/\hm/\*^/ v-r/ V' .^ ON THE DISEASES OF CHILDREN. i i PRACTICAL TREATISE DISEASES OF CHILDREN. .a BY D. FRANCIS CONDIE, M.I)., SECRETARY OF THE COLLEGE OF PHYSICIANS; MEMBER OF THE AMERICAN MEDICAL ASSOCIATION; MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY, ETC. FOURTH EDITION, REVISED AND AUGMENTE: \.v^ -^gton, d.>- PHILADELPHIA: BLANCHARD AND LEA 1853. JZ? \.*t> : l£53 Entered, according to act of Congress, in the year 1S;>3, BY BLANCIIARD & LEA, In the office of the clerk of the District Court, for the Eastern District of Pennsylvania. PREFACE. The demand for another edition has afforded the author an oppor- tunity of again subjecting the entire treatise to a careful revision, and of incorporating in it every important observation recorded since the appearance of the last edition, in reference to the pathology and therapeutics of the several diseases of which it treats. The leading object of the Author has been to present in each suc- ceeding edition a full and accurate exhibition of the actual state of medical knowledge, in reference to those maladies which most usually occur between birth and puberty—maladies that form in some de- gree a class distinct from those of the adult, and demand for their cure a particular plan of treatment. In the preparation of the present edition, as in those which have preceded, while the author has appropriated to his use every impor- tant fact that he has found recorded in the works of others, having a direct bearing upon either of the subjects of which he treats, and the numerous valuable observations—pathological as well as practical— dispersed throughout the pages of the medical journals of Europe and America, he has, nevertheless, relied chiefly upon his own observe tions and experience, acquired during a long and somewhat extensive practice, and under circumstances peculiarly well adapted for the clinical study of the diseases of early life. He has made use of the labours and adopted the opinions of others, only when he has found them to correspond with, or to be confirma- tory of the results of his own observations and inquiries. In the few instances in which, from the high professional standing and authoritative character of the individuals from whom they ema- nate, he has considered it proper to notice pathological views or plans of treatment, the accuracy of which he has had no opportunity of testino-, or which are in discordance with his own observations and experience, the fact is invariably stated, so that the credit or re- V] PREFACE. sponsibility may rest with their respective authors. And, in all cases, in which an opposition of opinion, upon any leading point, exists be- tween medical authorities of equal weight, he has always adopted those views which comport the nearest with his own observations; presenting, at the same time, when it is demanded by the importance of the subject under consideration, a fair exposition of the views of others in relation to it. In reference to the directions given for the management of the se- veral diseases of infancy and childhood, these are almost exclusively based upon the results of the personal experience of the author. To notice every remedy that has been proposed, at different periods, and by different practitioners, the recommendation of which is founded,, perhaps, upon the supposed good effects resulting from its use in two, three, or, at the furthest, half a dozen cases, would have been a means, certainly, of filling up his pages, and might have gained for him the credit of extensive research—but would have contributed but little towards the instruction of his readers. He has therefore preferred to present only those remedies and plans of treatment which he has found, from actual observation made at the bedside of the patient, to be best adapted to relieve or to remove the several forms of disease of which he treats; and which he is convinced will be the least likely to disappoint the expectations of the practitioner, when promptly and judiciously administered. He has not failed, however, to notice every remedy and plan of treatment which comes to us with the re- commendation of practitioners of unquestionable authority, even al- though he may not have had an opportunity of testing its efficacy. Every species of hypothetical reasoning has, as much as possible, been avoided. The author has endeavoured throughout the work to confine himself to a simple statement of well ascertained pathological facts, and plain therapeutical directions—his chief desire beino* to render it what its title imports it to be, a practical treatise on the DISEASES OF CHILDREN. He feels persuaded that it will be found a useful and faithful guide to the student, and that the practitioner, also, should he be induced to consult its pages, may derive from them some few facts and practical hints, not altogether unworthy of his notice. Philadelphia, September, 1853. CONTENTS. PART I. CHAPTER I. THE HYGIENIC MANAGEMENT OF CHILDREN. 1. Air. Temperature, --.--.-33 2. Cleanliness. Bathing, - - - - - - - 37 3. Clothing, ........ 41 4. Food, - - - - - - - - - 43 5. Sleep, --------- 57 6. Exercise, .-..--.--62 7. Moral Treatment, - - - - - - - 69 CHAPTER II. ON THE PECULIARITIES OF ORGANIZATION AND FUNCTION, DURING INFANCY AND CHILD- HOOD. 1. Infancy, - Organization, Functions, 2. Childhood, - Organization, Functions, CHAPTER III. PATHOLOGY OF INFANCY AND CHILDHOOD. - - - 97 CHAPTER IV. SEMEIOLOGY OF THE DISEASES OF INFANCY AND CHILDHOOD. 1. Of the Countenance, 2. Of the Gestures, 7y 79 86 92 92 93 - 128 130 viii contexts. 3. The Phenomena During Sleep, - 4. The Cry, .... 5. Respiration, - 6. The Tongue and Mouth, 7. Of the Surface, 8. The Breath, - - - - 9. Discharges by Vomiting and Stool, 10. The Urinary Discharge, 11. The Bones, - PART II. SECTION I. DISEASES OF THE DIGESTIVE ORGANS. CHAPTER I. DISEASES OF THE MOUTH. 1. Erythematic Stomatitis. Inflammation of the Mouth, 2. Erythematic Stomatitis, with curd-like Exudation, 3. Follicular Stomatitis. Aphthae, 4. Ulcerative Stomatitis, - 5. Gengivitis. Inflammation of the gums, 6. Gangrene of the Mouth, . - - - 7. Difficult Dentition, . - - - CHAPTER II. DISEASES OF THE THROAT. 1. Tonsillitis, - - . - 2. Pseudo-membranous Inflammation of the Throat, 3. Gangrene of the Throat, - 4. Parotitis. Inflammation of the Parotids. Mumps, 5. Angina Externa, - - - - - CHAPTER III. (ESOPHAGITIS. CHAPTER IV. DISEASES OF THE STOMACH. 1. Indigestion, - 2. Gastritis. Inflammation of the Stomach, CONTENTS. ix CHAPTER V. DISEASES OF THE INTESTINES. 1. Enteralgia. Colic, - 2. Diarrhoea, ...--- 3. Cholera Infantum, - - - 4. Prolapsus Ani, - - ... 5. Polypus of the Rectum, - 6. Invagination of the Intestines, - 7. Intestinal Worms, - 8 • Enteritis. Inflammation of the Small Intestines. Ileitis, - 9. Colitis. Inflammation of the Large Intestines. Dysentery, CHAPTER VI. Peritonitis. Inflammation of the Peritoneum, CHAPTER VII. The Remittent or Gastric Fever of Infancy, SECTION II. DISEASES OF THE RESPIRATORY ORGANS. 1. Asphyxia, - - - - - 2. Coryza, - 3. Bronchitis, - 4. Pneumonia, - Atelectasis Pulmonum, 5. Pleuritis, - 6. Tracheitis. Croup, 7. Spasmodic Croup, - 8. Spasm of the Glottis, 9. Pertussis. Hooping-Cough, 10. Foreign Bodies in the Larynx and Trachea, SECTION III. DISEASES OF THE NERVOUS SYSTEM. 1. Hypertrophy of the Brain, - 2. Cerebral Hyperemia and Hemorrhage, 3. Convulsions, 4. Acute meningitis, - Meningitis Encephalica, 5. Epidemic Meningitis, 6. Subacute Meningitis, - 7. Chronic Hydrocephalus, 8. Chorea, - - 214 232 - 242 244 - 247 248 - 260 264 - 281 286 - 290 299 - 316 317 - 323 341 - 346 361 - 380 - 388 392 - 413 423 - 424 436 - 451 453 X CONTENTS. SECTION IV. DISEASES OF THE SKIN. CHAPTER I. ERUPTIVE FEVERS. EXANTHEMATA. 1. Measles, --------- 465 2. Scarlet Fever. Scarlatina, ------ 472 Inflammatory Scarlatina, ------- 476 Scarlatina Anginosa, ------ 478 Congestive Scarlatina, ------- 492 3. Roseola. Scarlet Rash, - - - - - - 501 4. Variola. Small-pox, .....-- 503 5. Vaccination, -------- 522 Phenomena of Vaccination, ------ 528 Period for Vaccination, - - - - ' - - 529 Mode of Vaccination, ------- 531 6. Modified Small-pox. Varioloid, - - - - - 533 7. Varicella. Chicken-pox, ------- 536 CHAPTER II. CUTANEOUS ERUPTIONS. Eruptions occurring previous to Weaning, and during Dentition, - - 539 1. Strophulus, -------- 539 2. Prurigo, - -- - - - - - 541 3. Crusta Lactea, ....... 543 4. Impetigo, ....... 543 Eruptions chiefly connected with Gastro-enteric Disease, ... 545 5. Erythema, ....... 545 6. Eczema, -------- 547 7. Urticaria. Nettle Rash, ------ 548 8. Erysipelas, -------- 550 9. Phlegmonous Tumours, - - - - - - 557 10. Herpes, - - - - - - - - 561 11. Psoriasis, .------. 563 12. Follicular Wart, - - - - - - - 565 13. Porrigo, -------- 566 Eruptions connected with Languid Cutaneous Action, ... 572 14. Pityriasis, --.-.._ 572 15„ Ichthyosis, ........ 573 16. Ecthyma. Rupia, - - - - - - 574 17. Pemphigus, ---.--.. 577 18. Purpura, -------- 579 From Infection, independent of Visceral Disease, - - - . 583 19. Psora. Scabies. Itch, ------ 533 20. Syphilitic Eruptions, ------- 537 CONTENTS. xi SECTION V. DISEASES OF THE NUTRITIVE FUNCTION. Scrofula, ...... Scroiulous Inflammation of the Lymphatic Glands, - Ophthalmia, ------ Otitis, - - - - - - Discharges from the Vagina, - - - - Disease of the Mesenteric Glands. Tabes Mesenterica, Disease of the Bones, - - - - - Rickets, - White Swelling, Hip Disease, - - . - - Disease of the Spine, - Tubercular Depositions, - - - Tuberculization of the Bronchial Glands, - - - - Lungs, - - - - - Tubercles of the Brain, - - - - Treatment of Scrofula, - Scrofulous Enlargement of the Lymphatic Glands, Ophthalmia, - - - - - Otitis, ------ Discharges from the Vagina, Tabes Mesenterica, - - - - - Disease of the Bones. Rickets, White Swelling, - Hip Disease, - - - - - Disease of the Spine, . - - - - Tubercular Depositions, . . - - SECTION VI. DISEASES OF THE URINARY ORGANS. 1. Dysuria. Painful and Difficult Micturition, 2. Anuria. Suppression of Urine, 3. Ischuria. Retention of Urine, 4. Enuresis. Incontinency of Urine, - 5. Diabetes, SECTION VII. CONGENITAL AFFECTIONS, AND ACCIDENTS OCCURRING, MOST GENERALLY, WITHIN THE MONTH. 1. Fractures, 2. Congenital Malformation of the Intestines, 3. Tongue-tie, 4. Haemorrhage from the Navel, 5. Cyanosis. Morbus Cseruleanus, 6. Spina Bifida. Hydro-Rachis, 7. Inflammation and Ulceration of the Navel, - 596 597 - 600 602 - 602 603 - 604 605 - 606 608 - 609 613 - 614 615 - 617 623 - 6*24 628 - 629 629 - 630 632 - 633 634 - 635 - 641 643 - 645 650 654 - 655 657 . 658 664 - 671 675 Xll CONTENTS. 8. Intumescence and Inflammation of the Breasts, 9. Ruptures. Hernie, - Arrest of the Testicle, 10. Vaginal Hemorrhage, 11. OZdema of the Prepuce, - 12. Cohesion of the Labia and Nymphee, 13. Hare-Lip, 14. Club-Foot. Talipes, , 15. Induration of the Cellular Tissue, 16. Nevus, 17. Jaundice. Icterus Infantilis, 18. Purulent Ophthalmia, 19. Hydrocele, 20. Paronychia, 21. Burns and Scalds, - 677 678 - 683 683 - 684 685 - 686 687 - 689 694 - 698 701 - 708 709 - 713 \ I ON THE DISEASES OF CHILDREN. CHAPTER I. THE HYGIENIC MANAGEMENT OF CHILDREN. "When we reflect upon the many painful and dangerous maladies to the attacks of which children, from the earliest period of their existence, are liable, and by which so large a proportion of them are annually destroyed, and when we consider, also, that in many, perhaps in the majority of cases, these attacks might easily be avoided by a proper attention to those external agents, to the influence of which the infant is subjected from the moment of its birth, and which, while they are essential to its existence, become, when counteracted or mis- managed, the cause of nearly all its infirmities and diseases; the phy- sician'can scarcely be considered as fulfilling all his duties, when he neglects to point out and urge the administration of the means by which the occurrence of disease may be prevented, as well as those, which, when disease is already present, are adapted to remove it." (Faust.) These remarks, made upwards of a century since, by one whose writings have been consigned to unmerited oblivion, are still substan- tially true. A vast amount of the disease and suffering that occur in early life, is unquestionably produced by errors committed in regard to diet, clothing, and exercise,—by impure air, unwholesome dwellings, imprudent exposure, and a general neglect of physical and moral edu- cation. The proper management of infancy and childhood is still but imperfectly understood, and many erroneous opinions in rela- tion to it, giving birth to practices the most pernicious, are enter- tained, even by physicians. A general view of the more important par- ticulars connected with the subject would seem, therefore, to be a pro- per and necessary introduction to the consideration of the pathology and treatment of the maladies incident to the early periods of life. 1.—Air. Temperature. The first want of the new-born infant is a free supply of air—and this want continues to recur during every moment of its future exist- ence. But it is not only necessary that the infant should be supplied 3 34 DISEASES OF CHILDREN. with a sufficient amount of air to carry on the function of respiration; it is equally necessary that the air it breathes be perfectly pure; an impure and stagnant atmosphere being even more deleterious during infancv and childhood, than in more advanced life. From tin's cause alone, according to the statement of Dr. Clarke, in the year 1782, out of 7650 infants, born in the lying-in-hospital of Dublin, 2944 were destroyed within the first two weeks after their birth. They nearly all died in convulsions—many of them foamed at the mouth—their thumbs were drawn into the palms of their hands—their jaws were locked—and their faces swollen and of a bluish tint, as though they had been strangled. So soon as proper measures were taken, at the suggestion of Dr. Clarke, to insure a free circulation of pure air throughout the wards of the hospital, the dreadful mortality that had previously occurred among the infants inhabiting them, was almost immediately suspended. Even when not immediately productive of any violent or fatal train of symptoms, by gradually impairing the powers of life, a vitiated and stagnant atmosphere produces a general unhealthy condition of the organs—prevents their due development, and lays the foundation for maladies, that are always difficult, and often impossible to remove. Children that have been, from any cause, confined in small, unclean, badly ventilated or overcrowded apartments, almost invariably exhibit the deleterious influence of an impure and stagnant air, in their pallid countenances, flaccid muscles, and emaciated limbs; their impaired digestion—their panting respiration upon any trifling exertion—their stunted growth, and sickly appearance generally, and by their pre- disposition to some of the most dangerous affections of the lungs, stomach, brain, and other organs. There is no doubt, that in these cases, the injurious effects of a vitiated atmosphere are, in some degree, augmented by the want of proper and sufficient exercise; it would be in vain, however, to attempt to counteract them by any amount of exercise, so long as the little sufferers are debarred from enjoying the pure fresh air. The importance, therefore, of selecting as a nursery the largest and the most lofty room in the house, and of taking every precaution to insure, at all times, the purity of its air, by free bukcautious ventilation —by the strictest cleanliness of the apartment and its furniture, and by removing from it every possible source of vitiation, should be frequently and forcibly urged upon parents—and every neglect of the means adapted to preserve the infant from the influence of an impure and vitiated atmosphere, should receive a prompt rebuke on the part of the physician in attendance. Among the most usual causes, independent of a neglect of cleanli- ness and ventilation, by which the purity of the air in rooms occupied by young children, is liable to be impaired are, the smoke of lamps, and of wood fires—the gases produced by the combustion of stone or charcoal—the washing, drying, and ironing of the infant's gar- ments—the cooking of various articles of food—the smoke of tobacco, and all domestic processes that have a tendency to rob the atmosphere of its oxygen, or to load it with effluvia of any kind; all of these MANAGEMENT OF CHILDREN. 35 should therefore be carefully guarded against. The impropriety of exposing infants to the infected air of small, crowded, and confined apartments need scarcely be pointed out. As soon as a child is sufficiently old, it should be carried daily, for a few hours, into the open air, whenever the state of the weather, and the temperature of the season will permit. By no other means can we so effectually secure to it the full enjoyment of a pure, fresh air-— and contribute so essentially to insure its health and promote its sprightliness. " The open air," Struvc with great justness remarks, " is particularly grateful to the feelings of infants. When they have been accustomed to it for a few times, they evince, even at a very early age, a strong desire to return to it. When unable to walk, they point anxiously to the door, and make efforts to approach and open it. When they can scarcely crawl, they instinctively advance towards that part of the room from which they have a prospect of escaping. Often their cries can be arrested in no other way than by carrving them into the free open air." Not unfrequently, even when there is nothing to object to in the condition of the atmosphere which the child respires within doors, and notwithstanding the precaution is taken to carry it abroad, at short intervals, into the open air without, it is deprived of the Ml benefit of a pure atmosphere by various practices originating in ig- norance, prejudice, or misconception. Thus, during the many hours passed by infants in sleep, by covering their faces carefully with the bed-clothes; by enclosing the cradle or cot with a closely-drawn cur- tain: or when they are taken abroad, by enveloping the entire head in a hood or with a shawl; or carrying them completely enclosed beneath the shawl or cloak of its mother or nurse, they are made to breathe a confined atmosphere, which their own respiration and the exhalations from their bodies tend constantly to render impure, and in the highest degree noxious. We have, in several instances, seen convulsions and symptoms of decided asphyxia produced by these absurd and indefensible practices. # . A healthy and robust infant may be carried daily into the o£en air, in dry weather, and when the temperature of the season is suffi- ciently mild, as soon as it is two or three weeks old. Even during the winter season, days will frequently occur when a robust infant, of a more advanced age, may be exposed, for a short time, to the open air, provided its body be protected with a sufficient amount of clothing! not only without danger, but with positive advantage to ltSFrom the period when a child becomes able to walk alone, it should be allowed to pass many hours, every day, in the open air. The robust, fully developed and active limbs, and the ruddy and sprightly complexion exhibited by children who pass much of their time in the open air form a striking contrast with the pallid countenances the General listlessness, the fragile frames, and the inactive disposition Sf those who are confined nearly the whole day within doors The temperature of the air to which infants and young children are exposed!7equally important with its purity. It has been shown by 36 DISEASES OF CHILDREN. Dr. W. F. Edwards, that in the young of the human species, as well as of the warm-blooded animals generally, the power of generating heat is but imperfectly developed, and that, consequently, not only is the temperature'of their bodies less, but their capability of resist- ing the depressing influence of cold is far below what it is in after life. We can readily perceive, therefore, that exposure to air of too low a temperature must be peculiarly prejudicial to young infants; —and although the power of producing heat goes on increasing until adult age, still, young children, and especially those of a feeble con- stitution, will suffer discomfort, and have their health impaired by a degree of cold that would be tolerated with impunity by those who are older and more robust. According to Drs. Milne Edwards, and Villerme, of Paris, and Dr. Trevisano, of Castel Franco, in Italy—and the accuracy of these gentlemen's statements is fully confirmed by Drs. Lombard, of Ge- neva, and Quetelet, of Brussels, and by subsequent observers—the greatest mortality among children, from birth to the age of three months, occurs during the season of greatest cold, and consequently, we find that the mortality among children is greater in northern than in southern climates; and in the northern climates, during win- ter than during the other seasons of the year. Allowance, however, must be made for particular local circumstances, or the occasional visitation of epidemic diseases:—thus, in most of our larger cities, in the middle and southern states, the excessive heat of the summer, when conjoined with causes which prevent free ventilation, and tend otherwise to diminish the purity of the air, produces annually a very great mortality among children under two years of age; rendering, with us, the season of greatest warmth far more fatal to infants than even that of the greatest cold. From the foregoing facts it must be evident, that to maintain a sufficient degree of warmth in the air of the apartments occupied by children, is indispensable, not only to their comfort, but for the pre- servation of their health and lives. It will not do, however, for pa- rents or nurses to judge of the temperature required for the well-being of an infant by their own sensations—for what may be sufficiently comfortable to them may be destructive to the latter—nor should they suppose that because no alarming symptoms supervene immediately after the exposure of children to cold, their constitution does not suffer —uneasiness, at first sight, is, by a repetition of the cause, almost in- variably converted into serious disease. Thus, inflammation of the throat, air passages, or lungs, more or less severe, or a predisposition to incurable affections of these and other parts, is, in infants and young children, often the result of exposure to a degree of cold, from which dangerous consequences are least suspected to ensue. Infants, and children of a feeble constitution, or in whom, from any cause, the powers of life have been depressed, should especially be guarded from exposure to the external air during cold or damp weather. Important as the enjoyment of the fresh air is to the health and comfort of infants, the practice of carrying them abroad in cold weather, under the idea of confirming their strength or rendering MANAGEMENT OF CHILDREN. 37 them hardy, is not less cruel than absurd. A child of sufficient age and vigour to enable its system to react promptly under the depress- ing influence of cold, and, by an increased evolution of heat, to main- tain its temperature, may, it is true, sustain with impunity, or even derive advantage from exposure for a short period to a moderate de- gree of cold,—but, in all others, so far from an increase of strength and vigour, or the ability to endure without injury sudden vicissi- tudes of temperature, being acquired'by their exposure to cold, either in or out of doors, the very opposite effect will ensue—if an attack of severe disease be not immediately produced. While urging the importance of a due degree of external heat, to the comfort and health of infants, and the necessity of carefully pro- tecting them from exposure to even slight degrees of cold, we would not wish to be understood as recommending that the air of the rooms they occupy should be kept at a high degree of temperature. To subject children of any age constantly to an over-heated atmosphere, is highly improper. From the excessive stimulation thus produced, and the profuse perspiration in which their bodies are almost con- stantly bathed—especially during sleep—they soon become relaxed and enfeebled,—their nervous system, at the same time, acquires an undue degree of irritability; every trifling vicissitude of temperature causes them to suffer, and they become liable to attacks of severe disease from the slightest causes. A temperature of from 68° to 70° of Fahrenheit, is that best adapted to the nursery—a less degree of heat would not be prudent for very young children, and even those more advanced in age will scarcely tolerate, with perfect impunity, a much lower temperature. It is to be recollected, that notwithstanding a robust and healthy child, when a few years old, will suffer no injury from a dry and cold atmosphere, whilst engaged in active exercise—even out of doors—yet, when at rest, within doors, its health and comfort will be best promoted by the air of the room being sufficiently warm to prevent the least sense of chilliness. . The injurious consequences we have pointed out as resulting irom constant exposure to too high a degree of artificial heat, will indicate the propriety of protecting children, as much as possible, from the in- tense heat which usually prevails during the summer months, espe- ciallv in the cities of our southern and middle states—by a free ven- tilation of the apartments they occupy, and by frequent exposure to the fresh air, in open and shady situations. The deleterious effects of the heated and confined air of a large city upon the health of children, may, in a great measure, be counteracted by these means, as well as by daily rides into the surrounding country, or by excur- sions upon the water; the means for which, in most of our larger cities, is placed within the reach of all by the numerous steamboats that depart for short trips, at almost every hour. 2.—Cleanliness. Bathing. The important functions of the skin, and the intimate relations which exist between it and every other part of the body, point out the ne- 38 DISEASES OF CHILDREN. ccssity of guarding it from whatever is calculated to impede its free and healthful action. More especially should the utmost attention be paid to ] n-eservc it, by frequent ablutions, from the influence of loreign impurities, as well as from an accumulation of its own excretions. Whenever this is neglected, disgusting, painful, and obstinate cuta- neous eruptions are liable to be produced, or the foundation is laid for derangement of function or serious disease of one or other of the internal organs. At no period of life is injury more liable to be pro- duced by a neglect of cleanliness, than during infancy—at no period, therefore, are repeated ablutions of more importance. Immediately after birth, the body of the infant requires to be care- fully washed, and the same operation must afterwards be performed daily to insure its comfort, and to preserve it from disease. The skin of the new-born infant is more or less covered with a white unctuous matter, the vernix caseosa: whatever office this may perform in foetal life, it is unnecessary, and even injurious, to allow it to remain for any length of time after birth. It may be very readily removed by washing the_skin with warm water and a soft cloth or sponge. Dewces and others recommend, in order to facilitate the re- moval of the vernix caseosa, to "smear every part of the child with fine hog's lard," and then to wash with soap and water. Dr. Eberle recommends smearing the body with the yolk of eggs, when, he re- marks, -'simple warm water will be sufficient to cleanse the surface thoroughly." Notwithstanding the high authorities by which these practices are recommended, we doubt their necessity, and are far from being convinced of their propriety. When a sufficient amount of water, of a proper temperature, is employed, and sufficient care is taken in the process of washing, we have seldom seen any difficulty experienced in clearing the skin of its caseous coating. In washing a new-born infant, no degree of friction should be used, for fear of irritating or abrading the tender skin; and notwithstanding it is important to remove, as soon as possible, the caseous matter from the folds of the joints, where it is generally most abundant, yet if this cannot be readily done at the first washing, what remains should be left, and at the second washing, with ordinary care, the skin may be freed from every portion of it. The washing being completed with as little delay as possible, the surface, particularly the folds of the joints, the neck, the groin, &c, should be thoroughly dried with a soft napkin, and the child dressed as quickly as possible. We have directed the infant to be washed in warm water. This is not a matter of indifference ; to plunge the body of a new-born child in cold water, and keep it there until the process of washing is com- pleted, is to subject it to unnecessary suffering—if not to endanger its life. When the same process is pursued, day after day, although the robust and vigorous may survive it, and even acquire additional strength and vigour froni the dangerous ordeal through which they have been made to pass, the generality of infants will suffer from it serious discomfort^ if not permanent injury; while the feeble and de- bilitated will inevitably perish under it. MANAGEMENT OF CHILDREN. 39 The absurd notion so generally entertained, that the cold bath is adapted, in all cases, to augment the strength and invigorate the powers of life, and which has induced so many to view it as an im- portant agent in the physical education of infancy and childhood, has been fully exposed by the experiments of Dr. Edwards and others. By these it has been shown that the direct effect of cold water, when applied to the surface, is invariably to depress the strength and vigour of the system; and that this depressing effect is always in a direct ratio with the feebleness or exhaustion of the individual subjected to its influence. When we add to this, that by the same experiments it has been proved that the power of generating heat, and conse- quently, the ability to support a diminution of temperature, is at its minimum at birth, and goes on gradually augmenting as the child approaches maturity, we can readily understand the folly and danger of applying cold water to the skin of a young infant, as well as the necessity of the water in which it is washed being always sufficiently warm to prevent the production of the least degree of chilliness. As the infant increases in age, the temperature of the water may be gradually reduced—watching, however, its effects the more closely, the nearer it is reduced to a state of coldness. If its application to the surface be followed by a glow all over the body, and a sense of com- fort in the child, it is not too cold; but should it occasion chilliness, pallor of the face, or evident languor and depression, it must be im- mediately exchanged for water of a higher temperature. As a gene- ral rule, however, during no period of childhood should the washing be performed in perfectly cold water. Tepid water is better adapted to remove impurities from the surface, and to preserve the skin in a healthy condition, while injury to health is less liable to result from its use. As it is important that the entire surface of the body should be subjected to daily ablution—-for without this, personal cleanliness cannot be maintained—we are in favour—even from the period "of birth, of applying the water in which the child is washed in the form of a bath. It is much better to immerse the body of the new-born babe into a large basin of warm water, its head and shoulders being supported by the hand and arm of the nurse, than to subject its ten- der body to the handling and exposure which are necessary when it is washed upon the lap. By immersing it in a sufficient quantity of warm water, the washing, also, can be more promptly and effectually performed than by the too common practice of sopping portion after portion of the surface with a wet rag or sponge—while at the same time, the infant is spared the danger of becoming chilled, which can scarcely be done by any other plan. Nothing should be added to the water—with proper attention an infant may be kept perfectly clean without the use of soap. When, however, from any cause soap is required, the finest white kind should be employed. The practice so generally pursued of bathing the head of infants, at the first and subsequent dressings, with some spirituous li'quor, should be discountenanced; it does no possible good, but by irri- tating the scalp, cannot fail to cause considerable smarting, or even more serious mischief. 40 DISEASES OF CHILDREN. During the entire period of infancy, the whole surface of the body should be washed in warm or tepid water every morning—and dining the day, such portions of it as may become soiled by the natural eva- cuations, or from any other cause. Nor should the maintenance of personal cleanliness"? by similar means, be neglected after the child has passed beyond the term of infancy. The daily use of the bath, and more frequent ablutions of the face, hands and feet, should still be enjoined, and any neglect in regard to them prevented by a care- ful surveillance on the part of the parents or guardians. Frequent bathing in tepid water, independently of its removing from the sur- face every source of impurity, benefits the health of the child by pro- moting the functions of the skin and encouraging the free and regu- lar circulation of the blood through its numerous vessels, securing thus the regular growth and full development of every portion of the body. " I consider bathing," remarks Struve, " as the grand arcanum of supporting health, on which account, during infancy, it ought to be regarded as one of those sacred maternal duties, the performance of which should on no account be neglected for a single day." The time during which the child should remain in the bath will vary according to its age. For the first month after its birth the im- mersion should not continue longer than three or four minutes—the time being gradually prolonged as the child advances in age—conti- nuance in the bath beyond ten or fifteen minutes, is, however, unne- cessary, and scarcely prudent at any period of childhood. Children should not be permitted to enter the bath when in a state of profuse perspiration, nor for some hours after a meal. Intimately connected with the subject of cleanliness is a proper at- tention to the hair. In early infancy, all that is necessary is to sub- ject the head, in common with every other part of the surface of the body, to daily ablutions in warm water; as the child increases in age, and the hair begins to grow, a little soap may be added to the water with which the head is washed, and the hair should be repeatedly but gently cleansed with a soft brush. This will prevent the greasy matter which exudes from the scalp accumulating and forming a dry black crust—disgusting in its appearance, and liable to occasion ulce- rations of the skin beneath it of a most obstinate and painful character. Many parents are opposed to frequently washing the head of an infant, from a supposition that it will render it liable to take cold, and be otherwise prejudicial to health; no such fears, however, need be entertained—the child's health will be much more endangered by neglecting to keep its head scrupulously clean than by the too fre- quent application to it of water of a proper temperature. A soft brush should always be used instead of a comb, for cleansing and smoothing the hair of young children, there being less danger of the brush scratching or unduly irritating the skin. During the entire period of infancy and childhood the hair should be kept short. Nothing is more common than to see a luxuriant head of hair accompanied in children with paleness of complexion, weak- ness of the eyes, and frequent complaints of headache; independently of this, eruptions and ulcerations of the scalp are more apt to occur, than when the hair is kept short and thin. The degree of heat, also' MANAGEMENT OF CHILDREN. 41 which a profuse growth of hair produces in the head, invites to the brain an undue amount of blood, and augments its liability to those diseases to which at this period of life it is always more or less pre- disposed. " The trouble also, of keeping long hair sufficiently clean, and the length of time necessary for that purpose, are often a cause of much ill humour, and many cross words between children and their atten- dants, which would be better avoided. Mothers, whose vanity may be alarmed, lest constantly cutting the hair, until the eighth or ninth year, should make that of their daughters coarse, may be assured that they have no cause for this apprehension; if the hair be kept constantly brushed. I have never seen softer, better hair, than on girls who have had it kept short, like that of schoolboys, until they were in their tenth year." 3. Clothing. " The essentials in the clothing of children," remarks a sensible writer of the last century, "are lightness, simplicity, and looseness. By its being as light as is consistent with due warmth, it will neither encumber the child, nor cause any waste of its powers; in conse- quence of its simplicity, it will be readily and easily put on, so as to prevent many cries and tears; while by its looseness it will leave full room for the growth and due and regular expansion of the en- tire frame; a matter of infinite importance for the securing of health and comfort in after life."—(Willis.) The texture and amount of clothing, during infancy and childhood, should be such as to preserve every portion of the body of a sufficient and equable warmth—neither allowing it, on the one hand, to expe- rience the slightest sensation of chilliness, nor, on the other, unne- cessarily augmenting its heat. The younger the infant the warmer should it be clothed, and the more care should be taken to protect every part of its surface by an appropriate covering. Older children, especially in the variable climate peculiar to our northern, middle and western states, require their clothing to be adapted in its mate- rial and amount to the average state of the weather. It should be neither too flimsy and light in summer, nor too warm and oppressive in winter; a medium covering being that ordinarily worn throughout the year, with appropriate additions, adapted to changes in the wea- ther, to the prevailing temperature of the season, or to particular circumstances of exposure. For the under garments of children flannel is indispensable during the autumnal, winter and spring months. Worn in contact with the skin, flannel preserves, better than any other material, a moderate and equable warmth of the body, and more effectually protects it from the influence of sudden alterations in the temperature of the at- mosphere. During the summer season, however, the flannel may be changed for muslin or cotton; the softer species of which, that which is neither of a very fine texture nor highly dressed, should be se- lected. Even in winter, when from any unusual sensibility of the $urface, the contact of the flannel excites an irritation of the skin, or 42 DISEASES OF CHILDREN. produces profuse perspiration, thick muslin may be substituted, or a soft muslin dress may be worn next to the body, and over this a flannel garment. The fashion of a child's clothing is a matter of perfect indifference if the material of which it is composed be sufficiently warm, and it be made perfectly loose, and to protect effectually every part of the body. To leave the neck, shoulders and arms of a child nearly or quite bare, however warmly the rest of the body may be clad, is a sure means of endangering its comfort and health; violent attacks of croup or bronchitis, or even inflammation of the lungs, are often in- duced by this irrational custom; and it is not improbable that the foundation of pulmonary consumption is often thus laid during child- hood. It is an important precaution, therefore, to have the dress worn by children so constructed as to protect the neck, breast and shoulders, and with sleeves long enough to reach to the wrists. By having its garments of sufficient length, the lower extremities of an infant may be kept perfectly warm, especially if in cool weather the feet are covered with soft woollen socks; but when it becomes old enough to be carried abroad, or commences to walk, its legs and feet should be defended by soft woollen stockings which reach above the knees, but without garters, and by easy comfortable shoes, of some soft material, with leather soles; the latter are indispensable whenever the child is placed upon the floor, to protect its feet from being injured by any sharp substance with which they may acci- dentally come in contact. The head, even from birth, may be fully protected, under every degree of exposure to which it is proper to subject an infant, without the necessity of enveloping it day and night with a cap. When on the lap of the mother or nurse, if the room be of a proper tempera- ture, a soft woollen shawl, thrown loosely around the infant's neck and shoulders, and brought up over its head so as to form a kind of hood, will be sufficient to guard it from any accidental draft of cool air. When carried abroad in cool weather, a similar covering will render any other than a thin, light and soft cap, unnecessary. Caps when worn within doors, are objectionable by keeping the child's head too warm, and thus inviting to the brain an additional amount of blood, at a period when, from its soft texture and great vascularity, it is prone to hyperemia and to inflammation from slight causes. The material of which the cap is composed, being generally lace or worked muslin, by the roughness or harshness of its surface, is calculated also to fret and irritate the delicate skin with which it is in contact, and if not productive of eruptions, cannot fail to occasion considerable uneasiness to the child. By covering and confining the ears, and compressing them against the side of the head, the cap, even if it occasion no other injury, is apt to produce pain and inflam- mation of these organs, or a disgusting, sometimes dangerous, sore- ness and running behind them. It is all-important that every part of a child's clothing should be sufficiently loose to give perfect freedom to all its movements, and to prevent compression of any portion of the chest, loins or extremities j MANAGEMENT OF CHILDREN. 43 without this the muscles will fail to acquire their proper development and strength, the chest its full expansion, or the figure that upright- ness and perfectness of form, upon which beauty and health so inti- mately depend. As a general rule, the clothes worn at night should be both lighter and looser than the day clothes. The additional warmth produced by the bed and its coverings renders unnecessary the same amount of garments as is required during the day, and would be liable, were no change in the clothing made, to overheat the body, or to exhaust it by causing profuse perspiration; while the least restraint or com- pression of the limbs, chest, or abdomen, renders the sleep disturbed —and by impeding the free action of the heart and lungs, is liable to produce various uneasy sensations or even partial or general spasms. Every article of dress worn during the day should be changed on retiring to rest: this is demanded for the promotion of the comfort as well as the health of children; it allows the different portions of the clothing to be aired at short intervals, and prevents any injury that might result from the gaseous and vaporous exhalations given off by the skin, and imbibed, to a greater or less extent, by the clothes, be- ing retained too long in contact with the body. For infants, a simple long gown of flannel in cold, and of muslin in warm weather, made with wide sleeves covering the whole of the arms, is the most appropriate night-dress. For older children, of both sexes, who are very apt in their sleep to thrust their arms and legs from beneath the bed-clothes, it is better to make the night-dress in the form of a jacket and long trousers, with feet; the whole being, however, in one piece, and secured, where it is left open behind, to enable it to be put off and on, with tapes. Every article of clothing worn during infancy and childhood should be kept scrupulously clean, to which end it should be frequently changed. It is all-important likewise that* it be preserved as dry as possible. During the early period of infancy especially, the under garments should be examined at short intervals, and if any one of them has become wet, it should be immediately removed and replaced by a dry and clean one. If this be neglected, the child is liable to become chilled, and its health to be endangered. We have known severe inflammation of the skin about the upper portion of the thighs and nates to be induced when a wet diaper has been allowed to re- main on for too long a period. For fastening and adjusting the clothes of young children, tapes should be substituted as much as possible, for pins; painful punctures and scratches, from the points of the latter being brought in contact with the skin in handling infants or even by their own movements, are of daily occurrence, and we have numerous instances on record of more serious consequences resulting from the pins, accidentally de- tached, becoming imbedded in the infant's flesh. 4.—Food. The milk of the mother is the natural and only proper food for an infant. " Nature does not afford, nor can art supply any substitute." 44 DISEASES OF CHILDREN. To it, therefore, should the child be entirely confined, whenever it is possible, until the process of dentition has made some progress. The difficulty of rearing an infant, when from any cause it is de- prived of the maternal breast, or that of a healthy nurse, is pointed out by almost every writer that has treated on the subject of infantile hygiene. In the asylums for foundlings and young infants, where feeding by the hand has been substituted for the natural nourishment, the mortality has been, invariably, the most appalling. Forty, fifty, sixty, and even as high as eighty and ninety per cent, of the infants being destroyed.—(.lr>?iles, the different leguminous and farinaceous seeds or roots, variously prepared—the saccharine fruits of the season, either cooked or perfectly ripe—and the various dishes consisting of milk and vegetables, in common use, are all well adapted as food for a nurse; and, with bread, should compose a con- siderable portion of it. Acid and unripe fruits, pickles, and similar articles, will very generally prove injurious to her milk, and of course to the infant she suckles. " I have known," remarks Marley," a plentiful secretion of milk to be diminished in quantity, from the over anxiety of the mother; who, thinking it necessary her nurse should live well, allowed her to eat a greater proportion of animal food than her stomach could digest. Others, who are fond of indulging an excessive and gross appetite, take advantage of their situation as wet nurses to satisfy their pro- pensity for eating, under the plea of having two to support; others object to certain meats, as being injurious to their little charge. In fact, it is well known that upon taking the situation of wet nurses, those women who, a short time previous, would have been thankful for a plentiful meal, however homely, are suddenly transformed into fastidious and dainty beings, considering their wants and wishes of the greatest importance. I have alwrays observed, that if a woman who is nursing eat heartily, but not immoderately, of plain food, avoiding that which is stimulating, she will, generally speaking, pre- serve her health, the result of which will be a plentiful secretion of milk. I consider meat once a day as quite sufficient." The only drink of a nurse should be water—simply water. All fermented and distilled liquors, as well as strong tea and coffee, she should strictly abstain from. Never was there a more absurd or per- nicious notion, than that wine, ale, or porter, is necessary to a female whilst giving suck, in order to keep up her strength, or to increase the quantity, and improve the nutritive properties of her milk. So far from producing these effects, such drinks, when taken in any quantity, invariably disturb, more or less, the health of the stomach, and tend to impair the quality, and diminish the quantity, of the nou- rishment furnished by her to the infant. They "excite," to use the words of a recent writer, "a feverish state of the body, and create an artificial thirst,—a thirst which is not expressive of any real want of the constitution, but a certain proof that the want does not exist. The greater the craving for them, under these circumstances, the more certain we may be that they are not needed, and that they will cause positive mischief to both mother and infant. The constitutions of both are stimulated by them beyond what nature ever intended they should be. The lawTs which govern the animal economy are positively infringed, and it is impossible that either mother or infant can escape the penalty of that infringement. Both will suffer to a certainty in some shape or other, if not immedi- MANAGEMENT OF CHILDREN. 51 ately, at a future period." " Thousands of infants are annually cut off by convulsions, &c, from the effects of these beverages acting upon them through the mother." (Courtenay.—London Lancet, FeWy, 1840.) Moderate daily exercise in the open air, which, while it is sufficient to counteract the effects of her sedentary occupation, is not carried to the extent of producing fatigue, a nurse should never be induced to neglect. The place in which the nurse resides, if the infant be committed to her charge in her own habitation, is far from being a matter of indif- ference. It should be either in the driest and most healthy part of the city, or, what is preferable, in a healthy situation in the country— always freely ventilated and kept scrupulously clean. A country resi- dence for a nurse has one important advantage,—it indemnifies, in some degree, the infant for its removal from the maternal breast, par- ticularly when the mother inhabits the confined and illy ventilated streets of a crowded city, the air of which is always more or less pre- judicial in early life. Infants have been found invariably to suffer, to a certain extent, in health, when, after being accustomed to respire the pure atmosphere of the country, they are removed to the city, and made to breathe the confined and impure air which prevails in too many of its streets and dwellings. The proper period for the infant to be taken from the breast, or weaned, and nourished altogether independent of the mother's milk, may be stated, as a general rule, to be at the termination of a year; within which period, however, the occasional use of other food may with propriety be allowed, according to the directions already given. At the termination of the twelfth month, the cutting of the first set of teeth is, in general, considerably advanced, and the digestive organs of the child are in a condition to effect promptly the solution of almost every species of plain and wholesome food; hence the propriety of depriving it entirely of the breast at this period. But when, as is occasionally the case, the process of dentition is more rapid, and the infant is at the same time healthy and vigorous, it may be weaned at any period after the tenth month; while, on the other hand, when den- tition is more tardy, or the infant is weak and sickly, it may be pru- dent, if the mother have a sufficient supply of milk, to continue it at the breast somewhat longer than a year. We are to recollect that, while the health of an infant is very generally impaired by its being too early weaned, on the other hand, by confining it too long to the breast, it may likewise be seriously injured, as well from a diminution in the nutritive properties of the mother's milk, as by this being no longer adapted to the condition of the digestive organs of the infant —the functions of which have become more developed—nor to the perfect nutrition of the several organs of the body. In deciding upon the proper period for weaning, the season of the year should be taken into consideration. In many parts of the United States, especially in the larger cities, this is indispensable to the safety of the infant. When deprived of the breast at the commencement of or during the summer months, its liability to a disordered state of the bowels, or to a severe attack of cholera infantum, is invariably much 52 DISEASES OF CHILDREN. increased. Hence the spring or autumn should, if possible, be invaria- bly made choice of for the period of weaning; and only under circum- stances of the most imperious necessity, should it ever be attempted during the season of greatest heat, unless the stomach of the infant has already become fully accustomed to other species of food, ami the functions of the digestive organs are performed with perfect case and regularity. In almost every instance, therefore, when, upon the ap- proach of summer, a mother ascertains that, from any cause, slip will be unable to suckle her infant until cool weather again returns, it will be more judicious to wean it somewhat earlier than, under other cir- cumstances, would be desirable; so that its stomach may become ac- customed to the new kind of food which is to take the place of the mother's milk, before the intense and continued heat of the weather shall have augmented the irritability of the entire alimentary canal, and rendered this liable to disease upon a change of diet. When, however, nothing occurs to prohibit it, the infant's safety from dis- ease will more certainly be secured, if the period of weaning be post- poned until after the heat of summer is over. When the diet of the infant has been properly attended to,previously to weaning, and it has, for some months, been accustomed to other food than the milk of its mother, it may be deprived at once of the breast, without the least fear of inconvenience resulting. It will,never- theless, not be proper to allow the infant, immediately after it is weaned, any amount of solid or stimulating food; neither should its diet be composed of too great a variety of articles. It should still be kept, for some time, upon a simple, bland, semi-fluid aliment, taken in moderate quantities, and at proper intervals; otherwise we run great risk of over-stimulating the system, or of oppressing the stomach, im- peding or disordering the digestive process, and thus impairing or disturbing the regular nutrition of the different parts of the body. At first, the principal food should be bread with milk—milk boiled with rice—soft boiled eggs—roasted potatoes with milk—oat meal gruel—plain rice pudding—the different preparations of arrow-root, tapioca and sago, and simple meat broths, mixed with the crumb of bread or grated crackers, or in which rice or barley has been well boiled. After a time the child may be gradually accustomed to a more solid and nourishing diet. LTntil the age of puberty, preparations of milk and the farinaceous vegetables should, in fact, constitute the principal nourishment. During youth, a large amount of animal food is not necessary, as many imagine, to promote the growth and vigour of the body, nor to pre- serve it from the inroads of disease; these important ends are much more certainly attained by a more simple and less stimulating diet. Whatever may be the kind of food allowed during childhood, it should never be taken in excess; we are to recollect, at the same time, that children have usually very keen appetites, and that a suffi- cient supply of nourishing food is absolutely necessary to renew the waste of their systems, and to supply materials for their daily growth. Three, or perhaps four, light meals a day, will, in general, be all that is necessary. At one of these, the dinner or mid-day meal, animal food MANAGEMENT OF CHILDREN. 53 —beef, mutton, or fowl, plainly boiled or roasted—may be allowed. in moderation; for the others, bread, or potatoes and milk, various preparations of rice, or rice and milk, plain rice or bread pudding, or custard, will form a proper and wholesome diet. All salted and high-seasoned dishes, all fat gravies, every kind of overdone and richly cooked food, should be forbidden. Some have objected to butter for children; experience, however, would appear to show, that a very moderate allowance of butter, when eaten upon bread, is by no means unwholesome. Of vegetables, po- tatoes, carrots, turnips, beets, and cauliflowers, will be found the most wholesome; they should all be of good quality, and, with the exception of the potatoes, should be well boiled. In general, the po- tato is most easy of digestion, and agrees best with the stomach, when roasted; it, as well as the turnip, should be 'eaten without being re- duced to a fine pulp, or mixed with butter or fat gravy. Children should never be indulged in cakes or pastry of any kind; they may occasionally take a little of the cooked fruit of a pie, but even this should be only in moderation. The drink of children should be simply water; or, occasionally, they may be allowed milk, milk and water, whey, or very weak tea, with milk and sugar. Pure water, however, is the only beverage calculated effectually to quench thirst, and promote a free and healthy discharge from the various excretory surfaces and glands; and when children are accustomed solely to its use, they crave no other drink, but prefer it on all occasions to every other. Stimulating liquors, whether distilled or fermented, are not merely unnecessary during childhood, but positively injurious; by the undue excitement they produce, they endanger the occurrence of fever, indigestion, inflam- mation, or convulsions, to say nothing of the danger of a taste for "these pleasing poisons" being induced, leading, in after life, to habits of confirmed and beastly intemperance. The period of a child's meals should be so regulated, that the in- tervals between them may not be so great as to permit a sensation of hunger being experienced for any length of time; but at the same time a sufficient period should be allowed to elapse between the meals, to prevent a disturbance of the digestive process by the intro- duction of new food into the stomach, before it has properly disposed of that already taken. Children should get their first meal or breakfast, as soon as pos- sible after they have risen, and have been properly washed and combed; their stomachs are then empty, and the appetite is, in gene- ral, keen. If food be too long withheld under such circumstances, the cravings of the stomach become either too importunate, and too much food is taken, or the appetite entirely fails. Supper, or the last meal, should invariably be composed of the plainest and lighest articles of food, and be taken an hour or two before bed-time. As little variety of food as possible should be set before children, since every additional article becomes a new incentive to appetite, and consequently to excess. They should never be indulged with a second course. If they sit down with an appetite, they will always satisfy it 54 DISEASES OF CHILDREXX bv eating freely of the first article presented to them; hence all the rest is superfluous, and therefore injurious. If the appetite be but slight, the less they eat at the time the better,—as by taking but little the appetite will more certaiidy return at the next meal. But should this instinct of nature for an observance of moderation be neglected, or be attempted to be overcome by variety, repletion, with all its evils, will certainly ensue. Instead of a renewed and healthy appe- tite following, as would have been the case had the instinct been obeyed, the appetite will be found diminished, and even headache, fever, oppression, nausea, or vomiting may occur. Children should not be allowed to eat frequently of bread, bread and butter, bread and molasses, sweetmeats, cakes or fruit, between meals, for this will'either destroy the regular appetite, or induce them to eat too much. In the first case, the stomach will be inter- rupted in its regular routine of function, consequently the appetite will be either irregular or capricious; in the second case, all the evils attendant upon an over-distention of the stomach must follow^. They should, therefore, not be suffered to carry food in their pockets, to eat between meals, or during school-hours,—as this produces the in- jurious habit of requiring food at improper times, by which the di- gestion of the previous meal is interfered with—a fresh quantity of food being forced upon the stomach before it has properly digested that previously received. We are far from advocating the plan which debars a child from " an adequate quantity of wholesome food at any period throughout the day, when the cravings of a natural appetite ac- tually demand it;" but we nevertheless believe it far better that the child should be accustomed to partake of food only at regular periods; and this is very soon effected, when those periods are made to corres- pond pretty closely with the periods of stomachic digestion. Children who have no regular times for their meals, in general eat too much, and when refused food, however often they may crave it, become fretful and discontented. " They eat all day long—and soon impair their digestive powers, and become sick and debilitated." Children should be early taught to eat slowly and deliberately, so that each portion of whatever solid food they take may be fully mas- ticated. To hurry children at their meals, by requiring them to finish as soon as their parents, though they may be helped last, and have usually much greater appetites than adults, is injurious, by obliging them either to leave off before they have had enough, or to swallow their food without its being properly comminuted by chewing. Children are to be restrained from any violent exercise immediately after eating. They need not be kept perfectly at rest, but merely prevented from engaging in any pastime or occupation that requires considerable bodily exertion; and, as they should be early accus- tomed to eat slowly, and chew their food well, on this account alone the habit of resting after a meal is of importance, as it prevents them from swallowdng their food hastily, in order that they may return more quickly to their play. In regulating the diet of children, care should be taken not to force any particular article upon them, after it is found, by fair trial, not to MANAGEMENT OF CHILDREN. 55 agree with their stomachs. The contrary practice is both cruel and injudicious: cruel, because the poor child is forced to swallow what is disagreeable to it; and injudicious, because it is liable to perpetuate a disgust which, most probably, wTould have subsided, had no forcible attempt been made to overcome it. At the same time, however, great care must be taken that permanent, capricious dislikes are not formed at this period of life against certain wholesome articles of food. This, however, is often a matter of very great difficulty—a good deal of close observation and discernment being required in order to distin- guish between a wayward prejudice and an actual disgust. The «•» former, if indulged in too long, may be converted into the latter— while the latter may often, by judicious and well adapted means, be entirely removed. Children should never be allowed to eat alone, unless the proper amount of food be meted out to them; otherwise they will, almost always, eat too much. Whenever a child demands more than is judged proper for it, its importunities should always be resisted with firm- ness, or it will too certainly acquire habits of gluttony. Children would seem to have a natural taste for sugar, and all arti- cles in which saccharine matter abounds; and they, in fact, are able to partake of a greater quantity, and for a greater length of time, of these articles, without their appetite becoming cloyed, than is the case with adults. Whether or not children should be indulged in the use of sugar and other saccharine substances, has, however, been made a grave question of dispute by physicians. " He," says old Slare, " that undertaketh to argue against sweets in general, taketh upon himself a very difficult task; for nature seems to have recommended this taste to man and all sorts of creatures." Nevertheless, there are writers, and of no mean eminence, who condemn, in the strongest terms, the use of sugar and other sweet substances, as injurious to the stomach, destructive to the teeth, and otherwise prejudicial to the health of the system. Howr such an opinion could have originated it is cer- tainly very difficult to imagine; so far from any bad effects being pro- duced by the free use of sugar, at least under the ordinary circum- stances of health, it is shown, by the most conclusive evidence, to be a highly nutritious and useful article of diet. It is, in fact, to the saccharine matter they contain, that a long list of fruits and other vegetable productions, which constitute so large a portion of the food of man, and of the inferior animals, owe their nutritive properties; and experience has fully shown that sugar forms a very proper addition to the food of children as well as of adults. "It is the only condiment," says Leroy, "proper during the period of infancy." Whether, however, pure sugar can be eaten by itself, with perfect safety, is somewhat doubtful. To ensure its ready digestion, and in that manner prevent its turning sour in the stomach, it would appear to be necessary that it should be combined with other alimen- tary substances. It is in combination Avith mucilage and other vege- table matters, that it is met with in the juice of the cane, and in those fruits which the experience of mankind has shown to be the most nutritious. Hence, as a general rule, sugar should be given to chil- 56 DISEASES OF CHILDREN. dren rather as an addition to less palatable articles of diet, than as the principal food. Much difference of opinion, also, exists as to the propriety of allow- ing children to partake of fresh fruits: by many they are entirely in- terdicted, while by others their allowance is qualified by numerous restrictions not very easy, under ordinary circumstances, to be ob- served. By a healthy child, nearly all the saccharine fruits, when perfectly ripe and mellow, may be eaten in moderation with perfect safety; they furnish a very grateful and proper addition to their ordi- nary food. It must be recollected, however, that the wholcsomeness of fruit is always in proportion to its pulpiness, and to its saccharine and mucilaginous qualities. Unripe fruit, of every species, is deci- dedly injurious—as well on account of its being almost entirely indi- gestible, as from the injury inflicted upon the stomach by the crude acid juices it contains. All fruits that are invested with a firm cuti- cle or skin, are also improper for children: but the ripe pulp of those fruits, as in the case of grapes, where it can be entirely freed from the skin and seeds, is in general sufficiently wholesome and nutritive. Fruit containing an abundance of small, hard, and insoluble seeds, as strawberries, blackberries, whortleberries, currants, and the like, should be eaten by children only in very moderate quantities, as the seeds are liable to be retained in the alimentary canal, and may ex- cite considerable irritation of its lining membrane. Cherries are among the most pernicious fruits in common use, and ought to be wholly excluded from the list of articles with which chil- dren may be occasionally indulged. Even when eaten without the stones, they are peculiarly apt to derange the bowels; and when swal- lowed with the stones, which, with children, is not unfrequently the case, they are capable of producing violent, and even fatal impres- sions on the alimentary tube. No small number of instances have come under my notice, Dr. Eberle remarks, where the most alarming, and, in a few cases, fatal consequences, resulted from the irritation of cherry-stones lodged in the bowels. Convulsions, inflammation, unconquerable constipation, and exhausting and harassing diarrhoea, are among the affections which are apt to arise from this cause. Fruits stewed or roasted, with the addition of sugar, are always very acceptable to children, and when tolerably ripe, and not too sour, in general agree well with their digestive organs. The same remark will apply to fruits preserved in sugar: when eaten in moderation, with milk or bread, they form an innocent, and in the case of the habitually costive, an advantageous addition to their meals. They are improper only when the bowels are peculiarly irritable and liable to be disordered from slight causes—when taken in immoderate quantities, or upon a loaded stomach. Dried fruits, when deprived of their skins, and stewed with the addition of sugar, seldom produce any injury to the stomach of a child; but when uncooked, and eaten with their skins, they are difficult of digestion, and disorder, often to a very considera- ble extent, the digestive organs. We have, in repeated instances, seen attacks of violent vomiting and purging—distressing colic—and even convulsions of a very dangerous character, produced from the use of MANAGEMENT OF CHILDREN. 57 this kind of fruit—notwithstanding the amount taken has not been in the least degree immoderate. 5.—Sleep. During the first period of its existence, an infant passes the greater part of its time in sleep; it awakes merely to satisfy the instinctive calls for food, and, when these are appeased, falls again into a state of repose. This tendency to sleep is a wise provision of nature—abstract- ing the infant, for a time, from the influence of those agents, the con- tinued action of which would cause too great an excitement of its nervous system, and interfere with the regular and perfect perfor- mance of the functions of its various organs. Almost constant sleep is, in fact, equally important to a newr-born infant as sufficient and proper nourishment, in promoting the growth and due development of its system. We may rest assured, that whenever an infant is wakeful and rest- less for many hours, during the day or night, it suffers from too much or improper food, tight clothing, or from some uneasy sensation pro- duced by other causes. After the lapse of a few weeks, however, the senses become cognizant of external objects, and the sleep of the infant is less continued, occurring only when the organs, fatigued by the exercise to which they have been subjected, require to have their ener- gies renewed by repose. The infant sleeps now less during the day, when at night its repose is seldom broken. When six months old, it may be accustomed, by proper management, to require sleep only at regular periods, and soon after, during the night alone. As soon as this can with propriety be effected, it is of advantage to both child and mother. The sleep of an infant, to whatever period it is confined, should be the result, always, of the natural tendency to repose, prompted by pro- per nursing, and never, either by day or night, should it be procured by the administration of opiates. The mother or nurse, who, to gain time for other occupations, or to prevent her own repose from being disturbed by the wakefulness of the child during the night, causes it to sleep by the administration of stupifying drugs, runs the risk of pro- moting her own ease and comfort at the expense of the health and life of the infant. " Many an infant," says Combe," the true cause of whose death was not always suspected, even by the guilty person, has thus passed prematurely to its grave." A young infant requires a soft, warm couch for its repose, with sufficient covering to protect it from the slightest impression of cold. The covering should, however, be at the same time sufficiently light to prevent undue pressure upon any portion of the infant's body, and so accommodated to the state of the weather, as to preserve a suffi- cient degree of warmth, without overheating the child or endangering profuse perspiration. It is too much the custom to lay an infant, when asleep, with its body warmly clad, in a feather-bed, and to cover it carefully with a thick blanket or two. * The consequence is, that in mild weather, or in a warm room, a copious perspiration is quickly produced, which, besides weakening the child, exposes it to catarrhal 53 DISEASES OF CHILDREN. or even more dangerous affections, when, upon its awaking, it is ex- posed to the air of the room, or perchance to the draft from an open . door or window. During the first few weeks after birth, it is perhaps best that the infant should sleep at night in the same bed with its mother, especially if the weather be cold; subsequently, however, it may be accustomed by night, as well as by day, to sleep in a cradle or cot. " By a few physicians it is advised to have the cradle invariably without rockers—the motion communicated to the child in rocking being considered decidedly injurious. There are few infants, however, to which this motion does not appear to communicate a pleasing sen- sation, predisposing to quietude and sleep; and we are convinced that when gentle, and not employed to induce a state of repose at impro- per periods, it can be productive of no possible inconvenience or injury. We admit that violent, long-continued rocking, by the sudden and repeated jolts it communicates to the tender organs of the infant, may be productive of injury, and should, therefore, never be allowed. There is one disadvantage, however, resulting from the use of a cradle, which is, that infants often become so habituated to its motion as to be with difficulty made to sleep without it: they require, in consequence, an almost constant attendance, awaking the moment the motion of the cradle is suspended, and continuing to cry until rocked to sleep again; whereas, infants who have been accustomed to sleep in a cot, will remain comfortable and quiet for hours even after they awake. The cot has unquestionably some advantages over the cradle; nevertheless, with proper precautions, either may be adopted, according to the taste or convenience of parents. It is, unfortunately, too often the case, that in infants the natural instincts in regard to sleep and wakefulness are but little attended to. An infant is often aroused improperly from its repose, because it may be convenient for the mother or nurse at that particular moment to wash and dress it, or from a supposition that it has been too long without the breast; while, on the other hand, every means, and often very improper ones, are frequently made use of to force an infant into a state of repose when not inclined to sleep, or to prolong its repose when it is about to awake. The effect of this improper interference is to render the infant restless, peevish, and far more troublesome than it would have been had it been allowed to indulge freely its natural dis- position to repose or to wakefulness. When an infant is in perfect health, properly clad, and judiciously nursed, it seldom gives much trouble; it awakes when it requires nourishment, and falls readily asleep when its system demands repose; and every attempt to inter- fere with this natural state of things is attended with more or less injury to the health of the little being. When a healthy infant does not fall speedily asleep on being placed in its cradle, but lies awake, fretful and restless, we may in general be certain, either that it does not feel the want of repose, or that some- thing incommodes it or causes it pain; that some portion of its dress is too tight; or the point of a pin is in contact with its body: that it is in want of food, or has been over-fed or with improper aliment • or MANAGEMENT OF CHILDREN. 59 that it is suffering from cold or heat, or from a too confined or impure atmosphere. It will be readily perceived, therefore, that the only proper means to lull it to sleep is to remedy at once the cause upon which its wakefulness depends. It is important that the sleeping couch of an infant be placed in such a position that the eyes of the occupant shall be screened from a daz- zling or unequal light, and the latter prevented from falling upon them sideways or very obliquely. When the light which enters the apart- ment is moderate, and of a mellow character, the face of the infant should be directly in front of it; but when intense or dazzling, it is better to place the infant in such a direction as to allow it to fall upon the back part of the head, or on the back of the cradle or cot. When, in the evening, a lamp or candle, or an open fire is burning in the room, the same precaution should be observed. As an infant, the moment it wTakes, directs its eyes almost instinctively towards the light, there is danger, unless this be uniformly diffused throughout the apart- ment, or placed in a direct line with the eyes, that the child will acquire a permanent obliquity of vision, from the habit of viewing it sideways. This deformity is more particularly liable to take place, and to a much greater extent, when, from the head being sunk in the pillow, or enveloped in a cap with a projecting border, the light can "be viewed only with the eye which is the farthest from it. The position in which an infant when asleep is laid upon its couch, is a matter of much greater importance than, at first view, it would appear to be. If it be placed upon its back, the fluids which are abundantly secreted by the glands of the mouth and throat, are in danger of flowing into the windpipe, and thus impeding respiration, or causing a violent—almost spasmodic—paroxysm of coughing, which may be avoided by the infant being laid upon its side. Care should be taken, however, not to lay it always upon the same side of the body, lest permanent deformity be occasioned in consequence of the circu- lation of the blood, in the limbs upon which the infant constantly rests, being partially impeded, and their proper growth in this manner prevented. The face of an infant should never be entirely covered, nor so im- bedded in the pillow as to obstruct, in the least degree, the freedom of respiration. Occasionally it happens, that when a young infant is placed in a soft feather bed with a thick, soft pillow, its own weight causes it to slip, so that its head is brought entirely beneath the exter- nal coverings, and, in common with its body, becomes so completely buried in the feathers as to endanger suffocation. This accident is best guarded against by dispensing with the pillow entirely. In cold climates, and during the winter season, a feather bed is cer- tainly a very effectual means of securing to a new-born infant a neces- sary degree of warmth; but after a few months, especially in summer, or when the temperature of the air is mild, a well-constructed hair mattress, with a proper amount of light, soft bed-clothes, is to be pre- ferred. Independently of the undue degree of heat which is gene- rated by a feather or down bed and pillow, and the exhaustion which thence ensues, the attitude into which the infant's body falls during 60 DISEASES OF CHILDREN. sleep may induce, when it is resumed every night, a permanent dis- tortion. A feather pillow, also, by keeping the head too warm, not unfrequently becomes the remote or exciting cause of catarrhal af- fections, inflammations of the ear, eruptions, pain of the head, or even more serious disease. For the same reason, children should be ac- customed, from an early age, to sleep with the head bare—the cover- ing with which nature has, in general, so plentifully supplied this por- tion of the body being amply sufficient to protect it from cold. The cots occupied by infants should always be without curtains. which do injury, by preventing the proper circulation of the air; they become also receptacles for fine particles of dust, which are liable to be inhaled during sleep, whenever disturbed by the motion of the curtains or of the cot: this alone, according to Willich, is a cause to which may be referred the origin of many a consumptive attack in early life. Children should never be allowed to sleep on beds placed upon or too near the floor. It is well known, that in all apartments occupied by living beings, the inferior portions of the atmosphere are always the most impure. The most wholesome situation for a bed is in the middle of the room, and raised some feet from the floor. From the vitiated state of the atmosphere immediately above the latter, and the great importance of a free ventilation, the practice of placing the chil- dren's bed or cot beneath another bedstead, during the day, cannot be too severely reprobated. The chamber occupied by children, during their hours of repose, should be kept scrupulously clean, and free from dampness; and at all seasons, when the weather is not rainy or otherwise very humid, it should be freely ventilated during the day. It should be divested of all unnecessary furniture; and, unless of considerable size, should never contain more than one bed. There cannot be a more perni- cious custom, than that pursued in many families, of causing chil- dren to sleep in small confined apartments, in which two or three beds are crowded together. Plants, flowers, and strong perfumes of every kind, should be care- fully excluded from the sleeping apartments of children. The first have a tendency to render the air of the apartment impure, and the latter have been found to produce a very deleterious impression upon the nervous system of young children. An instance is related by Kopp, of a child, two weeks old, destroyed by the scent of savine oil, which became diffused through the room in which it was sleeping, while the father was applying it to his thigh as a rubefacient for the remo- val of a rheumatic affection. The child until then had been perfectly healthy, and no other apparent cause of death could be discovered. Children should not be allowed to sleep with persons advanced in age, nor with those of a broken down or debilitated constitution, or who are labouring under any chronic disease. The idea that any in- jury to health can result from passing the night in the same bed with the aged, or those who are labouring under any other than contagious or infectious maladies, has been ridiculed by some physicians, while bv others it is considered as fully established by numerous facts. We are MANAGEMENT OF CHILDREN. 61 amono* the number who believe the apprehension of injury from this cause°to be well grounded. Although we are not prepared to assert, with Carault, that in "young infants, accustomed to sleep with their grandfathers or grandmothers, or with an aged nurse, that part of their bodies, which, during sleep, approaches the nearest to their bed- fellows, will become enfeebled, pale, and emaciated," yet we have seen, in more than one instance, the general health of children sensibly impaired by sleeping with old and diseased persons—and quickly restored when the practice was discontinued. By many of the continental writers, to prevent the too frequent and close contact of young children with adults generally, of whose entire health we are not well assured, is considered, and we think very pro- perly, to be an important question. It is unquestionably a filthy and pernicious custom, remarks Struve, to suffer infants to be indiscrimi- nately embraced, fondled, and kissed by strangers or servants; be- cause in this manner there is danger of their becoming infected with many virulent diseases. But even though no particular malady should be imparted by their close contact with strangers, it is to befeared that the humours of the child may be contaminated by absorbing the poisonous saliva of a diseased individual. A young child should not be awoke from its sleep suddenly—nor by any rude motion or loud noise. The shock which is thus inflicted on its delicate brain and nervous system may occasion a severe attack of convulsions, spasmodic closure of the glottis, and other equally severe and dangerous effects. " Being of opinion," remarks a quaint old writer (The Marquis of Halifax,) "that it did trouble and disturb the brains of children, suddenly to awake them in the morning, or snatch them violently and over-hastily from their slumbers, wherein they are much more profoundly involved than we, my father caused me only to be waked by the soft strains of some musical instrument." To prevent infants from starting from their repose in affright at every slio*ht noise which occurs in their vicinity, no particular pains should betaken to maintain perfect silence when they are about to fall asleep, nor during their repose. If accustomed to the ordinary sounds of the nursery, they will fall readily asleep amidst them, and much of the danger of their being suddenly awoke or unnecessarily disturbed, is removed. With Combe, we agree that, when asleep, an infant should be excluded from "light and noise:7 "Even when they do not pre- vent sleep, these tend to render it troubled and unrefreshing;" and thev commit a great and pernicious mistake, who "act in direct oppo- sition to this rule, and think it of no consequence what talking or noise goes on in the nursery, provided the infant be not roused up broad awake." It is to the opposite error, of attempting to exclude from the vicinity of a sleeping child every kind and degree of sound, that we object. We have known children who have been so accustomed to a dead silence when falling into sleep, and during its continuance, that the occurrence of the most trifling sound would immediately awake them, and, if a little louder, would cause an alarming excite- ment, of long continuance, and difficult to subdue. ^ Children should be accustomed, from a very early age, to retire to 62 DISEASES OF CHILDREN. bed early in the evening, and to rise the moment they awake after day-light. Habits are thus formed, of the utmost importance to their health and comfort throughout life. 6.—Exercise. For the first few weeks of its existence the infant requires but little exercise of any kind; and it is not until some months have elapsed that its organization has acquired a sufficient degree of firmness, to permit of its enjoying any other than such as is of the most gentle, passive kind. From an early period, however, gentle friction with the hand over the whole surface of the body, carrying it abeut in a horizontal or slightly reclined position on the nurse's arms, cither within doors, or when the weather will permit, in the open air, will not only communicate a pleasurable sensation to the infant, but, by promoting a free and equal circulation of the blood, contribute to the full and regular development of every part of its body. But while this amount of exercise is decidedly beneficial, and should not be neg- lected, we are to recollect, that every species of dandling and toss- ing—every kind of motion, in fact, excepting of the gentlest kind, is liable to produce present discomfort, if not permanent injury. For the first month or two the infant should be handled as little as possible, and never placed in an erect or sitting posture. To set it upon the lap while its bones are soft and pliable, its joints slight, and imperfectly developed, and its muscles small and feeble, and to jolt it thus by the hour—its poor little head moving about as if palsied, and its tender back bending and twisting from side to side—is the very- worst plan that can be adopted to minister to its comfort, or to pro- mote its regular and symmetrical growth. Many nurses would appear to think that the greater the amount of motion to which an infant is subjected the better: they toss and roll it about as if it were a bundle of rags, and pull and twist its limbs, till the joints crack. Under such treatment, it is not to be wondered at that the poor child moans, cries, or screams, during the whole time occupied in dressing it, or that it should suffer from deformities and other injuries. Another barbarous practice is that of tossing an infant up and down in the arms, held at full length from the body. The motion thus com- municated is of too violent a kind to be borne with impunity by the tender frame of a young infant, to say nothing of the serious accidents which may result from the practice, even when the utmost care is observed. Until an infant is able to sit alone it may be allowed to amuse it- self upon its cot, or on a soft cushion spread upon the floor; here it will lie for hours, until it acquires strength to roll about, and is much more contented, and thrives far better than when continually nursed in the arms or upon the lap; the danger of deformity is likewise avoided, and the child acquires, at a more early period, the power to raise itself, and sit upright, without assistance; and at nine or ten months will, in general, be able to get upon its feet and walk. When sufficiently old to be attracted by surrounding objects car- MANAGEMENT OF CHILDREN.' 63 rying it frequently into the open air, especially into the country, during the mildest seasons of the year, has a highly beneficial ten- dency. The freshness, beauty and variety of the scenes of nature, are highly attractive, even at a very early period of life; and independ- ently of the healthful influence of a pure and unconfined atmosphere, the impressions thus resulting are always of a decidedly salutary kind. In carrying an infant, some important precautions are necessary. The spine, being soft and yielding, is incapable of supporting the weight of the head, and other parts of the body which rest upon it in the erect posture. To prevent deformity, therefore, an infant should not be held seated upon the arm of its nurse or attendant; it ought always to be carried in an inclined position, so that the head, and every part which bears upon the spine, may receive an equal and adequate support. Neither should the child be carried for too long a time in the nurse's arms without changing the position in which it is held—otherwise there is a danger of its becoming per- manently deformed, from its body being twisted to one or the other side. To obviate this, the child should be carried, alternately, on both arms. Even in suckling an infant, it is important that it be not confined exclusively to one breast, but nourished alternately, from both—as well to prevent its contracting a crookedness of form, as to guard against its acquiring a habit of squinting, from one of its eyes, while nursing, being constantly directed towards one point. Infants, in general, derive much pleasure from riding in a little car- riage drawn by the hand—and as it affords a convenient means of conveying them, frequently, when the weather is mild and otherwise favourable, to one of the public squares or parks which exist in most of our larger cities, or even to a garden or field without the town, where they may enjoy a free and fresh air—this species of exercise may be occasionally substituted for carrying in the arms— to which, for out-door excursions, it is, for very young infants, in many points of view preferable. The body of the carriage should be long enough to permit the in- fant to lie down at full length; and the sides ought to be sufficiently high to prevent it falling or rolling out. The wheels should be low, in order to lessen the liability of oversetting; and they should be carefully secured against running off when the carriage is in motion. Very young infants should be laid down in the carriage on a pillow or soft mattress, with the head slightly elevated, and so confined at the sides as to prevent them from rolling when in motion. After the child has acquired some degree of strength, it should be placed in a semi-recumbent posture, with its head and back supported by pillows, &c.; and when it is capable of supporting its head, it may be permitted to sit upright, and properly secured against being thrown from side to side, by the rolling of the carriage. The carriage should be drawn by none but a prudent and trusty person, with a moderate and steady motion, and never over rough or uneven ground: when the motion is too rapid, or uneven and jolting, much injury may be inflicted on the infant. Children, when placed in the carriage, should never be kept stand- 64 DISEASES OF CHILDREN. ing in the sun, if it be warm; nor should they be kept motionless, when the weather is cool. In cold weather, they should be amply covered, since from the passivencss of their situation, they will re- quire additional clothing. Nor should the ride ever exceed half an hour at a time, especially if the child is observed to become sleepy- it being hazardous to allow children to sleep in the open air; and after a few trials, the exercise almost invariably will predispose them to sleep^and thus destroy the benefit of the exercise, as well as in- terfere with their regular habits of repose. (Dewees.) It is only towards the end of the ninth or tenth month, and, when the child is feeble, even much later, that it is proper to teach it the use of its feet. It is perhaps always better that, before an infant attem] >ts to walk, it should first learn to crawl. With this intention, it should be placed upon a soft carpet, where it soon busily employs itself, moves and extends its limbs, or rolls about to reach its playthings. The instinc- tive desire for locomotion, and the various things that attract it in different parts of the room, will soon induce it to crawl upon its hands and feet. This it should be allowed, and even encouraged to do; as children who are permitted this " useful intermediate muscular dis- cipline," are sure to acquire a much firmer step, and enjoy more robust health, than those who have been taught to walk without it. In no instance should any particular attempt be made to induce children to use their feet at an early period, nor until the bones have acquired a sufficient degree of solidity to sustain the bod}r, without the danger of their becoming bent by its weight. In teaching a child to walk, it should be left pretty much to its own efforts; all artificial support is injurious. As generally applied, such support has a tendency to produce an unnatural elevation of the shoulders, wdiile the infant, depending upon it, almost alone, for maintaining the upright position of its body, is accustomed to bend too much forward, or to one side. By this may be laid the founda- tion of a permanent deformity, or at least of an ungraceful gait, which it is impossible in after life to correct. While in the nursery, infants may be taught to rise from the floor by laying hold of chairs; and, if occasionally supported under the arms, they will easily learn to stand erect; but they should never be raised up by one arm only. At an early age they may be held under both arms; and when thus supported, if the hands of the attendant be occasionally withdrawn for a moment, they will soon acquire the power of standing alone. Mild and persuasive language ought to be used in these experiments; while the infant may be encouraged by some toys, placed at a little distance, which will induce it to stretch out its little arms, and endeavour to advance towards the place con- taining the desired objects. By such means, it may be allured to visit different parts of the room. The first journey of this kind ought to be attempted only from one neighbouring chair to another; after- wards the little traveller may run towrards its mother, or nurse, who, with extended arms, stoops to receive it. As the infant improves in its efforts to walk alone, the chairs may be placed at a greater dis- tance from each other, until, finally, it walks firmly in every direction . without assistance of any kind. (Struve.) MANAGEMENT OF CHILDREN. 65 The practice of assisting a young child to walk, by holding him by one of his hands, is extremely reprehensible; the child's arm being thus continually and, more or less forcibly, extended upwards, should the little pedestrian lose his balance, or trip, or if, from the feebleness of his limbs, he be unable for any length of time to maintain the erect posture, the whole weight of his body becomes suddenly suspended bv one arm. It is easy to perceive that this practice must necessarily, and in no inconsiderable degree, tend to draw the shoulder and side of the chest out of their natural position, and, when frequently repeated, to cause permanent deformity of these parts. From the sudden and violent extension which the arm usually receives when the child stum- bles, the shoulder and elbow joints, also, are liable to be dislocated or sprained, or the clavicle may be torn from its attachment with the scapula. Dr. Eberle remarks that he has met with several instances of dislocation of the shoulder joint, which were occasioned in this manner; and the occurrence of painful sprains—often of several weeks' continuance—from violence done in this way, is by no means uncommon. Similar injuries are also inflicted by raising the child from the ground by one arm, in order to help it over some obstacle or. to hasten its progress over a rough and difficult piece of ground. We have seen a heavy child carried thus, by one arm, for a considerable distance. The practice cannot be too strongly condemned. Some of the most violent and troublesome affections of the elbow and shoulder joints that we have met with in children were thus induced. As soon as a child has acquired sufficient strength to walk alone, he should be allowed the most perfect freedom of exercise; upon this, with the free use of pure air, will depend, in a great measure, his health, vigour, and cheerfulness, during the period of youth, while it will contribute essentially to the permanence of the same blessings until the close of life. Throughout the whole animal kingdom the young are prompted, by an instinctive impulse, to almost constant exercise. Conformable to this intimation of nature, a large portion of the youth of man should be passed in those harmless sports, which exercise the limbs, dilate the chest, and communicate motion and vigour to every part of the body susceptible of it, without, at the same time, requiring any mi- nute direction from the head. Experience has shown that when attempts are made in early youth, to interfere with the natural movements and exercise of the body: when, from a false idea of improving the shape, or giving grace to the carriage, children are debarred the free and unrestrained exercise of their limbs, and are confined to any particular position for too long a period, they become restless and uneasy, and their muscles ac- quire tricks of involuntary motion. % Twitching of the features, ges- ticulations of the limbs, even dangerous and permanent deformity. or some severe nervous affection, may be the result of such unnatural restraint. Error in this respect, it is true, is but of occasional occur- rence in the physical education of boys. But how often has an over- anxiety for delicacy of complexion in a daughter, or the apprehen- sion that her limbs may become coarse and ungraceful, and her ha- 5 66 DISEASES OF CHILDREN. bits vulgar, been the means of debarring her from the enjoyment of either air or exercise, to an extent sufficient to insure the due deve- lopment, health, and vigour of her body. The consequence is, that in too many instances, females acquire in infancy a feeble, sickly, and languid habit, which renders them capricious and helpless, if not the subjects of some troublesome or painful disease, which may continue throughout the whole course of their after lives. The bodily exercises of the two sexes ought, in fact, to be the same. As it is important to secure to both all the physical advantages which nature has formed them to enjoy, both should be permitted, without control, to partake of the same rational means of insuring that vi- gour of body and cheerfulness of mind, which will enable their va- rious organs to perform, regularly and perfectly, their respective functions; and by which alone their health and comfort can be con- firmed. Girls should not, therefore, be confined to a sedentary life, within the precincts of the nursery, or, at most, permitted a short walk, veiled and defended from every gleam of sunshine, and from every breath of air. The unconstrained enjoyment of their limbs and muscles in the open air, without a ligature to restrain the free- - dom of their motions, or an over-watchful eye to curb the lively joy of their unclouded spirits, is equally important to their health and well-being, as it is to that of their brothers. To hope to communicate graceful form and motion to the limbs of a child, health and vigour to its constitution, and cheerfulness to its spirits, by confinement, belts, ligatures and splints, superadded to the lessons of the posture-master, is about as rational as would be the attempt to improve the beauty and vigour of our forest trees, by transferring them to the green-house, and extending their branches along an artificial framework. Equally absurd and irrational is it to fetter the active motions of a child, almost as soon as he has acquired the free use of his limbs, under the pretence of improving his mind. To confine a lad within doors, and especially in the heated and impure air of a crowded school-room, for the greater part of the day; to chain him to a desk, and require him to fix his attention, hour after hour, upon tasks, al- ways without interest, and often beyond his comprehension, may be a certain way to train up innervated puppets, or to produce, per- chance, a short-lived prodigy of learning; but it is illy calculated to form healthy, well-informed, and accomplished men. Every feeling heart must have looked with pity upon the sickly countenance and melancholy aspect of the poor little puny creatures of eight, ten, or twelve years, sometimes exhibited by parents as pro- ficients in learning, or for their early acquirements in languages, elo- cution, music, or drawing. Debarred from the healthful and joyous pastimes adapted to their age, and from inhaling "the pure fresh breath of heaven," their mind has been forced, through constant, pain- ful application, to a premature, but imperfect and unequal exertion of its faculties, the effect of which is to exhaust its powers and impede its full development; while, at the same time, the natural cheerfulness of youth is destroyed, the health and vigour of the body materially im- MANAGEMENT OF CHILDREN. 67 paired, the duration of life shortened, and the remaining period of existence rendered too often a burden rather than a blessing. We are far from objecting to an early attention to the proper cul- tivation of the intellect. All we insist upon is, that it should not, in early youth, be taxed beyond its powers; but that the greater part of every day should be devoted to active exercise in the open air. There is not, perhaps, remarks a sensible German writer, a greater and more reprehensible mistake in education, than the very common practice of compelling children to extraordinary mental exertions, and exacting from them an early and rapid progress in intellectual pursuits; this is, too often, the grave both of their health and of their talents. The age of infancy is designed for bodily exercise, which strengthens and perfects the frame, and not for study, which enfeebles it and checks its growth. Let the beginning of life, the first six years, perhaps, be devoted entirely to forming the body and the organs of sense, by exercise in the open air. It is not necessary that the child should be permitted to grow up like a wild animal; for, with proper care, his mind may be made to receive considerable and valuable instruction, through the medium of the senses, and the conversation of those around him. In these two ways he may, indeed, acquire more useful knowledge, by the end of his sixth year, than a child who had learned to read in his fourth. In his seventh year, he may spend an hour or two daily at his book; in his eighth, three hours; and so on until his fifteenth, when he may have six or seven hours allotted for study. Children are frequently confined to the school-room for many hours daily, when not occupied in any useful pursuit;—which time, without detracting from that necessary for the cultivation of the mind, might, with great propriety, be devoted to those bodily exercises and recrea- tions which tend to develope the strength, and promote the regular and energetic action of every organ of the frame—the brain and ner- vous system included. The first occupations of the day should be abroad, for the benefit of inhaling the early morning air. There is always a striking differ- ence in the health and freshness of complexion, and cheerfulness of features exhibited by the child who has spent some time in out-door exercise before his morning task, and the one who passes immediately from his couch to study, or other in-door occupations. Children are always fond of early rising, when their natural activity of disposition, and disinclination to remain long in a state of quiet, have not been counteracted by habits of indulgence. We are to recollect, that it is not amusement alone that is sufficient to confirm the health, and promote the growth and regular develop- ment of the frame, in childhood. Hence, as Struve well remarks, sedentary games are improper for children, whose principal occupa- tion should be to exercise their limbs. To walk, to run, to skip, to jump, to put things together, and sepa- rate them; to erect and destroy houses built of blocks and other simi- lar materials; to trundle a hoop, fly a kite, or arrange, construct, and manage little vehicles in their own way; all these are diversions that 68 DISEASES OF CHILDREN. ought to be scdulouslv encouraged, and the necessary articles for their pursuit supplied. The latter, however, should be simple, and of little intrinsic value, as this is soon enhanced in the possession of the young. For. boys, a ball, a top, a hobby-horse, a little chaise, a wheelbarrow, which children can manage without any extraneous assistance, are preferable to more expensive toys, which afford amusement without exciting to bodily exercise. A somewhat similar remark may be made in relation to the playthings proper for female children:—it is a material error in physical education, to make that ill founded dis- tinction between the sexes, which condemns female children, from the cradle, to a sedentary life, by permitting them scarcely any other playthings than dolls and tinsel-work, or toys, while their sprightly brothers are amusing themselves in the open air, by beating their hoop, or by other active diversions. Such premature confinement is dearly purchased at the expense of health and of a cheerful mind. All amusements, even the most active, are most beneficial wdien pursued in the open air. Were it possible to keep children of both sexes continually in the fields and gardens, there would be no neces- sity for supplying them with playthings;—the natural objects around them would present a sufficient variety for their amusement, and in these they would find an inexhaustible store of materials for con- structing toys, which, being works of their own creation, would please them far more than the most expensive artificial contrivances. Society increases the charms of exercise, and augments its benefi- cial effects. It is, therefore, desirable and proper to allow a number of children to assemble in their sports and amusements. It will, how- ever, be prudent to watch their conduct; but without rigour, or un- necessary interference on the part of the overseer. Children are the most happy, and most actively engaged in exercise when left to them- selves in its choice and pursuit. Even at an early age children should not be taught to depend too much on the assistance and direction of their nurses or superintendents. If the ground be favourable, that is, if it be soft or covered with grass, and free from stones, timber, 2od 126 5o 57 35 12 Respiratory Organs j °° 1-J 3977 2149 1192 1248 339 ~49~ Being nearly one-seventh of all the deaths in individuals under 15 years. It is probable that under the head of pneumonia are included many cases of bronchitis. Of deaths from laryngismus stridulus, no mention is made in the bills of mortality * these are probably included under the head of croup. PATHOLOGY OF INFANCY AND CHILDHOOD. 103 Softening and perforation of the stomach, constituting the disease to Avhich the denomination Gastro-malacia has been applied by the Ger- man writers, most frequently occurs during infancy. The inflammation in many instances extends from the alimentary canal to the mesenteric glands, producing their enlargement and dis- organization, attended, in a few extreme cases, with enormous disten- tion of the abdomen, and extreme emaciation of the body. It is seldom, however, that the existence of enlarged mesenteric glands can be detected during the lifetime of the patient. There is, as Dr. West remarks, no symptoms pathognomonic of tubercle of the mesen- teric glands, except their being perceptible through the abdominal parietes. This, however, they never are during the early stage of the affection. Inflammation frequently extends from the digestive mucous mem- brane to the peritoneum. It here often assumes a very chronic form, and, sooner or later, causes an effusion of serum into the cavity of the abdomen. Intestinal invagination is of very frequent occurrence during the .earlier stages of infancy. In many cases, its existence is not indicated by any other symptom than habitual costiveness. It often, however. gives rise to acute pain, considerable distention of the abdomen, ex- cessive vomiting, and death; and is always to be ranked among the most dangerous affections to which the infant is liable.1 Drs. Friedleben and Flesh, of Frankfort, in a paper on the patho- logical anatomy of the intestinal mucous membrane in the infant at the breast, remark, that hitherto, softening of the mucous membrane of the stomach, and enlargement of the mesenteric glands, have been usually regarded as the only causes of the acute or chronic diarrhoea, with atrophy, to which so great a mortality is due within the first year of life. This view they think they can disprove by exact post-mortem investigations. Softening of the mucous membrane of the stomach they regard as exceedingly rare, having met with it only in two in-* • In Philadelphia, within the period already mentioned, there occurred 6180 deaths from various diseases of the digestive organs, in children under 15 years of age, as fol- lows :— Under one Between 1 and 2 and 5 5 and 10 10 and 15 year. 2 years. years. years. years. From Diarrhoea, 832 535 205 79 8 5 " Dysentery, 546 151 169 117 85 24 " Infantile Cholera, 2583 1706 752 125 " Inflammation of 1 " the Stomach and I 825 411 163 131 85 35 a TntcstiiiGS " Marasmus', 930 596 210 100 22 2 " Aphthae, 43 33 9 1 " Worms, 57 4 12 21 8 1 " Colic, 21 19 1 1 Other affections of Sto-1 „., ,„, ._ „. mach and Intestines,}241 134 47 34 19 7 6068 3590 1568 609 227 74 If to these be added the deaths from teething, the majority of which are from disease of the alimentary canal, viz., under 1 year, 50; between 1 and 2, 51; between 2 and 5, 9; between 10 and 15, 2—total, 112—the total of deaths from these diseases will be 0180. Being about one-fourth of all the-deaths in individuals under 15 years. 104 MANAGEMENT OF CHILDREN. stances, in one of which it proved fatal within twenty-four hours; while in the other, there existed a fatal complication of intestinal disease. Diminished consistence at the fundus of the stomach was more frequently observed, but its origin was at all times secondary. They found enlargement of the mesenteric glands also to be uni- formly secondary, of limited extent, and rarely of distinct character, except in the glands on the root of the mesentery. The enlargement of these glands could not have been felt through the abdominal walls, and hence it seems certain that hardened feculent masses have been mistaken by many for enlarged glands. These gentlemen indeed affirm that even in the dissecting-room, after opening the abdominal cavity, the mesenteric glands cannot be felt enlarged until the intes- tines have been removed. Before entering on the pathological appearances, they give a sketch of the normal appearances of the parts concerned, in infants at the breast. The colour of the mucous layer, as well as of the subjacent mucous membrane itself, is either grayish-Avhite or yellow, from the colouring principle of the bile, or more or less of a darkish livid colour from imbibition of blood. It is to be remarked, however, that in this • last case the mucous membrane is free from any arborization or punctation. The mucous membrane adheres very closely to the sub- jacent tissue, so that, after being cut through, it can be detached only to a small extent. The mucous membrane of the colon, however, is less firmly adherent, owing, probably, to the greater amount of sub- jacent cellular tissue; its consistence is always great enough to pre- vent it from being rubbed off by the finger or with the back of a knife. Where the adhesion appears lessened, withoutsimultaneous diminution of its consistence, large pieces of the mucous membrane may be sepa- rated from the subjacent cellular tissue. Both the solitary glands, of the small intestines and of the colon, are invisible to the naked eye. As to those of the colon, however, we discover, occasionally, delicate roundish spots, presenting a contrast to the rest of the membrane by their opaque colour, but without any elevation. The villous layer, and the glands of Lieberkuhn, are also invisible. The Peyerian patches, on the contrary, may be discovered at the earliest period of life, when the intestine is held up to the light, owing to their greater opacity as compared with the rest of the membrane. Whenever these patches are recognised at first sight, a pathological state may be suspected. The largest of the patches are seated near the ileo-ccecal valve, where they may be distinguished by their marked limits. The number of the patches varies as much as from thirteen to thirty-six. The cases in which they are found to be only from one to six, are regarded by the authors as referrible to atrophy of the mucous membrane. After presenting a minute description of the several pathological conditions of the intestinal mucous membrane, the authors sum up their observations by the following general conclusions:— 1. Morbid alterations of the intestinal mucous membrane are a very frequent, probably the most frequent, post mortem appearance in the infant at the breast. 2. When of a chronic character these altera- tions lay the foundation of atrophy; when acute their most prominent effect is exhausting diarrhoea, which, from the cerebral symptoms often PATHOLOGY OF INFANCY AND CHILDHOOD. 105 attendant on it, had been mistaken by many observers for softening of the stomach (gastromalacia.) 3. The frequency of the alterations above described, is as remarkable as the rarity of those which were once believed to be of common occurrence,—for example, enlarge- ment of the mesenteric glands, aphthous formations, gastromalacia, &c. 4. It is also to be remarked, that the diseases of the intestinal tract are in general far more frequent than those of the stomach, which, with the exception of softening of the fundus, are proportionally rare at this period of life. 5. The ulcerations of the mucous membrane, unless when secondary, are in most cases isolated. 6. The most fre- quent of the alterations under examination is chronic inflammation of the Peycrian patches, and this is the only anatomical cause of atrophy. 7. Next to this, but far more rarely, tlie red and white softenings are essential causes of atrophy. 8. Red and white softenings are but dif- ferent stages of the same morbid process; the simple and gelatinous softenings give but a difference of form. 9. In the atrophy of infants at the breast, chronic ulceration of the solitary glands of the small intes- tines is among the rare occurrences. 10. The acute inflammation of the Peyerian patches, though hitherto little attended to, is among the most fatal of morbid alterations. 11. This is a true inflammation, as is attested by the attendant affections; for example, croup, lobular pneu- monia, 5 Oct. 1350 Dec 1214 Nov. 1143 In Childn under 1 year. Between 1 and 2. Brtween 2 and 5. Between 5 and 10. Between 10 and 15. July, 77" 4031 August, 75° 4£04 January, 32° 3'27 March, 40° 3379 June, 70° 372 April, 50" 3179 February, 32° 3171 May, ' 60° 3063 September. 6.5Q 2904 October, 55° 2*54 Xoveinher, 45° 2537 December, 35° 24P9 July 18-9 Aug. 1310 June 10,52 Jan.' 801 Mar. 762 Apr. 674 Sept. 642 Feb. (0"» May 557 Oct. 4P0 Dec. 457 Nov. 429 Aug. 733 Jan. 4j9 July 715 Mar. 4iH Sep. 430 i July 402 Mar. 354 : Apr. 381 June 351 June 378 Jan 344 May 3H6 Apr. 330 Aug. 357 Feb. 318 i Feb. 323 Oct. 288 ' Oct. 317 Sept. 283 I Sept. 312 Dec. 217 i DhC. 292 Nov. 201 i Nov. 291 Mar. 194 Apr. 11 Aug. 18: Jan. 170 June I6'i Feb. lfil July 159 May 155 Oct. 14t Dec. 130 Sept. 12!) Nov. 113 May (v4 June £3 July 62 Feb. 56 Pept. 55 :Aug. 53 Jan. 53 Oct. 55 Mar. 51 Dec. 48 Apr. 46 Nov. 39 Annexed, we present the proportionate ratio, in the first column, of the mortality in children under fifteen years of age, compared with the entire mortality; in the second column, the ratio of the mortality, in infants under one year, to the whole mortality; and in the third column, the ratio of mortality in infants under two years, to the entire mortality:—the months being ranged as above, according to their respective mortality: Ratio of children to whole mortality. Ratio in infants under one year. Ratio in infants under two years. June, 61*7 per cent. July, 61* « Aug. 58*8 " Sept. 56*5 " Mar. 55*3 « April. 53- " May, 48*8 " Jan. 48.7 " Dec. 48-7"/ « Feb. 48-37 " Oct. 47*3 " Nov. 45* " July, 40*7 per cent. June, 31*37 « Aug. 28*4 " Jan. 23*46 « Mar. 22*55 " Sept. 22* « Apr. 21* " Feb. 19* " Dec. 18*3 " May, 18* « Nov. 16*9 " Oct. 16*8 " l July, 56* per cent. Aug. 44*37 " June, 41*6 « Sept. 36- « Jan. 33* " Apr. 31*58 " Mar. 30* « Feb. 29. « May, 27*42 " Dec. 27- « Oct. 26*9 « Nov. 20*89 « Worms in the bowels are generally ranked among the most usual causes of the complaints of infancy. That their presence may give rise to a morbid degree of irritation in the gastro-enteric mucous membrane, and secondarily, in the mesenteric glands, the brain or the lungs, there can be little doubt; nevertheless, they are less often a cause of disease, than they are popularly supposed to be, or even than they were formerly esteemed to be by physicians. The symptoms that are commonly ascribed to the presence of worms, are produced, in the ' majority of cases, by a diseased condition of the alimentary canal, en 124 DISEASES OF CHILDREN. tirely independent of the presence of these animals, and may con- tinue, notwithstanding the destruction or removal of the latter. The first dentition is frequently accused of being the immediate cause of the diseases which occur during the second period of infancy. Dentition, however, cannot, of itself, be considered a disease, during either infancy or childhood; but when a predisposition to morbid action exists, the process of dentition may then become the exciting cause of the most alarming symptoms. The irritation produced in the gums, during the progress of the teeth to the surface, almost in- variably gives rise to increased heat and redness of these parts, and sometimes to positive inflammation; and as the irritation of the gums extends to the gastro-intestinal mucous membrane, which at this pe- riod, from the development and activity of its muciparous follicles, is readily excited to an increased secretion of mucus, some degree of diarrhoea very commonly attends the process of teething. If, from any cause, the stomach or bowels have been brought previously into a state of morbid irritability, excessive vomiting and purging, fever and other symptoms of more severe disease may be induced. In other cases, when the process of dentition is accomplished with great difficulty, violent inflammation or even sloughing of the gums may occur; and in children in whom the powers of life have been re- duced, and the nutrition of their bodies impaired, by constant ex- posure to a cold, damp, and confined atmosphere, or by deficient or improper food, the irritation, developed during the process of teething, may induce the peculiar gangrene of the mouth of children, to which the terms cancrumoris, water canker, &c, have been applied. In Philadelphia, and other large and crowded cities, the irritation of teething is a very common exciting cause, during the summer months, of the cholera infantum. In many instances, not only does the process of dentition excite irritation of the stomach and bowels, but in consequence of the in- creased amount of blood which it attracts to the vessels of the head and face, the tendency to disease in these parts is increased; hence, convulsions, ophthalmia, inflammation of the glands of the neck, ul- cerations behind the ears, eruptions of the face and scalp, meningitis, and hydrocephalus, very frequently occur at this period of infancy. Deformity and disease are often occasioned during infancy by.falls, by improper postures of the body long continued, by improper forms of clothing, calculated to impede the motion of the limbs, or to pre- vent the development of certain parts of the body, and by too early attempts to induce the child to assume the erect posture, or to walk. Some discrepancy of opinion exists, among pathological writers, as to the susceptibility of infants to contagion, some ascribing to them an entire immunity from its influence, while nearly all consider them to be less subject to it than adults. In very young infants, it is true, we seldom meet with any of the febrile affections, -the propagation of which is generally ascribed to contagion; but after two years of age, contagious diseases, if we include under this term small-pox, varicella, scarlatina, measles, and hooping-cough, are of far more frequent occurrence than after the period of puberty. SEMEIOLOGY OF INFANCY AND CHILDHOOD. 125 CHAPTER IY. SEMEIOLOGY OF THE DISEASES OF INFANCY AND CHILDHOOD. The detection and diagnosis of disease in the infant is based, the same as in the adult, upon a careful examination and analysis of its various phenomena; but in the infant, the occurrence and extent of these phenomena must be derived, altogether, from the attentive ob- servation of the physician, compared with those of the parents or nurse. From the little patient we can derive no other information than such as is expressed by the countenance, the positions of the body, the motions of the head, trunk, and limbs, the nature of the cries emitted, and the condition of the respective organs, as indicated by the regularity of their functions, or the -extent and manner in which these are disturbed. In the infant, the condition of the skin, the state of the various se- cretions and excretions, the appearance of the eye, the manner in which respiration is performed, have the same amount of value, as in- dications of the seat, nature, and extent of morbid action, and are as readily detected as in the adult. But, in the infant, the physician can derive no assistance in forming his diagnosis, from the character and location of any pain, or other uneasy sensation the patient may expe- rience—constituting, in many cases of disease, an important patholo- gical feature—excepting from the external physiognomy peculiar to the various grades of suffering that occur in the different organs. It is this physiognomy of suffering, as derived from the expression of the face, the cries, and the movements, which constitutes, in a great measure, the special semeiology of infantile diseases. M. Jadelot has attempted to present a correct exposition of the indications of disease, as derived from the expressions of the countenance, from the period of the first dentition until puberty:—his remarks, as furnished us by M. Do Salle, in his edition of Underwood, are certainly interesting, but, in many respects, they are purely hypothetical. The general phenomena of disease in infancy, notwithstanding they experience certain modifications, dependent upon the peculiar state of the organization, differ, nevertheless, but little from those observed in the adult. There are, however, a few morbid phenomena that are peculiar to the infant; and others, which in the correct diagnosis of disease, have an importance far bevond what they possess in after life. As a preliminary to the study of the semeiology of the diseases of infancy, it is essential that the physician should make himself fully ac- quainted with the external appearance usually presented by an infant during health: the expression of his countenance, the attitudes of his body, as well as with the physiological condition generally, at the dif- ferent stages of development, of his several organs, and of their re- 126 DISEASES OF CHILDREN. spective functions. It is only from the nature and extent of the de- viations from the normal standard, that, in many cases, he will be en- abled to appreciate the value of the morbid phenomena that exist, either individually or collectively. It is but within a very short period, that the physiology of infancy, and the manner in which its organism is developed, have been accu- rately investigated; and it is curious, that not a few of the phenomena which writers on the diseases of the early stage of existence, of no very remote date, described as important indications, or as results of morbid action, are found to be invariably present in the infant, during health. We have already presented a brief sketch of the condition of the different organs, duringinfancy, and the manner in which their re- spective functions are successively brought into action. We need here only remark, that, in the healthy infant, the limbs are uniformly covered with flesh, rounded and plump, and to the touch, present a certain feeling of firmness and elasticity. The skin is soft, flexible. and of a rosy hue; the-complexion lively and fresh. The eye, when attracted by any object, has a peculiar quickness and suddenness in its movements; the pupil is usually large when the infant is awake, but often minutely contracted during sleep; and always more or less turned upwards, beneath the upper eyelid. The countenance, when in repose, exhibits, in the earlier stages of infancy, but little or no ex- pression, except that of perfect calmness; but at a later age, it becomes quickly lighted up, smiling and animated, upon the approach of its parents or nurse, or when attracted by any pleasing object. The sur- face of the infant is cool; the abdomen full and soft—gentle pressure upon it seeming rather to please, than to cause the slightest uneasi- ness. The tongue is generally slightly covered with a whitish mucus: the mouth is always moist, and the lips fresh-coloured, and often pro- truding. The sleep of the healthy infant is quiet and profound: it awakes from it cheerful and smiling, and soon demands food. During its waking hours, after, at least, the first month or two, it is inclined to as much activity as its limbs will permit, and exhibits a surprising springiness and rapidity in all its movements. It delights to be played with and carried about, and, when old enough, to rolj and crawl about upon the carpet. In health, infants seldom cry, excepting to express their wants, or in consequence of experiencing some accidental uneasiness or pain. and are immediately quieted upon their wants being gratified, the cause of their uneasiness removed, or their pain appeased. Crying if* not, however, always the indication of either ungratified wants, pain. or disease:—some infante cry repeatedly, being with difficulty ap- peased, without our being able to detect any apparent cause of suf- fering, and without any interruption to the full nutrition, and regular development of their bodies. Every deviation from what wc have just given, as the picture of a healthy child, is not, however, to be considered, of itself, an indication of disease. The limbs of an infant may exhibit a certain decree of SEMEIOLOGY OF INFANCY AND CHILDHOOD. 127 meagerness—its complexion may be somewhat pallid—its sleep short, or occasionally restless—or many of its waking hours may be passed in crying, without the existence of any positive disease. All changes. however, occurring in an infant, either suddenly or gradually, whether in the ordinary expression of its countenance—in the condition of its body—its habits or disposition—should be looked upon with a suspi- cious eye, and be the signal for a careful examination into the con- dition of its several organs; in one or other of which, some com- mencing disturbance will, in general, be detected. Whenever there is observed in an infant any marked alteration in the countenance, or in the external appearance of the body—an un- wonted dulness of the eye—an indisposition to playfulness—a loss of its accustomed gaiety—unusual listlessness—disturbed sleep—un- common wakefulness—sudden starting in slumber or awaking with apparent affright—an unusual degree of somnolency—the occurrence of sudden paleness of the face, or paleness alternating with a suffusion of red, more or less deep—increased heat of the hands and feet, or of the entire surface—unusual coldness of the extremities—unaccus- tomed fretfulness—frequently repeated or prolonged fits of crying, or a marked change in the character of the cry—frequent or constant corrugation of the brow—twitching of the muscles of the face—re- jection of the breast, or of food—unusual movements of the head and limbs—and crying or moaning when the body is moved Qr handled, are invariably to be considered as the indications of nascent or confirmed disease. No disturbance or irregularity of function, occurring in an infant. however slight, should be considered as unimportant. The sudden- ness with which some of the most violent affections of this period of life are enveloped, and the rapid occurrence of effusion or of disor- ganization, in the tissues and organs in which morbid action is seated, give to every indication by which the inception of disease can be de- tected, even a greater degree of importance than in after life. In their commencement many of the maladies of infancy may be promptly arrested by simple remedies, that if allowed to become fully deve- loped, are scarcely within the control of the most judicious and active plan of treatment. A slight irritation of the gastro-intestinal mucous membrane of the infant, will often, by being suddenly reflected upon the brain, give rise to a violent convulsive attack, or produce some other and equally se- rious train of symptoms, which might have been prevented by the early detection and removal of the primary irritation. Not a few, also, of the rnaladies that occur during infancy, give rise, during their first stages, to so few prominent symptoms, that their existence is often unsuspected, until disorganization of some important organ has taken place, or a sympathetic affection of the brain occurs, and their character and extent are thus revealed, at a period when their cure is impossible. Even in these insidious forms of disease, by a close attention to the countenance, manners, and gestures of the little patient, the physician will seldom fail to detect the presence of morbid action, and make out, with sufficient accuracy, its diagnosis, J2S DISEASES OF CHILDREN. at a period when it is still within the control of appropriate reme- dial agents. The principal sources of diagnosis in the diseases of infancy, are the expressions of the countenance—the gestures—the phenomena of sleep—the mode in which respiration is effected—the cry—the condition of the tongue and mouth—the condition of the surface— the state of the breath—the evacuations. 1.—Of the Countenance. The infant's countenance offers to us the most interesting and the most intelligible page in nature's book. In its calm, we read the health and ease of all the organs,—of all the functions. In its smiles we read the happiness of body and of mind. In its expressions of un- easiness or pain we first discover the invasion of disorder or disease. Our attention will probably be first attracted by some undefined change, which it will require a stricter observation to decipher, and associate with its peculiar cause. (Hall.) Although we cannot go as far as does M. De Jadelot, and assert that, from the movements of the infant's face, we may determine the location of its diseases, in one or other of the great splanchnic cavi- ties—the disturbed expression of the upper part of the face, the fore- head, eyes, and brows, indicating disease of the brain, or of the ner- vous system; the altered features of the middle portion of the face, particularly of the nose, being indicative of affections of the thoracic organs; while the expression of the lower part of the face, the mouth and lips, point to the abdominal region as the seat of morbid adtion: yet we are convinced that from the condition of the countenance alone —often from some indescribable expression of suffering—the obser- ving physician will be able to detect, at once, the existence of dis- ease, and not unfrequently to determine its location. In most of the diseases of the alimentary canal, the face of the in- fant is pallid, and exhibits a very peculiar expression of fretfulness or peevishness—excepting when these diseases give rise to febrile re- action, during the exacerbations of which, the face is more or less flushed. In many of the chronic affections of the digestive organs. especially when attended with disease or functional derangement of the liver, the face and surface generally acquire a dirty brown, or a deep yellow hue. Great paleness of the face, if accompanied with diminished tempe- rature, or alternating suddenly with flushing and heat, is often the indication of exhaustion; as from profuse diarrhoea: it is likewise frequently observed previously to the occurrence of convulsive at- tacks, or of acute meningitis. In extreme cases of exhaustion, particularly from profuse evacua- tions from the bowels, as in protracted cases of cholera infantum, the cheeks are cold and pallid, and of a waxy appearance; the eyelids are half closed; the pupil contracted; the eyeball sunk in the socket, and rolled upwards, so as partially to conceal the pupil beneath the upper eyelid; the conjunctiva is injected with dark-coloured blood; the cor- SEMEIOLOGY OF INFANCY AND CHILDHOOD. 129 nea covered with a thin film of mucus; and the orbitar circle is of a livid or dark-brown colour. In the acute affections of the head, the face is usually flushed, somewhat turgid, and hot. In affections of the respiratory organs, the face is generally of a dusky red, and swollen; and in extensive hyperemia .of the lungs, the lips and cheeks are often of a deep livid hue. In hydrocephalus, the skin of the face, and especially of the fore- head, is tense and shining. The smooth and shining appearance of the skin upon the forehead is also very generally observed in pro- tracted cases of cholera infantum. Deep blueness of the countenance, in young children, is indicative of morbus cceruleanus, arising from an impediment to the free circula- tion of the venous blood. It usually exists from birth, and is in- creased in intensity by any exertion of the body. A sudden contraction of the countenance, especially if accompanied by a sudden motion of the body, and a sharp scream, is generally the indication of some sudden attack of pain, usually of a spasmodic character. If, at the same time, retraction of the abdominal muscles, drawing up of the knees, or a sudden extension of the body takes place, the pain is seated in some part of the alimentary canal. In this case there is also a whitish circle often observed about the mouth. When the painful sensation comes on more gradually, and is more prolonged in its duration, the brows are corrugated, the upper lip is stretched and elevated, and the nostrils become sharp and contracted. The contraction of the brows is usually most marked in pain of the head; sharpness of the nostrils, in painful affections of the chest; and drawing up of the upper lip, in abdominal pain. Upon the approach of convulsions, the upper lip is often stretched firmly over the gums, and of a whitish or livid hue; there occurs a slight divergence in the axes of the eyes; there is an unusual upturn- ing of the eyeballs, or a singular rotation of the latter upon their own axes; or a fixed staring condition of the eye, with a rapid contraction and dilatation of the pupils; there is often slight twitchings of the muscles, on one or other side of the face, and a quick alternation of flushing and pallor of the countenance. All these appearances are not observed to precede every convulsive attack; the occurrence, how- ever, of one or more of them is sufficient to call attention to the gums, alimentary canal, or nervous system, in order to detect the source of irritation, that, by its removal, the threatened attack may be prevented. Whenever there exists any great impediment to the freedom of re- spiration, the nostrils are widely dilated during inspiration, and strongly contracted during expiration, the mouth is held open, and the lips are often puckered, and always of a livid hue. In the more severe forms of gastro-intestinal inflammation, the mouth is extended, the lips—often pale, dry, and cracked—are applied closely to the teeth, and the chin has the appearance of unusual projection. In chronic irritations of the bowels, the nose and upper lip are often tumefied. A peculiar puckering of the corners of the lips is frequently 9 130 DISEASES OF CHILDREN. observed to precede the occurrence of gangrene of the mouth in children. The countenance of infants that have been subjected to an almost habitual use of opiates, has a peculiar and striking appearance; the skin is of a sallow or dirty brown hue, and thrown into wrinkles, from the emaciation of all the soft parts beneath it; the eyelids are red and tumid; the eyes dull and watery; the lips dry and pallid, and drawn, so as to leave the mouth partially open, and the chin pro- jecting. The whole countenance presents, indeed, a faithful minia- ture likeness of a sickly aged person. The eyes are usually prominent and suffused, their superficial blood- vessels being often minutely injected with blood, in violent paroxysms of crying, and of cough, and in all affections of the respiratory organs, attended with much difficulty of respiration, as in croup, the more violent forms of bronchitis, hooping cough, &c. The pupil of the eye, in infancy, is usually dilated, during health, and it is often closely contracted during sleep, and rapidly dilates upon the child's awaking. The state of the pupil, however, varies frequently, and it is only from its fixed or permanent dilatation, or contraction, that the indications of disease are to be derived. In the course of most diseases, the occurrence of a fixed dilatation or contraction of the pupil, indicates the extension of irritation to the brain. In the early stage of encephalic inflammation, the pupil is, in gene- ral, contracted, and, in the last stage, dilated, and insensible to light. Occasionally the form of the pupil is irregular; this has been ob- served by M. De Jadelot, in cases of intestinal irritation from worms. The sudden occurrence of strabismus, in the course of disease, is usually an indication of the occurrence of some cerebral affection, and is then always an unfavourable symptom. Slight irritation of the bowels, as from worms, indigestible food, &c., often gives rise, however, to temporary strabismus. 2.—Of the Gestures. In infants old enough to be attracted by surrounding objects or to be played with and amused, the approach of disease is often marked by a total disregard of everything that had previously pleased them, and an indisposition to motion of any kind; instead of being active and playful when awake, they lie still and listless upon the nurse's lap, and no efforts to attract their attention, or to excite a smile upon their countenance, are successful. The cooing, chirruping sound, with which they expressed their feeling of satisfaction or delight, gives place to perfect silence, or to a short querulous plaint when moved, or when teased by the importunities of those around them. If the infant had already commenced to hold up its head, to sit alone, or to stand, on the approach of disease, there often occurs a degree of muscular debility, which prevents these attitudes from be- ing continued, and the position assumed by the body and limbs is expressive of extreme languor. When in suffering, particularly in cases of intense abdominal pain, . SEMEIOLOGY OF INFANCY AND CHILDHOOD. 131 the infant will often draw up its knees, and bend forward its body, or throw about its limbs in a wildly agitated manner; or, as we have often observed, forcibly extend its whole body, and then suddenly relax it. When one limb is kept motionless, or moved with sudden jerks, particularly if its motion excites the cries of the child, that limb is generally the seat of pain. If, after an infant has commenced to walk, it is found to apply only the toes of one of the feet to the ground, and to exhibit a gradually increasing limp in his gait, particularly if he complain of pain in one of the knees, and exhibit uneasiness when that limb is handled, we should suspect ,the presence of articular inflammation of the hip. When a child is observed frequently to trip and stumble, in walk- ing, or when, as he moves hastily or unguardedly, his legs cross each other; when he stands upright, his knees totter and bend under him, and when seated, his legs are crossed and drawn up under the seat; particularly if he exhibit, at the same time, great languor and list- lessness, and complain of frequent pain and twitchings in his thighs, we may suspect some disease of the lower portion of the spine, proba- bly caries of the vertebrae. A frequent application of the hands to the head is, generally, an indication of suffering in this part of the body, the seat of which is to be detected by other symptoms. A pulling at one of the ears, and violent, often frequently repeated scratching of the parts in its imme- diate vicinity, with frequent moans, or short acute cries is, generally, , indicative of otitis. Rolling the head constantly from side to side, as it lies upon the pillow, or bending it forcibly backwards upon the spine, is usually an indication of cerebral disease. Picking at, or frequently rubbing the nose, is, usually, a symptom of irritation of the alimentary canal; it is a very common indication of the presence of worms. Convulsive movements of one or other of the limbs, of the muscles of the face, of one side of the body, or of the voluntary muscles generally, may result from irritation or inflammation of the brain, or spinal marrow; or they may be produced by an irritation seated in other organs, and transmitted to the nervous centres. Convulsions are often the precursors of eruptive diseases. Contraction of the fingers and toes, in consequence of which the first are forcibly flexed upon the palms of the hands, and the latter towards the soles of the feet, whilst the back part of the hands, and the upper surface of the feet, present a soft, puffy swelling, is an in- dication of convulsions. An opposite condition, or when the fingers and toes are forcibly extended, whilst the first are semiflexed upon the metacarpus, and this, at times, upon the carpus, and in the same manner the toes upon the metatarsus, is a common attendant upon laryngismus stridulus. As early as the fifth or sixth day subsequent to birth, infants are oc- casionally attacked by spasms of the muscles of the face, lower jaw, or neck, and, in severe cases, there is often a complete fixation of the jaw. This condition has been attributed to retention of the meco- nium, or to inflammation of the vessels of the cord:—it is more ge- 132 DISEASES OF CHILDREN. nerally, we suspect, produced by a confined and impure air, or cer- tain conditions of the atmosphere, endemic to particular localities. During dentition, and from trifling irritations of the digestive canal, infants are frequently affected with slight convulsive movements of the muscles of the face, which give to the countenance an appearance of smiling. This symptom is frequently the precursor of severe ge- neral convulsions. A rigid extension of the limbs with a turning inwards of the thumbs and great toes, is often the precursor of a convulsive attack. When, upon the child being put to the breast, it sucks eagerly for a moment or two, and then suddenly ceases, throwing back the head with an expression of anxiety in its countenance, it-will, in general, be found that it is labouring under some disease of the respiratory organs, as severe bronchitis or pneumonia. The same phenomena, with a rolling of the head from side to side, are often the precursors of an attack of convulsions. Sudden rejection of the breast after sucking for a few moments, the infant at the same time exhibiting pain or uneasiness by its cries and the movements of its body, is common in cases of coryza and of inflammation of the throat,—it is often observed, also, in severe cases of stomatitis. Weakness or contraction of certain muscles, or partial paralysis, often marks the formation of tubercles in the brain. Partial paralysis, as of one leg, is not, however, an uncommon symptom, during dentition and gastric irritation. Although this, in some cases, is a serious symptom, yet, very generally, the paralyzed limb, sooner or later, regains its power. An uplifted step, or staggering gait, and a rocking of the legs, or a total inability to stand erect, are indicative of serious disease of the brain or spinal marrow. These symptoms are often the precur- sors of sudden serous effusions upon the brain. A sudden increase of muscular activity in young children, with un- wonted exhilaration of spirits, and liveliness of manner, denotes in- creased excitement of the brain, and often precedes acute attacks of meningeal inflammation. Great restlessness, and frequent involuntary movements of the limbs, are, in general, when they occur in the course of protracted maladies, unfavourable symptoms, and depend upon disease of some portion of the brain. 3.—The Phenomena during Sleep. In a healthy infant, sleep is calm and profound; the position is, generally, upon the side, with the limbs perfectly relaxed; the respi- ration is full, slow, regular, and quiet. The eyelids are never for- cibly closed, and not unfrequently, are slightly separated; the cornea is partially concealed beneath the upper lid, the ball of the eye being turned upwards; the pupil is often greatly contracted. The skin is soft and cool. It is not uncommon in the sleep of infants for imperfect respiration to occur for a time, followed by a deeper inspiration, or sigh, to SEMEIOLOGY OF INFANCY AND CHILDHOOD. 133 -upply the previous deficiency in the function. This has sometimes been mistaken for an indication of disease; it is, however, a perfectly healthy, phenomenon, and results from the reduction of innervation that occurs during sleep. Cutaneous transpiration is always increased during the period of sleep:—if the room in which the infant reposes is warm, or he is too warmly clad, or covered with too many bed- clothes, profuse perspiration is liable to occur, particularly about the head and neck. On awaking from sleep, the healthy infant is lively and cheerful, and quickly seeks the breast or calls for food. The younger the infant, the greater is the time passed in sleep; after the first month or two, the intervals of waking and repose be- come more regular, and the infant will, very generally, fall asleep and awake, very nearly at stated hours. During sleep, the countenance of the infant will, by its expression, often give intimation of the existence of uneasiness or pain, of which no indication is presented during the period of wakefulness,—the infant's attention being then diverted from slight degrees of bodily suffering, by the various objects and sounds that occupy its external senses. The commencement of irritation in the bowels, or brain, may often be detected by slight twitchings of the mouth and eyelids, or by the grinding of the teeth, that occur during sleep, when no symptom is manifested while the child is awake. In the same manner, the approach of disease will be indicated by frequent movements of the body and limbs, and by sudden starts that take place during sleep. Sleeplessness, when not the result of suffering, is usually caused by a morbid excitability of the brain; it is often present during conva- lescence from acute affections. Sudden starting from sleep, with a wild, alarmed expression of countenance, or without the child appearing, for some time, to recol- lect himself, or to recognise surrounding objects, is often caused by irritation of the alimentary canal, and may, in many cases, be the precursor of convulsions, or of acute meningeal inflammation. Children often awake from sleep in affright, and quickly burst into tears; at other times, their sleep appears troubled, and, without awaking, the child sobs, or utters words or indistinct sentences; this is, generally, produced by the occurrence of dreams, excited by in- testinal irritation, or by the presence of too much or improper food in the stomach. An unusual degree of somnolency in general indicates hypersemia of the brain; it is sometimes observed during teething,, or when the stomach is overloaded with food. Deep soporose sleep, or coma, always indicates serious disease of the brain; and, when it occurs in the course of acute diseases, or sud- denly supervenes after protracted illness, is to be viewed as an un- favourable symptom. Short, disturbed sleep, the infant, on awaking, being fretful, peevish 134 DISEASES OF CHILDREN. or morose, is, very generally, an indication of disease of the alimen- tary canal. 4.—The Cry, Crying is the natural language by which the infant expresses its wants and sufferings. During health, an infant, properly nursed, cries' but seldom, and never exhibits violent and repeated paroxysms of crying, or the continued plaintive cry of distress. In new-born infants, loud and vigorous crying is always an un- equivocal sign of health and vigour; and is, doubtless, produced by the impression upon the bodj^ of the various novel stimuli to which it has become suddenly subjected. After the sentient surfaces have become accustomed to these, the infant's cries proceed from some want, from uneasy sensations or pain, accidentally induced, or from disease. Violent paroxysms of crying are usually the result of intense pain; occasionally, however, they are the expression merely of passion; and, when this is the case, the child will often suspend its breath for some time, and the face will become livid from the interruption of the cir- culation through the lungs. Violent and prolonged fits of crying, from whatever cause they re- sult, are always injurious, and in some instances, have been imme- diately succeeded by an attack of convulsions. A fretfulness of disposition and frequent crying, may be produced from the child being continually vexed and teased by its nurse, with- out the actual presence of pain or disease. Violent and frequently repeated crying, or shrill and piercing screams, are the indications of acute pain; and are, hence, observed to occur in most of the inflammatory affections to which infants are liable, especially in their early and acute stages. In inflammation of the gums, the cry will be more or less protracted; while in inflamma- tion of the chest and abdomen, the increase of suffering to which they give rise, will induce the child, as much as possible, to control its cries; the cry becomes then sudden, short, and at intervals. In severe pain of the head, as in the acute stage of meningeal inflammation, the cry is often a short, piercing scream, occurring at intervals. The same is the case also in spasmodic pains of the alimentary canal. To the seat of the pain we will be directed by the local symptoms. Intolerance of light, contraction of the brows, and tossing of the head, with, often, increased heat of the latter, will point to the brain as its seat. A quick, panting, or difficult respiration, rapid contraction and dilatation of the nostrils, and cough, to the lungs; constipation, diar- rhoea, or vomiting,—tenderness on pressure, and increased heat of the abdomen, to the alimentary canal; and loud, crowing, and difficult respiration, to the larynx. * When the cry is hoarse or husky, it is an indication of effusion within the bronchi, preventing the free passage of the air to the glottis, or of inflammation and thickening of the mucous membrane of the fauces, larynx, or trachea. When the cry has a nasal sound, there is inflammation or engorge- SEMEIOLOGY OF INFANCY AND CHILDHOOD. 135 ment of the tonsils, inflammation and thickening of the Schneidenan membrane, or a polypous tumour at the posterior nares. ^ A peculiar ringing sound of the cry is often the first indication of an impending attack of croup, or of laryngismusstridulus. When the cry is scarcely audible, and accompanied with alow, sibi- lant prolongation, there in general exists some disease of the glottis. Fretfulness, or peevishness, when habitual, or occurring in children who had previously exhibited a lively and cheerful disposition, may either be the indication of uneasy sensations, resulting from the action of a variety of irritating causes, and the consequent impairment of the general health of the system; of some chronic irritation, seated, most commonly, in the alimentary canal, or of the invasion of acute dis- ease. Habitual fretfulness, or its sudden occurrence, should, there- fore, never be overlooked. A low, moaning cry is, in the infant, invariably an important and alarming symptom of disease. In acute affections, the moaning is continued at each expiration. During painful dentition, the infant is often heard to moan, and grind its teeth at intervals. Moaning is particularly characteristic of painful diseases of the alimentary canal. When it occurs after violent excitement, accompanied with acute Screams, and is attended with stupor, it is an unfavourable symptom, indicating, in general, the early occurrence of effusion from cerebral disease. 5.—Respiration. In the healthy infant, respiration is full, regular, and quiet; more frequent than in the adult, and performed almost exclusively by the movement of the ribs. Difficult and loud respiration is present in all the diseases of the pulmonary apparatus. In affections of the larynx, glottis, and upper portion of the trachea, inspiration is performed with difficulty; while in diseases of the bronchi, the difficulty is experienced in expiration. When the difficulty of respiration gradually augments in intensity, it is an unfavourable indication in all affections of the lungs. Respi- ration often becomes irregular, and occasionally intermittent, in the course of pneumonia, and in affections of the brain this is always an unfavourable symptom. In pleurisy and peritonitis, inspiration is rendered short and diffi- cult from the increase of pain to which it gives rise. Difficult respiration, attended with heaving of the upper portion of the chest, elevation of the shoulders, violent exertion of the muscles of the neck, or rapid motions of the mouth and nostrils, is attendant upon serious disease of the thoracic viscera, and is usually the indi- cation of an unfavourable result. In the healthy respiration of the infant, no sound is heard unless the ear is applied to the chest; it is hoarse in bronchial inflammations; it is sibilant in affections of the larynx, glottis, and upper portion of the trachea; and presents a sighing sound in hyperemia of theJungs, and in cases of exhaustion, or debility of the respiratory muscles. The 136 DISEASES OF CHILDREN. sighing sound is an unfavourable indication in acute affections of the brain. The respiration is very quick and panting in most febrile affections, during the exacerbation; when rare, there in general exists debility of the muscles of respiration; a quick and rare respiration exists in pleu- ritis, or it may occur from exhaustion, from violent exertion of the re- spiratory muscles; it is also present in pneumonia, chronic bronchitis, or pleuritic effusions. The indications derived from auscultation and percussion are nearly the same in children as in adults, and need not, therefore, be noticed here. The respiratory murmur—puerile respiration—being remarka- bly loud Over every part of the chest in infancy, is not, as in the adult, so important an indication of disease. It is diminished in intensity in inflammation of the bronchial ramifications, and entirely absent in induration of the lungs, and in pleuritis. Cough may result from disease of some portion of the respiratory apparatus, or it may be caused by irritation transmitted to the respi- ratory organs from the alimentary canal, or from disease of the brain. In the first case, it is generally attended with mucous expec- toration; in the second, it is usually dry and irritative; and in the last, spasmodic. \ A short, hacking cough, with little expectoration^ is present in pleurisy, and in the incipient stage of tubercular phthisis. Con- tinued cough accompanies inflammations of the larynx, trachea, bronchi, and lungs. Intermittent cough is a symptom of croup, laryngismus stridulus, and hooping-cough. In the commencement of inflammation of the respiratory organs the cough is dry, but is soon accompanied with expectoration when the disease is seated in the mucous membrane; but in pneumonic in- flammation it continues longer dry, and the expectoration is seldom copious. In catarrhal affections, the cough is hoarse; in croup, it has a pe- culiar barking, or crowing sound; in hooping-cough, a loud shriek- ing sound; and in the early stage of bronchial inflammation, previ- ous to the occurrence of effusion within the bronchi, it has a whiz- zing sound, without hoarseness. Sneezing may arise from any accidental irritation of the Schneide- rian membrane, or from irritation transmitted to this part from the alimentary canal. It is one of the prominent symptoms of coryza in children, arising then from the increased irritability of the nasal mu- cous membrane, consequent upon inflammation. Hiccough is a frequent symptom in children of slight irritations of the alimentary canal; it may arise also from cerebral irritation, and be then a precursor of convulsions. When occurring in the course of inflammatory affections of the bowels, peritoneum, or brain, it is in general an unfavourable symptom. 6—The Tongue and Mouth- In the infant, during health, the tongue is moist, smooth, and gene- rally covered, in its middle and towards its root, with a thin coating SEMEIOLOGY OF INFANCY AND CHILDHOOD. 137 of whitish mucus. The mouth is always moist and of a palish hue, and the gums of a bright red. When the tongue is loaded with a white curdy matter, disturbance of the digestive process, or slight irritation of the alimentary canal, is generally present. Increased redness, heat, and dryness of the tongue and parietes of the mouth, indicate the first stage of stomatitis, and often accompany inflammations of the alimentary canal. Small white points, or patches, dispersed over the tongue and pa- rietes of the mouth, are the result of inflammation of the epithelium of these parts, and are usually symptomatic of disease of the stomach or bowels. As a local affection, this condition of the tongue may be produced by confined and impure air, want of cleanliness, &c. Aphthae of the tongue and mouth, are the result of follicular in- flammation; they may depend upon improper food and vitiated or confined air; or they may be developed by dentition, or be symp- tomatic of disease of the alimentary canal. A pale, flabby tongue is the indication of great debility or exhaus- tion. Redness of the tongue is symptomatic of acute inflammations of the gastro-intestinal mucous membrane. In scarlatina, the papillae of the tongue become enlarged and pro- minent, presenting numerous red points—the tongue itself is also red, and the throat covered with efflorescence. Swelling of the tongue occurs in scarlatina, measles, croup, laryn- gitis, and small-pox, and is usually an unfavourable indication. In febrile diseases, and in most of the affections of the alimentary canal, the tongue is covered with a whitish coat. In protracted irri- tations of the bowels, the coating of the tongue generally assumes a dirty yellow or brownish colour. Increased secretion of saliva occurs immediately preceding, and during the process of dentition, and in the course of stomatitis, it is also a common precursor of the gangrenous affection of the mouth in children. A diminished secretion of saliva takes place in most of the acute and febrile affections that occur during childhood. Great dryness of the mouth, with constant thirst, occurring in the course of acute dis- eases, is generally unfavourable. Increased heat and redness, with swelling of the gums, occurs at the period of dentition. A dark, red, and tumid state of the gums, generally precedes the occurrence of gangrene of these parts. Increased redness of the throat occurs in scarlatina, measles, and small-pox, in inflammations of the tonsils and larynx, as well as in chronic inflammations of the digestive and respiratory organs. 7—Of the Surface. In infancy, the skin, during health, is soft, moist, and cool, and uni- formly distended, from the large amount of soft, cellular tissue, and subcutaneous adipose matter. Whenever it becomes harsh, dry, and hot, or flabby and wrinkled, 138 DISEASES OF CHILDREN. it is an indication of the existence of more or less extensive disease, in one or other of the organs. A hot and dry skin is common in all the febrile and acute affec- tions of infancy; the heat is not, however, always diffused over the entire surface, but is often greater in one region than in the others; thus, in inflammatory affections of the brain, the heat of the head is increased, while the rest of the body may be of its normal tempera- ture, or the lower extremities even cold; in inflammations of the abdominal organs, the increased heat will often be confined to the epigastric, umbilical, or hypogastric regions, or to the surface of the abdomen generally. A dry, burning feel of the palms of the hands, is often attendant upon disturbance of the digestive function, irrita- tions of the alimentary canal, or irritation of the lungs connected with tubercles. A uniform redness, or rosy hue of the surface, is the indication of health in infancy; when, however, the lymphatic temperament is strongly marked, the skin, particularly of the face, may be pallid and puffy, without the existence of positive disease. Such a condition of the skin should, however, be always a warning for additional precau- tions in the hygienic management of the child, lest a scrofulous con- dition of the lymphatic glands, or tubercular depositions occur. This state of the skin is common in children who are too much confined within doors, or who are exposed to a damp, stagnant, or impure atmosphere, or fed upon food deficient in nutrition, or of a bad q uality: it occasionally presents itself when, after'scarlatina, and some other diseases, effusion, more or less extensive, takes place in the cellular tissue. Increased redness of the surface is either an indication of inflam- matory or eruptive diseases of the skin, or it may result from febrile excitement, or acute inflammations of internal organs. Thus, in in- flammation of the brain, the face becomes flushed; and in certain diseases of the lungs and digestive organs, a circumscribed redness of the cheeks is not unfrequently observed. Intense redness of the skin in children we have known to be pro- duced, in many instances, by certain articles of dipt, and to cease the moment these were discharged from the stomach by spontaneous vo- miting, or by the operation of an emetic. An alternate paleness and flushing of the face is common in me- ningeal inflammation. Intense blueness of the skin is observed in certain cases of malfor- mation of the heart; or it may arise from any cause which prevents the oxygenation of the blood in the function of respiration. Yellowness of the skin is usually connected with irritations of the alimentary canal, or with some affection of the liver, in consequence of which the serum of the blood becomes surcharged with the colour- ing matter of the bile; in this case, the adnata of the eye exhibits the same yellow hue as the surface of the body. In very young infants, however, yellowness of skin is occasionally produced by an unusual yellow colour of the serum, and in such cases is seldom a symptom of much importance. SEMEIOLOGY OF INFANCY AND CHILDHOOD. 139 In protracted diseases of the liamentary canal—chronic diarrhoea, cholera infantum, &c—the skin assumes a sallow, dirty yellow, or brownish hue. The fulness and tension of the surface is increased from hyperaemia of the cutis and subcutaneous tissues, in eruptive fevers, and in local cuticular inflammations. In hyperaemia and inflammation of the brain, the integuments of the face are very generally increased in fulness and tension. Tension of the integuments of one cheek, accompanied, at first, with increased redness, and subsequently with a shining whiteness, is an indication of one of the most common vari- eties of gangrene of the mouth. Tension of the abdominal integuments, when accompanied by ten- derness, is an indication of inflammation of the abdominal viscera, particularly of the alimentary canal; when unaccompanied by tender- ness, it may be produced by the formation of gas within the intestines, or by effusion within the peritoneum. General or local tension of the surface of the body, may be pro- duced by the effusion of serum within the cellular membrane gene- rally, as in anasarca, or in some particular portion of it, as in oedema: it is then distinguished by the diminished temperature of the surface, wherever the effusion occurs; by the pitting upon pressure, and by the paleness of the skin. A reduction of the fulness and tension of the skin, may be produced by the action of cold, or by deficient food, or it may result from ema- ciation, resulting from protracted disease. In serous diarrhoea, and the cholera of infants, it often occurs with great rapidity. Perspiration is readily excited in children;—during, or immediately succeeding a violent attack of coughing, of convulsive paroxysms, and of intense pain of the bowels, it is a common occurrence for a copious perspiration to break out about the head and face. A general mois- ture of the surface, occurring in acute diseases, with an abatement of their respective symptoms, is, in general, a favourable indication; but when the perspiration is local, being confined to the head and face, or to the extremities, it is, in general, an unfavourable symptom. A cold, profuse perspiration, with sunken eyes, a livid hue of the coun- tenance, and short, slow, imperfect respiration, is a sign of great prostration, and is always an unfavourable occurrence. The natural odour of the sweat in young children is acid; in the miliary eruption, the acidity is very decided. In particular forms of cutaneous eruption, the sweat presents a very peculiar and character- istic odour. Many of the cutaneous eruptions are indicative of disease of the alimentary canal, and other organs, or they may depend on simple derangement of the digestive process. Thus the several species of strophulus, prurigo, urticaria, and erythema, result, in general, from improper, or too much food, an unwholesome condition of the mother's or nurse's milk, acid food or drinks; from certain articles of food eaten at improper seasons, as fish; from food of too stimulating a character; and, in certain constitutions, or in particular conditions of the stomach, from articles of food not generally esteemed unwhole- 140 DISEASES OF CHILDREN*. some, as strawberries, honey, Arc. Many of these eruptions are attendant upon the process of dentition. Herpetic and erythematous eruptions, and pemphigus, are very generally connected with disease, either acute or chronic, of the di- gestive organs. The occurrence of ecthyma is often favourable in the acute affections of the intestinal canal; and herpes labialis in all febrile and acute diseases. Minute vesicular eruptions _ occur in chronic diarrhoea, and in protracted cases of cholera infantum. Petechia? are common in many of the intestinal diseases of children; they are usually an unfavourable symptom. Roseola may arise from irritation of the digestive tube, or it may occur in the course of catarrhal and other complaints. Itching and pricking of the skin are produced by gastric derange- ments or intestinal irritation. Itching of the nose is a common symptom of intestinal worms, and itching of the orifice of the rectum of the presence of oxyures. An itching and tingling of the skin often precede the occurrence of exanthematous diseases. 8.—The Breath. The breath of a young infant has often the smell of the breast- milk; occasionally its smell is slightly sour; it is generally, however, during the entire period of infancy and childhood, destitute of any peculiar or very decided odour. Every marked change in the odour of the breath is the indication of disease of the mouth, nostrils, or digestive apparatus; or of dis- turbance of the digestive function. When the breath of an infant is decidedly acid, it is usually in con- sequence of imperfect digestion of the food, and hence the occurrence of an acid breath is generally accompanied, sooner or later, with diarrhoea or colic. In the diseases of the alimentary canal, and in the febrile affections of children generally, the breath has a peculiar smell, difficult to de- scribe, but when once observed, always readily recognised. A fetid state of the breath may arise from indigestion, from dis- ease of the alimentary canal, from ulcerations of the nose, mouth and throat, and from gangrene of the gums or cheek. It is present, also, in small-pox, and the latter stages of the more violent forms of scar- latina anginosa. A rancid smell of the breath is, ordinarily, the result of indiges- tion, from overloading the stomach with animal food. 9.—Discharges by Vomiting and Stool. Infants at the breast often vomit from mere repletion of the stomach with milk; a greater amount being sucked than the stomach can di- gest. The vomiting, in this case, is beneficial, and is favoured by the peculiar position and structure of the stomach, during the first months of existence. The milk thrown up is unchanged, or partially coagu- lated. Vomiting, however, may be induced by some disturbance of the digestive process; the milk discharged, in this case, being decidedly SEMEIOLOGY OF INFANCY AND CHILDHOOD. 141 acid. Repeated vomiting is, in general, however, an indication of dis- ease of the alimentary canal, and is often accompanied with purging. In certain cases the caseous portion of the milk is retained in the stomach, undigested, in the form of a hard, tenacious coagulum; and gives rise often, to gastrodynia, colic, and even convulsions; when discharged by vomiting, an almost immediate relief of all the unplea- sant symptoms induced by its presence in the stomach is experienced. Almost incessant vomiting, increased upon any thing being taken into the stomach, the discharges being decidedly acid, and often of a green colour, is a symptom of gastro-malacia, or that form of stoma- chic disease of children, terminating in a gelatiniform softening of the coats of the stomach. Vomiting occasionally attends the process of dentition; it very gene- rally ushers in an attack of scarlatina, and not unfrequently terminates the violent paroxysms of spasmodic cough, in severe cases of pertussis. Vomiting, attended with increased bilious discharges from the bowels, is common in infants during the heat of summer, particularly at the period of weaning, or during dentition:—when violent and pro- tracted, and accompanied by repeated—almost constant discharges of a yellowish or colourless fluid from the bowels, it constitutes the cholera infantum. Frequent vomiting, attended with gradual, sometimes rapid, ema- ciation, is common in infants who are deprived at an early period of the breast, and attempted to be reared upon other food. Vomiting is occasionally symptomatic of diseases of the brain, and is often one of the indications of incipient hydrocephalus. In early infancy, repeated evacuations from the bowels occur in the course of the day; and during the whole period of infancy and child- hood, the evacuations from the bowels are much more frequent than in after life. Increased evacuations, are then also, in general, much more readily produced from trifling errors in diet, and slight degrees of irritation of the intestinal mucous membrane. The period of teeth- ing is very generally accompanied by increased discharges of thin mucus from the bowels. Diarrhoea in children may arise from improper, or too much food, the irritation of teething, irritation or inflammation of the intestinal canal, the action of cold, and from increased acid secretions in the stomach, the effect of functional derangement or disease of that or- gan. When profuse or long continued, it often proves fatal by the great exhaustion produced. Immediately after birth, the discharges from the bowels are of a very dark green or black colour—the meconium. During the early period of infancy, the discharges are of a soft, curdy consistence and appearance, occasionally tinged with bile and without fetor; during the remainder of infancy and childhood, they are more or less soft, and of a yellow or light brownish hue. Frothy, acid discharges from the bowels, of a light yellow, or slightly green colour, indicate a disturbance of the digestive func- tion; generally from over-feeding or improper food. Discharges of slimy mucus occur in irritations of the bowels, from 142 DISEASES OF CHILDREN. worms or teething; or in consequence of an increase of the mucous exhalation from the follicles of the intestines, caused by the impres- sion of cold upon the surface. Repeated discharges of viscid mucus, occasionally streaked with blood; or of a greenish fluid, mixed with small masses resembling the curd of milk, are frequent in most of the inflammatory affections Qf the bowels. Profuse and frequent discharges of thin or frothy fluid, nearly co- lourless, and devoid of fetor, mark the occurrence of cholera infantum. A deep green colour of the stools, the discharges resembling chopped grass or spinage, is generally a symptom of serious disease of the sto- mach or intestines, and is a striking feature in gastro-malacia, and the more acute grades of gastro-intestinal inflammation. In chronic diarrhoea the stools are thin, dark brown, and often in- tolerably fetid. In cases of worms, and in certain cases of intestinal irritation from other causes, the discharges from the bowels consist occasionally of a slimy fluid of a whitish colour, resembling milk. Light brown or clay-coloured stools are, in general, the indication of hepatic disease, attended with a diminished secretion of bile. Worms are occasionally passed with the stools, during the latter period of infancy, and in childhood, without any symptoms having been present to indicate their existence. A diminution in the number of stools, when diarrhoea occurs as a symptom of the diseases of children, with a return to the ordinary healthy condition in the colour and consistence of the discharges, is a favourable symptom. The appearance of natural faeces in cases of dysentery, and of bile in the discharges in infantile cholera, is a favourable indication. Blood is occasionally observed in the discharges of children, in hyperaemia, irritation and inflammation of the mucous membrane; it is generally mixed with mucus or faecal matter, and never occurs in any great quantity. The passage from the bowels of the substance taken as food, en- tirely unchanged, or but little altered, is an indication of excessive irritability of the alimentary canal; it occurs occasionally in inflam- mations of the stomach and bowels, but more frequently in protracted cases of cholera infantum, and chronic diarrhoea. Constipation is not unfrequent in the early stages of infancy, and in many cases appears to be constitutional, and in others to depend upon the quality of the mother's milk. We have frequently known in a young infant several days to pass, and no evacuation, by stool, to occur, without, apparently, any inconvenience resulting, but when, finally, the desire to discharge the contents of the bowels occurred, the violent straining, and the pain attendant upon the passage of dry, hardened masses of faeces, were particularly distressing to the little patient. Constipation should, therefore, never be overlooked, as it may be the means of inducing violent colic, invagination, or in- flammation of the intestines. Constipation often exists in the early period of many of the acute SEMEIOLOGY OF INFANCY AND CHILDHOOD. 143 affections of infancy, particularly of the head and chest; it may arise, in some cases, from functional derangement or disease of the liver, preventing the free secretion of bile. Constipation is, not unfre- quently, induced in infants and young children, by the imprudent use of opiates. In very young infants, the retention of the meconium occasionally gives rise to a deep comatose condition, terminating, if not speedily relieved, in asphyxia and death, while in other cases partial or ge- neral convulsions have been known to arise from this cause. 10.—The Urinary Discharge. The condition of the urine, during infancy and childhood, affords but little important aid in the diagnosis of the seat or character of morbid action. In most of the acute febrile affections the urine is high-coloured and scanty, and its passage often attended with some degree of pain. It is often white in intestinal irritation from the pre- sence of worms, and in hydrocephalus. In irritation of the gastro-intestinal mucous membrane, it is fre- quently of a bright yellow or deep orange hue. Incontinence of urine is frequent in children at all ages. It may simply depend upon the extreme irritability which the mucous mem- brane of the bladder possesses during infancy; from an augmented secretion of serous urine, in consequence of a derangement of the renal function, or from neglect on the part of the child of the sensa- tions incident to the natural call to urinate, in consequence of which, the command of the will over the action of the bladder and its sphinc- ter is lost. It occasionally results from irritations seated in the lower portion of the intestinal canal; and in some cases, from disease of the brain or spinal marrow. An excessive amount of limpid, watery urine is often voided by infants and children, and is indicative of a disordered state of the digestive function from improper food; it often occurs at the period of weaning, and is occasionally attendant upon dentition. The in- creased flow of urine in children is said to be, occasionally, diabetic. When pain and difficulty are experienced in urinating, it is indica- tive of inflammation of the kidneys, neck of the bladder, or urethra; or of calculous concretions in the ureters, bladder, or urethra. It may originate, however, from irritations seated in the rectum, or of the digestive organs generally. In young children, scanty and painful urination occurs from disease of the kidneys, connected, most generally, with long-continued intes- tinal disease, or with some affection of the brain. In these cases, the urine is passed only in small quantities, and is usually high-coloured, and stains the linen yellow. Retention of urine is occasionally present during difficult dentition. In very young infants it is sometimes produced by some peculiarity of the mother's milk. We have known it, also, to be a symptom of worms in the rectum. Scanty urine occurring towards the decline of scarlatina, and other 144 DISEASES OF CHILDREN. acute exanthemata, is in general connected with dropsical effusion within the abdomen or in the cellular tissue. 11.—The Bones. A premature, or very rapid development, in the longitudinal di- mension of the long bones, particularly, if, at the same time, there is not a correspondent but rather a deficient development in the dimen- sions of the chest, very generally indicates a predisposition to tuber- cular disease of the lungs. A rapid increase of the osseous structure in length, is a very fre- quent occurrence towards the decline or immediately after fevers, especially the febrile exanthemata. With this direction of the nutri- tive process, the development of rachitis and tubercles, so generally consequent upon rapid growth, would seem to be connected. (Schill.) Curvatures of the long bones of the lower extremities are often the result of too early attempts to induce the child to walk; of a bending or imperfect fracture of the bones from violence; this occa- sionally occurs in the upper extremities, from imprudently lifting an infant by the arms. Curvature of the bones is also one of the symp- toms of rickets. Curvatures of the spinal column in young infants, are sometimes the result of placing them too early in the sitting posture; in children they may arise from debility of the spinal muscles, or disturbed equi- librium in their action, the result of improper positions of the body, too long continued, and defective exercise. Curvature of the spine is, also, the effect of rickets, and of caries of the vertebrae. Lengthening of one of the lower extremities, exists as a symptom of the second stage, and a shortening of the extremity, of the third stage of hip disease. Enlargement of the articular extremities of the long bones is com- mon in scrofula and rickets. Enlargements of the larger joints occur sometimes after the acute exanthemata, or upon the sudden repulsion of chronic eruptions. Excessive development of the skull, is a symptom of hypertrophy of the brain; it also takes place in chronic hydrocephalus, and in rickets. In idiocy there is commonly a very decided diminution in the development of the skull. A diminished development in the capacity of the chest, or a flatten- ing of the ribs at the sides, with undue projection of the sternum, is common in children predisposed to tubercular disease of the lungs. THE DISEASES OF CHILDREN, PART II. 10 A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. SECTION I. DISEASES OF THE DIGESTIVE ORGANS. CHAPTER I. DISEASES OF THE MOUTH. STOMATITIS.—INFLAMMATION OF THE MOUTH. 1.—Erythematic Stomatitis. Erythematic inflammation of the mucous membrane of the mouth is a common disease during infancy. The inflammation may be con- fined to the tongue, or to a portion of the parietes of the mouth; or it may be universally diffused over the entire cavity. It varies in in- tensity in different cases—in some, being so slight as scarcely to at- tract the attention of the child's attendants, and disappearing prompt- ly—while in others it assumes a considerable degree of severity, and causes intense suffering to the little patient for many days or weeks, and by extending to the oesophagus and stomach, or into the larynx and trachea, it may prove finally fatal. Simple erythematic inflammation of the mouth is characterized by increased heat and redness of a part or of the whole of the parietes of the mouth and surface of the tongue, accompanied with more or less dryness of the parts affected. The sensibility of the inflamed membrane is increased, and pain is experienced by the infant, when any part of the mouth is touched, and in the motions of the tongue and lips in the act of sucking. The first indications of the disease are, in general, the fretfulness and restlessness manifested by the infant; its suddenly quitting the nip- ple after sucking for a few moments—or, when fed by the hand, refusing its food, and crying when this is attempted to be forced upon it. When the inflammation extends over the whole surface of the mouth, it often spreads, also, to the lips, which tumefy, excoriate, and crack, and not unfrequently becomes affected with herpes. 148 DISEASES OF CHILDREN. In very young infants, the disease is seldom attended with febrile reaction; but when it occurs about the period of dentition, it is fre- quently accompanied by some degree of fever, and when of any du- ration, it is then often attended also by profuse ptyalisin. Simple erythematic stomatitis may occur as an idiopathic affection, or it may be symptomatic of a diseased condition of the alimentary canal. In the first case it may be produced by exposure to cold, by too hot or stimulating food, by the violent exertions of the tongue and muscles of the mouth, in attempting to derive nourishment from an over-distended breast, or from a too small or badly formed nipple, or, finally, it may result from the irritation of the mouth consequent upon dentition. In its simplest form, erythematic stomatitis is seldom a very violent or obstinate disease, and is very promptly relieved by simple emol- lient washes, as a solution of the pith of sassafras or of the inner bark of the slippery elm, in cold water. When marked by a greater de- gree of severity, it may be necessary to apply a leech or two at the angle of the jaws. In aggravated cases of the disease, we have de- rived advantage from washing the parts affected with a weak solu- tion of acetate of lead in water. (Three grains of the acetate of lead to one fluid ounce of water.) When the inflammation of the mouth is symptomatic of irritation or inflammation of the alimentary canal, it will, in general, yield to the operation of the remedies adapted for the removal of the latter. 2.—Erythematic Stomatitis with curd-like Exudation. A common result of erythematic stomatitis is the secretion of a white matter, which appears, usually, in the form of small points or patches, resembling minute portions of curd, adhering to the surface of the inflamed membrane; this is particularly the case in infants at the breast. It constitutes the muguet of the French writers, the thrush or children's sore mouth, of nurses; and the aphtha lactumina and aphthce infantiles of the older physicians. This form of erythematic stomatitis is among the most common of the affections incident to the early stage of infancy, and many nurses are under the impression, that if it does not occur within the month, the infant is rendered liable at a later period to some other form of disease, which it might have escaped, had it gone through " the sore mouth," at the proper age. By most pathologists, the affection under consideration has been confounded with aphthae;—from the latter it differs, however, in many important particulars. Its occurrence is most commonly confined to the period of suckling. In many cases it is preceded by no very striking symptoms. The in- fant is, however, generally peevish and fretful, and exhibits more or less pain and difficulty in sucking, and often abruptly quits its hold of the nipple, or cries when attempted to be applied to it, or to be fed with artificial food. Occasionally there is considerable languor, or even drowsiness, and not unfrequently, more or less disturbance of the sto- mach, and bowels. If the mouth be now examined, the whole of its DISEASES OF THE DIGESTIVE ORGANS. 149 cavity will be found red, hot, and preternaturally dry. After a day or two, sometimes within a few hours, small white points make their ap- pearance at the extremity, or on the sides of the tongue, or at the angles and on the inner surface of the lips. These points have the appearance of minute fragments of curd, adhering to the parts men- tioned, which latter are of a dark-red colour, hot and dry. In mild cases, the inflammation, in a short time, disappears; the particles of white curdy matter become detached, and fall off, leaving the membrane beneath of a smooth and healthy appearance. If the inflammation continues unabated, the points of curcly matter increase in number, and often extend over the whole surface of the tongue and mouth, or a number of the points unite together upon the tongue or inner surface of the lips and cheeks, in the form of patches, often of considerable thickness; these patches, sooner or later, become detached and fall off, and their place is quickly supplied by a new exudation; and this separation and renewal of the patches is repeated so long as the inflammation continues. In other instances, however, i the patches formed upon the tongue, and upon the inside of the lips and cheeks, coalesce, and the whole of these parts become covered with a whitish granulated crust, which often extends into the fauces, pharynx, and in some cases into the larynx. The general symptoms connected with this form of stomatitis vary with the degree of intensity in the local disease. When the latter is mild, and of short duration, the child is fretful, or dull and peevish; he exhibits pain from the motions of the mouth in sucking, or in taking food, especially when this is warm or in the slightest degree stimulating. In general, the surface of the body is hot and dry, and the thirst is increased. In the more aggravated forms of the disease, there is often great restlessness, alternating with drowsiness: disturbance of the stomach and bowels, and other symptoms, dependent upon the affection of the alimentary canal, with which the inflammation of the mouth is very generally associated. The duration of the disease is various; in slight cases it terminates in a few days; in other cases, it may continue much longer, without producing any very severe or alarming symptoms. Excepting when complicated with inflammation of the alimentary canal, it is usually a troublesome, rather than a dangerous affection. In those cases in which large patches of exudation form upon the inside of the lips or cheeks, or upon the velum of the palate, the dis- ease, particularly in situations where a number of children are crowded together in ill-ventilated apartments—occasionally assumes a malignant character, and is then attended with very considerable danger. The patches of exudation acquire a dark colour—the breath becomes fetid—the submaxillary glands enlarge and become painful —and the face swollen, and of a dusky red. The lips and gums be- come tumid and bleed upon the slightest touch—while a fetid sani- ous saliva flows constantly from the mouth—diarrhoea, also, often attends, the discharges being dark-coloured and highly offensive— the surface of the body becomes dry and hot, and the child sleepless 150 DISEASES OF CHILDREN. and restless; finally, the patient sinks; death being occasionally pre- ceded by a deep comatose condition. The usual causes of this form of stomatitis, are bad or improper food, a neglect of cleanliness, and confined and impure air. It is often produced by the bad quality of the mother's milk, or by feeding the child with food unadapted to the condition of its digestive organs; children prematurely weaned seldom escape an attack of it. It is very prevalent, also, in public institutions, where many infants are crowded together; especially in small, ill-ventilated rooms. By some writers it has been supposed to be communicated by con- tagion; we know of no facts, however, in support of such an opinion. Baron and Billard positively deny its contagiousness; while Girelli states, that he has knoAvn healthy infants to become attacked by sucking from the same breast as those affected with the disease; and a similar statement is made by Marley. This fact may, however, be very readily explained by the deteriorated condition of the nurse's milk, without the necessity of admitting the communication of the disease by a contagious matter, derived from an infected infant, and communicated by the nipple it has sucked. The true character of the affection under consideration appears not, very generally, to be understood. By the majority of medical writers, it has been confounded, as we have already remarked, with aphthae, in connexion with which it occasionally occurs. Breschet, Guersent, Veron, Lelut, and Billard, have studied both diseases with great care, and it is evident, from the result of their observations, that, while aphthae are the result of follicular inflammation, the curd-like exuda- tion, which takes place in the erythematic inflammation of the mouths of children, is the result of an altered secretion from the inflamed mucous surface, in the form either of small curd-like particles or flocculi, or, as in other diphtheritic inflammations, of large patches of a soft pseudo-membranous matter, which Lelut has attempted to show is analogous to, or identical with the false membrane of croup, while Billard terms it coagulated mucus, and Guyot, mucus rich in fibrine. Upon the separation of these morbid exudations, the membrane be- neath is found to be smooth, and without solution of continuity; this fact we have tested in numerous examinations. According to Guer- sent, the morbid curd-like exudation is deposited beneath the epithe- lium, and its separation is consequent upon the*rupture of the latter: —Plumbe is of a similar opinion. Guyot and Billard, however, never saw it in any case, excepting upon the surface of the epithelium, and this accords with our own observations. There is some dispute among medical writers as to how far this morbid exudation extends beyond the mouth and fauces. It is gene- rally admitted that, in severe cases, it has been found in the oesophagus as far down as its cardiac orifice; but while some, including Billard, have asserted that it has been observed throughout the whole tract of the alimentary canal, others, with Veron, maintain that it has, in no instance, been known to occur beyond the oesophagus—the curd-like crusts occasionally found in the stomach being, in their opinion, con- veyed thither from the mouth, by deglutition. Guyot, however, gives DISEASES OF THE DIGESTIVE ORGANS. 151 a case in which the disease was detected, after death, throughout nearly the whole tract of the intestines. We have not had many opportunities ourselves of examining, after death, the condition of the alimentary canal in infants affected with stomatitis with curd-like exudation; but in the few we have examined, we were never able to trace the disease beyond the oesophagus:—a similar statement is made by both DeAvees and Eberle. M. Valleix maintains that the disease is almost invariably attended with softening of the gastric mucous mem- brane, often accompanied by redness and thickening. There can be little doubt that in the majority of the fatal cases, various morbid alterations of the mucous membrane of the alimentary canal are present, but these alterations have evidently no necessary connexion with the disease of the mouth. The treatment of erythematic stomatitis with curd-like exudation, will depend very much upon the extent of the local affection in each case, and of the morbid condition of the alimentary canal, with which it is accompanied. In the milder cases, the frequent application to the parts affected, of some emollient wash, as directed in simple ery- thematic inflammation, with proper attention to the food of the child, the daily use of the warm bath, and exposure to a dry and pure atmo- sphere of a proper temperature, will be sufficient to effect a cure. In the more severe and obstinate cases, Guersent advises a fourth part of chloride of soda to be added to the mucilaginous wash, and Billard a small quantity of alum; while Dr. Darling speaks in the highest terms of the solution of chlorate of soda, as one of the best means of subduing irritations of the lining membrane of the mouth and fauces. The application which we have found the simplest and most successful, is the borate of soda and white sugar—equal parts—rubbed together; a small portion of which, being occasionally sprinkled on the infant's tongue, soon becomes dissolved by the saliva, and applied to every part of the mouth; or the borate of soda may be .mixed with honey, in the proportion of one part of the former to six or eight of the latter: by some practitioners a solution of borate of soda in water, with the addition of a fourth part of alcohol, sweetened with honey or sugar, is preferred. In many cases, we have found the most decided good effects result from the Aveak solution of acetate of lead, noticed when speaking of simple erythematic stomatitis. Whatever washes are used, great care should be taken in their application, to avoid all harsh rubbing, or, indeed, any degree of friction of the inflamed surface. When large patches of curdy exudation occur, these may be touched with a mixture of hydrochloric acid and honey, (one drachm of the acid to one ounce of honey,) and when the exudation assumes a gan- grenous aspect, a wash of chloride of lime,1 or of a strong decoction of Peruvian bark with chloride of soda;2 a mixture of creasote and mucilage,3 or of vinegar and alcohol,4 or a solution of nitrate of silver, 1 R.—Mucilag. acaciae, ^j. ' Creasot. gtt. iv. Caleis chlorin. gr. xv. ad xxx. Mucilag. G. acaciae, t^ss. Syrup, cort. aurant. ^ss.—M. (Angelot.) Aq. Camphorae, §viij.—M. a Decoct, cinchonas, .^iij. * Aceti, gj. Syrup, cort. aurant. t!§j. Alcohol, giij. Sodae chlorin. Jj.—M. (Guersent.) Syrup, simpl. 3£j. Aquae, §iij.—M. 152 DISEASES OF CHILDREN. (from two to four grains to the ounce of Avater,) may be employed, and repeated at shorter or longer intervals, according to circumstances. In even the mildest forms of the disease, acidity of the alimentary canal, and some degree of diarrhoea, are.often present; in such cases occasional small doses of magnesia and rhubarb with ipecacuanha,1 Avill be found advantageous. In all the more severe cases, alterative doses of calomel, combined with magnesia or prepared chalk and ipecacuanha, will be demanded;2 and in those in which the exudation in the mouth assumes a gangrenous aspect, quinia should be adminis- tered.3 * Magnes. calcinat. J}j. " Calomel, gr. ij. ad iij. Rhei pulv. J)j. Magnes. calc. vel Cretae ppt. gr. xxxvj. Ipecacuanhae pulv. gr. j. ad ?)ij. M. f. ch. No. iv. One to be given daily or Ipecacuanhae, gr. iij.—M. f. ch. No. oftener. xjj. One to be given every two or three hours. ' Aq. purae, ,^iij. Sulph. quinine, gr. viij. ad xij. Sulph. aoid. dilut. gr. xv. ad xx. Syrup, simpl. |j.—M. A teaspoonful, every two or three hours. When combined with disease of the alimentary canal, the latter is to be treated by its appropriate remedies. 3.—Follicular Stomatitis. APHTHA. Follicular inflammation of the mouth is also a frequent disease of infancy and childhood, and constitutes the affection ordinarily de- scribed as aphthce, by medical writers. It is more commonly observed about the period of dentition, than at an earlier age; and it is espe- cially liable to occur in children in Avhom the lymphatic temperament predominates, or in whom haematosis is rendered imperfect, by im- proper or unnutritious food, a damp and cold, or an impure and stag- nant atmosphere, exclusion from the light, and neglect of cleanliness. It is likewise a common occurrence in the course of most of the chronic affections of the intestinal canal. The disease usually commences by the occurrence of a few sm'all white specks on the inner surface of the lips and cheeks, and upon the sides and inferior surface of the tongue, and often over the greater part of the soft palate. These specks are slightly ele\Tated, and usually surrounded by a red circle, more or less decided. They may be few in number, and irregularly dispersed over the angles and inner sur- face of the lips and cheeks; or they may occur in groups upon the lips, cheeks, and sides of the tongue; or they may cover every por- tion of the cavity of the mouth; extending, in some cases, into the oesophagus, and even throughout the alimentary canal; and in others, penetrating into the pharynx, and, according to some writers, into the trachea also. The inflammation of the follicles will often continue, for some time, Avithout making any further progress; or, as often happens, the disease DISEASES OF THE DIGESTIVE ORGANS. 153 may be arrested in its first stage and the mucous membrane of the mouth return to its natural condition. If, however, the inflammation proceeds, the specks enlarge, a whitish matter exudes from their centre and ulceration taking place, a superficial ulcer is produced, with slightly elevated edges, and sur- rounded by a circle of inflammation. From these ulcers, there is often secreted a white curdy matter, adherent, at first, to their sur- faces; but subsequently becoming detached, it is either swallowed,, or ejected with the saliva of the infant. When the aphthous ulcerations are numerous, and in close contact, the curdy exudation spreads from one to the other, forming a layer, often of considerable thickness and extent. Occasionally, instead of a curdy excretion, there exudes from the ulcers a small portion of blood, which forms upon them a dark-co- loured crust, that has not unfrequently been mistaken for a gangre- nous slough. Upon the disappearance of the inflammation, the ulcerated follicles readily cicatrize Avithout leaving any permanent scar. When the aphthous crusts, formed by the ulcerated follicles, be- come detached and fall off, they are often succeeded by others, which, in their turn, become detached; and thus, in protracted cases, the crusts are detached and renewed, for several successive times; or only a portion of the crusts are detached, while the general layer of curdy matter continues adherent for weeks. Follicular stomatitis is occasionally attended with scarcely any other than the local symptoms. The little patient is generally, how- ever, fretful and peevish; his skin is dry, and its temperature is in- creased; there is an augmentation of thirst; often some degree of ■diarrhoea; and an evident indication of pain and tenderness of the mouth, by the child, Avhen sucking, suddenly leaving off and crying. Even when the disease of the mouth is more extensive, fever is seldom present, excepting towards its close, or when it occurs subsequent to the period of infancy; but even then, fever is absent in many cases. When the follicular inflammation involves nearly the entire ex- tent of the lining membrane of the mouth, the general symptoms are usually much more violent. There is then great restlessness; con- siderable pain is experienced in the act of sucking; the infant seizes the nipple eagerly, but instantly relinquishes it and expresses its suf- fering by its cries. The mouth is dry and hot, but in the course of the disease there generally occurs a profuse ptyalism, with painful intume- scence of the salivary glands; the nipple of the nurse quickly ex- periences a sense of heat and irritation, and becomes excoriated and excessively tender. The child is troubled with frequent acid eructa- tions, and repeated watery discharges from the bowels, of a green colour, and attended with severe griping. Vomiting is apt to occur from an early period of the disease, particularly upon anything being taken into the stomach. The surface of the body becomes pale; the countenance exhibits considerable peevishness or distress; emaciation quickly ensues, and is often extreme; the child is wakeful; and occa- sionally great restlessness is alternated with dulness or some degree 154 DISEASES OF CHILDREN. of stupor. In some cases the attack is ushered in by extreme drow- siness. As the disease advances, the discharges from the bowels increase in frequency, though diminished in quantity; the verge of the anus becomes excoriated and inflamed; and in some instances we have knoAvn extensive erysipelatous inflammation of the nates to ensue. The abdomen is generally swollen, and occasionally tympanitic; and there is more or less tenderness of the epigastrium. Gangrene of the mouth occurs in some cases; but, in general, the patient dies from exhaustion, or from inanition, in consequence of the entire suspension of the digestive functions of the stomach and boAvels. When the disease extends to the oesophagus, there is usually great difficulty of swallowing; and when propagated to the larynx, the cry of the infant becomesdiarsh and sibilant. Occasionally, the apthous ulcerations become gangrenous. This form of the disease is well described by Billard. The edges of the ulcers shrink, and assume a ragged, flabby appearance; a brownish- coloured slough forms in the centre, which, on separating, leaves a granulated surface, of a vermilion hue; or, in place of a slough, the ulcers become covered with a broAvn, creamy fluid, that exhales a very decided gangrenous odour. The parts surrounding the ulcers become tumid, soft and of a violet colour. From the half-open mouth of the child, is discharged a ropy—often fetid—saliva. The countenance becomes pale and puffy; the pulse is feeble; and the entire surface of the body, pallid, and deficient in sensibility. Fre- quent vomiting, profuse diarrhoea, and a tympanitic condition of the abdomen, generally occur; and occasionally hiccup, and frequent eructations; and the child finally dies without febrile reaction, or cerebral excitement. The termination of this form of the disease is very generally fatal. Follicular stomatitis most commonly occurs in infants of a relaxed habit, Avith predominance of the lymphatic system. It may be pro- duced in infants at the breast, whose nutrition is impaired from the Avant of an adequate supply of milk on the part of the nurse, or from the milk of the mother or nurse being deficient in its nutritious pro- perties, or otherwise of a bad quality. It more frequently occurs, however, in infants, who are attempted to be nourished upon other food than the milk of a healthy nurse; or who have been premature- ly deprived of the breast. Improper or deteriorated food is, indeed, among its most common exciting causes. In infants at the breast, aphthae may result from their being at the same time imprudently fed, on thick, farinaceous substances—pap; paste composed of flour boiled with milk; crackers soaked in milk—especially if these are over-sweetened with brown sugar or molasses. Children born before the full period, or of weakly women, are said by Dewees to be more liable to aphthous inflammation of the mouth, than children born at the regular period, or of robust, healthy mothers. The infants of delicate females sometimes suffer considerably from this affection, by the mothers persisting in suckling them, even when assisted by what is supposed to be an adequate quantity of spoon DISEASES OF THE DIGESTIVE ORGANS. 155 victuals; while as soon as all attempts at suckling are abandoned, and the infant is confined entirely to other appropriate and wholesome food, the disease disappears, and the general health rapidly improves. The tendency to the disease is increased by every thing that impairs the general health of the infant, and impedes haematosis; as a neglect of personal cleanliness, and to remove, daily, with a piece of soft linen and fresh water, the sordes which collect in the mouth; an im- pure and confined, or a cold, damp atmosphere; exclusion from the light; neglect of exercise; and, according to Underwood, by allow- ing the infant to sleep constantly with its face covered, and thus to breathe an air contaminated by its own respiration, and often by the emanations from its parent's or nurse's body. Follicular stomatitis is also a common occurrence in the course of nearly all the pro- longed affections of the alimentary canal, that occur during infancy and childhood. The severer forms of the disease are more liable to prevail in low, damp situations. Van Sweiten, and subsequent Avriters, describe it as prevailing to a considerable extent in various parts of Holland; and Hecher notices a severe form of aphthae as very common in a part of Germany. The disease likewise prevails, in its more aggravated forms, in many of the public institutions of Europe for the reception of infants. It is said, occasionally, to occur as an epidemic; and by many wri- ters is supposed to be communicated by contagion. Frank declares this to be the case, when the matter is applied immediately to the mu- cous membrane of the mouth; and Girelii states, that in the foundling hospital of Brescia, he has known the disease to be communicated to healthy infants, who had been suckled at the same breast with one la- bouring under aphthae. Moss mentions the same fact, and Burns re- marks, that it would appear to be produced by sucking an excoriated nipple; this latter we have known to occur in numerous instances. There has existed not a little difference of opinion, as to the true character of aphthae. Many of the older writers describe them as a vesicular eruption. Among these are Van SAveiten, Arnemann, Calli- sen, Plenck, Etmuller, and Pinel. Among the more recent writers who regard them as vesicular, are Rayer, Bateman, Dendy, Girelii. and Evanson. Andral divides them into three species, the papular. Aresicular, and pustular; Gardien describes them as tubercles; and Guersent, Billard, Guyot, Marley, and others, as an inflammation of the follicles of the mucous membrane of the mouth, presenting two stages; the first, consisting of small, white, miliary tumours; the second, of superficial ulcers. This latter view of the disease, we are led, from our own observations, to believe to be the correct one. There can be little doubt, that the aphthous inflammation frequently extends into the pharynx, oesophagus, and even in severe and pro- tracted cases, through the entire extent of the alimentary canal. Nu- merous accurate observations attest this fact. The excoriation of the anus, which is usually adduced, to prove the extension of the disease to the lower portion of the intestinal tube, affords, however, no evi- dence of such being the case: in the majority of the instances in which the excoriation occurs, it is evidently produced by the acid and irri- 156 DISEASES OF CHILDREN. fating nature of the discharges; it is a frequent occurrence, also, in cases where no aphthae are present. Many writers speak of this disease as never occurring again, after a first attack. This is unquestionably a mistake; and one which, in all probability, has originated from confounding it Avith stomatitis with curd-like exudation, which is a disease seldom, if ever, met with, ex- cepting in young infants:—follicular stomatitis Ave have known, in repeated instances, to recur more than once in the same individual. The treatment of the early stage, and milder forms, of follicular sto- matitis, differs in nothing from that already recommended in simple erythematic inflammation of the mouth; namely, mild mucilaginous Avashes, frequently repeated. At the same time, it is all-important that the child should be placed in a pure, fresh, and dry atmosphere, of a proper temperature. If at the breast, and any suspicion is enter- tained of the insufficiency or bad qualities of the nutriment thence derived, the breast of a healthy nurse should be substituted for that of the mother; and if the infant be weaned, its food should consist, al- most exclusively, of barley or rice water, sweetened with loaf sugar. Care should be taken to preserve perfect cleanliness of the surface, and to promote the functions of the skin, by the daily use of the warm bath, folloAved by gentle friction. The thirst which generally attends the disease, should be allayed, by presenting to the child, frequently, in the course of the day, a few spoonfuls of cold water, in which a small portion of gum acacia has been dissolved. This is peculiarly grateful and refreshing to the little patient; and by some, it has been consi- dered, in conjunction with the daily washing of the mouth with cool, fresh water, as a very powerful means of preventing the occurrence of the disease. An occasional dose of magnesia, or of magnesia and rhubarb, will, in general, be required, and will tend to remove, in part, the acid which generally abounds in the stomach and boAvels. When the disease extends over a considerable portion of the mouth and is attended Avith great pain, as indicated by the uneasiness and cries of the child in the act of sucking, a few leeches should be applied to the angles of the jaw. Billard advises, in such cases, the addition of syrup of poppies to the mucilaginous washes, in the proportion of one or tAvo drachms of the former, to two ounces of the mucilage;— Ave have derived much advantage from a weak solution in Avater, [three or four grains to the ounce,] of acetate of lead. Acetate of tcad is recommended by Stoll, as a local application, in cases of aphthae, on the authority of " certain English physicians," and by Latham, in what he terms, Cachexia Aphthosa. Of the perfect safety with which it may be employed, in this manner, and of its good ef- fects, in allaying the pain and inflammation, our own experience has fully satisfied us. In cases attended with considerable stupor, ac- cording to Girelii, a blister to the back of the neck, has been found beneficial. After ulceration has occurred, a good,—probably the best —local application, is the borate of soda and sugar, applied in the form of poAvder, as directed for stomatitis with curd-like exudation. When the aphthae remain stationary, or become confluent, the addi- tion of a few drops of sulphuric or hydrochloric acid to the mucilagi- DISEASES OF THE DIGESTIVE ORGANS. 157 nous Avash, will be often beneficial, or the mouth may be washed with the chloride of soda. Eberle recommends, as a wash, a solution of nitrate of silver, one grain to an ounce of water; and Billard advises the ulcers to be touched with a piece of alum. We have seen the most decided good effects in obstinate cases, from the use of a weak solution of the sulphate of copper, as a wash. When the aphthous ulcerations assume a gangrenous character, we should endeavour to arrest the progress of the gangrene, by the ap- plication of the chloride of soda, or of creasote, by the internal use of quinia, and by a generous diet. Billard directs the application of a drop or tAvo of sulphuric or hydrochloric acid, by means of a capil- lary tube, to the gangrenous ulcerations; and afterwards to touch the remaining gangrenous parts, with a pencil of nitrate of silver, sharp- ened to a point. When the disease is attended Avith frequent watery discharges, and griping pains of the abdomen, it has been recommended by some of the German writers, to administer, internally, a solution of borate o soda. Pitshaft (Hufeland's Journal) declares, that in severe cases of aphthae, one of our most effectual remedies is the borate of soda, (two to four grains,) combined with the carbonate of magnesia, (five to six grains,) repeated two or three times in the twenty-four hours. We are in the habit of employing, in these cases, a combination of acetate of lead, calomel, ipecacuanha, and extract of hyoscyamus.1 Under the use of this combination, the irritation of the bowels is very often quickly diminished, the griping stools are suspended, and the general symptoms of the case improved. 1 Acetat. plumbi, gr. vj. ad xij. Calomel, gr. iij. Ipecacuanhae pulv. gr. ij. Ext. Hyoscyami, gr. iv. ad vj. M. f. Chart. No. xij. One to be given every three or four hours according to circumstances. In cases attended Avith inflammation of the bowels, leeches to the epigastrium, warm, emollient fomentations to the abdomen, and the other remedies applicable to such inflammation, are to be resorted to, in conjunction with the local treatment already recommended. Care should be taken throughout the disease to keep the parts about the anus perfectly clean. The diaper should be removed immediately after every stool, and the nates, and orifice of the anus carefully washed with an infusion of the bark of slippery elm; and after being well dried, the parts which appear red and irritated, may be smeared .with a little perfectly fresh lard. When the irritation is considera- ble, the occasional use of a wash of a weak solution of acetate of lead, will be found advantageous. In cases of aphthae attended with evident prostration of strength, without any acute disease of the alimentary canal, some light tonic, as the cold infusion of cinchona, or the sulphate of quinia, may be administered. In prolonged cases of aphthous ulceration, the use of iodine, and other alteratives, with change of air, and a well-regulated diet, will, in 158 DISEASES OF CHILDREN. many instances, by restoring the nutrition of the system to a healthy condition, effect a cure. 4.—Ulcerative Stomatitis. Independently of the aphthous ulcerations just described, the mouths of children are liable to be the seat of ulcers, resulting from acute phlegmonous inflammation. These may occur upon any part of the lining membrane of the mouth, but are usually situated on the sides of the fraenum, along the inferior margin and edges of the tongue, on the gums, the inner surface of the cheeks, and the palatine arch. They seldom occur upon the upper surface of the tongue. The disease usually commences with some degree of febrile .excite- ment, indicated by increased heat and dryness of the surface, aug- mented thirst, lassitude, and restlessness. The infant becomes un- usually fretful—lets go the nipple when it has commenced sucking, and indicates the painful state of its mouth, by its cries. On examining the mouth, one or more small, inflamed, and slightly elevated points are perceived; the apex, or central portion of these, in the course of a day or two—often within a much shorter period—becomes softened, and of a yellowish hue, and, finally, a small ulcer is formed, at first superficial, but gradually becoming more deeply excavated, and often exhibiting an inflamed and elevated margin. The ulcerated surface is generally covered with an ash-coloured or yellowish matter, but it is occasionally bare, and readily bleeds. When the ulcers occur upon the upper surface of the tongue, they are in most cases superfi- cial, having the appearance, rather, of slight excoriations. After ulceration has taken place, there occurs, in general, a pro- fuse ptyalism, with a subsidence of the febrile excitement. The bowels are ordinarily costive at first, but become loose, and often purged in the course of the disease. In some eases, but one or two ulcerations, of no great extent, are present, which, after a short time, fill up with granulations, and rapidly cicatrize; in other cases, however, the ulcers are more numerous; sometimes thickly studding the inside of the cheeks, the gums, the arch of the palate, and both sides of the base of the tongue. In other cases, again, one or two ulcers will occur, which slowly extend in size and depth, and exhibit no disposition to heal; the little patient, at the same time, wasting away with a species of hectic fever, with exacerbations night and morning. Denis describes a species of ulceration, caused by a softening of the mucous membrane of the palate, and which invariably occupies its centre, either on the median line, or on the outside of this line. The- mucous membrane is changed into a kind of pulp, of a red, inclining to a fawn colour. If the pulpy matter be removed, the edges of the ulceration are found to be perpendicular, with the bare bone at the bottom of the ulcer, apparently in a healthy condition. This affection we have never observed. Ulcerative stomatitis frequently occurs during dentition, and is a common disease in children labouring under a disordered state of the digestive organs, with a costive or irregular state of the bowels, vari- DISEASES OF THE DIGESTIVE ORGANS. 159 able appetite, offensive breath, inertness of disposition, a pale puffy complexion, and hard tumid abdomen. " It may also occur in the course of other acute or chronic dis- eases, as pneumonia, eruptive fevers, &c, which entail constitutional injury. It is endemic in certain wards of the Hopital des Enfans Trouves, according to M. Taupan, who also believes it to be contagious—that is, to be communicable by using the same spoon for feeding, &c. And occasionally, also, it would appear to prevail as an epidemic." (Churchill, Diseases of Infants and Children.) The treatment differs but little from that directed for aphthous ulceration. When unattended with serious derangement of the di- gestive organs, simple mucilaginous washes for the mouth, and when the bowels are confined or irregular, a small dose of calomel, followed, in the course of a few hours, by a dose of castor oil, with the tepid bath daily, and a plain, unirritating diet, will, in general, promptly effect a cure. If, however, the ulcers are tardy in healing, they may be washed with a solution of borax in water (15 grains to the ounce;) or with the chloride of lime, or a weak solution of nitrate of silver (one grain to the ounce;) or of sulphate of copper (5 grains to the ounce.) According to Dr. Dewees, the following wash has never failed to quickly arrest the ulceration.1 ' R.—Sulph. Cupri, gr. x. Pulv. Cinchonae, gij. " G. Acaciae, gj. Mellis, gij. Aq. purae, §iij.—M. \¥ith this wash the ulcers are to be touched twice a day, with the point of a camel's hair pencil. Dr. F. W. Mackenzie of London, in cases of ulcerative stomatitis, gives the preference to the following method of treatment. It con- sists in removing, in the first place, any apparent cause of irritation, such as a decayed tooth, should it exist, and in applying daily, the dilute nitric acid of the pharmacopoeia, to the whole of the ulcerated surfaces, by means of a sponge, or camel's hair pencil, whilst, at the same time, the sesquicarbonate of ammonia is given in full doses^ combined with citrate of iron. When the tongue is coated, and the alvine discharges are unhealthy, it is necessary to premise an emetic of ipecacuanha and squills, as well as a purgative of calomel and rhubarb. It is also necessary that the patient should be well sup- ported by a nutritious diet, and an adequate allowance of malt liquor or wine. The application of the dilute nitric acid, Dr. Mackenzie remarks, appears to have a remarkable influence in improving the character of the ulceration and arresting its progress. The sloughy, dirty, yellowish appearance, which it generally presents is soon changed for a florid, healthy, granulating surface, and this result would appear to depend upon the moderately stimulating properties of the remedy which are not disproportionate to the exhausted vital powers of the ulcerated tissues. 160 DISEASES OF CHILDREN. When accompanied Avith extensive derangement of the alimen- tary canal, the proper remedies adapted to the removal of the latter will be demanded. In many eases, indeed, the ulcerations of the mouth will be found to resist every local application, until the di- gestive organs are restored to a healthy condition, and the nutrition of the system generally is improved. 5.—Gengivitis.—Inflammation of the Gums- The gums, from the period AAdien dentition commences, until the completion of the first set of teeth, are liable to become inflamed, independently of the residue of the buccal cavity. In some cases, the inflammation is but slight, and of short duration; but in others, particularly Avhen it occurs in children whose general health has be- come impaired, in consequence of a deranged state of the digestive organs, the inflammation is often severe, and productive of extensi\re ulceration, by which the alveola and teeth are frequently 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 general, very languid, with a hot and dry skin, a small and quick pulse, impaired appetite, and considerable thirst. The tongue is usu- ally 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 takes place, as it frequently does, previously to the protrusion of the molar teeth, a small ulcer is liable to occur upon the surface of the gum, immediately over the teeth about to pro- trude, and, quickly extending, often lays bare the alveola, and causes the destruction of the teeth. In other cases the ulceration occurs at the edge of the gum, and extends rapidly doAvnwards. In every case in which the ulceration is alloAved 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 ahvays a copious flow of fetid saliva, the breath becomes extremely offensive, and the counte- nance of the child assumes a pale, salloAv hue; a bloody fluid oozes from the gums upon the least pressure, and often a very profuse di- arrhoea 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 Avith 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, tAvice 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 inflammation is not promptly reduced by these means, a few leeches should be applied to the angles of the jaw, or to the gums themselves. Some writers ad- vise the gums to be freely scarified, and in many instances, when Avell timed, we have seen advantage to result from this procedure. DISEASES OF THE DIGESTIVE ORGANS. 161 The bowels should be freely opened by the administration of a few grains of calomel, combined with magnesia, and followed, after a few hours, by a dose of castor oil, or sulphas magnesiae; the tepid bath should be administered daily, and the child put upon a diet composed 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 infu- sion of oak bark, with alum,1 we have found peculiarly advantageous; the chloride of lime will, also, in many cases, speedily arrest the ul- ceration; or, we may employ, as a wash, diluted hydrochloric acid.2 We have often found a solution of the sulphate of copper to succeed, however, when other topical applications have failed. * R.—Corticis Querci. gj. a R.—Acid Hydrochlor. ^ss. ad 3J. Aquae, Oss. Mellis, Boil to a pound and strain, then add— Aquae Rosae, ai ^j.—M. Sulph. Alumin. Qj. To be applied three or four times a day. To be applied to the ulcerated parts by means of a soft sponge or dossil of lint, several times a day. The child should be exposed to a 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 materi- ally 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—GANGRJENOPSIS—CANKER OF THE MOUTH—WATER CANKER.) Gangrene of the mouth is not a disease of so common occurrence in this country, as it would appear to be in many parts of Europe; it, nevertheless, does frequently occur, and has, in more than one of our public institutions for the reception of infants, prevailed endemically. Gangrene may ensue in either of the forms of stomatitis already noticed; and, occasionally, in the follicular form, it becomes 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 tempera- ment, or the energies of whose organic functions have been impaired by previous disease, that gangrene of the mouth most frequently takes place. The patient is, in general, affected with great languor 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 usually his thirst is increased. The countenance becomes pale and dejected, and a peculiar puckering of the cheeks, about the 11 162 DISEASES OF CHILDREN. corners of the mouth, is often observed. There is, in many cases, considerable emaciation, with 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 fetid, 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 leaden hue, swollen, and spongy, and bleed upon the slightest touch. The discharge of saliva becomes more profuse, ac- companied 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 the appearance of the gums, at this stage of the dis- ease, bear so strong a resemblance to those of a case of mercurial pytalism, that we have known it to be mistaken for such by physicians of skill and experience. 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 be- come loose, and often fall out of their sockets; or, if they remain, be- come covered with a thick coating of a dirty white or ash colour. Fever now generally occurs, at first towards evening, and attended often by an increase of the nocturnal sweats. The bowels are also often affected with diarrhoea. MM. Rilliet and Barthez state that in the cases observed by them the skin was always rather dry than humid; a similar remark is made by MM. Baron and Destrees. The disease may continue in the state just described for many weeks, or even months. 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 ensues 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 infe- rior 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 in- creases in extent. At this stage, and sometimes much earlier, a difficulty is experi- enced in moving the lower jaw, in consequence of which, the mouth becomes occasionally firmly closed. This, Reimann has erroneously considered to result from an actual tetanic affection; it is, evidently, the mere effect 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 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 offen- sive odour. DISEASES OF THE DIGESTIVE ORGANS. 163 The fever, which now often augments in intensity, presents a ner- vous or hectic character, and the child dies upon the eighth, or, at farthest, on the fourteenth day from the commencement of the gan- grene, his body presenting all the indications of a general colliquation. The disease just described is evidently a gangrene of the gums, extending thence to the surrounding soft parts, and induced by acute inflammation, 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 to a damp and chilly atmosphere, or by previously existing disease, particularly of the digestive organs. It is this 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, hoAvever, another form of gangrene of the mouth, of much less frequent occurrence than the former, and differing from it in many important particulars. 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 wererabruptly; without, at least, any previous symptom, indicative of its occurrence. A hard indolent tumour 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 red- ness of the skin by which it is covered. Upon examining the mouth, nothing unusual is discoverable. For a few days, the tumour gradually augments in size, and the skin becomes of a deeper red; the internal surface of the cheek, over the tumor, assumes a gangrenous appear- ance, and an extremely offensive odour is exhaled from the mouth, Exacerbations of fever generally occur towards evening; the appetite and disposition of the child are 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 gray- ish hue, and surrounded by a red areola, which extends as the disease progresses. In a few hours, frequently, the gray sphacelated 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 this has made considerable progress. Necrosis of the maxillary bone is seldom observed in the variety of gangrene just described; death usually taking place from a general sinking of the powers of life, previously to any very extensive de- struction 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 mar- 1G4 DISEASES OF CHILDREN. gin, and of various sizes, occur suddenly upon the lips, near to their angles, and upon the cheeks; the general system of the patient re- maining apparently unaffected. In some cases, the gangrenous spots are preceded, for "one or two days, by a slight redness of the skin where they occur. The gangrene is ahvays superficial, involving little more than the skin, and there is but little loss of substance when the sloughs separate; a suppuration of a healthy character quickly ensues, followed by granulations and cicatrization. Occasion- ally, 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, hoAvever, 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, according to Richter, Baron, Romberg, and others, 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. We have seen it more frequently, however, in children who have laboured for some time under symptoms of irregu- lar remittent fever, connected with chronic gastro-intestinal disease. 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, pome in- tumescence of one side of the face will be detected. The disease is occasionally, 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 be- comes greatly distended, the centre of the tumour 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 fetid odour. If the mouth be now examined, one or more grayish vesicles will be perceived upon the internal surface of the affected cheek, which, after some days, rupture, and form an ulcer of a dirty gray colour, of a rounded form, with red, distinctly circumscribed 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 those unacquainted with the disease; the whole of the attention being directed upon the external swelling. There is, in fact, some difficulty in making an accurate examination of the inner surface of the cheek, from the difficulty the little patient experiences in opening his mouth to a sufficient extent, after the external swelling has acquired any size. As the gangrenous ulceration Avithin becomes deeper and more ex- tended, alivid spot, surrounded by a red areola, makes its appearance DISEASES OF THE DIGESTIVE ORGANS. 165 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 to eight weeks, nearly the whole of the soft parts on that side of the face. Portions of it are soft and of a gray or greenish hue, and present all the characteristics of humid gangrene, while other portions are completely mummified, hard, and of a deep black colour. If the gums be now examined, they will be found to be in a gan- grenous condition, immediately opposite to where the gangrene com- menced 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 consequence of the preceding mortification of the cheek; whereas, in the first variety, the gums are the part in Avhich the gangrene com- mences, 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 offensive; 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 soporose 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 fe- brile symptoms of a remittent character. In no one of the cases, however, which have fallen under our care, did the gangrene involve the whole thickness of the cheek. In every instance, we were ena- bled to arrest its progress, before it had extended beyond the mucous membrane lining the cheek in Avhich 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 Euro- pean writers. Gangrene of the mouth is an affection almost exclusively confined to the period of infancy. It may occur at any time between the second and tenth years, but is most commonly observed between the second and fourth. By Rilliet and Barthez it was observed most frequently in children between the age of three and five years. Few, if any, cases have been met with in infants during the period of lac- tation. The children in whom gangrene of the mouth most usually occurs, are those of delicate habits, of a lymphatic temperament, with soft and flaccid muscles and pale skin, and in whom the functions of assi- milation and nutrition have been depressed from a variety of morbific influences. In no instance has the disease been known to occur in children of a robust and healthy constitution. It is hence seldom met with excepting among the children of the poor, who are imperfectly fed, or upon food of an improper quality; those who are exposed to the influence of a damp and chilly, or impure and confined atmo- 166 DISEASES OF CHILDREN. sphere; in whom personal cleanliness is neglected, or who have be- come 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, Avhere a number of children are crowded together in small, Ioav, or illy venti- lated 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 tAvo hundred and forty inmates of the institution, 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 conse- quence, an affection extremely prevalent in Holland, Sweden, Den- mark, Nonvay, 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 dis- ease, are sufficiently established by the report of the physicians at- tached to the French army which occupied Spain, they having to treat, frequently, a gangrenous inflammation of the mouth which oc- curred among the soldiers, and which received from the Spaniards the name oifegar, or fegarite.—(Richter.) The disease is mentioned by more than one writer as having pre- vailed epidemically in the Netherlands, as a consequence of gastric fevers. Gangrene of the mouth is, no doubt, in the majority of instances, intimately connected with gastro-intestinal disease. The causes which have been enumerated evidently predispose to the disease, by disturb- ing the healthy condition of the stomach and the other organs appro- priated to digestion and assimilation, and to nutrition generally. In all of Poupail's cases, seventy-two, the disease followed an at- tack of intermittent or remittent fever; in nine of the cases reported by Dr. Jackson, formerly of Northumberland, it 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. In the observations of Rilliet and Barthez, it was in the lungs and intestines that disease was most frequently detected. The affections of the intestines were entero-colitis, either acute or chronic, or softening. In all the cases which have fallen under our notice, the affection of the mouth was preceded by more or less decided indications of gastro-intestinal disease; in the majority, the children had suffered for some time from the infantile remittent and intermittent fe\*ers. Another fruitful cause of the disease would seem to be the acute exanthemata; an imperfect crisis, or sudden repulsion of the cuta- neous eruption, appearing to favour, in an especial manner, the de- velopment of gangrene of the mouth. Dr. Willan notices its occurrence in scarlatina, and Dr. Marshall Hall, after variola, rubeola, and scarlatina. Dr. Cuming states that, DISEASES OF THE DIGESTIVE ORGANS. 167 in two cases which fell under his observation, the disease occurred as a sequela of measles; in another, in the advanced stage of dysentery; in a fourth, upon the termination of infantile remittent fever; and adds, that it is more generally observed at the close of the exanthe- mata, than at that of any other of the acute affections to which chil- dren are liable. Rilliet and Barthez state, that the disease, in the course of which they have more frequently observed gangrene of the mouth to occur, is measles. They have occasionally observed it in scarlatina, small-pox, and pneumonia. They have also known it to follow intestinal affections, hooping-cough, scrofula, &c. In Dr. Dun- can's cases, the disease appears to have tnost generally occurred in children labouring under some affection of the intestinal canal; although in several of the cases the gangrene occurred after measles. Of the six cases observed by Dr. West, of London, two succeeded to typhus fever, two to measles, one occurred in a child Avhose health had been completely broken down by ague, and one supervened in a tuberculous child, who had been affected for many weeks with ulce- rative stomatitis in a severe form. By a few of the writers on gangrene of the mouth, its propagation by contagion is asserted; but of this no well-authenticated instances have been recorded. In every case, however, as a prudent precau- tion, it will be proper to separate as much as possible the individuals affected from those in health, as well as from each other. A number of patients labouring under gangrene of the mouth being confined in the same room cannot fail, even with every precaution in regard to cleanliness and ventilation, to render the disease, to a certain extent, more unmanageable than when the patients are placed in separate and distinct 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 little accuracy, so that of the pathological anatomy of the disease Ave 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 pa- tients—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 hyperaemia, rather than Avith any structural change. In the majority of cases the mesenteric glands were greatly enlarged. In none of the cases observed by Rilliet and Barthez was the gan- grene of the mouth the only lesion detected. The internal organs were invariably found to be affected with indications of disease, which had existed anterior to that of the mouth, or was concomitant with or consecutive to it. The most frequent were acute affections of the lungs—entero-colitis, acute or chronic, and softening of the intestines; more rarely tubercles, which, however, were very abun- dant in one case. In a very feAv cases, gangrene of the pharynx and lungs was present, and in a still fewer number, pleurisy, pneumo- thorax, peritonitis, pharyngitis, and nephritis. 168 DISEASES OF CHILDREN. In the examinations made at the Children's Asylum, at Philadelphia, between June 1st, 1827, and January 1st, 1830, the morbid appearances exhibited were enlargement and hardening of the mesenteric glands; a scrofulous condition of the glands of the neck; and, in every instance, tubercles of the lungs. Ingeneral,the whole substance of the lungs was thickly studded with tubercles, in various stages of development. 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 if it be not entirely beyond the control of medical treatment, it speedily pro- duces, in at least the majority of cases, the death of the patient; while Rilliet and Barthez declare that death is the ordinary termination of the disease. It 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 im- pure or to a damp and chilly atmosphere, or when it occurs in chil- dren greatly exhausted by previous illness, the disease is one very generally fatal. When, too, its real character is misunderstood; when it is overlooked in its first stages, or treated by inert or im- proper 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, however, 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. B. H. Coates, who had the charge of the Children's Asylum of Philadelphia, previously to the year 1828, and of his successor in that institution; where, although the disease had frequently prevailed epidemically, it has been productive of a very small mortality. 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-im- portant to insure its success. This, perhaps, more than almost any other circumstance, will determine, in the majority of cases, the greater or less mortality of the disease. When the physician has been enabled to detect it at the period of its development, he will, very generally, 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 commences by a tumour or livid spot upon the cheek, it is very generally under the control of medicine. 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, it is of a less ma- lignant 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 dis- ease with care; and, according to Richter, the two other varieties, DISEASES OF THE DIGESTIVE ORGANS. 169 also, result from an inflammation of the parts in which they first occur—an opinion which we believe to be well founded. Gangrene of the mouth has been ascribed to inflammation of the lymphatics, by Bidloe; to a softening of the affected tissue, similar to what takes place in the stomach, uterus, brain, and other organs, by Klaatsch, Hesse, Weigand, and Boer; to a scrofulous affection, cheilocace, byLontin; to a scorbutic affection, by Van Sweiten, Sei- bert, and most of the older writers, and finally, to an induration of the cellular tissue from infiltration, similar to what occurs in new- born infants, by Fischer and 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 be done to prevent its occurrence, by directing our remedies to the removal of 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 re- spect to the substances of which it is composed, to the actual con- dition of the digestive organs in each case. If the gums are in a state of inflammation, 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, howeArer, that altera- tive doses of calomel, even when indicated by the symptoms present, are to be employed with the utmost caution, in every instance in which Ave 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 judiciously pre- scribed, and their effects are carefully Avatched, small doses of calo- mel will, nevertheless, often be productive of beneficial results. In a few instances, we have found the administration of the sul- phate of quinia, and washing the gums repeatedly with a strong de- coction of oak bark, to be beneficial in preventing gangrene of the mouth, in cases in which we had every reason to anticipate its speedy occurrence. In every case in which decided symptoms of local in- flammation exist, leeches to the part will be proper. When tume- faction of the cheek occurs, blisters over the tumour have been, also, found beneficial by Dr. Jackson, formerly of Northumberland, now of Philadelphia. The remedies that have been applied locally, with a view of ar- resting 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 success- ful, is a strong solution of sulphate of copper (thirty grains to the ounce of water,) applied very carefully twice a day, or oftener, to the full 170 DISEASES OF CHILDREN. extent of the gangrenous ulceration. A solution of the sulphate of zinc (one drachm to an ounce of water,) either alone or with the ad- dition of tincture of myrrh,1 will also be found, in many cases, an admirable remedy. Nitrate of silver was the only local remedy em- ployed in the cases of gangrene of the mouth, that occurred in the Children's Asylum of Philadelphia, from June 1st, 1827, to January 1st, 1830, the greater portion of which terminated favourably. As soon as the disease of the mouth was detected, the nitrate of sih'er, either in pencil or solution, was applied freely to the parts affected. 'B.-Sulph. Zhici. 3j. Aquae, gij. M. et solv. Dein adde Mellis, Tinct. Myrrh, aa, Jjij.—M. Creasote, Dr. Dunglison informs us, was found to be an admirable local application in the gangrene of the mouth, Avhich occurred, as an epidemic, in the Philadelphia Almshouse, in 1838, incisions being first made through the gangrenous sloughs. His prescription is crea- sote and alcohol, equal parts, to be applied by means of a pencil. In the Children's Hospital at Paris, cauterization of the gangrenous spots Avith hydrochloric acid, and afterwards covering them with powdered chloride of lime, with the use of tonics—generally the syrup of cinchona, given per anum,—is said, by Baudelocque, to have proved a very successful mode of treating the disease. The hydrochloric, sulphuric, and acetic acids, have all been highly recommended, as local applications. Van Sweiten employed the hydrochloric acid, tAventy drops to half an ounce of honey, or when the case was of an aggravated character, the acid alone, and invariably found the extension of the gangrene to be arrested, and the dead parts to separate in a short time: it was equally successful in the hands of Seibert, and is spoken of in terms of commendation by Bernstein, Richter, Jadelot, Boyer, Baron, and others. Heuter con- siders one of the best local applications to be a mixture of hydro- chloric and acetic acids. The application of sulphuric acid has succeeded in effectually ar- resting the disease, in the hands of Bruineman and Courcells; and the acetic acid, in the hands of Klaatsch and Reimann. To obtain from the acids any beneficial effects, their application should be re- peated every half hour, or, at furthest, every hour. They may be applied either by a pencil, or by covering the affected parts with lint moistened with them; their application being continued until the gangrene ceases to spread, and granulations are formed. When thick firm sloughs occur, these should be freely scarified previously to the application of whatever wash is used. The actual cautery is recommended by Baron, the chloride of lime or soda, by others, and the tincture of iodine by Davies. Cases il- lustrative of the good effects of the actual cautery, have recently been published by Henry Obree, Esq. When sloughs have formed upon the cheeks, some advantage may be derived from poultices, containing the chlorides of lime or soda, or the pyroligneous acid. The early extraction of the loosened teeth s of importance, and should never be neglected. DISEASES OF THE DIGESTIVE ORGANS. 171 The administration of internal remedies would appear to interfere but little with the progress of the disease. The diet of the patient should be light and nutritious; it may con- sist of beef tea, plain beef or mutton broth with rice; milk with rice; tapioca, sago, and the like farinaceous articles. Wine whey may be occasionally given with advantage; and we can conceive of cases, in which a moderate use of sound wine may be necessary, in order to sustain the sinking powers of the little patient. Such cases, how- ever, have never fallen under our notice. From the administration of the sulphate of quinia in solution, or of the cold infusion of cinchona, we have, in many instances, seen much good to result.1 1 R.—Quiniac sulphat. gr. x. Or R.—Quiniae sulphat. gr. viij. Acid, sulph. dil. TTJ^. x. Aq. chlorin. &j. vel *". Sacch. alb. %iv. Acid, sulph. dil. %. v. Aq. cinnamon, giv.— M. Syrup, limon. giv.—M. {Dunghson.) Dose, a teaspoonful every three hours. The chlorine water and the chloride of lime, or the chloride of soda, are said to prove advantageous internally administered.2 a R.—Calcis chlorin. gr. x. vel. Liq. sodae chlorin. Ity viij. Syrup. 31J. Aquae, J;iv.—M. [Dunglison.) Dose, a dessert-spoonful every three hours, for a child six years old. The free internal use of the chlorate of potassa—one to three scruples, in twelve hours, according to the age of the child, is strongly recommended by Hunt. The iodide of iron has also been suggested by Dr. Dunglison as a means of improving the condition of the nutritive function, which, in this disease, is evidently impaired.3 ^ R.—Vini Hispan. (sherry) §iv. Ferri iodid. J"jj.—M. Dose, a teaspoonful 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 so- lution 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.4 4 R-—Acetat. plumbi, gr. xvj. Cretae ppt.^ijss. Ipecacuanhae, gr. iv. Opii pulv. gr. ij.—M. To be divided into xvj. portions. One to be given every three or four hours. 7.—Difficult Dentition. Dentition is a purely physiological process, and in the healthy in- fant, with an organism in no part of which there exists any strong predisposition to morbid action, it is attended in general with little suffering or danger. It may, nevertheless, give rise to much suffer- ing, or even be the exciting cause of some violent and quickly fatal 172 DISEASES OF CHILDREN. malady, whenever the irritability of the infant's system has become unduly augmented—Avhen 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, hoAvever, the period when the teeth begin to protrude from the gums, 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 in- creased 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 discharges 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—in some cases an erythe- matic inflammation, and ulceration behind the ears, and not unfre- quently a slight tumefaction of the salivary glands. As the ad- vancing tooth approaches the surface of the gum, the fingers of the child are frequently held in his mouth; and he presses firmly be- tAveen his gums the nipple in sucking, or any object Avhich 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 rub- bing the gum with a finger. The foregoing symptoms are not invariably present during denti- tion. In some children, the process is attended with such slight in- convenience, that the first tAvo incisors are frequently cut without attracting the slightest attention, until their points are seen pro- truding beyond the gum. It is principally when there is a disproportion between the de- velopment of the teeth and jaw, as when dentition commences very early, or when a number of teeth are cut at the same time, that much pain or difficulty occurs. The molar teeth are, also, cut with more difficulty than the incisors. Even when the symptoms we have described above 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 acaciae has been dis- solved; or if he has been weaned, to restrict him to a diet composed chiefly of milk and farinaceous substances, and for his drink, to toast, barley, or rice water; animal food, all stimulating drinks, and every kind of spice being withheld. The child 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 occupies.. 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. DISEASES OF THE DIGESTIVE ORGANS. 173 Little attention need be paid to the diarrhoea that is usually atten- dant upon dentition—it is seldom very profuse. If accompanied with considerable griping, an injection of thin starch, of of a decoction of flaxseed, with the addition of a little sweet oil, will, in general, be sufficient; but 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, by a dessert-spoonful of castor oil. If, as occasionally hap- pens, the bowels, in place of being more free than usual, are con- stipated, a dose of magnesia, or of castor oil may be given. The eruptions, which often appear about the face, and the inflammation and ulceration which occur 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 erup- tions and ulceration very commonly disappear when the teeth have protruded beyond the gums. As infants appear to derive relief from a slight degree of pressure upon the gums during dentition, something should be allowed them for that purpose. A substance that will yield to the pressure of the gums is to be preferred; an oblong piece of gum caoutchouc, 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 cold, mucilaginous drinks:—the good effects that have been attributed to them, in allaying the irritation of the gums, is referrible, we sus- pect, entirely to the gentle friction 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. In such cases inflam- mation of the mouth or gums, terminating in ulceration or gangrene —long-continued and extensive disease of the bowels, accompanied Avith frequent and vitiated discharges—spasmodic closure of the glottis —convulsions, often of a violent character—and hyperaemia, inflam- mation, or dropsy of the brain, are among the most common results of difficult dentition. In the children of the poor especially, who are exposed to the overheated, stagnant, and impure atmosphere of the confined streets, courts, and alleys, of our larger cities in the Middle and Southern States, dentition becomes, during the summer season, one of the most common exciting causes of the cholera of infants. Recently attention has been directed by Dr. Fliess, of Neusalt, to a paralytic condition of the limbs which sometimes occurs during dentition. (Journal fur Kinderkrankheiten, July and August, 1849.) 174 DISEASES OF CHILDREN. Paralysis is much less frequent during the first, than during the second dentition. Its attacks are almost always sudden. The child is cheerful, as playful as usual, has a good appetite, and goes to bed in the e\-ening apparently quite well. At first, perhaps, it sleeps very quietly; but it soon becomes restless, tosses about in a restless manner, groans and screams out in its sleep, grinds with its teeth, is thirsty, has some heat of the head, and towards morning, is rather feverish. On the next day, when perfectly awake, it is discovered that the child is unable to use one of its arms, or, in rare cases, an arm and a leg. If the arm alone be paralyzed, it hangs down, useless, by its side; it is warm, but in consequence of the gravitation of the blood in the limb, the joints of the hand and the fingers are of a bluish red colour, and swollen. The sensibility of the arm is either entirely lost, or is very obtuse; and the excito-motory power can be but little, if at all, excited by strong stimulation. If the child, at last, complains of pain, it is only from the dragging of the muscles of the shoulder. The paralysis sometimes extends to the leg of the same side,—the child is then unable to move it, and the sensation of the limb is lost, or at least impaired. More rarely, one arm and both legs, or both arms without the legs, are affected. The duration of the paralysis is very uncertain. In many cases, it lasts from a fortnight to three weeks, in others many months, and even, in some, many years, and then becomes incurable. Convulsions not unfrequently precede, or occasionally accompany the paralysis, without any apparent exciting cause, or from a very slight one. If the child be in a passion, or annoyed about any thing, the paralyzed limb sometimes becomes convulsed, and performs various movements which the child has not the power to restrain. The termination of the paralysis, under judicious treatment, is in many cases favourable; the limb regaining gradually its lost power, Avith a pricking sensation, or a feeling of formication. Not unfre- quently, however, the paralysis is obstinate, resisting the ordinary remedies, while other symptoms, indicative of an affection of the ner- vous centres and brain, make their appearance. The child is attacked with dyspnoea, palpitation, twitchings of the muscles of the eyes; it commences to squint, becomes dull, falls into a comatose state, and dies. The paralysis may become chronic; there are then no obvious indications of-an affection of the nervous centres, but the affected limb remains paralyzed, and ultimately becomes atrophied; the individual may be, in other respects, in the most flourishing health, even active and strong. According to Dr. Fliess, in cases of dental paralysis, it is generally the molar teeth that are at fault; much more seldom the incisors; at least, in those cases which he has found recorded by various writers, where the situation of the teeth about protruding was given; the molars have almost always been mentioned as in progress of escaping from the gums. Much may be done by a judicious course of treatment, towards pre- venting the mischief which the process of dentition has a tendency to develope. The child should, as far as possible, be removed from DISEASES OF THE DIGESTIVE ORGANS. 175 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; while, if he be labouring under great exhaustion or debility, it may be necessary to allow him beef, mutton, or chicken broths, or even a portion of the meat of which these are prepared, plainly cooked, 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 condition of the gum should be daily and carefully examined; and the moment it appears hard and SAvollen, and the teeth are evi- dently distending it, a free incision should be made with a lancet, at the points where they are about to protrude, so as completely to di- vide the tough membrane by which the tooth is enveloped, the dis- tention of which by the advancing tooth, being the cause of much of the pain and irritation consequent upon difficult dentition. The lan- cet should, in every instance, be carried down until it reaches the tooth, and if it be one of the molar teeth that is about to protrude, a crucial incision will be necessary. This operation gives but little pain, and is rarely, when judiciously performed, attended with dan- ger or inconvenience, while, in many cases, it is folloAved by imme- diate relief, and may be the means of preventing the occurrence of fever, convulsions, or fatal disease of the brain.1 Even subsequent to the occurrence of convulsions, of spasmodic closure of the glottis, or of 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, appa- rently died, and was laid out for interment. M. Lemonnier, having some business at the house of the nurse, with whom the child resided, after fulfilling the object of his visit, was desirous of ascertaining the condition of the alveola. He accordingly made a free incision through the gums; but, on preparing to pursue further his examina- tion, he perceived the child to open its eyes, and give other indica- 1 We have said that the division of the gum over the protruding teeth, when performed at a proper time, and in a proper manner, is "rarely attended with danger or inconve- nience." It should be performed only when the gum is evidently raised by the advancing tooth, and the surrounding parts are red and painful. We have never seen the aphthous or gangrenous ulceration which Billard apprehends may be produced by the incision. Were it to happen, 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, which fell under our notice, both occurring in children of a scrofulous 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 resorted to, including the actual cautery. 176 DISEASES OF CHILDREN. tions of life. He immediately called for assistance: the shroud was removed from the body, and "by careful and persevering attention, the child's life Avas saved; the teeth in due time made their appear- ance, and its health was fully restored. When considerable redness and tenderness of the gums occur about the period when the process of dentition is expected to commence, without, however, either of the teeth having adAranced sufficiently near to the surface of the gum, to render an incision of the latter necessary, emollient washes should be frequently applied to the gum, and a leech or two to the angles of the jaw. If the boAvels are cos- tive, a purgative of calomel, followed by castor oil, may be adminis- tered. Should a considerable degree of febrile excitement be present —particularly if it be attended by heat and tenderness of the abdo- men—a few leeches to the gums, and over the epigastrium, the tepid bath, and small doses of calomel and ipecacuanha,1 will be generally found advantageous. ■R.—Calomel, gr. ij. ad iij. Magnes. calc. gr. xxiv. Ipecacuanhae, pulv. 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 consistence, and accompanied with more or less griping—bland mucilaginous drinks, and the tepid bath, will, in general, afford relief; if, however, the diarrhoea continues un- abated or increases, we have found the best means of arresting it to be a solution of acetate of lead given by the mouth.2 * R.—Acetat. plumbi, gr. viij. Acid. Acet. impur. ttj^ viij. Sacch. Alb. gj. Aq. purae, ^j.—M. An ordinary-sized teaspoonful of which may be given as a dose, and repeated, three or four times a day, until the frequency of the discharges is 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 wa- ter, with the addition of one-fourth of proof-spirit; while 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 de- cided, after the application of leeches, blisters behind the ears, re- peated as they heal up, will often prove serviceable. The slightest indication of an approaching attack of convulsions or spasms, should be carefully watched, and treated by its appropriate remedies. In the paralysis which occasionally attends dentition, Dr. Fliess re- commends scarification of the gums, repeated cupping in the neigh- bourhood of the origin of the brachial nerves, mild purgatives, and wrapping the affected limb in flannel. The application of stimulants to the paralyzed extremity, or even the use of electricity, he remarks, can produce no good effect. DISEASES OF THE DIGESTIVE ORGANS. 177 The dysuria, so common in cases of difficult dentition, is best as- suaged by the free exhibition of some mild demulcent drink. ^ If the pain be considerable, and there is nothing present to forbid its use. an opiate may be administered.1 1 R.—Sulph. magnes. t^ij. ad ^iij. Solve in Or, R.—Hydrochlor. ammoniae, &. Aquae purae, .^j.'dein adde Pulv. ipecacuanha?, gr. iv. Spir. aether, nitrici, ,^ij. Pulv. opii, gr. ij. M. f. ch. No. xv. Tinct. opii, rrg vij. ad xv. One to be given once or twice in the Dose—a teaspoonful, to be repeated accord- course of the day, according to cir- ing to circumstances. cumstances. CHAPTER II. DISEASES OF THE THROAT. 1.—Tonsillitis. Inflammation of the tonsils and veil of the palate is a frequent disease of the latter stage of infancy, and during the entire period of childhood. It seldom, however, assumes the decidedly acute cha- racter so common in the tonsillitis of adults. From a very early- age, the tonsils are liable to a subacute form of inflammation, pro- ducing, in many cases, a very considerable enlargement of these parts, Avhich often continues for a long period, changing the tone of the patient's voice, and impeding his breathing, deglutition, and hearing. Tonsillitis usually commences with a sense of pain or uneasiness in the throat, a huskiness of the voice, and a sense of chilliness and lan- guor, quickly followed by more or less febrile reaction. The pain in the throat increasing, 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, Avhile one or both tonsils are found to be swollen, and generally covered Avith 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 ©edema- tous appearance. The throat is tumid, and painful to the touch, ex- ternally. The tongue is covered with a white fur, through which the papillae, enlarged and of a bright red hue, project—a thick pellicle of transparent mucus being spread over the whole; when, as is occa- sionally the case, the inflammation of the throat is complicated with gastric disease, the tongue is generally 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, impeding res- 12 178 DISEASES OF CHILDREN. piration, often entirely preventing deglutition, rendering the voice indistinct and Avhispering, and the hearing obtuse. The disease, when properly treated, commonly terminates by reso- lution. We never recollect to have seen an instance of extensive sup- puration in a child. A substance, someAvhat resembling pus, is, how- ever, occasionally seen, adhering to the surface of both tonsils; and, in some cases, a slight, circumscribed, diphtheritic exudation. Very frequently, the redness and tumefaction of the velum and pharynx subside, Avhile the enlargement of the tonsils continues. More frequently the symptoms, from the commencement of the attack, are of a much less marked character. The child, if at the breast, exhibits a difficulty and pain in swalloAving, and throws up its milk soon after it is swallowed; the throat, externally, is someAvdiat 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 a difficulty of breathing, and a frequent hawking up of a thick, tenacious mucus. On examin- ing the throat, a slightly increased redness of the palate is observed, with considerable and irregular enlargement of the tonsils, which present a kind of lobulated appearance, their surface being covered Avith a thick coating of tough mucus. This 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 san- guineous temperament, and plethoric 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 the 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,1 followed by an emollient poultice; a purgative of a few grains of calomel, with a moderate dose of the sulphate of magnesia a few hours subsequently, and a warm pediluvium at bed- time, will frequently be sufficient to arrest the inflammation. 1 R.—01. olivae, gj. Aq. ammoniae, £ij. Sp. terebinth, gj.—M. When, however, the inflammation of the throat is more conside- rable, 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,2 or in a solution of sulphate of magnesia.3 a Aquae purae, gij. ad iv. s Sulph. magnes. ^iv. Solve in Tart, antimon. gr. J.--M. Aq. purae, Jiv. dein adde Dose, a teaspoonful every two or Tart, antimon. gr. j.__M. three hours. Dose, the same. We have derived very great advantage, in cases of tonsillitis, from DISEASES OF THE DIGESTIVE ORGANS. 179 the use of a combination of the hydrochloride of ammonia, ipecacu- anha, and calomel.1 1 Ammoniae hydrochlor. gr. xxxvj.ad. 3J. Ipecacuanhae 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 physicians. Loeffler recommends it in tonsillitis, to be given inter- nally, dissolved in water with the addition of the extract of liquo- rice. . . Blisters to the throat are directed by most writers, when the in- flammation of the tonsils is severe, and is not quickly arrested by the other remedies employed. We have seldom seen much good re- sult from the application of blisters to the throat in young children; nor any instance in which they were required, in the disease under consideration. If resorted to, they should be kept on onlyso long as to redden the skin; and on their removal, the part to^ which they Avere 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 dis- charged by regurgitation or vomiting. Its thirst may be assuaged by a few spoonfuls of water, rendered somewhat mucilaginousby an infusion of slippery elm bark or pith of sassafras, or by a mixture of milk and water, given occasionally. Older children should 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 Avhich is of a moderate and equable temperature. When accompanied by disease of the alimentary canal, the latter should be treated by its appropriate remedies. The treatment of the subacute 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 Avill be occasionally required. The mixture of hydrochloride of am- monia, ipecacuanha, and calomel, will be found particularly advan- tageous. 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. 180 DISEASES OF CHILDREN. 2.—Pseudo-membranous- or Diphtheritic 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 cha- racter is the early excretion of a thin, pseudo-membranous pellicle, either continuous or in patches, and closely adherent to the sur- face of the inflamed mucous membrane, upon which it is produced. Pseudo-membranous inflammation of the throat commences often with symptoms of so mild a character, as to attract scarcely any at- tention, until the local disease has made considerable progress. The deglutition is but little—or not at all—impeded; only a trifling sore- ness, or rather a sense of roughness in the fauces is experienced, while no febrile excitement is present. The child often continues to in- dulge in its ordinary sports, with, perhaps, a little more fretfulness and dejection than usual, and becoming, apparently, more quickly tired. In other cases there is, from the commencement of the attack, a sense of languor and general discomfort; a feeling of chilliness, al- ternating with flushes of heat; increased thirst; pain of the head; a sense of heat or burning in the throat; while the act of swalloAving, and the slightest motion of the neck, cause more or less pain. The skin is hot and dry; the eyes are often red and watery; and the coun- tenance flushed. Frequently, hoAvever, the countenance is tumid, pale, and expressive of sadness or dejection. When there exists any decided febrile excitement, an exacerbation generally occurs night and morning. There is, in many cases, considerable nausea, and tenderness of the epigastrium. At first, there is usually a con- stipated state of the boAvels:—diarrhoea, however, occasionally su- pervenes in the course of the disease, and in severe and protracted cases is often copious. From the very commencement of the attack, the mucous membrane of the fauces and tonsils is of a deep red colour, and becomes speedily covered with a layer of tenacious transparent mucus. The mucous membrane, particularly of the pharynx and soft palate, is in some cases 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 feAv dry, oblong, grayish 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 grayish 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. These patches increase in extent, more or less rapidly;— sometimes, in the course of a few hours the whole of the posterior fauces becomes coA-ered 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 Avhich they adhere by numerous minute fila- DISEASES OF THE DIGESTIVE ORGANS. 181 ments, that appear to penetrate the orifices of the mucous follicles. Their detachment is generally followed by more or less oozing 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 submucous cellular tissue assumes, occasionally, an oedematous appearance; in conse- quence of Avhich, the corresponding portion of the membrane is ele- vated, and causes the portions that are occupied by the pseudo-mem- brane to assume somewhat the appearance of ulcers, covered with a tenacious exudation. The patches, very generally, become soon con- fluent; so that, in many cases, the whole of the soft palate, the pharynx, and the inner surface of the cheeks, are lined by a continu- ous pseudo-membranous exudation, often of considerable consistence, which is rapidly renewed, as often as it is detached. In the commencement of the disease, 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 admixture of blood discharged from the mucous membrane as por- tions of the pseudo-membranous deposit are detached, and of an of- fensive 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 mucous membrane beneath becoming of a dusky red hue. The tongue 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 affection of the throat is of any extent, and the inflammation is not early arrested, the submaxillary glands become enlarged and painful, and the surrounding cellular tissue infiltrated with serum, causing often a considerable intumescence of the neck. More or less tumefaction of the tonsils and soft palate, and occasionally of the tongue, takes place, frequently to such an extent as to interfere with the freedom of respiration; ulcers form along the edges of the tongue, the palate, and upon the inner surface of the cheeks; and 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 sometimes continues with but little abate- ment, until towards the close of the disease. The heat of the surface, however, in general abates—the skin assuming a dusky appearance, and doughy feel; profuse diarrhoea often occurs; the secretions, gene- rally, become vitiated, and either increased or diminished in quan- tity; the prostration of strength augments; and a state of torpor, or eAren 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 in- creased difficulty of swallowing—every attempt at which is produc- tive of severe pain. When the disease extends, through the posterior 1S2 DISEASES OF CHILDREN. 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, yelloAvish and flocculent or bloody sanies, often of a very fetid odour/and which produces more or less inflammation and exco- riation of the external openings. When the disease extends to the Eustachian tube, pain is experienced in the ear, Avith more or less defect of hearing, often complete deafness, Avhich, in consequence of the obliteration of the tube, is, occasionally, permanent. The pseudo-membranous inflammation is particularly liable to ex- tend into the larynx, trachea, and bronchi. This extension of the disease, in some cases, takes place almost immediately upon the first appearance of the patches in the fauces; in other instances the res- piratory organs are not affected until about the second or third day, or even later. At whatever period the respiratory tube becomes af- fected, the symptoms of croup—hoarseness, shrill cough, great diffi- culty of respiration, and more or less aphonia, are immediately de- veloped, and, in the greater number of cases, the patient is rapidly destroyed. It is supposed by many pathologists, that croup is in every instance produced by an extension of the pseudo-membranous inflammation from the throat to the larynx and trachea: although avc cannot admit that such is invariably the case, still Ave have reason to believe that croup is more frequently preceded by pseudo-membra- nous inflammation of the throat, 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 by Guersent to be productive, also, in certain cases, of a species of pneumonia, extremely insidious in its commencement, and marked, in part, by the symptoms Avhich are referrible to the disease of the throat. The cough, in this affection, is different from that of croup, and is unattended 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. There is not only a tendency in the pseudo-membranous inflamma- tion to extend along the mucous membrane of the throat, into the cavities of the nose, even to the frontal sinuses, into the Eustachian tube, the pharynx, oesophagus, larynx, trachea, and bronchi, but it, likeAvise, often seizes upon remote parts of the body, particularly in situations covered by a mucous membrane, or from which the cuticle has been accidentally removed by a blister, or by ulceration, (Trous- seau.) Thus, it is often observed upon the lips, the alae nasi, the concha, the external meatus, and the parts behind the ear, upon the nipples, in the folds of the groin, around the contour of the anus. within the vulva, upon the surface 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. In other cases, the exudation, instead of being separated in fragments, becomes, in part, softened to a pulpy consistence, and is discharged from the mouth, mixed with bloody mucus. This separa- • DISEASES OF THE DIGESTIVE ORGANS. 183 tion and renewal of the pseudo-membranous deposit continue, in most cases, for the space of eight or ten days; when, finally, it ceases to appear, leaving, most generally, the mucous tissue to which it had been attached perfectly sound throughout its whole extent, of a light red, uniform colour, and covered, usually, with a thick yellow mucus, more or less resembling pus. As the disease in the throat disappears, the glands of the neck, provided they are not in a state of suppuration, which very rarely occurs, diminish in volume, and are no longer painful or tender to the touch. The difficulty in deglutition disappears; the tongue loses its pointed appearance, and becomes clean and moist, the skin soft. moist, and of a more natural appearance, the countenance more ani- mated and cheerful; while the stomach and bowels gradually resume the regular performance of their functions, and the general strength and vigour of the patient become 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 diar- rhoea becomes profuse, and the strength of the patient more and more exhausted; general colliquation ensues, and death takes place, fre- quently 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, and generally yields readily to an appropriate treatment; or, when the inflammation is of little extent, it may even disappear 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 inflam- mation will be noticed after we have described the gangrene of the throat. 3.—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 aggravated 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 pseudo-membranous an- gina, and particularly in the angina accompanying epidemics of scar- latina of a very malignant character. Malignant angina, in its commencement, differs but little from ordi- nary pseudo-membranous inflammation of the throat. The fauces pre- sent the same membraniform exudation: it is more generally confined, however, to the mucous membrane anterior to the larynx, oyer which it is more uniformly spread; it also assumes at an earlier period, a dull 184 DISEASES OF CHILDREN. ash-colour, quickly changing to dark bnnvn or black. The disease seldom, if ever, extends to the trachea or bronchi. The pain and tu- mefaction of the submaxillary glands are much more considerable than in the preceding form of the disease; and they are, also, more liable to run into suppuration. The mucous membrane of the fauces is almost uniformly injected Avith 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. The face exhibits a bloated, bronzed, aspect; the eyes are heaAry, dull, and watery. There is often extreme difficulty of deglutition; the voice is en- tirely guttural, and the poAver 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, ur- gent thirst, and often considerable delirium. The fever is attended with an exacerbation towards evening. Nausea, vomiting, with ten- derness and oppression at the epigastrium, and diarrhoea, accompanied with thin, acrid, and intolerably offensive discharges, are often present from the commencement of the attack, or occur at an early period. A fetid, 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. In the milder cases of the disease, upon the separation of the pseudo- membranous exudation, the mucous surface beneath presents a moist, red appearance, without ulceration or loss of substance; the discharges from the mouth become of a less offensive character, and are dimi- nished in quantity; the tumefaction of the throat subsides; the tongue becomes cleaner and more moist; the febrile symptoms gradually abate, or entirely disappear; the dejections from the bowels diminish in frequency, and become more natural in appearance; a general amelioration of all the other symptoms ensues, and the patient by sIoav degrees acquires his accustomed strength and vigour. In cases of greater malignancy, the symptoms rapidly increase in intensity; the pseudo-membranous deposit in the throat assumes a dark colour, and separates in flocculi, or shreds, of an intolerably fetid odour. The mucous membrane at first presents a dark red, and raw appearance, Avhile from its surface there oozes a dark- coloured blood; but it 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 condition extends from the mucous membrane to the tonsils and soft palate. The accompanying fever assumes a low, typhoid character, and petechiae of the external surface are often observed. Dark-coloured vesicles occasionally occur about the cor- ners 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 destruc- DISEASES OF THE DIGESTIVE ORGANS. 185 tion of the surrounding soft parts. The diarrhoea increases^ in fre- quency, the discharges becoming more thin, acrid, and offensive; the strength of the patient becomes 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, after which period the "febrile symptoms abate or disappear. It may destroy life in a very short period, but occasionally runs a pro- tracted course of several weeks. When it terminates fatally, death usually takes place within the first week, either from extreme exhaus- tion of the vital powers, or in consequence of the occurrence of extensive lesions of the digestive or other organs. When the disease occurs epidemically, it is often productive of a very great mortality. Under all circumstances it is a dangerous ma- lady, and one but little within the control of medicine. No little difference of opinion prevails, as to the pathological cha- racter 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. Em- manguard also adopts this opinion. There can be no doubt, that, in numerous instances, the affection of the throat is preceded or accom- panied by symptoms of more or less severe gastro-enteric disease; but it has been known to occur as frequently, perhaps, without any such symptoms being present—at least in its early stages. Jolly refers the disease to a haemorrhagic inflammation, in which the colourless fibrine is exuded upon the surface of the mucous mem- brane ; and Naumann, with a few other German pathologists, supposes it to result from 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 af- fection; 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 erythema of the mucous membrane, giving rise to an albuminous exudation, there can, we conceive, be little doubt. This exudation is a common occurrence in the inflammations of the mucous tissue in children; and in them appears to be connected with a peculiar organization of this tissue, and a certain condition of the blood, difficult to be under- stood. Its gangrenous form is doubtless the result of defective or- ganic power, and consequent impairment of 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, 186 DISEASES OF CHILDREN. and marshy situations, especially during the spring and autumn. It is of most common occurrence, also, among the children of those classes by whom personal and domestic cleanliness is neglected, and who, from poverty or other causes, are deprived of a sufficient amount of AA-holesome nutriment. The disease is liable to occur endemi- cally in situations Avhere a number of children are croAvded together. and due attention is not paid to preserve the air pure, and freely ventilated. It is, also, a common accompaniment of epidemic scar- latina. 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 propagated by a contagious miasm, generated in situations where many per- sons are crowded together, without a proper attention being paid to cleanliness and free \~entilation. In looking over the arguments by Avhich this opinion is attempted to be established, Ave find them, however, altogether inconclusive. They are derived entirely from certain endemic or epidemic occur- rences of the disease, and instead of proving its propagation from one or more foci of contagion, they merely sIioav that a number of individuals had been exposed to the same local or general morbific cause; and that, while many Avere affected by it simultaneously, in some it produced the disease at an earlier, in others at a later period. That the disease has occurred sporadically, affecting only one mem- ber of a family, or a single individual of a community, is admitted by nearly all Avriters; but that.it has ever been communicated di- rectly 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 re- medies will be demanded from its very onset. In every instance in Avhich there is no disease of the gastro-intes- tinal 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 mild emetics will very frequently do good, by expelling the tenacious excretions accumulated 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 im- peratively demanded in pseudo-membranous inflammation, as in the other acute inflammatory affections of the throat in children, cases of the disease do, nevertheless, frequently occur, in which it is unques- tionably 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 are considerable, and attended with symptoms of intense febrile excitement, general, as well as local bleeding, should be re- DISEASES OF THE DIGESTIVE ORGANS. 187 sorted to. Even when general bleeding may not be considered ad- missible, leeches to the throat, behind the ears, or to the angles of the jaws, will, in many cases, be found advantageous. Broussais, Em- manguard, and others, recommend, in all cases, leeches to the epigas- trium ; 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, Avith considerable fetor of the breath, bleeding from the arm would be inadmissible, and even the application of leeches might be, under such circumstances, 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 purgative, and in those cases in which the larynx and trachea are implicated, it constitutes one of our most important remedies; it should be adminis- tered in large and repeated doses, either alone or combined with ipe- cacuanha.1 Even in the ordinary forms of the disease, occurring in patients possessed of some degree of vigour of constitution, calomel has been found advantageous,—relieving the throat of the membra- nous exudation, and other vitiated excretions, and producing a marked amelioration of the symptoms generally. ! R.—Calomel, gr. xxxvj. ad xlviij. Ipecacuanhae, pulv. gr iij. ad iv. Magnes. calc. ^ss. M. f. ch. No. xij. One, to be repeated 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, the drinks should consist of iced water, iced lemonade, or cold water slightly acidulated with vinegar; even por- tions of powdered ice may be placed in the patient's mouth, and al- loAved gradually to dissolve. In other cases, cool drinks may be al- lowed; but where the powers of the patient are depressed, and the skin cool, the drinks should be given of a tepid, or eATen Avarm tem- perature. In cases attended Avith decided febrile reaction, the neu- tral or effervescing mixture may be advantageously administered. In the commencement of the attack, the tepid bath, with friction of the skin, Avill invariably be found productive of good effects; and Avhen the heat of the surface is considerable, generally diffused, and steadily maintained, the surface should be sponged with cold water, or cold vinegar and water. In cases where the inflammation and swelling of the throat are considerable, warm pediluvia, with the addition of salt or mustard, will act beneficially as a revulsant. Where the poAvers 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- 188 DISEASES OF CHILDREN. ing the throat in young 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, folloAved by warm emollient cataplasms, 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 deple- tion, little else should be alloAved than barley Avater, rice water, or water gruel. Rennet Avhey 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 diminished heat 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, ac- cording 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 invariably resorted to with the greatest caution, and their effects upon the symptoms of the case care- fully 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 enemata, 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 tumours, or they may be kept constantly covered with cloths wet with cold water, or cold Adnegar and water, the effects of which are often peculiarly striking. Various local applications to the fauces, in the form of washes or gargles, have been proposed in the treatment of pseudo-membranous inflammation of the throat, and, by many, are considered to constitute the most efficient remedies for the disease. In the early stage, a wash or gargle of equal parts of good vinegar and water, is, perhaps, one of the best we can employ; diluted hydrochloric acid, or solutions of the chloride of soda or of lime, or a saturated solution of the borate of soda, also, in many cases, form an excellent wash for the throat. 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 DISEASES OF THE DIGESTIVE ORGANS. 189 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, particularly when the occurrence of a gangrenous con- dition is apprehended. The application to the fauces, two or three times a day, of hydro- chloric acid, either pure, or combined with three parts of honey, has been highly extolled by many of the French and German pliysicians. Among the local applications, in favour of the beneficial effects of which we have the greatest amount of evidence, is that of the nitrate of silver, either in strong solution, from fifteen to twenty grains in an ounce of water, or in its solid form. It will not only cause the separation of the pseudo-membranous deposit, but also produce a more healthy action in the inflamed mucous membrane 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. Alum, reduced to a very fine powder, and bloAvn 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 Bretonneau, Guersent, Bourgeois, and other practitioners. The sulphate of copper has been employed in the same manner by Gmelin. 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 form- ing 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 swelling of the throat, or the 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,1 or—what we have found particularly beneficial in such cases—a combination of poAvdered galls, camphor, and ipe- cacuanha,2 or the acetate of lead, in solution. • R.—Mucil. G. Acaciae, giij. * R.—Pulv. Gallae, gj. Cretae ppt. gj. " Camphor, gr. iv. ad. vij. Tinct. Kino, gij.—M. " Ipecacuanhae, gr. iij. ad. iv. A teaspoonful every two or three hours. M. f. chart. ISo. 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 in- flammation perfectly clean, and of a moderate, equable temperature, and freely ventilated. 190 DISEASES OF CHILDREN. 4.—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, occasionally, it is attended with very considerable swelling and pain, and febrile symptoms of some intensity. It is usually preceded by more or less 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 a difficulty in mastication, is very commonly present. Sooner or later, a 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 tumour, sometimes on both sides of the neck. The skin co- vering the tumour is often unchanged in colour; and, occasionally, when the tumefaction is rather oedematous than inflammatory, the colour of the skin by which it is covered is even paler than natural. In severe cases, the swelling assumes a bright or deep red colour. The inflammation frequently extends from the parotids to the sub- maxillary glands, and is attended with symptoms of considerable febrile excitement, increased thirst, and constipated bowels. The tumefaction usually attains its height by the fourth or fifth day, when it begins gradually to diminish, and soon entirely disap- pears; the febrile and other symptoms declining and disappearing Avith the diminution and resolution of the swelling in the neck. It is extremely rare for the disease to terminate in suppuration, though a feAv instances of this are on record. A curious circumstance in connexion Avith this disease is, the lia- bility of the inflammation suddenly to disappear from the neck, and to 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. In some instances, the inflammation sud- denly ceases in the testicles or mammae, and the pain and tumefac- tion 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 inflammation has ceased in the neck and been followed by inflammation of one of the mammae or testes. Parotitis generally occurs in children over five years of age; and, as Ave 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 cer- tainly met with the disease as often in females as in males. DISEASES OF THE DIGESTIVE ORGANS. 191 Parotitis 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 transi- tions 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 the so called metastasis less frequently to occur, when it prevails in warm and dry, than in cold and damp weather. We have found the disease, hoAvever, 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 Avarm, and to immerse the lower extremities in warm Avater, 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 Avith considerable pain, heat, and fever, it will be prudent to apply leeches to the seat of the disease, in numbers proportioned to the ex- tent of the local symptoms; and, after the boAvels are fully evacuated, by a mixture of sulphate of soda and magnesia, the following may be administered internally.1 1 R.—Sulph. magnesiae, giv. Solve in Aq. purae, t^iv. et adde Tart. ant. gr. j. Spir. aether, nitrici, giij. Sacch. alb. gvj.—M. Dose, a teaspoonful every three hours. Warm pediluvia will be found beneficial, and, in many cases, the tepid bath. When the testicles or mammae become affected, leeches may be applied to these parts, followed by emollient fomentations; purgatives, 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 mam- mae being as readily controlled by its appropriate remedies, as when the disease is seated in the parotids. 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. 5.—Angina Externa. Under the name of phlegmone paroiidea, Dr. Good describes a very common affection in children, consisting in an inflammatory tumour, occurring in the neighbourhood of the parotids, and proceeding slowly 192 DISEASES OF CHILDREN. 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 erroneous pathology. The affection consists simply in an in- flammation of the cellular tissue surrounding the parotid or other glands of the throat, which is generally circumscribed, but occasion- ally diffused. The disease usually 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 tumour now gradually diminishes in size, cicatrization takes place, and all the symptoms of inflammation finally disappear. Often, however, 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 are situ- ated immediately below the chin, and we have seen cases where the tumour occupied the whole of the front of the throat from ear to ear. Instead of a circumscribed inflammation and suppuration, the in- flammation is, occasionally, deep-seated and diffused, and the pus, when it forms, is then liable to extend, under the angle of the jaw, to the pharynx, or downwards, into the upper part of the thorax, pro- ducing extensive destruction of the cellular membrane about the neck, and great distress to the patient. In this form of the disease, the ex- ternal 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 in 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 now assume a low typhoid character, the strength of the patient is rapidly exhausted, and death very gene- rally ensues; or if recovery takes place in these extreme cases, an extensive and unsightly cicatrix 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 rich animal food, in which they are allowed to indulge to excess. It is, very frequently, connected with more or les3 disease of the alimentary canal. We have seen the DISEASES OF THE DIGESTIVE ORGANS. 193 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 cir- cumscribed; and, if suppuration ensues, a simple circumscribed abscess results, the disease being rather troublesome and painful than dangerous; but, when in children of an unhealthy habit, the inflam- mation is diffused, unless a free exit is given to the pus by early in- cisions, the affection is one 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 their repetition, after a short interA^al, if the local symptoms are not sufficiently reduced by the first application. After the leech-bites have ceased bleeding, the tumour should be covered with pledgets of linen, kept constantly wet with cold AA-ater, or with a solution of the acetate of lead. A dose of calomel should early be administered, followed by a sufficient dose of sulphate of magnesia, to insure its speedy operation. The patient should be restricted to a mild unirritating diet,—in severe cases, no other food being allowed than barley water qr water gruel. In cases attended with considerable febrile excitement, the solution of sulphate of magnesia, with tartarized antimony, as directed in parotitis, will be beneficial. So soon as a disposition to suppuration is observed, the tumour should be covered with emollient poultices, frequently re- newed ; and, when a distinct fluctuation is observed, the abscess should be opened with the lancet, and a free exit given to the pus;—the ap- plication of the poultices being continued until cicatrization com- mences, when a dressing of simple cerate spread upon lint, may be substituted. When the inflammation is diffused, a similar treatment will be de- manded 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 in- fusion of bark, or of a solution of the sulphate of quina. The treat- ment of each case, must, however, be governed by the particular symptoms present; the safety of the patient not unfrequently depend- ing entirely upon the promptitude and judgment of the practitioner. 13 194 DISEASES OF CHILDREN. CHAPTER III. OESOPHAGITIS—INFLAMMATION OF THE ODSOPHAGUS. It is to Billard that we are indebted for our knowledge of the oesophagitis 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 re- lation to which our own observations have not furnished us with any ad- ditional facts. We have repeatedly recognised in infants the symp- toms 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 Avere taken. The child refuses the breast, and fluids generally—but often swallows without much difficulty half solid aliments. The undigested food and drinks A^omited by the patients are, occasionally, mixed with matters secreted by the stomach, particularly if the latter be affected, at the same time, Avith inflammation. More or less pain is no doubt experienced along the whole track of the oesophagus, but at the age at which the disease occurs, we cannot determine its pre- sence 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. (Esophagitis is seldom accompanied by any degree of febrile excitement. The disease may consist in a simple erythematic inflammation of the mucous membrane of the oesophagus, in inflammation, with al- tered 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 at- tended with curd-like exudation, or with follicular inflammation, the inflammation of the oesophagus will also be attended with altered se- cretion, or with aphthous ulceration. It is, however, difficult to distin- guish the existence of ulcers or gangrene of the oesophagus, unless the matters vomited contain shreds, derived from the disorganiza- tion of the oesophageal mucous membrane. More extended observa- tions, Billard remarks, will probably enable us to form a more accu- rate diagnosis of the several forms of the disease. The pathological changes detected after death, in cases of oesopha- gitis, are, vivid redness, with destruction of the epithelium of some portion of the mucous membrane of the oesophagus, especially at its upper part; aphthous ulceration; curd-like exudation, more or less extensively diffused; separation of the epithelium, often in large DISEASES OF THE DIGESTIVE ORGANS. 195 shreds; numerous red or dark-coloured striae, where the epithelium is not destroyed; large, irregular eschars of a black colour, with in- tervals of deep, bright red excoriations, and gelatinous softening of nearly the entire thickness of the oesophagus. The pharynx, in ge- neral, exhibits considerable injection; the glottis is infiltrated and reddened. The stomach is often perfectly free from disease, but, oc- casionally, presents the various lesions incident to gastric inflamma- tion. 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 sti- mulating food. When infants are fed Avith the spoon, if wine or spiced victuals, or if broth, milk, or panada of too high a tempera- ture be given them, we can readily conceive that a very serious irri- tation may be excited in an organ, already predisposed to disease, in consequence of its habitual state of hyperaemia. The treatment of oesophagitis is very simple. The child should be debarred from all stimulating and hot drinks; it should be sup- plied, at short intervals, with small portions of some plain, mucilagi- nous 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 stomatitis, and a few grains of calomel may be adminis- tered, followed by injections of milk with the addition of sugar. If necessary, the strength of the patient may be supported by injections of milk and broth, or of 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.—Acetat. plumbi, gr. iv. Acid. acet. impur. 11^ iv. Aq. purae, gj.—M. Dose, a teaspoonful every three hours. CHAPTER IV. DISEASES OF THE STOMACH. 1.—-Indigestion. We employ the term indigestion, to indicate an affection of the stomach, very common in children, in which the function of that organ is suspended or disturbed, and the food, either unchanged or imperfectly digested, is discharged by vomiting or by stool, while no symptoms exist, indicative of gastric inflammation, or of disease of other organs. 196 DISEASES OF CHILDREN. Indigestion is invariably dependent upon too much, or improper articles of food, or upon some accidental circumstance interfering with the process of digestion. There can be no doubt that more or less disease of the mucous membrane of the stomach is present in every case, and that if the cause of the functional disturbance be con- tinued, or repeated, inflammation of an acute or chronic character may be excited. Nausea and vomiting are the most common symptoms of indiges- tion, during infancy. Infants at the breast Avill 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 un- attended by either nausea or straining. The milk is usually returned unaltered; occasionally, however, it is coagulated in masses of greater or less size. This species of vomiting generally occurs in very young infants, of a robust habit, particularly when suckled by a nurse in Avhom the sup- ply of milk is profuse, and flows with great freedom. It is rather salutary than injurious; preventing the effects of over-distention of the stomach; hence the common saying among nurses, that those in- fants who throw up their milk thrive the best. But as the cause is a 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, as Dewees directs, 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. A common cause of vomiting from repletion of the stomach in in- fants 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 Avalking them about soon after they have sucked, even Avhen no undue quantity has been taken. As a general rule, therefore, 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 infants 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 vo- miting more frequent. The more or less coagulated state of the milk discharged from the stomach, most generally arises from its having remained in that or- gan a short time before its ejection; the milk invariably undergoing coagulation in the infant's stomach, previously to its digestion. DISEASES OF THE DIGESTIVE ORGANS. 197 In some cases, however, the coagulation of the milk, as Avell 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 coagu- lated milk thrown up, have then a sour smell, and very often sour, curdy evacuations take place from the bowels, preceded by more or less griping. The cause of this acidity it is very difficult to deter- mine; whether it results from an irritation of the stomach, causing an excessive secretion of acid, or from the occurrence of acetous fermentation 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 coagula. The retention of these coagula in the stomach appears to arise from the 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 Avith paleness, and other indications of considerable nausea; pre- ceded, generally, 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 considerable degree of uneasiness, and continues fret- ful and languid for some time after the spontaneous evacuation of the stomach and bowels. In such cases there exists a disturbance of the digestive function, attended with considerable irritation of the mu- cous membrane of the whole of the alimentary canal, but seldom any symptom of positive inflammation. The mischief is almost in- variably 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. When the milk of the mother or nurse is perfectly healthy, adapt- ed in all respects to the condition of the infant's digestive organs, and sufficient in quantity, indigestion may still be produced by the prac- tice too commonly pursued, of giving to the child, occasionally, a portion of artificial food, often of the most indigestible quality. Previously to the appearance of the first molar teeth, under ordi- nary circumstances, no other nourishment is required than the breast- milk of the mother; and every kind of food which differs materially in its qualities from the latter, will produce serious disturbance of the digestive organs. We have seldom known an infant, to whom there was given, in addition to its mother's milk, any of the vari- ous compounds of bread and water, bread and milk, flour and milk, and the like "vile nurse compounds," who has not suffered from in- digestion, and often from severe irritation, or even inflammation of 198 DISEASES OF CHILDREN. the stomach and intestines; disease of the alimentary canal being more certainly produced, in the generality of these cases, by the carminatives, antacids, and opiates, administered to relieve the vomit- ing, expel the Avind, 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 Avhen too much food, or food of too stimu- lating a quality is alloAved at this period. Children too early weaned are especially liable to be troubled with indigestion, as well as those who, Aveaned at a proper period, are placed immediately upon a too rich and stimulating, or other- wise unfitting diet. Vomiting and diarrhoea—more or less griping pain of the bowels—and rapid emaciation, are the prominent symp- toms induced. The matters vomited consist usually of the partially digested aliment, often of a decidedly sour or rancid smell:—the de- jections 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 eAren increased; but, from the disturbance or suspension of the di- gestive 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 superAene; or a chronic inflammation of the mucous membrane of the stomach and bowels 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, peevishness, restlessness and want of sleep; the tongue is covered with a layer of Avhite or yellowish mucus; the breath isoftensour, and,in some cases, aphthae appear upon the parietes of the mouth. There is constant diar- rhoea, intense thirst, and great emaciation and exhaustion. The diar- rhoea, 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 shrunken 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 tympanitic. The child becomes more and more exhausted, and finally, expires quietly, and without convulsions. This appears to constitute that form of disease which is described by Camerer, Pommer, Hergt, Romberg, Droste, and others, as gas- tromalacia; the stomach and intestines generally presenting, after death, a gelatinous softening of their parietes, to a greater or less extent, but without any indications of inflammation; the softening DISEASES OF THE DIGESTIVE ORGANS. 199 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 are best promoted by a large amount of ani- mal food. Acid and unripe fruits, and the cakes and confectionary, with Avhich children are so apt to overload their stomachs, very gene- rally produce an attack of indigestion, attended with excessive nausea, a sense of weight and oppression about the praecordia, severe griping pains of the boAvels, followed, sooner or later, by repeated vomiting, and a copious diarrhoea; the attack being succeeded, in some cases, by long-continued loathing of food; and in others, by an augmented 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 Avith 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 as- similation. We must, however, recollect, that in all cases, more or less disease of the mucous membrane of the alimentary canal is pro- duced, and that if the causes of the disease are continued, inflamma- tion 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 boAvels, or a 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 eructa- tions, followed by vomiting, and generally by diarrhoea, the matters discharged by vomiting and stool being the food taken, partially or not at all altered, and exhaling a sour or rancid odour, and occasionally mixed with yelloAv or greenish bile; the absence of febrile symptoms and of tenderness of the epigastrium; more or less emaciation; with paleness of the surface, and occasionally, flatulent distention of the bowels. The appetite is often unimpaired, or even increased. Not unfrequently the irritation is reflected from the boAvels upon the brain, producing convulsions; or upon the nerves of the larynx, pro- ducing spasmodic constriction of the glottis; or inflammation 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 gene- rally 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 oc- curred, very generally terminate fatally. The dissections in cases of simple indigestion have been very rare: death seldom taking place excepting in protracted cases, or until 200 DISEASES OF CHILDREN. structural 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, anaemic condition of the membrane, Avith softening, sometimes in circumscribed patches, and in other cases in- volving a considerable portion of the mucous coat of the stomach, or small intestines.( This softening is evidently the effect of imperfect or suspended nutrition; it is also often met with in the brain, and other organs. 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 intes- tines. 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 repletion 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 alloAv it to remain at perfect rest for some time after it has been at the breast. A young infant is natu- rally inclined to perfect quietness, and generally to sleep, after suck- ing, and the interfering with this inclination is seldom unattended Avith 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, imme- diately after taking it from the breast. Whenever the milk of the mother is found to disagree with the in- fant's stomach, if the cause of this be under the control of diet and regimen, it should be at once removed. When young infants are troubled with indigestion, and the cause cannot be traced to the condition of the mother's milk, it will, in gene- ral, be found to result from the injudicious overloading of the infant's stomach with some kind of pap or panada,—articles which are inva- riably injurious, even when, from a deficient supply of milk on the part of the mother, additional aliment is required. In addition to the proper regulation of the infant's diet, in cases of indigestion, the functions of the skin should be promoted by the daily use of the warm bath, followed by gentle friction of 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 advan- tageous. 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. Medicine of any kind will seldom be required in a case of simple indigestion. When considerable nausea and retching occur without DISEASES OF THE DIGESTIVE ORGANS. 201 free vomiting, it may, however, be proper to unload the stomach by a gentle emetic of ipecacuanha. If considerable acidity of the sto- mach exists, a dose of calcined magnesia may be given; or, if the bowels are constipated, a dose of equal parts of magnesia and rhubarb; if diarrhoea be present, the simple cretaceous mixture, or what we prefer, the prepared chalk in powder, combined with small doses of ipecacuanha, will be proper. R.—Cretae ppt. gj. Ipecacuanhae, 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. R.—Aq. puree, giij. Gum. acacias, pulv. J}ij. Sacch. alb. purae, gij. Aq. cinnamom. simpl. vel, Aq. anisi. ^ss.—M. et adde Aquae ammoniae, Ify xlviij.—lxxx. A teaspoonful to be given every one, two, or three hours, according to circumstances. 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 hyoscyamus, calomel, and ipecacuanha.1 In some cases, a feAv drops of aq. camphorata, or of the ethereal solution of camphor, will promptly allay the colicky pain.2 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 favour- able effect. 1 R.—Magnesias calc. Qijss. ad gj. a R.—Camphorae, gj. solve in Ext. Hyoscyami, gr. viij. ad xij. iEther. Sulphuric, gj. Pulv. Ipecac, gr. iij. Add thirty drops of this solution to one Calomel, gr. iij.—M. f. chart. No. ounce of simple aniseed water, with xij. two drachms of refined sugar. The One to be given every two or three hours. dose is one or two teaspoonfuls, ac- cording to the age of the child. When, however, 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 sweet- ened aniseed water, or it may be administered in the form of enema combined with thin starch. Great caution should, however, be ob- served in the employment of opiate enemata in the affections of in- fants,—neither to resort to them unnecessarily, nor to repeat them too often. The opiate should be, also, in small doses, and its effects care- fully watched, as very minute doses of the tincture of opium have, even when injected into the rectum, not unfrequently proved fatal to infants. In cases of indigestion attended with frequent and copious dis- charges from the boAvels, it will, occasionally, be prudent to administer some slight astringent. The tincture of kino will, in general, very 202 DISEASES OF CHILDREN. promptly suspend the diarrhoea; it may be given in combination with the cretaceous mixture. R.—Mucilag. G. acaciae, gij. Sacch. alb. purae, gij. Aq. cinnamom. gj. Cretae, ppt. T^ij. Tine. Kino, gj. ad gij.—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 Aveaning is usually very readily managed by a proper attention to diet, the warm bath, daily exercise in the open air, when the weather will permit, and the remo- val of any symptom of unusual 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 farina- ceous 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 acescent 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 symptom indicative of the occurrence of even a slight degree of inflammation in any part of the gastro-intestinal mucous membrane be detected; if the skin be- comes dry and parched, the tongue red at its edges and extremity, and coated on its upper surface with a whitish mucus; or if increased heat of the epigastrium, with tenderness or pain upon pressure, are found to exist, leeches and fomentations to the abdomen, with cool mucilaginous drinks internally, will be demanded. In protracted cases of indigestion in children, with entire suspen- sion of the function of the stomach—the food and drinks passing through the bowels Avithout change almost 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 hydrochlo- ric acid; or of the tincture of the sesquichloride of iron, or caly- beate Avine in small doses—one or two drops of the first, and from three to six of the latter, in a teaspoonful of water. We have oc- casionally seen good effects result from the carbonate of iron, com- bined Avith hyoscyamus and acetate of lead. R.—Ext. Hyoscyami, gr. vj. ad viij. Carb. Ferri, gr. xxiv. ad. xxxvj. Acetat. plumbi, gr. xij.—M. f. chart. No. xij. One to be given every three hours. DISEASES OF THE DIGESTIVE ORGANS. 203 Friction along the spine with the weak liniment of ammonia, re- peated 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 arrowroot. What would be the effect of tannin, or of the pure sul- phate of alumina 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 Avhich softening of the sto- mach is most likely to occur, trial may be made of the hydrochloride of iron, Avhich 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. Mucil. G. Acaciae, giij. Sacch. alb. pur. gij.—M. A dessert-spoonful to be given every hour. Or, R.—Tinct. Ferri. sesquichlorid. Extract, cinchonae, aa Qss. Aq. flor. aurant. gij. Syrup.cort. aurant. gj.—M. A teaspoonful to be given every hour. 2.—Gastritis. Inflammation of the Stomach. Inflammation of the mucous coat of the stomach is of more frequent occurrence during infancy and childhood than is generally supposed. It varies in degree, in different cases, from a slight erythematic in- flammation, confined to a small portion of the gastric mucous mem- brane, and attended by symptoms so obscure as to cause its exis- tence, in its earlier stages, to be entirely overlooked; to an intense inflammation of the greater part of the stomach and bowels, accom- panied 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 extends to the duodenum, and the 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 restlessness; and small and contracted pulse, often greatly in- creased in frequency; augmented thirst, and generally, aversion from food. These symptoms vary in intensity, in different cases, and are often complicated with others, arising from disease of adjoining or remote organs, by which the gastritis has been preceded, or which became developed simultaneously with, or subsequently to, its occur- rence. The most constant symptoms are, frequent vomiting, heat, tension, and pain upon pressure of the epigastrium, and an expression of countenance indicative of suffering. 204 DISEASES OF CHILDREN. The vomiting is most liable to occur upon any drink or food being taken into the stomach, which is almost immediately rejected. The vomiting is occasionally attended Avith considerable retching, and is evidently, in severe cases, a cause of much suffering to the patient. The matters vomited are the food and drinks taken, or a thick, ropy, or frothy mucus, often mixed with yellow or greenish bilious matter ;— brownish, or dark broAvn, and even bloody discharges are occasion- ally observed. The matters vomited are not unfrequently decidedly acid. Some degree of heat and tension of the epigastrium is seldom absent. These symptoms are at first generally slight; but when the inflammation of the stomach is fully established, and of any degree of intensity, the heat and tension of the abdomen are usually 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 pres- sure ; by the patient starting and moaning, or crying out with the pecu- liar 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 its 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 performed, almost exclusively, by the ribs. Diarrhoea is common in cases of gastritis; the matters discharged from the bowels being at first faecal, but, subsequently, similar to those ejected by vomiting. Gastritis is occasionally, hoAvever, at- tended with constipation. The disease is often, especially in young infants, unattended, throughout, with any degree of febrile excitement; occasionally, hoAv- ever, there is considerable fever, with a hot and burning skin, quick and frequent pulse, and delirium, or a tendency to coma. In general, the febrile symptoms are remittent, with exacerbations toward even- ing, or even later. Gastritis may terminate in resolution, ulceration, or gangrene, or in 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, attended with profuse perspiration about the head and face, subsequently extending over the greater part of the body, hiccough, cold extremities, a sinking of the pulse, and often convulsions, early occur,and are, generally, speed- ily 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—a dry and harsh condition of the surface—febrile symptoms of a remittent character—and progressive emaciation. DISEASES OF THE DIGESTIVE ORGANS. 205 White softening of the stomach, with perforation, may occur in these cases; or, the brain may become affected, and effusion in that organ take place; or, tubercles becoming developed in the lungs, the pa- tient 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 poisonous 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 ulcerations behind the ears. In many cases, particularly in young in- fants, the inflammation of the stomach is preceded by an attack of stomatitis; in others, the stomatitis occurs subsequently to the gastritis. The disease would appear to prevail, occasionally, as an epidemic. Inflammation of the stomach, however, rarely occurs in children as a primary affection; in the great majority of cases, it becomes developed in the course of other diseases. The appearances observed after death, in cases of gastritis, are in- jection and redness, with thickening, or a softened condition of the mucous membrane of the stomach. The redness may consist in simple injection of the blood-vessels, and present an arborescent arrangement: —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—or in irregular striae, which follow, generally, the course of the corrugations of the stomach, or in numerous, closely approximated red points. (Billard.) The sto- mach often contains a quantity of thick, tenacious mucus. The pa- pillae, or villosities of the mucous membrane, appear occasionally to be someAvhat enlarged. 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; or the mucous membrane may be the seat of aphthous ulcerations, or of ulceration extending through the inner and middle coats. AVhen the inflammation of the stomach terminates in gangrene, Avhich is of exceedingly rare occurrence, (we have never met Avith a single case,) sloughs of various extent, implicating the whole of the coats of the stomach, occur, which, on becoming detached, give rise to perforations; or the mucous membrane alone may be reduced to a gangrenous condition. In cases of gelatinous softening of the stomach, the mucous mem- brane alone may be found reduced to a jelly-like consistence; or the softening 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 condi- tions may exist in the same stomach at different points. Thesevsoften- ings, or perforations, occur especially at the great curvature, seldom extending beyond the most depending parts. Some observers, how- ever, describe the softening as involving, occasionally, the greater part of the mucous membrane. Distinct traces of inflammation are frequently observed surrounding the softened parts; and the parietes of the stomach often present a serous infiltration. 206 DISEASES OF CHILDREN. Rilliet and Barthez describe the softening as being, in some cases, to such an extent that by the slightest scraping the mucous membrane is reduced to a soft amorphous mass, leaving bare the submucous tis- sue. This degree of softening occurs only in very severe cases, and coincides almost always with a decided uniform redness of the stomach. In the ordinary run of cases, the mucous membrane, which still pre- serves a certain degree of consistence, gives way upon the slightest scratching, and is thus easily removed. (Maladies des Enfans, Tome lr, 444.) Many pathologists have denied the connexion, in any instance, of softening of the stomach with inflammation, 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 organ; others, with Jaeger, Zeller, and Camerer, refer it to a paralysis of the nerves of the stomach, with increased acidity of the gastric fluid, by which the sto- mach is dissolved during the lifetime of the patient. A somewhat similar opinion is entertained by Laisne, Chaussier, Desbarreaux, Ber- nard, 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 stomach, and of other parts of the alimentary canal, may be produced by causes affect- ing the nutrition, and impairing the cohesion of the various tissues, altogether independent of inflammation, we are still convinced, from the result of our own observations, that the gelatinous softening, so frequently observed in children that have died of acute gastritis, is in- variably the effect of intense inflammation of the mucous and other tissues of the stomach. Increased redness and softening of the gastric mucous membrane, remark MM. Rilliet and Barthez, when they occur together, are suffi- cient indications of inflammation, of the existence of which there can be no doubt, when to these is added a thickening of the mucous mem- brane. In general, the thickened parts project slightly above the healthy portions of the membrane, but without its limits beingmarked by a decided boundary. The thickening often occupies several very small portions of the membrane, very near to each other. It may be described as a swelling of the villi, rendering them projecting, firm, and enlarged. The surface of the mucous membrane is, in conse- quence, rendered rough or granulated like chagrin. This appearance coincides most frequently with a more general thickening of the mu- cous membrane, and indicates a violent inflammation. The subjacent tissues of the stomach are not involved in the thick- ening. Under certain circumstances, however, particularly when the inflammation is of a chronic character, the submucous tissue becomes somewhat hypertrophied, fibrous, hard, and resistent, the part feels heaA-y, and as if its substance were increased. The treatment of gastritis is that proper in cases of inflammation generally, modified, somewhat, by the seat of the disease, and by the age of the patient. Leeches should be applied to the epigastrium, in numbers proportionate to the violence of the symptoms; and if the DISEASES OF THE DIGESTIVE ORGANS. 207 attack 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 bloodletting will be found of advantage. The necessity for a repetition of the leeches will depend upon the particular charac- ter of the attack, and the effects produced by the first application. Should the tenderness and heat of the epigastrium continue, with little abatement, after the first application of the leeches, it will be proper to renew them. In general, however, a less number will be required than at first. The leeches should be followed by warm fomentations, or by a soft emollient cataplasm, over the epigastrium;—the fomen- tations and cataplasm being renewed at short intervals. The occa- sional 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 neglected. The diet and drink of the child should be composed exclusively of some simple mucilage, as gum-water, or Avater 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 adminis- tration of a spoonful of cold water, we have found to be peculiarly grateful to the patient, and often to remain upon the stomach, when everything 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, excepting at long intervals, and for a very short period each time. A considerable difference of opinion exists, as to the propriety of administering 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 general 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, very promptly, the irritability of the stomach, and to produce a favourable change in the symptoms generally. In cases attended with frequent thin, acid eva- cuations from the bowels, the calomel we have found very generally to arrest the diarrhoea, and render the stools of a more consistent and natural appearance. We ordinarily combine with each dose of the calomel a grain or two of calcined magnesia, and give it mixed in a little mucilage: but where there exists a very great irritability of the stomach we direct the calomel, combined with a few grains of pow- dered 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 sufficient- 208 DISEASES OF CHILDREN. ly long to produce a redness of the skin, and then removed, and the epigastrium covered Avith 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 attend- ed with a condition of the pulse and surface, and a degree of extreme prostration, which have induced the inexperienced practitioner to sup- pose that some remedy adapted to support the strength of the patient, was demanded; in every instance, however, its use Avill 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, unirritating diet, of some farinaceous preparation, Avith milk—by the warm bath —and blisters to the epigastrium, frequently repeated. In this form of the disease, Ave have derived great advantage from small doses of calomel, combined with ipecacuanha and extract of hyoscyamus. R.—Calomel, gr. iij.—iv. Magnes. calc. gr. xxxvj. Ipecacuanhae, gr. ij.—iij. Ext. hyosciami, gr. iv.—vj.—M. f. chart. No. xij. One to be given every three hours. 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. In that form of the disease which is attended with gelatinous soften- ing of the stomach—the occurrence of which, sooner or later, may be suspected, from the severity of the symptoms at the very com- mencement of the attack; the yellowish or greenish matters ejected from the stomach and bowels, the latter particularly being often ex- tremely acid; the coldness of the extremities; the habitual expres- sion of suffering which the countenance of the patient assumes, and the general state of prostration that early ensues—the most ener- getic 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 with the violence of the disease, and the age of the patient, will often promptly abate the intensity of the inflammation, and prevent the occurrence of disor- ganization of the stomach or limit its extent. In cases attended with repeated vomiting, or copious diarrhoea, and with a rapid depression of the powers of life—where there is every reason to fear a gelatiniform softening of the stomach,—Rilliet and Barthez recommend the administration of the gummy extract of opium, either in a pill or dissolved in water, in doses of one centigramme every two hours, until three centigrammes (not quite half a grain) shall be taken during the day.—When no accident results, and when the age of the child will permit of it, they give the opium every hour in the same dose, stopping Avhen five centigrammes (rather more than three- DISEASES OF THE DIGESTIVE ORGANS. 209 quarters of a grain) have been taken. When any obstacle exists to the administration of the remedy by the mouth, they recommend to sprinkle, twice a day, over a small blistered surface upon the, epigas- trium, half a centigramme (about one twelfth of a grain) of the hy- drochlorate of morphia. 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 has reported to have been employed with advantage, were evidently those from defective or disturbed nutrition, unattended with inflammation. The utmost care should be paid to the diet and regimen of the patient, for a long period after his recovery from an attack of gastritis, as the disease is one very liable to a relapse, from slight causes, but par- ticularly from errors in diet. The food should consist, if not of the breast-milk of the mother or a healthy nurse, chiefly of milk and fari- naceous 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 neg- lected. The surface should be preserved of a comfortable 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 oc- casionally happens during infancy and childhood:—Avith the excep- tion of the administration of such articles as have been found to sus- pend the action of, or to neutralize whatever poison has been taken, the same remedies precisely are demanded, as in the cases of ordinary gastritis. CHAPTER V. DISEASES OF THE INTESTINES. 1— Enter algia—Colic Intense pain of the bowels is of frequent occurrence during in- fancy. We have already noticed its connexion with indigestion, and the means best adapted for its relief, in such cases. Enteralgia, how- ever, often occurs during 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 be- 14 210 DISEASES OF CHILDREN. tween four and six o'clock, p. M.; while others have noticed its oc- currence at a regular period, in the morning or forenoon. In most cases, this species of colic is attended with the formation of gas Avithin the intestines, and, occasionally, the tumid and tympa- nitic state of the abdomen is very considerable. In other cases, liow- ever, little or no flatulence is perceptible, the paroxysms of pain oc- curring 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 simple enteralgia, never having known death to occur from it. In slight attacks of colic, the infant becomes suddenly very fretful, draws up its knees, cries for a few minutes, and then resumes its usual quiet state, as though nothing had occurred. These attacks may be repeated at shorter or longer intervals, and seldom cease permanently, or for any length of time, until a portion of gas is discharged by the mouth or per anum, or an evacuation of faeces, often thin and frothy, takes place. In more violent attacks, the infant commences, suddenly, to utter sharp, piercing 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 counte- nance indicates 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 pain is induced by pressure upon any part of the abdo- men ; 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, becomes quiet, cheerful, and playful, and exhibits nothing in its appearance to indi- cate the severity of its recent sufferings. Its appetite is seldom im- paired, the digestive and nutritive functions are in no degrse dis- turbed or interrupted, 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 we 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, throAvs itself back, and stiffens its body, as in cases of flatulent colic; the paroxysm ceases, generally, in a feAv 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 mothers and nurses immediately attribute to uneasiness in the cavity of the abdomen. Flatulent discharges by the mouth or anus are frequently productive of great relief. The formation of gas within the intestines DISEASES OF THE DIGESTIVE ORGANS. 211 is generally very abundant, producing, often, a tympanitic swelling of the abdomen. The peculiarity of this variety of enteralgia consists in its being accompanied by a species of convulsion, resembling an epileptic fit; from which it differs, however, in the patient, immediately on its ces- sation, becoming quite sensible, and sometimes even playful. Occa- sionally, two or more of these convulsive attacks will occur in quick succession, 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. According to the observations of Dr. Parrish, if the child survive the period of dentition, it is usually safe. In the only case in which a post-mortem examination was made, the greater portion of the small intestines were found irregularly contracted, being reduced, in some parts, for more than an inch in extent, to the size of a goose-quill; in other parts, the caliber 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. The brain unfortunately was not examined. The peculiar phenomena of the species of enteralgia described by Dr. Parrish, evidently result from some degree of cerebral or spinal irritation being combined with the neurosthenic condition of the in- testines. 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; but we have met with it, most frequently, within the first three or four months. It is very commonly attended with an habitually constipated state of the bowels, and the paroxysms are often excited 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 enteritis to become developed at an early period. Dr. Parrish, who refers that 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 during 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 212 DISEASES OF CHILDREN. be opened by an injection of warm water, to which a few grains of asafoetida, dissolved in milk, may be adA'antagcously added. Inter- nally we have occasionally administered, with prompt relief, a few drops 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 uncommon 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 venturing 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 hot 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 repeated after an hour, if necessary. When the bowels are distended with gas, prompt relief may be occasionally obtained by the introduction 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, from the abdomen; the child to be immersed in a warm bath, antispas- modics, particularly the asafoetida, to be given by the mouth, and as an enema. According to the age of the child, from two to five grains of asafoetida may be administered by the mouth every two hours in the form of emulsion, and from ten to twenty grains as an enema, re- peated, more or less frequently, according to circumstances. If the asafoetida 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 Avith gum acacia, loaf sugar, and cinna- mon water, may be substituted. If there should be intense pain, a few drops of laudanum may be combined with the asafoetida or oil of amber, or from four to eight drops of laudanum may be injected into the rectum. Dr. Parrish likewise directs frictions along the spine with a liniment composed of oil of amber and laudanum, of each a teaspoonful, and olive oil and brandy, of each a table-spoonful; and, in severe cases, a large blister to the abdomen:—the distention of the bowels being at the same time relieved, by abstracting the accumulated gas by means of a syringe introduced per anum. In the few cases which we have seen of this form of enteralgia, we have succeeded in affording very speedy relief, by the use of the Avarm bath, folloAved by warm fomentations to the abdomen, injections composed of asafoetida dissolved in milk, and the administration of a few drops of aqua camphorata, or of spirits of turpentine, in a spoon- ful of sweetened aniseed water. In severe cases, the application of a few leeches behind each of the ears, we have invariably found to pro- duce a decidedly beneficial effect. DISEASES OF THE DIGESTIVE ORGANS. 213 From the evident tendency to cerebral disease 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 steeped in hot Avater, 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 sy- ringe, introduced into the anus, are unquestionably productive of good effects. In the intervals of the paroxysms of that form of enteralgia which ordinarily occurs in young infants, we 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 per- formed; and in the majority of cases, it is difficult to detect any cause to which the production of the disease can be referred. There is fre- quently, however, an habitually inert condition of the bowels; this we should endeavour to counteract by a proper regulation of the diet of the mother, which should be composed principally of articles of a laxa- tive character, and the child should be immersed daily in a warm bath, followed 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 sodium; or a suppository, formed 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 introduction of a large-sized urethra bougie a few inches up the rectum will gene- rally cause an evacuation, and is attended with less irritation and in- convenience than either injections or suppositories. In some cases of habitual costiveness, according to Merriman, frictions over the abdo- men, daily, with a mixture of one ounce of soap liniment and half an ounce of the compound tincture of aloes, have been found very beneficial in procuring a regular state of the boAvels. We have derived the best effects, as well in counteracting a habi- tually costive habit in infants, as in preventing the recurrence of pa- roxysms of colic, from the use of a combination of extract of hyoscy- amus, ipecacuanha, and magnesia, in small doses. R.—Ext. hyoscyami, gr. iv. ad vj. Magnes. calc. gr. xxiv. ad xlviij. Ipecacuanhae, 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 ra- ther 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, previously to putting others on. Dr. Dewees, viewing the disease as one of a strictly periodical cha- 214 DISEASES OP CHILDREN. racter, administered a decoction of bark, in many cases with the hap- piest effect; in others, however, no benefit resulted from its use. Dr. Eberle has seen good effects from the cyanuret 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; the dose to be repeated every three or four hours, during the intervals of the paroxysms. To prevent the recurrence of the convulsive form of enteralgia,, Dr. Parrish directs a proper regulation of the diet of the child; at- tention 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 advisable; with blisters behind the ears, kept open by some stimulating dressing; and, if there exist acidity of the stomach and bowels, the frequent adminis- tration of some alkaline remedy. Dr. Parrish prefers the alkaline infusion of Physick, diluted to suit the palate of the infant, in doses of a teaspoonful every two or three hours:—we should certainly pre- fer, in these cases, calcined magnesia, or carbonate of soda. The following will be found to be a very excellent prescription in most instances. R.—Mucil. G. Acaciae, giij. Sacch. Alb. pur. giij. Spir. Terebinth, gj. Magnes. calc. gr. vij.—M. A teaspoonful 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 de- tected, should be met by its appropriate remedies. 2.—Diarrhoea. 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 in- flammation; it would seem necessary, therefore, to consider it se- parately, as its treatment differs in many important particulars from that proper in the diarrhoea attendant upon enteritis. In infancy, diarrhoea may be caused, independently of inflammation of any portion of the gastro-intestinal mucous membrane, by im- proper 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 alimentary canal in infants renders them particularly liable to the occurrence of diarrhoea from slight causes; it is, consequently, an affection of far more frequent occur- rence during the early period of life, than at any subsequent age. It may last for only a few hours, and then cease spontaneously, or tho evacuations may occur every few minutes, and continue, with little or no abatement, for a considerable length of time; exhausting DISEASES OF THE DIGESTIVE ORGANS. 215 the strength of the patient, and producing extreme emaciation, with- out, in many cases, the occurrence of any inflammatory affection of the intestines. When, however, the diarrhoea assumes a protracted form, it will, very generally, be found to be dependent upon subacute inflammation of the intestinal mucous membrane. In the diarrhoea of infants, the discharges from the bowels may be more or less thin, of a dirty white or grayish colour, of a curdled appearance, and of a decidedly acid odour, or they may be almost entirely fluid, of a bright yellow or greenish hue, and often mixed Avith blood: these are the general conditions of the evacuations oc- curring in early infancy. In older children, the discharges may be thin and feculent, yel- low, green, or dark brown; or they may consist, at first, of portions of undigested food, very acid, and often, when the diarrhoea has re- sulted from the use of crude acescent vegetables, in a state of fer- mentation. Occasionally the discharges are very thin and watery, with- out any decided smell, and nearly colourless; or they may be com- posed of a fluid mixed with bile, of a yellow or green colour. In many cases, particularly during 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 offen- sive. 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 af- fected, and the appetite remains unimpaired. Increased thirst com- monly 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 abdo- men may be swollen, when the diarrhoea is connected with an over- loaded 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 tem- perature increased. Whenever pain is excited by moderate pressure upon the abdomen, especially when accompanied by tension, and increased heat of its surface, the diarrhoea will be found to be dependent upon enteritis. In such cases there is usually more or less heat of the surface gene- rally, dryness, with a sense of heat or burning of the palms of the hands, and other symptoms of febrile excitement, with evident exa- cerbations towards evening. When the diarrhoea is prolonged, 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 appearance of premature old age; while the discharges from the bowels are frequent, but small in quantity; occa- sionally 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 fetid. 216 DISEASES OF CHILDREN. 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. Whenever, hoAvever, from any cause the diarrhoea 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 consequently, very few examinations have been made of the pathological condition of the intestines. In the more prolonged cases, the intestinal mu- cous membrane has often presented no marks of disease, with the exception, perhaps, of unusual paleness, and, occasionally, of soften- ,ing to a greater or less extent. The parietes of the intestines have, in a few instances, been found of unusual thinness, almost trans- parent 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 who die whilst labouring under serous or mucous diar- rhoea unattended 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 plexuses. In most cases of chronic diarrhoea, the mu- cous membrane is thickened, often softened or ulcerated, and, occa- sionally, presents large patches of a livid or slate colour. The mu- cous glands are generally 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 con- tains greenish bile, and the liver is occasionally more vascular than natural. (Brunner, Stark, Bang, Andral, Copland.) The most usual seat of the lesions in chronic diarrhoea, are the ileum, especially its lowest third, and the coecum. The most common form of diarrhoea in infants and young children, is that resulting from over-feeding, from the bad quality of the mo- ther's or nurse's milk, or from some change produced in it by acci- dental 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 practice of gorging the infant's stomach with alimentary substances, often of the worst kind, previous to the secretion of its natural and congenial nourishment. Nurses are always fearful that the infant will suffer from the want of nourishment, previously to the appearance 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. Ordi- narily no kind of nourishment is requisite until the child can be ap- plied to the breast. Should the secretion of milk, however, not take place for one or two days, as is occasionally the case, a little new milk, with the addition of about one-third warm water, and sweetened with'loaf sugar, may be given, and repeated, if necessary. DISEASES OF THE DIGESTIVE ORGANS. 217 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 cha- racter of the food employed, than from the stomach of the infant being habitually over-loaded, by the food being 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 indigestion in the child that partakes of it, will it be liable, also, to cause an at- tack of diarrhoea. 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;—thus arrow-root, so generally recommended as an appropri- ate 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 generally ceases spon- taneously 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 sus- pended—the food and drinks taken pass through the bowels un- changed; great emaciation is produced, and the infant dies, sooner or later, from extreme exhaustion; or an acute, or subacute inflamma- tion 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, sometimes in considerable quan- tity, with the discharges, in the diarrhoea of young infants, is the re- sult of a true hemorrhagic effusion, caused by the state of hyperaemia of the intestinal mucous membrane, which almost invariably exists for a short period after birth. Improper articles of food, or excess in eating, are among the most common causes of diarrhoea, subsequent to the period of weaning. Unless the utmost attention is paid to the proper regulation of the in- fant'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 feculent, or faeces mixed with imperfectly digested food, but speedily becoming composed of a serous fluid, of a dirty yellow, or greenish yellow. Intestinal inflammation is early developed, or the diarrhoea^assumes a chronic and peculiarly 218 DISEASES OF CHILDREN. unmanageable form. It is this diarrhoea which is described 1 >y Cheyne as a new and peculiar form of disease, under the name of "atrophia ablactatorum." In older children, diarrhcea is generally produced by 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—pastry, fruits, and confectionary—the inordinate quantities of these that are 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 cause no further inconvenience than nausea, vomiting, and a rather profuse diarrhcea, ceasing spontaneously soon after the offending substances are expelled. But when excess in eating, or improper food is habitually indulged in, a much more serious disorder of the alimentary canal ensues; the diarrhcea, often, then becomes profuse, and, if not promptly and judiciously treated, inflammation of the bowels is liable to be produced, running, generally, into a chro- nic form, and producing death from marasmus; or disease of the brain is excited, terminating, most generally, in serous effusion. The application of cold to the surface of the body, and especially exposure to cold or damp, 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 more or less febrile excitement, and tenderness and heat of the abdomen, indicating the existence of some degree of intestinal inflammation. Slight catarrhal symptoms are frequently present; 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 diarrhcea, if its true character is overlooked, and it is, in conse- quence, improperly treated in its commencement, is very liable to be- come a serious disease, giving rise to extensive disorganization of the intestines, or early involving the brain. Some degree of diarrhcea 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 ex- hausted, 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, occasionally, faecal, 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 DISEASES OF THE DIGESTIVE ORGANS. 219 is still further augmented, if the cutting of the teeth be tedious, or attended with difficulty. Although this morbid development and acti- vity 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 pe- riod of dentition, upon a strict regimen, and closely watching, lest inflammation should 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 ulcerations behind the ears. These cases appeared to be, in the majority of instances, accompanied with some degree of inflammation of the intestinal mucous membrane. Repeated mucous discharges are often accompanied with the pre- sence of intestinal worms; whether, however, they are in any instance attributable to an irritation produced by the latter is a question still in dispute. Of the existence of worms in the intestines, we have no positive evidence, excepting that derived from their appearance in the discharges. A superabundance of viscid mucus in the bowels, and its copious discharge by stool, being generally enumerated as leading indications of their presence, the latter is often inferred, merely from the fact, that a child is affected with mucous diarrhoea, particularly in its chronic form. 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 con- fined 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, feculent, but soon become almost exclu- sively composed of a thin mucus, mixed with bile, of a bright yellow, or green colour: they are extremely copious, and are generally attend- ed 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 in- fluence of a heated and confined atmosphere, the diarrhoea will con- tinue, 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 exco- riation of the anus to take place. In such cases, symptoms of cholera infantum may quickly develope themselves, or, after a few days, and sometimes earlier, the bilious discharges may cease, and frequent copious evacuations occur, of a 220 DISEASES OF CHILDREN. serous fluid, at first of a yellowish or greenish colour, but, subsequent- ly, almost colourless. At the same time, not unfrequently, the abdo- men 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 Avith a dirty white or yellowish mucus; great thirst is experienced, and, whatever fluid is taken, is instantly expelled, and often with great violence; aphthae frequently appear upon the parietes of the mouth, and rapid emaciation ensues. The brain is, in some cases, early affected, and the patient expires with all the symptoms of hydroce- phalus; in other cases, the 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, appears to be produced by an undue 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 observed after death. We have frequently detected in our autopsies, increased redness of the stomach and duodenum, occurring in points grouped together, in irregular striae, in large patches, or irregularly diffused, and presenting a kind of elevation from the thickening of the mucous membrane. Follicular inflammation was occasionally detected in the stomach, but more frequently in the ileum. 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 inflamed. Contractions of different parts of the intestinal tube were frequently observed, and in a few instances, numerous invaginations. The small intestines were generally empty, while the mucous coat of the large intestines was frequently coated with a thick tenacious mucus, and often contained a frothy mucus, of a grayish or yellowish colour. The liver was usually in a state of hyperaemia, while 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 diar- rhoea had assumed a somewhat protracted or chronic form, by no means of so decided a character; and in a few cases, the only indica- tions of disease were unusual paleness of the mucous membrane, with enlargement of the muciparous follicles. The discharges, in some cases of diarrhoea, occurring during child- hood, are of a very white, opaque appearance, having some resem- blance to a mixture of chalk and water. This constitutes the chy- lous 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 children, the peculiar condition of the stools arising, probably. DISEASES OF THE DIGESTIVE ORGANS. 221 from some morbid change in the intestinal secretions. Some have supposed it to depend upon irritation, with altered secretion of the pancreatic gland. W^e have had no opportunity of observing the condition of the alimentary canal, and other abdominal organs in this form of diarrhoea, never having met with it in any case that ter- minated fatally; it is one, indeed, judging from our own experience, of not very frequent occurrence in this country. From the preceding description of the several species of diarrhoea occurring in infants, it will be perceived how intimately all of them are connected with intestinal inflammation of an acute, subacute, or chronic 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 finally produce the death of the patient by suspending the assimilative and nutritive functions, and still no indications of inflammation be present through- out the attack. It must, nevertheless, be 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 development of inflammation of a more or less acute form, in every case, unless the cause of the diarrhoea be early re- moved, and it be, in this manner, promptly suspended. Under whatever circumstances, therefore, diarrhoea occurs, a close scrutiny into, and careful analysis of all the accompanying symptoms, should be made, and if the case be a protracted or obstinate one, the state of the abdomen as to tension, heat, and tenderness upon pressure, should be cautiously examined;—and if intestinal inflammation be de- tected, its removal by a judicious course of treatment is essential to the cure of the diarrhcea, 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 infant may be nourished upon diluted milk, with the addition of the best loaf sugar, by means of the sucking-bottle. If the infant be fed by the hand, in those instances in which 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 stomach, by taking too much at a time, or being fed Avith it at too short intervals. When diarrhoea occurs at the period of weaning, the utmost at- tention 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 ar- ticle of diet, which although in itself perfectly wholesome, may, from some peculiar idiosyncrasy in the child, disagree with its stomach, 222 DISEASES OF CHILDREN. and caus& 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 the bowels of infants, immediately after weaning, to be disordered by all the ordinary farinaceous preparations, and by milk, while meat broths, with the addition of rice or crackers, agreed perfectly well with them. In older children it will be proper, upon the occurrence of diar- rhoea, to suspend every species of solid aliment, and to confine them entirely, for a short period, to moderate quantities of some prepara- tion 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 diarrhcea; 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 some mild but active purgative, in the com- mencement of the attack, will be proper in most cases, to remove any irritating matters that may be retained in the alimentary canal. The repeated exhibition of active purgatives is, however, not only unnecessary, but positively injurious, by increasing and prolonging the irritation by which the disordered action of the bowels is pro- duced. If the diarrhoea is not quickly suspended by a proper regulation of the infant's diet, and the use of the warm bath—particularly 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 hyoscyamus, to be attended with the best effects. R.—Calomel, gr. ij. ad vj. Cretas ppt. gr. xviij. Ipecacuanhae pulv. gr. ij. Extract. Hyoscyami, 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 the stools to become less frequent, more natural, and of greater consis- tence; the digestion to be improved, and the irritability of the intes- tines diminished. 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 oc- curs, 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, combined with a quarter to a third of a grain of ipecacuanha, and the half of a grain to a grain of extract of hyoscyamus, may be given DISEAS-ES OF THE DIGESTIVE ORGANS. 223 twice or thrice a day, with some slight astringent every three hours. The tincture of kino, or catechu, or either of these substances in powder, or the compound infusion of catechu, may be given. R.—Catechu pulv. gij. Cinnamom. contus. gss. 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 pa- tient, or the nature of the case. With many American physicians, we prefer as an astringent, in cases of simple diarrhcea, a decoction of the root of the geranium maculatum, or of the blackberry (rubus villosus,) especially the for- mer, which, when the decoction is made with milk, is a very excellent and agreeable astringent, well adapted to relieve the irritable state of the bowels, by which, in many cases of ordinary diarrhoea, the dis- ease 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, however, in consequence of the sleep being disturbed 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 ipecacuanha, and carbonate of soda,1 by the mouth, may be given in the evening. But it is better, if possible, to dispense altogether with the use of opiates in every form. 1 R.—Opii pulv. gr. j. Ipecac, pulv. gr. iij. ad iv. Carb. Sodas, £)j.—M. f. ch. No. xij. For a child 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 ipecacu- anha and calomel, every two or three hours;2 and as soon as the dis- charges 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 diarrhcea is attended with thin mucous or serous discharges, even the mother's milk will, sometimes, be found to irri- tate the bowels, and increase the disease. Hence it is better to con- fine the patient always to simple mucilaginous fluids. 2 R.—Calomel, gr. j. ad ij. Ipecacuanhas, gr. ij. ad iij. Sacch. alb. ^ij.—M. f. ch. No. xij. One to be given every two or three hours, according to the.age of the child. As the disease arises, in most cases, from the effects of cold and dampness, the warm bath will be found an admirable remedy, particu- larly if followed by gentle friction 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. 224 DISEASES OF CHILDREN. When the discharges from the bowels are very 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 hyoscyamus, will be found promptly to arrest them.1 Ample ex- perience has taught us that the acetate of lead may be given with the most perfect'safety to children: in the combination just stated, Ave know of no more effectual means of arresting the profuse serous discharges Avhich often occur in the diarrhcea of infancy, A\rhich, if al- lowed to continue, would produce in a very short time, a degree of exhaustion, that is not unfrequently fatal. 1 R.—Calomel, gr. j. ad ij. Ipecacuanhae, gr. ij. ad iij. Acetat. plumbi. gr. vj. ad xij. Ext. Hyoscyami, gr. iv. ad. vj.—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 de- tected, or distinct febrile excitement occurs, it will be proper to apply leeches to the abdomen, in numbers proportioned to the age of the pa- tient, and the urgency of the symptoms; followed by warm fomen- tations, or an emollient cataplasm. As soon as the inflammatory ac- tion is subdued, if the discharges from the bowels still continue to be frequent, and of a serous character, the combination 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 yelloAv, grayish, 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 strain- ing 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 Avith minute portions of Dover's powder; we have likewise administered the copaiba in many 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. Copaibae. gj. Magnes. calc. gr. x. Spir. aether, nitr. giij. Sacch. alb. giij. Aq. cinnamom. giij.—M. Dose.—One teaspoonful every two or three hours: each dose to be followed in the course of an hour by the fifth of a grain of Dover's powder. DISEASES OF THE DIGESTIVE ORGANS. 225 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, how- ever, be found to disagree with the patient, when probably, simple chicken water, with or without rice, may be advantageously substi- tuted. 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 result 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, the proper treatment is, a careful regulation of the diet—which should be restricted to preparations 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. No attempt should be made to arrest the discharges, so long as they con- tinue moderate in quantity, and unattended by any unusual symptom. When, however, they are profuse, when emaciation ensues, or symptoms of intestinal inflammation present themselves, the diarrhoea de- mands immediate attention; it should then be treated in the same manner as though it had occurred independently of dentition. The mucous diarrhoea so frequent in cases of intestinal worms, has generally been ascribed to the irritation produced by the presence of the latter. Hoav far this opinion is correct it is somewhat difficult, as we have already remarked, to determine. We have, it is true, in numerous instances where worms have been discharged in great numbers 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, diaphanous mucus, which appeared to come away at once, without straining, or any unusual effort. These discharges frequently alternate Arith regular, healthy stools, or those composed, in a great measure, of natural faeces. They are always unattended with febrile excitement, or the slightest indication of inflammation. The children are generally pale, of a lymphatic temperament, with capricious ap- petites, and tumid, but soft abdomens; their breath has, generally, a sickly, disagreeable 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 na- tural condition of the stools, and removing the principal symptoms 15 226 DISEASES OF CHILDREN. of the disease, by the administration of turpentine in emulsion, fol- lowed by light astringents, the use of the warm bath daily, and a careful regulation of the diet and regimen. R.—Mucil. G. acacice, giij. Sacch. alb. pur. gvj. Spir. aether, nitr. giij. Spir. terebinth, gij. Magnes. calo. gr. xiij. Lavend. spir. comp. gij.—M. Dose, a teaspoonful, repeated three times a day, or oftener, 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 reference to the presence of worms in the intestines:—the remedies usually employed for the destruction and expulsion of the latter would be calculated to increase the diarrhoea, or even to induce severe inflammation of the intestinal mucous membrane. In the treatment of bilious diarrhoea, the first indication is to re- move the cause by which the morbid secretion of bile has been pro- duced. As this is usually intense heat, with a stagnant and impure state of the atmosphere, the prompt removal of the child to a more free, and cooler atmosphere is essential to insure its recovery. When such a removal cannot be effected, domestic cleanliness and free ven- tilation should be enforced, as well as the free exposure of the child. in dry weather, to the external air, in the most healthy and open situa- tions, in its immediate neighbourhood. It may be either carried out in the arms, in an open hand-carriage, or by riding in any open ve- hicle, or by 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. 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 immersed daily in a tepid or warm bath, according as the tempe- rature of its surface is augmented or depressed, and its clothing should be light and loose, and so adapted, in the materials of which it is com- posed, as not unduly to augment the heat of the body, but, at the same time, to guard it fully 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 calo- mel, calcined magnesia, ipecacuanha, and extract of hyoscyamus, will generally produce the desired effect.1 Under the use of this combi- nation, 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. DISEASES OF THE DIGESTIVE ORGANS. 227 1 R-—Calomel, gr. ij. ad iij. Magnesias calc. gr. xxiv. ad xxxvj. Ipecacuanhae, gr. ij. ad iij. Ext. hyoscyami, gr. iv. ad vj.—M. f. ch. No. xij. One to be given every two or three hours. Purgatives, opiates, and astringents are seldom proper—never, un- less 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 treatment of mucous diarrhoea, is the remedy which we have found the most frequently to succeed in arresting the disease. When the discharges are profuse, and the patient becomes rapidly exhausted, a small portion of opium may be substituted for the extract of hyos- cyamus; and a solution of the acetate of lead, with such an addition of laudanum as is adapted to the age and condition of the patient, may be thrown into the rectum. As soon as the profuse serous dis- charges are suspended, the calomel in small doses, combined with ipecacuanha and extract of hyoscyamus, will, in general, complete the cure; or, if after the discharges assume a more natural appear- ance, 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 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 one of the most useful compounds in protracted cases of diarrhoea.1 We have ourselves never employed it, but have seen good effects re- sult from the administration, in these cases, of nitrous acid, in com- bination with aqua camphorata and opium, or Avith hyoscyamus.2 1 R.—Infusi simaroubae, gjss. Acidi nitrici dil. Ttyij. ad iv. Syrupi caryophyl. giv. Tine, opii, %vj.—M. One or two teaspoonfuls, in a little barley water, to be repeated three or four times a day. *R.—Acid, nitros. Tfyviij. ad xv. Or, R.—Acid, nitros. %x. ad xv. Aquae camphor, gj. Sacch. alb. giij. Tine, opii, TT^vj.—M. Ext. hyoscyami, gr. vj. A teaspoonful every three hours. Aq. cinnamom. 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 disease, 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 Avarm 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 adminis- tering minute doses of calomel; placing them upon the tongue in a 228 DISEASES OF CHILDREN. dry form, if they are quickly ejected from tho stomach when admi- nistered in the usual manner. From an eighth to a sixth of a grain may be given, every half hour or every hour, according to circum- stances; 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 diarrhcea; a careful Avatch 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 urgency of the symptoms. It is probable that, in most cases, a blister over the abdomen will be sufficient to remove the inflammation, without again resorting to leeches. Even when the latter are considered necessary and proper, they should be followed, in a short time, by a blister, left on only so long as to produce a decided redness of the skin; the part to Avhich 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 Avith very serious consequences. By many physicians, the exhibition of opiates has been strongly ad- vocated, in the inflammatory form of bilious diarrhoea; we have oc- casionally resorted to them, but have never been pleased with their effects; in some instances they were evidently decidedly injurious. After the inflammatory action has been somewhat reduced by leeching, a combination of calomel, extract of hyoscyamus, and ipe- cacuanha, in small doses—from a fourth to 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, in each case, of the mucous membrane of the alimentary canal, the state of the liver, and of the other organs that are liable to become involved in disease. In many cases of prolonged diarrhoea, no other morbid condition of the intestines would appear to be present than an undue irritability of their mucous membrane, with increased exhalation from its folli- cles. 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 secretions poured into the intestines. The manage- ment of these cases is attended with great difficulty, and the best-di- rected plan of treatment is very frequently unsuccessful. The discharges in chronic diarrhoea may be composed of a thick, tenacious, jelly-like mucus, 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, again, they are composed of a thin fluid of a dirty green, DISEASES OF THE DIGESTIVE ORGANS. 229 reddish-brown, or yellowish colour, and in some instances, they con- sist of the food or drinks taken, which pass immediately through the bowels without having undergone the least change. The stools have often a peculiar rancid odour, but are generally more or less fetid. The discharges are not generally large in quantity, and vary much in regard to frequency—a number often taking place in ^ quick suc- cession, and then a considerable interval occurring without any. More or less griping may precede 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 continu- ance, and when enlargement of the mesenteric glands occurs:—occa- sionally, extreme tympanitic distention takes place at an early period. There is always great emaciation, with dryness and harshness of,the surface and discoloration 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 continuance of the causes by which the diarrhoea was originally produced, or by its repeated recurrence, in the same child, within a short period of time. In the great majority of cases, it may be re- ferred to a neglect of dietetic management, or to a recurrence to the use of improper food, immediately after recovery from an attack of ordinary diarrhoea. For a long time after the bowels have re- sumed their natural action, strict attention to the diet of the child is essential to prevent relapse. Even indulgence in articles which, under other circumstances, would be considered perfectly wholesome and appropriate, will not unfrequently produce a return of the diarrhoea, and each recurrence 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 confined entirely to some plain, farinaceous article of food, with or without milk, according as the latter is found to affect the stomach and bow- els. 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 an 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 impor- tant remedy; it may be repeated daily, and in many cases every morning and evening, with decided advantage. 230 DISEASES OF CHILDREN. In those cases in which the discharges indicate a disordered state of the biliary secretion, small doses of calomel should be adminis- tered twice or thrice a day, or oftener, according to the circum- stances of the case, and the effects produced by the remedy. Clarke, Cheyne, Underwood, and Marley administer the calomel by itself, Dewees in combination with prepared chalk and opium, and Eberle, Seele, and Jager, with opium alone. We prefer its administration in combination with prepared chalk, ipecacuanha, and extract of hy- oscyamus. R.—Calomel, gr. ij. ad. vj. Cretae ppt. gr. xxxvj. Ipecacuanhae, gr. ij. ad. iv. Ext. Hyoscyami, gr. iv. ad vj.—M. f. ch. No. xij. The use of this combination should be continued until the dis- charges assume a more natural appearance. In many cases, we have experienced the best effects from the em- ployment of turpentine in the following formula. R.—Mucil. G. acaciae, giij. Sacch. alb. pur. giij. Spir. terebinth, gij. Magnes. calc. gr. xiij. Tinct. opii camph. gij.—M. Dose, a teaspoonful every three or four hours, according to circumstances, Under the use of the turpentine 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 intestines, even when this has been the seat of a subacute inflamma- tion, we have found it to produce a directly soothing influence. When there is much tenderness of the abdomen, and the child evinces the existence of pain by its fretfulness or almost constant whin- ing 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 occasional circumscribed flush of one or both cheeks, with a suffering expression of countenance, it will often be found advantageous to ap- ply 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, according to the directions already given, generally produces a very beneficial effect. In all cases of chronic diarrhoea, the derivative ef- fects of blisters to the abdomen are adA^antageous, often very deci- dedly so, and in many cases the blister may be repeated as soon as the first heals. When acidity prevails in the alimentary canal, the occasional use of some alkaline preparation will be proper; a few grains of bicarbo- nate 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.—Cretaa ppt. gj. Or, R.—Cretae ppt. gij. Calomel, gr. iij. Sacch. alb. pur. gij. Ipecacuanhae, gr. iij. Mucil. G. acaciae". gss. Ext. hyoscyami, gr. viij.—M. Aq. cinnamom. gij. f. chart. No. xij. Tine, opii camph. gj.—M. One to be given three times a day. A teaspoonful to be given every three or four hours. DISEASES OF THE DIGESTIVE ORGANS. 231 When the acidity is accompanied with much flatulence, 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 in- testines, 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. ]J.—Acetat. plumbi, gr. vj. ad xij. Pulv. ipecacuanhae, gr. iij. Opii pulv. gr. j.—M. f. ch. No. xij. One, to be repeated three times a day, or oftener, 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 poAvder. 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. R.—Pulv. gallae, gr. xxxvj. ad gj. 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 perses- quinitrate of iron, which is spoken of in the highest terms by Kerr, Kopp, and Graves, as a remedy in certain forms of chronic diarrhoea in adults, appears to us well deserving of a trial in the cases occur- ring in children, which often bear a strong resemblance to those de- scribed 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 Avater; the dose being gradually augmented. From 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 appear- ance of the discharges. So long as these continue of a decidedly un- healthy appearance, to attempt to suspend the morbid irritability of the intestinal canal by opiate or astringent remedies, is merely to prolong the disease. In those cases, however, in which the evacuations are, in a great measure, composed of thin, faecal matter, or serum tinged with bile, the combination of the 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 simarouba, and from the persesquinitrate of iron. Recently, the nitrate of silver has been strongly recommended as a remedy in obstinate cases of diarrhoea in children. Hirsch of Konigsberg (Hufeland's Journal,) found it particularly efficacious in 232 DISEASES OF CHILDREN. the advanced stage of the diarrhcea of newly weaned infants, when emaciation and prostration were extreme, and the evacuations were frequent,fetid, and wanting altogether the foecal character, consisting ofaA*ariously coloured, sometimes greenish or bloody mucus; and when aphthous ulcerations pervaded the mouth, he gave it in the following formula. R.—Argent, nitrat. crystall. gr. J. Aquae distill, gy. Gum. acaciae, Qij. Sacch. alb. gij.—M. ' A teaspoonful to be given every two hours. He also administered the nitrate of silver in the form of enemata* containing each a quarter of a grain of the salt, with mucilage and a little opium. The good effects of this treatment, he remarks, were occasionally visible in a few hours, sometimes not until the second day. He pronounces the nitrate of silver, thus administered, a speci- fic in the diarrhoea of infants. Canstatt, also, extols it in the diarrhoea ablactatorum. The efficacy of this article in the diarrhcea of infants is also acknowledged by Bouchart (Manuel Pratique des Nouveau-nh) as well as by Troupeau, and in a communication of Mr. Aiken (Dub- lin Med. Press, Sept. 1847,) a case is given in which the remedy proved promptly successful in arresting a severe and protracted diar- rhoea in an infant one year old, after all the ordinary remedies had failed. We have employed the nitrate of silver in a number of cases of chronic diarrhoea in children, and have invariably been pleased with its effects. To patients under two years of age, we give one sixth of a grain every three hours; and to older children from one fifth to one fourth of a grain, at the same intervals. 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 disease 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- rhcea being treated by calomel, ipecacuanha, and extract of hyoscya- mus. We are to recollect, however, that stupor, and other symptoms of an affection of the brain, terminating rapidly in effusion, may be produced by extreme exhaustion, the result of the frequent and pro- fuse evacuations from the bowels. In this case, the diarrhoea should be arrested as speedily as possible, and the strength of the child re- stored by some tonic, as the sulphate of quinia, or the persesquini- trate of iron, with a nourishing but bland and easily digested diet. 3.—Cholera Infantum. (the summer complaint of infants.) The cholera infantum is a disease that has, with great propriety, been considered 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 DISEASES OF THE DIGESTIVE ORGANS. 233 all its features, the infantile cholera of this country:—certainly none that prevails 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, Vir- ginia, 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 com- monly 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 ten years, from 1835 to 1844, inclusive, 2583 in- fants perished from this complaint; being nearly eleven per cent, of the whole number of infants under five years of age, who died during that period, and 5-3 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 impossible, to remove the infants who become attacked. Cholera infantum most usually commences with a profuse diar- rhoea, 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 af- fected with almost constant vomiting and purging; the discharges from the bowels being, ordinarily, a perfectly colourless and inodorous fluid, containing minute mucous flocculi. They are sometimes small in quantity, and squirted, as it were, from the anus; but occasionally, they are very copious, and passed without the least effort. In whatever manner the disease commences, the child soon be- comes affected with great languor 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 234 DISEASES OF CHILDREN. head and abdomen are hot, while the extremities retain their natu- ral temperature, or, when the attack is violent, are decidedly cold. There is always intense thirst, but whatever fluid is taken is almost immediately ejected from the stomach. Towards evening, there oc- curs, 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, Avhile the diarrhoea con- tinues unabated, or increases in violence; the irritability of the in- testinal canal being often such, as to cause Avhatever 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 at- tack, 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 dose, with half-closed eyelids, and so insensible to external impressions, that we have repeatedly seen flies light upon the half-exposed eyeballs, without the patient exhibiting the least consciousness of vtheir presence. The surface of the body is now cool and clammy, of a dark brown- ish hue, and often covered with petechiae; the tongue is dark-coloured, smooth, and shining, or covered, as well as the whole of the inner surface-of the mouth, with aphthae. 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 abdo- men becomes more or less tympanitic, and the hands and feet pallid, or of a leaden hue, and oedematous. The discharges from the bowels are now generally frequent and profuse, dark-coloured and very of- fensive—resembling the washings of stale meat; in many cases, how- ever, they are small in quantity, and composed entirely of dark- coloured mucus, mixed with 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. DISEASES OF THE DIGESTIVE ORGANS. 235 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 examination of the bodies of those who have fallen victims to cholera infantum, exhibits various lesions, chiefly of the alimen- tary canal. When death occurs early in the attack, the only morbid appearance 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, gene- rally, of minute extravasations of blood. At other parts of the bowels, these points occur in clusters:—the patches vary in size, but are never very large, and are often slightly elevated, from a thick- ening 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 caliber to such an extent, as scarcely to permit the insertion of a small-sized quill. The muciparous follicles of the intestines are very generally en- larged, 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, tenacious mucus. Dr. Page describes the appearance of dark spots upon the mucous membrane of the stomach, about its pyloric orifice, but particularly of the duodenum; and Dr. Lindsly mentions a similar appearance; —we have never detected it. The liver is, in general, enlarged, and more or less congested; Avhile 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. Dewees, Hor- ner, James, Jackson, and Lindsly, 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 not often to the extent noticed by most writers, and seldom 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, Avithout indications of inflammatory action, but in others, with thickening and opacity of the arachnoid mem- brane. 236 DISEASES OF CHILDREN. A very excellent paper on endemic follicular gastro-onteritis, or summer complaint of children, by Dr. E. Hallowell, of Philadelphia, is contained in the American Journ. of the Med. Sciences, for July, 1847. The author divides the disease into three stages based upon its ana- tomical characters. Those in the first or early stage of the disease, consist in an undue deAr.elopment of the follicles of both the stomach and intestines, or of one only of these organs, without inflammation of the mucous membrane. Children rarely die of cholera in this early stage, consequently, opportunities seldom occur for observing the morbid appearances. In the second, more advanced or chronic stage, the anatomical characters consist essentially in inflammation with softening of the mucous membrane, and ulceration of the follicles, more especially of the large intestines. The mucous membrane of the stomach* in many cases presents its usual appearance and consistence; in others, it is more or less injected and softened, the softening extend- ing occasionally to all the coats. The lining membrane of the stomach is not unfrequently covered with a layer of whitish opaque mucus, easily scraped off with the handle of the scalpel; the mucous follicles both of the stomach and intestines are more or less apparent; the mucous membrane of the small intestines is occasionally softened, and for the most part pale in the greater portion of its extent. In one case the lower portion of the ileum presented a brickdust colour, with alternations of a pale yellow, mottled with red; in some points minute vessels were seen freely inosculating with each other; in other portions, the inosculations were less distinct, the reddish tinge being uniform. In another case, the inflamed portion was of a dull red, or brickdust colour, minutely injected with red vessels, and in several points, especially upon the surface of the valvulae conniventes, presented a dotted appearance; it occupied a portion of the intestine four inches in extent from the pylorus. In another case, the duode- num, at its upper portion, presented a slight shade of pink, with a few minute arborizations; and in several other instances there was a slight degree of inflammation, affecting the duodenum at its upper extremity. There was also a slight inflammation of the glands of Peyer in one or two cases, but for the most part these bodies pre- sented nothing remarkable. The small intestines contained a con- siderable quantity of orange^coloured mucus. The large intestine was more or less inflamed, and softened, in almost every instance; the inflammation existed in the form of bands, and presented a dotted ar- borescent appearance; in one case these bands were longitudinal. In most cases the redness was diffused, with occasional ramifica- tions; in one instance the inflammation occupied the whole extent of the colon; it Avas of a vivid red throughout, and the membrane was much thickened. From the margin of the follicles, minute vessels were seen to radiate to the surrounding membrane, occupying the entire surface of the intestine, showing that the inflammation com- menced in the follicles and extended subsequently to the mucous mem- brane. The follicles were often found to be more or less ulcerated, DISEASES OF THE DIGESTIVE ORGANS. 237 the ulcerations sometimes extending as far as the muscular coat; they were more or less numerous, and penetrated more deeply in the rectum than in other port'ons of the intestine; the rectum was often com- pletely riddled with them. The mucous membrane was more or less softened in the greater number of cases; in one instance it was thick- ened and intensely inflamed. The coats of the intestine were covered with a layer of mucus, sometimes so thick as to diminish consider- ably its caliber. It ordinarily contained a quantity of grayish-co- loured faeces, of the consistence of gruel. In uncomplicated cases the lungs presented nothing remarkable, except a slight engorgement posteriorly. The peritoneum was healthy. The liver was greatly enlarged in only one instance; the gall-bladder was more or less dis- tended with dark-coloured bile; the mesenteric glands, spleen, and kidneys presented nothing remarkable. In nearly all the cases, the veins of the pia mater were more or less distended; the arachnoid was pale and moist, except in one case, in which there was a slight opacity at the base of the brain. There was more or less effusion in the subarachnoid cellular tissue; for the most part limpid; occasionally it presented a whitish, opalescent, or citron-coloured appearance. The pia mater was more or less injected, for the most part confined to the larger ramifications of the vessels; the membrane was easily removed by traction from the surface of the brain. The substance of the brain was natural, excepting in two cases, in which it was in- jected ; in the one at its central, and in the other at both its central and vertical portions; it was softened in four cases. There was little or no effusion in the ventricles; in one case the lateral ventricles ap- peared quite dry, as if wiped with a cloth. In the third stage, marked by an unusual disposition to drowsi- ness or stupor, rolling of the head, and a chewing motion of the under jaw, succeeded by convulsive movements, or rigidity of one or more of the extremities, followed by paralysis, the anatomical characters consist, essentially, in disorganization of the brain from softening of its tissue. The softening is sometimes general, but more often con- fined either to the cortical or central portions of the brain and cere- bellum. It may be to such a degree as to cause the brain readily to give way on slight pressure, or to render it quite diffluent. When cut into, the substance of the brain usually presents numerous red spots from effusion of blood. The pia mater is more or less injected, and its veins much distended. There is also effusion of serum in the subarachnoid tissue, and, to a greater or less extent, in the lateral ventricles.—Sometimes, however, these are quite dry. Cholera infantum, comparing the symptoms during the lifetime of the patient, with the appearances discovered after death, would ap- pear to depend, in its earlier stages, upon hyperaemia of the mucous membrane, with an augmentation in the size and activity of function of the muciparous follicles of the alimentary canal—inflammatory action being frequently excited, in the course of the disease, 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 238 DISEASES OF CHILDREN. of a heated, confined, and impure atmosphere, directly upon the skin. and indirectly upon the digestive mucous surface, at an age Avhen the latter is already strongly predisposed to morbid action, from the ef- fects of dentition, and from the increased development and activity of the muciparous follicles, which takes place at that period. It is an affection exclusively confined to the stage of infancy—few cases occurring beyond the second, and none beyond the fifth year. During twenty years, the deaths from cholera infantum, in Phila- delphia, 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 oc- curred 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 produc- tion of cholera infantum, is shown by the fact, that its prevalence is always in proportion to the heat of the summer—increasing and be- coming more fatal, Avith 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 AA'ill diminish, if not entirely suppress it. In those infants who have been prematurely deprived of their natu- ral aliment, or whose diet is composed of crude, indigestible, stimu- lating, or otherwise unwholesome articles, a heated and confined at- mosphere would appear to be alone sufficient for the production of the disease. But the extensive prevalence of the cholera of infant;-' during the summer months, is not dependent alone upon the influence of heat, but upon the combined influence of a high atmospheric tem- perature, and confined and impure air. Hence it is almost exclusively confined to the larger and more croAvded 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 al- leys, or in situations abounding with accumulations of filth. When it occurs in the country, which is rarely the case, it is almost exclu- sively 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 DISEASES OF THE DIGESTIVE ORGANS. 239 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 in- stance, to effect a permanent cure; while in most cases, in their com- mencement at least, little else is required to arrest the disease; and even at a later period, its effects are often evinced in the rapid im- provement 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, hoAvever. 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, In- 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, Avith milk, and immersed daily in a bath, warm or tepid, according as the temperature of the skin is deficient or increased, the disease may generally be arrested without the administration of any remedy in- ternally; excepting, perhaps, some cool, perfectly bland, slightly mu- cilaginous drink, as gum water, or, what we prefer, rennet Avhey, with a slight addition of gum acacia. Even in cases in which a removal to a healthy and airy situation in the country is impracticable, mucli benefit may be derived from carrying the patient frequently into the air, in any open and healthy situation in the neighbourhood of his residence, in a carriage, or in the arms; or where his residence is near a large river, by sailing daily in an open boat. At whatever period of the attack we may be called to the patient, his removal to the country should, if possible, be effected; or, if this be impracticable, as free an exposure to a pure and open atmosphere as can be accom- plished, should be insisted on. The apartment occupied by the patient should be kept strictly- clean and dry, and freely ventilated. His clothing, besides being perfectly clean and dry, should neither be too warm, so as to over- heat 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 flan- nel, 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 mattress, or on a blanket, folded and laid upon the sacking-bottom of the bedstead, or upon the floor of the crib, his body being de- fended by a light, loose covering. 240 DISEASES OF CHILDREN. 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 diarrhcea, the warm bath repeated daily, or even night and morning, and followed by gentle 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, ordinarily, very quickly arrest it. If there exists great irritability of the stomach, everything 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 sprinkled upon the tongue, will in general be retained, and speedily quiet the stomach, so that other remedies may be administered. When, however, 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.1 Dr. Cain, of Charleston, S. C, recommends creasote as a remedy admirably adapt- ed to check simultaneously both the vomiting and purging. When the vomiting is violent and frequent, the application of a few leeches to the epigastrium will be found decidedly advantageous. When everything else fails, we have very seldom been disappointed in re- moving the irritability of the stomach by the administration of the acetate of lead in solution.2 A blister may, at the same time, be ap- plied over the epigastrium for two or three hours, and then taken off and replaced by a bread-and-milk, or flaxseed poultice. 1 R.—Camphor, gj. a R.—Aq. purae, gj. iEther. sulphuric, gj.—M. Acetat. plumbi, gr. v. Acid, acetat. impur. njv. Sacch. alb. pur. giij.—M. A teaspoonful to be given every 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, a3 pecu- liarly beneficial. The tepid bath should be repeated night and morn- ing. A teaspoonful 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 fifth 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; Avith a wild and in- jected state of the eye; aversion from light, with delirium, or other symptoms of cerebral irritation, leeches should be applied to the DISEASES OF THE DIGESTIVE ORGANS. 241 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 alloAv 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. R.—Calomel, gr. iij. Cretae ppt. gr. xxxvj. Acetat. plumbi, gr. xij. Ipecacuanhae 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 com- posed exclusively of farinaceous articles with milk, we have, in gene- ral, found the inordinate discharges from the bowels to be quickly sus- pended, and replaced by natural, regular evacuations. As soon as the frequent Avatery discharges from the bowels are arrested, we are accustomed to suspend the use of the acetate of lead, continuing the calomel, prepared chalk, and ipecacuanha, in the same proportions as above, with the addition of half a grain to a grain of extract of hyoscyamus 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; blisters over the abdomen; anodyne injections, composed of thin starch, and a few drops of laudanum; light astringents, as kino, decoction of dewberry root or of 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 favourably of the effects of a solution of the tartrate of iron. The persesquinitrate of iron, may likewise be administered with good effect. In many cases, the sul- phate of quinia, in solution, besides exerting a beneficial influence upon the disordered condition of the bowels, 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 flatulence 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 irritability of the bowels is present, we usually direct the addition to the turpentine mixture of 3iij. tine, kino, or 242 DISEASES OF CHILDREN. 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 pulverized charcoal: we have usually administered it in com- bination with powdered rhubarb, ipecacuanha, and extract of hyos- cyamus. R.—Tartrat. Ferri, gr. xl.— R.—Carbon. Ligni, gj. to gij. Aq. purae, gij. Pulv. Rhei, J)ij. Syrup. Zingiber, gss.—M. Ipecacuanhae, gr. iv. ad xij. Dose, 20 to 40 drops every three hours. Ext. Hyoscyami, 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 re- moved, the full restoration of the patient's strength, and the preven- tion of relapse are only to be insured by the influence of a cool and pure atmosphere, a mild unirritating diet, and the most scrupulous cleanliness of his person and clothing. 4.—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 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 patient had an evacuation from his bowels, but even when he continued for any length of time in the erect posture. In slight cases, a very small portion of the mucous membrane is pro- truded beyond the rectum, with a sense of bearing down and smart- ing, that continues until the protruded membrane is returned, which may take place either spontaneously, or upon the slightest pres- sure being made upon it. In other cases, a considerable portion of the mucous membrane is protruded, in the form of a small, coiled, py- ramidal tumour, of a bright red colour, and is with difficulty returned —being firmly embraced by the sphincter. If it be allowed to remain protruded for any length of time, the tumour becomes often more and more swollen, of a darker red, or even purple hue, and inflammation, terminating in ulceration or sloughing of the protruded portion of the intestine, may rapidly take place. Occasionally, a considerable por- tion of the rectum may become prolapsed, and if allowed to inflame, can no longer be reduced, but subjects the patient to much inconve- nience 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 conncx- DISEASES OF THE DIGESTIVE ORGANS. 243 ions, in consequence of the imperfect development of the neighbour- ing organs, the slighter curvature of the sacrum, and the perfect mo- bility 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, the pres- sure being made in such a direction as shall tend to return the^ tu- mour within the sphincter; or the forefinger may be introduced into the gut, in order to remove the resistance of the sphincter, when gentle, well-directed pressure will generally cause the protrusion to pass within it. The utmost care should -be taken to effect the re- turn, every time, and as soon after the prolapsus occurs as possible. If the patient is affected with a disposition to bear down subse- quent to the reduction of the intestine, an anodyne enema, composed of a small portion of opium and three grains of acetate of lead, in- timately combined with a little thin mucilage, 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 sAvollen 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 preventing 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 those in Avhom there is a predisposition to catarrhal affections, or who are in a state of exhaustion, from long-continued diarrhoea, or other dis- ease. In such cases, hoAvever, astringent washes and injections of a tepid warmth will often produce a beneficial effect. R.—Quercus cort contus. gj. Aquae purae, Oij. Coque ad Oj. The decoction of oak bark 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 of ten grains to the ounce of water. A decoction of galls, with or Avithout 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 pos- 244 DISEASES OF CHILDREN. ture. In such cases, the intestine must be retained by a soft com- press, applied upon the anus, and supported by a T bandage. By this means, and the use of astringent injections, and a proper atten- tion to the state of the bowels, a radical cure may often be effected. But should the prolapsus continue still to recur, notwithstanding the employment of these means for a reasonable length of time, the pro- priety of an operation should be considered. The nature of the ope- ration will depend, in a great measure, upon the particular circum- stances of each case:—whether the removal of a portion of the pro- jecting folds of the skin, at the verge of the anus, as practised hy 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 Macfarlane; or the application of the ac- tual cautery to the margin" of the anus, as recommended by Mr. Ben- jamin Phillips, and practised by him on a child of three years of age, 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 arms, and of such a height that their feet may not touch the ground. 5.—Polypus of the Rectum. The attention of the profession was a few years since directed, by Dr. Stolz, of Strasburg, to the circumstance of the occasional occur- rence of a polypous tumour within the rectum of children. Polypus, in this situation, had previously 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, never- theless, 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 careful 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. In its commencement, polypus of the rectum in children is marked by few symptoms indicative of its presence. After it has attained some size, however, there is, most commonly, an exudation, or even a flow of blood by the anus, with some degree of tenesmus; the faecal matters are then stained, and sometimes bathed in and softened by pure blood, without any admixture of mucus. When the polypous tumour increases still more in size, the little pa- tient is usually 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 red, smooth tumour is protruded from the anus- varying in size, in different cases, from that of a cherry to that of a large hickory nut. The tumour 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 DISEASES OF THE DIGESTIVE ORGANS. 245 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 tumour is protruded, it is situated in the centre of the anus, and en- tirely without the sphincter, and appears at the first view 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 tumour, for a short distance within-sthe gut, to the inner surface of which it is attached. In some cases, in consequence of the shortness of the pedicle, or from its being attached very high up, the polypus does not protrude without the anus, and its presence can only be de- tected by the introduction of the finger, or by the speculum ani. When the polypus is of considerable size, the straining efforts to evacuate the bowels are often very Adolent, and attended, sometimes, with considerable pain, and often with the discharge from the anus of more or less blood. The little patient is usually affected with loss of appetite, paleness of complexion, and emaciation. When the polypus is finally protruded, it is found to be surrounded by a slight eversion of the loAver portion of the rectum. In one of the cases that came under our notice, the tumour, which was of a large size, separated, and came away spontaneously; 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 tumours were readily remo\red by ligatures—in the application of which there is not the least difficulty—without the occurrence of any severe or untoward symptom. In consequence of the readiness with which these polypi become spontaneously detached, after they have attained a certain size, it is probable that they are occasionally present without being detected— producing frequent bloody discharges, which, after remedies of vari- ous kinds have been tried without success, suddenly cease in conse- quence of the spontaneous expulsion of the tumour. Authors are not agreed upon the nature of these growths. Some consider them to be of a fibro-cellular structure,—others, on the con- trary, believe them to be always of a mucous texture. M. Stoltz sup- poses, that in many cases they are the result of frequently repeated prolapsus ani, a portion of mucous membrane, incarcerated within the ring of the sphincters, becoming congested, swollen, and, after a cer- tain period, pediculated. Such may, perhaps, be, in some cases, the manner in which the polypus is generated, but there are many excep- tions. Polypus of the rectum has repeatedly been observed in sub- jects who had neArer suffered from prolapsus ani; while, again, in some instances, the insertion of the pedicle in the mucous membrane of the rectum is too high up to admit of our explaining the production of the polypus in such cases according to the theory of M. Stoltz. M. Guersant has usually found these polypi to consist of a mucous sheath borrowed from the mucous membrane of the rectum, envelop- ing a spongy texture. In the number of L'Experience for June, 1843, Dr. Gigon has re- lated the history of six cases of polypus of the rectum in young chil- dren, three of which were under his own care, and three under that of his colleague, M. Brun. 246 DISEASES OF CHILDREN. The polypi in these cases were fleshy, of a red colour, resembling a large cherry deprived of its epidermis, and with a bleeding surface. They were suspended by a narrow pedicle or stalk. When cut in pieces they were found to be fleshy, of variable consistence, but usually having about the firmness of a portion of liver. To the naked eye they presented no appearance of vessels or of fibres; in one case, by the aid of the microscope, some traces of vascularity Avere discovered; while in another, in which the polypus had existed for along period, a Avell-marked fibrous disposition was detected. The pedicles were membranous, smooth, soft, and of a grayish co- lour. They were insensible, and had but little firmness. In one case the pedicle broke upon the application of the ligature, and in another was ruptured during the passage of hardened faeces. The pedicles were implanted within the anus, at a distance varying from a few lines to two inches or more. The rupture of the pedicle was often unattended with haemorrhage, which would, at first sight, seem to prove that the polypi were not vascular, and that the discharge of blood which so often accompanies the disease, comes from the rectum, and is produced by the irritation attendant upon the presence of the polypus. In one instance, however, after applying a ligature, blood no longer exuded, notwithstanding the continued presence of the tumour in the rectum, and in another, the excision of the pedicle was followed by severe haemorrhage, showing, conclusively, that it is to the vessels Avhich traverse the pedicle, that the sanguineous exu- dations and haemorrhages, by which polypi of the rectum in children are so commonly attended, are due. According to Dr. Gigon, the diseases with which polypus of the rectum may possibly be confounded, are dysentery, haemorrhoids, and prolapsus of the rectum. From dysentery it may readily be distinguished by the absence of the glairy matter in the stools, of abdominal pain, of fever, and, in fact of every symptom of the latter disease, excepting the presence • of blood in the evacuations, and, perhaps, frequent ineffectual calls to evacuate the bowels. From hemorrhoids it may be distinguished by the colour and gene- ral appearance of the tumour, and its place of insertion:—the age of the patient will also serve as a diagnostic mark. A careful examination will, as we have already remarked, very readily enable the practitioner to distinguish a protruding polypus of the rectum from a prolapsus of the intestine. In the application of the ligature for the removal of these poly- pous tumours, Dr. Gigon directs the child to be placed on his stomach, and made to strain, so as to protrude the tumour beyond the anus: it is then to be seized with a pair of forceps and drawn out still far- ther, so as to get at the pedicle, which is readily effected in conse- quence of the lax condition of the mucous membrane in children. It is often somewhat difficult to distinguish Avhere the pedicle ends and the mucous membrane commences, in consequence of the colour of both being the same. It is necessary, hoAvever, to pay some atten- tion to this, in order that as little as possible of the mucous mem- DISEASES OF THE DIGESTIVE ORGANS. 247 brane may be included in the ligature. A waxed ligature is to be passed around the pedicle, but not drawn too tightly, for fear of rup- turing it. It is better, after the ligature is properly applied, to return the whole into the rectum, without dividing the pedicle be- Ioav the ligature, as in one case, which fell under the notice of Dr. Gigon, in which excision was practised, a troublesome haemorrhage followed. The tumour, in general, comes away on the second or third day after the operation, which is unattended with pain, and when properly performed, is not liable to be followed by any acci- dent. Dr. James Syme (London and Edinburgh Jour, of Med. Science, July, 1845,) describes a form of polypus of the rectum, of which he has met with only one case in children beyond the ninth or tenth year. The polypus is extremely soft and vascular, of a florid red colour, and either of a cylindrical form, two or four inches in length, or re- sembling somewhat a strawberry, Avith a connecting footstalk, two or three inches long. It seldom protrudes except when the bowels are evacuated, and then admits of ready replacement, though not with- out occasional haemorrhage, which may be of considerable amount. A somewhat similar form of the disease is described by Dr. Bour- geois in the Bulletin General de Therapeutique Med. et Chirurg. In the removal of the tumour, Mr. Syme has always employed the liga- ture, and though the soft texture readily gives way when the thread is drawn, bleeding has never occurred in a single instance, nor any other symptom in the least degree disagreeable. 6.—Invagination of the Intestines. Intestinal invaginations or intussusceptions, that is, the passage of one portion of the intestine within that above or below it, are often met with in children who have died of various diseases, and appear to take place in the act of dying, from some convulsive or irregular movement of the muscular fibres of the intestinal canal. These in- vaginations give rise to no symptoms during the lifetime of the patient, and after death are reducible with perfect ease. Occasion- ally, however, 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- siA'e tumefaction of the abdomen, with tenderness upon pressure, often repeated paroxysms of acute pain, vomiting of food and drinks, and subsequently of faecal matter, Avith coldness of the extremities; the case terminating, sooner or later, in death. The cause of the obstruction to the onward passage of the faeces in cases of invagination, as Avell as of the other symptoms by which they are ordinarily attended, is, in all probability, the occurrence of inflammation in the intestine, at the part where the invagination has occurred, in consequence of which, an adhesion of the peritoneal sur- 248 DISEASES OF CHILDREN. faces that are brought into contact, takes place, and in this manner, not only is the caliber of the intestine narrowed, but its regular peri- staltic 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 ileum. Cases are related in which the invaginated portion has sloughed off, and been discharged by the rectum; this seldom occurs, howeArer, in children. The disease is, very generally, fatal; in no instance, that has fallen Avithin our own observations, has a case, in which the symptoms con- sequent upon invagination were present, terminated favourably. The appearances exhibited upon dissection, are those of inflamma- tion of the mucous membrane of the intestines, and often of their peritoneal coat. At the invaginated portion, the mucous surface is often highly inflamed, of a dark red colour, and thickened, and co- vered frequently 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 re- peated—leeches and Avarm 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 of restoring the natural condition of the intestine, pre- vious to the occurrence of inflammation. We know of no instance, however, in which this means has been crowned with success;—after the occurrence of inflammation it will necessarily fail, and may even be productive 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 hardened and impacted faeces, by the retention of which we have reason to be- lieve 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. Although a better acquaintance with the pathology of the diseases of early life, especially those of the digestive organs, has shown that intestinal worms play a much less important part in their production than was supposed, it nevertheless still re- mains a matter of dispute to Avhat extent they are to be considered as the causes of certain phenomena, that are very generally, but by no means constantly, associated with their presence. While by one party, the existence of Avorms is deemed invariably detrimental to health; by another they are regarded as always the effect, and not the cause of disease; while a third, with Dr. Rush, DISEASES OF THE DIGESTIVE ORGANS. 249 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 catenation of symptoms, which indicate positiA-ely the existence of worms in the intestines, independently of their pre- k sence in the evacuations. They have repeatedly been discharged during life or discovered after death in cases in which their presence was not suspected. One species in fact, the tricocephalus, 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 lifetime 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 eause of severe irritation;—but much less frequently than is gene- rally supposed. It is important to recollect, that even when the pre- sence 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. The worms that infest the intestines are, the tricocephalus dispar, the oxyuris vermicularis, the ascaris lumbricoides, and the bothrioce- phalus latus. The tricocephalus dispar—the trichuris or long thread-worm 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 indi- viduals. The mouth is at the capillary extremity, which is always found adhering to the surface of the intestine. This worm is met Avith in the large intestines—most commonly in the caecum—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. 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 Avith a rounded mouth. It is found in the large intestines, and parti- cularly 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 lum- bricoides 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. 250 DISEASES OF CHILDREN. The bothriocephalus latus—the tcsnia lata, or broad tape-worm of many writers, is thinner, and generally wider than the common taenia; it is often twenty feet long, and may greatly exceed this length, reach- ing, in some cases, it is said, to sixty, and in others to upwards of a hundred feet. (Bremser, Robin, Frank, Gebze, Sibbargarrde.) It is of a dirty white colour; and becomes grayish when immersed in alcohol. It has a large head, with two lateral grooves, which are considered by Rudolphi to be the organs for the absorption of nou- rishment. 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 in some parts of France. The ttenia solium, or common tape-worm, 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 some- times be discovered a small mouth, surrounded by a circle of five hooks. The joints that separate from the posterior extremity of the taenia so- lium have received the denomination of cucurbitani. This worm in- habits 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 faecal discharges is no evidence, as Bremser remarks, 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. 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. It is said by Fortassin to occur most frequently in persons engaged in preparing materials from fresh animal substances. It is unnecessary to enter into an examination of the several theories that have been advanced to account for the production of worms in the intestinal canal of man and other animals—whether they are pro- duced by ova received from without, or are the result of spontaneous 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, Switzerland, and in cer- tain districts of Germany and Russia, they are stated, by Dauquin and Bremser, to be of frequent occurrence among nearly all classes of society. According to Mr. Marshall, deputy inspector-general of hospitals, Europeans are very liable to worms in India, and Africans even more so. Few post-mortem examinations are made without dis- covering them. One negro passed forty lumbrici in a day, and in the course of seven days, two hundred. 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 prevalence of different DISEASES OF THE DIGESTIVE ORGANS. 251 species of worms; thus, in Switzerland, Poland, Russia, and in some parts of France, the bothriocephalus latus is most commonly met with; Avhile in Egypt, Holland, Germany, and in the greater part of France, Italy, and Sweden, the taenia solium is the most frequent worm. (Ru- dolphi, 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 Wept 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 autumn, than during the other seasons of the year. The poor, likewise, who are badly nourished and lodged, and filthy in their persons and habi- tations, are reputed to be more liable to intestinal worms, than those in comfortable circumstances 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 pre- \'alent 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 true; for it has been invariably found that the same causes which dis- turb 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, accompa- nied with the presence of worms, often in considerable quantities. Of the real nature and cause of this fever we have no means of forming a positive judgment; Ave think it probable, however, that it was one connected with disease of the alimentary canal; one of the conse- quences, rather than the cause of which was a discharge of Avorms already existing. Andral met with Avornis—the ascarides lumbri- coides and trichocephali—in only a very small number of the autop- sies performed by him in cases of death from fever; they were very numerous in one case, but very few in the others; he deemed them merely an accidental complication of the disease. In one instance, they coincided with most of the symptoms characterizing mucous fever. In the intestines of most of those who died of the epidemic mucous fever of Gottingen, Roederer and Wagler found a great num- ber of worms; and the same, according to Thibault, was observed in a species of mucous fever Avhich, in 1836, prevailed, in conjunction with the cholera, at Naples. Rilliet and Barthez state, (tome iii. 605,) that in the greater number of cases, they found the mucous membrane in contact with the lum- bricoides in a perfectly healthy condition. The worms were enve- 252 DISEASES OF CHILDREN. loped in a viscid mucus, or mixed with faecal matter precisely simi- lar to that found in other parts of the intestinal tube, and in subjects unaffected with worms. In some cases a fine Arascular injection Avas detected, similar to that observed in erythematic enteritis; a dimi- nution in the consistence of the mucous membrane Avas very rarely met with. As these slight alterations of that membrane existed only at the point where a number of lumbrici Avere collected, and nowhere else; it is inferred that they were the result of the local irritation pro- duced by the worms. From the frequency of worms in cases of intestinal inflammation, Broussais considered them as most generally the product of the altered condition of the intestinal mucus, and the heat, of greater or less in- tensity, which results from gastro-enteric inflammation. 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 Avith every pos- sible 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, Avhether 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, by the observations of Sarconi, that in cases of epidemic mucous fever, worms are not always present. As remote causes of worms, the followingare generally enumerated; —too rapid growth; a scrofulous habit; a sedentary inactive mode of life; habitual exposure to a damp, confined atmosphere; indulgence in crude unripe fruits; the abundant use of fat, farinaceous, and sac- charine articles of diet, and of fresh milk. Some attribute them to the Avant of a sufficient quantity 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 intes- tines, excepting so far as it has the tendency to disorder or interrupt the functions of the digestive organs. When, from any cause, digestion becomes impaired, 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 increased irritability of the intestinal mucous membrane, generally associated with a disordered state of the digestive function, that they are then apt to give rise to a variety of morbid phenomena. Worms so frequently exist in early life, without any—even the slight- est—indication of disease, that we can only consider them as produc- tive of injury from their numbers, or from some co-existing patholo- gical condition of the alimentary canal. Though worms may occur at any period of life, they are most com- monly met with during infancy and childhood; more particularly the oxyures and lumbricoides. It is stated by J. Cloquet, that at La Sal- petri&re, the hospital at Paris for the reception of patients advancedin DISEASES OF THE DIGESTIVE ORGANS. 253 life, worms are scarcely ever met with in the bodies of those Avho die; Avhile in the Foundling Hospital of the same city, they are very com- monly present, and often in great numbers, in the same body. The number of lumbricoides that are occasionally discharged by children, or are found in their intestines after death, is often almost incredible. Eighty lumbricoides 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 lumbri- coides 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 Avith worms are said to be usually of a pale or salloAv 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, hiccough, and gnaw- ing pains of the stomach or intestines; their breath is foul; their tongue more or less coated; their appetite is irregular and capricious, often voracious; and their bowels are either affected with costiveness or Avith diarrhoea. Whatever kind or amount of nourishment is taken, they are generally thin and pale, and of an indolent and languid habit, Avhile their sleep is often disturbed by frequent startings and grinding of the teeth. So far, however, from any or all of these symptoms being diagnostic of the presence of worms in the intestinal canal they have been observed in numerous cases in which, after death, not a single worm was detected. According to Rosen, one of the most certain indications of worms, is the relief eKperienced by the patient after having discharged portions of them, or after taking a glass of cold water, Avhile according to Monro, the most positive indication is a dilatation of the pupils, especially when the dilatation is unequal. We are furnished by medical Avriters with a long list of sympathetic affections, all of which are said to have been repeatedly produced by the irritation of intestinal worms, and to cease on 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, hy- drophobia, 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, the removal of an irritation of the intestines totally inde- pendent of the presence of worms. 254 DISEASES OF CHILDREN. A number of cases are related, in which the mostviolent paroxysm? 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 bronchi, and caused the death of the patient. By many writers worms are supposed, in some cases, to destroy life, by perforating the coats of the intestine; Rilliet and Barthez, to our surprise, are inclined to admit the correctness of this opinion. 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 though a perfora- tion of the intestine, and apparently so firmly fixed in the opening as to be unable to proceed further. In all these cases a close examina- tion 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. Rodolphi declares that they possess no apparatus for effecting a passage through any continuous mem- brane; and Andral remarks, that there is no well-authenticated in- stance on record of such an occurrence. How far, in any case, the perforation may be the result of an inflammation, followed by soften- ing or ulceration, excited by the presence of worms in the intestines, is a question difficult of solution. So far as our OAvn observations ex- tend, we should unquestionably assume the negative. With Dr. Evan- son, we believe that worms may exist at the same time with intesti- nal inflammation or ulceration, as these affections are common in those children who are most subject to worms; and, should the intestines be perforated 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, whe- ther they are, in any degree, concerned in the production of the morbid phenomena under which the patient labours. Both of these circumstances, 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 dis- charge of worms occasionally produced by them, exhibits no improve- ment, but sinks, more or less rapidly, into a state of suffering and debility, the termination of which is death. We are to recollect, that almost every symptom said to indicate the presence of worms in the intestines, may be produced by irri- tation of the alimentary canal, and may occur without their exis- tence; and, that even in those cases in which the presence of worms is established by their appearance in the discharges, there is no cer- tainty that they are the cause of the symptoms which exist, or. that they are not a mere coincidence. In every supposed verminous case, therefore, we would advise DISEASES OF THE DIGESTIVE ORGANS. 255 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 generally. We have been in the habit of pursuing this plan for a number of years, and have seldom been disappointed in promptly and effectually 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 subacute 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 spe- cies of confectionary should be interdicted. It will frequently be found difficult, at first, to induce children who have been indulged with all kinds of improper food to restrict them- selves 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. The child should be allowed and encouraged to exercise in the open air, for several hours every day; and, as far as possible, a situ- ation should be made choice of for this exercise, in which dryness is combined with perfect purity of 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 re- sulting, 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 symp- toms present indicate that the latter are in a state of severe irrita- tion, or of inflammation, whether acute or subacute, it will be neces- sary, before resorting to the administration of any internal remedy, 256 DISEASES OF CHILDREN. to allay the irritation or inflammation, by leeches, fomentations, and cool mucilaginous drinks. There are feAv cases in which, however, Ave may not venture upon the administration of calomel, either in a full dose, followed, in a few- hours, by a portion of castor oil, or in smaller and frequently re- peated doses, combined Avith ipecacuanha and extract of hyoscyamus. Three grains of calomel, with half a grain of ipecacuanha and the same quantity of hyoscyamus, 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, calomel, jalap, and scammony, given at first in a full dose, and repeated subsequently, in small alterative doses, on every alternate night, at bedtime, suc- ceeded, on the following morning, 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 in- flammation, we have found this to act very favourably. The article, however, from which we have derived the most deci- dedly beneficial effects in verminous cases, is the spirits of turpentine. It may be given when there exists considerable irritation of the ali- mentary canal, or even subacute 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 beneficial action upon the digestive organs, and to aid in restoring them to a healthy condition. The turpentine maybe 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.1 It is generally recommended to be given in much larger doses, from half a drachm to a drachm, combined with or followed by castor oil; we have preferred, however, smaller doses; either from fifteen to 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 anthel- mintics it is the one, in favour of the efficacy of which the greatest amount of evidence can be adduced. ! R.—Mucilag. G. acaciae, gij. Sacch. alb. gx. Spir. 33ther. nitr. giij. Spir. terebenth. rec. giij. Magnes. calcinat. Qj. Aq. menthae, gj.—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, especially the lumbricoides and oxyures.2 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 honey or syrup, and to pre- DISEASES OF THE DIGESTIVE ORGANS. 257 vent any portion from being spilled upon the lips, face, breast, or arms of the patient. R.—Spicular. Dolichi, gj. Or, R.—Spicular. Dolichi, Qj. Mellis vel sacchari liquid, impur. Syrup, cort. aurant. gj.—M. f. q. s. ut fiat electuarium. electuarium. Dose.—A teaspoonful to be given every Dose.—A teaspoonful to be given three morning, fasting, for three successive times a day, for two or three succes- days, and then followed by a brisk sive days, and then followed by a cathartic. purgative. The oleum chenopodii is a remedy in considerable repute with Ame- rican practitioners; we have employed it in some cases with decided advantage. R.—01. chenopodii, gj. Sacch. alb. pur. Gum. acaciae, aa gjss.—M. dein adde Aq. menth. sativae, gijss. Dose.—A teaspoonful every three hours, for two days in succession, to be followed then by a dose of castor oil. 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 ac- companied with febrile excitement. The following formula is strongly recommended by Bremser, in cases of lumbricoides: it has been employed by Eberle in several cases, with complete success. He considers, that when it is exhibited to such an extent as to produce frequent and watery evacuations, it does far less good, than when so managed as to procure three or four consistent stools daily. R.—Sem. Santon. Fol. tanaceti vulgar, contus. aa gss. Rad. valerian, pulv. gij. " Jalapae " gjss. Sulphat. potassae, gij. Oxymel. sciUee 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 ali- mentary canal, favourable to the production of worms. An ounce of the helminthocorton, 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 diar- 17 258 DISEASES OF CHILDREN. rhoea, arising from mere debility of the digestive organs, and a vitia- tion of the secretions of the bowels. Common salt is, perhaps, one of the best anthelmintics we possess; it has often succeeded in the destruction of Avorms when other reme- dies have failed. It was a favourite remedy with Dr. Rush, and whenever we have been able to induce children to take it in a suffi- cient dose, we have never been disappointed in its effects; an ordi- nary-sized teaspoonful, dissolved in a wine-glassful 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 Marilandica, the green rind of unripe walnuts. Those we have enumerated above are, perhaps, among the best and most successful we possess. Several of the German practitioners have recommended the ethereal tincture of the buds of the male fern, (polypodium filix mas,) as a most effectual remedy in cases of intestinal worms. Peschier, of Geneva, is the discoverer of this tincture; his brother asserts that he has cured 150 cases of lumbricoides, tricocephali, 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. Recently the seeds of the common garden pumpkin have been re- commended as an effectual anthelmintic, especially in cases of tenia. Half an ounce of the recent seeds, beat up into a pulp with sugar, may be given every one, two, or three hours, according to the age of the child, the urgency of the case, and the effects produced. After the removal of the worms, some light bitter infusion, or a chalybeate 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 sesquichloride of iron by itself, or in combination with an equal quantity of the tincture of aloes, as recommended by Stokes; the dose of this combination is twenty-drops, three or four times a day. The carbonate of iron was a favourite prescription of Dr. Rush, in the dose of five to ten grains to a child a year old, every morning. Dr. Dewees considers a combination of equal parts of carbonate of iron and common 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 disposition to the generation of worms. The powders should be given in syrup or molasses, in the morning, fasting, for twelve suc- cessive days. In cases in which children are infested with oxyures,the same gene- ral 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 DISEASES OF THE DIGESTIVE ORGANS. 259 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,1 aloes,2 an infusion of helminthocorton,3 lime water and milk, camphor,4 a solution of sulphate of iron,5 or a solution of asafoetida in milk.6 1 R.—Spir. terebenth. rec. gj. ' R.—Fuc. helminthocorton, gj. Lactis, giv.—M. Aquae, Oj. Or, R—Spir. terebenth. rec. gj. Boil to one-half. Vitell. ovi, * R.—Camphor, gr. xv. Aquae, giv.—M. Olei olivae, giv.—M. " R.—Decoct, aloes, giij. s R.—Ferri sulphat. gj, Lactis, gj.—M. Aquae, giv.—M. Or, R.—Gum. aloes, gss. 6 R.—Asafoetidae, JJij. Lactis, giv.—M. Lactis, giv.—M. Dr. Schultz speaks highly in praise of the quassia amara, in tho form of injection as a means of effecting the discharge of these worms. He prepares each injection with four drachms of quassia to four ounces of fluid. A bougie smeared over with strong mercurial ointment, and intro- duced into the rectum, will often prove successful; while the precipi- tated sulphur, taken for a few mornings in succession, is said by Von- vert to be a most efficacious means for the destruction of the ox- yures. The complete removal of these worms is a work of no little difficulty. They are surprisingly productive, and even after thousands have been discharged, they are found, within a very short period, to have re-ac- cumulated 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, however, succeed in preventing, finally, their reproduction, by the use of purgatives com- posed of blue mass, aloes, Venice turpentine, and extract of hyoscya- mus, and the occasional use of either of the enemata just enumerated. R.—Mass. f. pil. hyd. Terebenth. Venet. Aloes, gr. aa xxxvj. Extract, hyoscyami, gr. xx.—M. f. pil. 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 insuppor- table titillation and itching about the anus. This is generally expe- rienced to the greatest extent towards evening, or soon after the child is put to bed; often preventing sleep, and producing a considerable 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. 260 DISEASES OF CHILDREN. 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 generally 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 groups of morbid phenomena described by the leading writers on the affections of children, as distinct diseases, are, in fact, the result of different grades of inflammation, seated in the mucous membrane of the small intestines:—this is unquestionably true, as has been ably pointed out by Drs. Cheyne, Marsh, Mackintosh, and Stokes, of the intermittent or worm fever of infants, and of the tabes mesenterica in its most usual form. 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 accompanied by augmented heat 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 in- flammation affects the ileo-caecal valve, the consequent tumefaction may prevent, or so far obstruct the passage of the faeces as to give rise to faecal 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 more or less fluid, of a green or yellow colour, and sometimes bloody. Some degree of tension of the ab- domen, with pain, or at least tenderness upon pressure, are very common 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 over the surface of the abdomen. The tongue is in some cases red at its point and edges, dry, and coated on its upper surface with a layer of white or yellowish mu- cus; the redness and dryness of the tongue, however, are most marked in cases of gastro enteritis; in those of simple enteritis, the tongue is in general moist, and often of its natural colour. There is commonly more or less thirst; but the desire for cold drinks is not so evident as in the acute febrile affections. Notwith- standing the increased heat and dryness of the skin, and the aug- mented thirst, a decided febrile reaction is seldom met with in cases of enteritis occurring previous to dentition; subsequently, however, DISEASES OF THE DIGESTIVE ORGANS. 261 the disease is often attended with fever of a remittent form, with evident exacerbations towards evening. There is also considerable and rapid prostration 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 de- creases; the skin assumes an ashy hue, and becomes cool, particu- larly at the extremities, which are often decidedly cold; great ema- ciation ensues, the cheeks become hollowed, the eyes sunken, and the face wrinkled and contracted; which, when the teeth are not yet de- veloped, gives to it the appearance of premature old age. The whole expression of the countenance 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 tempe- rament, but it may occur without this predisposition to glandular af- fections, in consequence, as Dr. Stokes has pointed out, of the propa- gation of disease along the course of the lymphatics, from the mu- cous surface of the intestines, to the mesenteric ganglia. In the great majority of instances, tabes mesenterica is, in fact, the result of chronic or subacute enteritis. This connexion 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 inflammation. This is not a matter of merely theoretical nicety, but has a very important practical bearing—the usual treat- ment pursued in cases of tabes mesenterica being one rather calcu- lated to augment, than 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 me- senteric 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 pa- tient, in a state of extreme marasmus, dies from exhaustion; occa- sionally, however, the disease assumes an acute form, and death occurs at an early period, from violent peritonitis, the result of a per- foration of the coats of the intestines from ulceration or softening. It is important to bear in mind the fact that in cases of enteritis, irritation of the brain, or of the lungs, is very liable to take place; and when these 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 should be well understood; for while the secondary af- fection is not to be overlooked, lest it run into inflammation of the 262 DISEASES OF CHILDREN. 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 af- fection is with great difficulty effected. The pathological appearances observed after death in cases of enteritis, are various. It is seldom that the inflammation is seated at the upper portion of the intestinal tube; in a few of the milder cases, however, it is confined to the duodenum, when the free edges of the valvulae conniventes will be found more or less intensely red- dened. In the more violent cases of enteritis it is in the mucous membrane of the ileum, particularly in the neighbourhood of the ileo-caecal valve, that the marks of inflammation are most usually detected. There is either a uniform redness of the membrane, or the redness occurs in irregular patches, of greater or less extent, in- differently situated, either in a depending or non-depending portion of the tube. These patches are generally accompanied with tume- faction 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 dissolved appearance. In many cases, the intestinal mu- cous membrane is studded with flakes of curd-like matter, generally of a yellow or greenish colour; these flakes adhere to the surface of the membrane, and cannot be separated without a slight degree of force. The muciparous follicles of the intestines are often enlarged; occasionally they are also red, and frequently in a state of ulcera- tion. The inflammation may occur also in the isolated follicles, or in the follicular plexuses. In the first case the follicles are elevated, of a rounded appearance, feeling, when the finger is passed over them, like small, soft granu- lations, which differ in size from the head of an ordinary pin to that of a hemp seed. They are usually pale and more transparent than the rest of the membrane, and are often surrounded by a small red areola. When the inflammation affects the patches of Peyer, they become swollen, red, and soft. In some cases their surface presents small red projections, in others, it is unequal and rugous. Occasionally some of the areolae remain more depressed and broader than others, presenting the appearance of ulcers. The intermediate partitions may become so far developed in a single direction as to resemble valves imbricated from above downwards. (Rilliet and Barthez.) In chronic cases, dark purple or slate-coloured patches or striae, upon some portion of the intestinal mucous membrane, are not un- common. 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. The ulcerations, as well as the softening, may implicate the entire thickness of the in- testinal coats, giving rise to perforations, with escape into the peri- toneal cavity of the contents of the bowels: in such cases, death quickly ensues, in consequence of the occurrence of acute peritonitis. Billard, B6clard, Cloquet, and others, describe a species of gangre- nous ulceration, as one of the terminations of enteritis; thus certain DISEASES OF THE DIGESTIVE ORGANS. 263 ulcerations of the ileo-caecal region, occasionally exhibit the same black, soot-like edges, that occur in ulcerated aphthae of the mouth, or some circumscribed points of the mucous membrane become changed to a grayish pulp, which, on separating, gives place to an ulcer with 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 in- testines, and prevent an escape of the contents of the bowels. We have never met with the particular lesion here referred to. Ulcerations are extremely common, in all protracted cases; they are sometimes very numerous throughout the whole of the ileum, and vary in diameter from that of a split pea, to that of a sixpence. The mesenteric glands are frequently enlarged, and very vascular, and, in chronic cases, are often in a state of suppuration, or con- verted 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 im- pure and confined state of the atmosphere. They are the same with those usually noted as productive of diarrhoea in infancy and child- hood. In fact, in a large number of cases, the disease commences with an attack of ordinary diarrhcea, which, being neglected or mis- managed, tenderness or pain of the abdomen, heat and dryness of the surface, with the other symptoms of intestinal inflammation, are successively developed. 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. The warm or tepid bath is an all-important remedy; no- thing in all the inflammatory affections of the alimentary canal pro- duces so soothing and tranquillizing an effect. 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, ac- cording 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, especially in children. Few cases occur, in which a moderate application of them will not be proper and beneficial; and whenever the pain, heat, and tension of the ab- domen 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 cau- tious, in no instance, to carry the depletion 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 dis- 264 DISEASES OF CHILDREN. ease will, in a great measure, depend upon the early employment of a sufficient number of leeches. To allay the diarrhoea, which, in numerous cases, is a prominent and very troublesome symptom, many physicians recommend the em- ployment of opiate injections; but in acute cases, we are by no means convinced of their propriety. We have, however, derived advantage from the exhibition of minute doses of calomel, ipecacuanha, extract of hyoscyamus, and acetate of lead in combination.1 This we have found not only to arrest the diarrhcea, but to have a beneficial effect upon the intestinal disease, allaying pain and irritation, and producing natural and regular evacuations. If, from any cause, this combination should be considered as unadapted to the case, the acetate of lead in solution may be given by the mouth, or in the form of enemata. 1 R.—Calomel. Ipecacuanhae, aa gr. ij. Ext. hyoscyami, gr. iv.—vj. Acetat. 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 synapised pediluvia, or sinapisms to the extremities, will generally be produc- tive of good effects. In chronic cases, the warm bath, blisters to the abdomen, the in- ternal exhibition of calomel, ipecacuanha, and extract of hyoscya- mus, with the addition, when diarrhoea is present, of the acetate of lead; and when the discharges are thin and offensive, the use of tur- pentine, are the remedies from which the greatest amount of relief will be obtained. 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 sup- porting the patient's strength, which, in cases of chronic enteritis, is very apt to be greatly prostrated. By some practitioners, it is con- sidered beneficial to dress the blisters upon the abdomen with mer- curial ointment, or to apply this by friction over the abdominal sur- face in cases where blisters have not been applied. When a state of convalescence has been procured, the skin be- coming soft and moist, the tongue clean, the stools more regular and natural in appearance, with a disappearance of the tenderness and tumefaction 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 ren- dering a relapse less liable to occur. 10—Colitis.—Inflammation of the large Intestines.— Dysentery. Inflammation of the large intestines seldom occurs independently of some degree of inflammation of the small intestines, and is occa- sionally accompanied with more or less gastro-enteritis. It is chiefly distinguished from ordinary enteritis, by frequent small discharges DISEASES OF THE DIGESTIVE ORGANS. 265 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 simple diarrhoea, the discharges being at first feculent, but soon be- coming 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 even- ing exacerbations, is often present, with redness of the tongue and increased thirst: nausea and vomiting are occasionally observed, but are seldom frequent or severe, unless the stomach is the seat of some degree of inflammation. The discharges from the bowels be- come, 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 fol- lowed by tormina. There is seldom any appearance of feculent matter in the stools, though occasionally it is passed in hardened masses, of various sizes, with blood and mucus. If the disease is not arrested, the anus becomes red, hot, and ex- ceedingly painful—and the abdomen hot, swollen and tympanitic, and often affected with severe pain, or it 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 all the symptoms of chronic intestinal disease. The mouth often becomes covered with aphthae, which also occasionally appear about the verge of the anus. Colitis may terminate in death at an early period, from the inten- sity of the inflammation, but in general it runs a protracted course, and the patient sinks finally 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, and with friability or softening of the tissue, at the part where they are situated. The surface of the colon and rectum are occasion- ally covered with filaments, varying in size, of a curd-like matter. Enlargement, inflammation, and ulceration of the muciparous glands and follicles are very commonly met with; gangrenous ulceration is occasionally present, and, in chronic cases especially, thickening, with a dark purple or a slate colour, of the mucous membrane of the colon or rectum, in patches of 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, to be highly vascular, and covered with granulations of a yellow, or dirty yellow colour, as if from a coating of wax; in several, ul- cerations had taken place; these ulcers were disposed in patches, with well-defined edges. In cases that terminated favourably, a quan- tity of yellowish, branny scales, were seen floating in the discharges from the bowels, like minute portions of wax from honey-comb. 266 DISEASES OF CHILDREN. Colitis would appear, in the majority of cases, to be the result of sudden transitions of atmospherical temperature, particularly the sudden change from warm and dry, to cold and damp Aveather. It is most prevalent during the latter part of summer, or the com- mencement of autumn, when the days are hot, but the nights chilly and damp. It is apt to prove endemic in unhealthy localities, espe- cially those favourable to the production of intermittent and remit- tent fevers, and often prevails epidemically with fevers of a catarrhal character. A few days of cool, rainy weather, occurring in the sum- mer, will often cause the prevailing bowel complaints of children to assume a dysenteric character. Colitis may, however, be produced by the same causes which give rise to inflammation in other portions of the alimentary canal. In the treatment of colitis, the same general directions are applicable as in the other intestinal inflammations. All solid, stimulating, and indigestible food should be avoided. The patient may be allowed 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 but- termilk has been found advantageous, in many cases of dysentery in children. The warm bath and warm fomentations or cataplasms to the abdomen, are equally beneficial here as in cases of enteritis. The patient should be kept at perfect rest in a recumbent posture, and not allowed to rise every time he feels an inclination to evacuate his bowels; nor should he be permitted to sit for a long period, in- effectually straining, when, probably, only a drop or two of bloody mucus is discharged. Leeches should be applied, along the course of the colon, in numbers proportioned to the violence of the disease, and the strength and age of the patient, and repeated, if, after their first application, the symptoms remain without considerable abate- ment. 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 in children; we have occasionally found the haemorrhage produced by them continue for some time after their removal, and to be with difficulty controlled. In cases in which symptoms of gas- tritis 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 diversity of opinion among practitioners. To the common practice of giving small and repeated doses of castor oil, either with or with- out an addition of laudanum, we are decidedly opposed; we have seen much injury result from it, and cannot understand the princi- ples 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 hyoscyamus, agreeably to the plan pursued by many of the Ger- DISEASES OF THE DIGESTIVE ORGANS. 267 man physicians, forms an admirable addition.1 The relief derived from this combination is often prompt and considerable, while a fa- vourable change is produced, in a very short time, in the character of the discharges. 1 R.—Calomel, gr. iv. ad xij. Ipecacuanhae, gr. iij.—iv. Ext. hyoscyami, gr. iv.—vj. Cretae ppt. gr. xxxvj.—M. f. 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 of lead, with or without laudanum, are calculated to allay the tormina 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 prepa- rations, in the form of enemata, in the diseases of children. Expe- rience 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 quantity given by the mouth; the same fact has been noticed by other practitioners. 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 hyoscyamus, 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 dis- ease. The nitrate of silver, in from a sixth to a quarter of a grain doses, made into a pill with extract of gentian, and repeated every two or three hours, will often be found to produce prompt relief at this pe- riod of the disease. In chronic cases of colitis, the same treatment is applicable as in 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, New York, an infusion of white oak bark, blackberry-root, and yarrow, in milk, with the addition of sugar,1 was found, according to Dr. Cogswell, to be productive of the best effects. The persesquinitrate of iron is also spoken of by Williams and others as a useful remedy, in cases of dysentery occurring in children. 1 R.—Cort. querci alb. Rad. Rub. villosi, aa. gss. Fol. achill. millefol. giij. To be boiled in Oj. of milk. A dessert-spoonful to be given frequently. 268 DISEASES OF CHILDREN. CHAPTER VI. PERITONITIS — INFLAMMATION OF THE PERITONEUM. Inflammation of the peritoneum may occur 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 effusion; a coating of coagulable lymph, either in the form of flocculi or membranous shreds; adhesions between the intestinal convolutions and other abdominal viscera, some slight and recent, and others very firm and apparently of long continuance; or tuber- cular granulations of the peritoneum, that we are perhaps to include peritonitis among the most common and fatal of the diseases to which the foetus in utero or the child immediately after birth is liable. Peritonitis, in an acute form, is by no means a very frequent dis- ease of children. It may, however, occur as a primary affection, but is more frequently developed in the course of some other disease. It is indicated by tension and pain of the abdomen, more or less acute, and invariably increased upon pressure; restlessness, consti- pation, 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 insupportable. The child lies upon his back with his knees drawn up, and exhibits extreme restlessness;—his cries are often constant and acute. The abdomen is commonly tense and swollen, rising in a point towards the umbilicus. The tension is sometimes perfectly circum- scribed, and upon palpation a painful tumour is detected, without any change in the colour of the skin, and presenting a dull sound upon percussion. (Rilliet and Barthez.) 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 considerable febrile excitement. The pulse is generally very small and frequent, and there is always great prostration of strength, with a contracted and suffering expression of the countenance, and not unfrequently considerable dyspnoea. As the disease advances, there is generally frequent eructation or vomit- ing—coldness of the surface, particularly at the extremities, and often a livid or dusky appearance of the face. Peritoneal inflammation, occurring in children, requires the closest attention and tact on the part of the physician, to distinguish it from inflammation of the intestinal tube, with which it is often complicated. Peritonitis may be distinguished from pleurisy by the absence of the physical signs of the latter; and from severe paroxysms of colic, by the pain being continued, and increased upon pressure, while, in cases of colic, the pain is remittent, and is very generally diminished by pressure upon the abdomen. DISEASES OF THE DIGESTIVE ORGANS. 269 In acute peritonitis, death often occurs at a very early period, the patient appearing to sink from exhaustion. In many cases, however, the peritonitis of children assumes a chronic form, when it constitutes probably one of the most insidious affections of early life, its real cha- racter being very often overlooked, and a most injudicious course ot treatment pursued. , ■, j ij In chronic peritonitis there is generally pam in the abdomen, seldom severe or continued, but occurring, most commonly, in short pa- roxysms. More usually, however, there is only tenderness upon pres- sure—the patient shrinking or crying out, upon being lifted or handled. The appetite is irregular, or but little affected; the bowels are gene- rally costive, but occasionally there is more or less diarrhoea, alter- nating 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 sal- low, and the expression of the countenance that of distress. The ab- domen is generally more or less distended, and very often exhibits some degree of tympanitis. The emaciation is always considerable, particularly in children over two years of age. In the early stage of chronic peritonitis, the symptoms are fre- quently so slight, and of so obscure a character, that but little atten- tion is paid to them by the parents; or the child is supposed to be labouring under worms, the serious character of the disease being en- tirely unsuspected, and a few, often improper, domestic remedies, are all that are prescribed. The progress of the disease is generally marked by increasing, and often extreme emaciation and debility; with a small, frequent pulse; hectic 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 being entirely confined to the peritoneal cavity, and unattended with oedema of the extremities even in protracted cases The tumefaction of the abdomen caused by the effusion, is some- times 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. The effusion increases daily in extent, and causes a gradual augmen- tation in the size of the abdomen. Every portion of the body, with the exception of the face, becomes, at the same time, 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, and 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. 270 DISEASES OF CHILDREN. The appearances discovered after death, in cases of peritonitis, are redness and thickening of the peritoneum, particularly of that portion enveloping the intestines; the redness is occasionally confined to the larger omentum, or to the peritoneum covering the right iliac fossa (Rilliet and Barthez); adhesions, more or less extensive, of the convo- lutions of the intestines to each other, or of these to the surface of the abdomen, or to the other viscera, are frequently present. The intes- tines are often coated with a layer of purulent, and at others of albu- minous matter. Very generally the cavity of the abdomen contains more or less serum of a whitish or citrine colour, sometimes with small albuminous flocculi diffused throughout it. In chronic cases, circumscribed collections of puriform matter occasionally exist be- tween the convolutions of the intestines. The peritoneum is often studded with tubercles. The mucous coat of the intestine presents frequently the indications of chronic inflammation, particularly ulcera- tions, 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 diseases, as measles, or scarlatina. It may attack children of any age, but is more common after the fifth year than previously. 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 appli- cation 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 reme- dies from which, if judiciously managed, and perseveringly employed, the very best effects may be anticipated. Internally, it is generally proper to administer at the commencement 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 opera- tion of which, small doses of calomel, combined-with ipecacuanha and extract of hyoscyamus, 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 ne- cessary 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 advisable, 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 THE REMITTENT FEVER OF INFANCY. 271 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 extends; 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 exhaus- tion 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 sufficient numbers, will often produce a very marked change in the character 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 hyoscyamus. In cases of chronic peritonitis, after effusion has taken place, we have derived the best effects from the addition to this prescription of minute doses of powdered digitalis. Wolff recommends, in these cases, the digitalis Avith the bitartrite of potass, in small doses, frequently repeat- ed. Even when considerable diarrhoea is present, he states that he has observed, under the use of the remedy, a gradual abatement of all the symptoms of the disease to take place; and by following it with a course of mild bitters, in conjunction with digitalis, and an in- fusion of roasted acorns, he has, in a large number of instances, effected a perfect cure, even in cases which, when they were first presented to him, he had almost despaired of being able by any means to save 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 atmosphere to one that is mild and dry, will often expedite the patient's recovery. CHAPTER VII. 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 in- fancy, 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 272 DISEASES OF CHILDREN. 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 conside- ration of the febrile forms of the several gastro-enteric inflammations of infancy. The invasion of infantile remittent fever is occasionally very sudden. A child, apparently in good health, shortly after retiring to bed, is at- tacked with a severe febrile paroxysm: the skin becomes hot, the coun- tenance flushed, the eyes injected, and the pulse quick and frequent. The thirst is generally intense; the tongue dry, and often 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 these symptoms gradually abate; the skin be- comes 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; the child exhibits more or less languor and fretfulness, and is without appetite; the abdomen is still often painful or tender, and the urine scanty and high-coloured, often depositing a white sediment. In the course of the morning, the remaining symptoms abate or dis- appear, and the child becomes more lively and playful, but still exhi- bits a degree of languor and peevishness, which, in general, increase towards evening, when a febrile paroxysm occurs, as on the preceding night; and is again succeeded in the morning by a more or less per- fect remission. In this manner, with daily exacerbations and remis- sions, the disease, unless cut short by appropriate remedies, runs on for many days, and often assumes a chronic and very protracted form. The disease more generally, however, 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 the skin, particu- larly at night—when he is also restless and uneasy. These symptoms increase, gradually, in intensity, and towards evening, the heat and dryness of the skin become more marked; the thirst and restlessness greater; the breathing becomes somewhat hurried; the pulse more quick and frequent:—towards morning, the skin becomes again moist and cool, and the patient falls into a short, disturbed sleep. Each night the febrile paroxysm is more and more distinct, and of longer duration, and the morning remission less complete. In the commencement of the attack, the bowels are ordinarily con- stipated; in some cases, however, there is diarrhoea, or a frequent inclination to go to stool without much being passed. When evacua- tions from the bowels occur, they are always unnatural, and highly THE REMITTENT FEVER OF INFANCY. 273 offensive; being dark-coloured, or clay-like, or of the appearance and consistence of tar: they are often mixed with mucus, and occasionally bloody. The vitiated secretions from the intestines, liver, and perhaps the pancreas, are frequently accumulated in the bowels in large quan- tities, and constitute the morbid and offensive discharges which are so commonly produced by the action of purgatives. Not unfrequently there occur repeated evacuations from the bowels, accompanied with violent tormina and tenesmus—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 intes- tines, and constitute the dysenteric fever of some writers. There is in most cases more or less pain or tenderness experienced upon pressure of the abdomen, which is also often hot to the touch, Avhile the extremities are cool, or cold—even during the febrile exa- cerbations, when the face is flushed, and the residue of the body dry and parched. The patient usually lies upon his back, with his knees draAvn up—cries frequently, and exhibits that peculiar expression of countenance indicative 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 gene- rally very irritable, and rejects, immediately, every thing taken into it. Frequent vomiting is not unusual. The tongue becomes, in the pro- gress of the disease, more coated, dry, and pointed. The breathing is often quick and hurried, and a short, hacking cough is a very frequent symptom. In many cases an eruption of rose-coloured lenticular spots occurs upon the abdomen or inner surface of the thighs, and occasion- ally sudamina appear upon the abdomen, or along the front andjSides of the neck. Infantile remittent fever often assumes a chronic form; the exacer- bations being of longer duration, but marked by symptoms of less in- tensity 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, the dejections being ahvays unhealthy in appearance, and fetid. The tongue is thickly coated upon its upper surface with a yellowish broAvnish 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, depositing a copious Avhite sedi- ment, particularly during the remissions; 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 oc- casionally unimpaired, and, in some cases, even voracious; in gene- ral, however, it is altogether lost. The child is very generally affected Avith 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 portions of its face or body, or at the bed- clothes, or face and arms of its attendants. If, as remarked by Locock, 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 18 274 DISEASES OF CHILDREN. attacked, so that the fingers are constantly stained with blood. This picking is, by many, considered as one of the diagnostic 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 usually very con- siderable. In the advanced stages, the child is sometimes affected with a species of stupor, in Avhich he remains for hours, as in a doze, with half-closed eyelids; he is, however, readily aroused, but quickly falls into the same state again, when undisturbed. This condition is often mistaken for that resulting from effusion in the brain; there is, how- ever, no increased heat of the head, no affection of the pupil, nor any of the other symptoms characteristic of effusion within the cranium. Disease 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 tubercular meningitis, with serous effusion, or to acute meningitis. In other cases, the respiration, which has been hurried from the first, becomes laborious, a troublesome short cough occurs, and very fre- quently, upon examination, a more or less extensive inflammation of the bronchial mucous membrane will be detected; and if the disease be not subdued, wheezing, expectoration, and the other symptoms of bronchial inflammation, or of a tuberculous condition of the lungs, finally ensue. Occasionally the symptoms will appear to abate for a few weeks, and then suddenly recur; during these remissions, the patient will often gain flesh and strength, but the abdomen still remains tumid, and the boAvels irregular; and these alternations of improvement and relapse may continue until the mesenteric glands become enlarged, or serous effusion takes place within the abdomen. The emaciation now in- creases ; 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 case, in fact, presenting all the symptoms of tabes mesenterica. The duration of infantile remittent fever will depend, in a great measure, upon the character and extent of the lesions of the intes- tinal 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 temperament, in whom there is a tendency to the development of tubercles in the lungs, to a diseased condition of the mesenteric glands, or to tubercular meningitis or peritonitis, the termination of the fever 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. Often, however, even in the more protracted cases, attended with great emaciation and debility, a complete reco- very may be effected by an appropriate treatment. Frequent re- THE REMITTENT FEVER OF INFANCY. 275 lapses, which are liable to be produced by slight errors in diet, ex- posure to cold or damp, or over exertion during con\'alescence, pro- duce ordinarily a chronic form of the disease, which is particularly unmanageable, and seldom permanently removed. The lesions discovered after death from infantile remittent fever A-ary, according to the longer or shorter duration of the disease. They are chiefly inflammation, more or less extended, of the diges- tive mucous membrane—in some instances, of the stomach and upper portion of the small intestines—most commonly of the ileum, at its loAver part, and in some instances, of both the ileum and colon. The mucous membrane is either reddened in patches, points, or striae, and is generally thickened and softened, or ulcerated. The isolated mu- ciparous follicles, as well as the follicular plexuses, are often found tumefied, reddened and ulcerated. The mucous membrane is often covered with a thick layer of tenacious mucus. . Dark, livid patches of the lining membrane of the small, but more commonly of the large intestines, are frequently met with, and. occasionally gelatinous softening, with perforation of all the coats. The mesenteric glands are very frequently enlarged—sometimes enormously so; occasion- ally in a state of suppuration, but more commonly converted into a cheesy matter. Peritoneal inflammation is sometimes present, and, in chronic cases, the peritoneum is not unfrequently thickly studded with tubercles. In some instances acute peritoneal inflammation seems to have been the immediate cause of death, and to have result- ed from perforation of the intestines. The liver is usually enlarged and in a state of extreme hyperaemia; sometimes changed in texture, and at other 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 substance or meninges. In the thorax, the most common mor- bid appearance is increased redness of the bronchial mucous mem- brane, the bronchial ramifications and air-cells being filled with mucus. The lungs occasionally display traces of inflammation; and in protracted cases, tubercles in the lung's, and upon the surface of the pleura, are frequently met with. Infantile remittent fever is, in every case, the result of inflamma- tion, most commonly subacute, of some portion of the digestive mu- cous membrane; the inflammation of 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 ana- lysis, will be found to point to the mucous surface as the original seat of morbid action. The result of numerous autopsies have placed this fact beyond the possibility of doubt; it is, therefore, chiefly to a morbid condition of the mucous membrane of the alimentary canal that Ave are to look for the pathology of the disease; and to the re- moA-al of this condition are our remedies to be primarily and mainly directed. When the stomach is the seat of inflammation, of a subacute cha- racter, there will be pain on pressure at the epigastrium; a vi\rid red- 276 DISEASES OF CHILDREN. ness of the point of the tongue, extending some distance round its edges; and generally a loathing of food; nausea, retching, or vomit- ing are sometimes observed. When the inflammation is seated in the mucous membrane of the small intestines, it is generally in the lower part of the ileum. We 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; excepting when the stomach and upper portion of the small intestines are also affect- ed. When the inflammation extends to the large intestines, its seat is almost always at the upper part of the colon. The tongue will then present the same appearance, and the same tenderness of the abdo- men will be present, as in inflammation of the small intestines, and the discharges from the bowels will consist of a muddy, loose, offen- sive feculent matter, or of a little mucus mixed Avith blood, the abdomen, in all these cases, being more or less tense and hot. Some- times there is a torpid condition of the colon, with great distention, from retained fecal matter. When the liver is affected, we have pain or tenderness when pres- sure is made in the region of that viscus, and the discharges from the bowels Avill show a deficiency, or depraved state of the biliary secre- tion. From the sympathy which exists between the skin and mucous membrane of the digestive organs, an irritation is experienced either at the external termination of the mucous orifices, or upon some part of the surface, and it is to remove or abate this, that the child is prompted to pick incessantly at the nose, mouth, eyes, face, &c. 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 indulging in stimulating and indigestible articles of food,—pastry, confectionary, crude fruits 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 fever 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 this by the foolishness of parents and friends. The disease may likewise be produced by cold and damp, and hence it very frequently occurs towards the close of summer, and early part of autumn, when transitions of atmospherical temperature are most frequent, and when the system of the child is more liable to be af- fected by them, in consequence of the over-stimulation of the skin, and of the organs which sympathize most closely with it, by the heat of the preceding season, which often still continues during the middle THE REMITTENT FEVER OF INFANCY. 277 portion of the day, and contrasts strongly with the coolness, often chilliness and dampness 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 mem- brane, particularly of its muciparous glands and follicles, no doubt often predisposes to inflammation of the alimentary canal, and of course to remittent fever; of the agency of the latter in its produc- tion, we have not, in any case, the slightest evidence. Among the more common causes of the disease are the neglect or mismanagement of the bowel affections of children generally; more especially the abuse of purgatives on the one hand, and of stimu- lating remedies and diet on the other. Infantile remittent fever is said to prevail occasionally as an epi- demic, or, more properly speaking, as an endemic. Of this there can be little doubt. By some it is supposed, particularly in its Ioav ty- phoid or chronic form, in other Avords, when connected with subacute inflammation and ulceration of the mucous glands and follicles of the intestines, to be propagated by contagion. The production of dis- ease 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 be- come affected, from this cause, with some of the worst forms of intes- tinal inflammation, accompanied with the phenomena ascribed to the low or typhoid remittent fever, the progress of which could only 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 fever 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. De- pendent for its production and continuance upon inflammation, more or less extensive, and of an acute, subacute, 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 alloAved, however, some cold mucilaginous fluid as a drink—any of those directed in gastro-enteric inflammation will be proper—but even of these, the patient should not be allowed such quantities as to unduly distend the stomach; this is particularly necessary, 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, may be allowed, at proper intervals. Occasionally, in very chronic cases, Ave have found beef 278 DISEASES OF CHILDREN. tea, chicken water, or plain mutton broth with rice, to agree better with the stomach, and to produce a less amount of irritation than fa- rinaceous preparations. On this point, of course, the judgment of the physician, guided by a knoAvledge 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 avcII as all solid food; and not to allow even that which is proper to be given at im- proper 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 ge- nerally bring away a large amount of undigested matter and vitiated secretions, with a manifest improvement in the condition of the pa- tient. As to the propriety of repeating the purgative, this will de- pend 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 matter Avith Avhich the intestines are, in such cases, often loaded, and which is a constant source of ir- ritation to the mucous membrane, is all-important; if, therefore, pretty free discharges have not been produced by the first purgative, an ad- ditional dose of castor oil, or of magnesia and rhubarb, may be given on the succeeding day. The repeated administration of active purgatives, so generally re- commended in this disease, and their continuance 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 administration, 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; Avhile 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, Ave are accus- tomed to add to each dose a small portion of extract of hyoscyamus. 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, in children over five years of age, Avill be ad- visable; or leeches may be applied to the abdomen, in numbers pro- portioned 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 treatment of these cases. Even in the protracted and THE REMITTENT FEVER OF INFANCY. 279 chronic forms of the disease, pain, heat, and tension in the epigastric, umbilical, or hypogastric regions, or in either hypochondrium, should be the signal for their application, in numbers adapted to the circum- stances of each case. From the fact that the disease is one attended with so much exhaustion, and liable to be protracted, the abstraction of any amount of blood has been condemned by many; but an active treatment, judiciously pursued in its early stage, and in its more acute forms, is unquestionably the best adapted speedily to arrest the dis- ease, and prevent the exhaustion consequent upon its more protracted forms. 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 folloAved by an improvement in the pulse, the skin, and in the ap- pearance of the stools, the very reverse of those from increased de- pression. It has been suggested by Dr. Eberle, and with a good deal of plau- sibility, that the intestinal torpor that so frequently exists in the dis- ease, is often the result of hyperaemia of the brain; and hence it is that an efficient abstraction of blood almost always increases the sus- ceptibility of the bowels to the action of mild aperients. In every instance the tepid or Avarm bath is, as in the case of gas- tro-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, 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 emol- lient cataplasms, perseveringly employed, as well as warm or sinapised pediluvia, especially when there is a tendency to coldness of the ex- tremities, or to 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. AVhen delirium, increased heat of the head, aversion from light, an injected state of the eyes, or stupor ensues, a few leeches may be ap- plied 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 symp- toms of bronchial inflammation are distinctly marked, and of any de- gree of severity, leeches should be applied about the clavicles. In these cases, small doses of calomel, ipecacuanha, digitalis, and extract of hyoscyamus Avill be found a useful remedy. R.—Calomel, gr. iij. ad iv. Ipecac, pulv. gr. iij. Digitalis pulv. gr. iij. ad iv. Ext. hyoscyami, 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 tym- 280 DISEASES OF CHILDREN. panitis, and vitiated, mucous, or dark offensiAre 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 diarrluea. It has not only the effect of exciting the boAvels to contract and expel the gas by Avhich they are distended, but it generally exerts a benefi- cial influence upon the morbid state of the intestinal mucous mem- brane, allaying irritation, and producing a decided improvement in the excretions. We have employed this remedy very extensively, in all the chronic affections of the boAvels 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 treatment should be pursued as di- rected in cases of chronic peritonitis. The treatment of cases attended with enlargement of the mesen- teric glands differs in nothing from that already laid down. As soon, however, as the symptoms of intestinal inflammation are reduced, the administration of some of the milder preparations of iodine may be entered upon, with the inunction of the same, in the form of ointment, about the groins and over the surface of the abdomen: the hydriodate of potassa is the preparation we have generally employed, and occa- sionally with very great advantage. In all cases, after the symptoms of the disease have subsided, the discharges from the bowels have become more regular and healthy in appearance, and the tongue cleaner and more moist, some light bitter, as a weak infusion of cinchona or calomba, may be given, in combi- nation with the sulphuric or hydrochloric acids, and, as convalescence 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 re- peated, and followed by friction of 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 to bear it, 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 beneficial effects. Great caution, however, must be observed, not to commence too early upon the use of tonics, or to improve too rapidly the diet of the patient. 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 Avhich has any tendency to oppress the stomach, Avill 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 ventila- tion, and by artificial heat when necessary. DISEASES OF THE RESPIRATORY ORGANS. 281 SECTION II. DISEASES OF THE RESPIRATORY ORGANS. 1. Asphyxia. Cases of still-born infants 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 respi- ratory 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 in its passage through the pelvis. In all these cases, as well as in those in which the poAvers of life in the foetus are too feeble to carry on the functions of the organism in the independent state of existence, no hopes can be entertained of resuscitation being effected or the dura- tion of life 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 resusci- tation may be effected.1 The most common causes of asphyxia in new-born infants are: tedious and protracted labour, from defective uterine efforts, from rigidity of the os uteri, or from a disproportion betAveen the size of the foetal head and the dimensions of the pelvis; the cord being twisted around 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 infant and the walls of the pelvis; the placenta becoming partially or entirely detached before the expulsion of the infant; the os uteri or the constrictor muscle of the vagina being spasmodically contracted around the neck of the infant, as is apt to occur in a first labour, particularly Avhen ergot is injudiciously administered to expe- dite delivery; the infant being born with the face invested Avith the membranes; the mouth and fauces being filled with viscid mucus, or, as sometimes happens, the tongue falling backwards, and closilig up the fauces; or, finally, the infant being exceedingly feeble and ex- hausted. Asphyxia is likewise observed in cases of very rapid de- livery, when the infant is protruded by a quick succession of severe uterine contractions. ' In the 10 years preceding 1845, of the 81,324 children born, 3,679, or about 4*5, were dead. How many of these latter were premature births, or to what particular cause the death of the foetus was owing, we have no means of ascertaining. The law requires that in every instance in which the foetus 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. 282 DISEASES OF CHILDREN. Asphyxia in new-born infants may occur after birth, and even after the infant 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 and operation 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 Avith only a feeble, obscure pulsation, sometimes none at all, at the heart or in the cord; in other cases 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 sloAr 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 effort at respiration occurs, the heart and cord may pulsate Avith more or less vigour, while, again, a few ineffectual respi- ratory efforts may be made, or even faint cries may be uttered, and then a complete state of asphyxia ensue. All the causes to Avhich the asphyxia of new-born infants 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 innervation—as an apoplectic condition of the brain. In those cases, hoAvever, of not unfrequent occurrence, in which there exists no impediment to the passage of air into the lungs, and no undue distention of the vessels of the brain, it is difficult to assign the real cause for the non-establishment of respiration. Some have supposed the asphyxia, in these cases, to arise from a state of extreme debility; others from anaemia, or from the functions of the placenta having become suspended 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 stimulation of the brain and other or- gans, which is essential to the proper performance of their functions, and which must necessarily cause the death of the infant, unless res- piration be promptly established by artificial means, and the due vi- talization 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 infant opens its eyes, moves its limbs, and exhi- bits a few imperfect respiratory efforts, a smart slap upon the but- tocks, or a few drops of cold water sprinkled upon the chest and ab- domen, will very generally cause it instantly to breathe, and to cry out lustily. In all cas*es, 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 Avith the finger, surrounded Avith a piece of soft linen. The infant should be subsequently placed upon its side, in such DISEASES OF THE RESPIRATORY ORGANS. 283 a position that if any of the mucus remains it may flow from the mouth, at the same time that its entrance into the trachea is pre- vented. The practice of turning the child upon its face, slapping it between the shoulders, and gently shaking it, as recommended by a feAv highly respectable writers, " with the view of disengaging any mucus that may be lodged in the trachea," is one that we cannot be- lieve to be either safe or useful. In all cases in which the asphyxia is unaccompanied with symptoms of cerebral congestion—a puffy and dark purple or livid appearance of the face—it is not proper to tie the umbilical cord, until its pulsa- tion has ceased, or has become quite feeble. The premature applica- tion 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 cord may be divided, and the infant 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 Avith 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 re- suscitation 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. Even when respiration is produced, as it often will be, by the action of the bath, the immersion should not be continued over a few mi- nutes; 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 atmospheric air to the surface of the body, which always exerts a very powerful vivify- ing influence. When the child is removed from the bath, gentle fric- tion should be applied to the surface of its body with a warm dry flannel cloth. Cold affusion 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 resusci- tation. In tAvo cases, related by Dr. Patterson, of Dublin, in which the infant Avas placed in a tub, and three quarts of water, at a tem- perature of about 60°, were twice dashed over it, strong friction being at the same time applied to the parietes of the chest, active respira- tion Avas quickly established; the infant Avas then removed from the tub, Avell dried, and wrapt in flannel; in both cases, an entire reco- very Avas effected. In the Journal fiir Kinderkrankheiten it is stated by Dr. Tott, that 284 DISEASES OF CHILDREN. he has often succeeded in restoring life in cases of asphyxia asthenicn infantum after the failure of the usual means, by causing a person standing on a table to pour cold water from the spout of a tea kettle on the pit of the stomach of the asphyxiated infant. In this Avay, it is added, Professor Hasselberg has saved many lives. But of all the means that have been employed in the asphyxia of infants, inflation of the lungs is the one upon Avhich, experience has taught us, the most confidence is to be placed, if early resorted to, ju- diciously practised, 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 infant, 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, Avhen the mouth of the operator is to be withdraAvn, 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 res- piration 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, generally, a tremulous motion of the respiratory organs; the infant next makes a feeble attempt to inspire, and the cheeks begin to redden: when these marks of returning life are observed, if the inflation be suspended, the infant will frequently be found to make a spontaneous effort at respiration; a deep sigh is the first breath it draAvs, and in a feAv 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 stop 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 infant to carry on respiration being tested, at another, the respiration being supported 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 better effect than introducing stimulants into the stomach. A few smart slaps on the gluteal muscles will noAv generally complete the recovery. In favour of the efficacy of artificial respiration, in cases of asphyxia occurring at or soon after birth, we have the most incontestable testi- mony. 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 expe- rience, which is decidedly in favour of this means of resuscitation. But it must, to be generally successful, be persevered in"until the na- tural action of the respiratory organs is fully established, or 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 DISEASES OF THE RESPIRATORY ORGANS. 285 respiration was fully established; and in a communication of Sir James Eyre, in the London Medical Gazette, March, 1840, a case is referred to in which the artificial means were persevered in for from thirty to forty-minutes, and to two cases in Avhich 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 diffi- culty 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 cases 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 labours, where the child has remained for several hours under the direct'influence of the uterine contractions, subsequent to the discharge of the waters; where a loop 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 in all proba- bility it may also frequently result, like the preceding variety, from the want of a proper revivification of the blood. It is, in many cases, produced by the too early and injudicious use of ergot. In the apoplectic form of asphyxia, the countenance, with 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 ex- tremity, very generally, the lividity and turgid state of the face and neck Avill disappear, and respiration be 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 Avarm bath to the hips, Avhile 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 is perceptible in the cord, or at the heart—notwithstanding there is but little hope that resuscitation can be effected, it is nevertheless proper that suitable efforts should be made for the establishment of respira- tion. AVe are in no instance hastily to pronounce success impossible. Many a foetus, Dr. Blundell remarks, has been laid aside as dead, which by a diligent use of proper means might, in all probability, have been saved. In the cases just referred to, it is seldom that a sufficient quantity of 286 DISEASES OF CHILDREN. 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 in- flated. It has been suggested by Dr. Eberle, with the view of solicit- ing 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 ex- hausting syringe. It is supposed that by exhausting the cup, a How of blood may sometimes be obtained from the divided cord, even after the heart has ceased to act. 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 oftens 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 AArhich resuscitation 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. 2.—Coryza. The simple catarrh, or inflammation of the mucous membrane of the nares, occurring in infants, has received various appellations. It is usually described, however, by writers on the diseases of children, under the denomination of coryza, gravedo, or snuffles, to which, occa- sionally, the terms malignant or morbid, have been added to distin- guish the more aggravated form of the disease, or that in which the Schneiderian membrane is affected Avith diphtheritic or exudative in- flammation. 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. 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 con- tact with the membrane. There often occurs, also, at a very early period, an abundant secretion of mucus, Avhich, in some infants, flows constantly from the nose, apparently without 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 Avhich ensues. The first indication of the disease is frequent sneezing; the inner surface of the nostril soon after becomes red, dry, and swollen, and the cry of the infant is altered, from the impediment to the free pas- sage of the air through' the nose; a watery, or thin muculent fluid DISEASES OF THE RESPIRATORY ORGANS. 287 soon begins to flow from the nostrils; in a short time the discharge assumes a thick, white, opaque appearance, subsequently changing to a yellow, and becoming finally purulent, exhaling frequently a pecu- liar fetid odour. The child sleeps with its mouth open; the respira- tion is difficult and noisy; and instead of the usual rale, a Avhistling sound occurs in the nasal fossae; this becomes greater, and the diffi- culty of respiration increases, in proportion as the discharge from the nose becomes thicker and more abundant; the nose becomes red ex- ternally, and somewhat swollen, while the central portion of the upper lip, constantly irritated by the discharges from the nostrils, becomes frequently red, swollen, and excoriated. Often it is covered with a false membrane. In severe cases, the child experiences great difficulty in sucking, from its inability to breathe through the nose, from the diminution of the nasal cavities, caused by the submucous infiltration, resulting from the inflammation of their lining membrane; and as the discharge, by drying at the orifices 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 in- stantly 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 deficient nourishment, the infant may perish from inanition; or the brain becoming affected, 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-con- ditioned ulceration. Dr. C. D. Meigs believes that the chief danger to the young infant affected with coryza results from one of two causes; of which the first and the most common is the filling up of the nostrils with a plug of dried viscid mucus, and the other, the submucous infiltration, causing the sides of the cavity to collapse. Now as the nostrils are the principal—Dr. Meigs considers them to be the only—instinctive respiratory orifices in the young infant, it is evident, that so long as their obstruction from either of the above causes continues, the aera- tion of the blood in the lungs must be imperfectly performed. As a necessary consequence, the vitality of every tissue must become impaired, and the functions of the several organs impeded or de- ranged. 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 ton- sils and fauces occasionally present a swollen and dark red appearance, their surface being covered Avith ash-coloured specks, terminating, in some cases, in extensive ulcerations. In violent cases, death may occur in three or four days, while in 288 DISEASES OF CHILDREN. other instances, the symptoms are mild from the commencement, the inflammation very rapidly abates, the secretion gradually lessens in quantity and in consistence, the respiration improves in proportion, and in a few days every symptom of the disease disappears. The danger is always in proportion to the degree of tumefaction of the mucous membrane of the nares, and the abundance and tena- city of the excreted fluid. When the inflammation is slight, and the mucus of the nose is only a little more abundant and ropy than natu- ral, the difficulty of respiration is but slight, and the infant is able to suck without much difficulty. All other things being the same, coryza is, as already remarked, always more serious and dangerous, in proportion to the tender age of the patient. The appearances discovered after death, in those Avho have fallen Adctims to this disease, are increased redness, with thickening and softening of the mucous membrane throughout the Avhole extent of the nasal fossae, the membranes being generally thickly coated with pus or an opaque tenacious mucus. In some cases, small patches of a pseudo-membranous exudation are scattered over its surface. In other instances the exudation covers the Avhole interior surface of the nares, and extends from the superior part of the glottis, upwards, towards the sinus and cornua of the nose; the mucous membrane be- neath, to which it firmly adheres, being much tumefied, and of a vivid red colour; softening of the mucous membrane, and extensive ulcera- tion are frequently present. In chronic cases, various morbific affec- tions of the alimentary canal, lungs, and brain, are frequently met with. The disease, when it occurs as a primary affection, 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 these 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 almost' ahvays ob- served that they sneeze, and are affected with 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 casesj the application of a feAv leeches to the root of the nose will be advisable, with some gentle diaphoretic.' In some instances 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, also, often produce very considerable relief. In all cases great benefit will be derived from anointing occasionally the inner surface of the nostrils by means of a DISEASES OF THE RESPIRATORY ORGANS. 289 camel's hair pencil, with a few drops of glycerine, or of the oil of sweet almonds. • R.—Hydrochlor. ammonise, gr. xxyj. ad xlviij. Pulv. ipecacuanhae, gr. ij.—iij. Ext. Hyoscyami, gr. iij.—M. f. chart. No. xij. One to be given every three hours, mixed in a little sugar and water. Dr. C. D. Meigs' plan of treating coryza is to keep the interior of the nostrils, after they have been carefully freed from mucus, con- stantly anointed with some of the finer animal oils, or, what he be- lieves well adapted to the case, the ointment of cucumbers. The ^effect of this application would be, Dr. Meigs remarks, to cover the lower part of the aperture with a thin glazing of oil, upon which the viscosities will not rest and dry, but fall outwards upon the lip, Avhence they may be readily wiped away, whereas upon the dry epithelial surface of the orifice, the viscosities adhere, become inspis- sated, and convert themselves into hard, dry, and solid crusts or scabs. Dr. Meigs also directs that a light flannel cap, fitting closely to the infant's head, should be applied and worn until the coryza disappears. This he has found to be alone sufficient, in a large number of instances, to cure the malady. There can be little doubt that in the majority of cases of simple coryza, occurring in young infants, the plan of treat- ment here recommended will be all that is necessary. 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. If, after the inflammation is reduced, there should be formed any pellicular concretions in the nasal fossae, Billard directs some fine ca- lomel, or a mixture of sugar and alum finely powdered, to be gently blown into the nostrils. In cases attended with pseudo-membranous exudation, the nitrate of silver in solution constitutes the most efficacious local application. Five to ten or fifteen grains may be dissolved in an ounce of water, and applied to the interior of the nostrils by means of a camel's-hair pencil, several times a day, according to the severity of the case. In chronic cases, alterative doses of calomel, with ipecacuanha, pre- pared chalk, and extract of hyoscyamus1 will, in general, if conjoined Avith 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 recom- mended when the disease continues for many weeks, and the infant becomes pallid and very feeble. Underwood states that it has at once removed the snuffling, and given vigour to the patient in the course of a few days. A weak infusion of bark, the sulphate of qui- nia, or the persesquinitrate of iron, will, however, in most cases be found a better tonic than the oak bark. « JJ.—Calomel, gr. iij. Ipecac, pulv. gr. iij. Cretae ppt. gr. xxxvj. Ext. Hyoscyami, gr. iv.—M. f. chart. No. xij. One to be given every three hours. 19 290 DISEASES OF CHILDREN. When, in the course of the disease, symptoms of cerebral congestion or irritation, or convulsions occur, these are to be combated by 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 magnesia, or purgative enemata. During convalescence from the more chronic cases, the restoration of the patient's strength is to be promoted by a Avell-regulated diet, gentle daily exercise in the open air, and appropriate clothing. 3.—Bronchitis. Bronchial inflammation, varying in extent and intensity, is a very * common disease 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; followed, after a short period, by more or less febrile re- action. The patient, if old enough, now complains of dull, aching pains in the head, back, and extremities; the pulse becomes frequent, full, and somewhat tense; the face is slightly flushed; the surface is dry and harsh, but is seldom much increased in temperature; the bowels are, in general, constipated, and the urine is 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 fre- quent sneezing. Cough and some degree of hoarseness, with soreness or a sense of roughness in the throat, are usually present from the commencement of the attack. Frequently, however, the cough is not developed until the second or third day, and while its violence is always in proportion to the extent and intensity of the inflammation, it generally becomes more frequent and severe as the disease adA'ances. In some cases the cough is attended with pain of the thorax, or at the base of the sternum. The respiration is, in general, more or less short, difficult, and oppressed from an early period of the attack, and is at- tended 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 in mild cases is but little ac- celerated, but when the inflammation is intense and extended, it is always frequent, amounting, sometimes, to one hundred in a minute; the act of inspiration, in severe cases, being attended with a dilatation of the nostrils, and a heaving motion of the chest. The respiration becomes always more frequent in the progress of the disease. During the first period of the disease, the infant at the breast sucks without much difficulty; bu{; subsequently, although it seizes the nipple with aA'idity, it cannot suck for more than ten or fifteen seconds, when it will suddenly quit the breast, and throw its head backwards, and continue in this position for some time, even after the cough has pro- duced an expulsion of mucus. DISEASES OF THE RESPIRATORY ORGANS. 291 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 a thin, transparent sero-mucous fluid, or of a yellowish frothy mucus, but subsequently of masses of a Adscid, opaque, muco-purulent matter, of a yellowish or greenish colour. In young children, the matter brought up from the lungs is most gene- rally swalloAved, or retained for some time in the throat. In some few cases, the matter expectorated is found to contain thin, white, soft fragments of a membranous appearance. 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, like- wise, often occurs in occasional fits, at irregular, and generally short intervals. 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 disease, 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 circum- scribed dulness may often be detected at some part. 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 in- spirations are, occasionally, suddenly arrested, and attended with an expression of suffering in the countenance, probably from an accom- panying pleuritic inflammation. The countenance, in the milder cases, does not exhibit any particular change—the cheeks are generally slightly flushed; in the progress of the disease, hoAvever, the eyes be- come surrounded with a dark circle, the countenance assumes an anxious, suffering expression, and the nostrils are dry and crusted— the lips are pale, but at intervals acquire a violet hue, especially after a violent paroxysm of coughing. Delirium occasionally occurs, par- ticularly towards the close of the day, and at night. As the disease advances, the cough and difficulty of respiration in- crease; the physical signs, resulting from the impediment to the free passage of the air 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 suffering; he becomes drowsy, his face acquires a pale or livid hue, and the expression 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 pre- sent from the commencement of the attack, and by preventing the patient from complaining or coughing is apt to mask the disease of 292 DISEASES OF CHILDREN. the chest, which is thus rendered peculiarly insidious and dangerous. A close attention will, however, detect an augmented frequency in the breathing, and on applying the ear to the thorax, the universal rhonchi, sibilant and mucous, at once declare the true nature of the case. The physical signs of simple acute bronchitis are, in very young subjects, a combination of mucous and sibilant rhonchi—slight, and of short duration; in older children these sounds are more decided and continuous, with a predominance of the mucous rhonchi. In cases of greater intensity there is a combination of loud or sibilant rhonchi and mucous rhonchi. In some cases the rhonchi are sub-crepitant. In infants, the epigastrium and right hypochondrium become, occa- sionally, tumid, tense, and tender upon pressure; the discharges from the bowels being, generally, small in quantity, and whitish or clay- coloured at first, but subsequently containing a large amount of light green or dark-coloured bile. In some cases, the evacuations from the bowels become thin and muddy or reddish, and contain more or less mucous flocculi, the abdomen, at the same time, being greatly SAvollen and tympanitic. This complication is evidently the result of gastro-enteric inflammation, attended with an engorged and torpid state of the liver. It is to this form of bronchitis that the term ca- tarrhal fever has been generally applied. In that form of bronchitis in which the inflammation extends to the more minute ramifications of the bronchi, giving rise, not unfrequently, to a pseudo-membranous exudation, constituting the capillary bron- chitis of many writers, the general symptoms are of a much more se- vere character than in the simple acute form of the disease. There is a greater degree of restlessness and irritability; more decided fe- brile symptoms, and a fuller and more frequent pulse. The face is flushed, the surface dry and liot, the thirst urgent, and the appetite entirely deficient. The respiration is short and quick, the cough oc- curs in frequent short paroxysms, and is, occasionally, attended by a decided stridulous or croupy sound, and hence, the disease is denomi- nated, by some authors, bronchial croup. The cough is not unfre- quently painful, and, although at first very generally dry, it is usually attended, after a few days, by an expectoration of a tough, yellowish matter, and occasionally, of fragments of a pseudo-membranous ap- pearance. • If the disease is protracted, and increases in intensity, the respira- tions become still more oppressed, frequent and irregular, and attended with violent action of the alae nasi; the pulse increases in frequency and becomes small and irregular. The face assumes a leaden or a more or less decidedly livid hue, while the temperature of the entire surface of the body is reduced. The paroxysms of coughing are fre- quent and distressing, and the expectoration scanty and difficult. The patient cannot assume the recumbent position without causing an increase of the difficulty of respiration. In the still more protracted cases, there occasionally occur irregular and deceptive remissions of the leading symptoms, but finally, the difficulty of respiration augments, the pulse becomes almost impercep- DISEASES OF THE RESPIRATORY ORGANS. 293 tible, the countenance a peculiar anxious expression—the extremities become cold—while the patient is in a constant state of jactitation or falls into a soporose condition, and death very quickly ensues. The duration of capillary bronchitis is various. When severe, and occurring in very young infants, it may terminate fatally within a few hours. In children at the breast its usual duration is from two to six days; in older children it may continue from one to three weeks. Bronchitis in children is not unfrequently complicated with pneu- monia, giving rise to hepatization, to a greater or less extent, of the lower and posterior portions of the lungs. This is, in fact, the ordi- nary form of lobular pneumonia, as it occurs in children under tAvo years of age; it is a common complication of the bronchitis incident to the acute exanthemata, and to hooping cough. In a very interest- ing paper by Dr. West, of London, on the pneumonia of infants, he remarks that the evidences of bronchial inflammation are very com- monly met with in children who have fallen victims to lobular pneu- monia, especially where the latter supervenes upon pertussis. Rilliet and Barthez state that the anatomical characters of acute bronchitis are rarely met with in children under five years of age, without at the same time traces of pneumonia being present—the latter being sometimes a secondary, at others a primitive or concomi- tant disease. Hence the value of the sub-crepitant rhonchus, as a diagnostic sign of bronchitis, differs with the age of the child. If, in those under five years of age, the sound is heard on one or both sides of the chest, there is danger that the bronchitis is complicated with pneumonia—whilst, in older children, there is less probability that such is the case, though from the tendency even then to lobular pneu- monia, its presence may still be suspected. When the crepitant rhon- chus is heard, Rilliet and Barthez have invariably found, with one ex- ception, that portions of the lungs were affected with pneumonia. The bronchitis of children occasionally assumes a chronic form, at- tended Avith copious perspirations and hectic fever, the exacerbations occurring in the evening, when its symptoms closely resemble those of phthisis. A very common and dangerous form of bronchitis, which is referred by Mackintosh to a subacute inflammation of the bronchial mucous membrane throughout both lungs, is of common occurrence in young children. The cough and dyspnoea are but slight, and attract but little attention, so long as the expectoration is free, and the excreted matter is discharged Avith ease; but if, from any cause, the secretion of mucus in the bronchi is increased, and the cough arrested, speedy death from suffocation inevitably results, unless the air-passages can be freed from the accumulated mucus, by the administration of an emetic. An unfavourable change in these cases is often produced by exposure to cold. This form of the disease avc 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 he early makes himself acquainted Avith its true character, by an attention to the physical signs to be derived from a careful examination of the chest. The prognosis in cases of bronchitis is to be drawn from a careful 294 DISEASES OF CHILDREN. estimate of the general and local symptoms; the age and condition of the child in Avhom it occurs, and the hygienic circumstances under which it is placed. In many cases the disease is of little intensity or extent, and readily yields to an appropriate treatment. In attacks of greater intensity, hoAvever, the disease is often more protracted— even Avhen the termination is favourable. The respiration becoming less frequent and laborious; the febrile symptoms abating; the skin becoming softer and moist; the cough less frequent, prolonged, and ' suffocative, and attended with a free expectoration, are the general indications of the decline of the disease. The occurrence of convul- sions, and of great somnolency or drowsiness, with increased difficulty of respiration, accompanied AA-ith a feeling of suffocation, and Avith livi- dity of the cheeks and lips, and coldness of the extremities, are all un- favourable symptoms, that are but too generally quickly followed by a fatal termination. From the facility Avith which the inflammation extends to the Avhole of the bronchial tubes, even to the minutest ramifications, and the danger of its becoming complicated with pneumonia, bronchitis is always to be considered a serious affection, Avhich requires to be care- fully watched and promptly treated. Capillary Bronchitis, or that form of the disease in which, from the commencement of the attack, the entire extent of the bronchi are inflamed, even to their smallest ramifications, is inA-ariably attended with very considerable danger. When there is intense fever, great acceleration of the respiration, and severe dyspnoea, with a copious purulent or pseudo-membranous secre- tion, it is an extremely unmanageable affection. Under such circum- stances, according to the experience of MM. Rilliet and Barthez, as Avell as that of M. Fauvel, its termination is very generally in death. The appearances discovered after death from bronchitis, are a bright redness of the bronchial mucous membrane, either in patches, and partial in extent, or more diffused, and of a brownish or violet shade, with more or less thickening and roughness of the membrane, and occasionally softening. The bronchial ramifications are generally filled with a quantity of frothy viscid mucus, sometimes transparent, at others opaque and yellow, and occasionally sanguinolent, or with a muco-purulent fluid, the presence of which, by preventing 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. In some cases, the more minute ramifications of the bronchi are lined with a pseudo-membranous concretion, very soft, and slightly adherent; of a Avhite colour, and of variable thickness. This occurs, in some cases, only at certain portions of the bronchial tubes, while in others it occupies the whole of the bronchial ramifications. Be- neath these membranous concretions, the mucous membrane is occa- sionally firm, and remarkably pale; at other times it is red, softened, and rugous. It is in the bronchi of the inferior lobes that the fluid products of inflammation are ordinarily most abundant. The bronchi are in many cases dilated, either in some portion of their branches, or at their extremities. The dilatation is occasionally very considerable. DISEASES OF THE RESPIRATORY ORGANS. 295 When the bronchi are dilated at their extremities, a section of the lung presents an areolated surface, formed by the presence of a num- ber of small rounded cavities, communicating with each other, and with the bronchi of which they appear to be the continuation. The most part of these cavities are central; some of them, however, exist at the surface of the lungs, and are formed by the pleura, lined by the thinned membranes of the dilated bronchi. These produce upon the exterior of the lung slight rounded transparent projections, which col- lapse when punctured, and simulate emphysema. The interior of these cavities contain the same fluid as is found in the bronchi; their parietes are smooth and thin, and they are lined by a continuation of the lining membrane of the bronchi. In cases of vesicular bronchitis, the lungs are flaccid and soft at their surface, and more or less shrunken, according to the extent of the dis- ease. A section presents a large number of granulations, about the size of a millet seed, of a grayish colour, inclining slightly to yellow. These may at first view be readily mistaken for miliary tubercles; from these they are readily distinguished by their giving discharge to a drop of purulent liquid, and becoming immediately effaced, when punctured by the point of the scalpel, leaving in their centre a small depressed point, which is sometimes, however, difficult to detect. Of- ten a very narrow canal with smooth parietes may be traced for some lines, being no doubt a small bronchial tube, the termination of which is at the central depression of the granulation. In these cases it is probable that the inflammation is seated only in the extremities of the bronchial tubes, and that a certain number of pulmonary vesicles, separately inflamed, have become filled with a puriform fluid and dilated, without the surrounding cellular tissue being involved in the disease. If several neighbouring vesicles become inflamed, the inflammation may extend also to the tissue by which they are united, and there will then result a small induration, of the size sometimes of a lentil, the section of which presents, after a discharge of a fluid, a number of granulations or of depressed points. This constitutes lobular pneumo- nia, which forms the connecting link between bronchitis and the latter disease. (Rilliet and Barthez, vol. i. p. 21.) When the disease succeeds to the pustular exanthemata, the lining membrane of the bronchi often presents traces of follicular inflamma- tion—often ulceration. In severe and protracted cases it is not un- common to meet with distinct patches of red hepatization, particularly 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 raAV, variable, and humid Aveather 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 of rain, attended with a reduction of the atmospherical temperature, after a long continuance of intense heat and dryness. It may result, also, from the application of cold and damp to the surface 296 DISEASES OF CHILDREN. of the child's body, by wet clothing, or exposure to a draft of air while in a state of profuse perspiration; it is an almost constant symptom in measles, and probably in pertussis, and it not unfrequently supervenes on variola and scarlatina, and, occasionally, upon gastro-enteric in- flammation. It sometimes prevails epidemically, affecting as Avell children as adults, or confined, in a great measure, to tho former. The treatment of bronchitis will differ somewhat according to the violence of the disease, and in its different stages. In mild cases, an emetic administered in the commencement of the attack, particularly 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 dyspnoea occurs, from the clogging up of the bron- chial tubes with mucus, nothing will be found to give more prompt re- lief. In infants and young children we invariably prefer the ipecacu- anha as an emetic, to the tartarized antimony; the effects of the latter being, in early life, often peculiarly prejudicial. The powdered ipecacuanha, mixed with sugar and Avater, or the wine or 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, bloodletting is the remedy upon which alone our chief reli- ance should be placed. It should be resorted to as soon after the in- flammation is developed as possible; if it be delayed until a copious secretion from the lining membrane of the bronchi has taken place, it is ahvays far less efficacious, while in some cases its effects will be even 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 con- siderable acceleration of respiration, a dry, hard cough, dyspnoea, 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 continuance of the inflammation, leeches may be applied upon the fore part of the chest, or cups betAveen the shoulders. It is better, however, in most cases, to carry our first bleeding to a sufficient extent to make a de- cided impression upon the action of the heart:—we shall be much more likely, in this manner, to cut short the disease, than by a repe- tition of the bleeding from the arm, or by the application of leeches. Although, as a general rule, bleeding is not advisable in the ad- vanced stages of bronchitis, still there occasionally takes place a sud- den recurrence of inflammatory symptoms, or a congested condition of the lungs, in which a prompt and judicious amplication 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 bloodletting in cases of bronchitis, whether by the lancet or by local means, demand the ut- most judgment on the part of the practitioner. In severe attacks, a DISEASES OF THE RESPIRATORY ORGANS. 297 cure can scarcely be anticipated without the abstraction of a sufficient amount of blood during the early periods of the disease. In those instances in which the disease is complicated with gastro- intestinal inflammation, the application of a feAV leeches to the epigas- trium will always be found highly beneficial. By most writers, tartarized antimony is recommended as being, next to bloodletting, the most efficacious remedy in the bronchitis of children. It is probable that, in severe cases, after the immediate effects of bloodletting 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 until vomiting or faintness is produced, may render a repetition of the bleeding unnecessary; but it is under these circumstances alone, that Ave 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 Avhich is borne with great difficulty in the early periods of life. In the generality of cases we prefer the administration of small doses of ipecacuanha. After the first bleeding, we are accus- tomed to direct from a fourth to a half grain, in combination Avith a quarter of a grain of calomel and from four to five grains of hydro- chlorate of ammonia, and have always found it to produce a very de- cided impression upon the symptoms of the disease. When the cough continues dry, and the surface hot, with quickness and frequency of pulse, we have repeatedly added to this prescription a quarter of a grain of powdered digitalis; and notwithstanding its general condem- nation, we are persuaded that, under the circumstances just referred to, it will in most cases be found a highly useful remedy. After the occurrence of expectoration, the ipecacuanha may be.em- ployed, combined with extract of hyoscyamus, which latter, while it has a tendency to relieve irritation, is unattended with any of the dis- agreeable effects that 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 bronchitis, 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 Adtiated discharges. In the commencement it will be proper to administer some purgative, and perhaps the best is a full dose of calo- mel, folloAved by a portion of castor oil. The use of the combination 298 DISEASES OF CHILDREN. of ipecacuanha and calomel, already recommended, will render the repetition of purgatives unnecessary. The administration of expectorants will seldom be found of any benefit in the first stages of the disease, but in the latter period, after the inflammatory symptoms have been reduced, and a copious secre- tion has taken place in the bronchi, they are occasionally of advan- tage; the mel scillm compositum of the United States Pharmacopoeia, may be employed, or the following combination.1 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. 1 R.—Infus. polygalae, ^iv. Vin. ipecacuanhae, gij. Oxy. scillae, giij. Tinct. hyoscyami, gj.—M. A teaspoonful to be given every three hours. M. Valleix directs attention to the importance of mechanically re- moving the mucus from the throat of the patient, in the suffocative paroxysms that occur in the generalized bronchitis so fatal to young children. As soon as the infant's countenance assumes a violaceous as- pect, and suffocation seems imminent, the little finger should be passed along the back of the tongue. The child will close its jaws and resist violently, but the finger should be gradually advanced. Whenit reaches the isthmus, the child opens its mouth, and we should then pass the finger on behind the epiglottis, so as to bring the pulp of the finger several times over the orifice of the larynx. This produces efforts at coughing and vomiting, and the mucus is expelled from the air passages, a part being drawn out by the finger, and the rest swallowed. The child appears, after the operation, much flushed and agitated, and almost suffocated, but it soon becomes calm, until renewed signs of asphyxia call for a repetition of the procedure. In a case related by M. Val- leix, apparent death, after one of these paroxysms, was successfully treated by artificial respiration, the employment of which he strongly recommends in similar cases. When there is much prostration, with a small and feeble pulse, and a degree of drowsiness, the carbonate of ammonia will often produce considerable relief.2 In such cases, wine whey, in small quantities, judiciously administered, will be occasionally serviceable; the patient being sometimes so weak and languid that he cannot make any volun- tary efforts to cough, upon which, perhaps, his life depends. Hoff- mann, and some other of the German practitioners, speak very favour- ably of a combination of benzoin and camphor,3 in cases attended with great debility; it is said to have produced complete relief, under cir- cumstances to all appearances hopeless. a ]J._Carb. ammoniae, ^ij. Or, R.—Asafcetidse, gss. Ext. glycyrrh. gij. Liq. ammoniae acetat. Aquee, =fiv. Aquae menth. aa ,^ij.—M. Oxym'el scillse, giv.—M. A teaspoonful to be given every three A teaspoonful to be given every two or hours. three hours. DISEASES OF THE RESPIRATORY ORGANS. 299 ' R.—Flor. benjoin. gr. iij. ad iv. Camphor, gr. iv. ad vj. Sacch. alb. gss.—M. f. chart. No. xij. One to be given every two or three hours. The diet, throughout the early stages of the disease, should be mild and unirritating. Infants at the breast may be alloAved, occasionally, fresh whey, or gum or barley water sweetened with loaf sugar, and prevented from sucking more than once or twice in the course of the day; the diet of older children may consist of thin water gruel, barley or rice water, or fresh whey; and as a drink, cold toast water or Aveak lemonade. During convalescence, the diet should be gradually and cautiously improved; milk and preparations of the usual farina- ceous substances should, however, constitute the chief food of the pa- tient, for a considerable period after the disease has been removed. The child should be carefully guarded from exposure to cold or damp- ness, and from any sudden alternation of temperature; the air of the apartment he occupies should be kept perfectly pure, by attention to strict cleanliness and free ventilation. As soon as he is sufficiently recovered, much benefit will be derived from gentle exercise in the open air, during dry mild weather, the patient's body being protected by appropriate clothing. During convalescence, the same directions are applicable as were given Avhen treating of coryza. 4.—Pneumonia. Inflammation of the substance of the lung ranks among the most frequent diseases of children; as a primitive or secondary affection, it may occur at any period, from birth upwards, differing greatly in its extent and violence in different cases. The inflammation may com- mence in the minute lobules of the lung, constituting what has been denominated lobular pneumonia, or it may take place in one of the pulmonary lobes, constituting lobar pneumonia. In both cases the dis- ease will vary considerably in extent; it may be confined to a very small portion of one lung, or involve nearly the Avhole of one or both. In young children, or those under six years of age, the disease would appear, in a large number of cases, to be the consequence of exten- sive bronchial inflammation, and is probably, in these, very generally produced by the extension of inflammation from the extreme rami- fications of the bronchi to the substance of the lung: in very many instances, hoAvever, the inflammation of the bronchi and of the lungs is unquestionably simultaneous. In older children, the disease more commonly commences in the lung, and the circumscribed bronchial inflammation, which so generally attends it, is, in all probability, a secondary affection. The general symptoms of pneumonia, in very young children, are often extremely obscure in the onset of the disease, and even when most strongly marked, they differ but little from thdse of bronchitis. There is invariably more or less cough, some degree of dyspnoea, in- creased frequency of respiration, and fever. There is seldom any very decided pain of the thorax. 300 DISEASES OF CHILDREN. The attack, which is often preceded, in infants, by symptoms of a slight bronchitis, usually commences with a chill, more or less severe and prolonged, followed by increased heat and dryness of the skin, increased frequency of pulse, accelerated respiration, dyspnoea, and a slight dry cough; which symptoms very quickly increase in intensity: often at the very onset of the disease there is vomiting, and in young children diarrhoea. Many cases are attended with considerable agi- tation- and anxiety, or drowsiness, more rarely with convulsions. Ac- cording to the observations of Rilliet and Barthez, it is in pneumonia occurring at the summit of the lungs, in young infants, that the attack commences with compulsions, which are sometimes violent and re- peated, and followed often by loss of consciousness. The lips are usually of a bright red, the tongue of a florid hue, someAvhat dry, and frequently coated along its centre with a thick white fur. Dr. West describes a peculiarity in the mode of sucking and respi- ration, Avhich, in the early stage of the disease, Avhen it occurs in in- fants at the breast, affords a valuable indication of its true character, So soon, he remarks, as the lungs become affected, even when no other symptom exists than general febrile disturbance, and perhaps vomiting, the infant will be seen no longer to breathe solely through the nose, as in health, but to lie with the mouth partly open, and drawing in air through it. This imparts to the tongue its preter- natural dryness, and the same inability to respire through the nares causes the child to suck by starts. The infant seizes the breast eager- ly, sucks for a feAv moments with greediness, and then suddenly drops the nipple, and in many instances begins to cry. The respiration in pneumonia is invariably accelerated, the number of inspirations being generally upwards of thirty, and sometimes be- yond seventy, in a minute; there is also a peculiar abruptness in the inspiration, it occurring suddenly, before the expiratory movement in completed; the nostrils during the act of inspiration being more or less dilated. The acceleration of respiration does not always corre- spond in extent with the violence of the disease, nor does it in all cases progressively increase from the onset of the attack to its fatal termination. It is often absent or very slight in the pneumonia that frequently occurs in the course of chronic enteritis, and it may be masked by the symptoms of abdominal or cerebral disease. Accelera- tion of respiration is often strongly marked in cases of broncho-pneu- monia, the dyspnoea being so great in some cases as to threaten suffo- cation. This symptom follows ordinarily the same course as the pulse, increasing with it, and diminishing at the period when it diminishes. In cases of primitive pneumonia, the acceleration of the pulse and respiration obtain their greatest intensity generally by the end of the fourth or fifth day. By the seventh, or at the furthest by the ninth day, in favourable cases, the heat of the skin and frequency of the pulse diminish, the inspiratory movements become less frequent and unat- tended with dilatation of the nostrils; and the cough more free and moist: the fever now quickly disappears, the face becomes paler, and the expression of the. countenance more natural. The respiration as- sumes, finally, its normal rhythm, the appetite returns, the cough rapidly diminishes, and in a few days convalescence is fully established. DISEASES OF THE RESPIRATORY ORGANS. 301 In all the cases, except one, which fell under the notice of Rilliet and Barthez, and terminated favourably, the earliest period at which the acceleration of respiration disappeared was the sixth day, and the latest the twelfth; the general period of its disappearance being the seventh, eighth, or ninth. In pneumonia of the summit of the lungs, occurring in infants, ac- cording to the last-mentioned authors, there is an inequality to be ob- served in the respiration, it being effected by short, abrupt, broken efforts. There is always more or less dyspnoea, which is proportionate to the violence and extent of the pulmonary affection, and goes on increas- ing with the progress of the disease, and is often attended with great anxiety, and, in severe cases, Avith a sense of impending suffocation, rendering a recumbent position insupportable. The cough, which is at first frequent, short, dry, and painful, soon becomes moist; the expectoration, when it occurs, which is seldom the case in young children, is at first slight, and consists of a whitish, viscid mucus, but becomes subsequently reddish; it is rarely, however, rust-coloured. Pain of the chest is not invariably present; when it occurs it is generally acute, though sometimes dull; it is commonly felt, according to Dr. Gerhard, at the anterior margin of the axillae; it is augmented by the cough, and often declines long before the other symptoms disappear. There is generally a diminution or entire loss of appetite, and in- creased thirst. The bowels are commonly torpid; though, occasionally, when the disease is complicated with intestinal inflammation, profuse diarrhoea may be present throughout the disease. There is often an anxious expression of the countenance. In cases occurring in the course of chronic enteritis, the skin becomes, occasionally, covered with furunculi or ecchymoses, while the parts to which blisters have been applied are liable to become ulcerated. When the pneumonia is severe and extensive, the patient exhibits considerable dulness or drowsiness, often amounting to complete stupor. Delirium is not often observed, and when it is, we have generally found it to be an unfa- vourable symptom. The cough varies greatly in violence and frequency, according to the extent and intensity of the pulmonary inflammation, the stage of the disease, and various concomitant circumstances. It usually aug- ments from the first day, but as it becomes more moist, in favourable cases, it gradually declines in violence, until towards the eighth or ninth day, when it diminishes rapidly, and finally disappears. Should, how- ever, the pneumonia become more diffused, or occur in the course of some acute affection, and in children not much debilitated, the cough is very frequent and intense, and is rarely attended with a free ex- pectoration. In some cases, in which the inflammation of the lungs is extensive, there is a sense of suffocation, with a dark violet hue of the lips and tongue, analogous to what is observed in capillary bronchitis. In the attacks'of pneumonia that so frequently occur in the course of chronic enteritis, there is seldom much cough; occasionally, indeed, it is en- 302 DISEASES OF CHILDREN. tirely absent: the skin in these cases is pale and cool, the pulse small, and the face and extremities oedematous. The disease, in fact, is often so destitute of leading symptoms, that its existence might be over- looked, were it not for the physical signs revealed by auscultation. The peculiarities which distinguish that form of pneumonia which is preceded by bronchitis, are very accurately sketched by Dr. West of London. The disease often comes on insidiously, and developcs itself gradually without its being possible for us, in most cases, to fix the exact date of its attack. Occasionally, however, there is a well- marked accession of fever and dyspnoea, and an aggravation of all the symptoms, sufficient to mark the time when the pneumonia super- venes. The fever and heat of skin are less than in the other forms of the disease, but the dyspnoea and distress are usually greater, and the face presents, from the first, a more livid hue. The cough is less hard, but often comes on in paroxysms, which greatly distress the patient; the respiration is more hurried and more irregular; the irregularity coming on at an earlier stage of the disease. Head symptoms are more frequent; the patient's sleep is disturbed, and he often mutters in his sleep, and has far more restlessness and jactitation when aAvake. Convulsions and coma more frequently precede death, and death occurs at an earlier period than in the other forms of pneumonia. It is almost exclusively from the physical condition of the chest, that our diagnosis is to be derived in this disease. The physical signs are the same as in the pneumonia of adults,—crepitant rhonchus, bron- chial respiration, and a flat sound upon percussion. Fine, crepitant rhonchus is seldom, if ever, present without bronchial respiration;— Avhile these, with diminished sonorosity of the chest, are always at- tended with bronchophony. The crepitus is generally larger in chil- dren ; and if, for a short time, it is not heard, it may be generally re- produced, by causing the child to cough, when it is again distin- guished, in the strong inspiration that succeeds the cough, giving rise to a sound like the cracking of a whip. (Gerhard.) In cases of simple primitive pneumonia, if of the lobar form, even from the very onset of the disease, crepitant or subcrepitant rhonchi may be detected, and often bronchial respiration on one side of the thorax towards its base. In the lobular form, the subcrepitant rhonchi are more generally diffused, while the bronchial respiration is rarely heard; the extent of the latter increases with the increase of the dis- ease, while the rhonchi decrease. - By the time the acceleration of the respiration and of the pulse has attained its maximum the bronchial respiration becomes intense, and is accompanied with bronchophony, or with a ringing sound of the voice, and extensive dulness of the chest. As the symptoms diminish in intensity, and the cough becomes more moist, the subcrepitant rhonchi are very abundant, the ringing sound of the voice is heard over a greater space, the bronchial expira- tion continues, but the dulness of the chest is much less marked. Even after convalescence has been established, a slight prolongation of the expiration is still to be detected, as well as a diffused ringing sound of the voice. The respiration continues feeble for several days, and does not for a long time recover its proper vesicular tones. DISEASES OF THE RESPIRATORY ORGANS. 303 When the inflammation is of a still more violent character from the first, humid rhonchi are heard throughout the chest, intermixed with others of a drier character, or with bronchial expiration and a diffused ringing of the voice. Bronchial respiration, as Dr.West has remarked, must always be regarded as a very grave sign. In eleven out of twenty cases of pneumonia in children where it was detected by that gentleman, the disease had a fatal termination. The mucous rhonchus is heard in most cases of broncho-pneumonia, and in cases of lobar pneumonia, in the neighbourhood of the subcre- pitant rhonchus, and, occasionally, where distinct bronchial respiration exists, and it often persists for a long time after every other sign of disease has disappeared. The physical signs of lobular pneumonia, as it usually occurs in young children, are at first limited to the mucous and subcrepitant rhonchus, dependent upon the secretion of mucus in the bronchi. The subcrepitant rhonchus is frequently continued throughout the disease, being often the only stethoscopic symptom present: it is rarely re- placed by the fine crepitant rhonchus, as in the pneumonia of adults. When induration has extended to a considerable portion of the paren- chyma of the lung, bronchial respiration becomes developed, chiefly at the upper and middle portions of their posterior part; it is rarely heard in the lower lobe, from the comparative smallness'^of the bronchi, and their early obliteration, by the progress of the disease. The respira- tory sounds are very peculiar; the inspiratory murmur, instead of being full and expansive, as in a healthy child, is short, obscure, and almost without the vesicular murmur, and may or may not be accom- panied with the mucous or subcrepitant rhonchus; the expiration is rarely distinct, unless the bronchial respiration is fully developed, when it is usually louder than the inspiration. The signs indicative of inflammation of the parenchyma of the lung are often entirely ob- scured by the mucous rhonchi of bronchitis. (Gerhard.) When lobular inflammation of the lungs is more generally diffused, upon percussion, the sound, on both sides of the chest, posteriorly, will be dull, compared with that of a healthy child; more or less so, ac- cording to the extent of the induration. The duration of pneumonia in children will, in a great measure, de- pend upon the severity of the attack; the extent of the inflammation; the nature of the treatment; and the period at which it is commenced. In very violent attacks, the disease implicating a considerable portion of.the lung, death may take place very promptly; in other cases, the fatal termination may occur at a much later period, from extensive disorganization of the lungs. We have seen the disease, in what were evidently very severe attacks, promptly cut short, by appropriate re- medies; but in general, even in cases where recovery takes place, the disease is of some continuance. In the cases reported by Dr. Gerhard in which the commencement and termination of the symptoms were ascertained, the mean duration of the pneumonia was nearly fifteen days. In the more severe and unfavourable cases the dyspnoea is very in- tense from the onset of the disease—the pulse is extremely small, the 304 DISEASES OF CHILDREN. face pallid, with a violet tinge of the lips, and at the summit of the cheeks. The general symptoms augment with the progress of the local disease, and death may occur upon the third or fourth day. In other cases, after the fifth or sixth days, the symptoms exhibit no far- ther increase, but remain stationary; or, more generally, while the ac- celeration of the pulse, and a frequent, difficult, and painful cough, with loss of appetite and some degree of thirst continue, the fever abates, the face becomes pale, a wasting diarrhoea sets in, the child becomes rapidly emaciated, and, in a state of the utmost debility, at the termi- nation of perhaps three or four weeks, expires. The fatal termina- tion may be hastened by the occurrence of pleurisy, measles, gangrene of the mouth, &c. Acute pneumonia, occurring in the course of some other acute dis- ease, was found by Rilliet and Barthez to seldom continue beyond the twenty-fifth day. The progress of chronic pneumonia is very gene- rally sIoav; the disease may continue for three or four weeks, or even longer. The pathological anatomy of pneumonia in children has of late years attracted much attention. Among those who have investigated it with the greatest care are to be ranked Rufz, Valliex, Lanoix, La Berge, Barrier, Becquerel, Billard, Rilliet and Barthez, Bailly and Legendre, of France, West, of England, Albers, Jorg, Succow, of Germany, and Dr. Gerhard, of Philadelphia. The anatomical lesions differ very materially, according as the pneumonia is lobular or lobar, and according to the period of the dis- ease when death takes place. The lung affected with lobular pneumonia is generally soft and flaccid; externally it presents a mottled appearance; portions of a deep red or violet colour being interspersed in the midst of others having the natural grayish-red tint. The dark red or violet patches are usually distinctly circumscribed, and of a circular or oval form, slightly projecting, and hard to the touch. They are most commonly situated at the inferior edge of the lung, but may occur at other por- tions of its surface. The part occupied by them does not collapse upon the chest being opened. In some cases the marbled appearance of the lung is absent, but spots of induration, more or less deeply seated, may be detected by the finger, the lung having an uneven or knotted feel. A section of the diseased lung presents the same marbled appear- ance as the exterior. In the first stage of the disease, the dark red or violet portions are more or less accurately circumscribed; they are somewhat firmer than the surrounding parts, swim when thrown into water, crepitate beneath the finger, and however carefully separated from the sound portions of the lung, they yield, upon pressure, a red- dish fluid intimately mixed with air. In the second stage, the dark red portions form nodules of a firmer and more compact consistence. Their cut surface is smooth, and when carefully detached from the surrounding parts, they crepitate none, or but slightly, and sink rapidly when placed in water. When the central portion alone of the nodule is subjected to pressure, a red sanious fluid escapes, without any ad- DISEASES OF THE RESPIRATORY ORGANS. 305 mixture of air. It is comparatively rare that single lobules are found affected, the indurated portions usually comprising four or five, which together form a mass of the size of a nut or almond. If the patient lives for some time, the intervening substance usually becomes affected, and the lobular is thus converted into lobar pneumonia. This change does not appear to take place from the gradual extension of disease, from each inflamed lobule, as from so many distinct centres; but sooner or later, the whole intervening pulmonary substance seems at once to become the seat of inflammatory action, which runs its course, as in ordinary lobar pneumonia. In the third stage of the disease, the section of the lung presents a grayish colour, inclining more or less to yellow, in different cases. The pulmonary tissue is very friable, and when pressed gives dis- charge to a purulent fluid, its tissue being infiltrated with pus. If the inflamed portions of lung are attentively examined, it will be seen that some of the lobules are more projecting than others, and that here the vesicles are not compressed as in the surrounding parts. When the lobules are pressed, they give discharge to a purulent fluid. Rilliet and Barthez describe two forms, or rather varieties of lobu- lar pneumonia, the mammelonnated and the partial. In the first, there exists a nodule of hepatization, differing but little in colour or appear- ance from the surrounding tissue. Its limits are clearly circumscribed, even when the neighbouring tissue is engorged. It is sometimes com- pletely surrounded by a layer of about half a line in thickness, white, firm, and of a fibrous appearance. The hepatized nodule slightly pro- jects above the surface of the incised lung, from the collapse of the surrounding air-cells. The nodule varies in size from that of a hemp seed to that of a pigeon's egg. It is spheroidal in form, and has usually a regular surface. There may exist but a single nodule in one lung, or they may amount to twenty, thirty, or more. This form of lobular pneumonia results, according to Rilliet and Barthez, from the inflammation being confined to one or more lobules. They have found invariably the hepatized nodules to be surrounded by a circle of pulmonary tissue in a state of engorgement. The disease very generally runs on to the third stage, and terminates in the forma- tion of an abscess. In the same lung there may be detected circum- scribed nodules of hepatization in the first and second stages, and, also, rounded masses of a straw-colour, very humid wjien cut into. At a more advanced stage, the pus, which was at first deposited in the in- terstices of the pulmonary tissues, becomes collected in the centre of the nodule. This minute collection of pus is surrounded by two con- centric zones, the internal one yellow—hepatization of the third de- gree ; the external one red—hepatization of the second degree. At a later period, the exterior zone passes into suppuration, and the size of the central cavity is increased at the expense of the inner zone. At a later period, an incision through the diseased part reveals cavities varying in size from a few lines to four or six. They are, in general, round, more rarely oval, and contain usually a thick tenacious yellow or greenish pus, perfectly free from any admixture of air. Sometimes small coagula of blood are mixed with the pus. 20 306 DISEASES OF CHILDREN. At first, these cavities are formed by a layer of hepatized pulmonary tissue, lined with a layer of concrete pus, or, in some cases, Avith a false membrane, yellow, soft, and readily detached. Subsequently this membrane becomes changed into a thin, smooth, polished tissue, analogous to a serous membrane. The abscesses sometimes freely communicate with each other, and at the point where the bronchus penetrates their cavity, its mucous membrane presents a true solution of continuity. When the inflammation invades separately several neighbouring no- dules, the cavity of the abscess is multilocular, each cell being isolated by a lamina of hepatized pulmonary tissue, upon the rupture of which the different abscesses communicate with each other. These abscesses may occur in different parts of the lung; they have generally, however, a tendency to approach the surface. It often hap- pens that an adhesion takes place between the opposing surfaces of the pleura, or the pleura of the lung becomes gradually thinned, and finally perforated, giving rise to a true pneumo-thorax. In a single case, Rilliet and Barthez have seen an adhesion take place between the base of the left lung and the diaphragm, the abscess of the lung communicating, by a perforation of the diaphragm, with the peritoneal cavity. The pulmonary abscesses are often completely isolated, and, with the exception of a thin layer of hepatized parenchyma, in their imme- diate vicinity, surrounded by perfectly healthy pulmonary tissue. Oc- casionally, however, the greater portion or the whole of one of the lobes may have been invaded by the inflammation. The number of abscesses is very variable; sometimes there is but one; at others, but very rarely, they are so numerous that we cannot count them. Their size is usually in inverse proportion to their num- bers. They are, in far the greater number of cases, confined to a single lung; and they more frequently occur in the left than in the right. They are met with most commonly in subjects under six years of age. Partial lobular pneumonia is much less circumscribed than the pre- ceding variety. There is no distinct limit between the healthy and diseased portions. In extent, the disease very generally exceeds the mammelonnated. Its form is not always regular. The diseased por- tions may throughout have reached the second stage, or at the centre alone, the circumference being still in the first stage. In the last case, the circumference may be in contact with several other parts of the lung, in a diseased condition, so that nearly the whole of an entire lobe may present an intermixture of the characteristics of pneumonia in the first and second stages. This Rilliet and Barthez denominate generalized lobular pneumonia, which, when it has reached the third degree," is strictly lobar. There is, according to the observations of Rilliet and Barthez, a difference between lobar pneumonia and generalized partial pneumo- nia. Although in both there is a union of the several stages, yet they are differently disposed. Thus, in ordinary lobar pneumonia, when the inflammation commences at the base, it successively invades the DISEASES OF THE RESPIRATORY ORGANS. 307 superior portions of the lung, and while the base passes to the second stage, the superior portions are in the first, and when these last have arrived at the second, the first have attained the third: in the case of generalized partial pneumonia, many lobules, indiscriminately disse- minated, become inflamed and finally unite. Sometimes, however, the partial pneumonia, in becoming general, does not pass to the third stage. But even hare we find ordinarily in the same lung, or in that of the opposite side, lobules in the second stage of inflammation, the remains of Avell-marked lobular pneumonia. The lobular pneumonia is of much more frequent occurrence than lobar pneumonia; partial and generalized lobular pneumonia is more frequent than the mammelonnated form; partial pneumonia is more common than generalized pneumonia. In the great majority of cases lobular pneumoijia is double. Fre- quently the pneumonia is much more extensive on one side than the other. Thus it is partial in one lung, generalized lobular in the other. A union of the three forms of pneumonia—mammelonnated, partial, and general—is often found in the same patient. Mammelonnated pneumonia is equally frequent in every portion of both lungs, while generalized pneumonia is far more frequent in the inferior than the superior lobes. Partial pneumonia is often disseminated through all the three lobes; it is more frequently met with, however, in the infe- rior. Mammelonnated pneumonia is ordinarily equally diffused in both the right and left lung, while generalized pneumonia predomi- nates in the left. Mammelonnated pneumonia is of much more rare occurrence beyond the sixth year than partial pneumonia, while ge- neralized pneumonia is still more rare than the former between the sixth and fifteenth years. (Maladies des Enfans, T. i. p. 61.) It has been doubted Avhether all the changes in the texture of the lungs described as characteristic of lobular pneumonia are really the result of inflammation. Hasse, in his Pathological Anatomy, refers many of these changes to the persistence of the foetal state of the lung subsequent to birth; a condition which Jorg has described under the name of atelectasis pulmonum, and has pointed out the distinction be- tAveen the latter, and the changes in the pulmonary tissue produced by inflammation. In atelectasis, the colour of the diseased portions of the lung always approaches more to a violet, their exterior appearing smooth and shining, contrasting thus with the dull, brown-red surface of inflamma- tion. In inflammation, again, the diseased portions are preternaturally distended, whilst in atelectasis they are collapsed, and inferior in vo- lume eAren to the healthy texture, but susceptible, provided the condi- tion has not lasted too long, of artificial inflation, and in this manner, of acquiring a perfectly natural appearance. In inflammation, fhe pul- monary tissue is softened; in atelectasis it is hard, and the cut surface is smooth, not granular. In short, we have nothing like pneumonia, excepting the solid, non-crepitant mass, which has been confounded Avith red hepatization. Views similar to those of Hasse are adopted by Dr. West in his very excellent monograph on the pneumonia of children. More re- 308 DISEASES OF CHILDREN. cently, the subject has been minutely investigated by MM. Bailly and Legendre, the results of Avhose observations are published in the Ar- chives Gen. de Med. for February and March, 18-14. These gentlemen deny the generally received opinion of the inflam- matory nature of what has been termed lobular pneumonia, and main- tain that, in every instance, it is a peculiar state of .condensation of the lung, similar to that of the foetal state. It consists in an occlusion of the pulmonary vesicles, which may result from the mere contractility of the tissue, or may depend on congestion of the vascular network exterior to the vesicles. The former is the simple, the latter the con- gestive form of this affection. The congestive form is usually met Avith along the posterior border of the lungs, and generally accompanied catarrhal inflammation of the vesicles. In either of these forms of the foetal lung, insufflation reproduces, more or less completely, the natural condition of the lobules. Though occasionally met with unassociated with inflammation, yet, in by far the majority of cases, this condition becomes developed under the influence of catarrh and catarrhal pneu- monia. When unattended with catarrh, and involving only isolated lobules, it cannot be detected until after death, but in the new-born infant it usually assumes the lobar form, is attended by the physical signs of deficient respiration, and associated with the absence of all signs of constitutional reaction. Lobular pneumonia has, they main- tain, strictly speaking, no existence; the action of inflammation never being confined to a single lobule. Partial pneumonia would therefore be a fitter term. Insufflation does not modify the patches of true he- patization, and the bronchi leading to such hepatized nodules are exempt from catarrh; two characters which distinguish partial pneu- monia from the lobular engorgements of partial broncho-pneumonia. True partial pneumonia, according to MM. Bailly and Legendre, is by no means common in children, though when hepatization does occur in those under five years of age, it almost always affects the partial form. The statements, therefore, that have been made with reference to the variety of lobar pneumonia in infancy are correct; but almost all that has been said about the extreme frequency of lobular pneu- monia at that age, must be taken as referring to the foetal state of the lung. Broncho-pneumonia may affect healthy lobules, or those in the foetal state. In the latter case it gives rise to appearances which have led to the supposition that these lobules were the seat of a parenchy- matous inflammation. Dr. West has repeated the experiments of MM. Bailly and Legendre on many occasions, and fully substantiates the correctness of their statements. Dr. Fuchs, in his very excellent monograph on the Bronchitis of Children, published at Leipzig, in 1849, denies that, in children under five years of age, he has ever met with an instance of true pneumonic condensation, and adduces conclusive e\ddence of the connexion of Avhat has been denominated lobular pneumonia with bronchitis, and of its relation to bronchial obstruction. This connexion and relation has also been ably illustrated in a treatise On the Pathological Ana- tomy of Bronchitis, and the Diseases of the Lung connected with Bronchial Obstruction, by Dr. W. T. Gairdner, of Edinburgh. (Edin- burgh, 1850.) DISEASES OF THE RESPIRATORY ORGANS. 309 The general results to which he has been led from a careful series of observations are, 1st, that in all cases of collapse of the lung, as well in the adult as in children, not caused by external pressure, the bronchi have presented unequivocal appearances of obstruction; 2d, that in most, if not all, the instances of severe and fatal bronchitis, especially if tho secretions had become ropy or inspissated, more or less collapse of the pulmonary texture has also been present—that, under peculiar circumstances, a much less amount of obstruction may be attended with collapse of the pulmonary texture, the symptoms in such cases probably attracting little attention. In reference to the mechanism and causes of bronchitic collapse, Dr. Gairdner remarks, " It is clear, from experiment, as well as from pa- thological observation, that the most usual and most direct effect of obstruction, or of diminished caliber of the bronchi, however caused, is not accumulation, but diminution in quantity, of the air beyond the obstructed point. It is probable that this is due in part to the com- parative weakness of the inspiratory poAver, and that the proposition of Laennec may, therefore, correctly enough be inverted. There is also, however, another mechanical condition which comes into play in producing collapse from obstruction, especially in the case of a A-iscid plug of mucus, AA-hich is most commonly, in bronchitis, the source of this affection. This condition is found in the form of the tubes. " The bronchi are a series of gradually diminishing cylinders, di- viding, for the most part, dichotoneously. If a plug of any kind, but especially one closely adapted to the form of the tube, and possessing considerable tenacity, be lodged in any portion of such a cylinder, it will move with much more difficulty toAvards the smaller end, and in doing so will close up the tapering tube much more tightly against the passage of air, than when moved in the opposite direction into a Avider space. If such a plug be placed over a bifurcation, it will, even if freely moving in the larger space in which it lies, be of sufficient bulk to fall back upon one or other of the subdivisions during inspira- tion, in the manner of a ball valve upon the orifice of a syringe, and thus completely to occlude it. The consequence of this mechanical arrangement must inevitably be, that at every expiration a portion of air Avill be expelled, which in inspiration is not restored,partly owing to the comparative weakness of the inspiratory force, and in part to the valvular action of the plug. If cough supervene, the plug may be entirely dislodged from its position, or expectorated, the air of course returning freely into the obstructed part; but if the expiratory force is only sufficient slightly to displace the plug, so as to allow of the outward passage of air, the inspiration will again bring it back to its former position, and the repetition of this process must, after a time, end in perfect collapse of the portion of lung usually fed with air by the obstructed bronchus."—"In considering, as a whole, the causes which tend to produce bronchitic collapse, they seem to resolve themselves into the following: firstly, the existence of mucus in the bronchi, which is more liable to produce obstruction according as it is tenacious and viscid; secondly, weakness or inefficiency of the inspi- ratory power, hoAvever caused; thirdly, inability to cough and expec- 310 DISEASES OF CHILDREN. torate, and thus to remove the obstructing mucus. Of these condi- tions, the first must be considered as the immediate exciting cause, the others, as predisposing causes, co-operating with the first, but in- capable, without it, of producing collapse." The circumstances producing inefficiency of the inspiratory act Dr. Gairdner considers to be weakness of the muscles of inspiration, usu- ally concurring with general debility; distention of the abdomen, im- peding the descent of the diaphragm; and, finally, which is one of the greatest importance in relation to this subject, want of due resistance on the part of the thoracic parietes. The full dilatation of the lungs is only effected when the depression of the diaphragm is accompanied by the elevation of the ribs and widening of the thorax; and if tho bones of the latter be very yielding, the external muscles of inspira- tion cannot, of course, act effectively under an obstruction. This is obviously the reason of the greater tendency in children to collapse of the lung as a consequence of bronchitis. The respiration of the child is at all times, even in health, more diaphragmatic than that of the adult; and the observations of Rilliet and Barthez afford satis- factory evidence of the comparatively small dilatation of the thorax in children, particularly of its lower part. When any obstruction exists to the entrance of air into the chest, even this small dilatation ceases, and collapse of the lung very readily takes place. Under such circumstances, Dr. Rees (on Atelectasis Pulmonum, London, 1850) has pointed out that in very young children the motions of the chest are absolutely reversed, and instead of the descent of the diaphragm being accompanied by expansion of the chest, the ribs give Avay be- neath the exhaustion caused by it within the thoracic cavity, and bend inwards to accommodate themselves to the collapsed lung in inspira- tion. This altered movement of the chest in infants is regarded by Dr. Rees as pathognomonic of atelectasis. It is also a prolific source of that permanent deformity of the chest which, in the early years of life, is often ascribed, Avith too little discrimination, to rickets.1 The origin of the minute abscesses which so often occur in the por- tions of lung supposed to be in a state of hepatization from lobular pneumonia, Dr. Gairdner explains as follows: When pus accumulates in the central bronchi of a collapsed lobule, the evacuation of that pus is prevented from occurring, firstly, in consequence of the absence of the expiratory vis a tergo ; and secondly, from the resistance opposed by the thickened mucous membrane and its secretion, closing up the bronchus in front. The coats of the ultimate bronchi, therefore, soft- ened and injured by disease, gradually give way to ulceration, and the pus, which thus accumulates in still larger quantity, may at first scarcely be circumscribed, but soon begins to be surrounded by a false membrane exactly similar to that of an abscess in any other part of the body. The continuity of the membrane with that of the original bronchus may be either maintained from its first formation, or it may be secondarily established. It is asserted by M. Bouchut, that even true hepatization may be removed by insufflation; in this, however, he is decidedly wrong. 1 Gairdner, op. cit., pp. 33, 34. DISEASES OF THE RESPIRATORY ORGANS. 311 The hepatized portion may sometimes be made to assume a brighter colour, but not to resume the texture of healthy lung, as is the case Avith lung in the foetal state. Dr. Gairdner remarks, however, that he does not believe that inflation alone is applicable to the determi- nation of the presence or absence of true hepatization in those mixed cases in which alone there is any difficulty. For he has observed that on the one hand, the partially pneumonic lung may be inflated when the affection is recent, and combined, as it frequently is, with bron- chitic collapse; and on the other, that in the latter lesion in its purest forms, complete inflation is often very difficult or impossible after the collapsed state has been of some duration. In fact, the lung then begins to undergo a modification in its nutrition and structure, which ultimately leads to permanent atrophy. The anatomical characters of the lobar pneumonia of children are identical with those of the same disease in adults; it is unnecessary for us, therefore, to detail them here. We meet Avith the evidences of inflammation in the stage of engorgement and hepatization, both red and gray, these lesions proceeding ordinarily from the base to ' the summit. The termination in abscess is rarely met Avith. The disease is most generally confined to one lung, and occurs more fre- quently in the right than in the left. It is most generally accompa- nied with pleuritis, to a greater or less extent. Beside the lesions already described, there are others which occa- sionally occur in the lungs of those who die of pneumonia. Portions of the surface of the lung are found to be without crepitation, de- pressed, soft, and flaccid. Their colour is violet, or pale red, marked by white lines disposed in lozenges or squares, which designate the lobes. Their section presents a smooth surface, of a red colour, and somewhat firm texture, resembling a portion of muscle. When pressed, they give discharge to a serous, bloody fluid, without any mixture of air. The carnified portion is often found around the lower edge of one of the lungs, or it may occupy a considerable portion of one lobe, or the individual lobules. It is as frequent in one lung as in the other, and is very generally confined to one.' There is some difference of opinion as to the exact character of this lesion; the supposed carnification is no doubt, in many cases, merely portions of persisting foetal lung. True carnification Rilliet and Bar- thez refer to the effects of inflammation, and in this opinion Dr. West would seem to coincide, and, we believe, very properly. Inflammation of the bronchi, from a simple injection with increased mucous secretion, to a dilatation of the bronchi with purulent effusion, or the formation of false membrane, is a common complication of pneumonia. It is very generally confined to the smaller bronchial ramifications. Pleurisy is also a frequent complication of pneumonia, and is often of a very intense degree. Emphysema of the lung is not unfrequently met with; its extent is in direct proportion with the extent of the pneumonic and bronchial affections, their violence, and the amount of dvspnoea with which they are attended. It generally occupies the summit of the organ, or its sharp edge. It is commonly double; Avhen 312 DISEASES OF CHILDREN. on one side only it is confined to the inflamed lung, and is here always most considerable. By a few writers, lobular pneumonia Avas supposed to be peculiar to children under five years of age; but by the investigations of Dr. West, Rilliet and Barthez, and others, it has beon shoAvn that al- though more frequent, perhaps, in young children, lobular pneumonia may, nevertheless, occur at any period of childhood; a fact Avhich our own observations very fully confirm. It has been asserted that pneumonia in children under five years is invariably preceded by bronchitis. The result of the more recent researches of Rilliet and Barthez has convinced them that lobar pneumonia, Avithout bron- chitis, occurs more frequently in children under five years than they supposed in 1838, the date of their first publication; that lobular broncho-pneumonia is much more frequent than simple lobular pneu- monia; but that it is incontestable that lobular pneumonia, mam- melonnated, partial or generalized, may, exist in children without bronchitis; and, finally, that inflammation of the bronchi and of the lungs is, in some cases, simultaneous. The lobular form of pneumonia is not only the most frequent during childhood, but it is also the most* serious. Lobar pneumonia, when it occupies only one lung, and occurs in children between six and fifteen years, whose health has not been impaired by previous disease, unless complicated by some secondary affection, is not a very fatal disease, if a judicious course of treatment be commenced with in its early stages. . Its serious character is greatly enhanced by its being complicated with certain other diseases. The most common of these are measles, hooping cough, chronic enteritis, and small-pox. The most fatal of its complications is that with measles, and perhaps with chronic inflammation of the bowels, and with small-pox. Pneumonia in children may be produced by any of the causes which ordinarily give rise to bronchitis. It is, consequently, most prevalent during spring, autumn, and winter—and among the chil- dren of those classes who are most liable to be exposed to cold or to sudden alternations of temperature. Cases, however, occur at all sea- sons of the year, but comparatively seldom during those months the temperature of which is mild and equable. The disease occurs in both sexes, but most frequently in boys. Of 245 cases which are noticed by Rilliet and Barthez, 150 occurred in boys and 95 in girls; in 118 observed by Dr. West, 65 were in boys, and 53 in girls; and in 104 cases, of Avhich an accurate account has been kept by ourselves, 60 were in boys and 44 in girls. In Phila- delphia, during the ten years preceding 1845, of sixteen hundred and fifteen deaths from pneumonia, 872 were in boys, and 743 in girls. Pneumonia is very liable to recur in the same child, after a shorter or longer interval. Of seventy-eight children who came under the care of Dr. West, with inflammation of the lungs, 31 are reported to have had previous attacks, namely, 21, once; 4, twice; 2 four times; and 4 several times, the exact number of attacks not being mentioned. The treatment of pneumonia in children must be, in a great mea- sure governed by the particular circumstances of each case. The DISEASES OF THE RESPIRATORY ORGANS. 313 employment of bloodletting will very generally be found beneficial; and in children over three years of age, in the commencement of the disease, when carried to a proper extent, it will not only greatly and promptly relieve the dyspnoea and cough, but have a tendency to ma- terially shorten the duration of the attack. In young children leeches or cups to the anterior parietes of the chest, or between the scapulae, in numbers proportioned to the violence of the symptoms, and the age and strength of the patient, will, in general, suffice; but in older children, whenever it can be effected, we should prefer, in severe cases of pneumonia, bleeding from the arm, which has always appeared to us to produce a more decided impression upon the dis- ease, than the more gradual abstraction of blood by leeches or cups. The propriety of repeating the bleeding must be left entirely to the judgment of the practitioner: when the first bleeding has been well- timed, and carried to a sufficient extent, a second will not generally be required. Whenever, however, the leading symptoms, particularly the dyspnoea, continue with little abatement, we should never hesi- tate to repeat the bleeding, either from the arm, or by leeches or cups, according to the violence of the remaining symptoms, the age of the patient, and the amount of strength remaining. It is, how- ever, in the early period of the attack alone, that we are to expect any very decided advantage from bloodletting; in the more advanced stages of the disease, it is seldom beneficial or admissible; though we have occasionally met with cases that had existed several days, in which the cautious application of cups between the shoulders has been attended with very marked relief. In all cases the exhibition of some mucilaginous drink, in small portions, and at short intervals, will be found to abate, very sensibly, the cough, and relieve the dryness of the fauces, which, in the early stage of the disease, is often a harassing symptom. A solution of gum, or the mucilage of the elm bark, or pith of sassafras sweetened, will be the best we can employ. By many physicians, the employment of tartarized antimony, in large doses, has been recommended in the treatment of pneumonia occur- ring in children, as in that of adults, either in conjunction with blood- letting, or as the sole remedy; and cases have been published by Guersent and others in proof of its efficacy. M. Herard, in a paper published in L'Union Medicate, Nos. 127, 131, considers that tartar emetic, in large doses, should be regarded as almost the exclusive re- medy in children over two years of age; although, in exceptional cases, one or two emissions of blood or a blister may be required. He does not believe that the injurious effects upon the alimentary canal, which are said to result from the continued administration of tartar emetic to young children, are of so common occurrence as has been supposed. In thirty-one cases of pneumonia in children treated exclusively by large doses of tartar emetic by MM. Baudelocque and Blache, in the Hospital for Infants in Paris, seven died; of these, two fell victims to tubercular pneumonia, and in the other five, lobular pneumonia was very extensive. This form of pneumonia Dr. Herard considers as far less amenable to tartar emetic than the lobar, while cases of broncho* 314 DISEASES OF CHILDREN. pneumonia, occurring in children under two years of ago, are gene- rally far more efficaciously treated by emetics than by antimony given in contra-stimulant doses. The rapidity with which convalescence takes place, is, he remarks, one of the most striking and advantageous results of the use of antimony. Given as an emetic, in the commence- ment of severe cases, we have often derived advantage from the em- ployment of tartarized antimony; and the same appears to have been the experience of others. In young infants, we have never employed the remedy in any form, believing it to be, at best, one of doubtful propriety at this period of life; but in the pneumonia of older children, Ave have repeatedly given it in divided doses, subsequently to bleeding, and often with very great benefit. In the cases occurring in infants under three years of age, small doses of ipecacuanha, combined with calomel, may be given; it is a remedy, with the effects of which we have had cause to be much pleased. In numerous instances, we have combined with it a small portion of powdered digitalis, and we think not without very decided advantage.1 In many cases, we may add to the mucilaginous drinks of the patient a small quantity of the wine of ipecacuanha, and of the tincture of hyoscyamus.2 This will often be found, after bloodletting, to aid very materially in allaying the cough, dyspnoea, and general restlessness. If the calomel should purge, as is sometimes the case, this may be obviated by combining it with a portion of Dover's powder. 1 R.—Calomel, gr. iv. ad vj. a R.—Mucil. G. acaciae, ^iv. Ipecac, gr. iij.—iv. Vin. ipecac, gj. Pulv. digitalis, gr. iij.—iv.—M. Tinct. hyoscyami, gj. f. chart. No. xij. Sacch. alb. pur. giij.—M. One to be given every three hours. A teaspoonful to be given every two, three, or four hours, according to the age of the infant. In the commencement of pneumonia, if the bowels of the child are costive or torpid, it is proper to administer a full dose of calomel, to be followed, in a few hours, by a dose of castor oil; or, in robust chil- dren, over three years of age, a dose of equal parts of magnesia and sulphate of magnesia. Subsequently the bowels should be preserved regularly open by enemata, or occasional doses of some mild purga- tive; a grain of calomel, with half a grain each of ipecacuanha and extract of hyoscyamus, administered twice or three times a day, will usually effect this object. Costiveness is not, however, very common in the pneumonia of children; an opposite condition of the boAvels is a more frequent and troublesome symptom. Blisters are remedies from which much advantage will be derived in most of the cases of pneumonia occurring in children. In violent cases, or in those attended with much febrile excitement, they should not be applied until the violence of the symptoms has been abated by direct depletion, and they should never be allowed to remain on longer than is necessary to produce a general redness of the skin; when removed, they should be immediately replaced by an emollient cataplasm. In slight cases, a weak sinapism may be employed, instead of a blister; a very good one consists of a thick slice of bread, dipped in vinegar, and lightly sprinkled, with powdered mustard. DISEASES OF THE RESPIRATORY ORGANS. 315 Warm pediluvia, with the addition of mustard, or sinapised hip baths, produce always a favourable revulsion from the lungs, and should. not be overlooked in the treatment of the pneumonia of children. After the violence of the disease has been somewhat abated, we have found great advantage from the administration of small doses of calomel, ipecacuanha, and extract of hyoscyamus, every three hours. Under the same circumstances, the compound honey of squill may be administered; given in divided doses throughout the day, it forms an excellent expectorant in cases of children. Dr. West speaks highly of mercurial inunction in stubborn cases. Under its employment, he has seen recovery to take place even where circumstances had seemed to warrant a most unfavourable prognosis. It is especially, he remarks, in cases of neglected pneumonia, where the time for depletion has long gone by, the patient having become ex- hausted, and the employment of calomel is forbidden by the presence of diarrhoea, that the full value of mercurial inunction is seen. Dr. West employs it in the proportion of one drachm, rubbed into the thighs and axilla every four hours in children of four years of age. He has never observed salivation to be induced by it, but he has seen the symptoms of the disease gradually diminish in severity during its em- ployment, and the solid lung become once more permeable to air. In chronic cases, our chief dependence is upon revulsives, applied either upon the chest, or upon the surface generally, and perhaps upon a judicious mercurial course, particularly by inunction. When in the advanced stage of the disease, there is great exhaus- tion, with symptoms of impending suffocation, the use of carbonate of ammonia has been strongly recommended;1 but, under such circum- stances, there can be but little hope of the patient's recovery. 1 R-—Decoct, senegas, ,^iij. Carb. ammoniae, gj. ad gjss. Sacch. alb. gij.—M. A teaspoonful to be given every three or four hours. It must be evident, that in severe cases, our chief hopes of a favour- able termination must be founded upon an early detection of the true character and extent of the disease, and the judicious employment, in the commencement of the attack, of bleeding, and the other antiphlo- gistic remedies adapted to the age of the patient, and the violence of the symptoms. After a change has occurred in the texture of the lungs, we can do but little beyond moderating the more pressing symptoms. The diet of the patient, in the early period of the more acute cases, should be confined, almost exclusively, to plain mucilaginous fluids, or Avhey; in the more prolonged cases, however, after the violence of the disease has been subdued, plain water gruel, arrow-root, or tapioca, may be allowed. When the disease occurs in infants, they should be always taken from the breast, and the mother's milk given to them in moderate quantities by means of a spoon, as well to prevent their stomach from being overloaded, as to guard against the mischievous effects of the violent exertion of the respiratory function in sucking. The apartment occupied by the patient should be kept of a comfort- 316 DISEASES OF CHILDREN. able, uniform temperature, and, at the same time, the purity'of the air should be secured by proper ventilation, and a strict attention to cleanliness. The patient should be placed always in a half-recum- bent posture, in order to render the respiration more easy, and to prevent the injurious consequences resulting from the stasis of fluids in the posterior portions of the lungs. Dr. West has given another very important precaution, that should never be neglected, which is, Avhen the disease has reached an ad- vanced stage, or involves a considerable extent of the lungs, to move the little patient with the greatest care and gentleness, lest com-ulsions should be brought on. He has known instances in which children have been seized with convulsions immediately on being lifted some- what hastily from bed, and placed in a sitting posture. ^ After convalescence is fully established, gentle exercise in the open air, in mild dry weather, may be taken Avith great propriety, but for a long period, the utmost care should be observed, by appropriate clothing, and other precautionary measures, to guard the patient from exposure to cold and damp; and, while a gradual improvement is made in his diet, rich, indigestible, and irritating food must be avoided, as well as excess in the use of those articles that are allowed. Having alluded, in the foregoing section, to that condition of the lung which has been denominated by Jorg Atelectasis Pulmonum, it may be proper to give a short notice of the disease, for the informa- tion of such of our readers as may not have met with that gentle- man's work, Die Fotuslunge in gebornen kinde. The disease consists in a compression or obliteration, to a greater or less extent, of the pulmonary cells, but especially the inferior lobes of one or both lungs, and the posterior half of the remain- ing lobes. It is usually most extensive in the right lung. The por- tion of the lung in which the obliteration of the cells exists, is de- pressed below the level of the surrounding tissue, of a dark red or violet hue, and neither by incision nor pressure is any crepitation pro- duced. It presents, when incised, a smooth red surface, from which a bloody serum may be squeezed, but in which no air bubbles can be detected; when separated from the sound tissue, and placed in water, it sinks to the bottom. When the diseased portions are artificially in- flated, the cells become dilated, and they assume the same condition as the surrounding parts. This condensation of the tissue of the lung, from compression of the air cells, is not produced by either in- flammation or effusion, but is the result of imperfect respiration, which prevents the air from penetrating and distending all the cells of the lungs; the parts affected, consequently, retain the colour and density of the foetal lung, and sink when placed in water. In infants who had died of atelectasis, Jorg invariably found the foramen ovale of the heart still open: this fact is confirmed by Hasse, who, however, very correctly remarks, that the patulence of the foramen is not un- common at the age at which death from atelectasis occurs. The causes assigned for this affection are, a very rapid and easy DISEASES OF THE RESPIRATORY ORGANS. 317 delivery, or a too strong compression of the head of the child during parturition;—both of which circumstances are common causes of as- phyxia in new-born infants;—or, when respiration does take place, they prevent it from being sufficiently full to dilateTthe whole of the texture of the lungs, and, hence, give rise to the disease under con- sideration. The affection is especially characterized by an imperfect, short, anxious, and sometimes scarcely perceptible or intermittent respira- tion; a feeble, plaintive, cry, difficulty of sucking, an imperfect ele- vation of the ribs and sternum, often a livid or blue colour, Avith cold- ness of the surface, a weak languid pulse, and symptoms of general prostration. In consequence of the imperfect respiration, and im- peded circulation, nutrition is always impaired, and hence, if the child survive, it becomes emaciated, and cannot bear the slightest motion or exercise. In some cases congestion of the brain is produced, and convulsions; or,from the violence of the respiratory efforts, inflamma- tion of the bronchi and lungs. The endeavour of the obstetrician should be, as early after delivery as possible to induce in the infant a deep, full, vigorous inspiration; for, if the respiration be allowed to continue weak, and the lungs to be but imperfectly expanded, the infant seldom survives for any length of time. The mouth of the infant should, therefore, be cleared of any mucus that may be present in it; and by smart slaps upon the glutei muscles, or upon the palms of the hands and feet, respiration will often be fully established, or we may proceed as di- rected in the section on asphyxia. Rubbing the chest and back with sulphuric ether, and introducing it into the nostrils and mouth, im- mersion in an aromatic warm bath, and repeated clysters and emetics are recommended by Jorg, all of which, however, are of doubtful propriety. Emetics, and all means which tend to increase the en- gorgement of the' vessels of the brain, are, indeed, strongly contra- indicated Avhen the brain has been injured during labour; in these cases a feAv grains of calomel, and stimulants to the lower extremities, cool lotions to the head, and even leeches to the latter, will often be found of advantage. 5—Pleuritis. Inflammation of the pleura is not an unfrequent disease of infancy and childhood. It may occur at any period, from birth upwards; but it is more frequently met with in children over two years of age. According to Rilliet and Barthez the primitive acute form of the dis- ease is very rarely met Avith in children under six years of age. In younger children, pleurisy is most generally a complication of severe bronchitis or pneumonia, though it may occasionally occur alone. Mr. Crisp, in a paper read before the South London Medical Society, (Lancet, January, 1847,) has shown, however, that pleurisy is by no means of so rare occurrence in infants as is generally believed. In forty-one post-mortem examinations made by him, of children under two years of age—the greater number under one year—six cases of in- flammation of the pleura were detected. In five it was combined with 318 DISEASES OF CHILDREN. pneumonia; in one it was complicated with pericarditis; in another Avith peritonitis and hydrocephalus; in one case only did the pleura alone appear to be affected. Although in some instances the disease is more difficult of detec- tion in young children than in the adult, and is especially liable to escape observation in infantile life, where many valuable signs, ob- tainable in more advanced life, are wanting; still, when the inflam- mation is confined chiefly to the pleura, he believes it may be easily recognised: even when complicated with pneumonia, attention to the auscultatory signs will enable us to ascertain its existence. The symptoms observed by Mr. Crisp in infantile pleurisy were: great restlessness, violent screaming at the onset of the attack, very quick "pulse, hot and dry skin, glassy eye, dry, unfrequent cough; the head thrown back, and great apparent pain on placing the child erect. On auscultation a dry, rubbing sound was heard. Many of these symptoms may be present in other diseases, as pneumonia, thus in- creasing the difficulty of the diagnosis; but when the dry, rubbing sound is heard, with frequent screaming, and an apparent increase of pain on elevating the head, he considers the existence of pleurisy to be pretty clearly indicated. If, in addition, mucous and crepitating rhonchi are heard, and only a small portion of the serous membrane is inflamed, the diagnosis is more obscure; but the disease may still, he remarks, be recognised by careful investigation. In older children the symptoms of pleurisy are more marked and characteristic. The disease generally commences with a chill, in some cases slight, in'others more severe, which is soon succeeded by more or less febrile reaction; the skin being usually dry and hot, the face flushed, and the pulse frequent, full and strong. To these symp- toms are soon added cough, dyspnoea, and acute pain of some portion of the chest. Immany cases there is vomiting of bilious matter, and sometimes pain of the head. The respiration is short, quick, and somewhat oppressed; the oppression being aggravated when the pa- tient is in a recumbent posture. The respiration is performed chiefly by the action of the abdomi- nal muscles and diaphragm; the motion of the chest being instinc- tively restrained by the patient, in consequence of the pain attendant upon the elevation of the ribs; sometimes each inspiration gives rise to a sharp cry or moan, and an expression of countenance indicative of suffering. The cough is at first short, dry, and stifled; it is gene- rally increased when the child is lying down, and more so when lying on one side than on the other. When both pleurae are affected the only position in which ease can be obtained is upon the back, with the head and shoulders elevated. Pain is generally complained of, and usually referred to one side or other of the thorax—sometimes to both. The pain is increased by the cough and on inspiration; and when intense, gives to the coun- tenance that peculiar contraction which is the common expression of suffering in children. If the disease is arrested in its first stages, the pain and dysp- noea generally abate; the last, as well as the fever, often entirely DISEASES OF THE RESPIRATORY ORGANS. 319 disappearing. The cough, in the course of the disease, becomes more moist, and a little viscid mucus is often raised by it: expectoration, hoAvever, is seldom attendant upon pleurisy, unless when complicated with bronchitis or pneumonia. When pleurisy occurs in the course of some acute disease in young infants, its onset is occasionally marked by an attack of convulsions or of suffocation, and in older children, by acute pain of the thorax. The dyspnoea and acceleration of pulse are often very considerable. The duration of pleurisy, when the disease is properly treated, is generally short, and its termination favourable. When accompanied with bronchial or pneumonic inflammation, it is somewhat difficult to ascertain, with precision, either its commencement or termination. In such cases it is usually very acute, and terminates much more promptly than when it occurs alone. Pleurisy may assume a very chronic form, and is then marked, at first, with very obscure symptoms. There is some degree of pain in the side—often a slight fever, with evening exacerbations. Effusion in the pleural cavity takes place to a very * considerable extent, and the form of the chest becomes changed. The patient loses his appetite, becomes pale, languid, and emaciated; evening exacerbations of fever, and copious night-sweats ensue, and after being reduced, in the course of one or several months, to a state of extreme marasmus, expires; or, in more favourable cases, the fluid effused into the chest is absorbed, or being evacuated by a surgical operation, the patient may recover his ordinary health. The physical signs of pleuritis in infants are extremely equivocal. According, however, to the observations of Rilliet and Barthez, the disease, whatever is the age of the patient, is marked from its very onset by the presence of bronchial respiration. It is heard at first during very strong inspirations, superficial or profound, and having a peculiar metallic tone. It is usually detected in the posterior part of the chest on a single side; at first at the superior portion of the chest, subsequently only in the neighbourhood of the inferior angle of the scapula, or between the scapulae. It may disappear on the first, second, or third day, or it may continue for a longer period, when it is heard in both the movements of respiration, or only during expiration or in- spiration. Rilliet and Barthez have known it to continue until the tAventy-seventh day. In favourable cases, most generally, the bron- chial inspiration is replaced, at variable periods, by a feebleness of the respiratory murmur, more rarely by the friction sound, and some- times by the normal respiration. It is in the more acute cases, in which effusion probably occurs very promptly, that the bronchial ex- piration is most decided; when, on the contrary, the inflammation is slow in its progress, and the effusion takes place gradually, it has been entirely absent. Bronchial respiration is often accompanied with aegophony, heard at the posterior part of the chest, below the interscapular space, and at the inferior dorsal region. It may be de- tected as late as the fourth day of the disease; it sometimes disap- pears and again returns. It is present only in cases attended with serous effusion, when this is very abundant, or when thick false mem- branes are formed. It is often present in infants of two or three years, but is more distinct in older children. 320 DISEASES OF CHILDREN. In cases of subacute or chronic pleurisy, when the effusion taken place gradually, and, as it collects, forces upAvards the lung, or in cases occurring in debilitated subjects, with little reaction and tardy respi- ratory movements, the respiratory murmur becomes gradually ob- scured, at first at the base of the chest, and then higher and higher; the obscuration extending, finally, over the whole of one side of the thorax, and at length being lost entirely. In very acute cases the absence of the respiratory murmur may occur at the very onset of the attack, and over a large portion of one side of the chest, and very soon the respiration can be heard only at the interscapular region. The obscu- rity of the respiratory sound in these cases disappears early; in the more chronic cases it may persist in some part of the chest for several months. In very acute cases, upon percussion, the chest is tolerably sonorous. When the disease is prolonged or is of a chronic form, the dull sound of the chest becomes more and more considerable, folloAving in its march and in its extent the obscuration of the respiratory murmur. In very acute cases the dulness will disappear, sometimes very sud- denly, at the same time that the respiratory sound becomes perfectly free. When the chest is inspected the ribs of the side on which the effu- sion has taken place Avill be found to be confined in their movements, while the intercostal spaces are enlarged. When the effusion is very considerable the chest on that side is more or less dilated. Rilliet and Barthez lay it down as a principle that when a pleuritic attack occurs in a child labouring under hepatization of the posterior part of the lung, all the abnormal sounds that were perceived at the level of the diseased point become considerably exaggerated, and the sonorosity disappears. This occurs, however, only in cases sufficiently extensive and profound, to prevent the lung from collapsing. Thus it may be inferred, that if an entire absence of the respiratory murmur succeeds the symptoms of a well-determined pneumonia, the hepatiza- tion was of slight extent, and but little profound; whilst, on the other hand, if the bronchial expiration, the resonance of the voice, and the dulness of the chest are suddenly increased, the pneumonia, to which the pleuritic effusion has just been added, occupies a large extent both in depth and surface. (Maladies des Enfans, T. i. 148.) Upon examination, after death, of patients who have fallen victims to pleurisy, the appearances discovered are: adhesions of the pleura, more or less recent; the pleura covered, to a greater or less extent, Avith yellowish lymph, forming, in some cases, a coating of considerable thickness; effusions into the cavity of the pleura of a serous or sero- purulent fluid, or of serum mixed with numerous small flakes of lymph. The serum is, sometimes, perfectly transparent, but at others is troubled and more or less opaque. The fluid secretions usually occupy the most depending portions of the pleural cavity; they are occasionally col- lected in separate cavities formed by recent false membranes or ad- hesions of the pleura. The most common lesion met with after death from pleurisy is unquestionably false membranes; they most frequently cover the costal pleura, often the pulmonary, and frequently both. In DISEASES OF THE RESPIRATORY ORGANS. 321 some instances the pleura is studded with numerous small red points, arising from ecchymoses beneath the membrane; we have observed this occasionally upon the costal pleura, but more frequently upon that of the lungs. The pleura is not unfrequently thickly studded with minute tubercles, the lungs generally being in a similar condition: we have met with tubercles of the pleura, however, where none existed in the lungs. The pleuritis is most commonly confined to one side of the chest, but may affect both. It is more frequent on the right than on the left side. According to the observations of Rilliet and Barthez, when the pleurisy complicates pneumonia it is, however, more fre- quently on the left than on the right. Pleurisy, especially as a primitive disease, occurs more frequently in boys than in girls. It is a common complication of pneumonia; often, however, it is in such cases of little intensity, though in others it assumes as serious a character as the accompanying pulmonary in- flammation. It is a frequent complication of rheumatism, scarlatina, and Bright's disease. It is of more frequent occurrence in spring, autumn and winter, than in summer, or seasons of moderate, equable temperature. Pleurisy is not, of itself, a very fatal disease, and is readily con- trolled by an appropriate treatment. We have never seen a case in which the disease terminated fatally in its acute stage. Even when extensive effusion has taken place in the cavity of the chest, this will often be entirely absorbed, if it consists chiefly of serum; but when purulent, it frequently produces considerable uneasiness and suffering, and, sooner or later, causes the death of the patient. When extensive adhesions occur between the pleura costalis and pulmonalis, in chronic oases, a very marked contraction of the chest takes place, on the side on which the adhesions exist, productive, when of any extent, of de- cided deformity. In cases of copious effusion into the cavity of the pleura, the lung is more or less pressed upAvards, and its functions impeded. If, after this condition has existed for some time, a rapid absorption of the effused fluid takes place, the lung not expanding with sufficient celerity to fill the chest, the ribs will consequently contract upon the com- pressed lung, and more or less contraction of the chest will be pro- duced. This deformity often disappears during the growth of the child—though occasionally it may exist, to a certain extent, through- out life. Of the treatment of pleurisy but little need be said, as it differs in no important particular from that proper in cases of bronchitis and pneumonia. The remedy upon which the chief dependence is to be placed is bloodletting, early employed, and carried to a sufficient extent to pro- duce a decided impression upon the symptoms of the disease. Pre- cisely the same remarks that were made in relation to the employment of this remedy in cases of pneumonia, are applicable to the disease before us. In young children, a few leeches to the chest, followed by soft Avarm cataplasms, will often produce a very decided abatement of the disease. In the commencement of the attack, the bowels 21 322 DISEASES OF CHILDREN. should be freely opened by a purgative of calomel, followed by castor oil, or sulphate of magnesia, and kept in a regular condition by small doses of ipecacuanha and calomel, repeated daily. In the latter period of childhood, when pleurisy is most apt to occur independently of inflammation of the lungs, the tartarized antimony, either alone or combined with nitre, will often be found a powerful auxiliary to bloodletting, in arresting the progress of the disease.1 The tartarized antimony, combined with nitre and calomel,2 is particu- larly advantageous in those cases in which, after bloodletting, the skin remains hot and dry, and the cough short and frequent. Under the same circumstances, the warm hip-bath and warm pediluvia act bene- ficially. 1 R—Nitrat. potassae, gj. ' R.—Nitrat. potassse, gj. Tart. ant. gr. ij. Tart. ant. gr. j. Aquae, giv. Calomel, gr. iv.—M. f. chart. No. xij. Sacch. alb. gij.—M. One to be given, mixed in sugar and water, A teaspoonful to be given every two or three every three hours. hours, according to the age of the patient. As soon as the violence of the disease has been subdued by direct depletion, a blister to the chest, as directed in cases of pneumonia, will, often, very promptly relieve the cough, pain, and dyspnoea. Under the same circumstances that blisters become proper, considerable benefit will be derived from small doses of the combined powder of ipecacuanha, particularly in the evening; when well-timed, nothing will be found more effectually to relieve the cough and restlessness, and promote the healthy action of the cutaneous exhalants, particularly if, at the same time, a warm pediluvium be employed. When effusion to any extent has occurred within the chest, and the fluid is not speedily removed, 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, and digitalis,3 given every three or four hours, will often cause the effused fluid to be absorbed. In some cases a combination of digitalis and bi-tartrate of potassa4, or a mixture of the syrup and oxy- mel of squill,5 with sweet spirits of nitre, will prove highly efficacious. 'R.—Pulv. scillse, gr. iij. ad. iv. *»R.—Bi-tart. potass, giij. Calomel, gr. iij. Pulv. digitalis, gr. iv.—M. f. chart. No. iij. Digitalis, gr. iij.—M. f. chart. No. xij. One to be given every three or four hours. 6 R.—Syrup, scillae, gvj. Oxy. scillse, gij. Spir. aeth. nitr. gvj.—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 pa- tient 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 parietes of the chest, and internally, calomel in small doses, combined with some of the diuretics, of which, perhaps, digitalis and squill are the best, though occasionally the tincture of Sanguinaria Canadensis will be found a very valuable remedy in these cases, in the dose of DISEASES OF THE RESPIRATORY ORGANS. 323 from two to ten drops, according to the age of the child, repeated three times a day. In some cases mercurial inunction, employed in the same manner as was directed in pneumonia, will produce a benefi- cial effect. The bowels should be kept open by mild laxatives, or pur- gative 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 by Herpin, that by an operation, the pus has been evacuated, eAren in a child only seven years of age, and entire recovery has en- sued, with the exception of a slight contraction of the chest on the affected side. During convalescence 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. 6.—Tracheitis.—Croup. CYNANCHE TRACHEALIS—ANGINA POLYPOSA VEL MEMBRANACEA—LARYNGEO-TRACHE1TIS. If we take into consideration its frequency, the rapidity of its pro- gress, the distressing and painful symptoms by which it is accompa- nied, and the amount of mortality produced by it, tracheitis or croup must be regarded as one of the most formidable of the diseases pecu- liar to infancy and childhood. In Philadelphia, during the ten years preceding 1845, there occurred 1150 deaths from croup, being an average of 115 per annum; in London, 391 deaths from this disease are reported in 1840; and in the whole of England, during the same year, 4,336.1 The croup is, strictly speaking, an inflammation of the mucous mem- brane of the larynx and trachea, the former being, in the great majo- rity of cases, the part first affected. The peculiarity of the disease consists in the early occurrence of an exudation upon the surface of the inflamed surfaces, forming, in many cases, a pseudo-membrane, Avhich extends often from the larynx throughout the larger, and even sometimes into the smaller divisions of the bronchi. It has been sup- posed by Blaud, Duges, and others, that in certain mild cases, of fre- quent occurrence, unattended with fever, and readily cured by simple means, the pseudo-membranous exudation does not take place. These cases of simple laryngeo-tracheitis have been denominated by Guer- sent and Bertin spurious croup; they are evidently cases of spasmodic laryngitis. The distinguishing symptoms of croup are: dyspnoea, a peculiar hoarseness of the voice, a loud ringing cough, sibilant inspiration, and fever. In the majority of cases the disease is preceded by symptoms of catarrh or bronchitis. The patient is affected with more or less chilli- 1 Entire mortality of London during 1840,45,284; and of the whole of England, 359,561. In Paris, the deaths from croup in 1838, were 187; in 1839, 286; and in 1840,326. 324 DISEASES OF CHILDREN. ness, succeeded by increased heat of the surface, lnssitudo, loss of ap- petite, and cough. These symptoms vary in intensity and duration; in some cases presenting simply the characteristics of a slight catarrh for several days; Avhile 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 dis- ease are developed. The child, after retiring to rest, suddenly awakes from his sleep wdth 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 com- plains 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 symp- toms of any serious disease:—the pulse, however, will, in general, still be found to be more frequent than natural, and the cough more hoarse and resonant. On the ensuing evening the respiration becomes again suddenly dif- ficult, loud, and wheezing, and the cough convulsive and ringing; the patient experiences a sensation of impending suffocation, and often 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 Avith blood. The violence of the foregoing symptoms may, after a time, moderate; but if so, soon again increase in violence, and usually continue, with slight remissions, and exacerba- tions 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. Unless the disease be arrested by an appropriate treatment, the symptoms constantly augment in intensity, and the remissions become slighter and of shorter duration; the cough loses, however, its acute ringing sound, while the loud wheezing respiration of the patient is heard even beyond the apartment he occupies. The dyspnoea becomes excessive, the patient is in a constant state of agitation, his face swollen and livid, his lips purple, and his forehead 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 diffi- culty 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 membra- nous appearance. These symptoms may continue for a longer or shorter period, ac- cording to their intensity. The voice, however, soon becomes ex- tinct, the respiration short and convulsive, and the patient is every moment in danger of suffocation; his face becomes pale or livid, 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 ex- DISEASES OF THE RESPIRATORY ORGANS. 325 pectoration, the pulse is feeble, irregular, and intermittent, and the patient at length ceases to breathe,—the intellect, being, in general, unaffected throughout the attack. In other cases, however, the disease commences much more ab- ruptly, and proceeds with greater rapidity and violence. The patient, who retired to bed apparently in perfect health, is suddenly aAvoke from his sleep with a violent fit of loud, ringing cough; his respiration is loud, wheezing, and oppressed, and attended with a feeling of im- mediate suffocation; there is the utmost anxiety and restlessness; the face is tumid, and of a dark red colour, the eyes injected and pro- truding, 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 ac- tual 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—croup may present very various shades of inten- sity. 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 ap- propriate remedies, even in the more violent cases, the disease will oc- casionally be removed within a short period. The ordinary duration of the disease is from tAventy-four to seventy-two hours; 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 or three weeks. We very much doubt, however, the correctness of the diagnosis in these latter cases. The disease is usually described as one peculiarly liable to recur in the same individual, after a longer or shorter interval: this statement is made by nearly every writer upon the disease; it has, according to Jurine and Albers, been known to recur seven, and even nine times in the same individual. The subsequent attacks are described as Arary- ing in intensity in different cases; an infant, it is said, may promptly recover from one, two, or three consecutive attacks, and finally be destroyed by a fourth, exceeding in intensity either of the preceding. We have never met ourselves with what could, with any propriety, be denominated a second attack of croup. We suspect that Avhat are reported to have been repeated attacks of croup, Avere in fact cases of the false or spasmodic form of the disease. The diagnostic symptoms of croup are: the hoarseness of the voice, the peculiar deep ringing cough, and the loud wheezing or sibilant inspiration. The hoarseness of the voice is generally among the first symptoms that occur; even, in many cases, being observed previous to the dysp- noea, cough, or febrile reaction. It is at first slight, but becomes more marked in the progress of the disease; not unfrequently, in the second and third stages, amounting to an entire extinction of the voice. In 326 DISEASES OF CHILDREN. the cases that are preceded for some days by simple catarrhal symp- toms, the peculiar hoarseness of the voice Avill early warn the ob- serving 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 disease has been entirely removed, and only slowly disappears. It is extremely difficult to present a correct description of the dis- tinguishing croupal cough. In cases preceded by catarrhal symptoms, a cough is present from the onset of the disease, differing in nothing from the ordinary cough of bronchitis; but from the moment that in- flammation of the larynx is developed, the cough becomes deep and hoarse, and Avith 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 com- pared to the crowing of a young cock, to the barking of a hound, or to a cough heard through a brazen trumpet: these comparisons, however, but illy characterize its deep, ringing resonance. It must be heard, to form a correct idea of it; and, when once heard, it will scarcely be possible afterwards to confound it with any other. 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 hav-e become nearly destroyed, the cough is always entirely suppressed, and loses its peculiar characteristics. In the event of a favourable termi- nation, the cough very frequently disappears entirely; or, as is more commonly the case, resumes its catarrhal character, and continues to recur for a longer or shorter period. The paroxysms of coughing are excited by the most trifling cause, as the act of drinking, speak- ing, 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 Avith a loud wheezing, in some cases, amount- ing almost to a low, lengthened whistle. This wheezing inspiration continues throughout the attack, being less intense, hoAvever, 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 glotti- dis and upper portion of the trachea, in consequence, in the first in- stance, of the thickening of the inflamed mucous membrane of these parts, and subsequently, of the pseudo-membranous exudation Avith which they become covered. But the circumstance of these symp- toms, in many cases becoming aggravated at irregular intervals, di- Added by distinct remissions, thus constituting, as it Avere, paroxysms, that commence suddenly, and decline with equal abruptness, have in- duced many to suppose that the peculiar symptoms of croup are, to a DISEASES OF THE RESPIRATORY ORGANS. 327 certain extent due to a spasmodic constriction of the muscles of the larynx and glottis. It is probable, however, that it is chiefly the ex- treme dyspnoea 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 attack is preceded for some days by catarrhal symptoms, the dyspnoea 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 convulsive action; the mouth and nostrils dilate, the larynx ascends and descends rapidly; the entire thorax is elevated, and the shoulders are drawn up at every inspiration. In most cases, the dyspnoea 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 to give to the air a more free passage into the lungs: this, however, is not in- variably the case, and hence, as Royer-Collard very properly remarks, cannot be considered as one of the diagnostic phenomena of the dis- ease. In the final stage of croup, the dyspnoea is equally intense; but res- piration is effected almost entirely by the action of the diaphragm, the contractions of which are violent and convulsive; the cartilages of the ribs and the 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, en- dangering, every instant, the suffocation of the patient. In the se- cond, and even at the commencement of the third stage, the dyspnoea may present very distinct remissions. These remissions occasionally are so complete, that the disease appears to be suddenly suspended, and the parents have rejoiced in the speedy recovery of the child: 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 other cases, the febrile excitement is less intense; and again, in Avhat have been termed spurious croups, the laryngeo-bronchial variety of Duges, there is often, especially in young children, no symptoms whatever of fever. In the more violent attacks of croup, 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, how- ever, this symptom may be Avanting. By some writers, a swelling of the neck, at the upper part of the trachea, has been described as frequently occurring. The swelling is represented as varying in size in different cases, of an oedematous cha- racter, and disappearing immediately upon the recovery or death of 328 DISEASES OF CHILDREN. 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 by Albers and others, 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 Avill 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 portions of tubes. The discharge of these matters, when copious, is followed by a very marked relief of the dyspnoea and cough, which, however, is never of long duration*. The condition of the bowels is various; but in the majority of cases, according to our experience, 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 Avhitish 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. There is often a disposition to somnolency in the commencement of the disease, which, in some cases, amounts to complete stupor, arising, probably, from a slight congestion of the brain; drowsiness or stupor, however, is by no means an invariable—we should think not even a frequent—attendant upon croup, as has been supposed, especially in its first and second stages. Some, with Cailleau, have described the senses, as Avell as the intellectual powers of the patient, to be increased in activity: although we have seldom seen the mental powers much impaired throughout an attack of croup, we cannot say that we have ever 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, bronchi, 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 tube, and an effusion of mucus or muco-purulent matter, filling the larger and sometimes the smaller bronchial ramifications. In cases that have terminated rapidly in death, the exudation is found only in the larynx and upper portion of the trachea, or is confined to the latter situation: when death has occurred at a later period, it is in the trachea alone, or in the trachea and bronchi that it is detected; it never exists in the bronchi alone. In the larynx, the exudation is often in the form of a thin coating, extending over the whole of its internal surface, but more frequently it is disposed in membraniform patches, or is found upon the inferior surface of the epiglottis alone. In the trachea, it often lines the whole of the tube, and varies in consistence and thickness; or it occurs in detached patches, or in the form of soft concretions, resembling polypi, DISEASES OF THE RESPIRATORY ORGANS. 329 attached to the posterior surface of the tube; or the trachea is filled Avith a mucuform fluid, containing small masses of a more solid con- sistence. These same appearances are occasionally present in the up- per part of the bronchi; but more frequently in the bronchial tubes there is only found 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, according to Martinet, to find the exudation assuming a pseudo-membranous ap- pearance, the respiratory tubes in such cases containing only mucus, somewhat more abundant and viscid than natural. The larynx and trachea have, however, been found, according to Blaud, lined Avith a pseudo-membranous concretion, in cases in which the entire duration of the disease did not exceed twenty-four hours. 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 sometimes even the larynx and upper por- tion of the bronchi, and presents, throughout nearly the whole of their extent, considerable firmness. In cases in which death occurs at a still later period, in the upper portion of the trachea there is seldom found anything but a quantity of viscid mucus, which becomes more consistent at the lower part of the tube, and often forms here a more or less complete membrane, separated from the mucous membrane by an abundant layer of fluid matter. In the bronchi this pseudo-membrane becomes much softer, and soon loses entirely its membraniform character, the bronchi be- ing filled in their final ramifications with a thick, ropy mucus. (Royer- Collard.) The colour of the membraniform exudation is either whitish, yel- lowish, or gray; 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 firmness; it is, in general, most thick and firm in the trachea, particularly at its posterior part. Vanberger, Bohmer, and a few other writers on the disease have described the pseudo-membrane of croup as an organized substance, possessing minute fibres and blood-vessels; a supposition which is con- tradicted by the most conclusive testimony. 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 placed beyond doubt. The chemical composition of the pseudo-membranous exudation of croup is the same as that of the diphtheritic inflammations generally, and of the pseudo-membranes of serous surfaces, it being composed chiefly of albumen. According to Dr. Seitz, upon a microscopic ex- amination of a portion of the pseudo-membranous exudation of croup, of about half a line in thickness, and of slight consistence, it was found to be composed almost entirely of pus globules, mixed with inflamma- 330 DISEASES OF CHILDREN. tion corpuscles, and a species of cell double the size of the pus glo- bule, but in other respects similar to it. When the pseudo-membranous exudation, and the viscid mucus are removed from the surface of the respiratory tubes, the mucous mem- brane of the larynx, trachea, and bronchi is generally found to be in a state of inflammation throughout the greater part of its extent, though in many cases it has been found free from any mark of dis- ease. When death takes place in the early stage of the more violent cases, the larynx and upper portion of the trachea are of a deep red colour and more or less thickened, and sometimes more or less softened. 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 en- tirely absent. The affection of the bronchi is in proportion to the extent and duration of the disease; the earlier in the attack 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 ex- tensively 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 hepatiza- tion; pleuritic inflammation is also occasionally met with, as well as interlobular and sub-pleural emphysema. The physical signs of croup are not of a very positive character. In the early period of the disease, it is said that the stridulous respiration may be detected by the stethoscope, applied to the trachea, before it is otherwise distinct. According to Barth, when the stethoscope is ap- plied upon the trachea, there is perceived a kind of tremulous vibra- tion, as though a thin, movable partition was agitated by the air. This indicates the presence of floating portions of false membrane, and when confined to the larynx, is not an unfavourable symptom; if, on the contrary, it extends to the trachea and bronchial tubes, it indicates that the false membranes occupy the greater portion of these tubes. So long as the disease is confined to the larynx and trachea, upon per- cussion, no dulness will be found to exist. When bronchitis or pneu- monia is 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 de- tected, if present. (Stokes.) When the pseudo-membrane in the tra- chea is partially detached, it is said by Maunsel, 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 the larynx. We have never, ourselves, observed this sound. It is unnecessary to enter into an examination of the various hy- potheses that have been emitted in reference to the nature of croup DISEASES OF THE RESPIRATORY ORGANS. 331 The investigations of modern pathologists have shown that the dis- ease is an inflammation of the mucous membrane, and probably, ac- cording to Ryland, of the submucous cellular tissue of the larynx and trachea, and in many cases of the bronchi also; the inflammation, in the early stage of the disease being, in most cases, confined to the larynx and upper portion of the trachea, but extending subsequently to the bronchi, often throughout their ramifications, and to the tissue of the lung itself. It gives rise, more or less rapidly, to the exuda- tion of an albuminous fluid, Avhich most generally forms a pseudo-mem- branous coating upon the larynx, trachea, and commencement of the bronchi. The collapse or adynamic symptoms of the third stage, re- sult from the interruption to the function of respiration, and the con- sequent imperfect haematosis, caused by the presence of the exudation, and the congestion of the lungs. As we have already remarked, nearly all the characteristic phenomena of croup indicate that there also exists a spasmodic affection of the glottis, which, however, is the result of the increased irritability of the parts labouring under inflam- mation, and probably of the irritation of the morbid secretion, and not, as some pathologists have supposed, the chief cause of the promi- nent symptoms of the disease. Various divisions of croup have been attempted by different writers. By Blaud, 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 puriform secretion; and the third, the most aggravated form, with pseudo-mem- branous exudation. This division, which is of little benefit in a practi- cal point of view, even were it Avell founded, is not borne out by the re- sults obtained from autopsical examinations. By others, croup has been divided into the laryngeal, laryngeo-tracheal, and laryngeo-bronchial, according as the inflammation is confined to, or predominates in the larynx, trachea, or bronchi; this division is a much more accurate one than the preceding. It is probable, that in many cases, the bron- chi are the part first affected; in the great majority, however, the disease evidently commences in the larynx, and we suspect there are few, if any cases, in Avhich it is confined to the trachea alone. Jurine has attempted to shoAv, that in the ordinary 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. Although this is not correct in fact, yet our observations have taught us, that in cases attended Avith violent symptoms, sudden in their onset, and rapid in their progress, there exists, most generally, considerable inflammation, Avith pseudo-membranous exudation, about the larynx, glottis, and up- per portion of the trachea, to a much greater extent always, than in those cases especially, 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 332 DISEASES OF CHILDREN. febrile reaction, 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 children, or those reduced by previous disease, and attended with a Ioav, obscure fever, feeble pulse, early collapse, and other indications of asthenia. The first, or sthenic form, corresponds very nearly with the primary croup, and the second, or asthenic form, with tho secondary croup of medical writers—the second, very generally, resulting from the extension of pseudo-membranous inflammation from 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, they are succeeded by those of a mild bronchitis, which continues for many days; in other cases the bron- chitis becomes chronic, and occasionally terminates finally in tuber- cular disease of the lungs. Age is evidently the chief predisposing cause of croup; the disease being principally confined to children under ten years of age, seldom occurring beyond that period as a primary affection. It is rare in the first months of life, but is met Avith most frequently in children between one and seAren years old. By numerous writers, the occurrence of croup previously to the seventh month, has been denied. Others, how- ever, declare that they have met with it repeatedly, as a primary dis- ease in children at the breast. In Philadelphia, during the ten years preceding 1845,475 deaths are reported from croup, in infants between 2 and 5 years; 238 in those betAveen 1 and 2 years; 319 in those under one year; 112 in those between 5 and 10 years; and 6 in chil- dren 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 Aveaned, the more liable, according to Home, they are to attacks of the disease. Judging from our own experience, we should say that the croup oc- curs more frequently between the tenth month and fifth year from birth, than at any other period. This is the period of childhood when there exists a peculiar tendency to the formation of pseudo-membra- niform exudations in all the inflammations of the mucous surfaces, espe- cially those of the respiratory organs, which readily assume, in par- ticular constitutions, the croupal character, rendered still more marked and dangerous by the imperfect development in early life of the larynx and trachea, and the small size of the glottis. Boys would appear to be more frequently affected with the disease than girls.' Of 543 cases of true and false croup, collected by Guer- sent, 325 occurred in males, and 218 in females; of the 1150 fatal cases of croup reported to the Health Office at Philadelphia, during the ten years preceding 1845, 612 occurred in boys, and 538 in girls. The deaths from croup in the London Hospitals during 1840, were, in the male sex, 3 to 1 in the female. Children of a sanguineous temperament, of a florid complexion, in- clined to fat, and apparently in the enjoyment of perfect health, are DISEASES OF THE RESPIRATORY ORGANS. 333 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, Avhen, 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. It may be produced, however, at any season of the year, by sudden alterations 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 particularly apt to occur, in the course of, or immediately subsequent to, an attack of measles or of pneumonia. Croup is said, occasionally, to prevail epidemically. In such cases, however, we suspect that the disease was not primary, but secondary croup, resulting from pseudo-membranous angina. The latter differs, in some degree, from primary croup. Independently of the inflamma- tion of the larynx and trachea, being secondary to disease of the pha- rynx and throat, and its occurring always in the course of some other affection, the symptoms are usually of an asthenic character; the deglutition is more or less difficult, the breath fetid, and instead of a tendency appearing in the course of the attack to acute pneumonic in- flammation, it is disease of the mucous membrane of the stomach and bowels, with which, in cases of secondary croup, the laryngeo-tra- chcitis is most commonly complicated. Stokes enumerates other points of difference, which Ave do not recognise, as, for instance, the conta- giousness of secondary croup, and its chiefly affecting adults. Under no circumstances, do we belieA-e croup to be contagious;—even A\-hen it accompanies or succeeds to small-pox, measles, or scarlatina, it is scarcely correct to refer it to contagion, merely because the affection Avhich it accidentally complicates is in this manner propagated. 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 Avarm bath, and subsequently the exhibition of small doses of antimony combined with calomel, will, in many instances, put a stop to its further progress. Nearly every writer upon the disease has spoken of the good effects of emetics, administered 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; others refer a peculiar efficacy 334 DISEASES OF CHILDREN. to the sulphate of copper; while others, again, prefer the sulphate of zinc. Some of the American practitioners esteem the Sanguinaria Canadensis, in infusion, as almost a specific, while a few prefer the Lobelia inflata. Dr. Meigs considers that alum in powder, from the certainty and speediness of its operation, forms the best emetic in cases of croup; and Dr. Hubbard, of Maine, recommends the turpeth mineral, the yellow sulphate of mercury, as an emetic in this disease, in consequence of its promptness and certainty, and its never pro- ducing catharsis, or being followed by the prostration caused by tartar emetic. The great objects to be kept in view, in our choice of an emetic in croup, are the promptness, certainty, and activity of its operation; and these properties being combined in the tartarized antimony, we have invariably preferred it in the commencement of the attack. In many of the milder cases, the compound honey of squill, given in a sufficient quantity to operate freely as an emetic, and continued 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, isvGoodlad. In cases of greater violence, or in which the emetic given in the forming stage, has failed to arrest the disease, our most effectual remedy is, unquestionably, bloodletting. In many cases, the applica- tion of leeches to the throat will be sufficient, but in every instance in which the disease is marked by symptoms of considerable 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 impression 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 bleed- ing should be repeated, or leeches should be applied around the throat, in numbers proportioned to the age and strength of the pa- tient, and the intensity of the disease. The repetition of the bleed- ing must be governed by circumstances; in some cases, one bleeding, in the early period of the attack, will most effectually control the symptoms; but in others, when the system reacts with force, the pulse continues firm, the skin warm, and the dyspnoea considerable, a repe- tition of the bleeding will be proper. There is certainly no disease, in which bleeding, when well timed, and carried to a sufficient extent, is calculated to produce more bene- ficial effects than in croup. The practitioner, who, in violent cases, neglects this important measure, and places his hopes on any other remedy, or combination 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 practi- tioners of Europe. But, it must be recollected, that it is only in the first stages, the beneficial effects of bloodletting 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, DISEASES OF THE RESPIRATORY ORGANS. 335 there will then be but little hopes of arresting the fatal termination, by whatever other remedial measures may be resorted to. From the difficulty often experienced in obtaining blood from the arm, in young children, it has been recommended by Cheyne and Goodlad, to open one of the jugular veins; others, however, have ob- jected 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 haemorrhage; and as to the extent of the bleeding, this being measured not by the number of ounces of blood drawn, 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 immediately 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 calomel and hydrochlorate of ammonia. R.—Calomel, gss. ad gj. Tart. ant. gr. j. Hydrochlor. ammon. 9ijss.—M. f. chart. No. xij. One to be given every two hours. The employment of nauseating doses of antimony in croup, subse- quently 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, an assertion which we consider, judging from the result of our own experience, scarcely too strong. Stokes places it even above bloodletting. Steinmitz trusted to it alone in the second stage, as also did Jadelot, who combined the tartarized antimony with ipecacuanha, squill, and senega.1 Cheyne also speaks highly of the efficacy of the 1R.—Infus. senegae, %iy. Syrup, ipecac, gj. Oxy. scillse. giij. Tart. ant. gr. jss.—M. A teaspoonful every ten minutes. tartarized antimony, both as an emetic, and in nauseating doses through- out the first and second stages of croup. A recent writer (C. Wilson) gives the tartarized antimony throughout the disease, at first in doses of a quarter or a third of a grain every hour, until a decided impres- 336 DISEASES OF CHILDREN. sion is produced upon the symptoms, and subsequently every two hours. Combining the article with calomel, we have certainly found to increase very materially its efficacy. Of the good effects of calomel in croup, Ave have abundant testi- mony. 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; Avhile in someAvhat smaller doses, after bleeding, an emetic, and the warm bath, it is strongly recommended by a host of authorities. By some practitioners calomel is directed in enor- mous doses, far greater than we should be inclined to prescribe; we nevertheless 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. 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, hoAvever, 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 manner, but often the most decided benefit. Its tendency is to reduce the laryngeo-tracheal inflammation, and thus to counteract the pseudo- membranous exudation. The hydrochlorate of ammonia appears to us to be a remedy well adapted to nearly all the inflammations attended with diphtheritic ef- fusions; we have employed it pretty extensively for many years in croup, and have always been pleased with its effects. Chamerlat re- commends it as almost a specific, Avhen employed as a wash or gargle. In the early stage of those cases of croup in Avhich the disease is preceded by pseudo-membranous angina, M. Guersant, Jr., (Gazette des Hopitaux, Nos. 48, 52,) strongly recommends the local application of the nitrate of silver. In the cases referred to, the symptoms are at first but little urgent; and a physician who is not accustomed to treat children, will often neglect to examine the throat. M. Guersant lays it down as an invariable rule to make such examination when- ever a child manifests any febrile reaction; and in this manner he has frequently been enabled to detect the approaching disease, the presence of which would not, otherwise, have been suspected. At first, and while the tonsils alone are covered with the plastic exuda- tion, although the symptoms, as already remarked, are not severe- it is, nevertheless, according to M. Guersant, a precious moment for the physician, as he may now frequently arrest a disease, which, if allowed to go on, is usually fatal. While employing the solid caustic, M. Guersant directs the child to be held by a strong assistant, the tongue to be depressed by a broad instrument, as a very large spatula, or the handle of a large spoon, or what M. G. prefers, a large wooden tongue depressor. For fear of DISEASES OF THE RESPIRATORY ORGANS. 337 accident, the caustic should project only very slightly from its case. Many practitioners prefer the caustic in solution. In the earliest stage of the disease a weak solution, applied three times a day, will suffice, but in serious cases the solution must be very strong—1 part to 3 or 4 of water—and need, then, be used only once a day. It may be applied by means of a sponge fixed to the end of a piece of whale- bone by sealing wax. To prevent the extension of the false mem- brane, the caustic should be applied beyond its margin as well as upon it. The application, M. Guersant remarks, frequently dissipates the exudation from the tonsils, and yet it may extend to the epiglottis. The caustic is still our best remedy. A larger sponge is now required, which must be fixed upon a strong whalebone, bent at an obtuse angle. The operator places himself on one side, and, introducing the sponge directly to the base of the tongue, executes some semi-rotary move- ments. Sometimes the epiglottis is raised, and the fragments of false membrane are detached from its inferior surface, which may be known by the paroxysm of dyspnoea this gives rise to. The caustic, in these cases, requires to be repeated three or four times in the twenty-four hours. A number of cases are on record in which the treatment here re- commended was pursued Avith entire success. In those cases in which the pseudo-membranous exudation is still confined to the pharynx, it is certainly deserving of a fair trial. Blisters to the throat are strongly recommended by many practi- tioners in the treatment of croup. Mackintosh confines their applica- tion to the first stage, after the violence of the disease has been re- duced by bleeding and leeching. Dewees doubts their utility; and Goodlad, Stokes, and Porter, condemn them entirely. We have oc- casionally employed them, but cannot say that we have perceived any benefit to result from their use. Rubefacients, followed by warm fomentations or emollient cata- plasms to the throat, will, in the forming stage of the disease, be often productive of the best effects. As a rubefacient, the spirits of turpen- tine is the one Ave have generally employed: its action upon the skin is prompt and sufficiently powerful: a strip of flannel wet with tur- pentine should 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 disease, even rubefacients should not be resorted to until after blood- letting. A German physician, Dr. Willige, states (Schmidts Jahrbiicher, 1847,) that he has been very successful in the treatment of severe cases of croup by the external application of iodine to the upper part of the neck. He directs the tincture of iodine to be applied by means of a feather over the front portion of the neck, corresponding to the larynx and trachea, and repeated several times at intervals of about four hours, until irritation and redness of the skin are produced. In most cases, he declares this to be followed by a subsidence of the diffi- culty of respiration, the spasmodic affection of the glottis, and the other distressing symptoms. He details three cases in which he believes 22 338 DISEASES OF CHILDREN. that by the external application of the iodine, he succeeded in avert- ing impending death. When the disease persists after the use of the lancet, leeches, eme- tics, and calomel, very great adA-antage 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 the pseudo-membranous exudation has occurred, our chief dependence is to be placed on the use of calomel and tartrate of anti- mony; the latter being occasionally carried to a sufficient extent to ex- cite vomiting. The administration of repeated emetics in this stage, was the practice pursued by Jadelot, Steinmitz, Cheyne, and Currie, and the result of their experience is certainly decidedly in its favour. Tartrate of antimony was the article employed by these physicians; and Cheyne states, that the only cases he saw recover from the second stage of the disease, were those in which the patient was kept under its effects for two or three days. Fielitz, Hoffman, and Droste em- ployed the sulphate 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 lo- belia will often be found advantageous; or, perhaps, the infusion of the Sanguinaria Canadensis.1 We know nothing of the latter remedy from our own experience; it comes to us, however, very highly re- commended by respectable practitioners. It often happens, from the impediment to haematosis, produced by the effusion within the respiratory tubes, and the deficient innervation from the venous congestion of the brain, that emesis is with difficulty produced, even by very considerable doses of antimony; it has under these circumstances been recommended to employ the sulphate of zinc or of copper in solution, alone,2 or combined Avith ipecacuanha. • R.—Rad. sanguinar. canadensis, pulv. ^j. ' R.—Sulph. zinci vel cupri, gij. Aquae calidae, j^iij.—M. Aquae, ^j.—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 in- tervals, but with little febrile excitement or tenseness of pulse, re- mains, a strong decoction of senega will be often found a useful aux- iliary to the other remedies. R.—Rad. polygalae senegne, ,^j. Aq. bullient. Oj. Simmer to 3xij. then add Mellis, giij. Dose.—One, two, or three teaspoonfuls, every one or two hours; according to the age of the patient, and the urgency of the symptoms. In the third stage of the disease, blisters may be applied upon the upper part of the chest, or between the shoulders; sinapisms, or cloths wet with hot turpentine, or the decoction of turpentine and cantharides, DISEASES OF THE RESPIRATORY ORGANS. 339 may at the same time be applied to the extremities, and internally a strong decoction of senega, with the addition of camphor and asa- foetida, may be resorted to; and if there is great and increasing ex- haustion, it will be proper to support the patient's strength by am- monia or wine whey. Occasionally, even under apparently the most desperate circumstances, recovery will ensue; but seldom,*when the disease has reached this stage, will its fatal termination be arrested by any course of treatment. Of the good 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. Asafoetida, likeAvise, has been extolled, given as Avell by the mouth, as by injec- tion into the rectum, to the extent of half a drachm to a drachm a day. By some of the European physicians, the employment of cold affu- sions upon the back, from the occiput to the sacrum, has been strongly recommended in cases Avhere every other remedy has failed to afford relief. The immediate effects ascribed to the cold affusion, are cer- tainly surprising, but the result of the practice is not such as strongly to press it upon our attention. The operation of tracheotomy has been suggested by some as a last resource in cases of croup, and by others as a measure that should only 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, Trousseau, Valleix; while it is opposed by Crawford, Ferriar, Cheyne, Vieusseux, Double, Albers, Jurine, Royer-Collard, Porter, Bricheteau, Becquerel, Boudet, and others. In the cases in Avhich tracheotomy was performed by Guersant and the Hospital Internes, in the Parisian Hospital for Children, during the year 1841, the operation, while it was of no advantage whatever Avhen the pseudo-membranous exudation extended into the bronchi, appeared, in many cases, to accelerate the fatal termination, by in- ducing severe bronchitis or an excessive secretion of mucus in the bronchi, 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. The subject of tracheotomy in croup is certainly one of considerable interest. That it may, in many cases, when timely performed, save the life of the patient, we have the most unquestionable evidence. In a statement of Trousseau of the result of the operation in one hun- dred and fifty cases, the patients recovered in thirty-nine, and M. Valleix gives seventeen cases of recovery out of fifty-four, of unquestionable pseudo-membranous croup, in which the operation was performed. In the case of his own child, three weeks old, published by Dr. Scoutetten, the operation was performed on the third day of the disease, under circumstances apparently the most desperate, with complete success —the infant recovering in a short time from the effects of the opera- tion, as well as from every symptom of the croup. A somewhat similar case AATas related by Dr. C. D. Meigs to the College of Physi- 340 DISEASES OF CHILDREN. cians of Philadelphia.—[Summary of Transactions, vol. ii. page 27.").) The class of cases, the period and particular circumstances of the disease, in Avhich the operation is most likely to afford relief, are ques- tions of no little importance, and it is more than probable that much of the want of success experienced from the operation, is to be attri- buted to its having been resorted to under improper circumstances. M. Trousseau, whose experience on this subject has been someAvhat extensive, has presented the following as a summary of the prognosis of tracheotomy in croup. 1st. If the commencement of the attack dates several days back, the disease having advanced slowly—whatever may be the extent of the false membranes in the trachea and bronchi, the child either recovers, or, at least, lives several days after the operation. 2d. If the child has been subject to chronic catarrhs, and when he has been suffering from a cold for some time before the attack of croup, the operation is more successful. 3d. So long as the respiration is silent, or the noise is only occasioned by the displacement of mucosity, there is nothing to fear; but Avhen the respiration is attended with a sound like that produced by the saAv- ing of stone, death is certain. 4th. If the croup supervene upon measles, scarlatina, small-pox, or pertussis—tracheotomy does not succeed. 5th. There is no reason to despair of the patient, even if an attack of pneumonia or pleurisy should supervene. 6th. When the disease has been very rapid, even though at the time of the operation the false membranes do not extend beyond the larynx, the child dies very quickly. 7th. When, previous to the operation, the false membranes have ex- tended to the nares, or if they cover the blistered surfaces—Avhen the child is pale and somewhat bloated, without having taken mercury or been bled—or when he has lost much blood, there is little to be expect- ed from the operation. 8th. When, previously to the operation, the pulse is moderately fre- quent ; and, if after it the pulse remains calm, hopes may be enter- tained. 9th. The more deeply the false membranes have extended, the greater, ceteris paribus, the danger. 10th. It is a bad sign, if. immediately after the operation, the respi- ration becomes very frequent, without or with very little cough; even when all is going on favourably, the occurrence of a very great fre- quency of respiration is a bad sign. 11th. More boys than girls recover after the operation; but chil- dren under two and over six years of age seldom recover. 12th. The more rapid and energetic the inflammation which attacks the wound in the trachea, the more are the chances of success; a sud- den sinking of the wound is a mortal sign. 13th. Should the wound become covered with false membranes; if after Avithdrawing the cannula, it remains gaping for a long time, or if, after having become completely cicatrized, it reopens largely, the child is in danger. DISEASES OF THE RESPIRATORY ORGANS. 341 14th. Agitation and sleeplessness are bad signs, so is also the oc- currence of convulsions. The younger the patients, and the more blood they have lost before or during the operation, the more liable are convulsions to supervene. 15th. The sooner after the operation the larynx is disembarrassed, the sooner may the cannula be removed, and the more rapid and cer- tain the cure. 16th. If the expectoration becomes mucous and catarrhal by the third day after the operation, the child will recover. If there is no expectoration, or it is serous, or like half-dried portions of gum Arabic, he will die. 17th. If the patient reacts vigorously under the injections into the trachea, of warm water or a solution of nitrate of silver, and the sponging out of the trachea, we should not despair, however unfavour- able the other symptoms. 18th. When, after the tenth day, the drinks pass almost entirely from the pharynx into the larynx and trachea, even if they are readily rejected, the child most generally dies. 19th. The increase of the fever after the fourth day, agitation, sink- ing of the wound, dryness of the trachea, frequency of the respiratory movements, and attempts to cough, announce the invasion of pneumo- nia, which, at first, lobular, becomes sometimes pseudo-lobar, and is to be treated by the same means as are employed in the pneumonia of children; we should however exclude blisters, because they too often become covered with false membranes. AVe 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 height of the disease, little or nothing- else should be allowed, than some mild, mucilaginous fluid in small por- tions at a time; while after the disease has been subdued, and through- out 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 danger of a relapse, upon the slightest exposure to cold or moisture, or to the most trifling transitions of temperature; from these, therefore the child Avho has recently recovered from an attack of croup, should be care- fully guarded, by appropriate clothing, and every other judicious pre- caution. The daily use of the warm bath, and daily exercise in the open air, during mild and dry weather, should never be neglected. 7.—Spasmodic Croup. millar's asthma.—spasmodic laryngitis.—false croup.—catarrhal croup. There is a form of disease of frequent occurrence during childhood, which has very generally been confounded with croup, to which it bears a strong resemblance in some of its features, but differs from it, nevertheless, in its less serious character, and the absence of any ten- dency to the formation of a false membrane, in the air passages. The disease to which we allude has been variously named by different 342 DISEASES OF CHILDREN. writers. Millar, who was the first that directed attention to it, de- nominated it Asthma, which name Avas retained by Wichmann and others; Bretonneau named it Stridulous Angina, Guersant, Laryngis- mus Stridulus, Avhile Rilliet and Barthez prefer the denomination Spasmodic Laryngitis, as indicating Avhat they believe to be the true character of the disease. The attack of spasmodic croup is usually preceded, for a day or two, by slight catarrhal symptoms; coryza, Avatering at the eyes, a sense of chilliness folloAved by flushes of heat; slight hoarseness, and cough. The paroxysm usually occurs during the night, though it oc- casionally takes place during the day. The child is, generally, sud- denly aAvoke from sleep by a sense of impending suffocation. lie starts up in a sitting posture, or throAvs himself upon his knees, Avith the body bent forward. He cries out that he is suffocating, tears away every covering from his throat, and pushes aAva.y those Avho sur- round, or offer to assist him. The face becomes congested, and of a red or violet hue, the eyes projecting and humid, and the expression of the countenance anxious in the extreme. Tho respiration has a peculiar prolonged hissing sound, Avhich is occasionally so loud that it may be heard in a neighbouring apartment. There is at the same time a frequent hoarse cough. The voice is constrained, but seldom Avhispering or abolished. There is great quickness of pulse and heat of the skin. After continuing for a short time the paroxysm ceases suddenly, and the child falls asleep. The disease may be confined to a single attack, or a second attack may succeed upon the same night; more usually, the child continues during the ensuing day tolerably well, though in many cases affected with hoarseness, and a frequent short, barking cough, Avith or with- out expectoration, and during the night following is again attacked with a paroxysm of suffocation. The disease may continue in this manner for several days, and then the paroxysms cease to recur, and the cough and remaining symptoms speedily disappear. In a case detailed by Jurine, a decided alteration of the voice continued for a long time after the cessation of the disease. In some cases, the pa- roxysms continue to recur, and at the same time to augment in inten- sity, and death finally takes place from asphyxia. In other instances, after one or more paroxysms have taken place, the patient becomes affected with the utmost inquietude, constant nausea, repeated vomit- ing, with great exhaustion, and a small frequent pulse, and soon sinks. Usually, however, the disease is one readily managed, and having very seldom a fatal termination. Spasmodic croup is one very liable to return. According to Rilliet and Barthez, its recurrence may take place at the end of six months or of one or two years. In a case reported by Vidal, the first attack occurred when the child was two years old, the second when it was five, and then in the space of three months, it had three attacks. We have seen it more frequently recur at intervals of nine and twelve months than at shorter periods; we have known it, however, to attack three times Avithin the same year. The prognosis in spasmodic croup is to be drawn chiefly from the DISEASES OF THE RESPIRATORY ORGANS. 343 progressive violence of the paroxysms, and the short intervals at Avhich they recur. When they do not continue to recur beyond the second or third day—and gradually decrease in intensity—when the voice is but little affected—the cough moist—and the febrile reaction slight—a favourable termination may be anticipated. When, on the contrary, the paroxysms are protracted beyond the third day, and gradually increase in violence; and particularly, when the paroxysms are succeeded by a state of great restlessness, nausea, and vomiting; when the pulse continues soft and feeble, Avhen a suffocative cough remains, and Avhen the patient's strength gradually diminishes, an unfavourable termination is to be apprehended. The true pathology of this affection has not yet been very accu- rately made out. Millar, and after him most of the German physi- cians, have considered it to be a purely spasmodic disease, someAvhat resembling hooping cough, while Desruelles and Bricheteau believe it to be merely the first stage, or a Arery mild form of croup. Guer- sant supposes it to consist in a transient inflammation of the mucous membrane of the larynx: Bretonneau considers the local affection to consist in mere congestion of short continuance; a simple, transient intumescence of the rima glottidis. Rilliet and Barthez believe that the disease consists in an actual inflammation of the larynx, and they found their opinion upon the fact of the attack being generally the result of sudden exposure to cold; the disease being usually pre- ceded by coryza, watering of the eyes, oppression, &c, and attended by some degree of febrile excitement: in connexion with this mild laryngitis, they presume that there occurs a spasmodic affection of the glottis, by which the sudden paroxysms of suffocation which cha- racterize the disease, and which are excited by the slightest causes, are produced. The correctness of this opinion is borne out by our own observations. That the disease is connected with some degree of laryngeal in- flammation is proved by the result of post-mortem examinations. For although these have been but few in number,—the disease rarely ter- minating in death—yet, not unfrequently, traces, more or less decided, of inflammation of the mucous membrane of the larynx, are to be de- tected; CAcn when no increased redness of this part exists, its secre- tion aa ill generally be found augmented, and of an opaque yelloAvish or reddish colour. When death takes place with great suddenness, it is probable that it is the result of the spasmodic closure of the glot- tis, and the consequent asphyxia. The spasmodic croup is essentially a disease of children; according to Guersant it occurs most frequently between two and seATen years, and according to Rilliet and Barthez betAveen three and eiglit. We haA-e met with it in children of nine or ten months, but less frequently than in those between two and eight years. There is unquestionably, in many instances, a peculiar predisposi- tion to the attacks of spasmodic croup in the children of the same family; we have known families in Avhich all the children Avhen they attained the age of between two and three years Avere successively affected AA-ith it. This predisposition is said, in many instances, to be 344 DISEASES OF CHILDREN. hereditary. The disease occurs more frequently in boys than in girls. Though generally sporadic, it occasionally prevails as an epidemic. Jurine describes an epidemic of spasmodic croup which occurred in Geneva in 1808. Its occasional cause is, almost exclusively, exposure to cold, or a sudden alteration of the temperature of the atmosphere. After an attack has happened, the occurrence of any sudden or violent mental emotion is liable to excite a paroxysm. Tho disease with which spasmodic croup may most readily be con- founded, is tracheitis or genuine croup. The following comparative diagnostic peculiarities, borrowed partly from Valleix, and partly from Rilliet and Barthez, will enable the two diseases very readily to be distinguished. In Genuine Croup. The disease commences with fever of variable intensity, and, most generally, pseudo-membranous angina, and slight hoarseness. There is a gradual increase of the hoarseness, to which, sooner or later, there is added a hoarse ringing cough. The fever does not remit; the cough becomes hollow and feeble, and the voice faint or extinct. There is occasionally an expectoration of false membrane. The dyspnoea constantly increases in intensity—the croupal sound continues during the intervals of the paroxysms—finally, the voice and cough become extinct. In Spasmodic Croup. The symptoms of invasion are slight—there is generally a slight catarrh, and a cough somewhat hoarse—the throat is unaffected—sometimes there are no prodroma. The paroxysms attack suddenly—usually at night. Between the paroxysms the patient appears tolerably well—the fever disappears or declines—the voice may be hoarse, but never be- comes extinct. There is an expectoration of mucus. The paroxysms gradually decrease in violence. The remedies to be employed in a case of spasmodic croup will depend pretty much upon the violence of the attack, and on the age and condition of the patient. When the indications of laryngeal in- flammation are strongly marked, and when the spasmodic paroxysms are very violent and prolonged, the application of leeches to the throat, in numbers proportioned to the age and strength of the child, will be demanded. When the patient is over five years of age, and of a robust habit, a bleeding from the arm will often be attended with the best effects. In no case, however, should the amount of blood drawn from the arm or by leeches be considerable, nor the operation repeated at short intervals, or too late in the disease. The warm bath is always an important remedy; it may be employed in the commencement of the attack, or subsequent to bleeding. Lehmann advises, at the very onset of the paroxysm, the applica- tion of a sponge, of the size of the fist, dipped in very hot Avater, and then carefully squeezed in the hand, to the fore part of the neck; it DISEASES OF THE RESPIRATORY ORGANS. 345 being left a moment in contact with the skin and its application re-' newed at short intervals. This produces a redness of the neck, and a general perspiration, which is to be promoted by the exhibition of the infusion of elder and camomile. By this means, we are told, the paroxysm is cut short, and all the leading symptoms of the disease quickly removed. When the paroxysm is very violent and long continued, and there is danger of asphyxia occurring unless immediate relief be obtained, the operation of tracheotomy should be performed without delay. An emetic given on the first accession of the disease will often, when followed by the warm bath and sinapisms to the extremities, have the effect of abating the violence of the paroxysm and shorten- ing its continuance. When considerable hoarseness of the voice, and a short barking cough continue during the intermissions, the exhibi- tion of an emetic will be found advantageous—generally removing very promptly the remaining symptoms, and preventing the recur- rence of a paroxysm. We have usually preferred, in the cases occurring in young chil- dren, the ipecacuanha to the emetic tartar—excepting where this, as is often the case, fails to produce a prompt and full operation; under these circumstances, as well as in older children, we have never hesi- tated to prescribe the tartarized antimony. We are in the habit of giving the ipecacuanha in small nauseating doses, every two or three hours, either alone or combined with extract of hyoscyamus, in the intervals of the paroxysms, and have invariably been much pleased with its effects. In mild cases, small repeated doses of the mel scillae compositum of the United States Pharmacopoeia, may be advanta- geously substituted for the ipecacuanha. Blisters upon the chest or between the shoulders are recommended by some writers—when employed, they should be allowed to remain on only long enough to redden the skin, when the parts occupied by them should be covered by a soft emollient poultice. We have sel- dom, however, seen much good result from the application of blisters in cases of spasmodic croup. Covering the breast, however, with a hemlock or asafoetida plaster, has appeared to us very generally to have a decidedly beneficial effect. Purgatives are only required in those cases in which their use is indicated by a costive or torpid state of the bowels. Here a dose of calomel, followed by castor oil or magnesia, will be proper, and a free state of the bowels should be subsequently maintained by an occasional dose of some mild laxative. Asafoetida, either by the mouth or by enema, is unquestionably a remedy from which the best effects are to be anticipated in violent cases of the disease, subsequent to depletion and the use of the warm bath. It should be administered a few hours after the paroxysm has terminated. Wichmann recommends the musk as a specific in this disease; Henke, Wendt, Goelis, and others, speak also in strong terms of its curative powers. Wendt gave it in the dose of a grain every hour. It is all-important that the child affected with spasmodic croup 346 DISEASES OF CHILDREN. should be kept in a state of perfect tranquillity, Avarmly clad, and in an apartment where the atmosphere is pure and of moderate and eijua. ble temperature. During the paroxysms he should be supported in an erect posture, and all covering or ligatures should be immediately re- moved from about the neck. His food should be light and of easy digestion—his drinks should not be given cold—tepid lemonade or barley water slightly acidulated, "will perhaps be the best. 8.—Spasm of the Glottis. (LARYNGISMUS STRIDULUS.—THYMIC ASTHMA.—KOPP's ASTHMA.) 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, but without fever, and often without any material derangement of the general health, is of much more frequent occurrence than is generally sup- posed. It has often 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 during or upon awaking from sleep, or in taking drink or food, or upon being teased or irri- tated, with a difficulty of respiration; inspiration being often entirely suspended for a few seconds. After violent, even convulsive struggles, he finally succeeds in getting breath, Avith a shrill crowing sound, someAvhat similar to the ringing inspiration of hooping cough. In severe attacks, during the vehement efforts at inspiration, the whole of the respiratory muscles are thrown into violent action. The nostrils are dilated, the mouth is extended, the eyes are rolled up- wards, and the Avhole countenance expresses the utmost anxiety and suffering. The head is throAvn backwards, and the chest upwards; the diaphragm and abdominal muscles contract violently, and even the extremities become rigid; while the feet and hands are cold. 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, according to Ley, may continue long after the cessation of the paroxysms. The backs of the hands and in- steps are often swollen and hard; the thumbs are rigidly contracted, and locked across the palms of the hands, and the toes are bent down toAvards the soles of the feet; the wrists and ankles being rigidly and permanently bent by the action of the flexor muscles. In many cases these carpo-pedal contractions have a very singular appearance, and in the opinion of Rees, are characteristic of the disease; the fingers arc 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 laryngismus are paroxysmal, and vary in duration and intensity. At first a single paroxysm may occur, and after a short time, often a few minutes, cease spontaneously, and the breathing, at first somewhat hurried, soon become perfectly free and regular, and the child present no apparent indications of disease. Days, and even DISEASES OF THE RESPIRATORY ORGANS. 347 Aveeks may pass without the occurrence of a second paroxysm; but in other cases, the paroxysms recur with alarming frequency, and are protracted to fifteen or thirty minutes, or even longer; Avhile, in many instances, the paroxysms recur Avith such rapidity that there is scarcely a complete interval; their intensity and duration increasing, generally, Avith 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 im- mediately ensues; but when the disease is more fully established, the paroxysms take place at all times of the day or night. Other symptoms are described as of constant or occasional occur- rence; thus, Kopp has noticed a thrusting out of the tongue between the lips, which is also present to a certain extent during the intervals of the paroxysms; Hirsch, an involuntary discharge of the contents of the bladder and boAvels; and, in severe cases, Caspar has observed a convulsive contraction of the muscles of the hands, and abductors of the thumbs, during the intermissions. Immediately preceding, as Avell as subsequently to, a paroxysm, the sound of the patient's breathing is often that which Avould result from an increased secretion of mucus in the respiratory tubes. 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 epileptic convulsions, deep coma, hydrocephalic symptoms, or those of acute meningitis. Laryngismus is to be distinguished from spasmodic croup by the absence of all catarrhal symptoms, febrile excitement, and cough, by the respiration being unaffected during the intervals of the pa- roxysms, and by the contractions observed in the extremities. The crowing inspiration also, of laryngismus, is not marked by the peculiar hoarse, rough and grating sound peculiar to the inspiratory effort in croup. From hooping cough, laryngismus may be distinguished by the ab- sence of the convulsive cough, and the retching, vomiting or free ex- pectoration of glairy matter, by Avhich the paroxysms of pertussis are so generally terminated. Hooping cough is also more gradual in its approach, the characteristic paroxysmal cough being in general pre- ceded by catarrhal and febrile symptoms. Dr. James Reid of London, who has written a very instructive trea- tise on Infantile Laryngismus, describes it as occurring under four different forms. The first is caused by a slight constriction of the edges of the rima glottidis, which occurs suddenly, and in a transient manner, causing, for an instant, an exertion on the part of the infant to recover its breath, and producing a feeling of oppression and alarm, indicated by a short cry, and the anxiety depicted on its coun- tenance. This slight and temporary spasm of-the glottis is not asso- ciated Avith convulsive action of any part of the body. The attacks come on at irregular intervals, and at uncertain times, although most generally Avhilst the infant is asleep, or at the moment of awaking. So little importance is generally attached to this symptom by nurses, that the physician, when called upon at a later period to treat the 348 DISEASES OF CHILDREN. more severe form of the disease, finds that the "catching'' alluded to is often not mentioned until questions are put, Avhich at once recall the recollection of its having been of frequent occurrence, though always arrested immediately upon the child being lifted from the re- cumbent to an erect position. In the second form of laryngismus, according to Dr. Reid, the area of the glottis is still more diminished by the nearer approximation of its edges, the closure, however, not being perfect except perhaps for a moment. In this form of the disease there is a much longer interruption of the respiratory function, and the symptoms of impending suffocation are more imminent: there is a violent effort to inspire through the contracted aperture of the windpipe. The countenance exhibits the characteristics of great anxiety and distress, becoming at first red, but soon changing to the purple hue of strangulation; the face, and, in some cases, the tongue also become turgid and swollen. In other instances there is an ashy paleness of the face. The arms are throAvn out; the eyes are either wide open and staring, or, more rarely, turned up in their sockets; the nostrils are dilated; the head is thrown back; the limbs become rigid, and the abdominal muscles contracted. There is frequently, also, a convulsive and violent action of other muscles, especially of the flexors, causing a peculiar contraction of the wrists and ankles, a state which has been called the carpo pedal spasm. Occasionally, the body itself is bent suddenly backwards, as if by a violent effort, and it appears to the bystanders as if nature could hold out no longer, when, at length, the attempt at respiration is partially successful, being attended by a shrill whooping noise, which has been termed crowing, although it more closely resembles the concluding rising note produced by the clucking of a hen. This sound is not of so full and sonorous a character as that of hooping cough, but seems more acute, and it is Avithout the rough hoarseness of croup. It is often an indication that the paroxysm has terminated, but sometimes a succession of incomplete or interrupted, shrill, sibi- lant catches supervenes before a full and complete inhalation takes place, as if the margin of the glottis were for a time somewhat re- laxed, becoming immediately again constricted, so that the expirations bear, in some degree, a resemblance to the short and feeble bleating of an animal. When respiration is again properly re-established, the infant most commonly bursts into a fit of crying, and falls asleep; when, hoAF- ever, the attack is unusually severe, a listlessness and torpor often remain for a short period afterwards, whilst in rarer instances of the disease, the child continues, during some hours, in an anxious state of distress. These paroxysms vary much in their frequency, duration, and se- verity; there is no regularity in the intervals betAveen the attacks, but as the complaint advances, they generally become shorter, and, in some instances, do not continue beyond an hour at a time, or even half that period, the slightest noise or emotion being quite sufficient to produce a paroxysm. The breathlessness, or struggling for air, is DISEASES OF THE RESPIRATORY ORGANS. 349 apparently relieved, in some cases, by a violent expulsion of wind from the stomach or per anum, which is succeeded by a fit of scream- ing; occasionally, also, there are involuntary evacuations during the paroxysms. Repeated attacks of this nature may occur, without the accom- panying croAving noise, especially when the disease becomes less severe in its character. An acute plaintive cry frequently commences or terminates the paroxysm; when the child remains quiet and sub- dued for some minutes, after which period, it resumes its natural cheerfulness and aspect, enjoying perfect health in the intervals. The duration of the paroxysm varies from a few seconds to three or four minutes, but in the latter description of cases, it is more a succession of paroxysms; air occasionally gaining admittance into the lungs, during the slight and almost imperceptible intervals be- tween them. Remissions and exacerbations often take place for weeks, and sometimes for months, before a complete cure can be ef- fected ; whilst in other cases, on the contrary, the complaint suddenly disappears. Dr. Reid describes the third form of laryngismus as a combination of the foregoing variety of the disease, with* the addition of general or cerebral convulsions, which, in all probability, are sometimes pro- duced by the blood supplied to the brain being imperfectly decar- bonized, in consequence of partial asphyxia. In the fourth form of laryngismus, according to Dr. Reid, there is complete asphyxia produced by a sudden and convulsive closure of the glottis, which proves as speedily fatal as if the infant were plunged under Avater, or strangled by a cord around its neck. No crowing sound is audible, as inspiration is totally suspended, and the face of the child, instead of being flushed and turgid, exhibits often a cadaverous aspect, similar to that of persons asphyxiated by car- bonic acid gas, or other noxious vapours. An infant, Dr. Reid re- marks, may have passed through repeated severe attacks of the dis- ease, combined with cerebral convulsions; it may be also, perhaps, improving otherwise in general health, at the same time that the pa- roxysms have latterly occurred at longer intervals, yet, notwithstand- ing all the apparent amendment, it is sometimes carried off by this form of the disease, Avithout any previous warning. The infant may be laughing at the time, or quietly observing the occurrences taking place around it, without the slightest precursory symptoms being per- ceived. 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 ventricles, or at the base of the brain, is of frequent occur- rence; tubercles 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 dis- ease of the gastro-intestinal, and in some cases, of the respiratory 350 DISEASES OF CHILDREN. mucous membrane. No one of these morbid appearances is, however, constantly present in the bodies of those avIio have died of spasm of the glottis. Perhaps, judging from the cases on record, most of which have, however, been adduced to support particular pathological views, Ave ought to enumerate enlargement of the thymus body, and effu- sion Avithin the cranium, as among those most commonly met with; we suspect, hoAvever, that upon a more minute inquiry it will be found that enlargement of the thymus body is a much less frequent accom- paniment of the disease than has been asserted. Dr. Reid states that on several occasions he has sought for indications of disease, but has been unable to detect any, even in the spinal cord. As a gene- ral rule, it may be stated, he remarks, that no unusual appearances are found to exist in the glottis itself, or in the adjacent parts; no trace of oedema, inflammatory action, or persistent constriction. Dr. Reid has never met Avith any enlargement of the neighbouring glands suf- ficient to account for a fatal termination. Spasm of the glottis is almost exclusively confined to the period of infancy and childhood; it may attack, according to Kerr, at any period from within a few days after birth, to three years, but most common- ly it occurs between the fourth and tenth month: Mr. Robertson, (London Med. Gaz., Jan. 1849,) has found the accession of the dis- ease to be most frequent from about the fifth to the twelfth month. Of twenty-one cases related by him, in three only did the disease occur in infants beyond twelve, and in none were they beyond fifteen months of age. Dr. Reid, in common with the majority of those who treat of the disease, states, in regard to the age of infants most liable to its attacks, that it corresponds, with few exceptions, to the period of dentition. An affection, he remarks, closely resembling spasm of the glottis, if not identically the same complaint, may be caused at any period of life by local or mechanical agency; but it must, he thinks, be considered a peculiar disease of infantile life, when it fol- lows as the result of constitutional irritation. Most of the Avriters enumerate the lymphatic temperament as one of the predisposing causes of the disease; it is in consequence of this that we find it to at- tack almost all the children of some families, while those of others are entirely exempted from it. 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. In Mr. Robertson's cases the attacks occurred between the months of October and May. As the patients belonged to that class of society the infants of which are at this season of the year in a great measure confined Avithin the limits of the nursery, he thinks it probable that it is by this seclusion from the external air the predisposition to the occurrence of spasm of the glottis is induced, a conclusion which the fact of the disease being one rarely observed in the infants of the la- bouring classes, who are abroad in almost all kinds of Aveather, daily, throughout the year, would seem to favour. Dr. Reid considers that infants of a nervous temperament, who are easily excited, Avho are awakened by slight noises, and who are not satisfied unless they are DISEASES OF THE RESPIRATORY ORGANS. 351 kept constantly "on the move," are those most susceptible to laryn- gismus. As exciting causes Mr. Robertson enumerates the irritation of teething, disturbance of the digestive organs, and any sudden ex- citement. Dentition is, unquestionably, one of its most common pre- disposing 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 con- dition of the atmosphere; exposure to a current of cold air, efforts to swallow, or even suddenly stooping to pick something from the ground. According to Dr. Reid, and his views are fully borne out by our own experience, one of the most common causes of laryngismus is a deranged state of the stomach and bowels. He has never known more than two instances of the complaint to occur Avithout the pre- sence of such derangement, as indicated by constipation, a morbid con- dition of the stools, flatulence, &c. And it is seldom, he adds, that we observe decided signs of amelioration in the little patients, until the secretions become of a more healthy character. In fact, most of the writers upon the disease, whatever may be the difference in their views as regards its pathology, admit that a vitiated state of the al- vine secretions is a prominent symptom, some describing this as ag- gravating the disease, whilst others view the disordered condition of the bowels as a primary cause. Another cause, which experience convinces us, if it be not alone sufficient to originate laryngismus, at least materially aids in keep- ing up the irritation which has been produced by other causes, is atmospheric influence. This is proved by the fact that, in many cases of the disease, on a change of air, the symptoms have imme- diately ceased, but recurred when the infant was brought back to its former residence. The rare occurrence of the complaint in rural dis- tricts, as compared with its prevalence in crowded towns, is, Dr. Reid remarks, a proof that atmospheric influence is concerned, in the majority of cases, as one of the exciting causes. He adduces the returns of the mortality in 117 districts of England, to prove that the morta- lity of infants, during the ages of teething, is six times greater in tOAvn than that met with in an equal population of a country district. It has been supposed that a damp or low locality, even in the coun- try, is apt to give rise to laryngismus. Dr. Reid considers that under certain circumstances, it may, perhaps, have some effect, in combina- tion with other causes, but that its influence cannot be very powerful. Some, as yet undetected, local influence has, at all times, no doubt, much to do in assisting to generate the disease in certain situations. Dr. Hall mentioned at a discussion of the London Medical Society, that he had known of three fatal cases of laryngismus occurring in a family who resided upwards of four miles from a large country town; the other infants of the same family were, on this account, removed from the place, and thus escaped the disease. Dr. Reid can find no decisive evidence that cold weather has any 352 DISEASES OF CHILDREN. prejudicial influence on cases of laryngismus. In more than one case he has known a removal from town to Hampstead Heath, or to the coast, during the cold bleak winds of spring, immediately to arrest the complaint. In one instance it was found that exposure to the open air in cold weather, invariably stopped the paroxysms, and that one of them never occurred during such exposure. Peculiar odours seem occasionally to act as a sufficient cause for inducing the paroxysms of laryngismus. Cases are referred to in which the paroxysms were caused by the fumes of alcohol, the atmo- sphere of a newly painted room. A great number of similar cases could be cited. Dr. Reid considers that the most frequent, and in the majority of cases the combined exciting causes of laryngismus, are the improper description of food which is administered to the infant, and the im- pure and irritating atmosphere Avhich it breathes. Under the head of improper food, may, in certain circumstances, be included the breast milk of the mother or nurse. That is, when from any cause this has become deteriorated. Dr. Reid believes, however, that comparatively few cases of laryngismus occur in infants avIio are fed altogether upon breast milk. Of the numerous instances which have come under his notice at various times, the disease occurred in two infants only who were not fed by hand, either altogether or partially: one of them was a child six months old, who had a wet nurse. By a curious coincidence, the nurse herself, two nights pre- viously to the child being affected, had a similar spasmodic affection of the glottis, caused by hysteria, and the sound produced by it so precisely resembled that which the father of the infant, a medical practitioner, had been accustomed to hear whilst his elder children had suffered from laryngismus, that he hastened up stairs, thinking the infant was also attacked by it. Two days subsequently, the child, for the first time, did show symptoms of the disease, although they were slight, and of short duration, compared with those of the other children. North includes laryngismus among the premonitory symptoms of convulsions, and Beatty considers it in many instances to be one of the earliest symptoms of incipient hydrocephalus, which accords with our own experience. Goelis describes all its symptoms as occurring in the advanced stage of chronic hydrocephalus. Dr. Reid believes it may be fairly inferred that laryngismus is sometimes complicated with, or followed by hydrocephalus, but that in very rare instances does the latter act as a cause of the disease. Laryngismus stridulus, as we have already remarked, consists, essen- tially, in a spasmodic closure of the glottis, impeding the ingress of air into the lungs, and sometimes so completely closing it, as to sus- pend, for a few seconds, the respiration entirely. Mr. Ley, however, denies that the difficulty of inspiration is owing to a spasmodic closure of the glottis, but maintains that it is due rather to the inability of this part to enlarge to its normal size, from a want of innervation, in consequence of pressure upon the nerves by diseased glandulae con- catenatae. From the same cause, he conceives that the transverse DISEASES OF THE RESPIRATORY ORGANS. 353 fibres, behind and connecting the rings of the trachea, lose their con- tractile power, and alloAv the sputa to accumulate, giving rise to the rattling sound heard in the upper part of the trachea, particularly when the patient is asleep. FeAV, however, have adopted these views of Mr. Ley,—the spasmodic character of the disease being admitted by the generality of those who have studied its phenomena Avith care. Upon the nature of the cause by which the spasmodic affection of the glottis is produced, there, hoAvever, 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 con- dition of the thymus gland, and numerous observations have been re- corded, in support of this hypothesis, by Kopp, Frank, Kirmaul, Hirsch, Lcke, Van Velson, Most, Kyll, Montgomery, Hughes, Flackman, Rees, Mitchell, Pury, and others. 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 investigated, this 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 gland is capable, under any circumstances, of exerting upon the nerves which pass in its vi- cinity, such a degree of pressure or irritation as w-ould produce the phe- nomena of the disease under consideration. M. Trousseau, who refers the disease to a spasmodic condition, with want of harmony in the ac- tion of the respiratory muscles, states, that during the six years he has been at the head of the wards of his hospital, he has not in a single instance met with the thymus gland sufficiently enlarged to give rise to the slightest inconvenience. We have numerous observations upon record, which prove that the thymus gland 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 oc- currence of the disease, even in its mildest form. 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 size. From our own observations upon the relative size of the thymus, at different ages, from birth to puberty, we are strongly inclined to be- lieve that in many of the cases recorded as instances of enlarged thy- mus, the gland was either not at all affected, or was actually below the size which it frequently presents in perfectly healthy children at the same age. We are to recollect, also, as Dr. Hall correctly re- marks, that its enlargement, even when it occurs, may be the effect and not the cause of the morbid phenomena. It may be the natural result of the violent convulsive efforts at inspiration, observed in this terrific malady. The thyroid gland has been known to become and remain enlarged, in like manner, after the efforts of severe and pro- tracted labour; the eyes to become bloodshot from hooping cough: the eyelids to be distended with blood from epilepsy, and from the 23 354 DISEASES OF CHILDREN. efforts of vomiting and of parturition. In this manner we can readilv understand how enlargement of the thymus may be an effect of a spasmodic closure of the glottis, and subside with the disease, which Avould not be the case if it was dependent on change of structure. Numerous cases are recorded by Beatty, Rullman, Toogood, Burgess Ryland, Marsh, Rees, and others, in which the disease was produced, entirely independent of the slightest enlargement of the thymus, or of any of the cervical glands. Dr. Corrigan considers inflammation of the cervical portion of the spinal cord to be the cause of spasm of the glottis, and has published an interesting case in the London Medical and Surgical Journal, (1836,) to illustrate this position. But this case, in which spinal irritation seems evidently to have produced the disease, is a solitary one, and Avhile it compels us to admit that spinal irritation may occasionally induce spasmodic contraction of the glottis, does not prove it to be its only cause. Dr. Herard has made the disease the subject of an inaugural thesis. He observed numerous cases of it in the Children's Hospital at Paris. He believes it to be the result of spasm of the glottis, or of the dia- phragm, and describes three forms of it, according as one or other, or both of these organs are affected. When the spasmodic attack is limited to the glottis, the respiration is simply arrested for a feAv se- conds, and is restored without the production of the special cry pro- duced by inspiration during convulsions of the diaphragm. In the se- cond form, in which the diaphragm alone enters into spasmodic action, the attack is marked by several successive and sonorous inspirations; the symptoms of asphyxia are by no means so well marked as in the first variety. In the third form both the glottis and the diaphragm are simultaneously convulsed; respiration is first suspended, and one or more sonorous inspirations are heard, which, not being followed by expiration, asphyxia is soon imminent. These sonorous inspirations resemble the crowing of hooping cough, and are produced by the same cause. Death may occur during the attack from asphyxia, from cere- bral disease, or it may be the consequence of gradually increasing debility. On the examination of the bodies of children who have died of this disorder, Dr. H6rard asserts that no characteristic alteration can be detected. As to the hypertrophy of the thymus gland, he refuses to admit that it has anything to do with the production of the disease, and shows from carefully drawn up statistics that the volume of the gland is in harmony with the states of health or the strength or Aveak- ness of the constitution, and not with the presence of asthma. Dr. H. attributes the large size which the thymus sometimes attains entirely to the vigorous constitution of the child. The agency of hypertrophy of the thymus gland in its production is denied also by Caspar, Pagenstecher, Ley, Hall, Merriman, Fricke, Oppenheim, Cheyne, and Clarke. Mr. Ley attributes the disease to a suspended or impeded state of the functions of that portion of the eighth pair of nerves which is distributed to the larynx, caused by pressure from enlarged cervical and bronchial glands; while Marsh DISEASES OF THE RESPIRATORY ORGANS. 355 \ refers it to an irritation seated at the origin of the pneumogastric nerve, and others, with Clarke, Cheyne, Beatty, Rullman, Fricke, and Oppenheim, to disease of the brain. Were pressure from enlarged thymus or cervical glands a frequent cause of laryngismus, it is difficult, Dr. Reid remarks, to comprehend Avhy the attacks are often separated by long intervals in some cases, al- though the pressure continues the same. Such continued pressure would also act as a direct mechanical cause, Avhereas the history of the disease proves it evidently to be the effect of reflex action. Dr. Marshall [fall asserts, moreover, "that such pressure Avould cause per- manent paralysis and constant closure of the glottis." The experiments of modern physiologists sIioav that the Inferior or recurrent laryngeal nerves, which alone govern the muscles of the glottis, are exclusively motor nerves, and that irritation, applied even to them, will produce convulsive closure of that aperture, Avhilst cut- ting or compressing them renders the glottis and movements of the arytenoid cartilages inert or passive, but does not prevent ingress or egress of air, although they impede the former. The sudden manner in which the paroxysm is resolved, in many se- vere cases of laryngismus, upon a change of air, the cutting of a tooth, the discharge of worms, or of large unhealthy stools, or the exhibi- tion of antispasmodics, is inconsistent with the supposition of its de- pendence upon pressure from an enlarged and indurated gland. According to Dr. Hall, the disposition to spasm of the glottis con- sists 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 excitement of this property; the most ob- vious of which are dentition, indigestible food, morbid alvine matters, external agents, and mental emotions. Nearly the same views are expressed by Mr. Ryland, and they are those advocated by Dr. Reid. In one case related by Mr. Ryland, however, he 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 exciting cause of the disease. Our own observations incline us to adopt the views of Dr. Burgess, namely, that the disease is simply a spasmodic affection of the respi- ratory muscles; its chief exciting causes, when it occurs during the earlier period of dentition or previously to its occurrence, being an irritation of the digestive organs, a cold, confined, or impure atmo- sphere, and dentition; but that when it occurs during, or subsequent to dentition, it is almost invariably symptomatic of cerebral disease. Nearly the same views are expressed by Mr. Rees: this gentleman' refers", it is true, the disease, previous to dentition, invariably to en- largement of the thymus gland, or enlarged agglomerated glands in the vicinity of the recurrent nerves; but observes, that one remark- able point in these cases is, the dependence of the paroxysms of dysp- noea 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 evidently depends upon a mechanical cause." The same difficulty, he further re- 356 DISEASES OF CHILDREN. marks, 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 exclu- sively directed to the supposed agency of glandular enlargement in the production of the disease. We have, in repeated instances, seen the most severe attacks of laryngismus produced solely from irritation of the alimentary canal, resulting from indigestible and improper food, and other errors of diet, or from the influence of an impure, irritating, and confined at- mosphere, the disease being promptly and effectually relieved, in its early stages, by getting rid of the exciting cause in the stomach and boAvels, or by removal to a pure and wholesome atmosphere. The cases combined with cerebral disease are seldom met with un- til after dentition has commenced. It is remarked by Rees, that if the patient survive the appearance of the first molar teeth, the case gene- rally terminates favourably. In this form of the disease the patient usually remains, during the intervals, dull, heavy, listless, and droAvsy; the pupil of the eye is dilated; the head hot, and frequently held ex- tended on the spine; and unless appropriate remedies be resorted to, an attack of convulsions or inflammation of the brain is always liable to supervene; carpo-pedal spasms also frequently occur. These lat- ter are generally attended Avith considerable derangement of the gas- tro-intestinal mucous membrane. Dr. Reid, while he admits that cerebral or general convulsions are often associated with laryngismus, and that a paroxysm of the latter may sometimes terminate in the former, denies, however, that laryngis- mus is dependent upon primary disease of the brain. If, he remarks, careful observation be made respecting this point, I think it will be found, in all cases not complicated with cerebral convulsions, First, that there are not present the usual symptoms of congestion of the brain: secondly, that, in the great majority of cases, no unusual pa- thological appearances in the brain are met with after a fatal termi- nation from spasm of the glottis; and, Thirdly, that the remedies most successful in this complaint are not those which are usually cm- ployed in cerebral congestion, whilst, on the contrary, those which are indicated have frequently been productive of great injury in the treatment of laryngismus. 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, in many of the cases, to symptoms of such intensity, as to require an operation to preserve life. The prognosis Avill depend entirely upon the nature of the lesion by which the spasm of the glottis is produced. In cases in which the disease 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 DISEASES OF THE RESPIRATORY ORGANS. 357 proper change of diet or air; but when symptomatic of disease of the brain, or of any permanent irritation of other organs, or when it occurs in infants in whom there is an undue excitability of the nervous centres, it is always to be considered as a serious affection, and very frequently proves fatal. Nevertheless, the prognosis must in every case be somewhat uncer- tain, for the disease occasionally proceeds in a mild manner for a time, and then suddenly assumes the most dangerous form. There are no regular intervals between the attacks, and a sudden and very severe paroxysm may unexpectedly occur at any moment, particularly during the period of dentition. The principal dangers to be appre- hended are suffocation and cerebral convulsions. Thus, the prognosis Avill be worse when the child is constantly dull and heavy, with slug- gish pupil, and indications of venous congestion about the head. Should there be any family tendency to cerebral disease, the prog- nosis assumes a still worse aspect. An unhealthy state of the mesen- teric glands is said to augment the danger of the disease, as also the occurrence of acute bronchitis; though, in a case narrated by Dr. Reid, the crowing noise disappeared during an attack of bronchitis, and re- turned after it was subdued. The duration of laryngismus is variable—the patient may be carried off by the first attack, although this is a rare occurrence: in other in- stances, as in one related by Rullman, the infant may struggle through the disease for twenty months, and then fall a victim to its effects. The mortality in this complaint varies considerably in the state- ments of the authors who have described it. Dr. Gooch states that the disease proves fatal in one-third of those attacked. In Sir H. Marsh's cases, five recovered, and two proved fatal. In Hirsch's cases, three out of five died—one complicated with hooping cough, and the other with general convulsions. Dr. Ley considers the dis- ease to be " not very commonly fatal;" Avhilst Dr. Davies states it to be frequently so, especially when complicated with convulsions; he also considers the danger from the disease to be greater during the period of dentition, which accords with the experience of Dr. Reid, as well as our own. The latter gentleman reports six fatal cases of laryngismus out of fifty that came under his observation. His expe- rience leads him to consider the disease more likely to prove fatal in male children than in female; but according to Pagenstecher, Hack- man, and others, it attacks boys much more frequently than girls. It is astonishing, remarks Dr. Reid, in some cases, how many at- tacks of the spasms and convulsions combined may take place during the twenty-four hours, without proving fatal. He has known them to occur on every slight noise in the room, so that the mere gentle displacement of any article on the table would cause a paroxysm, and yet a favourable termination of the disease ensue. The treatment during the paroxysm consists in placing the patient in an upright position, Avith the head slightly inclined forwards, and exposed to a full draught of fresh, cool air, while cool 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. 358 DISEASES OF CHILDREN. Slapping the child slightly on the back and nates, will occasionally aid in removing the spasm; frictions along the spine should, also, hv resorted to. If the paroxysm does not yield to these means, the patient should be placed in a Avarm bath; Avhilst in the bath, cold Avater should be sprinkled on the face, which will generally cause a strong inspiration and lengthened expiration, folloAved by a scream that usually puts a period to the paroxysm. It may be also useful to apply ammonia or ether to the nostrils. Irritation of the pharynx, by a feather, will sometimes induce vomiting, which will, of course, solve the spasm of the glottis. Dr. Charles D. Meigs recommends the application of a piece of ice, Avrapped in a cloth, to the epigastrium and Ioavci* part of the sternum. This procedure will often cause a speedy solution of the paroxysm. An enema, with the addition of asafoetida or turpen- tine, will be useful, in violent attacks. If the dyspnoea continue un- abated, and death from asphyxia is threatened, artificial respiration should be resorted to, by bloAving at intervals into the child's mouth, closing at the same time the nostrils, pressing the trachea against the oesophagus, and afterwards compressing the thorax and abdo- men with the hands—thus alternating an imitation of inspiration and expiration. If by this means, hoAvever, the patient is not speedily aroused, the operation of tracheotomy should be immediately per- formed. If, during the paroxysm, there is evident congestion of the brain, a few leeches behind the ears, with cold lotions to the scalp, Avill 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 teeth have already appeared. He directs this for the purpose of correcting a state of the blood-vessels and nerves of the gums, which, though physiological, still borders on a pathological character; and hence he orders the incisions to be re- peated for several successive days. The boAvels of the patient should be well moved daily. But, in ac- complishing this, all irritating remedies should be avoided, and we must also be careful not to produce severe purging, which, by ex- hausting the patient, will augment the susceptibility to subsequent at- tacks. When the discharges from the bowels are of an unhealthy character, small doses of calomel, or of the blue mass, combined with ipecacuanha and extract of hyoscyamus,1 repeated at short intervals. and an occasional dose of the infusion of rhubarb, with tartrate of potass and manna, will in general, ansAver our purpose. To the last- mentioned prescription, it has been recommended to add a few drops of tincture of hyoscyamus, 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, espe- cially when the evacuations are clay-coloured, to be the repeated use of enemata of warm water or barley Avater. DISEASES OF TBE RESPIRATORY ORGANS. 359 1 R.—Calomel, gr. -vj. ad xij. Ipecac, pulv. gr. iij. Ext. hyoscyami, 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. Dr. Reid considers both the internal and external use of antispas- modics as invaluable in the treatment of laryngismus. Asafoetida or musk, he remarks, occasionally succeeded in arresting the symptoms in some cases of simple convulsions arising from teething, when leech- ing and purging have not alone had the desired effect. In those cases Avhere the bowels are in a very irritable state, the exhibition of small doses of hyoscyamus, Dover's powder, the hydro- cyanic acid, ammonia, or a combination of them, will often, according to Dr. Reid, produce a most striking effect in subduing the tendency to the spasmodic paroxysm. The following prescription is one which he has been in the habit of employing with excellent results: Jfc.— Spir. ammoniae foetidi, 3ss.; tinct. hyoscyami, gtt. x.; syrup, aurantii, gss.; spir. anisi, 3J.; acid, hydrocyanici diluti, gtt. v.; aquae, gj.— 51. A teaspoonful to be given, three times a day, to a child ten or twelve months old—the doses being graduated according to the age of the patient. Should the above not prove speedily efficacious, the following may be tried: B/.—Pulv. Valeriani, 3ij-5 ammoniae sesqui- carbonatis, gr. viij.; syrup, aurantii, ^ss.; aq. carui, gjss.—M. To be rubbed together. The sixth part to be taken as a dose three times a day. A stimulating embrocation, with the addition of some narcotic, ap- plied to the spine, chest, and abdomen, Dr. Reid recommends as pro- ductive of decided benefit; especially when the hands and feet are affected wdth spasmodic contractions. The following is Dr. Reid's usual formula: fy.—Tinct. opii, 3jss.; tincturae lyttae, 3j.; liniment. saponis, gjss.—M. To be applied two or three times a day. The ad- dition of four grains of the extract of belladonna, or 3ss. of the tinc- ture of aconite, in obstinate cases, will increase the effect. " In the secondary part of the treatment," Dr. Reid remarks, " tonics Avill frequently be found to possess great influence in removing the lingering symptoms of laryngismus. The different preparations of iron and bark are those best adapted for the purpose, when purgatives and antispasmodic medicines have previously prepared the way for their employment. Some judgment, however, is requisite in selecting the appropriate time for commencing their use." Among the different preparations of iron, Dr. Reid prefers the vi- num ferri of the old London'Pharmacopoeia; but the ammonio-citrate and the potassio-tartrate are, owing to their comparative slight taste, eligible forms of the same mineral, as they do not nauseate the little patient. In those cases which are actually combined with a scrofulous taint, the syrupus ferri iodidi may be advantageously employed. The importance of an attention to the diet of a patient need not be insisted on; nor need Ave, after Avhat has been already said in many of the preceding sections, lay doAvn any precise directions in regard to the proper articles to be employed. The repetition of the attack, remarks Dr. Hall, Avhose therapeutical directions in respect to the dis- 360 DISEASES OF CHILDREN. ease under consideration are replete with good sense, has so often, within my own experience, been the result of improper and indiges- tible 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 confinement of the infant to the breast-milk of a healthy nurse, during the ordinary period of suckling, cannot be too strongly insisted on. In individual cases, it will be advisable to continue this mode of nourishment even beyond the usual period. If the mother or nurse's milk is suspected to be deteriorated in quality, no time should be lost in placing it at a breast from which it will be supplied with a more healthy nutriment. The importance of a pure, fresh, dry, and cool atmosphere, in this disease, is recognised by nearly every writer who has treated of it. A very slight vitiation of the air will frequently bring on the most violent attacks, Avhich are as quickly terminated by its removal; in one case, related by Marsh, a paroxysm was induced, whenever the child wras brought into a newly-painted house. When the little pa- tient has been long free from attacks, a sudden change of the wind to the north-east frequently induces a return of them; and even Avhen they have been long«obstinately repeated, and have become, as it were, chronic, a change of air, Dr. Hall remarks, has induced as suddenly a suspension of them. We have known a recurrence of the paroxysms to be kept off, so long as the patient remained in the city, and to hap- pen whenever the child was taken into the country. In the cases treated by Mr. Robertson, he employed as one of his principal means of cure, more especially in the aggravated forms of the disease, free exposure to a cool dry atmosphere, and with the most decided good effects. 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 Avea- ther, 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 curative as well as prophylactic means. Mr. Robertson recommends cold sponging night and morning. In cases of excessive irritability the cautious use of this remedy may be found advantageous. There is one cause capable of exciting a spasmodic closure of the glottis in infants, which, though too often overlooked, should be kept constantly in mind by the medical practitioner; namely, sudden, men- tal eniotion, and especially fright, or that state of nervous excitement into which infants are often thrown, when thwarted, teased, or vexed. The infant should not be suddenly awoke 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 treat- DISEASES OF THE RESPIRATORY ORGANS. 361 ment of the infant, and the unwholesomeness of her milk. The slightest alarm is still more serious in its effects; all sudden noises, all rapid movements 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 enforced 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 spasm of the glottis. It has happened to us to see, in several instances, most violent parox- ysms, though in none attended with a fatal result, excited solely by mental emotion and fright; hence Ave should be cautious not to irri- tate it by unnecessary examinations; the mere act of looking at the gums, by forcibly opening its mouth, will sometimes induce a severe attack. It has been suggested by Dr. Hall, that the morbid suscep- tibility of the patient's system may be subdued by keeping him for some time constantly under the gentle influence of the tincture of hyoscyamus, and the infusion of hops. The tonic influence of tepid salt Avater, applied to the surface by sponging, is also highly benefi- cial. In those cases in which there is an evident tendency to cerebral disease, the proper remedies indicated by the nature and extent of the latter should be immediately resorted to. In all cases, indeed, if we direct our attention to the congested condition of the brain, which is so liable to occur during paroxysms, we shall perceive the impor- tance of adopting measures to counteract it. Under ordinary cir- cumstances, the spirit lotion applied to the head, and repeated seve- ral times in the course of the day, is an efficacious means of effect- ing this, and perhaps a much safer remedy than depletion, which, un- less there is an absolute necessity for resorting to it, should be avoided, in consequence of its tendency to increase the susceptibility of the nervous system, and consequently the disposition to an attack. In severe cases, Hall suggests the application of the ice cap. A variety of remedies have been recommended, with the view of controlling the spasmodic affection of the throat, as the aq. lauro- cerasi in small and graduated doses; and the oxide and cyanuret of zinc; as well as others for destroying the predisposition to and cause of the disease, as a very low diet, copious and repeated local bleed- ings, issues on the chest, frequent, active purgatives, mercury, anti- monials, cicuta, digitalis, animal charcoal, and iodine, internally and externally. To the greater part of these Ave object, as altogether unadapted to the disease, or positively prejudicial; while the recom- mendation of others is evidently based upon an erroneous pathology, and even by the strongest supporters of that pathology, they are ad- mitted to be of doubtful efficacy. 9.—Pertussis.—Hooping Cough. The hooping cough is usually described as a disease peculiar to childhood, occurring but once in the same individual, and propagated by a specific contagion. That it occurs most commonly at some 362 DISEASES OF CHILDREN. period previous to puberty, is unquestionably true; we have, never- theless, repeatedly met Avith it in adults, particularly Avhen it has pre- vailed epidemically; and the memory of every practitioner Avill fur- nish him with instances of its occurrence, in even elderly subjects. Heberden saAv it in a female of seventy, and in a man of eighty years of age, and Eberle notices two cases occurring in individuals over fifty years of age. Instances, also, of its recurrence in the same in- dividual are, by no means, unfrequent; we have seen several, and the same fact is noticed by various writers. As to its contagious nature, notwithstanding it is so considered by the generality of Avritcrs 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. 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 neccessary 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 is made by Desruelles and others. The diagnostic symptom of hooping cough is a suffocating, convul- sive cough, returning in paroxysms, terminating in an excretion of thick, glairy mucus, which is frequently discharged by vomiting. The cough is marked by a prolonged, stridulous, 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 inspiration is again almost immediately re- peated, and the paroxysm continues, often for many minutes, until a discharge occurs of a portion of thick, slimy mucus, by expectora- tion or vomiting, when the respiration becomes again comparatively free. During the paroxysms of coughing, the child often 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 spasmodic 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 vio- lent 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, in different cases, so many important variations, in their symptoms and duration, that it is difficult, as remarked by Billard, to assign to each its proper limits or distinctive characters. By Desruelles and Lombard, it is divided into the period of invasion, the period of increase, and the period of decline; by others, into the catarrhal stage, the nervous. spasmodic, or convulsive stage, and the stage of decrement; and by Blache and Williams, into the inflammatory, the congestive and ner- vous, and the simple nervous stage. DISEASES OF THE RESPIRATORY ORGANS. 363 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 ex- citement, Avith exacerbations towards evening. The duration of this stage varies considerably: it may be followed by the characteristic symptoms of hooping cough, in a few days, or be prolonged for a week or two, or even longer; the cough, however, increases from day to day, and becomes gradually moro convulsive and resonant. In some cases, the catarrhal phenomena have been entirely wanting, the pecu- liar symptoms of the disease occurring, as it were, suddenly: while during the prevalence of hooping cough, as an epidemic, many chil- dren will exhibit no other symptoms than those of the catarrhal stage. 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 in- tervals being in general longer during the period of increase, in the day, and during the decline of the disease, at night. The cough is generally preceded by a mucous rhonchus, which is more eArident 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 fauces, 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 paroxysms. The duration of the paroxysms is very various; in some instances, they last scarcely a minute, while in others they are prolonged for five or six minutes, or even longer. The intervals between the pa- roxysms vary from half an hour to three or four hours; but in very violent cases, at the height of the disease, the paroxysms are often diA'ided by intervals of only a few minutes' duration. The paroxysm usually terminates by the discharge of a large quantity of viscid mu- cus, generally by vomiting, resulting probably from the compression of the stomach, by the forcible contraction of the abdominal muscles Avhich 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 terminate more frequently and speedily by vomiting or retching. 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 returns to his ordinary amusements. When, hoAvever, the paroxysms are frequent, of long duration, and marked by great violence, the patient recovers from his distress only by de- grees, remaining exhausted for some time, with hurried or panting respiration, and complains, if old enough, of a tensive pain in the fore- head, and pain or soreness of the chest. In some instances, the vio- lence of the paroxysm is such as to produce a loss of consciousness from temporary asphyxia; or the asphyxia may be complete, and 364 DISEASES OF CHILDREN. death ensue. In other cases, convulsions, or cerebral congestion and deep coma may occur. The paroxysms often recur Avith some degree of periodicity; but they may be induced at any time by too much, or improper food, ex- citement 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, as remarked by Lombard, that motion, amusement, and the open air, contribute to lessen the cough; while rest, the horizontal position, and the close air of sleeping apartments, increase the tendency to its return. In slight attacks, there may be but little or no fever during the con- vulsive period of the disease, and but little functional disturbance in the intervals of the paroxysms; but, usually, the presence of the so- norous 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 consis- tent 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 feAv cases, diarrhoea is present, with vitiated discharges, a loaded tongue, nausea, loss of appetite, epigas- tric fulness and tenderness, and other symptoms of gastro-intestinal disease. In the cases accompanied by severe bronchial inflammation, there is generally more or less cough between the paroxysms, and conside- rable febrile excitement; and the convulsive, hooping, cough is gene- rally preceded and followed by considerable uneasiness, or oppression and pain of the chest. The bronchial inflammation, 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 inflam- mation, are common occurrences in this disease. Hydrocephalus is one of the most serious complications of hooping cough, and a very frequent one. It is marked by its usual symptoms —grinding of the teeth, rolling of the head, intolerance of light, con- tracted pupil; followed by squinting, vomiting, screaming, insensibi- lity, &c. We have, in a few instances, seen a state of deep coma oc- cur in the course of hooping cough; the brain, after death, exhibiting extensive serous effusion, Avithout any of the symptoms of meningitis or hydrocephalus having presented themselves. Anasarca is also a frequent complication 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. An attack of croup will often supervene during hooping cough, particularly in its early stage. DISEASES OF THE RESPIRATORY ORGANS. 365 Children of robust, plethoric habits, are most subject to this compli- cation. The duration of the second stage is very various; it may continue for a Arery short time, or be prolonged for three or four weeks, or even longer; the symptoms then gradually diminish in intensity; the expec- toration becomes more abundant, opaque, and thicker; the cough loses, by degrees, its convulsive character; the paroxysms are of less fre- quent occurrence, and of shorter duration; and, finally, by the end of two or three months from the commencement of the disease, it disap- pears, Avith the assemblage of other symptoms. The period when the symptoms begin gradually to decline, to their final termination, con- stitutes Avhat 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 vio- lence : this relapse, though occasionally prolonged, is generally of short duration; usually after two or three days, the regular decrease will occur and continue its course. 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 reco- vered from the disease, by the occurrence of the slightest catarrhal affection. A curious case is related by Percival, in which the hoop- ing cough assumed a periodical form, a paroxysm occurring daily, at a certain hour, for several months, and returning at the same season for two years. In children of a lymphatic temperament, strongly predisposed to tubercular disease, and in those in whom the formation of tubercles in the lungs has already commenced, the occurrence of hooping cough in a severe and protracted form, very rarely fails to develope pulmonary consumption; the progress of which is often very rapid, upon the de- cline of the acute stage of the attack. The physical signs of hooping cough are those of mild bronchitis; variable, sonorous, sibilant, and mucous 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 complicated with pneumonia, the mucous and crepitant rhonchi, 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 vary with the violence of the attack, the period at Avhich death has taken place, and the simple or complicated character of the case. Nearly every writer Avho has given the result of his autopsical examinations, mentions the existence of more or less of the indications of inflammation of the mucous mem- brane of the bronchi, 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-purulent fluid filling the ramifications of the bronchi. Ulcerations about the glottis, and in the larynx and trachea, are noticed by Astruc, Mackin- tosh, and Alcock. 366 DISEASES OF CHILDREN. When death is caused by asphyxia, in the early period of the attack, the mucous membrane of the respiratory tubes is of a dark red or bluish appearance; the lungs are gorged Avith dark-coloured blood; the whole substance of the brain is a little more livid than natural, ami the bronchial tubes contain a little mucus, occasionally stained with blood. A very common lesion in severe cases is dilatation of the bronchi. Inflammation of the lungs, especially lobular inflammation, is of common occurrence, and very frequently inflammation of tho pleura, with exudation or effusion. To these lesions may be added. tumefaction and redness of the bronchial glands, and emphysema of the lungs. In a large number of cases, inflammation of the meninges of the brain, and effusion beneath the membranes, and into the ventri- cles, have been observed. A diseased condition of the phrenic and pneu- mogastric nerves, is noticed by Clarus, Holzhausen, Hufeland, Bresohet, Bauer, Kilian, and Autenreith. There is some doubt, hoAvever, as to the correctness of these latter observations; it is certain, at least, that a lesion of the nerves just mentioned, is of very unfrequent occurrence. Hooping cough most commonly occurs as an epidemic, but generally 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 territories,as is the case Avith most other epidemics. If, however, we are to receive as correct the accounts of the epidemics of 1510, 1557, 1580,1757, 1767, and 1769, as given by De Thou, Sennertus, Sauvages, Riverius, Diversus, Conario, Geller, and Arrand, we find that these were of Avide 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, variable cli- mates, are admitted, by nearly all writers, to be the most favourable to its prevalence; and it is in these seasons and climates that the hoop- ing cough proves most fatal, from its being most usually complicated with severe bronchial, pneumonic, or laryngeo-tracheal inflammation. The general production of the disease, by the joint influence of a cold and moist atmosphere, is insisted upon by Klinge, Richter, Marcus, Desruelles, and Vondembush. It has been found frequently to pre- vail most extensively, either immediately before, during, or subse- quent to the occurrence of epidemic measles. 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 Avhen attacked, to have it but lightly. The fact, hoAvever, is denied by Hoffman, Haase, and others, and it is not sustained by the general re- sult of more recent observations. In regard to the true pathology of hooping cough, much diversity of opinion has existed, and still continues to exist. DISEASES OF THE RESPIRATORY ORGANS. 367 A majority of the most authoritative writers refer it to bronchial in- flammation, which, by a few, is considered to be of a specific charac- ter. 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 exist- ence. Most of the writers refer it either to disease of the pneumogas- tric or phrenic nerve, or to disease of the brain, affecting the origin of the respiratory nerves, whilst others consider the cerebral irrita- tion to be secondary to the bronchial disease, and often absent. That the essential symptoms of hooping cough are the result of a spasmodic closure of the glottis, there can be little doubt; but whether this is OAving 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 inflammation has existed for some time, that the irritation is transmitted to the laryngeal nerves, and the convulsive cough and difficulty of respiration occur. Desreulles has attempted to show that these latter symptoms are the result of an in- termittent 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 re- ciprocal 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. This much is very certain, that we cannot account very readily for the phenomena of the disease, excepting by referring them to irritation of the laryngeal nerves, as well as to disease of the respiratory mucous membrane. When hooping cough is unaccompanied with severe symptoms of bronchitis, and is uncomplicated with pneumonia, or tracheitis, or with congestion or inflammation of the brain, it is seldom attended with much danger; but in its more severe and complicated forms, it is with difficulty managed, and very frequently fatal. The younger the pa- tient, also, as a general rule, the more danger attends it. Very fre- quently, as remarked by Guersant, when it occurs in infants at the breast, it is accompanied with cerebral congestion from its very onset, and is then particularly fatal. We have also found, that when, in young children, it is accompanied with an excessive serous diarrhoea, it is seldom recovered from: a similar remark is made by Richter. In many of the more extensive epidemics, the mortality from hoop- ing 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 GlasgoAv, the deaths have been pretty nearly 5| per cent, of the en- tire mortality; and in one year, (1809,) they amounted to 11^ per cent. (Watt.) In Prussian Pomerania, the deaths were as 1 to 25| of the entire mortality. In Neumarck, 1 to21|. In Brandenburg, 1 to 29^. In SAveden and Finland, 1 to 13 J. In Strasburg, 1 to 94. In 368 DISEASES OF CHILDREN. 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. There are two affections with which the hooping may be confounded; namely, acute bronchitis with paroxysmal cough, and tuberculization of the bronchial ganglions. The diagnosis between these affections, has been very ably drawn by Rilliet and Barthez. (Maladies des En- fans, T. ii. 223.) In Hooping Cough; in the great majority of cases, the paroxysms of cough are preceded by catarrhal symptoms. The paroxysms, more or less intense, are accompanied Avith a pro- longed hissing sound, and succeeded by an expectoration of a tena- cious mucus, and very generally, by vomiting. In its simple form, it is in general unattended with fever, and during the intervals there is neither acceleration nor other change in the respiration. The paroxysms continue, more or less frequently, without change of character, and then decrease; and the cough assumes a simple ca- tarrhal character, and the child, if the attack is without complications, becomes conAralescent. There are no relapses. The acute bronchitis with paroxysmal cough, commences suddenly with paroxysms of cough. These are in general shorter, less intense; the hissing sound is very unfrequent, or in the few cases in Avhich it occurs it is intermittent; there is little or no expectoration, and no vomiting. The attack is attended from its onset with intense fever, and accele- ration of respiration, which constantly augments in intensity—sibilant and mucous rhonchi, afterwards subcrepitant. The pulse is very small, the dyspnoea is extreme, and these, with pallor of the face, appear, persist, or augment, and the disease termi- nates almost invariably in death within a variable period, often very short. Relapses are possible. In their more chronic stages, these two diseases are attended by the same symptoms. The diagnosis between the hooping cough and tuberculization of the bronchial glands is still more difficult, than between it and the disease just referred to. The characters which constitute the diagnosis are the following: Hooping cough—frequently epidemic—contagious. Three distinct periods, of which the sound alone is attended with a paroxysmal cough. The paroxysms attended with a hissing sound, expectoration of viscid mucus and vomiting. Respiration and pulse natural in the intervals, when the disease is simple. The voice natural. Progress most commonly acute. Tuberculization of the bronchial ganglions. Always sporadic; not contagious; without distinct periods. Paroxysms of cough generally very short—without any hissing sound—without viscid expectoration or vomiting. DISEASES OF THE RESPIRATORY ORGANS. 369 Physical symptoms of ganglionary tuberculization, but in certain cases an absence of these signs. An access of asthma in certain cases, alternating with the paroxysms of cough, continued fever, with evening exacerbations, night-sweats, progressive emaciation, &c. Occasionally a change in the tone of the voice. Progress chronic. To complete the diagnosis, the age of the subject should be carefully inquired into, and the causes under the influence of Avhich the disease has occurred. "We should examine whether, by the constitution or the descent of the patient, Ave may presume the existence of tuberculization —Avhether before the commencement of the paroxysmal cough the child had become pale and emaciated—whether he Avas subject to cough, &c. It is during the second period that the tAvo diseases above alluded to may be confounded with hooping cough. But there are others Avhich it is not always easy to distinguish from it during its first and third periods. A slight attack of bronchitis does not differ in any of its symptoms from the prodroma of hooping cough. The nature of the disease may, hoAvever, be suspected from the character of the reigning epidemic, and the circumstances preceding the attack. When the hooping cough becomes chronic, and the paroxysms, after having diminished in intensity, become more rare and unattended with the hissing inspiration, or when the cough is simply catarrhal—the dis- ease, or rather the dilatation of the bronchi by which these secondary symptoms are induced, may be readily confounded with pulmonary or ganglionary tuberculization. The diagnosis is the more difficult, as it is precisely at this period that phthisis is liable to succeed to hooping cough. The emaciation, hectic fever, pallor of the skin, the sweats, all the collection of general symptoms, in fact, are the same; auscul- tation alone can throw light upon the nature of the disease. Still, hoAvever, even here there is difficulty in establishing the diagnosis Avith any exactness. The dilatation of the bronchi, by which the fever is kept up, and gives to the child the appearance of one labouring under phthisis, simulates so closely pulmonary or ganglionary con- sumption that it may be mistaken for it. The ulterior progress of the disease, is often the only criterion by which the true character of the complication can be determined. If the child regains his flesh—re- covers his gayety and his strength—if the paleness of the skin disap- pears, and the fever or sweats cease, it is more than probable that tubercles are not present. If, on the contrary, the fever persists, the emaciation augments, and the appetite is lost; if copious diarrhoea oc- curs, and each day the symptoms become more unfavourable, it is then but too certain that tuberculization exists and makes daily prog- ress. The treatment of hooping cough Avill differ, according to the stage of the disease, the violence of the attack, its simple or complicated 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 ma- nagement of this stage that will depend, in many cases, the safety of 24 370 DISEASES OF CHILDREN. the patient; his diminished liability to the occurrence of severe bron- chial or pneumonic inflammation, as avcII as to the danger attendant upon intense cephalic congestion being induced during the paroxysms 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 nause- ating 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 Avould prefer the ipecacuanha. By many practitioners, the latter article is considered to be particu- larly adapted to the treatment of hooping cough. They prescribe it in the first, and during the acute period of the second stage, occa- sionally as an emetic, and subsequently, in small doses, the fourth of a grain every three or four hours, either alone or in combination with sulphur, or with sulphur and belladonna. We have followed this practice in a very large number of cases with the happiest effects: we have usually combined the ipecacuanha with sulphur and extract of hyoscyamus. R.—Pulv. ipecac, gr. iij. ad iv. Sulph. praecip. gss.—3J. Ext. hyoscyami, gr. iv.—xij.—M. f. chart. No. xij. One to be repeated every three or four hours. Horst recommends the flowers of sulphur as almost a specific in hooping cough. He gives it throughout the disease, from its onset until its termination. Schneider, Kopp, Randham, Riecken, and others, confine its use to the more advanced periods of the attack. The sulphur is given to children between two and four years of age, in the dose of from 6 to 8 grains, two or three times a day, and to older children in doses of from 15 to 20 grains; in both cases the dose being gradually augmented. Jadelot is said by Rilliet and Barthez to have derived the best effects from the sulphur as a remedy in hooping cough, and in bronchitis unattended with fever. 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 calomel, followed, in a few hours, by some mild purgative, as castor oil, rhu- barb and magnesia, or in children over tAvo years of age, in Avhom the first stage is often attended with considerable febrile excitement, by small doses of sulphate of magnesia, will not be found advantage- ous. The boAvels being kept subsequently in a regular state, by occasional doses of some mild unirritating purgative, or by simple enemata. Perhaps the best purgative we can employ in hooping cough, parti- cularly in its 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 boAvels, 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 DISEASES OF THE RESPIRATORY ORGANS. 371 calomel as a mild purgative in the first, and during the acute period of the second stage of hooping cough. We are accustomedto com- bine Avith the evening dose of calomel, a third of a grain of ipecacu- anha, and the same quantity of the extract of hyoscyamus, and have seldom found it necessary to-give any purgative in the morning to in- sure its operation. In every case in w-hich, 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- pensable remedy, and it should be resorted to, also, whenever the same indications present themselves at a later period of the disease, previous, at least, to the occurrence of extensive effusion in the bron- chi. The extent of the bleeding should always be proportioned to the violence of the symptoms, and the strength of the patient;—upon our promptitude and decision in the use of this remedy his recovery will often depend. 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 when the symptoms are severe, it will be better to have recourse to the lancet, followed, if necessary, by leeches. We are aware that bloodletting has been considered by some an improper remedy in the treatment of hooping cough, and by others as of doubtful propriety; but independently of our own expe- rience, we have in its favour that of nearly every authoritative writer on the disease. 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 Avhole 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 tempera- ture, or exposure to cold and damp; almost invariably will these ag- gravate the paroxysms of cough, and endanger, inflammation of the respiratory tubes or lungs. The diet should be perfectly mild and un- irritating, 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 betAveen the shoulders, will be found highly beneficial: blisters are recommended by some, and if properly managed, produce, certainly, a very excellent effect; but a few of the European as well as of the American practitioners prefer the production of a more powerful and permanent irritation, such as results from the ointment of the tartrate of antimony. Autenreith states that, in two severe epidemics, in which he employed frictions with tartar emetic ointment, he lost not a single patient.1 In order to insure the efficacy of this plan of treatment, we must not, we are told, be satisfied Avith merely producing pustules; the use 372 DISEASES OF CHILDREN. of the ointment should be continued until small ulcerations 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 ap- plication is fomentations Avith a decoction of hemlock. Luroth cm- ployed the ointment in this manner, in a very fatal epidemic of hoop- ing cough, with, we are assured, the most gratifying results. Corsin also employed the emetic tartar, as an external irritant, during an epi- demic of the disease, and, according to his statement, Avith decided benefit in every case. He prefers, however, its application in the form of a plaster,2 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 observed more advantage to result from the use of the oint- ment of the tartrate of antimony, than from any other external appli- cation. 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,) in consequence of the severe pain, and deep ulceration produced. We have no doubt, how- ever, that in severe cases, it may prove a very A-aluable derivative. AVc have generally resorted to blisters, and frictions Avith turpentine, the compound camphorated liniment, or a liniment of the oil of amber and oil of rosemary, to the spine,3 and Avith the best results. 1 R.—Tart. ant. gjss. a R.—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 epigas- Spread on leather, and sprinkle the sur- trium, three times a day. face with from 6 to 12 grs. of the tartar emetic. 3 R.—01. oliv. giv. — succini, gij. — rosmarin. gij.—M. In many cases, a plaster of Burgundy pitch, worn upon the chest, or between the shoulders, produces a very powerful rubefacient effect, and will, consequently, prove highly beneficial. At the meeting of the medical section of the British Association, in 1840, it Avas stated by Dr. Hannay, that rubbing the chest with cold water, two or three times a day, with so much activity as to produce a rubefacient effect, has been found of very great efficacy, in cases of hooping cough; and that this practice may be resorted to, even Avhen the case is attended Avith bronchitis. We have no doubt of the effi- cacy of the friction, but should certainly prefer olive oil to the cold water, which can have no other good effect, than to prevent abrasion of the cuticle. An'occasional emetic of ipecacuanha will often giA-e great relief at this period; and we have generally found the administration of small doses of ipecacuanha, extract of hyoscyamus, and magnesia, repeated every three hours, of unquestionable efficacy. When Ave have succeeded in removing the inflammatory symptoms, DISEASES OF THE RESPIRATORY ORGANS. 373 or these have been so far abated, that the paroxysms are kept up chiefly by nervous irritation, and there exists no decided tendency to cerebral'disease, we may commence with the use of narcotics, anti- spasmodics, and tonics. Nearly every article upon the lists, has been recommended by different AA-riters, as almost a specific, in certain stages of the complaint, and as strongly reprobated by others, as either ineffectual, or positively injurious. It is certainly true, that the treat- ment of hooping cough has been, in too many instances, marked by the grossest empiricism, without any reference whatever to the true patho- logy of the disease, or to its occasional complications with encephalic, thoracic, and abdominal disease, and that not a few of the articles de- tailed in the books as certain remedies, are calculated, often, to do more harm than good, while others are perfectly inert. In regard to narcotics, strongly objected to by some, evidence of too conclusive a character has been presented in favour of their em- ployment, to leave any reasonable doubt as to their beneficial influence after the acute stage has passed by, and the paroxysms of convulsive cough are kept up from nervous irritation alone. We are constantly in the habit of prescribing them, and AA-ould certainly find it very dif- ficult to control the cough in the spasmodic stage of many of the more violent cases, without their aid. It is true, that much may be effected in this stage by a proper regulation of the diet, boAvels, and clothing, and by a change of air. We agree Avith Mackintosh, as to the importance of confining the child to bland, nutritious food, keep- ing his boAArels gently open by mild aperients, and protecting the surface by flannel, together with the occasional use of the warm bath, followed by frictions, and free daily exposure to the open air, Avhen the weather is perfectly mild and dry; under the use of these means Ave shall invariably find the violence of the paroxysms to decrease, and in mild attacks, often gradually to cease. There are, neverthe- less, feAv cases of hooping cough, in which the continuance of the dis- ease Avill not be very materially-shortened, and convalescence hastened and confirmed, by the judicious employment, in conjunction with the hygienic measures referred to, of narcotics, antispasmodics, and occasionally of tonics. There exists among writers some difference of opinion as to the narcotic best adapted to hooping cough; opium has been recommend- ed by many, either alone, or in combination with tonics and expecto- rants. We have employed an aqueous solution of opium, with some benefit;1 and Lombard recommends the syrup of the white poppy, in the dose of a teaspoonful, once, twice or three times a day. In some cases, the syrup of poppy has been found to remove only the more troublesome symptoms, Avithout shortening the duration of the dis- ease. It is said to have proved particularly beneficial in diminishing the number of paroxysms during the night, by inducing sleep, but even then, it has appeared to exert but little influence over those oc- / ' R.—Opii pulv. gj^ Aq. bullient. giij. Let it stand for three hours, then strain, and add gj. bi-carbonate of soda. Dose, for a child two years old, a teaspoonful every three hours. 374 DISEASES OF CHILDREN. curring during the day; this is precisely the result of our experience, in relation to the effects of the aqueous solution of opium. M)r- phia has been employed endermically, and according to .Meyer, with good effect; a blister is applied over the praecordia, and when the cuticle is removed, the blistered surface is sprinkled every evening Avith half a grain of morphia, rubbed up with dry starch. The narcotic from which, however, the greatest amount of benefit is to be anticipated in this disease, is unquestionably the belladonna: it has been very extensively employed, and the evidence in its favour is strong and conclusive. It has been given in doses of from one half to one or two grains of the poAvdered root, or from one-eighth to one-fourth of a grain of the extract, twice or thrice a day. Kali- leiss administered the belladonna, in combination Avith Dover's poAV- der and sulphur,1 and between each dose, a mixture containing hy- drocyanic acid.2 We have given to the belladonna a very fair trial, and have in many cases been pleased with the prompt and decided re- lief produced by it, Avhile, 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-sixth of a grain, tAvo or three times a day, sometimes oftener, combined Avith from one-fourth to one-third of a grain of ipecacuanha. 1 R-—Rad. belladonnas pulv. gr. v. 2 R.—Aquaechamomil. gss. Pulv. ipecac, compos, gr. x. Syrupi simpl. gij. Sulphur, praecip. gss. Acid, hydrocyanic, njxij. Sacchar. alb. Qij.—M." Twelve drops to be given between each f. ch. No. xx. dose of the belladonna. One to be given every three hours to a child two years old. Dr. Pieper recommends frictions upon the epigastrium with the ex- tract of belladonna, dissolved in saliva. In children of six months, he rubs in one grain of the extract thus dissolved, augmenting gra- dually the dose. Other narcotics have been recommended, as the camphor, the co- nium maculatum, the hyoscyamus, the stramonium, and the extract of nicotiana. Of the effects of these, with the exception of the hyoscy- amus, Ave have no experience. The hyoscyamus we have repeatedly employed from a very early period in the attack, always in combina- tion with ipecacuanha, and have invariably derived advantage from its use. The hydrocyanic acid has been strongly recommended, as a remedy in hooping cough, by Muhrbeck, Kahleiss, Volk, Heller, Granville, and others: by some, it is considered to possess a "specific power" over the disease. Professor Thompson regards it as the sheet anchor of the practitioner; he commences its use, immediately after the opera- tion of an emetic and brisk purgative, and continues it, Avith no other alteration than a gradual increase of the dose, until the disease is sub- dued. Dr. Roe is coiiAinced, that in Avarm weather, it will cure al- most any case of simple hooping cough, in a short time; that in all seasons, it will abridge its duration, and that in almost every instance Avhere it does not cure, it will, at least, materially relieve the severity DISEASES OF THE RESPIRATORY ORGANS. 375 of the cough.1 Dr. Atlee, of Lancaster, has, in a number of cases, effected a cure, in from four to fourteen days, by its use;2—he restricts it, hoAvever, to the second stage of the disease. Dr. Lombard gave from half a grain to a grain of the hydrocyanuret of potass, in the twenty-four hours, in cases in which there was much irritation, and a great variety of nervous symptoms. Employed, comparatively, on a brother, whose sister was taking the sub-carbonate of iron, this last remedy had, however, a most undoubted advantage. 3 R-—Acid, hydrocyanic. (Scheele's)TT]txij. * R.—Syrup, simpl. gj. Liquor, antimon. tartarisat. gj. Acid, hydrocyanic. Tfyj.—M. Tinct. opii camphorat. gijss. A teaspoonful morning and evening; and if Misturse camphorae, gvijss.—M. no uneasiness, dizziness or sickness, is Dose.—A tablespoonful every four hours, in produced within forty-eight hours, the some warm drink; the patient to remain dose to be repeated three times a day. in a warm room, and to live upon light This prescription is for a child six pudding and broth. This prescription months old: one drop more of the acid Dr. Roe directed for a delicate boy four being added for each year of the child's years old. For a healthy-looking female age, beyond one year. He has never child, five years old, he directed— repeated the dose more than four times R.—Acid, hydrocyanic, (Scheele's) tt^ xx. a day. Liq. antimon. tartarisat— Vini ipecacuanhae, ail gjss. Aquae gxiij.—M. Dose.—A teaspoonful every two hours. In the feAv cases in which we have prescribed the hydrocyanic acid, the remedy certainly produced very favourable effects; but we never trusted to it alone, and hence, it is difficult to say, whether all, or how much of the benefit derived could, with propriety, be attributed to the acid. It comes to us, however, too strongly recommended, not to demand a more extended trial, particularly in the more violent cases of the disease. Of the antispasmodics that have been recommended in the treat- ment of hooping cough, the asafoetida, zinc, and sesquioxide of iron, appear to be those most deserving of trial. The asafoetida has in its favour very strong testimony. We have employed it extensively, and have ahvays been pleased with its effects; we have given it, by itself in solution, or in combination with the tincture of hyoscyamus, or the wratery solution of opium. Dr. Lombard states that he has often known frictions to the spine Avith the tincture of asafoetida, of great service, and we have found a plaster of asafoetida applied on the chest, promptly to relieve the cough which is liable to remain after the more acute symptoms have abated. The oxide of zinc will, in many cases, be found a useful remedy in arresting the spasmodic cough, in the second stage of the disease. Dr. Lombard has employed the remedy extensively, in the dose of from four to twelve grains a day; he found it generally to abate the violence of the paroxysms, and has seen complete cures effected by it alone. In tAvo very young infants, Avhose cough Avas attended with symptoms resembling epilepsy, the oxide of zinc stopped both the cough and the fits. Dr. L. has never seen any bad effects result from its use; our OAvn experience is decidedly in its favour. But the remedy which appears to claim, above all others, our attention, is the precipitated sub-carbonate of iron, (sesquioxydum Ferri.) This was first recom- 376 DISEASES OF CHILDREN. mended by Dr. Steymann, Avho directed two and a half grains every three hours, increasing one grain for each year of the child's age be- yond the first. Dr. Lombard, however, gave it to the extent of from twenty-four to thirty-six grains, in water and syrup, or some cough mixture. "I think," Dr. L. remarks, "I may assort with confidence, that the sub-carbonate of iron enjoys a remarkable property to lessen the violence of the paroxysms, to diminish their frequency, and after a certain number of days, to cure entirely the hooping cough. It en- joys, besides, the advantage of strengthening the little patients, and thus gives them the force to resist a complaint, which sometimes lasts for Aveeks, and generally leaves them Aveak, low, and exhausted. In some patients I have seen it cause, during the first day or two after it Avas commenced Avith, a temporary increase of the cough, but this always subsided after two or three clays, and did not prevent the good effects of the remedy." We have not yet had an opportunity of fully testing the powers of this remedy, and can, therefore, say nothing in regard to it, from our own experience. In the few cases in which Ave have employed it, its effects were not very striking. A great variety of other remedies have been proposed, for the cure of hooping cough; as the tincture of cantharides, either alone, or combined with the tincture of bark, with quassia or Avith cicuta, of scarlatina, is occasionally spoken of in very favourable terms. As yet we have not in our possession a sufficient amount of evidence. in regard to the general results of the practice, to enable us to form any correct opinion in respect to it. We have had no opportunity of testing its effects in our own practice, but from the decided bene- fit we have invariably derived, in cases of erysipelas, from covering DISEASES OF THE SKIN. 491 the inflamed surface with a thick coating of fresh lard, we should in- fer that the same practice might be beneficial, also, in scarlatina. Throughout the attack, the patient should be confined to a large well-ventilated apartment, the utmost attention being paid to insure the strictest cleanliness of the chamber, as well as of the bed-clothing, and of the garments worn by the patient. His diet should be adapted to the degree and stage of the disease, but should be invariably spare, light, and easy of digestion—being composed entirely of farinaceous articles, boiled in water. His drinks should be given cool, and slightly mucilaginous; the addition of a small portion of lemon juice will ren- der them more palatable, and at the same time, as many suppose, somewhat remedial. In the anginose form of the disease, the dilute mineral acids have been considered advantageous? The free use of diluted sulphuric acid, is said, by Steiglitz and Wolff, to produce an excellent effect; while, by Montsey, and a few other practitioners, the hydrochloric acid, largely diluted with water, is recommended both as a drink and as a medicine. We have found, in many cases of scarlatina attended with disease of the throat, much advantage from the use of hydrochloric acid in- ternally. Our common prescription is a drachm of the acid to five ounces of Avater, well sweetened Avith sugar: of this we direct a tea- spoonful to be given every two or three hours. Dr. J. P. Hiester, and Dr. Beaver, of Berks county, Pa., both speak favourably of the effects of diluted hydrochloric acid in scarlet fever, when freely ad- ministered. (Trans. State Med. Soc, vol. ii. pp. 96, 98.)" In the fourth volume of the Medical Gazette of London, there is a communication from Messrs. Tayton and Williams, in praise of chlo- rine as a remedy in scarlatina. The chlorine is procured by dis- solving two drachms of the chlorate of potass in two ounces of hydro- chloric acid, diluted with two ounces of distilled water. The solu- tion is to be immediately put into a stoppered bottle, and kept in a dark place. Two drachms of the solution are to be mixed with a pint of distilled water, and one or two tablespoonfuls of this, accord- ing to the age of the patient, may be given for a dose frequently. The plain soda Avater of the shops affords, in many cases, a very grateful and refreshing drink. The boAvels of the patient should be kept regularly open, by any mild laxative. The daily use of the tepid or warm bath will always be found advantageous. After the disappearance of the eruption, it will be necessary to allow a more nutritious diet; but at the same time, we should be cautious to proscribe all indigestible and stimulating articles of food, and to pre- vent too much of even the lightest and most appropriate from being taken. Daily exercise in the open air, in mild, dry weather, will be proper, as soon as the patient is sufficiently strong to attempt it. In some cases, it will be necessary to aid in the restoration of the patient's strength, by the administration of some gentle tonic; the cold infusion of cinchona, the sulphate of quinia or an infusion of Avild cherry tree bark, may, in such cases, be employed with advantage. The more stimulating tonics and Avine should be avoided. 492 DISEASES OF CHILDREN. For some considerable time subsequent to his recovery, the patient should be carefully guarded against exposure to cold or damp, which is very apt, even after recovery from attacks of the mildest and most simple character, to produce dropsical effusion, and other disagreeable consequences. 9 To promote the growth of the hair, AA-hich is liable to fall out after an attack of scarlatina of any severity, the head, during convalescence, should be shaved two or three times, and frequently washed with warm water, followed by smart friction with a brush or coarse towel —care being taken, in cold and changeable Aveather, to preserve the head moderately warm by a light cap. ^Congestive Scarlatina. It is this form of the disease Avhich constitutes the malignant scarla- tina of most writers. The suddenness of the attack, in tho more violent cases, the extreme faintness, and the pale and sunken countenance of the patient; the dark livid or dusky appearance of the eruption; the absence of any decided reaction; the dark, gangrenous appearance of the throat; the rapid occurrence of a general depression of the vital powers, with the dissohred state of the blood, the petechiae, vibices, &c, have all concurred to deceive physicians in regard to the real character of the disease, and lead them to view it as one bearing the unequivocal stamp of putridity, and requiring for its cure the most active stimulants, antiseptics, and tonics. Sounder notions of general pathology have led, however, to more correct views in regard to the nature of this form of scarlatina, and its appropriate treatment. The congestive form of scarlatina has, with great propriety, been divided by Armstrong into the regular and irregular; the first being unattended Avith any marked reaction, while in the latter, a partial and irregular reaction is manifested. The more violent cases of the first variety run their course with extreme rapidity, and are always at- tended with the utmost danger. Often has the patient been known, when the disease prevails epidemically, to sink, almost immediately, upon exposure to its infection, into a state of complete insensibility, terminating shortly in death. The irregular form of congestive scar- latina, though confessedly a very formidable malady, is, however, by no means so dangerous as the former, nor so rapid in its progress; and as it forms a kind of intermediate link between the inflammatory and purely congestive varieties, it will be first considered. It attacks pretty much in the same manner as the inflammatory; with a sense of chilliness, headache, sickness and lassitude, phate of quinia must be prescribed; and should this fail, much benefit will, in many cases, be obtained from the use of the solution of arsenite of potassa, given in small doses gradually increased. 8.—Erysipelas. The proper infantile erysipelas of medical writers is happily of un- frequent occurrence in this country. It usually occurs Avithin a feAv days after birth, and is, in many instances, of intra-uterine origin. It seldom makes its appearance after the fourth or fifth week, though a few cases have been observed as late as the sixth or even twelfth month. The invasion of the disease is often extremely insidious. The in- fant appears somewhat morose; his sleep is slightly diminished and disturbed, and he sucks rather less than before: Avith these trifling symptoms, there is associated a small patch of redness on the lower parts of the body, particularly about the nates, pubes, groins, and umbilicus, which is painful upon pressure, and changes subsequently to a purplish or livid hue. In new-born infants, according to the ob- servations of Meckel and Osiander, occasionally, its origin is umbilical phlebitis. The inflammation spreads gradually and irregularly over the abdo- men, along the back, and on the inside of the thighs; the parts occu- pied by the inflammation being swollen, hard, and extremely tender to the touch, as indicated by the movements and cries of the child. Gene- rally, at the end of twenty-four hours, there arise upon the inflamed surface a few scattered vesicles, with inflamed livid bases, which ter- minate rapidly in gangrenous ulcerations. The vesicles appear, in some cases, upon the first occurrence of the inflammation, and in others, not until this has continued several days: occasionally, vesica- tion does not take place, and the disease is then of little danger or duration, the inflammation subsiding in two or three days. _ In those instances in which the inflammation is not very intense, it spreads DISEASES OF THE SKIN. 551 rapidly in one direction, while the disease ceases in the parts originally affected; or suddenly disappearing in the part first attacked,it speedily reappears on some other, and, perhaps, remote portion of the sur- face, and in this manner, may successively invade every part of the skin. In many cases, the skin surrounding the inflammation, to the dis- tance of nearly an inch from its margin, is hard to the touch, and cannot be pinched up or moved over the subjacent parts, as in a state of health. In the majority of cases, this results from the infiltration with serum of the cellular membrane surrounding the inflammation. AVhen vesications appear early, the gangrene generally spreads rapidly, and the case soon acquires a very dangerous and hopeless character. This is more apt to be the case when the inflammation occurs upon the abdomen; on the extremities and nates it is more liable to terminate in deep-seated suppuration, with destruction of the subcutaneous cellular structure. AVhen suppuration occurs, the pus is of a grayish colour, and of a very thin sanious character; it penetrates through the cellular membrane, beneath the skin, and between the muscles. Small portions of the skin finally slough off, and give exit to the confined matter, mixed with flocculi and large shreds of spha- celated cellular membrane. The genital organs, in some cases, spha- celate when the disease extends to them, and in many acquire an em- physematous appearance. In some rare instances the disease has been known to continue for fourteen or fifteen days, with but little vesication, and no diffused suppuration. In the more violent cases, the cessation of the gangrene is marked, in the early stages, by a white line of demarkation; and in the latter stages of the more protracted cases, by a secretion of healthy pus taking the place of the ichorous or sanious discharge. In many cases the disease would appear to be at first perfectly local. Several days elapse before any remarkable degree of general restless- ness, crossness, and fever present themselves. In the first period of the disease, there is often considerable febrile reaction, which, upon the occurrence of vesication, assumes a low typhoid character: upon the approach of suppuration, there is always more or less depression of the vital energies—though, in many cases, the tendency to sinking is evident from the commencement of the attack. Frequently the colour and expression of the countenance remain for some days without exhibiting any striking change; when suddenly an ashy, cadaverous paleness is observed; the child cries incessantly; there is constant jactitation and complete loss of sleep, with frequent pulse and increased heat of the skin. These symptoms are succeeded, more or less rapidly, by stupor and death. Few cases occur in which the indications of gastro-intestinal disease are wholly absent. There is generally more or less tenderness of the epigastrium—griping colicky pains—constipation, or frequent dis- charges from the boAvels of a thin, grass-green fluid, preceded and accompanied with griping. Convulsions are not unfrequent. Those 552 DISEASES OF CHILDREN. portions of the surface of the body Avhich are not occupied by tho erysipelatous inflammation, often present a slightly jaundiced appear- ance, and the urine usually contains bile. A A*ery common form of erysipelas in infants, according to our ex- perience, is that described by Dr. Friebo in the Journal for the Diseases of Children, under the name of Omphalitis exsudativa. It commences about the umbilicus, within a few Aveeks after birth, and is frequently accompanied Avith ulceration of the navel, and infiltration of lymph or pus into the subcutaneous cellular tissue, and deposits of a similar nature in the partially obliterated umbilical vessels. It is attended by great and rapidly increasing exhaustion, and occasionally convulsive symptoms of more or less severity. It usually proves fatal; often within the course of forty-eight hours, and Avithout having extended more than three fingers' breadth around the navel. Dr. Friebe is inclined to view the disease as a variety of partial induration of the cellular substance, in consequence of the cachectic condition of the infants in whom he has seen it occur, and the erysi- pelatous character of the inflammation; while the circumstance of the umbilical vessels being in part converted into fibrous cords, pre- viously to the commencement of the disease, leads him to believe that it cannot arise from umbilical phlebitis. He appears to have seen but three cases. We have met with it among the infants of the poor much more frequently, and our observations have convinced us that, in the majority of cases at least, it is dependent upon phlebitis of the umbi- lical veins; the evidences of inflammation of the latter were unques- tionably present in almost every instance in which we have made an examination. M. Trousseau remarks that the umbilical vein is often found inflamed and filled with pus, as far as the transverse furrow of the liver, while inflammatory exudations are found on the peritoneal surface of the abdominal viscera. M. Trousseau has observed that, in infants predisposed to erysipelas, the umbilical cicatrix does not form readily, and the ulceration which results is sometimes the occasional— the local cause of the cutaneous disease. In older and more robust children, erysipelas presents itself under the same forms as in the adult. A bright scarlet, shining efflorescence appears upon some portion of the skin, preceded for a day or two by heat, and a sense of tingling, and some degree of febrile reaction. The disease occasionally declines by the third or fourth day, the skin assuming a yellowish hue, and desquamating. In other instances, the disease runs a more protracted course; vesications, more or less ex- tensive, form upon the inflamed surface, which sometimes become filled with a purulent fluid. The vesications rupture in the course of two or three days, and give discharge to a thin, glutinous fluid. In other cases, the inflammation extends more deeply, and is attended with symptoms of greater severity. Rigours and severe febrile reaction precede the local disease, which is attended with considerable swelling of an oedematous character: suppuration early occurs, and a thin, purulent sanies is formed, which travels along the cellular structure, beneath the skin, and among the muscles and tendons, mixed often with clots of thin, grumous blood. The disease, unless energetically DISEASES OF THE SKIN. 553 treated in its early stages, is now very liable to assume a gangrenous character, attended with great depression of the vital energies, and most commonly terminating in death. In the acute stage, inflamma- tion of the cutaneous vessels is occasionally observed, and often puru- lent depositions take place in the serous cavities, and in the lungs. In the examinations that have been made of infants who have died from erysipelas, phlebitis of the umbilical vessels has been occasionally met with; we have observed it in several cases. Inflammation of the peritoneum, with puruloid or serous effusion into the cavity of the ab- domen, is more commonly met with. Pleuritic inflammation, with effusion, is more rare—pneumonia, vesicular, lobar, and lobular, is very frequent; enteritis is the most common morbid appearance, al- though gastro-enteritis not unfrequently occurs. Various opinions have been advanced in regard to the causes of infantile erysipelas. So far as our own observations extend, the dis- ease would appear to originate, almost exclusively, in infants exposed to a confined and impure atmosphere, or in the nursing of whom pro- per attention is not paid to cleanliness of person, bedding, and clothing —in young children who are allowed to lay for hours with diapers imbued with excrement and urine, or, if their diapers are removed more frequently, having them hastily exchanged, without the surface being properly Avashed and dried, for others that have been worn already, and merely dried. Bad nutriment, no doubt, contributes, in the majority of cases, to the production of the disease. Erysipelas of infants very commonly occurs during the prevalence of epidemic puerperal fever—children of mothers who become affected with the fever, are often born with erysipelatous inflammation; others are attacked almost immediately after birth. Whether, in these cases, the disease is to be referred to a morbid matter applied to the skin in the womb, or to the same epidemic or endemic influence which gives rise to the disease of the parent, it is difficult to say. According to M. Trousseau, infantile erysipelas is principally observed when puer- peral fever prevails in the wards of the lying-in hospitals of Paris. The infants appear to him to inherit from their mother a purulent diathesis, and seem to be still, within certain limits, subject to the same maladies as the mother. In the treatment of erysipelas, as it occurs during infancy and child- hood, the nature of our remedies must be governed by the stage of the disease, and the character of the symptoms in each case. In a large number of cases, every remedy of a debilitating character is strongly counter-indicated, and the early symptoms of prostration which pre- sent themselves, force us at once to resort to such measures only as are calculated to support the patient's strength. In every instance, it will be proper to pay attention, from the onset of the disease, to the condition of the bowels. A grain or two of calomel, followed in a few hours by a teaspoonful of castor oil, or laxative enemata, will be sufficient to procure a free evacuation of the intestines, without much irritation, and they may be kept in a regular state subsequently, by the exhibition, every three hours, of divided doses of calomel, combined with ipecacuanha and extract of 554 DISEASES OF CHILDREN. hyoscyamus1—the addition of the latter is calculated to pre von t or allay irritation, without interfering with the aperient action of the other articles. AVhen the skin is warm and dry, the liquor ammonias acetatis alone, or combined with antimonial wine, will often be found beneficial.2 Under the same circumstances, the occasional use of the warm or tepid bath will prove highly advantageous. 1 R.—Calomel, gr. iij.—iv. 2 R.—Liquor, acetat. ammon. ^ij. Ipecac, pulv. gr. iij. Vin. antimonii, Ttyxxxv.—xlv. Carb. sodae, gr. xij. Aq. cort. aurant. t^j. Ext. Hyoscyami, gr. iv.—vj.—M. Sacchar. puris, ji'j.—M. f. ch. No. xij. Ten to thirty drops, every two or three One for a dose. hours, may be given. If, with a hot and dry skin, there should occur symptoms of cerebral irritation, as intolerance of light, screaming, or convulsions, a leech or two should be applied to the temples, and cold applications to the scalp—the bowels should be freely opened by castor oil, Avith the ad- dition of turpentine, and warm pediluvia should be resorted to. There cannot be a doubt that cases of erysipelas frequently occur in young children, which in their early stage are accompanied by symptoms that indicate the employment of local depletion, and that in these, a few leeches applied upon the sound skin in the neighbour- hood of the inflamed parts, Avill prove positively beneficial; we have repeatedly met with such cases, and proved the good effects of the practice. Much judgment, however, is required to discriminate the kind of cases which are likely to be benefited by local depletion, and to determine to what extent it may be prudently carried:—as a gene- ral rule, a very moderate abstraction of blood will be sufficient. When a tendency to gangrene is obvious, and the disease assumes a Ioav typhoid character, it will be necessary to resort, at once, to the use of the carbonate of ammonia, in doses adapted to the age of the patient, and the urgency of the symptoms; and, at the same time, the child should be nourished at the breast of a healthy nurse, or, if weaned, its diet should consist of animal jellies dissolved in water, beef tea, chicken water, or sago. Where the symptoms of prostra- tion are more considerable, we may combine the use of the ammonia with the sulphate of quinia, and the extract of hyoscyamus. R.—Sulph. quinine, gr. ij.—iij. Extract, hyoscyami, gr. ij.—iij. Magnesia* calcinat. gr. xxxvj.—M. f. ch. No. xij. One to be given for a dose every two or three hours. It is hardly necessary to say, that our chance of success in the treatment of these cases will be greatly diminished, unless we have it in our power to remove the patient to a healthy situation, where he may enjoy the tonic influence of a pure, free atmosphere. Should diarrhcea ensue after suppuration has taken place, it should be immediately checked by the cretaceous mixture, with the addition of tincture of kino and laudanum; or, if this should not succeed, the acetate of lead, ipecacuanha and opium may be substituted. R.—Acetat. plumbi, gr. xij. Ipecac, pulv. gr. iv. Opii pulv. gr. j.—M. f. ch. No. xiv. One to be given for a dose three times a day. DISEASES OF THE SKIN. 555 When the discharges from the bowels are of a vitiated character, or attended with griping or colicky pains, a feAv drops of turpentine, three times a day, will be found a very valuable remedy. The tur- pentine may be combined with the tincture of kino and laudanum. R.—Aq. cinnamom. giij. Tinct. kino, J*jij. Spir. terebenth. 33. Magnesiae calc. gr. viij.—M. A teaspoonful may be given at a time, three times a day, or oftener. Various local applications have been recommended, by different practitioners, as highly beneficial in the treatment of infantile erysi- pelas, Avhile by many these are denounced as invariably injurious. Washing the parts frequently with tepid water, or some mucilaginous fluid, will, in many cases, be productive of very great relief to the patient, and we think that we have seen an abatement of the disease take place under its use; in the intervals, the parts may be dusted with powdered starch, or covered with carded cotton. AVhen the disease is attended with considerable distention of the skin, a lotion composed of the acetate of lead and subcarbonate of ammonia, (half a drachm of each dissolved in eight ounces of water,) has been highly recommended. Other washes have been proposed as occasionally very beneficial, but of the effects of which we have no experience—as the camphorated tincture, applied by covering the diseased parts with rags wet with it; a solution of corrosive sublimate, three grains to an ounce of water, applied in the same manner; a so- lution of nitrate of silver, three grains to the ounce of water, simi- larly applied. Applying, once or twice, a very strong solution of the nitrate of silver, by means of a pencil, upon the sound skin, for about an inch around the margin of the diseased parts, has been said to ef- fectually arrest the progress of the disease. The chloride of lime. in solution, half a drachm to the pint of Avater, and applied by folds of linen saturated Avith it, is said to be one of the best washes, in cases which early show a tendency to gangrene. A solution of the sulphate of iron, half an ounce to eight ounces of water, has also been employed with advantage by Velpeau. This is said to have subdued the erysipelatous inflammation in two days. We have used a wash of acetate of lead, ten grains to the ounce of Avater, in many cases of infantile erysipelas, with the very best effects, but our favourite application, in the ordinary cases of the disease oc- curring in children, is fresh lard, with the addition of acetate of lead, in the proportion of ten grains to the ounce. To those cases which exhibit, from the first, a decided tendency to gangrene, this applica- tion is not adapted. The local remedies just recited are to be em- ployed in the early stage, previous to the rupture of the vesications, and to the occurrence of suppuration or gangrene. Among the local remedies which appear to be the most generally applicable to erysipelas occurring in children, is a blister, sufficiently large to extend over the diseased surface, and for a short distance beyond it; after vesication has been produced, the serum should be evacuated, and the vesicated surface dressed with fresh lard. AVhen 556 DISEASES OF CHILDREN. the erysipelas occurs upon the extremities, a blister applied around the limb beyond the affected surface, Avill frequently arrest the pro- gress of the disease in that direction. In the cases in Avhich avc have resorted to blistering, we have usually applied strips of leather, spread with blistering ointment, along the edges of the inflamed part, partly on the latter, and partly upon the sound skin, and at the end of three hours, have removed them, and immediately covered the parts with a soft emollient poultice, Avith the addition of lard. The most im- portant result which Ave have derived from the use of blisters, is the prevention of the spread of the disease. The mercurial ointment has been strongly recommended in the treatment of infantile erysipelas, as well as in that of adults, by Dewees and Metmeyhr. The mode in which it is applied is to cover the diseased surface Avith a piece of soft linen, with the ointment spread upon it: we know nothing of the effects of this remedy from our own experience, having never employed it. In many cases, attended with an intolerable sensation of burning, we have seen some good to result from the use, as a lotion, of a watery solution of opium. In those instances in Avhich the disease is attended with conside- rable restlessness, and when the patient is prevented from sleeping at night, a few grains of the Dover's powder, or a dose of the cam- phorated tincture of opium, adapted to the age of the patient, should be given at bed-time. AVhen erysipelas terminates in gangrene, washes of a solution of the chloride of lime or soda, of a few drops of creasote, diffused in water, or of a strong decoction of galls or black oak bark, should be immediately employed; or the sphacelated surface may be covered Avith either the charcoal or yeast poultice. Pencilling the edges of the gangrenous ulceration Avhich often ensues, with the creasote wash, or the balsam of tolu, will occasionally arrest its progress. We have seen, we think, good effects result, in some instances, from washing the gangrenous surface with a very strong solution of the sulphate of copper. In all cases in which the cellular membrane is involved in disease, free incision should be early made, as well to unload the vessels, and relieve the swelling and distention, as to give exit to the purulent fluid and dead portions of cellular structure. The pus, if allowed to remain, by making its way beneath the skin, and between the mus- cles and tendons, has a tendency to increase the extent of the disease, and to cause the death of the patient, by the irritation and exhaus- tion to which it gives rise. After the incisions, the parts should be covered with a soft emollient poultice. The patient, or the affected limb, should be kept at rest, and the inflamed part, if possible, some- what elevated, so that the flow of the blood from it may be facilitated by gravity. Should indications of pulmonary or cerebral disease occur in cases of erysipelas, these will demand their appropriate remedies. When convalescence has been established, and a degree of weak- ness and languor remains, some light mineral tonic, with the mineral DISEASES OF THE SKIN. 557 acids, should be administered, and the child should be allowed a nu- tritious, but mild and easily digested diet; he should be immersed daily in the Avarm or tepid' bath, and enjoy a dry, fresh, Avholesome atmosphere. 9.—Phlegmonous Tumours. These occur on various parts of the body, and in different tissues, either as indications of internal disease, or of some constitutional de- rangement. They are often critical Avhen they occur at the decline of acute febrile diseases. They have received a great variety of appellations, but may all be included under the general denomination, phlegmon. There are two leading species: the one involving the cutis', and the cellular tissue beneath, often to a great extent; while the other is confined to, and only involves, in the suppurative process, the sub- stance of the cutis. The first appears in the form of a painful, dark-red, circumscribed tumour, of a somewhat conical form, excessively painful to the touch, and often attended with more or less febrile excitement. At the apex of the cone, a little white speck or slough is generally observed, which, when picked off, is not followed by the discharge of matter, but leaves an excavation of a corresponding size and shape. It is very probable, Plumbe remarks, that the matter is formed, in this species of phlegmon, within a very few days after the occurrence of the disease, deeply embedded in the cutis, and is prevented from making its way to the surface, in consequence of the thickening of the superincumbent structure from adhesive inflammation. The second species of phlegmon is in thecoma of a dark-red, lenti- cular SAvelling, very painful to the touch, and slow in maturating. When pressure is applied to the sides of one of these small tumours, soon after suppuration has commenced, a transparent serum exudes. Pus first appears in a minute yellow elevation on the centre of the tumour, the surrounding parts of the latter being hard, solid, and pain- ful. The abscess seldom gives discharge to much matter, and in most cases, Avhere the inflammation is not very obvious at the surface, a small portion of the cutis is destroyed, and comes away in the form of a slough. After the excavation, formed by the separation of the latter, is filled up, and the inflammation has subsided, a thickened and hardened condition of the part, which is of a bluish colour, remains, and is only slowly removed. These phlegmons appear in the great- est number upon some portion of the trunk, particularly the abdomen, Avhile the first species occurs most commonly on the arms, thighs and nates. (Fosbrooke, Plumbe.) AVe have very frequently seen the lat- ter in children of a gross habit of body, upon the back part of the neck, and between the shoulders. The second species of phlegmon is always of a chronic character, and very generally a new crop makes its appearance as fast as the first subsides, and it thus continues to occur until the diseased condition of the system, by which the local affection is produced, is overcome. Children of full, gross habits, and who are fed upon coarse and 558 DISEASES OF CHILDREN. rich food, are most subject to phlegmonous tumours. They are more common during the spring and summer than at the other seasons of the year. When extensive, they often give rise to a greater or less degree of febrile excitement. The treatment of the disease consists in placing the patient upon a plain vegetable diet; the evacuation of the bowels by a dose of calo- mel, followed by a saline cathartic, and free exposure to a fresh, pure atmosphere; and when the phlegmonous tumour is very extensive, hard and painful, particularly when accompanied by febrile symptoms. the application of a few leeches to its centre. The early suppuration of the tumour should be encouraged by the application of large emollient poultices, of which the best are "those composed of the crumb of stale bread, or linseed meal, boiled in milk, with the addition of lard. When suppuration has taken place, and the matter does not readily find its way to the surface, the abscess may be opened with a lancet, and the application of the poultices con- tinued. In general, in a few days, the excavation will be filled up with healthy granulations, and completely cicatrized. If, after the abscess bursts, or is opened, it exhibits no disposition* to heal, it should be dressed with the common resinous ointment. In the second species of phlegmon, the use of the sulphuric acid internally, continued for a length of time, has been said to prove pe- culiarly efficacious. It should be used largely diluted with water, and in as large doses as is compatible with the age of the patient. Under its use, we are assured by Fosbrooke, that the pain of the tu- mours is deadened, and the latter gradually absorbed, without suppu- ration. An alterative course of treatment, continued for many Aveeks, with the use of the compound decoction of sarsaparilla, will, in general, be required. Children, who are subject to boils, should be restricted to a light, unirritating diet, composed chiefly of farinaceous substances; they should use daily exercise in the open air, and be daily immersed in the warm or tepid bath. Children are often affected with a phlegmonous inflammation of the glands of the neck and groin, unconnected with indications of scrofu- lous disease, and occurring under the same circumstances as the cuti- cular phlegmon. Its treatment differs in nothing from that recommended for the more extensive forms of the latter; low diet, saline purgatives, and the application of leeches, and of cooling applications when a consi- derable degree of inflammmation is present; and when the tendency to suppuration is evident, emollient poultices frequently repeated. In many cases the inflammation and swelling of the glands are of an indolent character, and will often remain for a considerable time without either increase or diminution. In these cases we have gene- rally found the application of a blister to cause a rapid suppuration to ensue. AVhen an abscess forms, it should be early opened by a free inci- sion, and the application of the poultices continued, until the cavity is filled up by granulations, and a disposition to cicatrization is ap- parent. DISEASES OF THE SKIN. 559 There is a form of phlegmonous abscess of common occurrence in children which we have not seen noticed by any writer. It is conse- quent upon a deep-seated inflammation beneath the fascia, upon the anterior part of the thigh, or upon the lower part of the back; some- times immediately above the hip. It may, perhaps, occur in other parts, but the above are the only ones in which we have seen it. The disease generally occurs in children of a lymphatic temperament. The first symptoms are usually deep-seated, dull pains at the part where the inflammation occurs, which are often increased at night, and always upon the application of pressure. If the inflammation occur in the thigh, or upon the hip, the child walks lame: in many cases, when in the latter situation, the symptoms bear a strong resemblance to those of morbus coxarius, for which the disease may be mistaken by an in- experienced physician. There is at first no redness or increased heat of the part, and but little or no swelling:—by degrees, however, a swelling is perceived, which gradually increases in extent, and finally, upon a cautious examination, a fluctuation of matter may be detected. The skin over the tumour is smooth and shining, and very tense, and a deep-seated, throbbing pain, increased by paroxysms, is complained of:—it is often so severe as to deprive the child of his rest. In children over four years of age, we have seen, after suppuration has occurred, a well-marked hectic fever, with two exacerbations in the course of the twenty-four hours, profuse perspirations at night, and occasionally colliquative diarrhoea. We have never observed any dis- position in these abscesses to approach the surface; this has usually been prevented by the matter forming beneath the aponeurosis or fascia enveloping the muscles. Occasionally, the matter in the thigh has tra- velled downAvards, and given rise to a swelling in the neighbourhood of the knee; and in one case in which the abscess formed in the loAver part of the back, the matter found its way to the groin, where it formed a fluctuating tumour of considerable size. When the contents of these abscesses is discharged by an incision, it is of a healthy appearance, though occasionally containing flocculi, and large fragments of dead cellular matter. The treatment we have pursued in these cases is, in the early stage, the application of leeches over the seat of inflammation, followed by blisters—a dose of calomel, succeeded by saline cathartics, and if the discharges from the bowels are of an unhealthy appearance, the admi- nistration, three or four times a day, of small doses of calomel, in com- bination with ipecacuanha, extract of hyoscyamus, and magnesia. The moment matter is formed, we consider it all-important to make a free incision down to the abscess, and then to dress with emollient poul- tices. This gives relief to the pain, and the patient, in general, very quickly recovers his usual health; though, in cases in which there exists considerable exhaustion, the administration of some light tonic will be proper. In one case, occurring in a lad between eight and nine years of age, attended with hectic fever, night sweats, and a profuse diarrhoea, the stools being thin, dark-coloured, and very fetid, upon a free incision being made to give discharge to the contents of the abscess, which 560 DISEASES OF CHILDREN. Avas seated upon the anterior surface of the left thigh, a manifest im- provement in the condition of the patient was almost immediately manifested. For the relief of the diarrhuea, a powder composed of the sixth of a grain of sulphate of copper, subsequently increased to one-fourth of a grain, the third of a grain of opium, and two grains of the extract of quinia, was administered every three hours. On the fourth day, the evacuations from the bowels were reduced to two in the twenty-four hours, and became of a natural appearance; all symptoms of fever were gone, and the appetite and strength of the patient considerably improved. In a Aveek, he was able to walk about, and quickly regained his normal degree of health. The left thigh, how- ever, remained, for some time longer, less in size, and the whole limb much weaker than the other. Inflammation, followed by suppuration, frequently attacks the ciliary and follicular glands of the eyelids, in which case a small dark-red tumour forms upon the tarsal edge of one of the eyelids, attended with some swelling and redness of the lid, redness and injection of the eye, aversion from light, and considerable soreness, increased by the mo- tions of the eye or eyelids, (hordeolum, stye.) The disease usually oc- curs under the same general circumstances as the other phlegmonous tumours. After the inflammation has continued for a shorter or longer period, a white or yellow speck forms at its centre, which, on bursting, gives discharge to a small quantity of pus, when the inflammation and swelling quickly subside, and finally disappear. It is very usual for a succession of these little phlegmonous tumours of the eyelids to occur; no sooner one set disappears, than another makes its appearance, and runs the same course. AVhen the inflammation and swelling are considerable, a leech or two should be applied to the lid, and calomel, followed by saline ape- rients, administered, so as to procure a free discharge from the bowels; the diet being, at the same time, carefully regulated. Very warm wa- ter applied frequently to the inflamed lid, by means of a sponge, or a soft poultice of crumb of bread and milk applied over the closed eye, may be used to promote suppuration:—as soon as this takes place, the minute abscess should be opened by means of a fine sharp-pointed lancet, and the stye then cautiously touched with the point of a pencil of lunar caustic. This causes the quick subsidence of whatever inflam- mation and swelling may remain, and prevents the induration and red- ness, which often continue for a considerable time, especially in chil- dren of a Aveakly or lymphatic temperament. Should the latter, how- ever, occur, they may be moderated by a poultice, composed of crumb of bread, a grain or two of the extract of belladonna, and the campho- rated tincture; or, perhaps, what is better, by touching the part with lunar caustic. A chronic inflammation of the ciliary bulbs not unfrequently takes place, which by degrees pervades the entire ciliary circle, and, if not checked in its early stage, terminates in a chronic inflammation of the edges of the eyelids, accompanied by a slight glutinous discharge from the ciliary glands. In time the bulbs lose their power of secreting the eyelashes, which fall out; and the loss of these, with the permanent DISEASES OF THE SKIN. • 561 red circle which surrounds the eye, causes no inconsiderable deformity. (Tinea ciliaris, lippitudo, chronic stye.) This affection most generally occurs in children of a weakly, un- healthy constitution, and of a lymphatic temperament, and it is very commonly conjoined with a more or les^ disordered condition of the digestive organs. In the early period of the inflammation, leeches should be applied in the vicinity of the lashes, followed by the application of warm water, or soft emollient poultices, and after the disease has assumed a chronic form, the unguentum hyd. nitratis diluted, or the cautious use of the nitrate of silver, will generally effect a cure. But these local remedies will be of little service, unless attention be directed to the condition of the general health of the patient, and to the state of the digestive organs. The first should be strengthened and invigorated by a proper diet, daily exercise in the open air, the warm or tepid bath, followed by friction of the surface, or by sponging the skin daily with salt water of tepid Avarmth, followed by friction, and by the administration of light tonics and alteratives. The healthy functions of the digestive organs should be restored by a course of treatment adapted to their particular condition,—which it is unnecessary here to particularize. 10.—Herpes. An eruption of transparent vesicles, varying in size from that of a millet seed to that of a pea; either distributed like a belt around, or partly around the body, (H. zoster, zona) or in defined clusters, (H. phlyctanodes,) or in circular patches around an inflamed area, the surface of which desquamates as the vesicles decline (H. circinnatus;) or, very rarely, in three or four concentric circles, or rings of varied and beautiful colours, and elevated above the surface of the surround- ing skin. When herpes occurs around the lips, as it often does towards the decline of catarrhal fevers, or in the course of various disorders of the digestive organs, it has been denominated herpes labialis. Herpes occurs on various parts of the body, and is generally pre- ceded by some degree of febrile excitement, which is often so slight as scarcely to attract attention; or by pain in the epigastrium, and other symptoms of disease of the digestive organs. The fever and other symptoms, —particularly languor, loss of appetite, headache, nausea, pain of the abdomen, heat of the surface, and hurried circulation,— generally remain as long as fresh vesicles continue to be produced. The abdominal pain generally pursues the course of the eruption, be- ing felt at the regions of the stomach, liver, &c, when it extends around the waist; and when the eruption occurs upon the shoulder, deep-seated pain of the scapula, spine, or, as it extends down the arm, of the os humerus, is complained of. At the seat of the eruption, there first appears a bright red efflores- cence, accompanied by a sense of heat and tingling. The redness is distributed in patches, varying in size, and separated from each other by a greater or less extent of the surface retaining its natural colour. Upon the largest of these patches, near its centre, a few small vesicles arise, and still fewer upon the adjoining patches, and upon the next 562 • DISEASES OF CHILDREN. perhaps none, or only a minute pimple, which in an hour or two, be- comes a perfectly formed vesicle. Slight pressure at this period pro- duces a sensation of prickling; but, as the disease advances, it is at- tended with a severe smarting pain. Within twenty-four hours, the vesicles that first appeared attain the size of small pearls, and several of those which are the closest together, coalesce, and form a large ir- regular blister, the areola of inflamed skin being also increased. The eruption extends, in an irregular line, from the spot where it first commenced, to distant parts of the surface, by the occurrence of a succession of inflamed patches and vesicles, which continue to appear for four or five days: at the end of this period, the first formed vesi- cles become opaque, shrivel up, and terminate in a brown scab, that is gradually extended by a similar change taking place in the other vesicles of the same cluster:—the inflamed patch upon which they are situated at the same time acquires a bluish tint, and loses all appear- ance of heat and irritation. In about two weeks from the appearance of the eruption, the scabs separate, and leave a tender, discoloured state of the skin, which gradually disappears: in some cases, however, the disease is protracted to twenty or twenty-seven days. When the constitution of the patient is much diseased, or the erup- tion has been improperly treated, small white sloughs occasionally form at the points occupied by the vesicles, leaving permanent pits or scars upon the skin, after the healing process is completed. A slight eruption of herpes, and one limited in extent, is apt to as- sume a circular form, and hence has obtained the popular appellation of ringworm. In such cases the vesicles are sometimes extremely minute, and they generally soon dry up, the cuticle falling off in a few days, in the form of small exfoliations, leaving a reddened scurfy areola. This form of herpes occurs on different parts of the body, and seldom requires much attention. Herpes labialis is not often a very troublesome form of the disease; it generally goes through its course in a week or ten days; the vesi- cles first becoming turbid and yellow, then drying up, and ultimately falling off, in the form of scales. The posterior part of the fauces is sometimes affected, when the disease appears suddenly, after checked perspiration and cold; a few vesicles being distributed upon this part, surrounded by an erysipelatous redness. The causes of the herpetic eruption have not been very accurately determined. It is most commonly met with in persons of a lymphatic temperament, and is most prevalent in warm climates and seasons, and inthe neighbourhood of marshes. It sometimes prevails epidemi- cally. We have already noticed the occurrence of one variety, to- Avards the close, or during the course of catarrhal and gastro-intesti- nal disease. It is often observed in infants, during the period of den- tition. Sudden suppression of perspiration—sudden changes in diet and regimen—the habitual use of food of a fatty or oily nature, or of fish, and inattention to personal cleanliness, have been enumerated, as common exciting causes of herpes. Like erysipelas, the disease is said, by some authors, to occur after violent paroxysms of anger. The different varieties of herpes require but little treatment. It Avould be useless, if not dangerous, to attempt to suppress the erup- DISEASES OF THE SKIN. 563 tion. The tingling, smarting, aching and burning by which it is ac- companied, may, however, be allayed, and in this manner the patient rendered more comfortable, by lotions composed of a solution of ace- tate of lead, with a slight addition of alcohol, or by the application to the part of the ungt. plumbi acetatis. In the more severe cases, the strictest rest should be enjoined, with the antiphlogistic regimen ge- nerally, the tepid bath, and occasional doses of some mild aperient, as sulphur and bitartrate of potass, or sulphur and magnesia. When the eruption is confined to a very small space, and the vesicles are very minute, the application of substances possessing slightly caustic or powerfully astringent properties, will often speedily effect its re- moval, as the juice of the green rind of walnuts, tincture of galls, or a strong solution of the sulphate or acetate of copper; but, under all other circumstances, such applications will prove decidedly injurious. If each vesicle is carefully punctured, so as to allow the escape of its fluid contents, the pain will be much diminished, and the irritation more speedily subside; but the vesicles must not be cut or rudely broken. It is stated by Plumbe, that the spreading of the eruption may be prevented, and the progress of the disease shortened, by the applica- tion of a small blister upon the uninflamed skin, at the part to which the eruption seems disposed to extend. The blister should never be applied upon the vesicles themselves, as this may cause a sloughing of the integuments at the seat of the latter, followed by small irritable ulcers, which heal with difficulty and leave permanent marks upon the skin. AVhen herpes occurs as a concomitant of other diseases, the treat- ment should be exclusively directed to the removal of the latter, with- out any attention being paid to the eruption. The decoction of dulcamara, and, in very severe cases, the arsenite of ammonia dissolved in distilled water, in the dose of the one-twenty- fourth of a grain, have been recommended as peculiarly efficacious. In some cases of uncommon severity, or where the disease has been improperly treated in its early stages, a rupture of the vesicles takes place, followed by ragged ulcers, which spread, often with great ra- pidity, (H. exedens.) These ulcers should be treated by carrot poul- tices, or touched with a weak solution of nitrate of silver, or chloride of soda. 11. Psoriasis. SCALLY TETTER--DRY SCALL—LEPRA ALPHOIDES. This form of squamous eruption consists in a rough and scaly con- dition of the cuticle, sometimes in separate patches, varying in size, and of irregular form, and sometimes occupying continuously a large portion of the surface. For the most part, psoriasis is accompanied with rhagades or fissures of the skin. Soon after the appearance of reddish points or projections on the skin, small white or pearl-like scales appear, either separate or in clusters, or surrounding a central pink-coloured space, with a slight discoloration of the surrounding skin. In "other cases, the patches are of a reddish or brownish colour, interspersed with fissures, and 564 DISEASES OF CHILDREN. accompanied with intense itching, or a sense of burning, increased by heat or friction; sometimes producing ulceration, and the discharge of a purulent fluid, which, intermixed with the scales, on becoming concrete, forms a more elevated crust. The scales are usually sur- rounded by a circle of a deep rose-colour, which is increased in inten- sity by exertion, or by food of a stimulating quality: beneath the scales, the skin is red and irritable. When the patient is in bed, the scales often become detached in great quantities, and, by their fric- tion, aggravate the tingling and itching. When the disease occurs in the neighbourhood of joints, or parts endowed with considerable motion, blood frequently issues from the fissures, accompanied by severe pain and smarting. Psoriasis is, occasionally, at its commencement, formed of small distinct patches, with irregular circumferences (P. guttata.) These appear on almost every part of the body, even on the face. In other cases, the patches are of some extent, and also irregularly circum- scribed (P. diffusa.) The patches, in other cases again, present^ a tortuous or serpentine appearance (P. gyrata;) while, in some in- stances, the patches, at first separate and irregular, become, in a short time, confluent, until at length the disease covers the greater part of the surface of the body, Avith a universal scaliness, interspersed with deep furrows, and a harsh, stiff and thickened state of the epidermis In infants, the disease very commonly affects the cheeks, chin, fore- head, nates, abdomen, &c. When the face is affected, the eyes some- times partake of the inflammation, and generally the mucous mem- brane of the nose becomes inflamed and thickened, causing snuffling, difficulty of respiration, and some discharge from the nostrils. In protracted cases, there is often great emaciation, which rapidly increases until death takes place. The disease, in early life, is com- monly attended with more or less affection of the alimentary canal, which may have been the primary cause of the eruption, or may im- pede its cure. , . Psoriasis generally occurs among the children of the poor, who in- habit unhealthy localities, and is mainly to be attributed to bad food and bad nursing, in conjunction with the morbific influence of an im- pure and confined atmosphere, and a neglect of personal and domestic pl pfinlinpss. ° In the treatment of psoriasis, a change to a more wholesome atmo- sphere, an improved diet, proper clothing, and frequent tepid bathing, with a course of treatment adapted to restore to their healthful con- dition the functions of the digestive organs, are the first steps to be taken, and, with frequent ablutions of the more irritable parts with warm water or mucilaginous fluids, will, in general, be sufficient to accomplish a cure. If there be much irritation, with_constanfretful- ness and want of sleep, the parts may be bathed with the watery so- Sn of opkim, and the same, with the addition of the carbonate of oda may be administered internally, should there be nothing to forbid its use. When severe local inflammation exists, leeches around the edges of the squamous patches will be proper. DISEASES OF THE SKIN. 565 On the subsidence of the local irritation, the sulphur-bath may be employed, and repeated every two or three days, provided it is not found to increase the irritation of the skin. If the latter effect result, the bath should be at once suspended, and gentle purgatives adminis- tered, at such intervals as will be sufficient to preserve the bowels freely open: the following has been recommended, as one well adapted to these cases: R.—Sulph. prascip. %j. Magnes. calc. gss. Pulv. rhsei, gr. xxiv. Bi-tart. potassae, gr. xxiv.—M. f. ch. No. xij. In tho chronic stage of psoriasis, the decoction of dulcamara, and small doses, three times a day, of the solution of the arsenite of potassa, will be proper; or in cases attended with considerable derangement of the alimentary canal, with unhealthy discharges from the bowels, in which, of course, the arsenical solution Avould be improper, the decoc- tion of dulcamara may be employed, in conjunction with the spirits of turpentine: three to eight drops or more of the latter, according to the age of the patient, may be given three times a day, dropped on a piece of mint candy. AA7hen the scales do not readily separate, they may be carefuily touched with the liquor potassae, or dilute hydrochloric acid; or the ointment of the nitrate of mercury may be used, taking care to wash off that already applied, before it is renewed. If the disease is attended with a state of considerable prostration, and especially if the skin, at the seat of the eruption, acquires a dark or violet hue, the sulphate'of quinia should be administered, or some one of the preparations of iron, or the tincture of iodine in doses of from tAvo to eight drops, twice or thrice in the course of the day. A pure, fresh atmosphere, and the daily use of the warm bath, are, in these cases, all-important. AVhen psoriasis occurs simply as a concomitant of other diseases, our Avhole attention should be directed to the removal of the latter; as the disappearance of these will very generally be followed by that of the cutaneous affection. This is a rule which will apply generally to all of the diseases of the skin. 12.—Follicular Warts. Hard, white, and rather shining elevations of the skin, usually oc- curring on the cheeks and forehead; they are often stationary for some time, but, in some instances, one or more of them become enlarged, of a pale pink colour, and surrounded by an inflamed margin. These tumours ordinarily result from an obstruction of the cuticular follicles,' preventing the discharge of their sebaceous secretion, AA-hich, accumulating in the follicles, and concreting, causes their distention, and, ultimately, excites an inflammation, that often involves for a short distance the neighbouring skin. Soon after the inflammation occurs, a suppurative process commences in the follicle, and the seba- ceous matter is dislodged; and speedily all disease disappears; but, oc- 566 DISEASES OF CHILDREN. casionally, the matter accumulates within the follicles, and an abscess of considerable size is produced; from a small opening in Avhich, an exudation of cheesy matter, mixed with pus, continues for some time, or, concreting upon the surface, forms a crust. This affection generally occurs towards the close of childhood, in both sexes, but more commonly in boys, and is ordinarily produce*I by derangement of the digestive organs; in females, it is frequentlv connected with that condition of the digestive and assimilating func- tions which gives rise, at a later period, to chlorosis. A proper regulation of the diet, brisk but gentle purgatives, pure air, and the warm or tepid bath, followed by brisk friction of the sur- face, are the only remedies required; excepting in cases in Avhich the derangement of the bowels is of a more serious and extensive cha- racter, when the proper treatment adapted to the particular character of the intestinal disease present in each case will be demanded. When the tumours are large, few in number, and of an indolent character, they may be seized by a pair of forceps, and excised by a sharp scissors; or the inspissated matter by which they are filled may be expelled by gentle pressure. When inflammation takes place, sup- puration should be promoted by warm fomentations, or a small poul- tice; and as soon as matter is formed, it should be allowed early to escape by a slight incision. In some cases, towards the period of puberty, these tumours become the seat of chronic inflammation, and the face then becomes studded with hard, dull, red, and painful pimples, (A. indurata,) which con- tinue for a long time. They are generally connected with very con- siderable derangement of the digestive organs; and until these are restored to a healthy condition, very seldom disappear. Various local applications have been recommended for these pimples, but we must confess we have, in no instance, seen any advantage derived from their use. A course of treatment adapted to the condition of the alimentary canal, with an appropriate diet and regimen, is the only means which, in our hands, has succeeded in freeing the patient from the deformity consequent upon acne indurata. 13—Porrigo- TINEA FAVOSA--FAVUS—TINEA CAPITIS—SCABIES CAPITIS FAVOSA—TEIGNE fcAVUSE—HONEYCOMB SCALE—SCALD-HEAD. This is one of the most obstinate, disgusting, and infectious, of the simple cutaneous affections of childhood. There are several varieties of the disease. In one, (P. lupinosa) an eruption of minute, flat, umbi- licated vesicles, of a yellow colour, occurs upon the scalp, attended by more or less itching. The contents of these pustules, by speedily de- siccating, form a number of small circular scabs, of a yellow or fawn colour; each scab being hollowed in its centre, and raised at its edges, and having its base deeply embedded in the skin, and strongly ad- hering to it. The scabs gradually increase in size, but still preserve their circular and cupped form. When the pustules of porrigo occur in clusters on different parts of DISEASES OF THE SKIN. 567 the scalp, the edges of the scabs formed by them approach each other, and by their aggregation give rise to crusts of considerable extent; in which, howeArer, the cup-like form of the individual scabs is readily detected, giving to the crusts some resemblance to honeycomb. Some- times the cutis is deeply involved in the irritation of the disease, and fissures of considerable extent are formed, from which an ichorous or purulent matter is discharged; and occasionally, according to Ali- bert, in severe and protracted cases, the cutis, and sub-cuticular cel- lular membrane are destroyed, and the bone of the skull laid bare. Between the different clusters of scabs the skin is covered with fur- furaceous scales. In some individuals the disease extends to the forehead, temples, and neck; or occurs upon other and remote parts of the body. The attendant itching is, in some cases, almost intolerable, and causes the patient to scratch himself incessantly and severely. Pedi- culi, which multiply in great numbers under the edges of, and between the scabs, add farther to this irritation. The smell emitted by the scalp is peculiar and disgusting, resembling that of the urine of the male cat. When the crusts are removed by the application of emollient poul- tices, the epidermis is found to be destroyed, and the reticular structure beneath red and inflamed. A yellow, viscous, and fetid discharge exudes from numerous ulcerations;—a number of small abscesses are seen dispersed over different parts of the scalp, of a lenticular form, and appearing as so many centres of inflammation. When the disease is neglected and allowed to proceed, it is finally attended by an al- most universal falling out of the hair, leaving the skin smooth and shining; the few hairs that remain being thin, languid, and altered in colour and structure. AVhen the scabs in this form of porrigo are allowed to become per- fectly dry, they assume a white appearance, wear off, break, and de- tach themselves from the scalp; their remains presenting no regular form. In another, and very common form of the disease, (P.furfurans,) there is, at first, a slight desquamation of the cuticle of the scalp, often attended with considerable itching. There is discharged from the affected surface an ichorous matter, which dries, and forms a scurfy covering to the scalp; the disease gradually and slowly spreads over the greater part of the scalp; the layers of scurf thicken, and resemble a coating of bran, or coarse flour, the lower surface of which is satu- rated with fluid. Upon freeing the scalp from this adhesive substance, it is found to be divested of its cuticle, presenting a smooth shining surface, like varnish, and usually of a pink colour. The hair, in this form of porrigo, becomes matted and glued together; and, when the finger is pressed upon it, the whole mass has, in nearly every part, a soft yielding feel. The disease is chiefly confined to the scalp, but sometimes extends to a slight distance upon the forehead, in the form of crusts, resem- bling a portion of bran, cemented by some adhesive fluid, the edges of which are sometimes dry, and perfectly white. Much itching attends the disease, and great numbers of pediculi range freely over the affected 568 DISEASES OF CHILDREN. parts; ulcerations to a small extent occur here and there, from which a fluid is discharged. The scalp emits the smell of sour milk. In other cases, the disease presents itself in the form of numerous small, deeply-seated, yellow pustules, of a circular form, and umhili- cated, seated upon a circular red patch, Avhich precedes them. The pustules are crowded together, especially around the circumference of the patches. They are commonly each traversed by a hair, and are attended by intense itching (P. scutulata;)—their contents soon con- crete, forming a small cupped scab, which adheres by its edges to the adjoining scabs, producing thus a continuous crust, of the form and dimensions of the patch upon which the pustules arose. The indivi- dual scabs, in coalescing, lose their cupped form. Around the circumference of the patches, new crops of pustules successively arise, and, forming scabs, cause the greater portion of the scalp to become covered with a continuous, thick incrustation, of a whitish colour, around which portions of the original blotches, in the form of semicircles, or segments of circles, are perceived. In these cases, there is no hair, except around this incrustation, where the few remaining hairs form a sort of crown. (P. decalvans.) Por- tions of the scalp are frequently covered with circular patches, varying in size, showing the disease in a more or less advanced stage, Avith here and there a Avhite and shining space, entirely bald;—the inter- vening portions of skin being covered to a greater or less extent, Avith a furfuraceous desquamation. This form of porrigo may extend to the forehead and neck. In other cases, the disease is more circumscribed: the pustules, on drying, form small brownish, or dark-gray crusts, varying in form and size, and strongly resembling fragments of old mortar, or the plaster from walls discoloured by damp and dust;—they are often very hard, even of a stony consistence. (P. granulata.) The patches of disease are generally separated from each other, and are not so deeply im- bedded in the dermoid tissue, as those of the P. lupinosa; they are sometimes surrounded by thin, dry, furfuraceous scales. The disease is attended with severe itching; and, upon the separa- tion of the crusts, the parts beneath are found to be red and inflamed, smooth, polished, and often swollen. Here and there, small, depressed, whitish abscesses occur, from which issues a small quantity of a vis- cous, colourless fluid, which thickens and drys, forming new crusts, analogous to those which preceded. Before the matter becomes per- fectly dry, it exhales a nauseous smell, somewhat resembling rancid butter, or milk beginning to turn. (Plumbe.) This form of porrigo is confined to the scalp and parts immediately adjacent. AVhen porrigo furfurans occurs in children possessed of a less de- gree of irritability of skin, the disease is of a much more chronic cha- racter; there is less disposition to pustulation, or to the exudation of fluid. A constantly repeated exfoliation of the epidermis, in the form of minute, dry scales, takes place; and the cuticular sheath Avhich envelops each hair for a short distance beyond its exit from the scalp, becomes more elongated, opaque, dry, and shining; giving to the hair, near its root, a shining silvery appearance, resembling the fibres of DISEASES OF THE SKIN. 569 asbestos. (Teigne amiantacee of Alibert.) When the diseased hairs are cut off with the scissors, the skin appears furrowed, and somewhat red and inflamed. The itching sensation is inconsiderable; and, as the diseased parts are usually destitute of moisture, no unpleasant smell is emitted. In severe or neglected cases, the lymphatic glands at the back of the head, and of the neck, sometimes becomes enlarged; occasionally the tongue has been seen studded with patches and vesicles. (Dendy.) AVhen it spreads in the direction of the eyes, porrigo will occasionally produce severe ophthalmia. Tinea ciliaris will, in other cases, be pro- duced, with an oedematous state of the puncta lacrymalia, and a dis- charge of the tears over the cheek; or even, in very protracted cases, ectropium, especially of the lower lid, may finally ensue. $ Porrigo is capable of being propagated by inoculation or contact: the disease, however, frequently occurs spontaneously in children of unhealthy constitutions, fed upon coarse, fat food, and in whom no attention is paid to preserve the head, and body generally, perfectly clean. It is under these circumstances, and particularly when the disease, in its early stages, has been neglected, or treated by improper remedies, that the most obstinate and aggravated cases of porrigo occur. The disease is said to be of most frequent occurrence in Ioav, marshy, and otherwise unhealthy situations. In the children of those in comfortable circumstances, to whose personal cleanliness daily attention is paid, the disease is generally produced by contagion, or results from a deranged state of the digestive, assimilating, and nutritive functions, the consequence of excess in the use of rich, fat, or oily food:—in such children, the eruption is generally small in ex- tent, and Avithout much difficulty removed. AVith respect to the treatment of porrigo, in every case, the condi- tion of the patient's general health, and the state of the digestive or- gans particularly, should be first attended to; and AA-hatever indica- tions of internal derangement or disease exist, should be met by their appropriate remedies; the local treatment being restricted to frequent ablutions of the head Avith warm water, the hair being previously re- moved from and around the affected portions of the scalp, by a pair of sharp scissors, and any loose hairs detached by the forceps. This simple treatment, in recent cases, and where the general health, or that of the assimilating organs, is not extensively impaired, will very often succeed in effecting the complete removal of the cutaneous affection. The entire removal from the scalp of the incrustations produced by the desiccation of the morbid discharges, and the matting of the hair, is all-essential to the entire and speedy eradication of the disease; and, hence, when these have been allowed to accumulate, the head should be repeatedly Avashed with tepid water, and the diseased parts covered with simple emollient poultices. AVhen, by these means, however, Ave do not readily succeed in softening and detaching the crusts, alka- line washes may be employed, made stronger or weaker according to the greater or less thickness and firmness of the crusts. From half a drachm, to one or tAvo, or even three drachms, of the subcarbonate of potassa, may be employed, according to circumstances. In detaching 570 DISEASES OF CHILDREN. the crusts, no violence should be employed. The removal of the dead and loosened hairs is also a matter of some importance, and should not be neglected; the best plan is to pull them out by means of a small forceps. After all local irritation has been removed by emollient washes and poultices, we have seldom failed, in slight and recent cases, to cause the speedy removal of the disease, by the application, night and morn- ing, of the unguentum hydrargyri nitratis, or of an ointment of the hydriodate of potassa, (one drachm to two ounces of lard,) applied in the same manner; the parts being well Avashed with tepid water in which a small portion of castile soap has been dissolved, preA-ious to the re-application of either ointment. In some recent cases, touching the diseased parts with the nitrate of silver, will often cause an im- mediate arrest of the disease. The ointment of the ioduret of sul- phur has been recommended by Biett and Schedel as a very effica- cious local application; improving the condition of the scalp, prevent- ing the formation of fresh pustules, and causing a healthy growth of hair. But so long as any irritation of the scalp exists, all irritating applications are injurious; emollient poultices, and washes of tepid warmth, are then alone proper, and they should be immediately re- sorted to, should any degree of local irritation occur during the em- ployment of any of the ointments or lotions recommended. Care should be taken to prevent the contact of the diseased dis- charges from the scalp with the healthy skin; as, in this manner, the disease may be extended and kept up for a considerable time. During the treatment, the patient should be put on a diet composed principally of farinaceous substances; he should be afforded the bene- fit of a pure atmosphere, and have his bowels regulated by the occa- sional use of mild aperients; while the healthy action of the cutaneous capillaries is promoted and maintained by the daily use of the Avarm or tepid bath, according as the heat of the surface is deficient or in- creased. In many cases, sulphurous baths, and gentle sulphurous douches every morning, will prove very useful adjuvants. In chronic cases, a variety of lotions have been recommended; as solutions of the sulphate of copper or of zinc; of the deuto-chloruret of mercury, or of the nitrate of silver, or the sulphuric, nitric or hy- drochloric acids, more or less diluted. Quickly washing the diseased portions of the scalp with diluted nitric or hydrochloric acid, by means of a feather, and then pouring water on the parts, to prevent the action of the acid from penetrating too deeply, we are assured by Schedel will very certainly cause the removal of the disease. By the same authority, touching the diseased parts with a small hair pencil, dipped in creasote, and subsequently applying an ointment of creasote, (twenty grains to an ounce of lard,) is asserted to have succeeded in the eradication of the malady, in cases where many other means had been ineffectually employed. By Dr. A. L. AVigan, of London, a plan of treating the disease has been proposed, which is described as prompt in its effects, and uniformly successful. The whole of the scalp is, in the first place, to be care- fully shaved twice, unless the quantity of hair is very small, and offers DISEASES OF THE SKIN. 571 no obstacle to the complete examination of the skin. This, according to Dr. AVigan, is all-important, inasmuch as Avhen the scalp is covered Avith even a moderate quantity of hair, in parts that have become in- fected, the disease may gradually progress, whilst the whole attention is paid to those in which it is already apparent. A narroAv circlet of hair may be left around the face, as a concession to parental vanity, if there be no indications of the disease at this part, and it is care- fully washed with hot vinegar. The scalp being denuded of hair, is to be washed with the pyrolig- neous or concentrated acetic acid. In its first application, Dr. Wigan employs the acid diluted with three times its weight in water. This wash generally causes a number of red patches to appear upon por- tions of the scalp, which before its application looked perfectly healthy, —showing that these parts had become infected, but without the dis- ease having gone through its stages, which Dr. AVigan supposes, from a large number of observations, to require a space of eight days. The Avhole extent of the disease being thus determined, with a piece of fine sponge tied to the end of a stick, or held in a pair of silver sugar tongs, each spot is to be thoroughly imbued with the con- centrated acid, for the space of three or four minutes; when, accord- ing to Dr. Wigan, the disease will be fully arrested. He has often applied the acid a second time, but he firmly believes that this is unnecessary whenever the scalp has been completely denuded of its hair, and the extent of the infection tested by the preliminary appli- cation of the diluted acid. The crusts are gradually raised up with the growth of the hair, which soon sprouts again if the eruption be recent. As soon as a pair of fine scissors can be inserted beneath them, they should be re- moved by clipping the hair; but we are warned not to do this pre- maturely, lest a sore place be produced. AVe confess, we have seldom met with much trouble in curing cases of porriginous disease of the scalp, excepting in constitutions of a very unhealthy character, particularly those strongly predisposed to scrofulous or tubercular disease. Our success we have mainly at- tributed to the attention we pay to the complete cleansing of the scalp, by repeated ablutions with warm water, and the occasional use of alkaline lotions; to the early removal of the hair by the scissors, and the removal of loosened and diseased hairs by the forceps; to the constant attention we direct to the condition of the digestive, as- similating and nutritive processes, Avith the view of detecting and re- moving any derangement which may exist in either. This course, with perfect cleanliness of the patient's person and habiliments, free exposure to pure, fresh air, with a well-regulated diet, and appro- priate exercise, has enabled us, in a very large number of cases, to succeed in the removal of the diseased condition of the scalp, with no further local application than the emollient washes and poultices above referred to; or the application for one or two days of the ci- trine ointment, diluted or undiluted; or of the ointment of the hy- driodate of potassa. The disease, however, is not one of very frequent occurrence in Philadelphia, at least in its more aggravated forms. 572 DISEASES OF CHILDREN. ERUPTIONS CONNECTED AVITH LANGUID CUTANEOUS ACTION. 14. Pityriasis. DANDRIFF. Exfoliations of the cuticle in different parts of the body, but in in- fants chiefly occurring on the hairy scalp, unaccompanied by much irritation or fluid secretion. We are to recollect that in all infants, for some days after birth, a slight exfoliation of the cuticle takes place; which is ahvays to be considered a healthy natural process. Dandriff, however, is the pro- gressive desquamation of thin scales from the scalp, succeeding light, pink,' unelevated patches; attended, in most cases, by a trifling degree of chronic inflammation of the vessels secreting the cuticle, but Avith- out the discharge of fluid. If the infant in whom this affection occurs is not very much ne- glected in regard to cleanliness, it usually disappears in a few weeks; but now and then, under different circumstances, and particularly, when, at the same time, there is derangement of the alimentary canal, from improper or unwholesome food, it is followed by considerable irritation of the scalp, a fluid secretion, and scabbing, (P. scabida,) or a state resembling the porrigo furfurans. Under circumstances of peculiar aggravation, according to Plumbe, there is, in fact, no real difference between the two affections. In these severe cases, too, the hair often falls off, and the eyelids, likewise, occasionally become dis- eased. On the breasts of children, about the tenth year are often seen a few light, yelloAvish scales, scattered here and there, and sometimes so indistinct as scarcely to be perceived, (P. versicolor.) In this si- tuation, they sometimes resemble freckles, or light yellow stains; upon more minute examination, however, their squamous character will be readily detected. In children of unhealthy constitutions, the spots will occasionally assume a dark or livid hue, (P. nigra, melasma;) this Avill often be observed in children, more especially, Avho have become debilitated by a residence in Avarin or tropical climates. AVhen the dandriff occurs upon the scalp of infants, it is, no doubt, in very many instances, dependent on the disposition to determination to the head, so common at this age; and it is not improbable, Avhen attended by much irritation and fluid secretion, hyperaemia of the ce- rebral vessels may be prevented by it. (Plumbe.) The condition of the patient's health, therefore, requires to be closely considered, in deciding upon its treatment. Sedative applications are seldom advi- sable, or eyen safe; and those of an irritating character should never be employed. Upon AAdiatever part of the body the disease may present itself, it will demand little attention beyond what may be necessary to restore the patient's general health, and the regular action of the digestive functions, with strict attention to cleanliness of the surface generally. The exfoliation will usually be quickly checked, by simply washing with Avarm water. In more obstinate cases, a weak alkaline solution, DISEASES OF THE SKIN. 573. as one drachm of the liq. potassae to four ounces rose water, may be gently rubbed upon the part. 15.—Ichthyosis. FISH-SKIN DISEASE. A morbid thickening, with a dry and hard condition of the cuticle, evidently dependent upon chronic inflammation of the vessels by which the cuticle is produced. Ichthyosis is unattended, at first, by any uneasy sensations, but, as the thickening of the Cuticle increases, a sensation of increased heat, Avith redness, and other marks of more or less irritation are observed on the healthy skin, around the margin of the diseased part. When the thickening of the cuticle causes it to rise above the surrounding surface, it begins to exhibit the appearance of minute and innumerable fissures, which soon increase in length; and extensive cracks form, intersecting each other, and dividing the surface into innumerable fragments, of AA-hich each, considered separately, ex- hibits a great similarity, in structure, to the common wart. The dis- eased cuticle now assumes a dusky, dark-brown colour, which gra- dually approaches to blackness. This discoloration results from the entanglement of dirt by the rough and fissured surface of the skin, which even frequent ablutions will not prevent. On drawing the finger over the diseased surface, the sensation is the same as though the part was covered with large warts of long standing. The arms and legs are the most common situations of this disease; it very rarely occurs upon the face. , The skin of those infants in whom the disease is subsequently de- veloped, instead of the usual smooth and soft texture, has, according to Rayer, a sallow, dry, shagreen-like appearance. The cuticle, during the first or second month, becomes more rough, and of a grayish hue, communicating to the touch a feeling like that produced in many cases by the skin of the aged. This condition may continue throughout life, or it may increase with the progress of years. The appearance of the skin in cases of ichthyosis is more like that of the legs of fowls, than the scales of fishes, or of serpents; and, when the thickening of the epidermis is very considerable, it has been likened by Rayer to the bark of certain trees. The skin may be- come, in some cases, so rough that the hand, when passed over it, ex- periences a sensation similar to what is felt Avhen a file or shagreen, or the skin of certain fishes is handled. The squamae formed by the diseased cuticle may, with the excep- tion of the largest, be detached without causing pain, or any unplea- sant sensation. AVhen detached by friction, or in any other manner, they are speedily reproduced, with the same characters as,before. Desquamation of the diseased cuticle often takes place during the summer season; but the disease again constantly recurs, on the return of autumn. On the separation of the squamae, the skin is found to retain its natural colour; its furrows, hoAvever, are more marked than natural, and its exhalations and secretions are found to be entirely suspended. 574 DISEASES OF CHILDREN. The disease is often congenital; and is then seldom got rid of during life. Its remote and exciting causes, are equally involved in obscurity. In numerous cases, where it has been studied Avith the utmost care, it Avas found impossible to trace it to any pre-existing derangement of health, or local irritation. According to Girdlestone, Martin, and Rayer, it is frequently hereditary; but it as frequently occurs in chil- dren whose parents, and grandparents, have presented no traces of the disease. Neither climate, nor season, nor locality, nor mode of life, would seem to exercise any marked influence upon its production. When local, of small extent, and occurring subsequent to birth, in the children of healthy parents, there is some hopes of effecting a cure. Repeated blisters, and topical stimulants, have succeeded in removing the disease in some cases. In two instances, in which it was limited to the legs, Plumbe succeeded in effecting a cure by strapping tbe affected parts tightly with adhesive plaster, and applying a long roller, kept constantly moistened with cold water, the straps being renewed every fourth or fifth day. When the disease is of greater extent, we must content ourselves vfith the frequent use of emollient washes, mucilaginous and soothing fomentations, the warm bath, frequently repeated, the vapour-bath, and the occasional use of alkaline baths. Internal remedies have not been found to produce any good effect. In a practice of thirty-six years, we have met with but six cases of well-marked ichthyosis; in one, the disease was evidently here- ditary, and resisted every means employed; in the others, it Avas of comparatively small extent: the parts affected were daily washed Avith diluted nitric acid, by*which the squamae were rendered much thinner; a succession of blisters was then resorted to, and in from eight to ten weeks from the commencement of the treatment, a complete cure was effected. In one case, twenty-two years have now elapsed Avith- out any indication of the disease returning. 16.—Ecthyma.—Rupia. ATONIC ULCER. Ecthyma is an eruption of hard, red elevations, painful upon pres- sure, and with inflamed bases; the elevations, in a few days, increase irregularly in size, and pus is formed at their apex. The eruption is occasionally attended by a violent smarting pain. The pustules occur in irregular groups of various dimensions, and suppuration proceeds, with greater or less rapidity, in different cases. In some, we have a large inflamed base, with a small pustule in the centre; in others, the pustules are in the form of blebs, with a central spot. In three or four days, the matter of the pustules becomes dry, and forms .thick, brown scabs, which fall off in the course of a week or ten days, leaving a dark-red stain, or superficial cicatrix. In in- fants, the elevations slowly disappear, without suppuration, by cuticular desquamation. AVhen ecthyma is confined to a particular part of the surface, the eruption may come out at once; but in other cases there is generally a succession of pustules. The duration of the disease, in the first case, is from one to tAvo weeks, but in the latter it may continue for DISEASES OF THE SKIN. 575 months. It occurs most frequently upon the extremities, shoulders, and nates. Several varieties of the disease are described by Willan and others, as the E. vulgare, the E. infantile, the E. luridum, and the E. cachec- ticum; but as these varieties are the mere results of different degrees of constitutional debility, or of irritability of the skin, it is unnecessary to describe their individual characteristics. Rupia is the eruption of one or more flattened blebs, of the size of a shilling, containing a serous, transparent fluid. The blebs soon be- come flaccid, their contents increase in consistence, and become tur- bid, and finally drying, form scabs of a dark-brown colour, rough on the surface, thick and prominent in the centre, and adhering, at their edges, to the surrounding cuticle, which is there slightly elevated. (R. simplex.) * On the separation of the scab, a superficial ulceration of the skin remains, which usually heals rapidly, though it may remain for a time open, sometimes covered with a scab, and sometimes with- out one. The ulcer generally leaves behind it a deep red stain. In some cases the blebs are much larger, and are surrounded by an inflamed margin, several lines wide. The blebs are very quickly con- verted into rough scabs of a very dark colour, which are also sur- rounded by an inflamed areola; from this the cuticle is raised by suc- cessive formations of matter and bloody serum, which, upon drying, add to the size and thickness of the scab, with the increase of which the areola advances, and, by continually forming new rings of matter, increases the primitive scab in width and thickness, until it acquires the size, and almost the shape and appearance of the outer surface of a small limpet or oyster shell. (R. prominens.) (Bateman.) The scabs in this variety, which is usually confined to the lower extremities, often adhere for a long time: when they separate, they leave an ulce- rated surface, which has often a bad appearance. Sometimes the scabs are reproduced; in other cases, the ulcer remains open, extend- ing constantly in depth, and is with difficulty healed; and when cica- trized, leaves a dark-coloured, livid mark upon the skin, which dis- appears very slowly, if at all. In other cases, the disease commences with slightly raised patches of a dark livid colour, upon which flattened, irregular-shaped blebs soon form, surrounded by a dusky red margin. The fluid contained in the blebs is thick and dark-coloured, which, in place, of drying, escapes by the bursting of the blebs, and an excoriation of the skin remains, attended with pain, which soon degenerates into an ill-con- ditioned ulcer, that spreads rapidly in extent and depth. (R. tscha- rotica.) Successive blebs arise and burst, and in this manner multiply the points of unhealthy ulceration. Cicatrization is always slow and protracted. This variety generally occurs on the loins, thighs, and lower extremities. Ecthyma and rupia occur only in children who have been subjected to causes, the operation of which has a tendency to reduce the ener- gies of their system, and to produce a languid state of the vitality of the skin; hence impure and confined air, a cold and damp atmosphere, and deficient or impure food on the one hand, or a state of debility, 576 DISEASES OF CHILDREN. from preceding diseases, on the other, are their usual predisposing and exciting causes. Both forms of disease are very apt to occur after measles, scarlatina, small-pox, and other severe affections of childhood; and in nearly every case of any severity, they arc accom- panied by a low, irritative fever,—frequently assuming a hectic cha- racter—by a general Avasting of the body, and by the utmost languor and debility. In the treatment of these affections, our attention should be chiefly directed to the restoration of the general health and vigour of the patient's system. AVhen this restoration can be effected, the local dis- ease will seldom demand much attention, it being generally soon arrested, the scabs separating, and the ulcerations assuming a healthy aspect, and rapidly cicatrizing. The means by which this object is to be obtained, will, in some measure, be governed by the circum- stances of individual cases: as a general rule, they will consist in pure, fresh air, cleanliness of person, appropriate clothing, a Avholesome, nourishing diet, consisting of meat, gravy or jellies, chicken, beef, or mutton broth; and when the exhaustion of the patient is extreme, Avine whey, or wine and water. The cold infusion of bark, the sulphate of quinia, and other vegetable tonics, may, in some cases, be employed Avith advantage; they are best adapted to the more severe and pro- tracted forms of these diseases. In the early stage of most cases, gentle purgatives, occasional doses of a mercurial alterative,1 and the warm bath daily, Avill generally be required. In more protracted cases, if the discharges from the bowels are of a vitiated character, the spirits of turpentine will often be found to produce a beneficial effect. In such cases, we must be cautious in the administration of mercury in any form. Good air, wholesome food, and the sea-air and sea-bathing, with, perhaps, some light tonic, will generally succeed in effecting a cure, unless tlrre health of the patient is completely impaired. A cautious use of wreak alkaline baths has, in numerous instances, been found of benefit. 1 R.—Mass. f. pill. hyd. gr. iv. ad xij. Or, R.—Calomel, gr. vj. Ipecacuanha, gr. ij.—iij. Magnesise calc. gr. xxiv. Ext. hyoscyami, gr. iij.—vj. Ipecac, pulv. gr. iij. Carb. sodae, Qj.—*"jss.—M. f. pil. Ext. hyoscyami, gr. iij.—M. f. No. xij. chart. No. xij. One to he given for a dose, every evening. To be given as above. In regard to the local treatment, so long as the pustules or ulcera- tions present a decidedly irritable condition, emollient washes and ap- plications are alone to be employed. AVhen the ulcers are tardy in cicatrizing, a lotion of red wine and water, or of red wine and honey, may be employed. AVhen the ulcerations of rupia are of an indolent character, a wash of the bitartrate of potassa, or dusting their surface with this substance in a dry state, is said by AVillan to answer very well. If the above ap- plications do not succeed, the ulcers may be washed with a solution of nitrate of silver, or of sulphate of copper. If much itching or pain is present, an ointment of hydrocyanic acid and sugar of lead has been recommended.2 The ointment of the nitrate of mercury has, in our DISEASES OF THE SKIN. 577 hands, very generally proved successful. Washing the ulcers with diluted nitric or hydrochloric acid, will often be a means calculated to improve their condition, and promote their cicatrization: the degree of dilution necessary will depend upon the more or less indolent and un- healthy condition of the ulceration. Ointments of the proto-ioduret, or of the deuto-ioduret of mercury have likewise been used, according to Biett, Avith great success, in obstinate cases. 2 R.—Acid, hydrocyanic, gj. Plumbi. acetat. gr. xv. Ungt. cetacei, gij.—M. For the more malignant ulcerations, the chlorides of lime and soda, as an external application, and the latter internally, may be tried. But we are to recollect, that in no case, but especially in those in which the disease is of an extensive and aggravated character, will external applications be of much avail, unless the general health of the patient be, at the same time improved by a proper diet and regimen, and by the cautious employment of invigorating remedies: in many cases, when this can be effected, the local disease very readily disappears, with very simple applications. AVhen we fail in our attempt to restore the vigour of the system, the most "active topical applications will be unproductive of good. 17.—Pemphigus. POMPHOLTX.--BULLAE FEBRILIS.—PEMPHIGOID FEVER. The eruption of large bullae, preceded and accompanied by febrile phenomena, which generally assume a typhoid character; the disease, in its progress, having many features in common with the gangrenous form of infantile erysipelas. The eruption is usually preceded, for several days, by a sense of chilliness or shivering, followed by pain in the head and epigastrium, increased heat of the surface, and a frequent, feeble, irritable pulse, with great languor and fretfulness. A dull erythematous blush, or patches, sometimes of a livid hue, and slightly elevated above the sur- rounding parts, appear on various parts of the body, but chiefly on the neck, upper part of the breast, inner surface of the thighs, and the groins; a very common situation for them is behind the ears. Large, irregular vesications now quickly make their appearance; they are generally flattened on the top, and at first filled with a trans- parent fluid, which, as the vesicles enlarge rapidly in size, becomes turbid, and of a purplish hue. The vesicles are usually surrounded by an inflamed border, of a livid red colour. The fever now assumes a typhoid character, with a dry, brownish tongue, and a rapid sinking of the pulse. AArhen the vesications break, and discharge their con- tents, an ulcerated surface is left, which is extremely painful, and spreads over the surrounding surface, often Avith great rapidity. The discharge is often fetid, and large in quantity, and the edges of the ulceration acquire a livid hue. AAHien situated behind the ears, the connexion of the posterior cartilage with the cranium may be de- stroyed, the ulceration extending often to the meatus auditorius, to the 37 578 DISEASES OF CHILDREN. eyes,—the sight of which becomes destroyed,—and even to the vertex. (Stokes.) AVhen the disease occurs upon the hands, exfoliation of the bones of the fingers sometimes takes place. In other cases, vesications arise in rapid succession, on different parts of the body, followed by gangrenous ulcerations, and the patient sinks in a few days, from the pain, loss of sleep, and intense fever. Death, it is stated by Dr. Stokes, generally takes place about the tenth or twelfth day; it is often preceded by convulsions. Pemphigus may occur at any period, from a feAv days after birth to the ninth year:—it is most frequent, however, according to AVillan, within the first year. Its causes are evidently impure and confined air, neglect of domestic and personal cleanliness, deficient or unwhole- some nutriment, and the effects of cold and damp:—it is hence almost exclusively confined to the offspring of the poorest classes, among whom it often prevails epidemically. There is reason to believe, how- ever, that like infantile erysipelas, the disease is in some way connected with puerperal fever, affecting particularly the offspring of mothers who become attacked with the latter disease. It is said by Stokes to be more prevalent in summer than in winter. This, however, is contrary to our experience; the few cases we have met with—the disease being one of comparatively rare occurrence in Philadelphia and its vicinity—all occurred in the winter. The treatment of pemphigus, as it occurs in children, should be commenced by the removal of the patient, whenever it is possible, to a pure, fresh atmosphere, cleansing his skin by the use of the Avarm or tepid bath, and if there is no affection of the digestive organs present to forbid it, furnishing him with wholesome, nourishing food. If the disease is seen in its earliest stage, and tenderness of the epi- gastrium, with derangement of the bowels, is found to exist, a few leeches should be applied to the abdomen, and followed by warm fomen- tations or the application of a warm emollient cataplasm, and inter- nally, small doses of calomel, ipecacuanha, and extract of hyoscya- mus, and an occasional dose of castor oil may be given; if, at the same time, there exist muoh heat and dryness of the surface, some gentle diaphoretic will be proper, with frequent tepid sponging. R.—Acetat. ammonias, gviij. Aq. camphorae, §ij. Vin. ipecac, gj. Tine, hyoscyami, gj. Syrup, limon. gij.—M. Dose, a teaspoonful every three hours, for a child two years old. On the formation of vesications, the warm bath and fomentations of an infusion of camomile, with the sulphate of quinia internally, in con- junction with the mineral acids, if the state of the bowels will permit of their use, should be administered. If the vesications are very large, they should be punctured, and the ulcerated surface washed with a very weak solution of the nitrate of silver:—at the same time the patient should be put upon a mild, but nourishing diet. In the gangrenous or phagedenic form of the disease, an ointment prepared from the great fig-wort (Scrofularia nodosa) has, we are as- DISEASES OF THE SKIN. 579 surod by Maunsell, been found particularly successful in causing the ulcers to assume a healthy condition, and cicatrize. This remedy was introduced by Dr. Stokes, the elder, of Dublin, who found it in use among the Irish peasantry. His practice was, at first, to apply a car- rot poultice or one of porter and oatmeal: this was kept on for about eight hours; when removed, the ulcerated surface Avas gently wiped with lint, and the ointment of scrofularia, previously melted, was spread over it carefully, by means of a soft feather; the ulcer was then dressed with the ointment, to which an eighth part of wax had been added, the dressing being repeated, in severe cases, every fourth or sixth hour. Dr. Stokes also directed the internal use of yeast, which he believed to be of service. In a comparatively chronic form of pemphigus, Dr. Maunsell states that the employment of iodine has been found to be attended with the most decided benefit. 18—Purpura. A subcuticular extravasation of blood, occurring without external violence, and not disappearing upon pressure; sometimes accompanied with haemorrhage from one or other of the internal organs, and ap- pearing either with or without febrile reaction. The appearance of the skin, at the parts at which the extravasation takes place, differs in different cases; thus, the extravasation may ap- pear in the form of minute red, or violet-coloured spots, (petechia) or of patches of a ruddy violet colour, often livid, and sometimes quite black; generally of a deeper hue in the centre than at the circumfe- rence, and varying in diameter from a few lines to several inches, (ecchymoses.) Both varieties of extravasation are very generally ob- served in all cases of purpura. In some cases, purpura occurs without being preceded by any marked disturbance of health, though usually the patients exhibit for some days previous to its appearance considerable lassitude, dejection, and fretfulness, Avith indications of general debility. It is unattended throughout Vith any degree of febrile excitement. (P. simplex.) The subcuticular extravasation may consist entirely of petechia?, having some resemblance to flea-bites, but not quite so large, unsur- rounded by an areola of inflammation, and uneffaceable upon pressure; or the petechiae may be intermixed with ecchymoses—occasionally, but very rarely, the extravasation appears only in the latter form. The petechiae may occur only upon particular regions, or be disseminated over nearly the whole surface of the body; they may occur in every part at the same time, or appear successively during several days—- Avhen in place of being all of the same hue, they will vary from a red- dish-purple, or brown, to a clear or faint yellow. Petechiae occur principally upon the legs, but often appear upon the face also, in Avhich case, a number of ecchymoses are frequently seen upon the conjunctivae. The extravasations constituting P. simplex are always unattended Avith local heat or pain, or any febrile excitement, and occasionally, 580 DISEASES OF CHILDREN. without the least apparent disturbance of either of the principal func- tions of the system. Soon after their formation, the petechiae undergo a change of colour, passing from reddish-brown, through various intermediate shades, to yelloAv; and most commonly, the blood is entirely reabsorbed in twelve or fourteen days. Occasionally, as remarked by Bayer, the spots of extravasation form a slight eminence, of the size of a pin's head, caused by a minute drop of blood being effused immediately beneath the cu- ticle, which it raises. On the drying of the blood, a small dark crust is formed. AVhen the eruption of petechiae is considerable, they are sometimes, at particular parts of the surface, collected into irregular clusters. In a few very rare cases, there is observed, interspersed among the pete- chiae, a kind of marbling of a light violet colour, like the eruption in rubeola nigra. Occasionally, there are very feAv or no petechiae, but ecchymoses, in considerable numbers, are disseminated over the body and limbs, particularly over the dorsal surface of the feet and hands, and the inner surface of the extremities. They resemble often the marks left by the strokes of a whip: their colour, which is of a dark or livid blue, fading very slowly. These ecchymoses are, in some cases, suc- ceeded by an exfoliation of the cuticle, particularly when the latter has become detached by the quantity of sanguinolent serum effused beneath it. In some instances, the effusion is to so great an extent as to pro- duce bullae or phlyctenae. The blood, in certain cases, is effused into the subcutaneous and in- termuscular tissues, and then the skin commonly presents a number of broad, slightly prominent spots, dark in the centre, and of a greenish- yellow towards the circumference, and unattended with pain. Some- times the backs of the hands are affected with a species of oedema. In a few instances, the subcuticular extravasation is preceded by somewhat prominent, reddish, oval, or circular spots, accompanied by a smarting or tingling sensation, similar to, but not so decided as that of urticaria. (P. urticans.) These spots, at the end of two or three days, sink to a level with the surrounding skin, and acquire a dark- red, or liver colour; new spots at the same time making their appear- ance. They are sometimes intermixed with true petechiae. P. urti- cans occurs most frequently upon the legs, which are often at the same time oedematous, or affected with a sensation of stiffness or hea- viness. The eruption generally continues for a month, but may be of longer duration. Immediately after the disappearance of the petechiae and ecchy- moses, in cases of P. simplex, they in some cases return suddenly, in a single night. These haemorrhagic phenomena may be repeated se- veral times at very short intervals, prolonging the duration of the disease to several months. AVhen P. simplex presents itself under the form of ecchymoses, it is generally a more serious disease than when it appears under the petechial form; the P. urticans is the least important of all the forms of the disease. A much more serious form of purpura is that accompanied with DISEASES OF THE SKIN. 581 haemorrhage. The body is often covered with livid spots, similar to those that follow bruises; actual thrombus occasionally forms under the hairy scalp, and the blood has even been seen exuding from behind the ears, and from the vertex; the subcuticular and cutaneous effusion covering nearly the whole surface. The disposition to haemorrhage in some patients is so great that the mere act of feeling the pulse, the pressure of a loose ligature, or the weight of the body in sitting, leaning, or lying down, is sufficient to cause actual ecchymoses. In such cases, the slightest puncture, the mere grazing of the skin, is followed by a copious and continued dis- charge of blood; and most commonly, either from the commencement, or in the course of the disease, haemorrhages occur, to a greater or less extent, from the nose, bowels, stomach, or lungs. P. hemorrha- gica. In some of these cases, the Avhole of the fauces are of a dark- red colour, and blood issues from every part of them. P. haemorrha- gica is sometimes, according to Rayer, complicated with angina mem- branacea; occasionally, the gums are livid and spongy, and blood exudes from their surface; the tongue is swollen, livid, and blackish; the inner surface of the cheeks presents some blackish and soft patches, with which the palate is also covered. On all these parts, irregular phlyctenae, or bullae appear, filled with dark-coloured blood; Avhen these burst, a discharge of blood takes place from the excoriated sur- face ; deeper ulceration sometimes occurs, with haemorrhage to a much greater extent. Children have been known to die in a single night, from the haemorrhage, in such cases. When, in P. haemorrhagica, the discharge of blood is very consider- able, or recurs frequently, the feet and legs become oedematous, the face blanched, and the surface of the body, generally, of a yellowish, or livid hue; the petechiae and ecchymoses increase in number, and acquire a deep brown tint; the blood becomes more and more serous; the temperature of the body, but particularly of the extremities, sinks, the pulse becomes small and feeble, and the strength of the patient completely prostrated. Convulsive movements, tremors of the whole body, or fainting fits, sometimes occur. The patient finally dies ex- sanguine, unless febrile symptoms, or serious internal disease, should ensue previously to death. Purpura is occasionally accompanied by febrile reaction. P. febri- lis. The occurrence of petechiae and ecchymoses, in this form of the disease, is preceded by a sense of extreme lassitude and depression, and hy shivering fits, of longer or shorter duration, succeeded by in- creased heat of the skin, pains in the back and limbs, headache, quick- ness of pulse, nausea, retching, or vomiting. The subcuticular extra- vasations appear betAveen the third and sixth days, sometimes with haemorrhage from the mucous membranes, and at' others, preceded by exanthematous spots, similar to those of urticaria febrilis. Febrile purpura may appear under the form of ecchymoses. In some cases, it is attended with haemorrhage from the nose, throat, stomach, in- testines, flabby, and repeatedly covered with a thick tenacious mucus, or uniformly red, or maculated: In many instances the child exhibits early symptoms of intelli- gence, but is more often dull, heavy, and stupid. As the child advances in years, the throat, fauces, and tonsils ex- hibit symptoms of disease. The latter, especially from slight attacks of inflammation, become greatly swollen, and of a raggedy uneven shape, and often remain permanently enlarged for a considerable length of time, though seldom very painful; the only inconvenience resulting from the enlargement being an impediment to the freedom of respiration, particularly when the child is asleep, some slight diffi- culty in swallowing, a dulness of hearing, and a peculiar intonation of the voice in speaking. The eyes are often the seat of slow in- flammation ; the edges of the eyelids are affected with chronic dis- ease, increased exudation from the follicles, stye, &c. The glands of the neck become enlarged, and after remaining long in an indolent state, frequently inflame, suppurate, and give rise to ulcerations, sIoav in healing, and which often leave fistulous openings, from which a thin discharge takes place, for many months, or even years. The term scrofula has generally been restricted to a chronic en- largement of the lymphatic glands, terminating finally in their inflam- mation, and a species of imperfect suppuration, forming abscesses filled with a pale, whey-like fluid, that gradually becomes thicker, of a yellowish colour, and intermixed with portions of curd-like mat- ter. When the abscess is opened or ruptures, it gives rise to an ir- regular, ragged ulcer, in which large, spongy granulations slowly form, of different heights at the different parts of the ulcerated sur- face, and when cicatrization finally takes place, an uneven, puckered, and'often deep, indelible scar is left. The swelling of the lymphatic glands may be detected when they are no larger than a pea. They are then, hard, movable, and with- out pain or even tenderness when touched or handled. They often continue, for a great length of time, without increase, forming a chain of small tumours, extending from ear to ear. Occasionally, one of the salivary glands, or the thyroid body becomes affected. V, hen the glands commence to augment in size, the progress of the swelling is, generally, extremely slow, and often months or years elapse, be- fore the skin over the tumour inflames. Occasionally, the swelling subsides before this takes place; but, in general, it has a tendency to soften, forming a species of encysted tumour filled Avith a whey* like or curdy fluid. Even at this stage, absorption will sometimes take place, and the swelling disappear. Usually, however, suppura- tion proceeds slowly; the Avhole structure of the diseased gland be- comes destroyed, and a large abscess is formed, that finally bursts, forming an ulcer, varying in size, with indurated edges, and uneven surface from which is discharged a thin watery fluid, mixed with DISEASES OF THE NUTRITIVE FUNCTION. 597 flakes of curdy matter, and occasionally small masses of a tubercu- lous appearance. In other cases, the diseased gland is less uniformly softened, and becomes converted into a curd-like substance, intermixed with a softer, less opaque matter, of a light yellow colour, with a small col- lection of pus near its centre. Sometimes a number of small ab- scesses occur in the body of the diseased gland, each filled with curdy matter. The gland finally becomes a large abscess. Inflam- mation subsequently attacks the tissues surrounding the gland; which latter is eventually entirely destroyed by suppuration;—suppuration sometimes taking place around the new-formed matter within the gland. The gland may continue, hoAvever, for a number of years in a diseased state, without suppuration taking place. The scrofulous ulcer is ahvays slow and difficult to heal; it may often remain open for months; or it may heal in one part and extend in another. AVhen cicatrization does take place, it is irregular, puckered, often crossed by projecting bands, and of a peculiar white, unhealthy colour. The intumescence of the glands is frequently the effect of expo- sure to cold, or occurs in conjunction with more or less disease of the digestive organs. It is sometimes connected with cutaneous erup- tions about the head and face; but occasionally comes on without any very evident exciting cause. It is generally confined to the glands about the neck, though the lymphatic glands of the axilla and groin may become diseased in the same manner. We have seen well-marked-scrofulous disease of the axillary glands, but have never met Avith a case in which those of the groin were affected. Scrofulous disease of the glands of the neck most commonly occurs after the fourth year; it may occur,however, much earlier; we have seen it previously to the first year, and repeatedly between the second and fourth. It seldom, however, tends to suppuration in children under two years of age. AVhen the disease occurs in this form, uncon- nected with any serious affection of the internal organs, though tedious and troublesome, and often resulting in very considerable deformity, it is seldom, if ever, fatal. It has even been proposed, in cases in which a tendency to tuberculous depositions in the lungs presents itself, to overcome this by exciting disease in one of the glands of the neck, by the insertion of vaccine matter in numerous points over the gland; and instances are related, by the late Dr. Parrish, of Philadelphia, of the presumed successful result of this procedure. Scrofulous Ophthalmia.—Inflammation of the eye is a very common affection in children of a strongly-marked lymphatic tempe- rament ; and is often the first indication which presents itself of the scrofulous predisposition. Very generally, the edges of the eyelids are first affected with a degree of soreness, and soon become red and slightly thickened; the secretion from their follicles is increased, and drying during sleep, causes the lids to become agglutinated. Upon everting the eyelids, their inner surface is found to be somewhat reddened, and a feAv red 598 diseases of children. vessels are observed upon the globe of the eye. The redness of the conjunctiva is at first slight, and, in many cases, confined entirely to the lids. There is generally, however, an abundant secretion of the tears, and very great intolerance of light, so that the patient cannot be persuaded to raise his eyes to the light, but walks with the face inclined doAvnwards, and often shades the eyes Avith the hands. This intolerance of light is usually most severe in the early part of the day; in the afternoon it -will, occasionally, so far remit as to permit the patient to open his eyes. The presence^ of daylight, as Taylor remarks, would appear to produce a spasmodic action of the orbicularis muscles, so that even when the child is willing, he is un- able to unclose the eyelids during daylight; or, if he does succeed, by a kind of convulsive effort, the cornea is immediately rolled up- ward beneath the margin of the tarsus, so as to be completely hid from view. As the disease augments, the redness of the conjunctiva increases in extent and intensity. In the commencement, the disease is not attended with much pain; though, occasionally, severe pain is experienced during the night, by which sleep is often broken or prevented. In some cases, the vessels running from the conjunctiva to the cornea are somewhat in- jected, whilst in other cases, several enlarged vessels are perceived: the redness of the conjunctiva of the eye itself is, however, not usu- ally very strongly marked. In recent and acute cases^ an effusion of serum sometimes occurs beneath tb,e conjunctiva immediately around the cornea, forming an elevated oedematous circle, of a pecu- liar reddish-brown appearance, and about a line or more in thickness. In all cases of true scrofulous ophthalmia, there exists a strong dis- position to the formation of pustules, which appear upon many points of the eyelids, and along the edge of the tarsus, and often produce ulcerations, attended with considerable irritation. The skin imme- diately beneath the eye is also very commonly inflamed and covered with a minute pustular eruption. In the majority of cases, small vesicles or pustules appear upon the conjunctiva and cornea. They vary in number and size,_ but are generally smaller upon the cornea; at the same time, a pencil of red vessels is often developed on the latter. The vesicles or pustules, upon rupturing, form small, round, superficial, or funnel-shaped ul- cers. The vesicles or pustules, may be absorbed previously to burst- ing, and then they leave, in the cornea, a slight degree of cloudiness, which disappears in time. Sometimes, upon the removal of this, a transparent dimple remains, which is long in filling up. In some cases, the cloudiness spreads over the cornea, and large red vessels run into it, forming a vascular speck, which is always a very tedious and troublesome symptom. Occasionally, a general cloudiness or a permanent opacity of the cornea may also be produced. Dr. Maunsell describes the ulceration of the cornea as sometimes presenting an appearance, as if a small portion of its conjunctival layer had been removed by a sharp chisel, leaving a distinct facet, sometimes level, and in other instances concave: this condition may remain unaltered for a considerable length of time, and is unattended DISEASES OF THE NUTRITIVE FUNCTION. 599 with opacity of the cornea. We have met with this form of ulcera- tion in many cases. The ulcers of the cornea, particularly when superficial, often cica- trize, leaving an opaque, permanent cicatrix, which may become les- sened in time, but never entirely obliterated. When the ulcerations arc of some depth, they are often attended with considerable irrita- tion and pain upon every motion of the eyelids. They sometimes penetrate entirely through the cornea,?and a protrusion of the mem- brane of the aqueous humour takes place, in the form of a small vesi- cle: when this gives way, the aqueous humour escapes, the iris is prolapsed, and a dense, opaque cicatrix is the result; or the ulcer may at once penetrate the anterior chamber, with a similar result. When the ulceration of the cornea is of considerable size, and the iris extensively prolapsed, the pseudo-cornea which forms over the protruded portion of the iris, sometimes give way before the pressure of the humours, forming a partial staphyloma. A general protrusion of the whole cornea may take place from the same cause, when its texture has become Aveakened by inflammation, and the iris is adhe- rent to its posterior surface. The transparency of the cornea may also be impaired by a ramification of red vessels, forming a vascular netAvork in its conjunctival layer. The inflammation may be propagated from the cornea to the scle- rotica and iris, or even to the more deeply-seated structures of the eye, producing extensive disorganization of the interior of the globe, par- ticularly when the disease is of long standing, or has repeatedly re- curred. Hydrophthalmia may be induced by increased secretion of the humours; or, occasionally, the eye may become atrophied, appa- rently from interrupted nutrition. Scrofulous iritis is generally of a chronic form, and unattended with symptoms of any severity: it may, in the course of time, extend to, and cause disorganization of the surrounding tissues, terminating in amaurosis and atrophy of the globe. Scrofulous ophthalmia occasionally assumes a much milder form. Its principal feature is the occurrence of pustules upon the conjunc- tiva, usually a line or tAvo from the margin of the cornea. (Pustular ophthalmia.) The pustules are generally of considerable size, and filled with an opaque, yellow matter: they are accompanied with a fascicular injection of the conjunctiva in their immediate vicinity. Occasionally, the injection of the conjunctiva is more diffused, and accompanied Avith ecchymosis. On the pustules bursting, they form broad, elevated ulcers, which, after a time, cicatrize. There is little or no intolerance of light, and an entire absence of the spasmodic contraction of the lids observed in the ordinary form of scrofulous ophthalmia; and the transparent textures of the eye are unaffected. It is eften combined with catarrhal conjunctivitis. This form of ophthalmia is, according to our experience, of much more common occurrence, than the more violent one described above. The local disease is generally attended with some degree of febrile reaction—a fretful and irritable temper, and a disordered condition of the alimentary canal. Frequently, the abdomen is tumid and tense, 600 DISEASES OF CHILDREN. the breath very offensive, and the alvine discharges of an unnatural appearance. When the case is one of long continuance, there is con- siderable emaciation, particularly of the extremities, "with a general manifestation of feebleness and irritability. Scrofulous ophthalmia is frequently preceded by eruptive affections of the head and face, and ulcerations behind the ears, Avhich disap- pear soon after the inflammation of the eye is fully developed. AY ben associated Avith these eruptive affections, the disease has been de- scribed by AVardrop and Christian, as exanthematous, or porriginous ophthalmia. Scrofulous ophthalmia usually attacks both eyes, though seldom in an equal degree; or the disease may occur, first in one eye, and then extend to the other; or, it may attack the two eyes alternately. The disease most generally occurs during childhood, rarely in adults, and never, unless they have previously suffered from it. The most common period for its attack is between the first and fourteenth years of life. It is produced by the usual causes of ophthalmia—cold, irritating vapours, or other substances admitted into the eye. It frequently occurs, also, about the period of dentition, or subsequently to an at- tack of one or other of the febrile exanthemata. Scrofulous Otitis.—This is a very common affection during child- hood. The inflammation may be confined to the lining membrane of the external meatus, when it very generally assumes a chronic form. The inflamed membrane becomes, sooner or later, studded Avith mi- nute pustules, upon the rupture of Avhich, ulcers form, and give dis- charge to thin, unhealthy, and often very fetid pus. The discharge from the ear usually continues for a great length of time, and the lining membrane of the meatus very frequently assumes a thick, spongy, and highly irritable condition, and presents an appearance as though it were covered with a kind of curdy exudation. In other cases, the discharge ceases for a longer or shorter period, and then again suddenly recurs. Sometimes the suppression of the discharge is followed by scrofulous ophthalmia, porriginous eruptions upon the scalp, intumescence of the glands of the neck, &c. The disease may cause finally a destruction of the membrana tympani, and of the os- sicula of the ear, and thus occasion permanent deafness. In other cases, the inflammation affects the deep-seated structure of the ear; or this may become affected in consequence of the exten- sion of the disease from the external meatus. This form of otitis is attended with more or less dull pain, which often extends over the side of the head, alternating, occasionally, with very severe paroxysms of more acute suffering; with deafness, singing, humming or other noises in the ear; disturbed sleep, fretfulness, and irritability of tem- per, and, occasionally, Avith some degree of febrile reaction. AVhen a discharge takes place, it is of a thin, grayish, dirty-coloured fluid, often more or less sanguinolent, and exhaling a peculiar, but, gene- rally, very fetid odour. It is often acrid, and causes irritation, and more' or less swelling, of the lobe of the ear, and of such parts of the skin as it comes in contact with. In the progress of the disease, the DISEASES OF THE NUTRITIVE FUNCTION. 601 discharge from the ear will occasionally contain small fragments of carious bone. The mastoid cells are very often affected in cases of scrofulous otitis. AVhen this occurs, a dull pain is felt over the mastoid process, which , is tender upon pressure;—the skin covering this part becomes red- dened, slightly swollen, and an accumulation of matter takes place beneath it. After a time, the skin assumes a more dusky or violet hue, becomes gradually more and more thin, and, finally, ulcerates, giving discharge to a fluid similar to that from the ear. The cellular structure of the mastoid process is now found to be destroyed, to a greater or less extent, and infiltrated with matter, while a fistulous communication is formed between the external surface and the cavity of the tympanum. Occasionally the matter travels dowmvards, be- tween the muscles attached to the mastoid process, and opens low doAvn in the neck. In other cases, the whole cellular structure of the mastoid process becomes disorganized and broken down, and is discharged from the external meatus, mixed Avith a sanious fluid, and the mastoid projection disappears Avithout the skin becoming affected. In other cases, again, the pus and disorganized matter of the cells, find their way from the mastoid process through the Eustachian tube; —the arrival of the matter in the fauces being attended with cough- ing and expectoration, a nauseous, disgusting taste, loss of appetite, and occasionally vomiting. In some cases, the mastoid process is en- larged, and converted into a soft, homogeneous mass, readily cut, like cheese, with a knife. The petrous portion of the temporal bone is occasionally affected. In some instances, the facial nerve is involved in the disease, and acute pains in the ears are experienced, with spasmodic contractions of the muscles of the face, on the side affected, terminating, finally, in paralysis. Several cases of this kind are noticed by Lallemand, Berard, and others, and we had one under our care, in Avhich, besides paralysis of the muscles of the left side of the face, there was a loss of the power of articulating. In this case, Avhich was in a boy seven years of age, the otitis occurred subsequent to a severe attack of scarlet fever. In many instances, the disease of the petrous portion of the temporal bone involves the brain, and various symptoms of cerebral disease are produced. One or two cases are referred to by Lallemand, in which the dis- ease extended to the occipital bone and involved the first two cervical vertebrae. Caries of the bones, at the basis of the cranium, has like- wise been observed by Krukenberg. Scrofulous otitis is, most generally, a disease of childhood; it com- monly affects but one ear, though Ave have seen a feAv cases in which it occurred simultaneously in both. It may be produced by any of the ordinary causes of inflammation. It is frequently observed about the period of dentition; and, in a large number of instances, subse- quent to attacks of one or other of the acute exanthemata. The dis- ease is frequently preceded by ulcerations behind the ears, erysipelas of the face, porriginous eruptions about the head and face, and, as these frequently disappear when the inflammation of the ear takes 602 DISEASES OF CHILDREN. place, it has been generally attributed to their being suddenly dried up or repelled—in most instances, however, as Krukenbergvery justlv remarks, Avith very little foundation. Scrofulous otitis is frequently accompanied by more or less febrile reaction, and by the same disordered condition of the alimentary canal, noticed when treating of scrofulous ophthalmia. Discharges from the Vagina.—These not unfrequently take place in female children, even at an early period of infancy, and, occa- sionally, about the fifth year. They result from a subacute inflam- mation of the mucous membrane within the labia, and are, in many cases, attended with aphthous ulceration. The matter discharged is various in its character, being often a thin sanious fluid, containing small flocculi, of a curdy appearance: not unfrequently, hoAvever, the discharge is of a thicker, more opaque, somewhat purulent appear- ance, and is often so acrid as to produce redness and irritation, and a slight pustular eruption of those portions of the skin with which it comes in contact. The discharge is sometimes very slight. This affection has been repeatedly mistaken for gonorrhoea, com- municated by infection from the parents; or, in older children,—for the disease, when neglected, may even continue, according to Dewees, up to puberty—it is apt to give rise to' suspicions of a very grave character, which the physician is occasionally called upon, by his professional opinion, to remove. The true nature of the affection is, in most cases, rendered evident, by the patient labouring, at the same time, under other decidedly scrofulous symptoms, or which indicate a very strong predisposition to affections of that character. A very striking case is related by Dr. Ferriar, which shows the importance, in a medico-legal point of view, of a correct knowledge of the nature of this affection. The disease just described is a very different one from that noticed by Boivin, Duges, Kinderwood, Mackintosh, and others, as affecting the labia of female children, and terminating most commonly in gan- grene. Tabes Mesenterica.—Scrofulous disease of the mesenteric glands. The glands of the mesentery are said to be, after those of the neck, the most common seat of scrofulous disease. From the frequency with which, in those predisposed to scrofula, subacute or chronic in- flammation of the alimentary mucous membrane occurs, there can be no doubt that disease of the mesenteric glands is a very common in- dication of such predisposition. The error committed by most pa- thologists, until a very late period, has been, in attributing to the diseased condition of these glands the entire chain of symptoms by which it is preceded and accompanied; when the affection of the glands is probably, in the majority of instances, the consequence of gastro-intestinal irritation. Contrary, however, to the generally received opinion, Rilliet and Barthez do not consider tuberculization of the mesenteric glands to be a frequent affection of the first period of childhood. It occurred to a considerable extent in only about one-seventh of the cases where the mesenteric glands were-affected, and in only about one-sixteenth diseases of the nutritive function. 603 of all the children who presented tubercles in other parts of the body. In but one-half the cases of tuberculous children, the mesenteric glands were found affected, and then only slightly. Rilliet and Barthez state that the disease scarcely ever attacks children under three years of age—that it is slighter the younger the child is, and that it reaches its maximum of development between five and ten years, after which it is very rare. The reason why it has been generally considered so frequent among children, is, they conceive, because other diseases,- as tuberculous peritonitis, enteritis, &c., have been mistaken for it. The most common characteristic of tuberculization of the mesen- teric glands is prominence of the abdomen, with emaciation, particu- larly of the limbs. Its only certain diagnostic, however, is the per- ception of the enlarged glands, by manual examination, through the parietes of the abdomen. It may, however, be suspected whenever chronic disease of the alimentary canal occurs in children of a strongly marked lymphatic temperament, especially if such disease becomes at- tended in its course with a fulness and irregular hardness of the abdomen. The glands exhibit, in the various stages of the disease, nearly the same changes that occur in scrofulous glands of other parts; in some cases, being simply increased in size and density, in others, enlarged, reddened, and softer than natural; while in others again, their texture is changed, and they become filled with a soft, white, curdy matter, sometimes mixed with a purulent fluid. AVhen the disease is pro- tracted, the patient generally dies in a state of complete marasmus; and, not unfrequently, tuberculous depositions are found in the lungs and other organs. Scrofulous Disease of the Bones.—In that condition of the sys- tem, which during childhood predisposes to the occurrence of scrofu- lous affections, the bones are always sloAvin attaining the firmness of ossification which is necessary to fit them for their respective offices. There is, in fact, a deficiency of the phosphate of lime throughout the entire osseous system. This deficiency has been referred to a want of sufficient energy in the circulation, which may undoubtedly con- cur, to a certain extent, in producing the retardation of the ossific process: the true cause of the latter, however, is to be sought for in some deficiency in the healthy constitution of the blood, and in an abnormal state of the nutritive process generally. The bones not being possessed of sufficient firmness, become bent and distorted by the action of the muscles, the Aveight of the body, or the pressure of the ordinary clothing. Those of the extremities are curved, often to a very great extent; the pelvis becomes narrowed by the lateral pressure of the heads of the thigh bones; the spine is curved in one or other direction, diminishing permanently the height of the body, and causing very considerable and serious deformity. The scapulae become prominent and projecting, and the shoulders so far thrown upwards, as to giA-e an appearance as though the head had sunk between them; the ribs become flattened, or unnaturally curved, sometimes on both sides, but more generally to a greater extent on one side than on the other. The anterior part of the chest is projected 604 diseases of children. forwards, and the sternum forms a prominent ridge, or it is sunk be- tween the cartilages of the ribs, the anterior curvature of the latter forming a ridge on one or both sides of it. The head is often greatly enlarged, and the sutures and fontanelles remain long unconsolidated. The chin is usually prominent, and the sides of tho face flattened. The heads of the bones are large, and unusually spongy, and the joints loose, and destitute of firmness. Dentition is long in taking place, and when it commences is slow and protracted, and the teeth soon decay. There is generally great and progressive emaciation, from diminished nutrition of the soft parts, and, in many cases, tho softened state of the bones is accompanied by a diseased Condition of the glands of the neck and of the mesentery, and it seldom exists long without some part of the bony structure—either the spine, the knee, or hip-joint—becoming the seat of disorganization; or Avithout tuber- culous depositions occurring in the brain or lungs. The phenomena now described constitute the affection knoAvn by the name of rachi- tis or rickets, which is fortunately one of comparatively rare occur- rence in this country. AVhen death does not take place during infancy, but the bones be- come more firmly ossified, and the patient attains to adult, or, as is occasionally the case, advanced age, his body is generally perma- nently deformed, and often crippled, if disease do not occur to add to the deformity positive suffering. The subjects of rickets, to Avhat- ever age they may attain, have always debilitated frames, and are constantly liable to the occurrence of convulsions, or tubercular af- fections, particularly of the lungs. In the female, contortion of the pelvis may give rise to tedious or difficult labour, or it may render the birth of the child impossible. Independently of the defective ossification of the bones, in children predisposed to scrofulous disease, their structure is peculiarly liable to become the seat of a morbid action, by which portions of them arc often completely disorganized. The spongy bones, as well as the spongy heads and extremities of the long bones, are especially the seat of this process of disease. There is, at first, increased vascularity of the bony structure, with a diminution of the earthy constituents; the cancelli become filled with a transparent fluid, which is subsequently replaced by the de- posit of a cheese-like matter. The morbid change often commences at the centre of the bone, the exterior remaining unaffected. In ge- neral, however, the affected bone becomes softer and more spongy, the cartilage is either detached entire, and becomes gradually soft- ened, or it is detached slowly, and in layers, or irregularly absorbed. A portion of the diseased bone sometimes exfoliates; and sometimes the disease extends to the shaft of the cylindrical bones, so as to con- vert them into a thin shell of earthy matter, the whole interior structure being disorganized. In the progress of the disease, inflammation, generally of a sub- acute character, takes place in the cellular membrane surrounding the affected joint, with the effusion, at first of serum, and afterwards of coagulable lymph; causing a puffy, elastic swelling, which becomes, DISEASES of the nutritive function. 605 subsequently, oedematous. The ligaments and synovial membrane are finally involved in the disease, and an external opening, or seve- ral openings taking place, a discharge of matter occurs, and nume- rous circuitous sinuses extend from the cavity of the joint into the neighbouring cellular tissue. AVhite Swelling.—When the affection of the bones we have just described occurs at the joint of the knee, ankle, elbow, or wrist, it constitutes the disease denominated white swelling. The first symp- tom is usually a weakness of the joint; this is succeeded by a dull, heaA-y pain, which is generally increased by the motion of the joint, and sometimes Avhen the patient is warm in bed. In the commence- ment the pain is often very slight, though occasionally of considera- ble severity. It is very uniformly referred to the centre of the ar- ticulation. The pain in many cases is continued, in others irregu- larly intermittent, and in others again, someAvhat periodical. There is, at first, very little or no swelling of the joint; sooner or later, however, more or less fulness is perceived, Avhich gradually increasing, causes the joint, in time, to acquire a very considerable magnitude. The swelling, at first, sometimes yields slightly to pres- sure, but never pits, and is always sufficiently firm to lead the inex- perienced to suppose that it is produced by an enlargement of the ends of the bones. The enlargement of the joint appears greater than it really is, in consequence of the emaciation of the limb above and below. The skin enveloping the diseased articulation" is not changed in colour, but becomes tense, smooth, and transparent, the veins being visible beneath it. The pain is now generally increased, though it may still be comparatively trifling, amounting, in many in- stances, rather to a sense of uneasiness than of actual pain. AVhen the swelling is seated in one of the lower extremities, the child is observed to limp occasionally. As the disease increases, the patient is unable to bear his weight upon the affected limb, in conse- quence of the great increase of pain which it occasions; he conse- quently acquires the habit of touching the ground with the points of the toes only, and the knee being thus kept constantly bent, soon loses the power of being fully extended. A collection of matter finally forms about the joint. The pain now usually becomes more severe and continued, and the skin more tense, and of a darker, and finally purplish colour. Suppuration proceeds very slowly, and when, at length, the matter reaches the surface, one or more, generally several, openings are formed, which give discharge to a thin, serous pus, with portions of curdy matter floating in it: as the discharge decreases in quantity, it becomes thicker, and ultimately assumes the same appearance as the matter found in scrofulous glands. Sometimes sinuses are formed, and the matter is discharged at a distance from the joint. From these openings, not unfrequently, small pieces of bone escape. Occasionally, abscesses form around the affected joint within a few months from the invasion of the disease, while, on the other hand, the disease may continue for many years, without the occurrence of suppuration. 606 DISEASES of children. The openings sometimes heal up very speedily, but other collec- tions of matter generally form, and new openings take place, and this may continue to occur for a long period. Disease of the bones may exist for many months, and even longer, without the occurrence of other than the local phenomena described. But, Arery generally, hectic fever, with profuse night sweats, and col- liquative diarrhoea, sooner or later ensue, under which the patient speedily sinks. In some cases, however, the diseased action in the bony structure is arrested, .a curative action results, and the patient recovers with anchylosis of the joint. Unless the disease is arrested in its first stages, the cure is always difficult and tedious, and the mo- tion of the joint is invariably lost. When the bones of the carpus or tarsus are the seat of the disease, it is always more difficult to manage, from the facility with which the disease extends from one to the other of the small bones of these parts. Very often, white swelling is accompanied with a scrofulous affec- tion of the glands of the neck, and frequently, when the knee-joint is the seat of the disease, enlargement of the lymphatic glands in the groin occurs; the latter affection, however, is seldom very trouble- some. The disease may occur without any very evident exciting cause, but is generally attributable to the effects of cold or damp, to vio- lence, or to over-exertion of the joint. Hip Disease.—Morbus Coxarius.—When the disease of the bones is seated at the hip joint, the symptoms to which it gives rise are, in the earlier stages, extremely obscure, and very apt to mislead the inexperienced physician in regard to the real nature of the case. The first thing that usually attracts attention is a slight limp in the gait of the child. More or less uneasiness, scarcely amounting to pain, is soon experienced by the patient, but this is almost inva- riably referred to the knee, the hip being seldom complained of:—in many cases, however, there is a fixed pain behind the great trochan- ter, and in others, the patients complain of a painful sensation in the oroin, shooting down, in the course of the vastus externus, to the knee. 3 From an early period, the limb on the affected side becomes ema- ciated, and very decidedly diminishes in diameter. The natural ful- ness and convexity of the nates become diminished, and that part which is usually most prominent soon becomes flattened. Pressure on the front of the hip joint, a little on the outside of the femoral ar- tery, below the pubis, will give rise to severe pain. The motion of the joint is evidently impeded; extension is performed with difficulty, and the heel of the diseased limb scarcely rests upon the ground; there is, also, great difficulty in flexion; hence, when the child attempts to stoop, he bends only the knee. If desired to raise his foot upon a chair, the effort is so painful that he cannot accomplish the movement; while the rotation of the joint, especially inwards, is impeded, and cannot be accomplished without great pain. In consequence of the weight of the body being chiefly supported upon the sound limb, the pelvis is thrown doAvnwards upon the affected side, so as to give to the limb on this side an appearance of increased DISEASES OF THE NUTRITIVE FUNCTION. 607 length. If the patient be placed upon his back, and a line drawn from the spinous process of one ilium to that of the other, there will be found to exist a difference of an inch or more between the height of the two. The patient soon acquires the habit of throwing the entire weight of the body upon the sound limb, while the thigh of the affected side is bent somewhat forwards, and the knee flexed, so that only the toes come in contact with the ground. This position is found to be the most eomfortable, and every attempt to extend the limb is attend- ed with considerable pain. In some cases, the parts surrounding the diseased joint become somewhat swollen, tense, and extremely painful, and occasionally the skin is reddened, and severe febrile reaction occurs; a circumscribed tumour forms in the vicinity of the joint, a fluctuation of fluid is per- ceived, the skin bursts, and a discharge of matter takes place. More generally, suppuration within the cavity of the joint occurs slowly; the pain becomes less intense, but more continued; a thicken- ing of the capsular ligament and synovial membrane gradually takes place; the articular cartilages are, to a greater or less extent, de- stroyed; the round ligament becomes detached from the head of the femur, which is finally pushed out of the articular cavity, until it passes beyond the acetabulum, and lodges upon the dorsum of the ilium, the foramen ovale, or the ramus of the pubis. The two latter modes of luxation are, however, extremely rare;—the dislocation being, in ge- neral, upwards and outwards; the affected limb is consequently short- ened, the toes are turned inwards, the great trochanter is approxi- mated to the crest of the ilium, and the leg is in a state of flexion. AVhen shortening of the limb results from destruction of the head and neck of the bone, the toes are turned outwards, while the limb may remain parallel with the trunk. Dislocation of the femur may occur, and the disease terminate in anchylosis, long before any suppuration takes place in the parts sur- rounding the joint. Very frequently, however, abscesses form, and the matter travels, generally, down the thigh, between the trochan- ters and integuments, but, in other cases, in the direction of the fe- moral artery, and by its pressure may occasion the absorption of a considerable portion of the vessel. When these abscesses burst ex- ternally, they continue, in general, to discharge, for a considerable time, an unhealthy, thin, purulent matter, often mixed with curdy flakes. After it has existed for some time, the disease of the hip is very generally attended with hectic symptoms, and considerable emaciation. In some patients these symptoms occur at an early period; in others, hoAvever, not until late, or only in very protracted cases of the disease. Sometimes before the head of the bone is dislocated, it is partly absorbed; at other times it remains entire. In the dissections that have been made, at an early period of the attack, inflammation of the head of the thigh bone, with slight thick- ening of the capsular ligament, has been observed. A small quantity of matter has been found in the cavity of the joint, and slight erosions 608 DISEASES OF CHILDREN. of the articular cartilage lining the acetabulum, with disease of the innominata. In more protracted cases, the parts surrounding the joint contain a quantity of adhesive matter, with destruction of the cartilages and ligaments of the articulation; the bony structure com- posing the acetabulum being extensively diseased, and in part ab- sorbed, as well as the head and neck of the femoris. In general, some surgeons say invariably, the bones of the pelvis exhibit more extensive marks of disease than the head of the thigh bone. In many cases the disease appears to occur, as it were, spontane- ously; in others it is brought on by external violence, cold and damp, or too long-continued, or violent exercise of the joint. Disease of the Spine.—When the bones of the spine become the seat of scrofulous disease, the child becomes languid, listless, disin- clined to play or move about, and is quickly tired when he attempts it. He frequently trips and stumbles, and when he moves hastily or unguardedly, his legs cross each other involuntarily, and he is thus often suddenly thrown down. If he endeavour to stand by himself, still and upright, his knees totter under him. He cannot, with any de- gree of precision or certainty, direct either of his feet to any particular point, but in attempting to do so, one will be brought across the other. He soon begins to complain of frequent pains and twitchings in the thio-hs, particularly when in bed, and of an uneasy sensation at the pit of the stomach. AVhen he sits upon a chair, his legs are almost invariably drawn across each other, and up under the seat; finally, the child loses entirely the power of walking. If the disease be in one or more of the cervical vertebrae, the child finds it inconvenient and painful to support his head erect, and is desirous of leaning it on a table or pillow. If seated in the dorsal vertebrae, there is often a dry, hard cough, laborious respiration, and the early occurrence of hectic symptoms; and frequently the arms are affected with spasmodic twitchings, involuntary contractions, and finally, entire loss of motion. AVhen the lumbar vertebrae are affected there is often difficulty in voiding the urine, and the faeces will at length be discharged involuntarily. In some cases, the loss of motion m the lower extremities is com- plete; in other cases, the patients are able to. move about with the aid of crutches, or by grasping the thighs just above the knees, with both hands; some patients can sit in an arm-chair, without mucn trouble or fatigue; others cannot sit up at all. The first indication of the disease is, very generally, when the pa- tient is old enough to describe his feelings a fixed pain in some part of the spine, extending in the direction of the nerves which arise from the affected portion. There is, at the same time a sense of weakne- in the back, and pain in the sides, more marked in one than in the other. Sooner or later there takes place a destruction of the bodies of one or more of the vertebrae, producing an incurvation ol the spinal column forwards, and a corresponding projection backwards. A wasting of the muscles of the back very generally precede* the soinal curvature, which is evinced by the child's head being inclined forwards more than natural, by one shoulder being raised above the DISEASESOFTHE NUTRITIVE FUNCTION. 609 other, and by a disposition to lean or recline, when sitting down. This, however, is much more common in cases of lateral curvature, in which the bones are not primarily affected Avith disease, but Avhich results, in the majority of instances, from a want of power in the muscles inserted in the spine, than in angular curvature, which is invariably dependent upon the destruction of the bodies of one or more of the vertebrae. We have occasionally noticed, however, this wasting of the dorsal muscles to take place early, in cases of the latter. The lateral curvature may, and often does, occur in children predis- posed to scrofula, from defective nutrition of the muscles, and is not connected, necessarily, with scrofulous disease of the bony structure of the spine. The spinal cord becomes incurvated with the vertebrae, and sub- jected to more or less pressure, from which there results, in the pro- gress of the disease, irritation and inflammation of the spinal nerves, chronic inflammation of the membranes of the cord, and occasionally of the cord itself. In some cases, the cord becomes so much com- pressed as to deprive the parts which receive nerves from below the point at which the pressure exists, almost entirely of motion and sensation. The natural cure of the disease of the spinal structure is by anchy- losis, produced by the deposition of osseous matter, so as to attach together the surfaces of sound bone, which are brought into contact. Caries of the spine is very frequently the cause of psoas and lum- bar abscess. The danger of the disease will depend, in a great measure, upon its extent, and the nature of its complications, and the period at which the treatment is commenced. Where only one or two of the vertebrae are affected, and the dis- ease is placed under proper tnedical care in its early stages, a cure may, in many instances, be effected, and little or no deformity remain. AVhen several of the vertebrae are involved in disease, even though a cure should be effected, very extensive deformity will nevertheless be the consequence, rendering the patient, perhaps, a cripple for life. In those cases in which the disease of the spine is complicated with tubercular disease of the lungs, or with psoas or lumbar abscess, the event is generally sooner or later fatal. Tubercular Depositions.—Under precisely the same circumstances as produce a predisposition to scrofulous disease, and most generally associated with the latter, we find to take place, in the texture of nearly all the organs, as wrell as upon the surface of the mucous and serous membranes, the formation of tubercles, A-arying in size and appearance, either in their different stages, or according to the par- ticular tissue in Avhich they occur. Ararious opinions have been en- tertained as to their nature and origin, the merits of which it is not our province, on the present occasion, to examine into. Tuberculous matter has been detected in the blood, a morbid con- stituent of which it Avould appear, therefore, to be; and it has been plausibly suggested, by Carswell, that this matter is deposited in the tissues during the imperfect process of nutrition which takes place 39 610 DISEASES OF CHILDREN. in certain constitutions, or that it is separated from the blood with the secretions. Rilliet and Barthez, who have given, in the third volume of their work on the diseases of children, the most complete and accurate ac- count of tubercles, as they occur in early life, describe the crude tu- bercle as a solid, homogeneous mass, of a dull, yellowish-white colour —of a somewhat moist consistence, and easily broken or crushed. When broken it exhibits a somewhat granulated surface. Miliary tubercles consist of quite small granules of a round or oval shape, either perfectly distinct from each other, or collected together in groups. In the latter case they gradually augment in size, and often form masses of considerable extent, which not unfrequently in- clude a portion, more or less extensive, of the surrounding tissue. The miliary tubercle is most generally surrounded with a vascular network, which, after the tubercle has become considerably enlarged, unites with the surrounding cellular tissue, and forms a kind of fibrous cyst, more or less dense. Yellow tuberculous infiltration occurs in the form of an irregular mass, the edges of which are confounded with the neighbouring tissue. The edges extend themselves, by irregular prolongations, in different directions. In their neighbourhood, irregular tubercles often occur, which sooner or later become united with one of the prolongations of the former. Sometimes the yellow infiltration assumes more or less of a rosy tint, which gives to it the appearance of being tra- versed by small vessels. The miliary tubercles and yellow infiltration very often, after a time, become confounded; the first, by agglomeration, forming large masses, when they can be distinguished from the latter only by the presence of the network of vessels by which they are surrounded. Gray granulations occur under the form of very minute bodies, either spheroidal, or oval, or flattened and almost lenticular. They feel beneath the finger like a small grain, which is with difficulty crushed under the nail. Occasionally they contain a drop of serous fluid. They may, in some cases, be detached readily from the tissue in which they are formed, leaving a small smooth cavity; in other cases they have been found appended to a filament resembling a ves- sel. Their colour is a decided gray; but when removed from the tissue in which they are seated, they are more clear and transparent. They have this latter appearance in the liver, even when surrounded by the parenchyma of the organ. Their substance is usually homo- geneous ; occasionally, however, a black point exists in their centre, —or they are surrounded by a circle of black matter, disposed in very fine ramifications. They now and then occur in groups of from three to twenty, scarcely separated by the tissue of the organ; thus forming small hard masses. Laennec describes a form of tubercle as occasionally occurring betAveen the miliary tubercles, in the form of a fine gelatinous infil- tration, either colourless or sanguinolent. The yellow granulation is a small body, softer, and of a clearer yel- low colour than the crude tubercle. It has the appearance of a false DISEASES OF THE NUTRITIVE FUNCTION. 611 membrane. It cannot be broken or crushed under the nail. Its form depends on the resistance of the tissue in which it is developed; thus, in the parenchymatous tissues it is rounded, in the serous, lenticular, in the pia mater rounded on the side of the brain, and flattened on the side of the arachnoid. It is invariably surrounded, in the serous tissues, by a network of blood-vessels. These granulations occur either distinct from each other, or united in small groups. Rilliet and Barthez describe, under the name of tuberculous dust, a form of tuberculation, occurring under the appearance of numer- ous very minute white or yellow points, not sufficiently close together to constitute a continuous yellow surface, but strewed throughout the tissue, which is almost invariably invaded by an acute or chronic inflammation, sometimes by gray infiltrations. According to Rilliet and Barthez, the origin of the yellow tuber- culous matter is either, 1st. The gray granulation, which passes into the yellow granula- tion, and afterwards into the miliary tubercle, or yellow infiltration. The gray granulation may also pass into the gray infiltration. 2d. The gray infiltration, which gives birth indifferently to the yellow granulation, the miliary tubercle, or the yellow infiltration. 3d. The tuberculous dust, which may be the origin of the yellow infiltration. 4th. The yellow granulation, which may appear originally. 5th. The formation from the first of crude yellow matter. The inflammation, acute or subacute, of the organs, precedes, in a large number of cases, their passage into the condition of the semi-transparent gray tissue. In retracing these facts in a different order, we perceive that the miliary tubercle may occur originally, or in the gray infiltration, or succeed to the granulation, gray or yellow. The yellow infiltration may occur either originally, or in the gray infiltration, or it may result from the union of the yellow granulations or the tuberculous dust. The large tuberculous masses result from the development and union of the partial infiltrations, or of the miliary tubercles. The crude yellow tubercle succeeds to an inflammation, only through the intermedium of the semi-transparent gray tubercu- lous matter, and perhaps of the tuberculous powder. The yellow tuberculous matter may soften and become reduced to a fluid state, or it may become dry and pass to the stony or cretaceous condition. When the tubercle becomes softened, and an inflammation, followed by suppuration, occurs in the surrounding tissue, there results a cavity varying in extent and form, the parietes of which may be lined with a soft tuberculous tissue, and its cavity filled with a mixture of pus, tuberculous matter, and the debris of the organ in which the cavern is seated. In the serous membranes, tubercles manifest less tendency to soft- ening than in other situations, and it is a remarkable fact, which Rilliet and Barthez have found to be invariable, that perforation of the serous membranes, resulting from the softening of tubercles, is oc- 612 DISEASES OF CHILDREN. casioned by the softening of those seated on their external surface, which also have a tendency to perforate the natural canals with which they are in contact. More extended consideration of the successive changes which take place in the several forms of tubercles, and the various causes which tend to promote their growth and softening, belongs to a treatise on general pathology. Tubercles are incapable of organization, but appear to have the power of exciting certain morbid actions in the parts in which they are seated, which affect their own softening, while it produces disor- ganization of the latter. It has been supposed by some, that in every instance of scrofulous disease, the peculiarities of the latter result from the deposition, in the affected tissues, of tuberculous matter, modified in its appearance and mode of deposition by the particular structure in which it occurs. Tubercles may occur, during childhood, in almost every organ and tissue of the body. The organs which most frequently present tubercles are also those, in general, where tubercles occur to the greatest extent. These are, in the order of their frequency, the lungs, the bronchial glands,— then, at a long distance, the mesenteric or abdominal glands, the small intestines, liver, &e. As regards the general distribution of tubercles in the different or- gans, the more nearly children approach the age of puberty, the more generally do we find tubercles limited to the lungs and intestines, and to present the same aspect as in the adult. In younger child- ren, we find, occasionally, all the organs studded with small, gray granulations, which, if united in one organ, would form a consider- able mass, but disseminated throughout, they do not profoundly alter any one; or, miliary tubercles of a uniform size occur in all the organs, constituting a larger mass than in the previous case; or, in a third set of cases, considerable quantities of yellow granulations are pre- sent in several organs, causing at times a degree of disorganization which is surprising. These three forms may be partial or general, —the latter most frequently partial, the others more usually gene- ral. As an almost invariable rule, the number of organs at the same time invaded by tubercles is greater in children than in adults, and certain organs, which at a more advanced age are rarely the seat of tubercles, are particularly so in children. The pathological influence of tubercles upon the tissue in which they are deposited, it is not easy to understand:—they would appear, however, to predispose it to the occurrence of inflammation of a sub- acute character, and of which it modifies, to a certain extent, the phe- nomena, progress, and results. AVhether, in any instance, tubercles can be considered as an ex- citing cause of disease, is uncertain. In numerous instances Ave have met with them after death, in cases in which, during life, there were no indications to lead us to suspect their existence. They are, more probably, in many cases, the result, rather than the cause of diseased action. DISEASES OF THE NUTRITIVE FUNCTION. 613 The general symptoms indicative of the existence of tubercles vary somewhat Avith the organs in which they chiefly occur. Usually, however, there is paleness of countenance, general progressive ema- ciation and debility, a dry, rough, harsh state of the skin; often re- peated desquamations of the cuticle, and oedema of the face, lower extremities, or scrotum. Usually, in the course of protracted cases, hectic fever occurs, Avith circumscribed redness of the cheeks, eve- ning exacerbations, and more or less profuse night sweats. Tuberculization of the Bronchial Glands is almost peculiar to childhood. It is a frequent and serious affection, giving rise to symp- toms with difficulty distinguishable from those of tubercular phthisis. The enlarged bronchial glands may act mechanically on the neigh- bouring organs contained in the chest, or they may perforate them. Hence result a variety of symptoms depending on the position or function of the injured part. Thus, the aorta and pulmonary artery, the vena cava, or the pulmonary veins, may be compressed by the tu- berculated glands, and the Aoav of blood be more or less impaired. M. Tonnelle has related a case in which the superior cava was com- pletely obstructed, and Dr. Green has seen one where the pulmonary artery was perfectly flattened between two enormous glands. From this compression of vessels may arise pulmonary apoplexy, fatal hae- morrhage, effusions of serum, or symptoms closely resembling those of organic disease of the heart. The trachea, bronchial tubes, and lungs, may be compressed, and in such cases the symptoms will vary considerably, according to the seat and extent of the mechanical lesion. When the enlarged glands act on the lower portion of the trachea, Rilliet and Barthez have noticed the existence of a loud, sonorous rhonchus, Avhich persists for a considerable length of time. In other cases, the pressure on the large bronchial tubes causes more or less feebleness of the respiratory murmur, which is remarkable in being intermittent. Pressure on the eighth pair of nerves or its branches, is often at- tended by very peculiar modifications of the voice, and cough. The former is hoarse or occasionally subdued, and even lost, or the hoarse- ness and loss of voice may alternate. The cough, also, is frequently hoarse, or occurs in fits, which bear a close resemblance to those of hooping cough, but are not followed by vomiting; or the fits may simulate an access pf asthma, with great oppression of breathing, anxiety, agitation, congestion of the head, and cold viscid sweats. The enlarged or softened glands may give rise to another order of symptoms, by perforation of the neighbouring parts. Thus, fatal hae- morrhage may arise from perforation of the pulmonary artery; pneu- mothorax, from perforation of the lung; difficulty of deglutition, and an access of cough on swallowing, from perforation of the oesophagus; but we should observe, that these symptoms may equally depend on the pressure of tubercular matter, or of a cavern in the lungs. On the subject of the diagnosis of this form of phthisis, Dr. Green remarks:—AVhenever a child presents several of the rational symp- toms of consumption, Avithout our being able to detect any physical signs of the presence of tubercles in the lungs or abdomen, we have 614 * DISEASES OF CHILDREN. good reason to suspect that the bronchial glands are tuberoulated. As long as the case continues to present this simple aspect, avc cannot go beyond suspicion; but it rarely happens that the glands acquire a considerable degree of development, without acting on the sur- rounding parts or tissues. As these become successively involved, we have a scries of varying symptoms which could not arise from any other source. The eyelids become oedematous, and in proportion to the degree of pressure on the vena cava, the oedema extends to the Avhole of the face, Avhich is sometimes pale, sometimes tinged with venous injection. This oedema will appear and disappear several times during the course of the dis- ease. The cough suddenly changes its character, and occurs in fits, like those of hooping cough; the voice gets hoarse, and for days may be altogether lost; while fits of asthma or of suffocation, as if the heart were diseased, occur. On examining the chest, we hear a loud sonorous rhonchus, which persists for a length of time, and then disappears, or is replaced by other rhonchi of an anomalous character. When these symptoms are superadded to the rational signs of phthisis, we can have little hesitation in deciding that they arise from tubercular enlargement of the bronchial glands. Tuberculization of the lungs.—All the forms of tubercular matter may be developed in the lungs of children. Pulmonary phthisis is, in fact, a very common complaint at this age. The main character Avhich distinguishes the phthisis of children from that of adults, is the much larger surface of the lung the tuber- cular deposition occupies, its more rapid secretion, and its more fre- quent complication with tubercular disease of other organs. Hence, children affected with phthisis often die before the complaint has ar- rived at its third stage, while the modifications produced by an exten- sive diffusion of tubercular matter often render the diagnosis obscure and difficult. AVe have, in addition, the peculiarities occasionally induced by extensive tuberculization of the bronchial glands. The physical signs are rarely as well marked as in the adult, and the young child frequently dies before the practitioner is able to de- cide whether the lung is actually the seat of cavern or not. The cause of this is, the tendency of the tubercular matter in children to implicate many important viscera: thus, in the brain it may excite meningitis; beneath the serous membrane of the chest, pleurisy; in the abdomen, peritonitis; in the intestines, ulceration. These com- plications rarely fail to undermine the resisting power of the little patient; diarrhoea sets in, and death ensues, long before the period at which a fatal termination takes place in the adult. There is an important modification that should guide the practi- tioner when he seeks to determine the existence of a cavern in young children, viz.: that under five years of age, the cavernous excavation is generally seated in the lower or middle lobes, and is almost always confined to one side of the chest. Infants and children under five years of age, hardly ever expecto- rate. They swallow everything that comes up into the mouth from DISEASES OF THE NUTRITIVE FUNCTION. 615 the lungs. Haemoptysis is hence-an exceedingly rare symptom. The phenomena which constitute hectic fever are, also, seldom present in so marked degree as in the adult. Tubercles occur very frequently in the brains of children, and are intimately connected with many of their cerebral diseases. They may form at almost any period of infancy or childhood, but are rarely met with previous to the first year, and would appear to be most common between the third and seventh years. " In thirty-four cases noticed by Barrier, sixteen were under five years, thirteen from five to ten, and five only from ten to fifteen years. Of Dr. Green's thirty cases, in thirteen it occurred between two and four years; and in seventy- five cases, he states that it occurred most frequently in children from three to seven years. Of Rilliet and Barthez's twelve cases, six were from three to five years; four from six to ten and a half; and two from eleven to fifteen years, and eight were boys. Dr. Mauthner found, in seventeen out of thirty-two, that the age did not exceed six years, which Avas the case in seven out of eight cases observed by Dr. West." (Churchill.) The sex of the child does not appear to have any influence in the production of the disease. The majority of Dr. Green's cases were females; the majority of Rilliet and Barthez's cases males. In many instances they give rise to no symptom during life; in others, merely to a periodical headache or to deafness, combined with purulent discharges from the ear. The most common symptoms, how- ever, to which tuberculous depositions in the brains of children give rise, are headache, vomiting, convulsions, amaurosis, paralysis, and diminution of the intellectual faculties. Death generally takes place from acute hydrocephalus, softening of the brain, consumption of the lungs, or from the occurrence of some accidental disease, as small-pox, &e. The chronic stage of cerebral tubercles varies in duration from a few weeks to two years. In one class of cases, the disease commences Avith headache, followed by various lesions of sensibility, or of mus- cular power. The headache is often very severe and obstinate, pre- venting sleep, rendering the child fretful, peeAdsh, or morose, and causing sometimes the utterance of acute cries, similar to those in cases of hydrocephalus. The pain is commonly seated in the fore- head ; in a few cases, however, in Avhich the tubercles occupy the cerebellum, it is experienced in the occiput, and extends downwards towards the neck. The attacks of headache are, occasionally, asso- ciated with vomiting: they recur on each exacerbation of the pain, and are independent of any disorder of the digestive organs. Consti- pation occasionally occurs, but less frequently than vomiting. The symptoms which succeed consist, chiefly, in lesions of the senses, of the muscular power, or of the intellectual faculties; as, loss of hearing, dimness or total loss of vision, and a diminution of the cutaneous'sensibility on one side of the body.^ Convulsive movements may occur at irregular intervals, and terminate in partial or total paralysis of one or more of the limbs; in other cases, we have merely a Aveakness of certain muscles, not amounting to paralysis—the child 616 DISEASES OF CHILDREN. stumbles as it walks, and progression is much impeded; particular muscles, also, may be affected; thus, there may be a peculiar convul- sive movement of the muscles of the eyeball:—in a few cases, stra- bismus occurs. The child's temper may undergo a notable change, and the intellectual powers may become dull; but the disturbance or loss of the latter is rarely observed, except in cases of long stand- ing, and towards the close of the disease. The various symptoms just noticed are seldom permanent; the headache often disappears, after having existed several months, and again returns; the strabismus and amaurosis may also disappear, but f the paralysis is generally permanent, especially when it occurs in the limbs. In another class of cases, there is a sudden occurrence of convul- sions, or an attack of true epilepsy: these recur at regular intervals, and gradually terminate in paralysis or coma. The convulsions may be general or partial, and are often followed by contraction of one or both extremities of the same side, or, the head may be draAvn on one side, and remain in that position for a considerable length of time. Sometimes the convulsions commence with a nervous tremor of one arm, which may last for several weeks, and then terminate in epilepsy. In other cases, several attacks of convulsions may be fol- lowed by a peculiar rotary motion Of the head, and in others, by squinting, and a lateral motion of the lower jaw. According to Green, the convulsive attacks are rarely attended with either vomiting or constipation; our own observations would, however, lead us to a diffe- rent conclusion: vomiting we have certainly found to be as frequent in these as in the former cases. In a third class of cases, the first symptom of disease is a paralytic affection of one or more muscles, or organs of sense. In the acute forms of cerebral tubercle, there is a succession of symptoms of an irregular character, and more or less allied to those of acute hydrocephalus, or softening of the brain. Sometimes an attack of general convulsions terminates in fatal coma, or it may be so violent as to cut off the patient in a few hours. Upon dissection, tubercles, varying in size from that of a small nut or bean, to that of a hen's egg, are found, most generally, in the substance of the hemispheres, either of the cerebrum or cerebellum, or of both, and occasionally in the cerebellum and pons varolii, or in the latter alone. Tubercles of the brain often coincide with tuber- culation of the meninges, producing a marked influence upon the general symptoms of the case. The tubercles are often single, often numerous; twenty to fifty have been observed by Green in one brain; but by Rilliet and Barthez, never more than from fifteen to twenty. In many cases, even when the tubercles are of considerable size, we are unable to discover the slightest change in the surrounding nervous substance, or in the neighbouring membranes. The gradual development of the tubercular mass seems to pass unheeded by the central neiwous system. In other cases, the membranes adhere to the cortical substance, over the site of the tubercle, and are more or less infiltrated and thickened. Sometimes, AA-hen the tubercle is large, the convolutions are flattened or completely effaced. DISEASES OF THE NUTRITIVE FUNCTION. 617 The colour and consistence of the nervous substance immediately surrounding the tubercle present a great variety of modifications :—•- there may be slight injection and softening to the depth of a few lines only; or the softening of the nervous tissue, with or without injec- tion, may extend to the central parts of the brain: in some cases, nearly the whole of the cerebellum is reduced to a mere pulp. In these cases, effusion, often to a very considerable extent, takes place within the ventricles, which it distends; and traversing the ventri- cular membrane, infiltrates and softens the cerebral substance.. In a few rare examples, on the contrary, Green describes the surround- ing nervous tissue as being more pale, and of a denser structure than natural; sometimes it is soft, and of a straw colour. Abscess, or true infiltration of pus, in the immediate vicinity of cerebral tuber- cle, is rarely, if ever, observed. Tubercles of the brain are very generally associated with other scrofulous indications. The first dentition Avould appear to be their principal epoch, though in many cases they will be found to suc- ceed to acute or chronic affections of the gastro-intestinal mucous membrane, or to the exanthematous fevers. Treatment of Scrofula.—There is no specific for the cure of scro- fula. If we are correct in our views, in regard to its pathology—if the morbid condition of the system depends upon a defective assi- milation and sanguification, by which the blood is rendered deficient in its healthy organization, and nutrition is, in consequence, imper- fectly performed:—if the whole of the organic functions are inactive; it is evident that our endeavours should be entirely directed to im- prove the condition of the blood, and render nutrition more active and perfect, and, in this manner, to correct the morbid constitution of the body, which constitutes the essential foundation of the disease. Medicinal agents, however important and essential they may often become, for the removal of certain morbid symptoms, are not to be considered as those upon which our chief dependence is to be placed in effecting that change in the condition of the organic functions which is essential in order to improve the general tone and vigour of the system:—this can only be done by placing the body under the influence of those natural agents by which alone its healthful action is to be promoted and sustained. From alteratives and tonics we can expect but little, but from a proper diet, pure fresh air, sufficient exercise, cleanliness, and proper clothing, in conjunction with a due regulation of the moral and intellectual powers, when sufficiently early resorted to, the most prompt and decided benefit will be inva- riably derived; and without their influence, under no circumstances can we expect to prevent the inroads of painful and destructive dis- ease, or to arrest its progress, after it has occurred. In regard to every child, the same hygienic agents are essential to preserve and promote the health, vigour, and regular development of its frame; but in one who is delicate from birth, or who exhibits, at an early period, the striking characteristics of the lymphatic tem- perament, Avith languid circulation, and a predominance of the white fluids and tissues, they become doubly important; their neglect will 618 DISEASES OF CHILDREN. then endanger the occurrence, sooner or later, of serious and even fatal disease, while proper and unremitting attention to them will seldom fail to improve the constitution of the blood, and render nu- trition more active and healthy. AVe have, in the commencement of the present treatise, entered, with sufficient minuteness, into a consideration of the hygienic ma- nagement of children, to render it unnecessary, in this place, to go into further details:—we need only add a few remarks in regard to it, so far as it respects such patients as already present indications of the invasion of scrofulous disease. Air, exercise, and proper nourishment are, in these cases, our chief remedial agents. Animal food, with a proper mixture of the more readily-digested farinaceous vegetables, will, in general, be essential, after the child is weaned; but previously to this, the only appropriate diet is the breast-milk of a perfectly healthy nurse. The proper spe- cies of animal food, and the manner in which it is cooked, require, also, to be attended to. Beef, mutton, venison, chicken, turkeys,and most kinds of game, fresh-laid eggs, and fresh milk, with stale bread, crackers, potatoes, and rice, should constitute almost the exclusive diet, in the cases referred to. In regard to cookery, the meats should be plainly roasted, broiled, or boiled, or the beef may be eaten in the form of steak, and the mutton in that of chops. The milk may be taken without any preparation, or simply boiled, according as it is found to agree with the patient's stomach; it may, also, be taken occasionally with mush, boiled with rice, and sweetened, or with eggs, in the form of plain custard, or with rice, or bread, in the form of plain pudding. The eggs should be boiled, but not hard. The bread should be of wheat, or wheat and Indian, and not eaten until twenty- four hours after it is baked. The potatoes should be roasted, in which form they are easier of digestion, and agree better with the stomach, than when boiled. In regard to condiments, these should consist ot sAt and Cayenne pepper, for the animal food, and of sugar and per- haps cinnamon or nutmeg, for the preparations of milk. 1 he condi- ments, however, should be used in moderation, and rather with the view of imparting an agreeable relish to the food, than for the pur- pose of stimulating the appetite. While a sufficiency of food is allowed properly to nourish the sys- tem, caution must invariably be exercised to prevent its being par- taken of in too great quantities at a time, or too frequently. ^ JNo general rule can be laid down in respect to these important points: much will depend, in regard as well to the quantity of food, as to tne frequency of the meals, upon the condition of the patient s stomacn, his age, and the particular circumstances of his case. For drink, nothing should be allowed but pure water or toast water: we say pure water, for there can be no doubt, that impure water is decidedly prejudicial to health, and some have even sup- posed that hard water is a cause of scrofula. The effects of the water habitually used as drink, like that of the air we breathe, though insensible, are not the less certain and powerful:—the quality of the water made use of, during health as well as in disease, merits more attention than has generally been paid to it. DISEASES OF THE NUTRITIVE FUNCTION. 619 By most of the English physicians, an occasional glass of good beer, porter, or wine is recommended, but to this we must positively ob- ject. Alcoholic drinks, whether fermented or distilled, are not, in any degree, calculated to promote digestion, nor to improve the nu- trition of the organs, Avhile they have a decided tendency to promote habits, which, in after-life, may even prove a greater curse than the worst effects that can result from that defective state of the organic structure in which we have presumed the tendency to scrofulous disease mainly, if not entirely, to consist. Pure and fresh air is as essential as proper and sufficient nourish- ment. It is too much the custom to confine, within doors, the weak and delicate, whereas of all persons they the most demand frequent exposure to the open air; and, with proper clothing and due precau- tion, such exposure may, with great propriety and decided advantage, take place in children of four or five years of age, even in the colder season of the year, during perfectly clear weather. Even when the Aveather is such as to prevent the child from being taken out, the advantages of a fresh and pure air may be afforded it by proper ven- tilation, the strictest attention to domestic cleanliness, and by guard- ing against over-crowded apartments, by night as well as by day. AVhere we can command it, the atmosphere of a dry eleA^ated situa- tion in the country should always be preferred to the atmosphere of a large or crowded city. In connexion with the subject of air, is that of exercise, a proper daily amount of which should invariably be taken out of doors. The exercise must, of course, be adapted to the strength and age of the child, but should always be as active as can be allowed, without the fear of its inducing undue fatigue. Sir Astley Cooper states, that he has seen five hundred cases of scrofula, in the course of a single year, with scarcely a boy among them, and this, from the cir- cumstance that boys will take exercise, while girls are not allowed to. As a substitute for exercise, in cases in which the debility of the patient is so great as to render a sufficient amount of such as is of a more active kind impossible, friction of the surface, repeated daily, either with the hand, or a proper flesh-brush or cloth, will be useful; and, in all cases, it will be proper, even in connexion with exercise; but it can never supply fully the place of the latter, Avhen taken in a pure fresh atmosphere. For young children, the usual sports of their age—riding occasion- ally in an open carriage—short walks or jaunts, with some pleasing and moderate occupation of the mind, in the intervals, will suffice. For older children, various recreations present themselves, of an in- nocent character, which call into sufficient exercise the muscles of the body. Riding on horseback is a very admirable mode of exercise for those sufficiently old to partake of it with safety; especially for girls, Avho cannot easily obtain a sufficient amount in any other manner. Frequent bathing will be necessary, as well for the maintenance of personal cleanliness, as to promote and sustain the regular actions of the cutaneous exhalants. The warm bath should be employed when the temperature of the surface is deficient, with considerable 620 DISEASES OF CHILDREN. languor of the circulation; but in patients possessed of greater vi- gour, and in Avhom the temperature of the skin is better maintained, the tepid bath may be substituted. Sponging the surface Avith tepid water, or with salt and water, folioAved by brisk friction, will also be highly beneficial. A bath of sea-water, Avhen practicable, may be taken three times a week, at eleven o'clock in the morning. The temperature of the bath should be ninety-four degrees, and the child may remain in six- teen or twenty minutes; after which friction to the skin may be em- ployed, or a walk taken. A child may be brought to bear the bath by sponging or sprinkling the surface daily with tepid Avater. Bathing in the open sea, when it can be borne Avithout producing languor or chilliness, will unquestionably be proper, in the generality of cases. Against cold bathing, Avhich is recommended by writers of even a recent date, we most positively protest; the idea of its exerting a direct tonic effect has originated in false views, as wrell of the action of cold upon the human system generally, as of the particular cir- cumstances under which the reaction it gives rise to invariably oc- curs. To immerse a weakly child in cold water, Avould be more likely to produce and increase the tendency to scrofulous disease, than to prevent it, if it did not cause more immediate, and even more dangerous results. In regard to clothing, this should be accommodated to the tempe- rature of the season, and adapted in quantity, material, and form, to preserve, as far as possible, a uniform temperature of the surface;— guarding against the slightest sensation of chilliness in cold or change- able weather, and too much heat or excessive perspiration during the summer. As a general rule, liable, however, to some exceptions, flannel next the skin should be worn during the autumn and win- ter, and late in the spring: for the remainder of the year, coarse muslin may be substituted. The mind should be occupied and amused, without being fatigued, or too much excited; and every means calculated to promote cheer- fulness, buoyancy of disposition, and equanimity of temper, should be put in requisition, and every depressing influence carefully re- moved. AArhen there exist considerable torpor of the digestive functions, and constipation of the bowels, with dark-coloured, or pale, clay-like, unhealthy evacuations, it will be proper, at an early period, to endea- vour to excite the whole alimentary canal to a more healthy action. Purgatives will, in general, be required. Rhubarb and magnesia, the compound powder of jalap, or, in older children, the blue mass, com- bined with rhubarb and ipecacuanha, will generally answer our pur- pose, or an occasional dose of calomel combined with magnesia, and followed by moderate doses of senna tea, of the compound powder of jalap, or of the sulphate of magnesia, may be employed. The article which has answered best in our hands has been the compound powder of jalap. This was a favourite prescription Avith Dr. Physick, in scro- fulous disease of the hip joint:—he gave it every day or every second day, so as to keep up a steady and tolerably brisk action upon the DISEASES OF THE NUTRITIVE FUNCTION. 621 bowels: under its use we have known the health and strength of the patient rapidly to improve, and his attenuated limbs to become aug- mented in bulk, and increased in firmness. Of course, the doses of the purgatives employed, and the frequency of their repetition, must be governed entirely by the age of the child, the condition of the boAvels, and the effects produced. In many cases, after the bowels have become more regular, and the stools of a more healthy appearance, some light tonic may be given, Avith the vieAv of improving the digestive powers of the stomach. The proto-carbonate of iron may be administered, in the dose of a few grains combined with the sulphate of quinia, daily, for a short time; or, we may give the carbonate of iron with rhubarb, and a little orange peel;1 or the following, Avhich is a good preparation for the same purpose.2 AAre may remark, that preparations of iron appear to constitute the best tonic, in that state of the constitution which predis- poses to scrofula. J R.—Carb. ferri, gr. xxxvj.—gj. a R.—Sub. carb. sodae desiccat. gr. xlviij.— Pulv. rhaei, gr. xxiv.—gss. Qiijss. ----cort. aurant. ^ij.—M. f. Pulv. calombae, gij. chart. No. xij. ----rhsei, gss.—M. f. One for a dose daily, or twice a day. ch. No. xij. (A. Cooper.) To be given as the last. During the exhibition of these remedies, whether purgative or tonic, constant attention should be paid to the diet, and general hygienic management of the child. AVe have, heretofore, presumed that the symptoms of local disease have not presented themselves; that the child is merely labouring under a state of general debility, the result of imperfect assimilation and haematosis, and deranged or deficient nutrition; and that our only indication is to improve digestion, render sanguification more perfect, and the nutrition of the solids more regular and complete. It is true, that in every case and stage of scrofulous disease, this indication is still to be fulfilled; but the mode of fulfilling it will demand some im- portant modifications, according to the particular circumstances of each individual case. AVhen the usual symptoms of gastro-intestinal disease are present— tenderness of the epigastrium or right hypochondrium, loss of appe- tite, nausea, irregularity of bowels, dryness and inoreased heat of the surface, and a red, dry tongue—animal food should be forbidden—a moderate quantity of some of the lighter farinaceous preparations— weak chicken AArater or Avhey, Avith gam, barley, rice, or toast Avater for drink—should constitute the diet, until the above symptoms are re- moved. The treatment of the gastro-intestinal disease is to be con- ducted on general principles—leeches, according to circumstances— warm fomentations—minute doses of calomel and ipecacuanha, Avith the occasional interposition of a saline purgative, among which one of the best is probably the citrate of magnesia. The nitrate of potassa has been highly spoken of as a remedy in cases of gastro-intestinal disease occurring in subjects presenting a tendency to scrofula, and it is asserted by Todd, that, when combined with mercurials, the efficacy of the latter is increased. AVe have used 622 DISEASES OF CHILDREN. it, in many cases, in small and repeated doses, Avith certainly very good effects. During the continuance of disease of the digestive mucous mem- brane, active exercise will be improper; indeed, friction of the surface, repeated daily, will, in the majority of cases, have to be substituted for exercise of every species. After we have succeeded in completely removing the irritation or subacute inflammation of the alimentary canal, the diet of the patient should be gradually and cautiously improved—chicken water, beef tea, afterwards the gravy of meat, then broths, then small portions of chicken, or mutton, or beef, may be allowed until a full animal diet can be taken with safety. At the same time, the use of tonics may be entered upon with benefit, when, if they had been given previously, they would have rather tended to augment and confirm than to re- move effectually the debility of the system. The chalybeates, as al- ready remarked, either alone or conjoined with weak cold infusions of bark, infusion of camomile, or the colomba in substance, will be among the best tonics, in these cases. The proto-carbonate or the ferrum tartarisatum, or a combination of the latter with small doses of carbo- nate of iron, or the nitrate or sulphate of potassa, may be given, or the tincture of the sesquichloride of iron combined with iodine;1 or we may employ the iodide of iron. 1 R.—Tinct. ferri, sesquichlor. Tinct. iodine, aa. gij. Aquae purae, gss.—M. [Todd.) Dose,—thirty drops, three times a day, for a child ten years of age, and a smaller portion for those younger. These articles should be administered for several days in succession, and then intermitted for a day or two, the bowels being, in the mean time, kept regularly open by means of occasional doses of some mild purgative; and at the same time the child should be placed upon a proper hygienic treatment, without which tonics, however judiciously selected or long continued—and in general, to derive from them their full effects, they must be persevered in for a length of time—will be productive of little or no good. Cod-liver oil as a remedy in scrofula is spoken of in favourable terms by many practitioners. It is one from which, in most cases of the disease, decided advantage will be derived, when its use can be continued perseveringly for a sufficient length of time. According to Rilliet and Barthez, it possesses at once tonic and discutient pro- perties. Notwithstanding its disagreeable taste and odour, children exhibit to it no great repugnance. It may be given to children three years of age in the dose of from one to two dessert-spoonsful, and from three to four, to older children, combined with some aromatic. The following are the formulae recommended by Tourtual. r R.—01. jecoris aselli, gij—giij. R—01. jecoris aselli, gj. Gum. acaciae, q. s. Liq. carb. sodae, gij. Aq. foenelic. gj. 01. calam. aromat. tr^iij. Syrup, cort. aurantii, gss.—M. Syrup, cort. aurantii, gj.—M. Dose, a teaspoonful every three hours. Dose, one to two teaspoonsful, morning and evening. DISEASES OF THE NUTRITIVE FUNCTION. 623 R.—01. jecoris aselli. gij. Vitell. ovi, No. j. Syrup, menthi, " flor. aurant. aa..gij.—M. Dose, a dessert spoonful three times a day. The remedy should be continued, in order to derive from it its re- medial effects, for many weeks, or even months. There is scarcely any form of scrofula Dr. Phillips has not seen to improve under the use of cod-liver oil, but he seldom was able to carry it far enough to produce any considerable amelioration: he con- siders that its good effects result from its improving digestion and nutrition, which is the opinion of the generality of those physicians who have given to the remedy the most extensive trial. When enlargement of the lymphatic glands occurs, so long as the swellings remain indolent, no other treatment is required than that which is calculated to improve the general condition of the system. _ Iodine, both internally and locally, has, by many writers, been con- sidered almost a specific, in these, as well as in most of the local affections of a scrofulous character, while others consider it of very little value in any of them. We have never, certainly, seen those striking effects produced by its use, reported to have been observed by others: the evidence in its favour is too strong, however, to allow of our doubting its curative powers in many cases. The solution of Lugol is, perhaps, the best form in which the iodine can be given internally,1 or we may employ the iodide of iron.2 Ex- ternally, iodine may be used in the form of solution3 or of ointment.4 1 R.—Iodin. gj. »R.—Ferri iodid. gr. v. Potassi iodidi, Qij . Aquae destillat. gj.—M. AquiE destillat. gviij.—M. Dose, a teaspoonful, three times a day, in For children under seven years, the dose is sugared water; gradually increased by two drops, twice a day, gradually increas- adding ten drops, daily, to each dose, ed to five drops. From the age of seven until the dose amounts to two teaspoons- to fourteen, sixteen drops, twice daily, in ful. sweetened water. 3 R .—Iodin. gij. « R. —Iodin. gr. xij. Potassi iodidi, giv. Potassi iodidi, gss. Aquae destillat. gv.—M. Axung. gij.—M. By Dr. Phillips, the curative powers of barium, in scrofula, is consi- dered as little, if at all, inferior to that of iodine. Its field of useful- ness is, however, more limited. The barium seems to him to be a more certain stimulant, or he might even say irritant, than iodine, and consequently its use is clearly contra-indicated where there is much inflammatory excitability of the system; but, in cases marked by a tallow-like complexion, pale tongue, languid circulation, and irritabi- lity of the mucous surfaces^'its good effects will often be very decided. Dr. Phillips usually gives it in solution, one grain to an ounce of dis- tilled water, with ten drops of compound tincture of gentian. Of this solution he commences with half an ounce, twice a day; on no occa- sion has he exceeded three grains in the day, and he has never expe- rienced any check in the administration of the remedy. The solution of caustic potassa, the same gentleman is satisfied, has, in many instances, exercised a salutary influence, and these are most- 624 DISEASES OF CHILDREN. ly cases in wdiich much acidity pervaded the secretions, and acted upon the general economy. The state of the boAvels should be attended to, agreeably to the di- rections already given. AVhen the enlarged glands become painful and sore to the touch, the ordinary local applications for the removal of inflammation should be resorted to. In many cases, a feAv leeches will be useful; but, in general, we may trust to cooling or eA-aporating lotions, or the solu- tion of the acetate of lead. As soon as a tendency to suppuration is evinced, an ordinary emol- lient poultice should be applied, and Avhen a distinct fluctuation is de- tected, an opening, transversely, in the direction of the folds of the neck, should be made with a lancet:—this will often prevent extensiA-e ulceration, and its consequent unsightly scar. It is true, that even after suppuration has taken place, the contents of the abscess will oc- casionally be absorbed, and the tumour disappear without rupturing: we are not, however, perfectly convinced, that this result is alAvays to be desired:—after matter is formed in a scrofulous gland, we confess that we should prefer its discharge to its absorption. After the open- ing of the abscess, a common poultice is one of the best applications that can be made to the part. AVhen ulcerations form and show no disposition to cicatrize, a solu- tion of the sulphate of zinc—one grain to the ounce of Avater—will often be found useful to promote their healing: in some cases, how- ever, it will be necessary to touch the edges of the ulcer Avith the nitrate of silver. AVhen very irritable, the ulcer may be washed with a Aveak solution of the nitrate of silver, and then covered with a poul- tice of bread and water. In these cases, poultices of the leaves of hemlock, or of sea-Aveed, have been recommended; but our great ob- ject should be to correct the condition of the general system, for until this is effected, the ulcers seldom, if ever, are found to assume a healthy appearance, and to heal perfectly. A hard, indolent tumour will sometimes remain subsequent to the cicatrization of the ulcer, the discussion of which may be attempted by some one of the, various ointments of iodine: so long as any pain or tenderness remains in the part, hoAvever, the use of these -will be improper; and, if pain or irritation arise during their use, they should be immediately discontinued, and soothing applications resorted to._ In cases of Scrofulous Ophthalmia, if the affection of the eye is recent and acute, the application of a few leeches to the temples, and to the external angles of the eye, will often be advantageous; but in cases of a decidedly chronic character, or which have already existed for some time, leeching will not only be useless, but often decidedly injurious. In cases of a very acute character, in which there exist considerable redness and pain of the eye, and a decided febrile re- action, it may be even necessary to repeat the leeches; but, in every instance, we must be cautious not to carry the depletion too far. The best local application, when the eyes are very red and painful, is the crumb of bread wet with cold Avater, during the day, and a por- tion of alum curd, enclosed in a fine muslin bag, during the night. DISEASES OF THE NUTRITIVE FUNCTION. 625 The eyes should be invariably shielded from the direct rays of light by a broad, deep-green silk shade, so shaped that it may stand out Avell from the forehead, and admit the access of air to the eyes. This management of the shade is of great importance; as those usually employed, which are small and lie close to the eyes, do more harm than good. (Maunsell.) All local-applications of an astringent or sti- mulating character are not only wholly useless, but decidedly impro- per : avc have repeatedly seen them keep up the pain and redness of the eyes, Avhich have rapidly improved in appearance so sOon as such ap- plications were discontinued, and a poultice of bread and water sub- stituted. AVhen the appetite is variable and capricious, with a hot, dry skin, quick pulse, and coated tongue, considerable advantage will often be derived from an emetic early administered. An aqueous solution of tartar emetic would appear to be the best article in these cases; the emetic may be followed up with minute doses of tartarized antimony combined Avith the sulphate of magnesia.1 This treatment, however, is more particularly adapted to the acute form of the disease, occur- ring in children over ten years of age. In place of the combination just mentioned, we may administer minute portions of calomel and pulvis antimonialis, to Avhich, Avhen there is Arery great irritability, and Avant of rest at night, a small portion of Dover's powder may be advantageously added. 1 R.—Sulph. magnes. giij. 2 R.—Calomel, gr. ij. Antimonii tart. gr. j. Pulv. antimonialis, Aquae, giij.—M. " Doveri, tLa gr. vj.—M. f. ch. Dose.—A teaspoonful every two or three No. xij. hours. One of which may be given every three or four hours. In many cases of the disease, there is a loaded and torpid condition of the alimentary canal, wdth a hard and tumid abdomen, irregularity of the boAvels, and an unnatural appearance of the discharges. In these, actiA-e purgatives will be found of advantage; by their action a large amount of unhealthy-looking faeces is often brought away, to the manifest improvement of the condition of the patient. A dose of calomel, combined with rhubarb and magnesia, may be given, and repeated every two or three days, so as to produce a brisk action upon the bowels; or we may administer a few grains of calo- mel in the evening, and on the succeeding day, the compound powder of jalap, castor oil, and turpentine, or an infusion of senna, with the addition of the sulphate of magnesia.' After the bowels have been Avell evacuated, they should be kept regularly open by occasional small doses of calomel, followed by the compound poAvder of jalap, or by the use of this latter alone. AVe are to recollect, however, that, while the most decided advantage is to be derived from the judicious em- ployment of purgatives, too violent or long-continued purgation is in- variably prejudicial. After a more healthy and regular condition of the alimentary canal has been produced, the carbonates of soda and potassa, either by them- selves, or combined with rhubarb, calomba, or a weak infusion of 40 626 DISEASES OF CHILDREN. camomile, quassia, or bark, will often be productive of the best effects. The sulphate of quinia is, however, probably the tonic best adapted to these cases,1 and when administered after the disordered condition of the digestive organs has been removed, will, generally, very quickly effect a complete cure. The preparations of iodine Avill also, in the more chronic cases, be found beneficial, particularly the iodide of iron. The hydrochloride of barytes is very strongly recommended by a few writers in the disease before us, as well as in the other forms of scrofulous disease: it may be employed in solution.2 We knoAv no- thing of its effects from our own experience. 1 R.—Aq. cinnamom. giij. a R.—Hydrochlor. baryt. gj. Sulph. quiniae, gr. vj.—x. Aq. destillat, gij.—M. Acid, sulph. dilut. Ityiv.—vj. Dose.—From ten to twenty drops, two Sacch. alb. giij.—M. or three times a day, to a Dose.—A teaspoonful every four hours, for child between three and se- a child from three to seven years ven years of age, in the sy- of age. rup of sarsaparilla. The diet of the child should be carefully attended to during the acute stage. In the more violent forms of the disease, he should be confined exclusively to some simple farinaceous article of food, with toast, barley, or rice water for drink. He should be immersed daily in a tepid bath, or have the whole surface sponged daily with tepid salt water. Friction of the surface, with the hand or flesh-brush, Avill also be important. The purity and dryness of the air which the patient breathes is a matter of very great importance, and should never be neglected; a patient with scrofulous ophthalmia will rapidly improve in a dry, fresh atmosphere, with very few remedies beyond those of a hygienic cha- racter, while one confined in a close, impure, and damp atmosphere, will exhibit but slight indications of amendment, under whatever plan of treatment we may adopt. The body of the patient should be sufficiently, but not too warmly clothed; the hair should be cut short, and the head and neck sponged with tepid water every morning, and then thoroughly dried. He should not, when it can be prevented, be allowed to keep his bed during the day, nor, at night, to lie with his face buried in the pillow. It is not proper to confine the patient, for any length of time, to a darkened room; with the shade for the eyes already described, free exposure to the open air, whenever the weather is perfectly clear and mild, is of advantage, and will contribute very powerfully to the cure. It is one of the best means of removing the morbid sensibility of the retina which forms so prominent and troublesome a symptom of scrofulous ophthalmia. Blisters to the nape of the neck or behind the ears, kept on for a few hours, and then removed; the blister being reapplied as soon as the inflammation produced by the first has subsided, are directed by Travers, and Avill, in most cases, be found advantageous. In mild, recent cases, the occasional use of a collyrium, eomposed of a solution of the sulphate of zinc or alumine in rose-water, from three to five grains to the ounce, will occasionally be found useful; or DISEASES OF THE NUTRITIVE FUNCTION. 627 we may employ a very weak solution (one grain to eight ounces) of the bichloride of mercury, in pure water, or rose-water. AVhen the pain and intolerance of light are very severe, warm fo- mentations to the eye, as hot as they can be borne, will often afford very decided relief; a pledget of soft muslin, or of lint, or a piece of soft sponge, saturated with warm water, or an infusion of poppy-heads or camomile flowers, may be applied upon the eye during the day, and replaced by warm bread-and-water poultices during the night. The anodyne effects of the vapour of laudanum, or of a vinous tincture of belladonna Avill often prove beneficial; either of these being mingled with a cupful of hot Avater, the eye should be exposed to the vapour two or three times a day. After the intolerance of light and spasmodic contraction of the orbi- cular muscle have so far subsided as to permit the patient to unclose his eyes in a moderate light, scarification of the conjunctiva of the lids will often be followed by very considerable relief; the operation may even be repeated a few times, after intervals of two or three days, until the increased fulness of the vessels, and the thickening of the lid is removed. Subsequent to the scarification, benefit will generally result, in cases of a very obstinate character, from inserting a small piece of the ointment of the peroxide of mercury fifteen grains to the ounce of lard within the eyelids. The introduction of the ointment may be repeated at bedtime, every night, or every second night. In severe and obstinate cases, this will be found a useful practice, even when scarification has not been resorted to; or, a few drops of the solution of nitrate of silver, two grains to the ounce of water, or of the vinous tincture of opium may be instilled into the eye, daily, or every other day. These applications have a very decided effect in diminishing the irritability of the diseased organ, in promoting the healing of the ulcerations of the cornea, and in dispersing any opaci- ties which these may have occasioned. AA7hen a granular condition of the conjunctiva occurs, in chronic cases, collyria of a solution of the nitrate of silver or of a solution of sulphate of copper, (four grains to the ounce of water,) will be re- quired. In cases where there exists considerable disease of the tarsal edges of the eyelids, this may be relieved by the application of the ointment of the peroxide of mercury, or, what is still better, of the ointment of the nitrate of mercury, diluted with one-half or one third of its weight of fresh lard: this being rendered soft, should be applied, by means of a hair pencil, along the edges of the lids every evening. Large ulcerations of the cornea, which exhibit any tardiness in healing, may be touched by means of a hair pencil, with a solution of nitrate of silver; or, when the ulcer is small, deep, and funnel-shaped, with a pencil of lunar caustic, cut to a fine point. When prolapsus of the iris occurs, the protruding portion should be touched every second or third day with the caustic. In cases of deep central ulceration, with adhesion of the iris, the ex- tract of belladonna, reduced by the addition of water to the consist- ence of a thin paste, and smeared upon the forehead, over the eye- 628 DISEASES OF CHILDREN. brow, by causing the dilatation of the pupil, will either have a ten- dency to free the iris or to elongate to such an extent its attachment, as to prevent the loss of vision. When a vascular speck occurs, its progress may often be arrested by removing a portion of the enlarged vessels running into it. Let it be recollected, hoAvever, that in every case of scrofulous oph- thalmia, and during every stage of the disease, our chief attention should be directed to correct the morbid state of the general system: unless this can be effected, remedies directed solely to the local dis- ease are worse than useless; while, by restoring health and vigour to the organic functions, and thus improving the strength and tone of the whole body, cures have been repeatedly effected, Avithout a_single local application, or so called specific remedy. Scrofulous inflammations of the ear require the same unremitting attention to the condition of the digestive organs; the same course of treatment, directed to render assimilation, haematosis, and nutrition more active and complete, as is demanded in the disease Ave have just considered. The same general remedies—purgatives, when the bowels are loaded and sluggish, followed by mild laxatives, or small, repeated doses of calomel, with the occasional interposition of a mild laxative, and succeeded, when a more healthy and regular condition of the bowels has been obtained, by similar tonics to those directed in cases of scrofulous ophthalmia, will be called for. In regard to the treatment of the local disease, this must be con- ducted upon general principles. In cases attended with symptoms of a good deal of severity, leeches, a mild, unirritating diet and the use of the tartarized antimony, with nitre and calomel, or with the sul- phate of magnesia in solution, as directed in scrofulous ophthalmia, will be proper. The local applications consist in the injection into the ear of simple tepid and emollient fluids, and the application, externally, of an emol- lient poultice. When the meatus externus is hot, and its lining mem- brane red and swollen, warm fomentations should be assiduously ap- plied to the ear and side of the head, and leeches behind the ear. Blisters to the nape of the neck, or behind the ear, frequently re- peated, are all-important remedies. In the more deep-seated inflammations of the ear, the tartar emetic ointment may be rubbed updn the mastoid process, until local irrita- tion is produced. In the more chronic cases of the disease, slight as- tringent injections may be resorted to, at first of tepid rose-water, and subsequently of a very weak solution of the acetate of lead, tAvo or three grains to the ounce of Avater, or of the acetate of zinc, of similar strength, or of the nitrate of silver, one grain to the ounce. The strength of these injections may be gradually and cautiously increased; but in all cases we must be careful not to arrest too early or suddenly the discharge from the ear, nor until the health of the general sys- tem is considerably improved. If the discharge becomes offensive, a few drops of the chloride of soda, in an ounce of water, may be injected. Whenever, during the use of astringent injections, the discharge be- DISEASES OF THE NUTRITIVE FUNCTION. 629 gins rapidly to diminish, it is as well to desist for a time from their use, and resort to those of a simple emollient character. Should the arrest of the discharge be followed by any unpleasant symptoms, Avarm fomentations and simple bread poultices should be applied to the ear, as hot as they can be borne. The Discharge from the Vagina, in scrofulous girls, requires little treatment beyond that which is demanded for the improvement of the general health of the system. Frequently washing the parts with some mild emollient, or slightly astringent fluid, will be proper. In most cases, the condition of the alimentary canal will indicate a course of purgatives and alterative doses of calomel, as in the last two diseases. Tabes Mesenterica.—The particular treatment of scrofulous enlarge- ment of the mesenteric glands is of secondary importance to that of the gastro-intestinal disease, with which it is almost invariably con- nected. This demands precisely the same remedies as when it occurs in a patient in whom no predisposition to scrofula exists, with this only exception,—that the extent to which the depletory treatment is to be carried, must be governed by the condition of the patient's system, as well as by the urgency of the symptoms present;—in other words, it must be constantly borne in mind, that in patients in whom there exists a decided tendency to scrofulous disease, remedial measures of a de- bilitating character, even with the same violence of symptoms, cannot be carried as far as in a patient in whom no such predisposition is present. As soon as the disease of the mucous membrane of the alimentary canal is subdued, the child should be put upon an improved diet. Meat broths, prepared with particular reference to their nutritive and digestible properties, may be given as soon as prudence will permit, and at the same time a course of purgatives should be commenced with. The carbonate of potassa or soda, with some light bitter infu- sion, or where there is a tendency to constipation, combined with rhu- barb and nitre, may be commenced with at an earlier period, perhaps, i than more active tonic remedies, and will be very useful so far as the disease of the glands is concerned. Iodine, both internally and externally, would appear to be the re- medy best adapted to the cure of enlarged mesenteric glands, occur- ring in children of scrofulous habits. Lugol's solution may be given, in doses of from three to six drops, two to three times a day; or, we may employ the hydriodate of potassa, in the dose of half a grain to a grain, in a spoonful of the decoction of sarsaparilla, two or three times a day. The hydriodate of potassa is the preparation that will, in most cases, agree best with the bowels:—if these are in the least degree irritable, the addition of a small portion of the syrup of white poppy, or of the tincture of opium to each dose, will lessen its liability to disagree. The iodide of iron may, in many cases, be advan- tageously employed instead of, or in alternation with the foregoing. If, however, under the internal use of iodine, irritation of the di- gestive organs should ensue, it must be at once suspended, and the means for allaying the irritation resorted to. The best form for the external application of iodine is that of the ointment of the iodide of lead, (half a drachm to the ounce of lard.) 630 DISEASES OF CHILDREN. When, however, its use can be persisted in sufficiently long, without inducing considerable irritation of the skin, we have experienced the very best effects from the ointment of the hydriodate of potassa, (half a drachm to the ounce of lard.) The ioduretted baths avc have never employed; of their effects, therefore, Ave know nothing from our own experience: they are, however, highly recommended by others, and will, in some cases, no doubt, be found of benefit. These baths arc formed by dissolving one grain of iodine and two of hydriodate of potassa in a gallon of AA-ater. In protracted cases, change of air, frequent bathing in tepid salt water, or daily sponging with simple warm or salt Avater, folioAved by brisk frictions to the surface, a cautious course of chalybeates, and a well-regulated diet, constitute the plan of treatment to be pursued. When, hoAvever, the disease has been of long continuance, little hopes are left of effecting a cure. Very generally the patient sinks under hectic fever, night sweats, and colliquative diarrhoea, or tubercular depositions take place in the lungs or other important organs, and sooner or later, by impeding their functions, terminate the life of the patient. In the Scrofulous Disease of the Bones denominated rickets, little else is demanded than a strict attention to those hygienic measures that are adapted to improve digestion, and render more vigorous and perfect the Avhole of the organic functions. A proper diet, pure air, the tepid bath, and sponging Avith tepid salt water, together with fric- tion of the surface, daily but cautiously performed, are the agents from which the greatest amount of good is to be anticipated. The diet of a rickety child should be light, easy of digestion, and abound- ing in nutritive matter. Previous to Aveaning, the breast-milk of a healthy nurse is invariably to be preferred; and, subsequently, meat broths, with the farinaceous vegetables, or beef and mutton plainly cooked. Children suffering from rickets are unfortunately precluded from active exercise; the utmost care should indeed be taken, not to allow them too soon to assume the erect position, or to attempt to walk. They may, however, be passively exercised, by being carried abroad in a carriage, or in the arms of an attendant. In carrying or even handling a rickety child, or one strongly pre- disposed to become so, great pains must be taken to avoid undue pressure upon any part of the body, or to place it in any position by which the spine or either of the long bones may become distorted. Its clothing, also, should be perfectly free and loose. In the soft and yielding condition of the entire bony structure, any part of the clothes being allowed to bind, or to compress unduly the chest or limbs, by preventing the full development of the first, and producing a change of shape in the latter, may, independently of the deformity to which it gives rise, cause permanent decrepitude, or a serious interference with the free and regular action of important organs. The child should not even be allowed to lie too long in the same position, in order to o-uard against too much and constant pressure on particular bones. Any symptoms of local disease which may occur in patients af- fected with rickets, must be combated by their appropriate reme- DISEASES OF THE NUTRITIVE FUNCTION. 631 dies. The sluggish and deranged state of the bowels will very gene- rally call for purgatives, and the employment of calomel in alterative doses; carefully, however, guarding against the production of its spe- cific effects. As soon as the regular and healthy condition of the alimentary canal has been established, tonics, as in other cases of scrofulous disease, may be administered, and will often be productive of very decided advantage. The chalybeates and iodine, and, occa- sionally, the sulphate of quinia, constitute our best tonics in these cases:—it is in these, also, that the hydrochloride of barytes is said to be particularly beneficial. During the whole treatment, the tepid salt-water bath, sponging with salt-Avater, and brisk friction to the surface, should be daily resorted to. ATarious plans of support and of machinery have, at different times, been proposed to prevent the occurrence of distortion and deformity in the bones, and to remove it after it has taken place; we believe them all, however, to be worse than useless; indeed, every mechani- cal means adapted to effect the former object, will be absolutely perni- cious—invariably increasing the evil it was intended to avert. Those which have been resorted to to effect the second object, are generally unsuccessful, and are occasionally attended with mischievous effects. It has been recommended, upon the authority of Dupuytren, to place children whose breasts have become Avedge-shaped, from the effects of rickets, against a flat resisting surface, and then to press with the palm of the hand upon the projecting sternum, so as to flatten the thorax in its antero-posterior diameter, and by increasing thus the convexity of the ribs, to augment its capacity laterally. In the success of such a procedure, we have not the least confidence. We believe, with Dr. Maunsell, that much more may be effected by a course of well-regu- lated gymnastic exercises, commenced Avith after the strength of the patient is well established, and he is sufficiently old to permit of their being put in practice. It will be evident to any one acquainted with the mechanism of the human frame, and the mechanical effects pro- duced upon it by the continued action of particular muscles, that modes of exercise could be easily devised, which, if repeated suffi- ciently often, would have a very powerful tendency to remedy many of the distortions consequent upon rickets. In scrofulous disease of the ends of the long bones, independently of the general treatment adapted alike to all cases of scrofulous disease, it is essential that the limb be kept in a state of perfect rest, which can scarcely be effected without the aid of appropriate splints and ban- dages;—and, although these, when the disease is seated in the bones of the loAver extremities, will prevent the patient from taking exercise, they cannot be avoided. When inflammation takes place, this is to be removed by moderate local depletion in the commencement, aided by evaporating lotions, as a mixture of water and alcohol, or water and camphorated spirits, or a solution of the acetate of lead. In many cases, blisters, applied in the immediate neighbourhood of the affected joint, frictions with a solution of hydriodate of potassa, or Avith the ointment of thd"latter, or Avith the tartar emetic ointment, will often prove beneficial. It has been recommended to keep open the blister, 632 DISEASES OF CHILDREN. by dressing it with the unguentum sabinae, or other irritating appli- cations* we are persuaded, however, that a frequent repetition of the blister is a far preferable practice. Purging will be found, in most instances, to be demanded, in consequence of the torpid and loaded condition of the bowels; and, in general, it will produce, also, a good effect upon the diseased condition of the joint. So long as a disposition to suppuration continues, it is probable that blisters to or in the neighbourhood of the joint, Avith the use of iodine internally, will constitute the most prudent and judicious practice. When the disposition to suppuration has subsided, gentle pressureupon the joint, by means of strips of soap-plaster, should be applied, and continued for some time. Motion of the joint must not be attempted so long as the least degree of irritation remains, or the slightest pain is excited. In all scrofulous diseases of the joints, motion should be delayed for a much longer period than in almost any other of the affections in which the bones of the extremities are implicated. As soon as the limb becomes perfectly free from irritation, it is necessary to subject it daily to gentle friction. In the management of the scrofulous affections of the joints, the utmost patience, caution, and perseverance will invariably be de- manded; a too early desire to permit the natural use of the affected limb, may eA-entuate in complete anchylosis, or more serious injury; while, in even severe cases, by prudent and judicious management, a complete cure may sometimes be effected. The treatment of White Swelling consists in perfect rest of the affected joint. When this is hot and painful, or tender upon being handled, leeches, lotions of a solution of the acetate of lead, or evapo- rating washes, brisk purgation, and a light, unirritating diet will be demanded. When the swelling is indolent, presenting no increased heat, nor tenderness upon pressure, blisters will, in general, be found the most efficacious application; though, in some cases, benefit has been derived from dry friction, or by friction with the iodine in so- lution, or in the form of ointment. According to Latta, applying a blister, first upon one side of the joint, and then upon the other, and thus repeated alternately, until the pain and swelling are reduced, has, in many cases, been found more successful than when the blister is made to envelope the whole joint. When blistering induces an increase of the heat and pain, an issue upon each side of the joint, may be substituted. In cases in Avhich the parts involved in the swelling become infil- trated with matter, encircling the joint with strips of adhesive plaster, applied pretty tight, has been found, in many cases, highly beneficial. This practice is equally proper after abscesses or sinuses have formed. In many patients a cautious use of opiates will be demanded, to re- lieve the pain, and procure sleep at night, and in the latter stages of protracted and severe cases, to arrest the copious diarrhoea which then so generally prevails: in this latter case they should be combined with the acetate of lead. Splints, in cases where the disease is seated in the knee, are neces- sary, as Avell to prevent motion, as to counteract the tendency Avhich DISEASES OF THE NUTRITIVE FUNCTION. 633 exists in these cases to permanent flexure of the joint. When the elbow joint is affected, and anchylosis cannot be prevented, angular splints should be applied, in order that the limb may become flexed so far as to render it as serviceable as possible to the patient. The question of the propriety of amputation, in cases of white swelling, is a purely surgical one; its discussion does not fall within the scope of the present treatise. Hip Disease—morbus coxarius.—In relation to the special treatment of this affection, nearly the same remarks will apply, as in the case of white swelling. The most perfect rest of the affected joint is ab- solutely necessary to the accomplishment of a cure in all cases; and this can only be maintained by a splint, so carved or modelled, as to fit accurately the side of the pelvis, as well as the thigh and leg of the side on which the disease exists:—such a splint, properly padded, while it prevents motion, produces no injurious pressure about the joint, nor at any part of the limb. AArhenever there is much heat, pain, or tenderness, leeches will be proper, with the same cooling and evaporating lotions as were directed in cases of white swelling. Some surgeons prefer the application of cups to leeching. In many cases, in the earlier stages of the com- plaint, previous to the soft parts about the joint becoming affected Avith any considerable amount of inflammation, we have been more pleased with the effects of cupping, than with those derived from leeching; but we have been repeatedly called to cases, at a later stage of the complaint, in which, although local bleeding was demanded, the extreme tenderness of the diseased joint prevented the applica- tion of cups, and obliged us to resort to leeches. In this affection, we know of no practice which will be found more generally beneficial, than pretty active purging with the compound powder of jalap, as pursued by the late Dr. Physick. Under this treatment, with perfect rest of the limb, leeches, and cooling lotions, we have repeatedly seen the general health of the patient rapidly im- prove, and a perfect cure effected. The diet of the patient, in the early stages, should be light and easy of digestion. Milk, with any of the farinaceous substances, or light meat broths, in moderation, may be allowed. Blisters are unquestionably useful in the early period of the disease. We prefer repeated blisters, to keeping up a discharging surface by stimulating ointments. In very chronic cases, a caustic issue, just before and below the great trochanter will probably be more bene- ficial than blisters. Frictions with iodine in the form of solution or ointment, in conjunc- tion with its internal use, will often produce very happy results. When suppuration is about to occur, or an abscess or abscesses have already formed, the effects of gentle, continued pressure may be tried. AVe think that in a few instances we have seen it beneficial. AVhen abscesses form, it is better to avoid, if possible, opening them, lest we cause the cavity of the joint to become exposed. In regard to general treatment, this is to be conducted upon pre- cisely the same plan as in any other case of scrofulous disease. 634 DISEASES OF CHILDREN. Disease of the Spine.—Children of a delicate, enfeebled frame of body, particularly females, Avhen approaching the period of puberty, are liable to curvature of the spine, entirely independent of disease of the vertebrae; though, when long-continued, disease of these, as well as of the intervertebral cartilages, is liable to take place. The spe- cies of curvature we now refer to is the result of a defect of power in the muscles by which the erect position of the trunk is maintained. It is often increased, if not produced, by improper articles of dress, which furnish an artificial support to the upper part of the body, and thus deprive the muscles of the trunk of their proper office; these consequently obey the general physiological law—by Avhidi muscles long disused diminish in bulk, and finally lose entirely their power of acting. Stays, corsets, and braces produce this effect, under all cir- cumstances, when worn during the period of youth, and, in too many instances, the mischief is increased by the undue pressure they exert upon the muscles and bony structure of the chest. The general plan for giving increased vigour and tone to the whole system, by improving its nutrition, must be pursued in these cases; at the same time a loose style of dress should be adopted, and artificial supports of every kind abandoned. The power of the muscles about the spine and chest may be very materially increased, and even considerable curvatures of the spine removed, by a proper course of calisthenic exercises, daily practised, and firmly persevered in. Such exercises as gradually accustom the patient to support the entire weight of the body by the arms, in climb- ing, swinging, and the like movements, have a tendency to give de- velopment, strength, and activity to the muscles upon the chest, as well as to those of the back and spine, concerned in maintaining the body in its erect position, while, at the same time, when carried on in the open air, they promote the general health of the system. Fric- tions with the hand or flesh-brush over the entire surface of the back, employed daily, as well as sponging with tepid salt water, a well- regulated diet, and daily general exercise, are all-important mea- sures, which should never be neglected. In the proper spinal disease, from an affection of one or more of the vertebrae, exercise, either general or regulated, is out of the question: perfect rest in the recumbent position must be enjoined, and perse- veringly maintained, until the disease of the bones is fully arrested. Various contrivances have been devised to take off the pressure of the head and upper portion of the trunk from the spine, when the patient is in the upright position, and by this means to allow him to exercise his body by walking about. We confess that we have seen but little good result from these contrivances, and, in many cases, positive in- jury •—we prefer the recumbent posture, until the cure of the local disease is considerably advanced, when, probably, the machine in- vented for cases of diseased spine by Dr. J. K. Mitchell, of Philadel- phia, may be resorted to, for a short time daily, with advantage. _ From diseased vertebrae, a certain amount of angular curvature is inevitable; though, by a prudent and judicious course of treatment, early commenced with, we may be enabled to diminish, very materi- ally, the extent of the deformity. DISEASES OF THE NUTRITIVE FUNCTION. 635 The great object of the practitioner, in these cases, sliould be, to give, as quickly as possible, increased tone and vigour to the whole system; for when this can be readily effected, the disease of the ver- tebrae is very generally arrested, and their complete consolidation produced. The morbid condition of the system is to be removed by a nourishing diet, friction of the surface, and the internal use of tonics; —the different preparations of iron, as the carbonate, proto-carbonate, ferrum tartarisatum, the tincture of the sesquichloride of iron, the iodide of iron, the hydrochloride of barytes, iodine, and the sulphate of quinia, are to be preferred. Iodine, externally and internally, has, unquestionably, in a large number of cases, been attended with the most happy effects; even when the disease of the bones has made considerable progress, its use has appeared to arrest the disease, and allow anchylosis to take place. With the administration of iodine by the mouth, the diseased por- tion of the spine should be rubbed daily with the ointment or solution. During the treatment, the bowels should be kept freely open by mild aperients. In the early stage of many cases of the disease, ac- tive purgatives, particularly the compound of jalap and bitartrate of potassa, will be found of advantage. After all, however, we believe that the plan of treating the disease with caustic issues, formed along the spine, on each side of the dis- eased vertebrae, as originally recommended by Pott, should not be neglected; we have unquestionably strong evidence in favour of its success. We have seen the most decided benefit result from it in numerous instances; and by resorting to it, we in no degree preclude ourselves from whatever advantages are to be derived from rest in the recumbent position, purgatives, the local application of iodine, or its internal use, either alone, or in conjunction with tonics. The time necessary for the cure of diseased vertebrae is very various in different cases: in some, complete consolidation of the spine may take place at the end of a month or two; in others, not until after many months. In all cases it is important that the patient should not resume the upright position until we are certain that anchylosis has made considerable progress; nor should it be retained, at first, for any length of time, and on no account should much active exercise be attempted. So soon, however, as anchylosis has taken place, gentle daily exercise, at first by the aid of crutches, subsequently without any support but that derived from a cane, and finally, entirely with- out support, should be commenced: by this means the natural strength and movements of the muscles of the lower limbs will be gradually regained, and the general health of the body improved. In cases marked by a strong predisposition to tubercular depositions, the best that the physician has it in his power to do, is to endeavour to prevent the formation of the tubercles by means adapted to restore health, strength, and vigour to every portion of the system; or when they have already formed, by the use and proper regulation of the same means, to endeavour to prevent their subsequent development, and the irritation produced by them in the tissues in which they are seated. AVhatever symptoms are produced by them, when they are 636 DISEASES OF CHILDREN. seated in the lungs or brain, must be treated upon general principles; always recollecting, however, that the particular constitutions in which tubercular depositions ordinarily take place, will not bear cither de- pletion being carried to so great an extent, nor so restricted a diet, as many of the symptoms which arise Avould often seem to demand, ,or which would be proper, Avere they to occur in other constitutions. AATe have no means of positively judging of the presence of tuber- cles in the brain, and most of the other organs, during the lifetime of the patient: we may suspect their presence, however, whenever chro- nic and anomalous affections of any of the organs occur in individuals Avho exhibit a very strong predisposition to affections of a scrofulous character. SECTION VI. DISEASES OF THE URINARY ORGANS. l.—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 ex- tent, as a symptom of any febrile excitement under which they may labour, and is very common 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, though ge- nerally only a temporary inconvenience, may nevertheless continue for a considerable length of 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 A-iolent agitation, and cause him to utter uninterrupted shrieks, until the discharge is com- pleted, 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 con- dition 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 continu- ance,—if it do not, sooner or later, terminate in a complete suppres- sion of the urinary secretion: it is described by some of the conti- nental writers, under the denomination of urodialysis neonatorum. In this form of dysuria the urine is passed in very small quantities, often only a few drops at a time, and, evidently, with intense pain, as diseases of the urinary organs. 637 indicated by the screams of the patient, the drawing up of his legs to- wards 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 Avhich it passes, and, finally, excites inflammation of the lining membrane of the bladder, and probably of the urethra also, as indi- cated by the mucus with which the urine becomes charged. The patient usually exhibits more or less febrile excitement;—the skin is 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 mar- bles. The digestive function is invariably deranged;—the breath having a very decided acid odour. There is, generally, considerable irritability of the skin: while inflammation and superficial ulceration, attended with a thin, acrid, fetid discharge, by which the mischief is extended to the neighbouring parts, are almost certain to occur, wherever two surfaces are in contact. Cutaneous eruptions, of va- rious kinds, are also very common; sometimes assuming the form of psydracious (impetiginous) pustules, scattered over different 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. The more violent forms of dysuria occurring in children, are, very generally, accompanied with more or less derangement of the diges- tive process, and the formation of acid in the alimentary canal. Se- vere 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 coexists an insatiable appetite for food of a rich, stimulating quality. " Children," to adopt the lan- guage of the elder Schmidt, "who, 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 in them some trifling cause to rouse it into more open and rapid action." 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 increased secretion of lithic acid by the kidneys, and thus changing the normal constitution of the urine, may, during childhood and in- fancy, be the cause of a very considerable degree of irritation about the neck of the bladder—then easy to be excited, from the physiolo- gical 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 Avhich occur during dentition, or during slight febrile attacks, the dysuria is evidently the result of the increased irritability which the lining membrane of the bladder experiences, in common Avith the other mucous tissues, and, although the urine may also con- 638 DISEASES OF CHILDREN. tain a slight excess of acidity, this is too small a quantity to produce the degree of dysuria experienced, without the former. Ararious intestinal irritations are an occasional cause of difficult and painful micturition in young children. AVe 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. AVe have known, also, an ordinary attack of dysentery in a child, to be accom- panied with severe dysuria. In a few cases that have fallen under our notice, we have had rea- son to believe that dysuria depended upon a degree of inflammation about the neck of the bladder. The urine, in these cases, notwith- standing the calls to void it were very frequent, was passed with more or less pain, in very small quantities, and loaded with mucus. Partial retention of urine is common in such cases. According to Eberle, in female children, a very common cause of dysuria, and one very often overlooked, is an inflamed condition of the orifice of the urethra. 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 considera- ble 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 act, 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, hoAvever, 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 it may be the cause of gravelly or calculous 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, in- tense 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. AVhen dependent upon disordered assimila- tion, it is important to employ such means as are calculated to render DISEASES OF THE URINARY ORGANS. 639 the digestive process more prompt and regular. Previous to weaning, the breast-milk of a healthy nurse, pure air, the warm bath daily, fol- loAvad 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 acescent kind should be entirely prohibited; at the same time, daily exercise should be taken in the open air, cold and dampness being 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 suf- ficient 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 hyoscyamus, repeated once, twice or thrice a day, as may be necessary. R.—Calomel, gr. vj.—xij. Pulv. ipecac, gr. iij. Magnes. calc. gr. xxxvj. Ext. hyoscyami, gr. iv.—vj.—M. f. ch. No. xij. 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-carbonate 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 camomile, and then diluted with barley, rice, or gum water. When dysuria occurs during dentition, the state of the gums should be carefully watched, and inflammation, distention, and pain of these promptly removed, by free incisions 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 ammonia, with the addition of a small quantity of the sweet spirits of nitre, will be proper. 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, there- fore, with the administration of the latter. 1 R.—Aq. cinnamom. gij. Spir. terebenth. gjss. Magnes. calc. gr. viij. Spir. aeth. nitr. giij. Tinct. opii camph. gij.—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 Avhitish or yellowish sediment, and becomes rapidly putrid Avhen suffered to remain at rest, the diet of the child, 610 DISEASES OF CHILDREN. if weaned, should be mild but nutritious, and taken in moderate quan- tities, so as not to endanger the overloading of the stomach, or the disturbance of its functions. In addition to milk, and the usual fari- naceous preparations, the child may, w-ith 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, and plainly cooked, Avithout much seasoning. For drink, we may direct weak lemonade, or Avater sweetened Avith 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 condition of the digestive organs, the bowels should be freely evacuated Avith 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 Avhich this form of dysuria is generally accompanied, either the Dover's powder,1 in ' small doses, or a combination of ipecacuanha and extract of hyoscya- mus,2 will, very frequently, be found beneficial. 1 R.—Pulv. Doveri, gr. vj. aR.—Pulv. ipecac, gr. iij. Pulv. valerian, gr. xij.—M. f. ch. No. Ext. hyoscyami, gr. iv.—vj.—M.f. ch. xij. (Eberle.) No. xij. Of these one may be given every six hours, One every three hours. to a child between 2 and 5 years of age. After the bowels have become regular, and their discharges natural, benefit may be derived from the administration of the tincture of the sesquichloride of iron, in small doses, or of the protocarbonate of iron. Daily exercise in the open air, the tepid bath, and frictions of the surface, are all-important measures, and should never be neglected. All alkaline substances are improper. AVhen dysuria appears to be dependent upon a morbid degree of irritability in the lining membrane of the bladder, the condition of the urine being normal, or very nearly so, the treatment should con- sist of a mild, unirritating diet, the use of the warm or tepid bath dailv, 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 hyoscyamus and ipe- cacuanha, as directed above, three or four times a day. A weak infu- sion 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, has been found, in some of these cases, peculiarly beneficial. R.—Sem. dauc. carotae, gij. Or, R.—Rad. apii petroselini, gij. Aq. bullient. gviij.—M. Aquae bullient. gviij. Let it stand until cold, then strain, and add half a pint of the mucilage. Very active exercise will not.be proper; but a short Avalk, 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 DISEASES OF THE URINARY ORGANS. 641 dysuria, it is important to defend the surface against cold and damp, and hence the importance of flannel being worn next the skin. AVhen dysuria is connected with inflammation of the neck of the bladder, a leech or tAvo may be applied to the perineum; the bowels should be kept freely open by the mildest laxative enemata, and the warm hip-bath should be used every evening. In other respects, the treatment differs in nothing from that directed for irritability of the bladder. In the cases of painful micturition, occurring in female children, from inflammation of the orifice of the urethra, we have frequently found speedy relief to be derived from washing the part, three times a day, Avith a solution of acetate of lead, keeping the bowels freely open by mild laxatives, putting the patient upon a mild, unirritating diet, and using the warm or tepid bath daily. Covering well the inflamed part Avith perfectly fresh lard, or spermaceti ointment, by protecting it from the contact of the urine, will often enable the in- flammation to heal, if it be of a simple erythematous or phlegmonous character. Some prefer, as a wash, a strong solution of the borate of soda. In many cases, there exists a slight pustular eruption around the orifice of the urethra, often occupying the whole of the fossa in which the urethral orifice is situated: in these cases, the diluted citrine oint- ment Avill seldom fail to effect a speedy cure. R.—Ungt. nitrat. hydrarg. gj. Axung. porcinae, gj.—M. In every case in which there occurs dysuria, or any other symptom most generally connected with a change in the composition of the uri- nary secretion, it is all-important to pay strict attention to the condi- tion of the urine voided, and to ascertain with accuracy its prevailing character, and according as this indicates an excess of the lithic acid, or of phosphatic matter, to direct such a course of treatment as will be calculated to arrest the secretion of either. By these means, perse- veringly carried out, the formation of stone in the bladder may be al- most certainly prevented; while, by their neglect, or the careless man- ner in which they are pursued, the child may be subjected, eATen before he attains to adult age, to all the pain and suffering attendant upon calculous formations. 2.—Anuria.—Suppression of Urine. The kidneys perform their secretive function previously to birth; and, very generally, the moment the child is born, or, at least, within a very few hours subsequently, a discharge of a pale-coloured, inodor- ous urine takes place from the bladder. It is by no means uncommon, however, for six, twelve, twenty-four, thirty-six, and even forty-eight hours to elapse, before the infant passes any Avater: in these cases, it is reasonable to suppose that the function of the kidney has not been established. Tho infant exhibits no uneasiness whatever, that can be referred to this cause, and the discharge, when it occurs, generally goes on regularly. The physician need give himself little uneasiness, in consequence of 642 DISEASES OF CHILDREN. the child's not urinating for the first twelve hours after birth. If the discharge does not then take place, however, it will be proper, in the generality of cases, to attempt to excite the action of the kidneys by some simple means. The bowels should be freely evacuated, by means of castor oil, or laxative enemata, the child should be immersed to the hips in a warm bath, and a few drops of the sweet spirits of nitre may be given every half hour, in a dessert-spoonful of the infusion of parsley root, or of wild carrot seed. AVhen these simple means fail, Ave confess that we have seldom seen any good result from those of a more active character. We are recommended, however, to employ frictions over the loins and hypogastric region, with warm vinegar of squill, or a mixture of juniper oil and sweet oil, or with the expressed juice of onions, diluted with water; and, internally, to exhibit a few drops of the vinegar of squill, or a drop of spirits of turpentine, in a teaspoonful of milk, or four or five drops of the expressed juice of roasted onions, every thirty or forty minutes; in conjunction with warm bathing, laxatives, and, if necessary, laxative enemata. So long as the child exhibits no unusual drowsiness, or restlessness, there is a possibility of the kidneys commencing their secretory func- tion, and the child doing well. . We have repeatedly known the urinary discharge to be suspended for upwards of twenty-four hours, without the least injury resulting. In some cases, however, the suppression of the urinary discharge in young infants is the result of congenital malformation of the kid- neys, ureters, or bladder, or a disorganization of the kidneys from intra-uterine disease. Absence of the kidneys, ureters, or bladder, though of very rare occurrence, has been occasionally observed: occlusion of the ureters, or of the urethra, is more common, and many cases are related, in which, at birth, there was softening of the kid- neys, or the pelves were entirely filled with calculous concretions; or the kidneys were converted into cysts, or filled with hydatids. The absence of the urinary secretion has, in many cases, been dependent upon congenital disease of the spinal marrow. We have met with one or more of these cases. AArhen the suppression of the urine is dependent on malformation, extensive disease, or disorganization of the kidneys, or of the urinary organs generally, of course nothing can be done for the relief of the patient, who seldom survives more than a day or two; he quickly falls into a state of stupor, which sooner or later terminates in death. Anuria may occur at any period during infancy and childhood, from disease of the kidneys. In many of their acute febrile affections, the secretion of urine is very considerably diminished, or, for a time, en- tirely suspended. Complete anuria is a common symptom of the latter stage of hydrocephalus, as Avell as of other affections of the brain, or of the spinal marrow. In such instances, of course, the reinstate- ment of the function of the kidneys is dependent upon the reduction or removal of the disease with which it is connected. In a very interesting case, related by Fosbroke, of suppression of the urinary discharge in a child, in which the anuria was preceded by diarrhoea, aphthae of the mouth, cough, strabismus, stupor, and con- DISEASES OF THE URINARY ORGANS. 643 vulsions, the kidneys were found, upon dissection, to be very vascular, the papillae projected through the infundibula, and were of a bright red colour, while the pelves and ureters contained a quantity of sabulous matter and tenacious mucus. 3—Ischuria-—Retention of Urine. In ischuria, the urine is regularly secreted by the kidneys, and con- veyed into the bladder, but its discharge being prev-ented by some affection of the latter organ, or of the urethra, it accumulates in the bladder, causing it to become greatly distended, with other very serious, and often painful consequences. Complete or partial retention of the urine may occur in the new- born infant, in consequence of an obstruction existing at the neck of the bladder, or in the course of the urethra, from inspissated mucus. This species of retention is said to be very common; but we should not infer it to be so from our OAvn experience, having met with but one or two cases of it, in upwards of thirty-six years' practice as an ob- stetrician. A much more common cause of retention in new-born in- fants, is that from occlusion of the urethra, either by a thin, semi- transparent membrane, situated at its orifice, or a short distance within it, or by an adhesion of the lips of the external orifice. In some cases, the retention is caused by a complete closure of the prepuce. In other cases, the cause of retention has appeared to be a spasmodic contrac- tion of the bulb of the urethra. In cases of ischuria in the new-born infant, as the urine gradually accumulates in the bladder, this becomes more and more distended, and may, at length, be distinctly felt, forming a circumscribed tumour above the pubes. The infant very soon exhibits indications of more or less pain and distress, which are increased by pressure upon the hypo- gastrium. The little patient becomes very restless and fretful, his coun- tenance has an expression of suffering, and his legs are constantly drawn up towards the abdomen; while the latter, if the impediment to the discharge of urine be not removed, becomes often enormously distended, and the skin covering it acquires a smooth shining appear- ance, as in cases of ascites; the superficial veins being, at the same time, greatly enlarged and gorged with blood. If the accumulation within the bladder be allowed to go on, rupture of the latter may, sooner or later, take place, and quickly destroy the patient; or the urine, after enormously distending the bladder, may accumulate within, and produce distention of the ureters, and, finally, of the pelves of the kidneys. In some of these cases, the kidney itself becomes expanded into a kind of cyst, filled with urine. Inflammation of the peritoneum, effusion into the cavities of the brain, and other serious consequences, may result from irremediable obstructions to the discharge of the urine—altogether independent of rupture of the bladder, which we have not found to be a very common occurrence. It is surprising to what an extent, in some of these cases, the blad- der will become distended: it has been found by Billard, to fill the whole cavity of the abdomen, and by Howship, Parrish, and others, to 644 DISEASES OF CHILDREN. contain from eight to twenty ounces of urine, sometimes mixed with mucus or albuminous flocculi. The ureters have, in some cases, been so far dilated as to present a diameter of from half an inch to one or more inches. In all cases of ischuria, in which a permanent and irremediable ob- struction to the exit of the urine from the bladder exists, death must, necessarily, sooner or later, take place. In those, however, depending upon occlusion of the external orifice of the urethra, or the want of an opening in the prepuce, the obstruction may be very readily remedied by a very simple operation. In every instance in which a new-born infant is found not to have an evacuation of urine within twelve hours, at the furthest—or sooner, if any indications of pain or distress exist—the physician should make a cautious examination of the urethra, by the careful introduction of a small bougie, by which any obstruction in that part will at once be detected; and if this result from inspissated mucus, it will at the same time be removed. If the urethra is found to be pervious, and the in- troduction of the bougie is not followed by a Aoav of urine, a small flexible catheter should, Avith the utmost caution, be passed into the bladder—for there is reason to believe, that, in some instances, the re- tention is caused by a spasmodic action of the membranous portion of the urethra, or, when the bladder has been allowed to become greatly distended, that its contractile power may have become temporarily impaired. In this latter case, it will, in general, be prudent to pass the catheter daily, until it is found that the bladder has regained sufficient power to completely evacuate itself without artificial assist- ance, and no tendency to a reaccumulation remains. Whenever, in cases of retention of urine occurring in infants, no obstruction to the exit of the urine can be detected in the urethra or at the neck of the bladder, the boAvels of the patient should be freely opened by purgative enemata, after which he should be immersed to the hips in a warm bath, and, at the same time, gentle friction may be made over the pubic region with the hand, or with a little campho- rated oil. This will often be sufficient to procure the discharge^ of urine, especially should it happen to depend upon a spasmodic affection of those muscles of the urethra Avhich act as a sphincter vesicae. During the whole of infancy, and the earlier period of childhood, suppression of urine is liable to occur from this latter cause. The in- ability to evacuate the bladder may occur suddenly after exposure to cold, but, more commonly, it results from some irritation seated in the rectum, as the oxyures, or other worms. In these cases, the warm bath, an active cathartic, as castor oil or infusion of senna, followed by an anodyne injection, and frictions over the perineum with cam- phorated oil, with the addition of a very small portion of extract of belladonna, will be the proper treatment. AVe have met with a num- ber of cases of suppression of urine in children about the period of den- tition, arising evidently from this cause; and the practice detailed has always been productive of prompt and entire relief. Occasionally, retention of urine in children results from an inflam- mation of the neck of the bladder. When this is the case, leeches to DISEASES OF THE URINARY ORGANS. 645 the perineum, emollient and laxative enemata, the hip-bath, and small doses of Dover's powder and ipecacuanha, or of extract of hyoscya- mus and ipecacuanha, are the remedies indicated. If by these means the ischuria is not quickly relieved, the urine must be drawn off by the cautious introduction of a small catheter. It is scarcely necessary to say, thai) all remedies which act directly upon the kidneys, are improper in cases of retention of urine; they augment the distress and danger of the patient, by increasing the amount of fluid secreted, and consequently the distention of the bladder. Under ordinary circumstances, there is scarcely a possibility for any mistake being made in the diagnosis of ischuria; nevertheless, Avhen the obstruction to the discharge from the bladder is only partial, after the latter has become distended to a certain extent, small por- tions of urine are, occasionally, evacuated, notwithstanding a con- stantly increasing accumulation is, in fact, taking place; and, unless the physician makes, himself, an examination of the condition of the bladder, he will be very liable to be deceived by the report of the mother or nurse, and attribute the suffering of the patient to other causes. Cases have occurred, in which the bladder was finally ruptured by over distention, and death ensued from peritoneal inflam- mation, when relief might have been afforded, had a retention of urine been suspected to exist: a small discharge from the bladder deceived the attendants, and by incautiously depending upon their report, the physician was led to form a very erroneous, and unhappily fatal diagnosis. AVhenever we are called to a young infant, wdio is restless and fret- ful, and persists in keeping its legs drawn up towards its abdomen, Ave are scarcely free from censure, if, notwithstanding the assurances of those about it, that it passes its urine regularly, we neglect to make a cautious examination of the abdomen, by which, if retention of urine exists, the fact may be readily detected. 4—Enuresis—Incontinence of Urine. In early infancy, the discharge of the urine, as Avell as of the faeces, takes place involuntarily. As the infant increases in age, and soon after it assumes the erect position and has learned to walk alone, Avith a very little precaution, it will acquire a command over the sphinc- ters of the rectum and bladder, and be able to retain the contents of either, until a proper place and opportunity is offered for their evacua- tion. Children who have not been taught regular and cleanly habits in regard to their evacuations, will often, even after they have arrived at tAvo or three years of age, void their urine and faeces the moment the desire is felt; and what at first resulted from a mere inattention of parents to restrain, under any circumstances, the natural calls, will at length degenerate into a partial loss of the controlling power of the Avill over tho sphincters of the rectum or bladder—more particularly over the latter—and the children finally may become affected with real incontinence of urine. Happily, however, a sense of decency, 646 DISEASES OF CHILDREN. which children early acquire, the ridicule of companions, or other in- fluences, prevent this latter occurrence, excepting under very particu- lar circumstances. Still, incontinence is of very common occurrence among children of all ages, even up to the period of puberty, and sometimes until late in life. In some cases, it evidently originates from paralysis of those muscles by which the expulsive action of the bladder is resisted; or perhaps from paralysis also of the bladder: in these cases, of which we have seen many, the urine dribbles aAvay constantly, being dis- charged, guttatim, as it reaches the bladder. Some of the patients thus°affected passed from under our notice; some survived until their fourteenth, sixteenth, and eighteenth years, and then died of other dis- eases,—in the majority of cases of a tubercular character,—while others became early affected with paralysis, hemiplegia, or paraple- gia; and when they died, exhibited extensive lesions of the brain or spinal marrow: one died with all the symptoms of genuine tetanus, more probably, however, the result of an overdose of strychnia, exhi- bited by an empiric of the homoeopathic school. But the most common form of incontinence of urine is that which presents itself in a discharge of urine at night, while the patient is asleep in bed. . There are few young children, Avho, during the intense nocturnal slumber peculiar to their age of life, do not occasionally pass their urine in bed, particularly if care has not been taken to cause them to urinate just before going to sleep; or, if they have been indulged in the use of tea or other fluids late in the evening. But this docs not constitute a case of incontinence, properly speaking, though it may become so by neglect. m Children affected with enuresis, at first occasionally, but very soon habitually, and very generally at a particular hour of the night or morning, discharge their urine whilst asleep. It is not true that incontinence of urine occurs only during sleep: not only are the calls to urinate at all times more frequent and press- ing than in health, but the urine, according to Willis, is always more copious, and of lower specific gravity; it very rarely contains the due proportion of characteristic animal ingredients, but is colourless and WThiT'is unquestionably true in the majority of cases of enuresis in children: it is not, however, invariably so; in numerous instances as Prout remarks, the urine contains an excess of sedimentitious matter particularly lithic acid and its compounds, which impart to it an acrid and irritating character. The patient has, at all times, frequent call, to pass his urine, and is unable to retain it for any time after the desire is experienced. . ^ It is probable that the discharge, during sleep, in many cases, par- ticularly Avhen it has become habitual, is entirely involuntary, and takes place without the patient being at all conscious of the act. in numerous instances, however, there is no doubt, as Prout yery just > remarks, that the discharge is a voluntary effort, excited by a Jivcl) dream: the dream being prompted either by the distention of the blad- der, or by the stimulating properties of the urine. DISEASES OF THE URINARY ORGANS. 647 It has been said, that a discharge of urine never takes place during sleep, excepting when the individual is lying on his back; the urine, in this position, gravitating in such a direction as to press directly upon the "sensible spot—the master spring" of the muscles of the bladder, "situated a little behind and below its orifice." (Charles Bell.) This statement is by no means correct; from personal obser- vations, made under circumstances peculiarly favourable for arriving at correct conclusions, avo know—and the same thing has been re- marked by AAlllis—that children affected with nocturnal incontinence of urine, pass their water while sleeping in any position, probably even more frequently when they happen to be lying on their face, than in any other posture. Whoever, therefore, trusts to position alone for the cure of incontinence of urine in children, will be sure to be disap- pointed. That the affection, whatever may have originated it, is very com- monly continued and confirmed by habit, is proved by the fact, that by Avatching the patient, to ascertain the particular hour at which the discharge takes place, and Avaking him just before it arrives, to enable him to evacuate his bladder, he will in a very short time either awake of himself, and thus the wetting of the bed be prevented, or he will acquire, in time, the power of retaining his urine during the entire night. Though a trifling malady in itself, so far as the general health of the individual is concerned, incontinence of urine is often one of serious importance, from the physical suffering and moral misery it occasions, when the child arrives at an age capable of feeling the shame so gene- rally attached to his infirmity, and the scorn and ridicule heaped upon him for what he had as little agency in the production of, as he has power to prevent its continuance. Boys, remarks Willis, have been known, who had been beaten unmercifully for wetting the bed, to sleep, or rather pass the night, in their clothes, on the floor or in a chair, for several nights afterAvards, till, worn out Avith fatigue, they found themselves compelled to undress, and take natural rest; hoping, as they had escaped one or two nights, passed between sleeping and waking, they might possibly get through another, and yet sleep soundly. But in vain: the very first night after betaking themselves to their bed, they were as unfortunate as ever; and then came the renewed beating, and, far worse to bear, the ridicule and scoffing of companions, or the other members of the family. It is the duty of physicians to point out, on CArery proper occasion, the serious consequences which such im- proper and cruel means, originating in an entire misconception of the nature of the complaint, are capable of producing. It is curious, that in relation to an affection of every-day occur- rence, so great a difference should exist as to the sex in wdiich it is most commonly observed; thus, byAVardrop, it is said to occur only in boys; by Steward thai girls are more subject to it than boys; while Millar affirms that it is equally common in children of both sexes. Now the fact is, that neither sex is exempt from its occurrence, al- though, according to our OAA-n experience, it is certainly far more fre- quent in the male than in the female. 648 DISEASES OF CHILDREN. In regard to the treatment of nocturnal enuresis in children, avc be- lieve the general want of success, attendant on the various plans that have been proposed for its cure, has arisen from an entire mistake in regard to the true nature of the disease, and from the remedies being directed to remove some supposed morbid condition of the bladder, which seldom if ever exists. Our own observation has taught us the entire correctness of the vieAvs of those writers who refer the disease, primarily, to a derangement of the digestiA-e and assimilative organs, and a consequent morbid change in the constitution of the urine. We have seldom seen a case of nocturnal incontinence of urine, Avithout its being accompanied by more or less derangement of the digestive organs; and have very generally found, that Avhen this is removed, the involuntary discharge of urine ceases. In those cases in which the urine contains an evident excess of lithic acid, the course of treatment directed, under similar circumstances, for the cure of dysuria, will-be equally proper here. Daily exercise in a pure, dry air; avoidance of cold and dampness; a diet composed of a moderate portion of plainly-cooked beef, mutton, or chicken, with the least acescent of the farinaceous preparations, and the daily use of the warm or tepid bath, with friction to the surface, and a prudent use of alkaline carbonates, as magnesia, the bicarbonate of soda, or the carbonate of potassa, with light bitters and tonics, and a gentle purgative and Avell-directed alterative course, will in most cases be found sufficient to improve the condition of the digestive organs, as well as of the urinary secretion; and as these changes take place, the involuntary discharge of urine during sleep will become less frequent, and finally cease entirely. When the condition of the urine is that pointed out by AVillis— namely, pale and watery, of diminished specific gravity, and deficient in its usual animal ingredients, the same attention should be directed to restore the healthy function of the digestive organs, and bring back the urinary secretion to its normal state. Any light bitter infusion, acidulated with hydrochloric acid, with the addition of a very small proportion of the tincture of opium, will be found a useful remedy in these cases; or we may administer, as directed by AVillis, a couple of tablespoonsful of the concentrated decoction of uva ursi, with the ad- dition of ten drops of the tincture of the sesquichloride of iron, two or three times a day. The dose of the latter remedy here directed, is that adapted to a child of five or six years of age; but a younger pa- tient will seldom bear more than a teaspoonful at a time of the de- coction, and from three to five drops of the tincture of the sesqui- chloride 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, according to AVillis, a blister to the sacrum has succeeded in relieving the complaint; w-e have used the blister frequently, occasionally with complete success; in others, with no advantage whatever. Success has more than once followed the use of sedatives, as camphor, digitalis, nitrate of potassa, benzoic acid, &c, where tonics DISEASES OF THE URINARY ORGANS. 649 and stimulants, which at first appeared to be rationally indicated, have failed. Children, as a general rule, but more especially when affected with nocturnal incontinence of urine, should not be alloAved to partake of large quantities of any kind of fluid, either as drink or food, in the latter part of the afternoon and evening. They should indeed be prohibited from the use of every species of food a short time before retiring to rest. The caution should be observed to cause them to evacuate the bladder just before being put to bed; and to wake them for this purpose at regular intervals during the night. Cases, however, occasionally occur, in Avhich none of the means employed is productive of any permanent benefit. In these obstinate cases, it has been supposed that the infirmity could be traced to a con- genital deficiency of control over the sphincter of the bladder, the chil- dren Avetting themselves whenever sharply spoken to, or frightened:— we have repeatedly 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. It is in these cases 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 Aoav, a degree of stran- gury occurs, sufficient to aAvaken the patient, and thus prevent the evacuation taking place in 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 child will become accus- tomed to aAvake Avhen the desire to urinate occurs, and thus all the disagreeable consequences resulting from his unfortunate infirmity be prevented. From three or six, to ten or fifteen drops of the tincture of catharides, according to the age of the child, may be given three times in the course of the day, and the dose should be gradually in- creased, until a degree of strangury 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, un- connected with derangement of the digestive organs, and a morbid state of the urinary secretion. Should too violent a degree of strangury ensue from the action of the cantharides, it may be abated by the free use of emollient enemata and mild mucilaginous 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. Morand has long been in the habit of employing belladonna, in- ternally, in nocturnal incontinence of urine in children, and with very satisfactory results. It is, however, only when the incontinence re- 650 DISEASES OF CHILDREN. suits from debility that it is beneficial. He gives it in gradually increased doses. A pill containing three-fifths of a grain is at first given to children betAveen four and six years of age, night and morn- ing. If no effect is produced at the end of a week, a third pill is given at noon; and, after fourteen days, a fourth, if necessary. In this manner the remedy must sometimes be continued for two, three, or four months in succession. In cases of children between eight and fifteen years he begins with three pills, increasing the number as above. If signs of narcotism supervene, the medicine must, of course, be for a time suspended. Dr. Berengieur, in cases of incontinence of urine succeeding to obstinate attacks of intermittent fever, in children betAveen seven and fourteen years of age, found the most successful remedies to be a combination of copaiba, laudanum, and protoxide of iron, made into pills, in the proportion of three parts by weight of the former, to six of the latter. Of this mass one pill, weighing from two to three grains, wras given morning, noon, and evening; and after every two or three days, an additional pill, until the patient takes^ten daily. Along with the pills, an infusion of the folia juglandis was ordered as a common drink. The employment of strychnine has been recommended in cases of enuresis occurring in children, by Moudiere, Cherchiare, Lendrich, Schnatz, and others. Upon what principle it is supposed to prove bene- ficial, we are unable to conceive: Ave have given it a trial, but found it, when administered in very small doses, to do no good; and Avhen given in larger doses, its effects upon the nervous system have been too violent to warrant a continuance in its use. AVhen everything else fails, we may resort, in the male, to mechani- cal contrivances for compressing the urethra, and thus prevent the escape of the urine. The best is, that recommended by AVillis, in Avhich a firm, but not hard pad, is kept applied by means of a spring to the membranous portion of the urethra. This should not, however, be permitted to be worn habitually; it may be used, occasionally, Avith perhaps considerable benefit; and when children are visiting from home, will insure from the shame and mortification incident to this infirmity. Ligatures 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. AVhen this is the case, an enema of aloes, or asafoetida, 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 friction of the surface, 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. 5—Diabetes. There can be no doubt that children are frequently affected Avith a species of hyperuresis, in Avhich the urine discharged differs but little in its sensible qualities from common water, being perfectly DISEASES OF THE URINARY ORGANS. 651 limpid, entirely colourless, with scarcely any odour, and after standing for ten or tAvelve hours, becoming slightly opalescent or milky. This affection usually occurs in children of debilitated constitutions, emaciated, or quickly becoming emaciated, with soft protuberant abdo- mens, and listless, torpid, indolent dispositions. The appetite is gene- rally voracious, and the thirst incessant and insatiable. The child desires everything 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 disturbed, as well by a diseased condition of the stomach, as by the amount of food, often of a crude and insolu- ble kind, with which this organ is always overloaded. It is not un- common for the discharges from the bowels to be mixed with portions of undigested aliment, particularly of the vegetable substances 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 by M'Gregor and AVillis, in boys of three and five years of age, and in both boys and girls about twelve. In one of the cases referred to by Morton (Phthisisologia,) 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 appear to depend, very generally, upon derangement of the digestive and assi- milative functions, consequent upon the use of improper food, subse- quent to weaning. A confined, damp, or impure atmosphere, the want of sufficient exercise, and a congenital infirmity of constitution, are, no doubt, also, very common exciting or predisposing causes. The child exhibits at first no striking symptoms of disease, but be- comes gradually dull, listless and fretful; loses its usual playful and active disposition, and exhibits an uneasy, discontented and anxious 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 pe- riod, however, there is an increased discharge of urine, increased thirst, and a more craving appetite than usual; and these symptoms, Avith the gradual emaciation, and dry, harsh state of the skin, are in general referred to the presence of worms in the intestines, for Avhich the child is treated—the real nature of the disease being entirely overlooked. The emaciation goes on increasing, while the abdomen becomes more tumid, but Avithout much tenderness or tension. The tongue be- comes coated with a thick layer of mucus; the bowels become consti- pated or irregular, and the stools acquire an unnatural appearance, being occasionally slimy and green, or mixed with portions of undi- gested food; Avhile occasionally they are frothy, light-coloured, and apparently in a state of fermentation. The thirst rapidly increases, as Avell as the craving for food, and at the same time the discharge of urine augments rapidly in quantity, becoming often enormous; exceeding, at times, perhaps very gene- 652 DISEASES OF CHILDREN. rally,^ the amount of fluid taken. The emaciation goes on with in- creasing rapidity, and is attended often Avith extreme debility; while the skin becomes uniformly dry and very harsh. There is almost in- variably a gnawing sensation at the pit of the stomach, and increasing dulness, inactivity of disposition and depression of mind. The pulse, which wras at first somewhat accelerated, now becomes small, quick and hard. The latter stage of the disease is often accompanied with a consi- derable degree of febrile excitement, often attended Avith headache, vertigo and temporary delirium. In cases of long continuance, (ede- matous swellings of the lower extremities, or even general dropsy, have been known to occur. The child gradually sinks, apparently from an entire suspension of the nutritive process; in other cases, a state of deep coma precedes the fatal event. The urine discharged is generally pale, perfectly limpid, Avithout 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. AVhen 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 sloAvly in amount, that it is entirely overlooked by the parents of the child, or if noticed, is ascribed to the enormous amount of fluids which his morbid thirst prompts him to take. Even when a physician is consulted, the case is too often considered as one of worms, mesenteric disease, marasmus, or dropsy of the brain; and an improper course of treatment adds then 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 inordinate 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 prepa- rations of milk, eggs, and rice or oatmeal, without sugar; crackers should be given in preference 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; probably 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, acescent, or saccharine vegetables or fruits; and for his drink, he may take toast-water, slightly acidulated Avith 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 prohibited. AVith this diet, a due amount of exercise should be taken daily, in DISEASES OF THE URINARY ORGANS. 653 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 wea- ther will permit. 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 boAvels 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;1 or aloes, gamboge, carbonate of soda, and extract of hyoscyamus.2 AVhen the bowels have been fully evacuated by either of the foregoing purgatives, they may be kept regularly open by a combination of calomel, extract of hyoscyamus, magnesia and ipecacuanha.3 1 R.—Aloes, gr. xij. 2 R.—Aloes, gr. xij. Pulv. rhsei, gr. xxxvj. Gambog. gr. xij. Bi-carb. sodse, gr. xxiv.—M. f. Bi-carb. sodas, gr. xxxvj. pil. No. xiij. Ext. hyoscyami, gr. xij.—M. f. Of which one, or two, or three maybe given, pil. No. xiij. according to the age of the child, every This forms a \ery prompt, gentle and ef- ^ three hours until they operate freely. fectual purgative, when one pill is given every three hours. 8 R-—Calomel, gr. xij. Magnesise, gr. xxxvj. Ipecac, pulv. gr. iij. Ext. hyoscyami, gr. vj.—M. f. ch. No. xij. One to be given once or twice a day, as may be necessary. In some cases, according to Richter, emetics of ipecacuanha, re- peated daily, for two or three days, in the commencement of the dis- ease, have been found beneficial. Occasional small doses, say one grain tq a child between one and two years old, of the compound pow-der of ipecacuanha, may be given two or three times a day, after the bowels have been fully evacuated. Combining the opiate Avith uva ursi, or the carbonate or phosphate of iron,4 is said, by Venables and Reirson, to be attended, in many cases, with the most decided benefit. A combination of uva ursi, carbonate of soda, extract of hyoscyamus, and carbonate of iron, Avill likewise be found a very valuable remedy;5 or the uva ursi, extract of hyoscy- amus, and iron may be prescribed in a fluid form,6 Avhich is prefera- ble, generally, in cases of the disease in children. 4 R.—Pulv. ipecac, comp. gr. xij. s R.—Pulv. uvse ursi, gss. Pulv. uvae ursi, gss.—gj.—M. f. Bi-carb. sodae, gi*. xxiv. pulv. xij. Ext. hyoscyami, gr. xij. Carb. ferri, gr. xxiv.—M. f. ch. Or, R.—Pulv. ipecac, comp. gr. xij. No. xij. Carb. ferri, gijss.—gj.—M. f. One to be given three times a day. pulv. xij. 6 R.—Extract, hyoscyami, J}j. Or, R.—Pulv. ipecac, comp. gr. xij. Aquae, ^j.—M. Phosphat. ferri, gr. xxiv.—xxxvj. Five drops of this solution, and the —M. f. pulv. xij. same quantity of the tincture of the One of either of these formula** may be given sesquichloride of iron, may be given to a child between one or two years of age, three times a day, in a teaspoonful of every four hours. an infusion of uva ursi, one ounce to the pint of boiling water. 654 DISEASES OF CHILDREN. Infusions of calomba, gentian, or quassia, may be used occasionally, Avith very good effect. During the period of dentition, careful attention should be paid to the condition of the gums, and if these be SAvollen, painful, and red, they should be freely scarified. By Dewees, the external application of the spirits of turpentine is recommended in cases of diabetes in children. 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 character, tur- pentine constitutes, Avhen judiciously employed, one of our most bene- ficial remedies; and, so far as the disease of the digestive organs is concerned, we have no doubt it would prove an appropriate remedy internally, in the species of hyperuresis under consideration. We have been deterred from prescribing it, however, lest its action upon the kidneys might prove prejudicial. The tannin has been used by Giadorou in some cases of diabetes, Avith success; and is worth a trial, in a disease, which, in children, it is particularly difficult to control. R.—Tannin, gj. Ext. hyoscyami, 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 quan- tity of tannin in each dose being gradually increased to ten or fifteen grains. SECTION VII. CONGENITAL AFFECTIONS, AND ACCIDENTS OCCURRING, MOST GENE- RALLY, WITHIN THE MONTH. 1.*—Fractures. Fractures of the bones of the extremities are sometimes produced during birth, especially in cases where, from a mal-position or presen- tation, turning, or other, manual interference, is required: we have known the fracture of the humerus repeatedly take place by improper and unskilful attempts to bring down the arm after the protrusion of the head in cases of ordinary labour. In all instances in which this 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 CONGENITAL AFFECTIONS, ETC. 655 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, present a sufficient resistance to the feeble action of the infant's muscles. It is necessary, however, to watch carefully the limb until the drying of the splints, lest in handling the child it be accidentally bent at the place of fracture, or the fractured extremities of the bone be otherAvise displaced. Fractures in infants heal rapidly and promptly, and give little in- convenience, if properly secured. As nutrition at this period is rapid, reparation takes place also readily; a child may suffer more, observes Blundell, and incur more danger from cutting a tooth, than*a new-born infant from fracture of the femur or of the humerus. 2.—Congenital Malformations of the Intestines. 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. The malformation may consist in the constriction of the caliber of the intestines, at different points—in the entire closure of the canal by transverse membranes—in its division into separate parts—in the ab- sence of the lower portion of the rectum, and in its termination in the vagina in the female, or in the bladder in the male—or in the occlu- sion 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, and in many in- stances, there is discharged from the stomach 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 ex- tremely emaciated. A more frequent species of malformation is the closure of the anus by a membrane, differing in density and thickness, in different cases. This malformation is readily detected by the absence of any external opening—and the distention of the anus by the meconium accumu- lated in the rectum: this distention is more apparent when the child cries; at which time, also, a fluctuation can be very readily felt be- neath the occluding membrane. As soon as this malformation is detected, a crucial incision should be made, Avith 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 invo- luntary discharge of the faeces. Occasionally, the imperforation is situated some distance within the anus, the latter being perfectly formed. AArhenever 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 gut, it will generally be detected by the introduction of a gum elastic catheter. The ob- struction may, in many cases, be removed by an operation; the nature 656 DISEASES OF CHILDREN. of which will, in a great measure, be governed by the circumstances of each case—whether by the introduction of a trocar and cannula, as directed by some, or by the straight-pointed bistoury, as directed by others. The greatest caution should be observed in the introduc- tion of the instruments, as well as in the division of the obstructing membrane, lest the sides of the intestine be Avounded, or an opening be made into the bladder or vagina. We have lately seen a case of this species of malformation, in Avhich the obstruction, consisting of a transverse membrane, existed about an inch and a half Avithin the anus, the lower portion of the rectum being in 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 discharges from the bowels. Shortly before death, great tumefaction of the ab- domen from the development of gas took place, Avith evident pain on pressure of any portion of the abdomen: no operation was permitted by the parents. An examination of the body revealed 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 contracted, and free from the least trace of disease; the colon was enormously distended with gas, and, throughout its Avhole extent, injected AA-ith blood; the upper portion of the rectum Avas likewise greatly distended, and con- tained nearly eight fluid ounces of meconium and thick, ropy mucus; its mucous coat presented very decided marks of inflammation. The colon, as well as the rectum, was found congenitally deficient in a case recorded by Lehman; the ileum, on arriving at the place where the colon should have commenced, terminated in a blind sac filled with meconium. Another common malformation of the rectum is a firm adhesion of its sides, often for many inches above its natural termination, Avith 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 in 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; occasion- ally, it opens into the bladder or vagina. AVe 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 obliquely for- wards and downwards to the fundus of the bladder, into Avhich it opened by an orifice 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, and then gradually to deepen it 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 keep- CONGENITAL AFFECTIONS, ETC. 657 ing the artificial passage permanently dilated by tents of oiled linen or bouiries, of a proper size, the life of the child may be preserved. It is seldom, however, that the patient will acquire the power of retain- ing the faeces, or that the use of the tents can be abandoned, at any time subsequently, 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 trocar, 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. AVhen an outlet for the faeces cannot be procured by either of the above means, it has been proposed by Littre and Sabatier, to make an opening into the abdomen above the pubes; near one of the groins: by Duret in the left iliac region; by Callisen and Amussat in the lumbar region between the posterior border and crest of the ilium, parallel with the posterior edge of the quadrates muscle, or perpendicularly, in order to get at the colon, and form an artificial anus, in one or other situation. Duret is said to have performed the operation in the iliac region, and Amussat in the lumbar region, with success, in several r cases. A case is related by Roux, in which the rectum opened in the ure- thra, and others by Dubreuilh, and by Steele of New York, in which the rectum was entirely wanting, the colon opening into the neck or summit of the bladder. The case of Roux was successfully treated by incisions from the natural position of the anus, in the direction of the rectum. It has been supposed by many surgeons of eminence, that inconti- nence of faeces must be an inevitable result of an artificial anus esta- blished in the perineum or coccygeal region, not in connexion with the sphincter ani. The inaccuracy of this supposition is proved by the case of a patient operated on some years ago by Amussat of Paris. This patient has been under the care of Sir P. Crampton, up to the present period, and he states that no such infirmity exists. 3.—Tongue-Tie. 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 fraenum 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 impediment to the free motion of the tongue thence resulting, may render sucking very diffi- cult, or even impossible. We confess that we have never met with such a case; though, if nurses are to be believed, it is a thing of the most common occurrence. Infants occasionally 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. AVe have, hoAvever, repeatedly examined the tongue in such cases, and have de- 42 658 DISEASES OF CHILDREN. tected no malformation of it, or of its fraenum:—nothing, in fact, 7.) Mr. Aberle, of Vienna, gives the following conclusions as the result of the analysis of 180 cases of cyanosis. In 100 cases there Avas a defect in the partition of the ventricles; in 87 of these cases, there was also an abnormal communication of the ventricle with the aorta; in 22, the foramen ovale Avas closed, and in 65, it was open. In four cases only, the pulmonary artery arose from both ventricles. In the 87 cases in which the aorta arose from both ventricles, the pulmonary artery was 37 times strictured, or even quite closed. Of the 180 cases, two-thirds were males. Sufficient evidence is thus afforded, that abnormal communications between the cavities of the heart, particularly the auricles, by the non-closure of the foramen ovale, and various malformations of the heart, and of the main arterial and venous trunks, occur, in perhaps the majority of cases of cyanosis. The mixture of the arterial and venous blood, which is supposed to result from the free communication between the two auricles, in con- sequence of the patency of the foramen ovale is evidently inadequate to explain the blue colour of the skin, inasmuch as no such discolora- tion takes place in the foetus; Avhile the communication exists in the majority of infants for many days after birth, without a single symp- tom indicative of cyanosis being present. The foetal openings in the heart, and the communication between the aorta and pulmonary artery, by means of the ductus arteriosus, are not usually obliterated for some time subsequent to birth, and have been found open as late as the third week in infants who have died of disease totally unconnected Avith any disturbance of the respiratory apparatus in the slightest de- gree resembling that which occurs in cyanosis.1 It has been shoAvn, that in repeated instances the foramen ovale has remained open for a very considerable period, Avithout the occurrence of cyanosis; while the foramen has been found closed before birth, the foetus neverthe- less presenting all the symptoms of cyanosis. An interesting case is related by Mr. H. J. Johnson, in the London Lancet, for, February, 1843, of an adult female who died in St. George's Hospital of erysi- pelas, and in AA-hom, upon dissection, the foramen ovale was found so patent as to admit of tAvo fingers being passed through it from one auricle to the other. The heart was large, flabby, and somewhat di- lated. During the lifetime of this patient she presented no symptom from Avhich the nonclosure of the foramen could be inferred. It has indeed been denied by Cloquet and Louis, that any admixture of ■ Dr. Elsasser of Stuttgard, (Henle's Zeitschrift, iv. 1852,) after 870 examinations of the condition of the foetal openings and blood vessels at different periods subsequent to birth, states that in regard to the closure of the foramen ovale and ductus arteriosus, o-reat varieties occur. The completion of the process in much the greater number of instances, takes place within the first six weeks, and the obliteration of one or other duct before birth, or previously to the fourth or sixth week after birth, are exceptions, chiefly interesting- in a forensic point of view. CONGENITAL AFFECTIONS, ETC. 667 venous and arterial blood can take place, even with a free opening betAveen the two auricles, from nonclosure of the foramen, so long as the communicating cavities are of equal strength or provided all the orifices are free. It has been supposed by Louis, Frank, and others, that the contrac- tion of the pulmonary artery, which is so commonly met with in those who have perished after labouring under symptoms of cyanosis, is the chief cause of the non-closure of the foramen ovale, in consequence of the constant state of over-distention which it keeps up in the right cavities of the heart. In a paper contained in the Edinburgh Medical and Surgical Jour- nal, for October, 1843, this point is very fully considered by Dr. Cragie. This gentleman states that from the facts of the case related in the paper referred to, and of several others, he is satisfied of three circumstances, namely: first, that the open state of the foramen ovale is rarely a primary and solitary lesion; secondly, that when it is a solitary lesion it is not attended with any injurious effects, and that the venous blood of the right auricle is not thereby necessarily mixed with the arterial blood of the left auricle; and thirdly, that, in opposi- tion to what has been hitherto usually taught, the open state of the foramen ovale is, in a large proportion of cases, the means of pro- longing life. However paradoxical, Dr. Cragie remarks, the latter conclusion may appear, and however opposed to the usually received dogmas, it flows almost directly from the facts which may be traced in every case of open foramen ovale. It is not, in fact, the primary lesion. From the phenomena of the cases on record, on the contrary, and from the frequency of the arctated or contracted state of the pulmo- nary artery, it must be inferred that the primary lesion is the ob- structed state of that artery; and that it is this Avhich is the cause, not only of the open state of the foramen ovale, but of the hypertrophy, also, qf the right ventricle. This is the result, whether the pulmonary artery is only greatly narroAved in caliber, or terminates in a cut de sac, or is obstructed by a membranous partition formed by a coalition of the semilunar valves. The effect of such an impediment is manifest. The blood cannot pass into the pulmonary artery with the requisite freedom and facility; there is, consequently, over-distention, first, of the right ventricle, and excessive labour of its muscular apparatus; secondly, of the right au- ricle, and excessiA7e labour of its muscular apparatus, with extreme dilatation of its membranous portion; thirdly, over-distention and con- gestion of the whole venous system throughout the body. The lungs, meanwhile, receive little or no blood, and, consequently, the blood is not duly aerated. This is doubtless a very serious evil; but Bichat has obscurely suggested, and Drs. Williams and Kay have clearly shown, that dark-coloured blood, or that which is venous, is adequate to maintain vital action. Every thing that Ave now know of the cases of cyanosis shows that the obstruction to the circulation through the pulmonary artery, must be the main cause of the uncertain and tran- sitory existence of persons labouring under this severe lesion, and 668 DISEASES OF CHILDREN. that the open state of the foramen ovale, instead of being as William Hunter imagined, and most subsequent writers have taught, the cause of death, furnishes, in fact, the only means by which life can be pro- longed; while a function so important as that through the lungs is impeded. Dr. Cragie considers himself further entitled to infer from various facts in the history of the development of the ovum, that the ob- structed, or, it may be, the undeveloped state of the pulmonary artery, is the anatomical cause of the perforated septum, and of the origin of the aorta from the two ventricles Avhen that malformation is observed. Dr. M. Stille, in a very able paper on cyanosis, contained in the.7//;p- rican Journal of the Medical Sciences, (vol. viii. p. 25,) maintains, that in every instance cyanosis is dependent upon congestion of the gene- ral venous system resulting from a partial or complete contraction or obstruction, or upon an imperforation of the pulmonary artery; that this lesion alone will account satisfactorily for the discoloration of the skin and the dyspnoea; that it is present in almost every case of cya- nosis—or, if absent, that there is always some other efficient cause for the disturbance of the pulmonary circulation; and, finally, that the lesion referred to never exists without the concurrence of cyanosis. These several positions are very fully borne out by the series of facts adduced in the paper referred to. That the disease is caused invariably by delay to the passage of the blood through the lungs, resulting from the presence of a fixed impe- diment to the circulation, is the opinion advocated by the leading pa- thologists of the present day. Morgagni appears to have been the first who attributed the intense lividity of cyanosis to obstruction in the trunk of the pulmonary artery. Louis ascribed it to some obstacle to the circulation of the blood through the veins, and MM. Bertin and Berard, and, more recently, Professor Rokitansky, of Vienna, agree in referring the blue appear- ance of the surface, in those affected with abnormal apertures in the cardiac septa, to a stasis of the blood in the right cavities of the heart, and the consequent difficulty with which the venous blood circulates. Though it be complicated, in many cases, with the admixture of the venous and arterial blood, still it is very evident that the disease is not produced by this admixture. Dr. Chevers, in a very able paper published in the London Med. Gaz., March, 1847, states that the results of his investigations into the causes of cyanosis, are almost entirely confirmatory of the general conclusions of Dr. Stille. Cases of cyanosis will very rarely occur, in which the morbid anatomist will fail to discover some organic cause which acts virtually as an impediment to the pulmonary circu- lation. Dr. Stille, he remarks, has, perhaps, referred somewhat too exclusively to the right side of the heart and the pulmonary artery as the seats of the mechanical obstacle to the circulation in these cases; for it will occasionally, though rarely, be found that the physical im- pediment to the circulation exists in the pulmonary tissue, or is even external to the lungs, as in Dr. Marcet's well-known case (Ed. Med. and Surg. Journ., vol. i., p. 412;) and in some few instances the cause of obstruction is seated either in the left heart, or in the aorta. CONGENITAL AFFECTIONS, ETC. 669 Still, in every case of cyanosis, there will be found to exist some cause or other which tends essentially to prevent the free and com- plete circulation of the blood through the lungs, to retard its passage through the venous system, and, consequently, to render the process of its arterialization slow and incomplete. * Dr. Stille has also argued that obstruction to the pulmonary artery is never found without the concurrence of cyanosis. This is perfectly true, as regards most of .the cases of congenital narrowing of this vessel, but it does not hold good in all; for instance, where congenital imperfection of the pulmonary valves does not become seriously ob- structive until late in life, the symptoms which it produces are not necessarily those of cyanosis. Dr. Chevers cites an instance in which extreme narrowing of the pulmonary orifice, the result of endocar- ditis, occurring at the adult period, was not attended with the slightest appearance of lividity of the surface; in fact, it appears that, for the complete establishment of that generally dilated condition of the en- tire venous system which attends cyanosis, the obstruction to the cir- culation must have been present either at or before birth, when the capillary vessels are naturally more capacious than they are in the adult; or it must become confirmed previously to the full development of the body, while the entire vascular system is pliant and dilatable, and is still capable of readily adapting itself to permanent changes in the circulation. It is well known that various kinds of obstructive disease of the heart and lungs, occurring in adult life, are liable to produce extreme internal venous congestion, and considerable lividity of the surface; but Dr. C. is not acquainted with any instance in which an impedi- ment of this kind, coming into operation subsequently to the age of twenty-five years, has produced that general and intense blueness of the entire surface which forms the characteristic feature of true cya- nosis depending upon congenital malformation of the heart. In extreme cases of original defect of the cardiac apparatus, such as those in which the ascending pulmonary trunk is obliterated Or ab- sent, the cyanosis appears to be due less to the circuitous course by Avhich the lungs are supplied with blood, than to the unnatural nar- roAvness of the pulmonary vessels, which are almost invariably far less capacious than in the ordinary condition; hence the pulmonary veins and left auricle are usually more or less contracted in these cases, while the lungs are either badly developed and imperfectly ex- panded, or present the evidences of chronic impediment in the dilated condition of their tubes. There are still a feAv pathologists who adhere to the old opinion, that cyanosis mainly depends upon the circulation of carbonized blood through the arterial system, insisting upon the fact that, in the great majority of cases of cyanosis, the septa of the heart are more or less deficient. It is noAv established that cyanosis may exist quite inde- pendently of imperfection of the cardiac partitions, or of admixture of the venous and arterial blood; still, Dr. C. apprehends that M. Berard and Dr. Stille have argued somewhat too exclusively in main- taining that admixture of the two currents has no influence whatever 670 DISEASES OF CHILDREN. in producing cyanosis, as it appears by no means unreasonable to conclude, that, in extreme cases of this kind, where the impediment to the pulmonary circulation is great, and where a large quantity of venous blood evidently passes into the aorta at every systole of the ventricles, the discoloration of the surface, and especially the lividity of the mucous membranes, which is so frequently observed in these cases, is in part, at least, due to the dark hue and impure condition of the arterial blood. Admitting this, it must* be borne in mind that the principal reason why cyanosis is generally present in cases of extensive communication between the cavities of the heart, will be found in the fact, that a cause of obstruction which is capable of preventing the natural closure of the septa, will rarely fail to occa- sion permanent and severe impediment to the circulation. Where an abnormal opening is discovered in the cardiac apparatus of one who has only lately become cyanosed, or where such an aperture presents traces of recent enlargement, it must not be at once concluded that the presence or augmentation of this communication has occasioned the cyanosis; but the first cause of the disease must be sought for, and this will generally be discovered in the form of some manifest impediment to the circulation wdiich has determined the patency of the opening from birth, and which, having become recently aggravated, has produced the cyanosis at the same time that it has increased the size of the abnormal foramen. Cyanosis, whether congenital or acquired, is very rarely recovered from. If, as already remarked, the infant survive the first few days or weeks, it may live on to puberty. An aggravation of the symp- toms every now and then will take place, and these paroxysms are liable to be very severe at the period of weaning, during dentition, or when the child begins to walk, and at puberty: if this latter period be passed, the patient may live to eighteen, twenty, thirty, forty, sixty years, or even to extreme old age. The chances of life depend pretty much upon the nature of the organic disease present, and of the ac- cessory morbid phenomena: thus, in a child whose pulmonary artery was found completely obstructed, death took place on the thirteenth day from birth; while in three patients, in whom the foramen ovale and ductus arteriosus were simultaneously patescent, one lived seven- teen, another twenty-nine, and the last forty-two years. The duration of life in the cases of cyanosis analyzed by M. Aberle, is indicated by the following list: Death occurred, in the first twenty-four hours, in 4 cases; within the first fourteen days, in 16; before the end of the first month, in 7; from the second to the third month, in 6; from the third to the sixth month, in 8; from six to twelve months, in 12; from one to two years, in 7; from two to three years, in 9; from three to six years, in 11; from six to eight years, in 11; from eight to eleven years, in 13; from thirteen to sixteen years, in 12; from sixteen to twenty years, in 8; from twenty to twenty-five years, in 10; from twenty- five to thirty years, in 6; from thirty to thirty-five years, in 5; from thirty-five to forty-five years, in 5; from forty-five to sixty years, in 4; and at eighty years in 1 case. In 10 cases, the age is not Indi- cated. CONGENITAL AFFECTIONS, ETC. 671 A few cases are on record, in which the phenomena of cyanosis, after continuing for a very considerable time, finally, entirely disap- peared ; and in cases connected with certain affections of the lungs, intestinal canal, uterus, and brain or spinal marrow, the cyanosis has disappeared with the cure of the pulmonary, gastro-intestinal, uterine, and cerebral disease. As a general rule, however, the disease is en- tirely beyond the control of medicine. It is said to prove more quickly fatal in males than in females; and the mortality is certainly greater in winter than in summer. (Jour. Hebdom. No. 113.) It is unnecessary to say anything on the treatment of cyanosis. If the pathology of each case be attentively and carefully examined, and the true character of the disease be kept in mind, it will be easy to adapt our palliatives to the most urgent distress. The patient, in every instance, should be kept as much as possible in a state of rest, and everything should be avoided, liable to produce mental or physical excitement, or which in any manner has a tendency to hurry the res- piration or circulation. He should enjoy a pure, fresh atmosphere, gentle, passive exercise, and be allowed a mild, easily-digested diet; his bowels should be kept perfectly free, and his body be carefully protected from cold or damp. When cyanosis appears in a new-born child, and persists after res- piration is established, it has been recommended by Corvisart to em- ploy gentle frictions over the head and body with a warm, soft cloth, Avhile the infant is held near the fire. The frictions should be perse- veringly continued, attention being, at the same time, paid to procure a free evacuation of the meconium. 6.—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 with either hydrocephalus or spina bifida. In the latter case, one or more tumours 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 tumours vary in size, from that of a hazel-nut to that of the adult head, or the entire spine being bifid, the tumour may occupy its whole length. The tumour is usually globular or ovoid in shape, having either a large base or narrow neck; in one case, recorded by Brewerton, it was bi-lobed. It may be invested by the common integuments, in a healthy, unin- flamed condition, or the skin covering it may be thin, almost transpa- rent, and crossed by purplish lines, and as if about to rupture, with a sero-sanguineous fluid exuding through it; or, the tumour may be rup- tured, its contents having escaped through a very small, ulcerated opening, which is surrounded by a red, rugose, unequal elevation of the skin and subcutaneous tissue. The two latter conditions of the tumour are much more common than that in which it is covered by healthy skin, and far more dangerous. The tumour is always situated over a deficiency in the vertebrae, arising, most commonly, from an imperfect development of the late- 672 DISEASES OF CHILDREN. 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 vertebrae, body as well as processes. 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 tumours, or, as wc have already seen, it may exist throughout the whole extent of the spine. The tumour itself is formed by a cyst, communicating Avith the spi- nal cavity, and filled by a fluid secreted within the latter. In the most favourable cases, its parietes are composed of one or both layers, con- sisting of the arachnoid membrane, the dura mater, and the common integuments, in a natural condition; more generally, however, its pa- rietes are thickened, inflamed, ulcerated, gangrenous, or covered with fungous granulations, or tufts of hair. To the touch, the tumour 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 tumour very frequently induces a state of coma, or convulsions, and in one case, referred to by Dr. M. Hall, pressure, even that resulting from the supine recumbent position of the child, invariably produced attacks similar to the croup-like convulsions of laryngismus. In some cases, the tumour has been observed to expand during ex- piration, and sink during inspiration. The contents of the tumour may be either a limpid, colourless serosity, or a turbid fluid, often con- taining albuminous flocculi, or a purulent matter. The fluid of the tumour communicates freely w-ith that collected within the cavity of the spine; and in many cases, there is a free communication between the ventricles of the brain, the intercranial arachnoid cavity, the entire canal of the spine, and the cavity of the external tumour, so that pres- sure 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 tumour, it being covered by the common integuments, and Avhen the accumulation of fluid within the vertebral canal exercises no pressure upon the brain, or spinal marrow, sufficient to interfere with the free exercise of their functions, individuals affected with spina bifida, though generally of a weak and infirm constitution, may exhibit no particular symptoms of disease, and even live to an advanced age, Avithout the occurrence of any serious evil that immediately results from the spinal tumour. Cases of individuals labouring under spina bifida of almost every age, from ten years to fifty, and upwards, have been observed. Generally speaking, however, from a greater or less deficiency in the spinal cord, or other morbid conditions of it or of the brain, the CONGENITAL AFFECTIONS, ETC. 673 infants labouring under spina bifida are liable to be affected with para- lysis of the lower extremities, convulsions, and open state of the sphinc- ters, and difficulty of respiration. They are occasionally unable 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 tumour, the more intense and rapid is this train of symptoms. When, in particular, the tumour 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 most cases, the patient is very quickly de- stroyed. If, however, the opening in the tumour is very small, notwithstand- ing a portion of fluid is constantly escaping, no very important suffer- ing may result for a length of time. But, very commonly, the fluid discharged becomes more or less turbid, purulent, or even fetid, and symptoms of spinal inflammation soon occur. When the tumour is of considerable size, its sudden rupture may produce a paroxysm of con- vulsions, terminating almost immediately in death. It has been asserted by Duges, that a rupture of the tumour has taken place in utero, and the opening has again closed, previously to birth. This appears to us, however, to be very doubtful; the case cited in confirmation 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 cavity, or between the dura mater and bony wall of the spinal cavity. When in the first two situations, the effused fluid very generally communicates freely with the ventricles of the brain, and with the arachnoid cavity within the cranium, in which there also exists a morbid effusion of serum. Occasionally, when the tumour 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. Even the medulla spinalis may present' no apparent indications of disease. The effused fluid is usually perfectly limpid, excepting when menin- gitis has occurred, when it is generally thick, turbid, and flocculent It may be of a light yellow, greenish, or dark hue, and is often mixed Avith 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 found to be of a different colour from that in the latter, showino* the two to be perfectly distinct. In other cases, the fluid was prevented from escaping from the fourth ventricle into the subarachnoid cavity by a firm, reddish membrane, which formed a cul-de-sac below the inferior angle of the ventricle. The spinal cord may either present congenital deficiencies, or mal- formations, or more or less traces of disease. The substance of the 674 DISEASES OF CHILDREN. cord has been found entirely wanting, the membranes alone remaining; forming sometimes a closed sac, filled with a fluid. It may be dimi- nished in size, divided into two parts, or expanded into a membrane. It is often, according to Ollivier, preternaturally long. The spinal nerves have been seen floating in the fluid of the tumour. They have been found, also, distributed on the inside of the tumour, forming, oc- casionally, a kind of nervous network. More commonly, however, the substance of the cord is softened, like the walls of the cerebral \rentricles in hydrocephalus; and very generally, traces of meningitis of the spine exist, often extending even to the brain. 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; the defi- ciency in the vertebrae, as well as the external tumour, being the result of the accumulation and pressure of the fluid within the cavities of the cranium and spine. When the tumour in the spine is not formed, the child usually perishes soon after birth, with symptoms of hydrocephalus; or tu- mours, 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 arachnoid membrane, through an opening in one of the bones of the cranium. Dropsy of the spine, with the formation of an external tumour, has succeeded to hydrocephalus, produced by contusion of the head; or has resulted from disease of the spinal cord. In regard to the treatment of spina bifida, it would appear, from a careful examination of all the facts upon record, and from the result of the few cases which have fallen under our own notice, that, when the tumour is small, and more especially when it is covered with the common integuments in a sound state, 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 tumour from accidental pressure, and from every source of irritation. So long as the tumour remains unopened, there is, comparatively, little danger, but soon after it be- comes opened, meningeal inflammation, with all its train of fearful consequences, soon sets in, and quickly destroys the child. The opening of the tumour is always, therefore, to be considered a most unfortunate circumstance. Hence, if the infant be born with an ulcerated tumour, but incompletely perforated, it ought not to be opened for the purpose of allowing the discharge of its contents. It is true that the operation first practised by Ruysch, and revived by Aberne- thy, of puncturing the tumour with a fine needle, and afterwards em- ploying gentle pressure, has been performed, and it is said, in several .cases, with success. Very recently, two cases are related by Dubourg, in which a perfect cure was effected by cutting off the tumour, and then bringing the edges of the divided skin together, and retaining them so by means of the twisted suture, until union took place; 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. The applica- tion of gradual and gentle pressure, as recommended by Abercrombie nnd Sir Astley Cooper, is unquestionably the treatment that will be CONGENITAL AFFECTIONS, ETC. 675 found the best adapted to the generality of cases of spina bifida; it is said to have produced a radical cure in some instances. It has been very correctly remarked, that when the tumour is very large, puncture should not be attempted, while in cases where the fluid effused in the spine communicates with the ventricles of the brain, pressure must al- ways be of very doubtful propriety. In all cases of spina bifida, much benefit will unquestionably be de- rived from placing the patient under such a hygienic course of treat- ment as will be adapted to improve the health and nutrition of the body generally. Hence, the importance of changing the milk of the mother, if the quality of this be doubted, for that of a healthy nurse; of re- moving the infant from the confined and impure air of the city, to a dry, healthy situation in the country; of clothing it warmly, and car- rying 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 tu- mour, 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 promote the absorption of the fluid. The preparations of iodine may also be ad- ministered 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. 7.—Inflammation and Ulceration of the Navel. AVithin the first nine or ten days after birth, inflammation followed by ulceration of the navel is very liable to occur, if the utmost atten- tion is not paid to prevent it. Upon the separation of the cord, instead of a quick and perfect cicatrization succeeding, the navel in some cases remains raw, and soon becomes irritated and inflamed, presenting a deep, red, ulcerated surface, with an inflamed condition, to a greater or less extent, of the surrounding skin. A thin, purulent, and often offen- sive discharge takes place from the surface of the ulcer, and the infant evidently suffers considerable pain, as is evinced by its general fretful- ness, and its cries when the ulcer is examined or accidentally touched. Not unfrequently the navel presents an elevated, ulcerated surface, with somewhat prominent edges; in these cases, the discharge is generally the most profuse. In other cases, a kind of fungous excrescence, of a 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 remain perfectly natural. The fungoid tumour, which generally bleeds upon the slightest irri- tation, may either present a narrow base with a round, expanded head like a cherry, or a broad base, tapering gradually towards the summit' being more or less conical in form. Ulceration of the navel, as we have already remarked, is very gene- rally the result of neglect or mismanagement on the part of those who 676 DISEASES OF CHILDREN. 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 consequence 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 injudicious attempts to facilitate its separation, or by the ridiculous practice of dressing the navel subsequently, with a burnt rag, grease, and even more improper applications. It may, also, arise from inattention to cleanliness, in the first washing of the child, in consequence of which a quantity of the vernix caseosa is left upon the skin surrounding the umbilicus, which soon acquires an irritating character. From a 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 filament, the division of this, and the removal of the cord, will often, as stated by Dewees, be sufficient to allay the irritation, and thus allow the navel to cicatrize. When the ulceration is superficial, without much inflammation, wash- ing it with a little rose water, tAvice 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 causing cicatriza- tion, the ulcer may be washed daily with a solution of sulphate of cop- per (ten grains to an ounce of water,) and then dressed with the same salve. In slight cases, by sprinkling the ulcerated surface with finely powdered oak bark or galls, we have repeatedly found cicatrization to take place very promptly, without any other dressing. If the ulceration should still show no disposition to heal, it may be washed by a weak solution of the nitrate of silver, and then dressed with an ointment formed of one scruple of the acetate of lead, inti- mately combined with an ounce of lard. In aggravated cases of ulce- ration of the navel, prompt and very decided benefit is said by Dr. Eberle to be derived from applying to the ulcerated surface, three or four times daily, by means of a soft hair pencil or feather, a liniment made by slowly simmering the coarsely powdered root of the wild indigo, (baptisia tinctoria,) in cream, and afterwards squeezing it through a thick piece of muslin or flannel. 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 the inflammation is reduced by soft, emollient poultices, and frequent washing of the in- flamed skin with a solution of the acetate of lead. In some instances, 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, CONGENITAL AFFECTIONS, ETC. 677 and attended Avith griping:—whenever this is the case, the administra- tion 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 tumour forms or protrudes from the navel after the separation of the cord, if it have a narrow base, we may readily re- move it by a ligature applied around its pedicle, sufficiently tight to arrest the circulation, without cutting into its substance. The tumour usually separates in the course of a few days, when the ulcerated sur- face may be washed with a solution of sulphate of zinc, (fifteen grains to an ounce of water,) or dressed with the ointment of acetate of lead. It is seldom, however, that the separation of the tumour by means of the ligature is attended with any permanent benefit; very generally, the fungous growth will recur to as great an extent as at first. It is better, therefore, to treat it at once by astringent applications, as the decoction of galls or oak bark, or 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 tumour 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 tumour is soft and spongy, and not invested by a mem- brane, 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. 8.—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 some cases, attended with a degree of redness and inflammation of the external skin. This affection, even when the swelling and hardness are very con- siderable, after continuing for a wreek or two without any sensible abatement, will then, very generally, subside entirely. Unfortunately, however, a vulgar notion is prevalent among mothers and nurses, that the swelling, in the female at least, 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, sometimes, of a white-coloured fluid, resembling milk, at the nipple, and which induces 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, in not a few cases, severe inflammation, followed by suppuration, and the formation of an abscess: many instances 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. This intumescence in the breasts of young infants would appear to be the result of a subacute inflammation, attended with serous infiltra- tion of the cellular tissue of the part. Occasionally, the inflammation 678 DISEASES OF CHILDREN. extends to the substance of the mamma, and the skin by Avhich the gland is covered, becomes very tense, shining, and of a dark-red colour. EA-en this aggravated form of the disease will very generally give way in a few days to the simplest treatment; and we do not recollect ever having seen a case which was attended with any degree of trouble, or any great or prolonged suffering, and certainly no one Avhich showed any tendency to terminate in suppuration, excepting when the tumour has been subjected 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 tumour daily with a little sweet-oil, or fresh lard, and to cover it with a piece of tolerably thick, soft muslin. AVhen, from any cause, considerable inflammation, pain, and swelling of the breasts take place, the case should be treated by a few leeches, and the appli- cation 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. R.—Hydrochlorat. ammoniae, gss. Aquae, Acid. acet. impur. 5.5 _^ij.—M. To be applied warm, by moistening pieces of soft linen rag with it, and laying 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 immediately any swelling that may occur; and when it does appear, to direct the proper measures to be pursued, forbidding posi- tively, at the same time, any attempt being made on the 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. 9.—Ruptures-—Hernise. Hernia is, by no means, unfrequent in early infancy. Children have even been born with an umbilical, inguinal, or scrotal hernia, or with two or more hernial protrusions. More commonly, however, the pro- trusion 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 circumstance, that by proper treatment, a radical cure may then, in many cases, be ef- fected, and thus the patient saved, in after life, from all the serious consequences invariably attendant upon this infirmity, in whatever 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 intes- tine, at the same time, retire within the cavity of the abdomen, and an CONGENITAL AFFECTIONS, ETC 679 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 it, forming at birth a hernial sac of a round or rather conical form; the summit correspond- ing Avith the proper commencement of the cord, and the base to the circumference of the aponeurotic ring at the umbilicus, which is of larger size than natural. The hernial sac is composed in these cases of the peritoneum with the skin and cellular tissue more or less con- densed. This form of hernia, though strictly congenital, may not be percep- tible until some days after birth, Avhen the intestines become distended by aliment, and crowded downwards towards the umbilicus by the contractions of the diaphragm during inspiration, and the act of cry- ing. 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 convolution 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 sac may be readily forced back into the cavity of the abdomen, when, through the parietes of the empty sac, 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 addition to the usual bandage, a compress formed of a few folds of soft linen imme- diately over the umbilicus. As soon, hoAvever, as cicatrization is com- pleted, a more effectual course of treatment must be commenced; and the earlier this can be done, the greater will be our chances of effect- ing a radical cure. Our object is to keep the protruding bowels com- pletely and permanently Avithin the abdomen, so as to permit the natu- ral 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 about an inch in thickness: this 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 proportion, how- ever, as the infant advances in age, the umbilical opening contracts, and at the same time the intestines acquire a greater volume, so that they cease to pass through it, and finally, the use of the compress and bandage may be discontinued. We have, in numerous instances, ef- fected a complete cure, by the means here 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 that described by Dr. Maunsell. It consists in the ap- plication of a graduated compress, formed of Avhite leather, spread 680 DISEASES OF CHILDREN. with adhesive plaster, over the opening, and above this, the common flannel roller. The apex of the compress, Avhich 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 externally, so as to keep each piece in situ. We should always adjust the compress with our own hands, as great care is necessary to insure the complete return of the hernia; and un- less the child exhibits marks of uneasiness, it should not be removed, until the plaster loses its adhesive 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 explained to the friends at the beginning. It has been recommended by A. Cooper to apply a section of an ivory ball over the umbilicus, and retain it there by adhesive plaster and a bandage. 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, we are informed by Dr. Maunsell, very well, when there is a small open- ing with a considerably elongated sac: it is, after reducing the con- tents, 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 sac, which will thus form a natural truss, and prevent protrusion through the opening in the linea alba: it cannot be employed, however, when the hernial tu- mour is broad and flat. It has been proposed by Desault and Dupuytren to apply a ligature around the base of the tumour, with the view of inducing inflammation and adhesion of the sides of the hernial sac. This plan, which is the one described by Celsus, though apparently well adapted to effect a permanent cure, has, nevertheless, been abandoned by most modern surgeons, in consequence of its being found that the patients in whom it was tried, are liable subsequently to a return of the hernia. In the male, congenital inguinal 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 enve- loped, and which also forms the vaginal sac in which they are con- tained. This sac may become perfectly closed at its upper part, so as to cut off all communication between it and the cavity of the omen- tum : 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 testicle, and becoming sometimes adherent to it. The communication between the vaginal cavity of the scrotum and the abdomen, may, however, exist without giving rise to hernia; and it is possible for a portion of intestine or omentum to descend to the bottom of the sac, although the testicle may still remain within the abdomen, or have descended_ no farther than the ring, while, again, ordinary, non-congenital, inguinal hernia, CONGENITAL AFFECTIONS, ETC. 681 with strangulation, has been observed, according to Lawrence, in an infant of fourteen months. 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 tumour in the groin; we must be cautious not to mistake this for hernia, and as the testicle may remain in this position even while a portion of intestine has descended into the sac, this fact must ahvays be kept in mind, as no truss should be ever applied, until the testicle has passed fully into the scrotum. Scrotal hernia should not be confounded with hydrocele, which is of common 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 sac. The fluid dis- tending the vaginal sac 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. A curious case is related by Billard, of congenital inguinal hernia in a female infant. There existed in this instance, in the left inguinal region, a rounded tumour about the size of a filbert, rather hard to the touch, and incapable of being returned into the abdomen or diminished by pressure, neither was it enlarged by the crying of the child. The tumour was directed obliquely towards the labium of the same side, but did not quite reach to it. The child died from pneumonia, when it was found that the tumour was a real hernial sac, containing the left ovarium, with the fimbriated extremity of the Fallopian tube, a little reddened and swollen. These had descended and passed through the inguinal canal and ring—which latter was much larger than it usually is in the female infant—and were contained in a sac formed of a prolongation of the peritoneum, with the cavity of which it communi- cated. There were no convolutions of intestine adhering to the sur- rounding 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 ter- minated in the labium by an aponeurotic 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 umbilicus, namely, to retain permanently the protruding boAvel 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. AVhen the hernia is present at the period of birth, or appears soon 682 DISEASES OF CHILDREN. after, it should be at once reduced and a temporary bandage applied, with a small compress upon the abdominal ring. But little compres- sion, however, should be at first resorted to, and the bandage and com- press should be frequently changed, as well from a due attention to cleanliness, as to prevent the irritation of the skin, which would other- wise 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 constantl)*- 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, chafing 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 avo will often be completely foiled. 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 tu- mour covered with a light emollient poultice, and the bowels freely evacuated 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 tumour by the ordinary means. 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 sac, enclosing a portion of in- testine, is formed by the base of the cord alone; this covering is some- times so thin that the intestine may be seen through it. In a case of this kind, a permanent occlusion of the umbilical opening was pro- duced by reducing the intestines, the return of which was prevented by an assistant compressing the cord close to the abdomen; when a compress, formed of circular pieces of leather spread with adhesive 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 con- tact, 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 abdomen, and at the expiration of a fortnight after the separation of the funis, the aper- ture at the navel was so far contracted, that not the least protrusion was occasioned even by the crying of the child. This case will sufficiently indicate the general plan upon which the CONGENITAL AFFECTIONS, ETC. 683 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. Early 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 lives. Arrest of the Testicle.—As closely connected with the subject of con- genital inguinal hernia, a few words will be proper, in this place, in relation to a not unfrequent occurrence, from which we have repeatedly seen a very considerable amount of suffering result; we allude to the arrest of the testicle at the abdominal ring, or in the groin, in its pas- sage from the abdomen. In this situation, it frequently becomes in- flamed, which after causing severe pain, sometimes of several days' continuance, attended with considerable febrile reaction, and occa- sionally with tension and tenderness of the abdomen, nausea, or vomit- ing, obstinate constipation, and the other symptoms of peritoneal in- flammation, produces, in the groin, or at the ring, a small, intensely red tumour, exquisitely painful to the touch and upon every motion of the patient's body; in this, suppuration, sooner or later, occurs, forming an abscess of considerable size. This inflammation is often attended with complete disorganization of the testicle. The treatment consists in leeching, warm bathing, and emollient poultices to the groin, laxatives by the mouth, and gentle purgative enemata. The child should be kept as much as possible at rest, and as soon as an abscess forms it should be opened. 10—Vaginal Haemorrhage- 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 ex- ternal 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. The whole of the mucous surfaces are, it is true, during the early period of infancy, in a state of extreme vascularity, amounting often to per- fect hyperaemia; but we can trace the excretion of blood by the va- ginal membrane of the infant to no very evident exciting cause. The haemorrhage, in these cases, has been attributed by Ollivier, of Angers to the same physiological cause which, in after life, produces the cata- menial 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. This suggestion would appear to derive some support from the character of the discharge, which has cer- tainly much resemblance to the catamenial flux in the adult female The discharge always ceases of itself, and requires no particular treatment; the preservation of perfect cleanliness by repeated ablu- tions ot the vulva will, of course, be necessary. The alarm and anxiety which this haemorrhage almost invariably 684 DISEASES OF CHILDREN. excites in the mother, and those about the child, should be quieted by an assurance that it is unattended with danger. 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 con- tinued beyond the first few Aveeks after birth. 11— (Edema of the Prepuce. The cellular structure of the prepuce, in the male infant, is occa- sionally the seat of a serous effusion, by which this part becomes some- times enormously distended, and very hard to the feel: in a feAv in- stances, we have found the whole of the integuments of the penis to be similarly affected. When the prepuce is at the same time retracted behind the glans penis, a species of paraphymosis is produced, and Ave have known considerable difficulty to be experienced in the passage of the urine, from the stricture upon the urethra which is thus occa* sioned. A similar difficulty may also result, when the tumefied parts envelope the glans, from the closure of the prepuce: ordinarily, how- ever, the intumescence gives little or no trouble, and is unattended with pain or suffering, and generally disappears spontaneously. We have known it, however, to continue for a long time, with little or no abate- ment. Although we have arranged oedema of the prepuce among the dis- eases occurring within the month, it is by no means confined to this period; we have met with it frequently in children from one to six years of age. The causes of this affection it is, in many cases, somewhat difficult to trace. It would appear to be occasionally produced by an irrita- tion seated within the urethra, as a stone sticking in the canal, or a small splinter of wood or fragment of straw, introduced by the child. In one case, we saw it produced by a portion of thread that the child had wound round 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 an herpetic eruption around the external skin of the prepuce at the point of duplicature. In some cases it is attended by a discharge from within the prepuce, resembling a strong lather of soap, or the froth of milk; this is evi- dently 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 camphorata 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 CONGENITAL AFFECTIONS, ETC. 685 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 tumour, and foment it freely with tepid water. AVhen connected with an erysipelatous inflammation of the penis and scrotum, this should be treated by its appropriate remedies; and in cases in which an 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, we have found to be generally sufficient for its speedy removal. 12.—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 cas^s 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 trans- parent 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 oc- clusion of the external orifice of the vagina, which is usually con- nected with a deficiency 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 happens from a congenital and perfect fusion of the two labia, no operation should be attempted previously to puberty, unless we are able to determine with certainty that the vagina or uterus is not wanting, inasmuch 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 accuracy, as to the existence or non-existence of the internal organs, and, con- sequently, 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. When thenymphae cohere, upon the separation of the labia, they are extended in such a manner as to form a flat, continuous covering to the origin 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 surrounding 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 if the cohesion was not congenital, we may learn from the nurse, 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 b°b DISEASES OF CHILDREN. destroyed by the mere separation of the labia; or a probe being passed behind the coherent nymphae, and made to bear upon the line of juncture, this may often be gently torn asunder, by merely draw- ing 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, moist- ened with sweet oil, or fresh lard, to prevent the divided surfaces from again adhering. 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. 13.—Hare-Lip- It is not our province to enter into a description of the several forms of hare-lip, nor of the surgical operations by which they are to be remeified. The only question in relation to them we propose to notice, is, at what period should any operation be performed. This question will be often 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 may be the risk attendant upon an early operation, it must be encountered, as the removal of the deformity is the only means we have of saving the infant from a lingering death from inanition. If the deformity, how- ever, 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 inducing convulsions, or other dangerous consequences, and when there is a greater chance of its proving successful. The question, nevertheless, still presents itself, how long is it proper to wait before performing 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 opera- tion. A much earlier period, however, has recently been recom- mended by Dr. Houston, as the most suitable for its safe and efficient performance, and several cases are adduced by him to prove the resi- lience of a young infant, under the operation, and the strength of its reparative powers. 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 consequences, that the young infant is liable to, to which it is not liable Avhen a year or two older. Dr. Hullihen, of Wheeling, Virginia, is decidedly in favour of ope- rating early. He states that he has operated on thirteen cases before dentition had commenced; three of the infants were only four Aveeks CONGENITAL AFFECTIONS, ETC 687 old. He remarks, that he has yet to witness the first untoward event, or the slightest unfavourable indication resulting from the operation Avhen thus early performed. Paul Dubois, in a paper read before the French Academy of Medicine, in May, 1845, adduces his experience in favour of an early operation for hare-lip. He details a number of cases operated on by himself or his friends, at intervals varying from a few minutes to several days or weeks after birth, all of which had proved completely successful. Dr. Dawson, in a paper in the Dublin Medical Press, for 1842, advocates the same practice, and relates two cases, one of a child four days old, and the other of a child seven hours old, in which he operated successfully. Guersent, the younger, agrees with Dubois in believing that the best time for the operation is immediately after birth; and that if this favourable opportunity be allowed to pass by, it is better to wait until the eighth, tenth, or twelfth year. Malgaigne has operated nine hours after birth, on a child with simple hare-lip, complicated with a wide fissure of the palate, and of the alveolar process. The operation succeeded perfectly, but the child died on the sixteenth day, from diarrhoea and aphthae. The cicatrix was found to be admirable, and the separation of the bones was so much lessened, that, had death not occurred, the fissure would un- doubtedly have been quite obliterated. Baudon has operated, and with success, in a case of double hare-lip and fissure of the palate, in an in- fant aged four days. He operated first on the right, and at the end of a fortnight on the left side. Mestenhauser, of Raaste, in Silesia, during a practice of thirty-two years,-operated for hare-lip eighty times, and prefers the children to be at least ten or twelve w-eeks old before it is undertaken. Dieffenbach has operated upon a thousand cases, and states that, while union has taken place at every age, from a few days after birth up to extreme old age, it is better to wait until dentition is accomplished, as when performed very early, the cicatrix is apt to yield as growth advances. If it were not for the danger supposed to attend upon 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 re- moval of the deformity, and the inconvenience attendant on it, being then more easily and certainly effected, than when the operation is de- ferred to a later period. We are persuaded with Dr. Houston, that the dangers and difficulties attendant upon early operations are, how- ever, 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 few 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 recom- mend its adoption very generally at the termination of the third month, or, where the deformity is very great, at even an earlier period. 14-—Club-foot—Talipes. Children are frequently born with various deformities of the feet, to which the popular denomination, club-foot, has been applied. The foot 688 DISEASES OF CHILDREN. may either be turned outwards, so as to allow its inner margin to rest upon the ground, (valgus, talipes valgus;) or inwards, its outer edge being directed to the ground, (varus, talipes varus;) or the heel may be drawn up, so as to direct the toes downwards, and extend the foot, causing it to approach a right line with the leg, (pes equinus, talipes equinus.) A fourth variety has been described by Little, in Avhich the foot is flexed upon the leg, and the heel only is applied to the ground. 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 they are not remedied at an early period, the child is, in general, doomed to lameness and deformity 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. 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, liga- ments, and aponeuroses become more and more contracted, the de- formity increases, and first, the side of the foot, and finally, its dorsum, is applied to the ground; the bones of the tarsus are at the same time thrown into an unnatural position, and after the child begins to walk, being subjected to continual pressure, become altered in shape, in con- sequence of which the deformity, which in the first instance might, with due care, have been removed, becomes permanent. The twisting of the foot outwards, which is of comparatively unfrequent occurrence, is produced by a shortening of the abductor muscles. The remote cause of club-foot 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 anta- gonist muscles. Distortions of the feet have been met with in foetuses of from three to five months, with co-existing deficiencies, and malformations in the brain and spinal cord; in anencephalous and hemicephalous em- bryos, the hands, as well as the feet, have exhibited similar distor- tions. Children born with a deficiency or disease of the spinal mar- row, are also very commonly affected with club-foot; the deformity is hence a common accompaniment of spina bifida. 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 extensors. CONGENITAL AFFECTIONS, ETC. 689 Distortions of the feet are said to be hereditary, in consequence of the transmission of a morbid irritability of the nervous system, pre- disposing to convulsive and spasmodic contractions of the muscles. AVe 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 contri- vances, 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 po- sition, and counteract the distorting force. It is not within the province of the present work to present a de- scription of these several apparatus, 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 whatever contrivance Ave adopt, simplicity and lightness are of the first importance, as Avell as such a form as Avill prevent any undue pressure upon the part that is made the point dappui. The form of the apparatus will vary somewhat, according 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. AVhen the shortening of the muscles is very considerable, or the force they exert in drawing the foot in an unnatural position too powerful to be overcome by any mechanical means that it would be prudent to employ, it is probable that a division of the tendons may 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 accom- plished without a long-continued use of appropriate mechanical means; —while the latter alone, will, in most cases, be fully adequate to produce a complete removal of the deformity, if commenced with suf- ficiently early, when the parts involved in the deformity are still sufficiently flexible and the ligaments, aponeuroses, and bones of the foot have undergone no important changes, and Avhen the confinement of the foot can be borne with greater ease than at a later period. 15—Induration of the Cellular Tissue. INDURCISSEMENT DU TISSU CELLTJLAIRE—CEDEMA CELLULARIS—SKIN- BOUND. A peculiar hardness and tension of the skin of .the lower extremities, often of the trunk, and occasionally of the face, with coldness and a 44 690 DISEASES OF CHILDREN. yelloAvish or wax-like appearance, or a pale red or purple colour of the affected parts, are often observed in infancy, during the few first days or weeks after birth. The disease sometimes commences at the feet, but more generally about the pubic region, and inner surface of the thighs; from whence it gradually extends over a considerable portion, and in sonic cases, over the whole of the surface of the body. The affected parts be- come swollen, hard, and incompressible; the skin is tense, and adheres firmly to the parts beneath, so as not to allow of its being pinched up or moved over them; it is at the same time dry, harsh, and decidedly cold to the touch, and, in some cases, presents a yelloAvish, or waxen appearance; whilst in others, it is of a pale red, purple or livid hue. In the latter case, the swelling is the most considerable; whilst the firmness and tension of the parts are the greatest when the skin as- sumes a pale yellowish colour. The diminution of temperature is always remarkable; and when the disease extends over the greater part of the surface, the body is acted upon by external heat in the same manner as so much dead matter. M. Rogers (Archives Gen. deMed.) states that in 19 cases he found the temperature to be less than 91°, in 7 it sank below 78°, while the mean of 52 observations was only 87-8°. In extreme cases the tem- perature may sink to 77°, 74°, 72°, and in one instance it was as low as 71-6°. According to M. Rogers, a diminution of temperature pre- cedes the occurrence of induration, or at least exists in a very marked degree while the induration is still very slight. The reduction of the temperature is always in direct proportion to the degree of indura- tion, and consequently forms an important element in the prognosis. Recovery took place in only a single case after the temperature had sunk below 90*5°, though life was often prolonged for several days, notwithstanding a much greater reduction of temperature. The slow- ness of the pulse and respiration likewise bear a direct relation to the lowness of the temperature and degree of induration, the former having sunk even as low as 60, the latter to 16 or 14. The infant labouring under this disease refuses to suck; its counte- nance becomes pale and contracted; it is restless; appears unable to make a full inspiration, or cry out, but almost constantly makes a peculiar kind of moaning noise, which has been compared by Dorf- muller to the cry of young mice. Deglutition appears, in general, to be attended with difficulty, and is sometimes impossible. The pulse is usually small, rapid, and irregular; and there is always more or less disorder of the alimentary canal, with frequent discharges of a bright green, or whitish, or clay-coloured appearance. There is ge- nerally a deficient secretion of urine; though to a greater extent in some cases than in others. Respiration becomes gradually more and more difficult, until death ensues; usually before the fourth day, but sometimes not until a much later period. In some cases, tetanic spasms supervene towards the close of the disease; the head and trunk being occasionally bent rigidly backwards, and the jaws firmly locked. The disease is unattended, throughout, with any degree of febrile CONGENITAL AFFECTIONS, ETC. 691 reaction; though in some cases a degree of febrile excitement may precede its occurrence. Occasionally it is accompanied with a jaun- diced condition of the entire surface. Induration of the skin in infants is an affection which is always of a dangerous character; generally terminating fatally, within one, two, or, at farthest, three weeks. In slight cases, in which the morbid condition of the integuments is of limited extent, sometimes, in a few days, the respiration of the infant improves, the parts affected increase in temperature, and become softer, and by slow degrees an entire re- covery takes place. On the examination of the bodies of infants who have died of in- duration of the skin, the subcutaneous cellular tissue is usually found to be thickened, condensed, and loaded with serum. It is often of a reddish or granular appearance, not unlike a portion of hepatized lung. In many cases the adipose substance is firm, hard, and indu- rated; with or without infiltration of the cellular tissue. The Avhole of the tissues are engorged with venous blood, with which every organ is unusually loaded. The most frequent lesion of the viscera is inflammation of the ali- mentary canal, with more or less morbid change of the liver. The lymphatic glands are frequently found indurated and enlarged; more especially those of the mesentery. In general, the serous infil- tration is not confined to the subcutaneous cellular tissue; it has been observed in the subperitoneal tissue, in the cavity of the mediastinum, and in the plexus choroides: we have met with it in the interlobular structure of the lungs, at the base of the brain, and along the whole of the spinal marroAv. When free incisions are made through the skin, the serum gradually flows out, and the swelling and hardness of the diseased parts disappear, excepting in those cases in which there co- exists Avith the serous infiltration a hardening of the adipose tissue. (Andry, Auvity, Denis, Duges, Wolff, Billard.) Induration of the skin usually occurs soon after birth; occasionally it is congenital. It is more frequent in winter than in summer. It prevails to the greatest extent in hospitals appropriated to the recep- tion of children, and among the offspring of the impoverished classes of society, who inhabit unhealthy localities, and small, ill-ventilated, and filthy habitations. It has been observed by Caspar, Billard, Wolff', and others, that infants reared by the hand are more liable to the dis- ease, under all circumstances, than those who are nourished at the breast. Although the disease may attack infants apparently in perfect healtli, yet, in the great majority of instances, those who become the subjects of it are observed to be feeble or languid from birth; or to labour under more or less disorder of the alimentary canal previously to^ the occurrence of the cutaneous affection. AVe should hence be in- clined to refer the disease to gastro-intestinal disease, and a generally languid and debilitated condition of the organism, the result of conta- minated air, and improper or unwholesome diet; and probably, in some instances, an additional morbific cause, a cold and humid atmo- sphere, may concur in its production. The connexion of the disease # 692 DISEASES OF CHILDREN. with gastro-intestinal irritation had already been noticed by Denis and it is further proved, by the fact of the frequency with which, in post-mortem examinations, inflammation of the mucous membrane of the digestive organs is detected. The causes of the disease appear to differ but little from those which give rise to infantile erysipelas, to which it has a very close re- semblance. It is often attended with a condition of the skin not very dissimilar from that which occurs in erysipelas; while the latter is frequently associated with considerable induration of the surface, for some distance beyond the inflamed margin. The morbid condition of the surface is evidently dependent upon the simple infiltration of the cellular membrane with a serous fluid: this is proved by the appearance of the subcutaneous tissue after death, as well as by the fact, that when, during the lifetime of the patient, in- cisions are made into the indurated parts, and pressure is applied, the serum is discharged, and the swelling, tension, and hardness, entirely disappear. It would appear, therefore, that the disease is, in fact, a genuine oedema; the extreme hardness of the skin resulting from the less loose and yielding nature of its tissues in early infancy. The oedema has been referred, by Billard, to a languid circulation, the result of a venous plethora, and the action of such external agents as have the effect of suspending the cutaneous transpiration, and thus favouring the accumulation of serosity in the subcutaneous cellular tissue. When the oedema is general, and the venous congestion exists to a very great degree, all the organs abundantly supplied with cellular tissue have their functions more or less disturbed, in consequence of the infiltration of serum. Thus, the glottis becoming oedematous, while the lungs are overloaded with venous blood, the cry of the infant is rendered painful, acute, and smothered. The coldness of the sur- face is the result of the languid state of the capillary circulation, the deficient oxygenation of the blood in the lungs, and the general de- bility of the patient. All this is no doubt true, so far as it regards a certain class of cases: in others, hoAvever, which have fallen under our notice, the venous congestion, and consequent serous infiltration of the subcutaneous cel- lular tissue, were evidently the result of an imperfect distention of the lungs at birth, and the consequent production of the condition denomi- nated atelectasis by Jorg. The probability of this as a frequent cause of the disease was suggested by Dr.Maunsell: its certain occurrence in several cases, we have established by the result of our _ autopsies. ■M. Rogers notices the frequency with which partial indurations of the lungs are met with in the induration of the cellular tissue of infants. He "conceives that the pulmonary affection must differ very essentially from true inflammation of the lungs. AVhile in the latter the tempe- rature rises even to 105°, in that peculiar condition of the lungs which accompanies induration of the cellular tissue, it sinks as low as 71°, the pulse and respiration at the same time being slow, in place of accelerated. We believe that there is still another class of cases, by no means CONGENITAL AFFECTIONS, ETC. 693 unfrequent, in Avhich the serous effusion into the subcutaneous cellular tissue is the result of a subacute inflammation of the latter, consecu- tive, most frequently, to irritation of the alimentary canal. There are, evidently, two distinct varieties of induration of the skin; that from serous infiltration of the cellular tissue, and another from induration or concretion of the adipose matter. The latter may exist with or without general infiltration of the subcutaneous cellular tissue. It is usually seated in the cheeks, nates, calves of the legs, or back, and occurs Avith or without derangement of the circulation or respiration, and is seldom attended with symptoms of a nervous character. (Billard, Rostan, Wolff.) AVhen the adipose tissue is alone diseased, the affected parts are but little swollen, and have the firm feel, and yellowish-Avhite appear- ance of wax, or concrete suet; in the latter stages of the disease they are said to be sonorous upon percussion, and are perfectly cold to the touch. In these cases, upon dissection, the subcutaneous adipose sub- stance is found hardened and condensed like suet, with the skin com. tracted, and firmly adherent to it. In this country, induration of the skin is an extremely rare disease. Although connected, as physician, for eighteen years, with one of the' largest medical charities, perhaps, in this country, we met with but twelve cases of the disease during that period. In the hospitals for children, in Europe, it is, however, of more common occurrence. In the Foundling Hospital of Paris, 645 cases occurred between the years 1808 and 1811; of which number, 567 terminated fatally; and in 1826, there occurred in the same institution 240 cases, of which fifty died. The disease is described by the generality of the Avriters on the sub- ject, as being but little under the control of medical treatment, and as terminating fatally in the majority of cases. The condition of the skin, hoAvever, appears to be of less importance than that of the sys- tem generally; and death more seldom results, according to Billard, from the morbid state of the integuments, than from the serious dis- eases of the internal organs—the alimentary canal, the lungs and the brain—with Avhich it is commonly associated. AVhen limited in extent, and occurring in infants possessed of some vigour of constitution, or even when general, but not of an aggravated character, and uncomplicated with severe visceral disease, it will often yield to very simple remedies. The proper treatment of induration of the skin in infants, will de- pend pretty much upon the particular character of each case. In some, there is no doubt that the general plethora or local accumulations of blood, Avill demand the employment of leeches, cups, or even general bloodletting, and gentle purgatives; and that a cautious use of these remedies will be attended with the best effects. Friction of the sur- face with the hand, or Avarm flannel, and the use of flannel garments next the skin, are all-important remedies in the generality of cases, and should not be neglected. Blisters have been strongly recom- mended by Richter, and according to the experience of Dr. Eberle, Avhen early applied to the affected parts, they would appear to remove 694 DISEASES OF CHILDREN. the sanguineous engorgement of the subcutaneous tissues, promote the absorption of the effused serum, and prevent its undue accumulation. AVe have,- in several instances, seen good effects result from a avcII- timed blister:—it should be kept on about three hours; immediately upon its removal, the part being covered with a large emollient poul- tice. The exhibition of an emetic of ipecacuanha, for the purpose of re- lieving the air-passages from accumulations of mucus, and unloading the vessels of the lungs, has been recommended; and Ave have no doubt that it will prove, in most cases, highly beneficial. The vapour-bath has been considered by some practitioners one of the most effectual remedies that can be employed in this disease; and when it is dependent upon subacute inflammation of the subcutaneous tissues, or gastro-intestinal irritation, will no doubt prove advanta- geous; but it is not a remedy adapted to the generality of cases: in many, dry heat, and friction of the surface, as directed by Baron, will have a far better effect. In some cases, the respiration, during tbe continuance of the patient in the bath, is painfully accelerated, and congestion and effusion in the lungs or brain have, it is asserted by Billard, occasionally followed its use. Incisions through the skin, at the seat of the disease, have been sug- gested by Andry, Wolff, and others, as a means of relieving the over- loaded state of the subcutaneous vessels, and of giving exit to the serum distending the areola of the subcutaneous cellular tissue. AVe are not aAvare that this procedure has been practised to any great ex- tent; nor are Ave acquainted with the results of the cases in Avhich it has been tried: we can, hoAvever, see no valid objection to it. In cases attended with derangement of the alimentary canal, small doses of calomel in combination with ipecacuanha, three or four times a day, with the occasional interposition of a dose of castor oil and turpentine, as recommended in infantile erysipelas, should be admi- nistered. If, however, the symptoms indicate that the gastro-intestinal mucous membrane is the seat of acute or subacute inflammation, a few leeches should be applied to the epigastrium, or wherever the ten- derness is most decided, and followed by large emollient cataplasms. AVhere there exists very great debility, wine whey, or even ammo- nia in combination with the aqua camphorata, with friction of the sur- face Avith camphorated spirits, or the oil of amber, followed by the application of a flannel envelope, will be the most appropriate treat- ment. 16.—Naevus. Children are often born with permanent spots or marks upon the skin, varying in extent, and very materially in their nature and im- portance. The whole of these have been generally included under the vague denomination of navi materni. A very common form of naevus is that of a mole or slightly elevated tumour,"differing in size in different cases; generally of a dark colour, and often covered thickly with fine, short, silky hair, of the same colour as the mole. These naevi may occur upon any part of the body, and CONGENITAL AFFECTIONS, ETC 695 when seated upon the face or neck, or upon the shoulder or breast in the female, produce very considerable deformity. They often increase sloAvly in size, and acquire a darker colour, until toAvards puberty; * after which period they commonly remain stationary for the remain- der of life, and are unattended Avith pain or inconvenience. They are generally attributed to some alteration in the structure of the rete mu- cosum: their true nature does not appear, however, to be as yet, well understood. It is not customary to interfere with them; they could certainly be dissected out Avithout much difficulty, but the deformity resulting from this procedure would probably be as great as that it Avas intended to remove. Another very common form of naevus is a dark-red circumscribed stain, Avhich generally appears upon one side of the face, and is some- times of considerable extent. It is perfectly superficial, and has been supposed to result from a simple dilatation of the subcuticular capil- lary vessels at the part affected: it would appear to us, however, rather to depend upon a local abnormal condition of the rete muco- sum. Like the former, it sometimes increases in extent until about the period of puberty, Avhen it undergoes no further change throughout the remainder of life;—being attended with no other inconvenience than its unsightliness. AVe have known it, however, to disappear en- tirely during childhood. It has been proposed by Friinkel to diminish the deformity by tattooing the part affected with a white pigment. The naevus appears frequently in the form of a slight dilatation of the capillaries; in some cases superficial, and in others extending deeply into the mucous membrane of the lips. In some instances the dilated capillaries appear as tortuous, wide-spread lines, proceeding from a small round spot, like the legs of the spider from its body; in others, they form small, defined, granular tumours, of a bright red colour; in other cases, again, the naevus is composed of a congeries of venous capillaries, and is of a deep blue, or bluish-red colour. These sometimes disappear before puberty; at others, they continue station- ary, neither enlarging nor diminishing during life. They are never troublesome, constitute but a very inconsiderable deformity, and, as a general rule, should not be interfered with. The most important of the naevi is that which appears in the form of a deep red-coloured, slightly elevated spot, which often rapidly augments in size, with a well defined margin, and a granular surface; it is obliterated by pressure, but rapidly rises again when this is re- moved. It is formed of an erectile, vascular tissue, and if acciden- tally wounded, often gives rise to copious, prolonged, and dangerous haemorrhage. When seated near to an arterial trunk of any size, it pulsates powerfully beneath the finger, and is attended by a thrilling purr, synchronous with the action of the heart. (Aneurism by anasto- mosis.) Various plans have been proposed for the removal of the vascular naevus. 1st. The application of cold and pressure. (Abernethy.) This will frequently succeed when the naevus is small, and not disposed to in- crease rapidly in size, and Avhen it is seated over a bone; but in those 696 DISEASES OF CHILDREN. of larger size, of rapid growth, and seated over soft parts, it is al- together inefficient. 2d. Araccination over the surface of the tumour. (Hodgson.) This will frequently succeed: it is ahvays, however, productive of a con- siderable scar, and if ulceration or sloughing occur, as is sometimes the case, the scar is often large, and forms a very decided deformity in parts exposed to vieAv. 3d. Caustic. (Wardrop.) This will also repeatedly succeed when the vascular tumour is of small size, and inactive. A portion of ad- hesive plaster, with an orifice in its centre, of less diameter than that of the naevus, should be applied closely around the tumour. The kali purum is then to be rubbed upon the surface of the naevus, until slight discoloration takes place; the whole is then to be covered Avith adhesive plaster, and suffered to remain some days. When the tu- mour is flat, one of its largest vessels may be punctured, and a stick of the caustic, finely pointed, passed into the orifice, vinegar being immediately applied to prevent the too extensive action of the caus- tic. The caustic will not succeed in the removal of large, diffused, or deeply seated naevi; it cannot be applied in those seated in the im- mediate vicinity of the eye, and however carefully performed, is pro- ductive of an unsightly scar. 4th. Ligature. (Bell, White, Lawrence.) There are several modes of applying the ligature. When the base of the tumour is very nar- row, the simple ligature may succeed; but when the base is large, a needle armed with a double ligature may be passed beneath the tu- mour, and one portion tied around each hemisphere, and tightened, as it becomes loosened by ulceration; or, two double ligatures may be passed beneath the tumour, one in the direction of each of the di- ameters, and the tumour strangulated at four different points by ty- ing together the single ends of the ligatures nearest to each other; or a hare-lip pin may be passed under the naevus, and then a double ligature under that at right angles; the separate ligatures are then to be tied lightly, and twisted round the pin twice or thrice. In both of the latter methods, it is as well to divide freely the substance of the naevus above the ligatures. . A new plan for applying the ligature has been proposed by Mr. Christopher, and practised by him in six cases with perfect success. (Lond. Med. Gaz., Dec, 1848.) A strong silk, half a yard long, one half of which has been dyed black by dipping it in ink, after being well waxed, is to be passed through the eye of a needle so as to leave the ends equal. The needle is then to be passed beneath the centre of the part to be removed. The ligature being divided in the middle, so as to leave the needle on the black portion, the latter is to be passed through the skin, immedi- ately below the part to be strangulated. The superior, or white half of the ligature being now armed with the needle, this is to be passed through the skin in an opposite direction to the black ligature, im- mediately above the part to be strangulated. The needle being re- moved, the two ends of the black loop that includes the inferior half of the naevus, are to be tightly tied, and then the tAvo ends of the white loop, including the superior half of the naevus. The four ends re- maining, two black and two white, are now to be tied alternately C ONGENITAL AFFECTIONS, ETC 697 and tightly the one to the other. The whole mass to be removed is thus completely and entirely enclosed in a double circle, both from within and without, and is most effectually and permanently strangu- lated. We have seen the ligature often perfectly successful: it is generally, however, attended with considerable pain, and cases are recorded in which it was productive of conA-ulsions. It is always tedious, and leaves, generally, a large irregular scar. According to Mr. Christopher, the plan proposed, by him is productive of little pain, and in the cases in w-hich he has put it in practice, it has been unattended by any untoward accident. 5th. Setons. (Adams.) Twelve or fourteen threads passed through the tumour at different points without tying. This is said to succeed perfectly in the removal of the naevus. 6th. Ligature of the principal arterial trunk which supplies the naevus. (Travers.) This will unquestionably succeed in some cases, and in the more extensive and distinctly marked aneurism by anasto- mosis, is, in fact, the only operation that can be depended on: it is, however, a very serious one, and has been found repeatedly unsuc- cessful. In the ordinary forms of vascular naevi, it is uifnecessary to resort to it. 7th. A plan of treatment has been suggested by M. Hall, which is said effectually to remove these tumours, to be applicable in all cases, without reference to size or locality, to be without danger of haemor- rhage, and to be unattended with the inconvenience of ulceration or sloughing, and consequent deformity. It consists in passing a mode- rately sized needle, with cutting edges, through the naevus so fre- quently as to induce adhesive inflammation with the deposit of lymph, and thus to obliterate and consolidate the vessels of which it is com- posed, yet so seldom as not to incur the risk of inducing sloughing. The needle must be passed in several directions from one point in the circumference of the naevus, to several points more or less opposite; near the surface, in the superficial arterial naevus, but more deeply in the deeper-seated capillary naevus. The operation is to be repeated at intervals of two, three, or four months, according to the state of the case, and the progress of the cure. We know nothing, personally, of the merits of this operation, never having seen it performed. 8th. Excision. (Bell.) This is the plan which wre have invariably adopted in all true arterial naeATi that have fallen under our notice, and have repeatedly seen it performed by others. It is said by AA7ardrop to be frequently dangerous, from haemorrhage, and to have even proved fatal. We have never found any injury to result from it. The incision through the skin should be made at some distance from the margin of the tumour, which should be dissected out beneath its base: but little haemorrhage has resulted in the majority of cases, and this was readily commanded by pressure: occasionally, however, one or two small arterial branches had to be secured by ligature. By approximating and securing the edges of the wound, a very small cicatrix is produced. 9th. Lafargue recommends five or six punctures to be made on and around tho naevus, with a lancet dipped in croton oil, as in vaccina- I 698 DISEASES OF CHILDREN. tion. By each puncture a pimple is immediately produced, which be- comes, in thirty-six hours, a little boil. The several boils unite and form a painful, burning tumour, covered Avith white crusts, and re- sembling a small carbuncle. Two days aftenvards the scabs separate. and in place of the naevus is seen an ulcer, which is to be treated on general principles. M. Lafargue considers that it Avould be dange- rous to make more than six punctures on a very young infant, as the irritation and fever that result are considerable. AVhatever operation is adopted, it is important that the child should have attained its third year previous to its performance, and at the same time be in tolerable health, and free from fever, or other posi- tive disease. If considerable pain, restlessness, or fever result from the operation, these should be treated by their appropriate remedies. 17.—Jaundice—Icteris Infantilis. In infants, two or three days after birth, it is not unusual for the whole surface of the body, as well as the tunica conjunctiva, to acquire a yellow hue, more or less intense, which, in the course of a few days, in general, gradually disappears. (Icterus neonatorum.) Generally speaking, this is an affection of very little importance, ap- pearing to depend upon a temporary excess of the colouring matter of the bile in the serum of the blood, and to be unattended with dis- ease of the liver, or any of the other organs. In some cases, it has appeared to us to be connected with the want of a free evacuation of the meconium. Occasionally, this discoloration of the skin we have known to be accompanied with a good deal of drowsiness, and an evident sense of uneasiness in the skin. Nothing more is required in any case, than a dose of castor oil, or a grain or two of calomel, and the same quantity of rhubarb, with the daily use of the warm bath. In some instances, the skin of the infant will be marked by dull yellow, irregular blotches, (macula hepatica,) more or less extensive, and sometimes occupying the greater part of the surface. The colour. of these blotches varies very much in intensity; and in cases where there exists considerable derangement of the alimentary canal, they occasionally assume a very dark hue (melasma)—in some instances, they are accompanied with a prickling or tingling sensation. The disease appears to be most generally connected with derange- ment of the digestive organs,—the colour of the skin being dependent upon a morbid secretion from the cutaneous vessels:—it has little or no affinity with jaundice. Considerable debility and languor, and indications of a disordered state of the alimentary canal, generally T)rpc6(3.G its occiirrGiiCG. Its removal is to be effected by such means as are calculated to restore the regular and healthy functions of the digestive organs, and to improve the health of the infant generally: in all cases, the breast- milk of a healthy nurse, a pure fresh air, and the daily use of the warm bath, with gentle friction of the surface, are important parts of the treatment. Genuine jaundice, with intense yellowness of the skin and tunica CONGENITAL AFFECTIONS, ETC. 699 conjunctiva, nausea or vomiting, costiveness—the evacuations, when procured, being white or clay-coloured—and a deep yellow colour of the urine, may occur in infants, from congenital obstruction or malfor- mation of the biliary ducts. Under such circumstances, the disease is incurable, and sooner or later will prove fatal. In the Northern Journal of Medicine, Dr. A. B. Campbell relates three cases of icterus in new-born infants, all of which terminated fa- tally. In two, the disease was found to depend on congenital absence of the hepatic and cystic ducts, and in the other upon obstruction of the common biliary ducts by inspissated bile. In the first case the jaundiced hue of the skin appeared the day after birth: the infant, however, continued well until the ninth day—though the evacuations from the bowels were white: a haemorrhage from the umbilicus then occurred, and returned on the following day, Avhen the child died. The gall-bladder Avas found to be a shut sac, the hepatic and cystic ducts being both wanting—the blood was tinged with bile. In the second case, the symptoms occurred early—no haemorrhage took place. The infant wasted away, while its abdomen enlarged in both hypochondriac regions. The patient lived until the sixth month, being attacked im- mediately preceding its death with violent diarrhoea, and vomiting of a fluid like coffee grounds. The liver was large—the gall bladder, as well as the ducts, were absent,—the blood and various tissues were tinged Avith bile. The third case closely resembled the first; haemor- rhage from the umbilicus occurred on the seventh day, and returned at intervals until the eleventh, when the child sunk into a comatose state and died. The whole amount of blood discharged did not ex- ceed an ounce and a half. The gall-bladder was full of bile, the escape of which was prevented, however, by a plug of inspissated bile, Avhich filled the common duct. The brother of this infant died at the same age and with similar symptoms. The same morbid phenomena, with the addition of pain and tender- ness of the epigastrium, vomiting of the food soon after it is swallowed, ox, if retained, violent paroxysms of pain, occurring an hour or tAvo after it is taken, may be produced in infants, by inflammation, acute or subacute, of the mucous membrane of the duodenum. Here the treatment must be directed entirely to the removal of the latter dis- ease : mild mucilaginous fluids, in small quantities, a few leeches to the epigastrium, followed by warm fomentations, or an emollient ca- taplasm; and, after the inflammation has been, in this manner, reduced, a blister to the epigastrium, for a couple or three hours, succeeded by a soft bread and milk poultice, and internally, very minute doses of calomel and ipecacuanha, three or four times a day. In many cases, however,—we have certainly met with a great num- ber—the jaundice of infants is dependent upon a state of hyperaemia or of subacute inflammation of the liver. In these cases, the colour of the skin and eye is of a dirty yellow—the surface is harsh and dry • the urine is charged with bilious matter; the stools are dry and clay- coloured ; the countenance has an anxious, distressed expression, and the infant is apt to fall into a languid, drowsy state; there is'con- siderable thirst, acidity of stomach, flatulence, and frequent griping or 700 DISEASES OF CHILDREN. colicky pains; and with these symptoms, there'is ahvays more or less fulness of the right hypochondriac region, Avith great tenderness upon pressure. The disease, in general, assumes a chronic character, and is attended with considerable and progressive emaciation, and with tumefaction and hardness of the abdomen; frequently with oedema of the lower extremities, and sometimes with effusion within the peritoneal cavity. The tongue, which was at first coated with a thin layer of yelhnvish mucus, becomes, in the progress of the disease, dry, and of a dark- brown colour. It is occasionally accompanied by induration of the subcutaneous cellular texture, and more frequently, with purpura, either simple or haemorrhagic. The disease is, in general, produced by the same causes which give rise, in infancy, to derangement of the digestive organs. AVhen de- pending upon hyperaemia of the liver, it is usually connected Avith the indications of a general plethoric condition of the system, and a very languid circulation. It has been supposed by Eberle, that this condi- tion is most apt to occur in infants who, when born, present a turgid and livid appearance of the face and body, and an oppressed state of the brain, and which have not been sufficiently relieved by a Aoav of blood from the divided vessels of the cord. In the treatment of the jaundice of infants, our remedies will depend upon the character of the symptoms in each case. AVhen simple hyperaemia of the liver exists, an emetic of ipecacuanha should be given, and repeated, in a day or two, if circumstances require it. The emetic should be succeeded by the warm bath, and gentle friction over the whole surface of the abdomen, and a grain or tAvo of calomel, fol- lowed by castor oil, or magnesia and rhubarb. The bowels should be kept regularly open by divided doses of calomel, magnesia, and ipe- cacuanha, given tliree times a day, with an occasional dose of castor oil, the activity of which may be increased by a few drops of turpen- tine. The warm bath should be repeated daily, and the infant allowed the benefit of a free, pure atmosphere. ^ . . • When the case is marked by symptoms indicative of hepatic in- flammation, a few leeches should be applied to the right hypochon- drium, and folioAved by an emollient cataplasm. The leeches may be repeated, after a short interval, if the fulness and tenderness of the risht hypochondrium continue Avith little abatement. Calomel should be" administered in the same manner as directed above. After the hepatic inflammation has been somewhat reduced, the warm bath, followed by a blister over the liver, will, in general, be found ot de- cided advantage; the blister should be removed in three hours and the part to Avhich it has been applied covered with a soft emollient poultice. When the calomel produces irritation of the intestines, we may combine it with small doses of the extract of hyoscyamus,1 which in no degree interferes with its action upon the bowels. Ihe use ot the calomel, with an occasional purgative of castor oil and turpentine, should be continued, until natural, bilious, stools are procured, when it should be suspended, and the freedom of the bowels maintained by the use of the citrate of magnesia and rhubarb, or castor oil. CONGENITAL AFFECTIONS, ETC. 701 1 R-—Calomel, gr. iij. Ipecac, pulv. gr. ij. Magnes. calc. gr. xxxvj. Ext. hyoscyami, gr. iv.—M. f. ch. No. xij. In the chronic form of infantile jaundice, the warm bath, followed by frictions, blisters to the right hypochondrium, and a cautious use of calomel and ipecacuanha, in alterative doses, are the remedies from Avhich the most benefit is to be anticipated. The carbonate of soda may, in many cases, be administered with advantage; a gram or two should be given every two or three hours, dissolved in a teaspoonful of carbonated water, or in the same quantity of a weak infusion of hops; or, it may be given in combination with taraxacum.1 AVe have seen very striking advantage result, in many of the chronic cases of jaun- dice occurring in infants, from the taraxacum, in combination with the vegetable alkalies; whilst in other cases, again, Ave have given it in tolerably large doses, and continued its use for some time, without any benefit Avhatever. When, in the chronic form of infantile jaundice, there is considerable flatulence of the intestines, with frequent griping or colicky pains, the turpentine has, in our hands, succeeded the best, in removing the ten- dency to the formation of gas, and relieving the suffering of the pa- tient AVe have, generally, at the same time that we administered the turpentine—in the dose of from five to ten drops, according to the age of the patient, every three hours—directed a dose of extract of hyos- cyamus, in combination with ipecacuanha and carbonate of soda, three times a day,2 and a camphorated mercurial plaster over the whole of the right hypochondrium. 1 R.—Taraxaci, ^ij. a R.—Extr. hyoscyami, gr. iv.—vj. Bicarb, sodse, gr. xxiv.—xxx. Pulv. ipecac, gr. ij.—iij. Aquse, ,^ij. Bicarb, sodae, gr. xxiv.—xxxvj. Sjrup. limon, gij.—M. —M. f. pil. No. xij. Dose, a teaspoonful every four hours. AAlien Ave have succeeded in procuring natural, bilious, discharges from the bowels, and the skin begins to assume its natural hue, the restoration of the patient's strength may be promoted by some light tonic; either the cold infusion of bark, or the sulphate of quinia, or the proto-carbonate or tincture of the sesquichloride of iron, with a light vegetable diet, the warm bath daily, gentle exercise in the open air, and occasional doses of some mild purgative, to keep the bowels regular if they are inclined to costiveness. 18.—Purulent Ophthalmia.—Ophthalmia neonatorum— Infantile Conjunctivitis. The purulent ophthalmia of infants commences, usually, within a few days after birth—generally betAveen the third and seventh. We have seen it, however, upon the second day, and occasionally, not until the third Aveek. The first indication of the disease is, generally, the eyelids becoming glued together during the night, Avith swelling and redness externally! AAThen the lid is raised there occurs a gush of tears, and its conjunc- 702 DISEASES OF CHILDREN. tiva is found to be uniformly red, and slightly thickened, and covered often with a somewhat tenacious, transparent coating. As the disease proceeds, the lids become more constantly aggluti- nated, and an increased secretion from the surface of the inflamed conjunctiva takes place, of a thick, purulent matter, a portion of Avhich exudes from betAveen the lids, but the greater part is retained, causing a considerable bulging of the palpebrae—the integuments of which as- sume a dark-red hue. The child becomes fretful and uneasy, and manifests the utmost intolerance of light—keeping the eyes firmly and constantly closed, and averted from the light. The tumefaction and redness of the conjunctiva rapidly increase, and extend over the globe of the eye. Every separation of the eyelids is attended with a gush of purulent matter, which sometimes is so copiously effused as to burst open the firmly closed lids, and run doAvn the cheek in large drops. The thickening of the conjunctiva often becomes so considerable, in the course of three or four days, as to rise up around the cornea, nearly concealing it, or causing it to appear as if sunk deep into the eye. The intumescence of the conjunctiva causes it to become everted upon every attempt to examine the affected organ, or every time the child cries; not unfrequently, the constant pressure of the orbicularis muscle renders the eversion permanent. The discharge from the eye is generally of a pale straw-colour; but sometimes of a deeper yellow; and, not unfrequently, it assumes a greenish hue; it is said, in some cases, to be ichorous, or mixed with blood. An ichorous state of the discharge we have never seen; but occasionally, have known a small amount of blood to be mixed Avith it. A slight hazy condition of the cornea very generally occurs, and this may continue for a week or longer, without any permanent de- struction of its transparency. About the tenth or twelfth day, some- times later, purulent infiltration of the cornea, however, takes place; or, an interstitial deposit in the conjunctival layer or substance of the cornea. When purulent infiltration occurs, ulceration may ensue, either of the entire cornea, or of a small, circumscribed portion of it, giving place to prolapsus of the humours, or of the iris only. When an in- terstitial deposit takes place, complete opacity of a part, or of the Avhole of the cornea may result, or a thin, bluish-gray film may form over its surface. When a considerable portion of the cornea is de- stroyed by ulceration, the humours of the eye ordinarily escape, and the globe collapses. There appear to be two forms of purulent ophthalmia, as it occurs in children: one in which the inflammation is confined exclusively to the conjunctiva of the lids; another in which the conjunctiva of the eyeball becomes equally involved in the disease. In the first, the dis- ease is of a much milder character, and is seldom attended with any very serious injury to the eye: occasionally, hoAvever, the disease is equally severe in its symptoms, and protracted in its course, as when the inflammation affects the whole of the conjunctiva. AVe have re- CONGENITAL AFFECTIONS, ETC 703 peatedly seen the disease confined, for a number of days, to the palpebral, conjunctiva, and then suddenly to extend over the ball of the eye, and be quickly followed by infiltration and ulceration of the cornea. In cases unattended with complete opacity or extensive ulceration of the cornea, adhesion of the iris to the latter may take place; or an opaque spot, not larger than the head of a small pin, may be formed in the centre of the anterior hemisphere of the capsule of the lens. Both eyes are generally attacked, either simultaneously, or within a very short interval of each other. The result, favourable or unfavourable, of infantile purulent -oph- thalmia, will depend pretty much upon the greater or less violence of the attack, and the period at which the treatment is commenced. In its early stages, the disease is by no means difficult to cure; but in its advanced stages, it is seldom arrested, until more or less injury to the eye has taken place. So long as the cornea retains its transparency, there is a possibility of saving the eye; but when ulceration or purulent infiltration of the cornea has occurred, although the inflammation may still be removed, the sight will be permanently destroyed. Opacity of the cornea, resulting from a thickening of its conjunctival covering, may disappear completely in the course of time, but that from superficial ulceration is generally permanent, and may interfere, to a greater or less extent, with vision. ^ Protrusion and adhesions of the iris may impede or totally destroy vision, according to the part at which these occur; while the loss of vision resulting, at first, from central opacity of the capsule of the lens, may in time, with the enlargement of the pupil, which takes place with the growth of the child, disappear in part; but permanent short-sight- edness may remain. Not a little discrepancy of opinion has existed, and still exists, as to the true character and cause of purulent ophthalmia. By some, the disease has been supposed to be of a specific character—an erysipela- tous affection of the conjunctiva; others believe it to be simple catar- rhal inflammation, occurring in children of unhealthy constitutions. By the majority of authors, however, it is referred to some acrid or morbid matter secreted in the vagina of the mother, and applied to the infant's eyes during birth. It is unquestionably true, that children born of mothers labouring under leucorrhcea, are far more liable to be affected with purulent ophthalmia after birth, than those born of women who are entirely free from disease; yet so many cases of the disease occur in the latter that those physicians certainly err, who refer it invariably to morbid vaginal discharges in the mother. During twelve months, Cerderschjold informs us, three hundred and sixty women were delivered in the General Lying-in Hospital of Stock- holm, and subtracting those of whom the children were dead-born or died within a clay or two after birth, of the remaining three hundred and twenty-eight, one hundred and forty-seven laboured under leucor- rhcea, and the remaining one hundred and eighty-one were free from 704 DISEASES OF CHILDREN. disease. Thirty of the children Avere affected Avith purulent ophthalmia, namely, twenty of those whose mothers had the discharge, and ten of those Avhose mothers had none. From these facts it would appear, that discharges from the genitals are extremely common among pregnant w-omen; that women may labour under them Avithout causing purulent ophthalmia in their chil- dren; and that infants may be affected with this disease, notwithstand- ing their mothers have no discharge: it is evident, therefore, that the ophthalmia is not necessarily produced by infection received from the mother. Nevertheless, when Ave consider that twenty out of the one hundred and forty-seven children born of mothers in Avhom a vaginal discharge existed, or about one in seven, suffered from ophthalmia, while only ten in one hundred and eighty-one, or one in eighteen, of those whose mothers were unaffected, had the disease—the proportion of the former being nearly three times greater than the latter—Ave must conclude, that a discharge from the genitals of the mother, though not the sole cause of purulent ophthalmia in neAv-born infants, is, at least, a very frequent one. The disease is attributed by some to the too early and unguarded admission of light and heat to the eyes of the neAv-born infant. AVe cannot say that we have been able to trace purulent ophthalmia to this cause, though we admit that the practice of placing an infant, as soon as it is born, and day after day subsequently, on the nurse's lap, before a bright fire, witli its face turned towards the latter, and with perhaps a candle or lamp at no great distance, and keeping it there, not only during the time necessary for dressing or changing it, but frequently, long after this is completed, is certainly one very liable to produce injury to the eyes. Impurities of the atmosphere, particularly smoke and other irritating vapours diffused in the air, are, no doubt, common causes of purulent ophthalmia; cold and dampness may also produce it; and, perhaps, slight mechanical injuries of the conjunctiva. Purulent ophthalmia is a common affection of infants in almshouses and children's asylums, where the inmates are crowded together, without sufficient attention being paid to cleanliness, and to the se- curing at all times, a due supply of fresh air; and it is among the chil- dren of the miserably poor, by whom little care is taken of the hygienic management of their offspring, that, in private practice, we most fre- quently meet with the disease. Contaminated air, with its often asso- ciated morbific causes, neglect of cleanliness, defective nourishment, and want of sufficient exercise, is liable to produce a general tendency to disease, in the mucous tissues of children; the mouth, anus, and vulva, under such circumstances, being alike liable to affections ter- minating rapidly in gangrenous ulceration. In cases of purulent ophthalmia, it is said by Morrell, that the vagina is liable to be affected with a purulent discharge, precisely similar to that from the conjunctiva. By some physicians, purulent ophthalmia is supposed to be conta- gious; and numerous instances are referred to, in Avhich the disease is said to have been communicated to the nurse, by the accidental appli- CONGENITAL AFFECTIONS, ETC 705 cation of the matter from the eye of the infant to hers. Our " oppor- tunities for observation on this subject have been tolerably extensive," but we have never met Avith such an occurrence. The disease occa- sionally occurs epidemically, generally at periods when catarrhal affections prevail; being produced, probably, by the same causes as the latter. After the first three or four days, there is always a very great diffi- culty in obtaining a vieAv of the ball of the affected eye, particularly of the cornea, in consequence of the thickening and disposition to e ver- sion of the conjunctiva; and the irritation produced by every attempt to force open the lids, sufficiently to enable the practitioner to ascer- tain distinctly the actual condition of the affected organ, has induced us to forego it entirely, and trust to "what information can be obtained from the external condition of the lids, and the nature of the discharge which issues from beneath them." (Taylor.) At the same time, how- ever, we consider it absolutely necessary to open the lids once or twice a day, first sopping them well with a little warm water, or milk and water, so as to soften the matter which glues them together, in order to give discharge to the morbid secretion which accumulates behind them; an object which may be further promoted by the cau- tious injection of tepid Avater, or an infusion of pith of sassafras be- tAveen the lids. The agglutination of the lids may be prevented, by covering the eyes, as the patient lies upon his back, with a small por- tion of soft linen rag, and dropping upon the inner canthus, occasion- ally, a little warm milk and water. In the commencement of mild cases, we have seen the disease very quickly arrested, in numerous instances, by warm fomentations, assidu- ously applied to the eye externally, and the occasional use of a wash formed of a strong infusion of common green tea, great attention being paid at the same time to the condition of the bowels, which are very generally deranged. They are occasionally constipated, when a grain or two of calomel, followed by castor oil, should be administered: much more frequently, however, there is diarrhoea, with green, watery discharges: in such cases, small doses of calomel, ipecacuanha, and magnesia,1 and the daily use of the warm bath will be required. AVhen, however, there is general and decided redness and swelling of the conjunctiva, or if the eyelids are much swollen, and red exter- nally, local depletion by leeches will be absolutely necessary; and if not resorted to sufficiently early, and carried at once to a proper ex- tent, the only opportunity of saving the sight of the child may be lost The number of leeches—which should be applied as near as possible to the eye—will depend altogether upon the strength and vigour of the child, and their size; the best rule, perhaps, is to draw as much blood m this manner as will be sufficient to produce a slight paleness of the patient's skin. If the first application has not been sufficient to arrest the inflammation, the leeches should be repeated after a shorf interval. The leeches should be followed by purgatives, of which the best is calomel, succeeded by castor oil; or, the combination of calomel and ipecacuanha, as directed above. By some practitioners, a combina 706 DISEASES OF CHILDREN. tion of calomel and the pulvis antimonialis is considered pcculiarly beneficial in this disease.2 1 R—Calomel, gr. ij. 2 R.—CAlomel. gv. iij. . Pulv. ipecac, gr. ij. Fulv. antimonial. gr. xij.—M. 1". Magnes. calc. gr. xxxvj.—M. f. chart. No. xij. ch. No. xij. One to be given every three hours. One to be given every three or four hours. There can be no doubt that in all cases, minute doses of calomel, repeated daily, will be productive of the best effects, and that their efficacy will be increased by the addition of either the ipecacuanha or antimonial powder. If by this means the bowels are not kept sufficiently open, an occasional dose of castor oil, or of magnesia and rhubarb may be given. If there be continued derangement of the alimentary canal, the spirits of turpentine, in small doses, by the mouth, or in the form of enema, will often be particularly serviceable. The patient should be kept in a dark, well-ventilated room; the eyes should be repeatedly fomented with warm water, or with a warm infusion of pith of sassafras, or of poppy-heads, and the directions already given to keep the eyes free from the purulent discharge, con- stantly attended to. After the violence of the inflammation is reduced, it has been directed to apply blisters to the temples or over the closed eyelids; the latter mode of applying them is certainly to be preferred, and we have occa- sionally seen the best effects derived from their use. In young chil- dren, particularly whenof a weakly and debilitated constitutionjelisters must, however, be employed with the utmost caution, otherwise very dangerous consequences are apt to result from them. At that particular period of the disease when alone blisters, if they are resorted to, should be applied—that is, after the intensity of the inflammation has been considerably mitigated by leeches, purgatives, omollient applications, and a general antiphlogistic regimen—lightly scarifying the thickened conjunctiva, the eyelids being first carefully everted, and by this means procuring a free discharge of blood from its enlarged vessels, is considered by some as among the most effec- tual means for the complete removal of the disease: by Saunders and others, however, it is condemned as in all cases injurious. In chronic cases, attended with very great vascularity of the conjunctiva, we have known scarification to prove of the utmost service; we have never employed it, however, in the acute stage of the disease. AVe shall be obliged, in most cases of purulent ophthalmia, to judge of the effects of our remedies upon the disease, by the diminution of the general symptoms, and the quietness of the infant, and by the re- duced redness and tumefaction of the palpebrae, the diminished amount of the discharge, and by the child being able to open to a certain ex- tent, and for a longer or shorter period, his eyes; but to determine properly this latter, it is necessary to watch the motions of the patient before light is admitted into the apartment; because the moment this takes place, the eyes will be very generally closed, and he will forcibly resist their being opened. Whenever it can be done without inducing considerable pain, or an increase of irritation, it is always important, CONGENITAL AFFECTIONS, ETC. 707 however, that the state of the eye should be ascertained by actual in- spection. By an early resort to the treatment just recommended, and by its judicious employment, we shall generally find that about the third, fourth, or fifth day of the attack, the pain, swelling and irritation of the eye, will begin very rapidly to subside; the discharge at the same time becoming much less in quantity, and of a thin, gleety nature, and the conjunctiva of a paler and more flabby appearance, but Avith its vessels still gorged with a considerable amount of blood. Mild astringent applications will now be proper. Ararious formulae for these have been recommended by different practitioners; each one recom- mending his own as the best. Solutions of the acetate of zinc, (one scruple to four ounces of rose water,) or of the acetate of lead, (five grains to an ounce of water,) of the bi-chloride of mercury,1 of alum, (five grains to an ounce of water,) or of the nitrate of silver, (four grains to an ounce of water,) may be employed. With either of the first three, the eyes should be bathed three or four times in the twenty- four hours, and a portion carefully injected into the eye. Previously, however, to their use, the lids should be gently everted and the dis- charge carefully and cautiously wiped from their inner surface, by means of a soft sponge, wrung out of warm water. The solution of nitrate of silver may be applied once daily, with a large hair pencil, over the whole of the inflamed conjunctiva; it may be used in con- junction with either of the other collyria. 1 R.—Bi-chlorid. hydrarg. gr. j. Hydrochlorid. ammoniae, gr. vj. Aquae, gviij.—M. (Mackenzie.) The chloride of lime, (one scruple to two ounces of water,) has been strongly recommended in the treatment of the purulent ophthal- mia of infants, and deserves a trial. 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 membrane be- comes soft, spongy and granular, the solid nitrate of silver, or the ointment, (composed of ten grains to one ounce of lard,) may be ap- plied. 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 two three' or five grains daily, according to the extent of the exhaustion under which the patient labours. It is all-important, in every case of purulent ophthalmia, and during the entire continuance of the disease, that the patient should enioy a free, pure atmosphere; and 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. Although not convinced of the infectious character of the discharge 708 DISEASES OF CHILDREN. from the eye in this disease, Ave think it proper, however, not to run any risks; and hence, the attendants should be cautioned against in- curring the danger of communicating the infection to themselves or others, by the accidental contact of the matter with their eyes, which may be easily prevented by the most scrupulous cleanliness. 19.—Hydrocele. Hydrocele in infants may result from the distention of the vaginal sac of the scrotum with serum; the communication between this sac and the cavity of the abdomen being obliterated, or still continuing 0pen -—0r, the accumulation of serum may be confined to the vaginal tunic of the cord, without any communication Avith the scrotum or abdomen, or with a free communication with the latter. The diag- nosis is somewhat different in these different cases. In hydrocele of the vaginal sac of the scrotum, the tumour is semi- diaphanous, and the testicle, if it has descended, may be felt near its inferior posterior part. If no communication exists between thesac and abdomen, the SAvelling undergoes no change in its dimensions during crying or coughing; it usually gradually augments in size, presenting a kind of pyramidal form, with the apex towards the ring; and when the integuments of the scrotum are put upon the stretch, their natural rugosity is obliterated, and they become smooth, pale- coloured, and shining. If, however, a communication still exists between the scrotal and abdominal cavities, the tumour will increase in size when the child coughs or cries, and pressure upon the tumour 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 re- moved. In this case, our diagnosis is to be founded upon the senn- diaphanous character of the swelling, the presence of fluctuation, and the inability to feel within it any fold of intestine, or portion of omentum. In hydrocele of the cord, the tumour most generally occupies a situa- tion midway between the testicle and groin; it is of an oblong figure, perfectly circumscribed, and generally very tense;—it undergoes 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. AVhen 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 the swelling immediately returns upon the pres- sure being removed. With the exception of a slight dragging sensa- tion, which is the greatest Avhen the hydrocele is low down upon the cord or in the scrotal sac, these tumours are unaccompanied by either 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 ol the scrotum or cord; but most generally, it is not noticed until four or CONGENITAL AFFECTIONS, ETC. 709 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, when they occur 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 young infants, frequently sponging the tumour with a weak solu- tion of the acetate of lead, or with a mixture of two parts of aqua camphorata and one of vinegar is, perhaps, the only treatment that it is proper to pursue. If, under this treatment, the swelling does not dis- appear, when the child has arrived at twelve or eighteen months of age, as well as in those cases in which the swelling appears late in in- fancy or during childhood, the affusion of cold water—the water being poured upon the hydrocele out of a tea-pot, and from a height—four or five times a day, will very generally cause its dispersion. The affu- sion must be unremittingly persevered in for a considerable time. In this manner we have, in repeated instances, effected a complete cure. The effects of the cold water may be increased, in children over two years of age, by brisk purging, and a simple farinaceous diet. R.—Bitart. potassae, gij. Pulv. jalap, gj.—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 bowels. Where the hydrocele is of considerable size, and, in place of dimi- nishing, continues steadily to increase in bulk, we have found that puncturing the tumour, 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 tumour, of a seton composed 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 oblitera- tion of the cavity of the tunica vaginalis, does not come within the scope of the present treatise. 20-—Paronychia. ONYCHIA—PANARITIUM—WHITLOW—FELON. Children are very liable to an inflammation, occurring usually near the end of one of the fingers or toes, or about the edge or root of the nail. It may be seated in the cutis, in the subcutaneous cellular tissue, or in the thecae or synovial sheaths of the tendons, particularly on the inside of the fingers. When the inflammation occurs in the cutis, we have usually the symptoms of a slight phlegmon,—heat, pain, tension, and redness of the part, with some degree of febrile excitement. The inflammation 710 DISEASES OF CHILDREN. terminates quickly in suppuration, marked by a semi-transparent ele- vation of the cuticle. The pus frequently travels around the finger, separating the cuticle to a considerable extent. AVhen the inflammation is seated in the subcutaneous cellular mem- brane, the local symptoms are more severe, and there is often a de- cided febrile reaction, attended Avith distinct rigors. The suppuration occurs early, but the matter is sIoav in reaching the surface, and often extends laterally, burrowing beneath the nail. This form of parony- chia is generally attended Avith very severe pain throughout its course. The affection is of a still more severe character when seated in the thecae or synovial sheaths. The pain is deep-seated, and generally intense. There are often sev-ere rigors, followed by very decided symptoms of febrile reaction from the very commencement. The swelling is more extensive than in the other forms, often spreading over the whole hand or foot, and even to the forearm or leg; distinct red lines or streaks of inflammation—probably inflamed absorbents— extending to the axilla or groin. At this period, in very excitable children, convulsive action often ensues, and very generally extreme restlessness, or delirium. From the unyielding nature of the tissues, the matter formed, in place of reaching the surface, passes along the synovial sheaths, or tendinous thecae, to the palm of the hand or wrist, or to the sole of the foot; producing intense suffering for weeks, causing the death of the tendons, and destroying the motion of the joints, or even, in some cases, affecting the periosteum, and producing caries of the subjacent bone. In children of a lymphatic temperament, or of a plethoric, but un- healthy condition of body, the inflammation is often seated in the matrix and soft parts at the root of the nail. (Onychia maligna.) The disease commences with redness, swelling, heat, and tension at the root of the nail; attended with a dull, throbbing pain, great ten- derness upon the slightest pressure, and shivering, succeeded by febrile excitement. From'the sulcus at the lower part of the nail there soon takes place an oozing of a thin, ichorous fluid, succeeded by ulceration, which spreads round the semicircular edge of the soft parts covering the root of the nail: the ulcer is of an unhealthy appearance, with thin, flabby edges, and covered with a dirty yellow lymph; the skin is separated from the nail, which becomes exposed to its very root, and discoloured. The ulceration extending beneath the nail this becomes gradually detached from the parts beneath. The surrounding soft parts are swollen, of a dusky red or purplish hue, and intensely sore; bleeding profusely upon the slightest touch. When allowed to pro- ceed, the toe or finger becomes a deformed, bulbous, ulcerated mass, and may continue so for months; exhibiting not theslightest disposi- tion to heal, so long as any portion of the nail remains attached. Paronychia often occurs in perfectly healthy children, without any very apparent cause: in many cases it would appear to be intimately connected with derangement of the digestive and assimilative organs; but its most common cause is either external injury, puncture, contu- sions or slight wounds, cold, or the retention of some acrid or extra- neous substance about the nail. CONGENITAL AFFECTIONS, ETC. 711 During the inflammatory stage of paronychia, if any extraneous substance is present, it should be extracted or removed by repeated al dutions with warm water and a sponge, according to its nature. In the superficial variety, the best application is, probably, the common bread-and-milk poultice, frequently repeated, with a brisk purgative internally, and a mild restricted diet. In the cases in which the in- flammation is more deeply seated, leeches, saline purgatives, Ioav diet, and perfect rest are required. If the local inflammation is very considerable, and attended with much febrile reaction, in robust, plethoric children, a few ounces of blood should be taken from the arm, and some saline diaphoretic with antimony administered.1 The free application of leeches to the seat of the disease is the most effectual means of abating the inflammation, and in this manner relieving the extreme pain. The early applica- tion of a blister around the affected finger or toe, has often arrested the progress of the disease. 1 R.—Sulph. magnes. giv. Pulv. nitri, gj. Tart. ant. gr. j. Spir. aeth. nitr. giv. Aquae, ^iv.—M. Of which a teaspoonful may be given every three hours. Various rubefacients have been recommended, as hot Avater, hot ley, hot turpentine, &c.: these will, when applied sufficiently early, often do good: we believe, however, that the blister should always be pre- ferred. It is hardly necessary to say, that any derangement of the digestive organs that may be present, will require the appropriate remedies for its removal. In subcuticular paronychia, when suppuration has commenced, it is to be promoted by frequent poultices, and when the cuticle is raised by the formation of matter it should be freely divided, and then cau- tiously removed as far as it has become separated from the skin beneath. This is an important precaution, as suppuration is very apt to continue, if any portion of the detached cuticle is allowed to re- main; and the disease thus travels around and over a considerable portion of the finger or toe. After the separation of the cuticle, the parts may be dressed with simple cerate, or the cerate of the oxide of zinc, and they, in general, heal very promptly. In the more deeply seated forms of paronychia, when we find that we are unable to arrest the course of* the disease, an early and free incision is all important. If we wait until suppuration has taken place, Ave not only prolong, unnecessarily, the patient's sufferings, but endan- ger the loss of motion in the affected finger or toe, if not more serious injury. The incision should be made freely, and through the cellular texture of the part, down to the periosteum, and when the tendinous theca is affected, this should be freely divided with the knife. If the matter has burrowed beneath the nail, this should be scraped very thin, and then divided with a pointed bistoury. The incision gives almost immediate relief, allows the escape of whatever matter may 712 DISEASES OF CHILDREN. have already formed, or if suppuration has not commenced, prevents it by arresting the inflammation. After the incision, the parts should be dressed with soft bread-and-milk poultices until they heal. If we have not been called to the case until deep-seated suppura- tion has taken place, and one, or perhaps several openings have been formed externally, through Avhich fungous granulations extend and spread out in the form of mushrooms, free incisions are essential to the cure. If the tendons or thecae are found to be dead or slough- ing, the diseased portion should be clipped off Avith a scissors, with a small portion of that which is yet sound; if the bone is found to be in a state of caries, it should be extracted as soon as it becomes suf- ficiently loose. The best local application in these cases is a common bread-and-milk or carrot poultice. AArhen the dead bone and tendons are removed, we have never seen much delay in the healing of the parts. ' Onychia maligna requires a somewhat different treatment. It is, according to our experience, one of the most frequent forms under which the disease presents itself in children, and unless properly ma- naged, is apt to produce a troublesome, painful ulceration, w hi ch may continue, without the slightest appearance of amendment, for many months, and when finally healed, leave a very disagreeable deformity of the finger or toe, upon which a nail is seldom reproduced. The child is to be placed upon a well regulated diet, composed chiefly of farinaceous articles and milk. It should be exposed to a pure fresh atmosphere, and take such exercise daily in the open air, as is adapted to its age and strength. Mild purgatives should be ad- ministered according to circumstances; and if the alimentary canal exhibit very considerable derangement, a mild, alterative course, with occasional light tonics, and the warm or tepid bath every morning. The local treatment consists in the application of leeches, followed by emollient poultices. After ulceration has occurred, in some cases, benefit will be derived from an ointment composed of the ungt. hy- drarg. peroxyd. and sulphate of zinc; or of the sulphate of zinc and corrosive sublimate; but whenever the ulceration has extended be- neath the nail and exposed its root, Ave have never seen any treatment in the least degree beneficial, until the whole of the nail is removed. This is certainly a very severe operation; but when skilfully and quickly performed, the suffering produced by it is infinitely less than that resulting from the long-continued painful ulceration kept up by the dead and partly detached nail. Upon the removal of the nail, the ointment just mentioned, or the black wash, or a weak solution of nitrate of silver, with a continuance of poultices, will quickly ef- fect a cure. R—Ungt. hyd. peroxyd. gj. R.—Sulph. zinci, Sulph. zinci, gr. xv. Chlorid. hydrarg. aa J-)j.—M- Cerat. simpl. |j.—il. To be sprinkled thickly upon-the diseased surface, and then covered with a pledget of lint, wet with tincture of opium. (Per- kins. Physick.) The removal of the diseased matrix of the nail, by making a deep CONGENITAL AFFECTIONS, ETC. 713 incision down to the bone, about three or four lines below the lower edge of the ulcer, and then carrying it around so as to dissect out entirely the diseased surface, has been recommended by Dupuytren and Bynd: we prefer, however, the removal of the whole nail, as a more effectual, and even less painful operation. 21.—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 apartments, of their being brought in close proximity to the open fire, or heated stoves, render these accidents of such frequent occurrence, that no Avinter passes without our seeing a number of children who have suffered from them. They occasionally happen under circum- stances where they Avere 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 thems^ves:—some of the most serious scalds in chil- dren that we have been called upon to treat, have been produced in this manner. There is a great variety in the character and extent of these accidents, which require 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 vesication; 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 involve a very large portion of the surface, would appear to be 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 occurrence, a very great depression of the whole of the vital powers, which con- tinues for some time before reaction takes place; while, in other cases, no reaction Avhatever takes place; the patient falls into a deep coma- tose sleep, from which he never aAvakes. The danger in burns is always in proportion to their extent, taken in connexion with their depth;—but even superficial burns, seated on certain portions of the body, are attended with very great, and some- times immediate danger. Thus a burn, of even small extent, upon the head or stomach, has been known to produce very speedy death. In superficial burns, in which there is produced a simple redness of the skin, the best immediate application is, cold water, vinegar, or any alcoholic liquor. The application of these fluids must be unremittingly persevered in; they ahvays relieve the intense smarting with which the burn is attended: and often very speedily allay the inflammation. AVhen nothing else is at hand, the common potato, scraped or mashed ^14 DISEASES OF CHILDREN. into a pulp, in its raw state, 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 ahvays a soothing effect. If any considerable degree of inflammation still continue, we have found the best application to be a liniment composed of fresh lard and acetate of lead (twenty grains to one ounce of lard.) After all, how- ever, even in the most superficial burns, our own experience Avould 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 surprised 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. AVhen vesication is produced by the burn or scald, the same treat- ment should be pursued. If the vesicles are large, it is best to punc- ture them, to allow of the escape of the serum, but without removing any portion of the cuticle. In burns attended with extensive vesication* in general, suppuration, with a copious discharge of matter, ensues. If the suppurating surface continues red and inflamed, the common bread and milk poultice, with a proper attention to the state of the bowels, and, if the child is weaned, a light farinaceous diet, will be proper, until the inflammation sub- sides, when, as well as in cases in Avhich the ulceration of the skin is unattended with any considerable degree of inflammation, the parts may be dressed with the ceratum oxyd. zinci, or the simple cerate, intimately combined with a portion of prepared chalk. In deep burns, attended with a destruction of the integuments, warm emollient poultices should be applied until the inflammation of the surrounding skin is entirely removed, when the burnt part should be covered with a pledget of lint, thickly spread with the common resi- nous ointment, mixed with an equal portion of spirits of turpentine; which dressing should be continued until the dead portions of integu- ment slough out. We have found, in deep burns, attended with con- siderable inflammation of the surrounding parts, the usual domestic application, of common lamp oil and molasses, spread on cotton, to be often a very useful one. When the dead parts are entirely separated, a simple bread and milk poultice should be applied, until granulations begin to form, when the ulcer may be dressed with the ointment of the oxide of zinc; and if cicatrization is long in taking place, adhesive strips should be applied, and the part subjected to the pressure of an appropriate bandage. In all burns situated near joints, or in the neighbourhood of parts possessing a good deal of motion, care should be taken during the pro- cess of healing, to prevent, as much as possible, 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 peculiari- ties of the cicatrices of burns is, the formation of firm, elevated ridges, CONGENITAL AFFECTIONS, ETC. 715 by the gradual contraction of AA-hich, 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 occurring to a certain degree; nevertheless, the extent of the deformity may be greatly diminished by proper care and at- tention. AArhen the burn is seated upon the hand or foot, or in the vicinity of the ear, caution must also be observed to prevent the un- natural 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 fun- gous granulations very commonly takes place; nor is it possible en- tirely to restrain them by the application of pressure, caustics, or other escharotics. The first, however, we have found, in general, the most successful; it may be applied, by covering the ulcer with a pledget 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 confess, 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: Ave 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, everything, 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. LIST OF AUTHORS AND WORKS REFERRED TO. Aberle. De Tussi Convulsiva. Vindobonce, 1843. Abercrombie. On the Nature and Origin of Tubercular Disease. Edinburgh, Medico- Chirurgical Transactions, vol. i. Albers. De Tracheitide Infantum. Berlin, 1816. Alibert. Description des Maladies de la Peau. Paris, 1814. Alibert. Precis Theorique et Pratique sur les Maladies de la Peau. Paris, 1810. Alderson. On the Pathology of Hooping-Cough. London Medico-Chirurgical Trans- actions, 1830. Alison. On the Pathology of Scrofulous Diseases. Edinburgh Medico-Chirurgical Transactions, vol. i. Andry. Memoire sur les Maladies du Fastus et ses A nnexes. Journal des Progres, 1830. Archer. A Treatise on Croup. Philadelphia, 1798. Armstrong, G. On the Diseases most fatal to Infants. London, 1767. Armstrong. Practical Illustrations on the Scarlet Fever, Measles, and Pulmonary Consumption. London, 1818. Ashburner, J. On Dentition and some Coincident Disorders. London, 1834. Atlee, E. P. Observations on the use of Hydrocyanic Acid in Hooping-Cough. American Journal of the Medical Sciences, 1832. Autenrieth. Versuche fur die Praktische Heilkunde. Gbttingen, 1768. Babington, B. G. On Chorea. Guy's Hospital Reports, 1841. Badham. Essay on Bronchitis. London, 1814. Bailly and Legendre. Nouvelles Recherches sur quelques Maladies du Poumon. Ar- chives Gcnirales de Medecine, 1844. Bampfield. Essay on Curvatures and Diseases of the Spine. London, 1824. Bard. Inquiries into the Nature and Treatment of Angina Suffocans. New York, 1771. Barnard. Cases of Chronic Hydrocephalus. London, 1839. Baron. Memoire sur une Affection de la Bouche. Bulletin de la Faculte de Medecine, 1816. Baron, Ch. De la Pleurisie dans L'Enfance. Paris, 1841. Barrier, F. Traite Pratique des Maladies de PEnfance. Paris, 1845. Bateman. A Practical Synopsis of Cutaneous Diseases. London, 1814. Battersbt. On Hare Lip. Dublin Quarterly Journal of Med. Sciences, 1846. Baumes. Memoire sur le Traitement de la Maladies Scrofuleuse. Paris, 1805. Baumes. Traite de l'lctere, ou Jaunesse des Enfans. Paris, 1805. Baumes. Traite des Convulsions dans PEnfance. Paris, 1805. Beck, J. B. Essays on Infantile Therapeutics. New York, 1849. Becquerel. Recherches Cliniques sur la Meningite des Enfans. Paris, 1845. Bednar. Die Krankheiten der Neugebornen und S'auglinge. Wein, 1850. Bell, Luther V. An attempt to investigate some obscure and undecided Doctrines in relation to Small-pox, Varioloid, and Vaccination. Boston, 1836. Behrend. On the Periodic Nocturnal Cough of Children. Journal der Kinder Jcranh- heiten, 1846. Ben-vet, E. P. On the Salaam Convulsion. Amer. Journal of the Med. Sciences, 1843. Bennett. On Hydrocephalus. Tweedie's Library. Berard. On Tracheotomy in Croup. Dublin Medical Press, 1841. , Bertin. Traite des Maladies des Enfans. Paris, 1837. Billard. Traite des Maladies des Enfans. Paris, 1828, Blaud. Nouvelles Recherches sur la Laryngo-Tracheite. Paris, 1824. Blaud. On Hooping-Cough. Revue Medicate, 1831. Bouchardat. On Aphthae. Annuaire Therapeutique, 1844. 718 LIST OF AUTHORS AND WORKS REFERRED TO. Boudet. On Epidemic Croup. Archives Ginerales, 1842. Bouchut. Manuel Pratique des Maladies des Nouveau-nes. Paris, 1845. Boudin. Recherches sur les Complications que Accompagnent la Rougeole chez l'Enfant. Paris, 1835. Bouillaud. Traite Clinique et Physiologique de I'Encephalite. Paris, 1825. Branson. On Chorea and its Consequences. Provincial Medical and Surgical Journal, 1845. Brachet. Memoire sur les Causes des Convulsions. Paris, 1824. Brera. Treatise on Verminous Diseases. Translated into French, with notes by Bar- toli and Calvet, and into English, with Additions by John G. Coffin. Boston, 1M7. Bremser. Traite Zoologique et Physiologique, sur les Vers Intestinaux de l'Homme. Translated into French by Grandler, with notes by Blainville. Paris, 1824. Brendt. Ueber Keichhusten. Griesswold, 1834. Bretonneau, P. Des Inflammations Speciales du Tissu Muqueux. Paris, 1826. Brunet. Sur la Pneumonie Lobulaire. Journal Rebdomadaire. 1833. Bryce. Practical Observations on the Natural and Modified Small-pox. Edinburgh, 180*2. Bull, Thos. Maternal Management of Children. Philadelphia Ed., 1840. Burgesson. Laryngismus Stridulus. Provincial Medical and Surgical Journal, 1842. See also London Lancet, 1838. Burrows. On Measles and Scarlatina. Tweedie's Library. Butler. A Treatise on the Infantile Remittent Fever. London, 1782. Butler. Treatise on Kink Cough. London, 1773. Butlek. Treatise on the Hooping-Cough. London, 1782. Camerer. Versuche iiber die Natur der Krankhaften Magenerweichung. Stuttgard, 1828. Capuron. Traite des Maladies des Enfans. Carrault. Guide des Meres. Paris, 1828. Cartwright. Pathology and Treatment of Cholera Infantum. Amer. Med. Record, 1826. Cazenave and Schedel. A Practical Synopsis of Cutaneous Diseases. Philadelphia Ed., 1829. Cazenave and Schedel. Abrege Pratique des Maladies de la Peau. Paris, 1828. Chambon. Maladies des Enfans. Paris, 1799. Chapman, N. On Croup. Philadelphia Journ. of the Med. and Phys. Sciences, vol. i. Cheyne. On Croup. Cyclopaedia of Practical Medicine. Cheyne. Essays on Hydrocephalus Acutis, or Water in the Brain. London, 1819. Cheyne, J. Essay on Cynanche Trachealis, or Croup. Edinburgh, 1801. Cheyne, J. Essays on the Diseases of Children. Edinburgh, 1802. Cheyne, J. Pathology of the Membrane of the Larynx and Bronchia. London, 1809. Chevers. On the Causes of Cyanosis. London Medical Gazette, 1847. Churchill. On the Diseases of Infants and Children. Philadelphia Ed. 1850. Clark, Jas. Treatise on Pulmonary Consumption and Scrofula. Clarke, Jno. Commentaries on the Diseases of Children. London, 1798. Cloquet. Anatomie des Vers Intestinaux. Paris, 1824. Coaxes. Description of the Gangrenous Ulcer of the Mouths of Children. N. A. Me- dical and Surgical Journ. 1826. Coindet. Memoire sur l'Hydrencephale. Geneva, 1818. Coley. A Practical Treatise on the Diseases of Children. London, 1846. • Cook. Apoplexia Hydrocephalica, or Hydrocephalus Internus. Treatise on Nervous Diseases. Combe, A. On the Management of Infancy and Childhood. Philadelphia Ed. Edited by J. Bell, M. D., 1840. Coxe, Jno. R. On Croup. Amer. Journ. of the Med. Sciences, vol. iii. Coxe, Jno. R. On Chorea. Philadelphia Med. and Phys. Journ. vols. xiii.—xviii. Coxe, Jno. R. Observations on Vaccination. JV. A. Med. and Surg. Journ. 1828. Crampton. On Cyanosis. Cyclopedia of Practical Medicine. Chaigie. On Cyanosis. Ed. Med. and Surg. Journal, 1843. Crampton. On Hydrocephalus. Trans, of the King and Queen's College in Ireland, 1S17. Crisp. On Infantile Pleurisy. London Medical Gazette, 1846. Cuming, Thos. Observations on the Peripneumonia of Children. Trans, of King and Queen's College, Ireland, vol. v. Cumin. On Rickets and Scrofula. Cyclopaedia of Practical Medicine. Currie, Wm. Hydrocephalus. Croup. Cholera of Infants. Diseases of the United States. Philadelphia, 1811. LIST OF AUTHORS AND WORKS REFERRED TO. 719 Dance. Observations pour Servir a l'Histoire de l'Hypertrophie du Cerveau. Danz, F. G. Versuche Einer Algemeine Geschichte des Keickhustens. Marbourg, 1791. Davis, D. D. Acute Hydrocephalus, or Water in the Head, an Inflammatory Disease. American Ed., 1840. Dendy. Practical Remarks on the Diseases of the Skin. London, 1837. Denis, R. S. Recherches Anatomique et Physiologiques sur Quelques Maladies des Enfans. Comercy, 1816. Paris, 1824. De Salle. Traite des Maladies des Enfans. Desruelles. Traite. Theorique et Pratique du Croup. Paris, 1822. Desruelles. Traite de la Coqueluche. Paris, 1827. Detmold. Essay on Club Foot. New York, 1840. Dewees. A Treatise on the Physical and Medical Treatment of Children. Philadel- phia, 1844. 9th Ed. Dismelles. Traite Therapeutique et Pratique du Croup. Donne. On Certain Pathological Conditions of the Milk as a cause of disease in Infants. Cours de Microscopic Paris, 1844. Droste. On Gelatinous Softening of the Stomach in Children. Zeitschrift fur die Ge- sammte Medicin, vol. i. Duncan, Jas. On the Epidemic Ulceration of the Gums in Children. Dublin Journal of Medical Sciences, 1845. Duges. Recherches sur les Maladies les plus Importantes et les moins Connues des En- fans Nouveau-nes. Paris, 1821. Dunglison, R. Commentaries on the Diseases of the Stomach and Bowels in Children. London, 1823. Duplay. On Inflammation of the Umbilical Vein in Infants. Medico-Chirurgical Re- view, 1838. Eberle. A Treatise on the Diseases and Physical Education of Children. Philadel- phia, 1839. Cincinnati, 1833. Ebelung. Dissertatio de Tussi Infantum Convulsiva. Gbttingen, 1768. Edwards. W. F. G. On the Influence of Physical Agents upon Life. Philadelphia Ed. 1838. Eisenmann. On the Exanthemata. Hufeland's Journal, 1840. Elam. On Chorea. Provincial Medical and Surgical Journal, 1849. Elsasser. Die Magenerweichung der Saiiglinge. Stuttgard, 1846. Emangard. Memoire sur l'Angine Epidemique ou Diptherite. Paris, 1829. Englehard. Ueber der Croup. Berlin, 1&29. Englemann. On the Treatment of Hydrocephalus by Compression. Chelius und Nagele's Medicinische Annalen, vol. viii. Evanson and Maunsell. A Practical Treatise on the Management and Diseases of Children, 5th Ed. London, 1847. Farre. On Worms in the Intestines. Tweedie's Library. Faubel. Recherches sur la Bronchite Capillaire, 1840. And Memoires de la Societe Medicale d'Observation. Tome 2d, 1844. Feiler. Paediatrik oder Anleitung zur Erkenntniss und Heilung de Kinderkrankheiten, 1814. Francis. On Croup. New York Med. and Phys. Journ. vol. iii. Friedleben and Fleisch. On the Pathology of the Intestinal Mucous Membrane in young Infants. Zeitschrift fur Rationelle Medicin. Heidelberg, 1846. Fuchs. Historische Untersuchung iiber Angina Maligna. Wurtzbourg, 1828. Gardien. Des Maladies des Enfans. Gas. Recherches sur 1'Acarus ou Scarpote de la Gale. Paris, 1834. Geddings. On Pseudo-membranous Inflammation of the Throat. Amer. Journ. Med. Sciences, 1839. Gerhard, W. W. On Pneumonia in Children. Tweedie's Library. Amer. Journ. Med. Sciences, 1834. Gerhard, W. W. On the Cerebral Affections of Children. American Journal of the Medical Sciences, 1834. Gintrac, E. Observations et Recherches sur la Cyanose. Paris, 1824. Girard. On the Influence of the Quality of the Nurse's Milk on the Health of the In- fant. Journal de Pharmacie, 1845. Girtanner. Ueber de Krankheiten der Kindern. Berlin, 1794. 720 LIST OF AUTHORS AND AVORKS REFERRED TO. Glover. On the Pathology and Treatment of Scrofula. London, 1810. Goelis. Treatise on Acute Hydrocephalus. Translated by Robert Gooch, M. D. Lon- don, 1821. Goelis. De rite Cognescenda et Sananda Angina Membranacea. Vienna. Goelis. Pracktische Abhandlungen. Vienna, 1S20. Gregory. On Small-pox, Chicken-pox, and Vaccination. Cyclopaedia Prac. Med. See also Tweedie's Library. Gregory. On Vaccination. London Med. Gaz., 1827—28. Gregory. On Vaccination and Small-pox. Medico-Chirurg. Trans, vol. vi. See also London Lancet, 1841. Gregory. Lectures on Eruptive Fevers. New York Ed. 1851. Green. A Practical Compend of the Diseases of the Skin. London, 1835. Green. Contributions on the Pathology of Children. London Lancet, vol. ii. et seq. Green. On Nervous Tremors in Children. Provincial Med. and Surg. Journ., 1S44. Green, Hennis. On Hypertrophy of the Brain. Provincial Med. and Surg. Journ., 1H40. Green, Hennis. On Tubercle of the Brain in Children. Medico-Chirurg. Trans., vol.xxv. Graves. Clinical Lectures. American Edition, 1842. Graves. On Infantile Convulsions. London Med. and Surg. Journ., 1833. Grissolle. Traite Pratique de la Pneumonia aux differens Ages. Paris, 1841.^ Guersent. On Muguet; on Gangrenous Angina; on Croup. Bictionnaire de Medecine. Guersent etj Blache. Smallpox. Bictionnaire de Medecine. Guersent. On Tonic Convulsions of Children. Gazette Medicate, 1832. Guibert. Recherches Nouvelles et Observations Pratiques sur le Croup et laCoqueluche. Paris, 1824. Guibert. Observations sur l'Hydropericarde chez les Enfans. Journal des Progres, 1830. Hall, Marshall. On the Diseases and Derangements of the Nervous System. London, 1841 Hall, Marshall. On Scarification of the Gums during Dentition. London Lancet, 1844. Hall, Marshall. On the Nature and Treatment of Stridulous Convulsions in Infants. London Lancet, 1842. _ Hallowell, Ed. On the Endemic Follicular Gastroenteritis, or Summer Complaint of Children. American Journal of the Medical Sciences, 1847. Hamilton, Robt. Observations on Scrofulous Diseases. London, 1791. Hamilton, Jas. Hints for the Treatment of the Principal Diseases of Infancy and Child- hood. London, 1809. _ Hamilton. On the Treatment of Scarlatina Anginosa. Edinburgh Med. and burg. Journal, 1839. _ . Hamernjk. On Tubercular Meningitis-. Schmidt's Jahrbucher, 1845. Harris. De Morbis Acutis Infantum. London, 1689. _, ,. . 1O01 Harrison. On Hydrocephalus. Transylvania Journal of Medicine, 1831. Hache. Maladies des Enfans. Paris. . Heilborn. Zur der Charakteristik der Kuhpocken Narben. Rust s Magazine, lS^J. Henke. Handbuch der Kinderkrankheiten. Berlin, 1813. Heine. On Revaccination. London Medical Gazette, 1834. Herard. On Tartar Emetic in the Pneumonia of Children. British and Foreign Medico- HE^TcTf" BeoStungen und Bemerkungen iiber den Rasch Verlaufenden Wasserkoff. He^se7.' Ueber die erweichung der Gewebe und Organe der Menschliken Korpers. Leipsic, 1827. ,mn Heyfelder. Beobachtungen iiber der Krankheiten der Neugebornen, 1S22 Hildreth, C C. Practical Observations on Chorea. American Journalofthe Medical Sciences, 1848. _ Home. Medical Facts and Experiments. London, 1759. Hood. A Practical Treatise on the Diseases most fatal to Children. London, 1 i-lo. Horner, W. A. An Inquiry into the Anatomical Characters of Infantile Follicular In- flammation of the Gastro-intestinal Mucous Membrane. American Journal of Medical HornerTw. A. ' Contribution to the Pathology of Infantile Convulsions. Amer. Journ. of the Med. Sciences, 1831. . 7„ Hosack, D. Observations on Croup, or Hives. American Medical and Physical Ke- Humer! Beobachtungen und Bemerken iiber den Wasserkrebs. Berlin, 1829. LIST OF AUTHORS AND WORKS REFERRED TO. 721 Hufeland. Ueber Verschiedene Kinderkrankheiten, 1798. Hufeland. Neues System der Kinderkrankheiten, 1803. Hufeland. A Treatise on Scrofulous Diseases. Translated by C. D. Meigs, M. D. Philadelphia, 1829. Hullihen. On Hare Lip. American Journal of Bentat Science, 1844. Hurteloup. Sur I'Inflammation de la Membrane Muc. Gastro-pulmonaire chez les Nouveau-nes. Paris, 1823. Honter. On Rotatio or Chorea. Ed. Med. and Surg. Journ., 1825. Iselin. On the Softening of the Stomach in Infants. Edinb. Med. and Surg. Journ. 1840. Isnard. Dissertation sur tine Affection Gangreneuse Particuliere aux Enfans. Itard. Sur PHydrocephale Aigue. Diet, des Sciences Med< Jackson. On Gangraenopsis. Amer. Med. Recorder, 1827. Jackson. On Cholera Infantum. JV. E. Journ. of Med., vol. i. Jansecowich. Einige Bemerkungen iieber den Croup. Oestereichische Jahrbuch, 1837. Jaeger. On the Softening of the Stomach in Infants. Hufeland's Journal, 1811. Joerg. Handbuch izum Erkennen und Heilen der Kinderkrankheiten, 1836. Joerg. Die Foetus Lunge in Gebornenkinde. Grimma, 1836. Johnson. On Carpo-pedal Spasms. Medico-Chirurg. Review, vol. iii. Johnson. On Hooping-Cough. Ibid. Joy. Tabes Mesenterica—Disorders of Dentition—Worms—Hydrocephalus—Infantile Remittent Fever. Cyclopcedia of Prac. Med. Judd, W. H. On the' Structure of the Small-pox pustule. London Lancet, 1841. Katona, M. Von. On the Inoculation of Measles. Oesterreiche Medicinische Wochen- schrift, 1842. Kennedy, E. On the Apoplexy, Paralysis, and Convulsions of New-born Infants. Guy's Hospital Reports, 1836; and Bublin Journal of Medical Sciences, 1836. Kennedy. Account of the epidemics of Scarlatina in Dublin from 1834 to 1842. Dub. 1843 Kenedy. On the Management of Children. Glasgow, 1825. Kerr. On Laryngismus Stridulus. Ed. Med. and Surg. Journ., vol. lviii. Kirkland. De Pertussi. Edinburgh, 1772. Kirkbride. On the Employment of Cimicifuga in the Treatment of Chorea. American Journ. of the Med. Sciences, 1840. Kopp. Dissertatio de Asthmate Puerorum. Frankford, 1830. Kopp. Denkwiirdigkeiten in der arztlichen Praxis. Frankford, 1830. Krukenberg. On Hydrocephalus—Inflammation of the ear—Hooping-Cough—Measles and bcarlet Fever. Jahrbucher der Ambulaterischen Klinik zu Halle, 2 vols., 1824. Laennec. Observations pour Servir 1'Histoire de l'Hypertrophie du Cerveau. Revue Medicate, 18*28. Lallemand. Recherches Anatomico-Pathologiques sur l'Hypertrophie du Dependances. laflSj IoIi5*» Landouzy. Sur l'Hemiplegie Faciale chez les Enfans Nouveaux-nes. Paris, 1839 Langenbeck. On Purulent Ophthalmia. Neuve Chirurg. Bibliothe. Lasserre. On Apoplexy in the Foetus and New-born Child. Journal de Midecine de loulozi.se, 1845. Lee, Chas. A. On the Thymus Gland; its Morbid Affections and the Diseases which arise from its Abnormal Enlargement. American Journ. of the Med. Sciences, 1842 Lees, C. On Hypertrophy of the Brain. Bublin Journ. of the Med. Sciences, 1842. L,eger. bur la Pneumonie des Enfans. Paris, 1823. Legendre. Recherches Anatomico-pathologiques sur Quelques Maladies de PEnfance. JtariSj lo4b» Lenhosseck. Einige Bemerkungen iiber die Erweichung des Magens. Vienna 182'? Leroy. On Pertussis. Medecitie Matemelle. Paris, 1803. LE7' S?7 °n the La,Tngismus Stridulus or Croup-like Inspiration of Infants. Lon- Lindsley. On Cholera Infantum. Amer. Journ. of Med. Sciences, 1839 Lloyd. Treatise on the Nature and Treatment of Scrofula. London 182] Locock. On Infantile Convulsions. Cyclopedia of Prac. Med. ' Lombard. On Hooping-Cough. Bublin Journal of Medical Sciences, 1838 T n™ p \A' uRecherch^s Anatomique et Pathologique sur le Croup. Paris, 1826 Louis. Recherches sur la Gastro-enterite. Paris, 1829. ' Louis. M^moires, ou Recherches Anatomico-Pathologiques. Paris 1826 rhrnblaur^ri^iSf" Geschlchtederbei^-inirtenB;obachtu„ge„Me^ 46 722 LIST OF AUTHORS AND AVORKS REFERRED TO. Mackensie. A Practical Treatise on Diseases of the Eye. London, 1832. Macilwain. Clinical Observations on the Constitutional Origin of the Various Forms of Porrigo. London, 1834. Magill. On Scarlet Fever. American Journ. of Med. Sciences, 1839. Malins. De Cynanche Tracheali. Edinburgh, 1830. Marcus. Der keichhusten; iiber Seine Erkenntniss, Natur, und Behandlung. Bamberg, 1816. Marcus, A. F. Traite de la Coqueluche. French Translation by M. Jacques. Paris, 1816. Marley, M. On the Nature and Treatment of the most frequent Diseases of Children. London, 1830. Martin, J. C. On the Identity of Cow-pox and Variola. Boston Medical and Surgical Journal, 1841. Mathey. Memoire sur I'Hydrocephale. Paris, 1818. Mauthner. Die Kranken des Gehirns und Riichenmarks bei Kindern. Vienna, 1814. Mende. Analekten iiber Kinderkrankheiten. Stuttgard, 1834. Meigs, J. Forsyth. A Practical Treatise on the Diseases of Children. Philad'a, 1849. Meigs, C. D. On certain of the Diseases of Young Children. Philadelphia, 1850. Michaelis, F. De Angina Polyposa. Gbttingen, 1779. Miller, Ed. Cholera or Bilious Diarrhcea of Infants. Medical Works, New York, 1814. Millar. Observations on the Asthma, and on the Hooping-Cough. London, 1769. Miguel. On the means of Preventing Scarlatina. Transactions of the Royal Academy of Medicine, 1834. Mills. On Hydrocephalus. Trans, of the King and Queen's College iu Ireland, vol. v. Mitchell and Bell. History of the Natural and Modified Small-pox as it prevailed in Philadelphia in the years 1823, 1824. N. A. Med. and Surg. Journ., 1&26. Mitchell, J. K. Observations on the Treatment of Curvature of the Spine. N. A. Med. and Surg. Journ., 1827. Mohl. De Varioloidibus et Varicellis. Copenhagen, 1827. Monro. Morbid Anatomy of the Brain, vol. i. Hydrocephalus. Edinb. and Lond., 1827. Monro, A. L. On Small-pox. Edinburgh, 1818. Moss. On the Management and Nursing of Children. London, 1782. Montgomery. On Rubeola. Cyclopaedia of Prac. Med. Montgomery. On the Sudden Death of Children from Enlargement of the Thymus Gland. Bublin Journal of the Medical Sciences, 1836. Morton, Richard. Opera Medica. London, 1697. Musgrove. Essay on the Nature and Treatment of the so called Worm Fever. Lon- don, 1776. Matter.. A Lecture on Loxarthus, or Club Foot. Philadelphia, 1839. Naumann. On Pseudo-membranous Inflammation. Handbuchder Med. Klinik, voLiv. Neumann. Krankheiten des Menschen, 1836. North. Practical Observations on the Convulsions of Infants. London, 1826. Odier. Manuel de Medecine Pratique. Geneva, 1821. Oesterlen. ^Etiologie und Pathologie der Krankheiten Neugebornen Kindern. Heidel- berger Klinische Annalen, 1831. Olliffe. On the Treatment of Variola by the Ectrotic Method. London Lancet, 1841. Oppenheim. Ueber die Punction der Chronischen Innerren Wasserkopf. Rust's Ma- gazine, 1827. Otto. On Pertussis. Nyehygaea, 1824. Ozanam. Historie Medicale, Generate et Particuliere des Maladies Epidemiques, &c. Paris, 1817. Page. Essay on Diseases of Children. Amer. Med. Recorder, 1829. Papavoine. Sur les Tubercles Considered Specialement chez les Enfans. Journ. des Progres, 1830. Papavoine. Observations des Convulsions chez les Enfans. Journal des Progress, 1830. Parrish, I. Observations on a Particular Complaint in Children. N. A. Medical and Surgical Journal, 1827. Parrish, 1^ On Infantile Convulsions, arising from Spasms of the Intestines. 2V. A. Medical and Surgical Journ., 1827. Paldam, V. H. L. Ueber die Stickhusten. Halle, 1805. Parent-Duchatelet et Martinet. Recherches sur I'Inflammation de I'Arachnoide Cerebrale et Spinale. Paris, 1819. Penada, G. Memoria sulla Tusse Convulsiva. Verona, 1815. Pearson. Medical Dissertations on Chincough. LIST OF AUTHORS AND WORKS REFERRED TO. 723 Pemberton. A Practical Treatise on the Various Diseases of the Abdominal Viscera. London, 1806. Phillips. Scrofula, its Causes, its Prevention, and the Principles of Treatment. Lon- don, 1846. Plumbe. A Practical Treatise on the Diseases of the Skin. London, 1824. Pohl. Analogia-inter Morbillos et Tussim Convulsivam. Leipsic, 1809. Porter, W. H. Observations on the Surgical Pathology of the Larynx and Trachea London and Edinburgh, 1826. Porter. On Spasm of the Glottis. Bublin Medical Press, 1840. Piorry, P. A. De l'Irritation Encephalique des Enfans. Paris, 1823. Quin. De Apoplexia Hydrocephalica. Dublin, 1799. Racieorski. On the Influence of Menstruation on the Milk of Nurses. Bublin Medical Press, 1843. Ramisch. De Gastromalacia et Gastropathia Infantum. Prague, 1824'. Raspail. Sur l'Histoire de 1'Insect de la Gale de 1'Homme. Paris, 1834. Rayer. Traite Theorique et Pratique de la Maladies de la Peau, 1826. Rayer. Traite des Maladies des Reins. Paris, 1839. Rees. Treatise on Diseases of Children. London, 1817. Rees, G. A. On Laryngismus Stridulus. London Lancet, 1841. Reid. On Infantile Laryngismus. London, 1849. Renucci. On the Itch insect. London Lancet, 1834. Richter. Der Wasserkrebs der Kinder. Berlin, 1828. Rilliet and Barthez. Traite Cliniqueet Pratique des Maladies des Enfans. Paris, 1843. Ritscher. Pneumonia Infantilis. Rust's Magazine, 1830. Roberton. On the Physical Management of Children. London, 1827. Robertson. On Aphthae. Cyclopaedia of Practical Medicine. Roberts, W. C. On Thymic Enlargement. New York Medical Gazette, 1842. Roe, G. H. Treatise on the Nature and Treatment of Hooping-Cough. London, 1838, Roesch. On Scrofula. Haeser's Archives, 1841. Roger. De la Temperature chez les Enfants. Paris, 1844. Roger. On the ffidema of New-born Infants. Archives Generates, 1845. Rokitansky. Pathologische Anatomie, 1848. Romberg. Einige Falle von Magenerweichnng, Wasserkrebs, und Rose bei Kindern. Rust's Magazine, 1830. Rosen Von Rosenstein. Anweisung zur Kenntniss nnd Kur der Kinderkrankheiten. Gottingen, 1798. Rosen Von Rosenstein. Treatise on Diseases of Children. Translated from the Swedish. London, 1776. Rosseau. Hydrops Capitis Infantum. American Medical Recorder, 1819. Royard, Collard. On Croup. Bictionnaire des Sciences Midicales. Rudolphi. Entozoor, sive Verminum Intestinum Historia Naturalia. Amsterdam, 1811. Rufz. Researches on some Points of the History of Chorea in Children. Archives Ge- nerates, 1834. Rush. On Dropsy of the Brain, and Croup. Med. Inq. and Observations, vol. ii. Ryland. On Laryngismus Stridulus. Provincial Medical and Surg. Journ., 1842. Salle. French Translation of Underwood, with Notes. Paris, 1823. Schedel. On the Diseases of the Skin. Tweedie's Library. Schaeffer. On Vaccination. Medicinische Zeitung, 1844. Schmid. De Angina. Vienna, 1790. Schmidt. Convulsiones Infantum. Berlin, 1826. Scoutteten. Hypertrophy of the Brain. Archives Centrales, vol. vii. Senn. Recherches Anatomico-pathologiques sur la Meningitis. Paris 1825. Shapter. On Scrofula. Tweedie's Library. Sidey, Chas. On Epidemic Scarlet Fever. Edinburgh Med. and Surg. Journ 183& Sims. On Hypertrophy of the Brain. Medico-Chirurgical Trans., 1835 Smith, Thos. On the Nature, Causes, Prevention, and Cure of Acute Hydrocephalus or Water-brain Fever. London, 1845. i Smyth. On Rickets and Hydrocephalus. Miscellaneous Contributions to Pathology and lherapeutics. London, 1844. s- Stiebel. On St. Vitus's Dance. Wochenschrift fur die Gesam%ite Heilkunde, 1837 Steinbrenner. Traite suf la Vaccine. 1846. Stewart, James. A Practical Treatise on the Diseases of Children. New York 184ft Stille, Moreton. On Cyanosis. American Journ. of Medical Sciences. 1844 ' Streeter. On the Nature and Seat of Hooping-Cough. London Med. Gazette, 1844 724 LIST OF AUTHORS AND AVORKS REFERRED TO. Stuart, Jno. On the Use of Hydrocyanic Acid in Chorea. Edinburgh Medical and Surgical Journal, 1827. Symonds. On Diseases of the Mouth. Tweedie's Library. Tait. On the Treatment of Scarlatina. London Medical Gazette, 1837. Taupin. On Vaccination. Bictionnaire de Medecine. Taupin. Clinical Researches on Typhoid Fever in Children. Journal des Connais* sances Medico Chirurgicales, 1839—40. Taupin. On Gangrenous Inflammation of the Mouth. Ibid., 1S38. Thilenius. Medicinische Chirurgische Bemerkungen. Thompson. On the Varioloid Epidemic. Edinburgh, 1S20. Thompson. On Chorea and Tabes Mesenterica. Tweedie's Library. Thore. De la Peritonite chez les Nouveau-nes. Archives Gen. de ATc'rf.,l84C. Tonnelle. On Tonic Convulsions of Children. Gazette Medicate, 1 ^3*2. Troccon. Sur la Maladie Connue sus le nom d'Endurcissement du Tissue Cellulaire, 1814. Trousseau. On Infantile Syphilis. Archives Generates de Med., 1847. Trousseau. On Pneumonia in Infants. Medical Times, 1846. Trousseau. On Diphtheritis. Bictionnaire de Med. Trousseau. On Thymic Asthma. Journal de Midecine, 1845. Trousseau. Croup. Tracheotomy. Bictionnaire de Medecine. Tweedie. On Scarlatina. Cyclopaedia of Practical Medicine. Uldall. De Dentitione Infantile. Copenhagen, 1833. Underwood. Treatise on the Diseases of Children, with Notes by S. Merriman, M. D., and Marshall Hall, M. D., and John Bell, M. D. Philadelphia, 1841. Vaidy". Hydrocephaly Aigue Essentielle et Symptomatique. Bid. des Sciences Med. Vieusseux. Memoire sur le Croup. Paris, 1812. Valleix. CUnique des Maladies des Enfans Nouveau-nes. Paris, 1838. Valleix. On Croup. Bulletin Generate de Thirapeutique. Paris, 1843. Valentin, L. Sur le Croup. Paris, 1812. Veron. Observations sur les Maladies des Enfans. Paris, 1821. Volz. On Hooping-Cough. Haeser's Archives, vol. iv. VondemBusch. German Translation of Desruelles on Croup, with Notes. Bremen, 1S2H, Vrolik. Traite sur l'Hydrocephalie Interne. Amsterdam, 1839. Watt, R. Treatise on the History and Treatment of Chincough. Glasgow, 1813. Wendt. Die Kinderkrankheiten Systematische Dargestellt. Vienna, 1827. West. On Pneumonia in Children. British and Foreign Medical Review, 1843. West, J. W. On the Salaam Convulsion. London Lancet, 1841. West, Chas. Lectures on the Diseases of Infancy and Childhood. Phila. Edit., 1850. Whatton. On the Pathology and Treatment of Pertussis. London Lancet, 1831. Whitlock, N. Practical Remarks on Disordered States of the Cerebral Structures oc- curring in Infants. London, 1821. Willan, Robt. On Vaccine Inoculation. London, 1806. Williams. On Croup, Laryngismus, and Hooping-Cough. Tweedie's Library. Willis. Urinary Diseases and their Treatment. London, 1838. WrLsoN. A Practical and Theoretical Treatise on the Diagnosis, Pathology, and Treat- ment of the Diseases of the Skin. London, 1842. Winter. On Softening of the Stomach. Rust's Magazine, 1830. Wolff. Beitrag zu der Lehre von den Kinderkrankheiten. Hufeland and Osann's Journal, 1831. Wood. On Scarlet Fever. Edinburgh Med. and Surg. Journ., 1839. Worcester, N. A Synopsis of the Symptoms, Diagnosis, and Treatment of the more common and important Diseases of the Skin. Philadelphia, 1845. Worthington. On Gangraenopsis. American Medical Recorder, 1828. Wyatt. Observations on the Dropsy in the Brain. Edinburgh, 1768. Yeats. A Statement of the Early Symptoms which lead to the Disease termed Water in the Brain. 1817-1819. Zangert. Ueber die Convulsionem in Kinderlichen Alter. Vienna, 1834. Zeller. Dissertatione de Natura Morbi Ventriculo Infantum Perforantes. Tubingen, 1818 Zeroni'. Practical Remarks on Croup. Henle and Pfevffer's Zeitschrift fvr Rationalle Medizin, 1-47. Zichner. De Angina Membranacea. Berlin, 1S25. INDEX. A. Accidents occurring within the month, 654. Adipous tissue, induration of the, 689. Affective faculties, state of, in infancy, 92. Air, importance of pure, 33, 118, 594. cold and damp, injurious effects of, 36, 122, 594. overheated, injurious effects of, 37, 122. impure and stagnant, productive of disease, 120, 593. Albuminous nephritis in children, 112. Alimentary canal, state of, in infancy, 81. Amusements for children, 67. Aneurism by anastomosis, 695. Anger, bad effects of, in children, 73. Angina, externa, 191. pseudo-membranous, 180, 185. malignant, 183, 185. polyposa or membranacea, 323. Anginose scarlatina, 478. Ani, prolapsus, 242. Anuria, 641. Anus, imperforate, 655. Aphtha lactumina, 148. Aphthae, 152. deaths from, 103. Apoplexy, 368. deaths from, 106. Arachnoid cavity, haemorrhage of the, 390. Asphyxia, 281. Asthma, Kopp's, 346. Millar's, 341. thymic, 346. Atelectasis pulmonum, 307, 316. Atmosphere, impure, injurious effects of, 34, 594. cold and damp, injurious effects of, 36, 122. overheated, injurious effects of, 37. 122. Atonic ulcer, 574. Atrophia ablactatorum, 218. B. Bathing, importance of, 39. Beds, proper for infants and children, 57.1 47 Bilious diarrhoea, 219. Black pock, 509. Bladder, urinary, state of, in infancy, 82. Blood, in infancy and childhood, 83. Blue disease, 664. Boils, 557. Bones, state of, in infancy and childhood, 80, 93. indications of disease from state of, 144. scrofulous disease of the, 603,631. Bowels, indications of disease from the discharges from the, 140. Brain, organization of, in infancy and childhood, 83, 93. liability of, to disease, in infants, 105. deaths from diseases of the, 106. hydrencephaloid disease of, 451. hypertrophy of the, 382. hyperaemia of the, 388. haemorrhage of the, 389. inflammation of the, 413, 436. dropsy of the, 436, 451. tubercles of the, 111, 436, 615. Breasts, intumescence of the, 677. Breath, indications of disease from the state of the, 140. Bronchi, inflammation of the, 290. Bronchial croup, 292. glands, tuberculization of, 613. Bronchitis, 290. capillary, 292, 294. vesicular, 295. deaths from? in children, 102. Broncho-pneumonia, 293, 302. Bullae febrilis, 577. Burns and scalds, 713. C. Calorification, state of, in infancy, 88. Cancrum oris, 151. Capillary system, state of, in infancy, 83. bronchitis, 292, 294. Caps, injurious, 42. Caries of the vertebrae, 609. Carrying infants, caution to be observed in, 63, 74. Carriages for infants, 63. 726 INDEX. Catamenia, influence on milk, 119. Catarrhal fever, 292. Cellular tissue, induration of the, 689. Cerebral hyperaemia and haemorrhage, 388. tubercles, 111, 615. Cerebro-spinal meningitis, 424. Chicken-pox, 536. Childhood, organization of, 92. functions of, 93. Cholera infantum, 232. deaths from, 103. Chorea, 453. Chylous diarrhcea, 220. Circulation, state of, in infancy, 87. Circulatory organs, state of, in infancy, 83. Cleanliness, domestic, importance of, 34 personal, importance of, 34. Clothing of infants and children, 41. Club-foot, 687. Cold, its injurious effects on infants, 36. and dampness a cause of disease, 36, 122, 594. diarrhcea from, 218. Cold-bath, improper during infancy. 39. Colic, 209. deaths from, 103. Colitis, 264. Colon, inflammation Of the, 264. Confinement of children, injurious effects of, 47, 66. Confined air, a cause of disease, 120,593 Congenital affections, 654. Congestion of the brain, deaths from, 106. Congestive measles, 469. scarlatina, 492. small-pox, 506. Conjunctivitis, infantile, 508. Consumption in children, 108, 614. deaths from, 108. Contagion, susceptibility of infants to, 124. Convulsions, 106, 398. deaths from, 106, 398. epidemic, 403. nine-day, 404. salaam, 411. tonic, 412. Convulsive enteralgia, 210. Coryza, 286. Couch, sleeping, proper for young in- fants, 57. management of, 59. Countenance, indications of disease from, 128. Cow-pock, 522. Cradles, the use and abuse of, 58. Croup, 323. bronchial, 290. false, 341. spasmodic, 341. Croup, deaths from, 102, 823. \ Crusta lactea, 543. Crusted tetter, 543. Crying in infants, causes and morbid ef- fects, 74. Cry, indications of disease from the, 134 Curd-like exudation, stomatitis with, MS. Cutaneous disease, frequency of, in in- fancy, 99. eruptions, 539. Cyanosis, 664. Cynanche trachealis, 323. D. Damp and cold, injurious effects of, in infancy, 36, 122, 594. Dandriff, 572. Debility, deaths of children from, 97. Dentition, 92. as a cause of disease, 124. difficult, 171. diarrhcea from, 218. convulsions from, 404. cutaneous eruptions during, 539. Diabetes, 650. mellitus, 651. Diagnosis of disease in infancy, 125. Diarrhcea, 214. deaths from, in children, 103. bilious, 219, 226. chylous, 220. chronic, 215, 229. mucous, 218, 223. from cold, 218. dentition, 218, 225. errors in diet, 216, 221. excessive heat, 219, 226. Diet of infants and children, 43, 52. a wet nurse, 49. diarrhcea from errors in, 216, 221. Digestive organs, condition of, in infancy, and childhood, 81, 87, 93. diseases of the, 147. deaths from affections of the, 103. Diphtheritic inflammation of the throat, 182. Discharges from stomach and bowels, indications of disease from, 140. Disease, causes of, in infancy and child- hood, 118. seldom simple in children, 98. Diseased persons, impropriety of children sleeping with, 60. Drink of infants and children, 48, 53. Dropsy in children, 107. of the brain, 436,451. deaths from, 106. Dry scall, 563. Dysentery, 264. deaths from, 103. Dysuria, 113, 636. INDEX. 727 E. Ear, inflammation of the, 600, 628. Ecchymoses, 579. Ecthyma, 574. Eczema, 547. lactea, 543. Education, too early attempts at mental, improper, 66, 75. moral, 69. Effusion of serum or lymph in children, 99. Emotions of the mind, influence of, on nurse's milk, 119. Endocarditis in children, 111. Enteralgia, 209. Enteritis, 260, 264. deaths from, 103. Enuresis, 645. Epidemic meningitis, 424. Eruptions, cutaneous, 539. syphilitic, 587. from gastro-enteric disease, 545. during lactation and dentition, 539. with languid cutaneous action, 572. from infection, independent of vis- ceral disease, 583. frequency of, in infancy, 99. Eruptive fevers, 465. Erysipelas, 550. Erythema, 545. Erythematic stomatitis, 147. Evacuations, indications of disease from state of the, 140. Example, its powerful influence, 76. Exanthemata, 465. Exanthematous ophthalmia, 600. Exercise, its importance during child- hood, 62, 65. precautions in regard to, 68. defective, a cause of disease, 594. External senses, state of, during infancy and childhood, 84, 89, 94. Eye, inflammation of the, 597. Fauces, diphtheritic inflammation of the, 180. Favus, 566. Fear, injurious effects of, in children, 71. Feeding of infants, artificial, 44. Feet, defence of, in infants, 42. Felon, 709. Fever in children, 115. deaths from, 115. the remittent or gastric, of infancy, 271. catarrhal, 292. eruptive, 465. rubeolous, 468. scarlet, 475. pemphigoid, 577. Fever, variolous, 509. verminous, 271. Fish-skin disease, 573. Flannel, importance of, for children, 41. Follicular gastro-enteritis, 236. stomatitis, 152. warts, 565. Food of infancy and childhood, 43. as a cause of disease, 119, 593. of the nurse, influence of, on her milk, 119. Foreign bodies in the larynx and trachea, 380. Fractures, 654. Fruits, the use of, by children, 56. Functions, state of the, during infancy and childhood, 78, 86, 93. G. Gall-bladder, during infancy, 83. Ganglionic system, during infancy, 84. Gangrsenopsis, 160. Gangrene of the mouth, 160. throat, 183. Gastro-enteric disease, eruptions con- nected with, 545. liability of infants to, 102. enteritis, follicular, 236. Gastro-malacia, 103, 198. Gastric fever of infancy, 271. Gastritis, 203. deaths from, 103. Gelatinous softening of the stomach, 198, 208. Genital organs, state of, in infancy, 84. Gengivitis, 160. Gestures, indications of disease from, 130. Girls, exercise of, 66. Glands, bronchial, tuberculization of, 613. lymphatic, disease of, 596-623. mesenteric, disease of, 602, 609. Glottis, spasm of the, 346. Gravedo, 286. Gravel, 114, 638. Gray granulations, 610. Growth of the body, 88. Gum, the red, 540. white, 540. Gums, inflammation of the, 160. H. Haemoptysis, rare in infants, 108, 615. Haemorrhage, cerebral, 388. vaginal, 683. from the navel, 658. of the brain, 388. Hemorrhagic purpura, 579. Hair, management of, in infancy and childhood, 40. Hare-lip, 686. 728 INDEX. Harsh treatment of children, morbid i effects of, 71. Healthy child, its appearance, 125. Heart, condition of, in infancy, 83, 85. disease of the, in children, 110. malformations of, in infants, 665. deaths from diseases of, 111. Heat, importance of, to infants. 35. excessive, morbid effects of, 36, 122. diarrhcea from, 219. Head, covering proper for, in infants, 42. Hernias, 678. Herpes, 561. Hip-disease, 606-633. Honeycomb scall, 566. Hooping-cough, 361. deaths from, 102. Hordeolum, 560. Humid tetter, 543. Hygienic management of children, 33. Hydrencephaloid disease, 451. Hydrocele, 708. Hydrocephalus, acute, 436, chronic, 451. false, 451. Hydro-rachis, 671. Hyperemia, frequency of, in infancy, 97 of the brain, 388. Hypertrophy of the brain, 382. Hyperuresis, 643. Inflammation of the nares, 286 navel, G75. oesophagus, 194. pleura, 317. parotids, 190. peritoneum, 268. stomach, 203. tonsils, 177. throat, 177, 180. trachea, 323. Intellectual faculties, state of, during in- fancy and childhood, 81, 92, 94. injury from too early exercise of, 66, 75. Intestinal mucous membrane, pathology of, in infants, 103. Intestines, state of, in infancy, 81. diseases of the, 209. congenital malformations of the, 635. deaths from disease of, 103. inflammation of the, 260, 264. invagination of the, 103, 247. worms in the, 248. intumescence of the breasts in infants, 677. Intus-susception, 103, 247. Invagination of the intestines, 103, 247. Iritis, scrofulous, 599. Ischuria, 643. Itch, 583. Ichthyosis, 573. Icterus infantilis. 698. Ileitis, 260. Impetigo, 543. larvalis vel mucosa, 543. Impure air, morbid effects of, in infancy, 34, 120, 593. Indigestion, 195. Induration of the cellular tissue, 689. Indurcissement du tissu cellulaire, 689. Infancy, period of, 79. Infant, picture of a healthy, 125. Infants, cautions in handling, 62. cautions in carrying, 63. Inflammation of the brain, 413. deaths from, 106. breasts of infants, 677. bronchi, 290. colon, 264. , digestive organs, deaths from, 103 fauces, 177. ear, 600-628. eye, 597. gums, 160. intestines, 260-264. lungs, 299. mammae, in infants, 677. mouth, 147. Jaundice, 46, 698. Joints, scrofulous disease of the, 603, 604. K. Ranker of the mouth, 160. Kidneys, state of, in infancy, 82. inflammation of, in infancy, 112. Kopp's asthma, 346. L. Labia, adhesion of the, 685. Lactation, cutaneous eruptions during, 539. injury from protracted, 120. Larynx, state of, during infancy, 8*2. foreign bodies in the, 380. Laryngeo-tracheitis, 323. Laryngismus stridulus, 346. Laryngitis, spasmodic, 346. Laudanum, danger of its administration during infancy, 57. 75. Lepra alphoides, 563. Light, influence of, on health of infants, 121. Lippitudo, 561. Liver, state of, in infancy, 82. Lobar pneumonia, 100, 311. Lobular pneumonia, 100, 304. INDEX. 729 Lungs, state of, during infancy, 82. inflammation of the, 299. imperfect dilatation of the, 316. tuberculization of the, 108, 614 Lymph, effusion of, in diseases of in- fancy, 99. Lymphatic glands, scrofulous disease of, 596, 623. system, liable to disease in infants, 106. M. Maculae hepaticae, 550. Malformations of the intestines, 655. Mammae, intumescence of the, 677. Marasmus, deaths from, 103. Meals of children, regulation of, 53. Measles, 465. false, 467. deaths from, 100. Medulla spinalis, during, infancy, 83. Melasma, 655. Mellituria, 651. Meningitis, acute, 413. subacute, 436. Meningitis, tubercular, 436. encephalica, 423. epidemic, 424. Menstruation, its influence on the milk, 119. Mental emotions, influence on milk, 120. Mesenteric glands, disease of the, 103, 602, 629. Micturition, difficult, 636. Miliary tubercles, 610. Milk of the nurse, a cause of disease, 118, 593. influence of menstruation on the, 119. pregnancy, on the, 120. mental emotions, on the, 120. food on, 119. Millar's asthma, 346. Modified small-pox, 533. Months, mortality of children during the different, 122. Moral treatment of children, 69. faculties, state of, in children, 90. Morbilli, 465. Morbus coeruleanus, 664. • coxarius, 606, 633. Mortality of children in Philadelphia, 122. Mouth, condition of, in infancy, 81. indications of disease from state of, 136. diseases of the, 147. / inflammation of the, 147. sore, of children, 148. gangrene of the, 160. canker of the, 160 liable to disease, in infants, 100, 102. diarrhcea, 218, 223. Muguet, 148. Mumps, 190. Muscles, in infancy and childhood, 80, 93. tonic contraction of the, 412. N. Naevus, 694. Narcotics, dangerous during infancy, 57, 75. Nares, inflammation of the, 286. Navel, inflammation of the, 675. haemorrhage from the, 658. Nephritis in children, 113. Nerves, state of, in infancy, 84. Nervous excitement a cause.of disease, 118. functions, in infants, 91. system, diseases of the, 382. Nettle rash, 548. New-born infants, washing of, 38. Night dress of infants, 43. Nine-day convulsions, 404. Nursery, proper location of the, 34, 60. management of, 60. Nurse, choice of a wet, 48. diet of a " 49. drink of a " 50. residence of a u 51. Nursing, protracted, a cause of disease, 120. Nutritive functions in infants and chil- dren, 88, 94. diseases of the, 590. Nymphae, cohesion of, 685. O. Obstinacy in children, its management, CEdema cellularis, 689. of the prepuce, 684. Oesophagitis, 194. Oesophagus, inflammation of the, 194. Old persons, danger of children sleeping with, 60. r b Omphalitis exsudativa, 552. Onychia, 709. maligna, 710. Opiates, dangerous during infancy, 57, Opthalmia, scrofulous, 597, 624. purulent, 701. Organization, during infancy and child- hood, 79, 92. Organic disease, blueness of skin from 668. ' ■.auAoi m me, iou. nerves, state of, during infanr>v S4 Mucous membrane, state of, in infancy, | Organs, their devefopm^t d££J in fancy, 85. 730 INDEX. Otitis, 600. Over-fatigue a cause of disease, 595. P. Palsy, 388. Panaritium, 709. Paralysis, 388. Paronychia, 709. Parotitis, 190. Parotids, inflammation of the, 190. Passions in infancy, 69. depressive, a cause of disease, 118, 595. Pathology of infancy and childhood, 97. Peevishness, its causes and treatment, 70. Pemphigus, 577. Pemphigoid fever, 577. Perceptive faculties of children, 77. Pericarditis in children, 111. Peritonitis, 268. chronic, 269. Peritoneum, inflammation of the, 268. Pertussis, 361. Petechiae, 579. Petechial small-pox, 509. Phlegmonous tumours, 557. Phlegmone parotidea, 191. Phthisis in children, 108, 592, 614. Pityriasis, 572. Pleura, inflammation of the, 317. Pleuritis, 317. Pneumonia, 100, 299. lobular, 304. mammelonated, 305. lobar, 311. partial, 306. deaths from, in children, 102. Polypus of the rectum, 244. Pompholyx, 577. Porrigo, 543, 566. Porriginous ophthalmia, 600. Pregnancy, influence of, on the milk, 120. Prepuce, oedema of the, 684. Prickly heat, 547. Primary and secondary diseases of chil- dren, 98. Prolapsus ani, 242. Prurigo, 541. Pseudo-membranous inflammation of the throat, 180. Psora. 583. Psoriasis, 563. Pulmonary cells, obliteration of the, 307. consumption in children, 108, 614. Pulse, state of, in infancy, 87. Purpura, 579. simplex, 579. haemorrhagica, 581. febrilis, 581. Purulent ophthalmia, 701. Pustular ophthalmia, 599. R. Rachitis, 604. Rash, the scarlet, 501. Rectum, polypus of the, 244. Red gum, 539. Relation, functions of, during infancy, 88. Remittent fever of infants, 271. Repose of infants, 58. Respiratory organs, during infancy, 82. diseases of the, 281. function, during infancy and child- hood, 86, 94. Respiratory mucous membrane, its lia- bility to disease in infants, 100, deaths from disease of, 102. Respiration, indication of disease from the state of, 135. Revaccination, 525. Rickets, 604,607. Ringworm, 562. Roseola, 501. Rubeola, 465. Rubeolous fever, 468. Rupia, 574. Ruptures, 678. Salaam convulsions, 411. Scabies, 566, 583. Scald head, 566. Scalds, burns and, 713. Scall, 543, 566. Scarlatina, 475. inflammatory, 476, 484. anginosa, 478. congestive, 492. maligna, 492. deaths from, 100. Scarlet fever, 475. rash, 501. Scrofula, 590, 617. Scrofulous ophthalmia, 597. disease of lymphatic glands, 596, 613. otitis, 600, 628. discharge from the vagina, 602. disease of the mesenteric glands, 602. " bones, 603. Seasons, influence of the, upon the health and mortality of infants, 122. Semeiology of disease in infancy, 125. Senses, external, in infancy and child- hood, 89, 94. Serous effusion, common in diseases of children, 107. Sickly persons, danger of children sleep- ing with, 60. Skin, state of, during infancy, 80. its liability to disease in infancy, 99. INDEX. 731 Skin, diseases of the, 465. induration of the, 107, 689. bound, 689. Skull, state of, during infancy, 84. Sleep of infants and children, 57, 91, 95. indications of disease from the phenomena of, 132. Small-pox, 503. distinct, 506. confluent, 506. congestive, 506, 509. malignant, 509. black, 509. modified, 533. mitigated, 533. deaths from, 100. Snuffles, 286. Softening of the stomach, 198, 208. Sore mouth of children, 148. Spasmodic colic, 210. croup, 341. laryngitis, 341. Spasm of the glottis, 346. Speech in infancy, 91. Spina bifida, 671. Spinal apoplexy, 389. marrow, state of, in infancy, 84. Spine, disease of the, 608, 634. Spleen, state of, in infancy, 82. Still-born infants, treatment of, 282. number of, in Philadelphia, 281. Stomach, state of,-during infancy, 81. deaths from diseases of, 103. discharges from, as indications of disease, 140. diseases of the, 195. softening of the, 198, 208. inflammation of the, 203. Stomatitis, follicular, 152. simple erythematic, 147. with curd-like exudation, 148. ulcerative, 158. Stools, indications of disease from the, 140. Stridulous laryngismus/ 346. Strophulus, 539. Strumous diathesis, 112. Study, injury from too early application to, 66, 75. Stye, 560. Sugar, the use of, by children, 55. Summer complaint of infants, 232. Surface, indications of disease from state of, 136. Swine-pox, 536. Syphilitic eruptions, 587. T. Tabes mesenterica, 103, 261, 274, 602, 629. Talipes, 687. Teething, 85, 92, 171. as a cause of disease, 124. deaths from, 103. Temperature proper for infants, 35. Temperaments, 96. Testicle, arrest of the, 683. Tetter, crusted, 543. humid, 543. scally, 563. Thirst in infants, 48. Thorax, its form in infancy, 82. Throat, diseases of the, 177. gangrene of the, 183. inflammation of the, 180. diphtheritic inflammation of, 180. Thrush, 148. Thymic asthma, 346. Tinea muciflua, 543. capitis, 566. ciliaris, 561. favosa, 566. Tongue, indications of disease from state of, 136. Tongue-tie, 657. Tonsillitis, 177. Tonsils, inflammation of the, 177. Trachea, foreign bodies in the, 380. inflammation of the, 323. Tracheitis, 323. Tracheotomy in croup, 339. Trismus, nascentium, 404. Tubercles, liability of children to, 107. of the brain, 110, 436, 615. Tubercular meningitis, 436. depositions, 609, 635. Tuberculous infiltration, 610. dust, 56, 610. Tumours, phlegmonous, 557. Typhoid fever in children, 115. U. Ulcer, atonic. 574. scrofulous, 597. Ulceration of the navel, 675. Ulcerative stomatitis, 158. Umbilical haemorrhage, 658. Urinary organs, diseases of, in children, 112. diseases of the, 636. discharge, indications of disease, from state of, 143. Urinary bladder, state of, in infancy, 82. secretion in infants, 88. Urine, suppression of the, 641. retention of the, 643. incontinence of the, 114, 645. Urodialysis neonatorum, 636. Urticaria, 548. 732 INDEX. V. Vaccination, 522. phenomena of, 528. period for, 529. mode of, 531. Vagina, discharges from, 602, 629, haemorrhage from, 683. Varicella, 536. Variola, 503. distinct, 506. confluent, 506. congestive, 506, 509. malignant, 509. nigra, 509. vaccina, 523. Varioloid, 533. Ventilation, importance of, 34, 595. Verminous fever, 251, 271. Vertebrae, state of, in infancy, 84. disease of the, 607. Vesicular bronchitis, 295. Vomiting, indications of disease discharges by, 140. of infants at the breast, 196. from W. Walk, precautions in teaching to, 64, 90. Warmth, necessary to infants, 36, 41. Warts, follicular, 565. Washing infants, mode of, 38. Water kanker, 161. Water in the brain, 436, 451. Weaning, proper period for, 51. eruptions previous to, 539. mode of, 52. Wet-nurse, on the choice of a, 48. White gum, 539. swelling, 605, 632. Whitlow, 709. Worm fever, 251, 271. Worms, intestinal, 248. as a cause of disease, 123, 248, 251. convulsions from, 405. diarrhcea from, 219, 225. deaths from, 103. Yellow granulations, 610. CATALOGUE OF ELANCHARD & LEA'S MEDICAL AND SURGICAL PUBLICATIONS. PHILADELPHIA, AUGUST, 1853. TO THE MEDICAL PROFESSION. In submitting the following catalogue of our publications in medicine and the collateral sciences, we beg to remark, that no exertions are spared to render the issues of our press worthy a continuance of the confidence which they have thus far enjoyed, both as regards the high character of the works themselves, and in respect to every point of typographical accuracy and mechanical execution. Grentlemen desirous of adding to their libraries from our list, can in almost all cases procure the works they wish from the nearest bookseller, who can readily order any which he may not have on hand. From the great variation in the expenses of transportation through territories so extensive as those of the United States, prices cannot be the same in all sections of the country, and therefore we are unable to affix retail prices to our publications. Information on this point may be had of booksellers generally, or from ourselves, and all inquiries respecting any of our books will meet with prompt attention by addressing BLANCHARD & LEA, Philadelphia. August, 1853. TWO MEDICAL PERIODICALS, FREE OF POSTAGE, FOR FIVE DOLLARS PER AITOUM. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, subject to postage, when not paid for in advance,.......$5 00 THE MEDICAL NEWS AND LIBRARY, invariably in advance, - - 1 00 or, eoth periodicals furnished, free of postage, for Five Dollars remitted in advance. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, Edited by ISAAC HAYS, M. D., is published Quarterly, on the first of January, April, July, and October. Each number contains at least two hundred and eighty large octavo pages, appropriately illustrated, wherever neceVsarv by engravings on copper, stone, or wood. It has now been issued regularly for a period of thirty five years during a.quarter of a century of which it has been under the control of the Sent editor. Throughout this long space of time, it has maintained its position in the highest Enkrf medical .periodicals both at home and abroad, and has received the cordial support of he entire oro- fessionin this country. Its list of Col aborators will be found to contain a large number of The ^n.«?dSo1ed toname' P " m CVery SeCti°n °f the Unhed StatCS> *«33£ «* de- ORIGINAL COMMUNICATIONS full of varied and important matter, of great interest to all practitioners Jiett/rMiX^^ h* a11 the di*-nt REVIEW DEPARTMENT will be found extended and impartial reviews of all important nfwwnrh ™>^.,.- •.- novelty and interest, together with very numerous impo"ant new works> Panting subjects of BIBLIOGRAPHICAL NOTICES, including nearly all the medical publications of the dav, both in thi« <.»„„•„, onin . r> • . a choice selection of the more important continental works ThESowe*f by E? Bntai"' With 2 BLANCHARD & LEA'S MEDICAL QUARTERLY SUMMARY, being a very full and complete abstract, methodically arranged, of the IMPROVEMENTS AND DISCOVERIES IN THE MEDICAL SCIENCES. This department of the Journal, so important to the practising physician, is the object of especial care on the part of the editor. It is classified and arranged under different heads, thus facilitating the researches of the reader in pursuit of particular subjects, and will be found to present a very full and accurate digest of all observations, discoveries, and inventions recorded in every branch ol medical science. The very extensive arrangements of the publishers are such as to afford to the editor complete materials for this purpose, as he not only regularly receives ALL THE AMERICAN MEDICAL AND SCIENTIFIC PERIODICALS, but al*o twenty or thirty of the more important Journals issued in Great Britain and on the Conti- nent thu« presenting in a convenient compass a thorough and complete abstract of everything interesting or important to the physician occurring in any part of the civilized world. An evidence of the success which has attended these efforts may be found in the constant and -teadv increase in the subr-cription list, which renders it advisable for gentlemen desiring the journal to make known their wishes at an early day, in order to secure a year's set with certainty, the oublishers having frequently been unable to supply copies when ordered late in the year. Io their old -ubscribers, many of whom have been on their list for twenty or thirty years, the publish- ers feel that no promises are necessary; but those who may desire for the first time to subscribe can rest assured that no exertion will'be spared to maintain the Journal in the high position which it has occupied for so long a period. Rv reference to the terms it will be seen that, in addition to this large amount of valuable and practical information on every branch of medical science, the subscriber, by paying in advance, becomes entitled, without further charge, to THE MEDICAL NEWS AND LIBRARY, * monthly periodical of thirty-two large octavo pages. Its "News Department" presents the current^ nformation of the day, while the <• Library Department" is devoted to presenting stand- ^wk^rvaHous branches of medicine. Within a few years, subsonbers have thus received, without expense, the following works which have passed through its columns :- WATSON'S LECTURES ON THE PRACTICE OF PHYSIC. BRODIE'S CLINICAL LECTURES ON SURGERY. TODD AND BOWMAN'S PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. Parts I., II., and HI., with numerous wood-cuts. WEST'S LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. MALGAIGNE'S OPERATIVE SURGERY, with wood-cuts, and SIMON'S LECTURES ON GENERAL PATHOLOGY. While the year 1853, presents THE CONTINUATION OF TODD & BOWMAN'S PHYSIOLOGY, beautifully illustrated on wood. rsf Subscribers for 1853, who do not possess the commencement of Todd and Bowman can obKifht a handsome octavo volume, of 552 pages, with over 150 illustrations, by mad, free of postage,'on a remittance of f2 50 to the publishers. It will thus be seen that for the small sum of FIVE DOLLARS, paid in advance, the subscriber will obtain a Quarterly and a Monthly periodical, EMBRACING ABOUT FIFTEEN HUNDRED LARGE OCTAVO PAGES mailed to any ^^^^^^^^^i^n with the view of removing all These very favorable terms are now^ e.emea^> F Medical Journal to the office of d.fficulties and objections to a fu^J^^SSsmel The rap.d extension of mail facih- every member of the profession tfir«W°u"?%".. ith a certainty and dispatch not hertofore upoT an eqStotlig^?£r^yrIJnMe pric/of Five Dollars for two penod.ca.s, without KeTr^oSg^ fhJr^pSe^mS: Advantage of a Remittance when orde, ^T^^^^^^^110 case sent W'th0Ut adVanCC Payrnen,' ^ SUbSCnbCrS will always receive£t^^fig publishers wiH now take the risk of remittances by mail, only reding, in cases of loss, a certificate from the subscriber's Postmaster, that the money was ^■^Sfit p^aTtSsubscriber's place of residence received in payment of subscriptions. ^= Funds at par at uw Addres6, BLANCHARD & LEA, Philadelphia. AND SCIENTIFIC PUBLICATIONS. 3 ASHWELL (SAMUEL), M.D. A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. Illustrated by Cases derived from Hospital and Private Practice. With Additions by Paul Beck Goddard, M. D. Second American edition. In one octavo volume, of 520 pages. One of the very best works ever issued from the press on the diseases of females.—Western Lancet. This is an invaluable work.—Missouri Medical and Surgical Journal. We strongly recommend Dr. Ashwell's Treatise to our readers as a valuable book of reference, on an extensive, complicated, and highly important class of diseases.—Edinburgh Monthly Journal of Med. Sciences. ARNOTT (NEILL), M. D. ELEMENTS OF PHYSICS; or Natural Philosophy, General and Medical. Written for universal use, in plain or non-technical language. A new edition, by Isaac Hays, M. D. Complete in one octavo volume, of 484 pages, with about two hundred illustrations. ABERCROMBIE (JOHN), M. D. PATHOLOGICAL AND PRACTICAL RESEARCHES ON DISEASES OF THE STOMACH, INTESTINAL CANAL, &c. Fourth edition, in one small octavo volume, of2G0 pages. BENNETT (HENRY), M. D. A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS AND ITS APPENDAGES, and on Ulceration and Induration of the Neck of the Uterus. Third edition. In one neat octavo volume, of 350 pages, with wood-cuts. We shall not call it a second edition, because, as Dr. Bennett truly observes, it is really a new work. It will be found to contain not only a faithful histo- ry of the various pathological changes produced by inflammation in the uterus and its annexed organs, in the different phases of female life, but also an ac- curate analysis of the influence exercised bv inflam- mation in the production of the various morbid con- ditions of the uterine system, hitherto described and treated as functional.—British and Foreign Medico- Chirurgical Preview. Few works issue from the medical press which are at once original and sound in doctrine ; but such, we feel assured, is the admirable treatise now before us. The important practical precepts which the author inculcates are all rigidly deduced from facts. . . . Every page of the book is good, and eminently practical. ... So far as we know and believe, it is the best work on the subject of which it treats.— Monthly Journal of Medical Science. We refer our readers with satisfaction to this work for information on a hitherto most obscure and diffi- cult class of diseases.—London Medical Gazette. One of the best practical monographs amongst modern English medical books.—Transylvania Med. Journal. BEALE (LIONEL JOHN), M. R. C.S., &c THE LAWS OF HEALTH IN RELATION TO MIND AND BODY £t™r2ot°hf LeUer3 f,'°m "" °'d Practitioner t0 a Patient- In ™ handsome volume, royal 12mo.', BILLING (ARCHIBALD), M. D. THE PRINCIPLES OF MEDICINE. Second American, from the Fifth and Improved London edition. In one handsome octavo volume, extra cloth, 250 pages. BLAKISTON (PEYTON), M. D., F. R S &.C PRACTICAL OBSERVATIONS ON CERTAIN DISEASES OT? tp™ CHEST, and on the Principles of Auscultation. In one volume. 8vopp 384 THE BENEDICT (N. D.), M. D. COMPENDIUM OF LECTURES ON THE THEORY ANT) ppa™™, OF MEDICINE, delivered by Professor Chapman in the University nfp! ,PRACTICE octavo volume, of 258 pages. niversity of Pennsylvania. In one BURROWS (GEORGE), M.D ON DISORDERS OF THE CEREBRAL CIRCULATION arJ m ,i n nection between the Affections of the Brain and Diseases oft bl H7aVt \ 2° tLe Con" colored plates, pp. 216. es 0I tae HeaTt- In one 8vo. vol., with 4 BLANCHARD & LEA'S MEDICAL BUDD (GEORGE), M. D., F. R. S., Professor of Medicine, in King's College, London. ON DISEASES OF THE LIVER. Second American, from the second and enlarged London edition. In one very handsome octavo volume, with four beautifully colored plates, and numerous wood-cuts. pp. 468. New edition. (Now Ready.) The reputation which this work has obtained as a full and practical treatise on an important class of diseases will not be diminished by this improved and enlarged edition. It has been carefully and thoroughly revised by the author; the number of plates has been increased, and the style of its me- chanical execution will be found materially improved. The full digest we have given of the new matter introduced into the present volume, is evidence of the value we place on it. The faet that the profes- sion has required a second edition of a monograph such as that before us, bears honorable testimony to its usefulness. For many years, Dr. Budd's work must be the authority of the great mass of British practitioners on the hepatic diseases ; and it is satisfactory that the subject has been taken up by so able and experienced a physician.—British and Foreign Medico-Chirurgical Review. We cannot too strongly recommend the diligent study of this volume. The work cannot fail to rank the name of its author among the most enlightened pathologists and soundest practitioners of the day. —Medico-Chirurgical Review. We feel bound to say that Dr. Budd's treatise 1a greatly in advance of its predecessors. It is the first work in which the results of microscopical iinatnmy and the discoveries of modern chemistry have betn brought fully to bear upon the pathology and treat- ment of diseases of the liver; and it is the only work in which a method of studying diseases of this organ, founded upon strictly inductive principles, is de- veloped.— Dublin Medical Press. Having thus attempted to give a brief summary of the more important contents of this work, we would, in conclusion, recommend it to every practitioner and student as well worthy of a careful and patient perusal.— The New Orleans Medical and Surgical Journal. BLOOD AND URINE (MANUALS ON). BY JOHN WILLIAM GRIFFITH, G. OWEN REESE, AND ALFRED MARKWICK. One thick volume, royal 12mo., extra cloth, with plates, pp. 460. BRIGHAM (AMARIAH), M.D. ON MENTAL CULTIVATION AND EXCITEMENT. 18mo., extra cloth. In one neat volume, BRODIE (SIR BENJAMIN C), M. D., &c. CLINICAL LECTURES ON SURGERY. 1 vol. 8vo., cloth. 850 pp. BY THE SAME AUTHOR. PATHOLOGICAL AND SURGICAL OBSERVATIONS ON THE DIS- EASES OF THE JOINTS. 1 vol. 8vo., cloth, pp. 216. BY THE SAME AUTHOR. LECTURES ON THE DISEASES OF THE URINARY ORGANS. 1 vol. 8vo., cloth, pp.214. *ik* These three works may be had neatly bound together, forming a large volume of" Brodie's Surgical Works." pp.780. BIRD (GOLDING), A. M., M. D., &.C. URINARY DEPOSITS: THEIR DIAGNOSIS, PATHOLOGY, AND THERAPEUTICAL INDICATIONS. A new American, from the third and improved London With over sixty illustrations. In one royal 12mo. volume, extra cloth, pp. 338. nary secretion, which have contributed so much to the increase of our diagnostic powers, and 10 the extension and satisfactory employment of our thera- peutic resources. In the preparation of this new edition of his work, it is obvious that Dr. Golding Bird has spared no pains to render it a faithful repre- sentation of the present state of scientific knowledge on the subject it embraces. Although, of course, there are many topics which are open to differences of opinion, we cannot point to any well-substantiated result of inquiry which the author has overlooked.— The British and Foreign Medico-Chirurgical Review. edition. The new edition of Dr. Bird's work, though not increased in size, has been greatly modified, and much of it rewritten. It now presents, in a com- pendious form, the gist of all that is known and re- liable in this department. From its terse style and convenient size, it is particularly applicable to the student, to whom we cordially commend it.— The Medical Examiner. It can scarcely be necessary for us to say anything of the merits of this well-known Treatise, which so admirably brings into practical application the re- sults of those microscopical and chemical researches regarding the physiology and pathology of the uri- BY THE SAME AUTHOR. ELEMENTS OF NATURAL PHILOSOPHY; being an Experimental Intro- duction to the Physical Sciences. Illustrated with nearly four hundred wood-cuts. From tha third London edition. In one neat volume, royal 12mo. pp. 402. AND SCIENTIFIC PUBLICATIONS. 5 BARTLETT (ELISHA), M. D., Professor of Materia Medica and Medical Jurisprudence in the College of Physicians and Surgeons, New York. THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS OF THE UNITED STATES. Third edition, revised and improved. In one octavo volume, of six hundred pages, beautifully printed, and strongly bound. In preparing a new edition of this standard work, the author has availed himself of such obser- vations and investigations as have appeared since the publication of his last revision, and he has endeavored in every way to render it worthy of a continuance of the very marked favor with which it has been hitherto received. The masterly and elegant treatise, by Dr. Bartlett is invaluable to the American student and practi- tioner.—Dr. Holmes's Report to the Nat. Med. Asso- ciation. We regard it, from the examination we have made of it, the best work on fevers extant in our language, and as such cordially recommend it to the medical public.—St. Louis Medical and Surgical Journal. Take it altogether, it is the most complete history of our fevers which has yet been published, and every practitioner should avail himself of its con- tents.— The Western Lancet. Of the value and importance of such a work, it is needless here to speak ,* the profession of the United States owe much to the -author for the very able volume which he has presented to them, and for the careful and judicious manner in which he has exe- cuted his task. No one volume with which we are acquainted contains so complete a history of our fevers as this. To Dr. Bartlett we owe our best thanks for the very able volume he has given us, as embodying certainly the most complete, methodical, and satisfactory account of our fevers anywhere to be met with.— The Charleston Med. Journal and Review. BY THE SAME AUTHOR. AN INQUIRY INTO THE DEGREE OF CERTAINTY IN MEDICINE, and into the Nature and Extent of its Power over Disease. In one volume, royal 12mo. pp. S4. BOWMAN (JOHN E.), M.D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. volume, royal 12mo., with numerous illustrations, pp. 288. In one neat BY THE SAME AUTHOR. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANA- LYSIS. With numerous illustrations. In one neat volume, royal 12mo. pp.350. COLOMBAT DE L'ISERE. A TREATISE ON THE DISEASES OF FEMALES, and on the Special Hygiene of their Sex. Translated, with many Notes and Additions, by C. D. Meigs, M. D. Second edition, revised and improved. In one large volume, octavo, with numerous wood-cuts. pp. 720. The treatise of M. Colombat is a learned and la- j M. Colombat De L'lsere has not consecrated ten bonous commentary on these diseases, indicating i years of studious toil and research to the frailer sex very considerable research, great, accuracy of judg- j in vain; and although we regret to hear it is at the ment, and no inconsiderable personal experience, i expense of health, he has imposed a debt of oratitude With the copious notes and additions of its experi- as well upon the profession, as upon the mothers and enced and very erudite translator and editor, Dr. j daughters of beautiful France, which that gallant Meigs, it presents, probably, one of the most com- | nation knows best how to acknowledge— New Or- plete and comprehensive works on the subject we i leans Medical Journal. possess.—American Med. Journal. COPLAND (JAMES), M. D., F. R. S., &c. OF THE CAUSES, NATURE, AND TREATMENT OF PALSY AND APOPLEXY, and of the Forms, Seats, Complications, and Morbid Relations of Paralytic and Apoplectic Diseases. In one volume, royal 12mo., extra cloth, pp.326. CHAPMAN (PROFESSOR N.), M. D., &c. LECTURES ON FEVERS, DROPSY, GOUT, RHEUMATISM, &c &c In one neat 8vo. volume, pp. 450. CLYMER (MEREDITH), M. D., &c. FEVERS; THEIR DIAGNOSIS, PATHOLOGY, AND TREATMENT Prepared and Edited, with large Additions, from the Essays on Fever in Tweedie's Library of Practical Medicine. In one octavo volume, of 600 pages. ^ior«J.ry ot CARSON (JOSEPH), M. D. Professor of Materia Medica and Pharmacy in the University of Pennsylvania ^ndphar^c?^ C0,UIl?HE r?F LECTURES ON MATERIA'MEDICA io^otm^l.^^ M ^ ^^^ °? *™*Y^™. In one very neat octavl 6 BLANCHARD & LEA'S MEDICAL CARPENTER (WILLIAM B.), M. D., F. R. S., &c, Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applications to Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. Fifth American, from the fourth and enlarged London edition. With three hundred and fourteen illustrations. Edited, with additions, by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the Pennsylvania Medical College, &c. In one very large and beautiful octavo volume, of about 1100 large pages, handsomely printed and strongly bound in leather, with raised bands. New edition. (Just Issued.) From the Authors Preface to tlie present Edition. "When the author, on the completion of his ' Principles of General and Comparative Physiology,' applied himself to the preparation of his ' Principles of Human Physiology,' for the pre**, he found that nothing short of an entire remodelling of the preceding edition would in any degree satisfy his notions of what such a treatise ought to be. For although no fundamental change had taken place during the interval in the fabric ot Physiological Science, yet a large number of less important modifications had been effected, which had combined to produce a very considerable alteration in its aspect. Moreover, the progressive maturation of his own views, and his increased experience as a teacher, had not only rendered him more keenly alive to the imperfections which were inherent in its original plan, but had caused him to look upon many topics in a light very different from that under which he had previously regarded them ; and, in particular, he felt a strong desire to give to his work as practical a character as possible, without foregoing the position which (he trusts he may say without presumption) he had succeeded in gaining for it, as a philosophical exposiiion ol one important department of Physiological Science. He was led, therefore, to the determination of, in reality, producing a new treatise, in which only those parts of the old should be retained, which might express the existing stateof knowledge, and of his own opinions on the points to which they relate." The American edition has been printed from sheets prepared for the purpose by the author, who has introduced nearly one hundred illustrations not in the London edition ; while it has also enjoyed the advantage of a careful superintendence on the part of the editor, who has added notices ol such more recent investigations as had escaped the author's attention. Neither care nor expense has been spared in the mechanical execution of the work to render it superior to idrmer editions, and it is confidently presented as in every way one of the handsomest volumes as yet placed before the medical profession in this country. The standard of authority on physiological sub- jects. * * * In the present edition, to particularize the alterations and additions which hav been made, would require a review of the whole work, since scarcely a subject has not been revised and altered, added to, or entirely remodelled to adapt it to the present state of the science.—Charleston Mtd. Journ. The changes are too numerous to admit of an ex- tended notice in this place. At every point where the recent diligent labors of organic chemists and micrographcrs have furnished interesting and valu- able facts, they have been appropriated, and no paim have been spared, in so incorporating and arranging them that the work may constitute one hBimonioua system.—Southern Med. and Surg. Journal. Any reader who desires a treatise on physiology may feel himself entirely safe in ordering this.— Western Med. and Surg. Journal. From this hasty and imperfect allusion it will be seen by our readers that the alterations and addi- tions to this edition render it almost a new work— and we can assure our readers that it is one of the best summaries of the existing facts of physiological science within the reach of the English student and physician.—N. Y. Journal of Medicine. The profession of this country, and perhaps also of Europe, have anxiously and for some time awaited the announcement of this new edition of Carpenter's Human Physiology. His former editions have for many years been almost the only text-book on Phy- siology in all our medical schools, and its circula- tion among the profession lias been unsurpassed by any work in any department of medical science. It is quite unnecessary for us to speak of this work as its merits would justify. The mere an nouncement of its appearance will afford the highest pleasure to every student of Physiology, while its perusal will be of infinite service in advancing physiological science.—Ohio Med. and Surg. Journ. The most complete work on the science in our language.—Am. Med. Journal. The most complete exposition of physiology which any language can at present give.—Brit, and For. Med.-Chirurg. Review. We have thus adverted to some of the leading "additions and alterations," which have been in- troduced by the author into this edition of his phy- siology. These will be found, however, very far to exceed the ordinary limits of a new edition, "the old materials having been incorporated with the new, rather than the new with the old." It now certainly presents the most complete treatise on the subject within the reach of the American reader ; and while, for availability as a text-book, we may perhaps regret its growth in bulk, we are sure that the student of physiology will feel the impossibility of presenting a thorough digest of the facts of the science within a more limited compass.—Medical Examiner. The greatest, the most reliable, and the best book on the subject which we know of in the English language.—Stethoscope. The most complete work now extant in our lan- guage.—N. O. Med. Register. We do not hesitate a moment in pronouncing it the best text book in the English language. In this new edition, theauthor has again displayed his great zeal. The work is almost a new one, having been entirely remodelled ; a vast amount of valuable ma- terial has been added, and with great propriety, as- signed its appropriate place.—St. Louis Med. and Surg. Journal. The best text-book in the language on this ex- tensive subject.—London Med. Times. A complete cyclopaedia of this branch of science. —A\ Y. Med. Times. BY THE SAME AUTHOR. PRINCIPLES OF GENERAL AND COMPARATIVE PHYSIOLOGY. Intended as an Introduction to the Study of Human Physiology; and as a Guide to the Philo- sophical pursuit of Natural History. New and improved edition, (preparing.) AND SCIENTIFIC PUBLICATIONS. 7 CARPENTER (WILLIAM B.), M. D., F. R. S., Examiner in Physiology and Comparative Anatomy in the University of London. ELEMENTS (OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIO- LOGICAL ANATOMY. Second American, from a new and revised London edition. With one hundred and ninety illustrations. In one very handsome octavo volume. (Lately Issued.) In publishing the first edition of this work, its title was altered from that of the London volume, by the substitution of the word "Elements" for that of " Manual," and with the author s sanction the title of "Elements" is still retained as being more expressive of the scope of the treatise. A comparison of the present edition with the former one will show a material improvement, the author having revised it thoroughly, with a view of rendering it completely on a level with the most advanced state of the science. By condensing the less important portions, these numerous additions have been introduced without materially increasing the bulk of the volume, and while numerous illustrations have been added, and the general execution of the work improved, it has been kept at its former very moderate price. To say that it is the best manual of Physiology now before the public, would not do sufficient justice to the author.—Buffalo Medical Journal. In his former works it would seem that he had exhausted the subjectof Physiology. In the present, he gives the essence, as it were, of the whole.—N. Y. Journal of Medicine. Those who have occasion for an elementary trea- tise on Physiology, cannot do better than to possess themselves of the manual of Dr. Carpenter.—Medical Examiner. We do not hesitate to pronounce it the best and most comprehensive system of modern surgery with ■which we are acquainted.—Medico-Chirurgical Re- view. The fullest and ablest digest extant of all that re- lates to the present advanced state of surgical pa- thology.—American Medical Journal. As complete as any system of Surgery can well be.—Southern Medical and Surgical Journal. It is not needful that we should compare it with the other pharmacopoeias extant, which enjoy and merit the confidence of the profession : it is enough to say that it appears to us as perfect as a Dispensa- tory, in the present state of pharmaceutical science, could be made. If it omits any details pertaining to this branch of knowledge which the student has a right to expect in such a work, we confess the omis- sion has escaped our scrutiny. We cordially recom- mend this work to such of our readers as are in need of a Dispensatory. They cannot make choice of a better.—Western Journ. of Medicine and Surgery. The best and most complete expose of modern Physiology, in one volume, extant in the English language.—St. Louis Medical Journal. With such an aid in his hand, there is no excuse for the ignorance often displayed respecting the sub- jects of which it treats. From its unpretending di- mensions, it may not be so esteemed by those anxious to make a parade of their erudition; but whoever masters its contents will have reason to be proud of his physiological acquirements. The illustrations are well selected and finely executed.—Dublin Med. Press. The most learned and complete systematic treatise now extant.—Edinburgh Medical Journal. A complete encyclopaedia of surgical science—a very complete surgical library—by far the most complete and scientific system of surgery in the English language.—N. Y. Journal of Medicine. The most extensive and comprehensive account of the art and science of Surgery in our language.— Lancet. There is not in any language a more complete and perfect Treatise.—N. Y. Annalist. In conclusion, we need scarcely say that we strongly recommend this work to all classes of our readers. Asa Dispensatory and commentary on the Pharmacopoeias, it is unrivalled in the English or any other language.—The Dublin Quarterly Journal. We earnestly recommend Dr. Christison's Dis- pensatory to all our readers, as an indispensable companion, not in the Study only, but in the Surgery also.—British and Foreign Medical Review. BY THE SAME AUTHOR. A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTH AND DISEASE. In one neat 12mo. volume. by the same author. (Preparing.) THE MICROSCOPE AND ITS REVELATIONS. In one handsome volume, beautifully illustrated with plates and wood-cuts. CHELIUS (J. M.), M. D., Professor of Surgery in the University of Heidelberg, &c. A SYSTEM OF SURGERY. Translated from the German, and accompanied with additional Notes and References, by John F. South. Complete in three very large octavo volumes, of nearly 2200 pages, strongly bound, with raised bands and double titles. CHRISTISON (ROBERT), M. D., V. P. R. S. E., &.C. A DISPENSATORY; or. Commentary on the Pharmacopoeias of Great Britain and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Ac- tions, Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and im- proved, with a Supplement containing the most important New Remedies. With copious Addi- tions, and two hundred and thirteen large wood-engravings. By R. Eglesfeld Griffith, M. D. In one very large and handsome octavo volume, of over 1000 pages. BLANCHARD & LEA'S MEDICAL CONDIE (D. F.), M. D., &.C. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Third edition, revised and augmented. In one large volume, 8vo., of over 700 pages. Every important fact that hnB been verified or developed since the publication of the previous edi- tion, either in relation to the nature, diagnosis, or treatment of the diseases of children, has been ar- ranged and incorporated into the body of the work ; thus posting up to date, to use a counting-noose phrase, all the valuuble facts and useful information on the subject. To the American practitioner, Dr. Condie's remarks on the diseases of children will be invaluable, and we accordingly advise those who have failed to read this work to procure a copy, and make themselves familiar with its sound princi- ples.—The New Orleans Med. and Surg. Journal. Dr. Condie's scholarship, acumen, industry, and practical sense are manifested in this, as in all his numerous contributions to science.—Dr. Holmes's Report to the American Medical Association. Taken as a whole, in our judgment, Dr. Condie's Treatise is the one from the perusal of which the practitioner in this country will rise with the great- est satisfaction —Western Journal of Medicine and Surgery. One of the best works upon the Diseases of Chil- dren in the English language.—Western Lancet. We feel assured from actual experience that no physician's library can be complete without a copy of this work.—N. Y. Journal of Medicine. Perhaps the most full and complete work now be- fore the profession of the United States; indeed, we may say in the English language. It is vastly supe- rior to most of its predecessors.—Transylvania Med. Journal. A veritable pediatric encyclopajdin, and an honor to American medical literature.—Ohio Medical and Surgical Journal. AVe feel persuaded that the American medical pro- fession will soon regard it not only as a very good, but as the vkry best " Practical Treatise on the Diseases of Children."—American Medical Journal. We pronounced the first edition to be the best work on the diseases of children in the English language, and, notwithstanding all that has been published, we still regard it in that light.—Medical COOPER (BRANSBY B.), F. R. S., Senior Surgeon to Guy's Hospital, &c. LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. In one very large octavo volume, of 750 pages. (Lately Issued).' For twenty-five years Mr. Bransby Cooper has been surgeon to Guy's Hospital; and the volume before us may be said to consist of an account of the results of his surgical experience during that long period. We cordially recommend Mr. Bransby Cooper's Lectures as a most valuable addition to our surgical literature, and one which cannot fail to be of service both to students and to those who are actively engaged in the practice of their profes- sion.—The Lancet. A good book by a good man is always welcome j and Mr. Bransby Cooper's book does no discredit to its paternity. It has reminded us, in its easy style and copious detail, more of Watson's Lectures, than any book we have seen lately, and we should nut be surprised to see it occupy a similar position to that well-known work in professional estimation. It consists of seventy-five lectures on the most im- portant surgical diseases. To analyze such a work is impossible, while so interesting is every lecture, that we feel ourselves really at a loss what to select for quotation. The work is one which cannot fail to become a favorite with the profession ; und it pro- mises to supply a hiatus which the student of sur- gery has often to deplore.—Medical Times. COOPER (SIR ASTLEY P.), F. R. S., &c. A TREATISE ON DISLOCATIONS AND FRACTURES OF THE JOINTS. Edited by Bransby B. Cooper, F. R. S., &c. With additional Observations by Prof. J. C. Warren. A new American edition. In one handsome octavo volume, with numerous illustra- tions on wood. BY THE SAME AUTHOR. ON THE ANATOMY AND TREATMENT OF ABDOMINAL HERNIA. One large volume, imperial 8vo., with over 130 lithographic figures. BY THB SAME AUTHOR. ON THE STRUCTURE AND DISEASES OF THE TESTIS, AND ON THE THYMUS GLAND. One vol. imperial 8vo., with 177 figures, on 29 plates. BY THE SAME AUTHOR. ON THE ANATOMY AND DISEASES OF THE BREAST, with twenty- five Miscellaneous and Surgical Papers. One large volume, imperial 8vo., with 252 figures, on 36 plates. These three last volumes complete the surgical writings of Sir Astley Cooper. They are very handsomely printed, with a large number of lithographic plates, executed in the best style, and are presented at exceedingly low prices. AND SCIENTIFIC PUBLICATIONS. 9 CHURCHILL (FLEETWOOD), M.D., M.R.I.A, ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American, from the last and improved English edition. Edited, with Notes and Additions, by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Children, &c. W ith ldy illustrations. In one very handsome octavo volume, pp. 510. (Lately Issued.) To bestow praise on a book that has received such marked approbation would be superfluous. We need only say, therefore, that if the first edition was thought worthy of a favorable reception by the medical public, we can confidently affirm that this will be found much more so. The lecturer, the practitioner, and the student, may all have recourse to its pages, and derive from their perusal much in- terest and instruction in everything relating to theo- retical and practical midwifery.—Dublin Quarterly Journal of Medical Science. A work of very great merit, and such as we can confidently recommend to the study of every obste- tric practitioner.—London Medical Gazette. This is certainly the most perfect system extant. ft is the best adapted for the purposes of a text- book, and that which he whose necessities confine him to one book, should select in preference to all others.—Southern Medical and Surgical Journal. The most popular work on midwifery ever issued from the American press.—Charleston Med. Journal. Were we reduced to the necessity of having but one work on midwifery, and permitted to choose, we would unhesitatingly take Churchill.— Western Med. and Surg. Journal. It is impossible to conceive a more useful and elegant manual than Dr. Churchill's Practice of Midwifery.—Provincial Medical Journal. Certainly, in our opinion, the very best work on the subject which exists.—N. Y. Annalist. We regard this volume as possessing more claims to completeness than any other of the kind with which we are acquainted. Most cordially and earn- estly, therefore, do we commend it to our profession- al brethren, and we feel assured that the stamp of their approbation will indue time be impressed upon it. After an attentive perusal of its contents, we hesitate not to say, that it is one of the most com- prehensive, ever written upon the diseases of chil- dren, and that, for copiousness of reference, extent of research, and perspicuity of detail, it is scarcely to be equalled, and not to be excelled, in any lan- guage.—Dublin Quarterly Journal. After this meagre, and we know, very imperfect notice of Dr. Churchill's work, we shall conclude by saying, that it is one that cannot fail from its co- piousness, extensive research, and general accuracy, to exalt still higher the reputation of the author in this country. The American reader will be particu- larly pleased to find that Dr. Churchill has done full justice throughout his work to the various American authors on this subject. The names of Dewees, Eberle, Condie, and Stewart, occur on nearly every page, and these authors are constantly referred to by the author in terms of the highest praise, and with the most liberal courtesy.— The Medical Examiner. To these papers Dr. Churchill has appended notes, embodying whatever information has been laid be- fore the profession since their authors' time. He has also prefixed to the Essays on Puerperal Fever, which occupy the larger portion of the volume, an interesting historical sketch of the principal epi- No work holds a higher position, or is more de- serving of being placed in the hands of the tyro, the advanced student, or the practitioner.—Medical Examiner. Previous editions, under the editorial supervision of Prof R. M. Huston, have been received with marked favor, and they deserved it; but this, re- printed from a very late Dublin edition, carefully revised and brought up by the author to the present time, does present an unusually accurate and able exposition of every important particular embraced in the department of midwifery. * # The clearness, directness, and precision of its teachings, together with the great amount of statistical research which its text exhibits, have served to place it already in the foremost rank of works in this department of re- medial science.—N. O. Med. and Surg. Journal. In our opinion, it forms one of the best if not the very best text-book and epitome of obstetric science which we at present possess in the English lan- guage.— Monthly Journal of Medical Science. The clearness and precision of style in which it is written, and the great amount of statistical research which it contains, have served to place it in the first rank of works in this department of medical science. — N. Y. Journal of Medicine. Few treatises will be found better adapted as a text-book for the student, or as a manual for the frequent consultation of the young practitioner.— American Medical Journal. The present volume will sustain the reputation acquired by the author from his previous works. The reader will find in it full and judicious direc- tions for the management of infants at birth, and a compendious, but clear account of the diseases to which children are liable, and the most successful mode of treating them. We must not close this no- tice without calling attention to the author's style, which is perspicuous and polished to a degree, we regret to say, not generally characteristic of medical works. We recommend the work of Dr. Churchill most cordially, both to students and practitioners, as a valuable and reliable guide in the treatment of the diseases of children.—Am. Journ. of the Med. Sciences. We know of no work on this department of Prac- tical Medicine which presents so candid and unpre- judiced a statement or posting up of our actual knowledge as this.—N. Y. Journal of Medicine. Its claims to merit both as a scientific and practi- cal work, are of the highest order. Whilst we would not elevate it above every other treatise on the same subject, we certainly believe that very few are equal to it, and none superior.—Southern Med. and Surgical Journal. demies of that disease. The whole forms a very valuable collection of papers, by professional writers of eminence, on some of the most important accidents to which the puerperal female is liable.—American Journal of Medical Sciences. BY THE SAME AUTHOR. ON THE DISEASES OF INFANTS AND CHILDREN. In one large and handsome volume of over 600 pages. BY THE SAME AUTHOR. ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- CULIAR TO WOMEN. Selected from the writings of British Authors previous to the close oi the Eighteenth Century. In one neat octavo volume, of about four hundred and fifty pages. 10 BLANCHARD & LEA'S MEDICAL CHURCHILL (FLEETWOOD), M. DM M. R. I. A., &.c. ON THE DISEASES OF WOMEN; including those of Pregnancy and Child- bed. A new American edition, revised by the Author With Notes and Additions, by D Fkax- cis Condie, M. D., author of "A Practical Treatise on the Diseases of Children." In one lar*,*c and handsome octavo volume, with wood-cuts, pp. 684. (Just Issued.) From the Author's Preface. In reviewing this edition, at the request of my American publishers, I have inserted several new sections and chapters, and I have added, I believe, all the information we have derived from recent researches; in addition to which the publishers have been fortunate enough to secure the service-. of an able and highly esteemed editor in Dr. Condie. We now regretfully take leave of Dr. Churchill's | larity. This fifth edition, before us. is well caleu- book. Had our typographical limits permitted, we should gladly have borrowed more from_ its richly stored pages. In conclusion, we heartily recom- mend it to the profession, and would at the same time express our firm conviction that it will not only add to the reputation of its author, but will prove a work of great and extensive utility to obstetric practitioners.—Dublin Medical Press. Former editions of this work have been noticed in previous numbers of the Journal. The sentiments of high commendation expressed in those notices, have only to be repeated in this; not from the fact that the profession at large are not aware of the high merits which this work really possesses, but from a desire to see the principles and doctrines therein contained more generally recognized, and more uni- versally carried out in practice.—N. Y. Journal of Medicine. We know of no author who deserves that appro- bation, on '* the diseases of females," to the same extent that Dr. Churchill does. His, indeed, is the only thorough treatise we know of on the subject; and it may be commended to practitioners and stu- dents as a masterpiece in its particular department. The former editions of this work have been com mended strongly in this journal, and they have won their way to an extended, and a well-deserved popu- DEWEES (W. P.), M.D., &c. A COMPREHENSIVE SYSTEM OF MIDWIFERY. Illustrated by occa- sional Cases and many Engravings. Twelfth edition, with the Author's last Improvements and Corrections. In one octavo volume, of 600 pages. (Jztst Issued.) BY THE SAME AUTHOR. A TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILDREN. Tenth edition. In one volume, octavo, 548 pages. (Just Issued.) BY THE SAME AUTHOR. A TREATISE ON THE DISEASES OF FEMALES. Tenth edition. In one volume, octavo, 532 pages, with plates. (Just Issued.) DICKSON (PROFESSOR S. H.), M.D. ESSAYS ON LIFE, SLEEP, PAIN, INTELLECTION, HYGIENE, AND DEATH. In one very handsome volume, royal 12mo. DANA (JAMES D). ZOOPHYTES AND CORALS. In one volume, imperial quarto, extra cloth, with wood-cuts. ALSO, AN ATLAS TO THE ABOVE, one volume, imperial folio, with sixty-one mag- nificent plates, colored after nature. Bound iu half morocco. ALSO, ON THE STRUCTURE AND CLASSIFICATION OF ZOOPHYTES. Sold separate, one vol., cloth. DE LA BECHE (SIR HENRY T.), F. R. S., &.C. THE GEOLOGICAL OBSERVER. In one very large and handsome octavo volume, of 700 pages. With over three hundred wood-cuts. (Just Issued.) lated to maintain Dr. Uhurchill s nigh reputation. It was revised und enlarged by the nnthor, for hit American publishers, and it seems to us that there ii scarcely any species of desirable information on its subjects that may not be found in this work.—The Western Journal of M'.dicineand Surgery. AVe are gratified to announce a new and revised edition of Dr. Churchill's valuable work on the dis- eases of females We have ever regarded it ns one of the very best works on the subjects embraced within its scope, in the English language; and tho present edition, enlarged and revised by the author, renders it still more entitled to the confidence of the profession. The valuable notes of Prof Huston have been retained, and contribute, in no small de- gree, to enhance the value of the work. It is a source of congratulation that the publishers have permitted the author to be, in this instance, his own editor, thus securing all the revision which an author alone is capable of making.—The Western Lancet. Asa comprehensive manual for students, or a work of reference for practitioners, we only speak with common justice when we say that it surpasses any other that has ever issued on the same sub- ject from the British press.—The Dublin Quarterly AND SCIENTIFIC PUBLICATIONS. 11 DRUITT (ROBERT), M.R. C.S., &c. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new American, from the last and improved London edition. Edited by F. W. Sargent, M. D., author of " Minor Surgery," &c. Illustrated with one hundred and ninety-three wood-engrav- ings. In one very handsomely printed octavo volume, of 576 large pages. accessible to the American student, has had much currency in this country, and under its present au- spices promises to rise to yet higher favor. The il- lustrations of the volume are good, and, in a word, the publishers have acquitted themselves fully of their duty.—The Western Journal of Medicine and Surgery. No work, in our opinion, equals it in presenting so much valuable surgical matter in so small a compass.—St. Louis Med. and Surgical Journal. Druitt's Surgery is too well known to the Ameri- can medical profession to require its announcement anywhere. Probably no work of the kind has ever been more cordially received and extensively circu- lated than this The fact that it comprehends in a comparatively small compass, all the essential ele- ments of theoretical and practical Surgery—that it is found to contain reliable and authentic informa- tion on the nature and treatment of nearly all surgi- cal affections—is a sufficient reason for the liberal patronage it has obtained. The work before us is a new edition, greatly enlarged and extended by the anthor—its practical part having undergone a tho- rough revision, with fifty pages of additional matter. The editor, Dr. P.W.Sargent, of Philadelphia, has contributed much to enhance the value of the work, by such American improvements as are calculated more perfectly to adapt it to our owri views and practice in this country. It abounds everywhere with spirited and life-like illustrations, which to the young surgeon, especially, are of no minor consi- deration. Every medical man frequently needs just such a work as this, for immediate reference in mo- ments of sudden emergency, when he has not time to consult more elaborate treatises. Its mechanical execution isof the very best quality, and as a whole, it deserves and will receive from the profession, a liberal patronage.—The Ohio Medical and Surgical Journal. The author has evidently ransacked every stand- ard treatise of ancient and modern times, and all that is really practically useful at the bedside will be found in a form at once clear, distinct, and interest- ing.—Edinburgh Monthly Medical Journal. Druitt's work, condensed, systemati*, lucid, and practical as it is, beyond most works on Surgery The most accurate and ample resume of the pre- sent state of Surgery that we are acquainted with— Dublin Medical Journal. A better book on the principles and practice of Surgery as now understood in England and America, has not been given to the profession.—Boston Medi- cal and Surgical Journal. An unsurpassable compendium, not only of Sur- gical, but of Medical Practice.—London Medical Gazette. This work merits our warmest commendations, and we strongly recommend it to young surgeons as an admirable digest of the principles and practice of modern Surgery.—Medical Gazette. It may be said with truth that the work of Mr. rDiuitt affords a complete, though brief and con- densed view, of the entire field of modern surgery. We know of no work on the same subject having the appearance of a manual, which includes so many topics of interest to the surgeon ; and the terse man- ner in which each has been treated evinces a most enviable quality of mind on the part of the author, who seems to have an innate power of searching out and grasping the leading facts and features of the most elaborate productions of the pen. It is a useful handbook for the practitioner, and we should deem a teacher of surgery unpardonable who did not recommend it to his pupils. In our own opinion, it is admirably adapted to the wants of the student.— Provincial Medical and Surgical Journal. DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &c. &c. In four large super royal octavo volumes, of 32-34 double-columned pages, Wrongly and handsomely bound. *^* This work contains no less than four hundred and eighteen distinct treatises, contributed by sixty-eight distinguished physicians. unquestionably one of very great value to the prac- titioner. This estimate of it has not been formed from a hasty examination, but after an intimate ac- quaintance derived from frequent consultation of it during the past nine or ten years. The editors are practitioners of established reputation, and the list of contributors embraces many of the most eminent professors and teachers of London, Edinburgh, Dub- lin, and Glasgow. It is, indeed, the great merit of this work that the principal articles have been fur- nished by practitioners who have not only devoted especial attention to the diseases about which they have written, but have also enjoyed opportunities for an extensive practical acquaintance with them, and whose reputation carries the assurance of their competency justly to appreciate the opinions of others, while it stamps their own doctrines with high and just authority.—American Medical Journ. The most complete work on Practical Medicine extant; or, at least, in our language.— Buffalo Medical arid Surgical Journal. For reference, it is above all price to every prac- titioner.—Western Lancet. One of the most valuable medical publications of the day—as a work of reference it is invaluable.__ Western Journal of Medicine and Surgery. It has been to us, both as learner and teacher, a work for ready and frequent reference, one in which modern English medicine is exhibited in the most advantageous light.—Medical Examiner. AVe rejoice that this work is to be placed within the reach of the profession in this country, it being DUNGLISON (ROBLEY), M.D., Professor of the Institutes of Medicine, in the Jefferson Medical College, Philadelphia. HUMAN HEALTH; or, the Influence of Atmosphere and Locality, Change of Air and Climate, Seasons, Food, Clothing, Bathing, Exercise, Sleep, THE HUMAN BODY. Royal 12mo., with ^^m^Ji^l^%0V 16 BLANCHARD & LEA'S MEDICAL GLUGE (GOTTLIEB), M.D., Professor of Physiology and Pathological Anatomy in the University of Brussels, &e. AN ATLAS OF PATHOLOGICAL HISTOLOGY. Translated, with Notes and Additions, by Joseph Leidy, M. D., Professor of Anatomy in the University of Pennsylva- nia. In one volume, very large imperial quarto, with three hundred and twenty figures, plain and colored, on twelve copperplates. We are glad to see this excellent work of Gluge translated into English by so competent a hand, and put within the reach of the profession in this coun- try. The history of the development and changes of the elements of pathological tissues, has become now a necessary introduction to the study of morbid anatomy. It can no longer be looked uponasmerely accessory. Bearing the same relation to it as does normal histology to normal anatomy, it appears to us to be' of still higher importance, since it has a closer and more direct bearing upon practical medi- cine. Whatever makes our knowledge of diseased structure clearer, must throw light also upon the plan of cure, and show us, too, in many instances, where a cure is impossible. This being, as far as we know, the only work in which pathological his- tology is separately treated of in a comprehensive manner, it will, we think, for this reason, be of infi- nite service to those who desire to investigate the subject systematically, and who have felt the diffi- culty of arranging in their mind the unconnected observations of a great number of authors. The development of the morbid tissues, nnd the formation of abnormal products, may now be followed and studied with the same ease and satisfaction as tha best arranged system of physiology. — American Med. Journal. Professor Gluge's work will be found a very valu- able addition to the micrologist's collection. It contains, in the compass of one volume, a concise description and well-executed illustrations of the elements to be observed under the microscope in the principal pathological lesions.—Dublin Quarterly Journal of Medical Science. GRIFFITH (ROBERT E.), M. D., &.C. A UNIVERSAL FORMULARY, containing the methods of Preparinc* and Ad- ministering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceu- tists. In one large octavo volume, of 568 pages, double columns. Dr. Griffith's Formulary is worthy of recommen- dation, not only on account of the care which has been bestowed on it by its estimable author, but for its general accuracy, and the richness of its details. —Medical Examiner. Most cordially we recommend this Universal Formulary, not'forgetting its adaptation to drug- gists and apothecaries, who would find themselves vastly improved by a familiar acquaintance with this every-day book of medicine.—The Boston Med. and Surg. Journal. A very useful work, and a most complete compen- dium on the subject of materia medica. We know of no work in our language, or any other, so com- prehensive in all its details.—London Lancet. Pre-eminent among the best and most useful com- pilations of the present day will be found the work before us, which can have been produced only at a very great cost of thought and labor. A short de- scription will suffice to show that we do not put too high an estimate on this work. We are not cog- nizant of the existence of a parallel work. Its value will be apparent to our readers from the sketch of its contents above given. We strongly recommend it to all who are engaged either in practical medi- cine, or move exclusively with its literature.—Lond. Med. Gazette. A valuable acquisition to the medical practitioner, and a useful book of reference to the apothecary on numerous occasions.—Amer. Journal of Pharmacy. BY THE SAME AUTHOR. MEDICAL BOTANY; or, a Description of all the more important Plants used in Medicine, and of their Properties, Uses, and Modes of Administration. In one large octavo volume, of 704 pages, handsomely printed, with nearly 3d0 illustrations on wood. One of the few books which supply a positive de- ficiency in our medical literature.—Western Lancet. We hope the day is not distant when this work will not only be a text-book in every medical school and college in the Union, but find a place in the li- brary of every private practitioner.—N. Y. Journal of Medicine. One of the greatest acquisitions to American medi- cal literature. It should by all means be introduced, at the very earliest period, into our medical schools, and occupy a place in the library of every physician in the land.—South-western Medical Advocate. Admirably calculated for the physician and stu- dent __we have seen no work which promises greater advantages to the profession.—N. O. Med. and Surg. Journal. GREGORY (WILLIAM), F. R. S. E., Professor of Chemistry in the University of Edinburgh, &c. LETTERS TO A CANDID INQUIRER ON ANIMAL MAGNETISM. Description and Analysis of the Phenomena. Details of Facts and Cases. In one neat volume, royal 12mo., extra cloth. GARDNER (D. PEREIRA), M. D. MFDTCAL CHEMISTRY, for tho use of Students and the Profession: being a ManuaUfTheScience, with its'Applications to Toxicology, Physiology, Therapeutics, Ilyg.ene, &c. In one handsome royal 12mo. volume, with illustrations. AND SCIENTIFIC PUBLICATIONS. 17 HASSE (C. E.), M. D. AN ANATOMICAL DESCRIPTION OF THE DISEASES OF RESPIRA- TION AND CIRCULATION. Translated and Edited by Swaine. In one volume, octavo. HARRISON (JOHN), M. D. AN ESSAY TOWARDS A CORRECT THEORY OF THE NERVOUS SYSTEM. In one octavo volume, 292 pages. HUNTER (JOHN). TREATISE ON THE VENEREAL DISEASE. With Notes and numerous Additions, by Dr. Ph. Ricord, Surgeon to the Venereal Hospital of Paris. Translated from the French, with additional Notes, by F. J. Bumstead, M. D. In one octavo volume, with plates. (Nearly Ready.) Ricord's Annotations to Hunter's Treatise are very extensive, amounting to nearly half as much as the original work, and bringing it thoroughly up to the present state of the subject. HORNER (WILLIAM E.), M. D., Professor of Anatomy in the University of Pennsylvania. SPECIAL ANATOMY AND HISTOLOGY. Eighth edition. Extensively revised and modified. In two large octavo volumes, of more than one thousand pages, hand- somely printed, with over three hundred illustrations. This work has enjoyed a thorough and laborious revision on the part of the author, with the view of bringing it fully up to the existing state of knowledge on the subject of general and special anatomy. To adapt it more perfectly to the wants of the student, he has introduced a large number of additional wood-engravings, illustrative of the objects described, while the publishers have en- deavored to render the mechanical execution of the work worthy of the extended reputation which it has acquired. The demand which has carried it to an EIGHTH EDITION is a sufficient evi- dence of the value of the work, and of its adaptation to the wants of the student and professional reader. HORNER (W. E.) in connection with H. H. SMITH. ANATOMICAL ATLAS. One volume, imperial 8vo. (See Smith.) HOBLYN (RICHARD D.), A. M. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. Revised, with numerous Additions, from the second London edition, by Isaac Hays, M. D., &c. In one large royal 12mo. volume, of four hundred and two pages, double columns. We cannot too strongly recommend this small and cheap volume to the library of every student and practitioner.—Medico-Chirurgical Review. HOPE (J.), M. D., F. R. S., &c. A TREATISE ON THE DISEASES OF THE HEART AND GREAT VESSELS. Edited by Pennock. In one volume, octavo, with plates, 572 pages. HERSCHEL (SIR JOHN F. W.), F. R. S., &.C. OUTLINES OF ASTRONOMY. New American, from the third London edition In one neat volume, crown octavo, with six plates and numerous wood-cuts. (Just Issued.) JOHNSTON (ALEXANDER KEITH), F. R. S., &c. THE PHYSICAL ATLAS OF NATURAL PHENOMENA. For the use of Colleges, Academies, and Families. In one large volume, imperial quarto, handsomely and strongly bound, with twenty-six Plates, engraved and colored in the best style. Together with 112 pages of descriptive letter-press, and a very copious Index. 18 BLANCHARD & LEA'S MEDICAL JONES (T. WHARTON), F. R. S., &.C. THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MHDICIXK AND SURGERY. Edited by Isaac Hays, M. D., &c. In one very neat volume, large royal 12mo., of 529 pages, with four plates, plain or colored, and ninety-eight wood-cuts. We are confident that the reader will find, on perusal, that the execution of the work amply fulfils the promise of the preface, and sustains, in every point the already high reputation of the author as an ophthalmic surgeon as well as a physiologist and pathologist. The book is evidently the result of much labor and research, and has been written with the greatest care and attention ; it possesses that best quality which a general work, like a sys- tem or manual can show, viz.: the quality of having all the materials whencesoever derived, so thorough- ly wrought up, and digested in the author's mind, as to come forth with the freshness and impressive- ness of an original production. We regret that we have received the book at so late a period as pre- cludes our giving more than a mere notice of it, as, although essentially and necessarily a compilation, it contnins many things which we should be glad tn reproduce in our pages whether in the shape of new pathological views, of old errors corrected, or oi sound principles of practice in doubtful cnsei clearly laid down. But we dare say most of our readers will shortly have an opportunity of seeing these in their original locality, as we entertain little doubt that this book will become what its author hoped it might become, a manual for daily reference nnd consultation by the student and the general practi- tioner. The work in marked by that correctness, clearness, and precision of style which distinguish all the productions of the learned author.—British and Foreign Medical Review. KIRKES (WILLIAM SENHOUSE), M. D., Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c; and JAMES PAGET, F. R. S., Lecturer on General Anatomy and Physiology in St. Bartholomew's Hospital. A MANUAL OF PHYSIOLOGY. Second American, from the second and improved London edition. With one hundred and sixty-five illustrations. In one large and handsome royal 12m o. volume, pp.550. (Just Issued.) In the present edition, the Manual of Physiology has been brought up to the actual condition of the science, and fully sustains the reputation which it has already so deservedly attained. We consider the work of MM. Kiikes and Paget to constitute one of the very best handbooks of Physiology we possess —presenting just such an outline of the science, com- prising an account of its leading facts and generally admitted principles, as the student requires during his attendance upon a course of lectures, or for re- ference whilst preparing for examination. The text is fully and ably illustrated by a series of very supe- rior wood-engravings, by which a comprehension of some of the more intricate of the subjects treated of is greatly facilitated.—Am. Medical Journal. We need only say, that, without entering into dis- cussions of unsettled questions, it contains all the recent improvements in this department of medical science. For the student beginning this study, and the practitioner who has but leisure to refresh his memory, this book is invaluable, as it contains all that it is important to know, without special details, which are read with interest only by those who would make a specialty, or desire to possess a criti- cal knowledge of the subject.—Charleston Medical Journal. One of the best treatises that can be put into the hands of the student.—London Medical Gazette. The general favor with which the first edition of this work was received, and its adoption as a favor- ite text-book by many of our colleges, will insure a large circulation to this improved edition. It will fully meet the wants of the student. — Southern Med. and Surg. Journal. It possesses the especial merit of being clear nnd concise, and at the same time affording a good out- line of Physiology .—Western Lancet. Numerous new and superior illustrations have been introduced for the purpose of making the sub- ject of more easy comprehension by the student. This edition has evidently been prepared with great care, and is handsomely printed on good paper, and wilf prove a very valuable book for the student in acquainting himself with all the leading well-es- tablished facts in physiology, and for the practitioner as a work of reference.—iYeu> York Medical Times. Particularly adapted to those who desire to pos- sess a concise digest of the facts of Human Physi- ology.— British and Foreign Med.-Chirurg. Review. We conscientiously recommend it as an admira- ble " Handbook of Physiology."—London Journal of Medicine. KNAPP (F.), PH. D., &c. TECHNOLOGY; or, Chemistry applied to the Arts and to Manufactures. Edited, with numerous Notes and Additions, by Dr. Edmund Ronalds and Dr. Thomas Richardson. First American edition, with Notes and Additions, by Prof. Walter R. Johnson. In two hand- some octavo volumes, printed and illustrated in the highest style of art, with about five hundred wood-engravings. LEHMANN. PHYSIOLOGICAL CHEMISTRY. Translated by George E. Day, M. D. In one very large octavo volume. (Preparing.) LEE (ROBERT), M. D., F. R. S., &c. CLINICAL MIDWIFERY; comprising the Histories of Five Hundred and Forty-five Case* of Difficult, Preternatural, and Complicated Labor, with Commentaries. From the second London edition. In one royal 12mo. volume, extra cloth, of 238 pages. AND SCIENTIFIC PUBLICATIONS. 19 LAWRENCE (W.), F. R. S., &.c. A TREATISE ON DISEASES OF THE EYE. Third American edition, much improved and enlarged. With over two hundred illustrations. By Isaac Hays, M. D., Surgeon to Wills Hospital, Philadelphia, &c. In one very large and handsome octavo volume, of over eight hundred pages. This new edition to be ready by July. This work, by far the largest and most comprehensive on the subject within reach of the profes- ?ion in this country, will receive an entire revision on the part of the editor. Brought up in this manner to the most advanced state of science, and presenting an equal improvement over its prede- cessors as regards mechanical execution, it is confidently presented as worthy of the extended repu- tation which it has hitherto enjoyed. BY THE SAME AUTHOR. A TREATISE ON RUPTURES; from the fifth London edition. In one octavo volume, sheep, 480 pages. LEIDY (JOSEPH), M. D. Professor of Anatomy in the University of Pennsylvania, &c. ATLAS OF PATHOLOGICAL HISTOLOGY. By Gottlieb Gluge, M. D. Translated from the German, with Additions, by Joseph Leidy, M. D , Professor of Anatomy in the University of Pennsylvania. In one vol., large imperial quarto, with 320 figures, plain and colored, on twelve plates. BY THE SAME AUTHOR. HUMAN ANATOMY. By Jones Quain, M. D. From the fifth London edition. Edited by Richard Quain, F. R. S., and William Sharpey, M. D., F.R. S., Professors of Anatomy and Physiology, in University College, London. Revised, with Notes and Additions. by Joseph Leidy, M. D., Professor of Anatomy in the University of Pennsylvania. Complete in two large 8vo. vols, of about 1300 pages, beautifully illustrated with over 500 engravings on wood. LISTON (ROBERT), F. R. S., &c. LECTURES ON THE OPERATIONS OF SURGERY, and on Diseases and Accidents requiring Operations. Edited, with numerous Additions and Alterations, by T. D. Mutter, M. D. In one large and handsome octavo volume, of 566 pages, with 216 wood-cuts. We can only say, in conclusion, that Liston's Lectures, with Matter's additions, should be in every surgeon's library, and in every student's hand, who wishes to post up his surgical knowledge to the present moment.—AT. Y. Journ. of Medicine. It is a compendium of the modern practice of Sur- gery as complete and accurate as any treatise of similar dimensions in the English language.— West- ern Lancet. LALLEMAND (M.). THE CAUSES, SYMPTOMS, AND TREATMENT OF SPERMATOR W^a'a T'^'^^^'^byHKNRYj.McDouGAL. In one volume, octavo," 320 pa-e* Second American edition. (Now Ready.) ' Pdee-* LARDNER (DIONYSIUS), D. C. L &c HANDBOOKS OF NATURAL PHILOSOPHY AND ASTRONOMY First Course, containing Mechanics, Hydrostatics Hv,t,.a,,i,^ t> •• cV ^vlvvji i . In one large royal 12mo. volume, of 75VpSe!with 424 toSy£ iT^'n0™*' a"d ^'^ Heat, Electricity, Magnetism, and GalvaPnifi,lZvoluJne late ovan^n ^rf' Con,ain,nS 250 illustrations. Third Course (nearly ready), wiHcSin Motrin T' !?a f ?age*> WU X numerous steel-plates and wood-cuL hJv^M^ The work furnishes a very clear and satisfactory account of our knowledge in the important depart- ment of science of which it treats. Although the medical schools of this country do not include the study of physics in their course of instruction, yet no student or practitioner should he ignorant of its laws. Besides being of constant application in prac- tice, such knowledge is of inestimable utility in fa- cilitating the study of other branches of science. To students, then, and to those who, having already en- tered upon the active pursuits of business, are desir- n .u Pi686^ treat'se is a most complete digest of all that has been developed in relation to the great forces of nature, Heat, Magnetism, and Electricity ineir laws are elucidated in a manner both pleasine and familiar, and at the same time perfectly intelli- gible to the student. The illustrations are suffi- ciently numerous and appropriate, and altogether ousto-sustainand-^proVe'"^ ^ rtll^bor^t^^ra^^^hf "-d<- , i .------ -----.«.. ,oung. home literature. It cannot but prove an acceptable | Western Journal of Medicine and Surgery. offering to the profession at large.—N. Y. Journal of | T))e wQrk before us -g undoubtedly a valuable Medicine. addition to the fund of information which has al- We take much pleasure in recommending this 'ready been treasured up oili the subjects '" questmn. excellent little work to the attention of medical It is practical, and therefore '*I*»?e»tJ^"PtehdllJ" practitioners. It deserves their attention, and af- , the general practitioner. Dr. Meigs' «w« «■ have ter they commence its perusal, thev will not wil- ; the same fascination which belongs to l.mnsell.- lingly abandon it, until they have mastered its ; Medical Examiner. contents. We read the work while suffering from a I ON THE NATURE, SIGNS, AND FEVER. In one handsome octavo volume. by the same author. (Preparing.) TREATMENT OF PUERPERAL BY the same author. (Preparing.) A TRE\TISE ON ACUTE AND CHRONIC DISEASE OF THE NECK OF THE UTERUS. With numerous plates, drawn and colored from nature in the highest style of art. In one handsome octavo volume. AND SCIENTIFIC PUBLICATIONS. 21 MILLER (JAMES), F. R. S. E., Professor of Surgery in the University of Edinburgh, &c. PRINCIPLES OF SURGERY. Third American, from the second and revised Edinburgh edition. Revised, with Additions, by F. W. Sargent, M. D., author of " Minor Sur- gery," ike. In one large and very beautiful volume, of seven hundred and fifty-two pages, with two hundred and forty exquisite illustrations on wood. (Extensively used as a text-book.) The publishers have endeavored to render the present edition of this work, in every point of me- chanical execution, worthy of its very high reputation, and they confidently present it to the pro- fession as one of the handsomest volumes as yet issued in this country. This edition is far superior, both in the abundance nnd quality of its material, to any of the preceding. We hope it will be extensively read, and the sound principles which are herein taught treasured up for future application. The work takes rank with Watson's Practice of Physic ; it certainly does not fall behind that great work in soundness of princi- ple or depth of reasoning and research. No physi- cian who values his reputation, or seeks the interests of his clients, can acquit himself before his God and the world without making himself familiar with the sound and philosophical views developed in the fore- going book.—New Orleans Medical and Surgical Journal. Without doubt the ablest exposition of the prin- ciples of that branch of the healing art in any lan- guage. This opinion, deliberately formed after a careful study of the first edition, we have had no cause to change on examining the second. This edition has undergone thorough revision by the au- thor; many expressions have been modified, and a mass of new matter introduced. The book is got up in the finest style, and is an evidence of the progress of typography in our country.—Charleston Medical Journal and Review. We recommend it to both student and practitioner, feeling assured that as it now comes to us, it pre- sents the most satisfactory exposition of the modern doctrines of the principles of surgery to be found in any volume in any language.—N. Y. Journal of Medicine. by the same author. (Now Ready.) THE PRACTICE OF SURGERY. Third American from the second Edin- burgh edition. Edited, with Additions, by F. W. Sargent, M. D , one of the Surgeons to Will's Hospital, &c Illustrated by three hundred and nineteen engravings on wood. In one large octavo volume, of over seven hundred pages. This new edition will be found greatly improved and enlarged, as well by the addition of much new matter as by the introduction of a large and complete series of handsome illustrations. An equal improvement exists in the mechanical execution of the work, rendering it ir a companion volume to the " Principles." We had occasion in a former number of this Jour- nal, to speak in deservedly high terms of Professor Miller's work on the " Principles of Surgery," and we are happy to be able to pronounce an equally favorable judgment on the manner in which the pre- sent volume is executed. * * * We feel no hesitation in recommending Professor Miller's two volumes as affording to the student what the author intended, namely, a complete text-book of Surgery. —British and Foreign Medical Review. in every respect Although, as we are modestly informed in the preface, it is not put forth in rivalry of the excel- lent works on Practical Surgery which already exist, we think we may take upon ourselves to say that it will form a very successful and formidable rival to most of them.—Northern Journ. of Medicine. Taken together they form a very condensed and complete system of Surgery, not surpassed, as a text-book, by any work with which we are ac- quainted.—i7Z. and Ind. Med. and Surg. Journal. Mr. Miller has said more in a few words than any writer since the days of Celsus.—N. O. Med. and Surg. Journal. MALGAIGNE (J. F.). OPERATIVE SURGERY, based on Normal and Pathological Anatomy. Trans- lated from the French, by Frederick Brittan, A. B., M. D. With numerous illustrations ou wood, in one handsome octavo volume, of nearly six hundred pa"*es. We have long been accustomed to refer to it as one of the most valuable text-books in our library.— Buffalo Med. arid Surg. Journal. Certainly one of the best books published on ope- rative surgery.—Edinburgh Medical Journal. To express in a few words our opinion of Mal- gaigne's work, we unhesitatingly pronounce it the very best guide in surgical operations that has come before the profession in any language.—Charleston Med. and Surg. Journal. MOHR (FRANCIS), PH. D., AND REDWOOD (TH EOPH I LUS). PRACTICAL PHARMACY. Comprising the Arrano*ements A-nmr*itn« nnd Manipulations of the Pharmaceutical Shop ind Laboratory. Edited wifhextE A m by Prof. William Procter, of the Philadelphia Collie of PI armacv Tn ITT, ,0n,S' printed octavo volume, of 570 pages, with over 500 engravings on wood 7' ia"**°-™ly It is a book, however, which will be in the hands of almost everyone who is much interested in phar- maceutical operations, as we know of no other pub- lication so well calculated to fill a void long felt.— Medical Examiner. The book is strictly practical, and describes only manipulations or methods of performing the nume- rous processes the pharmaceutist has to go through, in the preparation and manufacture of medicines, together with all the apparatus and fixtures neces- sary thereto. On these matters, this work is very full and complete, and details, in a style uncom- monly clear and lucid, not only the more comnli- cated and difficult processes, but those not less im- portant ones, the most simple and common__Buffalo Medical Journal. M The country practitioner who is obliged to dis- pense his own medicines, will find it a most valuable assistant.—Monthly Journal and Retrospect 22 BLANCHARD & LEA'S MEDICAL MACLISE (JOSEPH), SURGEON. SURGICAL ANATOMY. forming one volume, very large imperial quarto. With. Sixty-eight lar^a and splendid Plates, drawn in the test style, and beautifully colored. Containing one hundred and ninety Figures, many of them the size of life. TOGETHER WITH COPIOUS AND EXPLANATORY LETTER-PRESS. Strongly and handsomely bound in extra cloth, being one of the cheapest and best executed Surgical works as yet issued in this country. Copies can be sent by mail, in five parts, done up in stout covers. This great work being now concluded, the publishers confidently present it to the attention ofthe profession as worthy in every respect of their approbation and patronage. No complete work of (he kind has yet been published in the English language, and it therefore will supply a want long felt in this country of an accurate and comprehensive Atla* of Surgical Anatomy to which the student and practitioner can at all times refer, to ascertain the exact relative position of the various portions of the human frame towards each other and to the surface, as well as their abnormal de- viations. The importance of such a work to the student in the absence of anatomical material, and to the practitioner when about attempting an operation, is evident, while the price of the book, not- withstanding the large size, beauty, and finish of the very numerous illustrations, is so low as to place it within the reach of every member of the profession. The publishers therefore confidently anticipate a very extended circulation for this magnificent work. One of the greatest artistic triumphs of the age in Surgical Anatomy.—British American Medical Journal. Too much cannot be said in its praise; indeed, we have not language to do it justice.—Ohio Medi- cal and Surgical Journal. The most admirable surgical atlas we have seen. To the practitioner deprived of demonstrative dis- sections upon the human subject, it is an invaluable companion.—N. J. Medical Reporter. The most accurately engraved and beautifully colored plates we have ever seen in an American book—one of the best and cheapest surgical works ever published.—Buffalo Medical Journal. It is very rare that so elegantly printed, so well illustrated, aud so useful a work, is ofTered at so moderate a price.—Charleston Medical Journal. Its plates can boast a superiority which places them almost beyond the reach of competition.—Medi- cal Examiner. Every practitioner, we think, should have a work of this kind within reach.—Southern Medical and Surgical Journal. No such lithographic illustrations of surgical re- gions have hitherto, we think, been given.—Boston Medical and Surgical Journal. As a surgical anatomist, Mr. Maclise has proba- bly no superior.—British and Foreign Medico-Chi- rurgical Review. Of great value to the student engaged in dissect- ing, aud to the surgeon at a distance from the means ot" keeping up his anatomical knowledge.—Medical Times. The mechanical execution cannot be excelled.— Transylvania Medical Journal. A work which has no parallel in point of accu- racy and cheapness in the English language.—N. Y. Journal of Medicine. To all engaged in the_ study or practice of their profession, such a work" is almost indispensable.— Dublin Quarterly Medical Journal. No practitioner whose means will admit should fail to possess it.—Ranking's Abstract. Country practitioners will find these plates of im- mense value.—N. Y. Medical Gazette. We are extremely gratified to announce to the profession the completion of this truly magnificent work, which, as a whole, certainly stands unri- valled, both for accuracy of drawing, beauty of coloring, und all the requisite explanations of the subject in hand. To the publishers, the profession in America is deeply indebted for placing such a valuable, such a useful work, at its disposal, and at such a moderate price. It is one of the most finished and complete pictures of Surgical Anato- my ever offered to the profession of America.— With these plates before them, the student nnd prac- titioner can never be at a loss, under the most despe- rate circumstances. We do not intend these for commonplace compliments. We are sincere; be- cause we know the work will be found invaluable to the young, no less than the old, surgeon. We have not space to point out its beauties, and its merits ; but we speak of it en masse, as a whole, and strongly urge—especially those who, from their position, may be debarred the privilege and opportu- nity of inspecting the fresh subject, to furnish them- selves with the entire work.—The New Orleans Medical and Surgical Journal. This is by far the ablest work on Surgical Ana- tomy that has come under our observation. We know of no other work that would justify a Btu- dent, in any degree, for neglect of actual dissec- tion. A careful study of these plates, and of the commentaries on them, would almost make an ana- tomist of a diligent student. And to one who has studied anatomy by dissection, this work is invalu- able as a perpetual remembrancer, in matters of knowledge that may slip from the memory. The practitioner can scarcely consider himself Equipped for the duties of his profession without such a work as this, and this has no rival, in his library. In those sudden emergencies that so often arise, and which require the instantaneous command of minute anatomical knowledge, a work of this kind keeps the | details of the dissecting-room perpetually fresh in the memory. We appeal to our readers, whether any one can justifiably undertake the practice of rnedi- [ cine who is not prepared to give nil needful assist- ance, in all matters demanding immediate relief. We repeat that no medical library, however large, I can be complete without Maclise's Surgical Ana- tomy. The American edition is well entitled to the confidence of the profession, and should command, among them, an extensive sale. The investment of | the amount of the cost of this work will prove to | be a very profitable one, and if practitioners would ' qualify themselves thoroughly with such important j knowledge as is contained in vyorks of this kind, there would be fewer of them sighing for employ- ment. The medical profession should spring towards such an opportunity as is presented in this republica- tion, to encourage frequent repetitions of American enterprise of this kind.— The Western Journal of Medicine and Surgery. $gST° The very low price at which this work is furnished, and the beauty of its execution, require an extended sale to compensate the publishers for the heavy expenses incurred. AND SCIENTIFIC PUBLICATIONS. 23 MULLER (PROFESSOR J.l, M.D. PRINCIPLES OF PHYSICS AND METEOROLOGY. Edited, with Addi- tions, by R. Eglesfeld Griffith, M. D. In one large and handsome octavo volume, extra cloth, with 550 wood-cuts, and two colored plates. The Physics of MO Her is a work superb, complete, | tion to the scientific records of this country may be unique: the greatest want known to English Science | duly estimated by the fact that the cost of the origi- could not have been better supplied. The work is I nal drawings and engravings alone has exceeded the of surpassing interest. The value of this contrihu- | sum of £2,000.—Lancet. MAYNE (JOHN), M. D., M. R. C. S., &c. A DISPENSATORY AND THERAPEUTICAL REMEMBRANCER. Com- prising the entire lists of Materia Medica, with every Practical Formula contained in the three British Pharmacopoeias. With relative Tables subjoined, illustrating, by upwards of six hundred and sixty examples, the Extemporaneous Forms and Combinations suitable for the different Medicines. Edited, with the addition of the Formulae of the United States Pharmacopoeia, by R. Eglesfeld Griffith, M. D. In one 12mo. volume, extra cloth, of over 300 large pages. MATTEUCCI (CARLO). LECTURES ON THE PHYSICAL PHENOMENA OF LIVING BEINGS. Edited by Pereira. In one neat royal 12mo. volume, extra cloth, with cuts, 388 pages. MARKWICK (ALFRED). A GUIDE TO THE EXAMINATION OF THE URINE IN HEALTH AND DISEASE. Royal 12mo. (See Manuals on Blood and Urine.) MEDLOCK (HENRY), AND F. SCHOEDLER. BOOK OF NATURE; or Elements of the Science of Physics, Astronomy Chem- istry, Mineralogy, Geology, Botany, Zoology, and Physiology. (See Schoedler.) In one vol., large 12mo. An admirable work for families and District Schools. NEILL (JOHN), M. D., Demonstrator of Anatomy in the University of Pennsylvania; Surgeon to the Pennsylvania Hospital, &c; FRANCIS GURNEY SMITH, M. D., Professor of Institutes of Medicine in the Pennsylvania Medical College AN ANALYTICAL COMPENDIUM OF THE VARIOUS °BRANCHES OF MEDICAL SCIENCE ; for the Use and Examination of Students. Second edition, revised and improved. In one very large and handsomely printed royal 12mo. volume, of over one thousand pages, with three hundred and fifty illustrations on wood. Strongly bound in leather, with raised bands. (Extensively used by students.) PREFACE TO THE NEW EDITION. The speedy sale of a large impression of this work has afforded to the authors gratifying evidence of the correctness of the views which actuated them in its preparation. In meeting the demand for a second edition, they have therefore been desirous to render it more worthy of the favor w^h dvln^in uZ heH• reCe'VCd- ^° accomPlish this> *hey ha™ spared neither time nor labor in embo- dying m it such discoveries and improvements as have been made since its first appearance and such alterations as have been suggested by its practical use in the class and examiSi-room Considerable modifications have thus been introduced throughout all the departments treated ofTn he volume but more especially in the portion devoted to the « Practice of MeSe,'' which has been entirely rearranged and rewritten. The authors therefore again submit their work to The S°med» educa!?oenhOP° ^ ^ ^^ *** tCnd' h°WGVer humb^>t0 ad— ^ S« cauS Notwithstanding the increased size and improved execution of this work, the price has not been increased, and it is confidently presented as one of the cheapest volumes now befEre the profession" In the rapid course of lectures, where work for the students is heavy, and review necessary for an examination, a compend is not only valuable, but it is almost a sine qua non. The one before us is in most of the divisions, the most unexceptionable of all books of the kind that we know of. The newest and soundest doctrines and the latest im- provements and discoveries are explicitly, though concisely, laid before the student. Of course it is useless for us to recommend it to all last course students, but there is a class to whom we very sincerely commend this cheap book as worth its weight in silver —that class is the graduates in medicine of more than ten years' standing, who Having made free use of this volume in our ex- aminations of pupils, we can speak from experi- ence in recommending it as an admirable compend for students, and as especially useful to preceptors m^iT'"-? the,r,Pupils. It will save the teacher much labor by enabling him readily to recall all of the points upon which his pupils should be ex- amined. A work of this sort should be in the hnnds ef every one who takes pupils into his office with a view of examining them; and this is unquestionably tne best of its class. Let every practitioner who has pupils provide himself with it, and he will find the abor of refreshing his knowledge so much facilitated have not studied medie^e'^ucT'h.eTwinUrhn'Z I litrte oZ' 1^° t0fdo J,U,StiCe ^is ^i]siit very find out from it that the science h.no?eTacfly 5VvaniaZdVoTrtnl ^^ t0 him^-Trans9K what it was when they left it off.-The Stethoscope ™ '' 24 BLANCHARD & LEA'S MEDICAL NELIGAN (J. MOORE), M. D., M. R. I. A., &.c. A PRACTICAL TREATISE ON DISEASES OF THE SKIN. In one neat royal 12mo. volume, of 334 pages. (Just Issued.) V\ e know of no other treatise on this interesting I The greatest value of Dr. Nelignn's trcatiae con- arid important class of diseases that so happily meets | sists in the plain and thoroughly practical exposition w w^el1' vv'ants of the great mass of physicians.— I he has given of this class of maladies.—Brit, and N. Y. Journal of Medicine. \ For. Mtd.-Chirurg. Review. PHILLIPS (BENJAMIN), F. R. S., &c. SCROFULA; its Nature, its Prevalence, its Causes, and the Principles of its Treatment. In one volume, octavo, with a plate. PEREIRA (JONATHAN), M. D., F. R. S., AND L. S. THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. Third American edition, enlarged and improved by the author; includin;? Notices of most of the Medicinal Substances in use in the civilized world, and forming an Encyclopfedia of Materia Medica. Edited by Joseph Carson, M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. In two very large octavo volumes, on small type, with about four hundred illustrations. Volume I.—Lately issued, containing the Inorganic Materia Medica, over 800 pages, with 145 illustrations. Volume II.—Embracing the Organic Materia Medica, was left by the late author in nearly a com- plete state, is now revising with his MSS., by Alfred S. Taylor and G. Owen Rees, and may be expected in October 1853, with plates and several hundred wood-cuts. The present edition of this favorite and standard work, will be found far superior to its predeces- sors. Besides very large additions and alterations which were made in the last London edition, the work has undergone a thorough revision on the part of the author expressly for this country; and has farther received numerous additions from the editor. It is thus greatly increased in size, and most completely brought up to the present state of our knowledge on this important subject. A similar improvement will be found in its mechanical execution, being printed with new type on fine white paper, with a greatly extended series of illustrations, engraved in the highest style of art. The work, in its present shape, and so far as can be judged from the portion before the public, forms the most comprehensive and complete treatise on materia medica extant in the English language.— Dr. Pereira has been at great pains to introduce into his work, not only all the information on the natural, chemical, and commercial history of medi- cines, which might be serviceable to the physician nnd surgeon, but whatever might enable his read- ers to understand thoroughly the mode of prepar- ing and manufacturing various articles employed either for preparing medicines, or for certain pur- poses in the arts connected with materia medica and the practice of medicine. The accounts of the physiological and therapeutic effects of remedies are given with great clearness and accuracy, and in a manner calculated to interest as well as instruct the reader.—The Edinburgh Medical and Surgical Journal. PAGET (JAMES), F. R. S., AND W. S. KIRKES. MANUAL OF PHYSIOLOGY. Second American edition. One vol., large 12mo. (See Kirkes.) PIRRIE (WILLIAM), F. R. S. E., Professor of Surgery in the University of Aberdeen. THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill, M. D., Demonstrator of Anatomy in the University of Pennsylvania, Surgeon to the Pennsylvania Hospital, &c. In one very handsome octavo volume, of 780 pages, with 316 illus- trations. (Just Issued.) However well it may be adapted for a text-book ] by accurate wood-engravings. Then, again, every (and in tnis respect it may compete with the best, of j instrument employed by the surgeon is thus repre- them) of this much our reading has convinced us, | sented. These engravings are not only correct, but that as a systematic treatise, it iscarefully and ably really beautiful, snowing the astonishing degree of written, and can hardly fail to command a prominent perfection to which the art of wood-engraving has position in the library of practitioners; though not arrived. Prof. Pirrie, in the work before us, has complete in the fullest sense of the word, it never- i elaborately discussed the principles of surgery, and theless furnishes the student and practitioner with | a safe and effectual practice predicated upon them. as chaste and concise a work as exists in our Ian- Perhaps no work upon this subject heretofore issued guage. The additions to the volume by Dr. Neill, is so full upon the science of the art of surgery.— ure judicious; and while they render it more com- , Nashville Journal of Medicine and Surgery. plete, greatly enhance its practical value, as a work . . . . for practitioners and students.—N. Y. Journal of- We have made ourselves more intimately acguaint- rvr /i* «<■ e(1 Wlth lts details, and can now pronounce it to be meaictne. i one of the begt treatjses on 8Urgery in the English We know of no other surgical work of a reason- j language. In conclusion, we very strongly recom- able size, wherein there is so much theory and prac- I mend this excellent work, both to the practitioner tice, or where subjects are more soundly or clearly I and student.—Canada Med. Journal. taught.—The Stethoscope. 0ur impregsion iSi that ag a manual for students, There is scarcely a disease of the bone or soft' Pirrie's is the best work extant.— Western Med. and parts, fracture, or dislocation, that is not illustrated ' Surg. Journal. AND SCIENTIFIC PUBLICATIONS. 25 RAMSBOTHAM (FRANCIS H.), M.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND SURGERY, in reference to the Process of Parturition. Sixth American, from the last London edition. Illustrated with one hundred and forty-eight Figures, on fifty-five Lithographic Plates. In one large and handsomely printed volume, imperial octavo, with 520 pages. In this edition, the plates have all been redrawn, and the text carefully read and corrected. It is therefore presented as in every way worthy the favor with which it has so long been received. From Prof. Hodge, of the University of Pa. To the American public, it is most valuable, from its intrinsic undoubted excellence, and as being the best authorized exponent of British Midwifery. Its circulation will, I trust, be extensive throughout When the whole profession is thus unanimous in placing such a work in the very first rank as regards the extent and correctness of all the details of the theory and practice of so important, a branch of learning, our commendation or condemnation would be of little consequence; but regarding it as the most useful of all works of the kind, we think it but an net of justice to urge its claims upon the profession.—N. O. Med. Journal. our country We recommend the student who desires to mas- ter this difficult subject with the least possible trouble, to possess himself at once of a copy of this work.—American Journal of the Med. Sciences. It stands at the head of the long list of excellent obstetric works published in the last few years in Great Britain, Ireland, and the Continent of Eu- rope. We consider this book indispensable to the library of every physician engaged in the practice of midwifery.—Southern Med. and Surg. Journal. RIGBY (EDWARD), M. D. Physician to the General Lying-in Hospital, &e. A SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations. Second American Edition. One volume octavo, 422 pages. The repeated demands for this work, which has now for some time been out of print, have in- duced the publishers to prepare another edition. The reputation which it has acquired for the clearness of its views, especially as regards the physiological portion of obstetrical science, will secure for it the confidence of the profession. A copy of the first edition was placed in the hands iW'tlie late Professor Dewees, a few weeks before his death, and obtained from him the expression of his most favorable opinion. RICORD (PH.), M. D. HUNTER ON VENEREAL, with extensive Additions by Ricord. {Nearly Ready.) See Hunter. ROYLE (J. FORBES), M.D. MATERIA MEDICA AND THERAPEUTICS; including the Preparations of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States. With many new medicines. Edited by Joseph Carson, M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. With ninety-eight illustrations. In one large octavo volume, of about seven hundred pages. This work is, indeed, a most valuable one, and I ductions on the other extreme, which are neces- will fill up an important vacancy that existed be- sarily imperfect from their small extent.—British tween Dr. Pereira's most learned and complete and Foreign Medical Review. system of Materia Medica, and the class of pro- | REESE (G. OWEN), M. D. OX THE ANALYSIS OF THE BLOOD AND URINE IN HEALTH AND DISEASE, and on the Treatment of Urinary Diseases. Royal 12mo., with plates. (See Blood and Urine, Manuals of.) RICORD (P.), M. D. A PRACTICAL TREATISE ON VENEREAL DISEASES. With a Thera- peutical Summary and Special Formulary. Translated by Sidney Doane, M. D. Fourth edition. One volume, octavo, 340 pages. SKEY (FREDERICK C), F. R. S., &c. OPERATIVE SURGERY. In one very handsome octavo volume of over 650 pages, with about one hundred wood-cuts. Its literary execution is superior to most surgical treatises. It abounds in excellent moral hints, and is replete with original surgical expedients and sug- gestions.—Buffalo Med. and Surg. Journal. With high talents, extensive practice, and a long experience, Mr. Skey is perhaps competent to the task of writing a complete work on operative sur- gery—Charleston Med. Journal. We cannot withhold from this work our high com- mendation. Students and practitioners will find it an invaluable teacher and guide upon every topic con- nected with this department.—N. Y. Medical Ga- zette. A work of the very highest importance—a work by itself.—London Med. Gazette. 26 BLANCHARD & LEA'S MEDICAL SHARPEY (WILLIAM), M. D., QUAIN (JONES), M. D., AND QUAIN (RICHARD), F. R. S., &c. HUMAN ANATOMY. Revised, with Notes and Additions, by JosEPn Leidt, M. D. Complete in two large octavo volumes, of about thirteen hundred pages. Beautifully illustrated with over five hundred engravings on wood. fully It is indeed a work calculated to make an era in anatomical study, by placing before the student every department of his science, with a view to the relative importance of each ; and so skilfully have the different parts been interwoven, that no one who makes this work the basis of his studies, will hereafter have any excuse for neglecting or undervaluing any important particulars connected with the structure of the human frame; and whether the bias of his mind lead him in a more especial manner to surgery, physic, or physiology, he will find here a work at once so comprehensive and practical as to defend him from exclusiveness on the one hand, and pedantry on the other.— Monthly Journal and Retrospect of the Medical Sciences. We have no hesitation in recommending this trea- tise on anatomy ns the most complete on thnt sub- ject in the English language; and the only on*, perhaps, in any language, which brings the stntr of knowledge forward to the most recent disco- veries.—The Edinburgh Med. and Surg. Journal. Admirably calculated to fulfil the object for which it is intended.—Provincial Medical Journal. The most complete Treatise on Anatomy in the English language.—Edinburgh Medical Journal. There is no work in the English language to be preferred to Dr. Quain's Elements of Anatomy__ London Journal of Medicine. SMITH (HENRY H.), M.D., AND HORNER (WILLIAM E.)f M. D. AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, with about six hundred and fifty beautiful figures. With the view of extending the sale of this beautifully executed and complete " Anatomical Atlas," the publishers have prepared a new edition, printed on both sides of the page, thus mate- rially reducing its cost, and enabling them to present it at a price about forty per cent, lower than former editions, while, at the same time, the execution of each plate is in no respect deteriorated, and not a single figure is omitted. These figures are well selected, and present a late the student upon the completion of this Atlas, complete and accurate representation of that won- as it is the most convenient work of the kind that derful fabric, the human body. The plan of this has yet appeared ; and we must add, the very beau- Atlas, which renders it so peculiarly convenient tiful manner in which it is''got up" is so credituhl* for the student, and its superb artistical execution, to the country as to be flattering to our national have been already pointed out. We must congratu- pride.—American Medical Journal. SARGENT (F. W.), M. D. ON BANDAGING AND OTHER POINTS OF MINOR SURGERY. In one handsome royal 12mo. volume of nearly 400 pages, with 128 wood-cuts. The very best manual of Minor Surgery we have seen ; an American volume, with nearly four hundred octavo pages of good practical lessons, illustrated by about one hundred and thirty wood-cuts. In these days of " trial," when a doctor's reputation hangs upon a close hitch, or the roll of a bandage, it would be well, perhaps, to carry such a journal as Mr. Sargent's always in our coat-pocket, or, at all events, to listen attentively to his instructions at home.—Buffalo Med. Journal. We have carefully examined this work, and find it well executed and admirably adapted to the use of the student. Besides the subjects usually embraced in works on Minor Surgery, there is a short chapter on bathing, another on anaesthetic agents, and an appendix of formulae. The author has given an ex- cellentwork on this subject,and his publishers have illustrated and printed it in most beautiful style.— The Charleston Medical Journal. In one volume, octavo, STANLEY (EDWARD). A TREATISE ON DISEASES OF THE BONES. extra cloth, 286 pages. SMITH (ROBERT WILLIAM). A TREATISE ON FRACTURES IN THE VICINITY OF JOINTS, AND ON DISLOCATIONS. One volume octavo, with 200 beautiful wood-cuts. SIMON (JOHN), F. R. S. GENERAL PATHOLOGY, as conducive to the Establishment of Rational Principles for the Prevention and Cure of Disease. A Course of Lectures delivered at St. Thomas's Hospital during the summer Session of 1850. In one neat octavo volume. (Lately Issued.) His views are plainly nnd concisely stated, and in such an attractive manner, as to enchain the atten- tion of the reader, and should they be adopted by the profession at large, are calculated to produce im- portant changes in medicine. Physicians and stu- dents will obtain from its perusal, not only the latest discoveries in Pathology, but that which is even more valuable, a systematic outline for the prosecu- tion of their future studies and investigations. Alto- gether, we look upon it as one of the most satisfactory and rational treatises upon that branch now extant. —Medical Examiner. SMITH (TYLER W.), M. D., Lecturer on Obstetrics in the Hunterian School of Medicine. ON PARTURITION, AND THE PRINCIPLES AND PRACTICE OBSTETRICS. In one large duodecimo vo ume, of 400 pages. OF AND SCIENTIFIC PUBLICATIONS. 27 SOLLY (SAMUEL), F. R. S. THE HUMAN BRAIN; its Structure, Physiology, and Diseases. With a Description of the Typical Forms of the Brain in the Animal Kingdom. From the Second and much enlarged London edition. In one octavo volume, with 120 wood-cuts. SCHOEDLER (FRIEDRICH), PH.D., Professor of the Natural Sciences at Worms, &c. THE BOOK OF NATURE; and Elementary Introduction to the Sciences of Physics, Agronomy, Chemistry, Mineralogy. Geology, Botany, Zoology, and Physiology. Trans- lated from the sixth German edition, with Additions, by Henry Mkdlock, F. C. S., fire. And Additions and Alterations by the American Editor. In one thick volume, small octavo, with over 000 illustrations on wood. (Suitable for the higher Schools.) SMITH (F. GURNEY), M. D., AND JOHN NEILL, M. D. ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE. One vol., large 12mo. (See Neill.) TAYLOR (ALFRED S.), M. D., F. R. S., • Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital MEDICAL JURISPRUDENCE. Third American, from the fourth and improved English Edition. With Notes and References to American Decisions, by Edward Hartshorne M. D. In one large octavo volume, of about seven hundred pages. (Just Ready.) In the preparation of the English edition, from which this has been printed, the author has found it necessary to revise the whole of the chapters, as well as to make numerous alterations and addi- tions together with references to many recent cases of importance. A Glossary has aN0 been added for the convenience of those whose studies have not been directed specially to this subject I he notes of the American editor embrace the additions formerly made by Dr. Griffith who revi-ed the work on its first appearance in this country, together with such new matter as his exnerienoe and the progress of the science have shown to be advisable. The work may therefore be regarded as fully on a leve with the most recenj discoveries, and worthy of the reputation which it his ar■ qui red as a complete and compendious guide for the physician and lawyer! So well is this work known to the members both , to desist before completing it. In the last I ondnr, of the medical and legal professions, and so highly edition, all the newly observed and ?ccur.teTv rf is . appreciated by them, that it cannot be necessary corded facts have been inserted, •ncludTn^mucfth^ lor us to say a word in its commendation ; its having is recent of Chemical, Microscopical and r m, if already reached a fourth edition being the best pos° gical research, besides p8peroSiwbt Bible testimony in its favor. The author has ob- never before published; in the supervision ofthi* v.ously subjected the entire work to a very careful the third American, one of the las?ffi« «fLl l ' rev-won. We find scattered through it numerous mentedDr. Griffith, we findaModlvn mh^J !a" additions and alterations, some of them of consider- | and additions. TheTpublishe?^ Pl notes able importance; and reference is made to a large of the profession for the^publication "r 5 , PE0r number of ciises which have occurred since the date —-■* -'-'-- - " " ■ P "'ilcat,on <»f n work o of the last publication.—British and Foreign Med - Chirurg. Review. The fourth edition of Dr. Taylor's Manual of Medical Jurisprudence needs merely a simple an- nouncement at our hands; the merits of the work have been freely canvassed by us on a former occa- sion, and we have now but to say that the author has spared no pains in keeping it on a par in all re- spects with the advance of both medical and leeal science.—Dublin Med. Journal. This work of Dr. Taylor's is generally acknow- ledged to be one of the ablest extant on the subject such sterling merit.—Charleston Medical ^Journal and Review. *v*,nui It is not excess of praise to say that the volume before us is the very best treatise extant on Medical Jurisprudence. In saying this, we do not wish to be understood as detracting from the merits of the excellent works of Beck, *byM, Traill, Gu>, and others; but in interest and value we think it must be conceded that Taylor is superior to anything has preceded it. The author is already well km w, to the profession by his valuable treatise on Poison™ and the present volume will add materially to his tt?„&ti°?j:,,r -aCCUra'e ant* extensive'know! icugeu 10 oe one ot the ab est extant on the subicet \e.-d m^ny """"era of interest with plying so much both to intere"? anUnrtrnet' thS't work ^b o.f Z™™ f^V,te Uw' &c*' so that the we do not hesitate to affirm that after bavin- once h^, L2 completely up to the wants of (he commenced its perusal, few could be prevS upon I SS^^S^f1^' ^--V- TT. BY THE SAME AUTHOR. i>i ina sa.uk AUTHOR. °;L?0TS0NS' IN RELATION TO MEDIC iL JTmTSPTm™?vr^ MEDICINK Edited, with Notes and Additionsby^RE^JK P A ND volume, of 688 pages. y Griffith, 1U. D. In one large octavo The most elaborate work on the subject tint onr l n„« „<• *u literature possesses.-British and Foreign MedUo- on Poi ^r' PTacticBl and ^""worthy works Chirurgual Review. 8>l MetllC0 | Medicin" language.-Western Journal of al/ ^T^^t^^^^^tt ! rably^ V^J™?** *«*"<•> ™™^ necessary to the guidance ofthe medical jurist and ! 'reec ediLble to thl* ^bjBCt* in ,the ,,i8he«t de- ( jv. x > Annalist. THOMSON (A. T.). M. D. F R S X,^ DOMESTIC MANAGEMENT OF THE SICK POmi • ., Medical Treatment for .he Cure ofD^eaJ Flii, h p 1*°™' nCC^ary m aid of royal 12mo. volume, with wood-cuts, 3G0 JS's ^ by R' K Gr™"> M. D. I„ one large 28 BLANCHARD & LEA'S MEDICAL TODD (R. B.), M. D., AND BOWMAN (WILLIAM), F. R. S. PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With numerous handsome wood-cuts. Parts I, II, and III, in one octavo volume, 552 pages. Part IV will complete the work. The distinguishing peculiarity of this work is, that the authors investigate for themselves every fact asserted; and it is the immense labor consequent upon the vast number of observations re- quisite to carry out this plan, which has so long delayed the appearance of its completion. Part IV, with numerous original illustrations, is now appearing in the Medical News and Library for 1853. Those who have subscribed since the appearance of the preceding portion of the work can have the three parts by mail, on remittance of $2 50 to the publishers. TRANSACTIONS OF THE AMERICAN MEDICAL ASSOCIATION. VOLUME V, for 1852, large 8vo., of 940 pages, with numerous maps. Also to be had, a few sets of the Transactions from 1848 to 1851, in four large octavo volumes'. These volumes are published by and sold on account of the Association. WATSON (THOMAS), M. D., &c. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Third American, from the last London edition. Revised, with Additions, by D. Francis Condie, M. D , author of a " Treatise on the Diseases of Children," &c. In one octavo volume, of nearly eleven hundred large pages, strongly bound with raised bands. To say that it is the very best work on the sub- ject now extant, is but to echo the sentiment of the medical press throughout the country. — N. O. Medical Journal. Ofthe text-books recently republished Watson is very justly the principal favorite.—Holmes's Rep. to Nat. Med. Assoc. By universal consent the work ranks among the very best text-books in our language.—Illinois and Indiana Med. Journal. Regarded on all hands as one of the very best, if not the very best, systematic treatise on practical medicine extant.—St. Louis Med. Journal. Confessedly one of the very best works on the principles and practice of physic in the English or any other language.—Med. Examiner. Asa text-book it has no equal; as a compendium of pathology and practice no superior.—New York Annalist. We know of no work better calculated for being placed in the hands of the student, and for a text- book; on every important point the author scenu to have posted up his knowledge to the day.— Amer. Med. Journal. One of the most practically useful books that ever was presented to the student. — N. Y. Med. Journal. WALSHE (W. HJ, M. D., Professor ofthe Principles and Practice of Medicine in University College, London. DISEASES OF THE HEART, LUNGS, AND APPENDAGES; their Symptoms and Treatment. In one handsome volume, large royal 12mo., 512 pages. We consider this as the ablest work in the En- glish language, on the subject of which it treats; the author being the first stethoscopist of the day. —Charleston Medical Journal. The examination we have given the above work, convinces us that it is a complete system or treatise upon the great speciality of Physical Diagnosis. To give the reader a more perfect idea of what it con- tains, we should be glad to copy the whole table of contents and make some extracts from its pages, but our limits forbid. We have no hesitation in recom- mending the work as one of tfce most complete nn this subject in the English language; nnd yet it is not so voluminous as to be objectionable on this ac- count, to any practitioner, however pressing his engagements.—Ohio Medical and Surgical Journal. WHAT TO OBSERVE AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES. Published under the authority of the London Society for Medical Observation. In one very handsome volume, royal 12mo., extra cloth (Just Issued.) Did not the perusal of the work justify the high opinion we have of it, the names of Dr. Walshe, the originator, and of Dr. Ballard, as the editor of the volume, would almost of itself have satisfied us that it abounds in minute clinical accuracy. We need not say that the execution of the whole reflects the highest credit not only upon the gentlemen men- tioned, but upon all those engaged upon its produc- tion. In conclusion, we are convinced that the possession of the work will be almost necessary to every member of the profession—that it will be found indispensable to the practical physician, the pathologist, the medical jurist, and above all to the medical student.—London Medical Times. We hail the appearance of this book as the grand desideratum.—Charleston Medical Journal. This little work, if carefully read by even old practitioners, cannot fail to be productive of much good; us a guide to the younger members of the pro- fession in directing their attention specially to the best mode of investigating cases so as to arrive at correct diagnosis, it will prove exceedingly valua- ble. The great difficulty with beginners, who have not been under the immediate training of an expe- rienced physician, is continually found to be in the appreciation of the true condition of the organs and tissues. Let such provide themselves with this work and study it thoroughly, and they will find much of the difficulty removed.—Soutliern Medical and Surgical Journal. This is truly a very capital book. The whole medical world will reap advantages from its publi- cation. The medical journals will soon show its influence on the character of the " Reports of Cases" which they publish. Drs. Ballard and Walshe have given to the world, through a small but useful medical organization, a cheap but invaluable book. We do advise every reader of this notice to buy it anil use it. Unless he is so vain as to imagine him- self superior to the ordinary human capacity, he will in six months see its inestimable advantages.— Stethoscope. AND SCIENTIFIC PUBLICATIONS. 29 WILSON (ERASMUS), M. D., F. R. S., Lecturer on Anatomy, London. A SYSTEM OF HUMAN ANATOMY, General and Special. Fourth Ameri- can, from the last English edition. Edited by Paul B. Goddard, A. M., M. D. With two hun- dred and fifty illustrations. Beautifully printed, in one large octavo volume, of nearly six hun- dred pages. In many, if not all the Colleges of the Union, it i It offers to the student all the assistance that can has become a standard text-book. This, of itself, be expected from such a work.—Medical Examiner. is sufficiently expressive of its value. A work very | The moat complete and convenient manual for the desirable to the student: one, the possession of \ stu([ent we possess.-,!,™rican Journal of Medical which will greatly facilitate his progress in the Science study of Practical Anatomy.—New York Journal of Medicine. Its author ranks with the highest on Anatomy.— Southern Medical and Surgical Journal: Science. In every respect, this work as an anatomical guide for the student and practitioner, merits our warmest and most decided praise.—London Medical Gazette. BY THE SAME AUTHOR. THE DISSECTOR; or, Practical and Surgical Anatomy. Modified and Re- arranged, by Paul Beck Goddard, M. D. A new edition, with Revisions and Additions. In one large and handsome volume, royal 12mo., with one hundred and fifteen illustrations. In passing this work again through the press, the editor has made such additions and improve- ments as the advance of anatomical knowledge has rendered necessary to maintain the work in the high reputation which it has acquired in the schools ofthe United States, as a complete and faithful guide to the student of practical anatomy. A number of new illustrations have been added, espe- cially in the portion relating to the complicated anatomy of Hernia. In mechanical execution the work will be found superior to former editions. BY THE SAME AUTHOR. ON DISEASES OF THE SKIN. Third American, from the third London edition. In one neat octavo volume, of about five hundred pages, extra cloth. (Just Issued.) Also, to be had done up with fifteen beautiful steel plates, of which eight are exquisitely colored ; representing the Normal and Pathological Anatomy of the Skin, together with accurately colored delineations of more than sixty varieties of disease, most of them the size of nature. The Plates are also for sale separate, done up in boards. The increased size of this edition is sufficient evidence that the author has not been content with a mere republication, but has endeavored to maintain the high character of his work as the standard text-book on this interesting and difficult class of diseases. He has thus introduced such new matter as the experience of the last three or four years has suggested, and has made such a terations as the progress of scientific investigation has rendered expedient. The illustrations have also been materially augmented, the number of plates being increased from eight to sixteen. The "Diseases of the Skin," by Mr. Erasmus H ilson, may now be regarded as the standard work in that department of medical literature. The plates by which this edition is accompanied leave nothing to be desired, so far as excellence of delinea- tion and perfect accuracy of illustration are con- cerned— Medico-Chirurgical Review. As a practical guide to the classification, diag- nosis, and treatment of the diseases of the skin, the book is complete. We know nothing, considered in this aspect, better in our language; it is a safe authority on all the ordinary matters which, in this range of diseases, engage the practitioner's attention, and possesses the high quality—unknown, we believe, to every older manual—of being on a level with science:s high-water mark; a sound book of practice.—London Med. Times. Of these plates it is impossible to speak too highly. The representations of the various forms of cuta- neous disease are singularly accurate, and the color- ing exceeds almost anything we have met wilh in point of delicacy and finish.—British and Foreign Medical Review. BY THE SAME AUTHOR. °?vpmuTioII^TpIS^sL tAND HEREDITARY SYPHILIS, AND ON «*fVTi a T fERi:JPTI0NS* ^ »ne small octavo volume, beautifully printed, with four exmii site colored plates, presenting more than thirty varieties of syphilitic eruptions. ^ This, in many respects, is a remarkable work, pre- senting views of theory and principles of practice which, if true, must change completely the existing state of professional opinion.—New York Journal of Medicine. J a Dr*...wilson'8 views on the general subject of bypnilis appear to us in the main sound and judi- cious, and we commend the book as an excellent monograph on the subject. Dr. Wilson has pre- sented us a very faithful and lucid description of Syphilis and has cleared up many obscure points in connection with its transmissibilitv. pathology and sequela;. His facts and references Will, wearl'satis- fied, be received as decisive, in regard to many E^T VeX,tiE- J\ey aPPear to us entitled to w, It „ Tm? lerngth- Ve have Perh"Ps been some- what prodigal of space in our abstract of this book. But it is certainly a very good resume of received opinions on Syphilis, and presents, to many, original and striking views on the subject -Med. Examiner WHITEHEAD (JAMES), F.R.C S &c THE CAUSES AND TREATMENT OF ABORTION AND STFRrTTTV «&^\^^t^^? ^ «» PhyslgictS S^Zl 30 BLANCHARD & LEA'S MEDICAL WILDE (W. R.), Surgeon to St. Mark's Ophthalmic and Aural Hospital. Dublin. AURAL SURGERY, AND THE NATURE AND TREATMENT OF DIS- EASES OF THE EAR. In one handsome octavo volume, with illustrations. (Just Ready.) So little is generally known in this country concerning the causes, symptoms, and treatment of aura! affections, that a practical and scientific work on that subject, from a practitioner of Mr. Wiide*s great experience, cannot fail to be productive of much benefit, by attracting attention to this obscure cla>s of diseases, which too frequently escape attention until past relief. The im- mense number of ca*es which have come under Mr. Wilde's observation for many years, have afforded him opportunities rarely enjoyed for investigating this branch of medical science,'and his work may therefore be regarded as of the highest authority. WEST (CHARLES), M. D., Senior Physician to the Royal Infirmary for Children, &c. LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. In one volume, octavo, of four hundred and fifty pages. Every portion of these lectures is marked by a ge- neral accuracy of description, and by the soundness of the views set forth in relation to the pathology and therapeutics of the several maladies treated of. The lectures on the diseases of the respiratory ap- paratus, about one-third of the whole number, are particularly excellent, forming one of the fullest and most able accounts of these affections, as they The Lectures of Dr. West, originally published in the London Medical Gazette, form a most valuable addition to this branch of practical medicine. For many years physician to the Children's Infirmary, his opportunities for observing their diseases have been most extensive, no less than 14,000 children having been brought under his notice during the past nine years. These have evidently been studied with sjreat care, and the result has been the production of the very best work in our language, so far as it goes, on the diseases of this class of our patients. The symptomatology and pathology of their diseases are especially exhibited most clearly; and we are con- vinced that no one can read with care these lectures without deriving from them instruction of the most important kind.—Charleston Med. Journal. present themselves during infancy and childhood, in the English language. The history of the seve- ral forms of phthisis during these periods of exist- ence, with their management, will be Tend by nil with deep interest.—The American Journal of the Medical Sciences. WILLIAMS (C. J. B.i, M. D., F. R. S., Professor of Clinical Medicine in University College, London, &c. PRINCIPLES OF MEDICINE; comprising General Pathology and Therapeu- tics and a brief general view of Etiology, Nosology, Semeiology, Diagnosis, Prognosis, and Hvienics. Edited, with Additions, by Meredith Clymer, M. D. Fourth American, from the lasrfand enlarged London edition. In one octavo volume, of nearly five hundred pages. Now Ready. This new edition has been materially enlarged and brought up by the editor. It pos-c^e-* the strongest claims to the attention of the medical student and practitioner, from the admirable manner in which the various inquiries in the different branches of pathology are investigated, combined, and generalized by an experienced practical physician, and directly applied to the investigation and treatment of disease.—Editor's Preface. The best exposition in our language, or, we be- 1 Few books have proved more useful, or met with lieve in any language, of rational medicine, in its |a more ready sale than this, and no practitioner •■resent improved and rapidly improving state.—I should regard his library as complete without it. British and Foreign Medico-Chirurg. Review. \ —Ohio Med. and Surg. Journal. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON DISEASES OF THE RESPIRATORY ORfrANS; including Diseases of the Larynx, Trachea, Lungs, and Pleurae. With numerous Additions aud Notes, by M. 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