.]^~«VVj,VV.;,.-..'-•:;•;: •. ,x. ^«jiu..xvx ■•/,■:,■;■--;::•■'. ■ S'^W^'A/;;^,.,^.;;..^^....- _____ a,. ViKtr-T.^nif^Wrtiii.'■■«;■ ■<• '■'.:.' " k-#ilt£ «r^ * ' ~ ' .'■A. ^...".".V. ■v.. V .^.►^*f:'^.v ., ,-v ^3&^$*g.,, ;w„\ .at****!**-*.* ft-. - *,<» . * -, i- * ► . . -, » .... J^S^^3^^C::^^~ viiv:-: !.X^ v'-Xt: , i^ES^^k^ "X^dfiv :x^5: -t^:: ■•• ■■ ■ aa.yt^tap.^p-f.ffr-.v --••>.■ -.y-,---;,......-..... wy.^lvi/ ."T r*t» V ' •' "»'"•' ,••'.-■ ...... . ^Hu-rw '"•'.IS.* W ■"Tjf •' • f^Vr'»l» ■"• "t M^w^i-^-'-■'>■ -x UNITED STATES OF AMERICA *" * . FOUNDED 1836 WASHINGTON, D. C. GPO 16—67244-1 ON THE DISEASES OE CHILDREN. ^ ^ c A /^4^ fr //R.—Sulph. Cupri, gr. x. Pulv. Cinchonas, 3ij. " G. Acacias, 3i. Mollis, 3ij. Aq. puras, 3iij.—M. With this wash the ulcers are to be touched twice a day, with the point of a camel's hair pencil. When accompanied with extensive derangement of the alimentary canal, the proper remedies adapted to the removal of the latter will be demanded. In many cases, indeed the ulcerations of the month will be found to resist every local application, until the digestive organs are 138 DISEASES OF CHILDREN. restored to a healthy condition, and the nutrition of the system gene- rally is improved. 5.—Gengivitis.—Inflammation of the Gums. The gums, from the period when dentition commences, until the com- pletion of the first set of teeth, are liable to become inflamed, indepen- dently of the residue of the buccal cavity. In some cases, the inflammation is but slight, and of short duration; but in others, particularly when it occurs in children whose general health has become impaired, in consequence of a deranged state of the digestive organs, the inflammation is often severe, and productive of extensive ulceration, by which the alveola and teeth, are often entirely destroyed. This disease has very commonly been confounded with scurvy of the gums. The gums become of a deep red or livid colour, swelled and pain- ful; the tender state of the gums, rendering mastication difficult, and often causing even spoon victuals to be refused. The child is, in gene- ral, very languid, with a hot and dry skin, a small and quick pulse impaired appetite, and considerable thirst. The tongue is, generally, covered with a thick yellowish fur. The patient's sleep is seldom much disturbed, and in some cases, there is increased somnolency. When the inflammation occurs, as it frequently does, previously to the protrusion of the molar teeth, a small ulcer occurs upon the surface of the gum, immediately over the teeth about to protrude, and, quickly extending, often lays bare the alveola, and the teeth become destroyed. In other cases, the ulceration occurs at the edge of the gum, and extends rapidly downwards. In every case in which the ulceration is allowed to go on, the teeth become loose, black, and carious, and are often reduced to a soft, pulpy state. When ulceration takes place, there is always a copious flow of fcetid saliva, the breath becomes extremely offensive, and the countenance of the child, assumes a pale sallow hue ; a bloody fluid oozes from the gums upon the least pressure, and often a very profuse diarrhoea ensues. This disease is very often produced, by too much, or improper food, particularly that which is of too stimulating a nature; and it is, very generally, attended with more or less—often with very extensive —derangement of the digestive organs. In the early stage of the complaint, the proper remedies are, mild emollient washes to the gums, with, twice or thrice a day, a wash of a solution of acetate of lead, (five grains to an ounce of water,) applied by means of a soft sponge, or dossil of lint. If the inflamma- tion is not promptly reduced by these means, a iew leeches should be applied to the angles of the jaws, or to the gums themselves. Some writers advise the gums to be freely scarified, and, in many instances, we have seen advantage to result from this procedure. The bowels should be freely opened by the administration of a few grains of calomel, combined with magnesia, and followed, after DISEASES OF THE DIGESTIVE ORGANS. 139 a few hours, by a dose of castor oil, or sulphas sodas; the tepid bath should be administered daily, and the child put upon a diet com- posed entirely of milk and farinaceous substances. When ulceration has taken place, and the inflammation of the gums is diminished, some light astringent wash will be beneficial; an infusion of oak bark, with alum," we have found peculiarly advantageous; the chloride of lime, will, also, in many cases, speedily arrest the ulceration ; or, we may employ, as a wash, diluted hydro- chloric acid.b We have often found a solution of the sulphate of cop- per to succeed, however, when other topical applications have failed. *R.—Corticis Querci, 3j. b R.—Acid. Hydrochlor. 3ss. ad, 3j. Aquas, Oss. Mellis, Doil to a pound and strain, then add— Aquas Rosas, aa. gi.—M. Sulph. Alumin, 9i. To be applied three or four times a day. To be applied to the ulcerated parts by means of a sol'tj-ponge, or dossil of lint, several times a day. The child should be exposed to fresh, pure air, and be supplied with a nourishing, easily digested, and perfectly unirritating diet. When the ulceration of the gums is very extensive, and the strength of the child is evidently impaired, the cold infusion of bark, or the sulphate of quinia may be administered ; and will often, very materially accelerate the healing of the ulceration of the gums. It is important that the teeth which have become destroyed by the disease, be early removed. The disordered state of the alimentary canal, will demand, of course, its appropriate remedies. 6.—Gangrene of the Mouth. (cANCRUM ORIS--GANGE..32NOPSIS--RANKER OF THE MOUTH--WATER RANKER.) Gangrene of the mouth, is not a disease of so frequent occurrence in this country, as it would appear to be in many parts of Europe ; it, nevertheless, does, occasionally occur, and has, in more than one of our public institutions for the reception of infants, prevailed ende- mically. Gangrene may ensue in either of the forms of stomatitis already noticed ; and, occasionally, in the follicular form, it forms one of the most unmanageable and fatal of its terminations. It is, however, in cases of inflamed gums, occurring in children of lax and debilitated habits, of a strongly marked lymphatic temper- ament, or the energies of whose organic functions, have been impaired by previous disease, that gangrene of the mouth most frequently occurs. The patient is, in general, affected with great langour and listless- ness. He is indisposed to engage in play, or even to move about; but is peevish and discontented, and unable to sleep; he has no appetite for food, but, in general, his thirst is increased. His counte- nance becomes pale and dejected, and a peculiar puckering of the 140 DISEASES OF CHILDREN. cheeks, about the corners of the mouth, is often observed.—(Richter.) There is, in general, considerable emaciation, and nocturnal sweats. In the course of one or two weeks, the patient begins to complain of sharp pains in his mouth and gums; his breath becomes, more or less, fcetid, and there is an increased discharge of saliva. A sense of itching, or pricking, and heat is experienced in the gums, which become of a dark red, or purple hue, swollen, and spongy, and bleed upon the slightest touch. The discharge of saliva becomes more profuse, accompanied, often, with a slight discharge of dark coloured blood, and a tumid and painful condition of the salivary glands. The odour of the breath, and appearance of the gums, at this stage of the disease, bear so strong a resemblance to those of a case of mercurial ptyalism, that we have known physicians of skill and experience mistake it for such. The disease being allowed to proceed, the edges of the gums, most generally those of the inferior jaw, separate from the necks of the teeth, and present a ragged, flabby, and livid aspect. The teeth become loose, and often fall out of their sockets; or, if they remain, become covered with a thick coating of mucus of a dirty white or ash colour. Fever, now, generally occurs; at first, towards evening, and attended by an increase of the nocturnal sweats. The bowels are, also, often affected with diarrhoea. The disease may continue in this state for many weeks, or even months.—(Wepfer.—Coates.) Usually, however, in the course of a few days, a number of ash coloured vesicles appear upon the gums, which rapidly enlarge in size, coalesce, and, finally, rupture, the denuded gum presenting a black and gangrenous appearance. When the dead portions of the gum separate, the ulcer which occurs, assumes, immediately, a gangrenous appearance, and, very rapidly, the entire gum becomes destroyed, and the whole of the alveola, and, sometimes, the greater part of the inferior maxillary bone, are laid bare:—the alveola are, generally carious, portions of which, with the teeth, are separated and thrown off. From the gums, the gangrene, sooner or later, extends to the lips and cheeks, which become more and more swollen, as the disease increases in extent. At this stage of the disease, and sometimes much earlier, a diffi- culty is experienced, in moving the lower jaw, in consequence of which, the mouth becomes firmly closed.—(Richter.) This, Reimann has erroneously considered to result from an actual tetanic affection; it is, evidently, altogether the result of the intumescence of the soft parts, and the pain which is consequent upon any effort to move the jaw. In the course of a few days, should the little patient not sink under the disease at an earlier period, which is generally the case, the whole of the soft parts surrounding the mouth, will become involved in the disease, assuming a dark livid colour, and discharging a putrid sanies, of a most offensive odour. DISEASES OF THE DIGESTIVE ORGANS. 141 The fever, which now often augments in intensity, presents a nervous, or hectic character, and the child dies upon the eighth, or, at furthest, on the fourteenth day from the commencement of the gangrene, his body presenting all the indications of a general colliqua- tion. The disease just described, is, evidently, a gangrene of the gums, extending thence to the surrounding soft parts, and induced by acute inflammation of the parts, occurring in children in whom the organic energy has been reduced, either by bad or deficient food, long continued exposure to an impure and stagnant, or a damp and chilly atmosphere, or by previously existing disease, particularly of the digestive organs. It is that form, which, according to Richter, prevails endemically in the asylums and hospitals for children, and in low, damp situations, bordering upon the sea. There is, however, another form of gangrene of the mouth, of much less frequent occurrence than the former, and differing from it in many important particulars. In this there is no preceding inflammation of the gums; but the disease, which commences in the soft parts surrounding the mouth, often at one of the angles of the lips, generally makes its appearance, as it were, abruptly ; without, at least, any previous symptom, indica- tive of its occurrence. A hard indolent tumor, about the size of an almond, is, commonly, first observed, in some part of the lips or cheeks; the tumour is deeply seated, and accompanied by a slight degree of redness of the skin by which it is covered. Upon examin- ing the mouth, nothing unusual is discoverable. In a few days, the tumor gradually augments in size, and the skin becomes of a deeper red; the internal surface of the cheek, over the tumor, assumes a gangrenous appearance, and an extremely offensive odour is exhaled from the mouth. Exacerbations of fever, generally occur towards evening ; the appetite, and disposition of the child, is seldom, however, much affected. If the disease be allowed to proceed, the external circumscribed redness of the lip or cheek, soon becomes paler, livid, then of a greyish hue, and surrounded by a red areola, which extends, as the disease progresses. In a few hours, frequently, the grey spacelated portion becomes completely black. If the mouth be now examined, it will be found, that in the imme- diate neighbourhood of that portion of the lip or cheek at which the disease commenced, the gums are in a state of gangrene; the teeth here become loose, covered with an ash coloured mucus, and, finally, drop out. The affection of the gums, is, in this form of gangrene of the mouth, secondary to that of the cheek or lip, and does not occur until that has made considerable progress.—(Richter.—Jackson.) Necrosis of the maxillary bone, is seldom observed in the variety of gangrene just described ; "death, usually taking place, from a general 142 DISEASES OF CHILDREN. sinking of the powers of life, previously to any very extensive destruc- tion of the soft parts. A much milder form of the disease is described by Richter, many cases of which have fallen under our notice. In this, circumscribed spots of gangrene, of a dark brown colour, surrounded by a red margin, and of various size, occur suddenly upon the lips, near to their angles, and upon the checks ; the general system of the patient remaining apparently unaffected. In some cases, the gangrenous spots, are preceded, one or two days, by a slight redness of the skin where they occur. The gangrene is always superficial, involving little more than the skin, and but little loss of substance is presented when the sloughs separate ; a supuration of a healthy character quickly ensues, followed by granulations and cicatrization. Occasionally, when the gangrene occurs at the commissure of the lips, it affects the entire thickness of the latter; the slight loss of substance which ensues, is, however, speedily filled up by granulations, and little or no deformity ensues. These mild cases usually occur subsequently to attacks of some of the acute exanthemata; indeed, the disease in this form, accord- ing to some writers, succeeds to acute affections of the skin, as small pox, measles, scarlatina, &c, where these have run an irregular course, or have, by any means, been suddenly arrested during their evolution (Richter, Baron, Romberg.) We have seen it more frequently, however, in children who have laboured for some time under symptoms of irregular intermittent fever, dependent upon chronic gastro-intestinal irritation. A third form of gangrene of the mouth, and the one which next to that consequent upon acute gengivitis, we have the most frequently met with, in private practice, is that in which the gangrene commences upon the centre of the internal surface of one of the cheeks. Its occurrence, is in general,* like the last described variety, sudden. The patient becomes, all at once, unusually restless and peevish; and affected with slight accessions of fever. If closely observed, some intu- mescence of one side of the face will be detected. The disease is occa- sionally, however, ushered in by nausea, vomiting or diarrhoea. One of the cheeks becomes quickly swollen, hard, dark red and shining; as the external swelling augments in size, and the skin is greatly dis- tended, the centre of the tumor often assumes a perfectly white and shining appearance ; the eyelids at the same time become oedematous; an increased flow of saliva takes place, and the breath acquires a very peculiar foetid odour. If the mouth be now examined, one or more greyish vesicles will be perceived upon the internal surface of the affected cheek, which, after some days, rupture, and form an ulcer of a dirty grey colour, of a rounded form, with red, distinctly circum- scribed edges; and at the same time, a slight excoriation or fracture of the skin, often occurs at the angle of the mouth on the affected side. This form of gangrenous ulceration of the mouth is not always immediately detected, and is occasionally entirely overlooked, by DISEASES OF THE DIGESTIVE ORGANS. 143 those unacquainted with the disease. The whole of the attention be- ing directed upon the external swelling. There is, in fact, some dilficulty in making an accurate examination of the inner surface of the cheek, from the difficulty the little patien.t experiences in opening his mouth to a sufficient extent, after the external swelling has ac- quired any size. As the gangrenous ulceration within becomes deeper and more extended, a livid spot, surrounded by a red areola, makes its appear- ance on the external surface, at the spot where the tumefaction is the greatest; this soon acquires a darker hue, and augmenting in size, involves, in the course of from four 1o eight weeks, nearly the whole of the soft parts on that side of the face. Portions of it are soft and of a grey or greenish hue, and present all the characteristics of humid gangrene, while other portions are completely mumified, hard, and of a deep black colour. If the gums be now examined, they will be found in a gangrenous condition, immediately opposite to where the gangrene commenced on the cheek, while in every other part they are apparently sound :— the gangrene of the gums being in this, as in the last variety, a con- sequence of the preceding mortification of the cheek (Richter, Jack- son, Guersent, Heuter), whereas, in the first variety, the gums are the part in which the gangrene commences, the jaw being frequently destroyed previously to the cheek becoming affected. In the progress of the disease, the functions of the alimentary canal become deranged, the appetite of the patient is destroyed; his thirst augments ; nausea and vomiting often occur ; the diarrhoea becomes more copious, the discharges being thin, dark coloured, and offen- sive; the skin of the body is dry and hot, while that of the extremities is colder than natural; the abdomen becomes tympanitic; the patient falls finally into a soperose condition, and death speedily ensues. In our own practice, this variety of gangrene of the mouth has most usually occurred in children who had for some time been affected with disease of the gastro-intestinal mucous membrane, attended with febrile symptoms of a remittent or intermittent character. In no case, however, in the cases which fell under our care, did the gangrene involve the whole thickness of the cheek. In every instance, we were enabled to arrest its progress, before it had extended beyond the mucous membrane lining the cheek in which it had commenced, and a small extent of the gums, in the immediate neighbourhood. It may be, however, that the cases we have seen, were, even in their earlier stages, of a much milder character than those described by the European writers. Gangrene of the mouth, is an affection almost exclusively confined to the period of infancy. It may occur at any time between the first and tenth years, but is most commonly observed between the second and fourth. Few, if any, cases have been met with in infants during the period of lactation. The children in whom gangrene of the mouth most usually occurs, arc, those of delicate habits, of a lymphatic temperament, with 144 DISEASES OF CHILDREN. soft and flaccid muscles, and pale skin, and in whom the functions of assimilation and nutrition have been depressed, from a variety of morbific influences. (Richter.) In no instance, has the disease been known to occur, in children of a robust, and healthy constitution. It is seldom met with, excepting among the children of the poor, who are imperfectly fed, or upon food of an improper quality; those who are ex- posed to the influence of a damp and chilly, or impure and confined atmosphere; in whom personal cleanliness is neglected, or who have become reduced by some severe acute affection, particularly of the skin, or have suffered from chronic disease of the stomach and bowels. It is a disease of frequent occurrence in public institutions, where a number of children are crowded together, in small, low, or illy ventilated apartments. Hence, in the asylums and hospitals, destined for the reception of children, the disease frequently occurs as an endemic. In the Children's Asylum of Philadelphia, there was, at one period, among the two hundred and forty inmates of the insti- tution, seventy affected with gangrene of the mouth.—(B. H. Coates.) As the children of the poorer classes in Europe, who live upon the borders of the sea, are exposed, at one and the same time, to most of the predisposing causes of gangrene of the mouth, it is, in consequence, an affection extremely prevalent in Holland, Sweden, Denmark, Norway, and in many parts of England, Ireland and Scotland. The influence of long continued exposure to a damp climate, and the constant use of unwholesome food, in the production of the disease, are sufficiently established by the report of the physicians attached to the French army which occupied Spain, they having to treat, frequently, a gangrenous inflammation of the mouth which occurred among the soldiers, and which received from the Spaniards, the name oifegar or fegarite.—(Richter.) Gangrene of the mouth is, no doubt, in the majority of instances, intimately connected with gastro-intestinal irritation. The causes which have been enumerated, evidently predispose to the disease, by disturbing the healthy condition of the stomach, and other organs appropriated to digestion and assimilation, and to nutrition generally. The disease is mentioned by more than one writer, as having pre- vailed epidemically in the Netherlands, as a consequence of gastric fevers. (Thomassen and Thyssen.) In all of Poupail's cases, seventy- two, the disease followed an attack of intermittent or remittent fever; in nine of the cases reported by Dr. Jackson, of Northumberland,* the disease occurred in the course of, or subsequent to, an attack of remittent or bilious fever. Dr. Marshall Hall, states, that in all the cases he has seen, the disease succeeded to disorders of the digestive organs, typhus fever, or some inflammatory affection; and in all the cases which have fallen under our notice, the affection of the mouth, had been preceded by, more or less, decided indications of * Now of Philadelphia. DISEASES OF THE DIGESTIVE ORGANS. 145 gastro-intestinal irritation; in the majority, the children had suffered, for some time, from the infantile remittent and intermittent fevers. Another fruitful cause of the disease would seem to be, the acute exanthemata; an imperfect crisis, or sudden repulsion of the cutaneous eruption, appearing to favour, in an especial manner, the develop- ment of gangrene of the mouth.—(Richter, Thomassen and Thyssen, Huxham, Cummins, Baron, Wendt, Fischer, Siebert, Romberg.) By a few of the writers on gangrene of the mouth, its propoga- tion by contagion, is asserted. But of this, no well authenticated instances have been recorded. In every case, however, as a prudent precaution, it will be proper to separate, as much as possible, the indi- viduals affected, from those in health, as well as from each other. A number of patients labouring under gangrene of the mouth, being con- fined in the same room, cannot fail, even with every precaution in regard to cleanliness and ventilation, to render the disease, to a cer- tain extent, more unmanageable, than when the patients are placed in separate and distant apartments. Few examinations of the lesions presented by the internal organs, in the children who have died of gangrene of the mouth, are upon record ; and of the few that are reported, the majority appear to have been performed with very Utile accuracy, so that of the pathological anatomy of the disease, we know but little. In the examinations we have made, which, however, have been very limited—for we have had the good fortune to lose but few of our patients—the principal organs in which morbid appearances were pre- sent, were the stomach, intestines and liver. In all the cases, the two former presented the indications of inflammation, of a more or less chronic character; the latter appeared to be affected with hyper- aemia, rather than any structural change. In the majority of cases, the mesenteric glands were greatly enlarged. In the examinations made at the Children's Asylum, between June 1st, 1827, and January 1st, 1830, the morbid appearances exhibited, were enlargement and hardening of the mesenteric glands ; a scrophu- lous condition of the glands of the neck, and, in every instance, tuber- cles of the lung.-?. In general, the whole substance of the lungs was thickly studded with tubercles, in various stages of inflammation and suppuration. The condition of the gastro-intestinal mucous membrane is not recorded. Richter remarks, that every physician who has had an opportunity of treating the gangrene of the mouth in children, agrees that it is one, which, if not entirely beyond the control of medical treatment, speedily produces, in at least the majority of cases, the death of the patient. ft is certainly true, that when the disease occurs in illy constructed and crowded asylums for children, or in any situation in which the patients remain constantly exposed to a confined and impure, or a damp and chilly atmosphere, or when it occurs in children, greatly exhausted by previous illness, that the disease is one very generally fatal. When too, its real character is misunderstood; when it is 10 146 DISEASES OF CHILDREN. overlooked in its first stages, or treated by inert or improper remedies, death can very seldom be prevented. We have not found the disease, in any case in which we have been enabled to treat it in its early stages, so difficult to cure, as most of the European writers describe it to be. We have, indeed, seldom failed in arresting, very speedily, the progress of the gangrene. This is also the experience of Dr. Coates, who had the charge of the Children's Asylum of Philadelphia, previously to the year 1828, and of his suc- cessor in that institution ; where, although the disease has frequently prevailed epidemically, it has been productive of a very small mortal- ity. With a judicious treatment, early commenced, the disease would appear to be even more manageable, than many of the other severe affections of childhood. The period when the treatment is commenced, is, however, all important to ensure its success. This perhaps, more than almost any "other circumstance, will determine, in the majority of cases, the greater or less mortality.—When the physician has been ena- bled to detect it at ihe period of its development, he will, very gene- rally, be able to arrest its further progress, and to save the life of his patient. It is remarked by many writers, that when the gangrene com- mences by a tumor or livid spot upon the cheek, it is very generally under the control of medicine.—(Muys, Lund, Seibert, Klaatsch, Rei- mann, Jackson.) We have not, however, found the other forms of the disease to be less so. According to Richter, when the gangrene of the mouth occurs subsequently to affections of the alimentary canal, itisofa less malig- nant'character than when it succeeds to diseases of the skin, or to fever, in children of a scorbutic habit. Upon the true pathological character of gangrene of the mouth, much difference of opinion exists among the writers who treat upon it. That the first variety we have described, is the result of inflam- mation of the gums, no one can doubt, who has examined the disease with care; and, according to Richter, the tw7o other varieties, also, result from an inflammation of the parts in which they first occur—an opinion which we believe to be well founded. By others, ganerene of the mouth has been ascribed to inflamma- tion of the lymphatics, (Bid/oe) ; to a softening of the affected tissue, similar to what takes place in the stomach, uterus, brain, and other organs, (Klaatsch and Hesse, Weigand, Boer); to a scrophulous affec- tion, Cheilocace, (Lcvtin); to a scurbutic affection, (Van Sireiten, Seibert, and most of the older nriters) ; and finally, to an induration of the cellular tissue from infiltration, similar to what occurs in new born infants, (Fischer, Billard.) In the majority of cases, the treatment of gangrene of the mouth consists simply in the application of remedies, adapted to arrest the further progress of the local disease. When, however, we are called in previous to the occurrence of gangrene, in many cases, much may DISEASES OF THE DIGESTIVE ORGANS. 147 be done to prevent its occurrence, by adapting our remedies to remove the existing predisposition. Whenever it can be accomplished, the patient should be subjected to the influence of a dry and pure atmosphere; the strictest cleanli- ness, of both person and clothing, should be enjoined, together with a diet, perfectly unirritating and easy of digestion, and adapted, in respect to the substances of which it is composed, to the actual condition of the digestive organs in each case. If the gums he in a state of inflam- mation, the remedies directed in the section on that disease should be resorted to. In the great majority of cases, more or less disease of the stomach and alimentary canal generally, will be found to exist— this is to be treated by its appropriate remedies; recollecting, however, that alterative doses of calomel, even when indicated by the symp- toms present, are to be employed with the utmost caution, in every instance in which we have reason to apprehend the occurrence of gangrene of the mouth—for there can be no doubt that the disease has, in many cases, been developed by the incautious>use of mercury. When cautiously prescribed, and their effects are carefully watched, small doses will, nevertheless, often be productive of beneficial results. In a few instances, we have found the administration of the sulphate of quinia, and washing the gums repeatedly with a strong decoction of oak bark, to be beneficial in preventing the occurrence of gangrene of the mouth, incases in which we had every reason to anticipate its speedy occurrence. In every case in which decided symptoms of local inflammation exist, leeches to the part will be proper. When tumefaction of the cheek occurs, blisters over the tumor have been, also, found beneficial.—(Jackson.) The remedies that have been employed locally, with the view of arresting the progress of the gangrene, are very numerous. All of them are reported to have succeeded in the hands of some physicians, while in those of others, they have entirely failed. The wash or lotion which we have found by far the most successful, is a strong solution of sulphate of copper, applied very carefully, twice a day, or oftener, to the full extent Of the gangrenous ulceration.* A solution of the sulphate of zinc, (one drachm to an ounce of water,) either alone or with the addition of tincture of myrrh,b will be found, in many cases, an admirable remedy. Nitrate of silver was the only local remedy employed in the cases "of gangrene of the mouth, that occurred in the Children's Asylum of Philadelphia, from June 1st, 18 27, to January 1st, 1830, the greater portion of which terminated favourably. As soon as the disease of the mouth was detected, the nitrate of silver, either in pencil or solution, was applied, freely, to the parts affected. iR.—Sulph. Zinci,3i. »R—Sulph. cupri, 3ij. Aquas, gij. M.et solv. Aquas, 3iv.— M. Dien adde mollis, Tine. Myrrh, aa 3ij.—M. Or, R.—Sulph. cupri, 3ij. Pulv. cinchon. 3SS- Aquas, 3iv.—M. (Coates.) 148 DISEASES OF CHILDREN. Creasote was found to be an admirable local application in the gan- grene of the mouth, which occurred, as an epidemic, in the Philadel- phia almshouse, in 1838, incisions being first made through the gan- grenous sloughs. (Dunglison.)* 1 R.—Creasot. Alcohol, aa 3 pies, in twelve hours, according to the age of the child, has been^y strongly recommended recently. (Hunt.)f^ t3*c<.J%- --x'. The iodide of iron has also been suggested as a means of improving the condition of the nutritive function which, in this disease, is evi- dently impaired. (Dunglison.y a R.—Vini Hispan. (sherry) 3'V. Ferri iodid. 3i.—M. Dose, a tea spoonful, four times a day. When a profuse diarrhoea occurs in the course of the disease, we have found it often to be very quickly arrested, by adding to the solu- tion of sulphate of quinia, two or three drachms of the tincture of kino. In some cases, we have given, with good effect, three or four grains of powdered galls, repeated every three or four hours; should these remedies fail, we may give the acetate of lead, in the following prescription.11 a R.—Acetat. plumbi, gr. xvj. Cretas ppt. 9ijss. Ipecacuanhas, gr. iv. Opii pulv. gr. ij.—M. One to be given every three or four hours. 7.—Difficult Duntition- Dentition, although a purely physiological process, and one, that in the healthy infant with an organism, in no part of which there exists any strong predisposition to morbid action, is attended, in general, with little suffering or danger, may, nevertheless, give rise to much suffering, or even be the exciting cause of some violent and quickly fatal malady, whenever the irritability of the infant's system has be- come unduly augmented—when its energies have been impaired, and a tendency to disease in the alimentary canal, in the brain or in the respiratory organs, has been developed by bad nursing—or by an impure, heated, or confined air. It is usually between the fifth and seventh month, that dentition, in the ordinary acceptation of the term, commences; in different cases, however, the period, when the teeth begin to protrude from the gums, 150 DISEASES OF CHILDREN. will be found to vary—in some, the teeth appearing earlier, and in others, not until some weeks, or even months, later. As soon as dentition commences, there is very generally an increased redness, attended with considerable heat and tenderness of the gums, and an increased secretion of saliva. Occasionally, there is a slight febrile reaction—redness of the cheeks, watering of the eyes, and augmented thirst. The child is often fretful, and disturbed in its sleep. The dis- charges from the bowels are more frequent and fluid than usual, and occasionally of a greenish hue; and the^stomach is morbidly irritable, the matters" discharged from it, having often a strong acid smell. Occasionally, eruptions appear upon the skin, particularly upon the forehead and cheeks—an erythematic inflammation and ulceration be- hind the ears, and not unfrequently a slight tumefaction of the salivary glands. As the advancing tooth approaches the surface of the gum, the fingers of the child are frequently held in his mouth ; he presses firmly between his gums the nipple in sucking, or any object which he can readily seize and convey to his mouth ; this appears to ease some un- easy sensation experienced by the child, as does also, pressing or rubbing the gum with a finger. The foregoing symptoms are not invariably present during dentition. In some children, the process is attended with such slight inconveni- ence, that the first two incisors are frequently cut without attracting the slightest attention, until their points are seen protruding beyond the gums. It is principally, when there is a disproportion between the development of the teeth and jaw, as when dentition commences very early, or when a number of teeth are cut at the same time, that dentition is attended with much pain or difficulty. The molar teeth are, also, cut with more difficulty than the incisors. Even, however, when the symptoms we have described do occur, all that is necessary, is, to confine the child to the breast of a healthy nurse, and to supply him occasionally, with moderate portions of fresh water in which a small quantity of gum accacioe has been dissolved ; or if he has been weaned, to confine him to a diet composed chiefly of milk and farina- ceous substances, and for his drink, to toast, barley, or rice water; ani- mal food, all stimulating,drinks, and every kind of spice should be with- held. He should be kept in a pure, fresh air, and not overheated either by too much clothing, or by too great a temperature of the room he oc- cupies. His head, in particular, should be kept cool, as well during the night, as in the day. The daily use of the tepid or warm bath will be advantageous ; and if the weather permit, daily exercise in the open air should not be neglected. Little attention need be paid to the diarrhoea that is usually at- tendant upon dentition—it is seldom very profuse. If attended with considerable griping, an injection of thin starch, or of a decoction of flaxseed, with the addition of a little sweet oil, will, in general, be sufficient; if the griping still continue, a few grains of calomel may be given by the mouth, followed, in the course of four or five hours, DISEASES OF THE DIGESTIVE ORGANS. 151 by a dessert spoonful of castor oil. If, as occasionally happens, the bowels, in place of being more free than usual, are constipated, a dose of magnesia, or of castor oil may be given. The eruptions, which occasionally appear about the face, and the inflammation and ulcera- tion behind the ears, demand no particular attention ; the latter may be washed, night and morning, with some mild mucilaginous fluid, as water in which the pith of sassafras or the inner bark of the slippery elm has been infused. The eruptions and ulceration very commonly disappear, when the teeth have protruded beyond the gums. As children appear to derive relief from a slight degree of pressure upon the gums during dentition, something should be allowed them for this purpose. A substance, that will yield to the pressure of the gums, is to be preferred ; an oblong piece of gum catchouc, two or three inches in length, and half an inch in breadth, will probably be the best; it should be suspended round the neck by a ribbon or tape. All hard, rough, or unyielding substances are positively injurious. A variety of washes for the mouth have been recommended, by different writers, to " soften, soothe, and refresh the gums, during den- tition." When composed of any simple mucilage, these washes will do no harm ; they are unnecessary, however, if the child be supplied with cool mucilaginous drinks ; the good effects that have been at- tributed to them, in allaying the irritation of the. gums, is referable, we suspect, entirely to the gentle friction of the gums produced by the nurse's fingers, in their application. . It is not always, however, that the process of dentition is accom- plished with so little inconvenience. In children of very irritable habits, in those who are gross and plethoric, or in whom there exists a strong tendency to disease in one or other of the organs, dentition may become the exciting cause of some of the most serious and fatal maladies, incident to the period of childhood. Inflammationof the mouth or gums, terminating in ulceration or gangrene—long continued and extensive disease of the bowels, accompanied with frequent and vitia- ted discharges—spasmodic closure of the glottis—convulsions, often of a violent character—hyperaemia, inflammation, or dropsy of the brain, are among the most common results of difficult dentition in children predisposed to disease. In the children of the poor, espe- cially, who are exposed to the overheated, stagnant, and impure atmos- phere of the confined streets, courts, and alleys of many of our larger cities, dentition becomes, during the summer season, one of the most common exciting causes of the cholera of infants. Even, in such cases, much may be done, by a judicious course of treatment, towards preventing.the mischief which the process of den- tition has a tendency to develope. The child should, as far as possi- ble, be removed from the influence of whatever morbific causes he may be surrounded with. He should be placed in a pure, fresh atmosphere. His diet should be mild, nourishing, and easy of digestion; if of a plethoric habit, every species of animal food should be withheld from him ; while, if he be labouring under great exhaustion or debility, it may be necessary to allow him beef, mutton, or chicken broths, or 152 DISEASES OF CHILDREN. even a portion of the meat of which these are prepared, plainly cook- ed, and in moderate quantities. The strictest cleanliness of person and clothing should be observed:—the daily use of the warm bath, and frequent.exposure to the open air, in suitable weather, with an amount of exercise adapted to his age and state of health, should be strictly enjoined. The state of the gums should be daily and carefully examined ; and the moment they appear hard and swollen, and the teeth are evidently producing a distension of them at the points where they are about to protrude, a free incision should be made with a lancet, so as com- pletely to divide the tough membrane by which the tooth is enveloped, the tension of which, by the advancing tooth, being the cause of much of the pain and irritation consequent upon difficult dentition. The lancet should, in every instance, be carried down until it reaches the tooth, and if it be a molar tooth that is about to protrude, a crucial incision will be necessary. This operation gives but little pain, and is rarely, when judiciously employed, attended with danger or incon- venience,* while, in many cases, it is followed by immediate relief, and may be the means of preventing the occurrence of fever, convulsions, or fatal disease of the brain. Even, subsequent to the occurrence of convulsions, of spasmodic closure of the glottis, or deep stupor from hyperaemia of the brain, a free division of the gum over the advancing teeth has been known, in repeated instances, to be followed by an almost immediate cessation of every alarming symptom. A curious case is related, by M. Robert, in his Treatise on the prin- cipal objects of Medicine, illustrative, as well of one of the effects of difficult dentition, as of the division of the gum. We give it upon the authority of M. Carault, not having seen the work of M. Robert. A child, after having suffered greatly from difficult dentition, ap- parently died, and was laid out for interment. M. Lemonnier, hav- ing some business at the house of the nurse, with whom the child resided, after fulfilling the object of his visit, was desirous of ascer- taining the condition of the alveoli in this case. He accordingly made a free incision through the gums; but, on preparing to pursue further his examination, he perceived the child to open its eyes, and give other indications of life. He immediately called for assistance; the shroud was removed from the body, and, by careful and persevering atten- tion, the child's life was saved; the teeth made their appearance, and its health was fully restored. When considerable redness and tenderness of the gums occur * We have said that the division of the gum over the protruding teeth, when performed at a proper lime, and in a proper manner, is " rarely attended with danger or inconveni- ence." It should be performed only, when the gum is evidently raised by the advancing teeth, and the surrounding parts are red and painful. We have never seen the apthi us or gangrenous ulceration which, Billard apprehends, may be produced by the incision. Were it to occur, in the majority of cases, it would be a less troublesome and unmanage- able occurrence, than that, to prevent which the incision is made. In two instances, however, both occurring in children of a scrophulous habit, and who had suffered from long continued chronic disease of the bowels, a constant oozing of blood took place from the incision, and which could not be arrested by any means that were resoited to, including the actual cautery. DISEASES OF THE DIGESTIVE ORGANS. 153 about the period when the process of dentition is expected to com- mence, without, however, either of the teeth having advanced suffi- ciently near to the surface of the gum, to render an incision of the latter necessary ; emollient washes should be frequently applied to the gums, and a leech or two to the angles of the jaw. If the bowels are costive, a calomel purgative, followed by castor oil, may be adminis- tered. If a considerable degree of febrile excitement be present—particu- larly, if it be attended by heat and tenderness of the abdomen—a few leeches to the gums, and over the epigastrium, the tepid bath, and small doses of calomel and ipecacuanha,11 will generally be found ad- vantageous. a R.—Calomel, gr. ij. ad iij. Magncs. calc. gr. xxiv. Ipecacuanhas pu*. gr. ij. ad iij.—M. f. ch. No. xij. One to be given every three hours. When dentition is attended with frequent and copious discharges from the bowels, of a thin watery consistency, and accompanied with more or less griping—bland mucilaginous drinks and the tepid bath, will, in general, afford relief; if, however, the diarrhoea continues unabated or increases, we have found the best means of arresting it to be a solution of acetate of lead given by the mouth." a R.—Acetat. plumbi, gr. viij. Acid. acet. impur. TTL viij. Sacch. alb. 3j- Aq. puras, gi.—M. An ordinary sized tea spoonful of which may be given as a dose ; and repeated, three or four times a day, until the frequency of the discharges are abated, When there exist increased heat and redness, with turgescence of the vessels about the head—particularly if, at the same time, the child is unusually drowsy, or starts frequently from its sleep with a wild, affrighted aspect—a few leeches should be applied behind the ears and the head sponged frequently, with cold water alone, or cold water, with the addition of one-fourth of proof spirit; the bowels should also be freely opened by calomel, followed by castor oil or epsom salts. Where the tendency to disease of the "brain is very decided, after the leeches are applied, blisters behind the ears, repeated as they heal up, will often prove serviceable. The slightest indication of an approaching attack of convulsions or spasm, should be carefully watched, and treated by its appropriate remedies. The dysuria, so common in cases of difficult dentition, is best assuaged, by the free exhibition of some mild, demulcient drink. If the pain be considerable, and there is nothing present to forbid its use, an opiate may be administered.a » R—Sulph. magnes. 3ij. ad 3iij. Solve in Or, R—Hydrochlor. ammonias 3j. Aquas puras gj. dein adde Pulv. ipecacuanhas, gr. iv. Spir. asther. nitrici, 3'j. Pulv. opii gr. ij. M. f. ch. Nc. xv. Tine, opii 1T[ vii. ad xv. One to be given once or twice in the Dose—a tea-spoonful to be repeated, accord- course of the day, according to cir. ing to circumstances. cumstanccs. 154 DISEASES OF CHILDREN. 8—Tongue Tic= Physicians are frequently called upon, to relieve, by an incision, the tied tongue of infants; an accident supposed to be produced by a malformation of the frsenum linguae. It often happens, that in young infants, the fraenum approaches very near to the apex of the tongue; and it is possible that, in some instances, the imped- iment to the free motion of the tongue, thence resulting, may ren- der sucking very difficult, or even impossible. We confess that we have never met with such a case; though, if nurses are to be be- lieved, it is a thing of the most common occurrence. Infants occa- sionally appear to suck with difficulty, frequently letting go and reseizing the nipple; in other cases, the act of sucking is accompanied with a kind of clucking sound :— this is almost invariably attributed to the tongue being tied. We" have, however, repeatedly examined the tongue in such cases, and have detected no malformation of it, or of its fraenum :—nothing, in fact, to interfere with its movements. Burns declares that he has not seen two children, where a malforma- tion of the fraenum, rendered any operation really necessary. Mar- ley has seen but one; the operation U-nderwood declares to be very rarely necessary; and the same observation is repeated by Maunsel. The tongue is sufficiently free for all its functions, if the tip can be advanced beyond the outer margin of the lip, or placed upon the roof of the mouth. An operation is requisite only, in cases where the con- finement is such, as to prevent either of these movements. (Blundell.) When an operation is absolutely necessary, it consists in dividing, with a. knife or scissors, the anterior edge of the fraenum; taking care that the incision be not carried too far, so as to endanger a division of the lingual vessels, and give rise to a troublesome and dangerous haemorrhage. The head of the child should be held firmly, with the face upwards. The operator standing behind the top of the head, inserts the first and second fingers of the left hand into the mouth, beneath the tongue, and places one on each side of the fraenum, when the latter may be cautiously divided, to the extent deemed necessary. Of the accidents/that have been said to result, in some cases, from this operation, we need not speak:—by proper caution and skill, on the part of the operator, they can, in every instance, be very readily avoided. DISEASES OF THE DIGESTIVE ORGANS. 155 CHAPTER II. DISEASES OF THE THROAT. 1.—Tonsillitis, Inflammation of the tonsils and veil of the palate, is a frequent dis- ease, in the latter stage of infancy, and during the entire period of childhood. It seldom, however, assumes the decidedly acute charac- ter, so common in the tonsillitis of adults. From a very early age, the tonsils are liable to a sub-acute form of inflammation, producing, in many cases, a very considerable enlargement of these parts, which often continues for a long period, changing the tone of the patient's voice, and impeding his breathing and deglutition. Tonsillitis usually commences, with a sense of pain or uneasiness in the throat, a htiskiness of the voice, a sense of chilliness and lan- gour, quickly followed by more or less febrile reaction. The pain in the throat increases, deglutition becomes more difficult, and a sense of heat or burning is often complained of in the pharynx. There is often considerable nausea, and in children at the breast, regurgita- tion of the milk, shortly after it is swallowed ; in children a few years old, there is a frequent hawking and rejection of tough mucus. The throat being examined, the velum palati and pharynx, are found to be increased in redness, and tumid ; both the redness and intumes- cence,.being often more considerable on one side than on the other; one or both tonsils are swollen, and generally covered with a coat of thick, tough mucus, often of a dirty white colour. In some cases, the soft palate and uvula, present a dark red and cedematous appear- ance. The throat is tumid, and painful to the touch, externally. The tongue is covered with a white fur, through which the papillae of the tongue, enlarged, and of a bright red hue, project—a thick pellicle of transparent mucus, being spread over the whole; when com- plicated, as it is occasionally, with gastric disease, the tongue is gen- erally covered with a yellowish fur, and a sense of pain or heaviness is experienced over the eyes. The swelling of the tonsils is often very considerable, imped- ing respiration, often entirely preventing deglutition, and rendering the voice indistinct and whispering. The disease, when properly treated, commonly terminates by resolution. We never recollect to have seen an instance of extensive suppuration in a child. A substance, somewhat resembling pus, is, however, occasionally seen, adhering to the surface of both tonsils; and, occasionally, a slight, circumscribed diptheretic exudation. Very frequently, the redness and tumefac- tion of the velum and pharynx subside, while the enlargement of the tonsils continue. More frequently, the symptoms, from the commencement of the attack, are of a much less marked character. The child, if at the 156 DISEASES OF CHILDREN. breast, exhibits difficulty and pain in swallowing, and throws up its milk soon after it is swallowed ; the throat, externally, is somewhat swollen, and tender to the touch ; and there is a peculiar huskiness of the cry. If the child is old enough, it complains of pain in the throat, increased at every attempt to swallow; and the swelling of the throat externally, is often very considerable; there is difficulty of breathing, and a frequent hawking up, of a thick, tenaceous mucus. On exam- ining the throat, a slightly increased redness of the palate is observed, with considerable and irregular enlargement of the tonsils, which pre- sent a kind of lobulated appearance, their surface being covered with a thick coating of tough mucus. This latter form of the disease, is very generally complicated with disease of the alimentary canal; and is more common in children of a lymphatic, than in those of a sanguineous temperament and pleth- oric habit. The causes of tonsillitis are, in general, exposure to cold and damp- ness— sudden vicissitudes of atmospherical temperature—cold drinks, when the body is in a state of perspiration—and cold to the feet. It frequently exists simultaneously with acute exanthemata. It is more prevalent in spring and the latter part of autumn, than in the middle of either summer or winter. The treatment of inflammation of the tonsils is very simple, and, if early commenced, a very prompt resolution of the inflammation may in general be effected. In slight cases, some rubefacient to the throat, externally,a followed by an emollient poultice; a purgative of a few grains of calomel, with a moderate dose of the sulphate of soda a few hours subsequently, and a warm pediluvium at bed-time, will fre- quently be sufficient to arrest the inflammation. * R.—Ol. olivee, gj. Aq. ammonias, 3'j- Sp. terebenth. 3j.—M. When, however, the inflammation of the throat is more considera- ble, a few leeches should be applied to the neck, or behind the ears; and, internally, minute doses of tartar emetic, either simply dissolved in water,a or in a solution of sulphate of magnesia.b a Aquas purae, 3ij. ad iv. b Sulph. magnes. 3iv. solve in Tart, antimon. gr. j.—M. Aq. puras, giv. dienaddc Dcse, a tea-spoonful every two or Tart, antimon. gr. j.— M. three hours. Dose, the same., We have derived very great advantage, in cases of tonsillitis, from the use of a combination of the hydrochloride of ammonia, ipecacu- anha and calomel.a 1 Ammonias hydrochlor. gr. xxxvj. ad 3j- Ipecacuanhas pulv. gr. ij.—iv. Calomel, gr. iij.'—vj.— M. f. chart. No. xij. One of which is to be given every three hours. The hydrochloride of ammonia, in inflammations of the throat in children, is a favourite prescription with many of the continental DISEASES OF THE DIGESTIVE ORGANS. 157 physicians. Loeffler recommends it in tonsillitis, dissolved in water, with the addition of the extract of liquorice. Blisters to the throat, are directed by most writers, when the inflammation of the tonsils is severe, and is not quickly arrested by the other remedies employed. We have seldom seen much good result from the application of blisters to the throat in children; nor any instance in which they were required, in the disease under con- sideration. If resorted to, they should be kept on only so long as to redden the skin; and, on their removal, the part to which they were applied should be covered with an emollient poultice. If the child be at the breast, it is better not to allow it to suck, until the inflammation of the throat is subdued—it sucks in general with so much avidity, that a large quantity of milk is carried to the throat at one time, which is almost immediately afterwards discharged by regurgitation or vomiting. Its thirst may be assuaged by a few spoonfuls of water, rendered somewhat mucilaginous, by an infusion of slippery elm bark, or pith of sassafras, or by a mixture of milk and water, given occasionally. Older children shoutd be debarred from all food, and allowed toast- water, or some simple mucilaginous fluid as a drink. Patients affected with tonsillitis, should be kept in a dry apart- ment, the air of which should be of a moderate and equable tempera- ture. When accompanied by disease of the alimentary canal, the latter should be treated by its appropriate remedies. The treatment of the sub-acute form of tonsillitis, which, according to our experience, is the one most frequently met with in children, differs in nothing from that of the acute form. Leeches to the throat, will be occasionally required. The mixture of hydrochloride of ammonia, ipecacuanha and calomel, will be found particularly ad\4antageous in the sub-acute form. When an indolent enlargement of the tonsils remains, after the removal of the inflammation, the application of solid nitrate of silver over the surface of the enlargement, will occasionally be found ser- viceable. We have seldom, however, seen much injury, or very serious inconvenience, to result from enlarged tonsils in children; they have usually gradually dispersed, and have seldom continued beyond the period of puberty. h—Pseudo-membranous, or Diptheritic Inflammation of the Throat. This is one of the most common forms of inflammation of the throat in children, and is that which most generally accompanies scarlatina, when the latter prevails as an epidemic. Its most conspicuous char- acter, is the early excretion of a thin, pseudo-membranous pellicle, either continuous or in patches, and closely adherent to the surface of the inflamed mucous membrane, upon which it is produced. Pseudo-membranous inflammation of the throat, commences often 158 DISEASES OF CHILDREN. with "symptoms of so mild a character, as to attract scarcely any attention, until the local disease has made considerable progress. The deglutition is but little—or not at all—impeded; only a trifling soreness, or rather a sense of roughness in the fauces is experienced, while no febrile excitement is present. The child often continues to indulge in its ordinary sports, with, perhaps, a little more fretfulness and dejection than usual, and, becoming, apparently, more quickly tired. In other cases, however, there is, from the commencement, a sense of langouf and general discomfort; a sense of chilliness, alter- nating with flushes of heat; increased thirst; pain of the head ; a sense of heat or burning in the throat; while the act of swallowing, and the slightest motion of the neck, cause intense pain. The skin is hot and dry; the eyes are often red and watery; and the countenance flushed. Frequently, however, the countenance is tumid, pale, and expressive of sadness or dejection. When the febrile excitement is considera- ble, there is generally an exacerbation, night and morning. There is, in many cases, considerable nausea, and tenderness of the epi- gastrium. At first, there is usually a constipated state of the bow- els:—diarrhoea, however, commonly supervenes, in the course of the disease, and is often copious, particularly in severe and protracted cases. From the very commencement of the attack, the mucous mem- brane of the fauces and tonsils, will be found to be of a deep red colour, and covered with a layer of tenaceous transparent mucus. The mucous membrane, particularly of the pharynx and soft palate, is often infiltrated with blood, in the form of small disseminated points, having a linear arrangement; or of small, oblong ecchymoses, of a dark red colour. Occasionally, the mucous membrane presents a few dry, oblong, greyish spots, as though it had been, at these points, cauterized with an acid. As the disease advances, the exudation becomes more abundant, and forms a firm pellicle, of a dirty yellow, or greyish colour. It is usually disposed, at first, in patches, more or less circumscribed, often slightly elevated in the centre, but thin and flocculent at the circum- ference. The patches increase in extent, more or less rapidly. Some- times, in the course of a few hours, the whole of the posterior fauces becomes covered with them. They are at first thin, but become increased in thickness, by successive depositions, and acquire often so much firmness, as to permit them to be detached entire, from the mucous membrane, to which they adhere, by numerous minute fila- aments, that appear to penetrate the orifices of the mucous follicles. Their detachment is generally followed by more or less oozino* of blood, from the denuded membrane, which exhibits but little intumes- cence, and is of a dark red colour, often variegated with points or striae, of a deeper hue. Between the pseudo-membranous patches, the sub-mucous cellular tissue, assumes, occasionally, an oedematous ap- pearance; in consequence of which, the correspondino- portion of the membrane is elevated, and causes the portions that are occupied by DISEASES OF 'THE DIGESTIVE ORGANS. 159 the pseudo-membrane, to assume somewhat the appearance of ulcers, covered with a tenaceous exudation. The patches, very generally, become soon confluent; so that, in many cases, the whole of the soft palate, the pharynx and inner surface of the cheeks, are lined by a continuous pseudo-membranous exudation, often of considerable con- sistence, which is rapidly renewed, as often as it is detached. In the commencement, the tongue is pointed, red at the edges, and covered on its surface with a thin layer of white mucus, through which the enlarged and florid papillae protrude. There is an increased secretion of saliva, which soon becomes dark coloured, from the ad- mixture of blood, discharged from the mucous membrane, as portions of the pseudo-membranous deposit are detached, and of an offensive odour, from the vitiated state of the secretions of the throat and mouth. In the course of the disease, the colour of the pseudo-membranous excretion changes to an ash, brown, and, finally, black colour; the mu- cous membrane beneatfi, becoming of a dusky red hue; the tongwe and mouth are often dry, and dark coloured, and the teeth more or less thickly covered with a dirty white, or blackish incrustation. If the disease of the throat is of any extent, and the inflammation is not early arrested, the glands become enlarged and painful, and the surrounding cellular tissue infiltrated with serum ; more or less tume- faction of the tonsils and soft palate, and occasionally of the tongue, takes place ; often to such an extent, as to interfere with the freedom of respiration ; ulcers form along the edges of the tongue, the palate, and inner surface of the cheeks. There is a constant oozing of blood from the mucous membrane of the mouth and fauces, which is increased upon the slightest irritation. The febrile excitement usually continues, with but little abatement, until towards the close of the disease; the heat of the surface, how- ever, in general abates—the skin assuming a dusky appearance and doughy feel; profuse diarrhoea often occurs; the secretions, gener- ally, become vitiated, and either increased or diminished in quantity; the prostration of strength augments; and a state of torpor, or even decided coma, is not unfrequent. When the inflammation and pseudo-membranous deposit extend into the pharynx and commencement of the oesophagus, there is a sense of soreness and of heat in these parts, accompanied with increas- ed difficulty of swallowing—every attempt at which is productive of severe pain. When the disease extends through the posterior nares to the mucous membrane of the nose, the patient is unable to respire through the nostrils ; from these there takes place a discharge of a serous, yel- lowish and flocculent, or bloody sanies, often of a very fcetid odour, and which produces more or less inflammation and excoriation of the external openings. When the disease extends to the Eustachian tube, pain is experienced in the ear, with more or less defect of 160 DISEASES OF CHILDREN. hearing, often complete deafness, which, in consequence of the oblit- eration of the tube, is, occasionally, permanent. The pseudo-membranous inflammation is particularly liable to extend into the larynx, trachea, and bronchii. This extension of the disease, in some cases, takes place almost instantaneously, on the first appearance of the patches in the fauces; in other instances, the respiratory organs are not affected until about the second or third day, or even later. At whatever period the respiratory tube becomes affected, the more prominent symptoms of croup—hoarseness, shrill cough, great difficulty of respiration, and more or less aphonia, are immediately developed, and, in the greater number of cases, the patient is rapidly destroyed. It is supposed by some, that croup is, in every instance, produced by an extension of the pseudo-membran- ous inflammation, from the throat to the larynx, and trachea ; (Bret- toneau;) although we cannot admit that such is invariably the case, we have reason to believe, that the secondary croup, from pseudo-mem- branous inflammation of the throat, is more frequent than is generally supposed. Besides the extension of pseudo-membranous inflammation to the larynx and trachea, giving rise to the phenomena of croup, it is said to be productive, also, in certain cases, of a species of pneumonia, extremely insidious in its commencement, and marked, in part, by the symptoms which are referable to the disease of the throat. The cough, in this affection, is different from that of croup, and is unat- tended with aphonia ; the mucous expectoration is often streaked with blood, while auscultation and percussion give all the indications of a more or less extensive catarrhal engorgement of the lungs. (Guersent.) There is not only atendency in the pseudo-membranous inflammation to extend along the mucous membrane of the throat, into the cavi- ties of the nose, even to the frontal sinuses, (Guersent?) into the Eustachian tube, the pharynx, oesophagus, larynx, trachea, and bron- chii, but it, likewise, often seizes upon remote parts of the body, par- ticularly in situations covered by a mucous membrane, or from which the cuticle has been accidentally removed by a blister, or ulcera- tion, (Trousseau) Thus it is often observed upon the lips, ihe aloe nasi, the concha, external meatus and parts behind the ear, the nip- ples, folds of the groin, the contour of the anus, the vulva, the sur- face of blisters, leech bites, &c. In favourable cases of pseudo-membranous inflammation of the throat, as the membranous exudation becomes detached from the mucous membrane, its place is quickly supplied by a new formation, and, after each separation, it becomes, in general, whiter, and much thinner. This separation and renewal of the pseudo- mem- branous deposit, continue, in most cases, for the space of eight or ten days; when, finally, it ceases to appear, leaving the mucous tis- sue to which it had been attached, perfectly sound throughout its whole extent; of a light red, uniform colour, and covered, usually, DISEASES OF THE DIGESTIVE ORGANS. 161 with a thick yellow mucus, more or less resembling pus. In other cases, the exudation, instead of being separated in fragments, becomes, in part, soCtened to a pulpy consistence, and is discharged from the mouth, mixed with bloody mucus. As the disease in the throat disappears, the glands of the neck, provided they are not in a state of suppuration, diminish in volume, and are no longer painful or tender to the touch. The difficulty of deglutition disappears ; the tongue loses its pointed appearance, and becomes clean and moist, the skin soft, moist, and of a more natural appearance, the counte- nance more animated and cheerful; while the stomach and bow- els gradually resume the regular performance of their natural functions, and the general strength and vigour of the patient are slowly reinstated. In severe and unfavourable cases, the disease is often more pro- longed ; the whole of the symptoms become aggravated; the mouth, tongue, and throat become dry, and of a deep black colour ; the diarrhoea becomes profuse, and the strength of the patient more and more exhausted-; general colloquation ensues, and death takes place, frequently preceded by deep coma, or, in children somewhat advanced in age, by violent delirium. When the disease is confined to the soft palate, isthmus of the fauces, and pharynx, it is seldom attended with much danger, yield- ing readily to an appropriate treatment; or, when the inflammation is of little extent, disappearing spontaneously in a few days. When, however, the disease extends to the larynx, it is, very frequently, fatal, by the occurrence of tracheitis, bronchitis, or pneumonia. The causes, nature and treatment of pseudo-membranous inflamma- tion will be noticed, after we have described the gangrene of the throat. ^.—Gangrene of the Throat. Actual gangrene of the throat is of far less frequent occurrence than it was generally supposed to be by the older writers, or is still believed to be by many physicians of the present day. That form of anginose disease to which the term putrid, malignant, or gangrenous, has been most commonly applied, is, strictly speaking, unattended with either gangrene or sloughing of the throat; it is, in fact, a highly aggra- vated, or malignant form of pseudo-membranous inflammation. Sloughing of the throat, or a species of gangrenous ulceration of this part, may, however, occur in certain cases of epidemic angina, and particularly in the angina accompanying certain epidemics of scar- latina, of a very malignant character. Even in these cases, however, it is probable that the disease invariably commences with pseudo- membranous inflammation of the throat. Malignant angina in its commencement, differs but little from ordinary pseudo-membranous inflammation of the throat. The fauces present the same membraniform exudation; it is more gen- erally confined, however, to the mucous membrane anterior to the 11 162 DISEASES OF CHILDREN. larynx, over which it is more uniformly spread. It also more early assumes a dull ash colour, quickly changing to dark brown or black. The disease seldom, if ever, extends to the trachea or bronchii. The pain and tumefaction of the sub-maxillary glands, are much more considerable than in the preceding form of the disease; and they are, also, more liable to run into suppuration. The face exhibits a bloated, bronzed aspect; the eyes are heavy, dull, and watery. The mucous membrane of the fauces is, almost uniformly injected with blood, of a violet colour, and more or less swollen, but without the ecchymosed appearance, noticed in the preceding variety; the tonsils, also, are more swollen, softer, and infiltrated with mucus and pus. (Guer- sent.) There is often extreme difficulty of deglutition; the voice is entirely guttural, and the power of articulation is, occasionally, sus- pended. In some instances, the respiration is rendered difficult, from the excessive tumefaction of the tonsils, and soft palate. In the commencement of the attack, there is, generally, intense febrile excitement, with a dry, hot, burning skin, parched mouth, urgent thirst, and often considerable delirium. The fever is attend- ed with exacerbations, towards evening. Nausea, vomiting, with tenderness and oppression at the epigastrium, and diarrhoea, attended with thin, acrid, and intolerably offensive discharges, are often present from the commencement of the attack; or occur at an early period. A fcetid, sanious discharge from the nostrils, occurs often from the very commencement, and the patient discharges from the throat, at first a thin, bloody mucus, which becomes, subsequently, puriform, and mixed with shreds of a membranous appearance. In some cases, the discharge is dark coloured, almost putrid, and highly offensive. When the disease is of a favourable character, upon the separation of the pseudo-membranous exudation, the mucous surface beneath presents a moist, red appearance, without ulceration or loss of sub- stance ; the discharges from the mouth become of a less offensive cha- racter, and are diminished in quantity; the tumefaction of the throat subsides; the tongue becomes cleaner and more moist; the febrile symptoms gradually abate, or disappear; the dejections from the bowels diminish in frequency, and become more natural in appear- ance; a general amelioration of all the other symptoms ensues, and the patient, by slow degrees, acquires his accustomed strength and vigour. In cases of greater malignancy, the symptoms rapidly increase in intensity ; the pseudo-membranous deposits in the throat assume a dark colour, and separate in flocculi, or shreds, of an intolerable fcetid odour. The mucous membrane, at first, presents a dark red, and raw appearance, while from its surface there oozes a dark coloured blood ; but speedily assumes a sloughy condition ; the tongue becomes dry and parched, and coated with a dark brown or black crust; the teeth and gums are covered with dark coloured sordes; and the gangrenous con- dition extends from the mucous membrane to the tonsils and soft palate. The accompanying fever assumes a low, typhoid character, and DISEASES OF THE DIGESTIVE ORGANS. 163 petechia of the external surface, are often observed. Dark coloured vesicles occasionally occur about the corners of the mouth, and on the inner surface of the lips and cheeks, and occasionally upon the tongue, and becoming ruptured, form gangrenous ulcers, that quickly extend, and cause extensive destruction of the surrounding soft parts. The diarrhoea increases in frequency; the discharges become more thin, acrid, and offensive; the strength of the patient more and more prostrated ; and stupor and insensibility ensue, which are quickly succeeded by death. The progress of gangrenous angina is ordinarily very rapid, the disease often running through all its periods in the space of a week or twelve days. It generally attains its height in seven or eight days, when the febrile symptoms abate or disappear. It may destroy life in a very short period, but occasionally runs a protracted course of several weeks. When it terminates fatally, death usually takes place within the first week, either from extreme exhaustion of the vital pow- ers,or in consequence of the occurrence of extensive lesionsof the diges- tive, or other organs. When the diseaseoccurs epidemically, it is often productive of a very great mortality ; under all circumstances, it is a dangerous disease, and one but little within the control of medicine. No little difference of opinion prevails, as to the pathological char- acter of pseudo-membranous angina. Bretonneau, Guersent, and many other of the continental writers, denominate it a specific inflam- mation ; which, in fact, amounts to little more than a confession of their ignorance of its true character. Broussais maintains, that the disease is in fact a gastro-enteritis ; the affection of the throat being secondary to the inflammation of the digestive organs. Emangard, also, adopts this opinion. There can be no doubt, that, in numerous instances, the affection of the throat is preceded or accompanied by symptoms of more or less severe gastro-enteric disease ; but it has been known to occur as frequently without any such symptoms being present—at least in its early stages. Jolly refers the disease to a haemorrhagic inflammation, in which the colourless fibrin is exuded upon the surface of the mucous membrane; and Naumann with a few other German pathologists, suppose it to result from a separation and exudation of the albuminous portion of the blood, in consequence of a change in the condition of the latter, produced by an epidemic influence. Collineau regards the disease as one dependent upon a general, and not upon a merely local affection ; while according to the views of Andral, the disease consists in an acute hyperaemia, of the mucous membrane of the fauces, with exudation of coagulable lymph. That pseudo-membranous angina consists in an intense ery- thema of the mucous membrane, giving rise to an albuminous exuda- tion, there can be little doubt. This exudation is a common occur- rence in the inflammations of the mucous tissue in children; and appears to be connected with a peculiar organization of this tissue, and certain states of the blood which then exist, difficult to be under- 164 DISEASES OF CHILDREN'. stood. Its gangrenous form is doubtless the result of a defective organic power, and consequent impairment ot the nutritive function. The causes of the disease have not been well made out: it is met with at all seasons, and in every variety of climate, and locality. It may occur either sporadically, or as an epidemic. It is, however, most prevalent during cold, wet, and damp seasons, and in low, damp and marshy situations, especially during the spring and autumn. It is of most common occurrence, also,among the children of thoseclasscs by whom personal and domestic cleanliness is neglected, and who, from poverty or other causes, are deprived of a sufficient amount of wholesome nutriment. The disease is liable to occur endemically, in situations where a number of children are crowded together, and a due attention is not paid to preserve the air pure, and freely venti- lated. It is a common accompaniment of the epidemic scarlatina. By nearly all the earlier writers, as well as by some of the more recent, the disease, especially its gangrenous form, is considered to be due to a specific contagion ; or to be capable of being propogated by a contagious miasm, generated in situations where many persons are crowded together, without a proper attention being paid to cleanliness and free ventilation. (Bretonneau, Trousseau, Guersent, Velpeau, Bourgeois.) In looking over the arguments by which this opinion is attempted to be established, we find them, however, altogether incon- clusive. They are derived entirely from certain endemic or epidemic occurrences of the disease, and instead of proving its propogation from one or more foci of contagion, they merely show that a number of indi- viduals had been exposed to the same local or general morbific cause; and that, while many were affected by it simultaneously, in some it produced the disease-at an earlier, in others at an later period. That the disease has occurred sporadically, afiecting only one member of a family, or a single individual of a community, is admitted by nearly all writers ; (Bourgeois;) but, that it has ever been communi- cated directly from the sick to the well, we have not the slightest evidence. The treatment of pseudo-membranous inflammation of the throat, will, in a great measure, depend upon the character of each case. In mild, sporadic cases, the disease will generally yield to a very simple treatment; while, in its more aggravated forms, and especially when it prevails as an endemic or epidemic, the most energetic remedies will be demanded, from its very onset. In every instance, in which there is no disease of the gastro-intesti- nal mucous membrane to counter-indicate its use, an emetic of ipe- cacuanha, administered in the commencement of the attack, will, in general, be found beneficial; and even at a later period, emetics will not unfrequently do good, by expelling the tenacious excretions accu- mulated upon the fauces, and thus rendering the respiration freer, and deglutition more easy. Although the detraction of blood, either from the arm, or locally, by means of leeches, from the neighbourhood of the throat, is not so imperatively demanded in pseudo-membranous inflammation, as in DISEASES OF THE DIGESTIVE ORGANS. 165 the other acute inflammatory affections of the throat in children ; cases of the disease do, nevertheless, frequently occur, in which it is unquestionably called for, and will be productive of the best effects. In robust children, particularly in those of a sanguineous temperament, and plethoric habit, in whom the swelling and inflammation of the throat is considerable, and attended with symptoms of intense febrile excitement, general, as well as local bleeding, should be resorted to. (Gcudron, Jolly.) Even in cases in which general bleeding may not be considered admissible, leeches to the throat, behind the ears, or to the angles of the jaws, will often be found advantageous. Broussais, Emmangard, and others, recommend in all cases, leeches to the epi- gastrium ; and whenever there exists tenderness, with increased heat at this part, their application should not be neglected. In cases attended with evident depression of the vital energies, with little febrile action, a cool skin, the fauces being of a dark colour, with considerable fcetor of the breath, bleeding from the arm would be inadmissible, and even the application of leeches might then be attended with danger. There can be no doubt of the beneficial effects of calomel, in many cases of the disease; in the earlier stages, it forms our best pur- gative, and in those cases in which the larynx and trachea are implicated, it constitutes one of our most important remedies; it should be administered in large and repeated doses, either alone or combined with ipecacuanhas—even in the ordinary forms of the dis- ease, occurring in patients possessed of some degree of vigour of con- stitution, it has been found advantageous, relieving the throat of the membranous exudation, and other vitiated excretions, and producing a marked amelioration of the symptoms generally. (Bretonneau.) a R—Calomel, gr. xxxvj. ad xlviij. Ipecacuanhas, pulv. gr. iij. ad iv. Magnes. calc. 3SS- M. f. ch. No. xij. One to be repealed every three hours. The employment of calomel, at first with emetics, and subsequently, by itself, in small, repeated doses, was a favourite practice with Dr. Rush, in malignant angina. In all cases the patient should be liberally supplied with diluent drinks. In the same class of cases in which active depletion has been recommended, these should consist of iced water, iced lemonade, or cold water slightly acidulated with vinegar ; even portions of ice may be placed in the patient's mouth, and allowed, gradually to dis- solve. In other cases, cool drinks may be allowed, but where the powers of the patient are depressed, and the skin cool, it is perhaps, better that the drinks be given of a tepid, or even warm temperature. In cases attended with decided febrile reaction, the neutral or effer- vescing mixture may be advantageously administered. In the commencement of the attack, the tepid bath, with friction to the skin, will invariably be found productive of good effects ; and when the heat of the surface is considerable, generally diffused, 166 DISEASES OF CHILDREN. and steadily maintained, the surface should be repeatedly sponged with cold water, or cold vinegar and water. In cases where the inflammation and swelling of the throat are considerable, warm ped- iluvia, with the addition of salt or mustard, will act beneficially, as a revulsant. Where the powers of life are depressed, the pulse feeble, and the skin cool, the warm bath should be substituted for the sponging with cold fluids, as recommended above. Much difference of opinion exists, as to the propriety of blisters to the throat, in this disease. We confess that we are averse to blister- ing the throat in children; and in the few instances in which we have applied them, in pseudo-membranous angina, we have had reason to regret their use. In the early stage of the disease, the rubefacients recommended under the head of tonsillitis, followed by a warm, emolli- ent cataplasm will occasionally be found useful. In cases of great violence, blisters may be applied to the back of the neck, with some active rubefacient to the throat. The diet should be regulated, according to the leading symptoms of each case; where the attack is one which calls for active depletion, little else should be allowed than barley water, rice water, or water gruel. Rennet whey and buttermilk we have, occasionally, found to be useful and refreshing articles of diet in this disease. When the inflammation occurs in children of debilitated habits, or is attended with symptoms of exhaustion, beef tea, or plain mutton or beef broth, in moderate quantities, may be allowed. In the gangrenous form of the disease, with coldness of the skin, a feeble pulse, and other symptoms indicative of a depression of the vital energies, a discreet use of tonics and stimulants, will frequently arrest the progress of the gangrene, and produce a favourable change in its leading symptoms. The cold infusion of cinchona, the sulphate of quinia, the mineral acids, an infusion of serpentaria, or the acetate or carbonate of ammonia, or wine whey, may be administered, according to the circumstances of the case. The acetate of ammonia, either alone, or combined with camphor; an infusion of serpentaria, or the cold infusion of cinchona, with some light aromatic, will be found among the most efficacious excitants and tonics in this disease. We have often combined with each dose of the bark, a portion of the hydrochloric or sulphuric acid, with decided advantage. The use of these remedies should, however, be invari- ably resorted to with the greatest caution, and their effects upon the symptoms of the case, carefully watched ; if they produce dryness of the tongue, increased heat of the surface, inclination to stupor, or other unfavourable effects, their use should be discontinued. When we are unable to administer tonics by the mouth, a decoction of bark, or of serpentaria may be given, in the form of enema, and in many cases will, in this manner, produce a very beneficial result. When extensive tumefaction and tenderness of the glands of the neck occur, leeches may be applied upon the tumors, or they may DISEASES OF THE DIGESTIVE ORGANS. 167 be kept constantly covered with cloths, wet with cold water, or cold vinegar and water. The effects of which areeften peculiarly striking. (Warren.) Various local applications to the fauces, in the form of washes or gargles, have been proposed in the treatment of pseudo-mem- branous^ inflammation of the throat, and, by many, are considered to constitute the most efficient remedies for the disease. (Breton- neau.) In the early stage, equal parts of good vinegar and water, is, perhaps, one of the best gargles we can employ; diluted hydrochloric acid, or solutions of the chloride of soda or of lime, or a saturated solu- tion of the bi-borate of soda, also, in many cases, form an excellent wash for the throat. (Guersent, Bourgeois, Roche.) A solution of the acetate of lead, may be employed for this purpose; it will be found, in general, in the commencement of the disease, very beneficial. A strong infusion of cinchona, or of oak bark, with the addition of alum ; creasote diffused in water, or a saturated solution of the sulphate of copper, will also be found to constitute useful washes for the throat in this disease, particularly, when the occurrence of a gangrenous condition is apprehended. The application to the fauces, two or three times a day, of hydrochlo- ric acid, either pure, or combined with three parts of honey, has been highly extolled by many of the French and German physicians. (Bretonneau, Guersent, Trousseau, Bourgeois, Fischer, Muhll) Among the local applications, in favour of the beneficial effects of which we have the greatest amount of evidence, is the nitrate of silver, either in strong solution,3 or in its solid form. It is said, not only to cause the separation of the pseudo-membranous deposite, but also to produce a more healthy action, in the inflamed mucous mem- brane of the throat. It may be applied in the liquid form, by imbuing a portion of soft sponge, firmly attached to a whalebone, with the solution; great care being used to prevent any portion of it from entering the pharynx.—(Gendron, Guersent, Baudelocque, Authenac.) »R.—Nitrat. argent, gr. xv. ad. xx. Aq. I'uras gj. To be applied two or three times a day. Alum, reduced to a very fine powder, and blown into the throat through a tube, the end introduced into the patient's mouth being defended by a piece of fine gauze, is strongly recommended in this disease, by many practitioners. (Bretonneau, Guersent, Bourgeois.) The sulphate of copper has been employed in the same manner. (G/nelin.) We have never administered these remedies in the manner here described, from the apprehension that a portion of the powder should pass into the larynx, and excite violent coughing. A much better mode of applying them is, in solution as a wash, or by forming them into a stiff paste, by the addition of honey and water, which "may be smeared upon the diseased surface by means of a sponge, brush, or small spatula. When the patient is unable to gargle, or when, from the extensive 168 DISEASES OF CHILDREN. swelling of the throat, or extreme restlessness of the child, it is found to be impossible to apply, effectually, any of the washes to the throat, by means of a sponge or swab, they may be injected into the mouth through a small syringe, the nostrils being closed, to prevent their immediate escape." Any of the local applications noticed above, may be applied in this manner, with the exception of the nitrate of silver or the mineral acids. When the disease is attended with a profuse and exhausting diar- rhoea, we may employ the cretaceous mixture, with the addition of the tincture of Kino,a or—what we have found particularly beneficial in such cases—a combination of powdered galls, camphor, and ipeca- cuanha,1" or the acetate of lead, in solution. a R.—Mucil. G. Acacias, giij- bR.—Pulv. Gallas, 3j. Cretas ppt. gj. " Camphor, gr. iv. ad vi. Tiuct. Kino, 3ij.—M. " Ipecacuanha, gr. iij. ad. iv. M. f. A tea spoonful every two or three hours. chart. No. xij. One to be given every three hours. We need scarcely refer to the importance of keeping the apart- ments occupied by patients labouring under pseudo-membranous inflammation perfectly clean, and of a moderate equable temperature, and freely ventilated. b—Parotitis.—Inflammation of the Parotids.—Mumps. Inflammation of the parotids, generally occurs epidemically, and seldom attacks the same individual more than once. In the majority of cases, it is a very trifling affection, subsiding spontaneously in a few days; while in others, it is attended with very considerable swelling and pain, and febrile symptoms of some intensity. It is usually preceded by some degree of chilliness, succeeded by increased heat of the skin, and a sense of pain, or uneasiness, in the region of one, or both parotids. A stiffness of the jaws, producing some difficulty of mastication, is, very commonly, present. Sooner or later, a degree of tumefaction is observed, behind the angle of one, or both jaws, with, frequently, augmented heat and redness, and, more or less, severe pain, which is increased by the motions of the jaw, and by pressure. The swelling, in general, goes on increasing, producing a large, hard, movable tumor, sometimes on both sides of the neck. The skin, covering the tumor, is, frequently, unchanged in colour; and, occasionally, when the tumefaction is rather cedematous than inflammatory, the colour of the skin by which it is covered, is even paler than natural. (Andral.) In severe cases, the swelling assumes a bright or deep red colour. The inflammation frequently extends from the parotids, to the submaxillary glands, and is attended with symptoms of considerable febrile excitement, increased thirst, and constipated bowels. The tumefaction generally attains its height by the fourth or fifth day, when it begins gradually to diminish, and soon entirely disap- DISEASES OF THE DIGESTIVE ORGANS. 169 pears. The febrile and other symptoms declining and disappearing, with the diminution and resolution of the swelling in the neck. It is extremely rare for the disease to terminate in suppuration, though a few instances of this are on record. A curious circumstance in connection with this disease, is, the liability of the inflammation suddenly to disappear from the neck, and be immediately followed by a painful swelling of the testicles, in the male, and of the mammae in the female. The latter affection, under an appropriate treatment, in general terminates very promptly by resolution; in males, it has been known, however, to produce an entire absorption of the testicle. (Hamilton.) In some instances, the inflammation suddenly ceases in the testicles or mammae, and the pain and tumefaction of the parotids reappear. Instances occasionally occur, in which the sudden subsidence of the inflammation of the parotids, has been succeeded by intense febrile symptoms, and more or less cerebral disease, indicated by deep coma, convulsions or delirium. This occurrence has taken place, even in cases in which the transfer of the irritation had taken place to the mammae or testes. Parotitis generally occurs in children over five years of age ; and, as w% have already remarked, the occurrence of one attack, usually produces such a change in the parts affected, or in the organism gene- rally, as to prevent a recurrence of the disease in future. Males are said to be more frequently attacked than females:—our own experi- ence does not confirm the truth of this observation; we have certainly met with the disease as often in females as in males. It is evidently produced by some epidemico-endemic influence, it being, most generally, confined-exclusively to certain localities ; though it is probable, that, with the predisposition produced by the prevailing atmospherical influence, exposure to cold, or sudden transitions of temperature, may tend to bring on an attack. The disease prevails at all seasons, and in almost every variety of climate, but it is said to be much milder, and metastasis less frequently to occur, when it prevails in warm and dry, than in cold and damp weather. (Marley.) We have found the disease, however, to be but little influenced by the state of the atmosphere. Parotitis, is seldom either a severe or dangerous affection, and, in the majority of instances, spontaneously disappears, when the patient is kept within doors, and upon a mild, unirritating diet. It will be proper, in most cases, to administer a saline purgative, to keep the neck moderately warm, and to immerse the lower extremities in warm water, the child being, at the same time, kept at rest, and upon a plain, farinaceous diet. Should the tumefaction of the neck be very extensive, and attended with considerable pain, heat, and fever, it will be prudent to apply leeches to the seat of the disease, in numbers proportioned to the extent of the local symptoms; and, after the bowels are fully evacu- 170 DISEASES OF CHILDREN. ated by a mixture of sulphate of soda and magnesia, the following may be administered internally.a * »R.—Sulph. Sodas, giv. Solve in Aq. puras, giv. ct adde Tart. ant. gr. j. Spir. oether. nitrici, 3iij. Sacch. alb. gvj—M. Dose a tea spoonful every three hours. Warm pediluvia will be found beneficial, and, in many cases, the tepid bath. When the testicles or mammas become affected, leeches may be applied to these parts, followed by emollient fomentations; purga- tives, and antimonials, will likewise be proper, according to the nature and extent of the symptoms present. It has been generally recommended, to attempt by stimulating applications to the neck, "to bring back the inflammation to the parotids." We do not, however, believe, that any good can result from this practice ; according to our experience, it is not calculated to effect the desired result; and, if it were so, no advantage will be gained; the inflammation of the testicles or mammae, being as readily controlled, by its appropriate remedies, as when seated in the parotids. s When symptoms of cerebral disease manifest themselves, these should be promptly attacked by leeches to the temples, or behind the ears, active purgatives, warm sinapised pediluvia, cold applications to the scalp, and antimonials. Angina Externa.—Under the name of phlegmone parotidea, Dr. Good describes a very common affection in children, consisting in an inflam- matory tumor, occurring in the neighbourhood of the parotids, and pro- ceeding slowly on to suppuration, forming, often, an extensive abscess. The same disease is described by James, in his " Observations on the general Principles and on the particular Nature and Treatment of various species of Inflammation," as angina externa. Both names are founded upon an erroneous pathology; the affection not consist- ing in an inflammation of the parotid, but in an inflammation of the cellular tissue surrounding the parotid, or other glands of the throat, generally circumscribed, but often diffused. The disease generally commences in the same manner as parotitis. The swelling is, however, more extensive, red, and painful; in many cases preventing deglutition, and rendering the respiration so difficult, that the patient can scarcely sleep, from the sense of impending suffo- cation. There is, ordinarily, considerable febrile excitement. When the swelling is very great, extensive oedema of the face, not unfre- quently occurs. Suppuration usually takes place, sometimes very early, but, in the majority of instances, very slowly; the swelling becomes more pro- minent at some part of its surface—the skin here becomes paler—a fluctuation is soon after detected, and, sooner or later, the skin gives way, and a discharge of healthy pus takes place. The tumor now DISEASES OF THE DIGESTIVE ORGANS. 171 gradually diminishes in size, and cicatrization takes place, and all symptoms of inflammation, finally, disappear. Often, some degree of hardness of the parts occupied by the inflammation, remains for a considerable time, and only diminishes by very slow degrees. It occasionally happens, that the inflammation and swelling is situated immediately below the chin, and we have seen cases, when it has occupied the whole of the front ©f the throat from ear to ear. Instead of a circumscribed inflammation and suppuration, the inflam- mation is, occasionally, deep seated and diffused, and the pus, when it forms, is liable to extend, under the angle of the jaw, to the pharynx, or downwards into the upper part of the thorax, producing extensive destruction of the cellular membrane about the neck, and great distress to the patient. In this form of the disease,' the external swelling is less prominent and circumscribed, and there is less redness of the skin. When suppuration takes place, the swelling acquires a doughy feel, and an indistinct fluctuation may be observed at one or more points. The matter is slow in arriving at the surface, and discharging itself externally. In some instances, distinct, deep seated collections of matter form, and the pus, mixing with the dead cellular membrane, becomes putrid, and the evolution of gas thus produced, causes a kind of emphysematous condition of the parts. The febrile symptoms, assume a low typhoid character, the strength of the patient is rapidly exhausted, and death very generally ensues; or, if recovery takes place in these extreme cases, an extensive and unsightly cic- atrix deforms the patient for life. Inflammation of the cellular tissue of the neck, generally occurs in children of gross plethoric habits, particularly in those who are fed upon a diet consisting principally of coarse animal food, in which they are allowed to indulge to excess. It is, very frequently, connected with more or less disease of the alimentary canal. We have seen the disease in children of almost every age; it is more common, however, subsequent to the period of dentition, than in infants at the breast. In, perhaps the majority of cases, the inflammation is perfectly circumscribed ; and, if suppuration ensues, a simple circum- scribed abscess results, the disease being rather troublesome and painful than dangerous; but, in children of an unhealthy habit, the inflammation is occasionally diffuse, and unless a free exit is given to the pus by early incisions, it is an affection attended with severe suffering, and very generally terminates fatally. In cases of simple phlegmonous inflammation the treatment con- sists in the application of leeches to the neck, in numbers propor- tioned to the extent of the inflammation, and repeated, after a short interval, if the local symptoms are not sufficiently reduced by the first application. After the leeches, the tumor should be covered with pledgits of linen, kept constantly wet with cold water. A dose of calomel should early be administered, followed by a sufficient dose of sulphate of magnesia, to ensure its speedy operation. The patient should be restricted to a mild unirritating diet; in severe cases, no 172 DISEASES OF CHILDREN. other food being allowed than barley water or water gruel. In cases, attended with considerable febrile excitement, the solution of sulphate of soda, with tartarized antimony, as directed in parotitis, will be beneficial. So soon as a disposition to suppurate is observed, the tumor should be covered with emollient poultices, frequently renewed ; and, when a distinct fluctuation is observed, the abscess should be opened with the lancet, and a free exit given to the pus;— the application of the poultices being continued, until cicatrization commences, when a dressing of simple cerate spread upon lint, may be substituted. When the inflammation is diffuse, a similar treatment will be demanded in the early stage; but as soon as the swelling of the neck acquires a doughy feel, especially if there is great difficulty of swal- lowing, impeded respiration, or a constant dry cough, free incisions should be made, followed by the application of emollient poultices. If the patient's strength becomes depressed, a plain nourishing diet should be allowed ; and, if necessary, moderate doses of the cold infusion of bark, or of a solution of the sulphate of quinia. The treatment of each case, must, however, be governed by the particu- lar symptoms present; the safety of the patient not unfrequently depending entirely upon the promptitude and judgment of the practi- tioner. CHAPTER III. OESOPHAGITIS. INFLAMMATION OF THE (ESOPHAGUS. It is to Billard, that we are indebted for our knowledge of the oeso- phagitis of infants :—he first pointed out its frequent occurrence in the first period of infancy, and described its diagnosis. From him, therefore, we shall be under the necessity of borrowing our account of the disease, it being one mentioned by no other writer, and in rela- tion to which our own observations have not furnished us wilh any additional facts. We have repeatedly recognized in infants, the symptoms referred by Billard to inflammation of the oesophagus, but have not had an opportunity, as yet, of testing, by an examination after death, the accuracy of his diagnosis. The principal symptom of oesophagitis in infants, is frequent vomit- ing, occurring almost immediately after the deglutition of drinks or aliments ; which are discharged almost in the same state in which they DISEASES OF THE DIGESTIVE ORGANS. 173 were taken. The child refuses the breast, and fluids generally—but often swallows, without much difficulty, half solid aliments. The undigested food and drinks vomited by the patient, are occasionally mixed with mattery secreted by the stomach, particularly if the latter be affected at the same time, with inflammation. More or less pain is probably experienced along the whole track of the oesophagus, but at the age at which the disease occurs, we cannot determine its presence by any exterior sign ; it is probable, however, that pressure upon the throat, in the direction of the oesophagus, may excite the cries of the child. Nutrition is interrupted, and emaciation rapidly ensues. Oesophagitis is seldom accompanied by any degree of febrile excite- ment. The disease may consist in a simple erythematic inflammation of the mucous membrane of the oesophagus; in inflammation, with alter- ed secretion, or in gangrenous inflammation. As oesophagitis is almost invariably preceded by stomatitis, it is pro- bable, that according as the mouth is affected with inflammation, attended with a curd like exudation, or with follicular inflammation, the inflammation of the oesophagus will also be attended with altered secretion, or with apthous ulceration. It is, however, difficult to dis- tinguish the existence of ulcers, or gangrene of the oesophagus, unless the matters vomited contain shreds, derived from the disorganization of the oesophagial mucous membrane. More extended observations will probably enable us to form a more accurate diagnosis of the sev- eral forms of the disease. (Billard.) The pathological changes detected after death, in cases of oesopha- gitis, are vivid redness, with destruction of the epithelium, of some por- tion of the mucous membrane of the oesophagus, especially of its upper portion ; apthous ulceration ; curd like exudation, more or less exten- sively diffused; separation of the epithelium, often in large shreds; numerous red or dark coloured striae, where the epithelium is not destroyed ; large, irregular eschars of a black colour, with intervals of deep, bright red excoriations, and gelatinous softening of nearly the entire thickness of the oesophagus. The pharynx, in general, exhibits considerable injection ; the glottis is infiltrated and reddened. The stomach is often perfectly free from disease, but occasionally presents the various lesions incident to gas- tric inflammation. The hyperaemia of the mucous membrane of the oesophagus, which always exists in the early stage of infancy, is the chief cause of the frequency of oesophagitis at this period; its occasional causes are the same as those of stomatitis. It may be produced by too hot or stimu- lating food. When infants are fed with the spoon, if wine or spiced victuals, or broth, milk, or panada of too high a temperature be given them, we can readily conceive that a very serious irritation may be excited in an organ, already predisposed to disease, in consequence of its habitual state of hyperaemia. (Billard.) The treatment of oesophagitis is very simple. The child should be 174 DISEASES OF CHILDREN. debarred from all stimulating and hot drinks ; it should be supplied, at short intervals, with small portions of some plain, mucilaginous fluid, as gum water, or an infusion of the pith of sassafras, or of the inner bark of the slippery elm ; the throat, externally, should be covered with an emollient poultice,especially when the oesophagitis succeeds to stomati- tis; a few grains of calomel may be administered, followed by injec- tions of milk with the addition of sugar. If necessary, the slrength of the patient may be supported by injections of milk and broth, or milk with rice flour, tapioca, or arrow root. We have derived advantage in cases presenting the symptoms of oesophagitis, from leeches along the sides of the neck, and internally a solution of acetate of lead. R.—Acctat. plumbi, gr. iv. Acid. acet. impur. Tt|_ iv. Aq. puras, gj.—M. Dose a tea spoonful every three hours. CHAPTER IV. DISEASES OF THE STOMACH. 1.—Indigestion. We employ the term indigestion, to indicate an affection of the sto- mach, very common in children, in which the function of that organ is suspended or disturbed, and the food either unchanged or imper- fectly digested, is discharged by vomiting or by stool, while no symptoms exist, indicative of gastric inflammation, or disease of other organs. Indigestion is invariably dependent upon too much, or improper arti- cles of food, or upon some accidental circumstance, interfering with the process of digestion. There can be no doubt that more or less irri- tation of the mucous membrane of the stomach, is present in every case, and that if the cause of the functional disturbance be continued, or repeated, inflammation will be excited of an acute or chronic cha- racter. Nausea and vomiting, are the most common symptoms of indiges- tion, during infancy. Infants at the breast, will repeatedly discharge from the stomach, immediately after sucking, by a species of regurgi- tation, or by actual vomiting, a portion of the milk taken, without appearing to suffer any inconvenience. The vomiting in these cases, arises generally, from an overloaded state of the stomach, and is unattended by nausea or straining. The milk is usually returned DISEASES OF THE DIGESTIVE ORGANS. 175 unaltered ; occasionally, however, it is coagulated in masses of great- er or less size. This species of vomiting, generally occurs in very young infants, of a robust habit, particularly when nourished by a nurse, in whom the supply of milk is profuse, and flows with great freedom. It is rather salutary than injurious, by preventing the effects of over distension of the stomach; hence the common saying among nurses, that those infants who throw up their milk thrive the best. But as the cause is an habitual repletion of the stomach—more milk being taken than can be readily digested—it must be evident, that in every instance, there is danger of a disturbance of the digestive function, or even more serious injury being, sooner or later, induced. The cause of the vomiting should therefore be removed, by preventing the infant from sucking too much at a time, or too frequently in the course of the day. It should be removed from the breast, the moment it begins to dally with it, or as soon as it ceases to suck with avidity, as if it were gratifying a necessary and proper appetite. (Dewees.) A common cause of vomiting from repletion of the stomach in infants, is applying them to the breast whenever they are fretful, or with the view of lulling them to sleep, or allowing them to lie at the breast all night. There is, in some infants, also, a disposition to eject the milk taken into the stomach, that is induced by dandling them in the arms or jolting them upon the knee, or walking them about soon after they have sucked, even when no undue quantity has been taken by them ; as a general rule, but especially when vomiting is readily excited, the infant should be allowed to remain perfectly quiet for a short time after its removal from the breast. A common error committed by nurses, is that of giving the breast to the infant, immediately after they have ejected the contents of the stomach. This should be avoided in every instance, it being calcu- lated to increase the irritability of the stomach, and render the vomit- ing more frequent. The more or less coagulated state of the milk discharged from the stomach, most generally arises from its having remained in that organ, a short time before its ejection ; the milk invariably undergoing coag- ulation in the infant's stomach, previously to its digestion. In some cases, however, the coagulation of the milk, as well as the vomiting, appears to be due, to the secretion in the stomach, of an undue amount of acid. The breath of the infant, and the coagulated milk that is thrown up, have then a sour smell, and very often, sour, curdy evacua- tions take place from the bowels, preceded by more or less griping. The cause of this acidity it is very difficult to determine; whether it results from an irritation of the stomach, causing an excessive secre- tion of acid in the stomach, or from the occurrence of acetous fermen- tation in the milk, we have been unable to satisfy ourselves. It is not uncommon for dense coagula of milk to form in the sto- mach of an infant; in some cases causing severe colicky pains, and in others, violent convulsions, which cease upon the rejection of the 176 DISEASES OF CHILDREN. coagula. The retention of these coagula in the stomach, appears to arise from a disturbance of the digestive process, independent of gastric inflammation; though some degree of this is liable to be induced, if the irritation of the dense coagula does not cause their speedy ejection by vomiting. Not unfrequently, repeated vomiting occurs in children, attended with paleness, and other indications of considerable nausea; preceded, gen- erally, by severe griping pains of the bowels, and followed by more or less diarrhoea ; the matters vomited, whether milk, or other articles of food, are, usually, partially digested, and exhale an acid or rancid odour. Preceding the vomiting, the child exhibits, ordinarily, a con- siderable degree of uneasiness, and continues fretful and languid for some time after the spontaneous evacuation of the stomach and bow- els. In such cases, we have a disturbance of .the digestive function, attended with considerable irritation of the mucous membrane of the whole of the alimentary canal, but seldom any symptom of positive inflammation. The mischief is almost invariably owing to improper, or too much food. When the disease occurs in infants at the breast, its cause is, gene- rally, to be sought for in some condition of the mother's or nurse's milk, by which it is rendered either indigestible, too irritating to the stomach, or unadapted to the functional powers of the latter; or to the child being occasionally fed with improper kinds of artificial food. We have already spoken, in a former section of this treatise, on the importance of a proper regulation of the diet of a female, during the period of suckling. Every physiologist is aware of the change pro- duced in the properties of the milk, by the nature, as well as by the quantity of the food, habitually taken. Too much, or too little food ; a too stimulating diet; the use of vinous or distilled liquors, more espe- cially if taken in excess; and articles of food of difficult digestion, can- not fail to affect the secretion of milk, and render the latter unfitted for the nutriment of the infant who partakes of it; milk thus deterio- rated, will very generally produce irritation of the infant's stomach, and all the symptoms of indigestion. If an infant, in consequence of the inability of the mother to suckle it, is nursed at the breast of a female, whose own child is several months older than it, indigestion will very generally ensue, in conse- quence of the milk containing an amount of caseum, to the digestion of which, the stomach of the younger child is inadequate ; the pro- portion of caseum in the milk of the human female, always augment- ing with the age of the infant. (Payen). The occurrence of the menstrua] discharge, is generally enumerated as a cause of deterioration in the milk, calculated to occasion serious injury to the infant who partakes of it. When the catamenia are suspended during the first eight or nine months subsequent to parturi- tion, and then re-appear, there will, very generally, be found to take place a diminution in the supply, and a decided change in the properties of the milk; and the child very generally suffers, if it be continued at DISEASES OF THE DIGESTIVE ORGANS. 177 the breast. But we are by no means convinced that every occurrence of the-menses, during lactation, is calculated to produce similar effects upon the milk. We know several females who menstruate regularly during the entire period of suckling, and their infants thrive equally well with those of mothers in whom the catamenial discharge is sus- pended. From a series of observations, recently published, it has been ascertained, that the health of children nursed by menstruating females, suffers no kind of injury. (Raciborski.) If, however, upon the appear- ance at any time of the menses, the milk is found to disagree with the child at the breast, it will be prudent to cease suckling it, so long at least, as the discharge continues. Pregnancy is, also, set down as producing an alteration in the milk, unfitting it for the nourishment of the infant. During the first three months of pregnancy, we have certainly seldom noticed any parti- cular change to occur in the milk; at a later period, however, it is probable, that the safety of the mother, as well as the health of the infant at the breast, will require it to be weaned, or if too young for this, that the milk of a healthy nurse be substitu'.ed for that of the mother. It is true, that infants have been suckled to a late period of pregnancy, or even to its termination, without apparent injury; while in other cases, so great a deterioration of the milk has occurred, as to require that the child should be taken from the breast at a very early period. (Dewees.) Another cause which is generally supposed to render the milk of the mother injurious to an infant, is continuing the latter for too long a period at the breast. This is unquestionably true ; if after the appear- ance of the molar teeth, the child be confined exclusively to the breast, symptoms of indigestion will very generally occur; and even with a supply of other food, continuing it at the breast after the ninth or tenth month, will often be found productive of injury. And yet there are striking exceptions to this rule; some of the finest children we haveseen, were among those who were suckled—taking, however, at the same time, a portion of other food—until they were fifteen months old. We may remark, that in all these cases, the menstrual discharge was sus- pended during the whole period of lactation. Intense grief, mental anxiety, paroxysms of violent passion, or any long continued or violent emotions of the mind, are unquestionably, causes of very considerable deterioration in the milk:—severe vomiting, and even general convulsions, have been known to result, from the child being applied to the breast, immediately after the nurse has experienced any intense mental excitement—whether of an exciting or depress- ing character; and it is a general remark, that the children nursed by females who are labouring under intense grief, or mental anxiety of any kind, seldom thrive. We have met with several cases of indiges- tion in infants from this cause, where the safety of the child required its being taken from the mother's breast, and where every symptom of disease ceased, soon after it was furnished with the breast milk of a healthy nurse. 12 178 DISEASES OF CHILDREN. It is needless to say, that most of the acute, and the generality of the chronic diseases, produce changes in the milk, which entirely unfit it for the nourishment of an infant, even where the mother is able to perform the office of nurse. When the milk of the mother or nurse is perfectly healthy, adapted in all respects to the conditionof the infant's digestive organs, and sufficient in quantity, indigestion may be produced, by the practice, too commonly pursued, of giving to the child, occasionally, a portion of artificial food—often of the most indigestible quality. Pre- viously to the appearance of the first molar teeth, under ordinary circumstances, no other food is required, than the breast milk of the mother; and every kind of food, which differs materially in its quali- ties from the latter, will produce serious disturbance of the digestive organs. We have seldom known an infant, to whom has been given, in addition to its mother's milk, any of the various compounds of bread and water, bread and milk, flour and milk, and the like—"vile nursery compounds,"—who has not suffered from indigestion, and often from severe irritation, or even inflammation of the stomach and intestines. Disease of the alimentary canal being more certainly produced, in the generality of these cases, by the carminatives, anta- cids and opiates, administered to relieve the vomiting, expel the wind, and allay the griping caused by the improper diet. Slight symptoms of indigestion are frequently attendant upon the process of dentition, in consequence of the irritation of the gums being extended to the digestive organs; they seldom, however, occur to any extent, unless when too much food, or food of too stimulating a quality, is allowed at this period. Children too early weaned, are especially liable to be troubled with indigestion, as well as those who, weaned at a proper period, are placed immediately upon a too rich and stimulating, or otherwise unfitting diet. Vomiting and diarrhoea—more or less griping pain of the bowels—and rapid emaciation, are the prominent symptoms induced. The matters vomited, consist usually, of the partially digested aliment, often of a decidedly sour or rancid smell :—the dejections from the bowels are similar in character. In some cases, however, the food taken into the stomach passes through the alimen- tary canal, and is discharged entirely unchanged, while little or no vomiting is present. The appetite often continues unabated, or is even increased ; but from the disturbance or suspension of the digestive process, the nutrition of the system ceases, and the child dies from inanition; in many cases, however, the irritation of the alimentary canal is reflected upon the brain, and violent convulsions supervene; or a chronic inflammation of the mucous membrane may occur. In children brought up by the hand, or improperly fed subsequently to weaning, indigestion occasionally occurs, attended by symptoms of considerable severity. There is generally loss of appetite, peevish- ness, restlessness and want of sleep; the tongue is covered with a layer of white or yellowish mucus; the breath is often sour; and in some cases, apthae appear upon the parieties of the mouth. There is con- stant diarrhoea, intense thirst, and great emaciation and exhaustion. DISEASES OF THE DIGESTIVE ORGANS. 179 The diarrhoea, after a time, frequently diminishes, or ceases entirely, but soon returns with increased violence—the discharges being a thin, serous fluid, of a yellowish or greenish colour, and exhaling a strong, acid smell. The face and extremities become cold ; the pulse small and irregular; the respiration quick and short. The countenance becomes shrunk and pale. The child utters continually, a low piteous moan, or lies upon his back, with the eyes fixed, glassy, and half closed. No pain or tenderness is indicated upon gentle pressure of the abdomen; the latter, however, is often greatly swollen and tym- panitic. The child becomes more and more exhausted, and, finally^ expires quietly, and without convulsions. This appears to constitute that form of disease described by Came- rer, Pommer, Hergt, Romberg, Droste, and others, as gastro-mala- cia ; the stomach and intestines generally, presenting a gelatinous softening of their parietes, to a greater or less extent, but without any indications of inflammation ; the softening appearing to depend upon a diminished cohesion of the tissues—the result of disordered or suspended nutrition. In older children, indigestion is usually the result of too much or improper food. Over-feeding is among the most common of its causes, and is often induced by parents supposing that the strength and growth of the body is best promoted by a large amount of animal food. Acid and unripe fruits, and the cakes and confectionary, with which children are so apt to overload their stomachs, very gen- erally produce an attack of indigestion, attended with excessive nausea, a sense of weight and oppression about the praecordia, severe griping pains of the bowels, followed, sooner or later, by repeated vomiting, and copious diarrhoea; the attack being succeeded, in some cases, by long continued loathing of food; and in others, by an aug- mented appetite: this difference depending, probably, upon the greater or less degree of irritation produced in the stomach. The affection of the stomach and bowels we have described as indigestion, is unattended with febrile excitement; it is essentially a disturbance or suspension of the functions of the digestive organs, in consequence of the food taken, being too great in quantity, or una- dapted in quality to undergo the changes necessary to its proper assimilation. We must, however, recollect, that in all cases, more or less irritation of the mucous membrane of the alimentary canal is produced, and that if the causes of the disease are continued, inflam- mation of that tissue will be very liable to ensue ; or, if this be not the case, from defective nutrition alone, softening of the stomach and bowels, or disorganization of other organs may result. It is hardly necessary to enumerate the symptoms of indigestion, as it occurs during infancy and childhood, these having been already pointed out. They are, chiefly, uneasiness after eating, fretfulness and peevishness, nausea, griping or colicky pains, and frequent acid eructations, followed by vomiting, and generally by diarrhoea. The matters discharged by vomiting and stool, being the food taken, par- tially or not at all altered, and exhaling a sour or rancid odour, and 180 DISEASES OF CHILDREN. occasionally mixed with yellow or greenish bile ; the absence of feb- rile symptoms and of tenderness of the epigastrium ; more or less emaciation; with paleness of the surface, and occasionally, flatulent distension of the bowels. The appetite is often unimpaired, or even increased. Not unfrequently the irritation is reflected from the bow- els, upon the brain, producing convulsions ; or upon the nerves of the larynx, producing spasmodic constriction of the glottis; or inflam- mation of the stomach and bowels may take place ; in other cases the vomiting or purging continuing unabated, extreme emaciation ensues, and the child dies from inanition. When indigestion is properly treated in its early stages, it is gen- erally a very manageable disease, and even at a later period it may often be remedied ; but protracted cases, especially when we find it difficult to remove its cause, and when excessive marasmus has occur- red, very generally terminate fatally. The dissections in cases of simple indigestion have been very rare; death seldom takingplace excepting in protracted cases,oruntil structu- ral changes have occurred in the alimentary canal, or some other organ. Traces of inflammation are occasionally observed in the mucous membrane of the stomach, or intestines ; more commonly, however, there is a pale, anemic condition of the membrane, with softening, sometimes in circumscribed patches, and in other cases, involving a considerable portion of the mucous coat of the stomach, or small intes- tines. This softening is evidently the effect of imperfect or suspended nutrition, and is often met with in the brain, and other organs. (An- dral.) Portions of the intestinal tube are generally distended with gas, and have a transparent appearance, from the small amount of blood in the vessels, and the paleness of all the coats. A quantity of white frothy mucus is frequently found in the stomach and intestines. Invagination of the intestines is also, a very common occurrence. The treatment of infantile indigestion consists almost entirely in the removal of the cause, by which the disturbance of the functions of the stomach has been produced. In young infants, when mere reple- tion of the stomach produces a regurgitation or vomiting of the milk, we have already pointed out the proper remedy; namely, preventing the infant from sucking too much at a time, and being careful not to place it too often at the breast; and when the irritability of the stomach is such as to cause the ejection of its contents upon the slightest motion communicated to the infant, being careful to allow it to remain at perfect rest for some time after it has been at the breast. A young infant is naturally inclined to perfect quietness, and generally to sleep, after sucking, and the interfering with this inclination is seldom unattended with injury. Rude dandling, jogging upon the knee or in the cradle, jolting in the arms, or even carrying a young infant rapidly up and down the room, is at all times improper, but particularly so, immediately after taking it from the breast. When, from any cause, the milk of the mother is found to disagree DISEASES OF THE DIGESTIVE ORGANS. 181 with the infant's stomach, if the cause of this be under the control of diet and regimen, it should be at once removed. Mothers often produce a deleterious change in their milk, in their attempts to improve its quality, and keep up the supply, by partaking of too much food, and that, generally, of a too stimulating kind ; and often by indulging daily in malt liquors, or in wine, during the period of suckling. A plain, moderate diet, composed, chiefly, of farinaceous articles, and plainly cooked beef or mutton, once a day, with a sufficient amount of daily exercise, will be found, invauably, to render the supply of milk fully adequate to the wants of the infant, and of a far better quality than when the stomach is overloaded daily with a variety of rich and simulating food Water, we have already said in a former part of this treatise, is the only proper drink for a female, whilst suckling ; and we here repeat, that so far from malt and vinous drinks promoting the secretion or improving the qualities of the milk, they almost invariably produce a contrary effect. Whatever is calculated to interfere with the digestive and assimilative functions of the mother cannot fail, by deteriorating the milk, to cause more or less injury to the infant. On this account, the use of strong tea and coffee should be abstained from ; late hours, and the frequenting of crowded assemblies should be avoided; regular periods of retiring, and early hours of rising should be observed; and as soon after delivery as prudence and the state of the weather will permit, exercise, at first passive, and subsequently of a more active kind, should be taken daily, in the open air; violent exercise should, however never be indulged in. Anxiety, and every intense excitement of the mind, should, if pos- sible, be avoided:—a female, of a calm, cheerful, and contented dis- position, makes, always, the best nurse. Violent paroxysms of passion often produce so deleterious a change in the milk, as to cause almost immediate vomiting and purging, or even convulsions, in the infant that partakes of it. (Boerhaave, Baumes, Hufeland.) In cases of indigestion, occurring in the children of mothers of violent tempers, or of such as are labouring under deep mental depression, or intense excitement of the mind, the only remedy is, either to nourish the child by the hand, or to substitute the breast of a healthy and compe- tent nurse. Where a sufficient supply of milk of good quality, is furnished by the maternal breast, no other food will be necessary for the child, until dentition has made some progress, when some additional aliment may be allowed; but upon this subject we have said all that is neces- sary when treating of the hygienic management of infants. It is ortly necessary in this place to remark, that when young infants are troubled with indigestion, and the cause cannot be traced to the condition of the mother's milk, it will, in general, be found to result from the injudicious overloading of the infant's stomach with some kind of pap or panada,—articles which are invariably injurious, even when from a deficient supply of milk, on the part of the mother, addi- tional aliment is required. In addition to the proper regulation of the infant's diet, in cases of 182 DISEASES OF CHILDREN. indigestion, the functions of the skin should be promoted by the daily use of the warm bath, followed by gentle frictions to the surface ; and when the weather will permit, the child should be carried into the open air daily. Riding short distances in an open carriage, or sailing in a boat, when practicable, will invariably be found advantageous. The body should be preserved of a proper and equable temperature, by appropriate clothing, and by rooms sufficiently heated in winter, and well ventilated in summer. Medicines of any kind will seldom be required in a case of simple indigestion. When considerable nausea and retching occur without free vomiting, it may, however, be proper to unload the stomach by a gentle emetic of ipecacuanha. If considerable acidity of the stom- ach exists, a dose of calcined magnesia may be given ; or, if the bowels are constipated, of equal parts of magnesia and rhubarb ; if diarrhoea be present, the simple cretaceous mixture, or what we pre- fer, the prepared chalk in powder, combined with small doses of ipe- cacuanha,* will be proper. »R.—Cretas ppt. 3j. Ipecacuanhas, pulv. gr. ij. ad iij.—M. f. ch. No. xij. One to be repeated every three hours. Dr. Kuhn preferred, in all cases of acidity affecting the alimentary canal of children, and unattended with inflammation, the aqua ammo- nia, to either the magnesia or carbonate of lime. He prescribed it in the following formula.* aR.—Aq. puras, giij. Gum. acacias, pulv. 9ij. Sacch. alb. puras, 3ij- Aq. cinnamon, simpl. vel., Aq. anisi, gss.—M. et adde Aquas ammonias, V![ xlviii.—lxxx. A teaspoonful to be given every one, two, or three hours, according to circum- stances. When the infant is troubled with severe griping pains, the warm bath, friction with some anodyne liniment, followed by warm fomen- tations to the abdomen, and the use of the aqua ammonia, as directed by Dr. Kuhn, will be found, in many cases, to afford prompt relief. The remedy from which we have seen the best effects to result in the colic of children, from indigestion, is a combination of magnesia, extract of hyosciamus, calomel, and ipecacuanha.* In some cases, a few drops of aq. camphorata, or of the etherial solution of camphor, will promptly allay the colicky pain in these cases.b Three to five drops of spirits of turpentine, mixed with a little sweetened water, and repeated in the course of an hour, will, also, often produce a decidedly favourable effect. »R.—Magnesias calc. 9ijss. ad 3j. bR.—Camphoras, 3j. solve in Ext. Hyosciami, gr. viij. to xij. ^Ethcr. Sulphuric, ^j. Pulv. Ipecac, gr. iij. Add thirty drops of this solution to one Calomel, gr. iij.—M. f. chart. No. ounce ofsimpleannisecd water, with two xij. drachms of refined sugar. The dose is Que to be given every two or three hours. one or two teaspoonfuls, according to the age of the child. DISEASES OF THE DIGESTIVE ORGANS. 183 When the pain,is very intense, and is not promptly allayed by the remedies already enumerated, a dose of tincture of opium, adapted to the age of the child, may be given in a little sweetened anniseed water, or it may be administered in the form of enema combined with thin starch. Great caution should, however, be observed in the employment of opiate anodynes in the affections of infants, neither to resort to them unnecessarily, nor to repeat them too often. They should be given, also, in small doses, and their effects carefully watched, as very minute doses of the tincture of opium have, when injected into the rectum, not unfrequently proved fatal to infants. (Alison, Christison, Marley, Merriman.) In cases of indigestion attended with frequent and copious dis- charges from the bowels, it will, occasionally, be prudent to admin- ister some slight astringent; the tincture of kino will, in general, very promptly suspend the diarrhoea. It may be given in combina- tion with the cretaceous mixture.* * R.—Mucilag. G. acacias, gij. Succh. alb. puras, 3ij. Aq. cinnamon, gj. Cretas, ppt. 9ij. Tine. Kino, 3j. ad 3ij.—M. A teaspoonful three times a day. In cases of indigestion from too early weaning, when practicable the infant should be reapplied to the breast, or if this cannot be effected, it should be confined entirely to milk and water, sweetened with loaf sugar, as directed in our section on the diet of infants. The indigestion occurring at the period of weaning is usually very readily managed by a proper attention to diet, the wrarm bath, daily exercise in the open air, when the weather will permit, and the remo- val of any symptom of unusal severity that may occur by the reme- dies already detailed. In older children, it will be proper, in most cases of indigestion, to administer an emetic of ipecacuanha, followed, if the bowels are much disturbed, by a moderate dose of magnesia and rhubarb; after which, a proper regulation of the diet, as well in regard to quality as to quantity, will, in general, very speedily remove every unpleasant symptom and restore the regularity and activity of the digestive func- tion. Confining the patient for a short time to a milk and farinaceous diet alone, or with the occasional use of plain meat broths, with the addition of rice or crackers, will be proper. Every species of pastry and confectionary, crude and ascescent fruits, and flatulent vegetables should be strictly proscribed. Every case of indigestion occurring in children, should be carefully scrutinized and cautiously watched, and if any sympton indicative of the occurrence of even a slight degree of inflammation in any part of the gastro-intestinal mucous membrane, should be detected ; if the skin becomes dry and parched, the tongue red at its edges and extremity, and coated on its upper surface with a whitish mucus; or if increased 184 • DISEASES OF CHILDREN. heat of the epigastrium, with tenderness or pain upon pressure arc detected, leeches and fomentations to the abdomen, with cool muci- laginous drinks internally, will be demanded. In protracted cases of indigestion in children, with entire suspension of the function of the stomach—the food and drinks passing through the bowels without change as soon as they are taken—but little can in general be done to prevent a fatal result. In some cases, much benefit, however, has resulted from the use of a cold infusion of bark, with the addition of a few drops of hydrochloric acid; from the tincture of the sesquichloride of iron or chalybeate wine in small doses—one or two drops of the first, and from three to six of the latter, in a tea- spoonful of water. We have occasionally seen good effects result from the carbonate of iron, combined with hyosciamus and acetate of lead.* » R.—Ext. Hyosiciami, gr. viij. ad xij. Carb. Ferri, gr. xxiv. ad xxxvj. Acetat. plumbi, gr. xij.—M. i. chart. No. xij. One to be given every three hours. Friction along the spine, with the weak liniment of ammonia, repeated daily, and frequent exposure to the open air, by riding in a carriage, will, in general, be found useful. The diet should consist exclusively of beef-tea or milk, with the addition of rice flour, or arrow root. What would be the effect of tannin, or of the pure sul- phate of alumine in these cases, we are not prepared to say—never having had an opportunity of making a trial of them. In that form of infantile indigestion in which softening of the stom- ach is most likely to occur, trial maybe made of the hydrochloride of iron, which appears to have frequently succeeded in restoring the healthy functions of the stomach, in the hands of Pommer, Hergt, Camerer, Droste, and others.* » R.—Ferri hydrochlorid, gr. x. ad xv. Mncil. G. Acacias, giij. - . Sacch.alb. pur. 3ij.—M. A dessert spoonful to be given every hour. Or, R.—Tinct. Ferri. sesquichlorid., Extract, cinchonas, aa 9ss. Aq. flor. aurant. gij. Syrup, eorum, gj.—M. A teaspGonful to be given every hour. (Droste.) t—Gastritis. Inflammation of the Stomach. Inflammation of the mucous coat of the stomach is of far more fre- quent occurrence during infancy and childhood than is generally supposed. It varies in degree, in different cases, from a slight erythe- matic inflammation confined to a small portion of the gastric mucous membrane, and attended by symptoms so obscure as to cause its exist- DISEASES OF THE DIGESTIVE ORGANS. 185 I ence, in its earlier stages, to be entirely overlooked ; to an intense in- flammation of the greater part of the stomach and bowels, accompanied by symptoms of a very decided and violent character, and rapidly producing disorganization of the tissues in which it is seated. It is seldom that the stomach is alone affected ; in the great majority of instances, the inflammation extending to the duodenum, and other small intestines. The leading symptoms of gastritis in the infant are retching or vomiting; increased heat and tension of the epigastrium ; shrinking and painful cries when this part is compressed ; an expression of coun- tenance indicative of distress; a dry, parched skin ; redness of the point and edges of the tongue; a coating of white mucus over its surface, through which the enlarged and florid papillae protrude ; great rest- lessness ; a small and contracted pulse, often greatly increased in fre- quency; augmented thirst, and, generally, aversion from food. These symptoms vary in intensity in different cases, and are often compli- cated with others, arising from disease of adjoining or remote organs, by which the gastritis has been preceded, or which become developed simultaneously with, or subsequently to, its occurrence. The most constant symptoms are, frequent vomiting, heat, tension and pain upon pressure of the epigastrium, and an expression of countenance indicative of suffering. The vomiting is most liable to occur upon any drink or food being taken into the stomach, which are almost immediately rejected. The vomiting is occasionally attended with considerable retching, and is evi- dently, in severe cases, a cause of much suffering to the patient. The matters vomited, are the food and drinks taken ; a thick, ropy or frothy mucus, often mixed with yellow or greenish bilious matter;— brownish, or dark brown, and even bloody discharges are occasion- ally observed. The matters vomited, are not unfrequently decidedly acid. A certain degree of heat and tension of the epigastrium are seldom absent:—in some cases,they maybe slight, but when the inflam- mation of the stomach is fully established, and of any degree of intensity, the heat and tension of the abdomen, are very considerable; the heat of this part, in many cases, being the more marked, from the temperature of the surface generally, not being augmented; while that of the lower extremities, is perhaps reduced. The tenderness of the epigastrium may be detected only upon pressure; by the patient starting and moaning, or crying out, with the peculiar acute tone belonging to the cry from pain: or it may be to such an extent, as to render the slightest touch, a source of suffering, and to cause the patient to lie upon his back, with his knees drawn up. In these cases, the countenance, as well as the restlessness and constant cries of the infant, indicate the severity of his suffering. When the child is old enough to express his feelings, he, in general, complains of a burning pain in the stomach. When the gastric pain is severe, respiration is short and quick, and peiformed, almost exclusively, by the ribs. Diarrhoea is common in cases of gastritis; the matters discharged 186 DISEASES OF CHILDREN. from the bowels, being at first fcecal, but subsequently, similar to those ejected by vomiting. Gastritis is occasionally, however, at- tended with constipation. The disease is often, especially in young infants, unattended, through- out, with any degree of febrile excitement; occasionally, however, there is considerable fever, with a hot and burning skin, quick and frequent pulse, and delirium, or tendency to coma. In general, the febrile symptoms are remittent, with exacerbations, toward evening, or even later. Gastritis may terminate in resolution, or in ulceration, gangrene, or softening of the gastric mucous membrane, or of the whole of the coats of the stomach, causing a perforation of the organ. In violent cases, great prostration of strength, with profuse perspi- ration about the head and face, subsequently extending over the greater part of the body, hiccup, cold extremities, a sinking of the pulse, and often convulsions, early occur, and are speedily followed by death. Gastritis may become chronic, and continue for a length of time, with occasional vomiting—some degree of tenderness and tension of the epigastrium—irregular appetite—occasional diarrhoea, alternating with costiveness—dryness and harshness of the surface—febrile symp- toms of a remittent character—and progressive emaciation. White softening of the stomach, with perforation, may occur, in these cases; or, the irritation being transmitted to the brain, effusion in that organ, may take place; or, tubercles becoming developed in the lungs, the patient may die, with all the symptoms of tubercular phthisis. The causes of gastritis in children, are, either irritating substances —improper or deteriorated articles of food, or some acrid or poison- ous matter, introduced into the stomach—cold and moisture applied to some portion of the surface—sudden alternations of temperature— the sudden suppression of cutaneous eruptions, or of the discharge, from ulceration behind the ear. (Underwood, Eberle.) In many cases, particularly in young infants, the inflammation of the stom- ach is preceded by an attack of stomatitis; in others, the stoma- titis occurs subsequently to the gastritis. The disease wrould appear to prevail, in some cases, as an epidemic. (De Rein, Cruveilheir, Iselin.) The appearances observed after death, in cases of gastritis, are injection and redness, with thickening, and a softened condition of the mucous membrane of the stomach. The redness may consist in sim- ple injection of the blood vessels, and present an arborescent arrange- ment:—this occurs chiefly in the slighter cases of the disease:— when the inflammation is more intense, the redness is more or less diffuse; or it occurs in patches of a greater or less extent—in irregular striae, which follow, generally, the course of the corrugations of the stomach, or in numerous, closely approximated red points. (Billard.) The stomach often contains a quantity of thick, tenaceous mucus. The papillae or villosities of the mucous membrane, appear, occasion- DISEASES OF THE DIGESTIVE ORGANS. 187 ally, to be somewhat enlarged. (Lauret.) In a few cases, large patches of curd-like exudation, adhere to the mucous membrane ;—in others, the follicles of the stomach are morbidly developed, forming a number of small, rounded granulations, of a white colour, terminating in a black point; (Billard;) or the mucous membrane may be the seat of apthous ulcerations, or of ulceration, extending through the inner and middle coats. When the inflammation of the stomach terminates in gangrene, which is of exceedingly rare occurrence, (we have never met with a single case,) sloughs of various extent, implicating the whole of the coats of the stomach, will occur, which, on becoming detached, give rise to perforations ; (Billard;) or^the mucous membrane alone may be reduced to a gangrenous condition. (Denis.) In cases of gelatinous softening of the stomach, the mucous mem- brane will be found reduced to a jelly-like consistency; or the soften- ing may extend to all the tissues of the stomach, rendering them liable to be perforated by the slightest force; or a complete perforation of the coats of the stomach may have occurred. All of these conditions may exist in the same stomach, at different points. (Iselin.) These softenings, or perforations, occur especially at the great curvature, seldom extending beyond the most depending parts. (Baron.—Bil- lard, Iselin.) Some observers, however, describe the softening as involving, occasionally, the greater part of the mucous membrane. Distinct traces of inflammation, are occasionally observed, surround- ing the softened parts; and the parieties of the stomach often present a serous infiltration. (Billard.) The softening here described, is unquestionally the result of inflam- mation. It is preceded by the most unequivocal symptoms of acute gastritis,—constant vomiting, increased upon any thing being taken into the stomach—intense thirst—pain, induced by pressure upon the epigastrium—distension and increased heat of the latter—a counte- nance and cries, indicative of suffering—copious diarrhoea, the dejec- tion being at first of a greyish colour, but subsequently, a yellowish or greenish serum decidedly acid. The softened parts are occasionally surrounded by distinct traces of inflammation ; patches of inflamma- tion often exist also in different portions of the intestinal canal, especi- ally in the small intestines. Softening and perforation, in many cases, occur simultaneously in the stomach, oesophagus, small intestines, mesentery, and lungs. (Iselin) Many pathologists have denied the connection of softening of the stomach, with inflammation of that organ, and maintain, that in the majority of cases, it is a cadaveric phenomenon, resulting from the action of the gastric juice,upon the tissues of the stomach; (Cars- su-cll, Allan Burns, Gairdner, Carwell, Hope); others refer it to a paralysis of the nerves of the stomach, with increased acidity of the gastric fluid, by which the stomach is dissolved during the lifetime of the patient. (Jceger, Zeller, Camerer.) A somewhat similar opinion is entertained by Laisne, Chaussier, Desbarreaux, Bernard, 188 DISEASES OF CHILDREN. and others. Without denying that the stomach may be dissolved after death, in consequence of the generation in its cavity, of an excess of acid ; and being well aware that a softening of the tissues of the stom- ach, and of other parts of the alimentary canal, may be produced by causes affecting the nutrition, and impairing the cohesion of the vari- ous tissues, we are still convinced, from the result of our own observ- ations, that the gelatinous softening, so frequently observed in chil- dren that have died of acute gastritis, is invariably the effect of intense inflammation of the mucous and other tissues of the stomach. The treatment of gastritis, is that proper in cases of inflamma- tion generally, modified, somewhat, by the seat of the disease, and by the age of the patient. Leeches should be applied to the epigas- trium, in numbers proportionate to the violence of the symptoms; and if the disease be one of considerable intensity, occurring in a robust and plethoric child, and not too young to permit a vein to be opened in the arm, general blood-letting will be found of advan- tage. The necessity for a repetition of the leeches, will depend upon the particular character of the attack, and the effects pro- duced by the first application. Should the tenderness and heat of the epigastrium continue, with little abatement, after the first appli- cation of leeches, it will be proper to renew them. In general, however* a less number will be required. The leeches should be followed by warm fomentations, or a soft emollient cataplasm, applied over the epigastrium;—the fomentations and cataplasm being renewed at short intervals. The occasional use of pediluvia of warm water, with the addition of a small quantity of mustard, will, in general, be productive of good effects, and should not be ne- glected. The diet and drink of the child, should be composed exclusively of some simple mucilage, as gum-water, or water in which the pith of sassafras, or the slippery elm bark has been infused. These should be given cold, and in small portions at a time. The occasional administration of a spoonful of cold water, we have found to be pecu- liarly grateful to the patient, and often to remain upon the stomach, when every thing else is instantly rejected. It is hardly necessary to say, that if the child is at the breast, it should not be allowed to suck, so long as the inflammation of the stomach continues. Great difference of opinion exists, as to the propriety of adminis- tering remedies internally, in this disease; some proscribing them entirely, trusting the cure of the inflammation exclusively to external means; while others think it very necessary, to administer, in the early stage of the attack, some mild purgative, especially, if a costive state of the bowels exists. We have been in the habit, immediately after the application of leeches to the epigastrium, or the employment of genera] bleeding, when this has been indicated and admissible, to administer to the patient, calomel, in small doses, repeated at short intervals—say from the sixth to the half of a grain every one or two hours. This we have known, in a large number of cases, to suspend, DISEASES OF THE DIGESTIVE ORGANS. 189 very promptly, the irritability of the stomach, and to produce a favourable change in the symptoms, generally. In cases attended with frequent thin, acid evacuations from the bowels, the calomel has been found to suspend the diarrhoea, and render the stools of a more consistent and natural appearance. We generally combine each dose of the calomel, with a grain or two of calcined magnesia, and give it mixed in a little mucilage; but where there exists very great irri- tability of the stomach, we direct the calomel, combined with a few grains of powdered gum acacia, to be placed dry upon the tongue, the child being shortly afterwards given to drink a spoonful of thin mucilage. After the inflammation of the stomach is somewhat reduced, a blister to the epigastrium will often be found of essential service: when too early applied, blisters, however, have appeared to us to do more harm than good:—the blister should be kept on only sufficiently long to produce a redness of the skin; it should then be removed, and the epigastrium covered with a common bread and milk poultice. In young children, great inconvenience, and often severe and protracted suffering, have been the result of a blister being allowed to remain on until vesication occurs. Inflammation of the stomach, in its most acute form, is often attended with a condition of the pulse and surface, and a degree of extreme prostration, that have induced the inexperienced practitioner to suppose, some remedy adapted to support the strength of the patient, was demanded; in every instance, however, its use will be found to aggravate the symptoms, and hurry on a fatal result. In these cases of extreme prostration, with a cool skin, and small thready pulse, we have repeatedly seen the most beneficial results, from the use of the warm bath, repeated daily—in some instances, night and morning. The chronic form of gastritis, is to be treated by a mild, unirri- tating diet, of some farinaceous preparation, with milk—by the warm bath—and blisters to the epigastrium, frequently repeated. In this form of the disease, we have derived great advantage from small doses of calomel, combined with ipecacuanha and extract of hyosci- amus.* If a frequent and troublesome diarrhoea is present, from half a grain to a grain of acetate of lead may be added to each dose. »R—Calomel, gr. iij.—iv. Magnes. calc. gr, xxxvj. Ipecacuanhas, gr. ij.—iij. Ext. hyosciami. gr. iv—vj.—M. f. chart. No, xij. One to be given every three hours. In that form of the disease, which is attended with gelatinous soften- ing of the stomach—the occurrence of which, sooner or later, may always be suspected, by the severity of the symptoms, from the very commencement of the attack; the yellowish or greenish matters ejected from the stomach and bowels, the latter particularly, being often extremely acid; the coldness of the extremities; the habitual expres- 190 DISEASES OF CHILDREN. sion of suffering which the countenance assumes, and the general state of prostration that early ensues—the most energetic treatment is demanded, from the very onset of the disease. The remedies differ in nothing from those proper in other cases of acute gastritis. The early and judicious detraction of blood, from the arm, or by leeches, to an extent commensurate to the violence of the disease, and the age of the patient, will often promptly abate the intensity of the inflamma- tion, and prevent occurrence of disorganization of the stomach. It is hardly necessary to say, that the hydrochloride of iron, recom- mended by Pommer, Hergt, and others, in gelatinous softening of the stomach, is not adapted to the softening from acute gastritis; the cases in which it is reported to have been employed with advantage, were evidently those from defective or disturbed nutrition, unattended with inflammation. The utmost care should be taken, in regard to the diet and regi- men of the patient, for a long time after recovery from an attack of gastritis, as the disease is one very liable to a relapse, from slight causes, but particularly, from errors in diet. The food should con- sist chiefly of milk and farinaceous articles, in moderate quantities. Gentle exercise, at first of a passive kind, should be taken daily, when the weather is fine, in the open air. The daily use of the warm bath should not be neglected. The surface should be preserved of a com- fortable and equal temperature, by appropriate clothing, and by rooms properly warmed and ventilated, in cold weather, and cooled by the admission of a current of air, and the exclusion of the sun's rays, during the heat of summer. We have said nothing of the treatment of gastritis from the acci- dental ingestion of poisonous substances into the stomach, which occasionally happens in infancy and childhood :—with the exception of the administration of such articles as have been found to suspend the action, or to neutralize the poison, the same remedies precisely are demanded, as in cases of ordinary gastritis. CHAPTER V. DISEASES OF THE INTESTINES. 1.—Congenital Malformations. Congenital malformations of the intestines being of frequent occur- rence, and capable of being removed or relieved, in many cases, by an operation, a treatise on the diseases of children would seem to be incomplete without some notice of these affections. DISEASES OF THE DIGESTIVE ORGANS. 191 The malformation may consist in the constriction of the calibre of the intestines, at different points—in the closure of the canal, by trans- verse membranes—in a division of the intestines into separate parts —in the absence of the lower portion of the rectum, and its termination in the vagina in the female, or in the bladder in the male—or in the occlusion of the anus, by a membrane of greater or less thickness. The first three of these species of malformation, are necessarily and promptly mortal. Neither meconium nor excrement is voided— the milk and other fluids taken, are speedily vomited, followed, in many instances, by the discharge, from the stomach, of a yellowish or dark brown fluid or meconium. Death may occur in a few hours, or not until the termination of several days—the child often becoming extremely emaciated. A more frequent species of malformation, is the closure of the anus by a membrane differing in density and thickness. This is readily detected, by the absence of any external opening—the distension of the anus by the meconium accumulated in the rectum ; this distension is more apparent when the child cries; at which time, also, a fluctu- ation can be very readily felt beneath the occluding membrane. As soon as this malformation is detected, a crucial incision should be made, with a sharp pointed bistoury, through the membrane by which the anus is closed,—care being taken not to divide the sphincter ani, as this may give rise to a troublesome and long continued invol- untary discharge of the faeces. Occasionally, the imperforationis situated some distance within the anus, the latter being perfectly formed. Whenever no discharge takes place from the infant's bowels, within a few hours after birth, a careful examination should be made into the state of the rectum ; and if the imperforation exists at the lower portion of the rectum, it may generally be detected by the introduction of a gum elastic catheter. The obstruction may, in many cases, be removed by an operation; the nature of which should be, in a great measure, governed by the circumstances of each case—whether by the trochar and canula, as di- rected by some, or by the straight pointed bistoury,as directed by others. The greatest caution should be observed in the introduction of the in- struments, as well as in the division of the obstructing membrane, lest the sides of the intestine be wounded, or an opening be made into the bladder or vagina. We have lately seen a case of this species of malformation, in which the obstruction, consisting of a transverse membrane, existed about an inch and a half within the anus, the lower portion of the rectum being, n all respects, perfectly formed. The child lived four days, and, until within a few hours previous to its death, presented no indication of the existence of the obstruction, excepting the absence of all dis- charges from the bowels. Shortly before death, great tumefaction of the abdomen from the development of gas took place, with evi- dent pain, on pressure of any portion of the abdomen ; no operation was permitted by the parents—An examination of the body revealed 192 DISEASES OF CHILDREN. the nature of the obstruction —a firm, membranous partition, existing about one and a half inches above the termination of the gut, and forming a complete obstacle to the further passage of the contents of the bowels. The small intestines were perfectly empty, greatly con- tracted, and free from the least trace of disease; the colon was enor- mously distended with gas, and, throughout its whole extent, injected with blood ; the upper portion of the rectum was likewise greatly dis- tended, and contained nearly eight fluid ounces of meconium and thick ropy mucus; its mucous coat presented very decided marks of inflammation. Another common malformation of the rectum is a firm adhesion of its sides, often, for many inches above its natural termination, with a total absence of any trace of anus or of sphincter muscle. The skin retains its natural colour over the whole space between the parts of generation and the coccyx, without being elevated, in one place, more than another, and having the same firm, fleshy feel throughout. In such cases, the intestine sometimes terminates in a cul de sac, about an inch above the ordinary situation of the anus, or it may not descend lower than the projection or upper portion of the sacrum; occasionally, it opens into the bladder or vagina. We have seen a case in which the gut, upon reaching the top of the sacrum, suddenly became contracted to the size of one of the ureters, and passed directly to the fundus of the bladder, into which it opened by an ori- fice that would scarcely admit a large bristle. In these cases, it has been advised to make an incision, about an inch long, in the situation where the anus ought to have existed; the incision being gradually deepened, in the natural direction of the rectum, by successive strokes of the scalpel, the index finger of the left hand being used as a director. By this means, the end of the rectum may be often reached, and a discharge of the faeces procured ; and, by keeping the artificial passage permanently dilated by tents of oiled lint or bougies of a proper size, the life of the child may be pre- served. It is seldom, however, that the patient will acquire the power of retaining the faeces, or that the use of the tents can be aban- doned, without a contraction of the passage speedily taking place. If the termination of the rectum cannot be reached by the operation just described, it has been advised—as death must inevitably follow— after the incisions have been carried as far as the finger can reach, to introduce upon the latter a long trochar, in such a direction as will be best calculated for finding the termination of the rectum. We have seen this tried in several cases, but never with any success. When an outlet for the faeces cannot be procured by either of the above means, it has been proposed to make an opening into the ab- domen above the pubes, near one of the groins, (Littre, Sabatier,) in the left iliac region, (Duret), or in the lumbar region, between the posterior border and crest of the ilium, parallel with the posterior edge of the quadratus muscle, or perpendicularly, (Callisen, Amussat,) in order to get at the colon, and form an artificial anus, in one or other situation. DISEASES OF THE DIGESTIVE ORGANS. 193 Duret is said to have performed the operation in the iliac region, and Amussat in the lumbar region, with success, in several cases. Cases are related, in which the rectum opened in the urethra, (Roux), or, the rectum being entirely wanting, the colon opening into the neck or summit of the bladder. (Steel, of N. Y., Dubreuilh.) The case of Roux was successfully treated by incisions from the natural position of the anus, in the direction of the rectum. 2.—Enteralgia—Colic. Intense pain of the bowels is frequently observed in infants; we have already noticed its connection with indigestion, and the means best adapted for its relief, in such cases. Colic, however, occurs dur- ing infancy, under circumstances where we have no reason to suspect, as its cause, any disturbance of the digestive function from the bad quality, or undue quantity of the food ; we have known it to occur daily, during the first month or two, and nearly at the same period of the day—generally towards the latter part of the afternoon ; Dewees remarks that it generally occurs between four and six o'clock, p. m. ; while others have noticed its occurrence at a regular period, in the morning or forenoon. In most cases, this species of colic is attended with the formation of gas within the intestines, and occasionally the tumid and tympanitic state of the abdomen is very great. In other cases, however, little or no flatulence is perceptible, the paroxysms of pain occurring at irregular intervals, and being readily induced by the feet becoming cold or wet. We have not been able to examine the pathological condition of the alimentary canal in cases of enteralgia, never having known death to occur from it. The disease appears, however, to depend upon neuristinia of the intestinal mucous membrane, attended, in most cases, with a morbid secretion of gas. In slight attacks of colic, the infant becomes suddenly very fretful, draws up its knees towards the abdomen, and cries for a few minutes, and then resumes its usual quiet state, as though nothing had occur- red. These attacks may be repeated at shorter or longer intervals, and seldom cease permanently, or for any length of time, until a por- tion of gas is discharged by the mouth or peranum, or an evacuation of faeces, often thin and frothy, occurs. In more violent attacks, the infant commences, suddenly, to utter sharp, pcircing screams, which are often long continued or only inter- rupted by a few moments of quiet; the knees are forcibly drawn up; or the legs are drawn up and extended in rapid succession ; the trunk of the body is occasionally forcibly extended, with the head thrown back, and the hands firmly clenched. The expression of the countenance indi- cates severe suffering; the face being occasionally flushed, or covered with large drops of perspiration. The abdomen is often distended, tense and tympanitic, or presents an irregular or knotted surface. No 13 194 DISEASES OF CHILDREN. pain is induced by pressure upon any part of the abdomen ; gentle pressure and frictions appear, indeed, in most cases, to afford decided relief. Notwithstanding the severity of the paroxysms, in this form of infan- tile colic, the child, immediately upon their cessation, is quiet, cheer- ful, and playful, and exhibits nothing in its appearance, to indicate the severity of its recent sufferings; its appetite is seldom impaired, the digestive and nutritive functions are, in no degree, disturbed or inter- rupted, and the general health seems, often, actually to improve ; as, Dr. Dewees very correctly remarks, some of the fattest and healthiest children are those affected with it. It is a popular nursery opinion, that boys are more subject to this species of colic than girls ; but wc have not observed it to occur more frequently in one sex, than in the other. Dr. Parrish has described a species of enteralgia which we have occasionally met with. The child often screams out suddenly, throws itself back, and stiffens its body, as in cases of flatulent colic; the paroxysm ceases, generally, in a few moments, and is succeeded by a state of perfect ease. Even when the pain is less severe, the peculiar motions and complaints of the infant are such, as experienced mo- thers and nurses immediately attribute to uneasiness in the cavity of the abdomen. Flatulent discharges by the mouth or anus are fre- quently productive of great relief:—the formation of gas within the intestines, is generally very abundant, producing, often, a tympanitic swelling of the abdomen. The peculiarity of this variety of enteralgia, consists in its being ac- companied by a species of convulsion, resembling an epileptic fit; from this, it differs, however by the patient, immediately on its cessa- tion, becoming quite sensible, and sometimes even playful. Occa- sionally, two or more of these convulsions will occur in quick succes- sion ; and then, days and weeks will elapse before their return. If not arrested, however, they become more frequent and distressing; and at length the infant is almost constantly affected with severe spasms or partial convulsions, and finally sinks under the disease. This form of enteralgia occurs usually in infants, between five and twelve months of age. If the child survive the period of denti- tion, it is usually safe. (lJarrish.) In the only case, in which a post-mortem examination was made, the greater portion of the small intestines were found irregularly con- tracted ; being reduced, in some parts, for more than an inch in extent, to the size of a goose quill; in other parts, the calibre of the intestine was almost entirely obliterated, as if it had been tied with a thread. The omentum was folded up in the form of a thick twine or small rope, and lay upon the arch of the colon. The gall bladder was filled with a light-coloured, glairy fluid. No other indication of disease was detected in the cavity of the abdomen or thorax. (Parrish.) The brain unfortunately was not examined. The peculiar phenomina of the species of enteralgia described by Dr. DISEASES OF THE DIGESTIVE ORGANS. 195 Parrish, are evidently the result of the neuropathic condition of the intestines being combined with some degree of cerebral irritation. The occasional causes of enteralgia are but little understood; a very attentive study of the disease has not enabled us to detect any particular circumstances, under which it is most liable to occur. It may appear at any period, between birth to the termination of the first dentition ; we have met with it, more frequently, within the first three or four months. It is very commonly attended with an habitu- ally constipated state of the bowels, and the paroxysms are often ex- cited by allowing the feet to become wet and cold. The disease is not necessarily connected with any degree of inflammation of the alimentary canal, though, in very severe cases, we have known en- teritis to become developed at an early period. Dr. Parrish, who refers the form of enteralgia described by him, to " intestinal spasm," remarks, that " there can be no doubt, that it is greatly aggravated by difficult dentition." The treatment of enteralgia may be divided into that proper dur- ing the paroxysms, in order to allay the violence of the pain, and that during the intervals, to prevent their recurrence. During the paroxysms, the warm bath and warm fomentations to the abdomen are among our most valuable remedies; we have found prompt relief, often to be produced, by applying to the abdomen, after immersion in the warm bath, a cataplasm formed of hops steeped in warm water, and enclosed in a thin gauze bag. The bowels should be opened by an injection of warm water, to which a few grains of assafoetida, dissolved in milk, may be advantageously added. Inter- nally we have occasionally administered, with prompt relief, a few grains of aqua camphorata, or of spirits of turpentine, rubbed up with sugar. Three to five drops of spirits of turpentine may be given to an infant, and repeated, every one, two, or three hours, according to the urgency of the case. When, however, the paroxysm is one of un- v common severity, and does not promptly yield to the means that have been enumerated, we have never hesitated to administer an opiate, either by injection or by the mouth, graduating the dose according to the age of the infant, and carefully watching its effects before ven- turing upon its repetition. We have been much pleased with the effects, in the colic of infants, of a watery infusion of opium :—five grains of opium may be infused, for three hours, in two fluid ounces of water; the infusion being then filtered, ten grains of bicarbonate of soda are to be added; of this, ten drops may be given to a child, within the month, in a little sweetened aniseed water—the same dose being re- peated after an hour, if necessary. When the bowels are distended with gas, prompt relief may be occasionally obtained by the introduc- tion, into the rectum, of a large gum elastic catheter, or. a common enema syringe. In the species of enteralgia described by Dr. Parrish, he directs the bowels to be freely evacuated by castor oil, magnesia, or some other gentle cathartic ; blood to be taken from the arm, or by leeches 19G DISEASES OF CHILDREN. to the abdomen ; the warm bath,and antispasmodics, particularly the assafoetida, given by the mouth, and as an enema. Accord- ing to the age of the child, from two to five grains may be given, every two hours, in the form of emulsion, and from ten to twenty grains as an enema, repeated more or less frequently, according to circumstances. If the assafoetida is not retained upon the stomach; or produces when injected into the rectum, an unpleasant irritation, the rectified oil of amber, two to five drops, rubbed up with gum acacia, loaf sugar, and cinnamon water, may be substituted ; if there should be intense pain, a few drops of laudanum may be combined with the assafoetida or oil of amber, or four to eight drops of laudanum may be injected into the rectum. The doctor likewise directs frictions along the spine with a liniment composed of oil of amber and laudanum, of each a tea spoonful, and olive oil and brandy, of each a table spoonful; and, in severe cases, a large blister to the abdomen:—the distension of the bowels being, at the same time, relieved, by abstracting the accu- mulated gas, by means of a syringe introduced peranum. In the few cases which we have seen of this form of enteralgia, we have succeeded in affording very speedy relief, by the warm -bath, followed by warm fomentations to the abdomen, injections composed of assafoetida, dissolved in milk, and the administraiion of a few drops of aqua camphorata, or of spirits of turpentine, in a spoonful of sweet- ened aniseed water. In severe cases, a few leeches behind each of the ears has been invariably found to produce a decidedly beneficial effect. From the evident tendency to cerebral irritation, in these cases, we have been deterred from the use of opium, and have never seen any advantage to result from the application of a blister or any stimulating embrocation to the abdomen. A cataplasm of hops steep- ed in hot water, or cloths wrung out of warm water, and then sprinkled freely with laudanum, has occasionally been followed with very decided relief. Frictions along the spine, with the oil of amber, as directed above, and the removal of the gas from the bowels by a tube or syringe, introduced into the anus, are unquestionably produc- tive of good effects. In the intervals of the paroxysms, of the enteralgia which ordinarily occurs in infants, we really feel at a loss to say what ought to be done to prevent their recurrence:—the child appears to enjoy perfect health ; the functions of its organs generally are regularly performed ; and in the majority of cases, it is difficult to detect any cause to which the pro- duction of the disease can be referred. There is frequently, how- ever, an habitually inert condition of the bowels ; this we should endeavour to counteract by a proper regulation of the diet of the mother, whicfi should be composed principally of articles of a laxative character ; and the child should be immersed daily in a warm bath, fol- lowed by gentle frictions over the abdomen :—the occasional use of laxative enemata will often counteract the inert state of the child's bowels; a very good one is that composed of milk and molasses, with a slight addition of chloride of soda; or a suppository, formed DISEASES OF THE DIGESTIVE ORGANS. 197 of the common resinous soap, about one inch long and a quarter of an inch thick, shaped round and slightly tapering to a point, may, after being dipped in water, be passed within the anus. The intro- duction of a large sized urethra bougie a few inches up the rectum, will generally cause an evacuation, and is attended with less irrita- tion and inconvenience than either injections or suppositories. In some cases of habitual costiveness, frictions over the abdomen, daily, with soap liniment and compound tincture of aloes,* has been found very beneficial in procuring a regular state of the bowels. a R.—Liniment, sapon. cotnp. gj. Tine. aloe. comp. gss.—M. (Merriman.) We have derived the best effects, as well in counteracting an habi- tually costive habit in infants, as in preventing the recurrence of paroxysms of colic, from the use of a combination of extract of hyos- ciamus, ipecacuanha, and magnesia, in small doses.* a R.—Ext. hyosciami, gr. iv. ad viij. Magnes. calc. gr. xxiv. ad xlviij. Ipecacuanha, gr. ij. ad iij.—M. f. ch. No. xij. One to be given, every three hours. / Castor oil, which is usually given to obviate the costiveness of in- fants and young children, will in most cases be found to increase rather than to remove the inert state of the bowels. Care should be taken to keep the child's feet dry and warm, by proper clothing, and by changing the stockings or socks the moment they become wet, and thoroughly drying the feet before the fire or by gentle friction with a soft cloth, previous to putting others on. Dr. Dewees, viewing the disease as one of a strictly periodical charac- ter, administered in many cases, a decoction of bark, with the happiest effect; in others, however, no benefit resulted from its use. Dr. Eberle, has seen good effects from the prussate of iron, in combina- tion with powdered valerian—in the proportion of half a grain of the first, to three grains of the latter, for a child between two and three months old—repeated every three or four hours, during the intervals of the paroxysms. To prevent the recurrence of the spasmodic form of enteralgia, Dr. Parrish, directs a proper regulation of the diet of the child; attention to the state of the gums, which, if inflamed, are to be freely lanced, and the operation repeated, whenever the incisions heal, so long as the continuance of the inflammation may render it advisea- ble; with blisters behind the ears, kept open by some stimulating dressings; and, if there exists acidity of the stomach and bowels, the frequent administration of some alkaline remedy. Dr. Parrish prefers the alkaline infusion of Physick, diluted to suit the palate of the infant, in doses of a tea spoonful every two or three hours :—we should certainly prefer, in these cases, calcined magnesia, or carbonate of 198 DISEASES OF CHILDREN. soda. The following will be found to be a very excellent prescrip- tion in most instances.* »R—Mucil, G. Acacias, giij. Sacch. Alb. pur. 3iij. Spir. Terebenth, 3j- Magnes. calc. gr. vij.—M. A tea spoonful to be given every three hours. In every case of severe colic occurring in children, the symptoms should be carefully scrutinized, and attentively watched ; inflammation of the bowels being very apt to occur, which, the moment it is detected, should be met by its appropriate remedies. L—Diarrhcea. Notwithstanding that diarrhoea is one of the common symptoms of inflammation of the alimentary canal, it, nevertheless, occurs in a large number of cases, from a degree of irritation of the intestinal mucous membrane, which cannot be considered as amounting to inflamma- tory ; it would seem necessary, therefore, to consider it separately, as its treatment differs in many important particulars, from that proper in the diarrhoea attendent upon enteritis. In infancy, diarrhoea may be caused by improper articles of diet, by excess in feeding, by cold and damp, by the irritation of teething, and by excessive heat, combined with an impure and stagnant state of the atmosphere. The excitable condition of the intestinal canal in infants, renders them particularly liable to the occurrence of diarrhoea from slight causes; it is, consequently, an affection of far more frequent occurrence during the early period of life, than at any subsequent age. It may last for only a few hours, and then cease spontaneously, or the evacuations may occur every few minutes, and continue, with little or no abatement, for a considerable length of time, exhaust- ing the strength of the patient, and producing extreme emaciation, without, in many cases, the occurrence of any inflammatory affec- tion of the intestines ; in general, however, when diarrhoea assumes a protracted form, it will be found to be dependent upon sub-acute inflammation of the intestinal mucous membrane. The discharges from the bowels may be more or less thin, of a dirty white or greyish colour, of a curdled appearance, and of a decid- edly acid colour, or they may be almost entirely fluid, of a bright yellow or greenish hue, and often mixed with blood—these are the gen- eral conditions of the evacuations occurring in early infancy. In older children, they may be thin and feculent, yellow, green or dark brown; or they may consist, at first, of portions of undigested food, very arid, and often, when the diarrhoea has resulted from the use of crude and ascescent vegetables, in a state of fermentation. Occasionally the discharges are very thin and watery, without any decided smell, and nearly colourless; or they may be composed of a fluid mixed with bile, of a yellow or green colour. In many cases, particularly during DISEASES OF THE DIGESTIVE ORGANS. 199 dentition, the stools consist, almost exclusively, of a thick, jelly like, semi-transparent mucus. In the more prolonged forms of diarrhoea, the discharges are, in general, very thin, small in quantity, of a dark colour, and extremely offensive. Diarrhoea in children is usually attended with loss or irregularity of appetite, and often with more or less nausea and vomiting; in many instances, however, the stomach is not in the least degree affected, and the appetite remains unimpaired. Increased thirst commonly attends, and some degree of griping generally precedes and follows each discharge from the bowels. Occasionally there is some degree of flatulence and severe paroxysms of colic. The skin is ordinarily dry, and the countenance pale and languid. The abdomen may be swollen when the diarrhoea is connected with an overloaded condition of the bowels, or, when a development of gas takes place, but it is seldom tense or tender to the touch, nor is its temperature increased. Whenever pain is excited by moderate pressure upon the abdomen, especially when accompanied by tension and increased heat of its surface, the diarrhoea is dependent upon enteritis, and in such cases there is usually more or less heat of the surface; dryness, with a sense of heat or burning of the palms of the hands, and other symptoms of febrile excitement, with evident exacerbations towards evening. When the diarrhoea is pro- longed, or assumes a chronic form, the skin becomes dry, harsh and discoloured; great emaciation ensues; the countenance becomes wrinkled, of a dirty yellow or brownish hue, and assumes the appear- ance of premature old age. The discharges from the bowels are frequent, but small in quantity; occasionally they are suspended for a day or two ; they vary in colour and appearance, but are generally very thin and dark coloured, and are often intolerably fcetid. Simple diarrhoea is not often a very troublesome or unmanageable complaint; with the removal of the cause by which it has been pro- duced, it will, in many cases, cease spontaneously, or, may be readily controlled by appropriate remedies. When, however, from any cause it is prolonged, it may produce so great a degree of exhaustion, and so far disturb the nutrition of the system, as to render a permanent cure difficult, and, sooner or later, to cause the death of the patient; or, at an earlier period, an acute or chronic inflammation, or extensive disorganization of the mucous membrane of the intestines may occur, and a fatal termination rapidly ensue. Death seldom occurs in cases of simple diarrhoea; and, conse- quently, very few examinations have been made of the pathological condition of the intestines :—in the more prolonged cases, the intestinal mucous membrane, has often presented no marks of disease, with the exception, perhaps, of unusual paleness, and, occasionally, of softening to a greater or less extent. The parieties of the intestines, have, in a few instances, been found of unusual thinness, almost transparent, and easily torn. A contracted state of the tube at different parts, and its distention at others with gas, is a common occurrence. In children 200 DISEASES OF CHILDREN. who die whilst labouring under serous or mucous diarrhoea, unat- tended with symptoms of inflammation, the follicles of the intestines will be found greatly developed, studding the surface of the intestines with small, white projections, or occurring in distinct clusters, or plexes. In most cases of chronic diarrhoea, the mucous membrane is thickened, often softened or ulcerated, and, occasionally, presents large patches of a livid or slate colour; the mucous glands are gene- rally found enlarged, inflamed, or ulcerated, or of a dark, nearly black colour. The mesenteric glands, are often inflamed, enlarged, or indurated. The gall bladder sometimes contains greenish bile, and the liver is occasionally more vascular than natural. (Hrunner, Stark, Bang, Andral, Copland.) The most usual seat of the lesions in chronic diarrhoea, are the ilium, especially its lowest third, and the coecum. The most common form of diarrhoea in infants and young children, is that resulting from overfeeding, from the bad quality of the mother's or nurse's milk, or from some change produced in it by accidental causes, or from improper articles of food. The foundation of diarrhoea is often laid during the first twenty- four hours after birth, by the reprehensible, but too common prac- tice, of gorging the infant's stomach with alimentary fluids, often of the worst kind, previous to the secretion of its natural and congenial nourishment. Nurses are always fearful of the infant suffering from the want of nourishment, previous to the appear- ance of the mother's milk, and, very generally, introduce into its stomach a quantity of food, which cannot fail to produce a degree of irritation, often resulting in an obstinate diarrhoea of some continuance. Ordinarily no kind of nourishment is requisite, until the child can be applied to the breast. Should the secretion of milk, however, not take place for one or two days, as is occa- sionally the case, a little new milk, with the addition of about one- third warm water,.and sweetened with loaf sugar, maybe given, and repeated, if necessary. Infants who are partly nourished by artificial food, as well as those brought up by the hand, are particularly liable to attacks of diarrhoea, often of a very obstinate character. In these cases, the irritation of the alimentary canal is frequently produced, less by the improper character of the food employed, than by the stomach of ihe infant being habitually overloaded, when it is given to it in too great quan- tity, or at too short, intervals. The quality of the mother's milk is often the cause of diarrhoea ; under the same circumstances as the breast milk produces indiges- tion in the child that partakes of it, will it be liable, also, to cause an attack of diarrhoea. Mr. E. Wilkinson has observed diarrhoea to be produced in infants that are suckled during the period of menstruation ; the stools were of a dirty white colour, appearing to consist of a small .portion of excrementitious matter dissolved in a large proportion of serous fluid, and of an excessive, almost intolerable fceter, not dissimilar, Mr. Wil- DISEASES OF THE DIGESTIVE ORGANS. 201 kinson thinks, to that of the menstrual secretion. We have observed nothing similar to this ; the statement of Mr. W. requires further observations to confirm its accuracy. There is a curious circumstance in relation to the effects of parti- cular articles of food, upon the stomach and bowels of infants and young children, which should be kept constantly in mind in directing their diet, in every case in which it becomes necessary to allow other food, than the breast milk. It is that some infants are invariably purged by particular kinds of food, which agree perfectly well with others. Arrow root, so generally recommended as an appropriate article of diet for infants, particularly when labouring under bowel complaints, we have so often found to produce purging, that we have almost entirely ceased from directing it. The diarrhoea which results, in infants, from improper or too much food, is generally attended with vomiting, the generation of an undue amount of acid in the stomach and intestines, colicky pains, paleness of the face, and general relaxation of the muscles. The discharges are thin, curdled, of a bright yellow or greenish colour, and often decidedly acid. The disorder of the bowels, gene- rally ceases spontaneously in a short time, if the cause by which it has been produced is at once removed ; but, if this be continued, the discharges become more frequent, thin, and watery, often intensely green, the functions of the alimentary canal are imperfectly performed, or entirely suspended; the food and drinks taken, pass through the bowels unchanged; great emaciation is produced, and the infant dies, sooner or later, from extreme exhaustion; or an acute, or sub-acute inflammation of the mucous membrane of the intestines is developed, by which the child is more or less promptly destroyed. The blood which is often mixed with the discharges, in the diarrhoea of young infants, sometimes in considerable quantity, is the result of a true haemorrhagic effusion, caused by the state of hyperaemia of the intestinal mucous membrane, that is commonly observed for a short period after birth. Improper articles of food, or excess in eating, is among the most common causes of diarrhoea, subsequent to the period of weaning. Unless the utmost attention is paid to the proper regula- tion of the infant's diet, for some time after it is taken from the breast, more or less disorder of the bowels invariably results; often an excessive diarrhoea occurs, the discharges being at first faeculent, or faeces mixed with imperfectly digested food, but speedily becoming composed of a serous fluid, of a dirty yellow, or greenish yellow. In- testinal inflammation is early developed, or the diarrhoea assumes a chronic and peculiarly unmanageable form. It is this diarrhoea which is described by Cheyne as a new and peculiar form of diseaes, under the name of " atrophia ablactatorumP In older children, diarrhoea is generally produced by similar errors in diet. The appetite at this age is keen and very liable to lead to excess in eating, and especially to an indulgence in rich food, 202 DISEASES OF CHILDREN. pastry, fruits and confectionary, the inordinate quantities of which devoured by children who are uncontrolled in their diet by those who have the care of them, often produce the most deleterious effects. An occasional excess, may excite no further inconvenience than nausea, vomiting, and a pretty profuse diarrhoea, ceasing spontaneously soon after the offending substances are expelled. But when ex- cess in eating, or improper food is habitually indulged in, a much more serious disorder of the alimentary canal ensues; the diarrhoea then often becomes profuse, and, if not promptly and judiciously treated, inflammation of the bowels is liable to be produced, running, generally, into a chronic form, and producing death from marasmus; or, by exciting disease of the brain, that terminates, most generally, in serous effusion. The application of cold to the surface of the body, and especially exposure to a cold and damp atmosphere, or a sudden transition from a close and heated, to a chilly and humid atmosphere, will, in many cases, give rise, in children, to a more or less profuse diarrhoea, with mucous or thin watery discharges. These cases are often attended with some degree of febrile excitement, and tender- ness and heat of the abdomen, indicating the existence of intes- tinal inflammation. Slight catarrhal symptoms are frequently pre- sent, and, in some cases, the latter precede the diarrhoea; hence the common observation of nurses, that " the cold is working itself off by the bowels." This form of diarrhoea, if its true character is over- looked, and it is, in consequence, improperly treated in its commence- ment, is very liable to become a serious disease, giving rise to exten- sive disorganization of the intestines, or early involving the brain. Some degree of diarrhoea is usually attendant upon the process of dentition; when moderate, its effects are salutary ; but, when exces- sive, or of long continuance, particularly if the infant becomes exhausted, or considerable febrile excitement, with tension, heat and pain of the abdomen occurs, it should not be allowed to go on, but should be promptly arrested by an appropriate course of treatment. In the diarrhoea which occurs during dentition, the discharges are, occasion- ally, fcecal, of a bright yellow, or green colour, and more or less acid, but more commonly, they consist of thin mucus, often mixed with a portion of faeces or bile. It has been very correctly remarked by Billard, that the frequency of these thin mucous discharges about the period of dentition, is in consequence of the rapid development, and increased activity, of the muciparous follicles of the intestines, which takes place about the same time. The degree of irritation communicated to the digestive mucous membrane during the normal development of the teeth, is sufficient, with the existing condition of the muciparous follicles, to cause an undue amount of fluid to be poured into the intestines, which is still further augmented, if the cutting of the teeth be tedious, or attended with difficulty. Although this morbid development, and DISEASES OF THE DIGESTIVE ORGANS. 203 activity of the muciparous follicles, is not an inflammatory action, it is, nevertheless, one bordering closely upon it, and hence the propriety of always keeping children affected with mucous diarrhoea at the period of dentition, upon a strict regimen, and closely watching, lest inflammation suddenly occur. We have repeatedly seen cases of mucous diarrhoea, occasionally of a very severe and protracted character, ensue, upon the sudden disappearance of cutaneous eruptions, or the drying up of the discharge from ulceration behind the ears. These cases appeared to be, in the majority of instances, accompanied with some degree of inflammation of the intestinal mucous membrane. Mucous discharges are often accompanied with the presence of intestinal worms. Atmospheric heat, particularly when combined with the influence of a confined and impure atmosphere, is a common cause of diarrhoea. During the summer months, in our large cities, few children escape a slight attack ; and among the children of those who inhabit the confined houses, situated in narrow, ill ventilated courts, lanes and alleys, the disease prevails in a form of uncommon severity. It is of less frequent occurrence in high, elevated, and healthy situations in the country, but occasionally prevails to a considerable extent, in low, marshy, or, what are usually termed miasmatic districts. The discharges are, at first, faeculent, but soon become almost exclusively composed of a thin mucus, mixed with bile, of a bright yellow, or green colour; they are extremely copious, and are generally attended with nausea, often'with bilious vomiting, and more or less griping. This latter symptom is, however, absent in a large number of cases; the discharges taking place as it were involuntarily. In slight cases, occurring in children properly nursed, and resident in comparatively healthy localities, the disease often Ceases, in a short time, spontaneously. In those who are exposed to the constant influence of a heated and confined atmosphere, the diarrhoea will continue, with occasional temporary cessations, for many days; the urine becoming tinged with bile, and the skin and whites of the eyes of a yellowish hue; or the discharges from the bowels are often attended with a sense of heat or scalding, and it is not uncommon for an excoriation of the anus to take place. The symptoms of cholera infantum may quickly develope themselves, or, after a few days, and sometimes earlier, the bilious discharges may cease, and fre- quent copious evacuations occur, of a serous fluid, at first of a yellowish or greenish colour, but, subsequently, almost colourless ; at the same time, not unfrequently, the abdomen becomes tense, hot, and painful upon pressure; the skin dry and harsh ; the tongue red at the tip and edges, and covered on its surface with a dirty white or yellowish mucus; great thirst is experienced, and, whatever fluid is taken, is instantly expelled, and often with great violence ; apthas often appear upon the parieties of the mouth, and rapid emaciation ensues. The brain is, in some cases, early affected, and the patient expires, with all the symptoms of hydrocephalus ; in other cases, the 204 DISEASES OF CHILDREN. diarrhoea assumes a chronic form, and the child, after becoming reduced, literally to " skin and bones," and to a state of extreme exhaustion, expires apparently from inanition. The bilious diarrhoea of hot seasons, in its simplest form, ap- pears to be produced by an excessive secretion of bile, the result of the excessive stimulation of the skin by atmospheric heat, but in the more violent cases, the presence of acute inflammation of the mucous membrane of the stomach, and upper portion of the intestinal tube, or of the lower portion of the small intestines, is indicated as well by the symptoms during life, as by the pathological changes detected after death. We have frequently detected in our autopsies, increased redness of the stomach and duodenum, occurring in points grouped together, in large patches, or irregularly diffused, and presenting a kind of elevation from the thickening of the mucous membrane, or in irre- gular striae. Follicular inflammation was occasionally detected in the stomach, but more frequently in the ilium. Distinct ulcerations and softening of the mucous membrane, were of common occurrence. In repeated instances, the follicles of the intestines were considerably enlarged, without appearing to be inflammed. Contractions of different parts of the intestinal tube, were frequently observed, and, in few instances, numerous invaginations. The small intestines were generally empty, while the mucous coat of the large intestines, was frequently coated with a thick tenaceous mucus, and often contained a frothy mucus, of a greyish or yellowish colour. The liver was usually in a state of hyperaemia, and the gall bladder, contained more or less thin and very light yellow or greenish bile. The marks of inflammation were, however, in a number of instances, particularly when the disease had assumed a somewhat protracted or chronic form, by no means of so decided a character; and, in a few cases, the only indications of disease, were unusual paleness of the mucous membrane, with enlargement of the muciparous follicles. The discharges, in some cases of diarrhoea, are of a very white, opaque appearance, having some resemblance to a mixture of chalk and water. This constitutes the chylous diarrhoea of many authors; chyle, however, never being present in the intestines, could scarcely be expelled by stool, especially in quantities sufficient to account for the copious, white, milk-like evacuations we often observe to take place; neither do the physical appearances of the discharges bear any resemblance to those of chyle. It has appeared to us to be merely a variety of the mucous diarrhoea of infants, the peculiar con- dition of the stools arising, probably, from some morbid change in the intestinal secretions. Some have supposed it to depend upon irrita- tion, with altered secretion of the pancreatic gland. We have had no opportunity of observing the condition of the alimentary canal and other abdominal organs in ihis form of diarrhoea, never having met with it in any case that terminated fatally ; it is one, indeed, judging from our own experience, of very unfrequent occurrence in this country. From the preceding description of the several species of diarrhoea DISEASES OF THE DIGESTIVE ORGANS. 205 occurring in infants, it will be perceived how intimately all of them are connected with intestinal inflammation of an acute, sub-acute, or chron- ic character ; it is true, as already remarked, that, in its commencement, diarrhoea may be the result simply of an increased peristaltic action of the intestines, with augmented secretion from the mucous membrane, and from the liver, without the slightest indication of inflammatory action ; it may even continue for a long period, and produce the death of the patient by suspending the assimilative and nutritive functions, and still no indications of inflammation be present throughout the attack ; but it must be still kept steadily in mind, that not unfrequently the diarrhoea may be dependent upon inflammation of the intestines, from its very commencement, and that there is a tendency to the devel- opment of inflammation of a more or less acute form, in every case unless the cause of the diarrhoea be early removed, and it be, in this manner promptly suspended ; under whatever circumstance, therefore, diarrhoea occurs, a close scrutiny into, and careful analysis of all the accompanying symptoms, should be made, and if the case be a pro- tracted or obstinate one, the state of the abdomen as to tension, heat, and tenderness upon pressure, should be cautiously examined ;— an*d if intestinal inflammation be detected, its removal by a judicious course of treatment, is essential to the cure of the diarrhoea, and to secure the safety of the patient. In the treatment of every form of diarrhoea, the first and most important indication is, to remove the cause by which it has been produced. In that caused by improper food, or excessive feeding, the aliment should be at once improved in quality, or reduced in quantity. If the mother's milk be in fault, that of a healthy nurse should be substituted ; or, if this be impracticable, the child may be nourished upon diluted milk, with the addition of the best loaf sugar, by means of the sucking-bottle. If the child be fed by the hand, provided the breast of the mother does not afford a sufficient supply of nourishment, the additional aliment should be the same as directed above ; taking care that the child be not allowed to overload its sto- mach, by taking too much at a time, or being fed with it at too short intervals. When diarrhoea occurs at the period of weaning, the utmost attention should be paid to the food of the patient, agreeably to the directions given in our chapter on the diet of infants; care being taken at the same time, to observe the effects of any particular article of diet, which, though in itself perfectly wholesome, may, from some peculiar idiosyn- crasy in the child, disagree with its stomach, and cause more or less purging ; whenever this is found to be the case, its use should at once be relinquished, and another kind of food substituted. We have known infants in whom, immediately after weaning, the bowels were dis- ordered by all the ordinary farinaceous preparations, and by milk, but with whom meat broths, with the addition of rice or crackers, agreed perfectly well. In older children it will be proper, upon the occurrence of diarrhoea, 206 DISEASES OF CHILDREN. to suspend every species of solid nourishment, and confine them entirely, for a short period, to moderate quantities of some preparation of rice with milk ; to water gruel, or to crackers and milk. Fruits of every kind—pastry, confectionary, sweetmeats—and every species of fresh vegetables, should be entirely prohibited. For drink, cold water, or cold toast, rice, or gum water, may be given in small quantities at a time. The proper regulation of the diet, with the use of the warm or tepid bath daily, and gentle exercise in the open air, will, in a large number of cases, be all that is necessary for the cure of this form of diarrhoea ; and without such regulation of diet is carried strictly into effect,—and in so doing, the physician will find himself constantly opposed by the prejudices and inattention of parents and nurses,—it is in vain to attempt its removal by the administration of medicine. The exhibition of two or three doses of some mild but active purgative, is commonly directed to remove any irritating matters that may be retained in the alimentary canal, and by some writers it is even advised that an emetic should be administered for the same object. (Underwood, Burns, Dewees, Eberle, Marley, Evanson.) We believe that in very few instances, diarrhoea will be found to be kept up by the retention of irritating substances in the intestines; it is" very certain, that in the majority of cases, the use of active purga- tives is not only unnecessary, but positively injurious, by increasingand prolonging the irritation by which the disordered action of the bowels is produced. If the diarrhoea is not quickly suspended by a proper regulation of the infant's diet, and the use of the warm bath—particu- larly if the stools are attended with griping—we have found a dose or two of a combination of calomel, prepared chalk, ipecacuanha, and extract of hyosciamus, to be attended with the best effects.* » R.—Calomel, gr. ij. ad vj. Cretas, ppt. gr. xviij. Ipecacuanhas pulv. gr. ij. Extract. Hyosciami, gr. iij. ad vj.—M. f. chart. No. vj. One to be repeated every two, three, or four hours, according to circumstances. Under the use of this combination, we have generally found that the stools become less frequent, more natural, and of greater consistency; the digestion improved, and the irritability of the intestines dimin- ished. It sometimes happens in cases of simple diarrhoea from errors in diet, that a large amount of acid is generated in the stomach, which appears to keep up the discharges from the bowels; when this occurs, a few grains of carbonate of soda in solution ; a teaspoonful or two according to the age of the child, of the aqua calcis, combined with an equal portion of new milk, or a few grains of prepared chalk, com- bined with a quarter to a third of a grain of ipecacuanha, and the half of a grain to a grain of extract of hyosciamus, may be given twice or thrice a-day; with some light astringent every three hours. DISEASES OF THE DIGESTIVE ORGANS. 207 The tincture of kino, or catechu, or either of these substances in pow- der, or the compound infusion of catechu,* may be given. »R.—Catechu, pulv. 3ij. Cinnamon, contus. 3s3, Aq. bullient. gv. Macerate for an hour in a closely covered vessel, and strain. Dose.—A teaspoonful every two three or four hours, according to the age of the patient, or the nature of the case. With many American physicians, we prefer, as an astringent, in cases of simple diarrhoea, a decoction of the root of the geranium macu- latum,orof the blackberry, (rubus villosus,) especially the former, which, when the decoction is made with milk, is a very excellent and agree- able astringent, well adapted to relieve the irritable state of the bowels, by which in many cases of ordinary diarrhoea, the disease is liable to be kept up after the original cause has been removed. The opiates generally recommended in this form of diarrhoea, are seldom, if ever, required; if in consequence of the sleep being dis- turbed by frequent evacuations occurring during the night-time, an opiate is indicated, an injection composed of thin starch and a few drops of laudanum, or a small portion of opium, combined with ipecac- uanha, and carbonate of sodae,* may be given in the evening. But it is better, if possible, to dispense altogether with the use of opiates in every form. aR.—Opii pulv. gr. j. Ipecac, pulv. gr. iij. ad iv. Carb. Sodas, 9j.—M. f. ch. No. xij. For a chi'd over one year of age, the proportion of opium may be somewhat increased. The treatment of mild cases of mucous or serous diarrhoea, will consist, principally, in the substitution of mild mucilaginous fluids, as rice water, gum water, or an infusion of slippery elm bark, for the ordinary food and drink of the patient: in the use of the warm bath morning and evening, and the exhibition of a combination of ipecac- uanha and calomel, every two or three hours ;a and as soon as the discharges have become less frequent, and of a natural appearance, the administration of some light astringent, as directed above. It is all important, that every species of solid food be abstained from, in cases in which the diarrhoea is attended with thin mucous or serous dis- charges; even the mother's milk will, sometimes, be found to irri- tate the bowels, and increase the disease. Hence it is better to confine the patient always to simple mucilaginous fluids. As the disease arises in most cases from the effects of cold and dampness, the warm bath will be found an admirable remedy, particularly if followed by gentle frictions over the abdomen and surface of the body generally. The common practice of administering frequent doses of castor oil in mucous diarrhoea, is one calculated to increase the irritation of the intestines, and in this manner render the disease more protracted and difficult to manage. »R.—Calomel, gr. j. ad ij. Ipecacuanhas, gr. ij. ad iij. Sacch. alb. 9ij.—M. f. ch. No. xij. One to be given every two or three hours, according to the age of the child. 208 DISEASES OF CHILDREN. When the discharges from the bowels are v».ry profuse, and con- sist, principally, of a thin, often nearly colourless, serous fluid, the use of small doses of calomel, ipecacuanha, acetate of lead, and extract of hyosciamus, will be found promptly to arrest them.* Ample experi- ence has taught us, that the acetate of lead may be given with the most perfect safety to children ; in the combination just stated, we know of no more effectual means of arresting the profuse serous dis- charges which often occur in the diarrhoea of infancy, which, if allowed to continue, produce, in a very short time, a degree of exhaustion, that is, not unfrequently, fatal. aR.—Calomel, gr. j. ad ij. Ipecacuanhas, gr. ij.ad iij. Acetat. plumbi, gr. vj. ad xij. Ext. Hyosciami, gr. iv. ad viij.—M. f. ch. No. xij. One to be given every two or three hours. The proportion of the several ingredients and the frequency of repetition being regulated by the age of the patient. In every case of mucous diarrhoea, the liability to the development of intestinal inflammation should be kept constantly in mind; and the moment that tension, heat, and tenderness of the abdomen are detected, or distinct febrile excitement occurs, it will be proper to apply leeches to the abdomen, in numbers proportioned to the age of the patient, and the urgency of the symptoms; followed by warm fomentations, or an emollient cataplasm. As soon as the in- flammatory action is subdued, if the discharges from the bow:els still continue to be frequent, and of a serous character, the com- bination of acetate of lead, directed above, may be advantageously administered. In some cases, mucous diarrhoea assumes a kind of chronic form, the discharges being frequent, small in quantity, and attended with a good deal of straining. They consist, chiefly, of a transparent, occa- sionally, jelly-like mucus, sometimes perfectly white, at others, of a dirty yellow, greyish, or green colour. The bowels are occasionally distended with gas, but the abdomen is seldom painful to the touch, or exhibits any increase of temperature. There is, generally, great emaciation, and sometimes, diminished temperature of the surface of the body, or of the extremities. In these cases, we have found the calomel and ipecacuanha, as directed above, to produce an excellent effect; mucilaginous injections, with a suitable addition of opium, or the combination of opium, ipecacuanha, and soda, noticed under the head of simple diarrhoea, will be required, to relieve the straining, frequently attendant upon the discharges. Dr. Eberle recommends in this chronic form of the disease, from five to ten drops of balsam copaiba, in the form of emulsion, with the addition of a few drops of tincture of opium, or given in conjunction with minute portions of Dover's powder ; we have likewise administered the copaiba in many DISEASES OF THE DIGESTIVE ORGANS. 209 cases, and have often witnessed the best effects from its use. The form in which we have generally given it is as follows :* •R.—Bals. Copaibas, 3j. Magnes. calc. gr. x. Spir. asther. nitr. 3<'j- Sacch. alb. 3iij. Aq. cinnamon, giij.—M. Dose.—One tcaspoonful every two or three hours : each dose to be followed in the course of an hour by the fourth of a grain of Dover's powder. The frequent repetition of the warm bath will be found advanta- geous in these cases:—the abdomen should be kept covered constantly with a broad flannel roller:—blisters to the abdomen have been recom- mended ; we have seldom, however, seen much advantage from their use. The diet in this chronic form of the disease, should consist chiefly, of very thin preparations of rice flour or tapioca, with milk and a small quantity of loaf sugar; in some instances, these will be found to disagree with the patient, when probably, simple chicken water, with or without rice, may be advantageously substituted. When mucous diarrhoea proceeds from the sudden disappearance of cutaneous eruptions, or from the drying up of discharges from behind the ears, the treatment is the same as directed above ; we have never seen any good effects from attempts to renew by stimulating applications, the irritation of the skin, or the ulceration behind the ears. When diarrhoea occurs during the process of dentition, it is, occa- sionally, merely faecal, but more frequently mucous, or serous; when moderate, and occurring in children of a robust and plethoric habit, a careful regulation of the diet—which should be restricted to prepa- rations of the farinacea with milk—cool mucilaginous drinks, the warm bath, and attention to the gums—the protrusion of the teeth, if tardy, particularly if the gum covering them is hard, tense, and swollen, being promoted by incisions—are the only means required. No attempt should be made to arrest the discharges, so long as they continue moderate in quantity, and unattended by any unusual symp- tom. When, however, the discharges are profuse, emaciation ensues, or symptoms of intestinal inflammation present themselves, the diarrhoea demands immediate attention ; it should then be treated in the same manner as though it had occurred independently of denti- tion. The mucous diarrhoea so frequent in cases of intestinal worms, has generally been ascribed to the irritation produced by the piesence of the latter. How far this opinion is correct it is somewhat diffi- cult to determine. Of the existence of worms in the intestines, we have no positive evidence, excepting that derived from their appear- ance in the discharges. A superabundance of viscid mucus in the bowels, and its copious discharge by stool, being generally enumer- ated as leading indications of their presence, the latter is often inferred, merely from the fact, that a child is affected with mucous 14 210 DISEASES OF CHILDREN. diarrhoea, particularly in its chronic form:—we have, it is true, in numerous instances where worms have been discharged in great num- bers from the intestines, observed the children to labour under a species of diarrhoea, attended with stools rather more frequent than usual, and composed entirely of a mass of thick, tenacious, diapha- nous mucus, which appeared to come away at once, without strain- ing, or any unusual effort. These discharges frequently alternate with regular, healthy stools, or those composed, in a great measure, of natural faeces. They are always unattended with febrile ex- citement, or the slightest indication of inflammation. The children are generally pale, of a lymphatic temperament, with capricious appetites, and tumid, but soft abdomens. Their breath has, gener- ally, a sickly, diagreeable odour. Their tongue is coated with a thin layer of slimy mucus. Their urinary discharge is copious, and light coloured; and in many cases, more or less oedema of the feet, and about the eye-lids occurs. We have generally succeeded in restoring the natural condition of the stools, and removing the principal symptoms of the disease, by the administration of turpentine in emulsion, followed by light astringents, the use of the warm bath daily, and a careful regulation of the diet and regimen. R. Mucil. G. acacias. 3'iij. Sacch. alb. pur. 3vj- Spir. asther. nitr. 3iij. Spir. terebenlh. 3'j- Magnes. calc. gr. xiij. Lavend. spir. comp. 3'j-—M. Dose, a tea spoonful repeated three times a day, or oflener, when the child is over two years of age. When ordinary mucous diarrhoea occurs in a child suspected to have worms, and especially when it assumes an acute form, it should be treated by the means proper in that form of the disease, without refer- ence to the presence of worms in the intestines :—the remedies usu- ally employed for the destruction and expulsion of the latter would be calculated to increase the diarrhoea, or even to induce severe inflam- mation of the intestinal mucous membrane. In the treatment of bilious diarrhoea, the first indication is to remove the cause by which the morbid secretion of bile has been produced. As this is usually intense heat, with a stagnant and im- pure state of the atmosphere, the prompt removal of the child to a cooler, more free, and cooler atmosphere is essential to ensure its re- covery ; when such a removal cannot be effected, domestic cleanli- ness and free ventilation should be enforced, as well as the free expo- sure of the child, in dry weather, to the external air, in the most healthy and open situations, in its immediate neighbourhood ; it being either carried out in the arms, in an open hand carriage, or by riding in any open vehicle, or sailing in an open boat, properly shaded from the sun, or in one of the steamboats, which, in most of our large cities, make repeated short trips, in the course of the day. DISEASES OF THE DIGESTIVE ORGANS. 211 The diet and drinks of the patient should consist exclusively of gum water, rice water, or infusion of slippery elm bark—taken cold, and in small quantities at a time, but at short intervals. It should be im- mersed daily in a tepid or warm bath, according as the temperature of its surface is augmented or depressed, and its clothing should be light and loose, and adapted, in the materials of which it is composed, so as not unduly to augment the heat of the body, but to guard it from the effects of sudden transitions of temperature. This treatment will be sufficient, in a large number of cases, in which the disease consists simply in an undue secretion of bile, to arrest the diarrhoea, and restore the discharges to their natural condi- tion. If, however, these still continue with little or no abatement, and neither fever nor intestinal inflammation exists, small doses of calomel, calcined magnesia, ipecacuanha, and extract of hyoscia- mus, will generally produce the desired effect.* Under the use of this combination, the discharges will generally assume, in a short time, a faecal character, and be diminished in quantity. If there exists irritability of stomach or vomiting, the calomel should be given alone. » R.—Calomel, gr. ij. ad iij. Magnesias calc. gr. xxiv. ad xxxvj. Ipecacuanha, gr. ij. ad iij. Ext. hyosciami, gr. iv. ad viij.—M. f. ch. No. xij. One to be given every two or three hours. Purgatives, opiates, and astringents are seldom proper—never, unless the disease assumes a chronic form, unattended with inflamma- tion. When the discharges lose their bilious character, and become thin and serous, if no tension, pain, or heat of the abdomen, is observed, the acetate of lead, in the formula directed when speaking of the treat- ment of mucous diarrhoea, is the remedy which we have found the most frequently to succeed in arresting the disease. When the dis- charges are profuse, and the patient becomes rapidly exhausted, a small portion of opium may be substituted for the extract of hyoscia- mus ; and a solution of the acetate of lead, with the addition of lauda- num, adapted to the age and condition of the patient, may be thrown into the rectum. As soon as the profuse, serous discharges are sus- pended, the calomel in small doses, combined with ipecacuanha and extract'of hyosciamus, will, in general, complete the cure ; or, if after the discharges assume a more natural appearance, they still continue thin and frequent, some of the astringents already mentioned, as the catechu, the geranium maculatum, or kino, will be proper, with a dose of the Dover's powder at night. This form of diarrhoea occasionally assumes a chronic character, when the treatment will be the same, as in the chronic stage of cholera infantum. In many cases, it is probable that the following prescrip- tion will be found advantageous:—it is recommended, by Evanson, as 212 DISEASES OF CHILDREN. one of the most useful compounds in protracted cases of diarrhoea.'1 We have ourselves never employed it, but have seen good effects result from the administration, in these cases, of nitrous acid, in combination with aqua camphorata and opium, or with hyoscia- mus.b 1 R.—Infusi samaroubas, JJjss. Acidi nilrici dil. 1T[ ij. ad iv. Syrupi caryophyl. 3'v- Tine, opii, 1T{_ vj.—M. One or two teaspoonfuls, in a little barley water, to be repeated, three or four times a day. i> R.—Acid, nitros. TTL viij. ad xv. Or, R.—Acid, nilros. TTj_ x. ad xv. Aquas camphor, gj. Sacch. alb. 3iij. Tine, opii, TT[ vj.—M. Ext. hyosciami, gr. xvj. A tea spoonful, every three hours. Aq. cinnamon, gj.—M. Dose, the same. As we have already remarked, in a large number of cases, bilious diarrhoea is accompanied with evident symptoms of intestinal inflam- mation. In this form of the decease, the safety of the patient, as well as the cure of the diarrhoea, will depend upon a correct diagnosis being early made, and the appropriate remedies for the control of the inflammation promptly resorted to—plain mucilaginous drinks— leeches to the epigastrium, followed by warm fomentations, or an emollient cataplasm, and warm sinapised pediluvia. When extreme irritability of the stomach or vomiting is present, we are in the habit of administering minute doses of calomel; placing them upon the tongue in a dry form, if they are quickly ejected from the stomach, when given in the usual manner; from an eighth to a sixth of a grain may be given, every half hour or every hour, according to circumstances; we have seldom been disappointed in quieting the stomach by this means, in a few hours. After the inflammatory symptoms are subdued, the case may be treated as an ordinary attack of bilious diarrhoea; a careful watch being, however, kept upon the symptoms, lest intestinal inflammation be renewed ; should this happen, the propriety of a re- application of leeches will depend upon the strength of the patient, and the violence of the symptoms. It is probable that, in most cases, a blister over the abdomen will be sufficient to remove the inflamma- tion, without again resorting to leeches; even when the latter are con- sidered necessary and proper, they should be followed, in a short time, by a blister, left on only so long as to produce decided redness of the skin, the part to which it has been applied, being then covered with a common bread and milk poultice. During the continuance of the diarrhoea, the utmost attention should be paid to the diet and regimen of the patient; the slightest error or neglect, in this respect, being always attended with very serious consequences. By many physicians, the exhibition of opiates has been strongly advocated, in the inflammatory form of bilious diarrhoea; we have occasionally resorted to them, but have never been pleased with their effects; in some instances they were decidedly injurious. After the DISEASES OF THE DIGESTIVE ORGANS. 213 inflammatory action has been somewhat reduced by leeching, a combi- nation of calomel, extract of hyosciamus, and ipecacuanha, in small doses, from a fourth to a half a grain of the first two, and from a sixth to a third of a grain of the last, repeated every three hours, will be found, in many cases, to produce a very favourable change in the symptoms of the disease. It is not very easy to lay down the proper treatment of chronic diarrhoea, without a reference to the condition of the mucous mem- brane of the alimentary canal, the state of the liver, and of the other organs that may become involved in disease, in different cases. In many cases of prolonged diarrhoea, no other morbid condition of the intes- tines would appear to be present than an undue irritability of their mucous membrane, with increased exhalation from its follicles; here the cure of the disease is readily effected by a judicious course of astringent remedies, in conjunction with a well regulated diet and regimen:—but much more frequently, the diarrhoea is kept up by chronic inflammation of the alimentary canal, and a diseased condition of the liver, with a vitiated state of the bile as well as of the other secre- tions poured into the intestines. The management of these cases is attended with great difficulty, and the best directed plan of treatment is very frequently unsuccessful. The discharges in chronic diarrhoea may be composed of a thick, tenacious, jelly-like mucous of a dark green, chocolate or black colour, or of a thick, tenacious matter, resembling tar. In other cases, they have the appearance of light clay or thin mortar; while in others they are composed of a thin fluid of a dirty green, reddish brown, or yellowish colour, and in some instances, they consist of the food or drinks taken which pass immediately through the bowels without hav- ing undergone the least change. The stools have often a peculiar rancid odour, but are generally more or less foetid. The discharges are not generally large in quantity, and vary very much, in regard to frequency—a number often taking place in quick succession, and then a considerable interval occurring before they again occur; more or less griping ma)' proceed and accompany the discharges, though, in many cases, the patient appears to suffer no pain. The abdomen is generally swollen, particularly in cases of long continuance, and when enlargement of the mesenteric glands occurs:—occasionally extreme tympanitic distension takes place at an early period. There is always great emaciation, with dryness and harshness of the sur- face—discolouration of the skin, which acquires, in severe cases, a dark brown hue ; the features are shrivelled, and the countenance assumes the wrinkled, haggard look of premature old age. The patient, finally, sinks from extreme exhaustion—from perforation of the intestines, the result of softening or inflammation,—or the brain may become affected, and effusion within its cavities take place, sooner or later. Chronic diarrhoea is generally the result of neglect or mismanage- ment of the ordinary forms of the disease, or it may be produced by a 214 DISEASES OF CHILDREN. continuance of the causes by which the diarrhoea was originally pro- duced, or by its repeated recurrence, in the same child, within a short period of time. In the great majority of cases, it may be referred to a neglect of dietetic management, or to a recurrence to the use of improper food, immediately after recovery from an attack of ordin- ary diarrhoea. For a long time, after the bowels have resumed their natural action, strict attention to the diet of the child is essential to pre- vent a relapse ; even indulgence in articles which, under other circum- stances, would be considered perfectly wholesome and appropriate, will not unfrequently produce a return of the diarrhoea, and each re- turn of the disease will be found to be more unmanageable than the preceding, and more liable to assume a chronic form. In the treatment of chronic diarrhoea, the child should be con- fined entirely to some plain, farinaceous article of food, with or with- out milk, according as the latter is found to affect the stomach and bowels. Rice, or rice flour, with milk, we have found, in most cases, to agree best with children labouring under the chronic form of the disease—though occasionally even this will aggravate it; beef tea or plain chicken water may, then, be tried, or a mixture of fresh cow's milk, with a further addition of cream. In some instances, we have found that no diet could be taken by the patient, without increasing the disorder of the bowels, excepting gum water, fresh rennet whey, or infusion of the slippery elm bark. For drink, gum, rice, or toast water, taken cold, should be the only fluids allowed. In all cases of chronic diarrhoea, the warm bath forms an important remedy; it may be repeated daily, and in many cases, morning and evening, with decided advantage. In those cases in which the discharges indicate a disordered state of the biliary secretion, small doses of calomel should be administer- ed twice or thrice a day, or oftener, according to the circumstances of the case, and the effects produced by the remedy. Some are in the habit of administering the calomel by itself, (Clarke, Cheyne, Underwood, Marley,) while others combine it with prepared chalk and opium, (Dewees,) or with opium alone, (Eber.'e, Seele, Jiiger.) We prefer its administration, in combination with prepared chalk, ipe- cacuanha, and extract of hyosciamus.* * R.—Calomel, gr. ij. ad vj. Cretas. ppt. gr. xxxvj. Ipecacuanhas, gr. ij. ad iv. Ext. Hyosciami. gr. iv. ad viij,—M. f. ch. No. xij. The use of this combination should be continued until the discharges assume a more natural appearance. In many cases, we have exper- j ienced the best effects from the employment of turpentine, in the fol- lowing formula.* Under its use, we have found the discharges to be speedily reduced in frequency, and improved in appearance. So far from augmenting the irritation of the mucous membrane of the intes- tines, even when this has been the seat of a sub-acute inflammation, we have found it to produce a directly soothing influence. DISEASES OF THE DIGESTIVE ORGANS. 215 aR.—Mucil. G. acacias, giij. Sacch. alb. pur. 3iij. Spir. terebenth. 3'j- Magnes. calc. gr. xiij. Tine, opii camph. 3'ij.—M. Dose, a tea spoonful, every three or four hours, according to circumstances. When there is much tenderness of the abdomen, and the child evinces the existence of pain by its fretfulness or almost constant whining cry, or by drawing up its knees towards the abdomen when lying; more especially, if there is redness and dryness of the tongue, and an occa- sional circumscribed flush of one or both cheeks, with a suffering ex- pression of countenance, it will often be found advantageous to apply a few leeches to the abdomen, and upon their removal to cover this part with a large emollient cataplasm. After a few hours, the leeches may be followed by a blister, which, when properly managed, accord- ing to the directions already given, very generally produces a very beneficial effect. In all cases of chronic diarrhoea, the derivative effects of blisters to the abdomen are advantageous, often very de- cidedly so, and in many cases, the blister may be repeated as soon as the first heals. When acidity prevails in the alimentary canal, the occa- sional use of some alkaline preparation will be proper; a few grains of bicarbonate of soda, or a few drops of aqua ammonia, may be given in a weak infusion of hops, or we may employ the prepared chalk." » R.—Cretas ppt. 3j. Or, R.—Cretas ppt. 3ij. Calomel, gr. iij. Sacch. alb. pur. 3ij. Ipecacuanhas, gr. iij. Mucil. G. acacias. 3ss. Ext. hyosciami, gr. viij.—M. Aq. cinnamon. 3ij. f chart. No. xij. Tine.opii camph. 3j.—M. One to be given, three times a day. A tea spoonful, to be given, every three or four hours. When the acidity is accompanied with much flatulency, we have found the turpentine, in the formula given above, to produce the most prompt and effectual relief. In cases of extreme tympanitis, we may succeed, in many cases, in drawing off the gas from the intestines, by the introduction of an elastic tube into the anus, or by the use of the syringe, as noticed in the section on enteralgia. When the patient's sleep is disturbed and restless, or frequent eva- cuations from the bowels Occur at night, a dose of Dover's powder, or an anodyne enema may be given in the evening. As soon as the inflammatory symptoms are removed, and the dis- charges assume a more healthy appearance, the exhibition of some astringent may be ventured upon. The one which, in our hands, has succeeded in the greatest number of cases, is the acetate of lead, com- bined with ipecacuanha and opium.* The acetate of lead, as we have already remarked, may be given to children, without fear of any in- jurious consequences resulting, provided care be taken to procure the article perfectly pure, and not to administer, in conjunction with it, any thing calculated to cause its decomposition. 216 DISEASES OF CHILDREN. a R.—Acctat. plumbi, gr. vj. ad xij. Pulv. ipecacuanhas, gr. iij. Opii pulv. gr. j.—M. f. ch. No. xij. One to be repeated, three times a day, or oflener, if required. Next to the acetate of lead, the best astringent, according to our ' experience, in the chronic diarrhoea of children, is the galls in powder. It may be given, in the dose of from three to five grains, three times a day, in combination with a small portion of camphor." a R.—Pulv. Gallas, gr. xxxvj. ad 3j- Camphor, pulv. gr. iij —iv. Sacch. alb. gr. xxv.—M. f. ch. No. xij. A great variety of other astringents have been recommended, as the kino, catechu, and the blackberry and geranium roots. The pcrsesquini- trate of iron, which is spoken of in the highest terms, as a remedy, in certain forms of chronic diarrhoea in adults, (Kerr, Kopp, Graves.) appears to us well deserving of a trial, in the cases occurring in children, which often bear a strong resemblance to those described in the clinical lectures of Dr. Graves. Two to three drops of the liq. ferri persesquinitratis may be given, every three hours, in sugar and water; the dose being gradually augmented. In the use of astringents in chronic diarrhoea, we shall be con- stantly disappointed in obtaining any permanent good effects, if they be entered upon previously to a change being procured in the ■i appearance of the discharges; so long as these continue of a decidedly unhealthy appearance, to attempt to suspend the morbid irritability of the intestinal canal by opiate or astringent remedies, is merely to pro- long the disease. In those cases, however, in which the evacuations are, in a great j measure, composed of thin, foecal matter, or of serum, tinged with bile, the combination of acetate of lead, ipecacuanha, and opium, may be commenced with at once. It is in such cases we suspect, that the most advantage will be derived, from the combination of nitric acid, with the infusion of samarouba, and from the persesquinitrate of iron. During the continuance of the disease, daily exercise in the open air, when the weather will permit, to an extent adapted to the strength of the patient, with proper clothing, should not be neglected. The state of the brain must be carefully and closely watched. If any degree of cerebral irritation is detected, leeches should be applied to the temples, blisters behind the ears or to the nape of the neck, and warm, sinapised pediluvia repeated night and morning; the diar- rhoea being treated by calomel, ipecacuanha, and extract of hyocia- mus. We are to recollect, however, that stupor, and other symp- tums of an affection of the brain, terminating rapidly in effusion, may be produced by extreme exhaustion, the result of the frequent and profuse evacuations from the bowels; in this case, the diar- rhoea should be arrested as speedily as possible, and the strength of the child restored by some tonic, as the sulphate of quinia, or the persesquinitrate of iron, with a nourishing but bland, and easily digested diet. DISEASES OF THE DIGESTIVE ORGANS. 217 4.—Cholera Infantum. (THE SUMMER COMPLAINT OF INFANTS.) The cholera infantum is a disease that has, with great propriety, been considered as indigenous to the United states. It is certain, that in the various and minute descriptions that have been published, of the bowel complaints of children, which ordinarily occur, in different parts of Europe, or elsewhere, we meet with none that resembles, in all its features, the infantile cholera of this country:—certainly none that pre- vails to so great an extent, and produces an equal amount of mortality. The disease occurs, as an endemic, in all the large cities through- out the middle and southern, and most of the western states, during the season of the greatest heat; making its appearance and ceasing, earlier or later, according as the summer varies, in the period of its commencement and close. Thus, in Pennsylvania, Maryland, Virgi- nia, Kentucky, and Ohio, it commences sometimes early in the month of June, and continues until October; prevailing to the greatest extent in July and August: whilst in the more southern states, it appears as early as April and May, and frequently, cases of it occur, until late in November. Its only subjects are infants; chiefly those between four and twenty months of age;—seldom attacking those younger or older; being commonly confined to the period of the first dentition. So generally is this the case, that an infant's second summer is considered by mothers, as one of unusual peril; and should it escape at that age an attack of cholera, or pass safely through the disease, it is considered to have a fair chance of surviving the period of infancy. Cholera infantum is unquestionably one of the most fatal affections to which infants are subject, in the United States. In Philadelphia, during a period of fifteen years, from 1825 to 1839, inclusive, 3352 infants perished from this complaint; being almost ten percent, of the whole number of infants under five years of age, who died during that'period, and 4.5 per cent, of the entire mortality of the city. The cause of the large amount of deaths, produced by cholera infantum, is to be attributed, mainly, to the continued action of the endemic causes by which the disease is generated, from the influence of which, in the greater number of instances, it is very difficult, if not impossi- ble, to remove the infants who are attacked by the disease. Cholera infantum most usually commences with a profuse diarr- hoea, the stools being often of a green or yellow colour, but more commonly, light coloured, and very thin. The diarrhoea seldom con- tinues for any length of time, before an extreme irritability of the stomach manifests itself; every thing taken into it, being immediately rejected, often with great violence. In other cases, the infant is affected with almost constant vomiting and purging; the discharges from the bowels being, ordinarily, a perfectly colourless and inodor- ous fluid, containing minute mucous flocculi. They are sometimes 218 DISEASES OF CHILDREN. small in quantity, and squirted, as it were, from the anus; but occa- sionally, they are very copious, and passed without the least effort. In whatever manner the disease commences, the child soon becomes affected with great langour and prostration, and is rapidly emaciated —being reduced in a few days, often hours, to an extent that to those who are not familiar with the disease, would appear almost incredible. The pulse, in the commencement of the attack, is, usually quick, frequent, small, and often tense. The tongue is covered with a white. slimy mucus. The skin is, in general, dry and harsh; the head and abdomen are hot, while the extremities retain their natural tempe- rature, or, when the attack is violent, are decidedly cold. There is always intense thirst; whatever fluid is taken, being, however, almost immediately ejected from the stomach. Towards evening, there occurs, in most cases, a decided febrile exacerbation. The child fre- quently suffers more or less pain, as indicated by its fretfulness, low, moaning cries, frequent change of posture, the drawing up of its knees, and its occasional acute screams. The abdomen is often some- what tumid, and tender to the touch. In many cases, the excessive irritability of the stomach continues throughout the attack; but not unfrequently, the vomiting becomes suspended at a more or less early period, while the diarrhoea conti- nues unabated, or increases in violence; the irritability of the intestinal canal being often such, as to cause whatever food or drink that is taken to pass off rapidly, without having undergone the slightest change. Occasionally, the patient becomes affected, very early in the attack, with delirium;—his eyes become injected and wild;—his head is tossed violently backwards and forwards; and he frequently attempts to bite or scratch his attendants. In very violent attacks, the prostration which suddenly ensues, is so great, as to destroy the patient within twenty-four hours. In general, however, the disease runs a much more protracted course. The ema- ciation becomes extreme; the eyes languid, hollow, and glassy; the countenance pale and shrunken; the nose sharp and pointed ; and the lips thin, dry, and shrivelled—the skin upon the forehead becoming smooth and shining, as if tightly stretched over the frontal bone. The child lies constantly in an imperfect doze, with half-closed eye- lids, and so insensible to external impressions, that we have repeat- edly seen flies alight upon the half-exposed eyeballs, without the patient exhibiting the least consciousness of their presence. The surface of the body is now cool and clammy, of a dark brown- ish hue, and often covered with petechias; the tongue is dark-col- oured, smooth and shining, or covered, as well as the whole of the inner surface of the mouth, with apthae. At this stage of the disease, the fauces frequently become dry, causing a difficulty in deglutition, and inducing the patient to thrust his hand deep into the mouth, as if to remove some offending substance from the throat. The abdomen becomes more or less tympanitic, and the hands and feet pallid, or of a leaden hue, and cedematous. The discharges DISEASES OF THE DIGESTIVE ORGANS. 219 from the bowels are now generally frequent and profuse, dark col- oured and very offensive—resembling the washings of stale meat; in many cases, however, they are small in quantity, and composed entirely of dark coloured mucus, mixed with the food or drinks that have been taken. The infant becomes more and more exhausted, rolls its head about when awake, and utters constant short, plaintive, hardly audible cries. He falls, at length, into a state of complete coma, death being, in many cases, preceded by a convulsive attack. Not unfrequently, at a much earlier period of the disease, effusion takes place in the brain, and the patient dies, with all the symptoms of acute hydrocephalus. In most of the protracted cases, an eruption occurs upon the breast, of very minute, white vesicles. This Dr. Dewees considers to be invariably a fatal symptom; but we have, in many instances, known the patient to recover, even when this eruption has been the most extensive and distinct. The examinations of the bodies of those who have fallen victims to cholera infantum, exhibits various lesions, chiefly of the alimentary canal. When death occurs early in the attack, the only morbid ap- pearance discovered, is often an unusual paleness of the mucous coat of the stomach and intestines, with more or less congestion of the liver. Where the disease has continued for a longer period, in- creased redness, in points or patches, in different parts of the stomach and intestines, is often present. The red points are sometimes very minute and isolated, and spread over a considerable portion of the stomach and duodenum, or over the small intestines only. They have the appearance, generally, of minute extravasations of blood. At oth- er parts of the bowels, these points occur in clusters:—the patches vary in size, but are never ve'ry large, and are often slightly elevated, from a thickening of the mucous tissue at the part where they are situated. Oc- casionally, portions of the mucous membrane, either of the stomach or intestines, are more or less softened—often without the slightest trace of inflammation. In other instances, increased redness of some portion of the intestines exists, with contraction of their calibre, to such an extent, as scarcely to permit the insertion of a small sized quill. The muciparous follicies of the intestines, are very generally enlarged, often in a state of inflammation, and occasionally ulcerated. Dr. Horner describes the appearance of the enlarged follicles in the large intestines, as resembling a sprinkling of white sand upon the surface of the mucous membrane. The intestines are in general empty, or contain merely a small amount of thick, tenaceous mucus. Dr. Page describes the appearance of dark spots upon the mucous membrane of the stomach, about its pyloric orifice, but particularly, of the duo- denum; and Dr. Lindsly mentions a similar appearance:—we have never detected it. The liver is, in general, enlarged, and more or less congested; while the gall-bladder is filled with dark green bile, or with a pale and nearly colourless fluid. The enlarged and congested state of the liver, is noticed by most writers upon the disease. De- 220 DISEASES OF CHILDREN. wees, Horner, James, Jackson, and Lindslv, describe the enlargement as being in some cases immense. Page states it to be much enlarged, soft, and spongy; and Horner describes it as usually of a light yellow or mottled colour:—we have always found it to be more or less enlarged, but seldom to the extent noticed by most writers, and sel- dom much changed in colour. In a large number of the more protracted cases, serous effusion, upon the surface, at the base, or in the ventricles of the brain, is pre- sent— in many instances, without indications of inflammatory action, but in others, with thickening and opacity of the arachnoid mem- brane. Cholera infantum, comparing the symptoms during the lifetime of the patient, with the appearances discovered after death, would appear to depend upon hyperaemia of the mucous membrane, with an augmenta- tion in the size and activity of function of the muciparous follicles of the alimentary canal—inflammatory action being frequently excited, as well in the follicles, as in the mucous tissue, from accidental sources of irritation. The disease is evidently dependent for its production, upon the action of a heated, confined, and impure atmosphere, directly upon the skin, and indirectly upon the digestive mucous surface, at a period, when the latter is already strongly predisposed to disease, from the effects of dentition, and from the increased development and activity of the muciparous follicles, which takes place at that period. It is an affec- tion exclusively confined to the stage of infancy—few cases occur- ring beyond the second, and none beyond the fifth year. During twenty years, the deaths from cholera infantum, in Philadelphia, amounted to 3576 : namely, in infants under one year of age, 2122; between one and two years, 1186; between two and five years, 268. The entire number of cases of cholera morbus, that occurred during the same period, was 236: namely, in individuals over twenty years of age, 173; under twenty years, 63. The influence of a high atmospheric temperature, in the production of cholera infantum, is shown by the fact, that its prevalence is always in proportion to the heat of the summer—increasing, and becoming more fatal, with the rise of the thermometer, and declining with the first appearance of cool weather in the autumn. A few hot days in succession, in the month of May, are sufficient to produce it; while, during the height of its prevalence, a short period of cool weather, will diminish, if not entirely suppress it. In those infants, who have been prematurely deprived of their natural aliment, or whose diet is composed of crude, indigestible, stimulating, or otherwise unwhole- some articles, a heated and confined atmosphere would appear to be alone sufficient for the production of the disease; but the extensive prevalence of the cholera of infants, during the summer months, is not dependent alone upon the influence of heat; but upon the combined influence of a high atmospheric temperature, and confined and impure air. Hence it is almost exclusively confined to the larger and DISEASES OF THE DIGESTIVE ORGANS. 221 more crowded cities of the middle and southern states; and in these, it is especially prevalent, and destructive to life, among the children of the poorer classes, inhabiting small, ill ventilated houses, situated in narrow, confined lanes, courts and alleys, or in situations abound- ing with accumulations of filth. When it occurs in the country, which is rarely the case, it is almost exclusively in low, damp, and otherwise unhealthy situations. By many writers, dentition and errors in diet, are enumerated among the causes of cholera infantum. They are unquestionably to be viewed, in many cases, as predisposing, and in others, as exciting causes—but we have, in no instance, known an attack of genuine cholera infantum to occur, without exposure to the influence of a heated, stagnant, and more or less impure atmosphere; and this alone, in the great majority of cases, would appear to be the sole cause of the attack. The prognosis in cholera infantum will depend, in a great measure, upon our ability to abstract the patient from the continued effects of the endemic influence by which the disease has been produced, and is kept up, as well as upon the period of the attack, at which the treat- ment is commenced. According to our experience, the disease is one very readily controlled, whenever we are enabled, at an early period, to carry into effect, the proper remedial measures. The chief cause of the great mortality produced by it, being the impossibility, in the majority of instances, of removing the patients from the influence of the heated and impure atmosphere by which the disease has been generated. Without this removal, it is scarcely possible, in any instance, to effect a permanent cure; while inmost cases, in their commencement at least, little else is required to arrest the disease; and even at a later period, its effects are often evinced, in the rapid improvement of the patient, from almost the very moment the removal takes place. In very violent attacks, it occasionally happens, that the patient sinks at once—death ensuing in a few hours. Such cases, however, are of unfrequent occurrence; sufficient time being in general afforded for carrying into effect, a proper remedial course of treatment. Even after the disease has continued for many days, and reduced the patient to a state in which a fatal termination seems to be inevitable, by appropriate remedies, a very rapid cure may often be effected. This we have witnessed, not in a few rare instances, but repeatedly. It is all-important, the moment an infant is attacked with cholera infantum, that he be removed from the heated, confined, and impure atmosphere, by which the disease has been generated, to a situation where he may enjoy the advantages of free ventilation, and cool air. Whenever this can be done in the commencement of the attack, the patient being, at the same time, confined exclusively to the breast, or if weaned, to a diet of tapioca, pure arrow-root, or rice flour, with milk, and immersed daily in a bath, warm or tepid, according as the temperature of the skin is deficient or increased, the disease may, gen- 222 DISEASES OF CHILDREN. erally, be arrested, without the administration of any remedy inter- nally, excepting, perhaps, some cool, perfectly bland, and slightly mucilaginous drink—as gum water, or, what we prefer, rennet whey, with a slight addition of gum acacia. Even in cases in which a removal to a healthy and airy situation in the country is impractica- ble, much benefit may be derived from carrying the patient frequently into the air, in any open and healthy situation in the neighbour- hood of his residence, in a carriage, or in the arms, or where his res- idence is near a large river, by sailing daily in an open boat. At whatever period of the attack we maybe called to the patient, his removal to the country, should, if possible, be effected ; or, if alto- gether impracticable, as free an exposure to a pure and open atmos- phere, as can be accomplished, should be insisted on. The apartment occupied by the patient, should be kept strictly clean and dry, and freely ventilated: his clothing, besides being per- fectly clean and dry, should neither be too warm, so as to overheat the body, nor so thin and flimsy, as to expose it to the influence of every slight change in the temperature of the air. Fine, soft flannel, or soft, coarse muslin, worn next the skin, will be proper in most cases. The room occupied by the patient at night, should be as large and airy a one as can be commanded :—he should sleep upon a mat- tress, or on a blanket, folded and laid upon the sacking-bottom of the bedstead, or upon the floor of the crib, his body being defended by a light, loose covering. In every instance, a careful examination should be made into the condition of the gums, and if they are found to be hot, swollen and inflamed, they should be freely lanced. When the disease commences with a simple diarrhoea, the warm bath repeated daily, or even night and morning, and followed by gen- tle friction over the entire surface of the body, with the hand or a soft dry cloth; cold, mucilaginous drinks, and a combination of calomel, one sixth of a grain, and acetate of lead, half a grain, with about four grains of prepared chalk, repeated every two or three hours, will ordi- narily, very quickly arrest it. If there exists great irritability of the stomach, every thing taken into it being quickly rejected, minute doses of calomel, from a sixth to ' a quarter of a grain, rubbed up with a little dry loaf sugar, and sprin- kled upon the tongue, will in general be retained, and speedily quiet the stomach, so that other remedies may be administered. When, how- ever, the vomiting persists, we have found a few drops of spirits of turpentine, or of a solution of camphor in sulphuric aether,* repeated at short intervals, seldom to fail in removing it. When the vomiting is violent and frequent, the application of a few leeches to the epigastrium will be found decidedly advantageous. When every thing else fails, we have very seldom been disappointed in removing the irritability of the stomach, by the administration of the acetate of lead in solution.b A blister may, at the same time, be applied over the epigastrium for DISEASES OF THE DIGESTIVE ORGANS. 223 three or four hours, and then taken off, and replaced by a bread and milk, or flaxseed poultice. aR.—Camphor. 3j. bR.—Aq. puras, gi. /Ether, sulphuric, gj.—M. Acetat.plumbi, gr. v. Acid. acet. impur. Tt[ v. Sacch alb. pur. ^iij.—M. A tea spoonful to be given evpry hour or two, until the vomiting is suspended. When the patient appears to suffer much pain, with increased heat of the skin, particularly about the head and over the abdomen, the latter being tumid, and tender to the touch, leeches should be applied to the epigastrium, in numbers proportioned to the age and strength of the infant, and the violence of the symptoms, and followed by light, emollient cataplasms, or warm fomentations over the whole abdomen. The effects of fomentations to the abdomen of a strong infusion, or decoction of hops, have been spoken of by many practitioners, as peculiarly beneficial. The tepid bath should be repeated night and morning. A tea-spoonful of cold water may be allowed every fifteen or twenty minutes; but the ordinary drink of the patient should be toast, rice, or gum water. In these cases, small doses of calomel, the fourth of a grain, combined with three or four grains of calcined mag- nesia, administered every three hours, will usually be productive of good effects. When there exists much heat about the head; a wild and injected state of the eye ; aversion from light, with delirium, or other symp- toms of cerebral irritation, leeches should be applied to the temples, or behind the ears, with cold lotions to the scalp, and some stimulating embrocation to the lower extremities, or warm sinapised pediluvia. In all instances in which there appears to exist a tendency to disease of the brain, blisters behind the ears, kept open by the use of some irritating ointment, will be found decidedly beneficial. As soon as the irritability of the stomach is sufficiently quieted to allow of its administration, the remedy which we have found the most certainly and promptly to restrain the disordered action of the bowels, and complete the cure, is a combination of calomel, prepared chalk, acetate of lead, and ipecacuanha.0 CR.—Calomel, gr. iij. Cretas ppt. gr. xxxvj. Acetat. plumbi, gr. xij. Ipecacuanhas, pulv. gr. iij.—M. f. Ch. No. xij. One to be given every three hours. Under the use of this prescription, with the daily use of the warm bath, exposure to a dry, cool and pure atmosphere, and a diet composed exclusively of farinaceous articles with milk, we have, in general, found the inordinate discharges from the bowels to be quickly sus- pended, and replaced by natural, regular evacuations, As soon as the frequent, watery discharges from the bowels are arrested, we are accustomed to suspend the use of the acetate of lead, continuing the 224 DISEASES OF CHILDREN. calomel, prepared chalk, and ipecacuanha, in the same proportions as above, with the addition of half a grain to agrain of extract of hyosci- amus to each dose, until regular and healthy stools are procured. The use of some one of the light astringents, directed in cases of ordinary diarrhoea, continued for a few days, is always beneficial, by giving tone to the bowels, and preventing the danger of a relapse. When cholera infantum has been allowed to run into a chronic form, its treatment then, will differ but little from that of chronic diarrhoea. The most efficient remedies are, the warm bath, frequently repeated ; a blister over the abdomen ; anodyne injections, composed of thin starch, and a few drops of laudanum ; light astringents, as kino, decoction of dewberry root or geranium maculatum, with a change of air, and a diet of boiled milk, thickened with rice flour, or of plain beef tea or chicken water. Dr. Eberle speaks favoura- bly of the effects of a solution of the tartrate of iron.* The perses- quinitrate of iron, may likewise be administered, with good effect. In many cases, the sulphate of quinia, in solution, besides exert- ing a beneficial influence upon the disordered condition of the bow- els, will be found useful in restoring strength to the patient, who is always in a state of extreme prostration. When the discharges from the bowels are thin, small in quantity, dark coloured, and highly offensive, with flatulency, and a tendency to a tympanitic condition of the abdomen; or when frequent griping pains are experienced, we have derived the best effects from the use of the turpentine mixture, as directed in the treatment of chronic diarrhoea. When great irritabil- ity of the bowels is present, we usually direct the addition to the tur- pentine mixture, of C5iij. tine, kino or catechu, and the same proportion of the camphorated tincture of opium. In chronic cases of cholera infantum, with acrid, offensive and dark coloured discharges, much advantage will often be derived from the use of pulverised charcoal; we have usually administered it in combination with powdered rhu- barb, ipecacuanha, and extract of hyosciamus.b »R.—Tartrat. Ferri. gr. xl. lR.—Carbon. Ligni, 31. to 3ij. Aq. puras, gij. Pulv. Rhei. 9ij. Syrup. Zingiber. 3SS-—M. Ipecacuanhas, gr. iv. ad xij. Dose 20 to 40 drops every three hours. Ext. Hyosciami, gr. xij.—M. f. ch. No. xij. One to be given every 3 or 4 hours. When, by a judicious treatment, the disease has been entirely removed, the full restoration of the patient's strength, and the preven- tion of a relapse, are only to be ensured by the influence of a cool and pure atmosphere; a mild, unirritating diet, and the most scrupulous cleanliness of his person and clothing. §,—Prolapsus Ani. A prolapsus, or protrusion of the mucous membrane of the rectum, or of the rectum itself, is a. frequent consequence of long continued y„......... ^ cue X4. - ^ A..vc- DISEASES OF THE DIGESTIVE ORGANS. 225 diarrhoea in children; it may, however, result from the irritation of worms, or from costiveness, and we have occasionally met with it, where the only cause appeared to be a relaxed condition of the sphinc- ter ani; the prolapsus occurring, not only every time the patients had an evacuation from their bowels, but even when they continued for any length of time in the erect posture. In slight cases, a very small portion of the mucous membrane is protruded beyond the rectum, with a sense of bearing down and smarting, that continues until the protruded membrane is returned, which may take place spontaneously, or upon the slightest pressure being made upon it. In other cases, a considerable portion of the mucous membrane is protruded, in the form of a small, coiled, pyra- midal tumor, of a bright red color, and is with difficulty returned— being firmly embraced by the sphincter; if it be allowed to remain out for any length of time, it becomes often, more and more swollen, of a darker red, or even purple hue, and inflammation, terminating in ulcer- ation, or sloughing of the protruded portion of the intestine, may rap- idly take place. Occasionally, a considerable portion of the rectum may become prolapsed, and if allowed to inflame, can no longer be reduced, but subjects the patient to much inconvenience and suffering; his digestion becomes disturbed, and death may finally result from impaired nutrition, and long continued irritation. The prolapsus may occasionally be the result of an invagination of the upper portion of the rectum, or even of a portion of the colon ; in these cases the prognosis is generally unfavourable, though cases are on record, in which the invaginated portion has become separated, and discharged per anum. Children are peculiarly disposed to prolapsus of the anus, as well from the greater mobility of ;the intestine; its less extensive connec- tions, in consequence of the imperfect development of the neighbour- ing organs ; the slight curvature of the sacrum, and the perfect mobility of the os coccyx; as from the general laxity of all the tissues, and the deficient resistent powers at this period of life. In the generality of cases, if the prolapsus is attended to on its first occurrence, its reduction is seldom attended with much difficulty. The child being placed upon his back, gentle pressure is to be applied upon the protruded portion of intestine, with the thumbs or forefingers, previously smeared with fresh lard or dipped in sweet oil, in such a direction as shall tend to return it within the sphincter; or the fore- finger, being introduced into the gut, in order to remove the resis- tance of the sphincter, gentle, well directed pressure will then gene- rally cause the protrusion to pass within it. The utmost care should be taken to effect the return, every time, and as soon after the pro- lapsus occurs, as possible. If the patient is affected with a disposition to bear down subsequent to the reduction of the intestine, an ano- dyne enema, composed of a small portion of opium and three grains of acetate of lead, intimately combined with a little thin mucilage, 15 220 DISEASES OF CHILDREN. should be administered. Proper means, are of course to be pursued, for the removal of the cause by which the prolapsus is produced. If the prolapsed portion of the intestine should become swollen or inflamed, the application to it of cold water, or a solution of acetate of lead, or a few leeches will be proper, previous to any attempt being made to reduce it. When the prolapsus is the result of violent straining, incident to a costive state of the bowels, some gentle laxative, as ripe fruit stewed in molasses, or rye mush and molasses, should be given daily, and the child caused to evacuate his bowels in an erect posture. Washing the anus daily with cold water, or suddenly dipping the nates in cold water, night and morning, has been recommended as a means of pre- venting the recurrence of the prolapsus, and when there is nothing to forbid its employment, it may be practised, perhaps, with advantage; but it will not be proper in delicate children, in whom there is a predis- position to catarrhal affections, or who are in a state of exhaustion, from long continued diarrhoea, or other disease. In such cases, how- ever, astringent washes and injections of a tepid warmth will often produce a beneficial effect.* aR.—Quercus cort. contus. 3j- Aquas puras, Oij. Coque ad Oj. This may be used alone, or with the addition of half a drachm of alum ; or a solution of alum alone may be used, in the proportion often grains to the ounce of water. A decoction of galls, with or without the addition of alum, is preferred by some practitioners. When the prolapsus continues to recur at short intervals, for any length of time, the sphincter becomes, finally, so much relaxed, that the intestine comes down, often to a considerable extent, upon the patient making the slightest exertion, or even assuming an erect posture. In such cases, the intestine must be retained by a soft compress applied upon the anus, and supported by a T bandage. By this means, and the use of astringent injections, and a proper attention to the state of the bowels, a radical cure may often be effected. But should the pro- lapsus continue still to recur, notwithstanding the employment of these for a reasonable length of time, the propriety of an operation should be considered; the nature of which will depend, in a great measure, upon the particular circumstances of each case :—whether the removal of a portion of the projecting folds of the skin, at the verge of the anus, as practised by Dupuytren—the excision of the circular fold of loose skin around the anus, with a portion of the mucous membrane of the rectum, as recommended by Hey and Mac- farlane ; or the application of the actual cautery to the margin of the anus, as recommended by Mr. Benjamin Phillips, and practised by him on a child of three years, with complete success. It has been recommended, that children subject to prolapsus ani, should be made to sit on a hard, flat-bottomed stool or chair, without DISEASES OF THE DIGESTIVE ORGANS. 227 arms, and of such a height, that their feet may not touch the ground. (Underwood.) Polypus of the Rectum.—The attention of the profession has been recently directed to the circumstance of the occasional occurrence of a polypus tumor within the rectum of children. (Stolz, of Strasburg.) Polypus, in this situation, has been very generally overlooked, it being, probably, mistaken for prolapsus ani, to which it bears a very close resemblance. It is, nevertheless, somewhat remarkable, that it should have escaped the notice of almost every modern writer on the diseases of children :—for, although of not very frequent occurrence, it is, ne- vertheless, much more so than physicians would appear to be aware of. Several instances have fallen under our notice; and although they were generally presented to us as cases of prolapsus ani, yet, upon a care- ful and minute examination,—a neglect of which, in such cases, would be unpardonable—we have never found the least difficulty in detecting the true character of the complaint. When a polypous tumor forms in the rectum, during childhood, the little patient is troubled, at intervals, with a repeated, often ineffectual desire to evacuate the bowels, generally attended with considerable straining, during which, sooner or later, and finally, every time the straining recurs, a tumor is protruded from the anus—varying in size in different cases, from that of a cherry, to that of a large hickory nut. The tumor is, usually, of a bright, or dark red colour, but often white, or of a dirty yellow ; it is, in most cases, thickly covered with a tenacious, bloody mucus. When of a dark red, or purple hue, it is apt to bleed freely, especially when handled or irritated. When the tumor is protruded, it is situated in the centre of the anus, and entirely without the sphincter, and appears as if it were attached, all around, to the edge of the anus. On passing the finger into the rectum, a slender pedicle is found to proceed from the base of the tumor, for a short distance within the gut, to the inner surface of which it is attached. When the polypus is of considerable size, the straining efforts to evacuate the bowels are often very violent, and attended, sometimes, with considerable pain; and when it is finally protruded, it is found-to be surrounded by a slight eversion of the lower portion of the rectum. In one of the cases that came under our notice, the tumor, which was of large size, separated, and came away sponta- neously ; the haemorrhage which followed was very slight, and soon ceased, without the necessity of our resorting to even a compress. In the other cases, the tumors were readily removed by ligatures—in the application of which there is not the least difficulty—without the occurrence of any severe or untoward symptom. 6.—Invagination of the Intestines. Intestinal invaginations or intus-susceptions, that is, the passage of one portion of the intestine within that above or below it, are often 228 DISEASES OF CHILDREN. met with in children who have died of other diseases, and appear to take place in the act of dying, from some convulsive or inordinate movement of the muscular fibres of the intestinal canal; these invagi- nations give rise to no symptoms during the life time of the patient, and after death, are reducible with perfect ease. Occasionally, how- ever, the invagination, occurring in children, gives rise to symptoms of the most serious character, and speedily destroys the life of the patient. The symptoms of invagination are obstinate costiveness; progres- sive tumefaction of the abdomen, with tenderness upon pressure; often repeated paroxysms of acute pain; vomiting of food and drinks, and subsequently of faecal matter; coldness of the extremities, terminating sooner or later, in death. The cause of the obstruction to the onward passage of the farces in cases of invagination, as well as of the other symptoms by which they are ordinarily attended, is, in all probability, the inflammation of the intestine, at the part where the invagination has occurred, in con- sequence of wmich, an adhesion of the peritoneal surfaces which are brought into contact, takes, place, and in this manner, not only is the calibre of the intestine narrowed, but its regular peristaltic action is impeded or destroyed. Invagination may take place in any part of the intestinal canal, but is most generally seated near the termination of the ilium. (Staub, Thompson.) Cases are related in which the invaginated portion has sloughed off, and been discharged by the rectum; this seldom occurs, however, in children. The disease is, very generally, fatal; no instance has, in fact, fallen within our own observation, of a case, in which the symptoms consequent upon invagination were present, that has terminated favourably. The appearances exhibited upon dissection, are those of inflamma- tion of the mucous membrane of" the intestines, and often of their peri- toneal coat. At the invaginated portion, the mucous surface is often highly inflamed ; of a dark red colour, and thickened, and often cov- ered with a dark red effusion, intermixed with portions resembling coagulable lymph; the two serous surfaces in contact are likewise inflamed, with exudation and adhesion. In the treatment of invagination, such remedies should be employed as are calculated to prevent or reduce inflammation, and to restore the natural action of the intestines:—the warm bath, frequently repeated—leeches and warm fomentations to the abdomen, and absti- nence from food and drinks. The forcible injection of large quantities of warm water, or of air, by the rectum, has been strongly advised in cases of invagination ; with the view, previous to the occurrence of inflammation, of restoring the natural condition of the intestine. We know of no instance, how- ever, in which this means has been crowned with success:—after the DISEASES OF THE DIGESTIVE ORGANS. 229 occurrence of inflammation it will necessarily fail, and may be pro- ductive of mischievous effects. In cases in which the invagination has been preceded by costive- ness of the bowels, the injection of a large quantity of warm milk and water through a long elastic tube, passed into the sigmoid flexure of the colon, may do good, by removing from the intestines any har- dened and impacted fa3ces, by the retention of which, we have reason to believe, invagination is occasionally produced. 7.—Intestinal Worms. At one period, and that not a very remote one, nearly all the dis- eases of infancy and early childhood, were ascribed to the presence of worms in the intestines ; and notwithstanding repeated and more accurate observations, leading to a better acquaintance with the path- ology of the diseases of early life, especially those of the digestive organs, have shown that intestinal worms play a much less important part in their production than was previously supposed, it still remains a matter of dispute to what extent they are to be considered as the causes of cer- tain phenomena, very generally, but by no means constantly, associated with their presence. While by one party, the existence of worms is deemed invariably detrimental to health; by another they are regarded as the effect, and not the cause of disease; while a third consider their presence as altogether innoxious, if not, to a certain extent, beneficial.* This much is certain; namely, that there is no single symptom, or cate- nation of symptoms, which indicate the existence of worms in the intes- tines, independently of their presence in the evacuations ; they have re- peatedly been discharged during life or discovered after death, in cases in which their presence was not suspected ; one species in fact, the tri- cocephalus, Bremser has met with in nearly every body he has opened, and we have seldom failed, in any instance, to detect it; in other cases, in which the most unequivocal indications of the existence of worms were supposed to be present, a careful examination of the evacuations gave no evidence of their discharge during the life time of the patient, and not a single trace of them could be discovered in the intestinal canal after death. Worms are of very common occurrence in the intestines of chil- dren, and may, unquestionably, under certain circumstances, become a cause of severe irritation;—but much less frequently than is gene- rally supposed. It is important to recollect, that even when the presence of worms is established beyond doubt, by their appearance in the discharges, the symptoms of disease under which the patient labours, may be produced by causes totally independent of them, and continue, or even augment in violence, though we should succeed in effecting the complete expulsion or destruction of the worms. *Dr. Rush entertained this opinion. 230 DISEASES OF CHILDREN. The worms that infest the intestines are, the trichocephalus dispar, the oxyuris vermicularis, the ascaris lumbricoides, and the bothrioce- phalus latus. The trichocephalus dispar—the trichuris or long thread irorm, of some writers—is commonly from an inch and a half to two inches in length ; having the anterior two thirds of its body slender, like a hair, while the remaining third is much thicker; it is white, or of the colour of the substances it has swallowed. The sexes are in different individuals. The mouth is at the capillary extremity, which is always found adhering to the surface of the intestine. This worm is met with in the large intestines—most commonly in the coecum—which seems to be its natural locality. Frequently but a single individual exists there; and, in almost every instance, a very small number. It is the worm most universally met with.—(Bremser, Bellingham, Mtrat.) The oxyuris vermicularis—the ascaris of Rudolphi and most writers —popularly the maw or thread worm—is from a line to four or five lines long, white, slender, and elastic, blunt at the anterior end, and with a rounded mouth. It is found in the large intestines, and particu- larly in the rectum of children. This worm generally exists in great numbers ; often in the form of a ball, thickly coated or invested with mucus. The ascaris lumbricoides—this is the worm most commonly met with in the small intestines of children. It sometimes exists in great numbers; occasionally congregated in the form of a ball. The lumbricoides is usually from three to twelve inches in length, and varying in diameter, from a line to two or three. Its usual colour is white, but changes with that of the substances it swallows. When dead it becomes perfectly stiff. This worm frequently finds its way into the stomach, and may be discharged by the mouth, or through the nostrils. The bothriocephalic latus—the tcenia lata, or broad tape worm, of many writers—is thinner, and generally wider, than the common taenia; it is often twenty feet long, (Bremser,) and may greatly exceed this length, reaching, in some cases, sixty, and in others, upwards of a hundred feet. (Bremser, Robin, Frank, Gebze, Sibbargarrde.) It is of a dirty white colour, and becomes greyish when immersed in alcohol. (Pallas) It has a large head, with two lateral grooves, which are considered by Rudolphi to be the organs for the absorption of nourishment. It is found in the small intestines. It is seldom met with in the United States, either in children or in adults, but is said to be common in Poland, Russia, Switzerland, and some parts of France. The tcenia solium or common tape icorm, is of a white colour, and of a flat form, with the posterior extremity rounded, and the anterior long and slender, terminating in an extremely narrow neck, with a minute head, armed with four suckers, between which there may sometimes be discovered a small mouth, surrounded by a circle of five hooks. The joints that separate from the posterior extremity of the DISEASES OF THE DIGESTIVE ORGANS. 231 taenia solium, have received the denomination of cucurbitani. This worm inhabits the small intestines, and sometimes attains an enormous length. Several taenia are not unfrequently found in the same individual, and, according to Rosen, in conjunction with other species of worms. The fact of the head, or smaller extremity of the taenia solium, not being discovered in the fcecal discharges, is no evidence that the entire destruction of the worm has not been effected, as it is extremely easy to overlook so diminutive an object in such a medium. (Brem- ser.) The taenia is very seldom met with in children under five years of age:—it has, nevertheless, been found in the intestines of new born infants. (Pallas, Block.) It is said to occur most frequently in persons engaged in preparing materials from fresh animal substan- ces. (Fortassin.) It is unnecessary to enter into an examination of the several theo- ries that have been advanced, to account for the production of worms, in the intestinal canal of man, and other animals—whether they are produced by ova received from without, or are the result of equivocal generation. The question is one involved in the deepest obscurity ; from which it would be in vain to attempt, with the few imperfectly observed facts in our possession, its extrication. The prevalence of intestinal worms, would appear to be much more common in certain districts of country than in others. In Savoy and Chambray, in France, throughout Holland and Switzerland, in certain districts of Germany and Russia, they are stated to be of frequent occur- rence, among nearly all classes of society. (Dauquin, Bremser.) Accord- ing to Mr. Marshall, deputy inspector-general of hospitals, Europeans are veryfiable to worms in India, and Africans even more so. Few post- mortem examinations are made without discovering them. One negro passed forty lumbrici in a day, and in the course of seven days, two hundred. (Mackintosh.) The Hindoos are so infested with worms, according to Annesley, that scarcely one in ten is to be found free from them. Different districts of country, are liable to the pre- valence of different species of worms ;—thus, in Switzerland, Poland, Russia, and some parts of France, the bothriocephalus latus is most commonly met with; while in Egypt, Holland, Germany, the greater part of France, Italy, and Sweden, the taenia solium, is the most frequent worm. (Rudolphi, Bremser, Hasselquist, Merat, Rosen.) The lumbricoides and oxyuris, are the worms most usually met with in the United States, Great Britain, India, and among the negroes of the West Indies. According to Bremser, worms are more common in cities than in the country—a statement which our own experience has not confirmed. They are also said to be more prevalent in cold, damp, low, confined, and unhealthy situations, than in those which are temperate, dry, well ventilated, and elevated; and during the spring and autujnn, than during the other seasons of the year. (Mtrat.) The poor, likewise, who are badly nourished and lodged, and filthy in their persons and habitations, are reputed to be more liable to intestinal worms, than those in comfortable circum- 232 DISEASES OF CHILDREN. stances and of cleanly habits. We are not aware, however, that these statements are founded upon any very accurate observation of facts. So long as worms are considered a principal agent in the production of intestinal diseases, they will, of course, be reputed to be most prevalent in those situations, and among those classes of society, in which such diseases are most liable to occur. And this, to a certain extent is, in fact true; for it has been invariably found, that the same causes which disturb the healthy functions of the digestive organs, and predispose them to disease, are precisely those which favour the production and increase of worms. Worms have been said occasionally to prevail epidemically. It is certain, that at particular periods, they have been met with much more frequently, and in greater numbers, than at others. Many authors have described an epidemic of verminous fever; that is to say, fever of a gastric, mucous, or bilious character, accompanied with the presence of worms, often in considerable quantities. It is difficult to say, what was the real nature of this fever, and whether it might or might not be fever with irritation of the digestive appa- ratus, one of the consequences of which was, a discharge of worms already existing (Stokes.) Andral met wiih worms in only a very small number of the autopsies performed by him in cases of death from fever; they were very numerous in one case, but very few in the others. They were ascarides lumbricoides, and tricocephali; he deemed them merely an accidental complication of the disease. In one instance, they coincided with most of the symptoms characteriz- ing mucous fever. In most of those who died of the epidemic mucous fever of Gottingen, Roederer and Wagler found a great number of worms in the intestines ; and the same was observed in a species of mucous fever which, in 1830, prevailed, in conjunction with the cholera, at Naples. (Tliibault.) From the frequency of worms, in cases of intestinal inflammation, Broussais considers them as most frequently the product of the altered condition of the intestinal mucus, and the heat which results from gastro-enteric inflammation, of a greater or less intensity. This doctrine is by no means supported by the evidence of facts; for it has been proved that worms may exist in connexion not only with every possible pathological condition of the intestinal canal, but also, where this is free from the slightest trace of disease. Andral met with them in all conditions of the intestines, whether they were red or pale, dry or covered with mucus; they were most commonly enveloped in a quantity of mucus, and there was some redness of the part where they were lodged, but this appeared rather the effect of their presence, than their cause. I believe it to be a fact, remarks Dr. Stokes, that persons in excellent health, and with the intestinal canal in the normal state, may have worms. It has been shown, that in epidemic mucous fever, worms are not alwavs pre- sent. (Sarconi.) As remote causes of worms, the following are generally enumer- ated :—too rapid growth; scrofula; a sedentary inactive mode of DISEASES OF THE DIGESTIVE ORGANS. 233 life; habitual exposure to a clamp, confined atmosphere; indulgence in crude unripe fruits; the abundant use of fat, farinaceous and saccha- rine articles of diet, and of fresh milk. (Bremser, Marley.) Others attribute them to the want of a sufficiency of salt being taken with the food eaten. We do not believe that any particular articles of food, or course of life, has a tendency to promote the formation of worms in the intestines, excepting so far as they have a tendency to disorder or interrupt the functions of the digestive organs. When digestion becomes impaired, from whatever cause, we have the most unquestionable evidence, that an increased development of worms in the intestines is especially liable to take place; and it is, from the increas- ed irritability of the intestinal mucous membrane, so frequently associ- ated with a disordered state of the digestive function, that they are then so apt to give rise to a variety of morbid phenomena. Worms so fre- quently exist in early life, without any—even the slightest—indication of disease, (Heberden, Butter, Rush, Hosack, Merat, Block, Andral, Stokes,) that we can only consider them as productive of injury from their numbers, or from some co-existing pathological condition of the alimentary canal. Though worms may occur at any period of life, they are most commonly met with during infancy and childhood ; more particularly the oxyures and lumbricoides. At La Saltpetriere, the hospital at Paris for the reception of patients advanced in life, worms are scarcely ever met with in the bodies of those who die; while in the Foundling Hospital of the same city, they are very commonly present, and often in great numbers, in the same body. (J. Cloquet.) The number of lumbricoides that are often discharged by children, or are found in their intestines after death, is often almost incredible. Eighty lumbri- coides, have been expelled during a fever, and the whole intestinal canal has often been completely filled with them. (Frank.) We have known one hundred and twenty lumbricoides to be voided by a child five years old, in a single day, and have seen the rectum literally crammed with an immense mass of oxyures. Worms seldom occur in children who are confined to the breast. Dewees has never seen them in those under ten months of age ; others, however, have detected them in the youngest infants, even in still-born foetuses. Children who are affected with worms, are usually of a pale or sallow complexion, with a bluish circle around the eyes, and a more or less tumid abdomen. They are troubled with itching at the nose and anus, headache, foul breath, nausea, hiccup, and gnawing pains of the stomach or intestines; their breath is foul, their tongue more or less coated ; their appetite irregular and capricious, often voracious; and their bowels are either affected with costiveness or with diarrhoea. Whatever kind or amount of nourishment is taken, they are generally thin and pale—and of an indolent and languid habit—while their sleep is often disturbed by frequent startings and grinding of the teeth. Each and all of these symptoms, however, may be present, and not a single worm 234 DISEASES OF CHILDREN. be present in the intestinal canal. According to Rosen, one of the most certain indications of worms, is the relief experienced by the patient after having discharged portions of them, or after taking a a glass of cold water.* We are furnished by authors with a long list of sympathetic affec- tions, all of which are said to have been repeatedly produced by the irritation of intestinal worms, and to cease upon the expulsion or destruction of the latter. To this cause have been ascribed epilepsy, hysteria, chorea, convulsions, dilatation of the pupils, perverted vision, amaurosis, convulsive laughter, spasmodic closure of the glottis, hydrophobia, aphonia, and haemoptysis ; it is even asserted that symp- toms simulating those of hydrocephalus, disease of the heart and lungs, croup, and pertussis, have been produced by worms. That the several morbid conditions here enumerated, are capable of being produced by intestinal irritation, we are perfectly aware; how far, however, they are attributable to the presence of worms, it is somewhat difficult to decide. In many cases the very remedies to which the expulsion or destruction of the latter is attributed, may effect the cure of the morbid symptoms with which the patient was affected, by the removal of an irritation of the intestines totally inde- pendent of the presence of worms. A number of cases are related, in which the most violent paroxysms of dyspnoea and spasmodic cough, were produced by the passage of lumbricoides from the stomach into the posterior fauces ; they have occasionally also found their way into the trachea and bronchii, and caused the death of the patient. (Holler, Blandin, Andral, Fiichs, Fortassin.) By many writers worms are supposed, in some cases, to destroy life, by perforating the coats of the intestine. We have, in more than one instance, detected lumbricoides in the cavity of the peritoneum, the intestine being perforated at one or more points; we have seen them likewise in the act of passing through a perforation of the intes- tine, and, apparently so firmly fixed in the opening as to be unable to proceed further. In all these cases, a close examination has convinced us, that the perforation was the result of disease—either softening or ulceration—and not produced by the worms. It has indeed been denied, and very correctly, that worms are capable of perforating the intestinal coats. (Andral, Rudolphi, Frank, Cruveilheir, Clnqurt, Carswell, Stokes.) Rudolphi declares that they possess no apparatus for effecting a passage through any continuous membrane; and Andral remarks, that there is no well authenticated instance on record of such an occurrence. How far, in any case, the perforation may be the result of an inflammation, followed by softening or ulcera- tion, excited by the presence of worms in the intestines, is a question difficult of solution. So far as our own observations extend, we * Dr, Ebcrle has strangely mis-stated this observation of Rosen von Rosenstien. DISEASES OF THE DIGESTIVE ORGANS. 235 should unquestionably assume the negative. With Dr. Evanson, we believe, that worms may exist at the same time with intestinal inflam- mation or ulceration, as these affections are common in those children who are most subject to worms ; and, should the intestines be perfo- rated by softening or ulceration, the lumbricoides, if present, will often pass through, and be found in the peritoneal cavity; but this is a consequence, and not the cause of the perforation. In proceeding to the treatment of a supposed case of verminous disease, it is important, at the very outset, to determine, not only the fact of the actual existence of worms, but, if they do exist, whether they are in any degree concerned in the production of the morbid phenomina under which the patient labours. Both of these circum- stances, but particularly the latter, are too often taken for granted, and the most serious errors are, in consequence, committed; the real disease is overlooked, and one vermifuge after another is resorted to, while the patient, notwithstanding the abundant discharge of worms occasionally produced by them, exhibits no improvement, but sinks more or less rapidly, into a state of suffering and debility, the termina- tion of which is death. We are to recollect, that almost every symptom said to indicate the presence of worms in the intestines, is produced by irritation of the alimentary canal, and may occur without their existence; and that even in those cases in which the presence of worms is proved beyond doubt by their appearance in the discharges, there is no certainty that they are the cause of the symptoms which exist, or that they are not a mere coincidence.—(Stokes.) In every supposed verminous case, therefore,"we would advise that all heating and irritating vermifuges be abstained from, and that our treatment be directed chiefly to restore the regular healthy action of the digestive organs, and the strength and vigour of the body gene- rally. We have been in the habit of pursuing this plan for a number of years, and have seldom been disappointed in promptly and effectu- ally relieving our patients, and have had but little necessity for resorting to either of the articles which strictly appertain to the class of anthelmintics. A regulation of diet, is of the first importance in every case, and the articles of which it should be composed, will, in a great measure, depend upon the condition of the alimentary canal: if this is in a state of severe irritation, or of sub-acute inflammation, the diet should consist solely of rice water, or of rice with milk; but where the irritation is less decided, the child may be allowed stale wheat bread with milk, night and morning, and in the middle of the day, some fresh animal food, as mutton chop, boiled fowl, or beef steak, in small quantity, with bread or crackers. To this may be added, plain beef, mutton, or chicken broth, with rice, or plain rice pudding. Fresh vegetables, fruit, pastry, salted food, tea and coffee, and every species of confectionary should be interdicted. It will frequently be found difficult, at first, to induce children who have been indulged 236 DISEASES OF CHILDREN. with all kinds of improper food, to restrict themselves to so plain a diet; but it is better to let the child fast, than to deviate from it. With a proper degree of firmness on the part of the parents and attendants, the period of abstinence will seldom be a very protracted one. (Alex- ander.) The child should be allowed and encouraged to exercise in the open air, for several hours every day; and, as far as possible, a situation should be made choice of for this exercise, in which dryness is com- bined with perfect purity of the atmosphere. Nothing is better calculated, by invigorating the functions of the digestive organs, and improving the health of the body generally, to prevent the develop- ment of worms in the intestines, and the inconveniences thence resulting, than a sufficient amount of active out door exercise; and yet the weakly, debilitated child, in whom worms are most apt to occur, and to produce the greatest amount of mischief, as well from his own indolence and inertness of disposition, as from the prejudices and misplaced tenderness of parents, is the one most generally kept inactive and within doors. Next to diet, exercise, and exposure to fresh, pure air, nothing is so important in these cases, as frequent warm bathing—followed by frictions to the surface; the functions of the skin are promoted by it, the circulation of the blood is equalized, and the stomach and bowels, in common with every internal organ, become invigorated. In regard to the employment of medicinal articles, in cases of worms, the propriety, as well as the character of these, will depend very much upon the condition of the digestive organs. If the symptoms pres- ent indicate that the latter are in a state of severe irritation, or of inflam- mation, whether acute or sub-acute, it will be necessary, before resorting to the administration of any internal remedy, to allay the irritation or inflammation, by leeches, fomentations, and cool mucila- ginous drinks. There are few cases in which, however, we may not venture upon the administration of calomel, either in a full dose, fol- lowed, in a few hours, by a portion of castor oil, or in smaller, and frequently repeated doses, combined with ipecacuanha and extract of hyosciamus. Three grains of calomel, with half a grain of ipecacu- anha, and the same quantity of hyosciamus, given three times a day, will seldom fail to act as a pretty effectual purgative; and we have known it to bring away large quantities of lumbricoides. If nothing is present to forbid its use, we may give a purgative of calomel, rhubarb, and jalap—the proportions of each ingredient being adapted to the age of the child ; or, perhaps, a better combination will be, cal- omel, jalap, and scammony, given at first in a full dose, and repeated subsequently, in small, alterative doses, on every alternate night, at bed time, succeeded, on the morning following by a small dose of castor oil. (Alexander.) In cases of lumbricoides, attended with a disordered condition of the stomach and bowels, without any evidence of inflammation, we have found this to act very favourably. The article, however, from which we have derived the most DISEASES OF THE DIGESTIVE ORGANS. 237 decidedly beneficial effects in verminous cases, is the spirits of tur- pentine. It may be given in those in which there exists considerable irritation of the alimentary canal, or even sub-acute inflammation, without any fear of its increasing either; and while we have found it more certainly than almost any other article to effect the destruction of the worms, it, at the same time, would appear to produce a bene- ficial action upon the digestive organs, and to aid in restoring them to a healthy condition. The turpentine may be given with perfect safety, to the youngest child in which worms usually occur. The rectified spirits should be directed, and may be given in sweetened milk, in molasses, or in the following mixture.3 It is generally recom- mended to be given in much larger doses, from half a drachm to a drachm, combined with or followed by castor oil; (Alexander, Cop- land, Evanson;) we have preferred, however, smaller doses; either thirty drops upon a piece of loaf sugar, three times a day, or in the mixture referred to. The spirits of turpentine is a remedy equally adapted to all the varieties of worms, and of all the anthelmintics it is the one, in favour of the efficacy of which the greatest amount of evi- dence can be adduced. (Bartholine, Chabert, Fenwick, Chisholm, Copland, Coffin, Klapp, Alexander, Marley, Schmidt, Eberle.) aR—Mucilag. G. acacias, gij. Sacch. alb. 3X- Spir. aether, nitr. 3iij. Spir. terebenth. rec. 3iij. Magnes. calcinat. 9j. Aq, menthas, 3j.—M. Dose.—A dessert spoonful every three hours. The cowhage or down of the dolichos pruriens, is recommended as a safe and useful remedy for the expulsion of worms ; (Kerr, Cochrane, Macbride, Underwood, Bancroft, Chamberlaine, Stokes;) especially the lumbricoides, and oxyures.a We know nothing of the article from our own experience, having never employed it. In its use, care should be taken to combine it intimately with the honey or syrup, and to prevent any portion from being spilled upon the lips, face, breast, or arms of the patient. ■R.—Spicular. Dolichi, 3j. Or, R.—Spicular. Dolichi, 9j. Mollis vel sacchari liquid, impur. Syrup, cort. aurant. 3j.—M. f. elect- q. s. ut fiat electuarium. uar. Dose.—A teaspoonful to be given every Dose.—A teaspoonful to be given three times morning, fasting for three successive a day, for two or three successive days, days, and then followed by a brisk and then followed by a purgative. cathartic. The oleum chenopodii is a remedy in considerable repute with American practitioners ; we have employed it in some cases with decided advantage.1 aR—01. chenopodii, 3j. Sacch. alb. pur. Gum. acacias,aa 3jss-—M. dien adde Aq. menth. sativas, gijss. Dose.—A teaspoonful every three hours, for two days in succession, to be followed then by a dose of castor oil. 23S DISEASES OF CHILDREN. It should not be given in any case in which we have reason to suspect the existence of inflammation of the intestines, or that is accompanied with febrile excitement. The following formula is strongly recommended by Bremser, in cases of lumbricoides; and has been employed in several cases by Eberle, with complete success. Exhibited to such an extent as to produce frequent and watery evacuations, it does far less good, than when managed so as to procure three or four consistent stools daily." (Eberle.) aR.—Sem. Sanlon. Fol. tanaceti vulgar, contus. aa. ^ss. Rad. valerian, pulv. 3ij. " Jalapas " ojss- Sulpha!, potassas, 3'j- Oxymel. scillas q. s. ut ft. electuarium. Dose.—A teaspoonful two or three times a day, for six or seven days. The fucus helminthocorton is a favourite anthelmintic with most of the French physicians ; Dr. James Johnson, of London, declares it to be one of the most powerful of all anthelmintics. A strong decoction thrown into the rectum, destroys, he remarks, any worms domicili- ating there, as effectually as choke-damp would destroy the life of a miner. A strong decoction of the helminthocorton has appeared, to Dr. Eberle, not only valuable as a vermifuge, but particularly so, as a corrective of that deranged and debilitated condition of the alimentary canal, favourable to the production of worms. An ounce of the hel- minthocorton with a drachm of valerian, should be boiled in a pint of water down to a gill; of this, a teaspoonful may be given every morning, noon, and evening, with peculiar advantage. Dr. Eberle has known several instances, in which children, apparently suffering from verminous irritation, were restored to perfect health by the use of this remedy, without any appearance of worms in their excretions. It is particularly beneficial in cases attended with the usual symptoms of worms, with want of appetite, and mucous diarrhoea, arising from mere debility of the digestive organs, and a vitiation of the secre- tions of the bowels. Common salt is, perhaps, one of the best anthelmintics we possess ; it has often succeeded in the destruction of worms when other reme- dies have failed. (Marley.) It was a favourite remedy with Dr. Rush, and whenever we have been able to induce children to take it in a sufficient dose, we have never been disappointed in its effects; an ordinary sized teaspoonful dissolved in a wineglassful of water, is the proper dose for a child two or three years old. A number of other anthelmintics might be noticed, as garlic, tin filings, spigelia Marylandica, the green rind of unripe walnuts. Those we have enumerated, are, perhaps, among the best and most success- ful we possess. Several German practitioners have lately recom- mended the etherial tincture of the buds of the male fern, (polypodium fdix mas,) as a most effectual remedy in cases of intestinal worms. DISEASES OF THE DIGESTIVE ORGANS. 239 Peschier, of Geneva, is the discoverer of this tincture; his brother asserts, that he has cured 150 cases of lumbricoides, trichocephali, and teniae, in nine months, with this remedy alone. Dr. Fosbroke appears also to have had great success with the remedy ; dose—from one to ten drops in pills, or on sugar. After the removal of the worms, some light bitter infusion, or achaly- biate will be proper to restore tone to the stomach and intestines. The infusion of gentian or calomba, with an equal portion of an infu- sion of rhubarb, and a few drops of the compound spirit of ammonia, is recommended by Marley; we may, however, employ the tincture of the sesqui-chloride of iron, by itself, or in combination with the tincture of aloes, as recommended by Stokes ;a or the carbonate of iron, which was a favourite prescription of Dr. Rush ; of which five to ten grains may be given to a child a year old, every morning. Dr. Dewees considers a combination of equal parts of carbonate of iron and com- mon salt, from ten to thirty grains, according to the age of the child, to be one of our best tonics, in cases in which there is a strong dispo- sition to the generation of worms. The powders should be given in syrup or molasses, in the morning, fasting, for twelve successive days. »R.—Tinct. ferri sesquichlor. Tinct. aloes, aa partes asq. Dose.—Twenty drops, three or four limes a day. In cases in which children are infested with oxyures, the same general treatment will be proper, as in the other varieties of intestinal worms ; as these, however, almost invariably inhabit the lower por- tion of the rectum, and their presence can generally be detected by the inordinate itching at the anus, to which they give rise, as well as by their appearance, often in immense numbers, in the discharges, or by their passage from the rectum, while the child is asleep in bed ; we have it in our power to dislodge or destroy them by injections thrown into the rectum. A great variety have been recommended for this purpose; among the most effectual of which, may be ranked a solution of common salt, turpentine,* aloes,b an infusion of helminthocorton,c lime water and milk, camphor," a solution of sulphate of iron,e or a solution of assafoetida in milk.f BR.—Spir. terebenth. rec. 3j. CR.—Fuc. helminthocorton, gj. Lactis, giv.—M. Aquas, Oj. Or, R.—Spir. terebenth. rec. 3j. Boil to one-half. Vitell. ovi, dR.—Camphor, gr. xv. Aquas, giv.—M. Olei olivas. giv.—M. bR. — Decoct, aloes, giij. eR.—Ferri sulphat. 3j. Lactis, gj.—M. Aquas, giv.—M. Or, R.—Gum. aloes, 3ss. fR.—Assafcetidas, 9ij. Lactis, giv — M. Lactis, giv.—M. A bougie smeared over with strong mercurial ointment, and intro- duced into the rectum, will often prove successful; while the preci- pitated sulphur, taken for a few mornings in succession, is said to be 240 DISEASES OF CHILDREN. a most efficacious means for the destruction of the oxyures. (Von. vert.) The complete removal of these worms is a work of no little diffi- culty. They are surprizingly productive, and even after thousands have been discharged, they are found, after a very short period, to have re-accumulated to the same extent as before. By pursuing at the same time a course of treatment calculated to restore the healthy functions of the alimentary canal, we may very generally succeed in preventing, finally, their re-production, by the use of purgatives com- posed of blue mass, aloes, Venice turpentine, and extract of hyos- ciamus,* and the occasional use of either of the enemeta just enume- rated. ■R.—Mass. f. pill. hyd. Terebenth. Venet. Aloes, gr. aa xxxvj. Extract, hjosciurni, gr. xx.—M. f. pill. No. xxv. Two to be given every three hours, until an active purgative effect is produced. These worms are chiefly annoying from their becoming involved in the pouches and folds at the lower part of the rectum, and giving rise, occasionally, to violent tenesmus, or more commonly, to an insupportable titillation and itching about the anus. This is gene- rally experienced to the greatest extent towards evening, or soon after the child is put to bed ; often preventing sleep, and producing a con- siderable degree of nervous irritability. They are said occasionally to give rise to inflammation about the anus, and convulsions; the first may perhaps, be occasioned by the frequent rubbing and scratching of the part, by the child, to allay the inordinate itching;—the second we have never witnessed. 8.—Enteritis.—Inflammation of the Small Intestines.—Ileitis. Inflammation of the small intestines, either alone, or combined with inflammation of the stomach, or of the large intestines, is a much more frequent disease during infancy and childhood, than is even now gene- rally supposed. The diarrhoea, as well as vomiting, so common in the earlier stages of life, is, as we have already seen, in a large number of cases, the indication of enteritis, or gastro-enteritis; while many of the diseases, described by the leading writers on the diseases of children, as distinct affections, are, in fact, the result of different grades of inflammation, seated in the mucous membrane of the small intestines:—this is unquestionably true of the intermittent or worm fever of infants, and of the tabes mesenterica in its most usual form ; as has been ably pointed out by Drs. Cheyne, Marsh, Mackintosh, and Stokes; the same is true, likewise, of the atrophia ablactatorum, as our own examinations have fully proved; and the enumeration might, if necessary, be extended much further. The leading symptoms of infantile enteritis are, vomiting, diarrhoea, tension, and tenderness or pain of the abdomen upon pressure, often DISEASES OF THE DIGESTIVE ORGANS. 241 accompanied by augmented heal of its surface, tympanitis, redness and dryness of the tongue, and general heat and dryness of the skin. The matters vomited are usually of a yellow colour, and of a frothy appearance; vomiting is not, however, invariably present and, unless some degree of gastritis occurs, it does not take place immediately after the ingestion of food or drinks. When the inflam- mation affects the ileo-coecal valve, the consequent tumefaction may prevent, or so far obstruct the passage of the faeces, as to give rise to fiecal vomiting, as in other cases of intestinal obstruction. Diarrhoea is more generally present than vomiting—with it the disease often commences, or it occurs at an early period of the attack; the discharges are usually of a green or yellow colour, and sometimes bloody, but rarely serous. Tympanitis, and more or less tension of the abdomen, with pain, or at least, tenderness upon pres- sure, are almost constant indications of enteritis. The tenderness or pain is situated lower down than in cases of gastritis; it is also more diffused, and seldom so intense. The patient, in general, lies upon his back, with his knees drawn up, and his countenance is always expressive of great distress. The skin is usually hot and dry, and the increase of temperature is often most striking at the abdomen. The tongue is usually red at its point and edges, dry, and coated, on its upper surface, with a layer of white or yellowish mucus; the redness and dryness of the tongue, however, are most marked in cases of gastro-enteritis ; in those of simple enteritis, the tongue may be moist, and of its natural colour. There is usually more or less thirst; but the desire for cold drinks is not so evident as in the acute febrile affections. Notwithstanding the increased heat and dryness of the skin, and augmented thirst, a decided febrile reaction is seldom met with in cases of enteritis, occurring previous to dentition ; subsequently, however, the disease is often attended with fever of a remittent form, with evident exacer- bations towards evening. There is also considerable and rapid pros- tration of strength, far greater than can be accounted for by any degree of diarrhoea that usually attends the disease. in the advanced stage of enteritis, the diarrhoea in general decreases, but the abdomen continues tense and tympanitic; the skin assumes an ashy hue, and becomes cool, particularly at the extremities, which are often decidedly cold ; great emaciation ensues, the cheeks become hollowed, the eyes sunken, and the face wrinkled and contracted; which, when the teeth are not yet developed, gives to it the appear- ance of premature old age. The whole expression of the counte- nance is that of prolonged suffering ; and to the experienced observer affords a very certain indication of the existence of long continued and extensive intestinal disease. In the chronic forms of enteritis, it is not uncommon for very con- siderable enlargement of the mesenteric glands to take place ; this is particularly the case in children of a very decided lymphatic temper- 10 242 DISEASES OF CHILDREN. anient, but it may occur without this predisposition to glandular affections, in consequence of the propagation of disease along the course of the lymphatics, from the mucous surface of the intestines, to the mesenteric ganglia. (Stokes.) In the great majority of instances, tabes mesenterica is, in fact, the result of chronic or sub-acute enteritis; this connection of the two diseases was long since pointed out by Cheyne, and will be evident to any one who will trace back the history of each case to its earlier stages, and carefully examine, in the event of a fatal termination, the condition of the mucous membrane of the ileum; in which, very generally, will be found the evidences, if not of existing, at least of preceding inflam- mation. This L / u a matter of merely theoretical nicety, but has a very important practical bearing ; the usual treatment pursued in cases of tabes mesenterica, being one rather calculated to augment, lhan to remove the disease ; whereas, the treatment proper in cases of enteritis, if pursued from the commencement of the attack, will, very generally, prevent the occurrence of the mesenteric affection, and even where the latter has already occurred, it is the only one calculated to effect its removal. This statement we make as the result of a tolerably extensive experience, among a class of patients who are generally reputed to be most liable to tabes mesenterica. Most commonly, enteritis is more or less prolonged, and the patient, in a state of extreme marasmus, dies from exhaustion ; occasionally, however, the disease assumes a more acute form, and death occurs at an early period, from violent peritonitis, the result of a perforation of the coats of the intestines, from ulceration or softening. It is important to bear in mind the fact, that in cases of enteriiis, sympathetic irritation of the brain, or of the lungs, is very liable to take place ; and when these sympathetic irritations are somewhat intense, they are apt to obscure the original disease, and cause it to be entirely overlooked. It is essential to the safety of the patient, that the true character of these cases be well understood; for while the sympathetic affection is not to be overlooked, lest it run on into inflammation of the organ in which it is seated, and produce effusion or disorganization, at the same time the original disease should not be neglected, for so long as this continues unabated, the removal of the secondary affection is with great difficulty effected. The pathological appearances, observed, after death in cases of enteritis, are various ; in some, the mucous membrane of the ileum presents irregular patches of redness, of greater or less extent, indifferently situated, either in a depending or non depending portion of the tube. (Billard.) These patches are generally accompanied with tumefaction of the tissue, at the parts where they are situated, and often by a softened or friable condition of the latter; there is, at the same time, often more or less blood effused in the intestinal canal —often of a dark, softened appearance. In many eases, the intestinal mucous membrane is studded with flakes of curd-like matter, gene- rally of a yellow or greenish colour ; these flakes adhere to the sur- DISEASES OF THE DIGESTIVE ORGANS. 243 face of the membrane, and cannot be separated without a slight de- gree of force. The muciparous follicles of the intestines are often enlarged ; occasionally they are also red, and frequently are in a slate of ulceration;—the inflammation may occur in the isolated follicles, or in the follicular plexuses. In chronic cases, dark purple or slate coloured patches or striae, upon some portion of the intestinal mucous membrane, are not uncommon. Softening of the mucous membrane, to a slight degree, is very often present; but, in chronic cases, the tissue is occasionally reduced to a soft, reddish, sometimes diffluent mass. (Billard.) The ulcerations, as well as the softening, may implicate the entire thickness of the intestinal coats, giving rise to perforations, with escape into the peritoneal cavity of the contents of the bowels ; in such cases, death quickly ensues, in consequence of the occurrence of acute peritonitis. Billard, Beclard, Cloquet, and others, describe a species of gangrenous ulceration, as one of the terminations of enteritis; thus certain ulcerations of the ileo- coecal region, occasionally exhibit the same black, soot-like edges, that occur in ulcerated apthaeof the mouth,(Billard,) or some circumscribed points of the mucous membrane become changed to. a greyish pulp, which, on separating, gives place to an ulcer wTith projecting edges. The bottom of the ulcer is destroyed more or less quickly, and a complete perforation of the intestine ensues; adhesions are often promptly formed between the peritoneal surface of the intestines, and prevent an escape of the contents of the bowels. (Cloquet.) We have repeatedly observed all of the lesions here described, with the excep- tion of the last, with which we are not familiar. Ulcerations are extremely common, in all protracted cases ; they are sometimes very numerous throughout the whole of the ileum, (Abercrombie,) and vary in diameter from that of a split pea, to that of a sixpence. The me- senteric glands are frequently enlarged, and very vascular, and, in chronic cases, are often in a state of suppuration, or converted into a cheese-like matter of greater or less firmness. The causes of enteritis are, in general, overloading the stomach with food, improper articles of diet, the influence of cold, and an impure and confined state of the atmosphere. They are the same with those usually noted, as productive of diarrhoea in infancy and childhood; in fact, in a large number of cases, the disease commences with an attack of ordinary diarrhoea, which, being neglected or mis- managed, vomiting, intumescence and tenderness of the abdomen, heat and dryness of the surface, with the other symptoms of intestinal inflammation, are successively developed. In many cases, the occur- rence of enteritis is either caused or accelerated by the repeated purgatives to which infants and young children are so often subjected, for the cure of every accidental disturbance of their stomach or bowels, or for the removal of worms. The treatment of enteritis differs but little from that of gastritis. The diet should be restricted to some mild mucilaginous fluid, as rice water, gum water, infusion of the bark of slippery elm, or milk diluted with barley water, and sweetened with a small quantity of loaf sugar. 244 DISEASES OF CHILDREN. The warm or tepid bath is an all-important remedy ; nothing in all the inflammatory affections of the alimentary canal produces so sooth- ing and tranquillizing an effect upon the patient. The bath should be repeated daily, or, in severe cases, even oftener:—its temperature should be regulated, according to the state of the child's surface— being decidedly warm, when the heat of the skin is deficient, and of tepid warmth, when it is augmented. Warm, emollient cataplasms upon the abdomen exert likewise a beneficial effect upon the symp- toms of the disease, and tend to allay the local tension and pain. In most cases, leeching will be proper; the leeches should be ap- plied over the surface of the abdomen, and graduated in number, according to the intensity of the local symptoms. Some degree of judgment, however, will be demanded, in the employment of leeches, in inflammations of the intestines. Few cases occur, in which a mo- derate application of them will not be proper and beneficial; and whenever the pain, heat, and tension of the abdomen are considerable, they should be more freely employed, and may be repeated, if the first application fails to produce a decided abatement of the symptoms just enumerated. While we are cautious, in no instance, to carry the leeching to such an extent, as greatly to increase the prostration of the patient's strength, we should recollect that, in violent cases, a favourable termination of the disease will, in a great measure, depend upon the early employment of a sufficient number of leeches. To allay the diarrhoea which, in many cases, is a prominent and very troublesome symptom, many physicians recommend the employment of opiate injections ; but in acute cases, we are by no means convinced of their propriety. We have, however, derived advantage from the exhi- bition of minute doses of calomel, ipecacuanha, extract of hyosciamus, and acetate of lead.* These we have found not only to arrest the diar- rhoea, but to have a beneficial effect upon the intestinal disease, allay- ing pain and irritation, and producing natural and regular evacuations. If, from any cause, this combination should be considered as unadapt- ed to the case, the acetate of lead in solution may be given by the mouth, or in the form of enemata. 1 R.—Calomel, Ipecacuanhas, aa gr. ij. Ext. hyosciami, gr. iv.—vj. Acctat. plumbi, gr. viij.—xij.—M. f. pill. No. xij. One to be given every three hours. Blisters to the abdomen will often be found advantageous, especially in protracted cases ; they should be kept on a few hours, and followed by a bread and milk poultice. In very acute cases, warm sinapised pediluvia, or sinapisms to the extremities, will generally be productive of good effects. In chronic cases, the warm bath, blisters to the abdomen, the in- ternal exhibition of calomel, ipecacuanha, and extract of hyosciamus, with the addition, when diarrhoea is present, of the acetate of lead; and when the discharges are thin and offensive, the use of turpentine DISEASES OF THE DIGESTIVE ORGANS. 245 are the remedies, from which the greatest amount of relief will be ob- tained. The diet should be mild, unirritating, and taken in small quantities, at properly regulated periods ; plain chicken water, arrow root, tapioca and milk, or beef tea, will, in most cases, be proper articles of food—producing but little irritation, and supporting the patient's strength, which, in cases of chronic enteritis, is very apt to be greatly prostrated. By some practitioners, it is considered bene- ficial to dress the blisters upon the abdomen, with mercurial ointment, or to apply this by friction over the abdominal surface, in cases where blisters have not been applied. When a state of convalescency has been procured, the skin becom- ing soft and moist, the tongue clean, the stools more regular and na- tural in appearance, with a disappearance of the tenderness and tume- faction of the abdomen, and a return of the natural appetite, the administration of some light tonic will, in general, be found beneficial, —more rapidly restoring the patient's strength, and rendering a relapse less liable to occur. 9.—Colitis.—Inflammation of the large intestines.—Dysentery. Inflammation of the large intestines seldom occurs independently of some degree of enteritis, and is occasionally accompanied with more or less gastro-enteritis. It is chiefly distinguished from enteritis, by frequent small discharges from the bowels of mucus, generally mixed with more or less blood, and accompanied with severe tormina and tenesmus. In children, dysentery generally commences with the symptoms of ordinary diarrhoea, the discharges being at first fceculent, but soon becoming serous, with an admixture of blood. There is often tension of the abdomen, with pain or tenderness upon pressure along the course of the colon; the skin is generally dry and hot, and in chil- dren of a year old and upwards, distinct febrile reaction, with evening exacerbations, is often present, with redness of the tongue and in- creased thirst; nausea and vomiting are occasionally observed, but are seldom frequent or severe, unless the stomach is the seat of inflamma- tion. The discharges from the bowels become, at an early period of the disease, very frequent, but small in quantity, and composed entirely of a little bloody mucus. They are generally preceded by more or less tenesmus, and attended and followed by tormina. There is seldom any appearance of fceculent matter in the stools, though occasionally it is passed in hardened masses of various sizes mixed with blond and mucus. If the disease is not arrested, the anus becomes red, hot, and exceedingly painful—and the abdomen hot, swollen, and tympanitic, and often affected with severe pain, or is excessively sore to the touch ; the surface of the body becomes cool, and the extremities cold; the discharges from the bowels become dark coloured and offensive; great prostration of strength ensues, and the patient exhibits ail the symptoms of chronic intestinal 246 DISEAS.ES OF CHILDREN. disease. The mouth often becomes affected with apthre, which like- wise occasionally appear about the verge of the anus. Colitis may terminate, at an early period, by the intensity of the inflammation, but, in general, it runs a protracted course, and the patient sinks from extreme prostration ; or a state of coma ensues, and death is preceded by symptoms of encephalic effusion. The appearances upon dissection differ in nothing from those that occur in cases of enteritis, excepting in their seat; the mucous mem- brane of the colon and rectum is affected with red elevated patches or striae; with friability or softening of the tissue, at the part where they are situated. The surface of the colon and rectum are occasionally covered with filaments, varying in size, of a curd-like matter. En- largement, inflammation and ulceration of the muciparous glands and follicles are very commonly met with ; gangrenous ulceration is oc- casionally present, and in chronic cases especially, thickening, with a dark purple, or slate colour of the mucous membrane of the colon or rectum, to a greater or less extent. Dr. Crampton has observed, in cases of children who died of dys- enteric symptoms, the mucous membrane of the intestines, in many places, highly vascular, and covered with granulations of a yellow, or dirty yellow colour, as if from a coating of wax; in several, ulce- ration had taken place ; these ulcers were disposed in patches, with well defined edges. In cases that terminated favourably, a quantity of yellowish, branny scales, was seen floating in the discharges from the bowels, like minute portions of wax from honey comb. Colitis would appear, in the majority of cases, to be the result of sudden transitions of atmospherical temperature, particularly the sud- den change from warm and dry, to cold, damp weather. It is most prevalent during the latter part of summery or cpmmencement of au- tumn, when the days are hot, but the nights chilly and damp. It is apt to prove endemic in unhealthy localities, especially those favoura- ble to the production of intermittent and remittent fevers, and often prevails epidemically with fevers of a catarrhal character. A few days of cool, rainy weather, occurring in the summer, will often cause the prevailing bowel complaints of children to assume a dysen- teric character. Colitis may, however, be produced by the same causes which give rise to inflammation of other portions of the alimentary canal. In the treatment of colitis, the same general directions are applica- ble as in the other intestinal inflammations. All solid, stimulating, and indigestible food should be avoided. The patient may be allow- ed to take pretty freely of mild mucilaginous drinks ; but even with these he should not be allowed to overload his stomach. The free use of buttermilk has been found advantageous, in many cases of dysentery in children. (Young, of Chester.) The warm bath, and warm fomentations or cataplasms to the abdomen, are equally beneficial here, as in cases of enteritis. Leeches should be applied, along the course of the colon, in numbers, proportioned to the DISEASES OF THE DIGESTIVE OR.GANS. 247 viol nee of the disease, and the strength and age of the patient, and repeated, if, after their first application, the symptoms remain without considerable abatement. By some practitioners, leeches are directed to be applied to the verge of the,anus; occasionally, this will be found to produce a very favourable impression upon the symptoms of the case; but, as a general rule, we cannot recommend the application of leeches to this part; we have occasionally found the haemorrhage produced by them, to continue for some time after their removal, and to be, with difficulty, controlled. In cases, in which symptoms of gastritis are present, leeches should also be applied to the epigastrium. In robust children, over one year of age, when the disease is accom- panied by symptoms of any degree of intensity, blood may be taken from the arm. In regard to the use of internal remedies, there exists a very great di- versity of opinion, among practitioners. Tothe common practice of giv- ing small and repeated doses of castor oil, either with or without an addition of laudanum, we are decidedly opposed ; we have seen much injury result from it, and cannot understand the principles, upon which the treatment is founded. From the administration of small doses of calomel, in combination with ipecacuanha, we have derived the best effects, and believe that a small portion of extract of hyosciamus, agreeably to the plan pursued by many of the German physicians, forms an admirable addition.* The relief produced by this combina- tion, is often prompt and considerable, while a favourable change is produced, in a very short time, in the character of the discharges. a R.—Calomel, gr. iv. ad xij. Ipecacuanhas, gr. iij.—iv. Ext. hyosciami, gr. vj.—viij. Cretas ppt.gr. xxxvj.—M. K pulv. No. xij. One to be given every three hours. In protracted cases, the application of a blister over the abdomen, as directed in enteritis, we have repeatedly seen productive of very beneficial results. Injections, into the rectum, of a solution of acetate i of lead, with or without laudanum, are calculated to allay the tor- ' mina and tenesmus, and may be repeated with advantage; we must recollect, however, that much caution is to be observed, in the use of opium and its preparations, in the form of enemata, in the diseases of children. Experience early taught us, that very small portions of laudanum thrown into the rectum, will often produce a degree of narcotism, which would be scarcely anticipated from a similar quan- tity given by the mouth ; the same fact has been noticed by other practitioners. (Billard, Stokes.) As soon as the more acute symptoms of the disease have been sub- dued, we are in the habit of giving the acetate of lead, in the dose of one grain, combined with a third of a grain of ipecacuanha, one grain of extract of hyosciamus, or a twelfth of a grain of opium, and a sixth of a grain of calomel, repeated every three hours, and have seldom been disappointed in effecting by it the entire removal of the disease. In chronic cases of colitis, the same treatment is applicable, as in 248 DISEASES OF CHILDREN. chronic diarrhoea. The spirits of turpentine will, in such cases, be often found a very valuable remedy. During convalescence from colitis, more especially, in its more protracted and chronic forms, the vegetable astringents will be found advantageous, in restoring tone to the intestines, and facilitating the recovery of the patient's strength. In an epidemic of dysentery that occurred among children, in Washington county, j\'ew York, an infusion of white oak bark, black- berry root, and yarrow, in milk, with the addition of sugar,* was found to be productive of the best effects. (Cogswell.) The perses- quinitrate of iron is also spoken of as a useful remedy, in cases of dysentery occurring, in children. (Williams.) »R.—Cort. querci. alb. Rad. rub. villosi.aa, gss. Fol. achill. millefol. 3'iij. To be boiled in Oj. of milk. A dessert spoonful, to be given frequently. 10.—Peritonitis.—Inflammation of the Peritoneum. Inflammation of the peritoneum frequently occurs in children, even from the earliest periods, after birth. In still-born infants, as well as in those who have died a few hours after birth, so frequently has there been found to exist redness and opacity of the peritoneum, with serous or puriform effusions; a coating of coagulable lymph,either in the form of flocculi or membranous shreds; adhesions between the intestinal con- volutions and other abdominal viscera, some slight and recent, and others very firm and apparently of long continuance; or tubercular granulations of the peritoneum, that we are perhaps to include peri- tonitis, among the most common and fatal of the diseases, to which the foetus in utero, or the child immediately after birth, is liable. (Morgagni, Desormeaux, Cruveilheir, Juncher, Andral, Dugis, Veron, Brachet, Legouias, Krantz, Billard, Simpson, King.) Peritonitis, either in an acute or chronic form, is frequently deve- loped in children, from the period of birth to that of puberty; it is indicated by tension and pain of the abdomen, more or less acute, and invariably increased upon pressure ; restlessness, constipation, and a peculiar contracted and distressed expression of the face. The pain of the abdomen is constant, and often extremely acute, and the tenderness, in severe cases, is such as to cause the slightest pressure, even that of the clothes, or the coverings of the bed, to be insup- portable. The abdomen is commonly tense and swollen, rising in a point towards the umbilicus, (Billard,) and in the course of the dis- ease, tympanitis very generally occurs. The child lies upon his back with his knees drawn up, and exhibits extreme restlessness;—his cries are often constant and acute. The bowels are usually consti- pated, and the skin dry, but seldom hot. In children of two or three years of age, we have often seen the disease attended with very con- siderable febrile excitement; the pulse is generally small and frequent, DISEASES OF THE DIGESTIVE ORGANS. 249 and there is always great prostration of strength, with a contracted and suffering expression of the countenance, and not unfrequently considerable dyspncea. As the disease advances, there is generally frequent eructation or vomiting—coldness of the surface, particularly at the extremities, and often a livid or dusky appearance of the face. Peritoneal inflammation, occuring in children, requires the closest attention and tact on the part of the physician, to distinguish it from inflammation of the intestinal tube, wiih which it is often complicated. (Billard.) Peritonitis may be distinguished from pleurisy, by the absence of the physical signs of the latter; and from severe parox- ysms of colic, by the pain being continued, and increased upon pres- sure, while, in cases of colic, the pain is remittent, and is very gene- rally diminished by pressure upon the abdomen. In acute peritonitis, death often occurs at a very early period, the patient appearing to sink from exhaustion. In very many cases, however, the peritonitis of children assumes a chronic form ; when it constitutes probably one of the most insiduous affections of early life, its real character being very often overlooked, and a most injudicious course of treatment pursued. In chronic peritonitis, there is generally pain in the abdomen, seldom severe or continued, but occurring most commonly, in short paroxysms; more usually, however, there is only tenderness upon pressure—the patient shrinking or crying out, upon being lifted or handled ; the appetite is irregular, or but little affected ; the bowels are generally costive, but occasionally, there is more or less diarrhoea, alternating with constipation; the child is, in general, peevish, dull, and disinclined to exercise ; the pulse is small and quick; and the tongue covered with a whitish or yellowish mucus. The heat of the surface is often somewhat increased, and occasionally the disease is attended with fever of an intermittent form. The face is usually pale or sallow, and the expression of the countenance that of distress. The abdomen is generally more or less distended, and very often ex- hibits some degree of tympanitis. The emaciation is always conside- rable ; and, in most cases, there is tumefaction of the mesenteric glands. In the early stage of chronic peritonitis, the symptoms are frequently so slight, and of so obscure a character, that but little at- tention is paid to them by the parents; or the child is supposed to be labouring under worms, the serious character of the disease being entirely unsuspected, and a few, often improper domestic remedies are all that is prescribed. (Wolff, Abercrombie.) The progress of the disease is generally marked by increasing, and often extreme,emaciation and debility; with small,frequent pulse; hec- tic fever; night-sweats; often diarrhoea, with thin, dark coloured, and offensive discharges, and the patient finally sinks from exhaustion; in other cases, a serous effusion takes place within the cavity of the abdomen. The effusion is entirely confined to the peritoneal cavity, being unattended with oedema of the extremities even in protracted cases. (H7olff.) The tumefaction of the abdomen is never to the 250 DISEASES OF CHILDREN. extent which occurs in the common forms of acites. Sometimes it is so inconsiderable at first, that it is easily overlooked, especially in young children, in whom there is naturally a considerable promi- nence of abdomen. The fluctuation of the contained fluid can always, however, be distinctly perceived, by the usual means. Some writers mention a tumefaction occurring at the root of the nose, and causing a peculiar change in the appearance of the child's countenance, as a certain indication of peritoneal effusion. ( Wolff, JVasse, Konig.) The effusion increases daily in extent, and causes a gradual aug- mentation in the size of the abdomen ; every portion of the body, wiih the exception of the face, becomes more and more emaciated, and the exhaustion of the patient rapidly increases; the appetite, often, however, continues unimpaired, or is sometimes even increased. The bowels are variable; being at one time affected with diarrhoea, at others, constipated, or at least seldom opened. A febrile excitement of an intermittent form now generally occurs, and the patient in a state of extreme marasmus, sinks gradually into his grave. In the advanced stage of the more protracted cases, the symptoms are, tumefaction of the abdomen, emaciation of every part of the body, but particularly of the inferior extremities, with extreme debil- ity. The disease, under these circumstances, is very apt to be mis- taken for one of atrophy; and the usual irritating and deobstruent remedies, prescribed, under this supposition, serve only to aggravate the symptoms. The real nature of the case may, however, be very readily detected fr.om the previous history, and by the fluctuation discoverable upon an attentive examination of the abdomen; and by an appropriate treatment, it is still possible, in many cases, to pre- serve the life of the patient. {Wolff.) The appearances discovered after death, in cases of peritonitis, are, redness and thickening of the peritoneum—serous or puriform effusion —extensive deposition of flocculent matter, with adhesion, more or less extensive, of the convolutions of the intestines, or of these to the surface of the abdomen, or to the other viscera. The intestines are often coated with a thick layer of albuminous matter. The mesen- teric glands are generally enlarged, and occasionally in a state of suppuration, or softened, and converted into a curd-like matter. In chronic cases, circumscribed collections of puriform matter, occa- sionally exist between the convolutions of the intestines. Often the abdomen is distended, with a large amount of whitish or citrine col- oured serum, with small, albuminous flocculi, diffused throughout it. The peritoneum is often studded with minute tubercles. The mucous coat of the intestines, presents often the indications of chronic inflam- mation, particularly ulcerations, to a greater or less extent. Peritonitis is usually the result of cold :—it may however, particu- larly in its chronic form, supervene upon slight attacks of any of the acute affections of the alimentary canal, or upon other febrile dis- eases, as measles, or scarlatina. (Abercrombie.) It may attack chil- dren of any age, but is most common in those between two and fiye DISEASES OF THE DIGESTIVE ORGANS. 251 y ars of age. ('Volff.) An acute attack of peritonitis may be the result of perforation of the intestines, from disease of the alimentary canal. In the treatment of peritonitis, a careful regulation of the diet is all important:—thin gruel, or any of the mucilaginous fluids directed in enteritis, may be allowed. As early as possible in the attack, leeches should be applied to the abdomen, especially in the neighbourhood of the umbilicus, in numbers proportioned to the age of the patient, and the extent and violence of the local symptoms; and if the first application does not effect the removal of the pain and tenderness of the abdomen, they should be repeated after a short interval. The warm bath, and fomentations, or warm cataplasms to the abdomen, are remedies from which, if judiciously managed, and perse veringly employed, the very best effects may be antici- pated. Internally, it is generally proper to administer, in the com- mencement of the attack, a full dose of calomel, followed, in a few hours, by a dose of castor oil, or some simple purgative enema ; after the operation of which, small doses of calomel, combined with ipecacu- anha and extract of hyosciamus, may be given every three hours. In children over two years of age, affected with a severe attack "of acute peritonitis, some blood may be taken from the arm, and, if necessary, followed by leeches to the abdomen. In most cases, in which the symptoms are of any degree of violence, sinapised pediluvia will be found advantageous. After leeching has been carried as far as is thought adviseable, a blister over the abdomen, as directed in enteritis, will often cut short the disease. On the subject of local depletion, it will be proper to remark, that the indications for its employment, and the extent to which it is to be carried, as well as for its repetition, are to be drawn chiefly from the intensity of the local symptoms :—when there is pain or tenderness of the abdomen, leeches should be applied, in proportion to the surface over which it ex- tends ; and so long as it continues without decided abatement, the repetition of the leeches should not be neglected. The frequent absence, in peritonitis, of febrile excitement, and the exhaustion of the patient, will often mislead the inexperienced practitioner, and induce him to omit this important remedy, from the early and judicious employment of which, more is to be expected, than from any other. Even in the chronic form of the disease, pain and tenderness of the abdomen call for the employment of leeches, which, if applied in suffi- cient numbers, will often produce a very marked change in the char- acter of the case. The warm bath, fomentations and blisters to the abdomen, are equally important in the chronic, as in the acute form, as is also the internal use of calomel, with ipecacuanha and extract of hyosciamus. In cases of chronic peritonitis, after effusion has taken place1, we have derived the best effects from the addition to this prescription, of minute doses of powdered digitalis. Wolff recom- mends, in these cases, the digitalis with the bi-tartrite of potass, in small doses, frequently repeated. Even when considerable diarrhoea is pre-ent, he states that he has observed, under the use of the 252 DISEASES OF CHILDREN. remedy, a gradual abatement of alPthe symptoms of the disease to take place; and by following it with a course of mild bitters, in con- junction with digitalis, and an infusion of roasted acorns, has, in a large number of instances, effected a perfect cure, even in cases in which, when they were first presented to him, he had almost despaired of being able, by any means, of saving the life of the patient. During convalescence from attacks of peritonitis, whether in its acute or chronic form, it is all-important to place the patient upon a well regulated, mild and digestible diet, composed chiefly of farina- ceous articles and milk. Flannel should be worn next to the skin, and the arms and legs carefully protected from cold and damp. A change of air, particularly a change from a damp and chilly atmos- phere, to one that is mild and dry, will often expedite the patient's recovery. 11.—The Remittent or Gastric Fever of Infancy. The inflammatory affections of the alimentary canal, occurring in infants subsequent to dentition, are frequently accompanied by febrile symptoms, that usually assume a remittent form, with distinct exacer- bations towards evening. This constitutes the remittent fever of infancy—the worm-fever of some writers, and the mesenteric fever of others. It is, in fact, in every instance, either a gastro-enteritis— an ileitis—or an entero-colitis, accompanied with febrile reaction; and were it not that it is noticed as a distinct affection, in almost every work on the diseases of children, we should content ourselves with referring to the account already given, of the inflammations of the digestive organs, for its pathology and treatment; but as this, no doubt, would be considered, by many, a serious defect in our treatise, we shall, in obedience to general custom, devote a section to the con- sideration of the febrile forms of the several gastro-enteric inflamma- tions of infancy. The disease often occurs with great suddenness. A child, appa- rently in perfect health, shortly after retiring to bed, is attacked with a severe febrile paroxysm :—the skin becomes intensely hot, the countenance flushed, the eyes injected, and the pulse quick and fre- quent. The thirst is generally intense ; the tongue dry, and thickly coated on its surface, with a layer of white mucus, but red at its point and edges. There is always great restlessness, and often transient delirium. The patient generally complains of pain over the eyes, and of pain or soreness of the abdomen, which is more or less tender to the touch, and hot. There is not unfrequently nausea, or vomiting of a yellow or greenish fluid, and of a sour or offensive smell. Towards morning, the violence of the symptoms gradually abates; the skin becomes cooler; the pulse less quick and frequent, and the tongue moister; there is still, however, dryness of the skin; the tongue continues coated; the pulse is quicker than natural, and the child exhibits more or less langour and fretfulness; he is without appetite; DISEASES OF THE DIGESTIVE ORGANS. 253 the abdomen is still often painful or tender, and the urine scanty and high coloured, often depositing a white sediment. As the day advances, the remaining symptoms abate or disappear; the child becomes more lively and playful, but still exhibits a degree of langour and peevishness, which seldom deceives an experienced eye. Towards evening, there is, in general, restlessness, increased langour, and fret- fulness, and a febrile paroxysm soon occurs, as on the preceding night, which is again succeeded by a more or less perfect remission ; and the disease, in this manner, with daily exacerbations and remis- sions, unless cut short by appropriate remedies, runs on for many days, and often assumes a chronic and very protracted form. In other cases, and perhaps most generally, the disease commences less suddenly. The child is observed, for several days, to be languid and fretful, with loss of appetite, augmented thirst, and some heat of skin, particularly at night, when he is also restless and uneasy. These symptoms increase, gradually, in intensity, and towards even- ing, the heat and dryness of the skin become more marked; the thirst and restlessness are greater; the breathing is somewhat hurried; the pulse more quick and frequent:—towards morning, however, the skin becomes again moist and cool, and the patient falls into a short, dis- turbed sleep. Each night the febrile paroxysms become more and more distinct, and of longer duration, and the morning remissions less complete. In the remittent fever of infants, the bowels are most generally con- stipated ; in some cases, however, there is diarrhoea, or a frequent inclination to go to stool without much being passed. Whenever evacuations take place, they are invariably unnatural in appearance, and highly offensive; being dark coloured, or clay-like ; of the appear- ance and consistency of tar; often mixed with mucus, and occasion- ally bloody. The vitiated secretions from the intestines, liver, and perhaps the pancreas, are often accumulated in the bowels in large quantities, and when brought away by the action of purgatives, are always highly offensive. Not unfrequently there are frequent evacu- ations from the bowels, accompanied with violent tormina and tenes- mus—the evacuations consisting of little else than mucus, often mixed with blood. The symptoms of such cases are evidently dependent upon inflammation, seated in the large intestines, and constitute the dysenteric fever of some writers. There is always more or less pain or tenderness experienced upon pressure of the abdomen, which is also often hot to the touch, while the extremities are cool, or cold, even during the febrile exacerbations, when the face is flushed, and the residue of the body dry and parched. The patient usually lies upon his back, with his knees drawn up—cries frequently, and exhibits that peculiar expression of countenance, indi- cative of abdominal distress. The breath, from an early period in the attack, has a peculiar sickly odour, and often becomes decidedly offensive. The stomach is occa- sionally very irritable, and rejects, immediately, every thing taken 254 DISEASES OF CHILDREN. into it—frequent Vomiting is not unusual. The tongue become?, as the disease progresses, more coated, dry, and pointed. The breath- ing is often quick and hurried, and a short, hacking cough, is a very frequent symptom. The child is often observed to pick at his nose, or lips, or at the corners of his eyes, or his fingers. Infantile remittent fever often assumes a very chronic form ; the exacerbations are of longer duration, but marked by symptoms of less intensity, than in the more acute attacks of the disease ; the remissions are also less distinct. The abdomen is usually tender and hot, and generally tympanitic ; the bowels are often affected with diarrhoea, and the dejections are always unhealthy in appearance, and fcetid. The tongue is thickly coated upon its upper surface, with a yellowish or brownish mucus, and red and dry at its point and edges ; the teeth are often covered with sordes, and the lips parched and cracked : the urine is scanty and high coloured, throwing down a copious white sediment, particularly during the remission ; the skin is dry, harsh, and of a sallow or dirty hue ; the countenance is contracted and wrinkled, presenting the appearance of premature old age. The appetite is often unimpaired, and in some cases it is even vora- cious ; in general, however, it is altogether lost; the child is very generally affected with a short, hacking, and frequent cough. Most commonly there is urgent thirst. There is always more or less fretfulness, and the usual indications of suffering; and the patient exhibits a disposition to pick, almost constantly, at some portion of its face or body, or at the bed-clothes, or face and arms of its attendants. If there be an accidental pimple on the skin, this will usually be picked until a sore is produced, the edges of which are still more eagerly attacked, so that the fingers are constantly stained with blood. (Locock.) This picking, is, by many, considered as one of the diagnos- tic symptoms of infantile remittent fever;—it is, however, a common phenomenon in all the chronic affections of childhood, and is often observed when no disease whatever is present. The emaciation and prostration of strength, are almost always very considerable. In the advanced stages, the child is sometimes affected with a species of stu- por, in which it remains for hours, as in a dose, with half-closed eyelids, it is however, readily aroused, but quickly falls into it again, when undisturbed. This condition is often mistaken for that resulting from effusion in the brain ; there is, however, no increased heat of the head, no affection of the pupil, nor any of the other symptoms that are characteristic of effusion within the cranium. Irritation of the brain may, however, occur, either in the acute or chronic form of the remittent fever of children, and give rise, if neglected, to tuber- cular meningitis, with serous effusion, or to acute meningitis. In other cases, the respiration, which has been hurried from the first, owing, perhaps, merely to increased circulation through the lungs, becomes laborious, a troublesome short cough, also appears, and very frequently, auscultation will evince a moreorlessextensiveinflammation of the bronchial mucous membrane; and if the disease be not subdued, DISEASES OF THE DIGESTIVE ORGANS. 255 wheezing, expectoration, and the other symptoms of bronchial inflam- mation, or of a tuberculous condition of the lungs will ensue. Some- times the child appears to be recovering for a few weeks, and then relapses ; during these remissions, he gains flesh and strength, but the abdomen remains tumid, and the bowels irregular; and these alter- nations of improvement and relapse may continue until the mesen- teric glands become enlarged, or serous effusion takes place in the abdomen. The emaciation now increases; the exacerbations of fever are entirely confined to the night, and are followed towards morning, by profuse perspiration, and a complete intermission ; the appetite is occasionally voracious—the patient, in fact, presenting all the symp- toms of tabes mesenterica. (Mackintosh.) The duration of infantile remittent fever, will depend, in a great measure, upon the character and extent of the lesions of the intestinal canal, by which it has been produced, the constitution of the patient, and the treatment pursued. In many cases, an appropriate treatment, commenced in the early stage of the disease, will effect its entire removal in a few hours; in other instances, however, a cure is less easily effected : and in children of a strongly marked lymphatic tem- perament, there is a very great tendency to the development of tuber- cles in the lungs, of a diseased condition of the mesenteric glands, or of tubercular meningitis or peritonitis, the termination of which cases is very generally fatal. Death may take place at an early period, from the extent of the intestinal inflammation, or, in chronic cases, the child may sink from mere exhaustion. Even, however, in the most protracted cases, attended with an extreme degree of ema- ciation and debility, by an appropriate treatment, a complete recovery may often be effected. Frequent relapses, which are liable to be pro- duced, by slight errors in diet, exposure to cold or damp, or over ex- ertion, produce a chronic form of the disease, which is particularly unmanageable, and seldom permanently removed. The lesions discovered after death from infantile remittent fever, vary, according to the longer or shorter duration of the disease. They are chiefly inflammation, more or less extended, of the digestive mucous membrane—in some instances, of the stomach and upper por- tion of the small intestines—in most instances, of the ileum, at its lower part, and in some cases, of both the ileum and colon. The mucous membrane is either reddened in patches, points, or stria?, and is generally thickened and softened, or ulcerated. The muciparous glands are very generally inflamed and ulcerated. The mucous membrane is often covered with a thick layer of tenaceous mucus. Dark, livid patches of the lining membrane of the small, but more generally of the large intestines, are frequently met with, and occa- sionally, gelatinous softening, with perforation of all the coats. The mesenteric glands are very generally enlarged—sometimes enor- mously so; sometimes in a state of suppuration, but more commonly converted into a cheesy matter. Peritoneal inflammation is occasion- ally observed, and, in chronic cases, the peritoneum is sometimes 250 DISEASES OF CHILDREN. thickly studded with tubercles. In some cases peritoneal inflammation seems to have been the immediate cause of death, and to have resulted from perforation of the intestines. The liver is generally enlarged, and in a state of extreme hyperaemia; sometimes changed in texture, and at others times, of a lighter colour than natural. In the brain, there is often more or less effusion, between the membranes, and into the ventricles, with opacity of the arachnoid membrane, and tubercles of the sub- stance or meninges. In the thorax, the most common morbid appear- ance is increased redness of the bronchial mucous membrane; the bron- chial ramifications, and air-cells being filled with mucus. The lungs occasionally display traces of inflammation; and in protracted cases, tubercles in the lungs, and upon the surface of the pleura, are fre- quently met with. (Mackintosh, Armstrong.) Infantile remittent fever is evidently, in every case, the result of irritation or inflammation, most commonly sub-acute, of the digestive mucous membrane; inflammations of the other organs so frequently met with, being mere complications, occurring in the course of the disease. This is rendered evident, by the phenomena which are described as constituting infantile remittent fever, all of which, upon a close analysis, will be found to point to the mucous surface, as the original seat of morbid action. (Marsh, Stokes, Mackintosh, Armstrong, Locock.) The result of numerous autopsies, have placed this fact beyond the possibility of doubt; it is there- fore, chiefly to a morbid condition of the mucous membrane of the alimentary canal that we are to look for the pathology of the dis- ease ; and to the removal of this condition, are our remedies to be primarily and mainly directed; upon this depend the febrile phenom- ena, and with its removal will they disappear. The stomach being the seat of inflammation, this, which is gene- rally of a sub-acute character, will be denoted by pain on pressure at the epigastrium; by a vivid redness of the point of the tongue, extending some distance round its edges; generally there is a loath- ing of food; and nausea, retching or vomiting are sometimes observed. If the inflammation exists in the mucous membrane of the small intestines, it will generally be seated in the lower part of the ileum. We shall have then the same appearance of the tongue, with the papillae more prominent and distinct than natural. Pain will be excited by pressure lower down than when the inflammation is seated in the stomach; the discharges from the bowels will be more mucous than natural, often resembling thin oily paint, mixed occasionally with distinct masses of mucus. Nausea, retching or vomiting rarely occur; if they do, not only the ileum, but the stomach, and upper portion of the small intestines are also affected. When the inflammation is situated in the large intestines, its seat is almost always at the upper part of the colon, and the lower part of the ileum. The tongue will then present the same appearance, and the same tenderness of the abdomen, as in inflammation of the small intestines, and the discharges from the bowels will consist of a muddy, loose, offensive foeculent DISEASES OF THE DIGESTIVE ORGANS. 257 matter, or of a little mucus mixed with blood. The abdomen, in all these cases, being more or less tense and hot. Sometimes there is a torpid condition of the colon, with great distension, from retained faecal matter. When the liver is affected, we have pain or tenderness when pressure is made in the region of that viscus, and the discharges from the bowels will show a deficiency, or depraved state of the biliary secretion. From the sympathy which exists between the skin and mucous membrane of the digestive organs, an irritation is expe- rienced either at the external termination of the mucous orifices, or upon some part of the surface, and to remove or abate this, the child is prompted to pick incessantly at the nose, mouth, eyes, face, &c.— (Mackintosh.) The presence of worms in the intestines, which we have already seen to be a frequent occurrence in nearly all the disorders implicat- ing the digestive organs, has, perhaps in no instance, any agency in the production of either of the phenomena of the disease. (Butter.) Even the various symptoms supposed to indicate the existence of worms, many of which are present in cases of remittent fever occur- ring in infants, are, probably in every instance, the result of intestinal irritation, totally independent of the worms, though capable of being aggravated by the latter, when in large numbers. There is a certain sense in which worms may be said, however, to produce remittent fever. A child is affected with langour, has an irregular appetite, and a sluggish or disordered state of the bowels—is morose and peevish—rubs his nose or mouth—occasionally vomits, and starts in his sleep ; he is immediately pronounced to be affected with worms, and drastric purgatives, and other irritating remedies* are prescribed; should a worm—no unfrequent tenant of the bowels in early life—be discharged, the previous opinion is supposed to be confirmed ; and, too often, without considering whether the symptoms under which the child labours have been mitigated or aggravated by the remedies, their use is persevered in, with the view of removing entirely the supposed cause of its sufferings. Even should no worms appear in the stools, the reasoning is still the same; the child has worms, but the means employed have not been sufficient for their evacuation; pre- scriptions still more active are resorted to, and continued until the appearance of symptoms of an alarming character point out the neces- sity for their discontinuance; and the physician is then called upon to treat a case of acute or chronic inflammation of the digestive organs, with febrile symptoms of a remittent form.—(Wolff, Stokes.) The causes of infantile remittent fever, are the same to which we have, in the preceding sections, referred the production of gastro-in- testinal inflammation. In perhaps the majority of instances, it is the result of too much, improper, or unwholesome food. Long habits of * Aloes, tansey or garlic, dissolved or infused in gin, we have frequently known to be given to children for many d.iys in succession, in such cases. 17 258 DISEASES OF CHILDREN. indulging in stimulating and indigestible articles of food—pastry, confectionary, crude fruit, and vegetables, and various compound dishes—or swallowing food rapidly, and, consequently, without due mastication, are enumerated by writers upon the subject, as the usual causes of the disease. According to the experience of Locock and Merriman, the acute form of gastric remittent, is most prevalent about the period of Christmas, when the rich and indigestible fare of the season is partaken of to excess by children, who are too often encouraged in thisby the foolishness of parents and friends. (Merriman, Locock.) The disease may likewise be produced by cold and damp, and it hence very frequently occurs towards the close of summer, and early part of autumn, when these transitions are most frequent, while the system of the child is more liable to be affected by them, in con- sequence of the over stimulation of the skin, and of the organs which sympathise most closely with it, by the heat of the preceding season, and which often still continues during the middle portion of the day, and contrasts strongly with the coolness, often chilliness, of the night. Teething and worms have been generally set down among the pro- ducing causes of infantile remittent fever; the first, which is usually attended with increased irritability of the digestive mucous membrane, particularly of its muciparous glands and follicles, no doubt often predisposes to inflammation of the alimentary canal, and of course, to remittent fever; worms, however, we suspect to be very seldom concerned in its production. Among the more common causes of the disease, is, the neglect or mismanagement of the bowel affections of children generally; more especially the abuse of purgatives on the one hand, and of stimulating remedies and diet, on the other. In its chronic form, it is frequently observed to follow many of the ailments to which early childhood is liable, such as hooping-cough, measels, scarlet fever, &c, chiefly, perhaps, because, in the course of these diseases, the digestive organs often become the seat of disease, which is overlooked or maltreated ; or, in the anxiety to restore strength, nourishing diet is too early and too abundantly supplied. (Locock.) By somej infantile remittent fever is said to prevail occasionally as an epidemic, or, more properly speaking, as an endemic. Of this there can be little doubt. By some it is supposed, particularly in its low, typhoid or chronic form, in other words, when connected with sub-acute inflammation and ulceration of the mucous glands and follicles of the intestines, to be propagated by contagion. The pro- duction of disease of the bowels in children by an impure and confined atmosphere, particularly when combined with a neglect of personal cleanliness, and unwholesome diet, has been too much overlooked. We have known nearly all the children of a family, or neighbourhood, to become affected, from this cause, with some of the worst forms of intestinal inflammation, accompanied with the phenomena ascribed to the low or typhoid remittent fever, the progress of which could only DISEASES OF THE DIGESTIVE ORGANS. 259 be stayed by removal from the infected air in which it was generated, by an improved diet, and a strict enforcement of cleanliness of person and clothing. It is no doubt under such circumstances that the disease has been reputed contagious; in a strict sense, however, we do not believe that the disease is ever propagated by contagion. The treatment of infantile remittent fever will be readily under- stood from what has been advanced in relation to its pathology. Dependent for its production and continuance upon inflammation, more or less extensive, and of an acute, sub-acute, or chronic character of the mucous membrane of the alimentary canal—it is to the removal of this inflammation, that our remedies must be directed; and just in proportion as they are adapted to effect this object, will be our suc- cess in the cure of the disease. A proper regulation of the patient's diet is all important: in the more recent and acute cases every species of food should be with- held ; the child may be allowed, however, some cold mucilaginous fluid as a drink—any of those directed in gastro-enteric inflammation will be proper—but even these, the patient should not be allowed in such quantities as to unduly distend the stomach ; this is particularly neces- sary, if the case be attended with symptoms of gastric disease. In the more protracted and chronic forms of the fever, in addition to the mucilaginous drinks, a moderate portion of some plain farinaceous food, with or without the addition of milk, will be proper, given at proper intervals. Occasionally, in very chronic cases, we have found beef tea, chicken water, or plain mutton broth with rice, to agree better with the stomach, and to produce a less amount of irritation than farinaceous preparations. On this point, of course, the judgment of the physician, guided by a knowledge of the pathology of the dis- ease, and the particular circumstances of each case, must be exercised. The only general rule that can be given, is, to prohibit every article of diet of a stimulating or indigestible character, as well as all solid food; and not to allow even that which is proper, to be given at improper hours, or in too great quantity. In recent cases, the treatment may be commenced by the adminis- tration of a full dose of calomel, with magnesia, (five grains of each,) which should be followed, in the course of a few hours, by an appro- priate dose of castor oil, or a simple laxative enema. This will generally bring away a large amount of undigested matter and vitiated secretions, with a manifest improvement in the condition of the patient. As to the propriety of repeating the purgative, this will depend upon the particular circumstances of the case; if the attack has been evidently the result of excess in eating, or improper food, the evacuation of the undigested matters with which the intestines are, in such cases, often loaded, and which are a constant source of irritation to the mucous membrane, is important; if, therefore, pretty free discharges have not been produced by the first purgative, an addi- tional dose of castor oil or of magnesia and rhubarb, may be given on the succeeding day. The repeated administration of active purgatives, so generally recommended in this disease, and their con- 200 DISEASES OF CHILDREN. tinuance from day to day, until healthy stools are procured, is founded upon incorrect views of the pathology of the disease, and is rather calculated to augment, than to remove, its more prominent and dangerous symptoms. We are persuaded, however, that the admin- istration, at short intervals, of alterative doses of calomel, combined with chalk and ipecacuanha, is a good practice in infantile remittent fever. Calomel in this form and combination, keeps up a gentle laxative action upon the bowels; while under its use the discharges become more natural in appearance, the skin softer, the tongue more moist and clean, the pulse slower and more developed, the exacerbations shorter, and the remissions more perfect. In the more protracted and chronic cases, we are accustomed to add to each dose a small portion of extract of hyosciamus, which has the advantage of allaying irritation without binding the bowels. In every case in which the exacerbations of fever are marked by symptoms of any degree of intensity, the abstraction of a few ounces of blood from the arm, if the child is over two years of age, will be advisable; or leeches may be applied to the abdomen, in numbers proportioned to the violence of the symptoms and age of the patient. The application of leeches will be demanded whenever there is pain or tenderness upon pressure, with tension and heat of the abdomen ; when well timed, and in sufficient numbers to reduce the local inflam- mation, they are the remedy upon which most dependence is to be placed, in the treatmentof these cases. Even in the protracted and chro- nic forms of the disease, pain, heat, and tension in the epigastric, umbil- ical, or hypogastric regions, or in either hypochondrium, should be the signal for their application in numbers adapted to the circumstances of each case. Many have urged that the disease is one attended with so much exhaustion, and so liable to be protracted, that abstraction of blood should be avoided; but it will generally be found that an active treatment, pursued judiciously, in the early and acute form, will be the one best adapted speedily to arrest the symptoms, and prevent the exhaustion consequent upon the more protracted or chronic form. (Locock.) The intermissions will usually become more distinct, the tongue moister, the skin softer and more pliable, and the evacuations more regular and natural, after the local abstraction of blood ; and at a later period, when the indications for its use are present, it is often followed by an improvement in the pulse, the skin, and in the appearance of the stools, the very reverse of those from increased depression. It has been suggested, and with a good deal of plausibility, that the intestinal torpor that so frequently exists in the disease, is often the result of hyperaemia of the brain; and hence it is that an efficient abstraction of blood almost always increases the susceptibility of the bowels to the action of mild aperients.—(Eberle.) In every instance the tepid or warm bath is, as in the case of gastro- intestinal inflammations generally, a very valuable remedy. When the skin is hot and parched, sponging the entire surface frequently with tepid water, will often produce a pleasant coolness and moisture, DISEASES OF THE DIGESTIVE ORGANS. 201 and relieve entirely the restlessness of the patient. In the intervals of the paroxysms, as well as in those cases in which the temperature of the surface is not increased or is reduced, the warm bath by immersion should be preferred. Fomentations to the abdomen, or warm emmo- lient cataplasms, perseveringly employed, as well as warm or sinapised pediluvia, especially when there is a tendency to coldness of the extremities, or irritation of the brain, will always be found to produce a decidedly beneficial effect. In protracted or chronic cases, blisters to the abdomen, as directed in enteritis, will be proper, and, in general, are followed by a marked improvement in the condition of the bowels. When delirium, increased heat of the head, aversion from light, an injected state of the eyes, or stupor ensues, a few leeches may be applied behind the ears, and cold washes or lotions to the scalp, while at the same time, stimulating pediluvia or frictions to the lower extre- mities are employed. Cough, and hurried laborious respiration, will demand mucilaginous drinks, blisters to the thorax, and, if the symptoms of bronchial inflammation are distinctly marked, and of any degree of severity, leeches about the clavicles should be applied. In these cases, small doses of calomel, ipecacuanha, digitalis and extract of hyosciamus will be found a useful remedy.* aR.—Calomel, gr. iij. ad iv. Ipecac, pulv. gr. iij. Digitalis pulv. gr. iij. ad iv. Ext. hyosciami, gr. iv. ad viij.—M. f. chart. No. xij. One to be given every three hours. In the chronic forms of infantile remittent fever, attended with tympanitis, and vitiated mucous, or dark offensive discharges, one of the remedies from which we have derived the most decidedly beneficial effects is the spirits of turpentine ; it may be given in doses of from ten to fifteen drops, three or four times daily, in a little sugar, or in the form of a mixture, as recommended in cases of chronic diarrhoea. It has not only the effect of exciting the bowels to contract and expel the gas, but it generally exerts an evident beneficial influence upon the morbid state of the intestinal mucous membrane, allaying irritation, and producing a decided improvement in the excretions. (Eberle.) We have employed this remedy very extensively, in all the chronic affections of the bowels in children, and have always had occasion to be pleased with its operation. If there be evidences of serous effusion within the abdomen, with scanty secretion of urine, the same treat- ment should be pursued as directed in cases of chronic peritonitis. The treatment of those cases attended with enlargement of the mesenteric glands, differs in nothing from that already laid down. As soon, however, as the symptoms of intestinal inflam- mation are reduced, the administration of some of the milder pre- parations of iodine may be entered upon, with the inunction of the same, in the form of ointment, about the grojns and over the surface of the abdomen; the hvdriodate of potassa, is the preparation we have generally employed, and occasionally with very great advantage. In all cases, after the symptoms of the disease have subsided, the 262 DISEASES OF CHILDREN. discharges from the bowels become more regular and healthy in appearance, the tongue cleaner and more moist, some light bitter, as a weak infusion of cinchona or calomba, may be given, in com- bination with the sulphuric or hydrochloric acids, and, as convales- cence advances, the sulphate of quinia, the tincture of the sesquichloride or the persesquinitrate of iron, the bowels, at the same time, being kept regularly open by gentle aperients, and the diet slowly and cautiously improved. By this course, aided by the tepid or warm bath, daily repeated, and followed by frictions to the surface, the functions of the digestive organs will be very rapidly improved, and the strength of the patient promptly restored. As soon as the patient is able, gentle exercise in the open air, at first passive, and subsequently of a more active kind, will confirm the cure. When the case has been of a protracted character, change of air will often produce the most bene- ficial effects. Great caution, however, must be observed, not to commence too early upon the use of tonics, or to improve too rapidly the diet. During the stage of convalescence the utmost circumspection should be observed, as well in regard to the quantity, as to the quality of the food that is allowed. A slight excess, a premature indulgence in solid food, or the use of that which is indigestible, or has any tendency to oppress the stomach, will endanger a serious relapse. The surface of the body should be carefully guarded from the impression of cold or damp, by appropriate clothing, and due precaution ; and the proper temperature, dryness, and purity of the air of the apartment occupied by the convalescent, should be maintained by due ventilation, and by artificial heat when necessary. SECTION II. DISEASES OF THE RESPIRATORY ORGANS. 1.—Asphyxia. Cases of still born children are very common : and although it may not be strictly correct to say that the infant is, in such cases, invariably in a state of asphyxia, yet the term seems as little exceptionable as any other, provided proper attention be paid to the cause by which the establishment of the respiratory function is prevented. This may, in some cases, arise either from the imperfect development or malfor- mation of the heart and circulatory organs, of the lungs and respira- tory apparatus, or of some portion of the nervous system ; or from the extinction of life in the foetus, previous to, or during parturition, either from congenital disease, or from injuries inflicted upon it during its passage through the pelvis. In all these cases, as well as in those in which the powers of life in the foetus, are too feeble to carry on the DISEASES OF THE RESPIRATORY ORGANS. 263 functions of the organism in the independent state of existence, no hopes can be entertained of a resuscitation being effected, or the duration of life being prolonged, by any course of treatment. But, in a large proportion of the cases in which the infant is apparently dead born, there is merely a suspension of the respiratory function, and by proper means, persevered in for a sufficient length of time, complete resuscitation may be effected.* The most common causes of asphyxia in new born children, are*; tedious and protracted labour, from defective uterine efforts, rigidity of the os uteri, or a disproportion between the size of the foetal head and the dimensions of the pelvis; the cord being twisted round the neck of the infant, or around some other part of its body ; the cord, from its prolapsus being subjected to pressure between the head of the child and walls of the pelvis; the placenta becoming partially or entirely detached, before the expulsion of the child ; the os uteri or the constrictor muscle of the vagina being spasmodically con- tracted around the neck of the child, as is apt to occur in a first labour, when ergot is injudiciously administered to expedite delivery; the child being born with the face invested with the membranes; the mouth and fauces being filled with viscid mucus, or, as sometimes happens, the tongue falling backwards, and closing up the fauces; or, finally, the child being exceedingly feeble and exhausted. (Wildberg.) Asphyxia is likewise observed in cases of very rapid delivery, when the infant is protruded by a quick succession of severe uterine contractions. (Vel- peau, Jbrg.) Asphyxia in new born children, may occur after birth, and even after the child has breathed and uttered some feeble cries, when, from the ignorance, or the wilful neglect of the practitioner or attendants, the necessary means are not adopted for the preservation of its life; and occasionally, from causes, the nature of which it is very difficult to understand. In some cases of asphyxia, the infant, when born, is pallid, with open and flaccid mouth, relaxed limbs, and with only a feeble, obscure pulsation, sometimes none at all, at the heart or in the cord; in others, the face is swollen, livid or purple, with or without pulsation of the foetal heart, or of the cord ; occasionally, however, the cord is tense and pulsates strongly, while the pulsation at the heart is slow and feeble. The state of asphyxia may be more or less complete. The foetus may neither cry nor respire, and present no appreciable motion of the umbilical arteries or heart, being, to all appearances, actually dead ; or, while no eifort at respiration occurs, the heart and cord may pul- sate with more or less vigour, while, again, a few ineffectual respira- * In the 15 years preceding 1840, of the 110,526 children born, 4647,or about 4.25, were dead. How many of these latter were premuture births, or to what particular cause the death of the foetus was owing, we have no means of ascert lining. The law requires that in every instance in which the fetus has arrived at the term of six months, or at the termination of the full period of utero gestation, and is born dead, it shall be reported as a case of still birth. 264 DISEASES OF CHILDREN. tory efforts may be made, or even faint cries may be uttered, and then a complete state of asphyxia ensue. All the causes to which the asphyxia of new born children is to be immediately referred, have not been investigated with sufficient accu- racy. Some are, it is true, very evident, being causes which directly impede the passage of the air into the lungs, as the existence of a quantity of thick, tenacious mucus in the mouth, fauces or windpipe ; or which prevent the dilatation of the chest and other respiratory movements, by suspending inervation—as the apoplectic condition of the brain, with which the infant is frequently born ; but in those cases in which there exists no impediment to the passage of air into the lungs, and no undue distension of the vessels of the brain, it is difficult to assign the real cause for the non establishment of respiration. Some have supposed it to arise from a state of extreme debility; others from anemia, or from the functions of the placenta having become suspend- ed a short time previous to delivery, by which the condition of the blood is so changed, that it can no longer produce that degree of stim- ulation of the brain and other organs, which is essential to the proper performance of their functions, and which must necessarily cause the death of the child, unless respiration be promptly established by arti- ficial means, and the due vitalization of the blood, is in this manner effected. This latter, which is the opinion of Velpeau, seems to us the most plausible. When a new born child opens its eyes, moves its limbs, and exhibits a few imperfect respiratory efforts, a smart slap upon the buttocks, or a few drops of cold water sprinkled upon the chest and abdomen, will very generally cause it instantly to breathe, and to cry out lustily. In all cases, immediate attention should be paid to remove at once, any viscid mucus which may exist in the mouth and throat. This may be readily done with the finger, surrounded with a piece of soft linen. The child should be subsequently placed upon its side, in such a posi- tion that any of the mucus that remains may flow from the mouth, at the same time that its entrance into the trachea is prevented. The turning the child upon its face, slapping it between the shoulders, and gently shaking it, as recommended by a few highly respectable writers, " with the view of disengaging any mucus that may be lodged in the trachea," are procedures that we cannot believe to be either safe or useful. In all cases in which the asphyxia is unaccompanied with symp- toms of cerebral congestion—a puffy and dark purple or livid appear- ance of the face—it is not proper to tie the umbilical cord, until its pulsation has ceased, or has become quite feeble. (Levret, Smellie, Baudelocque, Petit, Chaussier, White, Denman, Velpeau, Dewees, Blundell, Rigby.) The premature application of a ligature to the cord has, we believe, in many instances, given rise to asphyxia. The dashing of a little cold water, or spirits, upon the chest and abdomen, will, in many cases of simple asphyxia, almost immediately excite the respiratory action, with loud and vigorous cries, when the DISEASES OF THE RESPIRATORY ORGANS. 265 cord may be divided, and the child suffered to remain'quiet, until its strength is, in some degree, recruited. The plan pursued by Velpeau, in imitation of Desormeaux, is a very excellent means of rousing the infant from a state of asphyxia. A portion of some spirituous liquor being held for a moment or two in the mouth, is then spirted with force, in the form of a douche, upon the breast of the child. Immersion in the warm bath is often a very successful means of resuscitation in cases of asphyxia. The use of the warm bath in these cases, however, requires some little management, to derive from it any advantage. The object of the bath is to excite the action of the heart and respiratory muscles ; if, however, within a very short time after immersion, neither respiration nor circulation ensues, the child should be taken out, as the effect of the bath is then decidedly injurious. (Edwards.) Even when respiration is produced, as it often will be, by the action of the bath, it should not be continued in it over a few minutes; a prolonged continuance in the bath would, by raising the temperature of the infant, render it less capable of enduring the state of asphyxia, and would also prevent the access of the atmos- pheric air to the surface of the body, which always exerts a very powerful vivifying influence. (Edwards, Kay.) When the child is removed from the bath, gentle friction should be applied to the surface of its body with a warm, dry flannel cloth. Cold effusion has been resorted to, in cases of asphyxia in new born infants, and there is no doubt, when it is judiciously managed, it may often prove a very powerful and successful means of resuscitation. In two cases, related by Dr. Patterson, of Dublin, the infant was placed in a tub, and three quarts of water, at a temperature of about 60°, were twice dashed over it, strong friction being at the same time applied to the parieties of the chest, active respiration was quickly established, when the infant was removed from the tub, well dried, and wrapt in flannel; in both cases, an entire recovery was effected. But of all the means that have been employed in the asphyxia of infants, inflation is the one upon which, experience has taught us, that the most confidence is to be placed, if early resorted to, judiciously practiced, and persevered in for a sufficient length of time. In inflating the lungs, the mouth of the operator should be applied to the mouth of the child, the latter being first covered with a silk handkerchief, or soft napkin ; its nostrils should be closed with one of his hands, while the other is applied upon its thorax. By a moderate, but uniform force of insufflation, the lungs will be very readily filled with air, when the mouth of the operator is to be withdrawn, and gentle pressure made upon the chest, so as to expel the air by which the lungs of the infant have been inflated ; in this manner, artificial respiration should be kept up for some time. If the cord be examined at a short distance from the abdomen, it will be often found to pulsate soon after the commencement of the operation, or the heart may be felt to beat beneath the ribs; the first symptom of returning life is, 266 DISEASES OF CHILDREN. generally, a tremulous motion of the respiratory organs; the child next makes a feeble attempt to inspire, and the cheeks begin to red- den ; when these marks of returning life are observed, if the inflation be suspended, the child will frequently be found to make a sponta- neous effort at respiration ; a deep sigh is the first breath it draws ; in a few seconds it breathes again. Now, if on suspending the artificial respiration, the heart continues to beat vigorously, the cord to pulsate, and the respiration to increase in frequency and depth, it need not be resumed. But should the pulsation cease in the heart and cord, and the respiration cease, or become more feeble, it must then be imme- diately resumed, and this repeatedly, as the case requires—at one time, the natural powers of the child to carry on respiration are to be tested, at another, we support the respiration by artificial means. As the efforts at spontaneous respiration increase, ammonia, or cologne water rubbed upon the hand, and held over the mouth of the infant during inspiration, will materially assist the recovery, and has a bet- ter effect than pouring stimulants into the stomach. A few smart slaps on the gluteal muscles, will now generally complete the recov- ery. In favour of the efficacy of artificial respiration, in cases of asphyxia,occurring ator soon after birth, wehave the most incontestible testimony. Blundell trusted to it alone, with the aid of the warm bath. Toogood declares that he never found any other means necessary, and believes, that if actively employed, and steadily persevered in, it will, in the majority of cases, be successful. We may add our own experience, which is decidedly in favour of this means of resuscita- tion. But it must, to be generally successful, be persevered in, until the recovery of the infant is shown to be impossible, by unequivocal signs. Toogood continued it for forty-five minutes, in several cases, before respiration was fully established ; and in a communication of Sir James Eyre, in the London Medical Gazette, March, 1840, he refers to a case in which the artificial means were persevered in by him, for from thirty to forty minutes, and to two cases in which they were continued by Mr. Terry, of Northampton—in one for one hour and a half, and in the other, for two hours and a half. Blundell recommends artificial respiration to be practised by means of a tube introduced into the trachea. We have never had any difficulty in effecting it by the mouth alone; this is also the experience of Mr. Toogood; and in the communication of Sir James Eyre, already referred to, he remarks, " I uniformly inflate with my own breath; in this matter, I perfectly agree with Dr. Cape, in a sensible letter of his, which appeared in the Medical Gazette, of October 7, 1837." In the case of suspended animation, occurring in new born infants, from a congested state of the brain, a somewhat different practice is to be pursued. This form of asphyxia is usually met with in large, robust, plethoric infants, after tedious and difficult labour, where the child has remained for several hours under the direct influence of the uterine contractions, after the discharge of the waters; where a loop DISEASES OF THE RESPIRATORY ORGANS. 267 of the cord strictures the neck or thorax; or where the cord is itself compressed, by any means, during labour. Its immediate cause is the engorgement or compression of the brain; though the want of a proper revivification of the blood, is in all probability, a frequent cause of this form of asphyxia, as it is of the preceding. (Velpeau.) It is, in many cases, produced by the too early and injudicious use of ergot. In the apoplectic form of asphyxia, the countenance, and often the scalp and neck, presents a dark red, or livid and bloated appearance, the lips are swollen, and purple, the eyes prominent, and the surface of the body warm, red, and somewhat tense. When an infant is born in this condition, no time is to be lost. The umbilical cord should be immediately divided, and more or less blood, according to circumstances, allowed to flow from it; if the pulsation in the cord has not already ceased, as the blood flows from its cut extremity, very generally the lividity and turgid state of the face and neck disappears, and respiration is very promptly established. When the pulsation of the cord is slow and feeble, inflation of the lungs should be resorted to, in addition to the abstraction of blood. The infant may, at the same time, be immersed in a warm bath to the the hips, while cold water is applied to its scalp. In those cases in which the child is born without any indications of life—its face swollen and livid, its body flaccid, and no pulsation per- ceptible in the cord, or at the heart—notwithstanding there is but lit- tle hope that resuscitation can be effected, it ought not to be aban- doned, without suitable efforts being made for the establishment of respiration. We are in no instance, hastily to pronounce success impossible. Many a foetus has been laid aside as dead, which, by a diligent use of proper means, might have been saved. (Blundell.) In the cases referred to, it is seldom that a sufficient quantity of blood can be procured from the cord, upon its division. We have often, however, found the blood to commence flowing, when the infant is immersed in a warm bath, as directed above, its head being, at the same time, washed with brandy and water, and its lungs properly inflated. It has been suggested, with the view of soliciting the flow of blood from the cord, to cut the latter short, and apply, over the navel, a wide-mouthed cupping-glass, furnished with an exhausting syringe. It is supposed that by exhausting the cup, a flow of blood maybe obtained from the divided cord, even after the heart has ceased to act. (Eberle.) The suggestion is a very plausible one, and worth a trial. When it is impossible to obtain blood from the cord, Velpeau directs leeches to be applied behind each ear. It often happens, that after we have succeeded in establishing respi- ration, the infant remains for many hours in a feeble condition ; the slightest fatigue or agitation being sufficient to extinguish life. It is of the utmost importance, therefore, in all cases in which resuscita- tion has been effected, that the infant be allowed to remain upon the bed, properly wrapped up, in a state of perfect repose, for several hours, before any attempt is made to dress it. 263 DISEASES OF CHILDREN. 2.—Coryza. The simple cattarrh, or inflammation of the mucous membrane of the nares, occurring in infants, has received various appellations. It is usu- ally described, however, by writers on the diseases of children, under the denomination of coryza, gravedo, or sniffles, to which, occasion- ally, the terms malignant, (Underwood,) or morbid, (Marley,) have been added, to distinguish the more aggravated form of the disease, in which the Schneiderian membrane is affected with diptheritic or exudative inflammation. The disease, though always troublesome, is in many cases, of little importance, disappearing spontaneously, after a few days; while in other instances, it is productive of considerable suffering and danger to the child. The younger the infant is, in whom it occurs, the more severe and dangerous it in general proves. The mucous membrane of the nares is particularly susceptible of irritation, in the early period of life; and inflammation is excited in it often by very slight causes. It is not uncommon to hear an infant sneeze soon after birth, or even immediately on the air coming in contact with the membrane. There often occurs, also, at a very early period, an abundant secretion of mucus, which, in some chil- dren, flows constantly from the nose, without apparently being attended by any degree of inflammation. Coryza may be simple, or complicated with the more or less rapid formation of a pellicular exudation throughout the whole extent of the nasal fossae; or, it may assume a chronic character, and occasion the death of the patient, by the disorganization which ensues. (Bil- lard.) The first indication of the disease is frequent sneezing; the inner surface of the nostrils becomes red, dry, and swollen, and the cry of the infant is altered, from the impediment to the free passage of the air through the nose; a watery, or thin muculent fluid soon begins to flow from the nostrils; in a short time, it assumes a thick, white, opaque appearance, subsequently changing to a yellow, and becoming finally purulent. The child sleeps with its mouth open ; the respiration is difficult and noisy ; and instead of the usual rale, a whistling sound occurs in the nasal fossae. This sound becomes greater, and the dif- ficulty of respiration increases, in proportion as the mucus of the nose becomes thicker and more abundant. (Billard.) In severe cases, the child experiences great difficulty in suckling, from its inability to breathe through the nose; and as the discharge, by drying at the orifice of the nostrils, often completely closes them, every attempt to take the breast, is attended with the utmost anxiety; the countenance of the infant becomes flushed, and it is obliged, instantly, to quit the nipple, to prevent suffocation. Its restlessness and cries, as well as the expression of its face, indicate the utmost distress and suffering ; which are increased by its sense of hunger, and the impossibility it experiences of satisfying it. Worn down by fatigue, pain, and dcfi- DISEASES OF THE RESPIRATORY ORGANS. 269 cient nourishment, the child may perish at an early period, from inanition; or, the irritation being transmitted to the brain, extreme prostration and drowsiness may ensue, and sooner or later terminate in death; or death may be preceded by convulsions or acute menin- gitis, quickly terminating in effusion. In the more prolonged, or chronic form of the disease, the mucous membrane of the nares may become softened and destroyed, or the seat of an extensive, ill-condi- tioned ulceration. The difficulty of respiration in coryza, is always greatest in those cases, in which the inflammation of the nasal mucous membrane gives rise to a pseudo-membranous exudation; in such cases, also, the tonsils and fauces occasionally present a swollen and dark red, appearance, their surface being covered with ash coloured specks, terminating, in some cases, in extensive ulcerations. (Denman, Schmidt.) In violent cases, death may occur in three or four days, while in other instances, the symptoms are mild, from the commencement; the inflammation very rapidly abates, the secretion gradually lessens in quantity and in consistency, the respiration improves in proportion, and in a few days every symptom of the disease disappears. The danger, in cases of coryza, is always in proportion to the degree of tumefaction of the mucous membrane of the nares, and to the abun- dance and tenacity of the excreted fluid. When the inflammation is slight, and the mucus of the nose is only a little more abundant and ropy than natural, the difficulty of respiration is but slight, and the infant is able to suck without much difficulty. All other things being the same, it is always more serious and dangerous, in proportion to the tender age of the patient. (Billard.) The appearances discovered after death, in those who have fallen victims to this disease, are, increased redness, with thickening and friability of the mucous membrane, throughout the whole extent of the nasal fossae, which is generally thickly coated with opaque tenaceous mucus—in some cases, small patches of a pseudo-membranous exu- dation are scattered over the surface of the membrane; in other instances, the membranous concretion covers the whole interior sur- face of the nares, and extends from the superior part of the glottis, upwards, towards the sinus and cornua of the nose, the mucous mem- brane beneath, to which it firmly adheres, being much tumefied, and of a vivid red colour; softening of the mucous membrane, and exten- sive ulceration, are present, in many cases. In chronic cases, various morbid affections of the alimentary canal, lungs, and brain, are fre- quently met with. The disease is usually the result of exposure to a cold or damp atmosphere, or of neglect in changing the diaper and clothing of the infant, when they become wet with the urine. Billard enumerates, among its common causes, exposure to a strong fire, and particularly, to the light and heat of the solar rays. When children are taken out, he remarks, for the benefit of the air, on the return of spring, it is 270 DISEASES OF CHILDREN. almost always observed, that they sneeze, and experience a discharge from the nose; we apprehend, however, that the exposure to an atmosphere many degrees colder than that to which the child has been accustomed, has more to do in the production of coryza in children, on their first being taken out in the spring, than the action of the sun's rays. In light attacks, little treatment is necessary beyond the avoidance of the occasional causes of the disease, with proper clothing, and con- finement to rooms of a warm, equable temperature. The use of the warm bath, daily, will be proper, however, in most cases, with the occasional use of some mild aperient, as castor oil, or magnesia and rhubarb. In more violent cases, the application of a few leeches to the root of the nose, will be advisable, with some gentle diaphoretic.1 In some cases we have found the administration of a few grains of calomel, followed by a dose of castor oil, highly advantageous. A small blister to the nape of the neck, will often produce very consid- erable relief. (Marley, Schmidt, Billard.) The infant should not be put to the breast during the stoppage of the nostrils, but the nurse's milk should be given with a spoon, or fresh cow's milk, diluted with barley or rice water, or with rennet whey, may be substituted. »R.—Hydrochlor. ammoniae, gr. xxvj. ad xlviij. Pulv. ipecacuanha?, gr. ij.—iij. Ext. Hyosciami, gr. iij.—iv.—M. f. chart. No. xij. One to be given every three hours, mixed in a little sugar and water. If, after the inflammation is reduced, there should be formed any pellicular concretions in the nasal fossae, some fine calomel, or a mixture of sugar and alum finely powdered, may be gently blown into the nostrils. (Billard.) In chronic cases, alterate doses of calomel, with ipecacuanha, pre- pared chalk, and extract of hyosciamus,* will, in general, if conjoined with a proper diet, the daily use of the warm bath, and some light tonic, effect a cure. A decoction of oak bark has been highly recommended when the disease continues for many weeks, and the infant becomes pallid, and very feeble; it is said to have at once removed the snuffling, and given vigour to the patient in the course of a few days. (Underwood.) A weak infusion of bark, the sulphate of quinia, or the persesquinitrate of iron, will, however, in most cases be found, we suspect, a better tonic than the oak bark. »R—Calomel, gr. iij. Ipecac, pulv. gr. iij. Cretae, ppt. gr. xxxvj. Ext. hyosciami, gr. iv.—M. f. chart. No. xij. One to be given every three hours. When, in the course of the disease, symptoms of cerebral conges- tion or irritation, or convulsions occur, these are to be combatted by DISEASES OF THE RESPIRATORY ORGANS. 271 their appropriate remedies—leeches behind the ears, or to the temples, warm sinapised pediluvia, cold applications to the scalp, blisters to the nape of the neck, and purgative doses of calomel, followed by castor oil, the sulphate of soda, or purgative enemata. During convalescence from the more chronic cases, the restoration of the patient's strength is to be promoted by a well regulated diet, gentle daily exercise in the open air, and appropriate clothing. 8.—Bronchitis. Bronchial inflammation of various grades of intensity, is a common complaint throughout every period of infancy and childhood. Its leading symptoms are cough, hoarseness, difficulty of respiration, and more or less febrile excitement. To these symptoms, in many cases, are conjoined, soreness of the throat, running at the nose, sneezing, and a red and watery appearance of the eyes. The disease, in general, commences with a slight degree of chilli- ness, or a complete chill, and some degree of languor, depression, and drowsiness; after a short period, a febrile reaction occurs. The patient, if old enough, now complains of dull, aching pains of the head, back, and extremities; the pulse becomes frequent, full, and somewhat tense; the face is flushed, the surface is dry, harsh, but seldom much increased in temperature; the bowels are, in general, constipated, and the urine small in quantity, and high coloured. The eyes are often red and suffused, and a thin transparent mucus is discharged from the nostrils, attended with frequent sneezing. Cough and some degree of hoarseness, with soreness, or a sense of roughness in the throat, are often present from the commencement of the attack; more generally, however, the cough is not developed until the second or third day, and usually becomes more frequent as the disease advances. The respiration is, in general, more or less short, difficult, and oppressed, from an early period of the attack; and is attended with a wheezing or rattling sound, heard first in the throat, and extending, subsequently, over the upper portion, and finally, over the whole of the chest. The respiration is always frequent, amounting, sometimes, to one hundred in a minute ; and during the act of inspi- ration, in severe cases, there is a dilatation of the nostrils, and a heaving motion of the chest. The wheezing or sibilant and mucous rhonchi are often perfectly audible, or may be detected by applying the ear immediately to the chest, or by the open hands being applied upon the opposite sides of the thorax. During the first period of the disease, the child at the breast sucks without much difficulty; but subsequently, although it seizes the nip- ple with avidity, it cannot suck for any length of time, perhaps not for more than ten or fifteen seconds, but suddenly quits the breast, and throws its head quickly backwards, and will continue in this posi- tion for some time, even after the cough has produced an expulsion of mucus. (Mackintosh.) 272 DISEASES OF CHILDREN. The cough is at first dry, frequent, and distressing: but, in the course of the disease, is attended with an expectoration of mucus, at first scanty, but subsequently, more free and copious. The expecto- ration consists, at first, of thin, transparent mucus, but subsequently, of masses of viscid, opaque, muco-purulent matter, of a yellowish or greenish colour. In young children, it is most generally swallowed, or retained for some time in the throat. The difficulty of respiration is not uniform throughout the attack ; the breathing being, occasionally, for a short period, tolerably easy, and then becoming suddenly extremely oppressed. The cough, likewise, often occurs in occasional fits, at irregular, and generally, short intervals, with comparative exemption from it, between them. As the expectoration becomes more copious, each fit of coughing is often attended by a paroxysm of suffocation, ending in vomiting. The cough, difficulty of respiration, and febrile excitement, gene- rally increase towards evening, and in the commencement of the attack, there is a distinct remission of the fever in the morning, though usually of very short duration. Upon percussion, at the commencement of the attack, the chest will usually be found sonorous throughout; but at a later period, a dullness may often be detected in some parts. When the child is old enough to describe its sensations, a feeling of weight, tightness, and soreness of the chest is generally complained of, but seldom any positive pain. When the paroxysms of cough are severe, infants are often known to scream, as if from pain, and the inspirations are, occasionally, suddenly arrested, and attended with an expression of suffering in the countenance, probably from an accom- panying pleuritic inflammation. The face, in severe cases of bron- chitis, is very rarely flushed, but generally pale, anxious, and often cedematous; sometimes, especially, as the fatal termination ap- proaches, the cheeks as well as the lips acquire a livid hue. Delir- ium occasionally occurs, particularly towards the close of the day, and at night. As the disease advances, the difficulty of respiration increases; the physical signs, resulting from the impediment to the free passage through the bronchial ramifications, in consequence of the amount of mucus by which they are filled, become extensive and evident; the child is unable to assume the recumbent posture without an increase of suffer- ing; he becomes drowsy, his face assumes a livid hue, and the expres- sion of his countenance is that of the utmost anxiety and distress; death finally occurs, often preceded by a state of complete coma, or by convulsions. In young children, a certain amount of drowsiness or stupor is present from the commencement of the attack, and by preventing the patient from complaining or coughing is apt to mask the disease of the chest, which is thus rendered peculiarly insidious and dangerous. A close attention will, however, detect a great frequency in the breath- ing, and on applying the ear to the thorax, the universal rhonchi, DISEASES OF THE RESPIRATORY ORGANS. 273 sibilant and mucous, at once declare the true nature of the case. (Williams.) In infants, the epigastrium and right hypochondrium become, occasionally, tumid, tense, and tender upon pressure ; the discharges from the bowels in these cases, are frequently small in quantity, and whitish or clay coloured at first, but subsequently they contain a large amount of light green or dark coloured bile; in other cases, the evac- uations from the bowels become thin and muddy or reddish, and contain more or less mucous flocculi, the abdomen, at the same time, being greatly swollen and tympanitic. This complication is evident- ly the result of gastro-enteric irritation or inflammation, attended with an engorged and torpid state of the liver; it is to this form of bron- chitis that the term catarrhal fever has been generally applied. Bronchitis in children is likewise not unfrequently complicated with pneumonia, giving rise to hepatization, to a greater or less extent, of the lower and posterior portion of the lungs. This is, in fact, the ordinary form of lobular pneumonia, as it occurs in children under two years of age ; it is a common complication of the bronchitis incident to the acute exanthemata and whooping cough. (Williams, Gerhard.) In the recent very interesting paper of Dr. West, of Lon- don, on the pneumonia of infants, he remarks, that the evidences of bronchial inflammation are very commonly met with in children who have fallen victims to lobular pneumonia, especially where the latter supervenes upon pertussis. The bronchitis of children occasionally assumes a chronic form, when its symptoms closely resemble those of phthisis. A very common and dangerous form of bronchitis, supposed to depend upon a sub-acute inflammation of the bronchial mucous mem- brane throughout both lungs, (Mackintosh,) very frequently occurs in young children. The cough and dyspncea are but slight, and attract but little attention, so long as the expectoration is free, and is dis- charged with ease ; but if, from any cause, the secretion of mucus in the bronchii is increased, and the cough arrested, speedy death from suffocation inevitably results, unless vomiting be excited, which seems to have the effect of emptying the air passages of the accumulated mucus. In other cases, an unfavourable change is produced by the inflammation becoming more acute, from exposure to cold, or other accidental cause. (Hastings, Mackintosh.) This form of the disease we have repeatedly met with ; it is one often neglected by parents in its early stage, and even the practitioner will be apt to be misled in his prognosis in regard to it, unless perfectly aware of its true character, from an attention to the physical signs derived from a careful examination of the chest. In mild cases of bronchitis, the symptoms gradually abate within a few days; in more violent attacks, the disease, however, is often more protracted—even when the termination is favourable. The respiration becoming less frequent and laborious; the febrile symp- toms abating; the skin becoming softer and moist; the cough less 18 274 DISEASES OF CHILDREN. frequent, prolonged, and suffocative, and attended with a free expec- toration, are the general indications of the decline of the disease. The occurrence of convulsions, and of great somnolency or drowsi- ness, with increased difficulty of respiration, accompanied with a feeling of suffocation ; lividity of the cheeks and lips, and coldness of the extremities, are all unfavourable symptoms, and are but too gen- erally quickly followed by a fatal termination. The appearances discovered after death from bronchitis, are a bright crimson or brownish redness of the bronchial mucous mem- brane, either in patches, or generally diffused, with more or less thick- ening, and occasionally softening. The bronchial ramifications are generally filled with a quantity of frothy mucus, frequently sanguino- lent, or with a muco-purulent fluid, the presence of which, by prevent- ing the escape of the air from the lungs, is the reason why these, in many cases of bronchitis, do not collapse when the thorax is opened. When the disease succeeds to the pustular exanthemata, the lining membrane of the bronchii often presents traces of follicular inflammation—often ulceration. In severe and protracted cases it is not uncommon to meet with distinct patches of red hepatization, par- ticularly at the lower and posterior portion of the lungs. Bronchitis is generally produced by exposure to cold and damp; it is hence most liable to occur during the raw, variable, and humid weather that so frequently prevails late in autumn, or in the commence- ment of spring; it is common, also, in winter from accidental expo- sure, more especially when the season is mild and damp. It often occurs, likewise, during the summer, in consequence of the sudden occurrence, after a long continuance of intense heat and dryness, of rain, attended with a reduction of the atmospherical temperature. It may result, also, from the application of cold and damp to the surface of the child's body, by wet clothing, or exposure to a draft of air while in a state of profuse perspiration ; it is a constant symptom in measles, and probably in pertussis, and not unfrequently supervenes on variola, and scarlatina, and, occasionally, upon gastro-enteric inflammation. It sometimes prevails epidemically, affecting as^well children as adults, or being confined, in a great measure, to the firmer. The treatment of bronchitis will differ somewhat, according to the violence of the disease, and in its different stages. In the mild cases, an emetic administered in the commencement of the attack, particu- larly if followed by a warm pediluvium, will very often be sufficient to arrest the disease ; in all cases of bronchitis occurring in children, an emetic given at the beginning of the attack will be found decidedly beneficial; and even at a later period, when great oppression at the chest, with severe dyspncea occurs from the clogging up of the bron- chial tubes with mucus, nothing will be found to give more prompt relief. In infants and young children we invariably prefer the ipe- cacuanha as an emetic, to the tartarized antimony; the effects of which latter, are, in early life, often peculiarly prejudicial. The powdered ipecacuanha, mixed with sugar and water, or the Wine or DISEASES OF THE RESPIRATORY ORGANS. 275 syrup may be employed; the dose being proportioned to the age of the patient. Whenever bronchial inflammation is attended with symptoms of any degree of severity, more especially when it occurs in robust, plethoric children, blood-letting is the remedy upon which alone our chief reliance should be placed. It should be resorted to as soon after the inflammation is developed as possible; if it be delayed until a copious secretion from the lining membrane of the bronchii has taken place, it is always far less efficacious, and in some cases, its effects will be decidedly prejudicial. In robust and plethoric children over two years of age, particularly when the pulse is full and active, and the disease is attended with considerable acceleration of respiration, a dry, hard cough, dyspncea, and much febrile excitement, blood should be taken from the arm to an extent proportioned to the condition of the child, and the violence of the case; and subsequently, if rendered necessary by the continu- ance of the inflammation, leeches may be applied upon the fore-part of the chest, or cups between the shoulders. It is better, however, in most cases, to carry our first bleeding to a sufficient extent to make a decided impression upon the action of the heart; we shall be much more likely, in this manner, to cut short the disease, than by a repeti- tion of the bleeding from the arm, or by the application of leeches ; but although as a general rule, bleeding is not advisable in the advanced stages of bronchitis, there occasionally takes place a sudden recurrence of inflammatory symptoms, or a congested condition of the lungs, in which a prompt and judicious application of leeches or cups to the chest, will be productive of the very best effects. In young children, and in cases of little severity, the abstraction of blood by leeches or cups will be sufficient. The employment, extent, and repetition of blood-letting in cases of bronchitis, whether by the lancet or by local means, demand the utmost judgment on the part of the practitioner. In severe attacks, a cure can scarcely be anticipated, without the abstraction of a sufficient amount of blood, during the first, and perhaps the early period of the second stage. We are to recollect, that in some cases, notwithstanding the extent of the bronchial inflammation, the general symptoms do not indicate a very violent attack, and unless the condition of the chest is early detected by auscultation, active measures may be neglected until too late to effect any good. In those instances in which the disease is complicated with gastro- intestinal inflammation, the application of a few leeches to the epi- gastrium will always be found highly beneficial. By most writers, tartarized antimony is recommended as being next to blood-letting, the most efficacious remedy in the bronchitis of children ; it is probable that in severe cases, after the immediate effects of blood-letting have subsided, should the fever and dyspnoea not be materially relieved, a twelfth to an eighth of a grain of tartar- ized antimony, according to the age of the patient, given every hour 276 DISEASES OF CHILDREN. until vomiting or faintness is produced, may render a repetition of thebleeding unnecessary ; (Maun sail;) but it is under these circumstan- ces alone, that we should be inclined to recommend the employment of tartar emetic in infantile bronchitis; experience having taught us, that it is a remedy, the operation of which is borne with great diffi- culty in the early periods of life. In the generality of cases we pre- fer the administration of small doses of ipecacuanha. After the first bleeding, we are accustomed to direct from a fourth to a half grain, in combination with calomel and hydro-chlorate of ammonia," and have always found it to produce a very decided impression upon the symptoms of the disease. When the cough continues dry, and the surface hot, with quickness and frequency of pulse, we have repeat- edly added to this prescription a quarter of a grain of powdered digi- talis; and notwithstanding its general condemnation, we are per- suaded, that under the circumstances just referred to, it will very generally be found a very useful remedy. »R.—Ipecacuanha? pulv.'gr. iij.—vj. Calomel, gr. iij. Hydrochlor. ammonia?, gr. xlviij. ad J5j-—M. f. chart. No. xij. One to be given every two or three hours, according to the urgency of the case. After the occurrence of expectoration, the ipecacuanha may be employed combined with extract of hyosciamus, which latter, while it has a tendency to relieve irritation, is unattended with any of the disagreeable effects which so frequently result from the employment of opiates in the diseases of young children. The warm bath, especially when confined to the lower extremities, the child being immersed only to the hips, is, in all cases of bron- chitis, productive of the best effects. In mild cases it may be employed at the very commencement of the attack, subsequent to the operation of an emetic; but in cases of considerable severity, it should invariably be preceded by bleeding, or the application of leeches. When bleeding, either general or local, has been carried as far as is thought advisable, there is, perhaps, no remedy from which more decided relief will be derived, than from a blister, applied to the upper part of the chest, or between the shoulders; it should be allowed to remain on until the skin is uniformly reddened, and then be replaced by a large emollient cataplasm. In the generality of cases of bronchial inflammation, the bowels are constipated, or at least inactive, although occasionally, when accom- panied with intestinal inflammation, there is more or less diarrhoea, with vitiated discharges. In the commencement it will be proper to administer some purgative, and perhaps the best is a full dose of calomel, followed by a portion of castor oil; the use of the combina- tion of ipecacuanha and calomel, already recommended, will render the repetition of purgatives unnecessary. The adminisiration of expectorants will seldom be found advanta- DISEASES OF THE RESPIRATORY ORGANS. 277 geous in the first stages of the disease, but in the latter period, after the inflammatory symptoms have been reduced, and a copious secretion has taken place in the bronchii, they are occasionally of advantage ; the mel scilla compositum of the United States Pharmacopoeia, may be employed, or the following combination/ When, however, the oppression of the chest is very considerable, from the amount of mucus filling the bronchial tubes, an occasional emetic will produce far more prompt and decided relief than will be derived from any other expectorant we can employ. One to be given mixed in sugar and water, A tea spoonful to be given every two or every three hours. Ihree hours, according to the age of the patient. When effusion to any extent has occurred within the chest, and the fluid is not speedily absorbed, after the inflammation of the pleura has been subdued, its presence being indicated by auscultation as well as by the inability of the child to assume a recumbent posture without experiencing more or less dyspnoea and cough, small doses of Calomel, squill, anddigitalis,a given every three or four hours, will often cause the effused fluid to be absorbed. In some cases, a combi- nation of digitalis and bi-tartrite of pottassa,b or a mixture of the syrup and oxymel of squill/ with sweet spirits of nitre, will prove highly efficacious. *R.—Pulv. scilla?, gr. iij. ad. iv. bR.—Bi-tart. potass, giij. Calomel, gr. iij. Pulv.digitalis, gr. iv.—M. f. chart. No. xij. Digitalis, gr. iij.—M. f. chart. No. xij. One to be given every threeor four hours. eR.—Syrup scilla?, gvj. Oxy. scilla?, 3'j- Spir. a?lh. nitr. Qvj.— M. Dose, twenty-five drops three or four times a day. The same rules are to be observed in regard to the diet of the patient as were directed in pneumonia. In chronic pleuritis, our chief remedies are a mild unirritating diet, composed principally of the farinacea and milk, counter-irritants to the parieties of the chest, as blisters, or tartar emetic ointment, and inter- nally, calomel in small doses, combined with some of the diuretics, of which, perhaps, digitalis and squill are the best, though occasionally the tincture of ISanguinaria Canadensis, will be found a very valuable remedy in these cases, in the dose of from two to ten drops, accord- ing to the age of the child, repeated three times a day; the bowels s s~*. /?&,/• yyJ 294 DISEASES OF CHILDREN. being kept open by mild laxatives, or purgative enemata. Iodine, both internally and externally, may, in some cases, be productive of benefit. When effusion of pus has taken place in the pleura, the case, as we have already remarked, is generally hopeless; nevertheless, we are assured that by an operation, the pus has been evacuated, even in a child only seven years of age, and entire recovery has ensued, with the exception of a slight contraction of the chest, on the affected -*' side.—(Herpin.) During convalescency from chronic pleuritis, change of air will often be advisable, especially the removal from a cold, damp, and variable climate, to one warmer and more equable. 7.—Tracheitis.—Croup. CYNANCHE TRACHEALIS—ANGINA POLYPOSA VEL MEMBRANACEA. If we take into consideration its frequency, the rapidity of its progress, the distressing and painful symptoms by which it is ac- companied, and the amount of mortality produced by it, tracheitis or croup, must be regarded as one of the most formidable of the diseases peculiar to infancy and childhood. In Philadelphia, during the eight years preceding 1840, there occurred eight hundred and twenty deaths from croup, being an average of 102.5 per annum ; in London, 391 deaths from this disease are reported in 1840 ; and in the whole of England, during the same year, 4,336.* The croup is, strictly speaking, an inflammation of the mucous membrane of the trachea and larynx, the latter being, in the majority of cases, the part first affected. The peculiarity of the disease consists in the exudation, at an early period, of coagulable lymph, upon the surface of the inflamed membrane of the trachea, forming, in many cases a pseudo-membrane, extending often from the larynx through- out the larger, and even sometimes into the smaller divisions of the bronchii. It has kbeen doubted, however, whether in certain mild cases of frequent occurrence, unattended with fever, and readily cured by simple means, there is any tendency to the pseudo-mem- branous exudation. (Blaud, Dugts.) These cases of simple laryngeo- tracheitis, have been denominated spurious croup.—(Guersent, Ber- ton.) The distinguishing symptoms of croup are, dyspnoea, a peculiar hoarsness of the voice, a loud ringing cough, sibbilant inspiration, and fever. In the majority of cases, the disease is preceded by symptoms of bronchitis. The patient is affected with more or less chilliness, succeeded by increased heat of the surface, lassitude, loss of appetite, * Entire mortality of London during 1840, 45,284; and of the whole of Finland, 359,561. Iu Paris, the deaths from croup in 1838, were 187 ; in 1839, 286; and in 1840,326. DISEASES OF THE RESPIRATORY ORGANS. 295 and cough. These symptoms vary in intensity and duration; in some cases presenting simply the characteristics of a slight bronchitis for several days; while in others, the tendency to croup is exhibited from the commencement of the attack. It is usually during the night that the proper symptoms of the disease are developed. The child, after retiring to rest, suddenly awakes from his sleep, with difficult and wheezing respiration, and frequent paroxysms of a loud, ringing cough ; his skin is intensely hot, his face flushed, and his voice hoarse and indistinct. Frequently he complains of a sense of constriction in the throat, and sometimes of pain about the larynx. In general, these symptoms, after a short period, gradually abate, the respiration becomes. more free, the patient falls again into sleep, and on awaking in the morning, with the exception of some degree of hoarseness, and a slight cough, presents no symptoms of any serious disease :—the pulse, how- ever, will, in general, still be found to be more frequent than natural, the cough more hoarse and resonant. On the ensuing evening the respiration becomes ag.iin suddenlydifficult,loud and wheezing,and the cough convulsive and ringing; the patient feels a sensation as of im- pending suffocation, and carries his hand to his throat, as if to remove the cause of his suffering. His face becomes swollen and flushed, his pulse hard and frequent, and his voice hoarse and almost inaudible. The cough is unattended with expectoration, or perhaps causes the discharge of a small amount of glairy mucus, streaked with blood. The violence of these symptoms may, after a time, moderate ; but if so, soon again increase in violence, and usually continue, with slight remissions and exacerbations of augmented severity, during the • night. Sleep appears to favour their return ; or if the patient remains awake, they are excited by his cries, or by the slightest paroxysm of coughing. The symptoms constantly augment in intensity, and the remissions become slighter and of shorter duration; the cough looses, however, its acute ringing sound, while the loud wheezing respiration of the patient is heard even beyond the apartment he occupies. The dyspncea becomes excessive, the patient is in a constant state of agitation, his face swollen and livid, his lips purple, and his fore- head covered with large drops of perspiration. The skin becomes cool, and the pulse small, feeble, and extremely rapid. The thirst is often excessive, and not the least difficulty is experienced in swallowing the fluids presented. There is often expelled by the cough, or by vomiting, at this period, a quantity of thick, ropy mucus, sometimes mixed with fragments of a membranous appear- ance. These symptoms may continue for a longer or shorter period, according to their intensity :—the voice, however, soon becomes extinct, the respiration short and convulsive, and the patient is every moment in danger of suffocation; his face becomes pale, his eyes dull and inanimate, and his head, face and neck, are bathed in a cold, clammy sweat. There is now but little, if any, cough or expec- toration, the pulse is feeble, irregular and intermittent, and the patient 296 DISEASES OF CHILDREN. at length ceases to breathe,—the intellect being, in general, unaffected throughout the attack. In other cases, however, the disease commences much more - abruptly, and proceeds with greater rapidity and violence. The patient, who retired to bed, apparent!)' in perfect health, is suddenly awoke from his sleep with a violent fit of loud, ringing cough ; his respiration is loud, wheezing and oppressed, and attended with a feeling of immediate suffocation ; there is the utmost anxiety and restlessness ; the face is red and tumid, the eyes injected and protruding, and the pulse frequent and hard. These symptoms present not the slightest •remission, but increase in intensity, and the patient, in the midst of the most frightful agony, perishes as though from actual strangulation. In these extreme cases, death may occur in a few hours, or the attack may be prolonged for one or more days. Between the two forms of the disease we have described, that in which it is gradually developed, and of some duration, and that in which it occurs suddenly, with symptoms of the utmost severity, and runs a rapid course, tracheitis may present very various shades of intensity. Its duration will vary in different cases, according to the intensity of the disease, the age and constitution of the patient, and the nature of the treatment pursued. When attacked, in its early stages, by appropriate remedies, even in the most violent cases, it will often give way almost with the same abruptness that marked its invasion ; and in a few hours, the little patient will appear to pass from the midst of health, to a situation in which death seems inevitable, and, . again, as quickly to be restored to almost perfect health. The ordi- nary duration of the disease, is from twenty-four to thirty-six hours; (Royer-Collard;) though cases have been related in which it has been protracted until the twelfth day from its invasion; or the disease assuming a chronic character, it may, it is asserted, continue for two and three weeks. (Albers, Gblis, Marley, MaunseU.) We should very much doubt, however, the correctness of the diagnosis in these cases. The disease is one that appears to be peculiarly liable to recur in the same individual, after a longer or shorter intei val; this fact is noticed by nearly every writer upon the disease ; it has been known to recur seven, and even nine.times in the same individual. (Jurine, Albers.) The subsequent attacks vary in intensity in different cases ; an infant may promptly recover from one, two or three consecutive attacks, and finally be destroyed by a fourth, exceeding in intensity either of the preceding. The diagnostic symptoms of croup are, the hoarseness of the voice, the peculiar deep ringing- cough, and the loud wheezing or sibbilant inspiration. The hoarseness of the voice is generally among the first symptoms that occur; even, in many cases, being observed previous to the dyspnoea, cough, or febrile reaction. It is at first slight, but becomes more marked in the progress of ihe disease; not unfrequently, in the second and third stages amounting to an entire DISEASES OF THE RESPIRATORY ORGANS. 297 extinction of the voice. In those cases that are preceded for some days by simple cattarrhal symptoms, the peculiar hoarseness of the voice will early warn the observing physician of the true character of the attack. The roughness or hoarseness of the voice, to a certain extent at least, often continues for some time after the tracheitis has been entirely removed, and it only slowly disappears. It is extremely difficult to present a correct description of the distinguishing croupal cough. In cases preceded by catarrhal symptoms, a cough is present from the onset of the disease, but it differs in nothing from the ordinary cough of bronchitis ; but from the moment that inflammation of the larynx and trachea is developed, the cough becomes deep and hoarse, and with the first accession of the phenomena dependent-upon the laryngeo-tracheitis, it assumes the peculiar loud, ringing sound, constituting the proper croupal cough. This sound has been compared to the crowing of a young cock, the barking of a hound, or to a cough heard through a brazen trumpet, these comparisons, however, but illy characterise its deep,ringing resonance. It must be heard, to form a correct idea of it; and, when once heard, it will be scarcely possible afterwards to confound it with any other. (Royer- Col lard.) During the paroxysms of the disease, the cough occurs by fits more or less violent and prolonged ; during the intervals the cough still retains its croupal sound, but is less violent; towards the close of the disease, when the natural functions of the respiratory tube have become nearly destroyed, the cough is always entirely suppressed, and looses its peculiar characteristics :—in the event of a favourable termination, the cough very frequently disappears entirely ; or, as is more commonly the case, resumes its catarrhal character, and con- tinues to recur for a longer or shorter period. In tracheitis, the paroxysms of coughing, are excited by the most trifling cause, as the act of drinking, speaking, crying and the like. The respiration is more or less short and hurried from the com- mencement of the attack, and the dyspnoea augments in intensity with the progress of the disease, being sometimes so great as to threaten, every moment, strangulation. During the paroxysms', inspiration is prolonged, and attended with a loud wheezing, in some cases, amount- ing almost to a low, lengthened whistle. This wheezing inspiration continues throughout the attack, being less intense, however, during the intervals, and disappearing entirely with the disappearance of the disease. The hoarseness of the voice, the peculiar croupal cough, and the loud, wheezing and prolonged respiration, are evidently dependent, in a great measure, upon the diminished capacity of the rima-glottidis and trachea, in consequence, in the first instance, of the thickening of the inflamed mucous membrane of these parts, and subsequently, of the pseudo-membranous exudation with which they become covered. But the circumstance of these symptoms, in many cases, becoming aggravated at irregular intervals, divided by distinct remis- 298 DISEASES OF CHILDREN. sions, thus constituting, as it were, paroxysms, that commence sud- denly, and decline with equal abruptness, have induced many to suppose, and not without good reason, that the peculiar symptoms of croup are, to a certain extent, due to a spasmodic constriction of the muscles of the larynx and glottis. It is probable, however, that it is chiefly the extreme dyspncea of croup, that is the result of this spasm, and which gives to the disease its apparent paroxysmal character. In the more violent attacks of croup, the dyspnoea commences with the very onset of the disease, and continues, with little abatement, until its close; when, however, the disease is preceded for some days by catarrhal symptoms, the dyspncea does not occur until somewhat later, and attains its peculiar character only in the second stage; when, during the paroxysms it is only by the utmost efforts that the child appears to be capable of effecting the respiratory movements; the muscles of the face, neck, shoulders, chest and abdomen, are thrown into violent, almost spasmodic action, the mouth and nostrils dilate, the larynx ascends and descends incessantly, the entire thorax is raised, and the shoulders are drawn up at every inspiration. In most cases, the dyspncea is increased by the horizontal position, and the patient in a state of the most violent agitation, throws his body successively in every position to obtain ease; very generally the head is bent backwards, as it were to augment the size of the larynx, and thus give to the air a more free passage into the lungs ; this position, however, is not invariably assumed by patients labouring under croup, and hence, cannot be considered as one of the diagnostic phenomena of the disease. (Royer-Col/ard.) In the final stage of the disease, the dyspnoea is equally intense; but respiration is effected almost entirely by the action of the diaphragm, the contractions of which are violent and convulsive; the cartilages of the ribs, and abdominal muscles, are, at one moment, drawn inwards towards the spine, and at the next, return suddenly to their former position. Ordinarily inspiration is long and almost continuous, endangering, every instant, the suffocation of the patient. In the second, and even at the com- mencement of the third stage, the dyspnoea may present very distinct remissions; these remissions have occasionally been so complete, that the disease appeared to be suddenly suspended, and the parents have rejoiced at its speedy recovery; nothing, however, is more insidious, than this sudden occurrence of a deceitful calm. Fever is very generally present in croup; it is in some cases strongly marked, commences with the disease and continues until its closing stage ; in others, the febrile excitement is less intense; and again, in what have been termed spurious croups, the laryngeo-bronchial variety of Duges, there is often, especially in young children, no symptoms whatever of fever. In violent laryngeo-tracheitis, there is frequently pain of the larynx and trachea, in general of an obtuse, rather than an acute character, and increased upon external pressure; in slight cases, of croup, however, this symptom maybe wanting. By some writers, a swelling of the neck, at the upper part of the trachea has been DISEASES OF THE RESPIRATORY ORGANS. 299 described as frequently occurring; the swelling is represented as varying in size in different cases, of an cedematous character, and disappearing immediately upon the recovery or death of the patient; it must, however, be of very rare occurrence, as we have never had an opportunity of observing it. Vomiting occasionally occurs on the accession of the disease, but is not an invariable symptom, as has been supposed, (Albers,) even in the more violent cases. The fact is, that in these latter cases, vomiting is with difficulty excited, even by the administration of the most active emetics. Occasionally, however, vomiting will be provoked by the violent fits of coughing which occur during the height of the disease ; the matters vomited in these cases, are usually a thick, viscid mucus, or muco-purulent matter, mixed with shreds of false membrane, sometimes in the form of tubes or por- tions of tubes. The discharge of these matters, when copious, is fol- lowed by a very marked relief of the dyspncea and cough, which, however, is never of lonar duration. The condition of the bowels is various; but in the majority of cases, according to our expe- rience, they are more or less torpid. The urine is sometimes clear, pale and abundant, and at others, small in quantity, thick, and deep coloured; it is very often whitish and turbid, particu- larly towards the close of the second period. This condition of the urine, however, is neither diagnostic of the disease, nor critical. (Schwilgue.) There is often a disposition to somnolency in the com- mencement of the disease, which, in some cases, amounts to complete stupor, arising, probably, from a slight congestion of the brain ; drow- siness or stupor, however, is by no means an invariable, we should think, not even a frequent, attendant upon croup, as some have supposed, especially in its first and second stages. (Burns, Dewees.) Some have described the senses, as well as the intellectual powers of the patient to be increased in activity, (Cailleau,) but although we have seldom seen the mental powers much impaired throughout an attack of croup, we cannot say that we have observed any increase in their activity. The pathological changes presented by the bodies of those who have fallen victims to croup, are principally confined to the larynx, trachea, bronchii and lungs. One or other, or all of these, invariably present traces of disease, differing somewhat, according to the inten- sity exhibited by the symptoms during the life of the subject, and the period at which death has taken place. The lesion most commonly observed, is a pseudo-membranous exudation, covering some portion of the mucous membrane of the respiratory tubes, and an effusion of mucus or muco-purulent matter, filling the larger and sometimes the smaller bronchial ramifications. In cases that have terminated rap- idly in death, the exudation is found only in the larynx and upper por- tion of the trachea; when death has occurred at a later period, it is in the trachea alone, or in the trachea and bronchii that it is detected; it never exists in the bronchii alone. In the larnyx, the exudation is often in the form of a thin coating, extending over the whole of its 300 DISEASES OF CHILDREN. internal surface, but more frequently it is disposed in membraniform patches, or is found upon the inferior surface of the epiglottis alone. (Davis.) In the trachea, it often lines the whole of the tube, and varies in consistency and thickness: or patches of the exudation occur here and there,or it appears in the form of soft concretions, resem- bling polypi, attached to the posterior surface of the tube; or the trachea is filled with a mucuform fluid, containing small masses of a more solid consistence. These same appearances are occasionally found in the upper part of the bronchii, but, more frequently, in the bronchial tubes there is found only a viscid mucus, more or less fluid, and containing often albuminous flocculi. In those cases in which the invasion of the disease has been sudden and violent, and its termination in death, rapid, it is rare to find the exudation assuming a pseudo-membranous appear- ance; the respiratory tubes in such cases, containing only mucus, some- what more abundant and viscid than natural. (Martinet.) The larynx and trachea have, however, been found lined with a pseudo-membran- ous concretion, in cases in which the entire duration of the disease did not exceed twenty hours. (Blaud.) When the fatal termination occurs towards the close of the second stage, the pseudo-membranous exudation very frequently lines the whole of the trachea, and some- times even the larynx and upper portion of the bronchii, and presents throughout nearly the whole of their extent, considerable firmness. (Blaud, Bretonneau.) In cases in which death occurs at a still later period, in the upper portion of the trachea there is found nothing but a quantity of viscid mucus, which becomes more consistent at the lower part of the tube, and often presents here a more or less com- plete membrane, separated from the mucous membrane by an abun- dant layer of fluid matter; in the bronchii this pseudo-membrane becomes much softer, and soon looses entirely its membraniform character, the bronchii being filled in their final ramifications, with a thick, ropy mucus. (Royer-Collard.) The colour of the membrani- form exudation, is either whitish, yellowish or grey; the part applied to the surface of the respiratory tubes is often marked by slight, bloody striae or points. It is sometimes very closely adherent to the mucous membrane, but in other cases, there is interposed between it and the surface of the tube a layer of mucus or puriform fluid. It is in some cases soft, and readily torn, while in others it has considerable firm- ness; it is, in general, most thick and firm in the trachea, particularly at its posterior part. Some have described the pseudo-membrane of croup as an organ- ized substance, possessing minute fibres and blood vessels, (Vanber- gen, Bbhmer,) a supposition which is contradicted by the most con- clusive testimony. (Royer-Collard.) That in some cases after the cessation of the disease, a portion of the membrane intimately attached to the mucous membrane of the trachea, may remain, and become organized, has, however, been conclusively established. (Albers, Royer-Collard, Blache, Skiers.) The chemical composition of the pseudo-membranous exudation of DISEASES OF THE RESPIRATORY ORGANS. 301 croup, is the same as that of the diptheritic inflammations generally, and of the pseudo-membranes of serous surfaces, it being composed chiefly of albumen. (Schwilgue, Bretonneau.) When the pseudo-membranous exudation, and the viscid mucus are removed from the surface of the respiratory tubes, the mucous membrane of the larynx, trachea and bronchii, are found to be in a state of inflammation throughout the greater part of its extent. When death takes place in the early stage of the more violent cases, thelarynx and upper portion of the trachea are of a deep red colour and more or less thickened. When the disease has continued for a longer period, the redness is less intense ; the blood vessels of the mucous-membrane are, however, strongly developed, and when the mucus is scraped from its surface by the scalpel, is of a reddish colour; at a still later period of the disease, traces of inflammation are less perceptible, and often entirely absent. The affection of the bronchii is in proportion to the extent and duration of the disease; the earlier the death of the patient occurs, the less marks of disease are presented by them; the - later in the disease the fatal termination takes place the more exten- sively do they appear to be involved. Cases not unfrequently occur in which their minutest ramifications are filled with a pulpy matter. Pneumonia is not an unfrequent complication of croup ; portions of the lungs being in a state of inflammatory engorgement and hepati- zation : pleuritic inflammation is also occasionally met with, as well as interlobular and sub-pleural emphysema. (Bard, Jurine, Mathey, Portal, Mackintosh, Cheyne, Stokes, Boudet.) The physical signs of croup are not of a very positive character. In the early period of the disease, the stridulous respiration may be detected by the stethoscope, applied to the trachea, before it is other- wise distinct. ( Williams.) So long as the disease is confined to the larynx and trachea, upon percussion, no dullness will be found to exist. When bronchitis or pneumonia are present, it will be indicated by its appropriate signs; these, however, may in a great measure, be obscured by the loud sound of the tracheal respiration. In the early stage of the disease, or after vomiting, the tracheal sound being less, the sonorous breathing and rhonchi of bronchitis and the crepitation of pneumonia may be detected, if present. (Stokes.) When the pseudo mem- brane in the trachea is partially detached, it is said that we may have a clapper or valve-like sound, upon inspiration, when the upper, and upon expiration, when the lower extremity is the one detached and moved by the passage of the air through thelarynx. (Maunsel.) We have never ourselves observed this sound. It is unnecessary to enter into an examination of the various hypoth- eses that have been emitted in reference to the nature of croup. The investigations of modern pathologists have shown that the disease is an inflammation of the mucous membrane, and probably of the sub- mucous cellular tissue (Ryland,) of the larynx and trachea, and in many cases of the bronchii also. The inflammation, in the first stage of the disease, being confined to the larynx and upper portion of the 302 DISEASES OF CHILDREN. trachea, but extending subsequently to the bronchii, often throughout their ramifications, and to the tissue of the lung itself; giving rise in the second stage of the disease, to the exudation of an albuminous fluid, which most generally forms a pseudo-membranous coating upon the larynx, trachea, and commencement of the bronchii; the collapse or adynamic symptoms of the third stage, resulting from the interrup- tion to the function of respiration, and the consequent imperfect haematosis, caused by the presence of the exudation, and the conges- tion of the lungs. As we have already remarked, nearly all the cha- racteristic phenomena of croup indicate that there also exists, a spas- modic affection of the glottis, which, however, is the result of the increased irritability of the parts from inflammation, and probably from the irritation of the morbid secretion, and not, as some patho- logists have supposed, the chief cause of the disease. Various divisions of croup, have been attempted, by different wri- ters. By one, it has been divided into three forms, dependent upon the intensity of the inflammation, and the character of the secretion from the inflamed mucous surfaces; the first being a mild form, with the secretion of a moderate quantity of thin, limpid, frothy mucus; the second, a more aggravated form, but still comparatively mild in its progress, and favourable in its termination, with opaque and puri- form secretion ; and the third, the most aggravated form, with pseudo- membranous exudation. (Blaud.) This division,, which is of little benefit in a practical point of view, even were it well founded, is not borne out by the results obtained from autopsical examinations. By others, it has been divided into the laryngeal, laryngeo-tracheal, and laryngeobronchial, according as the inflammation is confined to, or predominates in the larynx, trachea, or bronchii; this division is a much more accurate one than the preceding. It is probable, that in the majority of cases, the bronchii are the part first affected ; in many, however, the disease commences in the larynx, and we sus- pect there are few cases in which the disease is confined to the trachea alone. (Dugis.) It has been attempted to be shown, that in the ordi- nary form of croup, the disease is, in its first stages, a tracheitis alone, and that in the more violent form, (suffocating croup,) it is simply a laryngitis. (Jurine.) Although this is not correct in fact, yet our observations have taught us, that in cases attended with violent symp- toms, sudden in their onset and rapid in their progress, there exists, most generally, considerable inflammation with pseudo-membranous exudation about the larynx, glottis and upper portion of the trachea, to a much greater extent always, than in cases in which the disease succeeds to bronchitis, and pursues a less violent and more protracted course. Another division of croup is into the sthenic and asthenic; the first occurring in robust and plethoric children, and attended with decided febrile re-action, firm pulse, pain in the larynx, and other indications of severe inflammation ; the disease usually occurring as a primary affection; the second form, occurring in debilitated and cachectic chil- DISEASES OF THE RESPIRATORY ORGANS. 303 dren, or those reduced by previous disease, and attended with a low, obscure fever, feeble pulse, early collapse, and other indications of asthenia. (Albers, Royer-Collard, Williams.) The first, or sthenic form, corresponds, very nearly, with the primary croup, and the second, or asthenic form, with the secondary croup of medical wri- ters—the second, very generally, resulting from the extension of the pseudo-membranous inflammation of the fauces into the larynx and air tubes. Upon the termination of the symptoms characteristic of croup, the patient is frequently perfectly convalescent within a very short period; more commonly, however, it is succeeded by a mild bronchitis which continues for many days; in other cases the bronchitis becomes chronic, and occasionally terminates finally in tubercular disease of the lungs. Age is evidently the chief predisposing cause of croup. The dis- ease being principally confined to children under fifteen years of age, seldom occurring beyond that period as a primary affection. It is rare in the first months of life, but is met with most frequently in children between one and seven years. By numerous writers, the occurrence of croup previously to the seventh month, has been denied. (Vanber- gen, Home, Crawford, Rosen, Cheyne, Michalis, Pinel, Barthez, Cail- leau) Others, however, declare that they have met with it repeatedly, as a primary disease, in children at the breast. (Dewees, Marley, Duges.) In Philadelphia, during the eight years preceding 1840, 286 deaths are reported from croup, in infants under one year of age; 275, in those between 2 and 5 years; 171, in those between 1 and 2 years; 67, in those between 5 and 10 years; and 21 in individuals over 10 years of age. Of 330 cases of croup, presented in a tabular form, by Andral, 141 occurred in infants between 2 and 5 years old ; 71, between 5 and 8; 61, between 1 and 2; 36, over 8; and 21 under one year of age. The earlier the children are weaned, the more liable they are said to be to the disease. (Home.) Judging from our own experience, we should say that the croup occurs, more fre- quently, between the tenth month and fifth year from birth, than at any other period. This is the period also, when children are particu- larly liable to catarrhal affections, which, in consequence of the ten- dency that then exists to the exudation of coagulable lymph, in the inflammations of the mucous surfaces, especially those of the respira- tory organs, readily assume, in particular constitutions, the croupal character, rendered still more marked and dangerous, by the very great excitability of the mucous tissue in early life, and the imperfect devel- opment of the larynx and trachea, and the small size of the glottis. (Albers, Royer-Collard, Cheyne.) Boys would appear to be more frequently affected with the disease than girls. (Jurine, Albers, Blaud, Gblis, Guersent, Ramsey, Boudet.) Of 543 cases of true and false croup, collected by Guersent, 325 occurred in males, and 218 in females; of the 820 fatal cases of croup reported to the Health Office at Philadelphia, during the eight years preceding 1840, 448 occurred 304 DISEASES OF CHILDREN. in boys, and 372 in girls. The deaths from croup in the London Hos- pitals during 1840, were, in the male sex 3, to 1 in the female. Children of a sanguineous temperament, of a florid complexion, inclined to fat, and apparently in the enjoyment of perfect health, are those in whom the croup is most liable to occur as a primary disease, and hence we find of those families in which this temperament pre- vails, almost every infant attacked with the disease, as it reaches its first or second year. Children are rendered more liable to an attack of croup, when by the improper fashion of their dress, their neck, shoulders, upper portion of their breast and the greater part of their arms are left entirely bare, or only slightly covered. The chief exciting cause of croup, is unquestionably, the impression upon the body, of a cold and damp atmosphere or sudden transitions of temperature; hence, we find the disease most prevalent during the variable, damp, and chilly weather, which prevails in the commence- ment of spring and close of autumn. It is also of much more frequent occurrence, in situations naturally abounding in moisture, than in those of an opposite character. It may be considered as, to a certain extent, endemic in valleys surrounded by high mountains, and in the vicinity of lakes and large rivers. (Home, Dewees, Rush, Currie, Archer, Mackintosh.) It may be produced, however, at any season of the year, by sudden alternations of temperature. Sitting or lying down on a damp grass plat, or in a current of air, after the body has been heated by exercise, or a sudden chilling of the body from any other cause, is very apt to induce the disease. It is also particu- larly apt to occur, in the course of, or immediately subsequent to an attack of measles.or of pneumonia. (Ferriar, Stokes, Marshall, Boudet.) It is said, occasionally, to prevail as an epidemic. (Vanhcr- gen, Rosen, Autenrieth, Jurine, Albers, Boudet.) In many of these epidemics, however, we suspect that the disease was not primary, but secondary croup resulting from pseudo-membranous angina; the latter diners, in some degree, from primary croup; independently of the inflammation of the larynx and trachea, being secondary to disease of the pharynx and throat, and its occurring always in the course of some other affections, the symptoms are usually of an asthenic cha- racter; the deglutition is more or less difficult, the breath foetid, and instead of a tendency appearing in the course of the attack to acute pneumonic inflammation, it is disease of the mucous membrane of the stomach and bowels, with which, in cases of secondary croup, the laryngeo-trachitis is most commonly complicated. Stokes enume- rates other points of difference, which we do not recognize, as, for instance, the contagiousness of secondary croup, and its chiefly affect- ing adults. Under no circumstances, do we believe croup to be con- tagious; even when it accompanies or succeeds to small pox, measles, or scarlatina, it is scarcely correct to refer it to contagion, merely because the affection which it accidentally complicates, is in this man- ner propagated. Secondary croup, as well as angina membranacea, is also much more frequent in children than in adults; it is very DISEASES OF THE RESPIRATORY ORGANS. 305 probable that the cases of croup that have been described by Dewees, Duges, Marley and others, as occurring in infants under seven months of age, were produced by the extension of pseudo-membranous inflam- mation from the fauces to the larynx and trachea; it is certain, that in the numerous instances in which secondary croup has occurred during epidemics of scarlatina and small pox, the patients have been chiefly infants. (Boudet, Schmidt.) The treatment of croup varies somewhat, according to the stage of the disease, and the violence of the attack ; in mild cases, or in the early, or forming stage, an active emetic, followed by immersion in the warm buth, and subsequently the exhibition of small doses of antimony combined with calomel, will, in many instances, put a stop to the further progress of the disease. Nearly every wri- ter upon the disease, has spoken of the good effects of emetics, admin- istered in the cases and at the period noticed ; much discrepancy of opinion, however, exists as to the best emetic to be employed ; by the majority of physicians, the tartarized antimony is preferred., but others refer a peculiar efficacy to the sulphate of copper ; (Hoffman, Droste, Fielitz, Steinmitz ;) others to the sulphate of zinc. (Smith, Farre, Fran- cis.) Some of the American practitioners esteem the sanguinaria Can- adensis, in infusion, as almost a specific, (Tully, Smith and Ives, of New Haven, and Andrews of New York,) while a few prefer the lobelia inflata. The great objects to be kept in view, in our choice of an emetic in croup, is the promptness, certainty and activity of its operation, and these properties being combined in the tartarized anti- mony, we have invariably preferred it in the commencement of the attack.3 In many of the milder cases, the compound honey of squill, given in a sufficient quantity to operate freely as an emetic, and con- tinued subsequently in nauseating doses, will, very effectually, cut short the disease. The only writer whom we have met with, that condemns emetics in the treatment of croup, is Goodlad. »R.—Ant. tartaris.gr. iij. Aqua?, gij..—M. A tea spoonful to be given every five or ten minutes, until full and repeated vomiting is produced. In cases of greater violence, or in which the emetic, given in the forming stage, has failed to arrest the disease, our most effectual rem- edy is, unquestionably, blood letting. • In many cases, the application of a sufficient number of leeches to the throat, will be sufficient, but in every instance in which the disease is marked by symptoms of con- siderable severity, or the patient is robust and plethoric, the pulse hard and full, and the dyspnoea very considerable, blood should be drawn from the arm, to an extent sufficient to make a decided im- pression upon the symptoms, but never if possible, to the extent of inducing syncope; and if the symptoms should again recur with any degree of violence, the bleeding should be repeated, or leeches should be applied around the throat, in numbers proportioned to the age and strength of the patient, and the intensity of the disease. The repetition 306 DISEASES OF CHILDREN. of the bleeding must be governed by circumstances; in some cases, one bleeding, if of sufficient extent, will most effectually control the symp- toms ; but in others, we must bleed again and again, if the system reacts with force, the pulse continues firm, the skin warm, and the dyspnoea considerable. (Dewees, Royer-Collard, Currie.) There is certainly, no disease, in which bleeding, when well timed, and carried to a sufficient extent, is calculated to produce more beneficial effects. The practitioner, who in violent cases of croup, neglects this impor- tant measure, and places his hopes on any other remedy, or combina- tion of remedies, will have but little reason to flatter himself upon his success in the management of the disease. This assertion is based upon a tolerably extended personal experience, as well' as upon the recorded experience of nearly every American practitioner, and a majority of the most authoritative of the practitioners of Europe. But, it must be recollected, that it is in the first stages, that the bene- ficial effects of blood letting are to be obtained ; if it be then neglected, or timidly practised, the time for its employment will have passed, and in those cases in which it is strongly indicated, there will be but little hopes of arresting the fatal termination, by whatever remedial measures may be resorted to. (Currie, Kuhn, Dick, Chapman, Eberle.) From the difficulty often experienced in obtaining blood from the arm, in young children, it has been recommended to open one of the jugular veins ; (Cheyne, Goodlad ;) others, however, have objected to the operation, from the difficulty of measuring the quantity of blood drawn, and of arresting the bleeding when a sufficiency has been obtained. We have repeatedly drawn blood from the jugular veins, in violent cases of croup, and with very decided advantage; the promptness of the relief has occasionally been very striking. We have never experienced any difficulty in performing the operation, or in arresting the bleeding; and as to the extent of the bleeding, this being measured not by the number of ounces of blood drawn from the patient, but solely by its effects upon the disease, we have had no more trouble in judging of this when the jugular vein was opened, than when the bleeding has been performed from a vein in the arm, back of the hand, or foot. Immediately after the first bleeding the exhibition of an emetic and immersion in the warm bath will prove powerful auxiliaries. It often happens that an emetic exhibited upon the accession of the disease, will not operate, sometimes not even excite nausea, until the patient is bled and the warm bath employed, when immediate copious vomit- ing will occur, and render the repetition of the emetic unnecessary. After the patient is removed from the warm bath, he should be placed in bed and enveloped in blankets, the perspiration induced by the bath and emetic being encouraged by the employment of divided doses of tartarized antimony ; we generally combine the antimony with calo- mel and hydrochlorate of ammonia.1 DISEASES OF THE RESPIRATORY ORGANS. 307 »R.—Calomel. JJss, ad 3j. T;irt. ant. gr. j. Hydrochlor. arnmon. 9ijss.—M. f. chart. No. xij. One to be given every two hours. The employment of nauseating doses of antimony subsequently to full vomiting and sufficient depletion by the lancet, has the sanction of the best writers upon the disease. Cheyne declares, that he has found no other remedy worthy of confidence in the second stage of croup, an assertion which we consider, judging from the result of our own expe- rience, scarcely too strong. Stokes places it even above blood-letting. Steinmitz trusted to it alone in the second stage,as also did Jadelot, who combined the tartarized antimony with ipecacuanha, squill, and senega.* Cheyne also speaks highly of the efficacy of the tartarized antimony, both as an emetic, and in nauseating doses throughout the first and second stages of croup. A recent writer (C. Wilson) gives the tar- tarized antimony throughout the disease, at first in doses of a quarter or third of a grain every hour, until a decided impression is pro- duced upon the symptoms, and subsequently every two hours. Com- bining the article with calomel, we have certainly found to in- crease, very materially, its efficacy. Of the good effects of calo- mel in croup, we have abundant testimony. Given in large doses and at short intervals, it is the remedy upon which many physicians have almost exclusively depended for the cure of the disease; while in somewhat smaller doses, after bleeding, an emetic and the warm bath, it is strongly recommended by a host of authorities. (Kuhn, Bond, Bard, Rush, J. Hamilton, J. P. Frank, Michdlis, Authenreith, Currie, Hosack, Dewees, Olbers, Albers, Ryland, Bretonneau, Guer- sent, Mackintosh, Billard, Chapman.) Some of these have directed the calomel in enormous doses, far greater than we should be inclined to prescribe ; notwithstanding we still believe that the good effects of the remedy, in a disease of such rapid progress as croup, can be obtained only from its free administration. »H.—Infus. senega?, giv. Syrup, ipecac. 3j- Oxy. scilla?. 3"j* Tart. ant. gr. jss—M. A teaspoonful every ten minutes. After the first bleeding, the operation of an emetic and immersion in the warm bath, from two to five grains of calomel may be pre- scribed every two hours, so long as the symptoms of the disease con- tinue with any degree of violence; ~as these subside, the dose of the remedy may be reduced, or it may be exhibited at longer intervals. We have generally found, however, that when the use of the calomel produces at an early period, deep green discharges from the bowels, it is better to reduce the dose; or if frequent green discharges still occur under its use, to discontinue it entirely ; we have in no instance seen any bad effects from the employment of calomel in this man- 308 DISEASES OF CHILDREN. ner, but often the most decided benefit. Its tendency is to reduce the laryngeo-tracheal inflammation, and ihus to counteract the pseu- do-membranous exudation. The hydrochlorate of ammonia appears to us to be a remedy well adapted to nearly all the inflammations attended with diptheritic effu- sions ; we have employed it pretty extensively for many years in croup, and have always been pleased with its effects. Chamerlat recom- mends it as almost a specific, when employed as a wash or gargle. Blisters to the throat are strongly recommended by many practi- tioners in the treatment of croup. (Currie, Hosack, Lheyue, Farre, Royer-Collard, Burns, Eberle.) Mackintosh confines their applica- tion to the first stage, after the violence of the disease has been reduced by bleeding and leeching. Dewees doubts their utility ; and Goodlad, Stokes, and Porter condemn them entirely. We have occasionally employed them, but cannot say that we have perceived any benefit to result from their use. Rubefacients, fol- lowed by warm fomentations or emollient cataplasms to the throa*, have certainly, in the forming stage of the disease, been often produc- tive of the best effects. As a rubefacient, the spirits of turpentine is the one we have generally employed ; its action upon the skin is prompt and sufficiently powerful; a strip of flannel wet with the tur- pentine may be applied around the neck, and kept on for ten or fifteen minutes ; it may be reapplied at short intervals, from time to time, if necessary. In very violent cases, in the incipient stage of the dis- ease, even rubefacients should not be applied to the neck until after blood-letting. When the disease persists, after the use of the lancet, leeches, emetics, and calomel, very great advantage will often be derived from a tobacco cataplasm, composed of the moistened leaves of tobacco, mixed with the crumb of stale bread or ground flaxseed, and applied around the throat. The effects of the cataplasm should be carefully watched, lest its depressing effects be carried too far. After effusion has taken place, our chief dependence is to be placed on the use of calomel and tartrate of antimony; the latter being occasionally carried to a sufficient extent to excite vomiting. The administration of repeated emetics in this stage, was the practice pur- sued by Jadelot, Steinmitz, Cheyne, and Currie, and the result of their experience is certainly deeidedly in its favour. Tartrate of antimony was the article employed by these physicians ; and Cheyne stales, that the only cases he saw recover from the second stage of the dis- ease, were those in which the patient was kept under its effects for two or three days. Fielitz, Hoffman, and Droste employed the sul- phate of copper in the dose, of one fourth to one half of a grain every two hours. It is in this stage that the tincture of lobelia will often be found advantageous ; or, perhaps, the infusion of the sanguin- aria canadensis." We know nothing of the latter remedy from our own experience ; it comes to us, however, very highly recommended by respectable practitioners. It often happens from the impediment to hasmatosis, produced by the effusion within the respiratory tubes, DISEASES OF THE RESPIRATORY ORGANS. 309 and the venous congestion of the brain, that emesis is with diffi- culty produced, even by very considerable doses of antimony ; it has, under these circumstances, been recommended to employ the sulphate of zinc or copper in solution, alone,b (Francis,) or combined with ipecacuanha. (Farre.) aR—Rad. sanguinar. cnnadensis, pulv. 9j. bK.—Sulph. zinci vel cupri, 3ij. Aqua? c:ilida?. giij.—.\I. Aqua?, gj.—M. Dose—A teaspoonful every half hour. Dose.—A teaspoonful every twenty minutes. In conjunction with emetics, either in full or nauseating doses, and calomel, the frequent use of warm sinapised pediluvia, will generally be found advantageous. After the violence of the disease has been to a considerable extent reduced, or the case has assumed a somewhat chronic character, when a dry, hoarse cough, with oppressed breathing, increased at intervals, but with little febrile excitement or tenseness of pulse, remains, a strong decoction of senega will be often found a useful auxiliary to the other remedies.1 (Currie, Chapman, Royer-Collard.) aR.—Rad. polygala? senega?, 3j- Aq. bullicnt. Oj. Simmer to gxij. then add Mellis JJiij. Dose.—One, two, or three teaspoonfuls, every one or two hours : according to the age of the pjtient, and the urgency of the symptoms. In the third stage of the disease, blisters may be applied at the upper part of the chest, or between the shoulders; sinapisms, or cloths wet with hot turpentine, or the decoction of turpentine and cantharides, may be applied to the extremities, a^id internally a strong decoction of senega, with the addition of camphor and assafoeiida, may be resorted to; and if there is great and increasing exhaustion, it will be proper to support the patient's strength by ammonia or wine-whey. (Oilers, Stokes.) Occasionally, even under apparently the most des- perate circumstances, recovery will ensue ; but seldom, when the dis- ease has reached this stage, will its fatal termination be arrested by any course of treatment. Of the effects of musk, given in large doses, from twelve to twenty-four grains in the course of twenty-four hours, in the latter stage of croup, we have certainly very strong testimony. (Olbers, Albers, Royer-Collard.) Assafoetida, likewise, has been extolled, given as well by the mouth, as by injection into the rectum, to the extent of half a drachm to a drachm a day. (Jurine, Vieus- seu.r, Royer-Collard.) By some of the European physicians, the employment of cold effu- sions upon the back, from the occiput to the sacrum has been strongly recommended in cases where every other remedy has failed to afford relief. (Schmidt, Baumbach, Midler, Harder, Aberle.) The imme- diate effects ascribed to cold affusion, are certainly surprising, but the result of the practice is not such as strongly to press it upon our atten- tion. The operation of tracheotomy has been suggested by some as a last resource in cases of croup, and by others as a measure that 310 DISEASES OF CHILDREN. should be resorted to before effusion has taken place in the trachea. Among the advocates of the operation are Home, Huxham, Caron, Maingault, Hosack, Farre, Maslhieurat, Berard, Petel; while it is opposed by Crawford, Ferriar, Cheyne, Vieusseux, Double, Albers, Jurine, Royer-Collard, Porter, Bricheteau, Becquerel, Boudet, and others. The following table exhibits a tolerably fair estimate of the ratio of success which has attended the operation, in the hands of the different operators whose names are given. Operations. Cures. Deaths. Amussat, ..... 6 0 C Baudelocque, .... 15 0 15 Blandin, .....5 0 5 Bretonneau, .... 18 4 14 Gerdy,......C 4 2 Guersent...... 9 0 9 Maslhieurat,.....2 1 1 Petel,...... 6 3 3 Roux,......4 0 4 Trousseau,.....109 27 62* Velpeau, ...... 6 0 6 186 39 147 In the cases in which tracheotomy was performed by Guersent and the hospital internes, in the Parisian Hospital for Children, during the year 1841, the operation, while it was of no advantage whatever, when the pseudo-membranous exudation extended into the bronchii, appeared, in many cases, to accelerate the fatal termination, by inducing severe bronchitis, or an excessive secretion of mucus in the bronchii, pneumonia, or convulsions; while in many cases the patient died immediately after the operation, without any local lesion exist- ing, to which the fatal termination could be referred. (Becquerel, Boudet.) We have said nothing, as yet, on the subject of diet in croup. During the forming stage, the diet should be the same as in violent cases of bronchitis ; during the-heighth of the disease, little or nothing else should be allowed,than some mild,mucilaginousfluid,given insmall portions at a time ; while after the disease has been subdued, and throughout the period of convalescence, the child should be allowed the mildest and most unirritating articles of food, care being taken that even in regard to these, no excess be committed. For a long time after recovery, there is very considerable dan- ger of a relapse, upon the slightest exposure to cold or moisture, or to the most trifling transitions of temperature ; from these, there- fore, the child who has recently recovered from an attack of croup, should be carefully guarded, by appropriate clothing, and every other Journ. des Connaiss. Medico-Chirurg. Oct. 1840. DISEASES OF THE RESPIRATORY ORGANS. 311 judicious precaution. The daily use of the warm bath, and daily exercise in the open air, during mild and dry weather, should never be neglected. 8.—Laryngismus Stridulous—Spasmodic Croup. s, (THYMIC ASTHMA.—^HLLAr's ASTHMA.--SPASM OF T,HE GLOTTIS.) This disease, which consists in a sudden spasmodic closure of the glottis, giving rise to a severe paroxysm of dyspnoea, and a peculiar crowing sound in inspiration, as if from strangulation; unattended with fever, and often without any material derangement of the gen- eral health, is of much more frequent occurrence than is generally supposed. It has very frequently been mistaken for and treated as croup, and in its milder form, it has received the vague term of " inward fits." The disease generally comes on suddenly; the child, apparently in perfect health, is suddenly seized, either upon awaking from sleep, or in taking drink or food, or upon being teazed or irritated, with a difficulty of respiration; inspiration being often entirely sus- pended for a few seconds: after violent, even convulsive, struggles, the child finally succeeds in getting breath, with a shrill crowing sound, not unlike the ringing inspiration of the whooping cough. In severe attacks, during the vehement efforts at inspiration, the whole of the respiratory muscles are thrown into violent action. The nos- trils are dilated, the mouth is. extended, the eyes are rolled upwards, and the whole countenance expresses the utmost anxiety and suffer- ing. The head is thrown backwards; and the chest upwards; the diaphragm and abdominal muscles contract violently, and even the extremities become rigid. The face is commonly pale, or of a livid cadaverous hue, and the external veins, turgid with highly carbonized blood, form black streaks upon the forehead and temples, which con- tinue long after the cessation of the paroxysms. (Ley.) The backs of the hands and insteps are often swollen and hard ; the thumbs are rigidly contracted, and locked across the palms of the hands, and the toes are bent down towards the soles of the feet; the wrists and ancles being rigidly and permanently bent by the action of the flexor muscles; in many cases, these carpo-pedal contractions are of a very singular appearance, and in the opinion of some, characteristic of the disease ; (Rees;) the fingers being extended upon themselves, but semiflexed upon the metacarpus, and this at times, upon the carpus; in the same manner the toes are flexed upon the metatarsus. The attacks of the disease are paroxysmal, and vary in duration and intensity. At first a single paroxysm may occur, and after a short time cease spontaneously, and the breathing of the child, at first somewhat hurried, soon becomes perfectly free and regular, and the child presents no apparent indications of disease ; and days, and even weeks may pass without the occurrence of another paroxysm ; but in other cases, the paroxysms recur with alarming frequency, and are 312 DISEASES OF CHILDREN. protracted to fifteen or thirty minutes, or even longer ; finally, in many cases, the paroxysms recur with such rapidity, that there is scarcely a complete interval; their intensity and duration increasing, generally, with their frequency. In the early periods of the disease, the paroxysms usually occur in the night, or after a tranquil sleep, from which the child awakes as it were in a fright, and the difficulty of inspiration immediately ensues ; but when the disease is more fully established, the paroxysms take place at all times of the day or night. Other symptoms are noticed as of constant or occasional occurrence, as a thrusting out of the tongue between the lips, which is also present to a certain extent during the intervals of the paroxysms ; (Kopp ;) an involuntary discharge of the contents of the bladder and bow els; (Hirsch ;) and, in severe cases, a convulsive contraction of the mus- cles of the hands, and abductors of the thumbs, during the intermis- sions. (Caspar.) Immediately preceding, as well as subsequently to, a paroxysm, the sound of the patient's breathing is that which would result from an increased secretion of mucus in the respiratory tubes. (North.) The patient may expire during the first paroxysm of asphyxia ; or the disease may be protracted to many days, weeks, or months, and death be preceded by convulsions, deep coma, hydrocephalic symp- toms, or those of acute meningitis. The appearances upon dissection are very various; the thymus and cervical glands are often enlarged or in a state of disease; the heart is often found empty and flaccid ; the lungs are generally gorged with dark coloured blood; the vessels of the brain are also often unduly distended, and serous effusion between the membranes, in the ven- tricles, or at the base of the brain, is of frequent occurrence ; tuber- cles of the brain are often met with, and occasionally, hypertrophy, or induration of its substance. The foramen ovale is often found open, and not unfrequently, there exists more or less disease of the gastro- intestinal, and in some cases, of the respiratory mucous membrane. No one of these morbid appearances is constantly present in the bodies of those who have died of laryngismus stridulous, perhaps, judging from the cases on record, most of which have been adduced, however, to support particular pathological views; we ought to enumerate enlargement of the thymus, and effusion within the cran- ium, as among those most commonly met with ; upoii a more minute inquiry, we suspect that enlargement of the thymus gland will be found a much less frequent accompaniment of the disease than has been asserted. The disease is almost exclusively confined to the period of infancy and childhood ; it may occur at any period from w ithin a few days after birth, (Kerr,) to three years, but most commonly between the fourth and tenth month. Most of the writers enumerate the lym- phatic temperament as one of the predisposing causes of laryngismus stridulous, and hence we find it attacking almost all the children of some families, while those of others are entirely exempted from it; DISEASES OF THE RESPIRATORY ORGANS. 313 the predisposition from organization may also account for its greater prevalence in some localities than in others. Thus it is generally admitted that the disease prevails much more in cold and damp, than in temperate or warm climates. Dentition is, unquestionably, one of its most common predisposing causes; nearly all the cases upon record occurred during, or immediately preceding the evolution of the first set of teeth ; and we have but few instances of the disease occurring beyond this period. Among the exciting causes may be enumerated sudden motions, or any agitation of the body, improper food, fright, or any violent or sudden mental excitement; impure, confined, or some particular condition of the atmosphere, exposure to a current of cold air, efforts to swallow, or even suddenly stooping to pick something from the ground. North includes it among the premonitory symptoms of convulsions, and Beatty, in many instances, as one of the earliest symptoms of incipient hydrocephalus, which accords with our own experience. Laryngismus stridulous, as We have already remarked, consists essentially, in a spasmodic closure of the glottis, impeding the ingress of air into the lungs, and sometimes so completely closing it, as to suspend, for a few seconds, the respiration entirely. Mr. Lee, how- ever, denies that the difficulty of inspiration is owing to a spasmodic closure of the glottis, but rather to the inability of this part to enlarge to its normal size, owing to the want of innervation in consequence of pressure upon the nerves from diseased glandulae concatenatse ; from the same cause, he conceives, the transverse fibres, behind and con- necting the rings of the trachea, lose their contractile power, and allow the sputa to accumulate, giving rise to the rattling sound heard in the upper part of the trachea, particularly when the patient is asleep. Few, however, have adopted these views of Mr. Lee, the spasmodic character of the disease being admitted by the generality of those who have studied its phenomena wdth care. Upon the nature of the cause, by which the spasmodic affection of the glottis, is pro- duced, there exists a very great diversity of opinion. By the greater part of the German medical writers, and many of those of Great Britain, it is referred to an enlarged or diseased condition of the thymus gland, and numerous observations have been .recorded, in support of this hypothesis. (Kopp, Frank, Kirmaul, Hirsch, Ecke, Van Velson, Most, Kill, Montgomery, Hughes, Flackman,Rees,Mitchell.) This view of the pathology of the disease would appear to be very fully made out, were we to take only the quantity, without reference to the quality of the evidence, upon which it rests. But, when closely inves- tigated, it will be found defective, in many important points. There has not been adduced a single well established fact, to show that a hypertrophied condition of the thymus is capable, under any circumstances, of exerting upon the nerves which pass in its vicinity, such a degree of pressure or irritation, as would produce the pheno- mena of the disease, under consideration. We have, in fact, numer- ous observations upon record, which prove, that the thymus gland 314 DISEASES OF CHILDREN. may be greatly enlarged, and that numerous enlarged lymphatic glands may exist in the course, and in immediate contact with the laryngeal nerves, without the disease, even in its mildest form being produced. (Pagenstecher, Marsh, Burgess, Johnson.) We are, in fact, so little acquainted with what constitutes the exact normal size of the thymus gland—it being found to vary materially in bulk and weight, in different subjects, during a state of apparently perfect health,—that it is very difficult to determine, with certainty, when it is to be consi- dered of abnormal magnitude, or of a normal size. From our own observations upon the relative size of the thymus, at different ages, from birth to puberty, we are strongly inclined to believe, that, in many of the cases, recorded as instances of enlarged thymus, the gland was either not at all affected, or was actually below the size which it generally presents, in children of the same age. We are to recollect, also, that its enlargement, even when it occurs, may be the effect, and not the cause of the morbid phenomena. It may be the natural effect of the violent convulsive efforts at inspiration, ob- served in this terrific malady. The thyroid gland has been known to become and remain enlarged, in like manner, after the efforts of severe and protracted labour; the eyes to become blood-shot from hooping cough ; the eyelids to be distended with blood from epilepsy, and from the efforts of vomiting and parturition. In this manner, we can readily understand how enlargement of the thymus may be an effect of laryngismus stridulous, and subside with the disease, which would not be the case if it was dependent on change of structure. (M. Hall.) Numerous cases are on record, in which the disease was pro- duced, entirely independent of the slightest enlargement of the thymus, or of any of the cervical glands. (Beatty, Rullman, Toogood, Burgess, Ryland, Marsh, Rees.) The agency of hypertrophy of the thymus gland, in its production, is denied by Caspar, Pagenstecher, Ley, Hall, Merriman, Fricke, Oppenheim, Cheyne, and Clarke. Mr. Ley attri- butes it to a suspended or impeded state of the functions of that por- tion of the eighth pair of nerves, which is distributed to the larynx, caused by pressure from enlarged, cervical, and bronchial glands; while Marsh refers it to an irritation, seated at the origin of the pneu- mogastric nerve, and others to disease of the brain. (Clarke, Cheyne, Beatty, Rullman, Fricke, Oppenheim.) According to Dr. Hall, the disposition to spasm of the glottis consists in a peculiar susceptibility of the excito motor property of the nervous system. The immediate cause of the attacks being the action of sources of irritation, or ex- citement of this property ; the most obvious of which are dentition, indigestible food, morbid alvine matters, external agents, and mental emotions. Nearly the same views are expressed by Mr. Ryland; in one case related by him, however, the latter is inclined to believe, that the main cause of the paroxysms was to be referred to bronchial inflammation, which Mr. Ley also enumerates as an occasional ex- citing cause of the disease. This conclusion is probably correct; for many cases are on record, in which the paroxysms were fir-t ob- DISEASES OF THE RESPIRATORY ORGANS. 315 served, in the early stages of pertussis, or of measles, or upon the occurrence of an attack of bronchitis; it is in such cases, that the disease has been most usually mistaken for croup. Our own observations incline us to adopt the views of Dr. Burgess, namely, that, when it occurs previous to dentition, the chief exciting causes of the disease are irritation of the digestive organs, a cold, confined, or impure atmosphere, and dentition; but that when it oc- curs during and subsequent to dentition, it is almost invariably symp- tomatic of cerebral disease. Nearly the same views are expressed by Mr. Rees ; he refers, it is true, the disease, previous to dentition, inva- riably to enlargement of the thymus gland, or enlarged agglomerated glands, in the vicinity of the recurrent nerves ; but observes, that one remarkable point, in these cases, is the dependence of the paroxysms of dyspncea upon the state of the digestive organs; whenever these are out of order, the intensity of the attacks being increased, which it seems difficult to account for, since, he adds, the affection so evi- dently depends upon a mechanical cause. The same difficulty, he further remarks, presents itself, in accounting for the constant and immediate good effects obtained from a change of air. The difficulty, however, arises solely from the attention of the observer having been too exclusively directed to the supposed agency of glandular enlarge- ment, in the production of the disease. We have, in repeated instances, seen the most severe attacks of laryngismus stridulous produced solely from irritation of the alimentary canal, resulting from indiges- tible and improper food, and other errors of diet, or from the influence of an impure, irritating, and confined atmosphere, and promptly and effectually relieved, in its early stages, by getting rid of the exciting cause in the stomach and bowels, or by removal to a pure and whole- some atmosphere. The cases combined with cerebral disease, are seldom met with, until dentition has commenced-; if the patient survive the appearance of the first molar teeth, the case generally terminates favourably. (Rees.) In this form of the disease, the patient generally remains, during the intervals, dull, heavy, listless, and drowsy; the pupil of the eye is dilated; the head hot, and frequently held extended on the spine ; and unless appropriate remedies be resorted to, convul- sions or inflammation of the brain is always liable to supervene ; carpo-pedal spasms, also, frequently occur. These are generally at- tended with considerable derangement of the gastro-intestinal mucous membrane. (Rees.) Several cases are recorded, in which spasm of the glottis was evi- dently induced by an irritation caused by the arrest of some foreign body, in the oesophagus, which, nevertheless, could not have produced sufficient pressure upon the larynx, to interfere, in the least, with the freedom of respiration, but must have excited, by some remote, and as yet unexplained influence, a spasmodic closure of the glottis; giving rise often to symptoms of such intensity, as to require an ope- ration to preserve life. (Porter.) The prognosis will depend entirely upon the nature of the lesion by 316 DISEASES OF CHILDREN. which the spasm of the glottis is produced. In cases in which the dis- ease has resulted from a temporary irritation of the alimentary canal, or other slight functional disturbance, the paroxysm may be but of short duration, and the attack cease spontaneously, or upon a proper change of diet or air ; but when symptomatic of disease of the brain, or any permanent irritation of other organs, it is always to be considered as a serious affection, and very frequently proves fatal. The treatment, during the paroxysm, consists in placing the patient in an upright position, with the head slightly inclined forwards, and exposed to a full draught of fresh, cool air, while cold water is, at the same time, sprinkled over the face. Every means should be taken to remove, as far as possible, compression from the vessels of the neck : — slapping the child slightly on the back, will occasionally aid in remo- ving the spasm; frictions along the spine may, also, be resorted to. If the paroxysm does not yield to these means, the patient should be placed in a warm bath; whilst in the bath, cold water should be sprinkled on the face, which will generally cause a strong inspiration and lengthened expiration, followed by a scream, which usually puts a period to the paroxysm. (Ley.) It may be, also, useful to apply ammonia, if at hand, to the nostrils. Irritation of the pharynx, by a feather, will sometimes induce vomiting, which will, of course, solve the spasm of the glottis. (Johnson.) An enema, with the addi- tion of assafoetida or turpentine, will be useful, in violent attacks. If the dyspnoea continue unabated, and death from asphyxia is threaten- ed, the operation of tracheotomy should be immediately performed. (Marsh, Porter.) If, during the paroxysm, there is evident congestion of the brain, a few leeches behind the ears, with cold lotions to the scalp, will be found advantageous. The moment the fit is over, an examination of the gums should be made, and if these are found to be, at any part, swollen or inflamed, a free incision should be made, down to the tooth. Dr. Hall recom- mends incision of the gums, not only in cases of actual dentition, but in cases in which no immediate appearance of the teeth is expected, or even in cases in which all the tee:h have already appear- ed. He directs this, for the purpose of correcting a state of the blood- vessels and nerves of the gums, which, though physiological, borders on a pathological character; and hence he prescribes it to be repeated, for several successive days. The bowrels of the patient should be well moved daily. But, in ac- complishing this, all irritating remedies should be avoided, and we must be careful not to produce severe purging which, by exhausting the pa- tient, will augment the susceptibility to subsequent attacks. When the discharges from the bowels are of an unhealthy character, small doses of calomel, or of the blue mass, combined with ipecacuanha and ex- tract of hyosciamus,* repeated at short intervals, and an occasional dose of the infusion of rhubarb, wTith tartrate of potass and manna, will, in general, answer our purpose. To the last mentioned prescrip- DISEASES OF THE RESPIRATORY ORGANS. 317 tion, it has been recommended to add a few drops of tincture of hyos- ciamus, and of the aromatic spirits of ammonia, and a little of the syrup of ginger. Dr. Hall considers a most important remedy in these cases, especially when the evacuations are clay-coloured, to be the repeated use of enemata of warm water or barley water. aR.—Calomel, gr. vj. ad xij. Ipecac, pulv. gr. iij. Ext. hyosciami, gr. iv.—M. f. chart. No. xij. One to be given every three hours. Or, Mass. f. pill, hydrarg. gr. xij. may be substituted for the calomel. The importance of an attention to the diet of the patient need not be insisted on; nor need we, after what has been already said in many of the preceding sections, lay down any precise directions, in regard to the proper articles to be employed. The repetition of the attack, remarks a writer, whose therapeutical directions in respect to the disease under consideration, are replete with good sense, (Hall,) has so often, within my own experience, been the result of improper and indigestible food, that I invariably fix upon some one article or kind of diet, of the most unquestionable character, to the exclusion of all others. The importance of a pure, fresh, dry, and warm atmosphere, in cases of laryngismus stridulous, is recognized by nearly every writer on the disease. A very slight vitiation of the air will frequently bring on the most violent attacks which are as quickly terminated by its removal; in one case, a paroxysm was induced, whenever the child was brought into a newly painted house. (Marsh.) When the little patient has been long free from attacks, a sudden change of the wind to the north-east frequently induces a return of them; and even when they have been long obstinately repeated, and have become, as it were chronic, a change of air has induced as suddenly a suspension of them. (Hall) We have known a recurrence of the paroxysms to be kept off, so long as the patient remained in the city, and to happen whenever the child was taken into the country. Change of air, with a well regulated diet, is often more effectual than any other means, in preventing the renewal of the paroxysms ; but where this cannot be effected, the child should be taken out daily, in mild, dry weather; and the apartment it occupies should be freely ventilated, and kept strictly clean ; care being taken, in so doing, to prevent exposure to partial currents, and to guard against dampness. The clothing of the child should be adapted to the state of the weather, and temperature of the season, and so made as to guard the breast, shoulders, and arms, against exposure to cold or draughts of air. The use of the warm bath daily, as in most of the diseases of children, is an important prophylactic means. There is one cause capable of exciting the paroxysms in infants, which, though too often overlooked, should be kept constantly in mind by the medical practitioner ; and that is sudden, mental emotion, and especially fright, or that state of nervous excitement, into which young 319 DISEASES OF CHILDREN. children are often thrown, when thwarted, teazed, or vexed. The infant should not be suddenly awaked out of sleep, nor slapped, nor harshly scolded by an angry nurse. When the latter is out of temper, there is frequently a double source of injury—her rude treatment of the infant, and the unwholesomeness of her milk. The slightest alarm is still more serious in its effects ; all sudden noises, all rapid move- ments in nursing, every attempt to frighten or surprise the infant, should be carefully avoided. It should be addressed invariably, in a soft, soothing tone of voice; in a word, every source of mental emo- tion should be carefully avoided. This advice should be strongly en- forced by the physician, for though important, in reference to every infant, it becomes doubly so, in reference to such as are predisposed to, or have already suffered from an attack of laryngismus stridulous. It has happened to us to see in several instances, most violent parox- yms, though in none attended with a fatal result, excited solely by mental emotion and fright. It has been suggested to subdue the mor- bid susceptibility of the patients, by keeping them for some time con- stantly under the gentle influence of the tincture of hyosciamus, and the infusion of hops. (Hall.) The tonic influence of tepid salt water, applied to the surface by sponging, is also highly beneficial. In those cases in which there is an evident tendency to cerebral disease, the proper remedies indicated by its nature and extent, should be immediately resorted to. In all cases, if we direct our attention to the congested condition of the brain, we shall perceive the importance of adopting measures to relieve it; under ordinary circumstances, the spirit lotion applied to the head, and repeated several times, in the course of the day, is an efficacious means of effecting this, and per- haps a much safer remedy than depletion, which, unless there is an absolute necessity for resorting to it, should be avoided, in conse- quence of its tendency to increase the susceptibility of the nervous system, and consequently the disposition to an attack. In severe cases, the ice cap should be applied. (Hall.) A variety of remedies have, been recommended, either with the view of controlling the spasmodic affection of the throat, as the aq. lauro-cerasi in small and graduated doses, musk, zinc, (Hirsch,) the cyanuret of zinc, (Pagenstecher,) or for destroying the predisposition to and cause of the disease ; as a very low diet, copious and repeated local bleedings, issues on the chest, frequent, active purgatives, mer- cury, antimonials, cicuta, digitalis, animal charcoal, and iodine, inter- nally and externally. (Hirsch.) To the greater part of these we object, as altogether unadapted to the disease, or positively prejudicial, while the recommendation of others is evidently based upon an erroneous pathology, and even by the strongest supporters of that pathology, they are admitted to be of doubtful efficacy. 9.—Pertussis.—Hooping Cough. The hooping cough is usually described as a disease, peculiar to DISEASES OF THE RESPIRATORY ORGANS. 319 childhood; occurring but once in the same individual, and propogated by a specific contagion. That it occurs most commonly, at some period previous to puberty, is unquestionably true ; wfe have, never- theless, repeatedly met with it in adults, particularly when it has pre- vailed epidemically ; and the memory of every practitioner will furnish him with instances of its occurrence, in even elderly subjects. (Maunsetl, Eberle, Mackintosh, Williams.) Herberden saw it in a female of seventy, and in a man of eighty years of age. Instances of its recurrence in the same individual are, by no means, unfrequent; we have seen several, and the fact is noticed by various writers. (Morris, Mackintosh, Stewart, Williams, W. England.) As to its con- tagious nature, notwithstanding it is so considered by the gene- rality of writers on the disease, the fact is very far from being fully established, and is positively denied by a large number of accurate observers, who have particularly directed their attention to the subject. (Stoll, Sprengel, Deivees, Laennec, Wendt, Billard, Gar- dien.) The hooping cough most commonly prevails as an epidemic, and hence a number of individuals may be attacked at the same time, or in quick succession ; but to prove its contagiousness, it is necessary to show, that when sporadic cases "occur, the disease spreads from these, or that patients affected with it, when removed to distant places, communicate it there to others; which we have never known to occur, and the same remark has been made by others. (Desruelles.) The diagnostic symptom of hooping cough is a suffocating convul- sive cough, returning in paroxysms, terminating in an excretion of thick, glairy mucus, and frequently accompanied with vomiting of the same kind of fluid. The cough is marked by a prolonged, stri- dulous, convulsive inspiration, attended with a rattling in the trachea, and succeeded by several short efforts at expiration, which follow each other in quick succession. The long convulsive hooping inspi- ration is again repeated, and the paroxysm continues, often, for many minutes, until the discharge of a portion of thick, slimy mucus, by expectoration or vomiting, occurs; when the respiration becomes again comparatively free. During the paroxysms of coughing, the child exhibits all the symptoms of impending suffocation, redness and swelling of the face, injection of the conjunctiva, shedding of tears, profuse perspiration about the head and forehead, and violent spas- modic action of all the respiratory muscles; the agitation of the whole body is such, that the child is obliged to lay hold of something to support him ; in violent cases, a discharge of blood from the nostrils, and involuntary evacuations from the bladder and bowels are not unfrequent. Nearly all writers, since Rosen, have divided the hooping cough into different periods. In its development and progress, the disease unquestionably exhibits several stages, but these present so many im- portant variations, indifferent cases, in their symptoms, and duration, that it is difficult to assign to each its proper limits or distinctive cha- racters. (Billard.) By some, it is divided into the period of invasion, 320 DISEASES OF CHILDREN. the period of increase, and the period of decline. (Desruellcs, Lom- bard.) By others, into the catarrhal stage, the nervous, spasmodic, or convulsive stage, and the stage of decrement, (Blache,) and br- others, into the inflammatory, the congestive, and nervous stage, and the simple nervous stage. ( Williams.) The disease is very generally preceded by the symptoms of catarrh or mild bronchitis. There is a dry cough, hoarseness, some sense of constriction in the chest, and a feeling of weight, or dull pain of the head, redness and suffusion of the eyes, and some degree of febrile excitement with exacerbations towards evening. The duration of this stage varies considerably ; it may be followed by the characteris- tic symptoms of hooping cough, in a day or two, or be prolonged for a wreek or two, or even longer; the cough, however, increases from day to day, and becomes gradually more convulsive and reson- ant. (Lombard.) In some cases, it has been entirely wanting, the peculiar symptoms of the disease occurring, as it were suddenly : (Cullen, Dewees, Desreufles, Lombard.) While during the prevalence of hooping cough as an epidemic, many children exhibit no other symp- toms than those of the catarrhal stage. (Billard, Lombard.) Sooner or later, however, the cough assumes its peculiar, convul- sive, and suffocating character, and shrill hooping sound ; it occurs in paroxysms, at irregular periods, during the day and night; the intervals being, in general, longer in the day, during the period of increase, and at night, during the decline of the disease. The cough is generally preceded by a mucous rhonchus, which is more evident, as the paroxysms become more frequent. The patient is, in general, aware of the approach of a paroxysm, by a sense of chilliness of the surface of the body, and a tickling in the throat, succeeded by a sense of constriction about the throat and chest, and a dread of suffocation, which induces him to fly to his nurse, or to lay hold of any thing within his reach, for support, during the paroxysm. The duration and frequency of this is very various; in some instances, it continues scarcely a minute, while in others it is prolonged during five or six minutes, or even longer. The intervals between the paroxysms vary from half an hour to three or four hours ; in very violent cases, at the height of the disease, the paroxysms are often divided by intervals of only a few minutes duration. They usually terminate by the discharge of a large quantity of viscid mucus, generally by vomiting, induced pro- bably from the compression of the stomach by the forcible contrac- tion of the abdominal muscles which occurs during the violent effort at inspiration. The disposition to vomit is apparently increased by habit; and consequently as the disease advances, the paroxysms of cough often terminate more frequently and speedily by vomiting or retching. (Williams, Lombard.) Immediately after the fit, the child appears entirely relieved, and a craving for food is often experienced ; after this is satisfied, he is perfectly cheerful, and re- turns to his ordinary amusements. When, however, the paroxysms are frequent, of long duration, and marked by great violence, the pa- DISEASES OF THE RESPIRATORY ORGANS. 321 tient recovers from his distress only by degrees, remaining exhausted for some time, with hurried or panting respiration, and complains, if old enough, of a tensive pain in the forehead, and pain or soreness of the chest. In some instances, the violence of the paroxysm is such as to produce a loss of consciousness from temporary asphyxia; or the asphyxia may be complete, and death ensue. In other cases, convul- sions, or cerebral congestion and deep coma may occur. The paroxysms often recur with some degree of periodicity; but they may be induced by too much, or improper food, excitement of the mind, or exposure to cold, or a confined and impure atmosphere. They may also be excited, by seeing another attacked by one. It is probable, that motion, amusement, and the open air, contribute to les- sen the cough; while rest, the horizontal position, and the close air of sleeping apartments, increase the tendency to its return. (Lombard.) In slight attacks, there may be but little or no fever, during the convulsive period of the disease, and but little functional disturbance, in the intervals of the paroxysms; but, usually, the presence of the sonorous and mucous rhonchus, particularly before and after the cough, and the mucus expectoration, in which the cough generally terminates, indicate, that in conjunction with the nervous affection, upon which the spasmodic, stridulous respiration, and sonorous cough depend, there still exists more or less bronchitic, or catarrhal disease: in fact, as the stage declines, the expectoration generally assumes the more consistent and opaque form which characterizes the concocted sputa of a terminating bronchitis. (Williams.) The bowels are variously affected in hooping-cough. Though often perfectly regular, and the discharges natural, yet, occasionally, they are costive or sluggish, and in a few cases, diarrhoea, with viti- ated discharges, a loaded tongue, nausea, loss of appetite, epigastric fullness and tenderness, and other symptoms of gastro-intestinal dis- ease, are met with. In those cases of the disease, accompanied by severe bronchial inflammation, there is generally more or less cough between the par- oxysms, and considerable febrile excitement; and the convulsive, hooping, cough, is generally preceded and followed by considerable uneasiness, or oppression and pain of the chest. The bronchial inflam- mation, in these cases, is apt to run into pneumonia, which is hence a frequent complication of the disease. When this occurs, we have the general symptoms of the latter affection, superadded to those of hooping-cough, as well as its distinctive physical signs. Lobular pneumonia, and pleuritic inflammation, are common occurrences in this disease. (Alderson, West, Williams.) Hydrocephalus is one of the most serious complications of hoop- ing-cough, and a very frequent one. It is marked by its usual symp- toms—grinding of the teeth, rolling of the head, intolerance of light, contracted pupil; followed by squinting, vomiting, screaming, insen- sibility, &c. We have, in a few instances, seen a state of deep coma occur in the course of hooping-cough; the brain, after death, exhib- 21 322 DISEASES OF CHILDREN. iting extensive serous effusion, without any of the symptoms of men- ingitis or hydrocephalus having presented themselves. Anasarca is also one of the frequent complications of hooping-cough. In most of the more violent cases, there is a slight degree of oedema of the face and arms; but in some cases, serous effusion occurs throughout the cellular tissue, and in the cavities. (Richter, Lombard.) An attack of croup will often supervene during hooping-cough, par- ticularly, in its early stage. Children of robust, plethoric habits, are most subject to this complication. The duration of the second stage is very various ; it may continue for a very short time, or be prolonged for three or four weeks, or even longer; the symptoms then gradually diminish in intensity; the expectoration becomes more abundant, opaque, and thicker; the cough loses, by degrees, its convulsive character; the paroxysms are of less frequent occurrence, and of shorter duration ; and, finally, by the end of two or three months from the commencement of the dis- ease, it disappears, with the assemblage of other symytoms. The period when the symptoms begin gradually to decline, to their final termination, constitutes, w hat has been termed, the third stage of the disease. It often happens, that after a very decided abatement of the symp- toms has taken place, the cough again returns, with considerable violence; this relapse is, however, seldom of long duration; and, after two or three days, the regular decrease will continue its course. (Lombard.) The disease, in many cases, assumes a kind of chronic form, and may be protracted to a very long period, the paroxysms being well marked, but occurring at considerable intervals, and of little intensity or duration; or they may be induced, in those who have lately recov- ered from the disease, by the occurrence of a slight catarrhal affec- tion. A curious case is related, in which the hooping-cough assumed a periodic form, a paroxysm occurring daily, at a certain hour, for several months, and returned at the same season for two years. (Per- cival.) The occurrence of hooping-cough, in a severe and protracted form, in children of a lymphatic temperament, strongly predisposed to tubercular disease, or in whom the formation of tubercles in the lungs, has already commenced, very rarely fails to develope pul- monary consumption ; the progress of which, is often very rapid, upon the decline of the acute stage of the attack. The physical signs of hooping-cough are those of mild bronchitis; variable sonorous, sibilant, and mucus rhonchi, in the upper and mid- dle portions of the chest. During the height of the paroxysm, there is diminished sound of respiration within the chest. When compli- cated with pneumonia, the mucous and crepitant rhonci, with partial absence of the respiratory murmur, and dulness on percussion, will indicate the existence and extent of the pulmonary disease. The appearances upon dissection, will vary with the violence of the DISEASES OF THE RESPIRATORY ORGANS. 323 attack, the period at which death has taken place, and the simple or complicated character of the case. Nearly every writer, who has given the result of his autopsical examinations, mentions the existence of more or less of the indications of inflammation of the mucous membrane of the bronchii, and often, of the trachea ; as, injection of the blood-vessels, thickening of the membrane, and the existence, upon its surface, of a layer of thick mucus, and occasionally, a muco-puru- lent fluid filling the ramifications of the bronchii. (Lettsom, Bad- ham, Watt, Hastings, Marcus, Bauer, Shdfer, Wardrop, Ozanam, Baumes, Blache, Armstrong, Albers, Mackintosh, A/cock, Lombard.) Ulcerations about the glottis, and in the larynx and trachea, are noticed by some authorities. (Astruc, Mackintosh, Alcock.) When death is caused by asphyxia, in the early period of the attack, the mucous mem- brane of the respiratory tubes, is of a dark red or bluish appearance, the lungs are gorged with dark coloured blood, the whole substance of the brain is a little more livid than natural, and the bronchial tubes con- tain a little mucus, occasionally stained with blood. (Mackintosh, Ger- hard.) A very common lesion in severe cases is dilatation of the bron- chii. (Laennec, Dubreuil, Jadelot, Blache, Bertin, Bell, Alderson, Bil- lard.) Inflammation of the lungs, especially lobular inflammation, is of common occurrence; and very frequently, inflammation of the pleura, with exudation or effusion. (Marcus, Colter, Mackintosh, Alderson, Blache, West, Constant, Lombard.) To these lesions may be added, tumefaction and redness of the bronchial glands, and emphysema of the lungs. (Marcus, Wardrop, Mackintosh.) In a large number of cases, inflammation of the meninges of the brain, and effusion beneath the membranes, and into the ventricles, have been observed. (Colter, Wardrop, Ozanam, Webster, Guibert, Mackintosh, Lombard.) A dis- eased condition of the phrenic and pneumo-gastric nerves, is noticed by some writers. (Clarus, Holzhausen, Hufeland, Breschet, Bauer, Kilian, Autenreith.) There is some doubt, however, as to the cor- rectness of these observations; it is certain, at least, that a lesion of these nerves, is of very unfrequent occurrence. Hooping-cough most generally occurs as an epidemic, but gene- rally of very limited extent, its influence being confined, usually, to a single city or district, and often to a part, only, of these. Seldom, if ever, has it extended, either at once, or gradually, over large terri- tories, as is the case with most epidemics. If, however, we are to receive, as correct, the accounts of the epidemics of 1510, 1557, 15S0, 1757,1767, and 1769, as given by DeThou, Sennertus, Sauva- ges, Riverius, Diversus, Conario, Geller, Arrand, we find these of wide extent, many of them prevailing throughout the greater part of Europe. The disease occurs at all seasons, and in all climates; but the spring and autumn, especially when cold and damp, and cold, varia- ble climates, are admitted, by nearly all writers, as the most favoura- ble to its prevalence; and it is in these seasons and climates, that the hooping-cough proves most fatal, from its being most usually com- plicated with severe bronchial, pneumonic, or laryngeo-tracheal 324 DISEASES OF CHILDREN. inflammation. The general production of the disease, by the joint influence of a cold and moist atmosphere, is insisted upon by a num- ber of physicians. (Klinge, Richter, Marcus, Dtsreulles. Vondem- bush.) It has been found frequently to prevail most extensively, either immediately before, during, or subsequent to the occurrence of epi- demic measles. (Richter, Desreulles, Vondembush.) Its prevalence at the same time with epidemic catarrh, has also been repeatedly observed. Children of all ages are liable to its attacks; infants at the breast, are, however, less liable to it, than those who are weaned: indeed, so generally does the disease attack, during the period of dentition, that many have supposed this to be its most common predisposing cause. Boys and girls are equally liable to it, though, perhaps, a greater num- ber of the former will generally be found to escape an attack, than of the latter. Children labouring under chronic cutaneous eruptions, have been supposed to be rarely affected with the disease; or when attacked, to have it butdightly. (Hufeland, Lentin, John, Autenreith.) The fact, however, is denied by others, (Hoffman, Haase.) and is not sustained by the general result of more recent observations. In regard to the true pathology of hooping-cough, much diversity of opinion has, and still exists. A majority of the most authoritative writers, refer it to bronchial inflammation; which, by a few, is considered to be of a specific char- acter. By some, however, who have written very ably upon the dis- ease, the bronchial affection is viewed as a mere concomitant, or effect of the hooping-cough, and not, in any degree, essential to its existence. The most of these refer it, either to disease of the pneumo- gastric or phrenic nerve, or to disease of the brain, affecting the ori- gin of the respiratory nerves. (Hufeland, Jahn, Lbbel, Holzhausen, Lc- roy, Coiter, Bauer, Guibert, Albers, Breschet, Clarus, Webster;) whilst others consider the cerebral irritation to be secondary to the bronchial disease, and often absent. (Boisseau, Begin, Otto, Vondembush.) That the essential symptoms of hooping-cough are the result of a spas- modic closure of the glottis, there can be little doubt; but whether this is owing to an irritation, seated in the larynx and trachea, or in the brain, it is difficult to determine. In the greater number of cases, the disease commences as a simple, and often very mild, bronchitis; and it is not until after the bronchial irritation or inflammation has existed for some time, that the irritation is transmitted to the laryngeal nerves, and the convulsive cough,and difficulty of respiration occur. It has been attempted to be shown, that these latter symptoms are the result of an intermittent irritation and congestion of the brain, which precedes each paroxysm, ceases with the latter, but soon returns, giving rise to a re- newal of the paroxysm, and hence, that the disease consists in a recip- rocal irritation of the brain and of the respiratory apparatus; the latter, upon the one hand, acting upon the brain, through the medium of the eighth pair of nerves, the phrenic nerves, and those branches which are distributed to the muscles of the thorax; while on the other hand, the brain reacts upon these muscles, the glottis and diaphragm. DISEASES OF THE RESPIRATORY ORGANS. 325 (Dcsruelles.) This much is very certain, that we can, in no other manner, account for the phenomena of the disease, excepting by referring them to irritation of the laryngeal nerves, as well as of the respiratory mucous membrane. (Blache.) When hooping-cough is unaccompanied with intense bronchitis, and is uncomplicated with pneumonia, tracheitis, or severe conges- tion, or inflammation of the brain, it is seldom attended with much danger; but in its more severe and complicated forms, it is with dif- ficulty managed, and very frequently fatal. The younger the patient, also, as a general rule, the more danger attends it. Very frequently, when it occurs in infants at the breast, it is accompanied with cere- bral congestion from its very onset, and is then particularly fatal. (Guersent.) We have also found, that when, in young children, it is accompanied with an excessive serous diarrhoea, it is seldom recov- ered from ; a similar remark is made by Richter. In many of the more extensive epidemics, the mortality from hooping-cough has been very considerable. Thus, in Sweden, during the sixteen years, from 1749 to 1764, 43,393 deaths occurred from the disease; and of these, 5,832 took place in the year 1755 alone. (Rosen.) In Glasgow', the deaths have been pretty nearly 5i per cent, of the entire mortal- ity; and in one year, (1809,) they amounted to 111 per cent. (Watt.) In Prussian Pomerania, the deaths were as 1 to 25i of the entire mor- tality. In Neumark, 1 to 2l£. In Brandenburg, 1 to 29£. In Sweden and Finland, 1 to 131. In Strasburg, 1 to 94. It Boston, 1 to 82. In Charleston, 1 to 46.6. In Baltimore, 1 to 95.38. In New York, 1 to 64.7; and in Philadelphia, 1 to 63.1. The treatment of hooping-cough will differ, according to the stage of the disease, the violence of the attack, its simple or compli- cated character, and the age and vigour of the patient. The remedies proper, in the first or catarrhal stage, are the same, precisely, as in simple bronchitis. It is chiefly upon the proper man- agement of this stage, that will depend, in many cases, the safety of the patient; the diminished liability to the occurrence of severe bron- chial or pneumonic inflammation, as well as the danger attend- ant upon violent cephalic congestion, induced, during the paroxysm of the disease, in the second stage. We believe, that in all cases, very great relief will be afforded, by the administration of an emetic, at the very commencement of the attack, and the continuance of the remedy, subsequently, in nauseating doses. In robust children, over two years of age, tartrate of antimony should be preferred; but in younger children, in whom this article is seldom a very safe one, we would prefer the ipecacuanha. By many practitioners, the latter article is considered to be particularly adapted to the treatment of hooping-cough. They prescribe it in its first, and during the acute period of the second stage, occasionally, as an emetic, and subse- quently, in small doses, the fourth of a grain every three or four hours, either alone, or in combination with sulphur, or with sulphur and bel- ladonna. (Kopp, Astruc, Sims, Sagar, Hufeland, Kahleiss, Vondem- 326 DISEASES OF CHILDREN. bush.) We have followed this practice, in a very large number of cases, with the happiest effects: we have usually combined the ipe- cacuanha with sulphur and extract of hyosciamus.* aR.—Pulv. ipecac, gr. iij. ad iv. Sulph. praecip. 3ss—3j. Ext. hyosciami, gr. iv.—xij.—M. f. chart. No. xij. One to be repeated every three or four hours. There are few cases, in which, at the onset of the disease, after an emetic, and the warm bath, the exhibition of a full dose of calo- mel, followed, in a few hours, by some mild purgative, as castor oil, rhubarb, and magnesia, or in children over two years of age, in whom the first stage is attended with considerable febrile excitement, by small doses of sulphate of magnesia, will not be found advantageous. The bowels being kept subsequently in a regular state, by occasional doses of some mild unirritating purgative, or by simple enemata. Per- haps the best purgative we can employ in the hooping-cough, par- ticularly in the first or catarrhal stage, is calomel, an occasional small dose, say from two to five grains, given in the evening, and followed in the morning by a small quantity of castor oil, will generally have the effect of preserving a free, regular condition of the bowels, with- out unduly irritating them, or inducing severe purgation—an occur- rence which should be always carefully avoided. Whatever opinion we may adopt of its mode of action, we are certain of the utility of calomel as a mild purgative in the first, and the acute period of the second stage of hooping-cough. (Dewees.) We are accustomed to combine with the evening dose of calomel, a third of a grain of ipecacu- anha, and the same quantity of the extract of hyosciamus, and have seldom found it necessary to give any purgative in the morning to insure its operation. In every case in which, during the first stage, severe bronchial or pulmonic inflammation is present or threatened, particularly if the patient be of a plethoric or robust habit, bleeding becomes an indis- dispensable remedy, and it should be resorted to, also, whenever the same indications present themselves at a later period of the dis- ease, previous, at least, to the occurrence of extensive effusion in the bronchii. The extent of the bleeding should alwavs be proportioned ot the violence of the symptoms, and the strength of the patient; upon our promptitude and decision in the use of this remedy will olten depend the life of the patient. Leeches to the chest and about the clavicles, or cups between the shoulders, will be sufficient in young children ; but in those who are older, and the symptoms severe, it will be better to have recourse to the lancet, followed, if neces- sary, by leeches. We are aware that blood-letting has been con- sidered by some an improper remedy in the treatment of hooping- cough, and by others as of doubtful propriety; but independently of our own experience, we have in its favour that of Willis, Sydenham, Stoll, Sauvages, Astruc, Hillary, Huxham, Rosen, Hoffman, Matthiii, Home, Wendt, Willan, Lettsom, Forbes, Badham, Hufeland, Rush, DISEASES OF THE RESPIRATORY ORGANS. 327 Underwood, Armstrong, Guibert, Webster, Dewees, Mackintosh, Billard, and many others. Mackintosh applied leeches over the larynx, and speaks confidently of the success of the practice. Whenever there is a decided tendency to an affection of the brain, whether of a congestive or irritative character, blisters to the temples, or behind the ears, cold lotions to the scalp, and warm sinapised pedi- luvia, or sinapisms to the feet, should be immediately resorted to. During the whole of the first, as well as during the acute period of the second stage, the patient should be confined to his chamber, which should be kept of a proper temperature, but well ventilated ; nothing has a more deleterious tendency than sudden transitions of temper- ature, or exposure to cold and damp; almost invariably will these aggravate the paroxysms of cough, and endanger inflammation of the respiratory tubes or lungs. The diet should be perfectly mild and unirritating, and in violent cases should consist entirely of some simple mucilaginous drink. The occasional use of the warm bath should not be neglected. As soon as the acute character of the disease is reduced, some counter irritant, applied to the chest or between the shoulders, will be found highly beneficial; busters are recommended by some, and if properly managed, produce, certainly, a very excellent effect; but some of" the European practitioners prefer the production of a more powerful and permanent irritation, such as results from the ointment of the tartrate of antimony. (Autenreith, Luroth, Dewees, Corsin, Mackintosh.) Autenreith states that, in two severe epidemics, in which he employed frictions with tartar emetic ointment, he lost not a single patient.a In order to insure the efficacy of this plan of treat- ment, we must not, we are told, be satisfied with merely producing pustules; the use of the ointment should be continued until small ulcer- ations occur in the intervals between the crusts. The treatment should be persisted in for eight or twelve days. If the eruption is very painful, the best application is fomentations, with a decoction of hem- lock. Luroth likewise employed the ointment in the same manner, in a very fatal epidemic of hooping-cough, with the most gratifying results. Corsin also employed the emetic tartar, as an external irri- tant, during an epidemic of the disease, with decided benefit in every case. He prefers, however, its application in the form of a plaster,b which is to be worn upon the epigastrium, or between the shoulders, as long as the patient can endure it. Dr. Dewees thinks that he has observed more advantage to result from the use of the ointment of the tartrate of antimony, than from any other external applica- tion. He used it of the same strength as directed by Autenreith, with the addition of fifteen drops of oil of lavender, or essence of lemon, and applied it high up between the shoulders. Nearly the same remarks are made, in relation to the remedy, by Mackintosh. We know nothing of its effects, from our own experience; in the few cases in which we have employed it, we could never persist in its use, (and this is said to be essential to its efficacy,) (Autenreith, Luroth,) 328 DISEASES OF CHILDREN. in consequence of the severe pain, and deep ulceration produced. We have no doubt, however, that in severe cases, it may prove a very valuable derivative. We have generally resorted to blisters, and frictions with turpentine, the compound camphorated liniment, or a liniment of the oil of amber and oil of rosemary, to the spine,c and with the best results. »R.— Tart. ant. 3jss. bR.—Empl. conii, 2 pts. Axung. gj.—M. Empl. picis abietinae, 1 pt. A portion of the ointment of the size of Dyachylon, 1 pt. a nut, is to be rubbed on the epi- Spread on leather, and sprinkle the gastrium, three times a day. surface with from 6 to 12 grs. of the tartar emetic. -)- i 330 DISEASES OF CHILDREN. dered root, or from one-eighth to one-fourth of a grain of the extract, twice or thrice a day. Kahleiss gave the belladonna, in combination with Dover's powder and sulphur,b and between each dose, a mixture containing hydrocyanic acid.0 We have given to the belladonna a very fair trial, and "have, in many cases, been pleased with the prompt and decided relief produced by it, while in other instances, it has appeared to exert no influence whatever. A similar remark is made by Vondembush and Lombard. We have generally employed the extract, in the dose of from one-eighth to one-fourth of a grain, two or three times a day, sometimes oftener, combined with from one-fourth to one-third of a grain of ipecacuanha. »R.—Rad. belladonnas pulv. gr. v. kR.—Aquse chamomil. gss. Pulv. ipecac, compos, gr. x. Syrupi simpl. 3ij. Sulphur, prsecip. 3j. Aquse destill. 3ss.—M. Thirty drops to be given every hour. The simple vapour bath (A. Hunter,) or the vapour bath impreg- nated with vinegar, (Itard.) has been noticed as a remedy of very considerable power, even in the last stage of the disease; we believe, that it will frequently be found of decided advantage, after the stage of excitement has passed. Various symptoms occurring in the course of the disease, will oc- casionally require particular remedies. When considerable tender- ness of the abdomen occurs, we have already noticed the propriety of applying to this part leeches followed by blisters. In milder cases, warm, emollient cataplasms will supersede the necessity of blisters. Vomiting is often a distressing symptom ; it will, in many cases, be effectually relieved by minute doses of calomel combined with mag- 392 DISEASES OF CHILDREN. nesia and ipecacuanha,* and the application to the epigastrium of a sinapism, or frictions with spirits of turpentine ; ten, fifteen, or twenty drops of the spirits of turpentine internally, or half a drachm of tur- pentine mixed up with thin starch, and administered as an enema, we have repeatedly found to allay very promptly the irritability of the stomach, in this disease. »R.—Calomel, gr. iij. Magnes. calc. gr. xxiv. Ipecac, pulv. gr. ij.—M. f. chart. No. xij. One to be given every one, two or three hours. Convulsions may be relieved by cups to the nape of the neck, fric- tions along the spine, warm pediluvia, cold effusion upon the head, and turpentine enemata. From the very onset of the disease, the patient should be confined to his chamber, which should be kept darkened, well ventilated, and of a moderate temperature, and every possible means should be adopted to screen him from noise of every kind, and all other causes of excitement. He should lie upon a hair mattress, with his head somewhat elevated, and be covered with no more clothing than is sufficient to keep him of a comfortable temperature. All sudden, or, indeed, all unnecessary movements of the patient should be avoided ; and the utmost kindness should be invariably ob- served by the attendants, in their deportment towards him. His diet and drink, in severe cases, and during the stage of excitement, should be restricted pretty much to simple mucilaginous fluids, given cool. At a later period, after the stage of excitement has fully passed, plain water gruel or panada may be allowed ; and in the last stage, when collapse has occurred, the diet should be nourishing, but mild and easy of digestion, as beef tea, plain chicken or mutton broth, animal jellies, &c.; at the same time, we may attempt to support the strength of the patient, by the cautious use of ammonia, wine whey, valerian or camphor, combined with infusion of gentian, calombo, or quassia. During convalescence, the utmost care should be observed to prevent a relapse. The bowefs should be kept regularly open by gentle laxatives ; the diet should be of the mildest and least irritating articles, but, at the same time, sufficiently nourishing; the patient's clothing should be cautiously adapted to the temperature of the season, and, in quantity and material, calculated to prevent the influence of sud- den changes in the weather; every source of fatigue or excitement should be avoided; but, at the same time, daily gentle exercise, in a dry, pure air, will be attended with the best effects. Sponging the body daily with warm salt water, the temperature being gradually reduced as the activity and tone of the patient's system is gradually increased, will act as a safe and very powerful tonic. The patient's hair should be kept short, and only a light covering worn upon the head. In cases in which there is a strong predisposition to a renewal of disease in the brain, it has been recommended, and the recommen- dation is certainly a judicious one, to insert an issue in the neck, or DISEASES OF THE NERVOUS SYSTEM. 393 to keep up a constant irritation, for a considerable period, at this part, by the use of the ointment of tartarized antimony. Several writers have described a morbid affection incident to the period of infancy, resembling, in nearly all its symptoms, the later stages of sub-acute arachnitis, but resulting invariably from exhaus- tion, (Hall, Goock, Abercrombie, Schmidt,) and which it has been pro- posed to designate by the term hydrencephaloid. (Hall.) We believe, however, as has been already pointed out by an able writer, (Bennett,) that this affection differs only from that described above, in its occur- ring in children labouring under considerable exhaustion and debility. This variety of the disease unquestionably demands a very important modification of treatment. All debilitating remedies are positively injurious. The strength of the patient should be supported by the breast milk of a healthy nurse, or if weaned, by beef tea, plain mut- ton or chicken broth, and similar articles of nourishment; where the exhaustion is very great, wine whey, the carbonate of ammonia, or even wine itself, may be required. These should be exhibited, how- ever, in moderate portions, and their effects closely and carefully watched. In young children, the exhaustion is very frequently the result of extensive serous diarrhoea; this, if it continue, should be checked as quickly as possible, and we believe the remedy, upon which, in these cases, the most dependence is to be placed, is the acetate of lead given in solution, in the dose of a grain, every two or three hours by the mouth, and to the extent of three or four grains as an enema. In many cases, however, the chalk mixture, with the ad- dition of catechu or the decoction of the dewberry root, will succeed. After the diarrhoea has ceased, the bowels may be regulated by small doses of calomel, prepared chalk, ipecacuanha, and extract of hyosci- amus. The warm bath will be found, in most cases, a very valuable remedy, and should be repeated daily. The patient should be kept, in a recumbent posture, and where he may enjoy the advantages of a free circulation of air, and the temperature of his extremities main- tained by dry friction and flannel. If the patient sink into a comatose condition, blisters or sinapisms should be applied to the nape of the neck, and to the lower extremities, and frictions made with some stimulating liniment along the spine. Chronic Hydrocephalus. This form of disease is very generally congenital, or is developed soon after birth. It consists in an accu- mulation of a serous fluid, often to an enormous extent, generally within the ventricles of the brain, but occasionally, upon its surface. When the disease occurs subsequently to birth, it is generally devel- oped slowly and insensibly; being seldom preceded by any very marked symptoms; the first thing that attracts attention being an enlargement of the whole head, which sometimes acquires an immense size—the sutures becoming separated, the fontanelles enlarged, and presenting, as it were, tense, semi-transparent tumors, in which a distinct fluctuation is perceptible upon pressure. The head gradually enlarges, as the effusion increases within the cranium, 394 DISEASES OF CHILDREN. until, in many instances, its size becomes so great, that the patient is no longer able to support it erect, and it droops, continually, when he is in the erect position, upon the shoulder, or forwards upon the chest; the face, at the same time, retaining its natural size, the phy- siognomy of the patient acquires a very peculiar expression. As the disease advances, the senses become blunted, the intellectual powers impaired, and the muscular power so much enfeebled, as to prevent the patient from moving about, or using the least exertion. Convul- sive movements, paralysis, and coma, occasionally occur; but gener- ally the patient sinks into a state of deep stupor, which terminates, sooner or later, in death. In some instances, in place of a general enlargement of the head, a large tumor gradually forms at the situa- tion of the posterior fontanelle, or somewhat lower, pressure upon which, produces coma or convulsions. Patients affected with chronic hydrocephalus, may live for many years, without any very decided impairment of the intellectual faculties. Occasionally, the sense of sight, hearing, and taste, are destroyed per- manently, or only for a time; in other cases, one sense only, is affected ; in others, two or more, the rest remaining entire. Emaciation is a common symptom ; as is also some degree of giddiness in the erect posture. Strabismus is frequently, and opacities of the cornea, are occasionally, seen in those affected with the disease. Death often takes place, from the intervention of other affections; very frequently ulceration of the bowels, sometimes phthisis pulmonalis, and occa- sionally, inflammation of the tissues of the lungs. (Mackintosh.) Upon examination after death, the brain presents the appearance of an extended bag, with thin parieties, filled with a serous fluid. It was supposed that, in these cases, the substance of the brain had become absorbed, in consequence of the pressure of the fluid within ; but upon a more accurate examination, it is found that no portion of the brain is destroyed, its convolutions being merely deployed. In other cases, however, the brain has been found in a perfectly rudi- mentary state. (Gall, Spurzheim, Cruvielheir, Breschet, Billard.) The lining membrane of the ventricles is occasionally vascular, and frequently very much thickened, and easily separated from the me- dullary matter to which it is attached. (Mackintosh.) Chronic hydrocephalus is not a very frequent disease in Philadel- phia. We have never seen a case, either congenital or developed subsequent to birth. In the treatment of chronic hydrocephalus, our chief object must be, to palliate the symptoms as they occur, by the occasional applica- tion of leeches, the use of repeated blisters, the tartar emetic oint- ment, or issues. The bowels should be kept regularly open, by gentle aperients, and the diet of the patient carefully regulated. Mercury has been strongly recommended, and is deserving of a fair trial. The radical cure of the disease has been attempted, by properly regulated and continued pressure applied to the head ; and cases of success, from this plan of treatment, have been published. (Blane, DISEASES OF THE NERVOUS SYSTEM. 395 Barnard, Engleman.) But the plan, in favour of the feasibility, safety, and success of which, the greatest amount of evidence has been adduced, is that of puncturing the brain, drawing off the effused fluid, and preventing its reaccumulation, by pressure applied around the head. (Rossi, Vose, Dugas, Graefe, Hbflung, Barnard, Conquest, F. Cooper, Russel.) The operation consists in passing a small and delicately constructed trochar, into one of the lateral ventricles, and •drawing off as much fluid, as the powers of the constitution will admit of. The most eligible spot at which the trochar can be intro- duced, is in the course of the coronal suture, about midway between the crista galli process of the ethmoid bone, and the anterior fonta- nelle, so that the danger of wounding the corpus striatum is avoided on the one hand, and the longitudinal sinus on the other. The instru- ment usually penetrates about two inches, and in most cases, the w serum discharged is colourless, but occasionally tinged with blood. Sometimes, on withdrawing the trochar, the water will not flow, until a probe has been passed along the canula, to remove portions of brain which block it up. After taking away all the fluid that can be removed, consistently with safety, the head, which should always be steadily compressed, by an assistant, during the operation, may be strapped with adhesive plaster, so as retain its diminished size, and avert the fearful consequences of suddenly removing long-contin- ued pressure from the brain. (Conquest.) In no instance, however, , y has a clearly marked congenital case been permanently benefited; the cases in which the operation has been most successful, are those in which the effusion has manifestly resulted from an inflamma- tory condition of the brain, and in which cerebral excitement follows the operation. (Conquest.) It is proper to remark, however, that, even in these, the operation has been found unsuccessful in numerous instances; (Dugas, F. Cooper;) and that it has been pronounced, by high authority, as one, in all cases, at once cruel and useless. (Gblis, Heister, Hecher, Portenschlag.) 6.—Chorea. Chorea is a very common disease of childhood, occurring more frequently between the eighth and fourteenth years, than at any other period of life. It consists in involuntary convulsive movements of the voluntary muscles, particularly of the face and extremities, and, occasionally, of those of the neck and trunk. In some cases, nearly the whole of the voluntary muscles, are more or less affected with convulsive or irregular movements; while in others, these are confined to one side, to the face and neck, or to a single extremity. The dis- tinguishing characteristic of the disease, is an incomplete subserviency of the muscles of voluntary motion to the will, by which their actions are rendered irregular and uncertain. Thus, the patient, intending to approach a cup of water to his lips, will involuntarily cast it from him, or throw its contents over his shoulder; or, in attempting to 396 DISEASES OF CHILDREN. advance his foot forward, in the act of walking, carries it in every possible direction, excepting the right one. The movements of the face, arms, and hands, often resemble the gesticulations of buffoonery. The name of the disease, (Ckorea Santi Viti—the Dance of Saint Vitus,) is derived from the circumstance of the patients affected with it, formerly repairing annually to the chapel of St. Vitus, near the city of Ulm, in Swabia, where they danced day and night, as a means of effecting their cure. (Horstius.) Chorea affects children of both sexes, but more frequently girls, particularly children of a weakly constitution, or whose health and vigour have been impaired by confinement, impure air, improper or deficient nutriment, or preceding disease. Previous to its occurrence, the patient is, in general, affected with the ordinary symptoms of derangement of the digestive organs,—a depraved, variable, or defec- tive appetite, tumid abdomen, constipated bowels, and a loss of his previous vivacity and playfulness. (Hamilton.) The attack in gen- eral, commences with slight, irregular, involuntary movements of dif- ferent muscles, particularly those of the face, which are often mis- taken for voluntary grimaces; these, after a shorter or longer period, are succeeded by the more constant and general movements, by which the disease is characterized. Any one set, or all of the mus- cles of voluntary motion, maybe affected, in different cases. Usually, the first indications of the disease, are, an unsteadiness in the patient's gait, which is marked, often, by a peculiar jumping or starting; or one leg is dragged along, in place of being lifted in the usual manner; while the arms are moved about, as if the patient were performing various intentional gesticulations. He is often unable to perform the common and necessary movements with the affected arm, the invol- untary actions of the muscles, entirely counteracting those directed by the will. These convulsive movements are more or less violent, and are often constant while the patient is awake;—during sleep, in most cases, they cease entirely. Although, occasionally, different muscles become successively affected, (Hamilton,) in the generality of cases, it is in those first attacked, that the convulsive movements remain throughout the disease. In consequence of the affection of the muscles of the tongue and throat, in some instances, articulation and deglutition are impeded, or performed with difficulty. In extreme cases, the eyes lose their lustre and intelligence, the face becomes pale, and the expression of the countenance is that of vacancy, indif- ference, and langour. The mouth is often distorted, so as to give to the face the appearance of a habitual, silly grin. The patient acquires, in fact, the features of idiocy. It is, indeed asserted, that when the disease has continued for a length of time, partial fatu- ity is liable to ensue. (Hamilton.) Fatuity, however, is by no means a very common sequel of chorea, even in its most violent and chronic forms. Many instances are on record, and similar ones have fallen under our own notice, in which the disease has continued, with but slight intermissions, from childhood to an advanced age, without the DISEASES OF THE NERVOUS SYSTEM. 397 integrity of the intellect being much, if at all affected. In some cases, the patients are affected with a species of melancholy, or with the peculiar nervous temperament, that commonly accompanies hysteria. Throughout the attack, the bowels are generally costive, and the appetite defective, capricious, or ravenous. Febrile reaction is not necessarily an attendant upon chorea, and when it does occur, is generally the result of gastro-intestinal irritation, or some accidental affection. When the disease is very violent and protracted, there in general occurs great emaciation, a flaccid state of the muscles, great depression of strength, paleness and discolouration of the skin, and the other indications of impaired energy of the digestive and nutritive functions. Epilepsy and hemiplegia are not uncommon results of chorea; and in many of the cases that have fallen under our notice, the patients have died from tubercular meningitis—the lungs and serous tissues of the thorax and abdomen, exhibiting, also, tubercular depositions. Chorea has been defined by some writers, to be an irregular motion of the muscles, when excited into action by the will, and hence, that the disease consists in a loss of the power of volition over their mode of action—that is, of directing and combining their action, for the accomplishment of any particular movement. The disease has, con- sequently, been supposed to result from some lesion of the cerebellum. (Carpenter.) This definition would, however, exclude a number of cases, in which the convulsive movements of the muscles certainly occur, independently of the will, and unassociated with conscious- ness, differing from convulsions only in the orderly nature of the motions. (T. Thompson.) Such are cases of malleation, (Morgagni,) in which the convulsive paroxysm consists, principally, in-a constant striking the knees with one or both hands, as with a hammer—of rotation of the whole, or a part of the body, as in the case described in an early volume of the Medico-Chirurgical Transactions, in which the patient, a girl ten years of age, was seized with an irresistible propensity to turn round on her feet like a top, then to lie down, and roll rapidly backwards and forwards; in a more advanced stage of her disease, while lying upon her back, to bend herself up like a bow, by drawing her head and heels together, and then suddenly to sepa- rate them, so as to cause the buttocks to fall with considerable force upon the bed; and to repeat this continually, for hours ; at a still later period, she was seized with a propensity to stand upon her head, with her feet perpendicularly upwards: as soon as her feet gained the per- pendicular, all muscular action ceased, and her body fell as if dead, her knees first striking the bed, and her buttocks striking her heels; this was no sooner done, than she instantly mounted up as before, and continued these evolutions, sometimes for fifteen hours consecutively, at the rate of from twelve to fifteen times in the minute. (Watt.) To this same class belongs also the salaam convulsions, noticed in a pre- vious section. But it would be impossible to describe all the various forms under which the disease occasionally presents itself; in many 398 DISEASES OF CHILDREN. of which, no description can convey an adequate idea of the odd appearance, and strange gesticulations of the patients; so that we need not be the least surprized, that in times of ignorance and super- stition, it was ascribed to supernatural causes, and the agency of demons. (White.) It is more than probable, that many cases of stammering are to be regarded as a species of chorea of the muscles of the voice. (Carpenter.) The disease, as it ordinarily presents itself in children, will be readily recognised by the symptoms already laid down. It ordinarily occurs, as already remarked, between the eighth and fourteenth years, but is by no means confined to this period. The convulsive actions may be continuous, intermittent, or remittent; they are excited and increased by observation, contradiction, ridicule, or any other cause of irritation, and especially, by any attempt, forci- bly, to restrain them. (Thomson.) Chorea is of itself seldom fatal; it frequently terminates sponta- neously, about the period of puberty in boys, or upon the establish- ment of the catamenia, in girls. When recent, and occurring in children possessed of some degree of constitutional vigour, it may often be entirely removed by an appropriate treatment; though not unfrequently, the patient preserves, during life, a tendency to involun- tary twitching of the muscles of the eye, eyelids, face, and even of the limbs. Pathological anatomy throws but little light upon the true nature of chorea, so far, at least, as regards the species and seat of the lesion of the nervous centres upon which the phenomena of the dis- ease immediately depend. In a large number of cases, no morbid changes are detected, that can be regarded as necessarily con- nected with the disease, after the most minute examination; (Dugds, Oliver, Hawkins, Rufz, Gerhard, Haclie, Vielde, Rostan, Lawrence;) while those which have been recorded by various writers, are evi- dently accidental lesions, unconnected with the disease; or they are to be regarded rather as effects than causes of the complaint; these are, inflammation of various parts of the brain ; (Clutterbuck, Serres;) turgescence of its vessels, with effusion of serum; (Cox<', Patterson, Rbser, Willan, Copland;) hypertrophy and injection of the brain and spinal cord; (Monad, Hutin ;) turgescence of the vessels of the brain and spinal cord, with several bony plates upon the pia mater, half-way up the spine ; (Bright;) a concretion in the medullary substance of the left hemisphere of the brain; (Brown;) a tumor pressing on the corpora quadrigemina, inflammation of these parts, and sanguineous effusion; (Serres;) ecchymosis of the membranes, with a pulpy condition of the spinal cord; (Keir;) and, in a single case, an abscess within the cerebellum. (Schrbde.) In the absence of positive facts, speculations upon the nature of any disease, are of little value. Reasoning from the nature of the phenom- ena by which the disease is characterised, chorea has been referred to lesions of the spinal system of nerves; (M. Hall;) but this, it has DISEASES OF THE NERVOUS SYSTEM. 399 been very properly remarked, can scarcely be regarded as a correct conclusion. (Carpenter.) Although there is often considerable irreg- ularity in the ordinary reflex actions; yet the disease mainly consists in an absence, or deficiency of the controlling power of the will over the actions of the muscles of animal life; and in many cases, in a spontaniety of action in the performance of certain movements. Ac- cording to the most probable view of the functions of the cerebellum, it is probable that this organ is the chief seat of the disease. The morbid phenomena, however, in the majority of cases, not resulting from any direct lesion of this portion of the brain, but from remote irritations, in which it participates sympathetically. The most common predisposing causes'of the disease, would appear to be the period of childhood; bad nursing ; impure and confined air; unnutritious or improper articles of diet, and deficient exercise ; and a disordered condition of the digestive organs. The usual exciting causes, are irritations seated in the bowels or stomach; retained faeces, worms, &c, fright, violent fits of anger, injuries of the head, difficult dentition, rheumatism, improper excitement, and certain affections of the genital organs. (Stoll, Dehaen, Wendt, Bouteille, Geoffroy, Salter, Darwin, Hamilton, Bright, Andral.) It has been stated that, in some cases, a predisposition to the disease may be trans- mitted from parent to child ; (Elliotson, Coste, Constant, Bright, H. Bell, Stiebel;) and this corresponds with the result of our own expe- rience. Like all other convulsive diseases, chorea may be excited by imitation, notwithstanding the fact has been denied by recent obser- vers. (Rufz, Blache.) The disease has not appeared to us to be much affected by atmos- pherical influences; it is said, however, to be most common in sum- mer. (Duges, Rufz, Spangenburg, Blache.) It appears to occur rarely in the southern hemisphere. (Rochoux, Chervin, Danste.) It is not a very frequent disease in Philadelphia. In the treatment of chorea, the first and most important indication, is the removal or avoidance, as far as possible, of the exciting causes. The means for effecting this, will of course, depend upon the circum- stances of each case. The remedies that have the greatest amount of evidence in their favour for the removal of the disease, are bleeding, active purging, counter irritants, anfi-spasmodics and tonics. Bleeding from the arm, or from the foot, or by leeches, from the head and upper part of the spine, has received the sanction of several eminent practitioners, and cases have been published in evidence of its efficacy. (Sydenham, Bouteille, Geoffroy, Babbington, Lisfranc, Serres, Clutterbuck, Stiebel, Watt.) There will be found, we appre- hend, but few cases, however, in which bleeding will be indicated. That the disease may occur under circumstances, and accompanied by symptoms, in which the detraction of blood may be demanded, we admit; thus, when it attacks children of a plethoric habit, and is attended by the indications of cerebral inflammation or hyperaemia, a 400 DISEASES OF CHILDREN. judicious and timely resort to general or local bleeding, will no doubt, be productive of immediate benefit, and prepare the system for the action of other remedies. Such cases, however, are of rare occur- rence. Purgatives are a remedy of much less doubtful propriety ; as a val- uable adjuvant to the other means employed, there are few cases in which they will not be indicated, while in those connected with a tor- pid and loaded condition of the bowels, they will, invariably, produce a decided alleviation, and in many, an entire removal of the symp- toms. From the time of Sydenham, there are few writers on the disease, by whom their employment is not strongly insisted on, while, by a few, they are considered as almost the only remedy. (Stoll, Stark, Hamilton, Par>\) In the early period of the attack, and in light cases, any of the purgatives which have the effect of unloading the bowrels, without producing much irritation or occa- sioning watery stools, will be proper. In the more advanced periods of the disease, and in the more severe cases, the bowels are very apt to be affected with a very considerable degree of torpor, and for their evacuation, will demand the more active purgatives, given in suc- cessive doses, in such a manner, as to produce a full and continued operation. Not only, however, is it necessary in these cases, effec- tually to unload the bowels, but by a judicious use of purgatives, to maintain their regular action ; not a day should be allowed to pass, without one or two full evacuations being obtained; The choice of the purgative is a matter of little importance, so that, while it excites a full and brisk action of the intestines, it produces little irritation or watery purging. In the early stages and ordinary forms of the disease, calo- mel with rhubarb or jalap, followed by castor oil, or infusion of senna, with the addition of any of the neutral salts will answer; but where these are not found sufficiently active, the croton oil, or combinations of aloes, scammony, colocynth,gamboge and blue mass, may be employed. A very certain and effectual purgative, in cases of chorea, is the spirits of turpentine, either alone, or combined with castor oil. (Powell, Graves. Copland, Watson.) We have employed it pretty extensively, preced- ing its use by a full dose of calomel, and in very few instances, without decided advantage.* iij. spoonful, according to the age of the Syrup, zingib. gij.—M. patient, and repeated three times a day, The dose the same as above. or oftener. In conjunction with active purging, the use of tartarized antimony has been suggested, in as large doses as the stomach will bear, without exciting vomiting, which is carefully to be avoided. (Breschet.) By others, emetics repeated every other day, for a period longer or shorter, according to the violence and obstinacy of the case, have been strongly recommended. (Cheyne, Geoffroy, the elder, White, Town- DISEASES OF THE NERVOUS SYSTEM. 401 send.) We have no experience as to the efficacy of either plan of treatment, but can easily conceive that cases may occur, where the disease is either produced or aggravated by an overloaded state of the stomach, or the presence of some irritating matter in that organ, in which great benefit may result from emetics. They can scarcely be considered, however, as a remedy generally applicable to chorea. Counter irritants have been extensively employed in the treatment of the disease, and doubtless in many cases, their effects will be found decidedly beneficial. Blisters along the spine, are recommended by some; (Stiebel, Chisholm ;) but friction with the tartar emetic oint- ment, appears to be better adapted to produce a counter-irritant effect in cases of chorea. It is more prompt in its effects and more easily managed than blisters, and is, perhaps even more efficacious. (R. Hunter, Wharton.) Pustulation with the croton oil along the spine, has, also, been recommended, as a valuable remedy in chronic cases. In the treatment of chorea, nearly the whole list of tonics have been prescribed, and for the superior efficacy of each article, the highest authorities may be cited. Bark, and the salts of quinia, may be taken, however, as the representation of the vegetable tonics, while in regard to the mineral articles, the sesqui-oxide and sulphate of iron. sulphate of copper, oxide and sulphate of zinc, nitrate of silver, and arsenite of potassa, have, in different hands, been all found eminently successful. The testimonies in favour of the sesqui-oxide or proto-car- bonate of iron in large doses, and of sulphate of zinc, are perhaps the strongest. (Mead, Vanderburg, Elliottson, Babington, Powell, Cramp. ton.) The cyanuret of iron, in the dose of three grains, three times a day, in the form of a pill, has also been strongly recommended. (Zol- lickoffer.) The cyanuret of zinc, in the dose of one third of a grain, twice a day, gradually increased to fourteen grains in the twenty-four hours, has recently been highly spoken of by the physicians of Berlin and elsewhere. (Miiller, Giinther, Pole.) There is a very great diffi- culty in pointing out the particular cases to which the one or other of these remedies is the best adapted. Perhaps the safest rule is to make trial of one, and if it does not succeed, after it has been continued for a reasonable time, to suspend its use, and substitute another. To derive any good from the employment of either of them, will, in gene- ral, require a perseverance in its use for some length of time. With the exception of the arsenite of potassa, to be noticed hereafter, the sesqui-oxide of iron, the oxide of zinc, and nitrate of silver, in combi- nation with some one of the vegitable tonics, and occasionally, a narcotic, are the articles, which in our hands, have succeeded the most promptly and generally, in the removal of the disease ; we have, nevertheless, found many cases to occur, in which the use of one, and then another, has appeared to be unproductive of the slightest effect, when, on substituting a third, the morbid phenomena have been very quickly, and permanently controlled. It is stated by a high authority, (Babington,) that the sulphate of 26 402 DISEASES OF CHILDREN. zinc has seldom failed in his hands, in curing the disease. He found it necessary to administer much larger doses, howe\ er,than are usually given; good effects being seldom perceptible, until twelve or fifteen grains are taken three times a day. By gradually increasing the quantity, a single grain at a time, even much larger doses may, generally, be given, without exciting sickness, and with the best effect. Sulphate of zinc, however, will not be borne by all stomachs, even in small doses; and even the other mineral tonics can with dilficulty be prescribed in the cases of children in doses sufficiently large, or be continued long enough to derive from them, in this disease, a decided remedial effect. In such cases, the liquor potassae arsenitis, in doses of three drops, gradually augmented to twelve, fifteen or twenty, two or three times a day, according to the age and strength of the patient, and other concomitant circumstances, may be prescribed; it is certainly one of the most powerful remedies we possess, in cases of chorea: and when cautiously employed, desisting from its use the moment that any sickness or griping pains, or intumescence of the face or extremities are found to result from it, we have found it a perfectly safe and manageable article. The testimonies in favour of its efficacy are numerous and positive. (Sal- ters, Heming, M. Hall, Babington, Reese of N. Y., Dunglison.) Recently very respectable and decided testimony has been pre- sented in favour of the efficacy of the cimicifuga, in cases of chorea. (Young, of Pennsylvania, Lindsly, of Washington, Hildbrctk, of Ohio, Kirkbride, of Philadelphia, Beadle, of New York, Professor Wood.) It may be given in the dose of half a teaspoonful of the powdered root three times a day; or from one to two drachms of the satu- rated tincture, or a wine-glassful of the decoction. Iodine has likewise been employed, and it is said with advantage. (Peltz, Gibney, Bardsley.) Nearly all the narcotics have been recommended by different writers, and for the relief of certain symptoms, their use would appear to be occasionally beneficial. Opium was employed by Syd- enham, after bleeding and purging, as an anodyne at bed-time, and Cullen declares, from a good deal of experience, that opiates are very generally successful in the cure of chorea; opium, in the hands of other physicians has, however, entirely failed in-prrjducing any decided relief; we cannot say that we have eve/ known it to produce any good effect, in cases occurring in children. Camphor has been found beneficial in some cases, in combination with tonics and the cold bath. (Wilson, Richter, Poissonnier.) We have occa- sionally employed it, in combination with the proto-carbonate of iron, and extract of gentian, with unquestionable advantage. The bella- dona, stramonium, and hyosciamus, are all highly extolled, especi- ally by the German writers. The latter we have employed very extensively, as well in combination with purgatives, as with the metallic salts; it is certainly, in most cases, a very valuable adjuvant. Graves employed it, in one case, with the best effect. The strychnia DISEASES OF THE NERVOUS SYSTEM. 403 (Romberg,) the veratria, (Ebers,) and the hydrocyanic acid, (Stuart,) have all been employed ; of their value we know nothing, from our own experience. In favour of the effects of assafoetida in large doses, we have very strong testimony. (Vautier, Jadelot, Gendfon, Powel.) In conjunction with the foregoing remedies, the cold bath, especi- ally in the form of douche, will be found an important auxiliary. Cases are recorded, in which it was evidently productive of very great advantage. (Crampton, Stiebel, Dupuytren, Rufz.) Stiebel directs the douche to be applied to the spine. Where too severe a shock is produced by the cold douche, the tepid or warm douche, or simple tepid bathing, may be substituted. We have seen the best effects produced, by daily sponging the entire surface with salt water, at first warm, and gradually reduced in temperature, until it can be used perfectly cold. The whole surface of the body being submitted, immediately after the sponging, to brisk friction with flannel or a flesh brush. Sulphurous baths, made by dissolving about four ounces of the sulphuret of potassa in about twelve bucketsful of water, and repeated daily, have been employed with very decided success. (Baudelocque, Rufz, Gerhard.) A number of cases are cited, in which the entire and permanent cure of chorea is referred to electricity. (Dehaen, Underwood, Fother- gill, Gordon, Baumes, Addison, Bird.) Its success in numerous instances, appears now to be very well established. In the hands of Dr. Bird, it is said to have cured twenty-nine out of thirty-six, and to have produced relief in five of the remaining cases; in one no benefit was experienced, and one patient left, alarmed by the remedy. In the majority of instances, nothing else was prescribed, excepting occasional mild cathartics ; which, in conjunction with other remedies, had been used previously without advantage. The electricity was applied in the form of sparks, taken in the course of the spinal column, every other day, for about five minutes each time, or until an eruption appeared, which is often caused by electricity, applied in this manner. From the transmission of electric shocks along the affected limbs, no good whatever resulted, but on the contrary, the involuntary movements were, in every instance, increased, often to an alarming extent; and if employed after the patient was convales- cent, they invariably aggravated every symptom, and frequently ren- dered the disease as severe as when the patient was first placed under treatment. During the whole course of the disease, the diet should be light and easy of digestion; in cases attended with hyperaemia, or evidences of cerebral excitement, it should, of course, be very moderate in quantity, and consist chiefly of simple farinaceous articles ; but in those cases in which tonics are indicated, it should be nourishing and more libe- rally supplied. Daily exercise in the open air, whenever it can be taken, is all important to the success of the cure; a properly regu- 404 DISEASES OF CHILDREN. lated course of gymnastic exercises, it is reasonable to suppose may aid the success of whatever remedies are employed, independently of their invigorating influence, by engaging the attention of the patient, and teaching, as it were, the muscles to obey the direction of the will, and to combine properly their actions. A country residence is to be prefened to one in a large city ; and it would be still better, if, with the advantages of country air, the patient could command those of sea bathing. The utmost caution must be observed, as well during the disease, as for some considerable time subsequent to recovery, to guard the patient against the occurrence of any of its exciting causes, whether of a mental or physical character. If the attack occur during the period of dentition, a close attention should be paid to the condition of the gums, and irritation from this source counteracted by repeated scarification. It is hardly necessary to say, that any disease with which the attack of chorea may be complicated, is to be treated by its appro- priate remedies, and that the remedial management of the case must be modified accordingly. SECTION IV. DISEASES OF THE SKIN. CHAPTER I. ERUPTIVE FEVERS—EXANTHEMATA. I.—Measles. (RUBEOLA—MORBILLI.) The eruptive or exanthematous fevers, are characterized by a febrile excitement, succeeded or accompanied by a specific eruption upon the skin ; which, in the majority of instances, appears, in each disease, constantly at a stated period, and runs a regular and definite course. The most prominent of these diseases, the measles, scarlet fever, chicken-pox, and small-pox, are manifestly capable of being propa- gated by contagion; and the individual in whom any one of them has occurred, is, as a general rule, ever afterwards sheltered from its DISEASESOF THE SKIN. 405 recurrence, though he still remains equally liable to be attacked by all the other affections of the class. The only exception we know of to this rule, is the well established fact, that the vaccine disease con- stitutes a prevention to the occurrence of small-pox; though; if the identity of the two latter affections shall be established, as there is every reason to believe it will be, if it has not already, even this will, in fact, form no exception. Measles, strictly speaking, is a catarrhal fever, attended with a specific eruption upon the skin. It is, for the most part, a disease con- fined to childhood; though adults, who have passed through that period, without being attacked, are by no means exempted from its occur- rence. The disease is ushered in by the usual febrile symptoms; languor, shivering, succeeded by increased heat of the skin, thirst, loss of appetite, &c.; to which, about the third or fourth day, are added all the usual phenomena of ordinary catarrh:—tenderness, injection and watering of the eyes, with a slight turgescence of the eyelids ; the discharge of a serous fluid from the nostrils ; frequent sneezing ; some degree of hoarseness, with a sense of roughness or slight soreness of the fauces; a harsh, dry cough, and some difficulty of respiration. The head is affected with pain, or a sense of stupor or drowsiness; the bowels are generally costive, and the stomach not unfrequently rejects its contents. About the fourth day, an eruption makes its appearance ; first about the forehead and chin, and then spreading over the rest of the face. On the succeeding morning it is visible, also, on the neck and breast, and by the evening has spread over the trunk, and finally over the extremities. The eruption on the face is most vivid generally about the fifth day, and on the sixth begins to fade. By the seventh day the eruption on the body, which is at its height on the sixth, begins to subside; while that on the backs of the hands, which was the latest in appearing, is likewise the latest in subsiding, seldom beginning to fade before the eighth day. By the ninth day, all that usually remains of the eruption on any part of the body, is a slight discolouration of the surface; which commonly dis- appears before the end of the tenth day, by which period, desquama- tion of the cuticle over the whole body is completed. The desquamation is in the form of minute scales ; it generally commences about the tenth day, and is usually attended with a troublesome itching of the skin. The eruption is not confined to the skin, but extends also to the mucous membrane; the fauces and mouth being covered at the height of the disease, with reddish, slightly elevated spots ; which are often strikingly visible upon the surface of the tongue. (Frank.) Upon the declension of the eruption, a diarrhoea in general occurs, if it has not, at an earlier period ; and often appears to afford relief to the remaining symptoms. Occasionally a copious diarrhoea comes on, immediately preceding the appearance of the eruption, and is then generally an unfavourable symptom. 406 DISEASES OF CHILDREN. With the appearance of the eruption, most commonly, there is an increase of the cough and pain of the head, while the difficulty of respiration, injection and suffusion of the eves, and other accessory symptoms, remain without abatement until the eruption has finished its course. In many cases, however, particularly from incautious exposure to cold or damp, or a strong predisposition in the patient to pulmonary disease, the catarrhal symptoms continue without abate- ment, after the subsidence of the eruption; or symptoms of violent pneumonia ensue, while in other cases, symptoms of tubercular phthisis are rapidly developed. Croup has likewise been known to be an occasional result of measles; and in children of a scrophulous habit, chronic inflammation of the deep-seated structure of the ear; and of the eyes and edges of the eyelids, and painful swellings of the lymphatic glands, occasionally terminating in suppuration, followed by tedious and extensive ulceration. Meningitis, either acute or sub-acute, may supervene in cases of measles ; and the disease is liable to be succeeded by gangrenous stomatitis, and in girls, by a peculiar ulceration of the pudendum. (fVatson, Ferriar, Mackintosh, Dunglison.) As the diagnosis in measles depends pretty much upon the charac- ter of the eruption upon the skin, a close attention to its form and general appearance is of some importance. The eruption usually shows itself first in the form of distinct, red, and nearly circular spots, resembling in their general appearance, very nearly, the areola of ordinary flea bites, though probably not quite so large. As these spots increase in number, they coalesce, forming small, irregular patches, approaching the nearest in shape to semicircles or cres- cents ; these patches are intermixed with the single circular spots, and separated by interstices in which the skin retains its natural hue. On the face especially, they are slightly raised above the surface of the cuticle, so as to give a feeling of roughness or inequality of surface to the finger, when passed over the skin. The whole face is often sensibly swelled at the height of the eruption; (Bateman;) and occasionally, in violent cases, the tumefaction of the eyelids is so great as to close the eyes for a day or two. In many cases, miliary vesicles appear upon the neck, breast, and arms, during the height of the eruption ; while papulae occasionally occur on the wrists, hands, and fingers. (Willan.) The febrile excitement in cases of measles, is, in general, of a very marked character, attended with a hot and dry skin, considerable thirst, and a quick, frequent, and hard pulse: the evening exacer- bations being often marked, in severe cases, with slight delirium. By several writers, a variety of measles is described, in which there is an absence of fever, catarrh, opthalmia, &c, and which leaves behind it a susceptibility to the future occurrence of the genuine or febrile variety. (Vogel, Stanbach, Metyger.) This is the false measles of most German writers, the rubeola sine catarrho of some, (Willan,) and the rubeola sinefebre of others. An interval of many DISEASES OF THE S K.I N. 407 months, even two years, may elapse between the occurrence of this and the subsequent febrile rubeola ; but the latter more frequently occurs about three or four days after the non-febrile eruption. (Bate- man.) Many of the cases described as false or non-febrile measles, were, we suspect, cases of roseola. According to the observations of a few physicians, a rubeolous fever may occur unattended by any cutaneous eruption. (Dehaen, Morton, Richter, Consbruck, Vogel.) In other words, during the prev- alence of epidemic measles, some patients are affected with catarrhal fever, without measles, and if the observations of Ritcher are to be depended upon, such patients are usually exempted from an attack of measles, during the subsequent continuance of the epidemic ; but we have no evidence that they are less liable than the unprotected, to the occurrence of the disease subsequently. In some cases the eruption occurs at. a very early period, as upon the second day; whilst in others, the catarrhal symptoms continue for two weeks or longer, previous to the appearance of the rash. Occasionally, the eruption makes its appearance first upon the body and subsequently extends to the face; while, in a few instances, it has been entirely confined to the face and trunk throughout the attack. Cases are related in which the eruption has declined, and then sud- denly reappeared with the febrile and catarrhal symptoms. (Frank, Willan, Conolly.) Not unfrequently the eruption is preceded by coma, or by partial or general convulsions. The autopsical appearances will vary, of course, according to the period when death has taken place, and the nature of the concom- itant disease, by which the fatal event has been produced. Measles in its simple form, uncomplicated with severe pulmonary, gastro- intestinal, or cerebral disease, is seldom, of itself, the cause of death ; and although the symptoms, during life, indicate more or less bron- chial affection, the exact nature and extent of this, it is impossible to determine with any degree of certainty. The mucous membrane of the trachea, oesophagus, and the surfaces of the abdominal viscera generally, have been said to present, when the case has terminated fatally during the eruptive stage, the same species of exantheme as the skin. (Lieutaud.) In some cases, effusion of lymph mixed with blood or pus, has been found in the cavity of the thorax; (Willan, Boudin ;) in others, inflammation of the substance of the lungs, with extensive effusion in their texture; (Williams;) in others, extensive bronchial or pneumonic inflammation; (Rayer, Boudin;) and in others, condensation of the pulmonary tissue, as in cases of pneu- monia. (Montgomery, Boudin.) The morbid appearances present, in the cases examined by ourselves, were, the various lesions observ- able in severe cases of bronchitis, lobar and lobular pneumonia; cedema of the lungs, extensive engorgement of their blood vessels with effusion of bloody serum in the air cells and minute bron- chial ramifications; tubcrculation of the lungs, and of the serous membranes generally; gastro-enteric inflammation; follicular inflam- 408 DISEASES OF CHILDREN. mation; occasionally ulceration of the ileum and colon, enlargement of the mesenteric glands,.and meningeal inflammation, particularly of the basis of the brain, with tubercular deposition and effusion within the ventricles and arachnoid cavity. There was no case in which some degree of bronchial or pulmonary disease did not exist; in a very large number there also existed indications of more or less disease of the gastro-intestinal mucous membrane; the indications of cerebral disease were the least frequent. The most frequent forms under which the measles presents itself, are the simple catarrhal, which we have described—the congestive and the gastro-intestinal. The congestive form of the disease is marked by imperfect reac- tion, and occasionally its entire absence ; a general depression of the energies of the system ; pallor of the face; a sunk and anxious expression of the countenance; torpidity of the bowels; a slow, weak, oppressed pulse ; slow and oppressed respiration, and coldness of the extremities, The eruption may not appear, or it occurs slowly on some portions of the surface only. If reaction does not take place spontaneously, or is not induced by an appropriate treatment, stupor or deep coma, and occasionally, convulsions, ensue. In some cases, symptoms of congestion ensue after the eruption has made its appear- ance ; in these cases, the latter either becomes of a pallid or livid hue, or entirely disappears. In those instances in which an autopsic examination has been made, extensive engorgement of the pulmonary vessels, and, generally, of the vessels of the brain also, were detected. The congestive form of measles is said to occur most commonly in infants, and in children of a feeble and relaxed habit; we have not, however, found it to be confined to any particular age or con- stitution ; in some epidemics it occurs much more frequently than in others ; we have met with it more often, however, in confined and unhealthy neighbourhoods, than in those of an opposite description. When measles is complicated with gastro-intestinal disease, it is ordinarily accompanied by a less decided febrile reaction, a small and feeble, though generally frequent pulse, and considerable pain of the forehead. A sense of tension and fullness is usually experienced at the epigastrium, which is more or less tender upon pressure. Vom- iting and profuse diarrhoea often precede or follow the appearance of the eruption, which is pale, and often indistinct. The skin is dry and harsh, but seldom much increased in temperature. The tongue is dry and brown, and often the patient complains of frequent sharp pains in the abdomen. There is considerable thirst, and occasionally great restlessness, dyspnoea, and an anxious expression of counte- nance; particularly on assuming an erect posture. The cough is short, dry, and almost incessant. In some cases, particularly in young and irritable children, great difficulty of respiration, and a sense of oppression in the chest, will suddenly ensue. The patient may sink under the ordinary symptoms of fatal gastro-intestinal dis- DISEASES OF THE SKIN. 409 ease, or of pulmonary inflammation, or symptoms of cerebral inflamma- tion may ensue quickly, terminating in coma, convulsions, and death. In its simple, uncomplicated form, the measles is ordinarily a dis- ease attended with very little danger; and so mild in its symptoms, as to run its course and terminate favourably, without the necessity of any very active interference on the part of the practitioner. For although in every case it is requisite to employ a precautionary treat- ment, that the occurrence of violent or unfavourable symptoms may be prevented, yet, as a general rule, active remedies will neither be necessary nor proper. When, however, the disease becomes compli- cated with severe affections of the respiratory organs, alimentary canal, or brain, it is invariably attended with considerable danger, and will often prove fatal, even under the most prompt, judicious, and energetic course of treatment; while its occurrence, under all cir- cumstances, in children of a feeble and debilitated constitution, or who, from any cause, are strongly predisposed to disease of the lungs or brain, is to be viewed in an unfavourable light, as in such, it is very apt to prove the exciting cause of some of the most unmanage- able and fatal maladies to which the infant constitution is liable. As a general rule, an individual who has suffered an attack of measles, is not subsequently liable to reinfection ; a few cases, how- ever, in which a second attack has occurred, have been noticed. (F. Home, Baillie, Marley, Rayer, Webster, Wolff, Moore.) Several of these have fallen under our own notice. Measles usually occurs as an epidemic, often of very considerable extent. Of the particular state or condition of the atmosphere, upon which the production of the disease depends, we know nothing. Epidemics of measles are said to commence, generally, in the month of January, and to cease soon after the summer solstice. (Sydenham.) According to our observations, they are very apt to occur at the same seasons, and under nearly the same sensible conditions of the atmos- phere, as epidemic catarrh. Sporadic cases of the disease may occur in almost every month of the year :—they have occurred in the midst of summer. (Morton.) Whether measles is capable of being propagated by contagion, is still a disputed question; although the affirmative is generally assumed, there are many who maintain the negative. The disease, it is said, occurs always as an epidemic ; that on its first appearance, a number of individuals are invariably simultaneously affected ; while the dis- ease cannot be traced from house to house, or from street to street, as in small pox and scarlatina. (Dewees, Wolff.) There can be no doubt, however, that measles may be communicated by innoculation. (Home, Horst, Speranza, Vogel, Brown, Rosen, Vaidy.) Dr. Home, for this purpose, drew blood from a cutaneous vein, where the eruption was most confluent, and applied a dossil of lint impregnated with this, to a wound made in the arm of the individual to whom the infection was intended to be communicated. Of the general certainty and 410 DISEASES OF CHILDREN. value of the operation, it is impossible to form any positive conclu- sions, from the few instances in which it has been practised. Although no age is absolutely exempt from an attack of measles, the most common period of its occurrence is from that of wean- ing, to the age of puberty; after which latter period, the older the patient, the more troublesome and dangerous it is generally said the disease proves. A late writer, however, (Montgomery,) dis- sents from this doctrine, and states, that from his own observations, he should pronounce a directly opposite opinion; which corresponds precisely with our own experience. The only disease with which there is any risk of confounding measles, is scarlatina; from which, however, it may be very readily distinguished by the following circumstances.—The distinctly marked catarrhal symptoms by which the eruption in measles is preceded and accompanied, and their absence in scarlatina; the appearance of the eruption of measles, being seldom very evident until the fourth day; whereas that of scarlatina usually appears on the second day of the fever. In measles, the colour of the eruption is dark scarlet, or of a raspberry hue; while in scarlatina it is of a vivid red, resembling the hue of the lobster after boiling; the eruption in the latter is also much more full and extended than in the former, forming large irregular patches, which often coalesce, so as to communicate a uniform redness over a considerable extent of surface. In the treatment of an ordinary simple case of measles, the atten- tion of the practitioner should be chiefly directed to the fever and catarrhal symptoms, which, when mild, the eruption at the same time following a regular course, will demand little else than a cautious attention to preserve the body of the patient of an equable tempera- ture, and to prevent exposure to cold or damp; to place him upon a spare, simple and unirritating diet, and to keep his bowels regular, by the occasional use of mild purgatives; while we endeavour to mitigate his cough by plain demulcient drinks, rendered more palatable by the addition of a small portion of some vegetable acid, as lemon juice, or the like. The patient should be kept at rest, and in a large, well ventilated apartment, of a suitable temperature, and free from currents of cold air. His drinks should be taken rather of tepid warmth than cold. When the cough is troublesome, the inhalation of the steam of warm water, will, in many cases, if the patient is sufficiently old to conduct the inhalation properly, prove an excellent palliative. In some cases, a pediluvium at bed time, followed by a dose of Dover's powder, will cause the patient to sleep, and mitigate the more trouble- some catarrhal symptoms. We are persuaded that in all cases, an emetic of ipecacuanha or tartarized antimony, administered in the early period of ihe attack, and followed by a full dose of calomel combined with magnesia, the operation of the calomel being promoted by a dose of castor oil given a few hours subsequently, will be found beneficial, by rendering DISEASES OF THE SKIN. 411 the course of the disease milder, and the occurrence of severe bron- chial or pulmonary inflammation less frequent. It is a practice we have followed for many years, and invariably with the best effects. When the febrile excitement is considerable, with a good deal of dry- ness and heat of the skin, the employment of antimonials, or the milder diaphoretics is demanded ;a when the catarrhal symptoms are very severe, the same remedies will be necessary as in severe cases of ordinary catarrh. »R.—Mucilag. g. acacia?, giij. Or R.—Liquor, acetat. ammonias, gvj. Syrup, limonis, 3j. Spir. asth. nitr. Spir. oeth, nitr. J3iij. Viui antimonii, aa 3iij. Tart, antimon. gr. j.—M. Syrup, limonis, gij —M. Dose, a tea spoonful every three hours. Dose, the same as the above. Or R.—Ammonia? hydrochlor. Pulv. ext. glycyrrh.aa 3'ij- Tart, antimon. gr. j. Aquae, gviij. Dose, a tea spoonful every three hours, for a child under two years of age, and a dessert spoonful every two or three hours, for one over two years of age. In regard to the employment of bloodletting in severe cases of measles, there appears to be very little difference of opinion; most practitioners concurring in its recommendation. Some difference of sentiment has, however, existed as to the most appropriate period for its employment. Some directing it only during the height of the the eruption; others postponing it until the eruption has subsided; while others again consider it equally proper at any period of the disease, when symptoms are present which call for its use. The proper rule, however, is easily laid down; whenever great shortness or difficulty of respiration; a full, hard and quick pulse, great heat and dryness of the surface; a frequent dry harrassing cough, with severe pain in the chest or head; and, more particularly, if these be accom- panied with the physical signs of extensive bronchial or of pulmonary inflammation—the abstraction of blood, to an extent sufficient to relieve these symptoms, will be proper and necessary at any stage of the disease ; but, more particularly, if the above symptoms supervene at the period when the eruption disappears. Of course, in directing the extent and repetition of the bleeding, due attention must be paid to the age and vigour of the patient. Under the circumstances just recited, general bleeding, cups to the chest, antimonials and blisters— in fact, all the remedies demanded in ordinary cases of severe bron- chial and pneumonic inflammation, will be necessary; and upon their prompt and judicious employment, will the safety of the patient, in a great measure, depend. Exposure to cold air, or even the use of the cold effusion, which has been found so beneficial in scarlatina, and other of the exanthe- mata, has likewise been recommended in measles. (Magrath, Bate- man.) In the latter disease, however, it is a remedy of, to say the least, very doubtful propriety. It certainly appears to us, calculated rather to augment the catarrhal and pulmonary affections, which, in 412 DISEASES OF CHILDREN. the great majority of cases, are unquestionably the most serious features of the disease. In the congestive form of measles, the remedies best adapted to promote reaction, and to relieve the oppressed state of the internal organs, are, 1st, Emetics, the action of which have been found among the very best means of favouring the eruption upon the surface, and unloading the engorged vessels of the lungs. (Rusk, Armstrong.) 2d, The warm bath. Immersion in the bath should succeed the opera- tion of the emetic, and be followed by brisk friction over the whole surface, with the hand or a soft flannel. 3d, Blisters or sinapisms to the extremities, and to different parts of the surface, particularly the neighbourhood of the organs which appear to be the most oppressed. There are few of the more violent cases, in which these remedies will not be found of decided advantage. In their applica- tion in young children, and in debilitated subjects, caution should be observed not to allow them, particularly the blisters, to remain on too long, but to remove them in one or two hours, the sinapisms in a much shorter period, and to substitute large emollient cata- plasms. 4th, Diaphoretics. The particular diaphoretic will depend, in a great measure, on the urgency of the symptoms; in most cases, the Dover's powder, a combination of camphor, ipecacuanha, and extract of hyosciamus,a or of the acetate of ammonia, aqua cam- phorata, Avine of ipecacuanha, and tincture of hyosciamus,b will be proper; the patient, at the same time, drinking freely of some tepid fluid. 5th, Bleeding. In a large number of the congestive cases of measles, a cautious abstraction of blood, either from the arm, or by cups, from about the head and chest, particularly after the operation of an emetic, and the warm bath, will often produce very decided relief. The effects of the bleeding, however, should be care- fully watched ; and the quantity of blood abstracted, or the necessity for the immediate cessation of the bleeding, should be governed by the degree of relief obtained, and the effects upon the pulse. If the symp- toms of oppression are evidently diminished, and the pulse becomes fuller and more free under the bleeding, it may be continued, within moderate limits; but if the oppression is augmented, the exhaustion of the patient increased, or the pulse sinks, these are signals for the immediate suspension of the operation, and the administration of some gentle stimulant, of which the best is, perhaps, the carbonate of ammonia, in combination with camphor. >> C M W « 6 4 10 21 61 78 42 36 56 69 29 79 138 130 223 ■a m ih s >» "C >R.—Acetat. plumbi, 9j. (,R.—Sulph. alumin. 9j. Aqute purse, giv.—M. Aq. puree, giv.—M. eR.—Nitrat. argent, gr. iv. Aquae, 3J.—M. The chloride of lime,3 has been strongly recommended in the treat- ment of the purulent opthalmia of infants, and deserves a trial. (Varlez, Guthrie, Pffiefer, Eberle.) *R.—Chlorid. calcis, 9j. Aquas, gij.—M. The conjunctiva continues often, after the inflammation has been subdued, in a relaxed puffy condition ; when a wash of a strong solu- tion of zinc, or alum, may be used; or the conjunctiva may be touched daily with the vinous tincture of opium. When the mem- brane becomes soft, spongy and granular, the solid nitrate of silver, or the ointment,4 may be applied. »R—Nitrat. argent, gr. x. Axung. porcin. gj.—M. (Guthrie.) When ulceration or disorganization of the cornea is threatened, it is all important to support the patient's strength, by the use of tonics, which will also be proper after ulceration or disorganization has taken place. The most convenient tonic will be, the sulphate of quinia, which may be given in divided portions, to the amount of one, two or three grains daily, according to the extent of the exhaustion under which the patient labours. It is all important, in every case of purulent opthalmia, and during the entire continuance of the disease, that the patient should enjoy a free, pure atmosphere; be defended from cold or damp, and from the influence of domestic and personal filth. He should be nourished at the breast of a healthy nurse. «. i ,■ i Although not convinced of the infectious character of the discharge from the eye in this disease, we think it proper, however, not to run any risks; and hence, the attendants should be cautioned against communicating the infection to themselves or others, by the acci- dental contacf of the matter with their eyes, which may be easily prevented by the most scrupulous cleanliness. DISEASES OF THE URINARY ORGANS. 601 SECTION VI. DISEASES OF THE URINARY ORGANS. 1.—Dysuria—Painful and difficult micturition. Infants and young children are not unfrequently affected with pain and difficulty in voiding urine. It is often observed, to a slight extent, as a symptom of any febrile excitement under which they may labour, but it is more frequent about the period of dentition. The child has a frequent desire to urinate, but passes a very small quantity at a time, and with evident distress and uneasiness. This may continue for a considerable time, and result, ultimately, in severe and dangerous disease. In some cases, the discharge of urine is attended with such severe paroxysms of pain, as to throw the child into violent agitation, and cause him to utter uninterrupted shrieks, until the discharge is completed, when the pain instantly ceases, and the child, if old enough, returns to his play as though nothing had occurred. Dysuria in children is very generally attended with a morbid condition of the urinary secretion; most commonly, the urine contains an excess of lithic acid, though, in some cases, it is highly charged with phosphatic sedimentous matter. There is a form of dysuria which is of frequent occurrence in young infants, and always a source of intense suffering during its continuance, —if it do not, sooner or latter, terminate in a complete suppression of the urinary secretion; it is described by some of the continental writers, under the denomination of urodialysis neonatorum. (Schbn- lein, Jakn, Klose, Schmidt) The urine is passed in very small quantities, often only a few drops at a time, and, evidently, with intense pain, as indicated by the screams of the patient, the drawing up of his legs towards the abdomen, the flushing of the countenance, and the general agitation of the whole body. The urine is always very high-coloured, and stains the diaper or linen of the child, of a deep reddish, yellow, or orange hue. It produces an irritation or scalding of the surfaces over which it passes, and, finally, excites inflammation of the lining membrane of the bladder, and probably of the urethra also, as indicated by the mucus with which the urine that is passed becomes charged. The patient, usually, exhibits more or less febrile excitement;—the skin being increased in temperature, and dry, the thirst augmented, and the bowels constipated. When a discharge of faeces is obtained, these are commonly in the form of small rounded masses, like marbles. The digestive function is invariably deranged; —the breath having a very decided acid odour. There is, generally, 602 DISEASES OF CHILDREN. considerable irritability of the skin ; while inflammation and superficial ulceration, attended with a thin, acrid, foetid discharge, by which the mischief is extended to the neighbouring parts, is almost certain to occur, wherever two surfaces are in contact. Cutaneous eruptions, of various kinds, are very common ; sometimes assuming the form of psydracious (impetiginous) pustules, scattered over diflercnt parts of the body, and especially in the folds of the neck, axillae, groins, &c, giving rise to superficial ulcerations of a very troublesome character. (Shbnlein.) All the more violent forms of dysuria, occurring in children, arc, very generally, accompanied with more or less derangement of the digestive process, and the formation of acid in the alimentary canal. Severe attacks of the disease will, most commonly, be met with in those children who have been indulged, from an early period of infancy, in animal food, rich gravies, and similar highly azotized articles, and in whom, with imperfect digestion, there co-exists an insatiable appetite for food of a rich, stimulating quality; " Children that, according to the short-sighted estimate of their parents, are in the enjoyment of the most robust health, while, in fact, disease, already commenced, only awaits some trifling cause, to rouse it into more vio- lent and rapid action." (Schmidt.) There is no doubt that deranged digestion, and the consequent pro- duction of an excess of acid in the fluids of the body, giving rise to an increased secretion of lithic acid by the kidneys, and thus changing the normal constitution of the urine, may, during childhood and infancy, be the cause of a very considerable degree of irritation about the neck of the bladder—then easy to be excited, from the physiologi- cal condition, in early life, of the mucous tissue generally—attended by pain and difficulty in passing the urine; and that the urine will, in these cases, indicate by its physical properties, and the usual tests, a predominance of the acid in question. But this is not the only cause of painful and difficult micturition in children; in many cases, parti- cularly in those which occur during dentition, or during slight febrile attacks, the disease is evidently the result of the increased irritability which the lining membrane of the bladder experiences, in common with the other mucous tissues, and, although the urine may, also, contain a slight excess of acidity, this is in too small a quantity to produce the degree of dysuria experienced, without the former. Various intestinal irritations, are an occasional cause of difficult and painful micturition in young children; we have seen it often con- nected with the presence- of oxyures in the rectum ; in these cases, the urine generally forms deposits of an alkaline character. We have known an ordinary attack of dysentery in a child, to be accompanied with severe dysuria. In a few cases, we have had reason to believe that the dysuria depended upon a degree of inflammation, about the neck of the bladder; the urine, in these cases, notwithstanding the calls to void it were very DISEASES OF THE URINARY ORGANS. 603 frequent, was passed in very small quantities, and loaded with mucus; —partial retention of urine is common in such cases. In female children, a very common cause, and one very often over- looked, of dysuria is, an inflamed condition of the orifice of the urethra. (Eberle) This is often red, swollen, and so extremely sensible, that it cannot be even lightly touched, without causing the child to shrink, and shriek with pain. In cases of this kind, the urine presents nothing abnormal, and the pain, accompanied by consider- able smarting, remains for some short time after the discharge of urine has ceased. We have met with this state of the female urethra so frequently, that we are never called to a case of dysuria, occurring in a girl, without making an examination. There does not appear to be any source of difficulty in the diagnosis of dysuria. Even in the youngest child, its symptoms are sufficiently evident, to prevent the disease from being mistaken for almost any other; and yet we have known it to be confounded with colic, and treated for several days accordingly; if, however, a child is found to become affected with spells of severe suffering, only during the period it is voiding its urine, the pain commencing and ceasing with the latter, the true cause of the paroxysms is at once pointed out. Happily, in the majority of cases, the remote and exciting causes of dysuria are only of temporary duration, and, hence, the affection is seldom productive of any very serious or permanent injury. When, however, the disease is connected with long-continued disturbance of the assimilative process, it may produce disease of the kidneys, ureters, or bladder, giving rise to a complete suppression of urine, or be the cause of gravelly or calculus concretions. Gravel, in children, is of more frequent occurrence than is gene- rally suspected ; and, when formed in the pelvis of the kidney, its occasional passage through the ureters, is attended with sudden, intense attacks of pain, which continue until the particle of gravel has found its way into the bladder; these attacks, the cause of which is at first not very evident, may give rise to convulsions ; occasionally the urine voided immediately after the cessation of the pain, is slightly bloody. In the treatment of dysuria, we must be governed by the peculiar character of each case. When dependent upon disordered assimila- tion, it is important to employ such means as are calculated to render the digestive process more prompt and regular; previous to weaning, the breast-milk of a healthy nurse, pure air, the warm bath daily, followed by friction to the surface, will, in general effect this; in older children, beef tea, or chicken water, should constitute pretty much their ordinary diet, and all articles of a saccharine and ascesent kind should be entirely prohibited ; at the same time, daily exercise should be taken in the open air, cold and dampness carefully guarded against, and the functions of the skin promoted and maintained by the tepid bath and friction. In all cases, the bowels should be, at once, freely evacuated by 604 DISEASES OF CHILDREN. sufficient doses of magnesia and rhubarb, aided by emollient enemata, and their regular action, subsequently maintained, by small doses of calomel, magnesia and ipecacuanha, with or without the addition of extract of hyosciamus,4 repeated once, twice or thrice a day, as may be necessary. When there is a strong tendency to acidity of the stomach and bowels, the'best prescription will be, either magnesia and milk, in small, frequently repeated doses, or, what is calculated in these cases, to produce the greatest amount of benefit, the bi-car- bonate of soda. This may be given in doses of from two to six grains, according to the age of the child, once, twice, or thrice daily. It should be dissolved in about half a drachm of a weak infusion of calomba, or chamomile, and then diluted w ith barley, rice, or gum water. >R.—Calomel, gr. vj.—xij. Pulv. ipecac, gr. iij. Magnes. calc. gr. xxxvj. Ext. hyosciami, gr. iv.—vj.—M. f. ch. No. xij. When dysuria occurs during dentition, the state of the gums should be carefully watched, and inflammation, distension, and pain of these promptly removed, by free incision, repeated daily, if necessary ; the bowels should be kept freely open, by occasional doses of magnesia and rhubarb, and, if any febrile excitement exists, as it generally does, the daily use of the tepid bath, and, internally, the acetate of am- monia, with the addition of a small quantity of the sweet spirits of nitre. During the paroxysms of pain, should they be of any continuance, the best means of alleviation is the hip bath, used tolerably warm, and, internally, a few drops of turpentine, sweet spirits of nitre, and the camphorated tincture of opium, in combination.1 In ordinary cases, however, the duration of the paroxysms is too short, to allow time for the preparation of the bath, we must content ourselves, therefore, with the administration of the latter. »R.—Aq. cinnamon, gij. Spir. terebenth. 3jss. Magnes. calc. gr. viij. Spir. aeth. nitr. 3iij. Tinct. opii camph. 3'j-—M- When dysuria is attended with a copious secretion of the phosphate of magnesia and ammonia, with pale or light-coloured urine, which deposits, upon cooling, a whitish or yellowish sediment, and becomes rapidly putrid when suffered to remain at rest, the diet of the child, if weaned, should be mild, but nutritious, but taken in moderate quantities, so as not to endanger the overloading of the stomach, or the disturbance of its functions; in addition to milk, and the usual farinaceous preparations, the child may, with propriety, be allowed a moderate portion, daily, of beef, mutton, venison, chicken, turkey, or any other meat of easy digestion,—which should be fresh, not too fat, DISEASES OF THE URINARY ORGANS. 605 and plainly cooked, without much seasoning. For drink, we may direct weak lemonade, or water sweetened with the acidulous lemon syrup. The bowels, in these cases, are generally irregular, and the func- tions of the entire alimentary canal, more or less deranged. To remove this, the bowels should be freely evacuated with rhubarb, castor oil, and turpentine, or the compound infusion of senna, and kept freely open by the occasional use of the latter, or by mild purgative enemata. To allay the general irritability of the system, by which this form of dysuria is generally accompanied, either the Dover's powder,a in small doses, or a combination of ipecacuanha, and extract of hyosci- amus,1" will, very frequently, be found beneficial. »R.—Pulv. Doveri, gr. vj. bR—Pulv. ipecac, gr. iij. Pulv. valerian, gr. xij.—M. f. ch. No. Ext. hyosciami, gr. iv.—vi.—M. f. ch. xij. {Eberle.) No. xij. Of these, one may be given every six hours, One every three hours. to a child between two and five years of age- After the bowels have become regular, and their discharges natural, benefit may be derived from the administration of the tinc- ture of the sesquichloride of iron, in small doses, or of the proto- carbonate of iron. Daily exercise in the open air, the tepid bath, and frictions to the surface, are all important measures, and should never be neglected. All alkaline substances are improper. When dysuria appears to be dependent upon a morbid degree ot irritability in the lining membrane of the bladder, the condition of the urine being normal, or very nearly so; the treatment should consist of a mild unirritating diet, the use of the warm or tepid bath daily, and the plentiful use of diluents, of a mucilaginous character. The freedom of the bowels should be maintained, by occasional doses of castor oil, or by laxative enemata; and, if there is nothing present to forbid its use, a dose, adapted to the age of the patient, of Dover's powder may be given at night, or the extract of hyosciamus and ipecacuanha, as directed above, three or four times a day. A weak infusion of the seeds of wild carrot, or of the root of parsley, mixed with an equal portion of the mucilage of the inner bark of the slippery elm a has been found, in some of these cases, peculiarly beneficial. Very active exercise will not be proper; but a short walk, or ride in a carriage, should be taken every day, when the weather is dry, and sufficiently mild. In this, as well as in all the other forms of dysuria, it is important to defend the surface against cold and damp, and hence, the importance of flannel being worn next the skin. :.R -Sem. dauc. carotte, 3ij. °r R-^ad- aP» Pftroselini, Sij. a. oBiu.uttuv.. " M Aquae bulhent, 3vm. Aq. bulhent, 3vuj—Al. ^ ^J^j, ^ then ^^ and adce, the involuntary discharge:o urine during sleep will become less freauent, and finally cease entirely. When the condition of the urine is that pointed out by Wilhs- nnmPlv naleand watery, of diminished specific gravity, and deficient in Ufusu'a^ aninraWngt/dients, the same attention should be directed to restore the healthy function of the digestive organs and bring back the urnaiy secretion to its normal state. Any light, bitter infusion, acid- 614 DISEASES OF CHILDHEN. ulated with hydrochloric acid, with the addition of a very small propor- tion of the tincture of opium, will be found a useful remedy in these cases; or we may administer a couple of table-spoonsful of the con- centrated decoction of uva ursi, with the addition often drops of the tincture of the sesquichloride of iron,two or three times a day. (Willis.) The dose here directed of the latter remedy, is adapted to a child of five or six years of age; but a younger patient will seldom bear more than a tea-spoonful at a time of the decoction, and from three to five drops of the tincture of the sesquichloride of iron, which may be repeated, if necessary, three times in the course of the day. Cold, or in very young and delicate children, repeated tepid sponging of the perineum and pubes, has been found beneficial in some cases. In others, a blis- ter to the sacrum has succeeded in relieving the complaint; (Willis;) we have used the blister frequently, occasionally with complete suc- cess ; in others, with no advantage whatever. Children, as a general rule, but more especially when affected with nocturnal incontinence of urine, should not be allowed to partake of large quantities of fluid, either as drink or food, in the latter part of the afternoon and evening. They should be prohibited from the use of tea, or, indeed, any kind of food, a short time before retiring to rest. The caution should be observed to cause them to evacuate the blad- der just before being put to bed ; and to wake them for this purpose at regular intervals during the night. Cases, however, occasionally occur, in which every means em- ployed is productive of no permanent benefit. In these obstinate cases, it has been supposed that the infirmity could be traced to a hereditary deficiency of control over the sphincters of the bladder at any time, the children wetting themselves whenever sharply spoken to, or fright- ened :—we have met with such cases in children of an eminently nervous constitution. But the most obstinate cases have appeared to us to occur in very profound sleepers, and to be kept up by the blad- der having acquired a confirmed habit of evacuating its contents at a particular hour. The bladder may acquire this habit, so that, even in the day-time, when the patient is perfectly awake, he finds the ut- most difficulty to retain his urine beyond the particular period when its discharge has been accustomed to take place. In these cases it is that the exhibition of the tincture of cantharides will be found beneficial; by the irritation it produces about the neck of the bladder, the moment the urine begins to flow, a degree of stran- guary occurs, sufficient to awaken the person, and prevent the evac- uation taking place in the bed. This effect being repeated for several nights in succession, the habit upon which the involuntary discharge takes place, is entirely broken up, or the patient will become accus- tomed to awake when the desire to urinate occurs, and thus all the disa- greeable consequences resulting from his unfortunate infirmity, be pre- vented. From three or six, to ten or fifteen drops of the tincture of can- tharides, according to the age of the child, may be given three times in the course of the day, and the dose should be gradually increased, until DISEASES OF THE URINARY ORGANS. 615 a degree of stranguary is experienced in voiding the urine. The moment this effect is produced, the medicine should be given only in small occasional doses, so as to keep up, for a few nights, a slight degree of irritation at the neck of the bladder. Of course, the employment of the cantharides is proper only in protracted cases, unconnected with derangement of the digestive organs, and a morbid state of the urin- ary secretion. Should too violent a degree of strangury ensue, it may be abated by the free use of emollient enemata and mild mucila- ginous drinks, small doses of camphor in the form of emulsion, and the warm hip bath. If these means are not immediately successful, an anodyne enema may be given. The employment of strychnine has been recommended in cases of enurisis occurring in children. (Moudiert, Cherchiare, Lendrich, Schnatz) Upon what principle it is supposed to prove beneficial, we are unable to conceive; we have given it a trial, but found it, when administered in very small doses, to do no good; and when given in larger doses, its effects upon the nervous system have been too violent to warrant a continuance in its use. When every thing else fails, we may resort, in the male, to mechan- ical contrivances for compressing the urethra, and thus prevent the escape of the urine. The best is that in which a firm, but not hard pad, is kept applied by means of a spring to the membranous portion of the urethra. (Willis.) This should not, however, be permitted to be worn habitually ; it may be used, occasionally, with perhaps con- siderable benefit; and when children are visiting from home, will in- sure from the shame and mortification incident To this infirmity. Lig- atures to the penis, or the use of jugums, should never be permitted, as much mischief is liable to result from them. In not a few instances, incontinence of urine is kept up by the irri- tation of the oxyures worm in the rectum ; when this is the case, an enema of aloes or assafoetida, dissolved in milk, or of turpentine dif- fused in mucilage, will destroy the worms, and a well-regulated diet, exercise, the warm or tepid bath, and frictions to the skin will, in general,'tend to prevent their return. Should, however, the rectum become' again infested with them, a repetition of similar enemata should not be neglected. §.—Diabetes. There can be no doubt that children are frequently affected with a species of hyperurisis, in which the urine discharged differs but little in its sensible qualities from common water, being perfectly limpid, entirely colourless, with scarcely any odour, and after standing for ten or twelve hours, becoming slightly opalescent or milky. (Willis) This affection usually occurs in children of debilitated constitutions, emaciated or quickly becoming emaciated, with soft protuberant ab- domens, and listless, torpid, indolent dispositions. The appetite is generally voracious, and the thirst incessant and insatiable. The child 616 DISEASES OF CHILDREN. desires every thing of an eatable kind that he sees, and is constantly crying for water, large quantities of which he will swallow at a time, if not restrained. The bowels are usually constipated or irregular, and the digestive process is so far disturbed, as well by a diseased con- dition of the stomach, as by the amount of food, often of a crude, and insoluble kind, with which this organ is always overloaded. It is not uncommon for the discharges from the bowels to be mixed with portions of undigested aliment, particularly of the vegetable sub- stances that have been swallowed, whether cooked or uncooked. Mellituria.—Diabetes mellitis, is a much more rare disease during childhood ; that it occasionally occurs, there can be no doubt. It has been observed in boys of three and five years of age, and in both boys and girls about twelve. (M'Gi-egor, Willis.) In one of the cases refer- red to by Morton, (Pkthisiologia) we are expressly told that the urine was mellea dulcedo; while in the disease described by Venables, as tabes diuretica, the urine was evidently insipid. Diabetes in children seldom occurs during lactation. It would ap- pear to depend, very generally, upon derangement of the digestive and assimilative functions, consequent upon the use of improper food, subsequent to weaning. A confined, damp, or impure atmosphere, the want of sufficient exercise, and a congenital infirmity of constitu- tion, are, no doubt, also, very common exciting or predisposing causes. The child exhibits, at first, no striking symptoms of disease, but becomes gradually dull, listless, and fretful; loses its usual playful and active disposition, and exhibits an uneasy, discontented, and anx- ious expression of countenance. The bowels are generally regular, with little or no deviation from the natural and healthy appearance of the discharges. The tongue has a natural appearance. At an early period, however, there is an increased discharge of urine, increased thirst, and a more craving appetite than usual; and these symptoms, with the gradual emaciation, and dry, harsh state of the skin, are in general referred to the presence of worms in the intestines, for which the child is treated—the real nature of the disease being entirely over- looked. The emaciation goes on increasing, while the abdomen becomes more tumid, but without much tenderness or tension. The tongue becomes coated with a thick layer of mucus; the bowels become constipated or irregular, and the stools acquire an unnatural appear- ance, being occasionally slimy and green, or mixed with portions of undigested food ; occasionally they are frothy, light-coloured, and ap- parently in a state of fermentation. The thirst rapidly increases, as well as' the craving for food, and at the same time the discharge of urine increases rapidly in quantity, becoming often enormous ; exceed- ing at times, perhaps very generally, the amount of fluid taken. The emaciation goes on with increasing rapidity, and is attended often with extreme debility ; the skin becomes uniformly dry, and very harsh. There is almost invariably a gnawing sensation at the pit of the sto- mach, and increasing dullness, inactivity of disposition, and depression DISEASES OF THE URINARY ORGANS. 617 of mind. The pulse, which was at first somewhat accelerated, be- comes now small, quick, and hard. The latter stage of the disease is often accompanied with a considerable degree of febrile excitement, often attended with head-ache, vertigo, and temporary delirium. In cases of long continuance, oedematous swellings of the lower extremi- ties, or even general dropsy have been known to occur. (Venables) The child gradually sinks, apparently from an entire suspension of the nutritive process j in other cases, a state of deep coma precedes the fatal event. (Venables) The urine discharged is generally pale, perfectly limpid, without the least trace of sedimentitious matter; in some cases, however, it is of a milky appearance, and slightly turbid, and occasionally of a very light yellow or greenish hue, having a very close resemblance to whey. Diabetes is always to be considered as a serious disease; when detected in its early stages, it is very possible, that by a proper course of treatment, its fatal termination may be very generally prevented; but, unfortunately, it is seldom that the disease falls under the notice of the practitioner, until it has existed for some time; the discharge of urine increases so slowly in amount, that it is entirely overlooked by the parents of the child, or if noticed, is ascribed to the enor- mous amount of fluids which his morbid thirst prompts him to take. Even when a physician is consulted, the case is too often con- sidered as one of worms, mesenteric disease, marasmus, or dropsy of the brain; (Venables;) and an improper course of treatment adds to the fatality of the disease. The first attention of the physician should be directed to restore the healthy action of the digestive and assimilative organs; for unless this can be accomplished, there is very little hopes of arresting the inor- dinate and unhealthy action of the kidneys. The child should be put upon a strictly regulated diet, composed of the more digestible kinds of animal food, plainly cooked, with preparations of milk, eggs, and rice or oatmeal, without sugar; crackers should be given, in prefer- ence to bread, or if bread be eaten, it should be well toasted. In the quantity of food taken, the patient should be so *far restrained as to prevent the stomach from becoming, at any time, overloaded ; pro- bably four meals a day, at stated hours, a very moderate quantity being eaten at each, will be most advisable. The patient should be positively restrained from the use of all crude, ascescent or saccha- rine vegetables, or fruits; and for his drink, he may take toast-water, slightly acidulated with hydrochloric or nitric acid, but in no larger quantities than is absolutely necessary to allay thirst; tea, coffee, lemonade, thin gruel, whey,' and the like, must be absolutely prohib- ited. With this diet, a due amount of exercise should be taken daily, in a dry, pure, temperate atmosphere:—the patient should be allured out of doors for a short walk, or if too torpid or debilitated for walk- ing, he should ride, or sail upon the water every day, when the weather will permit. 618 DISEASES OF CHILDREN. The functions of the skin appear to be, in a great measure, sus- pended, in cases of diabetes; hence, the warm bath, and friction of the surface, become important measures, and should be daily repeated. The bowels should be freely purged, and kept open, subsequently, by gentle aperients; in the first instance, we may give a combination of aloes, rhubarb, and the bicarbonate of soda ;" or aloes, gamboge, car- bonate of soda and extract of hyosciamus ;b and the bowels, after being once freely evacuated, may be kept regularly open by a combi- nation of calomel, extract of hyosciamus, magnesia and ipecacuanha.0 »R.—Aloes, gr. xij. bR.—Aloes, gr. xij. Pulv. rhei, gr. xxxvj. Gambog. gr. xij. Bi-carb. sodse, gr. xxiv.—M. f. Bi-carb. sodee, gr. xxxvj. pill. No. xiij. Ext. hyosciami, gr. xij.— M. f. Of which one, or two, or three, may be given, pill. No. xiij. according to the age of the child, every This forms a very prompt, gentle and efFcc- three hours, until they operate freely. lual purgative, when one pill is given every three hours. CR.—Calomel, gr. xij. Magnesias, gr. xxxvj. Ipecac, pulv. gr. iij. Ext. hyosciami, gr. vj.—M. f. ch. No. xij. One to be given once or twice a day, as may be necessary. In some cases, emetics of ipecacuanha, repeated daily, for two or three days, in the commencement of the disease, have been found beneficial. (Richter.) Occasional small doses, say one grain to a child between one and two years old, of the compound powder of ipecacuanha, may be given two or three times a day, after the bowels have been fully evacuated ; combining the opiate with uva ursi, or the carbonate or phosphate of iron,1 is said to be attended, in many cases, with the most decided benefit. (Venables, Reirson) A combi- nation of uva ursi, carbonate of soda, extract of hyosciamus, and car- bonate of iron, will likewise be _found a very valuable remedy ;b or the uva ursi, extract of hyosciamus, and iron may be prescribed in a fluid form,c which is preferable, generally, in cases of disease in children. "R.—Pulv. ipecac, comp. gr. xij. i>R.—Pulv. uvse ursi, gss. Pulv. uv33 ursi, 3ss.—3j.—M. f. Bi-carb. sodas, gr. xxiv. pulv. xij. Ext. hyosciami, gr. xij. Carb. ferri, gr. xxiv.—M. f. ch. Or, R.—Pulv. ipecac, comp. gr. xij. No. xij. Carb. ferri, JJijss.—3j.—M. f. One to be given three times a day. pulv. xij. CR.—Extract hyosciami, 9j. Or, R.—Pulv. ipecac, comp. gr. xij. Aquae, 3j.—M. Phosphat. ferri, gr. xxiv.—xxxvj. Five drops of this solution, and the same —M. f. pulv. xij. quantity of the tincture of the sesquichloride One of either of these formulae may be given of iron, may be given three limes a day, in to a child between one or two years of a teaspoonful of ;m infusion of uva ursi, age, every four hours. one ounce to the pint of boiling water. Infusions of calomba, gentian, or quassia, may be used occasion- ally, with very good effect. During the period of dentition, careful attention should be paid to the condition of the gums, and if these be swollen, painful and red, they should be freely scarified. CONGENITAL AFFECTIONS, ETC. 619 The external application of the spirits of turpentine has been recom- mended in cases of diabetes in children : (Deioees:)—there can be no doubt, that in nearly all the diseases of childhood dependent upon a highly deranged state of the alimentary canal, of a chronic charac- ter, turpentine constitutes, when judiciously employed, one of our most beneficial remedies; and, so far as the disease of the digestive organs is concerned, we have no doubt it would prove an appropriate remedy in the species of hyperurisis under consideration. We have been deterred from prescribing it, however, lest its action upon the kidneys might provejjrejudicial. The tannin has been used in some cases of diabetes, with success; (Giadorou;) and is worth a trial, in a disease, which, in children, it is particularly difficult to control.1 *R.—Tannin, 3j. Ext. hyosciami, gr. iv.—M. f. ch. No. xij. One of these may be given to a child over one year of age, every three hours, the quantity of tannin in each dose being gradually increased to ten or fifteen grains. SECTION VII. CONGENITAL AFFECTIONS, AND ACCIDENTS OCCURRING MOST GENERALLY WITHIN THE MONTH. 1.—Spina Bifida.—Hydro-Rachis. Hydro-rachis is, strictly speaking, an abnormal accumulation of fluid within the spinal column ; it is, in almost every instance, a con- genital affection, and may be associated either with hydrocephalus or spina-bifida. In the latter case, one or more tumors will be found to exist upon the spine, generally in its lumbar, occasionally in its dorsal and sacral, and very rarely in its cervical portion. These tumors vary in size, from that of a hazel-nut to that of the adult head, or the entire spine being bifid, the tumor may occupy its whole length. (Richter) The tumor is usually globular or ovoid in shape, haying either a large base or narrow neck; in one case, it was bi-lobed. (Brewerton) It may be invested by the common integuments, in a healthy, uninflamed condition, or the skin covering it may be thin, almost transparent,and crossed by purplish lines, and as if about to rup- ture with a sero-sanguineous fluid exuding through it; or, the tumor mav be ruptured, its contents having escaped through a very small ulcerated opening, which is surrounded by a red, rugous, unequal 620 DISEASES OF CHILDREN. elevation of the skin and subcutaneous tissue. The two latter condi- tions of the tumor are much more common than that in which it is covered by healthy skin, and far more dangerous. The tumor is always situated over a deficiency in the vertebrae, arising most commonly from an imperfect development of the late- ral arches; occasionally, however, the lateral arches may exist, but remain ununited, or, still more rarely, there may be a complete divi- sion of the whole vertebra, body as well as processes. (Fleischman) The opening in the vertebrae may be confined to one bone, or extend to two or more, or it may occur at different parts of the spine, giving rise to several tumors, or, as we have already seen, it may exist throughout the whole extent of the spine. The tumor itself is formed by a cyst, communicating with the spinal cavity, and filled by a fluid secreted within the latter. In the most favourable cases, its parieties are composed of one or both layers of the arachnoid membrane, the dura mater, and the common integuments in a natural condition ; more generally, however, its parieties are thickened, inflamed, ulcerated, gangrenous, or covered with fungous granulations, or tufts of hair. To the touch, the tumor is tense and protuberant, whenever the position of the infant is such as to allow the fluid from within the spinal canal to gravitate towards it but it is more or less soft and flaccid under opposite circumstances. By gradual pressure, its bulk may be diminished, and if of small size, the whole of its contents may be forced back into the spinal cavity, when the margin of the opening through the vertebrae may be felt with the finger. Pressure upon the tumor very frequently induces a state of coma, or convul- sions, and in one case, pressure, even that resulting from the supine recumbent position of the child, invariably produced attacks similar to the croup-like convulsions of laryngismus. (Hall.) In some cases, the tumor has been observed to expand during expiration, and sink during inspiration. (Cruveilhier) The contents of the tumor may be either a limpid, colourless serosity, or a turbid fluid, often containing albuminous flocculi, or a purulent matter. The fluid of the tumor communicates freely with that collected within the cavity of the spine; and in many cases, there is a free communication, between the ventricles of the brain and intercranial arachnoid cavity, the entire canal of the spine and the cavity of the external tumor, so that pressure made upon the latter may force the fluid back upon the brain, and cause more or less compression of that organ. Children affected with spina-bifida often present other malforma- tions, as imperforate anus, imperfect or irregular development of the alimentary canal, &c. When there exists no external opening in the tumor, it being cov- ered by the common integuments, and when the accumulation of fluid within the vertebral canal exercises no pressure upon the brain, or spinal marrow, so as to interfere with the free exercise of their func- tions, individuals affected with spina-bifida, though generally of weak CONGENITAL AFFECTIONS, ETC. 621 and infirm constitutions, may exhibit no particular symptoms of dis- ease, and even live to an advanced age, without the occurrence of any serious evils, that immediately result from the spinal tumor. Cases of individuals labouring under spina-bifida, of almost every age, from ten years to fifty, and upwards, have been observed, (Bonn, Martini, Paletta, Acrel, Henderson, Copland, Warner, Hockstetter, S. Cooper, Camper, Cowper, Swagermann, Ollivier) Generally speaking, however, from a greater or less deficiency in the spinal cord, or other morbid condition of it, or of the brain, the infants labouring under spina-bifida are liable to be affected with par- alysis of the lower extremities, convulsions, an open state of the sphincters, and difficulty of respiration. They are occasionally una- ble to take the breast, and become gradually more and more exhausted; their feet and legs become cold and oedematous, their cries more and more feeble, their pulse extremely quick and feeble, their breathing more and more difficult, and often stertorous, and, finally, death takes place, preceded by convulsions or coma. The larger the tumor, the more intense and rapid is this train of symptoms. When, in particular, the tumor bursts, inflammation of the membranes of the cord, in general, very rapidly ensues, and we have then all the symptoms of spinal meningitis, and, in general, the patient is quickly destroyed. If, however, the opening in the tumor is very small, notwithstand- ing a portion of fluid is constantly escaping, no very important suf- fering may result for a length of time. But, very commonly, the fluid discharged becomes more or less turbid, purulent, or even foetid, and symptoms of spinal inflammation very soon occur. When the tumor is of considerable size, its sudden rupture may produce a par- oxysm of convulsions, terminating almost immediately in death. It has been asserted, that a rupture of the tumor has taken place in utero, and the opening has again closed, previously to birth. (Duges) This appears to us, however, as very doubtful; the case cited in con- firmation of it is certainly very far from being conclusive. After death, the most common appearance met with is a more or less copious effusion of serosity, either between the pia mater and the arachnoid membrane of the spinal marrow, in the arachnoid cav- ity, or between the dura mater and bony wall of the spinal cavity; when in the two first situations, the effused fluid very generally com- municates freely with the ventricles of the brain, and the arachnoid cavity within the cranium, in which there also exists a morbid effu- sion of serum. Occasionally, when the tumor is small in size, and covered with the common integuments, in a normal state, the brain is found to be perfectly healthy, the effusion of serum being confined entirely to the spinal canal. (Billard.) Even the medulla spinalis may present no apparent indications of disease. The effused fluid is usually perfectly limpid, excepting when meningitis has occurred, when it is generally thick, turbid and flocculent;—it may be of alight yellow, 622 DISEASES OF CHILDREN. greenish, or dark hue, and is often mixed with pus, or with more or less blood. When an effusion of fluid exists, at the same time, in the cavity of the cranium, and in that of the spine, the fluid in the former has been of a different colour from that in the latter, showing the two to be perfectly distinct; in other cases, the fluid was prevented from escap- ing from the fourth ventricle into the sub-arachnoid cavity, by a firm, reddish membrane, which formed a cul de sac below the inferior angle of the ventricle. (Billard, Lediberder, Krause) The spinal cord may either present congenital deficiencies, or malformations, or more or less traces of disease. The substance of the cord has been found entirely wanting, the membranes alone remaining; (Otto;) forming sometimes a closed sac, filled with a fluid. It may be diminished in size, divided into two parts, or expanded into a membrane. (Meckel.) It is often preternaturally long. (Ollivier.) The spinal nerves have been seen floating in the fluid of the tumor. (Lecat, Ollivier, Cruvcil- hier, Krause, Gilman) They have been found, also, distributed on the inside of the tumor, forming, occasionally, a kind of nervous net- work. (Stafford.) More commonly, however, the substance of the cord is softened, like the walls of the cerebral ventricles in hydroce- phalus; (Meckel, Billard;) and very generally, traces of meningitis of the spine exist, often extending even to the brain. (Billard) In regard to the pathology of hydro-rachis, numerous discordant opinions have been entertained. The disease is evidently a true con- genital dropsy, either of the spine, or of the spine and brain; (Ruysch, Louth, Underwood, Ollivier, Billard;) the deficiency in the vertebrae, as well as the external tumor, being the result of the accumulation and pressure of the fluid within the cavities of the cranium and spine. When the tumor in the spine is not formed, the child usually perishes soon after birth, with symptoms of hydrocephalus; or tumors, in some instances, form upon the head, in all respects similar to those of spina bifida, the fluid protruding the dura mater and a layer of the arach- noid membrane, through an opening in one of the bones of the cra- nium. Dropsy of the spine, with the formation of an external tumor, has succeeded to hydrocephalus, produced by contusion of the head ; (Morgagni;) or from disease of the spinal cord. (Frank, Reydellet, Krause.) In regard to the treatment, it would appear, from a careful exami- nation of all the facts upon record, and from the result of the very few cases which have fallen under our own notice, that, when the tumor is small, and more especially when it is covered with the com- mon integuments, and the infant, as is generally the case, suffers little or no inconvenience, the most prudent course is to let it alone, merely guarding the tumor from accidental pressure, and from every source of irritation. So long as the tumor remains unopened, there is, com- paratively, little danger, but soon after it becomes opened, meningeal inflammation, with all its train of fearful consequences, soon sets in, and quickly destroys the child. CONGENITAL AFFECTIONS, ETC. 623 The opening of the tumor is always, therefore, to be considered a most unfortunate circumstance ; hence, if the infant be born with an ulcerated tumor, but incompletely perforated, it ought not to be opened for the purpose of allowing the discharge of its contents. (Billard.) It is true that the operation, first practised by Ruysch, and revived by Abernethy, of puncturing the tumor with a fine needle, and after- wards employing gentle pressure, has been performed, and it is said, in several cases, with success. (A. Cooper, Bampfield, Probart, Rosette, Robert, Stephens, of N. Y) Very recently, two cases are related, in which a perfect cure was effected by cutting off the tumor, and then bringing the edges of the divided skin together, and retain- ing them so, until union took place, by means of the twisted suture, great care being taken to prevent the entrance of air into- the spinal canal, and as much as possible, the escape of the spinal fluid. (Dubourg) The application of gradual and gentle pressure, as recom- mended by Abercrombie and Sir Astley Cooper, is unquestionably the treatment that will be found the best adapted to the generality of cases of spina bifida; it is said to have produced a radical cure in some instances. (Acrell, Ruysch, Krause.) It has been very correctly remarked, that when the tumor is very large, puncture should not be attempted, while in cases where the fluid effused in the spine com- municates with the ventricles of the brain, pressure must always be of very doubtful propriety. (Underwood.) In all cases of spina bifida, much benefit will unquestionably be de- rived from placing the patient under such a hygienic course of treatment as will be adapted to improve the health and nutrition of the body gen- erally ; hence, the importance of changing the milk of the mother, if the quality of this be doubted, for that of a healthy nurse ; of remov- ing the infant from the confined and impure air of the city, to a dry, healthy situation in the country ; of clothing it warmly, and carrying it abroad, every fine day, in the open air ; of sponging its body daily with warm water, and using frictions over its entire surface, and of keeping its bowels regular, by gentle aperients. It has been proposed to apply repeated small blisters above the tumor, in the course of the spine, each being kept on so long as to cause a rubefacient effect only, with a view, in this manner, to pro- mote the absorption of the fluid. (Bennett) The preparations of iodine may also be administered with the same intent. When the disease is associated with hydrocephalus, or with menin- geal inflammation, either of the brain or cord, the treatment adapted to the latter affections will, of course, become necessary. 2.—Club-Foot— Talipes. Children are frequently born with various deformities of the feet, to which the popular denomination, club-feet, has been applied. The foot may either be turned outwards, so as to allow its inner margin to rest upon the ground, {valgus, talipes valgus ;) or inwards, its outer 624 DISEASES OF CHILDREN. edge being directed to the ground, (varus, talipes varus ;) or the heel may be drawn up, so as to direct the toes downwards, and exteml the foot, causing it to approach a right line with the leg, (pes equinus talipes equinus.) A fourth variety has been described, in which the foot is flexed upon the leg, and the heel only is applied to the ground. (Little) This distortion is caused by a contraction of the muscles in front of the leg. These deformities are, in general, apparent from birth, but increase in extent as the child grows older, particularly as it approaches the period when it should walk; if not remedied at an early period, the child is, in general, doomed to lameness and defor- mity for the residue of its life. Much attention has been directed, of late years, to the investigation of the pathology and mode of remedying the various congenital dis- tortions of the feet, by several distinguished surgeons and physicians of Europe and America. (Delpech, Jbrg, Strohmeyer, Little, Scarpa, Colles, Mutter, Detmold) Their immediate cause would appear to be a shortening of the gastrocnemii and other extensor muscles, or of those which rotate the foot outwards. The pes equinus, or extended foot, from shortening of the extensor muscles, is probably the most common form of. distortion, the twisting of the foot inwards being produced secondarily, in consequence of the natural inclination of the os calcis, and the normal action upon this of the gastrocnemii, causing the foot to turn somewhat in that direction. As the turning inwards of the foot increases, the plantar muscles, ligaments, and aponeuroses become more and more contracted, the deformity in- creases, and first, the side of the foot, and finally, its dorsum, is applied to the ground, the bones of the tarsus are thrown into an un- natural position, and after the child begins to walk, being subjected to continual pressure, become altered in shape, in consequence of which the deformity, that in the first instance might, with due care, have been removed, becomes permanent. The twisting of the foot out- wards, which is of comparatively unfrequent occurrence, is produced by a shortening of the abductor muscles. (Delpech.) The remote cause is to be referred to a defect in the nerves distributed to the muscles of the leg, in consequence of which there is a want of balance in the development and action of the antagonist muscles. (Delpech.) Distortions of the feet have been met with in foetuses of from three to five months, with coexisting deficiencies, and malformations in the brain and spinal cord ; in anencephalus and hemicephalus embryos, the hands, as well as the feet, have exhibited similar distortions. Chil- dren born with a deficiency or disease of the spinal marrow, are also very commonly affected with club feet; the deformity is hence a common accompaniment of spina bifida. (Billard.) It may also take place subsequent to birth, when from disease of the spine, temporary paralysis of the muscles of the extremities is produced, and on a par- tial recovery taking place, the flexor muscles acquire more power than the flexors. Distortions of the feet are said to be hereditary, in consequence of CONGENITAL AFFECTIONS, ETC. 625 the transmission of a morbid irritability of the nervous system, pre- disposing to convulsive and spasmodic contractions of the muscles. We have no doubt that this may occasionally be the case, but of all the numerous cases of club-foot that have fallen under our notice, no one occurred in children born of parents, either of whom were simi- larly affected. In the treatment of club-foot, the grand object to be effected is to extend those muscles, the inordinate contraction or shortening of which has produced the distortion, and to increase the action and power of their antagonists. The first must be effected by mechanical contrivances, adapted to preserve the feet in their natural position, and counteract the force by which they are drawn out of it; and the second, chiefly by friction of the limbs, and a well conducted general hygienic treatment, calculated to reduce the excitability of the ner- vous system, and to give tone to the body generally. A variety of mechanical contrivances have been suggested, in the form of splints, stocks and shoes, to retain the foot in its natural posi- tion, and counteract the distorting force. It is not within the province of the present work to present a description of these several appara- tus, or to enter into a discussion of the question, as to which of them is the best adapted to effect the object for which they are employed ; we would merely remark, that in whatever contrivance we adopt, simplicity and lightness are of the first importance, as well as such a form as will prevent any undue pressure upon the part that is made the point d'appui. The form of the apparatus will vary somewhat, accordincr to the species and degree of distortion, in order to enable it to act°effectually upon the shortened muscles, which should be gradually and gently, but constantly extended. When the shortening of the muscles is very considerable, or the force they exert in draw- ing the foot in an unnatural position, too powerful to be overcome by an°y mechanical means that it would be prudent to employ, it is pro- bable that a division of the tendons might be advantageously resorted to but we must recollect that such division will not be sufficient to effect a cure; in no case can this be accomplished without a ong- continued use of appropriate mechanical means ;-while the latter alone, if commenced with sufficiently early, when the parts in- volved in the deformity are still sufficiently flexible and the liga- ments, aponeuroses, and bones of the foot have undergone no impor- tant changes, and when the confinement of the foot can be borne with greater ease than at a later period, will, in most cases, be fully adequate to produce a complete removal of the deformity. I.—Hare Lip. It is not our province to enter into a description of the several form soTLreU£ nor of the surgical operations^bywhich they are to be remedied. The only question in relation to them we propose to notice! is,at what period should an operation be performed; this 62G DISEASES OF CHILDREN. question will be put to the physician, and it is important that he should be able to answer it understandingly. As the deformity is always considerable, a natural feeling on the part of the parents urges them" to desire its early removal, and, in many cases, an immediate operation is absolutely necessary, in order to preserve the life of the little patient—the abnormal division of the lip, complicated, perhaps, with a division or deficiency of the bony palate, preventing the child from sucking; here, whatever risk, if there be any, is attendant upon an early operation, must be encountered, as the only chance we have by which the infant can be saved from a lingering death from inanition. If the deformity, however, does not interfere with suckling, we believe it will be better, in all cases, to defer the operation until the child has attained an age when it will be attended with less danger of induc- ing convulsions, or other dangerous consequences, and when there is a greater chance of its proving successful. The question neverthe- less, still presents itself, how long is it proper to wait before perform- ing the operation, or, in other words, what is the earliest period at which it may be undertaken, without danger to the child, or of its failure in the removal of the deformity. The end of the first or second year, is the time usually adopted for the operation. A much earlier period, however, has recently been recommended as the most suitable for its safe and efficient performance, and several cases heve been adduced to prove the ressilience of a young infant, under the operation, and the strength of its reparative powers. (Houston) The age which the gentleman just referred to considers the best for undertaking it is about the third month;—he has never seen convulsions follow its performance at this age, and he knows of no other evil conse- quences, to which the young infant is liable, to which it is not equally liable, when a year or two older. If it were not for the danger to life supposed to attend on an early operation, there would be no question at all as to the importance of remedying the defect, at the earliest age possible; the effectual remo- val of the deformity, and the inconvenience attendant on it, being then more easily and certainly effected, than when the operation is defer- red to a later period. We are persuaded with Dr. Houston, that the dangers and difficulties attendant upon early operations, are greatly overrated;—several instances of the successful removal of simple hare lip, at ages, varying from a few days, up to as many months, have been recorded within the last two years, and we have so repeatedly seen the operation performed in children, from six weeks to four months old, with perfect success, and without the occurrence of the slightest untoward symptom, that we feel it our duty to recommend its adoption very generally at the termination of the third month, or where the deformity is very great, at even an earlier period. 4.—Ruptures.—Hernia). Hernia is, by no means, unfrequent in early infancy. Children have even been born with umbilical, inguinal, or scrotal hernia, or CONGENITAL AFFECTIONS, ETC. 627 with two or more hernial protrusions. More commonly however, the protrusion takes place, within the first few days or weeks, after birth, and it is important, that it should receive early attention, as well to protect the infant from suffering or danger, as from the circum- stance, that, by proper treatment, a radical cure may then, in many cases, be effected, and thus the patient saved, in after life, from all the serious consequences invariably attendant upon this infirmity, in what- ever region of the abdomen it may be located. The most frequent form of hernia met with in the infant, is that of the umbilicus, (exomphalus) This results from the circumstance of the base of the umbilical cord, in early foetal life, forming a portion of the anterior parietes of the abdomen, and containing the greater part of the intestinal tube. In proportion as the development of the foetus is perfected, the base of the cord contracts, the convolutions of intestines, at the same time, retire within the cavity of the abdomen, and the aponeurotic sheath surrounds, and further contracts the base of the cord, allowing only a sufficient opening for the passage of the latter, with the urachus and umbilical vessels. In some instances, however, the commencement of the cord remains of a large size, and some of the convolutions of intestine continue within informing at birth a hernial sack of a round or rather conical form; the summit corres- ponding with the proper commencement of the cord, and the base, to the circumference of the aponeurotic ring at the umbilicus, (Billard) which is of larger size than natural. The hernial sack is composed in these cases of the peritoneum, with the skin and cellular tissue, more or less condensed. This hernia, though strictly congenital, may not be perceptible, until some days after birth, when the intestines become distended by aliment, and crowded downwards towards the umbilicus, by the contractions of the diaphragm, during inspiration, and the act of crying. The bulk of the protrusion varies very much; ordinarily, it is about the size of a hickory nut, but may increase to that of a walnut, or even beyond. It generally contains a convolu- tion of intestine, but may contain only omentum;—it is always larger and more tense, when the infant cries or coughs. Upon relaxing the abdominal muscles, and using gentle pressure, the contents of the sack may be readily forced back into the cavity of the abdomen, when, through the parietes of the empty sack, an aperture into which the point of the finger can be inserted, is perceptible in the linea alba. Until the separation of the cord, and the cicatrization of the navel, it is unnecessary to do any thing more than to apply, in addi- tion to the usual bandage, a compress formed of a few folds of soft linen, immediately over the umbilicus. As soon, however, as cicatrization is completed, a more effectual course of treatment must be commenced ; and the earlier this can be done, the greater will be our chances of effecting a radical cure. Our object is to keep the protrudincr bowels completely and permanently, within the abdomen, so as to°permit the natural closure of the opening, through which they escape, to take place:—the best means for effecting this, we have found to be, a portion of gum elastic of a conical shape, and 628 DISEASES OF CHILDREN. about an inch in thickness, which being neatly covered with a portion of soft muslin, is to be stitched to the centre of the ordinary belly-band. The apex, which should not be larger than the umbilical opening, is to be accurately applied over the latter, and the band fastened in the usual way. This compress should be kept on constantly, for it is only by long continuance, that we can expect any benefit to result from its employment, in these cases:—in proportion, however, as the infant advances in age, the umbilical opening contracts, the intestines acquiring too great a volume to pass through it. We have, in numer- ous instances, effected a complete cure, by the means described. Another mode of treating umbilical hernia in infants, and one that will no doubt be found admirably adapted to prevent the-protrusion of the intestines, is the application of a graduated compress, formed of while leather, spread with adhesive plaster, over tlie opening, and above this, the common flannel roller. (Maunsell.) The apex of the compress, which is to be applied next the navel, should be, as nearly as possible, of the size of the opening ; the compress should consist of three or four pieces, the largest being about three inches in diameter ; and a double stitch should be passed through them, and knotted exter- nally, so as to keep each piece in situ. We should always apply the compress with our own hands, as great care is necessary to ensure the complete return of the hernia. Unless the child exhibits marks of uneasiness, it should not be removed, until the plaster loses its adhe- sive quality, and then a new one should immediately be applied. In conducting the case, patience will be greatly exercised, as months will be required for the completion of the cure, and this should be explain- ed to the friends, at the beginning. (Maunsell) It has been recommended to apply a section of an ivory ball over the umbilicus, and retain it there by adhesive plaster, and a bandage. (A. Cooper.) To maintain an equal and constant compression, an elastic belt and pad might be found useful, in all cases. A plan originally adopted by Mr. Woodroofe, of Cork, answers, it is said, very well, when there is a small opening with a considerably elongated sack ; it is, after reducing the contents, to hold the pouch firmly between the fingers, and then to wind around it a narrow strip of adhesive plaster, commencing as close as possible to the abdomen, and continuing to the apex. This plan may succeed, by causing adhesion of the walls of the sack, which will thus form a natural truss, and prevent protrusion through the opening in the linea alba ; it can- not be employed, however, when the hernial tumor is broad and flat. (Maunsell.) It has been proposed to apply a ligature around the base of the tumor, with the view of inducing inflammation, and adhe- sion of the sides of the hernial sack. (Desault, Dupuytren) This plan, which is the one described by Celsus, though apparently well adapted to effect a permanent cure, has, nevertheless, been abandon- ed by most modern surgeons, in consequence of it being found, that CONGENITAL AFFECTIONS, ETC. 629 the patients in v/hom it was tried, are liable subsequently to a return of the hernia. (Rickerand, Riermann) In the male, congenital inguincd hernia is, by no means, unfrequent. It may exist upon one or both sides. In passing out of the abdomen of the foetus, through the abdominal ring, the testicles always carry with them a portion of the peritoneum, by which they become en- veloped, and which also forms the vaginal sack, in which they are contained. This sack may become perfectly closed at its upper part, so as to cut off all communication between it and the cavity of the omentum; often, however, it remains partially or entirely open, so as to allow a convolution of intestine, or a portion of omentum, to descend into it, the bowel being in contact with the intestine, and be- coming sometimes adherent to it. The communication between the vaginal cavity of the scrotum and the abdomen, may exist, without giving rise to hernia ; (Hassleback ;) and it is possible for a portion of intestine or omentum to descend to the bottom of the sack, although the testicle may still remain within the abdomen, or have descended no further than the ring ; (Pott;) while, again, ordinary, non-congeni- tal, inguinal hernia, with strangulation, has been observed in an infant of fourteen months. (Laicrence) It is no uncommon occurrence for the testicle, at the period of birth, to be arrested at the ring, or to have just passed through it, forming a hard rounded tumor in the groin ; we must be cautious not to mistake this for hernia, and as the testicle may remain in this posi- tion, even while a portion of intestine has descended into the sack ; the fact should always be kept in mind ; as no truss should be ever applied, until the testicle has passed fully into the scrotum. Scro- tal hernia should not be confounded with hydrocele, which is of com- mon occurrence in infants. The latter may be distinguished by its transparency, and by our being unable to feel the cylinder of the intestine rolling under our fingers, within the sack. The fluid distend- in«- the vaginal sack of the scrotum, we are to recollect, may, in many instances, be returned into the cavity of the abdomen, and when this is the case, the size of the hydrocele will be increased when the infant cries or coughs; but with a very little care, such swellings may very readily be distinguished from congenital or accidental hernia. As a general rule, there can be very little certainty as to the existence of the latter, until the testicle has descended into the scrotum. (Billard.) A curious case is related of congenital inguinal hernia in a female infant: (Billard:)—ihere existed, in this instance, in the left inguinal re-ion, a rounded tumor, about the size of a filbert rather hard to the touch/and incapable of being returned into the abdomen, or diminish- edby pressure/ neither was^it enlarged by the crying of the child. The tumor wa directed obliquely towards; the abium of the same size buTdid not quite reach to it. The child died from pneumonia, when i was found, that the tumor was a real hernial sack, containing Jhe left ovarium, and frimbriatcd extremity of the fallopian tube, a tie reddened and swollen. These had descended, and passed 630 DISEASES OF CHILDREN. through the inguinal canal and ring; which latter was much larger than it usually is in the female infant, and were contained in a sack formed of a prolongation of the peritoneum, with the cavity of which it communicated. There were no convolutions of intestine adhering to the surrounding parts:—the right ovarium was in its usual situation;—the round ligament of the uterus on the side, at which the ovarium had descended, was much shorter than that on the opposite side, and terminated, in the labium, by an aponeuro- tic expansion, instead of losing itself in loose filaments, as usual. Hence, it would appear, that the shorter and more firmly attached ligament had first caused the uterus to incline towards the left side of the bladder, and then drew with it the ovarium through the inguinal ring. In the treatment of congenital inguinal hernia, the same objects, precisely, are to be had in view, as in the treatment of that of the the umbilicus, namely, to retain permanently the protruding bowel within the cavity of the abdomen, and to favour the natural closure of the ring. The child should be kept as tranquil as possible ; it should be restrained, by every means in our power, from violent paroxysms of crying, and from all exertion likely to increase the protrusion. When the hernia is present at the period of birth, or appears soon after, it should be at once reduced, and a temporary bandage is, then, to be applied with a small compress upon the abdominal ring ; but little compression, however, should be at first resorted to, and the bandage and compress should be frequently changed, as well from a due attention to cleanliness, as to prevent the irritation of the skin, which would otherwise speedily result from their being constantly wet, and soiled by the natural discharges. As soon, however, as the infant is of sufficient age to allow of it, a properly constructed truss should be applied, and constantly worn. From the smallness of the pelvis, before the end of the first year, and the difficulty of keeping the straps from being continually wet, and causing, in consequence, chaffing of the parts, with which they, are in contact; it is scarcely possible to get any truss to fit, or to keep it on sufficiently constant, previous to that period, and even then we will often be completelyfoiled. (Maunsell) We have, in fact, seldom seen much good result from a truss, or any other retentive apparatus, excepting a simple bandage and compress, before the third or fourth year. Attention should be paid to preserve the bowels of children affected with hernia, freely and regularly open. If the hernia should become the seat of inflammation, indicated by increased tumefaction, pain, and tenderness upon pressure, leeches should be immediately applied, in numbers adapted to the age and strength of the child; the warm bath should be employed ; the tumor covered with a light emollient poultice, and the bowels freely evacu- ated by castor oil or mild laxative enemata. Should the hernia become strangulated, an operation will become necessary ; provided, we are unable to procure a reduction of the tumor, by the means just indicated. CONGENITAL AFFECTIONS, ETC. 631 Besides the herniae resulting from the escape of a portion of the bowels, at one or other of what are termed the natural openings in the walls of the abdomen, they may also be produced by a congenital deficiency in the parietes of this cavity. This usually occurs near the umbilicus, and on the median line. The integuments are sometimes wanting around the umbilicus, and the sack, enclosing a portion of intestine, is formed by the base of the cord alone ; this covering is sometimes so thin, that the intestine may be seen through it. In a case of this kind, a permanent occlusion of the umbilical opening was produced by reducing the intestines, the return of which was pre- vented by an assistant, compressing the cord close to the abdomen; when a compress, formed of circular pieces of leather spread with ad- hesive plaster, laid one upon another in a conical form, was placed upon the navel; the skin upon each side of the aperture was brought into contact, one lip slightly overlapping the other, and the whole was secured by a linen belt with a thick quilted pad, of a circular form, applied over the navel.—The bandage was renewed occasionally. By these means, the intestine was securely retained within the abdo- men, and at the expiration of a fortnight, after the separation of the funis, the aperture at the navel was so far contracted, that not the least protrusion was occasioned even by the crying of the child. (Hey) , , , . , This case will sufficiently indicate the general plan, upon which the irregular herniae occurring during infancy, are to be managed; of course, slight modifications will be required in particular cases, which the good sense of the practitioner will readily suggest. Ear y and judiciously treated, nearly all of these herniae may be permanently removed; whereas, if neglected or improperly managed, they may entail a serious infirmity, that will last, as long as the individual ^Arrest of the Testicle. As closely connected with the subject of congenital inguinal hernia, a few words will be proper, m this plac*e, in relation to a not unfrequent occurrence, from which we have repeatedly seen a very considerable amount of suffering re- sult, we allude to the arrest of the testicle at the abdominal ring, or in the groin, in its passage from the abdomen. In this situation, it frequently becomes inflamed, which after causing severe pain some- tmTs (/several days continuance, attended wit i considerablefebrile reaction, and occasionally with tension and tenderness of the abdo- men, nausea, or vomiting, obstinate consupation,and the other syrup toms of peritoneal inflammation, produces, in the gro.n or at the rin- a small, intensely red tumor, exquisitely painful to the touch, and upon' eve?v motion of the patient's body-in this, suppuration sooner nrPhter occuis forming an abscess of considerable size. This in- flamSion is o/t°e„ atfended with complete disorganization of the ^The'treatment consists in leeching, warm bathing, and emollient poultice-1J th!J groin, laxatives by the mouth, and gentle purgative 632 DISEASES OF CHILDREN. enemata. The child should be kept as much as possible at rest, and as soon as an abscess forms, it should be opened. 5.—Vaginal Hemorrhage. In many cases, a discharge of red fluid blood takes place from the vulva of the new-born female infant, and continues, without interrup- tion, for several days or even weeks, after birth. This sanguineous discharge is unattended by redness, swelling, or any other indication of the existence of the least degree of irritation in the vagina, or external parts of generation; nor do the functions and general health of the child appear to suffer any derangement. It is very difficult to understand the cause of this discharge, not- withstanding the extreme vascularity, amounting often to a perfect hyperaemia of all the mucous surfaces in early infancy ;—we can trace the excretion of blood, in these cases, to no very evident exciting cause, unless we adopt the explanation that has been offered, which attributes it to the same physiological cause which, in after life, pro- duces the catamenial discharge—nature appearing to anticipate, in some degree, the establishment of a function which is fully developed and regulated, only, at a much later period of life. (Ollivier, of An- gers) This suggestion would appear to derive some support from the character of the discharge, which has certainly much resemblance to the catamenial flux in the adult female. The discharge always ceases of itself, and requires no particular treament; the preservation of perfect cleanliness by repeated ablu- tions of the vulva will, of course, be necessary. The alarm and anxiety which this discharge almost invariably excites in the mother, and those about the child, should be quieted by an assurance, that, in no instance, so far as we are aware, certainly in no instance that has fallen under our notice, has any inconvenience resulted from it; nor has it ever continued beyond the first few weeks, after birth. G— Inflammation and ulceration of the Navel. Within the first nine or ten days after birth, inflammation and sub- sequent ulceration of the navel is very liable to occur, if the utmost attention is not paid to prevent it. Upon the separation of the cord, instead of a quick and perfect cicatrization succeeding, the navel remains raw, and soonbecomes irritated and inflamed, presenting a deep red, ulcerated surface, and an inflamed condition, to a greater or less extent of the surrounding skin. A thin, purulent, and often offensive dis- charge takes place from the surface of the ulcer, and the infant evi- dently suffers considerable pain, as evinced by its general fretfulness, and its cries when the ulcer is examined or accidentally touched. In some cases, the navel presents an elevated ulcerated surface, with somewhat prominent edges; in these, the discharge is generally the most profuse; in other cases, a kind of fungus excrescence of a CONGENITAL AFFECTIONS, ETC. 633 dark red colour protrudes from the centre of the navel, without any appearance of ulceration, and with but little discharge, and scarcely any inflammation of the surrounding skin. We have often, indeed, seen the skin up to the very edge of the umbilical depression perfectly natural. The fungoid tumor, which generally bleeds upon the slight- est irritation, may either present a narrow base with a round expand- ed head, like a cherry, or a broad base, tapering gradually towards the summit, being more or less conical in form. (Dewees.) Ulceration of the navel, as we have already remarked, is very generally the result of neglect or mismanagement on the part of those who wash and tend the infant; in a few instances, it is true, it may result from a slow and imperfect separation of the cord, in conse- quence of which it remains long attached by a thin, firm filament, and causes a constant irritation, by which the healing of the navel is prevented, and ulceration induced. More commonly, however, it is produced by rude management in washing and dressing the child, previous to the coming off of the cord, or by rude dragging or other im- proper attempts to facilitate its separation, or by the ridiculous prac- tice of dressing the navel subsequently, with a burnt rag, grease, and even more improper applications. It may, also, arise from inatten- tion to cleanliness, in the first washing of the child, in consequence of which a quantity of the vernix caseosea is left upon the skin, surround- ing the umbilicus, which soon acquires an irritating character. From peculiar irritability of the skin, some infants are more liable to ulceration, or rather tardy and imperfect healing of the navel, than others. In all cases, the utmost attention should be paid to cleanliness. The navel and surrounding skin should be carefully washed, at least twice a day, with lukewarm water, and then wiped perfectly dry with a soft linen cloth. If the cord still remains attached by a thin fila- ment, the division of this, and the removal of the cord, will often be sufficient to allay the irritation, and thus allow the navel to cicatrize. (Deuees) When the ulceration is superficial, without much inflammation, washing it with a little rose water, twice a day, and dressing it, as often, with the ceratum zinci oxydi impur. spread upon a soft rag, will often cause it promptly to heal; or, if this should not succeed in caus- ing cicatrization, the ulcer may be washed daily with a solution of sulphate of copper," and then dressed with the same salve. In slight cases, by sprinkling the ulcerated surface with finely pow-dered oak bark or galls, we have repeatedly found cicatrization to take place very promptlv, without any other dressing. If the ulceration should still'show no disposition to heal, it may be washed with a weak solu- tion of the nitrate of silver, and dressed with an ointment formed of lard and the acetate of lead." In aggravated cases of ulceration at the navel, prompt and very decided benefit is said to be derived from applying to the ulcerated surface, three or four times daily, by means of a soft hair pencil or feather, a linement made by slowly simmering the 634 DISEASES OF CHILDREN. coarsely powdered root of the wild indigo, (baptisia tinctoria) in cream, and afterwards squeezing it through a thick piece of muslin or flannel. (Eberle) aR.—Sulph. cupri, gr. x. bR.—Acetat. plumbi, 9j. Aq. purse, 3j.—M. Axung, 3j.—M. In all cases, however, in which the ulceration is attended with con- siderable inflammation, extending to the surrounding skin—stimulating applications of every kind should be withheld, until this inflammation is reduced by soft emollient poultices, and frequent washing of the inflamed skin with a solution of the acetate of lead. In some in- stances, we have seen the inflammation in cases of ulceration of the navel, so extensive as to demand the application of a few leeches. It is not unfrequent for the bowels of infants affected with ulcerated navel, to be considerably disturbed, the passages being frequent, thin, and attended with griping;—whenever this is the case, the adminis- tration of very minute doses of calomel and ipecacuanha combined with a few grains of magnesia, with the daily use of the warm bath, will be demanded. When a fungoid tumor forms or protrudes from the navel after the separation of the cord, if it have a narrow base, we may readily remove it by a ligature applied around its pedicle, sufficiently tight to arrest the circulation, without cutting into its substance; (Dewees;) the tumor usually separates in the course of a few days, when the ulcerated surface may be washed with a solution of sulphate of zinc,' or dressed with the ointment of acetate of lead. It is seldom, how- ever, that the separation of the tumor, by means of the ligature, is attended with any permanent benefit; very generally, the fungus growth will recur to as great an extent as at first:—it is better, there- fore, to treat it at once by astringent applications, as the decoction of galls or oak bark, solutions of the sulphate of copper or zinc, in the proportion of one drachm to the ounce of water ; or, we may sprinkle the surface of the tumor with finely powdered oak bark or galls, and wash carefully, night and morning, with lukewarm water. It is said, that the root of the sanguinaria canadensis, in fine powder, is an admirable application, for the removal of these fungoid growths. When the tumor is soft and spongy, and not invested by a membrane, applying to its surface daily, by means of a camel's hair pencil, a pretty strong solution of the nitrate of silver, will generally destroy it, in a few days, and allow the navel to cicatrize. aR.—Sulph. zinci, gr. xv. Aq. purse, 3j-—M. 7.—Intumescence and Inflammation of the Breasts. Infants of both sexes are very liable to a tumid, hard, and painful condition of the breasts, which is occasionally present at birth, but more generally presents itself a day or two subsequently, and is, in CONGENITAL AFFECTIONS, ETC. 635 some cases, attended with a degree of redness and inflammation of the external skin. This affection, even when the swelling and hard- ness are very considerable, after continuing for a week or two, with- out any sensible abatement, will then, very generally, subside entirely. Unfortunately, however, a vulgar notion being prevalent among mothers and nurses, that the swelling is the result of milk in the breasts, which it is necessary, by all means, to draw or squeeze out; an opinion that is confirmed, as they suppose, by the escape some- times, of a white coloured fluid, resembling milk, at the nipple, causes them, not unfrequently, to resort to very rude measures to get rid of the offending fluid, in order that the infant's breasts may be cured. The consequence is, severe inflammation, followed by suppuration, and the formation of an abscess; many cases of this are on record, and we have ourselves met with a number. Even the entire substance of the female mammae has, in this manner, been destroyed. The intumescence of the young infant would appear to be the result of a sub-acute inflammation, attended with serous infiltra- tion of the cellular tissue of the part. (Weber.) Occasionally, the inflammation extends to the substance of the mamma, and the skin by which the gland is covered, becomes very tense, shining, and of a dark-red colour. Even this aggravated form of the disease will very generally give way in a few days, to the simplest treatment; and we do not recollect having ever seen a case which was attended with any degree of trouble, or any great or pro- longed suffering, and certainly no one which showed any tendency to terminate in suppuration, excepting when the tumor has been sub- jected to the rude and unjustifiable processes adopted for the removal of the stagnant milk. All that would seem to be required in the generality of cases, is to anoint the tumor daily, with a little sweet-oil, or fresh lard, and to cover it with a soft piece of tolerably thick muslin. When, from any cause, considerable inflammation, pain, and swelling of the breasts take place, the case should be treated by a few leeches, and the application of soft emollient poultices. ..-,., ■, • A weak solution of the hydrochlorate of ammonia, in diluted vine- gar,' has been proposed as a prompt and certain application in the ordinary form of this affection; we have never used it ourselves, but we have no doubt that it will prove beneficial. aR.—Hydrochlorat. ammonire, 3ss. Aquas Acid. acet. impur. aa gij.—M. To be applied warm, by moistening pieces of soft linen rag wlth it, and lay.ng them upon the affected parts. {Eberle.) It would be well for the practitioner himself to examine daily for the first three or four days after birth, the breasts of the infant in order to detect^mediately any swelling that may occur ; and when it does appear, to direct the proper measures to be pursued, forbid- di^ posftively, at the same time, any attempt being made on the 636 DISEASES OF CHILDREN. part of the nurse or other attendants, to squeeze or draw out •• the stagnant milk," which, in their opinion, is the cause of the swelling. 8.—Haemorrhage from the XiiYd. Haemorrhage may take place from the cut end of the cord, in con- sequence of the imperfect manner in which this has been tied, or the improper materials of which the ligature is composed ; from improper handling, on the part of the nurse in adjusting the dressing of the naval, by which the ligature is displaced ; or, more rarely, from the thick, firm, gelatinous matter, with which the vessels of the cord are eveloped, preventing the ligature from acting with sufficient force upon them to cause their closure ; the prevention and remedy in this form of haemorrhage are sufficiently evident. But the haemorrhage does not always result from the divided end of the cord ; we have in several instances found the umbilical vessels perfectly secured, but a constant oozing or percolation of blood to take place around the root of the cord, at the part where it is implanted in the walls of the abdomen, and in only one instance were we able to arrest the flow of blood ; in all the other cases the patients perished exanguinous. In the instance alluded to, we directed a powder to be formed of starch, two parts, sugar one part, with an addition of powdered ace- tate of lead, amounting to one-half the quantity of sugar3; this powder was applied around the cord, at the seat of the haemorrhage, and an additional quantity constantly added as the blood penetrated through the former; after three hours close watching, a firm crust was formed, through which the blood no longer penetrated; at the end of twenty-four hours, the crust separated, without the haemorrhage return- ing. We tried this plan in another case without success; the blood flowed too freely to allow of the proper hardening and adhesion of the paste formed by its mixture with the powder, but flowed through, as well as beneath it. *R.—Amyl. 3ij. Sacch. alb. 3j- Acetat. plumb. 3$s.--M. Another, though more rare, still not uncommon form of umbilical haemorrhage in young infants, in which the flow of blood takes place from the sTde of the cord, in consequence of a rupture or ulceration of one of the varicose dilatations of the umbilical veins, is not unfre- quently met with. (Dewees.) We have seen one or two such cases. The arrest of the haemorrhage is, in general, very easily effected, by the application of a ligature around the cord, below the place at which the blood is discharged. In one instance, however, from this being situated near the base of the cord, we found a good deal of difficulty in applying the ligature, and only succeeded, finally, by drawing out the cord until the skin surrounding it was put upon the stress. °The ligature appeared at first to cause no inconvenience, to CONGENITAL AFFECTIONS, ETC. 637 the infant, but towards the close of the second day, so great a degree of pain was evidently produced by it, that we were induced to divide it; the haemorrhage, however, did not return. There is still another form of haemorrhage that occasionally occurs at the navel, and is sometimes attended with a good deal of trouble, and often endangers the life of the child. This takes place after the sep- aration of the cord:—in place of the navel cicatrizing, it remains open, and a soft fungus rises from its centre, from which there is a constant oozing of blood, that may continue for a long time, causing, by the extent of the haemorrhage, the utmost debility of the child, and putting his life often in imminent danger. The application of lunar caustic may stop, for a time, the discharge of blood, but we have never known it effectually to arrest it. We have occasionally succeeded by pursuing the plan recommended by Underwood, namely, the application of a dossil of lint, kept in its place by cross-strips of adhesive plaster, and secured by the proper adjustment of the belly-band; more frequently, however, we have found that covering the navel with the powder of starch, sugar, and acetate of lead, and then applying over this a graduated compress, secured by a broad bandage, passing around the child, more effectually prevented the discharge°of blood, and allowed the navel to cicatrize. However trifling these haemorrhages may appear when described in books, and however easy it may seem to the inexperienced to arrest them, they nevertheless are among the most troublesome accidents occurring in young infants, that the practitioner is called upon to treat, and will often foil the best directed efforts for their removal. 9.—(Edema of the Prepnce. The cellular structure of the prepuce, in the male infant, is occasion- ally the seat of a serous effusion, bv which this part becomes sometimes enormously distended, and very hard to the feel; in a few instances, we have found the whole of the integuments of the perns to be simi- larly affected. When the prepuce is retracted behind the glans penis, a species of paraphymosis is produced, and we have known con- siderable difficulty to be experienced in the passage of the urine, from the stricture upon the urethra thus occasioned; a similar difficulty may also result when the tumefied parts envelope the glands, from the closure of the prepuce; ordinarily, however, the intumescence gives little or no trouble, and is unattended with pain or suffering, and generally disappears spontaneously. We have known it, how- ever to continue for a very long time, with little or no abatement Altho°h we have arranged oedema of the prepuce among the dis- easesoccurring within the month, it is by no means confined to this period? Z"have met with it frequently, in children of from one to "'Vhrclus^of this affection it is, in many cases, somewhat difficult 638 DISEASES OF CHILDREN. to trace. It vrould appear to be occasionally produced by an irrita- tion seated within the urethra, as a stone slicking in the canal, (Under- wood) or a small splinter of wood or fragment of straw, intro- duced by the child. In one case we saw it produced by a por- tion of thread that the child had wound around the end of the penis. It is occasionally connected with an erysipelatous affection of the integuments of the penis and scrotum, and not unfrequently we have found it accompanied with a herpetic eruption around the external skin of the prepuce at the point of duplicature. In some cases it is attended by a discharge from writhin the prepuce, resembling a strong lather of soap, or the froth of milk; this is evidently caused by the retention of the natural discharges of the part, rendered perhaps more copious from the irritation of the urine, which often fills the cavity of the prepuce before it is discharged externally; the discharge almost invariably disappears as soon as the tumefaction subsides. In the treatment of this affection, if the tumefaction be not very extensive, and it presents no difficulty or impediment to the discharge of the urine, little else is required than to wash the part frequently with camphorated spirits, and an equal quantity of water, or with two parts of the aqua comphorata and vinegar, or to envelope the prepuce in crumb of bread moistened with a weak solution of the acetate of lead. In all cases it will be proper to examine the urethra, and if a stone or other foreign substance be found in the passage, to extract it. If the oedema be very extensive, and the free discharge of the urine is interfered with; the best plan is to slightly scarify the skin at the most depending portion of the tumor, and foment it freely with tepid water. When connected with an erysipelatous inflammation of the penis and scrotum, this should be treated by its appropriate remedies; and in cases in which a herpetic eruption is present, the application to this, night and morning, of a little of the unguentum nitratis hydrar- gyri, diluted with an equal quantity of fresh hog's lard, wre have found to be generally sufficient for its speedy removal. 10.—Hydrocele. Hydrocele, in infants, may result from the distention of the vagi- nal sac of the scrotum with serum ; the communication between this sac and the cavity of the abdomen being obliterated, or still con- tinuing open ;^-or the accumulation of serum, may be confined to the vaginal tunic of the cord, without any communication with the scrotum or abdomen, or with a free communication with the latter. The diagnosis is somewhat different in these different cases. In hydrocele of the vaginal sac of the scrotum, the tumor is somewhat transparent, and the testicle, if it has descended, may be felt near its inferior posterior part. If no communication exists between the sac and abdomen, the swelling undergoes no change in its dimensions, during crying or coughing; but usually, gradually augments in size, pre- CONGENITAL AFFECTIONS, ETC. 639 senting akind of pyramidal form, with the apex towards the ring; andby the integuments of the scrotum being put upon the stretch, their natural rugosity is obliterated, and they become smooth, pale coloured, and shining. When,however, a communication stillexists,between thescro- tal and abdominal cavities, the tumor increases in size when the child coughs or cries; and pressure upon the tumor will cause the serum by which it is distended in great part or entirely, to pass upwards into the abdomen; but it immediately returns upon the pressure being removed. In this case, our diagnosis is to be founded upon the semi- diaphanous character of the swelling, the presence of fluctuation, and the inability to feel within it any fold of intestine, or portion of omen- tum. In hydrocele of the cord, the tumor most generally occupies a situation midway between the testicle and groin; it is of an oblong figure, perfectly circumscribed, and generally very tense;—it under- goes no alteration from change of posture, or during coughing or sneezing. It may be accompanied by an inguinal hernia, and by hydrocele of the scrotal sac, in which case the true character of the disease is rendered very obscure, and its existence is, with difficulty, detected. When the hydrocele is situated higher up upon the cord, it often extends upwards" within the ring, or by gentle and continued pressure may be made to recede within it, but immediately returns upon the pressure being removed. With the exception of a slight dragging sensation, which is the greatest when the hydrocele is low down upon the cord or in the scrotal sac, these tumors are unaccom- panied either by pain or uneasiness. The hydrocele is very generally confined to one side ; occasionally, however, it occurs on both. , . , In some cases, children are born affected with hydrocele either of the scrotum or cord ; most generally, however, it is not noticed until four or five days, and sometimes even longer, after birth. Children are also liable to the occurrence of hydrocele at a later period, from the same causes which produce it in the adult. Notwithstanding the alarm to which these swellings, in infants and young children, give rise in the minds of the parents and those connected with the patient, they are seldom of much importance, and often disappear, after a time, spontaneously. . , . In youno- infants, frequently sponging the tumor with a weak solution of the acetate of lead, or with a mixture of two parts of aqua campho- rata and one of vinegar is, perhaps, the only treatment that it is proper to pursue. If, under this treatment, the swelling does not disappear, when the child has arrived at twelve or eighteen months of age, as well a in those cases in which the swelling appears late in infancy, or durin- childhood, the effusion of cold water-the water being Poured u?on the hydrocele out of a tea pot, and from a height-four oTf ve times a day, will very generally cause its dispersion (Pkysrck, 01 live times a■* % > f be unremittmgly persevered in for a Dewees.) The ell us on m have> in re eated instances, 7etTfoZlietel^ The effects of the cold water may be 640 DISEASES OF CHILDREN. increased, in children over two years of age, by brisk purging,' and a simple farinaceous diet. »R.—Bi-tart. potasses, 3"ij. 1'ulv. jalup, J5j —M. f. ch. No. xij. One of which may be given every day, or every other day, according to the effects pro- duced upon the bovvels.- Where the hydrocele is of considerable size, and, in place of dimin- ishing, continues steadily to increase in bulk, we have found that puncturing the tumor, and allowing the water gradually to drain off, has, after one or two repetitions, produced a radical cure; we have, also, seen the introduction through the tumor of a seton com- posed of a few threads of floss silk, effect a perfect cure, as well in cases of scrotal hydrocele, as of hydrocele of the cord, without the occurrence of much pain, or any disagreeable symptoms. The ends of the seton should be loosely tied together, and a thread drawn out every second or third day, until the whole is removed. The discussion as to the particular circumstances under which it may become necessary and proper to resort to the usual surgical means for effecting a cure of hydrocele in the child, by causing the obliter- ation of the cavity of the tunica vaginalis does not come within the scope of the present treatise. 11.—Fractures. Fractures of the bones of the extremities are sometimes pro- duced during birth, especially in cases where, from a mal-position or presentation, turning, or 'other manual interference, is requir- ed • we have known the fracture of the humerus repeatedly take place by improper and unskilful attempts to bring down ihe arm in cases of ordinary labour. In all cases in which the accident has, unfortunately, taken place, the fact should be at once explained to those who have the care of the infant, and measures immediately taken, after the child is washed, to secure the fractured extremities in apposition, by a proper bandage and splints. What we have found to answer perfectly well, even in fractures of the thigh in the new- born infant, are, narrow strips of thin pasteboard, well moistened in warm water, then neatly enveloped in soft linen, applied to the limb, after the proper adjustment of the latter, and secured in their place by a proper bandage. These splints, if made sufficiently soft, mould themselves to the shape of the limb, and when they again dry, pre- sent a sufficient resistance to the feeble action of the infant's muscles. It is necessary, however, to watch carefully the limb until the dry- ing of the splints, lest in handling the child it be accidentally bent at the place of fracture, or the fractured extremities of the bone otherwise displaced. Fractures in infants heal rapidly and promptly, and give little inconvenience, if properly secured :- as nutrition at this period is rapid, reparation takes place also readily ; a child may suffer more, and incur more danger from cutting a tooth, than a new- born infant from fracture of the femur or of the humerus. (Blundell.) CONGENITAL AFFECTIONS, ETC. 641 0.—Cohesion of the Labia and Nymphae. In female infants there is, occasionally, an adhesion of either the labia or nymphae ; but much more frequently of the latter. This cohesion may be congenital, or occur some time after birth. The cohesion of the labia, when present, is easily detected. In some cases it is so slight as to give way upon the mere separation of the labia; in others, it is produced by a very firm but delicate and transparent membrane, extending across from the inner surface of one labium to that of the other, for the division of which, the aid of the knife will become necessary; in other cases, again, the adhesion of the labia is more intimate and extensive, and requires a cautious use of the knife for its removal; finally, there may occur a complete occlusion of the external orifice of the vagina, which is usually connected with a defi- ciency of some one or all of the internal sexual organs. In all these cases' of cohesion of the labia, excepting the last, the sooner it is removed the better ; but when a complete closure of the vagina hap- pens from a congenital and perfect fusion of the two labia, no opera- tion should be attempted previously to puberty, unless we are able certainly to determine that the vagina or uterus is not wanting, inas- much as the child would otherwise be subjected to a severe and fruitless operation. By waiting, however, until the period of puberty, we shall then be able to decide with tolerable certainty, as to the existence or non-existence of the internal organs, and, consequently, as to the propriety or non-necessity of an operation. Adhesion of the nymphae is much more common than cohesion of the labia, and requires for its detection, a much closer inspection. (Blundell.) When the nymphae cohere, upon the separation of the labia, they are extended in such a manner as to form a flat, continu- ous covering to the orifice of the vagina, and by the blood being pressed out of their tissues when they are thus put upon the stretch, they become pale, and scarcely to be distinguished from the sur- rounding surface; hence, at first view, it appears as though the nymphae were wanting, and there existed no vagina; but by gradually approximating the labia, the nymphae assume their usual form and situation; a probe may also be passed behind them and the entrance to the va'tina, and if the cohesion was not congential, we may learn from thenurse, that the opening into the vagina was the same, at first, as it is in other infants. Cohesion of the nymphae, the same as of the labia, may often be destroyed bv the mere separation of the labia, or a probe being passed behind the coherent nymphs, and made to bear upon the line of Juncture, this may often be gently torn asunder, by merely drawing the instrument towards us; in some cases, however, the adhesion is so intimate and firm as to require the aid of the knife. Care must always be taken by the interposition of a portion of soft linen, mois- tened with sweet oil, or fresh lard, to prevent the divided surfaces from again adhering. 642 DISEASES OF CHILDREN. Simple cohesions of the nymphae should be remedied at an early period. The longer they are left, the more difficult, in general, does their removal become. li—Burns and Scalds. Burns and scalds are among the most frequent accidents that occur during the latter period of infancy, and during childhood. The care- lessness of parents and servants, the natural temerity and incautious- ness of children, and the necessity, in the ordinary mode of warming our apartments, of children being brought in close proximity to the open fire, or heated stoves, render these accidents of such frequent occurrence, that no winter passes without our seeing a number of children who have suffered from them. They occasionally happen under circumstances where they were the least to be anticipated :— infants being left for a few moments alone, have crawled or climbed to parts of the room where vessels of heated water were standing, which they have overturned upon themselves:—some of the most serious scalds in children that we have have been called upon to treat, have been produced in this manner. There is a very great variety in the character and extent of these accidents, which requires some modification in their treatment. The burn or scald may produce a simple and very circumscribed inflam- mation of the skin ; or an inflammation accompanied with vesica- tion ; or the cuticle may be completely removed to some extent; or the whole of the integuments of a part may be entirely destroyed. The pain and suffering are always greater in superficial burns than in those attended with an entire destruction of the cuticle. Burns which involved a very large portion of the surface, would appear to bo attended with no pain whatever;—the patient, if old enough, com- plains of a feeling of chilliness or cold, and is strongly inclined to sleep. There is, in all extensive burns, immediately upon their occur- rence, a very great depression of the whole of the. vital powers, which continues for some time before reaction takes place; while, in other cases, no reaction whatever occurs ; the patient falls into a deep comatose sleep, from which he never awakes. The danger from burns is always in proportion to their extent, taken in connection with their depth;—but even superficial burns, seated on certain portions of the body, are attended with very great, and sometimes immediate danger. Thus a burn, of even small extent, upon the head or stomach, has been known to produce very speedy death. (Pkysick) In superficial burns, in which there is produced a simple redness of the skin, the best immediate applications are, cold water, vinegar, or any alcoholic liquor. The application of these fluids must be unre- mittingly persevered in ; they always relieve the intense smarting with which these burns are attended ; and often very speedily allay the inflammation When nothing else is at hand, the common potatoe, CONGENITAL AFFECTIONS, ETC. 643 scraped or mashed into a pulp, without its being boiled, will often be found beneficial. After the cold application has been continued for some time, the injured part may be lightly covered or wrapped with loose cotton. This has always a soothing effect. If any considerable degree of inflammation still continue, we have found the best applica- tion to be a liniment composed of fresh lard and acetate of lead.* After all, however, even in the most superficial burns, our own expe- rience would lead us to recommend, in all cases, the immediate application of the spirits of turpentine;—it removes, at once, the smarting pain, prevents vesication, and we have often been surprized at the rapidity with which, under its use, the inflammation entirely subsides. To derive, however, these advantages from the turpentine, it must be applied without the least delay. In extensive burns, it ought, invariably, to be preferred to every other local application. t0 b^often tion, of --la^tfi^niXly separated, a a very useful one. When the aeau pa d u „ranuiations simple bread-and-milk poultice should^be agpUed^ un q. S^ of the begin to form, when the ulcer may be: diessed * adhesive oxyde of zinc; and if cicatmationi,s longnf^\^ ;meor an strips should be applied, and the pait subjected P appropriate bandage. . , neighbourhood of parts pos- P1I„ ill burns situated nearjoort ,o.n l^e*.| ^ F^ rf sessing a good deal of motion.caie suou 644 DISEASES OF CHILDREN. healing,toprevent,asmuch aspossible.by the use of splints and bandages, any deformity, from the contraction of the first, or the drawing of the latter out of their proper place; for one of the peculiarities of the cica- trices of burns is, the formation of firm, elevated ridges, by the gradual contraction of which, the utmost deformity, or even the entire loss of the use of a limb may be occasioned. Even by the best devised means, it will often be impossible, in extensive burns, to prevent this occur- ring to a certain degree; nevertheless, the extent of the deformity may be greatly diminished by proper care and attention. When the burn is seated upon the hand or foot, or in the vicinity of the ear, caution must also be observed to prevent the unnatural adhesion of the fingers to each other, or of the ear to the side of the head. During the healing of extensive burns, a rapid formation of fungous granulations very commonly takes place; nor is it possible entirely to restrain them by the application of pressure, caustic or other escharo- tics. The first, however, we have found, in general, the most suc- cessful ; it may be applied, by covering the ulcer with a pledgit of dry lint, and then enveloping it with a bandage; in some cases, the adhesive strips and bandage, will answer very well. If an escharotic is used, the best will be, perhaps, the nitrate of silver; we must con- fess, however, that we have seldom seen much good result from its application. As we have already remarked, in all extensive burns or scalds, there is a very great depression of the vital energies; the patient complains of a feeling of chilliness, and is usually inclined to sleep; we have seen a child, immediately after being scalded, shiver as though he were exposed to a very considerable degree of cold. In such cases, a dose of the camphorated tincture of opium, adapted to the age of the patient, will be proper; or if the depression is very great, a few drops of Hoffman's anodyne and spirits of camphor, com- bined, may be given, and the child should be placed in a room of a moderately warm temperature. The moment that reaction takes place, every thing whether in the form of food, drinks or medicine, of a stimulating character, should be withheld. In some cases, a restricted diet, purgatives, and even bleeding, will be required, in consequence of the extent of the local inflammation, and the degree of febrile reaction with which it is attended. INDEX. A. Acne, 506. Adipous tissue, induration of the, 515. Affective faculties, state of in infancy, 80. Air, importance of pure, 20. 577. cold and damp, injurious effects of, 22. 556. overheated, injurious effects of, 23. impure and stagnant, productive of disease, 96. 555. Alopecia, 523. Amusements for children, 55. Aneurism by anastamosis, 550. Anger, bad effects of when excited in civil- dren, 61. Angina externa, 170. polyposa or membranacea, 294. Anginose scarlatina, 416. Ani, prolapsus, 224. Anuria, 606. Anus, imperforate, 191. Apoplexy, 34!. Aptha lactumina, 126. Apt/ice, 130. Arachnoid cavity, hemorrhage of the, 3 the notice and pat™na6f £ bei imraediately under the novel and convenient; each page »■perfe« »n •«£"• *5 0bvi«eVthe necessity of continual refur- figures, so that the eye takes in the who e at a glance, and obviates ^ „^e J^ ^^ ^ ence backwards and forwards. . Th\cuts are sei^eciea irom u« Anatomical collection of the iffiiWfiS^ aT Samcf a,f X M^nrU. arising from the us"oFthVeamrcrosncopee in the investigation of the minute| B^cture of tw^e.- . in the getting up of V"8^.^ they hope* win meet their approbation in their endeavours finish i^Vt^ession wun u™ » « » novelty of design and great per- CYCLOPEDIA OF PRACTICAL MEDICINE. LEA AND BLANCHARD, PHILADELPHIA, WILL PUBLISH THE CYCLOPAEDIA OF PRACTICAL MEDICINE: COMPRISING TREATISES ON THE NATURE AND TREATMENT OF DISEASES, MATERIA MEDICA AND THERAPEUTICS, MEDICAL JURISPRUDENCE, &c. &c. EDITED BY JOHN FORBES, M.D.,F.R.S. Physician in Ordinary to her Majesty's Household, dec. ALEXANDER TWEEDIE, M.D.,F.R.S. Physician to the London Fever Hospital, and to the Foundling Hospital, &c. JOHN CONOLLY, M.D. Late Professor of Medicine in the London University, and Physician to the HarrweQ Lunatic Asylum, &c. THOROUGHLY REVISED, WITH ADDITIONS, BY ROBLEY DUNGLISON, M.D. Professor of the Institutes of Medicine, &c. in the Jefferson Medical College, Philadelphia, Lecturer on Clinical Medicine, and Attending Physician at the Philadelphia Hospital; Secretary of the American Philosophical Society, &c. TERMS OF PUBLICATION. THE WORK WILL BE PRINTED WITH A NEW AND CLEAR TYPE, AND BE COMPRISED IN TWENTY-FOUR PARTS, AT FIFTY CENTS EACH, POBMIKO, WHEN COMPLETE, FOUR LARGE SUPER-ROYAL OCTAVO VOLUMES, EMBRACING OVER THREE THOUSAND TTNUSUALL7 LARGE PAGES, IN DOUBLE COLUMNS. ««« T„,rntu Dollars, free of postage, in Current Funds, will be entitled to ,.XC0T£Tho,e"LTrS^»„,p^ d»H„« the ^ .844. PUBLISHERS' NOTICE TO THK CYCLOPAEDIA OF PRACTICAL MEDICINE. This important work consists of a series of Original Essays upon all subjects of Medicine, contri- buted by no less than SIXTY-SEVEN of the most eminent practical Physicians of Great Britain and Ireland, and among them many of the Professors and Teachers in London, Edinburgh, Dublin and Glasgow, whose reputation conveys a high and just authority to their doctrines. Each subject hai been treated by a writer of acknowledged eminence, whose particular studies have eminently fitted him for the task ; and all the articles are authenticated with the names of the authors. The Editors are men of elevated attainments, and in the undertaking have spared no personal pains; in the hope, by uniformity of plan, simplicity of arrangement, and the harmony and con- sistency of its several portions, to make the Cyclopaedia represent, fully and fairly, the state of PRACTICAL MEDICINE at the time of its appearance. From innumerable foreign and domcstie sources, the scattered knowledge, which has so fast accumulated since the commencement of the present century, has been gathered together and placed at the command of every reader of tin English language ; and whilst the great claims of the older cultivators of Medicine have never been forgotten, the labours of the moderns, and more particularly of the French, German, and Italian Pathologists, by which, conjointly with the efforts of British and American Practitioners, the whole face of Practical Medicine has been changed, have attracted the most diligent and thoughtful attention. The Editors affirm, that if the reader will take the trouble to inspect the mere titles of the articles contained in the work, comprising nearly THREE HUNDRED ORIGINAL ESSAYS of known and distinguished authors, and will bear in mind either the leading physiological divisions of disease, or consider them with reference to the Head, the Chest, the Abdomen, the Surface, or the gene* ral condition of the body, as well as the subjects of OBSTETRICAL MEDICINE, MATERIA MEDICA, or MEDICAL JURISPRUDENCE, he will sufficiently appreciate the care bestowed to make the Cyclopaedia satisfactory to all who refer to its pages, and, at the same time, strictly a book of practical reference. No subject, it is believed, immediately practical in its nature or application, has been omitted; although unnecessary disquisition has been, as much as possible, avoided. ^It entered consistently and properly into the plan of the Editors to admit a far wider range of subjects than appears heretofore to have been considered necessary in works written professedly on the Practice of Medicine, but a range comprising many new subjects of extreme importance to those engaged in practice, or preparing for it. Such are the subjects of ABSTINENCE \CONTAGION (EXPLORATION OF! FROGNOSIS ACUPUNCTURE \ CONVALESCENCE THE CHEST AND PULSE AGE {COUNTER-IRRITATION ABDOMEN SOFTENING GALVANISM MEDICAL STATISTICS HEREDITARY TRANS-! STETHOSCOPE MISSION OF DISEASED SUDDEN DEATH INDURATION \ SYMPTOMATOLOGY IRRITATION | TEMPERAMENT INFECTION \ TOXICOLOGY LATENT DISEASE8 {TRANSFORMATION MALARIA AND MIASMA TRANSFUSION PERFORATION TUBERCLE PSEUDO - MORBID AP- VENTILATION COLD {EXPECTORATION PEARANCES \MINERAL WATERS and those of various general articles on the pathology of organs. It will be found, too, that admirable articles from the best sources have been inserted on the important subjects of DISEASES OF WOMEN AND CHILDREN, AND OF MEDICAL JURISPRUDENCE. In order, however, that the nature and value of the work may be fully understood, a list of the articles, and the names of the contributors, is appended. The excellence of this work on every topic connected with Practical Medicine, has been admitted by all who have had the good fortune of being able to consult it. The hope, indeed, expressed by the Editors, has been amply realized —" That they have prepared a work required by the present wants of medical readers, acceptable to the profession in general, and so capable, by its arrangements, of admitting the progressive improvements of time, as long to continue what the general testimony of their medical brethren, as far as it has hitherto been expressed, has already pronounced it to be, "A STANDARD WORK ON THE PRACTICE OF MEDICINE." CHANGE OF AIR > CONGESTION AND DE ANTIFHLOGISTlci TERMINATION OF REGIMEN \ BLOOD ! ASPHYXIA \ DERIVATION AUSCULTATION {DIETETICS BATHING | DISINFECTION BLOOD-LETTING PHYSICAL EDUCATION MORBID STATES ELECTRICITY OF THE BLOOD ENDEMIC DISEASES CLIMATE EPIDEMICS Such a work, it is believed, will be most acceptable to the members of the profession throughout the Union, as there exists, at this time, no publication on Practical Medicine, on the extended plan of the one now presented. To adapt it to the Practice of this country, and to thoroughly revise the various articles, the atten- tion of PROFESSOR DUNGLISON will be directed ; whose character and established reputation are a sure guarantee that his portion of the work will be carefully executed. CONTENTS OF, AND CONTRIBUTORS TO, THE CYCLOPEDIA OE PRACTICAL MEDICINE. Abdomen, Exploration of, Dr. Forbes. Abortion.....Dr. Lee. Abscess......Dr. Tweedie. Abstinence.....Dr. M. Hall. Achor......Dr. Todd. Acne.......Dr. Todd. Acupuncture .... Dr. Elliotson. Age.......Dr. Roget. Air, Change of, . . . Dr. Clark. Alopecia.....Dr. Todd. Alteratives.....Dr. Conolly. Amaurosis.....Dr. Jacob. Amenorrhea .... Dr. Locock. Anajmia......Dr. M. Hall. Anasarca.....Dr. Darwall. Angina Pectoris ... Dr. Forbes. Anodynes.....Dr. Whiting. Anthelmintics .... Dr. A. T. Thomson. Antiphlogistic Regimen Dr. Barlow. Antispasmodics ... Dr. A. T. Thomson. Aorta, Aneurism of, . Dr. Hope. Aphonia......Dr. Robertson. Aphtha?......Dr. Robertson. Apoplexy, Cerebral, . Dr. Cluttereuck. Apoplexy, Pulmonary,. Dr. Townsend. Arteritis......Dr. Hope. Artisans, Diseases of, . Dr. Darwall. Ascites......Dr. Darwall. Asphyxia.....Dr. Roget. Asthma......Dr. Forbes. Astringents.....Dr. A. T. Thomson. Atrophy......Dr. Townsend. Auscultation .... Dr. Forbes. Barbiers......Dr. Scott. Bathing......Dr. Forbes. Beriberi......Dr. Scott. Blood, Morbid States of, Dr. M. Hall. Bloodletting .... Dr. M. Hall. _ . T „ r CDr. Quain. Brain, Inflammation 01, £Dr Adair Crawford. Bronchitis.....Dr. Williams. Bronchocele .... Dr. And. Crawford. Bullae......Dr. Todd. Calculus.....Dr. Thos. Thomson. Calculous Diseases . . Dr. Cumin. Catalepsy.....Dr. Joy. Catarrh......Dr. Williams. Cathartics.....Dr. A. T. Thomson. Chest, Exploration of, . Dr. Forbes. Chicken Pox ... • Dr. Gregory. Chlorosis.....Dr. M. Hall. Cholera......Dr. Brown. Chorea......Dr. And. Crawford. Climate......Dr. Clark. Cold ......Dr. Whiting. C Dr. Whiting. Colic......^Dr. Tweedie. ColicaPictonum. . . ^^^^0,, Combustion, Spontane- S Dr. Apjohn. ous Human, . • C„ Congestion of Blood Constipation . • Counter Irritation • . Dr. Williams. Croup......Dr. Cheyne. Cyanosis.....Dr. Crampton. Cystitis......Dr. Cumin. Delirium.....Dr. Pritchard. Delirium Tremens . . Dr. Carter. Dentition, Disorders of . Dr. Joy. Derivation.....Dr. Stokes. Determination of Blood Dr. Barlow. Diabetes.....Dr. Bardsley. Diaphoretics .... Dr. A. T.Thomson. _. . CDr. Crampton. Diarrhoea .... £ Dr. Forbes. Dietetics.....Dr. Paris. Dilatation ofthe Heart . Dr. Hope. Disease......Dr. Conolly. Disinfection .... Dr. Brown. Diuretics.....Dr. A. T. Thomson. Dropsy......Dr. Darwall. Dysentery.....Dr. Brown. Dysmenorrhcea ... Dr. Locock. Dysphagia.....Dr. Stokes. Dyspncea.....Dr. Williams. Dysuria......Dr. Cumin. Ecthyma.....Dr. Todd. Eczema......Dr. Joy. Education, Physical, . Dr. Barlow. Electricity.....Dr. Apjohn. Elephantiasis Arabum . Dr. Scott. Elephantiasis Graecorum Dr. Joy. Emetics......Dr. A. T. Thomson. Emmenagogues . . . Dr. A. T. Thomson. Emphysema .... Dr. Townsend. Emphysema of the Lungs Dr. Townsend. Empyema.....Dr. Townsend. Endemic Diseases . . Dr. Hancock. Enteritis......Dr. Stokes. Ephelis......5r-Tr0DD- Epidemics.....Dr. Hancock. Epilepsy......Dr. Cheyne. Epistaxis.....Dr. Kerr. Erethismus Mercuriahs Dr. Burder. Erysipelas.....Dr. Tweedie. ExVeSlnts . . '. '. Dr. A^T. Thomson. Expectoration. . . . %-Jlffi,^, Favus ' * cDr. Scott. Feigned Diseases. . |gr. Forbes. ^ Fever.General Doctrine of, Dr. Tweedie. " Continued, and its S j)r. Tweedie. Modifications, I rVmrr!n„ • ' Typhus . . . Dr. Tweedie. «« Epidemic Gastric Dr. Cheyne. .. Intermittent . . Dr. Brown. " Remittent ... Dr. Brown. " Infantile Remittent Dr. Joy. Contagion . • • • Convalescence • ■ Convulsions . • • Convulsions, Infantile Dr. Barlow. CDr. Hastings. 7 Dr. Streeten. Dr. Brown. Dr. Tweedie. Dr. Adair Crawford. Dr. Locock. Concisions', Puerperal gr. Lococ^ Coryza....... Dr. Brown. Dr. Lee. Dr. Gillkrest. Dr. Kerr. Hectic " Puerperal » Yellow Fungus Hcematodes . . Dr. Kerr. Galvanism.....Ut- APJ0H Gastritis..... Gastrodynia . . ■ Gastro-Enteritis . • Glossitis. . • • • Glossis, Spasm of the, Gout ■ • .• • Hemorrhoids . • • Dr. Stokes. Dr. Barlow. Dr. Stokes. Dr. Kerr. Dr. Joy. Dr. Barlow. Dr. Burns. CONTENTS, ice, OP THE CYCLOP '.EDIA OP PRACTICAL MEDICINE. Headach.....Dr. Burder. Heart, Diseases of the, Dr. Hope. " Displacement ofthe, Dr. Townsend. Hematemesis .... Dr. Goldie^ Hemoptysis .... Dr. Law. Hemorrhage .... Dr. Watson. Herpes......Dr. A. T. Thomson. Hiccup......Dr. Ash. Hooping-Cough . . . Dr. Johnson, Hydatids.....Dr. Kerr. Hydrocephalus . . . Dr. Joy. Hydropericardium . . Dr. Darwall. Hydrophobia .... Dr. Bardsley. Hydrothorax .... Dr. Daewall. Hypertrophy .... Dr. Townsend. Hypertrophy ofthe Heart Dr. Hope. Hypochondriasis . . . Dr. Pritchard. Hysteria......Dr. Conolly. Icthyosis.....Dr. A. T. Thomson. Identity......Dr. Montgomery. Impetigo.....Dr. A. T. Thomson. Impotence.....Dr. Beatty. Incontinence of Urine . Dr. Cumin. Incubus......Dr. Williams. Indigestion.....Dr. Todd. Induration.....Dr. Carswell. Infanticide.....Dr. Arrowsmith. Infection.....Dr. Brown. Inflammation Dr. A. Crawford, Dr. Tweedie. Influenza ...'.. Dr. Hancock. Insanity......Dr. Pritchard. Irritation.....Dr. Williams. Ischuria Renalis . . . Dr. Carter, Jaundice.....Dr. Burder. Kidneys, Diseases of, . Dr. Carter. Lactation.....Dr. Locock. Laryngitis.....Dr. Cheyne. Latent Diseases ... Dr. Christison. Lepra......Dr. Houghton. Leucorrhoea .... Dr. Locock. Lichen......Dr. Houghton. Liver, Inflammation of, Dr. Stokes. " Diseases of, . . Dr. Venables. Malaria and Miasma . Dr. Brown. Malformations ofthe Heart Dr. Williams. Medicine, Principles and C „ n Practice of, . . J Dr. Conolly. Melaena......Dr. Goldie. Melanosis.....Dr. Carswell. Menorrhagia .... Dr. Locock. Menstruation, Pathology of Dr. Locock. Miliaria,......Dr. Tweedie. Mortification .... Dr. CaIrswell. Narcotics.....Dr. A. T. Thomson. Nephralgia and Nephritis Dr. Carter. Neuralgia.....Dr. Elliotson. Noli me tangere, or Lupus Dr. Houghton. Nyctalopia.....Dr. Grant. Obesity......Dr. Williams. CEdema......Dr. Darwall. Ophthalmia .... Dr. Jacob. Otalgia and Otitis . . Dr. Burne. Ovaria, Diseases of the Dr. Lee. Palpitation.....Dr. Hope. Pancreas, Diseases of the, Dr. Carter. Paralysis.....Dr. R. B. Todd. Parotitis......Dr. Kerr. Pellagra......Dr. Kerr. Pemphigus.....Dr. Corrigan. Perforation ofthe Hol-Cp. r..„0„„,TT low Viscera . . ^Dr. Carswell. Pericarditis and Carditis Dr. Hope. Peritonitis .... Dr. M'Adam, Dr. Stokes. Persons found Dead . Dr. Beatty. Phlegmasia Dolens . . Dr. Lee. Pityriasis.....Dr. Plague......Dr. Plethora.....Dr. Pleurisy, Pleuritis, . . Dr. Plica Polonica .... Dr. Pneumonia.....Dr. Pneumothorax . . . Dr. Porrigo......Dr. Pregnancy, &c, Signs of, Dr. Prognosis.....Dr. Pseudo-morbid Appear-Cp ance9 ....(_ Psoriasis.....Dr. Puerperal Diseases . . Dr. Pulse.......Dr. Purigo......Dr. Purpura......Dr. Pyrosis ...... Dr. Rape.......Dr. Refrigerants .... Dr. Rheumatism .... Dr. Rickets......Dr. Roseola......Dr. Rubeola......Dr. Rupia......Dr. Rupture of the Heart . Dr. Scabies......Dr. Scarlatina.....Dr. Scirrhus......Dr. Scorbutus.....Dr. Scrofula......Dr. Sedatives.....Dr. Sex, Doubtful, ... Dr. Small-Pox.....Dr. Softening of Organs . Dr. Somnambulism and Ani- C ^ mal Magnetism . (_ Soundness, &c, of Mind Dr. Spinal Marrow, Dis-Cj-v eases of, ... £ Spleen, Diseases of, . Dr. Staiistics, Medical, . . Dr. Stethoscope .... Dr. Stimulants.....Dr. Stomach, Organic Dis-5r\ eases of, . . . ? Succession of Inherit- Sr)r ance--Legitimacy, £ Suppuration . . . . Dr. Survivorship .... Dr. Sycosis......Dr. Symtomatology . . *. Dr. Syncope......Dr. Tabes Mesenterica . . Dr. Temperament .... Dr. Tetanus......Dr. Throat, Diseases of the, Dr. Tonics......Dr. Toxicology.....Dr. Transformations . . . Dr. Transfusion . . . . Dr. Tubercle.....Dr. Tubercular Phthisis . . Dr. Tympanites .... Dr. Urine, Morbid States of, Dr. Urine, Bloody, . . . Dr. Urticaria.....Dr. Uterus, &.c. Pathology of, Dr. Vaccination .... Dr. Varicella.....Dr. Veins, Diseases of, . . Dr. Ventilation.....Dr. "Wakefulness .... Dr. Waters, Mineral, . . Dr. Worms......Dr. Wounds, Death from, . Dr. Yaws ...... Dr. Cumin. Brown. Barlow Law. Corrigan. Williams. Houghton. A. T. Thomson. Montgomery. Ash. R. B. Todd. Cumin. Hall. Bostock. A. T. Thomson. Goldie. Kerr. Beatty. A. T. Thomson. Barlow. Cumin. Tweedie. Montgomery. Corrigan. Townshend. Houghton. Tweedie. Carswell. Kerr. Cumin. A. T. Thomson. Beatty. Gregory. Carswell. Pritchard. Pritchard. R. B. Todd. BlGSBY. Hawkins. Williams. A. T. Thom«-<«:» Houghton, Montgomey . R. B. Todis Beatty. Cumin. M. Hall. Ash. Joy. Pritchari Sy.monds. Tweedie. A. T. Tho» Apjohn. Dues burt Kay. Cahsweli Clark. Kekr. Bostock. Goldie. Houghto, Lee. Gregory Gregory. Lee. Brown. Cheyne. T. Thom» a. Joy. Beatty. Kerr. ______LEA & BLANCHARD'S PUBLICATIONS. SIR ASTLEY COOPER ON HERNIA, WITH one hundred and thirty figures in lithography. THE ANATOMY AND SURGICAL TREATMENT OF ABDOMINAL HERNIA, BY SIR AvSTLEY COOPER, BART. Edited by C. Aston Key, Sur- geon to Guy's Hospital, &c Tliis important work of Sir Astley is printed from the authorised second edition, published in London, in large super-royal folio, and edited by his nephew, Professor Key. It contains all the Plates and all the Letterpress — there are no omissions, interpolations, or modifications —it is the complete work in ONE LARGE IMPERIAL OCTAVO VOLUME, WITH OVER 130 FIGURES ON TWENTX-SIX PLATES, AND OVER 400 LARGE PAGES OF LETTER-PRESS. The correctness of the plates is guaranteed by a revision and close examination under the eye of a distinguished Surgeon. The value of this work of Sir Astley Cooper's is so universally acknowledged by all medical men, that in presenting this edition to the American profession, the publishers nave only to state that they have used their iitmoft endeavours to render the mechanical execution of the work worthy its exalted reputa- tion, and to put it in such n form and at such a price as to place it within the reach of those who have been' prevented from obtaining it by the size and rarity of former editions. WATSON'S PRACTICE OF PHYSIC NOW COMPLETE. T PICTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC, DE- LIVERED AT KING'S COLLEGE, LONDON, BY THOMAS WATSON, M. D Fellow of the Royal College of Physicians, Physician to the Middlesex Hospital, &.c. &c. embracing Ninety Lectures—complete in one octavo volume of over nine huridred'large and condensed pages; well bound in leather. In predentin" the following, from numerous commendations of this work, the publishers would state that it is among the cheapest volumes ever offered to the profession. " I!v the publication of this work, the medical literature of this country has been enriched by a work of ,wnlanr"xMnencP. which we can proudly hold up to our brethren of foreign countries, as,airepre. "rntativ" of the.natural state of ISritsli medicine, as professed and practiced by our most en ightenecl »h.sh,ns -We hesitate not to declare our belief that for sound, trustworthy principles and substantial. Lood I'ract.ee it cam o, beparalleled by any similar production in any other country .-We would adv.se no one to set'hi.nself down in practice! unprovided with a copy.»-JJritt«* * Foreign Med. Remeio. •• We know of no other work better calculated for being placed in the hands of the student, and for a lext-book and as such we are sure it will be very extensively adopted."-.**. Med. Journal. « onen this huee and well-finished volume wherever we may, the eye immediately rests on something ,.,nr^rries value on Us front We are impressed at once with the strength and depth of the lecturer's that cam em lue °" 'l!» »^ ; ( . ■ ' )rticn to the extent of our acquaintance with h.s profound ScS "^-stet^ill ha've an acknowledged treasure, if the combined wisdom of the highesi authorities be appreciated."-^* Med. and Surg. Journal. CONDIE ON CHILDREN. A NEW WORK, NOW READY. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN, BY D. FR^NcisCONDE MR. Fellow ofthe College of Physicians, Member ofthe Americ.nPhilo8ophi.il Society, &c. &c. In one volume, 8vo. .• n, Condie has studiously endeavoured to be understood by student, who need to have the elements of Therapeutics presented to them ... a c™"™'^';,ble '^"p'art I. are considered the hygienic manage- The volume is methodically arranged it tyvo parts. I.' ^rl . ■ Uncy anr] childhood ; pathology ment of children ; the peculiarities of OFB.8""";* the d «ea "s of infancy and childhood. In Part II. are „f infancy and childhood ; and the semeiology of the eb. ea.es0I J stomach, intestines, rcspira- embraced diseafes of the digestive organs; the mouth tnrod ., u. ' nutritive functions, and ur.- oTorwns, nervous system, «h« »>•»• ""P^/^e£&£?,™™",i!g soon »*" J""" , C,,t U'iS 'S °nly nary organs ; and lastly, congenital »^„"hil notice "-««(»» Med. and Surg. Journal. an outline of the subjects brought under tp„cia> nol'cl- in ita descriptions, while it is « Re^-mling this treatise as a whole, it is i|«j>" «£"£ °te„*™ any of its predecessors, and we feel per- more cop.ous'and judicious ^"^^^^1^' Regard it not only as a very good, but as suaded that the An.er.can medical m...^, i , >dren-, „_^m. Mtd. Journal. tt. .„, oe,t • ^£^^Z S. Diseases of Children, and a very safe guide to the juvem.e practi't'ioner a°nd student."-^- ^aminer._____________ HARRISON ON THE NERVES. nJV^Q . rriRRFrT THEORY OF THE NERVOUS ta.h^'l'jic Jco°"gc of L.uisi.na. .„-ne volume 8»„.------------------- LEA AND BLANCH ARD'S PL' PLICATIONS. A NEW WORK ON PRACTICAL SURGERY, With over Two Hundred and Fifty Illustrations. A SYSTEM OF PRACTICAL SURGERY, BY PROFESSOR WILLIAM FERGUSSON, OF KING'S COLLEGE, LONDON. ILLUSTRATED BY OVER TWO HUNDRED AND FIFTY SPLENDID CUTS, EXECUTED BY GILBERT, FROM DESIGNS BY BRAGG ', WITH NOTES AND ADDITIONS, BY GEORGE W. N O R R I S, M.D. One of the Surgeons to the Pennsylvania Hospital. In One Volume, 8vo. The object and nature of this volume are thus described by the author:—"The present work has not been produced to compete with any already before the Profession ; the arrangement, the manner in which the subjects have been treated, and the illustrations, are all different from any of the kind in the English language. It is not intended to he placed in comparison with the elementary systems of Cooper, Burns, Liston, Symes, Lizar, and that excellent epitome by Mr. Druitt. It may with more propriety be likened to the Operative Surgery of Sir C. Bell, and that of Mr. Averill, both excel- lent in their day; or the more modern production of Mr. Hargrave, and the Practical Surgery of Mr. Liston. There are subjects treated of in this volume, however, which none of these gentlemen have noticed; and the author is sufficiently sanguine to entertain the idea that this work may in some degree assume that relative position in British Surgery which the classical volumes of Valpeau and Malgaigne occupy on the Continent." The publishers commend this work to the attention of the Profession as one combining cheapness and elegance, with a clear, sound, and practical treatment of every subject in surgical science. No pains or expense have been spared to present it in a style equal, if not superior, to the London edition, and to match the edition of " Wilson's Anatomy," lately published, and " Churchill's System of Mid- wifery," and " Carpenter's Physiology." CHURCHILL'S MIDWIFERY, WITH ONE HUNDRED AND SIXTEEN ILLUSTRATIONS. THEORY AND PRACTICE OF MIDWIFERY, BY FLEETWOOD CHURCHILL, M.D., M.R.I.A., Licentiate of the College of Physicians in Ireland ; Physician to the Western Lying-in Hospital, Lecturer on Midwifery, tc. in the Richmond Hospital School of Medicine, Author of " A Treatise on the Diseases of Females," &c. tec. WITH NOTES AND ADDITIONS, BY ROBERT M. HUSTON, M.D. Professor in the Jefferson Medical School of Philadelphia ; WITH 116 ILLUSTRATIONS FROM DRAWINGS BY BAGG AND OTHERS, ENGRAVED BY GILBERT, " This is incontestably one ofthe very best books, on the important suhject on which it treats. The author has had great experience, and is, withal, an able and accomplished writer; well read in his profession, and gifted with a vigorous and condensing mind; while the American editor is known as a skilful practitioner of obstetrics, and well acquainted with every thing that has been said or done in that department. The notes which he has added bear ample testimony to his possessing those qualifications. The work does not consist simply of the ipse dixit of the author. It embraces a brief statement, well expressed, of the views of the best authorities, and is illustrated, as the title Bets forth, with numerous wood-cuts, which, by the way, are beautifully executed. The book is altogether well 'got up,' and we can conscientiously recommend it most strongly as an excellent accompaniment to the tyro in his studies, and to the practitioner when beset with doubts or diffi- culties. It forms a fit accompaniment to Wilson's Anatomy, and Fergusson's Surgery." PROUT ON THE STOMACH. ON THE NATURE AND TREATMENT OF STOMACH AND RENAL DISEASES; Being an Inquiry into the Connexion of Diabetes, Calculus, and the other Affections of the Kidney and Bladder, with Indigestion; BY WILLIAM PROUT, M.D., F.R.S. FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, & C. From the Fourth revised London Edition ; with Coloured Plates. "This treatise was received with so much favour by the medical profession in F.neland, that within hree yean from the publication of the .bird edition of it, n fourth was made necessary by the increasing demand. Too much can hardly be said in its praise, as a practical essay upon a class of derangements but little studied, and less understood, though of frequent occurrence among us: for every enquiring student of these affections will find in its pages valuable precepts for their management, and many satisfactory explanations of the obscure and complex phenomena usually attending them."—Am. Medical Journal. LEA AND BLANCHARD'S PUBLICATIONS. A NEW TEXT-BOOK ON CHEMISTRY. THE ELEMENT^ OF CHEMISTRY: INCLUDING THE APPLICATION OF THE SCIENCE TO THE ARTS : With numerous Illustrations. By THOMAS GRAHAM, F. R. S., L. & ED., Professor of Chemistry in the University College, London, President of the Chemical Society, &c. &c. WITH NOTES AND ADDITIONS, BY ROBERT BRIDGES, M,D, Professor of General and Pharmaceutic Chemistry in the Philadelphia College of Pharmacy, and one of the Editors of the American Journal of Pharmacy. In one vol. 8vo. The great advancement recently made in Chemistry has called for a new and perfect treatise on the present state of the science. Such this work is presumed to be, while an attempt is made to apply it to the elucidation of the great questions of vegetable and animal physiology. It fully repre- sents the progress of the science up to the date of publication. The publishers have endeavoured to make this revised edition worthy of the eminent character of the author, and it will be found to have numerous additional cuts to illustrate the various subjects. It is already introduced as a Text-book into several Colleges, and has universal approbation. SIR ASTLEY COOPER'S WORK ON FRACTURES AND DISLOCATIONS, WITH CUTS, ETC. A TREATISE ON DISLOCATIONS AND FRACTURES OF THE JOINTS. By Sir Astley Cooper, Bart., F. R. S., Sergeant Surgeon to the King, &c. A new edition much enlarged ; edited by BRANSBY B. COOPER, F. R. S., Surgeon to Guy's Hospi- tal, with additional Observations from Professor John C. Warren, of Boston. With numerous en- gravings on wood, after designs by Bagg, a memoir and a splendid portrait of Sir Astley. In 1 vol. 8vo. The peculiar value of this, as of all Sir Astley Cooper's works, consists in its eminently practical character. His nephew, Bransby B. Cooper, from his own experience, has added a number of cases. Beside this, Sir Astley left behind hi.n very considerable additions in MS. for the express purpose of being introduced into this edition. The volume is embellished with ONE HUNDRED AND THIRTY- THREE WOOD CUTS, and contains the history of no less than three hundred and sixty-one cases, thus embodying the records of a life of practice of the Author and his various editors. There are also additional Observations from notes furnished by John C. Warren, M. D., the Professor of Anatomy and Surgery in Harvard University. WILLIAMS' PATHOLOGY.-BY CLYMER. PRINCIPLES OF MEDICINE, COMPRISING GENERAL PATHOLOGY AND THERAPEUTICS, and a brief general View of Etiology, Nosology, Semeiology, Diagnosis, and Prognosis. By CHARLES J. B. WILLIAMS, M.D., F.R.S., Fellow of the Royal College of Physicians, &c. With Additions and Notes, by MEREDITH CLYMER, M.D., Lecturer on the Institute of Medicine, &c. One Vol. 8vo. " With many excellent and elaborate treatises on the details of Medicine, we have scarcely any which treat of those general principles in the nature and treatment of disease, which are really funda- mental in the practice of medicine. We therefore think that the " Principles " of Dr Williams is enti- tled to assume a station along with the works of Chomel and Dubois, in the French, and Neumann, in the German. It is without a competitor in our language, and fills most successfully a decided gap in our medical literature. The actual state of our science is very fairly represented, and besides a free appropriation from the writings of his contemporaries, the Author has drawn largely from his own experience; ' a continual observation of disease for the last twenty years in Hospital and private practice,' affording him abundant opportunity for its accumulation." BRODIE oIFtHE JOINTS. PATHOLOGICAL AND SURGICAL OBSERVATIONS ON THE DISEASES OF THE JOINTS. By Sir Benjamin C. Brodie, Bart., F. R. S., Sergeant Surgeon to the King, &c. &c. From the Fourth London Edition, with the author's alterations and additions. In one volume 8vo., cloth. To both the practical physician and the student, then, this little volume will be one of much service, inasmuch as we have here a condensed view of these complicated subjects thoroughly investigated by the aid of the light afforded by modern Pathological Surgery.—JV. Y. Journal of Medicine. WALSHE on~the lungs. THE PHYSICAL DIAGNOSIS OF THE DISEASES OF THE LUNGS By Walter Hayle Walshe, M. D., Professor of Pathological Anatomy m University College, London &c. &c. In one volume 12mo., extra cloth. The British and Foreign Medical Review, edited by Dr. John Forbes the translator and annotator of Laennec's immortal work, says, " we do not hesitate to say that there exists in no language any work onThephSdiagnosis of diseases of the lungs, su.ted for students, so clear and precise, and wont on lTC P"y"™'" = , engive and practical as th s. It is one which no learner in auscultation SXuTd^^ is re which veryfew etSn.mongXm^ addmg sometmne t0 the'r Pil- ous stock of knowledge." L E A A N D B L A N C II A R D' S PUBLICATIONS. SIXTH EDITION OF SPECIAL ANATOMY AND HISTOLOGY, BY WM. E. HORNER, M.D. PROFESSOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, MEMBER OF THE IMPERIAL MEDICO-CHIRURGICAL ACADEMY OF ST. PETERSBURG, OF THE AM. PHIL. SOCIETY, &.C. In Two Volumes, 8vo. This edition has undergone a complete revision by Prof. Homer, and perfected from recent sources of information. The portion on Histology and Histooeny is two-thirds new, und a new chapter on Glandular Structure has been added. The author has deemed it advisable to have un Atlas ok Ana- tomical Plates prepared, to illustrate his lectures. This has been undertaken under his supervision, by Dr. H. H. Smith, and forms an additional volume. A TREATISE ON THE DENTAL ART, FOUNDED ON ACTUAL EXPERIENCE. ILLUSTRATED BY TWO HUNDRED AND FORTY-ONE FIGURES IN LITHOGRAPHY, AND FIFTY-FOUR WOOD CUTS j BV B. F. MAURY, DENTIST OF THE ROYAL POLYTECHNIC SCHOOL. Translated from the French, with Notes and Additions, BY J. B. SAVIER, DOCTOR OF DENTAL SURGERY. One Volume, 8vo. This work is used as a Text-hook in the Baltimore College of Dental Surgery, and commends itself to the Profession from the great reputation of the author, and as embracing the latest informal.on on the subject. Its steady demand is the best testimony of the general favour with which the profession has received it. It is in fact a Cyclopaedia of the science. CARPENTER'S PHYSIOLOGY, WITH OVER ONE HUNDRED SPLEKXID WCCD CUTS. PRINCIPLES OF HUMAN PHYSIOLOGY, With their chief applications to Pathology, Hygiene, and Forensic Medicine. Especially designed for the use of Students; with over One Hundred Illustrations. BY WILLIAM B. CARPENTER, M.D., LECTURER ON PHYSIOLOGY IN THE BRISTOL MEDICAL SCHOOL, &C. FIRST AMER. EDITION, WITH ADDITIONS UY THE AUTHOR, AND NOTES AND ADDITIONS BY MEREDITH CLYMER, M.D. Lecturer on the Institutes of Medicine, Physician to the Philadelphia Hospital, Fellow of the College of Physicians, &c. One Volume, Octavo. 55" This edition of Carpenter's Physiology has been most carefully prepared by Dr. Clymer, at the request ol Professor Jackson, for his lectures at the University of Penn- sylvania. "Though the resources of the author's comprehensive mind are apparently devoted to the advance- ment of new beginners in study, there is a splendid exhibition of the powers of analysis, an uncommon decree of success in making abstruse objects clear, and in forcibly impressing upon others the laws of life, which he so well understands himself, which will give eclat to Dr. Carpenter's repu- tation, when he will be insensible to praise. All who can alFord to have a good system of Physiology, should po.ssess this; and those who are ahle to keep pace with the progress of science should not he without it. There are 018 pages, large size octavo, on good paper, with a type as distinctly made as it can he executed. Prohahly this edition does not cost more than one-third the price asked for it in England, and yet it is superior in very many respects."—Boston Medical and Surgical Journal. WILSON'S DISSECTOR, WITH NUMEROUS OUTS. THE DISSECTOR, OR PRACTICAL AND SURGICAL ANATOMY. By Erasmus Wilson, author of a System of Human Anatomy, &c, edited and re-arranged hy Paul Heck Goddard, Ml)., Do.nonstrator'of Anatomy, &.C., in the University of Pennsylvania; in one large l'Jmo. volume, with numerous Illustrations. FIG. 4. FIG. 5. O-i FIG. 7. FIG. 4. A Longitudinal section of a Femur, showing the Cellular Structure at its extremity. FIG. 5. A Longitudinal section of a Tibia, showing 1. The Compact Structure. 2. The Cellular Structure. 3. A Transverse section of the Femur, showing its Compact Substance, its Internal Cellular Structure, and the Medullary Canal. FIG. 6. The Texture of a Bone as shown in a Humerus, after maceration in dilute acid. 1.1. The Compact Matter as usually seen. 2. 2. The same split, so as to show the Longitudinal Fibres composing it. 3. The^Internal Cellular Matter. 4. The Bone seen under its Articular Cartilage. FIG. 7. A view of the Concentric Lamellje of the Compact Matter of a Bone. LEA & BLANCHARD'S PUBLICATIONS. A MEDICAL LIBRARY FOR THE PRACTITIONER AND STUDENT. A SYSTEM OF PRACTICAL MEDICINE, Comprised in a Series of Orijrinal Dissertations, arranged and edited by ALEXANDER TWEEDIE, M.D., F.R.S., &c, &c. The whole revised, with Notes and Additions, by W. W. GERHARD, M.D., Lecturer on Clinical Medicine to the University of Pennsylvania. The second American Edition, now complete in Three large Volumes. The design of this work is to supply the want, generally admitted to exist in the Medical Literature of Great Britain, of a comprehensive System of Medicine, embodying a condensed, yet ample view ofthe Piesent State of the Science. The desideratum is more especially felt by the Medical Student, and by many Members of the Profession, who, from their avocations and other circumstances, have not the opportunity of keeping pace with the more recent improvements in the most interesting and useful branch of human knowledge. To supply this deficiency is the object ofthe LIBRARY OF MEDICINE; and the Editor expresses the hope, that with the assistance with which he has been favoured by contri- butors, (many of great eminence, and all favourably known to the Public), he has been able to produce a work, which will form a Library of General Reference on Theoretical and Practical Medicine, as well as a Series of Text-Books for the Medical Student. Advertisement of the American Publishers to their New Edition in Three Volumes. The matter embraced in the Three Volumes now presented, was published in London in Five separate volumes, and at intervals republished in this country. The rapid sale of these volumes, embracing as they do, a History of Practical Medicine, is the best evidence of the favour with which it has been re- ceived by the Physicians of the United States. Embodying as it does the most recent information on nearly every Disease, and written by men who have specially devoted themselves to the^tudy of the Disorders which form the subject of their Articles, the work is the most valuable for Reference within the reach of a Practitioner. The arrangement of the Library into Classes of Diseases, grouped accord- ing to the cavities ofthe body, is much more agreeable to the reader than the alphabetical order, and nearly as convenient for reference. DISEASES OF CHILDREN. A TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILDREN, BY WILLIAM P. DEWEES, M.D., late Professor of Midwifery in the University of Pennsylvania, &c. &c. The Eighth Edition, brought up to 1843, in 1 vol. 8vo. This edition embodies the notes and additions prepared by Dr. Dewees before his death, and will be found much improved. The objects of this work are, 1st, to teach those who have the charge of children, either as parent or guardian, the most approved methods of securing and improving their physical powers. This is attempted by pointing out the duties which the parent or the guardian owes for this purpose, to this interesting but helpless class of beings, and the manner by which their duties shall be fulfilled. And 2d, to render avail- able a long experience to those objects of our affection when they become diseased. In attempting this, the author has avoided as much as possible, " technicality;" and has given, if he does not flatter himself too much, to each disease of which he treats, its appropriate and designating characters, with a fidelity that will prevent any two being confounded together, with the best mode of treating them, that either his own experience or that of others has suggested. Physicians cannot too strongly recommend the use of this book in all families. A NEW WORK,—DUNGLISON'S THERAPEUTICS AND MATERIA MEDICA. GENERAL THERAPEUTICS AND MATERIA MEDICA, ADAPTED FOR A MEDICAL TEXT-BOOK, BY ROBLEY DUNGLISON, M.D., Professor of Institutes of Medicine, &c, in 2 vols. 8vo.—Just ready. A second edition of the work on General Therapeutics, being called for by the publishers, the author has deemed it advisable to incorporate with it an account of the different articles ofthe Materia Medica. To this he has been led by the circumstance, that the departments of General Therapeutics and Materia Medica are always associated in the Medical Schools. The author's great object has been to prepare a work which may aid the Medical Student in acquiring the main results of modern observation and reflec- tion ; and, at the same time, be to the Medical Practitioner a trustworthy book of reference. Throughout, he has adopted the Nomenclature of the last edition of the Pharmacopoeia of the United States, a work which ought to be in the hands of every practitioner as a guide in the preparation of medicines; and he has endeavoured to arrange the articles in each division, as nearly as he could, in the order of their efficacy as Therapeutical agents. DEWEES' MIDWIFERY. A COMPENDIOUS SYSTEM OF MIDWIFERY, chiefly designed to facilitate the inquiries of those who may be pursuing this branch of study. Illustrated by occa- sional cases, with many plates. The tenth edition, with additions and improvements, by W. P. DEWEES, M. D., late Professor of Midwifery in the University of Penn- sylvania, in one volume 8vo. LEA & BLANCHARD'S PUBLICATIONS, A NEW WORK ON ANATOMY, WITH ONE HUNDRED AND SEVENTY ILLUSTRATIONS. A SYSTEM OF HUMAN ANATOMY, GENERAL AND SPECIAL, BY ERASMUS WILSON, M.D., Lecturer on Anatomy, London. The American edi- tion, edited by Paul B. Goddard, A.M., M.D., Demonstrator of Anatomy in the Uni- versity of Pennsylvania, &c.; with one hundred and seventy illustrations on wood, by Gilbert, from designs prepared expressly for this work, by Bagg, printed from the second London edition, in 1 vol. 8vo.—Just ready. " An elegant edition of one of the most useful and accurate Systems of Anatomical Science, which has been issued from the press. The illustrations are really beautiful, and their execution reflects the highest credit on the able American artist who copied them for this edition of the work. In its style the work is extremely concise and intelligible. Dr. Goddard has added a number of valuable notes, and has made some judicious alterations of names. No one can possibly take up this volume without being struck with the great beauty of its mechanical execution, and the clearness of the descriptions which it contains is equally evident. Let Students, by all means, examine the claims of this work on their notice, before they purchase a text-book of the vitally important science which this volume so fully and easily unfolds."—Lancet. HOPE ON THE HEART-WITH PLATES. A TREATISE ON THE DISEASES OF THE HEART AND GREAT VES- SELS, AND ON THE AFFECTIONS WHICH MAY BE MISTAKEN FOR THEM, COMPRISING THE AUTHOR'S VIEW OF THE PHYSIOLOGY OF THE HEART'S ACTION AND SOUNDS, AS DEMONSTRATED BY HIS EXPERIMENTS ON THE MOTIONS AND SOUNDS IN 1830, AND ON THE SOUNDS IN 1834-5, BY J. HOPE, M.D., F.R.S., of St. George's Hospital; formerly Senior Physician to the Marylebone Infirmary; Extraordinary Member, and formerly President, of the Royal Medical Society of Edinburgh, &c. First American from the Third London Edition, with Notes and a detail of recent Experiments, by C. W. Pennock, M.D., Attending Physician to the Philadelphia Hospital, Blockley. In 1 vol. 8vo. " The addition of one-third of new matter to the present volume, and the care with which the whole has been revised and corrected, will, I trust, sufficiently prove my respect for the favourable opinion of my professional brethren, as evinced, not in this country only, but also on the European and American continents, by the sale of no less than six or seven editions and translations in as many years."—Ex- tract from Preface. MEDICAL REMEDIES. NEW REMEDIES. THE METHOD OF PREPARING AND ADMINIS- TERING THEM; THEIR EFFECTS UPON THE HEALTH AND DISEASED ECONOMY, &c. &c., BY PROFESSOR ROBLEY DUNGLISON. Fourth edi- tion, brought up to 1843. In one volume octavo. This work contains articles that have been recently introduced into the Materia Medica; or old articles. that have received new applications, some of these are in the general works on Materia Medica, but their properties are only briefly referred to. In this work, the experience of individuals is extensively given with reference to the original papers. Under Iodine, for example, all the information—pharma- ceutical and therai>eutical-tip to the time of the publication of the work, is afforded, with the prescrip- tions that have been proposed by various observers; each successive edition has incorporated with it the result of recent experience, and is therefore " new." MIDWIFERY WITH CUTS, A LATE WORK. A SYSTEM OF MIDWIFERY, WITH NUMEROUS WOOD CUTS, BY EDWARD R1GBY, M.D., Physician to the General Lying-in Hospital, Lecturer on Midwifery at St. Bartholomew's Hospital, &c, with notes and additional Illustrations, bv an American Practitioner. In one volume. „ , r. -„,„ „i,A=ptnnds this volume was placed a few weeks before his death, in retT'ni^^ should commend it to general favour. DISEASES OF FEMALES. a TRFATTSF 0\ THE DISEASES OF FEMALES, WITH NUMEROUS ENGR\V1NGSBYTHE LATE PROFESSOR W. P. DEWEES, in one volume 6vo—the Eighth Edition, revised and corrected.__________________________ LEA & BLANCHARD'S PUBLICATIONS. DISEASES OF FEMALES, PREGNANCY AND CHILDBED. THE PRINCIPAL DISEASES OF FEMALES, TOGETHER WITH THE DISEASES INCIDENT TO PREGNANCY AND CHILDBED, CHIEFLY FOR THE USE OF STUDENTS, BY FLEETWOOD CHURCHILL, M.D., L-ntunr on Midwifery and Diseases of Women and Children, in the Richmond Hospital, School of Medicine, &c. &c, with Notes and Additions by R. M. Huston, M.D., Professor, &c. in the Jefferson Medical College. Second American Edition, in 1 vol. 8vo.—Just rtady. ^AAAAAAAA DUNGLISON'S PHYSIOLOGY - WITH ILLUSTRATIONS. HUMAN PHYSIOLOGY, ILLUSTRATED WITH THREE HUNDRED ENGRAVINGS ON WOOD; BY PROFESSOR ROBLEY DUNGLISON; the fifth edition with numerous additions and modifications, in 2 vols. 8vo. This work is occupied with the functions executed by healthy man. It embraces a general exposition of the functions; the new views entertained in regard to the formation of the tissues; hut is especially intended to give an accurate view of the actions of the different organs, as an introduction to the study of pathology, hygiene and therapeutics. It treats moreover, of the anatomy of the organs so far as is necessary for a full understanding of the functions; and is largely illustrated by appropriate engravings. The last edition contains ninety additional illustrations to elucidate cither topics that have been already touched upon in the work, or such us are new. Every effort has been made to place the work, in all respects, on a level with the existing state ofthe science. THE DISEASES OF THE EYE. A TREATISE ON THE DISEASES OF THE EYE, BY W. LAWRENCE, Surgeon Extraordinary to the Queen, &c, from the last London Edition, with numerous additions, and sixty-seven Illustrations, many of which are from original drawings. By Isaac Hays, M.D., Surgeon to the Wills Hospital, &c, &c, in 1 vol. 8vo.— Just ready. The character of this work is too well established to require a word of commendation—it is justly considered the best on the subject. The present is a reprint of the last Loudon Edition, which appeared in 1841, completely revised and greatly enlarged by the author—ami to it considerable additions have been made by the editor. Several subjects omitted in the original are treated of in this edition, on which occasion free use has been made of the work of Mackenzie, to which is added the editor's own experi- ence, derived from many years' attention to the subject. THE URINARY ORGANS, &c. LECTURES ON THE DISEASES OF THE URINARY ORGANS, BY SIR B. C. BRODIE, BART. F.R.S. From the Third London Edition, with alterations and additions, a small 8vo. volume.—Now ready. The work has throughout heen entirely revised, some of the author's views have been modified, and a considerable proiiorlioii of new matter lias been added, among which is a Lecture on the Operation of Lithotomy. «/vw\,>.>/ww^ RICORD ON VENEREAL. A PRACTICAL TREATISE ON VENEREAL DISEASES; OR, CRITICAL AND EXPERIMENTAL RESEARCHES ON INOCULATION, APPLIED TO THE STUDY OF THESE AFFECTIONS; WITH A THERAPEUTICAL SUMMARY AND SPECIAL FORMULARY, BY PH. RICORD, M.D., Surgeon of the Venereal Hospital of Pari-!, Clinical Professor of Special Pathology, &c. Translated from the French, by Henry Pilkington Drummorid, M.D., in one volume. —Now ready. LAWRENCE ON RUPTURES. A TREATISE ON RUPTURES, BY W. LAWRENCE, F.R.S., Author of a Trenti.-e on the Diseases of the Eye, &c. &c, from the Fifth London Edition, consi- derably enlarged. In 1 vol. 8vo.—Now ready The peculiar advantage of the treatise of Mr. Lawrence is, that he explains his views on the nnntotny of hernia, and the different varieties of the disease, in a manner which renders his book peculiarly useful to the stuile.it. It must be superfluous to express our opinion of its value to the sur»ical practitioner. As a treatise on hernia, presenting a complete view of the literature of the subject, it stands in the first rank.—Edinburgh Medical and Surgical Journal. LEA &, BLANC HARD'S PUBLICATIONS, MEDICAL LEXICON, BROUGHT UP TO 1844. ANEW DICTIONARY OF MEDICAL SCIENCE; Containing a concise account of the various Subjects and Tenn.«, with the French and other Synonymes, and Formulae for various Officinal and Empirical Preparations, &c. Fourth Edition, brought up to LS44. BY ROBLEY DUNGLISON, M.D., Professor in the Jefferson Medical College, &e. In One Volume, royal 8vo. •' The present undertaking was suggested by the frequent complaints, made by the author's pupils, that tin y wri: unable to meet with information on numerous topics of Professional Inquiry,—especially of recent introduction,—in the medical dictionaries accessible to Ihe.n. " It may, indeed, be correctly affirmed, that we have no dictionary of medical subjects and terms which can he looked upon as adapted to the state of the ^ience. In proof*of this the author need but to remark, that he has found occasion to add several thousand Medical Terms, which are not to be .net with in the only medical lexicon at this time in circulation in this country. "The present edition will he found to contain many thousand Terms more than the first, and to have experienced numerous Additions and Modifications. " The author s object has not lieen to make the work a mere lexicon or dictionary of terms, but to nfford, under each, a condensed view of its various medical relations, and thus to render the work an epitome ofthe existing condition of Medical Science." This New Edition includes, in the body of the work, the Index or Vocabulary of Synonymes that was in lhe former Editions piintcd nt the end of the Volume, and embraces many Corrections, with the addi- tion of over Two Thousand New Words and Terms. PEREIRA'S MATERIA MEDICA, EDITED DY DR. CARSON, WITH NEAR THREE HUNDRED ENGRAVINGS ON WOOD. ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS; COMPRE- HENDING THE NATURAL HISTORY, PREPARATION, PROPERTIES, COMPOSITION, EFFECTS, AND USES OF MEDICINES, BY JONATHAN PEREIRA, M.D., F.R.S., Assistant Physician to the London Hospital, &c. Part I, contains the General Action and Classification of Medicines, and the Mineral Materia Medica. Part II, the Vegetable and Animal Kingdoms, and including diagrams explanatory of the Processes of the Pharmncnpauas, a Tabular view of the History of the Materia Medica, from the earliest times to the present day. and a very copious index. From the Second London Edition, which has been thoroughly revised, with the Introduction ofthe Processes ofthe New Edinburgh Pharmacopoeia, and containing additional articles on Mental Remedies, Light, Heat, Cold, Electricity, Magnetism, Exercise, Dietetics, and Climate, and many additional Wood Cuts, illustrative of Pharmaceutical Operations, Crystallogra- phy, Shape and Organization ofthe Feculas of Commerce, and the Natural History ofthe Materia Medica. The object of the author has been to supply the Medical Student with a Class nook on Materia Medica, containing a faithful outline of this Department of Medicine, which should embrace a concise account of the most important modern discoveries in Natural History, Chemistry, Physiology, and Therapeutics in so far as they pertain to Pharmacology, and treat the subjects in the order of their natural historical This great Library or Cyclopedia of Materia Medica has been fully revised, the errors corrected, and numerous additions marie, by DR. JOSEPH CARSON, Professor of Materia Medica and riiarmacy in the "College of Pharmacy," and forms Two Volumes, octavo, of near 1G0O large and closely-pnnted pa«e«; and it mav be fully relied upon as a permanent and standard work for the country—embodying, as'it does, full references to the U. S. Pharmucopea and an account of the Medicinal Plants indige- nous to the United States. PRINCIPLES AND PRACTICE OF SURGERY, WITH CUTS. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY, BY RO- RFRT'DRUITT From the Second London Edition, illustrated with fifty wood en- pravmrrs, with notes and comments by Joshua B. Flint, M.D., in one volume 8vo., at a low price. , EXTRACT FROM THE AUTHOR S TREFACK. , <• .v •. n.wi r„i. i - i beginning with the simple faintness lion at large, that may be produced byp» 'J "• °r "'j01,sil,er ,i,e varieties of fever and tetanus. or collapse that follows a blow, and |> oot ..n, o <.< . ,s of ,orn, (\Uoa^ ■ ,nat is to say, those m^ch^el WllS^^. ^h.rh are produced either immediately by external causes, or secondarily, through s