REPORT

                 ON THE


Clink  far ^imm td  Cjnlken,

                HELD IN THE

     NEW YORK MEDICAL COLLEGE,

             SESSION  1860-61.

          WITH  ESSAYS

       ON SOME OF THE MORE IMPORTANT POINTS OF

INFANTILE  THERAPEUTICS.



         By A.  JACOBI, M.D.,
      PROFESSOR OF INFANTILE PATHOLOGY AND THERAPEUTICS.
          NEW YORK:
HALL, CLAYTON & CO., PRINTERS, 46 PINE STREET.
             1861. 
 
[From the American Medical Monthly for June, 1861.]
1.    REPORT.
   When, in the autumn of 1860, the Faculty of the New York Med-
ical College was reorganized, it was thought proper to teach several
branches of medical science separately.  Infantile pathology and ther-
apeutics was determined  upon to form a distinct part of medical in-
struction, and a special chair was established for that purpose.   The
large number of infantile  patients in general practice, the difficulty of
diagnosticating their diseases, the importance of physical diagnosis and
close observation applied to their ailments, the modification of physiolog-
ical, and therefore pathological actions and symptoms, in early life, the
care necessary in selecting the remedies and determining their doses in
diseases  of infancy and childhood, the occurrence of a number of dis-
eases exclusively, or almost so, peculiar to  early life, appeared to ren-
der this  course  exceedingly proper.  As a special study of infantile
diseases  has  been generally  acknowledged to be a necessity, the pro-
fession, in my opinion, has the right of, as well as interest in, knowing
in what manner and to what extent the proposed aim has been reached.
   The following report will show that the poor of this city and neigh-
boring places have not been slow in recognizing the help offered them.
A large number of neglected or obstinate cases were brought to the new
institution, some from great distances, to  be relieved or cured, and a
number of others  that had been  given up as hopeless were presented
for the purpose of obtaining a final opinion.  Thus the students of the
college have had the opportunity of seeing infantile diseases to a con-
siderable extent;  the more so, as particular care was  taken to accus-
tom  them to  diagnosis and selection of remedies.  Every single case
that was presented  in the two  clinical hours a week, was  given in
charge of a member of the advanced class, who had  to examine, re-
port, and prescribe, before any remarks were made by the teacher.
Then, at last, the  case was  commented upon for its  own merits, by
comparison with general experience, and with reference to the theoret- 
4
CLINIC  FOR  DISEASES OP  CHILDREN.
ical lectures; thus affording, if not a universal  knowledge  of every
disease, the meaus of learning  and exercising a universal  scientific
method.   I am pleased to say  that the attention and  regular attend-
ance of the class, and their eagerness to visit a number of  patients at
their homes, have  afforded abundant  proof  of their appreciation of
the opportunities offered.
   I intend in this paper to pass in review the cases presented as brief-
ly as possible.  Such remarks as had to be made  during the course, I
expect to condense and treat of separately at the end of this report.
I intend  by this means to express in separate articles my opinions as
given in a number of clinical lectures, particularly on subjects concern-
ing therapeutics; selecting, for instance, the use of depletion, mercurials,
anti-febriles, narcotics, etc, in diseases of the infantile age.  Thus I
hope  both to serve my pupils and to elicit the always welcome criti-
cism of the medical profession.
   Of the reported cases, all such as  either terminated fatally or were
not watched to their final recovery, will be mentioned; those in which
no report to the contrary is given, got well, or were improved.
   1. Solomon M., aet. 2 years.   Lobular pneumonia of left  upper lobe,
after measles.   Percussion dull  over left upper lobe, anteriorly, mucous
rales  on  the  same side; respiration more or less  vesicular  on right
side.  The exudation absorbing, and the child being anaemic and with
a frequent and small pulse from no local acute disease, the treatment
consisted  of sulph. cinch., 9j; div.  in p.  iii.,  a powder every  morning,
and  nutritious  diet.   The same treatment  was  continued for three
more  days, and followed by syr. iodid. of iron, ten drops three times a
day, in a tea-spoonful of ol. morrh.  No new exudation took place in
the lungs, and the child recovered in about a month.
   2. Catharine K., aet. 6 years.  Anamia; excoriations at the introi-
tus vagina?.   Is reported to have, in regular monthly intervals, a copi-
ous leucorrhoeal discharge for several days.   Ordered to return at the
time of the next discharge, and meanwhile to take pulv. ferri., gr. j.,
three  times a day.   Was presented after a fortnight, and reported  no
better.  The same sallow, cedematous appearance,  the same listlessness;
none of her discharges.   The same  treatment continued,  as was  the
recommendation of nutritious diet, fresh  air and cold water, the want
of which is deemed the only  cause of the patient's anemic condition.
She looked decidedly better  a fortnight afterwards, was stronger and
more  lively, and had a good appetite.   No  discharge.  All the out-
ward  symptoms had disappeared eight weeks after her being present-
ed for the first time. 
CLINIC  FOR DISEASES OF  CHILDREN.
5
   3. William H. T., aet. 1 year, 4 months.  Scrofulous diathesis from
birth.  Stomatitis, pneumonia left upper and right middle lobes, anterior-
ly.  Enlargement of liver.   Father is believed to have been syphilitic.
Both parents dead.   Child lives in bad circumstances,  and looks
emaciated and poor.  No muscular power, no fat.   Extreme dyspnoea.
Respiration hurried; meteorismus; external veins of thorax, abdomen
and head very much injected.  Dull percussion sound anteriorly over
left upper  and middle  right lobes; mucous rales  all over both lungs.
•Submaxillary and cervical glands swelled; some suppurating.   Pulse,
120; respiration, 60. Treatment: Fresh air, beef and milk.  R.—Sulph.
cinch., 9j., div. in p. iii.  D. S.: A powder every morning.  Presented in
about  the same condition,  after a week; part of the remedy not yet
taken, as the druggist  had told the attendant it was enough to kill
two grown men.   The same treatment  again ordered.  After three
days the symptoms less severe; hepatization still in left  upper lobe.
Smaller doses of cinch, given;  the child continued to get better until
a  new  fever set in about a week afterwards.   No new  physical symp-
toms found,  but as the  pulse was again  144, and respiration 44, and a
new attack of pneumonia dreaded, R.—Hydrarg. submur., oxysulph. an-
timon., aa. gr. vj., div. in p. aeq. xii.   D.  S.: a powder every two hours.
At the same time  a daily dose of sulph. cinch., gr. vj.|, and recom-
mended  to go  to  the  country.  Patient presented  after four weeks,
well, hearty, and stout.  No pulmonary or hepatic symptoms; ulcera-
tions around the neck closing;  appetite good.  Nobody able to recog-
 nize our former patient.  01. morrhuae.
   4. Wolf St., aet. 7 months.    Ulcerations of the folds of the neck,
with much loss of substance,  and  erythema  around anus; resulting
from uncleanliness  and# the  free external use of starch-powder, which
is  the  most frequent  cause  of  simple erythema  to be transform-
ed into deep offensive ulcerations.  Treatment: cold water instead  of
starch-powder;  application  to the ulcerations of R.—Sulph. cupri., 9j.,
aq.  §viii.  When presented after four days, the erythema round  the
anus was nearly gone, and  the sores granulating and filling up rapid-
ly.  Perfect recovery after  some weeks.
   5. Elizabeth L., aet.  14 weeks.  Syphilis hereditaria, roseola syphilit-
ica, rhagadesani et oris, ecthyma syphiliticum.  The mother has been syph-
ilitic for  four years, and is still under treatment.   Roseolous eruption
visible for the last  fortnight, of pink color, round, irregular, confluent,
from the scapulae down to the lower extremities.  Five or six ecthy-
ma pustules on  back and abdomen.   Superficial rhagades of both an-
gles of the mouth;  deep ones round the anus.  Treatment: submuriat. 
6
CLINIC  FOR  DISEASES OF  CHILDREN.
hydrarg., gr. \, three times a day;  no external applications.   A week
afterwards the eruption commenced  getting paler.   The  same  treat-
ment was continued for about ten weeks, the child gaining flesh and
strength from week to week.   About the end  of this  period the
child contracted on three spots of the occiput,  tinea favosa, the favus
fungi appearing in  large number under the microscope, and required
some seven or eight cauterizations with either concentrated acetic acid,
or nitrate of silver.
   6—1. Two sons of the same mother, boru before she was syphilitic,
aet.  4  and 15 years.   Scrofula.   Enlargement of the submaxillary
glands, upper lip, nose, belly, etc.  01. morrh., A table-spoonful three
times a day.
   8. Jane K., aet. 6 weeks.   Frenulum oblongalum, to such an extent
as to embarrass nursing.  Treatment: incision.
   9. Harry D.,  aet. 3 years,  6 months.  Bronchitis, general, and with
high fever.  Oxysulph. antim., gr. ii., pulv. h. digital, gr.j.,  every two
hours;  12 doses.
   10.  Jane D.,  aet. 9 months, sister of 9.   Bronchitis, with the same
symptoms.  Oxysulph. antim, pulv. h. digital., aa., gr. ss.,  every two
hours; 12 doses.   Both were reported to be better three days after-
wards.   Then took oxysulph. antim. alone every three hours, and were
brought back four days later, recovered.
   11.  Fred. D,  aet. 10  months.   Catarrhus intestinalis.   Submur.
hydrarg., gr vj., pulv.  Doveri, gr. iv., cret. praepar., 3ss., div. in p.
aeq., No. xii.  A powder every two hours.
   12.  Catharine W., aet. 6 years.  Pneumonia, left upper lobe, ante-
riorly and posteriorly.  Pharyngitis; sloughing of tonsils; foul breath;
small glandular swellings around the neck.   The girl  had measles
five months ago, and has been coughing ever since.   Respiratory mur-
mur tolerably normal over right lung; no dull percussion sound; oc-
casionally a mucous  rale.   Lower lobe of left lung  equally normal;
over the upper lobe, left lung, dull percussion sound, and mucous rales
in the bronchi;  little action of  the inspiratory muscles.   As the hep-
atization appeared to be in a  process  of absorption, it was deemed
advisable to leave it to itself and attend to the  pharyngeal affection.
The deep ulcerations on the tonsils, and the glandular swellings around
the neck, small  though they are now, arouse the suspicion of a diph-
theritic affection  having been present.  Treatment: chlorat. potass.,
§ss., aq. §vj., i table-spoonful to be taken every  two hours. Patient got
better  under this treatment; continued for a week, with  nutritious
diet.  Took afterwards, for a week, tinct. muriat. ferri, 12 drops every 
CLINIC  FOR DISEASES OF  CHILDREN.             7
four hours.   Was presented again ten days  later,  three days after
stopping taking medicine, with gastro-intestinal catarrh, apparently
from indigestion.   At this time no symptoms of pneumonia left.
   13. Patrick  McC,  aet.  11 years.   Conjunctivitis trachomatosa.
Treatment: Solid, sulph.  cupri, twice a week.
   14. William S., aet. 1 year, 7 months.  Catarrhus intestinalis.  Mild
case.   Tinct. opii camphor., gtt. x., every two hours.
   15. Henry Y., aet. 11  years, 6 months.   Tuberculosis,  left upper
lobe,  anteriorly.   Left subclavicular region sunk;  dull  percussion
sound; respiratory murmur diminished; no mucous rales.  Respiratory
murmur increased on the  opposite side.  Patient emaciated and pale,
thorax narrow.  History very defective.  No feverish disease known,
but is reported to have coughed for the last six weeks only (1)  Pa-
rents dead; father had  consumption.  Treatment:  01.  morrh.  §j.
daily.   Gymnastic exercise, to enlarge  the thorax  and extend  the
lungs.
   16.  Lena M., aet. 1  year,  3 months.  Arterial navus on the fore-
head, half a square inch in size.   By means of a small brush, the fol-
lowing  cautery:  R.—Hydrarg. bichloride 5j., collodii, §j., was  ap-
plied on October 2d, 5th, and 12th, with perfect success.
   17. John M., aet. 4 years, 6 months.   Catarrhus laryngeus et bron-
chialis.   Croupy cough; mucous rales all  over  the thorax; moderate
dyspnoea;  coughing paroxysms iu  the night.  As an expectorant, the
following mixture was given: R.—Muriat. amnion., extr. glycyrrh. aa.,
3iij., aq. §vj., M.   D.  S., \ table-spoonful every two hours.  Besides,
tinct. opii camph., \ tea-spoonful, was ordered to be taken every night
Reported to be well the following week.
   18. F. N., aet. 1 year,  6 months.   Conjunctivitis  scrofulosa, pannus
cornece of the left eye.  The boy is decidedly scrofulous; has glandular
swellings around his neck, and is reported to have suffered from dis-
charges from the nostrils and left external ear.   01. morrh. internally
acetat, morph. in substance applied to the eye.   The same treatment,
although sometimes interrupted, was followed for several months, the
more so as exudation took place on the right cornea also.   Intercur-
ring acute swellings of glands in front of the left ear were successfully
treated with tinct.  iod. externally.   Another  attack of external otitis,
with copious  and  offensive discharge, was gradually diminished  by
injections  of acid,  tannic, 3iss., aq. §vi., and  the system generally im-
proved by generous diet  and the continued use of ol. morrh. §ss. daily,
and syr. iodid. ferri, 6-8  drops three times a  day.
   19. G. A. C, aet. 1 year, 6 months.  Eczema diffusum.  Eczematous 
8             CLINIC  FOR DISEASES  OF CHILDREN.
eruptions in every state of development on several parts of the body;
some being scarcely perceptible;  some larger vesicles filled with a
clear, transparent  liquid; some with thick purulent matter;  some
dried up, and forming a thick, hard  scab.  Treatment: Bathing in soap
and water twice a day. R.—Pulv. rad. rhei, gr. xviii.; oxysulphuret.
antimon., gr. vi.   Div. in p.  aeq. No. xii.   D.  S.: Two powders daily.
  20. Lewis K.,  aet. 2 years, 9 months.  Imbecillitas.  The boy is re-
ported to have been well  developed  up to  his eleventh month, when
he commenced walking.  After this  time he suffered from numer-
ous  attacks of convulsions,  12-20 a  day, for a  protracted period.
What muscular action  of the locomotive organs he had before he then
lost, until he  was nearly two years old.   About this time he com-
menced again to walk, but is unable  to speak.  His head is pretty
small in circumference,  forehead low, eyes small, occiput proportionally
large.   The cranium feels very hard  and solid to  the touch, and over
the region of  the large fontanel no local  impression, but a general
depression of the surface  is  perceptible.  The mother, who  has bred
children before this one, states  that the   pulsations in  the  fontanel
have never been perceptible.   The case, then, is considered as one  of
idiocy, resulting from  premature  ossification of the sutures  and fon-
tanels of the cranium,  and given up, from a medical point of view,  as
hopeless, the  prognosis  being  highly unfavorable;  for  either the
child will  remain idiotic for life, or will perish from any feverish dis-
ease that may occur.
  The cranial abnormity, in its  bearings on the mental  condition  of
the child, looks very much like the case reported by Sehutzenberger,
in which the disease lasted about four years, before the continually
increasing compression  of  the hard, compact, and eburneated cranium
succeeded in effecting the death of the patient, who  had endured all
his  life  frequently repeated faintings,  a long series  of epileptic and
tetanic  attacks, abnormal  irritability,  meutal  weakness, and, at last,
idiocy.  Or like the cases reported by  Baillarger, who observed  three
microcephalic  idiots whom their mothers reported to have been born
with their skulls  perfectly closed  and solid.  Two  other of her chil-
dren, who  were  well developed, both 'physically  and mentally, had
their large fontanel open for a long while after birth.   Similar facts
he learned from another woman, who was mother of one microcephalic
idiot, and of  some other children of normal development.  Yrolik
knew an idiotic boy of seven years whose cranial sutures  had entirely
disappeared.  Cruveilhier relates the case  of an idiotic child of eigh-
teen months, without  any discernible  sutures.  Thus the human era- 
CLINIC FOR DISEASES OF CHILDREN.
9
 nium, without any, or  with prematurely closed  sutures, is very much
 like that of animals, of which  class a  few varieties  of  apes are  the
 only ones who have for a  short while after birth small  and rapidly
 ossifying fontanels.  For this very reason Baillarger compares micro-
 cephalic idiots to animals,  both  from an anatomical and pathological
 point of view.  Gratiolet  does not even stop here, but  asserts that
 there is a  direct relation between the earlier or later ossification of
 the sutures,  in the  different races  and types  of mankind, and  the
 height  of their intellectual capacities.   He states that the cranial
 sutures  close later in Caucasians  than in  Negroes, and  particularly
 that  the coronal suture ossifies early in  Negroes, late in Caucasians.
 Far this raason a proportionally late ossification of the coronal suture
 seems,  cmfis paribus,  to  be favorable  to intellectual development.
 The high'forehead also of  the Caucasian, and the low one of the  Ne-
 gro type, are evidently depending on this physiological fact, although
 it  may be 'stated  that the synostosis of the sutures is not the only
 cause of cranial difference  in the races; the various characters of the
 crania, as they are  found  in different  types, being  partially formed
 before the synostosis of the sutures is complete.*
   Besides the probability of this boy remaining idiotic for life, there
 is another possibility.  I have  found that, although premature ossifi-
 cation of the  fontanel and sutures need not of itself absolutely and al-
 ways produce congestion of the brain or its  membranes,  which often
 is the final cause  of death  in  such  cases, every child whose fontanel
"and cranial junctures have  been prematurely closed, and who falls  sick
 with  symptoms of cerebral irritation or  depression, is predestined to
 certain death.  Condie, too, states that when the growth of the crani-
 um ceases, while  that  of  the brain continues, the morbid phenomena
 resulting from the compression  of the brain, which  invariably results,
 jnay  certainly be to a certain extent abated, the  comfort of the patient
 increased, and life prolonged by a proper hygienic course of treatment;
 but all  hopes of effecting a cure must be abandoned.   And I have fur-
 ther found, and proved by a number of cases of pneumonia, intermittent
 fever, etc., that in all cases of children, whose cranial junctures are
 prematurely ossified, any acute or febrile disease invading the system,
 Blight though the acute  intercurring affection may be, offers a most
  * On the Etiological and Prognostic Importance of the Premature Closure of
the Fontanels and Sutures of the Infantile Cranium, in JVew York Journal of
Medicine, January, 1858, and in Noeggerath and Jacobi's Contributions to Mid-
wifery and Diseases of Women and Children: New York, 1859. 
10
CLINIC  FOR  DISEASES OF  CHILDREN.
unfavorable prognosis.  Thus, in our case, we scarcely know what prog-
nosis is to be preferred, idiotism for life,  or an early death.
  21. William T.   Ulceration at the point of insertion of the frenulum
of the  tongue, probably resulting from previous  aphthae.  Repeated
cauterizations with the solid nit. argent, proved satisfactory.
  22. Charles S., aet. 1 year.   Syphilis hereditaria, roseola  syphilitica,
rhagades am.   The  father appears to  have  been, or  is  still, syph-
ilitic; at least  the mother impugns him with being the  cause  of the
child's illness.   The  boy was under medical treatment a number  of
months ago, with apparently good  result.   But  he again lost flesh,
strength, and  appetite, and showed the  former symptoms, which the
mother reports to  have been  of the  same character as these.  The
treatment  consisted of submur. hydrarg. gr. \ three times a day, for
two months; that is, three weeks after all the secondary symptoms had
disappeared.  For  a number of days the child  suffered, in the mean
time,  from  bronchial  catarrh, independent of  his specific disease,
and then only  the  usual formula was changed for: R.— Submuriat.
hydrarg., gr. iii.; oxysulph. antimon., gr. xvi.; sacch. alb., 9ij.; div. in
p. aeq. No. xvj.  D.  S.: 3 powders daily.
   23.  John D., aet.  7 years.   Catarrhus  Intestinalis.  The diarrhoea
having lasted for some time already, and the abdomen generally  ap-
pearing to be a little painful to the touch, we considered the case  as
one of consecutive irritation, rather than of real  anatomical disturb-
ance.  Two  drops  of laudanum given  every three  or four  hours,
proved sufficient to restore the boy to his general well-feeling,  and to
remove the serous secretion that still continued.
   24.  Raphael B.,  aet.  4 months.  Hydrencephaloid.  The  boy has
been suffering from  a  severe  intestinal  catarrh  for a  month, and is
perfectly exhausted and emaciated.   Extremities cold; head  very hot;
external veins o/ the cranium congested; large  fontanel elevated, ex-
tended, and pulsating; scalp  wet with  perspiration; conjunctivae in-
jected; pupils contracted; the child  moauing constantly; respiration
hurried; pulse 140.   Evidently the anaemia of the cerebral substance
resulting from the general condition, had given way, ex vacuo, to hy-
peraemia,  threatening exudation.   Treatment:  Generous diet; ice to
the head; extremities to be kept warm;  sulph. cinch., gr. i.,  acid tan-
nic, gr. ss., four times a day.   Injections with brandy into the  rectum
 ordered after the temperature of the  head had  become  diminished.
 The  boy was presented several times during the  next  fortnight;  de-
 cidedly not  worse; the temperature  of head and extremities  more 
CLINIC  FOR DISEASES OF  CHILDREN.            11
equal; excretions more normal, but was finally lost sight of.  Deple-
tion or any enfeebling remedial agent or method was carefully avoided.
   25. Caroline I., aet. 5 months.   Catarrhus Bronchialis.  Is reported
to have suffered from more dyspnoea and  fever than when presented.
No pulmonary infiltration; mucous rales  only.   No treatment.  Re-
ported to be well after seven days.
   26. Julius D., aet. 2 years.  Pneumonia  Bilateralis.  Dull percus-
sion sound, and bronchial respiration in the  subclavicular region, right
side; subcrepitant rale over left lung, inferior lobe, posteriorly.  Great
dyspnoea;  pulse 154;  temperature of head high; child  has vomited
twice.  Treatment:  R.—Tinct.  digitalis, 3iii.;  Syr. ipecac, 3'j.   M.
D. S., 20 drops every two hours.  Three days afterwards, dull percus-
sion sound  still over both the affected lobes; mucous rales in the right
lung.  Syr. ipec. alone.
   27. Eliza  T.,  aet.  7  months.  Broncho-Pneumonia, upper  lobe,
left lung.   The  greater part  of the lung  hepatized;  mucous  rales
heard on several places; fever  pretty high still, therefore it is thought
proper to  combine  an anti-febrile with an expectorant.  R.—Pulv.
 herb, digital., gr. xii.; acid, benzoic, gr.  viii.; sacch.  alb., 9j.   Div.
 in  p.  aeq. xvj.  A  powder every two  hours.  Was not brought  in
 before three weeks,  when there was no fever nor dyspnoea, but dull
percussion sound to  some  extent, and mucous rales.   R.—Oxysulph.
antimon., gr. viii.;  sacch. alb.,  E)ij.  Div.  in p. aeq. No. xvi.
   28. William M.,  aet. 6 years.   Pleuritic  Exudation and Spleniza-
Hon of the  left  lung, upper lobe.  Has  suffered from measles  nine
months ago, since then from otorrhcea aud  cough.  No accurate history.
Percussion  and auscultation show normal results over the right lung
and inferior lobe of the left, with the  exception of the respiratory
murmur  on the right side  being unusually puerile.  Percussion sound
over the diseased part exceedingly flat; respiratory murmur much di-
minished.   Treatment: Gymnastics and cod-liver oil.  Proper diet.
   29. Isabella N.,  aet.  1 year and 6 months.  Contusion of Shoulder-
Joint.  R.—01. Camphor.
   30. John H., aet. 1 year and  6 months.   Pneumonia Chronica  of
the right lung, upper lobe, Hypertrophia Hepatis.  Has suffered from
diarrhoea and cough for five months; is very much emaciated, and un-
able to stand  ou his feet.   Limbs very thin; cheeks  sunk; dyspnoea
moderate; abdominal; abdomen  enlarged;  veins on thorax and ab-
domen much injected.  Dull percussion sound in  the subclavicular re-
gion, right side, and over the hepatic region up to the fourth rib, over
the sternum, up to  the heart.   Treatment: Generous diet, cool air. 
12
CLINIC  FOR  DISEASES  OF CHILDREN.
 Sulph. cinch., gr. v., every morning;  Syrup, iodid. ferri, gtt. viii., three
 times a day, in a tea-spoonful of cod-liver oil.   This treatment was
 continued for two months, (with the exception of cinch., which was given
 in but six doses,) until both physical symptoms and  external appear-
 ance proved the boy to be well.
   31.  Henry H., aet. 9  months.  Pneumonia  of  right lung, upper
 lobe.   Hepatization; constipation.   R.—Syr. Scillae compos., 8 drops,
 every two hours.
   32. John V., aet.  6 years.  Pneumonia of left lung, upper  lobe.
 Subcrepitant rale;  slight dullness;  high fever; vomiting; moderate
 pain over the  affected part.  R.—Tinct. rad. aconiti,  gtt. vj. every
 two hours.  Was not presented  before  a week; the  morbid process
 not changed as to place,  but character;  hepatization fully developed.
 Loss of appetite and  strength perfect;  pulse 136, small; respiration
 36.  Treatment:  Wine, beef.  R.—Sulph. cinch., gr. xv., div. in p. aeq.
 No. ii.   D. S.: A powder every morning.  At the  same time:  R.—
 Acid, benzoic, 3ss.;  Sacch. alb., 3jss.  Div. in p. aeq. No. xxiv. D. S.:
 A powder every two hours.   After three days, the general condition
 improved, absorption commencing in  the  hepatized tissue.  The case
 then was left alone,  with  nutritious diet, and did well.
   33. Ann B., aet. 8  months.  Catarrhus Gastricus, from  injurious
 food.   Vomiting, furred  tongue,  foul breath.  Occasionally  an acid
 passage.  No particular fever.   R.—Bicarbon. sod., 5jss.;  Aq.  §iii.
 M.  D. S.: A tea-spoonful every two hours.
   34. Rachel B , aet. 2  years.  Diphtherilis vaginalis.   Diphtheritic
 membranes  over the whole  vaginal  surface,  ulcerated appearance of
 the tonsils, as if exudations had been already thrown off.  Treatment:
 Liq. ferr. chloridi, gtt. viii. every 3 hours; local  application of a satu-
 rated solution ofchlorat. potass, in water, (1:16.)
   35. James L. R., aet. 1 year and 1 month.   (Edema pedum ex anae-
 mia.  The  boy looks extremely anaemic, emaciated, and oedematous
 at the same time.   Had  scarlatina three months ago.  Afterwards
 suffered  for six weeks  from  an exceedingly  severe  diarrhoea  and
 vomiting.  Diagnosis:  Hydrops ex scarlatina.   Under this impression,
the boy was ordered to take, besides nutritious  food, tannic acid, gr.
ii. 3 times a day.  After three days worse.  Meanwhile  the urine had
been examined, and was found to contain neither albumen, nor blood,
 nor casts.  The diagnosis was then changed as above: R.—Ferri pulv.
Bj.; pulv. Doveri, gr. vj.; sacch. alb ,  9ij.   M.—Div. iu p. aeq. No. xx.
 D. S.:  3 powders a  day.  No decided improvement took place before
 three weeks, the cedematous swelling meanwhile increasing. 
CLINIC  FOR  DISEASES OF  CHILDREN.
13
  36. R. K., aet. 8  months.  Pneumonia  of left lung, lower lobe;
hepatization; absorption commencing.  R.—Oxysulph. antimon., gr.
viii.; Sacch. alb., 9'ii., m. f. pulv.  Div. in p. aeq., No. xvi.   D. S.: A
powder every two hours.
  37.  R. T.  H., aet. 11 years.   Febris  Intermittens Quotidiana.  At-
tacks daily, although intermittent fever at this age will more frequently
show the tertian type  of adult  age.   No  enlargement of spleen or
liver.  General health good.  R.—Sulph. cinch., gr. x. two hours before
the next attack.   Reported  well a week afterwards.   The same dose
ordered once more.
   38.  Mary  K., aet. 5 months.  Eczema Capitis et Faciei.   Scalp and
face* partially covered with thick scabs; purulent matter contained in
a  number  of pustules; a  transparent  liquid in others just  formed.
This case shows exceedingly well  the absence of any intrinsic differ-
ence between eczema and impetigo, the vesicles being evidently, by  a
gradual change taking place in  their contents, transformed into pus-
tules.   The child has suffered from diarrhoea for two  months, and is
still pale, and  fontanels a little sunk.  Therefore, in this case, some
care is taken not to suppress the secretion at the scalp suddenly.   As
a general rule, in  very young children,  an eruption complicated with a
large amount of secretion going on for  some length of time, especially
on the scalp, must not be suppressed  at once, although its cautious re-
moval will not bring on the dangers attributed to it  by the public
prejudice.   Treatment:  R.—Liq. potass, canst., 3ii.;  01.  morrh., §ii.
To  be applied  twice a day over one-half of the diseased surface.  The
scabs were mostly removed after a week, when application of Goulard's
wash was resorted to, and  the same proceeding commenced with on the
remaining half.  Some eruption and  secretion took place  a number of
 weeks  afterwards, as it  will generally do at this age;  but it was
treated in the  same manner, and  never reached any considerable ex-
 tent.
   39. James R., aet. 1 year and 5 months.  Erythema et  ulcera colli.
Deep ulcerations in the folds  of the neck, the result of carefully ab-
staining from Croton water, and adding " powder " and sweet oil to a
simple erythema.   Treatment:  Croton water, and R.—Argent, nitrat.,
gr.  v.,  adipis  suilli, 3j.; M. f. ung.,  to be  applied three  times a day.
 Wounds granulating well  after  a week.   Then local applications  of
R.—Sulph. cupri., 9j.; aq.,  gviii.
   40. Robert  D., aet. 1 year and 11 months.   Strabismus convergens,
left eye.   Operation recommended.
   41. Caroline C, aet. 1  year and 6 months.   Catarrhus Vagina. 
14            CLINIC FOR DISEASES OF CHILDREN.
 Purulent secretion from the vagina for several weeks, from unknown
 cause.  No dysuria.  Erythema  on and  around the perineum.   Aq.
 plumb, externally.
   42. Thomas M., aet. 2 years.   Pharyngitis.  Adenitis snbmaxillaris.
 Tonsils swelled, the  mucous  membrane of the velum palati  and  the
 posterior wall of the fauces injected; submaxillary glands tumefied;
 pulse 110.  No membranes found.  R.—Chlorat. potass., 3ij; aq., §iv.
 M.   D.  S., half a table-spoonful every two hours.
   43. John S., aet. 4  years.  Ulcera colli.  Ulceration of the left side
 of the neck, of the size of a square inch.  Has been observed for five
 weeks past, and appears, according to the relation of the  mother, to
 be the result of neglected furuncles.   Treatment: R.—Sulph. enpri.,
 gr. xv.;  aq., §v.  D.  S., for external use.  Granulations exhibited
 themselves very soon, and the sore was healed up in about a fortnight.
  44. M. K., aet. 5 years.   Bronchitis.  Fever already  less, mucous
 rales  commencing to be audible.  R.—Oxysulphur. antimon., gr. viij.;
 sacch. alb., 9ij.  M. f. pulv. div. in p. aeq., No. xvj.   D. S., a powder
 every two hours.
  45. Jane K., aet. 3 years.   Eczema Capitis, Faciei et Colli.   Ec-
 zematous eruption in every possible  form on  scalp, face,  and neck.
 Isolated pustules have been formed wherever a drop of the secretion has
 come  in contact with the healthy skin.  The glands of the neck slight-
 ly tumefied, general appearance of the child  scrofulous.  Treatment:
 01. morrhuae.   The scurf to be removed by means of warm oil and soap,
 and afterwards, to be applied three times  a day:  R.—Acid, tannic,
 3jss;  adip. suilli, §jss.  M.  f. ung.   Presented again eleven days after-
 wards; getting better.  The same treatment continued.
  46. Joseph B., aet. 8 years.    Vulnus Capitis.  Fresh  cut wound
 on forehead.  Suture.
  47. John P., aet. 1  year and  7 months.   Catarrhus Intestinalis.
 Diarrhoea has continued for a week, of a mucous character.   No fever,
 a little tenesmus, number of passages from five to eight.  R.—Opii,
 gr. ss.; carbon  calcar., 3ss.   M. f. pulv. div. in p. aeq., No. xii. D. S.,
 a powder every three  hours.
  48  Johanna L., aet. 11 years.  Adenitis Scrofulosa, Eczema Capitis.
The girl is reported to have been perfectly well until four  years ago,
 when  she suffered from malignant scarlet fever.  Her system appears to
have been thoroughly affected, and since that time symptoms of scrofula
 made  their first appearance; cheeks bloated, upper lip and nose thick,
submaxillary and  cervical  glands considerably enlarged, eczematous
eruption  all over the scalp for more than a year.   No other members 
CLINIC  FOR  DISEASES OF  CHILDREN.
15
of the family scrofulous.   As in this patient the cause of the scrofu-
lous  symptoms  is  certainly of a general deep-seated nature, having
been brought on by the intense general affection produced by scarla-
tina, it was resolved upon  to resort to a general treatment before ap-
plying astringents  externally.   R.—Syr. ferr. iodid., gtt. xii., in half
a table-spoonful of cod-liver oil, three times a day;  animal diet, avoid-
ing of amylaceous food;  and soap and water twice a day, besides gen-
eral  baths.
   49. Thomas B.   Eczema Diffusum.  A number of eczematous pus-
tules  dispersed  over the surface, particularly  of the lower extremities,
probably the result of uncleanliness only.  Ordered  to bathe in soap
and water daily.   No pustules a fortnight afterwards.
   50.  Mary S.,  aet. 3 years and 6 months.   Hernia In guinalis Sinistra,
Pleuro-Pneumonia Chronica, Pharyngitis Acuta.  The hernia in the left
inguinal region  was first observed when the child was three months old.
As no  appropriate treatment  was resorted to, it will still protrude
during an attack of coughing.  Truss  ordered.  Considerable enlarge-
ment of  tonsils and  uvula, and  acute swelling of pharynx generally;
fever moderate; constant cough, especially when  lying down, proba-
bly increased by the irritation produced  on  the posterior wall of the
fauces  by the  enlarged  uvula.   R.—Chlorat.  potass., 3iij.;  aq., §vj.
M.   D.  S.,  half a table-spoonful  every  two hours; pulv. Doveri, gr.
iiss. at  bedtime.   Acute  pharyngitis well after a  week,  but enlarge-
ment of tonsils, and particularly the uvula, still considerable.  Cough-
ing spells not frequent, but a short annoying cough after lying down.
Part of the uvula removed, with good result as  to the nightly attacks
of coughing, and the old pulmonary complaint attended to.   The child
had  measles several  years ago,  and  has  been  exposed  since to  a
number  of pulmonary  complaints of either catarrhal  or inflammatory
character; has  coughed almost constantly, and  often suffered from at-
tacks of dyspnoea. Respiration  somewhat abdominal, circumference
of the right  half of the thorax less than the left, while the normal con-
dition is the reverse.  Right subclavicular  region a little depressed,
and little action of inspiratory muscles visible over it.   Dull percus-
sion sound over the upper lobe of right lung, both  anteriorly and pos-
teriorly; respiratory murmur bronchial, audible as it were at a distance.
Diagnosis:  Pleuritic exudation and (or only) induration of pulmonary
tissue, being the result of one  or more  attacks of pleuro-pneumonia
during, or (and) after measles  some  years ago; as  some fever was
still perceptible, sulph. cinch, was  given  for  several  days, in a daily
dose  of gr. vj., and a dose of pulv. Dov., gr. iij., was still ordered for 
16
CLINIC  FOR DISEASES OF  CHILDREN.
some more nights; to be discontinued after several days, and replaced
by syr. ferri iodid., gtt. x., three times a day, in half table-spoonful  of
cod-liver oil; gymnastic exercise to dilate the thorax, nutritious diet.
The  child gained flesh and strength  during  the  following months, al-
though the physical symptoms of pulmonary disease were  never  en-
tirely removed.
  51.  Mary S., aet. 2 years, 6 months.  Synoviitis Chronica Genu Bex-
tri.  Right knee considerably swollen, the circumference being twelve
inches; leg inflected;  little spontaneous, not much forcible motion; not
much pain on pressure, but fluctuation or  rather elasticity perceptible,
showing a large  amount of liquid to be inclosed  by the synovial  mem-
branes.  No particular symptoms-of scrofula perceptible; no knowl-
edge of a traumatic injury.   The assumption of the latter having ta-
ken place is more probable than the former, as there are no symptoms
of general disease.  The child has always  been under treatment, tinct.
iodine  and vesicatories having been  applied  to some extent. Treat-
ment:  Compression of the knee  by means  of a  bandage.  A week
afterwards circumference of the knee ten inches.  Prescription wanted
for some internal medicine, and refused.  Patient not presented again.
  52.  Robert S., aet. 6 years.   Craniosclerosis Rhachilica.   Patient ia
the son of apparently  healthy  parents, but his brothers and sisters, of
whom  there  are  four,   are  all  more  or less  rachitic.   Devel-
oped very  slowly while an infant;  was   late in teething;  his  limbs
somewhat bent in the  direction of the flexor muscles, and the epiphyses
very much thickened on both radii and tibiae.  His intellect is reported
to have been bright during the first two years, but  then commenced to
diminish.   His eyes are deep-seated and  small;  the expression of his
face dull; his intellect of a very low character; his locomotion clumsy.
He is unable to articulate, and the only intellectual power that is left
is evinced by his doing mischief.  His  forehead is large, root of nose
thick,  circumference of cranium 22  inches; occiput normal, arid  small
in proportion to forehead.   Cranium feels very hard and  solid to  the
touch, and its anterior portions are evidently thicker and heavier than
normal.  Defecation and  emission of urine not frequent, but will  occur
without  the patient  troubling himself about  them.  All  the  other
vegetative functions in perfect order.  The case  must be taken as one
of a general nature, the result of vicious general development, and its
first origin  must be traced back to early  infancy.   In the first years,
when general symptoms of rachitis showed themselves, the bones were
soft, succulent, and full of blood-vessels, and the cranium and cerebrum
like  the  rest;  whether,  however, rhachitic  softening  of  the cranial 
CLINIC  FOR DISEASES OF  CHILDREN.
17
bones, craniotabes, has really been present, cannot be determined upon;
at all events, the bones of the posterior part of the cranium, in which
craniotabes is always seen,  appear more normal than the rest.   After
the period of rhachitic, spongy thickening, and consequent mollification,
osteoporosis was  followed  by  the stage  of  rhachitic eburneation.
During this period the peculiar osseous cells became more  numerous,
the layers of the osseous tissue that separated  from each other during
mollification filling up with them, and the canaliculi got thinner.   In
the physiological condition, the inner lamina of the  bones  is said  to
stop vegetating after the  tenth year;  and the  dura  mater  does not
form uew layers before the  regressive period of cerebral development
takes  its commencement, in  advanced years.   After the  fiftieth  or
sixtieth year of life, absorption begins to lose in power, the  brain gets
smaller, the veins  narrower, arteries wider.  If this development takes
place in early life, the case is, like that before us, without injury to the
cerebral  functions when the external layer only is affected, but with
decided troubles of the cerebral functions, resulting in spasms,  neural-
gias, paralysis, or idiotism,  when the process, takes place on the inner
lamina.
   The case before  us is well illustrated by  the investigations laid down
by Prof.  Huschke, of Jena,  in his last work on  " Craniosclerosis Tota-
lis Rhachitica."   Undoubtedly this case does  not compare  in import-
ance with that published by  Prof. H., but the  best-developed cases
will always do most in illustrating  the whole class.
   The case of total  osteosclerosis  described by H.  is that  of a girl
of seveutecn years  of age, whose skull (the normal weight being 600
grammes) weighed as much as 4,117  grammes.  The microscope
showed that the medullary (Havers') canaliculi were  large, and very
numerous on the surface, narrow and very few in the  interior of the
sclerotic  bones, and that the osseous canaliculi were more spherical and
irregular  in site aud shape.   The  chemical composition  was also ab-
normal, the constituents being phosphate of lime, 65.59;  carbonate  of
lime, 11.12; sulphate of magnesia, 1.14;  cartilage, very little fat, etc.,
22.15.   No Guorate of lime was found.   After all, the bones, taken  as
a  whole,  proved exceedingly solid, but fragile; when tried in small
pieces, very white in their interior, but yellowish on their surface; the
latter color  being  the relic of extravasated blood or other pigmentous
matter.   Another skull, in  the possession of  the author, and  appa-
rently  only in the beginning of sclerotic development, weighed, inferior
maxilla excluded,  1,075 grammes;  and a  third, in the museum of the
University of Jena, of the same description, is that of a young baboon,
            9 
18
CLINIC  FOR  DISEASES  OP  CHILDREN.
in which all the bones  covering  the hemispheres  had undergone the
sclerotic anomaly.
   The superior half of the skeleton, in the physiological state, exceeds
the inferior half by  a greater amount of calcaria.   But this prevalence
is not only absolute, but also relative, the single bones containing a
larger average proportion of earths in general, and lime in particular.
There is also a physiological craniosclerosis in families as  well  as  na-
tions; the th.ckest and hardest skulls being found  in African negroes,
whose crania, although they be not absolutely heavier than Caucasian
ones, undoubtedly have a greater weight in relation to the size  of  the
cranial cavity.  Further, the crania of the flesh-eating negroes of Guin-
ea are much harder and heavier than those of Persians and Hindoos.
Moreover, it is altogether  noteworthy, that  the human organism in
Africa is throughout prominent for the  exceedingly  strong  develop-
ment of the substances and organs taking the lowest  place in human
chemistry and physiology, viz., bone, fat, and sexual organs, etc.   Of
undoubted morbid  total craniosclerosis, there  are only ten  cases: those
of Malpighi,  1697;  Cuvier,  1822; Ribalt, 1828; G. Fors'er and Bo-
janus,  1826; llg,   1822; Kilian,  1822; Otto, 1822; Yrolik,  1848;
Albcrs,  1851; Huschke, 1858.  The  disease  does  not affect the audi-
tory bones, the condyles of maxillary and occipital  bones, and the sty-
loid process of the  temporal bone.  There are some symptoms of the
disease in the posterior part of the cranium and basis  eranii, but most
affected are the bones of the face, and the frontal, parietal, and cri-
broid bones.   Thus the disease takes  its origin in the anterior portion
of the skull, particularly  in the superior maxilla, and proceeds upward
and backward, terminating in the basis cranii, in the  neighborhood of
the infundibulum and appendices.   Two observers have been so fortu-
nate as to meet with the preceding disease in the living.  The average
amouut  of earthy matter is very considerable in all of them.   While the
normal proportion of earthy matter to organic  substance  in cranial
bones has been found  by Professor Frerichs to be = 2.1 (or 1.5)  : 1
—it is in the sclerotic bones from 3.5  to 4.4  : 1.   Generally, the  car-
bonate of lime is reported to have been found increased,  which proved
to be the like in spongy bones.  All the cases were those  of juvenile
individuals, or at least the disease had commenced  in childhood.
  The conditions necessary to  the development of  cranio-hyperostosis
are, first, abundance  of lime;  secondly, congestion,  and  sometimes
chsonic inflammation.   It is a  characteristic fact, that the  bones, the
development of which is  the quickest  after  birth, show the greatest
disposition to hyperostosis, as the  maxillary and cranial bones.  Abun- 
CLINIC FOR DISEASES OF CHILDREN.
19
dance of lime  may be  produced by such  food as meat.  One of the
patients  is  reported  to have been a very hearty eater.   Or, as  was
the case in Buschke's individual,  there is little excretion of lime by
the urine.   Or there is a metastasis of lime in such a mauner that lime
is resorbed in certain other places, and introduced into  the substance
of the cranium.   Frobably a number of cases co-operate  for the same
effect.   But, at all events, it must be borue in  mind, that the patho-
logical process, great though the anomaly may  be, is in a majority of
cases to be  explained by, and to be considered as, an extravagance  of
normal physiological development.*
   As to our case, mild though it be in proportion to those on which
Prof. Huschke has written in his excellent monograph, its prognosis
is very unfavorable.   The pressure on the  cerebral  substance cannot
be relieved  by any medicinal treatment.
   53.  John L., aet. 1 year, 6 months.  Ulcera Colli.   Half a dozen of
sinuous  ulcerations, of from two  lines  to an inch  in length, around
the  neck, reported  unchanged  for several months.  No intelligible
account is  given of their  origin,  but probably  they are  the result
of plasters and scabs covering a few eczematous pustules, forcing  the
secretion into the subcutaneous tissue.  In order to  remove  the loose
flaps of skin which could not be expected ever  to  adhere again,  they
were repeatedly  and deeply cauterized with solid nitrate of silver, and
afterwards  the whole surface treated twice a week  with light and su-
perficial cauterizations of the same kind.  At last, for  some weeks,
application three times  a day of: R.—Nitrat. argenti.,  gr. x.;  adip.
suill., 3ii. M. f.  ung.   Granulations formed  gradually, and  the  case
turned out  well, without leaving a cicatrix except on the spot  of the
largest ulceration.
   54.  Mary G., aet. 1 year, 1 month.  Ulcus Frontis.  The child was
hurt by a fall four weeks previously.  The wound had been maltreat-
ed with salves and plasters until a space of a little more than  a square
inch was in a fair way of ulceration.   The surrounding parts, the right
side of forehead, was swelled and erythematous, and a little  sensitive
to the touch.  Treatment:  Water dressing for three days.  After the
irritation around the ulceration  had subsided, application of: R.—
Zinc. oxyd. alb., 3ss.; adip. suill., 3iii.;  a small portion to be applied
three times a day.
  • Review of Prof. E. Huschke " On Craniosclerosis Totalis Rhachitica and Thick-
ened Skulls in General, with New Observations of that Disease.  Jena, 1858, pp.
54," and in Noeggerath and Jacobi's Contributions, etc., p. 406. 
20            CLINIC FOR DISEASES  OF CHILDREN.
   55. Mary F., aet. 1 year.   Kophosis Nervosa.   Patient  is reported
 to have been  a  healthy child, with  the exception of some  eruptive
 fevers, and a small number of attacks of convulsions in early infancy,
 up to her sixth year.  A year ago she appears to have been  severely
 ill, and to have suffered  from  tonic convulsions ("lock-jaw") for  sev-
 eral days, with unconsciousness.   She is reported to have recovered
 very  slowly, but to have showed no symptoms of disease except abso-
 lute deafness for the last six  months.   No contractions, no paralysis;
 pupils normal and equal.   On either side external  ear normal; tym-
 panum plainly visible, and quite normal;  eustachian tube easily entered
 by the sound.  Thus the deafness must be explained by the cerebral dis-
 ease that had taken place a year ago.  Beiug unable to distinguish the
 peculiarities of that affection from the poor report given by the  mother,
 it is   probably safe  to conclude, from the slow and gradual recovery
 during the first half year, that the disease was one of inflammatory and
 exudative  character; the exudation, of whatever  uature it may have
 been, undergoing a process of gradual retrograde metamorphosis and
 absorption.  Further, from the  deafness  being  unaffected during  the
 last half year, and all the other functions being perfectly normal, it is
 just  as safe  to conclude, that the origin of the auditory nerve is still
 paralyzed by an unabsorbed part of that exudation.  Thus, the prog-
 nosis is a very unfavorable  one, unless absorption may be  induced by
 remedial  ageuts, which  is  improbable.   Treatment: Iodid. potassii,
 gr. x., dissolved in water, daily.  Patient not presented again.
   56. John E., aet. 2 years.   Catarrhus Bronchialis.  Expectoration
 not so free as desirable, as  the cough appears to be hard aud  a little
 painful.  R.—Muriat. ammon., extr. glycyrrhyz , aa, 3ii.; aq., giv.  M.
 D. S.: A tea-spoonful every two hours.
   57. Johanna R., aet. 8 years.   Adenitis Chronica.  A  number of
 submaxillary glands and  the surrounding tissue swelled and indurated
 for four weeks.  No scrofula.   Appears to have had a glandular inflam-
 mation of an acute  character;  no pain;  no fever.   Treatment: R.—
 Iodid. potassii,  3ii.;  glycerin, §ss., for external use.  This formula  has
 always been preferred to the  commonly  used  salve, as its  ready  ab-
 sorption is  proved by well-conducted experiments,  which  cannot be
 said of the old preparation.  Further: R.—Iodid. potassii, 3ii.; aq.,
 iivss.  M.   D.  S.: A tea-spoonful  three times a day.
  58.  Henry H., aet. 1 year.   Scrofula,  Conjunctivitis et Keratitis Ex-
udativa, Catarrhus Meatus Auditorii Externi.  The general symptom3
 of scrofula well developed, although the child is but a year old; father
said to be consumptive.  The  inflammation of the cornea has resulted 
CLINIC FOR DISEASES OF  CHILDREN.            21
in an organized exudation over the right pupil; both of the external
ears discharging freely a whitish, purulent matter;  no affection of the
tympanum.   Treatment:  Four  daily  injections  into the  ears, after
they have been cleansed by injecting water, of a solutiou of:  R.—Acid.
tannic, 3j.;  aq ,  |vj.   Application to the eye of acet. morph., gr. i-ii.,
repeated several times a week.
  59.  Katharine W., aet. 3  months.   Teleangiectasia Femoris Sinislri.
A sanguineous tumor of arterial nature, soft and protruding,  but not
pulsating, two inches long  and an  inch wide,  on  the inner  side  of
the left femur, near the groin.  In order to  show  several operative
proceedings  on  this  tumor, the lower two-thirds were covered with:
R.—Tartar, emetic, E)ij.;  emplastr.  sapon., §ss.   Deep  pustules com-
menced to be formed  iu a few days, and the whole surface was  covered
with them a week after the first application.  They then were allow-
ed  to  heal  up, aud cicatrization to commence.  The result was satis-
factory,  no return having taken place  for five months.   The  remain-
ing part was not attended to for  the four months  following the com-
mencement of the treatment.  After this period,  an injection was made
into the tumor, of a mixture of six drops of Squibb's liq. persulphat.
ferri,  and eighteen drops of water.  Induration  of tumor  took place
immediately, no inflammatory action being brought on, nor any incon-
venience produced, but the  proceeding had to be repeated before com-
plete obstruction of the blood-vessels took place.   (See Appendix.)
   60.  Frank L., aet.  4  years and  6 months.   Stomatitis Ulcerosa.
Tongue, cheeks, and  soft  palate covered with round superficial ulcer-
ations; pharynx injected and swollen; foetid exhalation.   R.—Chlorat.
potass., §ss.;  aq., gviij.  M.  D.  S.: half a  table-spoonful every two
hours.
   61.  William B., set. 7 years.   Abscessvs  Capitis.  Large  abscess
on  the top of head, soft and fluctuating;  incision.  Bone  not affected.
Water dressing.
  62.  Mary McK., aet. 2 months.  Cephalhematoma. Large elastic tu-
mor, 1| inches high,  2| inches in diameter, on the right parietal bone,
limited by the coronal  and lambdoidal sutures.   Was observed on
the second day after  birth;  has increased iu size for several days, and
then remained stationary.   Osseous ring to be felt already; no pain;
no discoloration of scalp; child well developed;  reported to be treat-
ed without success; told that it will get well  without treatment.
  63.  Joseph M., oet. 4 months.   Pneumonia Catarrhalis,  upper lobe
of left lung.   Patient commenced coughing and sneezing two months
a"-o, aud has coughed more or less ever since.  A week ago had fever 
22
CLINIC  FOR  DISEASES OF  CHILDREN.
and dyspnoea, which still continues.   Pulse 140, respiration 40-48.
Mucous rales over the whole left lung; percussion  slightly dull over
upper lobe.   Child emaciated, and not always able to take the breast.
Large fontanel a little sunk, and extremities commencing to get cool.
Treatment:   Half an  ounce of pale brandy a day,  and R.—Acid.
benzoic, gr.  viii.;  sulphat. cinch., gr. iv.; sacch. alb., 9ii.  M. f. pulv.
Div. iu  p. aeq. No. xvi.  D. S.: A  powder every two hours.   Both
general condition and local symptoms improved after three days, and
treatment continued, without brandy.
   64 Eliza R., aet. 8 years.  Coryza Biphtheritica.  A year ago suffer-
ed  from malignant scarlet fever, during and  after which  time  there
were large glandular swellings around the neck.   At  the  same time,
the nose was obstructed for a long period.  Since which, she has had
a  mucous or viscid  discharge  from the  nostrils, sometimes with an
offensive smell.  At present no glandular swellings; not even enlarg-
ed tonsils, but they look torn and cicatrized.  Mucous membrane of
the nostrils, as far as they can be examined without instruments, in-
jected, livid,  velvet-like.  Treatment: Injections, four times a day, of
R.—Zinci. sulphat., 3ii.; aq., §vj.
   65. Francis McC, aet. 5 years.   Tuberculosis of the right lung' up-
per lobe.  Father died of tubercular phthisis;  mother is well; patient
is but poorly developed, small and emaciated, chest narrow, subclavicu-
lar region a  little sunk, hepatic region promiuent, and  liver enlarged;
had measles  six mouths  ago, and  has  been coughing and declining
ever since.   Dull percussion  sound  in right subclavicular region and
fossa supraspinata; respiratory murmur diminished, with slight mucous
rales; puerile  respiration on  the left side.   The diagnosis supported
principally by  the hereditary predisposition.  Treatment:  Generous
diet, gymnastic exercise,  cod-liver  oil;  general  condition apparently
improved a month afterwards, but physical symptoms the same.
   66. Herrraan K., aet. 7 years.  Pneumonia, right lung, upper lobe.
Hepatization; fever moderate; dyspnoea not exceedingly great.  Dull
percussion sound; bronchial respiration;  no mucous rales.  Treatment:
R —Oxysulphur. autimon., gr.  xii.;  sacch. alb., 9ij.  M. f.  pulv.
Div. in p. aeq. No. xvj. D. S.:  a powder every  two hours.  After
three days:  Dull percussion sound less extended; mucous rales;  same
treatment.
   67. Elizabeth L., aet. 6 months.  Tinea favosa,  (cf. Case 5.)   Re-
peated cauterization of the fungous deposits, with solid nitrate of sil-
ver; and later, concentrated acetic acid.
   68. Eugene S., aet. 2 years.  Paralysis Essenlialis.  Catarrhus In- 
CLINIC  FOR DISEASES OF  CHILDREN.
23
 testinahs.   The lower  extremities are almost entirely paralyzed, the
 extensor muscles apparently more so than the flexors.  This paralysis
 was first noticed two months ago, without any premonitory symptoms.
 The child is reported to have  been put  to  bed in its  usual  health,
 and  unable to move  the  following  morning.   A .number of such
 Cases are recorded in literature, but a larger number have been report-
 ed as  having been preceded by some feverish attack.  Thus antecedent
 attacks of eclampsia, inflammatory diseases,  eruptive or other fevers,
 have been observed to have been the ultimate causes of infantile paraly-
 sis.  At any rate, we are not justified in assuming that infantile paralysis
 has a different pathology and etiology from that of cases of paralysis
 in advanced life.   It depends on  the impaired action of some  part of
 the nervous system; it is the residue of a disease progressing with ma-
 terial  alterations  in  either the  nervous centres  or the  nerves, which
 either suffer from congestion, or inflammation, or extravasation, with
 their consequences.  These may be removed, sooner or  later,  by nat-
 ural processes;  thus, either the paralysis is also removed, or  it con-
 tinues in such cases where the nerves have already lost  their irritabil-
 ity.  As a general rule, such cases of so-called infantile paralysis have
 a great tendency  to  improve; for most cases, when they are brought
 under our observation, have had time to  get a little better than they
 were at the beginning, in consequence of absorption  to  a certain ex-
 tent having taken place.  In a small number of cases, more limbs are
 primarily  affected than  in  the  present case;  as  for  instance,  all the
 upper and lower, or an upper and the two  lower extremities.   But
 after a while, the two lower extremities,  or even one of them only, re-
 mains paralyzed.   But here, the spontaneous improvement comes to
 a stand-still, and even medical  service is sometimes  unable to render
 any services iu the recovery of the lost muscular functions.  This pa-
 ralysis, therefore, is a very  obstinate disease, and yields no very prom-
 ising results.   But life  is seldom threatened by it, all  the other func-
 tions of the patients  remainiug perfectly normal;  so little, indeed, does
 it prove fatal, that a French author reports the case of a patient who
 became paralyzed in early iufancy, and reached the age of 49 years,
 and that very few authors have been so fortunate as  to have the op-
 portunity  of making a post-mortem examination.   Rilliet and Barthez
 made two post-mortem examinations, in which nothing was found that
 could be taken as the cause of paralysis; and Fliess, in a case of pa-
 ralysis of the arm, found congestion of the spinal membranes at about
 the level of the brachial plexus.  From  the  fact  that  few cerebral
•symptoms, or none at all, are observed in cases of  infantile paralysis, 
24
CLINIC  FOR DISEASES OF  CHILDREN.
we have a right to conclude that the  seat of  the  affection must  be
Bonght for, generally, below this centre.  Some cases will be produced
by influences acting on the peripheric nerves—for instance,  rheumatic
ones; and. such will be those giving the scantiest results of anatomical
examinations—a-fact which is easily explained by both the exceedingly
great difficulties of detecting material alterations  in  the  peripheric
course of the nerves, and the length of time that elapses between the
first paralytic  attack and death.  Bat the vast majority of  cases are
of spinal origin.  Heine even goes so far as to consider  none but spi-
nal cases as entitled to be called infantile paralysis, and to describe
it  by  the name  of spinal  infantile  paralysis.   In  the  spine,  the
same alterations as  found in the  cerebrum  are met with; extrava-
sations are  not so frequent  in  the brain;  but there  are cases  on
record, and cases  of spinal congestion, inflammation,  and exudation,
will  occasionally occur in practice.   The majority of cases will be met
with at the age of from six months to two years, at a period when the
growth of the body is very rapid, and particularly the  development of
the nervous centres considerable.   At the  same  time, it so happens
that the first dentition takes  place also; and as generally a  number of
diseases, almost all  the diseases, indeed, of infantile age that  do not
proffer a very ready explanation or diagnosis, have beeu explained  by
and  attributed to dentition, this paralysis  occurring in  children has
been attributed to dentition,  and has ever been called  dental  paraly-
sis, with just  as little  right as we are  justified in speaking of dental
meningitis, or pneumonia, or intussusception.
   In our case, the probability is, that the premonitory symptoms have
been overlooked.  A mild fever may have  been present  without hav-
ing  been noticed;  at all events, as  there  neither are  nor  have been
any cerebral symptoms, we cannot  seek for the seat of the  disease in
the  brain; as two extremities are affected, both cotemporaneously and
in an equal manner, we certainly have no  case of  an affection of a
peripheric nerve before us.   Therefore, we are bound to take  it as a
case of spinal paralysis.   The probability in our case is, that it is the
result of congestion, and, as  it is of pretty long standing, without any
spontaneous improvement taking place, exudation—the former alone
being well able to produce paralysis, and the latter being likely to be
present unless there is extravasation of blood  in cases of longer dura-
tion, and exhibiting no change.
   The question of therapeutics  is  a very important one, and will be
answered  according .to the  diagnosis of the material lesion and the
stage of the disease.  In the acute attack, with fever  and sensitive' 
CLINIC FOR DISEASES OF  CHILDREN.            25
ness of the spine, etc., local  depletion, mercurials, antifebriles, etc.,
might be indicated.   Certainly not so in an old case.  Extravasation
will scarcely be the object of remedial treatment.  Congestion would
require, perhaps, local depletion and derivants; at all events, however,
such medicinal agents as are known to have  some influence in con-
tracting the lumen of the blood-vessels—for instance, quinine or secale
cornutum.   Exudation would indicate the  administration of  absorb-
ents, such as mercurials,  iodine,  and more or less powerful derivants,
both  external  and  internal.  Loss of  sensitiveness  of  the nerves,
finally, without any, or proceeding from a past, anatomical lesion, would
require the use of such remedies  as are known  to act  as powerful
stimulants for the nervous system, such as nux vomica and its prepar-
ations;  not to speak of gymnastics,  active and  passive movements,
faradization, frictions, etc., for the purpose of re-establishing the func-
tions of the muscles.   Thus, indeed, local depletion, vesication, moxae,
iodine, mercury, and strychnia play the most important part in all the
essays on the  treatment  of infantile  paralysis.
   Congestion, and probably  exudation, are likely to  have been the
anatomical change in or on the spinal column.
   Treatment : Passive movements  ; secal. cornut. recent, pulv., gr.
iii., three times a day; increased  to gr.  iv. after a week, and v. after
two weeks; and syr. ferri iodidi, gtt. v., viii., x., three times a day.
   A decided change for the  better already, four weeks afterwards, at
which time the  patient was  presented for an  intense pharyngitis; for
this he took for four days the following mixture:  R.—Chlorat. potass.,
3iii.; aq., §vj.   M.   D.  S.:  Haifa table-spoonful every two hours.
   69.  Charles P., aet. 7 years.  Anamia, Morbus Coxarius, left hip, first
stage.   Is  reported  to have  enjoyed  good health, with the exception
of occasional epistaxis,  until  three years ago, when he had a haemor-
rhage, probably from the stomach. Since that time, he is said to have suf-
fered from strabismus, loss of appetite and flesh, aud diminution of men-
tal powers. Ten months ago, he had a feverish disease, with unconscious-
ness and delirium, for thirteen days.   Three months ago, he complain-
ed for a  week of fever and pain in his left side, but has been well since.
Skin and conjunctivae pale, general emaciation, impulse of heart strong,
no enlargement of heart, lungs normal.  Fell  from a chair five  weeks
ao-o; complains of pain and stiffness after getting up in the momiug,
is easily  tired, drags his  left foot a little, and has pain  in left knee aud
ankle; some pain on direct pressure on the hip joint, and more by press-
im>- the caput femoris against the acetabulum.  The gluteal region of
the affected side commences to enlarge, and the fossa iutertrochauterica 
26
CLINIC  FOR  DISEASES OF  CHILDREN.
 to disappear.   Thus, the first stage is on the point of being transform-
 ed into the second.  Treatment: Five leeches to the hip-joint, to be
 repeated  after four days; Davis' splint; generous diet;  cod-liver oil,
 and  ferr. pulv., gr. iv. daily.
    70.  Rosa S., aet. 5 years.   Microcephalus,  Catarrhus Tnlestinalis, Li-
 enteria.  Hasan older brother, and a younger sister, both healthy and
 well developed, both physically and mentally.  Circumference of the
 head 17|  inches;  longitudinal diameter being normal;  frontal bone
 low aud narrow; anterior part of the cranium very small in proportion
 to its posterior; cranium solid and hard; face proportionately large, es-
 pecially the lower maxilla, strong and prominent; lips full and hanging;
 tongue prominent and thick; constant salivation; no articulation; rest-
 less,  troublesome, always laughing, breaking anything, passing faeces and
 urine carelessly; sleep sound,  with the exception of  sudden  interrup-
 tions;  extreme voraciousness;  swallows everything,  clean or dirty;  a
 large number of ingesta, food and other, will  pass the bowels unchang-
 ed; frame  robust and strong; the mother knows that this patient ex-
 hibited no  pulsation over the  region of the large fontanel, like her
 other children. The anatomical cause of this microcephalus and idiot-
t ism is evidently a precocious ossification of the cranial sutures, particu-
 larly the frontal aud coronal.   No medical treatment possible.
   71.  Mary Y., aet. 5 years.   Kyphosis of seventh and eighth dorsal
 vertebrae.
   72.  Ann M. L, aet. 1 year, 5 months.   Kyphosis of the  seventh and
 eighth  dorsal vertebrae.
   73.  Wilhelmiue  B, aet. 5 years.   Kyphosis of the last  dorsal ver-
 tebrae.
   74.  John G., set. 2 years.  Kyphosis of  twelfth dorsal and  first
 and second lnmbar vertebrae.
   75.  Thomas D., set. 8  years.  Kyphosis of lower cervical and upper
 dorsal  vertebrae.
   76.  John K., aet. 2 years, 8 months.  Kyphosis of seventh cervical
 and first and second dorsal, and of twelfth dorsal and first and second
 lumbar vertebrae.
   All  these cases of Pott's disease that were presented at the  clinic
 had  so many  symptoms and peculiarities in  common, that they  may
 safely be mentioned together.   Scarcely in any one of them was there
 a scoliotic deformity combined with kyphosis, and  there was  only one
 case  out of six not decidedly scrofulous.   Only one  out of the whole
 number had the same affection in two different parts of the vertebral
 column, viz., No. 76. He had never been a  thoroughly healthy boy; 
CLINIC  FOR  DISEASES  OF  CHILDREN.
27
the first symptoms of rhachitis still perceptible in the enlargement  of
his epiphyses and curvatures of his legs; he further had been suffering
from pulmonary troubles since he had n easles, when a year old.   Mu-
cous rales are still heard on both  sides; bronchial  respiration in the
upper lobe of right lung, and decidedly dull sound in right subclavicu-
lar region.  During the time he was presented, we  had  frequent occa-
sion to prescribe for a  new attack of bronchitis.  He was  extremely
emaciated, his submaxillary glands much enlarged,  and  eyes suffering
from chronic conjunctivitis.   Three months after he was first present-
ed, he all at once, in addition to his former  sufferings,  showed symp-
toms of the second  stage of morbus coxarius.   About a  week after
this, he was takeu ill with an acute  feverish disease, probably of one
of the thoracic  organs, the nature of  which may, or  may not, have
been explained by a coroner's inquest, no medical man having been in
attendance to make a diagnosis.
   In almost all the cases, a fall was accused of having  been the causa
proxima of the affection.   Pain over and  in the neighborhood  of the
affected vertebrae; moderate fever; sometimes hyperaemia of theskin;
immobility of the vertebral column; disinclination  to walk or stand;
tendency  to support the body by pressing the hands  down  on  the fe-
mur; absence of almost any symptoms of spasm, or paralysis, or sup-
puration, was found uniformly in all of them.
   The  treatment was  somewhat uniform  also; at least,  as to the
care given to the  general health.  Generous diet, cod-liver oil,  aud,
in the majority  of cases, the internal use of iron or quinine.  Quiuine
was generally given as a tonic, in more frequent  and small doses;  in
some cases in single daily doses, of from five  to eight grains, as an an-
tifebrile.  The  patients were kept in  a horizontal position, on their
back or side, for a sufficient time to reduce the acute pain, and at the
same time, in some cases, leeches were  applied repeatedly;  in others,
tinct. iodin. for some time.  Then, at last, an apparatus was advised,
and usually made  by Messrs. Otto & Reynders, to support the trunk
without inconvenience  to the inflamed vertebrae, and without the least
direct pressure  on the curvature.  In  one of the  cases its effects  in
removing the pain, evidently produced by spasmodic action of the lon-
gissimi dorsi, etc., was  wonderful; the  child had complained of this
pain continually, both  in the erect and the supine positions,  before the
use of the apparatus, but was so entirely relieved while it was on, that
she refused to sleep without it.
   77. Maria B., aet. 9 years.  Atrichia Circumscripta.   Patient is a
healthy-looking  child, with  well-formed head and soft aud thick hair. 
28
CLINIC  FOR  DISEASES OF  CHILDREN.
There are, however, on the lateral, and  particularly on the upper and
posterior portion of the scalp, some twenty  or  thirty spots, of the
average size of a Lima bean, entirely bald, and of  a white appearance;
they are not covered with any secretion or scab,  but they are elevat-
ed, forming  small tumors.  All those which have recently arisen are
somewhat painful on  being pressed; those, however, of longer stand-
ing are  not sensitive.  The  whole process commenced  a year  ago;
in no instance has hair grown again where it once fell out.   Before a
microscopical examination was  made, and  before the idea  of a para-
sitic  origin  of the disease was  thereby  suggested, the  following pre-
scriptions were given:  R.—Liq hydriodat. arsenic, et hydrarg.,(Don-
ovan,) §ss.  D. S.: 8 drops to be taken  twice a day.  R.—Bichlorid.
hydrarg., 3i., aq.  lb. v.  M.   D. S.: for external  use.  The micro-
scope showed the absence of  fungi, and  the case was then taken, the
symptoms,  moreover, perfectly corresponding with this  diagnosis, as
one of inflammation and induration of the follicles, with lasting pres-
sure on, and injury to, the roots of the hair.  Treatment: R.—Iodid.
potassii, 3ij.; aq., §iv.  M.   D. S.: A tea-spoonful three times a day.
R.—Iodid. sulphur., 9j.; adip. suilli, §j.  M. f. ungt.  D. S.:  For exter-
nal use, three times a day.  When last presented,  no new bald places
had arisen,  and the old oues were less indurated, but no  hair had  as
yet reappeared.
   78.  Isidor H., aet. 5  months.   Hamorrhagice  Subculanece  et Me-
ningum.  Mother of patient is a dirty, thin, poorly nourished woman,
with flabby breast, with other children who never showed similar symp-
toms.   Patient is a small child,  with thin lower extremities, otherwise
apparently well developed, but with sallow skin generally, and enlarged
liver.   On his cheeks, temporal  bone, chest, abdomen, back, in short,
over all the  surface of his body,  the skin is of a dark livid, brownish
color, elevated and hardened,  to compare with the induration and ele-
vation of urticaria.  But the circumference of those spots is  larger, be-
ing from one to six or eight square inches in size.  Thus, the color'and
nature of the disease being evidently of  petechial  character, the local
affections are enormously  larger.  Gums  not affected.  Lower ex-
tremities paralyzed for some time; as long, indeed,  as the haemorrhages
have occurred under and in the external skin.   Thus, the assumption
of haemorrhage inside the  vertebral column having taken place co-
temporaneously  with the others,  is more  than  probable.   Further,
the assumption of local affections  being the cause  of the haemorrhages,
almost countless in number, must be given  up.   The cause must  be
looked for in either a thorough change in the composition of the blood, 
CLINIC  FOR DISEASES OF  CHILDREN.            29
or a decomposition of  the walls of the blood-vessels, or  both.   For
such only are the means of explaining the haemorrhages occurring  in
all the cases of poisoning and decomposition of the blood, as in  pur-
pura, scarlatina, typhoid fever, scurvy, and others.   Treatment: Reg-
ulation of diet,  fresh  air, beef, etc.;  acids,  both vegetable and mineral,
carefully to be avoided—because, contrary to the belief in the styptic
powers of acids, nothing will  add more to  the decomposition of the
blood than a continued administration  of acids; and R.—Tinct. fer.
muriat., five  drops  every four hours.   This was from time to  time
changed for syr. ferr. iodat. in similar doses, but the treatment has  been
continued ever since, for five months.   Child meanwhile thrives; haem-
orrhages gradually change their color into a greenish-yellow; no new
ones make their appearance, and  those existing lose considerably in
intensity; the motory power of the lower extremities greatly improved.
   79.  Leonard H., aet. 3 years and 6 months.  Phlegmone, Cellulitis,
and Periostitis of first toe, right foot, caused by traumatic injury.   In-
tense pain for some weeks past; toe of a  deep-red  color, nail thrown
off;  abscess near matrix.   Treatment:  Deep incision to  the bone of
the last phalanx, and cold  water to the part;  after some days, appli-
cation of Goulard's  water with tinct. opii.
   80.  Michael T., aet. 4 months.    Eczema Capitis.   Apparently  mild
case, but is likely to  prove obstinate, as probably the breast-milk of the
mother, now constituting the  only food, is insufficient nourishment.
Treatment: Soap and water, and  frequent application of zinc, sulphat.,
3j.; axung. porci., 3vj.; continued for several weeks before  the scalp
appeared entirely clean.  Returns after  two months with  the same
symptoms, the eczematous scabs  being  even thicker  than before.
Treatment: Two meals daily, (in addition to breast-milk, which appears
very white and heavy,) of beef-tea, well salted;  and R.—Liq. potass.
caust, 3j.; ol.  morrhuae, §j.  M.    D. S.:  To be applied twice a day.
   81. Samuel D., aet. 5 years.   Terrores Nocturni ex Febri Intermittente.
 Spasmus Vesica Urinaria.  Is well all day, takes his food regularly,
his supper  at 6 p. m., goes to bed between 8 and  9 p. m., awakes  with
feverish symptoms and night terrors between 10 and 11 p. m., and can
hardly be quieted before  midnight.   Digestive  organs in order;  no
constipation;  no worms; heart normal, both in  anatomical  condition
and function;  no cerebral symptoms except  those mentioned; this
condition of things  has  come on suddenly, and has continued for
more than a week;  moreover, he has  a constant inclination to  pass
urine; its emission is scanty  and painful; no mucous deposits report-
ed to have  been observed by  the father.   Treatment: R.—Sulphat. 
30            CLINIC  FOR  DISEASES OF  CHILDREN.
 cinch., gr. xv.   Div. in p. ii.   D. S.: a powder at 7 o'clock, p.  m., on
 two subsequent days; besides, R.—Pulv.  rad. belladonn., gr. viii.;
 sacch. alb., 9ij.  M. f. pulv.  div. in p. aeq., No. xvj.   D. S.:  three
 powders  a day.  Reported to be  well after a week; no more night
 terrors after the first dose of quinine.
   82. Francis 1*., act. 7 years.  Benles  Incisores Ohliqui.   The mid-
 dle permanent lower incisors have protruded before the temporary had
 fallen out, aud point inward aud  upward.   The temporary teeth  ex-
 tracted.
   83.  Charles  B., set. 2 months.   Frenulum Lingua  Oblongatum.
 Incision.
   84  James A., aet. 9 years.   Bilatatio Cordis.  Anaemia.  Patient
 is believed to have been well during the greater part of his life, but
 for two months past  he has been exposed to five attacks  of a peculiar
 nature.   Shortly after falling asleep, he awoke with twitching of the
 muscles of the right side of face, which lasted about a minute;  after
 this his limbs got slightly rigid, a rattling noise was heard in his throat,
 his face grew pale, and his mental faculties seemed somewhat obnubi-
 lated for a short while; meanwhile his health otherwise, and his appe-
 tite, are not impaired.  A younger sister of patient fell sick half a year
 ago with  attacks of convulsions; she died after four weeks' illness.  A
 brother of twenty-one years  of age died after an illness of eighteen
 days, after having previously  repeatedly suffered from palpitations of
 the heart; they would return in a very troublesome manner whenever
 he partook of stimulants during his malady.   He died suddenly,  after
 half an hour's palpitation of the heart, brought on by taking a small
 quantity of brandy-punch.  This patient is very tall  for his age, thin
 and  pale; conjunctivae very anaemic; impulse of heart and pulse very
 feeble;  pulse 116; external veins on thorax  and abdomen greatly  in-
 jected;  dull  sound  on sternum and left side of thorax, from third  to
 sixth ribs ;  attacks  of weakness  and  syncope  from   time  to  time.
 Treatment:  Air, generous diet.  R.—Ferr. carbonat., 3j.  Div. in  p.
 aeq., No. xxx.  D. S.: three powders daily.   This treatment was con-
 tinued for a long time, and patient was, and  felt, greatly improved.
   85. Maria M., aet. 2 years.  Stomatitis. Amygdalitis.  Mucous mem-
 brane  of  the mouth, tonsils,  and pharynx  highly injected;  tonsils
 swelled, and  to be  felt externally;  tongue red; papillae clavatse ele-
vated; breath not particularly foetid; submaxillary or cervical glands
not particularly swollen.   Treatment:  R.—Chlorat. potass.,  3iii.; aq.,
§vi.   M.   D. S.: A tea-spoonful every hour.
   86. George B., aet. 6 years.   Rhachitis.   Is reported to have been 
CLINIC  FOR  DISEASES OF  CHILDREN.            31
affected with scarlatina when eight months old, this being about the
only sickness he has ever suffered from.  He  is not well developed;
his frame small; face and general appearance anaemic; intellect good.
The upper and lower condyles of tibiae are greatly swollen; so is the
lower  of the radius;  tibiae show curvature  inward; sides of the
thorax flat, there being nearly a right angle  in about the half length
of all  the ribs;  sternum  prominent;  no scoliosis;  impulse  of heart
very strong; sounds audible  at  a gre.it  distance; no disease of the
lungs,  except general  compression.  Treatment,  besides regulation of
,jiet: R.— Ferri. phosphat., gr. iv., three times a day; cod-liver oil.
   87.  Thos. J., aet.  4 years.   Fraclwra Clavicula, extr. Acromialis.
Clavicle was fractured in its outer third, transversely, from  a fall on
the  hand  and elbow.   Treatment: Mitella, fastened by  a  few pins.
Presented well a fortnight after.
   88.  James A., aet.  9 years.   Herpes Circinnatus, (ringworm,) on
four distinct localities  on  abdomen and right femur, of a quarter of
an inch to two inches in  diameter.   R.—Sulphat.  ferri, 5j.; Cerate
simplic, 3vj.  M. f. ungt.
   89. George F., aet.  12 years.  Prolapsus  Recti.   Had dysentery
 last year, and has suffered from prolapsus of the rectum  since.  The
 rectum, with all its  membranes, will  protrude about an inch aud  a
 half through the  anus after each defecation,  viz.. twice or three times
 a  day.   The  mucous  membrane will frequently bleed,  is  livid and
 swelled.   Treatment: R.—Ext. nuc. vom. ale, 9j.; cerat. simplic, 3ij.
 M. f.  ungt.  The size of a bean to be introduced three times a day.
 Reported a week after so much better, that sometimes a defecation
 will take place without prolapsus, and that the  rectum will  generally
 protrude but once a day.   Treatment had,  however, to be contiuued
 for six weeks.
    90.  John O'L., aet.  3 years,  3 months.   Prolapsus Membrana Mu-
 cosa Recti.  The  mucous  membrane will protrude after every defeca-
 tion,  (1 or 2 a day,)  for a little more than half an inch.   Patient has
 been sufferin"- from chronic intestinal catarrh  for a number of weeks,
 and has not been well for more than a fortnight.  R.—Acid, tannicae,
 3iii •  aq.  lb. iii.  M.   D. S.: An injection of an ounce to be made three
 times a day.
    91.  George C, aet. 2 months.  Fungus Umbilicalis.  Firm cicatri-
 zation has never taken place after the falling off of the funis, but a
 pediculated excrescence has been observed  growing from the wound
 for a number of weeks.  Now it has reached the size  of a bean.
 Treatment: Ligature. 
32            CLINIC  FOR DISEASES  OF CHILDREN.
   92.  Esther B., aet. 4 months.  Intertrigo.   The  folds of the neck,
 groins, and femur are partly erythematous, partly ulcerated, after hav-
 ing lost their epidermis.  The child is  well, fat, and hearty; no  diar-
 rhoea;  no  morbid predisposition probable.  R.—Sulphat. zinci.,  §ss.
 D. S.:  To be dissolved  in a quart of water, and applied externally.
   93.  N. M., aet. 4 months.  Intertrigo.   The folds of neck and groins
 erythematous.   No ulcerations.  The child, when presented, was  wet
 and dirty.   Scrofulous;  cleanliness and  cold water  recommended.
 Three  days after, still erythema.  Goulard's wash.
   94.  Mary L.  D., aet.  3 months.  Atheroma.   A small circumscribed
 tumor  of the size of a small revolver ball, on the outer end of left super-
 ciliary  arch;  not painful;  believed to have  been  caused by a fall
 some weeks ago.  Treatment:  Subcutaneous discission  and pressure.
 A clear, viscid liquid was squeezed through the external wound.
   95.  Ann L.,  aet.  12 years.   Chorea  Minor.   Involuntary move-
 ments  of all the  voluntary muscles, particularly of the right side.   Dif-
 ficulty  in speaking, swallowing; twitching  of the muscles of  the  face;
 sometimes, for a short time, strabismus.  Has been in about the same
 state for three months, without any premonitory symptoms, or with-
 out any preceding disease except a mild intestinal catarrh.   Jso  pul-
 monary symptoms; no heart disease.  Never had acute rheumatism.
 Is very tall for her  age,  and  anaemic; impulse of the heart pretty
 strong; cheeks and conjunctivae pale.   No fever.  Treatment:  Solut.
 arsenic. Fowler, §ss.   D. S.:  three drops three times a  day;  and
 R.—Syr. ferri iodid.   D. S.: twenty drops three  times  a day.  Pre-
 sented, after three weeks, greatly improved.
   96.  Charles L., aet. 9 months.   Vaccination  performed.
   97.  Peter L., aet. 8 years.  Helminthiasis.  A number of ascarides
 have been passed, previous to which, the boy had suffered for months
 from restlessness and occasional night terrors; from diarrhoea alter-
 nating  with constipation, and loss of  appetite, interrupted by vora-
 ciousness.  Cheeks bloated.   Pupils enlarged.   Treatment:  R.—San-
 tonia.,  gr. viii.;  Submuriat.  hydrarg., gr.  xv.   M.  f. pulv. div. in p.
 aeq. vj.  D. S.: Take three powders a day.
  98.  Edward P., aet. 12 weeks.   Eczema Capitis.   Conslipatio.  A
 brother of this patient, now  three years old, has  had an eczematous
eruption since his fourth month.  Thus, there  is probably a morbid
condition common to both, or the cause is to  be sought  for in  the
breast-milk of the mother.   Child is mostly constipated, having a pas-
sage once  a day, or once in two days.  Faeces look white, curdled,
are hard, and not of a uniform character.   The milk of the mother 
CLINIC  FOR  DISEASES OF  CHILDREN.           33
looks also whiter, and is less sweet than normal.  Thus, at all events,
there is some fault in the nutrition of the patient, being the probable
cause of both eczema and constipation, viz., superabundance of caseine
in the composition of the milk.  By  restoring a more normal composi-
tion, we shall probably remove one,  and greatly relieve the  other of
the two complaints.  Evidently, there is sugar wanting in the moth-
er's  milk,  if nothing more.   By restoring the power of producing lac-
tic acid, the caseine will  be digested and assimilated, and  the bowels'
will  no longer remain constipated.   Treatment: Give  the child, each
time before he is put to the breast, a tea-spoonful of powdered white
sugar in a little water.   Wash the head  with  soap and  water  thor-
oughly, three  times a day,  and afterwards rub it with, R.—Zinc.
oxyd. albi, 3j.;  adip. suilli, 3ij.  M.  f. ungt.  Child  had no constipa-
tion when presented a fortnight afterwards; fauces yellowish and uni-
form.   Eczema doing  well.
   99. Ellen McK., aet. 4 years.  Broncho-Pneumonia, Rhachitis,  Ana-
mia.  The girl is emaciated and anaemic from  two causes.   She has
been rhachitic for years, and suffering from bronchitis  and pneumonia
for six weeks.   Her limbs show the symptoms of rhachitic curvature
 and intumescence; her ribs are  laterally compressed;  cheeks and mu-
cous membranes very pale.  Percussion sound dull  over left fossa
supra-spinata;  mucous rales over left lung, both  anteriorly and poste-
riorly.   No fever,  no dyspnoea,  both of which are  reported  to have
been very intense some weeks ago.  As the pulmonary symptoms are
evidently diminishing spontaneously, the greatest care is to be  given
to the general health; the more so as the appetite is very low, tongue
furred, and pulse small and frequent.  Treatment: Nitrogeneousfood,
fresh air, and  R.—Sulph. cinchon., 9j.; subnit. bismuth, 3ss.   M. f.,
pulv. div. in p. aeq. No. xii.   D. S.: Three powders  a day.  This pre-
scription is again given after  some days, and digestion being in fair
order, cod-liver oil recommended.
   100. Mary D., set. 1 year, 2 months.  Oxyuris Vermicularis.   For
 a number of weeks the child has been observed to scratch  his anus and
 genitals,  both of which  are hyperaemic.  Slight discharge from vagi-
na.   Tenesmus.   A number of oxyurides have been found in the evac-
uations.   Treatment: Injections once a day, for three  days, of a fresh-
 made decoction of garlic in milk.  Cold water externally.
   101. James T.,  aet. 8 months.  Eczema Capitis.
   102. Edward P., aet. 3 months.  Eczema Faciei et  Colli.
   103. Conrad G., aet. 5  years.  Eczema Capitis et Faciei.
   104. Eliza C, aet.  3  years.  Eczema Capitis.  Rhachitis.  Catar-
             3 
u
CLINIC  FOR  DISEASES OF  CHILDREN.
rhus meatus auditorii extend.   Of these cases of eczema, 101 and 102
were such as are very common in general practice; cases of eruption
attending the normal development of early infancy.   The seat of the
greatest intensity in this development appears to be in both the solid
and soft parts of the head, exhibiting not only in its normal effect the
rapid growth of the  bones of the cranium and face, the  process  of
dentition,  and a high temperature of the cranium, but also, as morbid
symptoms, an exceedingly great inclination  to convulsive and exuda-
tive diseases.  Thus it happens that these eruptions are, under differ-
ent names, often considered not as co-ordinates of, but as results from,
a coincident process, viz., dentition.   Now, as they are, in many cases,
to be taken as  excesses of a normal  process, it  follows, first, that ec-
zematous eruptions, of long duration and great intensity in very young
children, must not be suppressed at  once, (cf. 38,) and further, that
such cases are apt to prove very obstinate;  the more so, as in a num-
ber of  cases some  errors of diet, sometimes  arising from a  defective
constitution of the breast-milk, are amongst  the causes.   101 and 102
were ordered to have  the scabs removed by the frequent use of soap
aud water, and three times daily: R.—Zinc.  oxyd. alb., 3j.; adip. suilli,
3vj.  M. f. ungt.;  and  in addition, the diet of the first was  changed,
so as to be more animal.   103 was a very hearty and stout boy, with
hard and solid  scabs  all over his head and face, nose and  eyelids
scarcely excepted, covering a  layer of  pus  and  the sore scalp.  The
layer of dried-up pus, epithelium and dirt  was so thick, (from l2-\
inch,) that the features of the boy could not be recognized.   He was
reported to have been  affected with this eruption for the  last four
years;  that it sometimes had disappeared, but always returned.   This
case was ordered to be submitted to a universal combing, oiling and
soaping, and to be presented three  days afterwards.   From  this time
forward he was washed, five  or six times  a day, with  a solution of
sulphate of zinc in water,  (gr.  vj.-xii. to §j.)   104 was a poorly-look-
ing girl, with eczematous  pustules  all over  her  head, after  like pus-
tules had disappeared  from the whole surface of her body, with symp-
toms of generally bad development.   Glands were found to be swelled
around her neck in a larger number than could be explained by the
presence of the eruption; even some of the inguinal being  tumefied.
Catarrh of the external ears, with muco-purulent discharge, had been
observed for several months, without there  being an  affection of the
inner ear  or  the  tympanum, and the  large fontanel was still open.
As this is  closed, not by osseous matter, but a  solid fibrous  bridge to
such an extent as not  to allow the pulse to  be felt  through it, at thir- 
CLINIC  FOR  DISEASES OF  CHILDREN.            35
teen or  fourteen months of age, in normally developed children, this
case exhibits a decided want of development in the  osseous system.
Moreover, the lower extremities show curvatures,  and the radial ex-
tremities of both forearms are swelled.  The discharge from the ex-
ternal  ear was  submitted to injections of: R.—Sulphat.  zinci,  9ij.,
aq. §vj., three times a day; the eczematous eruption treated with soap
and water,  and R.—Acid, tannic, 3j; adip. suilli,  3vj.   M. f.  ungt.
D.  S.:  To be rubbed in three times  a day; and the general constitu-
tion improved by mostly an animal  diet, and the use of  three  doses
daily of half a table-spoonful of cod-liver oil, with ten drops of syr.
iodid. ferri.
   105.  John S., aet. 5 years.  Heroes  Circinnatus (Ring-Worm) on
four different  places of left shoulder, neck  and face, of a diameter of
from half an inch to nearly two inches.  R.—Sulphat.  zinci, 3j.;  adip.
suilli, 3vj.   M. f. ungt.   D. S.: For external use, four times a day;
the same dose repeated after a week, when the boy was not yet quite
well.
   106.  Catharine B., aet. 3 years.   Atrichia Localis.  Erythema et
"Eczema.  The child had been severely burned over and near her large
fontanel when four months old.  No hair had grown there since, but
the spot had almost always been  sore.  Usually there would appear
small herpetic or eczematous vesicles, that would  dry up and fall off
after a while, leaving  a  sore  and sensitive  surface.  The skin  had
never looked natural.   Treatment consisted in  the frequent  applica-
tion of  a solution  of bichloride of mercury in distilled water, (gr. j. to
§j.)  The color  and consistency of  the skin grew more natural from
week to week, but the local baldness was not removed.
   107.  Patrick  T., aet. 4 years, 6  months.   Catarrhus Lnryngis.
   108.  Mary R.,  aet. 5 years.  Catarrhus  Laryngis et Pharyvgis.
   Both of these patients have the peculiar croupy cough  depending
on  catarrhal affection  of the mucous membrane of the larynx, with.
out  any affection  of the bronchi  or lungs, and with very moderate
fever.   107 was soon relieved by  the use of syr.  squill, compos.,
15  drops every two hours, and a single  dose, at bedtime,  of  pulv.
Dovcri,  gv.  iij.  The  other had  been  affected  with  measles fifteen
months  before, and was said to have coughed ever since.   Consonant
mucous  rales occasionally heard over  the bronchi, but none that could
be attributed to an affection of the bronchial mucous membrane itself;
no  diminution nor abnormal harshness of respiration; no dull  sound
on  percussion.   If, indeed, cough  has been  present  all the time, it
cannot  be explained by  any pulmonary trouble, but, depends  on the 
36
CLINIC  FOR  DISEASES  OF  CHILDREN.
catarrhal  affection of the larynx  aud pharynx  alone.  This  assump-
tion  is the more justified, the  more  it is proved by facts, that there
are few more obstinate affections than chronic pharyngeal  catarrh.
Treatment: Tinct, iodin. externally to the throat, twice a day.  Pulv.
Doveri, gr.  iij., every night.  Acid,  benzoic, gr. j., every two hours
for some  days; after which time, as the patient commenced to feel
relieved and to cough less, the expectorant was discontinued.   The
other treatment continued for some time, with good results.
   109.  Eliza S.,  aet. 1 year, 8 months.  Bronchitis.
   110.  Jeremiah G., aet. 10 months.   Bronchitis.
   111.  Edward D.,  aet. 3 years, 9 months.  Bronchitis.
   None of  these cases could  be  called severe.  The diagnosis  was
easily made, by the presence of sibilant and raucous rales; the former
predominant in 109  and 111, the latter in  110, (in  111  on the left
side only,) and the chest being sonorous  on percussion.  Fever mod-
erate; some dyspnoea in all of them.   No crepitating  rales  nor dull-
ness, no paroxysms  of cough.   In none of them was the  disease  a
secondary affection,  and all of them got well in a few days.   Internal
treatment of 109: R. —Oxysulphuret.  antimon., gr. viij.; extr.  hyos-
cyam.,  gr. iv.; sacch.  alb., 3ss.   M.  f. pulv.  Div.  in  p.  aeq.  xvj.
 D. S : A  powder  every  three  hours.  110:  R.—Muriat.  amnion.,
extr. glycyrrhyz., aa., 3'j ;  aq., §iij.  M.  D. S.: A tea-spoonful every
 two  hours.  Ill: R.—Oxysulphur. antimon., gr. xvj.; sacch.  alb.,
 9ij.  M.  f. pulv., div. in p. aeq.  No.  xvj.  D. S.: A powder  every
 three hours.  R.—Pulv. Doveri, gr. iij., every  night at bedtime.
   112. James J., aet. 7 years.    Tuberculosis, left lung, upper lobe.
   113. Edward D., aet. 3  years, 7 months.  Pneumonia, left lung.
   114. James McO, aet. 2 years, 3 months.   Bronchitis, right lung
 Pneumonia, left lung, upper lobe.
   115. Joseph F., aet. 14 years.  Pneumonia  Bilaleralis.
   116. Joseph McC, aet. 4 years. Pneumonia, right lung.  Rhachitis.
   Of 112 no exact history could be obtained, except  that the pa-
 tient had been coughing and  suffering for a long time.   Father said
 to be affected with  some pulmonary trouble.   Mucous rales all over
 the chest, especially in the right subclavicular region;  here, also, de-
 cided dullness on percussion.   Dyspnoea  moderate.   Pulse 124; res-
 piration  34.   Looks anaemic, and is evidently much emaciated.  Was
 taken to be a case  of pneumonia, right lung, upper lobe, accompanied
 by general bronchial catarrh, in its third stage, the hepatized parts being
 presumed to undergo a process of resolution.   No treatment was, there-
 fore, thought  advisable, except R.—Sulphat. quin., 3ss.,  div. in  p. 
CLINIC  FOR DISEASES OF  CHILDREN.
37
aeq. vj.  D. S.: A powder every morning.   After a week, the patient
was again presented. Yery few mucous rales; a few sibilant rales.  Dull-
ness in right subclavicular region as distinct as before; respiratory mur-
mur vesicular, and diminished; respiratory murmur in left subclavicular
region,  puerile; expiratory murmur  prolonged.  Nowhere  bronchial
respiration.  Moreover,  right subclavicular region sunk, and  right
thorax of less  circumference than left, by half  an  inch. From this
time,  the case was considered to be one of tuberculosis, and  an appro-
priate diet, animal food,  fresh air, gymnastic and other exercise, and
cod-liver oil, ordered.  No. 113 was  a very anaemic boy, who had suf-
fered  from  the first attack of  scarlatina five weeks before.   Thus he
had scarcely gone through the whole process.   This pneumonia was
in the left  lung, lower lobe, and probably small lobuli  had taken part
in the inflammatory process in other  places, as  there were sibilant and
mucous rales spread over the lungs   to a  large extent.  Treatment:
Pulv. Dov., gr. ijss., every night; sulphat.  quin., gr. vj., every morn-
ing. . No.  114 was a very instructive case, inasmuch as  it  distinctly-
showed the relation of bronchitis and pneumonia in the infantile lung.
When first seen, the child had bronchitis in the right lung, and a hep-
atized  upper lobe  of the right.  Treatment:  R. -Sulphat. quin.,
B'\).;  acid, tannic, gr.   viij.   M.   f.  pulv.    Div.  in  p.  aeq.  No.
xvj.  D S.: Two powders a day; and pulv. Dov., gr. ijss., every night.
 A week afterwards the  hepatization  had disappeared,  no dullness be-
ing perceptible any longer; but  where there was  bronchitis before,
hepatization had  now taken  place.   Under  a  similar  treatment,  the
 boy soon  recovered, but  some time  elapsed before his  anaemic and
general  weakness was overcome.  All the time, no sequelae of scarla-
tina were  observed.  Still better  than  in  this  case, the relation  be-
tween bronchitis and pneumonia, and the normal course of this latter
disease, was illustrated by No. 115, a boy of fourteen years, in whom
the disease had the peculiar lobular  character  of infantile  age.   He
 was presented on April  5th, with pneumonia, (hepatization,) in right
lung, upper lobe, anteriorly, aud bronchitis on  left side.  Treatment:
Generous   diet,  and R.—Sulphat. quin.,  gr.  xij.;  ac benzoic,  By,
gum-arabic, 3ss.   M. f.  pulv.   Div. in p. aeq., No. xvj.  D. S.: A
powder every two hours.  April 9th.—Dullness over right lung, up-
per lobe, diminished;  some mucous rales.   Bronchitis on left side ap-
parently in the same condition.  Same treatment, with the  addition
of some daily doses of bismuth, subuitrat., gr. v., as his digestive pow-
ers were very low in  consequence of an  inveterate gastric  catarrh.
April 12th.__No more  dullness  on  percussion over the right  lung;
 some mucous rales; some also in the lower lobe, right  lung, where no 
38
CLINIC  FOR DISEASES OF  CHILDREN.
infiltration had been before discovered.   Dullness on percussion over
left lung, upper lobe, posteriorly, with  bronchial respiration.   April
16th.—Yesicular respiration in right lung,  and  lower lobe left lung.
Mucous rales in, and slight dullness  on  percussion over  left lung, up-
per lobe.   No fever, no  dyspnoea, and  appetite  good.   Patient was
not presented afterwards.  No.  116 was one of the frequent cases of
lobular pneumonia in children whose constitution has never been good,
and whose lungs are, in  connection with  the  rhachitical misdevelop-
nient, very subject  to  catarrhal  affection.  Such are the very cases
that eminently  show the necessity of tonic  and  restorative diet and
treatment during the course of a large number of diseases of infantile
age, even such as are often believed, from their inflammatory charac-
ter, to require antiphlogistics, derivants, etc.  Such  are  the cases in
which quinine  in  large doses will prove  to be the  best antiphlogis-
tic   Treatment:  R.—Sulphat. quin.,  9j.   Div.  in  p.  aeq., iv,
D. S.:  A powder to be taken every morning and  afternoon.  Two
days afterwards, when  the fever  was less, and hepatization had fairly
commenced: R.—Sulphat.  quin., acid,  benzoic, aa.,  Bij.   M. f.
pulv.   Div. in p. aeq., No. xx.  D. S.: Give three powders every day.
   117. Rudolph M., aet. 1 year,  4 months.  Hernia Inguinalis Sinis-
tra.  Patient has had his inguinal hernia, left side, for a year.   Noth-
ing as yet  has been done for it.   Treatment:  Truss, to keep back the
hernia until the gradual change in the direction of the inguinal canal,
taking place in early infancy, will have  brought on a radical cure.
   118. Benjamin  B.,  aet. 3  years, 9 months.  Otitis Interna.  Pa-
tient had scarlatina a year ago, and hypertrophic tonsils still.   Was
observed to have a running ear soon after the scarlet fever.  Discharge
sometimes copious, sometimes little, white, yellowish;  in rare instances
bloody or serous.   Smell sometimes offensive; tympanum perforated
and  discharge evidently from the internal ear.   Hearing on the  left
ear impaired.  The disease is  evidently the  result of the throat com-
plication of scarlatina, transmitted through the Eustachian tube into
the internal ear.   Prognosis, after the process has lasted so long, un-
favorable as to a perfect restoration of hearing on the left ear.   Treat-
ment:  Blister  on the mastoid process;  utmost cleanliness,  and injec-
tions of a solution  of tannic acid in water, gr.  iv.  to gj.
   119.  Catharine  T., aet. 11 years.  Stomatitis, Pharyngitis.   Adeni-
tis Submaxillaris.   Inflammation of the pharynx and mouth was com-
plicated with swelling of the submaxillary glands to such an extent as
is  usually seen in diphtheritic inflammation only.   But no membranes,
nor any ulcerations which could  have been the seat of previous mem- 
CLINIC  FOR  DISEASES OF  CHILDREN.            39
 branes, were visible.  R.—Chlorat. potass., §ss.; aq., gviij.  M.  D. S.:
 Half a table-spoonful every two hours.
   120. N.  B. McF., aet. 3 years, 3  months.  Febris Exanthematica.
 Pulse 140; respiration 36;  face  flushed, and head very  hot.  Gen-
 eral temperature of all the body high; tongue slightly furred.  Mouth
 hot, and pharynx somewhat injected; tonsils and some lymphatic glands
 in the neighborhood a little swelled.  No cough, no dianhcea.  Threw
 up once.   No local disease being found, the case was pronounced  to
 be probably one of exanthematic fever, and  a daily dose  of sulphat.
 quin., gr. vj., recommended.   Three  days afterwards the  child was
 reported to be suffering from scarlatina.
   121. Michael C, aet. 4 years.   Ascites.  Patient had scarlatina ten
 months ago;  two months after this affection the dropsical  swelling of
 the abdomen was noticed.  Other accounts are difficult to obtain.  No
 anasarca, no  local pain;  no  local  disease  except the abdominal  effu-
 sion discovered.  The case was therefore, before an examination of the
 urine could be made, taken  as  one of hydrops depending on albumi-
 nuria, and  tannic acid, in three daily doses  of two grains each, was
 given for a fortnight.   Meanwhile no albumen was found in the urine,
 nor did the closest examination of every single organ reveal any ana-
 tomical degeneration that could be considered to be the cause of the
 disease.   The liver alone could  not be subjected  to a sufficiently rigid
 examination,  from the expansion of the  abdominal cavity with liquid.
 The treatment was therefore merely symptomatical and palliative, with
 the intention of stimulating  the secretions of other  organs.  R.—Iu-
 fus. colocynth., (e. gr. xij. parat.,) §iv., liq. ammon. acetat., syr. squill,
 aa., ij.  M.  D. S.: Half a table-spoonful four times a day.  The dose
 was gradually increased, until the perscription was this: R.—Infus. col-
 ocynth., (e. 9ij. parat.,)  §iv. ss,, iodid. potassii, 3v., liq., ammon. acetat.,
 syr. squill, aa., |j.   M.  D. S.: Haifa table-spoonful four times a day.
 The boy was under our care about seven weeks  altogether, and  was
 improved, but not cured.
   122. Sarah R., aet. 11 years.   Meningitis  Spinalis.  When patient
 was first  presented, on  April 19th, the following  history  was given:
 She had measles in January, 1860.   Afterwards, she constantly com-
 plained of pain in her back,  which gradually increased until in  May,
 I860, her locomotory power was somewhat  affected.  She, neverthe-
 less, walked till August, when she lost all power  over  her  limbs, and
 when sometimes "the water would stop,'" the catheter had to be used
 at different  times, and excruciating pain was felt all through her body.
 Two mouths before she was  presented, the first  convulsions weie no-
ticed.  She  would violently shake  upper and lower extremities, and 
40            CLINIC  FOR  DISEASES  OF  CHILDREN.
 would bite; at the same time her eyes would be shut.   The color of
 her  face would not  be changed much, and patient felt  very much
 exhausted  after such an attack.   She would  know when she was going
 to be taken with convulsions, which would come as frequently as eight
 or ten times during  a day, and  twice  or three times during a night;
 every  attack lasting  from three to  four minutes.  All  the weeks
 before she was presented, she had five or six attacks every day; and
 she was  sure never to  miss a day without having convulsions.   Her
 mind appears to be intact; her appetite is moderate;  thirst increased;
 pulse  averages  118-120;  bowels  costive;   water  is passed  slowly.
 Vertebral  column is  painful, both  spontaneously  and on pressure.
 There is no vertebra on which pressure is well borne; but the sixth and
 seventh cervical, and first, fourth, eighth and twelfth dorsal vertebrae are
 exceedingly sensitive.   Only a limited motion is possible in the upper ex-
 tremities; the hands are contracted, the flexor muscles overcoming the
 counteraction of the extensors.  The same contraction is noticed in the
 toes of either foot.  Both  lower extremities paralyzed.  The diagnosis
 was pronounced to be spinal hyperaemia, and a treatment was commenced
 according to the principles laid down recently by Brown-Sequard.   It
 has long been supposed or known, that there are remedies that have
 a direct  influence  on  the size  of  the  blood-vessels;  for instance—cin-
 chona.   On several others, Brown-Sequard has made  very careful and
 accurate investigations, viz., on ergot  and belladonna.   He attributes
 to ergot  the power of contracting the  elastic layer of the blood  vessels,
 and  vindicates  to belladonna  a similar action; so  much  so,  that it
 would  prove the exact contrast to opium, which is known to dilate the
 lumen  of blood-vessels.  Ergot  is declared to be of  excellent service
 in hyperaemic conditions of the spine and consecutive paralysis; where-
 as, strychnia, which has been the routine remedy in any and all spinal
 diseases complicated with paralysis, is indicated in  such only where
 there is anaemia.  Without, however, going  into details here, I wish
 to add, that in  a separate article I hope  to expose other experiments
 and  observations on  the  use  and effect of  ergot.   Our patient was
considered  to be a fit subject for the administration  of ergot, and the
following prescription  given: R.—Infus.  secal. cornut.  (e  3jss, cum
acid, sulphur, dilut. 9j.  parat.) §iv.; sulphat. quin.,  5ss. M    D. S.:
a tea-spoonful every three hours.   No local applications; no derivants
whatsoever.  On April 10th, she had two attacks; on  April  11th, a
 very short  one.   Not a single attack since.   On the 16th, a few drops
of laudanum were administered, to check a diarrhoea;  on  the 30th, the
ergot employed  for the infusion was  increased  to 3ijss.; and on the
7th of May, when it was thought proper to give a chalybeate  for her 
CLINIC  FOR  DISEASES  OF CHILDREN.
41
general auaemia, complicated with epistaxis at the same time, tinct.
muriat, ferri, gtt. xij., was  ordered to be  taken three times a day.
About this  time  she  not only had no attacks of convulsions, but re-
covered the power of her lower extremities.  She was presented to the
class  on May 24th, when she was able to walk, and the pain in her
back  was nothing compared with what it had been.  After this time,
she was taken, from a cause unknown to us, with catarrh of the stom-
ach ; so much so, that she commenced vomiting.  Subnitrate of bismuth,
carbonate of iron and  alkalines,  appeared not to operate so rapidly as
we desired,  and the condition  of the  stomach seemed to counter-indi-
cate the use cf the ergot;  of Squibb's fluid extract I at that time had
no reliable information.   After  ten days,  during which time our
patient had not taken  ergot, she was again taken with convulsions.
It was prescribed again, but according to what has been learned after-
wards, it had probably not been taken.  I then availed myself of the
kindness  of the  directors  of  the Jews'  Hospital, who  permitted the
patient to be transferred into one of their wards.   There I  commenced
the administration  of ergot again, and with the result  that no convul-
sions  were  observed  for  a  day  or two.  Slight twitchings  were
observed on the day of her transportation, and she complained much
of pain in her back; but she soon felt better.   Her stomach was still
disordered, and in  order to perfectly  restore her  digestive powers,  I
 omitted ergot for a short time,  ordering, however, a daily  dose of qui-
 nine  and gr. ss. of extr. belladon., three times a day.  She had no
 convulsions, and recovered her  appetite in two days, when  she was
 clandestinely over-fed by her  mother  on the next visiting day.   Again
 she vomited, throwing up immense quantities of indigestible food, but
 had no convulsions.   Next day, when I went to the hospital with the
 intention of recommencing another  course of  ergot,  having  selected
 for this  purpose Squibb's fluid extract, she was  non\ inventa.  Her
 mother had removed  her,  because " her darling did not get enough to
 eat,  and had no doctor to take care  of her;"  and a  day afterwards,
 she" had a clever doctor now, at last;  and he had told her right off,
 that her darling could not be saved."
    123. William C, aet. 7 months.  Rhachitis.  Epiphyses of the tibiae,
 radii, and  ulnae, greatly swelled;  legs curved outward; costal cartila-
 ges pointing forward; sternum prominent; ribs angular on both sides
 of the thorax; liver enlarged.  Skin pale, anasartic   Child generally
 badly  developed.  No  teeth;  little  hair.  Occiput nearly bald; not
 mollified.  Treatment:  Generous diet.  01. morrhuae.
    124. Leonora B., aet. 7 years.   Abscessus Auris externa. 
42            CLINIC FOR DISEASES  OF CHILDREN.
  125. Anna B., aet. 5 months.   Abscesses Capitis.   Eczema Frontis.
Over the mastoid process and in the external ear, and just in front of
the ear over the temporal artery, right side, there were deep and large
abscesses, which had been  maltreated with blisters, leeches, and hoc
genus omne.   Incision and water dressing.  The abscess,  125, was on
the top of the right parietal bone, near the small fontanel.  Incision.
The eczematous eruption was  treated with a wash  of sulphat. zinci,
(gr. viij.  to aq.  §j.)
  126. Moses F. B., aet. 8  months.   Synovitis.
  127. Th.  T., aet. 3 years.  Synovitis.  These two  cases were pre-
sented on two subsequent days,  and a  different teatment was resorted
to.   Both were in the foot-joint.   One was treated with tinct. iodin.
externally, twice a day,  and was not presented  long enough to afford
a fair opportunity of learning its effects.   The other was submitted to
compression by means of a bandage, and its size was soon considera-
bly reduced, but was also not presented until  a complete cure could
be accomplished.
  128. James G.,  aet. 2 years, 3 months.  Prolapsus  Recti.  Pertus-
sis.   Had gastro-intestinal catarrh last summer, and  since then after
each defecation the thickened  mucous membrane and submucous tis-
sue of the rectum would  protrude from six to  nine lines  in length.
Had, moreover,  whooping-cough, which commenced  last summer, and
continued still but  little  abated  up to March.   R.—Extr. nuc. vomic,
gr.  x.; cerat. simplic, 3ij.  M. f. ungt.  D. S.: To  be applied to the
mucous membrane of the rectum three times a day.  And:  R.—Extr.
bellad. alco.,  gr. viij.; sach. lact., 3j.  M. f. pulv., div. in p. aeq. No.
xvj. D.  S.:  Two powders  a day.   After a week, both the prolapsus
and whooping-cough were greatly improved, and the  treatment con-
tinued.
  129. Mary <F. T.,  aet.  1 year.  Adenitis Submaxillar is.  Patient
was a small, puny  child, with thin limbs, white skin, and  rhachitic ap-
pearance.  Her face was considerably swelled, in consequence of an
immense  tumefaction  of both  submaxillary regions,  particularly the
left.  On the right side, single glands  could  still  be distinguished,
large though the swelling was,  but the left side was a solid mass, with
but a single  spot on which a feeling like elasticity or  fluctuation was
perceptible.   The child  suffered from the  utmost  dyspnoea, snoring
loud, and gasping for breath, being unable to  open  the  mouth.  The
dyspnoea was very similar  to that  produced  by general suppurative
pharyngitis, or  retro-pharyngeal abscess.   The principal  and most ur-
gent symptoms were removed by an incision made  into the tumor of 
CLINIC  FOR  DISEASES OF  CHILDREN.
43
the left side.   A large amount of pus was removed.  From this time
forward, the greatest care was taken to obtain two points, viz., to im-
prove the general condition of the patient, and to reduce the size of
the tumors on  either side.   Poultices were applied to the left; a
second incision was made a week later; iodine was applied to the right
side, (R.—Iodid. potassii, 3ij.;  glycerin.,  §ss.)  and  ol.  morrhuae 3j.
given three times a day, with six, eight, or ten drops of  syr. iodid.
ferri.   Generous diet as  soon as the child was again able to swallow.
Low as the child was, and bad as her constitution appeared to have
originally been, it took two months  before even single glands could be
distinguished in the left submaxillary region.  But when the child was
presented for the last time, and ordered the same treatment, there was
no reasonable doubt of her perfect recovery after a little  more time
had elapsed.
   130. Michael T.,  aet. 3 years, 6  months.  Pannus, on  both eyes.
The spots on either eye have covered  the centre of each cornea, just
in front of the pupil,  for a  long  time.  The inflammatory process of
conjunctivae aud corneae, which has given  rise to them, has pursued
its course for  years.  Treatment:  Daily  application  of submuriat.
hydrargyr. to each eye.  A  fortnight  afterwards the spots  were re-
duced to  half their former  size.  Treatment continued.  Patient not
again  presented.
   131. Christian L., aet. 5  years.   Anamia.  Intermittens.   Patient
is tall enough for his age, but thin,  emaciate, feeble and  pale.  Con-
junctivae and mucous membranes generally very  anaemic.  Complains
of headache,  unilateral and  bilateral.   The impulse of heart strong,
but no abnormal sound; no  bellows murmur; nor is there abnormal
dullness on percussion.  Every night, for a week past, he has been
 awakened a few hours after  he has fallen asleep, by an attack of fever,
 that would last a few hours.   As uo cause of any other nature can
be found to explain  these attacks, they are taken as  attacks of inter-
 mittent fever.   R.—Sulphat.  quin.,  gr.  xv.    Div.  in  p.  aeq.  ij.
D. S.:  A powder at  bedtime on two subsequent days.   No other at-
tack was observed.   His general health was gradually improved, and
 his anaemia removed, by three daily doses of carbonat. ferri, gr. ij., each.
   132. Mary V., aet. 7 years  Insufficientia Valvula  Mitralis, Hy-
pertrophia Cordis, el  Hepatis, Icterus.
   133. Kate M., aet. 9 years. Insufficientia Valvula Mitralis.  Anamia.
   According  to'the history of No. 132,  she had acute rheumatism
some  four years ago.   She  had not  been herself since.  Was ema-
ciated; suffered occasionally from dyspnoea and palpitations, aud loss 
44
CLINIC  FOR  DISEASES  OF  CHILDREN.
of appetite.   Bellows murmur instead of the first sound, nearly cover-
ing the second; most audible below and near the left  nipple.  Im-
pulse of heart powerful; dullness  on percussion from above the third
rib down  to fully the sixth,  and even below; external thoracic, and
jugular, veins injected.  Lower margin  of the liver perceptible to the
touch; dullness on percussion as far  up  as  above the fifth rib.  The
color of the skin  is  greenish;  her bowels irregular—sometimes cos-
tive, sometimes loose.  The icterus, in  this case,  must be explained
by the hyperaemia of the blood-vessels, not of the liver, but  of  the
mucous membrane of the choledoch., etc., ducts, in a similar manner
as  those  frequent cases of so-called gastro-intestinal icterus.  Cos-
tiveness alternating with diarrhoea is  a common symptom in  cases of
enlargement of the  liver in which the circulation of the portal vein
and  its ramifications is disturbed.  Treatment: Ferri, digitalis, aa.,
gr. vj -viij.,  daily, in 3 doses.  After a number of weeks, all  the
symptoms, with the  exception of the dullness  belonging to  the  en-
largement of the  heart, were decidedly less prominent; icterus dis-
appeared; palpitations and  dyspnoea decreased;  she recovered her
appetite, and gained strength.  No.  131 was of a  similar character,
but without the prominent symptoms as in the preceding case.  Par-
ticularly,  there was no icterus, although great anaemia.
   134.  Catharine O'C, aet. 4 months.   Spina Bifida.   Patient was
well developed; a little smaller than children of her age.   No  de-
formity whatsoever, particularly no talipes.   Only the sensibility and
mobility of  the lower extremities  somewhat less  than  normal.   On
the lumbar region was a tumor of  about two inches and a half in di-
ameter in each direction, which was elastic and compressible, and evi-
dently contained liquid.  By pressing ou the tumor, a fissure through
at  least two of the  vertebrae was  perceived, while at the same time
the  child grew  restless and commenced  crying.  The whole  of  the
tumor, which was about two inches  in height, was not  covered with
cutis, but its most prominent point, which was semi-transparent, had
epidermis, and but a thin layer of cutis covering it.  Here, evidently,
the membranes of the spine  were almost the only  constituents of  the
sac in which the liquid (cerebro-spinal liquid) was  contained.    It was
thought proper to resort to as mild an operative proceeding  as possi-
ble, and therefore a thin silver wire was laid through it.   During the
operation  a  small quantity of cerebro-spinal liquid oozed out, the child
meanwhile scarcely noticing what  was going on.   The oozing out of
liquid continued slowly, and at no time  was there enough leaving the
sac so as to evacuate it entirely.   There always probably remained from 
CLINIC  FOR DISEASES OF  CHILDREN.
45
four to six drachms of liquid in the sac.   Nevertheless, the child was
taken with convulsions the same  evening, which continued until she
was seen the  following day.   She  then was  pale; perspiration on her
head;  pupils  a little dilated; not very active  under the influence  of
light;  large fontanel sunk, and not so large in circumference; sutures
narrow, so as to give the impression that the bones had approximated
each other; slight  twitchings around her mouth;  contraction of the
flexor  muscles of her hands and feet.  Bowels costive,  and  urine scan-
ty; pulse 120; respiration irregular and slow; sacral tumor not laterally
collapsed, but the fissure perceptible.   Handling the tumor did not ag-
gravate the  symptoms.  It was impossible  to gain any more particu-
lar knowledge of the exact nature of the contents of the sac, and espe-
cially  of the  ramification of nerves or medullar  substance in  its walls.
This condition of things remained for a number of days, with the ex-
ception of the occasional occurrence of developed convulsive attacks,
 which  again would be replaced by apparent quiet, at which  time the
child would  sometimes  take notice  of what  passed  around her, and
take a little  food.    The child died on the seventh day after  puncture
had been performed, the head growing as it were smaller aud  more
solid  from day to  day;  the pulse increasing in frequency during the
last two days, and getting  irregular at last,  and respiration grow-
 ing more irregular and slower  than before.   A post-mortem  examina-
 tion was not permitted.
    135. Gerard S., aet.  6  years.   Luxalio Femoris.   The  boy was
 presented but onCe in my absence.   He had fallen sixteen months ago,
 and had been walking  lame ever since.  On the records I find  a no-
 tice, that Prof. Bradley, who conducted that clinic and  referred the
 case to my subsequent examination, suspected it to be one of luxation
 of the caput femoris into the sciatic notch.
    136. James R.,  aet. 9 years.  Ilamorrhagia in Musculo  Sterno-cleido-
 mastoideo.   Patient was looking around and upward after his kite,
 when  he lost the  power of turning to the other, left side.  Slight
 swelling in the middle part of the right sterno-cleido-mastoid  muscle,
 with  very little pain on pressure.  Treatment:  Iodid. potassii, 3ij.;
 glycerin., gss.; liniment  volat.,  gss.  M.   D. S.: for external use.
    137. Francis I., aet. 9 years.  Contractura ex Abscessu.   Patient had
 a  large abscess three months ago, above the left scapula, and to the
left of the vertebral column.  It took several weeks to form and to
 break.  Since that, he  has  been unable to move freely to either side,
 or to  easily  bend  his  head.  There is a slight  drawing in of the skin
 over the  affected  part, the  layer of cellular tissue having disappear- 
46
CLINIC  FOR DISEASES OF CHILDREN.
 ed entirely, or being very thin.   Skin not movable over the subjacent
 tissue.   Induration of  the whole  region.  There is evidently still ex-
 udation in  and around the muscles.   Treatment:  Both  passive and
 active exercise, and R.—Iodid. potassii, 5ij.; glyceriu.,gss.; linim. vol-
 atile gj.  M.  D. S.. for external use.
   138. Mary I. Th., aet. 10 months.   Myositis.  Middle third  of the
 right thigh very much swollen and painful, the limb a little inflected.
 Skin very little affected, and movable over the larger part of the swell-
 ing.  A small opening  permits the sound to enter  for about an inch,
 and a little pus to escape.   Suppuration appears to be local only, and
 external absorbents tried.   R.—Iodid. potassii, 3ij.; glycerin.,  gss.
 A fortnight after, the size and sensitiveness of the tumor the  same;
 incision not permitted.   Patient sent off.
   139.  Daniel F., aet. 4 years, 6 months.  Panaritium Subcutaneum.
 The fourth toe considerably swelled and sensitive, both spontaneously
 and on  pressure.   Skin  normal.   Treatment,  (by  Prof.  Bradley:)
 Tinct. iodin., externally.
   140.  William S., aet. 1  year,  4 months.   Panaritium.   The  last
 phalanx of the right thumb  much inflamed and swelled.  All the tis-
 sues participate in the process.  Treatment: Incision, to be followed
 by a solution of sugar of lead with opium.
   141.  William S.,  aet.  1  year.   Erythema Regionis  Inguinalis et
 Scroti.  Inguinal region and scrotum erythematous, from urine,  faeces,
 and coarse diapers.  Treatment:  Cold water.
   142.  James W., aet. 2 years,  6  months.   Talipes  Varus Paralyti-
 cus.   Patient had  a severe  attack of  convulsions when nine months
 old, which resulted in paralysis of  both lower extremities.   His  right
 leg was soon restored again to normal action, while his left leg was
 partially paralyzed for a considerable time longer.  The same occur-
 rence then took  place which we  frequently meet with in cases  of in-
 complete paralysis, viz., the  flexor  muscles overcame by their action
 the power of the extensors.   Thus, the muscles depending on the  an-
 terior tibial nerve are still paralyzed, while the  power of the posterior
 tibial is proportionally not much injured.   Thus the club-foot in this
 case, with its slow development,  and based on  a previous  disease of
 the nervous centre, is the result of paralysis.  Treatraeut recommend-
 ed: Faradization of the  extensor muscles for some time, and tenotomy.
  143. Albert B., aet. 7 years.    Talipes Equinus.   Talipes Varus.
The former is on the right extremity, and has been the  result of  the
boy walking on his toes  for a long  time, in consequence of his heel be-
ing sore.  It is a mild  case, as produced by bad habit only.   The 
CLINIC  FOR  DISEASES OF  CHILDREN.
47
other deformity is quite a counterpart to 142.   Patient suffered from
couvulsions when six months old, was late  in walking, and has always
dragged his left foot.  Moreover,  the whole left inferior  extremity is
less developed  than the right.  The deformity, accordingly, has been
observed to come on gradually, depending, as it is, on a disproportion
between the nerve-power of the extensor and flexor muscles.   Treat-
ment recommended like that in the preceding case, with  the  addition
of R.—Nitrat.  strych.,  gr. j.; spirit, vini, gss.  D. S.: Ten drops,
twice a day.
   144. Walter H.,  aet. 8 months.   Catarrhus Meatus  Auditorii Ex-
ferni.
   145. Rosanna M., aet. 8 years.   Catarrhus  Meatus Auditorii Ex-
terni.
   146. Mary M., aet. 9 years.  Otitis Interna.   Beafness.
   No.  144 is a simple case of otorrhcea, as commonly seen  in early
infantile life.   Patient has no teeth as yet, but his gums are  swelled,
 the  mucous membrane of his mouth  and pharynx  injected; his scalp
shows the first beginning of eczematous eruptions, aud the glands of
 the neck are swelled.  Prognosis favorable.   Treatment: Four daily
 injections  (simple water injections preceding) of a solution of  sulphat.
 zinci, gr. vj., in aq.  §j.  No. 145  had scarlatina four  years ago, and
 has been suffering from otorrhcea since.   Unexpectedly, the affection
 is localized in  the external  ear only.   Tympanum is  healthy, throat
 not affected, and no symptom of the internal ear having ever  been af-
 fected.  Hearing not impaired.  The long duration of the complaint
, cannot be explained, except by its having been utterly neglected, the
 discharge  acting over and over again as a new irritation.  Treatment:
 Sulphat. zinci, gr. xxiv.; aq., giv.  M.  D. S.:  For external use.  No.
 146 is a case also depending on scarlatina, from which patient suffered
 three years ago.  Hearing is very defective in  the left ear; tympanum
 is gone, and the discharge, sometimes bloody, is seen to come from the
 internal ear.  Prognosis  highly  unfavorable  as to the recovery of
 hearing.   Treatment: Mild solutions of  tannic acid;  to begin with,
 gr. iij. to water %.
   147.  Isabella G., aet.  1  year, 2 months.  Stomatitis.  Pharyngitis.
 Mouth and pharynx injected;  mucous membrane swelled; uvula  and
tonsils tumefied.  From this cause the child has  pain in swallowing,
and a short cough, especially when in supine position.   Fever moder-
ate.  Treatment: R.—Chlorat. sodae,  3iij.; aq., §v.  M.  D. S.: A
tea-spoonful every two hours.  This will be a good solution, the chlo- 
48            CLINIC FOR DISEASES OF CHILDREN.
rate of soda being, at a medium temperature, soluble in three or four
parts of water, while the salt of potassa requires sixteen.
   148. Catharine W., aet. 1 year.  Catarrhus Inlestinalis, from an un-
known cause.   R.—Subnitrat. bismuth, gr. vj.; cret. praepar., 3ss.  M.
f. pulv., div. in p. aeq., No. xii.   D. S.: A powder every two hours.
   149. S., male infant, aet. 39 hours.   Befeclive Bcvelopment of the In-
testines.   The  history of the case was given by the attendants in  the
following manner:  The child had no  evacuation of the bowels for the
first twelve hours after birth.  A medical man  was called in, who re-
moved some  obstruction by means of his fingers  from the anus, and
gave an injection, whereon a string-like, hard, solid, whitish mass was
removed  through the anus.   The child then was declared  to be all
right, and left.  Nevertheless, no regular passage was had, but  the
patient  evacuated a mass like  that described, but less in  quantity,
several times.  He commenced  vomiting,  however,  bringing  up  a
black substance, which was  afterwards changed into  a brownish or
even  yellowish-gray  mass by the addition of  milk, which  the child
would readily take from the breast.   When  the infant was presented
he still looked well-developed;  no deformity perceptible on  any part
of the body.   Exhaustion began to  show itself, from  the somewhat
collapsed face and the sunken fontanel.   Abdomen not much inflated;
only across it, below  the liver,  and a little downward  to the left, an
intestine was  both seen and felt.   It  was inflated with gas, which  ap-
peared to be  unable to escape.  The rectum  was very narrow, but
could be explored to  the length of the first finger, and  no perfect im-
permeability found.   The  faeces  removed  last  were pretty greenish,
solid, about  a  fifth of an inch  in diameter, and completely formed.
Having no other means of diagnosis  ready, the case was declared to
be  one of stricture of the intestine, somewhere between the colon
transversum and rectum.   The last evacuation,  however, was submit-
ted to a microscopical examination, and  found  to contain a uniform
mass of cells, of middle size, with nuclei  and some nucleoli.   No fat,
nor hair, nor cholesterine, nor large epithelial scales; thus the evacu-
ation was  set down as intestinal  mucus only.  On the next day the
substance thrown up  from  the stomach was submitted to a microscop-
ical examination, and found to contain, besides milk, some crystals of
cholesterine and a large number of large epithelial scales.   The ease
was then put  down  as one of complete impermeability of  the intes-
tine, as there  were constituents of meconium above, but not below,  a
certain point.
  The elements of meconium were not sufficiently known before  the 
              CLINIC  FOR  DISEASES  OF CHILDREN.           49

year 1858, when  Prof. Forster, of Gottingen, submitted it to a very
careful examination.   The  priucipal results of his investigations  are
these:  that it does not consist, as it was formerly believed  to do, of
bile, and of the mucous and epithelial cells of the intestines, but mainly
of vernix  caseosa and  the pigraentous matter of the bile.   In their
largest part,  both vernix  caseosa and  meconium contain obdurated
pavement epithelium;  but the former has no coloring matter, and the
latter less fat.  Besides the  constituents  mentioued already, there is in
the meconium hair  from  the surface  of the body just like that found,
sometimes even without a microscope, in the vernix.  Stomach and intes-
tines have no pavement, but cylindrical epithelium only; nor are hard
and large  scales, like those  of meconium, found on  the mucous mem-
branes of the mouth and oesophagus.   The fat contained in the meco-
nium takes its  origin from the general surface;  cholesterine, which is
found in  meconium, has probably been a part of the bile.   Thus we
may safely conclude  that the principal  part of meconium  is vernix
caseosa,  which has been  swallowed.   Its water is rapidly absorbed,
and partially excreted by the kidneys.   Perhaps some part of the
fat, also, is absorbed, by the follicular glands of the small  intestines.
Thus, there is a singular  transformation  of matter  in foetal life, the
foetus swallowing the excretion of his surface, and again assimilating
perhaps part of what had been removed.   As yet, the contents of the
foetal iutestines have not been submitted  to a sufficient number of ex-
aminations to admit of a comparative estimation of the constituents
as to the relative age of the foetus.   Acephali have no meconium;
formerly, this fact was attributed to the absence of bile, in consequence
of absence of liver; but this malformation would account for the ab-
sence of coloring  matter and cholesterine only.
   Patient died with the  symptoms  of exhaustion, when seventy-two
hours  old.  Post-mortem examination  was  made   nine hours after
death, but abdominal  cavity only opened.  Rectum very narrow, aa
described  above.   Above, the colon appeared  only about a  fifth of
an inch in diameter, but could be inflated up to the vermiform pro-
cess; no  air would pass the valve.  A tube  was then introduced
through  a small  opening above the ileo-ccecal valve, aud inflation at-
tempted from above downward; but no air would pass the valve, thus
showing  a perfect  impermeability.   The whole  colon and  rectum
have a length of  about fifteen inches.  Stomach is normal; perhaps a
little larger than usual.   Duodenum and upper  part of  the  intestine,
to  a length of  about fourteen  inches,  are  very much dilated, and
terminate  in a very large cul-desac;  no opening   being found  into
             4 
50
CLINIC  FOR DISEASES OF  CHILDREN.
the remaining part of the intestine, which all of a sudden became of
a  decidedly diminutive size, of perhaps a  fifth  of an inch  in  diam-
eter.   This is the size of the  intestine  all through its  length  down
to  the valve, with  the following  exceptions.   As stated,  there
is  no connection whatever between the dilated upper portion of  the
intestinal canal and the suddenly contracted part, both of them end-
ing in a cul-de-sac.  Below this, about  two  inches  from this  first  im-
permeability, the  coarctated  intestine again ends in a cul-de-sac, after
which, to a distance of eight lines, no  intestinal  cylinder whatever is
found, the mesentery hanging  free in the  abdominal cavity.  Then,
again, a small intestinal cylinder, of nine or ten lines in length, is found
closed on either end.   Again,  the mesentery without its intestinal  ap-
pendix for about eight or nine lines.   Again, au intestinal cylinder of
the same length.   Again, absence of intestine  for a similar distance.
A third  intestinal cylinder of  the same length, closed on either end,
follows this;  and again, at last, free mesentery for about  half an inch.
Then,  finally, the intestine fairly begins again,  uninterrupted in  its
lumen, and unchanged as to its diameter of about a fifth of  an inch,
and measures, down to the ileo-ccecal valve, twenty-two inches.  Thus,
the whole length of  the intestine,  including, altogether, two inches
of mesentery not accompanied  with intestine, is about four feet and a
half, exhibiting in its  course, besides the dilatation of the upper por-
tion, a nearly equal coarctation of the lumen, the colon being a little
larger than the rest, and the rectum uot so narrow as the colon itself,
two perfect impermeabilities;  and beyond these  four total  interrup-
tions of the course of  the intestinal  canal, the  free intervals  being, in
the average, eight or  nine lines in length.
   Liver, spleen, kidneys, and bladder perfectly normal.   Both of  the
kidneys contain beautiful specimens of the so-called uric infarcts.
   Cases like the above are more than merely rare.  Perhaps there is
only one, if any, on  record, in which there was, as  it  were, such a
systematical anomaly; the only case that may be compared with that
given above being described by  Kiittner, of Dresden.   In  his case,  the
jejunum ended in  a cul-de-sac;  then there was  a  piece of intestine, of
three inches in length, ending in a cul-de-sac on either  side; further, a
second of the same description;  finally, a third one, five  inches  long.
Then, at last,  the colon, commencing with  a cul-de-sac  above, and end-
ing in a normal anus.   Cases of simple interruption of the lumen, com-
plete atresia, on a single locality, are even  quite  rare, (except in  the
rectum;)  the anomalies found by Kiittner,  and in the above reported
case, stand alone as extraordinary instances of imperfect development. 
CLINIC  FOR  DISEASES OF  CHILDREN.
51
  150.  Adolphus F., aet. 11 years.   Inflectio Radii.  Patient suffered
from a fall two weeks ago.  The fracture of the left radius was con-
tracted in about the middle of its shaft.   Very little care was given
to it, and the bone  healed in an obtuse angle of about 150°.  Union
had taken place when presented, the callus  being  large and  massive.
Treatment: Radius fractured, under chloroform, and splint.
  151.  James McJ., aet. 13 years.   Typhus Abdominalis.   Patient is
reported to have been sick for ten or twelve days; premonitory symp-
toms, such as loss of appetite, feverishness, headache and sleeplessness,
preceding.  He looks exhausted, emaciated, and  stupid; eyes sunk;
vertical wrinkles on his forehead; lips  dry, parched, and covered with
a layer of a thick black mass; tongue and gums covered in a similar
manner; respiration hurried, 44; mucous rales all over the chest; no
dull percussion sound; impulse of heart and arteries feeble; pulse ac-
celerated,  140; liver normal, spleen enlarged; copious and  frequent
passages  of yellowish-greeu, sometimes bloody masses;  pain  in  the
ileo-coecal  region.   Fever is always increased  in the night.   Delirium
will set in early in  the afternoon and continue to the following morn-
ing, with but few and short interruptions.  In these lucid  intervals
the  mental faculties of the patient are very  low; his comprehension
clouded,  and  his  answers  very slow, and  often erroneous.   The
case  presented, therefore, is one of a severe  form of typhoid fever,
such as is usually met  with in advanced, but seldom in infautile  or
juvenile age.   Typhoid fever is generally a mild disease in early age;
neither the symptoms nor the  pathological alterations  found at post-
mortem examinations, nor the mortality, being at all similar to those
observed in advanced age.  Real typhoid  ulcerations are seldom met
with;  the patches  of Peyer will often be found infiltrated; but gener-
ally single follicles only will be  affected, and their infiltration will  be
absorbed, or the follicle, bursting into the cavity of the intestine,  will
return to its normal condition without any cicatrization taking place.
Ulcerations and pseudo-membranes on the mucous membranes of the
pharynx, oesophagus, and larynx are rare exceptions, although others
are on record  similar to that of Dr. Mall, in which on and  after the
eighth day of the disease, in  a little girl of six years,  pseudo-mem-
branes showed themselves on  the mucous membrane of the nose, and
went  down into  the larynx, mouth,  oesophagus, stomach, intestines,
and vagina.  I have myself been  present at  the examination of the
body of a girl of four years, in which the whole length of the oesoph-
agus was  covered  with pseudo-membranes to  such  an  extent as  to
nearly fill up its lumen. 
52
CLINIC  FOR  DISEASES OF  CHILDREN.
  Of the symptoms of typhoid fever in early age the most important
are the enlargement of the spleen, diarrhoea,  and meteorismus, but
they are not always found.   Fever, accelerated respiration, and bron-
chial catarrh are often found, but are not pathognomonic.  Intestinal
haemorrhages  and chills  are rare occurrences; deliriousness, somno-
lence, and nervous symptoms generally are not  frequent.  Eruptions
on the skin, so frequent  in adults, are rarer  in this  age.   Severe
complications, as  parotitis and phlebitis, are  uncommon; but  during
convalescence  complications are  found  oftener  than  in adults, with
other  exanthematous  diseases,  as variola,  varioloid,  morbilli, and
scarlatina.   The usual  termination of infantile  typhoid  fever is greatly
more favorable than in adults, although  its duration  is not  confined
to certain limits;  sometimes a  few weeks, sometimes several  months
being necessary for its full course.  The prognosis,  therefore,  is usu-
ally a  favorable one, inasmuch as the symptoms are uot very severe
and exhausting, and the local anatomical alterations  are  not of such a
character as to imply severe and obstinate  consecutive  diseases; but
it will greatly depend  on the nature of  the epidemic, the circumstan-
ces of the patient, the age (patients from the first to  the fourth year
of life being more liable  to die) and the sex, (males  being more se-
verely affected.)
   It is a curious  fact that sometimes  there  will be found  qiidemics
of typhoid fever,  in which adults and children will suffer in equal pro-
portions;  others in which adults, others  again  in which children will
be affected  almost exclusively.   Of the cases collected by Prof. Le-
bert, ten per  cent, occurred in individuals  under fifteen  years  of age.
In but very few of these severe pathological  alterations were found;
in a number none at all; even at the age of fifteen the local intestinal
changes had  not taken place.   Nevertheless, all these cases were un-
 doubted cases of typhoid fever.   The case before us is  evidently one
 of a severe nature, the symptoms being those of unmistakable  typhoid
 fever, as found in adults.   As the patient is already  now, in the first
 period of  the disease, nearly exhausted, his  fever very high,  and  his
 nervous power very low, the prognosis  is pretty unfavorable.   There
 is  scarcely any hope without his being  sent  to a hospital, where  his
 strength  can be better kept up and his system  generally be better
 supported than under his present circumstances.
   152. Francis G., aet. 2  years,  6  months.   Catarrhus Gastro-Intes-
 tinalis.  Febris  Remittens.  Patient  has been well until, some  six
 weeks ago, he fell sick with a number of symptoms, attributed to  the
 influence of " cold."   He  coughed, was feverish, his respiration was 
CLINIC  FOR DISEASES OF  CHILDREN.
53
shortened, hurried, and his chest appeared to be sensitive to the touch.
There cannot be a doubt but that the case  was one of inflammatory
disease of the lungs.  Patient appeared  to  rally a short  while after-
wards, but never recovered  his former strength and general condition.
He remained  pale, restless, and feverish;  his skin became dry and
pale, a scanty desquamation of  small scales taking place from time to
time.   His bowels became irregular,  having three or four passages of
greenish, or mucous, or serous masses, very  seldom tinged with blood.
His appetite was bad; no particular food relished  in preference to any
other kind;  thirst increased, especially in the afternoon and during the
night.   Pulse is accelerated;  at 4 p. m., 136;  respiration  superficial,
but its number is proportioned to the pulse—40.   Child very much ema-
ciated;  cheeks and eyes sunk;  veins of temporal region swelled; face
a little flushed.   Extremities very thin, the skin  hanging  loose and
flabby over the bones.  Abdomen inflated, a little  seusitive  to the
touch.   Percussion  yields  a tympanitic sound all  over its  surface.
Examination of the thoracic organs shows no anomalies whatsoever;
respiratiou is very superficial, from the general muscular weakness of
the child.   Respiratory murmur vesicular,  with the puerile modifica-
tion of this age; percussion  sound sonorous.  The fever is  said  never
to leave the patient entirely.  It is highest  in the evening and night,
less in the morning, and will begin to rise  again early iu  the after-
noon.   Thus, it bears  the characteristics of what is called remittent
fever, and this is the diagnosis  with which patient, who has been un-
der medical treatment for some  time, was presented for advice.
   We are in the habit of applying the term of remittent  fever  to a
feverish  disease in which the principal symptom, the fever, shows  some
peculiar characteristics.   As in this case, it will never be absent; but
while the lowest rate of pulsations will be from 80-100 in the morning,
it will rise to 120-140-160 in the afternoon, evening, and night.  At
the same time the temperature of the skin is increased, cheeks flushed,
and thirst intense.  It has been stated  as  a characteristic of remit-
tent fever, that it is very obstinate, and  will resist the action of me-
dicinal  agents  for  some length of time; others  have regarded  it as
kindred  to intermittent and typhoid fever, its nature being considered
to be  eminently malarious.  Others, again,  have sought for the seat of
remittent fever in disorders of the intestinal  canal, catarrhs of the
upper oi'lower portion; and a number  of authors describe  the ab-
dominal symptoms in preference to  any  other.   Rilliet and  Barthez
have even discarded the name  of remittent fever, preferring that of
gastro-iutestinal fever; they evidently being of the opinion that the 
54            CLINIC FOR DISEASES OF CHILDREN.
local symptoms pointing to a disease of the mucous membrane of the
intestinal canal, and especially its follicular apparatus, are of prevail-
ing importance.   Moreover, a number of cases  of inflammatory dis-
eases of the thoracic  organs, general, and peritoneal, and  meningeal
tuberculosis, have been described as remittent fever; and certainly the
more obscure a disease is, the more inclined we  shall be to consider
one of the prominent symptoms  as the real  disease.   The  principal
symptoms of what is mostly described as remittent fever, such as high
temperature, vomiting, loss of appetite, thirst, furred tongue, in  fact,
the whole  number of "gastric" symptoms, will be found more or less
in every feverish disease, and  most in such the nature of which is  so
severe, and the danger so imminent, that it is of the  utmost import-
ance to arrive at a correct diagnosis at once.   A very minute examin-
ation of the thoracic viscera, and careful  attention to  meningeal and
cerebral symptoms, will generally correct the diagnosis; but a number
of pulmonary inflammations and brain diseases  have certainly  been
mistaken for remittent fever.  Tubercular meningitis, particularly, is
often mistaken for some gastric or intestinal disorder,  vomiting being
one of the first and most  constant symptoms; even the well-known
picking of the lips and nose is found in tubercular meningitis, though
it is believed  by the  public to be pathognomonic  of "worm disease,"
and found present by physicians in all and any diseases of the gastro-
intestinal canal.
   Diarrhoea is not  at all a constant  symptom of remittent  fever,
costiveness taking its place sometimes in the descriptions given by
authors.   There are even a large number of cases in which there are
said to be no  prominent gastric or intestinal symptoms, but  which are
attributed to  malarious influences, as above stated, and would be called
intermittent fevers, but for  the  absence of intermission  in  the  fever.
There are others, again, which  are described  with the  symptoms  of
typhoid fever, but distinctly stated not to be typhoid, but  remittent.
We know, however, that the range of the symptoms attending typhoid
fever, particularly in early age,  is very  large,  and their  severity very
different, and that there is no reason to change the name of a disease
just because there is  not such an  assemblage of fearful symptoms as
we sometimes find.    We  further  know, that there is scarcely any
disease, which, notwithstanding all its regularity, will,  in infantile age,
exhibit so many differences as intermittent fever, either as to*the time
and duration  of the attack, or the prominent  symptoms.  Pulmonary
and cerebral symptoms are not unusual in intermittent  fever in chil-
dren;  the  stages of the attack differ greatly, and their time and dura- 
CLINIC  FOR DISEASES OF  CHILDREN.
55
tion are not certain.  Thus, if we feel inclined to believe in the exist-
ence of remittent fever,  as kindred in nature or appearance to typhoid
and intermittent, we really do not know where the one commences and
the other ends.   Some uumistakable characteristics ought to be found
in every complex of symptoms which is to deserve the name of a dis-
ease in the indices of our text-books.   Have we a right to give the same
name to a symptom, prominent  though it be, which  may  be equally
found in intermittent fever, typhoid fever, acute  gastric catarrh, in-
testinal catarrh,  first  stage  of pneumonia, tubercular   meningitis,
rheumatic  fever, and, in fact,  all  such diseases  as  are apt  to last
for some time, and be connected with a protracted and high fever ?
It appears  to be  more rational, and more  in conformity with the
anatomical tendencies of our age, to regard the remittent, as any other
character of a fever, as  depending on the nature of the anatomical le-
sion.   This century has long endeavored to  get rid of those entities
called diseases, the seat of which nobody knew, nor cared  for; unless
we have a positive anatomical lesion by which a fever like that in our
case can be explained, we have  no right to take it as  the essence, the
principal nature of a  disease;  and  even if we  consider  remittent
fever  as  a malarious disease, belonging to the class of intermittent
and  typhoid fevers, we  shall scarcely be justified  in resorting to
the assumption of a new name, for symptoms which are not  new,
nor different in their  nature, but are slightly at variance  with  what
we generally see.   We  ought not to forget that nature is  not so uni-
form as our knowledge, ideas, and prejudices.
   I therefore  believe that, in some  future time, the term of remittent
fever, at the head of special chapters, will no longer be found.   As to
our case, we have no reason to assume any other cause of  the fever,
emaciation,  and exhaustion of our  patient, than the protracted  and
general catarrh of the intestinal  mucous membranes;  preceded, more-
over, by an  inflammatory pulmonary disease, which itself had its share
in the anaemic and weakened condition of our patient.  To give anti-
febriles in such a case, without attending to the local lesion of the gas-
trointestinal canal, would prove unsatisfactory.   The stomach would
scarcely tolerate, at all  events  would  not digest,  remedies given iu
sufficient dose  to check  the fever, if it could be thought possible to re-
move  the fever without  getting  rid  of its cause.  The indications are
clearly these:  1,  To suppress the catarrh of the mucous membrane of
the intestine; 2,  To improve the  digestive power of the stomach, which
is also in a catarrhal condition;  3, To improve the general condition
of the child  by digestible food.   Treatment:  Accordiug to the child's 
56            CLINIC FOR DISEASES  OF CHILDREN.
appetite and its expected improvement, beef-steak, raw beef, beef-tea,
milk, nitrogenous food generally.  R.—Subnitrat. bismuth., 3j.; sulph.
quiniae, gr. xviij.; acetat. plumb.,  9j.   M. f. pulv.  Div. in p. aeq. No.
xxiv.   D. S.:  Four powders daily;  and  Pulv.  Doveri, gr. iss., every
night.  The child improved considerably in the course of a week, di-
arrhoea disappearing, appetite returning, and sleep becoming sounder
and less disturbed.  Exactly the  same treatment was followed  up for
two or three weeks, with perfect success.
   153. Sarah Jane H., aet.  3 years.  Palatum Fissum Congenitum.
Patient is presented for the entire absence of articulation, the cause of
which anomaly is readily found on the first  inspection of the mouth.
The soft palate is cleft in its median line  from the posterior margin of
the hard  palate  down to the  uvula, which is divided into two equal
halves.   The child being well developed  otherwise, no other cause of
the anomaly complained of need be sought for.   Artificial junction of
the two  halves  of  the  soft  palate  is evidently indicated.   But  the
operation  of staphyloraphy is such a difficult and  tedious one even in
the adult, requiring an unusual amount of self-control in the patient, that
it cannot be thought of before the patient has attained a  certain age.
We are  not, however, deprived of all means of curing this defective
development, since the French medical literature has presented us with
a pamphlet of Dr. Cloquet's, in which this eminent surgeon publishes
his experience of  curing congenital cleft  palate by means  of the solid
caustic.   He publishes a few  cases in which  he  succeeded, by frequent
cauterizations of the ununited margins in their whole length, in bring-
ing about granulations, and finally cohesion  and a perfect cure.  The
same  plan has been followed by  me  in  the case  of  a vesico-vaginal
fistula, operated upon in the  usual way with but partial success.   A
fistula of about  a quarter  of an inch  remained unclosed after  the
removal of the silver wires; it has been cauterized five times since, in
intervals  of  from four to five weeks only, with a very good  success
taking into account that the vesico-vaginal wall is a very thin one in  this
case;  with such a success, indeed, that now already the lady is enabled
to hold her urine for hours.    We, therefore, may expect  this case to
be a fit  one  on which  to try the  method  alluded  to; the  intervals
between the single cauterizations  having to be shorter than in the case
of vesico-vaginal fistula, in which  a new cauterization  was  not resorted
to before it was certain that no further improvement would take place
after the  preceding one.   (Up to  the day of writing this report, during
a period of three weeks, cauterization with  the solid caustic has been
performed three times.) 
CLINIC  FOR DISEASES OF  CHILDREN.
57
   154.  William S., aet. 2 months.  Stomatitis.  Parotitis Secundaria.
A slight swelling has been noticed in front and below the left ear, for
two weeks; it has gradually increased, until the lobe of the ear appear-
ed turned outward and elevated, and the face was greatly disfigured.
Fever pretty  high; patient  salivating  much; mucous membrane of
mouth and pharynx  injected and swelled, and  covered with  a large
number of superficial ulcerations; odor, foetid.  Treatment:  R.—Iodid.
sodii, 3ss.; chlorat. sodae, 3iij.;  aq , gjss.  M.   D. S.: Half a tea-spoon-
ful three times a day.  Further: Tinct. iodin., externally, twice a day.
   155.   Walter  H.,  aet.  8 months.   Catarrhus Meatus Auditorii
Exlerni.  No  perceptible cause, except uncleanliness, and the child
at the same time being in the full progress  of  general development.
Treatment:  Injections  of water, and of R.—Sulphat.  zinci,  9j.; aq.
giv., four times a day.
   156.   Mary M., aet. 9 years.   Otitis Sinistra  Interna.   Surditas.
Muco-purulent discharge  from the left  ear.  Tympanum  gone,  and
discharge seen to fill  the  external ear.   Patient suffers from  this dis-
charge   and consecutive  deafness since  a severe attack of  malignant
scarlet fever, three years ago.   Prognosis as to recovery unfavorable.
Treatment to  consist of  mild  astringents, locally.  Acid, tannic, gr.
iv. to aq gj.
   157.  Adelaide P., act. 2 years, 2 months.  Conjunctivitis Scrophu-
losa.  Blepharospasms.   Examination could not be made, except under
the influence of chloroform.   Conjunctiva much injected and  swelled;
submucous tissue thickened;  margins of eyelids tumefied; phlyctae-
ous  ulcerations, most of  them collapsed  and healing, on the  conjunc-
tiva  scleroticae;  photophobia intense; cornea not affected,  although
the  process has  gone through a course of  six months.  Treatment:
Cauterization of conjunctiva with  solid  nitrat. argenti, and  neutrali-
zation  by means of  chloride  of sodium; and  embrocations  to  eye-
brows,  temporal and frontal region, four or five times a day, of a par-
ticle  of  the following ointment:  R,—Ungt. hydrarg. ciner. fort.,  3ij.;
extr. belladonna, 3ss.  M. f. ungt.
   158.  John  K , aet. 2  years.  Conjunctivitis  Trachomatosa.  Both
eyes affected.   Treatment:  Cauterization with  the solid caustic  and
neutralization.
   159. John  McM., aet. 2 years. 9 months.   Abscessus Galea Aponeuro-
tica.   Four large abscesses on the head of a healthy boy, after a similar
one  in  the submaxillary region had broken and healed  up.  Incision.
   160. James C,  aet. 6  years.   Catarrhus Laryngis.  Patient has
had  scarlet fever four months ago, there being  still the signs of diph- 
58            CLINIC FOR DISEASES OF CHILDREN.
theritic ulcerations on his tonsils.   Mucous membrane of the pharynx
thickened, and still  livid.   Auscultation  and percussion  give  normal
results.  Patient feels well; is hoarse, but  coughs from time to time,
especially after  awakening early in the  morning.   The  objects of
treatment are reduction  of mucous membrane  and submucous tissue
to their  uormal  condition, and  suppression of the superabundant  se-
cretion of  mucus.  Treatment: R.—Extr. cubeb. aeth.,  3jss.; syrup.
simplic,  gj.   M.  D. S.: Half a tea-spoonful three times a day, and the
external  use, over the larynx, twice a day, of tinct. iodin.
   161. Ellen McO, aet. 7 years.   Bentes Anomali.   Caries.   Herpes
Circinnatus, (on left shoulder.)   The right central upper incisor was
protruding from  the gums in its whole length,  the root  being unab-
sorbed, but  the  whole tooth, as far as it is uncovered, carious.  Be-
hind it the permanent tooth has cut long ago.  It is extracted, as is
also the left central incisor, which is carious, although no permanent
tooth  is visible.   In this one  the root is  already absorbed, proving
that the  corresponding  permanent incisor  was  in its  right place  di-
rectly above  and exercising the  normal, slowly  absorbing pressure,
whereas  in the former case the permanent tooth had been pressing
the deciduous  incisor from  behind forward.  Ring-worm treated  ex-
ternally with R.—Sulphat. zinc, 3j.;  axung. porci., 3yj.   M. f. ungt.
   162. James McC, aet. 10 years.   Cerumen  Induratum.   Patient
complains of hard hearing  and a  strange noise  in his right ear.   In-
durated wax is found to fill up a  portion  of the external ear.  Injec-
tions of water.
   163. Daniel P., aet. 1 year and 9 mouths.   Pneumonia  Chronica.
Catarrhus  Intestinalis.   The history  of  the  case is very iuaccurate.
Patient,  of healthy parents, is reported to have  always been well with
the exception of the last five months, during the larger part of which
he has been suffering from mucous, or serous, light-colored or greenish
diarrhoea, and from coughing.  Of a feverish disease nothing is known.
The physical symptoms, as far as the lungs are concerned,  (heart being
normal,) are  the following: Mucous  and  sibilant rales  to  some ex-
tent over the whole chest; respiratory murmur diminished nowhere;
over the  left upper lobe sometimes very much like the  bronchial.   No
prolongation of expiration.   Dull  sound on percussion over the upper
lobe of the left  lung, both anteriorly and posteriorly.  Treatment:
R.—Sulphat. quin., acid,  taunic, aa., By  pulv.  opii, gr. j.;  and M. f.
pulv.   Div. in  p. aeq. No. xxiv.   D.  S.:  Four  powders  daily.   Diet
generous.
   164. Ann W., aet. 1  year and 7  months.   Pneumonia, left upper 
CLINIC  FOR  DISEASES OF  CHILDREN.            59
lobe.   Bronchitis.  Measles  a month previously.  Sulph. quin.,  gr.
ijss., twice a day.   Pulv. Doveri, gr. j., every night.
   165. Edward D., aet.  4 years.   Bronchitis.  Oxysulphuret. antim.,
gr. j.,  every 3 hours.
   166. Mary T., aet. 2 years.  Pneumonia Bilateralis.  Little cough-
ing; very high fever; slight convulsions last night.  Vomiting has oc-
curred several times.  Pain  in left  side of thorax; subcrepitant rales
over left lung.  No dull percussion sound; constipation.  Tinct. digi-
talis, gtt. xij., every two hours.   After three days the fever disappear-
ed; no vomiting; not much coughing.  Bronchial respiration nowhere,
but dull  percussion sound over  left lung, upper lobe, anteriorly, and
right lung, middle lobe, both  anteriorly and posteriorly.  R.—Sulphat.
quiu.,  gr. viij.; oxysulphuret. antimon., gr. xvj.; sacch.  alb., 3ss.   M.
f.  pulv.   Div. in p. aeq.  No.  xvj.   D. S: a powder  every three hours.
   167. Richard  C,  aet.  4 years.  Hyperamia  Spinalis.   Patient is
reported to have always  been well until a short time ago.   Six weeks
ago he complained of a  severe pain in his back, corresponding with
the upper lumbar and  lower dorsal vertebrae,  which could  not be
traced to any external injury.  At the same  time  the  powers of his
lower extremities grew less, his knees would relax, and  his feet would
be thrown outward.  The pain increased for a week, until the lower
extremities were perfectly paralyzed.   The sphincter  muscles of both
urinary bladder and rectum  were not affected.   The pain gradually
decreased, but not so the paralysis, which remained stationary until a
few days  ago, after the  application  of a vesicatory to the  affected
part.   The motory power, however, is still  very little, no voluntary
motions to any considerable  extent being  possible.  Apparently the
sensory nerves  have, although affected, never been  suffering  in the
same degree as the motory ones.   Treatment according to  the princi-
ples laid down previously,  (Case 122.)  R.—Extr.  secal.  cornut.
fluid.,  Squibb, gss.   D. S.: Ten drops three times a day.
   168. Mary M., aet. 5  months.   Marasmus.  Patient  was a healthy
infant  when born, since which time, however, she  gradually lost flesh
and strength.  She has  been fed  on goat's milk,  arrow-root, and fari-
na, the mother having suffered from severe metritis  after confinement.
Patient has  a senile appearance; is very  thin and emaciated; eyes,
cheeks, and fontanels sunk; forehead covered with horizontal wrinkles;
iutercostal spaces and trigonum  colli sunk; abdomen large; extremi-
ties very thin.  The weight  of the child hardly  more than at birth;
mucous membrane of the mouth of normal color; respiration  a little
irregular: 35-40.  Expiration not  prolonged, but mucous rales all 
60            CLINIC FOR DISEASES OF CHILDREN.
over the chest, changing their place from time to time, according to the
child's efforts in crying.  Between the scapulae, on either  side of the
vertebral  column, the respiratory murmur more of a  bronchial char-
acter, percussion exhibiting at the same time a somewhat  dull sound.
No cough, nor hoarseness, but voice feeble  in accordance  with the
general weakness of the patient.   She has from  three to five passa-
ges a day, sometimes greenish, sometimes serous or raucous, generally
not preceded  nor  followed  by pain.  The case  is evidently one of
atrophy produced by vicious food; neither the goat's milk, nor arrow-
root, nor farina agreeing with the  digestive orgaus of the infant.   It
would  be  well if there was only a deficiency in her food as to quanti-
ty, as in those cases of infants who are nursed by their mothers, but
supplied with  less  than their proper amount of food.   Such  children
will be thin, emaciate, and voracious, will cry  after leaving the breast,
will suck all night, never being satisfied, because  always hungry;  but
no symptoms of pulmonary disease show any deeper lesion,  nor is there
any diarrhoea indicating  trouble of  the  digestive  organs.   They
are simply cases of healthy  children starving for want of food.   In
the case before us, however, there are plenty of nutritious elements
contained  in the food, but not in such composition as to be digestible
in tender age and  by  wholly unprepared organs.  Moreover, there is
in arrow-root and in farina more amylaceous matter than, even if digest-
ed, would prove beneficial to the infantile organism.  The irritation
produced  by indigestible  ingesta on  the mucous membrane of the
gastro-intestinal canal will result  in diarrhoea, aud the loss of albumi-
nous matter will increase  the emaciation brought ou already by de-
fective assimilation.
   It is in this case of  the utmost  importance to decide whether the
general marasmus depends on the insufficiency of food only, or whether
the pulmonary symptoms enumerated point to a  severe general  affec-
tion.   Mucous rales with a normal percussion sound  are  found in a
simple bronchial catarrh, as well as in  tubercular  infiltration; the ab-
sence of cough being  in no manner a proof of the absence of tubercles.
For tubercular deposits will  sometimes be found exclusively, without
coughing  having  given rise to any suspicion  in this direction.  Nor is
the harsher respiratory murmur between the scapulae a  symptom of
tubercular infiltration.  Its occurrence on both sides  appears in itself
to indicate its occasional presence under normal  circumstances.   The
respiratory  murmur  in  early age is, indeed, a good deal harsher
(puerile)  and there  is, for  this   reason, nothing  surprising in  the
quality of the respiratory murmur.   Even bronchophony may  be 
CLINIC  FOR DISEASES OF  CHILDREN.
61
observed  sometimes,  in  such  cases, where  the general  emaciation
and  the  little distance between the larynx of the patient and  the
ear  of  the examining physician change the  usefulness and  signi-
fication of the general symptoms.  We furthermore know, that al-
though  the tubercular dyscrasia  is not unfrequently found in early
age, it is not so very frequent in the first year of life, when the major-
ity of cases of atrophy resulting from insufficient and improper food
occur.   Of thirty-one tubercular children in the Paris Foundling Hos-
pital, Hervieux  noticed but teu who were less than a year old.   Nor
are there other symptoms  or indications arousing the  suspicion that
the intestinal catarrh in our case could be of a  tubercular character,
or the general emaciation  and exhaustion depending on  the same  dia-
thesis.   There are nowhere swellings of glands over the  surface of the
body, which will always be found in individuals with scrofulous or tu-
bercular predisposition.  And finally, there is no case  of tubercular
phthisis known to have occurred in  the same family.   An older sister
of our patient's, who had been so fortunate  as  to be nursed by  the
mother, is perfectly healthy and well-developed.
   The treatment in cases like this is as clearly  indicated as it is gen-
erally unsuccessful, because  of its being neglected.  Whenever it  is
possible to allow such children to return to the  breast,  they will gen-
erally recover very soon.   Where this is impossible, the food must be
as similar to the natural one as possible.  Beef-tea, boiled milk diluted
 with water  and mixed with a little salt and sugar, decoction of  bar-
ley mixed with milk where there is  tendency to  diarrhoea, or of  oat-
meal gruel where  there  is a  tendency to  constipation,  will  gen-
erally prove better in those early months of life  than any amount or
number of medicinal agents. 
2.   ESS  ^ Y  S  .
   The following pages are by no means intended to contain a full ex-
 position of the materia medica of the infantile age.  They are destined
 rather to show, condensed and summarily, part of the practice of the
 Clinic for Diseases  of Children in  the New York  Medical  College.
 Thus they will, I hope, prove a convenient compilation'to those gen-
 tlemen whom  I have had the honor to instruct, and perhaps a welcome
 subject for examination and criticism to the other members of the pro-
 fession.  They will  judge whether  the  principles adopted by me in
 the treatment of the diseases of children are correct, and particularly
 whether we are at all justified in  speaking of a materia medica of the
 infantile age.   I am sure  that we are.   A physiology and pathology
 of the infantile age  have long been  treated of as  separate subjects, and
 I am sure that therapeutics have the same right to  form special sub-
jects for investigation.  It will soon be seen that, for  the purpose  of
 attending the  diseases of children, it is not sufficient to diminish and
 sweeten the doses administered to adults.
   Of particular importance in the treatment of diseases of children is
 the regulation of their diet.  It is well understood that infants nursed
 by their mothers  will, under equal  circumstances, thrive better  than
 such as have been brought up by a wet-nurse, or by hand;  that regu-
 lar habits, cleanliness, aud fresh air contribute a great deal to their
 health and comfort;  that the health, temper, and physical affections
 of the mother or nurse influence  those  of the  infant;  that their  very
pleasures,  passions,  and habits will  leave their traces  in the nourish-
 ment and nature of the child.   It is most important, therefore, to reg-
ulate the quality and amount of food to be taken by infants, and  the
time when it is to be given.  Many irregularities or anomalies in  the
functions of the infantile organism will  be  removed or healed by at-
tending to these subjects, as it is  well known that, for instance, super-
abundance of  fat, or caseine, or want of sugar in the  mother's  milk, 
ESSAYS.
63
will bring ou  diseases of the digestive  organs of infants.  In  such
cases, a change in the diet is more important than any  pharmaceutic
remedy; many cases of constipation, for instance, in nurslings, are pro-
duced by the superabundance of caseous matter in the milk; it will
appear in the  hard faeces as white curdled  flakes.   The  most reliable,
and, at the same time, mildest remedy, is the addition of a portion of
sugar to the breast-milk.   I am in the habit of allowing the nursling
a piece  of sugar dissolved in a small  quantity  of  water, to  be  taken
immediately before each meal, in such a manner that the mixture of
sugar and breast-milk is effected in the stomach.
   Diseases of the digestive organs in infants and children are very
numerous, and the rate of mortality produced by  them  is  very large;
moreover, the digestive organs  suffer almost  in  any disease  of any
other organ, and the preservation of their  function is, therefore, of the
utmost importance, both as a prophylactic and healing agent.  While
the infant at the breast requires, under favorable  circumstances,  noth-
ing but the breast, the amount  of food must be diminished  in the ma-
jority of acute diseases; the  patient must frequently be  refused the
breast, which  he  will  instinctively turn to  to  soothe  his  thirst and
feverishness, and allowed water instead.   Many attacks of fever are
cured, that is, get well, under the influence of cooling beverages alone,
without the  addition of medicines; water,  soda-water, or lemonade,
 being more powerful than they are.   Many cases of indigestion will be
cured by the  addition of a  little salt  to every meal, or of a little veg-
etable slime to cow's milk,  where there is  a  great tendency to gastric
acidity and too rapid and hard  coagulation of the food.   Barley, with
its large proportion of phosphates; oatmeal, with its amount of phos-
 phates and mucine; arrow-root, with its superabundance of amylaceous
 matter, require their own individual  indications in practice.
   These remarks have been  made to remind  my readers of the fact
 that sometimes much can be done by apparently very little.  We all
 know, moreover, that  many patients will  sooner recover  their health
if left alone to the powers of nature, than  if fed on medicines.  If such
is the case in adults, it is  the more  so in infantile  age.   There is  a
great tendency in the nature  of children to help itself; in no other age
 do so many diseases take their regular course and disappear without
leaving any trace of their existence.   In such  cases the physician is
but the observer of the process;  in  being satisfied  with  this modest
position, he will prove the true  physician who feels himself the min-
ister of nature.  Such are  the cases in which  the so-called expectant
method is indicated; which have given rise to the nihilistic repudiation 
64                           ESSAYS.
 of all and  any remedial agents, and which  has formed the principal
 part of the curative feats of homoeopathy.   There are other diseases,
 however, the  course of which would probably be a  regular one, but
 which may be shortened by medicinal agents; they require medicines,
 first for their direct effect, and further, as a prophylactic given for
 the purpose  of avoiding any accidental  coincidence with  other  dis-
 eases.   Such a disease, for instance, is pneumonia in the infantile lung.
 It requires, in an otherwise healthy child, five or six  days  to take its
 usual course;  we know that, but nevertheless are justified and obliged
 to give proper medicines, to avoid complications, remove the danger of
 excessive exudation, and relieve certain troublesome symptoms.  In
 other affections, with apparently a very mild course,  some dangerous
 symptoms will sometimes arise suddenly, and require medicines;  there
 are others  which  can by no means get well without their administra-
 tion;  aud others  which would either lead finally to destruction, or to
 recovery, without the administration of  medicines, but in which prom-
 inent  symptoms require their use, to relieve  and comfort the patient
 for a certain period.
   The infantile organism is a growing, and, as it were, an incomplete
 one.   The organs are in full development, but not equally and harmoni-
 ously;  others undergo  a retrograde metamorphosis.   This  inharmoni-
 ousness of development explains a number  of abnormal functions and
 diseases, and the rapid growth the necessity of constant action of the or-
 gans of digestion and assimilation.  As disease constitutes the physiolog-
 ical function  and  structure of an organ under altered circumstances,
 and the organs alluded to are constantly at work, the many  diseases of
 the infantile digestive organs, and the frequency of diseases generally,
 are well explained.  Twenty-five per cent, of all children born in France
 die before they reach the age of a year,  and more than sixty per cent.
 of all the deaths occurring in New York are in children of less than
 five years of age.   Climate, age, and constitution of  the parents;  he-
 reditary disposition to syphilis, scrofula, tubercles, insanity, epilepsy,
 etc.; the diseases  peculiar to the infantile  age; the irritability of  the
 digestive and respiratory organs, and of the cutaueous and nervous sys-
 tems, swell the number of  diseases  occurring in early age  to a very
 large number.   The general irritability of this  age has  always been
known,  and better known than  understood; impressions  are  easily
made on the infantile organism, by  whatever cause.  Thus it happens,
firstly, that smaller doses of medicine will have the same effect  which
is produced by larger ones iu adults; but secondly, also, that a rapid
and decided effect is required to counteract the rapid devastations of 
ESSAYS.
65
disease.  The individuality of the cases and a correct diagnosis will
determine which of the two indications is present.
  A number of  authors have  attempted to determine  the doses of
medicines for certain  ages.   They, for  instance,  uniformly  declared
that, if the dose given to an adult was 1, that of a,child under a year
was from one-sixteenth to an eighth; from the first to the fifth year,
from one-sixth to one-third; from the  sixth  to the fourteenth, from
one-half to three-quarters;  from the fifteenth to the twentieth, from
four-fifths to one.  There is no such uniformity.  Not to speak of the
difference as to constitution, development, and strength in individuals
of equal  ages, we shall soon learn that a number of remedies are  tol-
erated, or efficient, in but a  very small; and others, in proportion-
ately a very large dose, in the infantile organism.
   I abstain from making any remarks on the  mode of administering
remedies to children, with the exception of this: that  it is not so un-
important in the diseases of  new-born children to take  in  regard  the
taste of  the medicine, for it  is  not true, as has  always been stated,
that new-born and very young infants show no action of the organs of
taste; but that great care should be bestowed on  the selection of the
corrigens.   Many disorders of the digestive  organs do not agree with
the administration of the syrups so commonly used; they will add to the
acidity of the gastric secretions, and disturb digestion generally.   In
the majority of diseases of  the digestive organs, particularly in ca-
tarrhal affections of the mucous  membrane  of the stomach and intes-
tinal tract, it is much better not to add a substance the transforma-
tion of which into acid is more than merely probable.

                             I.   Opium.

    A  number of medical  authorities object  to  the  administration
 of narcotic  remedies  in the  diseases of the  infantile  age.   A
 large  experience has  shown, indeed, that they have  sometimes been
 used  to a great disadvantage, even to the destruction  of  patients.
 It has been said that narcotics greatly weaken the powers of the ner-
 vous system; that they prove injurious to the circulatory organs and
 general  nutrition, by their diminishing the  number of  pulsations, and
 that they prevent the process of  secretion on the  mucous  membranes,
 in  the mouth, in the intestinal tract, and in the kidneys.
   Such  are, indeed, the effects of the  narcotics; and those who favor
 and advocate their  medicinal use have derived from these very facts,
established by both physiological experiments and  experience at the
             5 
66
ESSAYS.
bedside, a  number of  indications  for  their  administration.    It is
argued, then, that narcotics are invaluable in infantile diseases; they
are particularly required in cases of exaltation of the nervous  system,
as,  for  instance,  in  neuralgic affections,  (which,  however, are very
rarely met with in early age;) as well as to relieve pain in  incurable
diseases, aud even pain  in  inflammatory affections, in which there is
no proportion between the  pain and  the fever and other symptoms of
inflammation.   Again, increased secretion of the mucous membranes
forms an indication  for their employment.  They are further recom-
mended in all diseases  in which the nervous system is prominently
suffering, in  either its  centres or  peripheric parts,  from  spasmodic
affections, such  as tetanus  and convulsions of other nature; and  are
also much employed in cases of sleeplessness.
  The latter indication is  among  the first  to be confined to  certain
limits in the diseases of  the infantile age.  Children require sleep, and
incline to enjoy it; they will sleep  sufficiently, uidess  the functions of
their  system are  somewhere  disturbed.  When they  are  sick  and
sleepless, the question is a  very serious one whether the sensations of
sickness ought to be kept down to such  an extent as  to enforce sleep.
If this was  the  only effect of the narcotic, the indication  might be
followed up at any rate; but the suppressed  secretion of the  mucous
membranes, and the other  consequences of the administration of  the
narcotic, might add a  new pathological symptom  to those existing.
At all events, the circumstances of the  case will  have to be weighed
in all its relations, before sleep is to  be  enforced by narcotics.   As a
general rule, sound sleep will  not return, particularly  in inflammatory
aud painful  diseases, before the morbid process has commenced  to
take a favorable course.
   The objections raised to  the administration of  narcotics in general
have  particularly been  made  to  opium, the  most powerful amongst
them.   It has been stated, aud proved, that its action is a very strong,
and at the same time a very  uncertain  one, in infantile  diseases,  and
that its peculiar effect on the brain,  producing sleep, somnolence,  and
sopor, may  often give rise  to  sudden  death.   This  is  really so.
Death has often  ensued after the  administration of opium  iu  propor-
tionately small  doses, and  it  is good to bear in mind the memory of
such  untoward  events.  Dr.  Kelso, for  instance, reports  a  case in
which a child,  nine  months  old, was  destroyed iu  nine hours after
taking  four  drops of laudanum.   Tu another case, a child between
five and six years old died in  thirty six hours after having taken an
amount of  paregoric  containing from  three-quarters of a grain  to a 
ESSAYS.
67
grain and a quarter of opium.  In a third case, a child, aged seven
months, was destroyed  by a dose of paregoric equaling a quarter of
a grain of opium.   Dr. Taylor quotes the case of a child, four years
and a half old, who died of a dose of four grains of Dover's powder,
containing no  more  than two-fifths of a grain of opium;  and Dr.
Christison  mentions an instance in which 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.  Even smaller doses  have either proved fatal, or
given rise to very serious  accidents.  Clarke  has observed a fatal
effect from half a tea-spoonful of  the syrup of white poppies;  and a
patient of Marley's came  near death from the same dose.  Merriman,
Ryan, and Pereira have  seen an unexpectedly strong narcotic  effect
on the administration of  a single drop of laudanum; and the case of
the death of a newly-born, from the same dose, is on record.
   The  number of  these cases could be considerably increased  by ex-
tracts from the literature of  all countries.  They prove  that there is
some uncertainty iu the administration of opium to children, and render
it worth while to look into its effects and dangers.   Its effects are, as
above stated, eminently  those of narcotics  in general.  It relieves
 pain and removes sleeplessness; acts as  an  antispasmodic;  is a pow-
erful antiphlogistic, from its  effects on  the  action of the  heart  and
 bloodvessels; and suppresses the secretion of the mucous membranes
 and  the glands.   All  these  effects are of a secondary  nature, they
 being under the control of  the nervous system,  which in  infantile  age
 stands in a somewhat different position to the whole system from that
 observed in adults.
   We are hardly at liberty to say that in adults any organ  or system
 of organs is  the superior of  the others.  Except in  a diseased condi-
 tion of the system, there is,  in advanced age, harmony  amongst  the
 parts constituting the body.  Not so in children.  What is considered
 an abnormal  condition in adults, is frequently but too normal in early
 age.  At all events,  some superiority of the nervous  system is  well
 perceptible.    The brain  is, in proportion, the larger the younger the
 individual, and the  almost monstrous  proportion  of the size of tho
 head to that of the other parts of the body, at the time of birth, is
 but slowly counteracted  in the course of  the first years  of  life.   Not
 only the size  is in a different proportion to that of other organs and the
 body in general, the functions, some of them, at least, are even more so.
 There is scarcely any affection of the organism in which the nervous
 system  would  not  readily  participate.   Convulsions will, iu many 
68
ESSAYS.
young  children, prove a very frequent  companion of any feverish or
inflammatory disease, and follow a number of peripheric irritations,
which appear to be in no connection with the nervous centres, but through
a single peripheric  nerve.  I reed  not dwell  on  this  subject, nor
did  I intend saying anything but to direct the attention of my readers
to the  well-known general impressibility of the nervous system in in-
fantile  age.
  The  symptoms produced by a large dose  of opium are  those of cer-
ebral congestion.  The results of post-mortem examinations, in  cases
of poisoning  by opium,  are those of congestion.   But congestion,
or rather  hyperaemia, is  known  to be a very frequent occurrence in
children;  so much so, that many of them are always afflicted with or
suffering from it.  This shows, then, how small the boundary is between
the physiological  and pathological condition;  for while it  is  by no
means  doubtful that cerebral hyperaemia  may give rise  to a number
of severe  symptoms, it is certain that a considerable amount of blood
is found in the cerebral  and  meningeal blood-vessels  of young chil-
dren, in their physiological condition.  This fact is  explained  by the
peculiar formation of the infantile head.  The  brain is not contained
in  an osseous cavity, but  the cranium is  composed by  a number of
bones  connected with each other by loose,  movable bridges of  fibrous
tissue.   These  sutures will not ossify before the commencement of the
second  year of life.   Up to  this time  there is  not  acting  upon the
blood-vessels of the  brain and its membraues the lateral pressure of
later life,  produced by the immovable walls of the cranium.  Thus, iu
any case of sickness in which  the circulation is disturbed or obstruct-
ed  in any distant part of  the body, the brain in small children is apt
to act  as  a reservoir of the blood not  permitted  to enter or pass
another organ.  It is a peculiar occurrence that the  brain  has, aa
regards the distribution of the  blood, the very same function in the
infantile organism which is assigned the large glands of the  abdom-
inal cavity, liver, and spleen in advanced life.
   The dose of  the medicament sufficient to produce congestion  of the
brain varies a good deal, according to the state of health, the  temper-
ament and constitution  of the patient, and idiosyncrasies.   Idiosyn-
crasies certainly there are, perceptible in the action of this remedy,  as
well as in that of any other.  Medicinal agents and articles  of food
are not equally well tolerated by all individuals, and in a great  many
cases the  individual  capacity of tolerating  opium has to  be found out.
That bad effects have been observed, is  not doubtful; nor even that
they have occurred with  good observers  and  eminent  practitioners. 
ESSAYS.
60
They will, however, be easily explained  by such as have, perchance,
met with exhausting vomitations  after  an indefinitely small dose of
ipecac, or with copious salivation after a single small dose of  calomel.
I have, myself, effected a copious salivation in a he dthy man by the
administration  of half a grain of proto-iodide of  mercury, in a case
where I have not the slightest suspicion  of the drug  having beeu de-
composed.   Thus, there is danger  from even small doses  of opium,
but such only  as will occur with  any remedy  endowed with  powerful
effects.   This, however, is far from  counter-indicating its administra-
tion, but ought to have the effect of rendering us cautious.  We ought
to stop the administration of opium as soon as contraction of the pu-
pils takes place, and paleness of the face and somnolence sot iu.  Nor
ought we to commence by large doses.   The late  Schoepf  Merei, the
director of the  Children's  Hospital  at Pesth, Hungaria,  and  after-
wards Professor of Iufantile Pathology in  the Manchester, England,
School of Medicine, and  well known  as a medical writer, prescribes
opium very rarely to the newly-born; from the second to the third week,
his medium  dose  is the hundred and twentieth of a grain; from three to
six weeks, one-hundredth;  from  six  to  eight weeks, one-seventieth;
from two to four months, one-fortieth of a grain.  The action of  a
proper dose of opium is, according to Schoepf Merei, manifested half
an hour after its exhibition, and lasts from  three to  six hours.  He
has seen cases of narcotism produced by the administration  of opium;
even two cases of death;  but a moderate degree of narcotic  action he
has never seen to be dangerous in such cases where the  use  of opium
had been distinctly indicated.
   I may as well state here, that the doses  of opium given  by Prof.
Schoepf Merei are just the same I  have thought proper to give for  a
 number of years.   But the duration  of  its effect I have not found  so
long as he appears to have observed.   The doses  mentioned I  repeat
 about every three hours,  and add,  that  up to this time, I  have  not
 met with any untoward accident.  Certainly, I have met with cases
 of moderate narcotism, but I have not yet been so unfortunate as to
 cause death by the medicine.  Lastly, I wish  to  direct the attention
 to Schoepf  Merei's assertion, that  whenever opium has been really in-
 dicated, he  has not been  unfortunate in its administration.   I go fur-
 ther, contending, as I have done  in  a  lecture delivered a  long time
 ago in  the College of Physicians and Surgeons,  (Neiv  York Journal
 of Medicine, September, 1859,) that whenever a  medicine is really in-
 dicated, it  is tolerated in large doses.  Thus it is, that  iu peritonitis,
 for instance, in children, we  may at  once resort to  large doses  of 
70
ESSAYS.
opium, availing ourselves of the discovery of Prof. Clark, as well in chil-
dren as in adults, and following the example Prof. G. T. Elliot, pub-
lished some years ago; thus it is that, in a number of cases, opium will
sometimes be tolerated in really immense doses.   The case related by
Percival, and quoted by Dr. John B. Beck, in " Infant Therapeutics,"
p. 19, is illustrative of this  fact.   A young man was admitted into the
Manchester Hospital on account of a violent spasmodic  attack which
recurred periodically in the evening, and after trials  of  various reme-
dies, doses of opium sufficiently large to mitigate the violence of the
paroxysms were ordered; he took twenty-two grains every night  dur-
ing a week, without producing any soporific effect.   On the eighth
night he had no  return of the  spasms.   He nevertheless  took the
opium, and in the morning was found dead.   The effect,  then, depends
totally on the indication.   As a general  rule, it  ought  to be remem-
bered that no medicine ought ever to be given without a strict indica-
tion; and, as I have stated, wherever the diagnosis is correct and the
indications based on the distinct knowledge of a  case, the correspond-
ing remedies  may be selected with  boldness  and confidence.   I  dis-
tinctly remember the case of a boy of twenty-two months, who had a
very severe attack  of wide-spreading, gastro-intestinal catarrh.   Re-
covery did not take place in the usual time, and after a while  the usual
symptoms of  enterohelcosis,  ulceration  of the follicular   patches,
showed themselves.  The secretion and peristaltic motion of the intes-
tines were such, that between  twenty and thirty passages  occurred
day after day, week after week.   In order to check  the irritation, in
fact, to paralyze as it were the muscular layer of the intestines, and to
suppress the  superabundant secretion,  the use   of opium, internally
and in injections, was resorted  to.   Careful doses,  a  few drops  of
laudanum, daily, were commenced with.   But this dose  had no effect,
and had to  be increased daily; so much  so, that  the  patient took
nearly three  grains of opium internally, and  six   grains  in injections,
which he almost always kept  every day.   These immense doses  had
to be continued three weeks,  until decidedly   favorable symptoms
showed themselves, and then had to  be diminished  gradually.   The
same experience I have gained in a case  of intestinal  ulceration, re-
sulting from  typhoid fever  in a girl of three years; she  took as much
as a daily dose of two grains of opium, for a week.
   The question, why it is that such immense doses of opium  are tol-
erated, is still an open one; for we cannot say that the  fact based on
experience, that when indicated large doses of medicines are  tolerated,
amounts to anything like an explanation.   It is  a statement which we 
ESSAYS.
71
ought to be aware of from  a merely practical point of view, but noth-
ing else.   If it is true that a  bad  article only is  tolerated in large
doses in inflammatory diseases of the abdominal organs, why is it that
we never hear of so large doses required or taken by a person suffer-
ing from sleeplessness alone ?  Objects of experience, there are enough
in the practice of every physician, and nevertheless, no large doses are
ever given for the  purpose  of forcing sleep.   Or is the cause of the
large doses of opium being tolerated this, that  it passes the intestinal
canal without being absorbed ?   But is the stomach, in cases of intes-
tinal ulceration of the kind mentioned above, any the less  capable of
absorption ?   Are  not its  digestive powers in this very disease im-
mensely increased ?   And  is it not a fact which every one is aware of,
that the immense loss of secretion from the  intestinal mucous mem-
brane is barely made up by the introduction of immense quantities of
nutritious food ?
   After these remarks, I  proceed  to  lay before my readers a short
synopsis of the affections of infantile age in which I have administered
opium, besides those  alluded to  above.   I  beg permission to  state,
that I have not at all  pretended, nor  desired, to write an elaborate
article on  the subject,  but to enumerate a number  of diseases  and
symptoms in which I have found the use of opium not only pardon-
able, but useful and necessary.
   1.  Cerebral Irritation.—In spite of what I have said myself on the
frequency of primary or secondary  hyperaemia of  the brain and its
membranes, and although  the effect of opiates is apt  to show itself
first  in  cerebral congestion, I have given small doses of opium in
a number of cerebral symptoms.  Genuine diseases of the brain are
not so very frequent, as could be supposed from the indisputable pre-
disposition; nor are all the cerebral affections  occurring in the course
of the other diseases  of other  organs depending on  considerable ana-
tomical alterations.   A number of these are really nothing but the re-
sults of cerebral irritation, which does not require, and in many in-
stances even counter indicates, the use of antiphlogistics.  This  is so
well known, that I feel satisfied with alluding  to it.  Without  a cor-
rect diagnosis of the condition of the brain, opiates are not advisable;
but I desire this principle  not to be forgotten,  that without  a correct
diagnosis, no  powerful  remedy ought  to  be  administered; and less
than any others, antiphlogistics and antiplastics, so readily resorted to
in  every and  any cerebral complaint.   The. general impres>ibility of
the nervous system  iu infantile  age,  both central  and peripher'c, ia
an undoubted fact; we observe  a  number of nervous symptoms in 
72                         ESSAYS.

which we are unable as yet to discover  any anatomical  lesion, either
their central or peripheric; we know even, that the majority of attacks
of convulsions in infantile  age are reflected, and  we are  therefore jus-
tified in assuming that a central organ receiving such impressions and
irradiating them again to  its periphery,  must occasionally be in a thor-
ough state of  irritation, without intense anatomical  alteration.  In
such cases, the diagnostical differences of which are stated by the
books, I mostly rely on the use of small doses of sulphate  or acetate
of morphia, or codeinum.
       R.—Solut. morph., Magendie,    .     .     gtt.  v.
           Aq........§j-
  M.   D.  S.: Three or four times a day, half a tea-spoonful, to a  child
of half a year, or a  year of age; or,
       R.—Codeine......gr. j.
           Aq........SJ/3-
  M.   D.  S.:  Half a tea-spoonful three or four times, or more.
  2. Catarrh of the Stomach and Intestines.—There is, in  the catarrhal
affections  of the mucous membranes  generally, and especially in those
of the alimentary canal, an element of much trouble  and perplexity
to  the  practitioner.  I  mean  the  intense  irritation existing  from
the very beginning  of the  affection.  While the  majority of such  cases
are simple  catarrh,  they cannot run  their course without  influencing
the trophic and sensory nerves, and being influenced  by them.   Re-
flected  action will  spring up  in  the muscular layers, and increased
peristaltic  motion is the  next  result.   In  all such  cases opiates are
decidedly indicated.   I scarcely ever treat either  an acute or chronic
cat'irrh of  the intestinal canal  without opium,  as the occurrence of the
affection, without greatly increased  motion, is not possible.  At the
same time, the remedy has a decided influence on the  secretion of the
follicles of  the mucous membranes and glands generally: not directly,
it is true,  hut by means of the brain  and its peripheric nerves.   I add
it, usually  iu  the form of Dover's powder, to calomel, (which I use but
exceedingly seldom,  I may say scarcely ever,)  subnitrate of bismuth,
tannic  acid, and  subacetate  of lead.   I prefer  Dover's powder, be-
cause the  doses of  opium must necessarily be small, and the division
of the powder of opium would be rather difficult,  or sometimes uncer-
tain, and because of the, at times, desirable addition of ipecac.
        R.—Snbmuriat. Hydrargyr.,     .     .     gr. iv.-vj.
            Pulv. Dovei;i,      .    .     .     .  gr. iij.
            Crct. praeparat.,       .     .     .     3>SS-
        M. f.  pulv.,  div. iu p. aeq., No. xii. 
ESSAYS.
73
  D. S.: A powder every two  hours, for a child from  six months to
a year.
       R.—Subnitrat. bismuth.,     .     .     .   gr. viij.-xij.
            Pulv. Doveri,        ...     gr. iij.
            Cret. praeparat.,  ....   5ss.
       M. f. pulv., div. in p. aeq., No. xii.
  D. S.: As above.
  As a general rule, I never use tannic  acid and subacetate of lead
in recent cases of catarrh of the alimentary canal, and  have not been
in the habit of ever using it in affections  of the stomach, (except the
latter, in cases of haematemesis.)  The cases in which  I resort  to it
are usually those of chronic catarrh of the intestine, (tannic acid prin-
cipally in that of the intest. colon,) and mostly in children a  little
older;  in such the dose of the opium has  to be increased according to
circumstances.
       R.—Acid, tannic, (Subacet. plumbi,)     .     gr. viij.
            Opii,.......gr.j.
            Cret. praeparat.,     ....     Bij-
       M. f. pulv., div. in p. aeq., No.  xvi.
  D. S.:  A powder every three hours, to a child of 3 or 4  years.
  In fresh cases of gastro-intestinal catarrh, which  have got well
after a simple treatment of the first-mentioned kind, I almost always
follow it up with a simple opiate, in order to counteract the irritation,
which by itself is able to again give rise to a copious secretion of the
mucous membranes.
       R.—Laudan. liquid., Sydenham,      .     .      gtt. x.
            Mucil. g. arabic,.....§ijss.
  M.   D. S.: A  tea-spoonful every 2-3 hours, to a  child  of  eight
months or a year.
   Whenever  there appears to  be a necessity to apply opium to the
intestinal canal  locally, by  means of injections, I should urge the  ut-
most caution, and but small doses.  Opium is, like quinia and  some
other substances, readily absorbed by the rectum, and ought not  to be
given in any larger daily dose than internally, provided  that it is well
injected and not soon (jected.   DeWees may be practically right in
the majority of actual cases, and taking into account the  expulsive ten-
dencies ot the patient and carelessness of  nurses, in recommending the
triple  or quadruple  dose per rectum; and Beck: the double.  But I
n<>-ain state, and  lay stress  on  it as an indisputable experience, that
opium will  show its general symptoms  by the same,  and no  larger
dose, as in its internal administration;  while, for instance,  the subcu- 
74
ESSAYS.
 taneous  administration of morphia, which, however, I have  not re-
 sorted to iu infantile  practice, is more efficient and  requires a smaller
 dose than any other mode of using it.   As to opium injections, I pre-
 fer to  repeat them frequently with  small doses of  laudanum, and  to
 watch the effect, than to give large doses at once, which might prove
 dangerous or inconvenient;  dangerous from  its general effect, incon-
 venient and troublesome from  the sudden  suppression of local secre-
 tion.
   In simple and complicated catarrh of  the stomach, the administra-
 tion of carbonates, or  muriatic acid, or  bismuth, will  usually suffice.
 But in cases of incessant vomiting, which itself will increase the hyper-
 aemia,  and may even give rise to haemorrhage, sedatives are necessary.
 Now,  morphia, opium, and  laudanum will  sometimes  produce vomit-
 ing.  Extract of opium and tinct. opii camphor, are generally better
 tolerated, but  the taste of the latter is peculiarly disagreeable to some
 children;  besides,  there are  cases  of  irritability of the stomach
 in which absolutely nothing  will be kept except the mildest and bland-
 est remedy possible, besides ice.  In such cases, codeiuum or codeia
 acts admirably  in daily doses of from half a grain to a grain, accord-
 ing to  age.  1 remember several cases in which nothing  appeared to
 soothe the irritation of the muscular layer of  the stomach but codeia,
 and some in which I had to continue for some time to give a dose be-
 fore each  meal.
   3. Laryngeal Catarrh.—In those cases of catarrhal affection of the
 larynx called pseudo-croup, or laryngitis spastica, I have always used
 opium  in occasional doses with the best result, aud recommended them
 accordingly, in  a former lecture on the  subject.   Certainly I  should
 not think of giving it during  the attack of dyspnoea befalling chil-
 dren suddenly  during night,  and making the frightful impression  of
 pseudo-membranous croup—the first and only thing to  be thought  of
 is an emetic, if anything—but the irritation and spasm attending this
catarrh is best relieved by a  dose of  opium, given  at  bedtime.  The
spastic affection  attending a simple  laryngeal catarrh  illustrates ex-
ceedingly  well my remarks on the irritation  of the  mucous membrane
of the intestines.  The local  affection of  the mucous membrane of the
 larynx is of very little account, and would certainly not give rise to any
serious symptoms, but for the narrowness of the organ  and the  impli-
 cation  of a large number of small muscles.  But, as it is, a good dose
of opium is required before the time  the  attacks  will generally occur.
Dover's powder, to gr. ij<s.  in a single  dose, given  at bedtime  to  a
child of three years of age, will generally succeed in procuring a  relief 
ESSAYS.
75
from the spastic attack, and a good night's rest, and will afford time
for the effect of such other measures as are deemed proper.
   From some remarks made above, the  selection  of the opiate most
Appropriate in an individual case will, perhaps, not be very difficult.
I therefore abstain from making any addition.  At all events, but the
general rules can be laid down in expositions of so general a  character.
I desire, however, to add a very few words on the counter-indications
to the use of opiates in  infantile practice.   It is certainly of  at least
the same importance to know what remedies to avoid, than which  to
employ,  especially when we expect to  do either the right  thing, and
that entirely,  or nothing at all.
   A principal counter indication, in my opinion, is an uncertain diagno-
sis.  I should  never propose the  use of opium in a cerebral affection be-
fore I should be sure whether the case is one of simple irritation, or
of congestive or inflammatory character.   We must confess that many
cases are not  diagnostic-able, with our knowledge hitherto  acquired;
but then we better not  resort to powerful remedies,  which may  prove
as dangerous as useful,  if we do not know which.   We can afford, and
must be permitted to be ignorant, but we can neither  afford nor  be
permitted to do harm.   Nature will have less trouble in overcoming
a disease without our support, than she can come off victorious from
a fight against the disease and doctor  at the  same time.  And there
is no vigorous constitution nor a blooming life that a doctor cannot
ruin and destroy, by not indicated, or  contra-indicated remedies.
   Hyperaemia of the brain and  meninges, both active and passive, are
strong contra-indications.  Enough has been said  of them.
   Exhaustion and collapse are generally positive contra-indications to
the administration of opiates.   They are sedatives, and very powerful
as such.   Collapse  and  exhaustion  naturally require stimulants and
restoratives.   In such cases, the prevailing local  disease is  generally
of less importance in pointing out the  treatment than the general con-
dition of the patient, and such are  emineutly the cases  which  prove
that the individual patient, and not an ontological disease,  are  the
subject  of treatment.  If we cannot avoid the use of opiates in such
cases, the greatest  caution ought to  be preserved; and they  ought
never to be resorted to  without  at the same time  taking measures of
rallying the patient.   Such cases will occur in gastro-intestinal catarrh
with rapid collapse, as often seen during the warm season.
  The complication of severe intestinal catarrh with a pulmonary  af-
fection, particularly broncho-pneumonia, is a very serious, and  some-
times fatal one.   While the intestinal catarrh would probably require 
76
ESSAYS.
the use of opium, it will hardly  be possible to  give regular  doses  of
this drug in this  complication.   I have  gained the  impression from
what I have observed, that the oppression and  dyspnoea will be ag-
gravated by regular doses of opium in the  first  stage  of pneumonia,
and the only purpose for, and mode in, which I now give opium in cases
of the above description, is an occasional dose to procure rest.

                         II.  Belladonna.

   The  root and alcoholic extract of this powerful narcotic  have been
administered  by me in many hundreds  of cases of infantile diseases.
Those in which  they have proved eminently successful  are whooping-
cough, and incontinence of both urine and faeces.   A few  remarks will
suffice to lay  my experience before the profession.
   The most urgent objections that have been made to the use of bel-
ladonna in the diseases of early age were  illustrations of its powerful
effect.   Therefore, also, the administration of the herb was frequently
recommended in preference to both the root and the alcoholic extract.
Such a recommendation, however,  always originated in  the so-called
expectant  method, in  the principle of meddling as little as  possible
with the either wholesome or destructive proceedings of nature, in the
uncertainty of doing good, and  the fear of doing  harm.   But in re-
gard to  such diseases as really and positively require the intervention
of art, I know of no priuciple that proves more injurious than this;
and, instead of preferring the herb for its milder,  and  also more un-
certain effect, I  have discarded  it altogether in my  practice.  The
therapeutical effect of the root and extract  I  have found to be the
same; the remarks I have to make are therefore applicable to either
of them.
   Belladonna is  the most powerful remedy in whooping-cough.  I
scarcely remember a single case in which its administration, for years
past, proved unsuccessful in shortening the duration of the process.
The result obtained by me has generally been this: that a  well-developed
case of whooping cough, after the diagnosis was made certain beyond
a doubt, would last  for only three or five  weeks longer, instead  of
running through its full course of months and quarters of a year.   The
effect is  generally not a sudden one.  Many cases in which belladonna
is  given from  the first commencement will become worse for a  short
while, then remain at their height for some days or a week, and grad-
ually improve in both  the character and frequency of the  attacks.  In
others the effect is perceptible from the first days  after their first ad- 
ESSAYS.
77
ministration; the cases soon assuming a more favorable aspect.   Such
has been  my uniform experience during the last five years, in each of
which the children of this city have been suffering from a more or less
severe epidemic.
  My readers, many of whom doubtless have been in the habit of pre-
scribing belladonna in whooping-cough with more or less marked suc-
cess, need hardly be  as-ured  that I claim no priority.  Belladonna
has been recommended in this disease for many decenuia, and has just
as long been objected  to,  as either useless or dangerous.  I have touch-
ed the subject because of my conviction that both the former objection
and the latter fear are groundless.
   Belladonna is well  known readily to produce symptoms of poisoning.
An amount of two and a half or three grains  taken by an adult in the
course of a day, of either root or extract, has the effect of  dilating
the pupils, causing a feeling of dryness in the  throat, scintillation and
giddiness, and  even erythema of  the skin.   This latter effect is, how-
ever,  not frequently seen in adults, while the  effects on the pupil and
brain arc very common.   It was  therefore believed that, as  nervous
disorders are as common as they  are dangerous in infantile age, these
effects ought to counter-indicate its use; it was stated  that it would
cause  congestion, sopor, acute hydrocephalus, and idiocy;   and the
practical  consequence simply was, that the dose of the remedy, when
given at all in  a case where it appeared to be indicated, was entirely
too small.  Thus,  doses of a sixtieth, a forty-eighth, a thirtieth of a
grain  of extract of  belladonna,  repeated  three  or four times a day,
 were deemed sufficient and proper.  These doses could not but prove
 unsatisfactory, and thus it happened that  the remedy was misappreci-
ated and given  up.   The doses, however, administered  by me  proved
 successful, because they  were really sufficient.
   Infants of six or eight months of age  affected with whooping-cough
require a sixth  of a grain of either the root or  the  alcoholic extract
 three times a day;  children of three or four years tolerate  three doses,
each of half a  grain.  These doses appear to be very large in propor-
tion to those tolerated  by adults, but it is a  fact which can  easily be
verified, that the effect of belladonna on the pupil and brain will hardly
ever  be perceptible  in  children  from these or smaller doses.   The
 sequence of belladonna symptoms  in children differs,  moreover, alto-
 gether from that in  adults; the  erythematous and flushed appearance
 of  the face and neck, sometimes even  of the whole surface, is the first
 symptom iu infantile age; whereas  it is seldom observed in  adults, or
 in cases of  thorough poisoning only.   Some  of the old authors have
4 
78
ESSAYS.
 advised the administration of belladonna to such an extent as to pro-
 duce  the first symptoms of poisoning; others, however, have  insisted
 on this practice being dangerous and wholly objectionable.   I, for my
 part,  soon  found  that those children  suffering  from whooping-cough
 who  exhibited general  erythema  from an  apparent overdose  re-
 covered soon, while others, in whom no such  symptom was observed,
 remained  sick for a long time;  and continued experience has proved
 that the  occurrence of this symptom  is  absolutely necessary for  the
 full remedial effect.   To obtain a cure in whooping-cough, the reme-
 dy must be given in a dose sufficient to produce erythema, or at least
 a flushed  condition of the  face, and, as it  were, feverish appearance
 after  every dose of belladonna.  Thus the dose is to be gradually in-
 creased until this result is obtained.  It is  a  remarkable fact, that
 very  young infants may take unproportionately  large  doses;  at  all
 events, I do not remember a single case in which less than half a grain
 was taken  in the  course of a day.   The prescriptions I  have been in
 the habit of ordering are very simple ones.  I either give the medica-
 ment  as a  powder, or have the extract dissolved in water and sweet-
 ened  according to circumstances.

       R.—Rad.  (or extr.) belladon.,     .     .     gr. ii.—vj.
           Sacch. alb,  (or s. lactis.j   .     .       5ss.
       M.  f. pulv., div. in p. aeq., No. xii.
  D.  S.:  Three powders a day.

       R.—Extr. bellad., alcoh.,                      gr.  vj.
           Aq.........§ ss.
  M.   D.  S.: Twenty drops  three times a day, (for a child of three
 years.)

  The administration of belladonna alone is  indicated  in such cases
 of whooping-cough as are not complicated with catarrhal or inflamma-
 tory aflVctions of the  respiratory organs.   The latter take the lead
 in complicated cases as well in treatment as in the nature and »ravity
 of the symptoms.   This  is so certain, that whenever a pneumonia coin-
 cides  with or follows whooping-cough, the peculiar sound of the cough
 of the latter will disappear, nor return before the inflammatory affection
is removed.   As this is moreover the most dangerous of the  two, it  re-
quires attention before the other.   As to bronchial  and laryngeal ca-
tarrh, the  former especially is a very  common symptom in  whooping-
cough.  Where it is but slight it may be considered as unimportant;
where, however, it gives rise to fever or dyspnoea, it constitutes a  fur- 
ESSAYS.
79
ther indication to  interfere.  A dose of rad.  ipecacuanh., or of oxy-
sulph. antim., may ihen be given combined with the billadouna.
       R.—Rad. (or extr.)  belladon.,     .     .     .   gr. vj.
           Oxysulphur. antimon.,    .... gr. xij.
           Sacch. alb.,     .....      E)j.
       M. f. pulv., div. in  p. aeq., No. xii.
  D.  S.: Three powders daily.
  There are some old formulae combining belladonna and opium.  As
we  know at the present day, however, that in many regards belladonna
and opium counteract each  other, especially in their  bearing on the
action of the circulatory system, so that the two  have been consider-
ed  for some  time past  as direct antidotes of  each other, the idea of
combining these two narcotics must be given up as irrational.
  Incontinence of urine is another of the troublesome affections  which
are in almost all cases easily removed by the administration of bella-
donna.   From the almost regular effect it has, we must conclude that
the majority  of cases depend on  increased irritability  of  the bladder,
which is relieved by the administration of the narcotic.  The affection
is as frequent as it is  troublesome.   Dr. Addinell Hcwson  reports in
the American Journal  of Medical  Sciences,  October, 1858,  "some
facts  in relation to the nocturnal incontinence  of urine iu  children."
He observed seventy eight cases among the two hundred and ninety-
two boys in the House of Refuge, in Philadelphia; the average ratio
of the diseased being 1 : 3 75.  The  ratio was in the white boys, 1:7;
in the black, 1:2.7.  The  average age was  12| years;  the  youngest
affected with  the  disease was 7;  the oldest, 18 years  old; the great-
est number affected at any one age was 9; this was at the age of 14
years.  Of 63 cases, there was uric  acid  deposited in 31 specimens,
urate of ammonia  in 8, urate of soda in 1, ammon. magnes. phosph. in
1, no deposit in 22.   The prepuce and penis were discolored, and the
former much elongated, as either from frequent pulling to relieve the
itching of cystic  irritation, or from  masturbation; iu 33 there  was
every reason  to  suspect  this; in  12 there was no  suspicion.  Amount
of drinking and diet had a great influence; a suddeu fall of  the ther-
mometer  or  barometer  always  increased the number  of  patients.
Bromide of potassium in two and a half  and tli^ee grain doses, three
times  daily, cured 9 after a week's administration, and benefited  4
after  another  week.   The remaining 50  were not benefited at all.
To the 54 chloride of iron was given for six weeks without any effect.
Tincture of  cautharides was then given for  two weeks, brought on
dysuria iu the majority  of the  patients, but  cured  none.   Then, at 
so
ESSAYS.
last, belladonna was resorted to.   During two  nights, at  the end of
the first week, there was not a single case.
  I have given a pretty full account of this report, because of its ac-
curacy, and not because of its being the only one.  More than twenty
years ago, belladonna, and other narcotics also,  have been recom-
mended for  the same purpose, and the  medical journals  of  the  last
few years contain a large  number of cases of incontinence of urine,
cured in the same manner.   For four years past, during which time I
have given belladonna in every instance, I have not seen a single case
in which  the medicament proved unsuccessful.   A  complete cure  waa
generally obtained in half a week  or a week, by doses of the same
strength, or a little less than those given in whooping-cough.  Per-
haps, however, the administration can be greatly simplified.   One of
the former students of the New  York Medical  College, Dr. Guild, of
Rupert, Yermont, cured a girl  of  seventeen years, who  wetted  her
bed every night, and had been attended for her disease since her early
years, in  a few days, by a single daily dose of belladonna, administered
at bedtime.
  The admirable effect  belladonna has in  incontinence of urine  in-
duced me to give it in cases of incontinence of faeces, au affection not
so frequent as the former, but certainly  even more troublesome.   The
first case was that of a boy of three years, who, although  accustomed
to cleanliness and self-control, could not be induced to keep his faeces.
Three daily doses of half a grain of rad. belladon.  removed the affec-
tion in from five to six days.  Several  other cases were  relieved in
the same manner, and the experience of other writers  shows the same
results.   Dr. Richard administered belladonna  for the same  purpose,
and moreover, introduced into the rectum a  suppository  coated with
extract of belladonna.  In one case, a satisfactory result was  obtaiued
in two days.  And Dr.  Bercioux, after  having  tried,  and  generally in
vain, tonics, iron, cold, cantharides, and secale  cornutum, had com-
plete success with extr. bellad., gr. ^ (one-seventh) two, three, or four
times a day, even in inveterate cases.
  On the indications for the use of belladonna in other  affections I
have but little to say.   As others, I have frequently  used belladonna
in photophobia attending  the conjunctivitis of scrofulous children, and
its alkaloid  in more or less severe cases of keratitis.  My general prac-
tice  has been, in the former, to rub into the eyebrows, forehead and
temples,  many times a day, part of the following salve:
       R.—Ungt. hydrarg. ciner., .     .     .     3ij-iij.
            Ext. belladon.,     .    .     .     .  3j.  M. ft. ungt. 
ESSAYS.
81
   In cases of  exudative keratitis, a  solution of  atropia  in  distilled
 water, applied to the eye by means of a soft  brush, has  proved ex-
 ceedingly satisfactory:

       R.—Atropiae......gr. j.
            Solve in aq. destillat.,          .     .   3ij-§ss.   M. D.

   Finally,  of the prophylactic effect  of  belladonna in scarlatina,  on
 which so much has  been written and  said, I have but little personal
 experience.  This little, and a careful study of the  results and expe-
 rience of others, induces me to give it no further trial.
   III. Hyoscyamus.—After the expositions given on narcotics in gen-
 eral, and on opium  and belladonna in particular,  a few words will suf-
 fice  to  characterize the  value  of  hyoscyamus  in the  diseases  of
 children.   It has the general effect of narcotics, with less influence  on
 the cerebral functions than any of the above.  While it undoubtedly
 acts on  the nervous system, its centres appear less affected by it than
 its  peripheric  ramifications.   From  this fact, it  would  result that
 larger doses are not only tolerated, but  required.
   In regard to its  action on the nerves,  we find that it influences more
 the sensory nerves  than the trophic ones.  It does not suppress secre-
 tion like opium, nor has it so much of the contracting power over the
 lumen of the blood-vessels as belladonna.  While it is easily tolerated
 by  the stomach and intestines, it little  interferes, if at all, with their
 functions.  Thus, it may be given in  severe colic pains, added  to such
 remedies as are administered  for causal indications.   It  acts well, fur-
 ther, when added to medicines intended  to»relieve catarrhal affections
 of the respiratory organs.   It relieves pain without producing sopor,
 and irritation  of the  mucous membrane without interfering with  its
 secretion.   It is, therefore, a valuable additional remedy in laryngeal and
 bronchial catarrh, and intestinal catarrh  with great uneasiness or pain;
 in catarrh  of the bladder, with much straining  and pressing.   It  is,
 therefore, given merely for its symptomatica! action; but  we  are fre-
 quently under the necessity of attending to the  symptoms  of an affec-
 tion for their own sake, as well as we try to remove the cause of the
 disease.   Finally, hyoscyamus acts well  by counteracting the irritat-
 ing effect  of other  remedies, which may be  found  indispensable, but
 the irritating effect of which is nevertheless much  feared.   Thus, I
 have, since I did not  deem it proper to  add enough opium, especially
 in very young  children,  to counteract  the local  irritation of veratria,
 always added,  in infantile practice, extract of hyoscyamus to the tinc-
tmr^^f veratrum.
•  • 
J s>
■f/                -   »
 82                           ESSAYS."

        R.—Tinct. verat. virid.,  .     .     .     gtt. xx.
             Extr. hyosc,     .     .     .     .   gr. vj.
             AQ-,.....3iij.
    M.  D. S.: Ten drops every two (or three) hours, to children of a
 year, according to the indications of the tinct. veratri.
    I  add  extract of hyoscyamus  very >equently to  expectorants, the
 action of which is not  interfered  witty   ile the cough of bronchial
 affections is greatly relieved;  therefore, I ohen  combine it with pow-
 ders, or mixtures containing ipecac, oxysulphur. antimon., squill., liq.
 ammon. succin., or muriat. ammon.
        R.—Oxysulphur. antimon.,     .    .     gr. xij.
            Extr. hyoscyam.,   .     .    .     •   gr. vj.
            Sacch. lact......3ss.
                M. ft. pulv.  Div. in p. aeq., No. xvj.
   D. S.: A powder every two (or three) hours, in bronchial catarrh,
 to children of one or two years.
        R.—Muriat. ammon. pur.,
            Ext. glycyrrh. pur., aa.,    .     .    3ij.
            Ext. hyoscyam.,    ....  gr. xij.
            M-,  ■     •  '   •     •     •     •    giij.
   M.  D. S.: A tea-spoonjful  every two hours, in  bronchial catarrh,
 to children of two or three years.             •
       R.—Bicarbon. sodae,     ....     3ij.
            Extr. hyoscyam,,     .      .    .     .   gr. viij.
            Aq-,     •.....gij.
            Syr. gummos.,.....§j,
   M.  D. S.: A tea-spoonful every two hours, in catarrh of the blad-
 der, to children of one or two years.
   It is not necessary, however, to  multiply prescriptions, when the
 indications for both its independent aud additional administration are
 clearly given.   Independent of any addition, I have often ordered it in
 the irritation and colic following gastrointestinal catarrh, (in similar
 Cases, therefore, as those requiring the  use  of  codeia,) and  in  laryn-
 geal catarrh, in place of opium.  While in the former a frequent and
 small dose will prove sufficient, it is  better in  the latter  to  give  a
 larger doee, of a grain, or two  or four grains, at  once, in the evening.
   The dose of extract of hyoscyamus, as is  stated  above, and  as re-
 sults  also from the prescriptions given, is not so small as that of other
 narcotics.  Newly-born infants have  taken, with good effect from  a
 grain to a grain and a half a day, and  children of  two or four years
tolerate well doses of from two and a half to four or five grains.   „  a-«w
(M?5