tain medicines which act on the kidneys, even though they be of the seda- tive class, viz.: digitalis, and the vinous tincture of colchicum. Under judicious restrictions these last, and others of an analogous nature, will probably be the ones on which our faith will settle down, in the treatment of the mixed form of scarlatina, and in which, with symptoms of great depression, there is, also, inordinate action of the heart and bloodvessels. Medicines of this class, sedative'diuretics, will also, more probably, whilst abating the violence of the disease, prevent, also, the supervention of anasarca, or of dropsical effusions into any of the serous cavities. 19* 222 UNDERWOOD ON CHILDREN. The miliaria, or red eruption, is preceded by the usual symp- toms of fever, together with much itching ofthe skin, and a very profuse perspiration; which, however, procures no remission of the fever, until the eruption takes place, which is at the latest on the third or fourth day. It very much resembles the measles, but is a little elevated above the skin, giving it a very rough feel. It is sometimes intermixed, from the beginning, with very small crystallines, which, on the other hand, often do not appear for a day or two afterwards, and come out in successive crops, especi- ally if the child be kept over hot. Some of the red eruptions are often larger than others, and resemble those in the scarlet fever, with which the miliary rash is also sometimes thought to be mixed, in seasons when eruptive complaints are very rife. Previous to the eruption, as well as some time afterwards, the patient is usually very thirsty; is hot and cold by fits, and the breathing is short and difficult. The urine is high coloured, there is a slight delirium, and sometimes a sore throat, especially where the eruption is broad and very florid. Children generally revive as the rash comes out freely; but unless the complaint be very slight, the fever is rekindled, and they acquire no appetite for food until the eruption begins to turn dry. This fever being of the low kind, is attended with great lan- guor, and calls for support; on which account both the medicines and diet should be of the cordial kind. White wine whey, and wine in the panada and sago, in proportion to the degree of de- bility, are generally necessary, even for children of only a year or two old. The saline draught, with confect. aromatica, and mis- tura camphorata, is a good general medicine ; and if the symp- toms are more agravated, the bark, volatile alkali, and the spir. aether, vitriol, compositus ; blisters too are often very useful. A stool should be procured once a day, by means of a clyster, or of a little rhubarb ; and plenty of drink be allowed, which may be slightly acidulated, and at times taken cool. The chamber should be kept airy, but the child screened from the wind, and be con- fined to the bed until the rash disappears. If on the rash dying away, which in the milder species is in three or four days, no fresh eruption should take place, the appe- tite and spirits soon return: and only a little rhubarb,or other gentle laxative, is required, with the usual cautions in regard to diet, so necessary for every convalescent, and especially children, who have no discretion of their own. But if fresh crops appear, and the fever returns, the former plan must be continued; but if without fever, a few doses of physic, and quitting the warm bed, will probably put an end to the complaint. CYNANCHE PAROTIDEA, OR MUMPS. This is a tumour of the neck and throat, giving that peculiar cast of countenance from which the complaint has acquired the CYNANCHE PAROTIDEA, OR MUMPS. 223 English name.* It is usually only a slight disorder in children, but as it advances, the skin becomes inflamed, putting on a light damask-rose colour; but the parts very rarely suppurate, which is the more remarkable, as the disorder seems to be situated in the cellular or adipose membrane. This, however, does sometimes happen, but the abscess usually heals kindly. It is a complaint rather of young people than of infants; but frequently attacks children of five or six years of age. It is cer- tainly contagious, and is often an epidemic disease. It begins with the common symptoms of fever, which are usually slight, but the tongue is frequently covered with thick fur, or is very white. The patient complains early of a stiffness and pain of the neck, and generally the next day of a soreness of the throat; but this seems oftentimes to be merely symptomatic, the tonsils being rarely in- flamed. At this time a fulness of the neck may be discovered, which gradually extends to the throat, and the parts become tender to the touch, and, in some instances, the pain is exceedingly great, and recurs suddenly with almost regular intervals. The tumour generally continues to increase for two or three days, and then as gradually subsides. In general, very little medical treatment is required, it being sufficient to confine the patient to the house ; at most, to give, night and morning, a few grains of the pulv. contrayervae com., with, or without, a small proportion of nitre, and to procure a stool once in twenty-four hours. But should an unusual degree of fever attend, as is more common in such as are advancing towards puberty, bleeding will be found necessary in the beginning, and the patient should be kept in bed for the first or second day, and take a saline draught with nitre, once in six or eight hours. On the other hand, should it be attended with any uncommon languor, the conf. aro- matica may be given instead of the remedies before mentioned. When the swelling is thoroughly subsided, two or three gentle laxatives may be administered at convenient intervals. In a few instances, after suppuration has taken place, and the sores are healed up, a hardness of the parotid and maxillary glands remains, which is usually soon dispersed by rubbing a little mer- curial ointment, or sometimes by only anointing with the common linimentum ammoniac. Should it, however, prove tedious, a few doses of calomel, and common laxatives, should be exhibited at proper intervals. In adult males, or such as are growing up to manhood, the tumour of the neck has sometimes been found to subside very suddenly, without any abatement of the fever, and then the testicles have been as suddenly inflamed ; which is attended with more pain and fever than the swelling of the neck, and is cured more slowly; upon this metastasis, bleeding is always proper, though these parts have never been found to suppurate.t [* Mumps; sullenness, silent anger. — Johnson.] t A swelling ofthe testicles, attended with pyrexia, but unaccompanied with 224 UNDERWOOD ON CHILDREN. A translation from this part again, is sometimes very suddenly effected, and the irritation then generally falls upon the brain; and the worst consequences are justly to be apprehended. Every- thing necessary and proper for the true phrenitis is then speedily to be had recourse to, and the tumefaction invited to the parts it has left; and until that can be effected, the patient will be in great danger. Such a metastasis is much more common in North America than in these islands. HYDROCEPHALUS.* This complaint is distinguished into the external and internal; in the former the water lies upon the surface ofthe brain, over the pia mater, but in the latter it is seated much deeper, within the ventricles. Children are sometimes born with their heads enlarged from hydrocephalus externus, and are then commonly born dead. At other times it makes its appearance sjon after birth. I have known three children under this disease arrive at full ten years of age,t who were then unable to walk, or even sit upright in a chair. From a late instance, however, I have learned, that when no symptoms of hydrocephalus appear at the birth, although the enlargement should be manifest very soon afterwards, and increase rapidly, the water is sometimes, at least, contained within the ven- tricles of the brain :% and from the circumstance of no children living long with an internal hydrocephalus, but such whose heads enlarge within a few months after birth, I should suspect the dis- order has, in such instances, taken place in the womb. The foetus, at this time, enjoying only a kind of vegetative life, may come to maturity under such a disease : various instances being met with, in which full-grown foetuses have had neither head, nor heart, nor lungs. Accustomed to the above-mentioned disease, we may pre- sume such infants more likely to live for a certain time with water in the ventricles, than those in whom the disease is supposed to take place suddenly after birth. In the instance alluded to, the child's head began to be sensibly enlarged when the infant was about four months old, and the child lived to the fifth year, unable to walk, or even to support its head. Upon a careful examination of the parts after death, the water, to any affection of the glands of the face or throat, was epidemic not long since at Wallingford, in Berkshire, as reported by Mr. Golding. [* There is a valuable paper upon this disease by Dr. Mills, in the Trans, of the Col. of Phys. in Ireland ; vol. v., p. 350. — M. H.] f See Medical Communications, vol. 1., in which there is mention of two people then living, one of whom had attained the age of twenty-nine, and the other forty-five years ; the former did not appear to have any enlargement of the head for three weeks after birth. X In the Medical Journal, vol 2, p. 1, an instance is related by Mr. E. Ford, of a child seized with symptoms of water in the head, at the age of nine years, who lived eleven months afterwards; during the last eight of which he was un- able to stand upon his feet. After death, the sutures were found to be separated to a considerable degree, the ventricles containing eleven ounces of water; but there was no water exterior to the brain* HYDROCEPHALUS. 225 the quantity of three pints, as I am informed by the surgeon, was evidently contained within the ventricles, which were so stretched as to compress the brain in such a manner that it appeared only like a smooth thick membrane within the dura mater ; and of all the solid contents of the skull, scarce anything but the cerebellum remained. Tulpius, Hildanus, Vesalius, and Morgagni, have noticed the like in children from two to five years of age; and it must, therefore, be still more likely to happen where the hydroce- phalus internus has taken place in the foetus in utero, where the brain is much more tender. Dr. Whytt, of Dublin, likewise, men- tions no less than three instances of the same kind, in which the brain was so compressed by the great quantity of water within the ventricles, as to put on the appearance of only a small gland. The external hydrocephalus, at whatever period it may com- mence, has always been esteemed a fatal, as well as most distress- ing complaint; but I have been informed, that where the disorder has not been very manifest at the birth, blisters on the head have sensibly diminished the bulk. These should be applied, succes- sively, to different parts, especially along the top of the head, in the course of the longitudinal sinus, so as to keep up a constant discharge ; which may possibly, in some instances, effect a perfect cure: at least, the advantages already observed are sufficient to justify the attempt, in a disorder hitherto esteemed incurable. In a publication by Mr. Hill, we have the account of an effectual cure, under the employment of oxygen gas, after the head had acquired an enormous size.* Of the internal watery head, it may be proper to treat more largely. This melancholy disorder seems not to have been dis- tinctly known to the ancients, though there can be little doubt it must often have been met with ; but the want of those frequent ex- aminations of dead bodies which the moderns have made, deprived them of opportunities of distinguishing this disease from affections of the head, arising from other causes. Hieronymus Mercurialis,t who wrote in the beginning of the sixteenth century, was perhaps the first who mentions the disease as having its seat in the ventri- cles. Wepfer also just says, the water has been found within the cavities of the brain. J Boerhaave, Petit, and others, have likewise spoken of it; but no author, I believe, described it at all accurately before Dr. Whytt, who wrote expressly on the internal watery head, anno 1768. But it has not been generally noticed, that the water lies sometimes between the pia mater and the brain, as it is found to do in maniacs; and I have met with it both there and in the ventricles, in the same subject, and always in infants under two years old. The hydrocephalus usually takes place between two and ten * Practical Observations on the Use of Oxygen, or Vital Air, in the Cure of Diseases, &c. f Opuscula Aurea, Lib. de Morbis Puerorum. \ Histor. Apoplecticorum. 22G UNDERWOOD ON CHILDREN. years of age ; but I have known many instances of water in the head being found after death, in children under two years of age. I have noticed this early appearance twice in the same family; the infants also dying suddenly without any previous mark of the disease ; but as no dangerous symptoms of any other kind attended, it can scarcely be doubted, that the water found in the ventricles was in these instances the true cause of the sudden death ; as I am satisfied it hath sometimes been in others, by producing a fit. This complaint, however, at whatever early period it may com- mence, is also found sometimes to take place later than the tenth year. It is a like dangerous complaint with the hydrocephalus externus, and the method of treatment not yet well established ; and as it can scarcely be ascertained whether any have recovered from it, (the certainty of its existence rarely being known but by examination after death) it is not likely that a very determined and successful treatment will shortly be settled. It may arise from falls and blows on the head, from scirrhous tumours and excrescences within the skull; a watery state of the blood, or a lingering illness. It may likewise, probably, be owing to pressure on the brain, and fulness of the vascular system from other causes, as conceived by Dr. Quin. I have, at least, met with one case, in which there were all the usual symptoms of water in the ventricles, and the late Dr. Warren, whom I met on the occa- sion, was fully of that opinion. But upon examining the head thirty-six hours after death, a great number of sharp points of bone were found, and especially of the spinous process of the os frontis, which was most uncommonly long and sharp. The vessels were all found very turgid with blood, and there were light, flaky ap- pearances on the pia mater, similar to those found on the perito- naeum, pleura, and other membranous parts in a state of inflamma- tion. In this case, only half an ounce of water was found in the ventricles. A similar remark is made by Mr. Edward Ford,* who observes, that more remote causes may be an inflammation of the vessels of the pia mater, which may owe its origin to the measles, small-pox, scrofula, and other complaints ; which may affect the brain in the same manner they do the mesenteric and other glands, (w) As the disease may originate from such different causes, there can be no doubt that it may sometimes be a chronic disease, and its appearances very insidious. It appears, likewise, to be a family complaint in some instances, for I have known six children, born of the same parents, die successively of it at the age of two years, five of whom were afterwards opened. Children with a large head do not seem to be more subject to this disease than other children. * London Medical Journal, vol. 2, part 1. {w) This idea of the occasionally scrofulous origin of the disease has been recently put forth and suitably extended by Drs. Gerhard and Rufz. HYDROCEPHALUS. 227 The attack is sometimes very sudden ; but the complaint more commonly begins with the appearances of slow fever, especially in older children, with debility of the arms, and pains in the limbs, and frequently in the upper part of the neck. It has also been remarked, that, in the commencement, the child has appeared to be more acute and lively than ever before; but the spirits decline as the disease advances. After a while, the child is suddenly seized with pain in the head, and generally in the fore part, and retches once or more: it becomes heavy and dull; can bear no posture but that of lying horizontally; the pulse becomes irregular, but usually very slow ; in the progress of the disease the faculties and senses are impaired, and the eyes offended by the light; the patient sees objects double, and becomes delirious. As the disease advances, the pulse grows frequent, the cheeks become flushed, the pupils of the eyes are dilated, the stools and urine come away involuntarily, and the patient lies sleeping, or is convulsed, and at times in great pain. In the youngest subjects, 1 have known it begin with a cough, quick pulse, and difficulty of breathing, attended with circumscribed flushed cheeks, as in teething, recurring on every little exertion; with continual fever and costiveness, and sometimes a discharge from the nose and eyes. Other symptoms, indicative of the disease in very young subjects, are, a hand often put to the head, or lifted upwards, and waving about; vomiting; costiveness; expressions of anxiety, and dislike to be moved: at other times, an unmeaning look, and marks of insensibility; the fingers often clenched, and hands tumid; drowsiness ; picking of the nose ; and grinding of the teeth during sleep, as in the case of worms: the eyes are in some cases impatient of light, in others, vision is so imperfect that the child does not regard any objects, however close to them; and before this period, one, or both the eyes, are in many instances turned towards the nose. The pupils are often not dilated till near the close of the disease, and such young patients sometimes hear and comprehend, and take food to the last, and die suddenly upon the decline of the febrile symptoms, when they have been thought to be recovering. These, and other symptoms, however, laid down as indications of water in the brain, are, in some degree, common to other diseases of children, especially the dilatation of the pupil and sleepiness, in fevers arising from foul bowels, which, I am persuaded, are sometimes mistaken for the fever of hydroce- phalus. In such cases, some children have been erroneously though to have recovered from this disease, especially if calomel has been administered, though with another view; while others have perished from improper treatment, and mistaking their com- plaint. Perhaps, the most decided symptoms early in the disease (at which time it is of the most importance to ascertain it) are, an inclination to lie on the back, and unwillingness to be moved, and an increase of pain in the head upon being raised from a supine to an erect posture, but especially an almost constant drowsiness, 228 UNDERWOOD ON CHILDREN. and a tendency to fall asleep, after being roused by being lifted up, or otherwise disturbed. Sometimes, however, neither these, nor other decided symptoms, are found to take place until the second stage of the disease. Though it is sometimes a very short disease, and at others of many months standing, it seems always to be divided into three stages ;* which are best distinguished by the state of the pulse. In the first, the pulse is always quick, as in other complaints at- tended with fever : but the true nature of the disease is often over- looked till the next stage, in which the pulse is slow, irregular, and often intermitting ; and in the third it becomes again very quick, and usually regular. The urine frequently deposits a sediment of a light consistence, and white colour ; and the breath has an offen- sive and sickly smell, especially in the last stage. From what has been advanced, it is difficult to say if medicines are so often successful as has sometimes been imagined ; for when a patient recovers, it may be suspected he has not had the true disease. I offer this suspicion as well from my own experience, as from the doubts entertained by other writers having sometimes been persuaded (and supported in that opinion in consultations) that infants have been ill of water in the head, who have after- wards recovered from the use of medicines adapted to fever from a foul state of the bowels. Two such children, besides the dilated pupil, and other usual symptoms of hydrocephalus, lost the use of their speech (and one of them, of the sight) for several days ; but recovered after a daily discharge of very uncommon stools, resem- bling the meconium of infants. And it is very remarkable, that only calomel brought these away ; the experiment being repeatedly made by omitting it, and giving only the infusion of senna ; but upon the calomel being exhibited again, the same stools were always observed, as black and adhesive as meconium,! and in very great quantity, until the children perfectly recovered. Whatever may be supposed the immediate cause of hydroce- phalus, practitioners seem chiefly to have depended on repeated bleedings; purges with jalap, or calomel; blisters to the neck, or head; diuretic medicines, and the external use of mercurial oint- ment. A large bleeding early in the disease I have thought very beneficial, especially in children of a robust habit. The use of sternutatories, as the compound powder of asarum, or white helle- bore, have likewise been recommended by some experienced prac- titioners ; and, possibly, with some little prospect of advantage, some children having recovered in consequence of a discharge of a thin fluid by the nostrils, as Dr. 1 Iarvey acquainted me he had seen in two instances. With a view of promoting absorption, * See a treatise on this disease by Dr. Charles William Quin. — Anno 1790. f Stools of this colour take place in the month, long after the meconium seems to have been duly carried off, when infants are very dangerously ill; though it is at other times a very harmless symptom, as is remarked in the introduction, where notice is taken of suckling, and sore nipples. HYDROCEPHALUS. 229 electricity has likewise been recommended ; to all which I would add the application of a narrow caustic upon the head, along the whole course of the longitudinal sinus, instead of trusting to a small blister on the crown. Dr. Garnett has some very good remarks on this disease, which he conceives to arise from an inflammation of the brain, and says the water is not always met with: and that it may not, therefore, be the source ofthe disease, but rather an effect — that it should be treated as inflammation by cooling remedies, when assistance is called for in the first stage, which is not always the case. He remarks, that he has recovered three children by bleeding, (or by leeches in young subjects,) blisters, nitre, calomel, and mercurial ointment, and keeping the bowels open; and by the digitalis. To this I can add my own experience of early bleeding, and the antiphlo- gistic plan, having proved successful where I had no doubt of the existence of the precise disease. In regard to blisters there seems to be great propriety in the suggestion of Dr. Clarke, that they should be applied to the legs, in a view to derivation from the head. Mr. Recards, of Brentford,* speaks highly of calomel, and some drastic purgative; also of squills, (as a diuretic,) and the patient being supported by bark — for a child of eight years old, he directs as follows: — R Pulv. Cortic. Cinchon. flav. 5»« Tinct. Gentian, comp. 3ss. Aq : distil. Sjiiiss. misce. sumat. Cochl. ij. quartis horis. Every other morning, the calomel and jalap, or gamboge, or aloes, or even pulv. elaterii gr. ij. if the costiveness be very obstinate. Though I have made mention of mercury, I cannot say I have seen any decidedly good effects from its use, either as a purge or an alterative, (after the disease has been clearly ascertained,) ad- ministered either externally or internally, though I have had re- course to it very early, as well as late in the disease, and in con- sultation with different practitioners. Should the use of it, however, be determined upon, in whichever way it may be advised, it should be assisted by diuretics. Calomel is probably the fittest prepara- tion for internal use ; though the quicksilver,together with diuretics, has been thought to be administered with success in the following form, in infants of two or three years of age. R Confect Aromat. 3J« Hydrargyr. purif. §]. Simul terantur donee globuli visum fugerint. R Massae supraprsescriptae ^ss. Pulver. Scillse gr. ss. Aquas Menth. sativae ^ss. Spir. ./Ether, nitrosi. gtts. x. Misce, Fiat haustus, bis terve in die sumendus. * Medical and Physical Journal. 20 230 UNDERWOOD ON CHILDREN. The external application of mercury has, however, been more generally preferred, as acting more powerfully on the system, and creating less disorder in the bowels. Some physicians have directed it to be used both externally and internally ; and it may be so made use of very freely, as a salivation is not very easily raised in young children, especially in this disease. Though I have said that I cannot boast of success in the recourse I have had to mercury, it is proper, however, to observe, that it has been strongly recommended by Drs. Carmichael, Smith, Dob- son, John Hunter, Haygarth, Moseley, and Armstrong; but I am informed by other physicians of eminence, that they have not been so successful in the use of it; and some good arguments have lately been advanced against an indiscriminate recourse to it, by Dr. John Warren, who advises trial to be made of emetics. The digitalis purpurea has lately succeeded in one instance, and that a most unpromising one ; the patient, a youth of about four- teen years of age, having been some time greatly convulsed, and able to swallow only with great difficulty. This medicine was given in a strong tincture, half an ounce of the dried leaf being infused in two ounces of brandy, of which from five to twenty drops were taken once in five hours. It acted, as usual, very powerfully as a diuretic, but without producing any unfavourable symptoms, and though it was long ago given unsucessfully in some instances, by the late Dr. Fothergill, may be worthy of further trial; but should generally be joined with aromatics, or with assafoetida. As I am always happy in the opportunity of reflecting any light upon obscure diseases, I shall close these means of cure with some observations from Drs. Perceval* and Temple, as well as from Dr. Rush, and since confirmed by Dr. Patterson; but not having had any experience of their efficacy, I offer them only as the sentiments of the several writers. The latter is decidedly of opinion, that the commencement of this disease is always truly inflammatory, being what he calls a phrenicula, or diminutive species of phrenitis,and that it should be treated boldly as an acute disease : the aqueous effusion, he is per- suaded, being the mere effect of inflammation ; the tender structure of the brain, during infancy, very probably rendering that viscus more liable to such a consequence than it is at a more advanced age. Dr. Rush speaks of great success in treating the complaint agree- ably to this idea, and advises — 1st. Bleeding, which in some cases he directs to be repeated several times in the first stage of this disease. The second remedy in this stage is purging, plentifully and re- peatedly; to which he was first encouraged from the benefit derived from that remedy in palsies, and other cases of congestion in the brain * See Medical Facts, Vol. I. HYDROCEPHALUS. 231 3d. Blisters to the head, neck, and temples, for the relief of the pain in the head; which are, therefore, proper in any stage of the disorder. 4th. With the like view, linen cloths, dipped in cold vinegar, or ice-water, and applied to the forehead. 5th. Mercury, particularly calomel, as a purge, in any stage ; but mercury, in larger quantities, as a stimulant, as soon as may be, after the inflammatory action of the system is sufficiently subdued by previous evacuations, or otherwise. Bark, wine, opium, he says, promise success only in the last stage of the disorder, assisted by mercury, where the state of the system may call for them. If we may place much confidence in these observations of Dr. Rush, whose theory appears to be supported by plausible reasoning, and the history of several successful cases, some further light seems to be thrown upon this dangerous disease ; and the indications for the antiphlogistic plan, to which I have long been partial, particu- larly bleeding, and that often topical, and the proper use of mercury, pointed out with somewhat more precision than hitherto. The chief doubt remaining is, that his patients may have re- covered from some very different complaint, particularly fever from foul bowels; in which both the head and the eyes are often greatly affected. And this may be the more apprehended, from many of those who die of hydrocephalus being very tender, and previously sickly children, who can neither endure much evacuation of blood, nor much purging ; and in whom, indeed, there are no symptoms of congestion, either of solid fseces, bile, or other alvine stimulant. The intentions of cure, as laid down by Dr. Perceval, are very similar to the foregoing, being calculated, he says, To mitigate the pain and spasm ; To promote absorption; and To increase the serous excretions. When the pain and spasms are considerable, he advises opiates in large and repeated doses, unless there be coma, and in that case, he substitutes musk combined with sal cornu cervi. He directs repeated blisters to the head, and recommends joining the digitalis with opium and calomel; though he is inclined to think, that the good effects produced by this composition are rather attributable to the combination ofthe opium and calomel, than to the digitalis. If the mercury be disposed to run off by the intestines, he guards it further by opium. Dr. Temple* having observed, that the Doronicum germanicum administered in some paralytic affections was disposed to excite the cuticular vessels in the head, in a very extraordinary manner, producing a copious sweating of the part, was led to advise it in hydrocephalus internus ; and in one instance with marked success, in consequence of an abundant perspiration from the head. Opium and calomel were, indeed, joined with it; but as it is not known, * See his Practice of Physic. 232 UNDERWOOD ON CHILDREN. he says, that such effects have been produced from the combination of mercury and opium, he concludes that the doronicum had a considerable share in them.* Since the last edition, I am able to speak more decidedly in favour of Dr. Rush, with the very important addition, however, of opium with the calomel, and the use of the digitalis, first recom- mended, I believe, by Dr. Perceval; by which success may be expected beyond what has been experienced from any other mode of treatment, in cases decidedly hydrocephalic. As a prophylactic, or preventive, where several children in a family may have suffered by it, some writers have advised a caustic to be applied to the nape of the neck : and other physicians have thought, that the progress of the disease has been stopped, after threatening symptoms had taken place, by covering the whole crown of the head with a blister, and keeping the sore open for a year or more; of the good effects of which, I have seen one instance, in a family where the complaint had been three times fatal.t Since the last edition of this work, I am induced to add, as pre- ferable in some instances to the above severer applications to the head, the plan of covering the whole scalp with an oil-silk cap for a length of time ; first shaving the head very close, and repeating the shaving as often as the oil-silk would be raised from the head. The foregoing chapter on hydrocephalus appears to contain as much information upon the subject as Dr. Underwood could pro- cure. Since he wrote, several treatises upon this disease have been published, but they all fail to teach us how the disease is to be cured: — " Yeats's Statement ofthe Early Symptoms which lead to the Disease ;" and " Golis's Treatise, translated from the Ger- man by Dr. Gooch," may be recommended as among the most instructive. Like all who have gone before me, I must regret that I can point out no certain means of arresting the progress of this very calami- tous complaint. Yet in a few cases of cerebral oppression and * It hence appears that Dr. Temple had not seen Dr. Perceval's remarks on this disease — How very differently do men oftentimes argue from the same fact! t It may be worth noticing in this place the manner of making a perpetual blister, or what is called a perpetual issue at Edinburgh, which is, by applying a plaster, consisting of equal parts ofemplastrum cantharid. and ceras. This, it is said, does not erase the cuticle, or erode the parts under it, but leaves them entire, and suffers the hair to grow up. As these, in ten or twelve days, push off the plaster, it is necessary to leave it off; and as soon as the skin can bear the razor, to take off the hair, and apply a fresh plaster. This gives less pain, is free from the inconvenience usually attending the blistering plaster, where the cantharides are absorbed, and get into the blood, whereby a strangury is some- times brought on.. HYDROCEPHALUS. 233 oppilation, bearing so much resemblance to the early stages of hydrocephalus, as scarcely allowed me to doubt the identity of the affection, after going through the routine of leeches, calomel, purg- ings, cold lotions, &c, I have in despair of seeing anything relieve the patients, given at times the following remedies, and occasion- ally with success. First. — In about twelve cases I have given a grain of calomel, and half a grain of digitalis, every four or six hours. The most marked cases in which this did good, was in a child, a relation of the late Mr. Chevalier, with whom I was in attendance. The first symptom of the disease was an attack of convulsions. Ptyalism, and a great flow of urine were excited, and the child recovered. But it was some weeks before she regained the use of her tongue, and she dragged one leg after her for some months; when the symptoms began to yield, a blister to the head appeared to be of great service. This little girl is now in all respects well, and her mind as acute as most at her age. In cases of oppressed brain, bearing less decided resemblance to hydrocephalus, I have fre- quently seen the combination of calomel and digitalis beneficial. Secondly. — In several cases, I have given from a thirtieth to a sixteenth part of a grain of oxymuriate [bichloride] of mercury, every four or six hours. In two cases it stopped the progress of the disease, and the patients recovered. In these it produced copious olive-green coloured stools, and increased the flow of urine. One of these patients had strabismus, and the pulse was irregular, so as sometimes to intermit. Her attack took place during the process of dentition, when four molares were coming forward. The other case, that of a boy, showed from the first more distinct symptoms of hydrocephalus, and the parents, as I was informed, had already lost two children from that disease. Thirdly. — In about twelve cases I have given the tinctura lyttae, in doses of five to ten minims every four hours; and I think that in three cases the disease was decidedly arrested. In one case thero was strabismus, and the child had been several times con- vulsed. The tincture was continued till it produced most severe strangury, from which moment the cerebral symptoms began to give way, and the child recovered. Mr. Hammerton attended this patient with me. The boy, now seven or eight years old, is still unable to use, freely, one of his hands. He is obliged, in order to grasp anything, to have the fore arm supported on a table, or other flat surface. In the other two cases, severe strangury was the symptom which seemed to occasion relief to. the affection of the head. — S. M. [Hydrocephalus is generally the effect of inflammation, when it assumes the acute form, — of tubercles in the system, when it is generally of a chronic character, — or of exhaustion. Diseases ofthe head may be divided into, 20* 234 UNDERWOOD ON CHILDREN. 1. The inflammatory, the results of which are, 1. Effusion. 2. Softening. 2. The strumous, the results of which are, 1. Tubercles. 2. Slow effusion. 3. The hydrencephaloid, from, 1. Intestinal irritation. 2. Exhaustion, 8,-c. Of this last, as least known, I shall now proceed to give a detailed account. I have watched, with peculiar care, many cases of a morbid affection incident to infancy, which generally arises from circum- stances of exhaustion, but resembles, in many of its symptoms, the earlier and especially the later stages of hydrencephalus. This affection has not been noticed by practical writers as it deserves. I first gave a cursory sketch of this morbid affection in a little volume of "Medical Essays," published in 1825, but now out of print. It has since been briefly noticed by Dr. Abercrombie in his valuable " Researches on Diseases ofthe Brain and Spinal Chord," published in 182S. I read this present account to the Medico- Chirurgical Society, on the 9th of December, 1828. Lastly, Dr. Gooch treated of this affection in his excellent " Account of some Diseases peculiar to Women," published in the following year. These are all the notices I have hitherto seen of this singular and interesting disorder. The diseases of children best understood, are those which arise from irritation, and principally irritation in the stomach and bowels, and the irritation of teething, and inflammation. But there is another source of disorder in infancy, less frequent perhaps in its operation, but not less important in its consequences, and far less understood by medical men, in exhaustion. This exhaustion has its origin in early infancy, chiefly in diarrhoea or catharsis; in the later periods of infancy, in the loss of blood, with or without the relaxed or evacuated condition ofthe bowels. The state of diarrhoea has generally depended upon improper food. It has very frequently succeeded to weaning, or to other changes in the diet. The catharsis has followed the administration of an aperient medicine, which, at such a moment of disorder of the stomach and bowels, is apt to act excessively. The exhaustion from loss of blood generally follows the inappropriate or undue application of leeches or use of the lancet. I may observe, indeed, in this place, that of the whole number of fatal cases of disease in infancy, a great proportion occur from this inappropriate or undue application of exhausting remedies. This observation may have a salutary effect in checking the ardour of many young practitioners, who are apt to think that if they have only bled, and purged, and given calomel enough, they have done their duty ; when, in fact, in subduing a former, they have excited a HYDROCEPHALUS. 235 new disease, which they have not understood, and which has led to the fatal result. This question, and that of the effects of exhaustion in infants and children, open a new field of investigation. Almost all our works on infantile diseases are silent on the subject; and yet, with- * out an accurate knowledge of it, I regard it as totally impossible that we should be prepared to watch and treat the morbid affec- tions of this young and tender age. The subject must be taken up and investigated anew. All the affections which may arise from exhaustion, must be accurately observed, distinguished from similar affections arising from other causes, and traced back to their origin, and forward in relation to their remedies. In this manner some hydrencephaloid, convulsive, and even croupy affections, will be viewed in a new aspect; and we shall be preserved from some painful dilemmas into which we should assuredly fall, without this knowledge of the effects of exhaustion. But in the present essay I propose to confine my observations to one of the forms of disorder which arise from this cause, — the hydrencephaloid. It may be divided into two stages, the first that of irritability, the second that of torpor ; in the former there appears to be a feeble attempt at reaction, in the latter the nervous powers appear to be more prostrate. These two stages resemble, in many of their symptoms, the first and second stages of hydrencephalus respectively. This morbid affection has, as I have stated, usually been first induced by some change in the diet, by which the stomach has been loaded or disordered, and the bowels perhaps affected with diarrhoea ; and this latter state has frequently been exasperated by the untimely administration of an aperient medicine. The infant becomes irritable, restless, and feverish ; the face flushed, the sur- face hot, and the pulse frequent; there is an undue sensitiveness of the nerves of feeling, and the little patient starts on being touched, or from any sudden noise ; there are sighing and moaning during the sleep, and screaming; the bowels are flatulent and loose, and the evacuations are mucous and disordered. If, through an erroneous notion as to the nature of this affection, nourishment and cordials be not given; or if the diarrhoea con- tinue, either spontaneously, or from the administration of medicine, the exhaustion which ensues is apt to lead to a very different train of symptoms. The countenance becomes pale, and the cheeks cool or cold: the eyelids are half closed, and the eyes are unfixed, and unattracted by any object placed before them, the pupils un- moved on the approach of light; the breathing, from being quick, becomes irregular and affected by sighs; the voice becomes husky, and there is sometimes a husky teazing cough; a slight erythema- tous or uphonous affection of the palate and fauces ; and, eventu- ally, if the strength of the little patient continue to decline, there is crepitus or rattling in the breathing; the evacuations are usually green ; the feet are apt to be colcL 23G UNDERWOOD ON CHILDREN. A similar train of symptoms occurs in other cases, in which the strength of the little patient has been subdued, and the vascular system exhausted by the abstraction of blood. In both cases, leeches are sometimes again applied to subdue this new form of disease, under the erroneous notion of a primary cerebral affection. This measure infallibly plunges the little patient into imminent, if not irretrievable danger. Sometimes the sinking state goes on in spite of every appropri- ate remedy. Stimuli, if efficacious, reduce the frequency of the pulse, and re- store the wonted warmth, colour, expression, and smiles to the countenance. The condition of the cheeks in regard to colour and warmth, may be considered as the pulse of very young infants, indicating the degree of remaining power, or of exhaustion. In the present case especially, there is no symptom so important, so distinctive. It is from the condition of the cheeks, in conjunction with a due consideration of the history, that the diagnosis of this morbid state, and the indication of the appropriate remedies, are chiefly to be deduced. The general surface, and especially the hands and feet, also afford important sources of information as to the condition of the nervous or vital powers. Next to these, the degree of fre- quency of the pulse, and the character of the breathing, are points of the greatest importance; — during the stage of irritability, the breathing is quick ; during that of torpor, it is slower, irregular, suspirious, and finally crepitous; the pulse changes in its beat, from being full becoming smaller, but retaining, perhaps, its former frequency. We should be especially upon our guard not to mistake the stupor or coma, into which the state of irritability is apt to subside, for the natural sleep, and for an indication of returning health. The pallor and coldness of the cheeks, the half-closed eyelid, and tne irregular breathing, will sufficiently distinguish the two cases. It is equally important to distinguish this state from a hydrencepha- loid affection arising from derangement of the alimentary canal, and from the coma of hydrencephalus itself. This is done chiefly by observing the condition of the countenance, and by tracing the history and causes of the affection. In the very last or extreme stage of this affection, there was, in one case, with the coldness ofthe cheeks and comatose state of the brain, a visible mucous film seen over the half-closed, unfixed eyes, — very contracted pupils, — alternate suspension and sighing in the breathing. The infant did not appear so near dissolution as it really proved to be. The following remarks are copied from my " Medical Essays." They present a sketch of a morbid affection, of which I have, since the period of their publication, seen sufficient to enable me to describe it more distinctly. " The state of exhaustion is very apt to be induced in early HYDROCEPHALUS. 237 infancy, and as the reaction is feeble at this period of life, the case soon assumes the character of sinking. I have frequently been consulted when the original disease has been subdued, perhaps, and the chief complaint of the little sufferers was a state of exhaus- tion, which a truce from remedies and medicines, and a proper supply of nourishment, and perhaps stimulus, have removed. " This state of things is often mistaken for inflammation of the brain, or hydrencephalus. And it may be difficult to state the grounds for a just diagnosis between the two affections. It will, however, be of great assistance to be fully aware of the nature and character of exhaustion, and to conjoin with this knowledge a due retrospect of the history of the case, and a due consideration of the effects of the various remedies which may have been employed. " The state of exhaustion in infants is little marked by the symp- toms of reaction. At first there are restlessness, and irritability of temper, whilst the countenance is pale and expressive of great anxiety, and there is great frequency of the pulse; afterwards the temper and restlessness appear subdued, there are some dozing, and other false and deceptive appearances of amend- ment, but the pulse is still more frequent, the face pale and sunk, and the cheeks and extremities are cold: the voice is apt to be husky, and attended with a husky, hacking, and distressing cough. " When a child has been rather long ill, when active remedies have been employed, when the form of the disease has perhaps changed in some degree, and paleness of the cheeks is attended with irritability and restlessness, we should carefully consider whether the symptoms may not be those of exhaustion. I am persuaded that by relinquishing all lowering remedies, and adopt- ing a cordial and soothing plan of treatment, I have seen some children recover who would soon have sunk under the continu- ance of remedies calculated to subdue a supposed state of inflam- mation. In these cases, the idea that the original disease, and the remedies, had worn out the little patient, and led to a state of ex- haustion, had apparently never occurred to the practitioner. It is impossible to do justice to this subject in a short section of a short essay; but I am satisfied that the hints here offered,will,if care- fully considered and cautiously acted upon, be of great assistance to the young physician in his treatment of some of the diseases of 1 n th n t ^» Dr. Abercrombie observes, "In the last stage of diseases of exhaustion, patients frequently fall into a state resembling coma, a considerable time before death, and while the pulse can still be felt distinctly ; I have many times seen children lie for a day or two in this kind of stupor, and recover under the use of wine and nourishment. It is often scarcely to be distinguished from the coma which accompanies diseases of the brain. It attacks them * Pp. 72-76. 1825. 238 UNDERWOOD ON CHILDREN. after some continuance of exhausting diseases, such as tedious or neglected diarrhoea ; and the patients lie in a state of insensibility, the pupils dilated, the eves open and insensible, the face pale, and the pulse feeble. It may continue for a day or two and terminate favourably, or it may prove fatal. This affection seems to corres- pond with the apoplexia ex inanitione of the older writers. It differs from syncope in coming on gradually, and in continuing a considerable time, perhaps a day or two; and it is not, like syncope, induced by sudden and temporary causes, but by causes of gradual exhaustion going on for a considerable time. It differs from mere exhaustion, in the complete abolition of sense and motion, while the pulse can be felt distinctly, and is, in some cases, of tolerable strength. I have seen in adults the same affection, though it is perhaps more uncommon than in children."* In a letter which I had the honour to receive from Dr. Abercrombie, that gentleman observes, " The state of infants which I have referred to, is a state of pure coma, scarcely distinguishable, at first sight, from the per- fect stupor of the very last stage of hydrocephalus, the child lying with the eyes open, or half open, the pupils dilated, the face pale. It is difficult to describe distinctly the appearance, but it is one which conveys the expression of coma, rather than of sinking; and I remember the first time I met with the affection, the circum- stance which arrested my attention, and led me to suppose the disease was not hydrocephalus, and the state somewhat different from coma, was finding, on further inquiry, that it came on after diarrhoea, and not with any symptoms indicating an affection of the head. The child recovered under the use of wine and nourish- ment."? Dr. Gooch observes,—"I am anxious to call the attention of medical men to a disorder of children which 1 find invariably attributed to, and treated as, congestion or inflammation of the brain; but which, I am convinced, often depends on, or is connect- ed with, the opposite state of circulation. It is chiefly indicated by heaviness of head and drowsiness: the age of the little patients whom I have seen in this state has been from a few months to two or three years; they have been rather small of their age, and of delicate health, or they have been exposed to debilitating causes. The physician finds the child lying on its nurse's lap, unable or unwilling to raise its head, half asleep, one moment opening its eyes, and the next closing them again with a remarkable expres- sion of languor. The tongue is slightly white, the skin is not hot, at times the nurse rernarks that it is colder than natural; in some cases there is at times a slight and transient flush : the bowels I have always seen already disturbed by purgatives, so that I can scarcely say what they are when left to themselves; thus the state * Researches, &c, pp. 310, 311. 1828. f E ffects somewhat similar are apt to follow operations on very young children. The reader may consult Mr. Travers' late interesting work upon Constitutional Irritation, pp. 139-141, published in 1826. HYDROCEPHALUS. 239 which I am describing is marked by heaviness of the head and drowsiness, without any signs of pain, great languor, and a total absence of all active febrile symptoms. The cases which I have seen have been invariably attributed to congestion of the brain, and the remedies employedhavebeenleechesandcold lotions to the head, and purgatives, especially calomel. Under this treatment they have gradually become worse ; the languor has increased, the deficiency of heat has become greater and more permanent, the pulse quicker and weaker, and at the end of a few days, or a week, or sometimes longer, the little patients have died with symptoms apparently of exhaustion. In two cases, however, I have seen, during the last few hours, symptoms of oppressed brain, as coma, stertorous breathing, and dilated and motionless pupil."* But although this morbid affection is scarcely described by for- mer writers, it is, I find, sufficiently familiar to many observing practitioners, on recalling to their minds the circumstances of the singular and interesting state of things attending it, and I am indebted to several friends for notices of cases of this kind. The morbid appearances in this affection are the effusion of serum under the arachnoid, into the ventricles, generally in rather small quantity, and the deposit of lymph, in slight streaks, in the arachnoid itself. The remedies for this morbid affection are such as will check the diarrhoea, and afterwards regulate the bowels, and restore and sus- tain the strength of the little patient. With the first objects it may be necessary to give the tinctura opii, and chalk, and afterwards the pilula hydrargyri, rhubarb, and magnesia: with the second, sal volatile, but especially brandy, and proper nourishment, are to be given according to circumstances. But, in this, as in so many cases of infantile disorders, the young milk of a young and healthy nurse, is the remedy of most importance, — in the absence of which ass's milk may be tried, but certainly not with the same confident hope of benefit. Five or ten drops of the sal volatile may be given every three or four hours; and twice or thrice in the interval, five or ten drops of brandy in arrow-root done in water. As the diarrhoea and the appearances of exhaustion subside, these remedies are to be sub- tracted; the bowels are to be watched and regulated, and the strength to be continually sustained by the nurse's or ass's milk. The brandy has sometimes appeared to induce pain ; sal volatile is then to be substituted for it; a dose of magnesia has also ap- peared to do good. For the state of irritability, the warm bath is a remedy of great efficacy; for the coma a small blister or sinapism should be applied to the nape of the neck. A state of exhaustion of the general system, as I have observed elsewhere,! by no means precludes the * Account, &c. pp. 357, 358. 1829. f Commentaries on Diseases of Females, passim. 240 UNDERWOOD ON CHILDREN. possibility of real congestion ofthe brain; it rather implies it. In extreme cases there are not only the symptoms of cerebral conges- tion during life, but effusion of serum into the ventricles of the brain, and even opacity of the arachnoid, are found on examination after death. In every case the extremities are to be kept warm by flannel, and the circulation should be promoted in them by assiduous frictions. It is of the utmost importance carefully to avoid putting the little patient into the erect posture. A free current of air is also a resto- rative of the greatest efficacy. Dr. Gooch adds, " I shall not encumber this paper with a multi- plicity of cases, but state that the above are only specimens of a class of which I have seen enough to convince me that they deserve the attention of the profession. If I had any doubt about this, this doubt would be removed by the fact that Dr. Marshall Hall has already recognised them, and described them in a paper which has been read at the Medico-Chirurgical Society. He has therefore anticipated me in announcing them." " The only differ- ence between our experience seems to be this — that he attributes the state which I have been describing to the diarrhoea, produced by weaning, or to the application of leeches for some previous complaint. In most of the cases I have seen, however, the child has had no previous illness, and the leeches have been applied subsequent to the drowsiness, and as a remedy for it."t In regard to the difference in the experience of Dr. Gooch and myself, I would observe, that that of Dr. Abercrombie plainly con- curs with mine, and that, in all the cases published by Dr. Gooch himself, the bowels had already been disturbed by purgatives, so that a source of exhaustion had existed in them. All the cases which I have seen, or heard of, alike involved a state of ex- haustion. The first stage ofthe affection which has been described, or that of irritability, may, indeed, depend on a previous disordered condition of the stomach and bowels; but the state of torpor is obviously the result of exhaustion. To these observations I must add a few remarks on the due administration of bloodletting. The modes of bloodletting employed in infancy and childhood are, leeching, cupping, and venesection. I must first, once for all, protest against the usual plan of apply- ing leeches in infancy, and allowing the bites to continue to bleed. Nothing can be more indefinite—nothing more replete with danger. Most of all it is dangerous to apply leeches late at night; the bleeding may go on unobserved and unsuspected, and precipitate the little patient into a state of irremediable sinking. The proper mode of abstracting blood in infants or children, * Pp. 358-367. HYDROCEPHALUS. 241 whether by leeches, cupping, or venesection, is to place the little patient upright, and watch the countenance. On the very first indication of pallor, or faintness, the flow of blood must be stopped.* For this purpose the leeches, or the cupping-glasses, are to be re- moved, or the vein secured. The effects of exhaustion in infants and childeren are seen chiefly under three forms : 1, that of irritability ; 2, that of stupor; and 3, that of convulsions. Of the state of irritability the following case, though too briefly sketched, presents an interesting example. A little patient was reduced by too copious and repeated bleeding for croup. There supervened a state of irritability of temper, so that, when much exhausted, it made great efforts to bite, scratch, and beat its attendant. This state of agitation continued until the powers of life were gradually and entirely exhausted. The state of irritability frequently, though not always, leads to that of stupor. Of the latter I have given so many instances in Appendix II. to Part First, that it appears unnecessary to add more here. Yet I cannot refrain from inserting the following interesting account from my friend, Mr. Cox, relating as it does, not only to the symptoms of exhaustion, but to the use of bloodletting. My dear sir,— The subject you are now illustrating is of so important and interesting a character, and the examples you have already given in your tract are so striking, that it hardly needs any fresh case to confirm the truth of your statements. The state of exhaustion from loss of blood was most strongly marked in the case of my little boy. At five months old he was one of the strongest and most vigorous infants I ever saw ; between that and the age of six months, he was attacked on a Sunday with croup of a highly inflammatory character, which was relieved by the application of six leeches to the throat, and calomel and ipeca- cuanha given every three hours. On the succeeding day (Monday) he was so much better that I had the greatest hopes that the disease was vanquished; but in the night of Monday he was attacked with symptoms of inflammation of the lungs of the most violent cha- racter, whiGh were relieved only by the application of leeches, re- peated with the interval of a few hours only, till faintness was produced; this was sustained by frequent doses of the tinctures of colchicum and squill. The symptoms of inflammation of the chest were thus relieved, but I need scarcely tell you that they were succeeded by a state of exhaustion, which was extreme, and resembled hydrencephalus in many of its characteristics. There was a quick, irritable pulse, dilated pupil, insensibility, &c, &c. Although the inflammation had been of so serious a character, [* This may be done in the case of a leech-bite, or of venesection, if necessary, by taking up a small portion of the integuments by a mere stitch with a needle and silk. — M. H.] 21 242 UNDERWOOD ON CHILDREN. that it appeared to my friend, Dr. Bernard, of Clifton, and myself, that none but the most active means would save the life of the child; yet they were employed by myself, anxiously watching for an impression on the disease, and as soon as the breathing became less distressing, and faintness was produced, and the pulse was less strong, hard and vibrating, the depleting means were gradually withdrawn. The state of exhaustion which I have described, supervened, and in many symptoms simulated an affection of the head ; yet I was enabled to remove them by gentle stimulants. Had the symp- toms of oppression of the brain been met by further depletion, I can have no doubt that the result would have been fatal. He had repeated attacks of croup and inflammation of the lungs during dentition, but is now a strong healthy boy. I am, my dear Sir, yours, very faithfully, J. C. Cox. 33, Montague-square, Nov. 21, 1829. On the subject of convulsions as arising from exhaustion, I cannot do better than refer to various parts of the interesting treatise on this subject by Mr. North,* but especially to pp. 101, et seq. and pp. 202, et seq. Similar remarks apply to children and adults, in regard to the various powers and susceptibilities of the system to the effects of loss of blood, under the influence of different diseases. In affec- tions of the head, in inflammatory affections, there is great power ; in cases of irritation, and, still more, of exhaustion, there is great susceptibility. It will be obvious from this remark, that the various attempts to state the quantities of blood, which maybe taken from children, in their several ages, must have proceeded upon the most vague conjectures. This is further proved by the very various statements made upon this very point by various writers. In fact, were such a scale made, it must be made distinctly for every disease, in refer- ence to every age. Something of this kind I hope to effect, with the other objects already pointed out, in the course of my continued investigation of the effects of loss of blood. But it will be obvious that this can only be done by long and uninterrupted attention to the subject. I have, however, already observed sufficiently to be enabled to recommend that, in every case of general bloodletting, whether by leeches, cupping, or the lancet, the little patient be supported in the erect position, its countenance carefully watched, and the flow of blood arrested on the very first appearance of pallor. The quantity of blood which thus flows will vary with the cha- racter of the disease, precisely as I have described in relation to adults. * Practical Observations on the Convulsions of Infants ; 1826. GENERAL OBSERVATIONS ON VARIOLA AND MORBILLI. 243 The boundary which it would be dangerous to pass, is accu- rately fixed; And the result observed becomes accurately diagnostic of the character of the disease. It will be observed that I esteem the application of leeches and of cupping, in infancy, to be a mode of general bloodletting, as well as the use of the lancet. The precise number of leeches ap- plied will regulate the rapidity ofthe detraction ofthe blood; their prompt removal, and the immediate closure of the leech-bites, must be effected, on observing that the system is brought under the influence of loss of blood. The same observation applies to cupping, and, a fortiori, to the lancet. I am persuaded that this view of the subject, simple as it is, will reflect a new and important light upon the whole subject of the nature and treatment of the diseases of infants and children.* — M. H.] GENERAL OBSERVATIONS ON VARIOLA AND MORBILLI, WITH CUR- SORY REMARKS ON INOCULATION. It will scarcely be expected that I should treat distinctly of the small-pox, or the measles, in their several varieties; these diseases being in no respect peculiar to childhood, nor of a nature to demand a full investigation in a work of this kind. They are noticed only to point out a few principal indications, and to introduce some practical observations in regard to inoculation.! Though the small-pox is a complaint so incident to the early part of life, that comparatively few children living to the age of eight or ten years are found to escape it, yet it is not so readily communicated, in the state of early infancy, as has been generally imagined, unless by immediate infection.^ This is equally true in * [See Researches on the Effect sof Loss of Blood. Iivould add, that if a leech- bite, or if the opened jugular vein continue to bleed, in spite ofthe application ofthe usual measures, the hemorrhage may, in either case, be arrested at once by means of a needle and silk, taking a small portion of integument on each side of the orifice, and tying the knot gently. — M. H.] f I copy the following observations from Dr. Pearson,5 that inoculation for the small-pox was strangely neglected, till introduced into England from Con- stantinople; although it had been practised time immemorial in the Barozzo mountains, en the frontiers of Gallicia, in the same rude manner as it is at this day. This intelligence, Dr. Pearson observes, was communicated to him by a Portuguese nobleman, whose opportunities for information and accuracy autho- rized the Doctor to mention the fact; but an attested account from some of the inhabitants of those mountains is intended for him. —See a book written by Ja- cobus a Castra de Sacramento, in which Dr. Pearson says he is informed this fact is asserted. X Some evidence of the propriety of this assertion may be gathered from the consideration of there always existing a far greater number of infants within the month, than of children of any other age ; and, for the like reason, a greater num- \ Medical Review and Magazine, for August, 1799. 244 UNDERWOOD ON CHILDREN. regard to many other diseases, as I have noticed elsewhere, and the principle may very probably be, that the younger and weaker the subject is, the less of life it possesses, and the less susceptibility it has for these complaints. The poor furnish frequent instances of the truth of this observa- tion. I have attended where children borne in an air, saturated, as it were, with the miasma of this disease, and even lying continually in a cradle in which another child has died a few days before, have, nevertheless, escaped the disease, and sometimes, when they have slept together in the same bed with one loaded with it. Hence it appears, that highly-tainted air, and even personal contact, are often insufficient to communicate the virus. Yet we know that in- fants are very easily infected, receiving the small-pox by inoculation as readily as adults; though neither are at all times equally suscep- tible of it.* Perhaps this latter circumstance may not always be sufficiently attended to ; the mode of inoculation being often blamed, when its failure may be owing to the indisposed habit of the child. Possibly, on this account, it may not be perfectly safe to urge it at such a time : at least, instances are not wanting, where (twice in- troducing the virus having failed) an infant has had the disease very severely, and even fatally upon its being repeated a third time. In no other view, I imagine, can the repetition be accounted hazardous ; and this holds out encouragement to such, as from any uncertainty in regard to infection, may wish to be inoculated once or more. Dr. Richard de Hautefiercyt inoculated a young person every fortnight, for a whole year ; the first of these operations com- ber of those under a year old, than of such as are two or three years of age. For it is evident, that every infant dying at the earlier periods, must reduce the num- ber to which those ofthe more advanced ages might otherwise have amounted ; whereas, all the children who arrive to two or three years of age, having been first infants in the month, and of one year old, the number of the latter periods is not diminished by the death of those of a more advanced age. Now, every one knows how very few infants he has heard of having received the small-pox naturally, in the month, or even within the year; though fewer of these are inoculated than of children above a year old. And this exemption from the na- tural small-pox does not seem to arise from their not being exposed to the ordi- nary means of contagion, especially among the middling and lower ranks of people, who form the bulk of mankind; since the medical men who usually attend such lying-in rooms, are very much in the habit both of visiting patients in the small-pox, and of inoculating, all the year round ; and even in the higher ranks of life, if gentlemen in the general practice of physic happen to be con- sulted, the chance of their visiting at the same time infected patients is not so small as may be imagined ; not to speak of the probability there is, that some one of the numerous visiters, during the month, may, by accident, or otherwise, have been in some infected house in the course of the day in which their visits may be made. * Dr. Young inoculated several children at the Royal Infirmary at Edinburgh at about a week old ; yet in none of them could he perceive the infection to take place. And a respectable physician lately informed me, that he knew a young woman to be inoculated ei^jht times in the course of thirty days, who also at the same time attended several children who had the small-pox from inoculation, and yet was not infected herself. She, nevertheless, caught that distemper about seven weeks afterwards, and died of a confluent sort. | Nic. Rosen Von Rosenstein. GENERAL OBSERVATIONS ON VARIOLA AND MORBILLI. 245 municated the disease, and the subsequent ones in nowise injured his health. The like observation will apply to the measles : I mean the in- disposition to contagion during infancy. I have known, in more than one instance, a twin escape the disease, while the other child suffered by it severely, and both were nursed in the same apart- ment, and suckled by the mother. But in whatever way either of these diseases may take place, they are to be treated as in adults, with but little other difference than what every practitioner is well acquainted with, that of greater caution and tenderness; as infants cannot bear the powerful anti- phlogistic regimen and evacuations, often proper for the other.* In the mild, distinct small-pox, the eruption does not appear till the fourth day, inclusive, from the attack ; but in the severe, confluent kind, on the third, and even sometimes early on the second day. In the former, also, the fever and other complaints usually vanish, upon the eruption appearing on the skin, whereas in the confluent, however it may abate for a short time, the fever is rekindled, and increases with the progress of the disease. There are likewise some peculiarities in regard to young children, both in the mode of attack, and in the symptoms attending the latter stage of the disease, which may be slightly noticed in this place. The vomiting, shivering, and pain in the back, and head, are rarely succeeded by a sweat in infants, and are far less common in all young children than adults, under any of their complaints, and are less commonly salutary or critical. In the progress of the disease, there is likewise as frequent a difference, children having usually a purging in the bad confluent sort, in the place of that salivation which usually appears in adults; and demands a judicious management. It may,therefore, be further remarked, as too common an error, possibly, thatof pro- curing stools about the turn of the pock, when infants have this disease pretty full, whether of the distinct, or the confluent kind : children sometimes sinking suddenly after one or more copious stools, who would be in less danger from remaining costive at this period ofthe disease. These circumstances, as well as their tender age, will call for some little diversity in the treatment; with all which, however, the reader is supposed to be acquainted, who will be careful to make the proper discriminations in this complex disease. In the measles, children ought to be kept in bed, and not only ought the belly to be preserved open throughout the disease, and cooling medicines and diluting drinks be administered, and amongst others, linseed tea, where the cough is peculiarly troublesome ; but unless the children be very young, they will bear, and even require, one or more bleedings, at any period of it, when the symptoms indicate its propriety.t And, indeed, the cure of the secondary • Ex toto, non sic pueri, ut viri, curari debent. — Celsus, lib. iii. cap. 7, p. 134. t In all cases of local inflammation, or tendency to it, topical bleedings should have the preference, especially if it be not necessary to take away a large quan- 21* 246 CNDERWOOD ON CHILDREN. fever, and cough, however long they may continue, will turn upon repeated bleedings, laxatives, and a total abstinence from wine, and all animal food. It may be remarked, that instances occur even in the benign measles, of the eruption continuing much longer than four days, before it begins to dry off. Dr. Hamilton has disputed the propriety of bleeding, and argues strongly for the exhibition of purges, and of wine and bark at this period of the disease. For my own part, I have never lost a patient in this disease, probably from not being consulted in the worst cases, nor have I, for obvious reasons, frequently attended in this or the small-pox ; and therefore shall by no means oppose my experience to that of Dr. Hamilton, or Dr. Parr, (who has adopted the like sentiment,) but rather esteem it my duty to apprise the readers of this work of the different sentiments of practitioners of respectability. The same writer has mentioned a feverish disorder, resembling at first the measles in every respect, as occasionally met with. Within twenty-four hours after the eruption, the feverish symptoms are highly aggravated, attended with delirium, startings, and even convulsions; and on several parts of the skin, particularly on the face, the eruption recedes, leaving large portions of the surface of a pale yellow, with a small white blister, or vesication, in the middle. The eruption disappears in a day or two, and, under proper treatment, the fever soon abates. The alarming appearance of great determination to the head, in the first case or two of this kind to which I was called, led me to apply leeches to the temple, at the same time that I prescribed the warm bath, a brisk laxative, and a blister to the back. Since that time I have omitted the leeches ; and although the utmost danger seemed to threaten in all the cases 1 have witnessed, the recovery was rapid in every instance. INOCULATION. I shall drop a few words on this subject, because parents are very apt to fall into great mistakes respecting the age and circum- stances most proper for this operation, and sometimes draw medical people into an imprudent compliance. It has already been remarked, that young infants are not very liable to contagion, which is surely an argument against early tity of blood, (which it can rarely be in young children,) or if the operation be often repeated. In the present instance, therefore, if the child be very young, or ve'ry weak, it may be sufficient to draw off a little blood by leeches, from some part about the chest: but should it be designed only to lessen the quantity of the blood, they may be more conveniently applied to the leg, or arm, as the child may be less exposed to taking cold during the application ; and if the leeches should not draw well, those parts can afterwards be commodiously immersed in warm water, to promote the bleeding, or a bandage may be easily applied to restrain it, if it should prove too profuse. Cupping, in such cases, ia commonly very preferable to leeches. — S. M. INOCULATION. 247 infection, if it be attended with any peculiar hazard, as it most certainly is. Whereas, it is too common an opinion that a very young infant, sucking at the breast, is the fittest subject for inocu- lation. Children are then said to be clear from humours, their blood mild and balsamic, their food innocent, and their minds free from all violent passions. But all these advantages may be coun- terbalanced by the delicacy of their frame, their disposition to spasm, and their inability to struggle with a severe attack of the disease, if it should chance to fall to their share. And such, indeed, are the facts; infants usually have the small-pox very lightly, whether taken naturally or from inoculation ; though in both there are a few instances of their expiring in a fit at the time of the eruption, the risk being greater also the younger the infant may be ; and they seldom get through the disease, if they are full, or it proves of the confluent or malignant kind. And this furnishes a peculiar objection to inoculating infants at the breast, which arises from their frequently lying so much on the arm of the suckling mother, or nurse, especially in the night; the heat exposing them to a much more copious eruption than children who are weaned. This I have seen clearly exemplified in the instance of a child whose mother could suckle only with the right breast; the consequence was, that the left side of the child was perfectly loaded with the eruption, (though the pock was of the distinct kind) whilst the other had only a moderate sprinkling. This child, however, sunk under the secondary fever at the end of five or six weeks, though turned of two years old ; the only child I have known to die of inoculation at so advanced an age. A similar instance is related by Mr. Moss : who not being able to prevail on a young woman whom he had inoculated to keep her feet (which were very cold) out of the warm ashes of a hearth-fire, at the time of the eruption; they were in consequence so loaded with it, as to appear one con- tinued blister : though the disease was very distinct, and went on favourably in other parts. I am aware that many children are inoculated very young, and even in the month, and generally with very good success : but the frequency of this practice, among eminent surgeons, is owing to the urgent solicitation of parents, and their fear of contagion. I cannot therefore avoid saying, that however few may die under inoculation, under any circumstances, the fact is, that the far greater proportion that I happen to have had an account of, is amongst infants under six months old. A remarkable proof of this dispro- portion appeared a few years ago, under a general inoculation at Luton, during the progress of a malignant small-pox ; which had carried off one-half of those who were attacked by it in the natural way. In the midst of this fatality, twelve hundred and fifteen paupers were inoculated, through the humanity of the then Bishop of St. David's,* many of whom refused ail preparatory medicines, * See a Tract on Malignant Fevers, by the late Sir William Fordyce, 1790, 248 UNDERWOOD ON CHILDREN. and were besides addicted to the use of strong liquors; neverthe- less, out of the twelve hundred and fifteen only five died, all of whom were infants under four months old. Seven hundred adult people of better condition, in the same neighbourhood, were inocu- lated a short time afterwards, and with the like good success with the former. From this view of the matter, it is pretty evident, I think, that this operation ought, in general, to be postponed to a later period, which is pointed out by the child having cut all its first teeth ; to which may be added, another observation from the well-known fact, that more than fifty children die under the age of two years, of other complaints, to one that dies of the natural small-pox. Should it, however, be in the same house, or prevail in the neigh- bourhood, and the parents find it difficult to remove the child out of the way, it may run a less risk by being immediately inoculated, as that operation is now so well understood, and successfully conducted, than by taking the chance of escaping the infection, or of recovering from the disease, if it should happen to take place. I shall just observe, however, on this head, that the late Professor Monro recommends the use of a bath of water and juniper berries, and fumigating the chamber with the juniper tree, during the course of severe small-pox, which is said to have succeeded in eight or nine instances as a preventive. The inoculation of pregnant women being, in certain instances, dangerous to the infant, it is presumed that it cannot be totally foreign from the subject, to annex a caution on that head, it having, until of late, been generally imagined that the child is not infected by the "parent passing through the small-pox, whether from inocu- lation or otherwise. It is, indeed, comparatively rare that the unborn foetus takes the disease, howsoever severely the mother may suffer by it; yet, from a very accurate account published by Dr. Pearson, and some cases by Messrs. Kite and Turnbull, the fact is established as the result of much experience and reflection, where the parent has been infected after the sixth month of gesta- tion. Previous to that period, however, the foetus, (whatever be the cause,) has very seldom been known to take the disease ; and later than that, it is presumed, few mothers would be inclined to submit to the operation, unless from some urgent necessity. The parent, it is added, is not in much additional danger from being inoculated in a state of pregnancy, unless the disease should prove considerably more severe than it is ever expected from inoculation : but when communicated to the foetus, the infant always dies. One instance of infection at an early period of gestation, has lately been adduced by Mr. Rumball, of Abingdon, that does not precisely accord, the foetus taking the infection when its mother had only completed the fourth month of gestation. She was then seized with the natural small-pox of a bad confluent kind, and recovering with difficulty, was delivered, at the end of the seventh month, of VACCINE INOCULATION. , 249 an infant who bore strong marks of the disease, and was born alive, though it survived only half an hour. In regard to inoculation of the measles, it may just be noticed, that Dr. Francis Home, of Edinburgh, has practised it, in ten or twelve instances, with success ; and Dr. Rosenstein seems to inti- mate that the example has been followed in Sweden.* VACCINE INOCULATION. The extent to which vaccine inoculation has been practised, and the attention which has been paid to its progress and effects, have established a body of evidence upon the subject, which is highly satisfactory. Not only have medical gentlemen of the most respectable talents made it the subject of their attention, but public institutions have been founded and supported by the legislature, which have at once served to ascertain its merits, on the largest scale, and to give it universal spread. The result appears to be, that vaccination, though not an infallible preservative from the contagion of small-pox, is one in so great a majority of instances, as to render it highly probable, that if it were universally adopted, the small-pox would in a few years become entirely extinct. In the island of Ceylon, near 130,000 persons have been vaccinated, and the happy consequence appears already to have followed ; the small-pox not having appeared there since February 180S, except in a few individuals who had not been vaccinated, and who caught it from a boat that landed at Jaffapatnum from the Malabar coast. But its spread as an epidemic in that settlement is no longer apprehended. By a report of the Vaccine Institution in Broad Street, it appears, that only nine cases of failure had occurred in the practice of that charity in five thousand that had been inoculated ; and that all the authenticated cases of failure which had taken place amounted only to forty-three, which, among the many thousands who have been vaccinated in this country, is a proportion probably less than that in which small-pox has taken place twice. The latter occurrence has appeared three times in patients who have been under the care of one respectable practitioner at. the west end of the town.t It is probable, that in many cases where vaccination has failed, * I have allowed Dr. Underwood's observations on Small-pox and Inoculation to remain, though, at the present day, they are not likely to be much acted upon : but facts and practical remarks are always valuable. —S. M. j- Of the like'kind is the following: — Mr. Pallas in his Voyages dans les Gouvernemens Meridionaux de l'Empire de Russie en 1793 et 1794, relates the following circumstance, which occurred while he was at Sarepta. "Retenu malrge moi d'une part par la chaleur excessive qui'il faisoit au mois de Juillct, et augmentoit encore a un point insupportable par I'embrasement du step des deux c6les du Volga, dans une circumference bien etendue, je le fus encore par la maladie de la petite verole qu'y eut ma fille, bien assur^mentpour la seconde fois a une e'poque ou ce fleau epidemique qui s'etoit declaree avec violence depuis le commencement de l'hiver a Sarepta, commencoit a diminuer. 250 UNDERWOOD ON CHILDREN. some error has been committed as to the previous state of the sub- ject, or the progress of the pustule afterwards. It seems important, therefore, in order to perfect security, that the following observa- tions should be strictly attended to. The child to be inoculated should be at the time free from fever and every eruptive disease. If any irritation from teething arises, the gum should be lanced. The matter employed should be taken from a decidedly characterised cow-pock, which is proceeding regularly though its respective stages ; and it will be more certain of producing the disease, if it is taken before the tenth day. "If the infectious matter produce the required effect, in three, four, or five days there will be seen a red spot like a small gnat bite ; in six or seven days, a small vesicle will appear : in nine days, a circular vesicle (improperly called a pustule) will be found as large as a pea, or from about two-tenths to four-tenths of an inch diameter, usually surrounded by a red areola. By the eleventh day, the vesicle begins to scab, or grow dry, and turn black in the middle, and the areola becomes more extensive. By the fifteenth day, but often later, the pock becomes a mere scab, circular, prominent, well-defined, of a blackish or mahogany colour, adhering firmly ; but the areola disappears. Unless it be separated by violence, the scab does not fall off, in general, sooner than the twentieth day. It then becomes a cicatrix permanent through life." Little medicine is required during the progress of the disease. The bowels should be kept regular; and if feverish symptoms arise, a saline draught may be given occasionally. The principal incon- venience which the patient experiences, appears to arise from the soreness of the inoculated part; this will be alleviated when it amounts to any considerable degree, by laying on it a piece of linen dipped in water, which should be frequently renewed till the pain abates. When the vesicle begins to scab, a dose of any mild purgative may be given, and repeated in two or three days. If the scab falls off before the part is completely healed, a little spermaceti cerate may be applied, to defend it from the friction of the clothes. Where any doubt exists whether the vaccine inoculation has been effectual, it should be repeated ; for it appears from the report before alluded to, that re-inoculation with vaccine matter is as good a test of the patient having regularly gone through the cow- pock, as inoculation with small-pox matter ; the constitution being rendered insensible to both diseases, after it has gone regularly through either of them. It does not appear that vaccine inoculation induces any other disease, as was feared in the beginning of the practice. In children predisposed to scrofula, that disease occasionally follows, or is called into action by all eruptive complaints, but it more frequently succeeds the small-pox than any other ; the cases in which scrofula has followed the cow-pock will bear no com- VACCINE INOCULATION. 251 parison in number with the melancholy objects in whom small-pox has produced it, with its most dreadful symptoms. As it is also evident, in the experience of every practitioner, that scrofulous affections less frequently appear after the inoculated than the natural small-pox, (and it is presumed, as being a less severe disease, it produces less excitement of the system,) so it is not to be wondered at that they still more seldom occur after vaccination. It is to be hoped, therefore, that the great mildness of this pre- servative from so dreadful a disease as the small-pox, will ere long cause it to be universally adopted: and preponderate over the erroneous representations of those who, for want of better informa- tion, or from unworthy motives, still continue to oppose it, and to leave the helpless and innocent offspring of the poor exposed to one of the most destructive and injurious maladies to which the human body is liable. But whilst we recollect, that inoculation for the small-pox had to wade through a torrent of the like oblo- quies, and finally triumphed over them, we have further reason to hope, that the hour of cool reflection is at hand, when the sober good sense for which our nation has long been remarked will be no longer sullied by a fastidious rejection of a far greater blessing. I shall close this account with a few observations on facts. 1st, In regard to the vaccine inoculation failing to take effect; this is no more than has occurred in inoculation for the sinall-pox in the hands of the most eminent practitioners; the system not being always disposed to receive that, or other infections, and poisons, and yet shall in a short time afterwards be in a condition to receive it. 2dly, In regard to various eruptions, to scrofula, and other con- ceived ill consequences of vaccine inoculation, I would remark, that they are comparatively very few ; that they are more frequent in families not otherwise the most healthy ; and are very far less numerous than the complaints that follow either the natural small- pox, or inoculation for that disease. 3dly, That it is notorious that the proper vaccine virus has not always been employed, nor been taken at the proper period of the disease. 4thly, That where children previously properly vaccinated, have afterwards taken the small-pox, it has generally proved very favourable, has not been attended with secondary fever, nor have the pustules either been numerous, or continued so long as in the natural small-pox, or in those from inoculation for that disease ; nor has there been more than one instance, I conceive, of a person dying from the small- pox, after having been vaccinated by any medical man long in the habit of vaccinating.* * Dr. Burns of Glasgow has suggested two means to be resorted to, in order to discover if the system has been affected, so as to have a complete change induced by the vaccination. 1st. If a second inoculation be performed on the fifth or sixth day after the first, a vesicle will arise as usual, but itawill be surrounded with an areola, nearly as early as the first one. 2dly. If a second operation be performed any time after the twelfth day after 252 UNDERWOOD ON CHILDREN. But for a more full, and a very candid statement of vaccine ino- culation, I beg leave to refer my readers to Dr. Monro's " Obser- vations on different kinds of small-pox, and that which sometimes follows vaccination."*(#) the first inoculation, some degree of inflammation will be induced ; but if the system have been affected, no regular vesicle will be produced. — But, inocula- tion for the small-pox, he adds, is the most satisfactory test. * The following later publications on this very important subject deserve to be consulted, — "Cross's History of the Variolous Epidemic in Norwich" (1820); " Thomson's Account of the Varioloid Epidemic in Edinburgh" (1820); " Thomson's Historical Sketch" (1822). {x) VACCINATION. The extensive and fatal variolous epidemics within the last twenty-five years, and the very frequent occurrence of variolous disease after vacci- nation, generally in the mitigated and somewhat modified form called varioloid, have very naturally excited the profession to new and more extended inquiries and experiments on the whole subject. Some were induced to deny the protecting power of the vaccine against the variolous contagion, and others have contended that the protection was only effective for a limited period, — on the duration of which, there was, how- ever, little accordance of opinion. Extensive opportunities of experi- mental observation during an epidemic visitation of small-pox in Philadel- phia, in the years 1823 and 1824, procured at first in Dispensary and private practice, and subsequently during a six months daily attendance in the Small-Pox Hospital, convinced me that these fears and objections were either unfounded or greatly exaggerated. The chief cause of vario- lous seizure of vaccinated persons was and is the imperfect and incom- plete vaccination to which they had been subjected, either owing to spurious vaccine matter having been used, or the person on whom the operation was performed being at the time affected with a cutaneous disease. Giving additional force to these causes, was the predisposition induced by the state ofthe atmosphere during the prevalence of epidemic small-pox, so that contact with a patient labouring under small-pox, or still more, breathing the air contaminated by volatilized contagion from his body, subjected an imperfectly vaccinated subject to the varioloid, or modified small-pox, which under similar circumstances of personal expo- sure but different atmospherical constitution he would have escaped. A farther cause was to be found in the peculiarity of constitution of the vaccinated individual, by which he was liable to an attack of small-pox, just as persons of a particular constitution have had a second attack of small-pox, although the first had been of such violence as to threaten life and to scar and disfigure the skin. Overweaning confidence in the all preventive power of vaccination against small-pox was followed by undue mistrust of its efficacy. Phy- sicians had too generally forgotten, that Jenner himself, and some of his zealous contemporaries engaged in the same philanthropic task with him, had clearly pointed out the fact of small-pox supervening after vacci- nation had been duly performed. The reason then assigned was the short- ness of time that had elapsed between the vaccination and the exposure to variolous contagion. Since, and now, the reason set forth is the length VARICELLA, OR CHICKEN-POX. 253 VARICELLA, OR CHICKEX-POX. Though this disease is usually a very light one, it merits a few words, not only because more incident to children than to adults, but, also, that it is sometimes mistaken for the mild small-pox; which it sometimes exceeds in violence, and is now and then even of time, by which the vaccine impression on the system was worn out. Both of these two opposite and contradictory reasons cannot be true — the probability is, that neither rests on a stable foundation. In two papers which I wrote and inserted in successive numbers of the North American Medical and Surgical Journal, (Vol. II., 1826,) exhibit- ing the joint experience of Dr. J. K. Mitchell and myself, I concluded with the following inferences, the accuracy of which has been tested by succeeding observations in different parts of Europe, and of this country. The first inference was, that the disease which prevailed in Philadelphia, in 1823-4, and which we had been called upon to treat in so large a number of cases, was the real small-pox. 2. That this disease, distressing to the person labouring under it, and disgusting to all those in attendance, is usually violent, never without danger, and always in large proportion, under any known treatment, is of fatal termination. 3. That the unsusceptibility of persons who have once had the small- pox to a second attack, though of general notoriety and truth, is not uni- versal, and that with us, as elsewhere, persons, thus apparently protected were seized with the disease, of which some of them died. 4. That inoculation of the small-pox, though in general conferring on the person subjected to this process immunity from the effects of variolous contagion in after life, does not necessarily or infallibly guaranty him against the disease, nor prevent death when it has made its invasion. 5. That vaccination cannot now, any more than on its first introduc- tion, be received as a certain preventive to the effects of the variolous poison, though now, as formerly, it must be considered as the best and safest with which we are acquainted. 6. That occasionally under all circumstance of exposure, but more espe- cially during the epidemic prevalence of small-pox, its contagion will affect the inoculated and the vaccinated, and produce in them a fever and eruption, differing in no essential feature from the primary variolous dis- ease, except in the general mildness and speedier subsidence of the cuta- neous disorder, and the more common exemption from secondary fever. 7. That, ofthe inoculated and the vaccinated exposed to the variolous poison, the former will more probably escape its influence than the latter ; but, if both be affected by this contagion, the chances of recovery are in favour ofthe vaccinated. 8. That the protecting power of the vaccine virus on persons who have been duly subject to its influence, is not diminished or destroyed by the length of time from its first introduction into the bodies of such persons; and° that no proportion whatever exists between its efficacy, and the recency or remoteness of the epoch, when the constitution was placed under the influence of the virus. 9 That there is no reason for believing in the deterioration or altera- 22 254 UNDERWOOD ON CHILDREN. attended with danger. The danger is, indeed, so uncommon, that the disease has been very seldom noticed by medical writers ; and even Dr. Heberden, who was among the first that obliged the public with a distinct account of it, says he never saw any person tion of the vaccine virus, which is used at this time, from that which was in use during the first years of the practice of vaccination. I am well aware, that of late years re-vaccination has been practised on a large scale on the soldiers in the armies of Prussia and Wirtemburgh, as well as on the people, and with such results as would seem to weaken a belief in the continuedly protecting power through life of the first vacci- nation— but other and different testimony leave us nearly free to retain our first belief, with the explanations already offered. Identity of Variolous and Vaccine Virus. — A new, and to those who have overlooked or forgotten Jenner's opinion on the subject, a startling revelation has lately been made from experiments performed both in France and Great Britain." It is no less than the identity ofthe matter of variola and vaccine, — the latter being a mild modification of the former by its passage through the system of the cow. The facts are now reduced to a very simple proposition, viz., that the matter of mild small-pox of animals, and particularly the cow, serves to protect the human subject against the more virulent poison in man, and its dangerous, deforming, and often fatal operation. Iu a section of a petition presented last summer to Parliament by the Provincial Medical Association of England, consisting of nearly twelve hundred members, some important truths on this subject are expressed as follows : " That your petitioners have peculiar satisfaction in stating that the result of their enquiries has thrown much light on the nature of variolse vaccinae, and that Dr. Jenner's opinion, that it was an affection of a true variolous character, has been demonstrated by historical evidence, as well as by direct experiment, human small-pox having been recently communicated to the cow by inoculation, and the result having been the production of a variola-vaccine lymph, possessing all the properties of the original vaccine disease. " That this direct confirmation of a great doctrine adds infinite value to the original discovery, by explaining alike the nature and the degree of protection that may be derived from perfect vaccination, which is, in short, to use the language of the discoverer himself, to impregnate the constitution of man with small-pox in its mildest, instead of its pestilen- tial and fatal form. " That the diffusion of this truth may be made subservient to the best purposes, and, with the aid and countenance of your Honorable House, be rendered highly instrumental to the preservation of human life. " That your petitioners have learned, by the concurrent testimony of a very large portion of their members, that cow small-pox, if duly and carefully communicated, has an enduring influence in protecting the constitution ; that while they admit that this protection is not in all cases complete, they have unquestionable proof of its being capable, if gene- rally and properly employed, of mitigating, controlling, and, they might almost say, of extinguishing small-pox in any district, " That they have further learned that, while vaccination has been im- perfectly and insufficiently employed, in many places, small-pox has been VARICELLA, OR CHICKEN-POX. 255 with so many as three hundred pustules over the whole body. Physicians, indeed, as he observes, are not often called to visit patients under a complaint usually so trifling; or a gentleman of and continues to be diffused in a manner highly detrimental to the health and safety of the community. " That, before suggesting any measure for the more efficient diffusion of vaccination, they would specially implore your Honorable House to take measures for regulating the practice of small-pox inoculation; and they are induced to urge this prayer of the petition with greater earnest- ness, because they have ascertained that such practice has been abandoned by almost every respectable medical man in the kingdom, from a disin- terested conviction that it is uncalled for and dangerous, and ought to be universally superseded by vaccine inoculation." Age for Vaccination—Selection of Matter.—I have always my- self delayed vaccinating an infant before it was three or four months old : the practice, deemed to rest, by many of my medical friends, on speculation, is now gaining ground. Dr. Heim, of Wirtemberg, in a valuable work, of which a full analysis and critical notice are to be found in the British and Foreign Medical Review, for January, 1839, thinks that no child should be vaccinated within the first twelve-month. I do not believe that so long a period is necessary for the functions ofthe new being to acquire their proportionate and harmonious rhythm and sympathy with one another, and thus to insure an adequate and permanent im- pression being made on the system at large through the local affection on the skin produced by the vaccine virus: at the same time that I am fully convinced of the necessity of waiting some months after birth until this co-ordinate action and sympathy are established. "Four months," says the Reviewer," was the age at which variolous inoculation was most suc- cessfully practised, and we are convinced that the same period is equally fitted for the development of the vaccine. As to the kind of vaccine matter to be selected, there will be little difficulty, if due attention have been paid to the preliminary conditions for the performance of the operation on the persons from whom we pro- cure the vaccine matter. Although it is desirable on occasions to be able to use the fresh lymph, yet, for nearly all practical purposes, the dried matter of the scab, after the vesicle has attained maturity, will suffice. The greater convenience in keeping and transporting the vaccine matter in this state, has led pretty generally to vaccinating from the scab, moist- ened with water, and reduced to a consistence of mucus or thin mucilage, before its being used. A question recently argued with considerable zeal is, whether matter from the human subject, after its transmission from person to person for a series of years, is to be still preferred to matter recently procured from the cow. Means of ample comparison within the last three years have been furnished to the profession in England, and measurably to many physicians in the United States, chiefly through the labours of Mr. Estlin, of Bristol ; but as yet the question is not clearly settled. The few comparative trials made by myself do not incline me to give a pre- ference to the vaccine virus recently procured from the cow. Another question of practical moment is, the number of incisions or of points for the insertion of the vaccine. Commonly, one has been thought 256 UNDERWOOD ON CHILDREN. his long and extensive practice would have met with instances in which it must have appeared of more consequence, as will pre- sently be noticed. It is from this disparity, I apprehend, that this disorder is some- times denominated the swine-pox, which is only a ranker species of the disease, in which the symptoms may run higher, as well as the pustules become much larger and more purulent. In this case, I have known the head and face as much swollen as I have ever seen them in any distinct small-pox, however full, and the pustules containing a yellow matter, with highly inflamed bases, and exceedingly sore; and these have formed a complete mask on the face, after the turn, as is often seen in the small-pox. One such patient whom I was called to visit, a few miles from town, was about sixteen years of age, of a plethoric habit, but very healthy; and what makes it very certain that this complaint could not be the small-pox,* is, that the young gentleman died of that disorder a twelvemonth afterwards: possibly his death was owing to the disease being neglected in the beginning, under an idea that the former illness had really been the small-pox. The latter mistake arose from an improper answer having been then made to my inquiry as to the day on which the irruption had first appeared ; (for I was called to make him only one visit, when the pock was on the turn ;) a mistake the young gentleman's mother had a perfect recollection of after I was gone, and of which I reminded her upon being called to visit her son in the small-pox, only the day before his death. This case strongly verifies the remark of Dr. Heberden,that this complaint can, in some instances, be distinguished from the small- pox only by its quicker progress towards maturation, and the * So many cases of small-pox occurring twice in the same individual, have now been ascertained, that this argument cannot be allowed to be conclusive. — S. M. enough : but within a short period the practice of making numerous in- cisions has strong advocates, the chief of whom are Eichhorn and Gregory. The main advantage alleged to accrue from numerous insertions (by puncture or incision) is the greater probability of constitutional fever en- suing, and the consequent immunity from small-pox afterwards, or the necessity of re-vaccination. From three to twenty is the number of punctures or incisions and the insertions of vaccine matter in them recom- mended by different practitioners. I shall conclude this note by suggesting to the reader the strong pro- bability, resting on evidence from different quarters, of the influence of atmospheric temperature on the development of vaccine pustules. The effect of cold in retarding, and of heat in accelerating, their progress, must be admitted to a certain extent. But in addition to these more obvious conditions of atmosphere, there are others of a local kind which greatly affect this question, such as the sirocco in Italy, the hot winds in Egypt, eve. — See Brit. & For. Med. Rev. art. ut supra. AGUE. 257 shorter duration of the pustules ; a watery vesicle always appear- ing on the second or third day from the eruption, and the turn, at the furthest, taking place on the fifth. In young children, a teazing cough sometimes comes on about the time that the eruption is com- plete, and continues until two or three doses of physic have been taken ; which, on account of the cough, seems to be necessary. The symptoms preceding the eruption are sometimes so slight, that even where the eruption has proved pretty considerable, the disorder has not been expected so soon ; though, from its being in the family, the closest attention has been paid to it. The treatment of it differs nothing from that of the mild, dis- tinct small-pox; but it rarely calls for much attention, and only when a patient may have it very full; or, as sometimes happens, when a second crop appears after the first has dried off. AGUE. This is a complaint so well known, that it seems unnecessary here to enter minutely into a description of it. It is sufficient to say, that it consists of repeated cold and hot fits, regularly succeed- ing each other, with one or more well days between them; in which interval the patient passes a high-coloured urine, that depo- sits a red sediment. It, perhaps, partakes more of a nervous affection than other fevers may do, and is known to be endemic in some flat marshy situations, but is most frequent in the spring and fall of the year; in the former of which it is generally easily cured, and is even sometimes salutary. Autumnal agues, on the other hand, especi- ally in the country, and amongst very poor people who feed coarsely, will frequently continue a very long time, and return again next autumn ; whereby the constitution becomes considera- bly impaired. In such instances the legs are apt to swell, and more especially the belly, which becomes hard, particularly on the left side ; the tumour being termed the ague-cake. This tumefaction, however, instead of being a bad sign, as might be suspected, a priori, is a very favourable one, and indicates the recovery of the patient. This circumstance is noticed by Sydenham, and like other observations of that attentive practitioner, is a very just one, and was, doubtless, the result of his experience. The hardness is pro- bably owing to an infraction of the spleen, and usually subsides in the course of a few months, especially upon the use of moderate exercise, and a generous diet. It may be prudent, however, t» assist the resolution of the tumour, by administering small doses of calomel, and afterwards light bitters, adding likewise chalybeates, if the habit of the patient seems to require them, and there are no symptoms of a morbid affection of the viscera. Even the bark has been recommended with this view by Drs. Brocklesby and Starck, though formerly esteemed so improper under infarctions of the viscera. 22* 258 UNDERWOOD ON CHILDREN. It were needless to enter largely into the subject, and it is equally foreign from the present intention, to be more particular in regard to the cure of this oftentimes very troublesome complaint. Some notice of it, however, is taken, because though no more peculiar to children than the last-mentioned diseases, yet it may be said, that there are comparatively very few children who have not suf- fered by it during the years usually passed at school. The ague, indeed, attacks every age, so that infants, even under a year old, are very liable to it, whenever it rages among adults. It is with a peculiar view to patients of the former class that the following directions are given, the bark being usually a specific for older children and grown people: to whom, however, it is generally proper first to administer a vomit, and one or more doses of physic, as well as sometimes to assist the bark by the addition of aroma- tics, or steel. It would be improper, however, to administer these remedies very early in the disease, and not suffer the patient to have two or three regular fits before the bark and other tonics be administered, if the child be of a plethoric habit, and the febrile paroxysm severe. The small-pox, whether taken naturally, or by inoculation, as well as other acute complaints, has sometimes re- moved obstinate autumnal and chronic agues. In a state of infancy, the ague is often owing to, or connected with, a foul state of the bowels, and obstruction of the biliary ducts, and is frequently accompanied with worms, or such a state of the alimentary canal as affords a proper nidus for them. The tertian, or more common ague, at this age generally yields to purges of the pulv. e scammon. c. calomelane, or calomel and rhubarb, given on the days between the fits, and small doses of the pulvis antimon. on the return of the fever. Should this fail, a vomit should be administered an hour or two before the next cold fit is expected, if the powder should not already have had that effect. A linen waistcoat, with fine powder of bark quilted within it, may be worn by infants next their skin ; or, as a more expeditious remedy, the bark may be made into a poultice, and applied warm to the region of the stomach, and renewed through the day as often as it may get cool.* With the like view, a piece of bread hot from the oven,, and sprinkled with spir. camphor, is a very convenient mode of fomentation, in this and other com- plaints where a speedy perspiration is wished for. In older children, the common saline draught, taken once in six or eight hours, will frequently succeed ; as will warm bitters, and medicines that promote and keep up perspiration. Crude sal am- moniac also, in the dose of ten or twelve grains for children of five or six years of age, has sometimes cured this troublesome complaint; but may not be proper for delicate constitutions. Myrrh is a better remedy for such, giving from four to eight grains, before, or during the cold fit, and as much cream of tartar, every two or three hours, * See Rosenslein on the Diseases of Children ; also Med. Observ. and Inq.. vol. ii. p. 255. AGUE. 259 during the fever. Pepper, and likewise alum, are common quack remedies, and may be frequently given with success at this age ; the former from five to ten grains, the latter from three to five, joined with the like quantity of nutmeg, three or four times a day in the absence of the fever. Another good remedy is flower of brimstone, given in the quantity of a table-spoonful in a glass of brandy, before or during the cold fit; this is a proper dose for adults, but I have never administered this medicine to children. — These remedies are supposed to be beneficial by producing a different action of the parts. A remedy of late years brought into more common use, is lauda- num ; but I have not yet had a fit opportunity of making trial of it in younger subjects. Thirty or more drops should be admin- istered to an adult an hour or two before the cold fit may be ex- pected ; this, it is said, often proves an effectual remedy, even without the assistance of the bark, or when that medicine has failed, after three exhibitions, at the most, and not unfrequently on the first. Amongst popular remedies,* is a tea-spoonful of white resin in fine powder, mixed with the like quantity of pounded loaf-sugar, taken a little before the cold fit, and repeated afterwards night and morning; this I have found successful even where large doses of the bark have failed. Bracelets of mustard-seed and garlic have likewise been applied to the wrists and ankles, and, upon the tes- timony of Dr. G. Fordyce, with good effect. Such kind of remedies for this disease are numberless ; I shall, however, mention another, which, though as anile as any, seems to have been very often suc- essful (as I have been informed by the late Dr. Huck Saunders, as well as others); and is nothing more than the spider's web, rolled loosely up to the size of a child's marble, and washed down with a little warm wine and water, or chamomile tea, before the cold fit is expected : the child should then be put into a warm bed, and perspiration encouraged. This may be done, amongst other means, by fomentations to the pit of the stomach. A piece of bread, (as noticed above,) hot from the oven, and sprinkled with camphorated spirit, is not a contemptible one, in this and other complaints, where a speedy perspiration is wished for. I shall close the list of remedies with the following from Dr. Kirkpatrick, which is a very good one for patients no otherwise averse from the bark, than that the stomach will not bear it in large doses. Take of fresh sassafras bark, Virginia snake-root, roch-allum, nutmeg, calcined antimony, and salt of wormwood, of each one drachm; to these, well rubbed together into a fine powder, add the weight of the whole of the best Peruvian bark; then add three or four drops of the chemical oil of mint, and with syrup of saffron make all into the consistence of an electuary. This is to be divided * The occasional obstinacy of this complaint is offered as the apology for such kind of prescriptions. 2G0 UNDERWOOD ON CHILDREN. into twenty-four doses, one of which may be taken by children of eight or ten years of age, every four or six hours, unless the patient be asleep. To make this or any other preparation of the bark sit easy on the stomach, I have been long in the habit of advising the patient first to eat a bit of bread, or other light food with which it may mix, instead of being recieved into an empty stomach, whereby it frequently nauseates, (y) GENERAL OBSERVATIONS ON COUGHS. Previously to treating of the hooping, and what I have termed the spasmodic cough, it may not be unwelcome to students in medi- cine, that I should premise some slight observations on coughs in general; a complaint in children that we are often consulted for. It is, indeed, always of importance to be able to make proper dis- tinctions in this affection, as it accompanies divers complaints, espe- cially in infancy : and is sometimes a very harmless attendant, while at others it is of the greatest magnitude, and calls for its appropriate treatment from the beginning. My remarks here, however, will be very brief. From what has been said in different parts of this work, it will be very evident, that a cough is not always to be considered as the original complaint, like the hooping-cough, any more than a direct consequence of a cold, or of specific pulmonary affection, as in the measles. Where it may happen to be so, enough, it is presumed, has been said under the head of fevers; and the hooping and spas- modic coughs will be presently treated of distinctly. The intention here is principally to remind the reader, that a cough often attends teething, and some bowel complaints, or a foul state of the stomach, as well as a common cold, and inflammatory and other fevers, (which, however, are often suspected whenever children are at- tacked with a cough,) and is a recurring symptom in many delicate habits. Very slight occasions are oftentimes sufficient to excite it in such children, whether from a frosty or damp air, or from any little illness that has reduced the strength, and particularly if the child be of a scrofulous habit. Every confirmed glandular affec- tion will, indeed, be attended with a cough, which in that case is ofthe worst kind, as it is attended with fever, loss of strength, and manifest disease; in the last stage of which the cough becomes permanent. In every case, therefore, the cause and attendant symptoms, (y) The smallness of the quantity required for a dose, and the ready so- lubility ofthe sulphate of quinine, renders almost unnecessary all the for- mulae, into the composition of which Peruvian bark enters, described in the text. Inunction, with mercurial or iodine ointment, is useful in the more obstinate cases of enlarged and indurated spleen. Mercurial plaster, in- corporated with the sulphate of quinine, is also of late highly extolled by M. Voisin of Limoges. PERTUSSIS, OR HOOPING-COUGH. 261 rather than the mere cough, should be carefully attended to, and especially if the child be costive, or the bowels foul, and their dis- charges of an unusually offensive smell. Purging medicines are in this case the proper remedies, which should frequently be joined with saponaceous ingredients, such as the aqua kali, natron ppt., or spong. ust., nothing being more common than an obstinate and teazing cough, especially during the night, when the bowels have been long in a costive state, and the alvine discharges are very fetid, or of a stiff and clayey consistence. Though I have said my intention has been rather to discriminate the causes, than to direct the precise remedies for coughs, yet it may not be amiss to give a few suitable prescriptions for coughs attendant upon common colds, especially after the period of early- infancy. And to this I am inclined, on account of the more ordi- nary remedies met with in books being usually of the oleaginous kind, and ill suited to the state of the stomach in young people, and, indeed, not always well adapted to adults. R Mucil. gum. arab. Jiij Mellis acetati Jiss Aq. distillate 3X Syr. papav. albi 5'j ft* mistura. Addatur p. r. n. spir. sether. nitrosi gtt. xij R Pulv. etragacanth. comp. ^j Syrupi Limonis ^ss Papaveris albi vel mororum §iss Spir. setheris nitrosi 3'j Misce. ft. Linctus R Mellis acetati 3j Syrup, papav. albi mori aa 3vj Tinct. Tolutan. "gtt. xx. misce. Fiat Linctus. PERTUSSIS, OR HOOPING-COUGH. This complaint, called also tussis ferina, is a disease unknown, probably, to the old writers; and is supposed to have been con- veyed into Europe from Africa, or the East Indies : the Greek and Arabian physicians make no mention of it, and indeed it has not been well understood in any part of Europe till of late years. Hence, probably, its great fatality in Stockholm, where, from the year 1749 to 1763, inclusive, 43,393 children are reported to have sunk under it. Even Willis supposed its seat to be in the breast, but Harvey makes it a disease of the stomach, and Astruc an in- flammation of the larynx and pharynx, produced by an original affection of the former, from indigestion. He seems to have been one of the first that discarded the use of oily and pectoral medi- cines (which, indeed, some practitioners have since been weak 262 UNDERWOOD ON CHILDREN. enough to revive); though he advised bleeding too indiscrimi- nately.* This disorder furnishes another proof of the observation made on the impropriety of submitting the complaints of children to im- 4 proper hands — the care of old women, and frequent change of air, being all that this disorder is, by some people, thought to re- quire :t but perhaps the maxim was never worse applied. There is, indeed, a milder sort of hooping-cough, as there is of every dis- ease, which calls for very little medical assistance ; and it is always in such cases that matrons and old nurses acquire their credit. But there is no complaint of children with which I am at all ac- quainted, in which medicine is at times more evidently serviceable, than a bad hooping-cough. This disease is certainly highly infectious, and one of those that i never appears a second time. It more commonly takes place between the age of four months and twelve years ; but may attack ' at any time, adults being liable to its influence, though much less so than children. It often begins as a common cough, and is at- tended with the usual symptoms of having taken cold, but in its progress soon becomes more severe ; though the longer it may be before it plainly discovers itself by the hoop, the more favourable it is likely to be. A flux of rheum frequently comes from the mouth, nose, and eyes, and the food is thrown up, together with a viscid phlegm (often in great quantities) in the coughing fits; between which the child generally appears to be perfectly well, and eats its food very heartily. These are the more common symptoms; but when the disease is violent, and has continued for some time, they become greatly aggravated, especially in the night, and the child will seem almost strangled in each fit, the face and neck becoming perfectly livid, till by a violent effort, attended with a hoop, it recovers its breath; the blood will likewise sometimes rush from the nose and mouth ; and I have in two or three instances seen the eyelids as black as if injured by a violent blow, and re- main so as long as the cough has continued severe. When taken in time, however, and properly treated, the hooping-cough is rarely fatal, and scarcely ever but to young infants, and never, as long as the patient is free from fever, or other disease. It has been thought by some practitioners, that little more is required than emetics, and gentle laxatives, in which view it was, that the late Dr. James recommended his powder; though a late writer} has very imprudently wished to discard the former alto- * See bis Diseases of Infants. f If this be true to any degree, so that children, with very little assisiance from medicine, have seemed to get rid of an obstinate hooping-cough, by re- moving from one air to another; it is not improbable, that this may have arisen as much from getting out of infected beds and apartments, which might keep up the contagion, through the medium of respiration, as from any specific influence ofthe air, merely resulting from a change. X Mr. J. G. Jones. PERTUSSIS, OR HOOPING-COUGH. 263 gether ; whilst others have conceived, that this disorder will run a certain course, according to the degree of its violence, and the age and constitution of the patient; that no medicine tends much to shorten its duration, and that frequent change of air is the most appropriate remedy, as I was told very lately in a consultation with a very respectable physician.* But the fact is, that many other means are useful, and not unfrequently indispensably neces- sary, unless we would suffer the patient to be strangled in a fit of coughing, or fall into a decline, from the injury which the lungs must endure by a frequent repetition of such violence. It must be exceedingly apparent, from the above history of the disease, that its various symptoms demand a considerable diver- sity in the treatment. The more important ones are, the state of inflammation, sometimes inducing peripneumony ; the quantity and viscidity of the phlegm ; and the spasmodic affection, and dan- ger of suffocation ; together with the exhausted state into which the patient may be reduced by the long continuance of the disease. If the breathing therefore be difficult, a blister is indicated, which, if the child is not very young, may be kept open for two or three weeks ; or, what is sometimes preferable, the repetition of a small one, once in six or eight days; or a plaster of equal parts of the emplast. lyttae, and emplast. cerae. If the face should be very livid, and swollen, during the fits of coughing ; if any vessel give way ; or the patient be plethoric, and more than two or three years old ; or should be hot between the paroxysms; a little blood ought to be taken away, and a saline draught be administered every six or eight hours, and the bowels kept open, till the fever shall disappear. Otherwise, if none of these symptoms attend, bleeding does not seem, in general, to be indicated, nor much purg- * This very popular opinion is supported by the authority of Dr. Darwin, and Dr. Heberden, who, in his Commentaries on Diseases, p. 435, says, " Expe- rience has instructed us, that a change of air is of singular use in abating the force, and shortening the stay of this distemper." The efficacy of change of air, as a remedy for the hooping-cough, is, however, much more limited than many persons are willing to believe; and if by the expression "change of air," we are to understand, what many persons consider as synonymous, exposure to the open air, much mischief will often be produced. The hooping-cough is rarely a dangerous disease, unless an attack of inflammation of the lungs supervenes. This, then, is to be carefully guarded against, and one of the means of prevention is, to avoid exposure to an intemperate, or cold, or bleak air. 1 am not acquainted with many, if with any, instances in which the " force of the disease has been abated" by change of air, and should not recommend it for this purpose; but I have often witnessed its usefulness " in shortening the stay of this distemper" after its force was abated. I believe that change of air is sel- dom advisable (unless the patient be placed in a house particularly close and unventilated) during the active state of hooping-cough ; but when the violence of the complaint is subdued, it is highly beneficial, particularly if the change be from a cold situation to one of a warmer temperature, or when the coldness of winter, and the bleak east wind of March, is changed to the more genial warmth of spring, and the mild western breezes of April and May. But even then much discretion is required to regulate the time and mode of exposure to the open air, otherwise ill consequences are likely to ensue. — S. M. 264 UNDERWOOD ON CHILDREN. ing,* but may rather have a tendency to protract the disease, by increasing the spasmodic disposition, and by weakening the patient. On the other hand, stomachic cordials, such as the oil of cloves, and bitter tonics, are often exceedingly useful. There are instances, however, of a febrile diathesis continuing even in infants, after repeated bleedings by leeches or otherwise, blisters, and the use of various febrifuge remedies; and has then appeared to arise from the state of the bowels; and that not only when in a confined state, the stools in such cases being of a very dark colour, as in adult bilious subjects, and unusually fetid. Calo- mel, and repeated aperients, are here the appropriate remedies; and on which account it is of importance to examine the alvine discharges, whenever a febrile state is kept up, after the use of cooling medicines, bleeding, and other appropriate remedies. In every case, if there be an inclination to vomit, it ought to be encouraged, unless the phlegm be brought up with great ease in almost every fit of coughing, in which case nature seems able to accomplish the business herself, and it will then oftentimes be suffi- cient to keep the body open by the mildest laxative medicines. But it very rarely happens, unless in infants at the breast, that some kind of emetic is not necessary in the first stage of the complaint. The disease indeed frequently requires no other medicine, and often some of the preparations of antimony will be the most proper, for they frequently keep the bowels open as well as produce vomiting. Experience will soon demonstrate which of the preparations of antimony is best adapted to the age and constitution of the patient. If the cough should happen to be more violent at any particular time, the emetic should be given a little before the paroxysm is expected. Or perhaps a better method, at least in some cases, and particularly in very young children, is, to give tartarised antimony in small doses, together with a few grains of magnesia, or prepared oyster-shell powder, (according to the state of the bowels,) three or four times a day, so as to keep the stomach in such an irritable state, as shall secure a gentle puking every time the fits of cough- ing come on. But in whatever way this medicine be directed, it will prove of no service if it does not excite vomiting, and must therefore be given in a dose suitable to the strength of the stomach, which is exceedingly various, not only at different ages, but in children of the same age, and of the same apparent habit of body. If one preparation of antimony may have any advantage over another, they have all much more over every other emetic I have made use of; the ipecacuanha, and oxymel of squills, being ex- ceedingly unpleasant, and the latter, as far as my experience goes, usually more uncertain than any other emetic.t * Yet such a use of some aperient medicine, as shall secure one effectual mo- tion daily, is often beneficial. — S. M. | It may be doubted, whether antimonial remedies possess such decided ad- vantages over ipecacuanha, as Dr. Underwood seems to have believed. On PERTUSSIS, OR HOOPING-COUGH. 265 Such a plan is all that will be necessary in the common hooping- cough ; but there are many cases which require other means, and demand all the skill of the experienced physician. The cough, for instance, will sometimes increase not only for days, but for weeks together, and the strangulation be exceedingly alarming. In this case, the lac ammoniaci, but especially assafoetida, frequently proves a sovereign remedy, and though exceedingly nauseous, many children will take it tolerably well for the short time it appears to be absolutely required; when they will not, it may be administered by way of clyster, dissolved in a small quantity of pennyroyal or common water. These medicines, however, will be very improper in the advanced stage of the disease, when attended with hectic heat, hemorrhage, or other phthisical symptoms ; a caution equally necessary in regard to the bark, which in the absence of these symptoms, and after the stomach and bowels have been well cleansed, is frequently very useful at the latter stage of the disease, when the patient has been exhausted by its long continuance. Upon the same plan with the assafoetida, camphor, and castor, are frequently beneficial, and have the advantage of being less nause- ous, but I think proportionably less powerful. I take no notice of tincture of cantharides, though strongly recommended by some writers, because I have had no experience of it myself, and indeed have never found any necessity for trying it. For the like reason I say nothing of arsenic, recommended by Mr. Simmons of Man- chester.* It will sometimes be of no small service, to rub the hands, and the soles of the feet, with the spirit ammonise comp. several times in the day; or the spine of the back, and the pit of the stomach, with oil of nutmeg,t or oil of amber ; but as the smell ofthe latter is very unpleasant, it may be dispensed with, where the spasms are not exceedingly urgent. But when they are so, this oil is sometimes very useful, particularly when administered internally ; and children of three or four years old will take a few drops of it very well, mixed in a spoon with a little Lisbon sugar; from which I have seen as evident advantages as from any medicine whatever; and in certain cases, it has succeeded after all the other means I had made use of had failed. But frequently, no antispasmodic is equal to opium, in this, as well as in other diseases. With this view, a few drops of laudanum, or if a pill be preferred, two or three grains of the pil. e styrace, and to younger children, a small tea-spoonful of syrup of white poppies, taken at bed-time, will not only quiet the cough, and remove the strangulation during its many occasions ipecacuanha is found to exert a most beneficial effect; it may be given in various forms, so as to be but little unpleasant, and it is generally m certain in its operation as an emetic than antimony. — S. M. * See Duncan's Annals of Medicine, for 1797. f The futile remedy sold under the name of Roche's Embrocation, is said to consist of olive oil, mixed with about half its quantity of oil of cloves and am- ber.— S. M. 23 266 UNDERWOOD ON CHILDREN. operation, and procure the patient some rest, by which the strength will be recruited, but in many cases seems to have a kindly opera- tion on the disease itself.* It is in this way, I doubt not, that the cicuta has gained so much reputation, but, I believe, it is no other- wise a remedy for it than as an anodyne. From a mistake, how- ever, in this respect, the strong manner in which this medicine has been recommended by Dr. Butter, has certainly done harm; as I have known people depend solely upon it in very bad cases, to the exclusion of other remedies evidently indicated, which would, at least, have shortened the disease. Joined with emetics and other means, as the symptoms may indicate, it is, nevertheless, a valuable medicine ; and where the form of a pill be, on any account, objected to, may be dissolved in a little water, or syrup. Instead of the ol. succini, the following will often have a good effect, in children of four or five years of age; acting both as a tonic cordial, and ulti- mately a sedative. R Olei caryopbil. aromat. gtt. xxiv. Sacchari purissimi 3iss- Muc. gum. arab. §iij. Simul optime terantur, addendo gradatim Aq. cinnam. giss. vel oij. Aq. distil, %iv. ft. mistura, cujus sumatur cochl. j. largum tusse approprinquante, vel statim post tussem. If obstructions in the lungs be suspected, blisters should be ap- plied, and recourse had to gentle deobstruent medicines; but at this period the cure is chiefly to be accomplished by perseverance in cooling laxative medicines, by a vegetable and milk diet, (especi- ally asses' milk,) pure air, and gentle exercise.(z) * The draught recommended by Dr. Richard Pearson, in the Medico-Chi- inrgical Transactions, sometimes answers a very good purpose. It may consist of one drop of laudanum, from five to ten drops of ipecacuanha wine, two or three grains of subcarbonate of soda, and a little syrup and water. This dose is suitable-for a child upwards of a year old, and is to be repeated two or three times a day. — S. M. (z) The abstraction of blood by means of cups to the chest I have found to give great and almost immediate relief, even in children of very tender age, in whom the paroxysms of hooping-cough had been par- ticularly severe. Next to this, and substituted for it, where the fever and violence of coughing are less intense, is tartar emetic, at first as a vomit, and afterwards in smaller doses as a sedative ; then calomel and its adjuvants, castor oil, and the compound powder of jalap. The acute stage being over, or its violence measurably subdued, assafoetida, with ipecacuanha wine and the carbonates of potassa or of soda, and, in feebler habits, of ammonia, will complete the cure. The extract or tincture of hyosciamus, makes, also, with the alkalies, a useful combination to allay gastric and pulmonary irritation. Belladonna and prussic acid have been given with the same intent. If the disease display itself in paroxysms, separated by intervals of some length, and the excitement have been re- PERTUSSIS, OR HOOPING-COUGH. 267 The cough, after having disappeared for a week or more is some- times found to return with great violence, especially upon taking cold; but a gentle purge or two, a vomit, and abstaining from heavy food, generally remove it in a very short time. Should this fail, a grain of assafoetida, taken two, three, or four times a day, accord- ing to the age of the child, never fails to check it immediately. If these cautions should be neglected, the cough will oftentimes prove extremely tedious. And in this case I have known the lichen, or ash-coloured ground liver-wort, prove an excellent remedy. One ounce may be boiled in two pints of water to one ; and a table- spoonful may be given two or three times a day to infants of a year old : or a like decoction may be made ofthe oak-lungs, (Lichen pulmonarius,) or of the lichen islandicus. These have had an im- mediate good effect where infants have appeared to be going fast into an hectic state, after the cicuta, ol. succini, and cortex peruv. have failed, or the disorder has hung on unpleasantly. A mode of cure of a very different kind has lately been announced by Dr. Struve,of Gorlitz, and maybe noticed in this place, as worthy, at least, of a trial in obstinate cases, and in conjunction with other means; though with a caution to young practitioners, in regard to infants and delicate children. After prescribing an emetic, the following mixture is directed to be rubbed in every two hours, in small quantities, about the region of the stomach : — R Antimon. tartarizati ^j.* Aquae purs, §ij. ft. solutio; cui adde Tinct. cantharid. fort. nj. Ill various instances, the Doctor observes, that a gentle perspira- tion came on during the night, after the use of this application ; that * In Paris's Pharmacologia, the quantity of antimon. tart, is stated to be 3L — S. M. duced, quinine, or some preparation of iron, will come in quite seasonably as remedies adapted to restoring the lost tone to the system, and especially to the apparatus supplied by the pneumogastric nerve; a morbid state of which latter, and of the medulla oblongata, is represented, by some pathologists, to be the cause of the peculiar spasmodic cough and other phenomena of pertussis. Consistently with this view of its pathology, it has been recommended to apply leeches, and afterwards counter-irri- tants, below the ears and the mastoid processes, as well as on the nucha. A point more generally ascertained than the seat of pertussis, is its being complicated with gastric mucous inflammation, which, clearly indi- cated as this state is by the symptoms, requires a suitably modified treat- ment, viz., a few leeches on the epigastrium, mucilaginous drinks, laxative enemata, then calomel and castor oil, and an avoidance, for a time at least, of the stimulants, antispasmodics, and tonics, which have acquired vogue in other forms of the disease. 268 UNDERWOOD ON CHILDREN. the violence of the cough immediately abated, and in a short time the symptoms totally disappeared. In the like view of an auxiliary, I shall notice the experiments on inhaling the nitrous vapour, made by Mr. Paterson, surgeon to For- ton Hospital. This he has not only proved to be perfectly harmless in very young children, in the mode recommended for fevers by Dr. Car. Smith ; but was of very probable benefit in four of his own children, in all of whom the disease proved at least to be very slight The only thing that remains to be spoken of is the proper diet, which is, indeed, of considerable importance ; and for children, even of five or six years of age, ought to be little more than milk and broths. These are easily digested, and will afford them much more good nourishment than any kind of meats, and will sit much lighter on the stomach than puddings or pastry, the latter of which is ex- ceedingly injurious. The objection made by old nurses against milk, that it breeds phlegm, is utterly founded in a gross mistake, that cannot be too frequently controverted. It has, indeed, been sometimes mentioned by a certain class of medical people, but the objection is so truly unphilosophical, and unlike the objections of thinking men, that it scarcely deserves a reply. Should the milk, however, be found to curdle remarkably soon on the stomach, a little common salt, Castile soap, or testaceous powder, may be added to it occasionally, or asses' milk may be substituted for cows'. These light nourishments soon pass out of the stomach, or if brought up by coughing fifty times in the day, (as I have known them to be,) a child of four or five years old will im- mediately take more of them with avidity ; and will be better supplied in this way, (I mean by taking a tea-cupful at a time,) than by making set meals, or taking a large quantity at once. If the child should be thirsty, a little apple-water, toast and water, tama- rind tea, and other thin drinks, will be pleasant and useful. Patients treated in this way will get through the complaint, if not severe, in a very short time ; and where it proves violent, a child will struggle through this long disease without any considerable loss of strength, or will be very soon recruited by a decoction, or cold infusion ofthe bark, together with gentle exercise, and country air, the best restoratives after every kind of disease. [I certainly think a liniment perseveringly applied along the spine, and between the shoulder-blades, of the utmost value in hooping-cough. — M. H.] TUSSIS SPASMODICA. Much akin to the former complaint is a troublesome cough, properly enough denominated spasmodic, or convulsive. In a eertain state of the air it is sometimes epidemic, and young children, and even infants in the month, are then attacked by it, as well as TUSSIS SPASMODICA. 260 adults. The irritation seems to be about the larynx, or a very little lower down, and is exceedingly distressing at the time of cough- ing ; but the patient, though an infant, seems immediately after- wards to be quiet and comfortable. This cough is not usually attended with fever, nor other ordinary symptoms of a common cold, nor is it to be relieved by the like means ; the cough remain- ing dry and hoarse under the use of pectoral remedies. Children of two or three years old may be cured by the cicuta, and gentle laxative remedies; but the former being less adapted to infants in the month, such may take a few drops of the syrup of white poppies, three or four times a day, and their bowels be care- fully kept open ; which means seldom fail of removing the complaint in a few days. Should the syrup constipate the bowels, or other- wise disagree, the sp. ammon. succinat. may be tried in its stead ; which is a good medicine in other dry convulsive coughs, where there is no fever. I have met with this complaint very frequently in children from two to four years of age, in some of whom it had been of several weeks standing, and after various remedies for coughs had been made trial of. In every instance the complaint has been imme- diately relieved by the cicuta, and in a week or ten days has been usually removed. The like good effect has attended an infusion ofthe oak lungs, Lichen pulmonarius, after many ofthe ordinary remedies for coughs have failed; it may very well be administered together with the cicuta, if that should not be soon attended with good effect. There are, however, some more formidable cases, in which the symptoms are greatly aggravated, and children continue longer in a convalescent state. I have also been called to visit some under all the semblance of approaching death, with profuse sweats, rapid and feeble pulse, and laborious respiration, supposed by able phy- sicians to be sinking fast under peripneumonia notha, or the true pleuritis, though with more obscure fever. Although reduced to this state, under the best conducted anti- phlogistic plan, yet has a recourse to the cicuta succeeded equally well, giving immediate relief to all the symptoms. But a degree of dyspnoea, all along merely spasmodic, having, in some cases, still continued, it has been found expedient, after a week or ten days, to have recourse to the bark. At the same time, the violence of the cough, attended with very copious secretion of phlegm, which young children seldom spit up, has required two or three gentle emetics, which have then not failed having a happy effect: though administered previously to the cicuta, I have known them greatly aggravate the symptoms, probably, by increasing the debility, and disposition to spasm. As many practitioners, not very conversant with this complaint under its more aggravated appearances, have been led to consider it as inflammatory, so others, from the continuance and violence of the cough, have expected it to terminate in the hooping-cough, but 270 UNDERWOOD ON CHILDREN. have been equally mistaken; this being a distinct species of spasm, and never attended with the true hoop. Mr. Moss speaks of a spasmodic cough, different, he thinks, from any previously described,* and probably an endemic of Liverpool, resembling, however, the humoral asthma of adults (he says) more than any other. It is said to commence a few days after birth, and to continue for several weeks, or sometimes for months; and in either case so commonly proves fatal, especially amongst the lower class of people, that Mr. Moss is at a loss to suggest any appropriate remedy. If it be truly an endemic, I can probably judge but very imper- fectly of it; but from many circumstances in the spasmodic cough described in this chapter, it does not seem unlikely that the cough at Liverpool may be of the same kind. What the former might become, if very long neglected, or improperly treated, or in what time it might prove fatal, I am not prepared to say, having always soon succeeded in its cure by the means I have recommended; which may, possibly, be worthy of a trial at Liverpool, as they will not set aside the little general remedies in use. To these may be added, the use of musk, camphire, Peruvian bark, and quassia, which appear to have been given with success in the spasmodic I have described; but whether preferable, in general, to the plan here recommended, time alone can determine. SUFFOCATIO STRIDULA. The croup, or acute asthma, is a complaint somewhat similar to the two former; to which, perhaps, children only are liable,t called, therefore, asthma infantum spasmodicum,a\so suffocatio stridula, cynanche trachcalis, and esquinancie membraneuse. It is more probable that it is not contagious : as, besides other negative evi- dence, it appears that in Chesham poor-house, where there were nearly thirty children, only one had the croup, though it was much in the town at that time, in the year 1793 and 1794. Though this complaint has for several years infested this country, it has been greatly misunderstood both by writers and practition- ers ; there being certainly two species of it, perfectly distinct, and requiring very different treatment; the one being acute or inflam- matory, the other chronical, or spasmodic. These seem to have been confounded by some authors, and one of them, perhaps, not known to others. Neither of them is often found to attack those who have arrived at the age of ten or twelve years, and according to Dr. Millar, the spasmodic chiefly seizes infants newly weaned, and is then the most severe. The acute croup, however, has ap- * An. 1781. t Unfortunately events have shown that adults are not altogether free from an attack of the true croup. — S. M, SUFFOCATIO STRIDULA. 271 peared in children from within the year, to the fourteenth year. He is, perhaps, the first person in this country who has written particularly on this species ; but Dr. Home has treated more dis- tinctly on this complex disease, which had, however, been men- tioned by some German writers, and well described by them, long before it was noticed in Britain. Remote causes of this disorder may, possibly, be the lax fibres of children, the abundance of moist humours natural to them, and the vast -secretion from the bronchial vessels; and perhaps the change of food from milk, which is easily assimilated to one re- quiring more digestion. The prophylaxis is the same as in most other diseases peculiar to children. If this complaint arise from the laxity of their solids, (which is certainly not always the case,) the quality of their food, and the natural weakness of their organs of digestion, the general means of prevention, as well as of cure, will be readily indicated. Their food should be such as may be easily digested, and may prove nourishing. A due proportion of milk and broth,* (taken either separately or mixed,) whilst children are very young, or light meats when they become older : good air and exercise, and a care- ful attention to the state of their bowels. The proximate cause of the chronical croup is the presence of spasm, howsoever excited; the cause of the inflammatory, is a morbid secretion of a viscid mucus in the trachea, adhering so firmly to its sides as to impede respiration. The quantity and viscidity increasing, gradually lessens the diameter of the part, and if it effect this to a considerable degree, the disease must necessarily prove fatal. The symptoms of either kind are spasmodic, being such as would be produced by anything constantly irritating the trachea, or diminishing its diameter. They will therefore very much resem- ble those ofthe nervous asthma, but the complaint differs materially from the common spasmodic asthma of adults, in the peculiar croak- ing noise made in respiration, (from whence it has its name,) and in the violence ofthe paroxysms ; which, however, when the dis- order is light, and in its commencement, leave no apparent indis- position, save a certain dulness, and a sense of fear, in children capable of expressing it. The fits, especially in the spasmodic croup, frequently terminate by sneezing, coughing, or vomiting, and return without any regularity. It is attended with a sharp and shrill voice, and a flushed countenance, which grows livid during the paroxysms. Dr. Millar, who has written largely on this disease, (I apprehend, as it appears in Scotland,) divides it into two principal stages; in the latter of which no method of treatment has appeared to him to be effectual, but the medicine is never more efficacious, he thinks, than in the first, if the disorder be not combined with some other, * A diet of milk only, even in adults,when long persisted in, though otherwise proper, will create flatulencies. —Barry, on Digestion. 272 UNDERWOOD ON CHILDREN. and it be taken in time ; though the crouping may be very consid- erable. This I saw remarkably exemplified in the first instance I met with, which was in a little boy of my own, who was nearly cured in two days. The sovereign remedy he directs is assafoetida, which should be* administered both by the mouth and in clysters, in doses according to the exigency of the complaint; and where no marked inflammation has taken place,may be given very freely ; and afterwards the bark, when the spasms remit. This account of the disease can, however, apply only to the spasmodic, and is not the disorder usually known in this city [London] by the term croup, but a mere spasmodic complaint, totally unaccompanied with inflammation ; at least is so, whenever assafoetida is thus useful in the first instance. And this seems to be further evident from the recovery of such patients, and the con- sequent want of proof of the existence of that tough membrane found in those whose bodies have been examined after death; in whom the disease is always of short continuance after the croup, or croaking noise in respiration, has taken place. Whereas, the other kind of croup has sometimes been known to continue for two months, and then has yielded to opium. Instances have likewise been met with of children crouping for two or three days, and being then seized with hooping-cough, which has instantly removed the croup : these circumstances seem to prove that species of croup to be truly spasmodic. I have seen it repeatedly in this form attend the cutting of teeth ; being then the mere consequence of irritation, as we see cough, and various other symptomatic affections induced at this period. How far Dr. Millar may have mistaken what he calls the two stages of the croup, for two very different species of this complaint, has been hinted already. From my own experience, however, which has been considerable, as well as his authority, it seems very proper that a trial should be given to the assafoetida, when there is no degree of fever, and the child seems little, or no wise indisposed, in the intervals of the crouping. Emetics likewise will sometimes be found necessary,* as will the cicuta and bark; one or other of which must be persevered in, as long as any symp- toms ofthe disease, and particularly the croaking noise, shall remain. And from the success attending this practice, and a proper discri- mination of the disease, (one species being often mistaken for the * In one instance, medicines of this class were given in such uncommonly large doses, that it may not be amiss to notice them here. From beginning with one grain of pulv. antimon. which was several times re- peated, the child (under three years of age) took afterwards a drachm, and two drachms of vin. antimonii ; then ;>ulv. ipecacuanha ^ss. grs. xv. and 9j., to which was added gr. j. antimon. tartarisati : and at length gr. x. and afterwards 5j. of vitr. album. The trial of emetics was then given up for several days ; at the expiration of which he took oxym. scillae 3iij. ^j- Vlnl antim. which suc- ceeded better than anything, though it puked him only very moderately ; but continued to do so for the three or four times that he took it. — For remarks on the inertness of emetics and purges, see p. 113. SUFFOCATIO STRIDULA. 273 other,) there may be more room for hope in this cruel disorder, than some practitioners have been induced to think. But the other species of croup is a most dangerous disorder, being truly inflammatory in the first instance, and is, I believe, always attended with a quick pulse, cough, and laborious breathing very soon after the croaking noise has taken place, and sometimes before it, with a sensible fulness about the fore-part of the throat; although at the time of the attack other children have appeared in perfect health. It does not, however, always seem to be an original disease ; being sometimes a consequence of bad fevers, especially the febris scarlatina, as well as of some chronical disorders, that have re- duced the patient's strength, and is then much more dangerous. But the worst kind frequently appears to arise from the same causes as the malignant sore throat, only having its seat lower down, and is therefore more severe. And it has, in several instances, accompa- nied it, as may be known in the early stages of that complaint, by the croaking noise peculiar to the croup ; and I believe, is in such instances generally fatal. It has likewise accompanied the last stage of the putrid thrush, and has then carried off the little sufferer in a few hours.* The croup has likewise been found to hang on for several weeks, like the spasmodic croup, without any alarming symptom, and has even disappeared,and suddenly recur- ring, has ended very fatally in a very few days, before the child has seemed to be in danger, and after eating a hearty meal. An instance of this kind, with the appearances on dissection proving the nature of the complaint, is given by Dr. Edlin, of Uxbridge, in the Medical Review and Magazine for June 1800. On the means of cure for this species very few directions will be necessary; the disease (except in rare instances) being always short, and the treatment very evident. Bleeding is always neces- sary, if the physician be called at the commencement of the disease, or stridulous noise; and if the patient be visited too late to endure this evacuation, I believe no hope can remain of his being benefited without it, unless the infant be very young; which, however, in another view, cannot but add to the danger. If the patient be three or four years old, and plethoric, a pretty copious bleeding by the lancet may be the preferable mode ; but if much younger, or of a delicate habit, four, six, or even more leeches should be imme- diately applied to the throat,t especially if there be any perceptible fulness of that part, and a blister applied to the nape of the neck. The patient may likewise breathe the vapour of warm water with vinegar in it, or an embrocation be constantly applied, by com- f In this case, as in many others, the application of cupping glasses appears to me decidedly preferable to leeches. The quantity of blood removed is accu- rately ascertained, and is obtained in a much shorter space of time ; both of which are very important advantages. —S. M. * See note (aa) in which this secondary croup will be described. 274 UNDERWOOD ON CHILDREN. presses of linen, to the fore-parts of the throat. After the leeches and blisters, a vomit should be administered, and the sickness kept up for several hours, or even days, by small doses of the antimonial powder; which will generally succeed if had recourse to within six or eight hours of the commencement of the disease. If the bleeding, whether topical or general, should afford no relief, or if after an evident amendment, any exacerbation come on, leeches should be applied to the throat, and the vomiting kept up. At the close of the complaint, and to prevent a relapse, the bark proves highly serviceable, and will also restore the strength of the patient. In the fifth volume of the Memoirs of the Medical Society, are some good practical observations on this disease, by Mr. Field. He prefers general to topical bleeding, when called early in the dis- ease ; advises the body to be kept soluble, but dissuades from great evacuations by stool; objects to blisters to the throat; but recom- mends the following embrocation. R Aquoe ammonia? acetat. §ij. Spir. aether, vitr. comp. 3J. or for very young children, equal parts of these, and of water. He thinks he has reason to conclude the disorder to be con- tagious ; but as he has not mentioned the ground of his suspicion, the opposite presumption, from the accounts from Chesham, is the more probable one. The French writers likewise depend much upon emetics, and afterwards lenient purges, and, to prevent a return, advise apera- tives, stomachics and tonicsj particularly preparations of steel, and natural chalybeate waters. In the kingdom of Ireland, particularly about Mulligar, in the county of Westmeath, where are many lakes, the croup is a very common complaint, and equally inflammatory and dangerous as amongst us. It is likewise apt to return, (though seldom so violently as in the first instance,) if the patient ventures abroad too soon, and is exposed to the bad air of that quarter. The method of treat- ment there is somewhat different from ours, blood being immedi- ately drawn from the foot instead ofthe throat or arm, and often in a large quantity, the child being placed, at the time, in a warm bath ; a blister is then applied between the shoulders, and the bowels are kept open, chiefly by clysters. Emetics are not had recourse to, nor, indeed, any means but the above ; for, unless the violence of the complaint abates very soon, the child is thought to be past re- covery. The complaint is, possibly, not perfectly understood in this quarter, and in the northern parts of that kingdom neither this species, nor the chronical croup, is at all known, according to my information. In North America, a very different mode of treatment has been adopted ; calomel being recommended as a most successful remedy, after bleeding and the application of blisters, (when peripneu- monic symptoms attend,) and the ordinary remedies of emetics and purges. Dr .Rush, of Philadelphia, is so sanguine in regard to it, as SUFFOCATIO STRIDULA. 275 to assert that the bark is scarcely a more certain remedy for inter- mittents, than calomel, when thus administered, is in this species of cynanche. In a former edition I merely announced the sentiments of Dr. Rush, having then had no opportunity of making trial of calomel, his observations having but just come to hand. Since that time, however, I have made trial of calomel with success, though I do not feel myself warranted to speak of it in the strong terms that Dr. Rush and some others have adopted. Together with calomel, I have found it necessary to have recourse also to emetics and re- peated bleeding with leeches, even in young infants; the former being administered frequently, so as to keep an infant throwing up as often as it crouped throughout the day. Mr. Anderson, senior, of Edinburgh, testifies the merit of this medicine, after other means had failed, and the patients' lives been despaired of: other accounts, however, by Dr. Rumsey of Chesham, are far less favourable ; the exhibition of calomel, together with emetics and other remedies, failing of success in ten cases out of nineteen ; and the disease evi- dently less severe in the nine which terminated favourably. But Dr. Hamilton speaks equally favourably of calomel, given in fre- quent and large doses, until the breathing be relieved, and then to be immediately abated; this, together with the warm bath, with which he always begins, having succeeded in almost every instance. Upon the whole, every reader, from these statements, and his own experience, will judge for himself; whilst the author, from his own, has no doubt but that calomel will be highly useful, whilst bleed- ing, the warm bath, repeated emetics, and a blister to the throat, are very essentially necessary. In Dr. Ferriar's Medical Histories and Reflections, vol. hi., there are likewise some very good observations on this disease ; which he also has very properly divided into the acute and spurious. In the former he remarks certain precurrent symptoms, whereby this dangerous disease may be foreseen ; but I am satisfied this is not always the case : though much deference is due to his great atten- tion to this sad disorder, and the very considerable experience he has had. The treatment recommended is very agreeable to that I have laid down; but with the addition of one remark, very worthy of attention, viz., that the venesection should be very copious, and nearly addeliquium. Some years ago, Dr. John Archer, of Hartford county, Maryland. in America, strongly recommended the seneka-root, (Polygala Se- nega, Linn.) as an almost infallible remedy in this disease. I shall therefore present the reader with the doctor's account in his own words, in a letter he wrote to Dr. B. S. Barton, of Pennsylvania University. " I have in a great many instances found a decoction of the Sene- ka the most powerful medicine in the cure of this disease, and I am happy to tell you, that I believe it may be depended on. I make a strong decoction of the root in the following manner, viz., half an 276 UNDERWOOD ON CHILDREN. ounce of the seneka in coarse powder, is boiled in eight ounces of water, down to four. Of this I give a tea-spoonful every half hour, or hour, as the urgency of the symptoms may require ; and at in- tervals a few drops, to keep up the stimulus, until it either acts as an emetic or cathartic. I then repeat it, in smaller quantities, so as to preserve the stimulus of the seneka constantly in the mouth and throat. " If the disease be more advanced, and the breathing more difficult, with a peculiar harsh or shrill sound, like air forcibly drawn through a small aperture ; attended with a retraction of the upper part ofthe abdomen under the cartilages ofthe ribs ; I then give calomel freely and frequently, and rub mercurial ointment on the throat, and contiguous parts, so as to affect the gland of the throat and mouth, as quickly as possible. This I do that the mer- cury may co-operate with the action or stimulus of the seneka, and thereby hasten the separation of the membranous substance formed in the trachea. " In this method I have succeeded in the cure of the croup, even beyond my most sanguine expectations." Having never made trial of the seneka in this disease, (though I have found it very useful in the latter stage of pleurisy,) I have only to remark upon it, that I am informed it has been successful in this country, in one or more very bad cases, and seems to be very similar to the repeated doses of emetic tartar that have been recommended in this chapter ; while the exhibition of calomel and mercurial ointment accord with the application of blisters. Which of these means may be the more successful, or how far the appli- cation of leeches, at the commencement of the disease, may be safely dispensed with, actual experiment only can determine. Instances of success likewise with the tinct. digitalis, (as directed by Dr. Maclean,) have been twice announced by Mr. Custance, of Kidderminster. The last was in a child of two years of age, to whom gtt. vi. were administered every six hours. A great recom- mendation of this medicine is, that it succeeded in all the three cases; which were the only ones in which Mr. Custance had an opportunity of trying it.* I have examined the trachea after death in only three patients, in two of which I found the precise appearances described by Dr. Millar and others ; the wind-pipe being lined with a tough viscid coat, so as mechanically to close up the passage.t The third instance * Medical and Physical Journal, vol. iv. f It has been recommended, if an energetic trial of other remedies does not stop the progress of the disease, to perform the operation of tracheotomy, and some instances have occurred in which the patient's life has been preserved by this operation. In a case, which I attended with Mr. Lightfoot, this operation was proposed as a last and only remedy ; it was performed by my much esteemed friend, the la»e Mr. Chevalier, and was completely successful. The particulars are detailed in the sixth volume of the Medico-Chirurgical Transactions.— S. M. * LARYNGITIS MEMBRANACEA. 277 Was in an infant who died suddenly of the hydrocephalus, a few days after appearing to be recovered from the croup.(««) (aa) Laryngitis Membranacea, or Inflammatory Croup. Croup is properly laryngitis, with, for the most part, the production of falsi1 membrane in the larynx (laryngitis membranacea). Sometimes the disease is confined to this part: commonly, however, if it is not promptly relieved, the inflammation extends to the trachea, and even bronchia, which are often lined with a membranous exudation continuous with that in the larynx, and the bronchia are filled with a tenacious mucus, and the interstitial cells of the lungs sometimes with serum. Dr. Cheyne {Cyclopedia of Practical Medicine) says : we have known parts of the lungs to be hepatised, and inflammation to extend, not merely to the parenchyma, but to the serous membrane, in consequence of which we have seen fluid effused into the cavity of the pleura. In many dissec- tions the lungs have a solid feel, do not recede when the thorax is opened, and cannot be compressed. Croup, by some writers, has been divided into varieties according to the extent of the region of mucous surface affected ; as into laryngeal, laryngeo-tracheal and laryngeo-bronchial. It is of less moment to re- member these distinctions, than to be aware of the important fact of the coincidence of tracheitis and of bronchitis also, and, at times, even of pneumonia, with the laryngitis of children. Although, for the most part, the first lesions take place in the mucous membrane of the fauces and larynx, and subsequently extend to the tracheo-bronchial portion; yet, at other times, the irritation begins at the bronchial terminations, as mani- fested in cough, and then suddenly and violently fixes itself in the larynx. In a considerable number of cases, Dr. Stokes assures us, that laryngitis is preceded by some inflammatory affection ofthe lungs, which continues during its progress, but which is overlooked in consequence of the promi- nence of the croupy symptoms. These pathological considerations ought to regulate our treatment of croup ; and a knowledge of them will go far to explain the difference in the remedial measures adopted by many prac- titioners. As respects the age at which croup makes its attack, we learn that it may occur at any age between the second or third month after birth and puberty. It occasionally appears in adults, but the instances are rare. The younger children are when weaned, the more liable are they to the disease. Out of 350 cases presented in a tabular form by Mr. Andral (Pathologie Interne), 21 took place between birth and eleven months after this epoch; 61 between a twelvemonth and two years of age ; 45 between two and three years ; 54 between three and four years ; 42 between four and five ; 39 between five and six; 29 between six and seven ; 3 between seven and eight years. In the period between eight and twenty-six years of age, there were but 27 cases ; and between twenty-six and thirty, none. At thirty and at thirty-four years of age, there were for each 4 ; and 1 was reported at seventy years of age. Respecting the liability of the two sexes to croup, it would seem that this disease is much more frequent in males than females. Room is not allowed me here for an enumeration of all the symptoms of croup, which, it is important to know, are somewhat modified by the 24 278 UNDERWOOD ON CHILDREN. particular portion of the wind-pipe more especially affected. In laryngeal croup, the voice is puling, whining, and as if the throat was swelled. The cough is compared to the crow of a cock, to the low, sharp barkings of a dog, or better still, to the noise made by a dog or cat which has swal- lowed something the wrong way, as it is called, and makes half efforts at vomiting. The cough is succeeded by a sonorous respiration, not unlike the kind in pertussis. The ringing cough, followed by crowing inspi- ration ; the breathing as if the air were drawn into the lungs by a piston ; the flushed face, the tearful and bloodshot eye, quick, hard, and incom- pressible poise ; hot, dry skin, thirst and high-coloured urine, form a combination of symptoms which indicate the complete establishment of the disease. In tracheal croup, in which, although the larynx is not by any means free from disease, the trachea is chiefly affected, there is a dry, shrill, sonorous cough, and a sharp, lancinating pain in the course of the trachea, sometimes accompanied with slight tumefaction. The patient speaks in an under tone, but there is little hoarseness, and the voice and speech are not lost, or, at least, not so much affected as when the disease is seated partly or chiefly in the larynx. The cough, as the disease advances, although frequent and severe, has not the distressing sense of suffocation whicli accompanies the laryngeal variety. The fits of coughing are often followed by vomiting, or the rejection of mem- branous shreds, with a thick, glairy, and sometimes sanguinolent or pu- rulent mucus. Generally, the excretion of this substance is productive of much relief, which is increased after each discharge, unless the inflam- mation has extended down the ramification of the bronchi; and then the respiration continues to be extremely difficult, and the disease assumes all the characters of an acute bronchitis, and frequently terminates unfa- vourably. Cases of this description seldom run their course so rapidly as those do which chiefly affect the larynx. All the symptoms evince less severity, especially when treated early ; and the disease sometimes continues twelve or fifteen days, but usually from five to nine. Croup, with predominance of bronchial inflammation, corresponds with the Cynanche Trachealis Humida of Rush, and the Mucous Croup of some other modern authors. Dr. Copland describes it as not unfrequent in young children ofthe lymphatic temperament, who are fat and flabby, and have a soft, white skin. It is often met with soon after the period of weaning, and in those who are brought up without the breast. It begins with coryza and the other symptoms of catarrh, and often with a little fever. After these have been present for some time, the child is attacked in the evening, or during the night, with a sudden hoarseness, and a suf- focating, dry, sonorous or shrill cough, with a sibilous inspiration. The countenance is pale, and covered with perspiration, and the lips are violet. Several slight fits succeed to this first attack ; the voice remaining hoarse and low, the respiration sibilous and slightly difficult; but a re- mission usually takes place in the morning. In the following evening there is a return of the croupal cough in a slight degree. Sometimes the invasion is more gradual; the remissions but slight, or hardly evident, and the accession of expectoration much earlier ; the disease approaching nearer, as respects its seat and character, to acute bronchitis. This is the bastard, or false croup, of M. Guersent; more properly the laryngeo- bronchial variety of M. Duges : it is commonly milder in its character than the first described, or the laryngeal. LARYNGITIS MEMBRANACEA. 279 Whether croup be simply laryngeal, or laryngeo-tracheal, ovlaryngeo* bronchial, there can be no doubt of its inflammatory nature. The dif- ference is simply in the degree and diffusion of inflammation along the mucous membrane ofthe air passages ; and hence the treatment must be of the same kind. But there is another variety with more alleged distinctive peculiarities, represented to be common in children, and it is every now and then seen in adults. It is called Laryngismus Stridulus, or Spasmodic Croup. This has been represented to be a temporary affection of the nerves, by which the muscles of the larynx are thrown into spasmodic action, and thus diminish so rapidly and greatly this canal, as to cause feelings of imminent suffocation, and at times death itself. This variety of croup occurs chiefly in weak and irritable children, of a nervous temperament, and who are liable to worms. A quite different view of the cause of this affection was presented a few years ago in a work on this subject by the late Dr. Ley. He attributes it to a suspended or imperfect function of the branch of the eighth pair of nerves which is distributed to the larynx, and caused, as he supposes, by the pressure of the enlarged cervical and bronchial glands. Children of a strumous and scrofulous habit are the greatest sufferers. Dentition is an exciting cause, by the swelling and inflammation of the glands to which it gives rise. The distressing symp- tom of crowing and prolonged inspiration is not, Dr. Ley thinks, owing to a spasmodic closure of the glottis, but rather to an inability of this part to enlarge to its normal size, owing to the want of innervation from the diseased glandulse concatenatse. From the same cause the trans- verse fibres, behind and connecting the rings of the trachea, losing their contractile power, the sputa accumulate ; hence the "prodigious rattling in the upper part of the aspera arteria, resembling the sound which attends when there is phlegm that cannot be got up, scarce sensible when they are awake, but very great when they are asleep, described by Dr. Molloy, ' that kind of noise which an increased secretion of the mucus on the air passages would produce,' noticed by Dr. North." The approx- imation of the sides of the glottis, thus produced, Dr. Ley argues, is owing to defective power of the opening muscles, and may be either complete or partial. If complete, the child may be carried off by con- vulsions, or by asphyxia without convulsion. More commonly, however, the glottis becoming gradually, but partially open, air rushes through the still contracted aperture, producing the sonorous inspiration so character- istic of this disease, and this commonly announces the partial recovery of the child. The pathological views of Dr. Ley would lead to a prophylaxis which consists mainly in removing both the enlargement of the obstructing glands, and in giving time to nutrition so as to prevent their becoming subse- quently diseased. But whilst admitting the propriety of this course as far as it goes, we cannot give our adhesion to the pathology on which it is founded. Croup is too readily as well as promptly curable, and yields too frequently to a removal of specific irritation, such as dentition, indi- gestion, &c, for us to suppose that it could depend on a cause so de- cidedly organic as that advanced by Dr. Ley. In reference to spasmodic croup, in general, there is no sufficient dia- gnosis to enable us to distinguish it from common inflammatory croup. Cases of pure and unmixed spasmodic croup are rarely met with in prac- 280 UNDERWOOD ON CHILDREN. lice, the intermediate states between it and the inflammatory variety being more constantly observed. It is worthy of notice, also, that, in the undoubted inflammatory and membranous variety of croup, the ob- struction of the larynx, or the laryngeo-tracheal canal, by new formation, is not sufficient to prevent the access of air to the lungs, — but that a great part of the phenomena and consequences of the disease are to be attributed to spasm of the larynx and trachea. This, however, it has been justly re- marked, is spasm caused by inflammation for which no antiphlogistic will be equal to venesection. Doctor Copland says, that he has scarcely ever seen a well-defined case of spasmodic croup unconnected with dentition ; or one terminate fatally without the concurrence of convulsions in its advanced stages, or towards its termination ; and it has very commonly presented evidences of cerebral congestion. Dissection has revealed, in some cases, albuminous concretions, sometimes extensive, but more fre- quently consisting of small isolated patches in the larynx ; sometimes an adhesive glairy fluid, with vascular spots in the epiglottis and in the larynx. The congestions of the brain, particularly about its base and the medulla oblongata, and of the lungs, cavities of the heart and large vessels, which were also found, were most probably consecutive changes. Still, it must be conceded that there is a variety of croup of primary origin meriting the name of spasmodic. It may be induced by a preceding attack of the inflammatory ; it appears to be most common in strumous and scro- fulous habits. To the sudden invasion of croup, following and apparently caused by indigestible substances, such as nuts, apples, &c, and which is promptly removed by their expulsion, the title of spasmodic would seem to be applicable enough. The seat of the inflammation of croup has been already stated to be the mucous membrane which lines the air passages, and in a more parti- cular manner, the larynx and the trachea. The membranous exudation varies in thickness, consistence, and extent of surface over which it it spread : it is more commonly found in the larynx and upper third of the trachea than in any other situation (Ryland). Bretonneau gives three instances in which the false membrane extended from the epiglottis, without break of continuity, to the extremities of the bronchial ramifica- tions. In reply to the remark of Laennec, that this false membrane is generally found in the larynx, but that it very rarely extends above the glottis, we may cite the experience of Dr. Thomas Davis, who, in his published lectures, remarks, that, of six preparations then upon the table before him, nearly every one presents the false membrane on the inner surface also of the epiglottis. Treatment.— The leading points of cure have been stated with suffi- cient fulness by Dr. Underwood in the text, but in a more discursive manner than is desirable for the purpose of guiding the young practi- tioner. In summing up the treatment, I shall advert more particularly to the results of my own experience than give the opinions of others. Called up in the night to see a child who, after having gone to sleep early in the evening, is at this time suffering from well-marked croup, the physician, having ascertained the antecedent and collateral circum- stances, in regard particularly to prior attacks, their duration and treat- ment, and the general habit and morbid predisposition of the patient, pre- scribes an antimonial emetic. He may find that, before his arrival, either ipecacuanha or antimonial wine, or the compound honey or syrup of squills LARYNGITIS MEMBRANACEA. 281 had been administered. If already nausea has ensued by means of some one of these, and the system shows a readily excitable impression to their action, it will, sometimes, be enough to continue the article in perhaps larger doses than had been given before his arrival. But if no amelio- ration has been produced, he should at once proceed to administer the solution of tartar emetic in a dose of from a quarter to a third of a grain, to be repeated every ten or fifteen minutes, until either emesis and the accompanying relaxation are brought about, or the medicine fails to vomit at all, or to abate materially the violence of the symptoms. In reference to the dose and frequency of its repetition, and the entire quantity of tartar emetic to be given at this time, we must remember, that the greater the phlogosis in general, but more particularly of the thoracic viscera, the greater will be the toleration by the system of the medicine; or, less equivocally expressed, the longer will be the time before its ordi- nary effects are manifested. Commonly, between one and two hours will be the interval in which the salutary operation of the tartar emetic may be expected. If after two hours administration of the medicine in full doses it fails to even nauseate, recourse must be had, not to other emetics, but to means calculated both to abate the now evidently violent disease, and to renew the susceptibility of the system to the tartar emetic. The remedy next in order, and the one indicated by the symptoms and our knowledge of the pathology of the disease, is bloodletting. If a vein in the arm can be found it should be opened — if there be failure in this respect, we may sometimes procure blood near the ankle joint or the instep, both feet being immersed during the time of the flow of blood in warm water. We frequently read of a recommendation to open the jugular vein, on account of its being superficial. The operation is sim- ple, but not quite so easy as we might be led to suppose ; and the appear- ance of the thing is revolting to the mother and others present. But as essentials ought never to be sacrificed to appearances or prejudices, if we cannot open a vein elsewhere, we must not hesitate to draw blood from the jugular, even although there be sometimes difficulty in stopping the flow. A diminished pulse, paleness overspreading the face, and a feeling of sickness, nausea, and even vomiting, are frequent effects of the detrac- tion of blood, and evidences, in this case, of its having been carried to a suitable extent. Often, after venesection, free vomiting will be caused by the tartar emetic which had been given before the operation without any such effect resulting. Associated with the two remedies already mentioned, viz., tartar emetic and the lancet, is the warm-bath ; and hence it is proper that the physician, immediately on his arrival, should ask to have warm water in readiness in case of need. Failing to produce the desired impression with the tartar emetic, and either fearing to draw blood from a vein on account of the prior state and diseases of the patient, or unable to perform the operation, owing to the vein being imbedded in adipose and cellular tissue, it is proper, if a regular bathing-tub is not at hand, to have a large wash-tub three parts filled with water a little below blood heat, in which the child should be immersed up to its neck. If the vessel is not deep enough for this pur- pose, a blanket must be drawn over its back, so as to cover the shoulders and leave the head alone free. The period of immersion will vary from one hour to two or three hours, according to the effect produced by the 24* 282 UNDERWOOD ON CHILDREN. bath, and the other remedy or remedies which may be had recourse to conjointly with it. The system which, before immersion, was intract- able to the tartar emetic, will after a time evince its renewed susceptibility by nausea and free vomiting. It may be, also, that the attack is so vio- lent and the danger imminent, as to require recourse to the appropriate remedies in quick succession : so that immersion in the warm bath will accompany the administration of the emetic tartar, and whilst the pa- tient is yet subjected to the trial of this treatment, blood will be drawn from the arm or jugular vein. It rarely happens that a decided and salutary impression is not produced by these three agents in the cure of croup. I have found vomiting and the warm bath adequate to produce a complete solution of the paroxysm in cases in which, but for the fatness of the children and consequent difficulty of finding a vein, I should like to have bled. The free perspiration begun in the bath is kept up the remainder of the night by h-iving the patient enveloped in blankets and administering minute doses of tartar emetic and a little sweet spirits of nitre, with a drop or two of laudanum each time. In the city, when the indi- cation is urgent for the abstraction of blood, we can obtain the desired end by the use of leeches applied to the upper part of the sternum, or directly above the clavicle, on each side of the trachea. The same object is attained also by cupping between the shoulders, or on the nape of the neck. The quantity to be thus abstracted is little more than an ounce and a half for every year that the child has completed. In the few more severe cases in which the course of the disease is still unchecked by vomiting, bloodletting, and the warm bath, or in which we are not called on until the suppurative stage is begun, and the distressing symptoms undergo scarcely any remission, we must endeavour to act on the mucous surface, and procure a detachment of the false membrane, by combining with tartar emetic calomel in full doses; and if the bowels have been already freely acted on, we add a little opium. Impressed, as we should be, with a belief in the diffusive operation of mercury, and of its more especial action on the mucous membranes, we cannot hesitate to have early recourse to it in those cases of croup which do not yield promptly to tartar emetic and the lancet, as well as in those which evince complications of bronchitis or of gastro-hepatic disorder. To Dr. Benjamin Rush are we indebted for the introduction of this valuable remedy in croup. Dr. Hamilton, on the other side of the Atlantic, soon adopted the practice, which he carried to a still greater extent than our Philadelphia professor. As the ultimate effects of mer- cury, when given in large quantities, are to attenuate the blood by de- stroying its fibrin and colouring matter, and to produce a cachectic state of system utterly incompatible with the existence of adhesive inflam- mation, we have indications for its use in croup. It may be given in doses of one to three grains, combined with a fourth of a grain of tartar emetic, every two hours, until its effects are evinced on the bowels by increased and green alvine discharges. Afterwards, especially if the skin have lost its febrile heat and the excitement generally be diminished, a minute portion of opium may be added to the articles already men- tioned ; the more readily, too, if at intervals there is an aggravation of the distress in breathing by an apparent spasm ofthe glottis. The calo- mel once begun to be administered, its use should be persisted in until its desired effects are obtained ; care being taken all the while to adopt LARYNGITIS MEMBRANACEA. 283 other remedies which may be recommended at the same time to the vary- ing states of the general system. Thus, if there be a suffused blush in the face, turgid jugular vein, strongly throbbing carotids, with a heaving of the chest, we may venture, even though venesection has been freely used, to apply leeches in the manner advised already, and sinapisms to the extremities. Evidences of depression of the vital powers in a pale- ness of the face, coldness of the skin, and smaller pulse, will, on the other hand, require abstinence from the tartar emetic and recourse to the hot bath, frictions of the surface, and warm infusion of the root of the po- lygala senega, and oxymel of squills, with even the addition of a little car- bonate of ammonia. During all this time the calomel will be regularly administered, until the breathing is free and equable, and the expectoration loose and abundant. In the suppurative stage, or that of approaching collapse, we should stimulate the cutaneous surface by sinapisms to the extremities, volatile or turpentine liniments and epithems to the chest, or a blister between the shoulders. More stimulating expectorants, consisting of the fetid gums, as assafoetida, or ammoniacum mixed with squills and ammonia, are also to be administered by the mouth, and enemata given, both to evacuate the bowels and to produce derivation from the seat of disease. A warm hip bath will contribute to the same end. The inhalation of vapours-, never easy to be done by adult patients, is still less so in the case of children : when it can be accomplished it is no doubt of considerable service. The treatment of croup with bronchitis, or of croup followed by bron- chitis, is nearly the same as for this latter disease. Cups to the chest, or between the shoulders, succeeded by blisters; and calomel, with very minute doses of opium and tolerably free purging, are leading means of cure at this time. Having thus sketched the outlines of the treatment of croup of the severer kind, I must add a remark, that, in a majority of cases of this disease, an antimonial emetic will suffice to give immediate relief, and a purge in a few hours afterwards complete the cure. In spasmodic croup, or in that kind supervening suddenly on catching cold, or on indi- gestible matters in the stomach, even if it should be inflammatory, these remedies will generally suffice, on the day following an attack of croup. Febrile irritation, an unusual fulness of face and cough still remaining, we ought either to bleed, or to give full doses of calomel, until the mucous membranes of the air passages are relieved. This is done both by the direct removal of their congestion and inflammation, and indirectly by the full action of the medicine on the gastro-hepatic apparatus. It ought to be laid down, as an invariable rule, that a purgative is to be given in the morning following an attack of croup, or the preceding evening, if we would greatly diminish the probability of a fresh attack the second night. A croupy cough, without much fever or symptom of laryngeo-bronchial irritation, may often, in delicate subjects, be treated with antispasmodics, to which a little ipecacuanha or squills has been added. 1 have relieved entirely an adult from a second attack of croup by the extract of stra- monium and blue mass given in pill. 281 UNDERWOOD ON CHILDREN. Laryngismus Stridulus — Spasm of the Glottis. After all, it is doubtful whether laryngismus stridulus is properly identical with spasmodic croup. The latter mostly exhibits all the dis- tinctly marked symptoms of the inflammatory variety, with the addition of increased difficulty of breathing and sense of imminent suffocation ; the spasm being an incident in the train of inflammatory symptoms. In the laryngismus stridulus, on the other hand, the attacks will come and go, often suddenly like the asthma of adults, will return frequently, and on occasions, without any sinister result, although in general a first attack should excite watchfulness on the part of the mother or nurse, and induce them to give early notice to the physician of a repetition of the disease. The period is still more restricted, than that of croup, in which laryn- gismus stridulus is manifested; rarely exceeding three years from birth. Dr. Kerr (Edinb. Med. & Sur. Journ., 1838,) has known the symptoms of the latter to appear as early as eight days after birth. He agrees with Drs. Ley and Marsh in the opinion, that the children who are most liable are those of a very full and large habit of body, and who exhibit marks of the strumous diathesis, or have sprung from scrofulous parents ; but he also adds, and my own experience is confirmatory of the fact, that he has seen it in thinner habits, and in whom no scrofula could be sus- pected. In addition to the affection of the glottis, when it has occurred with such intensity and frequency as to excite attention and alarm, there are commonly other symptoms associated. The chief of these are exhibited in the thumbs being turned into the palms, and the hands more or less clenched, and when opened by force immediately return to their former position. The feet are turned inwards and downwards, and the backs of the hands and feet are swollen. These symptoms are most distinct when the crowings are numerous, or, as just remarked, when convulsions are threatened ; at other periods they are seldom present. The disease fre- quently terminates by convulsions ; and more rarely is ushered in by them. Other parts of the muscular system are affected, as when the child is unable to stand or walk erect, or to swallow liquids, except when given in small quantities. In severe cases, the child does not void urine as frequently as in health, and the quantity of the secretion is diminished. In a few cases, continues Dr. Kerr, the buttocks, or groin3, become ten- der, and exude watery lymph, and in perhaps every case of the disease, the buttocks, even when well covered, are as cool as if newly washed. Mental emotion, such as any vexation, is apt to bring on a paroxysm. Frequently the child is awakened out of sleep by one. A current of cold air will produce the same effect. In some days from twenty to thirty attacks of crowing will occur. During some weeks the crowings will be numerous, and during other weeks there may be very few. During an attack, the sufferings appear to be occasioned wholly by the want of air, and arc not unfrequently so great that the child becomes somewhat livid. Instances have occurred of a paroxysm of crowing terminating life by the glottis remaining so long shut as to occasion suffocation ; but in general, danger proceeds from the occurrence of convulsions. These are to be expected whenever the crowings become numerous. Sometimes they are succeeded by insensibility, and at other times the child becomes sen- LARYNGISMUS STRIDULUS. 285 sible as soon as the fit is over. In general, when the disease is approaching a fatal termination, the epileptic fits become more numerous, and the child dies apparently rather from the effects of convulsions, than from any affection of the glottis. Dr. Kerr thinks that the laryngismus stridulus is almost always a con- sequence of cold. Occasionally it commences in summer, but only when the weather is cold, and especially if the child resides in a cold or damp house. Aulopsic examinations have not revealed any deviation from health in the larynx or trachea. If convulsions have occurred, the mor- bid appearances in the brain are similar to those produced by convulsions unaccompanied with laryngismus (Dublin Journ. Med. Science, 1838). This disease is obviously the same, in its essential features, as that de- scribed by Dr. Underwood in the text under the head of Inward Fits, p. 109-10, and by Dr. Clarke as " A Peculiar Species of Convulsion in Children," whose account of it is introduced in a note by Dr. Hall, p. 111-12. It also closely resembles, if it is not identical with, the thymic asthma, a detailed description and pathology of which are fur- nished by Dr. Montgomery (Dublin Journ., 1836). Taking into con- sideration all the phenomena of the disease, we must go farther in our explanation of its organic cause than Dr. Ley, who supposes a paralysis of the glottis to be induced by pressure of swelled glands on the recur- rent nerves, and of Dr. Marsh, who suggests that the seat of the disease may be at the origin of the pneumogastric nerve. The real cause is that, a lesion of which will give rise not only to the affection of the glottis, but also to the convulsions, and occasionally paralysis in the muscles of the limbs as well as those of deglutition. This must necessarily be in the brain, or more particularly at the medulla oblongata. The explanation furnished by Dr. Montgomery, of the disease he describes being caused by pressure of the thymus gland on the nerves, is too partial: the disease has came on from other causes. The treatment of laryngismus stridulus is not of such a heroic nature as that of inflammatory croup. Laxatives, sometimes nausea induced by small doses of tartar emetic, or of ipecacuanha, assafoetida, and the alkalies, counter-irritants to the skin, and the warm bath, are the chief remedies adapted to the cure. Protection from cold, and a wholesome diet, are the chief measures of prophylaxis. With this view, the feet should be kept warm by woollen stockings and thick shoes, and the chest, up to the clavicles, and also the arms, covered with a flannel jacket. Within certain limits, some variety of food is desirable, so as to include milk, farinaceous articles, well dressed vegetables, and a small portion of plainly dressed meat once a day. To give suitable energy to the organs of nutrition, exercise in the fresh air, and the tepid or warm bath are excellent, indeed indispensable aids. A troublesome attendant on laryngismus stridulus is an almost continued, and consequently exhausting perspiration, by which the chances of fresh attack are increased on exposure to any inequality of temperature, and especially of humid cold. The curative measures in such a case will be at first to sponge the skin with tepid, and afterwards with cold, salt and water, or to use a shower bath of the same every morning; and then to impart a tone to the system by the hygienic measures already detailed, and the administration of a vegetable bitter, or a mild chalybeate, or in some cases, sulphate of quinine. 286 UNDERWOOD ON CHILDREN. Secondary Croup. — Diptheritis. This disease is spoken of in the text by Dr. Underwood as common croup — or that which assumes an epidemic character. But the laryngeal symptoms are here secondary to the angina; and the disease altogether demands a different treatment from thatof primary laryngitis, or croup. In the first few days there are symptoms of angina, with fever; the tonsils are somewhat enlarged, and deglutition is difficult. If not checked, the disease manifests itself still farther by membranous exudation, spread by continuity over the parts adjacent to the fauces and tonsils, and the soft palate and the pharynx: the glands at the angle of the jaw begin to swell, and deglutition becomes more difficult: the face is puffed, and the eyes glistening and watery. Sometimes the first concretion i3 detached, but is soon replaced by another, thicker and more tenacious. In most instances, at the end of four or five days, laryngeal symptoms begin to display themselves, such as hoarse cough, alteration of the sound of the voice, and dyspnoea. From this time the patient has every appearance of suffering from severe croup, with the addition of an almost complete inability to swallow ; the breathing is laborious and sonorous, the voice is soon extinct, the countenance livid, and the pulse small and intermit- ting, paroxysms of suffocation take place, till in one, more severe than the rest, death closes the scene. The chief anatomical character of diptheritis is the false membrane or lymphatic exudation, either continuous or in patches, occupying some- times the nasal fossae, the velum palati, tonsils, pharynx, oesophagus, larynx, trachea,]and even the divisions of the bronchi. M. Guersent has seen it extend into the frontal sinus, and M. Bretonneau once on the concha of the ear. Sometimes, as already stated when treating of croup, the exudation is found in the stomach, with an interruption of continuity, however, on the oesophagus. Often, if not in the majority of cases, its range is more circumscribed, covering only the pharynx and tonsils ; sometimes extending to the epiglottis and rima-glottidis, but without passing this latter. It is commonly adherent to the velum palati, the tonsils and the pharynx, whilst on the other hand it is, for the most part, loose in the tra- chea. In thickness it varies from that of a leaf of paper to a line. Contrary to what was generally imagined, before a careful inspection of the parts in late years, the subjacent mucous membrane is neither ulcerated nor gan- grenous. The numerous patches with which it is studded, and the central depressions on these, and the dark-red colour ofthe mucous mem- brane, together with the extreme fetor of the breath, gave rise at one time to a belief that the organic changes were the consequence of gangrene, and hence one of the names of the disease, gangrenous sore throat. But there was error in all this — the pseudo membrane is the result of either inflammation or of hemorrhage which does not even end in gan- grene. Diptheritis is occasionally sporadic, but much more frequently epi- demic. It attacks individuals of all ages ; displaying, however, a marked preference for children of either sex from the age of four or five to the time of puberty. According to M. Bretonneau it is decidedly contagi- ous, and especially when combined with scarlatina, which is one of its most frequent complications. We must regard as diptheritis the epidemic SECONDARY CROUP. 287 croups which are on record. The epidemic which prevailed during the winter months in successive years, from 1813 to 1816, in so many parts of the United States, presented numerous examples of diptheritis, in which the pneumonia and bronchitis were sometimes apparent, but in other cases they were completely masked by the anginose symptoms. Then, however, although but a student, I remember very distinctly that adults and those advanced in life were the greatest sufferers and most numerous victims : in some of the oldest persons the anginose symptoms were most predominant. M. Jolly (Dictionn. de Med. et de Chir. Prat., art. Angine), is inclined to believe that the membranous angina, or diptheritis, is the result of a hemorrhagic inflammation, in which the colourless fibrin is thrown out on the mucous membranes, and the engorgement of which with dark blood is regarded as farther evidence to the same purport. Treatment. — If we carry in our minds the antecedent and accom- panying circumstances by which diptheritis is modified, we shall begin the treatment with less hesitancy, certainly with less chance of serious error than they have done who, under the influence of an exclusive patho- logy, insisted either on its being a disease of pure asthenia, with a rapid tendency to gangrene, or on its being a phlegmasia. In those persons of a feeble frame and exhausted constitution, who have been badly fed and lodged, the prostration is great and the reaction slight. On the other hand, the strong, plethoric, and sanguine, exhibit, with great severity of the local symptoms, a frequent, full, and resisting pulse, and a general and almost acrid heat of the skin. In some, the angina is associated mainly with symptoms of gastric disorder: in others, the membranous exudation extends, in the manner already described, into the air passages, and the chief complications will be laryngitis, or broncho-pneumonia. Now it is very obvious that the same treatment cannot be applicable to all these- varieties, and that whilst venesection may be imperatively required in cases of the latter, it would be eminently prejudicial, if not fatal, in the former; and so, also, local and general stimulants which might be clearly indicated in one kind, would be more than useless in the other. In the same epidemic to which I have already referred, and in which even from the necessity of the time I was allowed to act a part as well as entertain an opinion, I well remember the opposite views and practice adopted by physicians. Some, who saw the anginose character predomi- nate, and accompanying the cold skin, feeble pulse, and general prostration, would not admit the safety of any other remedies than of emetics, stimu- lating gargles, blisters to the neck, and diffusible stimulants. Others, witnesses to distinct pneumonia and less-marked angina, shaped their practice accordingly, and bled their patients. Some, again, who met with a predominance of gastric disorder and hepatic derangement, relied on calomel and purgatives. In premising that bloodletting is less called for in plastic or membra- nous angina than in other inflammations ofthe pharynx, tonsils and larynx, we ought not, however, to exclude it entirely from our list of remedies. The plethoric and the sanguine, or the cases in which pneumonia is com- plicated with the angina, will be benefited often by venesection. M. Jolly, among others, gives cases ofthe benefit of this practice, and I have tried it myself with advantage. In more doubtful circumstances, but in which the pulse has still some fulness and resistance, and in which there is evi- 288 UNDERWOOD ON CHILDREN. dence of great determination to the throat, marked by redness and swel- ling, leeches may be applied under the angle of the jaw, and on each side, and in front of the neck, or cups to the nucha and under the mastoid pro- cesses. Here, as in acute laryngitis, we should have a definite object in view in detracting blood, viz., to produce a decided impression on the dis- eased membrane; failing to do this, we only aggravate the disease by encouraging a morbid reaction. Hence, if the first leeching or cupping do not produce the effect proposed, the operation should be repeated after a brief period. In the cases, again, in which the patient has but little vital energy, Owing to his having been badly nourished or exhausted by prior diseases, as phthisis, for example, or in which there is little or no augmentation of action of the pulse; but on the contrary a cold skin, but slight pain of the throat, and the voice nearly extinct, bloodletting, either general or local, is clearly contraindicated, and could hardly fail to be prejudicial. In this state of disease, revulsives of various kinds are serviceable; among which emetics are entitled to a trial first, provided the stomach be not inflamed. A combination of ipecacuanha and of the infusion of polygala senega would be preferred here to the tartar emetic, the use of which is applicable to the cases distinguished by vascular excitement and calling for previous detraction of blood. In croupal complications the emetic practice is still more requisite. Carrying out the revulsive treatment, we prescribe calomel, conjoined with jalap or scammony or colocynth, in such doses as shall purge freely. Medicines of this class are entitled to a preference over salines, which exhaust by copious watery evacuations without exciting to active secretion the intestinal mucous follicles and the liver. With a view of carrying out consistently the course begun, we should endeavour to stimulate the lower extremities by warm pediluvia, sinapisms and liniments, and to excite the cutane- ous function generally by the warm bath, and by the warm infusion of polygala or eupatorium. Calomel has been extolled as admirably adapted to bring about a removal of the membranous exudation in secondary, as it is believed by so many to do in primary croup. Its admin- istration with this view will not be incompatible with the employ- ment of the remedies just named. It should follow purging, and be conjoined with the external revulsives already named, as well as with those to be next specified. The dose may be a grain every hour or two, with a very minute fraction of opium if the bowels are loose, or of ipeca- cuanha. Among these vesication has always been a favourite. Like certain other remedies, however, it has retained its vogue from very opposite causes. Some prescribe a blister in angina, because it has been prescribed by others ; some, because they have seen positive good result from its application; and others, because they do not know what else to advise. It would argue prejudice, on my part, were I to tell merely of the frequent suffering without any correspondingly adequate relief which I have seen to be caused by blisters applied in the common fashion on the anterior part of the neck under the chin ; and yet my earlier reminis- cences of this kind are much more distinct than those of any decided good from the practice. On the nucha or over the trachea just above the sternum, is a preferable spot for the application of a blister ; and if coun- ter-irritation be still thought advisable near the affected part, an ammo- SWALLOWING BOILING WATER. 289 riiacal or turpentine liniment may be rubbed on the neck, from the angle of the jaw downwards and forwards over the larynx. But whilst a trial is made of some or all of these remedies in succession, we ought to be aware of the importance from the first of making applica- tions to the diseased mucous membrane of the fauces, tonsils, and pha- rynx— not, a3 M. Bretonneau would pursuade us, that this is the main and almost sole plan of treatment, but because it is of no little moment for preventing the farther spread of the plastic exudation, and thus far saving the larynx and air passages generally from dangerous participation in the disease. ,The topical remedies are hydrochloric acid, nitrate of silver, and alum : of these the two latter are to be preferred. The safest and easiest of application is the alum — blown on the part by means of a tube with gauze fastened on the end next the throat, or reduced to a paste by mixture with water and honey, and applied to the diseased surface with a small brush or the handle of a tea-spoon. The nitrate of silver may be used in the same way, or that which will be found to be more expeditious and complete, is to fasten a piece of the caustic, properly secured to a quill, and run it rapidly over the mucous surface ; the mouth being kept open by means of a spoon pressed on the tongue. Gargles have always been largely used in diptheritis, as well as the simpler forms of angina. The popular one, composed of vinegar, salt and capsi- cum, is often well adapted to the disease in question. The chlorides of soda and of lime, of late years, have been a good deal used, and with results which warrant a ready repetition of the practice. Creosote is also re- commended. [I may introduce, in this place, an account of a singular accident Which results from SWALLOWING BOILING WATER in the cases of certain poor children who have been observed to drink out ofthe tea-kettle, when their mothers have returned from replenishing this utensil at the spring or pump. This practice has led, in many instances, to the fatal or dangerous accident about to be described. The children have afterwards attempted to drink through the spout ofthe tea-kettle, when it has but shortly before been taken boiling from the fire, supposing it still to contain cold water. The effects of this accident are not, as might be supposed, ct, priori, the symptoms of inflammation of the oesophagus and sto- mach, but of inflammation of the glottis and larynx, resembling those of croup ; and the case constitutes another instance in which the operation of laryngotomy, or of tracheotomy, may be performed with the effect of preventing impending suffocation, and perhaps of saving life. It appears probable, indeed, that the boiling water does not actu- ally penetrate into the stomach, or even into the gullet, but that its course is arrested by a spasmodic action of the muscles of the pharynx. In passing to the posterior part of the mouth, however, 25 290 UNDERWOOD ON CHILDREN. it scalds the epiglottis and glottis, which afterwards become more and more swollen, until at length the rima glottidis, or orifice into the larynx, becomes completely obstructed. Of the four patients whose cases are about to be given, one re- covered from imminent suffocation immediately after violent scream- ing ; two died from suffocation—one ten, the other seventeen hours after the accident; the fourth was completely relieved by the ope- ration of tracheotomy — survived thirty-four hours, but died, ex- hausted by the irritation produced by the primary affection. Case I.— A. Litchfield, a little girl, aged three years, attempted to drink through the kettle-spout, a few minutes after it had been removed from the fire in a boiling state. She had no assistance for three or four hours, during which period a difficulty in respiration came on, and gradually augmented. A medicine, containing oil and syrup, was recommended. The dyspnoea continued to in- crease, and the little patient was bled from the jugular vein ; the difficulty in respiration still, however, became more urgent, and threatened suffocation. At this period leeches were prescribed, and directed to be applied to the throat. The little girl was much terrified on seeing the leeches, and screamed violently, so that they could not be made to apply. From this moment, however, the re- spiration became comparatively easy; and the little patient reco- vered completely in the course of a week, and still remains well. The parents of this child suppose that the violence of the scream- ing ruptured the vesicles by which the breathing was impeded, and thus proved an unexpected means of cure. Case II.— John Langton, aged two years. In August, 1816, about eight o'clock in the morning, and just after the water had boiled for breakfast, he attempted to drink through the kettle-spout. He cried out immediately. In about four hour she began to labour and rattle in breathing; the dyspnoea increased gradually; at length, the face became livid, and the feet cold, and he died from suffoca- tion, about seventeen hours after the accident. There was not much difficulty in swallowing, and there was no vomiting. The dyspnoea resembled that observed in the croup, and the noise was so great as to be heard at a considerable distance. The little patient was bled from the arm, and oil and syrup were given, without any appearance of benefit. Case III.— A little girl, aged two years and a half, about four o'clock in the afternoon, attempted to drink through the spout of a tea-kettle, which had been just taken off the lire with a view of preparing tea. She screamed out; her mother carried her to a surgeon : on her return home, the little patient began to breathe with difficulty and with a rattling noise. She could swallow, how- ever, and there was no vomiting ; she instantly cried out, indeed, for something to drink. The difficulty and rattling in breathing increased, and the respi- SWALLOWING BOILING WATER. 291 ration was performed with great effort, and the integuments of the neck near the trachea being drawn inwards at each inspiration. This little girl lay some hours as if she were gasping her last, and died suffocated, and rather suddenly, at two o'clock, ten hours after the accident, having previously become pallid and cold. Case IV.—A little girl, aged two years and a half, attempted to drink through the spout of a new tea-kettle, which had boiled only ten minutes before. The mother was brought up stairs by the cries of another child ; she sent for her medical man, who prescribed oil, mucilage and syrup. On seeing this little girl five hours afterwards, I found it affected with difficulty in breathing, with a hoarse croupy noise, referred to the top ofthe larynx. It was able to swallow without manifest pain, or coughing. The tongue and all the internal parts of the mouth were blanched and blistered. The pulse was frequent. The dyspnoea gradually increased. To prevent impending suffocation, tracheotomy was performed at half after four o'clock, a.m. twelve hours after the accident. The relief was immediate. The little patient sat up, played, and looked cheerful. The voice was extinct. The respiration was free through the orifice made into the wind-pipe. At ten o'clock, a.m. the difficulty in breathing had much returned. The face was pale, and the child appeared to be dying. In the afternoon, however, it was better, the difficulty of breathing being again much relieved. It swallowed imperfectly, a little passing, at each attempt, into the trachea, and being returned through the orifice by coughing. The little patient seemed once more to be in a promising state. The next day at ten o'clock, a.m. the little girl was worse, and apparently sinking. The respiration was not, however, difficult; but the pulse was almost imperceptible, and the extremities cool. She died at half-after two o'clock, p. m, thirty-four hours after the operation, apparently from the exhausting influence of the original disease. On dissection, there was observed a swollen, blistered, and cor- rugated state of the epiglottis: and a similar state of the posterior fauces, tongue, and internal mouth. There was a little mucus in the larynx, but no perceptible morbid condition of the oesophagus or stomach. There was no inflammation of the trachea, not even near the orifice made by the operation. Such have been the symptoms and results of the cases of this accident, with which I have hitherto become acquainted. The important question now is, what should be the plan of treatment in any future case ? If the suffocation were imminent, I should not hesitate to propose the operation of laryngotomy or tracheotomy, and the former would appear to reach below the seat of this af- fection. — M. H.*] * See a paper which I published in the Medico-Chirurgical Transactions, vol. xii. p. 1— M. H. 292 UNDERWOOD ON CHILDREN. [Diseases ofthe Thorax must be divided into those, 1. Ofthe Larynx, or Trachea. 2. Ofthe Bronchia. 3. Ofthe Lungs. 4. Ofthe Pleura. The first of these diseases is distinguished by the peculiar croupy sound ofthe cough, and of the respiration, when this is excited. , The second is known by the diffused bronchial rattles heard on applying the ear to the various parts of the throax, and by the diffused undiminished sound on percussion, and by much mucous expectoration. The third is ascertained by diminished respiratory murmur on applying the ear, and diminished sound on percussion at the pos- terior part of the thorax. The last is distinguished by the absence of respiratory murmur, and of sound on percussion. These observations are very easy and interesting iwinfants and children. I think it important to state, that in the first, third and fourth of these diseases, bloodletting is our sheet-anchor, and is at once re- quired and well borne : cupping, or leeches should be applied, and the blood be allowed to flow until the lips turn pale, carefully pre- serving the perfectly upright posture. In bronchitis, far the most frequent of infantile diseases, on the contrary, bloodletting is neither so much required, nor so well borne: the same mode of bloodletting must, however, be adopted at once, the lips will be found sooner to turn pale. Our next remedy is ipecacuanha, which is to be given in repeated doses until the disease be subdued.* Thoracic affections are very apt to assume a chronic form, or a disposition to return. In either of these cases, the long-continued application of a liniment of opodeldoc and ammonia, night and morning, is of the most extraordinary value and efficacy. It should be continued for months, not to say years. — M. H.] rachitis, or rickets. This is comparatively a late disorder in Europe; Astruc observes that England is said to be the part in which it first made its ap- pearance, and that it was then described by Glisson and Mayow ; but he thinks it probable, that it appeared at the same season over all Europe, through the coldness of the weather. It was named Rachitis, from the Greek, implying that the spina dorsi is particu- larly affected by it ;t though it rarely attacks the spine till the dis- order is far advanced. * There is a valuable paper on the peripneumonia of children by Dr. Cuming, in the Transactions ofthe College of Physicians in Ireland, vol. v. p. 28. f From this circumstance, it has been supposed to have been known in the time of Hippocrates; but his remark {Aphor. § 3.26) is certainly too concise to esta- RACHITIS, OR RICKETS. 293 It was first noticed in the western parts of England;* about the year 1628,t and is said to have taken place upon the increase of manufactures, when people left the villages and husbandry, to settle in large manufacturing towns ; where they wanted that exercise, and pure air, which they had enjoyed in their former situations and employments. This is a pertinent observation to have been made at that time, and accords with late experience and facts; manufacturing towns, abounding with this disease above all others, especially among the poor. It may, therefore, frequently arise from unhealthy parents, especially from mothers who pass too sedentary a life in a bad air, and feed upon a weak and watery diet; from children's food being weak, watery, or too viscid to be properly digested; but, above all, perhaps from bad nursing, and children being left wet, dirty, or exposed to a cold, moist air,J without sufficient covering; from want of proper exercise, and from close and crowded apartments. On this account, children of poor people are particularly liable to this disorder: parents and governors of workhouses, charity schools, &c, ought therefore carefully to guard against the last-mentioned causes. Or lastly, from the habit of body being reduced by the long continuance of almost any of the complaints hitherto consi- dered. From these sources arise what may be termed its proximate causes: such are, a load of undigested juices in the stomach, intes- tines, and all the first passages; an universal viscidity in the ex- treme vessels, especially of the joints : a corrosive acrimony from a too languid circulation, and a general obstruction in the fibres of the muscles. 9 The usual symptoms of rickets are soft flesh ; bloated, or a very florid countenance; weakness ; dislike to motion; with enlarge- ment of the belly, head, and joints. The wrists and ankles enlarge first, afterwards the back and breast bones; and, indeed, all the bones swell and become soft, especially the more spongy ones. The pulse is quick and feeble, and the appetite and digestion usually bad. Teething is commonly late, though not frequently difficult, but the teeth often rot early, and fall out. Great acuteness of mind has been observed in this, and some other chronical complaints. It seldom attacks children before they are six months old, or above two years; the reasons for which are obvious. blish the point; as it is simply observed, that among other complaints, infants, after the period of dentition, are liable to 7r*fws-8/«/* o-irovJvxov toy »*Tj« Rad. gentian, incis 9j. Affunde spir. vini gallici 5x'j- Fiat tinctura. Sumat a?ger cochl. infantum ad cochleare largum ex aqua? purae q.s. ter, qua- terve in die. I have had further reason to be confirmed in the above opinion respecting stimuli, from observations communicated to me by Mr. Partington, who, since the hints 1 threw out in the aforementioned work, has made use of electricity with very good effects, in these, as well as other cold tumours and ulcers I had mentioned; which have all healed very kindly, or been dispersed in a reasonable time, in consequence of this stimulus to the parts. When scrofulous ulcers have been healed, and only some small tumours remain, I have experienced very good effects from the external use of as strong a solution of camphor in oil of almonds as can be made, which has dispersed them very soon ; and it has been found a very successful remedy in the cure ofthe incipient bronchocele, though enlarged to the size of a turkey's egg; and requires only to be very well rubbed into the parts, three times a day. The patient should at the same time take a drachm or two of the tartarised natron every morning. The following is strongly recommended by Dr. Temple : — R Terra ponderos. st. gr. alix. Aq. menthae sativa? %\Q. Misce ft. haustus, ter quotidie sumendus : et sensim augeatur quantitas terra; ponderosae ad gr. xx. Tobacco has also been lately very strongly recommended, in a treatise on this disease, by Dr. C. W. Hufeland, of Jena, author of " A Treatise on the Art of prolonging Life." Readers may con- sult the former work with considerable profit, as it contains a fuller investigation of the disease, and a better selection and adaptation of remedies, than has ever fallen under the author's reading. An obvious discrimination should be made in regard to tumours about the neck, so frequently the early seat of this disease; since many of them are of a harmless nature, or even salutary, the con- sequence of a slight feverish disposition, or of some little cold from a sudden stroke of air on the neck. These, it is well known, rise suddenly, become painful, and increasing daily in size, either very soon put on the usual appearance of suppuration, or begin to subside ; and whether they break or not, are no indication of any thing materially wrong in the habit. On the contrary, scrofulous tumours always rise slowly, unless in very young infants, and im- mediately after the small-pox; often continue a long time at a stand, and sometimes are not only months, but even some years, before they suppurate; and then with very little pain, or true in- flammation. For such, particularly when very large as well as indolent, embracing a large part of the neck, the white lily root, with an equal quantity of bread made into a poultice with milk, 300 UNDERWOOD ON CHILDREN. has been followed with a good effect, the tumour subsiding entirely in the course of a few weeks. I shall only add further on the head of scrofula, what is very well known, that sea-bathing alone sometimes effects a perfect cure ; and, perhaps, in tepid water oftener than in its natural state. Should the child, therefore, have several scrofulous tumours, or the habit be much affected, trial should be made of the sea, and the tumours will, perhaps, be dispersed by the sea bathing: but this need not interfere with any other treatment of the tumours, should any other treatment be thought necessary, (cc) (cc) In the treatment of confirmed scrofula we must look to remaking in a measure the tissues before we can hope for a cure. With this view, a prolonged alterative course must be enjoined on the patient, the chief parts of which will be wholesome food, regularly taken, moderate and uniform exercise in the open air, bathing, and chiefly with warm or tepid water, and frictions, and a clothing which will give steady warmth to the skin. The medicinal part of the treatment will consist chiefly of the alternation of laxatives and tonics, the use of saline and sulphurous mineral waters, and iodine. Months, and indeed years, must often elapse before the requisite renovation of the tissues is accomplished. The occa- sional disappearance of the disease at puberty is explicable only in the greater activity of nutritive life and the better hematosis in young persons, owing to their better opportunities for exercise than at a more tender age. The value of this latter is well set forth by Mr. Phillips, (Lectures on Surgery,) where he expresses his conviction, that by the well directed employment of strong muscular exercise, many cases of disease, where even tumours are found in the neck, may be cured. The iodide of potassium (hydriodate of potassa) in solution, and the compound solution of iodine (the salt with iodine in water), are the pre- parations of iodine which I have generally directed for internal use in scrofula. At the same time the tumours are to be rubbed with ointment consisting of iodine and the iodide of potassium, mixed with lard, or the simple ointment of iodide. The effects of external applications are much less decided without the concurrent administration internally of some preparation of iodine. The favourite preparation just now for internal use, and the one which Mr. Phillips uses almost entirely, is the iodide of iron, in doses, he tells us, not exceeding in any case three grains three times a day. The minimum dose used in 232 cases, has been a grain twice a day. In one case it excited ptyalism. There is often a rapid diminution of a scrofulous tumour following the employment of iodine or the iodide ex- ternally; but after a fortnight or three weeks it appears to be stationary. A recourse to a new form produces good effects as at first; to keep up which, after a new suspension, it is necessary to employ a third one. As regards the local treatment, it has been found, that, in a large number of cases, in spite of the most prudent treatment, the tumour will end in abscess. As washes to scrofulous ulcers, solutions of the chlorides of lime and soda, and Lugol's iodine wash, as described in the Dis- pensatories, are among the best. For additional details of the pathology and treatment of scrofula, see Stokes' 4r Bell's Practice of Medicine, Philadelphia, 1840. ANASARCA AND ASCITES. 301 DYSURIA. Difficulty in micturition was mentioned in the chapter on denti- tion, and has been found more commonly troublesome during that process than any other period during infancy. The pain is some- times exceedingly great, if we may judge from the long and violent shrieks of the child, who at times seems likely to be thrown into fits : but upon voiding the urine, becomes instantly quiet, and re- turns to its wonted cheerfulness, and ordinary habits. Demulcent remedies, as noted in the chapter on teething, may be tried; but if the infant be very young, or nourished by the breast, they can rarely be taken in sufficient quantity for any length of time. If they fail, therefore, of good effect, I have added anti- monial wine, which has always very soon been of use. Some such form as the following has been prescribed :— > R Kali ppt. gr. v. Sue. limon. 3J- Aq. rosa?, gtt. xx. — distil, ^iss. — foenicuH Jss. Sp. juniper, gtt. xxv. Pulv. e. tragacanth. comp. gr. V. Vini antim. gtt. iij. ad. vj. Syr. alth. ^ss. Misce, ft. haustus, ter, quaterve in die exhibendus. Or a decoction of the semen dauci, has often afforded speedy relief: as also, a few drops of balsam capivi (mixed with vitel. ovi) in milk. Together with either of these, I have kept the bowels open with castor oil and manna ; have thrown up a clyster twice a day; and put the infant up to the waist in a tepid bath, twice or more every day, when the pain has been most urgent : and in older children, have directed from half a grain to a grain of opium, to be intro- duced into the rectum every night at going to bed. In some forms of this multifarious disease also, the solutio arse- nica has lately been administered with success, and with safety, if confined to very small doses once or twice a day.(dd) ANASARCA AND ASCITES. I shall not enlarge much on these disorders, however important, since they are not very common in young children; I have met with instances of both, however, at different ages. In the chapter on teething it was remarked, that although a con- siderable depot of water may be made on the tops of the hands and feet during dentition, a general anasarca, or ascites, does not take place, if there be no internal disease : and, indeed, whatever bad (dd) The bicarbonate of soda ; and camphor; the first in solution with silgarj the latter in mixture or emulsion, are very useful in dysuria^ 26 302 UNDERWOOD ON CHILDREN. health may, for a while, be induced by difficult teething, a morbid affection of any of the viscera is very rarely a consequence, unless a purging be improperly suppressed. But infants previously in bad health, and especially such as have been prematurely weaned, or fed upon too thick victuals, not un- frequently have indurations of the mesenteric glands ; and the complaint may be followed by dropsy, if dentition should at this time prove unusually difficult; and is then more likely to be fatal. One case of anasarca accompanied with ascites, was of this kind, the infant having previously had a tumid and hard belly, loss of appetite and fever; and though these symptoms had been entirely removed, and the child apparently for several weeks in good health, a renewed process of dentition was accompanied with an universal anasarca, and a large collection of water in the belly; with an almost entire suspension of the urinary secretion. Purging with calomel and jalap produced no good offect, nor moderate doses of the scilla, spir. aether, nitrosi, and other diure- tics ; but an increased dose of these, and an ointment, as in the following formulae, soon produced a change, and both the anasarca and ascites in a little time gave way. R Infus. amari 5'j- Aq. distil. Jj. Vini ferri ^ss. Tinct. scilla? gtt. viij. ad xij. Tinct, cinnamoni gtt. xv. Syrupi e cort. aurant. 3ss. Misce, ft. haustulus quartis horis sumendus. R Ung. hydrarg. fort. Jss. Spir. tereb. G. camphor, aa 5J- Olei olivar. 3xiij. Misce, ft. linimentum; quo totam umbilici et dorsi regionem inungatur bis quotidie. The following pill also recovered an infant of fifteen months old, after being in a very debilitated state; though the operation both as an emetic and a purge was very considerable, requiring strong cordials and wine for the infant's support. One pill was given every six or eight hours, for two or three days; nor would so pow- erful a medicine have been ventured upon if every gentler mean had not failed. R Gummi ammon. Scillse recent. Sapon. venet. Pulv. sem. card. am. aa3ss. EIaterii9j. Antim. tartaris. gr. x. Misce, ft. massa pilularis cum syrupo alth. et divid. in pil xxx. A remedy brought lately into use, as successful in adults, though I have had no opportunity of making trial of it in young children, seems worthy of notice, as it is not so nauseating as the above, nor ISCHURIA VESICALIS E MUCO. 303 as many others diuretics. Indeed, it does not always act upon the kidneys, though it frequently carries off the complaint; sometimes by promoting a general diaphoresis, and at others, by somewise promoting absorption, and strengthening the primae viae. The remedy consists only ofthe expressed juice of the leek, which I have given to an adult, in the following form : —- R Succi porri expr. 3J« ad 3iij- Mucilag. gum. arab. Jij. Tinct. cardam. comp. 3SS ad 3J* Misce, ft. haustus, bis ad quater in die sumendus. Externalstimulants are sometimes proper, especially in the serous dropsy consequent upon a debilitated, rather than a morbid state ; of this kind is the application of a broad flannel band round the abdomen and loins, dipped in the spirits of hartshorn diluted with water, about two parts of the latter to one of the former, which may be increased as the parts are found able to bear it; which has had an immediate good effect. In its stead the following may be had recourse to: — R Linimenti saponis ,$iss. Tinct. cantharidis^ss., misce. If but little benefit should be procured by medicine, in a reason' able time, it may be proper to make a few punctures on the tops of the feet, and especially on the praeputium penis, if that part be very anasarcous ; there being very little hazard in young children of the punctured parts inflaming or becoming otherwise trouble- some. After the water is got off, and diuretics laid aside, the steel joined with cordials should probably be continued, till the child's strength be restored. It may be needless to suggest, that as dry a diet as maybe should be employed, and the bowels be kept open throughout the dis- ease.(ee) ISCHURIA VESICALIS E MUCO. By this term is here intended an affection of the prostate gland, or the coats of the bladder ; though the same symptoms may also arise from the ureters or kidneys, whether owing to a stone or other stimulus. Like the last-mentioned complaint, it sometimes appears during dentition, and other inflammatory affections, and will then call for cooling remedies; it generally disappears when the teeth have (ee) In the treatment of dropsy it is of the utmost importance to detect the diseased organ by which the morbid secretion is kept up. If it be the heart, digitalis is to be prescribed ; if the liver, calomel or blue mass; and if the kidneys and the urine albuminous, colchicum with the alkalies. In its atonic form, ascites is sometimes greatly relieved by tincture of cantharides. 304 UNDERWOOD ON CHILDREN. made their way through the gums, and the fever subsides. Even in more advanced childhood, there is nothing like fever or other precise marks of disease excited by this complaint; though it may be said, this disorder more commonly attacks children of a tender and delicate habit. It is attended with the like frequent inclination to void the urine as in the former complaint, and with more or less pain in its excretion, or more commonly before it begins to come away. But in this disorder, the urine is always very foul, is loaded with a very ropy mucus, and sometimes comes away discoloured with blood, and at others, some coagula fall to the bottom. This disorder, indeed, puts on every appearance of the like disease common in adults, especially old men, but is usually much slighter, and therefore more easily and speedily cured ; for children being more irritable, the urinary passages are over stimulated by causes that would not affect adult persons. The appearance is nevertheless alarming, as it may, possibly, arise from a morbid affection ofthe prostate gland, or the bladder, and must then be a serious complaint; or it may be owing, as has been observed, to a stone in any of the urinary passages, in which case a cure cannot be effected as long as the stone remains. For- tunately, however, this is not a frequent cause in early childhood; and is not the case here intended. The disorder sometimes yields in two or three weeks to mere diluent and demulcent medicines, such as lac amygdal. with syrup. alth. barley water and gum arabic, spermaceti, and such like ; and it is probable, in such instances, might in a short time disappear of itself. In other instances more powerful means are required, which, either by creating a different stimulus, change the action of the parts affected, or, by their restringency, prevent that secretion which has been the cause of the irritation. The aqua calcis, aq. kali, [magnes. carb.] balsamum copaibae, or decoct, corlicis, seem to be the properest remedies in the absence of fever. From three to ten drops of the aq. kali, or balsam copaibas, according to the age of the child, will be a proper dose, and may be taken three or four times a day, as the urgency of the complaint may require. After appearances of being perfectly well, the urine, in some instances, has become as turbid and mucous as at first, and the former irritation returned. • In one such case, the complaint seemed to yield to an infusion of the golden rod, of which two or three spoonfuls were taken three times a day. INCONTINENCE OF URINE. This is not a very common complaint, I believe, in children,* unless combined with the stone in the bladder, and then is not so * Thi.sIcomPlaint has occurred in my practice rather frequently, and not com- bined with stone in the bladder, — S. M; INCONTINENCE OF URINE. 305 constant, nor to that degree that is intended here. It is an invo- luntary flow of the urine, sometimes by day as well as during the night; arising, I apprehend, from a relaxation or other affection of the sphincter of the bladder, as in very old people, but is not attended with manifest fever, or symptoms of decay. An affection of this kind, in which the urine runs away in the sleep only, is more common ; and I have known it continue to the age of fifteen or sixteen years when not properly treated, and afterwards yield to sea-bathing. If, however, it be an original affection, and confined only to the night, (when every part is more disposed to relaxation,) and the child be young, it usually disappears as the child grows up, and thereby acquires strength; but it may be often assisted in the meantime, merely by exercise, living on dry food, dashing the contiguous parts with cold water, and such means as may tend to impart tone to the sphincter muscle and neck of the bladder, and scrupulously abstaining from drink near the time of going to bed: perhaps camphor and laudanum, often useful in the like infirmity in old people, may not improperly be made trial of. The total incontinence generally comes on gradually, and is some^ times attended with excessive gonorrhoea, even in very young chil- dren,and is more difficult of cure: so likewise, if the complaint should succeed to other disorders, as the stone, inflammation of the neck of the bladder,or forcible use ofthe catheter; and especially if it follow any somniferous disease, or a palsy of any other part of the body; in which case the appropriate remedies must be employed. In a general way tincture of catechu, or of gum kino ; the cortex peruv., balsam, copaibae, vitriol, album, [and uva ursi,] may be made trial of; but nothing is usually so effectual as repeated blis- ters applied over the os sacrum ; with proper doses of the tinctura cantharidis, or the powder, carefully administered in some soft emulsion. The former may be administered in doses of ten or fifteen drops to children, from five to ten years of age, and increased to two scruples and a drachm, two or three times a day; or the powder from half a grain to a grain and a half, given as often; which has generally removed the complaint, if there has been no morbid affection of the spine, as is sometimes the case. If these means should fail, recourse should be had to sea-bathing and other tonic remedies. But from remarks made on this weakness in very young children, who from unwillingness to be disturbed in the night, almost constantly wet their beds, I have advised to take them up frequently in the night, and place them on the pot; not suffering them to rise from it till the bladder be emptied. By this means, children, whether from the habit of getting rid ofthe urine, or their dislike of being so often taken up, have been uniformly induced to call, and even awake their attendants as often as neces- sary; and the complaint has, in consequence, entirely disappeared. [" The involuntary discharge of urine in children is a sympa- thetic affection, never present without some derangement of the 26* 306 UNDERWOOD ON CHILDREN. digestive organs; and when that disturbance is once cured, the involuntary discharge of urine ceases. Indeed, so fully aware are some parents to whom I have communicated this view of the com- plaint, and in whose experience it has been verified, of the accu- racy of the remark, that the recurrence of the discharge of urine in a child who had once been afflicted with it, has been to them a sufficient warning of the return of the primary bodily evil. I may briefly remark, that the affection to which I here allude is confined to boys,* that it takes place only in bed, usually towards morning, and commonly about the same hour ; that in some patients it occurs every day ; in some irregularly ; in some it continues only for a few weeks or months, while in others it lasts for years. In all cases the digestive apparatus is deranged, and more commonly the large intestines. Case 1. A youth, fifteen years of age, had been for some years more or less subject to an involuntary discharge of urine, which took place in bed early, and usually at about the same hour, eaqh morning. On inquiry, it appeared that his health was always out of order when he was afflicted with this involuntary discharge of urine, the primae viae being then deranged. I ordered him every second night a succession of doses of one grain of calomel, with three of rhubarb, and a dose of senna on the alternate nights. By this treatment his general health rapidly improved, and in a few week the sympathetic affection of the urinary organ was com- pletely checked. Case 2. A youth, ten years of age, had been for some months subject to void his urine almost every morning whilst asleep, to correct which a variety of means had been contrived. When at school it was considered by the master to be a bad habit, and he was subjected to cruel and harsh punishments. He had a sallow complexion, a loaded tongue, a craving appetite, his bowels were irregular, and the abdomen was tumid. The alimentary canal being first evacuated by the free use of purgatives, I ordered him every alternate night one grain of calo- mel, combined with two of rhubarb, and a small dose of soda and rhubarb twice a day. Under this treatment, his health progres- sively improved, and in a few days he no longer suffered from the involuntary discharge of urine. He was, however, occasionally subject to attacks for several years afterwards, and whenever that symptom recurred, his parent considered it as a warning of a dis- turbance in his health, which was treated accordingly, and the habit ultimately destroyed."t •— M. H.] [* This is not strictly correct, as I have known it to occur in a little girl, and continue for several years. — M. H.] [f From Clinical Observations, by Mr. Wardrop : " Lancet" for Oct. 25, 1834.] TINEA, OR SCALD-HEAD. 307 SECTION V. ON THE TOPICAL DISEASES OF CHILDREN. In the former Part, considerable attention has been paid to cuta- neous disorders; either from their being found to require direct medical treatment, or from their standing in connexion with other complaints, strictly appertaining to the physician's department. There are, nevertheless, many affections of the skin of a different kind ; which, being either usually unconnected with any disorder ofthe system, or else forming sores on the surface requiring appro- priate topical remedies, accord more strictly with the province of the surgeon, and will therefore be considered in this place. Of the cutaneous affections coinciding with one or other of the latter descriptions, I shall, for the sake of some order, treat first of such as appear on the head. TINEA, OR SCALD-HEAD. (Porrigo Scutulata. Willan.) The tinea, or porrigo, is a very troublesome complaint, and is said to be often a scrofulous symptom; but it is certainly more commonly communicated by contact, and when lighting on a scro- fulous habit may be more difficult of cure. It is, indeed, highly contagious, especially amongst children at schools, or other places where they mix freely together, exchange hats, or other covering of the head, with such like intercourse; by which means, it has sometimes been communicated through a whole school. I hope, however, to point out a successful method of cure, the unpleasant- ness of which has improperly, I think, prevented its being more generally adopted. From considerable experience, I may venture to say, that this being usually a mere complaint of the skin, is most successfully treated by topical applications. The disease is seated in the little glands at the roots of the hair: is sometimes dry, but at others moist, and then produces little ulcers, which being thoroughly cleansed, and made to digest, may be safely healed up; as I have found in many other affections of the skin, in which the system has, often over-scrupulously, been conceived to be concerned. It is not uncommon, I know, to administer a variety of internal remedies, and perhaps they may sometimes be required, though I have seldom given anything more than lime-water, or a decoction of the woods; and a few purges at the decline of the eruption ; which is always prudent, and sometimes with the addition of calomel. 308 UNDERWOOD ON CHILDREN. If the complaint be taken early, before it has spread far over the head, and whilst the scabby patches are small and distinct, it may frequently be cured by an ointment made of equal parts of sulphur, flour of mustard, and powder of staves-acre, mixed up with lard, or other unctuous substance ; or by the sulphur ointment, with a small addition of the calx hydrargyri alba. And this last preparation may very safely be made use of, if the patient be kept within doors, and the body properly open; as it will be necessary to rub in only a small portion, once or twice a day, on the parts immediately affected. But if the disease should spread, or has already extended itself over a great part of the head, the hair must be shaved off, and the head washed twice a day with a strong de- coction of tobacco ;* repeating this process till the scabs disappear, and the hair grows up from the parts they had occupied. Or, instead of the decoction of tobacco, the head may be well washed with the lotio saponacea, with the addition of a small quantity of the liq. potassae, and the scabs anointed with the unguent, hy- drargyri nitrati, in the place of the sulphur ointment and calx of mercury, the former being a very powerful, as well as a safe ap- plication, and may be used in any quantity that may be necessary. But the complaint is sometimes of long standing before medical assistance is solicited, and is not only extended over all the head, but the scabs are thick, and rise high above the surface, returning as often as they may fall off. I have, however, never failed to cure the common tinea by a method, perhaps well known, but too seldom complied with in time, on account of its supposed severity. It consists of well-washing the head, first closely shaved, with a piece of flannel and a strong lather of soap-suds, and then rubbing in very forcibly an unguent umpicis,made ofthe petroleum, instead of the pix liquida, (and if this fail, adding a good quantity ofthe pulvis hellebor. alb. or other safe depilatory,) for near an hour at a time, always using it very warm; and covering the head with a bladder to preserve the ointment on the part, as well as to keep it from sticking to the cap, or other covering made use of; whilst it is otherwise useful, by promoting perspiration. When this has been done three or four times, not only the scabs, but the hairs will also loosen, which must be pulled out, however unpleasant the operation may be, as it will, indeed, prove a kindness in the end; and must be repeated till all the hairs be taken out: after which, new hair will rise free from scabs, which is a sufficient in- dication that the disorder is effectually removed. Some writers, with the like view, advise the application of repeated blisters, after the head has been close shaved. The following plaster is strongly recommended by Mr. Thomas Morrison, Surgeon in Dublin^as successful in the worst cases. The head is to be well washed, and a bread and milk poultice * A case of stupor, ending in death, occurred a few years ago at Shoreditch, from the incautious manner in which a father washed the head of his child, with a strong decoction of tobacco, for the cure of tinea. — S. M. SCURFINESS OF THE HEAD. 309 applied, if the scabs are very dry ; and the following plaster after- wards applied, spread on strips of linen, which are to be renewed every day. Take of common ale, one pound ; of the finest flour, three ounces ; mix them intimately ; and having set them over a very brisk fire, add two ounces of yellow resin, stirring them con- stantly until they shall be perfectly incorporated, and take on a smooth gelatinous appearance. There is, however, a spurious kind of scald-head, that is some- times more difficult of cure ; but it requires nothing but patience in the use of one or more of the above remedies, or at most, an alterative plan of the flowers of sulphur, or of some mild mercurial preparation, with the common decoction of the woods, or the Lis- bon-diet drink ; and in some cases to open an issue, or fix a seton in the nape of the neck. Or, should the difficulty consist in getting out the hair entirely, or destroying the diseased glands at its roots, the calx viva may be had recourse to, in one form or other, and is exceedingly preferable to an adhesive pitch plaster. In a few instances, the unguent, hydrargyri rnitius has a wonderful efficacy, but should be the last resort, and be very cautiously applied ; and instead of being forcibly rubbed in, like other topical applications, should be only spread lightly, and very thin on the scalp : the body should at the same time be carefully kept open. SCURFINESS OF THE HEAD, (Pityriasis capitis. Willan.) Some infants early contract a scurfiness on the head, which increases as they grow up ; becoming likewise very thick, and itching exceedingly. It is more commonly dry, but is sometimes moist, and even discharges a great quantity of a very thin fluid. In either case, it can rarely be termed a disease, and is scarcely worthy of notice, but in a view to preventing mischief, from the application of improper remedies, or its degenerating into a real complaint, through neglect. Amongst the poor, indeed, it often arises from that source, and can be removed only by proper combing of the head, and otherwise keeping it clean. But should it arise spontaneously, as it sometimes does about the time of teething, very little need to be done, nor ought to be, further than keeping the head clean, and often combing, or brushing it cautiously, as above directed : at most, the scabs may be touched, every now and then, with a little cream till they begin to loosen, or with a drop or two of arquebusade water, if they are too moist; at the same time carefully avoiding taking cold on the part.* I have, however, sometimes seen a scurfiness of the head take * Sponging the scurfy head with tepid water, with the addition of a little spirit, and afterwards diligently brushing it, I have always found a safe, and very often an effectual, remedy, for this complaint. — S. M. 310 UNDERWOOD ON CHILDREN. place even during the month, and attended with an excessive dis- charge of a thin fluid; which it would be alike improper either to repel or encourage. A good general application in this case, though truly anile, is that of warmed butter and beer, with which the head may be washed twice a day ; this keeps the head clean, and certainly not only does no harm, but has appeared in some instances to remove the complaint. HERPES, OR RING-WORM, (Herpes Circinatus. Bateman.) The herpes, like the foregoing complaints, is a disease of the skin, infesting some children almost annually, and appearing in dry scurfy blotches, on different parts of the body, and usually of a circular form. It becomes troublesome chiefly from the violent itching that attends it, and would, probably, get well of itself: it even sometimes has the appearance of being critical, or is, perhaps, rather an indication of some favourable change in valetudinarians, especially in adults, who are sometimes found getting the better of chronical complaints at the time the ring-worm makes its appear- ance. It is, however, often a blemish, as it frequently attacks the hands and face, and especially the forehead; and in the former case is sometimes sore. The herpes yields very readily to stimulating and astringent remedies. Spirit of wine; saturnine lotions, with the addition of vinegar, or white vitriol; and ointments containing lead, answer very well; or an ointment of calcined zinc and lard: but the unguent, hydrarg. nitratis is preferable to most others. The use of a flesh-brush is a good prophylactic, in habits accustomed to the complaint. It can be only in unhealthy children, that there can be any fear in regard to topical applications, or need of internal remedies. Should the shingles spread and become sore, it should be treated as directed below. HERPES EXEDENS, OR SERPIGO. (Herpes Phlyctcenodes. Bateman.) This is a malignant species of the above complaint, but is gener- ally local. It is mentioned in this place, as having relation to the former, being itself rather a sore than an eruption, and not very common in children. Suppurative applications may be made use of in the early stage ofthe complaint, such as ointments of minium, soap, and Venice turpentine, or a suppurative poultice, in order to liberate the dis- eased glands on the surface, and absorb the acrid discharge. A very good poultice of this kind may be made of figs, onions, and white lily roots, boiled in water to a soft pulp, with or without the OPHTHALMIA. 311 addition of a little bread and milk. After this, the parts should be washed with saponaceous lotions, and lastly, with strong solutions of sulph. zinci. Should these fail, the ung. hydrarg. nitratis will be proper; and, as the last remedy, caustic applications ; of which, butter of antimony is the best, with which the little ulcers may be touched lightly from time to time. The patient may take at the same time a decoction of burdock-roots, or sarsaparilla. HERPES MILIARIS. (Herpes Zoster. Bateman.) The herpes miliaris, zona herpetica, or shingles, was well known tot he ancients; but has not been accurately distinguished by modern writers, as I know of, except by Mr. Pearson; being con- founded usually with the common herpes, or ring-worm. It appears in the form of small vesications, which are filled with an almost transparent fluid, which if large and distinct, have but little redness in the interstitial spaces ; but when confluent, there is a much more considerable discoloration. This complaint is, however, attended with a feverish affection of the system, which the foregoing are not; and is often preceded by rigour, nausea, and sometimes vomiting; but is very rarely attend- ed with danger. The febrile symptoms do not usually disappear on the eruption of the pustules, which gradually subside as the fluid acquires a denser consistence ; after which the pustules dry off in the form of dark-coloured crusts ; and the disorder terminates in a period of from eight to twelve days, and not unfrequently without medical aid. In the confluent species, which is attended with more fever, the patient should be kept in a warm atmosphere, take gentle dia- phoretics and cordials, and sometimes diuretics; and on the drying off of the pustules, a gentle purgative should be administered. It is amongst the vulgar errors, that when it appears on the breast or loins, if it should extend round the whole body, it would prove fatal. It is this form of the disease that is termed zona her- petica.* OPHTHALMIA. Having discussed the foregoing trifling matters, we come to more serious complaints ; and first, those of the eye. This important organ, however, has also some slighter affections, which require but little attention. Accordingly we find, that the eyes of a new-born infant are very apt to water, as it is called, and be slightly inflamed, especially if born in the winter season. If it be owing to taking cold, it is probable, it has been either immedi- * For further information on this and other diseases of the skin, the reader is referred to Plumbe's valuable work, — Philadelphia edition. 312 UNDERWOOD ON CHILDREN. ately after the child was born, before it has been given away to the nurse, or very soon afterwards ; and on this account, a flannel cap becomes a very necessary part of its covering previously to its being formally dressed. This kind of inflammation, however, is seldom of much consequence ; generally disappearing of itself, upon merely keeping the head warm, or by washing the eyes with a little rose-water. Should it, however, continue many days, or increase, three or four drops of the aq. lithargyri acetati, and a grain or two of white vitriol, may be added to two ounces of the rose-water; and the infant take a little manna, or rhubarb and magnesia, if the bowels should not be sufficiently open. A still more trifling affection is the sugillatio, which will oftentimes remain during the month, return, and disappear again, without the slightest injury to the infant. But there is an inflammation to which infants are liable, that sometimes continues a long while, and therefore calls for further attention. This affection is accompanied with the true appear- ances of ophthalmia, attended with a discharge, as in the ophthal- mia of adults: it will sometimes get a little better by common means, but seldom remains so for many days together, and gene- rally increases at the end of the month. It often seems connected with the state of the bowels, and the coming on of a purging will then frequently cure it. Only the more common remedies, however, are called for, unless it prove tedious,* in which case the parts behind the ears should be made sore, and be kept so for some time. Previous to this, it is often necessary to apply a blister to the back, and a leech to one or both temples ; to keep the body open, and make use of the cool- ing collyrium before recommended. If the child be inclined to a frequent return of it for years, as I have known even in very healthy childreu,it will sometimes degenerate into what is termed the watery eye; an excellent remedy for which is a grain of white vitriol, mixed with such a small portion of any unctuous substance as will form it into a liniment, which should be put into the inner angle of the eye every night, at going to bed. In some of these cases, how- ever, the ointment of nitrated quicksilver has proved a more speedy remedy, and is a less painful application. There is, however, a case of watery-eye attending older children, in which the discharge is very hot and acrid, and the eye at the same time inflamed. These affections disappear, and recur again suddenly, without children having sensibly taken cold, or any other manifest cause'; and will continue so doing for a great length of time. It is not a common complaint, and as far as I have noticed it, has attended only such children as have other marks of humour, so called, or some disorder of the skin. , The complaint has proved very obstinate, both in regard to the inflammation and watery discharge, though all the common means * For a more full account of the treatment of ophthalmias, see the author's Surgical Tracts, 3d Edition. OPHTHALMIA PURULENTA. 313 of cure have been successfully attempted, until the head has been shaved, and an oiled-silk cap applied over the whole scalp. This never fails to procure a great discharge from the head, in conse- quence of which, I have known the disorder removed in two or three days. OPHTHALMIA PURULENTA. But there is a far more formidable inflammation, called the puru- lent ophthalmy, distinguished from every other by the vast quantity of thick matter discharged, and great swelling ofthe lids. This is so dangerous an inflammation, as to require the best advice on its very first appearance. It now and then appears at the birth, but more commonly seizes an infant a few days after- wards, without any previous complaint; and when neglected, has sometimes not only destroyed the sight, but dissolved the eye itself, in less than a week's time. I have likewise seen it exceedingly violent in children of four or five years old, but rarely at that age, without some blow, or other accident. In this disease, everything that may remove inflammation, and unload the vessels of the part, should be immediately had recourse to. The body should, therefore, always be kept open, and leeches be applied to the temples, especially in children of four or five years of age. In bad cases at this period, scarifications of the tunica conjunctiva are necessary, as are blisters to the back, nape of the neck, and behind the ears. It should ever be remembered, that in advanced childhood, the taking away of blood at the beginning is often not to be dispensed with, nor to be sparingly done. The application of one leech to the temple, or neck, will have no good effect, though often repeated ; two, three, or more, according to the strength of the child, should be put on at a time, and a blister to the back soon afterwards ; which will often do more to conquer the inflammation, than most other means. Even in new-born infants, it is expedient in some cases, both to take away blood, and to keep up a constant discharge from behind the ears, which may be done by applying, every three or four days, a narrow slip of blistering plaster to these parts, and afterwards dressing them with the ceratum spermatisceti, or other mild oint- ment. The edges of the eyelids should be kept constantly greased throughout the day, especially in new-born infants, that the thick matter may find an easy escape. At night the ceratum lithargyri acetati may be spread on soft linen, and applied to the eye, and over it a very soft cold poultice made with the aqua lithargyri acetati, laid on as lightly as possible ; that by its constant moisture, the eyelids may always be kept supple. But if the discharge should seem to be confined, or the eye affected, by the weight of the poultice, this application should be changed for soft linen rags, which should be frequently wetted with cold brandy and water, or some yet more astringent lotion. Throughout the complaint, astringent and stimulating applica- 27 314 UNDERWOOD ON CHILDREN. tions are to be made use of, unless the complaint be very slight, or Sensibly gives way very soon to mere greasing the lids, as it some- times Will. What may be the very best remedy, in the worst cases, it may not be very easy to determine ; but ever since I have seen Mr. Ware's first publication on diseases of the eyes, I have had such frequent and successful recourse to the aqua camphorata, as recommended by him, that I am inclined to give it a general preference to other remedies. One drachm of the aqua cam- phorata of Bate's dispensatory, to two ounces of water, will be a sufficient strength to begin with. A few drops should be instilled into the eyes, several times in the day, as well as the lids be fre- quently washed with it. It will sometimes be necessary to inject it into the eyes with a syringe, the lids being so much swelled, as not to admit of its entrance by other means. The topical remedies alluded to, in the place of the aqua cam- phorata, are tinct. opii, and the unguentum hydrargyri nitralis, which should be applied every night at going to rest; the former being dropped into the eye after the lids have been touched with the ointment. It is sometimes proper to lower and soften the ointment with a little fresh butter, or ol. amygdal. and to add a little cam- phor ; or sometimes one somewhat weaker, with the addition of camphire as directed in the note.* In one instance, the com- plaint was speedly removed by the electric aura.(jf/) * R Unguenti hydraTg. nitrati 3ss. -------Cerae 3J. Gummi camphor, gr. iij. Misce S: A: The above tincture and ointment are usually a very speedy remedy for the sore eye induced by the small-pox, and measles; as well as for the ophthalmy in scro- fulous habits ; a complaint, under almost every other mode of treatment, very tedious of cure. (ff) Leeches to the inner angles of the eyes, and, if more be required, to the outer also, relieve the suffering organ more completely than when they are applied to the temples ; whilst there is less risk of inconve- nient ecchymosis and temporary infiltration in the cellular tissue than if they had been put on the eyelids. We use earlier and with more freedom astringent collyria, the best of which are alum and sulphate of zinc, in this than in other varieties of ophthalmia. A strong solution of the nitrate of silver, ten grains to an ounce of water, is a very useful wash in this disease. Continued attention should be paid, the whole time, to the bowels, by the administration of purgatives, alternating with small doses of calomel and chalk. Purulent ophthalmia is a frequent disease in Alms-houses and in Children's Asylums, where children are crowded together and deprived of a due supply of fresh air, cause a steady contamination of that which is present. Dr. Morrell has observed, that contaminated air, with its often associated causes of defective nutriment and exercise, produced a general tendency to disease in the mucous membranes—"the mouth, anus, and vulva, were alike liable to ulcerations of a malignant character, which sometimes terminated in mortification ; he had seen the vagina, in OPHTHALMIA PURULENTA. 315 Where this inflammation has not been properly treated from the beginning, the eye is sometimes exceedingly injured by it, so that even the coats of the eye will burst. At others times the cornea becomes much thickened, and the pupil more or less opaque, by means of one or more specks which the inflammation has oc- casioned. It should be remarked, however, that we sometimes cases of purulent ophthalmia, discharging a purulent matter, precisely similar to that of the conjunctiva," and that this would produce vaginal secretive inflammation more destructive to the eyes of individuals to whom it was applied, than of such as were associated with the disease. In some ofthe cases met with by Dr. Morrell, the pain and inflamma- mation were excessive. In these he divided the temporal artery, and let the blood flow freely till the pain was relieved and the conjunctiva became pale : he then gave a large dose of wine of colchicum, and fol- lowed it with an emetic of tartrate of antimony, and ipecacuanha; and repeated the emetic as long as the patient can well bear the vomit. This treatment is sometimes followed after subsidence of pain and tumefaction by his applying a blister over the forehead and partly on the lids, as re- commended by Dr. Hoffman : the patient is enjoined to keep quiet, and the eyes are bathed with warm milk and water. Chemosis was relieved by cutting with a scalpel or lancet the conjunctiva, as near as can be, at its junction with the globe, for nearly half the circumference of the cor- nea. The blood flows freely, the chemosis subsides immediately, and danger to the eye is nearly past. The thickening and granulations of the eyelids which still remain, will be finally overcome by the steady application of the sulphate of copper and the internal use of the wine of colchicum, in doses of from five to twenty drops. Sometimes, in more obstinate cases, with honey-combed ulceration of the cornea, he opens the temporal artery and bleeds freely, and pushes the wine of colchicum as far as can be borne by the patient, and he applies the crystals of sulphate of copper to the lids daily. Some- times he divides every vessel of the conjunctiva carrying red blood to the ulcers. In some scrofulous modifications, if there be much pain, Dr. M., after bleeding, directs a blister to the back of the neck or between the shoul- ders, and gives Peruvian bark with wine, or quinine with milk punch, and with mild but nutritious diet. The pustular form of ophthalmia is to be treated with sulphate of cop* per or nitrate of silver. In another variety peculiar to Alms-houses, and which Dr. M. calls scorbutic, the child, after diarrhoea or dysentery, will have opacity of the cornea and ulceration without any apparent inflammation of the eye, until the ulcer penetrates and the aqueous humour is discharged. These cases require tonic constitutional treatment, are connected with a cachectic con- dition, and commonly portend a fatal termination. For scrofulous ophthalmia, Dr. Morrell directs at first for two months syrup of sarsaparilla, then Lugol's solution of iodine for two months more ; and the case still requiring it, adds to the solution just named, minute doses of corrosive sublimate; all the time giving a nutritious diet. Phosphorus given internally is also one of Dr. M.'s remedies. — (New York Journ. Med. & Surg., Jan., 1841.) 316 UNDERWOOD ON CHILDREN. meet with an agreeable surprise at the decline of this formidable complaint, and find the eye much less injured than had been sus- pected at the time we were first able to get a sight of it. And at others, even where the cornea has burst, the aqueous humour has been restored, and been confined by the cicatrice, the patient has re- covered his sight. On the other hand, the cornea has sometimes been so greatly injured, or the iris contracted, that though the eye has not been sunk, the sight could not be restored by any means. In other instances, a long and cautious use of escharotics, and paring off the thickened parts of the cornea, have afforded a certain degree of vision. PSOROPHTHALMIA. This complaint is so much of the nature ofthe former, but with more sensible affection of the lids, and less of the eye itself, that I need only to recommend for it the use of the like applications. In particular, slight scarifications of the lids in some instances, and the application of the ung. hydrarg. nitrati, and immediately after- wards instilling a few drops of laudanum into the eye, will usually very soon have a good effect; but the cure is often a work of time. VENEREAL OPHTHALMIA. In permanent inflammations in young infants, I have been in- clined to the opinion of the late Dr. Hunter, and others, who after having tried a variety of means, and assisted in consultation with different physicians, have been induced to think that many of the very stubborn ophthalmias originate from a venereal taint, and can only be successfully treated by its specific remedy, in one form or other. This sentiment, however, requires a nice discrimination; and every practitioner will be very careful how he takes up such an opinion in particular instances ;'* however, it is right to observe, that if none of the means above recommended should produce a favourable change in eight or ten weeks, I believe nothing but that specific species of alternative will have any lasting effect. Though it is not my precise design to treat on this disease, it may not be amiss to observe, that whenever a venereal taint actu- ally exists, it is more safely treated by unction than in any other way ; and infants would probably be cured much oftener than they are, if recourse were had to it in better time than it commonly is. If internal remedies, however, are for any reason preferred, * The French physicians seem too much inclined to regard the purulent ophthalmy in this view, being a very common symptom, amongst others, truly venereal, in many infants in the Hotel-Dieu, PHospice de la Salp£triere, Vau- girard, and des Enfans Trouves; but when this species of ophthalmy appears alone, the case should not be hastily concluded to be venereal, however violent the ophthalmy may be. HORDEOLUM STEATOMATUM, ETC. 317 I have found none so efficacious, convenient, and safe, as the late Mr. Ward's white drop. In a writer before quoted, I find a strong recommendation of the soft pulp of sarsaparilla reduced to a fine powder, and administered in the infant's pap. But having had no experience of it myself, I can only say, that where it may be found to agree with the stomach, it may have its advantages for new-born infants, or perhaps prove an auxiliary to mercury in those of a more advanced age. In an appendix given by Mr. Ware to his last account of oph-> thalmy, he mentions a species in young children, originating from a foul state of the primae viae. In this kind, no topical means will effect a cure, without administering at the same time active purges. He advises calomel particularly, of which a few grains should be taken at bed-time, and a dose of jalap the next morning. This course should be repeated three or four times in quick succession. Tonic remedies, such as the bark and steel, are said to be sometimes useful afterwards. A like inflammation he attributes to difficult dentition, which necessarily calls for a thorough, and sometimes a repeated lancing of the gums. HORDEOLUM STEATOMATUM, OR THE STITHE, OR STYE. The species of stithe here intended, is sufficiently distinguished by the nosological term. It is a small inflamed tumour on the edge of the eyelids, more commonly on the side towards the nose ; but there are sometimes two or more at a time. It rises suddenly, aa if from a cold, or blast, and in the end suppurates, forming matter of a thick, or cheesy consistence ; often, indeed, not for several weeks, or even months, but sometimes much sooner. It is occa- sioned by an obstruction in the glands of the eyelids; and the matter being enclosed in a hard cyst, the inflammation often re- turns in the same spot, till the cyst being destroyed by repeated suppurations, the cavity is afterwards filled up, and the complaint disappears. All that is necessary to prevent the return of this temporary blemish, which greatly weakens the eye, is to imitate this process of nature. To this end, the little abscess should be touched, as soon as it breaks, with the argentum nitratum, cut to a point, (care- fully avoiding doing injury to the eye,) which, by destroying the cyst, at once removes the complaint. When these stithes are small, or hang by a very narrow base, they may be safely cut off, or tied very tight with a bit of silk, and when separated, touched with the caustic as before mentioned. 27* 318 UNDERWOOD ON CHILDREN. DEAFNESS. Children are frequently rendered deaf in different degrees, in one or both ears, by very slight colds, and at the expiration of a few days the hearing returns, without recourse to any means. It is, however, sometimes otherwise, and it becomes necessary to give a little purging physic; to keep the ears warm; and to confine the child to the house : and where this does not succeed, the complaint is not a little difficult, to cure, unless when owing merely to indu- rated wax. In this case it will be proper to syringe the ears with warm water, to which should be added a tea-spoonful of lavender, or honey water; and a few dops of warmed oil of almonds may be instilled into the ears at going to bed. If these little means fail, warmer remedies should be made use of, such as the following, which, after properly syringing, will always be successful, if indu- rated wax be the only occasion of the complaint: — R Olei. amygd. §ss. 01. succini rectific. gtt. xx. Spir. camphorat. 2ss. Tinct. castor, ^j- Misce, et instill, guttas iv. vel vj. calefact. aur. affect, nocte et mane. Deafness, however, is sometimes owing to the want of a due secretion of wax, and is then much more difficult of cure. To promote this secretion, a few drops of the soap liniment, oil of almonds, and aether, and suchlike warm acoustics,should be tried, and continued for some time, if they should not occasion much pain: and in all cases, blisters may be applied behind the ears. The juice of onions, or a clove of garlic, raw, or roasted, put into the ears, has sometimes restored the secretion, and removed the deafness, and in many cases it has been effected by electricity: yet in not a few cases all these means have failed. I have, however, fallen upon a method that has been universally successful by very simple means, consisting only in adapting an entire covering to the ear, made of an adhesive plaster, spread upon thin leather, so as completely to exclude the external air. The plaster should be renewed as often as it gets anywise loose, repeating it till the se- cretion of wax is in sufficient quantity, which seldom requires more than five or six weeks. But I am sorry to add, that although aurists have found it so difficult to restore this secretion, and have therefore conceived deafness to be often owing to the want of it, I have frequently found it nowise relieved by a return of the se- cretion. Possibly this may be owing to the cause of deafness lying in the auditory nerve, which is frequently the case ; and here also electricity is particularly adapted, either through the meatus audi- torius externus, or the Eustachian tube. Medicated snuffs, also, that invoke gentle sneezing, and discharges from the head, have sometimes been found surprisingly efficacious; as hath likewise sea-bathing. Should these different methods fail, very little is to EARACHE. 319 be expected from art. Nature, however, sometimes effects the cure ; and children, after having been deaf for several years, suddenly recover their hearing.* ABSCESS WITHIN THE EAR. It is not uncommon to meet with fetid discharges from the in- ternal ear, either with or without inflammation and external sore- ness ; but this is usually in children of one or more years old, rather than very young infants. If a little cooling physic, and wiping out the matter frequently should not remove the complaint, detersive injection should be used, and some one of the warm acoustics directed for deafness be afterwards dropped into the ear. The child should also be made to lie, as much as may be, on the affected side, that the discharge may have a free vent. Should the quantity and fetor of the matter increase, a blister must be kept open on the nape of the neck, a few purges of calo- mel be taken, and on the intermediate days, the hydrargyrus cum sulphure. But above all, in the worst cases,fumigations with the hydrargyrus sulphuratus ruber, and hydrargyrus cum sulphure mixed together, should be made use of morning and evening; from which I have seen the best effects when the discharge and fetor have been very great, and the ulcer of long standing. EARACHE. It is needless to say much on this article. The pain is usually spasmodic, or if not, it is owing to taking cold in some part about the head, especially the teeth. In this case, a diaphoretic at going to bed, and a dose of cooling physic the next morning; with a clove of garlic put into the ear, or a poultice of onions applied over it, will remove the pain, which is liable to recur, however, if ac- companied with toothache. If these fail, a blister may be applied behind the ear. If it arise from spasm, the pain is often exceedingly severe, and is apt to return frequently ; being readily excited by every little cold, especially in some habits, tormenting young people at times for several years. The juice of rue is here a good remedy, * The deafness of children is very often dependent upon that cachectic habit, which improper diet and a deranged condition of the stomach and bowels prin- cipally tend to produce. When this is the case, no plan succeeds so well in curino- the complaint, as a combination of alteratives and daily aperients, with so much of some such tonics as sarsaparilla, uva ursi, steel, or bark, as may be found requisite. And this plan is found useful, not only in the affections of the ears, but of the eyes of children. Parents are too apt to place reliance upon local applications to these parts, when the cure can only be effected by a regular ex- hibition of internal remedies. — S. M. 320 UNDERWOOD ON CHILDREN. or if this fail, a little laudanum added to the acoustic directed for deafness, and dropped warm into the ear.(gg) CANCRUM ORIS. This is chiefly a complaint of children, is often talked of by nurses, and is usually as trifling as any. It has, indeed, been said by some writers to prevail very much in England and Ireland, and to be often a serious complaint. Such a disorder, if it really be canker, may be treated as under the next article ; but the com- mon canker is rarely troublesome to cure. It sometimes make its appearance in the month, at others, about the time of teething; and frequently at the age of six or seven years, when children are shedding their first teeth, and the second are making their way through the gums, which are covered with little foul sores, extending sometimes to the inside of the lips and cheeks. It seldom requires more attention than was mentioned under the article of dentition; any mild, astringent application, and keeping the body open, usually effecting a cure ; or if it does not, and the complaint makes its appearance at the time of teething, \\ will generally go away as soon as the teeth are come through. The worst species of this complaint that I have happened to see, has been during the second period of dentition, when a child has been shedding a number of teeth together, leaving the rotten stumps behind, which have been neglected to be drawn out. The whole gums will then become spongy, or dissolve into foul, spread- ing ulcers; and small apertures will be formed, communicating from one part to another, accompanied with an oozing of a fetid, and some purulent discharge. (gg) Otitis, in which the periosteum of the external ear and meatus is inflamed, is not an unfrequent disease of infants. Sometimes hydro- cephalus has been suspected on account of the agitation, occasional starts from sleep and screams of the patient. The little redness or tumefaction of the part prevent an early diagnosis, to which the physician may be led, however, by learning the disinclination of the child to sleep, or to rest its head in any way on a particular side : the skin ofthe concha and meatus has a white and very shining appearance, and it is more tense than usual; handling the ear, or even touching it, gives rise to great pain, and immediate expressions, by cries and tossing about, of distress. The foremost remedy is leeches on the outside of the concha and border adjoining ofthe mastoid process ; to be followed by tepid bathing ofthe part, and free purging. Subsequently recourse may be had to the remedies, recommended in the text for earache, Among the washes of late times, most relied on in cases of purulent discharges after otitis, are the chlorides of soda and lime, and creosote. I have in one case of long standing derived more benefit from a saturated solution of common salt, (chloride of sodium,) than from the preceding and other generally approved injections for this diseased state of parts, of which a discharge from the meatus is however but a symptom and an effect. CANCRUM ORIS. 321 If the stumps of the decayed teeth can be got at, they ought to be extracted ; after which, some such applications as the following will soon brace the loose gums, and heal up the ulcers, howsoever foul or numerous they may be. R Bol. armen. Gum myrrhae, Cort. Peruv. pulv. Cremor tartari aa 3i- Mel rosa? q.s. misce, ft. Pasta. R Aq. calcis ^vij. Tinct. myrrhae, Mel rosae aa ^ss. ft. Mistura. The gums should be touched several times in the day, especially after meals, and at going to bed, with the above paste, and the mouth washed occasionally with the mixture. If no considerable change for the better should take place in a week or ten days, a drachm of alum may be substituted in the place of one of the astringent powders ; and instead of the above mixture, one acidulated with as much of the muriatic acid as the parts will endure, occasionally made stronger, till some amendment be perceived; the bowels being, in the meantime, kept properly open. If internal remedies be thought necessary, Peruvian bark, sarsaparilla, and mineral acids, will be the properest; and the child may be kept on a diet of milk and vegetables.(hh) (hh) Dr. Benjamin Horner Coates, in an instructive paper on this dis- ease, which he terms " Gangrenous Sore Mouth of Children," (North American Med. and Surg. Jour., Vol. II.,) says, that its access was fre- quently preceded by no marks of visible disease, or at least none that attracted attention. The little subjects were, apparently, in merely a drooping or enfeebled state. In other instances, the ulceration followed a common remittent or intermittent fever; insomuch that, at one time, whenever a child was brought to the nursery (Children's Asylum), it was expected, as a matter of course, that its mouth would become sore. The ulceration may begin in many parts of the mouth, as we learn from Dr. Coates; but, he adds, that, in by far the greater number of cases, it commonly commences immediately at the edges of the gums, in contact with the necks of the teeth, and most generally of the two incisors. The spread of the disease is, he thinks, uniformly from the gums to the cheek. It commits great and unsuspected ravages, down the length of the root in the direction of the sockets; extending to the ed^es of the gums round other teeth, and frequently affecting a large portion of the dental arches. When gangrene is formed, a fever of irritation is generally developed — and generally upon inflammation of the mouth. It is aggravated by loss of rest, want of nourishment, and probably by putrid matter finding its way to the stomach. To the latter cause Dr. Coates refers a diarrhoea, which almost uniformly comes on towards the close. »' When the gangrene reaches the cheek or lip, however, very active inflammatory symptoms are uniformly developed. In the cellular sub- 322 UNDERWOOD ON CHILDREN. GANGRENOUS EROSION OF THE CHEEKS. This complaint has some resemblance to the canker, though it is a much more dangerous, and is not a mere local disease. I have seen no clear account of it in any late writer but Mr. Deasc, of Dublin, who seems to have met with the disorder pretty frequently, and describes it very accurately in his tract on the diseases of lying- in women, &c, to which I am very much indebted on this occasion. Mr. Hurlock, indeed, in his treatise on dentition, printed in 1747, mentions a complaint that seems to be of this kind, though he does not appear to be well acquainted with it. It usually attacks children from two to six or eight years of age, especially the unhealthy, and such as have been subject to worms. The whole body often feels cold on the approach of the disease : after which a black spot appears on one of the cheeks or lips, and stance of these parts, they assume the well-known characters which have been attributed to the phlegmonous species. We have a great thicken- ing, forming, in the cheek, a large, rounded prominent tumour, with great heat and pain. Sometimes redness is perceived externally ; but more frequently, the great distension of the skin of the cheek seems to mpty the cutaneous vessels, giving to the part a smooth, polished, dense, white appearance, very much resembling the effect of a violent salivation. I have no doubt that this is the tumour described by Poupart, and alluded to in an earlier part of this paper. Great thickness and hardness have always occurred, in the other situations where this gan- grene has approached the external cellular masses of the face ; in the lip they are, however, less remarkable, perhaps from the less amount of cellular matter. After reaching this stage, a black spot is frequently seen on the outer surface of the swelling. This spreads rapidly, and has always been in my experience the immediate harbinger of death." p. 14. In two cases the disease commenced in the fauces. But few cases, in Dr. Coates's experience, occurred during the second dentition ; and it is doubtful whether any one took place during the first The greater num- ber of cases occurred between 2 and 5 years of age, but some as late as 8 or 10. The treatment of this disease is a difficult matter. The remedy which, in Dr. Coates's experience, beyond all comparison succeeded best, was sulphate of copper. His formula was as follows : — R Sulph. cupri 3ij. Pulv. cinchonae ^ss. Aqua? Jiv. M. " To be applied twice a day very carefully, to the full extent of the ulcerations and excoriations. The cinchona here is not absolutely neces- sary, but operates by retaining the sulphate longer in contact with the edges of the gums." Sulphate of zinc in solution with tincture of myrrh was useful, also the simple solution of this salt 3h to an ounce of water. Extraction of the teeth early is an important part of the cure. Gene- ral remedies were little relied on. GANGRENOUS AFFECTION OF THE PUDENDUM. 323 spreads fast; but without any marks of inflammation. Oftentimes the whole side of the face is eaten away, together with the lip, so that the bare jawbone and inside of the mouth appear. In the end, the entire of the lower jaw falls down on the breast, and the whole side of the face is dissolved into a putrid mass; a colliqua- tive diarrhoea taking place from the offensive matter that is con- tinually swallowed, especially by very young children. In the cure, internal as well as external remedies are required ; but only such as correct putrescency, and support the strength, seem to be of any use. A few drops of the acidum muriatic, therefore, taken inwardly in the infus. rosae, or in the child's drink; the saline draught in effervescence ; and in the end, the bark, in doses suited to the age, with good broths, jellies, and wine, are the pro- per remedies. The parts should be washed, and likewise injected with muriatic acid in chamomile, or sage tea, and afterwards dressed with the acid mixed with honey of roses, and over all a carrot poultice. The child should in the meantime be gently purged with magnesia or rhubarb, to carry down the putrid mat- ters it may have swallowed. By this treatment, Mr. Dease informs us, he has recovered every patient except one, since he had recourse to this plan, which the world is much indebted to him for making public, though fortunately this complaint does not appear to be by any means a common one.* GANGRENOUS AFFECTION OF THE PUNDENDUM. [An account of this disease by Mr. Kinder Wood, will be found in the Medico-Chirurgical Transactions, vol. vii. p. 84. " The commencement of this affection is attended with chilliness succeeded by heat; slight pain in the head, dulness, nausea, loss of appetite and thirst; the tongue has a clay-coloured deposit; the bowels are torpid, and the patient is languid, inert and listless. These symptoms precede the affection ofthe pudendum about three days. The patients first call the attention of parents more particu- larly to the seat of the disease by complaints of pain in voiding urine, or when too young this is observed by the cries and strug- gles of the child during the act of emptying the bladder. When the genital organs are examined, one or both labia are found inflamed and enlarged, the inflammation is of a dark tint, and soon extends internally over the clitoris, nymphae and hymen ; the pain in voiding; the urine may induce a supposition that the inflam- mation extends into the urethra, and a thin secretion, which at this period may be observed coming from these parts, renders it not improbable that the lower part of the vagina maybe affected. " From this period of the formation of the inflammation, so rapid is the progress to ulceration, that scarcely twenty-four hours elapse [* See a paper by Dr. Marshall Hall, in the Ed. Med. and Surg. Jcurn. xv. 547.] 324 UNDERWOOD ON CHILDREN. before a number of small vesications forming within the labia, as well as externally, burst and form so many open surfaces, which, quickly spreading into each other, form larger ulcers; this was the progress in one case, in the other the skin opened without any pre- vious vesication. The thin discharge which the inner membrane secretes, is now mixed with the secretions from the ulcerations, and is dark coloured, peculiarly offensive, and copious, irritating the adjacent parts, and contributing to extend the disease along the perineum to the anus, and to the inner part of the top of the thigh, contiguous to the labia. I have also seen the inflammation spread over the mons veneris, and be succeeded by deep ulcerations pro- gressively extending as long as life continued. " The pulse is quick and irritable after the inflammation com- mences, and as the ulceration extends, the face becomes of a pecu- liar pallid hue, the skin having a very singular whiteness, which I have never seen absent after the ulcerations had formed. As the bowels are slow at this period, the opening remedies uniformly bring away dark, slimy and offensive stools; and in two or three cases I have seen aphthae spread extensively around the anus, and over the perineum." — M. H.] PARALYSIS OF THE LOWER EXTREMITIES WITH CURVATURE OF THE SPINE. This complaint has been of late years so thoroughly announced, that it should seem unnecessary for most readers to enter into a minute detail of it, after the accurate description given by the late Mr. Pott, whose early account and judicious treatment of this dreadful disease has added lustre to the reputation acquired by his former publications. Some late observations have, indeed, seemed to detract both from his merit and expected success; I can, never- theless, from my own experience, vouch for the great utility of the plan in this morbid deformity. It will be proper, however, carefully to distinguish it from the simple curvature of the spine, in which a great number of vertebrae is concerned, and the legs are not peculiarly affected ; as well as from a complaint presently to be noticed, under the name of debility of the lower extremities, in which there is no manifest change of figure in the spine. The palsy of the lower extremities is certainly confined to no age, and being at first very frequently mistaken in young children for the trifling effect of some fall or stain, is entitled to peculiar notice in this work. I have never met with it, indeed, where it has not been preceded by some fall or violent exertion, though, as Mr. Pott has observed, such supposed accidents are seldom much noticed previous to the debility taking place ; it is, however, pro- bable, there may be some predisposing cause, without which no common strain would induce so much mischief in a part continu- ally exposed to accidents. PARALYSIS OF THE LOWER EXTREMITIES, ETC. 325 The curvature is generally in the neck or back, though sometimes in the upper part of the loins, and varies in extent and degree ac- cording to the number of the vertebra? that may be affected. The first symptom noticed, by children of an age capable of expressing their feelings, is an increased sensibility, and irregular twitchings in the muscles of the thighs. This is succeeded by a dislike to mo- tion, especially to moving briskly; the patient on such occasions finding himself likely to fall, his legs getting entangled through their weakness, and a disposition to cross each other, in his attempts to step forward. Soon after this, he perceives himself unable to stand upright long together, and that the legs and thighs have lost much of their natural sensibility. Matters seldom continue long in this state, the weakness increasing, patients lose more and more the use of both the lower extremities,till some are unable to move them at all, even in bed : and these advances of the disease are said to be more rapid in adults than in infants. In the latter, I have particularly remarked that rigidity of the ankles noticed by Mr. Pott, by which the toes are pointed downwards, so that the heels cannot be brought to touch the ground. As my intention is only briefly to point out the disease, and the proper means of relief, it is not of importance to enter into a further detail ofthe progress of this disorder, and of other complaints which are induced by it, whenever the original disease has been long neglected. The obvious remedy is that first happily suggested by Mr. Pott, viz., a large issue or seton placed on each side the curve, at such a distance as may prevent their bursting into one. Where the cur- vature comprehends three or more vertebrae, the seton may be pre- ferable to an issue ; but if the latter be on any account elected, I should advise its being made by the knife rather than a caustic; not only as being less painful, but also for the very effect Mr. Pott has disapproved of, I mean the consequent inflammation before there has been time for suppuration to take place. It may indeed be doubted, whether the benefit derived from the issue may not arise rather from the inflammation and stimulus produced on the surface, than from the discharge ; to which, nevertheless, Mr. Pott solely attributes the cure.* In a very unpromising case, however, * It has been a common idea, that the discharge furnished by an ulcerated sur- face is the source of all the benefit that may be derived from abscesses unless blistered surfaces be an exception : in regard to which, physicians have usually considered the stimulus produced by the cantharides as the chief mean of benefit, especially in cases of great local pain and inflammation. It is, indeed, matter of some surprise, that thinking men have not more generally adopted the like idea in regard to other inflamed surfaces, whether induced by natural or artificial means. It should surely seem, that that state of the system, or of the parts, by which suppuration is induced, is more likely to be the occasion of benefit, than the discharge of a large portion of the richest animal juices, which is but the consequence of the other. Thus, in most critical abscesses, the fever is found to abate as soon as the external inflammation takes place, and the patient, instead of being afterwards benefited by a copious discharge, is not unfrequently hurried 326 UNDERWOOD ON CHILDREN. of an infant ten months old, a very sensible relief was afforded as soon as the inflammation took place and before any suppuration appeared ; and though the child had been some months a cripple, with loss of health and appetite, unable to support its head, and the sternum very much distorted, the relief was so great in one week after the incisions were made, as left no room to doubt of a per- fect recovery; which accordingly took place a short time after- wards, without any deformity remaining. Had Mr. Pott advanced any other reasons for the preference given to the caustic, or merely asserted such preference, I should readily have submitted to the reat experience he has had in this dreadful complaint; but though may very possibly be mistaken in my reasoning, it appeared a duty to state it, as well as to notice this instance in point, in a dis- ease of so much importance. The issue should be kept open till the patient perfectly recovers the use of his legs, or even a while longer ; at least one issue, which ought not to be dried up till the patient can walk firmly alone, and shall have recovered all the height which he may have lost in consequence of that stooping which the disorder had in- duced. In addition to the use of these means, Mr. Pott had suggested those of cold bathing, frictions, the bark, and such like; but I have myself had no experience of them, nor does it seem very probable that such auxiliaries are likely to avail much when the issues shall fail. After the recovery, however, if the patient is of a scrofulous habit, sea-bathing is peculiarly indicated. The moxa has been successfully made use of in one instance, by Mr. Gimes, after the caustic, as directed by Mr. Pott, is said to have failed. But as the burning was several times repeated, and the recovery appears to have been unusually slow, it is not very cer- tain, but that a repetition of the caustic might have proved equally beneficial. The assistance of the stay contrived by Jones, and since made by Bowley and Kebble, has been recommended upon the authority of Sir James Earle ; and a trial of it, under proper cautions, may be made whenever the issues may fail, or the cure seems to be at a stand.(n) by it into a fatal marasmus, when the abscess has been large, or improperly seated. There may be other instances, indeed, in which the suppuration, and even the great quantity of the discharge, may be beneficial to the system ; but it is probable, that this is not in general the case, and much less in the present in- stance, which is attended with symptoms of general debility. (ii) The best stays are the muscles of the spine ; and to strengthen them by moderate exercise is the best means of preserving erect the spinal column, or at least of preventing any farther curvature. At other times than those in which exercise is taken by the aid of a spine cart and the triangular swing, so as to allow of equal suspension by both hands and arms, a recumbent posture should be maintained. In the first stage of spinal curvature this posture must be continued without any alternation of rising and exercise. DEBILITY OF THE LOWER EXTREMITIES. 327 DEBILITY OF THE LOWER EXTREMITIES. This disorder either is not noticed by any medical writer within the compass of my reading, or is not so described as to ascertain the disease here intended. It is not a common disorder anywhere, I believe, and seems to occur seldomer in London than in any other parts of the kingdom. Nor am I enough acquainted with it to be fully satisfied, either in regard to the true cause, or seat of the dis- ease, either from my own observation, or that of others, with whom I have corresponded, except in the instance of teething, or of foul bowels; and I have not myself had an opportunity of examining the body of any child who has died of this complaint. I shall therefore only describe its symptoms, and mention the several means attempted for its cure, in order to induce other practitioners to pay attention to it. If it arises from teething, or foul bowels, the usual remedies should be employed ; and have always effected a cure. But the complaint as often seems to arise from debility, and usually attacks children previously reduced by fever ; seldom those under one, or more than four or five years old. It is then a chronical complaint, and not attended with any affection of the urinary bladder, nor with pain, fever, or any manifest disease ; so that the first thing observed is a debility of the lower extremities, which gradually become more infirm, and after a few weeks are unable to support the body. If there be no signs of worms, (as is here supposed,) nor other foulness of the bowels, mercurial purges seem to be of no use ; neither is the bark, nor hot nor cold-bathing. Blisters, or caustics on the os sacrum, and the great trochanter, and volatile and stimulating applications, with friction with mustard and oat- meal, dry, to the spine, legs, and thighs, have been chiefly depended upon ; though there is no appearance of an enlargement of any of the vertebrae, nor of suppuration in the external parts, and there- fore no resemblance to the inflammation of the intervertebral car- tilages, the psoas abscess, nor the morbus coxaris of De Haen. When only one of the lower extremities has been affected, the above means, in two instances out of five or six, entirely removed the complaint: but when both have been paralytic, nothing has seemed to do any good but irons to the legs, for the support of the limbs, and enabling the patient to walk.* At the end of four or five years, some have by this means got better in proportion as they have acquired general strength : but even some of these have been disposed to fall afterwards into pulmonary consumption, where the debility has not been entirely removed. On this account it may be suspected, that the complaint is sometimes owing to scrofula : * It may be doubted whether irons to the legs can ever be useful in a state of paralysis of the lower extremities. If the limbs are paralytic, how are irons to the legs to enable the patient to walk ? — S. M. 328 UNDERWOOD ON CHILDREN. and I have been very lately informed by a gentleman of character in the country, that he has seen one instance of a paralysis, or debility of this kind, in which, upon opening the body after death, the internal surface of the lower vertebrae lumborum was found carious, though there was no abscess of the psoas muscle, nor external tumour on the back, nor loins. I have seen a similar debility seize grown people, especially women, after a very long illness, and has continued a year or more ; during which time they were utterly incapable of walking without the help of crutches. These cases, however, have always been attended with great pain in the commencement of the com- plaint, though without tumour of the limbs ; and have seemed to be benefited by the external use of the waters at Bath. ON CUTTING THE FRJENUM OF THE TONGUE. The directions on this head, as well as the notice taken of many of the following disorders, proceed rather from a desire that nothing on the subject of children's complaints should be omitted, than from their real importance. Some of them, indeed, have been entirely overlooked by preceding writers; and though they will seldom require much attention, it may sometimes be of advantage to know what has been serviceable in similar cases. The instance under consideration, however, is too trifling a matter to dwell upon. And indeed the little operation, performed in order to lengthen the tongue, is very frequently called for where there is no absolute oc- casion for it, the confinement being seldom so considerable as to make it really necessary to divide the fraenum. The child will suffer so very little, however, in the operation, that when it is care- fully done, it will be attended by no inconvenience ; and if it can afford the mother any satisfaction, it will be very proper to comply with her request. It seems, therefore, only necessary to add, that some little care and steadiness are required, or the sublingual veins may be wounded, and in consequence an infant may lose its life. To avoid this danger, the bridle may be divided by a small curved bistoury, instead of scissors. The handle and blade, when open, need not exceed two inches in length ; and the point should be a little curved, and the back made broad, whereby the point may be easily forced through the fraenum in the most troublesome case, whilst the back of the instrument will sufficiently press down the veins, so as to be entirely out of the way of being injured. These cautions have been judged by some people to be very trifling; but besides that infants have actually bled to death, the following equally fatal accident has arisen from cutting too deep, which I shall therefore notice in this place, as well as describe an instru- ment contrived for suppressing the bleeding. HEMORRHAGE OF THE NOSE. 329 SUFFOCATION FROM SWALLOWING THE POINT OF THE TONGUE, AND HEMORRHAGE. The occasion of this accident, as has been said, is cutting too deep in dividing the fraenum; I have here to notice its symptoms and remedy. The former are those usually attending strangula- tion, and come on suddenly, and without any probable cause but that of the tongue having been cut; but to which they are seldom attributed by those who are strangers to the complaint. The infant appears greatly agitated; the face turns black; and unless these symptoms soon disappear, the child goes off in a convulsion. But if they are presently removed, the infant is as suddenly well; though they generally return again, and have in several instances proved fatal. M. Petit* has perhaps the credit of discovering the true cause of the complaint. The remedy consists in bringing the tongue into its proper place, and, if the infant be suckled, in putting it imme- diately to the breast, which will give the tongue a natural direction. Should the child be brought up by hand, the tongue should be watched for some time, at least till the bleeding shall be stopped; the complaint taking place only in consequence of that being con-* siderable, so as to become an inducement to the infant to continue sucking at the part. When the sublingual veins are actually wounded, the danger, it has been said, is considerable ; and it is to Mr. Petit that we are again indebted for the best contrivance for suppressing this hemor- rhage. The means consist only of a piece of ivory, in the form of a short fork; the prongs of which should be so placed as to press against the apertures in the veins, and the other end against the inside of the lower jaw, and should therefore be broad and some- what convex, that it may keep its place. HEMORRHAGE OF THE NOSE. This complaint was hinted at in the chapter on Sneezing, and some account of it is met with among the old writers; I shall therefore bestow a few words upon it, though it is not often of much consequence, I believe, before the age of puberty. If a child be feverish, or otherwise unwell, the hemorrhage is often a mere symptom arising from the complaint under which it labours, and will disappear upon that being properly treated. But a bleeding at the nose sometimes takes place in the healthiest chil- dren, the vessels of this part being weaker than those which are covered by the true skin, and often afford a salutary outlet, in the case of plethora, and therefore usually contract when the intention of nature is answered; after which a dose or two of cooling physic * Memoires de Lj'Academie des Sciences. 28* 330 UNDERWOOD ON CHILDREN. should be given. But it may be sometimes necessary to draw a little cold water up the nose, to which some vinegar may be added ; to compress the nostril from which the hemorrhage arises; and to confine the patient as much as may be to an upright posture. Should these little remedies fail, the head, hands, and feet may be bathed in cold vinegar and water, and the nostrils be stopped up with dossils of lint, which, upon urgent occasions, must be dipped in warm oil of turpentine, or other styptic liquor, and must extend to the posterior aperture. The last means will almost always suc- ceed ; but if otherwise, some blood should be taken from the arm, if the pulse does not forbid; the feet be bathed in warm water, and the body kept open by manna and cream of tartar; and the patient should live for a long time pretty much upon whey, vege- tables, and milk; at least he should not dine wholly upon animal food. In the intermediate days of purging, the testaceous powders and tincture of catechu may be taken; and in some instances of debility the bark, or the Nevilholt water, will be proper. HEMORRHAGE FROM THE NAVEL. The navel of new-born infants is liable to several disorders, some of which are of considerable importance ; but I speak in this chapter only of the slighter ones. Of these, one is an oozing of blood from the part, after an unkindly separation from the cord, and is owing to the shooting up of a soft fungus, which prevents the skin from covering the divided vessels in the manner it otherwise does. This rawness however is not always attended with hemorrhage, as will be noticed in the next chapter ; but when it is so, and has not been attended to, it may continue for several months, and in some instances, in such quantity as to prove alarming to the friends of the child, lest it should in the end be injurious to its health. The little vessel from whence the blood issues, lies always so deep that it cannot be secured by ligature, nor be conveniently cau- terized ; the latter of which, indeed, would be very disagreeable. I have, however, conveyed the lunar caustic to the part, which has stopped the bleeding for a time ; but it has always returned. Nothing further, however, is necessary, than to adapt a proper compress, and secure it by sticking-plaster and bandage; which should be continued for two or three weeks; or it may be restrained merely by a small dossil of lint, and cross strips of sticking-plaster applied in the mariner hereafter directed for the rupture at this part. There is indeed another kind of hemorrhage of more importance, but this seems to be sympathetic, and is attendant upon infants who are in an ill state of health during the month, and is, perhaps, a bad sign. It takes place where the cord has been apparently well healed; but the skin afterwards gives way, and the bleeding is much more considerable than in the former. It requires, how- ever nothing more than the application of common styptics, with SORENESS, OR ULCERATION OF THE NAVEL. 331 proper compress and bandage. The bleeding not appearing in the least to be critical, ought to be suppressed as soon as may be, and whatever complaint the infant may labour under, be treated ac- cording to its kind. SORENESS, OR ULCERATION OF THE NAVEL. The care of this part has been so uniformly submitted to nurses, that unless some very unusual complaint has appeared, medical men have seldom been consulted. On this account its disorders have been rarely mentioned by writers, nor probably have all the affections to which it is liable been generally known. The separation of the cord is the work of nature, whose opera- tions are usually performed in the best manner and time. It may here be remarked, however, that in regard to the time there is a considerable variety; a complete separation in some instances taking place in five days, and even earlier, and in others not till the fifteenth or sixteenth. When so late, the funis is usually found hanging only by a very slender filament, which, if perfectly dead, as it usually is, ought to be divided ; nature having herein failed of her intentions. The separation of the funis, however, is not often followed by much soreness or pain, though there is frequently a true ulcer of the part. The common applications of a bit of singed linen cloth, a toasted raisin, and dusting the part with hair-powder, or the powder of ceruse, are usually sufficient for the common soreness consequent upon the separation of the cord. In some instances, however, the discharge is very great, and the part continues to ap- pear raw, and indisposed to heal or dry up. In such cases, I have often found three or four small pieces of a soft cabbage leaf, one of the best applications. They should be laid one over another, that they may be preserved moist and cool, and should be continued as long as the discharge shall be considerable.* A more troublesome case is that of the part becoming sore, often some weeks after it has appeared to be healed ; and as far as I have seen, (unless in some very bad cases presently to be noticed,) has taken place only where the skin of the belly has extended an un- usual way on the cord ; occasioning, likewise, as will be noticed in a subsequent chapter, a disposition to exomphalos. This sore- ness is likewise attended with much thin discharge, which disap- pears and returns irregularly, together with a raw appearance of the pait; which is not many days in the same state. The bowels are in this case usually affected, and should therefore be carefully attended to, and proper remedies administered, according to the nature and number of the stools ; the part being at the same time covered with cabbage leaves, or with a poultice of bread and milk, • Pled^its of lint soaked in a solution of sulphate of zinc and borax, and kept upon the part, have proved a sufficient remedy for this inconvenience. — S. M. 332 UNDERWOOD ON CHILDREN. or of aq. litharg. acetati comp. or the decoct, corticis, according aa it may be more or less healed ; or the raw part touched, now and then, with the argentum nitratum, blue vitriol, pulvis lapid. cala- minaris, [or chloride of lime,] as its appearance and the quantity of discharge may suggest. By one or other of these means I have always found it get well, but sometimes not in less than five or six weeks, when it has usually dried up suddenly ; previous to which the infant has seldom thriven properly. In several instances, however, I have enclosed the raw part in a ligature, and this method has usually removed the com- plaint in a couple of days, and seems therefore always to be pre- ferable where it can be effected. But there is a much more alarming ulceration, which, like the former, takes place some time after the part has been properly healed, and is probably always the consequence of some other ill- ness, or a general debility of the infant. In such cases the sore has been found to spread over a great part of the belly, and even to mortify. Here very little can be done, I believe ; all the instances, excepting two, that I have known anything of, having proved fatal; not so much indeed from the local affection or tender age of the subject, as from the original cause of the gangrene. Whatever is found proper in a similar state of parts on other occasions, should be made trial of, such as fomentations, poultices, and a liberal exhibition of the bark and cordials, under the use of which, however, the infant rarely survives long enough to afford a due trial of their effects. Mr. Pearson, nevertheless, has informed me of two cases of this kind of ulceration, which took place in children turned of six months old ; one of whom recovered under his care by the means above recommended, which were had recourse to as soon as the sore began to spread. The other case had been attended by another gentleman, and was not seen by Mr. Pearson till a short time before the infant died. A case of this kind, but more mild, fell under my observaion, in which, upon the separation of the funis, a foul ulcer with great tumour and hardness took place, which was not healed till the end of the fifth week. Fomentations and poultices, however, with the exhibition of cordials, effected the cure, without recourse to the bark ; though the infant was not free from danger till near the end of the month, UNKINDLY SEPARATION OF THE FUNIS UMRILICALIS. The uncommonness of the appearance here intended may be offered as a reason for noticing it, as it can require but little if any medical assistance. I have only once seen such a case ; and being at a loss what turn it might take, it is imagined that other practi- tioners may not be displeased with this account of the probable result. TUMEFACTION OF THE PREPUCE. 333 This case is hinted at under the article of Hepartomphalos, the subject of which was born in the Lying-in Hospital; where the funis was tied in the ordinary manner, about three inches from the abdomen. But instead of separating close to it as usual, only the part inclosed by the ligature decayed, the portion below it preserv- ing its former appearance, except that it was a little shrunk or shortened : some unusual vessel, or vasa vasorum, it is probable, keeping up the life of this caducous part. In this state it remained for some days before the nurse made mention of it to any one ; and as it appeared probable it would gradually shrink away, no parti- cular directions were given; but it was purposed in a few days, to tie the funis close to the belly, if that should not be rendered needless by the cord becoming dry and dropping off in the usual manner. When the child was near three weeks old, the funis appeared a little raw and moist, and the ligature was then determined upon; but the mother being called to a place as wet-nurse at a great dis- tance, left the hospital suddenly, the remaining funis being still a living part, but only half an inch in length, and the child very healthy; and having heard nothing of it since, it is presumed it has continued so.* TUMEFACTION OF THE PREPUCE. This little complaint, like the hydrocele, arises from extravasated water, and is a partial anasarca; and if it be not attended with inflammation, nor owing to a stone sticking in the passage, as it sometimes is, never prove of any consequence. It is sometimes preceded by a copious discharge from the part, of a thick but soft consistence, resembling a strong lather of soap, or the froth of milk, which disappears as soon as the tumefaction subsides; by which the natural secretion from the glands has been confined. The part may be washed frequently with aq. litharg. acetati comp. or be wrapped up in a poultice of that kind [or camphorated spiritsoccasionally], and the body kept open, which usually removes the complaint in two or three days ; but if it should not, the part may be lightly scarified, and afterwards fomented. Should it arise from inflammation, as in the erysipelas infantile, the inflammatory cause must be properly treated. If from a stone in the passage, the stone must be extracted, if within reach; or if otherwise, it should be forced back into the bladder. * I have seen four or five cases of a disease of the umbilicus, which I suppose to be of the same nature with that above described. It appeared to me to be a true fungus springing up from the umbilicus to the height of half or three-quar- ters of a^n inch ; and°much resembled in shape and size the funis, except that it had no external covering. In one of the cases a ligature was applied, but did not cure the complaint, the fungis continuing to grow, after the tied portion had sloughed away. A daily application of the lunar caustic cured two of these cases, the others yielded to the constant application of a solution of sulphate of zinc. — S. M. 334 UNDERWOOD ON CHILDREN. PROLAPSUS, OR PROCIDENTIA ANI. This is a descent of the internal coat of the lower bowel, (this coat, it is well known, being much longer than the others, and full of folds,) and is either owing to its laxity or to irritation. It is no uncommon complaint, nor usually difficult of cure, being gener- ally a symptom of some other ; such as worms, or other foulness ofthe bowels ; or has been induced by rough purges, diarrhoea, long costiveness, a stone in the bladder, or other irritating cause ; and is usually preceded by tenesmus : to each of which the proper remedy must be applied, or the cure of the prolapsus will be attempted in vain. But if the complaint should remain, after the irritating cause has been removed, it will then depend merely upon a relaxation of the part, arising from the long habit of descending every time the child has gone to stool; and is, in general, easily cured merely by an astringent lotion. To this end, a compress of lint of soft tow, of sufficient thickness, wrung out of the dregs of red wine, to which may be added a few drops of the aq. litharg. acetati should be often applied, and secured by a linen bandage, so as to make a firm compression on the part: or a compress may be sprinkled with fine powder of myrrh, frankincense, and dragon's blood, or impregnated with the smoke of turpentine cast on burning coals. Or supposito- ries may be made of powder of balaustines, red rose leaves and oak-bark in honey, and introduced into the bowel after going to stool.— It may be found expedient to have the part supported at such times, by a servant placing a finger on each side of the gut, as well as for the child to sit on a high seat, so that the feet may not touch the ground, or for older children to stand ; but these cautions will not be necessary unless the complaint has been of longstanding, or the descent be considerable. When this is the case, astringent fomentations and injections will also be expedient. These may be made of a decoction ofthe cor- tex quercus, which must sometimes be rendered more powerful by the addition of alum, the quantity of which should be increased as the part may be able to bear it. Should such a case occur in children, as it frequently does in adults, in which the bowel may not be easily returned, on account of supervening tumour and inflammation, the stricture will never fail to yield to an injection of cold water with a few drops of aq. lithargyri acetati. with five or ten of the tine, opii.* An hour or two after such an injection has been thrown up, the prolapsed intestine, though perfectly black as well as swollen, will be found to retire of itself; the sedative quality of the injection removing the spasm and stricture, which afforded the only impediment to * I have found it necessary to apply leeches in such a case, before the inflam- mation and tumour could be reduced. — S. M. DISCHARGES FROM THE VAGINA. 335 the re-ascent of the bowel. — With the like view, Mr. Bell, in his System of Dissections, recommends the use of " a strong cone of paper softened (by being moistened at the point) and oiled. This is to be introduced into the gut with gentle but continued pressure ; and when the gut is completely reduced within the anus, the cone is easily withdrawn, with little risk of its bringing down the intes- tine again, (jj) Children affected with this complaint should usually sit on a hard, flat-bottomed stool, or a chair without arms, and of such a height that their feet may not touch the ground. — For children of eight or ten years old, who take much exercise, recourse may be had to Mr. Gouch's suspensory as improved by Mr. Savigny, in- stead of the linen bandage above recommended. DISCHARGES FROM THE VAGINA. These are either sanguineous, mucous, or purulent. As I speak professedly only of appearances before the age of puberty, I have merely to remark on the first, that infants have sometimes such a discharge from the vagina a few days after birth, and that the like happens to girls of eight or ten years old; but neither appears to be of any consequence. Should it, however, on any account be thought necessary to prescribe something, a little testaceous pow- der or magnesia, according to the state of the bowels, will be suffi- cient, as the discharge always disappears in a few days. Children of five or six years old are subject to a mucous gonor- rhoea, resembling the genuine fluor albus of adults, which will in some instances be in an excessive quantity, so as to run through all their clothes; and is sometimes, though rarely, tinged with blood. If it were suffered to continue, it would probably injure the health, but 1 believe may always be cured by one or other of the means recommended for the next, which may be called puru- lent gonorrhoea, (kk) [" The following case has not hitherto attracted sufficient atten- tion, both as an illustration of this point, and an additional evidence of the existence of this singular affection. " Jane Hampson,* aged four, was admitted an out-patient of * See Medical Ethics, by Dr. Percival. Note by Mr. Ward, of Manchester, page 231. (jj) Protrusion and bleeding from the rectum may often be prevented by resisting slight, particularly second calls in the morning to stool, after the regular fecal discharge has been procured. More severe forms of the disease are cured by excision ofthe prolapsed or altered parts, or of some of the folds of cellular tissue and cutaneo-mucous covering at the margin of the anus. (kk) The sameness of discharge from different and even remote mucous surfaces has been indicated already in my note on purulent ophthalmia. 336 UNDERWOOD ON CHILDREN. the (Manchester) Infirmary, Feb. 11,1791. The female organs were highly inflamed, sore and painful; and it was stated by the mother, that the child was as well as usual till the preceding day, when she complained of pain in making water. This induced the mother to examine the parts affected, when she was surprised to find the appearances above described. The child had slept two or three nights in the same bed with a boy fourteen years old ; and had complained that morning of having been hurt by him in the night. " Leeches, and other external applications, together with appro- priate internal remedies, were prescribed ; but the debility increased, and on the 20th of February the child died. The coronor's inquest was taken, previously to which the body was inspected, and the abdominal and thoracic viscera were found to have been free from disease. The circumstances above related having been proved to the satisfaction ofthe jury, and being corroborated by the opinion I gave, that the child's death was occasioned by external violence, a verdict of murder was returned against the boy with whom she had slept. A warrant was therefore issued against the boy, but he had absconded, a circumstance which was considered as a con- firmation of his guilt, when added to the circumstantial evidence alleged against him. " Not many weeks however had elapsed, before similar cases occurred, in which there was no reason to suspect that external violence had been offered; and in some it was absolutely certain, that no such injury could have taken place. A few of the patients died, though from the novelty and fatal tendency of the disease, more than common attention was paid to them. I was then con- vinced I had been mistaken in attributing Jane Hampson's death to external violence; and I informed the coroner of the reasons which produced this change of opinion. The testimony I gave was designedly made public, and the friends of the boy hearing of it, prevailed upon him to surrender himself. "When he was called to the bar at Lancaster, the judge in- formed the jury that the evidence adduced was not sufficient to convict him; that it would give rise to much indelicate discussion, if they proceeded on the trial; and that he hoped, therefore, they would acquit him without any witnesses. With this request the jury immediately complied."* — M. H.] PURULENT GONORRHOEA. This is also no uncommon complaint, even in children of two years old, and is then, in general, easily removed by a little cool- ing physic, and keeping the parts perfectly clean. I have some- times made use of a lotion of the aq. litharg. acet. comp. which I believe is preferable to most others, if had recourse to in the com- ♦ Med. Chir. Trans., vol. vii. p. 94. PURULENT GONORRHOEA. 337 mencement of the complaint; and if there be any excoriations, they should be covered with the unguent, cerussae acetatae, spread upon linen, or lint. Instances will now and then occur in this species also, m which the quantity of discharge will be exceedingly great, so as to run down the child's limbs several times in the day, and will last for two or three weeks: but it has always disappeared in that time, and not uncommonly, where it has been the most copi- ous, ceases almost suddenly. When the purulent discharge makes its appearance much later, as it not unfrequently does, and is much discoloured and fetid, it gives rise to a suspicion which young practitioners cannot be too guarded against. There are, indeed, instances of little girls, not more than six years old, being injured, and it is therefore of conse- quence to make a judicious discrimination: but there are, on the other hand, instances of a very suspicious appearance, as late as the age of thirteen or fourteen, where no injury could be received without the consent of the party, who is generally perfectly inno- cent, and where, therefore, the least suspicion would be very dis- tressing to her, and might make a whole family miserable.* Discharges with the worst appearances are frequently carried off in eight or ten days, merely by the treatment above recom- mended : but I have seen some cases in the youngest subject of a bad habit of body, where mercury, as a deobstruent, has proved useful, though I could not have the least suspicion of a venereal taint. In such cases I have found Ward's white drop a more con- venient medicine than any other preparation of mercury; it may be given in the dose of half a drop, and by degrees, be increased to two, and even in three drops, once or twice a day, for two or three weeks. But where this has failed, I have only to add, that I have been always able to succeed by giving the decoctum corticis, cum balsam, copaibae, ovi vitel, soluto ; which is also an admira- ble medicine in the fluor albus of adults. * Induced by motives of humanity, I hope I may be permitted to add a word or two more on this subject; since the prudence and information of practitioners may not only prevent a vast deal of unnecessary distress to many worthy fami- lies, but may even save the character, or life, of another party suspected of criminality. For, besides many instances wherein inattention or ignorance might give rise to injurious suspicions, there are cases which call both for great atten- tion and experience, in order to form a just and decided opinion. I have, indeed, known the discharge to be so ill coloured and fetid, and attended not only with great pain and inflammation, and excoriation in different parts, but such tumours and other appearances resembling violence offered, about thefurca, and in other instances, with an abscess in the labia, that had the patient herself ad- vanced any charge, I fear I should not have hesitated to have joined in with it; and yet from the event, as well as the whole history of several cases, it has been very evident that no kind of injury had been received, nor anything like inter- course taken place. 29 338 UNDERWOOD ON CHILDREN. ENCEPHALOCELE, OR HERNIA OF THE BRAIN. Many infants come into the world with various parts imperfectly formed, especially about the head ; and never more commonly than in the upper part of the skull. If the deficiency be very great, and accompanied With a like want of brain, which it usually is, such foetuses fall under the class of Monsters; and being never, or sel- dom born alive, are not subjects of this work. The hernia of the brain, on the other hand, is met with in infants otherwise completely formed, and is generally curable. The pub- lic is indebted to Mons. Ferrand for an accurate description of this complaint, given in the fifth volume of the Memoires de 1'Academic Royale de Chirurgie. The encephalocele is a soft circumscribed tumour, usually of a round form, and correspondent in size with the extent of the de- ficiency of cranium ; to which the complaint is owing. It is with- out fluctuation, or discoloration ofthe skin, but is attended with a perceptible pulsation of the brain, which synchronises with the pulse. The tumour retires and disappears upon pressure, and is always situate either on one of the fontanelles, or in the course of one of the sutures, and is never larger than a pullet's egg. Where the defect in ossification is very considerable, a much larger portion of brain is consequently protruded ; which, strictly speaking, it were less proper to call a disease, than a fatal malformation, as it is pertinently remarked by Mons. Ferrand; and no more resem- bles the true encephalocele, than an eventration resembles the common intestinal hernia. It will be very necessary, however, carefully to distinguish this incurable evil from other soft tumours of the scalp, presently to be noted, which it very much resembles; the latter having frequently the like precise feel of a bony margin around them, as is common, indeed, in cases of extravasation upon any solid surface. The tumour is also colourless, and often as large as in the fatal malformation, but has a considerable fluctuation ; and is further distinguishable by the tumour not retiring upon pressure, nor being attended with any pulsation. The encephalocele is, indeed, easily distinguished from them all, by the brief description above given of it; and fatal as it would be were it left to itself, requires only to be properly understood, in order to adopt a rational and effectual remedy ; which consists in a careful and due compression of the part. This may be effected by the application of a piece of sheet-lead, somewhat larger than the tumour, and pierced with holes, that it may be sewed to the child's cap. The compression should at first be very moderate, and never so great as to give an infant pain, or disturb any of the natural functions; though it should be gradually increased as the tumour shall retire. This is all that is required from art, the cure being the business of nature, which, if the child continue healthy, will proceed in the work of ossification, and in due time fill up the TUMOURS OF THE SCALP. 339 vacancy in the skull. The protrusion of the brain was before an obstacle to this process, whilst the injury that tender organ must sustain by the pressure from the sides of the bone, exposed it to all the evils which compression never fails to produce, and which it were needless to enumerate in this place. TUMOURS OF THE SCALP. There are other tumours on the head of new-born infants which it were improper entirely to pass over. The one I shall first men- tion is of the least importance of any, being occasioned merely by long compression in the birth. It is of different sizes, and the skin is always discoloured; but in any case can seldom require much attention, as it frequently disappears in a few hours. If large, it is common to bathe or foment such tumours with red wine, or with brandy, or vinegar, diluted with water; and, in general, they gradually subside, though sometimes not perfectly, for several days. Some of them, however, are of more consequence, and concerning the treatment of these, practitioners have differed. The absolute impropriety of opening any tumours arising from compression has been insisted on by many, but I believe it may in some cases be really necessary, in order to prevent a troublesome fungous sore, and even a caries of the skull. The discrimination, however, is sufficiently obvious, such assistance being required only where the above remedies and compression have had no effect, and the tUr mour is found sensibly to increase day after day, which in some instances has been the case to the end of the month. Such growth is always owing to the extremities of the arteries, ruptured by long compression, being still open, and pouring out an ichorous fluid into the cellular membrane, and thereby keeping up and increasing the original tumour. Upon opening the integuments, a bloody fluid is let out, and the tumour nearly subsides, which afterwards requires nothing but moderately astringent applications and pressure, which should be continued for a little time after the aperture is closed. Another kind of tumour, of a more unfavourable appearance, was hinted at under the article of Encephalocele, and of which it may be proper in this place to take a little further notice. These tumours contain a kind of serum, and are often very large, but without that discoloration of the scalp and bruised appearance, which there constantly is in those last described, nor do they, in- deed, seem to arise from compression. I have at least seen them extending over a third part ofthe head, and raised an inch or more from the skull, after the shortest and least painful labours. To the description before given of them, it may be added, that this kind of tumour, I believe, will always subside very kindly, though some- times not completelv, until the end ofthe month. In some instances, it begins to lessen in six or eight days after birth,but in others,not till nearthe end of the third week, and then subsides very rapidly; and 340 UNDERWOOD ON CHILDREN. as it falls, more and more of the skull may be felt, from day to day, in proportion as the absorption of the fluid takes place. To assist nature, therefore, in this operation, embrocations of acetum distil. sal ammon. crud. and spirit, camphoratus, should be made use of, with a gentle compression of the part; as well as keeping the bowels properly open. A tumour of a different nature from each of these is described by Michaelis,of Harburg; but as I have never seen it, and, indeed, imagine it is not known in this country, I shall merely state it as related by Loder.* This tumour is to be distinguished from swellings on the head, with which children are sometimes born, or that appear after a slow and difficult birth, occasioned by long pressure, or the rup- ture of some bloodvessels; and it differs by the following marks from any other swelling of the head, hernia cerebri, or hydroce- phalus internus : — 1st. By being often observed after very easy labours. 2d. By not always appearing on prominent parts of the head ; though this may sometimes be the case, on account of their gener- ally being remarked at the temples. 3d. By commonly appearing one day after birth. 4th. By being more elevated and circumscribed than any other swelling on the head, and by showing a perceptible fluctuation. 5th. By the skin, with which it is covered, keeping its natural colour and state, and by its being easily moveable on the tumour, without changing the situation of it, a circumstance that seems to prove its being deep ; the skin, therefore, appears to move on the tumour when the child is crying. 6th. By not disappearing, or diminishing on the application of pressure, and where, also, no stupor is occasioned ; a symptom that always takes place in a hernia cerebri, or hydrocephalus internus. 7th. It differs from a tumour caused by the rupture of blood- vessels, or from a lymphatic swelling by the singular change which the bone on which it is situated is observed to undergo. The ex- ternal table of the bone is entirely wanting ; the diploe uncovered, and the edge of the impression that is thus occasioned may be plainly felt. By this peculiar circumstance, the tumour is particu- larly distinguishable from any other. On opening it, a black and coagulated blood is found in it, lying immediately on the diploe. It is very probable that the tumour originates from a disease ofthe bone ; and that it is not occasioned by the former, on account of their both being found in the same state from the first moment. To remove this tumour by discutients, is an attempt that has, in most cases, proved ineffectual. The disease of the bone is increased by the pressure of the blood exciting the absorbent vessels to a greater action in the bone, whereby, at last, a hole is occasioned, Lod. Journal of Surgery, vol. ii. LYMPHATIC TUMOURS ON THE HEAD AND SPINE. 341 and the brain injured by its being pressed. The only thing that can be done is to open the tumour, and to let out the blood, in order to prevent the further absorption of the bone. This opera- tion is not without danger, on account of the loss of blood that runs from the bone as from a sponge: but by making the incisions small, it may in a great measure be avoided. It is, however, very seldom that it succeeds in healing the bone, and the children gen- erally fall a sacrifice to this singular affection. Fortunately, it is rarely observed, but, according to Michaelis, it seemed to occur more frequently at Harburg than anywhere else. He relates a case of this disease, which may be briefly stated as follows: a tumour of the size of an egg appeared on the right temple of a new-born infant the following day, after a labour which had been uncommonly easy. As it showed the above-mentioned characters, there could be no doubt of its being this species of tumour. He first tried to dissolve it, and a cold solution of sal ammoniac and saltpetre in vinegar, and cataplasms of the herb Arnica, were ac- cordingly applied ; but having continued them nearly a fortnight, without the least effect, the tumour was opened, and a black thick blood discharged from the wound. The bleeding, which was not very considerable, ceased on the application of alcohol, in which scraped linen was dipt. The wound began to suppurate the next day, and in twelve days it was healed up ; the child felt no pain whatever, and was quite well: an impression, however, remained from the want of the external table of the bone. A few weeks after, the child was seized with a general erysipelas, of which it died. Dr. Michaelis being curious to inform himself of the state of the bone, where the tumour had been situated, cut through the integuments, when he found the bone appearing with a rough sur- face, deprived of its external table, as far as the tumour had ex- tended, and only seeming to be regenerated in some places. LYMPHATIC TUMOURS ON THE HEAD AND SPINE. There is another kind of tumour appearing sometimes on the head, and at others on some part of the spine, which is not owing to accidents in the birth, but is of a morbid nature. These tumours contain a lymph, and are attended with evident fluctuation, as may be discerned by the touch ; and unless they are exceedingly small, ought in no case, I believe, to be punctured, or eyen removed by ligature, though adhering only by a small pedicle. Those on the spine of the neck, or back, or on the loins, if they do not arise from the dura mater inclosing the medulla spinalis, seem to originate at least from the periosteum of the spine ; and the issue having a morbid source, will be kept up after the tumours are opened, or even totally extirpated, and preventing the sore from healing, the infant sinks under the discharge, or dies in convulsions. 342 UNDERWOOD ON CHILDREN. SPINA BIFIDA, OR HYDRO-RACHITIS. This morbid affection is more commonly known here by the former of these terms, though the latter is thought by many to be the more proper name ; the first being taken only from an effect, the other being descriptive of what is deemed the original disease. It is also known by other names, as writers have been severally impressed by the cause, effects, or the appearance of the disease. Ruysch therefore calls it a dropsy, and Bertrandi,* a hernia of the medulla spinalis ; the medullary structure being in some instances destroyed, and a spongy substance filling up the cavity of the membrane, and protruding through the bifid spine. It is remarkable, that this complaint, or malformation, though now everywhere to be met with, was not described, as I believe, before Tulpius wrote, whose observations and cases were first pub- lished in the year 1641, and afterwards with some additions, as late as 1716, which is the edition I have seen, and which contains an accurate account of the spina bifida. Since the above period, the disorder has been irregularly noticed by various writers ; but not being a very common one, and very little having ever been attempted, or proposed for its relief, I judged it sufficient, in the earlier editions of this work,barely to notice and describe the complaint, in order to guard against its being mistaken, and an infant's life shortened by rashly opening the tumour. But as various solitary cases and observations are diffused through dif- ferent medical works, and as none of the late writers have me- thodically collected and arranged them, nor any since Morgagni paid much attention to the subject, I have now been induced to take it up more at large. Having also myself seen the disease about eight or ten times, (under which one child languished seven weeks and another several months,) as well as conversed with many practitioners who have as often met with it, I have thought, that in a work devoted to the diseases of children, it might be agreeable, if not instructive to the reader, to see all that is of importance of the subject brought into one view. With this intention, I briefly advert to the writers we are obliged to for any account of this congenite derangement; and after con- sidering its nature, cause, and the periods at which it proves fatal, shall state whatever has been proposed, or attempted in a way of palliation or cure. It is remarkable, that in a disease for which so little can be done, both the earliest and latest writers have agreed so well in their opinion, and description of it; though some, indeed, do little more than mention it, notwithstanding they all appear to have seen * Opere di Ambrogio Bertrandi. Tomo ii. Torino, 1786. SPINA BIFIDA, OR HYDRO-RACHITIS. 343 the disease It hath been observed, that it does not seem to have been noticed by any of the ancient writers : and Tulpius himself appears to speak of it as of one he had not long been anywise ac- quainted with : we accordingly find him saying but little on its precise nature or cause. Soon after him wrote C. Stalpart Vander Wiel, and Muys,* the one in the year 1682, the other in 1695, and about the same time Bonetus ;t but these throw very little light on the subject. Ruysch treats more largely upon it, and calls it a dropsy of the spinal marrow, as the hydrocephalus is of the head or brain, and with some propriety, as will presently appear. Bidloo,^ physician to King William the Third, and Salzmannus,§ his cotemporary, have noticed the disease, Rutty|| gives a good anatomical account of it. Titsingh wrote upon it in 1733.1T Zechar. Platner** more fully in 1745, and Acrell in 1748.tt Van Swieten and Morgagni wrote nearly at the same time, the former of whom copies Tulpius and Ruysch, but the latter quotes various other writers, and takes as much pains to investigate this disease as almost any other that he has recorded. Our countryman, Mr. Warner,!:): was weU acquainted with it, and relates an instance of a man living to twenty years of age, though the disorder had in- duced a palsy of the lower extremities ; but not so bad as to dis- able him from walking. Dr. Monro, in his treatise on the Dropsy, in 1756, merely names the disease, but Mr. White describes it well, in his surgical cases, written in the same year. Blanchard also mentions it; likewise Monsieur Le Cat§§ in 1765, Gooch in his Surgery in 1771, Ambrose Bertrandi|||| in 1786, and LouthlFIF as late as 1788 ; and a little before this, a remarkable case was no- ticed by the Royal Society of Medicine at Paris, the subject of which is said to have endured the complaint for twenty years, and at length was perfectly recovered from it; on which I shall pre^ sently have occasion to offer some remarks. By the accounts given by these writers, it appears, that this dis- ease fixes either upon the superior parts of the spine, and is then seated upon the last vertebra of the neck, and the first of the hack; or else is lower down on the last of the loins, or more commonly on the os sacrum, and is usually upon the centre and posterior part of these false vertebrae : but Wepfer*** saw one on the right side of the loins. * Praxis Medico-Chirurgica-Rationalis. f Sepulch. X Ridloo Opera Exercit. 7ma. § Dissertatio de Quibusdam Tumoribus Tunicatis Extends. || Philosoph. Trans. Abr. vol. vii. inter annos 1779, 1783. Tf De Spina Byfida. ** Platneri Institut. Chirurgicae. tf Memoirs ofthe Royal Academy of Sciences at Stockholm. XX Surgical Cases, 1750. §§ Dissertation sur la Sensibilite de la dure mere, &c. |||| Opere di Ambrogio Bertrandi, tomo ii. Torino. ff NosologiaChirnrgica. **■• Wepferi Observationes. 344 UNDERWOOD ON CHILDREN. The skin is sometimes entire, and sometimes ruptured externally at the birth; and in the latter case, 1 believe, the infant is always still-born,* at least it has been so in all the instances I have met with; though such foetuses are often full-grown. In this case,the edges are prominent, and the centre is of course depressed, the ulcer very much resembling the form of the human mouth, when the angles of the lips are drawn together and the middle part is pushed forward. When the skin is entire, the disease appears in the form of a tumour, varying in size from that of a pea, or even smaller, to that of a half-crown piece; being also more or less elevated. The highest point is usually very thin, and sometimes transparent, from having no true skin ; other parts of the tumour are red or livid, having very much the appearance of some Gancerous tumours upon the point of ulceration. The surface is generally very soft to the touch, especially in the centre, from which a fluid retires upon pressure, and round the margin of the swelling the bony edges of the spine may be distinctly felt; a circumstance that ought always to be attended to, as leading to a certain diagnostic. In other cases, no fluctuation is perceptible but a carneous substance, hard and thick ; and such infants cannot endure being laid on the back, but presently become convulsed. Muys mentions an instance of the disease being situated between the scapulae, in which the skin was not at all discoloured ; the deficiency of bone was, therefore, very small, as likewise seem to have been the case from the event, as will be mentioned in its place. The internal appearances are various : suffice it to say, that as the disease takes place during the process of ossification, the inter- nal derangement seems to depend very much upon the period at which the complaint may commence. In general there is a con- fusion of nerves, bloodvessels, membranes, and ligaments, together either with a hard flesh-like substance, or a certain portion of discoloured lymph. This is, probably, small at first; but the necessary support of bone being wanting, the lymphatics of the membrane investing the spinal marrow, it has been supposed, con- tinually deposit their contents, enlarging the tumour, and increas- ing the disease. I saw one instance in a foetus of about five months growth, where the bone (the os sacrum, as yet indeed, in a cartilaginous state) was complete on the outside, but deficient within; the spinal marrow was also wanting, and there was a considerable quantity of water. Many children, born with this complaint, do not seem to have suffered by it while in utero, being healthy, often large, and very strong ; but some are otherwise mutilated ; it being not uncommon to find one or both the ankles distorted, or to have the lower extre- mities weak, and sometimes totally paralytic; and there is in others a great deficiency of bone on the upper part of the cranium. The * This is not always the case, SPINA BIFIDA, OR HYDRO-RACHITIS. 345 higher up the seat of the spina bifida may be, the greater is usually the injury, and the sooner the infant perishes, unless the aperture of the bone be very small, which, as has been observed, is some- times the case.(//) From what has been said, as well as from a similar disease being occasioned by internal injuries of the spine, as mentioned by Le Cat,* it will appear, that the disease, as hinted above, may be owing to some interruption to the process of ossification, and a consequent distention of the membrane investing the spinal mar- row, from the pressure of the fluid, which in return becomes a further impediment to that process. It is not improbable, how- ever, that this undue secretion of lymph may be oftener the original source ofthe disease : the water, as an unnatural compression, either preventing the formation, or afterwards destroying a portion of the bony arch intended by nature as a protection to the tender marrow ; a part essential to the animal functions. Hence Louth has very properly defined the disease to be, Aqua in Specu Vertebrarum collecta in Infante, Vertebras ultimas Columnas Pondere suo findens et Tumorem prope Os Sacrum constituens; though it does not, as it has been said, appear always in this part. It is sometimes a mere local disease, confined within the circum- ference of the tumour, and at others, thejwater rises a little higher in the vertebral column; and hence Ruysch has considered this disease as a proper dropsy of the part, as the hydrocephalus is of the head. In some instances again, the column is open from the occiput to the os sacrum, and the water is even found to descend from the fourth ventricle of the brain ; the two diseases being then conjoined. These disorders have also sometimes been found to succeed each other ; several such instances being related by Wep- fer and Morgagni. The latter of these writers relates one of a child of four years of age, where a dropsy of the spine succeeded to a hydrocephalus, which had taken place in consequence of a contusion of the head. The former being opened, the tumour of the head in a little time greatly subsided, and upon pressing that part with a hand, a palish ichor rushed out from the aperture in the os coccygis; a circumstance recorded also in other instances; the above infant, he reports, recovered. In another, upon the con- solidating of the spina bifida after an aperture had been made, * Traite du Mouvement Musculaire; de la Sensibilite, de Hrritabilitd, &c. 1765. (II) M. Billard relates (op. cit.), that in seven children affected with hydro-rachitis and spina bifida, who died, there were five who exhibited spinal meningitis. In dissecting the vertebral column and the tumour of the children affected with spina bifida, he found in five of them an abun- dant effusion of serosity in the cranium and spine ; so that it is probable that the separation of the vertebra?, and the tumour following it, are the ordinary results of this accumulation of serosity, or of this encephalo- spinal dropsy. 346 UNDERWOOD ON CHILDREN. water in a few days began to form in the head, which afterwards enlarged to a very considerable size. On the other hand, it has been noticed, that there is sometimes no water, but the bony column is filled up with a carneous substance, or spongy marrow, and the complaint is then termed a hernia of the spinal marrow; agreeable to a similar congenite disease of the head, which has been aptly called a hernia ofthe brain. In this case, some malfor- mation of the spinal marrow may be considered as the original dis- ease, unless it be supposed, that the proper cause exists in some interruption given to the process of ossification; whereby the medulla being deranged for want of its natural support, is in con- sequence distempered. The disease becomes fatal in consequence of the tumour being opened, or the integuments otherwise giving way, which is usually from a little slough, or gangrene, forming upon the thinner parts, which soon spreads wider and deeper, and so opens a way for the escape of the lymph. In a few days afterwards, and usually on the third, the infant dies, unless the parts should soon close again ; which has but very rarely happened. A remote cause of the child's death then seems to be the escape of the lymph, which is frequently soon followed by a strong convulsion, in which the little sufferer expires. But where the integuments have remained entire for any length of time, their rupture has been followed by hectic fever and marasmus, in consequence of a profuse drain from the part. But it is more common for the little patient to die either in a few days, or a week or two after birth, and then, probably, from some morbid change taking place in the medulla spinalis, from the ad- mission of air; which is supposed to be always injurious to internal parts, and more particularly to membraneous ones, and therefore must be peculiarly offensive to the spinal marrow and its sensible covering. These parts have,indeed,sufferedfrom the birth,from the nature ofthe disorder, and it is not therefore to be wondered at, that such infants are more or less convulsed, and appear several times to be dying, before that event actually takes place, and that they are often otherwise ill; though some children appear pretty well till the integuments give way. I remember one child who would not take the breast for twenty-seven days, and was several times thought to be dying; but afterwards taking to it properly, was greatly recruited; appearing, except for this disease, in a promising way, and lived four weeks afterwards. The late Mr. Hunter told me, that he had seen a child living with the disease at the age of eighteen months; and one born at the British Lying-in Hospital was alive when six years old. The means of cure that have hitherto been proposed for this dreadful disease, are, opening the tumour, in order to evacuate the water; or pressure, with a view to retain it, and consolidate the parts; neither of which, that I can with any certainty learn, have ever succeeded, unless it be in the instance mentioned by Morgagni (in which the disease was not congenite); and the one I have alluded SPINA BIFIDA, OR HYDRO-RACHITIS. 347 to, reported by the French Royal Society of Medicine. In this, the tumour was opened when the sufferer was twelve years of age ; soon after which the tumour is said to have grown up again; but being ruptured eight years afterwards, by the patient acci- dentally lying upon it, after it had increased to the size of a child's head, the tumour was absorbed, and a firm cicatrix being formed, the patient survived. From this case, and that occurring some years ago at the hos- pital : as well as the one reported to me by Mr. Hunter, and one an infant, eighteen months old, in a family of high rank, where the best advice had been sought, I have entertained some doubts whether tumours precisely of the like appearance, are as precisely of the like kind, or whether there be in them all a deficiency of bone • it having been the opinion of several of the first physicians and surgeons in repeated consultations, that the case in this infant was not precisely the spina bifida.* If a mistake in this respect may have been made by the reporter in the Royal Society of Me- dicine in Paris, no inference can be drawn of any probable success attending the evacuation of the fluid, or a firm pressure made on the tumour. The means, however, do not always seem to have been employed with proper discrimination ; since the very possi- bility of their succeeding will depend upon the size, and other cir- stancesof the tumour: for the aperture can never be advisable where the tumour is large, and the consequent internal derange- ment of parts is considerable ; nor pressure where the water is found communicating with the ventricles of the brain. The size of the tumour, it has been noted, is various, and agree- ably thereto must be the possible chance of recovery, as well as the probable duration of the disease, where it proves ultimately fatal. This, indeed, is more frequently within three days after birth, or it the infant survives much beyond that time, it will be owing to the resistance of the integuments; young children seldom survive the third day after the water begins to be freely evacuated, ihis, to- gether with the matter of fact, where the tumour has been opened, furnish a sufficient caution against artificially letting out the water. Muyst records a case of this kind, in which a child had lived tope three years of age, but the tumour being then opened, a great dis- charge of water was kept up, which induced a hectic fever and the child sunk at the end of three weeks ; and a case related by Wepfer equally forbids the indiscriminate use of P"^f' *" ™| an aperture made by a surgeon, from whence thiee ounces ot * The above account was drawn up in a P^"8 ^^ ^tWr^nature. which, it has been determined in every consultation, to leave the matter The child is still living, (1819,) and in perfec health and good spir , about, and climbs up a chair or »°J^" P^d firflen, wh le he only uneasi- ^PSff MedSchiruigic. Rationalis, 1695. 3iS UNDERWOOD ON CHILDREN. water had issued, being healed up in consequence of firm pres- sure, an immense hydrocephalus formed by the end of the fourth week after birth. And Van Swieten, who copies the case, justly observes, that if nature cannot get relief in such cases, by letting out the water at so distant a part from the head, no benefit can be derived from any means that may necessarily occasion an accumu- lation in the brain itself. In such instances as the above, it is probable, that the source of the disease has been in the head, the water having made its way from the fourth ventricle of the brain; nature ever at- tempting to relieve the oppressed, and especially more noble parts. But in other cases it should seem, that the disease has commenced in the loins, and the secretion being great, and the resistance below considerable, (possibly from the ossification being far advanced,) the water has ascended to the head.* But by dissection after death, it appears, that the water has more commonly been confined to the spine alone, and then has not been in great quantity. It must be in the latter case only, as well as where the tumour and deficiency of bone are inconsiderable, that any benefit can be expected from puncture and bandage, as Mr. Abernethy has lately ventured to propose. But from several objections which have been noticed above, arising from circumstances which Mr. Abernethy does not seem to be aware of, and which cannot be always pre- viously ascertained, I should not think that parents would readily consent to the experiment, or that surgeons can have much to offer as an inducement to it; especially as the want of success must ne- cessarily hasten the death of the infant. These considerations, I imagine, have made surgeons in this country cautious of making any attempts, and have induced me to state, as 1 have done, the result as given by foreigners. Since this statement in former editions, Mr. Abernethy has' ven- tured to make the experiment: and though he is led to think that the attempt is at least proved to be harmless, I can, by no means, alter my opinion; and have, therefore, suffered my former observa- tions to remain. Mr. Abernethy acquaints us, that " the tumour was punctured every fourth day, for six weeks, during which time the child continued unaffected. No contraction, however, of the integuments took place ; and at this time one of the punctures did not heal, but permitted the fluid to ooze out. The discharge gra- dually changed from a limpid to a puriform appearance, and in a few days the child died. This case (he adds) is interesting, though unsuccessful; as it shows, that the attempt at a cure may, at least, be made without hazard." I should, however, rather conclude that the last aperture not healing up, and the child dying a few days after, serves to confirm the prognostic I had ventured to make, not only of the probable inutility of the puncture, but of the hazard. The collection of the water, if it be in any instances the first occa- See Opere di Ambrogio Bertrandi, torn. ii. SPINA BIFIDA, OR HYDRO-RACHITIS. 340 sion of the disease, is not the whole of the evil; there being dis- ease in the membrane, and generally of the bone, to which the admission of air cannot be harmless :* while the puncture cannot prevent a re-accumulation of the fluid. From the general report of authors, therefore, as well as the result of my own experience, it should seem, that little relief can, in general, be expected anywise from art. Some discrimination of cases, however, should be made, and perhaps this will refer principally to the absence of any symptoms indicative of water in the head, and to the size of a tumour, on whatever part of the spine it may be ; but the lower down on the os sacrum, the more favour- able. As to the first of these, the usual symptoms of compression of the brain do not indeed present themselves, and it is probably owing to the relief which that part receives from the descent of the water to the parts below. The presence of water in the head may, nevertheless, sometimes be discovered, it being reported by Morgagni, that upon pressing the tumour, the rising up of water has been felt by a hand placed on the fontanelle ; and that from a firm pressure, the water has again forcibly descended into the tumour on the spine. In the absence, however, of every symptom leading to the sus- picion of water in the head, and when the tumour on the spine, especially if low down on the sacrum, is very small, (for it has been met with of the size of a vetch seed,t) a firm compress, and sprink- ling the part with astringent powders, or the use of similar fomen- tations, may be had recourse to, as recommended by Acrell,J and also by Ruysch, who says he has seen ten cases. Acrell was led to this opinion, from some children having lived for several years with this complaint. In such cases only, I imagine, can the at- tempt with any propriety be made; as otherwise the tumour will, probably, be only ruptured the sooner by the bandage, and, in con- sequence, the life of the infant be shortened. There is not, however, the like objection to the use of an astrin- gent, or cold embrocation, or more especially to drying powders, such as bolus, armen. pulv. catechu, aluminis, and such like ; which may be sprinkled on the part as occasion may require, to prevent the oozing of the lymph, by forming a kind of crust over the pel- lucid surface. Such applications may also have a tendency to retard the rupture of the integuments, and thereby prolong the life of the child; which is generally all that art can effect; and I have myself, indeed, no further experience of their efficacy in the true spina bifida; although I have known such means, as well as exci- sion of the parts, effect a cure in cases very similar in form and * This sentiment, however, has lately been controverted ; and some decisive experiments thought to be adduced in opposition to it, by Dr. Haighton, in a paper on the Cesarean operation, in the Medical Records and Researches. An. 1798. 1 M^monTof the Royal Academy of Sciences at Stockholm. Anno 1748. * 30 350 UNDERWOOD ON CHILDREN. appearance to this fatal complaint, but without any deficiency of bone. In regard to bandage, I have been informed that Dr. Hunter in his lectures, at one time, used to caution against the attempt, from his own experience of its hastening, as he thought, the rupture of the integuments; but whether the trial had been made in the fittest case, as here described, I could get no information. Should the size or figure of the head, however, be from such management affected, or the infant manifest any increase of pain ; or if convulsions, coma, or other bad symptom should supervene, the bandage ought to be taken off, and the mildest application be substituted in place of the astringents. In this view, a bread and milk, or saturnine poultice, may be had recourse to, which is the modern practice whenever the tumour is large from the birth, and is, probably in such cases, the fittest application that can be made use of; as it will sit easy on the part, and, by forming a soft cushion, as it were, for the tender skin to rest upon, will in so far dispose it to be preserved entire as long as possible ; the life of the child, it having been noticed, in almost every case, depending entirely upon that circumstance.* [In a case of spina bifida, which occurred in the practice of Mr. Evans, of Hampstead, pressure upon the tumour always induced attacks like the croup-like convulsion: see page 111. The infant was carefully preserved from the pressure which would be induced by the supine recumbent posture. — M. H.] HEPARTOMPHALOS, AND HERNIA VENTRALIS. The congenite ventral hernia, in which, from a deficiency of muscular integuments and skin, some of the abdominal viscera, and not unfrequently the liver, is protruded, is very often met with in abortions in the earlier months ; though less commonly in the full-grown foetus. I have never seen it in living children, unless in that instance of it termed hepartomphalos, which is the more immediate subject of this chapter, and will be clearly exemplified in the annexed case. In the true hepartomphalos, however, there is, possibly, no actual deficiency of the muscular or ligamentous integuments, and still more probably not of the skin ; but, as the term strictly implies, some part of the liver forms a congenite hernia of the navel. The liver, while very small, is, as I conceive, somewise drawn down by the vessels of the umbilicus which enter it, possibly by some action of the foetus ; or, (as it has lately been said by Lassus on the um- bilical hernia,) the liver is preternaturally large and heavy, through its receiving an undue proportion of blood from the vena umbili- * In the second volume of the Medico-Chirurgical Transactions, Sir Astley Cooper has related several cases, in which puncturing the tumour with a needle, and afterwards employing pressure, has cured the patients. — S. M. HEPARTOMPHALOS, AND HERNIA VENTRALIS. 351 calis, and is thereby protruded at the muscular ring in the linea alba, and falls into the funis umbilicalis, which it dilates and dis- tempers. This disease is a very rare one, I believe, in living chil- dren, and I had met with no written account of it, until Dr. Combe put into my hands a Thesis de Hepartomphaloce Congenita, by Francisc. Henricus Rockholtz, printed anno 1768. The case there related corresponds exactly with the one I met with, and both the infants survived the disease ; but some months afterwards, dying of other complaints, and their bodies being care- fully examined, the fact is established, and demonstrates the powers of the animal machine, in removing obstacles to its well doing, that might be thought insurmountable. The subject of the present case being born in the neighbourhood of the British Lying-in Hospital, was brought there for the advice of the physicians on a day when I was in attendance. The child was then eight days old, the nurse informed me that the tumour still remained of the exact size it had acquired when the infant came into the world; but that previous to the binding it down tight, the skin had seemed to be thinner, but was even at that time discoloured, though it had a kind of transparency, as if it contained a fluid; and that the next day it turned black. The dry funis was now appending from the centre of the tumour, which was as large as a good sized china orange ; was black; and the skin, as I thought, in a sphacelated state. Whether this tumour contained the liver, or any of the intes tines, I could not at all determine; or whether it might be a mere parenchymatous enlargement of the funis umbilicalis, of which I had lately seen an uncommon instance of about one-third of this size ; but in that, the enlargement commenced about three or four inches from the belly. I had little doubt, however, from the size and colour of the tumour, that in the present instance the infant would die in a few days, or at least, soon after the integuments should give way, as it appeared highly probable there would then be an opening into the cavity of the abdomen. 1 directed nothing, therefore, but a bread- and-milk poultice, and this merely in the view of its being a soft cushion for the tumour to rest upon, which did not, however, appear to be very sensible, though the infant cried much upon being moved, as if it were thereby put to pain. Four days afterwards the child was brought again to the hospital. There was then but little change in the appearance of the tumour, nor much discharge from it: and the child having taken kindly to the breast, had a healthy appearance ; so that, save from the sus- picion arising from the nature of the tumour, it seemed very likely to live. Half an ounce of the decoction of bark was directed to be given to it three times a day. I did not see the infant again for three weeks; and it was then near five weeks old. I now learned that the child had thriven so 352 UNDERWOOD ON CHILDREN. well, the parents were satisfied it was likely to live ; and that the funis had fallen off on the fifteenth day without being followed by any unpleasant symptom. That the tumour had burst about a week after the funis came off, from which time the swelling had sensibly subsided as the discharge kept up ; and that at the end of the month the discoloured integuments all sloughed off, and left a superficial sore of the size of a small tea-cup, to use the mother's expression. The poultice was directed to be continued until I should see the infant again, which was about a week afterwards. There was then an oblong, benign ulcer, about the size of a sixpence, and dis- posed to heal up. I now desired the poultice might be left off, and only to apply a bit of cerat. e lapide calamin. and moderate com- press. By these means the sore was healed when the infant was eight weeks old ; soon after which I saw the child in perfect health. The integuments at this time had not the usual appearance of the navel, but were, on the contrary, thin and a little elevated, but without anything like an umbilical hernia. The scar was not larger than a sixpence, and was not precisely in the middle of the abdomen, but a little on the left side of the point from which the funis naturally rises. From the disagreeable appearance of this case when the infant was first presented at the hospital, such a termination was very pleasant to us, as it leads to encouragement concerning other obscure diseases ; and manifests what unexpected things nature is capable of effecting, even at this early period, when not interrupted by any improper treatment. The infant fell a sacrifice, about six months after birth, to an- other disease; in consequence of which its body was afterwards carefully examined by Dr. Marshall. Dr. Combe happening to hear of it, was present, and informed me that there could be no doubt of the liver having occasioned the tumour we had seen : there being yet a sensible depression remaining, evidently marking the stricture made upon it by the linea alba and recti muscles, which had included about one-third of its left lobe. Since the former impression of this work, I have met with another instance of the hepartomphalos, in a full-grown, but still-born, fcotus ; the complaint being also ascertained by an examination of the parts. Whence it should come to pass, that infants should not only be born alive with, but survive, the hepartomphalos, rather than the common ventral congenite hernia; or than they would do a large congenite exomphalos of the intestine, may be worthy of inquiry in this place. And the reason probably may be, that in the hernia ventralis congenita, whether from the protrusion of the liver, or any other of the abdominal viscera, there must be a deficiency of the muscular and other coverings of the abdomen, and therefore nothing to support or defend the protruded organs so essential to life, but the thin peritoneal expansion. But that, in the former, there is, perhaps, no actual loss of substance, but a mere dilatation of the parts; the liver being at the same time defended by the ON THE HARE-LIP, ETC. 353 strong expansion ofthe funis umbilicalis, which does not give way after birth, until nature has had sufficient time to withdraw that viscus into the cavity of the abdomen. This, it is imagined, is effected not only by the removal of the first cause of its descent, but also by that respiration which takes place immediately on the birth, and is further assisted by the ligament by which the liver is attached to the diaphragm : and by means of which it is mechanic cally drawn up, during every expiration. ON THE HARE-LIP, AND OTHER EXTERNAL BLEMISHES, OR DISORDER S SUPPOSED TO BE MARKS OP THE MOTHER. Though it be beyond the present purpose to treat in detail on surgical operations, I shall beg leave to notice a circumstance or two relative to that for the hare-lip, as I already have in a few others, which frequent opportunities of comparing the different success attending them have furnished. I shall afterwards advert to some other equally common blemishes, in a view to assisting the younger part of my readers to combat the unhappy prejudices of mothers in relation to marking their children. This, unfortu- nately for themselves, they are always disposed to attribute to a violent impression from the sight of some disagreeable object, or to a disappointment in something they may have longed for during their pregnancy. And I have chosen this place for such observa- tions as I have to offer on this head, because the hare-lip and some other blemishes remaining to be noticed, bear that resemblance to objects around us, which is wanting in those before-mentioned. The repeated experience of every attentive observer has link formly militated against the tormenting suspicion alluded to ; but still it prevails, though only to the injury of those who ought, for their own sakes, to be persuaded to the contrary. Every man long in business, has known many instances of mothers, tormenting themselves for six or seven months, in the painful apprehension of discovering some sad blemish in the child, and on this account have trembled to look on it when it has come into the world, which has afterwards proved to be as perfect as they could have wished, and as the more dispassionate amongst their friends have all along ventured to foretell. On the other hand, where children have been born with some real blemish, it has not been suspected by the mother,* unless now and then in a most timid person, (who * Among several instances of such blemishes in children born in the British Lying-in Hospital, we have had some remarkable ones ofthe entire ignorance of any supposed cause. In one, the infant was more marked than almost any one I had ever seen ; but I shall notice only that the eyelids, part of the nose and temple, and the greater part of one of the cheeks, were as black as ink, and ex- actly resembled a dry gangrene of the parts. In another instance, the extremities were uncommonly ill-formed, not unlike those of aquatics; but the mothers of these infants had gone on to their full time, without having received any fright they could recollect, or suspecting anything amiss in their children. These children, however, were really so disfigured, that a lively imagination, 30* 354 UNDERWOOD ON CHILDREN. has always bred in fear on account of one disagreeable object or other she had seen,) or else the blemish has turned out to be some- thing perfectly irrelative to it. And here it ought to be noticed, that where a child has really been marked, and the mother has insisted on her having seen, and been frightened by an object which the blemish has resembled, it has (to the best of my know- ledge at least) appeared always to be an after-thought, by which the supposed occasion of it has been discovered, and has not been taken notice of beforehand; whilst other women have borne chil- dren considerably disfigured, who have recollected no alarm or disappointment whatever. It is, however, the furthest from my thoughts to upbraid the sufferer on this painful occasion. I wish only to obviate the influence of a sentiment that I take to be with- out foundation — a sentiment that has originated in ignorance, and to which nothing but length of time and prescription could have given a sanction. That there are blemishes which bear a resemblance to various objects around us, daily experience has proved; though the precise occasion of them is not, perhaps, understood. The like deviations from the ordinary course is observed, not only in various other animals,* and that not unfrequently, but also in the vegetable kingdom; in which the supposed influence can have no place. Thus, fruits are often joined together and discoloured, having ex- crescences, and odd shapes, offering strange representations resem- bling animals, as well as anomalous irregularities, similar to those found on the bodies of infants ; all, doubtless, proceeding from the established laws of motion, though not well understood by us. In regard to various discolorations in the skin of infants, fancied to resemble fruits, and like them becoming of a deeper red in sum- mer, it may, however, be in point to observe, that the epidermis is, in such kind of marks, frequently altogether wanting, and if not, is always thinner than on other parts. The small bloodves- with a mind strongly impressed, might not only have conceived in them a great resemblance to many objects, but it is more than probable, that the parents must have actually noticed not a few such, during the period of gestation. Where any such deformity, therefore, may actually have taken place, practitioners may argue the point with their patients, and endeavour to persuade them that such sights have not been the true cause of it, and that such objects, therefore, cannot contribute to the production of the like appearances another time. In this view, I cannot help observing, that a few years ago a lady of rank acquainted me, that she had passed almost the whole term of gestation in the apprehension of her infant being born with a hare-lip, on account of her having been daily met by a labourer, working in her own grounds, who had such a blemish. In this instance, the imagination seemed to have done its utmost, as the lady conceived she met with this man oftener than any other, and that she could not avoid him, walk whichsoever way she might; and in consequence had his image continually be- fore her, either in reality or in recollection ; and being kept under a continual alarm by it, in the end declined walking at all in the garden. After the opinion I have advanced, it may be needless to add, that her child was born free from the apprehended, or any other, blemish. * See Mr. John Hunter on the Free Martin. ON THE HARE-LIP, ETC. 855 sels being also more numerous, or nearer the surface, the discolora- tion of the skin becomes a natural consequence, nor can it be any wonder that this discoloration should be greater in summer than in winter, the cutaneous vessels being then more turgid with blood. The like change takes place in every mark on the face, when the person either cries or is made angry, or when by any other means the blood is made suddenly to ascend to or rest longer than usual in the superior parts. All such appearances are, therefore, very easily accounted for, without supposing them the consequence of the parent having longed for such fruits as ripen, or grow red, in the summer months. We observe also similar changes in adults from long- continued severe exercise, or hard drinking; many people, before of a fair complexion, suddenly acquiring a red face, or have the nose both discoloured and misshaped. The laws of motion will also equally account for the mutilation, and want of parts, the growth of which is somewise interrupted : it being well known, that the several members and parts of the body are not all formed or unfolded at once, but are pushed for- ward in their turn after some established law of nature, and organic matter. If, therefore, a due proportion of nourishment be with- held from any part, its proportionate growth is suppressed, or its formation entirely prevented. The like process takes place in flowers; —thus, if a rose-bud, for instance, be blighted, some of its leaves are found curled up, and the flower turns out ill-shaped; or perhaps it is so much injured, and the bud so far withered, that only a few leaves appear, the rest being never completely formed, or unfolded. Hence, the hare-lip; the two sides of the face, which are said to be formed separately, being hereby prevented from growing together ;* the upper lip is, at least, one of the last parts that come into coalition. For the like reason it is, that infants come into the world with large ventral hernise, the muscular pa- rietes, and especially the skin, being one of the last processes in the embryo.t But whatsoever may be the weight of these observa- tions, there is certainly nothing that we know of in a fright or longing that can produce such a change in organized matter, or can operate in the manner that has been supposed, much less at such different periods ; but there is, on the other hand, everything against such an hypothesis ; which has accordingly always given way in enlightened ages. It is well observed by Dr. Blondel, that were a due catalogue drawn up of all the irregularities discovered at the birth, that are supposed to proceed from the mother's imagination, they would appear to be the same over and over again, with no great differ- ence, and very capable of being reduced into certain classes. Does not this intimate that they proceed from the laws of motion, and * For further remarks on this subject, the reader is referred to a paper written by Mr. Lucas of Leeds, in the Memoirs of the Medical Society of London, vol. iv. f Harvey, Exer. 56 and G9. 35G UNDERWOOD ON CHILDREN. the structure of the organs ? There are besides many considerable deformities, which are never referred to the imagination, viz., the irregular conformation of the viscera, &c. Is the whole empire of the microcosm so divided between Nature and the Imagina- tion, that one rules within, and the other governs the outward parts ? The foetus is also a distinct individuum; it has the circulation of the blood independent of the mother; its own genus nervosum; a separate secretion of juices, and all the functions of animal eco- nomy in itself. On this account, we see a feeble mother bearing a very strong and lusty child, and vice versd ; the mother being to her infant, what the earth is to a plant: the latter being strong, may not be injured by being moved into a very different soil: or being tender, may, or may not, be benefited by it. Children have likewise diseases of their own while in utero, such as cataract and gutta serena, varices, aneurisms, hydrocephalus; they are born blind, deaf, &c. The instance so often adduced from the sacred historian in oppo- sition to such arguments,* is by no means in point; for without adverting to the very peculiar physical circumstances in that trans- action, which are wanting in ordinary instances, it is sufficient to observe, that there was therein an evident supernatural interposi- tion. Should any one in this sceptical age doubt of this, he has only to make a similar experiment, the result of which will, pro- bably, have more weight than ten thousand arguments.t As mat- ter of fact, therefore, as before observed, does not at all countenance, but directly contradict the hypothesis, there is good ground for married women being argued out of such fears, and delivered from that painful conflict for weeks and months together which so many of them endure. It will give me great pleasure if anything I have advanced on the subject should answer so desirable an end; whilst reason, philosophy, experience, and everything on which we ought to depend, conspire to support such an attempt.^ Amongst the various marks resembling some of the objects around us, that called the Hare-lip is the most common; a blemish therefore too well known to require a formal description. It is sufficient to observe, that it is of two kinds: the simple, wherein the upper lip only is divided, either wholly or in part, with some loss of substance ; and the complex, in which the fissure ofthe lip is double: in some instances, the portion between the fissures is * Genesis, chap. 30, ver. 37—42. f Though I have ventured to say this, it is probable, there was also a coinci- dence of circumstances, although not in the manner vulgarly conceived of. For many critical and satisfactory remarks, however, on the above passage of holy writ, the more curious reader may consult a learned tract, on the Strength of the Imagination in Pregnant Women, written by Dr. Blondel, a Member of the Col- lege of Physicians, anno 1727. X Mr. Lawrence has published a very instructive and elaborate paper on the subject of deviations from the ordinary formation of parts, in the fifth volume of the Medico-Chirurgical Transactions. — S. M. ON THE HARE-LIP, ETC. 357 likewise too small to fill up the cavity, and in some it adheres to & ver/ tlp of the nose 5 and in a few instances, both lips are affected ; the upper jaw, also, with the palate of the mouth, and even the uvula are sometimes divided. It would be beside my purpose to treat of the manner in which this deformity and defec- tion is to be remedied, especially as that must vary considerably in different cases ; I shall confine myself to speaking only of the time in which it ought to be attempted. Various considerations contribute to make the distressed parent solicitous to have this blemish removed soon after the infant is born, or at furthest before the month shall be expired. On this account, I am convinced, the operation has sometimes been pre- maturely performed, contrary to the better judgment of the ope- rator, and the child has thereby fallen a sacrifice ; whilst others have received much less benefit than they would have done had the operation been postponed for a reasonable time. Where the blemish is very trifling indeed, and the operation simple, it may, in many cases, be done with safety in the course of the month, or a little after ; and if the child be able to suck, which is not always the case, there are even some advantages in performing it sooner. For as the child will not be able to suck for two days at least after the operation, it will with difficulty be kept tolerably quiet by the spoon after it has been once put to the breast; but as infants need but very little nourishment for the first days after birth, and gene- rally sleep a good deal, if the operation be done twenty-four hours after the child is born, it will be in a condition to suck by the time it requires much nourishment, and the mother's breast is prepared to furnish it. But in the complex hair-lip the case is exceedingly different, the longer the operation is postponed, the better it is likely to succeed; and it should be deferred till the child shall be, at least, four or five months old. By this time, also, the infant will have got over the period in which it is peculiarly liable to several pain- ful and dangerous complaints ; will be thoroughly weaned from its hankering after the breast, and have learned to feed contentedly with the spoon; by which children with this kind of hare-lip are obliged to be supported, they being generally unable to suck. At this period likewise, the parts will have acquired such a size as will admit of handling them to greater advantage, as well as a degree of firmness necessary to retain the needles; for the want of which, though the operation may appear to have been favourably performed, the needles will sometimes break out, and the deformity be but little removed, or perhaps sometimes increased. I have once seen another blemish of the mouth, in a child born at the hospital, which required a similar operation. In this infant, the mouth was much wider on one side than on the other, and appeared as if it had been divided far into the cheek, which occa- sioned a very awkward appearance ; but as it was capable of being remedied in the same manner as the hare-lip, I shall only observe, that when I withdrew the pins on the third day, the parts adhered very firmly, and the child left the hospital at the usual time. 358 UNDERWOOD ON CHILDREN. DISCOLOURED SPOTS.--N.ZEVI. Amongst other blemishes that may require surgical assistance, are those which women are wont more especially to call marks ; being spots, more or less elevated above the surrounding skin, and of various forms and colours. These may fall on any parts of the body, but are very little regarded except when found on some uncovered part, especially the face, where, perhaps, this kind is most commonly met with. These, however, vary so much in shape, size, and in some other more important circumstances, that it were nugatory to attempt to point out the precise operation adapted to many of them. Suffice it to say, that in some, excision of the discoloured and elevated parts, or destroying them by caustic, is the only remedy ; in others, compression alone is sufficient; and in a few,compression, together with slight puncture and caustic will be called for; though in the lips particularly, compression alone will frequently be sufficient, if proper attention be paid to it. In some parts of the face, as the cheeks, lips, the nose, and near the eyes, the knife or lancet must be had recourse to with caution ; though whenever made use of, it will be necessary to carry them full as deep and far, as the dis- tempered vessels may happen to extend, or the operation will not be completely successful. It is indeed sometimes necessary to repeat it; and it would, in many instances, be better to do so, than to risk, in the first operation, destroying any sound parts unneces- sarily, by which the scar might be extended. Where great cau- tion has been found necessary, it will sometimes happen, that though the blemish may seem to have been fully removed, the redness and tumour will after some months return ; but even here, as a touch with the argentum nitratum, after lightly scarifying the parts, or at most, the carrying the lancet a little deeper than at first, will perfect the cure, it were a pity it should be neglected, distress- ing as the idea of a second operation must be to the parents ofthe infant. In some instances, however, the recurring elevation as well as discoloration of the part, when slight, have gradually subsided without a second operation ; which it may be proper to defer for some months : an instance of which I once saw, where a second operation had been advised by the late Mr. Hunter. From the very great advantages derived from these means, in some very unpromising cases that I have been witness to, I have been led to offer these remarks; and not doubting that other practitioners have seen the like, 1 wish to impress the idea of consulting some skilful surgeon upon every great blemish; persuaded that many parents will, in the event, have occasion to be thankful for such consultation. [The principal modes of the cure of vascular naevus, which have been hitherto tried, are,— 1, the application of cold and pressure, proposed by Mr. Abernethy ; 2, vaccination by Mr. Hodgson ; 3, excision, by Mr. J. Bell; 4, the ligature, by Mr. J. Bell, Mr. White, DISCOLOURED SPOTS. — NJEVI. 359 and Mr. Lawrence ; 5, the application of the potassa, bv Mr. Wardrop; and G, the ligature of the principal artery which sup- plies the na2 vus. The first of these modes of treatment is usually insufficient; the second is only applicable to superficial nsevi, and frequently induces ulceration or sloughing, and eventually a scar ; the third is frequently dangerous from hemorrhagy, and proved fatal in one instance even in the hands of Mr. Wardrop ; the fourth is attended by extreme pain, and in one case there were convul- sions ;* the fifth must be liable to the same objections : all these remedies, except the first, leave a scar, and are totally inapplicable in many cases of diffused or deeply-seated naevus; the ligature of the artery is at once a formidable and unsuccessful operation. To this list of remedies must be added the tartar emetic ointment, the nitric acid, &c. The same observations apply to them. Their application is attended with pain, and followed by a scar. The question is, can we devise a mode of treatment in these cases, which shall, without the danger of inducing ulceration or sloughing, be efficient in the cure, applicable to all circumstances and localities of the disease — to parts not admitting of pressure, and to parts so deeply seated as to be removed from the action of vaccination, and not to admit of the ligature or of excision? All these objects may, I think,be attained by a simple operation: this operation is calculated to induce the slow adhesive inflammation in parts of low vitality, avoiding the destructive processes of ulcera- tion or sloughing ; it is applicable to any part not admitting of pres- sure, as the eyelid, the lip, the tongue, the labia pudendi, this auxi- liary not being required for hemorrhagy, or any other event, or for the cure ; and it may be carried deeply, to parts adjacent to an artery, to bone, &c. It only requires to be done thoroughly, to be repeated often enough, and to be followed by sufficient delay for processes, neces- sarily slow, to be established and completed. It seems long to wait weeks and months for the completion of nature's operations. Yet it is distinctly proved that that which cannot be accomplished in the present case, in one month, or in two months, is so in six. And if any part be left uncured, the remedy is as simple as it is easy and efficacious. I cannot have the slightest doubt that the most formidable cases would be cured by the per- severing repetition of this trifling operation every two months. And when this statement is contrasted with those in which the formidable operations of the ligature of the artery, of the ligature, or excision of the tumour, and of the application of the caustic potassa, are detailed, it must, I think, be admitted that the propo- sition for the cure of naevus, by mere punctures, or slight incisions, is not without its value. The mode of cure to which I have alluded, consists in passing a needle of moderate but sufficient size, and with cutting edges, through the naevus, so frequently as to induce the adhesive inflam- * Med. Chi. Trans, vol. ixt p. 203 ; vol. x. vol. xiii. 430. 300 UNDERWOOD ON CHILDREN. mation with the deposit of lymph, and so as to obliterate and con- solidate the vessels of which it is composed, yet so seldom as to incur no risk of inducing sloughing. The needle must be passed in several directions from one point in the circumference of the naevus, to several points more or less opposite. These punctures or incisions must be made near the surface in the superficial arte- rial naevus ; but in a place more or less deeply seated, in cases of the deeper capillary naevus. The operation must be repeated at distinct intervals of two, three, or four months, according to the state of the case, and progress of the cure ; this is not of the slightest consequence, for the operation neither inflicts pain nor occasions hemorrhagy of any moment; or the whole nasvus may be divided at two distinct operations, by severing alternate portions, after any convenient interval of time. The object of this proposition is to avoid pain, hemorrhage, and scar. Its principle is this: to substitute cicatrix for the naevous tissue. In fact, whatever may be done, sacrificing the skin, may be done preserving it, whether this be accomplished by punctures, incisions, or even by ligature. The sole difficulty in the proposi- tion is the length of time required for nature's operations: patients and even surgeons are unwilling to wait, and wait they must, if the cure depends upon the establishment of adhesive inflammation and the deposit of lymph. — M. H.] IMPERFORATE VAGINA. The vagina is sometimes imperforate on the external, at others only in the more internal parts; and in different degrees. The latter more commonly relates only to the hymen, which, requiring an operation to be performed about the age of puberty, I shall do no more than barely mention here, especially as it requires only a simple or crucial incision, and to preserve the orifice open. Where the imperforation is in the substance of the vagina itself, I have never found an operation to be of any use, though I have known it attempted, in the adult, with great address and resolution. I have never met with the external parts totally imperforate, there being always a small opening at the meatus urinarius ; but I have found the aperture to the vagina so very small as to require a little operation, which is mighty easily done with the point of a lancet, there being always a raphe, or line, directing the extent nature has seemed originally to intend; which being cut through, requires only that the parts be kept asunder for a few days, by a bit of fine lint. This has been the usual mode of remedying this defect: but I have, for some years, altogether rejected the assistance of the lancet, the parts being very easily separated by the fingers even in children of several years old. It is not improbable that the like method might succeed, though the operation should be neglected till the time of puberty, the parts seeming rather to adhere in con- IMPERFORATE ANUS. 361 sequence of some very slight inflammation, than to have been originally ill-formed. A mere oozing of blood is perceived in con- sequence of this mode of separating the labia, which in the present instance, at least, seems preferable to incision, and may possibly afford less pain to the infant, as well as be less unpleasant in idea to its parents. It is in this instance peculiarly important, that practitioners in midwifery, and others attending at the birth, should examine in- fants very attentively in regard to this complaint, which may be otherwise overlooked ; the defect proving no obstacle to the natural excretions. I have met with several instances* of it in children from three to six years old, in whom the complaint was but newly discovered, and it has been, in others, neglected to the time of pu- berty, and even of marriage, and must then prove of serious con- sequence, and may even be attended with hazard :t though I met with one instance in which nature alone overcame it in the hour of labour. The rectum likewise is sometimes found opening into the vagina ; a case that affords but little prospect of relief. It should, however, be attempted; but the kind of operation must depend so much upon circumstances, that it cannot be here pointed out with any precision. IMPERFORATE ANUS. The anus is sometimes closed only by a thin membrane, so that the day after birth the meconium may be distinctly felt, and in a manner seen shining through it. ZuingerusJ reports such a case, which was relieved by only a slight puncture, with a lancet, and passing the point of a finger into the bowel, for two or three days afterwards : — a bougie would be a more proper instrument. But more commonly the imperforate anus is a melancholy case, as it seldom allows of an effectual remedy, the gut often termina- ting in a cul-de-sac so high up as not to be reached; it is not, how- ever, always to be despaired of, though no fluctuation of the intestinal contents should be felt for two or three days after the infant is born. * In these cases the malformation was probably of recent date. In the grea majority of instances of vaginal closure, which have fallen under my observation, 1 have been quite satisfied that the membrane closing up the parts, was not con- genital, but adventitious, arising from excoriation ofthe labia, and ending in the adhesion ofthe inflamed parts. In one case the inflammatory adhesion had com- pletely closed up the pans for more than twenty-four hours, during which time the child had not passed a single drop of urine. This was the only case in which I have ever found it necessary to use a scalpel, for the purpose of dividing the parts. In other cases there is one small opening, at least, into which a probe may be passed, and the adhering edges are easily broken down by it. This clo- sure has been absurdly mistaken for an imperforate hymen. Mr. Howship in his Observations in Surgery and Morbid Anatomy, gives an accurate history of the closure ofthe labia. f See Henrici a Mornishen Observationes Medico-Chirurgicse. Dresdee, 1691. t Theodor. Zuingerus, Basilcse. 1722. o i 362 UNDERWOOD ON CHILDREN. Though this sad defect is not very uncommon, I remember only two cases ofthe kind in live-born children at the British Lying-in Hospital.* One of these it fell to my lot to attend, and I happened to succeed, contrary, indeed, to all expectation, and after the child had puked up a great quantity of meconium; and not only the belly, but also the face, was become exceedingly tumid, and the eyes had not been opened for some time. The manner of doing this operation must, in different cases, de - pend so much on the discretion of the operator, that I shall do no more than describe that which I made use of in the instance alluded to ; and this may, possibly, be acceptable, as the operation is not often performed with success.t It may be previously observed, that it ought to be postponed as long as it safely can, that the de- pending part of the bowel may be distended, and pushed as low down as possible ; the reason for which is sufficiently obvious : and to this delay I am much inclined to attribute the success with which it was followed in the operation I performed. This was not determined upon by my colleagues till the thir day. A longitudinal incision was then made, of about half a d inch, above and below the part where the anus ought to have been, which was marked by a little excrescence; a small bistoury was afterwards thrust up in the usual direction of the bowel for more than an inch. No meconium following this puncture, I ex- amined carefully with my finger, and feeling something like the fluctuation meconium would make, I introduced a trocar, and withdrawing my finger, I carried up the instrument in such a direction as to avoid injuring the bladder, or forcing the point against the os coccygis, for near an inch further ; making allow- ance, however, for the yielding of the parts, which might be some- what forced up by the trocar. The instrument having now passed forwards without that resistance it had hitherto met with, gave me * It has fallen to my lot to have seen ten or twelve cases of imperforate rec- tum in infants at the birth. In several of these cases it was found very difficult to prevail upon the parents to allow of an operation, and in two instances, the operation was absolutely forbidden. In several of these cases the delay of the operation appeared to be the principal cause of its failure. But I attribute the failure more frequently to the mode of operating, which was generally by passing a trocar, sometimes of too small a size, into the rectum ; this never failed to give a temporary relief to the symptoms, by procuring an evacuation of the meco- nium, but the aperture could seldom be kept properly open, though bougies and sponge tents were used to preserve a passage. In one instance of this kind, the child lived six months, and then died, with an immensely distended ab- domen. f In two cases a perfect cure was effected ; these children were both operated upon by the late Mr. Chevalier, who with a scalpel made a very free incision through the integuments, till he distinctly felt the fluctuation of meconium in the rectum; he then carried his instrument through the membranous expansion, or pouch, in which, in these cases, the rectum generally terminates ; taking care, effectually, to divide it by a crucial incision ; thus completely destroying its valvular structure. Both these children recovered without difficulty, and possessed the faculty of retaining, or expelling the fseces, nearly as well as if no malformation had ever existed. One of them is now fifteen years of age — S. M, IMPERFORATE PENIS. 363 the sensation of having entered a cavity ; when withdrawing the trocar, we had the satisfaction of finding the meconium running out at the canula. The child was now put into a warm-bath up to the waist, and in a few minutes, having voided a considerable quantity of meconium, it opened its eyes, looked cheerfully about it, and fell into a pleasant sleep before it was taken out of the bath. A piece of bougie was occasionally introduced, and sometimes left in the part for a few hours, for the first fortnight; after which the child recovered fast, and at the usual time was taken from the hospital in pretty good health, though it had been much reduced by a bad thrush, which unfortunately made its appearance soon after the operation; but it always voided its stools perfectly well.* IMPERFORATE PENIS. The imperforate penis is not quite so common a case ; but is not unfrequently suspected when the aperture of the passage is merely stopped up by a little mucus ; and should therefore be 'examined in good time. In this case washing the part with warm milk and water, or at most a little assistance with a small probe, or any such blunt-pointed instrument, will be sufficient to open the passage. But it is evident, if the urethra be wanting, no operation can be undertaken : it is, however, more commonly found open a certain way, and often as far as the basis of the glans, and sometimes near to its extremity; in which last instance, it is necessary only to make a small aperture with a lancet, or a fine trocar, and to keep the part open by the occasional introduction of a slender bougie. The more common complaint of this part, however, is that of the urinary passage terminating by a small aperture at a little distance below the glans, and sometimes on one side of it. In these cases, the precise circumstances must determine the propriety of any operation: which, if not judiciously nianaged, may render the case worse than it was. I recollect two, indeed, in which I was able to do considerable service, one of which was in the presence of the late Sir Caesar Hawkins, and the other of the late Dr. Hunter; in the latter, the urine was discharged from the side of the penis, and pretty low down, which was very happily remedied. There are other malformations of this part, by which it is drawn onwards, or to one side ; the peculiar circumstances of which must point out the nature of the operation most likely to afford relief. This will generally consist in a simple incision of the skin where it may happen to be too tight or short, and keeping the divided edges at a distance from each other, till the whole sore shall be healed; or sometimes by dividing the upper part of the prepuce, as in the paraphymosis. * A very curious case of imperforate rectum is recorded in the Memoirs ofthe Life and Writings ofthe late Dr. Lettsom, published by my friend Mr. Pettigrew. Kir T G Cullum, in one of his letters, (letter 30,) mentions a child, " who lived fiftv four days with an imperforate rectum. Notwithstanding the child lived so lorn* the intestines were not mortified, and scarcely inflamed. The faeces quite liquid of a good colour, and not the least appearance of meconium." 364 UNDERWOOD ON CHILDREN. SQUINTING. Another, and a very common blemish, is that called squinting, which is sometimes contracted by very young infants, and may then frequently be remedied, especially if confined to one eye ; but if a child be bom with this deformity, or if it be consequent to fits, it is not so likely to be removed. The means I have to recom- mend are indeed very simple. A very important one, however, is to apply a piece of sticking-plaster spread on some bright-coloured silk, in such a position, either on the temple or the nose, conform- ably to the side on which the eye is distorted, as may attract it the contrary way. In order to keep up this allurement, the colour of the silk ought to be varied from time to time, as well as its situa- tion, placing it a little higher or lower, both for the sake of change, that the skin may not be fretted, as well as to answer any other end, that a due observation on its effects may point out. Besides this, the child ought always to be placed with that side towards the light from which the eye is distorted ; and for the like reason, its parents, nurse, play-things, and every other object that can attract its notice, should as constantly as possible be on the same side, that the child may have every inducement its age and cir- cumstances will allow, to draw the eye the right way, and by early habit counteract a muscular action that is not yet become permanent. Another method more proper for older children, is covering the eyes with ogles, which are glasses fixed in a little case, such as many people wear when they ride on horseback. They must be so placed that the child can see no object but by turning the eyes to the sides from which they are distorted. Or an opake covering of a similar form may be worn, with only a very small aperture in the centre, by which a child will be obliged to look straight forward. It is scarcely necessary to add, that these contrivances must be worn constantly till the bad habit shall be overcome. Where the cast is confined to one eye, it has been recommended to cover the other; whereby the infant will, in a little time, acquire the habit of directing the affected one more properly. After this, the sound eye should be gradually uncovered, so as to admit the light by degrees. The child, it is said, will by this means very soon be enabled to direct both eyes properly to the same object. To this end, likewise, such children may be made to look at their own eyes in a mirror for a few minutes several times in a day; but with the precaution that each eye be directed to that which cor- responds with it in the glass ; contriving, somewise, to render this remedy a kind of amusement. I shall only add on this head, that children who are inclined to squint ought not to be exposed to a very strong light nor learn to read very young. INDEX. Abdomen, diseases within the, 157 Ague, 257 Air, cold and damp, hurtful, 31-34 ----ability to bear it, 32 ----close, fatal to children, 32 Alimentary canal, disorders of, 138 Anasarca and ascites, 301 Anus, imperforate, 361 Aphonia spasmodica intermittens, 186 Aphtha gangrenosa, 124 Aphtha?, or the thrush, 118-24 Atrophia lactantium, 215 Bath, cold, 25-27 ---- tepid, 194 Blister, for crusta lactea, 129 Bloodletting, rules for, in infants, 242 Bottle for feeding children, 45 Bowels, retention and excretion of the, 73 Breath, signs from the, 86 Breasts, tumid, of infants, 98 Bronchitis, treatment of, 292 Chorea sancti viti, remedies in, 186 Cold, a means of restoring infants still- born, 15, 16 ----its injurious effects, 33-5 ----a cause of laryngismus stridulus, 285 Cold bath, 25-6 ----its disadvantages, 27 Complexion in disease, 80 Convulsive affection of children, 111 Constipation and wind, disorders from, 114 Convulsions, 164-74 -----------causes of, 166, 173 ----------. in dentition, 195 __________. cured bychange of air,167 Copper, sulphate of, in gangrenous sore mouth, 322 Coryza maligna, 104 Costiveness, how remedied, 73 Coughs, 260 Countenance, signs from, 79 ------------convulsive, 80 Cradle, remarks on, 60 Croup, inflammatory, 277 ------spasmodic, 270 ------secondary, 273, 286 Crusta-lactea, 128 Crying, a healthful exercise, 74 Cry, signs from the, 85 Cupping advantages of, over leeching, 199-200 Cynanche parotidea, 222 Deafness, 318 Debility of lower extremities, 327 Deformities of children, 67-71 Dentition, 189 _________period for beginning, 190 Calomel, small doses of,in diarrhcea,149 , in cholera infan- tum, 155 ------in hydrocephalus, 220-30 ------in mesenteric fever, 207 ------in croup, 282 Cancrutn oris, 321 Cardialgia, 141 Carminatives and cordials, bad effects of, 106 Causes, predisposing, of infantile dis- eases, 88-9 Chafings, or intertrigo, 97 Cholera infantum, 153-6 Chorea sancti viti, 186 366 INDEX. Dentition, progress and order of, 191 --------anomalous symptoms in, 192 ——----treatment of diseases from, 193-8 ■--------how aided, 195 Diarrhoea, 142 --------■ important signs in, 149 --------caused by improper food,152 Diet adapted to different complaints, 49 Diptheritis, 286 Discoloration of new-born infants,91-2 Discoloured spots, 358 Diseases, early detection of, 75-86 Dressing, tight, injurious to infants, 28-30 Dropsy, treatment of, according to dis- eased organ, 303 Dysuria, 301 Earache, 319 Ears, sore, danger of suddenly drying up, 137 ----abscess within the, 319 Electricity, a means of resuscitating infants still-born, 15,17 Encephalocele, 338 Epileptic fits, 183 ------------best remedies in, 185 ------------prevention of, 185 Erysipelas infantile, 102 Essera, or nettle-rash, 132 Exercise, kinds of, for children, 61-4 -------- premature, injurious, 62 Exhaustion, a cause of hydrocephalus, 235-8 Febris scarlatina, 216 Feeding children, 45, 53 Fever, 198 ------eruption on the skin, 204 ------remittent, 205 ------typhous, 206 ------mesenteric, 207 ■------hectic and marasmus, 213 ------scarlet, 219-21 ------miliary, 220 Foetus, its own diseases, 356 Food, excess of, injurious, 52 Funis umbilicus, unkindly separation of the, 333 ---------------fungus of the, 333 Galvanic, or electric shocks to restore suspended animation, 17 Gangrenous sore mouth of children,321 Gangrenous erosion of the cheeks, 322 Gangrenous affection ofthe pudendum, 323 Gastritis, 141 Gestures, indications of disease, 81 Glottis, spasm ofthe, 281 Gonorrhoea, purulent, 336 Gums, cutting ofthe, 195 Hare-lip and other blemishes, 353 Heat, necessary to infant's health,35-6 Head and spine, tumours of the, 341 Hemorrhage,from cutting fra;num,329 -----------from navel, 331 -----------from nose, 329 Hepartomphalos, 350 Hernia ofthe brain, 338 Hernia ventralis, 350 Herpes circinatus,or phlyctsenodes, 310 ------exedens, 310 ------miliaris, or zoster, 311 Hooping-cough, 261 Hordeolum steotomatum, 317 Hydrocephalus, 224 ------------■ causes of, 226 —----------— symptoms of, 227 ------—----caused by exhaustion, 234-7 Hydro-rachitis, 342 Imperforate anus, 361 ----------■ penis, 363 Incubus, or night-mare, 187 Infants, still-born, 13 ------ means of restoring, 14, 17 ------ washing of, 25 ------ first clothing of, 28 ------ diet for, when sick, 49 ------weaning of, 57 ------ mortality of, 48, 65 Infancy, a hazardous period, 48 Inoculation, 247 Intestinal mucous membrane, ulcera- tions of, in mesenteric fever, 213 Inward-fits, 108 ----------pathology of, 113 Irritability with hydrocephalus, 241 Ischuria vesicalis, 303 Jaundice, infantile, 99 Lancing the gums, 195 Laryngismus membranacea, 277 ------------stridulus, 279, 284 Leeches, danger from, to infants,240 Lienteria, or watery gripes, 150 Lungs, means of distending, 14, 17 ------irritation from, in teething, 194 ------tubercles in, with mesenteric fever, 208 Marks of the mother inquired into, 353 Measles, 245 Meat and drink for infants, 37 Meningitis, spinal, 345 INDEX. 367 Meconium, retention ofthe, 93-6 Milk diet, 40-44 Motion and rest, 61 Mother, an observer of infantile disease, 76-7 ------ought to suckle her own child, 23-4, 38-9 Muguet, 119 Mumps, 226 Nsevi, 358 ---- modes of cure of, 359 Navel, hemorrhage from, 331 ------soreness, or ulceration of, 332 Nose, hemorrhage from, 329 Nursing, dry, 18 Opium, danger from, in infants, 106-7,143 Ophthalmia, 311 ----------purulent, 313 ----------in alms-houses, 314 ----------venereal, 316 Otitis, 320 Paralysis, 174 Paralysis ofthe lower extremities, with spinal curvature, 324 Passions, a cause of disease, 74 Pemphigus infantilis, 133 Penis, imperforate, 363 Peritonitis with fever, 212 Pertussis, 261 --------with peripneumony, 263 --------change of" air for, 263 --------sketch of treatment of, 266-7 ---------diet in, 268 Phlyctamae, 133 Pityriasis capitis, 309 Postures, production of deformity,67-70 Prepuce, tumefaction of the, 333 •Pressure in spina bifida, 346 Prolapsus ani, 334 Psora, or grocer's itch, 134 Psoriasis infantilis, 134 Psorophthalmia, 316 Pudendum, gangrenous affection of the, 323 Purging for infantile eruptions, 136 ------ useful in diarrhoea, 147 ------ in intermittent aphonia, 187 ------ in dentition, 193 ------ in fever, 206, 210 Rachitis, or rickets, 292 Respiration, means of restoring, 14,17 Respiration, signs from, 84 Ring-worm, 310 Scald head, 307 Scalp, tumours of the, 339 Scrofula, 297 ------long alterative course required for the cure of, 300 Scurfiness ofthe head, 309 Serpigo, 310 Singultus, or hiccough, 188 Skin, eruptions on the, 125 Skin-bound, 176 ----------pathology of, 180 Sleep, indications of disease in, 82 ---- and watching, 59 Spices and carminatives,objection to,50 ♦Spina bifida, pressure in, 342-6 Spinal meningitis in spina bifida, 345 Spinal curvature, 295-6 —-----------with paralysis of lower extremities, 324 Spinal column, means of preserving it erect, 326 Spleen, enlargement of, 257 Spirituous and fermented liquors inju- rious to wet-nurses, 54 Squinting, 364 Sternutatio, or sneezing, 188 Stomatitis, follicular, 118 Stomach, gelatiniform softening of,141 Stools, incontinence of, 154 Strophulus, or red-gum, 126 -----------from syphilis, 127 Stye, or stithe, 317 Suckling, duty and advantages of, 18-24,38-41 -------a prevention of sore breasts,20 Suffocation from swallowing the point of the tongue, 329 -------- and from hemorrhage, 329 Suffocatio stridula (croup), 270 Swallowing boiling water, 289 Swelling of hands and feet in dentition, 192 Swine-pox, 256 Swing cot, 61 Symptoms of first diseases of children, 90 Syncope, or fainting, 91-2 Testicles, swelling of, after mumps,223 Tetanus, 181 Thorax, diseases of, how to be divided, 292 Tinea, 307 Tobacco, fatal effects of lotion of, 308 * This has been practised with success in hydrocephalus. Puncturing and evacuating the fluid has, also, been successful in many cases of this disease. 368 INDEX. Tongue, signs from the, 85 ------ cutting the fraenum of, 328 Tooth-rashes, 130 Tormina, or gripes, 142 Tracheotomy in croup, 276 Tumours of the scalp, 339 --------after labour, 340 --------of the head and spine, 341 Tussis spasmodica, 268 --------------:— endemic, 270 Typhus, 206 Urine, retention of, 72 ■ incontinence of, 304 Urticaria, 132 Vaccination, 252-6 ----------age for, 255 Vaccine inoculation, 249 Vagina, discharges from the, 335 Vagina, imperforate, 360 Varicella, or chicken-pox, 253 Variola, 243 Varioloid, 252 Variolous and vaccine virus, identity of, 254 Vermifuges, 164 Vigiliae, or watchings, 117 Vomiting, causes and cure of, 138-40 --------from over-feeding, 139 Weaning, preparation for, 58 Weaning-brash, 153 Wet-nurses, choice of, 53 __________spirituous and fermented drink injurious to, 54 ---------- mortality among the chil- dren of, 21 Wine, objections to its use, 49 Worms, 153 THE END. July, 1843. Stantrartr Wottte ON ANATOMY, MEDICINE, SURGERY, AND THE COLLATERAL SCIENCES. PUBLISHED BY ED. BARRINGTON & GEO. D. HASWELL, Medical Publishers and Booksellers, PHILADELPHIA. NEW W03BKS AMB IIW JEBMHIOHS. ANDRAL'S CL.INIC, Complete. THREE VOLS. 8vo. Consisting of— DISEASES OF THE ENCEPHALON, DISEASES OF THE ABDOMEN, DISEASES OF THE CHEST. Either ofthe works can be had (separate,—-each forming a distinct yolume. " The ' Clinique Medicale' is the great work of its distinguished author. It is an immense storehouse of invaluable information in pathology and therapeutics. No medical library can be complete without it; and every physician, with the smallest pretensions to scientific at- tainment, or who is desirous of discriminating disease accurately, and of treating it skilfully, should study its pages by day and night." EVANSON 6l MAUNSELL. PRACTICAL TREATISE ON THE MANAGEMENT AND DIS- EASES OF CHILDREN. By Richard T. Evanson, M.D., Professor of Medicine,— and Henry Maunsell, M.D., Professor of Midwifery in the Col. of Surgs. in Ireland. From the 4th Dublin edition. Edited by D. F. Condie, M.D. 1 vol. 8vo. 96 2 STANDARD MEDICAL WORKS PUERPERAL FEVER. THE HISTORY, PATHOLOGY, AND TREATMENT OF PUER-> PERAL FEVER AND CRURAL PHLEBITIS. By Drs. Gordon, Hey, Armstrong, and Lee; with an INTRODUCTORY ESSAY by Charles D. Meigs, M.D., Professor of Obstetrics and the Diseases of Women and Children in the Jefferson Medical College, Philadelphia. 1 vol. 8vo. "We have peculiar satisfaction, in announcing the publication of this very judiciously arranged series of treatises, on one of the most important and interesting diseases, which demand the attentionofthe physician." "Dr. Meigs'Introductory Eesay is concise and judi- cious, and will be read with profit. He Speaks in the highest terms of commendation of Dr. Gordon's invaluable: treatise — a treatise which cannot be too generally diffused and studied. Altogether this volume presents the most acceptable and useful compend of the doctrines and practice of the best authorities, with regard to ' Puerperal Fever,' with which we have ever met."—2V. Y. Lancet. " We are pleased to see the republication of these valuable monographs upon Puerperal Fever. As they are all of them Essays founded upon an extensive observation, and contain a very large number of recorded cases, they must always be valuable."—New England Jour. Med. Scien. " Taken in connexion, the treatises it comprises present an invaluable mass of facts in relation to Child-bed Fever, without an acquaintance with which no one can, with propriety, be considered fully qualified to undertake its management."—Jour. Med. Scien. DIGESTION. DERANGEMENTS, PRIMARY and REFLEX, of the ORGANS of DIGESTION. By Robert Dick, M.D., author of " A Treatise on Diet and Regimen." 1 vol. 8vo. "It is the fullest, most comprehensive, and decidedly the best account of derangements of the digestive organs that wo nave encountered. While it embraces all that is important or interesting to be found in the writings of other authors, it contains much original informa- tion, which the physician will find of great practical usefulness.'—Western, and Southern Medical Recorder. " We recommend this volume most warmly to the attention of our readers.—London Lancet, No. 937. " This volume may, in fact, be denominated with no small degree of propriety, an ency- clopedia of dyspeptic disorders, and we unhesitatingly commend it, as the most useful and comprehensive treatise on this class of diseases with which we are acquainted."—N. Y.Lancet. " We have perused this work with pleasure and instruction. It is decidedly the best compilation in the English language on the extensive class of disorders and diseases comprehended under the term dyspepsia, united with a very large proportion of original matter, both in the form of able comments on ether writers, and practical information derived from the author's own experience.—Johnson's Medico-Cliirurg. for Jan. 1843. SEMEX01067. OUTLINES OF PATHOLOGICAL SEMEIOLOGY. Translated from the German of Professor Schill. With copious notes by D. Spillman, M.D., A.M., &c, &c. 1 vol. 8vo. " An elegant and accurate translation of a very ingenious and instructive work. We do not know any other source from which we can so easily and profitably obtain all that is really useful in the semeiology of the ancients; and the erudite translator and editor has so very creditably supplied the deficiencies of the author's abrige of the labors of modern workers, in this most important department of modern science, that we can in good con* science commend the book as one of unequivocal merit.—Atto York Lancet. MEDICAL EXPERIENCE. CURIOSITIES OF MEDICAL EXPERIENCE. By J. G. Mn> lingen, Surgeon to the Forces, Member of the Medical Society of the Ancient Faculty of Paris, etc., etc. " Curiosities of Medical Experience. By J. O. MilIiitoen, Surgeon to the Forces, etc. The Author or Coropilri derived the idea which prompted him to write this work from D'Israeli's'Curiosities of Literature;' and, in our view, he has made a book equally curious in its way with that one. The heads of his chapters arc numerous and varied, and all his subjects are treated in an agreeable and Comprehensible style to the general reader. The drift of the Author, too, is decidedly useful. We shall endeavour to give some extracts from this work."—JVat. Gaz. PUBLISHED BY BARRINGTON AND HASWELL. 3 MATERIA MEDICA. A PRACTICAL DICTIONARY OF MATERIA MEDICA, includ- ing the Composition, Preparation and Uses of Medicines ; and a large number of Extemporaneous Formulae: tbgether with important Toxi- cological Observations; on the Basis of Brande's Dictionary of Materia Medica and Practical Pharmacy ,• by John Bell, M.D., Lecturer on Materia Medica and Therapeutics, &c. &c. 1 vol. 8vo. , "Mr. Brande's is an excellent work, and with the retrenchments, additions,' and altera- tions of Dr. Bell, may be regarded as one of the most valuable works on the Materia Medica we now possess. It has an important advantage over many of the treatises on this subject, ingivinga large number of prescriptions for the administration of the principal articles. This renders it especially valuable to the young practitioner." —Bait. Jour. A THERAPEUTIC ARRANGEMENT and SYLLABUS of MATERIA MEDICA. By James Johnstone, M.D., Fellow of the College of Physi- cians, and Physician to the General Hospital, Birmingham. " This book cannot but be particularly useful to those who intend to lecture or write upon the Materia Medica: as well as to the students for whose particular use it is pre- pared."—Brit, and For. Med. Rev. LIVER AND SPLEEN. DISEASES OF THE LIVER AND BILIARY PASSAGES; by William Thomson, one of the Physicians of the Royal Infir- mary of Edinburgh; and CLINICAL ILLUSTRATIONS. OF THE LIVER AND SPLEEN, by William Twining; Surgeon of General Hospital of Calcutta, &c, &c. 1 vol. 8vo. " The work before us is an excellent compilation of the subject of hepatic affections. functional and structural; and, as such, it is infinitely more valuable to practitioners ana students, than any original essay, however ably executed. We cannot do better, therefore, than strongly recommend the work as the best in the English language, on the important subjects of which it treats.—Medico-Chirurg. Rev., October, 1841. " These two works, when united, form, we may safely say, one Of the most valuable and attractive volumes on this important class of diseases which have been issued from the press. We may, en passant, remark, that the volume is got up in a very superior style."— N. Y. Lancet, March 26, 1842. CLINICAL REMARKS ON SOME CASES OF LIVER ABSCESS PRESENTING EXTERNALLY. By John G. Malcolmson.M.D. Surgeon Hon. E. I. C. Service, Fellow of the Royal Asiatic Society, and the Geological Society, London, 1 vol. 8vo. VENEREAL. HUNTERS TREATISE ON THE VENEREAL DISEASE. With Notes by Dr. Babington. With Plates. 1 vol. 8vo. "Under the hands of Mr. Babington, who has performed his task as editor in a very exemplary manner, the work has assumed quite a new value, and may now be as advantageously placed in the library ofthe student as in that of the experienced sur- geon."—Brit. 8c For.Med. Rev. A PRACTICAL TREATISE ON~VENEREAL DISORDERS, AND MORE ESPECIALLY ON THE HISTORY AND TREATMENT OF CHANCRE. By Philippe Ricokd, M.D., Surgeon to the Venereal Hospital at Paris. 1 vol. 8vo. GRAVES 6l GERHARD. CLINICAL LECTURES; by Robert J. Graves, M.D., M.R.S.A., Professor of the Institutes of Medicine in the School of Physic. Trinity College, Dublin, with additional Lectures and Notes, by W. W. Gerhard, M.D., Lect. on Clin. Med. to the Univ. of Penn., Physician to the Philadelphia Hospital, Blockley, etc. 1 vol. 8vo. «In the volume before us, a series of clinical lectures by Dr. Gerhard is given, and forms a most appropriate and acceptable addition to those of Dr. Graves. Between these two dis- tinguished physicians we can trace many points of resemblance. We find in both the same rlrSpaiional zeal — the same powers of close and correct observation, —the same discnmi- nat ne tact -the same disregard of idle theory,-and the same decision in the application of right principles. No student or practitioner should be without this volume. It is in itself a library of practical medicine."—N. Y. Lancet. 4 STANDARD MEDICAL WORKS DISEASES OF CHILDREN. A TREATISE ON THE DISEASES OF CHILDREN; WITH DIRECTIONS FOR THE MANAGEMENT OF INFANTS; by the late Michael Underwood, M.D. From the ninth English edition, with Notes, by S. Merriman, M.D., and Marshall Hall, M.D., F.R.S., etc. ; with Notes, by John Bell, M.D.. etc., of Philadelphia. 1 vol. 8vo. JETIOLOGV. ARET.EUS ON THE CAUSES AND SIGNS OF ACUTE and CHRONIC DISEASE. From the Greek, by T. F. Reynolds, M.B., F.L.S., &c, &c. 1 vol. 8vo. " The correct detail of symptoms, the nervous style, the graphic delineation of disease, displayed in this author's work, the poetic and quaint fancies scattered throughout, give a certain value and interest, that may fairly excuse an attempt to reinvest part of them in a vernacular garb." " We certainly have no hesitation in recommending this curious volume to the notice of our readers. Its price is a mere trifle."—New York Lancet. EVES. A MANUAL OF THE DISEASES OF THE EYE. By S. Littell, Jr., M.D., one of the Surgeons of the Wills' Hospital for the Blind and Lame, &c, &c. "We confidently recommend the work of Dr. Littell to the senior, as well as to the junior, members ofthe profession. It is replete with information; yet so terse in style, and compressed in bulk, as at once to entice and repay perusal. It is no small triumph to the author to be able to say that he has introduced almost all that is valuable, and everything absolutely necessary to the student within the compass of 200 pages, and we would deliberately recommend our young friends to read this work."— Br. e\ For. Med. Rev. GU1VES. THE GUMS; with late Discoveries on their Structure, Growth, Connections, Diseases, and Sympathies. By George Waits, Member ofthe London Royal College of Physicians. 1 vol. 8vo. TEETH. A TREATISE ON THE TEETH. By John Hunter. With Notes by Thomas Bell, F.R.S. With Plates. 1 vol. 8vo. " The treatise on the teeth is edited by Mr. Bell, a gentleman accomplished in his art. Mr. Bell has studied his subject with the greatest minuteness and care; and in ap- propriate notes at the foot of the page corrects the author with the air of a gentleman, and the accuracy of a man of science. The matter contained in these short notes forms an ample scholum to the text; and without aiming at the slightest display of learning, they at the same time exhibit a ready knowledge on every point, and an extensive in- formation both of comparative anatomy and pathology.—Med. Ouiette. CONSTIPATION. A TREATISE on the CAUSES and CONSEQUENCES of HABITUAL CONSTIPATION. By John Bdrne, M.D., Fellow ofthe Royal College of Physicians, Physician to the Westminster Hospital, &c. 1 vol. 8vo. " For some interesting cases illustrative of this work, the author is indebted to Dr. Williams, Dr. Stroud, Dr. Callaway, Mr. Morgan, Mr. Taunton, Dr. Roots, Sir Astley Cooper, Sir Benjamin Brodie, Mr. Tuppcr, Mr. Bailer, Dr. Paris, Mr. Dendy, Dr. Hen. U.Thomson," Sec—Preface. CHEST. LECTURES on the PHYSIOLOGY and DISEASES of the CHEST, including the Principles of Physical and General Diagnosis, illustrated chiefly by a rational Exposition of their Physical Signs: with new re- searches on the sounds ofthe heart. Br Charles J. B. Williams, M.D. Third edition, 1 vol. 8vo. « w'denlly writlen bv a man thoroughly acquainted with his subject."—Lancet. «ti Sir°nsly- recommend this work to the attention of auscultators."—Med. Chir. Rev. V gladly avail myself of this opportunity of strongly recommending this very valuable wor£- —-Dr. Forbes's Translation of Laennec. nr 9 JiXl tne w°rks °n this subject, we are inclined much to prefer that of Dr. Williams."— Med. Gaz. LECTURES ON THE DIAGNOSIS, PATHOLOGY, AND TREAT- MENT OF THE DISEASES OF THE CHEST. .By W. W. Gerhard, M.D., Lecturer on Clinical Medicine in the University of Pennsylvania, etc., etc. 1 vol. 8vo. "A series of clinical lectures —concise, lucid, and eminently instructive. We have no more able expositor of diseases ofthe chest than Dr. Gerhard, and any work of his on these important subjects is certain of grateful acceptance by his professional brethren."—New York Lancet. " To our readers, therefore, we recommend the book of Dr. Gerhard as the fullest and most judicious manual, in relation to the diseases of the chest, which they can procure."— Western and Southern Recorder, June, 1842. " These lectures constitute a useful and practical digest of the existing knowledge of the diseases of the chest (lungs and heart)."—Bulletin of Medical Science. A PRACTICAL TREATISE onlhe PRINCIPAL DISEASES of the LUNGS. Considered especially in relation to the particular Tissues affected, illustrating the different kinds of Cough. By G. Hume Weatherhead, M.D., Member of the Royal College of Physi- cians, Lecturer on the Principles and Practice of Medicine, and on Materia Medica and Therapeutics, &c. &c. 1 vol. 8vo. PRACTICAL OBSERVATIONS on~DISEASES ofthe HEART, LUNGS, STOMACH, LIVER, &c, OCCASIONED by SPINAL IRRITA- TION: AND ON THE NERVOUS SYSTEM IN GENERAL, AS A SOURCE OF ORGANIC DISEASE. Illustrated by Cases. By John Marshall, M. D. 1 vol. 8vo. CUTANEOUS DISEASES. A PRACTICAL TREATISE ON DISEASES OFTHE SKIN, arranged with a view to their Constitutional Causes and Local Character, &c. By SAMUEL PLTJMBE, late Senior Surgeon to the Royal Metropolitan Infirmary for Children, &c. Illustrated with Splendid Coloured Copper- plate and Lithographic Engravings. 1 vol. 8vo. Plumbe on Diseases of the Skin.—" This excellent Treatise upon an order of diseases, the pathology of which is, in general, as obscure as the treatment is empirical, has just been republished, edited by Dr. John Bell, of this city. We hail with pleasure the appear- ance of any new work calculated to elucidate the intricate and ill-understood subject of skin-diseases. The late Dr. Mackintosh, in his Practice of Physic, recommends it as the ' best pathological and practical treatise on this class of diseases, which is to be found in any language.' "—Phil. Med. Exam., Jan. 17, 1838. " This work is one of the most excellent on the Diseases of the Skin in the English language."— West. Jour, of Med. and Phys. Sciences, Jan. 1838. PHYSICAL AGENTS. ON THE INFLUENCE of PHYSICAL AGENTS on LIFE. By W. F. Edwards, M.D., F.R.S., etc. Translated from the French, by Drs. Hodgkin and Fisher. To which are added, some Observations on Elec- tricity, and Notes to the work. 1 vol. 8vo. " This is a work of standard authority in Medicine; and, in a physiological point of view is pre-eminently the most valuable publication of the present century ; the experi- mental investigation instituted by the author, having done much towards solving many problems hitherto but partially understood. The work was originally presented in parts to the Royal Academy of Science of Paris, and so highly did they estimate the labours of the author and so fully appreciate the services by him thus rendered to science and to humanity, that they awarded him, though a foreigner, the prize founded for the promotion of experimental physiology. 6 STANDARD MEDICAL WORKS TETANUS. A TREATISE ON TETANUS, being the ESSAY for which the Jackson ian Prize was awarded by the Royal College of Surgeons in London. By Thomas Blizard CuKLiNG.Assistant Surgeon to the London Hospital,&c. " This book should be in the library of every surgeon and physician. It is a valuable work of reference. It does not pretend to originality, for originality on such a subject was not wanted. But a compendium of facts was wanted, and such a compendium is this volume. We cannot part from Mr. Curling without thanking him for the information we have received in reading his work, and for the matter it has enabled us to offer to our readers."—Medico-Chir. Rev. BLOOD, INFLAMMATION, ETC. TREATISE ON THE BLOOD, INFLAMMATION, AND GUN-SHOT WOUNDS. Br John Hunter, F.R.S. With Notes, by James F. Palmer, Senior Surgeon to the St. George's and St. James's Dispensary, &c, &c. 1 vol. 8vo. LECTURES ON BLOOD-LETTING. By Henry Clutterbuck, M.D. 1 vol. 8vo. HISTORICAL NOTICES ON THE OCCURRENCE OF INFLAMMA- TORY AFFECTIONS OF THE INTERNAL ORGANS AFTER EXTERNAL INJURIES AND SURGICAL OPERATIONS. By William Thompson, M.D., &c. &c. 1 vol. 8vo. A TREATISE ON INFLAMMATION. By James Macartney, F.R.S., F.L.S., &c., &c. Member of the Royal College of Surgeons, London, &c, &c. 1 vol. 8vo. LECTURES ON THE BLOOD, and on the CHANGES which it undergoes during DISEASE. By F. Magendie, M.D. 1 vol. 8vo. ANIMAL (ECONOMY. OBSERVATIONS ON CERTAIN PARTS OF THE ANIMAL CECO- NOMY, Inclusive of several papers from the Philosophical Transactions, &c. By John Hunter, F.R.S., &c, &c. With Notes by Richard Owen, F.R.S. lvol.8vo. MIDWIFERY, LECTURES ON THE PRINCIPLES AND PRACTICE OF MID- WIFERY. By James Blundell, M.D. Edited by Charles Severn, M.D. 1 vol. 8vo. Just published. " The eminently fluent and agreeable style —the large and accurate information —the great experience — and original mind of Dr. Blundell have secured for him a very enviable reputation as a public lecturer. It is impossible to read these lectures without being deli»htcd — U. is equally impossible to avoid being instructed. Were these discourses more gene'rally diffused and studied here —were their sound and judicious directions recollected and their salutary cautions observed, we would hear of fewer cases of malpractice. This work forms a complete system of midwifery, with the diseases of the puerperal state and ofthe infant.''— N. Y. Lancet. A PRACTICAL TREATISE on MIDWIFERY; Containing the Results of Sixteen Thousand Six Hundred and Fifty-four Births, occurring in the Dublin Lying-in Hospital. By Robert Collins, M.D., Late Master of the Institution. 1 vol. 8vo. "The author of this work has employed the numerical method of M. Louis ; and by accurate tables of classification, enables his readers to perceive, at a glance, the conse- quences of the diversified conditions, in which he saw his patients. A vast amount of information is thus obtained, which is invaluable to those who duly appreciate precision in the examination of cases."—Bait. Chron. A PRACTICAL COMPENDIUM OF MIDWIFERY; being the Course of Lectures on Midwifery and on the Diseases of Women and Infants delivered at the St. Bartholomew's Hospital by the lale Robert Gooch, M.D. Prepared for Publication by George Skinmer, Member ofthe R. Coll. of Surg., Lond. 1 vol. 8vo. PUBLISHED BY BARRINGTON AND HASWELL. 7 ARMSTRONG'S LECTURES. LECTURES on the MORBID ANATOMY, NATURE, arid TREAT- MENT of ACUTE and CHRONIC DISEASES, By the late John Armstrong, M.D.; Author of " Practical Illustrations of Typhous and Scarlet Fever," &c. Edited by Joseph Rix, Member of the Royal Col- lege of Surgeons. J vol. 8vo. !Fw British and Foreign Medical Review savs of this work: We admire, in almost every page, the precise and cautious practical directions; the striking allusions to instructive cases; the urgent recommendations ofthe pupil to be careful, to be diligent in observation, to avoid hurry and heedlessness, to be atten- tive to the poor. Nothing can be more excellent than the rules laid down for all the parts ofthe delicate management of fever patients: nothing more judicious than the general instructions arising out of the lecturer's perfect knowledge of mankind...... His prudent admonitions respecting the employment of some of the heroic remedies, as mercury, arsenic, and colchicum, attest his "powers of observation and his practical merits." " The pious office of preserving and publishing his Lectures has been performed by Mr. Rix, with singular ability." INSANITY. A TREATISE on INSANITY and other DISEASES AFFECTING the MIND. By James Cowles Prichard, F.R,S, M.D. Corresponding Member ofthe Institute of France, &c. 1 vol 8vo. " The author is entitled to great respect for his opinions, not only because he is well known as a man of extensiye erudition, but also on account of his practical acquaint- ance with the subject on which he writes. The work, we may safely say, is the best, as well as the latest, on mental derangement, in the English language."—Medico-Ckir. Rev. --- A TREATISE ON MENTAL DISEASES. By M. Esquirol. APHORISMS on the TREATMENT and MANAGEMENT of the INSANE: with considerations on Poblic and Private Lunatic Asylums, pointing out the errors in the present system. By J. G. Milxingen, M.D., late Medical Superintendent of Lunatic Asylum, Hanwell, Middlesex, &c. 1 vol. 8vo. "Dr. Millingen, in one small pocket volume, has compressed more real solid matter than could be gleaned out of any dozen of octavos on the same subject. We recommend bis vade mecum as the best thing ofthe kind we ever perused."—Dr. Johnson's Review. CLINICAL MEDICINE. MEDICAL CLINIC; or, Reports of Medical CASES: By G. Andral, Professor of the Faculty of Medicine of Paris, etc. Condensed and Translated, with Observations extracted from the Writings of the most distinguished Medical Authors: By D. Spil- lan, M.D., etc., etc.; containing Diseases of the Encephalon, &c. with Extracts from Ollivier's Work on Diseases of the Spinal Cord 3nd its Membranes. 1 vol. 8vo. MEDICAL CLINIC: DISEASES OFTHE ABDOMEN. By G. Andral, M.D., Professor to the Faculty of Paris, Member of the Royal Academy of Medicine, etc., etc. Condensed and Translated, with Observations, by D. Spillan, M.D., Fellow ofthe King and Queen's College of Physicians in Ireland, Member ofthe Association ofthe Fellows and Licentiates ofthe College of Physicians, aud Formerly Physician to the Dublin General Dispensary. 1 vol. 8vo. MEDICAL CLINIC: DISEASES OF THE CHEST. By G.Andral, M.D., etc., etc. Translated by D. Spillan, M.D., etc. 1 vol. 8vo. LECTURES on Subjects connected with CLINICAL MEDICINE. Bv P. M. Latham, M.D. Fellow of the Royal College of Physicians and Physician to St. Bartholomew's Hospital. "We strongly recommend them [Latham's Lectures] to our readers; particularly to pupils attending the practice of our hospitals."—land. Med. Gaz. 8 STANDARD MEDICAL WORKS SURGERY. ELEMENTS OF SURGERY, in Three Parts. By Robert Liston, Fel- low of the Royal College of Surgeons in London and Edinburgh, Surgeon to the Royal Infirmary, Senior Surgeon to the Royal Dispensary for the City and Couuty of Edinburgh, Professor of Surgery in the London University, &c. &c. Third American, from the Second London Edition, with upwards of one hundred and sixty illustrative engravings. Edited by SAMUEL D. GROSS, M.D., Professor of Surgery, Louisville Medical Institute. Author of Ele- ments of Pathological Anatomy, etc., etc. 1 vol. 8vo. "We must not forget to mention that the volume is rendered still more attractive by the addition of numerous wood engravings (some of them introduced by Dr. Gross), all finely executed. These will be found of very considerable advantage to the student, materially assisting him in comprehending the explanation of morbid structure. Another admirable feature, is the printing of the notes in type of the same size as that of the text. This obvi- ates almost entirely.whatever objections can be alleged against foot-notes.''—Western Jour. of Med. and Surg., Dec, 1842. " We are here presented with a republication of Mr. Liston's admirable and much praised work on Surgery, which has been subject to the alembic of a critical and learned friend, Dr. Gross. He has added ' copious notes and additions,' such as the progress of surgery in the United States demands in order to meet the wants of the surgeon. Professor Gross has also given an entire article on Strabismus, and another on Club Feet, which were wholly omitted in the English copies. They may be regarded important, inasmuch as they give a completeness to an otherwise unfinished treatise. The execution of the book is good; the paper firm, and well secured in the binding. The plates are uniformly well executed, and the impressions distinct."—Boston Med. and Surg. Jour. " In another essential feature this edition is greatly improved. With the principles is taught also with it the practice of surgery; and both morbid structure and operations are doubly described ; first by the author and editor, and next by the graver of tne artist."— Bull. Med. Scien. " Mr. Liston has seen much, thinks accurately, and speaks independently. From a volume written by such a man, more really valuable practical instruction is to be derived than from all the books that were ever compiled."—Western and Southern Med. Recorder. " This is a work of established reputation. It has gone through two editions In Great Britain, and the same number in this country. The additions of the American edition are copious, and add materially to the value ofthe work."—Amer. Jour. Med. Sciences. ''The author is bold and original in his conceptions, accurate in deductions, plain and concise in style; a combination of good qualities not often found united in a single volume. The notes and additions, by Prof. Gross, are well arranged and judicious, sup- plying some evident deficiencies in the original work."—Western Lancet. LECTURES OF SIR ASTLEY COOPER on the PRINCIPLES and PRACTICE of SURGERY, with additional Notes and Cases. By Frederick Tyrrell, Esq., Surgeon to St. Thomas's Hospital, and to the London Ophthalmic Infirmary. 1 vol. 8vo. LECTURES ON THE PRINCIPLES OF SURGERY. Br John Hunter, F.R.S. With Notes by James F. Palmer, Senior Surgeon to the St. George's aud St. James' Dispensaries, &c. &c. With Plates. 1 vol. 8vo. " We cannot bring our notice of the present volume to a close without offering our testimony to the admirable manner in which the editor and annotator has fulfilled his part ofthe undertaking. The advancements and improvements that have been effected, up to our own day, not only in practical surgery, but in all the collateral departments, are constantly brought before the reader's attention in clear and concise terms."— Brit. Se For. Med. Rev. ____________________________ JOHN HUNTER'S WORKS. THE COMPLETE WORKS OF JOHN HUNTER, F.R.S.,4 vols. 8vo., comprising his Lectures on the Principles of Surgery; A Treatise on the Teeth; Treatise on the Venereal Diseases ; Trea- tise on Inflammation and Gun-Shot Wounds; Observations on Certain Parts ofthe Animal GSconomy ; and a full and comprehen- sive Memoir. Each of the Works is edited by men of celebrity in the Medical Science, and the whole under the superintendence of Jas. F. Palmer, of the St. George's and St. James's Dispensary. This is the only complete edition ofthe works ofthe distinguished physiologist ever published in this country. "One distinctive feature ofthe present edition of Hunter's works has been already mentioned, viz: in the addition of illustrative notes, which are not thrown in at hazard, but are written by men who are already eminent for their skill and attainments on the particular subjects which they have thus illustrated. By this means, whilst we have the PUBLISHED BY BARRINGTON AND HASWELL. views entire of John Hunter in the text, we are enabled by reference to the accompanying notes, to see wherein the author is borne out by the positive knowledge ofthe present day, or to what extent bis views require modification and correction. The names of the gentlemen who have in this manner assisted Mr. Palmer, are guarantees of the successful performance of their task."— Med. Gaz. HYSTERIA. AN ESSAY ON HYSTERIA, being an analysis of its irregular and aggra- vated forms; including Hysterical Hemorrhage and Hysterical Ischuria. With numerous Illustrative and Curious Cases. By Thomas Laycock, House Surgeon to the York County Hospital. 1 vol. 8vo. UTERUS. LECTURES on the FUNCTIONS and DISEASES of the WOMB, by Charles Waller, M.D., Bartholomew's Hospital. ON DISEASES of the UTERUS and its APPENDAGES, by M. Lisfranc, La Pitie Hospital. ON DISEASES of the PUERPERAL STATE, by J. T. Ingleby, Edinburgh. 1 vol. 8vo. " We can very cordially recommend them as affording a concise and practical exposition of the pathology and treatment of a most important class of diseases, and which cannot be too attentively studied."—N. Y. Lancet. " The present volume contains a short and succinct practical account ofthe principal mor- bid states either of the functions or the structure of the womb, the best methods of dis- tinguishing them, and the means which experience has shown to be the most effectual in removing them. The reader will find that he obtains, in a small compass, a distinct view ofthe nature and treatment of each disorder."—Edinb. Med. and Surg. Journ. URINARY DISEASES. URINARY DISEASES and their TREATMENT. By Robert Wil- lis, M.D., Physician to the Royal Infirmary for Children, &c. &c. " We do not know that a more competent author than Dr. Willis could have been found to undertake the task ; possessing, as it is evident from his work that he does possess, an accurate acquaintance with the subject in all its details, considerable per- sonal experience in the diseases of which he treats, capacity for lucid arrangement, and a style of communication commendable in every respect."—Brit. 8r For. Med. Rev. AMUSSAT'S LECTURES on the RETENTION of URINE, CAUSED by STRICTURES ofthe URETHRA, and on the Diseases of the Prostate, translated from the French by James P. Jervey, M.D. EPIDEMICS OF THE MIDDLE AGES. EPIDEMICS of the MIDDLE AGES. From the German of I. F. C. Hecker, M.D., &c &c. Translated by R. G. Babington, M.D. F.R.S— No. I—THE BLACK DEATH IN THE 14th CENTURY. ■« Uprker's account of the' Black Death,' which ravaged so large a portion of the globe • thP fourteenth century, may be mentioned as a work worthy of our notice, both as 111 ,„•„;„» tnanv interesting details of this tremendous pestilence, and as exhibiting a curious specimen of medical hypothesis.'-Cye/o/»cdia of Practical Medicine-History of Medicine by Dr. Bostock. M No. IL—THE DANCING MANIA. i. n/roHVnl History has long been in need ofthe chapter which this book supplies; and .u Hoiwncv could not have been remedied at a better season. On the whole, the i i nutrht to he popular; to the profession it must prove highly acceptable, as con- volume «ug informatjoni touching an important subject which had almost been veymg somu ^.^ .^ oblivion ant[ we tnink that to Dr. Babington especial thanks .utterea i" naturalised so interesting a production. The style of the translation, y add is free from foreign idioms: it reads like an English original."—Land. suffered to are we may Med. Gaz. 10 STANDARD MEDICAL WORKS PHYSIOLOGY AND HYGIENE. ESSAYS ON PHYSIOLOGY AND HYGIENE; viz: I. Reid's Experimental Investigation into the Functions ofthe Eighth Pair of Nerves. II. Ehrenberg's Microscopical Observations on the Brain and Nerves (with numerous engravings). III. On the Combination of Motor and Sensitive Nervous Activity; by Professor Stromkyer, Hanover. IV. Vegetable Physiology. V. Experiments on the Brain, Spinal Marrow, and Nerves. By Prof. Maykr, of Bonn (with woodcuts). VI. Public Hygiene. VII. Progress of the Anatomy and Physiology of the Nervous Sys- tem, during 1836. By Professor Muller. VIII. Vital Statistics. 1 vol. 8vo. ANATOMICAL EXAMINATIONS. EXAMINATIONS in ANATOMY and PHYSIOLOGY; being a complete series of Questions and Answers; designed and intended as preparatory to Examinations at the different Medical Schools throughout the United States. To which are annexed, Tables of the Bones, Muscles, and Arteries. By Thomas Sydenham Bryant, M.D., Surgeon U. S. Army. "This is a very useful manual of anatomy. We have pleasure in recommending it to the favourable notice of students. They will find it of immense service in preparing for exami- nations."—2V. Y. Lancet. THE LONDON DISSECTOR, OR GUIDE TO ANATOMY; for the use of students : comprising a description of the muscles, vessels, nerves, lymphatics, and viscera of the human body, as they appear on dissection ; with directions for their demonstration. Re- vised and corrected by Edward J. Chaisty, M.D., &c. 1 vol. 12mo. " Although there are several of these dissecting-room companions, there is not one in the whole caulogue that wears better, from its intrinsic value, than the old London Dissector With the improvements of this excellent edition, carefully revised, it will prove a very economical as well as certain assistant; and it therefore commends itself to the student."— Boston Med. and Surg. Jour. STOKES AND BELL. LECTURES ON THE THEORY AND PRACTICE OF PHY- SIC. By William Stokes, M.D., Lecturer at the Medical School, Park Street, Dublin : Physician to the Meath County Hospital, etc., etc., and John Bell, M.D., Lecturer on Materia Medica and Therapeutics : Member of the College of Physicians, Philadelphia and of the American Philosophical Society, etc., etc. Second American Edition. 2 vols. 8vo. « The work has now assumed the form of a quite complete system of medicine, eauallv valuable as a text-book to the student, and a book of reference to the practitioner " » VV> know of no book of the kind which we would more readily place in the hands of a student or to which we would more readily refer the practitioner, for a hasty investigation of a sub! ject."—New £»». Quart. Journ. of Med. and Surg. "Stokes and Bell's Practice being among the best works extant on practical medicine will at once commend itself to the practitioners of our country. It is not goine too far in declare, that no physician, whether his experience be large or small, should be without thia work in his library; and, having it there, he should study its various parts with care and attention."— Western Lancet. * nimwaio »uu "A second edition of this work of established reputation, is sent out from the nresq nf Messrs. Barnngtonand tiaswell, Philadelphia. No change in the mind ofthe medical Dublir touching the worth of this very celebrated series of medical lectures, has been wrought bv the advent of later publications on the same subjects. It is just as popular as ever and we believe, at this moment, is exerting a far more extensive influence than was ever predicted by the warmest personal friends ofthe two learned authors. "—Boston Med. and Surg. Jour. The following is from the pen of a distinguished Professor in one ofthe Medical Schools in the West. "We cordially recommend the joint labours of two such distinguished musicians a*. Drs, Stokes and Bell to the notice ofthe medical profession. They win befoUnd tS em vlmJmrnaT^ PraCUCe 0f medical sciencedown t0 l"e P^scnt moment "-Lou",. PUBLISHED BY BARRINGTON AND HASWELL. 11 MISCELLANEOUS. OUTLINES OF GENERAL PATHOLOGY. By George Freckleton, M.D., Fellow of the Royal College of Physicians. OBSERVATIONS on the PRINCIPAL MEDICAL INSTITUTIONS and PRACTICE of FRANCE, ITALY,and GERMANY: with Notices of the Universities, and Cases from Hospital Practice: With an Appen- dix on ANIMAL MAGNETISM and HOMOEOPATHY. By Edwin Lee, Member of the Royal College of Surgeons, &c. J vol.Svo. " Mr. Lee has judiciously selected some clinical cases, illustrating the practice pursued at the different hospitals, and he has wound up the volume with an amusing account of animal magnetism and homoeopathy—those precious effusions of German idealty, for which we refer to the work itself.—Medico- Chirurg. Rev. BOUILLAUD ON ACUTE ARTICULAR RHEUMATISM IN GEN- ERAL. Translated from the French, by James Kitchen , M.D., Philada. MEDICAL AND TOPOGRAPHICAL OBSERVATIONS upon the MEDITERRANEAN and upon PORTUGAL, SPAIN, AND OTHER COUNTRIES. By G- R- B. Horner, M.D., Surgeon U. S. Navy, and Honorary Member of the Philadelphia Medical Society. With En- gravings. 1 vol. 8yo. " An uncommonly interesting book is presented to those who have any disposition to know the things medical in Portugal, Spain, and other countries," and" will doubtless be read, also, with marked satisfaction by all who have a taste for travels.—Bost. Med. and Surg. Jour. AN ESSAY ON DEW, and several Appearances connected with it, by William Charles Wells, M.D., F.R.S., etc. ON DENGUE; ITS HISTORY, PATHOLOGY, AND TREATMENT. By S. Henry Dickson, M.D., Professor of the Institutes and Practice of Medicine in the Medical College of S.C. HINTS ON THE MEDICAL EXAMINATION OF RECRUITS FOR THE ARMY; and on the Discharge of Soldiers from the Service on Surgeon's Certificate : Adapted to the Service of the United States. By Thomas Henderson, M.D., Assistant Surgeon U. S. Army, &c, &c. MEDICAL NOTES AND REFLECTIONS. By Henry Holland,M.D.; F.R.S., Fellow of the Royal College of Physicians, apd Physician Extra- ordinary to the Glueen. THE MEDICAL PROPERTIES ofthe NATURAL ORDER RANUN- CULACEyE,&c, &c. By A. Turnbull, M.D. Prof. HORNER'S NECROLOGICAL NOTICE OF DR. P. S. PHYSIC K ; Delivered before the American Philosophical Society, May 4, 1838. THE LIFE OF JOHN HUNTER, F.R.S. By Drewry Ottley. 1 small vol. 8vo. "In the summing up of Mr. Hunter's character, Mr. Ottley exhibits equal judgment and candour."—Brit. $ For. Med. Rev. ESS\Y UPON THE QUESTION. IS MEDICAL SCIENCE FAVOR- ABLE TO SCEPTICISM? By James W. Dale, M.D., of New- castle, Delaware. Pamphlet. METEOROLOGICAL REGISTER for the years 1826-30 ; from Observa- tions made by Surgeons of the Army and others at the Military Posts of the United States. Prepared under the direction of Thomas Lawsow, M.D., Surgeon-General U.S.A. 12 STANDARD MEDICAL WORKS, ETC. JUST PUBLISHED, PIL.CHER ON THE EAR. A TREATISE on the STRUCTURE, ECONOMY, and DISEASES of the EAR; being the Essay for which the Fothergillian Gold Medal was awarded by the Medical Society of London. By Geo. PiLCHER,late Lec- turer on Anatomy, and Lecturer on Surgery at the Theatre of Anatomy and Medicine, Webb St., Borough, and Senior Surgeon to the Surrey Dispensatory. First American, from the 2d London edition, with Notes and numerous illustrative Plates. " This is a most valuable treatise, illustrated with elegant plates, is a standard work, and must have a great sale in its present form. It tells all about the anatomy and diseases of the ear."—N. Y. Herald.__________________________________ In Press, PRINCIPLES and PRACTICE of MEDICAL JURISPRUDENCE. By John Bell, M.D. THE PHYSIOLOGY, HYGIENE, and PATHOLOGY of Persons engaged in pursuits requiring intense Mental Application. By D. Spillan, A.M., &c. CLINICAL LECTURES on SYPHILITIC DISEASES. By Richard Car- michael, M.R I. A.; President of the Medical Association of Ireland, &c PRINCIPLES of MEDICINE; Comprehending GENERAL PATHO- LOGY and THERAPEUTICS. By Dr. Williams, F.R.S. STOKES on the CHEST, new edition. ANATOMY and DISEASES of the URINARY and SEXUAL ORGANS. By G. J. Guthrie, F.R.S. CLINICAL REMARKS on DISEASES ofthe EYE, and on Miscellaneous Subjects, Medical and Surgical. By Dr. Hall, F.L.S. A MANUAL of MEDICAL JURISPRUDENCE. By A. Taylor, F.L.S. GUTHRIE on INJURIES ofthe HEAD, &c. LEE'S MIDWIFERY, with 200 Illustrations. ARAN'S PRACTICAL MANUAL ON DISEASES of the HEART and GREAT VESSELS. Translated from the French, by W. A. Harris, M.D. A TREATISE on BANDAGING and MINOR SURGERY; or, Hints on the Every-day Duties of the Surgeon. By H. H. Smith, M.D., Lecturer on Minor Surgery, Fellow of the College of Physicians, Member of the Phila- delphia Medical Society. Illustrated by Engravings. PRACTICAL MEDICINE. Illustrated by Cases on the most Important Diseases. Edited by John M. Gait, M.D. B. fy H. continue to publish THE SELECT RIEDXCAL LIBRARY AND BULLETIN OF MEDICAL SCIENCE. EDITED BY JOHN BELL, M.D., AT FIVE DOLLARS PER ANNUM, IN ADVANCE. Each No. ofthe Library will consist of one or more approved works on some branch of Medicine, including, of course, Surgery and Obstetrics. Every work in the Library will be completed in the number in which it is begun, unless the subject naturally admits of division; and hence the size of the numbers will vary. It will be done up in a strong paper cover, and each work labelled on the back; thus obviating the immediate necessity of binding. Subscribers will receive fourteen hundred pages of closely printed matter of Library in the year. The Bulletin of Medical Science will be published monthly, in num- bers of thirty-six pages. It will be supplied to the subscribers to the Select Medical Library without any additional cost, on their remitting^uc dollars, the subscrip- tion price of the Library for one year. Those who wish to take the Bulletin alone, will have it sent to their address for $1 per annum. Clubs will be furnished with six copies ofthe Bulletin for $5. Subscription. — FIVE DOLLARS per annum, in advance; and in no single instance, out of the principal cities, will this rule be departed from. Any person ordering Books to the value of Ten Dollars from the following list, and remitting the amount free of postage, will be entitled to the Bulletin for one year, gratis. LIST OF WORKS SUPPLIED AS SELECT MEDICAL LIBRARY Extras,-by Mail. Subscribers to the Library and Bulletin, and the Medical Faculty in general, are respectfully informed that the Publishers will furnish the following Works as Extras ; for which purpose they are stitched in thick paper covers, with strong elastic backs, similar to the regular numbers; they can be sent by mail at the Periodical charge for Postage, which is per sheet, if under 100 miles, l\ cent9, exceeding that distance, 1\ cents. To the name of each work is stated its number of sheets and the selling price; so that any gentleman desirous of having one or more Extras will, by remitting a note, (or order payable in Philadelphia,) be furnished, by return of mail, with whatever he may select, to the amount. The Post Office regulations on Periodicals are such that remittances can be made with little or no expense to Subscribers or Publishers,—the Postmaster enjoying the privilege of franking all such letters. N.B. Those works comprised within brackets are bound in one volume, and must be ordered as one Extra. LEE'S OBSERVATIONS on the PRINCIPAL MEDICAL INSTIL TUTIONS and PRACTICE of FRANCE, ITALY, and GER- MANY, &c, with an Appendix on ANIMAL MAGNETISM and ! HOMOEOPATHY. { JOHNSTONE'S SYLLABUS of MATERIA MEDICA. LATHAM'S LECTURES ON CLINICAL MEDICINE. A TREATISE ON TETANUS, by. Thomas B. Curling. BOUILLAUD ON ACUTE ARTTCULAR RHEUMATISM general. Translated from the French, by James Kitchen, M.D. PRACTICAL OBSERVATIONS on DISEASES of the HEART,^) . f LUNGS, STOMACH, LIVER, &c. By John Marshall. M.D., &c. f WEATHERHEAD on DISEASES ofthe LUNGS ; considered especi- }£ { $ 0 80 ally in relation to the particular Tissue affected, illustrating the different j £ kinds of Cough, _______________________ J I PRICHARD on INSANITY and other DISEASES affecting the MIND. 14 sheets. ...... 1 25 DAVIDSON and HUDSON'S ESSAYS on the SOURCES and MODE OF ACTION OF FEVER. 8 sheets. . . . .80 MACROBIN'S INTRODUCTION to the STUDY of PRACTICAL MEDI- CINE being an outline of the Leading Facts and Principles ofthe Science. 6 sheets. ....... 70 SIR JAMES CLARK on the SANATIVE INFLUENCE of CLIMATE. 8 sheets. ....... 80 14 Catalogue of Works supplied by Mail, CHANGES of the BLOOD in DISEASE. Translated from the French of M. Gibert, by John H. Dix, M.D., M.M.S.S. 3 sheets. . • 50 SIR CHARLES BELL'S INSTITUTES OF SURGERY. Arranged in the order of the Lectures delivered in the University of Edinburgh. 19 sheets. $1 50 EPIDEMICS of the MIDDLE AGES, viz. The Black Death and Dancing Mania; translated from the German of Hecker, by Dr. Babington, F.R.S. 7 sheets. . . . . . . . 0 60 The ECLECTIC JOURNAL of MEDICINE, by John Bell, M.D., from November, 1836, to October, 1837. 19 sheets. . < ; 2 00 PLUMBE on DISEASES of the SKIN; with splendid coloured Engravings. 17 sheets. • . . . . . . . 2 25 TURNBULL'S TREATISE on the MEDICAL PROPERTIES of the ) . f Natural order RANUNCULACEyE, &c. &c. j 5 THE GUMS j their Structure, Diseases, Sympathies, &c. By George XS < 0 85 Waite. An ESSAY on DEW, &c. By W. C. Wells, F.R.S. J c COLLINS'S PRACTICAL TREATISE on MIDWIFERY. 11 sheets. 1 25 EVANSON and MAUNSELL on the MANAGEMENT and DISEASES of CHILDREN. A new edition in press, shortly to be published. EDWARDS on the INFLUENCE of PHYSICAL AGENTS On LIFE : with observations on ELECTRICITY, &c. 10 sheets. . ; .100 HORNER'S NECROLOGICALNOTICEOFDR.P. S. PHYSICK."! . f IS MEDICAL SCIENCE FAVOURABLE TO SCEPTICISM ? | f | By Dr. Dale, of Newcastle, Delaware1. }Ji ON DENGUE; its HISTORY, PATHOLOGY, and TREATMENT By Prof. Dickson of S. C. f " 0 30 THE FOLLOWING ESSAYS ON PHYSIOLOGY AND HY-^| GIENE: — Reid's Experimental Investigation into the Functions of the Eighth Pair of Nerves. Ehre*nberg's Microscopical Observations on the Brain and Nerves; with numerous Engravings. On the Combination of Motor and Sensitive Nervous Activity; by Prof. Stromeyer, Hanover. Vegetable Physiology. } J « Experiments on the Brain, Spinal Marrow, and Nerves. By Prof. Mayer, of Bonn; with wood cuts. Public Hygiene. Progress of the Anatomy and Physiology of the Nervous System, during 1836. By Pro. Muller. Vital Statistics. REID on the FUNCTIONS of the EIGHTH PAIR of NERVES. , 125 FRECKLETON'S OUTLINES of GENERAL PATHOLOGY. 7 sheets. . 0 75 URINARY DISEASES, and their TREATMENT. By R. Willis, M.D., &c. 10 sheets. . . . . . . 1 00 MILLINGEN'S CURIOSITIES of MEDICAL EXPERIENCE. 15 sheets. 1 50 in the Select Medical Library,—extra. 15 ASRlL'^3I8EheeISAL CLIN1C: Di°e™*oftheE«cephalo», Spinal Cord, ^V^^ «** CHEST. By LECTURES on BLOOD-LETTIN^: l^Dr^lu^rbuck. 5 sheets, , "S^^T^n^^^^^^upo. the^MEDI- ?a£J?> H°rner'. WK^^^ Mif N123shLLECTURE^7he BLOOD '^*«*» Wv i>4W, 1 20 $2 00 1 75 0 65 1 00 1 25 2 00 '^Sff^yga^jSjf'ggig:by J°h- B:"> MD- .**■ f<« HOLLAND'S MEDICAL NOTES and REFLECTIONS. 16 sheets. . 160 ^EggSSf^ REGISTE^^^ YEARS 1826,, f HIANpT^v°n ^MEWCAL EXAMINATION of RECRUITS for the • ARMY; and on the Discharge of Soldiers from the Service on >%\ ° 65 Surgeon s Certificate: Adapted to the Service of the United States. By I " Thomas Henderson, M.D., Assistant Surgeon U. S. Army, &c., &c.J MACARTNEY on INFLAMMATION. 5 sheets. . . 0 m BURNE on HABITUAL CONSTIPATION-its Causes and Consequences. 4 SllcGIS" • ♦ • • t\ i*fc A PRACTICAL TREATISE on VENEREAL DISORDERS, &c, . ( By P. Ricord ofthe Venereal Hospital, Paris. [ - AMUSSAT'S LECTURES on the RETENTION of URINE, > f < 0 75 CAUSED by STRICTURES of the URETHRA, and on the Diseases » ] Ofthe Prostate. Translated from the French by James P. Jervey, M.D. J ** (. ESQUIROL on MENTAL DISEASES. ~] % [ AN ESSAY ON HYSTERIA. With numerous Illustrative and Curious \ 2 ) l 00 Cases. By Thomas Laycock. ^ j CLINICAL REMARKS on some Cases of LIVER ABSCESS pre-, f senting externally. By John G. Malcolmson, M.D., Surgeon Hon. E. I. | » C. Service, &c. I £ I THOMSON'S NOTICES of INFLAMMATORY AFFECTIONS (-= \ ° » of the INTERNAL ORGANS after EXTERNAL INJURIES and I _ SURGICAL OPERATIONS. J { The ECLECTIC JOURNAL of MEDICINE, by John Bell, M.D., &c, from November, 1839, to October, 1840. 20 sheets. ' . . . 2 00 GOOCH'S PRACTICAL COMPENDIUM of MIDWIFERY. 14 sheets. . 1 00 GRAVES'S CLINICAL LECTURES. Uith Notes and Fifteen addUional Lectures, by W. VV. Gerhard, M.D., Lecturer on Clinical Medicine to the Uni- versity of Pennsylvania, etc. 23 sheets. ... 2 50 16 Catalogue of Works supplied by Mail— extra. 2 so J£ i 1 75 with notes by S. Merriman, M.D., and Marshall Hall, M.~ F.R.S., &c, with notes by John Bell, M.D., &c. tion, SJj i 1 LECTURES ON THE FUNCTIONS AND DISEASES OF THE"") WOMB; by Charles Waller, M.D., Bartholomew's Hospital. « ON DISEASES OF THE UTERUS AND ITS APPENDAGES; 1$ . by M. Lisfranc, La Pitie Hospital. /-fS 1 1U ON DISEASES OF THE PUERPERAL STATE; by J. T. Ingleby j © Edinburgh, 1 vol. 8vo. J r- APHORISMS ON THE TREATMENT AND MANAGEMENT OF THE INSANE; by J. G. Millingen, M.D. 1 vol. 8vo. 4 sheets. . 0 38 A PRACTICAL DICTIONARY OF MATERIA MEDICA, Includ-""! ing the Composition, Preparation and Uses of Medicine; and a large « number of Extemporaneous Formula;: together with important Toxi- i $ j cological Observations; on the Basis of Brande's Dictionary of Materia ( "§ , 2 25 Medica and Practical Pharmacy: by John Bell, M.D., Lecturer on I Materia Medica and Therapeutics, &c.&c. 1 vol. 8vo. J OUTLINES OF PATHOLOGICAL SEMEIOLOGY. Translated from the German of Professor Schill. With copious notes by D. Spillman, M.D..A.M., &c, &c lvol.8vo. 9 sheets. . . . .100 ARET^EUS ON THE CAUSES AND SIGNS OF ACUTE AND CHRONIC DISEASE. From the Greek, "wT. F. Reynolds, M.B., F.L.S., &c, &c. 1 vol. 8vo. 4 sheets. . . . . .50 LECTURES ON THE MORBID ANATOMY, NATURE, AND") . TREATMENT OF ACUTE AND CHRONIC DISEASES. By | § the late John Armstrong, M.D., Author of ", Practical Illustrations Typhous and Scarlet Fever," &c. Edited by Joseph Rix, Member the Royal College of Surgeons. 1 vol. 8vo. r V I a> ofX£< Ad J0* I 2 75 BLUNDELL'S LECTURES ON THE PRINCIPLES AND PRACTICE OF MIDWIFERY. Edited by Charles Severn. lvol.8vo. 19 sheets. . 150 I NATIONAL NLM 010SCH5A 5 NLM010509585